For Mary, life had become miserable because she couldn’t control her bladder. A vital and active Coral Gables resident, Mary had suffered from urinary retention since her cancer surgery. During remission, she faced the inability to urinate, as the nerves to the pelvic floor had been affected by the surgery to cure her cancer. She had used medication and pelvic therapy without improvement and had worsened. At anytime, her bladder could overflow, ruining her clothes and undermining her dignity, she told Dr. Jaime L. Sepulveda.
So, Dr. Sepulveda, a urogynecologist with a subspecialty in Female Pelvic Medicine and Reconstructive Surgery in South Miami, recommended a therapeutic modality known as neuromodulation. Neuromodulation involves placing an implant to stimulate the nerves that control the bladder, the bowels and the pelvic floor. On the same day Dr. Sepulveda inserted the testing implant, Mary asked her husband on their way home to pull over for a bathroom break. “We need to stop,” said Mary, making a simple request that for a year had not been possible. She had regained control.
Neuromodulation is one of a series of measures that can be undertaken to manage urinary retention, and urinary or fecal incontinence. Dr. Sepulveda explains that neuromodulation is an effective treatment for bladder and bowel dysfunction. “Neuromodulation is for the patient that doesn’t respond to anything else. It is a sophisticated technology that has given relief to many patients for over 20 years. We use it with the highest discretion as it is costly, but highly effective,” Dr. Sepulveda said.
Inspire Health spoke to Dr. Sepulveda about his high standard for the testing of technology, medicine and other procedures before recommending a procedure to his patients. His meticulous analysis of the testing data is at the heart of his practice, which has treated dozens of women suffering from bladder and bowel problems for more than a decade.
Q. What is urinary incontinence? Is it that they cannot urinate at a particular moment in the day?
A. No, it just comes out. When we are born, our bladder gets full and it empties with no control. That is why we wear diapers. As our brain matures and we get control, urination and defecation gets to be voluntarily controlled.
Q. So, educating your brain as a child makes it possible to be toilet trained and avoid urinary incontinence?
A. Yes, and the mechanism is pretty straightforward: Now when your bladder gets full, you have educated your brain to receive that signal that your bladder is full and that it is not appropriate to release urine. When you get to a toilet, your brain says to your bladder, “Yeah, you can go ahead and contract.” The urethra then opens up and you urinate. Afterwards the whole cycle starts again. A similar mechanism occurs with the bowel.
Q. Outside of medications and medical procedures, how do you help people suffering from incontinence to find relief?
A. Many of these patients get better just by timing urination. In other words, they void or urinate every two hours and modify their diet in various ways including by eliminating bladder irritants. We are all aware of the pitfalls of medication, such as the lack of efficacy in very severe cases, and long term costs, but some patients do find relief. For bowel incontinence, fiber and medication may work initially, but it is a difficult situation even in its milder form.
Q. Can the patient with urinary or bowel dysfunction due to cancer treatment find relief?
A. These are the most clinically challenging scenarios. A large number of these patients do not respond to conventional therapies and get frustrated by repeated attempts to get them better. This is a group that frequently require more technologically advanced modalities such as Onabotulinum toxin A (Botox) and neuromodulation.
Q. How does Botox compare to neuromodulation?
A. Botox, or Onabotulinum toxin A will suppress nerves and eliminate the chemical reactions that are necessary for the nerves that connect to the bladder to fi re and do the work. If you have someone that has an overactive bladder or urge incontinence, you inject Botox in the bladder and nerve activity is suppressed until new nerves take over. Neuromodulation sends signals to the brain and helps restore regulation of bowel and bladder function. The evidence supporting the use of both therapies is well established as both therapies have been evaluated for almost 25 years. The fact that efficacy and safety has been well established for both therapies gives me confidence to recommend and apply them. In the case of neuromodulation, the efficacy of the device can be tested ahead of time through a minimally invasive procedure.
Q. How important is testing and data to your practice?
A. As a physician you learn to recognize that your experience is important, but data is critical. You need to know and apply the science behind the use of each therapy. Onabotulinum toxin A and neuromodulation are therapies that we save to be used in patients that do not respond to medication or behavioral changes. They are considered third line interventions. These interventions have been tested to the highest level of scientific scrutiny. For bowel incontinence, the efficacy of neuromodulation is well established with efficacy, safety and tolerability superior to anything that we have previously used. Understanding all modalities of treatment allow us to help our colleagues treat the most severe cases effectively and collaborate to improve the lives of our patients.
WHAT IS FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY?
The American Board of Medical Specialties approved Female Pelvic Medicine and Reconstructive Surgery, also known as urogynecology, as a certified subspecialty in 2011, and the first doctors were board-certified in 2013. Dr. Sepulveda was in the first class of board certified subspecialists in Female Pelvic Medicine and Reconstructive surgery, formerly known as Urogynecology. Urogynecologists are physicians who complete medical school and a residency in Obstetrics and Gynecology or Urology. These physicians are specialists with additional years of fellowship training and certification in Female Pelvic Medicine and Reconstructive Surgery. The training provides expertise in the evaluation, diagnosis, and treatment of conditions that affect the muscles and connective tissue of the female pelvic organs. Pelvic floor conditions that urogynecologists commonly treat include urinary incontinence, overactive bladder, pelvic organ prolapse and cosmetic/reconstructive repairs of the female genitalia. These physicians are also knowledgeable on the latest research in the fi eld pertaining to these conditions.