Urinary incontinence (UI) in women is a common problem. These women often turn to their general practitioner (GP) for treatment. The Dutch society for GP’s has a well-designed guideline “urinary incontinence in women”. GP’s need to have a good knowledge of different types of UI and the specific guideline. The objective of this study is to gain insight in the treatment of women with UI started by GP’s before referral to a specialized continence outpatient department. Do GP's follow their guideline?

We conducted an observational cohort study of women referred to our specialized outpatient department with complaints of UI, between April 2015 and July 2017. Information from the GP's referral letter and information from the hospital medical records were used. Data were collected concerning different treatment options: physiotherapy, pessary, medication or a combination therapy.  Statistical analysis was done using SPSS.

A total of 425 women were included in this study, with a mean age of 56 years (SD 15.5 years). In 226 (53.2%) of the referred women a treatment was started by a GP. In 20 (4.7%) cases it was unknown if a treatment was started. 
Physiotherapy (pelvic floor) was started for 181 (80.1%) of the treated women. If a GP diagnosed stress urinary incontinence, the guideline was followed by starting a treatment of physiotherapy in 58.4% (87/149). A pessary was given to 28 (12.4%) of the treated women.
Drug therapy was started for 39 (17.3%) of the treated women. If a GP diagnosed urgency urinary incontinence, anticholinergic medication was given in 26.7% (16/60) of the cases. For mixed urinary incontinence this was 11.7% (13/111). A combination therapy of physiotherapy, pessary and/or medication was started for 22 women.

Different types of anticholinergic medication started by GP’s are shown in table 1. 

Most anticholinergic medications were given to women diagnosed with urge-incontinence (41%, 16/39) or mixed incontinence (33.3%, 13/39). According to the GP’s guideline generic Tolterodine is first choice in drug therapy; this was started in 38.5% (10/39). Non generic Solifenacin was the most used anticholinergic medication with 53.8% (21/39).

This study shows the difficulty amongst GP's to start optimal treatment for specific types of UI in women. Also, GP's tend to not follow their guidelines correctly. In only half of the referred women a treatment had been tried earlier on. Physiotherapy was chosen most often, but for women diagnosed with stress urinary incontinence the guideline was followed by this first choice therapy in only 58.4% of the cases. Also when choosing drug therapy in GP diagnosed urgency urinary incontinence, GP’s preferred a more expensive non generic type of anticholinergic medication instead of the guideline preferred generic one. It can be assumed that if general practitioners do not start correct treatment for urinary incontinence, therapy in the first line will not be optimal, leading to non referred disappointed women on one hand and unnecessary treatment in hospitals on the other hand. Furthermore, as we consider healthcare in The Netherlands as being high level, situation in other countries may even be worse.

To optimize treatment of women with UI in the first line as well as to prevent unnecessary hospital referral, increasing knowledge of GP’s on this very common problem and its treatment guidelines needs further attention.