Approaches to urinary incontinence in a rural population: a comparison of physician assistants, nurse practitioners, and family physicians

Abstract

Background: Although urinary incontinence is a challenge and a burden to older patients, many clinicians fail to query older patients about incontinence symptoms or, even when aware of a problem, fail to diagnose the underlying cause or recommend treatment. We wanted to compare the approaches of physician assistants, nurse practitioners, and family physicians to detection, diagnosis, and initial management of urinary incontinence in older adults seen in rural primary care practices.

Methods: One male and 2 female simulated patients portrayed otherwise healthy patients with urinary incontinence, including urge or obstruction-overflow type for the man, and stress or urge type for the women. The 3 simulated patients saw 3 physician assistants, 3 nurse practitioners, and 3 family physicians each, for a total of 27 visits during which they posed as new patients seeking primary care.

Results: Health professionals spontaneously asked about incontinence in only 18 percent of visits (33 percent for physician assistants, 11 percent each for nurse practitioners and family physicians). When incontinence was discussed (spontaneously or by patient prompting), queries were made about potential precipitants (ie, coughing, caffeine consumption) in 63 percent of visits. Questions about other urinary symptoms (eg, dysuria) were asked in 59 percent of visits. Rectal examinations were performed in 68 percent of the male simulated patient's visits but in none of the female simulated patients' visits. No pelvic examinations were performed. No attempts or recommendations were made to measure postvoiding residual volume. Tentative diagnoses were made in 48 percent of visits; some form of therapy was discussed in 52 percent of visits.

Conclusions: Asking about incontinence was uncommon, and potentially important questions about precipitants and associated symptoms were often omitted. The providers examined areas potentially relating to incontinence and recommended supplementary assessments and specialized testing infrequently. Commonly, they made diagnoses and offered therapy at the end of an initial visit despite minimal history taking and examinations and lack of any additional assessment or testing.