Expert panel of urologists OKs surgery as No. 1 treatment for incontinence
Provider-patient silence stonewalls treatment and ruins women’s lives
New guidelines released in late June elevate surgery to a new high on the list of incontinence treatments. A panel of urologists, through a study sponsored by the Baltimore-based American Urological Association, announced that two procedures produce cure rates as high as 85% for stress incontinence. Its findings suggest that women’s health providers consider surgery as a primary treatment for incontinence brought on by stresses such as sneezing or coughing.
"The efficacy of the treatment is such that the patient herself is the deciding factor in who’s a candidate for surgery," says panelist Roger R. Dmochowski, MD, from the University of Tennessee Medical Center’s Department of Urology in Memphis. "The physician needs to talk with the patient about her expectations for surgery."
A woman’s appraisal of the bother of bladder leakage is a critical factor, Dmochowski says, but many women and their doctors don’t even reach the point of such discussion because shame and embarrassment bar the mention of incontinence.
The truth is that incontinence is usually manageable and often curable. Further, surgery isn’t the only answer. Low-tech but time-intensive therapies produce excellent outcomes. Because incontinence is usually a woman’s problem, a women’s health program is an ideal treatment setting. Insurance plans often balk when asked to ante up for incontinence treatment services, but programs delivered by the right mix of providers pay their own way.
Two obstacles remain: embarrassment and ignorance. "A woman figures she’s had a baby or two, and she knows her mother and grandmother wore protective pads she figures it’s normal," says Lynda Christison, MPA, executive director of the National Association for Continence in Spartanburg, SC. "Sometimes a person will barely tiptoe into the subject with a doctor, but the doctor will shut down and not pursue it. Physicians are not well-trained in treating incontinence." (See story on asking the right questions to assess bladder problems, p. 101.)
Janis Luft, NP, MS, sees the unnecessary suffering caused by ignorance every day. "Most women will put up with problems if they can sit through a movie, which is about two hours," she says, "but I see women who visit the bathroom every 15 minutes. Normal bladder function is a bathroom visit every three to six hours. "
As director of pelvic floor rehabilitation at the University of California at San Francisco Women’s Continence Center, Luft sees "plenty of women in their 20s, 30s, and 40s who have some kind of bladder problem." She estimates that 25% of all women from menarche to menopause have occasional to regular incidents of leakage, while 40% of women over age 65 have bladder problems. Luft’s take on the extent of the problem is no exaggeration, according to recent studies1,2 and figures from the American Foundation for Urological Disease in Baltimore. (See chart, above.)
The range of treatment options is unknown to many physicians and women as well. Often, women don’t want to bother with surgery or don’t trust it because they know someone who had an unsuccessful operation. Yet in reality, Christison says, "There is almost always room for improvement or cure."
Physicians don’t have the time it takes to treat incontinence, says Pam Gillaspie, RN, program director of the Maturity Center at the Women’s Clinic of Lincoln (NE). "The trick to treating incontinence," she explains, "is to make sure you have the proper diagnosis."
Diagnosis and treatment take three to four months of intensive patient-provider cooperation. Appointments should be 30 minutes long, Luft advises. Some women need three to four biweekly sessions, while others require more frequent appointments or longer spans of treatment.
The improvement and cure rates for non- surgical treatment are impressive. Luft reports that 60% to 80% of her patients experience good results.
Diagnosis and treatment start with a bladder diary to track the frequency and circumstances of incontinence episodes. (For a copy to reproduce for your center, see insert, Your Daily Bladder Diary.)
Pelvic floor strengthening is essential. Even if a person has surgical treatment, Gillaspie notes, strengthening is a necessary follow-up to keep the surgical repair intact. Many facilities use biofeedback to teach strength-building pelvic muscle contractions, commonly called Kegel exercises. Biofeedback sensors connected to a computer are placed around the anal and vaginal openings as well as the abdomen. As the woman watches her contraction patterns on the screen, she learns to isolate the squeezing movements to the pelvic floor muscles.
Programs like Gillaspie’s build referral linkages with physical therapists for the biofeedback component. Luft does biofeedback herself.
Behavioral therapy involves urge control and bladder retraining. As Luft explains, "We teach women to calmly wait for longer intervals [of 10 to 15 minutes] instead of making the mad dash to the bathroom. This retrains the bladder to respond to the urge as a voluntary activity."
Medications comprise another component of nonsurgical therapy. Luft says that some women need anticolinergics or antispasmodics to control bladder urges. The most often-used drug is oxybutinin, which comes under the brand name Ditropan, manufactured by Hoecsht Marion Roussel in Kansas City, MO.
Successful surgeries
The Urological Association panel reports that two surgical procedures produce excellent results for stress incontinence. The standard of effectiveness is a "cure dry rate" of five years or more without urinary leakage.
Two surgical procedures produced cure dry rates in 85% of the cases. The first, retropubic suspension, is performed through an incision in the lower abdomen. The urologist places sutures near the bladder neck and urethra, securing them to a pelvic bone or to surrounding supporting structures. The second procedure, a sling, involves bolstering the urethra with a supporting strip of tissue or synthetic material.
Surgery offers the advantage of a one-time fix, says Rodney Appell, MD, of the Cleveland Clinic Department of Urology. Many women prefer that to the ongoing pelvic strengthening exercises required to maintain continence nonsurgically, he says.
Getting paid: Tough yet possible
Despite the proven effectiveness of surgical and nonsurgical treatment, "reimbursement is and has been the biggest issue," contends Mike Williams, chief executive officer for Advantage Medical Services in Bradenton, FL.
Williams says managed care plans in his area have been slow to come around, especially for behavioral and biofeedback therapies. In Florida, Medicare covers only a portion of the treatment costs, he notes, adding that each state adjusts Medicare reimbursement to the prevailing rates in the locale.
Instead of liberalizing coverage, Medicare is tightening up, Williams says. Where the reimbursement used to hinge on physician supervision, he explains, it now requires involvement of a physician in the treatment. That’s overkill, he argues. The nurse practitioners who deliver Advantage’s nonsurgical continence services have achieved an 88% rate of regained continence among the 1,800 patients served since they began the program in 1992, Williams says. He also points out that nonsurgical therapies cost $1,000 to $2,000, compared with $12,000 for surgery.
Panelists who wrote the new guidelines agree that securing payment for incontinence therapy isn’t exactly a breeze. But if patients demand payment, and they are in sufficient numbers and have enough persistence, the payers will listen.
Even now, getting third-party reimbursements depends on scoping out the possibilities in your state’s professional licensing regulations and the coverage of regional health plans. Then forge your alliances accordingly. Gillaspie’s center receives fees to perform assessments and histories for OB/GYNs and refers patients to the nearby Physical Therapy Center, which bills for biofeedback. Some women’s centers refer to private practice physical therapists.
In California, nurse practitioners such as Luft write prescriptions, so she handles that aspect of care when patients need it. Indeed, for a center whose lines of cooperation and referral are established, Gillaspie says, a continence treatment program is profitable. She notes that when women learn where they can go for good continence treatment, "the demand for the service is great." (For an overview of a successful treatment service, see story, above.)
References
1. Burgio KL, Matthews KA, Engel BT. Prevalence, incidence, and correlates of urinary incontinence in healthy, middle-aged women. J Urology 1991; 146:1,255-1,259.
2. Brown JS, Seeley DG, Fong J, et al. Urinary incontinence in older women: Who is at risk? Obstetrics and Gynecology 1996; 87:715-721. ß
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