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ORIGINAL RESEARCH |
From the School of Nursing, and Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey; and Department of Obstetrics and Gynecology, Loyola University Medical Center, Maywood, Illinois.
Address reprint requests to: Carolyn M. Sampselle, PhD, RNC, University of Michigan, School of Nursing, 400 North Ingalls, Ann Arbor, MI 48109-0482; E-mail: csampsll{at}umich.edu.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: Baseline data from the longitudinal cohort of the Study of Women’s Health Across the Nation, a prospective, multiethnic, multisite study of the natural history of menopausal transition was used (n = 3302). Interview and self-completed questionnaires assessed most variables of interest. Body mass index and diabetes mellitus were measured clinically. Incontinence severity was derived by multiplying frequency by volume leaked. Risk factors and effect on treatment seeking, bother, and nighttime voiding were assessed by the construction of multiple logistic regression models for each ethnic group and the total population.
RESULTS: Mean age was 46.4 years. Incontinence prevalence was 57%, with nearly 15% categorized as moderate and 10% as severe. Biologic factors constituted the most important risk for severity, specifically perimenopausal compared with premenepausal status (odds ratio [OR] 1.35), body mass index (OR 1.04), diabetes mellitus (OR 1.55), and current smoking (OR 1.38). Nonwhite groups had lower risk, but the relationship of ethnicity is complex. Severity was associated with likelihood of discussing with a health care provider, with bothersomeness, and with likelihood of nighttime voiding.
CONCLUSION: Large numbers of perimenopausal women experience urinary incontinence with 25% wearing protection or changing undergarments on several days per week. Mutable factors predicting severity included body mass index and current smoking.
Despite extensive epidemiologic investigation of urinary incontinence in women, understanding of the scope of the problem is hampered by the lack of standard categorization of symptom severity and the paucity of ethnically diverse data. Urinary incontinence affects at least one in three women,1,2 but this estimate is derived from primarily white samples. Most women who report the condition in surveys do not actually seek treatment, and the scope of severity and its impact on daily life is not well understood.3 Age, parity, and body mass index (BMI) are generally accepted risk factors for urinary incontinence. The evidence is mixed regarding the contribution of menopausal status, cigarette smoking, and diabetes mellitus.
Prevalence estimates are typically based on any incontinence, where even a few drops of urine loss constitute a positive designation. The absence of clearly defined categories of severity complicates interpretation of prevalence estimates and the prediction of risk. Some studies have used frequency of incontinence episodes as an index of severity,4,5 but the volume of urine lost is also a critical component. For example, leakage might occur less than weekly but in an amount that is evident on outer clothing. Such an event would likely have more of a life impact than would a greater frequency of concealable incidents. Sandvik et al6 have validated a severity index of female incontinence that combines frequency and volume. This method was used to calculate urinary incontinence severity in the study presented here.
The purposes of this investigation were to document the prevalence of mild, moderate, and severe urinary incontinence among ethnically diverse perimenopausal women, to identify significant risk factors, and to assess the impact on daily life by testing the relationship of severity to treatment seeking, level of bother, and nighttime voiding.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Common assessment protocols, approved by respective institutional review boards, were used across the seven study sites. At the baseline enrollment visit, after giving informed consent, women were asked to answer interview questions and a self-completed questionnaire. Their height and weight were measured. A blood sample to determine glucose level was taken following an 8-hour fast during days 2–7 of the follicular phase of the menstrual cycle. Blood was maintained at 40C (for up to 1 hour) until it was centrifuged. Serum was frozen at -80C until it was sent on dry ice to the Medical Research Laboratories. Throughout the study, the laboratories participated in, and remained certified by, the National Heart, Lung, and Blood Institute, Centers for Disease Control Part III program. Glucose was measured using a hexokinase-coupled reaction (Boehringer Mannheim Diagnostics, Indianapolis, IN).
Age, menopausal status, and ethnicity were self-reported. Menopausal status was classified as: early perimenopausal, indicating at least one menses had occurred in the past 3 months but had become less predictable; and premenopausal, indicating menses had occurred in the past 3 months with no change in predictability. Primary race/ethnicity was self-defined as black, non-Hispanic white, Chinese or Chinese American, Japanese or Japanese American, or Hispanic (Central American, Cuban or Cuban American, Dominican, Mexican or Mexican American, Puerto Rican, South American, Spanish or other Hispanic). Respondents could also specify "other," "mixed," or no primary ethnic affiliation; these latter women were not recruited into the longitudinal cohort.
Information on experience of urinary incontinence was obtained on the self-administered questionnaire. Participants were asked, "In the past year, have you ever leaked even a very small amount of urine involuntarily?" (yes/no). Those women who indicated incontinence were asked two questions related to the leakage. To assess frequency of incontinence, participants answered the question, "In the last month, on about how many days have you lost urine, even a small amount beyond your control?" (never/less than one day per week/several days per week/almost daily or daily), with responses scored from 1 to 4. Volume of leakage was estimated by the question, "How much urine do you leak?" A response of "A drop or two" was scored as 1, whereas other responses such as "Enough to change undergarments or to wear liner or pad" were scored as 2.
Severity of incontinence was derived from these two variables by multiplying the frequency score by the volume score. Slight incontinence was defined as a score of 1 or 2, moderate incontinence as a score of 3 or 4, and severe incontinence as a score greater than 4. Thus, we were able to calculate severity in a manner consistent with the scale developed and validated by Sandvik et al.6 Information about duration of urinary incontinence was obtained by the question, "How long ago did you notice leakage of urine?" (within the past year/1–2 years ago/3–4 years ago/5–9 years ago/10 or more years ago).
Women were asked to check off whether or not they had used specific measures to control or remedy the leakage. Participants who stated that they discussed leakage with a doctor, nurse, or other health care provider, had surgery, or were taking prescribed medications were categorized as having discussed incontinence with a health care professional. Participants were also asked to estimate the level of bother associated with leakage of urine on a scale from 0 to 10, where 0 = "Not bothered at all," 5 = "Somewhat bothered," and 10 = "Extremely bothered." For the purpose of the analysis, extent of bother was dichotomized at the median value, using a cutoff point of less than 5 or greater than or equal to 5, with the latter category including all women who indicated that they were somewhat to extremely bothered by the leakage. Nighttime voiding was assessed by the question, "How often do you usually get up from bed at night to urinate?," and the responses were classified as less than once per week or once per week or more.
Covariates included education (below college level/college or above), self-reported health status (excellent/very good/good/fair/poor), and parity (yes/no). Level of financial strain was assessed by the question, "How hard is it for you to pay for the very basics like food, housing, and medical care?" (very hard/somewhat hard/not hard at all). Smoking status was defined by two variables as currently smoke cigarettes (yes/no) and ever smoked cigarettes (yes/no). Women were categorized as diabetic if they reported that a health care provider had ever told them that they had diabetes or if their serum glucose level was greater than 125 mg/dL. Women were categorized as having leiomyomata if they reported that a health care provider had ever told them that they had the condition. Access to health care was evaluated using reported time since last visit to a health care provider (year or less/1–2 years or less/3–5 years/5 years or more/never). Body mass index was calculated as weight in kilograms divided by height in meters squared.
The analysis addressed three questions. We assessed the prevalence of urinary incontinence and risk factors associated with having any incontinence. Among women who reported any incontinence, we evaluated risk factors associated with having moderate/severe incontinence. Finally, we assessed the impact of incontinence on women’s daily lives using likelihood of discussing leakage with a health care provider, the level of bother associated with incontinence, and the likelihood of nighttime voiding as indicators of daily life impact. Of the 3302 women who were enrolled in the longitudinal cohort, 44 (1.3%) were missing information on presence of urinary incontinence; thus, 3258 women were eligible for this analysis. Information on severity of incontinence, discussing leakage with a health care provider, level of bother, and nighttime voiding was missing for an additional 23 (0.7%), 16 (0.5%), 11 (0.3%), and seven (0.2%) women, respectively. All analyses used SAS for Windows 6.12 (SAS Institute Inc., Cary, NC).
For each incontinence outcome, we first calculated frequency distributions for relevant covariates and then evaluated the association between the outcome variable and each independent variable using 
2 tests, analysis of variance, and Kruskal-Wallis tests as appropriate. Crude odds ratios and their corresponding 95% confidence intervals (CI) were calculated.
To evaluate risk factors associated with having any incontinence and with having moderate/severe incontinence, multiple logistic regression models were constructed for each race/ethnic group and for the total population of women. A three-stage approach was used to build the regression models. In the first stage, menopausal (perimenopausal versus premenopausal) status, age, and ethnicity were included. In the second stage, we individually added parity, BMI, diabetes, smoking, and leiomyomata. For continuous variables, age and BMI, we first examined the assumption of linearity. Age did not satisfy the assumption of linearity and was categorized as 47 or fewer years and more than 47 years. In the third stage, we included only those variables that were significantly associated with the outcome (P = .05) in the second stage. According to SWAN guidelines, site and ethnicity were retained in all models. To evaluate possible interactions with ethnicity, we examined whether the magnitude of the association differed by ethnicity in the ethnic-specific models. Possible interactions were then evaluated in the total population model. Log-likelihood ratio tests were conducted to examine the difference between models, and goodness-of-fit of the final model was assessed using Hosmer-Lemeshow 2 statistics, based on differences between observed and predicted values. We also compared risk factors in women with no incontinence with those in women with moderate/severe incontinence. The results of this analysis are not shown because they were consistent with results from the analyses of mild-to-moderate/severe urinary incontinence.
Next, we considered daily impact on life by estimating the effect of severity of incontinence on likelihood of women reporting they had discussed the problem with a health care provider (yes/no), on self-reported level of bother (somewhat/very bothered), and on the likelihood of nighttime voiding (less than once per week/once per week or more). Multiple logistic regression was used to adjust for potential confounders including age, duration of incontinence, access to health care, and sleeping difficulties as appropriate.
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RESULTS |
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). Any incontinence was reported most frequently by white women and least frequently by Hispanic women. Consistent with the eligibility criteria, women ranged in age from 42 to 52 years with a mean age of 46.4 (±2.7) years. Table 2 presents further information on the demographic and health characteristics of the study population.
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presents the final adjusted model of risk factors for self-report of any urinary incontinence in the past year. Older age, perimenopausal status, and parity independently increased the odds of urinary leakage. Each unit increase in BMI was associated with a 5% increase in the odds of having leakage. Thus, an increase in BMI per standard deviation (7.13 units) was associated with a 43% increase of urinary incontinence.
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Among women who reported having any urinary incontinence, biologic factors including perimenopausal status, BMI, diabetes, and current smoking were important risk factors for severity (Table 4). Consistent with SWAN guidelines, ethnicity was retained in the analysis, but neither age, ethnicity, nor education was associated with moderate or severe urinary incontinence.
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presents prevalence of discussing leakage with a health care provider, the level of bother women associate with their incontinence, and nighttime voiding, variables that we used as indicators of impact on daily life. Twelve percent of women had discussed the problem with a provider, with variation by ethnicity. Overall, 50% of women were somewhat to extremely bothered by the condition, with Hispanic women most likely and Chinese women least likely to report a high level of bother. Almost 60% of women reported having some nighttime voiding.
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). Severity was strongly associated with level of bother. Moreover, Hispanic women and women reporting financial strain had increased odds of reporting a high level of bother. Severity also was associated with nighttime voiding.
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DISCUSSION |
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The few studies that have compared incontinence in white and black women have reported inconsistent findings. Using prevalence in white women as the reference, other ethnicities in our sample were approximately two to three times less likely to report any incontinence. This finding converges with those of others10,11 with respect to decreased risk in black women and is consistent with higher levels of pelvic floor strength reported in this ethnic group.12 With respect to prediction of severity, the effect of ethnicity was not significant. A partial explanation for this may be the relatively low numbers of Chinese, Japanese, and Hispanic women in our sample. However, our black representation is robust and the lack of a race/ethnicity effect when severity is taken into account is convergent with the findings of Fultz et al10 that race was not related to severity of urine loss (as measured by frequency). It is noteworthy that in the study presented here, significant effects for ethnicity disappeared when BMI was entered into the model for prediction of severity (Table 4
). Study of ethnicity as a risk factor has not consistently taken BMI into account. Our findings suggest that BMI may subsume the effects of ethnicity on severity.
There are widely disparate levels of agreement in the literature for the contribution of various other factors to incontinence risk. Consideration of severity level enabled us to disentangle some of this confusion. Current evidence supports the association of age, parity, and BMI with incontinence: prevalence is greater among older as compared with younger women,13,14 in those with a history of vaginal birth as compared with their nulliparous counterparts,15,16 and in more obese as compared with thinner women.17,18 The published evidence is less convincing for the contribution of menopausal status, cigarette smoking, and diabetes mellitus. Our data suggest that menopausal status (perimenopause versus premenopause), BMI, and diabetes are significant predictors of any incontinence as well as of severity. BMI has long been recognized as a risk factor for the development of incontinence3; our analysis further demonstrates the contribution of BMI to increased severity. There have been conflicting reports about the role of menopause, with some investigators finding prevalence equal between pre- and postmenopausal women, but severity greater in postmenopause.8 Others have reported lower levels of incontinence after menopause.19 We focus on the perimenopause, and our data suggest that perimenopause as compared with premenopause is a risk factor for both the presence of any incontinence and increasing severity. Moreover, perimenopausal status was a stronger and more consistent predictor than was age. Our sample was restricted to 42–52 years of age, resulting in a relatively homogeneous age span that could contribute to the decreased effect of age. However, our results are consistent with those reported by others who found incontinence more prevalent in perimenopausal than premenopausal women.20 The neurologic pathology of diabetes mellitus would be expected to increase the risk of incontinence, but the demonstration of such a relationship has been inconsistent.21,22 We show diabetes to increase by more than 50% the risk of any incontinence and of increased severity.
In comparison with their white counterparts, it is noteworthy that black women without a history of leiomyomata had 1/3 the risk of incontinence, whereas those with such history had an increased risk of greater than 80%. We speculate that the propensity of black women to develop larger leiomyomata likely increases the prevalence of stress urinary incontinence, but without the ability to categorize type of incontinence in this data set, we were unable to test that hypothesis. Designation as a current smoker was associated with increased risk of moderate/severe incontinence levels. Earlier studies reported current smoking to be a contributing factor, but did not consider severity.23,24 This association of current versus previous history of cigarette smoking may be due to the greater likelihood of a smoker’s cough, which would yield increased intra-abdominal pressure as a factor in the significant association with severity.
Although women of greater parity were more likely to report any incontinence, variation in parity level was not associated with severity. Cumulative effects of parity have been observed in other studies,25 but in the study reported here, severe urinary incontinence was as common in primiparas as in multiparas, and higher parity did not necessarily add to symptom severity. This finding should be viewed with caution, given the inclusion of cesarean within the parity designation. Reported history of diabetes was considered sufficient basis for categorization as diabetic, regardless of current fasting glucose levels. Thus, a woman who might have experienced gestational diabetes could be classified as diabetic. This convention increases the potential association of diabetes with incontinence through parity; however, the association of diabetes persisted even when controlling for parity, reflecting the robustness of diabetes as a predictor.
More than 8% (95% CI 6.7, 9.2) of our respondents had not visited a health care provider in the previous year. This proportion is slightly more than the 6.7% (95% CI 6.4%, 7.1%) reported for the year 2001 in the National Health Interview surveys for older women.26 The higher proportion in our sample likely reflects greater numbers of ethnically diverse, lower-income cases. We expected to find a relationship between severity level and likelihood of discussing incontinence with a health care provider as has been shown in other studies.27,28 Even when controlling for ethnicity, site, duration, and access to health care, this relationship was significant (Table 5). These findings underline the substantial impact on women’s daily lives that moderate and severe urinary incontinence impose.
Impact on daily life is further demonstrated in the significant and progressive level of bother reported by women as the level of severity increases from mild to moderate to severe (Table 6). This finding is consistent with those of others,6,9 but we further show ethnic differences in the bothersomeness of this condition. Hispanic and black women experienced greater levels of bother with increasing severity than did their white counterparts. This suggests that all women should be carefully screened for urinary incontinence, despite decreased risk in nonwhite ethnic groups.
Historically, nighttime voiding has been an accepted aspect of aging, and various medical textbooks present it as a normal circumstance after the age of 50.29–31 In fact, 34% of our sample reported voiding "once a night every night or more often." A recent survey of communitydwelling women showed only 37% of those 40–60 years never experienced nighttime voiding, but no assessment of a relationship with incontinence was reported.1 Further analysis of our data was consistent showing only 40% never or rarely experiencing nighttime voiding. However, as presented in Table 6, increasing severity of urinary incontinence was significantly associated with nighttime voiding. In other studies, greater levels of nighttime voiding correlated positively with increased frequency of incontinence, but volume was not considered as an aspect of severity.2,8 We found incontinence severity to be an independent predictor of nighttime voiding. That is, women with no or mild incontinence were significantly less likely to experience frequent nighttime voiding than women with moderate or severe levels. Thus, the question emerges, might nighttime voiding decrease with effective treatment of incontinence? Prospective evidence of a beneficial effect of improved continence was demonstrated recently when nighttime voiding diminished significantly as incontinence episodes diminished.32
Taken together, it is clear that large numbers of women are affected by urinary incontinence. The proportion in the moderate and severe categories underlines the threat to women’s physical and emotional well-being. It is noteworthy that 25% of our sample experienced at least enough leakage to warrant wearing protection or changing undergarments on several days per week. More consistent screening without regard to ethnicity and more effective patient education about mutable risk factors such as BMI and current smoking are warranted.
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Footnotes |
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The manuscript was reviewed by the Publications and Presentations Committee of the Study of Women’s Health Across the Nation and has its endorsement.
The authors thank the study staff at each site and all of the women who participated in the Study of Women’s Health Across the Nation.
Received December 28, 2001. Received in revised form May 9, 2002. Accepted May 30, 2002.
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REFERENCES |
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J. S. Brown, H. Wessells, M. B. Chancellor, S. S. Howards, W. E. Stamm, A. E. Stapleton, W. D. Steers, S. K. Van Den Eeden, and K. T. McVary Urologic Complications of Diabetes Diabetes Care, January 1, 2005; 28(1): 177 - 185. [Full Text] [PDF]
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I. E. Nygaard and M. Heit Stress Urinary Incontinence Obstet. Gynecol., September 1, 2004; 104(3): 607 - 620. [Abstract] [Full Text] [PDF]
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R A. Jackson, E Vittinghoff, A M. Kanaya, T P. Miles, H E. Resnick, S B. Kritchevsky, E M. Simonsick, and J S. Brown Urinary Incontinence in Elderly Women: Findings From the Health, Aging, and Body Composition Study Obstet. Gynecol., August 1, 2004; 104(2): 301 - 307. [Abstract] [Full Text] [PDF]
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 L. R. Berkowitz Case 20-2004 - A 46-Year-Old Woman with Pelvic-Floor Relaxation after a Second Vaginal Delivery N. Engl. J. Med., June 24, 2004; 350(26): 2699 - 2706. [Full Text] [PDF]
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J. M. Holroyd-Leduc and S. E. Straus Management of Urinary Incontinence in Women: Scientific Review JAMA, February 25, 2004; 291(8): 986 - 995. [Abstract] [Full Text] [PDF]
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