Are we following the guidelines?

There are a lot of rules when you practice medicine.  We want everything to be evidence-based.  I want to be able to tell you exactly how well a surgery will work for you.  I want you to know the risk of all complications and be able to make the best choice for you.  But there are also guidelines about how we practice.  These guidelines help me determine how to establish the diagnosis, what tests to order, what the treatment options are, and which treatments to try first.  All of this helps me to determine how to treat someone best.  Guidelines help establish best practices.

Guidelines

There are guidelines that dictate how to best treat all medical conditions, even incontinence.  There are many organizations that have created these guidelines, including the American Urologic Association, the American College of Obstetrics & Gynecology, The American Urogynecologic Society, and the International Urogynecological Association.  These guidelines, while slightly different, generally agree.  So how often are these guidelines followed?

A recent study titled “Adherence to professional society guidelines among women with stress or mixed urinary incontinence” tried to answer this question.  This study was done by looking at commercial and medicare medical claims and not by interviewing the women or looking at their charts.  The researchers determined who had urinary incontinence based on diagnosis codes and then looked at how these women were evaluated and treated.  They then compared this to guideline recommendations.  This is a great way to look at large groups of women.  It does assume that all of the coding was done correctly, and medical coding is very complex.  So, what did they learn, and how often are the guidelines followed?

Most women get the proper evaluation for their incontinence.

The evaluation for bladder leakage should include a discussion of your symptoms and medical history, a physical exam, a urinalysis (making sure you don’t have anything abnormal in your urine like blood), and an evaluation to make sure you empty your bladder well.  This means a pretty standard doctor’s visit, including a pelvic exam, a pee test, and a quick ultrasound to make sure that you have emptied your bladder.  Most women do not need additional testing like a cystoscopy (looking in your bladder) or urodynamics (a test that looks for leaking and the pressures in your bladder and urethra).

There are definitely some women who need additional testing.

We always do a cystoscopy on women with blood in their urine.  I will often do urodynamics on women with previous bladder surgeries, complicated medical histories, or neurological diseases (like multiple sclerosis).  But more testing is not always better.  We should only do additional testing if it is needed for the diagnosis or will change the planned treatment.  Otherwise, it is a waste of time and resources (ok, I really mean money here, testing can be expensive).  Testing is also often uncomfortable because it involves placing something in the urethra (like a scope or catheter).  There can be risks like urinary tract infections or pain with peeing afterward.  You need to make sure the additional information that a test provides is worth having the test.  For women with routine bladder leaking, this is often not the case.

For example, when I am evaluating someone with stress urinary incontinence for a bladder sling, the guidelines recommend three parts to the evaluation (besides a routine history and physical)

1. A urinalysis
2. An evaluation to make sure the woman is emptying well (I do an ultrasound)
3. Visualizing the leaking to make sure the diagnosis is correct

I have two options for visualizing the leaking: urodynamics or a standing cough test.  The urodynamics is a formal test involving catheters, measuring the pressure in the bladder and determining what causes leaking.  A standing cough is exactly what it sounds like- I have someone stand and cough and look to see if they leak.  For most routine women, the standing cough test gives me all the information that I need.  It is important to understand why tests are recommended.  And to ask questions if you don’t understand.

Most women don’t do behavioral training or pelvic floor muscle strengthening for incontinence first.

All of the incontinence guidelines are very clear- the first-line treatment for bladder leaking should be behavioral training or pelvic floor muscle strengthening.  These treatments are effective and have virtually no complications.  But this study found that most women do not start here.  This is a shame because these techniques help more women than not, and there is little risk associated with strengthening or changing behaviors.  The worst thing that happens is it does not help as much as you want it to, and you’ve wasted a little time.  Many women aren’t sure if strengthening will help them.  A little discussion is usually all it takes to convince them to give it a try.

This study may have underestimated how often women do pelvic floor strengthening because it did not consider pelvic floor strengthening that you can do on your own- It only consider those options associated with medical billing like physical therapy.  They didn’t consider vaginal weight, peri-trainers, online or local classes.  There are also many areas where there are shortages of physical therapists, which isn’t a realistic treatment option.  And the women in the study may have already tried physical therapy before (this wouldn’t be captured in the study) and did not want to try it again.

Lots of women with stress urinary incontinence are treated with medication.

This is a problem.  There isn’t a medication in the US that has been approved for the treatment of stress urinary incontinence.  In general, medications don’t work for stress urinary incontinence.  Medications do work for overactive bladder and urgency urinary incontinence.  This study showed that many women with stress incontinence are started on a medication which won’t work.  This is frustrating for the women and shows a lack of understanding of how the bladder works.  So, if someone tries to give you a medication to stop your leaking with coughing and exercise, please decline.  It won’t work.  There are some medications that have been approved in other countries but not in the US.

Closing thoughts

I’m not a huge fan of this article.  I actually found it to be a little depressing.  There is so much work that needs to be done for women with leaking.  We need to make sure that everyone who leaks:

• Knows the treatment options that will work for their type of leaking
• Train all providers to differentiate between types of leaking and offer appropriate treatments or referrals
• Ensure access to pelvic floor strengthening to all women with leaking

When women are incorrectly treated, they stop looking for help.  They live with the leaking, and this has a negative effect on their quality of life.  Sometimes we do need to try a few things until we figure out how to best fix the leaking.  I think that it always makes sense to start with the treatments with the lowest risks (like strengthening and behavior changes).  There’s nothing better than when a little weight loss or exercise regimen cures the leaking.  And this is what the guidelines support.  For now, there is much work, training, and education that needs to be done.  So we can all be living our best lives without fear of leaking.

Pan, L. Neurourology & Urodynamics 2021.