Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women

Association between family income to poverty ratio and nocturia in adults aged 20 years and older: A study from NHANES 2005-2010

BACKGROUND

Nocturia, the most common lower urinary tract symptom (LUTS), significantly impacts socioeconomic factors and individuals' quality of life and is closely related to many diseases. This study utilized data from NHANES 2005-2010 to explore the relationship between family income to poverty ratio (PIR) and the presence of nocturia symptoms in adults aged 20 or older in the United States.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) in 2005-2010, including 6,662 adults aged 20 or older, were utilized for this cross-sectional study. The baseline data was used to display the distribution of each characteristic visually. Multiple linear regression and smooth curve fitting were used to study the linear and non-linear correlations between PIR and nocturia. Subgroup analysis and interaction tests were conducted to examine the stability of intergroup relationships.

RESULTS

Out of the 6,662 adult participants aged 20 or older, 1,300 households were categorized as living in poverty, 3,671 households had a moderate income, and 1,691 households were classified as affluent. Among these participants, 3,139 individuals experienced nocturia, representing 47.12% of the total, while 3,523 individuals were nocturia-free, constituting 52.88% of the total population. After adjusting for all other covariates, it was found that PIR was significantly negatively correlated with nocturia (OR: 0.875, 95%CI: 0.836-0.916 P<0.0001). This trend persisted when PIR was divided into three groups (PIR <1, PIR 1-4, PIR > 4) or quartiles. There was a non-linear negative correlation between PIR and nocturia.

CONCLUSION

Our findings indicated that lower PlR was associated with a higher risk of nocturia in adults aged 20 or older in the United States. These findings highlight the importance of considering socioeconomic factors in preventing and managing nocturia. Nonetheless, further exploration of the causal nexus between these factors was precluded due to the constraints of a cross-sectional design.

Racial Disparities in Sacral Neuromodulation for Idiopathic Fecal Incontinence

IMPORTANCE

Sacral neuromodulation (SNM) is an effective treatment for fecal incontinence (FI). Previous studies found that Black women undergo SNM for urinary incontinence less than White women, but there is less known about racial disparities for FI.

OBJECTIVE

This study assessed differences in Black and White patients' FI treatment; SNM counseling was the primary outcome.

STUDY DESIGN

This was a retrospective cohort study of adult non-Hispanic Black and White patients who received FI treatment at an academic institution from 2011 to 2021. Medical records were queried for treatments, testing, and treating specialties for a 2:1 age-matched cohort of White:Black patients.

RESULTS

Four hundred forty-seven women were included: 149 Black women and 298 age-matched White women. A total of 24.4% (109) of patients had documented SNM counseling, significantly fewer in Black patients (14.8% vs 29.2%, P < 0.001). A total of 5.1% (23) of patients received SNM, less frequent in Black patients (2.7% vs 6.4%, P = 0.003). Among patients with SNM counseling, there was no difference between cohorts. Black patients were less likely to be referred for physical therapy (59.7% vs 77.2%, P < 0.001), sphincter imaging (0.7% vs 5.7%, P = 0.011), and defecography (8.1% vs 17.1%, P = 0.009). Different specialties managed the 2 cohorts. Black patients were less likely to see urogynecology and colorectal surgery (21.5% vs 34.6%, P = 0.004; 9.4% vs 15.4%, P = 0.077). Patients seen by these surgeons were more likely to discuss SNM (48.6% vs 8.5%, P < 0.001).

CONCLUSIONS

There were differences between Black and White patients' FI treatment, including counseling about SNM. Multidisciplinary work is needed to provide equitable education for this life-altering condition.

Referral and Prescription Patterns for Female Patients With Urinary Incontinence

IMPORTANCE

Although behavioral modifications, medications, and other interventions can improve urinary incontinence (UI), many women never receive them.

OBJECTIVES

To better characterize UI treatment patterns in primary care, we examined prescriptions and referrals to pelvic floor physical therapy (PFPT) and specialist physicians within a large Midwestern academic health system.

STUDY DESIGN

Electronic health records were queried to identify a cohort of adult female patients receiving a new UI diagnosis during outpatient primary care visits from 2016 to 2020. Urinary incontinence referrals and referral completion were examined for the overall cohort, and medication prescriptions were examined for women with urgency or mixed UI. Logistic regression was used to assess the association of prescriptions and/or referrals with patient demographics, comorbidities, and UI diagnosis dates.

RESULTS

In the year after primary care UI diagnosis, 37.2% of patients in the overall cohort (n = 4,382) received guideline-concordant care. This included 20.6% of women who were referred for further management: 17.7% to urology/urogynecology and 3.2% to PFPT. Most women who were referred attended an initial appointment. Among those with urgency (n = 2,398) or mixed UI (n = 552), 17.1% were prescribed medication. Women with stress (odds ratio [OR], 3.10; 95% CI, 2.53-3.79) and mixed UI (OR, 6.17; 95% CI, 4.03-9.66) were more likely to be referred for further management, and women diagnosed during the COVID-19 pandemic were less likely to be referred for further care (OR, 0.39; 95% CI, 0.29, 0.48).

CONCLUSION

Only slightly above 1 in 3 women with a new diagnosis of UI in primary care received guideline-based medications or referrals within 1 year, suggesting missed opportunities for timely care.

Black women's perspectives on bladder health: Social-ecological and life course contexts

AIMS

This paper explores Black women's perspectives on bladder health using a social-ecological conceptual framework and life course perspective.

METHODS

We conducted a directed content analysis of data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE), a focus group study by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. Analysis was conducted on data from five focus groups and a member-checking session where all participants self-identified as Black or African American.

RESULTS

Forty-two participants aged 11-14 or 45+ years reported life course experiences with their bladder. The intersection of race and gender was the lens through which participants viewed bladder health. Participants' accounts of their perspectives on bladder health explicitly and implicitly revealed structural racism as an explanatory overarching theme. Participants described (a) historically-rooted and still pervasive practices of discrimination and segregation, engendering inequitable access to quality medical care and public facilities, (b) institutional barriers to toileting autonomy in educational and occupational settings, promoting unhealthy voiding habits, (c) internalized expectations of Black women's stereotyped role as family caregiver, compromising caregiver health, (d) lack of reliable information on bladder health, leading to unhealthy bladder behaviors, and (e) potentially stress-related comorbid chronic conditions and associated medication use, causing or exacerbating bladder problems.

CONCLUSIONS

Bladder health promotion interventions should address social-ecological and life course factors shaping Black women's bladder health, including social and structural barriers to accessing equitable health information and medical care.

Pelvic Floor Disorders in Black Women: Prevalence, Clinical Care, and a Strategic Agenda to Prioritize Care

Pelvic floor disorders are a group of common conditions affecting women of all racial and ethnic groups. These disorders are undertreated in all women, but this is especially magnified in Black people who have been historically marginalized in the United States. This article seeks to highlight the prevalence of pelvic floor disorders in Black women, evaluate the clinical care they receive, examine barriers they face to equitable care, and present a strategic agenda to prioritize the care of Black women with pelvic floor disorders.

Pilot Study of a Novel At-Home Posterior Tibial Nerve System for Overactive Bladder Syndrome

IMPORTANCE

Urgency urinary incontinence and overactive bladder are common conditions. Third-line therapies are often underutilized because of either being too invasive or being burdensome for the patient.

OBJECTIVE

We aimed to determine the efficacy and acceptability of a noninvasive, home-based posterior tibial nerve treatment system for the treatment of overactive bladder syndrome.

STUDY DESIGN

In this pilot study, 10 postmenopausal women with urgency urinary incontinence were given the SoleStim System for home-based posterior tibial nerve stimulation. Symptoms at baseline and completion of the 8-week study were determined by 3-day voiding diary and quality-of-life questionnaire (Overactive Bladder Questionnaire) to assess for reduction in incontinence episodes.

RESULTS

All patients were 100% adherent to the SoleStim System application over the 8-week period and reported statistically significant reductions in the mean number of voids (-16.3%, P = 0.022), urgency episodes (-31.2%, P = 0.02), and urgency urinary incontinence episodes (-31.4%, P = 0.045). Forty percent of participants reported a decrease of ≥50% in their urgency urinary incontinence episodes. SoleStim was scored a value of 1.8 ± 2.0 (mean ± SD) on a 10-point usability scale, indicating that it was highly acceptable from an ease-of-use perspective. No adverse events were reported.

CONCLUSIONS

The SoleStim System improved key overactive bladder (frequency, urgency, and urgency urinary incontinence episodes) and quality-of-life metrics. The results from this pilot study suggest that the SoleStim System may be a safe, effective, and highly acceptable at-home overactive bladder therapy.

Financial strain across 25 years and women's bladder health: a life course perspective

BACKGROUND

A small number of cross-sectional studies have found that financial insecurity-a social determinant of health-is associated with lower urinary tract symptoms.

OBJECTIVE

This study aimed to examine (1) whether women in the Coronary Artery Risk Development in Young Adult Study with higher levels of financial strain, assessed at 7 time points across 25 years beginning in 1985-1986, were more likely to report lower urinary tract symptoms and impact after the 2010-2011 financial strain assessment and (2) whether healthcare access and comorbidities mediated potential associations.

STUDY DESIGN

This prospective cohort study recruited Black and White participants aged 18 to 30 years at baseline (1985-1986) from the populations of 4 US cities. The analytical sample was composed of women with complete data for analyses involving financial strain trajectories across 7 assessments (n=841) and mediation tests of data collected at 4 assessments (n=886). The outcome variable was previously developed through a cluster analysis of urinary incontinence severity, urinary incontinence impact, other lower urinary tract symptoms severity, and their impact in 2012-2013, which yielded 4 lower urinary tract symptoms and impact cluster categories: women with no symptom or very mild symptoms and no impact vs women with mild, moderate, or severe symptoms and impact. Financial strain was defined as finding it "very hard," "hard," or "somewhat hard" (vs "not very hard") to pay for the very basics, such as food, heating, and medical care. Using proportional odds logistic regression, cluster categories were regressed on the financial strain trajectory group, adjusting for age, race, education, and parity. For mediation analyses, separate financial strain variables (difficulty paying for the very basics, such as food and heating, and difficulty paying for medical care) were created by combining 1995-1996 and 2000-2001 values. Two healthcare access variables (difficulty receiving care and underutilization of care) and a single comorbidity index (smoking, physical inactivity, body mass index, hypertension, diabetes mellitus, and depressive symptoms) were created by combining 2005-2006 and 2010-2011 values. Regression analyses and structural equation modeling were used to test whether healthcare access and comorbidities mediated associations between financial strain and lower urinary tract symptoms and impact cluster categories.

RESULTS

In comparison to women who were consistently not financially strained, women who were consistently strained (odds ratio, 2.10; 95% confidence interval, 1.13-3.91), shifted into being strained (odds ratio, 2.00; 95% confidence interval, 1.29-3.10), or experienced >1 shift in strain (odds ratio, 1.99; 95% confidence interval, 1.46-2.71) had roughly twice the odds of reporting greater lower urinary tract symptoms and impact. Underutilization of healthcare and comorbidities mediated the association between difficulty paying for medical care and lower urinary tract symptoms and impact. In the structural equation model, difficulty paying for medical care and underutilization of care were associated (β=.31; P<.01), as was underutilization of care and greater lower urinary tract symptoms and impact (β=.09; P<.01). Moreover, difficulty paying for medical care and the comorbidity index were associated (β=.34; P<.01), as was the comorbidity index and greater lower urinary tract symptoms and impact (β=.24; P<.01). Collectively, these mediation pathways eliminated a direct association between difficulty paying for medical care and lower urinary tract symptoms and impact.

CONCLUSION

Underutilization of healthcare and comorbidities explained an association between financial strain (difficulty paying for medical care) and lower urinary tract symptoms and impact. Research is needed to confirm the findings and examine other mechanisms that may further explain the association. Accumulated evidence may inform future policies and practices.

Prevalence and Influencing Factors of Help-Seeking Behavior Among Women with Urinary Incontinence: A Systematic Review and Meta-Analysis

Purpose: This systematic review and meta-analysis aimed to investigate the mean (weighted) prevalence of help-seeking behavior among women with urinary incontinence (UI) in relevant subgroups and the related influencing factors. Materials and Methods: Six English and four Chinese databases were systematically searched between 1996 and July 10, 2022. Two researchers independently screened the literature, extracted data, and evaluated the quality of the included studies. All statistical analyses were conducted using RevMan 5.4. Results: The mean (weighted) prevalence of help-seeking behavior based on the 41 included studies, including a total of 32,640 women with UI, was 28% (95% confidence interval [CI]: 22%-34%). We performed a subgroup analysis based on UI type, population, region, publication time, case definition of help-seeking, and use of validated tools to determine UI. The results of the subgroup analysis showed that the pooled prevalence of help-seeking behavior was 23% (95% CI: 14%-32%) among pregnant and maternity women, 27% (95% CI: 19%-35%) among menopausal women, 24% (95% CI: 14%-35%) among 20- to 50-year-old women, 31% (95% CI: 25%-36%) among those older than 50 years, 24% (95% CI: 17%-30%) in Asia, and 33% (95% CI: 22%-44%) in Europe. Meanwhile, the pooled odds ratio showed that education level, UI type, UI severity, and quality of life significantly influenced help-seeking behavior among women with UI. Conclusions: This systematic review revealed that the pooled prevalence of help-seeking behaviors among women with UI is 28%. These influencing factors have important implications for adapting to health care and social care systems.

Screening and Treating Urinary Incontinence in Primary Care: A Missed Opportunity

More than 60% of adult women in the United States have urinary incontinence (UI), with the prevalence increasing to over 80% in women over age 65. Despite its high prevalence, most patients do not seek care and few clinicians screen for UI. The Medicare Health Outcomes Survey queries patients about satisfaction with their provider's discussion and management of UI, but formal recommendations about screening, diagnosis, and treatment are lacking. This review presents a practical algorithm for primary care providers to incorporate management of UI into routine preventive care for women, and outlines UI prevalence, risk factors, screening, and non-surgical treatment options.

Comorbidities of community-dwelling older adults with urinary incontinence: A scoping review

BACKGROUND

Identifying comorbidities is a critical first step to building clinical phenotypes to improve assessment, management, and outcomes.

OBJECTIVES

1) Identify relevant comorbidities of community-dwelling older adults with urinary incontinence, 2) provide insights about relationships between conditions.

METHODS

PubMed, Cumulative Index of Nursing and Allied Health Literature, and Embase were searched. Eligible studies had quantitative designs that analyzed urinary incontinence as the exposure or outcome variable. Critical appraisal was performed using the Joanna Briggs Institute Critical Appraisal Checklists.

RESULTS

Ten studies were included. Most studies had methodological weaknesses in the measurement of conditions. Comorbidities affecting the neurologic, cardiovascular, psychologic, respiratory, endocrine, genitourinary, and musculoskeletal systems were found to be associated with urinary incontinence.

CONCLUSION

Existing literature suggests that comorbidities and urinary incontinence are interrelated. Further research is needed to examine symptoms, shared mechanisms, and directionality of relationships to generate clinical phenotypes, evidence-based holistic care guidelines, and improve outcomes.

Treatment for Urinary Incontinence in Women Older Than 65 Years

IMPORTANCE

Urinary incontinence (UI) is common among women older than 65 years and negatively affects quality of life. However, the prevalence of UI treatment and determinants of treatment are largely unknown.

OBJECTIVES

The aim of this study was to identify rates of UI treatment and factors associated with treatment in older women with self-reported UI.

STUDY DESIGN

This is a retrospective cohort analysis of a data set linking UI symptoms from the Nurses' Health Study to Medicare claims. We evaluated use of pharmacotherapy, noninvasive, and procedural treatments for UI within 1 year before symptom survey. For pharmacotherapy, we used multivariable logistic regression to estimate odds ratios (ORs) of UI treatment.

RESULTS

Of the 67,587 Nurses' Health Study respondents, 15,088 had linkage to Medicare, subscribed to part D, and answered UI questions. Of these, 8,332 (55.2%) women reported UI, and 10.9% with UI had a Medicare claim for treatment; pharmacotherapy represented 94.6% of all treatments.On regression analysis, women with more severe and longer-term UI had higher odds of treatment (severe vs slight UI: OR, 3.1; 95% confidence interval [CI], 2.2-4.3) (longer vs new UI: OR, 1.9; 95% CI, 1.5-2.3). Women with mixed (OR, 2.5; 95% CI, 1.9-3.2) or urgency UI (OR, 3.0; 95% CI, 2.2-3.9) had greater odds of treatment compared with women with stress UI.

CONCLUSIONS

We estimate that only approximately 1 in 9 older women with self-reported UI underwent treatment within the year before reporting symptoms, of which pharmacotherapy was the most common UI intervention, and women with more severe and longer duration of symptoms were most often treated.

Effect of cognitive-behavioral therapy on sexual self-esteem and sexual function of reproductive-aged women suffering from urinary incontinence

INTRODUCTION

Patients with urinary incontinence may fear sexual activity due to the unpredictability of urine leakage during intercourse. Given the effective role of cognitive-behavioral therapy in correcting negative thoughts and attitudes, this study was aimed to investigate the effect of cognitive-behavioral therapy on sexual self-esteem and sexual function of reproductive-aged women suffering from urinary incontinence.

METHODS

This study was a randomized controlled clinical trial conducted on 84 reproductive-aged women (18 to 45 years old) with urinary incontinence who referred to Health Centers of Dezful, Iran. After random allocation, the participants were divided into two groups of intervention and control (n = 42). The intervention group attended eight 45-min sessions of cognitive-behavioral therapy, while the control group received only routine interventions. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the Scale of Self-Esteem Index for Women-Short-form (SSEL-W-SF), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12) were completed before, immediately after, and 4 weeks after the end of the intervention by patients in both groups.

RESULTS

The overall scores of sexual self-esteem and sexual function immediately and 4 weeks after the end of the intervention showed a statistically significant difference in the intervention group compared to the control group (p < 0.001). Also, the results showed that in women with urinary incontinence, an increase in the sexual self-esteem score is associated with an increase in the sexual function score (r = 0.9), p < 0.001).

CONCLUSION

Cognitive-behavioral therapy was found to increase sexual self-esteem and improve sexual function in reproductive-aged women suffering from urinary incontinence.

Differences in Anorectal Manometry Values Among Women With Fecal Incontinence in a Racially, Ethnically, and Socioeconomically Diverse Population

IMPORTANCE

Anorectal manometry (ARM) is a valuable diagnostic and therapeutic tool that can both aid in identifying mechanisms contributing to fecal incontinence (FI) and inform management strategies. Consensus on standard reference range values has not been established, and women of varying racial and ethnic backgrounds are not well-represented in the current literature.

OBJECTIVE

We aimed to compare ARM values between women of different racial and ethnic groups with FI.

STUDY DESIGN

We conducted a retrospective cross-sectional study of women with FI who underwent ARM at a tertiary health system in an urban underserved community between 2016 and 2021. Demographic information and ARM values were collected from the medical record. Socioeconomic status (SES) was represented by the percent of the population living below the poverty line according to zip code using U.S. census data. Anorectal manometry values were compared between racial and ethnic groups, and multivariable logistic regression was conducted to control for patient characteristics.

RESULTS

Fifty-eight women were included in the analysis: 33% Hispanic, 22% Black, and 45% White. Hispanic and Black women had higher body mass index and higher rates of diabetes and loose stools and were of significantly lower SES compared with White women. Black and Hispanic women had significantly lower thresholds for volume at first sensation and higher mean anal squeeze pressure. Differences were maintained after controlling for body mass index, diabetes, SES, and diarrhea (P = 0.03 and P = 0.01, respectively). Other ARM values were not significantly different between groups.

CONCLUSIONS

Racial and ethnic differences in ARM values among women with FI exist. Further studies are needed to determine whether these differences have an impact on symptom severity, treatment selection and outcomes, and patient satisfaction.

The relationship between fecal incontinence and food insecurity in United States women: an analysis of 2005-2010 National Health and Nutrition Examination Survey

BACKGROUND

Fecal incontinence is a prevalent debilitating pelvic floor disorder characterized by the involuntary loss of stool. Fecal incontinence is known to be associated with constipation and loose stool, advancing age, chronic comorbidities, and previous anorectal trauma, among other biologic risk factors. The relationship between social determinants of health, such as food insecurity, and fecal incontinence is not well elucidated.

OBJECTIVE

This study aimed to investigate the association between fecal incontinence and food insecurity using a nationally representative sample of US adult women. Our secondary aim was to examine the role of diet by assessing dietary differences between participants with and without fecal incontinence and between food-insecure women with and without fecal incontinence.

STUDY DESIGN

This study analyzed data from the National Health and Nutrition Examination Survey, a nationally representative series of cross-sectional health surveys. Fecal incontinence was defined as accidental leakage of stool within the last 30 days. Food insecurity was assessed using the household food security measure created by the US Department of Agriculture. Dietary data from the National Health and Nutrition Examination Survey dietary interviews titled "Individual Foods, First Day" and "Individual Foods, Second Day," which estimate the foods and drinks consumed in the preceding 24 hours, were pooled. The association between fecal incontinence and food insecurity was analyzed using logistic regression after controlling for patient characteristics.

RESULTS

Overall, 3216 women were included, representing nearly 130 million US women. Of these women, 10.9% had fecal incontinence. There was no significant difference in diet between women with and without fecal incontinence (p>0.05). Food-insecure women in the overall sample reported higher carbohydrate and sugar intake and lower fiber and alcohol intake (all P<.05). Among food-insecure women, those with fecal incontinence had higher calorie and total fats intake than those without fecal incontinence; there was no significant difference in other dietary components (p>0.05). There was a significant association between food insecurity and fecal incontinence, such that women with food insecurity had higher odds of fecal incontinence after adjusting for patient characteristics and diet (odds ratio, 1.76; 95% confidence interval, 1.17-2.66; P=.008).

CONCLUSION

Food insecurity was associated with fecal incontinence even after accounting for diet. Understanding the role of social determinants of health in fecal incontinence symptomatology and treatment is important to potentially alleviate symptom burden and improve the quality of life in at-risk populations.

Healthcare resource use and cost burden of urinary incontinence to United States payers

Objective

To assess healthcare resource utilization and costs for female patients diagnosed with stress or mixed urinary incontinence (SUI/MUI) compared to a matched cohort of patients without SUI/MUI.

Methods

We conducted a retrospective matched cohort study of women using the IBM MarketScan research database. Women diagnosed with SUI/MUI between July 1, 2014 and June 30, 2016 were identified using International Classification of Diseases 9 and 10 codes for SUI or MUI with the date of first diagnosis as the index date from which 2‐year postindex healthcare resource use and direct cost data were derived from claims, examined, and compared 1:1 with patients without a SUI/MUI diagnosis, matched by age and Charlson's Comorbidity Index.

Results

A total of 68 636 women with SUI/MUI were matched 1:1 with controls. In the 2‐year postindex date, a significantly higher proportion of SUI/MUI patients had ≥1 inpatient visit and ≥1 outpatient visit compared to the control group (inpatient: 18.89% vs. 12.10%, p < 0.0001; outpatient: 88.44% vs. 73.23%, p < 0.0001). Mean primary care visits were significantly higher in SUI/MUI patients compared to controls (7.33 vs. 5.53; p < 0.0001) as were specialist visits (1.2 vs. 0.08; p < 0.0001). Mean all‐cause outpatient costs were higher in SUI/MUI patients compared to controls ($7032.10 vs. $3348.50; p < 0.0001), as were inpatient costs ($3990.70 vs. $2313.70; p < 0.0001).

Conclusion

Women with SUI/MUI consume significantly higher medical resources and incur higher costs to payers, compared to women without SUI/MUI. While reasons for this are not fully understood, improved and standardized treatment for women with SUI/MUI may positively affect cost and outcomes.

Health Needs and Their Relationship with Life Expectancy in People with and without Intellectual Disabilities in England

Health needs are common in people living with intellectual disabilities, but we do not know how they contribute to life expectancy. We used the Clinical Practice Research Datalink (CPRD) linked with hospital/mortality data in England (2017–2019) to explore life expectancy among people with or without intellectual disabilities, indicated by the presence or absence, respectively, of: epilepsy; incontinence; severe visual loss; severe visual impairment; severe mobility difficulties; cerebral palsy and PEG feeding. Life expectancy and 95% confidence intervals were compared using flexible parametric methods. At baseline, 46.4% (total n = 7794) of individuals with intellectual disabilities compared with 9.7% (total n = 176,807) in the comparison group had ≥1 health need. Epilepsy was the most common health need (18.7% vs. 1.1%). All health needs except hearing impairment were associated with shorter life expectancy: PEG feeding and mobility difficulties were associated with the greatest loss in life years (65–68% and 41–44%, respectively). Differential life expectancy attenuated but remained (≈12% life years lost) even after restricting the population to those without health needs (additional years expected to live at 10 years: 65.5 [60.3, 71.1] vs. 74.3 [73.8, 74.7]). We conclude that health needs play a significant role but do not explain all of the differential life expectancy experienced by people with intellectual disabilities.

Health disparities and access to advanced therapy for overactive bladder

AIMS

Refractory overactive bladder (OAB) is among the most common reasons for referral to specialists in voiding dysfunction. Significant racial and ethnic disparities exist in prevalence, severity, and management of OAB, presenting care barriers for marginalized patients. We aim to explicate these disparities and explore the factors that led to their existence and persistence. We will additionally offer suggestions to mitigate such disparities and approach equitable care for our patients.

METHODS

This is a narrative review of pertinent articles related to health disparities in OAB. Articles on OAB prevalence stratified by race and ethnicity, and variations in treatment patterns for patients of marginalized backgrounds were identified from the PubMed database. We also included a review of evidence from governmental and historical sources to provide sociocultural context.

RESULTS

Patients from marginalized backgrounds are underrepresented in OAB literature. There appear to be differences in symptom severity and prevalence based on race. OAB severity seems closely entwined with social determinants of health. Patients from marginalized populations experience numerous care barriers impeding the treatment of OAB. Finally, White patients are more likely to receive advanced management for OAB.

CONCLUSIONS

Numerous health disparities exist in the diagnosis and management of OAB. This review is grounded in societal context: health injustice in the United States ultimately stems from systemic racism. Improving our understanding of care disparities and the systems that allow them to persist will bring us closer to equity and allow our patients from marginalized backgrounds to obtain the evidence-based care they deserve.

Association between chronic conditions and urinary incontinence in females: a cross-sectional study using national survey data

BACKGROUND

Urinary incontinence affects up to half of women, yet few speak to their health care provider about or receive treatment for the condition. To aid with identifying subpopulations at risk for urinary incontinence, we examined the associations between 10 chronic health conditions and urinary incontinence among Canadian adult females.

METHODS

We conducted a cross-sectional analysis of survey data from the Canadian Community Health Survey (2013-2014) involving female respondents aged 25 years or older living in a private dwelling. Presence of chronic conditions and urinary incontinence were measured by self-report. We used logistic regression modelling with sampling weights, controlling for age, income, ethnicity, body mass index and smoking. Multiple imputation and probabilistic bias analysis were used to address missing covariate data and unmeasured confounding from parity.

RESULTS

Our analysis included 60 186 respondents representing more than 12 million Canadian females, of whom 45.8% (95% confidence interval [CI] 45.0%-46.6%) reported at least 1 chronic condition. Chronic conditions were associated with more than twice the odds of urinary incontinence (adjusted odds ratio [OR] 2.42, 95% CI 2.02-2.89). Associations were largest for bowel disorders (adjusted OR 2.92, 95% CI 2.44-3.49); modest for chronic obstructive pulmonary disease (adjusted OR 2.00, 95% CI 1.63-2.45), asthma (adjusted OR 1.82, 95% CI 1.52-2.19), arthritis (adjusted OR 1.98, 95% CI 1.74-2.24) and heart disease (adjusted OR 1.73, 95% CI 1.48-2.02); and smallest for diabetes (adjusted OR 1.20, 95% CI 1.02-1.41) and high blood pressure (adjusted OR 1.27, 95% CI 1.12-1.44). Results slightly attenuated but did not substantively change after imputation and bias analysis.

INTERPRETATION

We found that chronic conditions are associated with significantly higher odds of comorbid urinary incontinence among Canadian adult females, which is consistent with previous research. Our findings support routine inquiry regarding urinary incontinence symptoms among women accessing health care for chronic conditions.

Online prediction tool for female pelvic floor dysfunction: development and validation

INTRODUCTION AND HYPOTHESIS

The aim was to develop and validate (internally and externally) a prediction model for the presence and diagnosis of pelvic floor dysfunction (PFD) in women, including pelvic organ prolapse, stress urinary incontinence and/or overactive bladder via a patient-completed online tool.

METHODS

Using a retrospective cohort of women aged >18 years, from multiple tertiary gynaecology units within Queensland, Australia (2014-2018), the prediction model was developed via penalized logistic regression with internal and external validation utilizing multiple clinical predictors (42 questions from the Australian Pelvic Floor Questionnaire and demographics: age, body mass index, parity and mode of delivery). The main outcome measures were the accuracy of the model in predicting a diagnosis of pelvic floor dysfunction and its specific conditions of prolapse and incontinence.

RESULTS

A total of 3,501 women were utilized for model development and internal validation and 449 for external validation. On internal validation the model correctly identified those with PFD with 97% sensitivity, 74% specificity and a concordance index (C-index) of 0.96. Predictions of pelvic organ prolapse were also accurate, with 86% sensitivity, 83% specificity, C-index 0.83, as was stress urinary incontinence, 84% sensitivity, 87% specificity, C-index 0.87, and overactive bladder, 76% sensitivity, 77% specificity, C-index 0.77. External validation confirmed the model's accuracy with a similar C-index in all parameters.

CONCLUSIONS

This model provides an accurate online tool to differentiate between those with and without PFD and diagnoses of common pelvic floor disorders. It serves as a valuable self-assessment for women and primary care providers.

A Systematic Review of Racial/Ethnic Disparities in Female Pelvic Floor Disorders

Numerous studies have investigated the influence of health disparities among women with pelvic floor disorders with varied results. Racial/ethnic disparities, in particular, inconsistently indicate differences in prevalence of disease, disease severity, and treatment outcomes. We aim to review the body of literature examining racial/ethnic disparities in pelvic floor disorders, including overactive bladder, stress urinary incontinence, pelvic organ prolapse, and interstitial cystitis. A better understanding of these disparities may help guide clinicians, researchers, and advocates in providing improved education, outreach opportunities, and access to care in minority women with pelvic floor disorders.

Urinary Incontinence in Older Women: A Syndrome-Based Approach to Addressing Late Life Heterogeneity

Urinary incontinence is a prevalent pelvic floor disorder among women of all ages. However, in many older women, especially those who have multiple chronic conditions it may be a geriatric syndrome because of its shared characteristics of physical function impairments, cognitive decline, and mobility disability. The geriatric incontinence syndrome may represent a poorly characterized phenotype of UI among older women which in many ways reflects unhealthy aging. In this article, we explore the evidence behind these concepts together with potentiel impact on the diagnosis and management of UI in this group.

Applying a Health Equity Lens to Urinary Incontinence

Health equity is attained when everyone has the opportunity achieve the health they envision; however, health disparities are a barrier to health equity. As health disparities specific to urogynecology exist, it is critical to examine and contextualize them in a framework that improves understanding of what factors may drive these disparities to craft effective solutions. This article will review what we currently know about urinary incontinence disparities and provide a framework for evaluation as well as a framework for advancing health equity in the care of diverse patient populations with urinary incontinence.

Differences in Pelvic Floor Symptoms During Pregnancy Between Hispanic and Non-Hispanic White Women

OBJECTIVES

This study aimed to describe and compare pelvic floor symptoms and symptom burden between nulliparous Hispanic and non-Hispanic white women in the third trimester of pregnancy and to determine, in women with stress urinary incontinence (SUI), whether bother differs between groups, adjusted for UI severity.

METHODS

In this cross-sectional analysis, participants completed the Epidemiology of Prolapse and Incontinence and Incontinence Severity Index questionnaires. We compared differences in symptom domains between groups using logistic regression and tested the effect of ethnicity on bother in women with SUI using linear regression.

RESULTS

The sample comprised 418 non-Hispanic white and 154 Hispanic women. Prevalence rates of symptom domains ranged from 5.0% and 7.1% for pelvic organ prolapse to 95.2% and 94.2% for overactive bladder in non-Hispanic white and Hispanic women, respectively. After adjusting age, height, weight, education, physical activity, and gestational age, non-Hispanic whites had 2.37-fold increased odds (95% confidence interval, 1.44-3.92) for defecatory dysfunction and had nonsignificant increases in other symptom domains. Non-Hispanic whites were more likely to endorse symptoms in 3 or more domains than Hispanic women (58.9% vs 40.3%, respectively; P = 0.0001). Given the same UI severity (Incontinence Severity Index), Hispanic women with SUI reported 7.5 points greater bother (Epidemiology of Prolapse and Incontinence) than non-Hispanic white women (P = 0.07).

CONCLUSIONS

After adjustment, we found few differences in the prevalence of pelvic floor symptom domains between Hispanic and non-Hispanic white women, apart from defecatory dysfunction. If differences by ethnicity in other pelvic floor symptoms exist, they do not seem to originate during the first pregnancy.

Urinary incontinence and the association with depression, stress, and self-esteem in older Korean Women

The objectives were to investigate the prevalence of urinary incontinence (UI) and its relationships with depression, stress, and self-esteem in older Korean women from the Korean Study of Women's Health Related Issues (K-Stori), a nationally representative cross-sectional survey. A total of 3000 women between 65 and 79 years were the final study subjects. We applied multiple linear regression models to analyze associations with depression, stress, and self-esteem levels in relation to UI types. Types of urinary incontinence included stress, urge, and mixed UI. UI affects at least one in two older Korean women (52.2%). The prevalences of SUI, UUI, and MUI were 45.7%, 39.6%, and 33.1%, respectively. UI was found to be adversely associated with depression, stress, and self-esteem: women with UI reported significantly higher levels of depression and stress and lower levels of self-esteem than those without UI. Women with MUI reported significantly greater impairment than the women with SUI or UUI. Our results provide an evidence base for the evaluation of mental health in older women with incontinence. The prioritization of UI detection and the identification of psychological factors may help improve the diagnosis and management of UI and potentially yield significant economic and psychosocial benefits.

Patient-Provider Discussions About Urinary Incontinence Among Older Women

BACKGROUND

Urinary incontinence (UI) is prevalent in women and has been associated with decreased quality of life and institutionalization. Despite this, and the fact that several treatment options exist, few women discuss UI with clinicians. The aim of this study was to examine the proportion of middle aged and older women with urinary incontinence who have discussed UI with clinicians, focusing on female health professionals as a way to examine this question outside of issues of health care access.

METHODS

Data are from the Nurses Health Studies (NHS), two ongoing observational, prospective, cohort studies. The surveys collected detailed information about UI, including frequency, amount and type. Women were also asked if they had discussed UI with a clinician. We used multivariable-adjusted logistic regression to estimate odds ratios (OR) of participants reporting discussion about UI.

RESULTS

94,692 women with UI aged 49-91 years old were included in this study. Of these, 34% reported that they had discussed their incontinence with a clinician. Women with daily UI had 4.4 times greater odds of discussing it with clinicians when compared to those with monthly UI (OR = 4.36, 95% confidence interval [CI] 4.06-4.69). When controlling for severity of symptoms, the oldest women, greater than eighty years, were 20% less likely to have discussed UI with their clinician, compared to the youngest women (OR = 0.81, 95% CI 0.73-0.89).

CONCLUSIONS

A minority of women with UI, even among health professionals, discuss their symptoms with clinicians. Oldest women were the least likely to discuss their UI with a provider.

Urinary Incontinence in Climacteric Women With or Without Depressive Symptoms: A Cross-Sectional Study

OBJECTIVE

This study aimed to investigate whether the occurrence of urinary incontinence (UI) is associated with increased odds of depression in perimenopausal and postmenopausal women.

METHODS

This cross-sectional study included 208 women with depressive symptoms, confirmed by the Beck Depression Inventory, and 247 patients without depression. All participants were perimenopausal or postmenopausal women aged 35 to 65 years who attended an outpatient clinic from a tertiary-academic hospital in Northeastern Brazil. Urinary incontinence symptoms were assessed using patient's self-report and the validated versions of the International Consultation on Incontinence Questionnaire-Short Form and the Questionnaire for Urinary Incontinence Diagnosis. To investigate the severity of climacteric symptoms, the Blatt-Kupperman Index was used, and menopause-related quality of life was analyzed using the Utian Quality of Life Questionnaire.

RESULTS

In univariate analysis, the Beck Depression Inventory-II mean scores for UI and non-UI women were, respectively, 15.5 (95% confidence interval, 14.28-16.72) and 11.83 (10.52-13.13; P < 0.05). Patients with moderate and severe scores of depression reported higher International Consultation on Incontinence Questionnaire-Short Form and Questionnaire for Urinary Incontinence Diagnosis scores when compared with women with mild depression scores and women without depression (P < 0.001). Conversely, in multivariate analysis, having UI was not associated with having depression (odds ratio [OR], 0.85; 0.52-1.37; P = 0.50), after adjusting for confounders. Older age (>55 years) was associated with decreased odds of depression (OR, 0.43; 0.21-0.88; P = 0.02), whereas moderate (OR, 2.28; 1.40-3.71; P = 0.001) and severe (OR, 7.70; 2.79-21.23) intensities of menopause symptoms were associated with increased odds of depression.

CONCLUSION

Urinary incontinence was not associated with depression within climacteric women after multivariate analysis.

[Clinical path and life quality of women under 75 years with an urinary incontinence relevant to surgical treatment]

OBJECTIVES

Urinary incontinence has a high prevalence and a significant impact on quality of life, especially for women. Surgery is possible after failure of lifestyle changes, physiotherapy. Analyzing the care pathway of women under 75 years of age who have undergone surgery for urinary incontinence in link with recommendation and suggest possible improvements.

METHODS

Quantitative, multicentric, retrospective survey carried out between 10/09/2019 and 25/11/2019, based on anonymous self-report questionnaire, among women aged between 32 and 75 and operated in different hospitals in Loire (France).

RESULTS

Ninety-three answers were exploited out of 204. Among the women, 49.5 % had stress, 50.5 % mixed incontinence. Before the intervention, it had evolved for 5 years on average and caused discomfort evaluated at an average 7.5/10. Eighty percent frequently used protective pads and bladder training. Lifestyle changes and the voiding diary were not used much. Eighty-six percent of women felt comfortable to speak to a physician. Seventy-three percent had performed a urodynamic test, 47 % an abdominal ultrasound and 40 % a urinalysis. Seventy-seven percent performed physiotherapy, 39 % self-administered physiotherapy, 7 % used medication. The postoperative quality of life was evaluated at 7.8/10; 58 % felt healed and 69 % considered their sex life had improved.

CONCLUSIONS

The care pathway could be improved through systematic screening for urinary incontinence and its impact. The development of a care plan to coordinate and propose quick care could help patients to improve their life.

Urinary incontinence and its association with socioeconomic status among middle-aged and older persons in Taiwan: A population-based study

AIM

This study aimed to explore the association between socioeconomic status and urinary incontinence (UI).

METHODS

We used data from the three waves of the Taiwan Longitudinal Study on Aging. This study included 2458 women and 2866 men aged ≥50 years. We used logistic random effects models to examine the associations of interest, adjusting for demographics, health-related behaviors, disability, number of health conditions and prostate problems for men and numbers of children for women.

RESULTS

In adjusted analysis, women with secondary education least frequently reported UI compared with women with no formal education (adjusted odds ratio [AOR] 0.41, 95% confidence interval [95% CI] 0.22-0.79). Those with severe economic hardships (vs those with no economic hardships) had an increased risk of UI among men and women (AOR 2.71, 95% CI 1.72-4.25 and AOR 1.94, 95% CI 1.31-2.88, respectively). Compared with men doing mentally demanding jobs, service workers/salesperson and retired men were more prone to UI (AOR 2.67, 95% CI 1.14-6.36 and AOR 2.41, 95% CI 1.19-4.87, respectively). Further analysis showed that the associations of economic hardship with UI were attenuated when adjusting for access to healthcare.

CONCLUSION

No formal education in women and severe economic hardship in both the sexes were associated with an increased risk of UI among middle-aged and older persons. The disparities should be taken into account in interventions for prevention, treatment and management of UI. Geriatr Gerontol Int 2021; 21: 245-253.

Prevalence and determinants of non-fistulous urinary incontinence among Ghanaian women seeking gynaecologic care at a teaching hospital

The study assessed the prevalence and determinants of non-fistulous urinary incontinence among gynaecologic care seekers as well as its interference with everyday life activities of affected women. A cross-sectional study involving 400 women was conducted in a tertiary facility in Ghana. Urinary incontinence was assessed using the International Consultation on Incontinence Questionnaire-short form (ICIQ-SF) which has not been validated locally. The questionnaire was administered mostly in the Asante Twi language with translation done at the time of the interview. The data was analysed for proportions and associations between selected variables. The prevalence of urinary incontinence was 12%, the common types being urgency (33.3%), stress (22.9%), and mixed (20.8%). Age ≥60 years compared to 18–39 years (OR 3.66 95%CI 1.48–9.00 P = 0.005), and a history of chronic cough (OR 3.80 95% CI 1.36–10.58 P = 0.01) were associated with urinary incontinence. Women with education beyond the basic level were 72% less likely to experience urinary incontinence (OR 0.28 95%CI 0.08–0.96 P = 0.04). Urinary incontinence interferes with everyday life activities of most affected women. Non-fistulous urinary incontinence is relatively common among gynaecologic care seekers yet very few women were referred with such a diagnosis. Advocacy measures aimed at urging affected women to report the condition and educating the general population on potential causes, prevention and treatment are needed.

Incidence of Pelvic Floor Disorders in US Army Female Soldiers

OBJECTIVE

To determine the incidence of pelvic floor disorders (PFD) among active-duty US Army female soldiers.

MATERIALS AND METHODS

We studied 102,015 women for incident PFD using the Stanford Military Data Repository, which comprises medical, demographic and service-related information on all soldiers on active duty in the US Army during 2011-2014. Cox proportional hazards estimated adjusted associations with PFD diagnoses. In the adjusted models, military-specific characteristics and fitness were evaluated alongside known PFD predictors.

RESULTS

Among 102,015 subjects at risk there was a cumulative incidence of 6.4% over a mean of 27 months (median 29, range 1-42). In adjusted models, obese soldiers were more likely to have a PFD compared to those of normal weight (hazard ratio [HR] 1.23, confidence interval [CI] 1.14-1.34, P <0.001) and those with recent weight gain were more likely to have a PFD compared to those without (HR 1.32, CI 1.24-1.40, P <0.05). Women with the lowest physical fitness scores were more likely to have a PFD (HR 1.14, CI 1.04-1.25) compared to those with the highest scores.

CONCLUSION

Over a median follow-up time of 29 months, 1 in 15 women in this active-duty cohort was diagnosed with a PFD. Optimizing risk factors including body mass index and physical fitness may benefit the pelvic health of female soldiers, independent of age, children, and years of service.

Racial and Socioeconomic Factors Influence Utilization of Advanced Therapies in Commercially Insured OAB Patients: An Analysis of Over 800,000 OAB Patients

OBJECTIVE

To determine if racial and/or socioeconomic factors influence advanced therapy utilization for refractory overactive bladder (OAB) among the commercially insured.

METHODS

We queried Optum, a national claims database, between 2003 and 2017. Non-neurogenic OAB patients were identified using ICD-9/10 diagnosis codes. Demographic and treatment data were collected, including oral medication therapies (anticholinergic, beta3 agonists), and advanced therapies (OnabotulinumtoxinA [BTX], Sacral Nerve Stimulation [SNS], percutaneous tibial nerve stimulation [PTNS]). Associations between patient sociodemographic factors and advanced therapy utilization were explored.

RESULTS

Of 4,229,617 OAB patients, 807,612 (19%) received medical therapies, of which 95% received oral medications only and only 4.7% received advanced therapies. Asians had the lowest use of oral therapy use (14% vs 18%-19% in other races/ethnicities, P <0.05), and advanced therapy use (0.44% vs 0.71%-0.93%, P <0.05). Asians and Hispanics were least likely to utilize SNS therapy and most likely to use PTNS compared to Blacks and Whites. BTX use was similar between races/ethnicities (P <0.05). Female gender (OR 1.65 [CI 1.61,1.69]), younger age (<65) (OR 1.28 [1.25,1.31]), higher annual income ≥$40K (OR 1.09 [1.06,1.12]) and prior use of oral medications (OR 3.30 [3.21,3.38] for 1 medication) were significantly associated with receiving advanced therapies. Non-white race (OR 0.89 [0.87,0.91]), lower education level (less than a bachelor's degree) (OR 0.97 [0.94,0.99]), and Northeast region were associated with a lower likelihood of receiving advanced therapies (P <0.05 for all).

CONCLUSION

Among commercially insured, racial and socioeconomic factors predict utilization of advanced OAB therapies, including race/ethnicity, age, gender, education level, and region.

Review of the 6th International Consultation on Incontinence: Primary prevention of urinary incontinence

AIMS

To report the state of the science on primary prevention of urinary incontinence (UI) in adults from the 6th International Consultation on Incontinence with an update through January 2019.

METHODS

Online databases PubMed, CINAHL, PsycInfo, and Medline were searched in March 2016 and February 2019 with a focus on literature published after 2010. The International Consultation on Urological Diseases modified Oxford Centre for Evidence-Based Medicine Levels of Evidence and grades of recommendation were used to evaluate the literature.

RESULTS

Grade B recommendations to prevent UI in pregnant and postpartum women are available and promising evidence exists for educational interventions to prevent UI up to 2 years in older women. There is little evidence for adding preoperative pelvic floor muscle exercises to postprostatectomy pelvic floor muscle exercises for men to regain continence. Insufficient evidence exists for the effectiveness of screening for UI in women. The absence of information on primary prevention remains for adolescents, nulliparous and perimenopausal women, and middle-aged and aged men and women.

CONCLUSIONS

Few primary prevention interventions for UI exist for specific populations, especially pregnant and postpartum women. Research interest in developing foundational knowledge to design these interventions is growing.

Multifaceted self-management interventions for older women with urinary incontinence: a systematic review and narrative synthesis

OBJECTIVE

To synthesise the evidence for the multifaceted self-management interventions for older women with urinary incontinence (UI) and to understand the outcomes associated with these interventions.

DESIGN

A systematic review and narrative synthesis to identify randomised controlled trials that investigated the effect of multifaceted self-management interventions for older women with UI.

METHODS

MEDLINE, PsycINFO, EMBASE, The Cochrane Library, CINAHL and Applied Social Sciences Index and Abstracts databases were searched (January 1990 to May 2019) using a systematic search strategy, complemented by manually screening the reference lists and citation indexes. Study selection, data extraction and risk of bias assessment were undertaken independently. A narrative synthesis was undertaken in which studies, interventions and outcomes were examined based on the intervention components. The effect size and 95% CI were estimated from each study.

RESULTS

A total of 13 147 citations were identified and 16 studies were included. There was no study rated as of high quality. Three types of multifaceted interventions were found: those that had an element of pelvic floor muscle exercises (PFME), those with bladder retraining and some with combination behavioural interventions. Outcome measures varied across studies. A statistically significant improvement in incontinence symptoms was reported in the intervention group compared with the control in 15 studies.

CONCLUSION

Multifaceted interventions that included PFME, bladder retraining or combination behavioural techniques appear to be useful in some settings for UI management in older women, but the quality of the evidence was poor and unclear. There was insufficient evidence to determine whether any of the combination of components is superior to others in improving UI symptoms. There is a need for high-quality studies to confirm the effectiveness of these interventions and to identify comparative effectiveness.

PROSPERO REGISTRATION NUMBER

CRD42018104010.

Urinary Incontinence in a National Cohort of Older Women: Implications for Caregiving and Care Dependence

BACKGROUND

Urinary incontinence (UI) can interfere with older women's ability to perform activities of daily living (ADLs), but little is known about factors that predispose incontinent women to become functionally dependent or compromise their ability to serve as caregivers to others.

STUDY DESIGN

UI, caregiving, and care-receiving behaviors were assessed by questionnaire in a national sample of community-dwelling older women. Multivariable models evaluated associations between incontinence and care dependence, assessed factors associated with care dependence among incontinent women, and compared health among female caregivers with and without incontinence.

RESULTS

Of the 1703 women, 27% reported weekly or more incontinence and 13% monthly incontinence. Women with weekly or more incontinence were more likely than women without incontinence to report receiving care for ADLs (AOR = 2.39, CI = 1.61-3.56) or instrumental ADLs (AOR = 1.94, CI = 1.42-2.63). Compared to 46% of women without incontinence, 60% of women with monthly or weekly incontinence reported unmet care needs (p = 0.0002). Factors associated with care dependence included more frequent incontinence, older age, marital status, and fair/poor health (p < 0.05 for all). Overall, 15% of women served as a caregiver for another adult, which did not differ by incontinence status (p = 0.84), but female caregivers with incontinence reported worse health than those without incontinence (p = 0.0004).

CONCLUSIONS

In this national cohort, older women with incontinence were more likely to be functionally dependent and have unmet care needs than those without incontinence, after adjustment for other factors. At least one in ten incontinent women served as caregivers, despite having worse health than female caregivers without incontinence.

Urine leakage during sexual activity among ethnically diverse, community-dwelling middle-aged and older women

BACKGROUND

Urinary incontinence is associated with decreased female sexual function, but little is known about the prevalence, predictors, and impact of urine leakage during sexual activity among women in the community.

OBJECTIVE

The purpose of this study was to evaluate the prevalence and impact of urine leakage during sex in ethnically diverse, community-dwelling midlife and older women.

STUDY DESIGN

Urinary incontinence and sexual function were assessed by structured questionnaire in a multiethnic, community-based cohort of women enrolled in Kaiser Permanente Northern California, an integrated healthcare delivery system in California. All women were aged 40-80 years and sampled from 1 of 4 racial/ethnic groups (20% black, 20% Latina, 20% Asian, and 40% non-Latina white). Differences in frequency, bother, and fear of urine leakage during sexual activity were examined among women with monthly, weekly, and daily urinary incontinence and across different types of urinary incontinence (stress, urgency, mixed, and other type urinary incontinence), with the use of chi-square tests. Independent risk factors for urine leakage during sexual activity were identified through multivariable logistic regression.

RESULTS

Of the 509 women who reported being sexually active and having at least monthly urinary incontinence, 127 of them (25%) reported experiencing any urine leakage during sex during the past 3 months. Nineteen percent of the women reported being subjectively bothered by leakage during sex, and 16% of them reported restricting sexual activity because of fear of leakage. Women with more frequent underlying urinary incontinence were more likely to report experiencing or being bothered by leakage during sex and restricting sexual activity because of fear of leakage (P<.001 for all). Participants with predominantly stress or mixed type urinary incontinence were more likely to report experiencing leakage during sex and being subjectively bothered by this leakage (P<.002 for all). Factors independently associated with leakage during sex were depression (odds ratio,1.96; 95% confidence interval, 1.20-3.20), symptomatic pelvic organ prolapse (odds ratio, 2.10; 95% confidence interval, 1.11-3.98), mixed vs urgency type urinary incontinence (odds ratio, 3.16; 95% confidence interval, 1.70-5.88), stress vs urgency type urinary incontinence (odds ratio, 1.94; 95% confidence interval, 1.01-3.70), and frequency of sexual activity (odds ratio, 1.6395% confidence interval, 1.05-2.55), but not age or race/ethnicity.

CONCLUSIONS

Up to a quarter of women with at least monthly urinary incontinence in the community may experience urine leakage during sexual activity. Many incontinent women who leak urine during sex remain sexually active, which indicates that the preservation of sexual function should still be a priority in this population. Among incontinent women, depression, pelvic organ prolapse, and stress mixed-type urinary incontinence may be associated with urine leakage during sexual activity.

Nonbiologic factors that impact management in women with urinary incontinence: review of the literature and findings from a National Institute of Diabetes and Digestive and Kidney Diseases workshop

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI)-defined as a complaint of involuntary loss of urine-is common in women, with major public health, financial, and quality of life (QoL) implications. Despite the high toll of UI and the availability of effective conservative treatments, many women with UI do not seek care. Those who do often continue to experience symptoms. Improving UI treatment may require a comprehensive approach to urology research, including a broad set of potentially influential factors beyond biologic.

METHODS

To explore the effects of nonbiologic factors (NBF) on UI management and treatment response, the National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop for clinical and psychosocial researchers. Participants proposed a UI treatment pathway: recognizing the problem, willingness to seek treatment, access to care, receiving quality treatment, engaging in self-management, and adhering to chosen treatments; discussed potential NBFs that may affect the pathway; and identified areas for future research. After the meeting, a rapid literature review was conducted to assess the current state of research on NBFs in women with UI.

RESULTS

Participants identified several patient-level NBFs that may influence the UI management pathway, including QoL and perceived bother; stigma, shame, and embarrassment; knowledge and perceptions; social determinants of health; cultural and language characteristics; personal characteristics and skills; and physical abilities. Additionally, participants acknowledged that provider- and system-level factors also play a role and likely interact with patient-level factors.

CONCLUSIONS

NBFs that potentially affect the UI management pathway are not well understood, and a comprehensive, interdisciplinary approach to research is needed to understand and appropriately support effective UI treatment.

Urinary Incontinence as a Predictor of Death: A Systematic Review and Meta-Analysis

Background

The association between urinary incontinence (UI) and increased mortality remains controversial. The objective of our study was to evaluate if this association exists.

Methods

We performed a systematic review and meta-analysis of observational studies comparing death rates among patients suffering from UI to those without incontinence. We searched in Medline, Embase and the Cochrane library using specific keywords. Studies exploring the post-stroke period were excluded. Hazard ratios (HR) were pooled using models with random effects. We stratified UI by gender and by UI severity and pooled all models with adjustment for confounding variables.

Results

Thirty-eight studies were retrieved. When compared to non-urinary incontinent participants, UI was associated with an increase in mortality with pooled non adjusted HR of 2.22 (95%CI 1.77–2.78). The risk increased with UI severity: 1.24 (95%CI: 0.79–1.97) for light, 1.71 (95%CI: 1.26–2.31) for moderate, and 2.72 (95%CI: 1.90–3.87) for severe UI respectively. When pooling adjusted measures of association, the resulting HR was 1.27 (95%CI: 1.13–1.42) and increased progressively for light, moderate and severe UI: 1.07 (95%CI: 0.79–1.44), 1.25 (95%CI: 0.99–1.58), and 1.47 (95%CI: 1.03–2.10) respectively. There was no difference between genders.

Conclusion

UI is a predictor of higher mortality in the general and particularly in the geriatric population. The association increases with the severity of UI and persists when pooling models adjusted for confounders. It is unclear if this association is causative or just reflects an impaired general health condition. As in most meta-analyses of observational studies, methodological issues should be considered when interpreting results.