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Clinical Focus

Robert Dreicer, MD, MS, MACP, FASCO; Neal Shore, MD, FACS; Michael Morris, MD; Alicia K. Morgans, MD, MPH

Medical Crossfire®: How Will Emerging Data Inform Treatment Planning for Patients With Prostate Cancer in the Community?

Howard I. Scher, MD; Scott T. Tagawa, MD, MS, FACP; Mary-Ellen Taplin, MD

Medical Crossfire®: How Does Recent Evidence on PARP Inhibitors and Combinations Inform Treatment Planning for Prostate Cancer Now and In the Future?

Jason Hafron, MD; Aaron D. Berger, MD; Arpeet Shah, MD

Medical Crossfire® in Adjunctive Testing: Charting a New Course in Prostate Cancer Risk Assessment

® Assistant Editor Janelle Hart spoke with 

, about the presentation, “Feasibility and efficacy of transvaginal onabotulinumtoxinA chemodenervation of the trigone for the third line treatment of refractory overactive bladder,” which was given at the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Winter Meeting. Dobberfuhl is a urologist at Stanford Hospitals and Clinics and an assistant professor of urology at the Stanford University School of Medicine in California.

“This technique is feasible, it is very well tolerated, and there’s not much of a complication rate, so it appears to be very safe,” says Amy D. Dobberfuhl, MD, MS.

Dr. Dobberfuhl discusses novel onabotulinumtoxinA treatment for refractory OAB

 She discusses the stigmas associated with overactive bladder, and how urologists can take the burden off of primary care physicians to educate patients who have this condition. Rogers is a urologist who specializes in incontinence at Sansum Clinic in Santa Barbara, California.

“We need to improve the fact that 75% of these patients are untreated [or] unmanaged and frustrated,” says Alexandra Rogers, MD.

Destigmatizing Urology: Dr. Alexandra Rogers discusses OAB

. He discusses urinary incontinence in male and female patients and how this condition can trigger major anxieties and avoidance behaviors. Seth is a consultant urological surgeon at St. George’s University hospital, London, UK.

“As health care professionals, we've got…an incredibly important role and responsibility with regards to increasing awareness and education, and then really trying to address the barriers and bring down the barriers,” says Jai Seth, MD.

Destigmatizing Urology: Dr. Seth discusses urinary incontinence

® Assistant Editor Janelle Hart spoke with J

. He discusses onabotulinumtoxinA injection programs as a treatment for urinary incontinence and the bleeding risk associated with these injections for patients who also take blood thinners. Seth is a consultant urological surgeon at St. George’s University hospital, London, UK.

“We're not saying a blanket stop for all patients, but I think we do need to be taking each patient as an individual in terms of their backgrounds,” says Jai Seth, MD.

Dr. Seth assesses the bleeding risk of Botox treatments in patients who take blood thinners

Over 12 weeks, the average reduction in total UI frequency was 2.3 episodes per day among those in the pelvic yoga program compared with 1.9 episodes per day among those in the general physical conditioning program.

Pelvic floor yoga is not superior to general physical conditioning for urinary incontinence

Data from a real-world evidence study of the Leva System were recently published in JMIR Formative Research, supporting the safety and effectiveness of the program in the treatment of patients with urinary incontinence.

New telehealth service provides access to Leva System for urinary incontinence

Data from phase 2 of the SANS-UUI trial are expected to support an application to the FDA for approval of the device in patients with urge urinary incontinence. 

Trial progresses of SNM device for urge urinary incontinence 

At 12-week follow-up, TAS-303 demonstrated a least squares mean percent change in SUI episode frequency per 24 hours of -57.7% vs -46.9% with placebo.

Investigational medication shows encouraging efficacy in stress urinary incontinence

"We believe the collective findings are unique in urogynecology and offer strong evidence that first-line incontinence treatment is effective, and women can access it using the Leva System,” says Evelyn Hall, MD. 

Digital health treatment program found safe, effective for urinary incontinence

Gamal M. Ghoniem, MD, FACS, ABU/FPMRS, discusses his current research efforts

Research focuses on identifying targets for overactive bladder treatment

 discusses his current research efforts. Ghoniem is Emeritus Professor of Urology at UCI School of Medicine.

What research projects are you currently working on?

I'm working on a very interesting project. It's an anatomy project, on female cadavers, trying to find, where are these nerves? If we want to do a targeted therapy, we have to know exactly where and what we are treating. So that's what I'm working on...I'm very excited about it because we used to study the bladder alone, and gynecologists studied the vagina going alone. But this is between the whole spectrum, between the vaginal wall and the bladder wall. So that's what I'm working on now, and defining where these targets [are] [for treating] overactive bladder.

This transcription was edited for clarity.

Videos

"If we want to do a targeted therapy, we have to know exactly where and what we are treating," says Gamal M. Ghoniem, MD, FACS, ABU/FPMRS.

discusses the potential impact of the new AUA/SUFU guideline on overactive bladder on his practice

Dr. Das on the impact of the new overactive bladder guideline on his practice

 discusses the potential impact of the new AUA/SUFU guideline on overactive bladder on his practice. Das is a UCI Health urologist and a professor of urology at UCI School of Medicine.

Will the new AUA/SUFU guideline on overactive bladder change how you practice?

It will. There are people who come in and they say, "I have to go to the bathroom 20 times a day. I can't make it to the bathroom because the urgency is so strong." Throwing some medications with these side effects...I think if you can get a Botox injection, and you get better, it's hard to argue with that [vs] being on months and months of medications that may not work. I think it really is going to change my practice.

"I think it really is going to change my practice," says Akhil Das, MD, FACS.

Dr Sebesta on “Household Toilet and Sanitation Insecurity is Associated with Urinary Symptoms, Psychosocial Burden, and Compensatory Bladder Behaviors.” 

Household toilet and sanitation insecurity’s implications for urinary symptoms and beyond

 discusses the wider implications of the findings from her 

study “Household Toilet and Sanitation Insecurity is Associated with Urinary Symptoms, Psychosocial Burden, and Compensatory Bladder Behaviors.” Sebesta is an assistant professor of urology at Vanderbilt University Medical Center in Nashville, Tennessee.

Beyond the specific focus on urinary health, do you believe toilet and sanitation insecurity might have broader implications for public health? If so, in what areas?

Access to clean water and having reliable sewage systems is a huge public health issue. There are some public health implications we commonly think of when talking about clean water and sanitation access, like water-borne pathogens, water pollution, and infectious diseases due to exposure to unsanitary conditions. These things actually do still exist in the United States and other wealthy nations, for people who don't have access to clean water and functional sanitation. I think the COVID-19 pandemic obviously brought to light a lot of health disparities that exist in our country. In this context, for example, people who didn't have access to good running water in their home, can't wash their hands regularly, [so] they're at increased risk for COVID or spreading disease. It highlighted issues that people faced at home when they were forced to quarantine. Someone might rely on using a public or work or school bathroom several times a day [and are] now being forced to stay home and not have as good of access to other options. And so this is a huge public health problem. There are numerous reports throughout the COVID-19 pandemic of people having to come up with other solutions or landlords being unable to get plumbing fixed due to the pandemic. And so I think there's a huge, widespread public health issue that comes to light when you start compounding the limited access, like what happened during the pandemic. I specifically try to look at the effects on chronic health conditions like bladder health. You can imagine, although this isn't my area of expertise, the same might be true for the health and psychosocial impact for people with inflammatory bowel disease, or fecal incontinence. And so having a clean supply of reliable, safe place to urinate, are basic human rights. Everyone urinates, and so these things affect everyone to some degree. And so, when you look at the investment in the United States and other wealthy countries, on funding to help this issue, it's really lacking. There were a lot of federal resources allocated to water and sanitation in our country in the 1970s. And unfortunately, a lot of vulnerable populations didn't benefit from those initial investments. And then basically, the funding for sanitation has steadily declined since then. Our sanitation systems are aging, the population is growing. So there's a huge water access gap in the United States. That's really underappreciated. And the other side of this study is basically just understanding more about the people who are most impacted here. And so these are findings from other public health studies, in addition to my own, that race and ethnicity are some of the strongest predictors of plumbing poverty. It's been demonstrated time and time again, that Black, Latinx, American Indian households are disproportionately affected by these issues in major cities. Household income is a huge risk factor. People who are renters or basically people who don't own a single family home are huge risk factors. This became particularly of interest to me, because a lot of areas that surround Nashville, where I practice, the rural south, rural Appalachia, people have terrible issues with access to clean water, and issues with personal sewage systems in their home due to the soil type down here. And so these issues are really compounded by a lot of these other factors: racialized wealth gaps, housing sector problems, discriminatory infrastructure. And so my whole hope here is to draw attention to this and how it continues to be an active problem in our country. And if we can show that it has effects on long-term health outcomes, that's a good first step to draw some attention toward finding solutions. Urologists are certainly people in the medical community that are well suited to talk to people about this and to help give a voice to our patients that tell us that they're suffering from these problems.

"Access to clean water and having reliable sewage systems is a huge public health issue," says Elisabeth M. Sebesta, MD.

Zhina Sadeghi, MD, discusses her work on researching neurogenic bladder

Dr. Sadeghi on research into neurogenic bladder

 discusses her work on researching neurogenic bladder. Sadeghi is a UCI Health urologist and assistant professor of urology at UCI School of Medicine.

What do you feel is underreported or underappreciated in your field of expertise?

As I mentioned, I'm also a part of a national neurogenic bladder research group. We are a group of neurourologists across the United States. We have come together to be able to facilitate big multicenter clinical trials on patients with neurogenic bladder. That means bladders with spinal cord injury issues, multiple sclerosis, Parkinson's, any neurological issue that impacts the bladder, and we do have that in the society; a big proportion of our neurogenic patients have neurogenic bladder issues like retention; they leak urine, they have urgency, they may not be able to have a safe bladder for the kidneys to stay safe. So there are few trials right now we are running on patients with multiple sclerosis, both on neuromodulation of their bladder and also understanding the relationship between the level of their lesion in the central nervous system compared with bladder symptoms, and we are running those in collaboration with the University of Michigan. We also do have another interesting study we are running with Houston Methodist Hospital and we are working on finding a biomarker in the urine of patients with spinal cord injury that can help us predict if this patient would deteriorate fast with their bladder or are they going to be responsive to neuromodulation treatment? We are basically having a multi arm study going on with this. These are all very exciting for me. My goal as a "plumber" urologist is to see if we can find better options and also understand the mechanism behind the disease that are going around the urinary tract system; either it's a bladder or urethra.

"My goal as a 'plumber'/urologist is to see if we can find better options and also understand the mechanism behind the disease," says Zhina Sadeghi, MD.

Dr. Sebesta on future research on interventions for toilet and sanitation insecurity

 discusses potential mechanisms linking insecurity and both urinary symptoms and psychosocial factors. She is an author of the 

The study identifies a concerning link between insecurity and unhealthy compensatory bladder behaviors. Do you see potential for future research to explore interventions that could address both the insecurity and the negative coping mechanisms?

This is kind of the last part of this cycle that I'm talking about, connecting toilet and sanitation insecurity to urinary symptoms. We all have coping strategies that we use to deal with unpleasant emotions or situations. And in urology, there are certain toileting behaviors that people utilize to help cope with urinary symptoms or compensate for their disease state like overactive bladder. There are different types of coping, so there are primary strategies, which are focused on problem solving. In urology, this might be like planning an activity or restroom mapping. This is like what you would you would tell someone to do if you want to help them develop healthy bladder coping behaviors, but there are also disengaged strategies, which are more maladaptive. This results when you are managing a stressful situation with avoidance, so avoiding certain activities, avoiding socialization, staying home, that kind of stuff. We've found that people with toilet and sanitation insecurity are more likely to adopt any compensatory bladder behavior, but specifically some of those really maladaptive behaviors. And so this, like I said, is kind of the thing that helps connect this whole picture, like those people without reliable access to toilets and plumbing in their home have worse urinary symptoms, they have stress about this situation, anxiety about this situation. And then to cope with it, they develop maladaptive compensatory bladder behaviors, and this then becomes something that just continues to propagate forward. And so the lack of toilets just becomes the driver of this whole cycle. And so in terms of future knowledge about this, yes, absolutely. I think that coping is a key way that we can help intervene here, acutely if you're talking to someone or a patient who's experiencing some of these situations at home, teaching somebody primary control coping strategies over the avoiding maladaptive strategies is a great way to help them manage their stress and even manage their overall urinary symptoms. Enhancing coping strategies is a really practical thing that can be implemented in a clinical setting, and if coping continues to become a particular struggle for a patient, of course, they should be referred to someone with more specialization and coping like behavioral medicine to help. But yes, this is certainly something that would be interesting to consider for the future. Like, can you help toilet-insecure people manage their stress and anxiety and lower urinary tract symptoms by teaching them to improve their coping behaviors or on toileting?

"I think that coping is a key way that we can help intervene here," says Elisabeth M. Sebesta, MD.

Dr Zillioux on “Prevalence of Cognitive and Manual Dexterity Disorders Among Men Following Artificial Urinary Sphincter Placement.” 

Dr. Zillioux on assessing cognitive impairment and manual dexterity in patients undergoing AUS placement

study “Prevalence of Cognitive and Manual Dexterity Disorders Among Men Following Artificial Urinary Sphincter Placement.” Zillioux is an assistant professor of urology at the University of Virginia in Charlottesville.

What is the take-home message for the practicing urologist?

I think the take-home message is that cognitive impairment and manual dexterity issues are common in these patients, and we should not only be assessing for these at baseline but also ensuring that the patients have routine and longitudinal follow-up and that some sort of assessment is done at these follow up visits. It might be as simple as saying, "Show me how to cycle this device," which I think a lot of people are doing anyways. But it can also be doing a hand strength test or doing a timed get-up-and-go for frailty test. There are different cognitive screening tests. But the take-home is that we should be paying attention to these on follow-up.

Elisabeth M. Sebesta, MD, discusses potential mechanisms linking insecurity and both urinary symptoms and psychosocial factors

What mechanisms link toilet insecurity and urinary symptoms?

Your results highlight the association between insecurity and both urinary symptoms and psychosocial burden. Can you elaborate on the potential mechanisms linking these factors?

We talked a little bit about how I think that urinary symptoms might play into this. But basically as kind of mechanisms to understand the associations that I observed between being at risk for toilet and sanitation insecurity and worse urinary symptoms, we looked at both psychosocial burden and then some coping behaviors. And so in terms of the psychosocial aspect of things, people with toilet insecurity are more likely to experience greater stress and anxiety, report poorer social support, have a poor overall perception of their health, again, even after controlling for some confounders. And so this, I think, becomes like a moderator to link these 2 associations. We know that psychosocial burden can be experienced by people with worse urinary symptoms. This has been observed in many urologic conditions: overactive bladder, incontinence. And so if you have a lot of urinary frequency and you don't have good, reliable access to a toilet, it makes sense that this would like increase your overall stress and anxiety around this situation. And so my hypothesis is that the psychosocial burden experienced by people affected by this then becomes part of the mechanism that helps to drive the cycle forward and perpetuate it.

"In terms of the psychosocial aspect of things, people with toilet insecurity are more likely to experience greater stress and anxiety, report poorer social support, have a poor overall perception of their health, even after controlling for some confounders," says Elisabeth M. Sebesta, MD.

Dr. Sebesta on household toilet and sanitation insecurity and bladder health

 describes the background and notable findings from the 

Please describe the background for this study.

About 2 years ago now, I conducted a study that was designed to look at unmet social needs and urinary symptoms in a community-based sample of men and women. We've published several things from this initial study. But when designing it and thinking about different social determinants of health and associations with urinary symptoms, I was specifically very interested in how access to toilets and plumbing and sanitation in the home might be an under investigated unmet social need in this space. So I included several questions in this initial study about toilets and plumbing and water access that really hasn't been something previously looked at in the urology literature. And so this is the first publication that's a more in-depth look at these associations. I think it's a really interesting thing to think about in the context of bladder health. Previously, people have looked at public restroom access or access to restrooms in the workplace. But toilet access in someone's home is really not something we often think about as a problem in the United States or other wealthy countries outside of the unhoused population. Usually, it's talked about more in a global health setting, and the only estimates we had before this looking at toilet and sanitation access in the United States have comes from US Census data. They estimate about 2 million Americans lack access to functional plumbing. But the issues with the definition that they use, translated into wealthier countries like the United States, is that it's a really limited view. So they basically just ask 1 or 2 questions on the type or availability of plumbing that you have in your home. "Do you have a toilet? Do you have running water?" It doesn't really dive into the experience of use, the accessibility, reliability, affordability, number of people that share a toilet in the home, all that kind of stuff. Again, most of this comes actually from unhoused people or those in very metropolitan areas. So I hypothesized that it was more complicated than that; it's more than just having a physical toilet. I wanted to understand a little bit more about these issues, and then how having toilet access could affect people who have urinary symptoms.

What were some of the notable findings? Were any of them surprising to you and your coauthors?

We used a couple of questions, like I said, to broaden the view of how we're defining people who might be at risk for sanitation and toilet insecurity in their home, which included things like, are you worried about a place to urinate in your home, do toilets or plumbing not work consistently in your home, kind of broaden the definition to include some of that experience, even if you do have a toilet. The sample included a little over 4000 men and women throughout the country. And 17% answered positively to 1 of our questions indicating they might be at risk for some sort of home toilet or sanitation insecurity, or at least they experienced some sort of worry or stress about having access consistently to a working toilet in their home. This is way higher than what the US Census data suggests, which is basically around 1% of the US population is what they say suffers from this. I did aim to be a lot more inclusive with my definition, so I expected this. I expected to be including a higher proportion of people, but 17% is pretty high. Particularly in this study sample, which I recruited from Research Match, which is like an online research registry, and it generally includes people who are overwhelmingly educated, employed, have internet access, that kind of stuff. So I think that we certainly under appreciate how many people living in our country might actually be affected by this issue. You don't know how many people are suffering from this unless you ask or talk to them about it. In terms of the overall notable findings, the main takeaway is that people who we deemed were at risk for toilet or sanitation insecurity were also more likely to report more severe urinary symptoms, even after adjusting for a whole bunch of different other confounding variables. This makes sense to me; you can imagine having overactive bladder, for example, if you don't have reliable, consistent access to a toilet, even at home, that affects how you perceive your symptoms. Likewise, if you have a lot of urgency, you may not feel like you have good access to a toilet if you have to wait a roommate, for example. The relationship here certainly is kind of intuitive to me, and it's certainly bi-directional and a little more complicated. But that was the main takeaway from this study.

"17% answered positively to 1 of our questions indicating they might be at risk for some sort of home toilet or sanitation insecurity, or at least they experienced some sort of worry or stress about having access consistently to a working toilet in their home," says Elisabeth M. Sebesta, MD.

Study of cognitive and manual dexterity disorders after AUS placement raises questions for further research

 shares unanswered questions that arose from the 

What sorts of questions arise from this study?

This study is a first look at how common are these diagnoses in this patient population? But what it can't answer is, what is the appropriate baseline screening test that we do, and how should we follow these patients after implant? We know now that these diagnoses are likely common. And we know that, just based on common sense, we probably should be looking for these issues and patients on follow-up and ensure longitudinal follow-up. We don't know what interval makes sense. The median time to having one of these diagnoses show up in the patient's chart based off of this study was about 4 to 5 years, depending on which diagnosis you're looking at. That's well within the range of the patient normally potentially needing some sort of revision or replacement. And so, at the very least, they should be checked at the time of considering whether or not to do a device replacement or revision. What cognitive thresholds do you really need based off of objective screening tools? How closely should we follow these patients? Is it annually? Is it every other year? Is it just like the bare minimum, before you do anything else to them? Those are some outstanding questions.

"How closely should we follow these patients? Is it annually? Is it every other year?" asks Jacqueline Zillioux, MD. 

Dr Taghechian on underappreciated/underrated aspects of women’s health as well as her experience with Bulkamid

Dr. Taghechian on women’s health and her experience with Bulkamid

 discusses underappreciated/underrated aspects of women’s health as well as her experience with Bulkamid. Taghechian is a urologist with Georgia Urology.

What aspects of women's health do you feel are underappreciated/underreported?

Anything that has to do with sexual satisfaction, honestly. And then also, anything that has really to do in terms of pelvic health with perimenopause and menopause, it's just, again, not really talked about. I don't know why. Part of it may be just, the money doesn't go there. Who's in charge of the research money? I think we all know who's in charge there. But those are huge gaps in our knowledge and in our treatment, and even in coverage for those treatments. We may know what to do with the patient, but is insurance going to cover it? Most times, no. So it's big out-of-pocket costs for patients.

You have been designated a Bulkamid Center of Excellence. What have you learned about Bulkamid over time that has helped you to achieve this distinction?

I love Bulkamid. So what I know about women is, a lot of us have incontinence, especially after having children, getting older, collagen depletion. Many of us have problems with incontinence. But the other thing is, the gold standard for incontinence, even still, is putting in a mesh midurethral sling. But we don't want to have mesh in the vagina if we can help it. Even myself, I'd rather avoid that if possible. Sometimes you can, sometimes you can't. For the longest time, that's really the only treatment that we had, so we couldn't really avoid it if we had to fix the incontinence. But number 1, we don't want mesh. And then number 2, we're all busy. We have children, we have jobs, we have careers, we're busy housewives, whatever. We don't have that downtime to recover from a major surgery like a sling surgery. So that would often get in the way of women pursuing surgery for incontinence. But since Bulkamid came along, it's really been a game changer for me and for my patients. It is a simple procedure; it takes 15 minutes to do. There is 0 downtime; you literally jump off the table and you go back to normal life. The success rate is amazing. So far, we know that the results last at least 8 to 9 years, maybe longer, but Bulkamid has only been around for 8 to 9 years. So we'll see how long it does last. But even when I speak with and counsel patients, all of them are in agreement that even if they had to get a simple injection every couple of years, it's still worth it for them to do that than to undergo mesh midurethral sling surgery. So I love it. In the last 3 or 4 years that I've been doing Bulkamid, I've only done 2 slings in all of that time. Two slings, and that's all I used to do. So it's been great, and my patients have loved it.

"The success rate is amazing," says Shaya Taghechian, MD, of Bulkamid.

Panelists conclude their discussion by reflecting on key learnings and sharing advice for patient-centric management in overactive bladder (OAB) treatment.

Enhancing Patient-Centric Management in OAB in 2024 and Beyond

 So it seems like you both have really patient-centric management in regards to all the therapies, specifically for in -practice treatments, such as Botox therapy. Any advice you'd give to some of our colleagues listening here, what could they do? to enhance that patient experience that may be something simple? I know, Dr. Eilber, you actually mentioned you modified things recently, but I'll have each of you say what things could they do?

 I think the two things that people really fear are the catheterization, and that they will happen the middle of the night. So I think it's the same as when we're young. giving those post -procedure instructions, you say there is, and the patients get their first injection, of course, there is a risk of retention. It is very low. However, it doesn't happen instantaneously. We'll see you at two weeks. And if you're retaining a lot then, we can teach you how to empty your bladder. If you feel you're struggling more and more, call us, we'll see you sooner. But I can tell them in good conscience, I've never had anybody go into a cube retention. you know, within that timeframe because of that. And so I think that's really what people fear is that they're going to go into acute retention, no one's going to be around. And that's not really how it works.

 And Dr. Benson? Yeah, two things. The first, get it out of the operating room, if you can, and move it to your office.

 That'd be the single biggest thing. I can't tell you how many patients come to my practice that have been out. elsewhere and they say, you're not going to take me to the operating room and sedate me. And some of these have had, you know, eight, 10, 12, 20 injections and every time they're going to the operating room. So I first say, look at your practice model, try to take it out of the operating room. And then secondly is follow your data and follow your patient satisfaction data because if you're wondering whether it's working, it's really helpful. for you to somehow quantify that for yourself because it's a reinforcing tool to really help you to think about using it. Because there's very few things that we do with the exception of perhaps a sling that's so satisfying to patients, that's so reinforcing for not only you, but your staff. So we share these data with their staff, and we share kind of success data and stuff because it helps everybody on the team reinforce that central goal, which is we want effective care for patients. So really do take a methodologic way of looking at this and say, hey, how are we doing with this and strive to improve with it?

 Well, I think those are fantastic ideas and I'm sure they can be implemented. I just want to let you know this has been a fantastic discussion. It's been very interactive and lively your experts within your field. But before I conclude, I'd like to get some final thoughts from each of you. Really, what are you looking forward to in 2024, really to address the needs of the OAB landscape. And Dr. Benson, I'll start with you.

 For myself, it's the implantable tibial. You know, I think that that's going to be a game changer. It's going to open the landscape open to a lot more people. And I think that the other thing is perhaps looking at instead of a tiered therapy approach that whether it be through societies, through ourselves that we look at this to say, do we have to go through A to get to B to get to C? Or can we go through A to get to C? take a more-broad approach to offering more effective care sooner? So I hope that there will be a move of foot that we can ultimately change the ability to get patients care quicker and more efficiently.

 That was going to be my exact sentiment. Whether it happens in 2024 or whatever year, but I would love to get rid of some of these insurers that require patients fail. Multiple medications before moving on to other therapies. I think, yes, having the implantable tibial will be a game changer for a lot of people, but it is sometimes disappointing when you really want to offer something to a patient and they just cannot afford it. And you just watch them struggle. And these are people who would be fine, take medication. They're a little too scared to do something invasive and yet the only medication they can afford is the one that gives them corpus. A horrible side effect. So I do hope that the way our algorithm is in terms of approving the third line therapies changes soon.

Well, that's fantastic. Once again, I'd like to thank Dr. Kevin Benson. I'd like to thank Dr. Eilber, also to our viewing audience tonight. We hope that you found this few points discussion informative and hope that it'll benefit your practice.

*Video transcript is AI-generated and reviewed by Urology Times® editorial staff.

Panelists conclude their discussion by reflecting on key learnings and sharing advice for patient-centric management in overactive bladder (OAB) treatment, specifically focusing on effective communication and overlooked aspects of patient care. They offer guidance to other providers on enhancing patient experiences, particularly with procedures like Botox. The episode wraps up with each expert sharing their final thoughts and anticipations for advancements in OAB treatment in 2024, highlighting their commitment to addressing patient needs in this evolving field.

Viewpoints

Dr. Kennelly, Dr. Kevin Benson, and Dr. Karyn Eilber share their approaches to post-procedure care and follow-up for overactive bladder (OAB) treatments.

Optimizing Post-Procedure Care and Follow-Up in OAB Treatments

 Dr Eilber do you actually use after the procedure like a post procedure instruction sheet or how do you manage people afterwards? I'm probably a minimalist when it comes to afterwards.

 I mean, there's really not a reason to have to wait for people. to avoid. They all have OAB. The Botox doesn't work immediately. So, you know, there's no reason I think they're going to have any retention after the procedure. While I'm injecting, I am giving the post procedure instructions again to contribute to that verbal anesthesia. So I'll say, you know, remember, this doesn't work right away. You're going to be the same today, tomorrow and probably next week. You might have some pink urine. I think another thing to add. what we were talking about earlier is during the procedure, inviting the patients to look at the screen. The majority of people are fascinated and they will get very distracted. Some people look away, we've discussed immediately and that's okay too, but post procedure, there's not really a lot, there's no limitations. People can resume their regular activity, obviously except for the patients who get premedicated, maybe can't drive for a little bit, but for the most part, there's not really a lot. lot that needs to be done post procedure. I think it's just like with a regular cystoscopy, it's very unusual for people to have discomfort afterwards.

One of the most important things we reinforce is it's not going to be better overnight . And I can't stress that enough that it's a slow acting procedure and it's going to take time. We used to have patients who would call like day three, I'm not better. I'm not better. And so we always say it's two to four weeks, and you're going to see that improvement. Now, if we've done a first time Botox injection, we will see them back at that point to reassess efficacy to check a PVR and to make sure their urine's clear.So again, we go through some of that touch point during the procedure as well. Those that have done, you know, 12 of these, it's a different situation. But for those people new into the the procedure, we do really make sure that they feel like they're in the fold that they're going to get follow up after they've done this. And that it's going to be a gradual consistent improvement, you don't have to worry about waking up tomorrow and not being able to urinate because that's the other real concern they have when they leave is am I going to be in retention tomorrow? Because they've read that risk. We've tried to alleviate that put that into better, you know, terms and probabilities. But they are terrified. They're not going to be able to urinate. They're going to end up in the ER with a catheter. So I would really reinforce to go through that part of it with them and make sure they're comfortable.

 Yeah. I think you're, you both have mentioned that kind of the right out the procedure, the following up and early on fall for the first time, you know, botulinum toxin patient is great. And that may be at a one week to two week or three week touch point after that touch point to you. follow them beyond that? Or we know that at least in the clinical trials, the results lasted approximately six months. Is there a touch point between there or what have you found in your practices to keep people online?

I don't have a touch point after that, but when I see the first time inject or patients having their first injections at that two week mark, if it helped them, them and they're interested in continuing it, I go ahead and schedule them six months from them and tell them, you know, on average people last six months. If when you come for that one you tell me it really wore off it, you know, four and a half months and we'll schedule them every four and a half or five months moving forward. If you get to six months and you're really perfect, just postpone your appointment for a month and we'll figure out your duration of response, but it's like the OAB meds. Before telehealth, we just had this impression they would come back. I think it's good to make their six month appointment for two reasons. One is it's like the dentist. If you don't make it when you leave, you just forget. And despite what we tell people, there are a fair number of patients who still think it's supposed to last forever.

So they feel that the Botox didn't work because it wore off over a period of time. The other thing I think. is just from a practice efficiency perspective, you need to do that because if you're gonna be working with Botox a lot, you're gonna have limitations on equipment, you're gonna have limitations on spots. And the more predictable you can make that because we do have trouble where patients will call up and say, well, I would like to be in next week because it wore off and that's often just not attainable. So from just the practice efficiency and predictability perspective, it's important.

 One thing that we have done is we automatically will make their six month appointment and we always go with six months just Dr. Eilber said we want to make sure that that's kind of the general standard but about a week or two before we have an automated system that will send them a text just to remind them and also that in that text we say if you have other issues you'd like to discuss please let usknow. Because what we do find is patients have a lot of things going on. And oftentimes those patients back just for Botox are not really just back for Botox. So it's allowed us to take better assessment of other issues they might have so those appointments can be efficient. And also if they have any concerns about continuing Botox, why not change their dose, et cetera, they can make us aware of that. So I think those are some key considerations.

 Yeah, and I think you bring up some good points there and it sounded like earlier you stated that the first time Botox injection people have a lot of concerns and so checking in with them right away to alleviate some of those concerns but after their concerns have been alleviated they've been through it once it seems like Dr. Eilber people are on you know if you're consistent there they're on autopilot but you know their fears are there they get close comfortable with your staff staff, their procedure, and things can be managed in an efficient way. They can and just automatically schedule them. The one thing I have observed over the years though is invariably when people are five, six, seven into their series of injections, they'll say, you know, none of my injections were ever as good as the first. And you have to remind them that's because we never let you get back to your baseline. but it is kind of interesting that people perceive that it didn't work as well later and they forget how bad they were before their first one and I say, well, we're trying to be kind to you and not make you go back to baseline preemptively treating you.

 Right. And I think that's kind of the key I've noticed in my practice is once you get someone that's doing well, we want to maintain that. Don't let them sort of come back down.

 You know, the other thing that I found is patients very much know when Botox wears off for them and I always ask you know again trying to figure out how often we should have them back you know how do you think it's working they'll say you know what two weeks ago on Tuesday I quit working and I'm just I find it interesting that it's that black and white for them but they will almost always to a degree either A) it's working great or B) it wore off and then we try to tailor that based on what they've said. And I also let them know there is some variability between injections. Not every injection is going to be identical to the one previous. And, you know, one injection that may not work as effectively as this kind of a fluke, two might be a pattern. I don't necessarily change their injection paradigm if they have had one that's been a little off. But that's just another point for follow -up and staying connected with them to say, and staying connected with them to say, "Hey, if you had one that's been a little off, hasn't been as good, then we might bring them back in for another appointment before their next injection, just to make sure it's working well.

In this discussion, Dr. Kennelly, Dr. Kevin Benson, and Dr. Karyn Eilber share their approaches to post-procedure care and follow-up for overactive bladder (OAB) treatments. They detail the patient experience immediately after the procedure, the role of nursing and support staff, and methods for guiding patients through the recovery process, including managing potential complications and effective communication strategies. Additionally, they address challenges in patient adherence to follow-up visits, share insights on assessing treatment effectiveness during these visits, and discuss their strategies for enhancing patient engagement and satisfaction in their practices.

Dr. Kennelly, Dr. Kevin Benson, and Dr. Karyn Eilber discuss their strategies for ensuring patient comfort during overactive bladder (OAB) treatment procedures.

Fostering a Patient-Centric Environment During OAB Procedures

 Dr Eilber, we both mentioned about the procedure, you know, and let's say we're talking about botulinum toxin injections, how do you actually make patients feel comfortable? I mean, what do you have certain things that you're doing in your practice and that allow people to kind of feel at ease?

 I think one of the things that really makes people feel at ease is trying to have your same staff with them all the time. You know, this is a very obviously private area that we're working in. And so, So if you're rotating your staff just so they're getting experience in your office at different places I'm not sure that's the best idea when it comes to procedures like this because seeing familiar faces I think is really critical because when they check in they're not seeing you until it's right at the injection so they're seeing lots of other people beforehand.

Based on what we all met over the summer you know to discuss all these things I actually got a little aromatherapy and lights kind of device and it just has some background noise for people listen to it just sounds like sounds of nature. And it has lights so that they're not laying on their back waiting to get numb looking at these, you know, sterile fluorescent lights and my patients have been coming for a long time all comment that they really appreciate that. So I think the little things like that, and because a lot of people are kind of return customers if you will. they're just kind of used to it after a while and just having easy conversation with, you know, the staff really helps.

 Yeah, so I think when you, it's probably the hardest treatment, if something's repetitive, is that very first one. So it seems like you want to get it right the first time. And it seems like with your experience, you've evolved. So obviously, making lighting in the room, looking at what people are looking at, you're kind of putting yourself in the patient's shoes or what are they walking through and seeing what's going on.and visualizing, having music around that area. You both mentioned sort of verbal anesthesia during throughout that, friendly faces, the same people. I utilize a lot of those things in my practice also because I think that's kind of key. 

Dr. Benson, is there any other thing that during the procedure that you can kind of make patients feel comfortable or?

 Well, I think some of it, you know, has to do with you pre -medicate, you know, anxious patients. Do you get patients with chronic pain, other options? Do you, how do you utilize the lidocaine in the bladder, right? So just that alone, you got to give it some time to set up so you can't go in there one minute after you've done the installation and then do the procedure. Sometimes we, we instill lidocaine after the procedure additionally, but it's really finding out what, what are the patients concerned? concerns, because if you can just ask them what is there anything concerning you today, they'll very quickly tell you, well, it's my back, you know, or I have a bad hip and I need to be on my side, or, you know, those little things that just really do make a lot of difference for patients. And so it's just listening to them taking inventory.

In this episode, Dr. Kennelly, Dr. Kevin Benson, and Dr. Karyn Eilber discuss their strategies for ensuring patient comfort during overactive bladder (OAB) treatment procedures. They delve into the roles of clinical staff, the setup of the procedure room, and how they address patient needs and concerns to create a reassuring environment. The experts also share their experiences in handling challenges during procedures, illustrating how they've adapted their practices based on patient feedback to maintain a patient-centric focus throughout the treatment process.

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