Quality of life in women with urinary incontinence by alicejenny

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									ORIGINAL ARTICLE

Quality of life in women with urinary incontinence
Ljiljana Mladenović Segedi1, Dimitrije Segedi1, Katarina Parezanović Ilić2

1
 Clinical Center of Vojvodina, Clinic of Gynecology and Obstetrics, Novi Sad, 2Center for Physical Medicine and Rehabilitation, Medical
Center of Kragujevac; Serbia




                                                 ABSTRACT

                                                 Aim To determine the characteristics of urinary incontinence and
                                                 its impact on the quality of life in adult women with urinary incon-
                                                 tinence who presented to a tertiary care clinic of Vojvodina from
                                                 September 2008 to May 2009 for treatment

                                                 Methods We used a prospective case-control study. Cases were
                                                 defined as patients (47) with urinary incontinence symptoms. Con-
                                                 trols (50) were defined as patients without urinary incontinence
                                                 who presented to a tertiary care gynecology clinic for other rea-
                                                 sons. Both, cases and controls, completed two questionnaires re-
                                                 commended for the evaluation of symptoms, The Urinary Distress
                                                 Inventory, and quality of life impact The Urinary Impact Questi-
                                                 onnaire.

                                                 Results There was a significant correlation between aging
Corresponding author:
                                                 (r=0.614; p<0.01), body mass index (r=0.357; p<0.01) and me-
Ljiljana Mladenović Segedi                       nopause (r= -0.572; p<0.01) and urinary incontinence. All pati-
Clinical Center of Vojvodina,                    ents had symptoms of stress incontinence, 61.7% had urge incon-
Clinic of Gynecology and Obstetrics              tinence symptoms, 21.3% voiding difficulty and 85.1% dysuria.
Branimira Ćosica 37,                             Ninety-four patients believed that urinary incontinence impaired
21 000 Novi Sad, Serbia
                                                 their quality of life: 50% of patients reported an impaired ability
                                                 to do household activities, 59.1% avoided social activities, 70.4%
Phone: +381 21 489 92 81;
                                                 reported an impaired ability to travel more than 30 minutes by
fax.: +381 21 489 93 32                          car or bus, 88.6% avoided leisure activities, 45.5% of patients had
E-mail: ljiljaseg@eunet.rs                       impaired emotional health and 34% felt frustrated.

                                                 Conclusion The dominant type of urinary incontinence in more
                                                 than half of the respondents was a mixed type, with moderate to
                                                 very severe problems. Symptoms of urinary incontinence interfere
                                                 with the performance of everyday household and social activities,
Original submission:                             causing the appearance of anxiety, depression and frustration, and
11 October 2010;                                 in more than 50% of women leads to reduced quality of life.
Revised submission:                              Key words: urinary incontinence, women, quality of life
18 November 2010;
Accepted:
29. December 2010.


Med Glas Ljek komore Zenicko-doboj kantona 2011; 8(2):237-242




                                                                                                                                          237
      Medicinski Glasnik, Volumen 8, Number 2, August 2011




      INTRODUCTION                                            ght treatment for the problem of urinary inconti-
                                                              nence. The control group consisted of 50 patients
      Urinary incontinence is defined as an involuntary
                                                              without urinary incontinence, who sought trea-
      passage of urine, which presents a significant
                                                              tment for other reasons. No patient suffered from
      medical, social and hygienic problem (1). The
                                                              genital prolapse estimated by the criteria of the
      most frequent types of urinary incontinence in
                                                              POP-Q quantitative system (1). Following a ver-
      women are 1) stress incontinence, manifesting
                                                              bal explanation and signing an informed consent
      as an involuntary passage of urine during an in-
                                                              form, general history data were obtained (age,
      crease in intra-abdominal pressure (coughing,
                                                              body height, body mass, date of last menstrual
      sneezing, laughing, physical effort); 2) urge in-
                                                              period, number and type of deliveries, infants’
      continence, presenting as an involuntary passage
                                                              birth weights, performance of strenuous labor,
      of urine associated with an overwhelming urge
                                                              and the presence of chronic diseases). All pati-
      to urinate as a consequence of abnormal detrusor
                                                              ents in the study group answered the questionna-
      activity and not connected with increased intra-
                                                              ires belonging to the group of highly recommen-
      abdominal pressure; 3) a mixed type of incon-
                                                              ded questionnaires for estimating the severity of
      tinence meaning the simultaneous presence of
                                                              symptoms of urinary incontinence and the pati-
      both symptoms of stress, and the urgent type of
                                                              ents’ quality of life: “The Urinary Distress inven-
      incontinence (2). The prevalence of urinary in-
                                                              tory (UDI-6)-Short Form” and “The Urinary Im-
      continence in women, no matter the type, ranges
                                                              pact Questionnaire (UIQ-7) Short Form.” These
      from 10% to 58% increasing with age (3).
                                                              questionnaires contain psychometric questions
      Urinary incontinence influences the quality of          specific to urinary incontinence (8, 9). Both short
      life in women, because in addition to local com-        forms highly correlate with the original versions
      plications (skin rash, skin infections) it causes di-   (10, 11).
      fferent social and psychological limitations such
                                                              The first questionnaire (UDI-6) contains 6 que-
      as self-isolation, loss of self-respect, depression,
                                                              stions intended to measure the severity of symp-
      the avoidance of one’s sexual partner and contact
                                                              toms of urinary incontinence: the frequency of
      with family members (4-6). Recent studies have
                                                              urination, the presence and severity of symptoms
      shown that urinary incontinence disturbs the so-
                                                              of urgent incontinence, the presence and severity
      cial lives of 8% to 52% of women, 9% to 48%
                                                              of symptoms of stress incontinence, the volume
      experience sexual dysfunction, and a significant
                                                              of urine loss, the presence of aggravated urination
      number of women suffer from anxiety and depre-
                                                              as well as the presence of pain. Patients answe-
      ssion (7).
                                                              red by circling one of four numbers 1-4 (1- no,
      The problem of urinary incontinence has been            not at all, 2- a little, 3- moderate, 4- severe), so
      marginalized in Vojvodina since the 1990s, due          that by applying the appropriate formula, the sco-
      to either a lack of equipment or lack of motivati-      re of the questionnaire was determined as well as
      on among physicians. The prevalence of urinary          the answer to the question of the type of urinary
      incontinence as well as the quality of life of in-      incontinence and severity of the symptoms.
      continent women remains largely unknown in
                                                              The other questionnaire (UIQ-7) contains 7 que-
      this region.
                                                              stions intended to investigate the effect of urinary
      The aim of this study was to investigate the cha-       incontinence on all social spheres of women: ho-
      racteristics (type and degree) of urinary inconti-      usehold activities (cooking, washing, cleaning),
      nence in women reporting to a tertiary-level in-        physical recreation (walking, swimming, exerci-
      stitution for treatment, as well as to objectify the    se), leisure activities (going to a movie, theatre),
      effect of urinary incontinence on quality of life.      bus or car travel lasting longer than 30 minutes,
                                                              taking part in social events, emotional health
      PATIENTS AND METHODS
                                                              (nervousness, depression) and the feeling of fru-
      The research was conducted at the Department of         stration. The answer was also obtained by circ-
      Obstetrics and Gynecology of the Clinical Center        ling one of the numbers 0-3 (0- no, not at all, 1- a
      of Vojvodina from September 2008 to May 2009.           little, 2- moderate, 3- severe) and the score was
      The study group included patients who had sou-          obtained by applying the appropriate formula.



238
                                                  Mladenović Segedi et al Urinary incontinence and quality of life




Statistical data analysis was conducted using                       Table 2. Severity of symptoms of urinary incontinence
STATGRAPHICS Centurion software. The data                           using “The Urinary Distress Inventory (UDI-6)-short form”
                                                                    questionnaire
analysis included the Student’s T-test and F-test.                  Urinary                    Severity of symptoms            Overall
The value p < 0.05 was considered statistically                     symptoms              Slightly Moderately Greatly          (n = 47)
                                                                    Frequency
significant.                                                        No. (%)               2 (4.25)   20 (42.55)    7 (14.9)    29 (61.7)
                                                                    Urge incontinence
RESULTS                                                             No. (%)               2 (4.25)   22 (46.80)   5 (10.64)    29 (61.7)
                                                                    Stress incontinence
                                                                    No. (%)               2 (4.25)   29 (61.7)    16 (34.05)   47 (100)
General characteristics of the patients                             Urinary leakage
                                                                    No. (%)               2 (4.25)   29 (61.7)    16 (34.05)   47 (100)
There were 97 patients in total: 47 in the study                    Voiding difficulty
                                                                    No. (%)                  -        7 (14.9)     3 (6.4)     10 (21.3)
group and 50 in the control group.                                  Dysuria No.
General characteristics of the patients are presen-                 (%)                      -       28 (59.6)    12 (25.5)    40 (85.1)

ted in Table 1. Patients with urinary incontinence                  A linear regression analysis confirmed a highly
were on average older (60.83 +/- 8.63 years) than                   significant correlation between the parameters of
the control group patients (44.74 +/- 6.8 years)                    age (r=0.614; p<0.01) and urinary incontinence;
(p<0.01). 87.23% of the women in the study gro-                     the parameters of body mass index and urinary
up were menopausal (p<0.01). There was no dif-                      incontinence (r=0.357; p<0.01), as well as the pa-
ference in body mass between the patients of both                   rameters of menopause (r= -0.572; p<0.01) and
groups (77.37 kg vs. 67.50 kg; p>0.01), although                    urinary incontinence. This correlation was not
there was a significant statistical difference found                recorded in other investigated parameters (num-
between body mass index values (BMI) of the                         ber of deliveries, mode of delivery, mean infant
investigated groups (29.98 vs. 26.02; p<0.01).                      birth weight, performance of strenuous physical
85.1% of patients in the study group were obe-                      labor). The other data of both study and control
se (38.3% moderately obese, 42.6% significantly                     group patients are presented in Table 1.
obese and 4.3% malignantly obese) (p<0.01). No
patient used hormone replacement therapy.                           Characteristics of the study group patients
                                                                    in concern to the type and severity of urinary
No statistically significant difference was evident
                                                                    incontinence
relative to the mean parity (two children), mean
infant birth weight (3687.25 g vs. 3592.76 g),                      Only stress incontinence was recorded in 38.3
mode of delivery (vaginal delivery in 93.3% vs.                     patients (18/47), whereas the mixed type of stress
87.5%) and the performance of strenuous physi-                      incontinence was found in the remaining 61.7%
cal labor (63% vs. 46%) (p>0.05).                                   of patients (29/47).
Table 1. General characteristics of women with and without          The type and severity of urinary symptoms in in-
urinary incontinence                                                vestigated patients are presented in Table 2. All
                        Cases            Controls                   patients from the study group reported on urine
Age (mean +/- SD)       60.83 +/- 8.63   44.74 +/- 6.8    p<0.01
(years)                                                             loss while coughing, sneezing and laughing: se-
Body weight             77.37 +/- 12.76 71.50 +/- 8.67    p>0.01    veral drops (mild) - 4.25% of patients; a larger
(mean +/- SD) (kg)
Body mass index         29.98 +/- 4.94   26.02 +/- 2.91   p <0.01   number of drops (moderate) - 61.7% of patients
(mean +/- SD)                                                       and a stream (excessive) – 34.05% of patients.
 Normal weight (%)      14.9             38.0
 Slightly                                                           Frequent urination and urge type incontinence
 overweight (%)         38.3             48.0                       was recorded in 61.7% of whom 4.25% experi-
 Moderately
 overweight (%)         42.6             14.0
                                                                    enced slightly, 46.8% moderately, and 10.64%
 Greatly                                                            greatly pronounced difficulties. In 21.3 % of pa-
 overweight (%)         4.3              0.0              p< 0.01
                                                                    tients, the act of urination was associated with
Menopausal (%)          87.2             12.8             p< 0.01
Number of births        1.91 +/- 0.69    1.98 +/- 0.77    p>0.05    effort (14.9% - moderate effort and 6.4% great
(X +/- SD)                                                          effort), while 85.1% had a permanent feeling of
Birth weight (g)        3687 +/- 393     3593 +/- 284     p> 0.05
(X +/- SD)                                                          inconvenience and pain in the lower abdomen
Heavy lifting (%)       63.0            37.0              p> 0.05   and genital region (59.6% reported such a feeling
UDI-6 (X +/- SD)        67.82 +/- 13.34 25.58 +/- 1.68    p< 0.01
UIQ-7 (X +/- SD)        69.71 +/- 25.91 0.48 +/- 2.20     p< 0.01   as moderate, while 25.5% characterized this fee-
X, mean; SD, standard deviation                                     ling as extremely pronounced).



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      Medicinski Glasnik, Volumen 8, Number 2, August 2011




      The effect of urinary symptoms on the activiti-                       an section), infants’ birth weights and strenuous
      es of daily living and quality of life is presented                   physical labor, such a correlation was not shown
      in Table 3. A decrease in quality of life was not                     in our sample (14-16).
      recorded in 3 patients (6.38%) with slight symp-                      Urinary incontinence, no matter the type, does
      toms of urinary incontinence (one with only uri-                      not belong to diseases which threaten a woman’s
      nary incontinence and two patients with mixed                         life. However, it has been noted that the develo-
      type urinary incontinence). Urinary incontinence                      pment of urinary incontinence during adulthood
      had a negative effect on household activities in                      may have serious consequences, such as a de-
      50% of patients (13.6% to a large extent), 50%                        crease in self-esteem which leads to the develo-
      of patients limited their participation in different                  pment of other psychological problems. Studies
      social events, 70.4% avoided traveling by bus                         concerning the effect of urinary incontinence on
      or car for longer than half an hour, 88.6% avoi-                      women’s quality of life were not initiated until
      ded different entertainment activities whereas all                    about fifteen years ago. At first, general questio-
      patients avoided physical activities to a varying                     nnaires were used. In time, specific questionna-
      extent, such as swimming and exercising. Invo-                        ires were developed and improved. These were
      luntary urine loss caused feelings of nervousness                     quantitative questionnaires to which patients
      and depression in 45.5%, whereas 34% of pati-                         gave answers in numbers, enabling the precise
      ents felt frustrated.                                                 determination of the type and severity of urinary
                                                                            symptoms as well as of the degree of decrease
      DISCUSSION
                                                                            in quality of life relating to the effect of present
      There is a common opinion that urinary inconti-                       symptoms (17,18). These questionnaires pro-
      nence in women is a direct consequence of aging.                      vided precise, reliable and representative data.
      Nevertheless, after menopause it is very difficult                    Over time, new criteria have been developed by
      to separate the individual influences of aging and                    which the questionnaires were categorized into
      menopause on the development of urinary in-                           three categories, and the questionnaires of the
      continence (12). Obesity is also a significant fac-                   first category were highly recommended (19). In
      tor in the development of urinary incontinence.                       our study we used the recommended questionna-
      Our study found, in addition to aging (r=0.614;                       ires (highly recommended-grade A) to evaluate
      p<0.01) and menopause (r= -0.572; p<0.01) obe-                        the type and severity of the symptoms of urinary
      sity (even moderate) (r=0.357; p<0.01) to be an                       incontinence (UDI-6), as well as measuring of
      etiological factor in significant correlation with                    effects of urinary incontinence on quality of life
      the development of urinary incontinence (13).                         (UIQ-7)(19).
      Although literature data indicate the significan-                     Recent studies have shown that urinary inconti-
      ce of some other factors in the development of                        nence can be an obstacle to good physical health
      urinary incontinence, such as the number of deli-                     and a good social life. A large study including
      veries, delivery method (vaginal delivery/cesare-                     9,487 European women showed that more than
      Table 3. The impact of urinary incontinence on quality of life        60% suffered from moderate to severe urinary
      in women                                                              incontinence exercised to a lesser degree thanks
                                       Severity of symptoms     Overall
      Questions
                                    Slightly Moderately Greatly (n = 44)    to the possibility of involuntary urine loss during
      1. Ability to do household                                            exercise (21). Women with severe types of in-
         chores No. (%)             10(22.6) 6(13.6)   6(13.6) 22 (50)
      2. Physical recreation                                                continence exercised 2.64 times less often than
         No. (%)                    23(52.3) 15(34.1) 6(13.6) 44 (100)      continent women (22). Avoiding physical activi-
      3. Entertainment
         activities No. (%)         21(47.7) 13(29.5) 5(11.4) 39 (88.6)
                                                                            ty increases the risk of developing other diseases
      4. Ability to travel by car                                           such as osteoporosis, hypertension, coronary he-
         or by bus for more than
                                                                            art disease etc. (20).
         30 minutes No. (%)         19(43.2) 9(20.4)   3(6.8)   31 (70.4)
      5. Participating in social                                            Urinary incontinence causes negative changes in
         activities outside your
         home No. (%)               15(34.1) 6(13.6)   5(11.4) 26 (59.1)
                                                                            social communication, thus decreasing quality of
      6. Emotional health                                                   life. The basic reason for avoiding contact with
         No. (%)                    15(34.1) 2(4.6)    3(6.8)   20 (45.5)
      7. Feeling frustrated
                                                                            other people (either family members or friends)
         No. (%)                    10(22.6) 2(4.6)    3(6.8)   15 (34)     is the feeling of fear and shame caused by the po-



240
                                            Mladenović Segedi et al Urinary incontinence and quality of life




ssibility of sudden involuntary urine loss which              incontinence (29). Therefore, women with mo-
patients want to avoid, and that is why they pre-             derate and severe types of urinary incontinence
fer being alone (23). Particularly urgent inconti-            have recently been advised to seek the aid of a
nence has a strong negative effect on the social              psychiatrist for the possible diagnosis and adequ-
lives of the patients. Urgent incontinence has a              ate treatment of depression (30).
more significant impact on quality of life than the           In conclusion, in Vojvodina, the dominant type
stress incontinence, since a hyperactive bladder              of urinary incontinence is a mixed type, with mo-
is harder to control, and very often the patient has          derate to very severe problems in more than half
to get up at night because of an urgent need to               of the respondents. Symptoms of urinary inconti-
urinate or because of involuntary urine loss (24,             nence interfere with the performance of everyday
25). A direct correlation between depression and              household and social activities, causing anxiety,
urinary incontinence, particularly urgent inconti-            depression and frustration, and in more than 50%
nence, has been confirmed by numerous studies                 of women it leads to reduced quality of life.
(26-28). Nygard et al. report that women with se-
vere type of urinary incontinence are 80% more                ACKNOWLEDGMENTS/ DISCLOSURES
likely to develop depression, compared to a 40%
                                                              Competing interests: none declared.
greater likelihood among women with mild type


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      Kvalitet života žena s urinarnom inkontinencijom
      Ljiljana Mladenović Segedi1, Dimitrije Segedi1, Katarina Parezanović Ilić2
      1
       Odeljenje za ginekološku urologiju, Klinika za ginekologiju i akušerstvo, Klinički centar Vojvodine; 2Centar za fizikalnu medicinu i reha-
      bilitaciju, Klinički centar Kragujevac, Kragujevac; Srbija

      SAŽETAK

      Cilj Utvrditi vrstu i težinu urinarne inkontinencije i kvalitet života žena lečenih u Kliničkom centru
      Vojvodina, u periodu od septembra 2008. do maja 2009. godine.

      Metode Prospektivnim istraživanjem obuhvaćeno je 97 pacijentkinja (47 s urinarnom inkontinencijom
      i 50 bez). Pacijentkinje su popunile dva upitnika. Za procenu vrste i težine urinarne inkontinencije ko-
      rišten je upitnik The Urinary Distress Inventory, dok je za ispitivanje uticaja urinarne inkontinencije na
      kvalitet života korišten upitnik The Urinary impact questionnaire.

      Rezultati Linearnom regresionom analizom utvrdili smo da je postojala značajna korelacija između
      parametra godine života (r = 0.614; p < 0.01), indeksa telesne mase (r = 0.357; p < 0.01) i menopauze (r
      = -0.572; p < 0.01) s urinarnom inkontinencijom. Simptome stres inkontinencije imale su sve pacijent-
      kinje; urgentni tip inkontinencije 61,7% pacijentkinja; 21,3% pacijentkinja imale su otežano mokrenje;
      85,1% stalno prisutan osećaj nelagodnosti i bola u donjem delu trbuha i genitalnoj regiji. Urinarna
      inkontinencija kod 50% pacijentkinja otežavala je obavljanje kućnih poslova; 59,1% su izbegavale
      društvena dešavanja; 70,4% izbegavale su putovanje autobusom ili kolima duže od pola sata; 88,6%
      izbegavale su različite zabavne aktivnosti, a sve pacijentkinje su izbegavale fizičku rekreaciju; 45,5%
      pacijentkinja imale su znakove nervoze ili depresije, dok se 34% pacijentkinja osećalo frustrirano.

      Zaključak U Vojvodini dominira mešoviti tip urinarne inkontinencije, s umereno do veoma izraženim
      tegobama kod više od polovine ispitanica. Tegobe urinarne inkontinencije ometale su obavljanje sva-
      kodnevnih kućnih i društvenih aktivnosti, uz izraženu nervozu, depresiju i frustracije, te kod više od
      50% žena doveli do smanjenja kvaliteta života.

      Ključne reči: urinarna inkontinencija, žene, kvalitet života




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