Dreading the doctor? A physician shares his best advice for great appointments

Seven years. That's how long many patients live with leaks before they get the courage to see a doctor. And then when they do show up, the encounter can be so awkward and uncomfortable that they wind up not getting the help they need.

Today's guest is Dr. Travis Bullock, a urologist in private practice in St. Louis. He shares some very sound advice for patients who might be uncertain or apprehensive when it comes to seeking professional help, and he offers patients who are just getting started on their treatment journey some encouraging thoughts on what they can expect on the road to drier days.

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Music:
Rainbows Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

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Transcript

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. 

So welcome to another episode of Life Without Leaks. I'm your host, Bruce Kassover, and we're joined today with the Executive Director of the National Association for Continence, Steve Gregg. Welcome, Steve. How are you doing?

Steve Gregg: Thank you. Good to see you, Bruce. Excited to hear what Dr. Bullock has to say. 

Bruce Kassover: That's right – today's guest is Dr. Travis Bullock. He's a urologist fellowship trained in incontinence and pelvic medicine. He's in private practice in St. Louis. So welcome, Dr. Bullock.

Dr. Bullock: Hey, thanks so much for having me. This is going to be a lot of fun, I think. 

Bruce Kassover: Excellent. We're looking forward to it. So can you tell us a little bit about how you got into urology in the first place?

Dr. Bullock: Sure. It's a little bit of an interesting course of things. When I finished college, I wasn't sure what I wanted to do, but I thought I might want to do something in the medical field. So I had a year off and I had a friend who whose father was a urologist. And so I was over at their house at like the end of a college party, and I was talking to their dad, and I told him I was interested in medicine, but didn't really know what field… Any chance I could get a job at your office to get some experience in medicine?” And they had one for me as a research study coordinator.

So I worked as a research study coordinator in urology. And then that sort of convinced me that I liked medicine in general. So I went to medical school. When I was actually in medical school, I thought I would do OBGYN. I really liked the women's health aspect of things. You know, I was raised by mostly a single mother. I had a lot of female friends when I was growing up and I thought I'd really like a career in OBGYN, but that OBGYN lifestyle didn't, did not really go with my personality very well. I sort of ,I'm a very on-time person. I like things planned and that is definitely not the life of anyone who delivers babies.

And so I, then I kind of fell back to urology. Because I had experienced it within the past and I saw a clear pathway in doing women's health on the neurologic side of things, which is in the urology world. It's very, there's not a lot of people in the urology world who sort of specialize in incontinence and pelvic health and women's health. So it really opened up a nice window for me. 

Bruce Kassover: Now, when you say urology, I would imagine most people think men's health is the first thing that comes to mind.

Dr. Bullock: Yes, that is true. 

Bruce Kassover: Now, you're in private practice, right? 

Dr. Bullock: I am in private practice. 

Bruce Kassover: And do a lot of your patients just come to you off the street or do a lot of them get referred or… and of those, are a lot of them sort of surprised that they, they need to see a urologist in the first place?

Dr. Bullock: So fortunately I, you know, I'm in a large private practice group of all urologists, and there's two of us in my group who did female pelvic medicine fellowships. So everyone in our office is very aware that urologists treat women and specialize in women's health issues, and then we've done a great job in the community, I think educating our referring doctors, the primary care doctors, the GYNs, that, you know, this urology practice is a urology practice that's not only focused on men's health and prostate cancer and kidney stones, but we're really focused on incontinence and pelvic organ prolapse and pelvic pain in both men and women.

You know, since I'm in a urologist's office with a bunch of general urologists that generally see menk, I actually have stuff in the waiting room, out in the waiting room about incontinence and I'm not really leaving that for the men that are out there in the office seeing my partners about their prostate or their kidney stone or their bladder or their bladder cancer, prostate cancer.

That stuff's actually in the waiting room for the wife that brought them there that doesn't even know that urologists take care of women, and I've been in practice here for gosh, I can't hardly believe it when I say it, but 15 years now, and so I got to a point I exclusively now see women with pelvic floor issues.

I do see a few men here and there with multiple sclerosis and incontinence issues related to their multiple sclerosis, but my partner and I primarily see only women for incontinence and prolapse. 

Bruce Kassover: Tell me this: I would imagine that there's such a stigma that surrounds incontinence when you have patients who walk in the door. Is it really difficult to even get them to open up and discuss their problems? 

Dr. Bullock: It is hard. Yes. Fortunately, you know, sometimes incontinence is sort of a, this kind of a, “Oh, and by the way,” kind of appointment. You go to a, your primary care doctor, or you go to a general urologist because you've been, you know, referred for a bladder infection or kidney stones.And then it's, “Oh, by the way, while I'm here, let me ask you about your incontinence.”

Fortunately for me and my partner that really specialize in incontinence, when you're coming to see us, you know, that's something you're going to talk about. And so it's not really a hard jumping off place when you, when you know, it's something that you're, that you're primarily there.

One of the techniques I try to really do to bring people out of their shell when it comes to it is, as you know women, men with incontinence often have suffered with this problem for years before they finally come to a specialist about it. I think the average is seven-plus years. And I find the reason people generally, what, what sort of tips them over to come in is there's usually some event that caused it. Either it's I, you know, “ I have a vacation coming up and I'm afraid to get on this cruise because I don't know where the bathrooms are,” or “I want to go to a granddaughter or a grandson's graduation or wedding and I need to be able to be at this wedding and I'm afraid of what's going to happen to me.” Or worse yet, you know, “I, something happened in public. I wet myself at Target. I was over at a friend's house and I had an accident on their furniture.” 

So I really try to find out what is, what's that tipping point or what's brought you in. It's a very real-life conversation rather than, “Do you experience urgency? How often do you go to the bathroom?” I really try to find out what is that driving force. And I think that really brings people out of their shell and makes the conversation very easy because most of the time when they've gotten to the point to see me, they are, they are ready to do something. 

Bruce Kassover: And when they do come into see, are they expecting that there might actually be a cure or some sort of meaningful outcome, or do a lot of them come to you sort of without a lot of hope to begin with? 

Dr. Bullock: So it can be variable. I think the primary care and gynecologists in my referral network are very aware of incontinence and they're very aware that there are treatment options out there. They don't always start them on a, on a medication or even, or talk to them about behavioral therapies or timed voiding.

But I think they do a good job of saying, “Look, hey, I know there's these doctors out there who really specialize in this problem. I've had other patients that have done really well.” So I do think they really impart some hope upon them that there are treatment options available, but incontinence is a tricky thing. It's really embarrassing. It's hard for people to bring up. They don't always want to talk about it openly, even when they're there. And that's only urinary incontinence. When you're talking about bowel and fecal incontinence, that's an even more difficult conversation to have. But I hope people come with some expectation that there's a treatment option available.

And I think when they leave, I do a good job with laying down all the options for them and really starting them on a pathway to getting their incontinence improved. 

Steve Gregg: Dr. Bullock, one of the things you just mentioned is the network of primary cares that know that you do great work. That is not what we consistently hear. What can you do to make sure that those primary cares are willing and able to refer to you?

Dr. Bullock: So I, you know, I interact with them fairly often. Another – in terms of primary care doctors. In terms of gynecologists is we, I do a lot of operations with them since I'm a urologist that treats prolapse, but I don't generally do or I don't do hysterectomies. I let – the general gynecologist does. There's a lot of operations we do together. So I operate with a lot of gynecologists. And so I can, that's a great time for me to share experiences, to share patient outcomes. Some of my best referring doctors have been neurologists. I have, there's some neurologists in town that treat a lot of multiple sclerosis. And as you all know, people with multiple sclerosis, the vast majority of them have urinary issues. And they're some of my best champions, is that the neurologists I work with are the most in-tune on bladder control issues, and a lot of times I have a patient with MS who comes in and says, “My neurologist diagnosed me with neurogenic bladder, I have incontinence. They tried me on this medication, it wasn't, it wasn't successful for me. They've referred me here for you to fix my incontinence problem.” And so I had a lot of years to work with these referring doctors and a lot of close interactions, but it's been a very successful partnership. 

Bruce Kassover: That also brings up another question: What about patients arriving via caregiver or with caregivers? Do you deal with a lot of family members and other people like that? 

Dr. Bullock: So for a time there, it was a little hard to sort of figure that out because when we had a lot of intense COVID restrictions, we weren't allowing caregivers or family members into the room unless the person had significant impairment, you know, had mobility issues or cognitive issues and couldn't really participate in the visit without their caregiver.

But now I think a lot of women, they come, they tend to come to the doctor's office alone. A lot of them do, or occasionally a woman will bring her husband, but she kind of just kind of sits over in the corner and, you know, doesn't really participate. He's just kind of moral support. I find a lot of older women come with their daughters, which is a great source of information.

Very rarely I find a woman who comes with her son and my usual comment is, “Oh, you must not have any daughters.” And the answer is always, “Yes.” I think when people come with their caregiver, it's, it's important to find out why they've come with the caregiver. Are they coming with that caregiver just because this is moral support? Are they coming with that caregiver because they want an extra set of ears to hear everything? Are they coming with that caregiver because they have some cognitive issues? And maybe that family member is going to be your source of history. 

Or sometimes I find that that's, a lot of women come with somebody else and that's not their caregiver. I see sometimes a woman comes with her husband and maybe the husband has cognitive issues. And he can't be at home alone. So I try to find out what the purpose of this other family member is. And if it's just a, be an extra set of ears, that's great. I've always encouraged them to chime in. If it's someone with cognitive issues and that the caregiver is really there to help guide the history and organize medicines and organize the treatment plan, I think it's important to not sort of talk about that patient to their caregiver. I think there's ways you can do it where you're talking that eye contact is really focused on the patient. But it's very obvious that the questions are being asked to patient and caregiver and that everyone's sort of welcome to give responses. 

Bruce Kassover: You know, that makes me think about something. I remember I was reading once about an oncologist who was talking about one of the, one of his challenges was in communication. He talked about how he there was a woman who came in. He examined her and did all of the tests and found out that she did have breast cancer – very, very early stage – and it was a form that was very treatable, and he had total confidence that they'd be able to take care of it. So it was sort of like this, you know, “The bad news is this, but the good news is that we, we got you, we have you covered,” and he said that he tried to explain it as clearly and as encouragingly as possible, and she literally heard not a word that he said. He said, “You have cancer.” And that was it. There was, there was no good news. She couldn't, literally couldn't take a thing away from it other than that. 

And you talked about how caregivers can come in and can be an extra set of ears. And, you know, either with or without caregivers, do you find sort of, similar sorts of challenges, getting people to understand what the real diagnosis is, what they need to do to get to where they should be? How is the communication handled on your end? 

Dr. Bullock: So I try to break everything – I'm not a, I don't use a lot of big, fancy doctor words. I try to break everything down into bite-sized chunks of information. I try to use a lot of analogies and a lot of real-life examples. I'm also really big on, everything I say to you at your office visit, I have written down for you.

So I have a lot of patient education things I hand out. And I'm pretty good about, I shouldn't say – I'm very good, I don't tend to hand out branded information from drug companies or device companies. I have things that I've written myself, so it's in, you know, my language. And it'll be familiar because it's a lot of it that's written down as the exact same terminology you heard while you were with me.

So I have a lot of written information that I send people home with, a lot of things. And I have a really good support staff at my office. You know, we have a, we have something called a patient navigator who will actually call you a couple weeks later and sort of go over the appointment with you again to make sure you didn't have any questions. To make sure you knew what the treatment was, to see if you were given a medication, to see if there's any issues with the medication, if you have any side effects, any problems filling it, and if you have, if you wanted information about what other treatments that are out there other than medications, she goes over those with you also.

So we have a, I have a nice network of communication at the office. I find that repetition is what a lot of people need. So, and that's really helpful when people come. When they've had these kind of touch points in between their visits it really organizes that visit for me and the patient when they come.

Bruce Kassover: Yeah, I really love that idea of having that patient navigator because we know compliance is a real challenge. I mean, getting people to just take one medication a day is not. easy. And I imagine when you tell them things like, “Well, you're going to have to give up coffee,” that it's really a challenge. Do you find compliance is an issue with helping people on the treatment path?

Dr. Bullock: Yeah. Urinary incontinence is, it's interesting that the, when we say compliance, you know, I don't want to make it sound like you're a bad patient or you've done something wrong, but patient compliance is a big issue. Especially with incontinence, I think the national average is something like 60 to 70 percent of patients with incontinence when they see a specialist don't show up for a follow up visit.

They have that one visit and then there's not another visit after that. Even, we have ability with my electronic medical records to even chart that. And even in our practice, it ranges from, you know, 30 to 70 percent of people don't even show up for a second visit. I mean, I thought I was a big shot and “Oh, all my patients show up for a second visit.” I was about 43 percent.

Bruce Kassover: And why do you think that is? 

Dr. Bullock: It's an embarrassing problem, so people don't want to talk about it in the first place. So it's an embarrassing problem. You brought them in, let's say you give them a medication and maybe that medication doesn't work, or maybe that medication had side effects that were intolerable.

And if you didn't tell them that, “Look, there are options other than medication.” I think a patient might assume that, “They gave me this medicine. It didn't work. I guess there's nothing else they can do,” or, you know, some patients, they've been given one medicine by their primary care doctor or their gynecologist and I gave them a second one and it didn't work and well, I'm now, “I've tried two medicines. There must be nothing to do.” 

So that's why even at first visits, I'm very proactive about laying out all the treatment options. We're going to start off behavioral, timed voiding, pelvic floor exercises. “Yes, there's medications for it. Should those things not work for you, there are also these other options out there.”

So this is a chronic health condition, the same things going to work for one person may not work for a second one, there may be some trial and error involved here, it may take us several visits and several different things before we hit on the thing that's right for you, but I really need you to stick with me if you can.

And that's why we really implemented this navigator was to help with this compliance issue and this no-next-visit issue, to keep people engaged in their treatment and keep them coming back because the truth of the matter is with overactive bladder and urge incontinence, that may not be something I'm going to fix for you in one visit.

Now, stress incontinence, that may be a little different. It's a little more straightforward, that is, something we oftentimes have a very clear treatment plan with a very clear goal in mind, even after one visit. But urge incontinence is not that clear cut of an issue as stress incontinence. And sometimes there's some trial and error and many different modalities that need to be tried before we hit what's right for you.

Bruce Kassover: So, you know, that does bring up the question about outcomes. So can you give us an idea for patients maybe with urge incontinence or stress incontinence, various different types of incontinence, what are the keys to getting as good an outcome as possible? 

Dr. Bullock: For urge incontinence and overactive bladder, definitely need buy-in from the patient. There are some things that patients can do to help me help them get better. You know, no one wants to be told they need to limit their coffee and their caffeine and their fluids. But that is something that is definitely going to help. Behavioral interventions do help. 

People don't like necessarily pelvic floor muscle exercises. Some people don't know how to do them. And if you don't know how to do them, I have a whole network of pelvic floor physical therapists that can help you. And then when you do know how to do them, it's something that's difficult to remember to do. I'll tell people, you know, to do them at stoplights. Do them during commercials.

Medications can be effective, but there are side effects to those medications. I think, you know, if you look at patients that are started on overactive bladder medications after a year, somewhere between 70 and 90 percent of them are not taking them anymore after a year. And that's due to side effects or due to lack of efficacy.

There are some great third line options, but these become more procedural in nature. And I think it's important for me to establish with the patient, whether, are they ready to move forward with a procedure and are you to the point where your urinary symptoms are bothering you enough to move on to a third line therapy or some non medical, more procedural option?

Bruce Kassover: But even among those, there are some, there are some pretty non invasive options, aren't there?  

Dr. Bullock: The beautiful thing about overactive bladder and urge incontinence is the third line procedural – and notice I use the word “procedure.” I didn't use the word surgery because the options that we have for overactive bladder and urge incontinence are really more minimally invasive procedures than they are surgery. And they're very highly effective, have very few side effects, and they typically work significantly better than medications. 

Bruce Kassover: So why do you think they're not chosen as frequently as they might be? Is that patients are just not aware of them or there's some concerns that maybe aren't justified or there are, there are other reasons that I'm not thinking of?

Dr. Bullock: I think it's a combination of all of them. I think the biggest issue is patients are not aware that there are treatment options available. And I think a lot of primary care doctors and gynecologists are not aware either that there are treatment options available. They might just know that, “Oh, we get, there's pills out there for overactive bladder, but that's all I know.”

I don't think a lot of primary care doctors are even aware that there's treatment options available and patients definitely don't know that there's treatment options available. And then when you start talking about them, you know, they hear “procedures” and I can sort of see it in their mind, they start thinking, “Well, is my problem bad enough?”

Yeah, that's sort of what I hear a lot of comments: “I don't know if my problem is bad enough yet.” I always sort of ask them and ask myself, “Well, how many times do you have to wet yourself in public before your problems bad enough?” For me, that's once. It happens to me once, this problem is bad enough. And so I think between the lack of information of what's out there, the embarrassment of the problem itself, the maybe years of thinking, “This is just something that happens.This is just something I have to live with.” And then the thought of, you know, “Is my problem quote bad enough yet for a procedure?” This definitely leads to delays in getting people to appropriate treatment for their incontinence. 

Bruce Kassover: You know, before we even get to that point, there's one other thing you mentioned I wanted to touch back on. You were talking about working with physical therapists as well. You said that out of your office, you have a network of PTs that, that people can use in coordination with what you're prescribing for them. And I'm wondering if you talk a little bit about the synergy between physicians and physical therapists and the benefits for patients.

Dr. Bullock: Yeah. So I have an amazing, there's an amazing network of pelvic floor physical therapists. When I came here 15 years ago, there was like two. Now there's probably 10 or 15 I have to choose from. Sometimes minimally invasive options are the best option for incontinence. Physical therapists do a great job diagnosing and evaluating incontinence.

The way their appointments are set up, it's a one-on-one type physical therapy appointment. So it's not a group appointment. You're not having one physical therapist working with several different people on various exercise machines. It's a one-on-one. There's a lot of history taking that goes on. A lot of times during the first visit, no examined is done at all. It's all history taking. 

They have set aside and during their appointments, a lot of very valuable time to go over, you know, dietary interventions. What are you eating? What are you drinking? What kind of stressors are there in your life that could be impacting on your bladder condition? So they really spend a lot of time with these people.

They instruct them on how to isolate their pelvic floor. It's very easy for me to say to you, oh, squeeze those pelvic floor muscles. But a minority of people actually know how to isolate their pelvic floor. So the physical therapist can show them where their pelvic floor is, how to isolate their pelvic floor, how to use it to help with their urinary incontinence.

I actually, for about 12 or 15 years, we had a physical therapist in our office that we used. They weren't employed by me. They just simply rented out space in our office. And that was a really great thing for patient compliance. We don't have that anymore because they now have their own office literally less than a mile away. So it was more efficient for them to see patients out of their own office a mile away, rather than split their time that two offices that were so close together. But I've had really great success with pelvic floor physical therapy. 

A lot of times it's not the only treatment people are getting. It's combined with medications or other third line therapies, but it's very beneficial. I mean, patients find it to be very enlightening for their education also. 

Steve Gregg: You know, it's interesting, Bruce, that so much what Dr. Bullock says is what we continually hear, but he has an approach that doesn't exist in a lot of other places.

We love the idea of a nurse navigator. We think that's absolutely great. And the reason for that is, one of the questions we get oftentimes are “Boy, there's a whole lot of treatment options available to me.” Sometimes the urologist or your guy doesn't explain each and every one of them. So they want that, but they don't know how long they're going to be within one step versus another.

And Dr. Bullock, it sounds like you're pretty good at both describing the journey and then how long we're going to be at the various steps within the journey. That's not what we hear consistently across urologists.

Dr. Bullock: So I one time read something somewhere and I forget where I read it, but it really impacted on me. I read that as a specialist, you have three appointments before a patient loses confidence. So you come, you come to the doctor, you see me, you've got urge incontinence. Let's say I talked to you about behavioral therapies and medications. I send you in with the medicine. You get home with that medicine.

“Oh, I saw this great doctor today. He or she really seems to understand my problem. They gave me this medication. They're very confident this is going to work for me.” They set up a follow up visit in about six weeks. “Well, you know, this medicine, I took it. It helped a little bit, but it really dried my mouth out. I have an appointment coming up. I'll see what's next in line.” 

“Well, I saw this doctor again. They said, ‘Well, that medicine maybe wasn't the right medicine for you. Here's another medication for you.’ Well, I get home. I have this new medicine. This is the right one. That first one dried me out a lot. But this is going to be the one that works for me.”

That one doesn't work for you. Now you're on your third visit and now if you don't have a plan for this person going beyond what you're doing already, by that third visit, they're really gonna, you've sort of lost them, they're gonna think, “This is just is what it is for me. There's nothing else coming down from my bladder condition. I'm gonna go on for another several years living this way because there's nothing that can be done.” 

So I'm forthcoming early on about really throwing everything out there to let people know, you know, where I'm going in my mind or where I think we're going to take this long term rather than just medication after medication.

“See you in three months, see you in three months.” I don't think that's a, that's really moving forward in the right direction. 

Steve Gregg: The other piece that we've heard, and I don't know whether you've had the same situation, is patients want to talk to you about what my options are. Risks, benefits and pieces. And we've been seeing that for quite a while.

Recently, we're seeing patients that are saying, “Gee, my doctor outlined all the options and then said to me, ‘What do you want to do?’” 

Dr. Bullock: Yeah. 

Steve Gregg: And they say to us, “If I knew what I wanted to do, I would have gone to medical school. I want you to have an opinion, but I want you to then be able to talk to me about your opinion.” Do you see that?

Dr. Bullock: I see that. And I know where that comes from. So when we are in medical school, we're sort of taught over and over again, let the patient make the choice. Let the patient make, your job is to lay out the options… patient makes the choice. 

I think that is correct to an extent, but I'm here to sort of guide you. I'm going to lay out all the options for you, but if you're gonna, if I, if you're gonna ask me for a recommendation – and everybody does – I'm fully willing and fully able to sort of guide you down that pathway to what I think probably is the the best option for you. So I agree with you. I know where that's coming from.

We're, we're sort of trained that way. Generations ago, you know, the doctor was trained to be very paternalistic, you know: Ppatient comes in. I tell you, “That's what we're going to do.” And that's what we do. And then, and then there was a major shift in medicine. We were sort of trained the patient’s the boss, you're there working for the patient, where in reality, it really needs to be somewhere in the middle. You need to not dictate to a patient what their treatment is going to be, but you need to give them the choice, but really sort of help guide them down the pathway to what you think is best for them. 

Steve Gregg: I completely agree. So we sort of look at numbers – and I cheat on the numbers because it makes my math work out – there are roughly 33 million symptomatic folks for overactive bladder with urgency. It's actually 37, but that makes my numbers harder. And if only one in three ever comes to see you, that's 11 million. And then we know those are mostly started on a variety of medications, whether they're generics, the old stuff, to some of the more newer medications. But realistically, there's probably less than a million ever get to the advanced therapies where we know they can have a significant impact, certainly beyond medication, what medication can do. 

What can we do to get them to at least have a conversation with somebody who is knowledgeable about advanced therapies and then can guide them into what might be appropriate for them?

Dr. Bullock: One of the biggest issues out there in incontinence treatment is that not many people are aware of that there are third line or advanced therapies. That really is the biggest issue. Even amongst urologists and gynecologists don't even know what all the third line therapies are. And then if you do know what the third line therapies are, very few people actually perform third line therapies, whether it be Botox, sacral neuromodulation, or tibial nerve stimulation.

So very few people perform third line therapies. And then to sort of add another level of complexity on there, of the people that do perform third line therapies, there's a lot of them that sort of think it's only for my worst of the worst patients and don't offer it early or often enough. I think the statistics are, of all the people who are eligible for probably a candidate for a third line therapy, only about 3 percent of them actually proceed on to a third line therapy for various reasons.

And a lot of them are, you know, knowledge of what the third line therapies are or a lack of people that actually perform third line therapies. 

Steve Gregg: What could NAFC do to help that situation?

Dr. Bullock: It's so funny that incontinence is probably, if you look at those numbers, 33 million, and then another probably 20, 30 million stress incontinence.

You know, we know that incontinence is probably one of the biggest health care problems in the country. Yeah, it's more common than diabetes. It's more common than Alzheimer's disease. It's more common than arthritis. It's more common than all these other healthcare problems we talk about all the time.

You know, I watch TV and I, every time I turn around, I see some commercial about some diabetes drug that's new or some blood thinning medication that that's new, or there's some athlete or movie star telling me about some medicine for something I've never even heard of. And there's these commercials about it, but advertising for urinary incontinence treatment is almost unheard of.

The only advertisements I see out there for urinary incontinence treatments are for pads. I never see, or very, I shouldn't say “never,” extremely rare to see anything in commercials or print about medication options for incontinence or procedural or surgical options for incontinence. So there's really a, there's a real big knowledge gap out there, especially given the prevalence of the disease.

So anything we can do to inform patients of their options is the, is I think would be very beneficial. You know, some health care conditions, you know, hernias, kidney stones, those are easier things to know what to do with. But incontinence, it's really, marketing directly to patients I think is invaluable.

Yeah, we, we try awful hard to make sure that patients that don't have a satisfactory outcome, whether it's, “I'm using pads and I want to move to something different,” or “I'm on oral medication and that's not working for me,” at least understand what the care continuum looks like and then how to address it so that knowledge is power.

We also try very hard to make sure that we create pieces to help them have that conversation with a doctor that may not be quite as skilled as you are, to at least help them facilitate that conversation. Are we successful given those numbers? Probably not, you know, but it doesn't mean we're not trying.

Dr. Bullock: It doesn't mean you're not trying. It's a, it's a very difficult thing. It's, one of the things that makes it so hard is, there's, I think, a lot of times when primary care doctors are very busy, and I don't want to make them, demonize them or anything, but you know, they have limited time, and a patient goes in to see their primary care doctor, there's so many things they need to get through: high blood pressure, diabetes, cholesterol, weight management. You have to get all through this in like 10 minutes and then bring up, bring up incontinence. That is a, that's a huge conversation. And I think a lot of times that huge potential conversation that you could have had is, “You have incontinence. Well, we'll get you to see a urologist. Here's a card.” And it's kind of up to you to make, to decide if you're going to make that appointment or not. 

Steve Gregg: Those are actually the lucky ones. 

Dr. Bullock: Yeah. Those are the lucky ones. 

Steve Gregg: Those are the lucky ones. What we hear most often is, the doctor says what no individual wants to hear, which is “Make another appointment and come back.”

Dr. Bullock: Or even worse, they said, “Oh, that's just part of getting older.” It's just something…

Steve Gregg: We hear that too. 

Dr. Bullock: Yeah, that's, yeah, there is a knowledge gap on what the treatment options are. I mean, every day I see a patient who says to me, “I didn't know there was treatment for this.”

Bruce Kassover: So, Dr. Bullock, I'm wondering if you can give us an idea of what would be your best tip for a patient to live a life without leaks?

Dr. Bullock: I think that the, my best advice I can give you is sort of what I've mentioned here: Just because something is common doesn't mean it's normal. Incontinence is a common thing that happens, but it's not something that is a normal thing for you to have to live with. It's not something that is incurable.

We have a lot of treatment options out there for it. And not all of these treatment options are surgery or some sort of invasive surgery. We have physical therapy, we have medications and sure, yes, we do have procedures to fix this problem, but our outcomes in terms of incontinence are good. We have a lot of good treatment options for this.

Educate yourself. Be your own advocate. This is not something you should be embarrassed about or something you feel like you can't bring up or it's just something you have to live with because there are things we can do about this. 

Bruce Kassover: I can't imagine that there's better advice out there. So thank you very much. I really appreciate you joining us today and thank you for the time and all your insights.

Dr. Bullock: Hey, thank you so much for having me. It was great. 

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