First, overcome the embarrassment factor
New guidelines released last year on the treatment of stress incontinence elevated the role of surgery as a cure, but paying close attention to two obstacles - embarrassment and ignorance - can help stave off wound care problems associated with the condition.
The issue is critical for wound care providers because incontinence is a major risk factor associated with pressure ulcers, especially among the elderly. Moisture from incontinence makes the skin more susceptible to breakdown by increasing the frictional coefficient, which can cause shearing and rubbing damage. Moisture also promotes microbial growth.
A woman's appraisal of the bother of bladder leakage is a critical factor, says Roger R. Dmochowski, MD, from the University of Tennessee Medical Center's Department of Urology in Memphis. But many women and their doctors don't even reach the point of discussing the problem because shame and embarrassment bar the mention of incontinence.
"A woman figures she's had a baby or two, and she knows her mother and grandmother wore protective pads - she figures it's normal," adds Lynda Christison, MPA, executive director of the National Association for Continence in Spartanburg, SC. "Sometimes a person will barely tiptoe into the subject with a doctor, but the doctor will shut down and not pursue it. Physicians are not well-trained in treating incontinence."
"Most women will put up with problems if they can sit through a movie, which is about two hours," adds Janis Luft, NP, MS, director of pelvic rehabilitation at the University of California at San Francisco, "but I see women who visit the bathroom every 15 minutes. Normal bladder function is a bathroom visit every three to six hours."
Luft estimates that 25% of all women from menarche to menopause have occasional to regular incidents of leakage, while 40% of women over age 65 have bladder problems. Luft's take on the extent of the problem is no exaggeration, according to studies and figures from the American Foundation for Urological Disease in Baltimore.1,2
'There is almost always room for improvement'
The range of treatment options is unknown to many physicians, as well as to lay people. Women often don't want to bother with surgery or don't trust it because they know someone who had an unsuccessful operation. Yet in reality, Christison says, "There is almost always room for improvement or cure."
The first step toward improvement is diagnosis and treatment. Diagnosis and treatment start with a bladder diary to track the frequency and circumstances of incontinence episodes. This can take three to four months of intensive patient-provider cooperation. Appointments should be 30 minutes long, Luft advises. Some women need three to four biweekly sessions, while others require more frequent appointments or longer periods of treatment.
The improvement and cure rates for non-surgical treatment are impressive. Luft reports that 60% to 80% of her patients experience good results.
Specific treatments often include:
· Pelvic floor strengthening.
Even if a person has surgery, strengthening pelvic muscles is a necessary follow-up to keep the surgical repair intact. Many facilities use biofeedback to teach strength-building pelvic muscle contractions, commonly called Kegel exercises. Biofeedback sensors connected to a computer are placed around the anal and vaginal openings as well as the abdomen. As the woman watches her contraction patterns on the screen, she learns to isolate the squeezing movements to the pelvic floor muscles.
· Behavioral therapy.
This involves urge control and bladder retraining. As Luft explains, "We teach women to calmly wait for longer intervals [of 10 to 15 minutes] instead of making the mad dash to the bathroom. This retrains the bladder to respond to the urge as a voluntary activity."
Luft says some women need anticholinergics or antispasmodics to control bladder urges. The most often-used drug is oxybutinin, which comes under the brand name Ditropan, manufactured by Hoecsht Marion Roussel in Kansas City, MO.
A panel from the Baltimore-based American Urological Association reported last year that two surgical procedures produce excellent results for stress incontinence. The standard of effectiveness is a "cure dry rate" of five years or more without urinary leakage.
Two surgical procedures produced cure dry rates in 85% of the cases. The first, retropubic suspension, is performed through an incision in the lower abdomen. The urologist places sutures near the bladder neck and urethra, securing them to a pelvic bone or to surrounding supporting structures. The second procedure, a sling, involves bolstering the urethra with a supporting strip of tissue or synthetic material.
Surgery offers the advantage of a one-time fix, says Rodney Appell, MD, of the Cleveland Clinic Department of Urology. Many women prefer that to the ongoing pelvic strengthening exercises required to maintain continence nonsurgically, he says.
Getting paid: Tough yet possible
Despite the proven effectiveness of surgical and nonsurgical treatment, "[health insurance] reimbursement is and has been the biggest issue," contends Mike Williams, chief executive officer for Advantage Medical Services in Bradenton, FL.
Williams says managed care plans in his area have been slow to come around, especially for behavioral and biofeedback therapies. In Florida, Medicare covers only a portion of the treatment costs, he notes, adding that each state adjusts Medicare reimbursement to the prevailing local rates.
Instead of liberalizing coverage, Medicare is tightening up, Williams says. Where reimbursement used to hinge on physician supervision, he explains, it now requires involvement of a physician in the treatment. That's overkill, he argues. The nurse practitioners who deliver Advantage's nonsurgical continence services have achieved an 88% rate of regained continence among the 1,800 patients served since they began the program in 1992, Williams says. He also points out that nonsurgical therapies cost $1,000 to $2,000, compared with $12,000 for surgery.
Panelists who wrote the new guidelines agree that securing payment for incontinence therapy isn't exactly a breeze. But if patients demand payment, and they are in sufficient numbers and have enough persistence, the payers will listen.
Establish lines of referral to ensure payment
Even now, getting third-party reimbursements depends on scoping out the possibilities in your state's professional licensing regulations and the coverage of regional health plans.
Then forge your alliances accordingly. Gillaspie's center receives fees to perform assessments and histories for OB/GYNs and refers patients to the nearby Physical Therapy Center, which bills for biofeedback. Some women's centers refer to private practice physical therapists.
In California, nurse practitioners such as Luft write prescriptions, so she handles that aspect of care when patients need it. Indeed, for a center whose lines of cooperation and referral are established, Gillaspie says, a continence treatment program is profitable. She notes that when women learn where they can go for good continence treatment, "the demand for the service is great."
1. Burgio KL, Matthews KA, Engel BT. Prevalence, incidence, and correlates of urinary incontinence in healthy, middle-aged women. J Urol 1991; 146:1,255-1,259.
2. Brown JS, Seeley DG, Fong J, et al. Urinary incontinence in older women: Who is at risk? Obstet Gynecol 1996; 87:715-721.