Urinary incontinence in female outpatients in Singapore

  • Rui Luo
  • Wei Dai
  • Lee Hua Tay
  • Foo Cheong Ng
  • Li-Tsa Koh
Original Article
  • 126 Downloads

Abstract

Introduction and hypothesis

The aims of this study were to determine the prevalence, symptom characteristics, risk factors and impact on quality of life (QoL) of urinary incontinence (UI) in female outpatients in Singapore, to describe the attitudes of these women towards UI, and to investigate the barriers to healthcare-seeking behaviour in symptomatic women.

Methods

This was a cross-sectional study in a convenience sample and 249 women enrolled from outpatient clinics. A modified self-administered questionnaire which included two validated instruments (the International Consultation on Incontinence Questionnaire-Urinary Incontinence short form and the Incontinence Impact Questionnaire-7) was used.

Results

Questionnaires from 230 women were included in the analysis. The overall prevalence of UI was 41.74% (95% CI 35.49–48.26%). Most of the symptomatic women suffered from mild UI and the most common subtype was stress UI. Age (OR 1.03, 95% CI 1.00–1.05), vaginal delivery (OR 2.67, 95% CI 1.43–4.97) and being sexually active (OR 2.41, 95% CI 1.31–4.43) were associated with UI. Among symptomatic women, only 41.25% (95% CI 30.82–52.53%) had sought medical attention before. The most common barrier to healthcare-seeking behaviour was embarrassment. The median QoL score was 33.33, indicating a mild impact of UI on QoL. QoL score was associated with UI severity (p < 0.001).

Conclusions

Despite the high prevalence of UI, only about 41% of UI sufferers had sought medical attention before. Common barriers included embarrassment, fear of surgery and misconceptions. This study emphasizes the need for policy development for UI prevention and management in Singapore.

Keywords

Urinary incontinence Prevalence Risk factors Healthcare-seeking behaviour Quality of life 

Introduction

The International Continence Society (ICS) defines urinary incontinence (UI) as the complaint of any involuntary leakage of urine [1]. It causes a great deal of distress and embarrassment, as well as a heavy burden and high cost on both individuals and societies [2]. UI is a more common complaint in women than in men. The prevalence of UI varies widely in female populations, ranging from 4.8% [3] to 69.3% [4], with the lowest prevalence in Singaporean women [3]. Despite the high prevalence and generally effective treatment, only a minority of women with UI seek medical attention. Published articles on healthcare-seeking behaviour indicate that this is a common phenomenon in both developing and developed countries. Therefore, health system access factors alone cannot account for the low rates of healthcare-seeking behaviour. Many authors regard embarrassment and misconceptions as the most important barriers to seeking healthcare [5, 6, 7].

The available prevalence data on UI in women in Singapore (which was much lower than other countries) was published more than 20 years ago [3]. Since then, life expectancy and lifestyles have changed a lot. It is expected that the prevalence and characteristics of UI in women would have changed accordingly.

Materials and methods

Singhealth Centralised Institutional Review Board (CRIB) exemption was obtained before the start of this study. This cross-sectional study included women attending the ear-nose-throat outpatient clinics of Changi General Hospital in Singapore. A total of 249 consecutive female outpatients over 21 years of age were enrolled between February 2015 and April 2015 (Fig. 1). Data were gathered from all participants using a self-designed questionnaire. A trained nurse assisted participants as needed.
Fig. 1

Study flow chart

Questionnaire

A modified self-administered questionnaire was used which incorporated two international standard questionnaires: the International Consultation on Incontinence Questionnaire-Urinary Incontinence (ICIQ-UI) short form and the Incontinence Impact Questionnaire-7 (IIQ-7). According to the European Association of Urology, both of these questionnaires are classified as category A [2]. The ICIQ-UI short form has four items regarding UI frequency, amount, perceived impact on daily life, and subtypes of UI. IIQ-7 is a seven-item quality of life (QoL) assessment instrument specific to UI, with four domains: physical activity, travel, social activities and emotional health. According to the original developer of IIQ-7, researchers may add items to IIQ-7 from the long form versions [8]. Since sexual activity is closely related to UI and QoL, we added “sexual relations” (the 18th item in the long form version) to the questionnaire.

Sample size calculation

We set the confidence level at 95% and the confidence interval at 15. The sample size for barriers to healthcare-seeking model was 43. The prevalence of UI and the rate of not seeking healthcare were expected to be 30% and 60%, respectively. Therefore, we planned to enrol 240 participants.

Statistical analyses

Statistical analyses included descriptive analysis, comparison tests, bivariate and multivariate analyses. We used descriptive analysis to show the distributions of demographic characteristics and attitudes towards UI in women with and without UI experience. Categorical variables were compared using the chi-squared test or Fisher’s exact test. Continuous variables were compared using analysis of variance or the unpairedt test. Ordinal variables were compared using the Kruskal-Wallis test or the Wilcoxon Rank Sum test. Risk factors were estimated using logistic regression models. Possible risk factors were explored using a bivariate logistic model. Multiple logistic regression analysis was used to control for potential confounders. Variables that were significantly related to outcomes in the bivariate model were included in a multivariate model. The odds ratios (OR) and 95% confidence intervals (95% CI) were estimated. Backward stepwise regression analyses were performed to exclude variables with p values >0.1. All statistical assessments were two-sided and p values <0.05 were considered statistically significant. Statistical analyses were performed using Stata software 13.0.

Results

A total of 408 questionnaires were given out and 249 were returned. The response rate was 61%. Of the returned questionnaires, 19 were excluded from the analysis because of missing data on UI status. Therefore, 230 participants were included in the analysis. Among them, 96 confirmed that they had experienced UI before.

Demographic characteristics of participants

The women included in the study had a mean age of 40 years (range 21–85 years) and a mean body mass index (BMI) of 24.73 kg/m2, and 30 (13.04%) were obese. With regard to ethnicity, 97 women (42.17%) were Chinese, 94 (40.87%) were Malay, and 21 (9.13%) were Indian. There were significant differences in age, BMI, education level, vaginal delivery status and sexual activity between women with and without UI. Table 1 shows the characteristics of the participants with and without UI.
Table 1

Characteristics of participants

Variable

With UI

Without UI

p value

Age (years), mean (SD)

43.72 (1.39)

37.59 (1.19)

0.001*

Body mass index (kg/m2), mean (SD)

25.88 (0.53)

23.91 (0.45)

0.005*

Comorbidity, n (%)

 Yes

22 (23.40)

24 (18.75)

0.407

 No

72 (76.60)

104 (81.25)

Ethnicity, n (%)

 Chinese

45 (46.88)

52 (38.81)

0.079

 Malay

42 (43.75)

52 (38.81)

 Indian

5 (5.21)

16 (11.94)

 Other

4 (4.17)

14 (10.45)

Education level, n (%)

 No formal education

6 (6.25)

4 (2.99)

0.011*

 Primary school

6 (6.25)

5 (3.73)

 Secondary school

46 (47.92)

44 (32.84)

 Junior college

28 (29.17)

47 (35.07)

 University

10 (10.42)

34 (25.37)

Vaginal delivery, n (%)

 Yes

70 (72.92)

55 (41.04)

<0.001*

 No

26 (27.08)

79 (58.96)

Walking ability, n (%)

 Yes

91 (94.79)

120 (92.31)

0.592

 No

5 (5.21)

10 (7.69)

Sexually active, n (%)

 Yes

62 (65.26)

58 (44.27)

0.002*

 No

33 (34.74)

73 (55.73)

*p < 0.05

Prevalence of UI

The overall prevalence of UI was 41.74% (96 of 230, 95% CI 35.49–48.26%). Prevalence increased with age, previous vaginal delivery and being sexually active (Table 2).
Table 2

Prevalence of UI in various subgroups of women

Variable

Number of women

Prevalence of UI (%)

95% CI (%)

Age group

 21–39 years

123

33.33

25.51–42.20

 40–59 years

77

51.94

40.75–62.96

 ≥60 years

22

59.09

37.59–77.60

Vaginal delivery

 No

105

24.76

17.38–33.99

 Yes

125

56.00

47.12–64.51

Sexually active

 No

106

31.13

22.98–40.65

 Yes

120

51.67

42.68–60.54

Symptom characteristics

The characteristics of UI symptoms were evaluated in 81 symptomatic women. Only nine women (11.10%) had UI about once a day or more often, and 52 (64.20%) leaked a small amount of urine. The ICIQ-UI short form global score was used to define the severity of symptoms: mild <10, moderate 11–15, severe 16–21. Most women (50, 84.75%) suffered from mild UI. The most common subtype was stress UI (51 women, 64.56%).

Risk factors for UI

Table 3 shows the unadjusted ORs of potential risk factors for UI. Age, education level, previous vaginal delivery and being sexually active were significantly associated with UI. Women aged between 40 and 59 years and more than 60 years had more than twice the risk of developing UI than women aged less than 40 years (OR 2.16, 95% CI 1.21–3.88; OR 2.89, 95% CI 1.14–7.31, respectively). University graduates had a lower risk of developing UI (OR 0.20, 95% CI 0.05–0.83) than women with no formal education. Women who had previous vaginal delivery had a significantly higher risk of developing UI than those without a history of vaginal delivery (OR 3.87, 95% CI 2.19–6.82). Women who were sexually active had a higher risk of developing UI than those who were not sexually active (OR 2.36, 95% CI 1.37–4.08).
Table 3

Unadjusted odds ratios (OR) of potential risk factors for UI

Variable

Number of women

Unadjusted OR

95% CI

p value

Age (years)

222

1.85

1.22–2.79

0.003*

Age groups

 21–39 y

123

Reference

  

 40–59 y

77

2.16

1.21–3.88

0.010*

 ≥60 years

22

2.89

1.14–7.31

0.025*

Body mass index

220

0.94

0.70–1.25

0.660

Comorbidity

 No

176

Reference

  

 Yes

46

1.32

0.69–2.54

0.399

Ethnicity

 Chinese

97

Reference

  

 Malay

94

0.93

0.53–1.65

0.812

 India

21

0.36

0.12–1.06

0.065

 Others

18

0.33

0.10–1.08

0.066

Education level

 No formal education

10

Reference

  

 Primary school

11

0.80

0.14–4.53

0.801

 Secondary school

90

0.70

0.18–2.64

0.595

 Junior college/polytechnic

75

0.40

0.10–1.53

0.180

 University

44

0.20

0.05–0.83

0.027*

Vaginal delivery

 No

105

Reference

  

 Yes

125

3.87

2.19–6.82

<0.001*

Walking ability

 No

15

Reference

  

 Yes

211

1.52

0.50–4.59

0.461

Sexually active

 No

106

Reference

  

 Yes

120

2.36

1.37–4.08

0.002*

*p < 0.05

Table 4 shows the adjusted ORs of possible risk factors for UI in the final model. After entering all significant possible risk factors in Table 3 into a multivariate logistic model, education level was not significantly associated with UI. Therefore, education level was omitted from the final model. After adjusting the ORs of possible risk factors, age (OR 1.03, 95% CI 1.00–1.05), vaginal delivery (OR 2.67, 95% CI 1.43–4.97) and being sexually active (OR 2.41, 95% CI 1.31–4.43) were associated with UI. Possible effect modification was explored in the final model. There was an interaction between age and being sexually active. Therefore, an interaction term for age and sexually active was included in the final model. The goodness-of-fit of the final model was tested using Pearson statistics. The test was not significant (p = 0.734), indicating that the final model described the data adequately.
Table 4

Adjusted ORs of risk factors for UI in the final model

Variable

n

Adjusted ORa

95% CI

p value

Age (years)

222

1.03

1.00–1.05

0.028*

Vaginal delivery

 No

105

Reference

  

 Yes

125

2.67

1.43–4.97

0.002*

Sexually active

 No

106

Reference

  

 Yes

120

2.41

1.31–4.43

0.005*

*p < 0.05

aAdjusted for age, vaginal delivery and sexually active

Attitudes towards UI

Table 5 shows the attitudes towards UI among the participants. Compared with women with UI, women without UI were more likely to perceive UI as a normal part of ageing (p = 0.003). Among all the participants, very few regarded UI as an untreatable disease. About 12% of participants would not be willing to discuss their condition with others if they suffered from it. More than 75% of the participants claimed that they would seek help from a doctor if they had UI.
Table 5

Attitudes towards UI among the participants

Attitude

Agree, n (%)

p value

With UI

Without UI

UI is a normal part of ageing

40 (44.44)

81 (65.32)

0.003*

UI cannot be treated

1 (1.11)

6 (4.84)

0.129

If I had UI, I would not discuss it with anyone

11 (12.36)

15 (12.10)

0.558

If I had UI, I would seek help from a doctor

68 (75.56)

99 (79.84)

0.280

*p < 0.05

Barriers to healthcare-seeking behaviour

Among the 81 symptomatic women, only 33 (40.74%, 95% CI 30.82–52.53%) had consulted a doctor about their UI. Of the symptomatic women who had not sought medical attention, 55.32% were too embarrassed to talk about UI. Other main barriers included the fear of having to undergo surgery if UI was diagnosed (44.81%), and considering the symptoms not severe (27.66%).

Healthcare seeking behaviour was associated with attitude towards UI and UI subtype. Symptomatic women who were willing to discuss UI with others and those with urge UI were more likely to seek help. Among symptomatic women who were willing to discuss UI with others, 31 (46.97%) had consulted a doctor about UI, and among those who would not discuss UI with anyone, only 1 (10.00%) sought help (p = 0.038). Concerning UI subtypes, 6 women with urge UI (100%), 17 with stress UI (33.33%), 3 with mixed UI (37.50%), and 50.00% of those with unclassified UI had sought help (p = 0.016). Demographic factors, obstetric history, QoL and UI severity were not significantly associated with healthcare-seeking behaviour.

Impact of UI on QoL

The median of QoL score was 33.3 (IQR 16.7–45.8), indicating a mild impact of UI on QoL. Most symptomatic women considered that UI had no impact or only a slight impact on QoL. QoL was associated with UI severity (p < 0.001; Table 6). Age, education level, BMI, parity, sexual activity, healthcare-seeking behaviour and UI subtype were not significantly associated with QoL.
Table 6

QoL scores in different UI severity groups

UI severity

Number of women

QoL score

Median

Interquartile range

Mild

50

33.3

12.5–37.5

Moderate

6

66.7

66.7–70.8

Severe

3

100.0

75.0–100.0

Discussion

The overall prevalence of UI in this study was 41.74%, which is almost ten times higher than in Singaporean women 20 years ago (4.8%) [3]. However, these two studies were different in terms of study populations and definitions of UI. Our study was a clinic-based cross-sectional study in which the definition of UI used was “the complaint of any involuntary loss of urine”, while the other study was a community-based study in which the definition of UI used was “leakage of urine two or more times in the past month”. Great changes in life expectancy and lifestyle were also associated with the sharp increase in UI prevalence. The overall prevalence of UI in our study is quite close to those found in some studies with large sample sizes in western countries. These include the Nurses’ Health Study II in the USA (43%) [9], a community-based study in Australia (42%) [10], and a study in a single medical practice in the UK (40%) [11]. In all these studies the same definition of UI was used as in our study.

In multivariate logistic regression, age, vaginal delivery and being sexually active were associated with UI. Women of older age, with a history of vaginal delivery and who were sexually active were more likely to have UI. The studies in other countries also showed similar results [9, 12]. Age was found to be associated with UI in this study, but the adjusted OR was 1.03. An OR of 1.03 may not be statistically or clinically relevant. Maserejian et al. [13] found that age was not associated with UI (OR 1.02, p = 0.06).

Despite the high prevalence of UI, the rate of healthcare-seeking behaviour was low. Among symptomatic women, only 41.25% had consulted a doctor before. The most common barrier was embarrassment. More than half of the women who did not seek help admitted that they were too embarrassed to discuss UI. Embarrassment is also a common barrier to seeking healthcare in many UI patients in other countries [5, 6, 7]. Other common barriers explored in this study included fear of surgery, mild to moderate symptoms, and misconceptions (many patients perceived UI as a normal part of ageing). Although some participants in this study considered UI as untreatable, most understood that UI can be treated. In studies performed in Sri Lanka [6] and the United Arab Emirates [7], being “unaware that UI is treatable” was a common barrier to healthcare-seeking behaviour. This indicates that Singaporean women have relatively better disease knowledge than some other populations.

The results of this study are comparable to those found in western countries. This is likely to be due to our use of a standard definition of UI and validated international questionnaires, and that all the main ethnic groups (Chinese, Malay and Indian) in Singapore were included. The results of this study therefore update important epidemiological data on UI in women in Singapore; for example, data on UI prevalence, healthcare-seeking behaviour and the impact of UI on QoL.

However, this study had several limitations. Firstly, this was a cross-sectional study and no causal inferences can be drawn from the results. Secondly, this was a clinic-based study, so the study population may have been different from the general population, and this could have affected the external validity. Thirdly, there might have been bias in this study, including healthy volunteer bias and recall bias. Lastly, the sample size was relatively small and the precision in some comparisons was limited. In the future, we may perform a population-based study using a random sampling strategy.

In Singapore, there is an annual Singapore Continence Week jointly organized by the Society for Continence (Singapore) (SFCS) and the Singapore Urological Association. During the week, public forums and nursing workshops are conducted to increase awareness of UI. The information obtained from this research may be used in our nationwide education programmes. As the last survey on UI in Singapore was performed almost two decades ago, we are eager to present the results of this study. In addition, we hope that eventually we can compare public attitudes towards UI and treatment-seeking behaviour before and after these programmes to evaluate their effectiveness.

In summary, UI is a common disease among women in Singapore. Ageing, vaginal delivery and being sexually active are associated with UI. Among those with UI, only about 41% have sought healthcare before. Misconceptions and barriers to treatment were found to be common, so it is important for government and medical practitioners to develop programmes to increase the public’s awareness of UI as well as access to UI treatment.

Notes

Compliance with ethical standards

Conflicts of interest

None.

Patient consent

This was a questionnaire study, so only verbal consent was needed.

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Copyright information

© The International Urogynecological Association 2017

Authors and Affiliations

  • Rui Luo
    • 1
  • Wei Dai
    • 2
  • Lee Hua Tay
    • 1
  • Foo Cheong Ng
    • 1
  • Li-Tsa Koh
    • 1
  1. 1.Department of UrologyChangi General HospitalSingaporeSingapore
  2. 2.Saw Swee Hock School of Public healthNational University of SingaporeSingaporeSingapore

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