Female Bladder Leakage: Solutions to Get Control‎ | UCLA Obstetrics & Gynecology

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Good morning good afternoon or even good
evening depending on where you’re coming from welcome my name is Dr. Christopher
Tarnay and I am the chief of uro-gynecology here at UCLA in the
department of obstetrics and gynecology and today we’re going to talk about
female bladder leakage and we’re going to focus in on solutions solutions how
to get control of this very challenging problem for women so during the webinar
feel free to ask questions we’ve got cleave over here he’s monitoring our
Twitter account you can use the hashtag UCLA MD chat UCLA MD chat or you can
just put comments of comments on Facebook and during the webinar we’ll be
tracking them and at the end I’ll address some questions all right let me
start off from some geography does anyone know where this might be this is
the Blue Ridge Mountains and it’s an northern part of Virginia I had the
opportunity as a medical student in Georgetown when I was in DC to go and
visit them and one thing I didn’t know at the time was that the Blue Ridge
Mountains and the vagina share something in common I hope I have your attention
now and what they have in common is similar topography women have estrogen
and estrogen in the vaginal area creates a thickening and that thickening creates
small little buckling of the tissue creating tiny folds called rugae and
these rugae are very important to they create a functional impact on the vagina
it has rugae to allow lubricants and secretions it also those rugae allows
stretch and the rugae are like this peaks and valleys and that stretch
allows function during childbirth during intercourse and the problem later on as
estrogen decreases either during menopause or estrogen decreases during
breastfeeding or after childbirth is that that elasticity goes away the
vagina tissues can flatten and those rugae flatten it becomes thinner and
dryer and that can lead to challenges during these transition times with inner
core also bladder control and that’s what I
want to talk with you about today female bladder leakage is urinary incontinence
what is urinary incontinence the involuntary leakage of urine or simply
put urinating or leaking urine when you don’t want to one of the biggest
questions patients have for me when they come into the office is they feel kind
of isolated they go is this the only thing happening to me is this urinary
incontinence am I the only one who has it and it’s important that you know that
it’s extremely common two out of three women have a lifetime
risk of suffering from urinary incontinence
now although incontinence increases that was one gets older it actually can
happen anytime during the life span and women can experience symptoms at any
time it affects over 200 million people worldwide
and in the United States alone at least 25 million and of those 25 million 9 to
13 million women have either bothersome or severe symptoms how about a few more
facts urinary incontinence is under diagnosed it’s under under reported and
as I mentioned it increases as we get older it’s primarily a female problem as
over two thirds of people who have urinary incontinence are women there was
a study looking at random sample of forty five thousand different households
and during that survey 35 37 percent of the women reported incontinence just
within the last two months in the elderly over 70 percent have complaints
of urinary incontinence and this alone can be the reason for elderly
individuals to be transitioned to a different living situation to a skilled
nursing facility to assisted living just to manage the incontinence this graph
shows that as we get older urinary incontinence becomes more common and
young women in their 20s and 30s about 30% middle-aged women’s 40s and 50s 40%
and in the mid-60s 65 beyond the menopause
over half of women will suffer from urinary incontinence another question I
hear a awful lot is is it normal to leak a little urine or it’s just a little
urine is that that’s normal right no it’s not normal
leakage is common but it’s not normal and it’s really important to understand
that women who suffer incontinence can do so in a very gradual in an insidious
fashion because it’s a gradual and insidious problem so often women don’t
think it’s a medical condition and don’t bring it up with their physicians or
medical providers this causes delay in women seeking care and it’s very
important for us to communicate and you communicate with your friends and for
you to know one doesn’t have to live with urinary incontinence without
seeking treatment it’s important although urinary incontinence isn’t
life-threatening it’s what I call quality of life threatening and it can
affect a woman’s life in many different domains physical reducing physical
activities because they don’t want to leak psychological they don’t want to
they feel like they’re old they’re concerned about the odor they lose their
self-esteem higher rates of depression in women with urinary incontinence they
reduce their social act interaction one woman said to me I never go anywhere
anywhere without being near my boyfriend John I mean she always always near the
toilet she felt shackled to it padding
undergarment use very costly and problematic some women have will say
they pack two suitcases when they travel one for their clothes one for their pads
occupational can you know women who are working this can cause a reduction in
going to work and avoidance of intimacy all right women with incontinence offer
suffer in silence and this is part of the dialogue that we want to change
survey of women suggests that women don’t like to talk about this problem
even with their provider and candidly doctors aren’t so great at it either we
don’t do a great job asking patients about it throughout our four doctors in
one survey when after their visits during their annual
screening the doctor didn’t even ask them or screen them about issues of
incontinence this leads to a delay woman’s will often wait over six years
before with living with the condition before they even bring it up we need to
change the way we are looking at and incontinence bring it out from the
shadows bring it out from the bathroom and start to recognize it times are
changing and the the one of the ways and one of the avenues is the pharmaceutical
companies the companies that are selling medication medications and treatment are
going to direct to consumer marketing this ad was during the Super Bowl last
year for a new a new drug you see this in print ads media ads there’s Playtex
has gotten in on the action they have a product called impressa
that’s designed to help prevent urinary loss it works by inserting in the vagina
similar to a tampon to compress the urethra to prevent the leakage we have
celebrity endorsements now coming to the front talking openly about female
bladder leakage and urinary incontinence and offering ways for women to get
control but more importantly this I think is going to help bridge the the
big gap so we can start having a conversation so there’s two main types
of incontinence stress urinary incontinence or what I would call
exertional loss of urine so this isn’t any time losing urine with coughing
laughing sneezing or physical activity hey Doc I don’t jump I don’t jump in the
trampoline with my daughter anymore because it causes leaks I wanted to play
hopscotch I don’t I don’t I can’t do that with my daughter or my kids it’s
common after pregnancy particularly pregnancy that results with it with a
vaginal delivery so stress incontinence is basically increased pressure on the
bladder that overcomes urethral resistance coughing laughing sneezing
all can create urinary loss by pressure and a lack of support underneath the
urethra the other type of incontinence is urge urinary incontinence or I think
this is the symptom when patients say I got to go I got to go I can’t make it to
the toilet otherwise termed overactive bladder overactive bladder is to do with women
have this overwhelming inability to resist the the sensation to urinate it
has to do with early and inappropriate signaling of the bladder normally we
should be able to sense our bladder feeling if we’re out and about where I
say it not now I’m in the movie theater I’m at the store I’ll wait till I get
home overactive bladder is a problem when you’re unable to suppress that
sensation and either due to increased sensation or muscle contractility
squeezing the bladder involuntarily triggering urinary loss so urinary
urgent continence is leaking urine with strong urge it’s also typify by urinary
frequency and urgency often women can’t hold their bladder more than two hours
at a time they feel like they have to go and they may leak right before they make
it to the toilet that’s urinary urgent continence
sometimes it causes patients to wake up at night typical normal is about one
time but anyone who’s waking up 2 3 4 even 5 times a night to urinate is
classic for overactive bladder one problem patients often relay is that dr.
right when I get home I pull my car on the driveway where I’m walking up the
the walkway to the front door I put my key in the door I got to immediately
drop my bags run to the toilet and they when I ask them they go yep that’s me
it’s called locking key syndrome so who gets you’re nearing contents women two
times more likely than men that sounds awfully unfair why is that anatomy and
risk factors quick Anatomy trip we’ll talk a little bit about the physiology
the kidneys filter the blood the waste products of that blood filtration ends
up in the kidneys and delivering it to the bladder through conduits called the
ureters the bladder is a storage organ and it should store urine comfortably
and painlessly until you’re ready to urinate and then once you’re ready to
urinate was out through a tube called the
urethra one of the reasons women are particularly vexed with this problem is
physics they have a short urethra very short
tube men typically have a longer tube like a urethra increase increased
resistance women with a shorter tube less ability to resist and so anything
that might cause detrimental detriment to the anatomy can trigger urinary
incontinence like vaginal delivery or occupational exposures we’ll talk about
those what are the risk factors age as when we get older we talked about
estrogen as estrogen recedes the vaginal tissues change leading women susceptible
to overactive bladder and stress urinary incontinence what this changes in the
bladder lining pregnancy pregnancy itself does something to contribute to
bladder weakening if the pregnancy results with a vaginal delivery the more
vaginal deliveries higher risk of urinary incontinence medical conditions
with chronic repetitive straining coughing asthma chronic constipation
smoking can all contribute to unary incontinence activities women with
occupational exposures there was a study in Sweden looking at women who worked in
nursing homes transferring patients lifting Gurney’s those women when they
compared them to age match controls had higher rates of pelvic floor problems
including urinary incontinence obesity the more weight you have particularly if
it’s over 30 more pressure on the bladder more pressure and stretch to the
pelvic floor and genetics some people are just prone and this is a big area of
research and trying to understand which women might be at risk this is a slide
demonstrating the older you get the more common the problem is I talked a little bit about pregnancy
this is a cartoon just to show the impact on the various structures of the
pelvic floor during the act of childbirth here’s the bladder here’s the
vaginal canal here’s the rectum as the fetal head comes through this space it
puts pressure here press pressure on the rectum it can cause disruption of the
connective tissue it can cause stretch of the pelvic floor
muscles and all of those compression can can injure the bladder and it’s support okay what are the treatments for urinary
incontinence and that depends which set of symptoms are most bothersome or most
bothersome is it exertional loss of urine is that urgency and frequency and
sometimes is it both and then if they have both we try to target which problem
is most problematic for the patient so if it’s stress incontinence is an urge
incontinence or both types the first best option for all types is pelvic
floor muscle exercises conservative non-surgical non-medical therapy it’s
the foundation for all therapies a little bit about pelvic floor muscle
exercises also known as kegels the pelvic floor extends from the pubic bone
all the way back to the tail bone and in between this area you know in a woman
this is a side view is the bladder the vagina with the uterus and the rectum
and it’s contraction of these muscles that allow the squeezing and the
increased pressure around the outlets for these structures like the urethra or
the rectum and in this instance we’re trying to contract the pelvic floor to
increase resistance for urination contracting the pelvic floor also can
actually feed back on the bladder and reduce urgency called urge suppression
so as I said pelvic floor muscle exercises are the same thing as kegels
something patients get told to do all the time one of the important critical
features is that we have to recognize there is good evidence level one
controlled trials evaluating pellet or muscle exercises and its impact on
urinary incontinence and it works about two-thirds of the time it can be done on
your own or with the help of a sub physical therapists physical therapists
who actually train especially to take care of women’s health issues they can
work with patients teaching them how to do them properly learning tips to
identify the correct muscles is critical because when we ask patients just to do
kegels without any instruction about two or thirds of the time they’re not able
able to do them properly it’s very easy for us to identify if I say go do an arm
curl and I want you two to strengthen your biceps muscle it’s very easy to see
a biceps curl if I ask you to do a kegel exercise it’s impossible to see or know
if you’re doing it properly and so this is where therapists can really help with
that biologic feedback the biofeedback to help women learn how to do this
proper skill as with anything requires practice and a commitment because if you
stop there’s evidence to suggest patients who have initial benefit but
then stop doing their kegels or their pelvic floor exercises the incontinence
can come back it’s an excellent first option even with the benefits of Kegel
exercises in the pelvic for strengthening sometimes over the long
haul it’s not quite enough this is where we have to think about other issues like
surgery and the good news is there’s lots of good minimally invasive options
that we have available to help correct urinary incontinence for the long term
and I want to talk about those basically we want we want to be able to have women
run jump and sneeze without pain this is I thought these were cool hashtags
hashtag mom problems and hashtag underwareness all right so I mentioned
slings let’s talk about them for a moment
what’s a sling it’s a 20 minute 20 minute outpatient procedure home the
same day – correct urinary incontinence it’s been
around for over 20 years in its current form small incision surgery it places a
support under the urethra to prevent the loss of urine with exertion so this is a
video here’s a spore support pressure
triggering urinary loss we need to do something to help the support we can use
a sling it can be a small piece of material either permanent or your own
tissue that we put though provides that backboard and prevents urinary loss
highly effective very simple and this is what it looks like it can either be what
we call retro pubic and there’s ones that come out what we call trans
obturator through the through the groin small little piece one centimeter wide
underneath the urethra highly effective and with over with ten with ten years of
data over 80 year care improvement rates objectively at two years long-haul
seventy seventy year a seventy percent plus what else do we have a laparoscopic
surgery called the birch it’s also a same day surgery using small incisions
supporting the bladder neck from above no implant no materials bulking volcans
kind of like collagen many and we use it as a filler many women are sort of used
to seeing celebrities with lip filler it for collagen and the material that we
use is a similar type biologic material where we put it right at the bladder
neck here is an open bladder neck we put the bulking agent in like like a
collagen material and it increases the resistance by co-opting co-opting the
urinary outlet really increases the pressure and reduces a urinary loss
there’s also some new exciting things at UCLA were involved with research and one
of the most exciting areas is looking at essentially what is essentially extend
us a stem cell-based therapy we call cell based therapy it’s using muscle
cells muscle progenitor cells and we implant them into the urethra to restore
function the formal name is autologous muscle derived cells and we’re doing
studies ongoing at UCLA right now we take muscle cells from the patient’s
thigh we send them to a lab we grow them up in culture after a couple months we
bring them back and we do an office-based procedure to implant– them
near the urethra to give new finger function for the urethra no surgery no
foreign implants it’s your own tissue and no incisions all done in the office
very exciting very new getting back to the treatments like I said what are we
gonna do is so moving on to urge incontinence pelvic floor exercises
excellent first therapy for for women with overactive bladder dietary and
fluid fluid modification becomes very critical for these types of patients and
we put patients on what we call a bladder diet and it’s sounds a lot worse
than it actually is but it means removing triggers that
might cause blow-up bladder overactivity and here’s a list of just a few of the
ones and what I would call sort of the the common suspects that might
contribute to bladder overactivity caffeinated beverages alcoholic
beverages carbonated beverages acidic juices can all potentially cause bladder
irritation and urgency and frequency spicy foods even chocolate sorry ladies
but movie these things from the diet can often give you great insight as to what
your bladder triggers are and then you then have control over your bladder and
it’s all about giving control back to the patients all right what if kegels
don’t work what if that bladder diet doesn’t work what else do we have we’ve
got other things medication Botox neuromodulation and posterior tibial
nerve stimulation so medications have been around a long time you’ll see them
directly marketed to consumers and doctors may have told you about them
before but they’re all designed to help reduce the urinary urgency and frequency
and the incontinence episodes when we look at them over placebo most all of
them have some benefit sometimes it’s mild and the main class are these what
we call anticholinergic medicines and here’s a list with their trade names and
they all these ones all function in a similar fashion there’s all more recent
introduction that’s a what call a beta 3 agonist that acts a little different
mechanism and they all work pretty well reducing urgency and frequency and
incontinence episodes there’s no free ride there is some side
effects the anticholinergics most commonly are dry eyes dry mouth
constipation and dizziness and the beta 3 agonist headache joint pain dizziness
blurred vision all of them generally mmm mild and not severe but can be very
annoying and sometimes the side effects are more problematic than the condition
they’re trying to treat so it’s highly individual independent but if it used
quite commonly what else do we have well for patients who don’t do well with the
pelvic floor exercises who don’t do well on bladder diet and they’re still having
difficulty who have tried medicines and it didn’t work or tried medicines and
don’t want to take it we have some other options
how about Botox well everyone’s familiar with Botox used for cosmetic reasons we
can actually use it in the bladder it’s an office procedure we take a cystoscope
and we look inside the bladder and we place the Botox at different places
within the blood or using a small injection needle and when we look at the
results it reduces urinary urgency and improves bladder capacity and about 60%
of 60 to 65% of patients the benefit lasts but it’s not permanent
so it’s usually only about six months so often patients need one or two
treatments a year the side effects are very low but are important discuss
because sometimes the Botox does such a good relaxing the bladder muscle that
patients have a difficult time emptying completely but that occurs in only about
3 to 6 percent of patients how about other therapies well there’s a there’s a
therapy that we’ve been using for over 10 years called neural modulation it
involves placing a lead or a little wire right into the nerves above the buttocks
it’s for a severe and refractive overactive bladder patients who didn’t
do well on medications and it’s kind of like using a bladder pacemaker when we
put a little implantable pulse generator just in the back above the buttocks with
a little wire that connects through little nerve roots in the sacrum and
this reduces urgency and frequency considerably and the real nice thing
about it is we can actually evaluate plate patients before
do the implant with a temporary evaluation and for women who have
successful temporary leads placed when they go on to get the permanent one
eighty percent reduction in urinary leakage so that’s very exciting and no
medication in its long standing the batteries last up to five to seven years
and just would need to be replaced periodically another type of therapy
that’s a form of neuromodulation is posterior tibial nerve stimulation it’s
an office treatment requires nothing other than a small acupuncture needle
placed right at the ankle and we put a little mild electrical stimulation
through a little handheld battery pack this little stimulation on the ankle
works the nerves that work all the way up to the sacral nerve roots to affect
the bladder and reduces urgency it requires a 30-minute session so you come
in the office sit down with your clothes on with your book your iPad or your
Kindle have a 30-minute session after the acupuncture needle is placed and we
do it for 12 weeks and we look at this data it works about as well as
medication about as well as medication we’re still not sure about the long-term
benefit as often patients need boosters maybe once a month or so but that’s very
exciting for women who can’t tolerate medications and don’t want to go through
the troubles of other of their therapies so to summarize solutions for control
stress incontinence pelvic floor muscle exercises and dietary change if one
wants to do surgery we’ve got slings birch bulking all with excellent data
overactive bladder pelvic floor exercises Kegel exercises medications
Botox normal Asian or that posterior tibial nerve stim okay I think that’s
all I have for you but I’d like to answer some questions and I think Cleve
may have some for us okay all right the first question is a diet
question and then is should I remove all chocolate and alcohol and improve my
lifestyle before I decide on surgery I would say it’s always prudent to utilize
all conservative therapies before all conservative there are four therapies
before we talk about surgery the draconian implementation of removing all
chocolate and alcohol is kind of severe but I what I tell patients I say think
of it like an allergy avoidance take it out for a few days and see if it makes a
difference if caffeine if chocolate if alcohol is a true trigger you will
notice a difference in your bladder function with just two or three days of
removing it out of your diet and then it’s all about control because if you
notice your bladder does better you just if you have to be out that day you just
skip your morning latte but if you’re at home and you’re near a toilet no problem alright another question on
neuromodulation neuromodulation ten technique
what’s the pros and cons is it as effective as mesh alright so that’s a
good question I’m going to go back one slide just to differentiate when we talk
about neuromodulation it’s for patients with overactive bladder it’s the type of
incontinence with urgency and frequency the pros of neuromodulation is it
doesn’t require medication it’s a long-term treatment once you get it in
and it’s works you’re done you have to think about for five years it just
requires some maintenance programming that’s very simple to do and easy to
teach and it’s fairly safe complication rates with neuromodulation are very low
about 9% of the time patients have to have the implant removed either for it
that it’s not working or sometimes it can bother patients because it’s sitting
or pushing on the skin in an uncomfortable fashion it’s the question
is that is it as effective as mesh we don’t use any type of mesh at all for
our slings for overactive bladder that would be for stress incontinence so that
would actually be treating two different things
I hope that answers your question all right all right when do you know if you
have to have a mesh all right so I’m gonna go to that question right now
because I actually have a question prepared for you so let’s I’m going to
skip that for a sec and we’ll go back to so is the mesh safe and when do you know
you have to have it the mesh is safe and it should be utilized for patients who
have stress urinary incontinence for slings what you’ve heard and what the
FDA has intervened on is use of mesh for prolapse which we haven’t talked about
today that’s uh that’s prolapse of the bladder
prolapse of the vagina when we apply mesh in those settings it the
complication rates are in my opinion unacceptably Tigh and we I do not
advocate anyone getting transvaginal mesh for their prolapse however we have
great evidence of safety and effects the efficacy for slings and so using mesh
for slings I think is a reasonable idea because the safety and effectiveness of
slings is well established in clinical trials that followed patients for over a
year and since 2008 the FDA has consistently differentiated between
transvaginal mesh for prolapse and transvaginal mesh for sui we’ve got good
evidence that mesh slings can help stress incontinence not good evidence
that it’s safe for patients with transvaginal mesh for prolapse that
being said we have non mesh slings as well we can use your own ones own tissue
so patients who work who are leery about it and I would definitely advise you to
talk to your doctor before you consider anything like this to talk about using
your own tissue as well as a viable option this is just all the law as you
this is where all the all the patients when they come in they’ve all seen this
online and on TV all right if that but on any further questions I think I’ll go
to the Kegel question because that generated a lot of interest earlier so
I’m gonna swing back here so one one important thing I’d like to leave you
with is how do I do a Kegel all right so pelvic floor muscle
exercise are only going to help if done properly and there’s many ways to learn
and I’ll show you one way and I have a short cartoon this is from big bump TV
so typically the best thing to do is to do it when you’re not distracted do it
while you’re lying down or seated going back here’s your pelvic floor here’s the
rectum the vagina and the the first thing you want to focus on on
is the back think as if you’re holding in gas that you don’t want to pass gas
the next thing to practice is think as if you want to contract as if you don’t
want to pass urine and then do them both together and hold it for 3 5 even 10
seconds once you learn that skill do 15 contractions for 1 set 15 contractions
holding it for 5 to 10 seconds relaxing and repeating do 3 sets a day every day
that’s a good kegel exercise routine alright I think that’s all we have for
now one more question got one more question Cleve has it
alright one more question about leakage after urinating which category does that
fall into and what’s the best treatment for that alright so the last thing we’ll
talk about is what is what this individual is asking about is what we
would call post micturition leakage or dribbling many women will feel like
they’re empty they’ll stand up and they’ll lose a little bit of urine that
is often reflective of incomplete bladder emptying and it may be due to
poor poor Anatomy so patients might have you might have a dropped bladder or a
dropped urethra which actually contributes to a small amount of urine
pooling near the opening that’s not evacuated while you’re seated and then
once one stands typically that small amount of urine can leak out and that
can be addressed with a more proper evaluation in the office all right thank
you for signing on today and I appreciate you questions you

28 thoughts on “Female Bladder Leakage: Solutions to Get Control‎ | UCLA Obstetrics & Gynecology

  1. I had mesh surgery several years ago .over the years things have gotten worse I’m now78 yr s age. Now it’s. A soaking urination the min I have to pee I had better have a toilet real close real fast or else. I’m soaked. I have to wear depends plus a thickpad esp for leaking bladder. . Nothing worked for me guess I will have to be wet for the rest of my days.

  2. Its hard for me holding my pee when am walking,it always leaks but when am sitting or sleeping I can hold it but not for too long,I hate it because I haven't given birth,am not old so I don't understand it, sometimes I don't take fluids when I know am going out of the house or travelling…

  3. Thank you for sharing! The information and direction provided gives me much needed encouragement in dealing with this embarrassing condition.

  4. Thank you for making this video about diagnosing and cause of this problem, however these suggested solution doesn’t work even the surgery. I healed completely by holistic functional nutrition and diet. MD don’t learn about nutrition therapy anyway.

  5. so i have all of the above problems than i fell and broke my coccyx and now it hurts so bad to even try to do anything type of exercise. i have ever done 2 years with a chiropractor it still very tender it now 4 years still problems.😰😥😥

  6. a BIG HUG to you Dr.Christopher Tarnay..you are really GOD in true sense of the word….Love a lotz and lotz….truely love you …
    your vdo helped me a lot to understand all about urine incontinence through which my Mum has been suffering since last so many years…

  7. Hello Dr Tarney, Another cause of UI can be neurological. Spinal stenosis for example can cause paralysis to the muscles controlling the bladder.

  8. Thank you so much that was really informative because I do have all those problems and they've tried putting a pessary in sewing my inside uterus sort of thing upStill doesn't work

  9. I’ve had this issue from since I was a child and so I avoid going a gym or going on roller coasters, cross my legs when I sneeze or cough /: I just want an answer to why I’ve been like this

  10. so surprised you didn't mention diet, e.g., watermelon and other melon, dandelion, cucumber, cmeloelery, and many more things act as diuretic and will increase the need to urinate, sometimes more urgent, especially in my case being a vegan I eat LOTS of fruits and veggies, maybe half of a small watermelon and in a short time I will have to pee sometimes urgently from I think the volume of roughage pressing internally and the diuretic quality of the food.

  11. I told my dr. that I had a few accidents. He scheduled an operation, I had it. After that I now HAVE to wear diapers with added pads 24/7 (the diapers are almost like wearing nothing) Diapers are almost useless. When it rains or is cold, I can't stop urinating. Every 2 hrs at night. My legs are still swollen especially the left one.

  12. Everybody, google Overactive Bladder and go from there. It solved my problem. As good as new now. I was about to have TVT surgery. But the Lord showed me an article in the papers about coffee and tea and how bad they are for you. I cut out the little coffee i was having. My coffee was a mug of water with a nescafe right on the tip of d teaspoon. I couldnt believe that even that little could create such a big problem. Later i found out even a little sip of alcohol, which i dont drink, caused a problem and so did big amounts of bitamin C.

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