02-Prabhu

JRHS 2013; 13(2): 125-130

Copyright © Journal of Research in Health Sciences

Prevalence and Risk Factors of Urinary Incontinence in Women Residing in a Tribal Area in Maharashtra, India

Shruti Atul Prabhu (MD, DNB)a*,Sunita Shanbhag (MD, DPH)b

a Department of  Preventive and Social Medicine, Seth GS Medical College and KEM Hospital, Mumbai,  Medical Officer, District Tuberculosis Center Zone-6, Mumbai, India

b Department of Preventive and Social Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India

* Correspondence: Shruti Atul Prabhu (MD, DNB) , E-mail1: dr.shrutiprabhu@gmail.com , E-mail2: tbcaremumbai6@gmail.com

Received: 01 April 2013, Revised: 11 July 2013, Accepted: 15 August 2013, Available online: 27 August 2013

Abstract

Background: To study the prevalence and risk factors of urinary incontinence in tribal women and to assess the treatment seeking behavior of affected women.

Methods: A cross-sectional descriptive study was conducted in Khardi, a tribal village, selected by random sampling, in Thane district, Maharashtra, India during the period October 2010 to January 2011. All women aged 20 years and above were selected for the study except pregnant and lactating women and those with neurological disorders affecting bladder continence. A semi-structured questionnaire assessing socio-demographic factors of women, severity, type of incontinence, obstetric and other risk factors of incontinence was administered to the study participants. The participants who suffered from incontinence were inquired regarding their treatment seeking behavior for the same. Logistic regression analysis was used to determine the independent association between these factors and primary outcome of incontinence.

Results: Of 353 women participated in the study, 90 (25.5%) reported urinary incontinence. Prevalence of urinary incontinence showed significant association with increasing age (P<0.010). Associated obstetric factors included high parity (P<0.001), early post-partum resumption of heavy work (P<0.050) and prolonged labor (P<0.010). Other risk factors like hypertension, diabetes, chronic cough and constipation were predictors of incontinence in regression analysis (R2=0.47). Healthcare seeking rate was only 14.4% since they either accepted incontinence as a normal ageing process or were embarrassed to seek medical advice. 

Conclusions: Urinary incontinence is a neglected problem in tribal women predicted by obstetric and other risk factors.

Keywords: Urinary Incontinence, Tribal, Prevalence, India

Introduction

Urinary incontinence (UI) is defined by the International Continence Society as “the complaint of any involuntary loss of urine and which is a social or hygienic problem”1.  Urinary incontinence (UI) and associated lower urinary tract symptoms are widespread and troubling conditions affecting 11-57.0% of the adult women worldwide and it can severely compromise their social life2. The inability to control urine is quite an unpleasant and distressing problem. Though it does not lead to death, it causes substantial morbidity, social seclusion and psychological stress. Many women are too embarrassed to talk about it and some believe it to be untreatable even in the western countries3.

Most studies on this topic have been carried out in developed countries and affluent study populations. Scarce data exists on its prevalence in India, in minority women or in those of lower socio-economic status. A working hypothesis is that the prevalence of UI may be high in such a population as it could be under-reported by patients. This may be due to lack of education, economic hardships or social stigma4. The condition is usually under reported as many women hesitate to seek help or report symptoms to medical practitioners due to the embarrassing and culturally sensitive nature of this condition5.  Potential risk factors for UI include advancing age, high parity, vaginal deliveries, obesity, surgery, chronic constipation, and chronic respiratory problems6.

This study examined the prevalence of UI in tribal women, associated risk factors and the treatment seeking behavior of affected women. Economic hardships in tribal area and heavy physical work in farms make these women more vulnerable to UI; hence an attempt was made to study the condition in this group.

Methods

A cross-sectional study was conducted in Shahapur, a tribal block in Thane District, which is the field practice area for training of post graduate students of Community Medicine of a medical college and tertiary care hospital in Mumbai from October 2010 to January 2011. The block consists of 7 villages, all alike in the demographic, occupational and socio-economic factors. One village was selected by simple random sampling method (selected by considering the last digit of a randomly drawn note).  This being a cross-sectional prevalence study, all women of this village eligible as per the inclusion criteria were included in the study.

This village comprising of 6 divisions with an Anganwadi* each has a Survey/Family Register specific to that division which includes detailed information of the families residing in that area (i.e. age, sex, marital status, education, parity, pregnant and lactating women and under five population). *(An Anganwadi is a government sponsored child-care and mother-care center in tribal and rural areas in India, one per division in a village and it maintains all health/survey records pertaining to that division of a village.) All women aged 20 years and above were selected for the study since potential risk factors associated with UI (i.e. causes of acquired incontinence) usually manifest themselves from the third decade of life. Pregnant and lactating women were excluded from the study to remove the confounding effects of physiological changes induced by pregnancy that may lead to transient/temporary incontinence, which resolves shortly after delivery. Women with acute urinary tract infection and neurological disorders where urinary bladder continence was affected were excluded from the study.

As per the Survey/Family register, about 442 women were eligible for the study. A list of all such eligible women was prepared from these survey registers and the local village health volunteer accompanied the investigator for locating their houses and building rapport for the interview. Forty-eight women had left the village with their families to work in distant brick-kilns and were not expected to return during the stipulated study period while 11 women did not consent. Institutional Ethics Committee approval for the study was acquired prior to start of study.

Altogether 353 women participated in the study and were administered a semi-structured questionnaire which consisted of four parts: (a) Age, occupation, obstetric history (b) incontinence, its types and severity (c) risk factors for incontinence and (d) treatment seeking behavior. Pretesting and validation of the questionnaire were performed through a pilot study on 30 women (these were excluded from the main study). Women were interviewed in their house wherein the purpose of the study was explained, and informed consent sought and repeat visit was made to those houses which were locked at the initial visit. Privacy and confidentiality were ensured during the whole process.

Operational definitions for UI, stress, urge, and mixed incontinence were based on those provided by International Continence Society.1 A woman was considered to have stress incontinence if a positive response was elicited  to the question "Do you have episodes of involuntary leakage of urine on exertion or on sneezing/coughing/laughing or lifting heavy weights?", and Urge incontinence if the question "Do you have episodes of involuntary leakage accompanied by or immediately preceded by urgency?" provided a positive response. If a positive response was obtained for both questions, she was classified as a case of mixed incontinence.6,7

The risk factors evaluated for UI were parity, history of prolonged labor, heavy work in farms, early post-partum resumption of heavy work in farms, duration since menopause and history of hysterectomy or any other pelvic surgery in past. If 12 or more hours (i.e. half a day or more) had elapsed during labor after active pains began till the baby was delivered, the woman was considered to have had a prolonged labor. Women who worked in farms as laborers performing heavy work were assessed for the duration within which they resumed work post-partum. Early post-partum resumption of heavy work in farms (<1 month) was considered as a risk factor for incontinence. History of chronic cough was obtained and if cough was present for more than 3days per week for more than three months, then it was considered as chronic cough. Women were also assessed for presence of chronic constipation, hypertension, diabetes and addictions. Body mass index (BMI) of the study participants was assessed and was classified in four categories namely Underweight (BMI<18), Normal (BMI=18-24.99), Preobese (BMI=25-29.99) and Obese (BMI>30). The above-mentioned factors were evaluated as predictors for outcome of UI.

Data analysis was done using SPSS software, version 18. The statistical measures obtained were percentages and confidence interval levels (CI). Chi-squared test was used to evaluate factors potentially associated with urinary incontinence. Logistic regression analysis was used to control potential confounding variables and to determine the independent association between risk factors and urinary incontinence.

Results

The overall prevalence of UI in the study group was 25.5% (90/353 study participants). The most common type of incontinence was stress incontinence (56.2%) followed by urge (32.1%) and mixed incontinence (11.7%). Table 1 describes the general profile of the study participants. The median duration of symptoms was 2 years (range 6 months to 20 years) and majority (74.4%) of the women had symptoms since 1-5years. The definitions used by previous investigators7,9 was used to describe the frequency of incontinence and out of the study participants who had UI, majority (i.e. 32.2% (n=29/90) had infrequent symptoms i.e. strike off less than one day per month, followed by 28.9% (n=26/90) who reported weekly incontinence). Monthly incontinence was reported by 21.1% (n=19/90) and daily incontinence by 17.8% (n=16/90).

Prevalence of incontinence increased with advancing age (χ2= 23.513, df = 5, P<0.001), from 10.8% in the 20-29 years age group to 41.9% in the 60-69 years age group and  46.7%  in the age group of 70 years or more as shown in Figure 1. Univariate analysis to determine association of various risk factors with UI is shown in Table 2. High parity, early post-partum resumption of heavy work (<1 month), hysterectomy, hypertension, diabetes, chronic cough, chronic constipation and menopause were significantly associated with incontinence (P<0.050). However, other factors assessed for increased risk of incontinence but not found significant were history of prolonged labor, heavy work in farms, addictions and high BMI. Variables associated with incontinence (P<0.050) in univariate models were entered into multivariate models. Multivariate Logistic regression analysis was used to control for confounding factors and to determine the association between risk factors and urinary incontinence. In logistic models, age (OR=1.1, 95% CI: 1.1, 1.4), parity>5 (OR=1.6, 95% CI: 1.3, 2.1), diabetes (OR=2.38, 95% CI: 1.6, 4.1), chronic cough (OR=6.27, 95% CI: 2.2, 17.6) and chronic constipation (OR=2.6, 95% CI: 1.8, 3.8) were significantly associated with risk of incontinence as shown in Table 3.

Out of 90 women with UI, only 13 (14.4% of 90) ever discussed their problems with a doctor. Thus, consultation rate was only 14.4%. Most of the women (62.0%) who consulted a doctor for their symptoms were treated medically. Four women referred to a higher centre for further investigations did not comply with this advice while two women were advised surgery for this condition. However, none were told about any exercises for this condition. Table 4 describes the common reasons cited by study participants for not seeking medical help for their condition. No need of treatment as symptoms were not distressing (42.9%), accepting it as normal process of aging (25.2%) and embarrassment (24.5%) were the most common reasons for not seeking treatment.

Figure 1: Age wise distribution of women with Incontinence (N=353)

Table 1: Characteristics of the study participants (N=353)

Table 2: Comparison of the factors potentially associated with urinary incontinence using Chi-squared test

Table 3: Odds ratio (OR) estimates of factors associated with urinary incontinence (with P<0.1) using logistic regression analysis

Table 4: Reasons for not seeking help

Discussion

The overall prevalence of UI in this study was 25.5%. The distribution of the types of incontinence was as follows: 56.2% women had stress incontinence, 32.1% had urge, and 11.7% had mixed type. These findings were higher compared to the study conducted by Kumari et al.10, who reported the overall prevalence of UI as 12.0%, among whom 46.0% had stress incontinence, 26.0% had urge, and 28.0% had mixed type. It is lesser than the global prevalence of UI which may be due to variations in definitions used, age groups and populations studied 11.

Urinary incontinence though an important health problem in the community causing  significant morbidity leading to embarrassment, restriction of daily, physical and social activities is often under-diagnosed and is a considerable economic burden on the individual as well as the healthcare system12,13. Identification and early alteration of risk factors of UI can reduce this burden. In this study, the prevalence of UI increased with age from 10.8% in the 20-29 years age group to 46.7% in the age group of 70 years and beyond as shown in Figure 1. Though the exact etiology of higher prevalence of UI with advancing age, is unclear, it can be partly explained by progressive senile loss of muscle tone, decreased contractility, changes in the hormonal stimulation, and repeated injuries during parturition 13,14

High parity increases the risk for UI; repeated deliveries may cause pelvic floor dysfunction as a result of nerve damage, muscular damage, and direct tissue stretching and disruption5, 13,14.  A study by Morley et al.15 concluded that prolonged labor causes collagenous changes in the pelvic floor leading to UI. In this study, though the proportion of incontinent women with history of prolonged labor was higher, the association was not found to be significant.

Since the study participants belonged to a tribal area where they resume heavy work in farms immediately post-delivery due to financial constraints, a novel attempt was made to assess if resuming work early (<1 month) was associated with increased risk of UI. The association was found to be significant. An interesting observation from this study was that, a higher proportion (28.5%) of women involved in heavy work in farms had incontinence compared to those women who were housewives (16.0%). However, this association was not found to be significant. Hysterectomy may cause damage to the urethral and bladder supportive structures or to the pelvic nerve plexus, leading to incontinence later in life16. The association between hysterectomy and UI was found to be significant in this study group. Brown et al.16 also reported similar findings.

Excess body weight may increase abdominal pressure during physical activity, which in turn increases bladder pressure and urethral mobility, leading to urinary incontinence16. If urinary incontinence is primarily due to increased abdominal pressure, then modest weight reduction may decrease the severity of urinary incontinence. Though, BMI was not found to be a significant predictor in this study, significant association was reported by Brown et al. 16 and Song et al2. Elevated abdominal pressure due to chronic cough and chronic constipation leads to increased risk of UI17.Both chronic cough and constipation were significant predictors for UI in the regression analysis in our study. Chronic cough or constipation, shown to be associated with incontinence18, damages the urethral and bladder supportive structures causing urinary incontinence. Association between UI and medical ailments like diabetes (P=0.014) and hypertension (P=0.002) found highly significant in this study, has been previously reported 2,5, 16.

Consultation rate was only 14.4% for incontinence. No need of treatment as symptoms were not distressing (42.9%), accepting it as normal process of aging (25.2%) and embarrassment (24.5%) were the most common reasons for not seeking treatment. The findings are similar to that reported by Kumari et al. (20.0%) 10.

In this study, the data included was obtained solely on verbal response, recall bias for some obstetrical factors may have been present and examination of study participants/intervention could not be taken up due to limited resources and time constraints.

Conclusion

Urinary incontinence is a neglected problem in tribal women, with stress incontinence being the most common type. Simple epidemiological tools such as a questionnaire can unveil Age wise distribution of women with Incontinence (N=353)the incontinence subjectively. It is predicted by obstetric and other risk factors. However consultation rate was low. An attempt should be made by medical officer/doctor to screen at risk women for urinary incontinence by asking leading questions so that the affected can be timely referred for relevant management.

Acknowledgements

The authors are thankful to the study participants of the tribal area for willingly participating in the study.

Conflict of interest statement

None declared.

Funding

No sources of support provided.

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