Urinary Incontinence and how it fits in with an OB/GYN Practice

Roberta Speyer: “This is Roberta Speyer and I’m reporting for OBGYN.net. I have the pleasure of talking to Dr. Fleischman who is an Assistant Clinical Professor at Yale University and in private practice with Gynecology & Infertility, PC. Today we are going to talk about urinary incontinence and how OBGYN physicians can fit this into their practice. As a practicing OBGYN yourself, this is something you have a great degree of specialization in. Tell us a little about your practice Dr. Fleischman.”

Steve Fleischman, MD: “I currently am a general OBGYN and serve as an Assistant Clinical Professor at the Yale University School of Medicine. I have a general obstetrics and gynecology practice called Gynecology and Infertility in New Haven Connecticut. We are a general OBGYN practice and I just happen to have a special interest in urogynecology. I take care of all the urinary incontinence, or any urinary issues that we have in our clinic. I am one of six doctors in the practice and so I just take referrals from within the practice.” 

Roberta Speyer: “Is this a big part of physician’s practices nowadays, or could it be?” 

Steve Fleischman, MD: “Well it certainly could be. I would say, especially in the New Haven area, where we are, it has been a very small part of the general OBGYN practice. Urologists in our town were the ones who were dealing more with urinary incontinence. What’s been most interesting, and this has been going on in multiple studies, especially from small Consumer studies – National Association for Continence - which found that basically when they asked Consumer women who they would like to take care of this problem, overwhelmingly, 75% or greater said ‘I want my OBGYN.’ Which makes sense to me.” 

Roberta Speyer: “Absolutely, most women don’t have urologists. We don’t go to them unless we have some big problem. As a woman, I would feel comfortable going to my own gynecologist. How do you find most of these women?” 

Steve Fleischman, MD: “The corollary to it actually is that women said the biggest reason they don’t talk about urinary incontinence is they’re not asked. That is where I would say we can make a large change in our practice demographics – personally, on a routine annual exam I ask every woman, do you leak? I mean it’s part of my review of symptoms, do they have problems? And if they answer yes, it’s very difficult in an annual exam to suddenly add a whole urinary incontinence work up. But I leave the patient with the question ‘is this something you want to take care of?” We’ll look into it a little bit today but we’re going to need to set up an appointment because this is something we can take care of.’” 

Roberta Speyer: “So the first step is identifying possible candidates for getting a clinical work up for urinary incontinence just through the regular annual exam.” 

Steve Fleischman, MD: “Correct.” 

Roberta Speyer: “Then what’s the next step? First they tell you ‘Oh yes, I have this problem and that problem’ and then you progress to having a clinical work up for urinary incontinence?” 

Steve Fleischman, MD: “Correct. It’s just like anything, with any problem we have we start off with the history. We take their history; what are their leaking symptoms like, when do they leak, when do they not leak, what are aggravating factors, what are relieving factors, are there any other medications that they’re on, any other medical problems that might impact this, physical exams, identifying any underlying causes to the incontinence, identify any pelvic support defects so when you are repairing this you make sure you do a complete repair at the time of surgery. Your typical exam is examination of the vulva and you can find multiple things, atrophy of the vulva, dermatitis, and pain symptoms can also contribute to symptoms of incontinence. People that have severe vaginitis may have urgency or frequency symptoms. People can have a urethral diverticulum, there are a lot of things you can find in a physical. But basically those are the main things you are looking for. When you move to a typical pelvic exam you are looking for things that may cause their symptoms. Whether there’s any evidence of uterine prolapse, cystocele or rectocele that may aggravate or cause these symptoms.” 

Roberta Speyer: “Do you have any other methods you use to diagnose?” 

Steve Fleischman, MD: “I would do a urinalysis and culture, make sure there’s not an infection. Occasionally in certain patients, while it’s not a common thing, I will do a q-tip test, which is an attempt to look at urethral hypermobility. But I’m sort of moving away from that a little more. I always make sure we do a pelvic muscle assessment. Have patients squeeze their pelvic muscles as if they are trying to hold their urine, see how well their muscles are contracting to see if any sort of physical therapy may benefit beforehand. And then consider urodynamics for the sub-group of the patients who a) have a very complex medical history, b) have had previous failed surgeries c) I think I might be doing surgery on. Anyone who I’m going to do surgery on, I make sure I do a urodynamic evaluation.” 

Roberta Speyer: “Why is that?” 

Steve Fleischman, MD: “Well there are two major reasons why people can leak. One would be genuine stress incontinence, which is caused by urethral hypermobility. But there is another type of incontinence called intrinsic sphincter deficiency, where it’s not so much that the neck of the bladder is hypermobile leading to pressure differentials causing incontinence, but rather a function of the urethra itself losing some of its competency. And when that happens you might change your surgical intervention based on the underlying reason for the incontinence. The other thing that if you think you are going to take someone into the operating room you really want to make sure that they really do have true stress incontinence. I’ve had some patients who say they leak when they laugh, cough or sneeze and I perform urodynamic studies and they end up not needing surgery. I had a patient three days ago, and what I ended up doing was I filled her bladder and it turned out she didn’t even know that I had filled her bladder with anything at all. Her first sensation, which you would typically expect somewhere at 150ccs, she didn’t feel until I had 500ccs in her. But I had her cough, laugh, when I had her sneeze, and when I had her do these things at volumes of 150, 200, 250, 300 she didn’t leak. But as soon as she got to about 480ccs she started leaking. She doesn’t necessarily need surgery, I told her ‘we’re going to do some bladder retraining. We’re going to get your volumes down, you shouldn’t be letting your bladder go to 500ccs.’”  

Roberta Speyer: “Should she just go to the bathroom more often?” 

Steve Fleischman, MD: “Well, I told her go to the bathroom every three hours and see what happens. And I think in her case she won’t leak. She was putting so much pressure upon the bladder by letting it fill to 500ccs that there really was no more room for it to expand, and so the leaking at 500ccs isn’t what I would even consider abnormal. She had no concept that there was any fluid in her bladder. Overwhelmingly people with this problem don’t go to the bathroom on a regular basis.” 

Roberta Speyer: “So urodynamics can help with your surgical decisions but it can also eliminate non-surgical candidates? How do you get urodynamics into your practice economically? Is there a significant cost with this?” 

Steve Fleischman, MD: “Well, the other thing that you’ve got to keep in mind is, up to 40% of women can have what is called mixed incontinence where they can leak urine when they laugh, cough and sneeze from genuine stress incontinence and also have some overactive bladder. So the other reason I find it useful for patient care and surgery is that if I find on the study that they have both, I can often times put them on a medication to get rid of the detrusor component and then use surgery. Because if you do surgery and then they have overactive bladder symptoms – then they think you didn’t fix anything. I can sort of graphically describe to them that there are two problems. One because of this reason and one because of the other reason, show it to them on the computer screen and explain a little bit better. Now, in terms of getting it into your practice I chose the Lumax system, which is a unit that’s very small, self-contained, and hangs on a IV stand. It has a little stand to put a laptop computer on and does all the graphic interfacing and printing reports and clinical information. It uses fiber-optic cables that are disposable so it’s very easy to use and it doesn’t take up a lot of space in my office. From a standpoint of learning how to use it – it took me three or four sessions with a company rep. She worked with me on the unit, showing me how to use it. But if you’ve done it in your residency training, and a lot of people have done some form of urodynamics at some point during their training or at least seen it, this really is a very, very basic skill set. And actually for a lot or practices it’s not even the doctors that are doing this. In most places you either have a nurse or some sort of technician that’s actually doing the study itself. In my personal practice, just because of staffing issues, I do these myself. I find that allows me to explain the surgery at the same time.” 

Roberta Speyer: “And you also get to specialize in this area because you are part of a six person clinical team?.” 

Steve Fleischman, MD: “Right. So, it’s easier for me, especially since many of the incontinent patients are my partners’ patients. This process allows for me to meet the patients and get to know them so that I am not just meeting them on the operating table.” 

Roberta Speyer: “What’s the economics of this? Is this expensive? Can you make money on this?” 

Steve Fleischman, MD: “It certainly is a positive economic impact on your practice. The unit itself is somewhere in the ballpark of $13,000 and each study you are looking at is somewhere around $75 for the study material. It’s about $50 for the catheters, the id tags, some tape and some tubing. And the reimbursements vary, in my area of Connecticut , Medicare is about $500 per study. Now you have to understand that this is a study that takes about 25-35 minutes to do. So, from a standpoint of economics it pays for itself, at least for the machine, in about 30 studies.” 

Roberta Speyer: “And how many studies can someone expect to do in their practices?” 

Steve Fleischman, MD: “In my practice we do not advertise our urodynamics so all of our patients for this service come directly from in house referrals. With that said, I book about two studies a week and I’m always booked at least four to five weeks in advance on the urodynamics. I could open up more sessions, but again I wanted general OBGYN as well, and I don’t want to make my entire practice uro-gynecology. We easily made back our initial investment in the unit with just our Urodynamic patients. And that’s not including the fact that invariably the person who does the urodynamics studies also does any necessary surgeries. So not only is there a positive income from the urodynamics study but you have a positive income from you doing the surgery and taking care of the patient following the study results.” 

Roberta Speyer: “What can you say to another OBGYN who wanted to begin treating urinary incontinence in their practice? What steps should they take?” 

Steve Fleischman, MD: “We say, ‘You know, we’re going to start taking care of this problem. We’re going to be a little more aggressive about finding out about symptoms from our patients.’ Our patients love the fact that we are not referring them somewhere. Our patients love knowing that if my partner says, ‘you’re going to see one of my partners’, not some random urologist in another office somewhere else. There’s no loss of communication, when we send them to the urologists, sometimes you get information back, sometimes you don’t. We know everything that’s going on with our patients. Our patients love it. We got the urodynamics machine in and then right from there, from the moment we got it, within three, four weeks we were already booking patients and it’s just been a wonderful part of our practice.” 

Roberta Speyer: “Well, I know as a woman going to my OBGYN you get to know the whole staff too, especially if you’ve gone through pregnancy in that office. And I know that many women might not want to go to a new doctor because theirs can’t do urodynamics. They might just decide to live with it.’” 

Steve Fleischman, MD: “Right.” 

Roberta Speyer: “I think you can give better care if you can take care of them right there in the office. I’m more inclined to let your office do something to me than I would be to go see another doctor.” 

Steve Fleischman, MD: “I think that the other thing to keep in mind is that the treatment of urinary incontinence ten years ago was much different than it is today and a lot of the surgeries that people did traditionally have given us some complication rates. The slings were a little more invasive and a little more difficult to do and had a higher urinary retention rate. I think because we are seeing this influx of new procedures such as the TVT, bone anchoring slings, and better medication such as Detrol LA and Ditropan XL, and it is only a matter of time before there will be a medication out on the market for the treatment of urinary stress incontinence.” 

Roberta Speyer: “I think that’s the new one coming out from Lilly, isn’t there?” 

Steve Fleischman, MD: “Correct. There might have been a hesitancy to deal with some of these issues because our ability to treat them was somewhat limited. But with the technology and the ability to treat patients in an effective manner today, there is no reason why people shouldn’t really be open to this. And in 2003 with the changing economics of health care this is really an area where it’s open to a large flux of patients. Which is a positive economic impact on your practice. The patient care, customer satisfaction portion of it is just unbelievable. Patients are going to be thrilled that their OBGYN, who they’ve been seeing for X number of years is going to be taking care of this problem for them and not sending them to someone that they don’t have a relationship with. Urinary incontinence is a quality of life issue, but you know, it has its psychological self-esteem issues as well. It’s very hard to go to someone that you don’t know and never met before and talk to them about the fact that you leak urine all the time. Having someone you feel comfortable with that you have a relationship with and can also talk to about this issue is clearly what our patients want.”

Roberta Speyer: “This seems like an excellent model for treating women. You allow them to see the doctors they trust for all of their gynecological needs. And on top of that it is economically productive for the doctors involved. This is definitely a win-win for everyone involved. Thank you Dr. Fleischman.” 

Steve Fleischman, MD: “Thank you.”