European Journal of Obstetrics & Gynecology and Reproductive Biology 182 (2014) 86–90
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Urinary incontinence during pregnancy. Is there a difference between first and third trimester? Eva Martı´nez Franco a,*, David Pare´s b, Nu´ria Lorente Colome´ c, Josep Ramon Me´ndez Paredes a, Lluis Amat Tardiu c a b c
Obstetrics and Gynecology Department, Parc Sanitari Sant Joan de De´u, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain General and Digestive Surgery Department, Parc Sanitari Sant Joan de De´u, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain Obstetrics and Gynecology Department, Hospital Universitari Sant Joan de De´u, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 March 2014 Received in revised form 9 July 2014 Accepted 26 August 2014
Objective: The aim of this study is to determine the prevalence and severity of urinary incontinence and to see if there are any differences between first and third trimester of pregnancy. Study design: A cross-sectional study of two groups of women was conducted. All patients attending our hospital for obstetric ultrasound examination during the first trimester (group 1 = less than 13 weeks of pregnancy) and third trimester (group 2 = up to 28 weeks of pregnancy) were eligible for inclusion. All participating women completed self-reported questionnaires: ICIQ-SF, PFDI-20 (UDI-6, CRADI-8, POPDI6) and SF-36. The variables studied were biodemographic data and results from questionnaire responses. Results: From March 2012 to May 2012, 224 consecutive pregnant women were included in this study: group 1 (n = 58) and group 2 (n = 166). The incidence of urinary incontinence during pregnancy is different in first and third trimester: 18.96% (11 of 58) and 39.76% (66 of 166) (p = 0.008). 100% and 84.12% of women with UI in first trimester and third trimester respectively leak a small amount of urine. In 15.87% of group 2 the leakage was a moderate amount of urine. Participants mainly presented Stress UI (78.37%) and urge was only present in 12.16% of them. Conclusions: In conclusion, according to the results obtained, the prevalence of urinary incontinence in our population of pregnant women was 34.37%, which means that more than a third of the population of pregnant women is affected, and that this disorder is more common during the third trimester of pregnancy than during the first. The most common form was stress urinary incontinence, affecting 48.05% of the women. In all patients, leakage was slight-moderate that did not severely hamper their everyday life but did affect their physical, mental and social domains of their quality of life. Another problem, even more prevalent than incontinence itself, was the increase in urinary frequency, affecting 41.25% of the pregnant women and causing discomfort/distress in the 68.8%. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pregnancy Stress urinary incontinence Urinary incontinence
Introduction The most common form of urinary incontinence (UI) during pregnancy is stress urinary incontinence (SUI). It is more common as pregnancy advances and is estimated to affect the quality of life of 54.3% of pregnant women [1]. In addition, both urge incontinence and mixed incontinence can also occur and may
* Corresponding author at: Parc Sanitari Sant Joan de De´u, Universitat de Barcelona, C/Antoni Pujadas num 42, 08830 Sant Boi de Llobregat, Barcelona, Spain. Tel.: +34 936615208 E-mail address: [email protected] (E. Martı´nez Franco). http://dx.doi.org/10.1016/j.ejogrb.2014.08.035 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.
even have a greater negative impact on the quality of life of these patients [2]. The published data on UI during pregnancy are heterogeneous and there are few studies about prevalence of urinary incontinence during pregnancy [3]. Only two studies [4,5] have been published on this topic in Spain and only one of them compared data from the first and last trimesters [5]. In addition, there are few comparative data to determine whether there are any differences between the beginning and end of gestation. This information would be highly useful because the factors that favor the development of urinary incontinence during pregnancy are still scarcely known [6]. The aim of our study was to identify, in our population, the prevalence of UI during pregnancy, its severity, and its impact on
E. Martı´nez Franco et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 182 (2014) 86–90
the quality of life of affected women and to determine whether there are any differences in these parameters between the first and third trimesters of pregnancy.
Table 1 Description of the study population. Total
Materials and methods A cross-sectional cohort study of two groups of women was conducted between March and May 2012. All patients attending our hospital for routine obstetric ultrasound examination during the first trimester (group 1 = less than 13 weeks of pregnancy) and third trimester (group 2 = up to 28 weeks of pregnancy) of pregnancy were eligible for inclusion. We excluded all patients with difficulties in understanding or reading Spanish. All participants were informed of the nature and objectives of the study through a specific document and all signed an informed consent form. This study was approved by the research and ethical committee of our institution. Study variables We collected clinical data and participating women completed the following self-administered questionnaires: the International Consultation on Incontinence Questionnaire [7] (ICIQ-SF), the Pelvic Floor Distress Inventory (PFDI-20) [8], which included the Urinary Distress Inventory (UDI-6), the Colo-rectal Anal Distress Inventory (CRADI-8), the Pelvic Organ Prolapse Distress Inventory (POPDI-6) and the Short Form 36 Heath Survey [9] (SF-36) questionnaire, in validated to the Spanish language. Symptoms of urinary incontinence were classified based on the answer to the question ‘‘When does urine leak?’’ from the ICIQ-SF questionnaire. The patients were divided into four groups: ‘‘stress urinary incontinence’’ if the answer to this question was ‘‘when I cough or sneeze’’ or ‘‘when I am physically active/exercising, ‘‘urge incontinence’’ if the answer was ‘‘before I can get to the toilet’’ and mixed if the woman marked both options. The remaining options for this question were included in a single category that we called ‘‘other’’. The severity of urinary loss was assessed through the specific question of the ICIQ-SF: ‘‘How much urine do you usually leak (whether you wear protective or not)?’’ and was classified into: ‘‘small amount’’, ‘‘moderate amount’’ or ‘‘large amount’’ according to the answer obtained. The impact on quality of life was assessed through the response obtained in the ICIQ-SF and also more specifically with the answers obtained in the different domains of the SF-36 questionnaire. Statistical analysis Data from pregnant women in both trimesters of pregnancy who reported symptoms of UI and from asymptomatic pregnant women were compared using the Chi-square test for categorical variables and Student-t test or the Mann Whitney U-test for quantitative variables. The level of statistical significance of all the tests was set at a bilateral p-value less than 0.05. Results 224 women were included in the study: 58 in group 1 and 166 in group 2, with a total of 147 continent women (47 in first trimester of pregnancy and 100 in third) and 77 incontinent pregnant (11 in first trimester and 66 in third). The clinical data collected from incontinent versus continent women are shown in Table 1. The statistical analysis showed no statistically significant differences in any of the items studied except for body mass index (BMI). BMI was statistically significantly higher in patients with urinary incontinence
87
Age BMI
Continent (n = 147)
Incontinent (n = 77)
p
30.79 (16–42) 25.92 (17.04–41.66)
30.83 (17–42) 27.82 (19.57–41.14)
0.96 0.01
16/71 (22.5%) 37/77 (48%)
0.35 0.16
37/77 (48%) 1/77 (1.3%) 2/77 (2.6%) 3245.5 (2150–4160)
0.13
24/141 (17%) Smoke Primigravidae 85/147 (57%) Number of previous births 1 54/147 (36.7%) 2 7/147 (4.76%) 3 1/147 (0.7%) Maximum weight 3312.3 (2100–4300) of newborn Type of birth Eutocic 33/62 (53.2%) Forceps 11/62 (17.7%) Vacuum 0 Cesarian 18/62 (29%) Diabetes 6/123 (4.9%) 4/123 (3.2%) Hipertension Psiquiatric disease 6/123 (4.9%) Neurologic disease 2/123 (1.6%) Lung disease 3/123 (2.4%)
0.5
22/40 (55%) 11/40 (27.5%) 0 7/40 (17.5%) 2/67 (3%) 2/67 (3%) 6/67 (8.9%) 1/67 (1.5%) 2/67 (3%)
0.2
0.7 1 0.35 1 0.68
(27.82 vs 25.92, p = 0.01). When calculated in each trimester, separately, this difference is not statistically significant (Table 3). The general characteristics of UI during pregnancy are shown in Table 2. Of the 224 pregnant women, 77 (34.4%) reported symptoms of UI. This prevalence showed a statistically significant
Table 2 Incontinence data and questionnaire responses. Total Continent (n = 147) Prevalence Type of urinary incontinence Stress Urge Mixed Other Severity (ICIQ-SF) None A small amount A moderate amount A large amount Frequency (ICIQ-SF) Never About once a week o less often Two or three times a week About once a day Several times a day All the time QoL ICIQ-SF score UDI-6 score 6.59 (0–50) Frequent micturiation 59/147 (40.1%) (UDI-6) SF-36 score Physical function 70.97 (5–100) Role physical 65.45 (6.25–100) Bodily pain 65.57 (0–100) General health 77.66 (27–100) Vitality 50.36 (6.25–100) Social function 82.72 (12.5–100) Role emotional 89.34 (0–100) Mental health 75.30 (20–100)
Incontinent (n = 77)
p
77/224 (34.4%) 37/77 (48%) 7/77 (9.1%) 25/77 (32.5%) 8 (10.4%) 0 64/77 (83.1%) 13 (16.9%) 0 0 38/77 (49.3%) 6/77 (7.8%) 14/77 (18.2%) 15/77 (19.5%) 4/77 (5.2%) 2.09 (0–10) 6.59 (2–19) 31.06 (0–75) 33/77 (42.8%)
0 0.72
66.92 (0–100) 53.73 (0–100) 52.56 (0–100) 73.4 (0–100) 47.5 (0–93.75) 75.83 (0–100) 84.74 (0–100) 69.66 (0–100)
0.2 0.004 0 0.05 0.27 0.03 0.13 0.02
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E. Martı´nez Franco et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 182 (2014) 86–90
Table 3 Compared continent and incontinent women in both first and third trimester. 1st Trimester Continent (n = 47) 29.94(20–41) Age BMI 23.55 (18–34) Smoke 11/47 (23.4%) 27/47 (57.4%) Primigravidae Number of previous births 1 17/47(36.2%) 2 3/47(6.4%) 3 0 Maximum weight 3249.5 (2100–4100) of newborn Type of birth Eutocic Forceps Vacuum Cesarian Diabetes 3/43 (7%) Hipertension 2/42 (4.8%) Psiquiatric disease 3/42 (7.1%) 0 Neurologic disease Lung disease 0
3rd Trimester Incontinent (n = 11)
P
Continent (n = 100)
Incontinent (n = 66)
P
28.73 (18–36) 24.91 (20–32) 3/11 (27.3%) 5/11 (45.5%)
0.54 0.32 0.8 0.5
31.2 (17–42) 27.2 (17.04–41.66) 13/94 (13.8%) 58/100 (58%)
31.18 (16–42) 28.43 (19.57–41.14) 13/60 (21.7%) 32/66 (48.5%)
1 0.14 0.2 0.23
6/11 (54.5%) 0 0 3248.3 (2150–3840)
0.43
37/100 (37%) 4/100 (4%) 1/100 (1%) 3344.48 (2500–4300)
31/66 (47%) 1/66 (1.5%) 2/66 (3%) 3245 (2300–4260)
0.4
24/42 (57.1%) 7/42 (16.7%) 0 11/42 (26.2%) 3/80 (3.7%) 2/78 (2.6%) 4/81 (4.9%) 3/80 (3.7%) 1/80 (1.3%)
21/34 (61.8%) 9/34 (26.5%) 0 4/34 (11.8%) 1/57 (1.7%) 2/57 (3.5%) 5/57 (8.8%) 1/57 (1.7%) 2/66 (3%)
0.3
1/10 (10%) 0 1/10 (10%) 0 0
1
0.74 0.48 0.76
difference according to the trimester of pregnancy (Table 4): the prevalence was 19% (11 of 58) in the first trimester and 39.8% (66 of 166) in the third trimester (p = 0.004). Analysis of the type of UI revealed that the most frequent type was SUI, which affected 48% of the pregnant women with incontinence regardless of the trimester (Table 2) and 47% of women during the third trimester of pregnancy. During the first
0.36
0.49 0.75 0.37 0.49 0.6
trimester, SUI was also the most common type of incontinence, with prevalence, in our study, that was even higher than that in the third trimester (54.5%) (Table 4). In the entire sample, urgency urinary incontinence was present in 9.1% of the pregnant women with urinary incontinence and 32.5% showed symptoms of both stress and urgency urinary incontinence. Of the 77 pregnant women with urinary incontinence, 8 reported
Table 4 Compared characteristics of urinary incontinence and questionnaires responses in both trimesters. 1st Trimester Continent (n = 47) Mean
Median
Prevalence Type of urinary incontinence Stress Urge Mixed Other Severity (ICIQ-SF) None A small amount A moderate amount A large amount Frequency (ICIQ-SF) Never About once a week o less often Two or three times a week About once a day Several times a day All the time QoL (ICIQ-SF) 0 0 ICIQ-SF Score 0 0 UDI-6 Score 4.2 0 Frequent micturiation 18/47 (38.3%) (UDI-6) SF-36 score Physical function 86.9 90 (65–100) Role physical 77.4 87.5 (31–100) Bodily pain 70.2 72 (10–100) General health 75.6 77 (42–100) Vitality 51.9 50 (13–88) Social function 81.4 100 (13–100) Role emotional 91.1 100 (25–100) Mental health 75.1 80 (25–100)
3rd Trimester Incontinent (n = 11) Mean
2 6.09 20.8
83.9 60.4 74.1 70.2 55.1 72.7 81.7 62.7
P
Median
Continent (n = 100)
Incontinent (n = 66)
Mean
Mean
Median
Median
11/58 (19%)
66/166 (39.8%)
6/11 (54.4%) 2/11 (18.2%) 1/11 (9.1%) 2 (18.2%)
31/66 (47%) 5/66 (7.6%) 24/66 (36.4%) 6/66 (9%)
0 11 0 0
0 53/66 (80.3%) 13/66 (19.7%) 0
0 6/11 (54.5%)
0 32/66 (48.5%)
0
6/66 (9%)
4/11 (36.4%) 0 1/11 (9.1%) 2 6 16.7 3/11 (27.3%)
85(40–100) 62.5 (19–100) 72 (51–100) 72 (47–92) 50 (31–88) 62.5 (38–100) 95.84 (25–100) 70 (25–90)
0 0 0 0.49
0 0 7.67
0.59 0.15 0.53 0.3 0.67 0.24 0.34 0.12
63.2 56.02 62.15 78 50.36 83.37 84.64 75.3
0 0 8.33 (0–50) 40/99 (40.4%)
65 (5–100) 56.25 (0–100) 62 (0–100) 82 (25–100) 50 (6.25–100) 100 (25–100) 100 (0–100) 80 (20–100)
10/66 (15.2%) 15/66 (23.8%) 3/66 (4.5%) 2.1 1 6.68 6 32.76 33.33 (0–75) 30/66 (45.5%)
64 52 48.9 73.9 46.2 76.4 85.2 70.86
P
65 (15–100) 50 (0–100) 51 (0–100) 77 (22–100) 43.75 (0–93.75) 75 (12.5–100) 100 (0–100) 75 (20–100)
0 0 0
0.81 0.39 0 0.12 0.15 0.06 0.88 0.1
E. Martı´nez Franco et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 182 (2014) 86–90 Table 5 Quality of life affection in incontinent population. QoL ICIQ-SF
n
0 1 2 3 4 5 6 7 8 9 10
25/77 (32.47%) 15/77 (19.48%) 9/77 (10.39%) 8/77 (11.69%) 11/77 (14.28%) 3/77 (3.9%) 2/77 (2.6%) 2/77 (2.6%) 1/77 (1.3%) 0 1/77 (1.3%)
25/77 (32.47%) 43/77 (55.84%)
9/77 (11.69%)
symptoms of urinary incontinence of ‘‘Other type’’ (at the end of urination, when sleeping, etc.). The percentages of the different types of incontinence according to the trimester of pregnancy are shown in Table 4. In all patients, UI was mild to moderate: among the entire sample of pregnant women with incontinence, leakage was slight in 83.1% and moderate in 16.9% (Table 2). During the first trimester, all women with incontinence reported slight leakage, while almost 20% of pregnant women reported moderate incontinence in the third trimester (Table 4). The impact on the quality of life, assessed with the response obtained from the question of the ICIQ-SF, showed a mean value of 2.09 among all the incontinence pregnant women. The average score, in the cohort of first trimester, is 2 (0–5) and in the third trimester, 2.1 (0–10). The breakdown of values is shown in Table 5. The total score obtained in pregnant women with incontinence on the ICIQ-SF questionnaire was 6.59 points, of a maximum total of 21 (Table 2). There were no statistically significant differences between the two trimesters of pregnancy. The scores on the UDI-6 of the PFDI-20 were higher, with a statistically significant difference in patients with UI (31.06 vs 6.59, p = 0). Scores in pregnant incontinent women were significantly higher in women in the third trimester than in those in the first (32.765 vs 20.83, p = 0.04) (Table 4). Of the total number of pregnant women who completed this questionnaire, 92 (41.2%) reported having frequent micturitions in the specific question ‘‘Do you experience, and, if so, how much are you bothered by frequent urination?’’ (Table 2): 21 (36.2%) in group 1 and 71 (42.8%) in group 2, with no statistically significant differences. Women with affirmative response in this question are asked about the discomfort generated by this symptom: it causes some grade of discomfort in 68.48% (‘‘slight’’ discomfort in 31.5%, ‘‘moderate discomfort’’ in 28.3%, and ‘‘great’’ discomfort in 8.7%. of cases) and no discomfort in 31.52%. The responses to the SF-36 questionnaire showed statistically significant differences in the areas of Role Physical, Bodily Pain, General Health, Social Function and Mental Health, with the worst scores in women with symptoms of UI (Table 2). These differences do not appear when we analyze both subgroups, first and third trimester, except for bodily pain in third trimester, that have worst score in women with UI (Table 4). Comments The main objective of this study was to determine the prevalence of UI during pregnancy and whether there are any differences between the characteristics of incontinence and affected women during the first and third trimesters of pregnancy. Many factors can contribute to UI during pregnancy, such as increased pressure due to uterine volume, together with hormonal factors such as relaxin and progesterone [10]. Multiple studies
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show that one of the factors involved in this process is weight gain during pregnancy. Glazener et al. [11] demonstrated that all women with de novo SUI during pregnancy had a BMI above 25 (OR 1.68, 95% CI: 1.12–2.43). According to the literature [4,12], our sample also showed statistically significant differences in this parameter. In this study, pregnant women with urinary incontinence during pregnancy had a higher BMI than unaffected women (27.82 vs 25.92; p = 0.01). This difference was maintained when we analyzed both trimesters, but this difference is not statistically significant when both trimesters are separately analyzed. The most frequent type of UI during pregnancy, but with a highly variable prevalence, is SUI. According to various studies, the prevalence ranges from 18.6% to 75% and increases with gestational age [3]. It is assumed that mechanical and hormonal factors produce urethral hypermobility, which could be the cause of the higher prevalence of SUI in pregnant women than in nonpregnant young women. However, the exact causes of UI during pregnancy are still unknown. Given that both uterine volume and hormone levels differ between the first and third trimesters of pregnancy, the prevalence and characteristics of UI should theoretically also differ between the beginning and end of gestation. The average prevalence in our cohort of pregnant women was 34.37%. In the analyzed sample, the prevalence of UI was significantly higher during the third trimester than during the first (39.76% vs. 18.96%). In the analysis of the different types of UI, the most frequent type was SUI in both the first and third trimesters, but our data differ from those of other studies published to date [13–15]: SUI was more prevalent during the first than during the third trimester. This discrepancy may be due to the significant percentage of pregnant women with mixed UI (36.4%) in the third trimester, which did not occur in the first trimester cohort. If all these women were included within the SUI group—since they also had symptoms of this type of UI—our percentages would be closer to the published data. Urge incontinence was the least prevalent type during pregnancy and was more frequent during the first trimester (18.2% vs 7.6%). The responses to the UDI-6 question about urinary frequency showed that 41.25% of pregnant women experienced increased urinary frequency, which led to some degree of discomfort in 68.48%. This percentage was higher than the discomfort created by UI, suggesting that increased micturition frequency generates greater discomfort than UI. During the first trimester, UI was slight in all patients; however, in the third trimester, almost 20% of incontinent pregnant women reported moderate urine leakage. Nevertheless, the impact on quality of life was low, with an average score on the specific question of the ICIQ-SF of 2 (0–5) in the cohort of first trimester and of 2.1 (0–10) in the third trimester. A breakdown of the scores shows that 32.47% of the pregnant women with UI did not report that their quality of life was impaired by their symptoms (Table 4). In group 1, the highest reported impact on the quality of life was 5 points. In contrast, in group 2, 9.1% of women reported moderate– severe impairment of their quality of life, with scores of between 6 and 10. This finding is common to all publications on the topic [5,16], possibly because women have tended to consider UI as being associated with pregnancy itself, although this trend is undergoing a change, which is one of the motives for studies such as ours. An innovative feature of our study is the incorporation of the SF36 quality of life questionnaire to evaluate the involvement of the different domains in the daily life of the pregnant women with UI. As already mentioned, in 2004, Dolan reported an impact on quality of life in 54.3% of pregnant women, due to urinary incontinence in 4 areas: physical activity, travel, social relationships and emotional health. Our data refer to all domains explored in the SF-36 questionnaire: Physical Function (PF), Role Physical (RP), Bodily Pain (BP),
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General Health (GH), Vitality (VT), Social Function (SF), Role Emotional (RE) and Mental Health (MH). The patients with UI scored worse in all dimensions of the questionnaire, which was statistically significance in RP, SF, GH and MH. This finding indicates that all areas of the quality of life of pregnant women with incontinence are affected: physical, mental and social. Comparison of the scores of pregnant women with incontinence in the first and third trimesters showed that scores were worse for PF and BP, possibly because incontinence is more severe at the end of the pregnancy, but also because it is aggravated by the state of pregnancy itself, which causes the greatest discomfort in the last few weeks. One of the possible limitations of this study is the small number of first-trimester pregnant women with UI. Consequently, differences found between the first and third trimester cohorts should be interpreted with caution. A larger sample size in this cohort would have allowed the results to be analyzed without the using non-parametric tests and would also have allowed a distinction to be made between primiparous and multiparous women. This factor was analyzed in our study and no differences were found in the subgroup of primiparous women in the continent and incontinent samples, nor among the cohorts of the first and third trimesters, suggesting that the small sample size did not represent a possible bias when assessing the results. In conclusion, according to the results obtained, the prevalence of UI in our population of pregnant women was 34.37%, which means that more than a third of the population of pregnant women is affected, and that this disorder is more common during the third trimester of pregnancy than during the first. The most common form was SUI. In all patients, leakage was slight-moderate that did not severely hamper their everyday life but did affect their physical, mental and social domains of their quality of life. Another problem, even more prevalent than incontinence itself, was the increase in urinary frequency. Acknowledgements Mr Gail Craigie: language correction. Ms Raquel Iniesta: Statistical support.
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Urinary incontinence during pregnancy. Is there a difference between first and third trimester? Eva Martı´nez Franco a,*, David Pare´s b, Nu´ria Lorente Colome´ c, Josep Ramon Me´ndez Paredes a, Lluis Amat Tardiu c a b c
Obstetrics and Gynecology Department, Parc Sanitari Sant Joan de De´u, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain General and Digestive Surgery Department, Parc Sanitari Sant Joan de De´u, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain Obstetrics and Gynecology Department, Hospital Universitari Sant Joan de De´u, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 March 2014 Received in revised form 9 July 2014 Accepted 26 August 2014
Objective: The aim of this study is to determine the prevalence and severity of urinary incontinence and to see if there are any differences between first and third trimester of pregnancy. Study design: A cross-sectional study of two groups of women was conducted. All patients attending our hospital for obstetric ultrasound examination during the first trimester (group 1 = less than 13 weeks of pregnancy) and third trimester (group 2 = up to 28 weeks of pregnancy) were eligible for inclusion. All participating women completed self-reported questionnaires: ICIQ-SF, PFDI-20 (UDI-6, CRADI-8, POPDI6) and SF-36. The variables studied were biodemographic data and results from questionnaire responses. Results: From March 2012 to May 2012, 224 consecutive pregnant women were included in this study: group 1 (n = 58) and group 2 (n = 166). The incidence of urinary incontinence during pregnancy is different in first and third trimester: 18.96% (11 of 58) and 39.76% (66 of 166) (p = 0.008). 100% and 84.12% of women with UI in first trimester and third trimester respectively leak a small amount of urine. In 15.87% of group 2 the leakage was a moderate amount of urine. Participants mainly presented Stress UI (78.37%) and urge was only present in 12.16% of them. Conclusions: In conclusion, according to the results obtained, the prevalence of urinary incontinence in our population of pregnant women was 34.37%, which means that more than a third of the population of pregnant women is affected, and that this disorder is more common during the third trimester of pregnancy than during the first. The most common form was stress urinary incontinence, affecting 48.05% of the women. In all patients, leakage was slight-moderate that did not severely hamper their everyday life but did affect their physical, mental and social domains of their quality of life. Another problem, even more prevalent than incontinence itself, was the increase in urinary frequency, affecting 41.25% of the pregnant women and causing discomfort/distress in the 68.8%. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pregnancy Stress urinary incontinence Urinary incontinence
Introduction The most common form of urinary incontinence (UI) during pregnancy is stress urinary incontinence (SUI). It is more common as pregnancy advances and is estimated to affect the quality of life of 54.3% of pregnant women [1]. In addition, both urge incontinence and mixed incontinence can also occur and may
* Corresponding author at: Parc Sanitari Sant Joan de De´u, Universitat de Barcelona, C/Antoni Pujadas num 42, 08830 Sant Boi de Llobregat, Barcelona, Spain. Tel.: +34 936615208 E-mail address: [email protected] (E. Martı´nez Franco). http://dx.doi.org/10.1016/j.ejogrb.2014.08.035 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.
even have a greater negative impact on the quality of life of these patients [2]. The published data on UI during pregnancy are heterogeneous and there are few studies about prevalence of urinary incontinence during pregnancy [3]. Only two studies [4,5] have been published on this topic in Spain and only one of them compared data from the first and last trimesters [5]. In addition, there are few comparative data to determine whether there are any differences between the beginning and end of gestation. This information would be highly useful because the factors that favor the development of urinary incontinence during pregnancy are still scarcely known [6]. The aim of our study was to identify, in our population, the prevalence of UI during pregnancy, its severity, and its impact on
E. Martı´nez Franco et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 182 (2014) 86–90
the quality of life of affected women and to determine whether there are any differences in these parameters between the first and third trimesters of pregnancy.
Table 1 Description of the study population. Total
Materials and methods A cross-sectional cohort study of two groups of women was conducted between March and May 2012. All patients attending our hospital for routine obstetric ultrasound examination during the first trimester (group 1 = less than 13 weeks of pregnancy) and third trimester (group 2 = up to 28 weeks of pregnancy) of pregnancy were eligible for inclusion. We excluded all patients with difficulties in understanding or reading Spanish. All participants were informed of the nature and objectives of the study through a specific document and all signed an informed consent form. This study was approved by the research and ethical committee of our institution. Study variables We collected clinical data and participating women completed the following self-administered questionnaires: the International Consultation on Incontinence Questionnaire [7] (ICIQ-SF), the Pelvic Floor Distress Inventory (PFDI-20) [8], which included the Urinary Distress Inventory (UDI-6), the Colo-rectal Anal Distress Inventory (CRADI-8), the Pelvic Organ Prolapse Distress Inventory (POPDI-6) and the Short Form 36 Heath Survey [9] (SF-36) questionnaire, in validated to the Spanish language. Symptoms of urinary incontinence were classified based on the answer to the question ‘‘When does urine leak?’’ from the ICIQ-SF questionnaire. The patients were divided into four groups: ‘‘stress urinary incontinence’’ if the answer to this question was ‘‘when I cough or sneeze’’ or ‘‘when I am physically active/exercising, ‘‘urge incontinence’’ if the answer was ‘‘before I can get to the toilet’’ and mixed if the woman marked both options. The remaining options for this question were included in a single category that we called ‘‘other’’. The severity of urinary loss was assessed through the specific question of the ICIQ-SF: ‘‘How much urine do you usually leak (whether you wear protective or not)?’’ and was classified into: ‘‘small amount’’, ‘‘moderate amount’’ or ‘‘large amount’’ according to the answer obtained. The impact on quality of life was assessed through the response obtained in the ICIQ-SF and also more specifically with the answers obtained in the different domains of the SF-36 questionnaire. Statistical analysis Data from pregnant women in both trimesters of pregnancy who reported symptoms of UI and from asymptomatic pregnant women were compared using the Chi-square test for categorical variables and Student-t test or the Mann Whitney U-test for quantitative variables. The level of statistical significance of all the tests was set at a bilateral p-value less than 0.05. Results 224 women were included in the study: 58 in group 1 and 166 in group 2, with a total of 147 continent women (47 in first trimester of pregnancy and 100 in third) and 77 incontinent pregnant (11 in first trimester and 66 in third). The clinical data collected from incontinent versus continent women are shown in Table 1. The statistical analysis showed no statistically significant differences in any of the items studied except for body mass index (BMI). BMI was statistically significantly higher in patients with urinary incontinence
87
Age BMI
Continent (n = 147)
Incontinent (n = 77)
p
30.79 (16–42) 25.92 (17.04–41.66)
30.83 (17–42) 27.82 (19.57–41.14)
0.96 0.01
16/71 (22.5%) 37/77 (48%)
0.35 0.16
37/77 (48%) 1/77 (1.3%) 2/77 (2.6%) 3245.5 (2150–4160)
0.13
24/141 (17%) Smoke Primigravidae 85/147 (57%) Number of previous births 1 54/147 (36.7%) 2 7/147 (4.76%) 3 1/147 (0.7%) Maximum weight 3312.3 (2100–4300) of newborn Type of birth Eutocic 33/62 (53.2%) Forceps 11/62 (17.7%) Vacuum 0 Cesarian 18/62 (29%) Diabetes 6/123 (4.9%) 4/123 (3.2%) Hipertension Psiquiatric disease 6/123 (4.9%) Neurologic disease 2/123 (1.6%) Lung disease 3/123 (2.4%)
0.5
22/40 (55%) 11/40 (27.5%) 0 7/40 (17.5%) 2/67 (3%) 2/67 (3%) 6/67 (8.9%) 1/67 (1.5%) 2/67 (3%)
0.2
0.7 1 0.35 1 0.68
(27.82 vs 25.92, p = 0.01). When calculated in each trimester, separately, this difference is not statistically significant (Table 3). The general characteristics of UI during pregnancy are shown in Table 2. Of the 224 pregnant women, 77 (34.4%) reported symptoms of UI. This prevalence showed a statistically significant
Table 2 Incontinence data and questionnaire responses. Total Continent (n = 147) Prevalence Type of urinary incontinence Stress Urge Mixed Other Severity (ICIQ-SF) None A small amount A moderate amount A large amount Frequency (ICIQ-SF) Never About once a week o less often Two or three times a week About once a day Several times a day All the time QoL ICIQ-SF score UDI-6 score 6.59 (0–50) Frequent micturiation 59/147 (40.1%) (UDI-6) SF-36 score Physical function 70.97 (5–100) Role physical 65.45 (6.25–100) Bodily pain 65.57 (0–100) General health 77.66 (27–100) Vitality 50.36 (6.25–100) Social function 82.72 (12.5–100) Role emotional 89.34 (0–100) Mental health 75.30 (20–100)
Incontinent (n = 77)
p
77/224 (34.4%) 37/77 (48%) 7/77 (9.1%) 25/77 (32.5%) 8 (10.4%) 0 64/77 (83.1%) 13 (16.9%) 0 0 38/77 (49.3%) 6/77 (7.8%) 14/77 (18.2%) 15/77 (19.5%) 4/77 (5.2%) 2.09 (0–10) 6.59 (2–19) 31.06 (0–75) 33/77 (42.8%)
0 0.72
66.92 (0–100) 53.73 (0–100) 52.56 (0–100) 73.4 (0–100) 47.5 (0–93.75) 75.83 (0–100) 84.74 (0–100) 69.66 (0–100)
0.2 0.004 0 0.05 0.27 0.03 0.13 0.02
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E. Martı´nez Franco et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 182 (2014) 86–90
Table 3 Compared continent and incontinent women in both first and third trimester. 1st Trimester Continent (n = 47) 29.94(20–41) Age BMI 23.55 (18–34) Smoke 11/47 (23.4%) 27/47 (57.4%) Primigravidae Number of previous births 1 17/47(36.2%) 2 3/47(6.4%) 3 0 Maximum weight 3249.5 (2100–4100) of newborn Type of birth Eutocic Forceps Vacuum Cesarian Diabetes 3/43 (7%) Hipertension 2/42 (4.8%) Psiquiatric disease 3/42 (7.1%) 0 Neurologic disease Lung disease 0
3rd Trimester Incontinent (n = 11)
P
Continent (n = 100)
Incontinent (n = 66)
P
28.73 (18–36) 24.91 (20–32) 3/11 (27.3%) 5/11 (45.5%)
0.54 0.32 0.8 0.5
31.2 (17–42) 27.2 (17.04–41.66) 13/94 (13.8%) 58/100 (58%)
31.18 (16–42) 28.43 (19.57–41.14) 13/60 (21.7%) 32/66 (48.5%)
1 0.14 0.2 0.23
6/11 (54.5%) 0 0 3248.3 (2150–3840)
0.43
37/100 (37%) 4/100 (4%) 1/100 (1%) 3344.48 (2500–4300)
31/66 (47%) 1/66 (1.5%) 2/66 (3%) 3245 (2300–4260)
0.4
24/42 (57.1%) 7/42 (16.7%) 0 11/42 (26.2%) 3/80 (3.7%) 2/78 (2.6%) 4/81 (4.9%) 3/80 (3.7%) 1/80 (1.3%)
21/34 (61.8%) 9/34 (26.5%) 0 4/34 (11.8%) 1/57 (1.7%) 2/57 (3.5%) 5/57 (8.8%) 1/57 (1.7%) 2/66 (3%)
0.3
1/10 (10%) 0 1/10 (10%) 0 0
1
0.74 0.48 0.76
difference according to the trimester of pregnancy (Table 4): the prevalence was 19% (11 of 58) in the first trimester and 39.8% (66 of 166) in the third trimester (p = 0.004). Analysis of the type of UI revealed that the most frequent type was SUI, which affected 48% of the pregnant women with incontinence regardless of the trimester (Table 2) and 47% of women during the third trimester of pregnancy. During the first
0.36
0.49 0.75 0.37 0.49 0.6
trimester, SUI was also the most common type of incontinence, with prevalence, in our study, that was even higher than that in the third trimester (54.5%) (Table 4). In the entire sample, urgency urinary incontinence was present in 9.1% of the pregnant women with urinary incontinence and 32.5% showed symptoms of both stress and urgency urinary incontinence. Of the 77 pregnant women with urinary incontinence, 8 reported
Table 4 Compared characteristics of urinary incontinence and questionnaires responses in both trimesters. 1st Trimester Continent (n = 47) Mean
Median
Prevalence Type of urinary incontinence Stress Urge Mixed Other Severity (ICIQ-SF) None A small amount A moderate amount A large amount Frequency (ICIQ-SF) Never About once a week o less often Two or three times a week About once a day Several times a day All the time QoL (ICIQ-SF) 0 0 ICIQ-SF Score 0 0 UDI-6 Score 4.2 0 Frequent micturiation 18/47 (38.3%) (UDI-6) SF-36 score Physical function 86.9 90 (65–100) Role physical 77.4 87.5 (31–100) Bodily pain 70.2 72 (10–100) General health 75.6 77 (42–100) Vitality 51.9 50 (13–88) Social function 81.4 100 (13–100) Role emotional 91.1 100 (25–100) Mental health 75.1 80 (25–100)
3rd Trimester Incontinent (n = 11) Mean
2 6.09 20.8
83.9 60.4 74.1 70.2 55.1 72.7 81.7 62.7
P
Median
Continent (n = 100)
Incontinent (n = 66)
Mean
Mean
Median
Median
11/58 (19%)
66/166 (39.8%)
6/11 (54.4%) 2/11 (18.2%) 1/11 (9.1%) 2 (18.2%)
31/66 (47%) 5/66 (7.6%) 24/66 (36.4%) 6/66 (9%)
0 11 0 0
0 53/66 (80.3%) 13/66 (19.7%) 0
0 6/11 (54.5%)
0 32/66 (48.5%)
0
6/66 (9%)
4/11 (36.4%) 0 1/11 (9.1%) 2 6 16.7 3/11 (27.3%)
85(40–100) 62.5 (19–100) 72 (51–100) 72 (47–92) 50 (31–88) 62.5 (38–100) 95.84 (25–100) 70 (25–90)
0 0 0 0.49
0 0 7.67
0.59 0.15 0.53 0.3 0.67 0.24 0.34 0.12
63.2 56.02 62.15 78 50.36 83.37 84.64 75.3
0 0 8.33 (0–50) 40/99 (40.4%)
65 (5–100) 56.25 (0–100) 62 (0–100) 82 (25–100) 50 (6.25–100) 100 (25–100) 100 (0–100) 80 (20–100)
10/66 (15.2%) 15/66 (23.8%) 3/66 (4.5%) 2.1 1 6.68 6 32.76 33.33 (0–75) 30/66 (45.5%)
64 52 48.9 73.9 46.2 76.4 85.2 70.86
P
65 (15–100) 50 (0–100) 51 (0–100) 77 (22–100) 43.75 (0–93.75) 75 (12.5–100) 100 (0–100) 75 (20–100)
0 0 0
0.81 0.39 0 0.12 0.15 0.06 0.88 0.1
E. Martı´nez Franco et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 182 (2014) 86–90 Table 5 Quality of life affection in incontinent population. QoL ICIQ-SF
n
0 1 2 3 4 5 6 7 8 9 10
25/77 (32.47%) 15/77 (19.48%) 9/77 (10.39%) 8/77 (11.69%) 11/77 (14.28%) 3/77 (3.9%) 2/77 (2.6%) 2/77 (2.6%) 1/77 (1.3%) 0 1/77 (1.3%)
25/77 (32.47%) 43/77 (55.84%)
9/77 (11.69%)
symptoms of urinary incontinence of ‘‘Other type’’ (at the end of urination, when sleeping, etc.). The percentages of the different types of incontinence according to the trimester of pregnancy are shown in Table 4. In all patients, UI was mild to moderate: among the entire sample of pregnant women with incontinence, leakage was slight in 83.1% and moderate in 16.9% (Table 2). During the first trimester, all women with incontinence reported slight leakage, while almost 20% of pregnant women reported moderate incontinence in the third trimester (Table 4). The impact on the quality of life, assessed with the response obtained from the question of the ICIQ-SF, showed a mean value of 2.09 among all the incontinence pregnant women. The average score, in the cohort of first trimester, is 2 (0–5) and in the third trimester, 2.1 (0–10). The breakdown of values is shown in Table 5. The total score obtained in pregnant women with incontinence on the ICIQ-SF questionnaire was 6.59 points, of a maximum total of 21 (Table 2). There were no statistically significant differences between the two trimesters of pregnancy. The scores on the UDI-6 of the PFDI-20 were higher, with a statistically significant difference in patients with UI (31.06 vs 6.59, p = 0). Scores in pregnant incontinent women were significantly higher in women in the third trimester than in those in the first (32.765 vs 20.83, p = 0.04) (Table 4). Of the total number of pregnant women who completed this questionnaire, 92 (41.2%) reported having frequent micturitions in the specific question ‘‘Do you experience, and, if so, how much are you bothered by frequent urination?’’ (Table 2): 21 (36.2%) in group 1 and 71 (42.8%) in group 2, with no statistically significant differences. Women with affirmative response in this question are asked about the discomfort generated by this symptom: it causes some grade of discomfort in 68.48% (‘‘slight’’ discomfort in 31.5%, ‘‘moderate discomfort’’ in 28.3%, and ‘‘great’’ discomfort in 8.7%. of cases) and no discomfort in 31.52%. The responses to the SF-36 questionnaire showed statistically significant differences in the areas of Role Physical, Bodily Pain, General Health, Social Function and Mental Health, with the worst scores in women with symptoms of UI (Table 2). These differences do not appear when we analyze both subgroups, first and third trimester, except for bodily pain in third trimester, that have worst score in women with UI (Table 4). Comments The main objective of this study was to determine the prevalence of UI during pregnancy and whether there are any differences between the characteristics of incontinence and affected women during the first and third trimesters of pregnancy. Many factors can contribute to UI during pregnancy, such as increased pressure due to uterine volume, together with hormonal factors such as relaxin and progesterone [10]. Multiple studies
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show that one of the factors involved in this process is weight gain during pregnancy. Glazener et al. [11] demonstrated that all women with de novo SUI during pregnancy had a BMI above 25 (OR 1.68, 95% CI: 1.12–2.43). According to the literature [4,12], our sample also showed statistically significant differences in this parameter. In this study, pregnant women with urinary incontinence during pregnancy had a higher BMI than unaffected women (27.82 vs 25.92; p = 0.01). This difference was maintained when we analyzed both trimesters, but this difference is not statistically significant when both trimesters are separately analyzed. The most frequent type of UI during pregnancy, but with a highly variable prevalence, is SUI. According to various studies, the prevalence ranges from 18.6% to 75% and increases with gestational age [3]. It is assumed that mechanical and hormonal factors produce urethral hypermobility, which could be the cause of the higher prevalence of SUI in pregnant women than in nonpregnant young women. However, the exact causes of UI during pregnancy are still unknown. Given that both uterine volume and hormone levels differ between the first and third trimesters of pregnancy, the prevalence and characteristics of UI should theoretically also differ between the beginning and end of gestation. The average prevalence in our cohort of pregnant women was 34.37%. In the analyzed sample, the prevalence of UI was significantly higher during the third trimester than during the first (39.76% vs. 18.96%). In the analysis of the different types of UI, the most frequent type was SUI in both the first and third trimesters, but our data differ from those of other studies published to date [13–15]: SUI was more prevalent during the first than during the third trimester. This discrepancy may be due to the significant percentage of pregnant women with mixed UI (36.4%) in the third trimester, which did not occur in the first trimester cohort. If all these women were included within the SUI group—since they also had symptoms of this type of UI—our percentages would be closer to the published data. Urge incontinence was the least prevalent type during pregnancy and was more frequent during the first trimester (18.2% vs 7.6%). The responses to the UDI-6 question about urinary frequency showed that 41.25% of pregnant women experienced increased urinary frequency, which led to some degree of discomfort in 68.48%. This percentage was higher than the discomfort created by UI, suggesting that increased micturition frequency generates greater discomfort than UI. During the first trimester, UI was slight in all patients; however, in the third trimester, almost 20% of incontinent pregnant women reported moderate urine leakage. Nevertheless, the impact on quality of life was low, with an average score on the specific question of the ICIQ-SF of 2 (0–5) in the cohort of first trimester and of 2.1 (0–10) in the third trimester. A breakdown of the scores shows that 32.47% of the pregnant women with UI did not report that their quality of life was impaired by their symptoms (Table 4). In group 1, the highest reported impact on the quality of life was 5 points. In contrast, in group 2, 9.1% of women reported moderate– severe impairment of their quality of life, with scores of between 6 and 10. This finding is common to all publications on the topic [5,16], possibly because women have tended to consider UI as being associated with pregnancy itself, although this trend is undergoing a change, which is one of the motives for studies such as ours. An innovative feature of our study is the incorporation of the SF36 quality of life questionnaire to evaluate the involvement of the different domains in the daily life of the pregnant women with UI. As already mentioned, in 2004, Dolan reported an impact on quality of life in 54.3% of pregnant women, due to urinary incontinence in 4 areas: physical activity, travel, social relationships and emotional health. Our data refer to all domains explored in the SF-36 questionnaire: Physical Function (PF), Role Physical (RP), Bodily Pain (BP),
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General Health (GH), Vitality (VT), Social Function (SF), Role Emotional (RE) and Mental Health (MH). The patients with UI scored worse in all dimensions of the questionnaire, which was statistically significance in RP, SF, GH and MH. This finding indicates that all areas of the quality of life of pregnant women with incontinence are affected: physical, mental and social. Comparison of the scores of pregnant women with incontinence in the first and third trimesters showed that scores were worse for PF and BP, possibly because incontinence is more severe at the end of the pregnancy, but also because it is aggravated by the state of pregnancy itself, which causes the greatest discomfort in the last few weeks. One of the possible limitations of this study is the small number of first-trimester pregnant women with UI. Consequently, differences found between the first and third trimester cohorts should be interpreted with caution. A larger sample size in this cohort would have allowed the results to be analyzed without the using non-parametric tests and would also have allowed a distinction to be made between primiparous and multiparous women. This factor was analyzed in our study and no differences were found in the subgroup of primiparous women in the continent and incontinent samples, nor among the cohorts of the first and third trimesters, suggesting that the small sample size did not represent a possible bias when assessing the results. In conclusion, according to the results obtained, the prevalence of UI in our population of pregnant women was 34.37%, which means that more than a third of the population of pregnant women is affected, and that this disorder is more common during the third trimester of pregnancy than during the first. The most common form was SUI. In all patients, leakage was slight-moderate that did not severely hamper their everyday life but did affect their physical, mental and social domains of their quality of life. Another problem, even more prevalent than incontinence itself, was the increase in urinary frequency. Acknowledgements Mr Gail Craigie: language correction. Ms Raquel Iniesta: Statistical support.
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