Original Title: Avis: La rééducation périnéale et pelvienne pour la prévention et le traitement des dysfonctions du plancher pelvien - Volet 1 : Incontinence urinaire

Authors' objectives: Urinary incontinence is defined as the complaint of involuntary loss of urine (International Continence Society [ICS]). It compromises the quality of life of those affected on a physical, mental, sexual, and social level. It constitutes a significant health and economic burden, as one in three women will experience it in her lifetime. Urinary incontinence can be due to different causes, including pelvic floor dysfunction. It can be treated with conservative interventions, drugs or surgery. Surgical treatment carries risks for the woman, and there is a moratorium on suburethral sling surgery in Québec because of the complications associated with it. Perineal and pelvic rehabilitation including pelvic floor muscle training (PFMT) is one of the conservative approaches that can be used as a first-line therapy for urinary incontinence in women. In Québec, this alternative to surgery is performed by physiotherapists. It is mostly available in the private sector and is poorly covered by the public system, unlike in some other countries. Given the impact and potential benefits of perineal and pelvic rehabilitation, the Ministère de la Santé et des Services sociaux (MSSS - the Ministry) asked the Institut national d'excellence en santé et en services sociaux (INESSS) to assess the relevance of its inclusion in the range of public services offered in Québec to prevent and treat pelvic floor dysfunctions and, more specifically, urinary incontinence, the most common pelvic floor dysfunction (further work will look at other pelvic floor dysfunctions). More specifically, INESSS evaluated the efficacy of pelvic floor muscle training, its impact on quality of life, and the risks associated with it in the prevention and treatment of urinary incontinence. The organizational issues, cost-effectiveness and economic impact of a coverage program were examined as well.

Authors' results and conclusions: RESULTS: (#1 HEALTH PROBLEM): Urinary incontinence is a significant health issue that affects more than 30% of women during their lifetime. It is believed to be greatly underreported because of the stigma associated with it. • Urinary incontinence is a pelvic floor dysfunction that manifests in several forms, including stress urinary incontinence, urge urinary incontinence or overactive bladder, and mixed urinary incontinence. • Urinary incontinence can occur at any time in a woman's life, but the risk increases with age. Several other factors increase the risk of urinary incontinence, namely, pregnancy, the number and type of deliveries, life habits and the presence of comorbidities (diabetes, obesity, etc.). • Urinary incontinence constitutes a significant economic burden for individuals and healthcare systems. In Canada, the combined direct and indirect costs associated with urinary incontinence are currently between $2.6 and $8.5 billion annually. • Current management uses first-line conservative approaches, such as lifestyle changes and perineal and pelvic rehabilitation, or second-line approaches, such as pharmacological treatments and surgical procedures.(#2 STATE OF PRACTICE AND BACKGROUND): Several countries, including France, the United Kingdom and Australia, provide partial or full coverage for perineal and pelvic rehabilitation. • Few Canadian provinces offer perineal and pelvic rehabilitation programs to treat or prevent urinary incontinence. • In Québec, perineal and pelvic rehabilitation is offered by physiotherapists who practice mostly in private clinics. Perineal and pelvic rehabilitation fees are fully or partly borne by women, depending on the type of private insurance (approximately $100 per session). • In Québec, the offer of services varies according to the administrative region and is limited by the number of physiotherapists who offer perineal and pelvic rehabilitation, which results in wait times for consults. • In Québec, the number of trained physiotherapists offering this service is currently limited (approximately 600). A graduate training program in perineal and pelvic rehabilitation is currently training about 30 new therapists a year. Some private organizations also offer perineal and pelvic rehabilitation training to physiotherapists. (#3 EFFICACY AND CLINICAL RECOMMENDATIONS): A total of 11 systematic reviews and 17 clinical practice guidelines or health technology assessment reports were analyzed. The analysis focused on the efficacy and recommendations for use of perineal and pelvic rehabilitation minimally including pelvic floor muscle training to prevent or treat urinary incontinence at different stages of a woman's life: the perinatal period, other adult women, and women 55 years of age and older. (#4 ORGANIZATIONAL ISSUES): Issues related to the number of women who could avail themselves of perineal and pelvic rehabilitation were raised by the experts consulted, and some felt that the system could be overburdened by public coverage of perineal and pelvic rehabilitation. • The supply of services is limited by the small number of qualified professionals and the limited number of perineal and pelvic rehabilitation graduates. • It appears that access to perineal and pelvic rehabilitation in Québec varies according to the region and is particularly difficult in regions far from the major urban centres. • The various stakeholders consulted emphasized the need for an interdisciplinary approach involving the participation of a greater number of professionals in the management of urinary incontinence. (#5 PATIENT PERSPECTIVE): Women with urinary incontinence report that their condition affects their physical, psychological and sexual health, as well as their independence, self-esteem, and ability to function in day-to-day life. • Several barriers may prevent women from consulting or from undertaking perineal and pelvic rehabilitation treatment: contradictory and patchy information on urinary incontinence and perineal and pelvic rehabilitation, embarrassment, difficulty getting an appointment to discuss it, difficulty accessing perineal and pelvic rehabilitation, and costs. • Women in Québec who have undergone perineal and pelvic rehabilitation report that it: – prevents the onset or worsening of symptoms of pelvic floor dysfunction (including urinary incontinence) and improves their day-to-day well-being; – permits better control of their pelvic floor muscles and enables them to manage other associated symptoms, such as pelvic pain; – enables them to return to their daily activities quickly, facilitates delivery and reduces the trauma caused by childbirth. • The women consulted maintain that insurance that covers the cost of treatment (fully or partially), an individualized follow-up by a physiotherapist specializing in perineal and pelvic rehabilitation, the involvement of an interdisciplinary team, and an array of treatment options (e.g., group classes and telerehabilitation) would facilitate access and adherence to perineal and pelvic rehabilitation. (#6 ECONOMIC ASPECTS): According to the economic studies identified in the literature that were considered transferable to the Québec clinical context: – prenatal perineal and pelvic rehabilitation for the prevention of urinary incontinence and postnatal perineal and pelvic rehabilitation for the treatment of urinary incontinence are associated with low incremental cost-effectiveness ratios compared to the usual care or no care. Based on the various assumptions used in the budget impact analyses prior to the possible introduction of public coverage for perineal and pelvic rehabilitation in Québec: – adding prenatal perineal and pelvic rehabilitation for the prevention of urinary incontinence could result in additional expenditures of $53 to $106 million, depending on the number of sessions carried out (between 2 and 4). It would concern approximately 252,000 women and would prevent approximately 22,000 cases of urinary incontinence in 5 years;

Authors' recommendations: The members of the Comité délibératif permanent – Modes d’intervention en santé (CDP) unanimously recognized the clinical efficacy of perineal and pelvic rehabilitation for the prevention of urinary incontinence in pregnant women and the treatment of urinary incontinence in postpartum and other adult women, including women aged 55 and older. Given the efficacy and the consistency of all the data constituting the evidence, the safety of the intervention, and the few adverse events, INESSS recognizes the advisability of access to perineal and pelvic rehabilitation (i.e., public offer and/or coverage terms) for the treatment of urinary incontinence. INESSS recommends: • Facilitated access to perineal and pelvic rehabilitation when indicated: – in pregnant women to prevent urinary incontinence; – in postpartum women to treat urinary incontinence; – in all other adult women (including women 55 years of age and older) to treat urinary incontinence. • Access to this intervention for a maximum of: – four sessions for the prevention of urinary incontinence; – ten sessions for the treatment of urinary incontinence. • That the treatment be supervised by a qualified physiotherapist with the required expertise; • That the intervention be extended over a period of 12 or more weeks, depending on the patient's specific needs, before reassessing the treatment plan; • That access to perineal and pelvic rehabilitation be available more than once, at different times in a woman's life (e.g., during the perinatal and perimenopausal periods). Given the large number of women who might avail themselves of perineal and pelvic rehabilitation and the fact that perineal physiotherapy services are currently limited, INESSS recommends that the Ministry adopt a strategy and an implementation plan involving: • The gradual implementation of services according to the available resources; • The implementation of measures to promote equitable access to these services for all women in Québec for whom rehabilitation is indicated; • The development of knowledge transfer tools for informing women and health professionals about urinary incontinence and the existence of treatment modalities, such as perineal and pelvic rehabilitation, e.g., information sheet, websites, media, etc.; • The potential use of other complementary modalities for providing perineal and pelvic rehabilitation for certain patient populations, such as group sessions or telerehabilitation. These modalities: – should involve supervision by a qualified physiotherapist; – should be used with caution, as their efficacy has not been systematically evaluated in this project; – should be the focus of research projects in the Québec context and be adapted as new data become available. • The implementation of measures to support the training of physiotherapists; • The use of measures to promote an interdisciplinary approach involving the participation of other professionals (midwives, nurses, physicians, physiotherapy technologists) to support physiotherapists, in the observance of reserved acts. • Adapting the service offering to the demand over time, based on new developments or research in this field.

Authors' methods: A search of the scientific literature and other information sources was conducted: an umbrella review, a rapid review or exploratory review, or guidelines, depending on the evaluation question. Contextual and experiential data were gathered from clinical researchers, health professionals, and women with a pelvic floor dysfunction or at risk of developing one. The economic literature was reviewed to evaluate the cost-effectiveness of perineal and pelvic rehabilitation, using studies deemed transferable to the Québec context. A budget impact analysis was used to estimate the impact of adding perineal and pelvic rehabilitation to the range of public services available in Québec for the prevention and treatment of urinary incontinence. The work was supported by an expert advisory committee, a committee of patients and a follow-up committee. In order to mobilize and integrate the knowledge, a multidimensional approach was used in which scientific, contextual and experiential data were integrated and the quality of evidence was rated. The recommendations were deliberated on by the Comité délibératif permanent − Modes d’intervention en santé.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/la-reeducation-perineale-et-pelvienne-pour-la-prevention-et-le-traitement-des-dysfonctions-du-plancher-pelvien-volet-1-incontinence-urinaire.html

Year Published: 2022

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/la-reeducation-perineale-et-pelvienne-pour-la-prevention-et-le-traitement-des-dysfonctions-du-plancher-pelvien-volet-1-incontinence-urinaire.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)