Urinary incontinence in female outpatients in Singapore
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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.
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.
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).
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.
KeywordsUrinary incontinence Prevalence Risk factors Healthcare-seeking behaviour Quality of life
The International Continence Society (ICS) defines urinary incontinence (UI) as the complaint of any involuntary leakage of urine . It causes a great deal of distress and embarrassment, as well as a heavy burden and high cost on both individuals and societies . UI is a more common complaint in women than in men. The prevalence of UI varies widely in female populations, ranging from 4.8%  to 69.3% , with the lowest prevalence in Singaporean women . 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 . 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
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 . 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 . 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 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.
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
Characteristics of participants
Age (years), mean (SD)
Body mass index (kg/m2), mean (SD)
Comorbidity, n (%)
Ethnicity, n (%)
Education level, n (%)
No formal education
Vaginal delivery, n (%)
Walking ability, n (%)
Sexually active, n (%)
Prevalence of UI
Prevalence of UI in various subgroups of women
Number of women
Prevalence of UI (%)
95% CI (%)
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
Unadjusted odds ratios (OR) of potential risk factors for UI
Number of women
Body mass index
No formal education
Adjusted ORs of risk factors for UI in the final model
Attitudes towards UI
Attitudes towards UI among the participants
Agree, n (%)
UI is a normal part of ageing
UI cannot be treated
If I had UI, I would not discuss it with anyone
If I had UI, I would seek help from a doctor
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
QoL scores in different UI severity groups
Number of women
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%) . 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%) , a community-based study in Australia (42%) , and a study in a single medical practice in the UK (40%) . 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.  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  and the United Arab Emirates , 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.
Compliance with ethical standards
Conflicts of interest
This was a questionnaire study, so only verbal consent was needed.
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