How to Prioritize & Treat Urinary Incontinence in Primary Care: Part 1

The data paints a clear picture: female urinary incontinence is prevalent, has significant long-term negative impacts on health and quality of life, and often goes untreated and undiscussed.

What is UI and just how prevalent is it?

Let’s start with prevalence. 62% of women in the US report urinary incontinence (UI) and 1 in 2 women suffers from stress or mixed urinary incontinence¹. This fact alone makes it likely that as a healthcare provider, a substantial subset of your patient population has urinary incontinence whether or not they are reporting it to you.

Of the different types of urinary incontinence, stress urinary incontinence (SUI) is the most prevalent². SUI is most often seen in postpartum, athletic, and peri- and post-menopausal women^3,4,5,6. According to the North American Menopause Society (NAMS), aging and vaginal childbirth are the two primary risk factors for urinary incontinence.

As many as 4 in 10 women experience onset of UI during pregnancy⁷. Postpartum, 1 in 3 women report UI symptoms within 3 months of childbirth⁸ and 76.4% of women who reported UI symptoms at 3 months postpartum, continue to report UI 12 years later⁹.

Many of us associate urinary incontinence for women with pregnancy and childbirth, due to changes in the pelvic floor muscles, however UI is a problem for women in their non-reproductive years too. 68% of women in their 50’s, 72% of women in their 60’s, and 83% of women over age 70 report UI¹.

So, if UI is this prevalent, the question becomes - why are we not hearing about it from more patients?

Incontinence has historically been normalized for women, partially due to women believing that leaks must be accepted as part of motherhood or aging, and partially due to the societal and familial demands many women feel, leading many to place their needs low on their priority list.

The result is that although prevalence of UI is high, the health seeking behavior is low, with only 13-55% of women with UI symptoms seeking medical care¹⁰. In a study from the University of Michigan, only one-third of women who suffered from incontinence spoke to their doctor about it. Most women didn’t speak up. Many women stated they weren’t comfortable discussing their incontinence or that since their doctor didn’t ask, they didn’t tell¹¹.

But is it the sole responsibility of the patient to bring up their symptoms to their doctor? A 2016 study found that only 3% of conversations on incontinence were initiated by their healthcare providers¹².

With UI this prevalent in women, better screening procedures for UI are critical to providing effective treatment

We turned to Dr. Wanda Filer for her expertise on the topic. With almost 40 years of direct patient care and leadership roles including past Pennsylvania Physician General, NBC Affiliate, and President of the American Academy of Family Physicians (AAFP), Dr. Filer has a unique perspective on what treating the individual and the community looks like. She currently serves on the Board of Directors for Pelvital.

Dr. Filer’s comments highlight an important point – upstream providers such as family medicine, primary care, and OB/GYN are often the first touchpoint for women with health concerns. How can physicians be proactive about screening for urinary incontinence – and should they?

Dr. Filer weighs in. “Family Physicians have a lot on their plates these days and there are literally not enough hours in the day to do all the recommended screenings¹³. Having a brief validated screening tool such as the ICIQ UI-SF (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) increases the likelihood that a clinician will screen for UI. USPSTF recommendation is another reinforcement for screening, based on available data. No such recommendation exists from USPSTF yet, but the Women’s Preventative Services Initiative (WPSI) does recommend annual female UI screening¹⁴.”

The WPSI recommends: “screening women for urinary incontinence annually. Screening should assess whether women experience urinary incontinence and whether it impacts their activities and quality of life. If indicated, facilitating further evaluation and treatment is recommended.”¹⁴

Incorporating validated quality of life questionnaires into routine paperwork such as intake forms takes the burden off both the patient and the provider to initiate the conversation. If the questionnaire reveals UI is a problem, the provider can then use precious minutes of the visit to discuss the subject with their patient.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form (ICIQ-UI SF) Sample from www.iciq.net. [SK1] 

After all, those 10-15 minutes of the patient’s visit are precious. Primary care providers care for complex patients, navigating layers such as multiple diagnoses, numerous medications, and socioeconomic challenges. As a result, screening and prevention must sometimes take a back seat.

However, time isn't the only barrier to screening UI

“Payment or lack therein is another barrier,” Dr. Filer elaborates, “Longer visits are often not appropriately compensated and therefore discouraged. Quality measures are working to prioritize certain health topics, but they do not add time to the clock. Urinary incontinence is now a HEDIS measure¹⁵ for older adults so it is possible that some prioritization shuffling will occur. And in 2024, a documented treatment plan for women with UI became a MIPS High Priority measure.”

Beyond lack of time and challenges with compensation, changes in the primary care workforce have altered the long-term patient-clinician relationships many people once had.

Dr. Filer notes, “Patients may not see the same clinician; valuable minutes are used to reacquaint the clinician with the patient’s current situation and past medical history, with urinary incontinence never even making it into the conversation.”

Ultimately, if urinary incontinence is not being brought up in conversation, it has no chance in being addressed. More urgent concerns or concerns that are voiced take over in the time crunch. Dr. Filer says that this, along with the barriers mentioned above, makes it challenging to address UI. “When time is tight, it can be tough to take on the task of teaching Kegel exercises, discussing bladder diaries, and all of the other things that we are taught to utilize.”

Addressing UI in a brief 10–15-minute visit may feel like a daunting task. Only the most important concerns can be discussed during that time.

So now the question shifts to - is screening for urinary incontinence important?

The answer is a resounding yes.

UI causes significant negative impacts on a woman’s physical, mental, and social health.

Following a diagnosis of stroke, dementia, depression, Parkinson’s disease, or congestive heart failure, women with UI are twice as likely to be admitted to a nursing facility than those who do not¹⁹

Beyond interfering with daily activities of living, UI is associated with an increased risk of falls and more than 1 in 2 falls are associated with UI²⁰. According to the CDC, unintentional falls are the leading cause of injury and deaths from injury among older adults greater than 65 years of age²¹.

UI is linked to a significantly higher rate of recurrent urinary tract infections, in large part due to the use of pads.²²

UI has cascading ramifications on intimate relationships. Almost 1 in 4 women experience a type of UI during intercourse²³. A fear of leaking or coital incontinence means that women limit their sexual activity due to UI symptoms; one survey shows that 64.7% of respondents do just that²⁴.

Possibly most alarmingly, incontinence is linked to more than double the rate of severe depression ²⁵. In one study, 42.9% of women with SUI and mixed urinary incontinence (MUI) were prescribed antidepressants when compared to 28.6% women without UI²⁶.

With statistics like these, it is evident that screening for UI enables early intervention, treatment, and overall reduction in severe long-term impacts on major aspects of health – something that primary care providers are excellent at prioritizing.

Read Part 2 of A Conversation with Dr. Wanda Filer to see discussion regarding the standard treatment for SUI, why it may not always be the best option, and Dr. Filer’s suggestions on how primary care physicians can introduce effective, conservative treatment options to their patients without adding administrative burden.

 

 

References

1. Patel UJ, Godecker AL, Giles DL, Brown HW. Updated Prevalence of Urinary Incontinence in Women: 2015-2018 National Population-Based Survey Data. Female Pelvic Med Reconstr Surg. 2022 Apr 1;28(4):181-187. doi: 10.1097/SPV.0000000000001127. PMID: 35030139.

 

2. Minassian VA, Stewart WF, Wood GC. Urinary incontinence in women: variation in prevalence estimates and risk factors. Obstet Gynecol. 2008 Feb;111(2 Pt 1):324-31. doi: 10.1097/01.AOG.0000267220.48987.17. PMID: 18238969.

 

3. Sangsawang B, Sangsawang N. Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. Int Urogynecol J. 2013 Jun;24(6):901-12. doi: 10.1007/s00192-013-2061-7. Epub 2013 Feb 23. PMID: 23436035; PMCID: PMC3671107.

4. Hagovska M, Švihra J, Buková A, Dračková D, Švihrová V. Prevalence and risk of sport types to stress urinary incontinence in sportswomen: A cross-sectional study. Neurourol Urodyn. 2018 Aug;37(6):1957-1964. doi: 10.1002/nau.23538. Epub 2018 Feb 21. PMID: 29464810.

5. Teixeira RV, Colla C, Sbruzzi G, Mallmann A, Paiva LL. Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis. Int Urogynecol J. 2018 Dec;29(12):1717-1725. doi: 10.1007/s00192-018-3651-1. Epub 2018 Apr 13. PMID: 29654349.

6.  Kwon JK, Kim JH, Choi H, Chang IH, Park BR, Kwon SS, Lee ES, Choi GY, Lee JJ, Lee IS. Voiding characteristics and related hormonal changes in peri-menopausal and post-menopausal women: a preliminary study. Maturitas. 2014 Nov;79(3):311-5. doi: 10.1016/j.maturitas.2014.07.011. Epub 2014 Jul 28. PMID: 25150899.

 

7. Sangsawang, B., & Sangsawang, N. (2013). Stress Urinary Incontinence in Pregnant   Women: A Review of Prevalence, Pathophysiology, and Treatment. International Urogynecology Journal; 24(6): 901–912.

8.  Gao, Jiejun MD; Liu, Xinru PhD∗; Zuo, Yan MD; Li, Xiaocui MD. Risk factors of postpartum stress urinary incontinence in primiparas: What should we care. Medicine 100(20):p e25796, May 21, 2021. | DOI: 10.1097/MD.0000000000025796 

9. MacArthur, C., Wilson, D., Herbison, P., Lancashire, R. J., Hagen, S., Toozs-Hobson, P., Dean, N., &  Glazener, C. (2016). Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12-year longitudinal cohort study. BJOG, 1022(9). https://doi.org/10.1111/1471-0528.13395

10. Swenson, Carolyn; Solway, Erica; Singer, Dianne, et. al. (2018-11-01); National Poll on Healthy Aging November 2018, http://hdl.handle.net/2027.42/146144"

11. Perera J, Kirthinanda DS, Wijeratne S, Wickramarachchi TK. Descriptive cross sectional study on prevalence, perceptions, predisposing factors and health seeking behaviour of women with stress urinary incontinence. BMC Womens Health. 2014 Jul 2;14:78. doi: 10.1186/1472-6874-14-78. PMID: 24985068; PMCID: PMC4094634.

12. Duralde ER, Walter LC, Van Den Eeden SK, Nakagawa S, Subak LL, Brown JS, Thom DH, Huang AJ. Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women. Am J Obstet Gynecol. 2016 Feb;214(2):266.e1-266.e9. doi: 10.1016/j.ajog.2015.08.072. Epub 2015 Sep 5. PMID: 26348382; PMCID: PMC4830485. 

13.Porter, J., Boyd, C., Skandari, M. R., & Laiteerapong, N. (2023). Revisiting the TimeNeeded to Provide Adult Primary Care. Journal of General Internal Medicine, 1, 147-155. https://doi.org/10.1007/s11606-022-07707-x

14. Clinical Recommendations. (2024). Women's Preventive Services Initiative.

15.  Management of urinary incontinence in older adults (MUI). (n.d.). National Committee for Quality Assurance. Retrieved August 26, 2024, from https://www.ncqa.org/hedis/measures/management-of-urinary-incontinence-in-older-adults/

16.  Brown, W. J., & Miller, Y. D. (2001). Too wet to exercise? Leaking urine as a barrier to physical activity in women. Journal of Science and Medicine in Sport, 4(4), 373–378. https://doi.org/10.1016/s1440-2440(01)80046-3 

17. Hong, A. R., & Kim, S. W. (2018). Effects of Resistance Exercise on Bone Health. Endocrinology and Metabolism, 33(4), 435. https://doi.org/10.3803/enm.2018.33.4.435

18.  Mayo Clinic. (2023, August 26). 7 Great Reasons Why Exercise Matters. Mayo Clinic; Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/exercise/art-20048389

19.  Thom DH, Haan MN, Van Den Eeden SK. Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age Ageing. 1997 Sep;26(5):367-74. doi: 10.1093/ageing/26.5.367. PMID: 9351481.

20.  Moon S, Chung HS, Kim YJ, Kim SJ, Kwon O, Lee YG, Yu JM, Cho ST. The impact of urinary incontinence on falls: A systematic review and meta-analysis. PLoS One. 2021 May 19;16(5):e0251711. doi: 10.1371/journal.pone.0251711. PMID: 34010311; PMCID: PMC8133449.

21. Moreland, B., Kakara, R., & Henry, A. (2020). Trends in Nonfatal Falls and Fall-Related Injuries Among Adults Aged >/= 65 Years - United States, 2012-2018 (pp. 875–881). https://www.cdc.gov/mmwr/volumes/69/wr/mm6927a5.htm#:~:text=In%202018%2C%2027.5%25%20of%20adults,to%202018%2C%20the%20percentages%20decreased.

22. Ragnhild Omli, Liv Heidi Skotnes, Ulla Romild, August Bakke, Arnstein Mykletun, Esther Kuhry, Pad per day usage, urinary incontinence and urinary tract infections in nursing home residents, Age and Ageing, Volume 39, Issue 5, September 2010, Pages 549–554, https://doi.org/10.1093/ageing/afq082 

23.  Hilton P. (1988). Urinary incontinence during sexual intercourse: a common, but rarely volunteered, symptom. Br J Obstet Gynaecol; 95(4): 377-81. Doi: 10.1111/j.1471-0528.1988.tb06609.x.

24.  Burzyński B, Kwiatkowska K, Sołtysiak-Gibała Z, Bryniarski P, Przymuszała P, Wlaźlak E, Rzymski P. Impact of stress urinary incontinence on female sexual activity. Eur Rev Med Pharmacol Sci. 2021 Jan;25(2):643-653. doi: 10.26355/eurrev_202101_24622. PMID: 33577017.

25. Cheng S, Lin D, Hu T, Cao L, Liao H, Mou X, Zhang Q, Liu J, Wu T. Association of urinary incontinence and depression or anxiety: a meta-analysis. J Int Med Res. 2020 Jun;48(6):300060520931348. doi: 10.1177/0300060520931348. PMID: 32552169; PMCID: PMC7303787.

26.  Datar M, Pan LC, McKinney JL, Goss TF, Pulliam SJ. Healthcare Resource Use and Cost Burden of Urinary Incontinence to United States Payers. NeurourolUrodyn. 2022;41:1553‐1562. doi:10.1002/nau.24989