Referral to physiotherapy intervention for women with urinary incontinence: Unravelling the potential https://innovativepublication.com/journal-article-details/JSIP/article/8844/volume/262/issue/692

Abstract

Purpose and Relevance: Urinary incontinence is a common but under reported health condition, especially among women across the world. Data from various studies among Indian women suggest prevalence between 19% and 46%. International consultation on Incontinence (2018) recommends physiotherapy interventions as one of the first line of management. Data from an 800 bed tertiary care medical college hospital suggest limited utilisation of physiotherapy services for incontinence (one referral/month). Multiple barriers exist and needs a unified health systems approach to improve access to care. The present study, using hospital outpatient data, aimed to determine the potential for referrals to physiotherapy for management of urinary incontinence. Participants: Women above the age of 18 years and visiting any of the OPDs of the hospital were considered eligible to be included in the analysis. Materials and Methods: Using a retrospective design, the study analysed hospital outpatient statistics for a three-month period. After due administrative permission, details of adult women visiting the OPDs were obtained from the hospital IT department and categorised as per all department; high potential department (Urology & OBG); and Physiotherapy. Using national prevalence studies, potential burden of urinary incontinence among the women visiting the OPDs was estimated and a projection for potential for referral was made. Results: During the three-month period, a total of 26546, 5371 and 271 adult women (36±21 years) visited OPDs of all departments, high potential departments and physiotherapy department respectively. If there existed a clinical care pathway to screen for urinary incontinence among all adult women visiting the hospital; even at a conservative estimate of 25% prevalence and screening of 50% women, about 5309, 1074 and 54 women from all departments, high potential departments and physiotherapy department respectively could have been identified to have had incontinence. Conclusion: There is an extensive gap between potential for referrals and current practice. Creating awareness among the key stake holders is recommended. Implications: There is a strong need for developing and implementing appropriate clinical care pathways to improve access to physiotherapy services for incontinence. Introduction Urinary Incontinence (UI) as defined by International Continence Society (ICS) is 'the complaint of any involuntary loss of urine'. 1 Bladder problems affect more than two hundred million people worldwide according to the World Health Organisation. 2 UI is a very debilitating condition, affecting quality of life of millions of women worldwide. The estimated worldwide prevalence of urinary incontinence among men varies from 11% to 21%, while in women UI affects 25% to 45% with prevalence peaking around midlife years of 50 to 54 years. 3 Literature from various Indian studies suggests prevalence of urinary incontinence between 19% to 46%. 4-7 The prevalence of incontinence increases with age and decreases functional independence. The most common types of urinary incontinence among women are stress urinary incontinence, urge urinary incontinence, and mixed urinary incontinence. Common factors responsible for stress and urge urinary incontinence are weak pelvic floor muscles, increased pressure on the abdominal region during sneezing, coughing and overactive bladder with uncontrollable urge. Mixed incontinence results when there is loss of urine associated with both situations, i.e. it is preceded by efforts and symptoms of

Full text

Original Research Article
Journal of Society of Indian Physiotherapists, February, 2019;3(1):15-19 15
Referral to physiotherapy intervention for women with urinary incontinence: Unravelling
the potential
Vinita Soni1, Diana Rodrigues2, Sundar Kumar Veluswamy3,*
1Post Graduate Student, 2Lecturer, 3Assistant Professor, Dept. of Physiotherapy, M.S. Ramaiah Medical College, Bangalore, Karnataka,
India
*Corresponding Author: Sundar Kumar Veluswamy
Email: sundark94@gmail.com
Abstract
Purpose and Relevance: Urinary incontinence is a common but under reported health condition, especially among women across the
world. Data from various studies among Indian women suggest prevalence between 19% and 46%. International consultation on
Incontinence (2018) recommends physiotherapy interventions as one of the first line of management. Data from an 800 bed tertiary care
medical college hospital suggest limited utilisation of physiotherapy services for incontinence (one referral/month). Multiple barriers exist
and needs a unified health systems approach to improve access to care. The present study, using hospital outpatient data, aimed to
determine the potential for referrals to physiotherapy for management of urinary incontinence.
Participants: Women above the age of 18 years and visiting any of the OPDs of the hospital were considered eligible to be included in the
analysis.
Materials and Methods: Using a retrospective design, the study analysed hospital out-patient statistics for a three- month period. After
due administrative permission, details of adult women visiting the OPDs were obtained from the hospital IT department and categorised as
per all department; high potential department (Urology & OBG); and Physiotherapy. Using national prevalence studies, potential burden of
urinary incontinence among the women visiting the OPDs was estimated and a projection for potential for referral was made.
Results: During the three-month period, a total of 26546, 5371 and 271 adult women (36±21 years) visited OPDs of all departments, high
potential departments and physiotherapy department respectively. If there existed a clinical care pathway to screen for urinary incontinence
among all adult women visiting the hospital; even at a conservative estimate of 25% prevalence and screening of 50% women, about 5309,
1074 and 54 women from all departments, high potential departments and physiotherapy department respectively could have been
identified to have had incontinence.
Conclusion: There is an extensive gap between potential for referrals and current practice. Creating awareness among the key stake holders
is recommended.
Implications: There is a strong need for developing and implementing appropriate clinical care pathways to improve access to
physiotherapy services for incontinence.
Keywords: Clinical care Pathways, Urinary incontinence, Pelvic floor muscle training, Healthcare access, Barriers.
Introduction
Urinary Incontinence (UI) as defined by International
Continence Society (ICS) is ‘the complaint of any
involuntary loss of urine’.1 Bladder problems affect more
than two hundred million people worldwide according to the
World Health Organisation.2 UI is a very debilitating
condition, affecting quality of life of millions of women
worldwide. The estimated worldwide prevalence of urinary
incontinence among men varies from 11% to 21%, while in
women UI affects 25% to 45% with prevalence peaking
around midlife years of 50 to 54 years.3 Literature from
various Indian studies suggests prevalence of urinary
incontinence between 19% to 46%.4-7 The prevalence of
incontinence increases with age and decreases functional
independence.
The most common types of urinary incontinence among
women are stress urinary incontinence, urge urinary
incontinence, and mixed urinary incontinence. Common
factors responsible for stress and urge urinary incontinence
are weak pelvic floor muscles, increased pressure on the
abdominal region during sneezing, coughing and overactive
bladder with uncontrollable urge. Mixed incontinence
results when there is loss of urine associated with both
situations, i.e. it is preceded by efforts and symptoms of
urgency.8 The type of incontinence (stress or urge),
frequency and the urine lost in a each episode has a negative
impact on health related and global quality of life. It also
influences a woman’s social and sexual life. Triggers and
barriers for help-seeking behaviour among women differ
depending on the severity of UI.
Management of urinary incontinence includes wide
variety of treatments which consists of conservative
management (such as physiotherapy, lifestyle interventions,
behavioural training, and anti-incontinence devices),
pharmaceutical interventions and surgery. Physiotherapy
and lifestyle interventions are considered to be the most
effective first line of management of urinary incontinence in
women. Recent international consultation on incontinence
and Cochrane reviews have recommended pelvic floor
muscle training as an effective first-line of conservative
management for women with urinary incontinence.9,10
Pelvic floor muscle training involves graded program to
increase maximal muscle strength and endurance. Despite
the evidence, data from the physiotherapy department of an
800 bed tertiary care medical college hospital indicates sub-
optimal referrals to physiotherapy for the management of UI
(one referral/month).
The condition is usually under reported as many women

Vinita Soni et al. Referrals to physiotherapy interventions for women with urinary incontinence….
Journal of Society of Indian Physiotherapists, February, 2019;3(1):15-19 16
hesitate to seek help or report symptoms to medical
practitioners due to the embarrassing and culturally sensitive
nature of this condition.11 Appropriate clinical care
pathways that encourage self-reporting of urinary
incontinence by women, effective screening, immediate
intervention and regular follow up are known to reduce the
burden of this condition from society.12,13
It is evident from the literature across the globe that
there are multiple barriers which exist for women reporting
this problem to the health practitioner, most common being
the low help seeking behaviour.14 Most women only report
when they become apprehensive or when the incontinence
hinders their activities of daily living. When evaluating
adult or elderly women, health care practitioners screen for
a variety of conditions, including hypertension, diabetes
mellitus, upper and lower respiratory problems,
osteoarthritis, heart conditions and any neurological
condition. In contrast, urinary incontinence which is
traditionally perceived as a sensitive and embarrassing issue
remains untouched. Despite the higher risk of incontinence
post pregnancy, parity and aging; screening for UI is rarely
undertaken by healthcare professionals, thereby missing out
opportunities for identification of the problem and referring
women for appropriate management. The burden of urinary
incontinence among women and success of conservative
treatment options justify routine screening, individualised
assessment, and referral for treatment by health care
professionals.
Our experience of low referrals for physiotherapy for
the management of UI is not commensurate with the higher
burden of incontinence among women as reported in the
literature. This study, using outpatient data from a tertiary
care hospital, was therefore undertaken to determine the
potential for referrals to physiotherapy for management of
UI among women.
Materials and Methods
This study adopted a health systems research model to
understand the potential for referrals and was conducted
using outpatient data from a tertiary care medical college
hospital. After due administrative permission, number of
new individuals visiting any of the 33 outpatient
departments in the month of May, June and July 2018 were
extracted from the IT department. After applying necessary
filters, all the men, women below age of 18 and individual
visiting Department of accident & emergency,
anaesthesiology & psychiatry were excluded.
Confirming to standards of ethical conduct and privacy
of the patients, the data from IT department was restricted to
age, gender and department for which the individuals
registered. All identifying details such as name, contact
number and registration number were not retrieved.
National literature on UI prevalence studies was
reviewed to determine the variability in the burden of the
problem across categories of women (community dwelling
women, post-partum women, post-menopausal women,
elderly etc). Since most of the women visiting the hospital
are vulnerable to various health problems and more likely to
have urinary incontinence, from a reported prevalence
ranging from 19%-46% across categories, within the context
of hospital based samples, we used a conservative estimate
of 25% prevalence. Considering the busy schedule and
overcrowded outpatient departments, we assumed it would
not be possible to screen every woman for urinary
incontinence and created a model to determine potential for
referrals using the following two assumptions:
1. In the hospital setting, UI is prevalent among 25% of
women visiting various outpatient departments
2. During routine examination, it is feasible to screen 50%
of women visiting any given department.
Using this model, we estimated the potential for
referrals to physiotherapy from three sources: all
departments, OBG & GYN and urology, and physiotherapy
department (internal reference). Department of OBG &
GYN and urology was categorised as the high potential
departments. Projection for potential for referrals from these
sources was analysed. The procedure is schematically
represented in Fig. 1.
Results and Analysis
There were a total of 67739 new OPD registrations in
the three-month period. After applying all the necessary
filters, we obtained 26546 new registrations of adult women
visiting various outpatient departments of the hospital (Fig.
2). During the three-month period, a total of 26546, 5371
and 271 adult women (36±21 years) visited OPDs of all
departments, high potential departments and physiotherapy
department respectively.
If there existed a clinical care pathway to screen half of
the women for urinary incontinence among all adult women
visiting the hospital, even at a conservative estimate of 25%
prevalence, our analysis indicates that the number of women
identified with incontinence and thereby potentially referred
to physiotherapy would have been significantly high. (Table
1).
Table 1: The number of women identified with incontinence and were potential referrals to physiotherapy
Departments
All departments
Obg & Gyn and Urology
Physiotherapy
Total number of new registrations
26546
5371
271
New women potentially screened for UI*
13273
2685
135
Potential referrals**
5309
1074
54
* If there existed a clinical pathway to screen women and assuming 50% of women were screened.
**Estimated using a conservative prevalence of Urinary incontinence of 25% among the 50% women screened for UI

Vinita Soni et al. Referrals to physiotherapy interventions for women with urinary incontinence….
Journal of Society of Indian Physiotherapists, February, 2019;3(1):15-19 17
Fig. 1: Flow diagram of the process of calculation of potential for referrals
Fig. 2: Number of new registration of adult women during the three months study period
Our analysis and comparison with current practice
indicated that there is a huge gap between the current
referral pattern (one referral /month) and the potential for
referrals.
Discussion
The increased burden of urinary incontinence and
availability of effective treatment options mandates an
appropriate clinical care pathway to screen women for
urinary incontinence. During the three-month period,
women referred to physiotherapy for urinary incontinence
were just three which is less than 1% of the total women in
all outpatient departments. If there existed a clinical care
pathway, our current analysis indicates that in comparison to
current referral patterns, the referrals could potentially
increase by over 300 and 20 times from high potential
departments and physiotherapy department respectively.
Inadequate referral has been identified as a critical
factor contributing towards inequitable care. An in-depth
analysis is required to understand the attitude of the health
care professional towards continence awareness and
promotion and barriers to good quality service. Establishing
good quality service in terms of screening women for
urinary incontinence emphasises health professionals to
recognise the problem and implement a more rapid and
appropriate patient referral pathways. Screening, assessment
of women in high potential department and continence
promotion are identified as important steps for a good
quality service and improving health care delivery system.
Urinary incontinence is highly prevalent condition among
women which responds to conservative treatment and
justifies a routine screening.
A few organisations have attempted to address this

Vinita Soni et al. Referrals to physiotherapy interventions for women with urinary incontinence….
Journal of Society of Indian Physiotherapists, February, 2019;3(1):15-19 18
concern of low referral patterns and proposed effective
models. Chartered society of physiotherapy conducted a
project to evaluate patient self-referral to women’s health
physiotherapy pilot sites.15 The aim of the project was to
evaluate the impact of introducing patient self- referral,
increased access for incontinence management services
patients, effectiveness of the pelvic floor muscle training
provided and the clinical outcomes of the care provided.
They concluded patient self-referral as an additional route of
access to effective treatment and showed both patient
benefits and service benefits in terms of empowerment in
patients to refer themselves and providing easier access to
services and saved time. It was also shown to promote
equality of access of various services.
A tertiary public health hospital in Australia studied the
referrals pathways and identified facilitators and barriers for
women receiving physiotherapy management.16 A pilot
gynaecology physiotherapy assessment service was
designed as an initiative to improve the clinical care
pathway for women referred to the gynaecology Department
with symptoms of urinary incontinence. This model of care
was introduced with a aim to facilitate more timely and easy
access to appropriate care in the tertiary healthcare system.
This kind of model provides an advanced scope for the
physiotherapist, acting as a first point practitioner for
women who can respond positively to conservative
management and avoid lengthy wait times in gynaecology
department.
NHS, Wales has a documented guidelines for referring
patients to Physiotherapy for the treatment of pelvic floor
dysfunctions.17 They have documented out a model of good
and optimal level practice to help health care professionals
achieve more responsive, equitable and effective continence
services to benefit patients. These kind of documents assist
healthcare professionals in making appropriate referrals of
women with urinary incontinence for physiotherapy
management.
One out every three women will experience urinary
incontinence at some point in her life. The data from this
study suggest limited utilisation of physiotherapy services
for incontinence. There is a need to develop a unified health
systems approach to improve access to care.
Conclusion
There is an extensive gap between potential for referrals
and current practice. Creating awareness about the potential
of referrals for women with urinary incontinence among the
key stake holders is required. Introduction to specific
clinical care pathways are recommended to improve
physiotherapy services for urinary incontinence and raise
standards of health care delivery system.
Acknowledgement
The authors acknowledge Prof. Savita Ravindra, Head
of Physiotherapy Department for her constant support, Dr.
Narendranath V, Chief Administrator, and Ms. Sarla,
Assistant Hospital Administrator, Ramaiah Medical College
Hospital for their support in accessing hospital outpatient
data.
Declaration
This study won M.G. Mokashi Award for the best
platform presentation in the 4th Annual conference of
Society of Indian Physiotherapist, New Delhi 2019.
Author Contributions
SKV conceived the idea, all authors contributed to the
development of the idea, VS and SKV collected data and
performed the analysis. VS wrote the first draft and all
authors contributed to editing the manuscript and approved
the final version.
Conflict of Interest: None.
References
1. Haylen B, de Ridder D, Freeman R, Swift S, Berghmans B,
Lee J et al. An international urogynecological association
(IUGA)/international continence society (ICS) joint report on
the terminology for female pelvic floor dysfunction. Neurourol
Urodyn 2009;:n/a-n/a.
2. Abrams P, Andersson KE, Birder L, Brubaker L, Cardozo L,
Chapple C, Cottenden A, Davila W, De Ridder D,
Dmochowski R, Drake M. Fourth International Consultation
on Incontinence Recommendations of the International
Scientific Committee: Evaluation and treatment of urinary
incontinence, pelvic organ prolapse, and fecal incontinence.
Neurourology and Urodynamics: Official J Int Continence Soc
2010;9(1):213-40.
3. Milsom I. Epidemiology of urinary incontinence (UI) and other
lower urinary tract symptoms (LUTS), pelvic organ prolapse
(POP) and anal incontinence (AI). In: Abrams P, Cardozo L,
Khoury S, Wein A editor(s). Incontinence: 5th International
Consultation on Incontinence. Recommendations of the
International Scientific Committee: evaluation and treatment of
urinary incontinence, pelvic organ prolapse and faecal
incontinence; 2012 Feb 23-25; Paris. Belgium: International
Consultation on Urological Diseases (ICUD), 2013:15-107.
4. Hannestad YS, Rortveit G, Sandvik H, Hunaskaar S. A
community-based epidemiological survey of female urinary
incontinence: The Norwegian EPICONT study. J Clin
Epidemiol 2000;53:1150-1107.
5. Krishna Rao B, Nayak SR, Kumar P, Kamath V, Kamath A.
Prevalence of Pelvic Floor Dysfunction among Married
Women of Udupi Taluk, Karnataka, India. J Women’s Health
Care 2015;4:236.
6. Abha S, Priti A, Nanakram S. Incidence and epidemiology of
urinary incontinence in women. J Obstet Gynecol India
2007;1;57(2):155-7.
7. Agarwal BK, Agarwal N. Urinary incontinence: prevalence,
risk factors, impact on quality of life and treatment seeking
behaviour among middle aged women. Int Surg J
2017;4(6):1953-8.
8. Guin G, Choudhary A, Dadhich R. Prevalence of stress urinary
incontinence and its associated risk factors amongst females
attending tertiary referral centre. Int J Reprod, Contracept,
Obstet Gynecol 2018;7(6):2115.
9. Abrams P, Andersson K, Apostolidis A, Birder L, Bliss D,
Brubaker L et al. 6th International Consultation on
Incontinence. Recommendations of the International Scientific
Committee: Evaluation and Treatment of Urinary
Incontinence, Pelvic Organ Prolapse and Faecal Incontinence.
Neurourol Urodyn 2018;37(7):2271-2.

Vinita Soni et al. Referrals to physiotherapy interventions for women with urinary incontinence….
Journal of Society of Indian Physiotherapists, February, 2019;3(1):15-19 19
10. Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic
floor muscle training versus no treatment, or inactive control
treatments, for urinary incontinence in women. Cochrane
Database of Systematic Reviews 2014, Issue 5. Art. No.:
CD005654
11. Bodhare TN, Valsangkar S, Bele SD. An epidemiological
study of urinary incontinence and its impact on quality of life
among women aged 35 years and above in a rural area. Indian
journal of urology: IJU: J Urol Soc India 2010;26(3):353.
12. Aoki Y, Brown HW, Brubaker L, Cornu JN, Daly JO,
Cartwright R. Urinary incontinence in women. Nat Rev Dis
Primers 2017;3:17042.
13. Orrell A, McKee K, Dahlberg L, Gilhooly M, Parker S.
Improving continence services for older people from the
service-providers’ perspective: a qualitative interview study.
BMJ open 2013;3(7):e002926.
14. Waetjn. Factors associated with reasons incontinent midlife
women report for not seeking urinary incontinence treatment
over 9 years across the menopausal transition. 2018;25(1):29-
37.
15. Cook T, ten Hove R. Project to evaluate patient self-referral to
women\'health physiotherapy pilot series.
16. Beaumont T, Goode K. Identifying the Pathway to
Conservative Pelvic Floor Physiotherapy in a Tertiary Public
Hospital in Australia: A Retrospective Audit. Int J Allied
Health Sci Pract 2017;15(2):3.
17. [Internet]. Wisdom.wales.nhs.uk. 2019 [cited 15 March 2019].
Available from: http://
www.wisdom.wales.nhs.uk/sitesplus/documents/1183/
Referring%20Patients%20to%20Physio%20for%20Pelvic%20
Floor%20Dysfunction%5FAneurin%20Bevan%2
0Guideline%202011.pdf
How to cite this article: Soni V, Rodrigues D,
Veluswamy SK. Referral to physiotherapy intervention
for women with urinary incontinence: Unravelling the
potential. J Soc Indian Physiother 2019;3(1):15-19.