Hypothesis / aims of study
Functional disorders of the pelvic organs and lower urinary tract symptoms (LUTS) are highly prevalent in primary care practice. If conservative or pharmacological treatment fails, referral to a specialist physician for second line treatments is needed. Basic knowledge of the therapeutic possibilities is necessary in order to well inform refractory patients and extent the supporting care network of patients already been treated with those second line therapies. This study aims to explore the knowledge among general practitioners and trainees about the existence of the second line therapies for refractory pelvic organ dysfunctions and LUTS and their correlated factors.
Study design, materials and methods
A 22 item Dutch questionnaire was designed to explore the knowledge of second line therapies for therapy resistant pelvic organ dysfunctions and LUTS. An online link to the survey was sent by email invitation to Flemish general practitioner associations for further distribution to their members, including both general practitioners (GP’s) and GP trainees. After one month of collecting the results, the survey was closed. Having knowledge of a certain therapy was defined by the question if they had ever heard of the therapy before, reported as a dichotomous variable. Univariate descriptive statistics and bivariate analyses were performed. Variables with a p-value of < 0.05 in bivariate analysis were included in the multilineair logistic regression analysis. Variables showing a p-value <0.05 were considered as independent predictive factors for positive knowledge about SNM. A fisher’s exact test was used to compare trainees and GP’s.
Fifty-five (N=55) primary care providers with a median age of 31 years (IQR 26-50) and 26 % male and 74 % female from all 5 provinces of Flanders completed the survey. Among them, 58 % (n=32) worked as a general practitioner (GP) with a median duration of career of 28 years and 42 % (n=23) as a trainee with a mean duration of career of 1 year. Seventy-three % of them was active in a group practice and 16 % in a solo practice. On the question if they had ever heard about the following second line therapies for refractory LUTS, 6 % (n= 3/50), 92 % (51/55) and 71% (39/55) responded ‘yes’ for percutaneous tibial nerve stimulation (PTNS), intradetrusor botulinetoxine injections (BTX-injections) and sacral neuromodulation (SNM) respectively. From the ones who did know SNM, knowledge did originate in 52.7% from the medical training at university, in 16.4% from patients and in 14,5% from colleagues. Urinary incontinence is the most known indication, known by 40% (22/55) of the PCP. Only 23,6 % (13/55) is aware of fecal incontinence as an indication for SNM and 14% (8/55) had no idea of the indications of SNM. Bivariate analyses didn’t show any correlated variables for knowledge of PTNS, nor for knowledge about BTX injections. Statistical significant (p < 0,01) correlations were seen between age (Rs: -0,55), profession, i.e. GP vs. trainee (Rs: 0,46), university of graduation (Rs: -3,36) and SNM knowledge. After multilineair logistic regression analysis with university and profession as independent variables, the profession demonstrated to be the solely independent predictive factor for positive SNM knowledge (OR 13,56 (95% CI: 2,51 -121,38, p= 0,02). A Fisher’s exact test showed a significant difference (p< 0.01) in knowledge about SNM therapy between GP’s and trainees, but not for PTNS (p=0,09) or BTX (p=1) (Cfr. Table 1). Ninety-six % of the trainees is aware of SNM therapy, whereas only 53 % of the GP’s is (Cfr.Table 1 & Fig.1). Within the PCP who had never heard about SNM therapy, 94% are GP’s. Ninety-six % of the participants wants to know more about these 2nd line therapies to be able to inform his/her patient better in the future. Distribution of leaflets in the office and evening lectures were indicated as the first and second most preferred educational options to gain knowledge about these treatments.
Interpretation of results
The knowledge of second line therapies among PCP differ among the type of therapy. Intravesical BTX-injections are well-known among all PCP and are the most recognized therapy for refractory LUTS, followed by SNM and PTNS. Concerning having knowledge of SNM therapy, correlating factors were found. However after multilineair regression analysis, only being GP or trainee could be retained as a significant predictive factor for having SNM knowlegde. Trainees were almost 14 times more likely to be aware of the existence of SNM therapy than GP’s. Within PCP who had never heard about SNM therapy, the GP’s are the most represented group. The difference between PCP in having SNM knowledge in favorite of the trainees, could be declared by the relatively recency of SNM therapy and the recently acquired knowledge of trainees who just graduated from university. These results suggest that in the future educational interventions should be directed especially to the group of general practitioners in terms of SNM therapy. The small number of PCP being aware of the existence of PTNS and the lack of knowledge about indications of SNM therapy, suggest that there is need for further educational improvement.