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Female urinary incontinence in Tashkent (Uzbekistan): prevalence and risk factors
Section 8. Medical science
Abdurizaev Abdumalik Abdugaffarovich, E-mail: dr.abdurizaev@mail.ru Gaybullaev Asilbek Asadovich, E-mail: gaybullaiev52@mail.ru Sarimov Farruf Soatalievich, Tashkent Institute of Postgraduate Medical Education
E-mail: s.farrux@mail.ru
Female urinary incontinence in Tashkent (Uzbekistan): prevalence and risk factors
Abstract:
Purpose: To evaluate prevalence and character of urinary incontinence (UI) in women and to analyze the risk factors of the urinary incontinence in Tashkent.
Material and Methods: In this population study performed by cluster-typological method, the data from 2052 women obtained with use of questionnaire cards including Bristol Female Lower Urinary Tract Symptoms questionnaire were analyzed.
Results: The study performed showed that prevalence of UI in women at age 18 years and older accounts for 30 %. In the structure of diseases the stress UI appeared to be prevailing because uncontrolled urination occurred in physical loading in 52.3 % of women. The urgent UI was noted in 15.1 % of women, and the mixed type of UI was in 32.6 %.
The menopause has the most unfavorable effect on the development of urinary incontinence: the chance ratio (CR) was 6.1 (95 % CI 4.31-8.72). The rather high chance in the development of UI has obesity with CR 5.4 (95 % CI 3.0-9.61), constipations — CR 3.5 (95 % CI 2.43-5.04). The number of deliveries and abortions contributed significantly to the integral indicator characterizing chance for development of UI in women: CR 1.5 (95 % CI 1.23-1.73) and CR 1.3 (95 % CI 1.08-1.55).
Conclusion: UI is found almost in the third of uzbek women. Understanding of the nature and risk factors of UI will allow to allocate resources required for treatment and to provide prophylactic measurements in the future.
Keywords: urinary incontinence, prevalence, risk factors.
Urinary incontinence is one of the important problems in the urology, which results the patients in social des-adaptation, worsen the quality of life of the patients, induces psychoemotional discomfort. The patients frequently have complaints on depression, irritability which consequently lead to the disturbance of psychological climate in the family and at the work [1, 356-357; 2, 410].
To the present moment the great number of epidemiological investigations have been performed, and all they have different indicators of the prevalence of UI that attributed to various approaches to the determination of urinary incontinence, various characteristics of special population and, at last, various methods of information collection (post questionnaires, personal interview and clinical assessment). The parameters of UI prevalence varies from 12 % to 53 % in the review of 48 epidemiological investigations [3; 4].
Now it is known about many risk factors of the UI development. However, there are differences with regard to ethnical attribution and cultural-everyday life conditions [4, 23-26; 5, 887-892]. Consequently, the growth of interest to the race and ethnical differences of the risk factors of UI is natural. Absence of the epidemiological data about prevalence of urinary incontinence among women of Uzbek nationality made us to perform population investigation among the women above 18 years and more in Tashkent. The purpose of this investigation was to determination of prevalence and character of urinary incontinence in women and analysis of the risk factors connected with urinary incontinence.
Material and methods
Epidemiological study has been carried out by cluster-typological method. The bases for clinical researches were
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Section 8. Medical science
chosen on one territorial site of the central polyclinics of Shaikhantokhur and Khamza district of Tashkent. The women older than 18 years living in the territory of chosen sites were examined by the continuous method.
In total 2100 respondents underwent interview forming reliable representative sample of general set. From the returned cards of questionnaires 48 (2.3 %) were recognized as ineffective and were excluded from the subsequent analysis.
Card of questionnaire
The card of questionnaire consisted of three parts. The first part was designed for an estimation of the social status of the women, medical and obstetric histories: age, marital status, education, sort of working activity, number of labors and their character, height and weight, operative interventions on the abdominal cavity and small pelvis, chronic diseases, long receiving of medicines, presence recurrent infection of the urinary tract, presence of harmful habits, such as smoking, abusing by alcohol and coffee, presence of enuresis in the history of the nearest relatives, presence of menopause and use of estrogen replacement therapy. The second part was directed on definition of frequency, type and severity of urinary incontinence and its impact on the quality of life. The third part was developed for fixation of the results of urine examination and for ultrasonic scanning of bladder in the women having presence of urinary incontinence.
Definitions
Urinary incontinence at effort was defined as involuntary urine outflow at physical load, cough or sneezing.
Urgent urinary incontinence was determined as involuntary urine loss occurring immediately after urgent desire to urination.
When the respondents marked the symptoms of urinary incontinence at effort and urgent incontinence the UI mixed type was established [6, 167-178].
Estimation of urinary incontinence
In our research we defined urinary incontinence as more, than one episode of involuntary loss within one month. Such definition is used in the majority of previous researches of this type [4, 10-11; 5, 887-892]. To reveal the urinary incontinence among the studied contingent we applied the standard questionnaire Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaire, which was actively recommended (Grade A) at the fourth international meeting on urinary incontinence [7, 377-378], as the tool of an estimation of urinary incontinence in women. This questionnaire was translated previously to Uzbek and has passed validation.
At first we investigated prevalence of UI. Then from the women, included into the study according to the design of research “case — control”, there were selected two similar (by parameters and symptoms) groups — group 1 presented the women suffering from urinary incontinence (case) and group 2 — the women without urinary incontinence (control).
The xi-square the test was used for comparison of prevalence of various characteristics among the both groups and for an estimation of the probable factors connected
with UI. For revealing risk factors determining integrated risk of UI development in the women we used the multiple logistic regressive analysis. The factors connected with incontinence (P < 0.01) at simple regress were included into multivariational model. The results were presented as the ratio of chances (CR) with 95 % confidential interval. All analyses were made using a package of the statistical programs “R-project”. The level Р lower than 0.05 was considered as statistically significant difference.
Results
The average age of the women including in research was 39.4 ± 14.5 (min 18, max 88). The majority of the women — 1974 (96.2 %) were married, 7 (0.3 %) were single, 31 (1.5 %) were in divorce or widows. Initial education was in 406 (19.8 %) respondents, secondary — in 663 (32.3 %), secondary special — in 595 (29 %), higher education in 364 (17.7 %) of interviewed, without education 24 (1.2 %) women appeared to be. The most part of interviewed, 1225 (59.7 %), were working women, housewives were 404 (19.7 %), pensioners — 294 (14.3 %), and students — 129 (6.3 %).
The majority of the interviewed were childbearing women. Among them the great share seemed to include the women having from 3 up to 5 children — 981 (of 47.9 %), 1-2 children were in 599 (29.2 %), more than 5 children were in 337 (16.5 %) women who have been included into this study, and at last, 132 (6.4 %) women had no children at the moment of interviewing.
The study performed showed that the prevalence of urinary incontinence in women from Tashkent at the age above 18 years accounted for 30 %. The urinary incontinence at physical load formed the most part and was noted in 52.3 % of the women suffering from urinary incontinence. The urgent urinary incontinence was found in 15.1 % from the total number of the women with urinary incontinence, and in 32.6 % of the persons the mixed type urinary incontinence was revealed.
It is necessary to note, that through to 70-year-age the prevalence of UI increased. In the age category older than 70 years there was noted reduced number of the patients suffering from UI, but for this age there was characteristic more than two multiple prevalence of the mixed type UI in comparison with the rest its types. In the younger age categories the stress type of urinary incontinence was prevailed, though the tendency to growth of the mixed type UI was steady.
At the estimation of UI duration it was established, that the overwhelming majority of the women, 387 (62.8 %), have noted, that the suffered during the period from 1 till 5 years. In 20 (3.2 %) women there was noted occurrence of UI during the last year; 186 (30.2 %) women were bothered from UI from 5 till 10 years, and 23 (3.7 %) women — during 10 years and more.
The most part of the women suffering from urinary incontinence noted urine loss 1 time per one week or less often. Such periodicity of incontinence was revealed in 43.3 % of the patients, 2-3 times urine loss per one week was found in 19.6 %, 1 time per one week — in 13.3 %, some times per day — in 19.5 % and is constant — in 4.2 % of the patients.
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Female urinary incontinence in Tashkent (Uzbekistan): prevalence and risk factors
The volume of the urine lost was characterized as insignificant in 352 (57,1 %) patients, moderate in 194 (31.5 %), and 70 (11.4 %) persons have noted urine loss in a large volume.
The analysis of the social factors of life of the women who have been included into this study (Table 1) showed
that under the marital status the patients with UI differed from the women without UI. Thus, single among the women who are not suffering from UI, have appeared to be 9,4 times more, than among the women with UI (p = 0.0005).
Table 1. - Comparison of social-living factors of women with and without urinary incontinence
Control (n =) Case(n =) x2 P value
Marital status
Married 593 (96.3 %) 1312 (91.4 %) 14.8 0.0007
Single 4 (0.65 %) 88 (6.1 %) 28.95 0.0005
Divorced/widow 36 (2.5 %) 19 (3.1 %) 32.1 0.0005
Education
Initial 128 (20.8 %) 302 (21%) 0.0052 0.94
Secondary 181 (29.4 %) 482 (33.6 %) 3.26 0.07
Secondary special 177 (28.7 %) 418 (29.1 %) 0.01 0.91
High 130 (21.1 %) 234 (16.3 %) 6.5 0.01
Occupation
Housewife 40 (6.5 %) 154 (10.7 %) 8.5 0.0044
Retired (pensioners) 153 (24.8 %) 142 (9.9 %) 77.05 0.0005
Working 415 (67.4 %) 1019 (71 %) 2.47 0.116
Student 8 (1.3 %) 121 (8.4 %) 35.97 0.0005
In group of the patients with UI the women having higher education were 1.3 times more than in group of the women without UI. With regard to the other educational levels in both groups the women were distributed equivalently.
The analysis of working activity has revealed, that the greatest difference in compared groups was noted among the pensioners, which was 2.5 times more among the women with UI, and among the students, which, on the contrary, were 6.5 times more
among the women who are not suffering from UI. It was interesting that with regard to the number of the working women in the compared groups the differences were practically not.
We also have studied obstetric-gynecological histories ofthe interviewed women. As it may be seen from the data presented (Tab. 2), in the patients with UI the number of the women, having 3 deliveries and more accounted for 74 % that was 1.5 times more, than at the women without urinary incontinence.
Table 2. - Comparison of the characteristics of the obstetric-gynecological histories in the women with and without urinary incontinence
Control Case x2 P value
Vaginal delivery
No 104 (7.2 %) 22 (3.6 %)
1-2 608 (42.3 %) 138 (22.4 %) 0.024 0.87
3 and more 724(50.4 %) 456 (74 %) 21.11 0.0005
Abortions
No 1209 (84.2 %) 450 (73.1 %)
1-2 211 (14.7 %) 148 (24 %) 27.47 0.0005
3 and more 16 (1.1 %) 18 (2.9 %) 9.84 0.0026
Complicated deliveries
No 1340 (93.3 %) 558 (90.6 %)
Yes 96 (6.7 %) 58 (9.4 %) 4.29 0.0395
Caesarean section
No 1410 (98.2 %) 594(96.4 %)
Yes 26 (1.8 %) 22 (3.6 %) 5.1 0.024
Menopause
No 1276 (88.9 %) 288 (46.7 %)
Yes 160 (11.1 %) 328 (53.3 %) 419.29 0.0005
The results ofthe analysis have shown, that among the women suffering from UI, complicated deliveries (the application of obstetric forceps, episiotomy and others) were noted 1.4 times more often, than in the women without involuntary urine loss.
The number of the previous abortions was also differed in the women of compared groups. So, among the patients with UI the women having 1-2 abortion were 1.6 times more, than among the women without UI. This difference increase up
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Section 8. Medical science
to 2.6 times among the women having in the anamnesis 3 and more abortions.
From all interviewed women suffering from UI, 3.6 % underwent earlier operation Cesarean section, while
among the women without UI such patients were 2 times less. Among persons suffering from UI the women in menopause were 4.8 times more, than among the women without UI.
Table 3. - Comparison of the frequency of extra-genital diseases in the women with and without urinary incontinence
Control Case x 2 P value
Respiratory diseases
No 1381 (96.2 %) 573 (93%)
Yes 55 (3.8 %) 43 (7 %) 8.7 0.004
Diseases of the cardiovascular system
No 1394 (97.1 %) 592 (96.1 %)
Yes 42 (2.9 %) 24(3.9 %) 1.0 0.3
Arterial hypertension
No 1395 (97.1 %) 591 (95.9 %)
Yes 41 (2.9 %) 25 (4.1 %) 1.6 0.2
Diabetes mellitus
No 1418 (98.7 %) 591 (95.9 %)
Yes 18 (1.3 %) 25 (4.1 %) 15.2 0.0007
Obesity
No 1415 (98.5 %) 540 (87.7 %)
Yes 21 (1.5 %) 76 (12.3 %) 110.8 0.0005
Diseases of the thyroid gland
No 1428 (99.4 %) 611 (99.2 %)
Yes 8 (0.6 %) 5 (0.8 %) 0.1 0.7
Constipations
No 1357 (94.5 %) 511 (83%)
Yes 79 (5.5 %) 105 (17%) 70 0.0005
Varicose disease
No 1390 (96.8 %) 609 (98.9 %)
Yes 46 (3.2 %) 7 (1.1 %) 6.5 0.01
Diseases of nervous system
No 1413 (98.4 %) 582 (94.5 %)
Yes 23 (1.6 %) 34(5.5 %) 23.1 0.0005
Diseases of the urinary system
No 1400 (97.5 %) 599 (97.1 %)
Yes 36 (2.5 %) 17 (2.9 %) 0.03 0.9
Traumas of the spine
No 1427 (99.4 %) 605 (98.2 %)
Yes 9 (0.6 %) 11 (1.8 %) 4.9 0.03
As it is visible from the table 3, in which there was presented the frequency of extra-genital diseases in the women, who were included into this study, respiratory diseases, diabetes mellitus, obesity, constipations, diseases of nervous system were found more often in the patients with UI. Thus the largest difference in compared groups was with regard to the number of the women with obesity, who appeared to be among the patients with UI 8.2 times more than among the women without UI. Diseases of nervous system, chronic colitis and diabetes mellitus in the patients with UI were met more than 3 times more often, than in the women without UI.
The results of multiple logistic regressive analysis are presented in the Table 4.
The most unfavourable impact on the development of UI the menopause had: the ratio of chances (CR) — 6.1 (95 % CI 4.31-8.72). The obesity contributes rather high chance to the development of UI — CR 5.4 (95 % CI 3.0-9.61), the constipation showed CR 3.5 (95 % CI 2.43-5.04). The number of deliveries and abortion showed the significant impact in the integral indicator characterizing chance for development of UI in women: CR 1.5 (95 % CI 1.23-1.73) and CR 1.3 (95 % CI 1.08-1.55), respectively.
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Female urinary incontinence in Tashkent (Uzbekistan): prevalence and risk factors
Table 4. - The factors associated with urinary incontinence in women
Factors OR Standart error Р Confidence interval
min max
Age 1.013159 0.0062998 0.036 1.000887 1.025582
Occupation 1.064536 0.0602464 0.269 0.9527686 1.189415
Vaginal delivery 1.461971 0.1295343 0.000 1.228911 1.739232
Abortions 1.299731 0.1188284 0.004 1.086506 1.554802
Diabetes mellitus 1.63531 1.0324 0.436 0.4744839 5.636102
Obesity 5.376775 1.593982 0.000 3.007304 9.613165
Constipations 3.503397 0.65194 0.000 2.432714 5.045309
Diseases of nervous system 1.076437 0.1538856 0.606 0.8133964 1.424541
Caesarean section 0.8151558 0.3143906 0.596 0.3827788 1.735935
Complicated deliveries 1.315972 0.2787864 0.195 0.8688029 1.993298
Menopause 6.136008 1.103466 0.000 4.313308 8.728937
Discussion. The urinary incontinence remains to be the important problem touching the women of all ages, various cultures and races. Chan et al. (1991) [8, 326-328] informed, that only 4.8 % from 919 elderly women in Singapore suffered from urinary incontinence; Kondo et al. (1990) [9, 330-331] showed that 27.1 % of the women living in Japan had urinary incontinence at effort. In research including Chinese women at the age above 18 years living in Hong Kong, Ma S. S. (1997) [10, 327-331] reported, that 34 % of the women noted, at least, one episode of UI and 18.5 % of the women had constant urinary incontinence. According to the data of С. Hampel et al. (1997) [3, 3-12], G. Aggazotti et al. (2000) [11, 245-249], prevalence of symptoms of UI in the USA achieved 37 %, in the continental Europe — 26 %, in England — 29 %.
As, it is visible, the data on prevalence of urinary incontinence are differed. But the common opinion of all researchers is that urinary incontinence is the widespread disease. Our study showing that almost the third of the interviewed women suffer from urinary incontinence is one more confirmation of this situation. Moreover, according to our data the incidence of urinary incontinence increases with age, that will be coordinated to the literary data. Simeonova Z. et al. (1999) [12, 546-551] showed increase of incidence of urinary incontinence from 3 % in the age of20-29 years up to 32 % in an age category of the women more than 80 years.
From the majority of epidemiological studies of UI among the various population it is known about many risk factors of this disease at the woman. Some chronic diseases, such as diabetes mellitus, hypertension and constipation increase the risk id urinary incontinence occurrence [13, 634-641]. In our research obesity and constipations caused high chance of development of urinary incontinence in the women.
Uzbekistan is region with traditionally high birth rate. And consequently for us the special interest is given to the influence obstetric-gynecological histories on the development of urinary incontinence in the women.
According to data of Song Y. et al., (2005) [5, 887-892] more than 2 kinds are risk factors for development of urinary incontinence. Rortveit et al. (2003) [14, 900-907] informed,
that in comparison with non-parous women the risk of UI was higher among the women, which had Cesarean section and more above among the women, who had vaginal delivery.
The study performed has also confirmed, that vaginal deliveries increased risk of occurrence of UI. But Cesarean section had no impact on the development of urinary incontinence. Besides, on our data, it was appeared, that the abortions raise risk for development of urinary incontinence in the women, though in the earlier studies performed we did not meet the evidences about relations between abortion and occurrence of urinary incontinence. Probably, sharp body hormonal reorganization occurring in connection with interruption of pregnancy in the further effects on the mechanisms of urinary incontinence.
The most unfavourable influence on the development of UI in our research menopause showed. These data will be coordinated to the data received by Victor W. N. (2001) [15, 52-56] and Apolikhina I. A. (2006) [4, 16-17].
At the same time the study performed research has shown, that cultural features of the studied population exclude practically the influence of harmful habits, such as smoking, abusing by alcohol and coffee, which accordingly to the data of epidemiological studies performed in the other countries were significant risk factors for development of UI [4, 15-16; 5, 887-892].
According to the data of Mary H. P. et al. (1999) [16, 67-82] development of urinary incontinence in the women is connected to age. However, multiple regressive analysis performed by us has shown that the age had no significant impact on the value of integral indicator characterizing chance for development of urinary incontinence. This is evidently indicated that the increase of incidence of UI with age is caused, mainly, by greater prevalence of menopause and other diseases in the woman, which present prognostic status.
Conclusion. Thus, the study performed has shown that UI in the women of the Uzbek nationality is the widespread disease and meets at 30 % of the women.
The results obtained can be recommended for use as prognostic factors during performance of the mass prophylactic
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Section 8. Medical science
examinations and selection of the contingent of patients The understanding of a nature and risk factors of UI will
requiring differential therapeutic-prophylactic measures for allow to plan allocation of the resources required for treatment
strengthening health of the female population. and to supply preventive measures in the future.
References:
1. Alayev Yu. G., Balan V. E., Gadjieva Z. K. The prevalence of imperative disorders of urination among the women above 40 years.//Meeting of All-Russian Society of Urologists: Abstracts of the Reports. - Tyumen, 2005. - Р. 356-357.
2. Trapeznikova M. F., Dutov V. V., Bichkova N. V., Golovchenko K. V. Epidemiology of the hyperactive bladder in Moscow province. Materials of the Plenary session of the Authorities of the Russian Society of Urologists. - Tyumen, 2005. - P. 410.
3. Hempel С., Wienhold D., Benken N., Eggersmann C., Thuroff J. W. Preva-lence and natural history of female incontinence. //Eur urol. 1997. - 32: 3-12.
4. Apolikhina I. A. Clinical epidemiology, differential diagnostics and conservative treatment of urinary incontinence in the women. Abstract of Thesis. Dis. ... for scient.degree Doctor of Medical Sciences: 14.00.01. - Moscow, 2006.
5. Song Y., Zhang W., Song J., Xu B. Prevalence and risk factors of urinary incontinence in Fuzhou Chinese women.//Chinese Medical Journal, 2005. - Vol. 118. - No. 11: 887-892.
6. Abrams P., Cardozo L., Fall M., Griffiths D., Rosier P., Ulmsten U., van Kerre-broeck P., Victor A., Wein A. The Standardisation of Terminology of Lower Urinary Tract Function Neurourol. - Urodyn 21:167-178. - 2002.
7. Abrams P., Cardozo L., Khoury S., Wein A. Incontinence, 4th edition, 2009. - Р. 377-378.
8. Chan C.J., Lee K. S., Merriman A., et al. Urinary incontinence among the eld-erly people of Singapore. - Age Aging, 1991. - 38: 326-328.
9. Kondo A., Kato K., Saito M., et al. Prevalence of hand-washing urinary incon-tinence in females in comparison with stress and urge incontinence.//Neurourol Urodyn. - 1990. - 9: 330-331.
10. Ma S. S. The prevalence of adult female urinary incontinence in Hong Kong Chinese.//Int Urogynecol J. - 1997. - 8: 327-331.
11. Aggazzotti G., Pesce F., Grassi D. et al. Prevalence of urinary incontinence among institutionalized patients: a cross-sectional epidemiologic study in a midsized city in northern Italy.//Urology. - 2000. - Vol. 56. - No. 2. - P. 245-249.
12. Simeonova Z., Milsom I., Kullendorff A. M., et al. The prevalence of urinary incontinence and its influence on the quality of life in women from an urban Swedish population. Acta Obstet Gynecol Scand. - 1999. - 78: 546-551.
13. Kocak I., Okyay P., Dunbar M., Erol H., Beser E. Female urine incontinence in the west Turkey: prevalence, risk factors and impact on quality of life//European Urology. - 2005. - Vol. 48. - P. 634-641.
14. Rortveit G., Daltveit A. K., Hannestad Y. S., et al. Urinary incontinence after vaginal delivery or cesarean section.//N Engl J Med. - 2003. - 348: 900-907.
15. Victor W. Nitti. The Prevalence of Urinary Incontinence.//Rev Urol. - 2001. - 3 (Suppl 1): 52-56.
16. Mary H. Palmer, Sheila Fitzgerald, Susan J. Berry, Kristin Hart. Urinary Incontinence in Working Women: An Exploratory Study.//Women and Health. - July 1999. - Volume 29, Issue 3. - P. 67-82.
Azizova Feruza Lyutpillaevna, Tashkent medical academy, PhD, Department of Hygiene of children, adolescents and nutrition, Associate Professor E-mail: feruzaziz@mail.ru
Hygienic estimaton of allocation of schools and planning of district of boarding schools in Tashkent city
Abstract: Hygienic estimation of training and education of children and teenagers in a variety of specialized boarding schools.
Keywords: specialized boarding schools, children, teenagers, education and teaching condition.
The development of effective technologies of health protection of women and also children and teenagers, as a period of growth and development of the child related to important period which determining the condition of human health during the whole to subsequent life were related to the numbers of priority directions of the development of medical
sciences in the Republic of Uzbekistan to the period until 2018. Hygienically adequate environment with other factors is important supposition of protection and strengthening of the health and development of children. Thereupon a condition of education and upbringing of children in organized collectives, in which during this period located a great deal of children are
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