Discussing Bladder Issues in the No Stigma Zone

Bladder issues -- ranging from minor annoyances to major life disruptions -- are common. Talking about them is not.  Don't let an unwarranted stigma attached to these issues stop you from getting the information and treatment you need to improve your quality of life.

In this episode, host, Jonathan Fialkow, M.D. welcomes Baptist Health urologist Lunan Ji, M.D. to talk about the symptoms, causes and treatments for common bladder problems. Find out the facts on overactive bladder, stress incontinence, frequent urinary tract infections and how stress and working from home during the COVID-19 pandemic can affect your bladder health.  

While the focus is on female patients, there's helpful information for men as well.  

Transcript

Announcer:

At Baptist Health, South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist HealthTalk Podcast, where our respected experts bring you timely practical health and wellness information to improve your family's quality of life.

Dr. Jonathan Fialkow:

Hello Baptist HealthTalk Podcast listeners, I'm your host, Dr. Jonathan Fialkow. I'm a practicing preventative cardiologist and lipidologist at the Miami Cardiac and Vascular Institute at Baptist Health, South Florida, as well as chief population health officer. We started this podcast to address the kinds of health questions my colleagues and I often are asked by family and friends. Unfortunately, some of these topics may have a stigma attached and people don't always feel comfortable discussing them. This podcast is a no stigma zone, and we will dispel the myths and provide information you may need to be healthy and have a better quality of life.

Dr. Jonathan Fialkow:

And today we're talking about bladder health and some of the more common problems that affect the bladder in both men and women, though the bulk of this conversation will be around female related bladder problems. These issues can range from minor annoyances to actual major life disruptions.

Dr. Jonathan Fialkow:

My guest today is Dr. Lunan Ji, a urologist with Baptist Health who specializes in voiding dysfunction, female pelvic floor medicine, and reconstructive urology. Dr. Ji will address some of the causes and symptoms of bladder dysfunction and tell us what the treatments are available to provide this relief. Welcome to the podcast, Lunan.

Dr. Lunan Ji:

Hi, good morning, everyone. Thanks for joining us.

Dr. Jonathan Fialkow:

So again, broad topic, like most of my podcasts, again, as we talked about prior to recording the bulk of the interest, especially in older people is in women, which doesn't mean we'll denigrate a man's concerns regarding bladder health, but let's talk about what is the bladder, what does it actually do? We see the term, we see advertisements out there for bladder medications. Basic explanation, what is the bladder, what functions the bladder perform in our body?

Dr. Lunan Ji:

Yeah, so the bladder is an organ, like any of our other organs, like a kidney or liver, and it's located in our pelvis. It's composed of smooth muscles. So the same time of muscles that's around your intestines. It has really two main functions. The one is to store urine when we're not urinating. Then the second one is to empty urine or to void is the medical term for that, when we want to go on number one. Really about 98% of the time it's in that storage space. So, you can have issues with a storage kind of when it's storing the urine, it's not doing that properly. Then sometimes you can have problem with it emptying as well. And it's connected to the kidneys by two tubes, that's called a ureter. So your kidneys actually make the urine and feed it to the bladder. So, then [crosstalk 00:02:58].

Dr. Jonathan Fialkow:

So our blood circulates through the kidneys, they filter out toxins, things we want to get rid of-

Dr. Lunan Ji:

Exactly.

Dr. Jonathan Fialkow:

They help us get rid of excess water, but the bladder as you articulated very well, it's not a passive bag. It's an active organ. Talk a little bit about, like you said, the function is to collect and to help remove. What are the functionalities of the bladder in terms of how it provides those services to our body?

Dr. Lunan Ji:

Yeah. Like you mentioned, Jonathan, the bladder, along with the liver and our intestines are one of the three major organs to get rid of toxins and excess fluid from our bodies. It doesn't work on its own, like any of our organs, it doesn't work in isolation. Like I said, it's connected to the kidneys, so if you have our issue with your kidneys, that can certainly affect your bladder and vice versa.

Dr. Lunan Ji:

More importantly, I think, a lot of people are not aware is how our brain and our nervous system connects to our bladder. So the key controller system or the CPU for our bladder, it's really actually in our brain and connecting down through our spinal cord, through our nerves, and that controls the whole, "Hey, it's time to relax, and it's time to empty the bladder," to do some work and squeeze.

Dr. Lunan Ji:

There's actually a lot of receptors in the bladder. There are bladder receptors that tell it to, here's the time to relax and calm down, and time to contract and work and empty the bladder. As we go on later in this podcast, we're going to talk about when there's that imbalance between those two signals that can lead to a lot of issues.

Dr. Jonathan Fialkow:

So, that's great information. Again, it's a lot of how we address and we'll approach a patient with a bladder problem. But now let's get to some of the clinical things for the listeners to identify perhaps in themselves or their loved ones. So really what are the more common symptoms that one might experience that would be signs of a bladder problem, which they may or may not recognize as relates to the bladder. What are the more common symptoms people get, whether it's age-related, or lifestyle-related, what are you seeing?

Dr. Lunan Ji:

Yes. Some of the most common symptoms are, do you have pain or burning with urination. If you have a foul smelling or discolored urine, even if you find yourself rushing to the bathroom all the time, and sometimes you may not even make it in time and you leak urine. If you're going too frequently, and I'll say, if you're going more than every hour or so, I would call that frequent. And if you're waking in the middle of the night to urinate, and it's particularly doing that more than once or twice per night, that's fairly abnormal. It can really, seriously disrupt your sleep. Do you feel like after, your stream is not very strong, or even after you go, you feel like you had to go again quickly and you didn't get everything out.

Dr. Lunan Ji:

Of course, if you see blood in the urine, that's a pretty serious concern. You need to see a urologist fairly quickly, if you do see that. Or if you feel like, particularly for our female audience out there, if you feel like your bladder's dropping down, and you feel like a bulge in the vaginal area, that could be a sign of what's called vaginal prolapse.

Dr. Jonathan Fialkow:

So when, so again, I'm glad we're starting with the clinical symptoms for people to recognize. Does everyone who experiences any of those symptoms right away have to be considering a bladder problem and see urologist. Are there certain, if you will, normal times, not necessarily normal, but less dangerous times when, for example, you might have a painful urination or where you might have a little incontinence. In other words, is there a degree of those symptoms that warrant further investigation from the onset or there are times when someone might say, let me see where this goes before I get care? How would you address that?

Dr. Lunan Ji:

I think we've all, both men and women, we've all have like one episode of sometimes when you go to the bathroom, maybe you held it in for too long, and it feels like a little burning, but if it doesn't come back over and over again, you don't see some of the other symptoms, like pain in your pelvic area and stuff like that, that's probably okay. That probably does not require additional investigation. Or it also depends a lot on how much the symptoms bother you. For instance, you and I have patients that may leak a little bit of urine when they're doing really strenuous exercise and that happens very rarely and it doesn't really bother them that much. But then I have other, athletes for instance, that they could be young, fairly young patients and they leak just a little bit and that's significantly bothersome to the patient. So really have to tailor this to each individual patient as well in terms of.

Dr. Jonathan Fialkow:

Are most of these symptoms, quality of life issues, which in and of themselves are important. You did mention, for example, blood in the urine, which of the ones might be more problematic as a potential sign of something more significant?

Dr. Lunan Ji:

Well, I think, some of these symptoms are actually fairly nonspecific. So I think even, something like rushing to the bathroom that could usually indicate overactive bladder, but that doesn't necessarily. A lot of other things, it could be urinary tract infection, so if that's not treated fairly quickly that can spread to the kidneys or even to the blood and lead to more serious infections sometimes. So I do think a lot of them do need to be investigated further or something like bladder cancer can cause blood in a urine, but can also cause symptoms and mimic some of the more benign conditions, like overt activity. So I think it is important to talk to your physician if you are experiencing some of these symptoms.

Dr. Jonathan Fialkow:

Absolutely take home points, feel free to certainly, your primary care doctor, these should be discussed at any level. Then the higher acuity things can obviously be referred to a urology, which we'll get to.

Dr. Lunan Ji:

I just wanted to mention-

Dr. Jonathan Fialkow:

Go ahead.

Dr. Lunan Ji:

... something that you mentioned about not being, some of these problems can be fairly embarrassing to talk. I find a lot of patients can be embarrassed to even talk to their health care providers about some of these issues, particularly involving incontinence. So, I do want to let our audience know that there is absolutely no shame in these and these are very common problems and there are good treatments out there. So I think it is important to get over that stigma. We're here to help you to do that here at Baptist Health.

Dr. Jonathan Fialkow:

Well said. So let's go through a couple of the conditions. Again, people experience them. We hear about them. We see them advertised on TV for treatments. Let's start with overactive bladder, explain, specifically what are the signs or symptoms, what causes that, and then how you would approach a patient who may have an overactive bladder.

Dr. Lunan Ji:

Yeah. So overactivity is really, the way I like to think of it, remember when I talked about the balance, keeping the bladder calm and for it to do some work. And then it's really that signal, telling the bladder to relax when there's a lack, there's not enough of that, and there's an imbalance with it, so you get symptoms like rushing to the bathroom, you may not make it in time. You had to wake up rushing in the middle of the night to go urinate. It's almost like a muscle spasm. Because the bladder is a muscle and when you get a muscle spasm, unfortunately if that muscle is full of a urine, you may have some leakage or experience that rushing symptom sometimes.

Dr. Jonathan Fialkow:

And how would you approach a patient who might find that to be problematic?

Dr. Lunan Ji:

There are a number of treatments for it. It could be as simple as changing your behavior. For instance, there are certain bladder irritants and these may not be the same for different patients. We have to individualize that as well. It could be something like coffee, spicy food, could be as simple as avoiding some of these or monitoring our fluid intake and when to drink that. That might be enough for some patients, but there are also some medications out there such as, they're essentially muscle relaxants for the bladder, that could be helpful for some patients. Then for more cases that don't respond well to that, we can do other stuff like injecting Botox into the bladder. People are quite familiar with Botox injections.

Dr. Jonathan Fialkow:

Another Botox use, that's great.

Dr. Lunan Ji:

[crosstalk 00:10:47] Cosmetic purposes, but the way Botox, it works is it's a muscle relaxer and it paralyzes the muscle and in small doses, that can be a very powerful relaxant. And there are more advanced treatments such as, almost like an electronic acupuncture technique, as well as spinal cord stimulators that could be used for more advanced patients as well.

Dr. Jonathan Fialkow:

Great. So obviously what you're saying, it's this holistic approach to the patient. You get a history, you figure out how bothered they are by it, you might start with just lifestyle interventions, but there are other ways to approach these patients too, to help them with those symptoms. I assume that's how you and your team approach those patients.

Dr. Lunan Ji:

That's exactly. My philosophy is, even though I'm a surgeon and I love to operate, is always to try to do the least invasive thing possible first to see if that works before we move on to more invasive options.

Dr. Jonathan Fialkow:

And even medications, there's ways to-

Dr. Lunan Ji:

Exactly, yeah. And these are medications people, patients have asked me are these like antibiotics, you take it a few days and these are chronic medications and some of them do have side effects. I think we have to weigh the benefits versus the cons as well on some of these.

Dr. Jonathan Fialkow:

Let's talk about stress incontinence, again, hopefully not a stigma for both our conversation and people in the community. Talk a little bit about what might predispose someone to stress incontinence and similarly, what are the ways you would address it to offer the patient relief?

Dr. Lunan Ji:

Yeah. So let's talk about a little bit what stress incontinence is. So stress incontinence is really when someone stands up, when they're coughing, anything that increases abdominal pressure, could be during exercise or walking, or even something as simple as laughing, and you leak urine. It is more common in women. About one in three women actually suffer from some type of stress incontinence. It can occur in men as well, but usually more after some type of prostate surgery or treatment for prostate cancer. Again, there could be a lot of stigma associated with this. Some patients need to use multiple pads a day and they do that as a treatment for that. But there actually are some very good treatment options available for stress incontinence.

Dr. Jonathan Fialkow:

Great. Great. Let's talk a little bit about pelvic floor exercises mentioned, and something that again is out there a little bit. What are they, and what would be indications for them, obviously, arguably, that's good to do all the time, but what would be the medical conditions where that may benefit and how do you go about teaching people pelvic floor exercises?

Dr. Lunan Ji:

Yeah, so the pelvic floor exercises, also no known as Kegal exercises. We hear that in the news quite a bit. People saying, you should be doing that all the time, but it's really been shown to be helpful in stress incontinence. It does help in up to about 70% of women that have stress incontinence. Particularly, in younger women that they may be postpartum or just had a child recently, and they can experience a period of stress incontinence, in someone who's 20, 30 years old. That can be very distressing. But usually pelvic floor exercises can be very effective there.

Dr. Lunan Ji:

Something I do want to mention though, is that one of the common mistakes I see is patients not doing the pelvic floor exercises correctly. I see a lot of people working out their buttock muscle or their abdominal muscle. That's not what's keeping at the pelvic floor. Something that talking to a health care provider can help is to help you identify the correct muscles to be exercising.

Dr. Jonathan Fialkow:

Next on our hit parade. It's always just so common, and again, not only well understood, so again, appreciate that. You had mentioned early on UTIs, the burning in the urine and whatnot. When people, women more commonly than men obviously, have frequent UTIs, what can it be a sign of? What do we address? Is a recommendation, just stay on antibiotics forever and good luck. What are the concerns about that?

Dr. Lunan Ji:

Yeah, so I mean, UTIs is a very common problem. And it is more common in women than in men. There are anatomic reasons for that, the urethra, which is a tube that leads from the bladder to the outside and carries the urine out from the bladder that's significantly shorter in women compared to men. And that anatomic difference predisposes women to more frequent UTIs and allows the bacteria to travel into the bladder, to be easier to get there. Most of these bacterias come from our fecal bacteria, from our number two and stuff I suggest to my patients, particularly female patients is to when they're wiping, always wipe from front to back and not the other way around. Women that sometime develop UTIs frequently after sex, to always void after sex. So there are certain treatments we do offer, but I think if someone's having more than, I would say two UTS per year, two or three UTIs per year, I would call it that very frequent and recurrent UTIs. And you really, I think that does warrant being looked into further.

Dr. Jonathan Fialkow:

Lunan, if you could also speak to the concerns about chronic antibiotic use or more importantly, chronic inappropriate antibiotic use.

Dr. Lunan Ji:

Yeah. So, that's becoming a really, it's all physicians, so that's really becoming a major issue in terms of the antibiotic resistance out there. So, we're seeing more and more resistant infections in the kidneys and bladder and sometimes something that used to be able to treat it with just a pill, because you were seeing these highly resistant bacterias. Sometimes the patient needs to be admitted to the hospital just to get an IV put in to get a specialized antibiotic. So, a lot of that stems from overuse of antibiotics and when it's not needed. I like to always get a test before I start the patient on antibiotics. I recognize that's not always possible to really confirm the patient does have a UTI before treating them with antibiotics.

Dr. Lunan Ji:

Then more importantly, also treating them with the appropriate antibiotics. That's almost like a targeted therapy that works for that particular bacteria. Because sometimes there could be other diseases and symptoms, like overactive bladder. For instance like UTIs can cause overactivity, but that could, is it overactive bladder or UTI. And sometimes, I've seen patients that have been treated with antibiotics over and over again, and they ended up having something else like interstitial cystitis or something else. There not being something that antibiotics would even work for.

Dr. Jonathan Fialkow:

So going back, if a woman has relatively frequent UTIs, especially in the short period of time, it might be a sign of something either more important that should be checked out, or doesn't want to just go through a course of just keep taking antibiotics regularly through the year for the reasons we discussed.

Dr. Lunan Ji:

Exactly.

Dr. Jonathan Fialkow:

I think that's taken.

Dr. Lunan Ji:

And also when I see a patient that comes in for that, I don't always assume that it's actually UTIs they're having. I would say it's probably 50, 50, and sometimes it is actually, they're having frequent UTIs and there are certain things investigations and treatments we can offer, but sometimes it's some other disease that was mimicking that as well.

Dr. Jonathan Fialkow:

I got two more on my hit parade for you. You did mention early on again, in your introductory comments, let's talk about bladder or pelvic organ prolapse. What would predispose a woman towards that? What are the signs or symptoms of it? And again, how would you address it in your specialty practice?

Dr. Lunan Ji:

So let's just talk about what pelvic organ prolapse is. So it's really, the vagina is surrounded on three sides by, on top of it is the bladder. So above that is the uterus, and the cervix, and below that is the rectum. So any of these organs can what's called prolapse, fall into the vagina when we lose that supporting structure, when that weakens over time. It's almost like a hernia into the vagina. It's a good way I like to think about it. And it is more common as we age, as our supportive tissue becomes weaker. As well as, women that had particularly in multiple vaginal birth that does also weaken that tissue as well. And there are definitely genetic components as well. Some women that can deliver four babies through the vagina and never experienced this issue. I've seen patients also that never had any issues, never had a vaginal birth and they have significant pelvic organ prolapse.

Dr. Lunan Ji:

Sometimes when something like the bladder that comes down that can actually cause an irritated symptoms and mimic overactivity. Sometimes when the rectum, for instance comes down that can lead to all sorts of issues like constipation and it can be very bothersome to patients when they have something coming out and almost like a weight there all the time.

Dr. Lunan Ji:

Again, that usually... Again, the first line treatment for very mild prolapse is again, pelvic floor exercises, but there are a variety of very good surgical options available, including robotic options. Options that involve mesh or using your native tissue.

Dr. Jonathan Fialkow:

Okay. And then lastly, blood in the urine, and specifically when we're talking about some of the components of that. What would we be concerned about and what would be the kind of evaluation and or testing that someone might have?

Dr. Lunan Ji:

So in a number of things can cause blood in the urine, it can be coming from the kidneys or the tube of the kidneys or from the bladder. It could be caused from something like a UTI can cause blood in the urine or kidney stones. But the thing we're really concerned about, we don't want to miss, is some type of cancer in the urinary tract system. Whether it's bladder cancer or a cancer in the kidneys. So, whenever you see actual blood in the urine, that definitely warrants further investigation. But there's something that's more hidden what's called microscopic hematuria or blood that you can only see when you look under a microscope. And sometimes that can be an early sign of the issue as well. We do, based on how much blood we see there, what type of investigation we need to do for that.

Dr. Jonathan Fialkow:

We don't want people to think if they're told they have what we call microscopic hematuria, they give a urine sample to the doctor, comes back with some blood cells, or they actually are frank blood and urine, it doesn't mean it's cancer. We don't want people to [crosstalk 00:00:21:40].

Dr. Lunan Ji:

Right, right.

Dr. Jonathan Fialkow:

Right, right.

Dr. Lunan Ji:

I would say the majority of time it's not, but it's enough that it does put you at a higher risk for it, that it warrants further.

Dr. Jonathan Fialkow:

It warrants a further evaluation, okay. So you gave us great education about the structure and function of the bladder and as well as various complaints and medical disorders that lead those complaints, those treatments, talk a little bit about what makes your practice, your specialization unique, specialized for a lack of better way to put it. What are the processes that you bring to the table in evaluating patients and women in this particular capacity that differentiates it from whatever else maybe out there?

Dr. Lunan Ji:

Yeah. So, I do have additional training in, there's a lot of areas we talked about, from pelvic organ prolapse to, recurrent UTIs, as well as incontinence, for both men and women. But we probably maybe a little more of a focus on the female side. So I do have that additional fellowship training after residency. We do also are trained to use specialized investigative tools as well, such as urodynamic testing, for instance, where we could look at, it's the way I explained that to patients, it's almost like an EKG for your bladder. It tells how well it's working, when it's filling or emptying, and it can really, because something that you may have heard going back to overactivity, some of the symptoms of overactivity could be, is it caused by pelvic organ prolapse, is it caused by something else or could it be some other issue. Some of these [inaudible 00:23:21] will show investigative techniques can help us differentiate [inaudible 00:23:27].

Dr. Jonathan Fialkow:

So not every patient needs a medication, not every patient needs a procedure. You did mention that. And just to wrap up, we are in this COVID-19 pandemic, people's lifestyles have changed drastically, whether it's overeating, not exercising, a lot of stress. Are you seeing in your practice, any shifts in the number of patients coming in or the kinds of problems you're seeing people coming in with as a result of lifestyle changes that might've been negatively impacted by the pandemic?

Dr. Lunan Ji:

Yeah, that's a great point you're bringing up, Jonathan. We have. We have people who used to go into work and had a regular routine, that's really being disrupted. You may have someone who's sitting in their desk drinking five cups of coffee a day, that's completely changing up their routine. And as well as we all are aware is everyone's under a tremendous amount of stress and there is definitely that mind body, it may sound a little cliche, but it's true. We have increased stress, increased anxiety. And because our bladder is controlled by our mind that can lead to a lot of irritative symptoms, overactivity rushing to the bathroom or changes in their bathroom habits. The good news for that, for the majority of those patients, we can identify what are the behaviors that are causing those issues and help those patients adjust that. And we don't need to start them on a medication or any type of surgical procedure that can really benefit those patients.

Dr. Jonathan Fialkow:

Similarly, like many other medical disorders, the lifestyle does impact the medical condition and extensively a way to correct the problem without medications and surgeries and various other things which might otherwise be indicated for more significant problems. So again, the points have been great. I always love when I have podcast guests that I learned from, and I certainly learned from this one. I think, again, women in particular for the purpose of the podcast should know we do have resources for them like Dr. Ji who again, voiding dysfunction, female pelvic floor medicine, reconstructive urology. These are great therapies for relatively common problems. But again, the holistic approach is I think what's important looking at risk factors, lifestyle adjustments, other means of improving person's life and avoiding these problems or improving these problems as been well stated by Dr. Ji. Any other comments you want to make before we wrap up anything we left out that you think is pertinent, and certainly we can bring you back for other topics this is just a snapshot of what you do, and what a bladder does.

Dr. Lunan Ji:

I know we focus a lot on the female side of the issues, but a lot of these issues are not just isolated to women as well. Just to quick statistic I want to bring up to you for instance like overactivity, overactive bladder is not quite as common as stress incontinence. It affects about one in eight Americans and the prevalence of that, it's actually similar among men and women. So you can have a lot of similar issues among men and women. Of course the etiologies can be a little different, one common problem on men is enlarged prostate for instance, if that's not treated can actually cause the bladder to compensate to overgrow and lead to overactivity as well. So, I do want to address our male audience out there as well that a lot of these bladder issues can affect men as well.

Dr. Jonathan Fialkow:

Very important topic. And I think it will be well received. So we will have you back. Thank you very much, Dr. Ji. Thank you to Carol Higgins, our producer and Steve Pipho, our sound engineer who make all this sound worth listening to, and letting us be able to listen to our contact and our guests expertise. As usual, if you have any thoughts, ideas for future podcasts, any other comments, please email us at BaptistHealthTalk@BaptistHealth.net, that's BaptistHealthTalk@Baptisthealth.net. Thank you for listening and stay safe everyone.

Announcer:

Find additional valuable health and wellness information on our resource blog at Baptisthealth.net/news. And be sure to interact with us on our social media channels for live and upcoming events. This podcast is brought to you by Baptist Health, South Florida, Healthcare That Cares.