Dr Amita Jain, Consultant Urogynaecologist, Medanta Institute of Kidney & Urology, discusses with Shahid Akhter, ENN the surge in genitourinary complaints
What is urogynaecology all about?
Urogynaecology is a sub-specialty which deals with conservative and surgical management of women with urinary or faecal incontinence, persistent genitourinary complaints and disorders of pelvic floor supports.
Why do we need a dedicated setup for this?
The life expectancy for women has almost doubled through the 20th century and around one-third of all women suffer with these problems, at least once in their lifetime. These conditions are more common than commonly known disorders like hypertension, depression, or diabetes. Moreover, a dedicated urogynaecology clinic provides complete one-stop care to patients, helping them avoid too many visits to other specialists like gynecologists, urologists and colorectal surgeons for treatments.
What intricacies did you face in establishing this subspecialty setup?
Contrary to common notion, lack of money, education or resources is not a constraint for private sector in India. There are some common myths both among care seekers and care providers that these are just natural part of aging. Either nothing can be done about it or only surgery is the solution, which is not justified for these minor ailments. Next challenge is lack of reporting. Associated social stigma makes sufferers feel ashamed of mentioning their problems. In Indian scenario, as for the other functional disorders not involving the immediate threat to life, the patients are usually resigned to the fate of bearing the dysfunction, due to an extreme sense of modesty and considering the malady as relatively insignificant – probably due to lack of education and the low priority of these disorders impacting their quality of life. They land up doing other measures just to hide these, rather perhaps will come to take treatment of intolerable consequences like Urinary Tract Infections (UTI) and sometimes fractures, but will be reluctant to reveal their actual problems. This results in lack of data. In India, we do not have substantial data, as only few small-scale studies covering small set of local population are available. Therefore, we largely depend on world statistics. These data represent only tip of an iceberg, due to under reporting at outpatient clinics. For example, most women live with their Urinary Incontinence for approximately seven years before reporting symptoms. That’s the reason W.H.O. declared incontinence as an international health concern in 1998. Other issue is lack of responsibility. Age-old territorial conflict between urologist and gynaecologist has delayed the implementation of initiatives and impeded the growth of this specialty.
In nutshell, due to these intricacies and lack of substantial data, hospital administrations are not sure whether investing money in this specialty will give revenue in future. Also the new breeds of doctors do not feel confident about choosing this specialty as a career because dedicated structured training programmes are not available. This results in shortage of manpower.
How did you deal with these challenges?
We targeted two of these challenges. First, lack of awareness, which is common between both care seekers and care providers and secondly, lack of data.
To spread awareness among care seekers, we put attractive standees with eye catching information at Out Patient Department (OPD) area and other different crowded locations. We targeted every specific ailment separately by organising a dedicated internationally recognised week and kept special programmes like free consultations, patient awareness sessions to promote patients’ confidence in seeking help.
To spread information, we used posters with small catchy slogans. We pasted them at the back of toilet doors to make sure that these should be noticed. We took help of media by publishing news articles regarding the disease in newspapers of various cities of India targeting different set of population.
We asked our previously treated patients to come forward and to share their experiences with other sufferers. It is easier for new patients to shed the taboo of social stigma by clearing their doubts with already treated patients. We also initiated a social group with these patients to provide telephonic conversation, whenever required. We organised workshops and dedicated camps all over India.
Next challenge was the awareness among care providers. For which we conducted various workshops and CME, targeting both urologist and gynaecologists. We also established advisory panels with dedicated doctors working in this field to plan future strategies.
To convince administration for funds an internal study was done on young newly recruited hospital staff, maximum between 21 to 30 years age group. A set of questions both in English and regional languages was distributed among them. A noticeably high prevalence of all kinds of incontinence was found and it was significantly higher in women as compared to their male counterparts.
“The concept of Urogynaecology is not new for western countries, but the situation is very disappointing in developing countries”
All these efforts resulted in gradual increase in numbers of OPD patients in Urogynaecology Clinic, specially the referrals.
What is the future scope of this field in India?
The concept of Urogynaecology is not new for western countries, but the situation is very disappointing in developing countries. As you have understood, it is not that urogyneacological problems are less common, but doctors not doing dedicated practice in this field generally consider these patients as out of their scope. Hence, these conditions have been inadequately treated and poorly addressed by medical professionals, despite available treatments substantially improving health, self-esteem and quality of life of patients.
However, over the last decade there has been a remarkable change in the attitude of patients in our society due to education and improvement in socioeconomic conditions. Patients are now demanding relief from functional disorders such as incontinence. Surgical interventions for genuine stress incontinence are becoming more and more frequent, but due to the lack of highly sophisticated investigation facilities like urodynamics or dynamic MRI at remote areas, failures are still considerable.
UTI – A Global Concern
In 2003, around 34 million women worldwide were estimated to have prolapse and about 50% of postmenopausal women had some degree of prolapse. Similarly, Urinary Tract Infections (UTIs) affect 40 percent of females in their life time and incidence increases from 1—2 percent to 20 percent as they grow old. Incidence of urinary incontinence also increases from 10—25 percent to 15—40 percent beyond the age of 60.
Though we are able to overcome most of the hurdles, but still we require attention of our designated registered societies run by most acknowledged authorities, which can support us in fulfilling our aims of introduction of subject in medical curriculum at graduation level, well structured hands on training programmes in collaboration with recognised organisations and also the dedicated funds to run specialty units both at public as well as private sector.