Jan Chaseley

Good evening everybody, I hope you're well and welcome to our webinar on continence care. My name is Jan Chaseley and I'm the Clinical Nurse Specialist at Benenden Hospital and I am your host for this evening. Our expert presenter is Consultant Gynaecologist, Mr Abhishek Gupta. The presentation will be followed by a question and answer session. If you'd like to ask a question during or after the presentation, please do so via the Q&A icon which is on the bottom of your screen and this could be done without giving your name. If you would like to book a consultation, our friendly Private Sales Advisor, Jane, is available until 8.30 this evening and we will provide her phone number at the end of the session. Please note that this webinar is being recorded. I'll hand over now to Mr Abhishek Gupta and you'll hear from me again shortly, thank you.

Mr Abhishek Gupta

Good evening, everyone. Welcome to our webinar on female incontinence. My name is Abhishek Gupta and I’m a Consultant Urogynaecologist.

So why did we choose to specialise in this field? Most importantly, the whole thinking process in last couple of decades for urogynaecology has changed. Now it's all about quality of life and it has been more and more clear how bladder issues can have an impact on a person's life in more than one way and everybody's quality of life is impacted differently.

So, if a person is a kickboxer and they have incontinence, that can affect their profession. If they have small kids, they're running around with small kids, it can affect their ability to trampoline with the children. If you've got a bladder which can't hold urine, you can't go for a drive; so, it's all about quality of life. And one of those areas - which is well known, but all we see is the tip of the iceberg because obviously as there is a taboo to it, people don't come out and talk about it openly - but the treatment (and knowing what it's all about) can bring a quality of life back to you. And that's what we are focusing on here.

And it's important for us to recognise this is one of the very common situations and common conditions and it affects a lot of women. So, we'll start the presentation I'll go very slowly and at the end of the day, after the webinar is over, we just want more and more questions so that we can answer the common queries and questions you have. And it also gives an insight of how the bladder function works and also an insight into what you can do yourself to help and what the treatment levels are. So, if things are not getting better by doing simple measures, when do you need to see us?

So, as I said, what we see here is just the tip of the iceberg. It affects almost 35 percent of women and around 35 percent of women have a leak of urine at some point and this is we're talking about - a leak. And people who don't even have a leak may have rushed to the toilet more often; they have to get up more often and those problems are not even quantified. So, I think, at some point this affects roughly around one in two women.

So, the quantum as you can see, the number of people who get affected with these issues, is almost 50 percent - so it's quite widely prevalent. Now from a pure incontinence point of view - which is a leak of urine - there are two main types. One is urgency of incontinence.

So how does one feel what is called urgency? It is when you feel that you really need to rush for the toilet, you can't control, or you have to go often. So, you go more often. You don't hold that much in your in the bladder so, when you go to the toilet, you only pass a little amount. But that little amount you find difficult to hold in the bladder, so you become very uncomfortable very quickly and that's called urgency. And when you can't find the toilet and you leak it's called urge incontinence.

Now, typically, when somebody is cooking and they hear a tap going next to them or you’ve just parked your car on your driveway, trying to put a key in the lock and you say ‘Oh now I need to rush, now I need to rush’. This is kind of a feedback going on in your mind and that typically is an urge incontinence.

So, I'm just giving you a clue as to what can incite your feedback and the bladder is not under control because the bladder is doing this [motions].

Now stress incontinence is more defined. It is when you're doing physical work; so that can be when you cough, sneeze, trampoline, anything which increases your tummy pressure, basically. So, when you cough, your tummy pressure increases. When you run, your tummy pressure increases. You exercise, sneeze, jump up and down, change your posture, your tummy pressure increases.

So, what tummy pressure does is it puts the pressure on your bladder. Your bladder is like a balloon filled with water. If you don't have enough strong support below the bladder any pressure which increases in your tummy makes you leak.

So that's called stress incontinence. Often patients present with a mixed picture and that's not because you have one dominant factor of stress incontinence or urge incontinence in you. If somebody has their quality of life really affected – so, for example somebody is a runner and they go for a long run and they can't hold their bladder because they leak. So, what this means is we want to manage our lifestyle. And the way we want to manage our lifestyle is we cut off the events which embarrass us. So, what we'll do is we'll try to empty the bladder 10 times so that when we’re in a stressful environment or whenever we want to, say, play tennis or go for a run our bladder is actually empty. And that becomes a reflex, where we’re continuously trying to empty our bladder so that we don't leak with stress incontinence. So, though we think we have to go more often, the main problem is stress incontinence because we have trained our mind that we need to keep emptying so that we don't have that embarrassing moment.

However, it may coexist together, so you may have stress incontinence and you may have urge incontinence together. But sometimes the mixed picture is because we have trained ourselves, so that we don't have an embarrassing moment.

Now one thing is very important. This is quality of life and, as I said, we still are seeing the tip of the iceberg. So, I remember when I was training in this field 20 years ago, our main cohort of patients were of a postmenopausal age group. But more and more, when people know there is help available, people are more open about it. We can see a spectrum of patients who are in a younger age group for who this problem is affecting their quality of life, but they were not coming forward before. So as awareness grows, they're coming forward. So, talking about a problem, I think when it starts affecting you that's the time to seek help.

And this is the first step forward. It's a bold step to talk to your doctor or a stranger to say that you have a leak of urine, but that's very important for you. If it's affecting your confidence or it’s affecting your quality of life, it's affecting you doing day-to-day work which you like to do without thinking about an issue with the bladder, then I think that's the time to take the next step.

So, let's spend the next two or three minutes just thinking about what causes various kinds of incontinence. So, as I said, urge incontinence is the irresistible urge to go for waterworks. That’s urge incontinence. If your bladder is full every one of us gets the urge to go for it, but true urge incontinence happens when the bladder is only a little full and reflexively your bladder is doing this [motions] and then you can't control the bladder and you have to rush for the toilet. And that's called overactive bladder because the bladder is overactive.

So, on a normal human being, the bladder can hold around anything between 350 to 500 ml of urine without a problem. For people who have a typically overactive bladder you go, and you can pass only 50 to 150 to 200 ml of urine. So that means you have to go more often; you've got more urgency. And once it's at breaking point, your bladder is doing this [motions] and at 200 mls you're leaking. Now obviously going for water works that often is going to be problematic. If you've got a meeting which lasts for three hours you will find it difficult to sit in this meeting for two, two and a half, three hours. But there's some things which we can do to mitigate that risk.

Things which really irritate bladder are caffeine, fizzy drinks so if you typically have a problem of urgency and frequency or you have to go in the night (so if you get up in the night often it's called nocturia) first and foremost have a look at how much caffeine intake you've got. If you got a very high caffeine intake it’s not guaranteed that you’ll visit the toilet more often. It's not a problem, but when it becomes a problem for you then you really have to think about what coffee and tea intake you have. If you have a higher intake of caffeinated drinks, then try to make them decaffeinated because caffeine is a powerful irritant of the bladder.

Now a lot of people we’ve talked to over the years have changed their hot tea and coffee to more healthier options - or seemingly more healthier options - like green tea. But if you look at the label of green tea it's got a lot of caffeine in it. So, if you do want to change it, make sure you go for a decaffeinated option. Similarly, Coke, fizzy drinks are not the best news for the bladder. They irritate the bladder big time and it doesn't help the situation of an overactive bladder. And then, obviously, excessive amounts of alcohol. We all know that when we drink a bit more and sleep, we have to get up a few times in the night and that's what happens. Apart from that, you can have urinary tract infections and that's more common in the menopausal age group because the bladder is more susceptible to infections once you go into menopause because of lack of hormones or oestrogen.

And then there can be other neurological factors. If you have a spinal injury or if you have Multiple Sclerosis, which is more obvious, where the bladder is not under your control. Stress incontinence - as I said - is more when you do an activity, cough, sneeze, jumping up and down, change of posture, running, walking up the stairs, sneezing and you leak - that's called stress incontinence.

And this typically happens because of the weakness in what you define as your pelvic floor, which are the muscles which controls your whole pelvic floor, which is where it supports the bladder, your womb and the back side of the vagina

And the neck of the bladder which is just so. The bladder, if you look, it's a balloon. So if you want to just picture my wrist as a balloon and that's the urethra which is the tube draining water out, so the neck of the bladder has got what is called a sphincter, which is a muscle which contracts and doesn't let you leak water. So, the pelvic floor is supporting here in the vagina, this sphincter is inside, and these are the two powerful things which stop you leaking when you cough.

What makes them weak? One is vaginal deliveries. We love our children to bits, but they do cause trauma to the pelvic floor so vaginal delivery, especially when somebody has forceps delivery and all that; it does have a big, traumatic effect on the pelvic floor. So that causes you to leak. Obesity. Now weight is a factor which again leads to an increased chance of stress incontinence. So, it's well known if you've got really high weight or you're obese it causes problems with your knees. We all know that because the knees can't take your 20 kilos of extra weight every day for many years, but the pelvic floor also bears the brunt of your excess weight, so obesity is – again - a big factor in making you susceptible to leaking.

Unfortunately, we don't have the choice. All of us get older and when we get older, we lose our muscle strength, so we know that our tissues get weak. And one of the very underreported factor is - one of the biggest traumas that a female's body goes through (after childbirth) is - when they attain menopause, because oestrogen - which is a hormone that is so important for the pelvic floor muscles and the vaginal health of that area - once you have a lack of this it just makes you susceptible to many things, including weakness of the muscles, including susceptibility to infection. And therefore if, obviously, you don't have any risk factors, then a small amount of hormone in the vagina area - which is a local treatment - does do wonders and makes the pelvic floor and skin condition down below better.

Smoking, chronic cough, there's no surprises there. If you're a chronic smoker and have got a bad cough, you're constantly putting pressure on your pelvic floor. You'll keep coughing and that's not going to help. That will obviously give you increased susceptibility for incontinence. However, that also reduces a chance of success of any intervention you'll go through, so that is something to keep in mind. So if you do like a cigarette or two (or more) then, if you have a problem with your waterworks, if you really want to have a good, successful outcome of any surgical intervention or any other intervention - that's the first thing to make your chest better. And, as I said, neurological conditions can present with either overactive bladder or stress incontinence, so it's a nerve-related issue but they're far and few between.

So, what investigation and how do we diagnose things? So, when you come to us to say that you have a problem with your waterworks, what do we like to do? So, what we like to do is to ask you to fill in a bladder diary for 48 hours. So, what is a bladder diary? So, a bladder diary is something which we ask you to fill out to see what you drink, how often you drink, what kind of fluid you drink and how often you go for waterworks. And we kind of ask you to do a rough measurement of how often you go for water works and what amount of urine you drain.

So typically, if you're drinking, if you’ve got a desk job and you're drinking more than three litres of fluid, with half of them being coffee and tea or fizzy drinks, then obviously you will go to waterworks more often. There's nothing wrong with you. If you drink more, you will produce more urine so there's something very simple to see. However, if you're not drinking that much, and you're going to the toilet often and you're only passing 100 or 150 ml of urine, it's more likely that you've got an overactive bladder even before we start doing any invasive investigation. So, we can start the treatment without going into any invasive investigation into it.

And then we want to see if there is anything causing you to leak, either with an urge or when you cough or you're doing an activity. So, there’s a bladder diary which we send and it's an immensely helpful tool for us to initially screen what your condition can be. And that's one of the screening tools which you use, and which is non-invasive.

Obviously, when you come in we ask you basic questions. We also check if you have any high-risk issues, what your medical problems are and are you on any medication. Then we always examine you. We just assess your leaking pelvic floor for any signs of prolapse and we also rule out whether you have any other things in your pelvis; sometimes a big fibroid - which is a benign growth on your womb - or a big cyst on your ovary can press on your bladder and that may make you leak.

So when, or if, there's a prolapse which is basically, again, the weakness of pelvic floor and bladder is coming down, or the womb is coming down, this is all an assessment of prolapse. At the same time, we also judge how your pelvic floor is because if your pelvic floor is weak then there's some first line management to build the pelvic floor up, which can be very effective for mild to moderate issues and in future as well if you decide to have a treatment, then any procedure you do the more successful it will be if you continue with pelvic floor exercise for the long term, so the recurrence rate is less.

And then after this investigation, once we have done the basic investigation we may start your treatment as well, depending on what symptoms you've got. And if these things don't get better then we usually resort to what is called a urodynamic test.

Now a urodynamic test is a functional test to see how your bladder is behaving. So, there are three components of this test. It takes around 45 minutes to do this procedure. It's a bit of an intrusive test, but the nurses - Jan and Mary who do urodynamics here at Benenden - they explain it to the patients well. They make sure that they know exactly what's happening with them, they talk you through the procedure, so they also know what's happening with your bladder.

So, there are three components of this test. One is we ask you to come with a relatively full bladder and then basically what you do is a there is a little commode where we ask you to wee. What we want to see is how quickly you pass urine; is there any obstruction or - if you're not able to empty the bladder - how much you're keeping behind and how fast you're emptying the bladder.

Then we put a little catheter in your bladder. And this small catheter goes in your back passage. We fill up the bladder with water. So, what we want to see is that the catheter (which goes in the bladder) is picking up the pressure from the bladder as well as your tummy. We're not interested in tummy pressure; we're interested in what your bladder is doing. And hence the catheter in the back passage picks up the tummy pressure. So the two pressures - the catheter from the bladder (which is picking up the bladder pressure and the tummy pressure) and the catheter from the back passage (which is only picking up tummy pressure). So, we subtract the one from the other to just get the bladder pressure. That's what we're interested in.

So, we fill up the bladder with water and we see the pressure changes on the bladder. So, if somebody has got an overactive bladder, then you get the sense of urgency ‘Oh I need to go for waterworks’, and you tell Jan or Mary who do the test and record on the system.

At the same time, if you've got typical overactive bladder, we can see the pressure of your bladder going up on the machine and that's how you diagnose an overactive bladder. If you're too uncomfortable, obviously we'll stop filling. If you can tolerate it, we usually like to fill up the bladder with around 350 ml of fluid which is the normal bladder capacity and then we ask you to cough in between and we sometimes may ask you to do star jumps – it depends on what your symptoms are. If you leak, you leak, it's only water and that's why you're here - so we can get what's happening so that we can give the treatment you’ve come to seek.

And also, after the procedure, we also put tap on so that if the bladder gets irritated with the sound of water (which often happens) or put your hands in in cold water and see whether that instigates your bladder function, and the pressure is recorded. After that, we want to see that you're passing urine well, you're emptying the bladder well and if your flow is better, if your flow is good. So, this whole journey takes around 45 minutes and we check that you don't have an infection. We ask patients to drink plenty of water. This usually gives us a diagnosis whether you have overactive bladder or you have stress incontinence or you have a mixed picture and if there is anything which can prevent us offering you treatment, depending on what your bladder capacity is and how you empty the bladder. So, this determines what options for treatment we can give you going forward, depending on the test results.

So what are the treatment options? So, in a hospital, offering a treatment for the issue of bladder problems, it's my firm belief that the doctors or the Consultants can only offer so much. It's the team effort which is needed. So, the service is offered as a team. There's no gynaecology service or a urogynaecology service offered by the Consultant nevertheless this has to be a team effort because to have any optimal outcome of your problem you need an input from specialist nurses with physiotherapy input and the doctors and the Consultant in case that doesn't work.

So, doing conservative management that's one option. However, if you go for a surgical treatment the post-operative management (which are mainly done by nursing colleagues of ours) in any good setup is equally important, if not more. And this is a very important and a basic rule in a treatment of urogynaecology. The Consultants who are sitting probably with their shiny suits in the clinic are okay to do an operation, because we get trained to do an operation, but the real treatment and the value of treatment are provided by the specialist nurses because that's a total package of treatment. And if you haven't had a real optimal outcome, you have to give all the complimentary services and one thing in Benenden is very really good is we’ve got two specialist nurses and we’re also in the process of recruiting a third one. So we’ve got a complete cohort of services we offer and also, in line with all the previous recommendations which are happening because of the mesh problems and all that, every recommendation like having a multi-disciplinary meeting and all that is is being offered at Benenden.

So urogynae, or treatment or incontinence or prolapse is one of the key services we take pride in providing here. Jan, do you want to talk about this slide, about the treatment options for conservative management?

Jan Chaseley

Yeah absolutely fine. So obviously when you come along to our clinic, we allocate an hour for a new patient, so you get our undivided attention, and we can do a whole holistic assessment. But it's basically covering all the things that Mr Gupta has already mentioned; looking at your bladder diary, what are you drinking, what can we adjust, bladder retraining. So, if you're emptying your bladder every hour, we try and get you to empty every hour and 10 minutes and gradually stretch that through so that your bladder capacity increases.

You can only really do bladder retraining if we teach you deferment techniques and that's going to be all around pelvic floor exercises. And we'll help you with things like weight loss, advice about smoking. And I think sometimes it's just coming along and just being able to chat about actually what is going on and what can we do for you. There's always the option of medication but we would never do that as a first line. We would work through the things at the beginning and hope we get an improvement without having to try medication or without potentially having to refer you back to the Consultants for surgery. Thank you, Abhi.

Mr Abhishek Gupta

So, as we discussed, conservative management. So, when you come to us with a bladder issue, the important thing is you have come here for improvement. The goal is - there's no quick fix - the goal is for a long term, really good optimal outcome for the problems you have. And therefore, the engagement from you and us both is important to embark on the journey of making you better.

And that's what's important. We need to make you better and subtle changes will improve. Again, what I'm stressing is it's all about quality of life. It's not the leak which matters, it's about how it’s impacting your quality of life and how we can improve. That is the really important message to take from here.

Now we'll talk about medication first, which was on my previous slide. This is mainly for your overactive bladder. So, there are two kinds of medication for overactive bladder. One is called anticholinergics. Basically, what happens is this medication is given to you after you've done the lifestyle changes. This medication helps to prevent contraction of the bladder, that's how it works. It takes around four weeks to start acting. It has got some side effects and the side effects are usually palpitations, dry mouth and constipation.

The side effects come before the success of the medication kicks in or the effect of medication kicks in. So, if you can tolerate the side effects for a week or two, they're not going to get worse after that. But then you will start finding that this medication starts working. The other medication is something called a mirabegron which has a generic name called Betmiga. A normal medication which is known as mirabegron, which is the name of the medication that helps to relax the bladder.

So, there are fundamentally two different medications; mirabegron has got less side effects and it helps to relax the bladder more, rather than preventing the contraction. Now this is treatment for an overactive bladder. It's not to say that one medication is better than the other. You can start with either of them. If you suffer from severe constipation, for example, there's no point giving you anticholinergics. It’s better to go for mirabegron straight away. But if one medication doesn't work, we can start the second medication and see whether it works.

Because if that doesn't work and you really have an overactive bladder (and people who have a real overactive bladder, their bladders can't hold more than 150 to 200 ml of urine, if you're lucky) they go often to waterworks, they leak and that really affects your quality of life. Then we offer them the next step which is called a bladder Botox injection. It's a very simple procedure to do. It takes roughly around 10 minutes to do, it's not painful, it's done in our Ambulatory Care Unit here. It's basically an injection on the bladder wall, it's not painful at all. It takes around a week to 10 days to start acting and for patients who have really got an overactive bladder, they'll feel this is kind of life changing for them.

The advantage is, as I said, resistant overactive bladder which has not responded to medication responds very well to Botox. The flip side of the Botox is - I won't say the flip side - but it may need repeating, so usually anything between six months to two years you will need a top-up of Botox in the bladder and, for one in 12 women approximately, this relaxes the bladder so much that sometimes you can't empty the bladder. Therefore, when we give the Botox injection to the bladder we always teach, we always empower you, to catheterise yourself. It sounds more horrible than what it is, but Jan and Mary make it actually quite an easy procedure. They make sure that you have enough catheters and you're empowered in case the need arises. It's very simple; it's a small catheter which you can keep in your handbag and when you need to empty, go to a toilet and you can empty and use it and throw it in the bin.

It throws patients often quite a bit against Botox because of theoretical risks of one in 12 needing a catheter but actually using a catheter after being taught, it's such a simple procedure that once they know what it entails most of the patients become very confident, but this is not a big deal for them

And then comes the nerve stimulation and there's a little device which goes in your spine which controls your bladder which is all usually done in a tertiary unit, not done at any a normal unit and not offered at Benenden as it has to be in a specialised London centre.

Now for stress incontinence, which is when you leak with coughing and sneezing. The treatment options have changed remarkably since. All of you must have heard about the issues with ‘mesh’. Now issues with mesh surgery, we all know about so going back I think now, once you have done your weight loss, you've done pelvic floor exercises and you're still having a problem with stress incontinence then there are a repertoire of options you have.

So, we have the issues with mesh now, therefore more and more counselling is needed for patients to understand what they are. Gone are the days when anybody could have offered the treatment for incontinence as a surgery. Now it's only done in the specialist centres with specialists who do this routinely in a unit. It should only be done in a unit which has a complete, supportive environment and a unit which is completely a urogynaecology unit, which has multi-disciplinary team meetings, which has got specialist Consultants who do this kind of work routinely and has got specialist nurses and physiotherapists who can advise you about the procedures, the pre-procedure and the post-procedure issues and successes. So, this has now changed dramatically.

So, we'll talk about stress incontinence in a minute but for overactive bladder I think Jan also offers something called PTNS, which is a less invasive option. Jan, do you want to talk about PTNS quickly? That's for overactive bladders. Sorry, I jumped the gun a bit!

Jan Chaseley

Yeah that's fine. So PTNS stands for percutaneous tibial nerve stimulation. So, the tibial nerve, which is situated sort of just above your ankle bone, runs up to the base of your spine and it's responsible also for your bladder. So we offer it privately, it's a 12-week session and it's a tiny little acupuncture needle that just goes in at the side of your ankle, attaches to you like a TENS machine and it gives 30 minutes of stimulation to the tibial nerve. And what you hope is that it's going to help with the symptoms of the overactive bladder, the urgency and the frequency.

So, I mean you'd need to be properly assessed by a Consultant first to make sure it's an appropriate treatment, but it is something we offer here.

Mr Abhishek Gupta

Thank you, Jan., So when we come to stress incontinence what are our treatment options? So basically, before the mesh (everybody must have heard about the mesh because every patient I see the first question they asked is I hope, Doctor, you're not doing this horrible mesh) which was paused in England in July 2018, which is coming up to almost three years now. And this was a very successful procedure and still if you go into NICE, which gives us advisory capacity, still offers tape (TVT) as a treatment option for the patient was an incredibly successful operation and the operation itself is not bad, it's a very successful operation as a day case surgery. The problem happened before this time; it was unregulated. So, as I was saying, that it was unregulated in the sense that anybody who has a bit of leak. There was no regulation about who can do the steps and which clinician can treat it.

So, anybody who is now going through a surgical option has to be done by a trained Consultant who specialises. So gone are the days when general doctors can do these procedures.

And the second thing is each individual patient has to be discussed in a multi-disciplinary meeting, which it has to have two Consultants who specialise in the field present, including a specialist nurse or a urologist. They all have to discuss the suitability of this procedure. So anyway, the mesh is on hold. We don't know whether it will come back or not but it was a good operation. It had some side effects, I must say, but they were few and far between in our practice and we had a very good success rate. But at the moment it's on a national pause and I'm not sure when the pause can be lifted, or which hospitals will be allowed to do the tapes in future.

So, tape itself was not a bad option, it's just we have to assess which patient this mesh is really suitable for and that's when the problem happened, when it was unregulated before.

So what are the three other options? So, there are two major surgical options. One is what is called colposuspension, which used to be a gold standard operation before 2001 and still sometimes considered gold standard.

So, what do we do on the colposuspension? It’s either done with keyhole surgery or a little cut in the tummy which is a bikini line cut. We go deep in the tummy and then put a couple of stitches through the vagina through that tummy, very close to your bladder - almost in the vagina - and pull this up and stitch with the bone on the back of or near your pubic bone – deep in.

Now this procedure elevates the neck of the bladder which, I was saying, this is the bladder, that's the urethra which is the tube out, so this gives you support here from the top, wakes everything up like this.

The advantage of this procedure is; none of the procedure is one hundred percent successful so therefore I'm saying that we need to optimise the success rate by changing lifestyle and everything and doing pelvic floors. Seventy five percent to eighty percent of patients feel that their quality of life gets better with this operation. So, if it's around 75-80% successful it's a major surgery. You’ll need a couple of days of hospital stay and about six to eight weeks of recovery.

One in ten women may find it difficult to empty the bladder and may need catheters which usually settles down with time and this slightly increases your risk because it gives you such a good support in the front of the vagina; it slightly increases your chance of prolapse on the back of the vagina. That's colposuspension.

The autologous fascial sling is similar to the tape operation or the mesh operation we do, but without the tape. You use your own tissue to make this sling, so when we do like a bikini line incision. If somebody had a Caesarian section, it's exactly at the same point just above the pubic bone. We make around a six, seven-centimetre cut. We harness a tissue from there, which is called rectus sheath, then we go through the vagina just near the neck of the bladder. We open the vagina there and then put a hammock like this which goes up and gets stitched again at the tummy. And then we stitch it back.

So, this is all your own tissue as a sling to give you support at the neck of the bladder. This operation again has a success rate of around 80% and the data shows we are getting that kind of success rate. It's a major surgery. Patients do have to spend a night or two in hospital. One in ten to one in twelve patients may need to have catheters, which we may teach you how to catheterise yourself which usually settles down with time. But this can take a few weeks to settle down.

It doesn't increase your risk of prolapse on the back of the vagina so that's one advantage over colposuspension and it is quite a successful operation; around 80 percent. We’ve talked about the tape, so we're not going to talk anymore about that.

And the last, but not the least, is something called a bulking agent. Now bulking agent is a permanent gel which is a hydrophilic gel. What hydrophilic means is it’s 97 percent made of water and then the other three percent is polyacrylamide. It's an inert gel.

So, this procedure is done by having a look in the bladder with the tube where your urine comes out which is called the urethra. We have a look with the camera at the urethra just at the neck of the bladder. So, this is the bladder, that's the urethra just at the neck of the bladder. As we have a look inside. Four injections are given.

What this does is this gel creates cushions around the neck of the bladder, so it gives you support for where the urethral sphincter is to reduce the chance of leaking. Now the advantage of this procedure is it's the least invasive procedure and more and more patients can do it; most patients are suitable for it to be done by local anaesthetic. And there's no down time, you can have the procedure and you can go home and do normal activity pretty much next day.

So that's the least invasive procedure, use the permanent gel. But at the end of the day, because it's a gel, and it doesn't give that kind of support, the success rate is quoted as 55 to 60 percent. In our own audit (I've got my audit for my NHS practice) we’re getting similar 65 to 70 percent. We’re getting more than 55-60% results we're getting approximately 65 to 70 percent success rate with this procedure.

It's a permanent gel and we may need to do a top-up later on so once we do it if it's only partly successful, we do a top up. The local anaesthetic technique has now progressed so when we initially started doing this procedure three to four years ago, we used to do it under general anaesthetic. And then we brought it to outpatients, and we modified our technique based on the Helsinki technique. We modified and made our own technique and then the patients tolerated this procedure very well in outpatients.

So, the pain score - which is what we measure patients with - the pain score which is a visual analog score, which is 0 to 10 how the patient perceives the pain. On average the pain score for this this procedure is roughly two out of ten or three out of ten, so patients are tolerating this procedure very well in outpatients and therefore this we mainly offer this procedure in outpatients, I think both here at Benenden in our Ambulatory Care Unit and also on the NHS. And if you are overweight, if you have not finished your family, your fertility is still an issue but your incontinence is affecting your quality of life I would say that, rather than going for any major invasive surgery, try this procedure because at least you've got a less invasive procedure. Because if you get pregnant, or if there is a massive loss of weight here and there, then more than likely any surgical procedure will fail or there’s more likelihood of failure. And the first shot doing any operation is the best shot.

So, when somebody is unkind to you and say ‘lose weight’ or ‘finish your family’ it's not they’re unkind, they want to give you the best shot at making you better. And we need to have engagement between both of us - patients and clinician. So for those patients who have not completed their family or who've got medical problems, health problems who are not suitable for major operations or are patients who don't want to have any downtime because of other options then a bulking agent becomes a really good option for them.

So, there is an easy place where you can read about this, which is called the NICE decision aid, which I have just enumerated. You can Google it, you can get the NICE decision, you can read it and I really like this decision aid because it's written with the patient in mind. So, it’s cut the medical jargon out. It tells you in a language which is easy to understand for a patient about what this entails, what the success rates are and what complication rates are and how we compare this to others so this is - in short - from the NICE decision aid which we have just discussed, I've explained a bit better with how things work.

So that's a short and sweet summary of incontinence and what is available to help your condition. Jan, do you want to add anything more or we'll open it to the floor for questions now?

Jan Chaseley

No, I'm fine, I've got a few questions so - if you're happy - we'll take some questions. I think I can probably answer the first one. It says I'm constantly worried that I'll have an accident when I'm out and about so I go to the toilet as often as I can. Is this a bad habit to get into?

So basically, the short answer to that is yes, it is a bad habit to get into. I absolutely understand why you're doing it, because you worry about getting out and about, you know, and being able to do the things you want to do. But what you're doing is you're getting your bladder to start to think it's not meant to hold very much urine, which is slightly giving you those overactive bladder type symptoms.

So, to be honest, the best thing to do is - if you've gone to the toilet before you've left home - try not to go to the toilet again until you get there or don't go before you leave home and go when you get there. Work on the bladder retraining. If it's something you feel you need help with, please feel free to contact us in the Continence Care department and we can help. But try and just work on that bladder training so your bladder capacity doesn't get too small.

Mr Abhishek Gupta

And then, if there is a genuine problem that you really can't hold the bladder and you know that’s not in your head or you think it's not in your head and it's a genuine problem then there’s no harm in getting it investigated after you've done the bladder re-training and taken a trial of the medication to see whether there is a genuine problem going on rather than just your habit.

So, the habit has to be broken; that's what bladder retraining is all about. But if there is a problem and you're trying to hide that problem by just going for waterworks often and making sure your bladder is empty all the time so you don't leak, then we can address the problem itself.

Jan Chaseley

And a question for you, Mr Gupta, although I can't seem to see it but it was here earlier it was saying that I'm now post-menopausal and I've noticed I'm getting a slight leak. When should I seek help?

Mr Abhishek Gupta

It's actually a very good question, when to seek help. So, whether you have a slight leak, or you've got a large leak, it's very individual. So, depending on what it’s affecting you doing, that is the question which only patient can answer.

If you've got a slight leak, but this is affecting your confidence, it's affecting what you love to do, it’s affecting you playing golf (if you play golf), it's affecting you doing kickboxing, if you do, or it's affecting you doing trampolining, if that’s what you do, then you need to seek help.

If it's not affecting you and you've got a bit of a leak, then you can always do a pelvic floor exercise or see a nurse specialist to make sure it doesn't get worse in future. But if this affects your quality of life then you should come forward and see one of us so that we can give you help with what's needed.

So whether there is a small amount of leak, or there is a large amount of leak, when it starts affecting you as an individual - you and your quality of life - because everybody's quality of life is different, then it's time to seek help. If people wear a panty liner, they are not bothered with it, they can manage with pelvic floor exercises there's no point having any procedures done. But if that is something which makes you more conscious, makes your confidence go down, or you can't do the activity you love to do, come forward for help. It's not about the quantity of the leak, it's when it affects your quality of life.

Jan Chaseley

You're absolutely right because everybody is an individual. So the next question I can answer again is what is high intake in terms of caffeine? How many cups of coffee or tea for example?

So what we would generally advise is probably don't really have any more than two cups of caffeine in a day and switch your drinks to decaffeinated, so whatever brand of tea and coffee you have everybody now makes a decaf version. So, buy a decaf version because then the taste is still going to be the same and try and just maybe restrict it to two. And particularly again, as Mr Gupta said, look at green teas and some of those other ones. Just check you've got decaffeinated versions.

Mr Gupta, a question that says can you tell us the names of the medications you mentioned again?

Mr Abhishek Gupta

Two medications which I mentioned. One is anticholinergics, the commonest one which we prescribe is something called Oxybutynin or VESIcare. These are the commonest prescriptions you will get from your GP or us. Another for relaxing the bladder is called mirabegron which the commonest prescription you get is called Betmiga, so these are the three, four commonest prescription of medication we give.

And one and the first medication which is an anticholinergic which I said has a side effects like dry mouth also is available in patches (some people do prefer patches better) which is called Kentera patches. It's got a medication called oxybutynin. The second one which has got less side effects, which helps to relax the bladder, is not available on patches.

Jan Chaseley

Thank you. Next question is can stress incontinence be cured by diet and exercise and if so, how long does it take?

So from my perspective if I'm seeing you and we're going to be working on pelvic floor exercises and, to be honest, the way you're going to know if you're doing your pelvic floor exercises correctly is to have a proper assessment by either a women's health physiotherapist or by a specialist nurse like myself so that you're absolutely confident that what you're doing is the right thing to do. And the guidelines say you need at least three months of good, structured pelvic floor exercises before you're even necessarily going to see any improvement.

So, the really important thing is to stick with it. Don't get despondent. Hopefully you will get an improvement but it's not going to be an easy fix and again obviously if you're a little bit overweight, losing weight. It's all about reducing the pressure so that would help as well.

Mr Abhishek Gupta

And it's also a conservative option. If it helps you will avoid an operation so that's important.

But even when as I was trying to tell you about the outcomes of the surgeries which is 80% success rates or 55 to 60 with the bulking agent. If you are compliant with your exercises and compliant with other health, other lifestyle modifications you will more likely be in the category of eighty percent. But if you're non-compliant and you don't, say, stop smoking, you still have a bad chest, you still are overweight and you gain more weight or you don’t do your pelvic floor exercises when you get better in time you may risk falling into that 20% category of success.

So any ways you can improve it in the first place, you may avoid seeing me or if you do have to see me you will improve my statistics of success rates because you will be compliant with us!

Jan Chaseley

Why do I need to go to the toilet several times in the morning then the rest of the day I'm fine?

Mr Abhishek Gupta

It depends on what the last drink is that you drank. So, if you have a habit of drinking a big glass of water in the night and you get up with a very full bladder then it may take a couple of times to empty the bladder. It's well known, when you expand your bladder too much, then you cannot empty the bladder; nobody can empty the bladder completely in one go so, if the bladder is completely full, it will take a couple of times to empty the bladder.

Second thing it’s worth looking at if you've got any swelling on your leg because some people have something called lymphedema, which is swelling of your legs and that's what happens when you sleep. All this fluid, which when you're awake and you're walking around, gravity is helping that fluid in your legs come into your bloodstream and you produce more urine. Therefore, you get up with a very full bladder and you have to go a few times.

And the third thing which can also happen is to see what medication you have and if you are on a medication like a diuretic which makes you produce more urine what time you take your medication. So, these are the kind of lifestyle changes. If these are all taken care of and you still have to pass urine two or three times in the morning before you're fine then probably you might have to see Jan before doing anything because it may be just a lifestyle adjustment you need.

Jan Chaseley

Lovely and thank you very much. I'm sorry if we didn't get around to answering all of your questions and we will do so after the event. If you'd like to book a consultation either with us as a specialist nurses or with Mr Gupta, the Private Patient sales advisor Jane is available tonight until 8:30pm on the number that's showing on your screen. You will receive a short survey and I would be grateful if you could spare a few minutes to let us have your feedback on today's webinar.

Our next webinar is on Wednesday the 10th of November with Mr Steve Garnett, Consultant Urologist and he'll be discussing UroLift® which is a minimally invasive treatment for enlarged prostate. So on behalf of Mr Abhishek Gupta, myself and all the team at Benenden, I'd like to say thank you very much for joining us today and we look forward to you joining us again for another webinar very soon. Thank you, bye.