February 2006, Vol 28, No. 2 |
Original Articles
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A study on women with urinary incontinence attending a primary health care clinic in Hong Kong and reasons for their illness behaviourChing-Po Ngan 顏清坡, Soe-Tjhoen Lam 林樹春, Kwai-Wing Wong 黃桂榮, David V K Chao 周偉強 HK Pract 2006;28:60-65 Summary Objective:To study the prevalence of urinary incontinence in adult females and their illness behaviour in a public primary care clinic setting. Design: A cross-sectional survey. Subjects: Two hundred and sixty-nine randomly selected adult females aged 18 or above attending Ngau Tau Kok Jockey Club General Outpatient Clinic (a primary care clinic in Hong Kong) within the period from February to July 2004. Main outcome measures: (1) Prevalence of urinary incontinence in adult female patients of a Government General Outpatient Clinic; (2) The association between urinary incontinence and age; (3) The association between urinary incontinence and chronic illnesses; (4) The proportion of incontinent patients who reported the symptoms to their doctors; (5) The reasons for incontinent patients not seeking medical advice. Results: The prevalence of urinary incontinence in this group of 269 patients of the Government General Outpatient Clinic was 49.1%. The mean ages of incontinent and continent patients were 61.31 (SE=1.21) and 56.63 (SE=1.52) respectively. Incontinent patients had a statistically significant older mean age. (p=0.017). Diabetes mellitus was associated with urinary incontinence (p=0.0496). There was no significant association between urinary incontinence and other chronic illnesses. Among those with urinary incontinence, only 10.6% sought medical advice. There was an increasing trend of reporting their urinary incontinence with increasing frequency of symptoms (p=0.055). 89.4% of incontinent patients did not consult a doctor for the problem. In this group of patients, 62.7% perceived urinary incontinence as a minor problem, 36.5% thought urinary incontinence was a normal part of ageing, and 5.9% felt too embarrassed to seek help. Conclusion: Nearly half of the female patients in a public primary care clinic setting in Hong Kong experienced urinary incontinence, especially among those with diabetes mellitus and old age. The results of the present study would be of reference value in identifying the extent of the problem in the community and in planning the subsequent clinical care of incontinent adult women. Keywords: Urinary incontinence, illness behaviours, primary care, prevalence. 摘要 目的：研究政府基層診所成年女性小便失禁的患病率及其患 病行為。 設計：橫切面調查。 對象：2004年2月至7月，經隨機抽樣選出的269位18歲以上的在牛頭角賽馬會普通科門診就醫的女性病人。 測量內容：(1)政府轄下普通科門診成年的女性小便失禁的患病率；(2)小便失禁與年齡的關係；(3)小便失禁與長期疾病的關係；(4)失禁病者向醫生匯報病徵的比例；(5)失禁病者拒絕就診的原因。 結果：269位普通科門診病人中，小便失禁的患病率是49.1%。失禁病者與非失禁者的平均年齡分別是61.31歲(標準誤差為1.21)和56.63歲(標準誤差為1.52)，失禁病者的平均年齡較大(p值為0.017)。糖尿病與小便失禁有相關性(p值為0.0496)，小便失禁與其他長期疾病沒有相關性。小便失禁病者中，只有10.6%向醫生訴說這問題。失禁越頻繁，病人向醫生求診比例就越高(p值為0.055)。89.4%的失 禁病者不曾就此就診。其中62.7%認為小便失禁是輕微問題，36.5%認為是正常的老年化現象，5.9%因感到尷尬而不願求助。 結論：香港政府基層診所中，近半女病人患上小便失禁，尤其是糖尿病人和老年人。這個研究有助了解女性小便失禁問題在社區的嚴重程度，並可以做為制定長遠的臨床診療計劃的參考。主要詞彙：小便失禁，患病行為，基層醫療，患病率。 Introduction The prevalence of urinary incontinence (UI) in women is difficult to estimate because definitions vary between researchers and among women. In the present study, UI is defined as "the complaint of any involuntary leakage of urine" conforming to the standards recommended by the International Continence Society on a self reported basis through questionnaire survey.1 Common types of incontinence include stress, urge, overflow and functional incontinence. UI is a common but usually ignored health problem among women. Not only does UI claim large direct medical costs, but it is also associated with poor self-rated health, impairment in quality of life, social isolation, and depressive symptoms.2 Studies carried out in Caucasian populations on the prevalence of UI show the prevalence ranges from 3% to 55% in community dwellers,2-14 depending on the definition used and the demographic characteristics of population studied.15 In Hong Kong, the prevalence of UI also varies. In a local study performed among elderly in institutions, the prevalence was reported to be 24.5%.16 In another local study, 36% of patients in geriatric wards of a regional hospital were found to have UI.17 There were two community-based studies on UI in Hong Kong. In one study, 34% of women aged 18 and above in the Shatin District had experienced UI.18 In a community continence promotion programme of elderly centres, the prevalence of UI was 40.8%.19 Although UI is a common problem, affected women do not consult any health care provider for it.4,17,19,20 Some may believe it is an unavoidable ageing process, while others may feel embarrassed to raise the problem with their doctors. Knowing the reasons why some of the women with UI do not seek medical advice would help primary care physicians to manage this sensitive problem with their patients. Primary care physicians are usually the first points of contacts in the health care system. However, local study on UI in primary care setting is lacking. Government General Outpatient Clinics (GOPCs) in Hong Kong provide a substantial proportion of primary care encounters in Hong Kong. In our survey, we aimed to study the prevalence of UI in adult women and their illness behaviours in a public primary care clinic setting. Methods The prevalence of urinary incontinence (UI) in women is difficult to estimate because definitions vary between researchers and among women. In the present study, UI is defined as "the complaint of any involuntary leakage of urine" conforming to the standards recommended by the International Continence Society on a self reported basis through questionnaire survey.1 Common types of incontinence include stress, urge, overflow and functional incontinence. UI is a common but usually ignored health problem among women. Not only does UI claim large direct medical costs, but it is also associated with poor self-rated health, impairment in quality of life, social isolation, and depressive symptoms.2 Studies carried out in Caucasian populations on the prevalence of UI show the prevalence ranges from 3% to 55% in community dwellers,2-14 depending on the definition used and the demographic characteristics of population studied.15 In Hong Kong, the prevalence of UI also varies. In a local study performed among elderly in institutions, the prevalence was reported to be 24.5%.16 In another local study, 36% of patients in geriatric wards of a regional hospital were found to have UI.17 There were two community-based studies on UI in Hong Kong. In one study, 34% of women aged 18 and above in the Shatin District had experienced UI.18 In a community continence promotion programme of elderly centres, the prevalence of UI was 40.8%.19 Although UI is a common problem, affected women do not consult any health care provider for it.4,17,19,20 Some may believe it is an unavoidable ageing process, while others may feel embarrassed to raise the problem with their doctors. Knowing the reasons why some of the women with UI do not seek medical advice would help primary care physicians to manage this sensitive problem with their patients. Primary care physicians are usually the first points of contacts in the health care system. However, local study on UI in primary care setting is lacking. Government General Outpatient Clinics (GOPCs) in Hong Kong provide a substantial proportion of primary care encounters in Hong Kong. In our survey, we aimed to study the prevalence of UI in adult women and their illness behaviours in a public primary care clinic setting. Results During the study period, one of us (Dr. CP Ngan) saw 297 adult female patients. Thirteen patients refused to join the study. Fourteen patients were excluded from the study because of a communication problem. One patient with incomplete data was also excluded from the study. As a result, 269 patients were included for analysis. The response rate was 95.4%. The prevalence of UI in our study was 49.1% (132/269 subjects) (Figure 1) in which 66 reported more frequent (>3 times per year) symptoms of UI. The incontinence rate for women with more frequent UI symptoms (> 3 times per year) was 24.5% (66/269). The age of our study population ranged from 18 to 89 with mean age of 58.9 (SE=0.985). The mean age of incontinent group was 61.3 (SE=1.213) while the mean age of continent group was 56.63(SE=1.519). The incontinent group had a statistically significant older mean age (p value=0.017).
Concerning mobility, only one subject walked with a stick. Chi-square test showed significant association between diabetes mellitus and UI (p=0.0496). No significant association has been shown between UI and other chronic illnesses (Table 1). When all age group and chronic illnesses were taken into consideration in the logistic regression model, the p value was not significant. In subgroup analysis of patients over 65 years old, diabetes mellitus was associated with UI (p=0.0496) (Table 2) but not with other chronic illnesses. The incontinent group and continent group did not show statistically significant difference in the number of chronic drugs use (p=0.056).
Only 10.6 % (14/132 patients with UI) of patients had raised their problems of UI to doctors. Chi- square test showed no significant association between raising the problem to doctors and the presence of chronic illnesses including diabetes mellitus (p=0.090), hypertension (p=0.870), hyperlipidaemia (p=0.244), ischaemic heart disease (p=1.000), cerebrovascular accident (p=0.892), chronic obstructive pulmonary disease (COPD) (p=1.000) and asthma (p=0.727). There was an increasing trend of reporting UI with increasing frequency of symptoms though it is not statistically significant (Table 3). Among incontinent subjects, three subjects used pads. There is significant association between raising the problem with doctors and using pads (p<0.001). Age is not associated with raising the problem to doctors (p=0.462).
Reasons for not seeking medical advice in incontinent subjects are summarized in Table 4.
Discussion Our study found that the prevalence of UI in a GOPC was 49.1%. The prevalence was higher than those in previous local studies, which ranged from 24.5% to 40.8%.16-19 Wide variation in the prevalence also occurred in Caucasian studies.15 This may be due to differences in definition of UI, population studied, data collection method, how the questions regarding incontinence were asked and age groups.5,7,11,21 Person to person interviews also reported higher prevalence than studies using mailed surveys.11 Although some of the patients refused invitation for recruitment into our study, the bias is minimal because the response rate was high. Interviews using one interviewer with standardized questioning technique could eliminate inter-observer bias. On the other hand, physician to patient interview might have biased the patients' response. The findings may not be generalized to other GOPCs nor to all adult women population in Hong Kong because of potential differences in demographic characteristics in different districts. A multi-centre study involving GOPCs from different districts will give a better representation of the overall situation. UI was known to be associated with age, body mass index, parity and a wide range of medical diseases including dementia, cerebrovasular accident, diabetes mellitus, Parkisonism and COPD.5,7,9,12,17,21-25 Our study showed significant association between diabetes mellitus and UI (p=0.0496) only. Few patients in our study were suffering from ischaemic heart disease, stroke, COPD and asthma, which are positive risk factors for bladder dysfunction. This may help explain the insignificant statistical association between UI and these risk factors in our study. The sample size in our study may be too small to detect the weak associations, which were shown in other studies.2 Larger sample size would be required to further study these associations. The incontinent group had a significantly older mean age than the continent group in our study. This may introduce bias in analysis of the association between diabetes mellitus and UI because increasing age is also associated with diabetes mellitus. To eliminate age as a potential confounding factor, subgroup analysis of patients with age over 65 years old confirmed diabetes mellitus was associated with UI (p=0.0496). In our study, most patients with UI (89.4%) did not seek professional advice. The figure is comparable to that from other studies, which showed 44% to 88% patients did not report the incontinent problem to their doctors.10, 19-20 Among those who did not consult for their incontinent problem, 62.7% of patients perceived UI is a minor problem. Our study also showed there was an increasing trend of reporting UI with increasing severity of symptoms. In a study by Lagro-Janssen et al,14 they found the greater the worries and restrictions owing to incontinence, the greater the chance that the women would report UI to their general practitioners. 36.5% of patients thought UI is a normal part of ageing, a common myth among women. In fact, UI is never normal though age-related changes may predispose to the condition. Only 5.9% patients felt too embarrassed to seek medical advice. Nearly all of the patients in our study were ambulant and only one who needed a walking aid. Mobile patients are generally less troubled by UI. Moreover, 66 out of 132 with UI (50%) had <3 UI episodes in 1 year. This may help explain that most patients (89.4%) with UI in our study did not seek professional advice. It would be useful to do a subgroup analysis for those who had >3 episodes of leak per month as they would be more likely to report this to their doctor. A larger sample size would be required. A local telephone survey was conducted on treatment-seeking behaviour in Hong Kong Chinese women with urinary symptoms.26 In this study, 35.1% symptomatic subjects sought medical advice for their urinary problems. Among these subjects, 41.2% sought medical advice from their general practitioners. General practitioners are usually the first points of contacts for medical encounters. Rapport with the patients will encourage them to discuss sensitive issues, like UI, with their general practitioners. Many incontinent patients who are silent about their incontinent problem in fact wanted to know more about the management. In a study on assessment of the state of knowledge of women with UI, 85.7% women showed great interest in information about the disease.27 Many would seek professional help if they knew tests and effective treatments were available.10 On the other hand, it was suggested that there were many elderly in the community suffering from this problem but health care workers were unaware of their problem.17 Because of the high prevalence of UI and low reporting rate in our adult women patients, we should actively look for patients suffering from UI, especially in those with diabetes mellitus and those belonging to an older age group. The management of UI depends on the type of incontinence. In general, bladder training is first line treatment. For urge incontinence in particular, bladder training is the most effective treatment available.28 If bladder training fails, medication can be used to alleviate the symptoms. Surgical treatments are one of the options in selected patients especially those with stress incontinence. Situations which require specialized evaluation or referral include stress UI with failed conservative treatment, patient's preference in pursuing surgical options, uncertain diagnosis after evaluation, haematuria without infection, persistent symptoms of difficult bladder emptying or abnormal post void residual volume (normally, less than 50ml of residual urine is present after voiding, post void volume of ?00ml is considered abnormal), history of previous anti-incontinence surgery or radical pelvic surgery, symptomatic pelvic organ prolapse and presence of neurological condition such as multiple sclerosis or spinal cord lesion.2 Conclusion Our study found a high prevalence (approximately 50%) of UI amongst adult female patients surveyed in a public primary care clinic setting. Most patients with UI did not seek medical advice. They perceived UI as a minor problem. Some even thought UI was a normal process of ageing. These misunderstandings are barriers for their seeking proper care for UI related symptoms. The results of the present study may be of reference value in identifying the extent of the problem in the community and in planning the subsequent clinical care of incontinent adult women. Hopefully, this kind of study could help educate health care professionals about UI and improve their understanding of the help-seeking behaviour of incontinent adult women. Key messages
Ching-Po Ngan, MBBS(HK),
DCH(Ireland), Pdip Community Geriatrics (Hong Kong)
Soe-Tjhoen Lam, MBChB(CUHK), MRCP(UK), DCH(Ireland),
Kwai-Wing Wong, MBBS (HK), FRACGP,
FHKCFP, DCH (Ireland) David V K Chao, MBChB(Liverpool),
DCH(London), FRCGP, FHKAM(Family Medicine) Correspondence to: Dr Soe-Tjhoen Lam, HA Staff Clinic, Department of Family Medicine and Primary Health Care, United Christian Hospital, Kwun Tong, Kowloon. References
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