Racial differences in self-reported healthcare seeking and treatment for urinary incontinence in community-dwelling women from the EPI Study

Urinary Incontinence and Care Seeking Among Wisconsin Women

IMPORTANCE

Women who identify as Black or African American are underrepresented in research about pelvic floor disorders.

OBJECTIVES

The objectives of this study were to describe the prevalence of and factors associated with urinary incontinence (UI) and UI care-seeking among adult women in a Wisconsin household survey.

STUDY DESIGN

This was a cross-sectional analysis of data collected by the Survey of the Health of Wisconsin (SHOW). Using community engagement, individuals who identified as Black or African American were purposively oversampled in the 2018-2019 wave. Descriptive analyses compared women with and without UI, and those who had and had not sought care.

RESULTS

Among 237 study participants, 46% (110) had UI: 46% mild, 36% moderate, and 18% severe. Most participants (84%) self-identified as non-Hispanic Black (84%), with a mean age of 49 ± 16 years and mean body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 34 ± 9; 62% were insured by Medicaid. The prevalence of UI was 44% among women who identified as non-Hispanic Black versus 59% (P = 0.085) among other women. Older age, obesity, needing help to read medical instructions, and identifying as a race other than non-Hispanic Black were significantly associated with UI. Among 110 women with UI, 53% had previously sought care. Rates of UI care seeking were similar (P = 0.32) among women who identified as non-Hispanic Black (55%) and those who identified as another race or ethnicity (43%).

CONCLUSION

Needing help to read medical instructions emerged as a factor associated with UI diagnosis in this sample that included almost 200 women who identified as non-Hispanic Black.

Community-dwelling Black Women's Experiences With Urinary Incontinence: A Qualitative Study

OBJECTIVES

We explored Black women's experiences, concerns, decisions, and challenges of seeking care for urinary incontinence (UI).

METHODS

After screening for UI, we collected questionnaires confirming UI bother. We performed semistructured, one-on-one interviews via video or phone with adult participants who self-identify as Black women and had symptoms of UI. We asked about experiences with UI, perceived impact on quality of life, care-seeking behaviors, and any challenges to seeking care. Audio recordings were transcribed and coded. We then explored the patterns and relationships between codes to identify categories and themes.

RESULTS

We interviewed 24 Black women with UI, aged 19 to 73 years. All had some college education, and more than one-half had degrees ranging from associate to graduate. Five themes emerged: 1) UI symptoms bring up negative emotions and require adaptations; 2) normalization of UI decreases symptom reporting and care seeking; 3) participants' UI and other medical symptoms were often minimized or dismissed by clinicians; 4) participants desire routine UI screening by clinicians and enhanced UI education; and 5) participants encourage more diversity and higher quality care to improve patient trust.

CONCLUSIONS

In addition to embarrassment, Black women's challenges to seeking UI care include prior experiences of trauma within the health care system. Routine screening of patients, enhanced UI education, and provider trust building could improve Black women's experiences and willingness to seek UI care.

Differences in Advanced Therapeutic Modalities for Overactive Bladder in the United States by Race

OBJECTIVE

To investigate the impact of race on prescription patterns of therapies for overactive bladder (OAB).

METHODS

The TriNetX Diamond network was queried to identify adult females with a diagnosis of urinary urgency incontinence (UUI) or OAB, excluding those with stress incontinence or mixed incontinence. Treatments were defined as behavioral, medical, or minimally invasive in accordance with American Urological Association (AUA) guidelines. Propensity-score matching for multiple covariates was performed using the greedy nearest-neighbor algorithm. Cox proportional hazards regression analysis was employed to compare the matched cohorts. Rates of treatment by 3-digit zip codes were compared through chi-square tests or Fisher's exact tests and geographic distribution maps were generated via STATA 17.0.

RESULTS

We identified 2,687,316 adult females diagnosed with OAB; 767,159 identified as White and 108,464 as Black. Within these cohorts, 16.6% of Black patients and 20.4% of White patients received OAB treatment. Twenty-six-point three percent of US zip codes contained data for both White and Black patients, and in all these zip codes, White patients received significantly higher rates of prescriptions compared to Black patients. After propensity-score matching, significant differences in prescriptions persisted between the 2 groups with White patients exhibiting higher rates of any prescription.

CONCLUSION

Our results demonstrate a significantly lower rate of prescriptions of medical and minimally invasive therapies for Black women. These racial differences in prescription of advanced therapeutic modalities for OAB may not be secondary to diagnosis but are likely secondary to prescribing disparities. Further research is needed to understand these differences.

Variation in Overactive Bladder Treatment Type by Social Determinants of Health

IMPORTANCE

There is limited understanding of the relationship between social determinants of health (SDOH) and types of overactive bladder/urgency urinary incontinence (OAB/UUI) treatments.

OBJECTIVES

Our objective was to determine if OAB/UUI treatment type differs by SDOH, including insurance and estimated median household income (EMHI).

STUDY DESIGN

This was a cross-sectional study of adult patients assigned female at birth with OAB/UUI, identified from 2017 to 2022 within a tertiary academic health system. The primary outcome was any OAB/UUI treatment provision. Secondary outcomes included specific treatments and specialty care. We examined associations between SDOH and OAB/UUI treatments using univariable analysis and multivariable logistic regression.

RESULTS

Among 33,002 patients with OAB/UUI, 15.4% received treatment. Treatment provision was associated with American Indian/Alaska Native or Black/African American race, Latina ethnicity, Medicaid, low-income Medicare, or Medicare Advantage (vs private insurance) and EMHI ranging from $26,500 to $100,000 (compared with EMHI >$100,000). Patients with Black/African American race, Medicaid or no insurance, and EMHI ≤$80,000 had higher odds of anticholinergic prescription and lower odds of β3-agonist prescription. Advanced therapy was associated with traditional Medicare, Medicare Advantage, and EMHI $26,500-$100,000 and negatively associated with Asian race. Specialty care was associated with Black/African American race, Medicaid, Medicare Advantage, no insurance, and EMHI ≤$80,000.

CONCLUSIONS

Overactive bladder/urgency urinary incontinence treatment provision was associated with American Indian/Alaska Native and Black/African American race, Latina ethnicity, Medicaid, low-income Medicare, or Medicare Advantage insurance. Patients with Black/African American race and with lower EMHI had higher odds of receiving anticholinergic therapy and lower odds of receiving β3-agonist medication, despite higher likelihood of specialty care.

Addressing Health Care Access Disparities Through a Public Health Approach to Physical Therapist Practice

As the field evolves as a doctoring profession, the role and scope of physical therapist practice must also grow to meet important and urgent public health needs. Scalable, population-level interventions must be prioritized to the same degree as tailored, individual-level care. Drawing from public health frameworks, this perspective proposes an approach to population-level physical therapist care delivery that aims to mitigate disease and disability and improve health outcomes by expanding access, decreasing cost, and improving quality of care for those facing the greatest health disparities. Application of these frameworks prompts the development of novel approaches to rehabilitation service delivery to advance twin goals of promoting access to care and reducing health disparities. This paper describes how a population health framework and public health approach can be used to support necessary evolution and innovation within the field of physical therapy and to improve rehabilitation service delivery. Rapid developments in the digital and virtual health space have created a unique opportunity for physical therapists to lean into a new vision of their role as clinicians within the broader health ecosystem. This paper will provide clinicians with a broader perspective of physical therapist expertise and describe opportunities for the development and application of a physical therapist skill set toward driving population health outcomes. Real-world examples will guide clinicians to consider opportunities in their own practice for implementing this public health approach and potentially addressing various contributors to persistent health disparities.

Geographic Access to Urogynecology Care in the United States

IMPORTANCE

Although access to urogynecologic care is known to influence patient outcomes, less is known regarding geographic access to care and how it may vary by population characteristics.

OBJECTIVE

The primary objective of this study was to estimate geographic accessibility of urogynecologic services in terms of drive time and by population demographics.

STUDY DESIGN

We performed a descriptive study using practice location data by zip code for all board-certified urogynecologists who are American Urogynecologic Society members (n = 497) and pelvic floor physical therapists (n = 985). Drive times from each zip code to the nearest health care professional zip code were calculated. These data were then overlaid onto a map of the continental United States. Race/ethnicity, age, education, poverty status, disability status, health insurance coverage, and rurality were compared across travel times.

RESULTS

Of the 31,754 zip codes of the continental United States, 389 (1.23%) had at least 1 urogynecologist, and 785 (2.47%) had at least 1 pelvic floor physical therapist; 92.29 million women older than 35 years were represented in the demographic analyses. Seventy-nine percent of the studied population live within 1 hour of a urogynecologist, and 85% live within 1 hour of a pelvic floor physical therapist. Seven percent and 3% live >2 hours from urogynecologic services, respectively. Values for drive times to all health care professionals indicate that American Indian/Alaska Native individuals have a much greater travel burden than other racial/ethnic groups.

CONCLUSIONS

There are population groups with limited geographic access to urogynecologic services. Pelvic floor physical therapists are more geographically accessible to the population studied than urogynecologists.

Validation of the Hungarian version of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ)

Objective

The Prolapse and Incontinence Knowledge Questionnaire (PIKQ) is a self-administered, reliable and valid instrument which assess knowledge regarding urinary incontinence and pelvic organ prolapse. There is no validated Hungarian version of this questionnaire; therefore the aim of this study was to develop a reliable, valid and culturally sensitive Hungarian version of the PIKQ.

Study design

A cross-sectional study was conducted from March to October 2022 with a sample of 459 women. The PIKQ, which consists of the urinary incontinence and pelvic organ prolapse scales, was translated into Hungarian in accordance with international guidelines. The validity and reliability of the final version of the Hungarian PIKQ was evaluated using construct validity, comparison with known-groups, internal consistency and test-retest reliability.

Results

Regarding construct validity, all fit indices were found acceptable. Healthcare workers had significantly higher knowledge about urinary incontinence and pelvic organ prolapse (p < 0.001) compared to women who had not worked in a medical field. The Hungarian PIKQ had an adequate internal consistency with Cronbach alpha of 0.785 for the urinary incontinence scale and 0.826 for the pelvic organ prolapse scale. The correlation coeffcients between the test and retest was 0.931 for the urinary incontinence scale and 0.964 for the pelvic organ prolapse scale.

Conclusion

The Hungarian version of the PIKQ is a reliable and valid tool to measure the level of knowledge about urinary incontinence and pelvic organ prolapse among Hungarian speaking women.

Exploring the Hidden Struggles: A Qualitative Insight into Urinary Incontinence Among Prostate Cancer Survivors Post-Surgery

Objective

This study aimed to explore the experiences and challenges of prostate cancer patients suffering from urinary incontinence following radical prostatectomy.

Methods

A descriptive qualitative research design was employed. Purposeful sampling was used to select 22 prostate cancer patients who underwent radical prostatectomy and experienced urinary incontinence after surgery. These patients were interviewed between August to October 2023 at a tertiary B-grade hospital's pelvic floor center in Shanghai. The data were collected through semi-structured in-depth interviews and analyzed using content analysis to identify and refine themes.

Results

The experiences of urinary incontinence in patients can be categorized into four main themes: (1) Daily life disturbances (including 4 sub-themes: sleep disorders, fluid intake restriction, travel inconvenience, loss of sexual life); (2) Negative emotional experiences (including 4 sub-themes: perceived discrimination, concerns about recovery, loss of confidence in life, doubts about the surgical decision); (3) Social withdrawal (including 2 sub-themes: reduced desire for social interaction, decreased ability to socialize); (4) Limited support obtained (including 4 sub-themes: reliance on personal experience, seeking help from relatives and friends, difficulty discerning online information, lack of professional guidance).

Conclusion

Postoperative urinary incontinence in prostate cancer patients presents a multidimensional experience. Healthcare professionals need to pay attention to these patients' daily life, psychological state, and social interactions. Integrating various resources to provide professional support and rehabilitation guidance is crucial.

A mixed methods systematic literature review of barriers and facilitators to help-seeking among women with stigmatised pelvic health symptoms

BACKGROUND

Women's pelvic health is a globally important subject, included in international and United Kingdom health policies, emphasising the importance of improving information and access to pelvic health services. Consequences of pelvic symptoms are intimate, personal, and varied, often causing embarrassment and shame, affecting women's quality of life and wellbeing.

AIM

To understand the experience of seeking healthcare for stigmatised pelvic health symptoms by synthesising all types of published primary research and mapping the results to behavioural theory, to identify potential targets for intervention.

METHODS

Systematic search of MEDLINE, CINAHL, PsycINFO, SocINDEX, PubMED databases, CDSR and CENTRAL registers, from inception to May 2023 for all types of research capturing women's views and experiences of seeking help with stigmatised urogenital and bowel symptoms. Studies only reporting prevalence, predictors of help-seeking, non-health related help-seeking, or written in languages other than English, German, French, Spanish and Swedish were excluded. Reference checking and forward citation searching for all included studies was performed. A results-based synthesis approach was used to integrate quantitative and qualitative data. Themes were mapped to the Common-Sense model and Candidacy framework. The Mixed Methods Appraisal Tool was used for critical appraisal. Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research for assessing certainty of review findings.

RESULTS

86 studies representing over 20,000 women from 24 high income countries were included. Confidence was high that barriers to help-seeking were similar across all study types and pelvic symptoms: stigma, lack of knowledge, women's perception that clinicians dismissed their symptoms, and associated normalising and deprioritising of low bother symptoms. Supportive clinicians and increased knowledge were key facilitators.

CONCLUSIONS

Using the Common-Sense Model to explore women's help-seeking behaviour with stigmatised pelvic symptoms reveals problems with cognitive representation of symptom identity, emotional representations of embarrassment and shame, and a subjective norm that women believe their symptoms will be trivialised by clinicians. Together these barriers frustrate women's identification of their candidacy for healthcare. Addressing these issues through behavioural change interventions for women and clinicians, will help to achieve universal access to pelvic healthcare services (United Nations Sustainable Development Goal 3.7).

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021256956.

Pelvic Floor Disorders in Black Women: Prevalence, Clinical Care, and a Strategic Agenda to Prioritize Care

Pelvic floor disorders are a group of common conditions affecting women of all racial and ethnic groups. These disorders are undertreated in all women, but this is especially magnified in Black people who have been historically marginalized in the United States. This article seeks to highlight the prevalence of pelvic floor disorders in Black women, evaluate the clinical care they receive, examine barriers they face to equitable care, and present a strategic agenda to prioritize the care of Black women with pelvic floor disorders.

Prevalence and predictors of help-seeking behavior among post-partum women with urinary incontinence in China and Indonesia: A cross-sectional survey based on Andersen Help-Seeking Model

INTRODUCTION

Urinary incontinence (UI) is a prevalent condition among post-partum women, and it can significantly affect their physical and psychosocial well-being. Therefore, it's crucial for post-partum women to discuss any UI symptoms they may be experiencing with their healthcare provider and seek appropriate treatment.

PURPOSE

To investigate what leads post-partum women with UI to seek help in China and Indonesia based on the Andersen Help-Seeking Model.

METHODS

A cross-sectional digital survey among post-partum women (6 weeks to 1 year) was conducted from May to November 2021 in China and Indonesia. The survey contents included: (1) demographic characteristics, (2) social support, (3) health care needs, (4) capacity and resources. For analysis, descriptive statistics, independent sample t-tests and chi-square tests were used to determine the differences between help-seeking and non-help-seeking women with UI, and logistic regression analysis and the receiver operating characteristic curve (ROC) was used to determine the predictors of heal-seeking behavior in post-partum women with UI.

RESULTS

The prevalence of UI was 25 % (215/868) and 31 % (187/605) among post-partum women in China and Indonesia. Among post-partum women with UI, the help-seeking rate was 46 % (98/215) and 52 % (98/187) in China and Indonesia. Incontinence quality of Life, support from women of the family (Yes), knowing the available department for UI (Yes), current knowledge of UI and the current status of UI were independent risk factors for China (P<0.05). Support from husband (Yes), being asked about UI by a doctor (Yes) and the current status of UI were independent risk factors for Indonesia. The obtained area under ROC curve (AUC) for the model were 0.884 and 0.935 in China and Indonesia.

CONCLUSIONS

The prevalence of UI and the rate of seeking help for UI in Indonesia were higher than those in China. Social support, needs and the availability of resources and organizational support to assist patients in their help-seeking efforts, were the main predictors affecting help-seeking behavior among post-partum women with UI.

Prevalence and Influencing Factors of Help-Seeking Behavior Among Women with Urinary Incontinence: A Systematic Review and Meta-Analysis

Purpose: This systematic review and meta-analysis aimed to investigate the mean (weighted) prevalence of help-seeking behavior among women with urinary incontinence (UI) in relevant subgroups and the related influencing factors. Materials and Methods: Six English and four Chinese databases were systematically searched between 1996 and July 10, 2022. Two researchers independently screened the literature, extracted data, and evaluated the quality of the included studies. All statistical analyses were conducted using RevMan 5.4. Results: The mean (weighted) prevalence of help-seeking behavior based on the 41 included studies, including a total of 32,640 women with UI, was 28% (95% confidence interval [CI]: 22%-34%). We performed a subgroup analysis based on UI type, population, region, publication time, case definition of help-seeking, and use of validated tools to determine UI. The results of the subgroup analysis showed that the pooled prevalence of help-seeking behavior was 23% (95% CI: 14%-32%) among pregnant and maternity women, 27% (95% CI: 19%-35%) among menopausal women, 24% (95% CI: 14%-35%) among 20- to 50-year-old women, 31% (95% CI: 25%-36%) among those older than 50 years, 24% (95% CI: 17%-30%) in Asia, and 33% (95% CI: 22%-44%) in Europe. Meanwhile, the pooled odds ratio showed that education level, UI type, UI severity, and quality of life significantly influenced help-seeking behavior among women with UI. Conclusions: This systematic review revealed that the pooled prevalence of help-seeking behaviors among women with UI is 28%. These influencing factors have important implications for adapting to health care and social care systems.

Pelvic floor disorder assessment of knowledge and symptoms: an educational intervention for Spanish-speaking women (PAKS study)

INTRODUCTION AND HYPOTHESIS

Educational interventions have been effective in improving postpartum knowledge, performance of pelvic floor exercises, and bowel-specific quality-of-life. Our primary objective was to determine if a video-based educational intervention on pelvic floor disorders (PFDs) would increase Spanish-speaking women's knowledge of PFDs, and secondarily to assess if it would decrease pelvic floor symptoms. We hypothesized that Spanish-speaking women would improve their pelvic floor knowledge and symptoms post-intervention.

METHODS

Inclusion criteria included women age 18 years and older and self-reported as a predominantly Spanish-speaker or equally bilingual English- and Spanish-speaker. Changes in knowledge were assessed with the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). Changes in symptoms were assessed with the Pelvic Floor Distress Inventory-20 (PFDI-20). Linear regression assessed for independent effects.

RESULTS

One hundred and fourteen women were enrolled and 112 completed the pre- and post-intervention PIKQ. Mean (standard deviation [SD]) age was 50 (14) years. Immediate post-intervention scores showed significant improvement in knowledge. Total PIKQ score improved by 5.1 (4.7) points (p < 0.001). POP subscore improved by 2.7 (2.7) points (p<0.001) and UI subscore improved by 2.3 (2.5) points (p < 0.001). Improvement in knowledge continued after four weeks (p < 0.001). PFDI-20 prolapse (p=0.02), colorectal-anal (p < 0.001) and urinary (p = 0.01) scores significantly improved only for the most symptomatic women at baseline. Using linear regression, total PIKQ (p = 0.03) and total PFDI-20 scores (p = 0.04) were associated with predominantly Spanish-speakers versus fully bilingual.

CONCLUSION

Findings support the efficacy of a video-based educational intervention to improve knowledge of PFDs in Spanish-speaking women. The most symptomatic women benefitted from this intervention.

Evidence-Informed, Interdisciplinary, Multidimensional Action Plan to Advance Overactive Bladder Research and Treatment Initiatives: Directives From State-of-the-Science Conference on Overactive Bladder and Cognitive Impairment

ABSTRACT

This article outlines an evidence-informed, interdisciplinary, multidimensional, comprehensive action plan for the American Urogynecologic Society to improve care of women with overactive bladder (OAB) while minimizing treatment-related adverse events, including cognitive impairment. It is a "call to action" to advance basic, translational, and clinical research and summarizes initiatives developed at the State-of-the-Science Conference on OAB and Cognitive Impairment to (1) develop framework for a new OAB treatment approach in women, (2) define research gaps and future research priorities, (3) champion health equity and diversity considerations in OAB treatment, (4) foster community and promote education to remove stigma surrounding OAB and urinary incontinence, and (5) elevate visibility and impact of OAB, by creating partnerships through education and engagement with health care professionals, industry, private and public payers, funding agencies, and policymakers.

Impact of pelvic floor dysfunction in Aboriginal and Torres Strait Islander women attending an urban Aboriginal medical service

BACKGROUND

Pelvic floor dysfunction causes high-level disease burden, with Aboriginal and Torres Strait Islander women less likely to have access to best management for these issues due to multiple sociocultural barriers. There is limited data on the impact of pelvic floor dysfunction in this specific population.

AIMS

To explore the impact of pelvic floor dysfunction on Aboriginal and Torres Strait Islander women attending an urban Aboriginal medical service, considering barriers and facilitators for care, and the services that are desired to address these conditions.

METHODS

This is a mixed methods project utilising the validated Pelvic Floor Impact Questionnaire 7 in combination with qualitative data from semi-structured interviews. Quantitative data were analysed using SPSS Version 24 and analysis included the use of means, SD and Fisher's exact test for comparison. Interview transcriptions were coded into initial themes using thematic analysis and a theoretical approach was used to capture common patterned responses.

RESULTS

The majority of women reported urinary incontinence. Higher scores on the urinary impact questions were significantly associated with comorbid risk factors of chronic cough and obesity. Salient themes from interviews included help-seeking behaviours, embarrassment and normalisation of the condition. Women desired access to a pelvic floor physiotherapist, and preferred a female doctor and a consistent care provider.

CONCLUSION

Pelvic floor disorders cause high disease burden for Aboriginal women across a broad age range with associated comorbid risk factors frequently occurring. This study suggests service improvement and care delivery strategies that may improve long-term outcomes for Aboriginal women with pelvic floor conditions.

Female Urinary Incontinence Evidence-Based Treatment Pathway: An Infographic for Shared Decision-Making

Objectives:

Urinary incontinence (UI) is a highly prevalent burdensome condition among adult females in the United States, yet rates of care-seeking, evaluation, and treatment are nonoptimal. Components of evaluation and treatment are informed by research and professional society guidelines; however, a visual representation of this guidance does not exist. The objectives of this study are to review the literature regarding female UI care and to synthesize this information into a graphical format to facilitate health education, health care delivery, and shared decision-making.

Methods:

We reviewed published society guidelines, position statements, and associated references from the American College of Obstetrics and Gynecology, the Women's Preventive Services Initiative, American Academy of Family Physicians, American College of Physicians, the Society of Urodynamics and Female Urology, the American Urological Association, and the American Urogynecologic Society, and searched PubMed for related literature. We synthesized these findings into an evidence-based infographic depicting female UI risk factors, influences on care-seeking and provision, screening, evaluation, and a stepwise treatment approach.

Results:

This study summarizes current evidence and professional guidelines related to female UI into a compelling visual format and accompanying narrative. The infographic is intended as a tool for patient education, clinical practice, and research to facilitate shared decision-making and health care delivery.

Conclusions:

Female UI is highly prevalent, yet diagnosis and treatment are suboptimal. Use of an evidence-based infographic may positively impact patient knowledge and certainty about UI treatment and support health care provider counseling and decision-making.

Prevalence, social impact and help-seeking behaviour among women with urinary incontinence in the Gulf countries: A systematic review

BACKGROUND

Urinary incontinence (UI) in women is a common problem worldwide. It has a major impact on the physical and social activities and interpersonal relationships. The societies in the Gulf countries are conservative and favours large families, high parity and short inter-pregnancy intervals. Moreover, there is a high prevalence of gestational diabetes with many macrosomic babies. This study aimed to review the published literature on UI among women in this region.

METHODS

All published literature which investigated the prevalence, social impact and help-seeking behavior in women with UI in the Gulf countries was reviewed.

RESULTS

Nine studies met the criteria and were very heterogeneous. None of them was a true population-based study and all except one, investigated subjects from healthcare facilities. The prevalence of UI ranged from 20.3% to 54.5%. Stress UI was the main type reported. The main predisposing factors were chronic respiratory diseases and constipation. There was a large impact on the quality of life with major interference with prayers (34-90%) and sexual relationships (18-57%). The main reasons for not seeking medical advice were embarrassment to see doctors especially male doctors and the belief that UI is common, normal or incurable disease.

CONCLUSIONS

There is a need for true whole population-based studies of UI in this region with the use of validated international questionnaires. UI was shown to have a major impact on the act of prayers and sexual relationships. A large proportion of women are still embarrassed to discuss the issue with doctors especially male doctors.

A Systematic Review of Racial/Ethnic Disparities in Female Pelvic Floor Disorders

Numerous studies have investigated the influence of health disparities among women with pelvic floor disorders with varied results. Racial/ethnic disparities, in particular, inconsistently indicate differences in prevalence of disease, disease severity, and treatment outcomes. We aim to review the body of literature examining racial/ethnic disparities in pelvic floor disorders, including overactive bladder, stress urinary incontinence, pelvic organ prolapse, and interstitial cystitis. A better understanding of these disparities may help guide clinicians, researchers, and advocates in providing improved education, outreach opportunities, and access to care in minority women with pelvic floor disorders.

Representation of Minority Groups in Key Pelvic Floor Disorder Trials

BACKGROUND

Multicenter randomized clinical trials on pelvic floor disorders (PFDs) support evidence-based care. However, many of these studies include homogenous study populations lacking diversity. Heterogeneous sampling allows for greater generalizability while increasing knowledge regarding specific subgroups. The racial/ethnic makeup of key pelvic floor disorder (PFD) trials has not been examined.

OBJECTIVE

This study aimed to investigate racial/ethnic representation in major PFD clinical trials in comparison to racial/ethnic distribution of PFD in the National Health and Nutritional Examination Survey (NHANES).

METHODS

Demographic data were extracted from completed PFD Network (PFDN) and Urinary Incontinence Treatment Network studies, which have resulted in nearly 200 publications. Prevalence of PFD by race/ethnicity was obtained from the NHANES. A representative index (Observed "n" by PFD study/Expected "n" based on the NHANES-reported prevalence) was calculated as a measure of representation. Meta-analyses were performed for each outcome and overall with respect to race/ethnicity.

RESULTS

Eighteen PFDN/Urinary Incontinence Treatment Network studies were analyzed. White women comprised 70%-89% of PFD literature; Black women, 6%-16%; Hispanic women, 9%-15%; Asians, 0.5%-6%; and American Indians, 0%-2%. Representation of White women was higher in 13 of 18 PFDN studies compared with the NHANES prevalence data. Representation of Black women was either decreased or not reported in 10 of 18 index studies compared with the NHANES prevalence data. Hispanic women were absent or underrepresented in 7 of 18 PFDN studies compared with the prevalence data.

CONCLUSIONS

Our examination of PFDN and other landmark trials demonstrates inconsistent reporting of minority subgroups, limiting applicability with respect to minority populations. Our study suggests that PFD research would benefit from targeted sampling of minority groups.

Development of primary design guidelines for supportive underwear to elevate the bladder neck in women based on finite element analysis of the pelvis

The use of supportive underwear has been applied for preventing stress urinary incontinence (SUI) which is caused by descent of the bladder neck due to weakness in the pelvic floor muscles, because it is known that SUI can be improved by elevating the descended bladder neck. However, appropriate approaches to the underwear design are still being explored. In order to establish an appropriate first-order design strategy for supportive underwear, clarifying the relationship between the pressure from the underwear and the amount of elevation of the bladder neck is necessary. We constructed a finite element model of the pelvis based on magnetic resonance images of a subject in an upright position, experimentally explored Young's modulus of the soft tissue and analyzed the amount of elevation of the bladder neck when changing the combination of applied pressures from the underwear. The position of the bladder neck relatively elevated when the pressure in the region from the abdomen to the pubis decreased and when the pressure in the region from the perineum to the coccyx increased, suggesting an appropriate design for the supportive underwear.

Validation of a Spanish Version of the Prolapse and Incontinence Knowledge Questionnaire

OBJECTIVE

The objective of this study was to validate a Spanish version of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ).

METHODS

Validation and reliability testing of the Spanish version of the PIKQ was conducted in 2 phases. In the first phase, a translation-back-translation method by 6 bilingual researchers was utilized to generate a final Spanish translation. In the second phase, bilingual women were randomized to complete the Spanish or English version first, followed by the alternate language. Agreement between individual items from English and Spanish versions was assessed by percent agreement and κ statistics. Intraclass correlation coefficients compared overall PIKQ scores and pelvic organ prolapse (POP) and urinary incontinence (UI) subscores. To establish test-retest reliability, we calculated Pearson correlation coefficients. In order to have a precision of 10% for 90% agreement, so that the lower 95% confidence interval would not be less than 80% agreement, 50 bilingual participants were required.

RESULTS

Fifty-seven bilingual women were randomized and completed both versions of the PIKQ. Individual items showed 74%-97% agreement, good to excellent agreement (κ = 0.6-0.89) for 9 items and moderate agreement (κ = 0.4-0.59) for 14 items between English and Spanish PIKQ versions. Intraclass correlation coefficients of the overall score and POP and UI subscores showed excellent agreement (intraclass correlation coefficient = 0.81-0.91). Pearson correlation coefficients between initial and repeat Spanish scores were high: overall (r = 0.87) and for POP (r = 0.81) and UI subscores (r = 0.77).

CONCLUSIONS

A valid and reliable Spanish version of the PIKQ has been developed to assess patient knowledge about UI and POP.

Applying a Health Equity Lens to Urinary Incontinence

Health equity is attained when everyone has the opportunity achieve the health they envision; however, health disparities are a barrier to health equity. As health disparities specific to urogynecology exist, it is critical to examine and contextualize them in a framework that improves understanding of what factors may drive these disparities to craft effective solutions. This article will review what we currently know about urinary incontinence disparities and provide a framework for evaluation as well as a framework for advancing health equity in the care of diverse patient populations with urinary incontinence.

Patient-Provider Discussions About Urinary Incontinence Among Older Women

BACKGROUND

Urinary incontinence (UI) is prevalent in women and has been associated with decreased quality of life and institutionalization. Despite this, and the fact that several treatment options exist, few women discuss UI with clinicians. The aim of this study was to examine the proportion of middle aged and older women with urinary incontinence who have discussed UI with clinicians, focusing on female health professionals as a way to examine this question outside of issues of health care access.

METHODS

Data are from the Nurses Health Studies (NHS), two ongoing observational, prospective, cohort studies. The surveys collected detailed information about UI, including frequency, amount and type. Women were also asked if they had discussed UI with a clinician. We used multivariable-adjusted logistic regression to estimate odds ratios (OR) of participants reporting discussion about UI.

RESULTS

94,692 women with UI aged 49-91 years old were included in this study. Of these, 34% reported that they had discussed their incontinence with a clinician. Women with daily UI had 4.4 times greater odds of discussing it with clinicians when compared to those with monthly UI (OR = 4.36, 95% confidence interval [CI] 4.06-4.69). When controlling for severity of symptoms, the oldest women, greater than eighty years, were 20% less likely to have discussed UI with their clinician, compared to the youngest women (OR = 0.81, 95% CI 0.73-0.89).

CONCLUSIONS

A minority of women with UI, even among health professionals, discuss their symptoms with clinicians. Oldest women were the least likely to discuss their UI with a provider.

Burdens and Educational Needs of Informal Caregivers of Older Adults With Urinary Incontinence: An Internet-Based Study

PURPOSE

The purpose of this study was to describe the burden and educational needs of informal caregivers of care-dependent older adults with urinary incontinence (UI).

DESIGN

A cross-sectional, descriptive survey of informal caregivers recruited through Google Ads was performed.

METHODS

An online survey, including the Overactive Bladder-Family Impact Measure, was used to assess five areas of the experience of the informal caregiver that may be affected by caring for a person with UI and their educational needs.

FINDINGS

Respondents (n = 77) reported a substantial impact of their care recipients' UI on their lives, with concern, travel, and social subscales most affected. However, 42% never sought treatment on behalf of their care recipient. Educational needs included UI treatment strategies and guidance to select appropriate supplies.

CONCLUSIONS

Caregivers underreported their care recipient's UI and need substantially more support from healthcare providers to manage the condition.

CLINICAL RELEVANCE

Nurses should assess for UI among care-dependent older adults and, if present, provide information and strategies to lessen the impact on caregiver lives.

Women and healthcare providers' knowledge, attitudes and practice related to pessaries for pelvic organ prolapse: A Systematic review

OBJECTIVE

To identify the knowledge, attitudes and practice of women and healthcare professionals in relation to pessary use for POP.

METHOD

This systematic review was carried out in agreement with PRISMA recommendations. PubMed/MEDLINE, SCOPUS, Virtual Health Library, Web of Science, CAPES Periodicals and CINAHL databases were searched for studies without date or language limitations. Search strategies were developed for identifying studies examining knowledge, attitudes and practice toward vaginal pessaries use. Two reviewers independently screened titles and abstracts to identify eligible studies. Data extraction was performed independently in duplicate into a standardized form. Quality of included studies was assessed using the Joanna Briggs Institute quality assessment tool. The protocol was registered with the PROSPERO International prospective register of systematic reviews [CRD42018114236].

RESULTS

Fourteen studies were included. Knowledge and practice were the main domains investigated among patients and professionals, respectively. The results demonstrated poor patient knowledge; however, in urogynecologic patients, knowledge was better. Previous consultation with a Female Pelvic Medicine and Reconstructive Surgery specialist (p = .001) and a higher level of education (p = .006) were associated with improved knowledge of pessary use. Fear of vaginal discharge, irritation, bleeding, and pain were factors that supported the decision not to use a pessary. Previous consultation with a generalist gynecologist (p = .03)and a lower level of education (p = .03) predicted aversion to pessary use. Providers demonstrated adequate knowledge and recommended pessary in 86.4% to 98.0% of cases. Having specialist and pessary management training were some factors that influenced a better attitude towards pessaries among health professionals.

CONCLUSION

The knowledge, attitudes and practice of women and health care providers about pessary use are seldom investigated. Developing a psychometrically valid instrument for assessment of knowledge, attitudes and practice is desirable to examine the complex interactions between these three constructs, expose barriers to pessary care, and develop targeted educational interventions.

Prevalence, risk factors, and treatment for women with stress urinary incontinence in a racially and ethnically diverse population

AIMS

Black women may have lower rates of SUI than Whites, whereas the rate of SUI in Hispanic women varies. Most studies have been conducted in predominantly White populations, making it difficult to evaluate race and SUI. The objective of this study was to estimate the prevalence of SUI in a diverse population and examine racial/ethnic differences in risk factors and treatment.

METHODS

This is a retrospective cohort study of women ≥21 years with SUI seen at our medical center from June 1, 2013 to June 30, 2016. Risk factors measured included age, BMI, SES, diabetes, smoking, Charlson comorbidity index, hysterectomy, and pregnancy. SUI management included consultation with a specialist and active treatment (physical therapy, pessary use, or incontinence surgery). ANOVA, chi-square, and multivariable logistic regression were used to evaluate race and SUI.

RESULTS

The prevalence rate was 4.65 per 100 women (5557 cases/119 452 women). Hispanics comprised the majority (54.13% n = 3008), followed by Blacks (23.54% n = 1308), Other (12.74% n = 708), and Whites (9.59% n = 532). Black women were less likely to consult with a specialist or undergo treatment compared to White and Hispanic women, which persisted in multivariable analysis. Women classified as other were more likely to undergo active treatment in the logistic regression model.

CONCLUSION

SUI prevalence was highest in Hispanics, despite risk factors being more common in Black women. Black women were less likely to consult with a specialist. Mixed or unknown race/ethnicity women were more likely to undergo active treatment. Future studies will evaluate if racial/ethnic differences in SUI management are due to patient preference or provider practices.

Factors associated with reasons incontinent midlife women report for not seeking urinary incontinence treatment over 9 years across the menopausal transition

OBJECTIVE

We explored factors associated with reasons that women with urinary incontinence (UI) reported for not seeking treatment for their UI from a healthcare professional and whether reasons differed by race/ethnicity, socioeconomic status, or education.

METHODS

We analyzed questionnaire data collected from 1995 to 2005 in the Study of Women's Health Across the Nation. In visits 7 to 9, we elicited reasons that women with UI reported for not seeking treatment and condensed them into: UI not bad enough, beliefs about UI causes (UI is a normal consequence of aging or childbirth), and motivational barriers (such as feeling too embarrassed). We used Generalized Estimating Equations and ordinal logistic regression to evaluate factors associated with these reported reasons and number of reasons.

RESULTS

Of the 1,339 women reporting UI, 814 (61.0%) reported they did not seek treatment for UI. The most frequently reported reasons were as follows: "UI not bad enough" (73%), "UI is a normal part of aging" (53%), and "healthcare provider never asked" (55%). Women reporting daily UI had higher odds of reporting beliefs about UI causes (adjusted odds ratio UI 3.16, 95% CI 1.64-6.11) or motivational barriers (adjusted odds ratio UI 2.36, 95% CI 1.21-4.63) compared with women reporting less than monthly UI. We found no interactions by race/ethnicity, socioeconomic status, or education and UI characteristics in reasons that women reported for not seeking UI treatment.

CONCLUSIONS

Over half of women who did not seek treatment for their UI reported reasons that could be addressed by public health and clinical efforts to make UI a discussion point during midlife well-women visits.

Comprehension of Pelvic Organ Prolapse and Urinary Incontinence in Southern Appalachian Women

OBJECTIVES

Despite their growing prevalence, pelvic floor disorders (PFDs) remain undertreated and not well understood by patients, with treatment disparities noted in specific subgroups of women. The goal of the present study was to determine the basic understanding of PFDs of women in the southern Appalachian region of the United States, to determine factors that predict knowledge, and to explore the possible disparities in seeking access to care among women in this region who reported symptoms.

METHODS

A survey of patient knowledge of PFDs, specifically urinary incontinence (UI) and pelvic organ prolapse (POP), was conducted in Johnson City, Tennessee, and involved 305 female patients from this city and the surrounding region.

RESULTS

Almost half of the participants (43%) reported UI symptoms, with only 25% of these participants reporting treatment. A much smaller percentage (5%) reported POP symptoms, but 44% reported receiving treatment. Overall proficiency for UI knowledge was 54.4%, and 69.5% for POP knowledge. Higher UI knowledge was predicted (P < 0.05) by age younger than 60 years, annual income >$50,000, more than a high school education, and being married. UI knowledge was unrelated to the presence of UI symptoms, receipt of UI treatment, or having seen a urospecialist. Higher POP knowledge was predicted (P < 0.05) by annual income >$50,000, more than a high school education, and presence of POP symptoms. The only factor significantly predicting seeking treatment among women with UI symptoms was marital status.

CONCLUSIONS

Overall knowledge of both UI and POP was reasonably high in this population, suggesting appropriate self-education or education by providers in the region. The women most affected by UI, particularly those older than 60 years, were not well informed, and education by providers does not appear to specifically target women seeking treatment. We must continue to educate and further reduce the gap of knowledge and treatment regarding PFDs in southern Appalachia.

Urinary Incontinence and Health-Seeking Behavior Among White, Black, and Latina Women

OBJECTIVE

Fewer than half of women with urinary incontinence (UI) seek care for their condition. Our objective was to qualitatively assess the themes surrounding treatment-seeking behaviors.

METHODS

We conducted 12 focus groups with women and, using purposive sampling, we stratified by racial or ethnic group (white, black, Latina) and by UI frequency. All sessions were transcribed and coded for common themes. Comparative thematic analysis was used to describe similarities and differences among groups.

RESULTS

In total, 113 (39 white, 41 black, and 33 Latina) community-dwelling women participated in focus groups. There were no differences in treatment-seeking themes between groups with different UI frequency. However, certain themes emerged when comparing racial/ethnic groups. Women from all groups shared experiences of embarrassment and isolation because of UI, which were impediments to care seeking. White and black women described discussions with close friends or family that led to normalization of symptoms and prevented care seeking. Latina women maintained more secrecy about UI and reported the longest delays in seeking care. Women articulated a higher likelihood of seeking care if they had knowledge of treatment options, but white women were more likely to seek UI-related knowledge compared with black or Latina women. Physician communication barriers were identified in all groups.

CONCLUSIONS

Despite similar experiences, there are different perceptions about care seeking among white, black, and Latina women. Culturally relevant educational resources that focus on a range of treatment options may improve knowledge and thus improve care-seeking behaviors in women with UI.

Predictors and reasons for help-seeking behavior among women with urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of the study was to evaluate the predictors and reasons for help-seeking behavior among women with urinary incontinence (UI) in Germany and Denmark.

METHODS

This international postal survey was conducted in 2014. In each country, 4,000 women of at least 18 years of age were randomly selected. The questionnaires included validated items regarding help-seeking behavior and the ICIQ-UI SF. UI was defined as any involuntary loss of urine. Binary logistic regression analysis was used to assess factors predicting help-seeking behavior. Reasons for seeking or not seeking help were evaluated in terms of the severity of UI and as the most frequently reported.

RESULTS

Of 1,063 Danish women with UI, 25.3% had consulted a physician compared with 31.4% of 786 German women with UI (p = 0.004). The severity and duration of UI, and actively seeking information regarding UI, were significant independent predictors of help-seeking behavior. Women with slight/moderate UI did not seek help because they did not consider UI as a problem, whereas of women with severe/very severe UI, German women reported that other illnesses were more important and Danish women reported that they did not have enough resources to consult a physician.

CONCLUSIONS

Only a small proportion of women with UI had consulted a physician, and the driving forces for help-seeking behavior were severity and duration of UI and actively seeking information regarding UI. Public information campaigns might enhance consultation rates providing that passively receiving and actively seeking information have the same effects on help-seeking behavior. We show for the first time that reasons for not consulting a physician for UI vary depending on the severity of the UI.

Nonbiologic factors that impact management in women with urinary incontinence: review of the literature and findings from a National Institute of Diabetes and Digestive and Kidney Diseases workshop

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI)-defined as a complaint of involuntary loss of urine-is common in women, with major public health, financial, and quality of life (QoL) implications. Despite the high toll of UI and the availability of effective conservative treatments, many women with UI do not seek care. Those who do often continue to experience symptoms. Improving UI treatment may require a comprehensive approach to urology research, including a broad set of potentially influential factors beyond biologic.

METHODS

To explore the effects of nonbiologic factors (NBF) on UI management and treatment response, the National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop for clinical and psychosocial researchers. Participants proposed a UI treatment pathway: recognizing the problem, willingness to seek treatment, access to care, receiving quality treatment, engaging in self-management, and adhering to chosen treatments; discussed potential NBFs that may affect the pathway; and identified areas for future research. After the meeting, a rapid literature review was conducted to assess the current state of research on NBFs in women with UI.

RESULTS

Participants identified several patient-level NBFs that may influence the UI management pathway, including QoL and perceived bother; stigma, shame, and embarrassment; knowledge and perceptions; social determinants of health; cultural and language characteristics; personal characteristics and skills; and physical abilities. Additionally, participants acknowledged that provider- and system-level factors also play a role and likely interact with patient-level factors.

CONCLUSIONS

NBFs that potentially affect the UI management pathway are not well understood, and a comprehensive, interdisciplinary approach to research is needed to understand and appropriately support effective UI treatment.

Impact of Distance to Treatment Center on Care Seeking for Pelvic Floor Disorders

OBJECTIVE

The aim of this study was to evaluate the impact of distance from residence to treatment center on access to care for female pelvic floor disorders at an academic institution.

METHODS

A retrospective cross-sectional study was conducted of women seen for pelvic floor disorders at an academic institution from 2008 to 2014. Patient characteristics were extracted from charts. Geographical and US census data was obtained from public records and used to calculate distance from patient residence to physician office. Statistical analysis was performed using R Software (Version 0.98.1102) and Microsoft Excel (Version 14.4.7). Statistical significance was defined as a 2-sided P value of less than 0.05, and the χ test was used to determine associations of categorical variables.

RESULTS

A total of 3015 patients were included in the analysis. The mean distance traveled was 93 miles. Thirty percent of patients traveled more than 50 miles. Many patients (43%) reported having the symptoms for more than 2 years. Patients who traveled farther were significantly more likely to be white, English-speaking, and with pelvic organ prolapse as primary complaint. These patients were more likely to plan surgery at the first visit than patients who traveled less far (29% vs 14%). Patients who traveled farther were also more likely to live in counties with a low percentage of persons older than 65 years and low percentage of female inhabitants.

CONCLUSIONS

Women who travel the farthest for treatment of pelvic floor disorders have experienced the symptoms for longer duration and are more willing to plan surgery at presentation. These women also come from counties with fewer elderly women, suggesting future outreach care should focus on similar geographic areas.

Barriers to seeking care for accidental bowel leakage: a qualitative study

INTRODUCTION AND HYPOTHESIS

Fewer than 50 % of women with urinary incontinence (UI) and 30 % of women with accidental bowel leakage (ABL) seek care. We sought to describe barriers to care seeking for ABL to inform development of an instrument to measure these barriers.

METHODS

We recruited women with ABL with varied prior care-seeking experiences to participate in focus groups and cognitive interviews so we could understand factors that may have prevented or delayed care seeking. Focus groups continued until thematic saturation was reached using conventional content analysis. Final themes were established and characterized by comparing within and across the focus groups and with previously described UI and ABL care-seeking barriers. Cognitive interviews were confirmatory.

RESULTS

Thirty-nine women (aged 46-85) participated in six focus groups and ten cognitive interviews; 89 % were white, 8 % African American, and 3 % Latina. We identified 12 barriers to seeking care for ABL: (1) Lack of knowledge about the condition; (2) Lack of knowledge about treatment; (3) Fear of testing/treatment; (4) Normative thinking; (5) Avoidance/denial; (6) Life impact; (7) Embarrassment/shame; (8) Self-blame; (9) Stigma; (10) Isolation; (11) Provider barriers; (12) Access limitations. These 12 barriers encompassed three overarching themes: the internalized self in relation to ABL; perceptions about ABL and its treatments; and interaction with the healthcare system.

CONCLUSIONS

ABL care-seeking barriers are similar to those described for UI, with the notable addition of lack of knowledge that ABL is a medical condition experienced by others. Interventions to promote access to effective treatments for ABL should include information about prevalence and treatability.

Racial Disparities in Knowledge of Pelvic Floor Disorders Among Community-Dwelling Women

OBJECTIVE

To evaluate racial and ethnic differences in knowledge about preventative and curative treatments for pelvic floor disorders (PFD).

METHODS

The is a secondary analysis of responses from 416 community-dwelling women, aged 19 to 98 years, living in New Haven County, CT, who completed the Prolapse and Incontinence Knowledge Questionnaire. Associations between race/ethnicity (categorized as white, African American, and other women of color [combined group of Hispanic, Asian or "other" women] and knowledge proficiency about modifiable risk factors and treatments for PFD were evaluated. Associations were adjusted for age, marital status, socioeconomic status, education, working in a medical field, and PFD history.

RESULTS

Compared to white women, African American women were significantly less likely to recognize childbirth as a risk factor for urinary incontinence (UI) and pelvic organ prolapse (POP), to know that exercises can help control leakage, and to recognize pessaries as a treatment option for POP. Other women of color were also significantly less likely to know about risk factors, preventative strategies, and curative treatment options for POP and UI; however, these findings may not be generalizable given the heterogeneity and small size of this group.

CONCLUSIONS

Significant racial disparities exist in women's baseline knowledge regarding risk factors and treatment options for POP and UI. Targeted, culturally sensitive educational interventions are essential to enhancing success in reducing the personal and economic burden of PFD, which have proven negative effects on women's quality of life.

Elder American Indian women's knowledge of pelvic floor disorders and barriers to seeking care

OBJECTIVES

The objectives of this study are to evaluate urinary incontinence and pelvic organ prolapse knowledge among elder southwestern American Indian women and to assess barriers to care for pelvic floor disorders through community-engaged research.

METHODS

Our group was invited to provide an educational talk on urinary incontinence and pelvic organ prolapse at an annual meeting of American Indian elders. Female attendees aged 55 years or older anonymously completed demographic information and 2 validated questionnaires, the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) and Barriers to Incontinence Care Seeking Questionnaire (BICS-Q). Questionnaire results were compared with historical controls from the original PIKQ and BICS-Q validation study.

RESULTS

One hundred forty-four women completed the questionnaires. The mean age was 77.7 ± 9.1 years. The mean (SD) for PIKQ of urinary incontinence score was 6.6 (3.0) (similar to historic gynecology controls 6.8 [3.3], P = 0.49), and the mean (SD) for PIKQ on pelvic organ prolapse score was 5.4 (2.9) (better than historic gynecology controls 3.6 [3.2], P < 0.01). Barriers to care seeking reported by the elder women were highest on the BICS-Q subscales of "cost" and "inconvenience."

CONCLUSIONS

Urinary incontinence knowledge is similar to historic gynecology controls, and pelvic organ prolapse knowledge is higher than historic gynecology controls among elder southwestern American Indian women. American Indian elder women report high levels of barriers to care. The greatest barriers to care seeking for this population were related to cost and inconvenience, reflecting the importance of assessing socioeconomic status when investigating barriers to care. Addressing these barriers may enhance care-seeking southwestern American Indian women.

Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women

BACKGROUND

More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated.

OBJECTIVE

We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women.

STUDY DESIGN

We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment.

RESULTS

Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician.

CONCLUSION

Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

Barriers to urinary incontinence care seeking in White, Black, and Latina women

OBJECTIVE

We compared barriers to urinary incontinence (UI) healthcare seeking between white, black, and Latina women.

METHODS

This is a cross-sectional study using a convenience sample of white, black, and Latina women. Women completed the Barriers to Incontinence Care Seeking Questionnaire (BICS-Q), the Incontinence Quality of Life Instrument (I-QOL), the Questionnaire for Urinary Incontinence Diagnosis, and the Incontinence Severity Index (ISI). The primary objective was to assess barriers to UI care seeking among groups, as measured by the BICS-Q. Secondary objectives were to assess factors associated with barriers to incontinence care and to compare specific barriers using BICS-Q subscale scores. Regression analyses were used to further assess for differences among groups while adjusting for potential confounding variables.

RESULTS

We included a total of 93 subjects, including 30 white, 33 black, and 30 Latina women. Mean I-QOL, Questionnaire for Urinary Incontinence Diagnosis, and ISI scores were not significantly different among our 3 groups. Barriers, based on BICS-Q scores, were lowest in white women and higher in blacks and Latinas (2.9 vs 7.3 vs 10.9, respectively; P < 0.001). When adjusting for potential confounders such as age, income, education, presence of UI, ISI score, and I-QOL score, Latinas continued to demonstrate higher barriers compared with white or black women (β = 7.4; 95% CI, 2.2-12.7; P = 0.006). There were no significant differences between black women compared with other groups in the adjusted analyses.

CONCLUSIONS

Latinas experience more barriers to UI healthcare seeking compared with white and black women.

Factors associated with seeking treatment for urinary incontinence during the menopausal transition

OBJECTIVE

To examine whether longitudinal urinary incontinence (UI) characteristics, race or ethnicity, socioeconomic status, and education were associated with UI treatment-seeking in a prospective cohort of community-dwelling midlife women.

METHODS

We analyzed data from 9 years of the Study of Women's Health Across the Nation. The study asked participants reporting at least monthly UI about seeking treatment for their UI at baseline and in visit years 7, 8, and 9. Our main covariates included self-reported race or ethnicity, income, level of difficulty paying for basics, and education level. We used multiple logistic regression to examine associations between demographic, psychosocial, and longitudinal UI characteristics and whether women sought UI treatment. We explored interactions by race or ethnicity, socioeconomic status measures, and education level.

RESULTS

A total of 1,550 women (68% of women with UI) reported seeking treatment for UI over the 9 years of this study. In multivariable analyses, women had higher odds of seeking treatment when UI in the year before seeking treatment was more frequent (adjusted odds ratio [OR] 3.16, 95% confidence interval [CI] 1.15-8.67) and more bothersome (adjusted OR 1.09, 95% CI 1.01-1.18), with longer symptom duration, and with worsening UI symptoms (adjusted OR 1.75, 95% CI 1.01-3.04). Women who saw physicians regularly, had more preventive women's health visits, or both were more likely to seek UI treatment (adjusted OR 1.18, 95% CI 1.07, 1.30). Race or ethnicity, socioeconomic measures, and education were not significantly related to seeking treatment for UI.

CONCLUSION

We found no evidence of racial or ethnic, socioeconomic, or education level disparities in UI treatment-seeking. Rather, longitudinal UI characteristics were most strongly associated with treatment-seeking behavior in midlife women.

LEVEL OF EVIDENCE

II.

Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery

OBJECTIVE

To estimate the lifetime risk of stress urinary incontinence (SUI) surgery, pelvic organ prolapse (POP) surgery, or both using current, population-based surgical rates from 2007 to 2011.

METHODS

We used a 2007-2011 U.S. claims and encounters database. We included women aged 18-89 years and estimated age-specific incidence rates and cumulative incidence (lifetime risk) of SUI surgery, POP surgery, and either incontinence or prolapse surgery with 95% confidence intervals (CIs). We estimated lifetime risk until the age of 80 years to be consistent with prior studies.

RESULTS

From 2007 to 2011, we evaluated 10,177,480 adult women who were followed for 24,979,447 person-years. Among these women, we identified 65,397 incident, or first, SUI and 57,755 incident prolapse surgeries. Overall, we found that the lifetime risk of any primary surgery for SUI or POP was 20.0% (95% CI 19.9-20.2) by the age of 80 years. Separately, the cumulative risk for SUI surgery was 13.6% (95% CI 13.5-13.7) and that for POP surgery was 12.6% (95% CI 12.4-2.7). For age-specific annual risk, SUI demonstrated a bimodal peak at age 46 years and then again at age 70-71 years with annual risks of 3.8 and 3.9 per 1,000 women, respectively. For POP, the risk increased progressively until ages 71 and 73 years when the annual risk was 4.3 per 1,000 women.

CONCLUSION

Based on a U.S. claims and encounters database, the estimated lifetime risk of surgery for either SUI or POP in women is 20.0% by the age of 80 years.

LEVEL OF EVIDENCE

III.

Factors associated with treatment-seeking behavior for postpartum urinary incontinence

PURPOSE

To identify the factors associated with treatment-seeking behavior for urinary incontinence (UI) among postpartum women.

DESIGN

This is a cross-sectional study. A total of 142 women with postpartum UI responded a telephone interview between August of 2010 and March of 2011. The association between the treatment-seeking and the predicting variables were measured through odds ratio and 95% confidence interval.

RESULTS

The treatment-seeking percentage was 37.3% and the treatment percentage was 27.5%. The result of multiple logistic regressions indicated that: counseling about UI in pregnancy, postpartum physical exercise, and Spanish nationality predicted 47.8% of the variance in treatment-seeking behavior

CONCLUSIONS

The lack of counseling largely determines the low rates of treatment-seeking among Spanish mothers.

CLINICAL RELEVANCE

Nursing counseling during pregnancy can contribute substantially to increasing the number of women treated for postpartum UI.

Single-Arm Pilot Study to Determine the Effectiveness of the Support Power of Underwear in Elevating the Bladder Neck and Reducing Symptoms of Stress Urinary Incontinence in Women

OBJECTIVES

To verify the effectiveness of support power of underwear (the shaper) to elevate bladder neck and to reduce symptoms of stress urinary incontinence (SUI).

METHODS

This was a single-arm pilot study conducted in Japan by using the shaper (SLIM-up-Pants with Style Science, Wacoal Corporation, Kyoto, Japan). The bladder neck position in a sitting posture was recorded using an open-configuration magnetic resonance system and then compared between parous women with SUI, without and with the shaper. Women wore the shaper during the daytime for 12 weeks, followed by one week during which they did not wear the shaper. The symptoms of urinary incontinence (UI) were assessed based on the 1-h pad test, the Japanese version of the International Consultation Incontinence Questionnaire-Short Form, and the incontinence diary.

RESULTS

Forty-five Japanese women with SUI, aged between 27 and 65 years, were included. When the shaper was worn, the bladder neck was found to be significantly elevated by 11.5 mm (median; P < 0.05/6 = 0.008). After 12 weeks, all symptoms of UI decreased significantly (P < 0.05/3 = 0.016), and the bladder neck was further elevated by 4.7 mm (median; P < 0.001) even when not wearing the shaper. In addition, after one week of not wearing the shaper, the bladder neck position remained elevated and symptoms of UI did not recur immediately.

CONCLUSION

The shaper was considered to be effective in elevating the bladder neck and reducing symptoms of UI.

Knowledge of pelvic floor disorders in a population of community-dwelling women

OBJECTIVE

The objective of the study was to investigate baseline knowledge and demographic factors associated with a lack of knowledge about urinary incontinence (UI) and pelvic organ prolapse (POP).

STUDY DESIGN

This study was a community-based, cross-sectional survey of 431 racially and socioeconomically diverse women aged 19-98 years. The Prolapse and Incontinence Knowledge Questionnaire was used to assess participants' knowledge. Primary endpoints were the total number of correct responses on the UI and POP scales, respectively. Percentages of individuals answering each item or group of items correctly were explored as secondary outcomes.

RESULTS

All women lacked knowledge proficiency about UI and POP, although knowledge about UI was slightly greater than knowledge about POP. Overall, 71.2% of subjects lacked UI proficiency (<80% correct), whereas 48.1% lacked proficiency in POP knowledge (<50% correct). Black women demonstrated significantly less knowledge about UI and POP than white women, both before and after adjustment for age, education, and household income. When combined into 1 group, Asian, Hispanic, and other women also showed significantly less UI and POP knowledge than white women. Most women who reported symptoms of UI had not received treatment for their problems.

CONCLUSION

There is a global lack of knowledge about UI and POP among community-dwelling women, with more pronounced knowledge gaps among nonwhite women. UI and POP are chronic medical conditions that should be included in routine screening questions for well-woman care. Further studies are needed to explore how best to educate and improve women's awareness of these prevalent pelvic floor disorders.

Factors associated with care seeking among women with accidental bowel leakage

OBJECTIVE

The aim of this study was to characterize factors associated with care seeking among women with accidental bowel leakage (ABL).

METHODS

A secondary analysis of 938 women with ABL identified in a community-based Internet survey of 5817 US women 45 years or older was performed. Demographics, medical history, incontinence severity, quality of life, coping, and care seeking were assessed using questions derived from validated questionnaires. Accidental bowel leakage was defined as at least 1 episode of stool leakage in the past year in the absence of acute diarrheal illness. Women with ABL were asked, "Have you ever talked to a physician about accidental leakage of stool and/or gas?" and were designated "care seekers" if they responded affirmatively. Factors associated with care seeking on univariate analysis with P < 0.1 were included in a multivariate model.

RESULTS

The response rate overall was 85% (5817/6873) with 1096 women (19%) reporting ABL. Care-seeking data were available for 938 (86%). Of these, 85% were white, 6% were black/African American, 5% were of Hispanic/Latina/Spanish origin, and 4% other; median age was 55 to 59 years (range, 45 to 49, >75 years), and 87% were insured. Only 29% (268/938) of those with ABL sought care. Multivariate analysis demonstrated that care seekers were more likely to have a primary care physician (PCP), to have heard of ABL, and to have suffered longer with more severe leakage.

CONCLUSIONS

More than two thirds of women with ABL do not seek care. Because those with a PCP and those who have heard of the condition are more likely to seek care, educating the public about ABL and encouraging establishment of care and communication with a PCP may decrease silent suffering.