Expert opinion: Should routine use of PROMs in urogynaecology be mandatory as there is such good evidence that they increase disclosure of sensitive symptoms?

Expert opinion: Should routine use of PROMs in urogynaecology be mandatory as there is such good evidence that they increase disclosure of sensitive symptoms?

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Patient reported outcome measures (PROMs) are tools which seek to ascertain patients’ views of their symptoms, their functional status and their health-related quality of life, without interruption from a healthcare professional1. Usually PROMs are questionnaires, they may include multiple choice components and/or free text answers. In order for the use of these tools to be considered reliable and valid in clinical practice, psychometric testing to provide evidence of reliability, validity and functionality should be undertaken and only tools with good evidence of these properties utilised for clinical practice.
It has previously been shown that PROMs can increase discussion rates in consultations about sensitive symptoms, including urinary incontinence2. It is thought that this is because patients were able to complete the PROM in private and therefore felt better able to disclose potentially embarrassing symptoms, which they were then happier to discuss as these had been disclosed in a non-confrontational manner. The clinician is then able to better formulate a management strategy which aims to address these sensitive issues. Using PROMs in symptom areas with sensitive, taboo and potentially embarrassing symptoms can therefore be of great value.
A good example of PROMs increasing disclosure of sensitive symptoms is with the symptom of coital urinary incontinence. The reported prevalence of coital urinary
incontinence (leaking urine during sexual intercourse) in the largest study regarding coital incontinence to date was 47% in women also reporting urinary incontinence3.
However, a non-systematic review of the literature shows that six previous studies have shown rates of coital incontinence in women with urinary incontinence to vary between 10% – 66%. Three of these seven studies have assessed coital incontinence in women attending a urogynaecology clinic. The prevalence was 10% when direct questioning was used to assess prevalence and 36% and 47% when a validated questionnaire was used. Four studies assessed the prevalence of coital incontinence in women undergoing urodynamics, these women are likely to have a more severe degree of coital incontinence. Two of these studies used direct questioning to assess this and both found a prevalence of 11%. The other two studies used validated or non-validated (author’s own) PROMs to assess prevalence and found it to be 60% and 66% respectively. It is apparent that using a PROM, does significantly increase the disclosure of coital urinary incontinence, compared with direct questioning. This is likely to be due to embarrassment and the taboo nature of this intimate problem.
Similarly, in a systematic review which assessed tools (including PROMs) available to identify women with anal incontinence symptoms following childbirth, the type of tool (PROM or patient interview) was shown to be a significant factor in the reported prevalence of anal incontinence symptoms in studies included4. Significantly lower rates of anal incontinence were observed when personalised data collection methods (i.e. face to face interview or telephone interview) were used, compared with non-personalised methods (PROM or ePROM). This finding mirrored those of systematic
reviews of the prevalence of faecal incontinence where reporting of faecal incontinence symptoms was found to be lower when face-to-face and telephone interviews were used to assess these embarrassing symptoms, when compared to PROMs5.
Therefore, as there is good evidence that PROMs result in increased disclosure of taboo and embarrassing symptoms, it could be argued that their routine use in urogynaecology should be mandatory. This would allow for enhanced self-expression and potentially improve access to care for patients. Remote completion of paper-based or electronic PROMs prior to clinic review allows the patient the best opportunity to disclose their symptoms in a non-confrontational way and allows them to reflect on what is bothering them most. The allows the consultation to have greater acuity and value.

References
1. Black N. Patient reported outcome measures could help transform healthcare. BMJ. 2013;346:f167.
2. Schüssler-Fiorenza Rose SM, Gangnon RE, Chewning B, Wald AJ. Increasing Discussion Rates of Incontinence in Primary Care: A Randomized Controlled Trial. Womens Health 2015:24(11);940-9. 3. Gray T, Li W, Campbell P, Jha S, Radley S. Evaluation of coital incontinence by electronic questionnaire: prevalence, associations and outcomes in women attending a urogynaecology clinic. International Urogynecology Journal 2018:29(7);969-78.
4. Gray TG, Vickers H, Jha S, Jones GL, Brown SR, Radley SC. A systematic review of non-invasive modalities used to identify women with anal incontinence symptoms after childbirth. International Urogynecology Journal. 2019;30(6):869-79. 5. Sharma A, Yuan L, Marshall RJ, Merrie AE, Bissett IP. Systematic review of the prevalence of faecal incontinence. British Journal of Surgery. 2016;103:1589-1597.