Urinary Incontinence: Understanding the Silent Plight of Women

By Yasmin Nadeem Parpio¹, Anmol Minaz¹, Sonia Ijaz Haider²

Affiliations

1. School of Nursing, The Aga Khan University, Karachi, Pakistan
2. Department for Educational Development, Faculty of Health Sciences, The Aga Khan University, Karachi, Pakistan

doi: 10.29271/jcpsp.2022.04.519

ABSTRACT
Urinary incontinence (UI) is defined as the complaint of involuntary loss of urine. UI affects both men and women but is more common in women. It has been identified as a World Health Organization priority. The burden related to UI at local, national, and global levels is huge and its impact in terms of physical, social, mental, and financial aspects makes it a concerning issue. However, there exist several barriers in terms of knowledge and attitude in seeking healthcare among women experiencing UI. This calls upon a multi-disciplinary approach involving professionals from different disciplines and tackling it with collaborative and collective efforts.

Key Words: Urinary incontinence, Burden, Multidisciplinary approach, Pakistan, World Health Organization.

Urinary incontinence (UI) is defined as the complaint of involuntary loss of urine. UI affects both men and women but is more common in women.¹ It has been identified as a World Health Organization priority.² The sensitivity and stigma attached with the condition lead to hiding and resistance towards disclosing the problem and seeking a remedy. Thus, the condition has been underreported and underdiagnosed. Urinary incontinence was found to be correlated with different obstetric and non-obstetric factors like increasing parity, vaginal mode of delivery, high BMI, central obesity, standard of living, and smoking. The reasons for silent plight of women are associated with cultural factors and hesitance of women to discuss the suffering with family members and healthcare professionals, particularly with a male doctor.³ ‘World Continence Week’ is celebrated each year in the month of June with the prime objective of raising awareness about incontinence and its impact. It is significant to promote a multi-disciplinary approach to tackle the issue. This paper will shed light on the burden of UI, its impact on women, and will recommend strategies using a multi-disciplinary approach.

Urinary incontinence is a prevalent condition in women that ranges from 5% to 70%; however, most studies reported a prevalence of 25% to 45%.

It is reported in around three in four women over 65 years, 44 to 57% of middle-aged women and with post-menopause, and one in four reproductive-age women suffering from UI.⁴ A systematic review and meta-analysis found the global burden of UI in older women to be 37.1%. It is reported that the highest prevalence (45.1%) was found in Asian older women.² In Pakistan, a study involving a large sample of rural women found the prevalence of UI in women aged 15 years or older to be 11.5%. Additionally, 40% of affected women had complaints of urine leakage more than once a day, which impacted their daily lives substantially. The study also revealed the association of age, parity, and early age at marriage with UI among women.⁵

Women during pregnancy also experience stress urinary incontinence as the most common issue. It was found that the conditions like urinary tract infections, abortion history, constipation, number of pregnancies, smoking, and chronic cough have been linked to urinary incontinence.⁶

Incontinence is reported as an issue causing extensive physical, social, psychological and emotional problems. It not only causes pressure sores, poor sleep, and urinary tract infections; but also contributes to falls and fractures, which is the leading cause of death in the elder population. Women also encounter a number of social issues like difficulty in travel and work, and poor sexual relationship with their partners.² They experience anxiety and depression as the most common mental health issue, therefore their quality of life suffers. Along with its psychological impact, UI poses a substantial economic burden on the individuals, community and health services. Direct costs are related to diagnosis, treatment, routine care and outcome costs. The outcome costs are the costs related to health consequences of UI; for example, skin conditions, falls, etc. The indirect costs of the condition are related to loss of productivity, unemployment and early retirement as a result of mental health issues like depression, isolation and lack of confidence.³

Thus, UI leads to psychological distress, significant weakness, social seclusion, and increased economic burden of the country.¹ Thus, it has led to poor quality of life among women.⁷ A widespread misperception exists in general public and healthcare professionals, that incontinence is a normal consequence of childbearing or aging. Moreover, there is a delay or deferral going to a healthcare professional among women. Only a small percentage of individuals receive effective treatment among those who are accurately diagnosed.¹ in Pakistan, more than a quarter of women population had complaint of UI for more than five years; however, the percentage of women who consulted a physician was quite low (15.7%).⁴

A study, conducted on identifying health seeking behaviour of women with UI, found that the behaviour for UI was poor; and around 89.2% of study population did not seek medical therapy for UI. Often, majority of women, who receive treatment, are not satisfied as only about ten percent of women show satisfaction towards the treatment.⁸

A systematic review on women’s knowledge, attitude and practice related to UI revealed a low rate of seeking treatment among all studies. The underlying reasons, which served as barriers, included lack of knowledge regarding the condition, shame and embarrassment while sharing about the concerns, lack of time, costs of the treatment, and considering the condition as not severe enough. Additionally, inadequacy in knowledge related to UI treatment and prevention possibility, for example the use of pelvic floor exercises.⁹ In addition, another systematic review affirmed that UI is associated with a poor quality of life with high level of certainty.¹⁰

With regard to the available treatment, the most common interventions are behavioural therapy, anticholinergics and neuromodulation. For stress UI, behavioural therapy seemed to be more effective than hormones or α-agonists. Moreover, it was identified that neuromodulation was better than no treatment. Behavioural therapy was also proved effective in improving urgency UI as compared to anticholinergics.¹¹ Furthermore, the considerable psychosocial consequences of UI call out the need for more public health and medical attention.¹²

Despite the efforts and advances in the treatment, health-seeking attitude of women in relation to UI is still poor, which highlights the need to take on actions at multiple levels. The data on women outcomes, with UI treated and managed using a multidisciplinary approach, shows promising results.¹ When professionals with different backgrounds like community nursing, urology, geriatrics, and gynecology work in different context, their collective efforts can create significant difference in increasing knowledge and treatment seeking attitudes of women.^13,14

A number of general recommendations is proposed to help women with UI, which are: Women should be screened annually for UI. Screening should focus on the assessment of whether women experience UI and its affect on their level of activity and quality of life. Moreover, women should be referred for further evaluation and treatment, if needed. Health education sessions for women, their families and communities should be arranged to make them aware about the risk factors, symptoms, complications and coping behaviours of the condition. Another cost-effective strategy can be creating mass awareness about pelvic floor exercises and combat stigma associated with the condition in public via mass campaign. Support groups focused towards helping women break the stigma, combat negative attitudes; and seeking ongoing medical help can also create a significant impact. Adequate information related to cognitive and emotional coping strategies like wearing a particular type of clothing, frequent use of toilet, rearranging the physical environment, and frequent changes of undergarments should be provided. Capacity building of healthcare professionals shall be done to screen, counsel and refer the incontinence cases to the specialist as per the guidelines of the International Continence Society.

Urinary incontinence is a common and significant public health concern among women and it has a tremendous impact on various aspects of their life. There is ample evidence that women often do not seek help and continue to suffer and have difficulty accessing professional help. Prior to developing continence care services and protocols, it is imperative to recognise the barriers for not seeking treatment for the management of UI symptoms.

CONFLICT OF INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
YNP: Conception and design, drafting, critical revision, final approval.
AM: Design, drafting, critical revision, final approval.
SIH: Design, critical revision, final approval.

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