The prevalence of urinary incontinence and its impact on quality of life among the university female staff in South Africa

Abstract

Background: Urinary incontinence (UI) is a common problem among females and has been associated with significant decreased quality of life. Few women seek help for this condition with only a few who consult physiotherapy treatment.Purpose: To determine the prevalence of urinary incontinence and its impact on quality of life among the university women in South Africa.Method: A quantitative cross-sectional study design with 145 women ran-domly selected from the university. A questionnaire was used to determine UI Diagnosis; Impact on Qol and treatment seeking tendencies. BMI was meas-ured objectively. ethical clearance was obtained from University. Data was analysed using SPSS 17.0Results: Forty six(32%) women reported to having UI. Risk factors associated with UI included age, race, and obesity. UI had a significant negative impact on quality of life and only 4.4% of participants with UI consulted physio-therapy for this condition.Conclusion: There is a high prevalence of UI among the women at this university with a significant impact on quality of life.The role of Physiotherapy in management of UI has been demonstrated and there is therefore a need to empower women with non-invasive treatment options, like physiotherapy.

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SA Jo u r n A l o f Ph y S i o t h e r A P y 2011 Vo l 67 no 2
Research
Article
The Prevalence of Urinary Incontinence and
its Impact on Quality of Life among the
University Female Staff in South Africa
Corresponding Author:
Dr L Skaal
Department of Public Health
University of Limpopo
PO Box 1018
Medunsa
0204
E-mail: lskaal@ul.ac.za
Linda_Skaal@embanet.com
AbSTrAcT: Background: Urinary incontinence (UI) is a common problem
among females and has been associated with signicant decreased quality of
life. Few women seek help for this condition with only a few who consult
physiotherapy treatment.
Purpose: To determine the prevalence of urinary incontinence and its impact
on quality of life among the university women in South Africa.
Method: A quantitative cross-sectional study design with 145 women ran-
domly selected from the university. A questionnaire was used to determine UI
Diagnosis; Impact on QOL and treatment seeking tendencies. BMI was meas-
ured objectively. Ethical clearance was obtained from University. Data was analysed using SPSS 17.0
Results: Forty six(32%) women reported to having UI. Risk factors associated with UI included age, race, and
obesity. UI had a signicant negative impact on quality of life and only 4.4% of participants with UI consulted physio-
therapy for this condition.
Conclusion: There is a high prevalence of UI among the women at this university with a signicant impact on quality
of life.The role of Physiotherapy in management of UI has been demonstrated and there is therefore a need to empower
women with non-invasive treatment options, like physiotherapy.
Key wordS: URINARY INCONTINENCE; IMPACT, QUALITY OF LIFE; PHYSIOTHERAPY.
Skaal L, DrPh1
Mashola M.K, BSc1
1 University of Limpopo
leakage occurs during sexual activity in
12% of women, embedding a long term
psychological impact (Barber, Dowsett,
Mullen & Viktrup, 2005).
Few women seek help for this condi-
tion and it has been reported that of those
who consult, they tend to wait a long
time after it has developed and most
women nd it difcult to talk about their
condition (Mason et al, 1999). Although
urine leakage affects the quality of life
of sufferers, only a few women consult
a healthcare professional. Unfortunately,
physiotherapy is often overlooked by
women with urinary incontinence, maybe
because of their lack of knowledge/
awareness of the role physiotherapy in
the management of this condition. At
times, doctors prescribe medication for
prolonged periods without referring
these patients for physiotherapy. Pelvic
oor exercises have been shown to be
a safe and effective way of improv-
ing symptoms of urinary incontinence
(Aksac, et al, 2003). Despite these
proven benets, Chiarelli et al, (2003)
argues that lack of knowledge of benets
BACKGROUND
Urinary incontinence remains an under
reported and embarrassing condition
across all countries and cultures, with
severity directly related to decreased
quality of life (Minassian, Drutz &
AlBadr, 2003). Mason, Glenn, Walton
and Appleton (1999) also suggest that
the effects of urinary incontinence may
vary according to the severity of the
condition and the age of the woman.
Psychological effects associated with
this condition include depression,
anxiety, irritability, worry, frustration
and tension. The desire of affected
patients to take part in recreational or
sporting activities are also affected, as
well as restriction of activities where
toilet facilities are unknown (Mason et al,
1999). Apart from the feelings of embar-
rassment and anxiety, incontinence may
negatively affect social participation,
intimate relationships and self-esteem
(Danforth et al, 2007). According to
Mason et al (1999) urinary incontinence
has a negative impact on sexual rela
tionships. Studies suggest that urine
of these exercises leads to poor consul
tation and physiotherapy referral.
However, over the years, there has been
an increase in the number of women who
are referred for physiotherapy by their
gynaecologists, presenting with some
form of urinary incontinence, especially
stress incontinence. Kapoor, Meher,
Watkins and Das (2009), reported that
among urogynaecology referrals, 38.9%
are for urinary incontinence, indicating
the extent of the problem. More than a
decade ago, Mantle and Versi (1991),
reported that the majority of patients
referred for physiotherapy, are referred
by gynaecologists and more recently,

46 SA Jo u r n A l o f Ph y S i o t h e r A P y 2011 Vo l 67 no 2
Van Gerwen, Schellevis and Lagro
Janssen (2009) reported that only 20%
are referred by general practitioners. The
aim of this study was to determine the
prevalence of urinary incontinence, its
impact on the quality of life, as well as
physiotherapy consultation tendencies
among the female staff at the University
of Limpopo, South Africa.
METHODS
This was a quantitative, crosssectional
study, with a sample size of 145 females
who were randomly selected from the
female population of 336 obtained from
the Human Resource Department at
the University of Limpopo, Medunsa
campus. A total of 152 female staff
was approached and only 145 agreed to
participate in the study. The sample size
was determined using Raosoft sample
size calculation where n=N/2.96 = 113
and 32 was added to cater for non
response. The number for staff in each
stratum (strata included academic staff,
administrative staff and general work-
ers) was calculated according to the
total number of staff in each stratum.
Prospective participants were selected
from each stratum using a simple
random sampling method. Informed
consent was obtained from all identied
participants. Participants were excluded
if they were pregnant at the time of
conducting the study. In addition, those
who could not read/write were assisted
by the researchers to complete the
questionnaire. Before the main study,
the questionnaire was piloted for face
validity among 10 nonparticipating
staff. The questionnaire was translated
to SeTswana, to cater for those who did
not understand English. Ethical clear-
ance was obtained from the University
Research Ethics Committee (MREC).
Three selfcompleted questionnaires
were used to collect data and included
the “Questionnaire for Urinary Diag
nosis” (QUID), (Botlero et al, 2009) to
determine diagnosis of UI; “Incontinence
Impact Questionnaire” (IIQ7) (Uebersax,
Wyman, Shumaker, McClish, Fantl,
& the Continence Program for Women
Research Group, 1995), to determine
the impact and “Incontinence Quality of
Life” questionnaire (IQoL), (Bushnell,
Martin, Summers, Svihra, Lionis&
Patrick, 2005) to determine the qua
lity of life of those diagnosed with UI.
In addition, the demographic data and
anthropometric measurements and treat-
ment options were also recorded. Data
was analysed using the following scor-
ing system, which has been previously
validated by Botlero et al (2008).
QUID (Diagnosis): 5=Stress; 610 =
Urge; ≥ 11 = Mixed Incontinence
IIQ-7 ( Impact):Scores 7 – 9 =
Incontinence had an impact in their life.
IQOL ( Quality of life):Scores ≥ 10
showed a decreased quality of life.
Responses were analysed and the peak
incidences according to age and risk
factors were recorded. SPSS 17.0 sta-
tistical tool was used to analyse the data
and graphical and frequency tables, were
used to present the data. Chi square was
used to determine associations.
RESULTS
Demographic Characteristics
A total of 145 female staffs participated
in the study, 53.8% were above and
46.2% were below 40 years of age. The
majority of the participants (79.3%) were
black and 21% were white (Table 1).
The majority (77.2%) of women were
overweight (35.2%) and obese (42.0%)
compared to only 22.8% of those with
normal weight. In addition, 54% of the
women reported that they did not exer-
cise. According to race, a signicant
number of Blacks (80%) were over-
weight/obese compared to 61.8% of
whites (p=.005).
Most of the women had more than 2
deliveries and only 12.4% did not have
children. In addition, 57.9% with chil-
dren gave birth vaginally and 14.5% had
both Csection and vaginal deliveries.
Of the participants, 24% of those who
had children had episiotomies and 17%
had hysterectomies. Most of the staff
had hypertension (58.6%), 19% had dia-
betes mellitus, 16% were diagnosed with
cancer and 6.9% had a heart disease.
Of the 46 women with urinary incon-
tinence, 14 (30.4%) scored more than 7
points on impact index, indicating that
urinary incontinence had an impact in
their quality of life. Also, 28% of women
with urinary incontinence scored more
than 11 on the quality of life index (QOL),
indicating that they had decreased QOL.
The majority of women with urinary
incontinence (86.9%) did not consult
anybody for this problem and only
4.4% consulted health practitioners. Of
those 6 women who consulted, 2 (33.3%)
received medication, 2 (33.3%) surgery
and 2 (33.3%) were prescribed ‘kegel
Table 1: The demographic characteristics of participants (N=145)
Variables N %
Age <40yrs 67 46.2
≥40 yrs 78 53.8
Race Black 115 79.3
White 30 20.7
Occupation Lecturers 37 25.5
Admin staff 58 40
Service workers 50 34.5
Table 2: Body mass index and exercise history of participants (N=145)
Variables N %
BMI Norma; weight 33 22.8
Overweight 51 35.2
Obese 61 42.0
Exercise (Do
you exercise?)
Yes 66 45.4
No 79 54.5

47
SA Jo u r n A l o f Ph y S i o t h e r A P y 2011 Vo l 67 no 2
exercises’. Reasons for not consulting
a health professional are highlighted in
Table 4.
The majority of women (97.8%)
diagnosed with urinary incontinence
were not referred for physiotherapy. In
addition, 95.7% did not know that
physiotherapy can play a role and 89%
did not know that physiotherapy exer-
cises could help this problem.
DISCUSSION
Obesity has been reported to be one of
risk factors associated to urinary incon-
tince. Botlero et al (2009) and Luber
(2004) also found that obesity was a
signicant risk factor for both stress
and mixed incontinence. Khong and
Jackson (2008) also highlighted that
urinary incontinence could be attributed
to the accumulation of extra weight in
the midsection, which may put pres-
sure on the bladder. The results of this
study revealed that approximately 42%
of women were obese which poses a
risk of developing urinary incontinence.
The results of this study demonstrated
a high prevalence of hypertension
(58.6%)), diabetes mellitus (19%), can-
cer (15.5%) and cardiac diseases (6.9%)
in the studies population. Barclay (2009)
in his study on association between
diabetes and urinary incontinence preva-
lence, found that 85% of subjects with
diabetes had high prevalence of urinary
incontinence. It is of concern that a high
number of young participants in this
study suffer from urinary incontinence.
The results of the study showed there
was no signicant difference between
urinary incontinence prevalence and
age (p=.464). This was in contrast to the
ndings by Nitti (2001) which showed
that the prevalence of urinary inconti-
nence is low among young women and
peak post menopause and at older ages.
Botleroet al (2009) found that the peak
incidence of stress and urge incontinence
peaked in the ages over 40yrs. The nd-
ings of this study differ with ndings of
Nitti (2001) and Botlero et al (2009), and
may imply that these 2 types of urinary
incontinence are more prevalent across
all age groups. Therefore, awareness
interventions should be started as early
as 20 years in this population.
In the current study black women
(67.4%) had a signicantly higher pre
valence of urinary incontinence com-
pared to white women (32.6%, p= .041).
In contrast, Thom et al (2006), found uri-
nary incontinence to be more prevalent
in white women than in black women.
Newman (2001) and Thom et al (2006)
also reported that white women are
more at risk of urinary incontinence
because anatomically, they have a
shorter urethra, weaker pelvic oor mus-
cles, and a lower bladder neck than black
women, thus making them more likely
to have incontinence. It is not clear
whether these physiological differences
are present in the subjects of this study,
and the difference in outcome can thus
not be explained. The results of the cur-
rent study imply that black women are
vulnerable group to a higher prevalence
of urinary incontinence, possibly due to
increased obesity in this race.
Kim, McEwen, Sarma, Piette &
Herman (2008) found that urinary incon-
tinence affected activities after delivery
more frequently among women who
were less educated and that higher levels
of education and income were associated
with low levels of incontinence. In a study
done on Chinese women by Wong, Lau,
Mak, Pang, Cheon and Yip (2006), the
results showed that 78% of respondents
did not know that urinary incontinence is
a disease entity, but for those who sought
treatment, physiotherapy was their rst
Table 3: Cross-tabulation between variables and UI Prevalence (N = 46)
Variables UI Prevalence
n (%) P-value
Age < 40yrs 22 (47.8)
.464
≥ 40yrs 24 (52.2)
Job Category Lecturers 8 (17.4)
.174
Admin staff 20 (43.5)
General workers 18 (39.1)
Race Blacks 31 (67.4)
.041
Whites 15 (32.6)
BMI Normal weight 5 (10.9)
.010
Overweight 16 (34.8)
Obese 25 (54.3)
Exercise Exercise 20 (43.5)
.438
No exercise 26 (56.5)
Delivery
method
Normal 29 (63.0)
.601
Caesarean Section 6 (13)
Mixed 4 (8.7)
No child 7 (15.3)
Table 4: Reasons for not seeking medical intervention (N = 46)
Reasons for not consulting n %
Not serious problem 14 35
Embarrassed 2 5
It’s natural 8 20
Fear to consult 1 2.5
No time 8 20
Not going to toilet 3 7.5
Did not specify 4 10

48 SA Jo u r n A l o f Ph y S i o t h e r A P y 2011 Vo l 67 no 2
choice of treatment. The fact that the
majority of staff who exercise were lec-
turers, compared to general staff, could
be the reason why lecturers have lower
levels of urinary incontinence. Danforth
et al (2007) also did a study on effects
of physical activity on urinary inconti-
nence and found that increasing levels
of physical activity were signicantly
associated with reduced risk of urinary
incontinence. About 30% of women
reported that urinary incontinence had
a negative impact and also a decreased
quality of life. Minassian et al (2003) also
found that 50% of women with inconti-
nence reported that urinary incontinence
affected their quality of life.
An overwhelming 87% of women
with urinary incontinence did not seek
professional help. This is consistent with
the study by Mason et al (1999) who
stated that few women seek help for uri-
nary incontinence. Minassian et al (2003)
reported that despite 50% of the partici-
pants reporting that the leakage of urine
affected their quality of life, an over-
whelming 93% did not seek help. Even
with severe incontinence, only 42.5%
consulted a healthcare professional. This
study’s ndings are also consistent with
Luber (2004) who suggested that rea-
sons for not consulting can be related to
embarrassment to talk about the condi-
tion or fear that treatment may require
surgery. In the current study, only 4% of
the women knew the physio therapists’
role in this condition, with 13% know-
ing that there are exercises to treat
this condition. This is in contrast with
Wong et al (2006) who found that major-
ity of subjects in his study consulted a
physiotherapist.
CONCLUSION
There is a signicant prevalence of uri-
nary incontinence among the females in
the studied population, with a signi-
cant impact on their quality of life. The
majority of participants did not know
the signicant role of physiotherapy in
managing this problem. It is therefore
recommended that physiotherapists take
the initiative in empowering women
in general about the existing treatment
options that do not involve surgery. A
holistic approach should be empha-
sized in all high risk women, in order to
identify those at risk and educate about
the existence of urinary incontinence
and the treatment thereof. An extensive
health promotion intervention need to
be done by physiotherapists to raise
awareness, empower people and educate
both the community and the professional
colleagues about the role of physiothera
pists so that there will be future refer-
rals and patients can get the rstline,
lowcost and effective treatment that is
provided by physiotherapists.
Limitations of this study
Limitations of this study are that the self
reported leakage of urine questionnaire
QUID does not include frequency of
leakage and severity of leakage, which
may lead to misdiagnosis and participants
may feel that symptoms do not translate
into a level of ‘bother’ that qualies the
condition of Urinary Incontinence. The
researcher thus recommends that fur-
ther studies utilize the validated tool:
“Severity Index” by Hanley, Capewell,
Hagen (2001) to further classify urinary
incontinence into levels of severity and
amount of urine loss.
Implications of this study
Urinary incontinence is a big health
problem, with psychological impact
that affects women of all agegroups,
and race. Because of its presentation,
women continue to treat UI as a closet
problem. UI has an impact on quality
of life of women, especially of mid-
dle age group. UI poses a public health
challenge to all physiotherapists to
engage in awareness campaigns so as
to change perceptions; improve knowl-
edge and empower women to seek early
intervention such as physiotherapy for
this problem.
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