Download Top of Form Issue Date: October 01, 2003 Vol. 11 •Issue 10 • Page

Issue Date: October 01, 2003
Vol. 11 •Issue 10 • Page 26
Comprehensive Continence Care: The Role of the APC
By Helen Carcio, NP
As my grandmother aged, she experienced frequent episodes of incontinence and was horrified when she
leaked or smelled of urine. My grandmother felt loss of control, fear, frustration and shame. Her only option
for controlling leakage was cloth diapers. Fortunately, treatment and management options have changed
dramatically since then. In addition to simpler surgical techniques, today's conservative, nonsurgical
approach to the treatment of incontinence has changed the face of continence management. Women who
are accurately diagnosed and treated are now able to take back control of their lives, unhindered by
incontinence. Unfortunately, thousands of women are untreated and do not have access to care because
there aren't enough continence centers to treat and manage this widespread problem.
Scope of the Problem
The National Kidney and Urologic Diseases Advisory Board estimates that incontinence affects a staggering
13 million people, most of them older women. Because incontinence is often a hidden disease due to
associated embarrassment, researchers believe it is widely underreported and that the number of women
affected may actually be as high as 26 million. Untreated, incontinence can lead to embarrassment,
depression, decreased sexual activity, decreased job opportunities, powerlessness and social isolation. It is
a socially, emotionally and physically devastating problem affecting 20% to 40% of elderly women. 1
Critical demographic trends are changing the nature of the country and thus the health care landscape. The
fastest growing segment of the population is the aging baby boomers, now in their 40s and 50s. The
proportion of U.S. residents between 45 and 65 has dramatically increased over the last decade and will
continue to do so during the next 10 years. As the number of elderly people rises, so will their need for
health care services, particularly incontinence treatment.
When so many women are affected by incontinence, it is surprising that more services aren't available.
Treatment of this problem is not consumer driven, however, because so many women do not seek help.
Women are reluctant to discuss incontinence even with their primary care providers. The reasons are many
and varied. All women need current, accurate information to learn that their problem is common and
treatable. Table 1 lists some of the most common reasons why women are silent about incontinence.
Table 1: Reasons Why Women Do Not Report Their Incontinence
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They believe it is a normal part of the aging process — something they have to learn to live with.
They are able to limit fluids and thus decrease urination, increasing the risk of dehydration.
They are afraid they will be institutionalized. (Incontinence is the major reason for admission to
nursing homes.)
They are too embarrassed to admit to such a "shameful" condition.
They believe they will be socially isolated. (Perhaps they already are!)
They are able to rely on incontinence products.
They don't realize or believe that they are not alone.
They feel powerless and are resigned to their situation
A Fit for the Advanced Practice Clinician
The lack of available information and treatment for incontinence provides an exciting practice and business
opportunity for nurse practitioners. The goal of this article is to generate enthusiasm for the expanding role
of nurse practitioners in the establishment of nurse practitioner-managed continence centers. I established
and now operate two such centers, at Pioneer Women's Health in Greenfield, Mass., and Grace Urological
in Brattleboro, Vt.
Although I never thought I would prefer working with elderly women, I see my grandmother in their faces and
derive much pleasure from this patient population. For many years I have been dedicated to the health
needs of women, first specializing in adolescent contraception, then infertility, then perimenopause and
menopause, and now incontinence. It seems my career has evolved and progressed parallel to my own life
span. The administrator of my continence center has told me that I have reinvented myself more times than
Madonna. But that is what being a nurse practitioner is all about — being creative and responsive to
changes in health care
Nurse practitioners are emerging as frontline providers in the diagnosis of incontinence and treatments to
restore continence. The conceptualization, establishment, marketing and management of a continence
center or program offer an exciting and rewarding opportunity for an NP. You can accomplish this by
establishing an independent practice or collaborating with other health care providers. Reimbursement
barriers have been removed or minimized in most states, with a broadening of authority and ability to receive
direct payment for services provided. NPs are ideally suited for the role since most have the patience,
motivation, teaching skills, clinical knowledge and enthusiasm necessary to support and motivate women as
they make their way through an incontinence treatment program.
Taking Stock of Your Resources
This adventure is not for everyone. It requires a special personality. So begin with some self-analysis. Are
you creative, positive, dedicated, patient, attentive, motivated and motivating, knowledgeable about
incontinence, and free of heavy family responsibilities? Do you have a flair for business — an
entrepreneurial spirit? Do you have access to the following personal and professional resources:
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credibility as a nurse practitioner expert
potential to generate financial support
an experienced consultant
a collaborating physician
surgeons to refer to when necessary
access to the Internet for educational support
incontinence or other focused treatment centers as models for your venture
state requirements and regulations
billing codes for reimbursement?
To be licensed in most states, NPs must follow established clinical guidelines. An excellent resource and
appropriate guide for the nurse practitioner who wants to manage an incontinence center is a federal
guideline titled Urinary Incontinence in Adults: Clinical Practice Guideline, published by the Agency for
Healthcare Policy and Research.2
Conceptualization
As the organizer of a continence center, you must be committed to the venture and have the motivation and
the know-how (or at least know how to get it!) to complete the project. Consider all options and anticipate
potential problems. First, obtain or perform a community assessment. It is often best to offer continence
services in a community you are familiar with. Determine the existence of any other continence centers in
the surrounding areas. What would draw women to your proposed center? What is the population of women,
particularly older women? This information is usually on file with city offices or at local hospitals that have
obtained community grants. A formal business plan is necessary and is beyond the scope of this article, but
many communities have agencies that can assist with the formulation of such a plan. You can also refer to
the Business Guide for Nurse Practitioners published in the June 2003 issue of ADVANCE for Nurse
Practitioners (Reel SJ. Developing a business plan. Getting down to specifics. 2003;11[6]:53-54,90).
Additionally, computer programs that outline how to create a business plan are available.
An initial assessment of your concept should include deciding on a mission statement and objectives. A
mission statement and related objectives will help guide your course of action and help clarify your thinking
for potential grant writing. The following is a sample:
Mission Statement: To establish a holistic, community-based continence center to provide comprehensive,
compassionate and high-quality care, including diagnosis and management of women who are incontinent.
Objectives:
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to increase services, expand productivity and increase revenue for an existing practice
to increase access to health care for women who are affected by incontinence
to decrease the number of incontinence episodes through the diagnosis and management of
incontinence
to provide a conservative alternative to the surgical treatment of incontinence
to expand the work force by making it possible for older women to work productively well into their
later years
to prevent early institutionalization
to partner with existing community resources to meet a community need
to help women maintain the dignity they deserve as they age.
These simple objectives contain key words that can be used when applying for grants: lack of control,
dignity, women, aging, community and conservative treatment.
Practice Options
The name of your center is important, so choose it carefully. Think positive. The name "continence center"
sounds more positive than "incontinence center." A more general name might also work, such as "The
Center for Bladder Health" or "Urology Services for Women."
Your center can take one of many forms, ranging from a comprehensive treatment center to a program
within an established women's health center. Decide whether to set up an independent or collaborative
practice. The term "center" usually indicates a more independent setting where continence diagnosis and
treatment are the main functions. The term "program" tends to refer to a specific program for continence that
is part of a larger office, such as a women's health center. I will use the broader term "center" for the
remainder of this discussion.
An independent practice requires more financial resources and time than a collaborative arrangement. Many
NPs do not have a strong business sense, yet have many of the other characteristics necessary for success.
Therefore, I believe that a collaborative model is the most realistic for many NPs. Urologists,
urogynecologists and obstetrician-gynecologists in your community are likely to be interested in considering
a thoughtful and organized plan for managing incontinence. In most cases, it is a service they would like to
offer but that they probably do not have the time or energy to organize. They might have the financial
resources available to help you do so once they appreciate the revenue-generating possibilities. This
collaborative model makes the most sense since it presents the least amount of financial risk. You should
approach the collaborating physician of your choice with a detailed plan that clearly demonstrates how such
a center could increase existing services, expand productivity and generate revenue.
Choosing a Site
Tour potential office space and discuss space requirements with your collaborating physician. Since you will
be dealing with many elderly women, select a place that is easily accessible on the ground floor or by an
elevator, with nearby public transportation. One large room to use 1 to 3 days a week should be adequate at
first. Next, determine the personnel required. At minimum, you need a competent RN to assist with the
program.
Explore lease-to-purchase options for equipment for pelvic floor rehabilitation and urodynamic testing.
Specific equipment needs are discussed later in this article. Research the availability of local and regional
grants to assist in capital equipment acquisition as well.
Marketing Approaches
Marketing strategies are an integral part of your business plan and should target women and health care
providers in the community (Table 2). The major challenge is to dispel myths and misconceptions about
incontinence and to promote the positive aspects of conservative treatment modalities.
Table 2: Target Groups for Marketing
Women in the Community
Socially mobile
Homebound
Institutionalized
Providers in the Community
Primary care providers
Women's health centers
Specialty practices
Your marketing focus should be on developing strategies to reach older women in the community. Three
groups of women need to be identified and approached: the actively mobile, the homebound and the
institutionalized. Good sites for reaching actively mobile women are beauty salons, community and church
groups, and fitness or senior centers. To contact women at home, use newspapers, weekly circulars and
local cable television or radio programs. Visit assisted living facilities and senior apartment communities to
meet the administrators and assess the need for your services.
Community Education
Promote community education about incontinence. One way is to make a presentation to area hospitals.
Hospitals may want to partner with you to promote the center, since it provides a valuable community
service. The title of the presentation is important. Remember that this condition is still considered
embarrassing. The first presentation about my center was titled "Treatment Options for Urinary
Incontinence" and no one attended. I called the second presentation "I am Too Young for This — An
Approach to Bladder Health," and I had a large audience. Practice your presentation on smaller audiences,
then organize something larger. For example, arrange to be the luncheon speaker at a senior center.
Keep the presentation easy to understand. Use plain language, avoiding unfamiliar medical terms.
Emphasize that incontinence is a common, widespread problem that is definitely treatable. Inform your
audience that by using conservative measures, continence is improved in 85% of cases.3 Discuss strategies
to regain bladder control, such as pelvic floor rehabilitation, bladder retraining and pharmacologic treatment.
Review simple methods such as avoiding bladder irritants. Do not ask personal questions in this
atmosphere.
Incontinence Screening Day
Organize an incontinence screening day as part of your marketing plan to reach community women.
Consider partnering with a local hospital and include osteoporosis screening or breast cancer risk
assessment evaluation. An additional source of funding for this day may be pharmaceutical representatives.
It's a nice touch to offer a healthy snack. Each woman should be scheduled for a 15-minute visit and
progress through a series of stations. At the first station, a nurse performs a dipstick test of her urine sample
and records the results. At the second station, the woman fills out a risk assessment questionnaire. At the
third station, you make recommendations based on the dipstick results and questionnaire. Each woman
should leave with a brochure about your practice and a more comprehensive health history form to complete
on her own. Give each woman the opportunity to schedule an appointment. Have a sign-in sheet to build a
list of names and addresses for future mailing lists. You could also have a raffle (gift basket, recipe book)
that they would have to fill in their names and addresses.
Professional Networking
It is essential to make providers in your community aware of your new center. Initially you could arrange a
luncheon information session at larger medical offices, speak at grand rounds or provide an evening dinner
program. Consider seeking sponsorship by a pharmaceutical company.
At each session or event, discuss the various types of incontinence and the related symptoms. Explain the
diagnostic services your center offers, such as urodynamic testing. Review pharmacologic and
nonpharmacologic approaches and provide statistics about the success of pelvic floor rehabilitation. Explain
who and how to refer to your center, and supply referral forms and practice brochures. Inform the providers
about new treatment options and the availability of new state-of-the-art diagnostic services.
Many primary care providers do not have any interest in treating incontinence but would be happy to offer
this service to their patients through referrals, particularly if the treatment is conservative. Since many
women are reluctant to broach this embarrassing subject, all providers must ask their patients about bladder
control. Suggest that providers do this by including a question about urine leakage on their patient
information forms.
Be sure to send an initial marketing letter to all area practices, hospitals and extended care facilities in
surrounding communities. Then, send a follow-up letter after each initial consult and enclose more
information about the program and its potential for success. At the conclusion of a patient's treatment
program, send a summary letter to her referring provider that explains her progress and reinforces the
success of the center.
Clinical Services
The rest of this article discusses the backbone of your center — clinical services. As part of your business
plan, determine which services you will offer. Essential services to provide at a continence center include:
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assessment and evaluation of incontinence
diagnostic procedures such as EMG and urodynamic testing
counseling on dietary modification, including identification of bladder irritants
medications, particularly anticholinergics
identification and treatment of atrophic vaginosis
behavioral modification
pelvic floor rehabilitation using biofeedback and electrical stimulation
mechanical support using pessaries.
Assessment and Evaluation
Schedule an hour for each initial visit. Many elderly patients do not have a long attention span. Try not to
give too much information at once. It may be necessary to repeat much of the information at subsequent
visits. Mail the assessment form to the patient prior to the first visit and have her bring it to the visit for
discussion. Begin with an assessment of the home physical environment, including the location of toilets,
and suggest any modifications that might be helpful.
A comprehensive history and physical examination are essential. The focused history will help determine the
type and extent of urinary incontinence. The physical examination should include a pelvic examination to
evaluate anatomic support, assess muscle tone and determine neuromuscular innervation to the sacral
dermatomes. Perform a bimanual exam including a rectal examination to detect masses or suprapubic
tenderness.
In addition to the physical and history, obtain a post-void residual to determine if the patient is completely
emptying her bladder. This can be done by catheterization or bladder scan. Urinalysis and urine culture rule
out infection and other disease states. A catheterized specimen could be used for this, since the urine
sample is free of vaginal secretion contamination and many elderly women find it difficult to do a clean
catch. (At your new center, remember to always place a table next to the toilet where a woman can place
the urine collection cup and wipes.) A collection hat can also be helpful, especially with the elderly. It seems
many women have a "shy bladder" and although they have a problem with incontinence, they cannot
produce a drop when asked to do so!
Perform a provocative stress test when the woman has a full bladder. Ideally, the woman should be standing
up over a pad. Instruct her to spread her legs, relax the perineal area and provide a single, vigorous cough.
(Not always easy in a clinical setting.) Short spurts of urine with each cough may indicate stress urinary
incontinence. Immediate leakage that starts and stops with the cough constitutes a positive result. This test
is very subjective, however. A false-negative result may occur if the patient does not relax, the bladder is not
full, the cough is not strong, or the test is conducted in the upright position in a woman with a large
cystocele. Delayed or persistent leakage suggests detrusor overactivity (triggered by coughing) rather than
outlet incompetence. Performing the test when the patient has an abrupt urge may also cause false-positive
results.
Next perform the Marshal test. Support the bladder neck with two fingers on either side of urethra, and have
the patient cough again. If there is no urine loss with the maneuver, the test is positive for stress
incontinence. The Q-tip test (sway test) is indicated to rule out urethral hypermobility and anatomic
displacement with increased intra-abdominal pressure. Insert a cotton swab dipped in xylocaine jelly through
the urethra to the urethrovesicular junction and have the patient bear down. A >30-degree deviation of the
swab from the horizontal position is considered abnormal. I do not routinely perform this test using a swab
since most patients consider it invasive, but if a post-void catheterization is needed, you can observe the
displacement of a lightly held catheter instead.
Note that these simple office tests only offer a gross estimation of bladder function and should not be used
as absolute indicators of bladder dysfunction. I do not routinely perform a provocative stress test, Marshal
test or Q-tip test on women who appear to be candidates for urodynamic testing. Urodynamic testing
provides more accurate results and appropriate documentation. Table 3 lists the conditions under which
urodynamic testing is appropriate.
Table 3: Indications for Urodynamic Evaluation
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Uncertain clinical diagnosis with a resultant inability to develop a reasonable management plan
Prior urologic or continence surgery or pelvic radiation
An abnormal bladder capacity of < 250 mL or > 650 mL
Suspicion of intrinsic sphincter deficiency
Prior use of nondiagnostic simple cystometrics
Unsuccessful treatment for detrusor instability
Straining urethral axis > 30
No improvement in stress incontinence after a trial course of pelvic floor rehabilitation
Suspicion of neurologic disorders
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Refractory urinary tract infections without apparent cause
Symptomatic pelvic wall defects
Treatment failures despite adequate trial
Women older than 65
Multiple failed surgeries
History of mixed (stress and urge) incontinence
A bladder diary is critical to diagnosis and treatment because it provides a clear picture of a woman's voiding
patterns. Give each patient a diary at the initial visit and require completion of it before initiating any
therapeutic interventions. A woman is often surprised at what the diary reveals, which is the first step toward
behavior modification. Her notes help diagnose the type of incontinence she is experiencing.
It is also important to determine the woman's previous use of Kegel exercises. In the unlikely event she has
never tried them, send her home with proper instruction to practice for a month. A trial course of a month of
Kegel exercises must be documented in her chart in order for reimbursement to be authorized. Also at the
first visit, provide a list of bladder irritants to avoid, such as caffeine and alcohol
Common Bladder Irritants: The “C” list
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Coffee and tea (sometimes even decaffeinated)
Caffeine
Cranberry
Cocktails
Chocolate
Carbonation
Citrus in juice or fresh fruit
Chile or other spicy foods
Cold (fresh) or cooked tomatoes
Cola drinks
Other substances such as honey, sugar and
artificial sweeteners
As you can see, the initial encounter is critical and requires a long visit, usually at least 60 minutes. It can
usually be coded as a Level 5 E&M.
If your assessment concludes that the woman is a good candidate for pelvic floor rehabilitation, instruct her
to return for up to six visits for biofeedback and electrical stimulation. These visits will also include
assessment of compliance with bladder irritant avoidance, fluid management and medication titration.
Despite a thorough history and physical and series of diagnostic tests, the cause of incontinence is still
unclear in many cases. Documentation of the condition by urodynamics is often necessary.
Urodynamics
Urodynamic testing and evaluation are well within the scope of nurse practitioner practice. In many states,
urodynamics has recently been added to the Blue Cross/Blue Shield list of billable procedures for NPs. With
proper training and support, it is relatively straightforward to perform and interpret. You can find information
on urodynamic testing training for NPs at http://www.srsmedical.com/srs_clini cal_training_programs.htm.
Urodynamic testing does the following:
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evaluates bladder filling
measures bladder capacity
determines volume of first sensation of bladder fullness
identifies the presence or absence of uninhibited detrusor contractions
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identifies urethral competence
assesses voiding function.
The goal of urodynamic testing is to ascertain the most appropriate plan of care to improve the patient's
quality of life. It provides practical clinical information that documents the cause of urinary dysfunction, which
helps determine proper treatment. Two elements of urodynamic testing are cystometrograms (CMGs) and
urethral closure pressure profiles. Properly performed and analyzed cystometrogram and urethral closure
pressure profile studies are valuable for the dynamic evaluation of bladder function and the sphincteric
activity of the urethra.
It is important to try to replicate the woman's symptoms during urodynamic testing. The outcomes will help
you provide realistic counseling before subjecting a woman to invasive surgery. Complex cystometry
simultaneously measures multiple parameters of urinary pressure, which are recorded on computer tracings
of these pressures. A multichannel cystometrogram has the distinct advantage of detecting artifact produced
by abdominal pressures. By recording simultaneous pressures within the bladder and abdomen, increases
in detrusor pressure can be differentiated from increases in abdominal pressure resulting from other causes.
CMG also offers an enhanced sensitivity for detecting detrusor instability. Complex uroflow measures the
flow and pattern of urine during voiding.
Most new urodynamic equipment is compact and can easily be stored in the corner of the room when not in
use. The photo on page 33 represents one choice for urodynamic testing.
Behavior Modification
Bladder retraining can break frequent voiding habits and decrease urgency. This behavior modification helps
regain cortical control over the detrusor muscle of the bladder. Establishing a toileting schedule works best
when adjusted to and based on the woman's individual pattern. Instruct the patient to void by the clock
rather than when she has the urge. The usefulness of this technique has been confirmed in the treatment of
urge incontinence and frequency. Recent research suggests that a timed voiding interval schedule can also
be helpful in treating stress incontinence. Keeping the bladder as empty as possible decreases strain on the
muscles. Voiding on demand lets the woman regain voluntary control of her bladder.
Reduction of bladder irritants is considered first-line therapy for reducing symptoms of urinary urgency and
must be reinforced at every visit or treatment session. Not all of the substances listed in Table 4 cause
bladder irritation in all women. A patient can slowly add some of her favorites back to determine how she
responds to them. Caffeinated drinks and alcohol seem to be the worst offenders. Provide a list of irritants to
each patient and instruct her to check off her particular offenders. Suggest that she post it on her refrigerator
door with a magnet as a constant reminder.
Medications
Behavioral therapies alone are not always effective for the long-term treatment of incontinence. Offer
pharmacotherapy to enhance patient compliance and improve outcomes. Anticholinergics are recommended
as first-line therapy for urge incontinence, and research recently determined that they are helpful in treating
stress incontinence. Anticholinergics work at the ganglionic receptor to block detrusor contractions in the
overactive bladder. A low-dose regime is always recommended for elderly patients, and it should be titrated
according to effectiveness and side effects. The literature supports the use of two anticholinergic agents as
starting points of therapy: tolterodine (Detrol LA) or oxybutynin (Ditropan XL).4 Both are also available in
immediate-release doses, but the extended-release forms are more effective and have considerably
reduced side effects. Dry mouth, dry eyes and constipation are common dose-related side effects.
Pharmacologic treatment options are summarized in Table 5.
Vaginal Atrophy
A majority of elderly women have urogenital atrophy, which presents as vulvovaginal irritation and vaginal
dryness. Last year's Women's Health Focus Issue presented a full discussion of this topic (Carcio H.
Urogenital atrophy. A new approach to vaginitis diagnosis. ADVANCE for Nurse Practitioners.
2002;10[10]:40-51). Estrogen thickens the layers of the vaginal wall, enhancing support of the bladder and
rectum. In some cases, simply adding a convenient vaginal estrogen preparation (creams such as Premarin,
tablets such as Vagifem or rings such as Estring) can dramatically decrease incontinence after a few months
of therapy. Even women taking systemic hormones may still need local estrogen supplementation. A vaginal
pH can provide supplementary data about the presence of an alkaline, postmenopausal vagina.
Pelvic Floor Rehabilitation
Pelvic floor rehabilitation (PFR) with biofeedback should be the mainstay of conservative treatment at a
continence center. Pelvic floor rehabilitation is a training technique that utilizes electrical equipment to
monitor electrical activity of the pelvic floor muscles through a vaginal or anal sensor and record any
unwanted contraction of accessory muscles through a properly placed abdominal sensor. The woman can
view these tracings on the computer screen and use them to alter her responses. Electromyography is done
prior to biofeedback training and records the electrical potentials generated by the depolarization of muscle
fibers. This provides an objective assessment of patient progress. Any progressive increase in muscle tone
can be documented in graph form in testing computers such as the Orion PC. Women appreciate the
positive, definitive feedback, especially if you give them a printout of the graph to take home.
A computer program called ControlWorks, which is offered as a companion to the Orion, supports a powerful
database that stores clinical information from PFR sessions, as well as data about home training
assignments, goals and assessments. It also allows you to easily modify treatment protocols. Similar
programs are available from the Prometheus Group and Hollister.
PFR is an efficient, noninvasive and cost-effective therapeutic modality for the treatment of urinary
incontinence. The goal is to decrease incontinence by increasing the efficiency and magnitude of muscular
contraction of the pelvic floor muscles. Many women tend to compensate for weak pelvic muscles by
inappropriately using their abdominal muscles, buttocks and thighs to control continence. Performing these
exercises incorrectly can worsen urinary incontinence since improper use of the abdominal muscles can
increase pressure on the bladder. PFR should be considered as an initial alternative to surgery in properly
screened and motivated patients. It is also essential therapy for women who are planning pelvic surgery and
as follow-up afterward to strengthen pelvic floor muscles and achieve more positive, long-lasting surgical
outcomes.
A PFR program usually requires four to six visits, with yearly follow-up assessment. You can typically see
between six and 10 PFR patients each day in a continence center. The average revenue varies according to
what is reimbursed per PFR visit, but a general estimate is between $275 and $375 for the initial visit and
$225 to $275 for the next four to six subsequent visits.
Biofeedback is a behavioral therapy that utilizes visual feedback of pelvic muscle strength and resting
activity. Pelvic floor rehabilitation using biofeedback to teach Kegel exercises is indicated for people with
stress incontinence and can improve continence in women with urgency and mixed incontinence as well.
Biofeedback also treats a variety of other problems, such as vulvodynia and irritable bowel syndrome. PFR
re-education is also effective in treating women with sphincter deficiency and detrusor instability. 5 This
therapeutic plan should always be used with other modalities, such as maintaining adequate fluid volume,
eliminating caffeinated beverages and alcohol, bowel regulation, timed voiding, and pessary use when
indicated.
Most women are motivated to learn Kegel exercises. PFR provides the tools for a woman to improve, but
she must practice at home. At the end of each session, provide each patient with a homework sheet of
exercises. One suggestion is to have the patient write down three activities in her daily routine that would be
conducive to Kegel practice. It might be during the morning news or an afternoon soap opera, or before
going to bed. Another successful solution is to provide patients with a trigger to remind them when it is time
to practice. I have chosen the "forget-me-not" flower as that trigger. Most women love flowers and respond
well to this reminder. Another possible trigger is a lemon to remind them to "squeeze." I make refrigerator
magnets featuring favorite triggers and give them to my patients. I also suggest that women do "quick flicks"
whenever they stop at a stop sign or turn on the cold water faucet. All these triggers are vital to the success
of pelvic rehabilitation.
State-of-the-art equipment is now attainable and affordable to perform PFR and is well suited for the new
age of incontinence therapy. The equipment is portable, and most manufacturers provide a handy suitcase
for easy portability to other sites, such as extended care facilities and nursing homes. This convenience
opens up a new realm of revenue-producing opportunities.
Documentation is key to the success of your continence center. You must document the medical necessity
of each visit. This is the most scrutinized area during an audit. Individualize your program to your
environment and patient base. I usually do an initial visit for 1 hour; each subsequent visit for pelvic floor
rehabilitation lasts between 45 and 60 minutes. You must be familiar with state and Medicare regulations.
Once a woman completes a PFR program, she should return every 6 to 12 months to have her continence
status reevaluated. Research has demonstrated that improvement in incontinence persists over time. 6
Anecdotally, I have found that a woman who practices every morning and evening for a few minutes after
completing the program will maintain her muscle tone and retain the same degree of continence.
Electrical Stimulation
Electrical stimulation uses a probe and equipment that are similar to that used for biofeedback. Electrical
stimulation is usually used in conjunction with PFR and biofeedback. During this important therapy, tiny,
painless amounts of electric current are sent through the muscles of the pelvic floor and bladder. This
treatment is helpful for both stress and urge incontinence. For women with stress incontinence and very
weak or damaged pelvic floor muscles, electrical stimulation can help these muscles contract to become
stronger. A low dose of electrical current offers a passive form of pelvic muscle exercise. For women with
overactive bladder, electrical stimulation may help the bladder relax and prevent it from contracting
unnecessarily. Electrical stimulation is a vital part of the treatment protocol for women with incontinence.
Pessaries
A pessary provides yet another option in the management of incontinence. You would be remiss if you did
not offer this valuable treatment tool. In the recent past, pessaries were only recommended for women who
had no other options. Today, the pendulum has swung back in favor of pessary use as a first-line option in
incontinence management.
Pessaries are frequently mentioned in Greek and Latin literature. The earliest pessaries were stones. Not a
bad idea. There were certainly enough stones available to fit almost any historical pelvic floor. Though not
quite as plentiful as stones, pessaries on the market today offer a myriad of different sizes and shapes (see
photo).
Today, the term "pessary" usually refers to a mechanical device used to support the organs in the lower
pelvis. Some are similar to the common diaphragm. Most modern pessaries are made of medical-grade
silicone, which is non-toxic. Silicone is biologically inert, rarely causes allergic reactions and usually does not
absorb vaginal odors. A pessary can be autoclaved or boiled, or sterilized in a dialdehyde disinfectant such
as Cidex.
Pessaries have many advantages. They assist in restoring continence by stabilizing the bladder base, and
they support the pelvic organs in their proper anatomic position in women who have a prolapse, cystocele or
rectocele. For women who are not interested in surgery or who are not good surgical candidates, pessaries
offer a very viable treatment option. In addition to improving continence, pessaries can be used as a
diagnostic aid to determine whether cystocele or rectocele symptoms improve with a pessary. This
improvement serves as a predictor of a successful surgical outcome.
The prospect of fitting pessaries can be overwhelming to the new learner. The choice of pessary size and
style can be daunting, and you may initially feel insecure about which pessary to choose for which condition.
With knowledge and practice, you can become adept at fitting and caring for a supportive vaginal pessary.
Manufacturers often recommend a certain pessary for a specific problem. There is usually no right or wrong
choice, simply a better match for a specific condition. Many providers choose a few that they feel
comfortable with and use them primarily.
Pessaries should be removed and cleaned every 2 to 3 months, at which time the vagina should be
irrigated. This will necessitate three or four return visits a year for many years. Advanced information on
specific aspects of fitting pessaries are beyond the scope of this article. For a detailed review of pessary
use, refer to Advanced Health Assessment of Women: Clinical Skills and Procedures by Helen Carcio
(Lippincott, 1999, pages 307-349).
Fitting is the most challenging aspect of pessary use, and you should definitely expect a learning curve as
you gain this skill. Fortunately, most NPs have some experience in fitting diaphragms, and pessary fitting is
an extension of this skill. If you use diaphragm-fitting rings, remember that pessaries have thicker rims and
the size is only an approximation.
Remember that not all women can benefit from using a pessary — it may never fit properly (as with a gaping
introitus), or it may not solve the problem (and could make it worse). In many cases, a pessary may
decrease urine leakage but not completely stop the incontinence. Most women welcome any decrease in
incontinence. That is why a multifaceted approach is best. In most cases, a pessary should be used in
conjunction with the other therapeutic modalities described in this article. However, most women benefit
greatly from a properly fitted and well-chosen pessary.
Pessary fitting usually requires a series of office visits to determine the best fit. Explain the trial-and-error
nature of pessary fitting at the start of the process so that your patient does not get discouraged. As with a
diaphragm, you should be able to sweep your fingers around the outer rim of the pessary once inserted.
Unfortunately, the harder a pessary is to insert and remove, the more likely it is to stay in and provide proper
support and relief from incontinence.
Serial visits for pessaries are necessary and must be built into the functioning of your continence center.
Once a pessary is fit, the woman should return in 1 to 3 days — and sooner if the pessary is uncomfortable
or if urination or defecation is difficult. Once proper fitting is achieved, the woman should return every 2 to 3
months for removal and cleaning. The majority of pessary users are elderly and most are not interested in or
able to remove the device themselves. They are more than happy to turn care over to their providers.
At the time of cleaning, remove and clean the pessary, evaluate the mucosa and irrigate the vagina with a
solution of hydrogen peroxide or betadine mixed with warm tap water. Younger women and women who
have used a diaphragm in the past may feel very comfortable cleaning their pessaries and only need followup every 6 to 12 months to ensure proper fit and symptom relief.
Elderly women require vaginal estrogen to keep the mucosa healthy. A slight odor with a creamy discharge
is common. If a strong odor develops or if the discharge increases, the woman should return to the center.
The cost of a pessary ranges from $30 to $50, and reimbursement levels vary from state to state. Your initial
investment to have a variety of pessaries for proper selection may be expensive. It is best to choose three or
four sizes in the mid-size range of a few of the more commonly used pessaries. This also makes the fitting
choices less intimidating. The majority of pessary users do well with these common sizes. Additional
information on modern pessaries is available at www.bioteque.com.
Pessary use is a critical component in the treatment of incontinence and should be an integral part of any
continence center. Although labor intensive, providing pessaries is profitable because it develops a client
base: Women who use pessaries will be returning to your center many times a year for years to come.
Reimbursement
Billing and coding are extremely important but difficult to generalize in an article such as this. The rationale
for each visit, proper coding and proper documentation are key to the financial success of a center. Decide
how you will bill your services. "Incident to" is the coverage of services furnished incident to the services of a
physician. If billing incident to, the patient must consult with the collaborating physician first. During
subsequent visits by the same patient, the physician must be accessible but not necessarily on site (this
may vary from state to state). If you are billing under your own name, the physician does not have to see the
patient or be available. However, the reimbursement may be up to 15% less with some insurance
companies. Be sure to track reimbursement claims paid.
Finances
A continence center should net around $2,000 per patient who completes a pelvic floor rehabilitation
program. This does not include ancillary testing such as urodynamics. Based on experiences at
established centers, a continence center could gross $200,000 to $400,000 per year, particularly if
urodynamic testing is provided. The successful use of pessaries and pessary fittings guarantees an initial
three to five visits, plus three to four visits a year for pessary care for many years.
It is important to note that once the center is up and running, the potential to expand the practice to other
related areas is limitless. All that you need is a laptop computer and portable PFR equipment. Medicare
regulates the evaluation and management of incontinence. Nursing homes are often cited for their
deficiencies in this area, and many nursing homes would welcome an opportunity to improve that track
record. Extended care facilities, retirement communities, health clubs, rehabilitation settings and fitness and
wellness centers are other great potential markets.
Patient Outcomes
Pelvic floor rehabilitation programs now on the market allow you to keep a patient database to record
demographics and monitor patient success through a series of comparative graphs. Programs such as
ControlWorks detail patients seen per month and document patients seen by age and referring physician, as
well as treatment length statistics. Such programs allow you to monitor each woman's progress and
document each success. It is essential to document the success of your center in these ways. The data also
provide information about reimbursement and information to use when writing a grant.
Patient Satisfaction
Each woman should complete an evaluation tool at the end of your continence treatment program. This tool
should assess parameters such as quality of life, body image, hygiene and cost of incontinence supplies.
Additionally, if any woman drops out of the program, be sure to do a follow-up telephone assessment and
document the reasons why she dropped out. Then address any reasons that are relevant to you.
You should also call every eighth woman who completes the program to assess her satisfaction with the
program itself as far as scheduling time, staff friendliness, provider competency, room comfort and level of
care.
Ask each woman who completes the program to return in 6 months for a brief follow-up visit to further
document response, to address long-term success and to identify any subsequent problems.
Advertising Analysis
Be sure to review your method of reaching patients to determine whether advertising has been successful.
Keep logs to review referral patterns, documenting how a woman heard about your program. Collect data
about how patients heard about you and evaluate it to determine future advertising needs. I review the
attendance rosters at programs conducted at senior centers and health fairs. It is important to ask for patient
and provider feedback to determine success (and failures) as well as to determine the need to change or
restructure marketing strategies to expand future outreach.
The Need for Templates
It is cost effective to develop educational and practice templates to be used and modified as necessary.
These might include an incontinence fact sheet, instructional handouts in pessary care, how to perform
Kegels, or health history and examination forms. All should be updated routinely.
Templates of letters to referring community providers should also be a part of your database. Letters to
providers are important because they are an excellent way to continuously market your program. With each
letter, the provider is reminded about the program and its potential for successful treatment of incontinence
Concluding Thoughts
Your approach to women with urinary incontinence should be holistic. This distinguishes the quality of nurse
practitioner care from that provided by other clinicians. Women need to be monitored for proper calcium
intake, regular exercise and healthy diets. Since most incontinent women are menopausal, it is also
important to discuss issues such as vaginal dryness, bone loss and hormone replacement therapy. I usually
spend at least 20 minutes of each visit reviewing these issues. A good time to educate is during the time the
woman is using electrical stimulation. Health promotion can open up additional coding opportunities for
billing. These discussions can be coded as a Level 3 E&M. Don't forget to use a modifier 25 along with the
procedures performed that day.
As the director of a comprehensive continence center, I have broadened and enhanced my scope of
practice in a creative and challenging way. Using the techniques described in this article, I urge you to
approach your choice of collaborating physician with a detailed plan and clearly demonstrate how such a
center could increase existing services, expand productivity and increase office revenue . Make sure you do
your homework first!
Be knowledgeable about issues surrounding incontinence and possess a firm belief in the positive outcomes
of the continence program. A majority of nurse practitioners received little instruction about urinary
incontinence in NP school. Motivated learners can overcome this obstacle by seeking out continuing
education programs and specialty conferences.
For information including templates for use in incontinence management and access to educational training
seminars (17 contact hours) and post-graduate courses, contact me at the HC Institute for Health
Professionals Web site at www.bladdercenter.com. You can also e-mail me at [email protected] .
Good luck! You are about to embark on an exciting and lucrative career opportunity.
References
1. Wagneer TH, Hu TW. Economic costs of urinary incontinence. (Editorial). Int Urogynecol J Pelvic Floor
Dysfunction. 1998;9:127-128.
2. Urinary Incontinence Guideline Panel. Urinary Incontinence in Adults: Clinical Practice Guideline. AHCPR
Pub. No.92-0038. Rockville, MD. Agency for Health Care Policy and Research, Public Health Service, U.S.
Department of Health and Human Services, March 1992.
3. Sand PK, Richardson DA, Swift SE, Appell RA. Pelvic floor stimulation in the treatment of genuine stress
incontinence. American Journal of Obstetrics and Gynecology. 1995;173:72-79.
4. Drutz HP, Appell RA, Gleason D. Clinical efficacy and safety of tolterodine compared to oxybutynin and
placebo in patients with overactive bladder. Int Urogynecol J Pelvic Floor Dysfunction. 1999;10:283.
5. Burgio KL, Ives DG, Locher JL, Arena VC, Kuller LH. Treatment seeking for urinary incontinence in adults.
J Am Geriatric Society. 1994;42:208-212.
6. Bo K, Larson S. Pelvic floor muscle exercise for the treatment of stress urinary incontinence.
Classification and characterization of responders. Neurol Urodyn. 1992;11:497-508.
Helen Carcio is a women's health nurse practitioner at Pioneer Women's Health in Greenfield, Mass., where
she specializes in the treatment of incontinence, infertility, vulvovaginitis and menopause. She created and
operates two continence treatment centers, one at Pioneer Women's Health and another at Grace Urological
in Brattleboro, Vt. Carcio, who is a member of the ADVANCE for Nurse Practitioners editorial advisory
board, is also an adjunct graduate nursing professor at the University of Massachusetts in Amherst and is
nearing completion of her PhD.
Objectives: The purpose of this article is to educate nurse practitioners about the role of NPs in continence
care. After reading this article, the nurse practitioner should be able to:
List the steps in creating a continence center.
Compare and contrast the marketing strategies to women in the community and to health care providers.
Discuss the scope of services to be offered at an NP-run continence center.
Explain the benefits of pessary use as an additional option in the management of incontinence.
Discuss the evaluation process to determine the clinical outcomes of the newly established center.