Stress Urinary Incontinence in Younger Women in Primary Care: Prevalence and Opportunistic Intervention

Abstract

Background:

Stress urinary incontinence (SUI) is prevalent in females, even among young adults. Though their quality of life (QOL) is impaired and pelvic floor exercise is an effective treatment, not many affected women seek medical help. This study aimed to evaluate the feasibility of case finding and opportunistic intervention of SUI at a public Well Women Clinic in Macau, China.

Method:

A convenience sample of 408 consecutive female patients aged 30–50 years filled in the Urogenital Distress Inventory Short Form and the Incontinence Impact Questionnaire Short Form. They were also asked reasons for not seeking for medical help. The patients with incontinence were educated on pelvic floor muscle exercise during the gynecological examination.

Results:

SUI was reported by 153 (37.5%) women, of whom 47 (30.7%) had impaired quality of life despite mild symptoms. Of the SUI patients, 52.9% thought that incontinence was inevitable with age, 22.2% believed that they should cope with the problem themselves, 13.7% thought that no useful treatment was available, and 3.9% had sought medical advice before. After learning pelvic floor muscle exercise for 4 to 6 months, 9.8% of SUI patients had complete relief of the symptoms, 47% partial improvement, and 17.6% no significant change.

Conclusions:

SUI with impaired quality of life was common before menopause. Very few affected women sought medical help. Opportunistic case finding and education about pelvic floor exercise in a Well Women Clinic were effective in the detection and treatment of the silent SUI.

Introduction

The International Continence Society defines stress urinary incontinence (SUI) as “the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing.”¹ It is the most common form of female urinary incontinence,^2

–5 though the prevalence varies among different age groups, ethnic populations, and studies.^2,3,6 The prevalence peaks in the fifth decade,^2,6 but there are few studies of women's SUI specifically in women before age 50. A study of women aged 31–54 years attending a noncancerous gynecology clinic in the United States showed a prevalence of 39.4%.⁵ Other studies have included women aged 20 or above in the community, with some divided study populations into different age groups. These studies often showed a much lower prevalence in women younger than 50 years: 12.2% in Norway,⁷ 14.6% in the United States,⁸ 15.5% in Egypt,⁹ and 16.0% in Japan.¹⁰ A gynecology clinic where the prevalence seems to be higher could be an effective place to detect SUI.

Though their quality of life (QOL) might be diminished by the urinary incontinence, affected women seldom seek medical help.^2,4,11
–13 The reasons are mainly the belief that little or nothing can be done and embarrassment about consulting their doctors.^2,11,13,14 In fact, pelvic floor (Kegel) exercise has been shown to improve continence,^15,16 and it can be effectively taught in primary care.^1,14,17,18 We believe that both patients and doctors would feel comfortable discussing incontinence during a routine gynecological examination like those in a Well Women Clinic. The occasion is also optimal for teaching pelvic floor exercise to incontinent women.

Given that (a) SUI is the most common type of incontinence among young adult women, (b) this group of women is more likely to be physically active, and (c) early pelvic floor training would improve SUI, we aim to study the feasibility of case finding of SUI and opportunistic teaching of the pelvic floor exercise in a Well Women Clinic in primary care. Our target population was young women before the age of 50.

Methods

This was a prospective cross-sectional survey of consecutive patients attending the Well Women Clinic run by one of the authors (SFN) at a public Health Center in Macau, China, from November 2011 to March 2012. The Health Center serves 22.8% of the Macau population. The nurse at the registration counter explained the aim of the study to all women aged 30–50 years who attended the clinic. Those who consented to participate completed a questionnaire, with the nurse's help if necessary, and were then interviewed by the same author.

The questionnaire consisted of four parts: the Urogenital Distress Inventory Short Form (UDI-6), the Incontinence Impact Questionnaire Short Form (IIQ-7), whether doctors were previously consulted, and the patient's demographic data (age, education level, body mass index [BMI], operation history, exercise habit, and parity). Education was classified in three levels: primary or below, secondary, and tertiary. The BMI was dichotomized into normal (19–25) and above normal. The incontinent women who had not sought medical help could choose the explanatory reason(s) from the following list: one should cope with the problem by oneself, incontinence was inevitable with advancing age, the woman was too embarrassed to go to the doctor, no useful treatment available, and others.

This study used the UDI-6 and the IIQ-7¹⁹ because the translated Chinese versions were validated.²⁰ Women who answered “yes” to the question “leakage from effort or exertion” were categorized as having SUI. The severity of stress incontinence was classified as slight (leakage during ordinary to provocative activities, sneezing, and coughing), moderate (leakage during jumping, running, stair climbing, and carrying heavy things), and severe (leakage during dish washing, walking, and daily routines).

The IIQ-7 assesses the QOL specifically related to urinary incontinence. It covers seven domains: traveling ≥30 minutes away from home, social activities, emotional health, entertainment activities, household chores, feelings of depression, and physical recreation. It has a 4-point rating scale: 0 (not at all), 1 (slightly), 2 (moderately), and 3 (greatly). Thus a composite score can be computed with higher scores indicating poorer QOL (the possible maximum being 21).

The woman found to have incontinence was taught the pelvic floor exercise (2- to 3-second squeezes with 10–15 contractions per session and at least three sessions per day). During the pelvic examination, while the author's (SFN) fingers were in the woman's vagina, the woman was asked to contract her pelvic muscles. The woman was notified when she had contracted the correct muscles. It was emphasized that the exercise would take several weeks for noticeable effects, and a handout was given at the end of the consultation. The women with SUI were contacted by telephone 4 to 6 months later. They were asked if their continence had improved and by how much (complete, partial, none). If there was no improvement, they were asked whether the exercise was being done and how it was done.

The study was approved by the Health Bureau, Macau government.

Statistical analysis

We searched the computerized records of the Health Center for the diagnosis of urine incontinence (code U04, International Classification of Primary Care) among the female adults who came for health checks at the Government Employee Clinic. In the previous 6 months, the prevalence was around 38%. We estimated the sample size to be 368, with 40% as the presumed prevalence, 5% margin of error, 80% power, 5% type I error, and 95% confidence level. We decided to recruit around 400 women. We used the Student's t-test, chi-squared test, and logistic regression for testing any significant association between or among the variables. A p-value of<0.05 was taken as statistically significant.

Results

In total, 408 women were approached; all consented and completed the questionnaire. The age ranged from 30 to 50 years (mean 42.6±5.89) and the mean parity was 1.6 (±0.92). There were 153 women (37.5%, 95% confidence interval [CI]: 32.9%, 42.3%) with stress urinary incontinence; 74 (18.1%) had only SUI without other incontinence types. The women with SUI were significantly older than those without (ages 44.5±4.84 vs. 41.4±6.16, respectively, t=−5.649, p<0.001). The occurrence of SUI increased significantly with age (Table 1, p<0.001, OR: 1.099, 95% CI: 1.057, 1.143), while a normal BMI was a protective factor (p=0.042, OR: 0.231, 95% CI: 0.056, 0.946). Educational level, parity, operation history, and exercise habit were not associated with SUI.

Table 1.

Prevalence of Stress Urinary Incontinence by Age Groups (n=153)

Age (years)	Mild SUI	Moderate SUI	Severe SUI
30–34	6 (4.3%)	1 (7.1%)	0
35–39	16 (11.6%)	0 (0.0%)	0
40–44	38 (27.5%)	1 (7.1%)	0
45–50	78 (56.5%)	12 (85.7%)	1 (100.0%)
Total	138 (100.0%)	14 (100.0%)	1 (100.0%)

SUI, stress urinary incontinence.

QOL was impaired in 47 (30.7%) of the 153 SUI women. Most women reported mild functional impairment. The impairment was slight in 138 (90.2%), moderate in 14 (9.2%), and severe in one (0.7%). The mean patient-graded severity was 0.83±1.67 (ranging 0–10). The most frequent domains of impairment were emotion and outdoor health (Table 2).

Table 2.

Impairment of Quality of Life Among Women with Stress Urinary Incontinence (n=153)

Questions in IIQ-7	None (%)	Mild (%)	Moderate (%)
Home IIQ	135 (88.2)	18 (11.8)	0 (0.0)
Physical IIQ	144 (94.1)	9 (5.9)	0 (0.0)
Entertainment IIQ	144 (94.1)	7 (4.6)	2 (1.3)
Outdoor IIQ	129 (84.3)	22 (14.4)	2 (1.3)
Social IIQ	142 (92.8)	11 (7.2)	0 (0.0)
Emotion IIQ	118 (77.1)	34 (22.2)	1 (0.7)
Depression IIQ	138 (90.2)	14 (9.2)	1 (0.7)

IIQ, incontinence impact questionnaire.

Only six (3.9%) women had previously disclosed their SUI to doctors who offered no useful treatment, however. The most common reason for not seeking medical help was the belief that incontinence was inevitable with age (Table 3), followed by the belief in self-coping.

Table 3.

Reasons for Not Seeking Medical Help (n=147)

Reason	Frequency (%)
Self cope	34 (23.1)
Incontinence inevitable	81 (55.1)
Too embarrassed	5 (3.4)
No useful treatment	21 (14.3)
Others	6 (4.1)

All the 153 SUI women were taught on pelvic floor exercise. After 4 to 6 months, 138 women could be contacted (response rate 90.2%). About 10% had complete relief (Table 4), and nearly 50% had partial improvement. However 15.7% did not practice the exercise. Of the 114 women who did the pelvic floor exercise, 27 had no improvement. They were significantly older in age (46.5±4.45 vs. 43.5±5.04, t=−2.8, p=0.007) than those with complete or partial improvement. Also, no improvement was more likely in women with mixed incontinence (23 out of 67) than women with pure SUI (4 out of 47, χ²=10.187, p=0.001). Education level, BMI, parity, operation history, and exercise habit were not significantly associated with improvement. Women who did not do the pelvic floor exercise were significantly more likely to have a lower total score of IIQ-7 (0.13±0.448 vs. 1.04±1.860, t=2.399, p=0.018).

Table 4.

Self-Reported Outcome (n=153)

	Frequency (%)
Complete relief of symptoms	15 (9.8)
Partial improvement	72 (47.0)
No significant change	27 (17.6)
Didn't practice the exercise	24 (15.7)
Couldn't be contacted	15 (9.8)

Discussion

This study of 408 female patients (aged 30 to 50 years) at a public Well Women Clinic in Macau showed a prevalence of 37.5% for SUI. The rate increased significantly with advancing age and being overweight. Of 153 women with SUI, 90.2% had mild symptoms, but 30.7% had diminished QOL. After learning pelvic floor muscle exercise during the pelvic examination, 9.8% of SUI patients had complete and 47% had partial relief of symptoms in 4 to 6 months.

The prevalence of SUI in this study was high, similar to the 39.4% reported from a gynecological clinic in the United States.⁵ This supports the Well Women Clinic as a favorable place to detect undiagnosed SUI. Contrary to most other studies, we found no association between SUI and parity probably because most women in the present generation do not usually have more than two children. On the other hand, the association of SUI with only age and obesity was not unique in this study but was also observed in Japan where the average family size was <3 members after year 1990.^10,21 Although the affected women in this study had on average mild symptoms and mildly impaired QOL, a substantial proportion of 30.7% had diminished QOL. Early intervention for the young women could bring more years of better QOL and prevent or delay further deterioration of this condition.

Only six (4.1%) women had consulted their doctors. Due to this small number, we did not analyze the factors associated with seeking medical help. For the reasons of not seeking help, half (55.1%) of the SUI women believed that incontinence was inevitable with age and 23.1% believed that they could cope. These two reasons were also the important ones found in other studies.^2,11,13 The mild symptoms and mildly impaired QOL observed in this study might explain the low consultation rate. It is to be noted that just 3.4% women in this study felt embarrassed, while embarrassment was often reported in other studies to be an important reason for not seeking help.^2,11,22,23 Since the medical staff at the Well Women Clinic were female, the patients might have felt more comfortable in disclosing their problem. This further supports the Well Women Clinic as the suitable place for detecting silent incontinence.

Pelvic floor muscle exercise is commonly recommended as the first-line therapy for women with SUI.^15,16,24 For the success of this exercise, the correct technique should be taught and the training supervised.¹⁵ The pelvic examination at the Well Women Clinic provides a good opportunity training the correct technique. Accordingly, nearly 60% of the SUI women in this study had improvement in 4 to 6 months. The partial improvement might be partly due to the mixed incontinence in our recruits. The noncompliance rate of 15.7% was relatively low compared with other studies,^25
–27 but the follow-up time was also relatively short, not more than 6 months. It is uncertain if the training at the Well Women Clinic leads to better long-term compliance.

The willingness of women at the Well Women Clinic to disclose their incontinence was shown by the 100% response rate in this study and the low rate of feeling embarrassed in consulting for the incontinence. Together with the relatively high prevalence of SUI and good results from teaching the pelvic floor muscle exercise, this study strongly supports the role of the Well Women Clinic for screening and initial management of SUI.

Limitation

This study recruited women from a Well Women Clinic and not from the community. The findings might be different from those of the local general population. Since there were no local data on female incontinence, we could not make any comparison. Secondly, we did not design a control group for the pelvic muscle exercise since our aim was to test the feasibility and to estimate the outcome of the opportunistic intervention. Thirdly, we asked the women whether and how the pelvic exercise was done without any formal measurement of compliance. The effectiveness of the exercise has been well tested, but our results were limited by the relatively short follow-up.

Conclusion

SUI is prevalent among young adult women attending the Well Women Clinic, about one third of whom had impaired QOL. Opportunistic case finding of SUI and education of pelvic floor exercise are feasible and effective.

Footnotes

Author Disclosure Statement

The authors declare no conflict of interest and no financial interest connected with this paper.

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