I did not get assigned any fun surgical topics. And I'm back to non-surgical management. But we're going to talk a little bit more about when medications are not cutting it, some of the advanced treatment options for overactive bladder. I do have some case scenarios at the end. We may or may not have time to get to those, but some of the more, I think, trickier situations. My financial disclosures are relevant for this talk. I do have some funding from Medtronic for the sacral neuromodulation implant registry. I also get royalties from UpToDate because I wrote an article about Botox for lower urinary tract symptoms. And I have R01 funding in this space that I'm going to talk about very briefly. But all of this is to say I am utterly conflicted when it comes to talking about overactive bladder. But I hope it's equal. It's like I'm equally conflicted across the board because I basically just think that medications should not, we are all frustrated with using medications as our only option. So Miles went into this yesterday, but what is overactive bladder? This is the consensus definition. Symptoms of urinary urgency usually accompanied by frequency and nocturia with or without the incontinence. This is what we know. This is what people talk about. If you pull the publication and look at it, that sentence doesn't end right there. The next part of the sentence literally goes on to say, in the absence of urinary tract infection or other pathology. And how do we test for urinary tract infection? Standard urine culture. I told you yesterday, standard urine culture sucks for finding all microbes. So all of that is a bit of a segue to say that I do think that there is a proportion of our overactive bladder patients where there may be something more than just neurologic etiologies. And many of us in the field have asked questions like, could overactive bladder be due to a microbe that can't be detected with a standard culture? You think about the H. pylori example for GERD from years ago. And I don't think we found that smoking gun. But the other thing is, could overactive bladder symptoms result from an alteration in normal commensal microbes? And here you think about dysbiosis, like BV in the vagina or SIBO in the GI tract. And I think many of us have some inkling that there could be a subset of our patients that have something like this. So I do have this spidey sense, because this is my research life also, is studying the microbiome, that dysbiosis may play a role in some of our patients, not every patient with OAB. And I think here about the 30% who have overlapping OAB and recurrent UTIs. Or I think about some of the women who have onset of their urgency frequency, maybe some leakage around the time of their menopausal transition where they're also having other atrophy and GUSM symptoms. Those are the people that my spidey sense is sort of like, you know, maybe in a future state we will have some different things that we want to employ for those populations. Generally speaking, I've sort of evolved in my practice, particularly over the last five years, to really talk about UTI prevention regimens and people who are already having recurrent UTIs before we move into OAB treatment. So I usually tell them, I want your UTIs settled down for a good three months. And we're going to see how much residual OAB you really have. And I have been actually utterly surprised by times where women will come back and say, wow, you're right. Actually, this is better. And not always, but I do think that there's a subset where this occurs. And I love evidence-based medicine. I like to get up on that high horse. But I'm perfectly willing to dismount and talk to people transparently when I'm not using evidence-based medicine. And so some of my younger patients, or when I say younger, I'm saying in the 50s compared to our 80-year-olds, who might be having these symptoms coming on around the menopausal transition, I'm like, well, let's just try some vaginal estrogen in you and see if we can reshape the microbiome and see what happens. You go to five other doctors. They're not going to tell you this. But this is what I study in the lab. Let's try it. In three months, if you're not better, I will put you on the OAB treatment algorithm. Again, I've been surprised by some of the instances where patients come back and they're like, wow, this is great. So that, my spidey sense, is sort of evolving. And I do hope that in the future, we will have some better treatment options for some of these patients. We are actually studying this and have NIDDK funding to do some of this work in about 1,000 patients that have samples. We're looking at their microbiota. We're looking at their symptoms. These were all collected in other NIH trials. And to this answer of, could some of these symptoms come from an alteration in microbes, stay tuned because I hope to have some more information in about three to five years. But for now, this is what we live with, right? The OAB treatment algorithm. There's a question mark because recently, the most recent updated statement from the AUA did talk about the fact that really, we should be moving away from step therapy, where you do step one to step two to step three, and really kind of targeting therapies to patient symptoms. And I totally agree with that. And yet, we live in the world of insurance companies and people who tell us what we can and can't do. And so I'm going to go through some of the treatment algorithm because this is what in practice in real life happens. So typically, when we start, the simplest scenario or simpler scenario is this patient. A 50-year-old woman who comes in with episodic urgency, maybe episodic incontinence happening most once a week, something like that. She's otherwise generally healthy and really you don't uncover anything else. Now for this patient, I will say anecdotally nowadays, different than 20 years ago, this patient is looking at the internet. She is going on TikTok of all things now all of a sudden, before it was just Facebook and Instagram, but she is actually finding health information from other sources before she's necessarily coming to you. Femtech is a big industry, like industry players are all about Femtech these days. And so there's a lot of stuff that's being marketed that you may or may not be privy to or aware of. And I mentioned yesterday, the MCELA chair is really hitting in our area, at least I looked it up, it's called Stay Dry Med Spa. But there's three of them in North Carolina, one in Florida, but like you can go to the med spas, a lot of plastic surgery offices have MCELA chairs now. And so that's being, that's an option. You can get a Groupon for six sessions for $400. Some patients are going with their friends. There are the shorts that you can find online. There are different devices. So there's a lot of stuff that's being marketed to our patients and just be aware of that. This is an article about the best in continence underwear of 2023, which you guys might all be aware of. I think Historically Speaks by Thinks was the first one that I became aware of, but now there's a couple out there. This is an example. These, so Stephanie Molden talked about that CVS aisle yesterday. CVS is investing heavily in femtech, and so you can actually find these at your local CVS on the shelves now. So I just throw that out there for you all to be aware, if you are not already, that many of our patients are finding, they're sort of self-seeking some solutions before they even get to our office. So this pretty simple patient probably is one that we typically would have done, talked about lifestyle, behavioral modification, plus or minus PT, exercises. She may also be doing some of that other stuff that I've just talked about from online. But what about just changing that scenario just a little bit? Now we're like a decade later, 60-year-old woman, and now she's having daily urgency, one or two times per day. And she's already done all the normal things. She's already looked up what she can do and tried a bladder training app at home. And so this particular patient, what are you gonna do? I think most of us would probably talk about starting a medication, right? That's what we have. And so for this patient, you could pick just about any medication that you want to. That being said, as many of us now know, we have to be mindful about some of our medications. So let's just make her a little bit older now. Let's make her 70. Otherwise, same patient. Do we think a little bit more about which medications we're going to pick? I think most of us would say yes, we do. Because many of us now know, we have to think about protecting the brain while you're treating the bladder. And so we want to be cautious about anticholinergic use in particular in our patients who are 65 and older. Much of this comes from a body of evidence that has been collated over time about associations between anticholinergic use, heavy burden of that, and later onset of dementia. Not just the mild cognitive impairment, not necessarily just transient changes when you're on the med, but dementia. And much of this is happening when people are on these drugs for three months or longer. So if I have to do a trial for four weeks because I have to help that insurance company to know that I'm going to move to something else, I'm okay with that. But generally speaking, when you have your patients who are staying on a medication for three months or longer, I am trying to avoid anticholinergics. This is the Ogg's Choosing Wisely. One of their things on their Choosing Wisely campaign is to avoid anticholinergics in women older than 70. And I do think that the effects in cognition probably do vary based on a drug's access to the central nervous system. And a lot of that, you know, Miles kind of talked about this, can be based on drug molecule size. Active transport is also a thing that happens. So some drugs are actively transported out of the CNS in animal data and animal literature. And so essentially, I pretty much am trying to avoid things like oxybutynin and solafenicin when possible. That's where we see some of the market increase in dementia in trials. And if I have to pick an anticholinergic these days because of insurance costs, whatnot, I'm picking usually one of these two. And I say that having gone deep into the dive of the literature. Trospium, because of its structure, we think does not get into the blood-brain barrier. And it also gets actively transported out. Fesuteridine also gets actively transported out. And so again, if I have to pick an anticholinergic, these are the ones I'm going to. Incidentally, fesuteridine has been available on Cost Plus, which is the Mark Cuban online pharmacy. So again, if you're having difficulties with cost, that's one that I've sometimes gone to. Okay, so we have our 70-year-old woman. We're trying to avoid anticholinergics. We probably tried mirabagron or vibagron. You know, maybe had to go to one of those two drugs because of some other insurance or cost-related issue. Now, let's just change the situation a little bit more. 75-year-old woman leaking three times a day. She's already tried two medications. What are you going to do next? How many would say, let's do Botox? Raise your hand. How many would say neuromodulation? Yeah, which one do you do? But ultimately, you all know, it is time to bring out the big guns, right? We got to do, we're going to offer something else. So in our treatment algorithm here, we are left with either or. Some form of chemodenervation or neuromodulation. And when it comes to these, I've stopped calling them third tier because I'm trying to get away from tiering. First tier, second tier, third tier. I just call them advanced therapies with my patients. So, you know, we are not doing well with medications. Let's move on to an advanced therapy. Well, what are they? And so we have these two categories, which are essentially the Botox world and the neuromodulation world. And now the plot thickens when it comes to neuromodulation because we have several types. And we're just going to very briefly run through some of the information here. But I think the trickiest part is like, how do you pick? Which one are you going to pick? So when it comes to Botox, we do have good evidence, level one evidence, multiple randomized controlled trials demonstrating its effectiveness. Women are more likely to be dry with Botox when compared with medications. But obviously we do think about the adverse events. Quoted in the literature, UTI 25%. I think that's become a little bit lower as we've become more cognizant. And I say that only because I think if you have somebody who has recurrent UTIs, we've gotten better about treating that first or suppressing that first. Many of us are doing antibiotic regimens. I know some people think you don't need to. That's an area of controversy. I think the transient urinary retention from the trials is at about 4% for 100 units, 8% for 200 units. So while having to self-cath or catheterizing afterwards is a big fear, I'm usually telling patients, realistically, it's not that big of a, it doesn't happen that often. So Botox is certainly an option. Well, what about different forms of neuromodulation? PTNS, percutaneous tibial nerve stimulation, has been around for a long time. How many of you offer this in your practices? Yeah, good. A lot of people do. I think for patients, logistics is usually the big issue here of having to get back and forth to your office. So you have some who are retired, able to come once a week, great. But you have others who can't. And that is where the implantable versions of this that allow for home therapy may be another sort of attractive solution. I'm gonna give you full transparency. I personally don't do any of those implanted PTNS options, but one of my partners does. And so I'm gonna show you a little bit of the evidence. And some of those are her slides. Cyndia Munson is the partner I'm referring to. So anything with a black title is Cyndi's slide. I'm just gonna give her slide credit. So here's one of them. So these are some of the implanted posterior tibial nerve devices that have been studied. And different ones have different features. Some are above the fascia, some are below the fascia. They have different procedures of how they go in. The one over here that says RENOVA, this isn't working, but the one on the far right for your look is actually the next generation is called REVI. So that's eventually what turned into REVI. But these are different things that have been studied where you put something in as an implanted device and then you go home and you wear a cuff or a bracelet or some sort of method to stimulate with that once you're home. Do those work? I'm gonna show you a little bit of a data slide in just a moment. But obviously, the other thing that we are all pretty familiar with is other forms of implanted neuromodulation. We have two available to us, different forms of sacral nerve stimulation. So, how does sacral nerve stimulation, that implanted device, compare to implantable tibial nerve stimulation? Because I think that's a big question. Which place do you implant something into? And this is some data from a systematic review and meta-analysis that Cindy and her colleagues worked on fairly recently. They went through a lot of structure with this systematic review to try to minimize bias. They put a whole bias rating table out there for the various trials that they were looking at so they could figure out which ones had various amounts of bias. And essentially, this was the slide which I can't really point to here, but when you look at incontinence response and OAB response, which are the top two horizontal bars. And basically, you look at both implanted sacral nerve, which is the top line, and implanted tibial nerve, which is the next line below. You just see a lot of clustering where you see a lot of very similar effects. And when you look at device-related AEs, you see, again, similar proportion of events. So when it comes to different forms of implantable neuromodulation, my guess is that, like anything, we're going to be going with surgeon and patient factors. The thing that you choose to use, get comfortable with. We're probably all going to want to get comfortable with some form of an implantable tibial nerve somewhere maybe 10 years down the road, maybe. We'll see. And many of us are already comfortable with implanted sacral nerve stimulation. There's probably going to be various reasons why you might pick one versus another. I will say anecdotally, if you have somebody with poor vasculature, poor blood flow, puffy legs, don't try to do something implantable down there. My husband's an orthopedic surgeon, and he's like, that place gets terrible blood flow. Why do you want to be there? So all of that being said, I think we are stuck with, how do you choose? And for this, right now, it's probably a bit stylistic and based on patient factors. We do have a little bit of information on how to choose implanted sacral nerve stimulators versus Botox. And for that, we have the Rosetta trial, which was published in JAMA in 2016. So it's almost a decade old now. Ultimately, there were no major differences in efficacy. Holly, you took part in this trial. There were no major differences across the board, which makes us still as surgeons have to think about patient factors, logistic factors, things like that. But I do often consider co-occurring conditions when I'm trying to steer a patient who's like, I don't know which one, to one option versus another. I suspect many of you do the same thing. So let's go back to our 75-year-old patient with leakage three times a day. In your history, you also uncover that she has fecal urgency and some accidental bowel leakage once a week. What are your thoughts there? Who wants to give her Botox? Who wants to do sacral neuromodulation? Yeah, right? It's sort of like an obvious. Let's try to get a two-for-one effect here. How about 75-year-old woman who has recurrent UTIs? Who wants to do Botox? Nobody? Really? Nobody does Botox in a patient with recurrent UTIs? You're liars. Come on. I do. Right? So maybe this patient, and she's really like she might be scarred from having to be in the hospital or something, and she might be saying, I don't want to go there. OK, sure. Let's go down the sacral neuromodulation pathway. Or she might be somebody who is well-controlled, because you got her on a good suppression regimen, and you've rehabbed her microbiome, and she's in a better place. And you might say, well, we still have options of either. So I think this is a little bit of a case-by-case basis, depending on the level of severity of her recurrent UTIs. Because as you know, there's a big spectrum out there. There's recurrent UTIs light, and there's recurrent UTIs heavy with the MDR bugs and all that, where I'm like, yeah, I don't want to go there. Let's go to sacral neuromodulation. So I think this is a little bit of a case-by-case. All right, how about this patient? She has MS, or sub-N Parkinson's, or sub-N prior stroke with no residual deficits, but prior stroke. Who wants to do Botox? Only a few. Who wants to do sacral neuromodulation? OK, a few. We're just getting non-participation now here. This is one where I tend to go more towards the Botox route, to be honest. These are neurogenic patients, essentially. You have options to go straight to your 200-unit dose, which I think is a little bit more effective in some of these patients. So I would say that this is the patient that I might, if we really don't know, I might steer a little bit more towards Botox first for a couple of reasons. First off, sometimes with neurologic conditions, they're going to evolve over time. You do something now, and five years later, their neurologic condition might get worse. And so I don't know that that inner stem is going to be functioning the same way five years down the road, and the patient's going to come back and be like, this doesn't work anymore. And so having been in those situations, I just feel like this is my preferential Botox scenario. Now, how many of you require urodynamics before you do Botox? Raise your hand. Some do. If you look at the data, I don't. For all comers, I don't. But if they're neurologic, neurogenic, I do. So in this patient, I would do urodynamics before I necessarily do Botox, because there have been instances of some of the surprises. And again, I've gotten burned by some of the surprises myself, where you have somebody who maybe gives some subtle voiding dysfunction symptoms, but at a one-time check, maybe you had a normal PVR. Or in my instance, the PVR was done with a bladder scan, which I think was utterly false. And then you Botox that patient, and she really doesn't pee, and then she doesn't recover. And you're like, what's going on? And then you finally do urodynamics, and you're like, oh, she has total detrusor dysfunction. Her detrusor doesn't squeeze. She doesn't actually empty her bladder. So I want to detect those now earlier on, rather than after the fact, having been in that situation. So I will generally think about, for my patients who I am thinking about Botox, I always require a PVR. If I have any spidey sense that my bladder scan PVR may not be accurate, like they say they have some voiding dysfunction symptoms, and the PVR on the bladder scan is 25, I might cath them just to verify. But I want a good estimation of PVR. If the PVR is high, or if they have neurologic conditions, I am doing a urodynamic first before I do the Botox. But otherwise, in this patient, that might be the thing that I would choose first. I realize this is stylistic. Other people are going to do different things. How about this patient? She is 75, leaks three times a day. You did sacral neuromodulation, whichever one you prefer. And she had initial 75% improvement. But now, three years later, she's come back, and she's like, my leakage is back. Anybody have a patient like this in their practice? Yeah, we all do, right? Like, all of us have seen this. What have you done with that patient? I hear some Botox. Do you turn the interstim off, or leave it on? Dual therapy. Yeah, combination, dual therapy, right? Let's start to add things together. So when we have things that have partial effects, partial effect sizes, my general belief, I do this for UTI management all the time when I have little effect sizes. I stack them up. Well, why don't we do that for overactive bladder treatment also? The updated AUA guideline does talk about this. Combination therapies, we're trying to do therapies that are directed for symptom management. So yeah, in this particular patient who had initial improvement, first of all, we're going to try to salvage and tweak and reprogram and do what we can to see if we can optimize the neuromodulation effect, right? But there are going to be some instances where that just doesn't work. We might add back a medication. Maybe that doesn't work. We might add in Botox. I usually keep the InterStim on. I say InterStim because that's the one I usually use, but it could be either. I keep it on in the background. If somebody really tells me, like, I don't think this is working, I'm like, fine, shut it off. Let's shut it off for three months and keep a diary and let's see. And it has been fascinating to see. Sometimes it really truly isn't working, and sometimes it has been. And it's such an illuminating event for the patient when they turn it off and they're like, oh, yeah, maybe it was doing something. So I think you guys are all probably struggling with this. We are all in the same boat here, which is that many times we're trying to explore different versions of combination therapies in these patients. I think that's pretty much all I have. Obviously, Oggs has a really good, I think, a really good patient fact sheet. I use this one probably more than any other fact sheet I use in my office. The backside has the sort of lay of the land. I think that when I looked at it most recently, the way tibial nerve stimulation was described, it still kind of applies to implantable. I'm not sure if this will be kind of modified a little bit in coming years, but I really do like this. And I think patients like seeing the menu. It's very similar to the treatment plans that some people have in their offices. But basically, I kind of circle the stuff on that far right. I'm like, these are your advanced therapy options. We'll talk about this if medications don't work. And I'm sure that many of you do that same strategy. So we have a few minutes left for questions. I'm going to stop there. I think the treatment of overactive bladder has changed dramatically in the last few years because of the newer options as far as sacral neuromodulation and the fact that we have constant current and we have an improvement in efficacy, I think, over time. Not necessarily over a year, but 10, 20, 20 years. So if a patient responds to sacral neuromodulation, you have an option that's going to last for 10 to 20 years without having repeat procedures. And the problem is if you start with Botox, which I think Botox works great, but if you start with Botox, then you have to wait four to six months for the Botox to wear off to try the trial, which is much easier now we do it under local in the office. So I think that I like the idea of doing the trial. The trial, if it works, great. Then you go to something that can last for 10 to 20 years. If it doesn't work, then you can always go to Botox, but you can't go back the other way. So- Yeah, I mean, I think we all stylistically have variations of that approach. I probably only wait three months. If someone really did not have a response to Botox, I don't know that I'd make them wait the full four to six, but I do think you're right about the sort of thinking about the time span of a therapy. So if I have a younger patient, I'm pretty forthcoming about Botox as a repeated therapy. You're thinking one or two injections per year, and I have patients that I've injected eight times or whatever, but I don't know if injection number eight is gonna be as good in terms of its effect as injection number one. I bet you've all had that experience where you're re-injecting and the patient's like, oh, it just didn't work as well as the prior ones. So I do think for somebody where you're thinking about the duration of therapy for long-term, I'm very transparent about that, and some people actually choose based on that. Well, I want something longer duration, so I'm gonna move that direction. I think the bottom line, though, is that at least my approach is basically here are the pluses and minuses of each thing, and let's decide together what fits best with your lifestyle and your goals. I just don't really feel like I have a one-size-fits-all approach in that situation. Let's go. You were quicker with your hand. Well, I have two questions. I'll try to make them quick. The first relates to cognitive function and SNM, and I kind of get these older patients where they're starting to have some decline in their cognitive function, and at the same time, their OAB and or fecal incontinence is getting worse. So they seem to be correlated, and I'm kind of the last guardian before they're gonna end up in assisted living or the nursing home. In other words, if I improve these things, they can stay independent. If I don't, probably their cognitive function deteriorates, and they're gonna end up in assisted living. That's my sense. Do you have any data on whether my use of SNM is helping to slow the decline of their cognitive function? If there's evidence in the literature that that's true or if that's any of the experts' opinions, that's my first question, and the second relates to kind of the old InterStem data said the more core morbidities, the less effective the SNM was, and that seems to be true, and I'm just wondering if there's a line in the sand where you say, no, you're too frail, you have too many core morbidities, and so I'm not gonna take you there. So in terms of whether or not SNM will prevent cognitive decline or mitigate cognitive decline, I'm not aware of any data there. I do think we all frequently see exactly, and that's actually described in the literature that worsening incontinence tends to be a harbinger symptom when somebody is moving into worsening stages of cognition, and we see that frequently in the anticholinergic literature. Actually, it's been one of the criticisms is that sometimes people are getting put on those medications within those five years where they're already declining. So I think that's a tricky scenario. Some of those patients have a hard time managing technology, too, and so I do think that there are some of those patients who they and their families might actually choose Botox instead of SNM because they don't wanna manage a device, but I totally agree with you that that's a scenario where it's tough. Your second question was? Comorbidities, yeah. So that is very true in the literature, that when you get three or more comorbidities, like you have sicker patients, they're not gonna do as well with sacral neuromodulation. Also, with each decade of life. So if you are looking at an 80-year-old versus a 60-year-old, your 60-year-old has a higher chance of success than your 80-year-old. So that is something I probably keep in mind, but I'm not certain that it necessarily totally sways my decision-making. So if somebody's sick enough that I don't wanna take them to the OR, then I'm probably gonna move to Botox anyways, right? But I don't know that I necessarily say, oh, you have diabetes and heart disease and one other comorbidity, so I'm not gonna offer you SNM. I don't practice that way. I'm usually just like, well, we're gonna trial it and see what happens. But I'm also a little bit more skeptical of people who are right around 50, 60% benefit in their trial period. I think those are the patients who, three years later, say it doesn't work. So I probably thought a little bit more that I really prefer to implant the ones who are 75% or greater during their trial period, whereas the 50, 60-ish people, we may talk about whether or not you wanna try Botox first, or we'll put it in, but we might be looking at a dual therapy later. I just read a quick review, and I just wanna get your comment of people that are using Botox with intratrigonal injections for particular irritative symptoms versus leakage. You have any comments on that? Yeah, I do. I would love to know the answer. So I know Allergan was gonna do the trial. We were gonna be a site, and then it all got stopped. I preferentially like to inject. I go just a little bit above the trigone. So I personally don't inject in the trigone itself because I don't wanna be too close to the UOs, but I do think the nerves, when they're coming towards the bladder, those sensory nerves, that heightened sensation area that's right above the trigone, I like to inject that spot personally. So I think there might be something to that, but I don't know the answer. I have a quick question. So going back to the beginning of your talk, which I think is fascinating, but if someone doesn't have a history of recurrent urinary tract infections and they have OAV symptoms, tell me again what your thought process is on treatment. If they don't have a history, well, that's the tricky part. Like that patient, I don't know what to do with yet. I'm hoping in the future, we're gonna have some form of a calculator that helps with their, you know, you check their microbiome and you put in their clinical factors and it spits out a, you have a 60% chance you'll get better with whatever. So that's what we're aiming for five years from now, and I'm working on that, but right now, if they don't have a history of recurrent UTIs, if they basically have other atrophy, like if they're in that perimenopausal, early postmenopausal time, and this is where things have just all of a sudden come up, where I'm like, oh, this is the time where your microbiome might also be changing, that's the patient where I might tell them, listen, I'm getting off my evidence-based high horse for a moment. We're gonna go off book. Other doctors may not do this, but let's just try. Let's try to reset your microbiome and see what happens, and in three months, if nothing happens, we're gonna go back on our typical treatment algorithm. And resetting that microbiome, putting them on vaginal estrogen. Vaginal estrogen, probiotic, the stuff I talked to you about yesterday. So I'm gonna ask the faculty, how many of you guys, and we were talking about this yesterday, will do Botox in asymptomatic bacteria? Because this comes up for me quite a bit, and it's controversial, and so I'm interested to see. You do, you do it. I'm going to repeat for those online that Holly Richter is saying we should have some data on that question from one of the PCORI trials. Yeah. So women 70 years of age and older randomizing to 100 versus 50, and the urine is managed as the provider wishes. Now they're checking the urines and they're sending cultures, but they are collecting data. If it dips positive and they inject that, and they have a culture positive, that data is being collected. And the two people on that trial, they're up in Dartmouth and, oh, what's Ann's last name? A very well-known urologist on it, that was her big question as to get an answer for that. So that's very important to get. I've done it, but I have seen one or two patients then start getting UTIs. So they were symptomatic. I have stylistically, and again, this is not evidence-based per se, but stylistically. So we do a four-day antibiotic regimen with most of our Botox patients. We give them the antibiotics ahead of time. They start the day before, and then they take it for three days after. So that's our typical regimen. For people who have ASB, I'll basically give them a seven-day regimen and say start three days before, and then do a week. But I will tell you, that's controversial, because other people say you don't need to. Yeah, I just reviewed a study on this, actually, so it'll probably be getting published. But there's really not great data for antibiotic prophylaxis. Exactly. That's what I was going to say. And the more I've looked at it, yeah. Yeah. Very interesting, because I do, too, and I never really thought much about it, but they're actually showing you don't necessarily need to, or maybe just one dose the day of. So very interesting. My other question, I was going to just poll the audience. How many people are still doing 20 injections? The standard, when it first started, it was 20 injections. Sometimes. So I was just going to note, because I've changed because of the data that's come out. I'll do five, and it's awesome. And considering I do it in my center awake, that's even better, right? I mean, I do liquid numbing. We have a question in the back, but I agree with you. I really like to fan it out, like I said, just above the trigone. And then if I have extra, I'll throw it a little bit higher. But you had a question? I was just going to say one more thing. If you guys are doing the tibial nerve stimulators, make sure you're getting your reimbursement through your payers, because right now it is not paid, necessarily. It's still a level three code. We have worked on that at NOG's coding committee, and are trying to push for it as much as we can to move forward to a level one code. But you have to actually negotiate that payment with your payer. So if you're doing it and not talking to them, you very well might not get paid. So just careful there. Let's take one quick question from the back, and then we're going to leave everything for the coffee break. It's not a question, but it's a comment. We changed our approach to single site trigonal injections about five, six years ago. We haven't noticed any inferior or significant difference to multi-site detrusor injections. So one, you're doing one injection? One single site, one injection, 100 international units is standard. Which can- Where do you inject? Your one? In the trigone. In the trigone? Yeah.

overactive bladder

advanced treatment

microbiome

neuromodulation

vaginal estrogen

personalized treatment

anticholinergics