• E-mail
• Print
• Comment
• Font Size
• Digg
• del.icio.us
• Discuss article

Risk Factors for Urinary Incontinence in African-American Women

Posted on: Thursday, 24 February 2005, 03:00 CST

The majority of research on urinary incontinence (UI) has been conducted with Caucasian populations. This correlational, descriptive study was designed to identify prevalence and risk factors for UI and to determine the types of incontinence most commonly seen in healthy African-American women. Results of this study showed that age and education were risk factors for UI in African-American women. It is suggested that African-American women be routinely screened for symptoms of UI as a part of preventive health care.

Urinary incontinence (UI), he involuntary loss of urine sufficient to be a hygienic or social problem, is a health problem that can occur in people of all ages, primarily older females. Estimates of the prevalence of UI range from 10% to 15% in younger adults to 12% to 36% in community-dwelling older adults (Herzog & Fultz, 1990; Vinkers et al., 2001). Although UI is more prevalent as individuals age, it is neither an inevitable part of the aging process nor is it limited to the elderly. Additional risk factors may include race and reproductive risk factors. For the most part, the research on UI has been conducted with Caucasian populations.

Literature Review

The highest prevalence rates for UI have been observed in the elderly. Women 60 years of age and older report UI twice as often as men. In adults less than 60 years of age, the gender differences are more pronounced with younger women reporting prevalence up to three times higher than that for their male counterparts (Herzog & Fultz, 1990; Thorn, 1998). Additionally, institutionalized individuals of both genders experience significantly higher UI prevalence rates (Fantl, Newman, & Colling, 1996).

Associated risk factors for urinary incontinence include reproductive factors, health-related factors such as functional and cognitive deficits, and more recently behavioral risk factors including smoking and obesity. The literature on reproductive correlates of UI such as parity, hysterectomy, and menopause is mixed (Hunskaar et al., 2000). Foldspang, Mommsen, Lam, & Elving (1992) reported that parity increased the risk of stress incontinence. Additionally, vaginal delivery was an established risk factor for developing UI in the immediate postpartum period and in later life. Thorn and Brown (1998) reported that the relative risk of UI associated with parity ranged from 1.3 to 4.6, with the first vaginal birth being associated with the greatest increase in stress incontinence.

The role of hysterectomy in the development of incontinence is evolving. Recent studies showed that individuals who had a hysterectomy were more likely to report UI than those who did not (Hunskaar et al., 2000; Thorn & Brown, 1998). Women with mild or no incontinence prior to hysterectomy had new onset or a worsening of UI 1 year after surgery. This condition continued to worsen over the next 2-year period (Kjerulff, Langenberg, Greenaway, Uman, & Harvey, 2002). According to van der Vaart, van der Born, de Leeuw, Roovers, and Heintz (2002), the odds for incontinence following hysterectomy increased by 30% in women 60 years of age and older but not those who were younger than 60. Additionally, they found that hysterectomy was associated with increased risk for urge incontinence but not with stress incontinence in all ages. Thus the presence of UI following hysterectomy suggests a relationship to the woman's age at surgical intervention and may determine the type of UI that results.

Additional risk factors for incontinence have been cited. These include education, age, functional and sensory impairment, stroke, body mass, and behavioral risks such as cigarette smoking, alcohol use, and overeating (Fultz, Herzog, Raghunathan, Wallace, & Diokno, 1999).

As early as 1989, the National Institutes of Health (NIH) Consensus Development Panel recognized that most of the research on UI had been conducted on Caucasian women. The NIH Consensus Development Conference further emphasized the need for research on ethnic populations (1990). Since that time, limited research has examined race as a risk factor for UI (Bump, 1993; Burgio, Locher, Zyczynski, Hardin, & Singh, 1999). Bump (1993) investigated racial comparisons and contrasts for pelvic prolapse and urinary incontinence. He found no significant racial differences in the prevalence of UI but found differences in the risk profiles, distribution of symptoms, and the conditions causing UI. His findings showed that Caucasian subjects had a prevalence of genuine stress incontinence two to three times that of African-American women and African-American subjects were more likely to report urge incontinence. Fultz et al (1999) determined the prevalence of UI and found a statistically significant relationship between race and involuntary urine loss with 23% of Caucasian women reporting UI in comparison to 16% of African-American women. They reported similar ratios of stress and urge incontinence.

Racial differences in prevalence rates of UI have been, examined using urodynamic results. In a group of 195 African-American, Asian, Hispanic, and Caucasian women, Duong and Korn (2001) found that African-American women (42%) had lower rates of genuine stress incontinence than Hispanic (67%) and Caucasian (59%) women but higher rates of detrusor instability. They further noted that African-American women had higher maximum urethral closure pressures than Hispanic, Caucasian, or Asian women. Similar findings of greater urethral closure pressures along with greater vesicle neck mobility have been reported (Howard, Delancey, Tunn, & Ashton- Miller, 2000). Even though these studies we;re based on small sample sizes, they do provide a beginning explanation for the observed racial differences in ethnically diverse women. Since there may be anatomical differences in urethral sphincter function and urethral support, the question of risk factors for UI in African-American women warrants a closer look.

Bump (1993) cautioned that if the type and frequency of UI varies by race, then the diagnosis, treatment, and preventive strategies may also vary by race. Thus the delineation of racial characteristics in risk factors in UI becomes important for planning screening and other intervention strategies.

Purpose

The purpose of this correlational descriptive study was to identify prevalence and risk factors for urinary incontinence and to determine the types of incontinence most commonly seen in healthy African-American women.

Sample

The target population was healthy African-American women who were recruited from a prestigious African-American women's organization. This historical organization has a national and international presence with local chapters throughout the United States and abroad. Membership in the organization is open only to college students and/or college graduates who must be recommended by three members of the organization.

The convenience sample included anyone in attendance at the conference who volunteered to complete the survey instrument. The criteria for inclusion in the study were membership in the organization, attendance at one of the organization-sponsored conferences, and willingness to participate in the study.

Methodology

A correlational descriptive design was used to estimate the prevalence and risk factors for UI in African-American women. The Incontinence Screening Questionnaire (ISQ] (Romanzi & Blaivas, 1997) was used to collect data. This self-report instrument, shown in Figure 1, consists of 11 questions that differentiate urge from stress incontinence and provide information on number of pads used and amount of leakage. The instrument also measures the degree-of- bother using a visual analog scale with a range of 0 (not at all) to 10 (intolerable). The investigator established test retest reliability using split half calculation on a sample of 233 African- American women. The resulting alpha coefficient was 0.63.

Figure 1.

Incontinence Screening Survey Items

Procedure

The study was conducted at one of the African-American women's organizations regional conferences held in each of two cities in Virginia and two cities in North Carolina. At the beginning of the conferences, the researcher made a public announcement about the study and invited interested persons to meet with her at a designated time and place. Prior to data collection, the researcher explained the study to the prospective participants. Since the participants had no questions, the surveys were distributed. The researcher requested that completed surveys he placed in a box identified specifically for the completed survey forms. Completion and return of the survey instrument constituted a participant's consent to participate. This study was conducted in accordance with the guidelines for protection of human subjects of the Institutional Review Board of Howard University.

Table 1.

Demographic Characteristics (N=233)

Table 2.

Variable in the Equation

Table 3.

Logistic Regression of Predictor Variables

Table 4.

Duration of Incontinence

Data Analysis

Five hundred surveys were distributed at the four locations. A total of 233 surveys were returned, for a return rate of 47%. The surveys were later scored and tallied. The characteristics of the sample were summarized using descriptive statistics. Spearman rho correlation and logistic regression were used to reveal predictors for UI at a significance level of 0.05.

Result\s

Demographics. A total of 233 African-American women 19 to 82 years of age responded by completing the survey. Demographic characteristics of the sample are shown in Table 1. The women were all college students or college graduates with more than half having earned graduate degrees. A majority of the women had incomes ranging from $25,999 to $49,999. A few of the women had no regular source of income because they were full-time college students living at home. A small number (n=6) reported an income of $100,000 and above.

The reproductive history revealed 50% (n=116) of the women had vaginal deliveries. However, the number of vaginal deliveries varied with 37.6% (n=85) of the women reporting one to two vaginal deliveries. Twenty-four women (10.8%) indicated they had three vaginal deliveries and eight (3.5%) had four to five vaginal deliveries. The characteristics of the vaginal deliveries were not determined. When asked if they had experienced a hysterectomy, more than one-quarter (28.5%) of the women responded affirmatively. It is unknown if the hysterectomies were vaginal or abdominal, partial or total hysterectomies.

The women's medication history revealed 24 women (11%) were taking medications. Blood pressure medication was the most commonly reported medication (8%) followed by hormone replacement therapy (6%). Other medications reported included tranquilizers, insulin, arthritis medication, and allergy medication. Specific trade or generic names were not included in the survey.

Prevalence and risk factors. The African-American women in this study reported a prevalence rate for urinary incontinence at 37.6% (n=85). Urge incontinence was reported most often (84%) followed by stress incontinence (76%). Fifty-eight participants (68%) reported a combination of stress and urge incontinence.

Correlation analysis (see Table 2) showed a significant positive correlation between education and age; individuals with the highest education were older. All of the significantly correlated variables were entered into a Logistic Regression equation to identify the predictors of UI. The logistic regression results, shown in Table 3, indicated that education and age had significant effects on incontinence. Income had a negative effect, though the result was not significant.

Descriptive findings. Duration of incontinence ranged from a few weeks to more than 20 years (see Table 4). More than one half of the sample (53%) reported incontinence from 1 to 3 years. The frequency of type of incontinence indicated daily urge incontinence occurred slightly more often than stress incontinence (see Table 5). Nine (11%) of the women reported one or more daily stress accidents and 10 (12%) reported daily urge accidents. Mixed UI was reported by 57 (60%) of the incontinent women.

Table 5.

Frequency of Incontinence by Type (n=83)

Table 6.

Daily Pad Usage (n=48)

Table 7.

The Degree-of-Bother of Incontinence (n=78)

The women had variable pad usage ranging from one to more than four pads a day (see Table 6). More than 20% of the women used at least three pads a day. Four (12.6%) women reported the pads were wet to soaked at night and ten (20.7%) reported the pads were wet to soaked during daytime hours. Thirty-one percent (n=27) of the women stated they had sought prior treatment for their symptoms of UI. The type of treatment participants received, if any, is unknown as is the effectiveness of any treatment. Table 7 shows the degree-of- bother of the incontinence. Of note is that 12 women (15.4%) reported they were not bothered at all. Twenty- one women (32.4%) rated the bother at the midpoint of five and above indicating symptoms were bothersome. Four (5%) of the women reported the UI was intolerable.

Discussion

This prevalence survey provides data on UI in an understudied, nonclinical group of college educated African-American women. The prevalence rate of 37.6% found in this study is similar to that reported by Vinkers et al. (2001). Conversely, it is higher than that reported by Fultz and Herzog (2001) and Burgio et al. (1996).

The identification of age and education as UI risk factors is consistent with findings reported by Fultz et al. (1999) and Burgio et al. (1996). One could question if a more representative sample of African-American women might reveal education as an even stronger predictor of UI. Burgio et al. (1996) explained that women with higher education might be more willing to acknowledge their UI. On the other hand, since the significant effect of education on UI could be explained by its correlation with age, this made it a serendipitous finding secondary to concomitant increases in age. Additional investigation of education as a factor in UI is warranted. It is also likely that the negative effect of income was secondary to increases in age. This is to be expected since income generally tends to be lower in part due to reduced retirement income.

A strength of this study was documentation of the prevalence of UI according to type of incontinence based on the person's history of urine loss. Even though the majority of women had experienced incontinence for 3 years or less, four women had endured incontinence for more than 20 years. Given that two of the four women in that group used several pads during the day and at night, it is suggested that they might have endured a huge burden affecting their quality of life (Ruff, van Rijswijk, & Okoli, 2002). Interestingly, 31% of the women reported having sought treatment for urine loss in the past. However the type of treatment received, if any, and the effectiveness were not determined. In view of the prevalence and duration of the problem, the overall number seeking treatment remains consistently low. The small number seeking treatment is consistent with findings reported by Palmer and Fitzgerald (2002) who found a majority of the women said that getting treatment was of little or no importance to them.

These data documented stress incontinence as a close second behind urge incontinence. This finding is consistent with the literature, which showed that urge incontinence is more prevalent than stress UI in African-American women. The factors most often associated with stress incontinence were coughing and sneezing. It is questionable if the women would report more UI during the cold and flu season. More study is needed on the question of seasonal UI in African-American women.

More than one-quarter of the women reported severe UI based on their reports of having to wear three, four, or more pads daily. One could speculate that this extensive pad use had an impact on their quality of life and on personal finances. Nearly twice as many women had more accidents during the day than at night. This is likely due to the fact that activities that cause increased intraabdominal pressure such as lifting, standing, and coughing are curtailed during nighttime hours. Additionally, at night the women are less likely to consume beverages that increase urine production and subsequent urine loss. However, both of these statements are speculative.

Limitations

One limitation of this study is that the findings are based on self-report of quantity of urine loss which could vary from person to person. However, there is some relevance in having women self- report the amount of leakage and the extent to which they are bothered by it. This is important because the response and reaction to incontinence is unique to each individual with some women reporting no bother and others reporting extreme bother. A second limitation is that there was no attempt to control for the type of pad used by the women.

Another limitation is this convenience sample prohibits the generalization of the results beyond this study group. Additionally, the possibility of selection bias may exist because the participants were all volunteers. The low return rate could lead one to question if those individuals with incontinence were more likely to respond to the invitation to participate and subsequently return the survey.

Conclusion

In spite of the above limitations, several avenues for future inquiry are suggested. Additional research is needed on prevalence and impact of UI in a larger sample of African-American women. Of importance is the role of behavior, including lifestyle in UI, especially the role of education. A clinical implication is that African-American women do experience UI at similar rates as other women and should be routinely screened as a part of preventative health care. Finally this study should be replicated using a larger random and more diverse group of African-American women.

In summary the women in this study were relatively young, middle class, well educated, and at greater risk for UI as they aged. This group of community-based African-American women had a UI prevalence rate of 37.6% which was comparable to rates reported for Caucasian women. They were more likely to report urge incontinence and less likely to report stress incontinence. The impact of the incontinence varied from person to person with some not being bothered by the urine loss and others finding it intolerable.

Introduction

Urinary incontinence (UI) has been understudied in AfricanAmerican women. If type and frequency of Ul varies by race, than diagnosis, treatment, and preventive strategies may also vary by race.

Objective

A correlational descriptive study was used to identify prevalence and risk factors for Ul and to determine the types of incontinence most commonly seen in healthy African-American women.

Methods

The Incontinence Screening Questionnaire (ISQ) was used to collect data. This self-report instrument focused on questions that differentiated urge from stress incontinence and provided information on the number of pads used and amount of leakage. Spearman rho correlation and logistic regression were used to reveal prediction for Ul at a significance level of 0.05.

Results

The African-America\n women in this study reported a prevalence rate for Ul at 37.6%. Urge incontinence was reported most often (84%) followed by stress incontinence (76%). Fifty-eight participants (68%) reported a combination of stress and urge incontinence. Correlational analysis showed a significant positive correlation between education and age.

Conclusion

This sample of African-American women had a Ul prevalence rate of 37.6% which is comparable to rates reported for Caucasian women. African-American women should be routinely screened for symptoms of Ul as part of preventive health care.

References

Bump, R.C. (1993). Racial comparisons and contrasts in urinary incontinence and pelvic organ prolapse. Obstetrics and Gynecology, 81(3), 421-425.

Burgio, K.L., Locher, J. L., Zyczynski, H., Hardin, J. M., & Singh, K., (1996) Urinary incontinence during pregnancy in a racially mixed sample: Characteristics and predisposing factors. International Urogynecology Journal, 7(2), 69-73.

Duong, T.H., & Korn, A.P. (2001). A comparison of urinary incontinence among African American, Asian, Hispanic and White women. American Journal of Obstetrics and Gynecology, 284(6), 1083- 1086.

Fantl, J.A., Newman, D.K., & Colling, J. (1996). Urinary continence in adults: Acute and chronic management. Clinical practice guideline (Rep. No. 2, 1996 Update). Rockville: MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 96- 0682.

Foldspang, A., Monimscn, S., Lam, F.W., & Elving, L. (1992). Parity as a correlate on adult female urinary incontinence prevalence. Journal of Epidemiological Community Health, 46, 595- 600.

Fultz, N.H., Herzog, A.R., Raghunathan, T.E., Wallace, R.B., & Diokno, A.T. (1999). Prevalence and severity of urinary incontinence in older African American and Caucasian women. The Journal of Gerontology: Senes A: Biological Sciences and Medical Sciences, 54, 299-303.

Fultz, N.H., & Herzog, A.R. (2001). Self-reported social and emotional impact of urinary incontinence. Journal of the American Geriatrics Society, 49, 892-899.

Hunskaar, S., Arnold, E.P., Burgio, K., Diokno, A.C., Herzog, A.R., & Mallett, V.T. (2000). Epidemiology and natural history of urinary incontinence. International Urogynecology Journal, 11, 301- 319.

Herzog, A.R., & Fultz, N.H. (1990). Prevalence and incidence of urinary incontinence in community dwelling populations. Journal of American Geriatrics Society, 38(3), 273-281.

Howard, D., Delancey, J.O., Tunn, R., & Ashton-Miller, J.A. (2000). Racial differences in the structure and function of the stress urinary continence mechanism. Obstetrics and Gynecology, 95(5), 713-717.

Kjerulff, K.H., Langenberg, P.W., Greenaway, L., Uman, J., & Harvey, LA. (2002) Urinary incontinence and hysterectomy in a large prospective cohort study in American women. Journal of Urology, 167(5), 2088-2092.

National Institutes of Health Consensus Development Conference. (1990). Urinary Incontinence in adults. Journal of American Geriatrics Society, 38, 265-272.

Palmer, M., & Fitzgerald, S. (2002). Urinary incontinence in working women: A comparison study. Journal of Women's Health, 11(10), 879-888.

Romanzi, L.J., & Blaivas, J.G. (1997). Office evaluation of incontinence. In P.D. O'Donnol (Ed.), Urinaiy incontinence (p. 48). New York: Mosby.

Ruff, C.C., van Rijswijk, L., & Okoli, A., (2002). The impact of incontinence in African American women. Ostomy Wound Management, 48(12), 52-58

Thorn, D. (1998). Variation in estimates of urinary incontinence prevalence in the community: Effects of differences in definition, population characteristics and study type. Journal of American Geriatrics Society, 46(4), 473-480.

Thom, D., & Brown, J.S. (1998). Reproductive and hormonal risk factors for urinary incontinence in later life: A review of the clinical and epidemiological literature. Journal of American Geriatrics Society, 46(11), 1411-1417.

van der Vaart, C.H., van der Bom, J.G., de Leeuw, J.R.J., Roovers, J.P.W.R., & Heintz, A.P.M. (2002). The contribution of hysterectomy to the occurrence of urge and stress urinary incontinence symptoms. BJOG: An International Journal of Obstetrics and Gynecology, 109, 149-154.

Vinkers, S., Kaplan, B., Nakar, S., Samuels, S., Shapira, G., & Kitai, E. (2001). Urinary incontinence in women: Prevalence, characteristics and effect on quality of life. A primary care clinic study. Israel Medical Association Journal, 3(9), 663-666.

Coralease Cox Ruff, DNSc, RN, FNP, is Associate Professor of Nursing and Mentored Research Scientist, Howard University, College of Pharmacy, Nursing and Allied Health Sciences, Washington, DC.

Acknowledgments: The author thanks Carolyn Sampselle from the University of Michigan for her helpful comments and critique of this manuscript. Thanks also to Rosaline lkeakanan, a former graduate student at Howard University, for assistance with data entry.

Copyright Anthony J. Jannetti, Inc. Feb 2005

Source: Urologic Nursing

More News in this Category