Urinary incontinence (UI) is a common healthcare problem that is recognized as a worldwide concern, having a substantial medical and economic burden on healthcare systems. Primary care providers (PCPs) are in a perfect position to uncover, triage and/or initiate first-line therapy for females living with UI. However, it has been suggested that UI in females remains under-diagnosed and under-treated in primary care settings.

Objectives: To 1) describe PCPs practices for the evaluation and management of females with UI, and 2) compare and appraise PCP UI practices against recommendations made in high-quality clinical practice guidelines.

A systematic review was conducted, guided by Cochrane methods and PRISMA reporting guidelines (Protocol registered on PROSPERO). Four databases (Medline, EMBASE, CINAHL, Web of Science) were searched from their respective inception dates to March 6, 2023. All studies published in English and French describing PCPs evaluation and management practices for female patients reporting UI were eligible for inclusion (e.g., history taking, objective assessment, interventions, referrals, and follow-ups). Studies were excluded if they: 1) were focused on other healthcare providers (e.g., gynecologists, urologists, physiotherapists), 2) looked at subtypes of UI other than stress, urgency or mixed, and 3) included male, children, or pregnant female. Two reviewers independently selected studies, assessed their quality (Mixed Methods Appraisal Tool), and extracted data. Reported practices were narratively synthesized. Reported evaluation and management practices were then compared to recommendations that were consistent among four recent high-quality (≥70% in five domains using Agree-II) UI guidelines (AUA-SUFU, EAU, ICI and NICE). Consistent recommendations for initial evaluation and treatment are as follows:  focused history taking, pelvic and abdominal examination, pelvic floor muscle assessment, cough test, bladder diary and urinalysis to diagnose UI and conservative strategies as first-line treatment such as pelvic floor muscle training, bladder training and lifestyle modifications. Topical estrogen is also recommended, if needed, to treat vaginal atrophy. Adherence to guideline recommendations was appraised using a cut-off of poor: 0-33% of providers, moderate: 34-66% and high: 67-100%. Pharmacotherapy, referrals and follow-ups were reported descriptively only.

3475 articles were retrieved and underwent abstract screening inclusion, while 31 were retained after full text review. Among the included studies, 27 used quantitative methods, three used qualitative methods, and one used mixed methods (Figure 1). Nine articles were published before or in 2000, eleven were published between 2001-2010, and eleven were published between 2011-2022. Included studies assessed the practice patterns of PCPs in the United States (n=9), the Netherlands (n=5), the United Kingdom (n=5), Norway (n=3), Canada (n=3), Australia (n=1) Denmark (n=1), France (n=1), Germany (n=1) and internationally (n=1; France, Germany, Spain and UK). The majority of studies reported a poor to moderate adherence to performing a pelvic examination (6 of 8 studies reporting on this practice; percent range of all included studies: 23-76%), abdominal examination (2 of 3; 0-87%), pelvic floor muscle assessment (2 of 2; 9-36%), cough test (3 of 4; 12-75%), and bladder diary (8 of 9; 0-92%) while a high adherence to urinalysis was reported in a majority (5 of 9; 40-97%). For the conservative management of UI, studies revealed a poor to moderate adherence to pelvic floor muscle training (7 of 9; 13-82%), bladder training (8 of 8; 2-53%) and lifestyle interventions (5 of 6; 1-71%) (Figure 2). In terms of pharmacotherapy, PCPs mostly prescribed antimuscarinics (2-46%; n=9 studies reporting on this practice) while there was a wider variation for estrogen therapy (2-77%; n=7). PCPs referred to medical specialists (5-37%; n=14), more specifically to urologists (2-27%; n=2), to gynecologists (19-25%; n=2) and urogynecologists (10-12%; n=2). Referrals to medical specialists were generally made less than 30 days following UI initial assessment. From the studies that looked at referral preferences, urologists were the most sought out professional for UI consultations. Finally, there was high variability in PCPs practice patterns around scheduling follow-up appointments (3-79%; n=4). Regarding the quality assessment of included studies, the representative sample of the target population and the appropriate measurement criteria were rated mostly as having an unclear risk of bias across studies. The nonresponse criterion was an unclear or high risk of bias most of the time. For the qualitative studies, the most relevant bias noted was that the approaches chosen were not necessarily appropriate for answering the research question, making the overall coherence of each study unclear.

This review revealed a high variability in PCP adherence to guideline recommendations for the assessment and management of UI in female. However, some trends were observed, including: 1) most studies reported poor or moderate adherence to important objective assessments that allow for a proper diagnosis of UI (abdominal and pelvic exam, bladder diary), 2) an under-use of recommended conservative therapies as first-line treatment, 3) an overreliance on anticholinergic medication and 3) a dependence on medical specialists (based on less than 30 days referrals). Nevertheless, it was found that most PCPs tend to complete a detailed and focused history with their patients. Accounting for the variation in research methodology and clinical practices, our findings lead to the following discussion points. First, a high number of included studies were survey-based (cross-sectional) with a low response rate, thus affecting the generalizability of reported results. Nevertheless, a trend of low to moderate adherence to most guideline recommendations was observed. Second, regarding the methodological quality of the studies included in this review, it is mostly unclear if measurements (surveys, interview questions, etc.) were appropriate to collect data. Most questionnaires and interviews were not validated, and in most studies, it is unclear if they were pilot tested before use. This could lead to unknown measurement errors, with a risk of drawing inaccurate conclusions. Third, only six studies reported on management strategies used per UI subtype. Treatment recommendations for urgency and stress UI differ and, based on our findings, it is unclear if PCPs use the appropriate treatment per UI type, which could lead to false or biased conclusions. Fourth, time and geography could be potential confounders to the findings of this review. We included studies regardless of publication year; and it could reasonably be expected that PCPs studied in older publications may not follow the recommendations included in recent guidelines even though most assessment and treatment recommendations have not changed in two decades. Variation in study results could also stem from differences in geography, which include, but are not limited to the country and the region where data were collected. Each country has their own healthcare system, that could hinder or facilitate some practices.

The findings of this review reveal that PCPs report poor to moderate adherence to most clinical guideline’s recommendations that have been disseminated to them for decades. Despite that these findings are prone to high variability in reporting and may be limited in terms of generalizability, the key message is consistent: patient care for UI needs to be improved considerably. Researchers and audit experts should focus on collecting representative objective data with the use of validated UI quality of care indicators. A collaborative effort should also be made to reflect on the complexity of behavior/practice changes within the PCP community looking specifically at UI; all with the aim to find the best ways to optimize the provision of evidence-informed care for female with UI.

Continence 7S1 (2023) 100906
DOI: 10.1016/j.cont.2023.100906