Primary Care Physician Perceptions of Female Pelvic Floor Disorders

Abstract

Primary care physicians (PCPs) play a major role in patient access to appropriate health care. This study examines PCPs' perceptions and management of female pelvic floor disorders. Surveys were mailed to family medicine and internal medicine physicians associated with the Hawai‘i Medical Service Association. A total of 150 respondents were included. Only 34%, 38%, and 9% of respondents correctly identified the prevalence of urinary incontinence (UI), overactive bladder (OAB), and pelvic organ prolapse (POP), respectively. For disease-specific screening, the highest response was that PCPs “sometimes” screen for UI (36%) and OAB (45%) but “hardly ever” screen for POP (43%). With regards to management of UI and OAB, respondents would either treat (30% UI, 39% OAB) or start treatment then refer (53% UI, 49% OAB). For POP, nearly all of respondents (81%) would immediately refer. When consultation is necessary, there was a similar rate of referral to urology and urogynecology for UI (38% urology, 42% urogynecology), and a similar rate of referral to gynecology and urogynecology for POP (47% gynecology, 48% urogynecology). For OAB, PCPs would refer to urology (54.0%), then urogynecology (31%), and lastly gynecology (13%). A majority of respondents were “somewhat familiar” (56%) with urogynecology as a subspecialty, while 27% were “very familiar”, 13% were “slightly unfamiliar”, and 3% were “very unfamiliar”. This study shows that most PCPs are not comfortable managing common urogynecologic problems and would likely benefit from education on how to diagnose, treat, and refer for these conditions in order to optimize patient care.

Introduction

Urogynecology, also known as female pelvic medicine and reconstructive surgery, is a relatively new sub-specialty, receiving accreditation in the year 2011.¹ Urogynecologists are experts in treating female pelvic floor disorders (PFDs) such as female urinary incontinence, fecal incontinence, pelvic organ prolapse, and pelvic pain. Female pelvic floor disorders negatively impact the quality of life of those affected,^2–4 yet over half of affected individuals fail to seek medical care due to various reasons, including embarrassment and ignorance.^5–8 The healthcare burden of PFDs is expected to increase significantly over the next 30 years as the United States population ages and the rates of obesity, parity, and hysterectomies continue to rise. The prevalence of female PFDs is predicted to increase from 28.1 million Americans in the year 2010 to 43.8 million in 2050.⁹ Approximately 17% of women suffer from urinary incontinence (UI),^10,11 30% of women suffer from overactive bladder (OAB),¹² and 27% of women suffer from pelvic organ prolapse (POP).¹³

According to the University of Hawai‘i Division of Urogynecology, 78% of their patients are referred from gynecologists, 17% from PCPs, and 5% from self-referrals. This low referral rate from PCPs suggests a lack of knowledge about urogynecology as a subspecialty. In most healthcare systems, PCPs serve as “first-contact” care. When a new medical need arises, PCPs act as the entry point into the health care system. Thus, PCPs must be familiar with a variety of medical conditions because recognition is the first step in treatment. PCPs who feel confident managing female PFDs should proceed with treatment, but they must also know when and where referrals are appropriate, such as a case of UI that has failed conservative management or a case of POP complicated by urinary retention.

There is a current lack of knowledge regarding PCP competency with female PFDs. Only two previous studies have examined this important topic. These studies have shown that up to 75% of women with symptoms of UI fail to receive a diagnosis,¹⁴ and possibly more than half of family medicine physicians do not understand UI.¹⁵ The purpose of this study is to examine the perceptions and management of female PFDs among PCPs in Hawai‘i. This study is important because it highlights deficits in the healthcare system and identifies potential solutions to expand patient access to appropriate medical care.

Methods

This is an observational cross-sectional study. Study approval was obtained from the University of Hawai‘i institutional review board. An anonymous provider survey (Figure 1) was modeled after that created by Mazloomdoost, et al, 2017.¹⁶ The survey was designed to capture subject demographics (sex, specialty, practice type, years in practice, and number of patients daily), perceptions of female PFDs (prevalence, screening, management, and referral), and familiarity with urogynecology as a subspeciality. The survey was then piloted among 6 obstetrics/gynecology attending physicians, fellows, and residents. Suggested revisions were incorporated to enhance clarity. In August 2017, surveys were mailed to the offices of all family medicine and internal medicine physicians (N = 894) associated with the Hawai‘i Medical Service Association, the largest health insurer in the State of Hawai‘i. Surveys included an introductory letter signed by Dr. Ian Oyama, the Division Chief of Urogynecology at the University of Hawai‘i, in addition to a return envelope with a prefilled mailing address and prepaid postage stamp to facilitate participant response.

Figure 1.

Survey Mailed to All Family Medicine and Internal Medicine Physicians on the Hawai‘i Medical Service Association Provider List.

Only fully and properly completed surveys were included in the study, and the remainder was excluded. Common mistakes included skipping questions or selecting multiple answers when asked for only one. Data were analyzed using IBM SPSS Statistics for Windows, Version 25 (IBM Corp., Armonk, NY). Descriptive statistics were reported using percentages. Associations between demographic variables and responses were analyzed using Pearson's Chi-Square test. Statistical differences were considered significant for P-values less than .05.

Results

A total of 894 surveys were mailed out, with a response rate of 22% (n=198). However, only 150 of the surveys were completed properly and included in the study.

Respondents were evenly distributed with respect to specialty (42% family medicine, 58% internal medicine). However, the largest proportion of respondents were male (68%), private practice (81%), in practice for >20 years (53%), and caring for patients daily <20 (47%) or 21–30 (46%) (Table 1).

Table 1.

Demographics of Respondents.

	n	Percentage
Sex
Male	100	67%
Female	50	33%
Specialty
Family Medicine	63	42%
Internal Medicine	87	58%
Practice Type
University	3	2%
Private	122	81%
Hospitalist	3	2%
Community	22	15%
Years in Practice
0–10	33	22%
11–20	38	25%
>20	79	53%
Number of Patients Daily
<20	71	47%
21–30	69	46%
31–40	8	5%
>40	2	1%

When asked to report the prevalence of various pelvic floor disorders, only 34%, 38%, and 9% of respondents were able to correctly identify the prevalence of UI, OAB, and POP, respectively. A majority of respondents underestimated the prevalence of these pelvic floor disorders, (Figure 2). For disease-specific screening, the highest response was that PCPs will “sometimes” screen for UI (36%) and OAB (45%) but “hardly ever” screen for POP (43%) (Figure 2). Responses were evenly distributed among physicians who “always” screen (7% UI, 6% OAB, 4% POP) and “never” screen (6% UI, 7% OAB) for pelvic floor disorders, with the exception of 14.7% of respondents who “never” screen for POP (Figure 2). With regards to the management of UI and OAB, a majority of respondents will either treat (30% UI, 39% OAB) or start treatment then refer (53% UI, 49% OAB). For POP, 81% of respondents will immediately refer, while 17% will start treatment then refer (Figure 2). When consultation is necessary, there was not a statistically significant difference in referral to urology and urogynecology for UI (38% urology, 42% urogynecology) and OAB (54% urology, 31% urogynecology) nor a statistically significant difference in referral to gynecology and urogynecology for POP (47% gynecology, 48% urogynecology). The few respondents who would refer to an “other” specialty, either specified physical therapy or did not specify a specialty (Figure 2). A majority of respondents reported being “somewhat familiar” (56%) with the subspecialty of urogynecology, while 27% were “very familiar”, 13% were “slightly unfamiliar”, and 3% were “very unfamiliar” (Table 2).

Figure 2.

Survey Results (UI=urinary incontinence, OAB=overactive bladder, POP=pelvic organ prolapse).

Table 2.

Survey Results: Are you Familiar with the Subspecialty of Urogynecology?

Familiarity	n	Percentage
Very familiar	41	27%
Somewhat familiar	84	56%
Slightly unfamiliar	20	13%
Very unfamiliar	5	3%

There was a significant difference between respondent sex and estimated prevalence of UI (P-value .01) and OAB (P-value .04). Males PCPs were more likely than female PCPs to underestimate the prevalence of UI (56% vs 30%) and OAB (57% vs 40%). There was also a significant difference between years in practice and management of UI (P-value .01). PCPs practicing >20 years had higher rates of immediate referral (15%) than those practicing 0–10 years (3%) and 11–20 years (5%). However, the rates of starting treatment then referring were similar regardless of years in practice (55% for PCPs practicing 0–10 yeas, 50% for PCPs practicing 11–20 years, and 54% for PCPs practicing >20 years). No statistically significant difference by specialty was observed.

Discussion

PCPs play a major role in patient access to appropriate healthcare. To date, there are only two published studies evaluating PCPs' knowledge and treatment of female PFDs. In 2016, Mazloomdoost, et al, surveyed 108 internal medicine and family medicine physicians at a large academic community hospital system. The study found that PCPs were more familiar with UI and OAB than POP, and nearly one-fifth were unaware of urogynecologists in their system.¹⁷ In 2017, Mazloomdoost, et al, distributed surveys nationally via the American Medical Association internal medicine and family medicine residency database. The study received 391 responses from faculty physicians and found that nearly half of providers were unaware of urogynecologists to whom they could refer.¹⁶

Similar to the findings in Mazloomdoost, et al, 2016 and Mazloomdoost, et al, 2017, this large cross-sectional study of 150 PCPs in Hawai‘i found that PCPs were more familiar with UI and OAB than POP. This is supported by higher rates of correct estimated prevalence (34% UI, 38% OAB, 9% POP), “always” screening (7% UI, 6% OAB, 4% POP), and feeling comfortable treating UI and OAB compared to POP (30% UI, 39% OAB, 1% POP). While PCPs may perceive UI and OAB as more important than POP, in fact, the reported prevalence of POP (27%)¹³ is approximately that of UI (17%)^10,11 and OAB (30%)¹². A possible explanation for this phenomenon could be that increased knowledge, screening, and comfort level in treating UI and OAB could equate to a higher perceived importance than POP. In general, this study found that PCPs underestimate, under screen, and are unfamiliar with treatment of common pelvic floor disorders. This study also found that only 27% were very familiar with urogynecology and <50% would refer to urogynecology. The prevalence of female PFDs has continued to increase over the years. Approximately 17%, 30%, and 27% of women in the United States suffer from UI, OAB, and POP, respectively. Not many physicians surveyed were able to correctly identify the prevalence of these disorders (34% UI, 38% OAB, 9% POP), with a majority underestimating the prevalence. While the survey's question could have been further clarified as to the prevalence of which specific population, for example the general United States versus their personal practice, these results are still interesting. This large underestimation of the prevalence of female PFDs could suggest a minimization and/or lack of knowledge of these diseases that impede quality of life.

There was a significant difference between respondent sex and the estimated prevalence of both UI and OAB. Male PCPs were more likely than female PCPs to underestimate the prevalence of UI and OAB. Mazloomdoost found similar results and also found that male providers were less likely to have female patients report bothersome symptoms compared to female PCPs,¹⁶ which could explain why male PCPs perceive a decreased prevalence of UI and OAB. This phenomenon possibly stems from female patients feeling more comfortable with PCPs of the same gender. Moreover, females are more likely than males to experience UI and OAB.¹² Therefore, one hypothesis could be that female PCPs are more likely than male PCPs to personally experience UI and OAB, which could increase their vigilance towards such disorders.

There was also a significant difference between years in practice and management of UI. PCPs who have practiced >20 years were more likely to immediately refer (15%) than those who have practiced 0–10 years (3%) and 11–20 years (5%). This may represent a higher level of confidence and/or competency associated with recent graduates from residency, or perhaps a heightened sense of self-awareness and skill-level as a seasoned physician. Additional follow-up questions would be necessary to further explore this association between years in practice and management of UI.

Strengths of this study include identifying subjects by using the Hawai‘i Medical Service Association provider list, which is an up-to-date comprehensive list that includes 89% of all practicing PCPs in the state of Hawai‘i.^18,19 Therefore, this study can be generalizable to the entire state. Unlike previous studies, surveys were distributed to not only academic but also community physicians.

Limitations of this study include selection bias. As with any survey-based study, selection bias is difficult to avoid, and it is possible that only providers familiar with and interested in female PFDs could have opted to participate in this study. The study's largest limitation is its low response rate. Eliciting responses from busy physicians can be challenging. In the future, the response rate could be improved by distributing online surveys in addition to mailed surveys. Surveys could also be distributed multiple times to encourage participation. The sample size was further reduced by improperly completed surveys, such as skipping questions or choosing multiple answers for single-answer questions, which could be regulated and prevented with online surveys. Physicians practicing in the university (n=3) and hospitalist (n=3) settings were greatly underrepresented, which was probably associated with the study's small sample size. Also, providers outside of the Hawai‘i Medical Service Association are not represented in this study. Nonetheless, the study's low response rate does not necessarily invalidate its results, and its response rate and sample size (22%, n=150) were similar to Mazloomdoost, et al, 2016 (30%, n=108), which highlights the difficulty in obtaining a large response rate.

Some surveys were noted to have unsolicited comments written in the margins. Comments generally referred to a lack of resources, particularly in rural Hawai‘i. For example, “Not many urogynecologists around! Wish there were more!”, “I refer to gyn first due to shorter referral wait time”, “No urogyn on Maui”, and “No local resources on Big Island”. Future directions include categorizing PCPs by island, thus distinguishing PCPs practicing on urban O‘ahu and rural neighboring islands. Currently, there are six practicing urogynecologists on O‘ahu to support a state population of 1,428,538 people (238,090 persons per urogynecologist), which is similar to the persons-to-urogynecologist ratio in the United States (283,639:1).^20,21 However, a notable 31% of Hawai‘i's population resides on neighboring islands, geographically isolated from O‘ahu. Expanding services to neighboring islands would help to serve people who are unable to travel to O‘ahu due to the costs of travel, accommodations, and loss opportunities. This study could be the start of a larger discussion on the need for urogynecologic presence in rural Hawai‘i.

In conclusion, most PCPs are not comfortable managing these common urogynecologic problems and would likely benefit from education on how to diagnose, treat, and refer for these conditions in order to optimize patient care. In the future, research could examine the effect of educational sessions on PCPs' levels of comfort and competency in female PFDs.

Abbreviations

PCP

primary care physician

PFD

pelvic floor disorder

UI

urinary incontinence

OAB

overactive bladder

POP

pelvic organ prolapse

Conflict of Interest

None of the authors identify a conflict of interest.