How to Prioritize & Treat Urinary Incontinence in Primary Care: Part 2
In Part 1 of A Conversation with Dr. Wanda Filer, we shed light on just how highly prevalent urinary incontinence is in your patient population. With 62% of women reporting urinary incontinence, and 1 in 2 reporting the most prevalent form of urinary incontinence, stress urinary incontinence (SUI)1,2, Dr. Filer emphasizes the importance of screening for UI in primary care all while acknowledging the logistical barriers present in doing so.
However, with long-term impacts of urinary incontinence including increased rate of severe depression3, significantly higher rate of urinary tract infections4, and increased risk of falling5 to name just a few, screening for UI enables early intervention, treatment, and overall improvement in long-term quality of life. And improving their patients’ quality of life is something primary care physicians are excellent at doing.
However, according to Dr. Filer, the responsibility of the primary care physician extends beyond just screening
“It’s up to you to recognize the burden that patients are carrying, often silently, and be proactive. Stay abreast of new developments in UI treatments and those that fit well into primary care practice. Follow up on UI as you do other medical conditions. UI is NOT normal aging.”
Dr. Shravya Kovela, Director of Clinical Education at Pelvital, has significant experience as a practicing pelvic floor physical therapist. Dr. Kovela shares that many of her patients often expressed the wish that they had been offered treatment options for their UI when it first surfaced.
“Women don’t want to live with bladder leaks, but they don’t always know that effective treatment options exist. By the time they make it to me in pelvic floor physical therapy, they’ve usually been dismissed or discouraged countless times within the healthcare system or have felt such significant shame or embarrassment that it took them years to even bring up their incontinence with a healthcare provider. More providers need to be playing an active role in women’s health, not just specialty providers, so that women receive timely care.”
When women do speak with their primary care provider about their UI symptoms, at-home Kegels are the most common recommendation. The American College of Physicians (ACP) recommends pelvic floor muscle training as a first-line treatment for women with SUI6. But in practice…is this the best we can do?
“Pelvic floor muscle training is the gold standard for SUI in the research,” Dr. Kovela explains, “but the topic is more nuanced than that. Many women are not performing Kegels correctly, either rendering them ineffective or possibly even worsening overactive or tight pelvic floors, causing more harm than benefit.”
Kegels, the exercise of contracting the pelvic floor muscles, are not as easy as they might seem. 30-50% of women do Kegels incorrectly even with written instructions7,8. Additionally, staying compliant is a challenge and just like any other exercise, if the muscle group is not trained appropriately, with the right form, or at the right frequency, the results are subpar.
So, the answer may not always be recommending either at-home Kegels or surgery to your patients. Other evidence-backed conservative treatment options are available, including pelvic floor physical therapy and at-home medical devices.
“If you have access to pelvic floor physical therapy, that is a fantastic option to get your patients specialized care that addresses the entire body and their specific goals.” Dr. Kovela explains, “For those that may not have access to a pelvic PT, consider virtual care or other conservative treatments that are well-researched and something your patient can stick with – because that is important.”
According to Dr. Filer, referral to pelvic floor physical therapy varies based on geography, practice patterns, and availability of a pelvic floor physical therapist.
“Many patients cannot afford the out-of-pocket expense and will agree to only 1-2 visits. They decline physical therapy referrals for a multitude of conditions due to the recurring expense.”
She goes on to say, “Devices to treat pelvic floor dysfunction are not always in a primary care physician’s repertoire but with clinician education and insurance coverage, devices will be more commonly prescribed, as they are convenient for the patient and increase access to care.”
Ultimately, the right option for each patient is patient dependent. Including patients in the plan of care is essential to determining what treatment option will give them the greatest success.
The opportunity to meaningfully shift the paradigm of untreated UI all starts with regular screening. This allows for open dialogue around a historically stigmatized topic that affects the majority of women and enables proactive intervention via targeted evidence-backed treatment recommendations. The long-term impact of UI is undeniable; screening and treating UI can change lives.
Primary care providers are instrumental in introducing options that their patients may not have considered
Flyte by Pelvital is a first-of-its-kind urinary incontinence treatment, using the clinical modality of transvaginal mechanotherapy to treat stress urinary incontinence in women, in a standard treatment protocol of 5 minutes a day for 6 weeks9. It’s simple, intuitive to use, and backed by two peer-reviewed published clinical trials demonstrating treatment effect and durability of treatment outcomes comparable to surgery in an accessible, first-line, in-home treatment9,10,11,12,13. Pelvital provides both clinicians and their patients with support staffed by Doctors of Physical Therapy specialized in pelvic health.
“Flyte offers an opportunity for collaboration between women’s health providers.” Dr. Kovela emphasizes, “Primary care providers can feel empowered to play a role in urinary incontinence treatment by discussing conservative treatment options with their patients, knowing they have options ranging from specialized care to an at-home, evidence-backed treatment supported by pelvic health physical therapists.”
That said, we know it can be challenging to implement new options into daily practice. So, we asked the expert – as past AAFP president, Dr. Filer knows the ins and outs of primary care practice.
What are Dr. Filer's top three practical, actionable, tips for primary care providers to prioritize women's health screening in their practice?
Know your patient demographics and determine what screenings are most appropriate for them. If you see a lot of female patients or older patients, consider screening for UI in the same way you already do for other health concerns.
Empower your team to administer screening questionnaires, identify positive screens and bring them to your attention. Use technology such as tablets, EHR tools, and automated patient registration questionnaires to ease the burden on your teams.
Periodically assess your workflow and the team impact of screenings. What screening results are you seeing across the patient population? Is your team managing the workload well? Are positive screens being captured and action taken (closing the loop)?”
Ready to begin screening and treating your female patients for urinary incontinence? We can help. Contact us at info@flytetherapy.com for free screening tools, patient education handouts, and clinical support.
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. 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.
4. 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
5. 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.
6. Qaseem, A., Dallas, P., Forciea, M. A., Starkey, M., Denberg, T. D., & Shekelle, P. (2014). Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine, 161(6), 429. https://doi.org/10.7326/m13-2410
7. Bo K. Pelvic floor muscle strength and response to pelvic floor muscle training for stress urinary incontinence. Neurourol Urodyn. 2003;22(7):654–658. doi: 10.1002/nau.10153.
8. Pelvic floor muscles. (2024, May 27). Continence Foundation of Australia. https://www.continence.org.au/about-continence/continence-health/pelvic-floor
9. Nakib N, Sutherland S, Hallman K. Novel Pelvic Floor Treatment with Mechanotherapy: Final Clinical Trial Results in Women with Stress Urinary Incontinence (SUI). Neurourology and Urodynamics. Published online 2020. https://www.ics.org/2020/abstract/26.
10. Nilsen I, Rebolledo G, Acharya G, Leivseth G. Mechanical oscillations superimposed on the pelvic floor muscles during Kegel exercises reduce urine leakage in women suffering from stress urinary incontinence: A prospective cohort study with a 2-year follow up. Acta Obstet Gynecol Scand. 2018 Oct;97(10):1185-1191. doi: 10.1111/aogs.13412. Epub 2018 Aug 2. PMID: 29923602.
11. Pros and Cons of Bladder Suspension Surgery - HRF. (2015, June 30). HRF. https://healthresearchfunding.org/pros-and-cons-of-bladder-suspension-surgery/
12. Rogo-Gupta L, Baxter ZC, Le NB, Raz S, Rodríguez LV. Long-term durability of the distal urethral polypropylene sling for the treatment of stress urinary incontinence: minimum 11-year followup. J Urol. 2012 Nov;188(5):1822-7. doi: 10.1016/j.juro.2012.07.033. Epub 2012 Sep 19. PMID: 22999687.
13. Yao J, Tse V. Twenty-Five Years of the Midurethral Sling: Lessons Learned. Int Neurourol J. 2022 Jun;26(2):102-110. doi: 10.5213/inj.2142086.043. Epub 2022 Jun 30. PMID: 35793988; PMCID: PMC9260325.
