Primary care diagnostic and treatment pathways in Dutch women with urinary incontinence

Abstract

Objective To investigate how GPs manage women with urinary incontinence (UI) in the Netherlands and to assess whether this is in line with the relevant Dutch GP guideline. Because UI has been an underreported and undertreated problem for decades despite appropriate guidelines being created for general practitioners (GPs). Design Retrospective cohort study. Setting Routine primary care data for 2017 in the Netherlands. Subjects We included the primary care records of women aged 18–75 years with at least one contact registered for UI, and then extracted information about baseline characteristics, diagnosis, treatment, and referral to pelvic physiotherapy or secondary care. Results In total, 374 records were included for women aged 50.3 ± 15.1 years. GPs diagnosed 31.0%, 15.2%, and 15.0% women with stress, urgency, or mixed UI, respectively; no diagnosis of type was recorded in 40.4% of women. Urinalysis was the most frequently used diagnostic test (42.5%). Education was the most common treatment, offered by 17.9% of GPs; however, no treatment or referral was reported in 15.8% of cases. As many as 28.7% and 21.7% of women were referred to pelvic physiotherapy and secondary care, respectively. Conclusion Female UI is most probably not managed in line with the relevant Dutch GP guideline. It is also notable that Dutch GPs often fail to report the type of UI, to use available diagnostic approaches, and to provide appropriate education. Moreover, GPs referred to specialists too often, especially for the management of urgency UI. Key points Urinary incontinence (UI) has been an underreported and undertreated problem for decades. Despite various guidelines, UI often lies outside the GPs comfort zone. •According to this study: general practitioners do not treat urinary incontinence according to guidelines. •The type of incontinence is frequently not reported and diagnostic approaches are not fully used. •We believe that increased awareness will help improve treatment and avoidable suffering.

Management of urinary incontinence in females by primary care providers: a systematic review

“…Studies were published between 1990 and 2022: nine of the 31 studies were published before or in 2000, 11 between 2001 and 2010, and 11 between 2011 and 2022. Included studies assessed the practice patterns of PCPs in the United States (nine studies), the Netherlands (five), the UK (five), Norway (three), Canada (three), Australia (one), Denmark (one), France (one), Germany (one), and one pan‐European study in France, Germany, Spain and UK (Table 1 [10,27–57]).…”

“…From the recommended assessments highlighted in Box 1, PCPs adherence was variable: pelvic examination (23–76%; eight studies) [27–29,31–33,45,46,57], abdominal examination (0–87%; three studies) [29,33,45], pelvic floor muscle evaluation (9–36%; two studies) [49,57], bladder diary (0–92%; nine studies) [27,28,31,32,40,45,46,48,49,57], and urine analysis (40–97%; nine studies) [27–29,31,32,45,46,48,51,57]; see Table S6 for detailed reporting. PCPs also performed testing deemed unnecessary in guidelines for the initial assessment of UI or for uncomplicated cases of UI, including routine imaging, and urodynamics, which were respectively practiced (0–24%; five studies) [27,28,32,33,49,51] and (26–71%; three studies) [31,37,49].…”

“…From the recommended treatments highlighted in Box 1, the treatment offered or recommended by PCPs was highly variable, including pelvic floor muscle training (5–82%; nine studies) [27,28,32,34,38,39,46,48,49,57], bladder training (2–53%; eight studies) [27,28,32,34,38,39,46,48,57], pelvic floor muscle exercise and/or bladder training (0–55%; two studies) [41,45], lifestyle modification (6–52%; three studies) [38,43,48], weight management (1–71%; two studies) [49,57] and fluid restriction (6%; one study) [57]. See Table S7 for a detailed reporting on all treatment strategies reported.…”

“…Figure 4 shows PCP adherence to guideline recommendations for the treatment of UI. In terms of other treatment and advice, PCPs reported providing general education (18–53%; two studies) [27,28,57], recommending electrical stimulation (0–50%; four studies) [32,39,48,49], containment products (12–66%; eight studies) [27,28,34,38,41,45,47,48,57], treatment of comorbidities (1–13%; two studies) [48,57], management of constipation (6%; one study) [48], pessary (0–70%; three studies) [38,41,57], surgery (7–34%; four studies) [27,28,34,38,39,41], smoking cessation (33%; one study) [49], advising that UI is normal for their age (18%; one study) [43], to wait and see (16–19%; two studies) [43,45], or no treatment (2–8%; two studies) [43,54]. From the qualitative studies, some PCPs would fit pessaries themselves instead of referring to a different healthcare provider [44] and only a few would provide patients with educational pamphlets on UI [35].…”

“…When studies reported on non‐specific pharmacotherapy for the management of females with UI, PCPs prescribed medication (12–66%; five studies) [29,34,38,39,47]. Prescriptions included anticholinergics (2–46%; nine studies) [27,28,32,41,45,46,48,49,51,57], mirabegron (1%; one study) [57], duloxetine (4%; two studies) [48,49], sympathomimetics (11%; two studies) [27,28,32] and oestrogen (2–77%; seven studies) [27,28,32,39,41,45,48,49]. Anticholinergics were prescribed mainly for UUI (8–46%) and MUI (5–34%) rather than SUI (1–13%) (four studies) [27,28,41,45,57], and for SUI, they were noted to be prescribed for severe cases, although severity was not defined.…”