The prevalence and bothersomeness of lower urinary tract symptoms in women years of age

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1 Acta Obstet Gynecol Scand 2000; 79: Copyright C Acta Obstet Gynecol Scand 2000 Printed in Denmark All rights reserved Acta Obstetricia et Gynecologica Scandinavica ISSN ORIGINAL ARTICLE The prevalence and bothersomeness of lower urinary tract symptoms in women years of age LARS ALLING MØLLER 1, GUNNAR LOSE 1 AND TORBEN JØRGENSEN 2 From the 1 Department of Obstetrics and Gynecology and the 2 Center of Preventive Medicine, Medical Department, Glostrup County Hospital, University of Copenhagen, Glostrup, Denmark Acta Obstet Gynecol Scand 2000; 79: C Acta Obstet Gynecol Scand 2000 Aim. To assess the prevalence and bothersomeness of lower urinary tract symptoms in women aged years. Study design. Ongoing longitudinal cohort study. Methods. Four thousand women recruited on a random basis from the Civil Registration System, in one rural and one urban county in Denmark, were asked to fill in a self-administered, validated questionnaire on lower urinary tract symptoms. Logistic regression analysis was performed to assess the relationship between LUTS, bothersomeness, age, and county residency. Symptom scores and bother scores were compared in order to obtain a valid measure of lower urinary tract symptoms (LUTS). Results. The prevalence of LUTS occurring more than weekly was 27.8% (95% CI: 26.2% 29.4%) and 16.1% (95% CI: ) had urinary incontinence. The prevalence of stress incontinence increased from at 40 years up to the age of 55 years (ORΩ1.9 (95% CI: )) and declined thereafter. Irritative symptoms such as urge incontinence and urgency steadily escalated in an almost linear fashion with increasing age ((ORΩ2.7 (95% CI: ) and ORΩ2.1 (95% CI: ), respectively). Incontinence symptoms were the most bothersome. Age was positively associated with most LUTS, but not with bothersomeness. County residency was not associated with LUTS. Conclusion. Women aged years frequently have bothersome lower urinary tract symptoms. Age, but not county residency, is an important factor associated with the occurrence of lower urinary tract symptoms in perimenopausal women. LUTS occurring more often than weekly seem to be the most appropriate single measure of LUTS. Key words: age; bothersomeness; continence; county residence; incontinence; lower urinary tract symptoms (LUTS); prevalence Submitted 7 May, 1999 Accepted 9 October, 1999 Urinary incontinence and other lower urinary tract symptoms (LUTS) are common among women. The reported prevalence of urinary incontinence varies from 12% to 45% (1 7). The variation is due to differences in definitions, target populations and study design. Abbreviations: LUTS: lower urinary tract symptoms; CI: confidence interval; ICS: International Continence Society; OR: odds ratio. A steady decline in estrogen production and increasing weakness of the pelvic floor during the perimenopausal period may be associated with an increment of incontinence (8). However, the epidemiological evidence of a perimenopausal increment in LUTS (including incontinence) is controversial (1, 3, 9). Urinary incontinence represents a multidimensional phenomenon with wide-reaching effects, which may be quantified within various areas or

2 Prevalence and bothersomeness of LUTS in women aged domains (10). Most prevalence studies, however, only measure the frequencies of symptoms. The measures have seldom been validated against other Table I. Design of the questionnaire Subject Questionnaire Urgency Do you rush to the toilet because of a sudden desire to void? Urge incontinence Do you leak urine if suddenly you need to rush to the toilet? Stress incontinence Do you leak urine while laughing, coughing, moving or heavy lifting? Hesitancy Do you wait before voiding starts? Straining Do you strain while voiding? Incompletely emptying bladder Do you feel that your bladder is incompletely emptied while ceasing to void? Answers: No Yes, sometimes Yes, weekly or more Yes, daily or more If symptoms sometimes, weekly or more: Does it bother you? Not at all Yes, mildly Yes, severely Table II. Data on urinary incontinence, urgency, county and age from participants compared to non participants or non responders, respectively Numbers (%) Incontinence Participants Non responders Never 810 (28.4%) 315 (60.8%) Sometimes 1603 (56.2%) 160 (30.9%) Weekly 314 (11.0%) 30 (5.8%) Daily 124 (4.3%) 13 (2.5%) p (c 2 Ω206.9, d.f.ω3) Urgency Participants Non responders Never 1172 (41.2%) 363 (70.3%) Seldomly 1173 (41.3%) 115 (22.3%) Weekly 305 (10.7%) 23 (4.5%) Daily 193 (6.8%) 15 (2.9%) p (c 2 Ω150.3, d.f.ω3) County Participants Non participants Copenhagen 1430 (50.0%) 570 (50.0%) Storstrøm 1430 (50.0%) 570 (50.0%) Age (years) Participants Non participants (21.5%) 184 (16.1%) (20.3%) 219 (19.2%) (20.0%) 227 (19.9%) (19.2%) 251 (22.0%) (18.9%) 259 (22.7%) p 0.05 (c 2 Ω21.5, d.f.ω4) clinical parameters or quality of life measures (8). Few studies apply to the definition of the International Continence Society (ICS) (2, 3). According to the ICS urinary incontinence is urine loss, which is objectively demonstrable and is a social or hygienic problem (11). However, applying a problem assessments caseness definition caused under-estimation of some attributable risk factors as compared with analyses including a pure symptom caseness definition (12). With the purpose of assessing the epidemiology of lower urinary tract symptoms (LUTS) in perimenopausal women, we have established a cohort of women years of age. The aim of the present report was to ascertain the association between a symptom score, a bother score, age and county residency in order to characterize LUTS. Material and methods A questionnaire was sent to 4,000 women from through The women were selected at random from The Danish Civil Registration System (CPR), in which every person living in Denmark is identified by a unique ten digit number, which follows the person throughout life. The sample obtained consisted of women aged 40, 45, 50, 55 and 60 years from one urban county (Copenhagen County) and from one rural county (Storstrøms County) equally distributed with 400 in each age and county group. The number of selected women corresponded to 13.2% of the total female population with similar age and county residency at the time of the study. All women were mailed a questionnaire. Nonresponders were sent a reminder about three weeks later. Remaining non-responders were asked to complete a short form questionnaire. Questions were obtained from two detailed questionnaires previously tested in England and Denmark (13, 14). The questionnaire included questions on urinary incontinence, daytime frequency, nighttime frequency, postmicturition dribble, straining, urgency, sensation of an incompletely emptied bladder, and hesitancy. Women were explicitly asked about leakage due to coughing/sneezing, moving, lifting, sleeping, sexual intercourse, urgency, or rest. According to the ICS definition we interpreted stress incontinence as leakage caused by exertion (coughing/sneezing, moving, or lifting) and urge incontinence as leakage associated with urgency (11). Incontinence at rest, during sleeping and during sexual intercourse was denoted continuous, nightly and sexual incontinence, respectively. Participants were asked to score symptoms on a four point scale (never, sometimes, often/weekly, or each time/daily (nightly)).

3 300 L. A. Møller et al. Table III. The occurrence of lower urinary tract symptoms (LUTS) in 4,000 women selected at random. The proportion of symptoms occurring weekly or more is considered the prevalence rate Symptoms score Prevalence rate In all Never Sometimes Weekly (often) Daily (each time) Symptoms weekly (often) or more Type/cause n % % 95% CI Incontinence Laughing or coughing Moving Heavy lifting Stress (all above) Continuous Nightly Sexual Urge One or more types Other LUTS Hesitancy Straining Incompletely emptied bladdder Postmicturition dribble Urgency Daytime frequency Nighttime frequency In all: LUTS *200 women had no sexual relationship at the time of the questionnaire. Nighttime frequency was categorized as never, sometimes or often when the number of episodes were zero, in the range of 1 2 voiding, or exceeded 2 voiding nightly, respectively. Similarly, daytime frequency was expressed as often when the number of episodes exceeded ten times daily; otherwise daytime frequency was expressed as sometimes. To measure women s attitude towards symptoms we used a three-point scale Bother-score on which the women judged any symptom according to bother if any as mildly bothersome or severely bothersome (Table I). The short questionnaire to non-responders comprised questions on urgency and incontinence. To test and further adapt the modified questionnaire for the specific purpose we interviewed 13 women of age 45 to 55 years admitted to our hospital for a variety of lower urinary tract diseases. A subsequent test-retest addressing 100 women and a face validity test of the questionnaire addressing 294 women showed that overall agreements in answers ranged from 0.79 to 1.00 and from 0.47 to 0.84, respectively. Kappa coefficients ranged from 0.31 to 1.00 and from ª0.02 to 0.52, respectively. Pad tests performed on 69 women with reported incontinence randomly selected from the study material indicated incontinence in 53.7% reporting stress or urge incontinence. Leak- age of more than 8 g was considered to confirm incontinence. The local ethical committee (reg.nr ) approved the study. Statistical methods To ascertain the association between bother and symptom score G statistics were used (15). c 2 -test, and logistic regression analysis using the Statview statistical package were applied where appropriate. A 5% significance level was used. Results Nine questionnaires were returned marked unknown at this address. A total of 3,208 women returned the questionnaire. Of these 348 women returned an incomplete or blank questionnaire and were excluded from the study, reducing the number of participants to 2860 (71.7%). Five hundred and twenty-nine non-responders (13.3%) completed the short form questionnaire. Non-participants did not differ from participants regarding county residency, but some were older and had significantly fewer complaints on incontinence and urgency (Table II). The frequencies of lower urinary tract symptoms are shown in Table III. In each symptom the de-

4 Prevalence and bothersomeness of LUTS in women aged gree of frequency was proportional to the degree of bothersomeness (p 0.001; G statistics). The prevalence rate of LUTS was classified as the proportion of women reporting symptoms weekly or more (Table III). Accordingly the prevalence rate of urinary incontinence was 16.1% (95% CI: ) and the prevalence of one or more types of LUTS was 27.8% (95% CI: 26.2% 29.4%). When bother score and symptom score were combined a particular pattern in the distribution of bothersomeness was revealed. Figs. 1 and 2 show that for most LUTS the ratio bother: no bother is increased about tenfold in women with symptoms weekly (often) compared to women with symptoms occurring only sometimes. The ratio of bother: no bother for women with symptoms daily (each time) reached in all LUTS, except in women with laugh incontinence, sexual incontinence, urge incontinence, in women with an incompletely emptied bladder, in women with urgency, and in women with one or more types of LUTS (ratio bother: no botherω19.2, 4.0, 2.8, 12.8, and 16.1, respectively). These findings emphasize a clear difference in bothersomeness between women Fig. 1. Ratio Bother: No Bother in women with different frequencies of urinary incontinence. Log scale. Fig. 2. Ratio Bother: No Bother in women with different frequencies of non incontinence lower urinary symptoms. Log scale.

5 302 L. A. Møller et al. Table IV. The occurrence of bothersomeness in percent among 4,000 women with Lower Urinary Tract Symptoms (LUTS) selected at random Degree of symptoms (%) Some- Weekly Daily n times (often) (each time) Incontinence Laughing or coughing Moving Heavy lifting Stress (all above) Continuous Nightly Sexual Urge One or more types Other LUTS Hesitancy Straining Incompletely emptied bladdder Postmicturition dribble Urgency Daytime frequency Nighttime frequency In all: LUTS (one or more types) *200 women had no sexual relationship at the time of the questionnaire. with increasing frequencies of a symptom. While the majority of women with LUTS occurring only sometimes had no bother, the majority of women with symptoms weekly (often) or daily (each time) complained of bother. Nevertheless, because the number of women with symptoms occurring only sometimes were notable higher than women with symptoms weekly (often) or daily (each time) as shown in Table III the main part of all bothered women were women with symptoms occurring only sometimes (Table IV). Most LUTS were positively associated with age (Table V). The prevalence of stress incontinence almost doubled from baseline at 40 years up to the age of 55th year and declined thereafter. Irritative symptoms, as urge and urgency, steadily increased in an almost linear fashion with increasing age. Age did not associate with bothersomeness controlled for frequency of each symptom (Table VI). Discussion To our knowledge this study is so far the most comprehensive study addressing the occurrence of LUTS in a normal population. Our findings con- Table V. The occurrence of LUTS according to age Age (years) Type Significance Incontinence Stress OR % CI * Urge OR % CI * Resting OR % CI * Nocturnal enuresis OR % CI * Sexual OR % CI One or more types OR % CI * Other LUTS Hesitancy OR % CI Straining OR % CI Incompletely emptied bladder OR % CI Postmicturition dribble OR % CI Urgency OR % CI * Daily frequency OR % CI Nocturia OR % CI * In all: LUTS OR % CI *

6 Table VI. Bothersomeness according to age adjusted for the frequency of symptoms Prevalence and bothersomeness of LUTS in women aged Age (years) Incontinence Stress OR % CI Urge OR % CI Resting OR % CI Nocturnal enuresis OR % CI Sexual OR % CI One or more types OR % CI Other LUTS Hesitancy OR % CI Straining OR % CI Incompletely emptied bladder OR % CI Postmicturition dribble OR % CI Urge OR % CI Daily frequency OR % CI Nocturia OR % CI In all: LUTS OR % CI firm a high prevalence of bothersome LUTS suggested in earlier studies and indicate an almost linear increase in the frequencies of irritative symptoms (urge and urgency) in perimenopausal women (1 7). Our data, however, fail to support that bothersomeness due to LUTS per se differs according to age (16). No association between LUTS and county residency was observed. This observation indicates that differences between living in a typical rural and typical urban area have minor if any importance in terms of having LUTS in a modern society. We are not aware of any previous study addressing this aspect. The significant increase in irritative symptoms (urge and urge incontinence) during the perimenopausal ages in this study agrees with the findings in other studies (3, 9). Although the increase is followed by a decrease in estrogen production, any causal relationship has never been proved. In agreement with other cross-sectional studies, we observed a maximum in the prevalence of stress incontinence when women reach the age of 50 to 55 years (17, 18). The reason is unknown. A change in the physical environment (including a decrease in physical activity) in postmenopausal women is a straightforward explanation, but other reasons might be considered. Furthermore, the possibility of a cohort effect must be ruled out in a longitudinal study. Our study demonstrates that the prevalence of incontinence during sexual intercourse in a normal population is around 2%. This is new information suggesting that a rather high number of women may suffer from a potentially devastating condition. Urodynamic examinations of these women mostly reveal genuine stress incontinence, but detrusor instability seems to be an important associated cause, particularly when incontinence follows orgasm (20). It was observed that urinary incontinence is a relatively higher hindrance for social and sanitary interest in the younger group of perimenopausal women (16). In their study Hunskar et al. ignored the impact different frequencies may impose on the bothersomeness in different age groups. An increase in more severe symptoms with increasing age could mask the true association between

7 304 L. A. Møller et al. bothersomeness and age. However, despite adjusting for the influence of different frequencies across age groups we were unable to confirm that bothersomeness per se was associated with age (Table VI). This finding agrees with the findings of bothersomeness in men with prostatic hyperplasia (21). The clinical implications of non-incontinence LUTS are unsettled. This study shows, as does a previous Danish study (6), that these symptoms are less bothersome than urinary incontinence in perimenopausal women. In order to obtain a single parameter of LUTS we compared the information obtained by the bother score and the symptom score, respectively. We observed that almost every woman with symptoms weekly reported some degree of bother, while women with infrequent symptoms only inconstantly complained of bother (Figs. 1 2). However, in total, women with infrequent symptoms complaining of bother counted largely higher than women with more severe symptoms (Table IV). From this we conclude that the most appropriate single delineating criteria of LUTS is women with symptoms weekly or more. If otherwise, the criteria was all bothered women with any degree of symptom, the majority in the study group had been women with infrequent symptoms. A common score system comprising symptoms as well as bother has been recommended for assessing the severity of symptoms among men with complaints suggestive of benign prostatic hyperplasia (26). However, the benefit of a complex scoring system for clinical use can hardly be transformed to a scoring system applicable in an epidemiological setting. First of all, due to the lack of intrinsic logic as described above. Secondly, due to the loss of transparency it will imply. And thirdly, due to the loss of reproducibility in different cultural and national settings it presumably will cause. Alternatively, we propose the use of a pure symptom score as the relevant epidemiological tool for investigating LUTS and symptoms more than weekly as the relevant cut-off criteria. This suggestion in no way contradicts the advantage of including quality of life measures as outcome measures in a clinical setting. Our study has some potential limitations. Firstly, as fewer non-responders than responders report symptoms, a sample bias is indicated (Table II). Such bias is probably difficult to avoid, as attraction to a study of LUTS would appear more feasible in women with LUTS. As no association between the proportion of women with lower urinary tract symptoms and the time to respond was observed, the observation indicates that the chance of having lower urinary tract symptoms in fact has very little to do with a motivation for answering the questionnaire. Moreover, the reliability of a specific questionnaire in comparison with two-item questionnaires is definitively higher. This fact imposes a relative underestimation of symptoms among non-responders and thereby further lowers the possibility of a true bias. Secondly the inability of any questionnaire to approximate a urodynamic diagnosis suggesting urinary incontinence is well known, especially in case of urge incontinence (27 29). Urodynamic examinations have shown that coughing and sneezing may trigger involuntary detrusor contractions. These cases will be misclassified if symptoms alone are used to guide classification. However, urodynamic tests have a low repeatability and are therefore of questionable value as a golden standard of LUTS. In conclusion, women aged years frequently have bothersome lower urinary tract symptoms. Age, but not county residency, is an important factor associated with the occurrence of lower urinary tract symptoms in perimenopausal women. LUTS more than weekly appeared to be the most appropriate single measure of LUTS. Acknowledgments This study was supported with grants from Coloplast A/S, Pharmacia A/S, The Research Foundation of Bornholm, Frederiksborg, Roskilde, Storstrøm and Vestsjællands Counties, Rudolph Als Foundation, Kleins Foundation, Research Foundation of Copenhagen, Faroe Island and Greenland, Foundation of Niels and Desirees Yde, and Nykøbing Falster Centralsygehus. References 1. Thomas TM, Plymat KR, Blannin J, Meade TW. Prevalence of urinary incontinence. Br Med J 1980; 281: Elving LB, Foldspang A, Lam GW, Mommsen S. Descriptive epidemiology of urinary incontinence in 3,100 women age Scand J Urol Nephrol Suppl 1989; 125: Milsom I, Ekelund P, Molander U, Arvidsson L, Areskoug B. The influence of age, parity, oral contraception, hysterectomy and menopause on the prevalence of urinary incontinence in women. J Urol 1993; 149: Yarnell JW, Voyle GJ. The prevalence and severity of urinary incontinence in women. J Epidemiol Community Health 1981; 35: Samuelsson E, Victor A, Tibblin G. 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