NICE engagement exercise for quality standard on Urinary incontinence in women
In April 2014 NICE sought comments from registered stakeholders for the development of quality standards in the treatment of Urinary incontinence in women.
This is the submission made by SPM Ltd
Key area for quality improvement 1
The quality of advice, guidance and treatment in primary care must be dramatically improved.
Why is this important?
Urinary Stress Incontinence is a significant problem for many women but the subject matter is surrounded by taboo and ignorance. Its under-reporting is acknowledged by NICE.
Much improved outcomes could be achieved, at much lower cost to the NHS, if appropriate and effective physical treatments were positively offered in the first instance.
There is a real perception amongst women at large that the NHS does not care about USI and can offer no effective treatment.
This is borne out by the evidence and anecdotes of millions of women given poor advice and ineffective treatment in primary care who suffer in silence for many years before finally being directed to surgery.
The failure to address the main cause of USI at the outset (essentially as part of post-natal rehabilitation) means that women suffer for many years unaware of the simple effective treatments available.
When they do present they are not usually offered relevant and clear advice and end up being channelled towards pharmaceutical and surgical treatments that have a far greater impact on NHS budgets with outcomes that may be no more effective than physical therapies.
Why is this a key area for quality improvement?
This is a key area for improvement because dealing with the situation appropriately in the first instance would deliver much better outcomes at much lower cost.
This alone would improve awareness of the fact that positive outcomes were possible and encourage a more enlightened perception amongst the profession and the population at large.
A focus on simple effective physical therapies could deliver better patient outcomes for the majority of women and much lower cost to the NHS and enable scarce resources (eg physiotherapy) to be better used.
Unfortunately, the scope of CG171 chose to ignore developments in physical therapies despite intense lobbying by the author.
Supporting information
“Urinary incontinence is an embarrassing problem to many women and thus its presence may be significantly underreported.”
“Where the most inclusive definitions have been used (‘ever’, ‘any’, ‘at least once in the last 12 months’), prevalence estimates in the general population range from 5% to 69% in women 15 years and older, with most studies in the range 25–45%.”
“Women may take up to 10 years before seeking help. They may be too embarrassed to seek advice, may not wish to bother their general practitioner (GP), may believe UI to be a normal consequence of the ageing process or may not appreciate that treatments are available.” CG171
Key area for quality improvement 2
GP practices should, at the very least, follow NICE Guidelines NICE CG 40 and CG171 recommend SUPERVISED Pelvic Floor Muscle Training PFMT as the first line treatment.
Why is this important?
A survey of GP practices (Source: SPM Ltd online survey) found that fewer than 44% of practices followed this advice.
Over 47% believed it to be adequate to just hand out an instruction leaflet.
Why is this a key area for quality improvement?
In the absence of the adoption of Key Areas 3 and 4, adherence to the NICE Guidelines at least offers some hope to the patient.
There is absolutely no evidence and no clinical trials to support the practice of handing out an instruction leaflet.
There is published evidence that, without supervision, a third of women are unable to engage their pelvic floor muscle effectively.
Supporting information
Pelvic floor muscle training
29 Offer a trial of supervised pelvic floor muscle training of at least 3 months’ duration as first-line treatment to women with stress or mixed UI. [2006] CG171
Key area for quality improvement 3
Pelvic Floor Muscle Training PFMT should be rigorous and robust and follow a method based on clinical evidence.
Why is this important?
At the very least PFMT should follow the principles outlined in the largest clinical trial to date – unfortunately these principles are totally absent in the PFMT currently promulgated.
The PFMT approach that is promulgated in leaflets and by current practice has no basis in hard clinical evidence and represents an arbitrary and low level of ‘exercise’ that completely fails the patient.
Extensive research of the literature fails to reveal any basis for the level and duration of the ‘exercise’ recommended.
At no stage has the current methodology been tested against the ‘Gold Standard’ that formed the basis of an exercise treatment for USI in order to validate or improve the current method.
Why is this a key area for quality improvement?
In the largest clinical trial of its kind Arnold Kegel demonstrated objective cure for USI in over 80% of cases WITHIN TWO WEEKS.
Women following the current NHS guidance are unlikely to see any improvement in any reasonable timeframe and thus compliance is low or non-existent.
Supporting information
30 Pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 times per day. [2006] CG171
To understand why this is completely inadequate visit www.thekegellegacy.com
The principles of Kegel’s exercises play no part in the PFMT offered by the NHS with the result that improvement is neither seen nor expected within three months.
Kegel’s principles require positive confirmation that the correct muscles are engaged, the use of resistive force to ensure effective exercise, a rigorous regime comprising around 300 squeezes per day and a positive feedback mechanism to demonstrate to the patient that improvement is being achieved – thus building compliance.
Key area for quality improvement 4
The quality of treatment, compliance with treatment and patient outcomes could all be significantly improved, at lower cost, if the NHS adopted the tools readily available in its armoury.
Why is this important?
There is a clinically proven progressive resistance pelvic toning device on the Drug Tariff that offers a rapid and effective treatment for the majority of women and a tenth of the cost of the nearest alternative.
The extent to which this device is offered is derisory. Women are being denied effective treatment and suffering unnecessarily for many years.
The £7bn market for continence pads is evidence of the scale of the problem that is not being addressed.
The NHS is incurring unnecessary costs because of a clear reluctance to consider non-invasive, non-pharmaceutical and non-surgical options, despite evidence to the contrary
Why is this a key area for quality improvement?
By offering all women the opportunity to use the PelvicToner™ the problems associated with weak and stretched pelvic floor muscles in post-natal and post-menopause situations the majority of cases of USI could be prevented, managed or cured, thus enabling scarce physiotherapy resources to be focussed on more needy cases.
Supporting information
The PelvicToner™ progressive resistance vaginal exerciser has been on the Drug Tariff since January 2011.
It is clinically proven to be as effective as a three month course of supervised PFMT. (Clinical trial Bristol Urological Institute 2009. BJUI Jan 2010)
Users of the PelvicToner are better able to exercise effectively and with greater confidence. The fact that users see significant improvement within a couple of weeks increases their compliance with a long term exercise regime.
At a cost of £15 (Drug Tariff) the savings to the NHS are substantial.
Janey Lee Grace, broadcaster and author of many books on natural health, is a great advocate of natural solutions.