Innovative treatment modalities for urinary incontinence: a European survey identifying experience and attitude of healthcare providers

Urinary incontinence is a common condition in women, with a reported prevalence ranging from 25% to 51% [1]. Of these women, an estimated 38% suffer from stress urinary incontinence (SUI) [2], a condition that has a major impact on the quality of life [3]. Pelvic floor muscle training (PFMT) is an effective treatment for women with mild or moderate SUI [4] and is recommended as part of first-line conservative management programs for women with SUI [5]. However, because the efficacy of PFMT is directly related to adherence, poor compliance can significantly reduce the cure rates with this treatment [6, 7]. Healthcare providers try to support adherence with more frequent patient visits, which has been proven to be effective but makes the intervention more costly [8‐11].

A European research group, the WOMEN-UP consortium, collaborates on an innovative intervention to expose women with SUI to the benefits of pelvic floor physiotherapy, optimize adherence and reduce costs. This novel intervention involves a wireless vaginal biofeedback device and an abdominal belt, both with surface electromyography sensors, connected via Bluetooth to a smartphone with access to ‘serious games’. Both vaginal and abdominal biofeedback are obtained, enabling patients to improve their training technique. Exercise performance and results can be monitored by patients and their therapists through an online web portal with two-way messaging functionality.

In serious gaming, interactive training games are used for a primary purposes other than pure entertainment, that is to improve knowledge, skill or attitude with the added value of fun and competition [12, 13]. Serious games have been successfully used in, for instance, rehabilitation programs [14] and for promoting health behavior [15]. In the WOMEN-UP project, serious games will be employed to make PFMT more appealing and thereby possibly improve adherence. In these serious games, contracting and relaxing the pelvic floor operates a game on a smartphone via a Bluetooth biofeedback signal. In addition, to evaluate this innovative approach in terms of clinical and cost effectiveness, professionals’ attitudes towards pelvic physiotherapy, biofeedback and serious gaming need to be known. Implementation of new treatment modalities can be hampered by multiple factors, including healthcare providers’ attitudes towards and knowledge of the innovative technology. It is important to identify, assess and tackle these factors in a timely manner to optimize the intervention and facilitate its application in practice.

For example, sufficient knowledge of PFMT, biofeedback and serious gaming, and their therapeutic value seem essential. The lack of scientific evidence and the absence of a standardized protocol describing the treatment leave healthcare providers hesitant to use new treatment modalities. Therefore, as a first step, the current protocol and data on experience with and attitudes towards biofeedback combined with serious gaming need to be collected and described for the different European countries. It is also important to understand the attitudes of those who do not use biofeedback, and the conditions under which they would be willing to use such a treatment modality. Suggestions and criticisms should be taken into account and acted upon to minimize the risk of problems during subsequent implementation.

Therefore, the aim of this research was to investigate whether and when this innovative solution for the conservative treatment of urinary incontinence would fit in professionals’ daily practice by performing a Europe-wide survey.

Of a total of 1,844 questionnaires submitted, 341 were returned (response rate between 18% and 30%). As shown in Table 1, 306 (90%) of the respondents were urogynecologists and 17 (5%) were pelvic floor muscle therapists from 26 European countries. Many worked at university hospitals (118, 35%) or teaching hospitals (132, 39%). Most respondents were based in The Netherlands (117), UK (60), Turkey (25), Czech Republic (14) and Poland (13). Not all respondents answered all questions. Therefore, the results are presented as the numbers and percentages of respondents who answered each question.

We conducted an online survey to assess current practice of gynecological healthcare providers and to investigate their experience with and attitude towards pelvic physiotherapy, biofeedback and serious gaming. This European-wide survey showed that urogynecologists and pelvic floor physiotherapists have limited experience with these eHealth applications. Only a third of respondents used biofeedback in the treatment of SUI and very few (11%) had experience with serious gaming. Nonetheless, almost all respondents would welcome innovative solutions to improve existing conservative treatment modalities for SUI. In their opinion they could be of added value for their current therapeutic practice, but they needed clinical evidence to support this.

This is the first inventory of current clinical practice and attitudes regarding innovative technologies for the treatment of SUI in Europe. One of the strengths of this study is the design of the survey that was conducted by researchers from different European countries including gynecologists from university clinics in The Netherlands, Spain and Finland. Also, responses were received from professionals from 26 different countries. This geographical spread contributed to a diverse picture that provides some insight into different practices across Europe.

The questionnaire could be criticized for its relative simplicity. To adequately document local conditions, referral patterns and standard pathways of care for patients with different severities of SUI, a far more detailed and open-ended questionnaire would have been required. However, in order to minimize the nonresponse rate, the length of the questionnaire was minimized and clear, straightforward items were conceived, that may not have adequately reflected the variety in local practice. Despite our efforts to maximize the response rate, including several reminders, still only one-fifth of submitted questionnaires were returned. We do not know the exact response rate because some professionals are members of more than one urogynecology association and may therefore have received the questionnaire more than once. For example, some members of the Dutch and British pelvic floor societies will have received the survey twice, since they also received it as EUGA members. As a consequence, the response rate may vary between 18% and 30% depending on the degree of overlap in society membership. Another limitation is the seemingly limited response from some countries and the fact that the majority of respondents were based un The Netherlands and UK. We do not know the response rates for individual countries, since the characteristics of the members of professional societies were not available. Because respondents were mainly based in The Netherlands and the UK, it is questionable if the survey can be generalized to urogynecologists and pelvic floor physiotherapists across Europe. Therefore, the results of this research should be interpreted with caution.

It is remarkable that a third of European urogynecologists and pelvic floor physiotherapists did not have protocols available in their clinic for the treatment of SUI. The exact reason of this is unknown, but this is a rather worrying finding and suggests room for improvement in standard clinical practice. The absence of a protocol will likely result in unwanted variation between treatments, depriving some patients of optimal evidence-based care. When a novel treatment modality has been proven effective, it might lay the foundation for a Europe-wide protocol for the treatment of SUI. However, differences between nations need to be kept in mind.

We have addressed differences between countries in terms of referral patterns and reimbursement. Especially in those countries where there is no or little reimbursement for physiotherapy and where the infrastructure is relatively poor and/or the geographical spread large, the use of eHealth might be of added value. When access to healthcare is restricted, the need for alternatives becomes greater. Especially when commercially available and thus priced affordably, such an innovative treatment modality for SUI might have significant potential. In other fields of medicine, eHealth has been proven of value in motivation and education in women’s healthcare and self-management of disease [12‐17]. Some literature also suggests that adding biofeedback to PFMT improves outcome by increasing compliance rates, enhancing utilization and improving training technique [18‐22]. However, evidence is insufficient to provide strong recommendations about the best way to approach PFMT [11, 22, 23]. In particular, data on long-term outcomes are lacking [24‐26]. Respondents seemed aware of this, because only a third of urogynecologists currently used biofeedback. However, the fact that more than 90% considered that it could have added advantage suggests that respondents did believe in the potential benefits. When asked what needs to be improved, many stressed the importance of more scientific evidence. Feedback-mediated exercise has been proven of value in rehabilitation after stroke. Researchers describe prolonged endurance in training and greater improvement in certain aspects of motor function, as well as very high patient motivation and acceptance [14, 27]. These findings are promising for the utilization of biofeedback in urogynecology.

Besides insufficient evidence, respondents mentioned other important reasons for not using biofeedback, such as the cost and reimbursement. This drives the need for a more easily accessible, self-administered and commercially available system that is affordable for practices and patients. As shown in Table 2, when asked to suggest how currently available devices could be improved, most respondents suggested a more user-friendly, accessible, affordable self-management system to use at home. Apparently, there is an unmet clinical need for a better and cost-effective self-management system.

Evaluation of the use of serious gaming showed similarities to the use of biofeedback. Serious games have only recently found their way into clinical practice, although evidence has shown efficacy in divergent patient populations in other fields of medicine [12‐16]. A review by the WOMEN-UP consortium recently accepted for publication also suggests that serious gaming is efficacious [28]. Nevertheless, only a small percentage of respondents had some experience with serious gaming. As almost all respondents indicated they would use serious gaming when available, lack of familiarity might be responsible. The solution to this problem is appropriate education and training of healthcare professionals [29]. Many respondents also underscored the limited therapeutic value in certain patient groups, and indicated that the use of serious gaming should be restricted to certain patients (Fig. 3). As serious gaming may require some computer or technical skill, this is probably partially true, and also because research has shown that a substantial proportion of the population never use health apps and many stop using them [30]. However, the literature suggests that the attitude of healthcare providers is a significant factor in the acceptance and efficient use of information technology in practice. Successful implementation actually depends on the therapist, rather than on the patient [29].