Current Covid restrictions have forced many healthcare professionals to embrace technology and work in very different ways. Indeed, the traditional telephone has allowed the Newcastle continence service to provide a service to patients referred with all types of urinary incontinence. But, is it even possible to assess someone’s continence and devise a treatment plan over the telephone?

One of the most difficult challenges to the continence service has been for those women who present with stress urinary incontinence (SUI). The World Health Organization (WHO) estimates that 6–10% of women will have symptoms of SUI (Milsom, 2018), which can be more prevalent in younger women as overactive bladder (OAB) symptoms tend to increase with age (Milsom et al, 2016).
During the Covid-19 pandemic, patients have continued to be referred to the Newcastle-upon-Tyne continence service. Normally, these patients would receive a face-to-face assessment as a gold standard recommendation (National Institute for Health and Care Excellence [NICE], 2019), involving holistic health assessment including a vaginal examination of the patient’s pelvic floor. The pelvic floor examination, both external and internal, enables clinicians to tailor an individual pelvic floor rehabilitation programme for that patient.

As this vital part of assessment cannot be conducted over the telephone, due to Covid-19 restrictions the author’s service has had to adapt its procedure for some patients who present with SUI.
First, a comprehensive history is taken via telephone contact with the patient, including a record of their fluid intake and bladder charts. This information can be emailed by the patient or taken over the telephone and transcribed onto a new chart, i.e. trust endorsed bladder output and fluid intake charts. Questions specific to SUI, vaginal atrophy, menopause, signs of vaginal prolapse, pregnancies, etc are then asked and, if the woman consents, she is guided through a peroneal self-assessment. Using a mirror to identify potential vaginal prolapse, i.e. where the pelvic organs protrude into the vagina, the cough test is carried out to identify urinary leakage. At this point, if any potential abnormality is detected, a home visit following all Public Health England’s personal protective equipment (PPE) guidelines (2020) would be carried out. Carrying out a complete PERFECTR assessment (Haslam and Laycock, 2010) cannot be undertaken via the telephone. This assessment of someone’s pelvic floor muscle contractibility involves:
Power — healthcare professionals feeling the power of the muscle to grade its strength
Endurance — evaluating the patient’s muscle endurance, i.e. the time the person can contract the muscle in seconds
Repetition — assessing the number of times the patient can repeat that contraction with a two-second relaxation time between each contraction
Fast — ascertaining the number of quick contractions followed by immediate relaxation which the patient can do
Elevation — assessing the lift of the posterior vaginal wall
Co-contraction — seeing if the ancillary muscles also contract during the pelvic floor contraction, i.e. the abdominal wall, gluteal or quadricep muscles
Timing — noting if the pelvic floor contracts on coughing and if there is vaginal descent or urinary leakage
Relax — assessing the patient’s ability to relax the pelvic floor between contractions.
The Newcastle-upon-Tyne continence service has attempted to teach this intervention via the telephone to enable patients to start treatment programmes for their SUI until a face-to-face visit can be achieved. Thus, all patients are reviewed by telephone and the intention is to see all patients once the Covid-19 restrictions are lifted. To help patients with this self-assessment, the continence service has used the Educator® (a vaginal probe). When inserted into the vagina, this responds to the movement of the vaginal walls, while the external straw is a visual aid which clarifies if the movement is being carried out correctly.

While PERFECTR is not completely established with these patients, it is possible to assess that there is some power and that there is endurance, as a contraction can be shown to be held for a set number of seconds. The number of repetitions of the contraction can also be evaluated, as well as verifying fast contractions which the patient can perform.

To corroborate that co-contractions are not being involved and that the patient is correctly contracting their pelvic floor, they are advised to use a mirror and place one hand on the gluteal muscle and one on the quadriceps to feel or see any ancillary muscle movement, which they can then try to eliminate. Finally, they are asked to perform the cough test using a mirror to see if there is any vaginal descent or urinary leakage.
There are many challenges in supporting a patient with SUI when you have to rely on their reporting back their assessment outcomes. However, it is vital that we continue to support women with these symptoms, rather than not attempting to improve their situation because of Covid-19 restrictions. If a patient has the courage to visit a healthcare professional to say, ‘I wet myself’ and admit that they have a problem, we, as healthcare professionals, have a duty of care to see what we can do, as it would be devastating to be told, ‘sorry, I can’t see you’.

The assessment process is far longer via telephone, as everything has to be explored in more detail and there is a greater need to assess the individual patient’s level of understanding without using non-verbal cues. Only once the healthcare professional feels secure in the patient’s ability to self-assess, can it be undertaken.

Studies have shown that accurate assessment of the patient’s pelvic floor is ‘crucial’ to the assessment process (Tosun et al, 2016). The pelvic floor treatment programme needs to be individual to each patient and any red flags should be identified at initial assessment. NICE (2019) advised that it is important to ask if there is any visible haematuria or recurrent or persisting urinary tract infections (UTI) associated with haematuria in women aged 40 years or over, as this would need to be investigated further by a urogynacologist or urologist. Other red flags include identifying a vaginal prolapse, which can manifest with symptoms of incomplete bladder emptying, such as hesitancy, urgency of micturition, a sensation of dragging, or a vaginal bulge reported by the patient.

Pelvic floor rehabilitation when carried out in a study by Tsai and Liu (2009) indicated that when a patient complies with a 12-week individualised programme, there is a significant increase in pelvic floor strength observed at the end of the three-month period and a decrease in SUI episodes. Supervised self-assessment is not an alternative to face-to-face pelvic floor examinations. However, in the difficult circumstances we face during this pandemic, it is an option to be used short term so that women can start working towards regaining continence.

From my professional perspective, I feel we cannot carry out a traditional gold standard continence assessment via telephone, however with a specific group of patients with full mental capacity and motivation, a pelvic floor exercise programme can be started until a more comprehensive assessment can be completed.
This piece was first published in the Journal of Community Nursing. To cite this article use: Laws A (2020) Assessing continence issues during the Covid-19 pandemic. J Community Nurs 34(4): 16-18


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