|Year : 2018 | Volume
| Issue : 2 | Page : 71-77
Impact of urinary incontinence on quality of life among rural women
College of Nursing - A, King Saud Bin Abdul Aziz University of Health Sciences, King Abdul Aziz Hospital, Ministry of National Guard Health Affairs, Al Ahsa, KSA
|Date of Web Publication||27-Nov-2018|
Dr. Thilagavathy Ganapathy
Assistant Professor, College of Nursing -A, King Saud Bin Abdul-Aziz University for Health Sciences, King Abdul-Aziz Hospital, Ministry of National Guard Health Affairs, Mail Code 500, P. O. Box. 2477, Al Ahsa 31982
Source of Support: None, Conflict of Interest: None
Background: The exasperating symptoms of urinary incontinence(UI) adversely affect holistic well-being of women. Objective: This cross-sectional study aimed to evaluate the impact of symptoms of urinary incontinence on the health-related quality of life (HRQOL), using King's Quality of Life Health Questionnaire among women in India. Methods: A total of n = 611 women were screened for stress, urgency, and mixed urinary incontinence by purposive sampling method at Gottigere, Primary Health Center Bangalore South, Karnataka, India. Results: The prevalence of urinary incontinence (UI) was (23.08%) with majority presenting stress (54.61%) followed by urgent (27.66%) and mixed (17.73%) incontinence. The overall HRQOL in role limitations, daily activities, general health, physical/social well-being, sleep/energy, emotions, and personal relationships domains was poor with insignificant difference among stress versus urgency versus mixed incontinence (P = 0.641). The symptoms of UI such as frequency, nocturia, nocturnal enuresis, urgency, and stress, leakage during sexual relationships, infections, and pain had a negative impact on their QOL. Advancing age, parity, history of instrumental delivery, chronic cough, and constipation were found to be the most influencing factors for the episodes of UI and poor QOL among women. Conclusion: The detrimental consequences of urinary incontinence on the HRQOL of women need a paradigmatic shift in treatment approach.
Keywords: King's health questionnaire, quality of life, urinary incontinence, women
|How to cite this article:|
Ganapathy T. Impact of urinary incontinence on quality of life among rural women. Muller J Med Sci Res 2018;9:71-7
| Introduction|| |
Women are the second victim of urinary incontinence (UI), and it has a significant and substantial impact on physical, psychological, social, and sexual health-related quality of life (HRQOL). The World Health Organization (WHO) classified urinary incontinence as a social disease since it affects more than 5% of the general population. It is estimated that 30%–60% of perimenopausal and postmenopausal women report urinary incontinence at some point in their lifetime and nearly 50% of the women in the fifth and eighth decades of life usually manifest urinary incontinence.,
Stress urinary incontinence (SUI) is one of the most common types of urinary incontinence, which is defined as an involuntary leakage of urine during some strenuous activities. Urgency incontinence is the involuntary loss of urine accompanied by urgency. Mixed incontinence (MI) is the involuntary loss of urine associated with urgency and with effort, exertion, coughing, or sneezing., Generally, UI is not a deadly disease but rather a symptom as a result of either a bladder or sphincter disorder. However, its exasperating character may negatively affect physical, psychological, social, and sexual spheres of women's functioning in all the age groups. Epidemiological studies have shown that the severity and symptoms of urinary incontinence have a linear relationship with the QOL.,
Urinary incontinence, in whichever forms, intensively affects the QOL of women. The symptoms are perceived as a poor health which ultimately affects the holistic well-being., Women avoid social gatherings and lose self-confidence, which has a proportional impact on their social interactions and sexual and psychological health. Apart from the emotional and social repercussions, however, urinary incontinence is a risk factor for other physical conditions and diseases, while simultaneously being a financial burden on their family.,
In India, women with urinary problems silently suffer with symptoms even when their symptoms cause major distress and hinder daily activities due to culture of silence. Literature reported that lack of awareness of the condition, psychosocial embarrassment, financial constraints for consultations, and fear of treatment were the few factors influencing low health-seeking behavior and poor QOL among women with UI., In addition, fear and shame of losing urine in the public, feeling wet and smelling, not finding a bathroom when they need to change clothes or their protective pad involve unintended consequences in QOL of women.
The WHOQOL describes that the QOL is a subjective perception of an individual, influenced by multidimensional factors. That being said, health related to physical, social, psychological, and sexual aspects must be addressed when assessing QOL while trying to evaluate the personal experience of each individual.
Research reveals that one in ten women in India lead a poor QOL with UI, limiting their holistic functioning in daily activities of normal life. In general, women report that UI has a greater impact on physical, social, and sexual activities, economic burden, and self-perception. Nevertheless, comorbidity associated with urinary incontinence such as fungal infections, perineal dermatitis, skin irritation, sores, and rashes by wet skin involves several negative consequences in QOL of women., Frequency, nocturia, urgency, and urge incontinence have also been shown to increase the risk of falls, which may lead to fractures and other morbidities., Furthermore, the significant association of symptoms of urinary incontinence with anxiety, fear, and depression alters the QOL and general functioning of the women. A population-based study reported that majority (80%) of women with urinary incontinence presented with depression and panic disorders.
In India, studies that addressed the impact of urinary incontinence on QOL among rural women are scarce. Nonetheless, the healthcare-seeking behaviors for urinary symptoms among marginalized rural women are overwhelmingly low. Surrounded by cultural ideologies, taboos, and inhibitions regarding urinary morbidity, women from rural community do not seek treatment and lead a low QOL. Analyzing the impact of UI on QOL among rural women will help focus on the future interventions that would maximize the holistic well-being of women. Under this circumstance, the present study aimed to explore the impact of urinary incontinence on the QOL among rural women.
| Methods|| |
A cross-sectional study was conducted at Gottigere, Bangalore, Rural Primary Health Center (PHC), from January 2016 to August 2017. All women who attended the center were screened for various forms of urinary incontinence by a gynecologist based on their responses to the yes/no questions on involuntary loss of urine. Participants were divided into three groups according to the types of urinary incontinence (SUI, overactive bladder (OB), and mixed UI [MUI]), based on their answers. Those women who positively answered to the question on involuntary leakage of urine on coughing, sneezing, laughing, or any type of physical activities were categorized under SUI. Those who reported to have leakage of urine with intense desire and difficulty in controlling the desire to urinate were classified as overactive bladder (OAB) (urge incontinence [UI]). Participants who reported experiencing involuntary leakage of urine on exertion and urgency were categorized under MI. Stress incontinence, OAB, and MI were operationalized based on the clinical guidelines by the International Continence Society.
Based on the prevalence of urinary incontinence in rural women being 10% from the previous study in Karimnagar, Andhra Pradesh, India, the sample size was calculated with an acceptable error of 5% at 95% confidence interval and it was estimated to be 138. Anticipating nonresponse rate of 10% and missing data, a total of 150 women who reported urinary incontinence over a period of 1–3 months were included in the study. Women aged <18 years, physically and psychologically challenged, with a history of psychiatric consultation and pregnancy were excluded.
Official permission was obtained from the medical officer in-charge of the Gottigere PHC and Bruhat Bengaluru Mahanagara Palike (District Health and Family Welfare Office, Bangalore, South, Karnataka, India) (Maternal Child Health and Family Welfare). After detailed explanation on the purpose of the study, oral informed consent was taken from the participants. Participants were interviewed individually in privacy, maintaining the confidentiality of the information. They were assured that the findings of the study would be reported in an aggregate form without any identifying information of the individual participant. They were informed that they are free to withhold or refrain from providing information at any time during the interview without any adverse effects on their health care at PHC. The interview lasted for approximately 20–30 min, and the study procedures followed the Declaration of Helsinki principles.
The impact of symptoms of urinary incontinence on QOL was evaluated using the King's health questionnaire (KHQ). The KHQ is a valid and reliable instrument for the assessment of QOL in women with urinary incontinence. It is a patient-friendly questionnaire in three parts consisting of 21 items. Part 1 contains general health perception and incontinence impact (one item each). Part 2 contains role limitations, physical limitations, and social limitations (two items each), personal relationships and emotions (three items each), sleep/energy (two items), and severity measures (four items). Part 3 has a single item and contains ten responses in relation to frequency, nocturia, urgency, urge, stress, intercourse incontinence, nocturnal enuresis, infections, pain, and difficulty in voiding. The responses in KHQ have four-point rating system. The eight subscales (“domains”) score between 0 (best) and 100 (worst). The symptom severity scale scores from 0 (best) to 30 (worst). Lower scores in KHQ domains indicate participants' well-being and higher scores in KHQ domains depict that the woman is severely affected by the urinary incontinence, leading to poor QOL.
The questionnaire was translated into local language and back-translated into English by bilingual experts. The translated tool was validated by maternal child health experts and the content validity index (CVI) was computed and was found to be 0.91. The validated tool was subjected to internal consistency reliability by split-half method. Cronbach's alpha, α measures of internal consistency reliability yielded, α = 0.93. The validated tool was piloted among 38 participants.
The data were analyzed descriptively with mean, standard deviation, median, frequency, and percentages. The demographic and obstetric variables and problems associated with urinary incontinence were analyzed by descriptive statistics. Analysis of variance was used to identify the significant differences in the mean scores of SUI, UI, and MUI. The Pearson's Chi-square test or the Fisher's exact test was used to assess the association of overall scores in different QOL domains of urinary incontinence with sociodemographic variables. An alpha <0.05 was considered as significant for analyses. IBM SPSS Statistics (Version 21.0, IBM Corp., Armonk, NY, USA) was used for all analyses.
| Results|| |
The prevalence of urinary incontinence
Of the 611 women screened, n = 163 women presented with various types of urinary incontinence. Twenty-two women withdrew from the study due to time constraints. Final analyses consisted of n = 141 (23.08%) women with urinary incontinence. Among them, majority (n = 77; 54.61%) were found to have stress incontinence followed by urgent incontinence (n = 39; 27.66%) and MI (n = 25; 17.73%).
Risk factors associated with urinary incontinence
The prevalence of urinary incontinence was common in women aged above 40 years (n = 84; 59.57%) as compared to women aged < 40 years (n = 57; 40.43%). Similar trend was observed among multiparous women (n = 107; 75.89%); those who had instrumental deliveries (n = 61; 43.26%), and those with the history of chronic cough (n = 99; 70.21%), and those with the history of constipation (n = 101; 71.63%). Sociodemographic variables such as education (P = 0.731), economic status (P = 0.419), physical activity (P = 0.419), and body mass index (BMI) above 25 kg/m2 (P = 0.402) were not significantly associated with the types of UI [Table 1].
|Table 1: Baseline characteristics of the women with urinary incontinence|
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Problems with urinary incontinence
Regarding the problems with urinary incontinence, almost 98.58% of women reported frequency, nocturnal enuresis (68.09%), nocturia (66.66%), urinary leakage with coughing, laughing or any forms of physical activities (54.61%), and difficult to control desire to pass urine (urgency) (48.94%) disturbing their HRQOL a lot. Urinary incontinence during sexual activities was reported by 47.52% of women, nearly 37.59% reported urinary tract infections, and 34.75% complained of pain while voiding [Table 2].
Domains' mean scores among women with various forms of urinary incontinence
Regarding QOL, it was noted that women with stress incontinence and MI presented very high mean scores in role limitation domain as compared to those with urgency incontinence with insignificant difference across types of UI (92.41 ± 0.96 vs. 91.42 ± 0.31 vs. 89.69 ± 0.83; P = 0.741). Similar trend was noted in daily activities (91.71 ± 1.27 vs. 90.41 ± 2.49 vs. 90.41 ± 2.49; P = 0.561); general health (88.41 ± 2.06 vs. 88.17 ± 1.41 vs. 87.89 ± 1.34; P = 0.814); and physical/social limitations (87.54 ± 1.12 vs. 87.08 ± 0.93 vs. 86.65 ± 1.39; P = 0.643) with majority reporting generalized weakness, tiredness, in performing physical activities, ability to travel outside for work, and family and social gatherings. In relation to sleep and energy, women with stress, mixed, and urgency (83.43 ± 1.27 vs. 83.43 ± 1.27 vs. 83.29 ± 0.62; P = 0.597) were equally affected a lot, reporting sleep disturbances and inadequate sleep due to frequency and nocturnal enuresis. The effect of urinary incontinence on emotional health also revealed an insignificant difference among the various forms of incontinence (82.18 ± 1.12 vs. 81.23 ± 0.97 vs. 79.78 ± 1.92; P = 0.814) with majority expressing nervousness, anxiety, low self-esteem, and depression, indicating poor QOL in psychological well-being. Regarding the effects of UI on sexual life, women were generally affected with their sexual and family life abundantly resulting in resentment, shame, guilt, and anger with self and partner (81.1 ± 1.92 vs. 80.89 ± 0.61 vs. 80.01 ± 0.72; P = 0.137). In general, women with stress incontinence, MI, urgency (86.84 ± 1.389 vs. 86.05 ± 1.159 vs. 85.24 ± 1.131; P = 0.641) incontinence had unfavorable QOL, limiting their general physical, psychological, social, and sexual wellness [Table 3].
|Table 3: Domains mean scores among women with various forms of urinary incontinence (n=141)|
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Association of overall mean scores in different quality of life domains of urinary incontinence with sociodemographic variables
The association of overall scores in different QOL domains of urinary incontinence with selected sociodemographic variables showed a significant association in women with advancing age (P = 0.016), multiparous obstetrical score (P = 0.021), history of instrumental deliveries (P = 0.003) and those with chronic cough (P = 0.026) and constipation (P = 0.019). There was an insignificant association among education (P = 0.513), socioeconomic status (P = 0.627), BMI (P = 0.683), physical activity (P = 0.337), and QOL domain scores in SUI, urgency incontinence, and MUI [Table 4].
|Table 4: Association of overall mean scores in different quality of life domains of urinary incontinence with sociodemographic variables (n=141)|
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| Discussion|| |
Urinary incontinence (UI) is a crippling condition affecting women of all ages. Although urinary incontinence is not a fatal disease, it is debilitative and exhaustive in terms of symptoms, resulting in poor QOL among women. It affects the holistic well-being of women limiting physical, psychological, social, and sexual activities of daily life in addition to social stigmatization and economic burden.,
In the present study, majority of the women reported SI- Stress incontinence (54.61%), nearly (27.66%) reported Urge and (17.73%)mixed incontinence. A cross-sectional study among tribal women in Thane District, Shahapur, India, by Prabhu and Shanbhag reported consistent findings of overall prevalence of UI being 25.5%, with stress incontinence affecting the majority of women (56.2%) followed by urge incontinence (32.1%) and MI (11.7%). Bodhare et al. reported a similar prevalence rate of stress incontinence (57%), urge (23%) incontinence, and 20% MUI among rural women in Karimnagar district, Andhra Pradesh, India. This could be possibly explained by the fact of withdrawal of hormones, decreased bladder contractility, and progressive loss of muscle tone with increasing age and changes in the hormonal stimulation.,
Urinary incontinence is a significant health problem associated with modifiable and nonmodifiable factors. Potentially, identifying and characterizing the risk factors related to HRQOL in women with UI may minimize the burden on the individual and accelerate the development of preventive, diagnostic, and therapeutic strategies for the improvement of HRQOL in this population and the health-care system.
In this study, the prevalence of all types of urinary incontinence was higher in middle-aged group of women above 40 years of age, as compared to women in the age group of 19–40 years, with the mean age of the participants being 46.7 ± 14.6 years. This is consistent with the reports of Danforth et al. that the prevalence of incontinence peaks in mid-life with almost twice among women (34.1%) above 40 years of age. Singh et al. reported similar findings indicating that the prevalence of UI was high among women above 40 years of age, ranging from 27.8% to 42.8%. A similar trend of higher occurrence of UI was observed in multiparous as compared to primiparous women. Congruent findings were reported by a cross-sectional study among rural women that nearly 64% of the women who presented with UI were multiparous in their obstetrical scores which could be due to repeated injuries during parturition.
This study had established that the abnormal vaginal deliveries by the forceps and vacuum were the significant risk factors for UI. Well-designed epidemiological studies, reported congruent findings, indicating that the repeated vaginal and traumatic deliveries by instruments increased the prevalence of UI in women. Furthermore, history of chronic cough and constipation were identified as significant risk factors for UI. A cross-sectional descriptive study among tribal women in Khardi, Maharashtra, India, revealed homogenous findings that the chronic cough and constipation were strong predictors of incontinence in regression analysis (R2 = 0.47). Similarly, few other researchers,, argued that chronic constipation and cough were the leading risk factors for UI in women.
QOL is a significant predictor of health-seeking behavior among women with UI. Understanding the vital relationship between UI and HRQOL is crucial for the implementation of primary preventive measures. In this study, women with SUI, UI, and MUI had an impaired general, physical, psychological, social, and sexual HRQOL. Women reported a debilitating impact of symptoms of urinary incontinence on daily activities of life. A vast majority of the women experienced limitations in performing normal activities of daily life, doing household chores, work outside home, social gatherings, adequate rest, sleep, and traveling related to symptoms of urinary incontinence such as to frequency, urgency, odor, generalized weakness, and tiredness. In addition, fear of social victimization, anxiety, and depression were adversely affecting their QOL. Consistent findings were reported by Cheung et al. that women with UI reported poorer general health (66%), vitality (67.3%), and social (67%) aspects of QOL.
Consistent with our results, Kumari et al. found that the urinary incontinence symptoms had a significantly higher effect on QOL among women (r = 0.962 at P < 0.01). Similarly, Bhanupriya et al. had reported that SUI, urgency incontinence, and MUI had a more profound detrimental effect on HRQOL among women. Khan et al.'s study among rural women in UP, India, agreed with our results indicating a positive linear relationship of low level of holistic health with SUI, MUI, and urgency urinary incontinence. A cross-country study reported homogenous findings that more than a half of the women with urinary incontinence significantly experience lower QOL in physical, social, and psychological activities. The effect was remarkable on job and daily outdoor activities and in traveling for work or outdoor activities. Bushnell argued that frequency, severity, and stimulating factors of UI limit social, besides physical and emotional QOL functioning in women. A QOL among Turkish women with UI showed that one among four women experiences adverse impact of UI on QOL at mild-to-moderate degree.
A community study in Hong Kong by Pang et al. found that nearly 11.7% of the women with urinary incontinence reported impaired physical, social, and emotional well-being. Furthermore, the uncontrolled loss of urine in every form of urinary incontinence undoubtedly results in substandard psychological well-being, avoidance of social contacts, depression, and isolation. Our study indicated that majority of the women avoid social gatherings due to wetting, unpleasant odor, and social disgrace. Identical findings were reported by Ghafouri et al. and Minassian et al. that urinary incontinence adversely affects the social and personal QOL of women. Besides its deleterious effect on normal daily activities of life, it limits the psychological well-being, subjecting the women into higher degree of depression, shame, humiliation, and isolation from family, friends, and social gatherings. Mallah et al. agree with these findings, indicating that a significant number of women experience anger, frustration, dissatisfaction, and depression with UI (P < 0.002). The authors asserted that the poor quality of emotional well-being in women with UI was comparable to those with chronic illnesses, such as diabetes, hypertension, and heart diseases.
Besides being physiological problems, affecting physical, social, and emotional aspects of life, UI has a significant impact on sexual health and relationship with the partner. Supportive findings were reported by Nilsson et al. and Shaw that the prevalence rate of limitation of sexual activities related to UI ranges from 0.6% to 64% among women. A community-based study in Egypt revealed a congruent result that women with UI suffer from low self-esteem, guilt, and refrain from sexual activity and suffer from profound psychological and sexual ill health.
Generalization of research findings has its own potential limitations as the diagnosis of various forms of UI was based only on self-reported UI symptom questionnaire with dichotomous yes/no response rather than clinical and urodynamic examinations.
| Conclusion|| |
The study findings had revealed that stress, urgency, and mixed types of urinary incontinence adversely affect the holistic QOL of women. The destructive outcomes of urinary incontinence on the physical, psychological, social, and sexual HRQOL of women in addition to the significant financial impact on the society need a paradigmatic shift in the treatment for these traumatic symptoms. Although complete continence may not be feasible, measures to improve the QOL may be devised to help the women with this silent epidemic to lead a normal life.
The researcher is grateful to all the participants, medical officer, obstetrician, nurse midwives of the study setting for their support and cooperation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]