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Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America’s leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians, and caregivers. All available at nafc.org. 

Welcome back to another episode of Life Without Leaks. I’m your host, Bruce Kassover, and joining us today is a friend of the podcast that’s Dr. Travis Bullock. He’s a fellowship trained urologist in incontinence and pelvic medicine in private practice in St. Louis. And most importantly for this podcast, he had recently done a webinar discussing neuromodulation and the benefits that it could offer patients with incontinence and we’re here to follow up on that, give a little additional information. So Dr. Bullock, thank you for joining us today. 

Dr. Bullock: Hey Bruce. Thanks for having me back. It’s exciting to be back and to be able to give an update. I know we did a similar podcast a few years ago, and there have been some new treatment options and some new updates since then, so I’m really excited to share ’em with you and your audience. 

Bruce Kassover: I love new treatment options. And that’s really good to hear. Before we get into that though, for anybody who may have missed the webinar, maybe just a little brief background on yourself and how you got to be a urologist and where you are today.

Dr. Bullock: Sure. I’m a urologist. I am fellowship trained in female pelvic medicine and reconstructive surgery on, also known as urogynecologist. I’m in St. Louis in a private practice group with 30 other people. My sort of journey to urology was interesting. I actually had got exposed to urology before I even went to medical school.

I actually, in a year between college and medical school, I worked in a urology office in their research study department, mostly doing prostate cancer. At that time I didn’t really know much about urology in general other than prostate cancer. I knew a lot about urologists and, there were just, they were great people.

They were, they didn’t take themselves too seriously. They seemed to really love their job. They were smart. They took great care of patients. Patients like them. And so when I went to medical school, I naturally gravitated toward urology as well. It’s a interesting field. It’s got a nice mix of medicine and surgery.

You do get to take care of people for several years, but then there’s also issues that you can fix very quickly and get people back to life. It’s got a, just a great mix of medicine. It’s got a great mix of surgery and it’s a very broad specialty.

Most people don’t realize, but urologists can specialize in a ton of different things. Some do trauma, some do reconstruction, some do men’s health, some do infertility, some do stones, some do cancer, and then some like me do incontinence and female urologic conditions. 

Bruce Kassover: Yeah, I think there’s that stereotype, that old fashioned stereotype that a urologist is simply something that a man would go to when he’s having a prostate issue. And that’s about it. And it really is just the tiniest tip of the iceberg, isn’t it? 

Dr. Bullock: That’s very true. And a urologist’s practice, one of the most common diagnoses they’re actually gonna see is urge incontinence and overactive bladder. And that actually happens in men and women. More common in women, but when men get into an older age group, they do catch up with women and their incidences get about equal in the in the later years of life. 

Bruce Kassover: So let’s talk a little bit about that, because I think that was one of the focuses of the the webinar was on urge urinary incontinence and overactive bladder, if I’m not mistaken.

A lot of people are probably a little bit confused about what these different diagnoses are, so maybe you could explain a little bit about them. 

Dr. Bullock: So urge incontinence and overactive bladder are the same thing with two different names. It’s ping pong and table tennis. They’re both the same thing.

But what urge incontinence is and what overactive bladder is, it’s really defined by urinary urgency or the intense need to use the restroom with very little ability to delay it. And we call that ‘urgency.’ Now this is often – but not always – associated with frequency or that’s the need to go to the bathroom often.

It’s normal to go to the bathroom up to about seven times a day. Anything more than that’s considered abnormal. This overactive bladder may also be associated with something we call ‘nocturia.’ And that means to get up at night to use the restroom. Now this may, this is often shocking for people when I tell them this, but we always all sort of poll people as how many times a night do you think is normal?

And it’s actually two. We consider getting up twice a night to be somewhat normal, annoying but normal. Anything more than two is considered abnormal. And the last piece of the overactive bladder and urge incontinence, and not everyone has this, but a significant people do. It’s the urge leakage. It’s that inability to delay that urgency that actually results in an accident.

And these accidents are usually a large volume or a high amount of urine as opposed to the other type of incontinence that’s common; we call that stress incontinence. That’s the classic cough, sneeze, laugh, jump, lift, trampoline type of incontinence. That tends to be smaller an amount or smaller volume, where the urge incontinence sometimes can be a complete emptying of the bladder.

Bruce Kassover: Wow. Okay. That’s very interesting. I’m wondering though, all of us have experienced urgency at some point. You’re at the bar, you’re watching the game, you’re drinking some beer and eating chicken wings, and all of a sudden I really gotta go. What is the difference between that sort of ordinary expected type of urgency and something that becomes like a clinical condition?

Dr. Bullock: So when urgency becomes a clinical condition is when it really starts to impact the person’s quality of life. When they start to do things like isolate themselves. When they start avoiding going to places where they don’t know where the bathroom is. Where they start missing important family events like vacations and graduations because they’re nervous about embarrassing themselves. That’s, when it really impacts the quality of life, that’s when it’s really the time to focus on getting that problem treated. 

Bruce Kassover: That makes perfect sense. I’m also wondering about that urgency. I gave that example, you’re sitting you’re having a couple of beers and all of a sudden you feel it… with the medical condition, is it something that could just come out of nowhere or is it something that’s usually associated with “Yeah, I did probably drink more than I should ?”

Dr. Bullock: Certainly it’s a mix of those two things. Certainly, consuming or drinking a lot of fluids or a high volume of caffeine or alcohol can… and caffeine and alcohol are diuretics, which means they make your body make more urine. So certainly those things can be a normal part of high fluid intake or drinking a lot of caffeine. But in people with the clinical condition of urgent incontinence or overactive bladder, there’s typically not those inciting events. It is something that’s coming on all of a sudden with no warning, and it’s usually happening on a daily basis, if not multiple times per day, and it’s not really associated with any particular event at all, and it’s can be very disturbing and extremely troubling and embarrassing for these folks. 

Bruce Kassover: It sounds like it could be. So let’s say that it was somebody who’s experiencing these symptoms, and I have reached that point where it really is upsetting my life, and I realize I have to go to the physician. When I go and see you, what sort of treatment options would you be considering?

Dr. Bullock: So we actually have a lot of them. The most common treatment option right now is actually the thing that is pads. That’s the number one treatment option out there now. Now certainly, when you’re going to the visiting a physician or visiting a fellowship, you’re, hopefully your goal is to get out of or reduce those number of pads, but that remains the most common treatment option in America right now is pads.

We have some very simple treatment options, and some of those are things that patients can actually do on their own, like, doing things like time voiding, emptying their bladder on a regular schedule like every two hours or every three hours. Keeping the bladder empty does help with the urgency or help avoid the urgency. Doing things like fluid limitation, lifestyle changes, like cutting back on things that are bladder irritants, like caffeine or high volume intake.

Looking at people’s medications is important. Some people with high blood pressure are on diuretics, which are medications that make you make more urine, and it’s very likely that the doctor that maybe starred you on a diuretic for your high blood pressure, doesn’t know about your bladder condition. And they likely had other options. So we could look at medications.

Kegel exercises do help. Some people go to pelvic floor physical therapy, which is like doing Kegel exercises with a trainer that can be more effective than Kegel exercises alone.

All those are the conservative therapies that are non-medication. Then next we do have some medication-related options, which are oral pills. There are several of them on the market. They go by many names like Ditropan, Detrol Oxybutynin, Toviaz, Myrbetriq, Gemtesa. But basically they break down into two groups of medications…

one group is called the Anticholinergics, and then one group is called the Beta-3 agonists. Now these medications, they, if you ask me which one works better than the other, there’s not a good answer for that. They all typically work about the same in terms of how well they work, but it’s really managing side effects and looking at insurance coverage.

After conservative measures and Kegel exercises and medications, we do have things called advanced options. And those advanced options include things like Botox. They include things like neuromodulation, and there’s two forms of neuromodulation. One is called tibial neuromodulation, and one is called sacral neuromodulation.

Very rarely, we actually move on to other treatments that we really tried to avoid, like permanent catheters or major surgeries. Fortunately, in this day and age those things are very uncommon to have to pursue. 

Bruce Kassover: I’m glad to hear that. Before we talked a little bit more about some of these therapies, I did wanna go back for a second. You talked about timed voiding. 

Dr. Bullock: Yeah… 

Bruce Kassover: and I wouldn’t know about the opposite of that, about holding it in forever because I could tell you that when about. 20 minutes, my wife is gonna come through the door from work and she’s gonna go, “I gotta go to the bathroom. I haven’t gone all day.” So tell me, is that something you should be avoiding? Does it not make a difference? What are your thoughts on that? 

Dr. Bullock: You probably heard this term called bladder retraining. So my bladder retraining is, it’s partly time voiding and is a partially trying to hold. And what we do with time voiding is you want, or what we do in bladder retraining is you don’t really wanna hold your urine, but you want to train your bladder to empty itself in the absence of the urge.

That’s what sets up abnormal bladder behaviors is if you suddenly get the urge and you just give into your bladder and always go, when you have this intense urge, your brain will eventually set up a pathway to make that normal. “Every time I feel urge, I’m gonna rush to the bathroom,” and it actually makes the problem worse.

But if you get that intense urge and you stop. You take a few deep breaths, maybe you do a few pelvic floor squeezes or a few Kegel exercises, try to hold that urine for a short amount of time and then calmly walk to the restroom and empty your bladder in the absence of the urgency, that will actually go a long way into retraining your bladder to more normal urinary behaviors.

Bruce Kassover: That’s very good to know. So let’s go back to those treatments because in particular, your webinar you were talking about neuromodulation. And you mentioned sacral and tibial nerve stimulation. What are the differences between those and when might a patient consider one over the other?

Dr. Bullock: So neuromodulation is a really fascinating area in the treatment of urge incontinence and overactive bladder. And when I explain it to patients, it almost sounds like science fiction when I say it, but it’s very established treatment. We’ve been doing neuromodulation for now nearly 30 years.

So how it works is we all know that our bladder is controlled by nerves. These nerves run from our brain down our spinal cord and then all the way to our bladder. Now there’s an area near our tailbone, or the flat part of our tailbone just above where that end of that tailbone is, it’s called the sacrum.

Now this sacral bone is that nice flat part of our lower spine. And this sacral bone has these natural holes and through these natural holes there’s nerves that come out of our spinal cord, go through these sacral holes also called foramen. And then these nerves go to our bowel. They go to our bladder, and they actually go all the way down our legs, all the way to the tips of our toes.

Now about 30 years plus ago, some very smart urologists discovered that by giving some electrical signals to these nerves at the level of the sacrum, we can actually influence your bladder behavior. And then through years of research and collaboration with medical device companies, they came up with a device that was implantable that we called ‘sacral nerve stimulation’ or ‘sacral neuromodulation.’

And what it is, it’s similar to a cardiac pacemaker, but it’s a pacemaker for your bladder, and it’s actually implanted in your body in the upper part of your hip or butt cheek area. And then there’s a battery there, and then a small lead or a wire that goes just underneath the skin and touches these sacral nerves and gives low voltage electrical signals to these nerves that go to the bladder in the bowel to reorient their behavior and help not only urinary incontinence, but in some cases bowel incontinence as well.

Now, many years later and through more research, I talked about how these nerves also go all the way down your legs to the tips of your toes, they start looking at another nerve called the tibial nerve. The tibial nerve is a nerve in your leg. It’s in the inner portion of your leg, right behind that knob where the ankle bone is. And there’s a nerve there that actually influences bladder behavior as well.

 This has actually been known for centuries. In Chinese medicine, the acupuncture point for the bladder is the small area behind the ankle bone. And what they’ve come up with now more recently is, first was a device where you could place a small acupuncture needle in that nerve of your ankle to deliver nerve stimulation there. And then that actually turned into an implantable device similar to that pacemaker for your bladder that goes in your hip, but it can be placed now down in your leg, underneath the skin, near the inside part of your ankle. 

Bruce Kassover: Now. That’s very cool. So tell me this, you’re talking about nerves and electricity. Does it hurt? 

Dr. Bullock: No, it does not hurt. This Low voltage signals, which are very light electrical activity. It’s not painful. It’s actually not even distracting. How I describe it to patients is, I’m wearing glasses right now. Now do I feel those glasses on my face? No, I don’t really feel them on my face until I stop and think about it. “Oh yeah, I’m wearing glasses.” And that’s how this sort of nerve stimulation is. There’s this low voltage, little hum or a flutter people sometimes call it,, that they feel down in the pelvic area when you’re talking about sacral nerve stimulation or down in the foot when you’re talking about tibial nerve stimulation, but this sort of fades into the background and it’s not distracting at all unless you’re purposely paying attention to it, and then you can feel that it’s there.

Bruce Kassover: Now that’s reassuring. I like hearing that. So you mentioned science fiction. So tell me this, how effective is this? 

Dr. Bullock: So actually very effective. Sacral nerve stimulation is actually more effective than any medication I can give you for this problem. I mentioned those anticholinergics and those Beta-3 agonist medicines a few minutes ago.

The truth of the matter is about medications is that nearly 90% of people will stop their medications within a year, and that’s usually due to either side effects or it doesn’t work for them. When we’re talking about sacral nerve stimulation, about 80% of people will respond. And when we’re talking about tibial nerve stimulation, between 60 and 80% of people will respond to that as well. So it’s actually gonna be very effective. 

Bruce Kassover: That’s really cool to hear also. In America, in medicine, we hear all the time about how, especially when insurance is involved, there’s this sort of idea that you’re gonna do the minimum first, and if that doesn’t work, then you go on to the next and then the next and the next, sort of sequentially. Can you just start out immediately with neuromodulation, or do you have to go through these steps? 

Dr. Bullock: So great question, Bruce. And this is something that’s actually changed over the last few years. So we used to believe in that stepwise approach too. Look, we started off with Kegel exercises and limit your fluids and do time voiding.

And if that doesn’t work, we try a medication of one class and if that doesn’t work, we try a medication of another class, plus/minus physical therapy in there as well. And then if that doesn’t work, maybe we would think about one of these advanced options.

We don’t subscribe to that anymore. We really believe in shared decision making with these patients because some people are just not candidates for medicines. We know that medicines don’t work for a lot of people, so these options can be discussed early on. And I actually do discuss them very early on, and I believe in using these more advanced options as early as possible.

Now, the sort of trick to this is, I don’t make all the rules to medicines. Insurance companies are also involved. And even though I believe in shared decision making and the American urologic guidelines actually believe in the shared decision making and moving in these more advanced options earlier into people’s treatment paradigm, and there’s a long way to go still with insurance companies in getting them to understand this process.

And so currently we are still practicing a more stepwise approach. But we hope over with education of the insurance companies over the next few years, we’ll be able to give patients all the options and they can pick the option they want much earlier in the process. 

Bruce Kassover: That would be a wonderful thing if it would happen. But I’m also wondering about patients’ readiness for this. I would imagine that if you were to ask patients coming through your door, who, it’s their first appointment… “Do you know, have you ever heard of neuromodulation,” the extraordinary majority of them, if not all of them, would say, “neuro what?” Why don’t patients know more about this and what do you do to help bring them up to speed with what could be done today?

Dr. Bullock: Yeah. It’s amazing that, with how common urge continence is that more people don’t know about it. And when I say urge continence is common, or at least urgency is present in about one third of the population. So urinary incontinence overall is probably more common than diabetes. It’s more common than osteoporosis. It’s more common than breast cancer and is an extraordinarily common medical condition. And you are right. Most people do not know what the treatment options are, and some of that is just because after all these years and how many will actually have this problem, there’s still a lack of education piece on the part of the medical societies.

A lot of people think that Urinary Thomas is normal. Or it’s a normal part of aging or it’s just something people have to deal with, or that’s just something, “Oh dear, that’s just because you had babies. That’s just normal.” And the fact of the matter is none of these things are normal.

And then it’s even made more complicated by the embarrassment or the shame or the isolation that goes along with it. People don’t want to talk about these problems. They don’t usually want to tell their family or friends that they’re wearing pads or they’re having incontinence issues. So there’s a lot of shame and in a lot of embarrassment.

And then there’s a lot of misconceptions about the treatment options that maybe they’re invasive or they don’t work anyway. 

Bruce Kassover: So I certainly hope that, listening to this people get a better sense of what some of their options are and, really engage in that shared decision making with their physicians more, more thoroughly and more clearly.

One of the things we did wanna talk about, we got a few questions some follow ups to your webinar and wanted to get your thoughts on them. The first one that I have here is there were some questions about surgeries with metal impact and if that somehow affects eligibility for neuromodulation. I’m wondering what your thoughts are on that. 

Dr. Bullock: One thing I’ll point out about all these neuromodulation implants, they are made of metal, but they are all MRI compatible, so that is good. There’s no issues with having MRIs or CT scans or any x-rays, and now with people who already have metal in their bodies, which is, I think that’s what the question is asking.

People will often say, ” I’ve had back surgery. Am I a candidate for this?” in terms of sacral neruomodulation, the answer is, vast majority of time, yes. Urologists are working at a level way lower than anyone’s had any back surgery. So even if you have hardware from a back surgery, that should not be an issue.

In terms of tibial nerve stimulation, people ask about if I had a knee replaced or if I have a knee implant, is that an issue? And it’s not. If there is any metal maybe in the ankle, we do wanna have the implant away from any metal in the ankle. But as long as there’s not metal in both ankles, then the other leg would likely be eligible.

Bruce Kassover: What about men who’ve had prostate surgery? 

Dr. Bullock: So it depends on the type of incontinence they have. So again, we talked about the two types of incontinence people have. One is urge incontinence, which is the “all of a sudden I have to go, I have to go right now” incontinence. And the other one is stress incontinence, which is coughing, sneezing, activities.

So some men after prostate surgery can have leakage with cough, sneeze, activity, cutting the grass. That is not something that’s treated with neuromodulation. But if it’s the urgency and the urge leakage, then yes, that can be something treated with neuromodulation. 

Bruce Kassover: That’s good to know, at least for those men who are candidates. Speaking of, visiting your doctor and discovering what approaches make sense, I’m wondering, do you go straight to urologist or do you go to your general practitioner and if so, when would you ask for a specialist? 

Dr. Bullock: So you can go either way on this. I think if you would be more comfortable seeing a urologist, especially a urologist that specializes in this area, we are more than happy to see patients who are very early in their treatment paradigm. And that’s the majority of people I see. I’ll see them. I like, what have you tried for your bladder already?

And a lot of times it’s very little. “I tried some exercises. I’m using pads. I tried to cut back on my caffeine,” but it’s also very reasonable that your primary care physician, or your primary care nurse practitioner, or your OB GYN provider or their nurse practitioner, they can also institute therapy for overactive bladder and urge incontinence.

At the very least, they can counsel you on fluid limitation and time voiding and Kegel exercises, and they’re more than qualified to start folks on medications also, should they choose. Now when it comes to advanced treatment options, that would generally be performed by a specialized urologist or gynecologist that specializes in bladder disorders.

Bruce Kassover: I suppose though, who you see sometimes will depend on which insurance you have as well, and I’m wondering, I guess one of the biggest questions is, is neuromodulation covered by insurance ? 

Dr. Bullock: So fortunately, yes. So when it comes to sacral neuromodulation, it has been FDA approved for over 25 years. So we’ve been doing it for a long time and it is covered by insurance. There are some steps you need to go through and some documentation that you need to, the physician needs to put in your chart for the insurance provider. But it is very readily covered by insurance. Now tibial neuromodulation is much newer.

The devices for that were only FDA approved in the last few years, and sometimes insurance coverage on those can be a little bit more problematic and can require some extra documentation and some extra paperwork. Medicare has no issues with either one of these modalities, but like a commercial insurance, like Blue Cross Blue Shield, Aetna, UHC, there may be some special documentation that needs to happen first.

Bruce Kassover: That’s good to know and certainly hope that the patients will work with the physician’s office to try and make the the best financial decision, as well. I’m wondering now after you you’ve done your webinar, we’ve gone through some of the questions. Is there anything that we have not yet asked that you think is important for people to know?

Dr. Bullock: Sure. A lot of people will ask me, is this problem hereditary? They’ll say, I hear this a lot, “I’m coming in now ’cause I see what my mother’s going through. Is this problem hereditary?” And I tell people in general, no, this is not I mean there is maybe a small hereditary aspect to this, but I always tell people to look at other aspects of health, also. There are several other medical conditions that can impact on your bladder, such as sleep apnea. People with untreated sleep apnea make more urine at night. People with high blood pressure may be on a diuretic, which is causing to make more urine. People can have mobility issues, which limits their ability to make it to the bathroom fast enough before that leakage episode happens. So I always tell people that incontinence is multifactorial or it has many different causes, not just one, and to evaluate all those causes.

Another thing people often will come to me is with their incontinence, especially their urge incontinence, they think it’s an anatomic problem. Or they’ll say, “I’m coming in because I have this incontinence, ’cause my bladder’s falling.” And they, a lot of people don’t have a clear understanding of the difference between prolapse, or pelvic organ prolapse, which is like a cystocele, or actually something’s falling out of the vaginal opening, versus urinary incontinence, which are two totally separate things.

I usually tell people that urinary incontinence of the urge variety is not usually an anatomic thing, so it’s not something I’ll generally see on exam, like a bladder falling. It’s more of a functional thing or how the bladder’s behaving. 

Bruce Kassover: So how many people come into you and say, oh, it’s ’cause I have a small bladder?

Dr. Bullock: A lot of people think it’s because their bladder’s small. It’s a great point, Bruce. I love that. ’cause a lot of people will come in and say, my bladder’s just small. Where in reality, the bladder almost 100% of the time is normal size. It just thinks it’s full, even though it’s not. It’s an interplay with how those nerves… how the nerves to the bladder and the nerves to the brain are talking to one another.

It’s like a thermostat. My thermostat over on the wall is set at 71, and that’s what’s keeping this room comfortable. Maybe your bladder thermostat is set low. It’s a normal bladder. Should hold about two cans of soda or 500 ccs. Maybe your bladder thermostat is set at 250 and so it thinks it’s full, even though it’s not. 

Bruce Kassover: Well that’s fascinating and I appreciate you sharing all of this insight with us. This is Life without Leaks and one of the things we always like to do before we end is leave our listeners with one little hint, tip, strategy, bit of advice to help them live a life without leaks. So I’m wondering if you might have one you can share with us today. 

Dr. Bullock: I would say the biggest thing I can impart on people is be an advocate for yourself. Just because this problem of urinary incontinence is not life threatening, that doesn’t mean it’s not important. There are physicians out there that are passionate about this topic and really want to help people. I’ll also impart this on you just because a condition is common, like urinary incontinence, doesn’t make it normal. 

Bruce Kassover: Those are some real words of wisdom and I appreciate it and I hope that our listeners take it to heart as well. I wanna thank you so much for the webinar and for joining us today and sharing all of this information. I’m certain that people are gonna get a lot out of it, so thank you for joining us. 

Dr. Bullock: Hey, thank you Bruce.

Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. Our music is Rainbows by Kevin McLeod. More information about NAFC is available online at nafc.org.