Podcast Summary: "You Are Not Broken" – Episode 327: Bladder Matters, Leakage and What To Do

Host: Dr. Kelly Casperson
Guest: Dr. Alex Rogers
Date: July 20, 2025

Episode Overview

In this candid and empowering episode, Dr. Kelly Casperson is joined by fellow urologist Dr. Alex Rogers to shine a light on the real, unspoken struggles of bladder leakage and urinary incontinence. Together, they break down causes, treatments, and societal shame, discussing everything from pelvic floor therapy and hormone replacement to cutting-edge interventions and insurance battles. Their conversation balances expert insights and pragmatic advice with humor and vibrant honesty, empowering women to take back agency over their pelvic health.

Key Discussion Points & Insights

The Silent Epidemic of Bladder Leakage

• Stigma and Prevalence
  • Leakage is "incredibly common and not talked about." (A, 00:45)
  • "There is more shame to leakage than sexual dysfunction." – Dr. Casperson (A, 00:52)
  • Massive industry: More adult incontinence products than baby diapers, reflecting the scale of the issue. (C, 01:23)
• Societal Silence & Shame
  • “Why do no women talk about how many pads they're buying...?” – Dr. Rogers (C, 00:57)

Types of Incontinence: Stress, Urge, and Mixed

• Defining the Types
  • Overactive Bladder (OAB): Urgency, frequency, possibly leaking without warning; often seen in menopause. (A, 02:22–03:18)
  • Stress Incontinence: Leakage with physical stress, e.g., cough, sneeze, laughter. (A, 04:10)
  • Mixed Incontinence: Both urge and stress features, affecting about 30% of women. (A, 02:11)
• Devastating Daily Impact
  • OAB and urge incontinence are particularly hard due to unpredictability, affecting social life, exercise, and contributing to risk of falls and nursing home admissions. (C, 04:55; A, 05:42)
  • Average woman waits 8 years before seeking help. (A, 06:15)

Hormones and Menopause: Underrecognized Contributors

• Hormonal Role
  • Incontinence spikes in peri- and post-menopause; hormones are rarely discussed in urological training. (A, 02:22–03:18)
  • Vaginal estrogen is as effective as certain medications for OAB, yet underused due to lack of awareness among urologists. (A, 03:43)
  • “There's such underuse of estrogen and hormone replacement for bladder symptoms.” – Dr. Rogers (C, 03:55)

First-Line Approaches: Beyond Pads

• Pelvic Floor Physical Therapy & Vaginal Estrogen
  • Cornerstone treatments for many; should be started early, ideally before seeing a urologist. (A, 12:09; 13:19)
  • Not all communities have adequate access; pelvic PT under-utilized. (A, 13:43)

Pharmaceuticals: Anticholinergics & Beta Agonists

• Anticholinergics:

  • Oldest class, “dirty drugs” with wide side effects (dry mouth, constipation, cognitive risk). (A, 07:24)
  • Strongly discouraged in age 65+ due to dementia risk. (A, 07:24)
  • “Why is it age 65? ... Let's do it for decades if you're 30?” – Dr. Rogers (C, 08:07)

• Beta Agonists (Gemtesa/Vibegron & Mirbetriq/Mirbegron):

  • Safer, better tolerated, but expensive and harder to access (insurance obstacles, need for coupons/authorization). (C, 08:07; 09:18)
  • Mirbetriq caution in hypertension, all require physician monitoring. (A, 09:56)

Guidelines, Insurance, & Therapy Pathways

• New OAB guidelines (2024) now recommend "advanced therapies" without mandatory failure of two drugs first, though insurance hasn’t caught up. (C, 10:37)
• Progress in moving away from rigid, stepwise treatments toward shared decision-making. (C, 10:37)
• Barriers: “The hoops are always on women.” – Dr. Casperson (A, 09:56)
• Many women are dismissed or receive incomplete care. (C, 06:42)

Advanced Therapies: Botox & Neuromodulation

• Botox for OAB & Urge Incontinence:
  • “Game changer for urge incontinence.” (A, 15:56)
  • Underutilized due to poor experience and fears (retention/catheterization).
  • “Botox works. It's the experience that sucks.” (A, 18:57)
  • Tips for high retention: dedicated Botox days, comforting environment, warm blankets, positive staff attitude. (A, 17:13)
  • Risks include temporary retention or UTI, mitigated with proactive follow-up. (A, 19:41)
• Sacral Neuromodulation (“Pacemaker”):
  • For severe OAB or urge incontinence, especially transformative for severe cases and fecal incontinence. (A, 22:05; C, 22:05)
  • Competition between device makers has led to better technology and support. (C, 24:43)
  • Frustrations with insurance and lack of FDA neurogenic indication. (A, 24:43)
  • Sometimes combined therapies are needed (Botox + neuromodulation + drugs). (C, 25:49)

Tibial Nerve Stimulation

• Percutaneous Tibial Nerve Stimulation (PTNS):
  • Non-invasive, home of acupuncture roots, but limited by insurance, logistics, and adherence. (C, 27:08)
  • In some practices, it's spa-like, positive experience; in others, poor uptake. (C, 27:08)
  • New tibial implants may improve adherence and access but are early in rollout. (C, 27:08–32:26)

Who Should Be Treating Incontinence?

• Importance of seeing a dedicated, experienced clinician; preferably a high-volume urologist interested in leakage.
  • “See the one who actually likes doing bladder leakage work.” (A, 38:28)
• Rising concern about less-expert providers in other specialties marketing devices/treatments for profit without expertise. (A, 32:26–34:09)

Bulking Agents & Surgical Options: Bulkhamid & Slings

• Bulkhamid:
  • “Filler for your face put down there by your urethra.” – Dr. Casperson (A, 34:34)
  • Minimal downtime, fewer risks than slings, but threats to reimbursement could limit access. (A, 34:34)
  • Should be done in office for viability; mesh sling 'fear factor' makes Bulkhamid attractive. (C, 35:26)
  • “In 2025... thank god there’s Bulkhamid.” (C, 35:26)
• Surgical Slings:
  • Remain highly effective but face skepticism post-mesh controversy and are more invasive.
  • Only indicated after less invasive therapies are considered. (A, 36:42)
  • All with pelvic mesh should be on lifelong vaginal estrogen. (A, 36:42)

Finding the Right Specialist

• Difference between urologist, female urologist, and urogynecologist is “not just the definition... see the one who likes doing voiding dysfunction/leakage.” (C, 38:45)
• Many patients find help through personal research rather than primary care referral. (C, 39:33)
• Telemedicine has greatly improved access, though its future reimbursement is uncertain. (C, 39:37; A, 40:29)

Devices & At-Home Pelvic Health

• Emsella Chair:
  • Expensive, requires ongoing treatment, not in guidelines, promoted by non-expert providers. (A, 41:10; C, 42:33)
  • “Why don’t we go back to buying that $40 TENS unit off of Amazon?” – Dr. Rogers (C, 42:46)
• At-home pelvic floor trainers/apps:
  • Can benefit motivated users without pelvic PT access, but adherence is low and failures self-select for specialist review. (A, 42:11)
• Insurance/Cost Barriers:
  • Discussion on cost-saving programs (Mark Cuban’s pharmacy, Gemtessa assistance) and real-world price struggles for patients. (C, 43:38)

Empowering Stories & Patient Wins

• Restoring dignity and independence: examples include homebound woman regaining confidence with neuromodulation; perimenopausal woman going underwear-free after Bulkhamid. (A, 46:51)
• “Fixing quality of life is awesome.” (A, 46:51)
• Impact on patients with neurologic conditions (e.g., cauda equina), transformative outcomes post-procedure. (C, 47:27)

New Innovations & Future of Care

• Ambulatory Urodynamics:
  • FDA-approved systems for at-home, less invasive bladder function testing to improve patient experience and dignity. (C, 48:04)
  • Traditional testing is invasive and outdated; new methods could reduce discomfort and unnecessary procedures. (A, 48:32; C, 48:32)
• Pushing for more streamlined, patient-centered approaches; less unnecessary testing, more compassion, faster access to better. (A, 51:28–51:55)

Notable Quotes & Memorable Moments

• “There’s more shame to leakage than sexual dysfunction.” – Dr. Casperson (00:52)
• “Why do no women talk about how many pads they’re buying?” – Dr. Rogers (00:57)
• “Average woman waits 8 years before going to see somebody for their bladder leakage.” – Dr. Casperson (06:15)
• “Anticholinergics...are dirty drugs.” – Dr. Casperson (07:24)
• “Game changer for urge incontinence and overactive bladder—Botox.” – Dr. Casperson (15:56)
• “Botox works. It’s the experience that sucks. And that’s why they’re not coming back.” – Dr. Casperson (18:57)
• “In 2025...thank god there’s Bulkhamid.” – Dr. Rogers (35:26)
• “See the one who actually likes doing bladder leakage work.” – Dr. Casperson (38:28)
• “Everything gets better when you are treated by someone who cares about leakage.” – Dr. Rogers (paraphrased)
• “Fixing quality of life is awesome.” – Dr. Casperson (46:51)

Segment Timestamps for Key Sections

• Intro & Shame/Stigma: 00:18–01:46
• How Common? 01:18–02:11
• Types of Incontinence: 02:22–04:55
• Impact on Life & Delay in Care: 05:42–06:42
• Why Don’t Women Get Help? 06:42–07:24
• Medications - Anticholinergics/Beta Agonists: 07:24–10:22
• Guidelines & Insurance Barriers: 10:22–12:09
• Clinical Pathway & PT Start: 12:09–15:56
• Botox Deep Dive: 15:56–21:30
• Advanced Therapies: Sacral Neuromodulation: 21:30–26:42
• Tibial Nerve Stimulation, Implants, Devices: 27:08–32:26
• Who Should Provide Care? 32:26–34:09
• Bulkhamid & Slings: 34:34–37:44
• Specialists, Telemedicine, Access: 38:28–40:29
• Emsella Chair & At-Home Devices: 41:10–43:38
• Insurance/Cost-Saving: 43:38–44:45
• Success Stories: 46:51–47:27
• Ambulatory Urodynamics: 48:04–50:16
• Insurance Re-Visited & Testing Requirements: 50:16–51:55
• Wrap-up & Clinic Info: 44:50, 52:05

Tone and Takeaways

Drs. Casperson and Rogers blend compassionate expertise with humor and directness, stripping away stigma and jargon to offer hope and practical guidance. Their central message:
You are not alone or broken—help exists, options abound, and finding a caring, experienced clinician can be the game-changer for quality of life.

Find Dr. Alex Rogers at Bladder Boutique in North Denver (bladderboutique.com).
Dr. Kelly Casperson’s resources and future events are on her social media and website.

If you’re dealing with incontinence, don’t let shame stop you. Seek a provider who cares, understands, and can walk you through the growing menu of options—better really is possible.