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Forum Singlewomenadultservice U C Single Women Adult Service Videos De Jupiter The Planets Gustav Holst Single Women Adult Service Prevalence and risk factors of urinary incontinence in Fuzhou Chinese women

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METHODS

The study was a large survey in the city of Fuzhou, which is located in southern China. The study had approval of the ethics committees in Fuzhou and all participating women provided written informed consent. The female population aged 20 years or more, living in Fuzhou at the time of this study, was 200203. We randomly sampled 3.0% of these female residents by using information from a national census record. The distribution of ages in our cohorts was consistent with a report released in 2001 from Fuzhou Bureau of Population Census.

Each woman received a mailed questionnaire. The questionnaire consisted of two parts: part one included questions about participants' age, marital status, employment, weight, height, menstrual status, number of previous gestations, vaginal deliveries and Caesarean sections, child birthweight, history of chronic disease (diabetes, hypertension); part two was the Bristol Female Lower Urinary Tract Symptoms (BFLUTS) Questionnaire. BFLUTS questionnaire is a structured questionnaire, which covers all aspects of female lower urinary tract dysfunction.［4］ The questionnaire, which was obtained from Bristol Urological Institute, was translated into Chinese by ourselves. To access accuracy, reverse translation was then performed by an independent agent. The questions were validated by thirty local speakers who were fluent in English, all of whom confirmed that it was easily understood and accurately translated. A pilot study of 20 cases was carried out before the survey took place to ensure the validity of the questionnaire. A test and retest were conducted with a two week interval between tests. The correlation coefficient for part 1 of the questionnaire was r=0.92 (P<0.05) and for part 2 was r=0.88 (P<0.05).

All participants filled out questionnaires by themselves. Health care providers went to participants' homes to retrieve the questionnaires two weeks after distribution. Completely answered questionnaires were actively sought during data collection, to assemble an accurate cross sectional cohort and minimize the likelihood of response bias.

In this study, a woman had urinary incontinence if she replied ‘yes' to the question “Have you had any involuntary urinary loss during the last month?” Stress urinary incontinence (SUI) was defined as involuntary urine leakage when exercising physically. The question about SUI asked in the questionnaire was “Does urine leak when you are physically active, exert yourself, cough or sneeze?” Urge incontinence (UUI) was defined as involuntary urine loss following a sudden urge to void or uncontrollable voiding with little or no warning. The questions about UUI asked in the questionnaire were “Do you have to rush to the toilet to urinate? Does urine leak before you can get to the toilet?” When the respondents acknowledged both symptoms of stress and urge incontinence, the category of mixed incontinence was assigned.

Using these definitions, we then examined characteristics associated with stress incontinence and urge incontinence. Age was considered as a continuous variable in 10 year cohorts, beginning with age 20. Body mass index (BMI) was defined as weight in kilograms divided by square of height in metres. We defined 2 BMI categories: underweight (BMI<75th percentile), overweight (BMI≥75th percentile). A participant was a cigarette smoker if she reported current tobacco use. Women were asked to report their obstetric parity and the route of delivery for each birth. Thus, for each subject, we knew their parity, the number of vaginal births and the number of Caesarean births. For route of delivery, we defined two groups: women who had delivered only by Caesarean section (the Caesarean delivery only group), and women who reported at least one vaginal delivery (the vaginal delivery group). The vaginal delivery group included a small number of women who had also delivered at least one infant by Caesarean delivery. Women in vaginal delivery group were also asked to report if they had had an episiotomy during the second stage of labour.

Chi-square tests were used to compare the prevalence of difference types of symptoms among birth cohorts and to evaluate factors possibly associated with urinary incontinence. Multivariable logistic regression analysis was used to control for possible confounding variables and to determine the independent association between risk factors and urinary incontinence. Variables associated with urinary incontinence (P<0.01) in univariate models were entered into multivariate models. Results are presented as odds ratios with 95% confidence intervals. All analyses were performed using SPSS v11.5 software. A P value of less than 0.05 was considered statistically significant.

RESULTS

Of the 6066 questionnaires mailed, 4745 (78.2%) were returned and 4684 (98.7%) women with complete data were included in this study. There were no differences in age or profession between the population and our sample. The response rates were not significantly different among each of the birth cohorts. All the subjects were of the Han ethnic group, the principal ethnic group (about 93 percent) of the Chinese population.

The characteristics of the study subjects are shown in Table 1 . Their average age was 40.0±11.1 years. Most of the women who had no educational background (128, 13.1%) were older than 60 years. The BMI in this study was 21.9±3.0 kg/m2. The average parity was 1.1±0.8 (0-7) and 398 (8.6%) were nulliparous. There were 709 (15.1%) menopausal women and 877 (18.7%) women were unskilled workers.

The prevalence of three types of urinary incontinence is shown in Table 2 . The overall prevalence of stress incontinence, urge incontinence, and mixed incontinence was 16.6% (n=777), 10.0% (n=468), 7.7% (n=360), respectively. The prevalence of the three types of urinary incontinence in the 20 to 29 year cohort was significantly lower than that of the older age groups. In this cohort, stress incontinence was 8.9% (P<0.05), urge incontinence was 6.9% (P<0.05), mixed incontinence was 4.3% (P<0.05). The prevalence of the three types of urinary incontinence increased significantly with aging (P<0.01). In the 20 to 29 year cohort, there was no significant difference between stress incontinence and urge incontinence (P>0.05). In all other cohorts, the difference was significant between stress incontinence and urge incontinence (P<0.05). The analysis of risk factors of urinary incontinence is shown in Table 3 . The risk factors that might predispose women to stress urinary incontinence and urge incontinence were found after a univariate analysis. Menopause, vaginal delivery, Caesarean dlivery, parity (>2), constipation, alcohol consumption, higher BMI (≥75th percentile), unskilled worker, and a history of diabetes and hypertension were associated with increased occurrence of stress urinary incontinence. Similarly, menopause, vaginal delivery, Caesarean delivery, parity (>2), foetal birthweight, constipation, alcohol consumption, higher BMIs (≥75th percentile), unskilled worker, and a history of diabetes and hypertension were significantly associated with urge incontinence.

The results of a multiple logistic regression analysis are presented in Table 4 . In multiple logistic models, age (OR, 1.3, 95%CI, 1.1-1.4), vaginal delivery (3.0, 1.9-4.7), parity >2 (2.1, 1.5－2.9), hypertension (2.7, 1.4－5.6), constipation (2.6, 1.8-3.8), alcohol consumption (4.7, 1.1－20.2), episiotomy (1.7, 1.4－2.0), higher BMI (1.8, 1.5－2.2), and unskilled worker (0.7, 0.5－0.8) are potential risk factors for stress incontinence. Urge incontinence is associated with age (OR, 1.3, 95%CI, 0.9－1.3), menopause(1.6, 1.1－2.4), Caesarean delivery (0.2, 0.1－0.5), parity >2 (2.6, 1.8－3.8), constipation (2.3, 1.4－3.7), fatal birthweight(1.7, 1.1－2.4), episiotomy(1.4, 1.1－1.8), higher BMI (1.5, 1.2－2.0), and unskilled worker (0.7, 0.5－0.9).

DISCUSSION

Urinary incontinence remains a worldwide problem affecting women of all ages across different cultures and races. In our survey, urinary incontinence was selfreported and diagnosis was based on simple questions. Likewise, diagnosis of the type of UI and history of gynaecology were based on anamnesis. Thus, some misclassification may have occurred. One strength of this survey is that data was obtained from almost all of a large sample of a single community. Ideally, a high response rate from populations sampled in a certain geographical location does estimate the prevalence of UI more accurately than samples with a low response rate taken from doctors' offices.

The range of prevalence among the published studies is wide. This variation could be due to differences in definitions used, population surveyed, survey type, response rate, age and other factors.［5,12］ Five definitions of urinary incontinence have been used in the literature. These definitions include any UI in the previous 12 months (Definition Ⅰ), more than one episodes of UI in a month (Definition Ⅱ), two or more episodes of UI in a week (Definition Ⅲ), involuntary UI that is a social or hygienic problem and is objectively demonstrable (Definition Ⅳ), and any UI, past or present (Definition Ⅴ).［13］According to BFLUTS questionnaire, we defined urinary incontinence as “more than one episode of UI in a month (Definition Ⅱ)” in our study. This definition is used in most of previous studies of this kind so that it facilitates comparison of results.

In Asia, Chan et al［9］ reported that only 4.8% of 919 elderly women were incontinent in Singapore; Kondo et al［14］ reported that 27.1% of Japanese community dwelling women experienced stress urinary incontinence. In a community based study of Chinese women aged 18 and older in Hong Kong, Ma［10］ reported that 34% of women experienced at least one episode of urinary incontinence and 18.5% of women had persistent incontinence. The target populations of Ma's study included 1018 females, but only 362 women were interviewed (response rate 35.6%). Chen et al［9］ reported that 53.7% of the women sampled in Taiwan suffered from urinary incontinence and related symptoms and 35.0% had urinary incontinence. In their community based survey, 1253 women were interviewed using the BFLUTS Questionnaire. However, BFLUTS questionnaire was originally designed to be mailed to the patient who completed it, so data collected from patients using interview could be biased.［11］ Prevalence estimates made by using mail surveys are especially lower than those made by using face to face interviewing.［15］ Fultz and Herzog showed that the use of an introduction and followup probe question about UI resulted in a doubling of the prevalence rate.［16］ Our study found that 19.0% of the women in Fuzhou had urinary incontinence. The prevalence of urinary incontinence in Fuzhou is higher than that (4.8%) reported in Singapore,9 lower than that (35.0%) reported in Taiwan, but it is similar to that (18.5%) reported by Ma in Hong Kong.［10］ In our study, the prevalence of stress urinary incontinence (16.6%) is specially lower than that of occidental females (50.0%),［13］ but similar to that (18.0%) of Taiwanese women reported by Chen et al.［9］ Based on the comparison of the pelvic supporting tissues of Chinese women with those of occidental females, Zacbarin claimed that stress urinary incontinence was extremely rare in Chinese women.［17］

In our study, the prevalence of three types of urinary incontinence increases steadily with age, which is consistent with some reports. Simeonova et al［18］ discovered a linear increase in the prevalence of urinary incontinence from 3% in the 20 to 29 year cohort to 32% in the cohort of women over 80 years. But there are conflicting opinions regarding the pattern of this increase. Harrison et al［19］ found an increase in prevalence of urinary incontinence with age up to the fifth decade of life followed by a decline thereafter.

From many epidemiologic studies on incontinence in various populations, a number of risk factors have been identified. Some chronic medical conditions, such as diabetes, hypertension and constipation also increase the occurrence of urinary incontinence. A univariate analysis and a multiple logistic regression analysis provided further information to show that risk factors predisposed the subjects to stress urinary incontinence and urge incontinence. Some evidence suggests that the risk of incontinence is increased after vaginal delivery compared with Caesarean delivery. Rortveit et al［20］ reported the risk of incontinence was higher among women who had Caesarean delivery compared with nulliparous women, and was even higher among women who had vaginal delivery. In our study, vaginal delivery increases the occurrence of stress incontinence (OR, 3.0, 95%CI, 1.9－4.7), but Caesarean delivery is associated with lessurge incontinence (OR, 0.2, 95%CI, 0.1－0.5). Our findings were not consistent with other reports, for example, Viktrup et al［21］ stated that Caesarean delivery protected against the development of stress incontinence after delivery. Whether this difference is a result of race, ethnicity, or cultural differences is difficult to determine and controversial. In addition, age, parity >2, hypertension, const-ipation, alcohol consumption, episiotomy, and higher BMI are potential risk factors for stress incontinence, and urge incontinence is associated with age, menopause, parity >2, constipation, foetal birthweight, episiotomy, higher BMI.