Original Article
Assessing quality of life of women with urinary incontinence using the Kings Health questionnaire Avaliação da qualidade de vida em mulheres com incontinência urinária pelo uso do Kings Health questionnaire João Bosco Ramos Borges1, Larissa Neri2, Rosa Maria Silveira Sigrist3, Larissa Oliveira Martins4, Telma Guarisi5, Ana Carolina Marchesini6
ABSTRACT Objective: To evaluate the quality of life of women with urinary incontinence, as well as its association with other demographic and socioeconomic factors that may influence their perception of quality of life. Methods: A total of 50 patients were submitted to the Kings Health questionnaire and to other independent scales to evaluate severity of urinary incontinence, as well as presence and intensity of urinary symptoms. Results: One third of women considered their health status bad or very bad. Half of the patients referred that urinary incontinence symptoms greatly affected their quality of life. Patients with symptoms of overactive bladder and mixed urinary incontinence presented statistically higher scores of quality of life in the domain “sleep/mood”. There was no statistical difference between the groups concerning other quality of life domains, sociodemographic factors, and the correlation between bladder problem and general health perception. Conclusions: Most women with urinary incontinence considered their health status from regular to very bad. The sociodemographic factors did not influence the quality of life of the patients studied. The Kings Health questionnaire showed a negative impact of urinary incontinence on patient’s quality of life. Keywords: Urinary incontinence; Urinary bladder, overactive/pathology; Urinary incontinence, stress; Quality of life; Questionnaires
RESUMO Objetivo: Avaliar a qualidade de vida em mulheres com incontinência urinária; e a associação de outros fatores demográficos e socioeconômicos que poderiam influenciar a percepção de qualidade de vida. Métodos: Cinquenta pacientes foram submetidas ao Kings Health questionnaire e a outras duas escalas independentes
para avaliar a gravidade da incontinência urinária, a presença e a intensidade dos sintomas urinários. Resultados: 1/3 das mulheres classificou seu estado de saúde como ruim ou muito ruim. Metade das pacientes referiu que os sintomas ligados a incontinência urinária afetaram muito a qualidade de vida. As pacientes com sintomas de bexiga hiperativa e incontinência urinária mista apresentaram escores de qualidade de vida estatisticamente maiores no domínio “sono e disposição”. Não houve diferença estatística entre os grupos em relação aos demais domínios de qualidade de vida, a fatores sociodemográficos, e na correlação do problema vesical com a percepção geral da saúde. Conclusões: A maioria das mulheres com incontinência urinária considerou sua saúde variando de regular a muito ruim. Os fatores sociodemográficos não influenciaram a qualidade de vida das pacientes estudadas. O Kings Health questionnaire evidenciou impacto negativo da incontinência urinária na qualidade de vida das pacientes. Descritores: Incontinência urinária; Bexiga urinária hiperativa/patologia; Incontinência urinária por estresse; Qualidade de vida; Questionários
INTRODUCTION Urinary incontinence (UI) is defined by the International Continence Society as the involuntary loss of urine, which is a social or hygienic problem(1) and may affect women at any age. The prevalence among adult women ranges from 17 to 45%(2-3), with serious social implications, causing discomfort, loss of self-confidence and negative interference in quality of life (QoL) of several females. Many women do not seek medical
Study carried out at Serviço de Uroginecologia do Ambulatório da Saúde da Mulher, Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil. Full professor of Gynecology at Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
1
Medical student at Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
2
Medical student at Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
3
Medical student at Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
4
PhD, Lecture at Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
5
6
Associate professor of Gynecology at Faculdade de Medicina de Jundiaí – FMJ, Jundiaí (SP), Brazil.
Corresponding author: João Bosco Ramos Borges – Rua Francisco Telles, 250 – Vila Arens – CEP 13202-550 – Jundiaí (SP), Brasil – Tel.: 4587-1095 – e-mail:
[email protected] Received on May 29, 2009 – Accepted on Jul 30, 2009
einstein. 2009; 7(3 Pt 1):308-13
Assessing quality of life of women with urinary incontinence using the Kings Health questionnaire
care for this condition(4), since they often believe that urinary loss symptoms do not demand care or are not sufficiently intense to disturb them; moreover, many patients have no free time to make an appointment with a specialist(5-6). UI represents a public health problem, considering the high cost of clinical or surgical treatment and limited activities in patients at economically active age. In the United States of America, UI accounts for approximately 2% of health expenses(7), corresponding to an estimate of over 16 million dollars per year(8). Besides being a public health problem, stress UI (SUI) markedly reduces the QoL of professional women, representing an economic obstacle to society(9). Some women understand UI as a natural evolution due to age; therefore, 30 to 50% of people with UI seek medical care only one year after onset of symptoms(10). Regardless the type of UI, the symptoms have negative effects in women’s life, mainly in terms of physical activities, self-confidence, self-perception and social activities(11). UI interferes directly in the activities of daily living of females and they present low QoL rates(12). Hence, when these individuals seek care, they already present low self-esteem and depression, are very anguished and disturbed by urinary loss. There is a need to raise awareness of women, mainly the menopausal ones, about the benefits of seeking medical treatment for UI, in order to improve their QoL(13). Although UI is not a life-threatening condition, it may lead to severe medical, social, psychological and economic implications, adversely affecting quality of life(14). There is an increasing interest in studying QoL in several fields of knowledge. Despite the fact that QoL is subjective, multidimensional and influenced by diverse factors related to education, economic and sociocultural aspects, no consensus has been achieved as to its definition. Nevertheless, most authors agree that the physical, social, psychological and spiritual domains must be addressed when assessing QoL, trying to get the personal experience of each individual(15). The QoL issues related to UI are assessed in many countries by means of questionnaires. Two of them have been translated into Portuguese and validated: the International Consultation on Incontinence questionnaire – Short Form (ICIQ-SF) and the Kings Health questionnaire (KHQ). However, when compared, the KHQ showed much reliability(16) and proved to be effective in the analysis of measurement properties(17). The ICIQ-SF was not considered for being simple, brief and presenting satisfactory reliability(18). Using the methodology to apply the KHQ, the objective of this study was to assess QoL of women who seek specialized care due to UI; as well as the association of other demographic and socioeconomic
309
factors that could influence the perception of patients about their QoL.
METHODS A descriptive case series study was carried out in a crosssection analysis of data of 50 patients seen/interviewed at the Urogynecology Section of the Woman’s Health Outpatient Clinic in Hospital Universitário de Jundiaí, from August to December 2006. The exclusion criteria were patients aged under 18 years old and those denying taking part in the study. During the application of the questionnaires, only one patient rejected participation, claiming she had not enough time. All patients included read and signed the informed consent form, which was previously approved as a project by the Research Ethics Committee of Hospital Universitário de Jundiaí. This study was performed thanks to the Scientific Initiation Grant from Programa Institucional de Bolsas de Iniciação Científica of the National Counsel of Technological and Scientific Development (PIBIC-CNPq). The interview was conducted in a reserved area using the KHQ that had been validated before. The KHQ comprises 21 questions, divided into eight domains: general health perception (one item), UI impact (one item), role limitations (two items), physical limitations (two items), social limitations (two items), personal relationships (three items), emotions (three items) and sleep/energy (two items). The KHQ has scores for each domain, ranging from 0 to 100; in that, the higher the score, the worst the QoL related to that domain(17). Two other independent scales were applied to evaluate severity of UI, as well as presence and intensity of urinary symptoms. These scales have four options as follows: “not at all”, “a little”, “moderately” and “a lot”; or “never”, “sometimes”, “often” and “always”. The exceptions were the domain general health perception with five choices (“very good”, “good”, “fair”, “bad” and “very bad”) and the domain personal relationships (“not applicable”, “not at all”, “a little”, “moderately” and “a lot”). The types of UI were classified according to the International Continence Society(1), and described as Overactive Bladder (OAB) Syndrome (presence of urinary urgency and/or urge incontinence symptoms); SUI (loss of urine during physical activity); mixed UI (MUI) (association of loss of urine under stress and urgency and/or urge incontinence). The data were described using mean, standard deviation, median and percentages. The Fisher’s exact test was used to assess difference and association among control variables, domains of the Kings and the SUI, OAB and MUI variables (since there were frequencies einstein. 2009; 7(3 Pt 1):308-13
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Borges JBR, Neri L, Sigrist RMS, Martins LO, Guarisi T, Marchesini AC
with n < 5. In the domains represented by means and medians, the Mann-Whitney or Student’s t-tests were used (when data distribution passed the KolmorovSmirnov normality test). In case of MUI, there were more than two categories and the Kruskal-Wallis test was applied, followed by the Mann-Whitney test or ANOVA. The significance level considered was 5%.
Approximately 50% of women reported their health status as regular at that moment and roughly one-third classified it as bad or very bad. As to interference of UI in their lives, 48% described as little or moderate interference and 50% as much interference. Only one patient mentioned that incontinence did not affect her life. Table 1 presents the distribution of patients according to their general health perception mentioned during the interview, and how much UI affected their lives. Approximately half of patients (42 to 56%) referred the symptoms of frequency, nocturia, urgency, urge incontinence, stress incontinence as interfering much in their QoL. On the other hand, recurrent infections and pain in the bladder were symptoms described by most patients as affecting little or moderately. Nocturnal enuresis, incontinence during intercourse and difficulty voiding were complaints of a minority of patients (Table 2). As to the type of UI and domains of QoL assessed, it was observed that patients with OAB and MIU symptoms presented scores significantly higher in the domain sleep/energy when compared to those complaining only urinary loss with physical exertion. In the other domains there were no statistically significant differences (Table 3). There were no statistically significant differences correlating the sociodemographic factors, such as age, schooling, marital status and professional activity, with general health perception by patients, as well as the same factors related to interference of the bladder problem in their life. Finally, the correlation between the vesical condition with general health perception at a certain moment was analyzed and there was no statistically significant association (Table 4).
RESULTS The mean age of the patients was 51 years. Most women had a partner (66%), were Caucasian (74%), and the higher schooling level was incomplete middle school (68%). Family income of up to five minimum wages was found in 92% of cases and over half patients were housewives. Table 1. Percentage distribution of patients according to health perception and impact of urinary incontinence Characteristics
n
%
Very good
1
2
Good
8
16
Regular
24
48
Bad
10
20
Very bad
7
14
Not at all
1
2
Little
13
26
Moderately
11
22
Much
25
50
Health status now
Health problem affecting life
Table 2. Percentage distribution of women according to interference of urinary symptoms in quality of life Symptoms
Little
Moderately
Much
Absence of symptom
n
%
n
%
n
%
n
%
Increased urinary frequency
7
14
12
24
28
56
3
6
Nocturia
13
26
7
14
21
42
9
18
Urgency
9
18
4
8
26
52
11
22
Urge incontinence
11
22
7
14
21
42
11
22
Stress incontinence
9
18
11
22
21
42
9
18
Nocturnal enuresis
5
10
5
10
8
16
32
64
Incontinence during sexual intercourse
4
8
3
6
6
12
37
74
Frequent urinary infections
7
14
10
20
10
20
23
46
Pain in bladder
12
24
8
16
11
22
19
38
Difficulty voiding
4
8
3
6
6
12
37
74
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Table 3. Correlation between type of urinary loss complaint and QoL scores per King’s Health questionnaire domains (n = 48) Variables Limitations in daily activities Frequency Mean ± SD Median Physical limitations Frequency Mean ± SD Median Social limitations Frequency Mean ± SD Median Personal relationships Frequency Mean ± SD Median Emotions Frequency Mean ± SD Median Sleep and energy Frequency Mean ± SD Median Severity measures Frequency Mean ± SD Median Kruskal-Wallis test
OAB
SUI
MUI
7 59.5 ± 30.2 50
3 33.3 ± 57.7 0
38 49.1 ± 41.5 50
7 47.6 ± 29.6 50
3 27.8 ± 50.9 16.7
38 49.1 ± 41.5 50
7 50.8 ± 33.3 55.6
3 18.5 ± 32.1 0
38 36.1 ± 33.6 33.3
7 7.14 ± 48.9 0
3 44.4 ± 50.9 33.3
38 25.4 ± 55.7 8.33
7 81 ± 18.9 77.8
3 33.3 ± 22.2 33.3
38 54.4 ± 37.8 50
7 71.4 ± 36.9 83.3
3 5.56 ± 9.62 0
38 53.1 ± 34.6 50
7 56.2 ± 28.8 60
3 24.4 ± 15.4 33.3
38 60.2 ± 27.6 63.3
p-value 0.6771
0.3384
0.4279
0.6493
0.0633
0.0368*
0.0952
OAB: overactive bladder; SUI: stress urinary incontinence; MUI: mixed urinary incontinency.
Table 4. Correlation between general health perception upon interview and the bladder problem as affecting health (n = 50) Very good /good Bladder problems affecting life
Regular
n=9 FR
Bad
n = 24 %
FR
Very bad
n = 10 %
n=7
FR
%
p-value
FR
%
Not at all/a little
3
33.3
9
37.5
1
10
1
14.3
Moderately
3
33.3
6
25.0
1
10
1
14.3
Much
3
33.3
9
37.5
8
80
5
71.4
0,3080
Fisher’s exact test; FR: frequency.
DISCUSSION The KHQ is considered a complete questionnaire that assesses both the impact of incontinence in different aspects of QoL, and the low urinary tract symptoms perceived by patients(19-20). The International Continence Society classifies the questionnaire as “highly recommendable”, or level “A” to use in clinical research, mainly due to its popularity and for the fact of being already translated into and validated in other languages(21). The present study included patients referred by the primary healthcare network to the Urogynecology Outpatient’s Clinic due to any type of urinary complaint with no selection as to severity. Likewise, Tamanini et
al.(17), in the study to validate the KHQ, based on clinical complaints of patients presented to gynecologists or internal medicine physicians working at primary healthcare units. The same pattern to select patients has been reported by other authors in the literature(22). Like the study by Tamanini et al.(17), the present one may be limited by the predominance of patients from intermediate and low socioeconomic brackets. Thus, such patients could present some limitations in understanding the questions. Moreover, our sample population had low schooling levels. Some other factors, such as age and amount of urinary loss, could also be responsible for differences in personal behavior einstein. 2009; 7(3 Pt 1):308-13
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towards UI(11). However, even considering the individual variations, it is known that – to a small or great extent – UI and its associated symptoms can have negative effects not only in physical health but also in emotional and psychological aspects(23). Another possible limitation of the study is the moment the patients were interviewed, that is, when they arrived at the service to receive treatment, which could lead to valuing more the urinary complaint. Hence, the majority reported their health status from regular to very bad, and considered the problem of urine loss as moderately to severely affecting their lives. The symptoms of frequency, nocturia, urgency, urge incontinence and losses upon exertion were mentioned as causing much impact in QoL. On the other hand, pain and recurrent urinary infection were less important. Similar results were demonstrated in a previous study conducted in Brazil(20). Other literature reports show that UI associated with increased urinary frequency, nocturia and urgency led to poorer scores in the KHQ domains involving physical and housekeeping activities, social relationship, sleep and energy in most women(20,24). Different from North American women with UI who reported social relationship as the most affected area(25), for the patients of the present study it was the domains of emotions and sleep. Such discrepancy may be explained by differences in socioeconomic and schooling levels, as well as in paid work among these populations. Nonetheless, UI impacts in social life, resulting in restrictions regarding going to public places, traveling, sleeping out and even visiting friends(14). This is related to the fact that incontinent women – be them cases of nocturia, urgency or urge incontinence – avoid going out. They are ashamed of having the symptom and fear perception of urine odor; moreover, they do not know if they will find an appropriate place for voiding and personal hygiene, in case of urinary loss(11,26). The impact of incontinence in women’s QoL has been much studied(27-30), but there are scarce data on difference among the types of incontinence. In this study, it was observed that patients with OAB and MUI had a significantly higher score in the domain ‘sleep and energy’ when compared to those with complaint of urinary loss upon exertion. This was expected considering that OAB symptoms include nocturia, enuresis, primarily urgency and urge incontinence. These symptoms make patients wake up at night several times to urinate, making it difficult to fall asleep again since most are in the perimenopausal period. Although not differentiating the type of UI, a recent publication showed that 63% of patients studied felt tired for not having a good sleep pattern due to the fact of waking einstein. 2009; 7(3 Pt 1):308-13
up at night to void(20), which corroborates the findings of the present study. When trying to identify to what extent incontinence affects the life of patients and to compare it to some sociodemographic factors, no significant differences were found, probably because it is a sample of patients with similar characteristics. The present findings demonstrated that UI symptoms, whether associated or not with other urinary complaints, presented a negative impact in these women’s QoL. These results emphasize the need of healthcare professionals to address this problem. Furthermore, primary and secondary healthcare services should organize multidisciplinary teams to see UI patients, guide them and provide individualized care taking into account their emotional and psychosocial aspects.
CONCLUSIONS Regardless the type of UI, the KHQ showed a negative impact in QoL of patients complaining of incontinence. Most women considered their health status upon medical appointment as regular to bad or bad to very bad; and bladder problem affected approximately half of them. No sociodemographic and cultural factors were significantly associated with the patients’ QoL. REFERENCES 1. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology in lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167-78. 2. Thomas TM, Plymat KR, Blannin J, Meade TW. Prevalence of urinary incontinence. Br Med J. 1980;281(6250):1243-5. 3. Jolleys JV. Reported prevalence of urinary incontinence in women in a general practice. Br Med J (Clin Res Ed). 1988;296(6632):1300-2. 4. Wheeler JS Jr, Walter JS, Niecestro RM, Scalzo AJ. Behavioral therapy for urinary incontinence. J ET Nurs. 1992;19(2):59-65. 5. Guarisi T, Pinto-Neto AM, Osis MJ, Pedro AO, Costa-Paiva LHS, Faundes A. Procura de serviço médico por mulheres com incontinência urinária. Rev Bras Ginecol Obstet. 2001;23(7):439-43. 6. Guarisi T, Pinto Neto AM, Osis MJ, Pedro AO, Paiva LHC, Faúndes A. Incontinência urinária entre mulheres climatéricas brasileiras: inquérito domiciliar. Rev Saúde Pública. 2001;35(5):428-35. 7. Hu TW. Impact of urinary incontinence on health-care costs. J Am Geriatr Soc. 1990;38(3):292-5. 8. Agency for Healthcare Research and Quality. Clinical practice guidelines: AHCPR releases update to urinary incontinence guideline [Internet]. Rockville: AHRQ; 1996 [citado 2006 jun 1]. Disponível em: http://www.ahrq.gov/ research/may96/dept5.htm 9. Viktrup L, Koke S, Burgio KL, Ouslander JG. Stress urinary incontinence in active elderly women. South Med J. 2005;98(1):79-89.
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