1447Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Impact of Urinary Incontinence on Quality of Life among Residents Living in Turkey Muhammet Guzelsoy, Hakan Demirci, Soner Coban, Buket Belkiz Güngör, Emin Ustunyurt, Serhat Isildak Corresponding Author: Hakan Demirci, MD Department of Family Medicine, Sevket Yilmaz Research Hospital, Yildirim, Bursa, 16310, Turkey. Tel: +90 536 896 3330 E-mail: drhakandemirci@hotmail. com Received June 2013 Accepted February 2014 Department of Family Medi- cine, Sevket Yilmaz Research Hospital, Yildirim, Bursa, 16310, Turkey. FEMALE UROLOGY Purpose:‎To‎assess‎the‎impact‎of‎urinary‎incontinence‎on‎the‎quality‎of‎life‎in‎Turkish‎popu- lation. Materials and Methods:‎This‎was‎a‎cross-sectional‎study‎performed‎on‎530‎participants‎ admitted‎to‎Sevket‎Yilmaz‎Research‎Hospital‎in‎Turkey.‎Quality‎of‎life‎(QoL)‎was‎assessed‎ using‎Incontinence‎Impact‎Questionnaire‎(IIQ-7).‎Frequency‎and‎severity‎of‎urinary‎incon- tinence‎(UI)‎were‎diagnosed‎by‎answers‎to‎the‎International‎Consultation‎on‎Incontinence‎ Questionnaire‎Short‎Form‎(ICIQ-SF)‎instrument.‎The‎relationship‎between‎several‎demo- graphic‎data‎and‎QoL‎was‎examined. Results:‎The‎mean‎age‎of‎the‎attendees‎was‎55.36‎±‎10.62‎years‎(range‎40-91).‎A‎total‎of‎ 109‎(44%)‎women‎and‎46‎(16%)‎men‎suffered‎involuntary‎urine‎leakage.‎QoL‎changes‎for‎ all‎domains‎showed‎significant‎deteriorations.‎Frequency‎and‎severity‎of‎UI‎were‎negatively‎ associated‎with‎the‎QoL‎scores. Conclusion:‎‎Our‎results‎have‎shown‎that,‎UI‎considerably‎worsens‎QoL.‎Challenge‎with‎UI‎ should‎be‎priority‎of‎any‎project‎aiming‎to‎promote‎the‎quality‎of‎life. Keywords:‎urinary‎incontinence;‎quality‎of‎life;‎female;‎male;‎cross-sectional‎studies;‎Tur- key. 1448 | INTRODUCTION The‎International‎Continence‎Society‎defines‎urinary‎incontinence‎(UI)‎as‎‘involuntary‎loss‎of‎urine‎that‎is‎a‎social‎or‎hygienic‎problem’.(1)‎These‎social‎and‎ hygienic‎problems‎impair‎the‎quality‎of‎life‎(QoL)‎in‎pa- tients‎with‎UI.‎Assessment‎of‎QoL‎can‎be‎achieved‎by‎vari- ous‎questionnaires‎in‎patients‎with‎UI‎among‎them‎Incon- tinence‎Impact‎Questionnaire‎(IIQ-7)‎is‎a‎well-known‎and‎ easily‎applicable‎instrument‎to‎determine‎impact‎of‎UI‎on‎ QoL.(2)‎It‎is‎a‎self-reported‎questionnaire‎filled‎in‎by‎persons‎ and‎consists‎of‎seven‎items‎addressing‎four‎main‎domains‎of‎ life:‎physical‎activity,‎social‎relations,‎travel‎and‎emotional‎ status.‎This‎instrument‎was‎validated‎to‎Turkish‎by‎Cam‎and‎ colleagues.(3)‎On‎the‎other‎hand,‎general‎characteristics‎of‎ UI‎can‎be‎evaluated‎by‎the‎International‎Consultation‎on‎ Incontinence‎Questionnaire‎Short‎Form‎instrument‎(ICIQ- SF).(4)‎Although‎urodynamic‎tests‎are‎known‎to‎be‎a‎gold‎ standard‎ for‎ classification‎ of‎ UI,‎ history‎ taking‎ has‎ been‎ shown‎be‎an‎alternative‎to‎it.(5-8) Urinary‎incontinence‎is‎common‎especially‎among‎elderly‎ but‎it‎can‎be‎experienced‎at‎any‎age.‎Although‎it‎is‎a‎quite‎ bothersome‎situation‎to‎the‎patients‎some‎patients‎suffering‎ from‎UI‎do‎not‎go‎to‎a‎health‎care‎provider‎because‎they‎feel‎ the‎problem‎as‎a‎normal‎physiologic‎situation‎and‎some‎hide‎ the‎situation‎as‎they‎are‎ashamed.(9-11)‎Admission‎to‎a‎hos- pital‎with‎the‎complaint‎of‎UI‎is‎shown‎to‎be‎low‎especially‎ in‎female‎gender‎and‎they‎may‎usually‎prefer‎to‎solve‎the‎ problem‎by‎themselves‎using‎some‎adsorbent‎pads.‎Severity‎ of‎UI,‎type‎of‎the‎disease‎and‎impairment‎in‎QoL‎has‎been‎ shown‎to‎affect‎help‎seeking‎behavior.(12-14) The‎aim‎of‎the‎present‎study‎was‎to‎examine‎the‎impact‎of‎ UI‎on‎QoL‎among‎Turkish‎residents‎and‎find‎out‎an‎answer‎ to‎the‎question‎“why‎do‎they‎go‎to‎a‎physician‎in‎relation‎to‎ QoL”? MATERIAL AND METHODS Study Population A cross sectional study was conducted in 168 participants with‎UI‎who‎were‎referred‎to‎the‎outpatient‎clinics‎of‎Urol- ogy‎and‎Gynecology‎&‎Obstetrics‎departments‎ in‎Sevket‎ Yilmaz‎Training‎and‎Research‎Hospital‎between‎1‎January‎ 2013‎and‎31‎May‎2013.‎Patients‎were‎questioned‎if‎they‎had‎ UI‎and‎the‎first‎patient‎of‎the‎day‎during‎the‎study‎period‎ who‎had‎the‎complaint‎of‎UI‎was‎asked‎to‎participate‎in‎the‎ study.‎ Demographic‎ data‎ including‎ age‎ distribution,‎ sex,‎ education,‎occupation‎and‎marital‎status‎were‎noted.‎Help‎ seeking‎attempts‎of‎the‎patients‎was‎recorded.‎ Participants‎were‎asked‎ to‎fill‎ IIQ-7‎and‎ICIQ-SF‎forms.‎ Quality‎of‎life‎was‎evaluated‎by‎using‎IIQ-7.‎Scores‎obtained‎ from‎participants‎were‎multiplied‎by‎33‎to‎estimate‎the‎se- verity‎of‎ the‎changes‎ in‎QoL.‎The‎general‎characteristics‎ of‎urinary‎incontinence‎were‎assessed‎by‎the‎data‎provided‎ from‎the‎answers‎to‎the‎ICIQ-SF.‎It‎enabled‎us‎to‎determine‎ frequency,‎quantity‎and‎classification‎of‎UI.‎Frequency‎of‎ UI‎was‎categorized‎in‎6‎groups‎ranging‎from‎none‎to‎always‎ and‎quantity‎of‎UI‎was‎examined‎in‎4‎groups‎as‎none,‎a‎lit- tle,‎moderate‎and‎a‎lot.‎Maneuvers‎that‎UI‎provoked‎was‎ asked‎in‎the‎questionnaire,‎and‎so‎urge,‎stress,‎mix,‎overac- tive‎and‎total‎incontinence‎was‎differentiated. Exclusion‎criteria‎were‎patients‎with‎a‎history‎of‎a‎neurolog- ic‎or‎psychiatric‎disease,‎patients‎who‎had‎been‎operated‎for‎ prostatic‎disease,‎and‎patients‎who‎were‎unable‎to‎complete‎ the‎questionnaires. Ethical‎approval‎for‎this‎study‎was‎obtained‎from‎The‎Ethi- cal‎ Committee‎ of‎ Sevket‎ Yilmaz‎ Training‎ and‎ Research‎ Hospital.‎Participants‎were‎informed‎about‎the‎study‎objec- tives‎and‎a‎written‎informed‎consent‎was‎obtained‎from‎each‎ of‎them.‎ Statistical Analysis All‎statistical‎analyses‎were‎performed‎with‎the‎statistical‎ Female Urology Table 1. Sociodemographic characteristics of study participants. Variables Number Marital status Single 2 Married 166 Education Literate 31 Primary 91 Secondary 37 High 9 Occupation Housewife 85 Retired 55 Working 27 Unemployed 1 Self-reported economic status Low 21 Moderate 133 High 12 1449Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Urinary Incontinence on Quality of Life | Guzelsoy et al package‎ for‎ the‎ social‎ science‎ (SPSS‎ Inc,‎ Chicago,‎ Illi- nois,‎USA)‎version‎20.0.‎For‎descriptive‎statistics,‎means,‎ standard‎deviations‎(SD)‎and‎frequencies‎were‎calculated.‎ We‎used‎the‎student’s‎t‎test‎for‎the‎comparison‎of‎mean‎age‎ between groups. Mann Whitney U‎test‎was‎used‎to‎compare‎ two‎groups,‎Kruskal-Wallis‎test‎was‎used‎to‎compare‎three‎ or‎more‎groups‎for‎nominal‎values‎(i.e.;‎scores‎of‎IIQ-7).‎P values‎less‎than‎.05‎were‎considered‎as‎statistically‎signifi- cant. RESULTS A‎total‎of‎168‎participants‎(107‎women‎and‎61‎men)‎suf- fered‎involuntary‎urine‎leakage.‎There‎were‎10‎patients‎ex- cluded‎who‎couldn’t‎able‎to‎fill‎the‎questionnaires.‎None‎of‎ the‎patients‎refused‎to‎participate‎in‎the‎study.‎The‎mean‎age‎ of‎the‎attendees‎was‎59.8‎±‎11.2‎years‎(range‎40-91).‎Socio- demographic‎characteristics‎of‎the‎study‎group‎are‎shown‎ in‎Table‎1.‎ The‎impact‎of‎UI‎on‎QoL‎was‎mild‎to‎moderate‎in‎the‎study‎ group.‎QoL‎scores‎for‎each‎item‎were‎similar‎in‎both‎gen- ders‎(Table‎2).‎Aging‎was‎statistically‎significantly‎associ- ated‎with‎QoL‎in‎women‎(Figure‎1). Totally‎there‎were‎55‎patients‎with‎urge‎incontinence,‎41‎ patients‎with‎stress‎incontinence,‎51‎patients‎with‎mixed‎in- continence,‎12‎patients‎with‎overactive‎incontinence‎and‎9‎ patients‎with‎total‎incontinence.‎The‎most‎common‎type‎of‎ UI‎was‎urge‎incontinence‎(48.3%)‎in‎men‎and‎stress‎incon- tinence‎(35.5%)‎in‎women. Relationships‎between‎general‎characteristics‎of‎UI‎such‎as‎ the‎frequency,‎severity‎and‎type‎and‎QoL‎scores‎were‎shown‎ in‎Table‎3‎and‎Figures‎2-4.‎Physical‎activities‎and‎emotional‎ health‎were‎impaired‎in‎patients‎who‎had‎admitted‎to‎a‎phy- sician‎with‎the‎complaint‎of‎UI.‎Social‎relationships‎did‎not‎ show‎a‎significant‎difference‎between‎help‎seekers‎and‎the‎ rest‎of‎the‎study‎group‎(Table‎4).‎Duration,‎frequency‎and‎ quantity‎of‎UI‎affected‎the‎decision‎to‎go‎to‎a‎physician.‎Pa- tients‎with‎UI‎who‎seek‎for‎medical‎help‎were‎older‎than‎who‎ do not, [t‎=‎3.090,‎degrees‎of‎freedom‎(df)‎=‎156,‎P =‎.002]. Table 2. Impact of urinary incontinence on each life activity.* Gender Household Physical Entertainment Travel Social Emotional Feeling Female 31.4 ± 3.5 35.8 ± 3.5 31.3 ± 3.6 35.8 ± 3.6 39.2 ± 3.7 45.8 ± 3.2 48.0 ± 3.2 Male 28.2 ± 5.2 32.7 ± 4.5 27.6 ± 4.5 31.6 ± 4.9 38.9 ± 5.0 47.6 ± 4.4 44.7 ± 4.8 Total 30.2 ± 2.9 34.7 ± 2.7 30.0 ± 2.8 34.3 ± 2.9 39.1 ± 2.9 46.4 ± 2.6 46.9 ± 2.7 * IIQ-7 scores (mean ±SE) were multiplied by 33 to put scores on a scale of 0 to 100. Figure 1. Relationship between Quality of Life and age of the participant. Figure 2. Type of the urinary incontinence and average Quality of Life scores. 1450 | DISCUSSION Patients‎with‎self-reported‎UI‎reported‎a‎mild‎to‎moderate‎ impairment‎of‎QoL,‎similar‎to‎reports‎from‎previous‎stud- ies‎in‎Turkey.(15,16)‎The‎most‎affected‎domain‎of‎QoL‎was‎ emotional‎health. Frequency‎and‎quantity‎of‎UI‎affected‎QoL.‎Barentsen‎and‎ colleagues‎reported‎that‎severity‎rather‎than‎type‎of‎UI‎was‎ associated‎ with‎ QoL.(12)‎ However,‎ some‎ authors‎ claimed‎ that‎type‎of‎incontinence‎affects‎QoL.(13,14) In the present study‎we‎only‎found‎that‎QoL‎was‎not‎statistically‎different‎ between‎urge,‎stress‎or‎mixed‎incontinence‎patients. The‎decision‎of‎help‎seeking‎behavior‎among‎Turkish‎resi- dents‎was‎determined‎by‎impairment‎in‎all‎domains‎of‎QoL‎ other‎than‎‘participation‎in‎social‎activities’.‎Physical‎disabil- ity‎and‎impairment‎in‎emotional‎health‎direct‎these‎patients‎ for‎a‎medical‎help‎in‎the‎study‎group.‎ Limitations‎of‎this‎study‎include‎the‎fact‎that‎it‎was‎not‎pop- ulation-based,‎so‎results‎may‎not‎reflect‎the‎whole‎Turkish‎ population.‎And,‎types‎of‎UI‎were‎diagnosed‎by‎self-reported‎ history;‎an‎improved‎approach‎would‎measure‎UI‎by‎urody- namic‎tests.‎ Table 3. Relationships between characteristics of urinary incontinence and Quality of Life scores for each domain. Characteristics Physical Activity Travel Social Relationships Emotional Health Frequency of UI χ2 = 40.088 χ2 = 39.232 χ2 = 39.115 χ2 = 37.312 df = 5 df = 5 df = 5 df = 5 P = .000 P = .000 P = .000 P = .000 Quantity of UI χ2 = 40.203 χ2 = 41.999 χ2 = 41.643 χ2 = 33.348 df = 3 df = 3 df = 3 df = 3 P = .000 P = .000 P = .000 P = .000 Type of UI χ2 = 18.631 χ2 = 14.888 χ2 = 14.836 χ2 = 21.081 df = 4 df = 4 df = 4 df = 4 P = .001 P = .005 P = .005 P = .000 Keys: UI, urinary incontinence; df, degrees of freedom. Figure 3. Frequency of the urinary incontinence and average Quality of Life scores. Figure 4. Quantity of the urinary incontinence and average Qual- ity of Life scores. Female Urology 1451Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Table 4. Help seeking behavior and Incontinence Impact Questionnaire Quality of Life scores* Variables Household Physical Entertainment Travel Social Emotional Feeling Help-seeker 41.9 ± 5.1 44.1 ± 4.5 39.8 ± 4.8 41.4 ± 4.6 44.6 ± 4.8 55.2 ± 3.7 54.3 ± 4.1 None help-seeker 19.3 ± 3.2 26.7 ± 3.5 21.0 ± 3.3 27.5 ± 3.8 34.1 ± 3.9 39.1 ± 3.7 40.3 ± 3.8 Statisticalanalysis** Z = -3.304 Z = -2.813 Z = -2.867 Z = -2.167 Z = -1.520 Z = -3.043 Z = -2.505 P = .001 P = .005 P = .004 P = .030 P = .129 P = .002 P = .012 * Average scores (mean ± SE) were multiplied by 33 to put scores on a scale of 0 to 100. ** Mann Whitney U test. The Z score is a test of statistical significance that helps you decide whether or not to reject the null hypothesis. CONCLUSION Our‎results‎demonstrated‎that‎the‎impact‎of‎UI‎on‎QoL‎was‎ mild‎to‎moderate‎among‎Turkish‎residents.‎Emotional‎health‎ was‎predominantly‎impaired‎in‎patients‎who‎seek‎for‎help.‎ Attempts‎to‎overcome‎UI‎may‎promote‎patients’‎well-being. 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