ABSTRACT
Background:
A study was done on the prevalence, risk factors, and treatment-seeking behavior of elderly women with urinary incontinence (UI) residing in Kochi Corporation, Kerala, India. The community-based cross-sectional study was done in Kochi on 525 elderly women aged 60 years and above, selected by cluster random sampling, after getting consent, using a questionnaire. The overall prevalence of UI was found to be 64% (95% confidence interval (CI) 59.5–67.6). The most common type of UI was found to be the urge type of incontinence (38.3%, 95% CI, 34.14–42.45). Chronic cough (odds ratio [OR] 1.754, 95% 1.170–2.631), chronic constipation (OR: 1.563, 95% CI: 1.030–2.373), obesity (OR: 1.591, 95% CI: 1.110–2.280), diabetes (OR: 1.517, 95% CI: 1.036–2.222), and taking medications for diabetes and hypertension (OR: 1.476, 95% 1.008–2.163) were found to be risk factors of UI. Multiparity (OR: 1.757, 95% CI: 1.073–2.876), delivery at home (OR: 1.761, 95% CI: 1.205–2.575), undergoing any pelvic surgery (OR: 1.504, 95% CI: 1.052–2.150) were the gynecological and obstetric factors associated with UI.
Context:
Very few community-based studies are available on UI among elderly women.
Aim:
The primary objective of the study was to estimate the prevalence of UI among elderly women residing in the Kochi corporation. The secondary objective was to determine the risk factors of UI.
Settings and Design:
A community-based cross-sectional study was done in the Kochi Corporation of Ernakulam district.
Subjects and Methods:
A pilot study was conducted and based on this, the sample size was computed to be 72.41. Data from 525 individuals were collected using cluster random sampling. A questionnaire for urinary incontinence diagnosis questionnaire was used for assessing the type of UI.
Statistical Analysis Used:
Percentage prevalence, Chi-square test.
Results:
The overall prevalence of UI was found to be 64%. The most common type of UI was found to be the urge type of incontinence. Chronic cough, chronic constipation, obesity, diabetes, taking medications for diabetes, and hypertension were found to be risk factors of UI. Multiparity, delivery at home, and undergoing any pelvic surgery were the gynecological and obstetric factors associated with UI.
Conclusions:
The prevalence of UI among elderly women in this study was found to be 63.9%. The most common type of UI was found to be urge type of incontinence 38.3%, followed by mixed incontinence 32.3%, and stress incontinence 29.3%. Chronic cough (OR: 1.754), chronic constipation (OR: 1.563), obesity (OR: 1.591), diabetes (OR: 1.517), and taking medications for diabetes and hypertension (OR: 1.476) were found to be risk factors for UI. Multiparity (OR: 1.757), delivery at home (OR: 1.761) and undergoing any pelvic surgery (OR: 1.504) were the gynecological and obstetric factors associated with UI among elderly women in this study. Chronic cough (adjusted odds ratio [aOR] 1.64, 95% CI: 1.08–2.50), obesity (aOR: 1.64, 95% CI: 1.13–2.39), pelvic surgery (aOR: 1.64, 95% CI: 1.13–2.39), and delivery at home (aOR: 1.89, 95% CI: 1.27–2.82) were found to be independent risk factors for UI among elderly women.
KEYWORDS: Community study, elderly women, urinary incontinence
INTRODUCTION
In healthy humans, the process of urination is under voluntary control. However, under certain conditions such as intoxication, neurological disorder, coughing, sneezing, and involuntary release of urine can occur which is termed as urinary incontinence (UI). Loss of bladder control or UI is a highly prevalent condition in older people aged 60 years and over.[1] Although it occurs more often as people get older, UI is not an inevitable consequence of aging. The common types of UI in older people are stress incontinence and urge incontinence. Chronic diseases that are associated with UI include diabetes mellitus, Parkinson’s disease, dementia, stroke, chronic obstructive pulmonary disease, and arthritis.
Today, the world is facing an unprecedented phenomenon of population aging. The health-care system will need to prepare for the increasing incidences of chronic conditions within the aging population. Various studies worldwide show that UI has a profound impact on the quality of life of older people, their subjective health status,[2,3] levels of depression,[4] and need for care.[5] UI remains undetected and undertreated by health-care personnel worldwide, despite its substantial impact on affected individuals and health-care systems.[6,7] Different populations need to establish the epidemiology of UI within their communities as a necessary prerequisite to improving the management of this distressing global silent epidemic.[8]
Information about the burden and associated risk factors of UI is a deficit in our country. This study tries to address this gap.
Objectives
The primary objective of the study was to estimate the prevalence of UI among elderly women residing in Kochi corporation. The secondary objective was to determine the risk factors of UI.
SUBJECTS AND METHODS
A community-based cross-sectional study was done in Kochi Corporation of Ernakulam district. The study population included elderly women aged 60 years and above, who were residents of Kochi Corporation. Those with neurological disorders or currently having urinary tract infections were excluded.
Sample size
A pilot study was conducted among 50 elderly women for sample size calculation where the prevalence was found to be 58%. Based on this and with 95% power and 80% allowable error, using the formula (Zα)2 pq/d², the sample size was computed to be 72.41.(where Zα = 1.96, p = 58, q = 100p = 42, d = 20% of p = 11.6). Since the study adopted cluster sampling, the obtained sample was multiplied by a design effect of two and minimum sample size was calculated to be 144. Data from 525 individuals were collected for the study. The initial sample of 50 obtained for the pilot study was excluded from the final study.
Sampling technique
This study used cluster random sampling. Out of the 74 divisions in Kochi Corporation, 30 divisions were chosen randomly using computer. From each division, 17 houses that formed a cluster were taken.
Study tool
Was a self-designed questionnaire. After obtaining consent, a face-to-face interview was conducted and data was collected. The questionnaire included sociodemographic details (age, sex, occupation, education, marital status, and socioeconomic status), parity, mode of delivery, chronic constipation, chronic cough, diabetes, medications, history of pelvic surgery, and treatment-seeking behavior. A questionnaire for urinary incontinence diagnosis (QUID) questionnaire was used for assessing the type of UI. Height and weight were measured to calculate body mass index (BMI).
Statistical analysis
The values obtained were tabulated on a Microsoft Excel sheet and the analysis was done using IBM SPSS statistics for Windows, version 20 (IBM Corp., Armonk, NY, USA). The percentage prevalence of UI was calculated. To test the statistical significance between various risk factors and UI, the Chi-square test was done. The study was approved by the Dissertation Review Committee of the Amrita Institute of Medical Sciences.
RESULTS
The sociodemographic features of the population are given in Table 1.
Table 1.
Sociodemographic and socioeconomic characteristics of the study population
| Variable | Frequency, n (%) |
|---|---|
| Age (years) | |
| 60–69 | 328 (62.5) |
| 70–79 | 151 (28.8) |
| ≥80 | 46 (8.8) |
| Religion | |
| Hindu | 237 (45.1) |
| Christian | 257 (49.0) |
| Muslim | 31 (5.9) |
| Education | |
| Illiterate | 29 (5.5) |
| High school | 449 (85.5) |
| Predegree or above | 47 (9) |
| Marital status | |
| Married | 238 (45.3) |
| Widow | 270 (51.4) |
| Unmarried | 14 (2.7) |
| Divorced | 3 (0.6) |
| Occupation | |
| Homemaker | 283 (53.9) |
| Skilled worker | 50 (9.5) |
| Unskilled worker | 192 (36.6) |
| Ration card status | |
| APL | 271 (51.6) |
| BPL | 254 (48.4) |
| BMI | |
| Underweight | 32 (6.1) |
| Normal | 139 (26.5) |
| Overweight | 104 (19.8) |
| Obese | 250 (47.6) |
APL: Above poverty line, BPL: Below poverty line, BMI: Body mass index
The overall prevalence of UI was 64% (95% confidence interval [CI] 59.5–67.6).
The mean age of the population with UI was 68.15 ± 6.8.
The most common type of UI was found to be urge type of incontinence (38.3%, 95% CI: 34.15–42.45) followed by mixed incontinence (32.3%, 95% CI: 26.52–38.08) and stress incontinence 29.3%, (95% CI: 25.42–33.18) [Figure 1].
Figure 1.
Prevalence of different types of urinary incontinence (n = 334)
Univariate analysis for the association of sociodemographic and socioeconomic factors with UI was done and the level of education was found to be statistically significant with a P < 0.05 [Table 2].
Table 2.
Association of sociodemographic and socioeconomic factors with urinary incontinence
| Categories | Urinary incontinence | P | |
|---|---|---|---|
|
| |||
| Yes, n (%) | No, n (%) | ||
| Marital status | |||
| Married | 148 (62.2) | 90 (37.8) | 0.619 |
| Widow | 177 (65.6) | 93 (34.4) | |
| Unmarried | 7 (50) | 7 (50.0) | |
| Divorced | 29 (66.7) | 1 (33.3) | |
| Occupation | |||
| Homemaker | 185 (65.4) | 98 (34.6) | 0.560 |
| Skilled worker | 29 (58.0) | 21 (42.0) | |
| Unskilled worker | 120 (62.5) | 72 (37.5) | |
| Education | |||
| Illiterate | 19 (65.5) | 10 (34.5) | 0.018 |
| High school | 294 (65.5) | 155 (34.5) | |
| Predegree or above | 21 (44.7) | 26 (55.3) | |
| Religion | |||
| Hindu | 156 (65.8) | 81 (34.2) | 0.291 |
| Christian | 162 (63) | 95 (37) | |
| Muslim | 16 (51.6) | 15 (48.4) | |
| APL/BPL | |||
| APL | 167 (65.7) | 87 (34.3) | 0.326 |
| BPL | 167 (61.6) | 104 (38.4) | |
APL: Above poverty line, BPL: Below poverty line
Univariate analysis for the association of comorbidities with UI in elderly women shows chronic constipation (OR: 1.563, 95% CI: 1.030–2.373), chronic cough (OR: 1.754, 95% CI: 1.170–2.631), diabetes (OR: 1.517, 95% CI: 1.036–2.222), consumption of medications for diabetes and hypertension (OR: 1.476 95% CI: 1.008–2.163) and being obese (OR: 1.591, 95% CI: 1.110–2.280) to be statistically significant with P < 0.05 [Table 3].
Table 3.
Association of comorbidities with urinary incontinence
| Category | Urinary incontinence | P | OR (95% CI) | |
|---|---|---|---|---|
|
| ||||
| Yes, n (%) | No, n (%) | |||
| Chronic cough | ||||
| Yes | 100 (70.9) | 41 (20.1) | 0.006 | 1.754 (1.170–2.631) |
| No | 234 (60.9) | 150 (39.1) | ||
| Chronic constipation | ||||
| Yes | 115 (72.3) | 44 (27.7) | 0.035 | 1.563 (1.030–2.373) |
| No | 219 (59.8) | 147 (40.2) | ||
| Obesity | ||||
| Yes | 173 (69.2) | 77 (30.8) | 0.037 | 1.591 (1.110–2.280) |
| No | 277 (65.8) | 144 (34.2) | ||
| Menopause | ||||
| <40 | 6 (46.2) | 7 (53.8) | 0.384 | 0.483 (0.160–1.460) |
| >40 | 321 (63.9) | 181 (36.1) | ||
| Hypertension | ||||
| Yes | 188 (65.3) | 100 (35.7) | 0.384 | 0.853 (0.597–1.219) |
| No | 146 (61.6) | 91 (38.4) | ||
| Diabetes | ||||
| Yes | 129 (69.7) | 56 (30.3) | 0.011 | 1.517 (1.036–2.222) |
| No | 161 (69.2) | 114 (30.8) | ||
| Hypercholesterolemia | ||||
| Yes | 111 (68.1) | 52 (31.9) | 0.152 | 0.752 (0.508–1.112) |
| No | 223 (61.6) | 139 (38.4) | ||
| Medications for diabetes and hypertension | ||||
| Yes | 243 (66.4) | 123 (33.6) | 0.045 | 1.476 (1.008–2.163) |
| No | 91 (57.2) | 68 (47.8) | ||
OR: Odds ratio, CI: Confidence interval
Univariate analysis for the association of gynecological and obstetric factors with UI in elderly women shows multiparity (OR: 1.757, 95% CI: 1.073–2.876), delivery at home (OR: 1.761, CI: 1.205–2.575), those who underwent any type of pelvic surgery (OR: 1.504, 95% CI: 1.052–2.150) to be significant risk factors for UI [Table 4].
Table 4.
Association of gynecological and obstetric risk factors with urinary incontinence
| Variable category | Urinary incontinence | P | OR (95% CI) | |
|---|---|---|---|---|
|
| ||||
| Yes, n (%) | No, n (%) | |||
| Age of first delivery | ||||
| ≤22 | 160 (68.1) | 75 (31.9) | 0.056 | 1.42 (0.991–2.041) |
| >22 | 174 (60) | 116 (40) | ||
| Age of last delivery | ||||
| ≤26 | 107 (61.5) | 67 (38.5) | 0.491 | 0.876 (0.602–1.28) |
| >26 | 226 (64.6) | 124 (35.4) | ||
| Multiparity | ||||
| Yes | 295 (65.6) | 155 (34.4) | 0.024 | 1.757 (1.073–2.876) |
| No | 39 (52) | 36 (48) | ||
| Prolonged labor | ||||
| Yes | 99 (65.1) | 53 (34.9) | 0.646 | 0.912 (0.615–1.352) |
| No | 235 (63) | 138 (37) | ||
| Cesarean section | ||||
| Yes | 35 (59.3) | 24 (40.7) | 0.466 | 0.815 (0.469–1.416) |
| No | 299 (64.2) | 167 (35.8) | ||
| Postpartum sterilization | ||||
| Yes | 122 (67.4) | 59 (32.6) | 0.191 | 1.28 (0.88–1.88) |
| No | 212 (61.6) | 132 (38.4) | ||
| Any pelvic surgery | ||||
| Yes | 193 (68) | 91 (32) | 0.025 | 1.504 (1.052–2.150) |
| No | 141 (58.5) | 100 (41.5) | ||
| Delivery at home | ||||
| Yes | 141 (71.6) | 56 (28.4) | 0.003 | 1.761 (1.205–2.575) |
| No | 193 (58.8) | 135 (41.2) | ||
OR: Odds ratio, CI: Confidence interval
On multivariate logistic analysis for independent factors for UI, chronic cough (aOR: 1.64, 95% CI: 1.08–2.50), obesity (aOR: 1.64, 95% CI: 1.13–2.39), pelvic surgery (aOR: 1.64, 95% CI: 1.13–2.39), and delivery at home (aOR: 1.89, 95% CI: 1.27–2.82) were found to be independent risk factors for UI among elderly women [Table 5].
Table 5.
Multivariate logistic analysis for independent factors for urinary incontinence among elderly
| Variable | Adjusted OR | 95% CI |
|---|---|---|
| Chronic cough | 1.64 | 1.08–2.50 |
| Obesity | 1.64 | 1.13–2.39 |
| Diabetes | 1.42 | 0.96–2.11 |
| Pelvic surgery | 1.64 | 1.13–2.39 |
| Delivery at home | 1.89 | 1.27–2.82 |
OR: Odds ratio, CI: Confidence interval
DISCUSSION
The current study was conducted among elderly women aged 60 and above in Kochi Corporation, Kerala, India. In this cross-sectional study, UI was self-reported and the diagnosis was made using the QUID questionnaire. The prevalence of UI among elderly women was found to be 63.9% in the present study. Bergen also points this out in his work where the prevalence of UI in the elderly ranged from 30% to 50%.[9] Different studies from across the globe show that the prevalence of UI increases with age. Study done by Minassian et al. reported prevalence of UI ranged from 4.8%–58.4% and that prevalence of significant incontinence increased with age.[5] In a study in Italy, the prevalence of UI among 17–79 years old women was reported between 9% and 72%.[10] A population-based study from Iran also reported a similar prevalence (61%) in women aged 60 and older.[11]
Studies from India estimating the prevalence and burden of UI are scarce. In a cross-sectional descriptive study conducted in Karimnagar, India, the prevalence of UI showed a significant association with increasing age. One in 10 women reported episodes of UI with impaired quality of life.[12] In a hospital-based cross-sectional study, 21.8% of women were incontinent, with the prevalence of UI among elderly women being 64%.[13] In another study done in a tertiary care setting in Kochi, Kerala, the prevalence of UI reported was 26.47%, with stress UI at 13.9%, mixed UI at 7.2%, and urge UI at 5.4%. Chronic cough, recurrent urinary tract infections, and prolonged duration of labor were independent risk factors associated with UI in this study in postmenopausal women.[14]
On multivariate logistic analysis, chronic cough (aOR: 1.64, 95% CI: 1.08–2.50), obesity (aOR: 1.64, 95% CI: 1.13–2.39), pelvic surgery (aOR: 1.64, 95% CI: 1.13–2.39), and delivery at home (aOR: 1.89, 95% CI: 1.27–2.82) were found to be independent risk factors for UI.
Work done by Noblett et al. demonstrated that each 5-unit increase in BMI was associated with a 60% increase in daily UI, with obesity having the largest attributable risk for daily UI compared to other factors.[15] Women with respiratory symptoms have more severe symptoms and are more likely to have stress leakage than other women.[16]
Parazzini et al. found evidence that when compared with women with no birth, a history of cesarean section increases the risk of stress UI. However, in this study cesarean section was not a risk factor. A history of hysterectomy, recurrent urinary infection, and perineal trauma increased the risk of all types of UI.[17] The present study found that undergoing any type of pelvic surgery increases the risk of becoming urinary incontinent.
Works done by Prabhu and Shanbhag[18] identified diabetes to be a risk factor for developing UI. However, diabetes was not found to be an independent risk factor in the current study (aOR: 1.42, 95% CI: 0.96–2.11).
Delivering at home was identified as the most significant independent risk factor for UI in the current study. The cohort of elderly women in the current study belongs to the time when delivering at home was more common and institutional deliveries rare. Along with vaginal delivery and other risk factors, delivering at home might have played an important role in the high prevalence rate of UI among the elderly women of Kerala.
The limitations of this study are that since the study subjects are elderly women, there is a chance for recall bias. Besides comorbidities such as hypertension, diabetes, and use of medications are self-reported.
Based on the findings from the study, our recommendations are the following:
Since the prevalence of UI is found to be very high among elderly women, health-care workers should assess incontinence among their elderly patients as a part of a routine checkup. They should enquire about chronic cough, obesity, diabetes, or previous pelvic surgery during their regular visits
Underlying causes and associated morbidities should be effectively identified and treated. Proper diet and regular physical exercise should be encouraged among women to prevent obesity. As only a few studies are available regarding UI, more studies with larger samples, in different settings and different age groups should be encouraged.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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