The impact of urinary incontinence on the quality of life of women attending

family practice center at Fanara village - Ismailia governorate.

Rehab Ali Mohamed1, Ahmed Mahmoud Mostafa, MD1, Hanan Abbass El Gammal,
MD1, Amal Mohamed El Shahat, MD2.
1
Department of Family medicine, Faculty of medicine, Suez Canal University.
2
Department of Obstetrics and Gynaecology, Faculty of medicine, Suez Canal
University.

Abstract:
Objective: To assess urinary incontinence impact on the quality of life of women
attending family practice center at Fanara village, Ismailia governorate.
Patients and methods: This is a descriptive cross sectional study to determine the
impact of urinary incontinence on the quality of life of 124 women attending family
practice center at Fanara village, Ismailia Governorate by using an interview
questionnaire
Results: we found that mixed urinary incontinence was the most prevalent among the
studied women (45%). The prevalence of stress UI peaked at the 4th decade, whereas
urge and mixed UI peaked after the 50th decade and 70.2% didn't consult a physician
about their condition. We found that about 71% of the studied group report negative
impact on quality of life and 67.8% of the studied women was negatively affected
physical health and travel (mobility), followed by social relations (66.2%) then
emotional health (62.9%) and that the most prevalent complaint was affection in the
ability to pray.
Conclusion: UI is a common and often disturbing problem in women, but it does not
receive appropriate attention. Our study showed that 71% of the incontinent women
had a negative impact on their quality of life and the most affected domains were the
physical health and mobility.
Keywords: urinary incontinence, quality of life.

Introduction and Rationale:

Urinary incontinence (UI) is one of the most common chronic medical conditions
seen in primary care practice (1). The median prevalence of female urinary
incontinence was determined to be 27.6% (range: 4.8- 58.4%) in different
noninstitutional populations (2). Urinary incontinence is an under diagnosed and
underreported medical problem. An estimated 50-70% of women with urinary
incontinence fail to seek medical evaluation and treatment because of social stigma (3).
Results of a family-practice-based survey indicated that women with urinary
incontinence perceive their overall health as being poorer than that of their similar-
age counterparts without urinary incontinence (4). A primary care clinic study found
that Urinary incontinence is a common complaint among women attending primary
care clinics, but it does not receive appropriate attention. Though it often adversely
affects quality of life, only a small proportion of women seek medical advice (5).
Urinary incontinence impact on women's quality of life is important to be studied
even in a rural area, to estimate how much it affects these women to realize the need
for taking preventive measures and policy development for urinary incontinence. As
the scope of family medicine is the biopsychosocial context of the disease, the family
physicians should raise the issue as a part of the routine check- up.
Subjects & Methods:
This is a descriptive cross sectional study to determine the impact of urinary
incontinence on the quality of life of women attending family practice center at
Fanara village, Ismailia Governorate during July 2006 till March 2007. 124 Females
above 30 years old attending Fanara family care center were included in the study.
The females excluded from the study were those below 30 years old or pregnant at
any age, who do not have urinary incontinence handicaps or using diuretics, and who
refuse to participate in the study. Data were collected by using an interview
questionnaire, which is comprised of two parts.
The first part was designed to investigate: - Women's demographic characteristics:
name, age, occupation, marital status, educational level, family income and body
mass index.
- Identification of urinary incontinence from these four questions: (6)
In the past 4 weeks, did you wear any pad or other material to absorb urine that you
may have lost? Have you lost or leaked urine for any reason? Some people lose urine
on the way to the bathroom. Has this happened to you in the past 4 weeks?
In the past 4 weeks, when you had an urge to urinate, did you ever lose urine before
you could reach the bathroom?
To be classified as 'incontinent' and proceed to further questions about incontinence
the respondents had to respond 'Yes' to at least one of these questions.
Two additional questions were asked to differentiate stress incontinence and urge
incontinence symptoms:
- In the past 4 weeks, when you had urine loss, how often was it because of a physical
pressure on your bladder? By physical pressure, I mean from coughing, sneezing, or
laughing or activities like lifting, straining, or bending over …?
-In the past 4 weeks, when you had urine loss, how often was it because of a sudden
or uncomfortable urge to urinate?
Response options to these questions were: 'Never, Rarely, Less than half the time,
half the time or more, and always'. Respondents were grouped into type of
incontinence by their responses to the above questions:
SI; must have responded 'Half the time or more' or 'Always' to the question 1 and
'Never', 'Rarely' or 'Less than half the time' on question 2.
UI; must have responded 'Half the time or more' or 'Always' to the question 2 and
'Never', 'Rarely' or 'Less than half the time' on question 1.
MI; must have responded 'Half the time or more' or 'Always' to both questions.
The definitions of each incontinence type set forth by the ICS Standardization Sub-
Committee (7).
After meeting this criterion respondents were asked questions about:
- Duration of incontinence, number of parity, mode of delivery, menopause or any
surgery, history of diuretic intake, smoking, coffee or tea drinking.
- The number and frequency of incontinence episodes was classified according to
severity to: - mild; less than once a week, - moderate; two or three times a week, -
severe; once or more a day (8).
- History of nocturnal enuresis, factors increasing intraabdominal pressure and
chronic diseases.
The second part is designed to investigate the impact of urinary incontinence on
quality of life by using the incontinence impact questionnaire (9).
The incontinence impact questionnaire consists of 30 questions concerning four
domains: Physical activity, Travel, Social relationships, Emotional health.
Each domain includes sub-dimensions (items) to specific area of impairment.
Scoring was done for each item from 0 to 3.
- sub score for physical activity was from 0 to 18, sub score for travel was from 0 to
18, sub score for social relationships were from 0 to 30, sub score for emotional
health was from 0 to 24 and Total score was from 0 to 90.
Each score was divided to not at all, mild, moderate and severe.

Results:
A total of 124 women (100% response rate) completed the questionnaire. Mean age
was 51 ± 9.4 years, illiteracy was 41.9%, 73.4% were housewives, and 80.6% were
married. The prevalence of mixed, urge and stress incontinence were 45%, 36% and
19% respectively.
Stress UI was more frequent between 40 and 50 years of age, whereas mixed UI was
more frequent between 50 and 60 years of age.
The most mentioned risk factors of UI were 42.7% were obese (mean and standard
deviation of body mass index were 30.2 ± 7.09), 31.5% had more than three children,
70% were vaginally delivered, 74.2% were menopause, 34.7% had constipation, 57%
had chronic diseases.
About 66.7% of the stress incontinence group was obese which was highly
significant, while 87.5% of the mixed incontinence group was menopause which was
highly significant and 45.9 % of the stress incontinence group has factors increasing
intraabdominal pressure.
The relation between history of physician consultation and types of urinary
incontinence was not statistically significant however the increase need for physician
consultation was mostly among mixed UI group (35.7%).
There is a highly significant relation between physician consultation and severity of
UI (60% of females who ask for physician consultation has severe UI and only 15%
of females asking for physician consultation have mild UI). (P value: 0.001)
About 71% of the studied group report negative impact on quality of life.
severe
18% not at all
29%

m ode rate
m ild
22%
31%

Mixed UI was the most affected in quality of life (75%) followed by stress UI
(70.8%) then urge UI (65.9%)
About 77.8% of women having no effect on quality of life suffer from mild urinary
incontinence, while 54.5% of severely affected quality of life had moderate urinary
incontinence and this was highly significant.
Our study shows that 67.8% of the studied women was negatively affected in physical
health and travel (mobility), followed by social relations (66.2%) then emotional
health (62.9%). The most prevalent complaint was affection in the ability to pray and
to go to a mosque or a church (56.4%), followed by affection of daily home activities
(48.3%) then affection of sexual life (42%).
Discussion:
This study was designed to determine the impact of urinary incontinence on the
women's quality of life.
The prevalence of urinary incontinence types in our study shows that the prevalence
of mixed urinary incontinence (MUI) was 45%, urge urinary incontinence (UUI) was
36% and stress urinary incontinence (SUI) was 19%. Our results also agree with
Kocak et al. in 2005 who stated that the prevalence’s of urge, stress and mixed UI
were 25.6%, 33.1%, and 41.3%, respectively (8).
Also in turkey, the most frequent type of incontinence was mixed UI 61.3%, the
prevalence of stress UI among all incontinent women was 20.8% and urge UI was
17.9 % (10) and these results are also similar with the present study.
Another study in Jordan stated that 23.1% had stress UI, 26.4% had urge UI, and
18.1% had the mixed type (11) .This differs from the present study because of the
difference in the age group studied in each study.
In the present study, the mean age was 50.1± 9.4. The prevalence of SUI peaked at
the 4th decade, whereas urge and mixed UI peaked after the 50th decade which was
consistent with a recent review by Minassian et al. in 2003 (2).And also agree with
Kocak et al. in 2005 who reported that the prevalence of urge UI increased with
increasing age and became the most frequent type after 70 years and older (8).
In the present study about women (19.3%) were overweight, women (42.7%) were
obese and mean and standard deviation of body mass index were 30.2 ± 7.09 this is
similar to the results of Vinker et al in 2001 who stated that it was 27.6 ± 5.2 (5). Our
results shows that 66.7%% of obese women were of the stress group. This agree with
Al-Hayek & Abrams in 2004 and Farouk in 2005 who reported that stress UI was
increasing with the increase in the BMI (11, 12). But it differs from Kocak et al. in 2005
and Peyrat et al. in 2002 who reported no association between UI and obesity (8,13) this
difference may be regarded to the small sample sizes per group
Controversies continue on the effect of number and mode of delivery on UI.
Minassian et al. in 2003 showed that multiparty increased the risk of UI in 61% of the
related studies (2). Our study shows that 60% of the patients had parity ≥ 3; our results
agreed the results of Vinker et al in 2001 which showed that parity is a risk factor for
UI [11]. And also agreed with Tuncay et al. in 2006 (10). Abd el wahed H. in 2004 also
reported that urinary incontinence rises with parity as 87.5% of the patients had
parity≥ 3 (14). And as a consequence our study found that the severity of UI correlates
with the increased number of parity as 53.3% of women with severe symptoms had
parity ≥3. Our study shows that 82 % of the studied group was vaginally delivered
this coincides with Rortveit et al.in 2003 and Peyrat et al.in 2002 (15, 16). However there
are controversies, many clinical studies have attempted to discover the particular
obstetric event that causes the incontinence. The obvious suspects include large babies
and "difficult deliveries" marked by lengthy pushing phases with or without
instrumentation. Some suggested both caesarean section and vaginal delivery as risk
factors (17). This still wants to be proven.
The effect of postmenopausal estrogen deficiency on incontinence is debatable (18).
The relationship between menopause, estrogen replacement therapy and the risk of UI
are inconsistent (12).
The prevalence of menopause among the studied population in our study was 74.8%
perhaps because about 90% of the study population was above 40 years old. In our
study 87.5% of the mixed UI group was in the menopause period and 79.5%of the
urge UI group was in the menopause period.
Our results agree with Farouk in 2005 and Vinker et al in 2001 who found great
association between UI and menopause (5,11) .But it differs from Kocak et al. 2005
who did not found any association between UI and menopause (8). This because that
the role of decreased estrogen on incontinence after menopause has yet to be proven
(18)
.
Bowel dysfunction has long been known to affect voiding function and can lead to
incontinence (19).
Healthcare seeking among those with urinary incontinence is generally low (5). People
with incontinence may not express the desire for treatment unless they are asked;
most are unaware that a family practitioner can successfully treat incontinence (20) this
can be seen clearly in our study. Our study shows that 70.2% of the patients did not
ask for medical advice and only 29.8% ask for it and that the most common reported
reason is embarrassment followed by fear of surgery. Vinker et al. in 2001 agree with
our results and reported that only 32% of the affected women had sought medical
advice (5). Also agree with Margalith et al. in 2004 who found that the majority of the
sample (74%) delayed seeking help, and common reason for it were lack of time
(36.3%), shame (15.7%), and fear of surgery (14.7%) (21). The tendency of affected
women, especially in traditional cultures as ours, to hide the problem raises the
question of whether it is up to the family physician to broach the subject.
In the present study we found increase need for physician consultation among urge
and mixed UI which was 35.7% MUI and 27.3% for UUI comparing with SUI which
was 20.8% and this coincide with Coyne et al. in 2003 who found that respondents
with UI and MI rated their need for medical care higher than the SI group (6).
Indeed, UI should be diagnosed and treatment planned according to both the objective
and subjective severity of the condition.
There is also a relation between physician consultation and severity of UI in the
present study, as 60% of females who have a severe UI ask for medical advice which
coincide with Kocak et al. in 2005 (8).
And coincide with Vinker et al. in 2001 who said that when women perceive the
urinary leakage as mild they fail to ask for medical advice, but when symptoms
become intolerable they ask for it (5).
As regards to the impact of urinary incontinence on quality of life we observed that
71% of the incontinent women in our study found that UI is disturbing and claimed
that it had adverse effect on their quality of life; 53% of them reported that UI had a
mild to moderate effect on their quality of life and about 18% reported severe effect.
Our results agree with the results of Kocak et al. in 2005 who reported that 87.2%
women considered that UI have negative impact on their QOL and this bothersome
effect remained mostly at the mild or moderate level (8). And agree with Coyne et al.
in 2003 observed that more than half the affected women found UI disturbing and
claimed it had a detrimental effect on their daily functioning (6). In another study by
Papanicolaou et al. in 2005 in four European countries, more than 80% reported that
their urinary incontinence symptoms were bothersome (22). Our results did not differs
from Vinker et al. in 2001 who reported that 60% of the women with urinary
incontinence found it to be a disturbing symptom, and 44% reported that it had a
detrimental effect on their quality of life. 59% of the women with UI found the
symptom more than moderately disturbing, and 58% reported that UI had a moderate
to severe effect on their quality of life (5). Also Margalith et al. in 2004 found that
41% reported impairment in performing work and other activities (21).
In this study the financial impact of UI could not be detected accurately as only
29.8% seek medical advice and no one had surgery for UI. They only paid the
expenses of physicians or use of medication which they only used for a short time.
In this study, we found that there were no great differences in health related quality of
life affection between the mixed, urge and stress incontinence groups, patients with
mixed urinary incontinence had the mostly affected quality of life (75%) varying
from mild to severe followed by stress (70.8%) then urge (65.9%).
This agree with Kocak et al. in 2005 who Stated that the difference was statistically
significant for mixed UI compared to others and also agree with Van der Vaart et al.
in 2002 (8,23). Also our results agree with Coyne et al. in 2003 found the same and
claimed that urge incontinence and mixed incontinence are particularly distressing (6).
.
The definition of severe UI varies depending on the frequency, duration and amount
of leakage, use of pads etc, (24) .In this study, when we used frequency as a measure of
severity 77.8% of women with no effect on quality of life suffer from mild severity of
urinary incontinence, whereas 54% of severely affected quality of life was having
moderately urinary incontinence. This agree with Coyne et al. in 2003 who stated that
the significantly increase in symptom bother and reduced HRQL (6). And with
Papanicolaou et al. in 2005 who also observed that a negative impact on QOL was
associated with an increase in severity of incontinence (22). But it differs from Vinker
et al. in 2001 who demonstrated that there is no connection between the subjective
perception of UI and the actual severity of the condition, and physicians and patients
may view the impact of UI on quality of life differently (5).
Whereas physicians focus more on functional impact, patients are more often
concerned with their emotional well being and daily activities.
As regards to the effect of urinary incontinence on the different domains of quality of
life, the results of our study showed that 67.8% of women with urinary incontinence
was negatively affected in their physical health and travel (mobility), followed by
social relations (66.2%) then emotional health (62.9%).
Several important and specific complaints have been reported; the most prevalent
complaint was affection in the ability to pray and to go to a mosque or a church
(56.4%), followed by affection of daily home activities (48.3%) then affection of
sexual life (42%) and (32.2%) affect relationship with the family. This coincides
with Van der Vaart et al. in 2002 who reported that incontinent women were specially
limited in their mobility (23). And with Papanicolaou et al. in 2005 who also found in
four European countries that the greatest negative effect appeared to be on physical
and social activities (22). However it differs from Kocak et al. in 2005 who found that
anxiety and nervousness were the most frequent complaint (40.8%) (8).
And also differs from Pang et al. in 2005 in Hong Kong who reported that social and
emotional domains were the quality of life domain most affected by urinary
incontinence (25). However these differences between the previously mentioned studies
could be regarded to the different tools used for assessment of quality of life on these
several domains. Also the difference in culture between the study populations and
ours especially that our study setting is in a rural area.
Limitations of the present study: The incontinence classifications used are based
entirely on patients' reports of symptoms; there was no urodynamic testing to confirm
the type of incontinence in the present study.
Using a symptom-based diagnosis of urinary incontinence gives maximum weight to
the perception of the problem by the woman. Objective measures, e.g. urodynamics
and pad-tests, are known to correlate only moderately with reported symptoms and
psychosocial consequences. The study population need to be a community based
sample while in this study selected sample representing only those attending the
family practice center. that there was no control group.

Conclusion:
UI is a common and often disturbing problem in women, but it does not receive
appropriate attention.
Our study showed that 71% of the incontinent women had a negative impact on their
quality of life, 67.8% of the studied women was negatively affected in their physical
health and travel (mobility), followed by social relations (66.2%) then emotional
health (62.9%) and the most prevalent complaint was affection in the ability to pray
and to go to a mosque or a church
Although urinary incontinence can adversely affect the quality of life, only very few
affected patients (29.8%) seek medical advice and treatment.

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