Overactive Bladder: Prevalence and Implications in Brazil

european urology 49 (2006) 1087 1092 available at www.sciencedirect.com journal homepage: www.europeanurology.com Neuro-Urology Overactive Bladder: Prevalence and Implications in Brazil Claudio Teloken a, Fernanda Caraver a, Fernanda A. Weber a, Patrick E. Teloken a, *, João F. Moraes b, Paulo R. Sogari a,túlio M. Graziottin a a Fundação Faculdade Federal de Ciências Médicas de Porto Alegre e Complexo Hospitalar Santa Casa, Porto Alegre, Brazil b Pontifícia Universidade Católica do Rio Grande do Sul, Brazil Article info Article history: Accepted January 5, 2006 Published online ahead of print on February 9, 2006 Keywords: Overactive bladder Sexual function Quality of life Abstract Objectives: To assess overactive bladder (OAB) prevalence, associated factors and implications in a young population. Methods: An independent population-based study was carried out. A self-applicative questionnaire covering urinary symptoms, coping strategies, quality of life and treatment seeking behavior was developed. Results: A total of 848 subjects between 15 and 55 years completed the questionnaire. The overall prevalence of OAB was 18.9%. Women were significantly more affected than men ( p = 0.001). All age groups were equally affected ( p = 0.152). Subjects with OAB reported significant impairment on household chores ( p = 0.009), physical activities ( p = 0.016), sleep ( p < 0.001), work ( p < 0.001), social life ( p < 0.001) and sexual life ( p < 0.001). In addition, OAB individuals present higher prevalence of depression ( p = 0.036), anxiety ( p < 0.001), shame ( p < 0.001) and tiredness ( p < 0.001) OAB was independently associated to sexual life impairment (OR = 3.36, 95% CI = 1.20 9.39). Only 27.5% of OAB subjects sought for medical counseling. Conclusions: OAB is a highly prevalent condition, even in such a young population. It affects both genders, yet it is more frequently observed in women. OAB is an important health condition, with serious impact on quality of life and sexual function. A large percentual of individuals remain unrecognized, under treated and consequently suffer for long periods of time. # 2006 Elsevier B.V. All rights reserved. * Corresponding author. 245, Sarmento Leite, Porto Alegre, RS, 90050-170, Brazil. Tel. +55 51 99577916; Fax: +55 51 33281975. E-mail address: patrickteloken@gmail.com (P.E. Teloken). 1. Introduction In 2002, the International Continence Society (ICS) standardized the terminology of lower urinary tract function. The committee defined the equivalent terms OAB, urge syndrome, or urgency-frequency syndrome as the condition characterized by the 0302-2838/$ see back matter # 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2006.01.026

1088 european urology 49 (2006) 1087 1092 presence of urgency, with or without urge incontinence, usually with frequency and nocturia in a patient without infection or other obvious pathology [1]. Recent studies of OAB report an estimated prevalence of 2.4% to 18.6% in the general population [2 4]. However, one caveat is that none of these considered ICS new terminology. The importance of OAB symptoms was not well recognized in the past. Patients with OAB frequently have to change their daily habits and anticipate the localization of restrooms, causing anxiety and stress. The majority of men and women with an overactive bladder report that their symptoms have an effect on daily living [2]. Usually these patients suffer with the condition for long periods before the diagnosis is established [2]. Recently, quality of life (QoL) assessment became an important tool in the evaluation of OAB symptoms impact. Sexual function in men and women is a relevant component of quality of life. Lower urinary tract symptoms (LUTS) are an independent risk factor for sexual dysfunction, as long as sexual symptoms increase with LUTS severity. Urinary symptoms are associated with erection problems, ejaculatory dysfunction, dissatisfaction with sex life, decrease in libido, decrease in sexual activity, intercourse dissatisfaction, and overall impairment in sexual function in women [5 8]. Overactive bladder has the potential to affect sexual function. The impact of OAB symptoms on sexual function in women has been evaluated in a few studies [9 11]. Toour knowledge no study has evaluated its impact on men. This is the first independent population-based study assessing the prevalence of OAB symptoms in young men and women utilizing the new ICS terminology. General characteristics, treatment seeking behavior, impact on QoL, and sexual problems were also investigated. 2. Subjects and methods During the period of November 2003 to August 2004, an independent community-based survey was conducted in Porto Alegre, Brazil. Areas of the city with agglomeration of citizens were chosen to carry out the study. Individuals of both genders were invited to answer our self-applicative questionnaire. Inclusion criteria were age between 15 and 55 years, in the absence of the following medical conditions: current pregnancy, urinary tract infection, diabetes mellitus, stress urinary incontinence, use of diuretics, history of urinary system or gynecological cancer, urinary lithiasis, and previous surgery of gynecological or urologic tract. A total of 913 subjects answered the questionnaire. Our questionnaire was developed by the combination of questions from the King s Health Questionnaire validated for OAB syndrome [12,13], the AUA Symptoms Score [14] and original questions. Both questionnaires have been also validated in Portuguese [15,16]. A total of 34 questions were categorized into five domains: general characteristics (gender, age, body mass index (BMI), race, education, past medical history, and parity), urinary symptoms (urgency, frequency, nocturia and incontinence), coping strategies (avoid drinking liquids, regular schedule for urination, immediate localization of bathrooms in new locations, use of absorvent products), quality of life and treatment seeking behavior. The study was approved by the Institutional Review Board. We are the first study assessing the diagnosis of OAB based on the latest ICS definition: urgency, with or without urge incontinence, usually with frequency and nocturia. Urgency was characterized as the complaint of a sudden compelling desire to pass urine, which is difficult to defer; urge urinary incontinence as the complaint of involuntary leakage accompanied by or immediately preceded by urgency; nocturia as the complaint that the individual has to wake at night one or more times to void; increased daytime frequency as the complaint by the patient who considers that he/she voids too often by day [1]; and frequency as objectively assessed as voiding at least eight times per day [2,9,11,17,18]. The differences between proportions (prevalences) were compared by Z test. Categorical variables were analyzed by Chi-square. The threshold p value for variable inclusion in multivariate analyzes was 0.25. The strength of association between variables was determined by odds ratio (OD) and confidence intervals (CI), calculated by Woolf s method. All p values of <0.05 were considered statistically significant. Reported p values are two-sided. Statistical procedures were carried out with SPSS 11.5 (Chicago Inc.) software. 3. Results Out of 913 questionnaires, 848 were valid and met all the criteria. The characteristics of the interviewed population are described in Table 1. The overall prevalence of OAB was 18.9% (n = 160; 14.0% in men and 23.2% in women; p = 0.001), and was similar in all age groups ( p = 0.152). Urge incontinence, frequency and nocturia were reported by 5.4% (46), 13.5% (110) and 48.2% (407) of the subjects, respectively. Among individuals with OAB, 19.2% had urgency as the only symptom of the syndrome, and 80.8% had at least one of the other three symptoms associated to urgency (Fig. 1). The use of self-care strategies to cope with urinary condition is more frequently observed in OAB subjects than in the non-affected population (70.5% vs 42.6%; p < 0.001) (Table 2). Impairment of daily living caused by urinary habit is a complaint of 35.4% of OAB individuals, and only of 8.4% of the general population ( p < 0.001). Subjects with OAB reported significant impairment on

european urology 49 (2006) 1087 1092 1089 Table 1 General characteristics of the 848 subjects interviewed Characteristics All Subjects (N = 848) OAB (N = 160) non OAB (N = 688) p value no. of subjects (%) Gender 0.001 Male 399 (47.1) 56 (35.0) 343 (49.9) Female 449 (52.9) 104 (65.0) 345 (50.1) Age 0.159 <25 yr 503 (59.3) 91 (56.9) 412 (59.9) 26 35 yr 181 (21.4) 32 (20.0) 149 (21.7) 36 45 yr 112 (13.2) 21 (13.1) 91 (13.2) 46 55 yr 52 (6.1) 16 (10.0) 36 (5.2) Race or ethnic group 0.996 White 753 (90.8) 141 (90.9) 612 (90.8) Black 32 (3.9) 6 (3.9) 26 (3.9) Other 44 (5.3) 8 (5.2) 36 (5.3) Body Mass Index (BMI) 0.424 <18.49 41 (5.1) 10 (6.8) 31 (4.7) 18.5 24.9 589 (73.1) 101 (68.7) 488 (74.0) 25 29.9 154 (19.1) 31 (21.1) 123 (18.7) 30 34.9 18 (2.2) 5 (3.4) 13 (2.0) 35 39.9 4 (0.5) 0 (0.0) 4 (0.6) >40 0 (0.0) 0 (0.0) 0 (0.0) Education 0.004 Less than primary school 93 (11.3) 26 (17.0) 67 (10.0) Primary school diploma 83 (10.1) 10 (6.5) 73 (10.9) Less than high school 171 (20.7) 40 (26.1) 131 (19.5) High school diploma 301 (36.5) 56 (36.6) 245 (36.5) Some college 86 (10.4) 7 (4.6) 79 (11.7) College degree 91 (11.0) 14 (9.2) 77 (11.4) Parity 0.497 Yes 171 (39.9) 44 (42.7) 127 (39.0) No 258 (60.1) 59 (57.3) 199 (61.0) household chores ( p = 0.009), physical activities ( p = 0.016), sleep ( p < 0.001), work ( p < 0.001), social life ( p < 0.001) and sexual life ( p < 0.001). In addition, OAB individuals present higher prevalence of depression (3.28% vs 1.04%; p = 0.036), anxiety (23.68% vs 7.58%; p < 0.001), shame (10.59% vs 1.64%; p < 0.001) and tiredness (12.5% vs 1.49%; p < 0.001) (Table 2) (Fig. 2). Fig. 2 Seeking treatment behaviour in OAB individuals. Fig. 1 Prevalence of different overactive bladder symptoms reported. Subjects with OAB were divided in continent and incontinent and evaluated separetely according to coping strategies and quality of life. There was no statistical difference considering avoid drinking liquids, use of regular schedule for urination and immediate localization of bathrooms in new locations. Only the use of absorvent products was more frequent in incontinent OAB subjects ( p = 0.005). There was also no statistical difference considering household chores, sleep, work, social life and sexual life. Only physical

1090 european urology 49 (2006) 1087 1092 Table 2 Impact of OAB in quality of life and influence of incontinence as a determinant factor of quality of life of OAB patients OAB (N = 160) non OAB (N = 688) p value OR (95% CI) Incontinent OAB (N = 46) Continent OAB (N = 114) p value OR (95% CI) no. of subjects (%) no. of subjects (%) Use of coping strategies Avoid drinking 42 (27.1) 60 (9.1) <0.001 3.72 (2.39 5.80) 14 (31.8) 28 (25.2) 0.405 1.38 (0.64 2.97) liquids Regular schedule 26 (17.1) 117 (17.7) 0.862 0.96 (0.60 1.53) 9 (20.5) 17 (15.7) 0.484 1.38 (0.56 3.38) for urination Localization of 78 (51.7) 172 (26.1) <0.001 3.02 (2.10 4.35) 25 (58.1) 53 (49.1) 0.314 1.44 (0.71 2.94) bathrooms Use of absorvent products 8 (5.3) 1 (0.1) <0.001 36.75 (4.56 296.19) 6 (14.6) 2 (1.8) 0.005 9.26 (1.79 47.96) Impairment on daily living Household chores 13 (8.2) 24 (3.5) 0.009 2.47 (1.23 4.96) 5 (11.4) 8 (7.0) 0.373 1.70 (0.52 5.51) Physical activities 12 (7.6) 23 (3.4) 0.016 2.37 (1.15 4.86) 8 (18.2) 4 (3.5) 0.004 6.11 (1.74 21.50) Sleep 45 (28.5) 95 (13.9) <0.001 2.47 (1.64 3.72) 13 (29.5) 32 (28.1) 0.854 1.07 (0.50 2.31) Work 44 (27.8) 81 (11.8) <0.001 2.88 (1.89 4.37) 13 (29.5) 31 (27.2) 0.767 1.12 (0.52 2.42) Social life 19 (12.0) 22 (3.2) <0.001 4.12 (2.17 7.82) 6 (13.6) 13 (11.4) 0.699 1.23 (0.43 3.46) Sexual life 20 (12.7) 21 (3.1) <0.001 4.58 (2.42 8.68) 8 (18.2) 12 (10.6) 0.202 1.87 (0.71 4.94) Emotional distress Depression 5 (3.3) 7 (1.1) 0.036 3.24 (1.01 10.34) 2 (4.8) 3 (2.7) 0.617 1.78 (0.29 11.07) Anxiety 36 (41.4) 116 (15.7) <0.001 3.78 (2.36 6.06) 17 (40.5) 19 (17.3) 0.003 3.26 (1.48 7.18) Shame 16 (59.3) 135 (17.0) <0.001 7.11 (3.23 15.66) 9 (21.9) 7 (6.4) 0.006 4.14 (1.43 12.00) Tiredness 19 (65.5) 133 (16.7) <0.001 9.44 (4.29 20.77) 6 (14.6) 13 (11.7) 0.629 1.92 (0.46 3.66) activities were more impaired in incontinent OAB individuals ( p = 0.004). These subjects also reported more anxiety and shame than continent ones ( p = 0.003 and p = 0.006, respectively), but no difference was found regarding depression and tiredness (Table 2). Table 3 Multiple logistic regression analysis of OAB syndrome on daily living and QoL Model OR 95% CI p value Gender (reference = male) Female 1.81 1.12 2.91 0.015 Age (reference = <25 yr) 26 35 yr 0.73 0.40 1.35 0.316 36 45 yr 0.70 0.33 1.51 0.370 46 55 yr 2.13 0.88 5.14 0.094 Education (reference = less than elementary school) Elementary school diploma 0.56 0.22 1.42 0.238 Less than high school 0.89 0.42 1.88 0.756 High school diploma 0.53 0.26 1.07 0.078 Some college 0.25 0.09 0.71 0.009 College degree 0.32 0.12 0.88 0.028 Frequency (reference = no) Yes 2.13 1.21 3.73 0.008 Incontinence (reference = no) Yes 0.00 0.00 0.00 0.997 Nocturia (reference = no) Yes 2.47 1.56 3.93 <0.001 Possible confounders were controlled for by multiple logistic regression (Table 3). Female gender remained independently associated with OAB ( p = 0.015; OR = 1.81, 95% CI = 1.12 2.91). High educational level (undergraduate and college degree) emerged as a negative factor independently associated to OAB, ( p = 0.009; OR = 0.25, 95% CI = 0.09 0.71 and p = 0.028; OR = 0.32, 95% CI = 0.12 0.88, respectively). Nocturia and frequency were also independently associated to OAB ( p < 0.001; OR = 2.47, 95% CI = 1.56 3.93 and p = 0.008; OR = 2.13, 95% CI = 1.21 3.73, respectively), but the presence of incontinence was not. OAB was independently associated to sexual life impairment ( p = 0.21; OR = 3.36, 95% CI = 1.20 9.39) after controlling for gender, age, education, BMI, parity, frequency, urgency, nocturia, incontinence, coping strategies, depression, anxiety, shame, and tiredness. In OAB subjects, symptoms were present for less than 6 months in 9.8%, for 6 to 12 months in 12.6%, for 1 to 3 years in 20.3%, and for 3 years or more in 57.3%. Only 27.5% (44) sought for medical counseling. Of those who had consulted a doctor, 68.2% (30) were pharmacologically treated and 73.3% [22] reported some improvement under medications. Overall, only 13.7% of all OAB individuals received effective treatment.

european urology 49 (2006) 1087 1092 1091 4. Discussion Our study showed an OAB prevalence of 14.0% in men and 23.2% in women (overall 18.9%). This is the first published study considering the ICS terminology for the diagnosis of OAB. Although no definitive consensus for the diagnosis of OAB exists, the ICS considered urgency as the pivotal symptom of the syndrome and is sufficient for the diagnosis [19] Other studies considered urgency isolated or associated with other symptoms (frequency, nocturia, incontinence) for the diagnosis of OAB. A standardization of the diagnosis and utilization of the same criteria in scientific papers could be helpful for comparative analysis. Urgency was the only symptom in 19.2% of OAB individuals in our sample. The vast majority had urgency plus any combination of the others symptoms of the syndrome, as shown in Fig. 1. It means that if urgency alone was not considered a sufficient symptom for OAB, one fifth of our diagnoses would be missed out. In a large population-based study, Milsom et al. demonstrated an OAB prevalence of 16.6% [2]. On the other hand, a prevalence of 9.2% would be found if ICS criteria would be utilized [2,19]. Recently, Temml et al. demonstrated a prevalence of 13.5% in Europe utilizing urgency plus any other symptom of the syndrome (frequency, nocturia, incontinence [4]. Another caveat of that study is that subjects with mixed incontinence were not individually analyzed. In our sample a prevalence of 15.2% would be found if we had utilized Temml s criteria. The prevalence of OAB is believed to be higher in women [18,21], but this difference was not demonstrated by larger studies [2,20]. We have found a high prevalence in both genders; however, women were significantly more affected than men in our sample (23% versus 14%, respectively). The negative association between OAB and higher educational levels found requires further confirmation. One hypothesis is that lower educational level is associated with more difficult access to the health system, resulting in higher prevalence of OAB in this population. Another possible hypothesis is misinterpretation of the questionnaire in this population. In contrast to other studies, OAB prevalence was not correlated to age in our sample [2,3,20]. Nonetheless, this may be due to our young sample (15 to 55 years old). Although not increasing with age, our prevalence rates show that even this young group was highly affected by OAB. Psychosocial adjustment to illness is as important as the status of the physical disease itself [22]. In our sample, 70.5% of OAB individuals regularly use at least one self-care strategy to cope with urinary condition. This behavior can be responsible for great impact on physical health, like avoiding drinking liquids. Many studies proposed that LUTS and OAB have great impact on quality of life. Chiaffarino et al. showed that QoL was significantly impaired in women with urinary tract infection or OAB compared to controls [9]. In our study, more than one third of OAB subjects complained of impairment on daily living caused by anomalous urinary habit. They reported significant impairment on household chores, physical activities, sleep, work, social life and sexual life. It seems that the loss of urinary control, for any reason, affects the social, psychological, domestic, occupational, physical, and sexual lives [22]. It has been proposed that LUTS are an independent risk factor for sexual dysfunction in aging men and women [5,6]. Sexual activity, intercourse satisfaction, libido, and overall sexual satisfaction decreased significantly with LUTS severity, while the prevalence of erectile and ejaculatory dysfunction increased [5]. Women reporting UI or LUTS complained of sexual dysfunction in a significantly higher number than a general health female population [8]. The negative influence on sexual life of women with OAB was even higher that in women with stress UI [3]. Overactive bladder remained as an independent risk factor for sexual difficulties in our study. OAB subjects were more than three times as likely to experience sexual problems. It is believed that not only leakage, but also fear of leakage, during intercourse inhibits sexual activity [22]. OAB individuals are at great risk for emotional distress. Subjects suffer with great discomfort, shame and decrease in self-confidence, resulting in withdrawal from social life [22]. Self-reported depression and anxiety were much more frequent in individuals affected by OAB in our survey. Shame caused by the inconvenient urinary habit was seven times more frequent in OAB group. Tiredness is another pertinent condition, nine times more frequent in affected, with great potential to disturb daily living. Incontinent men and women reported a negative impact of their incontinence status on QoL [7]. However, incontinence was not a determinant factor for impairment in most aspects of QoL in our sample. Stewart et al. also showed that OAB, with or without incontinence, has a clinically significant impact on quality of life, quality of sleep, and mental health, in both genders [20]. Incontinent OAB subjects reported more anxiety and shame

1092 european urology 49 (2006) 1087 1092 than continent ones. They also reported greater impairment on physical activities. However, all other components of daily living, quality of life, and emotional distress were equally disrupted in continent and incontinent OAB subjects. Despite the large prevalence of OAB and great inconvenience of symptoms, many affected individuals fail to report this condition to their physicians, and often endure the burden of symptoms for many years. Milsom et al. showed that 60% of individuals with OAB had consulted a medical practitioner about their symptoms, but only 27% of those who had consulted a doctor were currently taking medication, and 27% of those who were not currently taking medication had tried it but withdrew from treatment [2]. The fact that the vast majority of affected individuals in our sample never looked for medical advisory and only 13.7% of all OAB subjects received effective treatment is probably because the public health care system in Brazil is ineffective and does not cover any treatment modality. This could also explain our higher OAB prevalence, since at our setting fewer people get treated and consequently continue to experience symptoms. In conclusion, overactive bladder is a highly prevalent condition, even in young populations. It affects both genders, yet it is more frequently observed in women. OAB is an important health condition, with serious impact on quality of life and sexual function. A large percentual of individuals remain unrecognized, under treated and consequently suffer for long periods of time. References [1] Abrams P, Cardozo L, Fall M, et al. 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