Increasing numbers of independent physiotherapist prescribers are being employed in many areas of clinical practice. Most are in musculoskeletal services, but this is extending into primary care and urgent treatment settings (Robertson, 2022).
The role of the pelvic health physiotherapist independent prescriber is one such specialist service that aims to expediate access to treatment and improve service user satisfaction. Pelvic health physiotherapy is recommended as the first-line treatment for patients with lower urinary tract symptoms and pelvic floor dysfunction (National Institute for Health and Care Excellence (NICE), 2019; 2021a, b). The service receives referrals from varied sources, including GPs, obstetrics and gynaecology, bladder and bowel specialists, midwives and self-referrals. However, for some referrals physiotherapy treatment alone will not fully alleviate the presenting condition and medication management is required.
Physiotherapists were initially given the rights to train as supplementary prescribers in 2005 and this was further extended to independent prescribing in 2013. Currently, physiotherapist independent prescribers can prescribe any medicine for any medical condition, including ‘off-label’ medicines but not unlicensed medicines, and they are subject to a specific list of named controlled drugs only. Independent prescribing enables the physiotherapist to safely prescribe medication, allowing a smoother, more efficient patient journey with quicker access to medicines (Chartered Society of Physiotherapy (CSP), 2018). This service aligns with the key principles of realistic medicine, ensuring safe, evidence-based and cost-effective care (Fenning et al, 2019).
The following case study presents a complete patient care episode of the pharmacological and non-pharmacological management of a patient with lower urinary tract symptoms and pelvic floor dysfunction conducted by a pelvic health physiotherapist independent prescriber.
Case study
Nisha, a 55-year-old female housekeeper, was referred for physiotherapy pelvic health review with a 2-year history of daily episodes of urinary incontinence when coughing, sneezing and when at work, making beds or lifting. In addition, Nisha was also experiencing dyspareunia, which is painful sexual intercourse.
Table 1. Personalised management plan
| History and clinical examination | Shared decision making | Management | |
|---|---|---|---|
| Non-pharmacological | Pharmacological | ||
Stress urinary incontinence
|
Tailored, supervised pelvic floor muscle exercise programme for minimum of 3 months | Solifenacin succinateOveractive bladder first-line managementMirabegronOveractive bladder second-line management | Pharmacological management not indicatedTailored exercise regime taught |
EpisodicConstipation
|
Fibre-rich dietAdequate fluid intakeToilet positioning techniques | LactuloseStool softener and osmotic laxative | Lactulose actions and side effects discussedPrescription available if required |
Dyspareunia
|
Over-the-counter non-hormonal lubricants | EstriolVaginal cream or gel applicationEstradiolVaginal tablets or pessary | Estradiol tablet prescribed10 micrograms daily for2 weeks, reducing to10 micrograms twice weeklyFollow-up appointment4 weeks and evaluate efficacy after 12 weeks |
As part of the initial assessment, Nisha was asked to complete the International Consultation Incontinence Modular Questionnaire (ICIQ-UI) for Urinary Incontinence (British Society of Urogynaecology, 2019). This is a brief, validated and commonly used outcome measure to evaluate the frequency, severity and impact of incontinence on quality of life. It can be repeated to assess patient progress and is completed at the start and end of the patient's care episode (Abrams et al, 2006). As part of a subjective assessment, past medical history is documented, including medication history.
Nisha had no significant health issues and was not being prescribed medication. She reported having previously tried over-the-counter vaginal water and oil-based lubricants for vaginal symptoms, but had felt minimal improvement of the dryness, itching and discomfort during intercourse. A digital vaginal examination was offered, with a full explanation prior to examination of rationale and expected procedure, and her written consent was gained.
Nisha also reported mild episodic constipation and that she occasionally had to strain for complete evacuation. The Bristol stool chart, which is a validated aid to classify stool consistency, showed stool type 2–3. The presenting history, symptoms and clinical examination were suggestive of a diagnosis of stress urinary incontinence, associated with weak pelvic floor muscles and affected by episodic constipation. In addition, the symptom of dyspareunia was attributed to post-menopausal dry vaginal tissue and atrophic changes leading to irritation during intercourse.
Stress urinary incontinence
Stress urinary incontinence is involuntary loss of urine on effort or physical exertion, and is the most common cause of urinary incontinence, accounting for about 50% of cases (Doumouchtsis et al, 2022). It occurs when, in the absence of detrusor contraction, intra-vesical pressure exceeds maximum urethral pressure. This is frequently in combination with, and exacerbated by, pelvic floor muscle weakness (Bø, 2020).
First-line treatment for stress urinary incontinence is a tailored pelvic floor muscle exercise programme for a minimum of 3 months (NICE, 2019). A personalised exercise regime was explained in detail to Nisha and she was advised to start a progressive pelvic floor exercise programme, which gradually increased in repetitions to reach 10 long holds of 10 seconds, and 10 short squeezes done three times a day in different postures. She was also taught ‘the knack’; a technique that activates pelvic floor muscles before and during cough to support reflex contraction to take place. The aim of the exercise regime was to develop pelvic floor muscle strength and endurance, which would improve functionality, as her main concern was urinary leakage with lifting or making beds at work (Miller et al, 2008).
Urinary incontinence accompanied by urgency and frequency can be symptomatic of an overactive bladder (Bø, 2020). The first-line choice of pharmacological treatment is solifenacin succinate, which is a competitive receptor antagonist medication with antispasmodic properties.
Alternative choice of medication includes mirabegron, an adrenergic receptor agonist used to relax the smooth muscle of the bladder reducing bladder and neurogenic detrusor overactivity. Mirabegron is unique among other overactive bladder treatment options as it lacks significant antimuscarinic activity, which is responsible for the therapeutic effects of these medications but also their expansive range of adverse effects.
On consideration of Nisha's history and presenting symptoms, a diagnosis of stress incontinence was most appropriate and as she did not report overt symptoms of an overactive bladder, the need for medications was not indicated at this point.
Constipation
Nisha was asked about her bowel habits, and reported mild episodic constipation and occasionally straining for complete evacuation. There is a well-established link between lower urinary tract symptoms and constipation, which if chronic and not treated appropriately can be debilitating, affect quality of life and worsen stress urinary incontinence (Averbeck and Madersbacher, 2011). Conservative management of sufficient fluid management and increased fibre consumption was advised, as this has been shown to relieve constipation and improve stool consistency, reducing the need to strain. She was also shown toilet positioning techniques to enable easier bowel evacuation.
First-line management of improving diet and fluid balance may be sufficient to minimise Nisha's constipation, but if conservative management was not effective, a mild laxative would be indicated. The benefits and possible side effects of lactulose, an osmotic laxative, were discussed. As a stool softener, this would be the most appropriate laxative to address issues with hard stool, rather than a stool bulker or stimulant. Initial daily dosage of lactulose can be adjusted according to response, and reviewed once normal bowel habit is restored, enabling Nisha to take ownership of her treatment.
Lactulose remains localised within the gastrointestinal tract to enact its laxative effect, but this also results in side effects of increased bowel sounds, bloated feeling, belching, frequent flatus and diarrhoea. Being fully informed of the benefits and risks of the medication provided Nisha with the opportunity to consider this option if dietary changes were insufficient to relieve her constipation.
Dyspareunia
Nisha disclosed a history of vaginal dryness and dyspareunia, which are considered symptoms of genitourinary syndrome of menopause (GSM) (Pertynska-Marczewska, 2021). GSM is an underdiagnosed and under-reported condition that affects more than half of postmenopausal women, significantly impairing their health and affecting sexual function (Nappi et al, 2016). Greater public awareness of GSM and being comfortable to discuss symptoms with health professionals is a critical factor for diagnosis. While most women with mild symptoms find non-hormone, over-the-counter therapies provide sufficient relief, low-dose vaginal oestrogens are a more effective treatment for moderate-to-severe GSM (North American Menopause Society, 2020).
On clinical examination, findings included the presence of dry and pale vaginal mucosa. These are suggestive of atrophic vaginitis and are associated with oestrogen deficiency, which plays an important part in the function of the urogenital tract. Atrophic vaginitis is a condition commonly found in postmenopausal women due to diminishing production of the natural hormone oestrogen, leading to thinning of tissue and a reduction in the mucus producing glands in the vaginal area (Weber et al, 2015; NICE, 2021b).
The most common symptoms affect the vulva and vagina, including dryness, itching and vaginal discharge. Use of low-dose topical oestrogen, either applied as a cream or pessary, is recommended to manage these symptoms (North American Menopause Society, 2020). Topical oestrogen is composed of synthetic 17-beta-estradiol, which is chemically and biologically identical to endogenous human estradiol. This enables improved maturation and less thinning of the vaginal tissue, and maintains the vaginal pH within a normal range, enhancing normal bacterial flora and reducing the symptoms of irritation and dryness.
Oestrogen preparations are administered topically as they are easily absorbed due to the high vascularisation of the vaginal tissues (Robinson et al, 2013). Previous studies suggest that with the use of topical oestrogen treatments, the risks of side effects are minimised when compared to systemic oestrogen drugs (Weber et al, 2015). Topical application of oestrogen therapy also has the benefit of avoiding first pass metabolism, thereby minimising dosage or frequency of use. Weber et al (2015) assessed outcomes of topical oestrogen therapies, concluding that even low doses can have a beneficial effect on subjective symptoms such as discomfort and pain, in addition to improving objective markers of maintaining natural vaginal pH. A lower topical dose can have the same effect on vaginal symptoms than a higher dose, and has the advantage of minimising the risk of toxicity and side effects (North American Menopause Society, 2020). Lethaby (2016) reviewed the effectiveness of topical oestrogen, and concluded that all oestrogen preparations used for vaginal atrophy improved symptoms of dryness and dyspareunia with similar efficacy.
Different treatment options were suggested to Nisha as part of shared decision making, but also to actively identify, understand and respond to the diverse needs of service users to ensure that suggested therapies met Nisha's physical and cultural preferences (Health and Care Professions Council, 2023). As she has already tried over-the-counter vaginal lubricants unsuccessfully in the past, vaginal oestrogen therapy was suggested.
Estriol cream or gel is used on the vaginal tissues directly, whereas estradiol pessary or tablet has to be inserted into the upper third of the vagina using an applicator. It is important to discuss not only the choice of drug, but also the route of administration as some patients have difficulty with manual dexterity or feel uncomfortable inserting pessaries.
Previous comparisons of treatment adherence to local oestrogen cream vs vaginal tablets noted more favourable outcomes for estradiol tablets (Portman et al, 2015). Women who were prescribed the cream had a higher discontinuation rate compared to the local applied tablet, and there was a higher rate of switching from cream to tablet. It was reported that the cream was hard to dose, leading to concerns over potential over- or under-use. Nisha preferred the option of the estradiol pessary over the estriol cream, as she considered this would be easier to use and less messy.
Conclusion
Nisha was given a prescription for estradiol vaginal pessary in addition to her tailored pelvic floor exercise programme and she was keen to make the dietary changes suggested. A review appointment was made for 4 weeks' time to check on progress and ensure there were no side effects from the medication. Nisha was aware that a laxative could be prescribed if there were no discernible improvements with conservative management of her constipation. Focus on empowerment of the patient and the ability to discuss treatment options is one of the key principles of realistic medicine, and Nisha was supported to self-manage symptom relief with the reassurance that further management was available.
Pelvic health physiotherapy is a good example of how independent prescribing can enhance patient management and provide efficient and individualised treatment concurrently, reducing pressures on other primary care services. With recorded high percentages of women embarrassed or reluctant to discuss genitourinary conditions with health professionals or self-medicating with over-the-counter products, there is an evident need for promotion of self-referral and holistic services such as pelvic health physiotherapists.
Key Points
- Pelvic health physiotherapy is recommended as the first-line treatment for patients with lower urinary tract symptoms and pelvic floor dysfunction
- Women with stress urinary incontinence should be offered a tailored and supervised pelvic floor muscle training programme of at least 3 months' duration as first-line treatment
- Genitourinary syndrome of menopause is estimated to affect more than 50% of postmenopausal women, significantly impairing their quality of life and affecting sexual function
- NICE guidance advises to offer vaginal oestrogen to women with urogenital atrophy continuing treatment for as long as required to maintain symptom relief
CPD reflective questions
- Many women are embarrassed or reluctant to discuss genitourinary or menopausal symptoms with healthcare professionals. What strategies could you adopt in your practice to promote an open dialogue about these conditions?
- Using evidence-based guidelines is an essential step in prescribing decisions, but it is also imperative that the practitioner reviews the evidence behind these guidelines. How does this promote shared decision making with the service user?
- The Royal Pharmaceutical Society Competency Framework for All Prescribers details the standards for all prescribers registered with the Health and Care Professions Council. Using the framework, consider whether your knowledge, understanding and skills meet these requirements