Hypothesis / aims of study
The self-reported prevalence of urinary incontinence (UI) in the post-partum period is widely researched. However, these prevalence figures vary greatly throughout published reports, depending on case definitions applied, recruited population and study methodology.
Cautious interpretation of (high) prevalence rates is needed when case definitions used do not incorporate a measure of symptom bother. Therefore, it is likely that the crude UI prevalence rate is higher and overestimated compared to the prevalence rate of significant or bothersome UI. As bothersome UI is associated with help-seeking behaviour, this discrepancy may also have crucial consequences for research planning, health care providers and policy makers. Consequently, the International Consultation on Incontinence (ICI) (1) recommends prevalence numbers to be accompanied by a measure of bother.
Therefore, we aim to investigate the prevalence of self-reported UI and level of experienced bother of UI between six weeks and 12 months post-partum in the Netherlands.
Study design, materials and methods
All women (regardless of parity) between six weeks and 12 months post-partum were eligible to participate in the study. Midwifery and pelvic physiotherapy practices were amongst others asked to share a social media message (using Facebook and LinkedIn), containing a message with a link to the patient information letter and digital questionnaire. Before proceeding to the digital questionnaire, eligible women signed informed consent electronically, in agreement with ethical regulations.
The digital questionnaire takes 10 minutes to complete and consists of three parts: 1. demographic variables like age, educational level and parity, 2. International Consultation on Incontinence Short Form (ICIQ-UI-SF) (2), and 3. International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol).
The ICIQ-UI-SF consists of four questions regarding urinary frequency, amount of UI, the impact on daily life, and a question on when UI occurs. The sum of the first three items ranges from 0 (no UI) to 21 (very severe problem).
The ICIQ-LUTSqol is a condition-specific health-related quality of life questionnaire. It contains 19 questions that can be scored on life restrictions, emotional aspects and preventive measures. The sum score ranges between 19 and 76. A higher score indicates a higher impact on quality of life. Every question is accompanied by a question regarding experienced bother (ranging from 0 (no bother) to 10 (extreme bother)). It is arbitrarily decided that a score of at least 5 indicates significant bother on a specific item.
The ICIQ-UI-SF and ICIQ-LUTSqol are high quality questionnaires and recommended by the ICI (2). Responding women were considered to be continent for urine, when they reported not having UI on the frequency item of the ICIQ-UI-SF.
The sample size calculation showed that a minimum of 340 women needed to fill out the questionnaire. Data were analysed using descriptive statistics (means, measure of variability and proportions). Analyses were done using SPSS version 26.0.
Results
In total, 415 women were included with a mean age of 30.6 years (SD 4.0, range 21-40). The overall prevalence of UI was 57.1%. Stress UI is the most frequently reported type (63%, Table 1). Nearly 44.0% of the women reported UI once a week or less and 89.5% had loss of a small amount of urine. The mean ICIQ-UI-SF score was 8.1 (SD 4.4, range 0-17), indicating that the vast majority (86.9%) reported slight to moderate bother in relation to UI.
The mean ICIQ-LUTSqol total score was 29.8 (SD 7.9). Post-partum women experienced significant bother in relation to having UI on three out of 19 aspects: 1. physical activities, 2. changing of wet underclothes, and 3. worry because of smell (Table 2).
Interpretation of results
The prevalence of self-reported UI in the first year post-partum in The Netherlands is high (57.1%) and comparable to results from other studies. In this population stress UI is the most prevalent type of UI. However, most women experienced having UI only as mild to moderate, based on the ICIQ-UI-SF. Only three items proved to significantly impact on the quality of life. These outcomes show that healthcare providers should not only assess the presence of UI, but also ask for experienced bother in relation to UI. This is of high importance, as the level of experienced bother will firstly influence help-seeking behaviour of post-partum women, secondly impact on the decision to offer medical care and on the selection of UI interventions. Thirdly, management and research decisions often rely on crude prevalence figures without taking into account the level of bother and thus has serious consequences.
Strengths of this study includes the high sample size and use of high quality and recommended questionnaires to measure the prevalence and bother of UI, and impact on quality of life. A limitation comprises the possible risk of bias due to the use of social media for recruitment. The participating women were slightly higher educated than the general population (3).
More research with regard to the association between bother of UI and help-seeking behaviour is advisable. This may improve clinical and research practice.