Impact of Urinary Incontinence on Quality of Life Among Women of Childbearing Age in Al Madinah Al Munawara, Saudi Arabia

Introduction Urinary incontinence (UI) is a widely prevalent problem with a great impact on quality of life. It affects a person’s physical, social, occupational, and phycological aspects of life. Our study aimed to estimate prevalence, risk factors, effect on life, and help-seeking behaviors among women with urinary incontinence. Methods This is a cross-sectional analytic study conducted in primary health care centers among women of childbearing age in Al Madinah Al Munawara, Saudi Arabia. A total of 342 women aged between 18 to 50 years were included and interviewed using a previously validated and pretested Arabic version of the King's Health Questionnaire (KHQ). Result Out of 342 patients, 71 (20.8%) had UI. The mean age of the patients was 31.51 +9.36 years. Risk factors associated with UI were: BMI (p = 0.022, odds ratio = 1.06), multiparity (p = 0.027, odds ratio = 1.16), smoking (p = 0.018, odds ratio = 4.71), and chronic constipation (p = 0.013, odds ratio = 5.83). Only 28.2% of the affected women sought medical consultation. The main reasons for not seeking medical advice were the belief that UI is a common, normal aging process in 45%, while 14.1% were embarrassed by the condition, and 5.6% did not know that there was a treatment. Overall, there was a limitation in all domains of quality of life among patients who suffer from UI. The majority of limitations were slight to moderate. The most affected domain was sleep and energy. Conclusion UI is common and adversely affects the quality of life of women of childbearing age in Al Madinah Al Munawara. Obesity, multiparity, smoking, and chronic constipation are significant risk factors. Less than half of patients with UI sought medical care.


Introduction
Urinary incontinence (UI) is a common condition, especially in women, with a profound impact on quality of life [1]. It is defined by the International Urogynecological Association (IUGA)/International Continence Society (ICS) as a complaint of involuntary pass of urine [2]. UI is classified into many types: (1) stress incontinence, which is an involuntary leak of urine on physical exertion or efforts such as coughing, sneezing, or laughing, (2) urgency incontinence in which the unintentional urine leak is synchronous with urgency, which defined as a sensation of a sudden, compelling desire to void that is difficult to defer, (3) mix incontinence, which is a combination of both stress and urgency urinary incontinence [2]. UI affects more than 423 million people around the world with an increased risk of three times in women than in men [3]. In North America, more than half of the women older than 45 suffer from UI [4]. However, it is often underreported by sufferers, because of misconception and consideration as a natural consequence of aging, giving birth, and due to a sense of shame [5]. The reported prevalence in the literature of UI worldwide ranges from 5% to 70% [1]. This wide variance is due to differences in case definition, population criteria, and sampling procedure [1]. In Saudi Arabia, the prevalence of UI was found to range from 29% to 56% [6][7][8][9][10][11].
Quality of life is defined as the degree to which a person enjoys important possibilities in his or her life. It reflects an individual's sense of well-being and satisfaction with life [12]. Although urinary incontinence is not considered a fatal disease, the loss of urine control has a significant effect on the quality of life [13,14]. It affects physical, occupational, social, psychological, and personal aspects of patients' lives significantly [13,15]. The key consequences include loss of self-confidence and social isolation in addition to other negative outcomes such as anxiety, depression, and a decrease in physical activity [16]. Risk factors significantly attributed to increasing urinary incontinence include increased age, obesity, parity, cigarette smoking, diabetes mellitus, and hysterectomy [15].
This study aimed to determine the prevalence, risk factors, and impact of UI on quality of life among women of childbearing age in Al Madinah Al Munawara, Saudi Arabia.

Materials And Methods
This study is a multicenter cross-sectional analytic study done in 10 primary health care centers (PHCCs) in Al Madinah Al Munawara. The study was approved by the Institutional Review Board, General Directorate of Health Affairs in Al Madinah (approval number H-03-M-084). A representative sample of 342 participants was calculated using Epi Info™/OpenEpi (Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States) free statistical software at confidence interval 95%, and 5% margin of error. Women of childbearing age who visit PHCCs were chosen randomly and invited to participate. Inclusion criteria were any women of childbearing age from 18 to 50 years, with or without comorbidities, who agreed to participate. Those who had delivered in the last three months, had gynecological or lower urinary tract surgery during the previous three months, and post-menopause women were excluded from the study. Informed consent was obtained prior to administering the questionnaire through a face-to-face interview. Definition of UI and its types was adopted from International Urogynecological Association (IUGA)/International Continence Society (ICS) as any leakage or involuntary loss of urine [2]. For the purpose of the study, the definition was confined to an incidence during last year. The final questionnaire contained sections on the sociodemographic characteristics, risk factors for UI, daily habits, gynecological information, experience of UI, severity of UI, and medical-seeking behavior for UI.
The impact of urinary incontinence on quality of life was assessed using a previously validated and pretested Arabic version of The King's Health Questionnaire (KHQ) [17]. KHQ is a disease-specific health-related quality of life (HRQOL) instrument for measuring QOL in women with UI. KHQ is widely used and proven to be valid and reliable [12]. In comparison to other tools used to measure the quality of life in women with UI, KHQ is the simplest to administer, easily understandable by the participant, and covers several domains of life [12]. KHQ has three parts consisting of 21 items. Part 1 contains general health perception and incontinence impact (one item each). Part 2 contains role limitations, physical limitations, social limitations (two items each), personal relationships, emotions (three items each) and sleep/energy (two items), severity measures (four items). Part 3 is considered a single item and contains 10 responses in relation to frequency, nocturia, urgency, urge, stress, intercourse incontinence, nocturnal enuresis, infections, pain, and difficulty in voiding. The responses in KHQ have a four-point rating system. The eight subscales ("domains") score between 0 (best) and 100 (worst). The Symptom Severity scale is scored from 0 (best) to 30 (worst). Note that the lower scores indicate patient well-being and higher scores mean that the person is suffering and severely affected by UI [12].
Data analysis was performed using Statistical Package for the IBM SPSS Statistics for Windows, Version 23.0 (Released 2015; IBM Corp., Armonk, New York, United States). Frequency and percentages were used to display categorical variables. Minimum, maximum, mean, and standard deviation were used to present numerical variables. The Chi-square test was used to test for the presence of an association between categorical variables. Multivariate logistic regression was used to determine the risk factors for having a UI among women of childbearing age. The logistic regression model included the following variables: age, BMI, current pregnancy status, parity, history of gynecological surgeries, smoking history, diabetes, hypertension, asthma, and chronic constipation. The level of significance was set at 0.05.

FIGURE 1: Patients' co-morbidities
The prevalence of UI was 20.8% (71 patients).     Table 4 and Table 5 present the quality of life assessment of patients with UI using the KHQ.

Discussion
UI is a global medical problem that is more prevalent in females [1]. The prevalence of UI among women in our study was 20.8% (71 patients), which lies within the worldwide prevalence range of 5-70% [1]. This figure is similar but slightly lower than the previous studies done in Saudi Arabia, which reported a prevalence between 29-56% in Riyadh [6,11], 34.3-41.4% in Jeddah [7,8], and 47.5% in Asir [10]. Other middle-eastern countries reported a concordance prevalence of 20.7% among Qatari women [18]. Higher percentages were reported in United Arab Emirates, Kuwait, and Egypt at 42.2%, 54.5%, and 54.8%, respectively [19,20,21]. Internationally, in the United States, 25-50% of women suffer from UI [22]. This is similar to the reported prevalence in Canada (51%) [23]. This variation in the prevalence can be attributed to the differences in study populations selected based on different inclusion and exclusion criteria and the sample size in those studies. Furthermore, the different definitions of UI that have been used and how each study have differently identified participants with UI might have influenced the estimation of UI prevalence across different studies.
Knowing and identifying risk factors for UI is the mainstay of management. The present study identified several risk factors and associated factors for UI. Obesity, multiparity, smoking, and chronic constipation were found to be significant risk factors for urinary incontinence in the present study; BMI (p = 0.022, odds ratio = 1.06), parity (p = 0.027, odds ratio = 1.16), smoking (p = 0.018, odds ratio = 4.71), and chronic constipation (p = 0.013, odds ratio = 5.83). Furthermore, diabetes mellitus, hypertension, older age, vaginal surgeries, device-assisted birth, and history of abortion were found to be significantly associated with UI. This is similar to Altaweel et al.'s findings of older age, obesity, vaginal surgery, high parity, and diabetes mellitus as risk factors for UI among women in Riyadh [6]. Similarly, Al-Bader et al. in Jeddah identified older age (postmenopausal), greater parity, chronic cough, constipation, and diabetes mellitus as significant risk factors for urinary incontinence [8]. In parallel, El-Azab et al. in Egypt reported that menopause, higher parity (>3), vaginal delivery, and previous multiple abortions (>3) were significantly associated with UI [21]. On the other hand, bronchial asthma was found to be significantly related to UI in Qatar [18], which is contrary to our study results (P = 0.362).
Almost two-thirds of women who had UI did not consider leakage as a problem and 60% of women who suffer from urine loss had never seek medical help for it [23]. The present study found that 64.8% of patients never disclose the problem to someone. Only 28.2% reported seeking medical consultation, while 71.8% never did. This low percentage is similar to previous results done in the same region, (14.5%) in Jeddah, and (16.3%) in Riyadh [8,17]. Of the women in this study, 45% did not find UI to be a big enough problem needing medical attention, 14.1% were embarrassed from the condition, and 5.6% did not know that there was a treatment. Likewise, in a systematic review done by Hammad et al. about UI in the Gulf countries, they reported that the main reasons for not seeking medical advice were an embarrassment to see doctors, especially male doctors, and the belief that UI is common, not abnormal, or untreatable [24].
In our study, overall, there was a limitation in all domains of quality of life among patients who suffer from UI. The majority of limitations were slight to moderate. These results are consistent with previous studies [6,8,17,24]. Altaweel and Alharbi in their work reported that UI did not impact patients significantly (less than 10% in each and all five areas and life: housework, attending entertainment events, physical activities, traveling by car more than 30 min from home, and social gatherings [6]. The most affected domain in the present study was sleep and energy. As half of the affected women reported that UI had affect their sleep badly on different degrees from mild to severe (Mean 21.13 + 23.56). This is similar to the finding reported by Bakarman et al. as they reported sleep and energy were the most affected in which the percentage of limitations reached 27.1% [7]. Considering the impact on emotions, 38% of patients in the present study admitted that they, slightly or moderately, feel anxious or nervous, while 26% admitted to feeling depressed. Similarly, Mallah et al. in Iran reported a significant impact on the quality of life generally and mental health specifically among women with UI compared to women without UI (P = 0.002 and 0.017, respectively) [25].
This is the first study conducted in Al Madinah Al Munawara region on the topic. It highlighted the prevalence, risk factors, severity, and the effect of the UI on the daily life of women. A potential limitation of this study is that the diagnosis of UI was based on subjective complaints by patients and wasn't confirmed by clinical examination. Further studies in older population should be carried out to investigate the problem in that age.

Conclusions
Urinary incontinence is common and adversely affects the quality of life of women of childbearing age in Al Madinah Al Munawara. Obesity, multiparity, smoking and chronic constipation are significant risk factors for UI. Less than half of the affected patients with UI sought medical care due to misconception of the problem as a normal or expected process and embarrassment from discussing it. Some of the risk factors for UI are modifiable, which should attract attention to be corrected. We recommend further health campaigns to enhance the awareness of women about UI and encourage them to seek medical help.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board, General Directorate of Health Affairs in Al Madinah issued approval H-03-M-084. The Institutional Review Board, General Directorate of Health Affairs in Al Madinah has reviewed all the submitted updated and amended documents and has approved the study titled "Impact of Urinary Incontinence on Quality of Life Among Childbearing Age Women in Al Madinah Al Munawara, Saudi Arabia". The approval is valid for one year commencing from date of this letter, 02/08/2021. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.