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Dr. Jones: There's a problem that is very common in women after menopause. It can cause significant discomfort, it's very easy to treat with a medication that's widely available and low-tech, and it's really, really expensive. What's going on? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is about vaginal health on The Scope.

Announcer: Covering all aspects of women's health. This is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Estrogen, my favorite hormone, is the primary hormone that keeps the vaginal skin healthy and elastic. The tissues in the vagina and the lower part of the urethra, the tube that comes out of the bladder are very sensitive to low doses of estrogens made naturally in women of reproductive years. Having these tissues be healthy and elastic is important for comfort during sexual intercourse, is important for the normal microbiome of the vagina, and helps women from getting too many urinary tract infections.

After menopause, women who don't take hormonal therapy with estrogen, and that's the majority of women actually, often find they have a sense of dryness or burning in the vaginal area. They may have painful intercourse. They may have more urinary tract infections. And the good news is the treatment is easy. Estrogen applied in very small doses to the vagina with the cream, a little pill, a suppository, or even a ring placed in the vagina that slowly releases small amounts of estrogens locally.

A big study that followed 50,000 women over 10 years, looked at these women who used local natural estrogen after menopause and compared their health outcomes to women who didn't use any estrogens. There was no increase in the risk of breast cancer, heart disease, or blood clots, diseases that can be slightly associated with postmenopausal estrogens taken in larger doses for hot flashes.

So what's the problem? It's a common problem, and it's a low-tech, easy fix. Now, if I wanted to take estradiol, my natural hormone, by pill for hot flashes, I could go to Walmart and get a 90-day supply for $10. If I wanted to use the same hormone vaginally, prepared to be absorbed by the vagina and this isn't rocket science, drug technology, it will cost $520 depending on how the estradiol is delivered. Now, $520 is the upper end, $300 is the lower end.

So what is the reason that the pharmaceutical industry puts such high prices on vaginal estradiol? It's because they can. Even women who might have a drug plan with their insurance might have to pay a lot for these drugs, much more than they would for oral contraceptives or birth control pills or oral estrogen. Drugs to treat sexual health for women like the estradiol products are frequently placed on a higher formulary tier, meaning you're going to have to pay a large percent of the list price. Although it may be covered by the insurance company, the amount that they might pay would be little.

The problem caused by vaginal atrophy, thinning of the vagina and the urethra are not only sexual. Women can have discomfort with some sports like bike riding, and they might have more urinary tract infections. Not only are the prices high, but they're going up, even doubling over the past five years, and the technology is not new.

The company that made the little vagina estrogen pill dropped the dose in half because the lower dose did a good job, but the price wasn't lower and it still keeps going up.

A new product just approved by the FDA with the rather odd, but sort of cute name called Imvexxy, it'll be available in July of 2018 and provides estradiol at a very low dose, the lowest of any product and could have made a big hit on the market if they'd priced it at a level that most postmenopausal women could afford. This drug is being priced about the same high cost as the other products. There is another product the FDA approved for vaginal atrophy, which isn't an estrogen, but is another naturally occurring hormone, DHEA comes in a vaginal suppository, and it's really expensive too.

So some women are turning to Europe or Canada to get these medications at a more reasonable price, even though it won't be covered by insurance, and it may not be strictly legal to import it. Also, many pharmacies that compound hormones with creams are selling the products at lower cost, but they aren't under the same control with respect to quality and consistency that the FDA approves manufacturers are.

So what is a woman to do? First of all, if you're a postmenopausal woman and having trouble with painful intercourse or symptoms of dryness or burning in the vaginal area or frequent urinary tract infections, you should talk to your clinician. They can easily check and make sure the problem is vaginal atrophy associated with low estrogen and not something else that might be treated in another way.

Speak up. If enough women complain to their insurance companies, maybe the word will get back to manufacturers. If your local compounding pharmacy can make vaginal estrogen at the correct low dose, that's an option. And this is the only situation where I actually recommend this particular option. There are some companies that are making these products generic, which will bring the price down a little bit, but not as low as the technology would suggest. They can keep the price up because they can.

Talk to your clinician about other options that might be available for your symptoms if you cannot afford vaginal estrogens or choose not to take them. Don't suffer, there are choices. Speak up, be heard. And thanks for joining us on The Scope.

Announcer: Have a question about procedure? Want to learn more about a health condition with over 2,000 interviews with our positions and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: It never used to happen but now you have to get up and go to the bathroom once or maybe even more times every night. Dr. Gary Faerber is a urologist. What could be going on with that? Could it be one thing or is it a lot of things?

Dr. Faerber: Well, it could be a number of things. Probably the most common along these lines comes from older men who can . . . you know, who are worried that these might be the signs of prostate cancer. That's the most sinister, you know, thing that they can think about.

Interviewer: So we're talking older, how old, 50?

Dr. Faerber: Oh, yeah, men in their 50's, 60's, 70's, yeah.

Interviewer: So like up until this point, they could sleep through the night and not need to go to the bathroom and all of a sudden now . . .

Dr. Faerber: Right.

Interviewer: Does it just kind of happen all of a sudden or is it just kind of over time like . . .

Dr. Faerber: Oftentimes, it's a gradual thing, you know. Initially, they may get up once a night and then it's two times and three times and . . .

Interviewer: So if that starts happening, then there could be something going on?

Dr. Faerber: Absolutely, yeah.

Interviewer: Could it just be that they've started drinking water late at night?

Dr. Faerber: That's . . .

Interviewer: Is that the first thing you look at?

Dr. Faerber: Sure. We certainly do keep track of how much fluid they take and when they take it in just to get a sense of whether this is a normal thing just because the amount of fluids that they drink, or is this, you know, not quite so normal.

Interviewer: All right. So if it turns out to be not quite so normal, let's talk about what some of the possibilities could be.

Dr. Faerber: It's probably related to their prostate. And it's not because they have prostate cancer but in most cases, it's because they have benign or normal enlargement of the prostate gland. And when that happens, it causes some changes in how the bladder functions. And they may not be emptying all the way. The bladder may become a little bit more overactive and therefore, they can't hold the urine as much as they used to when they were younger. And all of those reasons may result in them having to get up at night.

Interviewer: So an enlarging prostate's just part of life. As you age, it's going to happen, if I understand correctly.

Dr. Faerber: Yes.

Interviewer: So nothing to be concerned about really?

Dr. Faerber: That is exactly right. If you're 80 years old, 100% of you men will have benign enlargement of the prostate. So it is a normal aging process.

Interviewer: All right. So that's kind of the most common thing. What do you for that then?

Dr. Faerber: It depends on how bad it is. For example, if it's not too bad, you can do some behavioral changes. For example, just don't have that big glass of water before you go to bed or don't have a lot to drink in the evening. And to be honest with you, most men try that initially. You know, they experiment a little bit and they said, "Yes, I've done that."

Interviewer: Yeah, by the time they get to you, right?

Dr. Faerber: Right, exactly. And then, I'll do an exam on a gentleman and see how big his prostate gland is. And then, we then also look to see how well he empties. So we'll have a gentleman void and then we can do an ultrasound of the bladder to see how much urine is left in because we want to see whether or not they're emptying all the way or whether they're just sort of emptying a little bit but most of the urine is left in the bladder. And if that's the case, then you can understand that it doesn't take very long for the bladder to refill and then they feel the urge that they have to go again and . . .

Interviewer: All right. And that is caused by the . . . not emptying all the way is caused by the enlarged prostate?

Dr. Faerber: That's exactly right.

Interviewer: So if they're not emptying all the way, is there anything you can do?

Dr. Faerber: I tell men that enlarging prostate is sort of like, you're sort of pinching off a garden hose where the prostate, as it enlarges, it narrows the channel where the urine comes out of the bladder. And there are different ways of managing that and there are different types of medications that are available nowadays.

Interviewer: Do some men choose to do nothing and just continue to get up at night?

Dr. Faerber: Yes.

Interviewer: And that's completely acceptable as well?

Dr. Faerber: Yes. You know, if we find that they're actually emptying their bladder, then that's perfectly fine. And I would assume there are a lot of men out there who are very comfortable at getting up once or twice a night, and it's really not affecting them physically or emotionally or socially.

Interviewer: So that need to get up and go to the bathroom once or more each night could be an enlarged prostate. What are some of the other things? Let's not go too in-depth but I just kind of want to do a quick of what else it could be.

Dr. Faerber: Right. We do know that as we all get older, and this has to do with not only with men, but with women too, is that the bladder becomes overactive. We all know, myself included, that when I was 18 years old, I didn't have to pay attention to my bladder when my bladder told me it was full.

Interviewer: Right. Twelve-hour road trip, 8 hours in, you could still go another 4 hours, yeah.

Dr. Faerber: Right. It was no big deal. And I was always that, you know, chuckling at my mom and dad who had to make these more frequent bathroom breaks.

Interviewer: You chuckle no more.

Dr. Faerber: Right. Exactly. I do not chuckle anymore. I understand completely. So as we get older, our functional bladder capacity goes down. And that's a normal aging process. There are some medications which can help with some of those patients where it's really a problem. But in most cases, we don't need to really do anything about it. Oftentimes, if I can just reassure patients that, "If it's not bothering you, it's not bothering me so we don't need to do anything about that." So normal aging process is one.

Two is could there be something within the bladder which makes the bladder more irritable, for example, bladder tumor or a bladder stone or something else like that, that may need to be checked. Oftentimes, if that's the case, it's associated not just with having to get up at night but there may be blood in the urine or they may have frequent urinary tract infections, or something else like that which would tell us that there may be something more going on than just an overactive bladder.

Interviewer: Yeah. And of course, if the bladder symptoms accompany any other symptoms like you said, that's when, probably . . .

Dr. Faerber: . . . you really need to get concerned. Yes, absolutely.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 1, 2019
originally published: April 12, 2017

Announcer: Is it bad enough to go to the emergency room? Or isn't it? You're listening to "ER or Not" on The Scope.

Interviewer: You're having a hard time peeing. Is that a reason to go to the ER or not? Dr. Troy Madsen's an emergency room physician at University of Utah Health Care. Of course "ER or Not" is a game where we decide whether or not something is worth going to the ER or not, so having a hard time urinating. Like, I mean it's difficult to get a stream going. ER or not?

Dr. Madsen: So this is one where it really depends kind of on the context of this. If you're a 65-year-old male and you're having a hard time getting a stream going and you feel like your bladder is about to explode, then you absolutely need to go to the ER and this is a common thing we see in the ER where older men will get an enlarged prostate and then they just cannot pee. Nothing will come out, and then you push on their belly and it feels like they've got a basketball in their belly. It's just their bladder is so full and the bottom line is, these people need to have a catheter placed. Something up there to get the urine past that obstruction, past the prostate, get the urine flowing, and so it's absolutely a reason to go to the ER.

Interviewer: All right, so if it's your grandpa or your older dad? Yes. Not the case for women?

Dr. Madsen: Often not, and often in other people they're describing a sense that they have to pee and they just can't go, but in these individuals it's often because they are just going so frequently because they have a urinary tract infection and that creates a sense of just what we call . . . the medical term is urgency. It's exactly that. It's this urgent sense that you need to pee again and again and there's really nothing in there, and that's a pretty common thing with a urinary tract infection. That's something you can go to an urgent care, they can just do a quick urine test on you, say, "Yeah, you've got a urinary infection. Here you go. Here are some antibiotics. This will clear up in two or three days."

Interviewer: But that sensation of having a completely full bladder is not there. It's just the fact that you try to go and nothing comes out. People start to assume, "I must be blocked."

Dr. Madsen: Right. Exactly.

Interviewer: But it's just empty. It's just nothing there.

Dr. Madsen: It's empty.

Interviewer: Yeah.

Dr. Madsen: They just have this feeling like, "I need to go. I need to go," and then they just keep trying and trying and trying, but it's not like these individuals who come in who you push on their belly and, for a 65-year-old man, it feels like he's pregnant. He's got like this mass in his belly. We'll put a catheter in some of these individuals and get a full liter out. Just a huge volume of urine. It's just backed up in there causing lots of pain and discomfort and just nothing's coming out.

Interviewer: Other . . . So urinary tract infections, can that affect a man as well? So like somebody my age, in their 40s, has a hard time going?

Dr. Madsen: It can. It's less common in men, and usually when men get urinary tract infections, we think, "Could there be something else going on that's causing this?" Where in women, it's much more common, the reason being simple anatomy. The urethra is longer in men than in women. It's easier for bacteria to work their way up into the bladder for women, so that's why it's more common. So yeah it does happen, but often in men, especially older men, I start to think, "Could there be something else going on? Maybe an infection in the prostate." Start to think a little bit broader, rather than just saying, "Here's some antibiotics. This should talk care of itself."

Interviewer: What about other blockages, like stones or something like that?

Dr. Madsen: So kidney stones, the interesting thing with kidney stones, they start in the kidney and they cause pain as they work their way down the ureter -- down the tube that goes from the kidney to the bladder -- but once they hit the bladder, the urethra, so the tube that leads out from the bladder is bigger than the ureter, so once they get there it's really kind of weird and unusual that they would get stuck in the urethra and cause it so you can't pee.

Interviewer: Got you.

Dr. Madsen: So most people it's going to be in one of the ureters. You've still got the other side working. You've still got that kidney producing urine. The urine's still going to the bladder. So it's not quite so often I see with kidney stones where people say, "I just can't pee." I mean, usually they're just writhing around in pain because of the severe pain there, but they're still urinating regularly and I can't say I've ever seen where a stone's been so large that it made it's way down in the bladder and then got stuck in the urethra so they just couldn't get anything out.

Interviewer: All right, so just to be sure here, if somebody's having a difficult time peeing, if it's an older man it could be an enlarged prostate, definitely go to the ER. For everybody else, it's probably not a blockage. It's probably a urinary tract infection. Go to an urgent care.

Dr. Madsen: Probably.

Interviewer: And we've covered everything?

Dr. Madsen: Exactly, and you've got to, again, kind of take the whole thing in context. If you're talking about someone that has a lot of medical issues and you're thinking they can't pee because . . . they're just not peeing because they're in kidney failure, then that's another issue entirely. With those individuals it's not so much that they feel like, "I have to pee." It's more just like, "Hey, I'm not peeing."

Interviewer: Oh okay.

Dr. Madsen: It's just their body's not producing urine because their kidneys have stopped working.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with out physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

updated: September 21, 2018
originally published: November 7, 2016

Announcer: Is it bad enough to go to the emergency room? Or isn't it? You're listening to ER or Not on The Scope.

Interviewer: All right. Today's ER or Not, back pain. Should you go to the emergency room for back pain? Dr. Troy Madsen from University of Utah Health ER or Not.

Dr. Madsen: So this is going to come down to a few things, and these are basically a few things that you should go to the ER for. Number one, did your back pain start because you were directly injured on your back? That's something you should go to the ER for because you very well could have a spinal injury. That's a very serious thing.

Number two, are you having symptoms like, losing control of your bladder or your bowels? Maybe you didn't have a direct injury to the back, maybe you're just having pain in your lower back and you cannot get to the bathroom quickly enough, you just can't hold it, you're urinating on yourself or you try to go to the bathroom and you really can't urinate. That is something that also you need to go to the ER for.

So that's second thing, the first thing's probably kind of obvious, you figure, "Okay, if I've been injured, let's say I fell or something hit me on the back, I'm having pain right on my spine, probably need to get some X-rays or a CT scan," but the second thing it's kind of an unusual thing but something I always think about, It's a term, it's something medical condition called cauda equina, and what that means is cauda equina's Latin for the horse's tail.

So if you look at the spine it's just kind of a cord that goes down and then at the end of the spine it all spreads out and looks like a horse's tail. This is where all these nerves take off and spread out there. So down there at the bottom part of the spine, the low back, if you get a disc that's pushing in or something that's pushing in on the spine, that's a surgical emergency. You need to go to the operating room and get that repaired and treated and the typical symptoms that people have with that are low back pain, and then they say, "I cannot hold it, I can't get to the bathroom quickly enough," or, "When I try to go to the bathroom I just can't urinate, I feel like I have to go and nothing comes out."

In my mind, that really raises concern for that, and the way I diagnose that is an MRI. And that's something you would need in the ER. So those are the two things that would say go to the ER for.

There are lots of other types of back pain, maybe you've lifted something, you've got a back strain or a sprain, maybe you've got a herniated disc. We do see lots of people with chronic back pain where it flares up. These are all things that could probably be treated through your primary care doctor or even through an urgent care. But in terms of the things that are really serious, those are the things I recommend watching for.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 11, 2018
originally published: August 12, 2016

Dr. Jones: Multiple sclerosis is a disease that's more common in women than men. It's a complicated disease, it's a neurologic disease, but it affects many parts of the body and today we're going to talk about the bladder, and MS, and your health, on The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: Today in The Scope studio, we have Dr. Sara Lenherr, who is a specialist in neurology, she's trained as an urologist, but she's pretty clearly interested in the way the brain talks to the bladder. And today we're talking with her about MS, patients with MS, and problems they might have with their bladder, and what might be done. So talk a little about the brain talking to the bladder and multiple sclerosis.

Dr. Lenherr: In normal patients that don't have neurological problems, the brain is designed to tell the bladder to store urine for as long as is reasonable, and then when you're near a bathroom, then you volitionally go ahead and void out your urine. Unfortunately in multiple sclerosis and a lot of different types of neurological disorders, the communication between the brain and the bladder is disrupted by the nervous system problems that happen in MS.

And so specifically, sometimes that bladder becomes over-active and receives too many signals from the brain, and then it also, the sphincter that's supposed to keep you from leaking doesn't necessarily relax when you want to go ahead and pee.

Dr. Jones: So what happens? So a woman who has MS and has neurologic symptoms in her bladder, what would she experience?

Dr. Lenherr: So usually they'll present with urinary frequency and urgency, but sometimes they just don't empty their bladder at all, so they'll feel like they have to go, they try to go, and then they can't empty out their bladder completely. Either just a little bit comes out or none comes out at all, and interestingly, sometimes we catch these cases of multiple sclerosis before they're even diagnosed by a neurologist, because women will present when they're a little bit younger, and they have no reason to be in urinary retention to not empty their urine.

Dr. Jones: So let's back up, so urinary retention. You mean if they go a little bit, then their bladder gets fuller, and fuller? I see a balloon in my head.

Dr. Lenherr: Exactly.

Dr. Jones: How full is too full and what happens?

Dr. Lenherr: Well, if you have too much urine in your bladder, especially for women, usually when you have too much in your bladder and you're a female, you have what's called overflow incontinence, where the urine just comes out even though the sphincter is nice and tight. And so those women will notice that they just leak, and they can't empty out all the way. They feel full.

Dr. Jones: Well, so a lot of women leak, so how would you know that it's overflow? What test would you do?

Dr. Lenherr: So we can do either a catheterized volume to see if there's urine left over after you pee. Or we can just do a little bed side ultrasound to evaluate whether or not there's any urine leftover in your bladder.

Dr. Jones: So a urologist might actually pick up MS before the patient shows the other neurologic signs of MS.

Dr. Lenherr: That's correct.

Dr. Jones: And these are young women.

And young women being wet all the time is devastating, well it's what, it's devastating for any woman of any age, but for young women in particular, they don't want to be wearing pads, and Depends. So what kinds of things do you have to offer for women with MS?

Dr. Lenherr: So once we identify the problem, then we need to discuss with the patient what drives their quality of life, and what is a safety issue. So safety issues would be if your bladder doesn't empty all the way, and it ultimately causes the bladder to stretch out and cause damage, and sometimes could impact kidney function.

Dr. Jones: Oh, so it backs up and backs up?

Dr. Lenherr: It can back up all the way and it could cause the kidneys to have damage which is a bigger issue. The other thing that can happen with the urine sitting in the bladder for a long time, it can lead you to get urinary tract infections. So there's multiple things that we can address with a safety issue, and then we need to look at quality of life, so quality of life is impacted by leaking all the time, or having to go to the bathroom all the time.

Dr. Jones: So do women have to empty their own bladder with a tube? I mean do you give them medication to make their bladder squeeze a little harder?

Dr. Lenherr: So depending on how their bladder works when we evaluate it, we frequently have to have these patients go use a small catheter to empty their bladder on a timed basis. And that generally treats them very well because it empties the urine when they want to, and they're able to control risks of urinary tract infections and kidney damage, and then they also don't have the overflow incontinence that we discussed before.

That's one good strategy, sometimes if the over-activity is really bothersome, and they still have irritation even though there's a small amount of urine in their bladder, we put them on other types of medication and we also can offer them chemodenervation, which is called botox, which is similar to the botox that you put on your forehead for wrinkles, we can inject that in the bladder to relax it.

And we can also put in nerve stimulators that help act like a bladder pacemaker. So there are multiple different options we can offer women with multiple sclerosis to help them manage their bladders better.

Dr. Jones: Well that's great news, because for MS it's a condition that waxes and wanes through a life time. It often begins in women's early 20s, or 30s. So giving somebody the qualify of life so they can be the persons that they want to be, is a really important service that you guys can offer.

And I think for many women with MS, they feel like their life and their agency has been taken away, and empowering them to have a little more control.

Dr. Lenherr: Exactly, and also considering that we follow them for the rest of their lives, and sometimes their bladder conditions change, so we need to adjust the strategies that were working five years ago.

Dr. Jones: And here at the University of Utah, we have a medical record that helps our doctors talk to each other so you're not doing this just in the urology clinic. You talk to their other MS doctors.

Dr. Lenherr: Exactly.

Dr. Jones: Because often they're on a lot of meds.

Dr. Lenherr: We coordinate all their care and make sure that we're all working together to improve the quality of life and keep them safe.

Dr. Jones: That's great to know because I've had a lot of patients over the years with MS. It's very discouraging. Knowing that there's things that they can do is very helpful, and Sara thank you for joining us on The Scope.

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Dr. Jones: Diabetes and the bladder, you never think of these two things going hand in hand. You think of a cupcake and diabetes, not the bladder and diabetes, but today we're talking about diabetes, the bladder. This is Dr. Kirtly Jones and this is The Scope.

Here in The Scope studio, we have Dr. Sara Lenherr, who is a urologist by training, but subspecialty trained in neurology. Today we're talking about diabetes because diabetes is a complex disease. It affects every part of the body and the bladder is the final common pathway of both nerves and sugar and trouble. Welcome to The Scope, Sara.

Dr. Lenherr: Thank you for having me.

Dr. Jones: I think in my own practice sometimes I diagnose diabetes because of women's urinary frequency. So can you tell us a little bit about how the first signs of diabetes might affect the bladder?

Dr. Lenherr: Sometimes women with poorly controlled diabetes end up having a bladder that spasms too frequently, and that can be very bothersome. It makes them feel like they have to go more frequently and urgently.

Dr. Jones: Also, sometimes people who don't know they have diabetes yet, their sugars are high, the kidney is trying to dilute that sugar, and they just pee a lot.

Dr. Lenherr: Yes, frequently these patients make too much urine because their kidney function is affected, and so they just make more urine than the bladder can handle, and it makes them feel like they need to go more frequently, and they do.

Dr. Jones: So peeing a lot in large volumes, for me, I remember that from medical school, was you better make sure they don't have diabetes.

Dr. Lenherr: Exactly.

Dr. Jones: Over the long term, though, diabetes affects your nerves in your feet and affects other parts of your brain, but talk about the bladder in long-term diabetes.

Dr. Lenherr: Diabetes in patients that have had it for a long time can affect the fingers and toes, and all that sensation also affects all of the nerves that go to the bladder, and so the bladder doesn't necessarily contract at the right time. Either it's overactive, or it's underactive. It doesn't contract well enough, and so therefore it doesn't squeeze when you want it to and you don't empty your bladder completely.

Dr. Jones: So in terms of diabetes, we certainly want people to be in good control, because that might help early on a lot of their bladder symptoms, meaning if their sugars are in good shape, their bladder will probably be in good shape. But for people who have been diabetic for a long time and they weren't in such great control and now they have more permanent damage, how do you make that diagnosis?

Dr. Lenherr: Usually, we check and see whether or not the bladder empties completely, so once you go, we can then check and see if you have a residual left over in your bladder, and then we can also check bladder function tests where we measure the pressures inside the bladder and see how your bladder behaves with filling and then trying to empty your bladder.

Dr. Jones: Is that very comfortable? Reassure me that that's not going to be a painful test.

Dr. Lenherr: It's a very simple test that's done in the office. We put a very small catheter that's smaller than the mouse cord that goes to your computer, and we place that inside your bladder, and we place also a very similar small one inside the rectum. This helps us look at how the bladder behaves with filling and emptying to measure those pressures and see whether or not your bladder nerves are not working properly.

Dr. Jones: Okay, maybe I would have this test. Okay, I'll have this test. So, I had this test and my bladder isn't contracting very well. What are you going to do? What can you do to help me with this?

Dr. Lenherr: Depending on how much your bladder is injured, sometimes we have to have patients actually just pass a small catheter every four hours while they're awake to empty their bladder as opposed to trying to pee it out. But if you have a little bit of bladder function, then sometimes we can actually give you a bladder pacemaker that helps your bladder contract in a much more efficient manner, and therefore you're able to empty without having to use that catheter.

Dr. Jones: How about as people get older? I think of the elderly patient with what we call comorbidity, so they're older, they have diabetes, they have heart disease because it's affected their heart, maybe they had a stroke. Urinary incontinence is the number one reason to be admitted to a nursing home. So what do we do for older people? Can they do their own catheterizations, or is this something a family can help them with?

Dr. Lenherr: The complex patient with incontinence is definitely some of the more challenging cases that we have, and it's a balance between figuring out what the goals of care are. Some patients are very happy to have family help them catheterize if they need that to be done. Sometimes patients would rather not have their family members be going down there and helping them pass a catheter, and depending on how the bladder works, it can be a very good option to leave a chronic catheter in place.

Usually we try to place that in a suprapubic location, so right above the pubic bone below the belly button, and that helps drain the bladder and improves quality of life in a lot of patients. But these are really specialized conversations that we have with both the patients and their families to determine who is going to help out the patient and who is going to be able to help keep the patient safe and happy.

Some of the more rewarding conversations are having these discussions where you have patients understand these are my choices and this is what my goals of care are, and it's not always a quick fix, and it's not always the most complicated solution. Sometimes it just needs to be something simple that everyone agrees this is what I want to have my life be like, and I'm there to offer those solutions for them.

updated: November 24, 2021
originally published: December 23, 2015

Dr. Jones: Wait, can we stop at the next gas station? Yes, I know we stopped at the last one but this is your bladder speaking and maybe it's time to get some help. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and this is your bladder on The Scope.

Announcer: Covering all aspects of woman's health, this is The Seven Domains of Woman's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Urinary incontinence is common in women, as many as 30% of women have incontinence for one reason or another. Babies moved your bladder around or you have an overactive bladder. Incontinence pads are a billion dollar business. But if your primary care provider can't help or you have more complicated medical issues maybe you need to see a urologist.

Today in The Scope Radio studio we'll be talking to Dr. Sara Lenherr. Dr. Lenherr is a urologist at the University of Utah and she's going to help us understand some of the more complicated reasons for bladder problems. She has a special interest in neurology, let's talk about how our brain and our bladder communicate.

Dr. Lenherr: The brain and the bladder have a really important communication process that needs to occur and basically the bladder is designed to store urine as a vessel until your brain tells it that it's okay to go to the bathroom, like when you're near a bathroom. And then the sphincter is designed to hold urine in place. Again, when you're able to get to the bathroom in time.

Sometimes in some medical conditions and other things that have happened with pelvic surgery or other types of vaginal deliveries with babies, that communication can get disrupted and so we need to pay special attention to that type of communication.

Dr. Jones: I always admired dogs who could put a little here and put a little there and do exactly what they wanted and when. But when that's not working I thought only men went to urologists. You know, for their prostate problems or those guy things. So urology for girls? For women?

Dr. Lenherr: So that is a really common perception and actually women have bladders too and they need to be pee too and urologists are specially trained to take care of the bladders pretty much exclusively and so we're here to help both men and women.

Dr. Jones: Great. So I'm an OBGYN and in our department we see a lot of women with urinary problems and we can fix a lot of them. But we're not very good for those women with complex medical problems. So can you talk a little bit about that?

Dr. Lenherr: So women have many different sorts of disorders that can disrupt the way the bladder works. The common ones are ones that disrupt the signals that go back and forth between the bladder and the brain. And also there are signals that make too much urine, so some women have heart disease which causes their kidneys to actually make urine and shift that around at the wrong time, and so they need to go more frequently and urgently because they're just making more urine.

There are many different types of conditions that affect the way the bladder works and really with an in-depth evaluation with a specialized urologist is really useful in order to figure out do we need to work on the bladder squeezing too much at the wrong time? Or is it a problem with the sphincter being too leaky, causing you to leak when you don't want to?

Dr. Jones: Well I can see that really takes some specialty training and you did a specialty fellowship in this area?

Dr. Lenherr: Yes, so there's a new specialty that came out a couple of years ago called, "Female Pelvic Medicine Reconstructive Urology" and we specialize in basically bladder function and how the bladder and the brain communicate. In order to evaluate how the bladder and the brain communicate frequently we perform what's called, "urodynamic evaluation" where we study the bladder pressures and the sphincter pressures, the urethral pressures, and figure out how they coordinate and communicate with different sensations.

Dr. Jones: Well we're really glad you're here at the University of Utah for all of us who are getting a little older, having a few more medical problems, and don't have the bladder that we want. Voluntary control of the bladder is a beautiful thing, but if it's not working for you, we and Dr. Lenherr can help.

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