Urinary incontinence symptoms and impact on quality of life in patients seeking outpatient physical therapy services

Meryl Alappattu, Cynthia Neville, Jason Beneciuk & Mark Bishop

(2016) , Physiotherapy Theory and Practice, 32:2, 107-112

 

Review provided by Cynthia Neville, PT, DPT, WCS for Pelvic Physiotherapy Journal Club May 4, 2016

 

Why I wanted to review this article: Brooks Rehabilitation is the largest provider of OP PT services in the state of Florida serving upwards of 25,000 unique OP/year. When I arrived to start a WH program there, I instituted a screening program to identify current patients who might benefit from PT rx for UI, to generate referrals to the program, and collect outcomes.  This article is one of several articles stemming from this database.

Background:

The available evidence suggests that while UI may occasionally be a stand-alone disorder, it is also associated with a number of other medical and musculoskeletal

conditions commonly treated by physical therapists.  Screening for UI in patients with back pain is recommended in order to rule out medical red flags. UI may not just be a red flag but also a comorbid disorder associated with one of the most commonly treated conditions in ambulatory care settings.

Purposes:

1. To determine if patients seeking outpatient services for neuro-musculoskeletal conditions were experiencing UI and examined the types of incontinence being experienced by these patients.

2. To examine the extent to which incontinence impacted HRQoL in patients not seeking services for UI. We hypothesized that patients seeking care specifically for UI would report a greater impact of UI on HRQoL.

Methods:

·         Retrospective analysis, convenience sample.

·         Screening question on intake medical history form from 3IQ ““During the last 3 months, have you leaked urine (even a small amount)?” If patients responded “yes” to this question, they were also asked to complete the following three measures: (1) three incontinence questions(3IQ); (2) Incontinence Impact Questionnaire Short- Form (IIQ); and (3) the International Consultation on Incontinence Modular Questionnaire—Urinary Incontinence (ICIQ-UI).

·         Demographic information and frequency of UI type (stress UI, urge UI, mixed UI, or insensible UI) and incontinence symptoms (number of pads, IIQ, and ICIQ-UI) were compared among groups. Separate one-way analyses of variance (ANOVAs) were performed for incontinence symptom measures and were compared among condition groups. Bivariate correlations were calculated among pad use, ICIQ-UI scores, IIQ-7 score, and age using Pearson correlation moments.

Data analysis:

·         Demographics Table 1: 619 patients responded “yes” to the initial screening question; 599 subjects had complete data and were included.

·         Mean age = 49.8 years

·         94.7% female.

·         Rates of UI types based on Rx condition: Table 2: The condition group was based on the patients’ chief complaint and ICD-9 code associated with their referral to outpatient physical therapy. The primary author (MJA) coded condition groups as one of the following: urinary dysfunction, fecal dysfunction, pelvic pain, spine, neurological disorders, or extremity disorders.

UI and FI Symptoms and association with demographics

·         The mean IIQ and ICIQ-UI scores and number of pads in 24 h are listed in Table 3. In general and as expected, the urinary dysfunction group exhibited higher scores on the IIQ than all other groups (H(5) = 53.35, p < 0.001), including significantly higher scores than the pelvic  and spine groups.

·         The impact of UI on QoL DID NOT differ among the primary urinary dysfunction group, fecal dysfunction (p = 0.35), neurological (p = 0.66), and extremity (p = 0.03) groups.

·         Symptom severity was highest in the urinary dysfunction compared to all other groups (H(5) = 70.53, p <0 .001="" o:p="">

·         Lower frequency and symptom severity was identified in the pelvic pain and spine  groups with no differences between the urinary dysfunction group and the fecal dysfunction (p = 0.005), neurological disorder (p =0.16), or extremity disorder (p = 0.03) group.

·         The number of pads used in 24 h ranged from 0 to 12. The urinary dysfunction group demonstrated the highest average number of pads (H(5) = 23.64, p < 0.001), including significantly higher pad use than the pelvic pain and spine groups but no significant differences existed between the urinary dysfunction group and the neurological group (p = 0.15), extremity group, or fecal dysfunction group.  

·         Significant positive correlations existed between the severity of symptoms, HRQoL, age, and number of incontinence pads used in a 24-h period (Table 4).Strong positive associations existed between severity of symptoms and HRQoL scores and 24-h pad use (r = 0.55–0.67), indicating that those who reported more severe symptoms of leakage and more severe impact on QoL were also more likely to report a higher usage of pads.

·         Also, moderately positive relationships existed between age and 24-h pad use and age nearly 25% were individuals with spinal pain who reported symptoms of UI. This relationship is intriguing and emphasizes the importance of screening for UI, not only for patients  but particularly those seeking care for a wide range of other conditions including spinal pain, pelvic pain, neurological disorders, and extremity disorders.

Discussion

·         UI negatively impacts HRQoL in people whose primary complaint is not incontinence

·         Physical therapists should consider screening for the presence and impact of UI on HRQoL

·         UI affects patients with neuro-musculoskeletal conditions commonly seen in outpatient physical therapy and the impact of UI on QoL is similar among these different conditions.

Conclusion

·         The frequency and impact on HRQoL of UI extends to individuals beyond simply those seeking care for urinary dysfunction to other conditions commonly treated by physical therapists.

·         Screening for UI and its impact on HRQoL may be warranted in people seeking outpatient physical therapy as part of a routine initial evaluation.

·         The negative impact of UI on QoL is similar for people regardless of the primary reason for which they sought treatment.

·         We also recommend referring patients who report a negative impact on QoL to a provider who is qualified to evaluate and provide treatment for UI.

Future research

·         systematic screening of all patients in an outpatients etting to determine the prevalence and types of UI in patients seeking outpatient physical therapy services.

·         In the interim, before such studies are completed, we recommend using simple screening methods to ID UI.

·         Primary limitation of this study was that these data were collected from a sample of convenience

Questions for discussion:

·         Do you screen all patients for UI/LUTS?

·         Do you collect, measure, and report standardized outcomes relating to LUTS?

·         How can we improve the outcomes of all patients seeking rehab by providing interventions for UI?

·         What is the potential to gain referrals from groups outside of your clinical practice for the treatment of UI/LUTS?