A little nerve could be all it takes to stop your leaks...

If you think that your only hope for treating overactive bladder is to focus on your pelvic floor muscles, you may be overlooking a different type of approach that's been proven successful for hundreds of thousands of patients: Nerve stimulation. 

It turns out that certain nerves play a critical role in bladder function, and there are devices that can stimulate those nerves to substantially reduce leaks. Many patients find that their symptoms improve by 50% or more with a simple, in-office procedure called sacral neuromodulation. 

Today's guest is Dr. Vikas Desai, a urologist, a board-certified member of the American Urologic Association and a member of the Society of Prosthetic Urologic Surgeons, to tell us more about it. 

To learn more from Dr. Desai about bladder health, visit his YouTube channel at https://www.youtube.com/@DesaiUro.

For more information about the National Association for Continence, click here, and be sure to follow us on Facebook, Instagram, Twitter and Pinterest.

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

TenderHeart Health Outcomes offers individualized care plans and superior products to meet your unique needs.  Their coaching focuses on asking the right questions, and their high-quality products prevent leaking, are comfortable and skin friendly. Plus, their trained staff focuses on your individual needs. Your total satisfaction is their goal and healthy living is their mission. Learn more at www.tenderheart.com or call 1-877-394-1860 today.</

Transcript

The following transcript was generated electronically. Please let us know if you see any transcribing errors and we'll get them corrected immediately. 

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 as always is Sarah Jenkins, the Executive Director for the National Association for Continence. Welcome, Sarah. 

Sarah Jenkins: Thanks, Bruce. 

Bruce Kassover: And joining us today is a friend of the podcast, Dr. Vikas Desai. He is a urologist, a board-certified member of the American Urologic Association and the Society of Prosthetic Urologic Surgeons. Welcome back Dr. Desai. 

Dr. Desai: Thank you Bruce, and thank you again Sarah for having me on your podcast and look forward to informing our listeners on a very important topic. 

Bruce Kassover: Yeah. Maybe you want to tell us a little bit about what that important topic is? What are you interested in discussing today?

Dr. Desai: Yeah, so what I want to focus in on today on our podcast for our listeners is something known as overactive bladder and urge incontinence. And so, there's two main forms of incontinence, which is involuntary loss of urine, simply put, and that's something known as stress incontinence, which we've talked about on previous podcasts, and that's leakage with urine when you cough, sneeze and activity.

But what I really want to focus in on today is something known as overactive bladder/urge incontinence – so, basically, the involuntary loss of urine due to a strong urge, right? You gotta run to the bathroom. You feel like you're going more often than you would like. So typically, most people go to the bathroom on average, about seven times in a 24-hour period, if you're definitely exceeding that.

And the biggest thing I want to point out, it's something that is bothersome. So I have patients who come in to see me who are like, “Oh, I go to the bathroom eight or nine times, doc, in a day,” but they're not bothered by it. And so just because you're going more often than maybe this number of seven in 24 hours doesn't mean that meets intervention.

It's really something that bothers you. And it's, that's what's what I really want to focus in on today. And what I really want to focus in on is some of the surgical management of that. 

Bruce Kassover: Wait, surgery. So wait. I would imagine that surgery is the last thing that I'd want to have done. How can I tell that I've reached the point where I might really consider an intervention like that?

Dr. Desai: Yeah, I think one of the things that I would say is that, really, what I always tell my patients is, “What are your goals?” Right? And if your goals are to be where you don't have to use a pad or you potentially don't have to worry where the next bathroom is, or potentially where you don't want to be continually taking a medication that has certain side effects or whether it's medical or financial, where some of these medications are very costly.

Surgery could be a great option that's going to be more definitive, or life altering in the sense that it's going to help you regain that control without needing a daily pill or needing to look for the next bathroom. And surgery is pretty straightforward these days, and a lot of it starts right in the office for the first step.

Bruce Kassover: So tell me what are some of the surgical options that people might be presented with? 

Dr. Desai: Yeah, so really for overactive bladder or urge incontinence, which is a manifestation of overactive bladder where it kind of progresses where you just can't hold the urine, there's two really two main forms of surgical management.

One is known as Botox, and Botox has its host of side effects. It requires frequent physician visits every three to six months or every nine months where you're getting repetitive injections in your bladder, which increases your risk of infection. And so again, that's a good option for some patients, but for other patients who want a more definitive option where you don't have to see the doctor every three to nine months, and that is something known as sacral neuromodulation.

Sacral neuromodulation is the main surgical treatment for overactive bladder and a progression known as urge incontinence. And really what that is, I like to tell patients, sacral neuromodulation is simply a bladder pacemaker, right? 

So I tell people that if your heart gives way, you get a heart pacemaker. In the same way if you, if your shoulder gives way, you get a shoulder replacement or your knee gives way, you get a knee replacement. In the same way, if you have a lot of pain, you can get a pain pacemaker. And, so, this is really just a simple understanding that your bladder is not what it used to be.

Your bladder is not going to be what it used to be as you get older. Unfortunately, overactive bladder/urge incontinence issues, as many of our listeners are probably aware, continue to progress exponentially as you get older. And so the first step is simply targeting the nerves that can help regulate the bladder.

And many patients are unaware that there's something known as the sacral nerve, which is around the S3 region, that can help control the bladder. And that's not really where the bladder is located whatsoever, but those are the same nerves that kind of feed in. And so that's what we're doing is, we're targeting that nerve with a small implantable device to see if you're going to have meaningful improvement. 

Bruce Kassover: So what does the procedure look like? Is this like a major surgery or is this something that that's, you know, easier than, you know, what you might consider like a full, big-time procedure? 

Dr. Desai: Yeah, so the test in the office, as we were talking about, known as the peripheral nerve evaluation, is just done with local anesthetic.

So, there's nothing that can, is going to put you to sleep whatsoever. And that's done. It's, I almost like to describe it as acupuncture. It takes about five to 10 minutes, and that trial period will last anywhere from three to five days, where you're going to keep a detailed diary or log. And what we're really looking for is 50% improvement in your symptoms.

And so, if you have 50% of improvement in your symptoms, we remove all the external temporary leads that we place from the procedure, and then we take you to the operating room at a time that works out mutually for you as a patient and the physician and the operating room schedule. But that ends up being about an hour surgical procedure where again, you're not put fully to sleep.

It's almost like a colonoscopy-type anesthetic where you get something known as “monitored anesthesia care,” and we put a permanent, implantable lead into that region that we talked about, which is the S3 region, and a battery. And that battery for many patients will last 15 to 20 years. And so that really is a lifetime.

Now, for some of our younger patients, that battery might need to be replaced, but that replacement of the battery is about a 20-minute procedure in the operating room, and that's very minimal. And again, this procedure is MRI-safe. So many patients will ask, “Can I do MRIs?” No problem whatsoever. “Is this going to impact my activities of daily living?” Of course not, right? 

There's about a two-to-three-week recovery after that second surgery that we talked about in the operating room, then you can get back to usual activities. You can go swimming, jump in a pool, and, really, what we're trying to get you is at least 50% improvement. Many of my patients have much more improvement than 50%, but if you can meet that threshold, we can get you free of medications, free of repetitive physician visits and really getting you back to living life to the fullest.

Bruce Kassover: There's a little bit of me that wants to say, you know, maybe I'm a little skeptical, because, you know, you always hear when, when things sound too good to be true you, you really ought to, you know, dig a little deeper, especially because you're talking about a fairly straightforward procedure lasts an hour, hour and a half, and you can see 50% plus improvement in your symptoms. I mean, is that truly what, what a typical patient can expect to see? 

Dr. Desai: Yeah, so we're really identifying this by that trial period, right? And so that office trial is paramount in this, right? If that office trial does not lead to 50% improvement, then going to that hour, hour-and-a-half surgery that we talked about is not going to be a great option.

Now, there are other ways we can do a more advanced trial that's done in the operating room. So that ends up being two surgeries. And that's something that may be outside of the scope to our listeners today, but really, it's understanding that, you know, setting yourself up for success, right? So if you have a successful trial in the office where you got at least 50% improvement, and doing that hour, hour-and-a-half surgery in the operating room with the permanent lead and permanent battery is going to lead to those reliable results and likely even better results. 

Bruce Kassover: That's remarkable, but is sacral neuromodulation the only procedure? I think that there's another one that's the tibial nerve, if I'm not mistaken. Is, is that another alternative maybe for somebody who finds that sacral neuromodulation isn't right for them? Or is that just another alternative?

Dr. Desai: No, no. Bruce, that's a great question. You know, and again, I think there, there's two forms of tibial nerve stimulation right there, a tibial implantable procedure, and I'll hit on that in just a second, but one of the things that could be done, it's not done too often anymore, but something known as percutaneous tibial nerve stimulation, or PTNS, and that's typically weekly office visits with one of our nursing providers we're you're getting stimulation for about 30 to 60 minutes at the tibial nerve to help, you know, cut down on your urinary accidents. 

Now that is pretty time intensive where you're going in weekly for typically 12 weeks, and then after 12 weeks there's really no defined maintenance schedule.

Now, sometimes when patients come back every month or every three months, and so you're seeing the provider a lot of times, and one of the things that is very interesting, you know, that one of my patients told me is, and a lot of times, you know, incontinence issues, while it can affect all ages, it's, it's a lot of times sometimes older patients, you know, who are coming in where, you know, they're getting more exhausted of other options, and one of my older patients told me was that, you know, you exchange your working days for seeing the doctor.

And so, really, patients are seeing doctors. It's so many different levels and so many different providers and different specialists that if I can help cut down on at least one visit where they're not seeing one provider on multiple occasions, that, I think, is almost liberating for my patients. And so I think while PTNS is a great option for some, it's not really a great option for many. And I can speak on the… how many patients I actually have undergoing PTNS. 

Now to your other question, Bruce. There is an implantable tibial implant. There's a couple companies that are FDA approved. They're in their infancy and I do have some experience with one of them that's been around a little longer than the newer one.

The big difference on there, there are some different patient requirements to kind of say, “Hey, can you fit that bill for getting that?” But that is an office-based procedure. Now, the durability of those batteries if they're implanted are not as long as the 15 to 20 years. The, if it's an implanted battery, it's about three to five years only for one of the companies out there.

And then the other company you have to wear like an external generator, which is the battery, almost less like an ankle monitor, on a regular basis. Now that frequency of how often do you have to wear an ankle monitor beyond the one month after you've had that implanted is unknown. There's not been a good study on that, but, so there are things out there.

So again, I think obviously if a patient sees me, I go through all the options. And then obviously something that I would, I advise patients who are listening to our podcast to really seek those out, to say, “Hey, it is not just sacral neuromodulation, but if we're talking about the procedure that's been around the longest and been tested and had the most data, I would say sacral neuromodulation is the best, and the one thing that I do caution patients, it's the only one that's going to help provide context on how they will do afterwards, right? With the other tibial ones that we talked about in terms of the surgery that are done in the office, whether it's an implanted battery or an implanted lead with an external battery like an ankle bracelet, those don't require any trial period, right, to see if you're going to be successful, right? Whereas sacral neuromodulation does document or require documentation that you improved at least 50% from that stage one, which is typically done in the office or that peripheral nerve evaluation before we do that permanent implant. And so I think that's where we are going to see more reliable results with that in my practice pattern.

Bruce Kassover: So it sounds like these nerve targeting treatments are really good for overactive bladder and urinary incontinence. Do they have any use beyond that as well? 

Dr. Desai: Yeah, that's a great question, Bruce. I think ironically, sacral neuromodulation actually helps patients with bowel incontinence or fedal incontinence to a greater degree than even urinary incontinence or overactive bladder. And so, what I'm basically trying to say is that patients who have both, I think it's a no-brainer, almost, if they're looking for a surgical treatment to consider sacral neuromodulation over some of the other things like bladder Botox or tibial implants because sacral neuromodulation has been tested in both the bowel and bladder incontinence space.

And I'll go even further to say that patients who've unfortunately undergone rectal cancer or radiation for rectal cancer and have issues with incontinence for that, I've had patients in those camps have some of the greatest results from sacral neuromodulation. And so I do advise our listeners that this is a therapy that may be more encompassing depending on the conditions they have.

Bruce Kassover: It's amazing because one thing that we, we know from all of the people that we interact with at NAFC.org is that as debilitating as urinary incontinence can be – and it can be very debilitating – bowel incontinence for most people is like a step further. It is truly a life limiting condition. 

So if I'm somebody who's reached the point that it's bothersome enough that I really want to consider a treatment of this nature, what should I do? Should I see a specialist? Do I just go and talk with a urologist about it? What's the best approach?

Dr. Desai: That's a great question, Bruce. I think, as a patient who's frustrated with their incontinence, that's, or their overactive bladder issues, that's really defining their lives and they want something that's further done, I think the first step is talking to the urologist. The urologist, whoever he or she may be, should be able to define some treatment pathway that would be advantageous. Now again, with anything, there are some providers who might not be as comfortable doing some of these surgeries, and so hopefully the urologist will refer you to one of those providers; obviously they can see myself you know, get more information on my YouTube page, as we've talked about previously on one of our earlier podcasts, but really it, it's going to be seeking out information, and there are a couple industry websites that are two main players in the sacral neuromodulation space that can help plug patients into more focused providers who offer that treatment in with more regularity if they are looking for more comprehensive discussion.

Bruce Kassover: Yeah. So you mentioned your YouTube page. Maybe tell us how people can go and find you to hear more directly from you. 

Dr. Desai: Yeah, so I do have a YouTube page, definitely in its infancy, it's in a work in progress. But it's ‘DESAI,’ so my last name, D-E-S-A-I and then “URO,” and there's videos, typically one- to two-minute segments, that really, kind-of, hit home on some of the issues such as sacral neural modulation, urinary incontinence, and some other topics as well that are probably important to our listeners and so definitely seek it out. There and also links on that as well linking you over to some of these other industry websites that we were talking about. 

Bruce Kassover: We'll definitely make sure to put a link to your YouTube channel in the show notes because there's a wealth of information about incontinence and urology beyond just what we're talking about today.

But as you know, this is Life Without Leaks. And one of the things we always like to ask our guests before we before we go is if they can share one little hint, tip, strategy, bit of advice about how they can go ahead and try and live a life without leaks. So maybe you have one you could share with us today…

Dr. Desai: Yeah, no, thank, thank you again, Bruce, for allowing me the opportunity. And, and I'd like to leave our listeners with one tidbit, that leaking urine is not just a normal part of aging and there are options for you, right? Drinking less fluid will not necessarily improve your symptoms. And so I like to say, and just simply put, that if you think that what your urinary symptoms are not to where you are happy and they bother you where they are impacting your ability to go out of the house or impacting your ability to see your friends, then seek advice, whether it's surgical, as we've talked about and focused on today, or it's just simply maybe medical in terms of maybe a medication. And again, you don't have to let this condition define you because there is an option out there and the option may not be as intensive as you may think.

Bruce Kassover: Well, that is reassuring. So thank you Dr. Desai. Really appreciate you joining us again today and certainly hope that our guests get as much out of it as we did. So thank you for being a part of the podcast. 

Dr. Desai: Thank you again. Bruce and Sarah for the time. 

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