Nearly one million men and women in the Netherlands experience urinary incontinence. More than half of this group uses continence aids, such as pads or catheters (1). In the Dutch health care system, general practitioners (GPs) have a gatekeeper function. Therefore, GPs are the first health care professionals to be consulted by patients. Next to this, specialized continence nurses are available for patients, but it seems that not all GPs are aware of this. Next, it is unclear how GPs provide specific advices concerning continence aids to their patients.
We aimed to provide inside how GPs manage care for urine incontinence.

We developed a short online survey about the care provided by GPs in case of continence pad prescription. This online survey was distributed in two different networks for GPs (HAweb, a Dutch online platform for GPs) and a regional Dutch academic GP development network).
The survey consisted of 17 questions, addressing the following topics: 1) patient examination by the GP (3 questions); 2) management of incontinence by the GP (5 questions); 3) familiarity with the continence nurse (6 questions) and 4) knowledge about continence care in GP guidelines (3 questions). Most questions were multiple-choice questions. The final open question addressed possible duties for the specialized continence nurse in the general practice.
Frequencies for each category were expressed as a valid percentage of the total response.

The first 97 completed surveys of this on-going survey showed that the most common part of patient examination was asking for other pelvic complaints, with 61% of GPs always or frequently asking for this. Physical examination and testing pelvic floor muscles was always or frequently performed by 40% and 36% of the GPs respectively, before prescribing incontinence pads.
Most GPs indicated that they first prescribed another therapeutic option in 40-60% of the cases before prescribing incontinence pads and a quarter of the GPs indicated doing this in 20-40% of the cases. Slightly less than half of the GPs (always or frequently) gave patients supporting information. 
Lifestyle advice was regularly discussed with the patients before prescribing incontinence pads, with 55% of GPs doing this always or frequently. Doing pelvic floor muscle training with the patient before prescribing continence pads was always or frequently done by 86%. 
Anticholinergic drugs were never prescribed, or only occasionally prescribed by 86%, before prescribing incontinence pads. For mirabegron only one GP mentioned prescribing this more frequently. Collaboration with a pelvic physiotherapist was reported by 82% (always/frequently). Most GPs never or occasionally gave pharmacies specific advice about the choice for a certain type of continence aid. 
Seventy-five percent reported not to be familiar with the knowledge and skills of the specialized continence nurse and 94% was unaware who the specialized continence nurse in their region was. Only two GPs had consulted the specialized continence nurse in their region or referred a patient. 
Fifty-five percent of the GPs indicated that they could see a role for specialized continence nurses in their practice. These GPs most frequently named the expertise of the specialized continence nurse, which the GPs felt they lacked themselves, as a reason for a role in general practice. GPs that did not see a role for continence nurses mentioned that there would not be enough work for them. This was often followed by the suggestion of referring patients to a specialized continence nurse in a home care organization.
About three-quarters of the GPs would appreciate more information about continence care in the Dutch GP guidelines; 66% actually missed references for continence care in the guidelines ‘urinary incontinence in women’ (64%) and the ‘lower urinary tract symptoms in men’ (53%).

These preliminary results indicate that Dutch GPs tend not to physical examine patients with urinary incontinence. Although asking for other pelvic complaints is more common, still less than two thirds of the GPs do this frequently. 
Before prescribing incontinence pads as management of continence care, GPs frequently provided lifestyle advice or pelvic floor training. Only a minority of GPs  prescribed anticholinergic drugs and mirabegron. GPs frequently collaborated with pelvic physiotherapists, but almost never gave pharmacies specific advice about the choice for a certain type of continence aid. In almost half of the cases GPs gave patients supportive information.
Remarkable was that most GPs were unfamiliar with the knowledge and skills of specialized continence nurses and the specialized continence nurse in their region. Due to this unfamiliarity, hardy any GP consulted these nurses. Nevertheless, GPs would appreciate working together with specialized continence nurse, either in their general practice or in a consulting function in a home care organization. 
Knowledge about continence care in Dutch GP guidelines was missed by most GPs. Adding this information to future guidelines may help increasing the knowledge of GPs and improving continence care. 
Due to the sampling method, this study may not include a representative sample of Dutch GPs. In fact, we expect that GPs with an interest in this topic are more likely to participate. So, the results of this survey may reflect overestimations, suggesting that the situation in Dutch primary continence care is even worse.

This is the first study exploring continence care provided by GPs in the Netherlands. It shows that there is much room for improvement of continence care, both on a physician level (improving history taking, physical examination and providing proper support to patients) as on an organisational level (collaboration with continence nurses). Future studies should address the barriers and facilitators of good continence care in general practice, to better serve patients with urinary incontinence.

Continentie Stichting Nederland. Cijfers Incontinentie [internet]. 2016 [cited 2019-03-19]. Available from: http://continentie-stichting.nl/cijfers-incontinentie-0.