Female Urinary Incontinence Evidence-Based Treatment Pathway: An Infographic for Shared Decision-Making

Best evidence for rehabilitation management of urinary incontinence in patients with bladder cancer following orthotopic neobladder reconstruction

Objective

This study aims to establish the best evidence for the rehabilitation management of urinary incontinence (UI) in patients with orthotopic neobladder (ONB) following radical cystectomy (RC) for bladder cancer, providing a theoretical foundation for clinical practice.

Methods

A systematic search was conducted across evidence-based databases, guideline networks, and professional association websites to identify relevant literature on rehabilitation management for patients with ONB after bladder cancer surgery. Studies published in both English and Chinese, up to May 8, 2024, were included. Trained researchers assessed the quality of the literature and summarized the evidence.

Results

Fourteen documents were included, consisting of eight guidelines, two clinical decision documents, and four expert consensus reports. A total of 43 pieces of evidence were identified, covering seven key areas: preoperative UI assessment and counseling, preventive measures, UI assessment and diagnosis, conservative treatments, selection and use of nursing equipment, evaluation of effectiveness, and follow-up care.

Conclusions

The best evidence for UI rehabilitation management after ONB for bladder cancer can help standardize patient care and clinical practices. Healthcare providers should adapt this evidence to their local healthcare settings, cultural contexts, barriers, and patient preferences.

Systematic review registration

This study was conducted following the evidence summary reporting specifications of the Fudan University Center for Evidence-Based Nursing (Registration No. ES20244165).

U.S. payer budget impact of the Leva Pelvic Health System to improve pelvic floor muscle training as first-line treatment of female urinary incontinence compare to real-world clinical practice

AIM

Urinary incontinence (UI) is a common condition for adult women impacting over 60% of women with 9.8% experiencing daily symptoms and 32.4% experiencing monthly symptoms. It is associated with significant negative impacts on patients' quality of life, well-being, and social functioning, resulting in substantial healthcare costs to payers. The goal of this study was to analyze 24-month budget impact of treatment of urinary incontinence (UI) in adult women enrolled in a 1-million-member US commercial health plan by comparing clinical practice that includes the use of the Leva Pelvic Health System (CP with Leva) to current clinical practice without Leva (CCP).

METHODS

A budget-impact model compared 24-month costs associated with first-line pelvic floor muscle training (PFMT) in women seeking UI treatment in two cohorts: 85% receiving first-line CCP treatment/15% receiving the CP with Leva, compared to all patients treated with CCP. Medical spending per treated patient and per-member-per-month were calculated by summing 24-month UI treatment costs comparing CCP to CP with Leva. The treatment pathway was developed based on published guidelines and literature to obtain estimates of success and complications. Commercial payer costs were estimated by applying a 1.50× multiplier to published Medicare costs based on Congressional Budget Office data for Hospital and Physician Services.

RESULTS

In a 1-million-beneficiary US commercial health plan with 334,191 adult women, 31,438 (9.4%) adult women were treated for UI over a 24-month period. Total estimated 24-month cost per treated patient was $11,267 in the CCP and $10,447 in the CP with Leva groups, respectively. Estimated total health plan 24-month savings was $25,782,112, or $1.07 per-member-per-month.

LIMITATIONS

The model may not capture all events in the care pathway for female UI patients seeking medical treatment, as there are significant variations in practice patterns; the rate of Leva adoption as a first-line therapy is based on estimates. The costs and savings calculated in this model may not be generalizable to every commercial health plan, given that actual costs routinely rely on specifically negotiated reimbursement rates.

CONCLUSIONS

The model demonstrates that access to first-line Leva therapy can reduce two-year UI treatment costs compared to CCP.

Do We Have Sufficient Evidence to Derive Innovative Approaches to Assessing Unmet Need, Delivering Education on Bladder and Bowel Continence Health, and Providing a Better Environment for Joint Decision-Making? ICI-RS 2024

CONTEXT

Improved continence outcomes are reliant on identification of unmet need, education delivery, and shared decision-making. The evidence base on which to derive innovative approaches in these areas was unclear.

METHODS

A debate held at the International Consultation on Incontinence-Research Society meeting, held in Bristol in June 2024, considered ways to improve research requirements to advance these areas.

RESULTS AND CONCLUSION

Artificial intelligence solutions and digital approaches to healthcare are emerging at pace and offer possibilities to improve these three key areas but this must be driven by person-centered approaches. Care must be taken to avoid increasing inequality through digital exclusion and language barriers. Research questions are highlighted to derive innovation in these three key areas.

Addressing Health Care Access Disparities Through a Public Health Approach to Physical Therapist Practice

As the field evolves as a doctoring profession, the role and scope of physical therapist practice must also grow to meet important and urgent public health needs. Scalable, population-level interventions must be prioritized to the same degree as tailored, individual-level care. Drawing from public health frameworks, this perspective proposes an approach to population-level physical therapist care delivery that aims to mitigate disease and disability and improve health outcomes by expanding access, decreasing cost, and improving quality of care for those facing the greatest health disparities. Application of these frameworks prompts the development of novel approaches to rehabilitation service delivery to advance twin goals of promoting access to care and reducing health disparities. This paper describes how a population health framework and public health approach can be used to support necessary evolution and innovation within the field of physical therapy and to improve rehabilitation service delivery. Rapid developments in the digital and virtual health space have created a unique opportunity for physical therapists to lean into a new vision of their role as clinicians within the broader health ecosystem. This paper will provide clinicians with a broader perspective of physical therapist expertise and describe opportunities for the development and application of a physical therapist skill set toward driving population health outcomes. Real-world examples will guide clinicians to consider opportunities in their own practice for implementing this public health approach and potentially addressing various contributors to persistent health disparities.

Development and validation of a Decision-Making Ability Scale for postpartum urinary incontinence women engaging in pelvic floor physical therapy

OBJECTIVE

This study aimed to develop and validate a Decision-Making Ability Scale (DMA-S) for postpartum urinary incontinence (PPUI) women engaging in pelvic floor physical therapy (PFPT).

METHODS

Items were created in line with a review of the literature and exploratory qualitative study with 22 women. The items were submitted for expert opinion and a pilot implementation was made with 58 women with PPUI. Furthermore, the construct validity of the scale was tested with exploratory factor analysis (EFA) (n = 220) and confirmatory factor analysis (CFA) (n = 240). Internal consistency for the Chronbach's α and test-retest reliability for the intraclass correlation coefficient (ICC) were also investigated for the DMA-S in the study.

RESULTS

The results of the EFA indicated a Kaiser-Meyer-Olkin value of 0.85 and Bartlett's test of sphericity showed a χ2 value of 8352.101, p < 0.001. After removing one item with factor loading values below 0.50, the resulting factor structure accounted for 83.38% of the total variance. The fit indices of the scale model tested in the CFA were determined as χ2 /df = 1.08 < 3, root mean square error of approximation = 0.018 < 0.08, comparative fit index = 0.996 > 0.90, Tucker-Lewis index = 0.995 > 0.90, goodness-of-fit index (GFI) = 0.933 > 0.90, adjusted GFI = 0.916 > 0.90, and incremental fit index = 0.996 > 0.90. The Cronbach's α values were 0.95-0.97 for the subdimensions of the scale and 0.93 for the total scale. Data also showed a good test-retest stability (ICC = 0.984).

CONCLUSION

The DMA-S is a reliable and valid tool for assessing the decision-making ability for PPUI women engaging in PFPT.

Efficacy and safety of intraurethral Erbium:YAG laser treatment in women with stress urinary incontinence following failed intravaginal laser therapy: a retrospective study

Urinary incontinence (UI) is a prevalent condition affecting 25-45% of women and is linked to factors such as menopause, parity, high body mass index, and radical pelvic surgery. Among the three types of UI, stress incontinence (SUI) is the most common, accounting for almost 50% of cases, followed by urgency and overflow incontinence. UI has been found to be associated with reduced quality of life and mental stress. Non-invasive laser treatment is the safest and most effective option for managing SUI, with intraurethral Erbium SMOOTHTM laser treatment holding promise for patients experiencing SUI even after undergoing previous failed intravaginal Erbium:YAG laser treatment. The study recruited 93 female patients with mild to moderate SUI who had received two courses of intravaginal Erbium:YAG laser between January 2015 and June 2018. Of these, 22 patients (23%) who continued to experience SUI after a four-week interval for a second intravaginal Erbium:YAG laser were selected for intraurethral laser treatment in January 2019. The efficacy of the treatment was evaluated by comparing the pre- and post-treatment ICIQ-UI SF score. The urethral length was measured before the procedure. The main procedure involved delivering non-ablative laser energy using Erbium SMOOTHTM technology 2940 nm via a 4-mm cannula with personalized length and fluence was 1.5 J/cm. The 22 female patients with persistent SUI received intraurethral Erbium:YAG laser treatment. Their average age was 47.5 years, with an average of 2 parities and a mean body mass index of 20.97. All patients completed the ICIQ-SF questionnaire before and 3 months after the procedure. Of the patients, 77% reported improvement in symptoms, with 6 reporting strong improvement and 11 reporting improvement. The treatment was well-tolerated, with mild and transient adverse effects such as urinary infection in 1 patient (4.5%) and mild pain in 7 patients (31.8%). Intraurethral laser treatment may be helpful for Taiwanese women with persistent SUI after vaginal laser treatment. However, patients with prior pelvic surgery or pelvic organ prolapse history may limit the efficacy of intraurethral laser. Additional research is necessary to comprehensively investigate the advantages of intraurethral laser therapy. However, using intraurethral Erbium SMOOTHTM laser treatments to rejuvenate tissues and enhance structural support could be a promising avenue for managing stress urinary incontinence in Taiwanese women.

Motivations, psychosocial burdens, and decision-making modes of post-partum women with stress urinary incontinence engaging in pelvic floor physical therapy: a qualitative research

INTRODUCTION AND HYPOTHESIS

This qualitative research explores the motivations, psychosocial burdens, and decision-making modes of post-partum women with stress urinary incontinence (SUI) engaging in pelvic floor physical therapy (PFPT).

METHODS

This study was conducted face-to-face in a treatment room using qualitative semi-structured interviews with post-partum women who received PFPT for SUI between May and October 2022. Participant interviews were transcribed verbatim and thematically analyzed using NVivo software, which is most commonly used for qualitative data analysis.

RESULTS

Themes that impacted participants' decisions to receive PFPT included avoiding deterioration of SUI symptoms, believing that the sooner it is treated the better, being unable to adhere to home exercise programs, and dissatisfaction with quality of life. Some participants experienced psychosocial burdens when receiving PFPT, including impact on daily activities, worries about the baby, financial burdens, and uncertainty about the effect. There were two modes of decision making, which brought different experiences. Some participants preferred participant-provider shared decision making and reported effective doctor-patient communication, and striving for autonomous decisions. Other participants preferred their clinicians to decide on PFPT protocols in view of their trust in their midwives, institutional reputation, and lacking knowledge of PFPT.

CONCLUSIONS

We discovered that participants had both motivations and psychosocial burdens when receiving therapy. Some participants preferred participant-provider shared decision making, whereas others preferred their midwives to make decisions. Further more standardized studies with more robust samples are needed.

Digital Therapeutic Device for Urinary Incontinence: A Longitudinal Analysis at 6 and 12 Months

OBJECTIVE

To evaluate the long-term efficacy of an 8-week regimen of pelvic floor muscle training guided by a motion-based digital therapeutic device compared with a standard home program in the treatment of stress urinary incontinence (SUI) and stress-predominant mixed urinary incontinence (MUI).

METHODS

The primary virtual trial was conducted from October 2020 to March 2021; 363 women with SUI or stress-predominant MUI were randomized to complete pelvic floor muscle training using the device (intervention group) or a standard home pelvic floor muscle training program (control group) for 8 weeks. Primary outcomes included change in UDI-6 (Urogenital Distress Inventory, Short Form) score and SUI episodes on a 3-day bladder diary. The PGI-I (Patient Global Impression of Improvement) was also assessed, with "much better" and "very much better" responses considered as improvement. In this planned secondary analysis, symptom and adherence data were collected in follow-up at 6 and 12 months. A modified intention-to-treat analysis was performed using Student's t tests and χ2 tests as appropriate.

RESULTS

Of 299 participants analyzed at 8 weeks, 286 (95.7%) returned 6- and 12-month data (151 in the control group, 135 in the intervention group). Mean age was 51.9±12.8 years, and mean body mass index (BMI) was 31.8±7.4; 84.6% of participants were parous, and 54.9% were postmenopausal. Mean change in UDI-6 score from baseline to 6 and 12 months was significantly greater in the intervention group than in the control group (20.2±20.9 vs 14.8±19.5, P=.03 and 22.7±23.3 vs 15.9±20.3, P=.01, respectively). Participants in the intervention group had more than twice the odds of reporting improvement on the PGI-I compared with participants in the control group (OR 2.45, 95% CI 1.49-4.00).

CONCLUSION

Pelvic floor muscle training guided by a motion-based digital therapeutic device yielded significantly greater urinary incontinence symptom improvement compared with a standard home pelvic floor muscle training program at 6 and 12 months, although continued improvement waned over time. This technology may facilitate pelvic floor muscle training access and adherence for women with SUI and stress-predominant MUI and represents an effective modality for scaling first-line care.

FUNDING SOURCE

Renovia Inc.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04508153.

Prevalence and factors associated with pelvic floor dysfunction in university women: a cross-sectional study

Abstract Introduction Urinary incontinence (UI), fecal inconti-nence (FI), and genito-pelvic pain or penetration disorder (GPPPD) are considered pelvic floor dysfunction (PFD), and are mainly characterized by poor functionality of the pelvic floor muscles. Despite the relevance of these dysfunctions in women's lives, the demand for care is low. Objective To analyze the prevalence of PFD, in university women, and factors associated with PFD. Methods This is a cross-sectional study conducted at São Paulo State University, Marília, SP, Brazil, with undergraduate and/or postgraduate women aged over 18 years. An online questionnaire containing 40 open and multiple-choice questions about PFD was developed by the authors and a Google form was disclosed via social media (Facebook, Instagram) to the participants. The questionnaire was applied between April and July 2020. Results A sample of 707 participants was included. The average age was 22.5 ± 21.0 years old. The most prevalent PFD was GPPPD, reported by 30.7% of women, followed by UI (16.8%) and FI (3.2%). PFD was significant less reported in the Midwest region compared to other regions (p = 0.015) and significantly more prevalent in women who attended public university (p = 0.038), in women with UI, FI, and GPPPD. The association-test showed that attending public university showed association to UI (p < 0.001), FI (p = 0.008) and GPPPD (p = 0.006). In addition, parity showed association with GPPD (p = 0.032) and to attend health courses with UI (p = 0.002). Conclusion PFD is prevalent among university women and GPPPD was the most recurrent, followed by UI and FI. GPPPD was associated with parity and attending a public university. UI was associated with attending public university and health courses. FI was associated with attending a public university.

Female Urinary Incontinence Evidence-Based Treatment Pathway: An Infographic for Shared Decision-Making

Objectives:

Urinary incontinence (UI) is a highly prevalent burdensome condition among adult females in the United States, yet rates of care-seeking, evaluation, and treatment are nonoptimal. Components of evaluation and treatment are informed by research and professional society guidelines; however, a visual representation of this guidance does not exist. The objectives of this study are to review the literature regarding female UI care and to synthesize this information into a graphical format to facilitate health education, health care delivery, and shared decision-making.

Methods:

We reviewed published society guidelines, position statements, and associated references from the American College of Obstetrics and Gynecology, the Women's Preventive Services Initiative, American Academy of Family Physicians, American College of Physicians, the Society of Urodynamics and Female Urology, the American Urological Association, and the American Urogynecologic Society, and searched PubMed for related literature. We synthesized these findings into an evidence-based infographic depicting female UI risk factors, influences on care-seeking and provision, screening, evaluation, and a stepwise treatment approach.

Results:

This study summarizes current evidence and professional guidelines related to female UI into a compelling visual format and accompanying narrative. The infographic is intended as a tool for patient education, clinical practice, and research to facilitate shared decision-making and health care delivery.

Conclusions:

Female UI is highly prevalent, yet diagnosis and treatment are suboptimal. Use of an evidence-based infographic may positively impact patient knowledge and certainty about UI treatment and support health care provider counseling and decision-making.