Behind closed doors

New resources mean women no longer need to put up with incontinence, says Sally Priestley

Who wants to talk about urinary problems? Many women put up with them for years rather than seek treatment.

Now physios are breaking down the barriers, using innovative ways of both tackling the taboo and treating urinary incontinence (UI).

A new CSP leaflet provides robust evidence to convince commissioners that physiotherapy works for this common and distressing condition.

Some physios are working in multidisciplinary teams, to deal with the web of related issues that affect many women.

A self-referral pilot project launched by the CSP is bringing women through clinic doors. And the CSP website is playing its part in evaluating the effectiveness of self-referral – taking in the views of not only physios but patients too.

‘We feel this is a really appropriate group for self-referral because we know there is embarrassment involved in going to your GP with this problem, and women often take a very long time, up to 10 years or more, to report it,’ says CSP professional adviser Ruth ten Hove.


Pilot project launched

About one in four women have UI at some point in their lives, and many struggle on without treatment. Yet physiotherapy offers effective ways of dealing with it, in particular with pelvic-floor muscle training.

As a way of highlighting this, the CSP has launched a pilot project evaluating the effectiveness of self-referral for women with bladder or pelvic-floor problems.

It follows successful trials of self-referral to musculoskeletal physio services. This has been shown to streamline pathways of care, encourage patients to act in their own best interests and reduce GPs’ workloads and costs.

Seven trusts across England volunteered to take part in the pilot. Posters and leaflets were distributed, encouraging women to seek treatment for the condition and to make use of the self-referral scheme.

Patients have been shown to like self-referral, says Ms ten Hove, as do GPs, because it encourages self-care and management.

‘We have launched this off a particularly strong evidence base, with numerous trials showing physiotherapy to be the most effective form of intervention for UI, and NICE confirming this in its recommendations,’ she adds.

An exciting part of this project is the first use of online evidence capture through the CSP website.

Physios can submit information after patients finish treatment, meaning that a running record of demographics, evidence and effectiveness can be captured throughout the year.

Feedback from patients is also being collected through the CSP website, adding further capacity for evidence on self-referral.

Dianne Naylor is leading the self-referral project at Bradford Teaching Hospitals NHS Foundation Trust.

She says the trust sees a high number of women with incontinence and other pelvic floor dysfunctions. It offers a well-developed service that already uses an element of self-referral.

Ms Naylor hopes the project can provide evidence that this group of patients like being able to self-refer and that outcomes for those women who do are improved. Showing that UI self-referral is a cost effective pathway for GPs is also important, she says.

‘With early bladder weakness, symptoms are less pronounced, so women often buy pads at the local supermarket to deal with it,’ she says. ‘Yet treatment for these weaknesses is more successful if implemented earlier. Self-referral might encourage women to seek treatment and to seek it earlier.

‘Many women do not wish to approach their GP for help,’ she adds.

‘This may be due to both embarrassment and anxiety as to how the GP might react. They may worry that the GP will dismiss it as something they should accept as normal, or that they will be send straight for surgery.’



Surgery is unlikely to be the best option, however. The first line of treatment for women with UI should be conservative measures, says Paula Igualada-Martinez, lead physiotherapist for women’s health at Guy’s and St. Thomas’ NHS Foundation Trust.

These include supervised pelvic-floor muscle training, biofeedback, electrical stimulation and lifestyle advice.

These combined measures solve the problem for about two thirds of women with UI who seek treatment. They are recommended in NICE clinical guidance (2006), the Scottish Intercollegiate Guidelines Network (SIGN 2004) and the NHS Evidence Clinical Website.

Treatment has to include an element of supervision, adds Ms Igualada-Martinez, who is public relations officer for the CSP professional network, the Association of Chartered Physiotherapists in Women’s Health (ACPWH).

‘Research has shown that 30 per cent of women do not know how to activate their pelvic-floor muscles correctly, despite instruction,’ Ms Igualada-Martinez says.

‘Also, 61 per cent don’t comply with the recommended exercise regime. So women’s health physios play a pivotal role, both in ensuring that the treatment is followed correctly and in motivating patients to comply.’

Working as part of a multidisciplinary team is also key, she says.

‘A vast proportion of patients with UI will have concomitant bowel dysfunction or a pelvic organ prolapsed, so it’s important for physios to have a close relationship with other specialities such as urogynaecology, colorectal and urology,’ Ms Igualada-Martinez says.

‘We offer a combined clinic on a Tuesday when all the different specialities are present. We think this offers a much better experience for both patients and clinicians.’

More effective than drugs

The CSP’s new ‘Physiotherapy works’ leaflet on UI uses published research to make the case for physiotherapy. (It can be downloaded from Aimed at NHS service commissioners, it reports, for example, that pelvic-floor muscle training is cheaper and more effective than the commonly used drug Duloxetine.

And in May, the all-party parliamentary group for continence care published its report ‘Cost-Effective Commissioning for Continence Care’. Written by continence professionals, the document is backed by healthcare organisations including the royal colleges of physicians and of nursing, as well as by the ACPWH.

The report favours integrated continence-care services, including physiotherapy. Among the activities that must be monitored to ensure sufficient quality and provision, it says, is the ‘number of pelvic floor pathways for men and women commenced by nurse or physiotherapist in the community and secondary care’ (see

‘At a time of great change in the NHS, we feel it is vital to bring this issue to the attention of all commissioners and policy makers,’ said Baroness Sally Greengross, chair of the all-party group.

Backed by the newly revised NICE guidance, the case for funding self-referral to physiotherapy services is looking very strong. fl

Urinary incontinence (UI) affects about  one in four women eventually.

  • It can be treated very effectively with physiotherapy, in particular with pelvic floor muscle training.
  • Stress incontinence is the most common form of the condition in women under 50: urine is leaked on effort, exertion coughing  or sneezing.
  • Pregnancy, childbirth and menopause are common triggers. Intense sports training can also cause UI, as can pelvic surgery.
  • People with chest conditions are also at risk as a result of intense coughing.
  • It becomes increasingly common with age and is estimated to affect about one in three women over 80.
  • UI costs the NHS some £117 million a year, according to a recent Health Technology Assessment study.
Sally Priestley

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