Weinstein is an associate professor of obstetrics and gynecology at Harvard Medical School. Pulliam is an assistant professor in the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology at Tufts University School of Medicine.
Nearly every global society governing women's health recommends screening adult women for incontinence. It seldom happens. The reasons are inherent to the fabric of our health care system, including lengthy lists of recommended screenings, long wait times for short appointments, and sometimes, limited access to health care.
However, with 62% of adult women in the U.S. living with bladder and/or bowel leaks, it's imperative that we improve screening for this treatable disorder. Untreated incontinence is associated with profoundly negative health consequences that impact women's social, financial, physical, and emotional well-being. Shame keeps most of them silent. We believe small changes from government, professional societies, and insurers can make it easier for clinicians to screen and treat more women.
Leaks aren't an inevitable part of growing older. Treatment exists. Women don't need to live a life that fuels the $15.2 billion global adult diaper market and may lead them to a nursing home. The menopause movement is activating women who are demanding change. However, medicine has a discouraging history of sidelining women's health concerns. And vast advertising budgets normalize incontinence, obscuring an important clinical fact: Incontinence is a progressive condition. Without treatment, it can get worse.
Ample data show the uncertainty and unpredictability of living with incontinence can affect women's mental health, quality of life, and relationships. Women may limit social engagements, experience feelings of isolation and distress, and/or have problems with intimacy. Incontinence is also associated with increased economic burden and decreased physical activity. Research shows that women with urinary incontinence (UI) may reduce physical activity or stop exercising altogether to manage symptoms. When compared with continent women, data show women with incontinence experience physical decline at a more rapid rate, including declines in muscle mass and lower scores on physical performance tests.
Among older women, UI is a major risk factor for falls, hospitalization, disability, and dependance on a caregiver. The quality of life for caregivers is also affected. Physical demands can be intense. Psychological, relationship and social issues can also arise. Most recently, a September study found an association between overactive bladder, a syndrome that includes urinary urgency, frequency, and urgency incontinence, and suicidal ideation. An October paper closely followed, showing UI itself is an independent risk factor for death.
For many women, it's possible to stop this terrible cascade. Effective treatments exist, including conservative (read: inexpensive) first-line treatment, pelvic floor muscle training (PFMT). So why isn't routine screening happening? Short answer: It's complicated. However, we believe small changes from government, payers, medical societies, clinicians, and women could make a real difference.
Research confirms that the institutions guiding quality measurement, including organizations like the Centers for Medicare and Medicaid Services, the Joint Commission, and the Agency for Healthcare Research and Quality have the capacity to influence the provision of care, enhance patient safety, and improve outcomes. Earlier this year, the Core Quality Measures Collaborative (CQMC) reviewed OB-GYN core measures. For prevention and wellness, current core measures include screening for chlamydia, HIV, contraceptives, and depression -- all valuable screenings. We do not advocate for their removal. However, incontinence affects more women than all other measures except contraception, yet urinary incontinence (postpartum or for the general population of women) is not even mentioned as a measure for future consideration. Additionally, it is not mentioned or considered for primary care, though CQMC will review this in February 2025. Adding incontinence screening as a core measure is necessary and would help motivate clinicians and major healthcare facilities to prioritize screening in their practices.
As specialists, we're very familiar with the tests required for an incontinence diagnosis, which grants access to treatment. However, today's diagnostic pathway -- typically, pelvic exam, urinalysis, and post-void residual -- can be burdensome for primary care, which can lead to unnecessary referrals. Primary care providers (PCP) should be the first treatment step for most women. Medical and professional societies could help by simplifying the diagnostic pathway so that first-line care becomes more accessible immediately upon diagnosis by a PCP.
The average length of a primary care visit is 18 minutes, which can restrict our attention to only the most pressing health concerns. While a lengthier appointment would be ideal for engaging patients in additional concerns, we have to be realistic. In the absence of longer time with patients, planning what to say about incontinence could be useful immediately. As clinicians, we often have routine talking points for discussing a variety of different conditions. This preparation, honed over years of practice, is part of what can make a brief encounter efficient and incisive. For incontinence, clinicians could prepare to ask about leaks and, based on the response, have pre-planned talking points that allows them to connect women with treatment efficiently. This would take a little upfront work (most of these talking habits are initially formed during training) but would be incredibly worthwhile.
Prevention is also key.
Like many conditions that people are more comfortable talking about, incontinence has clear risk factors: Childbirth is No. 1. However, payers view postpartum leaks as a lifestyle issue. That's because serious consequences emerge later, commonly during menopause, and likely after several insurance changes. We encourage all payers to take the long view, just as they do with other conditions associated with long-term negative health outcomes, such as diabetes, cardiovascular disease, and obesity. Pelvic floor health must be a priority immediately following childbirth, and insurers should pay for this care.
That's happening in the U.K and France, where one payer is responsible for a woman's lifetime: Pelvic floor rehabilitation begins directly after childbirth. The National Institute for Clinical Excellence, which establishes treatment guidelines for the United Kingdom, found it could avoid 50% of surgeries for stress urinary incontinence if women performed PFMT first. Since 1985, the French government has paid for 10 sessions of pelvic floor physical therapy after childbirth.
Some U.S. insurers have adopted a long view and pay for new modalities that help women access PFMT, which data show can be challenging (an important fact that contributes to historically low screening adherence). Access to in-person PFMT can be limited by long wait times, a limited number of providers to supervise PFMT, financial constraints, and the challenge of taking time away from work or obtaining childcare. Paying for new technologies creates an opportunity for forward-thinking payers to help drive screening by giving clinicians an effective way to help women access PFMT without requiring significant out-of-pocket costs.
Women are accustomed to absorbing the challenges of incontinence. Shame and embarrassment are also silencing. Few things erode a person's dignity like accidentally leaking urine or stool. Menopause recently became a $15.4 billion industry. We hope that its tailwinds give more women the confidence to advocate for their health needs.
The U.S. health care system must think differently about a woman's pelvic floor. Anyone with a rotator cuff injury attracts the immediate attention of an orthopedic surgeon and qualifies for rehabilitation services regardless of whether they underwent surgery. Yet a woman who delivers her baby vaginally and experiences pelvic floor trauma -- leading to pelvic floor weakness, dysfunction, and ultimately urinary incontinence or other pelvic floor disorders -- receives a stool softener and a "congratulations." With a few tweaks, we can and should do better.