Collaborative for Education on Urinary Incontinence and Women's Health (ceUIwh)

Clinical Consult

Each month, questions with a common theme will be selected and answered comprehensively by one of our Steering Committee members. Previously answered questions will be archived each month for your reference. If you wish to submit a question, click here.

This Month's Question:

How does urinary incontinence affect a patient's quality of life?

Response by Thelma J. Wells, PhD, RN, posted 02/28/2005:

Quality of life (QOL) refers to a patient's evaluation of and satisfaction with their physical, psychological, and social well-being.¹ Urinary incontinence affects all of these areas, in addition to the sexual and occupational lives of women of all ages.² Employment situations that impose time constraints, particularly for assembly-line workers or teachers, may restrict toileting options and require strategies to manage incontinence. Moreover, urinary incontinence may cause women to alter their lifestyle to avoid social and physical activities, such as swimming, tennis, and dancing.³ Therefore, clinicians should question their patients about the impact of urinary incontinence on their lives and advise them about management options.^4,5 A tool that can be used by clinicians is the Incontinence Impact Questionnaire, which is a short form that assesses the QOL of those afflicted with urinary incontinence.⁶ This form can be downloaded from the following website: www.americangeriatrics.org/education/UItool02.pdf.

The impact of stress urinary incontinence (SUI) on QOL does not appear to be related to the duration of symptoms, and may be only moderately related to the severity of incontinence. Severity can be defined by factors such as frequency, amount, and subjective nuisance.⁷ The volume of urine lost is a critical component. Leakage might occur less than weekly, but in an amount that is evident on outer clothing; this would likely have more of a life impact than would a greater frequency of concealable incidents.⁸ Studies have found that younger women with SUI appear to be more distressed than older women with the condition.⁹ This may be because older women typically engage in less strenuous physical activities and spend more of their day at home, where a bathroom is more readily accessible.

Leaking urine may be a barrier to physical activity, especially among middle-aged women. The Australian Longitudinal Study on Women's Health, which aims to examine associations over time between aspects of women's lives and their physical and emotional health and well-being, surveyed more than 41,000 women on whether leaking urine prevents physical activity.¹⁰ Analysis of results indicated that more than one third of the middle-aged women (aged 45 to 50 years) and more than one quarter of the older women (aged 70 to 75 years), but only 7% of the younger women (aged 18 to 23 years) avoided sports because of fear of urine leakage.¹¹

A study has disclosed several strategies used to control urine loss by women working in a production facility. The most frequent strategies used to manage incontinence at work included wearing pads (47.3%), using deodorant spray or dusting powder (35.2%), limiting fluids (25%), and avoiding caffeinated beverages (22.4%).¹² Another analysis of the nature of urinary incontinence and management strategies used by full-time–employed working women reported that 21% of women who worked in an urban academic setting and 29% of women who worked in a rural manufacturing facility reported being incontinent at least monthly. Interestingly, the majority in both groups thought that it was not at all or just slightly important to get treatment, yet requested information about incontinence. ¹³ These findings support the need for clinicians to educate women about their bladder health and explain that efficacious treatments are available to women who suffer with urinary incontinence.^5,13

Fear of unpleasant odor was the most important effect cited by 40% of 110 women aged 20 to 65 years with SUI who reported the condition to their general practitioner. Nearly half of the study participants said that perceived smell, the fear of being smelled, and the associated embarrassment and shame were the worst aspects of urinary incontinence.³ Because using deodorant spray or a dusting powder may be a coping strategy for women to conceal their UI , 12 clinicians should be alert to heavily perfumed patients.

Many women are too embarrassed to discuss incontinence with their spouses, which may impact the relationship.¹ Women with urinary incontinence may avoid sexual intimacy for fear of incontinence during sexual activity. Women report experiencing urine leakage during sexual intercourse, which can inhibit desire and future sexual activity.¹ In a study of 324 women referred to a gynecologic urology clinic, 24% experienced incontinence during intercourse.¹⁴

Depression is commonly associated with urinary incontinence.^1,15 A study of community-dwelling adults aged more than 60 years, 78% of whom were female, found that among 230 participants with urinary incontinence, the frequency of urinary incontinence episodes and the perception that urine leakage interfered with life were significantly correlated with depression.¹⁵ However, the impact of urinary incontinence on psychological well-being should be evaluated within the context of other life events, chronic stressors, and objective health characteristics.¹

Clinicians can offer help through noninvasive strategies, such as pelvic floor muscle exercises.⁵ and the Knack.¹⁶ In addition, bladder training has been shown to be effective in improving the QOL of incontinent women.¹⁷ Duloxetine, a serotonin and norepinephrine reuptake inhibitor currently under investigation, significantly improved Incontinence Quality of Life (I-QOL) as compared with placebo in most clinical studies. It appears to be well tolerated and may be a promising new treatment option for women with SUI.^18-20 Surgery to correct urinary incontinence is performed only after all other interventions have failed.⁵

SUI can be effectively assessed, diagnosed, and treated in primary care. For a list of clinical tools, please visit www.stressui.org/clinical_tools.htm. Clinicians should routinely screen for and evaluate symptoms of SUI and, if the condition is identified, determine patient motivation and recommend available treatment options. By providing management strategies, clinicians can improve the overall health and QOL of women with SUI.

References

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Palmer MH. Prevalence, etiology, and risk factors in women at 3 life stages. Am J Nurse Pract. 2004;(suppl):5-14.
Lagro-Janssen T, Smits A, van Weel C. Urinary incontinence in women and the effects on their lives. Scand J Prim Health Care. 1992;10:211-216.
Fultz NH, Burgio K, Diokno AC, Kinchen KS, Obenchain R, Bump RC. Burden of stress urinary incontinence for community-dwelling women. Am J Obstet Gynecol. 2003;189:1275-1282.
Newman DK. Stress urinary incontinence in women: involuntary urine leakage during physical exertion affects countless women. Am J Nurs. 2003;103:46-55.
Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn. 1995;14:131-139.
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Sandvik H, Kveine E, Hunskaar S. Female urinary incontinence—psychosocial impact, self care, and consultations. Scand J Caring Sci. 1993;7:53-56.
Brown WJ, Bryson L, Byles JE, et al. Women's Health Australia: recruitment for a national longitudinal cohort study. Women Health. 1998;28:23-40.
Brown WJ, Miller YD. Too wet to exercise? leaking urine as a barrier to physical activity in women. J Sci Med Sport. 2001;4:373-378.
Fitzgerald ST, Palmer MH, Kirkland VL, Robinson L. The impact of urinary incontinence in working women: a study in a production facility. Women Health. 2002;35:1-16.
Palmer MH, Fitzgerald S. Urinary incontinence in working women: a comparison study. J Womens Health. 2002;11:879-888.
Hilton P. Urinary incontinence during sexual intercourse: a common, but rarely volunteered symptom. Br J Obstet Gynaecol. 1988;95:377-381.
Dugan E, Cohen SJ, Bland DR, et al. The association of depressive symptoms and urinary incontinence among older adults. J Am Geriatr Soc. 2000;48:413-416.
Miller JM, Ashton-Miller JA, DeLancey JO. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc. 1998;46:870-874.
Wyman JF, Fantl JA, McClish DK, Harkins SW, Uebersax JS, Ory MG. Quality of life following bladder training in older women with urinary incontinence. Int Urogynecol J. 1997;8:223-229.
McCormack PL, Keating GM. Duloxetine: in stress urinary incontinence. Drugs. 2004;64:2567-2573.
Dmochowski RR, Miklos JR, Norton PA, Zinner NR, Yalcin I, Bump RC; Duloxetine Urinary Incontinence Study Group. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol. 2003;170:1259-1263.
Millard RJ, Moore K, Rencken R, Yalcin I, Bump RC; Duloxetine Urinary Incontinence Study Group. Duloxetine vs placebo in the treatment of stress urinary incontinence: a four-continent randomized clinical trial. BJU Int. 2004;93:311-318.