Nearly every global society regulates women’s health recommends screening of adult women for incontinence. It rarely happens. The reasons are inherent in the structure of our health care system, including long lists of recommended screenings, long wait times for short appointments, and sometimes limited access to health care.
However, with 62% of adult women If we live with bladder and/or bowel leaks in the US, it is imperative that we improve screening for this treatable condition. Untreated incontinence is associated with very negative health consequences, affecting women’s social, financial, physical and emotional well-being. Shame keeps most of them quiet. We believe that small changes from government, professional organizations and insurers can make it easier for doctors to screen and treat more women.
Leaks are not an inevitable part of aging. Treatment exists. Women don’t have to live a life that fuels the energy $15.2 billion global adult diaper market and can take them to a nursing home. The menopause movement activates women who demand change. However, medicine has a disheartening history of neglecting women’s health concerns. And huge advertising budgets normalize incontinence, obscuring an important clinical fact: incontinence is a progressive condition. Without treatment it can get worse.
Ample data show the uncertainty and unpredictability of living with incontinence can impact women mental health, quality of lifeand relationships. Women may limit their social involvement, experience feelings of isolation and anxiety and/or have problems with it intimacy. Incontinence is also associated with greater economic burden and reduced physical activity. Research shows that women with urinary incontinence (UI) may reduce physical activity or stop exercising altogether to control symptoms. Compared to women on the continent, data shows that women with incontinence experience faster physical decline, including a decrease in muscle mass and lower scores on physical performance tests.
In older women the UI is a main risk factor for falls, hospitalization, disability and dependency on a caregiver. The quality of life for caregivers is also affected. Physical demands can be intense. Psychological, relational and social problems may also arise. Most recently one September Research has shown a link between overactive bladder, a syndrome that includes urinary urgency, frequency and urgency incontinence, and suicidal ideation. A October article closely followed, showing that UI itself is an independent risk factor for death.
For many women it is possible to stop this terrible cascade. Effective treatments exist, including conservative (read: cheap) first-line treatment, pelvic floor muscle training (PFMT). So why isn’t routine screening taking place? Short answer: it’s complicated. However, we believe that small changes from government, payers, medical associations, physicians and women can make a real difference.
Research confirms that the institutions that supervise quality measurement, including organizations such as the Centers for Medicare and Medicaid Servicesthe Joint Commissionand the Agency for Healthcare Research and Quality have the ability to influence the providing care, increasing patient safety and improving outcomes. Earlier this year, the Core Quality Measures Collaborative (CQMC) reviewed OB-GYN core measures. For prevention and wellness, current core measures include screening for chlamydia, HIV, contraception and depression – all valuable screenings. We do not advocate its removal. However, incontinence affects more women than all other measures except contraception, yet urinary incontinence (postpartum or for the general population of women) is not even mentioned as a measure for the future. consideration. Furthermore, it is not mentioned or considered primary carealthough CQMC will review this in February 2025. Adding incontinence screening as a core measure is necessary and would help motivate physicians and large healthcare organizations to prioritize screening in their practices.
As specialists, we are very familiar with the tests required for an incontinence diagnosis, which provides access to treatment. However, the current diagnostic process – typically pelvic examination, urinalysis and post-void residual – can be burdensome for primary care, leading to unnecessary referrals. Primary care providers (PCP) should be the first step in treatment for most women. Medical and professional associations could help by simplifying the diagnostic process, making primary care more accessible immediately after diagnosis by a GP.
The average duration of a primary care visit is 18 minuteswhich can limit our attention to only the most pressing health problems. While a longer appointment would be ideal to engage patients in additional care, we must be realistic. If there is no longer time to spend with patients, it can be helpful right away to plan what you will say about incontinence. As physicians, we often have routine conversation topics for discussing a variety of different conditions. This preparation, honed through years of practice, is part of what can make a short encounter efficient and astute. For incontinence, doctors can prepare to ask about leaks and, based on the response, have pre-planned talking points that allow them to efficiently connect women to treatment. This would take some upfront work (most of these conversation habits are initially formed during training), but it would be incredibly rewarding.
Prevention is also crucial.
Like many other conditions that people are more comfortable talking about, incontinence has clear risk factors: Childbirth is number 1. However, payers view postpartum leakage as a lifestyle issue. That’s because serious consequences occur later, usually during menopause, and probably after several insurance changes. We encourage all payers to take a long-term view, just as they do with other conditions associated with negative long-term health outcomes, such as diabetes, cardiovascular disease and obesity. Pelvic floor health should be a priority immediately after childbirth and insurers should cover this care.
This happens in Britain and France, where one payer is responsible for a woman’s life: pelvic floor rehabilitation begins immediately after childbirth. The National Institute for Clinical Excellence, which sets treatment guidelines for Britain, found this was possible avoid 50% of surgeries for stress urinary incontinence if women performed PFMT first. Since 1985, the The French government has paid for ten sessions of pelvic floor physiotherapy after childbirth.
Some US insurers have taken a long-term view and are paying for new modalities that help women access pelvic floor protection data show can be challenging (an important fact contributing to historically low adherence). Access to in-person pelvic floor training can be limited by long wait times, a limited number of providers overseeing pelvic floor training, financial constraints, and the challenge of taking time off work or obtaining child care. Paying for new technologies creates an opportunity for forward-thinking payers to boost screening by offering physicians an effective way to help women access pelvic floor muscle training without significant out-of-pocket costs.
Women are used to taking on the challenges of incontinence. Shame and embarrassment are also silent. Few things affect a person’s dignity like the accidental leakage of urine or feces. Menopause recently became one $15.4 billion industry. We hope the tailwind gives more women the confidence to advocate for their health needs.
The American healthcare system must think differently about a woman’s pelvic floor. Anyone with a rotator cuff injury attracts the immediate attention of an orthopedic surgeon and is eligible for rehabilitation services, regardless of whether he or she has undergone surgery. Yet a woman who delivers her baby vaginally and experiences pelvic floor trauma—leading to pelvic floor weakness, dysfunction, and ultimately urinary incontinence or other pelvic floor disorders—receives a stool softener and a “congratulations.” With a few adjustments we can and should do better.
Milena M. Weinstein, MD, is an associate professor of obstetrics and gynecology at Harvard Medical School. She is chief of the division of urogynecology and reconstructive pelvic surgery, co-chair of the Center for Pelvic Floor Disorders, and research director of the Urogynecology and Reconstructive Pelvic Surgery Fellowship. at Massachusetts General Hospital. Samantha J. Pulliam, MD, is an assistant professor in the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology at Tufts University School of Medicine and physician-in-chief at Axena Health Inc. in Auburndale, Massachusetts.