Hypothesis / aims of study
The present study is the first to report on the initial clinical interactions of patients with urinary incontinence (UI) from the experiences of clinicians in India.
UI has been found to affect one in three women above the age of 30 at some stage in their lives, often triggered by pregnancy and menopause (Kołodyńska et al., 2019). Typically, a gynaecologist serves as the primary point of contact and depending on symptoms and management they may refer the patient to a urologist, both integral in the treatment of UI (Madjar et al., 2001). Patients’ decisions regarding seeking healthcare depend on a myriad of factors: Lack of time (36.3%), humiliation (15.7%), and fear of surgery (14.7%) have been identified as the most prevalent explanations for delays (Koch, 2006). The ramifications of UI range from physical, and psychological to even social aspects of one’s life.
While prior studies have attempted to assess patients' health-seeking behavior, there exists a gap in understanding clinicians' perspectives on this matter in the Indian context. The present study aims to bridge this gap.
Study design, materials and methods
Gynaecologists, urologists, and urogynecologists were approached to be interviewed for the study. A semi-structured interview was used to maintain focus on the study objectives while allowing clinicians to express freely from their clinical practice. The interviews centred on their experiences with UI patients, covering the broad themes of patient presentation, diagnostic tools, patient experiences, prevention strategies, and other aspects of clinical interactions.
Interviews were recorded for those who consented, while a designated notetaker recorded notes for others. Patterns that emerged from the interviews were documented and used to formulate hypotheses. These hypotheses were then analyzed in conjunction with the collated interview data to determine their validity or invalidity, through an evidence-based approach. For example, Dr P. remarked, “Most patients come with an associated infection, stress urinary incontinence is a question asked by us (clinicians), it needs to be probed”. This observation is evidence of the challenge that clinicians face in diagnosing UI and the extra effort that they put in for this, as it often requires explicit probing and would remain undiscovered otherwise.
Results
A total of 29 clinicians participated in our study (19 urologists, all but two were male; 9 gynaecologists, all female; and 1 urogynaecologist, female). They had 3 to 38 years (median: 15 years) of experience as practitioners.
Upon completing one round of analysis, patterns were identified and the following two hypotheses were formulated: (i) More often than not, incontinence is identified by clinicians when patients come for a different complaint. (ii) The chances of older patients with incontinence seeking medical care increase with increasing levels of severity.
The collated interview data was analyzed again with a specific focus on these hypotheses, and data results were seen to confirm them. 76% (16 out of 21) of clinicians provided evidence that patients often present with a different complaint initially, only for it to be discovered upon probing that they are actually suffering from UI. Additionally, 65% (19 out of 29) of clinicians, primarily urologists, reported that older patients tend to seek medical attention at later stages or with high severity of UI. These findings shed light on diagnostic challenges and the timing of patient presentations in the context of UI.
Interpretation of results
Women's health issues in general have a sense of enigma. Knowledge about different issues at every life stage from menstruation to pregnancy to menopause is very limited among lay people. Consequently, it makes patients prone to present themselves for seeking care at a later stage as they are not aware that incontinence can be a serious problem and should be treated. The semi-structured interviews conducted with clinicians helped to recognise various facets of incontinence healthcare, exploring challenges, solutions, and new developments from the perspective of practicing clinical professionals.
Incontinence among patients is usually discovered when they come with a different complaint such as diabetes or other comorbid conditions. Dr. F reported that “Patients often come with conditions such as diabetes, prolapse etc. and urinary incontinence is found in later stages of consultation”. Clinicians further emphasized that patients typically lack awareness about urinary incontinence, and the clinicians end up making an extra effort during diagnosis. This resonates with what Dr. P. noted, highlighting the need for thorough probing to accurately ascertain the underlying issue when patients present with unrelated complaints.
One urologist shared about the importance of reaching out early which can lead to effective management. Dr S. stated, “I teach them lifestyle modification such as diet, and exercises alongside the medication that has helped them. Bladder diary initially and monitoring it has helped me. I have seen patients with moderate SUI and after 3-4 months, it is gone so if they come earlier it can be managed”. Expressing concern, she stressed the potential for early care and intervention to significantly improve the management of SUI. This insight from clinician interviews, is a new learning on the importance of proactive patient engagement in UI management, supplementing the understanding derived by previous research articles solely from the patient interviews.
Patient presentation and initial clinical interactions have been linked with the severity of symptoms. Clinicians noted that older patients tend to seek treatment when they experience higher levels of severity, indicating that they would try to manage early symptoms by themselves or not deem it important enough to require medical attention. Dr V. reported, “More degree of older patients usually come with severe levels.”
Furthermore, we found that these interactions are also impacted by beliefs and the narrative that being a woman and growing up they have to go through pain as reported by Dr F., “They believe that is part of womanhood to go through this and that delays their treatment”. According to research, women who thought that "UI is a natural part of getting older" were far less likely to ask for assistance (Koch, 2006). Notably, these insights were derived from patient experiences, while the present study reinforces them from clinician perspectives.
The authors recognize susceptibility to recall and availability biases due to the limited sample size, exclusive focus on the urban population and the semi-structured nature of the interviews conducted as limitations of the present study.
This study serves as a starting point in understanding clinician perspectives and lays the base work for a more comprehensive study in the future, including larger sample size, and evaluation of methods that can improve the process of diagnosis and treatment of incontinence.