Scott Webb (Host): Bladder and bowel conditions can affect people's quality of life in many different ways. And to have one of these conditions doesn't necessarily mean that you have to live with it. I'm here today with Dr. Marco Salazar from EvergreenHealth Urology Care to discuss the many treatment options available.

Hello and welcome to Check-Up Chat with EvergreenHealth. I'm Scott Webb. Dr. Salazar, thanks for joining me.

Dr. Marco Salazar: Thank you for having me.

Host: Yeah, it's great to have you here. And we're going to talk about treatment options for bladder and bowel dysfunction. And we're going to get to the InterStim therapy and what's involved. Before we get there though, what are the most common bladder and bowel control conditions that you treat?

Dr. Marco Salazar: So, with urination, you can have one of two problems. And sometimes they actually come together where you have trouble holding on to your urine, meaning that you feel like you have to pee more frequently, more urgently, or sometimes even out of your control, the urine will just start coming out, and that is a condition called urge urinary incontinence.

Alternatively, with defecation also, sometimes it's difficult to have control of the feces coming out and you feel like you have to go more often. And sometimes it comes out, despite your best efforts. And so, urge urinary incontinence where you actually have leakage; and urgency, that sudden need to go; and frequency, that need to go often can affect both urination and defecation.

Host: Okay. And as I mentioned, sort of teased that we're going to get to InterStim. But before we get there, just broadly speaking, what are the treatment options that are available for bladder and bowel dysfunction?

Dr. Marco Salazar: There are multiple potential treatment options and these all require an extensive evaluation. Sometimes it is what's called a functional problem whereas the muscles that are supposed to be relaxing are not listening to the nervous system telling them to relax. And when they squeeze when they're not supposed to, that leads to leakage of either feces or leakage of urine.

Alternatively, sometimes what happens is that there's a problem because of the shape, or there's a problem because there's a blockage because of a tumor, because of a prostate, because of a number of conditions. That is the reason why when someone has a problem like this, there's no one-size-fits-all answer. You need to undergo a formal evaluation in order to ensure that the correct cause of the problem is being identified and then appropriate treatment can be instituted.

Host: Yeah, I see what you mean. That's probably the perfect way to put that. It's not one-size-fits-all. So, let's talk about the InterStim therapy and how this neuromodulation system works.

Dr. Marco Salazar: So, InterStim, it is technically called InterStim sacral neuromodulation. And what that means is that it involves the nerves that emanate from the third sacral foramen. That is how the nerve that is involved in controlling both urination and defecation is accessed. The way to think about it is, in essence, the technology is a pacemaker for both the rectum, which stores feces and the bladder, the urinary bladder, which stores urine. There are certain conditions where these structures start to ignore the normal regulatory signals that they receive to tell them to relax. And so by using this technology, you re-establish to a greater or lesser degree those controlling mechanisms so that those muscles can actually relax.

Host: Sounds really interesting. I'm wondering how it compares to other treatment options, maybe in terms of a success rate, that sort of thing. And also, are there some folks that are just a better candidate for InterStim?

Dr. Marco Salazar: So typically, InterStim is not what we call a first line option. To begin with, when someone has urinary issues or problems with control of their feces, usually, first line therapy is to do behavioral modifications, to do physical therapy of the pelvic floor, in an attempt to try to gain control using a minimally invasive approach. When that fails, the next step is to use medication. When medication fails or is inadequate, especially when referring to urinary incontinence, we go to what's called third line therapy, and that can be either using this technology of InterStim or using what's called bladder botox, where you use a camera to access the bladder going through the urethra, which is a person's pee tube. And then, you inject through that instrument, you inject the back wall of the bladder with Botox. Botox is a medication that temporarily paralyzes muscle. And by doing so, it relaxes the bladder. The disadvantage of doing that is that it is temporary. The effect typically lasts approximately six months. But for some people, it can be less. And over time, as the condition progresses, oftentimes bladder Botox becomes insufficient.

Host: Yeah, I see what you mean. So when we think about someone who's a good candidate, it might have to be someone in terms of Botox, someone who doesn't mind coming in every three months or every six months, whereas InterStim would be semi-permanent, if I have that right.

Dr. Marco Salazar: That is correct. So InterStim, it's typically carried out first by doing a test procedure called a percutaneous nerve evaluation. And what that really means, it is a brief procedure that is done under a mild sedative. And temporary leads are placed. It is in the operating room. Temporary leads are placed in the area where these third sacral nerve is located. And over the course of five to seven days, you do a test to see whether or not the technology is going to have an effect. If it does, if the effect is sufficient where the patient considers it a beneficial intervention, then you go to true surgery.

True surgery involves placement of a permanent lead. It's an electrical lead all tunneled underneath the skin, and it goes into the area of the third sacral nerve. And that is attached to a generator, which lives at the top end of the buttocks, underneath the skin. And using a remote control device, you can turn the device on and off. You can change the program. So if over time, if you needed to provide more stimulation, you could. If one needed to turn the device off because of an MRI, one could. And as a result, it gives a person a lot of control over the management of their incontinence or their urgency. The battery typically has a life of 10 to 15 years before it has to be replaced.

Host: It's really amazing, you know, and it's exactly what folks who are suffering from bladder and bowel control conditions would want, which is the control, of course. Just give you a chance here at the end, final thoughts and takeaways. I know you mentioned that InterStim is sort of that third line, so you work your way up to that, starting with maybe PT, then medication, then InterStim perhaps. But just final thoughts for folks if they're sort of confronting this, considering this, what would you want them to know?

Dr. Marco Salazar: First of all, that it is safe. So, placing the device is a surgical procedure, but it is a safe device to place. And now, the technology such that it is MRI-compatible. So as a result of that, there are no limitations from that perspective for those patients that require an MRI on occasion or frequently.

The second thing is that, traditionally, it is a technology that has been mostly used in women, but I'd like to encourage men that have these conditions, that they are also candidates. Again, one needs to evaluate to make sure that the cause of their urgency and their incontinence is because of ignoring the signaling pathways.

But that said, this, I believe, is a technology that is really underused in men. And I want to emphasize that this is not just a technology for women, it can also very much have a positive impact in men.

Host: That's perfect. You know, It's not one-size-fits-all. Obviously, there's some investigation, some examination, getting to the exact root cause of the issues. But if someone is a good candidate, male or female, it sounds like a winner. So, thank you so much.

Dr. Marco Salazar: Thank you.

Host: EvergreenHealth Urology and Urogynecology provide expert evaluation and treatment for urinary tract and pelvic health issues to help you improve your quality of life. I'm Scott Webb. And please remember to subscribe, rate, and review this podcast and all the other EvergreenHealth podcasts. For more health tips and updates, follow us on your social channels.