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Interview with Dr. Sharon Knight: Incontinence in Women

Hear a Patient Power interview with Dr. Sharon Knight, gynecologist at the UCSF Women's Continence Center. Dr. Knight talks about the causes, diagnosis and treatments for incontinence, which affects about 25 percent of women in their reproductive years and 50 percent of postmenopausal women.

Interview Transcript

Andrew Schorr:

Hello, and welcome once again to another edition of Patient Power. I'm Andrew Schorr broadcasting with yet another expert from UCSF Medical Center. Today we have Dr. Sharon Knight. Dr. Knight is a urogynecologist at UCSF. She's an assistant clinical professor there, and she helps women, particularly with issues like incontinence.

Dr. Knight, thank you so much for joining us. Incontinence is a pretty prevalent condition among women, isn't it?

Dr. Sharon Knight:

Absolutely. So, up to 25 percent of women in their reproductive years and about 50 percent of women who are postmenopausal will experience incontinence at some point.

Andrew Schorr:

Now, when women experience incontinence, I imagine they can be embarrassed, and it can limit their activities. I mean, I've seen the TV commercials with one kind of incontinence. I think it's the urge incontinence, the gotta go, gotta go, those commercials, and even there you see women who feel there are things they're reluctant to do, and they always need to know where the bathrooms are, or there are people who maybe just don't go out or give up some activities because of that incontinence or others.

Dr. Sharon Knight:

Absolutely. I think that incontinence affects women's lives in many different ways. It often prevents them from exercising; that's a big thing that they stop doing; and that's something that I think really helps keep people healthy for their whole lives. So, if incontinence is stopping you from exercising, it's really affecting your life in many different ways.

The other thing that we hear commonly from women is one of the first things they stop doing is socializing or going out and spending time with friends, and often many of them feel like they can't travel at all because they don't want to spend the night in a place that they're not really familiar with and where they may be away from where they know the bathrooms are. So, I think it affects them on a social level too, which I think as we get older and even when we're young this is a really important part of our lives.

Incontinence Types and Treatments

Andrew Schorr:

Dr. Knight, tell us first of all, what is incontinence, and what are the different types?

Dr. Sharon Knight:

Okay. Urinary incontinence is basically the involuntary loss of urine. In other words, loss of urine when a patient or person is not in the bathroom ready to go to the bathroom. The most common type of incontinence is stress incontinence, which is incontinence that occurs with any kind of increase in abdominal pressure. So this is leakage with coughing, sneezing, exercising, laughing, and those kinds of things. The other most common type of incontinence is urge incontinence, and this is where patients feel a very strong urge to get to the bathroom. They really have to rush to get there and often will leak before they make it. Patients can also have a combination of those two things, and we call that mixed incontinence. If you look at urge, stress, and mixed incontinence those three things will account for about 95% of the cases of incontinence that women may suffer from.

Andrew Schorr:

Now, the point is today, you as a urogynecologist have a lot you can do, yet I understand that few women, and we're talking about millions of women, few actively seek treatment. Now, traditionally if you went to the urologist, it used to be always a man or most often a man, who were dealing with a lot of other issues, you know, prostate issues and things. I can understand that wouldn't be the most comfortable environment for women. At UCSF now you have a Women's Continence Center. So tell us about what you have to offer and what the environment's like, and can you help?

Dr. Sharon Knight:

Okay. Like you said, we have a continence center, and this is really just all about women. So, we have urogynecologists. There are also some issues that we work closely with, colorectal surgeons with because many women who have incontinence may also suffer from fecal incontinence where they lose their bowel movements, and we also have a very busy physical therapy program here.

So I think a few things have made women not come in for treatments in the past. One is just being embarrassed like you said before or thinking there aren't treatments available. Another thing that has stopped women many times is that I think people feel like, 'Well, I don’t really want surgery,' and a lot of women think that that's the only option available.

We actually have many, many different conservative options. Like I alluded to before, we have a physical therapy program using pelvic floor exercises and using a technique called biofeedback to learn how to do those better, and many women will improve. We also have medications, which help many women. Other options include devices, so we have things like pessaries and urethral inserts, so either vaginal or urethral inserts, that may help some women with incontinence. Lastly, we have surgery. What I always tell patients is that surgery is really a personal choice. So even though incontinence is a big issue and may really affect your quality of life, we're never going to tell a patient that they have to have surgery, so this is their decision, and they can try any of the other therapies first.

Andrew Schorr:

As far as the environment, though, I imagine as you said it's really for women, so it seems like a safer space, if you will.

Dr. Sharon Knight:

Absolutely. Like you talked about before, in some urologist's office you might go in, and really the focus is towards prostate cancer, and that's what the pictures on the wall are about, but I think that our practice is really geared toward taking care of women, and fortunately I think many practices in the country have taken this approach, so I think that women can feel comfortable coming in and talking about these issues.

Andrew Schorr:

Dr. Knight, I understand that your center, the UCSF Women's Continence Center, has really been award winning in that back in 2004, we should point out, it received the first annual Continence Care Champion award from the National Association for Continence. So, you've been at sort of the leading edge of a movement to help women come forward, feel comfortable, and bring together a team that can help with a variety of treatments.

Dr. Sharon Knight:

Absolutely, and I think that has been one of our big goals, which is just to get the word out to women that there is help for this kind of problem. Like we talked about before, women who have incontinence often suffer from many other issues such as fecal incontinence or pelvic organ prolapse, and we have built a center where we basically have the full breadth and depth of different treatment options for these things and basically have also made it so that we have a multidisciplinary approach where we have doctors from different disciplines when needed to help with these other issues.

Andrew Schorr:

Now, you mentioned physical therapy. You know, I think usually when we think of physical therapy it's that somebody needs help walking or some movement after they've had injury, but you're actually talking about physical therapists who specialize in treatments related to the bladder.

Dr. Sharon Knight:

Exactly. So, the pelvic floor muscles, or the levator ani muscles, are very important for both pelvic support and for continence, and these physical therapists focus specifically on this area teaching patients how to basically make these muscles stronger. The other thing that we know is that often if other muscles are weak that it may also help to strengthen the abdominal muscles or evaluate other muscles that may be contributing. So, I think they take that kind of approach.

Health Issues Associated with Incontinence

Andrew Schorr:

I want to ask you about two different age groups because I think the situations could be different. First let's start with older women because I know it can be more common there. You know, they say, 'Well I'm just going to live with it," but you've told me that there can be a connection between incontinence of at least one type and maybe a very serious problem in older people that could lead to mortality even, and that's falling. Explain that.

Dr. Sharon Knight:

Right. So, a study done by my colleagues here at UCSF showed that for women who have urge incontinence there is a significantly increased risk of falling and getting a hip fracture, and so there are other big medical ramifications to not seeking care for this type of incontinence.

Andrew Schorr:

Let's talk about younger women. So, there's a woman, you know, she's in her 20s or 30s. She has a baby or who knows maybe even a multiple pregnancy, and things are not quite the same. She goes to the gym or works out or coughs or sneezes, and there's incontinence, and that's unnerving. What are the treatments that are available to them so that they can get back to a normal life?

Dr. Sharon Knight:

Right, so I think the same treatment options are available. Many of those women, often if we rehabilitate their pelvic floor muscles like we were saying, will have improvement. I think you bring up another very interesting topic just about pregnancy and childbirth, and this is something that I think a lot of research is being done in this area right now because we know that there are some women who seem to have an increased risk of incontinence or other pelvic floor disorders after pregnancy and delivery, and the interesting thing is that it's not just about the delivery mode. A lot of it is about pregnancy itself, and what we don't know yet is which patients may benefit from changing their delivery mode.

For example, there are some studies that suggest that in women who already have incontinence while they're pregnant that they may not have any benefits even if they have a C-section, so they may have just a high a risk of having incontinence from having a C-section versus a vaginal delivery, and I think this is a really important topic that's being discussed a lot right now, and unfortunately we just don't have a lot of the answers yet.

Andrew Schorr:

Now, many women of course, and certainly the women who have gone through pregnancy, they're going pretty regularly to a gynecologist, but maybe they've been hesitant to bring it up, or maybe their gynecologist doesn't particularly have expertise in this area. What would you say to women to advocate for themselves and then see whether they should see subspecialists like you as a urogynecologist and go the Continence Center to really deal with this problem that maybe they've been living with?

Dr. Sharon Knight:

Right, so first of all, I think just bringing it up to their healthcare provider is the important thing, and I think that many, many of the general gynecologists have training in this area and can at least start with some of the basic treatments. Then I would say if a patient feels like they either aren't getting the therapy that they need or if they haven't improved to the point that they want, that would be the time to then see a specialist.

Andrew Schorr:

Now, sometimes the situations can be complex. Maybe somebody has diabetes, or they have had some kind of nerve damage to the bladder. Obesity I know can come into play, UTIs, and of course changes in pelvic floor muscles. So, it sounds like there are certainly cases where people may have lots of things going on, and they need someone like you to take that kind of specialized but sort of global look at what's going on.

Dr. Sharon Knight:

Right, that is true, and I want to point out one of the things that you just brought up, and that's the issue of obesity. There are a few studies that have come out recently that showed that weight loss can really significantly decrease the rate of incontinence, and I think this is another one of those big, kind of broad healthcare issues that treating your incontinence by losing weight, if that is an issue for a particular person, can really affect your overall health. In overweight patients even small amounts of weight loss. So, in patients who are over 200 pounds, even losing about 20 pounds has been shown to decrease incontinence episodes by up to 50%.

Andrew Schorr:

Wow, so a lot of times you can cover off a lot of health risks or health problems just by getting in shape, exercising that you mentioned I know is so important, and having an optimum weight for you.

Dr. Sharon Knight:

Exactly.

Concerns for Older Patients

Andrew Schorr:

Okay. Now, related to older people, sometimes they may be taking multiple medicines. Can medicines be a problem sometimes where those prescriptions need to be tweaked or looked at to see could they be causing incontinence?

Dr. Sharon Knight:

Absolutely. So this is one of the first things we do when a patient comes in is review their medication list as part of a good history. Many medications can definitely contribute to incontinence symptoms. Just as one example, many older patients have hypertension, and they may be taking a diuretic to treat their hypertension, and diuretics will often make people make a lot more urine just by definition, and that can in patients who have kind of marginal continence issues, it may really kind of throw them over the edge so that they have severe incontinence symptoms. Lots of other medications can contribute to incontinence in different ways, so I think this is a really important thing to review and just see if these can be, like you said, tweaked in some way or maybe changed to a slight different medication to still treat the problem that they have but not cause such an effect on their bladder symptoms.

Andrew Schorr:

Let's just talk about the medicines that have come out for incontinence that may help in one area. Let's say a woman tried one of those at some point. Does that mean that either that's not the medicine for them or that no medicine will work and maybe switching a medicine or a different dosage, could that help, or using it along with some other modality?

Dr. Sharon Knight:

Absolutely. One of the things I always say to patients is one of the reasons that we have so many different medicines is because some work well for some patients, and they don't work well for others, and the flip side is that some people will have side effects with one medication, but they may not have side effects with another medication. So particularly for patients who have urge incontinence, we have quite a few medications available to treat them, and I think even if they haven't had success with one medicine, it's definitely worth trying another one.

Andrew Schorr:

So, for the women who are listening who have been suffering, it sounds like they definitely should seek some consultation because suffering may be affecting who they see, where they go out, not exercising as much or at all; all of that limits their life and their overall health. It sounds like they should come forward, and what you have now at the Women's Continence Center is a place where they can feel more comfortable to do that.

Dr. Sharon Knight:

I can't even say it better than you just said it. I think that the big thing is coming in to get help, and I think there are lots of treatments available, and it affects people's lives in many, many different ways. One of our colleagues here says one of the goals is to make incontinence "cocktail conversation," and I don't know that we're going to ever do that, but I think just making it so that people are willing to talk to their friends about it or bring it up to their families, and these kinds of things. I think the other thing to keep in mind is that one of the most common reasons that patients actually get put into nursing homes or have to start living in a nursing home is because of incontinence, and many times it just gets to the point that their families and they just can't deal with it at home, and so this is kind of the step that's taken. So, I think, for many older patients having these kinds of things controlled and treating these things early can often kind of prevent those kinds of things in the future also.

Andrew Schorr:

Now let's talk to sort of adult children of older people for just a second. So, you know, Mom may be very embarrassed about talking to her adult daughter about it, or if she goes to the supermarket and is buying Depends or one of those other products, and is embarrassed about all that. So, what advice would you give to an adult child on how they could help it get out there for discussion a little more? Do you have any guidance on that?

Dr. Knight:

It's an interesting question, and I think a lot of it many times just depends on individuals' relationships with each other. I guess, you know, for the child who is trying to be not embarrassed about it themselves and just bring it up in a very casual way or maybe even to kind of whatever area they're in try to see if there is a, I guess check out the local options for treatment and maybe even say like, I know about this place where you could be evaluated, to see if they're interested in that, and for all they know maybe their parent has already sought care for it and is already working on those things, but I think maybe just being willing to talk about it is the first step.

Advances in Surgical Techniques

Andrew Schorr:

Right. I think that's great advice. One other area I want to ask you about is certainly in the range of treatment is surgery, but in surgery you all throughout surgery now keep coming up with what you call "minimally invasive" approaches.

Dr. Sharon Knight:

Right.

Andrew Schorr:

So, are there approaches now where people should not be worried about surgery, certainly you go into it with your eyes open, but where it can be done in a much simpler way than before and could be part of the answer?

Dr. Sharon Knight:

Yes. I think our surgeries are getting better and better, and you have to be careful of looking at things that have data, and I think that we're very careful to do that, but many of the surgeries that are available now require very small incisions and are mostly done primarily through the vagina, which tends to lead to a much easier recovery and a shorter hospital stay for most patients. In fact, many times, if the only surgery the patient is having is for stress incontinence, they can often go home the same day and usually back to work even within a week or two, or maybe longer depending on what the situation is.

Then for certain specific types of incontinence, we also have some types of injections where we just use a cystoscope, which is a camera where you look inside the urethra and bladder, and that procedure can be an outpatient procedure that literally takes about five minutes. So I think that even though surgery for many people can kind of be scary, I think things have gotten much simpler and much more straightforward and less risky for the patients.

Andrew Schorr:

Well I think our key message today is that first of all there's no reason to suffer, yet millions of women do, and it limits their lives, and it can cause complications in other health areas. So, if you're listening, listen carefully, and I think there's tremendous impetus now to go get care, and it sounds like as a model center the UCSF Women's Continence Center really can offer you in a very comfortable way a full range of options.

Also since, as you mentioned Dr. Knight, some women could be dealing for instance with mixed incontinence, or they have other conditions or medications they're taking that could be part of the cause. To see someone like you and your team that are specialized in this can really help people know what they're dealing with, get an accurate diagnosis, and then understand what's the full range of treatments. Well, thank you so much Dr. Sharon Knight for being with us and helping us understand incontinence in women and offering some suggestions on how people can get the right diagnosis and the right care. Thanks so much for being with us and all the best to you.

Dr. Sharon Knight:

Thank you very much, and the same to you, Andrew.

Andrew Schorr:

Yes, ma'am, and for more information about the physicians and services, please call the UCSF Physician Referral Service, and that's a very simple number, toll free 888- 689-UCSF, 888-689-8273.

I'm Andrew Schorr. You've been listening to Patient Power brought to you by UCSF Medical Center.

Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Recorded February 2008

 

Reviewed by health care specialists at UCSF Medical Center.

This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.

Related Information

UCSF Clinics & Centers

Women's Health Center

Women's Continence Center
2356 Sutter St., Fifth Floor
San Francisco, CA 94143-1754
Phone: (415) 885-7788
Toll-free: (877) 366-8532
Fax: (415) 353-9550

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