Female urinary incontinence the role of the general practitioner

Transcription

1 Acta Obstet Gynecol Scand 2000; 79: Copyright C Acta Obstet Gynecol Scand 2000 Printed in Denmark All rights reserved Acta Obstetricia et Gynecologica Scandinavica ISSN CONFERENCE REPORT Female urinary incontinence the role of the general practitioner ARNFINN SEIM 1 AND STEINAR HUNSKAAR 2 From the 1 Department of Community Medicine and General Practice, Norwegian University of Science and Technology, Trondheim, and the 2 Section for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway Acta Obstet Gynecol Scand 2000; 79: C Acta Obstet Gynecol Scand 2000 Subject. Urinary incontinence is a frequent disorder among adult females, but very few of the incontinent women have consulted a doctor. Discussion. This paper reviews and discusses the possible roles of the general practitioner in the diagnostic and therapeutic work with women with urinary incontinence. Some characteristics of general practice and the selection process from primary care to the specialist level are described. The selection process (gatekeeper function) of patients from community to hospitals may introduce bias into research and hamper the generalization of hospital-based research back to general practice. Recommendations and guidelines for diagnosis or therapy developed at secondary or tertiary care levels may be inappropriate at the primary care level, with a significantly different clinical picture of this condition. Results. Several studies show that most women seeking help in general practice can be satisfactorily treated at this level of care with fairly simple treatments, and that treatment is effective also in the long term. Some women with urinary incontinence need to be referred primarily to a specialist, or later if the response to treatment is disappointing. Recommendations. Based on literature studies and the authors own experiences from clinical work and research, recommendations are presented for a basic evaluation and treatment of women with urinary incontinence who seek help in general practice. Key words: general practice; referral; urinary incontinence; women Submitted 3 January, 2000 Accepted 27 June, 2000 This paper reviews and discusses the possible roles of the general practitioner (GP) in the diagnostic and therapeutic work with women with urinary incontinence (UI). As non-surgical methods have been shown to be effective in the treatment of this condition, management in primary care has become more important, and the GP may have own responsibility for diagnostic workup, treatment, and follow-up without the involvement of specialists in the field. Obviously there are differences in the competence of specialists and GPs in the handling of Abbreviations: GP: general practitioner; UI: urinary incontinence. most diseases, but like other conditions UI should be diagnosed and treated at a level of care where this can be done satisfactorily. Costs and capacity at the different levels of health care should also be considered. Some characteristics of general practice The main diagnostic tools in general practice are the history and the clinical examination. Even if many general practitioners use advanced technical equipment in their diagnostic work and in treatment of patients, general practice is still characterized by a low technological level compared with health care at the specialist level or in hospital. An-

2 Urinary incontinence in general practice 1047 other important point is that general practice takes place in a field where most diseases or conditions, at least those which are serious, are rare events. However, making a diagnosis may be rather easy after history taking and clinical examination, in many cases the history alone is enough. For most symptoms or disorders studies of patient behavior have shown that only a few people consult a doctor with their problem (1). Consultation behavior is influenced by several factors, including how bothersome the complaint may be to the patient. Knowledge about consultation behavior among patients with specific symptoms or disorders is an important part of the basis for diagnostic work in general practice. General practitioners meet a self-referred population of people with symptoms, illnesses and diseases. Even if general practice represents an essential part of the health care system, it relies on a competent and accessible secondary and tertiary service that provides diagnostic and management sources to selected patients when appropriate (2). This selection process (gatekeeper function) of patients from community to hospitals may introduce bias into research and hamper the generalization of hospital-based research back to general practice (3). Concerning female UI, empirical data from populations of patients with this condition have supported the existence of selection bias (4). Thus, recommendations and guidelines for diagnosis or therapy developed at secondary or tertiary care levels may be inappropriate at the primary care level, with a significantly different clinical picture of this condition. Consultation behavior Despite the fact that most women have had their incontinence symptoms for years (5, 6), most studies show that only a minority of women have consulted a doctor for their symptoms (7 10). In an epidemiological survey in a Norwegian community 29.7% of women aged 20 or over reported urinary incontinence, 20% of these had consulted a doctor. Increasing age and duration, and urge/ mixed type of incontinence were determinative factors for doctor consultation (10). Burgio et al. found urinary incontinence on a regular basis in 31% among middle-aged women, and 26% of these had sought help (7). Lagace et al. found that 28% of the incontinent women (prevalence 33%) had consulted (8). In the UK Jolleys asked 343 women with urinary incontinence why they had not consulted their doctor (11). Inappropriate leakage of urine was perceived by many women as a normal phenomenon or not so serious. Other reasons can be low expectation of benefit from treatment, or that women have found it difficult to talk about the problem (5, 12 15). Results from treatment in general practice Several studies on treatment of female urinary incontinence in general practice have been performed. In a prospective study from Norway 105 women seeking help for urinary incontinence in general practice were given treatment and followed for 12 months (16). Treatment options were pelvic floor exercises, electrostimulation, estrogen, anticholinergic drugs, bladder training, and protective pads. After 12 months follow-up 69 per cent of the women were cured or much better. Mean leakage per 24 h measured by pad test was reduced from 28 g at start to 13 g after 12 months. Number of pads or sanitary towels were reduced from 1.6 to 0.6 per day. Altogether 17 patients (16%) were referred to specialist. Lagro-Janssen et al. performed a controlled trial among 110 women who had reported urinary incontinence to their general practitioner (6). The women were randomly assigned to a treatment or control group. Treatment options were pelvic floor exercises in the case of stress incontinence, and bladder training in the case of urge incontinence. After three months 60% of the patients were either dry or only mildly incontinent compared with four per cent in the control group, and 74% felt they had improved or were cured (three per cent in the control group). After 12 months this successful outcome had further improved slightly. Jolleys found a cure rate of similar magnitude in another controlled trial (21). In this trial, stress incontinence was treated with pelvic floor exercises, urge incontinence was treated with habit retraining and regulation of fluid intake, and in addition, anticholinergics and estrogen therapy were used if indicated. In a randomized controlled trial from general practice in Norway 87 women aged years with urinary incontinence were treated with pelvic floor exercises, electrical stimulation and local estrogen. Treatment reduced severity and impact of leakage significantly. After six months, 61% of the patients were cured or improved compared with nine per cent in the control group (17). After 12 months, 56% were still cured or improved. A few studies of the long term effectiveness of treatment of female urinary incontinence in primary care have been performed. One study performed by O Brien used intervention by nurse, and included pelvic floor exercises and bladder training. The results showed that 68% of the patients reported cure or improvement after three months compared with five per cent in controls (18). At four year follow up 69% of the patients had either

3 1048 A. Seim and S. Hunskaar maintained improvement or improved further (19). Five years follow up of women with UI treated in general practice in Norway revealed that altogether 53% were still cured or much better compared to before treatment (20). These studies from general practice all show that female urinary incontinence can be satisfactorily treated in general practice with rather simple treatment options. Basic evaluation in general practice Based on literature studies and on our own experiences from clinical work and research, we have worked out recommendations for a basic evaluation of women with UI who seek help in general practice. The history The history presented by the incontinent woman in most cases constitutes the basis for making a diagnosis. Among women consulting for UI at the primary care level the pretest likelihoods (prevalence) of the different types of UI are approximately 50% stress incontinence, 10% urge incontinence, and 40% mixed incontinence. The history should include: questions about micturition habits and incontinence duration, precipitating factors, frequency, amount of leakage, how much bothered mapping of the relevant general medical history, including medications assessment of mobility, living environment, and social factors a mental status evaluation a frequency/volume chart is a helpful supplement to the history in many patients. Clinical examination gynecological examination (vaginal or rectovaginal): Look for cystocele and uterine prolapse, signs of vaginal atrophy, evaluate the pelvic floor muscles, exclude pelvic tumor a test of perianal sensibility or other neurological examinations if indicated palpation of the abdomen a stress provocation test (observation of urine loss while coughing with a full bladder) can be done if there is doubt about precipitating factors measurement of residual urine should be done if the patient has symptoms suggestive of bladder outlet obstruction laboratory investigations: Urinalysis, including glucosuria, hematuria, pyuria, and bacteriuria. Diagnosis According to the history and clinical examination the patients in most cases can be classified as having stress, urge or mixed incontinence, and whether they are premenopausal or postmenopausal. Patients who cannot be classified in these groups should be referred to a specialist. Referrals Referral to specialist should be considered at all stages of management in primary care. if the doctor is uncertain concerning diagnosis or treatment if the patient has an associated disorder which obviously needs evaluation by a specialist, e.g. trauma, tumor, neurological disease, fistula if the doctor suspects the incontinence to be secondary to other disease if the incontinence could not be satisfactorily classified if response to treatment is disappointing after 6 months. Treatment in general practice Based on a diagnosis with an acceptable level of accuracy, most women with urinary incontinence should be offered conservative, non-surgical treatment in general practice. Some authors have reported that this can be done successfully at a minimal level of care, and with a limited consumption of resources (6, 16, 21, 22). Possible therapeutic options in general practice are information and lifestyle advice only, no specific therapeutic action pelvic floor exercises bladder training drugs electrical stimulation pads and other supportive devices. A combination of different treatment options is often recommended. In the following a short review of the scientific documentation of the effect of each treatment option is presented. Information and lifestyle advice only, no specific therapeutic action Some women are only in need for information about their symptoms and the natural history of UI, and feel reassured with this (22). Most individuals with slight symptoms and no or slight bother do not need any follow up and should rather be asked to come back to their GP if the symp-

4 Urinary incontinence in general practice 1049 toms change or aggravate. Information should include lifestyle advices (encourage physical activity, weight reduction if overweight, smoking cessation), normal voiding pattern, complicating factors, and medications that impair lower urinary tract function. Pelvic floor exercises Many reports have been published showing that pelvic floor exercises are rather effective both in the short and the long term (21, 23 26). However, many women do not know how to contract their pelvic floor muscles. Instructions and follow up by health care providers are therefore recommended rather than giving the patient a brief verbal explanation or an education pamphlet (27). The GP should cooperate with a physiotherapist who is interested in this field to ensure that the patients get an optimal treatment. Pelvic floor exercises are mainly used as a treatment for stress incontinence, but have been shown to be effective also in urge incontinence (28). Bladder training Bladder training or scheduled voiding regimens are often recommended for treatment of bladder instability in patients with urge incontinence, and controlled studies have shown significant effect (29, 30). The general practitioner should give both oral and written instructions. Patients are requested to void only when scheduled, at progressively increasing intervals (31). A urinary diary should be kept as an aid to treatment and as a motivating factor. Drugs Estrogen, alpha-adrenergic agonists, and anticholinergics are drugs which are recommended in the treatment of female urinary incontinence (32). Concerning all these drugs both prescription and follow up can be done by the general practitioner. Most guidelines and management programs for female urinary incontinence in primary care recommend use of estrogen in postmenopausal women, although reports are divergent concerning the effect (21, 31, 33 36). Phenylpropanolamine is an alpha-adrenergic agonist which has been shown to be effective in the treatment of stress incontinence, especially in the combination with estrogen (37, 38). Anticholinergic drugs are recommended in urge incontinence (31, 34, 39). Emepronium bromide has been used for many years, even if only a few studies have demonstrated any significant effect of this drug. Tolterodine is a new anticholinergic drug which has shown promising results in treatment of urge incontinence and overactive bladder (40 42). It is at least as effective as other anticholinergics, but has significantly less side effects. Tricyclic antidepressants, such as imipramine or doxepine, are also recommended for the treatment of urge incontinence. These drugs have anticholinergic effect, but are also alpha-stimulators (43). Electrical stimulation Electrical stimulation of the pelvic floor has for some years been used as therapy both for stress and urge incontinence, mostly in the hands of specialists (44, 45). However, this therapy is also suitable for use in primary care. Home managed electrical stimulation devices have been used in Norway for many years. Experiences from management programs in general practice have shown that electrical stimulation can be handled by general practitioners without problems (16, 17). Urge incontinence is usually treated by short-term maximal stimulation, while stress incontinence is also treated by long-term stimulation of lower intensity. Pads and other supportive devices Pads and other absorbent products are widely used by women with urinary incontinence. There is a big variety of products from small perineal shields to big bed pads. Such absorbent products are recommended during evaluation, as an adjunct to other therapy, and for long-term care of patients with chronic, intractable urinary incontinence. For many patients absorbent products are a useful and rational way to manage the problem. Many different devices have been developed for patients with urinary incontinence. Examples include urethral plugs and different pelvic organ support devices. Some uncontrolled studies have shown that these devices can be effective, and represent an alternative in motivated patients who have tried other nonsurgical treatment without success (46 50). Recommendations for treatment in general practice According to the different diagnosed groups we have the following recommendations for treatment of female UI in general practice, as shown in Table I. Conclusions Urinary incontinence is a frequent disorder among adult females, but very few of the incontinent women have consulted a doctor.

5 1050 A. Seim and S. Hunskaar Table I. Recommendations for treatment of female urinary incontinence in general practice Stress incontinence Urge incontinence Mixed incontinence Pelvic floor exercises Estriol if postmenopausal Protective pads Anticholinergic drugs or electrostimulation (or both) Estriol if postmenopausal Bladder training Protective pads Pelvic floor exercises Anticholinergic drugs or electrostimulation (or both) Estriol if postmenopausal Bladder training Protective pads Referral should be considered if response to treatment is disappointing after 6 months, or if any of the above mentioned reasons for referral is the case. Different studies show that most women seeking help in general practice can be satisfactorily treated at this level of care with fairly simple treatments, and that treatment is effective also in the long term. Some women with UI need to be referred primarily to a specialist, or later if the response to treatment is disappointing. To ensure an adequate evaluation and treatment of women with UI in general practice, and a correct assessment of which patients should be referred, education of general practitioners is necessary. Moving from a simple gatekeeper and referring function, the GPs now may involve themselves in the continuing management and follow-up of women with UI, but must rely on a competent and accessible secondary and tertiary service that provide diagnostic and management resources to selected patients when appropriate. Recommendations and guidelines for diagnosis or therapy should be developed, based on mutual understanding and knowledge. When developing guidelines and recommendations for general practice it is urgent that they take into account the varying prevalence and variation in clinical picture between general practice and hospitals. They must also emphasize use of tests or equipment that are relevant to general practice. 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