WASHINGTON, DC — Even women with health insurance and access to care cite barriers to treatment for urinary incontinence, and on the list is physician attitudes, a qualitative focus-group study has found.

Fear of treatment and lack of knowledge were the top 2 problems named in the group sessions. These were followed by provider barriers and a belief that incontinence is a normal part of aging.

The study was conducted by Jennifer Lee, MD, assistant professor of OB/GYN at the University of California, Irvine, and colleagues. The study participants came from the university and from Kaiser Permanente Orange County.

"Even in this insured and educated study group, fear of treatment and lack of knowledge were the most frequently reported barriers," Dr. Lee said during her presentation here at the American Urogynecologic Society (AUGS) and International Urogynecological Association 2014 Scientific Meeting.

Less than 50% of affected women seek treatment, but among those who seek and receive treatment, an improvement in continence of about 80% can be achieved, Dr. Lee noted.

The message to physicians is to screen patients and ask if they have incontinence.

"The message to physicians is to screen patients and ask if they have incontinence," she told Medscape Medical News. "And if they're bothered by it, offer treatment and follow-up."

Hesitancy to seek care for urinary incontinence is a longstanding problem, said Charles Nager, MD, president of AUGS and director of the urogynecology and reconstructive pelvic surgery division at the University of California, San Diego, who was not involved in the study.

Direct-to-consumer advertising of drugs for overactive bladder has improved the situation in recent years, he told Medscape Medical News, but when women seek care, physicians aren't always helpful.

"There are physicians who would just prefer to ignore it. They may refer, or they just feel there are other issues they're more comfortable taking care of," Dr. Nager explained. "It tends to be put in the background."

Dr. Lee and colleagues conducted 4 focus-group sessions; 2 involved 9 women who received treatment for urinary incontinence and 2 involved 11 women with moderate to severe urinary incontinence who had not received treatment.

The groups were led by a neutral moderator, and recorded transcripts were analyzed for themes. By the end of the second session, no new themes were being raised.

All of the women were actively insured, mean age was 51 years, 47% were white, 21% were Hispanic, 21% were Asian, and 89% had at least a college education.

Eight barriers to treatment were identified during the focus-group sessions:

  • Normative thinking (urinary incontinence is a normal part of aging, childbearing, or hereditary)

  • Other priority health issues

  • Fear of treatment, including adverse effects of medication and surgery

  • Avoidance/denial ("if I ignore it, it will go away")

  • Communication issues, including embarrassment and hesitancy to mention the problem, particularly if the visit is under time constraints

  • Provider barriers, including not asking about urinary incontinence, dismissing the patient's concerns, or providing misinformation

  • Limitations to access, including HMO hassles, need for referrals, and need for multiple appointments

  • Lack of knowledge about treatment options

Fear of treatment was cited as a barrier by 25% of the untreated patients and 27% of the treated patients. Lack of knowledge was cited by 19% of both groups.

Provider barrier, cited by 12% of the untreated patients and 15% of the treated patients, was tied with normative thinking for third place, cited by 12% of the untreated patients and 16% of the treated patients.

Communication issues came in next, cited by 9% and 12%, respectively.

Some of the women reported that physicians told them that urinary incontinence is a normal part of aging or minimized the problem, Dr. Lee told Medscape Medical News. Several reported never being told that there is a subspecialty — urogynecology — that specifically treats the problem.

There are continence questions on the Medicare wellness visit form, but Dr. Lee noted that because urinary incontinence affects younger women as well, it might be a good idea to screen all women older than 35 years who are done with childbearing.

She recommended the AUGS Voices for PFD Web site as a good resource for patients with urinary incontinence.

Nearly all OB/GYN residency training programs now have rotations in pelvic floor disorders, a trend that has evolved over the past 15 years. "We now have enough subspecialists at the academic institutions to train them," Dr. Nager told Medscape Medical News.

Therefore, "the message to primary care physicians is if it's a bother to the patient, either address it or send her to someone who wants to address it," he said.

Even as women are becoming more vocal about urinary incontinence thanks to TV commercials, a related problem, fecal incontinence, remains in the shadows, Dr. Nager noted.

The public needs to be educated that fecal incontinence is a common disorder, and that "there are management strategies and treatment strategies for it," he said.

Dr. Lee and Dr. Nager have disclosed no relevant financial relationships.

American Urogynecologic Society (AUGS) and International Urogynecological Association (IUGA) 2014 Scientific Meeting: Poster OP116. Presented July 26, 2014.


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