« Previous Article
Next Article »

Original Research 


RESEARCH ARTICLE

Post-partum urinary incontinence among Saudi women

Nouf Al Mutairi1*, Maha Al Farra2
Correspondence to: Nouf Al Mutairi
*Associate Consultant (Family Medicine), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.
Email: dr-nouf1 [at] hotmail.com
Received: 08 September 2016 | Accepted: 13 October 2016

ABSTRACT

Background: Urine incontinence is known to affect an individual’s health related quality of life and is associated with medical and psychological morbidity. This condition limits the patient’s daily activities, resulting in loss of self-esteem. The aim of this study was to determine the prevalence, risk factors, common type and the impact of urinary incontinence on health related quality of life among Primiparous Saudi women.

Methodology: A cross-sectional study was carried out at three primary care centers in King Abdul-Aziz Medical City. The study included 285 participants from primiparous women visiting the primary care clinics. The data were collected through an approved questionnaire.

Results: The prevalence of urinary incontinence in our study was 56.5% of which 52.1% of cases were mixed, 33.7% were due to stress and 14.2% due to urgency.

Conclusion: Most (56.5%) of the primiparous women visiting NGHA primary care suffered from urinary incontinence, the most common type was mixed urinary incontinence.

Keywords: Primiparous, urinary incontinence, Stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence.

Introduction

The International Continence Society (ICS) defines urinary incontinence as the complaint of any involuntary leakage of urine [1]. Urine incontinence (UI) is known to affect an individual’s health related quality of life (HRQL). The common types of UI are stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI) [2]. SUI is the most common type affecting half of the women, with mixed UI next, followed by urge incontinence [3]. The total cost of urinary incontinence in the United States is estimated to be $20 billion [4]. UI limits the patient’s daily activities, resulting in the loss of self-esteem and a reduction in their ability to maintain an independent lifestyle [1]. The overall prevalence of urinary incontinence in the Middle East ranges from 20.3% to 54.8% [5,6]. In Qatar it is 20.6%, in the United Arab Emirates it is 20.3% [5,7], in Jeddah and Riyadh, cities of Saudi Arabia were estimated to be 41.4% and 29% respectively [8,9]. There are a number of risk factors for UI which include age, body mass index, medical co-morbidities i.e. obesity, diabetes, hysterectomy and parity [10]. Additionally, pregnancy and delivery seem to be a major risk factor among young and middle-aged women [11]. The modern trend in medicine is to lay emphasis on primary health care urinary incontinence prevalence because prevention is much less costly than treatment [12]. A study was conducted to assess the prevalence, incidence and risk factors of female urinary incontinence UI in Europe, the result showed that the prevalence of UI ranged from 14.1% to 68.8% [13]. Another study in Portland assessed the prevalence of urinary incontinence in 5,599 primiparous women and found that 955 (17.1%) reported the leakage of urine [14]. A study conducted to investigate the prevalence of urinary incontinence six months postpartum on 12,679 primigravidas reported that 31% of the women had urinary incontinence [15]. Obstetric and other risk factors for urinary incontinence that occur during pregnancy or after childbirth in primiparous were identified in 2009 by Glazener [16].

Methodology

The study was carried out at the department of family medicine and PHC at King Abdul-Aziz Medical City (KAMC), Health Clinics for Specialized Care (HCSC) and National Guard Clinics for Specialized Care (NGCSC), Riyadh, Saudi Arabia. This cross-sectional study included all primiparous women visiting the three primary care clinics between 1-June to 31-August-2013. An approved questionnaire was used. All the primiparous Saudi women who delivered a single live born neonate visiting the PHCCs in Riyadh, aged between 15-40 years were included in this study. And any other women incontinent before pregnancy, twin pregnancy or more than one-year post delivery were excluded. A sample size of 285 was estimated using test for single proportion, adjusted up to 300 with margin of error (0.05) and CI of 95%. This was carried out with 2-3 participants included in the study each day from a pool of 20-50 visitors. A well-structured data collection form was designed and validated. This questionnaire was distributed and collected from the patients by a well-trained nurse.

Data were analyzed via Statistical Package for Social Sciences (SPSS) software version 18.0. Both descriptive statistics (e.g., number and percentage) and analytic statistics were carried out. Chi-Square was used to test for the association and/or the difference between two category variables. P-value equal to or less than 0.05 was considered statistically significant. Regression analysis to obtain the correlations was also carried out.

Results

A total of 285 primiparous women were included in this study, all women were continent before pregnancy. Demographic and potential risk factors of urinary incontinence are presented in Table 1. The mean age was 25.5 ± 4.4 SD years, range was 15-40 years, mean body mass index was 26 ± 4.3 kg/m2 and range was 18.03-39.54 kg/m2. The total number of women who had normal delivery were 229 (80.4%) and the women who had delivered by cesarean section were 56 (19.6%). Among the 285 women, 39.6% had gained less than 8 kg in weight during pregnancy and around 63.9% of those women had given birth to babies weighing between 2.5 and 3 kg.

UI was reported by 56.5% (161/285), 27.7% during pregnancy, 37.1% after delivery and 35.2% reported UI in both during pregnancy and after delivery (figure 1).

Table 2 shows that there was no statistically significant difference in the prevalence of UI among women who delivered vaginally (55%) or cesarean section (62.5%), P value = 0.312. Additionally, we found no statistical difference in the prevalence of urinary incontinence among women who had elective cesarean deliveries or emergency cesarean section, giving a P value 0.434. We found the risk of UI increased in women who delivered vaginally with laceration, OR1.9, 95%CI 1.1-3.3, P value = 0.028 (Figure 2).

Women with high body mass index are more likely to have UI. We also found that women with higher weight at the beginning of pregnancy were more likely to have UI. It was statistically significant, P = 0.002 (Table 3).

Discussion

There is a high prevalence of UI that is reported in this study as compared to other studies [11,17]. This might be due to the use of broader inclusion criteria including any form of involuntary urine leak and marked as urinary incontinence. The common type of UI reported in the present study was 52.1% mixed, 33.7% stress and 14.2% urgency. In the mixed group of primiparous and multiparous women, some studies reported mixed UI as being more common than stress UI [6,18]. Other studies have reported stress UI as the most common [19,20]. We are not aware of any other studies that have investigated the prevalence of each type of UI in primiparous women although some studies have investigated the specific type of UI in primiparous women but not all types [17]. Interestingly, in our study, we did not find a significant association between mode of delivery and UI. The lack of association between mode of delivery and UI is hard to explain, however it could be due to small sample size. Most of the studies demonstrated an increase of UI among women who delivered by vaginal delivery [14,15,16]. Some studies mention that the type of delivery was not a significant risk factor for UI [17,21,22]. Although the relationship between UI and cesarean section delivery is controversial, some studies mention it is protective [8,10,23] and others demonstrate that there is an increase among women who have delivered by C/S as compared with nulliparous [14,15] which is similar to the findings of another study [14]. The present study detects no statistically significant increase in the risk of UI among women who had elective cesarean section compared with the emergency cesarean section. Lacerations in the delivery area and the use of any device during vaginal delivery have been shown in our study to be statistically significant in association with UI. Some studies reported that forceps-assisted delivery was a risk factor for the UI [14,24,25]. However, other authors did not find any significant association between assisted delivery and UI [14]. Other studies have found a relationship between UI and laceration in the delivery area [16]. The present study detects a statistically significant relationship between high BMI and UI, as a high BMI may worsen pelvic floor weakness during pregnancy and vaginal delivery. Interestingly, our results showed that weight gain during pregnancy did not seem to be a risk factor for urinary incontinence, which was similar to another study [26]. Results of our study showed no statistically significant relationship between baby weight and UI in primiparous women, where several studies support our finding [15,16]. In contrast, some studies reported the first child weight was already known to be a risk factor for UI after the first delivery [24]. Diabetes mellitus, bronchial asthma, chronic constipation have all been shown in our study to be significantly associated with UI, these risk factors have been described only by a study as significant risk factors for UI [14]. In our study, most of the women reported a mild effect of UI on their quality of life. Some studies that have been conducted to evaluate the impact of UI in primiparous women reported a mild effect of UI in HRQL [27]. The impact on quality of life is considered to be mild, perhaps because most women consider urinary incontinence as a temporary difficulty that will resolve on its own. Urinary incontinence remains an underreported and embarrassing condition. A small number of women seek medical care for this condition.

Table 1. Obstetric and medical characteristics of the study group (n = 285).
Characteristics
Frequency
Percent
Weight gain during pregnancy
<8 kg 133 39.6%
8-10 kg 108 37.9%
10-15 kg 47 16.5%
>15 kg 17 6.0%
Baby weight at birth
<2.5 kg 73 25.6%
2.5-3 kg 182 63.9%
3-4 kg 29 10.2%
4 kg 1 .4%
Delivery mode
Normal delivery 229 80.4%
Cesarean section 56 19.6%
History of assisted delivery
Yes 61 26.6%
No 168 73.4%
History of cut or laceration in the delivery area
Yes 155 67.7%
No 74 32.3%
Cesarean delivery
Emergency 45 80.4%
Elective 11 19.6%
diabetes mellitus
Yes 16 5.6%
No 269 94.4%
Bronchial asthma
Yes 66 23.2%
No 219 76.8%
Chronic constipation
Yes 59 20.7%
No 226 79.3%

Figure 1. Distribution of urinay incontinence among participants.
Figure 2. Relationship between urinary incontinence and laceration in delivey area.
Table 2. Relationship of incontinence with medical conditions in study subjects.
Risk factor
Do you have any involuntary loss of urine?
chi-square
P value
No %
Yes %
Weight gain during pregnancy
<8 kg 55 (48.7%) 58 (51.3%) 2.04 .56
8-10 kg 43 (39.8%) 65 (60.2%)
10-15 kg 19 (40.4%) 28 (59.6%)
>15 kg 7 (41.2%) 10 (58.8%)
Baby weight at birth
<2.5 kg 31 (42.5%) 42 (57.5%) .065 .968
2.5-3 kg 80 (44.0%) 102 (56.0%)
3-4 kg 13 (44.8%) 16 (55.2%)
Delivery mode
Vaginal delivery 103 (45.0%) 126 (55.0%) 1.024 .312
Cesarean section 21 (37.5%) 35 (62.5%)
History of cut or laceration in delivery area
No 41 (55.4%) 33 (44.6%) 4.803 0.028
Yes 62 (40.0%) 93 (60.0%)
Assisted delivery
No 86 (51.2%) 82 (48.8%) 9.835 .002
Yes 17 (27.9%) 44 (72.1%)
Cesarean section
Emergency 18 (40.0%) 27 (60.0%) 0.611 0.434
Elective 3 (27.3%) 8 (72.7%) 11 19.6%
diabetes mellitus
No 122 (45.4%) 147 (54.6%) 6.632 0.010
Yes 2 (12.5%) 14 (87.5%)
Bronchial asthma
No 114 (52.1%) 105 (47.9%) 28.101 .000
Yes 10 (15.2%) 56 (84.8%)
Chronic constipation
No 110 (48.7%) 116 (51.3%) 11.844 .001
Yes 14 (23.7%) 45 (76.3%) 226 79.3%

Table 3. Relationship between risk factor UI and effect of UI on HRQL Score.
Score of urinary incontinence affected life of women
N
Mean
(SD)
T test
P value
Normal delivery 131 8.72 3.273 .930 .354
Cesarean section 38 9.26 2.854
Assisted delivery
No 86 8.08 3.229 −3.182 .002
Yes 45 9.93 3.033
History of cut or laceration in the delivery area
No 34 8.94 3.541 .462 .645
Yes 97 8.64 8.64
Diabetic Mellitus
No 154 8.73 3.236 −1.483 .140
Yes 15 10.00 2.360
Bronchial asthma
No 113 8.58 3.294 .597 .138
Yes 56 9.36 2.907
Constipation
No 119 8.63 3.067 −1.326 .187
Yes 50 9.34 3.426

Conclusions

The majority (56.5%) of the primiparous women in PHCCS in Riyadh suffered from urinary incontinence, the most common types are mixed UI which was almost half of all the incontinence types. High BMI, DM, BA, chronic constipation and instrument use during labor, were signifcant risk factors. Urinary incontinence did affect women HRQL.

Recommendations

Future studies should be carried out with larger samples in a higher number of primary care centers. Urinary incontinence remains an underreported and embarrassing condition. A small number of women seek medical care for this condition. The main reason for not seeking help was that most women believed that incontinence is part of normal life. Therefore, we suggest that an awareness program should be carried out for all women through media or lectures.

Limitations of the study

The study was done on a limited population and its fndings cannot be generalized to all primary care populations. Our questionnaire was distributed to women from 6 weeks to one year after delivery so the recall bias cannot be excluded e.g. the weight at the start of pregnancy, weight gain during pregnancy and baby weight.

Acknowledgment

I would express my sincere gratitudeand appreciationto my supervisor Dr. Maha AL-Farra Consultant FM in NGH for her help, guidance and advice during this study. I am grateful to Dr. Saeed ur Rahman Consultant FM in NGH for all his efort and assistance. Also, thank Ms. Hind AlShatry Research Coordinator for her technical and administratie support.

List of Abbreviation

UI

Urinary incontinence

SUI

Stress urinary incontinence

MUI

Mixed urinary incontinence

UUI

Urge urinary incontinence

HRQL

Health Related Quality of Life

BMI

Body mass index

PHCCs

Primary health care centers

KAMC

King Abdul-Aziz Medical City

MNGHA

Ministry National Guard Health Affairs

Conflict of Interest

None

Funding

The research was funded by the King Abdullah International Medical Research Center.

Consent for publication

Not applicable

Ethical considerations

Written permission from King Abdullah International Medical Research Center in Riyadh was obtained. Informed consent was also taken from all subjects.

Author details

Nouf M. Al-Mutairi1, Maha Al Farra2

  1. Associate Consultant (Family Medicine), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
  2. Consultant (Family Medicine), King Abdulaziz Medical City, National Guard Clinics for Specialized Care, Riyadh, Saudi Arabia

References

  1. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardization of terminology in lower urinary tract function: Report from the Standardization Sub-Committee of the International Continence Society. Urology 2003;61:37–49.
  2. Melville JL, Walker E, Katon W, Lentz G, Miller J, Fenner D. Prevalence of co morbid psychiatric illness and its impact on symptoms perception, quality of life, and functional status in women with urinary incontinence. Am J Obstetric Gynecol 2002;187:80–7.
  3. Milson I, Altman D, Lapitan. Epidemiology of urinary and faecal incontinence and pelvic organ prolapse. In: Incontinence, 4th ed., Abrams P, Cardozo L, Khoury S, Wein A (Eds), Health Publications Ltd., Plymouth, UK 2009. p.35.
  4. Hu TW, Wagner TH, Bentkover JD, Leblanc K, Zhou SZ, Hunt T. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology. 2004;63:461.
  5. Saleh N, Bender A, Khenyab N, Al-Mansori Z, Al Muraikhi A. Prevalence, awareness and determinants of health care-seeking behaviour for urinary incontinence in Qatari women: A neglected problem? Maturitas. 2005;50:58–65.
  6. El-Azab AS, Mohamed EM, Sabra HI. The prevalence and risk factors of urinary incontinence and its influence on the quality of life among Egyptian women. Neurourol Urodyn 2007;26:783–8.
  7. Rizk DEE, Shaheen H, Thomas L, Dunn E, Hassan MY. The prevalence and determinants of health care-seeking behavior for urinary incontinence in United Arab Emirates women. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10:160–5.
  8. Ahmed Al-Badr, HadyaBrasha, Rajaa Al-Raddadi, Fatma Noorwali, Susan Ross. Prevalence of urinary incontinence among Saudi women. Int J Gynaecol Obstet. 2012;117(2):160-3.
  9. Waleed Altaweel, Mohannad Alharbi. Urinary incontinence prevalence, risk factor, and impact of health related Quality of life in Saudi women. NeurourolUrodyn. 2012;31(5):642-5.
  10. Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in U.S. women: A population-based study. Arch Intern Med. 2005;165:537–42.
  11. Chiarelli P, Brown W, McElduff P. Leaking urine: prevalence and associated factors in Australian women. NeurourolUrodyn. 1999;18:567-77.
  12. Hampel C, Wienhold D, Benken N, Eggersmann C, Thüroff JW. Definition of overactive bladder and epidemiology of urinary incontinence. Urology. 1997;50:4–14.
  13. Cerruto MA, D’Elia C, Aloisi A, Fabrello M, Artibani W. Prevalence, incidence and obstetric factors’ impact on female urinary incontinence in Europe: a systematic review. UrolInt. 2013;90(1):1-9.
  14. Boyles SH, Li H, Mori T, Osterweil P, Guise JM. Effect of mode of delivery on the incidence of urinary incontinence in primiparous women. Obstetrics & Gynecology. 2009;1;113(1):134-41.
  15. Wesnes SL, Hunskaar S, Bo K, Rortveit G. The effect of urinary incontinence status during pregnancy and delivery mode on incontinence postpartum. A cohort study. BJOG. 2009;116(5):700-7.
  16. Glazener CM, Herbison GP, MacArthur C, Lancashire R, McGee MA, Grant AM, et al. New postnatal urinary incontinence: obstetric and other risk factors in primiparae. BJOG. 2006;113(2):208-17.
  17. Arrue M, Ibañez L, Paredes J, Murgiondo A, Belar M, Sarasqueta C, et al. Stress urinary incontinence six months after first vaginal delivery. Eur J Obstet Gynecol Reprod Biol. 2010;150(2):210-4.
  18. Rizk DE, Hassan MY, Shaheen H, Cherian JV, Micallef R, Dunn E. The prevalence and determinants of health careseeking behavior for fecal incontinence in multiparous United Arab Emirates females.Dis Colon Rectum 2001;44(12):1850-6.
  19. Manonai J, Poowapirom A, Kittipiboon S, Patrachai S, Udomsubpayakul U, Chittacharoen A. Female urinary incontinence: a cross sectional study from a Thai rural area. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(4):321-5.
  20. Minassian VA, Drutz HP, Al-Badr A. Urinary incontinence as a worldwide problem. Int J Gynaecol Obstet. 2003;82(3):327-38.
  21. Kuh D, Cardozo L, Hardy R. Urinary incontinence in middle aged women: Childhood enuresis and other lifetime risk factors in a British prospective cohort. J Epidemiol Community Health. 1999;53(8):453-8.
  22. Pizzoferrato AC, Fauconnier A, Quiboeuf E, Morel K, Schaal JP, Fritel X. Urinary incontinence 4 and 12 years after first delivery: Risk factors associated with prevalence, incidence, remission, and persistence in a cohort of 236 women. Neurourology and urodynamics. 2014;33(8):1229-34.
  23. Press JZ, Klein MC, Kaczorowski J, Liston RM, von Dadelszen P. Does cesarean section reduce postpartum urinary incontinence? A systematic review. Birth. 2007;34(3):228-37.
  24. Casey BM, Schaffer JI, Bloom SL, Heartwell SF, McIntire DD, Leveno KJ. Obstetric antecedents for postpartum pelvic floor dysfunction. Am J Obstet Gynecol. 2005;192:1655-62.
  25. Arya LA, Jackson ND, Myers DL, Verma A. Risk of new-onset urinary incontinence after forceps and vacuum delivery in primiparous women. AJOG. 2001; 185(6):1318-23.
  26. Wesness SL, Hunskaar S, Rortveit G. Urinary incontinence And weight gain during pregnancy and postpartum: a cohort study. Am J Epidemiol. 2010;1;172(9):1034-44.
  27. Dolan LM, Hosker GL, Mallett VT, Allen RE, Smith AR. Stress incontinence and pelvic floor neurophysiology 15 years after the first delivery. BJOG: an International Journal of Obstetrics & Gynaecology. 2003;1;110(12):1107-14.


How to Cite this Article
Pubmed Style

Nouf Al Mutairi, Maha Al Farra. Post-partum urinary incontinence among Saudi women. IJMDC. 2017; 1(1): 5-10. doi:10.24911/IJMDC.1.1.2


Web Style

Nouf Al Mutairi, Maha Al Farra. Post-partum urinary incontinence among Saudi women. https://www.ijmdc.com/?mno=280044 [Access: September 30, 2022]. doi:10.24911/IJMDC.1.1.2


AMA (American Medical Association) Style

Nouf Al Mutairi, Maha Al Farra. Post-partum urinary incontinence among Saudi women. IJMDC. 2017; 1(1): 5-10. doi:10.24911/IJMDC.1.1.2



Vancouver/ICMJE Style

Nouf Al Mutairi, Maha Al Farra. Post-partum urinary incontinence among Saudi women. IJMDC. (2017), [cited September 30, 2022]; 1(1): 5-10. doi:10.24911/IJMDC.1.1.2



Harvard Style

Nouf Al Mutairi, Maha Al Farra (2017) Post-partum urinary incontinence among Saudi women. IJMDC, 1 (1), 5-10. doi:10.24911/IJMDC.1.1.2



Turabian Style

Nouf Al Mutairi, Maha Al Farra. 2017. Post-partum urinary incontinence among Saudi women. International Journal of Medicine in Developing Countries, 1 (1), 5-10. doi:10.24911/IJMDC.1.1.2



Chicago Style

Nouf Al Mutairi, Maha Al Farra. "Post-partum urinary incontinence among Saudi women." International Journal of Medicine in Developing Countries 1 (2017), 5-10. doi:10.24911/IJMDC.1.1.2



MLA (The Modern Language Association) Style

Nouf Al Mutairi, Maha Al Farra. "Post-partum urinary incontinence among Saudi women." International Journal of Medicine in Developing Countries 1.1 (2017), 5-10. Print. doi:10.24911/IJMDC.1.1.2



APA (American Psychological Association) Style

Nouf Al Mutairi, Maha Al Farra (2017) Post-partum urinary incontinence among Saudi women. International Journal of Medicine in Developing Countries, 1 (1), 5-10. doi:10.24911/IJMDC.1.1.2