By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
SYNOPSIS: The updated prevalence of urinary incontinence using the National Health and Nutrition Examination Survey data is 60% in community-dwelling women, which is an increase from prior estimates.
SOURCE: Patel UJ, Godecker AL, Giles DL, Brown HW. Updated prevalence of urinary incontinence in women: 2015-2018 national population-based survey data. Female Pelvic Med Reconstr Surg 2022;28:181-187.
The main objective of this study was to provide updated estimates of urinary incontinence (UI) prevalence in community-dwelling adult women in the United States using National Health and Nutrition Examination Survey (NHANES) data. As secondary objectives, the authors wished to characterize UI types and severity and to identify associated risk factors for UI. This was a descriptive analysis of 2015-2018 publicly available NHANES weighted data. The NHANES was designed by the National Center for Health Statistics to assess the health status of a nationally representative sample of the U.S. population in two-year cycles. It includes data obtained through structured personal interviews, consisting of demographic, socioeconomic, dietary, and health-related questions, as well as a physical exam for a subsample of respondents.
This analysis included 5,006 women who were age 20 years or older and who completed the mobile exam and computer-assisted personal interview portion of the exam (administered by trained interviewers) with the standardized UI questions. The prevalence of UI in this cohort was 61.8%, with nearly one-third reporting monthly symptoms. Of women with UI, 37.5% reported stress urinary incontinence (SUI), 22% reported urge urinary incontinence (UUI), 31.3% reported mixed incontinence, and 9.2% reported unspecified incontinence. Nearly 34% reported a level of bother that was “somewhat” or greater. Logistic regression modeling was used to determine adjusted associations with UI. In these analyses, any and moderate UI were associated with increasing age, body mass index (BMI) ≥ 25, prior vaginal birth, anxiety, depression, functional dependence, and non-Hispanic white ethnicity and race. Diabetes, education level, prior hysterectomy, smoking status, physical activity level, or current pregnancy status were not associated with UI.
COMMENTARY
The main finding of this study is an increase in the prevalence of UI in adult U.S. women compared to the prior NHANES analysis, which included data from 1999-2004. The authors found a prevalence of UI of 62%, nearly two-thirds of U.S. community dwelling women, which corresponds to more than 78 million U.S. women. Estimates from prior data had been 38% to 49%. In multivariate modeling, age older than 70 years, BMI > 40, and vaginal birth were most strongly associated with UI. Of the 78 million women affected by UI, nearly one-third have SUI alone, one-quarter have UUI, and another one-third have mixed incontinence with symptoms of both SUI and UUI. The increase in prevalence may be linked to the factors found to be most associated with UI. As the U.S. population ages and the prevalence of obesity increases, these changes may translate to more UI symptoms.
Although UI is not thought to affect mortality, its quality of life burden is significant and studied extensively. UI affects health and well-being in many ways and has been shown to be associated with anxiety and depression, social isolation, and loss of work function.1 Of the three strong associations found in this study, we cannot affect aging. The prevalence of UI in this study was 14% higher in women with vaginal birth compared to cesarean delivery. This finding has been reported in other studies and is an important element for providers to include while counseling women about route of delivery.2 However, prior studies have highlighted obesity as a significant modifiable risk factor for UI. Women with obesity are nearly three times more likely to experience urine leakage; the longer one is obese, the more likely one will develop leakage later in life.3,4 Weight loss has been associated with reduction of urinary leakage. Although sometimes daunting, addressing the many risks of obesity and its association with urinary leakage is essential. Providing patients with nonjudgmental weight management educational tools as well as referrals for nutritional services, endocrinology, and weight management consultations, can be beneficial.
Knowing that two-thirds of women may have UI can empower clinicians to embrace simple routine screening for UI. The Women’s Preventive Services Initiative recommends screening women annually for UI and referring women for further evaluation and treatment as indicated.5 Although many validated UI symptom questionnaires exist, the 3 Incontinence Questionnaire was developed specifically for use in primary care.6 It is quick, simple, and contains only three items. The first question (“During the last three months, have you leaked urine [even a small amount]?”) has a yes/no response. The remaining two questions (“During the last three months, did you leak urine [check all that apply]” and “During the last three months, did you leak urine most often [check only one]”) have multiple response options. Evaluation of the type of incontinence is based on these responses.
Merely screening, providing initial educational material, and referring women for further evaluation and treatment can begin to break the stigma that surrounds urine leakage. These simple steps not only help women be heard but can help them understand they are experiencing a common problem for which solutions exist. Knowing that treatment options for UI exist and span behavioral and lifestyle modifications, pelvic floor physical therapy, medication management, surgery, and procedural management can, in turn, empower women to seek treatment.
REFERENCES
1. Coyne KS, Wein AJ, Tubaro A, et al. The burden of lower urinary tract symptoms: Evaluating the effect of LUTS on health-related quality of life, anxiety and depression: EpiLUTS. BJU Int 2009;103:4-11.
2. Tähtinen RM, Cartwright R, Tsui JF, et al. Long-term impact of mode of delivery on stress urinary incontinence and urgency urinary incontinence: A systematic review and meta-analysis. Eur Urol 2016;70:148-158.
3. Al-Mukhtar Othman J, Åkervall S, Milsom I, Gyhagen M. Urinary incontinence in nulliparous women aged 25-64 years: A national survey. Am J Obstet Gynecol 2017;216:149.e1-149.e11.
4. Choi JM, Jiang J, Chang J, et al. Impact of lifetime obesity on urinary incontinence in the Women’s Health Initiative. J Urol 2022;207:1096-1104.
5. Health Resources & Services Administration. Women’s Preventive Services Guidelines.
6. Brown JS, Bradley CS, Subak LL, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med 2006;144:715-723.
The updated prevalence of urinary incontinence using the National Health and Nutrition Examination Survey data is 60% in community-dwelling women, which is an increase from prior estimates.
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