Prevalence and Factors of Urinary Incontinence among Postmenopausal Women Attending the Obstetrics and Gynecology Outpatient Service in a Tertiary Health Care Center in Kochi, Kerala.

INTRODUCTION: Urinary incontinence has an immense impact on the social and mental health, and the quality of life of a person. Women neither come forward seeking medical consultation nor do they discuss about their incontinence openly, and the condition remains underestimated in the society. Hence, this study was undertaken to assess the type of urinary incontinence in postmenopausal women visiting obstetrics and gynecology (OBG) outpatient in a tertiary health care sector and to determine the risk factors of urinary incontinence.
MATERIALS AND METHODS: All postmenopausal women of age 45-90 years visiting the OBG Department of Amrita Institute of Medical Sciences in the months of May and June 2018 were assessed for urinary incontinence. QUID questionnaire - a six item urinary incontinence diagnostic questionnaire to diagnose and differentiate stress, urge and mixed incontinence - was used.
RESULTS: The prevalence of urinary incontinence was 26.47%, stress urinary incontinence contributing 13.9%, mixed urinary incontinence 7.2%, and urge urinary incontinence 5.4%. Chronic cough, recurrent urinary tract infections (UTI), and prolonged duration of labor were independent risk factors associated with urinary incontinence in postmenopausal women.
CONCLUSION: Stress incontinence was found to be the major type of urinary incontinence in the postmenopausal women. Those having history of chronic cough, prolonged duration of labor, and recurrent UTI should be screened regularly for urinary incontinence. Copyright:

INTRODUCTION

Urinary incontinence has an immense impact on the social and mental health, and the quality of life of a person. Women neither come forward seeking medical consultation nor do they discuss about their incontinence openly, and the condition remains underestimated in the society. There are many unreported cases in the population as per se veral hospital-based studies done in India before.[1] The knowledge about the risk factors of urinary incontinence in this population will help us to take measures to reduce the burden of the condition.

The literature review regarding prevalence, type, and risk factors of urinary incontinence among postmenopausal women in Kerala is minimal. In most of the studies done till now, the objective was to measure the quality of life of women affected due to urinary incontinence, but the actual prevalence of urinary incontinence still remains largely hidden.

Urinary Incontinence means loss of voluntary control to pass urine. Pathophysiology lies in the epithelial changes in the urethral mucosa due to hormonal changes in the body of the woman after menopause. After menopause, there is cessation of ovarian function which results in estrogen deficiency. Hormonal changes cause incontinence by thinning of the urethral mucosa, loss of urethral closure pressure and bladder dysfunction, sphincter dysfunction, or a combination of both.[2]

There are three types of urinary incontinence – stress, urge, and a mixture of stress and urge incontinence (mixed) incontinence.

Stress incontinence or the sphincteric incontinence may occur during normal activities such as laughing, crying, coughing, climbing stairs, or lifting heavy objects.

Stress may occur during coughing, sneezing, straining while passing urine or stools, carrying heavy objects, bending down, or doing heavy exercise. Urge incontinence or the bladder incontinence results in symptoms such as leaking or wetting undergarments before entering the bathroom and increased frequency of micturition.[34]

The risk factors associated with urinary incontinence in the literature were age, parity, type of delivery, previous hysterectomy, smoking habits, body mass index (BMI), diabetes status, chronic cough, constipation, intake of drugs, tea, caffeine and alcohol, and physical activities.[567] As help-seeking behavior is seen to decrease with age and severity of the condition, identification of the problem and the risk factors is essential. Based on the identified risk factors, health services available, attitude, and need to treat the condition, women seek medical consultation and are treated.[8]

Hence, the study is carried out to estimate the prevalence, the types, and risk factors associated with urinary incontinence among postmenopausal women visiting the obstetrics and gynecology (OBG) outpatient (OP) in a tertiary health care center in Kochi.

MATERIALS AND METHODS

After obtaining approval from the Ethical Committee of Amrita Institute of Medical Sciences, a hospital-based cross-sectional study was carried out in the OBG Department of Amrita Institute of Medical Sciences which is a tertiary health care sector in Kochi, Kerala. Postmenopausal women of age 45–90 years, who came to the OBG department, were studied. All women with severe illness, mental illness, and those who refused to give consent were excluded. The sample size was calculated from the percentage of women who were incontinent (21.87%) in a study by Danforth et al., and with 95% confidence interval and 20% relative precision, as 345.[5]

All postmenopausal women of age 45–90 arriving to the gynecology OP were informed, and consent was taken. Consent was obtained from the respondent or a respondent-approved family member through signature, when the respondent did not know how to put a signature and did not want to give a thumb impression.

The details of sociodemographic factors, amount of physical exercise, habits of tobacco smoking/chewing and alcohol, use of beverages, use of medications, and obstetricgynecological predisposing factors were assessed through an interview schedule. The type of incontinence was diagnosed using QUID questionnaire, a validated 6 questionnaire which is used to calculate the stress incontinence score, urge incontinence score, and mixed incontinence score. 389 patients were interviewed in the 2 months of duration May and June, 2018. The data were collected and compiled in MS Excel. The data were analyzed in SPSS 16 trial version. After estimating the prevalence, a secondary case control analysis was done. Bi-variable analysis with urinary incontinence was done using Pearson's Chi-square test. Multivariable analysis was done using binary logistic regression.

RESULTS

The mean age of the study population was 60.2 (8.1) with a range of 45–87 years. BMI had a range of 13.9–44.4 with a mean of 24.95 (4.1). Seventy-two percentage of the study participants were homemakers and 18% were professionals. Manual laborers and factory workers constituted only 3.6% and the rest were retired hands. Mean parity was 2.33 (1.1) and mean duration of labor was 8.06 (10.94). Distribution of other obstetric factors, comorbidities, habits, and medications is given in Table 1.

Table 1

Distribution of study participants based on obstetric factors, comorbidities, habits and medications (n=389)

Factors	n (%)
Hysterectomy	75 (19.2)
Pelvic organ prolapse surgery	12 (3.08)
Adnexal surgery	366 (94.08)
Dilatation and curettage	326 (83.8)
Type of delivery
Vaginal delivery	314 (80.71)
LSCS	45 (11.56)
Vaginal delivery and LSCS	16 (4.11)
Not applicable	14 (3.59)
Delivery assisted by
Obstetrician	343 (88.17)
Local midwife	31 (7.96)
Medical officer	1 (0.25)
Not applicable	14 (3.59)
Physical activity IPAQ category
Active	299 (76.86)
Inactive	90 (23.14)
Comorbidities
Diabetes mellitus	128 (32.9)
Chronic cough	16 (4.11)
Recurrent UTI	47 (12.08)
Constipation	61 (15.68)
Caffeine intake
Tea	280 (71.97)
Tea and coffee	67 (17.22)
Coffee	27 (6.94)
Nonuser of tea or coffee	15 (3.85)
Medications
Diuretics	378 (97.17)
Anti-hypertensives	252 (66.67)

LSCS: Lower segment caesarean section, UTI: Urinary tract infection, IPAQ: International Physical Activity Questionnaire

The total prevalence of urinary incontinence in our study was 26.47%. Stress incontinence accounted for 13.9%, followed by mixed urinary incontinence, contributing 7.2% and finally, urge urinary incontinence - 5.4%, as depicted in Figure 1. Proportion of urinary incontinence in different age groups is depicted in Figure 2.

Figure 1

Distribution of different types of urinary incontinence (%)

Figure 2

Proportion of urinary incontinent and normal individuals in different age groups

Of 15 variables studied, only 4 were found to be significant using bivariable analysis. These variables were chronic cough (P = 0.006), recurrent urinary tract infections (UTI) (P < 0.001), duration of labor (P = 0.029), and the type of delivery (0.034) as depicted in Table 2. BMI did not show any association with urinary incontinence.

Table 2

Bivariable analysis - risk factors associated with urinary incontinence

Variable	Category	P	Crude OR	95% CI of Crude OR
Age	<75	0.174	0.637	0.331-1.225
Occupation	Homemaker	0.081	0.590	0.324-1.073
Physical activity	Inactivity	0.159	1.146	0.864-2.417
Parity	Unipara	0.100	0.518	0.234-1.147
Diabetes	No	0.135	0.700	0.438-1.119
Age at menopause	>45	0.148	1.433	0.880-2.335
Chronic cough*	Yes	0.006	3.816	1.383-10.530
Recurrent UTI*	Yes	<0.001	4.201	2.273-7.989
Duration of labour*	<8 h	0.029	0.600	0.379-0.950
Type of delivery*	Vaginal	0.034	2.553	1.47-6.222

*Significant at 95% confidence level. Chi-square test was used. P<0.05 was considered as significant. OR: Odd’s ratio, CI: Confidence interval, UTI: Urinary tract infection

Multivariable analysis was done using binary logistic regression - stepwise backward elimination method. All the variables having P value 0.2 or less were put in the model which included age, occupation, parity, menopausal age, duration of labor, type of delivery, diabetes mellitus, chronic cough, recurrent UTI, and physical activity. Chronic cough, recurrent UTI, and duration of labor were found to be independent risk factors as depicted in Table 3. The Cox and Snell R2 was found to be 0.076.

Table 3

Mutivariable analysis - independent risk factors of urinary incontinence

Variable	Category	P	Adjusted OR	95% CI of Adjusted OR
Chronic cough*	Yes	0.014	3.843	1.315-11.229
Recurrent UTI*	Yes	<0.001	4.110	2.164-7.808
Duration of labour*	<8 h	0.022	0.570	0.352-0.921

*Significant at 95% confidence level. Chi-square test was used. P<0.05 was considered as significant. OR: Odd’s ratio, CI: Confidence interval, UTI: Urinary tract infection

DISCUSSION

The total prevalence of urinary incontinence was 26.47%. Majority of the incontinent women comprised by stress type that accounted for 13.9%, followed by mixed urinary incontinence, contributing 7.2% and finally by urge urinary incontinence - 5.4%.

Urinary incontinence is an important multifactorial health condition that can deteriorate one's quality of life. One thing we noticed during this study was that most of the women were oblivious of their condition and considered themselves as “normal” and considered urinary incontinence, as a “natural consequence” of aging. This may be the main reason why it always goes unnoticed and underreported and this clearly depicts the “iceberg phenomenon.”

In this study, prevalence of urinary incontinence was more or less similar in women aged 75 and above (27%), women between 45 and 59 years (26.8%) and 60 and 74 years (25%). In a study done by Nojomi et al., urinary incontinence was higher among age group > 55 years.[6] Another study done by Singh et al. showed a low prevalence in age groups < 20 (7.6%), 31–40 years (11.6%) and > 70 years (20%) and the highest incidence among 61–70 years (42.8%).[1] Chronic cough, recurrent UTI, and duration of labor were obtained as independent risk factors.

Chronic cough has a direct association with urinary incontinence.[9] If there is a sudden increase in the intra-abdominal pressure that may produce the exhaustion of pelvic floor muscles. Even a momentary relaxation of these muscles may leak urine. Recurrent UTIs may be treated as a trivial matter by the community for which they resort to home remedies and drinking fluids in plenty and hardly taken seriously as a medical condition. But it is widespread and requires a proper diagnosis and treatment.[10]

Prolonged labor may act as a direct cause for pelvic floor dysfunction like nerve or muscle damage, direct tissue stretching, and disruption. A gynecologist's intervention during labor in case it is prolonged will include episiotomy which prevents harmful perineal tears and reduces the risk of perineal weakness. This may decrease the risk of pelvic organ prolapse and urinary incontinence.[11] However, there are many other recent studies saying episiotomy is not effective. Prolonged labor have been shown by other studies also as an associated factor for developing urinary incontinence, and physiological changes during delivery are attributed as a potential cause.[12]

While this study shows a decrease in the incidence of urinary incontinence among those who underwent cesarean section, hence concluding that it is a protective factor, the study done by Nojomi et al. brought out no difference between those who underwent previous caesarean section and nulliparous women. However, in the same study, the previous vaginal delivery was a risk factor.[6] The significance of caesarean section in our study obtained in bivariable analysis was lost in multivariable analysis though. This may have been due to the presence of duration of labor as a variable in the model which came out as an independent risk factor. Longer durations are invariably associated with vaginal delivery.

Previous studies have shown that multiparity, diabetes mellitus, obesity, hysterectomy and other pelvic surgeries, physical activity, constipation, and high caffeine intake to be high risk factors of urinary incontinence.[12413] In another study done by Kiran Panesar in the USA, pharmacologic agents including oral estrogens, alpha-blockers, sedatives, antidepressants, antipsychotics, angiotensin-converting enzyme inhibitors, loop diuretics, nonsteroidal anti-inflammatory drugs, and calcium channel blockers have been implicated to cause the onset and some degree of exacerbation of urinary incontinence.[3] Our study did not show any of these associations which might have been due to our secondary case–control mode of analysis rather than going for a case–control study.

Limitations

The sample was not sufficient to bring out a relationship between urinary incontinence and all the known risk factors as the study was primarily to estimate the prevalence. As the study population chiefly consisted of women below 60 years of age, the contribution of age as a risk factor was reduced. In this study, the information regarding factors such as delivery time, physical inactivity, and previous drug intake might have suffered due to recall bias. Women feel embarrassed and humiliated to disclose about urinary incontinence which is why many are reluctant to come forward and seek treatment or ask another family member for help.

CONCLUSION

The prevalence of urinary incontinence in our study is 26.47% and is mainly contributed by stress incontinence. This study revealed chronic cough, recurrent UTI, and prolonged duration of labor to be independent risk factors for the development of urinary incontinence in postmenopausal women.

Recommendations

Urinary incontinence is a trivialized matter by the society which requires great concern and attention. Knowledge among women about the risk factors may help to reduce the incidence, or at least the severity of the condition by seeking early treatment, thereby improving the quality of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.