Characteristics of female outpatients with urinary incontinence participating in a 6-month observational study in 14 European countries

Visit rates and risk factors of healthcare-seeking behavior for urinary incontinence, fecal incontinence, and pelvic organ prolapse among women: A systematic review and meta-analysis

INTRODUCTION

Female pelvic floor dysfunction(FPFD), including urinary incontinence, fecal incontinence, and pelvic organ prolapse, is an expanding global health problem among women, declining their quality of life. Healthcare-seeking behavior of FPFD patients plays a vital role in preventing symptom deterioration and reducing future burdens. Poor healthcare-seeking behavior has resulted in lower visit rates than prevalence. This study aimed to investigate the visit rate and risk factors of healthcare-seeking behavior in patients with FPFD and to provide a basis for developing prevention strategies against risk factors.

METHODS

An exhaustive systematic literature search was undertaken using the following databases: PubMed, Web of Science, Embase, The Cochrane Library, and CINAHL, published from inception to June 2022. Two investigators independently extracted data and assessed the quality of the studies using the Health Care Quality and Research (AHRQ) or Newcastle-Ottawa Scale (NOS). A meta-analysis was performed by using Review Manager 5.3.

RESULTS

Eighty studies were selected, including 83,996 participants. Data were extracted from 71 studies for urinary incontinence, 5 for pelvic organ prolapse, and 4 for fecal incontinence. Meta-analysis results indicated that the visit rates of urinary incontinence, pelvic organ prolapse, and fecal incontinence were lower, at 29%(95%CI:27% to 32%, I2=99%, P<0.00001), 42%(95%CI:18% to 65%, I2=99%, p=0.0005), and 35%(95%CI:16% to 54%, I2=99%, p=0.0004), respectively. The study shows that there are a variety of factors affecting the healthcare-seeking behavior of FPFD women, including sociodemographic factors(treatment and diagnosis costs are high, lack of time, type of UI, duration of UI, symptom severity, and impact of UI), psychological factors(shame, fear of medical treatment side effects, fear of examination, and fear of surgery), cognitive factors(considering it as the normal status of aging, the perception that symptoms are not treatable, believing that symptoms could recover naturally, lack of knowledge of available treatment, believing they should cope with the problem themselves, do not think it is serious enough), healthcare service factors(the physician said it was not necessary, other health problems taking priority). Age, fear of hospitals/doctors, and fear of diagnosis do not affect healthcare-seeking behavior.

CONCLUSION

Patients with urinary incontinence, pelvic organ prolapse, and fecal incontinence have a low visit rate. Many risk factors affect the healthcare-seeking behavior of female pelvic floor dysfunction diseases, mainly sociodemographic, psychological, cognitive, and healthcare service factors. However, due to a lack of data, high-quality studies are still required to confirm. In the future, attention should be paid to policy guidance and ethical changes, strengthening the training of medical personnel and comprehensive medical education on the diagnosis, treatment and management of FPFD as well as appropriate nursing pathways. In addition, public information campaigns on the comprehensive prevention of FPFD should be strengthened to raise women's awareness of the comprehensive prevention of FPFD, especially health education.

Innovative treatment modalities for urinary incontinence: a European survey identifying experience and attitude of healthcare providers

Introduction and hypothesis

Urinary incontinence is a common condition in women, with a reported prevalence ranging from 25% to 51%. Of these women, an estimated 38% suffer from stress urinary incontinence (SUI). A European research consortium is investigating an innovative system based on information and communication technology for the conservative treatment of women with SUI. When introducing a new intervention, implementation barriers arise and need to be identified. Therefore, we investigated healthcare providers’ experience with and attitude towards innovative care options.

Methods

We performed an online survey to assess (1) the characteristics and practice of healthcare providers, (2) current protocols for SUI, (3) current use of biofeedback, and (4) knowledge about serious gaming. The survey was sent to members of professional societies in Europe (EUGA), UK (BSUG) and The Netherlands (DPFS).

Results

Of 341 questionnaires analyzed (response rate between 18% and 30%), 64% of the respondents had access to a protocol for the treatment of SUI, and 31% used biofeedback when treating patients with SUI. However, 92% considered that biofeedback has a clear or probable added value, and 97% of those who did not use biofeedback would change their practice if research evidence supported its use. Finally, 89% of respondents indicated that they had no experience of serious gaming, but 92% considered that it could be useful.

Conclusions

Although inexperienced, European urogynecologists and physical therapists welcome innovative treatment options for the conservative treatment of SUI such as portable wireless biofeedback and serious gaming. Scientific evidence is considered a prerequisite to incorporate such innovations into clinical practice.

Normal reference values of strength in pelvic floor muscle of women: a descriptive and inferential study

Background

To describe the clinical, functional and quality of life characteristics in women with Stress Urinary Incontinence (SUI). In addition, to analyse the relationship between the variables reported by the patients and those informed by the clinicians, and the relationship between instrumented variables and the manual pelvic floor strength assessment.

Methods

Two hundred and eighteen women participated in this observational, analytical study. An interview about Urinary Incontinence and the quality of life questionnaires (EuroQoL-5D and SF-12) were developed as outcomes reported by the patients. Manual muscle testing and perineometry as outcomes informed by the clinician were assessed. Descriptive and correlation analysis were carried out.

Results

The average age of the subjects was (39.93 ± 12.27 years), (24.49 ± 3.54 BMI). The strength evaluated by manual testing of the right levator ani muscles was 7.79 ± 2.88, the strength of left levator ani muscles was 7.51 ± 2.91 and the strength assessed with the perineometer was 7.64 ± 2.55. A positive correlation was found between manual muscle testing and perineometry of the pelvic floor muscles (p < .001). No correlation was found between outcomes of quality of life reported by the patients and outcomes of functional capacity informed by the physiotherapist.

Conclusion

A stratification of the strength of pelvic floor muscles in a normal distribution of a large sample of women with SUI was done, which provided the clinic with a baseline. There is a relationship between the strength of the pelvic muscles assessed manually and that obtained by a perineometer in women with SUI. There was no relationship between these values of strength and quality of life perceived.

Electronic supplementary material

The online version of this article (doi:10.1186/s12905-014-0143-4) contains supplementary material, which is available to authorized users.

The Prevalence of Overactive Bladder Syndrome and Urinary Incontinence in a Turkish Women Population; Associated Risk Factors and Effect on Quality of Life

Aims

To investigate the prevalence and risk factors of overactive bladder syndrome and urinary incontinence in Turkish women; furthermore, to assess the impact on the quality of life.

Materials and Methods

A cross-sectional, epidemiological study was carried out in women of reproductive age to define overactive bladder syndrome, urinary incontinence, ICIQ-SF score and medical care seeking.

Results

The women's average age was 34.4 ± 5.26 years. The prevalence of UI was 26.9%. Stress UI was the predominant form. The prevalence of UI increased with age, BMI, number of pregnancies and children delivered. The prevalence of OAB was 20.7%. Women with OAB were older and had greater number of pregnancies than women without OAB. History of nocturnal enuresis was a significant risk factor for OAB and UUI. Women with MUI had more frequent and more abundant leakage of urine. 10.7% of women sought medical care for their condition.

Conclusions

Although prevalence estimates differ across studies, the available evidence indicates that UI and OAB are highly prevalent conditions among women. UI had negative effect on QoL, but only severely-affected women sought medical care. Public health and clinical management programs are needed to determine diagnosis and management of these social problems.

Prevalence, risk factors and quality of life in Turkish women with urinary incontinence: a synthesis of the literature

BACKGROUND

Urinary incontinence (UI) is not a life threatening condition but it adversely affects physical and mental health, sexual function and quality of life in women.

AIM

To review the related literature to identify prevalence, risk factors and quality of life among only Turkish women.

METHODS

Computerized searches on PubMed, Turkish Medline, EBSCO Host; articles from indexed journals related to the topics in this review and published between 1996 and 30 April 2012 were evaluated. After completion of database searches, a final total of 20 studies were identified that fitted the inclusion criteria.

RESULTS

This review revealed that the prevalence of UI among Turkish women was reported by 16 studies ranged from 16.4% to 49.7%. The most common risk factors were age, number of births, body mass index > 25 kg/m(2), recurrent urinary infection, diabetes mellitus and vaginal delivery. The effect of UI on the quality of life was mild to moderate.

CONCLUSIONS

We found that the prevalence of UI of Turkish women showed a wide range. It is important for health professionals to be aware of the high prevalence of UI in women and to ask about its possible presence. Improving the quality of life in women with UI is an important issue and nurses should direct women to seek psychosocial support. The findings of this review could serve as a source of information for health systems that deal with UI, and it may help to inform health professionals and women with UI on early diagnosis, treatment and management.

Diagnostic delay in secondary care for lower urinary tract and pelvic organ prolapse symptoms in women

PURPOSE

Many women suffering from lower urinary tract symptoms (LUTS) and pelvic organ prolapse (POP) symptoms. However, only a fraction actually seeks medical advice shortly after the onset of these symptoms. In this study, we sought to evaluate and compare the delay in seeking medical help in this patient population.

METHODS

A prospective cohort study was performed among 223 consecutive women who were referred to the urogynecology outpatient clinic for secondary assessment of LUTS and POP symptoms. The exclusion criteria included previous evaluation for the same symptoms, inability to communicate, or refusal to participate in the study. Each patient completed a detailed questionnaire of all pelvic floor symptoms (urinary, bowel and prolapse and sexual). Delay was measured from the time the symptoms were first noted by the patient to the first visit to our clinic.

RESULTS

Mean length of delay was 43.8 months without significant difference between the LUTS and POP groups. The symptoms affected daily activities in 41.7% of the total group with no significant between-group difference. The POP group had significant decrease in intercourse (11.8%) than the LUTS group (4.3%) (p = 0.043). The main reason for the delay was patients' delay in 65.9% of the total group with no significant between-group difference. About 22.5% of all women thought that their primary health physician was responsible for the delay and only 2.2% blamed the medical system for the delay.

CONCLUSION

There is a significant delay in seeking secondary medical help in women with POP and LUTS.

Cost-effectiveness of duloxetine: the Stress Urinary Incontinence Treatment (SUIT) study

OBJECTIVE

To assess the cost-effectiveness of duloxetine compared with conservative therapy in women with stress urinary incontinence (SUI).

METHODS

Cost and outcome data were taken from the Stress Urinary Incontinence Treatment (SUIT) study, a 12-month, prospective, observational, naturalistic, multicenter, multicountry study. Costs were assessed in UK pound and outcomes in quality adjusted life years using responses to the EuroQol (EQ-5D); numbers of urine leaks were also estimated. Potential selection bias was countered using multivariate regression and propensity score analysis.

RESULTS

Duloxetine alone, duloxetine in combination with conservative treatment, and conservative treatment alone were associated with roughly two fewer leaks per week compared with no treatment. Duloxetine alone and with conservative treatment for SUI were associated with incremental quality-adjusted life-years (QALYs) of about 0.03 over a year compared with no treatment or with conservative treatment alone. Conservative treatment alone did not show an effect on QALYs. None of the interventions appeared to have marked impacts on costs over a year. Depending on the form of matching, duloxetine either dominated or had an incremental cost-effectiveness ratio (ICER) below pound900 per QALY gained compared with no treatment and with conservative treatment alone. Duloxetine plus conservative therapy had an ICER below pound5500 compared with no treatment or conservative treatment alone. Duloxetine compared with duloxetine plus conservative therapy showed similar outcomes but an additional cost for the combined intervention.

CONCLUSIONS

Although the limitations of the use of SUIT's observational data for this purpose need to be acknowledged, the study suggests that initiating duloxetine therapy in SUI is a cost-effective treatment alternative.

Patient characteristics impacting health state index scores, measured by the EQ-5D of females with stress urinary incontinence symptoms

OBJECTIVE

To describe the characteristics of women seeking treatment for symptoms of stress urinary incontinence (SUI) and to investigate the association of SUI symptoms with generic health-related quality of life (HRQoL) as measured by the EuroQol (EQ-5D) instrument.

METHODS

The Stress Urinary Incontinence Treatment (SUIT) study was a 12-month observational study in four European countries that evaluated the cost-effectiveness of duloxetine compared with other forms of nonsurgical intervention in the treatment of the symptoms of SUI. Four hundred thirty-one physicians observed women seeking treatment for their SUI, and recorded the care provided and the outcomes of that care at enrollment and at 3, 6 and 12 months afterward The impact of SUI on baseline HRQoL as expressed by the EQ-5D index score was assessed by linear and logistic regression.

RESULTS

Three thousand seven hundred sixty-two women were enrolled into SUIT, with the largest patient group from Germany. Overall, the majority of women were postmenopausal, had a mean age of 58.0 years, were not current smokers, and tended to be overweight (mean body mass index [BMI]=27.7 kg/m2), with at least one comorbidity. The health state index scores were significantly and independently influenced by the presence of comorbidity(ies) affecting quality of life, total number of stress and urge incontinence episodes, urinary incontinence subtype, comorbidity(ies) affecting incontinence, BMI, socioeconomic status, educational status, age, and country.

CONCLUSION

This article describes the characteristics of patients at the SUIT enrollment visit, and demonstrates that the number of incontinence episodes has a significant impact on the EQ-5D index score.

Urinary incontinence in French women: prevalence, risk factors, and impact on quality of life

BACKGROUND

The lack of epidemiologic data on the prevalence of female urinary incontinence (UI) attending general practitioners (GPs) in France led us to conduct a cross-sectional study in our country.

OBJECTIVES

To determine the prevalence of UI and to assess its impact on the quality of life (QoL).

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of women aged >18 yr was conducted by attending GPs between June 2007 and July 2007.

MEASUREMENTS

The main outcome measures were urinary symptoms, functional impairment, International Consultation on Incontinence Questionnaire-Short Form score, and medical care seeking.

RESULTS AND LIMITATIONS

Overall, 241 GPs enrolled 2183 women seen during 1 d. The prevalence of UI was 26.8% (n=584) and increased with age, body mass index (BMI), and number of children delivered (p<0.0001). Among women with UI, 496 were included in a cross-sectional survey: 45.2% (n=224) had stress UI, 42.1% (n=209) had mixed UI, and 10.9% (n=53) had urge UI, while 2% (n=10) had UI of indeterminate type. Overall, 288 of 496 women (51.8%) stated that UI had a negative impact on their QoL; this effect remained mostly mild or moderate, and only 197 of 496 women (39.7%) had asked for medical help. Longer duration of symptoms, higher frequency of comorbid urinary symptoms, and altered QoL were most frequent among women with mixed UI (p<0.001). Misclassification may have occurred because the diagnosis of UI was based on self-reported data rather than on clinical or urodynamic examinations.

CONCLUSIONS

UI symptoms were found in almost one in four women attending GPs. Clinical and functional UI impairment were associated with age, BMI, and parity. UI caused distress to women, but only those who were severely affected sought help. The results emphasize the need for policy development for UI prevention and management in France.

Significado de ter incontinência urinária e ser incontinente na visão das mulheres

O objetivo deste estudo qualitativo foi compreender as repercussões da incontinência urinária na vida de mulheres e conhecer o significado das crenças, valores e atitudes de TER incontinência e SER incontinente. O método utilizado foi a história oral temática e a coleta de dados ocorreu de agosto a outubro de 2005 em dois momentos distintos. Inicialmente com a aplicação de instrumentos específicos para incontinência urinária e posteriormente foram coletados os dados subjetivos por meio de entrevistas com questões semi-estruturadas. Utilizando a análise temática, encontramos quatro unidades centrais - percebendo que a perda não é normal, tendo sentimentos diante da perda, tendo que assumir a incontinência urinária, tendo que ter controle para não perder ou cheirar urina. Identificamos, pela análise das unidades, a apreensão do fenômeno SER incontinente compreendendo que as mulheres possuem estratégias individuais para lidarem com a relação dialética entre o SER e o TER incontinência urinária.

How do patients with urinary incontinence perceive care given by their general practitioner? A cross-sectional study

BACKGROUND

Urinary incontinence (UI) is a widespread problem, affecting quality of life and leading to high costs, mainly caused by incontinence pads. It seems that, despite guidelines, many UI patients get pads from their general practitioner (GP) without adequate diagnostics or treatment.

OBJECTIVES

To assess what further treatment UI patients receive from their GP next to pads and to measure patient satisfaction with care.

METHODS

A postal survey among UI patients who started pad use in the past 12 months.

MAIN OUTCOME

Satisfaction with UI care.

RESULTS

We analysed 208 questionnaires. 29.3% of pad users had no direct contact with their GP for a pad prescription. Of 147 UI patients who visited their GP 50.3% only got pads. 25% of patients was not satisfied with the information on UI received from their GP, especially younger patients, women, less healthy patients and patients with urgency UI.

CONCLUSIONS

Dutch UI patients using pads experience suboptimal GP care and management. Factors identified through patient feedback should be used to improve quality of care for UI in primary care.

General preferences for involvement in treatment decision making among European women with urinary incontinence

Current health care policies advocate patient participation in treatment decision making. Little evidence on possible differences between European women's preferences for involvement in this process exists. In this study we explore preferences for involvement in treatment decision making in 15 European countries in a sample of 9434 women seeking treatment for urinary incontinence in an outpatient setting. Their generally preferred role in treatment decisions was assessed using the Control Preferences Scale. Results show variations within and between countries in preferences for involvement in treatment decision making. The 'collaborative role' was the most preferred role in Austria, Belgium, Denmark, France, Germany, Ireland, Sweden, Switzerland, the Netherlands and the UK. In Greece, Portugal and Spain the 'passive role' was most preferred. Over a third of women in Denmark, Finland and Norway preferred an 'active role'. Multinominal regression analyses found that, after adjusting for case mix and factors previously associated with role preferences, country membership was strongly associated with role preferences, with women living in Southern European countries preferring a more passive role. Such clear differences are of interest in the current health care environment where active patient participation is being encouraged. Greater efforts need to be made to establish whether patient preferences are genuine or merely a learned response influenced by cultural attitudes and traditions so that a balance can be struck between assisting women to play a more active role in the treatment decision-making process without disregarding some women's genuine preferences to play a more passive role.

Overactive bladder syndrome in older people

The overactive bladder symptom complex (OAB) is the commonest cause of urinary incontinence in older people, and is usually due to underlying detrusor overactivity, and as such is a treatable condition. Older people are a heterogeneous group, which includes fit community-dwelling individuals and those with significant medical comorbidity; thus the requirements of care for this group are many and varied. The International Continence Society definition of the frail elderly, those aged >65 years with continence problems, who by virtue of comorbidity are house-bound or living in an institution, is clearly not applicable to all. However, many conditions begin to appear in later life and practitioners need to be aware of the need to manage these, and their treatment, when dealing with older people. Studies of medication for OAB have included the elderly and there is evidence of an equivalent benefit in younger people. The impact of treatment on the cognitively impaired and those receiving acetylcholinesterase inhibitors is discussed.

Patient characteristics associated with quality of life in European women seeking treatment for urinary incontinence: results from PURE

OBJECTIVE

To investigate the association between patient characteristics and disease-specific and generic quality of life (QOL) as well as the degree of bother in women seeking treatment for urinary incontinence (UI).

METHODS

The Prospective Urinary Incontinence Research (PURE) was a 6-mo observational study with 1055 physicians from 15 European countries enrolling 9487 women. QOL was assessed at the enrolment visit using the urinary Incontinence Quality of Life questionnaire (I-QOL) and the generic EQ-5D. A single-item instrument was used to measure the degree of bother. UI severity was assessed using the Sandvik Index. UI was categorised into stress (SUI), mixed (MUI), and urge (UUI) urinary incontinence by a patient-administered instrument (Stress and Urge Incontinence Questionnaire [S/UIQ]). Multivariate linear (I-QOL, EQ-5D Visual Analogue Scale) and logistic (bother, EQ-5D health state index) regressions were performed.

RESULTS

Mean total I-QOL scores were significantly and independently associated with UI severity, nocturia, age, UI subtype, number of selected concomitant medical conditions, length of suffering from UI before contacting a doctor, smoking status, ongoing use of UI medication, and country. After adjusting for all the covariates, the total I-QOL scores for SUI, MUI, and UUI were 62.7, 53.8 and 60.1, respectively. As with I-QOL, UI severity was also the most important predictor for bother. The number of concomitant medical conditions, together with UI severity, was the variable most strongly associated with EQ-5D.

CONCLUSION

In addition to the UI subtypes, severity of UI should be given more importance in treatment algorithms and in treatment decision-making by both the patient and the physician.

Medical resource utilisation and cost of care for women seeking treatment for urinary incontinence in an outpatient setting

OBJECTIVE

To describe the medical resource use and direct costs of treatment for women with urinary incontinence (UI) in European countries.

DESIGN

PURE is a non-interventional, observational study of patients seeking treatment for UI in an outpatient setting.

SETTING

Investigators being either general practitioners (GPs) and/or specialists, i.e. urologists and gynaecologists, in 14 European countries participated in PURE. The results for medical resource use and cost of treatment in Germany, Spain and the UK/Ireland recorded retrospectively at the enrolment visit for the preceding 12 months are presented here.

SUBJECTS

Treatment-seeking women aged over 18 years who were under treatment or seeking treatment for UI, and who presented within the normal course of care for UI were enrolled in the 6 months study.

MEASUREMENTS

Information on the incontinence resource use was gathered on standard data collection forms. The direct medical costs were calculated by attaching the unit costs from the perspective of the relevant health insurance in each country to the country-specific resource use. Furthermore, the contribution of patients to the costs of pads, or any treatment for UI was assessed.

RESULTS

Variation in medical resource use and cost of treatment between the three countries was observed, reflective of the differences in the healthcare systems and whether specialists and/or GPs provided the care. We found that women in Spain and Germany are more likely to have consulted a specialist for their UI symptoms, which had implications for utilisation of diagnostic procedures. Conservative treatment, particularly pelvis floor muscle exercises, was more common in patients in the UK/Ireland treated in primary care by GPs. In all three countries most of the women had used protective pads, which more than half the patients paying for them out-of-pocket, despite potential healthcare reimbursement schemes. Mean total UI-related costs per year ranged from 359 in the UK/Ireland for patients predominantly treated in the GP setting to 515 in Germany and 655 in Spain for patients treated by specialists and GPs.

CONCLUSIONS

Our study provides an estimation of resource use and costs associated with UI in treatment-seeking European women, exemplified here in three countries.

Patient-reported impact of urinary incontinence—Results from treatment seeking women in 14 European countries

OBJECTIVES

To describe the patient-reported impact of urinary incontinence (UI) in treatment-seeking women in Europe.

DESIGN

PURE was a non-interventional, observational study, which aimed to describe the direct costs of treatment for European women seeking treatment for UI. A secondary study objective was to describe the impact of UI on health-related quality of life (HRQoL) by UI subtype and severity of disease. This paper presents the results from quality of life assessments as well as bothersomeness and interference with daily activities from the first study observation.

SUBJECTS

Nine thousand four hundred and eighty-seven European women who had UI symptoms in the last 12 months were enrolled. Their UI symptoms were frequently those defined as mixed urinary incontinence (MUI) and were moderate to severe in nature.

MEASUREMENTS

HRQoL was assessed at the first observation using the urinary Incontinence-specific Quality of Life Questionnaire (I-QOL) and the EQ-5D, a generic quality of life questionnaire. Data collected from EQ-5D provided insight into the patients' general health perception, while the I-QOL data indicated how affected the women were about their UI symptoms. Higher EQ-5D and I-QOL scores represent better quality of life. Patients were asked to indicate how much UI symptoms limited selected activities and to indicate the degree to which they found their symptoms to be bothersome.

RESULTS

Overall, the median self-rated health status on the EQ-5D visual analogue scale (VAS) was 70.0 and the median EQ-5D health state index was 0.85, with small but noticeable differences observed between countries. Of the five health dimensions of the EQ-5D, patients' self-care appeared to be the least affected by UI, with fewer than 10% of the women reporting that they had some problems. Between 20 and 40% of patients had some problems with their mobility and usual activities, or had pain/discomfort or anxiety/depression. However, the impact of existing co-morbidity was not assessed and may have affected some women's scoring of the EQ-5D domains. The mean total I-QOL score overall was 57.7 and of the three subscales of the I-QOL, psychosocial impact had the highest overall scores, representing fewer problems, with lower scores observed for the avoidance and limiting behaviour subscale, and even lower scores for the social embarrassment subscale. The greatest patient-reported impact of UI symptoms on activities was on exercise, with more than 45% of patients moderately to totally limited in this activity. In most of the countries, more than 60% of the women reported that they were moderately to extremely bothered by their UI symptoms.

CONCLUSIONS

There was considerable impact of UI on HRQoL in a treatment seeking population, as demonstrated by the disease-specific quality of life scale and by the high percentage of patients who were bothered by their symptoms.