Prevalence of Urinary Incontinence and Probable Risk Factors in a Sample of Kurdish Women *

OBJECTIVES
The most common manifestation of pelvic floor dysfunction is urinary incontinence (UI) which affects 15-50% of adult women depending on the age and risk factors of the population studied. The aim of this study was to determine the probable risk factors associated with UI; the characteristics of women with UI; describe the types of UI, and determine its prevalence.


METHODS
A cross-sectional study was conducted between February and August 2011, in the Maternity Teaching Hospital of the Erbil Governorate, Kurdistan Region, northern Iraq. It included 1,107 women who were accompanying patients admitted to the hospital. A questionnaire designed by the researchers was used for data collection. A chi-square test was used to test the significance of the association between UI and different risk factors. Binary logistic regression was used, considering UI as the dependent variable.


RESULTS
The overall prevalence of UI was 51.7%. The prevalence of stress, urgency, and mixed UI was 5.4%, 13.3% and 33%, respectively. There was a significant positive association between UI and menopause, multiparity, diabetes mellitus (DM), chronic cough, constipation, and a history of gynaecological surgery, while a significant negative association was detected between UI and a history of delivery by both vaginal delivery and Caesarean section.


CONCLUSION
A high prevalence of UI was detected in the studied sample, and the most probable risk factors were multiparity, menopausal status, constipation, chronic cough, and DM.

T he most common manifestation of pelvic floor dysfunction is urinary incontinence (UI).Incontinence can have a significant impact on women's health, leading to physical problems such as skin breakdown, infection, and rashes.][3] Through epidemiological studies, the International Continence Society (ICS) has developed a new definition of UI and its types.UI is defined as a complaint of involuntary loss of urine.Stress urinary incontinence (SUI) is defined as a complaint of involuntary loss of urine on effort or physical exertion.Urgency urinary incontinence (UUI) is defined as a complaint of involuntary loss of urine associated with urgency.Mixed urinary incontinence (MUI) is defined as a complaint of involuntary loss of urine associated with both urgency and physical exertion. 4rinary incontinence is a medical condition affecting 15-50% of adult women depending on the age and risk factors of the population studied.It is considered one of the top 10 sources of expenditure for treatment of illness. 5Approximately 50% of persons residing in nursing homes are incontinent and it is the tenth leading cause of hospitalisation. 6lthough half of all elderly people experience episodes of incontinence, it is also a problem that affects younger women. 7ven though information concerning its prevalence and incidence in the population as a whole remains uncertain, clinical attention is increasingly focused on UI and its treatment. 8he lack of adequate epidemiological data on the prevalence of female UI in the Kurdish population of Erbil led us to conduct a cross-sectional study on a sample of women attending the Maternity Teaching Hospital in Erbil, Iraq.The aim of the present study was to determine the prevalence and characteristics of women with UI, to describe types of UI, and to find probable risk factors associated with UI.

Methods
A cross-sectional study was conducted between 10 th February and 10 th August 2011 in the Erbil Maternity Teaching Hospital in the Kurdistan Region of northern Iraq.The Erbil Maternity Teaching Hospital is the only governmental maternity hospital in Erbil and so receives obstetrical and gynaecological cases from all over the Erbil governorate.Erbil is the capital of the Iraqi Kurdistan Region with a population approaching two million.
The study was approved by the Erbil Directorate of Health and the scientific and ethical committees of the Nursing College.Included in the study were women accompanying patients admitted to the hospital.The purpose of the study was explained to each woman during personal interviews, and informed verbal consent was obtained from all participants.
Participants were excluded if they were pregnant or had urinary system problems.Data were collected via an English-language questionnaire which was designed by the researchers after reviewing published literature and consultating with experts.The questionnaire was translated into the Kurdish language and then reverse translated by an independent party to ensure accuracy.A pilot study was prepared by testing the final questionnaire, on 20 women attending the Erbil Maternity Teaching Hospital, to ensure a correct translation and easy understandability for ordinary women and to explore any unclear points.The questionnaire was completed during personal interviews with the women.
Data collection was performed by three Kurdish-speaking nurses who were working in inpatient wards.The nurses were trained regarding how to administer the questionnaire by one of the investigators.The questionnaire was designed to investigate the following: women's demographic characteristics; medical and obstetric history; maternal age; marital status; place of residence; parity and mode of previous deliveries (i.e.vaginal or Caesarean delivery); previous deliveries of macrosomic babies; previous abdominal surgery; presence of chronic diseases, including diabetes mellitus (DM); chronic cough or constipation; smoking, and menopausal state.The types of UI were diagnosed by asking about the frequency of micturition during the day, the presence of nocturia or a sudden desire to urinate which could not be deferred, and the leakage of urine on coughing or sneezing.
The sample size was estimated using the Epi Info 6 statistical software, Version 6.04 (Centers for Disease Control, Atlanta, Georgia, USA, and the World Health Organization, Geneva, Switzerland).The following data were entered into the programme: the estimated number of admitted women during the 6-month study period was 21,708.The estimated prevalence of UI was 30% based on the average prevalence of some studies. 2,5The absolute precision was set at 2.5% (above and below the 30%) with a 95% confidence level.Accordingly, the estimated sample size was 1,218 women.A total of 1,107 women who were accompanying patients admitted to different departments of the same hospital were willing to participate in the study, so the non-response rate was 9.1%.Data were analysed using the Statistical Package for Social Sciences (SPSS), Version 18 (IBM, Inc., Chicago, Illinois, USA).A chi-squared test of association was used to test the significance of the association between UI and different factors.Binary logistic regression was used considering the UI as the dependent variable.A P value of ≤0.05 was considered statistically significant.

Results
The mean age (± standard deviation [SD]) of participating women was 50.59 ± 6.77 years, ranging from 28 to 85 years.All of the women were married.The overall prevalence of UI was 51.7%.The prevalence of SUI, UUI, and MUI was 10.5%, 25.7% and 63.8%, respectively.The prevalence among those living outside the city (66.2%) was significantly higher than the prevalence among those living in the city (48%) (P <0.001).Also, the prevalence was higher among smokers (69.4%) as compared with the prevalence among non-smokers (48.7%) (P <0.001).
Table 1 shows a highly significant association between certain age groups and UI prevalence.A high prevalence of UI (95.3%) was found among those aged less than 45 years.The prevalence rates of UI among age groups 50-54 (68.9%), 55-59 (76.4%), and ≥60 (65.9%) were high.However, no consistent pattern of UI prevalence could be detected in different age groups.
Table 2 shows a highly significant association between age groups and types of UI.The highest proportion of USI (29.3%) was in those aged 45 years or less.The overall proportion of UUI was 25.7%, while it was present in 33.3% in 45-49 year olds.The same table shows that 70.4% of those aged ≥ 60 years complained of MUI.
Results of the study showed a highly significant association between UI and menopause; parity (≥5); vaginal delivery; a history of giving birth to neonates weighing ≥4 kg; or a history of DM, chronic cough, constipation, or pelvic surgery [Table 3].Table 4 shows that there was significant positive association between UI and many factors like menopause (odds ratio [OR] = 1.9); parity (OR = 2.5); DM (OR = 4.2); chronic cough (OR = 4.02); constipation (OR = 2.1), and a history of gynaecological surgery (OR = 2.9), while a significant negative association was detected between UI and a history of either vaginal or Caesarean delivery (OR = 0.11).

Discussion
The prevalence of UI ranges from 3-55% depending on the definition of incontinence and the age of the population studied. 2 The results of the present study showed that 51.7% of the sample had UI, which is  much higher than the neighbouring countries of Turkey and Iran.In a study done by Kocak et al.  in Turkey on 242 women, the overall prevalence of UI was 23.9%. 9In another study conducted in Iran on 411 married women, the overall prevalence of UI was 18.9%. 10The high prevalence of UI in the present study could be due to the high number of vaginal deliveries in the Kurdistan region which is responsible for pelvic floor dysfunction.Also, UI health education is limited in our locality.
Regarding nutrition, which is responsible for the development of DM and overweight, both are strong risk factors for UI and could have been the cause the high prevalence of UI in our sample.In a study conducted by Al-Bader et al. on 379 Saudi women with a mean age of 35 years, the overall prevalence of UI was 41.4%.11In another study done in Egypt on 1,652 women, the overall prevalence of UI was 54.8%, which is consistent with the present study. 12In a study conducted by Katz et al. on 851 women aged 18 years and older who were selected randomly in Australia, 267 women (31.3%) stated that they had noted some degree of incontinence during the preceding 12 months, and 142 (16.6%) suffered two or more regular episodes of leakage per month.Daily incontinence was reported by 5%, and 2.3% were incontinent often or continuously. 13m et al. conducted a study on 276 women in South Korea and found that the prevalence of UI by type was 12.8% (UUI), 38.5% (SUI), and 48.7% (MUI).These rates were higher than those in the present study. 14The prevalence of the types of UI in a study conducted in the Turkey was 25.6% (UUI), 33.1% (SUI), and 41.3% (MUI), which was more or less consistent with the results of the present study. 9he prevalence of different types of UI in a study conducted in Iran was 4.1% (UUI), 18.7% (SUI) and 4.1% (MUI); the prevalence of SUI was higher than that in the results of the present study, where we found a 10.5% incidence of SUI, while the incidence of UUI, and MUI was much lower. 10Studies in Western countries have revealed that UUI is the most common type of UI in the elderly, occurring in 40-70% of those who present to physicians with  complaints of incontinence. 15Brown et al.'s study of the prevalence of UI among 2,763 postmenopausal women found the prevalence of UI as follows: 14.4% (UUI), 12.8% (SUI), and 12.3% (MUI); the mean age in their study was 66.7 years. 16n the present study, the percentage of UI among those in the <45 years age group was high.This research is the first conducted in our locality related to UI in of Kurdish ethnicity.This is significant as race/ethnicity differences exist in selfreported incontinence. 17,18However, it is unknown how ethnic differences affect UI prevalence in young women.Further research should be conducted in a larger sample size of young Kurdish females to correlate the risk factors, as the sample size in this study (n = 43) was too small for this purpose.
Bunyavejchevin found a significant association between UI and chronic cough and constipation in the study on 360 postmenopausal Thai women, which is consistent with the result of the present study. 19Tseng et al., in their study on 4,470 Taiwanese women, found a significant association between UI and multiparity, and no association with age, which was also consistent with the result of the present study. 20n the current study, there was a significant association between UI and DM, chronic cough, and constipation which is consistent with the results of other studies. 11SUI is triggered by physical exertion, including coughing, sneezing, straining, or exercise.In women, a weakness in the pelvic floor muscles, due to vaginal childbirth, may cause a defect in the support of the internal sphincter, ultimately leading to SUI.Multiparous women are prone to cystocele and urethrocele, which are also linked to SUI.A patient with DM has a 30-70% increased risk of developing UUI or MUI.][11] The limitations of the present study were as follows: there was no validated instrument to detect prevalence rates of UI in Kurdish women, the prevalence of UI was not studied in one specific age group, and UI was not studied in relation to obesity.Further studies should be conducted to test these important correlations.

Conclusion
A high prevalence of UI was detected in a selected sample of Kurdish women in the Maternity Teaching Hospital in Erbil, Iraq.Associated risk factors were found to be the delivery of a baby ≥4 Kg, chronic cough, DM, a history of a pelvic operation, multiparity, menopausal status, and constipation.A history of both types of delivery had no protective effect against UI.

Table 1 :
Association between urinary incontinence and age

Table 2 :
Association between types of urinary incontinence and age

Table 3 :
Prevalence of urinary incontinence by obstetrical history

Table 4 :
Output of binary logistic regression showing the association between urinary incontinence as a dependent variable, and some other independent variables