Jan Chaseley

Good evening, everybody. 

Welcome to our webinar on female incontinence. 

My name is Jan and I am a nurse specialist at Benenden I will be your host for this evening. Our expert presenter is Consultant Urogynaecologist, Mr Abhishek Gupta. 

This 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 by the Q and A icon which you'll find at the bottom of your screen, this can be done with or out with or without giving your name. If you'd like to book your consultation, we'll provide a phone number at the end of the session and please note that this webinar is being recorded. I'll now hand you over to Mr Gupta and you'll hear from me again shortly.

Mr Abhishek Gupta

Thank you, Jan. 

So, as Jan said, my name is Abhishek Gupta, and I'm a Consultant Urogynaecologist, I got trained in southeast London rotation so my teaching hospital was based was guidance and promises and then I got trained in Kent and then I developed a special interest in urogynaecology, which is prolapse and incontinence on patients and I grew interested more because this does the problem of incontinence and prolapse does affect patients in a very different way they affect patients quality of life and their confidence which is different than somebody who's got cancers and all that so but it's very rewarding when you can treat and improve somebody's quality of life and that's how I got interested into it. So I completed my specialist training around this area and then I've been a consultant for more than 10 years and have been practising on and private basis at Benenden Hospital. 

So, that's me and we'll just talk about what so that's me consultant gynaecologist and urogynaecologist specialists then we'll talk about incontinence in today's webinar and I'll try to explain what it means.

What is the confounding factor which leads to incontinence? What can we do to make your quality of life better in terms of treatment? and how we investigate this so that we can get to a point where we can start offering you the treatments. So, that's the kind of structure for this webinar. 

So, we'll talk about what different types of incontinence are, investigation and what examination we're looking at, how it can be managed without medication or surgery and then, if needed, how we do surgeries and do the medication and the treatment. 

So, what is incontinence? So, that's an involuntary leak of urine which is involuntary and it's a leak and that is urinary incontinence, so it's not a voluntary passing it's involuntary. Now somehow common it is so you can see on my slide it's almost between 30 to 40 per cent if you remember if you imagine every third to every fourth patient that is a woman will experience some form of incontinence in their lifetime. 

There are predominantly two kinds of it, one is the urgency of incontinence, now this is stress incontinence and most of the incontinence in a patient is usually a mixed picture. 

So, what is urge incontinence? Urgent continence is when you go for you get the urgency to go for ‘water works' and you can't hold it, typically presented as you need to rush to empty your bladder so you get the urge and you need to go straight away, that's typically what urge incontinence is and you might have to go more often, may have to get up in the night because your bladder can't hold after a certain while. So, if you imagine your bladder like a balloon which stretches when water is added or urine is filled in your bladder can hold in a normal average woman will anything between 350 MLS to 500 ml a normal bladder capacity, patients who have got urgency of ‘water works’ other urgency and some people who can leak but when the bladder is expanding the bladder starts doing, this which is a contraction of the bladder it's completely involuntary, the bladder muscles are not under your control so when this happens you see a balloon trying to squeeze water out it gives you a sense that you need to rush and if you don't reach there you start leaking that's called urge incontinence. Some of the neurological factors, you will see how it typically affects or can present is some people feel the need to go for passing urine they're in the car they get out of the car rush the toilet as soon as I put a key in the door, they start leaking that's typically called key in lock effect. You are in the kitchen open the tap sink you hear the water trickling and you start getting I need to go for ‘water works’ that's the urgency of the second is stress.

What stress incontinence? It's physical stress, so typically the patients will present with leaking, coughing, and sneezing when they go for exercise. They lose control and may have to wear a pad for going out. So, what happens with stress incontinence is if you imagine again the bladder being a balloon which is full of water the press the tube is transported out is called urethra so when in your inside your tummy when you cough, sneeze or exercise the tummy pressure increases. What your tummy pressure is doing is trying to squeeze the bladder to leak water out now the same pressure is coming on a hollow tube which is called the urethra which drains water out and is connected to the bladder.

The pressure comes from the top and if you have enough pressure on the bottom. When you never had children or they've never had the problem this hollow tube which drains water out closes so pressure from the top pressure from the bottom it closes if you have a weakness in that area which is the tube just below the tube where the bladder is which connects to bladder if you've got a weakness in this area, this tube doesn't close it kinks when the pressure comes. So there's enough space for urine to start leaking so thus for stress incontinences majority of patients will present to us with a mixed kind of picture some people because their bodies cannot differentiate generally may have mixed incontinence that they've got overactive bladder and the stress incontinence as well but they will majority of them will present to us with mixed picture because their body can't differentiate. For example, if you got stress incontinence you will train your mind to make sure that you keep emptying the bladder. What that means is you don't want to go anywhere with a full bladder because you don't want to leak in public so you will habituate yourself to keep going for ‘water works’ more often to make sure that you don't do embarrass yourself or you feel more confident going out and that becomes a habit and then when we when you present you feel that you're going for ‘water works’ often you're always looking to go for toilet when you're in a shopping mall or somewhere else and that's where you're getting the mixed picture but however initially for stress incontinence your body is trying to compensate so that you don't have embarrassing moments and most important thing it's a problem it is it is an issue and it's an issue and it becomes an issue for you and everybody's symptoms are different everybody's quality of life is different so gone are the days when we say this this problem used to be an older generation problem it happens to young people as well and the most important thing is to come out and talk about this problem if you feel this is effective quality of life. If you've got two little children and let's say 28 or 29 years old and you cannot do trampoline because you have stress incontinence, this is affecting your quality of life and you should come and talk about it. If it's not and this won't be embarrassed there are a lot of people who run these clinics both in NHS and Benenden dedicated to this problem so this is such a common problem and as I said every third or fourth woman will have this kind of issues and then we need to know how to effectively manage this.

Okay so what are the what are the typical causes of incontinence so first let's talk about the urge which is the over activity I'm talking about so the bladder is doing this you'll feel urged to go for ‘water works’ so what happens as I was describing you urgency is caused by the detective muscle which is the muscle of the bladder so when they become like this then this becomes an overactive muscle and so if it's doing this you'll find urgency frequency of ‘water works’ and if it goes like this then you'll have start leaking now a lot of risk factors include if you're taking a lot of alcohol, tea, coffee, or fizzy drinks, so basically caffeine irritates the bladder and it triggers your receptors, it produces a lot of urine and plus it helps it also activates the muscle receptors to go into this kind of motions, so if you're drinking quite a bit of tea, fizzy drinks then caffeine then you might have to reduce them and for tea and coffee you may have to make them decaffeinated and similarly for fizzy drinks like coke and this has to be reduced. If people smoke, this trigger the receptor it's very difficult to get on top of it. Bladder problems if you are a heavy smoker can mean sometimes you've got urine tract infections which happen again and again and if you have good tract infection again and again it does scar the bladder makes them very sensitive and some neurological conditions which affect the nerves and that can cause your bladder to go into spasms and over activity so these are some common issues and risk factors which can cause overactivity of the bladder what causes stress incontinence which is a leak involuntary leak when you're doing some form of exercises or coughing sneezing it's as I describe is the weakness in the neck of the bladder area which is either inside the bladder just at the level of the vagina where the tube which is draining water comes out. 

The risk factors include; the number of vaginal deliveries, especially if you if an instrumental derivative like forceps there is quite a bit of trauma to pelvic flow, then obesity because it weakens your pelvic floor and as unfortunately as we all get older our tissues are not that strong and there is a lot of laxities, then another traumatic factor which unfortunately a woman's body goes through is menopause and menopause causes lack of oestrogen and lack of hormones means the tissues are not that supple and they're not that strong and I think the menopause an effect on incontinence and the vaginal help is highly underreported and this causes a lot of issues. Incontinence as well as discomfort if you have smoking you will always have poor tissues and even if you want to have an operation in future then it will the success related users if you are if you constantly smoke and again if you've got a back chest and chronic cough then it will weaken the pelvic floor other things also which is not there in this slide but if you have a tendency it was constipation please treat them constipation can be the worst enemy and if you are chronically straining you're going to keep from traumatizing your pelvic floor and some neurological disorders where the bladder if you've got a little fistula which is a track between the bladder and the vagina if they're just there is a through and through the track or other neurological disorder which causes problem with sphincters which is the which is what controls in the continents then neurological issues can cause both overactive bladders as well as stress incontinence.

So how do we investigate and diagnose it? So, when we referred the patient we asked Jan and her team to review the patients, they assess you and they also a lot of patients may not like or need to see a consultant because sometimes the life at lifestyle adjustment and conservative treatment is all that they need and Jan will talk about it in a minute. So, what would like to see if you've got predominantly bladder issues to see a bladder diary for three days what we want to see in a bladder diary is how much you drink what kind of drinks you drink and how often you go for urination how much volume you pass urine and how many times you leak. So, for example, if you have got overactive bladder that means your bladder is never going to fill up properly because they're always doing this typically if you feel this bladder diary you will have to go to ‘water works’ more often you may get up in the night few times and the amount which comes out is small amounts anything between 50 MLS to 150 - 200 MLS because you bought that I can't hold and you will have a sense of urgency then we can also see if you are consuming a lot of drinks which are entering the bladder. Similarly, if you've got stress incontinence you can typically hold your bladder well you don't have to get up in the night that much you wake up in the morning you've got a bladder of 400 - 500 MLS which is normal for most other people and then you and you can hold it longer, you don't go forward that often and when you leak it's usually with some kind of activity so bladder diary can be very helpful for us to triage what kind of incontinence you have and if there is anything which we can be done to help you out looking at your behaviour your day-to-day consumption and your symptoms it also helps so some people have for example nocturia what the difference is getting up in the night to go for ‘water works’ which can be physiological when we get older it is known that we get up a couple of times more in the night but if you're drinking a cup of tea at 11 o'clock in the night before you go to bed then more than likely you'll be getting up in the night.

There is a scoring chart which is designed by which is accredited, it gives us a number just to see how these symptoms appear and correlate to how much is affecting your quality of life then most of the time if you come with continuous issues we do perform internal examination a to assess the leaking see what your pelvic floor is doing and if you've got any signs of significant prolapse and or you also like to examine to pick up if you got any fibroid cysts in the ovaries or anything which is pressing on your bladder and after this, if symptoms are not your symptoms of the conservative treatments are not help then we perform a test called urodynamic assessment which tells us exactly how your bladder is behaving. So, in the urodynamics what we do is to put a catheter in the bladder and then a small catheter goes in your back passage just to read the pressure then fill up the bladder with water to see the changes of the pressure on the bladder so that tells us differentiation between overactive bladder and stress incontinence. When the bladder is relatively full, we ask you to cough and if we see the leak and the bladder pressure doesn't go up that means we're seeing stress incontinence then we ask you to empty your bladder in a pot in the room which tells us how fast and it also tells us if there is any obstruction which makes you not been able to empty the bladder well which can happen if you've got a major problem so urodynamics is that test it takes off. If what I'm describing seems quite intrusive but this is very easy and it's not painful it takes roughly 45 minutes to do the test and mostly at the end of the test we get a clear picture of what the next steps should be.

Jan, I will let you take through the conservative management.

Jan Chaseley

Lovely, thank you, Abhi. 

I think Abhi's probably covered most of the things already but obviously with the conservative management, we're going to test your year in we want to make sure that you haven't got a urine infection and again we can get you to empty your bladder on something called a flow commode to measure your flow rate and also quite importantly as just a simple scan of your bladder to then just check you are emptying your bladder properly there's always the risk that actually you've got the overactivity because the bladder's not emptying out properly we'll spend a lot of time going through the bladder diary we want to give you all the advice about your drinking are you drinking everything all in one go is that why you're emptying your bladder every hour it's spreading your drinks out through the day advice about caffeine and also a bit of advice around things you know dietary things if you have a lot of fruit juices a lot of acidic things that's potentially going to make that urine fairly acidic and again that's going to give you symptoms of overactivity the bladder retraining you know we'll look at your bladder diary and we'll start from there and we'll say actually when you get that urge to go can you start by just holding on for five minutes every time and can we then increase that to 10 15 minutes to try and get your bladder to hold a better volume of urine the pelvic floor exercises their key and that doesn't matter if you've got overactivity symptoms if you've got stress incontinence symptoms pelvic floor exercises for at least sort of three months to get hold if you like of your symptoms and get some improvement will help to support you along with things like weight loss obviously as Mr Gupta said if you're overweight there's more pressure then onto that pelvic floor and again around stopping smoking being a real irritant to your bladder particularly for over activity.

Next slide Abhi, thank you. So looking at conservative management as I say when we've done all of the things on the previous slide what we'll do is we'll either give you a telephone call at sort of a couple of months or we'll see you back in the clinic face to face, whatever works best for you and if we've tried all of those conservative things for your overactivity and we're not thinking things are getting any better then there's the option of looking at something like medications. There are two types of medications you can have for overactive bladder, the first is what is called anticholinergic so which works to calm that bladder muscle down so you don't get urges quickly and it just gives you that time between getting that urge and getting to the toilet. There's a whole host of those, they do have side effects and they can give you a very dry mouth and that can be quite difficult to cope with particularly because we're trying to manage your bladder but sometimes just sticking with it and the symptoms will start to improve and medication can either be something that we ask your GP to prescribe or if you've seen the consultants they may prescribe that for you here. A different type of medication is something called mirabegron and again that still works on the bladder but it works on the inside of the bladder it's all about relaxing it down so it's not picking up those signals as quickly. We do also hear something called tibial nerve stimulation, it's only available on a private basis and that basically just works on having a little acupuncture needle in your ankle and the tibial nerve runs sort of from your ankle up to your spine to the base of the spine and it's involved in maintaining bladder function it's a 12-week course and again that's it's not used that often but you know it is always another option if you're looking at the stress incontinence. If you're following the national guidelines structured pelvic floor exercises for at least three months and it's going to take three months to just wake that muscle up to get it used to the fact it's supposed to be exercising. If you go to the gym, you're not going to be able to lift the big weight weights on week one so it's just building that up and then you know we'll reassess you where your point of contact we're here to help you all the way through. 

Thank you, Abhi. 

Mr Abhishek Gupta 

Thank you, Jan. Thanks for covering it comprehensively.

So just to add on to the medication for active bladder, medication has got more side effects. What they do is they prevent the contraction of the muscles and minor background relaxes the bladder, so there are certainly two different actions, one is preventing the contraction, and one is relaxing the bladder that's how they work differently and with stress incontinence as Jan was saying about structured pelvic floor exercises. The other thing is if you click into NICE guidance then optimizing your weight which is important both for the success of the operation as well as for if you ever go for an operation the complication rates and recovery periods are better if you optimize your weight. 

So, what are the surgical options now so if hopefully the conservative options will help the quality of life but for some people, the forms are quite severe and conservative options work to a certain extent to improve the quality of life but it's then if it's not helpful and it's still affecting the quality of life then we'll have to go down the route of surgical options so for an overactive ladder which is urgency in urge incontinence and the bladder is doing this always if the medication hasn't helped or you get side effects of the medication. 

What we often offer is a bladder Botox procedure so it's a procedure which is done in our creation here we've got the Ambulatory Care Unit where we do the procedure it's done with a little camera, it goes into the bladder and then we give the injection of Botox on your walls of the bladder. It's a fairly very effective procedure and for the patient who has an overactive bladder where the bladder is doing this is affecting the quality of life our Botox helps well it's not painful it's very well tolerated and outpatient under the local anaesthetic gel. There are two things to know about the Botox injection, one is at some point it will pass off your body so you may need it repeated, it's very difficult to say whether you need a repeat in six months or two years but when your symptoms come back you may have to repeat it up and sometimes one in 12 women approximately the Botox relaxes the bladder quite a bit and you're not able to empty the bladder well and hence before you go to vote off for Botox Jan and our team always teach you and empower you how to catheterise yourself just in case if the need arises in future this just in case it needs to arise in the future and this can do a catheterization yourself sounds more daunting than it is it's a fairly easy process and it is not difficult in the majority of the cases and once stored it and empowers you with this procedure. So don't get scared about if you ever need to go for a Botox and have to get the price for some time then stress and confidence so stress incontinence when you leak when you cough sneeze or lift weight and all that now there is a nice decision on stress and content surgery and you can Google exact those words magnate for stress and content surgery and you'll get um a whole decision rate which is written for pay for a patient so it's written in the language you understand very easily and it's a decision date which will help you to then choose what surgery you need to have and it's done by the by NICE which is National Institute of Clinical Excellence so this is a guidance we all follow and this is quite a good decision when you come and we give we go through surgical options with you we always follow a nice decision it and we actually give you a copy of to take it home to read it further so what are they so what are the options for stressing content surgeries so there are basically four options and I'll go through the most two most invasive options and then we'll go to less invasive options so the most investing options are called a call for suspension and fascia spring so what does corpus suspension was a cold standard operation before the meshes came in and what we do with Corpus suspension operation is either through a bikini light line incision or like Keyhole we go from the tummy very deep into the pelvis and from the from vagina we lift the vagina put the stitches just next to your blood or neck and Stitch it with the bone there's no mesh involved Stitch at the bone and it lifts the front of the bladder like this so it again gives a support just at the neck of the bladder Levels by lifting the pelvic floor just lifting the end the vaginal wall in the front up like this that gives you support there so autologous rectus fascia sling is again an incision we take out your own tissue which is called selector sheath then we go through the vagina and just at the neck of the bladder level we put the sheath there bring it up to the tummy and suture it up so your own we make a sheath as a hammock just below the neck of the bladder which is your own tissue and again there's no mesh involved so that's two surgical options where you usually are in hospital for 24 hours to 48 hours and the complete recovery after this operation takes around six to eight weeks the success rate for these two both two operations are roughly around 80 85 percent that is the nice quotes there success at around 70 to 80 percent but the success rates are around 80 to 85 percent what we're seeing and what I mean by success is how it improves your quality of life so that's what success is Improvement in equality five so 80 to 85 success right on the flip side it's both are fairly major operation and you will need six to eight weeks to recover we always send home a patient with a catheter for a week because we need things to settle down the swelling around the operation side to settle down before you can start we all the patients come back to Jan and her team in a week's time or then the week to 10 this time for removal of the capture ninety percent of patients will start passing urine very well by that time one in ten women we may have Jan and her team might have to teach how to categorize yourself and again I said don't get worried about catheters till the things settle down and that all the patients do settle down with time it's just a matter of time how long it takes for healing to process to settle up and things to settle down.

This is I would not go into too much detail with this that mesh operation which is tvt because naturally it was a day case operation and I still feel that in right circumstances in the right hand and for the right patient this is it was it's a good surgery and it's still nicely commenced it but bashes are on a national post since 2018 so it's more than four years so we haven't done for more than four years so we not doing them anymore so I think they're still on your nice guidance but we naturally it's not been offered anywhere in the country at the moment and the last option is bulking agent which is called bulk commit it's a hydrophilic gel which is 97 made of water and it's a gel so what how the gel works is we think we it can be done in local anaesthetic procedure so Advantage it's a local unnecessary procedure there's no downtime there's no long recovery period it can be an office procedure get it done go home start working on day-to-day activity so the way it's done is we've given it's again done it's our Ambulatory Care Unit where we do our cystoscopy and Botox injection we give in local anaesthetic injection just next to urethra which is a tube retains water out and then with the camera we look inside the bladder and just at the neck of the bladder level from inside we give four sides of this gel it bulks that area up so that it gives you support to the urethra for things for urine not to leak the advantages is the least invasive procedure it's a local anaesthetic it's a permanent job the disadvantage is the least successful operation procedure as well success rate is roughly around 55 to 60 percent and it may need repeating but if somebody excuse me somebody who has not completed a family want to have more children we try not to do major searches we try to offer you both committees affecting quality of life some people who are not ready to have major procedure for their own for one reason or another they won't avoid surgery they can offer welcome it but the patients who are unfit facilities some patients have got commodes health condition which doesn't make them fit to have major surgeries they can still have bulk commits for the procedures and that's helpful and it gives you a decent quality of life so it has a place and we do it quite routinely and as I said the success rate around 55 to 60 for the quality of life.

So this is where nice will tell you success rate and it's I like the decision eight because the return is patient in mind so how a patient perceives it so this is a corpus suspension in five years nice days nice course that is the success rate of 70 per cent usually we go to the success rate of 80 80 85 because that's how usually patients we get who are happier at the quality of life is better and similarly the rectus fascial sling the nice slightly better with the terms of successor with comparison to Corpus suspension but again it's ballpoint figure about 75 80 so roughly around 8 out of ten women are happy with both of the surgeries and their outcomes

and we won't go into mesh too much because meshes are still on a national hold before I leave on this we record all our incontinent surgery on a national database which is called the British Society of urogynae database so it's not mandatory but any doctor or consult in Euro gynaecologists who do incontinence or prolapse surgery it's a national recommendation that we should be recording our cases on a database for purely audit purposes so the click of the button I should be able to tell how many questions I do in a year what my success rates are and what my complication rates are and that's how I can give you the data about what success rate looks like and what complication looks like and how many patients do go into retention and what our outcomes are so that's the National Database which we use both in NHS and Benenden and we and that's how we constantly audit our results.

Jan Chaseley

Thank you. So, before we go to question and answers I just wanted to briefly talk to you about the Women's Health Hub this has been set up recently and it will cover all of the health things regardless of what age you are so I'd advise you to go on there and have a look they'll give you information about managing periods heavy periods about your sexual health about mental health menopause perimenopause post menopause keeping Active Health at work so as I say go onto the website have a look and you're going to find a lot of useful helpful information on there.

So, if we move to a question and answers Mr Gupta, I have got a letter here hold on bare with me it is now 15 years since I had my hysterectomy and my bladder is becoming progressively weaker I'm 64. I am probably visiting the toilet two to three times in the early hours of the morning is this normal? 

Mr Abhishek Gupta 

So 64 I think age is just a number but I think if you're getting up to three times early hours in the morning and you're not drinking till late in the night so if you're drinking till late at night and especially if you have a caffeinated drink then just cut down your drinking at least two hours before you go to bed and if this is a problem for you then we can have alert but if it's not a problem for you it's nothing to worry about continue doing pelvic floor exercises and just change what you drink and what time you go to bed so this is conservative options and management and you can manage it so it's not a problem till it becomes a problem for you.

Jan Chaseley

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

Mr Abhishek Gupta 

So stress incontinence can be helped by if in the diet is if you as we said if you're obese then the diet will help when you reduce weight it can help with stress incontinence and pelvic floor exercises if it helps it helps in three to six months so if you reduce or up I shouldn't say reduce but if you optimize your weight and do exercises and in six months it should help with stress incontinence if it has to so if it doesn't help by that time then you will need Specialists you should seek specialist help if it's affecting the quality of life so it can the diet there's no particular dietary factor which will help stress incontinence but it's just optimizing weight which helps.

Jan Chaseley

Thank you very much I think I can answer the next question which is how much tea is too much or in fact how much quality of the liquid in a day I drink on average four cups of tea a day no coffee and I drink also at least one and a half litres of water.

So what I would say to that as I said that's where we're looking at your bladder diary we would generally say two caffeinated drinks of tea in a day is going to be fine maybe have those in the morning and I'd be tempted to say get yourself some decaffeinated and have other fluids during the day keep that drinking round about one and a half to two litres in total if you're exercising you may need an extra you know 500 mils of water so you may on those occasions need to have up to two and a half but keep your drinking around two litres.

Next question, Mr Gupta. I am fifty-six and post-menopausal I have just started to notice a bit of leakage at what point should I seek help for this incontinence?

Mr Abhishek Gupta 

So seeking help for incontinence is always when you think is starting affecting your quality of life so it's quality of life can be very different so your quality of life may be that you're just going out for a walk and that doesn't affect you you're using a small panty liner it's not affecting you then you really don't need to go down the route of any surgical option but it's worth seeing someone like Jan or continence care specialist to go through exercises and pelvic floor but there's no point having any surgical or any invasive investigation like urodynamics at that point but it's starting to affect your quality of life if you're 56 you may like to go for a long walk you may like to pay tennis or you might like for running or you um have very active some of my I mean I recently saw a patient who goes to a lot of dancing and she was in her late 50s and if that's starting affecting her what she wants to do day to day and I think that's the call when you start needing to take some specialist help so it's when you start when this starts affecting quality flight but if the incontinence started and it's worth at least seeing at the local physiotherapist or saying someone that who's got a specialist in continence care to go through exercises.

Jan Chaseley

Thank you, very much. Next question I often need to go several times, in the morning but for the rest of the day I can hold my bladder for even longer even though I drink regularly is this a normal part of ageing or do I need to seek any help?

Mr Abhishek Gupta 

I think it's all usually I don't know whether you when you say it's a normal part of ageing what your age is but usually we wake up in the morning and we have a cup of tea most of us and a cup of coffee and we go for whatever's bit often in the morning which is normal if it's not affecting the problem in all day long and in the night I wouldn't worry too much but just not also notice if you're on your medication what medication you are on if you're on water tablet and you take in the night you may go forward Works a bit often in the night or morning and if you have a lot of swelling in your leg sometimes there's a lot of fluid which gets accumulated on your leg which is called lymphedema when you sleep in the night it comes back into the body and then it makes you get up in the night or go in the morning with often and that's not related to Bladder it's just you're producing more urine otherwise it's not a problem.

Jan Chaseley

Thank you, so I can answer the next question that I'm constantly worried that I 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 and basically the answer to that is yes the more often you keep going to the toilet your bladder will start to think actually I'm only supposed to hold a cup for half a cup full of urine whereas we want that bladder to be able to hold you know two couples of urine a good 300 400 mils so the more often you go and it sounds like a sensible thing to do to manage the leaking but you're almost storing up more problems so my advice would be you know if you're drinking one and a half to two litres you know you should be able to empty your bladder somewhere between two and three hourly so if you're going any more than two hourly try and work on the bladder retraining try and just hold on use your pelvic floor muscle or if not look at getting yourself you know a referral here to the continence care team so that we can help you out with that.

Mr Gupta, after multiple myomectomies to remove fibroids my bladder was impacted, and Urgent continence has increased I am looking forward to hearing if anything can help?

Mr Abhishek Gupta

Yeah, I mean if you're or as you said if the conservative options haven't worked after the surgery it can be sometimes scarring helps scarring can cause more of issues as well then we can go down the route of having a urodynamics to exactly see how your blood is behaving which is the test I was talking about during my presentation and a urodynamics does confirm that you cannot hold them out of that well or your bladder can't hold the urine that much then we can either start your medication which will help or if it's quite a bad or active bladder then we can always go down the route of Botox and see whether it helps you.

Jan Chaseley

Thank you, I've noticed an increase in stress incontinence since having a long covid could this be the way the nervous system has been affected?

Mr Abhishek Gupta 

I haven't come across or with affecting stress incontinence but obviously, we don't know everything about covered yet I don't have come across that virus will cause you more stress incontinence but if your covet has affected your chest and you have developed a lot of coughing that is more likely affected your pelvic floor and increase your stress incontinence and virus itself so you've got law and covered and have a bad chest for some time that probably has affected your stress and contents more than the virus itself 

Jan Chaseley

Thank you does being overweight play a key factor in needing to empty your bladder more frequently um

Mr Abhishek Gupta 

I mean it gives the pressure to the pelvic floor not so much with over activity but stress incontinence yes with weight but the important thing to understand if you've got significantly overweight or you know risk category is the treatment for bladder doesn't have that kind of success rate and especially if you have any operation the success that I reduce and complications are increased and when we go down the route of surgical output surgery for any form surgery for bladder issues during the first short of surgery is always the best show in times of success repeating the surges are not as successful so if you ever have to go down the route of surgery we should optimize everything first before we consider doing it but overact obesity doesn't usually cause overactive ladder but if you're obese and you have overweight then usually start related so you may like to look into your diet about how if you have very high sugar intake or you have high intake of fizzy drinks with sugar which is affecting your bladder but obesity should not cause you over activity of matter lovely.

Jan Chaseley

Thank you. Can we have the next slide please, Mr Gupta?

Thank you very much. So, thank you for attending our webinar. I'm sorry if we haven't answered all your questions but if you provided your name we'll do so after the event. If you'd like to book your consultation, please contact the number on your screen between 8 am and 6 pm, Monday to Friday and we are offering an attendee discount for this session with the terms on the screen. 

You will receive a short survey and I'd be grateful if you could please spare a few moments to let us have your feedback. We hope you have enjoyed the webinar. 

The next webinar is on Wednesday 2nd of November and that's on cosmetic surgery.

So, on behalf of Mr Gupta, myself and all of the team at Benenden I'd like to say thank you for joining us today and we hope to hear from you very soon. 

Thank you very much, goodbye.