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Prevalence of stress urinary incontinence symptoms and their impact on the quality of life of Palestinian women: the first large cross-sectional study among the general population

BMC Women's Health volume 24, Article number: 510 (2024) Cite this article

Abstract

Background

Little studies were conducted to assess the prevalence of stress urinary incontinence among Palestinian women. This study was conducted to determine the prevalence of stress urinary incontinence symptoms, their impact on the quality of life, and the risk factors that were associated with stress incontinence symptoms among Palestinian women.

Methods

This study was conducted in a cross-sectional design from 2023 to 2024. The data were collected through an interviewer-administered questionnaire. The questionnaire collected the demographic and health characteristics of the women. Additionally, the questionnaire also contained the PRAFAB questionnaire (PRAFAB-Q). Moreover, the questionnaire included the Assessment of Quality of Life (AQoL)-8D scale.

Results

Data were collected from 386 Palestinian women (response rate = 85.8%). The mean age of women in this study was 37.1 ± 14.7 years. In this study, 104 (26.9%) reported stress urinary incontinence symptoms. Of the women, 102 (26.4%) reported urinary leakage during coughing, 100 (25.9%) reported urinary leakage during sneezing, and 94 (24.4%) reported urinary leakage during laughing. The women who had a family history of stress incontinence were 2.5-fold (95% CI: 1.2–5.2) more likely to have stress incontinence symptoms compared to the women who did not have a family history of stress incontinence. Similarly, the women who were overweight/obese were 2.0-fold (95% CI: 1.1–3.7) more likely to have stress incontinence symptoms compared to the women who were underweight or had a normal weight. PRAFAB-Q scores were predicted by place of residence, family history of stress incontinence, and being recruited from a hospital.

Conclusion

The study reported a high prevalence of stress urinary incontinence and identified the risk factors that were associated with stress incontinence symptoms among Palestinian women. The findings showed that the intensity of stress urinary incontinence symptoms was associated with deteriorated quality of life of the affected women. These findings could be used by urologists, gynecologists, obstetricians, and other healthcare providers caring for women to design ways to reduce the burden of stress urinary incontinence among Palestinian women and improve their quality of life.

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Background

Stress urinary incontinence is a silent epidemic that has a serious impact on the quality of life of the affected patients [1]. Stress urinary incontinence is one of the most prevalent health problems in older age that is often reported among women [2]. This health condition was reported to cause physical, psychological, social, sexual, and economic issues leading to poor quality of life [3].

The prevalence of stress urinary incontinence among adult women was estimated at 46% [4]. Although the prevalence rates of stress urinary incontinence were variable, in general, these rates increased with age, body mass index (BMI), and during pregnancy [4, 5]. The other risk factors reported in the previous studies included White race and vaginal delivery [6]. Obesity and pregnancy can increase the intra-abdominal pressure. This can weaken the pelvic floor innervation and musculature [7]. This, in turn, can lead to more stress urinary incontinence symptoms. Additionally, these risk factors also contributed to the severity of the symptoms and their impact on the quality of life of the affected women [8].

The pathophysiology of stress urinary incontinence includes a reduction in urethral resistance in the absence of detrusor activity [9]. Exercises for the pelvic floor muscles and weight loss in overweight or obese women are examples of effective early therapies [10]. The mechanism of stress urinary incontinence is still imperfectly understood. Additionally, the optimal treatment strategies for the affected women still need further improvements. For women with bothersome symptoms that do not improve with previous treatments, there are still additional options, such as pessaries or surgery (most frequently mid-urethral mesh sling surgery) [6].

Stress urinary incontinence is a distinct type of urinary incontinence that is characterized by involuntary loss of urine while performing physical activity or movements that increase abdominal pressure [6]. These also include sneezing, coughing, laughing, exercising, and/or lifting heavy weights/objects. Given that the female reproductive and urine systems have similar physical characteristics, females are more likely to experience urinary issues that interfere with sexual function [1, 2, 9]. It is believed that stress urinary incontinence causes various self-esteem issues and anxiety in women. Female sexual function is impacted by the fear and anxiety of stress urinary incontinence during sexual intercourse, and this is linked to the unpredictable nature and chronicity of stress urinary incontinence [11].

In Palestine, a study was conducted to assess urinary incontinence among Palestinian women who had type 2 diabetes mellitus [12]. The study reported a high prevalence of urinary incontinence among Palestinian women with type 2 diabetes mellitus. However, few studies were conducted to assess the prevalence of stress urinary incontinence among Palestinian women with other risk factors. Therefore, this study was conducted to determine the prevalence of stress urinary incontinence among Palestinian women and to assess the risk factors that could be associated with stress urinary incontinence among Palestinian women. Additionally, the impact of stress urinary incontinence symptoms on the quality of life of the affected women was also assessed.

Methods

Study design

This study was conducted in a cross-sectional design. The study design was chosen because of its utility in enabling a reliable estimation of the prevalence of stress urinary incontinence symptoms among women. Therefore, the cross-sectional study design was the most appropriate design to meet the objectives of the study. The study was conducted and reported in adherence to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. Adherence to the STROBE statement is shown in Supplementary Table S1.

Settings

This study was conducted among women in the general Palestinian society. Because we aimed to recruit a large sample of Palestinian women from the general society to assess the prevalence of stress urinary incontinence, women were approached, invited, and recruited from universities, schools, primary healthcare centers, hospitals, and other places where women can be conveniently approached. The women who participated in this study were recruited in the period between October 2023 and March 2024.

Participants

The target population of the study was Palestinian women in the general society. The eligibility criteria included Palestinian women, living in villages, cities, and refugee camps, expressing willingness to participate in the study, and providing informed consent.

Variables, data collection, and measurements

In this study, demographic variables of the women including age, weight, and height were collected. The body mass index (BMI) was calculated from weight and height as body weight divided by the square of the body height. The BMI was categorized as follows: underweight weight: less than 18.5 18.5 kg/m2, normal weight: 18.5 to less than 25 kg/m2, overweight: 25 to less than 30 kg/m2, and obese: 30 kg/m2 or greater [13]. The place of residence was collected as city, village, or refugee camp, the marital status of the women was collected as never married (single) or ever married (currently married, divorced, or widow), and the employment status was collected as employed or unemployed. The women were also asked about their health status including smoking, history of parturition, menopause, history of diabetes mellitus, history of hypertension, history of pelvic surgery, history of chronic cough, and family history of stress urinary incontinence.

The women were asked to report stress urinary incontinence symptoms including urinary leakage during coughing, laughing, sneezing, and/or exercise.

To assess the severity and impact of stress urinary incontinence symptoms among women, the PRAFAB Questionnaire (PRAFAB-Q) was used [14, 15]. The PRAFAB-Q objectively and subjectively assessed the aspects of stress urinary incontinence symptoms in terms of protection (use of pads), amount (of urine leakage), frequency (of urine leakage), adjustment (changes in behaviors as a result of stress urinary incontinence symptoms), and body image (impact of stress urinary incontinence symptoms on self-image). Each part of the PRAFAB-Q contained 5 items and each item can be awarded up to 4 points (1 to 4). The maximal total PRAFAB-Q score can be 20 points (range 5–20) [16].

The impact of stress urinary incontinence symptoms on the quality of life of the women was assessed using the 35-item Assessment of Quality of Life (AQoL)-8D scale [17]. The AQoL-8D scale assessed the impact of stress urinary incontinence symptoms on 8 domains: independent living (4 items), pain (3 items), senses (3 items), happiness (4 items), mental health (8 items), coping (3 items), relationships (7 items), and self-worth (3 items) of the women. Items in each domain can be awarded up to 4–6 points. The maximal total AQoL-8D score can be 175 points (range 35–175). A higher score indicated severe deterioration in the quality of life of the affected woman.

The data were collected through an interviewer-administered questionnaire. The questionnaire collected the demographic and health status variables of the women. In addition, the questionnaire contained the PRAFAB-Q and the AQoL-8D.

The interviews were conducted by final-year medical students who were trained to conduct interviews with patients to collect their demographic information, and past medical and surgical history, and inquire about their health complaints. During the interviews, the women had the opportunity to ask the interviewer to clarify/explain any unclear item.

Validity and reliability

Both, the PRAFAB-Q and the AQoL-8D scales are reliable and valid tools. Previous studies have established that the scales had acceptable internal consistency and stable test-retest scores [14, 18]. As the women were native Arabic speakers, the items in the questionnaire were in Arabic. The items were translated from English to Arabic (forward translation). To assess the accuracy of the translation, the items were back-translated from Arabic to English (back translation) as previously done for other languages [19]. In this study, the PRAFAB-Q had a Cronbach’s alpha of 0.84 and the AQoL-8D had a Cronbach’s alpha of 0.95. These values indicated acceptable internal consistency of the scales used in this study.

Sample size and sampling technique

At the time of the study, approximately 1.5 million women were living in the West Bank of Palestine. The sample size was calculated using Raosoft sample size calculator (http://www.raosoft.com/) at a confidence interval of 95% and a margin of error of 5%. The response proportion was set at 50%. The sample size needed for this study was 385 women. A convenience sampling approach was followed to recruit the sample size needed for this study. To account for potential refusal to participate, it was planned to invite 450 women.

Data analysis

The data collected in this study were handled and analyzed using IBM SPSS v.24. The categorical data were described using frequencies (n) and percentages (%). Continuous data were described using means ± standard deviations (SD). Distributions of categorical variables were assessed using Chi-square tests. To control potentially confounding factors and to calculate the odds ratios (OR), the variables that were significantly associated in the Chi-square tests were included in a multivariate logistic regression model. Continuous data were compared using t-tests or analysis of variance (ANOVA), as appropriate. Correlations were investigated using Pearson’s correlations. To control potentially confounding factors, the variables that were significantly associated in the t-tests and ANOVA were included in a multiple linear regression model. The goodness-of-fit was assessed using the R2. Variance inflation factors of less than 1.8 and tolerance values of > 1.2 indicated an absence of multicollinearity problems. A p-value of < 0.05 indicated statistical significance.

Results

Characteristics of the women

Of the 450 women invited, data were collected from 386 Palestinian women, giving a response rate of 85.8%. The mean age of the women who participated in this study was 37.1 ± 14.7 years. The majority of the women (n = 253, 65.5%) were overweight or obese. Of the women, 228 (59.1%) lived in cities, 257 (66.6%) were ever married, and 123 (31.9%) were employed. The variables of the women are shown in Table 1.

Table 1 The variables of the women who participated in this study (n = 386)
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Prevalence of stress urinary incontinence symptoms among the women

In this study, 104 (26.9%) women reported stress urinary incontinence symptoms, and 282 (73.1%) women did not report stress urinary incontinence symptoms. Of the women, 102 (26.4%) reported urinary leakage during coughing, 100 (25.9%) reported urinary leakage during sneezing, and 94 (24.4%) reported urinary leakage during laughing. The stress incontinence symptoms reported by the women are shown in Table 2.

Table 2 Stress urinary incontinence among the women
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Answers of the women on the PRAFAB-Q

The mean PRAFAB-Q score was 7.0 ± 2.6. The distribution of the answers of the women on the PRAFAB-Q items is shown in Table 3.

Table 3 PRAFAB-Q scale answers among the women who had stress urinary incontinence symptoms
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Answers of the women on the AQoL-8D scale

The distribution of answers of the women on the AQoL-8D scale is shown in Table 4. The mean AQoL-8D overall score was 61.5 ± 18.4. The scores of the 8 domains: independent living, pain, senses, happiness, mental health, coping, relationships, and self-worth are shown in Supplementary Table S2.

Table 4 Distribution of answers of the women on the AQoL-8D scale
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Association between the variables of the women, stress urinary incontinence, PRAFAB-Q scores, and AQoL-8D scores

When the categorical variables were compared using Chi-square tests, stress urinary incontinence was significantly associated with older age, being overweight/obese, being married, having a history of diabetes mellitus, having a history of hypertension, having a history of parturition, being in menopause, and having a family history of stress urinary incontinence. These associations are shown in Supplementary Table S3.

The PRAFAB-Q scores were significantly higher for the women who were older than 50 years, lived in refugee camps, had a history of diabetes mellitus, had a history of hypertension, were in menopause, had a family history of stress incontinence, and were recruited from hospitals. These associations are shown in Supplementary Table S3.

There was a significant positive correlation (Pearson’s r = 0.38, p-value < 0.001) between AQoL-8D scores and PRAFB-Q scores. Similarly, the women who reported stress urinary incontinence symptoms also reported deteriorated quality of life as indicated by the AQoL-8D overall scores and the scores of the 8 domains: independent living, pain, senses, happiness, mental health, coping, relationships, and self-worth. The differences between the scores of the women who reported stress incontinence symptoms and those who did not report stress incontinence symptoms are shown in Supplementary Table S4.

When the variables that were significantly associated in the univariate analysis were included in a multivariate logistic regression model. The model showed that the women who had a family history of stress incontinence were 2.5-fold (95% CI: 1.2–5.2) more likely to have stress incontinence symptoms compared to the women who did not have a family history of stress incontinence. Similarly, the women who were overweight/obese were 2.0-fold (95% CI: 1.1–3.7) more likely to have stress incontinence symptoms compared to the women who were underweight or had a normal weight. These results are shown in Table 5.

Table 5 Predictors of having stress incontinence symptoms
Full size table

When the variables that were significantly associated in the univariate analysis were included in a multiple linear regression model. The model showed that PRAFAB-Q scores were predicted by place of residence, having a family history of stress incontinence, and the place from where the women were recruited. These results are shown in Table 6.

Table 6 Predictors of PRAFAB-Q scores
Full size table

Discussion

Stress urinary incontinence is one of the prevalent burdensome urological health conditions that affect a considerable proportion of women around the world [4, 20, 21]. Although the prevalence of stress urinary incontinence was previously reported among different populations including women, however, there is still a paucity of studies investigating the prevalence and the risk factors that could be associated with this bothersome urological health condition among Palestinian women. For the first time, this study aimed to fill this gap in the literature by assessing the prevalence of stress urinary incontinence among Palestinian women and identifying potential risk factors associated with this condition within the general Palestinian society. It is noteworthy to mention that stress urinary incontinence as characterized by leakage of urine during activities like laughing, sneezing, and coughing can impact the quality of life of the affected women [6]. Therefore, understanding the prevalence and the risk factors of stress urinary incontinence among Palestinian women could be important in informing decisions to mitigate the modifiable risk factors reduce the prevalence of this burdensome condition, and improve the quality of life of Palestinian women. The findings of this study could be valuable to urologists, gynecologists, obstetricians, and other healthcare providers caring for women.

In this study, the prevalence of stress urinary incontinence symptoms among Palestinian women was 26.9%. This prevalence rate was consistent with those reported in the literature. Previous studies have reported that stress incontinence affects between 15 and 30% of women around the world [6, 21]. It is important to note that the prevalence of stress urinary incontinence varied by the population investigated, the prevalence of other risk factors, and the methodology used to inquire about the frequency of the symptoms [6]. Stress urinary incontinence was previously shown to be influenced by age, number of vaginal deliveries, central obesity, and the health of the pelvic floor [6, 7, 9, 10]. The findings reported in this study were consistent with those reported among women elsewhere. These findings indicate that urologists, gynecologists, obstetricians, and other healthcare providers should consider assessing and addressing stress urinary incontinence symptoms among women at risk.

The results of this study showed that many demographics and health-related risk factors were associated with stress urinary incontinence among Palestinian women. These factors included older age, obesity, menopausal status, diabetes, hypertension, and family history of stress incontinence. These results were consistent with a previous study that investigated stress urinary incontinence among Palestinian women with diabetes and other studies that were conducted among women elsewhere [6, 7, 9, 10, 12]. All these factors are known to weaken the pelvic floor muscles, decrease support of the urethra, and predispose women to stress urinary incontinence [9, 10]. Therefore, healthcare providers should consider interventions that can improve the strength of the pelvic floor muscles and improve the support of the urethra [6, 10].

The PRAFAB-Q scores were significantly associated with older age, living in unfavorable conditions like living in refugee camps, and having other health conditions that are known to deteriorate urological bother symptoms like diabetes, hypertension, and multiparity [15, 16]. In this study, the women who were recruited from refugee camps had significant PRAFAB-Q scores compared to the women who were recruited from cities and villages. These findings indicated more severe stress urinary incontinence symptoms and a more pronounced impact on the quality of life of the affected women living in refugee camps. Our results can be explained by the unfavorable living conditions of the women living in refugee camps including high psychosocial stress, overcrowding, limited access to healthcare facilities, and limited affordability of healthcare services which are known to exacerbate health conditions including stress urinary incontinence symptoms [22, 23]. Moreover, the women who were recruited from hospitals had significantly higher PRAFAB-Q scores compared to the women who were recruited from schools, universities, and primary healthcare centers. These findings indicated that comorbidities can exacerbate stress urinary incontinence symptoms. These findings were consistent with those reported in previous studies [15, 16]. Together, these findings indicated that healthcare providers should consider environmental and contextual factors when assessing women with stress urinary incontinence symptoms. Moreover, these results indicated that the PRAFAB-Q can be used to screen for stress urinary incontinence and monitor improvements brought by treatments and other nonpharmacological interventions [14].

The Palestinian women who reported stress urinary incontinence also reported deteriorated quality of life as measured by the AQoL-8D scale. These findings were not surprising as stress urinary incontinence is known to deteriorate the quality of life of the affected patients [24, 25]. Understanding the negative impact of stress urinary incontinence on the quality of life and well-being of women might motivate designing measures and interventions to screen for and address this bothersome health issue.

Limitations

Because a convenient sample was used in this study, there is a possibility for selection bias. This bias could have limited the external validity of the results. Second, the study was conducted using a questionnaire. It could have been more interesting to clinically assess the women by urologists who are competent in evaluating the symptoms. The study was conducted using a cross-sectional design. This design has many disadvantages including limitations in establishing causal relationships between the variables.

Conclusion

The study reported a high prevalence of stress urinary incontinence and identified the risk factors that were associated with stress incontinence symptoms among Palestinian women. The findings showed that stress urinary incontinence symptoms were predicted by having a family history of stress incontinence and being overweight/obese. Moreover, the intensity of stress incontinence symptoms was associated with deteriorated quality of life of the affected women. These findings could be used by urologists, gynecologists, obstetricians, and other healthcare providers caring for women to design ways to reduce the burden of stress incontinence among Palestinian women and improve their quality of life.

Data availability

All data analyzed in this study were included in the manuscript or as supplementary materials. The datasets used in the analysis or entered into statistical software can be obtained from the corresponding author upon making a reasonable request.

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Acknowledgements

The authors would like to thank the study participants. An-Najah National University is acknowledged for making this study possible.

Funding

This study did not receive any specific funding.

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Authors and Affiliations

  1. Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine

    Mohamad AboAlheija, Eleen Masarweh, Yara Qasem, Hatim Hijaz & Riad Amer

  2. An-Najah National University Hospital, Nablus, Palestine

    Hatim Hijaz, Riad Amer & Ramzi Shawahna

  3. Department of Physiology, Pharmacology, and Toxicology, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine

    Ramzi Shawahna

  4. Clinical Research Center, An-Najah National University Hospital, Nablus, Palestine

    Ramzi Shawahna

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  1. Mohamad AboAlheija
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Contributions

Hatim Hijaz, Riad Amer, and Ramzi Shawahna were involved in the conception and design of the work, analysis and interpretation of data, and drafting and final approval of the manuscript. Mohamad AboAlheija, Eleen Masarweh, and Yara Qasem were involved in the data acquisition, analysis, drafting of the work and final approval of the version to be published. All authors approved the final manuscript.

Corresponding authors

Correspondence to Hatim Hijaz or Ramzi Shawahna.

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Ethics approval and consent to participate

Approvals were obtained from the Institutional Review Board of An-Najah National University (Ref. # Med.Nov.2023/27). Written informed consent was obtained from each participant. Moreover, approvals were also obtained from the Ministry of Health and managers of the hospitals/clinics. The women provided informed consent. All data were kept confidential and the privacy of the women was protected.

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AboAlheija, M., Masarweh, E., Qasem, Y. et al. Prevalence of stress urinary incontinence symptoms and their impact on the quality of life of Palestinian women: the first large cross-sectional study among the general population. BMC Women's Health 24, 510 (2024). https://doi.org/10.1186/s12905-024-03360-0

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