Hypothesis / aims of study
Pelvic floor dysfunction (PFD) is an umbrella term used to describe symptoms that occur as a result of disruption to the pelvic floor muscles or ligaments. Treatment of PFD is complex due to its concomitant symptomatology, spanning across different pelvic compartments. Efficient care for patients with PFD therefore requires multiple different clinical specialisms to work closely and cohesively to offer holistic joined up care.
In 2021, the UK Pelvic Floor Report identified several shortfalls in the current service provision for patients with PFD and subsequently made local and national improvement recommendations. The report states that pelvic floor (PF) conditions can be managed successful if patients are able to navigate the correct care pathway and be seen by those most appropriate to them and their condition1.
Approximately 6 million women and 3 million men in the UK have experienced combined faecal and urinary incontinence2. This number omits other PF symptoms and thus the overall volume of patients with PFD is likely in excess of this. The increasing burden of PFD on both patients and the overall healthcare system has triggered calls for increased clinician engagement. This work aims to summarise the current landscape for this group of patients and explore possible barriers to efficient care.
A multidisciplinary approach to the care of patients with PFD has been well established and is essential for specific and functional conditions3. We therefore engaged with healthcare groups who play a role in the care of patients with PFD.
Study design, materials and methods
Initially, clinical data was reviewed to establish the volume of patients presenting with greater than one PF symptom. Patients attending secondary care for physiotherapy (n = 52), urodynamics (n = 14,297) and anorectal physiology (n = 560) were included. Data was collected through clinical databases as well as clinic notes. This data was initially obtained through standardised questionnaires and clinical history taking. Patients were included if they reported any symptoms across more than one PF compartment.
Qualitative data was then collected from clinical groups who provide care for patients with PFD. Service provider perspectives included general practitioners, community continence services, secondary care teams and commissioning, reflecting on referral pathways, a joint formulary electronic platform, and their care provision. Service user perspectives were provided by patients.
A multi-channel approach to qualitative data collection was employed, including informal interviews, group workshops and an anonymous survey.
Results
Reporting of concomitant PF symptoms in our patient groups ranged from 15% - 69%. During urodynamic history taking 15% of patients reported bothersome bowel symptoms, 65% of those attending for anorectal physiology described bothersome urinary symptoms and finally 69% of those attending physiotherapy stated experiencing at least one additional PF symptom to their primary referral indicator.
The transcripts were reviewed, and thematic analysis was performed to identify common themes, topics and areas of concern that frequently appeared. They highlighted many of the challenges and barriers to joined up care. Themes focused on communication, education, specialist care, referral pathways and duplication of efforts. The term ‘streamline’ appeared in all healthcare conversations.
Additionally, problem statements were obtained. These are statements concisely outlining the current challenges experienced throughout the patient’s care pathway.
Interpretation of results
Prevalence of concomitant PF symptoms varies across local referral specialisms. This is possibly indicative of the physiologically progression of PFD but may also be contributed to through different clinical questioning and clinician interest.
Only 1.6% of anorectal physiology patients were not directly asked about their urinary symptoms compared to 53% of urodynamic patients who were not questioned regarding their bowel habits. This figure is likely to reflect the joint specialist training of those reviewing colorectal patients in the local department.
Large bodies of work have highlighted the need for joined up PF care. By exploring the themes extracted from our stakeholder interactions we can address current barriers and recommendations to facilitate better care for these patients.
‘Streamlining’ referral pathways may better ensure the right patients are seen by the right clinicians and at the right point in their healthcare journey. This could reduce the pressure on primary and secondary care by minimising duplication of work. It may also reduce the financial and personal cost to both the health service and the patient through wasted appointments and arduous care pathways. Single symptom care forces patients into dual services, often focusing on one symptom initially and delaying the management of other PF symptoms. Current NHS waiting times are at an all-time high and these patients must enter different treatment pathways to achieve overall management of their PFD, doubling an already lengthy wait.
Expert PF knowledge, through appropriately trained individuals, would mitigate the need for multiple appointments and separate specialists. It would allow patients the space to discuss all symptoms and have them managed collectively and with an appreciation of the overlapping physiology.
Improvements could be made via a clear PF pathway from primary through to secondary care, with visibility of all previous patient, clinician correspondence. This should be accompanied by a multimodal service within secondary care that has the specialist skills required to care for PF patients holistically and the autonomy to manage onward PF referrals. Treatment of PFD in silos presents problems throughout the patient pathway.