Female incontinence: Awareness needed

Mother’s Day marks the first day of the Centers for Disease Control’s National Women’s Health Week. This annual awareness event encourages women to make their health a priority. It’s also a gentle call to action for the people and organizations that care for women.

 

 Women’s health has a long history of being sidelined. Federal law only required the National Institutes for Health (NIH) to require grant recipients to include both men and women in clinical studies in 1994. Women's health research accounted for 10.8% of the NIH budget in fiscal year 2020.

 

Women’s health issues, especially those cloaked in embarrassment, are uniquely at risk of being overlooked or ignored. Urinary (UI) and fecal incontinence (FI) are among the conditions for which shame keeps women from speaking with their physicians about bothersome symptoms, which contributes to today’s grim reality: the adult diaper market now exceeds the market for baby diapers.

 

I believe this is wrong, particularly when easy, at-home treatment exists.

 

UI and FI are common progressive disorders that desperately deserve more attention. Vastly undertreated, they are the most prevalent pelvic floor disorders that women experience. UI affects 78 million and FI affects 12 million women in the U.S. alone. Globally, the numbers are in the hundreds of millions. The theme for this year’s Women’s Health Week is “Women’s Health, Whole Health: Prevention, Care and Wellbeing.” I believe continence is core to a woman’s well-being, and annual screening should be part of a woman’s annual wellness appointment regardless of age.

 

The impact of untreated pelvic floor disorders

Incontinence affects women disproportionately. Beyond the staggering prevalence numbers, pelvic floor disorders negatively impact women’s psychosocial and emotional wellbeing and are associated with increased economic burden, decreased physical activity, and functional decline. Among older women, UI is a major risk factor for falls, hospitalization, nursing home admission, and dependance on a caregiver. Women with UI experience faster and greater degrees of physical decline when compared to women who are continent. They score lower on physical performance tests and show significant declines in muscle mass. Research shows that women with UI may reduce physical activity or stop exercising to manage symptoms, which can lead to functional decline and even worsen UI symptoms over time.

 

Women rarely seek treatment. It is estimated that as few as 25% of women with UI seek care and of those who are care-seeking, many have had symptoms for six years or more. When queried, many women indicate they did not know treatment was available, they prioritized other issues, and their healthcare provider did not ask directly about these symptoms. Individual- and institutional-level barriers have been documented as limiting factors in care-seeking and participation in treatment. All the while, prevalence of pelvic floor disorders continues to increase in the population, sufficient to regard it as a population-level health concern.

 

First-line treatment: promise and perils

The first-line treatment for UI and FI is pelvic floor muscle training (PFMT). Clinicians often encourage women to access PFMT by doing “Kegels.” However, data show few women do them correctly or consistently enough to effectively reduce symptoms. This contributes to healthcare providers’ reticence to recommend first-line therapy, leaving many women living with leaks.

 

The pandemic accelerated the availability and adoption of telemedicine and digital health, which have favorably shifted how treatment can be accessed. Thanks to devices, wearables and apps, many can now receive treatment in the environment that’s most comfortable, the home. Pelvic floor health has benefitted. Today, women can perform PFMT at home using a mobile phone app paired with a medical device, supporting correct and consistent PFMT. While there are many pelvic floor strengtheners, very few are supported the rigorous data that women’s health deserves and allows clinicians to remain engaged in treatment. Level-one evidence shows pelvic floor muscle training is most effective when performed under the supervision of a skilled healthcare provider, which suggests that pelvic floor muscle strengtheners that require a prescription have the best chance for symptom relief.

 

The advent of digital health and telemedicine has made first-line treatment practical and accessible to a large group of women, regardless of location. However, awareness and discussion must occur before women can access treatment. The open-access manuscript and infographic, “Female Urinary Incontinence Evidence-Based Treatment Pathway: An Infographic for Shared Decision-Making,” seeks to increase access first line therapy by packaging evidence-based guidelines for UI screening and treatment in a graphical, easy to access format for use by clinicians on the frontlines of women’s health. Professional organizations and health systems may also find it valuable for clinician and member education. The infographic depicts female UI risk factors, influences on care-seeking, screening and evaluation. It also includes a stepwise treatment approach, for which there is broad international and multidisciplinary agreement. It synthesizes current evidenced-based literature as well as multiple UI screening guidelines, position statements, and associated references from the American College of Obstetricians and Gynecologists, 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.

 

Incontinence is common but it’s not normal

Incontinence can have significant negative impacts on women’s lives. The uncertainty and unpredictability that come with UI and FI can affect women’s mental health, quality of life and relationships. Women may limit their physical activity or social engagements, experience feelings of isolation and distress and/or experience problems with intimacy. 

 

Presently, 62% of adult women live with bladder leaks, and this is expected to rise due in large part to the size of the aging demographic and the national obesity epidemic, both of which are associated with increased risk of UI. I believe UI is an important health condition that warrants screening and treatment. Level I evidence supports PFMT effectiveness and describes this intervention as most effective when performed under the supervision of a skilled HCP (supervised PFMT/sPFMT) for a period of at least 12 weeks. Digital health tools allow clinicians to treat more women effectively while allowing treatment to take place where it’s most convenient, at home. Women’s Health Week offers an opportunity to remove the veil of shame that keep women from discussing their symptoms with their providers. While incontinence is common, it is not normal. Effective treatment is available and accessible. In some instances, treatment is covered by insurance. No woman should be left feeling that adult diapers are her only solution. From policy makers to families to individuals, all of us have a responsibility to prioritize women’s health. Women’s Health Week is an excellent first step.

 

 

Female incontinence: Awareness needed

By Samantha Pulliam, MD, FACOG

Chief medical officer, Axena Health