INTRODUCTION: The 6-item Urogenital Distress Inventory (UDI-6) was recently validated on 68 women with lower urinary tract symptoms. The purpose of the present investigation was to use the UDI-6 to determine the types of lower urinary tract dysfunction across different age groups, as described by women from Qalubia Governorate, Egypt.
METHODS: The study group was recruited from females attending hospitals for urological consultation between February and August, 2009. There were 378 participants who were 20-50 years old. They had lower urinary tract symptoms for 3 months and a negative dipstick test. Each had a medical history, clinical evaluation, urine culture, and pelvic-abdominal ultrasound. All participants completed the Arabic version of the UDI-6. They were divided into 3 groups according to age: (1) 20-30 years (n = 144), (2) 31-40 years (n = 94), (3) 41-50 years (n = 140). Results were compared by age group using t tests; a Bonferroni adjustment was applied and significant differences were noted at P < .001.
RESULTS: The most common symptoms of lower urinary tract dysfunction were stress urinary incontinence and lower abdominal or genital pain. Stress urinary incontinence was present in 182 (48.1%) of the 378 patients. It occurred in 4.8% of patients age 20-30 years, 8.1% of patients age 31-40 years, and 17.2% of patients age 41-50 years. Urge incontinence was present in 84 patients (22.2%). The presence of mild and moderate stress incontinence and mild urge incontinence increased significantly in patients who were 41-50 years old (all with P < .001). Micturition difficulty and micturition frequency occurred in < 7% of patients. Lower abdominal or genital pain was described by 204 patients (53.9%). Micturition difficulty, micturition frequency, and lower abdominal or genital pain did not have significantly different distributions across age.
CONCLUSION: The most common symptoms of lower urinary tract dysfunction were stress urinary incontinence and lower abdominal or genital pain. The presence of mild and moderate stress incontinence and mild urge incontinence increased significantly in patients who were 41-50 years old. These patterns are similar to those reported by authors from other countries.
Osama Abdelwahab, Ashraf Mohamed, Tarek Mohamed, Mohamed Abdelzaher
Urology Department, Benha Faculty of Medicine, Benha University, Benha, Egypt
Accepted November 17, 2010 - Published February 07, 2011
KEYWORDS: Stress urinary incontinence; Voiding dysfunction; Lower urinary tract symptoms.
CORRESPONDENCE: Osama Abdelwahab, Professor of Urology, Benha Faculty of Medicine, Benha University, 1st Gameel Street-Makkah Tower, Benha, Egypt ().
CITATION: UroToday Int J. 2011 Feb;4(1):art6. doi:10.3834/uij.1944-5784.2011.02.06
ABBREVIATIONS AND ACRONYMS: LUTS, lower urinary tract symptoms; UDI, Urogenital Distress Inventory; UI, urinary incontinence.
The International Continence Society (ICS) defines urinary incontinence (UI) as, "the complaint of any involuntary leakage of urine" . UI is a widespread condition in the general population that affects 19% of females and 10% of males over 60 years old . Its prevalence increases exponentially as the population becomes older and more care-dependent [3,4].
UI has a negative impact on physical, psychological, and social well-being [5,6]. Nursing home residents with UI, in particular, often have incontinence-associated dermatitis, feelings of shame, and limited quality of life. UI is also associated with high economic costs, increased risk of institutionalization, frailty, fractures, and depression [7,8].
One way to assess the outcome of incontinence management procedures in clinical practice and research is to assess the patient's symptoms by validated questionnaire. UI is a symptom of many causes such as stress incontinence or detrusor overactivity. The physical, social, and emotional effects of lower urinary tract symptoms (LUTS) are poorly reflected in objective tests such as urodynamic studies . Using a structured questionnaire ensures that all domains of LUTS are assessed, allowing changes in the symptom patterns and severity to be identified over time. Self-completed questionnaires are preferable to those that are interview-based because they minimize bias related to the caregiver .
A highly recommended scale is the Urogenital Distress Inventory (UDI). An "A-grade" recommendation was given to this scale by the International Consultation of Incontinence because published data indicate that the scale is valid, reliable, and responsive to change following standard psychometric testing. The questionnaire was shown to be relevant for persons with UI .
The UDI was recently validated in Arabic , but it was tested on only 68 patients with LUTS. Therefore, little is known about the responses of Arabic-speaking women with lower urinary tract dysfunction from Egypt. There may be differences in their responses to the questionnaire when compared with women from other countries because of lifestyle or cultural variations. Therefore, the purpose of the present prospective investigation was to use the 6-item UDI to determine the types of lower urinary tract dysfunction across different age groups, as described by women from Qalubia Governorate, Egypt.
The protocol of this prospective investigation was approved by the ethics committee of Benha Faculty of Medicine. All participants provided written informed consent. The study was conducted between February 1, 2009 and August 1, 2009.
The study group was recruited from females attending Benha University Hospital and other hospitals in Qalubia Governorate, Egypt. The women were attending for urological consultation.
There were 378 participants who were positive for lower urinary tract dysfunction. Positive cases were defined as females with LUTS for 3 months with a negative dipstick test. All were 20-50 years old. Exclusion criteria were: (1) active urinary tract infection, (2) neurological lesion, (3) associated bladder mass, (4) previous pelvic organ operation, and (7) pregnancy.
All participants completed the Arabic version of the short form of the Urogenital Distress Inventory, which contains 6 items (UDI-6) Figure 1. The survey was administered through face-to-face interview by the same resident. The participants also underwent a medical history, clinical evaluation, urine culture, and pelvic-abdominal ultrasound.
The 378 women were classified into 3 groups according to age: (1) 20-30 years (n = 144), (2) 31-40 years (n = 94), (3) 41-50 years (n = 140). Data were collected, tabulated, and statistically analyzed to determine the frequency of different forms of lower urinary tract dysfunction in the study group across age categories. The outcome measures were the 6 items on the UDI-6, related to stress incontinence, urge incontinence, micturition difficulty, micturition frequency, and lower abdominal or genital pain. Standard scores (z scores) were created. Age-group differences for each outcome measure were analyzed with a t test. Each age group was compared separately for each variable at each level of severity. Therefore, a Bonferroni adjustment was applied; significant differences were noted at P < .001.
Table 1 contains the results of the 6-item questionnaire. The z scores and probability values numbered 1, 2, and 3 on the table represent comparisons of age group 1 (20-30 years) with group 2 (31-40 years), group 1 with group 3 (41-50 years), and group 2 with group 3, respectively.
Stress urinary incontinence was a common symptom of lower urinary tract dysfunction in the study group, present in 182 (48.1%) of the 378 patients. It was present in 4.8% of patients in group 1, 8.1% of the patients in group 2, and 17.2% of the patients in group 3. There were significantly more patients in group 3 (age 41-50 years) with both mild and moderate stress incontinence when compared with the number of patients in the youngest group (both with P < .001). Similarly, there were significantly more patients in group 3 with mild stress incontinence when compared with the number of patients in group 2 (age 31-40) (P < .001). No other group differences were statistically significant.
Urge incontinence was present in 84 patients (22.2%). It was present in 3% of patients in group 1, 2.7% of the patients in group 2, and 7.9% of the patients in group 3. There were significantly more patients in group 3 (age 41-50 years) with mild urge incontinence when compared with the number of patients in the 2 younger age groups (both with P < .001). There were no significant age group differences for any of the other comparisons.
Micturition difficulty and micturition frequency were each present in 108 patients (28.6%). There were no significant age group differences for these outcome measures.
Lower abdominal or genital pain was described by 204 patients (53.9%). It was present in 10.2%, 10.5%, and 9.9% of the first, second, and third groups, respectively. There were no significant age group differences in the number of patients with these symptoms.
Stress urinary incontinence is a common problem, particularly for the aging population. Melville et al  stated that the prevalence of stress urinary incontinence was 17% in 40-49 year-old females in the USA in a population-based survey conducted in 2005. In 2000, Fitzgerald et al  found that the prevalence of stress urinary incontinence was 17.6% in working women younger than 50 years old. This also in agreement with Corcos and Schick  who found a 13.6% prevalence of SUI in Canadian females older than 35 years old.
In the present study, stress urinary incontinence was the most common feature of lower urinary tract dysfunction in the third (oldest) group of patients with LUTS (17.2%) and a common symptom among all of the patients with LUTS (48.1%), regardless of age. This is in agreement with Milsom et al . It is also in agreement with Irwin et al  who found that urinary incontinence is a widespread condition affecting 19% of females older than 50 years.
Mild urge incontinence was significantly more common in patients between 41 and 50 years old. The prevalence of mild urge urinary incontinence significantly increased with age. This is in agreement with Milsom et al . They found no significant difference between patients age 20-30 years and patients age 31-40 years in the presence of urge incontinence (each about 3%). Melville et al  agreed that the prevalence of urge incontinence was 3% in 30-39 year-old females. The frequency of urge incontinence in 41-50 year-old patients in the present study was 7.9%. Waetjen et al  found that the prevalence of urge urinary incontinence was 9% in 42-52 year-old females and 6.5% in females between 20 and 40 years old in the USA. Minassian et al  and Zhu et al  stated that the prevalence of urge urinary incontinence was 10% in women > 20 years old in 2008 in the USA and China, respectively. In 2004, Corcos and Schick  found a 6.5% prevalence for urge incontinence in females older than 20 years in Canada.
There were no significant age-group differences in the number of patients with micturition frequency in the present study. Tanagho  stated that frequency of urination rises dramatically from 2.0% in the youngest group (ages 18-24) to 19.1 in those 65 to 74 years of age. These older ages were not represented in the present study.
There were no significant age-group differences in the number of patients with micturition difficulty in the present study. Cheater et al  explained that difficulty with micturition typically decreases with age, probably due to age-related laxity of pelvic musculature and connective tissue supporting the urethra. These changes may not occur prior to age 50, which was the age of the oldest patients in the present study.
Pain in the lower abdominal or genital area was present in 53.9% of all patients with LUTS in the present study, representing approximately 10% of patients in each age group. Its frequency was not significantly different across age groups. Verhaak et al  said that the prevalence of chronic benign pain in the general population was at least 10% in the USA in 1998. In 2009, Song et al  reported the presence of pelvic pain in 4.5% of Chinese women over 60.
The most common symptoms of lower urinary tract dysfunction were stress urinary incontinence and lower abdominal or genital pain. The presence of mild and moderate stress incontinence and mild urge incontinence increased significantly in patients who were 41-50 years old. These patterns are similar to those reported by authors from other countries.
Conflict of Interest: none declared.
- Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology. 2003;61(1):37-49. PubMed; CrossRef
- Irwin DE, Milsom I, Hunskaar S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol. 2006;50(6):1306-1315. PubMed; CrossRef
- Fonda D, DuBeau CE, Harari D, et al. Incontinence in the frail elderly. In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Second International Consultation on Incontinence. Monte Carlo, Monaco: Plymbridge Distributors Ltd; 2002:1163-1240.
- Du Moulin MF, Hamers JP, Ambergen AW, Janssen MA, Halfens RJ. Prevalence of urinary incontinence among community-dwelling adults receiving home care. Res Nurs Health. 2008;31(6):604-612. PubMed; CrossRef
- Ouslander JG, Zarit SH, Orr NK, Muira SA. Incontinence among elderly community-dwelling dementia patients. Characteristics, management, and impact on caregivers. J Am Geriatr Soc. 1990;38(4):440-445. PubMed
- Hunskaar S, Vinsnes A. The quality of life in women with urinary incontinence as measured by the sickness impact profile. J Am Geriatr Soc. 1991;39(4):378-382. PubMed
- Wilson L, Brown JS, Shin GP, Luc KO, Subak LL. Annual direct cost of urinary incontinence. Obstet Gyncol. 2001;98(3):398-406. PubMed; CrossRef
- Thom DH, Haan MN, Van Den Eeden SK. Medically recognized urinary incontinence and risk of hospitalization, nursing home admission and morality. Age Ageing. 1997;26(5):367-374. PubMed; CrossRef
- Vigod SN, Stewart DE. Major depression in female urinary incontinence. Psychosomatics. 2006;47(2):147-151. PubMed
- Jackson S. The patient with an overactive bladder--symptoms and quality-of-life issues. Urology. 1997;50(6A Suppl):18-22. PubMed; CrossRef
- Donovan JL, Badia X, Corcos J, et al. Symptom and quality of life assessment. In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence. 2nd ed. Plymouth, UK: Health Publication Ltd; 2002:267-316.
- Altaweel W, Seyam R, Mokhtar A, Kumar P, Hanash K. Arabic validation of the short form of Urogenital Distress Inventory (UDI-6) questionnaire. Neurourol Urodyn. 2009;28(4):330-334. PubMed; CrossRef
- Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in US women: a population-based study. Arch Intern Med. 2005;165(5):537-542. PubMed; CrossRef
- Fitzgerald ST, Palmer MH, Berry SJ, Hart K. Urinary incontinence. Impact on working women. AAOHN J. 2000;48(3):112-118. PubMed
- Corcos J, Schick E. Prevalence of overactive bladder and incontinence in Canada. Can J Urol. 2004;11(3):2278-2284. PubMed
- Milsom I, Altman D, Lapitan MC, Nelson R, Sillen U, Thom D. Epidemiology of urinary (UI) and Faecal (FI) incontinence and pelvic organ prolapse. In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence. 4th Ed. Paris: Health Publication Ltd; 2009:35-111.
- Waetjen LE, Liao S, Johnson WO, et al. Factors associated with prevalent and incident urinary incontinence in a cohort of midlife women: a longitudinal analysis of data: study of women's health across the nation. Am J Epidemiol. 2007;165(3):309-318. PubMed; CrossRef
- Minassian VA, Stewart WF, Wood GC. Urinary incontinence in women: variation in prevalence estimates and risk factors. Obstet Gynecol. 2008;111(2 Pt 1):324-331. PubMed
- Zhu L, Lang J, Wang H, Han S, Huang J. The prevalence of and potential risk factors for female urinary incontinence in Beijing, China. Menopause. 2008;15(3):566-569. PubMed; CrossRef
- Tanagho EA. Anatomy of the lower urinary tract. In: Walsh PC, Retik AB, Stamey TA, Vaughan ED, eds. Campbell's Urology. Philadelphia: W.B. Saunders; 1992:40-69.
- Cheater FM, Castleden CM. Epidemiology and classification of urinary incontinence. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000;14(2):183-205. PubMed; CrossRef
- Verhaak PF, Kerssens JJ, Dekker J, Sorbi MJ, Bensing JM. Prevalence of chronic benign pain disorder among adults: a review of the literature. Pain. 1998;77(3):231-239. PubMed; CrossRef
- Song Y, Zhang W, Xu B, Hao L, Song J. Prevalence and correlates of painful bladder syndrome symptoms in Fuzhou Chinese women. Neurourol Urodyn. 2009,28(1):22-25. PubMed; CrossRef