Loading summary
Transcript147 lines
- [00:04]
A
Welcome to the you are not broken podcast.
- [00:06]
B
I'm your host, Dr. Kelly Casperson, a board certified urologist, thought leader and conversation starter on midlife living, hormones and sexuality. Enjoy the show.
- [00:18]
A
Bladder leakage, stress incontinence, urge incontinence, surgical options, medical options, and don't forget the pelvic floor. Physical therapists. We're here today to talk about bladder leakage with my good friend, Dr. Alex Rogers, another badass female urologist. Thanks for joining me, Alex.
- [00:34]
C
Oh, Kelly, such a pleasure. The queen. We love what you're doing. We're like just cheering you on. All the female urologists out there and yeah, I love talking about the leakage, dude.
- [00:46]
A
It's incredibly common and not talked about.
- [00:49]
C
Yeah. It's in a black box. How do we get it out of that black box?
- [00:52]
A
Is there's too much shame? I think there's more shame to leakage than sexual dysfunction. I don't know.
- [00:58]
C
Yeah. No. I think people talk about dry vagina, they talk about hot flashes, they talk about breast care. Now we can botox their faces without shame. Right. Why do no women talk about how many pads they're buying and that they can't make it to the bathroom on time and they don't even know what they have when it comes to leakage. Right. They just come in and they're like, I don't know, I leak. Right.
- [01:18]
A
Right. And it's an entire aisle in the grocery store. Which tells you how big of a problem this is.
- [01:24]
C
Yeah. I think there are more adult incontinence products going into landfills now than baby diapers.
- [01:31]
A
Ah, I heard, I heard this was years ago. I heard Japan was the first country to sell more adult diapers than baby diapers.
- [01:38]
C
Yeah. And they figured out too, because they're smart to incinerate their products to reduce landfill pollution.
- [01:45]
A
Interesting.
- [01:46]
C
Wow.
- [01:47]
A
Super big problem. The design of the female body is we're upright. We've got a lot of heavy things sitting on the pelvis. Our urethras are very short. They're small muscles. Babies go through vaginas and then throw the whole anatomy off. It's very common.
- [02:04]
C
Yeah. 40% of women have overactive bladder. A third have stress incontinence. Many have both overactive bladder and stress.
- [02:12]
A
Incontinence to tease out, which we call mixed incontinence. That's about 30% of them.
- [02:16]
C
Yep. And people don't know about getting better from it beyond buying pads.
- [02:22]
A
When I was in training, I remember being in a lecture of overactive bladder and for just to break it down for people. Overactive bladders, like, urgency, frequency, getting up at night to pee, may or may not leak with that. That's called urge incontinence. Doing a lecture, and they're like, we don't really know. It could be a nerve issue. It could be a muscle issue. We don't really know. But what we know now is that hormones play a huge role in it. It's like, why was nobody curious why this happens more when we get older? Like, menopause was in my memory, was never mentioned in residency. Hormones were never talked about in residency. And everybody's like, we just don't know why it happens. Statistically, the data, it's way more common in perimenopause and postmenopause.
- [03:06]
C
Each decade of life, increased incidence, especially the overactive bladder side. So, yep, I'm gonna do the plug, as expected, hormone replacement all day to help mitigate leakage symptoms.
- [03:18]
A
I love it. You know, the. An interesting thing, when I started getting into, like, really getting into hormones and menopause and stuff. And actually, like, I have a subscription to the menopause journal now, and it's. The menopause journal is where the equivalency studies for anticholinergics and vaginal estrogen are. And there's not a lot of studies, but, like, the equivalency studies are in menopause journals. And I'm like, dude, urologists are not reading menopause journals.
- [03:43]
C
Correct.
- [03:44]
A
Unless they're weird like us. But, like, how many urologists do you think understand vaginal estrogen as equivalent to anticholinergics for overactive bladder?
- [03:56]
C
Very few. That's crazy, right? Yeah, insane. The ones that listen to your podcast, the small subset of female urologists. But yeah, there's such a underuse of estrogen and hormone replacement for bladder symptoms.
- [04:11]
A
Yeah. Let's go through overactive bladder for people. Then we'll go through stress incontinence. So overactive bladder with or without leakage, urgency, frequency. It's like an awareness of, like, I know where all the bathrooms are between here and the next big city. You know where all the bathrooms are at Target and the grocery store. Like, you're just very aware. And a lot of people will have leak without warning with overactive bladder as opposed to stress incontinence, which is you kind of know when you're going to cough, sneeze, laugh, and be on a trampoline. So that's overactive bladder to break it down. Because again, I think a lot of women are like, I just leak they don't really haven't really paid attention to what is the cause of the leak. And the leak without warning, like I'm standing in the line at the grocery store ready to check out and I leak, that's much more likely to be.
- [04:56]
C
Overactive bladder and impair quality of life. So when I have patients come in and they have that mixed incontinence, overactive bladder symptoms, stress incontinence, or leakage with a high pressure event in regards to what really tends to be mitigating or more cumbersome for quality life, it's definitely the overactive bladder because it's unpredictable. You can avoid exercise, you can avoid getting on a trampoline, but if you're out and about, you may not be able to bathroom map appropriately. And it's obviously devastating when people have like accidents out of their control, out in public or even within the home around family members. But yeah, correct. Women come in and they. I actually get super excited when I have a patient and she comes in and she's like, I have oab. And I'm like, how do you know that? That is so exciting. Tell me how you know that.
- [05:43]
A
Right, right, right. I love that. That's so good. Yeah, it's super devastating. One of the most common reasons that people end up going into nursing homes is bladder leakage. The other risk of getting up at night to pee is falling.
- [05:56]
C
And it's, it's hard to treat those patients once, once they're in that environment because there's just such limited mobility, transportation. So, you know, if we can improve people with their leakage at a younger age, I think we would reduce a lot of the risk of nursing home admissions. Breaking your hip, getting up at night.
- [06:16]
A
I mean, I'm sure you see this too. But it's like by the time they come in to see me, they are frail, they can hardly stand, they're in diapers, their skin's breaking down. I'm sure for the non medical people listening, sorry, it's a little bit dramatic, but it's like, it's so bad. The average one, this was a stat I saw. The average woman waits eight years before going to see somebody for their bladder leakage.
- [06:43]
C
And what's more terrifying is they might not see the right person and they might be dismissed and say, oh, you know, well, you could try some kegels. Even though they may or may not get an exam to see if they can actually do a proper Kegel, they may or may not be sent to a trained physical therapist. They may or may not be presented with a full host of options, because we have a lot of options. They may simply be given a script that's $5 for an anticholinergic that is linked to cognitive risk and say, you know, come back as needed even amongst specialists that see these patients, but don't really want to take care of them long term. And it's a very chronic condition.
- [07:24]
A
Yeah, it's absolutely awful. So anticholinergics are the. They've been around the longest, they're dirt cheap at this point. They're actually, I call them dirty drugs. And what I mean by that is they act in multiple different places in your body. They're for overactive bladder. They do decrease urgency frequency by on the muscle of the bladder. But they are contraindicated in age greater than 65. It's in the beers criteria. In all fairness, the beer criteria also says estrogen, but I think that that's wrong based upon inaccurate WHI data. But if you want to go by like the biggest, most well known list of things you should avoid to put in your brain after age 65, anticholinergics is a big one. And there's multiple association studies linked with dementia.
- [08:07]
C
And why would you put that in your body long term, starting at age 30? Like why is it age 65? Right. It's kind of ridiculous. Like, oh, but let's do it for decades if you're 30. And also beyond just this cognitive noise out there, they're intolerable. Dry mouth, dry eyes, constipation. A lot of OAB patients are baseline constipated. I am in Colorado. Everyone has dry eyes and dry mouth naturally. So we're actually going against the treatment mechanism of action. And so I haven't prescribed anticholinergics since 2012 when we got a legacy beta agonist because it was safer. And only prescribe anticholinergics in a very short term period to get through prior authorizations, tier exemptions, things like that. But yeah, I try and keep minimal use of anticholinergics for so many reasons, low adherence. Personally, I think the beta agonists are anecdotally more efficacious and it's way less side effects.
- [09:10]
A
And for people who don't know, that's Gemteza and Mirbetric. The generics being Mirbegron and Virbegron.
- [09:19]
C
Correct. And of note, in theory, Mirbegron went generic last year, but we'll have to see where that lands. Cause there was an unfavorable lawsuit outcome with Astellas so it may go away, but yeah. So once again, these beta agonists since approval have been access to them, although efficacious and very safe and well tolerated, for the most part, access has been the biggest issue. We do get help. They're expensive. We get help from manufacturer coupons, tier exemptions, prior authorizations. Our friends in Canada sometimes can help us.
- [09:56]
A
But there's. Yeah, but there's hoops. It's always the burden of hoops. If you look at male urology, they've got dirt cheap drugs. Flomax, dirt cheap, Viagra, dirt cheap. The beta agonists, they work by helping the bladder hold more. So caution if you have trouble emptying. But any good urologist is going to be checking that in their office. And then Mirbegron, contraindicated or concerned if you have poorly controlled hypertension.
- [10:23]
C
That's fair. Yep.
- [10:25]
A
Yeah, I do anticholinergics, basically, to get insurance to move on to the third line therapies. Before we talk about third line therapies, they're no longer called third line therapies. There's a new OAB guideline update.
- [10:38]
C
Yeah, yeah, I like the rebranding. I call it advanced treatment options or advanced therapies. And it's great. So we got a new update to our Urologic society guidelines in 2024 and I think it was all positive. Number one, it takes away a stepwise situation of, oh, we have to fail 2 meds to even consider something as benign as putting a little needle in your tibular nerve down in the leg to get a positive restorative effect on your bladder, which is non invasive to your specialist should say, these are your options. And with shared decision making, how do we want to proceed? Now, granted, insurance may not follow that same line of thinking.
- [11:21]
A
That was what I was going to ask. Our insurance is still required. Failure of two medications.
- [11:26]
C
Oh, sometimes three, sometimes four. I mean, it's ridiculous. Sometimes pt, right. So they are not always aligned with the latest guidelines and latest treatments that are coming down the pipes. So it's frustrating because with these patients, when you look at adherence and following them through, half don't come back to their second visit with a specialist. Half to 70%, actually. And I think it's because the way we present things, it seems daunting. Like, gosh, it's just gonna take. It's just gonna be really hard to get relief. And our cure rates are only, you know, I'd argue 20% for dry. It can be very discouraging. So we have to like remove the barriers to how we're gonna get people better. Better is always my word.
- [12:09]
A
I mean, to me. And I think the, the urology clinic number one has to care about these women. Because if you're like, oh, this is whatever, not a sexy thing to take care of or whatever, you might. Your bias might be against it. It's a lot harder to have a pathway. So I have a clinical pathway of like, have you tried any meds? Crap, you haven't. Okay, well, we got to do something just for your insurance. 100% get pelvic floor physical therapy. 100% get vaginal estrogen. You start all of that now and I schedule the follow up before they even leave the office to be like, at that follow up. If you're not better, we are going to talk about Botox or sacral neuromodulation, because those are actually the success wise, your highest success treatment. This is a real good story about Bronx and his dad Ryan.
- [12:55]
C
Real United Airlines customers.
- [12:57]
D
We were returning home and one of the flight attendants asked Bronx if he wanted to see the flight deck and meet Captain Andrew.
- [13:03]
A
I got to sit in the driver's seat.
- [13:05]
D
I grew up in an aviation family.
- [13:07]
A
And seeing Bronx kind of reminded me of myself when I was that age. That's Andrew, a real United pilot. These small interactions can shape a kid's future. It felt like I was the captain.
- [13:17]
D
Allowing my son to see the flight deck will stick with us forever.
- [13:20]
A
That's how good leads the way. But there's plenty of people who get better on pelvic floor. Physical therapy and vaginal estrogen. And so it's like, rule that out now. Not everybody has a great pelvic floor PT in my town. Now they're really booked out. But it's like, in my perfect world, you wouldn't make it to a urologist without having done those things. You don't need a surgeon to do the low hanging fruit for you.
- [13:43]
C
But unfortunately, where healthcare is just so tapped out at this point, when I'm trying to get patients into my clinic, in my outreach in a new area for me, I moved from California to Colorado. I'm just asking them screen for are you bothered by leakage? That is my only question. And then send them to me. I don't need your note. I will take care of it. No tests, no pt, no meds. Because even getting them to ask that simple question, bothered by leakage, That's a challenge.
- [14:14]
A
Isn't that a Medicare a well person mandatory question?
- [14:18]
C
It is.
- [14:19]
A
So that'll take care of the 65 year old and up.
- [14:21]
C
Exactly. Yeah. But I think there's some of us where we realize, like, it's just really hard at the primary care level to add this to the laundry list of care for that patient. And so it depends on your market, right? Every market's different. That gets handed to me. And I think we're very similar where it's like a workout plan, right? Like, I'm like, here's your menu of options with me. I'm going to draw all over it. I'm going to highlight. I'm going to explain what you have. Like, this is like our direction. You're going to get two weeks of gem tested samples. Now, only half of people can sample beta agonists, so that's a barrier right there. I'm going to see you back in two weeks. You think you have stress incontinence? We're going to do a leak test. I'm going to borrow from Nicole Fleischman Audis. Are we treating women or are we testing them? And in my world, I really try and minimize testing where just urine, check for blood, standard of care, pvr, make sure there's not some concerning retention, and then just a simple leak test where you come back and you're modest and you're not being prodded by a lot of instruments that may or may not change our algorithm for care. And I think it's really, really important that patients know, man, there's a plan here. And if this med doesn't work, like, there's these other things that I've never even heard of. I mean, how many people's heads start spitting when you're like a Botox your platter? And they're like, but I want it in my face, right? Like, I mean, it blows their mind that we can treat them with pacemakers in the buttocks and stimulation down on the leg with multiple forms, right? Like, they're just. They look at you like, well, why have I never heard of any of this?
- [15:57]
A
I know. Well, I think it ties back to the shame of it all. People are going like, let me tell you about my pacemaker for my bladder. It's not happening. But, you know, I always joke, I'm like, yeah, insurance actually pays for Botox in your bladder. You know, that's what's so exciting about it, because it's a decent dose. It's Rare to get 100 units in your face, and the bladder Standard starts at 100 units. That's a decent dose of Botox to get it to work. But Botox in my opinion, is a game changer for urge incontinence and overactive bladder. Game changer. And people are shocked. They're like, I don't know. I'm like, it's been FDA approved since 2013. It was off label when I was in residency, finished residency in 2012. It was FDA approved right around there. So it's been over. Over 10 years, 15 years.
- [16:39]
C
And that was where it went from neurogenic to indicated for idiopathic. So it really opened up five out of six OAB patients, right? In theory, but so Botox. So let me. I want to ask you, Kelly. So when you look at the data, like 90% stop doing it by the fourth injection, right? So that's only two years of treatment. I think there's something special amongst female urologists. How do we keep them coming back? What are your tricks to make Botox? Something where patients are like, oh, that was awesome. And I'm in it with you on this treatment. Cause I'm a big Botox lover as well. So tell me your tips and tricks.
- [17:14]
A
So we looked at it. I was the highest Botox injector by volume on the west side of Washington state. So a ton of Botox, which means I'm not seeing that many new patients, right? So it means they're coming back. And so I had a very high return rate compared to the. For nationwide on this. And so they actually came and they're like, what do you do? So we have a dedicated Botox day. So the doctor's not running in between other patients, and they're late and they don't. And the staff doesn't know what they're doing and blah, blah, blah. So dedicated Botox day. All your staff is doing that day is Botox. So they're cleaning scopes, they're getting people prepped, blah, blah, blah. Number one, that. Number two, we love them. We love these people. We love seeing them. We're so excited that they're here. We love Botox day. Cause we just listen to music and drink coffee and do Botox all day long. It's very fun for everybody. And the staff can feel that in our mood. Number three, the lights go down. So we do ours in a surgery center, right? So the overhead fluorescent lights are off. We take these surgical lights and we basically shine them to the side of the room so there's like, light. It's not dark in there. Because for people to know, your bladder has to be numbed for about 10 minutes just with lidocaine numbing jelly. So you Kind of have to sit there and if you're staring at fluorescent lights, it's awful. So we turn the lights off so you're in a quiet room and we bring you a warm blanket. And it's amazing. Nobody fell asleep and fell off the bed. But like they're so relaxed instead of like, how long did you take? And blah, blah, and I'm cold and I'm staring at fluoresc lights. They're like, they're actually like, this is actually really peaceful and lovely. Right? And then I come in. If you're good at Botox, flexible scope. And I'm just chatting the whole time like, what are you doing this weekend? What dogs do you have again? Oh yeah, what's your great. And you get to know them because they're repeat people, right? And they're like, okay, done. It's not painful, it's not stressful. And they come back because here's the thing, Botox works. It's the experience that sucks. And that's why they're not coming back.
- [19:18]
C
We agree anecdotally, does it match up with this huge fear of retention when people Google it and they're like, I'm gonna need a catheter after.
- [19:26]
A
Yeah. At the beginning of Botox, this is again, years ago, there was a urologist who's like, I make all of my patients learn how to intermittent self cath in case they go into retention after Botox. And I'm like, oh good, that'll make you not interested in Botox.
- [19:41]
C
Yeah, that's my follow up question. Like how many actually showed up for their Botox procedure when that was your protocol?
- [19:46]
A
Well, and that's the other thing, you know, they talk about and like, how do I, how do we get people to come and to trust? This stuff is, it's how you talk to them. So if you say, yeah, the risk of this is that you won't be able to pee and you'll have to use catheters and that you'll get a urinary tract infection. That's not really explaining it in a way that feels safe and approachable. So I say, listen, the risk of this is not being able to empty your bladder as well. So I check your bladder now and I check it two weeks after the Botox to make sure you don't have that. It's actually very rare. And a risk of this procedure is a urinary tract infection. So we give you an antibiotic beforehand to decrease that risk. Like that is my talk track. I will have that memorized. Till the end of my life. Because what I'm saying is there are risks, but we're on top of it.
- [20:27]
C
Yep, agreed. Right.
- [20:29]
A
And it's, it's much less scary.
- [20:31]
C
And the other thing I like about Botox is like it's very easy to deliver. The therapy versus some of our other treatments are more precise. Whether it's needle placement in the leg, a lead perfectly aligned to the sacral nerve. Right. I feel our quality of delivery is much more consistent with Botox and I do think it's underutilized. Poor talk tracks around it, poor experience for patients, and especially in these geriatric patients, just soaking diapers that are not a good surgical candidate and have poor leg integrity. It is a very underutilized.
- [21:09]
A
Yeah. Oh, I love Botox. If somebody was like, hey Kelly, we'll fly you to Phoenix where you come down and you just do Botox for three days and we'll fly you back home. Like I could be a traveling Botox doctor. I love it. Shout out to manifesting that. Okay, let's. So that's again, Botox is. And this is where people don't understand. Botox is for urge incontinence, overactive bladder leak with urge.
- [21:31]
C
Thank you. Yep.
- [21:32]
A
Botox will not help with leaking, with cough, sneeze and laugh. We'll get to that. But Botox will not help with that other third line. I'm going to call them third line therapies till the end of my career. Other advanced therapies are sacral neuromodulation. So it's basically stimulating the nerve to the bladder. And you can stimulate this via the sacral nerve in the kind of the upper buttock. That's the classic one. It's been around for 20 years. There's two companies in that field now. And then you can stimulate it via the tibial nerve down by the ankle. Newer technology, but already multiple companies are coming out with that. Talk about those options.
- [22:06]
C
Yeah. So moving on from Botox, sickle neuromodulation, it's definitely one of our more extreme options compared to medications. Pt Botox injection that lasts six months a leg target, in my opinion. But when done by a very well trained specialist that has done high volume, it can definitely be a very life changing therapy option for patients with I'd say moderate to severe overactive bladder urge incontinence frequency. It can also help with fecal incontinence, fecal urgency, which affects 16% of women. And you want to talk about something that is not asked ever. I mean, only half a Woman will bring up urine leakage. Only half of healthcare professionals are screened for it. Oh. I mean, you think anyone's at screening for fecal incontinence? I mean, I've had patients cry because that's my third question. I ask, ask about overactive ov, then ask about stress incontinence, then ask about bowels and then ask about gsm. I get to that one too. But bowels, I mean, you will have ladies take a pause, stare at you and start crying because no one's ever asked them. And then they're like, oh, my God. There are things that might help with this. Right. So sacral neuromodulation, just a broader indication for a bladder that's not behaving, bowels that aren't behaving. You did a great description. Yep. It is literally like a pacemaker. And there's a testing period where you do a temporary test for patients, about three, five, seven days. You take out these temporary phishing wires. People have different ways of delivering that. New technologies coming out surrounding that that we're excited about coming down the pipes. And then two brands, which has been great. Competition always makes people behave better, be accountable. So it's been fantastic since 2019 to have competition in the space to get better imaging modality clearance. We can now get full body MRIs, which is great for patients because there are a lot of patients that need an MRI below the neck. Better remotes that are more patient friendly, better patient management by reps because it is a chronic therapy that needs to be monitored. You don't just put these things in and say, bye, bye, see you later. To get the best results out of these, a more advanced therapy option, you need some hand holding. So it's been a really fun landscape the last six years to watch it greatly improve just because there are two brands. So it's been a fun time. I think, Kelly, you can attest to that, to just have more choice for patients and see therapies improve.
- [24:43]
A
Yep, totally. The biggest problem with sacral neuromodulation, in my opinion, is that it is not FDA approved for neurogenics. And we have multiple published papers to say it works great in multiple sclerosis, stroke people. Parkinson's is progressive, but it does work. It works in people with neurogenic diagnoses, but it is not FDA approved. So getting insurance to cover it is fraught. Medicare will do clawbacks. That is impossible. You do not want to deal with that. You know, I've been bugging the companies for every, you know, every Chance I get, I'm like, dude, you guys need a neurogenic indication. It's going to open it up to so many people that we know will benefit. Is this stupid line in the sand. But again, insurance and fda, they practice medicine in this country. So I think that's my biggest problem with the technology. Nothing works better. Like Botox is great for most people. If you have somebody who has diapers a day, nothing will move the needle on the severity of overactive bladder urge like a sacral neuromodulation will. In my opinion.
- [25:45]
C
I think Botox is pretty good for that too.
- [25:48]
A
Sometimes you gotta do both.
- [25:49]
C
Sometimes you gotta do both, right? Sometimes, yeah. We do combination therapy. Absolutely. I have patients who have had all these therapies and we're also on a beta agonist. So that's the nice thing about our menu for overactive bladder. It's robust. So we have a lot of different targets with different mechanisms of action so we can tailor therapies. And once again, when we started residency, Kelly, all we had were anticholinergics. I mean, can you believe that? That's all we had. And so to see this landscape just keep adding and moving along, I mean, that's awesome. And that's why I love what I do. That's where I get so excited when they come in and say, why leak? And then you get to present all of these things that we didn't have when we started trainings. And it's only getting better. So I feel very blessed to be in the space.
- [26:43]
D
This episode is brought to you by Progressive Insurance. Do you ever find yourself playing the budgeting game? Well, with the name your price tool from Progressive, you can find options that fit your budget and potentially lower your bill. Try it@progressive.com Progressive Casualty Insurance Company and affiliates Price and coverage match limited by state law. Not available in all states.
- [27:09]
C
We can talk about tibial target. So just like the sacral nerve goes to the bladder and bowels and delivering energy to that makes this poor signal behave, it's restorative to this poor behavior. Just like it is in the pain world. If you stimulate the nerve, and there are many ways to stimulate, whether it's implanting something directly, doing it through the skin with a small needle that is placed to the nerve. When we take that down to the leg, there's a tibial nerve that runs along the lower leg and it's a highway into that same sacral nerve up the spinal cord to the brain back down again. When we stimulate the tibial nerve with just A little needle like acupuncture, but add electricity to it. We see frontal lobe changes on MRI that then have this positive effect. So it's going all the way up and back down to the bladder. And it comes from Chinese medicine, where we know that acupuncture can help dysfunctional nerve pathways. And so by what we call percutaneous tibial nerve stimulation. If we take a needle, put it in the tibial nerve, and then add energy and do weekly sessions for 30 minutes for roughly 12 weeks, and then monthly, we can get a positive effect on the bladder. The challenge of pts. It's a lovely paradigm. There's a lot of barrier challenges, right? You have to have a team that can deliver the needle. You have to have rooms that can be tied up. You can't have insurance companies calling it investigational, even though it's FDA approved. You got to fail 2 meds a lot of times. Sometimes insurance only covers it for a year. And when, even though certain data suggests 78% were responders at 12 weeks with this, this very benign tibial stimulation, only one out of four typically make it to 12 weeks. And then that drop off at monthly is that much worse. Plus, monthly stimulation may not be enough to manage symptoms. I practiced in central California for almost a decade. I had a wonderful setup for pts. I was like your Botox day. I ran a PTNS clinic and I was in the right market for it. I had a lot of older patients. I had a lot of very holistic hippie patients. They would rather come do PTS than take a pill. I had a really great team that delivered the needle really nicely. Plus we had an add on placebo effect because they would do diaries. They would add in that behavioral management. What's your stress in your life? What are you eating right now in your diet? So you definitely get really good results. In addition to behavioral changes that were chronic. 12 weeks of counseling with my team, right? And we had great parking and we had great weather. Guess what? I moved to Denver. I live in Boulder. But like, people are like, I'm not doing that. And I'm like, what do you mean? It's such a great option. So it's so funny, right? Like, you have certain places that can support it, whether it's the insurance, the team, your business model. But I'm a huge believer in it because I saw really great results. And you never hurt anyone beyond wasting their time, but they always read a book, right? So. And they love my team, right? So it was just a very positive experience. Much like you talk about With Botox, where, like, man, they made that experience, like, really great. For me, it was like a spa. So then there's this concept of, okay, like, in socialized countries, they don't have that level of help. They do just tens units. So simple. Tens unit, right. Like 40 bucks off Amazon. So I'm actually, like, a big fan of that. But there's no financial incentive for providers to do that. There's the whole, like, they have to buy it off Amazon. They have to be compliant with it. So that can be challenging. I occasionally use them. And then in the last. Since 2022, we've actually started to see approval of tibial implants, which is a pretty cool concept where you don't have to do surgery. It can be done with just local. There are quite a few different form factors surrounding that. I won't get into the weeds of that. I'm quite a nerd in that space. And we have more coming out right now. It's in a Category 3 code, so sometimes that's tricky from a reimbursement perspective. So I think this space is very to be determined. But I think it's exciting because maybe we'll get more people treated. And it was added to the 2024 OAB guidelines as a therapy option. So I just think it's going to take time. S and M has been around since 1997. We really didn't get cranking on it until we had a competitor in 2019. So people need to pace themselves. One of the big device makers, actually two, should be getting FDA approval sooner than later. And so, once again, the more competition we have, the more offerings we have, the more we sort out the reimbursement patient selection, how do we improve the efficacy? How do we improve the safety? And one of my biggest things is just being accountable in this space because I sure liked transvaginal mesh kits for the right patient when done the right way. And that was taken away from us. And that's kind of one of my biggest thought processes in this new space. How do we make sure we roll it out appropriately so that we can just keep giving patients more options with our menus?
- [32:27]
A
Yeah, well, I mean, I think it comes down to having urologists step it up. So many urologists don't want to deal with leaky ladies, right? And it's like, if the market is huge, which we know the market's huge, 80 million women over the age of 40. And urologists don't step it up for several reasons, it will go into the less trained hands, meaning People who haven't had the years experience of dealing with the complications.
- [32:51]
C
Right.
- [32:51]
A
Of. Because for the tibial, the tibial's like, dude, the orthopods are in the ankle way more than the surgeons are or the urologists are. The orthos don't know how to deal with bladders. So it's like at the end of the day, this is a bladder issue. They're much more comfortable putting urologists down in the tibia than having an orthopod do it and do bladder follow up. So it's really like if urologists don't take this domain, it will go to other people because the women need help.
- [33:19]
C
Kelly, let me poll you here. What do you feel about pain doctors doing snm?
- [33:26]
A
What do you. Yeah, don't get me. Like, it's like the cosmetic people puffing up up effing clitorises or ENT doctors.
- [33:35]
C
Having an Emsella chair for all of their patients.
- [33:38]
A
Yeah. So it's like. But I mean, it's going to happen more and more and more of like the true expertise person. There's not enough of them and we're not managing them efficiently to make them. You know how much more efficient I could have been had I had like unlimited support and resources. Right. But it's like you gotta have the people who are the biggest experts staying in the space because the demand's so big, people will. They don't. People don't know. People don't know that the ents don't know a darn thing about the bladder. You know, they just want help.
- [34:10]
C
Yeah. They just know how to bill for that chair. Well, I think this is a great pivot because I think we have a recent success story. When we talk about the adoption of Bulkhamid for stress incontinence. I think we've won in treating more women. How did we get there? I think we're making progress after the mesh sling debacle.
- [34:35]
A
Yeah. I mean, I'm holding breath. First of all, bulk of it's amazing. Basically, I say it's filler. Filler for your face put down there by your urethra. Because people know what filler is. Although people think with a medical code that insurance covers for, but people think that filler is Botox and they get confused that bulk of it's Botox and they're very separate things. Bulkhamid adds volume to the urethra and it's a revolutionary product which is way better than any other bulking agent. I went in super skeptical because I'm good At Slings. I have happy women with slings. And I love Balcomid. It's easy, there's no downtime. My biggest worry about Bulkhamid is declining reimbursement. The product price is going up, the reimbursement's going down, and pretty soon no urologist will be able to offer Bulkhamid because you actually have to pay money to treat patients with Balcomid. It's a big problem.
- [35:26]
C
Agreed. And also for it to make sense from a healthcare economic standpoint, it should be done in the office and we can't even do it right. So it breaks the system that much more. I love the product they need to make the reimbursement more favorable. But yeah, it's just been once again talking about markets in California. It was very challenging for me to offer mesh links to women. They just were terrified. And I'm the first one to say, slings work great, well trained in them, they're a great option. But in 2025, the amount of fear factor in patients and anxiety and googling, I mean, thank God there's Bulkhamid because, like, it's hard for me to even sometimes get through that offering with patients with a minimal risk of UTI bleeding, having to repeat it, risk of sedative. I mean, in 2025, even that talk track can be challenging with a certain patient. I can't even imagine a mesh sling anymore. Right. I just have to pass that off to other people where they can take that on. But in my community practice, if you fail pt and I always say we just need to cheat a little bit, sometimes it's okay to cheat GLP1, whatever it is, let's cheat a little bit and do a little filler in your urethra.
- [36:42]
A
Yeah. Women only had physical therapy and mesh links unless you were going to do the very invasive autologous rectus fascial slaying, which is incredibly invasive and not recommended as first line therapy, but it is in the stress incontinence, like guidelines as an option. But I'm like, it's way too invasive for first line therapy. So it was physical therapy or slings and that's it. And yeah, we needed an in between. And the bulk of it is the in between. I also think that everybody with mesh in their pelvis, sling or prolapse needs to be on vaginal estrogen for life. We have to care about the tissue. The big thing. Just going back to the whole pelvic floor mesh thing for a hot second. How many of those people were put and Kept on vaginal estrogen and just had thinning and erosion of mesh over time because of atrophy. Right. It was never talked about. My belief, if you ever have mesh in your pelvis, you have to stay on vaginal estrogen for life. But, I mean, I think everybody should be on vaginal estrogen for life. So it's not that big of an ask.
- [37:45]
C
We all need chapstick for our lips.
- [37:47]
A
Yeah. You don't stop sunscreen after age 65. You don't stop flossing.
- [37:50]
C
It's all care, self care.
- [37:52]
A
Yeah. Anything else you want to say about slings or bulkhamid?
- [37:55]
C
No. I mean, but once again, I'm very optimistic knowing that when we started training, we didn't have bulkhamid. We had bulking agents that didn't work as well. So outside the reimbursement piece, which is a burn, you know, I think it's a really exciting time for people practicing female urology, whatever you want to call it, urogynecology, we have a lot of growth in the space, I think. But yes, reimbursement needs to be sorted out. I think for patients that are bothered by this, finding the right person is the first step.
- [38:28]
A
Great question. So what's the difference? They've changed the definition, so it's even harder now. What's the difference between a urologist, a female urologist, and a urogynecologist? And how would you people are like, who do I see? It's like, well, you see the one who actually likes doing bladder leakage work.
- [38:46]
C
Exactly. It's not just the definition. There are people that are great at voiding dysfunction leakage with all those different terms in their fancy name. I'm just a female urologist who did a fellowship, and I love treating voiding dysfunction, leakage, things like that. I don't really love doing prolapse anymore. I used to do it. Went by the wayside with vaginal mesh being taken away. And I had a lot of old patients where I just didn't think of robotic sicklecorpopexy was appropriate. And pessaries are limited for many patients. So in finding the right person, like, your primary care doctor may not know where to send you. And so I recommend, honestly, most patients that find me, they just Google and do their own research of choices in the marketplace and are just like, yeah, you seem to kind of know about this stuff, and there's a lot of.
- [39:33]
A
Stuff I've never heard of, and you seem to care about it, so hopefully.
- [39:38]
C
There'S someone somewhat near you. But I Also throw out their telemedicine. I've actually like treated patients start to finish with an S and M implant and only touch them for the P and E temporary wire test and placing the implant and then all the follow up through telemedicine. So let's pray they don't get rid of telemedicine in September. It's always tenuous.
- [40:02]
A
My personal opinion right now. It wouldn't surprise me if they did. Like, I don't think telemedicine is secure at all right now. And I don't think people realize that.
- [40:12]
C
And it's such a, it's so challenging because access to people like us is so limited and patients, they have low motivation or hope about getting this improved. And telemedicine is such a good like first step.
- [40:29]
A
Yeah, yeah, I totally agree. But yeah, I mean, I think to me I'm like, dude, if Medicare is looking to cost cut and they're like, dude, doctors are gonna probably do telemedicine whether they get paid for it or not. Let's just cut reimbursement. It wouldn't surprise me. I don't think we have protection for telemedicine going forward after, after the end.
- [40:47]
C
Of this year they pushed it back twice now.
- [40:50]
A
Now we have a new administration.
- [40:52]
C
All we can do is hope they keep pushing it.
- [40:54]
A
Yeah, I don't think people know that it's under threat and so therefore people can't advocate for it. Cause they don't know it's under threat.
- [41:00]
C
Yeah, when I schedule patients out, I'm literally like, just so you know, you want to do telemedicine in October, but we may need to change it to in person if telemedicine's no longer an option.
- [41:10]
A
That's so forward thinking of you. Let's talk about two things. Let's talk about the chair. I think I can say the brand name because there is only one chair to my knowledge. It's the Emsella chair. I don't think there's more than one chair. And then the at home pelvic floor apps where you put something in your vagina and you squeeze, there's a bunch of different brand names for that. People always ask me what I think about it. I think for the at home apps, like they're cheap, they're easy, they do have proof that they work. But it's really your motivation that you're gonna do this on the regular. And I think that's where you see a big drop off. Like you get sold these sexy things and then you're like, well, it actually takes time and something in my vagina and I have to pull up an app. So I don't think long term implementation is great with them. And then for the Emsella chair, if it works, it's very expensive and it must be repeated. And that's where I think the cost does not outweigh. And people aren't told, you're going to have to keep doing this to keep it working. Do you have a more favorable opinion about any of that?
- [42:11]
C
So the cheap at home options, I especially think it's very reasonable if you don't have access to a pelvic floor pt, you're motivated to do it. Historically, when patients come in and they've done those apps, I haven't gotten the best reviews of it. In regards to success adherence.
- [42:30]
A
We see all the failures though. That's the thing, we see all the failures.
- [42:33]
C
But I'm not overly opposed. When it's not a huge wallet biopsy, the chair I have issues with because it's not part of our guidelines. So when patients ask me about it, I say, look, I'm here to offer things.
- [42:45]
A
And the guidelines were just updated.
- [42:46]
C
Yeah. And I'm here to offer things that are based on society guidelines. I try and practice within what is recommended and I have a problem with it being a massive wallet biopsy. And then I asked who recommended it. And once again, when it's like a ENT doctor, I'm like, I'm kind of confused by that. Like that doesn't really line up for me. It'd be one thing if I offered it right, but once again, it's kind of a glorified tens chair. Why don't we go back to buying that $40 tens unit off of Amazon?
- [43:16]
A
They're incredibly expensive to buy and so you're pushed to sell them to make your money back off of them. And they're very expensive to the patients and then patients. It'll work or it won't work. Either way, it does work in some people, otherwise they wouldn't exist. But you have to keep doing it because your muscles will. Then the effect wears off.
- [43:38]
C
And I don't know how many patients are willing to pay for it when. I don't know about you, but my patients are like, what do you mean I have a $30 copay? What do you mean my gem Testa is going to be 40 bucks a month. And I'm like, that's with the manufacturer coupon plus your coverage with insurance, I can't get it cheaper. Quick plug. Thank you. Mark Cuban. Goodrx does have a GEM Testa assistance program if you're very low income. And I have gotten a couple patients GEM tested for free where Medicare was not going to happen. Manufacturer could go on. Too expensive. So just once again, just awareness. There is a assistance program. You do have to be very low income and you have to provide the paperwork for it. But I have had success with that. But I just want people to know that these things are out there. Because all I hear is, how do you prescribe Gemtessa? How do you do it? And I'm like, there's so many ways to do it, but you just have to be dedicated to how to jump through those hoops of fire. And people will be like, well, I just don't want to do that. Well, I'll say this. All my patients on Gemtessa estrogen cream, guess what? They're all chronic patients to me. I get them chronically versus one visit of discouragement and then they're gone.
- [44:45]
A
And they're happy with you and they send you your friends. They're friends. Where can people find you?
- [44:50]
C
I have a little clinic called Bladder Boutique. And yeah, it's kind of a ridiculous name, but the feedback from women, they come in giggling and they're like, I literally came because this name was so funny.
- [45:05]
A
I love that dude. How are you brave enough to like name it that? Or is it like a no brainer?
- [45:10]
C
How are you brave enough to open the Casperson Clinic and pivot to podcasting?
- [45:16]
A
I love female urologists.
- [45:18]
B
Female urologists are the best people ever.
- [45:20]
C
I think it takes a little bit of crazy Kelly and a little bit of confidence that you have a product that's desired and you're willing to build and have a little bit of faith.
- [45:32]
A
Yeah, well. And for what it's worth, I think female urologists are incredibly badass. They're unapologetically themselves. Also unfiltered, slightly swear word leaning.
- [45:45]
C
I don't think we dropped a cuss word today.
- [45:48]
A
Good job. We did so good. I get to click the non explicit button on this podcast episode.
- [45:55]
C
I'm shocked. I'm actually shocked by that.
- [45:57]
A
I know it's good for us. So don't limit your exercise because you're leaking. Don't think there aren't options. You do have to go to somebody who cares, who likes doing this. That's my best advice. Go to somebody who does tons of it. High volume, high volume. Because they're gonna. They know the proofs in the pudding. They know that people get better. That's why they like doing it because they love seeing those wins and they get them a lot. You know, you want to be part of that team.
- [46:28]
C
Well, you love treating leakage because the bar is set so low. Right. They don't even know what it is. What these therapies are that they actually all have. They're perfectly imperfect, but they all have like some good efficacy. Risk profiles for many of them are reasonable. So like we're kind of set up to win with these patients if we're dedicated to what we're doing and quality.
- [46:52]
A
Of life fixing quality of life is awesome. So what are the top one two that come to my mind? I did a sacral neuromodulation on a woman. She was housebound, would not leave because her bladder leakage was so bad and she left her, got to leave her house then, which is like, that's a. Those are massive wins. And then my second one that comes to mind is a younger woman, perimenopause did a bulk amid for stress incontinence. She brought me a plant on the thank you post op visit and she's like, I'm not wearing any underwear right now because I'm not going to leak. And I was just. It totally cracked me up. Like she was so stoked about it, about not having to even wear underwear. Do you have any big wins that come to your mind?
- [47:28]
C
Oh, all the time. Especially with like the spinal cord injury patients who are just, just so humble and it's so meaningful to take care of those patients. But recently, 30 year old gal, she had cauda equina, horrible fecal incontinence, urinary retention. And when we did her, after we did her implant, she came back and she's like, oh my God, I went on a date. And this is someone who hadn't had a life for a year with their injury. Yeah, that's life changing. Can we do one more quick plug? Ambulatory urodynamics. Are you excited about that?
- [48:05]
A
I'm excited about that.
- [48:06]
C
Okay. Sorry, we don't have to deep dive in that hole. But that was one I wanted to bring up today.
- [48:11]
A
I mean, I didn't do a lot of urodynamics because like once, you know, bladder leakage enough, I don't need a test to prove what I've already heard in your story. Urodynamics is useful for the people who are like, I just don't know why I leak or like, they've got elevated post void residual and you gotta figure out retention. So not your bread and Butter people. But they're developing aerodynamics that you can do at home.
- [48:32]
C
Now, that triggered me because the CEO of that is podcasting before Memorial Day weekend. He was actually a Naval Academy graduate. Had the pleasure of meeting him a couple years ago. And he's very entrepreneurial, and he's like, you know, I'm going to do ambulatory aerodynamics. And it got FDA approved a couple months ago. Yeah. So he should be on your podcast. His name's Derek, and he was a Marine, and he was shot in Afghanistan. Paraplegic. And so he personally went through all the cathing and the urodynamics and the Botox and just. God, this is terrible. And how can I come up with solutions for this? And he's gone through a couple iterations, but his urodynamic system actually got approved recently, and I'm really excited to use it in the right patient and once again, giving dignity back. Because urodynamics, I mean, that has to be the most ridiculous. Once again, it has not evolved in so long. And it's such a heavy lift. Right?
- [49:28]
A
Yeah. I'm like, have you had urodynamics? And they're like, I don't know. And I'm like, that means you haven't had urodynamics because you know when you've had a catheter in your anus and a catheter in your bladder, and then people stare at you and tell you to urinate.
- [49:40]
C
Yeah. So I'm the same way in opening my practice here in the north Denver area. I wasn't going to purchase a urodynamics machine. I'm waiting on this ambulatory urodynamics because once again, why are we doing the urodynamics? Are we doing it to change our treatment algorithm or are we just testing to pay off that machine? And, you know, I hope it's. I hope it's. We're doing it to actually change our thought process on how to treat a patient or make sure their upper tracts are safe with high pressure and things like that. So very excited to play with that. Love playing with all these new things coming out in the space.
- [50:17]
A
I love it. Just to hit back on insurance again, our insurance, where we are for Bulkhamid. Cause these are old Bulkhamid code and approvals. This is old code and approvals. So they said you needed to either leak in the clinic or you needed a leak point pressure less than 100. And I'm like, you can only get a leak point pressure less than 100 on UroDynamics. And to take a healthy female with mild stress incontinence and put a catheter in her behind in her bladder to get insurance to approve something.
- [50:45]
C
Yeah.
- [50:45]
A
Pissed me off.
- [50:47]
C
Yeah. So I've had a couple peer TO Peers with 80 year old pulmonologists for Medicaid patients to get their bulkment approved and they're like, well you haven't done urodynamics. And I was like, well you can come and be abusive to a patient to do that. Unnecessary testing versus ma', am, why don't you just cough in front of me with a small drape of modesty and I see that leakage and we're good to go and they're like okay, approved. So when we first started it was really, really painful. I will say the stress urinary incontinence guidelines did get updated and they have scaled back with amount of testing that needs to be done. Once again it's much more like surprise, surprise, erectile dysfunction where a guy walks in with erectile dysfunction and the guidelines have always been like you can get whatever you want.
- [51:28]
A
Yeah, yeah. We're not like prove that you can't get an erection before you get treatment. Said nobody ever very nicely pointed out bias. Thank you Dr. Rogers.
- [51:38]
C
We need that philosophy for leakage because the adherence is so bad. How can we get these patients to better as fast as possible and safely? Not skipping corners. But once again for me, my typical worker was urinalysis, PVR leak test.
- [51:56]
A
I love it. Thank you for your time and your brain and everybody. Check out bladder boutique North Denver, bladderboutique.com, what, what is it?
- [52:06]
C
Bladderboutique.com and I'm not a big social media person. My website is really just geared, geared towards patient education.
- [52:14]
A
You do have the humor for it.
- [52:16]
C
I do, but I save that for my dance classes and I'm really active. Kids sidelines with my kids. Like that's where I like channel that energy. I don't know how I mean praise you and Rachel, Rubin and Rena, you guys are killing it with all this social media stuff and I'm so glad you guys channeling your energy in that way is so meaningful for you and you're helping so many patients and people out there with raising awareness for these issues that need to be talked about. So thank you for doing it so I can go run up a mountain.
- [52:50]
A
I really appreciate that, that you're very welcome. October 5th I'm going to be in Denver doing a keynote at an event called Thrive Follow my social media to find out more about that, but hopefully I get to hang out with my friend Alex Rogers when I'm in in Denver too.
- [53:05]
C
We'll be moving. Movement will be involved.
- [53:07]
A
Yeah, yeah. She we're either gonna she's either gonna kill me spinning or kill me hiking. And I'm here for it all.
- [53:12]
C
Or we'll go dance. Might just go dance.
- [53:15]
A
All right, talk to you soon. Love you.
- [53:17]
C
Bye, guys.
- [53:18]
B
Thank you for listening to this week's episode of you Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Masterclass where you learn adult things like communication skills, anatomy lessons and desire types, and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment and you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and Adult Sex ed Masterclass members. Get the master class for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests, including on this podcast are not giving individual medical advice or practicing medicine. See in Consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine, in case you were curious about that and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time, remember, you are not broken.