The Incontinence Solution

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Barbara Nesbitt: “I’m Barbara Nesbitt, I’m the editor of OBGYN.net and I’m at AUGS in Florida. It’s beautiful here. That’s the American Urogynecological Society and I have the pleasure and privilege of sitting with Dr. Amy Rosenman, who is a partner with someone we have all known for years, Dr. William Parker. We are going to discuss their new book, The Incontinence Solution. We are going to have the book on the urogynecology and the women’s page and you will be able to read chapters from it and purchase it just like you can with Dr Parker’s first book, A Gynecologist’s Second Opinion. Welcome, Dr Rosenman, it’s a pleasure to have you here and a pleasure to have you also be a member of the UroGynecological Editorial Advisory Board on OBGYN.net.”

Amy Rosenman, MD: “Thank you very much. The pleasure is all mine.”

Barbara Nesbitt: “Thank you. Tell me what brought about writing this book and, also, perhaps first off you can fill in the audience on how you and Dr Parker got together on all of this many, many years ago.”

Amy Rosenman, MD: “Bill Parker and I have been colleagues and partners in medical practice for the last 23 years. We met when we were mere children.

I developed an interest in urogynecology over the last 15 years as he was developing his interest in laparoscopic surgery and some five, six years into that process, we realized we should merge our interests and focus on laparoscopic approaches to urogynecologic problems. In that realm, we were teaching a fellowship at Harbour UCLA and he became a lot more active in urogynecology and decided that he should write a book because he had already successfully written A Gynecologist’s Second Opinion and that we should collaborate on it. As I have mentioned to others, it’s harder than birthing a baby, but we did collaborate and write this book with the goal of educating patients. It is a resource for patients where, in the privacy and comfort of their own home, they can learn a lot about the conditions of incontinence and prolapse, conditions that have been embarrassing in the past, conditions that really do not have a lot written about them in the lay literature. There was a need and we tried to meet that need.”

Barbara Nesbitt: “Well, I like the part here that says, “answers for women of all ages,” because I think we often think of women later in life having problems with incontinence or a prolapsed bladder and we think that’s just part of aging. But it is not true. It is not part of aging. It is part of something that happens to them at certain ages. But young women have problems, too.”

Amy Rosenman, MD: “The interesting part is, although it is more common as we age, it is not a normal part of aging. The vast majority of older women do not have incontinence and prolapse. But as we age, we have a greater likelihood of having those problems. But you are absolutely right: the problems go way back to the beginning of our reproductive years. They are related to birth injury and we do address that in this book. There are other problems of younger women related to sexual function, issues they are not likely to feel comfortable bringing up unless they understand that there is a relationship and that there are solutions.”

Barbara Nesbitt: “We talked before we came on camera about the fact that this is probably the one area of women’s health that women are the most shy about bringing up with their physicians. They will talk about all or many things but, for some reason, they just don’t want to talk about the fact that they have a problem, say, leaking urine, and you can’t get it out of them unless they bring it up.”

Amy Rosenman, MD: “Actually, you can get it out of them easily if you ask. But, as a group of physicians, we have not done our best to make patients comfortable to give us this information. They need to understand in the way the question is asked that it’s a common problem but, more importantly, that there are solutions. Nobody wants to tell you about an intimate, difficult problem for which you are going to say, sorry, you’re going to have to live with it. A lot of women make that assumption because their doctors have not asked about it. I guess there’s nothing you can do about it so I have to live with it. We are trying to bring it out of the darkness and say if you ask and if you ask enough people, if that first doctor does not know about it or does not give you a solution, there are solutions. Pursue it.”

Barbara Nesbitt: “Because we did do an interview about the fact that women should go to someone like you, who is a specialist in this particular area. You do not want to necessarily go to someone who just delivers babies all the time. So now we have a woman in a gynecological urologist’s office. What are the options she has? She’s been diagnosed, she has a problem with incontinence or prolapse. What are some of the options she might hear from you?”

Amy Rosenman, MD: “Basically, the options depend very much on the specifics of the problem. We pride ourselves on being able to specifically identify what kind of incontinence, what is the cause and there are certain evaluation processes that we go through. It has to do with a discussion of the history, we go through a specific physical examination. Sometimes it requires more advanced studies where we do pressure-flow computerized studies, which are painless, by the way. Patients worry about advanced studies, but they are completely painless. My mother had them done at one point and her response was, I’d rather be at the beach, but it didn’t hurt at all.”

Barbara Nesbitt: “But tests always sound scary.”

Amy Rosenman, MD: “They sound scary and painful and these are not painful at all. We have an office procedure where we can actually look in the bladder with a flexible telescope that does not hurt at all and we use local numbing medicines that are not injectable, they are just local gels. We are able to painlessly evaluate the patient completely in the office and, if it turns out their condition is amenable to what we call conservative treatment, that is, non-surgical treatment, we have a complete menu of services available for that. It may be something as simple as fluid control. We have a nurse practitioner who will go over how much you drink. Obviously, if you drink an excessive amount, it’s got to come out. Maybe we need to manage the timing and the quantity. Sometimes it has to do with bladder retraining. We will train the bladder to hold more than a thimbleful, more like a cup or two, and this can be done. We learned it when we two years old, we can learn it again when we’re 50 years old. Not that I’m 50 years old, by the way.”

Barbara Nesbitt: “No, no.”

Amy Rosenman, MD: “We have bio-feedback services where we can retrain pelvic floor muscles. We also use electrical stimulation which, again, doesn’t hurt, it’s like a tension where you feel a little tingle in the pelvic floor and it doesn’t hurt, it just allows the pelvic muscles to contract in women who perhaps on their own cannot figure out which muscles we are talking about. There are other treatments out there, things like an electromagnetic chair, where you can just sit fully-clothed, very much like a chair in this hotel room, and there is an electromagnetic device underneath it that will make those muscles contract.”

Barbara Nesbitt: “I have sat in that chair.”

Amy Rosenman, MD: “It’s amazing, isn’t it?”

Barbara Nesbitt: “Yes, it’s funny.”

Amy Rosenman, MD: “It’s funny but if you can do the kegels independently, we will encourage use at home and kegels are extremely effective. Looking at all women with incontinence, of all types, if you do kegels religiously for six months, 70% will be dry, leaving us only with that 30% who perhaps need more.”

Barbara Nesbitt: “These are all non-invasive, non-painful, with only a little training, pretty much a do-it-yourself type of thing that you can do.”

Amy Rosenman, MD: “They are one-on-one and will greatly improve the outcome if you work one-on-one with a nurse practitioner, a nurse, possibly a physical therapist. But, yes, they do not involve anything surgical and they are covered by most reimbursements.”

Barbara Nesbitt: “The next phase is probably not as invasive as complete surgery, but is there another phase in there?”

Amy Rosenman, MD: “There are minimally invasive approaches now to certain forms of incontinence and the next step up would be something like an injection, a collagen injection or a Durasphere injection. These injections are done through a cystoscope. As I mentioned, we do cystoscopy in the office. These injections could be done in some doctors’ offices. We happen to use a surgi-centre because it’s a special scope, not because it’s painful. It’s done again with the local gel and little bit of sedation. Patients go home the same day. Our oldest patient was 97 years old and she did phenomenally. It changed her life. It allowed her to go out and do things again. Patients of all health can do that. You do not need to be an able-bodied, well person to have collagen injections.”

Barbara Nesbitt: “When it is more advanced than that, we are here at this conference where they have all kinds of procedures that are surgical procedures mostly. What is that level?”

Amy Rosenman, MD: “The next level would be minimally invasive surgery where cuts in the realm of half an inch or less are made. One in the vagina and two just above the pelvic bone, they are each about a quarter of an inch. Through these small openings, needles pass a small piece of nylon-like tape and these procedures come, as you mentioned, in many varieties. There is a tension-free vaginal tape and there is a spark procedure. About five different companies make a variation, but they all come down to the same thing: a gentle sling of nylon-like material under the urethra that is held in place by tissue friction, very gently, it does not elevate. Then, when the patient stands up, it’s a backboard so that when they cough or sneeze and those muscles in the abdomen contract, it just gives a little gentle tension to that tape that is in place so that during those kinds of activities you do not leak.”

Barbara Nesbitt: “If I was to have this, what would I expect as the time in hospital and how long before I am back to living my normal life? How painful?”

Amy Rosenman, MD: “I am really glad you asked. Painful during - this does require an anesthetic. It has been described with a local anesthetic, but I think it requires like an epidermal or a short general anesthetic. But this is an out-patient procedure. Patients will go home the same day. They will have soreness, maybe a little bruising, in the area around the pelvic bone.”

Barbara Nesbitt: “But there are some nice mild painkillers.”

Amy Rosenman, MD: “They are taking oral pain medicine, they are comfortable, they are eating normally but, most importantly, they are urinating almost normally, maybe a little slower than before, but they are emptying their bladders, which is a big change from previous surgeries. I am saying the patients do not need to use a catheter - this is one of their biggest worries. Am I going home with a catheter? No, you are not going home with a catheter. Will I have to insert my own catheter (self-catheterization)? No, not with this procedure. Less than 5% or 10% of the patients have anything to do with a catheter. So that makes it very, very nice for the patient. How long should they be off? We advise our patients to take one to two weeks off from work, but that may be an over-estimate because most go back in a week.”

Barbara Nesbitt: “If you are in an office position or you are doing something that is not labor-intensive?”

Amy Rosenman, MD: “We are very specific about the limitations. After this kind of surgery, you cannot lift anything more than ten pounds for two months because that could dislodge or move the sling a little bit. Horseback riding you could probably resume in two weeks. Tennis, two weeks.”

Barbara Nesbitt: “This is a wonderful recuperative time.”

Amy Rosenman, MD: “Patients love this because it resolves the problem, it solves their issues without pain and suffering and without laying them up for any amount of time.”

Barbara Nesbitt: “What is a rough estimate or guess be at the success rate on this?”

Amy Rosenman, MD: “We don’t even need a rough estimate. It’s been well-studied. It’s in the realm of 90% success.”

Barbara Nesbitt: You cannot beat that.

Amy Rosenman, MD: “You can’t beat that. It’s as good as any previous procedure ever described and better than most, so we are really happy about that, too. Now it’s been around in this country since 1997 and in Europe for ten years prior so there is enough long-term experience to feel very safe and very comfortable with it.”

Barbara Nesbitt: “What we are telling these ladies today is find the right doctor. Go to your doctor who, obviously if your primary care doctor is your ObGyn, talk to him, tell him you would like a referral to a urogynecologist and they are so busy, they are happy to have you go, I would think.”

Amy Rosenman, MD: “Yes, and because they cannot all provide the menu of services that are necessary. You do not want to get what your doctor knows, you want to get what is right for you. You want to get someone who is truly versed in all of the possibilities.”

Barbara Nesbitt: “So you are going to go to someone just like Dr. Amy Rosenman and she is going to take care of your urinary problem and then you are going to go back to your doctor you’ve gone to for many years of your life and . . .”

Amy Rosenman, MD: “We work in conjunction with a lot of our local physicians. Some of them just want to send patients for conservative treatment. Some of them do some of the operations, that’s fine. We are happy to fill that gap.”

Barbara Nesbitt: “But if you feel you have a problem, investigate all of the areas.”

Amy Rosenman, MD: “Investigate it, get another opinion, the last book, A Gynecologist’s Second Opinion. We are really interested in patients being well-educated and we were talking before about how the patient makes a decision. It’s a collaboration. You educate yourself, you make sure your physician can give you all the options you need and help you make the best decision for yourself.”

Barbara Nesbitt: “I am in a unique place because I have a son-in-law who is a surgeon in the town I live in and I do nothing but associate with physicians like yourself. I am in a unique place because I could call you and you would help me. But everyone has the right to ask for and receive.”

Amy Rosenman, MD: “Yes, and we were hoping with this book, The Incontinence Solution, to give women the fodder to have the discussion with their physicians. They will go in as educated patients, educated consumers, and be able to say, who can help me with this, who can help me with that? They have the information right in front of them.”

Barbara Nesbitt: “Well, I thank you very much, Dr. Rosenman, and we’ll have the book and access to chapters and we will also have a link to your website with Dr. Parker and a way that you can buy the book from Amazon right off of our website.”

Amy Rosenman, MD: “Thank you so much.”

Barbara Nesbitt: “Thank you.”