Abstract
Objective
Urinary incontinence (UI) is an involuntary leakage of urine and affects the social, physical, and psychological aspects of many individuals worldwide. The purpose of our study was to examine the prevalence, quality of life (QoL), severity, and different types of UI in overweight and obese women.
Methods
We conducted a cross-sectional study of 1,351 consecutive patients, who were recruited between June 2021 and May 2022.
Results
The mean age of the patients was 39.7 ± 14.2 years with less than a half in the 19–35-year age group (46.9%); 65% of the subjects were overweight or obese. The overall prevalence of UI was 61.2%. Overweight and obesity accounted to 70.2% of patients with mild to very severe UI. The risk estimates to have UI were 1.84 in overweight and 5.4 in obese group. The risk estimate for severe and very severe UI was 2.33 in overweight and 10.34 in obese group. When considering all subtypes, 67.9% of women with overweight and obesity had any of the subtypes, urge UI, stress UI, and mixed UI. Overweight and obesity were significantly associated with poor QoL in women with UI (p < 0.0001). Among 36.1% of all patients with poor QoL, 79.9% were overweight and obese.
Conclusions
Overweight and obesity are important risk factors of UI affecting daily activity and QOL considerably. As the number of people with obesity is increasing, the prevalence of UI with increased severity is likely to increase in young to mid-aged women. Weight loss should be considered as first-line treatment for this patient population.
Keywords: Urinary incontinence, Obesity, Overweight, Body mass index
Highlights of the Study
Obesity is a complex chronic disease which impairs health, increases the risk of long-term medical complications, and reduces the lifespan.
Urinary incontinence has a negative impact on the quality of life in women.
Overweight and obesity are important risk factors of urinary incontinence, affecting daily activity and quality of life.
Weight loss should be considered as a first-line treatment for this patient population.
Introduction
Urinary incontinence (UI) is a highly prevalent condition which is considerably higher in Kuwait as compared to other parts of the world [1, 2]. The prevalence of UI ranges from 5% to 70% worldwide. In the Middle East, the overall prevalence of UI was between 20.3% and 54.8% [3]. UI is considered as a health priority by the World Health Organization (WHO) [4]. While it is not a life-threatening disease, it has a negative impact on the quality of life (QoL), and women do not always seek medical help or advice for this condition [5]. Several population-based studies have reported higher UI in females than males. Its predisposing factors are age, body mass index (BMI), and parity [6]. It was previously thought that older age and parity play important roles in the occurrence of UI [7, 8], but a systematic review has reported an increasing prevalence in both younger women and nulliparous women [9]. Many observational studies have shown that obesity and overweight is directly associated with UI [10, 11]. Each 5-unit increase in BMI is associated with a 30–60% increased risk of daily UI. When followed up for 5–10 years, the odds of UI increased by 7–12% for each 1 kg/m2 unit increase in BMI [10].
Obesity is a complex chronic disease which impairs health, increases the risk of long-term medical complications, and reduces the lifespan [12, 13]. Since 1980, the prevalence of obesity and overweight has doubled globally, and nearly one-third of the world’s population is now classified as overweight or obese [14]. In Kuwait, the prevalence of obesity in women is high (over 50%) [15], and it is listed by the WHO as one of the global epicenters for obesity [15, 16]. The high prevalence of obesity has been attributed to various factors including demographic, lifestyle, economic, and psychosocial factors [17].
Previous studies have focused mainly on parity and aging as the predisposing factors of UI. Other risk factors for UI, the severity of UI, and QoL of these women have not been thoroughly evaluated. The purpose of our study was to examine the prevalence, QoL, severity, and different types of UI using an internationally validated questionnaire form in overweight and obese women.
Subjects and Methods
Selection and Description of Participants
This cross-sectional study included women aged ≥19 years who visited six primary care centers in Kuwait between June 2021 and May 2022. A total of 2,000 women were contacted by phone. Of 1,755 women who agreed to participate in the study, 1,351 completed the online International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) questionnaire. The study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), the principles of the Declaration of Helsinki and approved by the Ethical Committee for coordination of health and medical research of the Kuwait Ministry of Health (study number 1302). All participants signed a written informed consent.
Questionnaire
We used the ICIQ-UI-SF. It is a validated questionnaire consisting of four sections.
Section 1: this section consists of a set of questions designed to collect data on demographic characteristics of the study population (age, BMI, menopause status, parity, vaginal birth, cesarean delivery). Section 2: the first question in this section is related to screening for UI and its frequency. The second question assesses the volume of urine leakage, and the third question is related to the patient’s QoL. We evaluated QoL based on the impact of UI symptoms on daily life activity. “Good” QoL is defined as “not bothered to mild bothersome” (scale of 0–3 out of 10) and “poor” QoL as “moderate bothersome to a great deal” (from 4 to 10 out of 10). Section 3: the sum of the scores from the first three questions in this section provides the ICIQ score (0–21). It is used to determine the severity of UI. The scores are grouped as no UI (score 0), mild UI (1–5), moderate UI (6–12), severe and very severe (≥13). Section 4: the fourth question assesses symptoms associated with different types of UI (stress [SUI], urge [UUI], or mixed UI [MUI]). SUI is defined as urine leakage associated with physical activities, exercise, straining, coughing, sneezing, or laughing. UUI is defined as urine leakage which occurs with sudden, strong desire to void or leakage before getting to the toilet. Women are diagnosed with MUI if they have features of both stress and UUI.
Statistical Analysis
Statistical analysis was performed using the SPSS software package (SPSS Inc., Chicago, IL). We used Shapiro-Wilks test to evaluate the distribution of the data. Comparisons were analyzed using the Student’s t test or the Mann-Whitney U test when appropriate. Proportions were compared with χ2 test or Fisher’s exact test. A multivariable logistic regression analysis was used to evaluate associated risk factors for UI. p < 0.05 was considered significant. Post hoc power analysis showed that our study had ample statistical power (>99.9%) to detect UI patients at the α level of 0.05.
Results
A total of 1,351 women completed the questionnaire in English or Arabic language (ICIQ-UI-SF). Table 1 shows the demography of the patients. Over a half of the study population (65%) were overweight or obese. Based on the ICIQ-UI-SF score, 827 of 1,351 patients (61.2%) had mild to very severe UI. Compared to patients without UI, those with UI were older, higher in weight, BMI, and parity (p < 0.0001). UI was encountered in 55.2% of premenopausal and 81.4% of postmenopausal women (p < 0.0001, 95% CI: 7.1–17.5). The prevalence of UI in nulliparous women was 43.7%, in women with 1–2 deliveries, 65.2% (p < 0.0001, 95% CI: 1.75–3.33), and in those with ≥3 deliveries, it was 76.9% (p < 0.0001, 95% CI: 3.31–5.55). Multivariate analysis was performed to ascertain whether there is an association between menopausal status with their demographic characteristics (Table 2). A significant association was observed between premenopausal status to higher age, greater weight, parity, and BMI >30 kg/m2 (p < 0.001). Postmenopausal status was also significantly associated to higher weight, parity, and BMI (25–29.9 kg/m2 and ≥30 kg/m2) (p < 0.001).
Table 1.
Demographics of 1,351 patients with or without urinary incontinence (UI)
| Characteristics | No UI (n = 524, 38.8%) | UI (n = 827, 61.2%) | p (95% CI) |
|---|---|---|---|
| Age, years | 33.7±12.1 | 43.4±14.1 | <0.0001 (8.3–11.1) |
| 19–35 years, n (%) | 350 (66.8) | 283 (34.2) | |
| 36–45 years, n (%) | 84 (16) | 142 (17.1) | |
| 45–60 years, n (%) | 59 (11.3) | 299 (36.2) | |
| >60 years, n (%) | 31 (5.9) | 103 (12.5) | |
| Weight, kg | 64.41±12.2 | 73.7±15.3 | <0.0001 (11.9–14.8) |
| BMI. kg/m2 | 25.2±4.4 | 28.9±5.8 | <0.0001 (3.2–4.3) |
| <19 kg/m2, n (%) | 24 (4.6) | 17 (2.1) | |
| 19–24.9 kg/m2, n (%) | 238 (45.4) | 194 (23.5) | |
| 25–29.9 kg/m2, n (%) | 185 (35.3) | 278 (33.6) | |
| ≥30 kg/m2, n (%) | 77 (14.7) | 338 (40.9) | |
| Parity | 1.3±1.9 | 2.9±2.5 | <0.0001 (1.3–1.8) |
| 0, n (%) | 314 (59.9) | 244 (29.5) | <0.0001 (0.22–0.35) |
| 1–2, n (%) | 80 (15.3) | 150 (18.1) | 0.08 (0.91–1.65) |
| ≥3, n (%) | 130 (24.8) | 433 (52.4) | <0.0001 (2.07–3.38) |
| Number of vaginal deliveries | 1.0±1.8 | 2.4±2.4 | <0.0001 (1.2–1.6) |
| Number of cesarean deliveries | 0.3±0.7 | 0.5±1.1 | 0.001 (0.1–0.3) |
| Menopausal status, n (%) | |||
| Premenopausal | 458 (87.4) | 539 (65.2) | <0.0001 (0.20–0.36) |
| Postmenopausal | 66 (12.6) | 288 (34.8) | <0.0001 (2.76–4.98) |
Table 2.
Multivariate analysis between menopausal status and demographic characteristics
| NO UI | UI | No UI | UI | |||
|---|---|---|---|---|---|---|
| Characteristics | premenopausal (n = 539) | premenopausal (n = 458) | p (95% CI) | postmenopausal (n = 81) | postmenopausal (n = 273) | p (95% CI) |
| Age, years | 30.21±7.6 | 35.8±9.4 | <0.0001 (4.52–6.7) | 58.26±5.1 | 59.35±5.7 | 0.12 (−0.29–2.48) |
| Weight, kg | 63.9±12.6 | 71.8±15.4 | <0.0001 (6.13–9.67) | 73.0±12.8 | 78.9±14.0 | <0.001 (2.48–9.32) |
| Parity | 0.97±1.7 | 2.3±2.5 | <0.0001 (1.06–1.60) | 3.7±1.8 | 4.33±2.2 | 0.01 (0.16–1.11) |
| BMI, n (%) | ||||||
| <25 kg/m2 | 290 (53.8) | 153 (33.4) | <0.0001 (1.79–3.0) | 9 (11.11) | 21 (7.70) | 0.36 (0.66–3.42) |
| 25–29.9 kg/m2 | 169 (31.4) | 159 (34.7) | 0.29 (0.66–1.12) | 44 (54.3) | 91 (33.33) | 0.001 (1.44–3.94) |
| ≥30 kg/m2 | 80 (14.8) | 146 (31.9) | <0.0001 (0.27–0.51) | 28 (34.6) | 161 (58.97) | <0.001 (0.22–0.62) |
Effect of Overweight and Obesity on Prevalence and Severity UI
Table 3 shows the prevalence and severity of UI in women with different BMI groups. BMI groups were underweight (<19 kg/m2), normal weight (19–24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2). No difference was observed in the prevalence of UI between underweight and normal weight women. Accordingly, we combined the two subgroups into one and compared this group with overweight and obese subgroups.
Table 3.
BMI versus severity of UI based on ICIQ score
| Categories | BMI | ||||||
|---|---|---|---|---|---|---|---|
| <25 | 25–29.9 | ≥30 | |||||
| (n = 473), n (%) | (n = 463), n (%) | OR | p (95% CI) | (n = 415), n (%) | OR | p (95% CI) | |
| UI (ICIQ ≥1) | 211 (44.6) | 278 (60.1) | 1.86 | <0.0001 (1.4–2.4) | 338 (81.4) | 5.45 | <0.0001 (4.0–7.4) |
| Mild UI (ICIQ = 1–5) | 86 (18.2) | 88 (19) | 1.47 | 0.05 (1.02–2.11) | 95 (22.9) | 3.81 | <0.0001 (2.57–5.66) |
| Moderate (ICIQ = 5–12) | 91 (19.2) | 132 (28.5) | 1.99 | <0.0001 (1.43–2.79) | 136 (32.8) | 4.95 | <0.0001 (3.40–7.19) |
| Severe + very severe (ICIQ ≥13) | 34 (7.2) | 58 (12.5) | 2.33 | 0.001 (1.45–3.74) | 107 (25.8) | 10.34 | <0.0001 (6.45–16.56) |
Comparison with BMI <25.
UI was reported in 60% of overweight women and 81.4% of obese women, with a risk of 1.86 in overweight and 5.45 in obese women. Compared to patients with BMI less than 25, urinary continence was significantly higher in those who were overweight/obese in all categories of UI severity. The risk of developing mild, moderate, and severe with very severe UI in overweight women are 1.47, 1.99, and 2.33. In obese women, the risk increased to 3.81, 4.95, and 10.34 in mild, moderate, or severe and very severe UI, respectively (shown in Fig. 1).
Fig. 1.
Severity of UI in overweight and obese women.
Effect of Overweight and Obesity on Subtypes of UI
67.9% of overweight and obese women suffered from one of the subtypes of UI (SUI, UUI, or MUI). The risks of UUI, SUI, and MUI were significantly higher in women with overweight and obesity as compared to those with BMI of less than 25 (Table 4). In overweight women, the risk estimate was 2.20 for UUI, 1.71 for SUI, and 2.20 for MUI. In women with obesity, the risks to have UUI, SUI, or MUI were 5.73, 5.88, and 8.34, respectively. There was a positive relationship with all subtypes of UI and BMI (shown in Fig. 2).
Table 4.
BMI and different UI
| Categories | BMI | ||||||
|---|---|---|---|---|---|---|---|
| <25 | 25–29.9 | ≥30 | |||||
| (n = 473), n (%) | (n = 463), n (%) | OR | p (95% CI) | (n = 415), n (%) | OR | p (95% CI) | |
| UUI | 74 (15.6) | 113 (24.4) | 2.20 | <0.0001 (1.55–3.12) | 123 (29.6) | 5.73 | <0.0001 (3.91–8.42) |
| SUI | 55 (11.6) | 79 (17.1) | 1.71 | <0.01 (1.17–2.5) | 95 (22.9) | 5.88 | <0.0001 (3.87–7.89) |
| MUI | 49 (10.4) | 72 (15.6) | 2.20 | <0.001 (1.47–3.33) | 114 (27.5) | 8.34 | <0.0001 (5.44–12.77) |
Comparison with BMI <25.
UUI, urge urinary incontinence; SUI, stress urinary incontinence; MUI, mixed urinary incontinence.
Fig. 2.
Subtypes of UI with correlation to BMI.
Effect of Overweight and Obesity on Daily Activity and QoL
Overweight and obesity were significantly associated with “moderate bothersome” to “great deal” UI interfering with daily activity (shown in Fig. 3). As shown in Table 5, in overweight women, the risk of “moderate” to a “great deal bothersome” UI interfering with daily activity was 2.62 and 1.92, respectively. As in obese group, the risk was 2.65, 5.23, and 6.93 in “mild bothersome,” “moderate bothersome,” and “great deal,” respectively. Poor QoL due to UI was reported by women in 36.1% of cases. Among these women, 79.9% were overweight and obese. The estimated risk to suffer from poor QoL with UI in overweight and obese groups was 2.11 and 4.35 (p < 0.0001) (Table 6).
Fig. 3.
Daily activity in women with UI with respect to BMI.
Table 5.
BMI and UI that interfered with daily activity
| Categories | BMI | ||||||
|---|---|---|---|---|---|---|---|
| <25 | 25–29.9 | ≥30 | |||||
| QoL (scale 0–10) | (n = 473), n (%) | (n = 463), n (%) | OR | p (95% CI) | (n = 415), n (%) | OR | p (95% CI) |
| Mild bothersome (1–3) | 88 (18.6) | 86 (18.6) | 1.34 | 0.13 (0.94–1.91) | 86 (20.7) | 2.62 | <0.0001 (1.81–3.87) |
| Moderate bothersome (4–7) | 52 (11) | 101 (21.8) | 2.62 | <0.0001 (1.77–3.86) | 102 (24.6) | 5.23 | <0.0001 (3.47–7.89) |
| Great deal (8–10) | 46 (9.7) | 66 (14.3) | 1.91 | 0.004 (1.25–2.92) | 121 (29.2) | 6.93 | <0.0001 (54.58–10.49) |
Comparison with BMI <25.
Table 6.
QoL among UI women and BMI
| Categories | BMI | ||||||
|---|---|---|---|---|---|---|---|
| <25 | 25–29.9 | ≥30 | |||||
| QoL (score) | (n = 473), n (%) | (n = 463), n (%) | OR | p (95% CI) | (n = 415), n (%) | OR | p (95% CI) |
| Good QoL (1–3) | 375 (79.2) | 296 (63.9) | 0.46 | <0.0001 (0.35–0.62) | 192 (46.3) | 0.22 | <0.0001 (0.17–0.3) |
| Poor QoL (4–7) | 98 (20.7) | 167 (36.1) | 2.11 | <0.0001 (1.57–2.85) | 223 (53.7) | 4.35 | <0.0001 (3.2–5.9) |
Discussion
The results of our study demonstrate that UI is a common condition among women with overweight or obesity with high impact on daily activity and QoL. The prevalence of UI was higher in overweight (BMI: 25–29.9) and obese (BMI ≥30) women compared to women with normal weight. In agreement with previous reports, UI was seen in 60% of the overweight women and in 81.4% of obese women versus 45% in normal weight women.
The overall prevalence of UI in our study was 61.2%. This is higher than that reported in other countries [18–25]. The prevalence of UI was 23% in Spain, 44% in France, 41–48.3% in Germany, 46.4% in Denmark, and 42% in the UK [24, 25]. In Middle Eastern countries, the prevalence ranges from 20.7% to 54.5%, and Kuwait had the highest with 54.5% [19–23]. The estimated prevalence of UI in Egypt was 55% [5], East Africa 31%, West Africa 16%, and South Africa 35% [18]. It is possible that this is related to the fact that 65% of our participants were overweight or obese; as mentioned earlier, the prevalence of obesity in Kuwait is highest in the Middle East [26]. It is also possible that those with minimal symptoms were not included in the previous studies.
In agreement with a previous study from Kuwait, we found that the most common type of UI was UUI, followed by MUI [20]. Other studies have reported that the association between UI and obesity is stronger for SUI and MUI [11, 27]. It should be noted that most of our participants were between 19 and 35 years of age and overweight or obese. Cohort studies have also suggested that an earlier appearance of obesity is associated with a higher probability of developing UI in middle age [20, 28]. Furthermore, a previous study reported that elevated BMI decreases the chances of improvement and increases the chances of worsening UI symptoms [29]. Increase in weight may exacerbate or contribute to pelvic floor disorders by increasing intra-abdominal pressure and chronic pressure on ligaments and nerves, leading to excessive stretching [30]. In agreement with previous studies [31], we found that overweight and obesity were strongly associated with poor QoL in women with UI.
The limitations of our study include the subjective nature of reporting and that it was conducted through web survey. However, to the best of our knowledge, this is the first study in Kuwait addressing the prevalence, the severity, the type of UI, and QoL among a large number of women with different age and BMI using an internationally validated questionnaire form.
Conclusion
Obesity is strongly associated with an increased prevalence of UI, thus leading to poor QOL. Given the high prevalence of obesity in our region, weight reduction should be advocated in the management and improvement of incontinence symptoms. Health policy-makers must consider raising awareness of UI.
Acknowledgment
We thank Carol Dsouza (research assistant, Kuwait University) for editing a draft of this manuscript.
Statement of Ethics
This study was conducted in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), the principles of the Declaration of Helsinki, and was approved by the Ethics Committee for coordination of health and medical research of the Kuwait Ministry of Health (study number 1302). All participants signed a written informed consent.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
No funding was obtained for this study.
Author Contributions
Conceptualization, protocol development, and data curation: Baydaa Alsannan, Fatima Alrahal, and Shaikha Al Mansoor. Data analysis and interpretation: Baydaa Alsannan, Fatima Alrahal, and Shaikha Al Mansoor. Preparation of the first draft of the manuscript: Baydaa Alsannan. Critical insights and refinement of the manuscript: Baydaa Alsannan, Jehad Alharami, Fatima Alrahal, Shaikha Al Mansoor, and Togas Tulandi. All authors have read and approved the final version of the manuscript.
Funding Statement
No funding was obtained for this study.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding authors upon request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding authors upon request.