I'm Dr. Rachael Sussman, and I'm a urologist at MedStar Georgetown University Hospital
specializing in female pelvic medicine and reconstructive surgery. My patients are people who
come to me with quality of life issues surrounding urinary leakage and their pelvic floor, so I see a
lot of men and women who have either difficulty urinating or difficulty holding their urine and
leaking urine. I also see a lot of women who suffer from pelvic organ prolapse which is when women
can sometimes feel a bulge in the vagina from dropped pelvic organs. I would say my philosophy
is to treat each patient uniquely and to kind of tailor treatments to what their goals are
and what their other medical problems are. You know, a lot of times people come to me with leakage of
urine, and they just want to know is this a sign of something bad or something scary. In which
case, you don't need to do anything aggressive to treat them if there's nothing of concern.
Other times people come because they're really bothered by a symptom and then we have lots of
good treatments that we can offer them. But I think it's really important to take into consideration
what a patient wants out of the visit and how we can best help them according to what their
particular goals are. I love coming to work every day because I see patients that have issues that
impact their quality of life tremendously, and we have tons of good treatments that we can do
to improve someone's quality of life. A lot of the issues that I deal with are sensitive issues that
women and men just don't talk about, and I feel like patients are so grateful when they've found
someone who asks the right questions and elicits a problem that they've often been struggling with
for years. Patients should come to Georgetown because we have tons of different treatments
that we can offer to help them with their issues. I think it's really important and good for patients
to be at a large academic center where we can work with other disciplines. For example, if someone has
issues with leakage we can work together with pelvic floor physical therapists. If they have
issues with infections, we can work with infectious disease doctors. A lot of women suffering from
issues with their bladder may also have issues with their bowel, and we work collaboratively
with colorectal surgery and GI to all bring care together for the goal of the patient,
Incontinence of urine is the involuntary loss of urine.
Basically, it's just when urine comes out when you don't want it to.
Stress incontinence is leakage of urine that occurs with an increase in activity.
So many women experience this as leakage of urine when they laugh, cough, sneeze, jump on a trampoline.
But in severe cases, this can occur when someone moves even from the sitting to standing position.
Incontinence becomes a lot more common as people age and about 50 of women and men
do experience some leakage of urine. There's a lot of different reasons that this can happen,
and incontinence can develop for a number of different reasons. For example, men can have
leakage of urine associated with an enlargement of their prostate which is more common as they age.
Overactive bladder, which is sort of frequent in urgent urination
which sometimes causes leakage of urine, also becomes more common as people age.
And as we age, the muscles that hold the urine back in our sphincter tend to become a little more weak.
There's also other types of incontinence that can occur due to issues with neurologic
conditions. For example, patients with MS or Parkinson's disease can also experience
leakage of urine, and those issues tend to become a little bit more common with age.
There is a relationship between overactive bladder and incontinence, but not everybody
with overactive bladder has incontinence. So overactive bladder is frequent in urgent
urination. And sometimes, people will leak urine with that urge
because they can't get to the bathroom in time, and that's called urgency incontinence.
Stress incontinence in women most often develops from having babies, from pushing babies through
the vaginal canal. It can create damage to the muscles and the nerves in that area,
and it can lead to a lack of support underneath the urethra.
Other things that can cause stress incontinence are things that cause increased abdominal pressure,
so that could be being overweight, smoking, having chronic constipation, having a chronic cough.
And then like everything else in the world, there is a role for genetics, so some people just have
weaker tissue quality. And oftentimes, when women go through menopause they have less strength in
the tissues surrounding the urethra and the bladder and that can exacerbate an underlying
issue. Incontinence does not need to be a lifelong condition, and there are many good
treatments that we can offer. Many women do not seek care for incontinence because
they just accept it as a normal part of aging, but they don't have
to accept it because there are lots of things that we can do to treat it.
Incompetence is treated differently depending on the type of incontinence.
So generally speaking, I would say there are two main types of incontinence. Stress
incontinence which occurs with coughing laughing sneezing, and urgency incontinence which is
leakage that occurs when the bladder is squeezing when you don't want it to. For stress incontinence,
there are many different treatments that we offer going from least invasive to most invasive. And
typically with patients, I'll start with the least invasive things first. So for example if someone is
only going to the bathroom two or three times a day, an easy thing they could do is just try and
go to the bathroom more frequently because they'll be less likely to leak urine if their bladder is
less full. Also, they could do Kegel exercises or pelvic floor exercises to help strengthen the
muscles of their pelvic floor. And oftentimes when I examine someone, I try and have them
do an exercise while I'm examining them to make sure that they're identifying the correct muscle.
It can be very difficult to identify the Kegel muscles, and there's actually a whole group of
physical therapists that specialize in pelvic health. And at MedStar, we have great pelvic floor
physical therapists that we can send patients to to help them really do the best job they can to
strengthen their pelvic floor muscles. So if Kegel exercises and pelvic floor physical therapy don't
work, they also make inserts that can be used in the vagina that prevent leakage of urine.
This doesn't really treat stress incontinence so much as it acts as a brace or a band-aid.
So, they make what's called an incontinence pessary which is a small plastic disc that's placed in the
vagina, and it puts a little pressure under the urethra to prevent leakage of urine. They also
make disposable inserts that are sort of like a tampon that someone can use. This is a good option
for someone who's older who really doesn't want to do anything invasive or for someone who leaks
reliably during a particular activity. For example, someone who leaks when they're on a trampoline
only and they want to be able to jump with their kids outside freely, they could use this sort of
insert at that time. But, they don't need to wear it all the time. If inserts or incontinence pessaries
don't work, there are also surgical treatments that we can use for stress incontinence. The gold
standard treatment for stress incontinence is the placement of a mid-urethral sling. This is a very
small piece of polypropylene mesh that's placed under the urethra to act as a firm backboard
for the urethra to push against and prevent the leakage of urine. This can be done as an outpatient
procedure, and the patient typically goes home the same day and has a very short recovery.
As an alternative to mesh slings if someone does not want mesh or they have a reason that
they can't have mesh, you can actually place a sling with a patient's own tissue where we take
some of the strong tissue from the patient's abdomen or from their thigh and we create a
sling with that to keep the urethra closed. That's called an autologous fascial sling.
Another great minimally invasive treatment for stress incontinence is a urethral bulking agent.
This is something that's placed in the office under local anesthesia,
and it's injected into the sides of the urethra to narrow it and make it harder for urine to leak out.
This is something that's been around for a long time. But typically, it has to be repeated about
once a year because the body degrades the material over time. Something we're very excited about is a
new FDA-approved bulking agent that has good efficacy and lasts up to about seven years.
There is a huge relationship between bowel movements and urinary symptoms. And that's
because the pelvis is a small crowded space, and your rectum sits right behind your bladder.
So, a lot of patients who have constipation where their rectum is full of stool find that if their
constipation improves, their urinary symptoms become increasingly better. There's also some
FDA-approved treatments that work to treat both incontinence of urine and incontinence of stool.
So we have a pacemaker that we can insert for the bladder that stimulates the nerves that go
to the bladder. And this can be used to treat patients with overactive bladder, so that's
frequency of urination urgency of urination, and it also treats incontinence of stool.
Overactive bladder is frequency and urgency of urination and some people can experience
leakage of urine when they're on the way to the bathroom because they can't hold it. I tell all my
patients that in a normal functioning bladder, your bladder should fill up, you should feel it filling up,
but it shouldn't squeeze until you're in the bathroom, it's socially appropriate, and you give
yourself permission to go to the bathroom. What can happen in a lot of patients is that their bladder
has a mind of its own, and it starts squeezing before you give it permission to which creates
a significant urge to go to the bathroom and it causes the urine to leak out before you get there.
Similar to stress incontinence, overactive bladder can be treated with many different treatments
going from least invasive to most invasive. So for overactive bladder, pelvic floor physical
therapy or Kegel exercises can also be used, and patients can use urge suppression techniques
to kind of recruit those muscles when they have an urge to go to the bathroom to give themselves
a little bit more time to get to the bathroom. In terms of other behavioral and dietary changes,
there are a lot of irritants of the bladder that people consume in their diet that they
might not be aware of that can really influence their symptoms. The most common bladder irritants
are coffee, tea, soda, spicy food, acidic food, artificial sweeteners, alcohol, and tobacco.
If behavioral or dietary modifications or pelvic floor physical therapy
doesn't work for a patient or simply if a patient says I'm not going to do that, there are
also medications that we can give to relax the bladder. And there are two types of medications
that we can use to to relax the bladder. One of them works to basically say to the bladder no
please do not squeeze, so it blocks the receptors on the bladder that cause it to contract.
And there's a lot of different medications in that class. The other type of medication works to
activate the receptors in the bladder that cause it to relax. And up until this year, there was only
one FDA-approved medication in that class which, unfortunately, is not covered by all insurances
so it can be somewhat expensive. But very exciting is there's a new FDA-approved agent in that group
of medications, so hopefully, the prices will be a little bit lower and be more affordable
for our patients. If medications don't work to treat overactive bladder, two medications can
be used together because sometimes two different medications together work better than one. And if
patients fail medications, there are three what are called third line therapies for overactive bladder.
The first of which is Botox. So just like plastic surgeons can use Botox to paralyze
the muscles in the forehead, we can put Botox into the bladder to paralyze the bladder muscle
and make it so it doesn't squeeze so frequently. That's something that can be done in the office
under a local anesthesia and works very, very well. There are also two other treatments for overactive
bladder that work by stimulating the nerves that go to the bladder and kind of resetting them
to make them function more normally. One of these treatments is an acupuncture like treatment called
PTNS, or peripheral tibial nerve stimulation. And patients come to the office and for once
a week for 12 weeks, we stimulate a nerve in the ankle that travels back up to the spine
and stimulates the nerves that go to the bladder. And that's been clinically proven to work about as
well as medications with very few side effects. The last third line treatment for overactive
bladder is insertion of what's called a sacral neuromodulator. This is a pacemaker for the bladder
that's placed in an outpatient procedure, and it has a small battery that sits under the skin and
constantly sends signals to the bladder to make sure that the nerves are functioning properly.
Urodynamics is a test that allows us to study exactly what's happening in the bladder when
patients are experiencing symptoms. This is an interactive test that's done in the office, and we
fill the bladder up with fluid, and we measure the pressure in the bladder as the bladder is filling
and as it's emptying to see what exactly is happening when a patient is experiencing a symptom
such as the urge to go to the bathroom or leakage of urine or even difficulty emptying
their bladder. And, this really allows us to study someone's particular bladder mechanics
and tailor our treatments to what their exact problem is.
Pelvic organ prolapse occurs when there's a lack of support in the muscles of the pelvis.
So in women, there's a lot of pelvic organs there. There's the vagina, the uterus, the bladder, and
the rectum. And when there's a disorder of the pelvic floor muscles, any of these organs can
drop and cause symptoms. Many women with pelvic organ prolapse don't experience any symptoms, but
others experience a lot of bothersome symptoms. This could include feeling a bulge in the vagina,
feeling some lower abdominal pain or pressure. Some women say that they feel like
they're wearing a tampon all the time when they're not. And then, they can also experience urinary and
fecal symptoms depending on if the bladder or the rectum are involved. So, some women can have
issues where they feel like it's difficult to empty their bladder because their bladder is
sort of dropping down, and it can block the flow of urine. In terms of if the rectum is involved, this
can also cause issues with constipation or feeling like stool is getting stuck.
Pelvic organ prolapse, like anything else, can be treated from the least invasive to
the most invasive things. So pelvic floor physical therapy, or strengthening the pelvic floor muscles,
can help prevent prolapse from occurring over time. And, it's never too early to start doing them.
If someone is not happy with pelvic floor physical therapy or exercises or they still have bothersome
symptoms, prolapse is really something that's an anatomic issue that we need to correct.
So, one good treatment that's very minimally invasive is wearing a pessary.
This is a small plastic disc that can be placed in the office, and it just sits in
the vagina and it supports the organs. This is something that a woman can learn to take
in and out herself in exchange or can come to the office and we can exchange it for her.
If a pessary doesn't work or if somebody just wants a surgical treatment, there's
also many different good surgical options to restore the normal anatomy of the pelvic floor.
So pelvic organ prolapse can be treated a number of different ways.
A lot of times we can approach the prolapse vaginally without any incisions on the abdomen.
So, we basically just correct wherever the defect is. We can restore the normal anatomy of the front
wall or the back well of the vagina. And if someone is post-menopause and they're done having children,
we can also do a hysterectomy vaginally as well to remove the uterus and then tack the top of
the vagina to some of the stronger ligaments higher up in the pelvis. Pelvic organ prolapse
can also be treated through minimally invasive robotic surgery. This is done through small
little incisions in the abdomen and with the help of a surgical robot which allows us for
very good visualization in the pelvis, we're able to attach pieces of mesh to the top and the back
of the vagina and lift the vagina up and tack it to some of the ligaments higher up in the pelvis.
This is very different from all of the mesh that you hear about in the news. That was for
mesh that was placed vaginally. The surgery that I'm referring to is called the sacrocolpopexy
and that does not have any of the same risks as vaginal mesh procedures for pelvic organ
prolapse, and it has the longest durability of any surgery for prolapse that we have.
A lot of the issues that I treat are quality of life issues, so leakage of urine or pelvic organ
prolapse, are things that impact someone's quality of life. But if left untreated, they can also cause
other issues. For example, some women can be more at risk for having urinary tract infections,
or women may have pain with intercourse which may impact their ability to have a
happy, healthy relationship with their partner. Similarly if someone's leaking urine,
they're spending a lot of money on pads, so it can have financial implications.
Or, they may even not go do things with their friends because they're worried about being
outside of the house. They may not want to run or exercise because they're going to leak urine.
And if you can correct that, someone can live a happier healthy life that's more meaningful.