Published online Jun 28, 2019. doi: 10.5662/wjm.v9.i2.26
Peer-review started: January 29, 2019
First decision: March 15, 2019
Revised: March 29, 2019
Accepted: April 8, 2019
Article in press: April 8, 2019
Published online: June 28, 2019
Approximately one half of the patients referred to a Female Pelvic Medicine and Reconstructive Surgeon for pelvic floor disorders (PFDs) did not receive any non-surgical treatment prior to referral. Rather than being managed conservatively, patients end up undergoing surgical procedures, which are associated with their own risks. Through education about these disorders, whether during residency training or through certification examinations, this may results in decreased healthcare costs and morbidities associated with surgical procedures.
The main topic of these articles revolves around female PFDs and conservative management prior to subspecialist referral. The key problem to be solved is determining the extent to which treatments are attempt prior to subspecialist referral and if education about PFDs would be beneficial. This could reduce the total number of surgical procedures performed, which would decrease the medical comorbidities associated with surgery. Furthermore, this would result in fewer healthcare costs associated with subspecialty referral and surgical procedures.
The objective of this study was to assess the types of treatments that primary care physicians and obstetricians and gynecologists (specialists) attempted prior to subspecialty female pelvic medicine and reconstructive surgery (subspecialists) referral. The secondary goal assessed the differences in referral patterns. Future studies can be aimed at understanding this question by surveying a large pool of physicians amongst various fields of medicine.
A retrospective cohort study of 234 patients was included in the assessment after the inclusion and exclusion criteria were met. The PFDs included urge, stress incontinence, and fecal inconti-nence as well as pelvic pain and pelvic organ prolapse during the study period. Certain patient information was abstracted, including demographics, specialty of the referring physician, type of PFD, and treatments utilized. Finally, patients that were referred to the urogynecology clinic by various specialists were compared to those referred by their primary care physicians. Descriptive statistics were generated to characterize the study population. This included the mean, standard of deviation, median and range. The number, length and types of treatments were compared.
There were 78.6% of referral by specialists and 21.4% by primary care provider (PCP). Treatment (with Kegel exercises, pessary placements, and anticholinergic medications) was attempted on 51% (n = 26) of the PCP compared to 48% of the OB/GYN referrals prior to FPMRS referral (P = 0.6). There was no significant difference in length of treatment prior to referral for PCPs vs specialists (14 mo vs 16 mo, respectively, P = 0.88). However, there was a significant difference in the patient’s average time with the condition prior to referral (35 mo vs 58 mo for PCP compared to specialist referrals) (P = 0.02).
Our results showed that there was no significant difference in the number of treatments attempted by PCPs versus specialists. We theorized that obstetricians would be more familiar and better prepared to treat PFDs given their background with gynaecologic problems. For this small subset of providers in our study, this was not the case. However, it should be noted that 121 more patients were sent by obstetricians than primary care physicians, which may indicate that they are more comfortable and familiar with the role of urogynecologists. Even though stress incontinence was the most often referred PFD, comprising 30.2% of the referrals, it was not the most often condition treated. By percentage treated, pelvic pain received treatment most often prior to referral (68.2%) versus stress incontinence which only received treatment 50.2% of the time. Our study showed no significant difference in the length of treatment prior to referral, but it did show a difference in the time with the condition prior to referral. Often the referred patients were impacted by the disorder for at least 1 year prior to referral. The true value of this study highlights the finding that half of the patients sent for urogynecologic evaluation did not receive any treatment prior to the referral. There is a plethora of reasons as to why physicians may not attempt treatments prior to referral. This could be due to lack of confidence with recom-mending and overseeing these treatments, lack of resources/time, or simply that they would prefer the disorder be managed by a specialist in PFDs given the possibility for surgical intervention.
Our study suggests that there is a potential paucity of knowledge about non-invasive therapy options available for PFDs. Future studies can be aimed at understanding this question by surveying a large pool of physicians amongst various fields of medicine. This study could be done retrospectively or prospectively.