Int Urogynecol J DOI 10.1007/s00192-013-2295-4
ORIGINAL ARTICLE
Genitourinary symptoms and their effects on quality of life in women with uterine myomas Murat Ekin & Huseyin Cengiz & Emine Öztürk & Cihan Kaya & Levent Yasar & Kadir Savan
Received: 13 September 2013 / Accepted: 29 November 2013 # The International Urogynecological Association 2013
Abstract Introduction and hypothesis This study was designed to determine the presence of genitourinary symptoms and their effects on quality of life (QOL) in women with uterine myomas. Methods A total of 145 women with ultrasonography (US) diagnosis of anterior myoma were divided into two groups according to myoma size: (1) those ≤5 cm (n=75), and (2) those >5 cm (n=70). The control group comprised previously matched 94 women with a normal-appearing uterus on US. Study participants answered the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7). Pelvic examination was performed, and urinary symptoms were recorded. The chi-square test and Fischer’s exact test were used to compare qualitative data. The Kruskal–Wallis test and Dunn’s test were used to compare groups. Statistical significance was set at P 5 cm than in other women (P5 cm (n= 70). The control group comprised 94 previously matched women who attended our department for a scheduled annual gynecological visit and were found to have a normalappearing uterine myometrium on transvaginal US examination. The control group had no history of endometriosis,
adenomyosis, or uterine myomas. All US examinations were performed by the same expert physician (HC) using a Voluson E6 US scanner (GE Medical Systems, Milwaukee, WI, USA) with a 4–9 MHz vaginal probe. Uterine size was calculated by the mean of the measured vertical and horizontal diameter of the myoma. The women also completed two validated questionnaires: the UDI-6 and the IIQ-7, the former of which screens for stress, irritative, and obstructive symptoms, and the latter how these symptoms affect QOL with regards to physical activity, travel, social relationships, and emotional health [6]. All women underwent a pelvic examination and were questioned by an expert physician regarding the presence of urinary symptoms, including SUI, urgency, urge urinary incontinence (UUI), nocturia, increased daytime frequency, anal incontinence (AI), and dyspareunia. SUI was defined as involuntary leakage of urine on effort, exertion, sneezing, or coughing. UUI was defined as involuntary leakage of urine accompanied by or immediately preceded by urgency. Mixed urinary incontinence (MUI) was defined as involuntary leakage associated with urgency and effort, exertion, sneezing, or coughing. Increased daytime frequency was defined according to the woman’s perception of voiding too often during the
Table 1 Comparison of women with myomas and controls in frequencies of genitourinary symptoms
Patient characteristics (mean ± SD) Age (years) Parity C/S
Controls
Myoma≤5 cm
Myoma >5 cm
P value
41.9±9.2 2.2±1.8 0.24±0.5
42.31±6.29 2.12±1.3 0.23±0.5
43.83±6.18 2.30±1.23 0.20±0.6
0.062 0.485 0.200
26.1±0.8
25.9±1.0
0.506
42 (56.0) 19 (25.3) 34 (45.3) 59 (78.7) 6 (8.0) 15 (20.0) 0 (0) 11 (14.7)
56 (80.0) 22 (31.4) 30 (42.9) 60 (85.7) 5 (7.1) 18 (25.7) 0 (0) 12 (17.1)
0.0001 0.01 0.027 0.0001 0.571 0.082 0.664 0.001
2.64±1.75 2 (1−4) 1.19±1 1 (0−2) 2.23±1.65 2 (1−3) 6.04±3.49
3.09±1.75 3 (2−4.25) 1.7±1.13 2 (1−3) 2.94±2.3 2 (1−4) 7.73±3.85
0.0001
BMI 26.8±1.9 Frequencies of genitourinary symptoms [n (%)] SUI 30 (31.9) MUI 10 (10.9) Urgency 27 (28.7) Increased daytime frequency of voiding 47 (50.0) UUI 7 (7.4) Nocturia 10 (10.6) AI 1 (1.1) Dyspareunia 4 (4.3) Symptom-related scores of the UDI-6 questionnaire (mean±SD) Irritative symptoms 1.86±1.82 Median (IQR) 1.5 (0−3) Urinary incontinence 0.79±0.97 Median (IQR) 0 (0−2) Obstructive symptoms 1.2±1.66 Median (IQR) 1 (0−1) Total 3.78±3.61
0.0001 0.0001 0.0001
C/S cesarean sections, BMI body mass index, SUI stress urinary incontinence, MUI mixed urinary incontinence, UUI urge urinary incontinence, AI anal incontinence, UDI Urogenital Distress Inventory, SD standard deviation, IQR interquartile range Bold indicates statistical significance
Int Urogynecol J Table 2 Association between genitourinary symptoms and myoma size SUI
Urgency Increased daytime frequency of voiding
Control patients 0.002 0.026 vs patients with myoma ≤5 cm Controls patients 0.0001 0.06 vs patients with myoma >5 cm Myoma≤5 cm 0.002 0.764 vs >5 cm
0.0001
MUI
Table 4 QOL-related scores of the IIQ-7 questionnaire in women with myomas and controls
Dyspareunia IIQ-7
0.001 0.006
0.269
0.415 0.683
Myoma≤ 5 cm
Physical activity 1.96±2.34 1.67±2.24 median (IQR) 1 (0–4) 1 (0–3) Travel median (IQR) 0.82±1.06 0.69±0.75 0 (0–2) 1 (0–1) Social relationships 0.28±0.63 0.56±0.81 median (IQR) 0 (0–0) 0 (0–1) Emotional health 0.83±1.3 0.95±1.44 median (IQR) 0 (0–1) 0 (0–2) Total median (IQR) 3.88±4.31 3.85±4.15 2 (0–8) 2 (0–6)
0.012 0.018
0.0001
Control patients
Dunn’s test SUI stress urinary incontinence, MUI mixed urinary incontinence
Myoma> 5 cm
P value
3.06±2.63 3 (0.75–4.5) 1.29±1.21 1.5 (0–2) 0.71±0.9 0 (0–1) 1.93±1.92 2 (0–3.25) 6.99±5.8 7.5 (1–11)
0.002 0.014 0.003 0.001 0.001
Values are in mean±SD
Bold indicates statistical significance
day. Nocturia was defined as waking during the night at least once to void. AI was defined as involuntary loss of flatus or liquid or solid stool [7]. Statistical analyses were performed using NCSS 2007 Statistical Software (Kaysville, UT, USA). The sample size was calculated with the assumption that the prevalence of myomas was 20–30 % of the population. To provide 80 % power of 0.05, it was calculated that 70 participants would be adequate in each group. For univariate analyses, continuous data were reported as the median [interquartile range (IQR)] and mean ± standard deviation (SD). The Kruskal–Wallis test and Dunn’s test were used to compare groups. The chi-square test and Fischer’s exact test were used to compare qualitative data. Statistical significance was accepted at a P value of 5 cm, respectively. Frequency of genitourinary symptoms was significantly higher in women with myomas, including SUI (P
ORIGINAL ARTICLE
Genitourinary symptoms and their effects on quality of life in women with uterine myomas Murat Ekin & Huseyin Cengiz & Emine Öztürk & Cihan Kaya & Levent Yasar & Kadir Savan
Received: 13 September 2013 / Accepted: 29 November 2013 # The International Urogynecological Association 2013
Abstract Introduction and hypothesis This study was designed to determine the presence of genitourinary symptoms and their effects on quality of life (QOL) in women with uterine myomas. Methods A total of 145 women with ultrasonography (US) diagnosis of anterior myoma were divided into two groups according to myoma size: (1) those ≤5 cm (n=75), and (2) those >5 cm (n=70). The control group comprised previously matched 94 women with a normal-appearing uterus on US. Study participants answered the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7). Pelvic examination was performed, and urinary symptoms were recorded. The chi-square test and Fischer’s exact test were used to compare qualitative data. The Kruskal–Wallis test and Dunn’s test were used to compare groups. Statistical significance was set at P 5 cm than in other women (P5 cm (n= 70). The control group comprised 94 previously matched women who attended our department for a scheduled annual gynecological visit and were found to have a normalappearing uterine myometrium on transvaginal US examination. The control group had no history of endometriosis,
adenomyosis, or uterine myomas. All US examinations were performed by the same expert physician (HC) using a Voluson E6 US scanner (GE Medical Systems, Milwaukee, WI, USA) with a 4–9 MHz vaginal probe. Uterine size was calculated by the mean of the measured vertical and horizontal diameter of the myoma. The women also completed two validated questionnaires: the UDI-6 and the IIQ-7, the former of which screens for stress, irritative, and obstructive symptoms, and the latter how these symptoms affect QOL with regards to physical activity, travel, social relationships, and emotional health [6]. All women underwent a pelvic examination and were questioned by an expert physician regarding the presence of urinary symptoms, including SUI, urgency, urge urinary incontinence (UUI), nocturia, increased daytime frequency, anal incontinence (AI), and dyspareunia. SUI was defined as involuntary leakage of urine on effort, exertion, sneezing, or coughing. UUI was defined as involuntary leakage of urine accompanied by or immediately preceded by urgency. Mixed urinary incontinence (MUI) was defined as involuntary leakage associated with urgency and effort, exertion, sneezing, or coughing. Increased daytime frequency was defined according to the woman’s perception of voiding too often during the
Table 1 Comparison of women with myomas and controls in frequencies of genitourinary symptoms
Patient characteristics (mean ± SD) Age (years) Parity C/S
Controls
Myoma≤5 cm
Myoma >5 cm
P value
41.9±9.2 2.2±1.8 0.24±0.5
42.31±6.29 2.12±1.3 0.23±0.5
43.83±6.18 2.30±1.23 0.20±0.6
0.062 0.485 0.200
26.1±0.8
25.9±1.0
0.506
42 (56.0) 19 (25.3) 34 (45.3) 59 (78.7) 6 (8.0) 15 (20.0) 0 (0) 11 (14.7)
56 (80.0) 22 (31.4) 30 (42.9) 60 (85.7) 5 (7.1) 18 (25.7) 0 (0) 12 (17.1)
0.0001 0.01 0.027 0.0001 0.571 0.082 0.664 0.001
2.64±1.75 2 (1−4) 1.19±1 1 (0−2) 2.23±1.65 2 (1−3) 6.04±3.49
3.09±1.75 3 (2−4.25) 1.7±1.13 2 (1−3) 2.94±2.3 2 (1−4) 7.73±3.85
0.0001
BMI 26.8±1.9 Frequencies of genitourinary symptoms [n (%)] SUI 30 (31.9) MUI 10 (10.9) Urgency 27 (28.7) Increased daytime frequency of voiding 47 (50.0) UUI 7 (7.4) Nocturia 10 (10.6) AI 1 (1.1) Dyspareunia 4 (4.3) Symptom-related scores of the UDI-6 questionnaire (mean±SD) Irritative symptoms 1.86±1.82 Median (IQR) 1.5 (0−3) Urinary incontinence 0.79±0.97 Median (IQR) 0 (0−2) Obstructive symptoms 1.2±1.66 Median (IQR) 1 (0−1) Total 3.78±3.61
0.0001 0.0001 0.0001
C/S cesarean sections, BMI body mass index, SUI stress urinary incontinence, MUI mixed urinary incontinence, UUI urge urinary incontinence, AI anal incontinence, UDI Urogenital Distress Inventory, SD standard deviation, IQR interquartile range Bold indicates statistical significance
Int Urogynecol J Table 2 Association between genitourinary symptoms and myoma size SUI
Urgency Increased daytime frequency of voiding
Control patients 0.002 0.026 vs patients with myoma ≤5 cm Controls patients 0.0001 0.06 vs patients with myoma >5 cm Myoma≤5 cm 0.002 0.764 vs >5 cm
0.0001
MUI
Table 4 QOL-related scores of the IIQ-7 questionnaire in women with myomas and controls
Dyspareunia IIQ-7
0.001 0.006
0.269
0.415 0.683
Myoma≤ 5 cm
Physical activity 1.96±2.34 1.67±2.24 median (IQR) 1 (0–4) 1 (0–3) Travel median (IQR) 0.82±1.06 0.69±0.75 0 (0–2) 1 (0–1) Social relationships 0.28±0.63 0.56±0.81 median (IQR) 0 (0–0) 0 (0–1) Emotional health 0.83±1.3 0.95±1.44 median (IQR) 0 (0–1) 0 (0–2) Total median (IQR) 3.88±4.31 3.85±4.15 2 (0–8) 2 (0–6)
0.012 0.018
0.0001
Control patients
Dunn’s test SUI stress urinary incontinence, MUI mixed urinary incontinence
Myoma> 5 cm
P value
3.06±2.63 3 (0.75–4.5) 1.29±1.21 1.5 (0–2) 0.71±0.9 0 (0–1) 1.93±1.92 2 (0–3.25) 6.99±5.8 7.5 (1–11)
0.002 0.014 0.003 0.001 0.001
Values are in mean±SD
Bold indicates statistical significance
day. Nocturia was defined as waking during the night at least once to void. AI was defined as involuntary loss of flatus or liquid or solid stool [7]. Statistical analyses were performed using NCSS 2007 Statistical Software (Kaysville, UT, USA). The sample size was calculated with the assumption that the prevalence of myomas was 20–30 % of the population. To provide 80 % power of 0.05, it was calculated that 70 participants would be adequate in each group. For univariate analyses, continuous data were reported as the median [interquartile range (IQR)] and mean ± standard deviation (SD). The Kruskal–Wallis test and Dunn’s test were used to compare groups. The chi-square test and Fischer’s exact test were used to compare qualitative data. Statistical significance was accepted at a P value of 5 cm, respectively. Frequency of genitourinary symptoms was significantly higher in women with myomas, including SUI (P
