Stress urinary incontinence in women as a medical, social, psychological and economic problem – assessing the extent of knowledge of students graduating in medical fi elds
Wysiłkowe nietrzymanie moczu u kobiet jako problem medyczny, społeczny, psychologiczny i ekonomiczny – ocena zakresu wiedzy studentów kończących kierunki medyczne
Joanna Witkoś 1 (A-F), Piotr Wróbel 1 (E,F), Barbara Błońska-Fajfrowska 2 (A,C,D)
1 Departament of Physiotherapy, Andrzej Frycz Modrzewski Krakow University, Poland
2 Departament of Basic Biomedical Science, Medical University of Silesia in Katowice, Poland
Key words
stress urinary incontinence, knowledge, students Abstract
Introduction:
Introduction: Stress urinary incontinence occurs when there is an increase in pressure inside the abdomen accompanied by in- voluntary leakage of urine associated with coughing, sneezing, laughing or demanding physical labour. It is a serious condition that isolates women from society, prevents effi cient functioning, limits social contacts and forces a change in lifestyle. The fear of leakage of urine and odour arouses embarrassment, adversely affecting the psyche - leading to decreased self-esteem, neu- rosis and depression. In addition, in the absence of appropriate hygiene measures, or the lack of fi nancial resources to acquire them, incontinence can be a factor excluding women from normal life.
Study aim:
Study aim: The aim of this study was to assess the extent of knowledge of students graduating in medical fi elds on stress uri- nary incontinence in women as a medical, social, psychological and economic problem.
Material and methods:
Material and methods: The study involved 1,581 students during their fi nal year of medical studies, studying at various univer- sities. The study involved 1,255 women and 326 men. We created a questionnaire which was verifi ed by the CEM - Institute for Market Research and Public Opinion in Krakow.
Results:
Results: The largest percentage of respondents (95%) in all groups believes that stress urinary incontinence is primarily a med- ical problem, approx. 92% of respondents also regarded it as a psychological problem.
Conclusions:
Conclusions: It was shown that stress urinary incontinence in women was found to be a medical, social, psychological and eco- nomical problem by more than half of the students of medical, obstetric and nursing fi elds.
Słowa kluczowe
wysiłkowe nietrzymanie moczu, wiedza, studenci Streszczenie
Wstęp:
Wstęp: Wysiłkowe nietrzymanie moczu występuje, gdy związanemu z kaszlem, kichaniem, śmiechem lub ciężką pracą fi zycz- ną wzrostowi ciśnienia wewnątrz jamy brzusznej towarzyszy mimowolne wyciekanie moczu. Jest to poważne schorzenie, któ- re izoluje kobietę ze społeczeństwa, uniemożliwia sprawne funkcjonowanie, ogranicza kontakty towarzyskie i zmusza do zmia- ny stylu życia. Obawa przed wyciekiem moczu i nieprzyjemnym zapachem budzi zażenowanie, wpływając niekorzystnie na psychikę – prowadząc do obniżenia samooceny, nerwic i depresji. Dodatkowo przy braku odpowiednich środków higienicz- nych, czy też przy braku środków fi nansowych do ich nabycia, nietrzymanie moczu może stanowić czynnik wykluczający ko- bietę z normalnego życia.
The individual division on this paper was as follows: a – research work project; B – data collection; C – statistical analysis; D – data interpretation; E – manu- script compilation; F – publication search
Received: 16th Jun. 2016; accepted for publication: 19th Jan. 2017
Please cited: Witkoś J., Wróbel P., Błońska-Fajfrowska B. Stress urinary incontinence in women as a medical, social, psychological and economic prob- lem – assessing the extent of knowledge of students graduating in medical fields. Med Rehabil: DOI:10.5604/01.3001.0009.5500
Internet version (original): www.rehmed.pl
Cel pracy:
Cel pracy: Celem pracy była ocena zakresu wiedzy studentów kończących kierunki medyczne na temat wysiłkowego nietrzy- mania moczu u kobiet jako problemu medycznego, społecznego, psychologicznego oraz ekonomicznego.
Materiał i metoda:
Materiał i metoda: Badaniami objęto 1581 studentów ostatnich lat kierunków medycznych, studiujących na kilku uczelniach wyższych. W badaniach wzięło udział 1255 kobiet i 326 mężczyzn. Do badań wykorzystana została ankieta własnego autor- stwa, zweryfi kowana przez CEM – Instytut Badań Rynku i Opinii Publicznej w Krakowie.
Wyniki:
Wyniki: Największy odsetek respondentów (95%) we wszystkich grupach, uważa, iż wysiłkowe nietrzymanie moczu to przede wszystkim problem medyczny, ok. 92% respondentów zauważa też problem psychologiczny.
Wnioski:
Wnioski: Wykazano, że wysiłkowe nietrzymanie moczu u kobiet za problemem medyczny, społeczny, psychologiczny i ekono- miczny uznała ponad połowa studentów kierunku lekarskiego oraz położnictwa i pielęgniarstwa.
INTRODUCTION
Urinary incontinence worsens liv- ing conditions in professional, social, mental, physical and sexual aspects. In addition, it entails enormous costs of treatment, rehabilitation and purchase of absorbent products. Nevertheless, despite such actual impact on the dai- ly lives of millions of women around the world, it is still a problem which is neglected and treated as merely a dis- comfort associated with the sphere of personal hygiene. Women very often adjust and accept their changed, crip- pled life, limited by the range of this ailment. The misconception that in- continence is an incurable symptom of aging causes the patient to not seek medical help and not make efforts to achieve improvement and better qual- ity of life. Unfortunately, the lack of or delay in treatment leads to serious secondary somatic and psychologi- cal complications. Urine leakage iso- lates women from society, prevents ef- fi cient functioning, limits social con- tacts and forces a change in lifestyle1,2. The fear of leakage of urine and odour arouses embarrassment, adversely af- fecting the psyche − leading to lower self-esteem, neurosis and depression.
Normal everyday activities like shop- ping, playing with children, gymnas- tics, travelling or sexual intercourse which cause episodes of urinary in- continence, contribute to the deterio- ration of the quality of life in women.
This is highlighted by the fact that the authors of this paper describe the neg- ative impact of incontinence and the restrictions related to in all spheres of functioning3-7. Urinary incontinence, despite signifi cant progress in its diag- nosis and treatment, is still perceived by the public as an embarrassing prob- lem and is reluctantly reported to doc- tors. Sometimes, the already men-
tioned shame felt by the patient is so large that s/he hides this ailment un- til it begins to interfere with normal life or even dictates the way of life.
Women come to terms with their dis- ability and do not seek medical help, which is not only the result of embar- rassment but also the fear of going to the hospital and possibly undergoing surgery. In the absence of appropri- ate hygienic measures or the lack of fi nancial resources to acquire them, incontinence can be a factor exclud- ing women from normal life. Lack of knowledge, regarding the possibilities of conservative treatment, means that women consciously forgo daily activ- ities. This behaviour has negative ef- fects on social relationships, family and marriage, and dramatically wors- ens the daily life of women, causing discomfort, helplessness, alienation and stress2,3.
It is the duty of the medical com- munity to inform women about the possibilities of prevention and con- servative treatment used in stress uri- nary incontinence, and to encourage their implementation as soon as pos- sible. This allows improvement in the quality of everyday life and a re- turn to normal social and family rela- tionships. In addition, it reduces the considerable costs related to: deter- mining the actual cause of the dis- ease and optimal methods of treat- ment, personal hygiene, prevention and treating the increasing incidences of urinary tract infections and possi- ble hospitalization, and fi nally, bear- ing the costs associated with inability to work by persons affected with this ailment. The above mentioned facts encourage the need to create a pre- vention program for women suffer- ing from or at risk of stress urinary incontinence, which would be an in- vestment in the future health and
quality of life of women, reducing in- dividual and social costs1,8.
Stress urinary incontinence occurs when there is an increase in pressure inside the abdomen accompanied by involuntary leakage of urine associ- ated with coughing, sneezing, laugh- ing or demanding physical labour9. It is the most common form of uri- nary incontinence and can occur at any age. Patients unknowingly leak a small volume of urine in the ab- sence of a feeling of urgency. The fact that the symptoms disappear during night-rest, and the frequency of mic- turition does not change during the daytime is characteristic for this type of incontinence3.
Pregnancy and childbirth, pel- vic operations, menopause, obesi- ty, performing occupations associat- ed with strenuous physical work, ex- cessive levels of physical activity, uri- nary tract as well as genital infections and diseases associated with chron- ic coughing are among the most im- portant causes of this disease10-17. The results of most epidemiological stud- ies verify the fact that pregnancy and childbirth burden the pelvic fl oor and are thus an inherent risk factor for urinary incontinence in a woman’s later life18. During pregnancy, a loos- ening of the connective tissue in the pelvic diaphragm occurs, which is a physiological process preparing the woman’s body for childbirth. At the time of birth, when the baby pass- es through the birth canal, the tis- sue and surrounding nerves are of- ten damaged – especially the muscu- lus levator ani - and additionally, de- lamination of the visceral pelvic fas- cia that is responsible for maintaining the sex organ statics18.
Another frequently listed risk fac- tor for urinary incontinence in wom- en is hysterectomy, which causes in-
voluntary urine leakage due to dis- turbances in sex organ statics and nerve damage following the proce- dure11,13. Menopause also predispos- es to the occurrence of the disease since estrogen plays a very important role in the functioning of the lower urinary tract. Estrogen receptors are found in the bladder, urethra and in the central nervous system, in the ar- eas responsible for the initiation and control of micturition. Additional- ly, estrogen-dependent regulation of blood fl ow through the submucosal venous plexuses increases inner-ure- thra pressure and supports the ure- thral sphincter mechanism15.
The close correlation between uri- nary incontinence and obesity has also been proven, which is fostered by: limitation of physical activity, ex- cessive caloric diet and slowing me- tabolism with age15,16,19-21. Obesity in Poland is noted in approximately 2/3 of women during menopause22. Increased body mass index (BMI), characteristic of overweight (BMI 25- 29.9 kg/m2) and obese persons (over 30 kg/m2), clearly correlates with the severity of symptoms of urinary in- consistency14,23,24. It has been shown that a body mass index greater than 30 kg/m2 predisposes obese wom- en to twice as high a risk of urinary incontinence. An individual increase in BMI raises the incidence of uri- nary incontinence by 19%25. Surgi- cal weight reduction in approx. 70%
of patients affects the relief of symp- toms of urinary inconsistency26.
It was noted that both too low and too high levels of physical activity are risk factors in urinary incontinence.
Symptoms of stress urinary incon- tinence are more common in young women representing high physical activity or professionally performing sports than women with only moder- ate levels of physical activity. The re- lationship between incontinence and lung diseases, such as: chronic ob- structive pulmonary disease, sleep ap- nea or chronic bronchitis, resulting, for example, from cigarette smoking was also demonstrated. These diseas- es cause disorders in the production of collagen which weakens the struc- ture of the pelvic fl oor. Consequently, when someone coughs, a sudden in-
crease in abdominal pressure occurs and then there are incidents of stress urinary inconsistency11-13,15,16,19.
Urinary incontinence is not only a problem of adult women, but is a common phenomenon in different age groups, ethnic minorities and in various clinical conditions. The ma- jor risk factors discussed above show that the pathogenesis of this disease is multifactorial and complex; it may be due to disease or impaired function- ing of many organs and systems1. For this reason, urinary incontinence is treated as a symptom and not a uni- form individual disease regarding eti- opathogenesis. Incontinence depends on the proper functioning of the cen- tral nervous system and peripheral nerves, accuracy and functional anat- omy of the bladder and urethra, as well as supporting tissues and mus- cles of the lower pelvic fl oor3,11. Ab- normalities or disorders in any of the aforementioned structures results in severe problems with urine consist- ency.
The aim of this study was to as- sess the extent of knowledge of stu- dents graduating in medical fi elds re- garding stress urinary incontinence in women as a medical, social, psycho- logical and economic problem.
MATERIAL
AND METHODOLOGY
The study involved 1,581 students during their fi nal last year of medical studies, including students from sev- eral universities. The study involved 1,255 women and 326 men. The MD group comprised of medical doctor students, totalling 432 persons, in- cluding 282 women and 150 men aged 24.9 ± 0.95 years. PT group – consisted of physiotherapy students, 402 persons, including 288 women and 114 men aged 25.4 ± 3.8 years.
Group ON – obstetrics and nurs- ing students, 258 women, aged 30.1
± 7.59 years. OF group − students from other medical faculties: den- tal, pharmacy, medical analysis, cos- metology and public health, 489 peo- ple, including 427 women and 62 men, aged 24.8 ± 4.1 years; this was considered the control group. In the
study, we used our own specially cre- ated questionnaire which was veri- fi ed by the CEM − Institute for Mar- ket Research and Public Opinion in Krakow.
The data obtained from the ques- tionnaires were entered into the da- tabase created on an Excel 2007 spreadsheet, and was statistically ana- lyzed using Statistica 8.0. The level of signifi cance was set at p = 0.05. Sta- tistical analysis was performed using the Chi2 test.
RESULTS
Considering the multifaceted prob- lems of stress urinary incontinence in women, the respondent expressed his/her opinion on whether stress in- continence is primarily an econom- ic, medical, psychological or social problem. Expressing their opinion was followed by selecting “I strong- ly agree,” “I rather agree,” “I rather disagree”, “I strongly disagree” for each of the presented aspects of the problem. Among the answers, the re- spondent could choose “I have no opinion”. S/he could also give his/
her personal opinion on this subject in the column “other (problem) – please, specify”.
Given the distribution of responses in different aspects of the problem, it can be stated that the highest percent- age of respondents believes that stress incontinence is primarily a medi- cal and psychological problem. Ap- proximately 78.2% of students from the group of doctors (MD) strong- ly agreed that this is a medical prob- lem (Figure 1). A similar opinion was shared by 75.2% of students from the group of nursing and obstetrics stu- dents (ON), 72.2% of students from the group consisting of other medi- cal fi elds (OF) and about 70% of stu- dents from the group of physiothera- pists (PT). “I rather agree” with such a statement was chosen by about 25%
of respondents from both the OF and PT groups, 23.3% in group ON and 17.6% of the MD group. A small mi- nority of respondents were of the op- posite opinion. “I strongly disagree”
or “Rather disagree” with treat- ing urinary incontinence as a medi-
Figure 1
The percentage of respondents qualifying stress urinary incontinence as a mainly medical problem
Figure 2
The percentage of respondents qualifying stress urinary incontinence as a mainly psychological problem
Figure 3
The percentage of respondents qualifying stress urinary incontinence as a mainly social problem
Figure 4
The percentage of respondents qualifying stress urinary incontinence as a mainly economic problem
cal problem, included 1.6% to 3.3%
of the respondents. No opinion on this subject was declared by 0.9% to 2.2% of respondents in three groups:
OF, PT and MD. Statistically signifi - cant differences were observed only between group MD and the OF and PT groups (p<0.05) (Figure 1).
About 85% of respondents from group MD fi rmly believed that stress incontinence is primarily a psycho- logical problem. The same answer was given by 76.4% of subjects from the ON group, 63.4% from the PT group and 55.2% from the OF group (Figure 2). 32.5% of subjects from the OF group, 25.6% from group PT, 19% from group ON and 10.2%
from the MD group rather agreed with this statement. Respectively, 7.2% and 1% of respondents from the OF group, 5.7% and 1.7% from the PT group, 3.5% and 0.8% from the ON group and 1.9% and 2.1%
from the MD group strongly disa- greed with this aspect of the problem.
0.3% to 4% of respondents had no opinion on the subject. Lack of statis-
tically signifi cant differences was only noted between the OF and PT groups (Figure 2).
Stress urinary incontinence as a so- cial problem was categorically recog- nized by 56.3% of respondents from the MD group, 55.4% from the ON group, 44.0% from group PT and 33.7% from the OF group (Figure 3). “I rather agree” with the state- ment was expressed by: 37% of the OF group, 34.8% from group PT, approximately 31.9% from the MD group and 29.8% from group ON.
“I rather disagree” with the fact that this is a social problem was expressed by 16.6% of students from the OF control group, 9.7% from group PT, 9.3% from group ON, as well as 8.8% from the MD group. “I strong- ly disagree” with the statement was verbalized by 1.9% to 4 3% of re- spondents. 1.2% to 8.4% of the re- spondents stated that they have no opinion on the subject. Lack of statis- tically signifi cant differences was only noted between groups MD and ON (Figure 3).
The lowest percentage of respond- ents strongly agrees that stress in- continence is primarily an econom- ic problem. Such responses were giv- en by 20.4% from group MD, 15.9%
from the ON group, approx. 10%
from the PT group and 9% from the OF group (Figure 4). 38.8% of stu- dents from the ON group, 37.3%
from the MD group, 26.6% from group PT and 21.1% from the OF group rather agree with such a state- ment. 20.4% from the OF group, 18.4% from group PT, 16.3% from the ON group and 9.5% from group MD strongly disagree with the per- ception of stress urinary incontinence as an economic problem. A slight- ly higher percentage rather disagrees with such a statement; this response being given by 33.1% in the OF group, 31.6% in group PT, 25.2% in group MD and 22.5% in group ON.
The answer “I have no opinion” was chosen by 6.6% to 16.4% of the re- spondents. No statistically signifi cant differences were only noted between the OF and PT group (Figure 4).
Figure 5
The percentage of individuals believing stress urinary incontinence to simultaneously be an economic, medical, psychological and social problem
Considering the data from litera- ture indicating that stress urinary in- continence in women is simultane- ously an economic, medical as well as psychological and social problem2, we regarded those choosing the an- swer “I strongly agree” or “I rather agree” in all the four aspects as in- dividuals with the most comprehen- sive conception of the problem. This answer was given by 52.3% of the group of doctors (MD), 51.6% by the group of nursing and obstetrics students (ON), 32.1% by the group of physiotherapists (PT) and 25.4%
in the control group, covering oth- er medical fi elds (OF) (Figure 5). Sta- tistically signifi cant differences were observed between the OF control group and the MD and ON group (p<0.001), as well as between the PT group and the MD and ON group (respectively, p<0.001 and p<0.01).
DISCUSSION
Stress urinary incontinence is a multi- disciplinary problem and should be considered from the perspective of the many aspects having signifi cant impact on all spheres of life of the women suffering from this ailment as well as on their quality of life3,27. The medical aspect emerges into the foreground and includes: prevention, diagnosis, methods of conservative and surgical treatment. Later, the so- cial aspect, the aim of which should be preventing the isolation of wom- en suffering from this disease, and to prevent social exclusion, revealing it- self in, inter alia, limited social con- tacts. The psychological aspect is also of considerable importance, includ- ing helping women who have found themselves in various emotional states such as depression, frustration, embarrassment, fear or indifference, which emerge during the occurrence of stress urinary incontinence symp- toms. Especially since such emotion- al states are not only often associ- ated with the symptoms of the dis- ease itself, but also occur as a result of restriction of physical activity and a sense of “lost freedom” that this disease brings about. Finally, the eco- nomic aspect is inextricably linked
with money or the lack thereof, need- ed for the purchase of drugs, absor- bents or vaginal inserts, designed to exercise the muscles of the lower pel- vis3,27.
In our study, we attempted to de- termine the extent to which fi nal-year students specializing in different medical fi elds recognize stress uri- nary incontinence as an interdiscipli- nary problem. It was found that more than half the students of nursing and obstetrics (group ON) and of medi- cal doctor studies (group MD), 1/3 of the physiotherapy fi eld (group PT) and only 1/4 of students from the OF control group, representing different medical fi elds regarded stress incon- tinence as a simultaneously − med- ical, psychological, social and eco- nomic problem. The largest propor- tion of respondents, reaching at least 95% in all groups, believed that this is primarily a medical problem, an av- erage of approx. 92% of respondents also noticed the psychological prob- lem. About 30% of people in the OF control group and 15%-20% in the other groups did not see stress uri- nary incontinence as a social prob- lem, and as much as about 70% of re- spondents from groups OF and PT, as well as about 45% from the MD and ON groups did not view the disease in terms of economic problems. Not noticing the economic consequences of persistent pain, often causing dif- fi culties in earning money with in- creased spending closely related to the disease1,3,6,7,27-28,29, should proba- bly be attributed to the young age of the majority of the respondents and its associated lack of life experience, including lack of practical knowl- edge, which is acquired during in- dependent management of a house- hold.
The psychological aspect is very im- portant and inextricably linked with the problem of stress urinary incon- tinence, because the constant anxie- ty and fear of urine leakage and the related consequences leads to a sense of embarrassment, stress and as a re- sult - often to depression30-35. As the research has shown, the respondents defi nitely agree with this point, as in all groups, the majority (almost 95%) believes that women suffering from
stress urinary incontinence are, above all, accompanied by a sense of embar- rassment. Slightly fewer respondents expressed a similar opinion about the emotional states, which are: frus- tration (approx. 85%), anxiety (ap- prox. 82%) and depression (approx.
80%). The opinions expressed by re- spondents are consistent with the re- ports from literature, which declare that the mental state of the patient is - next to the age and duration of dis- ease - one of the most important el- ements infl uencing the fi nal effect of therapy. In women suffering from stress urinary incontinence, much higher levels of somatic and men- tal anxiety as well as suspicion were found than in healthy women36. The study also showed that women suf- fering from this disease are charac- terized by increased irritability, low self-esteem, depression, sleep disor- ders, social isolation and even suicid- al thoughts. In addition, for 6.6% of women with the disease, their fami- ly relationship begins to fall apart30.
Stress urinary incontinence un- doubtedly has negative impact on all spheres of life of women and causes limitations in normal, everyday func- tioning, which is underlined in many publications27,36-38. In the opinion of about 90% of students from all fi elds, this is not a trivial problem, which se- riously hampers social contacts, dis- turbs the activity of women in pro- fessional and social spheres, limits physical activity and sex life, inter- feres with rest and greatly diminishes the quality of life of women. The ob- servations of the respondents in this study are consistent with the litera- ture27,35-41.
From the literature, it is also known that women are reluctant to talk about their suffering associat- ed with stress urinary inconsisten- cy8,41-44. The word “suffering” is used here not by accident, because it re- fl ects not only the physical ailments that may arise as a consequence of uncontrolled urine fl ow, but also the signifi cant psychological discomfort which is the result of shame, fear and helplessness. Do students of medi- cal fi elds, who in the near future will have contact with women suffer- ing from this disease, realize that the
shame and embarrassment associat- ed with leakage of urine are the cause of long-term concealment of this dis- ease? And that suffering women may never demonstrate willingness to dis- cuss this subject with health care rep- resentatives, even if they think that their disease is an inevitable conse- quence of aging? Our own analysis showed that the vast majority of re- spondents (85-90%) are aware that shame is the reason for the silence re- garding symptoms of stress urinary incontinence in women. However, 31% to 42% of respondents do not exclude that the reticence of wom- en with stress urinary incontinence can be caused by the small nuisance of this problem. The majority of re- spondents (62-77%) also believe that women suffering from stress inconti- nence are reluctant to discuss this is- sue with their family doctor, rather sharing the problem with relatives.
In the research by Krauze-Balwins- ka et al.36, it was shown that wom- en with stress urinary incontinence tell their spouse about the disease in 45% of cases, their children in 17.5%
of cases, but only daughters, and as much as 37.5% do not tell their fam- ily about the ailments.
Due to the growing importance of the problem of urinary incontinence, as well as social expectations, it is not only necessary but also needed to de- velop an interdisciplinary, most effi - cient and optimum scheme for diag- nostics and therapeutic management of patients with urinary inconsisten- cy1. As in any disease, in incontinence early diagnosis and quick implemen- tation of treatment are essential. A great role in the proliferation of pre- vention falls on doctors, nurses, mid- wives and physiotherapists, who hav- ing constant contact with the patient should take discussion on the topic upon themselves45. They should skil- fully break the barrier of a patient’s shame, collect his/her medical histo- ry and, fi nally, inform the patient of the suspected existence of a health problem and the need to undergo di- agnosis and treatment provided by a doctor. Health education, including presenting proposals for preventive measures is inscribed in their profes- sional competences.
CONCLUSIONS
1. It has been shown that stress urinary incontinence in women as a med- ical, social, psychological and eco- nomical problem was recognized by more than half of the medical doc- tor, obstetrics and nursing students.
2. The lowest percentage of respond- ents studying in all the surveyed fi elds recognized urinary inconti- nence as only an economic prob- lem.
Confl ict of interests
The authors declare that they have no confl ict of interests.
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Address for correspondence Joanna Witkoś MD PhD
Krakowska Akademia im. Andrzeja Frycza Mod- rzewskiego
ul. G. Herlinga-Grudzińskiego 1, 30-705 Kraków, Poland
e-mail: jwitkos@afm.edu.pl