Urotherapist activities in caring for patients with pelvic floor disorders: a prospective single-center observational study

Pelvic floor disorders (PFDs) consisting of an overactive bladder, chronic bladder diseases and urinary stress incontinence, recurrent urinary tract infections, pelvic organ prolapse and fecal incontinence [1, 2] are often chronic diseases that may require regular assistance over long periods of time [3]. The present worldwide increase in the proportion of older people (aged 65 years and over) is accompanied by a rise of pelvic floor disorders and multimorbidity [3, 4]. Pelvic floor disorders considerably reduce the well-being and quality of life of the affected by interfering with daily and social activities, which in the worst case leads to isolation [5, 6].

To overcome the health care needs of an aging population with a variety of chronic diseases, new treatment and management concepts, such as interprofessional collaborations, are emerging and have already been implemented in different settings [7‐9]. In 2010, the World Health Organization (WHO) [10] launched a call for collaboration concepts between different medical professional groups, especially between nurses and doctors. A care coordinator for people with multimorbidity seems to be pivotal for high-quality clinical work, the likelihood to continue living in the community and improved self-management by patients with chronic diseases. Furthermore, such integrated care programs aim to stabilize health care costs [11].

Interprofessional collaborations represent a new strategy designed to cover increasing patient demands with respect to medical, psychological and social skills and consultation time. As a consequence, the curricula of nurses and physicians will change, and the interactions/partnership between health care providers will increase accordingly. In particular, chronic conditions require the comprehensive involvement of medical, social and cultural aspects in an interprofessionally organized health care system that so far remains insufficiently explored [7, 9, 12].

The interprofessional approach for the treatment of pelvic floor disorders was initially introduced by pediatricians [13] whose clinical activities in treating children with urinary and fecal incontinence were supported by urotherapists, i.e., specialist nurses/advanced nurse practitioners [14, 15]. A review addressing urotherapy in children revealed that the urotherapist contributed to a reduced urinary and fecal incontinence [14]. However, information regarding the frequency, number and time of urotherapeutic consultations was not provided. Furthermore, comprehensive data on the clinical activities of urotherapists in adult urogynecology and their impact on the patient's quality of life are entirely lacking. In 2009, a nurse-led urogynecology triage clinic was established, offering a service for women with long-term urinary incontinence [16]. A retrospective study assessing the clinic led to the conclusion that patients with urinary incontinence were adequately managed by advanced nurse practitioners [17].

Growing interest in the work of advanced nurse practitioners motivated us to specifically examine the professional activities of the urotherapist. Like physicians in long-term care facilities and primary care for the aging population, urogynecologists do not have the capacity to meet all the needs of patients with pelvic floor disorders, especially when the complaints are chronic. In their review, Lovink et al. [18] concluded that the substitution of doctors by nurses achieves care processes and patient outcomes that are at least as good as those attained by doctors alone.

The aim of this study is to describe the main activities of the urotherapist in the care of patients with pelvic floor disorders and to evaluate patient satisfaction with the service urotherapists provide.

The study was approved by the Ethic Committee of the Canton Zurich (Swissethics: BASEC 2016-00211) and performed from July 2016 to June 2018 in the outpatient clinic of the Department of Obstetrics and Gynecology, of the Cantonal Hospital Winterthur/Switzerland, a tertiary referral center. All participants provided written consent. The urotherapist documented the type of pelvic floor disorder, the type of counselling, the time frame of the treatments and the patient satisfaction with the service.

From July 2016 to June 2018, 1709 patients were examined by urogynecologists. Of these patients, 514 (30%) were subsequently referred to the urotherapist for different reasons, including the need for counselling for a chronic disease, fitting pessaries, conservative treatments, multimorbidity, age, etc.

The study took place in a tertiary referral hospital and a teaching hospital for gynecologists, urogynecologists and advanced nurse practitioners. One-third of the patients with PFDs were co-managed by the urotherapist. Age ≥ 65 and increased bladder sensation complaints proved to be the parameters pointing to the highest frequency of urotherapist consultations (Table1). The small study subgroup had a higher proportion of ≥ 65 patients, and thus, an even higher incidence of increased bladder sensation complaints (87%) was observed. Of the different lower urinary tract symptoms, increased bladder sensation complaints are the most time-consuming disorders overall [20‐22]. The high inconvenience caused by increased bladder sensation complaints is also reflected in the scores of the German Pelvic Floor Questionnaire, which were highest in the bladder domain (Table 1). This corresponds to findings of a study by Agarwal et al. [22], where urinary urgency was the most common troubling symptom in a large population-based study.

Pelvic organ prolapse was the second most common PFD. The number of urotherapist consultations was lower for pelvic organ prolapse than for increased bladder sensation complaints (Table 1). It was previously reported that the counselling of patients with pelvic organ prolapse and the fitting of pessaries by an advanced nurse practitioner is an effective conservative treatment [23, 24]. Pessary treatment is gaining more importance as part of a urotherapy, especially since pelvic organ prolapse surgery is under debate due to recurrences and complication rates [25]. Pessaries are a safe and effective treatment option for women with pelvic organ prolapse; managing these patients needs person-centered care, which is a core activity of urotherapists [26].

The study revealed that most consultations took place by phone (59%). A small proportion of patients (16% of the main collective) needed five or more consultations, indicating that the comprehensive, competent management of some patients can be very time-consuming (Table 1). In chronic PFDs, urotherapy has a supportive, caring, long-term character and cannot be compared to treatment by medication or surgery.

The mean consultation time of the urotherapist per study subgroup patient was 5.7 h, which is more than twice the consultation time of the urogynecologist (Table 1). The length of the counselling time reflects the patient's need for information and education. In addition, the length of the consultation varies considerably; in general, older patients need more time as shown by our subgroup, which included significantly more patients ≥ 65 than the main collective.

Consultations by the theurotherapist varied widely from counselling for continence products or clarifying pre- and post-operative administrative issues to intense, long-term therapies, including percutaneous posterior tibial nerve stimulation (PTNS), bladder instillations or catheter management (inclusive instruction for self-catheterization). Patients with PFDs have different levels of personal requirements that have to be evaluated individually by the urotherapist. The questionnaire assessing patient satisfaction (Table 2) showed that this effort is highly appreciated by patients and, thus, likely to contribute to a high satisfaction with the service.

In multimorbid patients in need of tailored, person-centered care, among other nursing core components, urotherapy is deemed to be important in an effective integrated care model [27].

Evidence-based implementation theories should be applied when nurse-led integrated care models are developed and evaluated [28].

The reported study has limitations. First, because urotherapy was established as a new service, the data are only evaluated descriptively and were provided by one urotherapist, which makes the conclusions more difficult to generalize. Second, we did not employ a standardized written counselling protocol. Furthermore, we could not recruit as many patients for the subgroup as planned, which is not uncommon in real-life, observational studies [29]. Many patients found reading the ten pages of patient information too bothersome and declined participation in the study, but not management by the urotherapist. Another limitation is the high percentage of women (62%) that were satisfied with one or two urotherapist consultations and, subsequently, were no longer interested in participating in a substudy. When planning the study, it was impossible to predict how much time and effort the urotherapist would have to invest to adequately care for the patients according to their different PFDs; surprisingly, most patients needed only a limited number of consultations, mainly transmitted by phone.

Our study could not answer the question of whether or not the concept of an interprofessional approach has an impact on health costs [11]. In two recent reviews concerning interprofessional collaborations [7, 17] and in a Cochrane Database review from 2017 [9], the authors discuss how it is still not clear how the interprofessional collaboration concept should be realized. There is not sufficient evidence to draw conclusions on the effects of interprofessional interventions and whether or not this approach will have implications for a better and more economical health care system [7, 9, 17]. In the literature, greater efficiency and lower costs of an interprofessional approach are discussed controversially [30].

Despite the limitations, the study indicates that the care delivered by a urotherapist meets patients’ needs and can be extended to help treat the growing population of patients with PFDs. The integration of communication tools such as structured protocols for counseling by the urotherapist, specific hotline contact, telemedicine (for frail patients) and e-mail contact should be evaluated while taking into account issues regarding data safety (e.g., access to medical records). In addition, the results provide a good basis for negotiations with health insurances on covering patient-attributable costs.

By carrying out specialized activities that are related to the care of patients with chronic pelvic floor disorders, urotherapists could relieve the workload of urogynecologists, who would then have more time to deal with surgery and teaching. Further, as documented by the voluntary questionnaire (Table 2), nurse-led counselling covers a patient need in urogynecology.

In the future, the certification of an organization as a pelvic floor center could include the integration of a urotherapist as a prerequisite. Thus, the competencies and decision-making powers of the urotherapist in an interprofessional setting need to be precisely defined and further evaluated [31].

The management of chronic diseases, such as PFDs, calls for different models in primary care compared to acute medicine where cure mostly occurs within a foreseeable time frame. We could demonstrate that partnership between a urotherapist and urogynecologists in an outpatient clinic is a key component in the effective management of PFDs in adult patients. Furthermore, the activities of the urotherapist were highly appreciated by the majority of the study subgroup patients and these patients would also recommend seeing a urotherapist to other women. The overview of urotherapist activities provided by this study will facilitate the further development of interprofessional collaborations and partnerships between advanced nurse practitioners and doctors. The inclusion of such collaborations in patient care plans has the potential to transform health care services for women with PFDs for the better.