A Multipronged Approach to Incontinence: Vanita Gaglani, Physical Therapist, Author and Incontinence Expert

Michael Carrese: Hi everybody, I'm Michael Carrese. More than twenty-five million people in the United States experience bladder leakage every day and while the problem is more common in women, millions of men also confront this challenge. Well, today we're going to learn more about this condition and more importantly, ways to treat it with Vanita Gaglani, a registered Physical Therapist and owner of Vanita's Rehab in Melbourne, Florida who's treated more than 2,000 patients with incontinence issues in her thirty years of practice. She's also been an expert reviewer for Osmosis content, including our popular video on incontinence. 

Vanita is the author of two books: Life After Radical Prostatectomy and Other Urological Surgeries: From Incontinence to Continence in 10 Weeks, and the newly released Life After Prostate Cancer and Other Urological Surgeries: A Step-by-Step Guide to Stop Urinary Leakage in Ten Weeks. Vanita also has a special connection to Raise the Line which we'll be discussing at the end of the conversation today. But for now, thanks so much for taking the time to join us today. 

Vanita Gaglani: Thank you, Michael. Thank you, Raise the Line team. I appreciate being here. 

Michael: We are looking forward to it. So, as you probably know, we always like to start these programs by asking our guests to talk about how they first got interested in their field. So what was it that drew you to physical therapy?

Vanita: Actually, I applied to medical school and when I went to visit the college, I got snagged into the Physical Therapy Department and after that, I didn't look back. I just stayed there.

Michael: What was it about physical therapy that you liked?

Vanita: I think it was seeing the change in a person. For example, if somebody couldn't walk, to see them take steps, go ahead in life, go back to normal life...you could see the process and you could see an outcome. What really attracted me to it is that I could track the progress of a person.

Michael: And in a lot of areas of medicine, you really don't see progress...

Vanita: It is difficult because it is so chronic. Most physical therapy is acute, where you can see the difference, and that is very satisfying. 

Michael: Then, why focus on the pelvic floor and incontinence issues? 

Vanita: Well, I ended up having incontinence after a really bad birth and it was not the leakage that bothered me. Most women are not bothered by leakage as much as men. It was the smell. I could smell it everywhere. It just drove me crazy and I'm like, "Something needs to be done." So I started attending courses and classes on how to overcome this issue for myself. But as I worked at it, I found that a lot of people have this problem. So, I started expanding my field into incontinence rather than regular therapy. 

Michael: It is an issue that people are embarrassed by and hesitant to talk about. As a practitioner -- particularly keeping in mind that we have an audience of medical students and early career professionals -- what's your advice about speaking to people and making them feel comfortable in getting them to talk about an issue that they're embarrassed about?

Vanita: I'm glad you brought that up. I think it starts from primary care and from the students themselves. This is a topic that the patient will not talk about. So, we lead them into the conversation because they will never tell that they're leaking. So you say, "Are you going a lot to the bathroom?" Then they'll say, "Yes." And we'll say, "Okay, what happens?" "Well, sometimes I cannot make it." So, if the medical practitioner or the nurse or anybody in the medical field, if they just talk to the person and they talk naturally, the  person will respond and say, "Hey, I have it," or "My friend has it." or "My grandmother has it." And slowly they start speaking about it because, as you pointed out, it's a very common issue.

I ask my patients, "Do you have an overactive bladder? Do you have leakage of urine?" Then I follow it by, "I'm asking you this because it is very common." Once they realize it is not only them, then they start opening up and then they come out and say, "Hey, this is happening," or "I'm leaking," or "I cannot make it to the bathroom," or "If I stand up, the urine just comes out."

Michael: That's very important to make them feel comfortable, I'm sure. So, when you first started your practice, you treated mostly female patients but at a certain point that changed and you focused on treating men mostly. Why did you make the change?

Vanita: So forever -- even today -- men have been ignored and they have an equal problem. I don't think it's any less. But the focus was always women. Women have this problem. We will have our children. As women grow older, women have leakage. It was never the man. One day a gentleman called me. He was sixty-two years old and he said, "Look, can you just not see me? It is not fair. I would rather just die." Because he literally had a penile clamp, he had a urinal and he had to wear diapers. He's like, "This is not my life." So, I said, "Okay, come on in. Let's try it out," and in six weeks, he was back to work.

Michael: Wow.

Vanita: Without a pad, without anything. And the best part of it was he didn't even have a prostate issue. He had something called a neobladder. A neobladder is a bladder made from the intestine, but my protocol was very successful. He attended some men's group meetings with me and then from there I did not look back. It was men, and now nine out of ten patients of mine are men.

Michael: Of those patients, are people with prostate problems the most common?

Vanita: They are because they have two things going on. They have an enlarged prostate. They undergo all these different procedures. Then when they have prostate cancer, A, their prostate is removed or, B, they go for other factors like radiation or other treatments. So, almost always the prostate is affected in all these men.

Michael: Yeah, and why is that? Why is it so common that people with prostate treatment end up with incontinence issues?

Vanita: Primarily, because they don't know what to do. Say a woman who has had breast cancer...every little thing is in order. The plastic surgeon's phone number is there, the wig lady's phone number is there, and they have a support group. The breast cancer support group is really huge. With men, after the surgery is done, or treatment is done, they are left to hang out to dry, literally.

Michael: Hmm.

Vanita: They don't know who to go to. There is no structure. There is nothing for them to follow. There are no guidelines to follow. So, of course, A, they ask their friend. B, they go to Google and try to find that stuff from Google. As we know, you can learn a little bit from Google, but you really cannot resolve issues.

Michael: Right. And you can be led in the wrong direction as well. 

Vanita: Correct. Because the perception is different than reality.

Michael: Right. For the folks listening, that's a great sort of gap that you've identified in the healthcare system that maybe folks can plug as they get into their careers. So I think probably a lot of folks are familiar with Kegel exercises as the first thing to try, but you've demonstrated with your patients that it takes more than that. So, tell us exactly what your approach is and how you're able to get those kinds of results?

Vanita: So, what happens is whenever somebody has an overactive bladder or urinary leakage the doctors, the urologists, the gynecologists say, "Go do Kegels." Except A, nobody knows how to do Kegels properly. B, a Kegel is not an end-all and be-all of a treatment. 

Let me give the analogy of weight loss. If somebody wants to lose weight and all they do is get on the treadmill and just walk, walk, walk, then, they're not going to lose weight unless they add the behavior modification and other factors put in to lose weight. Similarly, Kegel's is not the end-all and be-all because we need to increase the bladder capacity, because if your bladder capacity is low, you'll still look for bathrooms. B, I think what most people don't realize is in men, the pelvic floor has not been stretched. They have not had children, and their pelvic floor is pretty much intact. What they lack is endurance. The pelvic floor lacks the endurance to control the urine.

So we have to focus on A, behavior modification. B, nutrition. C, increasing bladder capacity. D, body mechanics. Because what happens is by nature men tend to do all things a little bit more strongly and take a strong-armed approach. So when they do the Kegel, instead of doing it gently, they will do it very strongly. What people forget is the pelvic floor muscle is small, like your hand muscles. If you keep working with your hand all day long squeezing a ball, by the end of the day your hand is pretty cramped up. 

So a lot of men keep squeezing and doing the Kegel and doing the Kegel. What happens is their muscle gets fatigued. When their muscle gets fatigued, instead of holding, it just doesn't have the strength. It just lets go and then they leak more.

Michael: Ah. And then they probably get very frustrated because they're doing their exercises but it's not working. 

Vanita: You're right. So, instead of getting better, they end up leaking more. So then they are really mad and they go to their urologist and say, "I'm leaking more." That is why only Kegel's do not work and it's the same in women. Only Kegel's do not work. We have to have a multipronged approach, a complete approach to reducing leakage, overactive bladder, or pelvic pain. Anything with the pelvis. 

Michael: So one thing you mentioned caught my interest which is increasing the capacity of the bladder. How do you do that? 

Vanita: So what happens is that a bladder is a muscle and like any other muscle, it can shrink in size and it can in enlarge in size. But what is the go-to technique of most people who need to go frequently to the bathroom? They stop drinking fluids. Well, when they stop drinking fluids, the first thing that happens is the bladder shrinks in size. It is just like people who have had their stomach stapled. Well, as long as they keep the three ounces of food in them, they stay slim. The moment they start eating more the stomach increases in size. It is a paradox because they think, "If I drink more fluids, I leak more." That is where a physical therapist comes in. There are different methods and behavioral strategies and each is individual to a patient. You have to customize it on how to increase the bladder capacity. 

Michael: So give me an example of a patient where you've done that. What does it look like? 

Vanita: It is very difficult to convince people to drink more. But yes, I teach them, I educate them. Education is a big key because if something is logical, people will do it. If they know why. If you just go and tell somebody, "Do this, it's good for you" hey are not going to do it. So I show them how the bladder enlarges, how fluid helps, and how the kidneys are helped, and then they are more likely to follow the guidelines. There's a certain amount of trust involved, too.

Because I must say the urologists who send me patients are very good. They just tell them, "Go to her, listen to her and then come back to me. No matter what she says. You may not agree with what she says but do it." So that helps a lot because a urologist has much more power than me and they're like, "Well he said to come to you. So I'm going to do what you say."

Michael: Yes. Right. That's wonderful. They come to you and they are already in that mindset of trust. You also mentioned nutrition. So what are some of the changes that you have your patients make that help support this? 

Vanita: So, the bladder is a very soft muscle. A lot of things irritate the bladder. Anything acidic that you eat irritates the bladder. When the bladder is irritated, it starts contracting. Now, it doesn't spasm like with pain. It does minuscule contractions. When these contractions occur, the urethra tends to open and the pelvic floor starts to open and then you end up leaking because the bladder is trying to push out something which is not good for the body. A lot of acidic food and a lot of sodas just irritate the bladder and the bladder tries to get rid of it. Once we start controlling and changing the diet and the lifestyle a bit, everything falls in place just like everything else. Whether it's weight, whether it's running, or any factor....any behavioral change that you see requires a lifestyle change. 

Michael: So, there are some things to stop consuming and other things that you can consume that help the bladder in some way?

Vanita: Right. But we never stop anything because the moment you tell somebody to stop this, it becomes non-compliant. But you work with them so that they can see the benefit of it. What helps the bladder? Of course, it's something like water. Definitely. Milk, but many people are allergic to milk or lactose intolerant so we have to figure out what they like and how to make them like something much more. They all want to drink flavored water, but flavored water has a lot of chemicals.The body will reject those chemicals. So then we have to convince them, "Hey, we need this." They're like, "You're out of your mind. I'm already waking up 10 times a night! I'm already leaking and now you want me to drink more water or you want me to drink more lemon juice?" or something which they hate. 

Michael: Mm-hmm. So, in both books, it's a ten-week time frame. How come? 

Vanita: When I started working with people, I started a protocol and 90% of the people take about ten weeks to achieve the goal.  The goal is not to look for a bathroom, not to use a pad, to do any activity you want whether it is pulling out a tree from the yard or biking or mowing the lawn. You should not leak, you should not look for a bathroom because, for a lot of people, the bathroom becomes the end-all and be-all. And it's really bad. When people have had prostate surgery, they tell me, "My whole life is finding out at which point bathrooms are available so I can go change a pad. That is very stressful for a person.

Michael: Sure. 

Vanita: So that is the goal, ultimately. To be back to normal and not think about the bladder, not to think about leakage, and not think about finding a bathroom.

Michael: And that takes about ten weeks, generally. 

Vanita: It takes ten weeks. I've tried to hurry it up, but it's very rare.

Michael: That's interesting, how it falls into that pattern. So I mentioned that your second book just came out in March, I believe. Tell us more about that and what you're hoping it accomplishes.

Vanita: So, the first book was done for people who are a little elderly. You know, the late 70s, early 80s kind of patients and they don't go out much, they don't do much. But over the years, prostate cancer has become more aggressive. It started effecting a younger and younger population. The demographic started changing. People ended up being fifty or sixty years old getting prostate cancer and they really cannot just stay at home and do nothing. I mean, they have to go to work and they have an active lifestyle. So, I had to change the protocol significantly. As I changed the protocol and I added more intense exercises to incorporate their lifestyle, that is how the new book came about.

Michael: Was the biggest change in the exercise intensity?

Vanita: Intensity, and I added some more stuff. The old book doesn't have so much detail about the food and the bladder capacity and how body mechanics help, how behavior strategies help. The second book is much more comprehensive. My goal was that anybody who picks up this book at the end of several weeks, should be dry and they should not think this was a waste of my time and money. That was the goal of the book, that you should not regret buying it. 

Michael: That's a good goal, I would say. (laughs)

Vanita: It is a good goal and it works.

Michael: Yeah. To step back a second, there is a general sense, according to surveys anyway, that people think that incontinence is just something that happens with old age and you just have to accept it and live with it. What is your message to people who think that way?

Vanita: That is totally untrue because if you look at it nowadays, younger people have more overactive bladder. They don't realize it. They keep going to the bathroom frequently because what has happened is the demographics again have changed but also when we grew up, we had probably one bathroom that several family members shared. So we learned how to wait, A. B, our foods were different when we grew up. We always ate at home and we drank water. Ice cream was a treat. Now, a person grows up with several bathrooms and in the United States, there's a bathroom within 10 minutes of wherever you are. Anybody can find a bathroom. So then they end up with an overactive bladder. Now, can they control it to a certain extent? Yes, but then they end up with some different consequences because they also stopped drinking fluids, then they end up with constipation and pelvic pain or frequency and urgency.

In the older population, what happens is it's more an inability to hold urine. We see nowadays, 80-year-olds going to the gym. Shiv's investor runs half a marathon, 14 miles. He's 87 years old. Do you know Alan Patricof? We never thought about it being possible several years ago. There is a 100-year-old woman doing yoga. There are some 70-year-olds using heavy weights and doing marathons. 

So why is incontinence regulated as a problem of aging? Nothing is a problem with aging. It can be addressed. Of course, there are certain factors which would prevent somebody from recovering. For example, if they have Parkinson's or they have cognitive deficiency, but that's like in any other field, you know? 

If you have medical issues where you cannot do an activity, then you won't progress. But for I think 95% of the population, anything can be overcome once you follow a protocol and you work at it diligently. It can be overcome.

Michael: That's a great message and Shiv will be happy that you mentioned Alan Patricof who is one of his favorite people, which gets us to...

Vanita: He's amazing. I just read his book.

Michael: Yeah. He really is amazing. So that brings us to Shiv. You've mentioned this character, Shiv and I teased at the beginning that you have a special connection to Raise the Line and Osmosis. Why don't you tell our audience what that is?

Vanita: So I have always been known as Shiv and Anushka's mom. I have never been known as Vanita. They're like, "Oh, your Shiv's mom. Oh, you're Anushka's mom." That is all people talk to me about.

Michael: We had Anushka on the show, and her husband as well, who are dentists in the Chicago area. 

Vanita: Yeah. They both are dentists. They have several clinics. Anushka and Shiv are very similar in nature. He's our son and I still sometimes get fascinated looking at Shiv about how this child is my child.

Michael: In what way?

Vanita: Because he is just a unique person, and so is his sister. They are both unique people and I look in awe because I don't think I was such a good mother, in all honesty. 

Michael: laughs

Vanita: So I'm like, "How did you two turn out like this?" You know? I don't know. They're just good kids and I am blessed and my husband is responsible to a large extent for it, too.

Michael: If I was talking to your husband, he'd give you all the credit, I'm sure, or he should.  I have to say I think unique is a good word. He has this personality...this love of connecting with people and it's all about relationships and it's all about being supportive and for no return. It's not a quid pro quo situation. He just wants to be helpful to people. As I was saying before we started recording, it's an ethic, an approach, and an outlook that has infused itself throughout Osmosis, which makes it such an interesting and fun company.

Vanita: Right. So he follows a little bit of the Bhagavad Gita where it says do your job. Don't expect any returns. You do it because it's the right thing to do. Do something because that is what you're supposed to do. Not for what I can get back. Just do it. That is your karma. Follow it and leave the rest to God, or whoever you believe in. You don't worry about the reward. That has been what I think that they both have grown up with. Do the right thing, give a helping hand because really, to succeed in life, it gives more joy to help somebody than to get something back and we have all learned that. When you give, you feel happier than when you get.

Michael: Well, that's why he's such a happy guy, because he gives a lot.

Vanita: He does, he does. He just does things because he likes to do them.

Michael: Right.

Vanita: It makes him happy.

Michael: Right. And he's a joy to work with, I should say.

Vanita: Thank you. 

Michael: Although you have to tell him for me that he needs to use his microphone more often than he does. But that's a separate issue. 

Vanita: I will tell him that.

Michael: Well, listen, we're going to have to wrap it up here. This has been really such a pleasure to talk to you. I want to thank you very much for taking the time. I wish you the best of luck with the new book.

Vanita: Thank you, Michael. I really appreciate being on this program and most of all I do appreciate the message. I don't think people realize how many people have this problem and the more we talk, the more people will come forward. It is not supposed to be a stigma. If you talk about it, you can get help. So, it is important to me that you had me on this podcast. So, thank you.

Michael: Well, you're quite welcome. It is our pleasure. I'm Michael Carrese. I want to thank our listeners as always for checking out today's show, and remember to do your part to flatten the curve and raise the line. We're all in this together.