A magic treatment for bowel incontinence?

Today's guest is Dr. Joshua Bleier, a colorectal surgeon and chair of the Department of Surgery at Pennsylvania Hospital in Philadelphia, who shares with us about a treatment that provides relief to an enormous number of patients with bowel incontinence. It's minimally invasive, performed in office, and in Dr. Bleier's experience, can deliver meaningful improvement to as many as 90% of the patients he treats with these issues.

For more information about Medtronic's InterStim system for incontinence, visit talkleaks.com.

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

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Transcript

Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America's leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians, and caregivers, all available at NAFC. org. This podcast is supported by our sponsor partner, Medtronic, maker of Interstim systems for bladder and bowel control. To learn more about interstim therapy, visit talkleaks.com. 

Welcome back to another episode of Life Without Leaks. I'm your host, Bruce Kassover, and joining us again today is Steve Gregg, the executive director for the National Association for Continence. Welcome Steve. 

Steve Gregg: Thanks, Bruce. Really looking forward to this. This ought to be really exciting and we hopefully will learn an awful lot about bowel dysfunction and how we might go about treating it.

Bruce Kassover: Yes, I think that today we have a guest who's who's about as distinguished as it's possible to be as a physician. It's Dr. Joshua Bleier, a colorectal surgeon and chair of the Department of Surgery at Pennsylvania Hospital in Philadelphia. Welcome, Dr. Bleier. 

Dr. Bleier: Thank you for joining us. Thanks, Bruce. It's really quite an honor to be on the podcast. 

Bruce Kassover: Speaking of honor, I mean, I was taking a look at your CV over here and I have to say if I ever have the need for a colorectal surgeon, I have a feeling I know who I'm going to be going to because this is very impressive.

I'm wondering if you could tell us a little bit about your background and how you've reached the position that you're at today. 

Dr. Bleier: Sure. Well, I'm, I'm Philly born and bred. I grew up in just outside of Philadelphia and I went to college at the University of Pennsylvania and didn't... went to medical school also at the University of Pennsylvania.

And then I did a general surgery residency, which was the first time I left Philadelphia for Cornell in, in New York City. And...

Bruce Kassover: Just keeping it in the Ivy league then... 

Dr. Bleier: I try, you know, I've got to keep my mom happy. Yeah. So, and it was during my general surgery residency where I really sort of fell in love with the specialty of colorectal surgery.

I had amazing mentors and this was, you know, it was, it was very clear that this was the specialty that I, you know, you know, really wanted to be part of. And so after I finished my general surgery residency, I did my fellowship in colorectal surgery in Minnesota at the University of Minnesota. And then when I finished my fellowship, I came back to Penn and I've been working at Penn ever since.

Bruce Kassover: Are there any particular recognitions or achievements that really stand out to you that you'd like to mention, by the way? 

Dr. Bleier: I guess, well, I'm, as you said, I'm the chair of the Department of Surgery at Pennsylvania Hospital, which is one of the three Penn hospitals in Philadelphia. And I am a professor of surgery at the University of Pennsylvania.

And I guess my kids still mostly like me. I think that is a very significant accomplishment for me. And I have an amazing family and amazing wife and four amazing kids. 

Bruce Kassover: Yeah. Surgery may be tough, but getting your kids to like you is an achievement to be proud of. I can agree with that. 

Dr. Bleier: So, the other thing that I'm, I'm particularly proud of that I think I was one of the first, if not the 1st sickle nerve stimulator and planter in the tri state area back in 2012 and I think I was the 1st person in the world to implant the newest version of the Medtronic stimulator, the InterStim X. 

Well, that's pretty impressive. I mean, people who've been listening to our podcast or visiting the website there's a good chance that they're familiar, at least to a certain degree, with sacral neuromodulation. And if they are, they know that it's been done hundreds of thousands of times.

So to be somebody who really pioneers sort of the, the, you know, new, new versions of the technology has got to be pretty exciting, actually. 

Well, I can't, I mean, obviously the kudos for the technology goes to Medtronic and their decades of R& D and development of this amazing technology and the fact that I was the first person to put one in really, the credit goes to my Medtronic team and my reps who really made that possible.

It was, it was, it was a race to do it and they they stepped up and made it, made it happen. 

Bruce Kassover: Now, you know, that actually gets me thinking because when I think of a colorectal surgeon, I'm typically imagining that there's cutting involved, that it's sort of on the invasive side of things, that you're, you know, you're, you're going to the body, you're, you're doing, you know, things with scalpels and organs and all sorts of stuff.

And when I think about sacral neuromodulation, that's really an implanted, a small device that's implanted. What really comes under the umbrella of colorectal surgery and, you know, what is sort of the, the variation of different, different treatments that, that, that you provide. 

Dr. Bleier: Sure. Yeah, that's a great question.

And it's actually one of the things that drew me to colorectal surgery. The most is that it's a specialty, which really spans the gamut of an enormous number of different types of procedures that we do and disease processes that we treat the thing that originally initially drew me to it when I was a general surgery resident was the, as you say, the cutting the bowel surgery, part of it, the ability to treat colon cancer and diverticulitis and inflammatory bowel disease, But the other sort of big piece of that is the sort of anorectal procedures, which, you know, is sort of what people think of when they think of a proctology or something like that.

And that's, you know, dealing with hemorrhoids and infections and fistulas and things like that. But pelvic floor health and functional issues with. The bowel really didn't have, I mean, they're historically colorectal surgery was definitely involved with that, but prior to the development of sacral nerve stimulation, the treatments for the surgical treatments for fecal incontinence were very, very limited and had very limited efficacy if somebody was incontinent, meaning they couldn't hold their bowels and they had accidents and they had had a previous injury to their sphincter.

Which is the control muscle, which people use unconsciously and consciously to hold their bowels in. If there was an injury to that sphincter, then we could, we could try to fix it. And when that was the only sort of treatment we could offer, it was it was a good treatment. It worked fairly well, but it, it was, it's a very painful operation to recover from, and it didn't have great durability.

That was just the way it was. And there wasn't too much else that we could do when I was a fellow back in 2007 to 2008. It was when the initial sort of clinical trials looking at sacral nerve stimulation or sacral neuromodulation for the use in fecal incontinence were going on. And so when I was a fellow, I, I had the fortune to have mentors during my fellowship who were involved in that, those seminal studies to get approval by the FDA.

And I saw how incredibly amazing it was. And when I started practice in 2008, I had all of these patients who you know, had, you know, issues with, with continence and control. And up until signal nerve stimulation was available, we had limited ability to really help them. And many colorectal surgeons had never had the exposure, the knowledge about sacral nerve stimulation.

I was very lucky and I felt very fortunate that I had that experience as a fellow. And so, you know, I had these patients who didn't really have great options. Some of them weren't candidates for sphincter repairs and some of them had failed sphincter repairs. And so I was really, truly, you know, waiting with bated breath for when sacral nerve stimulation became FDA approved to treat fecal incontinence.

And, and really jumped on it as soon as I could, as soon as it became available in, in 2012. And sort of the rest is history, I guess. It, it was a magical treatment then, it remains a magical treatment now. It's incredibly effective. But as you say, you know, colorectal surgery spans the gamut of all of this.

And the treatment of of fecal incontinence and pelvic floor issues and anorectal diseases has always been a particular interest of mine. It wasn't exactly what entranced me about colorectal surgery initially, but what I really came to learn was that in addition to the enormous impact that you have being able to cut out colon cancer and cure colon cancer and treat diverticulitis and treat inflammatory bowel diseases, The issues related to pelvic floor health and continence are sort of very insidious and these are the things that slowly erode patient's quality of life.

And ultimately, if you boil down what a physician is supposed to do, what our job is, it's to improve patients' quality of life. And this was something that really struck me as just a particularly insidious issue. And it's, you know, it's not a cancer, you know, it's not a Crohn's disease. It doesn't rise to that level in the sort of consciousness of doctors everywhere.

And so when people think about people having problems, With bowel control or with anorectal disease or things like that, the automatic impact isn't there when you just think about it in black and white terms, but the actual reality is these are the things that affect patients every day and in truly profound ways and the ability to impact those as a surgeon, you know, really gets to the heart of what our core principle is, which is the ability to improve quality of life. And when I was a fellow, we were learning innovative new techniques for treatment of fistulas that previously had, you know, that were refractory to treatment without, you know, risking continence.

And we, you know, there was a new therapy that we started doing, you know, in the United States. It was developed in, in Thailand, and it was a surgical treatment for fistula disease. And that was something that I brought to the practice, having learned it from my mentors and fellowship. And that was really quite rewarding.

So that, you know, anorectal disease was always in a particular area that I enjoyed and focused on. And so the access and the success of having sacral nerve stimulation to treat these patients really resonated with me tremendously. 

Bruce Kassover: So, I'm wondering based on what you're saying about the path that people take when they reach you, because I don't imagine that somebody immediately starts to have a symptom and goes right into surgery.

And I'm wondering, you know, at what stage do people finally decide to go to a physician because it's got to be tough, and how as a physician do you sort of get them to open up and discuss their symptoms so you could figure out where they are in the progression of their disorder to try and develop the best treatment? Does that make sense? 

Dr. Bleier: Yeah, that does. And that really gets to a key issue regarding fecal incontinence and patients who suffer with it. And that is, the vast majority of these people suffer in silence. And they don't even know that there is potentially some therapy that's out there. They're so debilitated by this, as you say, psychically, it's devastating.

But they don't know who to talk to about it. Even if they can get over their embarrassment to talk about it, they don't know who to talk about it. So there's data out there that says that the vast majority of patients who have this problem, their primary care physicians don't know about it. And so how would they know who to talk to?

It's a very small slice of patients who actually are able to talk about it and bring it up with somebody. And the chances that even if they bring it up with their care provider or primary care physician. There's a very small chance that their primary care physician or whoever they're talking to knows enough about the ability that we have to treat this to refer them to somebody who might know who is doing it.

So it is the vast majority of patients who have this problem, and it's projected to be probably upwards of 12, 13 million patients in the United States who are suffering. And although over the years, there's been hundreds of thousands of implants done for fecal incontinence, it's a drop in the bucket.

Truly just a drop in the bucket of the patients who could benefit from it. So that's one of the reasons I feel really fortunate to be talking with you tonight because I hope that your podcast and your organization can help get that message out. 

So when patients are ultimately referred to me, it usually comes at the long line, at the end of a long line of disappointments, meaning they've finally spoken to doctors who really don't have a lot to offer to them and so when they come to me, the first thing that I think is really important is trying to let the patient understand and communicate with them that I see this, this horrible thing and I understand to the best of my ability how debilitating this issue is and by communicating really being able to just talk with the patients and connect with them that we can, I can understand by virtue of my experience treating this, how much this is a problem is where we sort of start to be able to get patients to have that conversation and to open up now, some of them.

Over the years have learned more about it. And as we've done more and more of these, and as I've, you know, done these things and had spoken with my referrers and, you know, made it known that this is something that I, you know, love doing and feel very strongly about, we're slowly, slowly getting the word out there that when patients come in to a doctor that I work with, that there is, you know, there is something out there for them, then, you know, they may be coming in a little bit more informed and looking for this, but a lot of them are just, you know, coming in as a final try for somebody that might be able to help them.

And I think the important thing is to really just let the patients know that I truly understand how devastating this is, and that there is a very good chance. that in working with them, that we should be able to make their quality of life better. And not every patient that comes in with these issues ultimately needs a sacral nerve stimulator.

A lot of them just need good medical care and figuring out what medications are causing the issues. Some people have accidents only when their stools are loose and not when they're solid. And so if we can figure out, you know, what's making their stools loose and we can do something about that, they may get much better.

I can't improve on if that we can get them better without the need for a procedure. That's always a better outcome than having to do a procedure. But for those who are still having issues, despite optimal medical management, that's where sacral nerve stimulation comes in. And I think the other key point in understanding this and talking with patients about it is like figuring out the difference.

And the way, and the ways that this affects them in the ways that it can manifest, it's not always just about having an accident and soiling yourself. I mean, obviously, that is the most dramatic and obvious way that people might think about this, but actually, a lot of patients, maybe, maybe more than half, the way they've adapted their lives is to avoid these accidents, but they do that at the complete expense of quality of life and social life. They don't leave their houses. They carry clothes around wherever they go. They don't do the things that people should just be able to take for granted to do every day. Go for walks, go to the mall, go out to a restaurant, hang out with your family. They don't do these things because they need to be near a bathroom, because the urgency, the, that sort of inability to defer a bowel movement without having an accident, they've learned to adapt that slowly, slowly by never going out, by being near a bathroom and that aspect of it is just as erosive to their quality of life. But if you ask them, do you have accidents? Well, they might say no, because they just don't allow them to be in a situation where they have accidents. And so understanding the various ways that this problem can manifest and the ways that it can slowly warp your day to day and your quality of life is really important because.

On a day-by-day basis, they may not see the changes and what they're giving up and the freedom that they've lost. But if they look back and compare what life was like 10 years ago to what it is now, you can see this huge gulf, this huge chasm that they have, that they're across, and that is just as bad.

So it's really trying to, you know, have that conversation and understand what the patients are going through, and really understand how their bowel issues have affected their quality of life. 

Steve Gregg: At NAFC, we've done a pretty good job trying to elevate general understanding of what bowel dysfunction could look like in their life, and you've talked about it really nicely.

And one of the things that we hear consistently that you addressed earlier was, I go in and talk to my primary care and they know nothing about this. Or they dismiss it as you know, you're getting older and you probably shouldn't eat Mexican food three days a week. Or they diminish it or try to treat it in a way that is not terribly satisfactory. Maybe with diet, maybe with exercise and some components, and we hear that a lot. And so what we're trying to do is find ways that we can educate patients To have that conversation, but then be demonstrative, and then, "How do I get to see you, you know, somebody who is a specialist in this space and knowledgeable in this space." And so I'd love to hear your thoughts on that. 

Before you answer that, the other piece we hear is, "I go to a lot of doctors and there's sort of a lot of teams and it's really hard to track what one doctor says versus another doctor. So I could go see a nutritionist. I go see a gastroenterologist, I got a primary care and they don't talk to each other unless you're at a great academic institution like the University of Pennsylvania or Vanderbilt."

And it's very frustrating for patients to go, well, that person said something different than this person. So how do we help at NAFC? How do we help patients move from less than satisfying conversations? With a primary care to get to you and a care team that can take care of them. 

Dr. Bleier: Well, that is the million dollar question because, because it's, you know, as you say, there are so many different types of practices and, you know, the, the communication is lacking. The education is lacking. The knowledge of what's out there is lacking. And so I think it's hard to probably nearly impossible. To get that message out in the medical community to all the practitioners who are out there in a meaningful way, and especially now, when everybody is so pressed for time, you know, there isn't enough time that is available to be spent with each patient, you know, primary care physicians are inundated.

They have so little time. And, you know, it's very hit or miss to understand what they may or may not know what's, what's out there. I mean, we try to, you know, one of the ways that is out there for medical professionals to do that is continuing medical education. But there's a million different topics. And so I think, you know, the most important thing is to try and reach the public to try and get that message out there to let them know that these therapies exist to leverage things like the Internet and electronic media to sort of get the message out there, and that's got its own pitfalls, too. 

And who knows what to believe? And who knows what's click bait and what's not? You know, it's funny. You know, I've struggled with this for a long time. You know, at Penn, as you say, we have a very connected network. An extended health system and an electronic medical record where all the, you know, the providers that are within the health system and within the extended practice circles can can see the notes.

And so if they are able to do that, then they'll be able to, you know, hopefully learn and see what is available. But it's, it's very difficult. You know, I spent a lot of time talking to referring doctors, talking to the GIs, talking to the primary care physicians, talking to the GYNs, the geriatricians, those specialties that may be the one seeing these patients.

But like, this made me have to look inward as well. And this was really epitomized by a patient that I saw early on in my practice who I treated for hemorrhoidal disease. And I helped her with her hemorrhoids, got her through the surgery, and I thought I was a great doctor. I thought I was a great colorectal surgeon.

And then a couple of years later, I was sitting in the OR with one of my colleagues who's a urogynecologist, who did sacral nerve stimulation for urinary incontinence. And I saw, we were talking about patients, and the name came up, and I recognized the name. And I, I asked her about it, and I looked into it, and this was the patient that I had seen.

And turns out, she had been having fecal incontinence this whole time, before the hemorrhoidectomy, after the hemorrhoidectomy. I didn't even know that, and I was a guy who was putting in sacral nerve stimulators. I was a colorectal surgeon, whose job it is to try and help patients like this, and I didn't even know.

And so, that sort of caused me to really rethink how I approach these. And so we sort of added, you know, a question to our review of systems. Our electronic medical records got a long list of questions. And you ask about migraines and you ask about, you know, do you feel safe at home? You ask about, does your right eyelid twitch, but on this, on this form nowhere was fecal incontinence, and so just by adding that and just by starting to ask all of my patients who are coming in for whatever reason they were there to see me, there were a lot of patients to it had that issue. So it's really, it's really a question. It's really an issue about asking and getting that out there.

And if we can't do it ourselves directly, and we can't control everybody who's doing it, I think we need to just continue to work. Thank you. To try to get that information out and empower the patients and empower the population to ask those questions, you know, should we be like advertising in the incontinence section of drug stores, on Amazon. You know, when you go to that area, you know, do you have an ad? I don't I don't know the answer But I do know that something more needs to be done this information needs to get out there because there are so many people that are suffering in silence and it is, it is such a easy and, and incredibly successful and reliable treatment for this devastating issue that if we just saw everybody that had it, you know, you'd, you'd cure so many people of this incredible, incredibly debilitating problem and with such reliability when there's no, there's never been a functional disorder in GI surgery and colorectal surgery.

That has been so reliably been able to be treated by a procedure as fecal incontinence, even urinary incontinence, which is the exact same operation. The exact same device. It's it's why we're doing it for fecal incontinence because there's so many patients who had urinary incontinence and fecal incontinence.

This device was brought to light and pioneered for urinary incontinence. And those smart urologists who were doing it were noticing that the patients who had both urinary and fecal incontinence were having this dramatic improvement in fecal incontinence symptoms, even more than the urinary incontinence symptoms. And that's really what launched, you know, this for fecal incontinence as a, as its own indication. 

Bruce Kassover: There is one question that, that I want to ask you probably the dumbest question that, that, that anybody will ask you in a while. But I think that it actually speaks to some of what you were talking about earlier about, you know, people getting on the treatment path.

And I'm wondering if you could give me an idea of, if I'm a patient, how do I know if I actually have fecal incontinence? I mean, if you're waiting to you, you've like adjusted your whole life around episodes or needing to use the bathroom, then, you know, that you already have a problem. But if you're somebody who has one episode, that is easy enough to dismiss, you know, "I ate something that disagreed with me," or "I'm sick" or whatever, but at what point do you realize, you know, this is not normal, this is a problem and I need to seek, I need to seek medical help. What is that point?

Dr. Bleier: Well, I guess I guess it's different for everybody. I mean, you're absolutely right. Like, you know, even somebody who's totally healthy has a totally healthy pelvic floor, they can get a bug and overwhelming diarrhea and have an accident. That's not really what we're talking about. 

We're talking about, you know, people that are having multiple accidents every day or every week, or even, you know, people are having accidents every month. It can range widely, and that's where, that's where talking to patients and trying to have this conversation and figure out what exactly is going on, and, and trying to really tease out the details and the frequencies about what's going on makes a huge difference.

You know, sacral nerve stimulation is a therapy that works in almost 90% of people, but we have to, we have to qualify that and say, well, when we say it's successful, our definition of success is at least a 50% reduction in the number of accidents. Okay. That's sort of the, the black and white text, but it also works incredibly well for those, for that urgency feeling that people have that, you know, keep them in the house, that keep them from running away, keep them from going out and keep them from running too far from a, from a bathroom.

So it, that's part of the conversation is figuring out what exactly is going on with that. And that's where sort of talking to patients and getting a bowel diary, you know, actually having them actively think about this and tracking it is incredibly enlightening for patients once they actively start having to track it and see what's going on. Then they can start to really get a sense of, of how frequent it is.

Sacral nerve stimulation works incredibly well, but you have to actually have enough accidents, sadly, or ironically enough to for it to be the appropriate therapy, because the way it works is, you test the system to see if it's going to work and you can you can do this test for a maximum of two weeks and within those two weeks you need to see at least a 50 improvement.

So if you think about the math, you need to have at least one or two episodes or accidents, whatever you're calling them, whether it's frank, you know, accidents or what I call these incontinent equivalents where If they they have to sit right next to the bathroom and if they hadn't been right next to the bathroom, they would have had an accident.

So I really, I go through that with them and I have them try to game out or actually go out and do what everybody else should be able to do and really see how much it's actually affecting them. So they need to have 1 or 2 accidents every week for us to in a minimum of a 2 week period of time to detect a 50% improvement.

Now, many people have accidents or urgent episodes every day or multiple times a day. So, you know, you'll know right away if the, if it's working and if it, and if the test shows at least a 50% improvement, then they get implanted. If the test doesn't work, then they don't, but that's such a small section of those patients.

Like I said, 90% of patients who come in who are appropriate patients to test will have a 50% or more improvement. In fact, maybe up to half of patients will have a perfect or near perfect response. And, you know, it's really a conversation in trying to figure out exactly how frequent this is. 

And that's, making the decision for doing sacral nerve stimulation, or at least doing the test to see if sacral nerve stimulation works for you, is the last piece of the pathway. The first piece of the pathway is talking to the patients, figuring out what's actively going on, right? If they have accidents, if they're soiling their underwear, if they are having, you know, solid stool or liquid stool that they can't control, figuring that out.

If they're only having accidents when their stool is liquid, well then, what can we do to make that better? If they're fine when their stools are solid, then being a good doctor means, "Let's figure out if there's something we can do about your diarrhea, your loose stools." 

Are they on medications which they didn't realize could be causing loose stools? Can they add simple dietary supplements to make their stools more firm and thus fix the problem? Things like that. But on the flip side, patients who have chronic diarrhea that take anti diarrheal medication so they don't poop at all. If there's no satisfying in between, but when they get so constipated, they're just as uncomfortable and just as miserable, that's not a better solution either. And so sacral nerve stimulation may, you know, be the right answer for them so that they don't have to spend their lives deliberately constipating themselves just so they won't have an accident. And all that comes out, you know, in the conversation that we have with them.

And when you talk about these types of issues with patients, they recognize that you understand the nuances of what they're going through and they're more likely to open up and talk about it and, and see if they're willing to, to undergo this, you know, to undergo the test to see if sacral nerve stimulation will work for them.

Bruce Kassover: It's pretty remarkable that, that, you know, you talk about some people actually seeing a full, you know, 100% improvement in their symptoms, which is sort of magical in a way. 

Dr. Bleier: That's exactly what I say. I tell them it's magical. 

Bruce Kassover: It's like we're living in the future. Everything, except for flying cars, everything that they told us we're going to have as kids, we have.

We have TVs on our wrists, and we have like, like, literal cures for things. That is amazing. I'm wondering though, what point does somebody who might be a candidate for sacral nerve stimulation wind up becoming a candidate for a more invasive type of surgery? 

Dr. Bleier: There are a couple of scenarios, and they're fairly rare because of how incredibly reliable sacral nerve stimulation is, but if they're in that very small percentage of patients, that 10% who don't respond to sacral nerve stimulation, then you have to consider something else and whether or not that that is something that is feasible or something that they are desirous of doing.

Like I said, before sacral nerve stimulation, the only surgical interventions that we had were really to repair a sphincter if damaged. And if the sphincter wasn't damaged and they were still totally incontinent and all other things had failed, you would talk to them about like a colostomy, like literally diverting their poop into a bag so that they're not having accidents.

It does give them the ultimate control, but at this, at the cost of an irrevocable change. Now, when you do a colostomy for somebody, because that's the right reason, nothing else is working. The data clearly show that it has a dramatic improvement in the quality of their life. Although it is enormous to consider, it actually has, you know, an important place and it really works, but obviously it is the far last resort for, for treatment of these patients.

So if somebody does not respond to sacral nerve stimulation, you've already selected out a group that is very hard to treat. At that point, we could talk about looking into whether or not they have a sphincter injury because, by the way, sacral nerve stimulation works whether or not their sphincter is injured or not.

And it's pretty amazing in that way as well. But if sacral nerve stimulation doesn't work, then you can start to talk about, you know, what are the pros and cons about trying to repair the sphincter. But that's where it really uncovers the fact that it's a painful operation and it doesn't have a lot of durability.

So most patients after three to five years after a sphincter repair have really returned to their pre-surgery level of incontinence, and I'm talking about a patient population by and large that is women in their 60s to 70s, because that's the sort of the largest demographic and those are the women who presumably had an injury during childbirth, which the functional outcome of which is now finally uncovered.

There is a very narrow role for sphincter repairs in young women who have had significant sphincter injuries. Or men who've had sphincter injuries for whatever reason, but the most common reason for a sphincter injury is childbirth. And If you repair a fresh sphincter injury, then there's a reasonable expectation of actually long term success with that.

It's trying to repair a sphincter that's been injured and scarred for 20 years where we don't get durable responses. So that's a narrow window of sort of immediately postpartum patients who have sphincter injuries and that haven't gotten any better after three to six months. You have about a one year window after that where repairing a sphincter that is a relatively fresh injury, you have a much better chance, although no guarantee, a much better chance of having long term success with that sphincter repair.

But you got to keep in mind that somebody with a three to six month old who then has to undergo a pretty hard to recover from surgery, which is really going to lay them up for a long time when they've got a toddler or, you know, a six month old at home. And so that's not a, you know, a great prospect either.

Although it would be nice, theoretically, not to have to have a device that was implanted for the rest of their life, the device will probably work for the rest of their life. You know, the battery might need to be changed, but all of the long term data with sacral nerve stimulation shows that if it's if it has worked and it continues to work, it will continue to work.

So I don't worry about the durability of of the of the therapy. It will still work. But that, you know, if you have a young woman, you try not to have to have them have an implanted device for their entire life. So there are patients who are potentially candidates for sphincter repair. They're just, it's just a very small segment who really fall into that group.

And even those patients, they might, you know, benefit, and I have done this many times, benefit from getting a sacral nerve stimulator, sort of bridge them till, you know, for that 6 month to 12 month period, while we still have a window. To do a successful sphincter repair, but until they can get things settled with the new child at home and, you know, feel like they're fully recovered and are in a, are in a space where they can be able to plan for a month, you know, a couple months recuperation from a sphincter repair. So you can use that sacral nerve stimulator to restore their continence, hopefully, and bridge them till when they can get a sacro- a sphincter repair. 

Bruce Kassover: That's, it's really interesting because the way you're describing things changes the way that I've been thinking about the sort-of progression of treatments totally because, you know, before this conversation, I sort of pictured the type of treatment that you get as related to the sort of severity of your symptoms so that if you have, you know, some issues, but it wasn't like, you know, absolutely life altering in every way, that you'd start off by changing your diet and, you know, doing some of the basic modifications.

And if things got worse, you would graduate maybe to medications. And if things got even worse, you would graduate to sacral nerve stimulation. And then if things got worse, you'd go on to surgery. But it sounds to me like what you're saying is that, realistically, after you've tried some of the, the behavior modifications, the dietary changes, that really sacral nerve stimulation is sort-of the go-to treatment from your perspective for people of, with a broad range of severities.

Is that, is that a fair, fair statement? 

Dr. Bleier: Yeah, I think the, the paradigm has totally shifted. Sacral nerve stimulation changed the paradigm of how we are able, as colorectal surgeons, and you're all, you're a gynecologist and everybody who deals with this and who implants and sees patients with fecal incontinence has changed the paradigm for how fecal incontinence is treated.

This is the, this is the current standard of care for those people who know about it. And if you look at the, the National Colorectal Society, the American Society for Colorectal Surgery has practice parameters for treatment of this. Sacral nerve stimulation is sort of the primary treatment. For fecal incontinence for those who have failed appropriate medical conservative management, all the things that you said is the right thing to do to start with the more conservative treatments, dietary, behavioral, medical management, and when those fail, the next step is sacral nerve stimulation.

That's the right next step. And fortunately, it works in almost everybody because there isn't a lot of really reliable, good options if it doesn't. 

Bruce Kassover: Well, I can't think of anything that's more encouraging for somebody who's, who's experiencing some symptoms than, than to know that, yeah, it's going to be a tough conversation and you're going to be a little bit, little embarrassed, but if you can get over just a bit of embarrassment, there's actually a treatment that has a genuinely remarkable shot of helping to give you relief.

Dr. Bleier: And I, I couldn't have said it better. And that's actually when I meet these patients for the first time, that's what I tell them, you know, it's part of sort of reassuring them that there's light at the end of the tunnel. We're not necessarily always going to jump right to sacral nerve stimulation, but when I tell them, here's what we're going to try and here's what we're going to do, and if this doesn't work, then at the end of, at the end of this path, we still have this, which is ultimately incredibly reliable.

This care pathway, this ability to sort of point them where they are and what comes next. Is incredibly reassuring for a lot of patients because they never got that probably they have not heard that from anybody else when they've been talking to people about this problem. They just say, "I don't know, or we'll try this. And if that doesn't work, I'm sorry. I don't have anything else to help you." And so they, they may give up or they may get, you know, get very pessimistic about it. But I think talking to them and saying exactly what you said, that there is this light at the end of the tunnel. Let's go there together. Let's take this path. Really makes the difference for so many patients. 

Bruce Kassover: So, Dr. Bleier, so for somebody who's been following along with us, we've talked about a lot of topics, and I want to try and sort of sum things up in a way for them that's really easy to digest and easy to remember. If I feel like I'm having some symptoms that are causing me enough trouble that I think I need to seek help, what does the treatment path look like from say, from, from bowel diary right through to, to the sort of treatment that you deliver? 

Dr. Bleier: Right. So the first step is really trying to get a good handle on what your symptoms are and how frequent they are. And if you're a patient who's starting along this pathway, Keeping track of those issues and trying to understand when is it bad, what are the issues that are causing the most problems, is it the urgency, is it the, is it the accidents? Understanding? Is it just when my stools are loose? Is it when my, is it both when my stools are loose or well formed? And how frequent is that happening? You know, are there medications that I'm taking that are contributing to this, you know, trying to get a good handle on what exactly is going on the frequency of the bowels and the quality of the complaints and the accidents that you're having and also trying to, you know, take a step outside of yourself and take a look and see, have I changed my entire life to deal with what's going on with my bowels? Am I thinking about this issue every day? Am I, have I changed everything that I do on a daily basis so that I'm near a bathroom? So that, do I not go out anymore because of this? Although I may not have an actual accident, is that because I don't go out? Is that because I know where every bathroom is and I remain within a 10 foot, you know, distance from those from those things?

So really kind of understanding, you know, what that is and and what the, you know, how frequent and how severe the issues are, you know, some people. Have other things going on. They may have other disease states like rectal prolapse, which or hemorrhoidal prolapse, which causes mucous seepage. And is that really what's going on?

So really being able to describe and quantitate. What it is that is bothering you about your bowels is like a really important place to start because once we have that we have a target to look at, we have a better idea of what it is that's going on, that's bothering you. And that can really help sort of tailor how we approach treatment of that.

And like I said, most of the time with just being in a doctor and listening and looking at your medications and making some lifestyle modifications, a lot of patients will get much better and don't need any surgery at all. But for those that do need it, it's important to know that there is this therapy that is out there and there's light at the end of the tunnel. 

Bruce Kassover: Well, that was great. Dr. Bleier, I really appreciate you joining us and I really appreciate all the insight you've shared with us So, so thank you very much. And with any luck, there's some people out there who are listening who've been going through a lot and with any luck, this is sort of giving people the courage and the confidence to actually seek the help that, that can make a real difference for them. So thank you very much. 

Dr. Bleier: You're very welcome. I hope they do. 

Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. This podcast was supported by our sponsor partner Medtronic, makers of the InterStim Systems for bladder and bowel control. To learn more about the InterStim Systems, visit talkleaks. com. Our music is Rainbows by Kevin MacLeod and can be found online at incompetech.com.