introduce Dr. Cheryl Carter-Brooks. She is currently faculty at GW in Washington, D.C. and is the Assistant OB-GYN Residency Program Director and the Departmental Director of Equity. She was recently inducted into the AOA Honor Society as a Distinguished Faculty Member and has been recognized by her peers as a top doctor in the Washingtonian Magazine numerous times. So please join me in welcoming her. I guess I'm a little bit visually challenged. I turned 40 this year, and it's hard to see small prints, so I will try to read this down here. I'm talking to you guys today about overactive bladder. When I finished fellowship, I was like, oh, I'm just going to do prolapse and prolapse surgery. It's going to be great. And then I got into practice, and I'm like, oh, my gosh, everybody has OAB. It is all around us. It is everywhere. And so the past seven years have really just spent a lot of time kind of honing my overactive bladder. Thank you. Who's making it bigger? My overactive bladder kind of pathway and discussion. And I feel like these are my patients that I really get to know. We bond. We're going to see each other once a year, maybe more than that. And I tell them, you know, it is not a sprint. It's a marathon. We can get your symptoms better. It is just going to take some time, and we have to work the pathway. And so I really come to enjoy overactive bladder. These are learning objectives. So overactive bladder is a symptom-based syndrome. And it's characterized by urinary urgency, plus or minus urgency incontinence. And there can also be accompanying frequency, nocturia, and you want to have the absence of urinary tract infection. And this graph here on your right, you can see that the prevalence of overactive bladder, both men and women, increases with time, right? In your 20s, it's much less common until you get into your 80s. And overall, I think that little dot there is showing about 15% of the population will have overactive bladder. And so who we see, most patients are going to have some of these symptoms that we're going to see in the office. There is a huge impact on the patient. And I think that's really why I love urogynecology and pelvic floor disorders, is because women, people often feel shame, embarrassment about these symptoms in their body and don't tell people what's going on. Like, even now in 2025, I see so many patients who are, like, underdiagnosed and undertreated for many reasons. And so it's really important to acknowledge that in our patients. There is physical impact, right? Health and fractures from that urgency, waking up at night, skin infection, as Dr. Propst talked about, vulvovaginitis. The financial burden, this data is old, but $900 per year for supplies there, it's probably twice that at this point in 2025 and will continue to rise. And the overall spending in the United States is well over $20 billion per year at this point. And then the emotional, the depression, social isolation, anxiety that goes along with these symptoms. When we think about overactive bladder, it's caused by a detrusor spasm, that's that bladder smooth muscle. And the pathophysiology, I'm not going to spend a whole lot of time on this, but you guys will have the slides if you want to review it in more detail. But there's neurogenic, myogenic, and urothelial causes. And basically results in hypersensitivity, abnormal function of the trusor muscle, increased afferent sensitivity, and then also decrease in our nitrous oxide, which is a relaxant of the bladder. So there's a number of different reasons why someone can develop overactive bladder. I think as we go through our history, and asking patients about their medical conditions, we can kind of focus on what aspects might be causing their overactive bladder and how to address those. Okay, so office evaluation. Office evaluation is one of the most important pieces of treating overactive bladder. Most of your time is going to be spent on your history. And your history will guide your exam and your treatment. And so we're going to start with the history, and we're going to use that to direct our exam. And then we're going to guide the remaining evaluation. I'm sorry, guys. It's really hard for me to see this. A little bit closer. I didn't realize I was so hard of seeing. And so our goal is to, from our history, have a clear understanding of what the patient is presenting with. So your type of urinary incontinence, the severity of your problem, the duration of your symptoms, the impact on their life, reversible factors, and medical conditions and surgical history. When we think about urinary incontinence, you want to think about it as a symptom, a sign, and a condition, right. And so it's kind of encompassing all three things. Our urgency urinary incontinence is that detrusor overactivity that we have there. And if it's combined with stress, then that's mixed incontinence. I listed the other types of urinary incontinence there because those may be caused by detrusor overactivity as well. And so you want to pay attention when you're asking, is that positional incontinence from sitting to standing from a bladder spasm, or is that stress incontinence? Do they feel the urge and then have the leakage? So you want to think about that even though it's not necessarily urgency incontinence that we're calling it. Detrusor overactivity is causing this condition, and I said that's urgency, which is uncontrollable desire to void. Your frequency, which is going eight or more times a day in 24 hours. Nocturia is waking up one or more times at night, okay. So any waking up at night is nocturia. It is not normal, and you need to address it. And then plus or minus the incontinence, which is the involuntary loss of urine with that detrusor spasm or overactivity. You want to ask about your lower urinary tract symptoms as well. So there are storage symptoms, right, as the bladder is filling, what's happening. That's going to be your urgency, frequency, nocturia, and your incontinence. Then you want to think about your voiding symptoms, right. How are people emptying? Your hesitancy, your slow stream. And then your post-mictuition symptoms, which are feelings of incomplete emptying. Incomplete emptying is hard too, right, because that can be a symptom. It can be a sign. It can be a diagnosis. And so just because a patient says they feel like they're not emptying their bladder does not mean they are not emptying their bladder. And I try to make that very clear to them. What you're feeling is that urge. That's that bladder spasm that's happening. You are actually emptying your bladder, as we showed by the PVR. And then your post-void dribbling, right. Again, after the patient gets up off the toilet, they go to wipe or whatever, and they get a few drops. Again, bladder spasm that's happening. I really like this questionnaire. I think it's a combination of multiple questionnaires. It's in the Walter and Karam textbook. But all of my patients get a new patient packet that have validated questions in there to kind of help assess their symptoms before I get to them. An overactive bladder, I highly recommend that you use some type of patient questionnaire before you go in there so you get a sense of what's going on to direct the history instead of letting people kind of just open up and tell you, you know, the first time they had a leakage episode back 30 years ago, you know. You will not make it out of that room, you'll be behind for the rest of the day. So use your questionnaires. This one's nice because it kind of goes through, gets to the symptoms, severity, history, UTI, and then voiding dysfunction. These are other examples of validated measures. You should have this, again, on the website, you'll have copies of the slides. But this one is nice and easy, just goes through severity. These are great tools and I highly recommend you use them. And then you can also use this to track your progress, right. As you institute a treatment, go back to your diary, compare or go back to your measures. Compare how they are now to how they were before because sometimes you lose sight of the progress that you've made, okay. It's really important to remind the patient an overactive bladder, look, you were leaking six times a day before, you were going to the bathroom every hour, you're waking up three times at night. Now you're able to go every two to three hours, you're leaking once a day, you're getting up once at night. Like that is an improvement, maybe it's not what you want, but it is much better than where we started. History. History, history, history. This is why I love working with my medical students because they will get a great history. But also, if you don't have time to do this yourself, again, using your patient packet, either paper or if you have Epic, you can build this into Epic to get the history so then you can target things in the history to discuss with the patient. So medical history, constipation, constipation, constipation, constipation. Everybody is constipated. We have to address it. We talk about constipation. I love magnesium. I'll just magnesium oxide for constipation. If your patients aren't using it, highly recommend. Diabetes is huge, huge, huge, huge. And diabetes can affect the nerves that go to the bladder, sensitivity, but also the increased volume production with having elevated glucose and then the medications that dump glucose into the urine. So a lot of diabetic patients. But just because they have diabetes doesn't mean that we can't treat them. They still deserve to be treated. Stroke, clearly. Lumbar disc disease, so much lumbar disc disease, right? Our patients with back pain, sciatica, patients who've had hip and knee surgeries. These are overactive bladder patients. They have the surgery. I don't know what's going to happen with your bladder symptoms. They could get better. They could stay the same. They could get worse. But a lot of patients I see with that, the psychological history, anxiety, depression, how is that playing into your bladder symptoms, especially for your younger patients and their teens and their 20s and 30s? A lot of that can be related to anxiety conditions. Sleep apnea. Sleep apnea, I think, is a true hidden epidemic, because everybody has it and nobody's being treated. I feel like everybody probably should be screened once they're in their 50s, but you don't have to be obese either. I think there was a misconception. You had to have the big belly, the big neck to have sleep apnea. But it's really a change in the ligaments and the connective tissue in your neck and in your airway that happen and through that menopause transition. And so sleep apnea is very common. If I have patients who are getting up two or more times at night, I'm like, here's a referral for sleep medicine for a sleep eval. And many of them do have it. And it can make a significant difference treating the sleep apnea and symptoms, because those patients with sleep apnea have a decrease in their antidiuretic hormone. And so getting back that sleep cycle helps decrease the volume of urine they get at night. Congestive heart failure, that's just to increase volume, right? Lower extremity. I touched everybody's ankles. I think the patients like it, but I feel their ankles. And I... Some people don't. They're like, oh, you're hurting me. And I press my thumb on their bone there, because it's like, oh, I don't have edema. And I'm like, look, it's like two plus here. They're like, oh, I didn't know I had that. So paying attention to what's going on in their legs. Of course, you're up at night twice, because you have all this fluid in your legs. So get those legs up, talk to your doctor, get some compression stockings. Surgical, the prior prolapse repair, incontinence repair, hysterectomy, spinal fusion. I didn't put C-section on here, but that can be on here. Endometriosis, whatever's activating that pelvic pain is probably activating the bladder as well. Fibroids, hypertonic pelvic floor. I was really excited to see tomorrow. It seems kind of like a pain day. I don't want to call it a pain day. But there's so much pain. And I think pain, urinary symptoms kind of go hand in hand. So pay attention to the pain symptoms, hypertonic pelvic floor, the vestibulodynia. Because if you treat those things, your urinary symptoms can get better. Deliveries, we typically think of vaginal deliveries causing all these risks. But C-sections, right, you have that scar on your anterior abdominal wall through your rectus muscles. You get tension at that scar in your belly. That puts tension on the pelvic floor muscles or the weak abdominal muscles just from being pregnant. It puts increased pressure on the back, increased pressure on your pelvic floor. And then work. A lot of patients can't go to the bathroom when they want to. A lot of our teachers are in the classroom. They can't leave. It's really stressful for them. In other careers, I have a lot of metro workers who drive the buses and things. They can't just stop the bus to go to the bathroom. They have to wait until they get a break. So thinking about someone's career and how that's impacting their urinary symptoms is really important. Living environment. Are they housed? Are they unhoused? Where are they living? Interpersonal violence, right? Trauma. All these things at home. There's been some studies recently that have shown that trauma, abuse, increase the risk of overactive bladder symptoms. So these are really hard topics to talk about, but so important with the patient that we kind of understand what's contributing to their symptoms, even if we can't fix that specific thing. I spent a long time on that, but I think the history is just so important for overactive bladder. This is a mnemonic. For those of you who like mnemonics to help you remember those things in the history and what can be changed. This will also be in your packet. I think the atrophic vaginitis I didn't touch on, that is important to remember when you're doing your exam too because that can cause these symptoms. And then delirium dementia as well. These are all the medications that can affect the bladder symptoms. There's a lot of them. I think the things that I focus on are usually on this are like the diuretics are what I tend to focus on. But every once in a while I'll get another medication in here that might affect the bladder. So you just want to kind of eyeball the medications that somebody's on too and how that could be affecting their bladder. Okay. So from your history, you should really be able to make a diagnosis, okay. So once you have finished talking to the patient, you should really understand what is going on and what you should be looking for in your exam. And it shouldn't be, you know, too surprising what you're going to find on your exam. So my exam includes looking at their weight, lower extremity edema, my pelvic exam, post void residual, and then urine analysis plus or minus a urine culture. And so if somebody just wants conservative management, not really interested in medications or other things, and even if they are interested in medication, you might be able to get away with not doing a pelvic exam. There's a lot more telemedicine that's happening these days. We're trying to increase the diagnosis. So you can't always do an exam on everybody. And that is okay in certain circumstances. So we talked a little bit in the last lecture about the exam. So I'm not necessarily going to go through the entire exam for incontinence. But it is important to look again at your vulva and the vestibule specifically near the urethra and posterior near the hymen to see if there's those signs of GSM, genitourinary syndrome of menopause. I also do a little Q-tip test with a moistened Q-tip there, anterior and posterior, to see if there's sensitivity. I, on the other hand, I'm very aggressive with vaginal estrogen cream and pretty much prescribe it to everybody. And then just bring people back to make sure that they understand why they're using it and make sure they're using it the right way. Assessing their pelvic floor is also part of my exam and not just a strength but for hypertonicity. I will put one digit in the vagina and feel at 7 o'clock for muscle tension and spasms. So the muscle should feel like soft, like your palm, right? If it starts to feel tight or firm, kind of, like more like beefy, I guess, or taut like strings on a guitar, that is very tense. That's how I describe it to the residents and my APPs when I'm working with them. So I just go to 7 and then I go on the other side five and two so I'm getting the levator anti-muscles and I'm also getting the obturators. Don't forget about the obturator muscles. When those obturators are tight you get a lot of urinary urgency symptoms. There's a really good paper that goes over the muscle dysfunction in the pelvic floor and what symptoms patients will present with. And these are just your your scales for measuring the strength of your pelvic floor. Neurologic examination you can definitely get more into this if you'd like. I really would reserve this for patients who have like a spinal cord injury or history of a stroke. I do work with a neuro urologist so I will send many of the more complicated spinal cord injuries type patients to them to manage. And then this is just the sensory dermatomes here on your vulva perineum and you can look for your anal link and your bulbous cavernosus reflex. Although you know if you don't see them it doesn't mean that their system is not the nervous system is not intact. Okay so we talked about these things. Now in terms of diagnostic tests which you want to do for overactive bladder you want to do your urine analysis. So microscopic urine analysis not a reflex. You want them to look under the microscope to count the red blood cells and then I'll usually add a culture for a new patient in case it does come back with blood to make sure there's not UTI there. And then your post-void residual I use a bladder scan to do that. Some practices will catheterize patients to get the PBR. You have to use what you have and consider that. Optional would be your voiding diary. I love a good voiding diary. I think it is insightful for the patient. It's insightful for me. We learn a lot together and I am very quick to give a diary to and have them send it back. I think it can be helpful. The pelvic floor PTs that I work with usually have the patients do a bladder diary so I don't always give it if they're gonna go to pelvic floor PT because I don't want them to do double work. But it can be very helpful for overactive bladder. And then pad counts. So used to be you'd like literally save all the pads that you use and put them in a bag and weigh them. I think my office would probably lose their mind if somebody brought bags full of wet pads into the office to be weighed. But kind of having a sense of how many pads somebody's using, the type of pads, the number is helpful. Urodynamics. We just went through a very nice kind of example of when urodynamics would be helpful. I think if somebody has refractory symptoms you could consider it mixed and you're not sure which is worse you consider it. Prior incontinence or prolapse procedures you could consider it. If someone is not emptying, that's usually when I do it, so someone's not emptying completely or if they have an underlying neurologic disorder then I will usually get urodynamics in those overactive bladder patients. Cystoscopy and other imaging are not routinely recommended unless you're concerned about erythrodiverticulum or a Skene's gland or a cystoscopy if they have microscopic hematuria or they've had a previous mesh and you're worried maybe there's a mesh in the urethra. You know I've been in practice what seven or eight years now and I saw my first mesh in the urethra recently and I was like oh there's not going to be anything here and there was. So sometimes you do you do find things and people have had previous surgeries so something to think about when I should consider doing a cystoscopy. Okay so this is we have about ten minutes. This is just kind of generally what we just talked about here. So you want to get your diagnosis from history. You want to document the impact of their symptoms. Your exam should supplement that history. You want to get your UA and your PVR and consider urodynamics but it's not needed and imaging and cystoscopy aren't really recommended. Treatment. So behavioral interventions are really like the mainstay treatment of overactive bladder and this is really where we deep dive into all that medical history that we got. Focusing on these interventions alone will improve symptoms 50%. That is what studies have shown right and I put my pelvic floor PT in here because that also can improve symptoms about 50% as well. So for our fluid management we want to avoid excess fluids. Your goal is about 64 ounces of fluid a day and that should be in the day not right before bedtime. You want to avoid your bladder irritants, spicy, pretty much anything that's good. Anything that you drink and you like it's probably not good for your bladder. Patients laugh but I know that they're probably crying on the inside. I'm like you can have milk, milk and water like who wants to drink that. I'm not too crazy about it. I'm like look if we're drinking six Cokes a day like we have to scale it back you know or like the person who like has their cup of black coffee that they drink throughout the day. I'm like can we scale this back a little bit to see if it helps add some water in but I'm not too crazy with restricting everything because I understand you want to also have quality of life. Definitely though restricting before bedtime and thinking about foods too like pasta, sauce, chocolate. Some people are very sensitive to that. Bladder training and bladder retraining. I really do love the bladder retraining is trying to defer that urge. Pelvic floor PT will do this with patients too. At least a lot of them will but I talk about that delaying the urge, your freeze and squeeze, your time void. So starting at an hour working up to an hour 15 minutes, hour 30 minutes, hour 45, setting a timer. Not just responding to your bladder when you need to go and the goal is to get to voiding every two to four hours if they can. Test part of the time voiding too and then weight loss. A five to ten percent loss in weight can result in 50% improvement in symptoms. So weight loss is important. It is hard. Now there's lots of medications. There's weight loss centers. I feel like it's a little bit easier than maybe it used to be and it's not shaming somebody because of their size or their weight but it is like you know this is literally the weight is putting pressure on your bladder you know and most people probably know they need to lose lose some weight and I think it's just being open and respectful with them about it. Okay pharmacotherapy. So our anti-muscarinics or kind of our mainstay medication for overactive bladder. They have an anti-cholinergic effect. They work on the parasympathetic side of things and they inhibit those bladder contractions. I put this beautiful little picture in here for you guys to review at your leisure about the mechanism. And so it's the M2 and the M3 receptors that are in the bladder. The M3 receptors we think really drive that contractility, the detrusor spasm that's happening. However there's other these other receptors or other places in the body and that's why we get the side effects from the medications right because those M2 are in the bowel they're in the eyes as well. And then there's the beta-3 which promote bladder relaxation. So the anti-muscarinics basically stop the contraction the beta-agonist relaxes the bladder. And so that's why sometimes we'll use both medications together because we're targeting the overactive bladder from two different mechanisms. There's no parasympathetic effect with the beta-adrenergic agonist and they activate that cyclic AMP cascade. And so studies have shown essentially that there's about a 50% improvement with the anti-muscarinic medications. So we said earlier the behavioral modifications result in about 50% improvement. Medications are about 50% improvement and that's why you can start both at the same time but I'm a big proponent of behavioral of pelvic floor PT because that is the one thing the patient can do themselves to reverse the symptoms right. People are, especially in DC no one wants medication and everyone's really active people don't want intervention. But I'm like well look if you don't want these things and you have to do the behavioral side of things that's the one thing you can do to change this for your body. Doesn't work for everybody but it's a good place to start. And you can see that it's pretty much the same efficacy as your medications without all the side effects. But the medication is about 50% effective it does decrease your urge incontinence episodes. You need to trial the medication for 4 to 12 weeks and really close for that 12 weeks to see your maximum efficacy. You want to start at the lowest dose possible and then titrate up. Again so this is a marathon it's not a sprint to get the improvement that we want. The continuation rate is was low at six months in some of the earlier studies and I think that has to do with again the side effect profile. So I do talk about that up front with patients and how to manage the side effects. And you can add the beta agonist for increased efficacy. So the side effects with the anti-muscarinics dry eyes dry mouth constipation in about 15 to 20 percent of patients. So for constipation I told you I love magnesium right like let's start that magnesium now so that way it's on board when we add our anti-cholinergic or daily Miralax or increasing your fiber for the dry mouth. There's that biotin you know you can use the artificial kind of moisturizer for the mouth. Same thing for your eyes we can use drops for your eyes. A lot of patients they can get through that initial period where they're having some side effects they'll start to decrease after that one month period. So I try to manage the side effects to get them past that first month. Did then actually see if the medication is helping or not. And just I didn't put this in here but oxybutynin is also helpful with hot flashes too. So if you have patients who are dealing with both that could be a medication that you'd want to use. The cognitive effects dementia urinary retention are much less but we're going to talk about the cognitive effect a little bit later. You don't want to use these in someone who has gastric retention narrow-angle glaucoma or myasthenia gravis. So you kind of want to burn these to memory and then caution in your elderly and patients with dementia. So there's different formulations of the anti-muscarinics. The ones that are m3 selective are better because they have less side effects. So that's going to be your solafenicin had a better effect on the bladder than the salivary glands. And your darafenicin which had less of this has less of the CNS or the nervous system and the cardiac side effect profile because they are more m3 selective than the other medications out there. Your extended release formulations are going to have less side effect profile than your immediate release. So if you can you want to choose your extended release over the immediate release. Efficacy was similar. I personally have been having a hard time getting trospium XR covered by insurance. Sometimes there I will use the twice a day dosing for patients. And then these are all the ones that have the extended release and IR release formulations. Your tolteridine, oxybutynin, and trospium. And then your quaternary amines theoretically should not cross your blood-brain barrier decreasing that risk of cognitive impairment with your anti-muscarinics. So less CNS effects. So you want to consider those in your elderly patients. An example of that is trospium. And just quickly touching on the risk of dementia. This is real. There have been a few pretty big studies. I put the references there if you guys want to look it up at the risk of dementia with using anticholinergics. And these were in men and women. And it kind of was all-comer anticholinergic medications. And I think the take-home is that there is a dose dependent increased risk. And actually the dose is very low that you need to use. And so the heaviest level of exposure in this study was daily use for more than three years of any of the following medications. And you can see our beautiful oxybutynin is up there. Five milligrams, right? And I think probably in this study was more the IR. But still only three years of daily use increased the risk of dementia. So that is that is real. And something that I think we are grappling with as a community to discuss with our patients. But also in combination with a lot of these other common medications that our elderly patients are already taking, the risk is real. AUGS put out this statement in 2021. I don't think it's been updated since. But really we want to try to avoid anticholinergics in patients who are 70 and older for these reasons. Insurance has not caught up with us yet. So we are still fighting that battle. Write a lot of letters trying to get other treatments approved. But you want to focus on those with lower CNS effects. Like your trisbumin and your darathenis. And if you can and move quickly to your third-line therapies. And we're gonna be talking about those therapies later today. But I probably move pretty quickly to third-line for my elderly patients because of this. And that's why I maximize my PT, my estrogen. You know sometimes you have to we can't use the anticholinergics. Maybe the beta agonist is covered. Maybe it's not. And then we're moving to our third-line therapies. Our beta agonist. We now have ibegron for the last few years. Similar efficacy, less side effects. Hypertension with the mirabetric elevated systolic blood pressure 10 to 15 points. So you don't want to prescribe it in someone who has uncontrolled hypertension or kind of labial hypertension. But if they're well controlled on medication I will start it and bring them back for a blood pressure check, headache, and then nasopharyngitis. And the discontinuation rate was much lower. But it can be cost prohibitive depending on the insurance. I don't know who else is kind of tired of the back and forth between mirabegron and ibegron with the insurance. Yeah changing is every January. I'm like okay what's gonna happen? And you get like the slew of MyChart messages. But here we are. One day it'll be better. Okay third-line therapies. I'm not oh I'm gonna skip this because we're talking about this later. But I did have one slide. This is our summary here. I just wanted to briefly talk. Oh my time's up. About OAB and marginalized group. Okay minoritized patients. So patients of color, patients who are gender diverse, patients with disabilities. There's probably a lot of people who would fit in this category. There are studies showing that disparities exist in diagnosis, in treatment, and what we are offering them. Women of color are less likely to be prescribed physical therapy, less likely to get a beta agonist, less likely to get third-line treatments. And so I think we just need to be cognizant as a specialty of who we are offering what and making sure that we are giving everybody evidence-based treatments for their a very very common condition. And this is your guys's break but obviously if we are sorry for questions no you're good then you can just put them in that chat box. Hi. Hi. You mentioned earlier in your slides about post-void dribbling and being caused by that residual detrusor spasm. How do you know when it's that versus incomplete relaxation during the void of those high tone pelvic floor muscles causing a little bit of trapping between the two? Because I would imagine the treatment would vary since an OAB med would help the detrusor spasm, the other ones the pelvic floor muscles. That's a good question and I think that is something that's hard to differentiate. Again going back to my history and my exam. If someone has a hypertonic pelvic floor, but hypertonic pelvic floor or pelvic floor doesn't relax can trigger those bladder spasms too. So that person we're going to do PT right. If they are having classic OAB, going to the bathroom every hour, leaking right before that then that tells me maybe it's more classic overactive bladder and then we can do PT plus an anticholinergic or beta agonist. But that's a good question. Hi. How are you? Hi. Going back to the beginning of your lecture, can you clarify again why you would send a urine microscopy for the initial diagnosis of OAB if it's like a straightforward diagnosis or it seems? Can you just clarify again why? Yeah. That's a good question. I didn't go through for the evidence of that, but it is in the guidelines for us for evaluation of urinary incontinence is to make sure they don't have microscopic hematuria. Because you don't, most of the time very low risk, but you don't want to miss a bladder cancer, upper tract cancer that could be the cause of their urinary symptoms. Good question. Yes. Thank you. Oh. Just wave your hand. Is somebody talking? Okay. This basically is talking concerning the teachers, bus drivers, and all of that. So I see a lot of them, and they saw the same cries. So is there an advocacy group that is speaking for this group of patients? I know some have unions that have made arrangements that they have to have bathroom within certain feet of their classroom. So is there anything at all that you know of that as a specialty that we are doing to help these patients that have a better life and not have sick bladders? That's a great point. No, I don't know of any. And I think that's great. I do think that we need more advocacy for patients with pelvic floor disorders compared to some of what we see out there. So I think my goal is to help them be able to work, right? And so whatever treatments we need to do to get you there, that is my goal. Because I think, again, a lot of the times somebody's at this point where they're having that severity of symptoms, they have been untreated for a very long time, probably five, 10 years sometimes. And so can we catch those patients earlier? That's talking to our primary care colleagues, our OBGYN colleagues, our pediatricians even who are seeing like high school and college age students and saying, are you asking these questions so that we can get them treatment earlier on, we can get them into PT in their 30s instead of waiting till they're 50 and these symptoms are so severe. So I think early intervention, early diagnosis and treatment needs to be included in that conversation too. Thank you so much. I have a question over here. Well, a comment and question. So there's a couple of things that you mentioned, Nocturia said greater than one. Do we have to be looking at the time? Because that's kind of weird, right? That means we all have overactive bladder, right? So what time? Is there like, okay, is it in the morning or something like that? And then my next comment is how many letters are being written to insurance companies about this oxybutynin because they want us to do so many prior authorizations and other not to, even though that's a first generation medication. And my third comment or question, I need, you said something about the, you checking their ankles and I know these are all in my questionnaire. Sometimes I skip it because I don't have enough time to do it. Can you please explain why you said you do it all the time? Thank you. Okay. So let me start with that one question first about the lower extremity edema. Cause usually when I'm talking to them, granted I do have the luxury, somebody has gone in before me. Usually right now it's the sub I or my resident. And so they have gotten all the information. So as I'm talking to the patient about risk factors for Nocturia, that is when I say, Oh, do you have any swelling in your ankles? And then I touch their ankles at that point. You know, I kind of do the counseling and the assessing all together, but if I can't do it, then we break it up and we bring them back. And that is why I'm grateful, you know, that I have my APP colleagues because we share those patients and I can say, okay, you know, Megan has appointment in a month, come back and let's talk more about this. In terms of letters. Yeah. I feel like every week I'm writing a letter. I think hopefully Augs is advocating for, for us in this kind of area with the insurance companies. But I think right now just with, you know, the economy, things are going to be hard quite frankly. And then the first question Nocturia, yeah. So if they wake up at six and they're getting up at 5am to go to the bathroom, is that Nocturia? Like technically yes, but maybe that doesn't require, you know, as much attention. But if they go to bed at 10pm and they're waking up at 12 and then two and then four to ultimately get up at six, like that's a lot and sleep is disrupted. And so that's where that bladder diary is helpful. If you don't have time to get into that nitty gritty and the appointment, you know, have them do the bladder diary and come back in two weeks, come back in four weeks to review it. And then you can go through and you're like, okay, well, this is actually, you're getting up at five, you know, you get up at six. That's okay. Or like, no, you're getting up every two hours. Let's talk about the lower extremity edema. Let's get a sleep referral for sleep apnea. Do you have diabetes? Those other, elevate your legs, compression stockings. Yeah. Sometimes I'll play with the timing of the medication depending on when it is. Like if their main complaint is nocturia, you know, I may have them take the medication in the evening instead of the morning because there might be a little bit of bump. You know, once that medication is taken, we get a little bit more efficacy. Yeah. Good question. This may be a question that might be answered tomorrow, but if somebody has urgency or frequency and they've done a diary and cut out foods, and maybe you're suspecting maybe some interstitial, do you ever add, we add a Zyrtec 10 milligrams daily? That's a good question. I don't use a lot of Zyrtec for interstitial cystitis. So you know, interstitial, or now it's sorry, bladder pain syndrome is these urinary symptoms plus pain for six weeks or more. So really with ruling out infection, like it catches a lot more people in that. And I start with conservative things, avoiding bladder irritants, pelvic floor PT, and then I usually will add finazopyridine. That's kind of my go-to for that bladder sensitivity. If people respond to that, then I will do bladder, a series of bladder installations.

urogynecology

overactive bladder

equitable healthcare

behavioral interventions

pharmacotherapy

patient care

health disparities

Dr. Cheryl Carter-Brooks