Original Article
Perception of patients in Urogynecology Outpatient Clinic about the host and conservative therapeutic approach in urinary incontinence Percepção das pacientes do Ambulatório de Uroginecologia quanto ao acolhimento e à abordagem terapêutica conservadora na incontinência urinária Amanda de Oliveira Beltrami1 , Lucas Ruiz Storti2, Adriana Muller3, Ana Carolina Marchesini de Camargo4, Telma Guarisi5, Thomaz Rafael Gollop6, João Bosco Ramos Borges7
ABSTRACT Objective: To describe the perception of patients with urinary incontinence concerning the secondary care facilities outreach and treatment programs. Methods: A cross-sectional descriptive study was carried out, when women referred to the Urogynecology Clinic between January and March 2008 answered to an interview. Results: Most patients included in the study had low schooling level and complained of frequent urinary loss in great quantity. As for the expected type of treatment, the patients were almost equally divided into three treatment types: drug therapy, physiotherapy, and surgery. Concerning their perception of and satisfaction with the received medical care, it was observed that all questions were answered by patients, most of them felt comfortable and safe during their appointment with the physician, and felt that their problem would be solved at the healthcare facility. Conclusions: There is a discrepancy between the patient’s idea of therapy and the treatment that is actually being proposed. However, although this discrepancy exists, a qualified multidisciplinary outreach program results in good satisfaction levels with the medical care, understanding of the problem, and expectation with the treatment. Keywords: User embracement; Urinary incontinence/therapy
RESUMO Objetivo: Descrever a percepção das pacientes com incontinência urinária em relação ao acolhimento no Serviço Secundário e às formas de tratamento para essa afecção. Métodos: Foi realizado estudo
descritivo de corte transversal, por meio de entrevista às pacientes do sexo feminino referenciadas ao Serviço de Uroginecologia, durante o período de Janeiro a Março de 2008. Resultados: A maioria das pacientes incluídas no estudo tinha baixo nível de escolaridade, queixava-se de perda urinária frequente e de grande quantidade. Em relação ao tipo de tratamento esperado, as pacientes se dividiram de modo parecido entre os três tipos de tratamento: medicamentoso, fisioterápico e cirúrgico. Quanto à percepção e satisfação das pacientes em relação ao atendimento recebido, observa-se que todas tiveram suas dúvidas respondidas, bem como a maioria sentiu-se à vontade e segura durante a consulta, achando que teria seu problema resolvido no serviço. Conclusões: Há uma discrepância entre a ideia que a paciente tem em relação à terapia, e o tratamento que de fato será proposto. Mas apesar dessa divergência, o acolhimento multiprofissional qualificado resulta em bons índices de satisfação da paciente em relação ao seu atendimento, ao entendimento do problema de saúde e à expectativa de tratamento. Descritores: Acolhimento; Incontinência urinária/terapia
INTRODUCTION Urinary incontinence (UI) is defined as any clinically shown involuntary urine loss that causes a social or hygienic problem(1). UI is divided into three main types: stress UI (SUI), when the involuntary urine loss is associated with exertion; urge UI, involuntary loss associated with a strong urinary urge; and mixed
Study carried out at Serviço de Uroginecologia do Ambulatório da Saúde da Mulher, Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil. Medical student at Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
1
Medical student at Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
2
Nurse in charge of the Woman Health Outpatient Clinic at Hospital Universitário da Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
3
Assistant professor of Gynecology at Faculdade de Medicina de Jundiaí; Graduate student at Faculdade de Medicina de Ribeirão Preto – USP, Ribeirão Preto (SP), Brazil.
4
PhD in Medicine from Universidade Estadual de Campinas – UNICAMP, Campinas (SP), Brazil.
5
Assistant professor of Gynecology at Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
6
Full professor of Gynecology at Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
7
Corresponding author: João Bosco Ramos Borges – Rua Francisco Telles, 250 – Vila Arens – Jundiaí – CEP 13202-550 – Jundiaí (SP), Brasil – Tel.: 11 4587-1095 – e-mail:
[email protected] Received on May 02, 2009 – Accepted on Aug 13, 2009
einstein. 2009; 7(3 Pt 1):328-33
Perception of patients in Urogynecology Outpatient Clinic about the host and conservative therapeutic approach in urinary incontinence
UI (MUI), the one in which the two symptoms are associated. UI represents a problem that affects a third of women of all ages especially during pregnancy or after normal delivery in the hormonal changes occurred in menopause, periods with fragile pelvic musculature and supporting structures. It is a social and hygienic problem, and it is probably an underreported condition. One of the reasons for this problem is that many people with UI do not spontaneously complain if they are not objectively interrogated by the physician(2). Studies show that 30 to 50% of people suffering from UI sought healthcare assistance only after the first year of onset of symptoms for thinking, initially, that urine loss is expected with aging(3). In general, by the time they seek healthcare attention, these patients already present reduced self-esteem and depression; feel very distressed and bothered by the problem of urine loss. In the USA, urinary loss accounts for approximately 2% of health expenditures which is estimated as more than 16 million dollars a year. It represents a public health problem, which seriously decreases the quality of life of professionally active women, regardless of the type of UI. Its negative effects affect mainly physical activities and self-confidence, self-perception and practice of social activities(4-5). Authors point to the need of providing better awareness to post-menopause women as to the benefits of seeking medical treatment for UI, in order to improve their quality of life(6). For many years, surgery was considered the best option for treating UI. However, relapses were frequent and patient experienced the same initial conditions of urine loss, sometimes with impaired prognosis. Conservative treatment techniques were not used for many years, only in the 1980’s they regained importance, although they appeared in 1948 with Arnold Kegel, who developed exercises aiming at strengthening the pelvic floor musculature to improve the efficiency of urethral sphincter function and the support of pelvic organs for maintaining appropriate blood pressure levels. Examples of this type of treatment include: kinesiotherapy, vaginal cones, electrostimulation and biofeedback(7). On the other hand, lack of resources or unawareness lead the professionals involved in healthcare assistance to these patients to use inadequate treatments without sticking to more precise diagnostic criteria that can clarify the etiopathogeny of each case(8-9). Therefore, it is very important to have a multiprofessional approach to these patients and a perfect interaction among the members of the same team, so that the patient is benefited and the diagnosis is a safe one. With advances in researches of the lower urinary tract and the improvement of diagnostic techniques, conservative treatment slowly took an important role in the rehabilitation of these patients through the perineal
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reeducation techniques. The positive results of these techniques depend on the patient’s good evaluation and the selection of treatment techniques and parameters for each specific type of incontinence that will be treated. Some studies point to significant improvement of the scores of incontinence impact, the limitations of daily activities and physical limitations after performance of a specific physical therapy protocol(10-12). Several patients come to a specialized service with some type of previous treatment; therefore, this is the importance as to how they are approached so that there is an appropriate host of these patients from the moment they arrive at the reference service until they complete all the steps of healthcare assistance. The word harbor is pointed to as the: act or effect of harboring, reception; attention, consideration; refuge, shelter and protection(8). There is also an approach citing biologists, which, based on numerous researches, talk about “harbor”, comparing it with a mother and son relationship. The mother would be a field of shelter and harbor with the responsibility of caring for her child. Taking into account this relationship in the healthcare services, the author indicates that workers can shelter their clientele, in such a way as to be responsible for the development of their users. In a service linked to a teaching institution, it is expected that the differences in terms of harbor may be found based on the behavior diversity ranging from the student, post-graduate, multidisciplinary team and finally the teacher. There is little data in literature related to the evaluation of healthcare assistance provided to patients with UI, as well as those related to the patient’s perception about the treatment received. These facts led us to carry out a study with the purpose of evaluating the healthcare to patients with UI at a recently implemented university service.
METHODS A cross-sectional and descriptive study previously approved by the Ethics and Research Committee of Faculdade de Medicina de Jundiaí. The caseload of the study included female patients who were assisted by medical professionals, nurses, medical school students, physical therapists and psychologists at the Uroginecology Outpatient Clinic of the Municipal Woman Health Outpatient Clinic of Jundiaí at Faculdade de Medicina de Jundiaí. Patients who were already being followed up and treated at this specialized outpatient clinic underwent an interview carried out by pre-trained students from Faculdade de Medicina de Jundiaí. In this interview, from January to March 2008, a pre-tested questionnaire for characterization of the study caseload was used (Chart 1). einstein. 2009; 7(3 Pt 1):328-33
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Beltrami AO, Storti LR, Muller A, Camargo ACM, Guarisi T, Gollop TR, Borges JBR
Chart 1. Characterization variables of the caseload Variable Age Color Marital status Parity Type of deliveries
Time of menopause Schooling
Employment
Concept In years Caucasian, Black, Mulatto, Indian or Asian. Single, married, living together, separated, divorced or widow Number of deliveries Vaginal, forceps and C-section
Details
- -
If C-section: occurrence, or not, of labor contractions, before C-section
In years Illiterate; Incomplete primary education; Complete primary education; Incomplete secondary education; Complete secondary education; Incomplete University education and Complete University education Yes or no
- - -
If yes: 40 hours/week or 20 or less hours/week
Questions related to common urinary complaints include those of the Norwegian EPINCONT Study(13). In order to inquire about hospital welcome and the treatment performed included the ones as follows: - involuntary urine loss reported by the patient; - frequency of urinary loss classified as: less than once a month, once a month or more, once a week or more, everyday and/or night; - quantity of urine loss subdivided into: drops or a little, small quantity and large quantity; - loss of urine upon stress, such as coughing, laughing, sneezing, carrying weight, dichotomized in no and yes; - type of stress in which the losses occur: minimum stress, medium stress, and large stress; - urge incontinence defined as involuntary urine loss associated with a strong and sudden urinary urge, divided into yes and no; - time of urine loss, defined as the time in years that the woman reports she has been presenting urine loss, it is classified as: zero to five years, five to ten years and more than ten years; - previous medical appointment due to urine loss, classified as yes or no; - manner how the patient considers the problem of urine loss, classified as: there is no problem, a little bothered, a little annoyed, a major problem; - number of urine voidings during the day, defined as the number of times that the woman reports going to the toilet to void, as well as the number of times recorded in the micturition diary classified as: up to seven times, more than seven times; - number of voidings at night, defined as the number of times the woman reports she goes to the toilet to
einstein. 2009; 7(3 Pt 1):328-33
-
- -
void at night, divided as: none; one to three; more than three; nocturnal enuresis, defined as the involuntary urine loss during the sleep divided as: yes and no; hematuria, defined as visualization of blood in the urine, reported by the patient as dichotomized as: yes and no; time elapsed since the referral by a physician from the Basic Health Unit and the appointment at the specialty outpatient clinic; request of exams by the Basic Health Unit’s physician; type of instruction received from the Basic Health Unit’s physician; performance of a previous treatment, subdivided into yes and no; type and duration of treatment performed; manner how the patient was welcomed at her original service and at the current service, classified as: very good, good, fair, poor.
Statistical analysis used the software SAS, version 9.02; nominal variables will be represented by absolute and relative frequencies, and interval variables by means of means and standard deviations.
RESULTS All 26 patients included in the study were referred from Basic Health Units. The mean age was 57.6 years; the majority (84.6%) was Caucasian; approximately half of them lived with a partner, was Catholic and had a low level of schooling (Table 1). Patients had a mean number of 5.1 gestations, with the majority being vaginal deliveries (76.9%) and without episiotomy (73.9%). Mean age at menopause was 46.2 years, and the majority (86.4%) reported not using hormone replacement therapy. Table 1. Sociodemographic characteristics of patients (n = 26) Characteristic Color Caucasian Black Mulatto Schooling Illiterate Incomplete primary education Complete primary education Complete secondary education
n 22 2 2 3 19 3 1
% 84.6 7.7 7.7 11.5 73.1 11.5 3.8
Considering the frequency of the complaint, most women presented daily urine loss. As to the quantity of urine loss, half of the patients reported a large quantity of loss and the other half reported a small
Perception of patients in Urogynecology Outpatient Clinic about the host and conservative therapeutic approach in urinary incontinence
quantity (Figure 1). As to the type of incontinence, more than half (69.2%) presented a complaint of MUI, that is, of stress, with the great majority at small and medium exertion, and urge incontinence. Nocturnal enuresis was reported by only one third just as nocturia (Table 2). The minority (23.1%) had not sought medical treatment due to the incontinence complaint, and the majority of patients considered the urine loss a major problem (53.8%) or felt very annoyed (38.5%).
80.00% 70.00% 60.00% 50% 50.00% 26.90% 40.00% 30.00% 23.10% 20.00% 10.00% 0.00% amount of urinary loss
69.20%
19.20% 3.80% 7.70%
small moderate large less than 1x/month Once or more/month Once or more/week Daily
frequency of urinary loss
(70.0%)
(65.4)
(60.0%)
(53.8)
(50.0%) (40.0%)
(34.6)
(34.6)
(30.0%)
Type of urinary loss
n
%
Loss upon exertion
Yes
18
69.2
No
8
30.8
Small
15
57.7
Medium
10
38.5
Large
1
3.8
Yes
18
69.2
No
8
30.8
Yes
7
30.4
No
19
69.6
Type of exertion
Urgeincontinence
Enuresis
As to the type of treatment the patients expected to receive, they were almost evenly divided into the three types of treatments: drug treatment (34.6%), physical therapy (23.1%) and surgical (34.6%). These percentages differ from what was really proposed by the medical team as treatment. In fact, less than one third had a surgical indication; two thirds were treated with drugs and physical therapy was indicated to more than half of the patients (Figure 2). Despite the discrepancy between the patients’ expectations as to how the treatment would be and the treatment proposed by the multiprofessional team, the majority of patients manifested satisfaction with the healthcare assistance. It was observed that all the patients
(26.9
(23.1)
(20.0%)
(19.2)
(10.0%) (0.0%)
(3.8) Drugs Physical therapy Treatment expected by patient
Surgery Does not know Treatment suggested
Figure 2. Comparison between type of treatment expected by patients and proposed by the service
reported their doubts were answered and the majority felt comfortable and safe during the appointment, and thought that they would have their problem solved at the institution (Figure 3).
Figure 1. Percentage distribution of patients per quantity and frequency of urinary loss Table 2. Percentage distribution of patients per type of urinary loss
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(100.0%) (90.0%) (80.0%) (70.0%) (60.0%) (50.0%) (40.0%) (30.0%) (20.0%) (10.0%) (0.0%)
(100.0)(96.2) (65.4)
Answered the questions Patient understood Management would solve the problem Met expectations
(76.9)
(11.5) (3.8) (3.8) (0.0) Yes
Partially
(23.1) (19.2) (0.0) (0.0) No
Figure 3. Distribution of patients per satisfaction with care received and expectations of treatment
DISCUSSION Several measurements have been used to determine the severity of UI in different studies(13). Like the present study, some authors have used a validated severity index in which the frequency and quantity of loss are taken into account. These authors define significant incontinence as the one in which women show moderate and severe incontinence, according to the severity index, and at the same time they feel annoyed with their condition. The results of this current study are in conformity with literature data, in which most patients presented daily frequency and a large quantity loss. This fact was already expected considering that all the patients were referred by gynecologists from Basic Health Units to a specialized service. As to the type of incontinence, most patients presented MUI, that is, stress and urge incontinence, with the great majority at minor and medium stress. einstein. 2009; 7(3 Pt 1):328-33
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Beltrami AO, Storti LR, Muller A, Camargo ACM, Guarisi T, Gollop TR, Borges JBR
Contrary to our findings, previous literature data found MUI in only one third of the patients(13-16). It is believed that the urge incontinence symptoms and MUI seem to be associated with the increased level of severity and annoyance, when compared to the symptoms of stress incontinence only. However, previous data from the present service suggest that a detailed clinical history allows us to more clearly identify the type of urinary loss. Likewise, when objectively questioned about the impact of complaint on the patients’ lives, we observed that most patients considered urine loss a major problem and felt very annoyed with this condition. It was also stated in other studies(17) that some topics in the anamnesis, when judiciously analyzed, allow the gynecologist to figure out a diagnosis and management very close to the ideal ones. When we analyzed the expectation as to the type of treatment, patients were similarly divided as to the types of drug treatment, physical therapy and surgery. At a first instance this may appear innovative, taking into account that several authors still believe that surgical treatment is the number one in terms of success(18-19) and consequently pass this idea to the patients. On the other hand, for more than a decade the conservative treatment was already appointed as being the first resource to be used in different types of UI(20). This explains the results observed in this study as to the type of treatment indicated, where only one third of patients had surgical indication, and in most cases the conservative treatment was indicated by the service as the first choice. When analyzing the patients’ perception and satisfaction in regard to the healthcare assistance received, we observed that all of them had their doubts answered, most patients felt comfortable and safe during the appointment and would have the problem solved at the institution. Subsequently, it was noted a low percentage of patients did not have their expectations met due to the lack of efficacy of some treatments. This fact does not frequently repeat when we search the literature for data related to patient adherence to the conservative treatment. According to van den Muijsenbergh and Lagro-Janssen, all the women who underwent physical therapy interrupted their treatment because they did not understand the reason for doing the exercises, did not do the exercises regularly or gave up for not feeling a beneficial effect; some women also reported that they felt the gynecologist was not paying appropriate attention to their problem, although the majority said they had understood the explanations provided by their physicians(21).
the patient has in regard to her treatment and the one that will actually be proposed. It is also observed that, despite this discrepancy between the expectation and treatment, qualified multiprofessional welcome results in good indexes of patient satisfaction in regard to the healthcare assistance, understanding of the health problem and the treatment expectation.
CONCLUSIONS With the data obtained from this study, we concluded that there is some discrepancy between the idea that
16. Harrison GL, Memel DS. Urinary incontinence in women: its prevalence and its management in a health promotion clinic. Br J Gen Pract. 1994;44(381):149-52.
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