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Research ArticleArticle Views : 6Article Downloads : 2

Urogynaecology service at a district general hospital in the United Kingdom-changing needs or a better understanding?

Farah Wali Lone*and Ainharan Raveendran

Department of Obstetrics & Gynaecology, Royal Cornwall Hospital NHS Trust, Truro, TR1 FD, United Kingdom

*Corresponding author: Farah Wali Lone, MBBS, FCPS, MRCOG (UK),Department of Obstetrics & Gynaecology, Royal Cornwall Hospital NHS Trust, Truro, TR1 3FD, United Kingdom, Tel: +44-1872-250000; Email: farah.lone1@nhs.net

Article Information

Aritcle Type: Research Article

Citation: Farah Wali Lone, Ainharan Arveendran, et al. 2019. Urogynaecology service at a district general hospital in the United Kingdom-changing needs or a better understanding?. Open J Nurs Med Care. 1: 21-25.

Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Copyright © 2019; Farah Wali Lone

Publication history:

Received date: 15 April, 2019
Accepted date: 11 May, 2019
Published date: 13 May, 2019

Introduction

The UK population is ageing rapidly, with 51% of the population predicted to be over 65 years of age by 2030 compared to 2010 [1]. The urogynaecological problems in women increase with age affecting over 20% of the adult population [2]. The National Health services (NHS) will have to transform to deal with very large increases in demand for and costs of health and social care. A study forecasting the prevalence of urogynaecological problems in the US forecasted a 50% increase in the service for urogynaecological conditions2. Role of integrated continence services within acute hospitals is gaining interest. A remarkable shift in NHS services will need good joined up primary and specialist care, community care and social care, with effective out of hour’s service. Urogynaecology offers a mix of problems affecting pelvic floor in a woman. It involves treating women with urinary and/or anal symptoms (urgency, incontinence, incomplete emptying) [3], pelvic organ prolapses (POP) and impact of these symptoms on sexual function. It is a relatively new sub-speciality which requires a holistic approach to a patient symptoms and expert skills to overcome demands from aging female population and fulfilling patient expectations.

Materials and Methods

This was a retrospective study of case notes of women attending the gynaecological outpatient clinic led by an Urogynaecology sub-specialist at a District General Hospital in the United Kingdom over a period 24 months (October 2012 to October 2014). An anonymised excel datasheet was developed to record information about the demographic details of the study population, source of referral, reason for referral, patients’ presenting symptoms, diagnosis and the treatment offered.

Results

We identified 777 women who attended the clinic with symptoms of pelvic floor dysfunction. The most frequently stated reason for referral was pelvic organ prolapse, followed by primary urinary incontinence. The wide range of diagnosis referred to Urogynaecology service is shown in Table 1. Majority of the patients (44%) had prolapse at diagnosis and 26% of the patients had multiple symptoms related to pelvic floor dysfunction after an Urogynaecologist’s consultation but only 5.6% of the patients had multiple symptoms at referral. None of the patients had combined urinary frequency urgency symptoms at referral but 5% of the patients had combined symptoms diagnosed at Urogynaecology clinic. Majority of the referrals were from the General Practitioners (43%), followed by the Gynaecologist (40%), followed by other specialities (12%) and Nurse Practitioners (5.5%) as shown in Table 2.

Table 1: Reported symptoms of study population at primary referral and at assessment in urogynaecology clinic.
Reported symptom At primary referral n (%) (Total =777) At assessment in urogynaecology clinicn (%) (Total = 777)
Prolapse 388 (49.9) 347 (44.6)
Primary prolapse 366 (47.1) 290 (37.3)
Recurrent Prolapse 81 (10.4) 22 (2.8)
Stress urinary incontinence (SUI) 82 (10.5) 162 (20.8)
Recurrent SUI 1 (0.1) 0 (0)
Overactive bladder (OAB) 22 (2.8) 22 (2.8)
Mixed incontinence 45 (5.7) 96 (12.3)
Recurrent urinary tract infection 11 (1.4) 36 (4.6)
Voiding dysfunction 12 (1.5) 75 (9.6)
Urinary frequency/Urgency 0 (0) 39 (5)
Urethral problems 4 (0.5) 11 (1.4)
Vaginismus 1 (0.1) 2 (0.2)
Vaginal stenosis 2 (0.2) 2 (0.2)
Primary dyspareunia 11 (1.4) 21 (2.7)
Female sexual dysfunction 1 (0.1) 2 (0.2)
Obstructed defecation syndrome 11 (1.4) 58 (7.4)
Faecal urgency/incontinence 15 (1.9) 0 (0)
Perineal tear 9 (1.1) 0 (0)
Multiple diagnosis 44 (5.6) 209 (26.8)



Table 2: Source of referral.
Source of referral Number of referral n (%)
General Practitioner 332 (42.7)
Gynaecologists 309 (39.7)
Other specialities 93 (11.9)
Nurse practitioners 43 (5.5)

Discussion

Urogynaecology history has number of questions that are not part of standard history taking format and therefore it is important to understand what information is expected to gain when taking a gynaecological history in a woman with pelvic floor disorders. History must be taken in a sensitive and non-judgemental manner. Women delay seeking help due to embarrassment and reticent about discussing anything to do with the genital tract. Even naming the areas can cause embarrassment and euphemisms. Marinating good communication skills with the patient in order to elicit proper history and to accurately recognize her problems is an important part of urogynaecology history. To our knowledge this is the first study looking in to the details of referral pattern and presenting symptoms in an urogynaecology clinic at a district general hospital in the United Kingdom. In our study the referrals were mainly from General Practitioners and hospital consultants (other Gynaecologists and other speciality consultants) equally. Since the establishment of Urogynaecology subspecialty by the Royal College of Obstetricians and Gynaecologists (RCOG), UK in 1982 the rift between the Generalist, Urogynaecologists and urologist is settling with Urogynaecologist taking lead in managing women with continence issues and prolapse which in turn increase the number of referrals. This could be partly due to the litigations associated with incontinence surgeries and use of mesh in the urogynaecology [4,5]. Problems with the bladder affect more than 14 million people in the UK and about 6.5 million have bowel problems. In addition, 900,000 children and young people reportedly suffer from bladder and bowel dysfunction.

Most women have been through the conservative advice for managing their pelvic floor problem. The National institute for clinical excellence (NICE) highlights the importance of conservative management with input from continence nurse specialist and physiotherapist as first line treatment for patients with urinary incontinence, to make this a reality local empowerment in an independent unit that could treat its own patients and train its own staff [6]. Most successful urogynaecological units are run not just by single clinician but include specialist nurses, physiotherapists, trainee doctors and Urogynaecologists. The concept of multidisciplinary team (MDT) management of Urogynaecology patients ensures that a balanced approach to treatment with all team members contributing has become the norm in such units [7,8]. Our unit over the past couple of years since the introduction of subspecialty Urogynaecology service has developed an MDT approach in managing women with pelvic floor disorders. Urogynecologist have a lead role in a multidisciplinary team in implementing a service with appropriate audit and undertake research which is likely to benefit the healthcare system overall. Subspecialists’ Urogynaecologists can also provide support to those with special interest in Urogynaecology which will ease the workload that will be shared so that primary prolapse and incontinence will be treated by generalists with special interest in Urogynaecology while complicated continence work would be a domain of subspecialist.

NHS is changing, patient expectations are changing, evidence is changing [9], and there is a need to review how the Urogynaecology service will be delivered safely within the given framework considering future training issues and workforce requirements. It is estimated that 50 subspecialist and about 225 special interest consultants will be required over the next 10 years [10]. Since 1992 Urogynaecology has moved from general Gynecology training after the first Urogynaecology subspecialty training was set up at St George’s Hospital, London. As of June2010 there were 16 approved subspecialty training (SST) centres and 18 approved programmes in the UK. There are 11 trainees registered for Urogynaecology SST and a further 37 who have already completed RCOG subspecialty training programmes (June 2010). SST and Advanced Training Skills Modules (ATSM) programmes have a well-defined syllabus produced by RCOG and BSUG. A recent survey of new consultant appointments indicates that less than 50% of those that complete subspecialty training in Urogynaecology are appointed as a subspecialist in Urogynaecology; this position is very different from other subspecialties.

The data from our study is confined to a single centre in Cornwall in a relatively affluent part of west of England and it may not reflect the population in the other parts of the country. The referral pattern could be due the availability of a sub specialist in the Urogynaecology. Despite the limitations of data derived from retrospective case notes review, there are strong indications that more Urogynaecologist are needed for delivery of this specialist care. We identified that in women when referred with one pelvic floor symptom, on a thorough assessment is performed of symptoms, there are often other related symptoms which are only revealed if explored as these are embarrassing to the patient and they might not mention about these unless asked. However, if these areas are not explored at the outset, the related symptoms might worse after an intervention. Therefore, a more holistic approach to patient assessment with ability to make real and lasting changes to raise standards of care for pelvic floor dysfunction is of benefit. This certainly demands for more time, however with team working together nurse specialist and conservative bowel and bladder management service, this is achievable, as shown in our newly organised service. This does require perseverance and patience and collaborative work and enthusiasm of like-minded and progressive members of the team. With a better understanding and a thorough symptom assessment of multi-compartment pelvic floor dysfunction, treatment can be initiated for various symptoms at the same time. This allows patients’ multiple symptoms improvement, avoids repeat referrals from primary care, avoids repeat visits to the clinics, avoids repeat interventions (medical/surgical), improves patients’ journey and therefore saves NHS funding and resources.

References

  1. Population ageing: 2012. Statistics - House of commons library. [Ref.]
  2. Kimberly A, Gerten Alayne D, Markland L, et al. 2008. Prolapse and Incontinence Surgery in the Older Woman. J Urol.179: 2111-2118.[Ref.]
  3. National audit of continence care. 2012. Pilot audition evaluation report. Published by the Royal College of Physicians (RCGP).[Ref.]
  4. Mayne C, Cutner A, Toozs-Hobson PM. 2008. Subspecialty training in urogynaecology. The Obstetrician & Gynaecologist. 10: 263-266. [Ref.]
  5. Mesh working group Interim report, Published by NHS England. 2015.[Ref.]
  6. Urinary incontinence in women: 2013. management. NICE guidelines [CG171]. [Ref.]
  7. Excellence in continence care: 2015. Practical guidance for commissioners, providers, health and social care staff and information for the public. [Ref.]
  8. Accreditation of Units - The British Society of Urogynaecology. 2016.[Ref.]
  9. The Scottish Independent Review of the Use. 2015.Safety and Efficacy of Transvaginal Mesh Implants in the Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse in Women Interim Report. Published by The Scottish Government. [Ref.]
  10. The Future Workforce in Obstetrics and Gynaecology England and Wales. 2009.[Ref.]

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