If We Don't Ask, They Won't Tell

Screening for Urinary and Fecal Incontinence by Primary Care Providers

Heidi W. Brown, MD, MAS; Wen Guan, BA; Nicholas B. Schmuhl, PhD; Paul D. Smith, MD; William E. Whitehead, PhD; Rebecca G. Rogers, MD

Disclosures

J Am Board Fam Med. 2018;31(5):774-782. 

In This Article

Abstract and Introduction

Abstract

Background: More than half of older adults experience urinary (UI) or fecal incontinence (FI), but the majority have never discussed symptoms with health care providers. Little is known about primary care providers' (PCPs') screening for UI and FI.

Methods: We conducted a cross-sectional electronic survey of PCPs within a Midwest academic institution to ascertain and compare PCPs' beliefs, attitudes, and behaviors regarding screening and treatment for UI and FI; determine factors associated with screening for FI; and identify potential barriers to and facilitators of FI screening and treatment.

Results: Among 154 PCPs, the screening rate for UI (75%) was more than double that for FI (35%; P < .001). PCPs believed that both UI and FI screening were important but felt better informed to treat UI (P < .001). Screening for FI was associated with UI screening (OR, 11.27; 95% CI, 4.9–26.0; P < .001); feeling informed to treat FI (OR, 10.21; 95% CI, 1.2–90.0; P = .01); screening verbally (OR, 3.9; 95% CI, 1.9–8.0; P < .001); perceiving screening as important (OR, 3.7; 95% CI, 1.8–7.4; P < .001); using the term, "accidental bowel leakage" (OR, 2.9; 95% CI, 1.2–6.7; P = .02) or "bowel control issues" (OR, 2.2; 95% CI, 1.1–4.5; P = .03); and being a resident (OR, 0.37; 95% CI, 0.16–0.82; P = .02). PCPs reported high interest in patient and provider educational materials about UI and FI.

Conclusions: Most PCPs screen for UI but not FI. High reported interest in educational materials, coupled with high reported rates of perceived importance of screening for UI and FI, suggests that PCPs welcome informative interventions to streamline diagnosis and treatment.

Introduction

More than half of independent adults aged 65 years and older suffer from urinary (UI) and/or fecal incontinence (FI) in the United States (US), and the prevalence among institutionalized adults is even higher.[1] UI is associated with increased risk of falls, caregiver burden, and hospitalization,[2–4] and both UI and FI are associated with increased caregiver burden and nursing home placement.[5] Incontinence is associated with negative impact on quality of life and mental health, and this impact is more pronounced in those with combined UI and FI, also termed dual incontinence.[6–9] While many clinicians are aware of the high prevalence of UI, few are aware that FI affects 8% of US adults (both male and female) monthly, or that the prevalence rises to 15% among older adults living independently and even higher among institutionalized adults.[1,10] Further, it is predicted that the prevalence of pelvic floor disorders, including UI and FI, will increase by almost 60% in the next 30 years.[11]

The last 2 decades have seen tremendous advances in treatment for both UI and FI. Current available treatment options for UI in the United States include behavioral modification and bladder training, medication, pelvic floor muscle exercises with or without biofeedback, vaginal pessaries, chemodenervation, neuromodulation, and surgery.[12] Similar options are available to treat FI. For FI, the American College of Gastroenterology recommends treating FI starting with education, dietary modifications, skin care, and pharmacologic agents to modify stool delivery and consistency, followed by pelvic floor muscle rehabilitation with biofeedback; these interventions will improve or resolve symptoms in 50% to 80% of patients.[13,14] For patients who do not respond to these interventions, additional options include the use of a vaginal pessary (Eclipse vaginal bowel control system) or rectal insert, several minimally invasive procedures to the anal canal, neuromodulation, and more invasive surgical options, which improve symptoms in approximately 85% of patients.[13,14]

Despite the range of effective treatment options available, most people with incontinence do not seek care, and those who do often delay seeking treatment. While as many as 50% of women with UI seek care,[15] estimated rates of care seeking for FI are lower and range from 10% to 30% with delays from onset of symptoms of 2 years on average for women and 3 years for men.[15–18] Screening by primary care providers (PCPs) has the potential to shorten this delay and improve access to effective treatments, but limited data exist about physician screening for these conditions.[19,20] We were able to identify only 1 existing study published in English that queried physicians about screening for FI, and that study included only 11 physicians.[20]

Given the prevalence and significant negative impact of UI and FI, availability of effective treatment options, and the limited rates of spontaneous care seeking for these conditions, we sought to quantify screening rates, attitudes, beliefs, and behaviors for these conditions among PCPs in our health care system. We particularly emphasized FI in our analyses given lower rates of care seeking by patients and the paucity of information about screening for FI in the existing literature.

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