055: When Pelvic Floor Exercises Aren’t Enough To Deal With Incontinence w/ Dr. Betsy Greenleaf

Joining me on the sofa this week to discuss what can often be a problematic area is the wonderful Dr. Betsy Greenleaf. I first met Dr. Greenleaf when we were both lecturing for the American College of Osteopathic Obstetricians and Gynecologists and I was immediately impressed by her passion for women’s health.

Dr. Greenleaf is an obstetrician-gynecologist and pioneering surgeon based in New Jersey. She received her medical degree from Rowan University School of Osteopathic Medicine and has been in practice for well over a decade. She specializes in pelvic floor disorders in women, such as incontinence.

min. 9.30–10.20 How Much Fluid Should I Be Drinking?

min. 10.45–15.30 Bladder Control Exercises

min. 15:39–16.12 How Often Should I Be Urinating?

min. 16.48–24.20 Non-Surgical Treatment

min 28.40–29.25 Were the Ancient Egyptians Onto Something?


Is Your Pelvic Floor Toned And Trustworthy?

Dr. Anna Cabeca:

Today we're going to dive deep into gynecologic health to talk about:
  • your bladder
  • issues of incontinence
  • incontinence exercises
  • treatments

These are issues that women really struggle with and ‘power through’ unnecessarily because they don’t want to talk about them.

We're also going to touch on surgical techniques which have been used over the past decade to help with bladder repair and look at the current trends in this area before discussing hormonal therapies.

To explore these topics with me today is the first board-certified female urogynecologist in the nation, Dr. Betsey Greenleaf.

Betsy is committed to women’s health and to empowering other physicians to really go deeper into an area that is difficult for so many physicians and patients. Dr. Greenleaf, it is great to have you here with us today. 

Dr. Greenleaf:

Thank you so much for having me; this is wonderful. 

Dr. Anna Cabeca:

Let’s start with a little background; what drove you into gynecology and where are you with it now? 

Dr. Greenleaf:

I started out in general surgery, but I switched to OB/GYN which I really liked because you develop more of a relationship with your patients. You get to see them grow from the time they were getting their first PAP to the time they're having their first baby and so on.

I was lucky enough to get into a fellowship in urogynecology. It’s a pretty new specialty in medicine which didn't exist until the 1970s. And even then, board certification in this field only came in the last few years.

There are only 1,200 urogynecologists in the country at this time. Although incontinence issues can show up at any age they tend to increase as people get older. As we have an aging population there is a very big need for doctors who can help patients with these problems. 

Dr. Anna Cabeca:

Yes, absolutely. 

Incontinence Can Be Treated

Dr. Greenleaf:

One of the things I find when we talk about incontinence – leaking urine – in women is that people think, “Oh, it's because they had babies. It’s normal.”

I tell people, “Just because it's very common doesn't mean that it's something you have to live with; there are so many different things that can be done about it”.

This field is changing and progressing so quickly that the procedures I was doing 5 years ago are now obsolete. There's always something new coming out tomorrow.

Expensive And Isolating

Dr. Greenleaf: 

As we raise awareness, more patients are hearing about it and realizing that they don't have to live this way. Pads are expensive, you know?

Dr. Anna Cabeca:

And not environmentally friendly.

Dr. Greenleaf:

No! And they cause irritation and they can lead to chronic urinary tract infections and they're not cheap!

I've had patients who won't leave their house because they leak. I had a woman, 82 years old, who hadn't been out of her house in five years. She said she’s missed family events including weddings and baptisms because she's too embarrassed to leave the house.

Dr. Anna Cabeca:

You can have incontinence postpartum, right?

Dr. Greenleaf:


Dr. Anna Cabeca:

Women can experience incontinence in their 30s, 40s, and 50s and that can limit what activities they choose to do and prevent them from getting the benefits those activities offer.

Let's talk about the types of incontinence.

The Two Main Types Of Incontinence

Dr. Greenleaf:

There are a number of different types of incontinence but the two main ones that people have are either urge incontinence or stress incontinence.

Urge incontinence is when you have to run to the bathroom. You can't hold it in, you got to go. It can start early in your 20s, but research has shown that the majority of people aged 70 and older are going to have this problem.

When You’ve Just Got to Go

Urge incontinence is complicated because we don't exactly know why it happens. It is some sort of nerve irritation along the urinary tract which causes the bladder to spasm and push the urine out without you receiving a signal to use the bathroom.

It can be triggered by irritation in the lining of the bladder or the urethra, by infections, by growths or cancers, or by any kind of inflammation in the bladder. It could also be related to pelvic nerve irritation or injury to the nerves sustained during childbirth or as the result of an injury.

It can also be related to your back because those nerves go from your bladder to your pelvis to your back to your brain. And as we get older, a lot of us develop herniated discs. When a disc is herniated, it pushes on the nerves and that can affect the bladder.

How Much Fluid Should I Be Drinking?

Dr. Greenleaf: 

Drink enough fluid so that your urine is clear. Some people purposely don't drink fluids because they think, “Oh, I'm leaking. If I don't drink, then I won't have to go.” But actually, when you don't drink, your urine becomes more concentrated and therefore more irritating to your bladder’s lining, and this can trigger more urgency.

Bladder Control Exercises

Dr. Greenleaf:

If you start giving in to your bladder and running to the bathroom every single time you’ve got to go, you're going to start shrinking the size of your bladder, so it won't be able to hold that much. It

When you have to go, it's tough, but force yourself to hold it in as it may be just a bladder spasm which will subside. Try this at home until your bladder gets used to it. Then, if you still feel full, go to the bathroom. That’s called bladder training.

You're going to get leakage and accidents but with constant practice, you'll be able to hold more and more. I'm sure in your practice you've seen doctors and nurses have large bladders.

Over the years, they've been forced to hold it in as they can't go to the bathroom whenever they want to because they can't leave their patients. So, I tell people, “You can train that.”

Dr. Anna Cabeca:

That's a great point. It reminds me of when my daughter who's now 21 was 6 years old, and she came to me – you'll love this story, Betsy – and said: “Mom, I need Detrol!”

She was asking for Detrol LA which is a treatment for urinary urgency incontinence symptoms. She saw this brainwashing commercial on TV and she had the symptoms – urgency and running to the bathroom.

How Diet Affects Your Bladder

We stopped her drinking caffeine and sugar. We're in the south so sweet tea is a biggie and that's a huge irritant. Food colorings, food dyes, gluten, and dairy, can all be irritating to the bladder. That’s how I got thrown into functional medicine – because of my daughter.

In 2002 I really started thinking, “Okay, we’ve eliminated those things and that really helped.” I think it's important to know that if we're having those urgency symptoms, that dietary management is good for that and for your lifestyle too. 

Dr. Greenleaf: 

I agree. That's such a great point. Sugar is probably one of our number one inflammatory producing products. Not only can it affect the bladder, but it can cause so much havoc in the body and many other inflammatory conditions.

In some people, citrus fruits and tomatoes can cause an overactive bladder. There are some really great resources on the internet for diets that help with bladder problems. 

Timed Voids

Going back to the bladder retraining, another thing you can do is timed voids.

It's a pain in the butt but practice it and you get better. If you are somebody who has to go every half an hour, the next time you need to go, just hold it in for 15 minutes. Do that for a couple of days and then add 15 minutes to your routine.

Keep adding 15 minutes to your schedule and you will slowly stretch the bladder so that eventually it gets to the point where you are going every 2 hours instead of every half an hour.

How Often Should I Be Urinating?

If you're drinking enough fluids, urinating 8 times a day is considered normal.

It can help to keep a diary and write down what you're drinking when you're drinking, how much you're drinking when you are going to the bathroom, and when you are leaking. Sometimes looking at that makes you more mindful of what's going on and we've actually seen people experience improvement in urinary symptoms just by doing that.

Dr. Anna Cabeca:

As we all say, “What gets measured, gets managed.” If you leaked but you can see from your diary you only used the bathroom twice that day, then probably you could work on using it a little bit more.

Available Medications

Dr. Greenleaf:

You can try Kegel exercises for women to strengthen your pelvic floor muscles. If that's not working, there are medications.

There are about 8 different medicines on the market now. One category is called anticholinergics which we see on the commercials. We’ve got Detrol LA, Ditropan, there's Vesicare, there's trospium (Sanctura)

Trospium and Enablex. They prevent urge incontinence by preventing the bladder from spasming.

They can produce some unfortunate side effects including dry mouth, and constipation. These medicines are not cheap, and a lot of people want to go for the generic one which is Ditropan.

I personally don't like that medicine. It's old and has the ability to cross into your brain and because of that, especially in elderly patients, it has a higher risk of confusion.

There's Oxytrol which is a patch that you can get over-the-counter. The only good news is it tends to have fewer side effects and less confusion than the pill but even then, it’s not my go-to.

There's a newer medicine that comes out probably in the last five years called Myrbetriq. It also works for an overactive bladder but in a different way. Where the other medicines prevent the bladder from spasming, Myrbetriq allows the bladder to relax.

It tends to work a little bit better and it has very few side effects. The downside is because it's newer it tends to be more expensive and insurance companies tend not to want you to use that one first because of the cost.

They usually want you to use another one first. And the way the protocols are is that you need to try at least two medicines before you can move on to other therapies.

Can Acupuncture Help?

Dr. Greenleaf:

Some insurance companies cover it and some of them don't, but acupuncture can sometimes help. There are two companies that have a device called a percutaneous tibial nerve stimulator. It’s like a glorified acupuncture.

There are two companies, one’s Medtronic and the other one’s Uroplasty. This treatment has about an 80% success rate and the good news is it's not invasive.

It’s covered by most insurance. There's a very tiny acupuncture needle that goes in your ankle. The needles are so tiny, they're like a hair, you don't feel them going in.

When you're hooked up to the machine, you do feel a little thumping sensation in your leg, but it's not painful. The treatments are 30 minutes once a week for 12 weeks. And then if it works you just come in once a month for treatment.

Hormone Therapy

Dr. Anna Cabeca:

The other thing too is vaginal hormonal therapy because sometimes the urgency symptoms are just the urethral irritation, or bladder neck irritation, and that's causing those spasms.

We're getting great results using Julva®

Julva is a vaginal cream that is perfect for the delicate tissue of the vulva because it only uses natural ingredients that are 100% safe for your body.

Apart from DHEA, it includes vitamin E, coconut oil, emu oil and shea butter.

It not only adresses symptoms like urinary leakage, vaginal dryness or discomfort but also helps you reclaim your libido and orgasms.

If you’d like to experience it for yourself, be my guest and try Julva for a week, for free. Just pay a minimal cost for shipping for your 7-day trial pack. There’s no risk on you, and it’s ready to send out today.

Dr. Greenleaf:

Yeah, and anyone who's postmenopausal will have thinner vaginal tissue. This causes a change in the pH of their vagina which means they’re more susceptible to urinary tract infections.

That thinness and the change in pH can affect the bacteria that normally live in the vagina, creating a low level of inflammation and causing overactive bladder or urge incontinence symptoms.

Products that reset that balance are great. Traditionally we've used hormonal products, hormonal creams, hormonal tablets, hormonal rings. But, I myself am postmenopausal with a mom who had breast cancer. So, even though the vaginal estrogen and the prescription vaginal DHEA are safe, I understand why there can be a nervousness to use those products.

Now we have this great product – Julva – which I'm very excited to use. Everything I've read about it is wonderful. I'd be using it already on my patients, but we just set up a new practice.

It's a great over-the-counter product that you don't need a prescription for. The ingredients are really exciting because there hasn’t been anything else out there that can work like that.

Dr. Anna Cabeca:

Thank you. And it’s something people can use concomitantly. If surgery's inevitable, it can be used preoperatively to get healthier tissue for the surgeon to work with. It also has anti-aging effects.

Stress Incontinence

Dr. Anna Cabeca:

Let’s get onto stress urinary incontinence which is plaguing more and more women. You mentioned earlier about people using pads; there’s toxicity associated with them and with tampons too.

Irritation and thinning of the urethra and the tissue of the vulva area can be as a consequence of using panty liners regularly ‘just in case’.

There's a company which makes reusable pads called Lotus liners. You just throw them in the wash. But we don't want to have to use pads at all, right? We want to keep being able to go, as one of my clients said, commando.

Dr. Greenleaf: 

Whilst urge incontinence is about nerves, stress incontinence is different because it’s more of a functional issue. Something's affecting the support under the urethra which is the tube that you pee through.

When you a cough jump, sneeze, laugh or do any kind of activity, your intestines and what's in your abdominal cavity are going to push on your pelvis. What happens normally is if these ligaments under the urethra are intact, or that tissue is nice and thick because it's not postmenopausal, or you've been using a product that's made it thicker and healthier, that'll give it support and it will push up against your urethra and prevent you from leaking.

When you have stress incontinence, it means that either your tissue’s thin or the ligaments are stretched out or torn from childbirth, or from lifting something heavy, or from a chronic cough.

Non-Surgical Treatment

Stress incontinence is a bit more straightforward because we know what's causing it and there are things to fix it. Treatment doesn’t always have to be surgery.

Going back to the products like Julva, or the hormonal creams, sometimes using something to regenerate that vaginal tissue and thicken it up can help.

Dr. Anna Cabeca:

And like you said, the pelvic floor exercises; maybe we need to do these until we die. They’re so important.

Dr. Greenleaf:

Yeah, they’ll basically add to some of that support. Your pelvis is just a big giant open hole. There's no bone; there's nothing there keeping things in other than your skin, your muscles, and some ligaments.

Over time, unfortunately, gravity takes over all parts of our body. By doing Kegel exercises you can keep everything where it should be.

Were the Ancient Egyptians Onto Something?

It's interesting what's coming back in favor, especially with some of the issues we've all heard in the news with some of the surgeries which we'll touch upon later, is a very, very old treatment that's been around since ancient Egyptian times and that’s pessaries.

Pessaries are just support devices that are fitted for the vagina. You wear them in the vagina and they just hold everything up or put pressure on the urethra to keep it closed. They come in so many different shapes and sizes. A professional gynecologist or urogynecologist can fit you for one.

In ancient Egypt women used to put pomegranates in their vagina. And in Rome, they used to use potatoes. I don't advise any of those things now.

Dr. Anna Cabeca:

So fascinating though!

Dr. Greenleaf:

Yes! Two to three years ago an over-the-counter product called Impressa was launched. Impressa is a tampon-like device. Just like a tampon it goes in, it opens up. I don't advise using tampons because tampons could absorb bacteria and there's a higher rate of toxic shock.

Dr. Anna Cabeca:

Plus, you have tampon trauma with an already dry vagina that is being irritated and is itching.

Dr. Greenleaf:

And the bleaching. Any pads or the tampons that are white, they are bleached and that can be very irritating to the tissue.

Impressa is produced by Poise. The company will tell you not to wear it for more than 6 to 8 hours, but it really can be worn longer. They’re going by the standards set for tampons, but it doesn't absorb so it doesn't hold in any bacteria.

It comes in a trial pack with 3 different sizes and you have to try to see which one works for you. The only complaint I have from patients is that because of the vaginal dryness, sometimes getting it out can be difficult. Using the Julva or another product to make the tissue moister will help with that.

Internal Therapies

Dr. Greenleaf: 

There are a couple of different companies that have internal therapies which have been shown to help. There basically Kegel exercises but with a little technology.

One which your doctor can prescribe is called InTone. It’s a device which is a little bit on the large size, and kind of looks like a big vibrator. It has metal plates that provide electrical stimulation to rebuild tissue.

It goes inside the vagina and it’s hooked up to a little handheld device which teaches you to go through your Kegel exercises and actually measures them.

There's another one that's less scary-looking called the peri-coach. It's a smaller device that tends to be a bit cheaper. It goes in the vagina and then you do your Kegels. It actually has an app so you can track your progress!

Taking A Surgical Approach

Dr. Anna Cabeca: 

What’s the latest and greatest in surgery? When I was doing my urogynecologic procedures, it was always the transobturator sling which I loved because it was super quick, and we were so concerned with mesh erosion.

I wanted the best tissue to work with, so I started using vaginal testosterone, DHEA, topical compounds, to create this preoperatively. What do you recommend for surgical approaches to stress urinary incontinence?

Dr. Greenleaf:

It's interesting. The sling is still considered the gold standard. They have actually gotten smaller over the years. The one that you talked about, the transobturator, was the second generation.

The initial one – called a super pubic sling - was very large. It’s still used and is still successful, but I think it's overkill. Now there are mini-slings, the length of my thumb.

Depending on what State you live in, they can be put in as an in-office procedure. It takes about 10-15 minutes to put one in.

Dr. Anna Cabeca:

Wow, that’s amazing.

Dr. Greenleaf:

There is some soreness associated with it, but my biggest problem is that patients feel pretty good afterward and want to go back to all their normal activities, but you need to let it heal in place for eight weeks before you see its full effects.

There is also urethral bulking, but it doesn't work that well. It involves going into the urethra and injecting some sort of material like collagen that fattens up the urethra.

An interesting fact about collagen is that it’s off the market. It was harvested from cows and the farmer who was supplying the collagen for that product retired, so that product went away, and no one's picked it up.

Laser Treatment

Dr. Greenleaf: 

Light lasers and radio frequency have shown good results. Both work by internally heating the tissue and triggering it to heal itself. This technology evolves very quickly so these treatments tend not to be covered by insurance, but you can pay cash for them.

These treatments are in line with the future of medicine where instead of implanting things in people we want to trigger the body to heal itself.

Stem Cells

Dr. Greenleaf: 

There is a treatment where they take extract stem cells from fat in the buttocks then inject the stem cells underneath the urethra and that basically triggers your tissue to heal itself.

There is a fascinating study where they're taking stem cells and injecting them into your vein and they're showing that people's continence is getting better from receiving this ‘IV of stem cells’.

Dr. Anna Cabeca: 

I’d be interested in that and the general rejuvenation process of stem cells too. I think we’ll bring that into our next discussion. Betsy, tell our audience where they can find you should they need a consultation?

Dr. Greenleaf:

Sure. I am now located at 108

Avenue of Two Rivers in Rumson, New Jersey. The number here is 732- 263-7903. The website is hackensackmeridianhealth.org.

Dr. Anna Cabeca:

And also, you're going to have your pelvic floor store; I have to throw that in there! Because it's a great thing to be able to offer a place that's recommended by your gynecologist for things for our pelvic floor.

Thank you so much for being with us.

Dr. Greenleaf:

Thank you so much for having me.

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Dr. Anna Cabeca

Dr. Anna Cabeca

Certified OB/GYN, Anti-Aging and Integrative Medicine expert and founder of The Girlfriend Doctor. During Dr. Anna’s health journey, she turned to research to create products to help thousands of women through menopause, hormones, and sexual health. She is the author of best-selling The Hormone Fix, and Keto-Green 16 and MenuPause.

Learn more about my scientific advisory board.