Patient-reported outcome measures for pain in women with pelvic floor disorders: a systematic review

INTRODUCTION AND HYPOTHESIS

Patient-reported outcome measures (PROMs) are helpful instruments when measuring and reporting changes in patient health status (Al Sayah et al. J Patient Rep Outcomes 5 (Suppl 2):99, 2021) such as the health-related quality of life (HrQoL) of women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The Australasian Pelvic Floor Procedure Registry (APFPR) aims to increase capacity for women to report surgical outcomes through the collection of HrQoL data (Ruseckaite et al. Qual Life Res. 2021) but currently lacks a pain-specific PROM for women with pelvic floor disorders (PFDs), particularly POP and SUI. This review aims to systematically review the existing literature and identify instruments that measure pain in women with POP and SUI for inclusion within the APFPR, which reports on complications from these conditions.

METHODS

We conducted a literature search on OVID MEDLINE, Embase, CINAHL, PsycINFO and EMCARE databases in addition to Google Scholar and grey literature to identify studies from inception to April 2021. Full-text studies were included if they used PROMs to measure pain in women with POP and SUI. Two authors independently screened articles, extracted data and assessed methodological quality.

RESULTS

From 2001 studies, 23 publications describing 19 different PROMs were included for analysis. Eight of these instruments were specific to the pelvic floor; four were only specific to pain and used across multiple disorders; three were generic quality of life instruments and four were other non-validated instruments such as focus group interviews. These instruments were not specific to pain in women with POP or SUI, as they did not identify all relevant domains such as the sensation, region and duration of pain, or incidents where onset of pain occurs.

CONCLUSIONS

The findings of this review suggest there are no current PROMs that are suitable pain-specific instruments for women with POP or SUI. This knowledge may inform and assist in the development of a new PROM to be implemented into the APFPR.

A systematic review of utility-based and disease-specific quality of life measurement instruments for women with urinary incontinence

AIM

This systematic review aims to identify disease-specific and generic quality of life (QoL) outcome measurement instruments used in populations of women with urinary incontinence (UI) and to determine the most psychometrically robust and appropriate disease-specific and generic tools for measuring the quality of life in this population.

METHODS

A systematic search was conducted of PubMed, Embase, SCIELO, and CINAHL databases for studies evaluating measurement properties of QoL instruments in women with UI. The methodological quality of studies and the quality of measurement properties were evaluated using the COnsensus-based Standards for the selection of health status Measurement INtruments (COSMIN) checklist and quality criteria. Overall, evidence for measurement properties was graded using the modified grading of recommendations, assessment, development & evaluation approach.

RESULTS

A total of 73 studies were included, and 27 specific and 6 generic instruments were identified. The Incontinence QoL questionnaire (IQoL) had the highest overall psychometric quality for English-speaking populations and was the most widely translated tool. Evidence for generic QoL tools in this population is limited. Few studies evaluated measurement error or cross-cultural validity.

CONCLUSION

The IQoL is the most psychometrically robust disease-specific tool for use in this population. More research is needed to determine the most psychometrically robust generic tool. Future studies should also evaluate measurement error and cross-cultural validity as evidence for these properties is particularly lacking.

A multicenter cross-sectional study on the prevalence of overactive bladder and its impacts on the quality of life in gynecologic outpatients

Objective

The present study assessed the prevalence of overactive bladder (OAB) symptoms in gynecologic outpatients and the effects of OAB on a patient's quality of life.

Methods

The survey was completed by adult female patients who visited the gynecology clinic for examination or treatment of gynecologic conditions. The subjects who met the exclusion criteria were excluded. The survey included a questionnaire assessing general characteristics, the purpose of the visit, diagnosis, and the presence or absence of OAB. The subjects were asked whether they were under medical treatment for OAB symptoms, and the degree of discomfort in daily activities was evaluated.

Results

In total, 1,990 female subjects visiting the gynecology clinics of 4 different institutions were recruited. On OAB Symptom Score, 188 subjects responded with scores of ≥2 for question #3 (≥1 time(s) weekly). The severity of OAB symptoms was as follows: 345 subjects had mild OAB, 127 subjects had moderate OAB, and 12 subjects had severe OAB. The prevalence of OAB symptoms was 10.30%.

Conclusion

The present study confirmed that OAB symptoms are common, with a prevalence of 10.30%. Patients with OAB symptoms frequently neglect to seek medical intervention. Our findings will help inform patients to recognize their condition and seek medical assistance, especially in gynecologic outpatient clinics.

How does the onset of incontinence affect satisfaction with life among older women and men? Findings from a nationally representative longitudinal study (German Ageing Survey)

Background

There is a large body of evidence showing that incontinence is associated with decreased health-related quality of life (HRQoL). Moreover, while a few cross-sectional studies have shown that incontinence is associated with decreased life satisfaction, there is a lack of studies regarding whether the onset of incontinence influences life satisfaction of affected individuals longitudinally. Thus, the objective of this study is: (i) to investigate the impact of incontinence on life satisfaction and (ii) whether this effect differed between women and men using a large population-based sample longitudinally.

Methods

Longitudinal data from 2008 to 2014 were retrieved from a nationally representative sample (9869 observations in regression analysis) of community-dwelling individuals aged 40 years and over (German Ageing Survey, DEAS). Physician-diagnosed incontinence was reported by respondents. Life satisfaction was quantified using the well-established Satisfaction with Life Scale. Linear fixed-effects regressions were used.

Results

After adjusting for potential confounders (e.g., self-rated health or depression), regressions revealed that the onset of incontinence was associated with a decline in life satisfaction in men (β = −.25, p < .01), but not in the total sample and in women. These differences were significant (p < .05). In a further sensitivity analysis, individuals with cancer were excluded. However, in terms of significance and effect size, the impact of incontinence on life satisfaction in men remained almost the same in both models.

Conclusions

The onset of incontinence markedly reduces life satisfaction among men aged 40 and over. Interventional strategies to postpone incontinence may assist in maintaining life satisfaction in men.

Quality of life of women with urinary incontinence in rehabilitation treatment

This article analyzed how sexual satisfaction, suffering, severity and impact of urinary incontinence, and psychological morbidity affected women's quality of life and whether suffering mediated the relationship between psychological morbidity and quality of life. The study included 80 women diagnosed with urinary incontinence receiving rehabilitation treatment. Regression analysis showed that sexual satisfaction, suffering, and urinary incontinence severity and impact predicted quality of life and that suffering mediated the relationship between psychological morbidity and quality of life. The findings suggest that interventions should be tailored according to the suffering reported by women and the impact of the urinary incontinence on the couple's sexual relationship.

Severity, not type, is the main predictor of decreased quality of life in elderly women with urinary incontinence: a population-based study as part of a randomized controlled trial in primary care

Background

Urinary incontinence negatively influences the lives of 25-50% of elderly women, mostly due to feelings of shame and being limited in activities and social interactions. This study explores whether differences exist between types of urinary incontinence (stress, urgency or mixed) and severity of the symptoms, with regard to their effects on generic and condition-specific quality of life.

Methods

This is a cross-sectional study among participants of a randomized controlled trial in primary care. A total of 225 women (aged ≥ 55 years) completed a questionnaire (on physical/emotional impact and limitations) and were interviewed for demographic characteristics and co-morbidity. Least squares regression analyses were conducted to estimate differences between types and severity of urinary incontinence with regard to their effect on quality of life.

Results

Most patients reported mixed urinary incontinence (50.7%) and a moderate severity of symptoms (48.9%). Stress urinary incontinence had a lower impact on the emotional domain of condition-specific quality of life compared with mixed urinary incontinence (r = −7.81). There were no significant associations between the types of urinary incontinence and generic quality of life. Severe symptoms affected both the generic (r = −0.10) and condition-specific (r = 17.17) quality of life.

Conclusions

The effects on condition-specific quality of life domains differ slightly between the types of incontinence. The level of severity affects both generic and condition-specific quality of life, indicating that it is not the type but rather the severity of urinary incontinence that is the main predictor of decreased quality of life.

The severity of urinary incontinence decreases health-related quality of life among community-dwelling elderly

BACKGROUND

Urinary incontinence (UI) is an important geriatric syndrome that has been associated with a wide range of health-related outcomes. However, UI severity has rarely been examined in the context of a comprehensive geriatric assessment. Therefore, the aim of this study is to examine the association between UI severity and health-related quality of life (QoL) when frequent geriatric issues are taken into account.

METHODS

We performed a cross-sectional study of 1,124 participants aged 70 y and older. UI was diagnosed when difficulty with urinary continence was reported, and its severity was assessed through a modified version of the Sandvik Index. Health-related QoL was measured using the SF-36, including its physical and mental component summaries. Multivariate linear regression was performed to determine the association between UI severity and health-related QoL.

RESULTS

Prevalence of UI was 18%, and it was severe in 29.3% of cases. Severely incontinent subjects were older and had worse self-perceived health status, greater disability, and more depressive symptoms in comparison with continent participants or with those affected to a lesser degree. Multivariate regression analysis showed a significant inverse association between the physical component summaries and moderate (B = -4.54) as well as severe UI (B = -6.72). The mental component summaries showed similar results (B = -1.44 and -4.43, respectively).

CONCLUSIONS

UI severity is associated with lower QoL scores in both its components. This association appears to be more important as severity increases. UI severity must be evaluated thoroughly in the elderly because of its potential adverse effects on physical and mental health.

Residents' perspectives on urinary incontinence: a review of literature

BACKGROUND

Individuals in residential aged care facilities experience urinary incontinence more than any other single population. Despite these factors, the impact of the condition on their quality of life, their perspectives of living with the condition, and their preferences for care have received little research attention.

AIM

To provide a descriptive overview of research about; the impact of urinary incontinence on residents' quality of life; residents' perspectives of having urinary incontinence; and their preferences for continence care'.

DESIGN

A descriptive review of literature.

METHOD

A broad search was undertaken for qualitative and quantitative research that evaluated residents' quality of life related to urinary incontinence; their perspectives on having urinary incontinence, and their preferences for managing it. Data were displayed in tabular format, summarized, and described.

RESULTS

Ten studies were identified and reviewed (six qualitative and four quantitative). They reveal many residents' value having independent bowel and bladder function, but believe that incontinence in inevitable and intractable. Some adopt self management strategies, however considerable barriers hinder their ability to maintain continence and manage incontinence. Residents often have low expectations, and hence decline further evaluation and treatment. Some express satisfaction with continence care even if this care is not consistent with their preferences. Little is known about how cognitively impaired residents perceive their condition. However some individuals with cognitive impairment respond with acute anxiety when carers' attempt to provide continence care.

CONCLUSION

Residents' perspectives on incontinence and preferences for continence care relate to low expectations for improvement. Such misconceptions should be addressed and residents and their family members should be given a range of options from which to choose. As urinary incontinence impacts on residents' quality of life, it is also important that continence care is delivered in a participative and sensitive way.

Physical therapy treatment in incontinent women provided by a Public Health Service

INTRODUCTION: Urinary incontinence affects more than 50 million people worldwide, it has a great impact on quality of life by affecting social, domestic, occupational and sex life, regardless of age. Objective: The objective of this study was to analyze the effectiveness of physical therapy treatment in women attending the Urogynecology service of Hospital and Maternity Leonor Mendes de Barros. METHOD: We retrospectively assessed 65 records of patients with diagnosis of urinary incontinence treated between November 2005 and November 2006. In order to have their data analyzed, patients were divided into two groups; group MF, which underwent medical treatment and physiotherapy, and group M, which had only medical treatment. In order to compare both groups' quantitative data, the analysis was performed in Statistica® software using Mann Whitney's non-parametric test. The analysis of association between the quantitative variables was performed through the Chi-Square test at 5% (p > 0.05) significance level. RESULTS: We observed that 60.6% of patients who underwent physical therapy treatment and medical treatment had the urinary incontinence symptoms decreased or completely cured, while 80% of women belonging to the medical treatmen only-group underwent surgery. CONCLUSION: Thus, we conclude that physical therapy is essential in treatment protocols of urinary incontinence outpatient clinics and to prevent surgery.

The effects of severity of urine leakage on quality of life in Hispanic, white, and black men and women: the Boston community health survey

OBJECTIVES

To investigate the relationship between the severity of urine leakage and quality of life (QOL) in men and women of different race/ethnicity.

METHODS

An epidemiologic survey was conducted with a population-based random sample of 3202 women and 2301 men (1767 black, 1877 Hispanic, 1859 white) aged 30-79 years in Boston, MA. Severity of leakage was based on frequency and amount by the Sandvik Severity Scale. QOL was measured with physical and mental component summaries of Medical Outcomes Study Short Form-12. Covariates included race/ethnicity, age, socioeconomic status, urinary incontinence risk factors, and comorbidities. Analysis included multivariate linear regression modeling by gender.

RESULTS

Urine leakage, most of which was mild or moderate, was reported in 30% of women and 18% of men. Women (5.1%) were more likely than men (0.9%) to report severe leakage. In multivariate analysis, as severity of leakage increased, both components of QOL declined, with decreases in scores of 7-8 points for men (P < or = .001 for each) and 4-6 points (P < .05 and P = .001, respectively) for women. Severe leakage was associated with a greater decline in QOL than that observed for most other comorbidities considered. The effect of urine leakage on QOL was similar among racial and ethnic groups.

CONCLUSIONS

Urine leakage impairs QOL for both men and women, with no evidence of different effects by racial/ethnic group. Leakage has clinically significant effects on physical health-related QOL for men and on mental health QOL for both men and women.

Health-related Quality of Life among hospitalized older people awaiting residential aged care

Background

Health related quality of life (HRQoL) in very late life is not well understood. The aim of the present study was to assess HRQoL and health outcomes at four months follow-up in a group of older people awaiting transfer to residential aged care.

Methods

Secondary analysis of data from a randomized controlled trial conducted in three public hospitals in Adelaide. A total of 320 patients in hospital beds awaiting a residential aged care bed participated. Outcome measurements included HRQoL (Assessment of Quality of Life; AQoL), functional level (Modified Barthel Index), hospital readmission rates, survival, and place of residence at four months follow-up.

Results

In this frail group the median AQoL was poor at baseline (median 0.02; 95%CI -0.01 – 0.04) and at follow-up (0.05; 95%CI 0.03 – 0.06). On leaving hospital, more than one third of participants who were moving for the first time into nursing home care rated themselves in a state worse than death (AQoL ≤ 0.0). Poor HRQoL at discharge from hospital (AQoL ≤ 0.0) was a significant predictor of mortality (HR 1.7; 95%CI 1.2 – 2.7), but not hospital readmission nor place of residence at four months follow-up. Improved function was a predictor of improved HRQoL among the surviving cohort.

Conclusion

People making the transition to residential aged care from hospital have very poor HRQoL, but small gains in function seem to be related to improvement. While functional gains are unlikely to change discharge destination in this frail group, they can contribute to improvements in HRQoL. These gains may be of great significance for individuals nearing the end of life and should be taken into account in resource allocation.

Urinary incontinence—prevalence, impact on daily living and desire for treatmentA population‐based study

OBJECTIVE

To investigate the prevalence of urinary incontinence in a representative population in Sweden, and to assess to what extent the condition affects daily life and to what degree those afflicted desire treatment.

MATERIAL AND METHODS

In a population-based study, a postal questionnaire comprising 12 questions on urinary incontinence was sent to a representative sample of 15 360 randomly selected residents (aged 18-79 years) of Orebro County, Sweden. This was a supplement to a comprehensive survey of public health and general living conditions.

RESULTS

The response rate was 64.5%. The prevalence of urinary incontinence was 19% when defined as "any leakage" and 7% when defined as "at least once a week". Women were more afflicted than men, and the proportion of people with urinary incontinence increased markedly with increasing age. Most considered their problems to be minor, having little impact on daily life, which was reflected by the fact that only 18% of those with urinary incontinence desired treatment. About 17% of those with urinary incontinence reported severe problems that interfered with daily life. Of respondents with severe problems, 42% did not want treatment.

CONCLUSION

According to this population-based study, urinary incontinence is not a major problem for most people in the community. Although a considerable proportion of the population report urinary incontinence, the majority experience minor problems and only 18% desire treatment. For a limited group of people, urinary incontinence is a severe problem. It is important that healthcare resources are optimized to identify and meet the needs of those who are most afflicted.

Perceptions of Urinary Incontinence Among Syrian Christian Women Living in Sweden

Purpose: The purpose of this study was to describe the perception of urinary incontinence (UI) among Syrian women living in Sweden. Design: A qualitative, descriptive design with focus group discussions (FGDs) was used and analyzed with content analysis. Fourteen Syrian women were interviewed in three FGDs. Findings: Three categories emerged, “Thoughts on UI,” “Managing UI,” and “Communication With the Health Care System.” Among the interviewees, UI was a common, and expected, problem, which could be managed. However, some expressed shame and embarrassment. Some talked about communication problems with health care. Discussion and Implications for Practice: The health care system should be adjusted to the women's needs, with awareness of the communication difficulties, which could result in misunderstanding and neglected treatments.

Differences between older Chinese men and women from Hong Kong in the impact of urinary incontinence on their lives

This study reports the epidemiology of urinary incontinence (UI) and its impact on the social lives of older Chinese people in Hong Kong, a modern city in China. It also examines the relationship between sex and this impact, as well as the extent of UI in a convenience sample of 101 sufferers aged 60 or older. This study was cross-sectional and used face-to-face interviews with a structured questionnaire. A number of findings concur with studies conducted in Western countries. Prevalence of UI increased with adult age, and it affected women more than men. UI had a negative impact on 86.1% of the incontinent respondents. There were no significant differences between men and women in the duration of UI, the level of UI, or health status. Out of the nine impacts on social lives, only one showed a significant difference between older men and women: "restriction on opportunities to participate in social activities." Statistically, men tended to report more negative impacts than women. More than 80% of the respondents were affected by their UI. The impact of UI on social lives was basically the same for men and women, though men reported significantly more social impacts than did women. However, this study does not support the claim that the social life of those who reported more social impacts was worse than that of those who reported fewer.

Qualidade de vida e estratégias de enfrentamento em idosos com incontinência fecal: uma revisão da literatura

RESUMO O objetivo desta revisão foi apreciar criticamente a literatura sobre a avaliação da qualidade de vida (QV) e das estratégias de enfrentamento em idosos com incontinência fecal (IF), tendo como referencial o envelhecimento populacional brasileiro e o aumento da incidência de doenças crônicas que comprometem o bem-estar dos idosos. Foi realizada pesquisa nas principais bases de dados e a qualidade metodológica das publicações foi avaliada. A perda involuntária de fezes gera conseqüências físicas, sociais, emocionais e econômicas, sendo mais prevalente em idosos e mulheres. Recentemente, a avaliação de medidas centradas no paciente, incluindo a QV e as estratégias de enfrentamento foram apontadas como fundamentais. A qualidade de vida de idosos com IF pode ser avaliada através de instrumentos genéricos, como o WHOQOL e de instrumentos específicos, como o FIQL e o GIQLI. Alguns estudos têm indicado variáveis que podem se associar a um maior ou menor comprometimento da QV, mas ainda há escassez de trabalhos com idosos incontinentes. Embora já existam instrumentos de avaliação genérica das estratégias de enfrentamento disponíveis para uso no Brasil, nesta revisão, não foram encontradas pesquisas sobre a forma de enfrentamento da IF na população em geral ou entre os idosos. Esta revisão confirma a necessidade de mais estudos sobre como a IF afeta os idosos e como os mesmos lidam com essa disfunção.

Race and ethnicity do not contribute to differences in preoperative urinary incontinence severity or symptom bother in women who undergo stress incontinence surgery

OBJECTIVE

The purpose of this study was to determine whether race/ethnicity affects urinary incontinence (UI) severity and bother in women who undergo surgery for stress incontinence.

STUDY DESIGN

We used baseline data from participants in the Stress Incontinence Surgical Treatment Efficacy trial. UI severity was measured by the number of leakage episodes during a 3-day urinary diary and by urodynamic evaluation. UI bother was measured with the Urogenital Distress Inventory. Race/ethnicity classification was based on self-report.

RESULTS

Of the 654 women, 72 women (11%) were Hispanic; 480 women (73%) were non-Hispanic white; 44 women (6.7%) were non-Hispanic black, and 58 women (8.9%) were of other race/ethnicity. No differences were seen in any UI severity measures. Non-Hispanic white women had the lowest Urogenital Distress Inventory scores on bivariate analysis, which was explained by socioeconomic status, body mass index, and age on multivariate analysis.

CONCLUSION

Factors other than racial/ethnic differences underlie variations in UI symptoms and bother in this group of women who sought surgery for stress incontinence.

The social consequences of living with and dealing with incontinence--a carers perspective

Incontinence is a discrediting and stigmatising condition for those who experience it, as it signifies a person who is lacking in self-control. For their carers, the very nature of undertaking 'dirty work' signifies a low status and low paid job. Those health care professionals higher in status and financial reward put distance between themselves and bodywork, especially bodywork that deals with bodily decay. However, little is known or has been highlighted about the social consequences that living with and dealing with incontinence can have on informal carers. In this paper we examine the notion of dirty work and 'unbounded' bodies in the role of informal carers. Through qualitative interviews with carers of stroke survivors the negative social consequences of dealing with incontinence for both the survivor and the carer are explored. We also examine the strategies employed by carers and stroke survivors in order to manage the symptom in an attempt to prove the adult status of the survivor and to protect both the identity of the survivor and the carer. The embarrassment of leakage and the moral danger of odour can lead some carers and survivors to make decisions that can isolate both within the confines of their home. In this sense the very meaning of home is transformed into an isolated and marginalised space.

Quality of life in women with stress urinary incontinence

The objective of this study was to identify clinical and demographic factors associated with incontinence-related quality of life (QoL) in 655 women with stress urinary incontinence who elected surgical treatment. The following factors were examined for their association with QoL as measured with the Incontinence Impact Questionnaire (IIQ): number of incontinence (UI) episodes/day; self-reported type of UI symptoms (stress and urge); sexual function as measured by the Prolapse/Urinary Incontinence Sexual Questionnaire; symptom bother as measured by the Urogenital Distress Inventory; as well as other clinical and sociodemographic factors. A stepwise least-squares regression analysis was used to identify factors significantly associated with QoL. Lower QoL was related to the greater frequency of stress UI symptoms, increasing severity, greater symptom bother, prior UI surgery or treatment, and sexual dysfunction (if sexually active). Health and sociodemographic factors associated with lower incontinence-related QoL included current tobacco use, younger age, lower socioeconomic status, and Hispanic ethnicity.

"It can always happen": the impact of urinary incontinence on elderly men and women

OBJECTIVE

To determine the impact of urinary incontinence (UI) on the quality of life of the elderly in the general population and to identify factors with the greatest effect.

DESIGN

Qualitative and quantitative analyses of interview data.

SETTING

Patients from the nine family practices of the Nijmegen University Research Network.

SUBJECTS

Independently living patients aged 60 and over.

MAIN OUTCOME MEASURES

All independently living patients aged 60 and over with uncomplicated UI were interviewed at home using the Incontinence Impact Questionnaire and open-ended questions.

RESULTS

In total, 56 men and 314 women were interviewed. A majority do not have such an impact. In the Incontinence Impact Questionnaire (IIQ) emotional well-being was most affected. Half to one-third of the patients felt nervous, embarrassed, or frustrated because of their incontinence. In the social domain "clothing" and "fear of odour" scored the highest impact. The most affected practical consequence in the IIQ was "going to places where you are not sure about the availability of a toilet" followed by "travelling longer than 20 minutes" and "entertainment". Men reported higher impact scores than women, despite the fact that incontinence was less severe in men. The most important effect of incontinence reported in men was "being out of control" while most women considered "feeling impelled to take several precautions" to be the most important consequence of UI.

CONCLUSION

UI affects nearly half of patients, particularly as regards their emotional well-being and in public activities. Men experienced more impact compared with women and experienced loss of control more often than women.

Impact of overactive bladder symptoms on employment, social interactions and emotional well-being in six European countries

OBJECTIVE

To determine the impact of overactive bladder (OAB) symptoms on issues related to employment, social interactions, and emotional well-being in a population aged 40-64 years.

SUBJECTS AND METHODS

The study comprised a cross-sectional population-based survey of 11 521 individuals aged 40-64 years, conducted in France, Germany, Italy, Spain, Sweden, and the UK. The survey involved a two-stage screening procedure. Initially, individuals with any lower urinary tract symptoms were identified. Those whose only symptom/(s) was suggestive of a urinary tract infection, stress incontinence, or prostate obstruction were excluded from further study. Respondents were asked questions about the impact that their symptoms had on their emotional well-being, social interactions and productivity at home and at work.

RESULTS

Of those with OAB, approximately 32% (1272) reported that having these symptoms made them feel depressed, and 28% reported feeling very stressed. There were statistically significant differences in reported feelings of stress and depression when OAB symptoms were stratified by OAB with incontinence (OAB+) vs those with OAB with no incontinence (OAB-), with values for emotional stress of OAB+ 36.4% vs OAB- 19.6%, for depression of OAB+ 39.8% vs OAB- 23.3%. Participants with OAB+ were significantly more likely than those with OAB- to express worry about having accidents and concern about participating in activities away from home because of their bladder symptoms. In addition, those with OAB+ were significantly more likely to report that these bladder symptoms were a source of great concern and made them feel uncomfortable in social situations compared to those with OAB-. Men were significantly more likely than women to report OAB+ having an impact on their daily work life, including worry about interrupting meetings, impact on decisions about work location and hours, and voluntary termination or early retirement. This effect was primarily in men reporting OAB+.

CONCLUSION

OAB symptoms have a significant effect on the emotional well-being and productivity of those affected, both at home and at work.

A review of quality-of-life questionnaires for urinary incontinence and overactive bladder: which ones to use and why?

Overactive bladder (OAB) and stress urinary incontinence have a profound impact on patients' health-related quality of life (HRQL). The purpose of this article is to identify and describe condition-specific HRQL measures validated among patients with symptoms of OAB or stress urinary incontinence. A Medline literature search was performed to identify published articles or abstracts focusing on the development and psychometric validation of relevant instruments. Target populations and psychometric properties (reliability, validity, responsiveness to change) of 16 questionnaires are reviewed. A range of well-validated, condition-specific HRQL measures are available. Recommendations are provided regarding which measures to use in different situations. When choosing among instruments, psychometric evidence and the match of an instrument to the study population should be considered.

Urinary incontinence: historical, global, and epidemiologic perspectives

Urinary incontinence (UI) is a devastating worldwide problem in older adults. Establishing the true prevalence and incidence of UI remains a challenge as different societies define and approach UI differently. Nevertheless, most societies share the common practice of stigmatizing elders with incontinence. Enhanced awareness of global perspectives and epidemiological trends of incontinence isa necessary pre-requisite to improving management of this distressing geriatric syndrome.

Psychosocial impact of urinary incontinence in the elderly population

The impact of urinary incontinence extends well beyond the evident physical and physiologic sequelae. Incontinence may leave affected persons in social, emotional, and mental disarray. Measuring the psychosocial impact of a disease, however, is difficult,and there is no single best tool to achieve such an assessment. Several incontinence-specific tools have been devised to document the impact of this condition and are described briefly in this review. Outcome measures have, until recently, focused on objective data; however, from the patient's viewpoint, subjective psychosocial measures may be a better reflection of the success ofa treatment intervention. For a variety of reasons, the majority of affected persons do not seek help. If the full benefit of treatment options is to be realized, the health care provider actively should seek a history of incontinence in patients who may be ashamed or embarrassed.

Symptom severity and QOL scales for urinary incontinence

Symptoms of incontinence are common, particularly among older people, and incontinence can have a severe effect on the quality of life of some individuals at any age. A number of treatments are available, most of which aim to reduce the occurrence of incontinent episodes or to limit the effects of the disorder on everyday life. In research and clinical practice, it is essential that the symptoms and effects of incontinence be properly assessed and recorded. The only valid means of measuring patients' perspectives is through the use of psychometrically robust self-report questionnaires. Incontinence may be experienced as part of the symptom complex of a range of conditions (e.g., benign prostatic diseases or fistulas), and the effect of incontinence on quality of life varies depending on the severity of the condition and other psychosocial and medical factors. Questionnaires with acceptable levels of psychometric testing are identified and recommended for use in clinical practice and research investigations according to the following categories: (1) questionnaires to assess symptoms of incontinence, (2) generic health-related quality-of-life questionnaires to assess the effect of incontinence on quality of life, and (3) incontinence-specific measures to assess the effect and bothersomeness of incontinence on quality of life.

Urinary incontinence among older women. Measurement of the effect on health-related quality of life

For women, urinary incontinence and other related lower urinary tract symptoms (e.g., nocturia, urinary urgency, frequency) are common, often increasing as women age. Urinary incontinence, however, is more than just a physiologic loss of urine. Emotional distress is also a significant issue for incontinent individuals. Researchers and clinicians are increasingly aware of the importance of identifying urinary incontinence and, in particular, urinary incontinence that causes distress or adversely effects health-related quality of life. This article addresses the effect of urinary incontinence on health-related quality of life among elderly women. Selected methods for evaluating health-related quality of life are highlighted and discussed. Suggestions are included for gerontological nurses interested in evaluating the effect of urinary incontinence on older women.

Correlations among measures of bladder function and comfort

There is a need for standard functional and psychosocial measurements of compromised urinary bladder syndrome (CUBS). Utilizing Kolcaba's Comfort Theory, the purpose of this study was to assess the psychometric properties and relationships among 8 measures of comfort, status of urinary frequency and incontinence, and quality of life. A convenience sample of 47 persons (45 women, 2 men) ages 25 to 92, who had UI for more than 6 months, was recruited. Data were collected twice with a 2-week interval. We examined (a) 1 measure of the immediate outcome of comfort related to CUBS, (b) 5 measures of UI status, and (c) 2 measures of quality of life. Reliabilities were adequate for all measures. Relationships among variables are presented and discussed. Recommendations are made for measures that detect improvement over time related to first line interventions.

Self-reported social and emotional impact of urinary incontinence

OBJECTIVE

Incontinence-specific and generic measures of well-being were regressed on potential predictors to identify incontinent respondents at risk for psychosocial distress and to understand the relationship between urinary incontinence (UI) and other determinants of social and emotional status.

DESIGN

Survey data were collected May 1994 through April 1996.

SETTING

Telephone interviews as a supplement to a nationally representative monthly consumer survey.

PARTICIPANTS

Analyses were based on 1,116 continent and 206 incontinent respondents age 40 and older.

MEASUREMENTS

Incontinent respondents self-reported the extent to which urine loss restricted social activities or affected their feelings about themselves. All respondents were asked whether they felt depressed, lonely, or sad. Covariates included sex, age, race, education, social desirability, health status, frequency of urine loss, quantity of loss, and urgency.

RESULTS

The majority of incontinent respondents reported that urine loss did not restrict activities or diminish self-esteem. Incontinent respondents who were younger, male, less educated, lower in social desirability, in poorer health, or losing greater quantities of urine were more likely to report psychosocial distress, although these correlates were not consistently significant. Compared with continent respondents, significantly higher percentages of incontinent respondents reported feeling depressed, lonely, or sad. In the multivariate models, incontinence retained an independent association with loneliness, but not with sadness or depression.

CONCLUSION

Even though the direct psychosocial impact of urine loss may be minor in many cases, UI is associated with a constellation of physical and behavioral factors that can impose a social and emotional burden. This suggests that UI cannot be adequately evaluated or treated without consideration of the patient's overall quality of life.

Health-related quality of life among adults with symptoms of overactive bladder: results from a U.S. community-based survey

OBJECTIVES

To assess, by means of a survey, the impact of the symptoms of overactive bladder (urinary frequency, urgency, and urge incontinence) on the quality of life in a community-based sample of the U.S. population.

METHODS

A telephone survey was conducted in the United States among an age and sex-stratified sample of 4896 noninstitutionalized adults 18 years of age and older. From the responses to the telephone survey, a total of 483 individuals with symptoms of overactive bladder and 191 controls completed a mailed follow-up questionnaire to assess their quality of life using the Medical Outcomes Study Short-Form 20.

RESULTS

After adjustment for age, sex, and the use of medical care, the greatest differences in the quality-of-life scores between the patients with incontinent overactive bladders and the controls were in the health perception (17.6 points; P <0.001) and role functioning (13.0 points; P <0.001) scales. Those with an overactive bladder with the symptoms of frequency or urgency, or both, but without incontinence, also had significantly lower scores than did the controls in mental health (P = 0.026), health perception (P = 0.01), and bodily pain (P = 0.016).

CONCLUSIONS

These data indicate that individuals with an overactive bladder experience decrements in their quality of life relative to community controls. An important new finding from this study is that individuals with an overactive bladder, even without demonstrable urine loss, also have a poorer quality of life than that of controls.

Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians

OBJECTIVES

This study explored reasons why older adults with urinary incontinence (UI) do not initiate discussions with or seek treatment for UI from their primary care provider.

DESIGN

A randomized, prospective controlled trial involving 41 primary care sites.

SETTING

Primary care practice sites.

PARTICIPANTS

49 older adults age 60 and older not previously screened for UI by their primary care doctor.

MEASUREMENTS

Demographic data, self-reported bladder-control information using questionnaires, and health status.

RESULTS

Adults who did not discuss UI were older, had less-frequent leaking accidents and fewer nighttime voids and were less bothered by UI than those who did. The two main reasons why patients did not seek help were the perceptions that UI was not a big problem (45%) and was a normal part of aging (19%).

CONCLUSIONS

Embarrassment or lack of awareness of treatment options were not significant barriers to discussing UI. Adults with a fairly high frequency of UI (average of 1.7 episodes per day) did not view UI as abnormal or a serious medical condition.

[Validity of the King's Health questionnaire in the assessment of quality of life of patients with urinary incontinence. The King's Group]

BACKGROUND

To assess the validity of the Spanish version of the King's Health Questionnaire (KHQ) for measuring the quality of life of women with different types of urinary incontinence.

PATIENTS AND METHODS

77 women with urinary stress incontinence (USI), 51 with urge incontinence (UUI) and 34 with mixed urinary incontinence (MUI) were consecutively recruited. Subjects were diagnosed using urodynamic tests. Patients completed the KHQ and SF-36 questionnaires on inclusion in the study, after 15 days, and again after one month.

RESULTS

There were no significant differences in socio-demographic and QOL characteristics between different UI groups. UUI and MUI patients had greater urinary frequency and urge than USI patients, and USI and MUI patients had a greater number of leakage episodes than UUI patients. Correlations between dimensions on the KHQ and the SF-36 were moderate to strong. Women with greater urinary frequency, greater urgency, more incontinence episodes during the week and who used pads and nappies perceived a worse quality of life. Changes in these variables correlated with changes in HRQOL. The internal consistency of dimensions was good (0.65-0.92) as was test-retest reliability (0.68-0.88). Dimensions most sensitive to change after one month of treatment were impact of UI, seriousness of UI, and the symptoms scale (effect size greater than 0.6).

CONCLUSION

The KHQ is a valid instrument for measuring the quality of life of patients with different types of UI. Improvements in urinary frequency, urinary urgency, number of leakage episodes, and changes in the type of protective material produces an increase in HRQOL.

The association of depressive symptoms and urinary incontinence among older adults

OBJECTIVES

To examine the relationship of urinary incontinence (UI) and depressive symptoms (DS) in older adults.

DESIGN

A randomized, controlled trial to determine the effects of clinical practice guideline implementation on provider attitudes and behavior, and patients' UI, health status, quality of life, and satisfaction with care. Baseline and endpoint data were collected from patients via computer-assisted telephone interviewing.

SETTING

Forty-one nonacademic primary care practices (PCP) in North Carolina.

PARTICIPANTS

A total of 668 community-dwelling adults (age > 60) who had visited the one of the selected PCPs.

INTERVENTION

PCPs in the intervention group were given instruction in the detection and management of UI, educational materials for providers and patients, office system supports, and academic detailing.

MEASUREMENTS

The dependent measure was assessed using an eight-item screener for DS. UI (status, frequency, amount), health (physical, mental), and demographic (age, gender, marital status) and self-report information about bladder control served as predictors.

RESULTS

Wilcoxon rank sum tests showed that UI status was associated with moderate to severe DS (43% vs 30%, P = .05). Multivariate analyses showed that UI status, physical and mental health, and gender were significant predictors of DS. Among UI adults (n = 230), physical and mental health, life satisfaction, and the perception that UI interfered with daily life were significant predictors of DS.

CONCLUSIONS

This study provides clear evidence that UI is related to DS in older adults.

Quality of life impact of urge incontinence in older persons: a new measure and conceptual structure

OBJECTIVE

To develop a condition-specific measure for assessing the impact of urge urinary incontinence (UI) on the quality of life (QoL) of older persons.

DESIGN

A 32-item Urge Impact Scale (URIS) was drafted using content area data from focus groups composed of urge incontinent older persons. Pilot testing in 21 urge incontinent persons (mean age 67.7 years) resulted in the elimination of eight items by internal consistency, skew, and patient response criteria. The resulting scale (URIS-24) was tested for reliability (internal consistency and test-retest correlation) and construct validity (correlation with UI severity from voiding records) in a separate group of 27 urge incontinent persons (89% women, mean age 72 years). Factor analysis of URIS-24 data from the combined 48 persons was used to explore the conceptual structure underlying urge UI-related QoL.

SETTING

University-affiliated community-based practice and tertiary hospital.

PARTICIPANTS

Community-dwelling women and men, older than age 60 and with urge incontinence at least twice weekly, recruited from newspaper, newsletter, and radio advertisements.

RESULTS

Cronbach's alpha for URIS-32 was 0.84, and for URIS-24 it was 0.94. When administered (mean +/- standard deviation) 9.2 +/- 5.1 days apart, URIS-24 had good test-retest reliability for total scores (interclass coefficient = .88, concordance coefficient = .88), and individual item scores at time 2 were within 1 point (on a 5-category Likert scale) of time 1 answers for 89% of responses. URIS-24 scores had modest but nearly significant correlation with the number of UI episodes (r = -0.39, P = .05). Factor analysis revealed a three component structure corresponding to psychological burden, perception of personal control, and self concept.

CONCLUSIONS

The URIS-24 is an internally-consistent, highly reproducible tool for the assessment of the QoL impact of urge UI on older persons. It can be used to evaluate QoL impact by specific items as well as by overall score. Compared with other UI-specific QoL measures, the URIS-24 had similar or superior internal consistency, test-retest reliability, and validity, but it is the first measure designed and tested specifically for older persons with urge UI. These results also highlight the multifactorial structure of urge UI-related QoL and the importance of its psychological dimensions.