Muhammad Osama  ( Foundation University Institute of Rehabilitation Sciences, Foundation University Islamabad, Pakistan )
Saman Shaukat  ( Foundation University Institute of Rehabilitation Sciences, Foundation University, Islamabad, Pakistan. )
Momnah Javed  ( Foundation University Institute of Rehabilitation Sciences, Foundation University, Islamabad, Pakistan. )
Maryam Naeem  ( Foundation University Institute of Rehabilitation Sciences, Foundation University, Islamabad, Pakistan. )

A cross sectional survey was conducted in 2018-2019 to determine the prevalence of urinary incontinence among university going nulligravid young female adults in Rawalpindi/Islamabad, Pakistan. A total of 608 participants were included in the study via convenience sampling. Data was collected regarding demographic and personal information, in addition to Medical, Epidemiologic, and Social Aspects of Aging (MESA) Urinary Incontinence Questionnaire (UIQ). Independent t-test and One-way ANOVA were used for inter-group comparisons. Pearson and Spearman correlation was used to determine the relationship between variables. The overall prevalence of urinary incontinence was observed to be 193(31.7%) and of stress, urge and mixed incontinence was found to be 64(10.5%), 56(9.2%) and 73(12%) respectively. A significant difference (p<0.05) was observed in terms of MESA-UIQ stress incontinence and urge incontinence scores based on tobacco use, menstrual disorders, eating disorders and marital status.

 

Keywords: Epidemiology, urinary incontinence, stress incontinence, urge incontinence, young adults, prevalence, nulligravidity.

 

DOI: https://doi.org/10.47391/JPMA.4282

 

Introduction

 

Urinary incontinence (UI) is a very common and troubling health condition in women, which is observed to have a negative effect on the quality of life, and is also associated with a substantial economic cost.1-6 Due to the nature of the problem, this condition usually goes unreported as patients feel a sense of humiliation and embarrassment in discussing such problems with health care professionals, especially in the eastern society and thus remain uninformed of the management options available.1,7 For this reason, if we take a look at the review of the literature, the prevalence of urinary incontinence is observed to be lesser in Asia as compared to Europe and America, with prevalence figures ranging from 1.5%-15.2%, 1.8%-30.5%, and 1.7%-36.4% respectively.8 Furthermore, the prevalence of UI ranges from 2.8%-57.7% in developing countries, with a mean prevalence of 25.7%.9 The prevalence of UI in Pakistan has been reported to be 11.5%, with stress incontinence being the most prevalent subtype with the figure of 4.7% followed by urge incontinence and mixed incontinence with prevalence figures of 3.2% and 2.8% respectively, with advancing age, early marriages and higher parity being major risk factors.7 However, it is imperative to point out that the prevalence figures vary depending on the definitions and assessment techniques used in the research process.7 Even though UI is a well-known and acknowledged health concern worldwide post pregnancy and in elderly women, but younger nulliparous and nulligravid women can also experience episodes of UI,10 however very little emphasis has been paid to this specific part of the population.1,11,12 A recent review comprising of 18 studies reported prevalence estimates ranging from 1% to 42.2% in nulliparous adolescent and middle aged women, with obesity, childhood enuresis and high impact sporting activities being the major risk factors.1 It is also important to point out, that of the 18 studies, 9 were from Europe, 2 were from US, Australia and Brazil, and 1 from Canada, China and Malaysia.1 There is lack of literature regarding the occurrence of UI among healthy young nulliparous and nulligravid female adults in the Indian subcontinent1 and for this reason, the purpose of the current study was to determine the prevalence of UI among university going nulligravid young female adults in Rawalpindi and Islamabad, Pakistan.

 

Subjects and methods

 

A cross sectional study was conducted in 2018-2019, and data was collected from university going nulligravid young female adults in the region of Rawalpindi and Islamabad, Pakistan. Healthy young nulligravid female adults aged 18 to 26 years were included in the study via convenience sampling. Male students were excluded from the study and females were asked not to fill the questionnaire if they were suffering from any severe health condition including diabetes, kidney, liver or respiratory disease, were or had ever been pregnant, had an acute major illness, had undergone a major surgery or a gynecological surgery in the previous 6 months and/or were diagnosed with or being treated for any sort of cancer. A sample size was of 384 was calculated using Raosoft sample size calculator,13 with a confidence interval of 95%, margin of error 5%, response distribution of 50%, and a population size of 605131, consisting of 163689 females aged 18-26 years residing in Islamabad14 and 441442 females residing in Rawalpindi.15 A total of 608 participants were included in the study to compensate for risk of missing data and to increase generalizability.

Informed consent was taken from all participants in writing before inclusion in the study and participation in survey was voluntary. Participants were permitted to withdraw at any time during the survey. Ethical approval was acquired from Foundation University Islamabad, Ethical Review Committee (Ref # FF/FUMC/215-3Phy/18) in line with the Declaration of Helsinki.

Data was collected via self-answered questionnaires consisting of demographic and personal information, in addition to Medical, Epidemiologic, and Social Aspects of Aging (MESA) Urinary Incontinence Questionnaire (UIQ), which was used as an outcome measurement tool to quantify the severity of stress and urge incontinence, with proven predictive validity for self-assessment of the severity of urinary incontinence. MESA-UIQ consists of 15 questions, out of which the combined score of questions 1-9 represent stress incontinence and questions 10-15 represent urge incontinence.16 To determine the prevalence of UI, the presence of UI was defined as a response of “sometimes” or “often” to any one of the questions of the MESA-UIQ.17 Mixed incontinence was defined as a response of “sometimes” or “often” to at least one of the questions of the MESA-UIQ stress incontinence subscale and at least one of the questions of the MESA-UIQ urge incontinence subscale. The participants that were categorized as mixed incontinence were not categorized as urge or stress incontinence separately to avoid repetition.  The questionnaire was comprehensively explained to the participants before they could fill the questionnaire. Data was analyzed using Statistical Package for the Social Sciences (SPSS) v.21.0 and Shapiro Wilk and Kolmogorov Smirnov tests were used for data analysis. Independent t-test was used to compare participants on the basis of marital status and, toilet and tobacco use, and One-way ANOVA was used to compare participants on the basis of menstrual disorders, caffeine consumption and eating disorders. Pearson and Spearman correlation was used to determine the relationship between variables. Confidence interval was kept at 95% and a p-value of less than 0.05 was considered significant.

 

Results

 

The mean age of the participants was 20.68±1.65 years, with a mean weight, height, and body mass index (BMI) of 53.67±8.13 Kg, 5.44±1.95 feet and 20.06±2.94 respectively. The overall prevalence of urinary incontinence among university going nulliparous young female adults was observed to be 193(31.7%). Based upon the type of incontinence, the prevalence of stress incontinence was 64(10.5%), urge incontinence was 56(9.2%) and mixed incontinence was 73(12%). Out of 608 participants, 403(66.3%) participants reported rarely, sometimes, or often for at least one symptom of either stress or urge incontinence, 315(51.8%) participants reported rarely, sometimes, or often for at least one symptom of stress incontinence and 318(52.3%) participants reported rarely, sometimes, or often for at least one symptom of urge incontinence (Table-1).

A significant difference (p<0.05) was observed in terms of stress incontinence and urge incontinence scores based on tobacco use, menstrual disorders and eating disorders, however, in terms of marital status, a significant difference (p<0.05) was only observed in scores of stress incontinence. (Table-2). No significant differences (p>0.05) were observed in terms of weight, height, and BMI between married and unmarried females except for age (<0.001), with the mean age of 20.64±1.616 and 20.64±1.616 years for unmarried and married females respectively. No significant differences (p>0.05) were observed in terms of age, height, and BMI on the basis of tobacco use except for weight (0.001), with the mean weight of 58.69±9.76 and 53.45±7.98 kg for tobacco users and non-users respectively. No significant differences (p>0.05) were observed in terms of age, weight, height, and BMI on the basis of menstrual disorders. Significant differences (p<0.05) were observed in terms of weight, height, and BMI on the basis of eating disorders except for age in which no significant differences were observed (p>0.05).

No significant correlations (p>0.05) of age, weight, height or BMI were observed with stress or urge incontinence. However, a significant positive correlation (r=+0.549, p=<0.001) was observed between stress and urge incontinence.

 

Discussion

 

The purpose of the current study was to determine the prevalence of urinary incontinence among university going nulliparous young female adults in Rawalpindi/Islamabad, Pakistan, and the overall prevalence of UI was observed to be 193(31.7%).  Furthermore, the prevalence of stress incontinence was found to be 137(10.5%), urge incontinence was 129(9.2%) and mixed incontinence was observed to be 173(12%). In comparison to the findings of the current study, the prevalence of urinary incontinence among nulliparous young female adults was observed to be 5.4%-38.6% in Sweden, 32% in Canada and Iceland, 1% in China, 42.2% in United States, 20.7%-22.9% in Brazil, 34.9% in Malaysia, 14% in Denmark, 10.6-13.2% in Australia, 12.4% in Italy, 20.1% in Netherlands, 19.9% in Portugal and 34.8% in Ireland respectively (Table-3). However, it is imperative to point out that the prevalence figures vary depending on the definitions and assessment techniques used in the research process.7

The most common subtype of urinary incontinence observed in the literature was stress incontinence with its prevalence ranging from 4.0%-23.3% (Table-3). In the current study however, mixed incontinence was observed to be the most common subtype of UI, in accordance with the findings of Daly D et al.18 A significant difference (p<0.05) was observed in terms of MESA-UIQ stress incontinence and urge incontinence scores based on tobacco use, menstrual disorders, eating disorders and marital status. Pre-existing evidence has shown age less than 19 years, BMI greater than 30 kgm2, existing history of constipation, childhood enuresis especially after the age of 5 years,19 positive history of psychological disorders and depression20 to be linked with the occurrence of UI in young women. No significant relationship of weight and BMI has been observed with the occurrence of UI among young women in the current study. However, the literature shows contradictory findings regarding the relationship of obesity with the occurrence of UI, with some studies reporting obesity as a risk factor21 and some not.22 Nulliparous women are less likely to have urinary incontinence as compared to parous women23 and a study conducted in Pakistan found out a positive association between gravida and urinary incontinence.24

In summary of the pre-existing literature and the findings of the current study, it can be concluded that the prevalence of urinary incontinence is notable among nulliparous healthy young adults which is a subset of the population that was previously not given much attention and it is suggested that perhaps addressing this condition at this stage of life would result in a lower prevalence figure among women in the later stages of life.

Limitations: Inquiring about being sexually active or not is a sensitive matter in the Pakistani society and for that reason the participants were only inquired regarding their marital status. However, being sexually active may or may not play a role in the occurrence of urinary incontinence which the current study was not able to explore. A considerable part of nulligravid young female adult population doesn’t seek university education and thus was not included in the current study. The use of MESA-UIQ in English was not justifiable for uneducated population and thus was not targetted in this study which also forms a considerable part of nulligravid young female adult population in Pakistan. It is recommended that cultural adaptation and Urdu translation of questionnaires should be carried out and larger studies should be conducted on community dwelling young females to target the above-mentioned uneducated subsets of the population.

 

Conclusion

 

The overall prevalence of urinary incontinence is observed to be 193(31.7%) and of stress, urge and mixed incontinence was found to be 64(10.5%) and 56(9.2%) and 173(12%) respectively. Being married, use of tobacco products, eating disorders and menstrual disorders can increase the risk of urinary incontinence.

 

Disclaimer: None.

 

Conflict of interest: None.

 

Funding disclosure: None.

 

References

 

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