Korean Women - Study Proves That Syndrome Does Not Effect on Sexual Life

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1 (25) 17, & 25 Nature Publishing Group All rights reserved /5 $3. The effect of overactive bladder syndrome on the sexual quality of life in Korean young and middle aged women YH Kim 1, JT Seo 2 and H Yoon 3 * 1 Department of Urology, College of Medicine, Soonchunhyang University, Bucheon, Republic of Korea; 2 Department of Urology, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea; and 3 Department of Urology, Medical Research Center, College of Medicine, Ewha Womans University, Makdong Hospital, Mokdong, Yangcheon-ku, Seoul, Republic of Korea Some reports showed that urinary incontinence () or female lower urinary tract symptoms (LUTS) affect life quality and sexual activity. In clinical practice, it is commonly found that not only the symptoms of but also overactive bladder () syndrome affect daily lifestyle and sexual activity, especially in women in the most active era in their social and personal life. However, there is lack of data proving the effect of syndrome on sexual activity or sexual life quality in sexually active age group. This study aimed at evaluating the effect of syndrome and on the sexual activity and on the sexual quality of life (QoL) of Korean women age from 2s to 4s. We investigated 3372 women aged between 2 and 49 y, enrolled via a multicenter internet survey. A structured questionnaire was used to collect data about their LUTS and sexual activities. The prevalence of syndrome and in 3372 women was 12.7 and 21.%, respectively. Mean subject age was y and 79.5% of subjects were 2 29 y old. Having syndrome or were found to be significant predictors of sexual life problems ( syndrome: OR ¼ 5.8, 95% CI ¼ ; : OR ¼ 4.16, 95% CI ¼ ). Sexual activity was significantly reduced in syndrome and versus the asymptomatic group ( syndrome: OR ¼ 4.8, 95% CI ¼ ; : OR ¼ 3.9, 95% CI ¼ ). This study is the first internet-based study concerning the sexual QoL in and syndrome. In this study, syndrome was found to cause a greater deterioration in the sexual QoL than. These results suggest that these symptoms have a significant impact upon women s personal and social lives and markedly affect the QoL. (25) 17, doi:.38/sj.ijir Published online 28 October 24 Keywords: overactive bladder syndrome; sexual life; quality of life Introduction *Correspondence: H Yoon, Department of Urology, Ewha Womans University, Makdong Hospital, #911-Mokdong, Yangcheon-ku, Seoul 1587, Republic of Korea. wowhana@ewha.ac.kr Received 4 December 23; revised 29 March 24; accepted September 24 Lower urinary tract symptoms (LUTS) affect personal lifestyle and life quality. In 1979, Surtherst 1 reported that 46% of women with urologic symptoms experience a reduced frequency of sexual intercourse due to symptoms such as deep dyspareunia, depression, and embarrassment. Clinically, we often meet patients complaining of significant lifestyle changes due to bothersome voiding symptoms. Moreover, there are several reports supporting the notion that LUTS may affect sexual life. 2 6 Overactive bladder () syndrome is defined by urgency, with or without urge incontinence, usually with frequency and nocturia. 7,8 Although we know that the incidence of syndrome increases with age, 9 11 little is known about the influence of syndrome on sexual life variables. There is lack of data even on younger age groups who are presumed to have much more active sexual lives. Urinary leakage or sexual life problems are highly personal issues and women are often ashamed of those symptoms. However, internet surveys guarantee anonymity, and offer accessibility and security. With these advantages and given the popularity of the internet, we performed an internet-based evaluation of the influence of urinary incontinence () and syndrome on the sexual activity and the sexual quality of life (QoL) in Korean women in

2 their 2 4s, who are generally considered to be a sexually active age group. Materials and methods Study subjects From 22 April 22 to 5 May 22, 3372 Korean women aged 2 49 y were enrolled in an internet survey through a website. We made our questionnaire displaying page on the website, and it was freely enterable if it was a registered user of this website. Women who visited to this website could enter and click the answers in the structured questionnaire page if they want. Among the 3932 registered women, respondents with: more than one missing answer, more than two answers to one question, a previous or current medical history of a cerebrovascular accident (CVA), spinal cord injury, or diabetes mellitus (DM) were excluded. Questions were prepared by research groups consisting of professors of urology, preventive medicine and nursing science. These groups constructed a Korean - and QoL questionnaire, which was based on the Bristol female lower urinary symptom questionnaire, 12 and the QoL questionnaire by Wager et al, 13 using the standardization terminology of the International Continence Society (ICS). 8 A total of 23 questions were categorized into six domains: general characteristics (age, occupation, residence, past medical history including urinary tract infection(uti), family history and parity), LUTS of syndrome (urgency, frequency, nocturia and urge incontinence),, sexual life (sexual activities and sexual life qualities), daily life activity limiting factors(limitation of water intake and going a certain place, toilet checking), QoL, and general insight about and syndrome (see Appendix A). The validity and reliability of the Korean - and QoL questionnaire were tested before using the questionnaire to this study. was ascertained by the reporting of a history of any involuntary leakage of urine. syndrome was defined using the ICS definition, that is, having urinary symptoms of urgency with or without urge incontinence, with frequency and nocturia. 8 Frequency was defined as voiding at least eight times per day. Nocturia was defined as more than one bothersome awakening to void, urgency was defined as an abrupt, strong desire to void, and when it was very hard to hold. Having problems or deteriorations in sexual life quality were regarded by answers to three questions (question number 19, 2, 21): need to empty bladder before and after the intercourse, coital incontinence, avoiding sexual intercourse or sexual activity because of current voiding problems (see Appendix A). Statistical analysis The data were analyzed using the statistical package for the social sciences for Windows (SPSS Inc., release.). Each response to question items was analyzed and compared among nonsymptomatic,, and syndrome groups. During exploratory data analysis, frequency distributions and cross tabulations for categorical variables were used to identify and validate the data. Statistical significance was accepted Po.5. To compare frequencies, we used the w 2 test. Multiple logistic regression analysis was applied to control for potential confounders (age, occupation, residence, family history, history of UTI, and parity) using sexual problems and daily life quality changes as the outcome variable. Associations are expressed as odds ratios (ORs) and 95% confidence intervals (CIs), Results The mean age of the subjects was and 2 29 y olds (79.5%) constituted the largest age group. This is probably the result of the make-up of internet users. Office workers, housewives, and students represented 25.8, 22.1, and 18.1% of the survey respondents, respectively (Table 1). In total, Table 1 General characteristics of 3372 subjects Variable Frequency (%) Age (y) (79.5) (18.3) (2.2) Type of occupation Office worker 869 (25.8) Housewife 745 (22.1) Student 611 (18.1) Others 78 (32.) No 69 (2.) Residence Rural 1154 (34.2) Urban 2218 (65.8) History of UTI No 2278 (82.4) Yes 594 (17.6) Parity No 2667 (79.1) Yes 75 (2.9) Urinary incontinence No 2665 (79.) Yes 77 (21.) Overactive bladder No 2943 (87.3) Yes 429 (12.7) 159

3 16 Table 2 Prevalence of problems or difficulties in sexual life by study variables a Sexual problems or difficulties Variable No Yes P-value Age group (y) (95.2) 13 (4.8) (93.8) 38 (6.2) (89.3) 8 (.7) % Yes No Occupation.4 Office worker 822 (94.6) 47 (5.4) Housewife 699 (93.8) 46 (6.2) Student 583 (95.4) 28 (4.6) Others 24 (95.) 54 (5.) No 68 (98.6) 1 (1.4) b Residence.72 Rural 96 (95.) 58 (5.) Urban 2 (94.7) 118 (5.3) History of UTI o.1 No 267 (96.1) 8 (3.9) Yes 526 (88.6) 68 (11.4) Parity.8 No 2537 (95.1) 13 (4.9) Yes 659 (93.5) 46 (6.5) Urinary incontinence o.1 No 2577 (96.7) 88 (3.3) Yes 619 (87.6) 88 (12.4) Overactive bladder syndrome No 2836 (96.4) 7 (3.6) Yes 36 (83.9) 69 (16.1) Total 3196 (94.8) 176 (5.2) o % of the subjects had experienced urinary tract infection, 79.1% were nulliparous, and 65.8% resided in an urban area. In all, 29% (977) of the respondents had urgency, 2.7% (698) had frequency, 7.2% (24) had nocturia, and 19.2% (646) had urge incontinence. The prevalences of and syndrome were 21. and 12.7%, respectively (Table 1). By bivariate analysis (Table 2), sexual problems tended to increase with age (P ¼.4). No differences were observed in terms of occupation, place of residence, or parity. Sexual problems were found to be related with a history of urinary tract infection (Po.1). Significantly more of those having and syndrome experienced sexual problems (Po.1, respectively). Regarding the effect of voiding symptoms on life quality, 5% of all respondents were wearing pads in daily activity due to urine leakage and significant numbers of women with syndrome or incontinence replied that they try to avoid going out due to their voiding symptoms: S 46.4%, 36.5% (Po.1) (Figure 1a). In 46.4% of syndrome group and 3.3% of group replied that they drink less fluid % c % Yes when they go out to avoid voiding problems, and it was more significant in syndrome group compared with group (Po.1) (Figure 1b). They also replied that they check where the toilet is when going to an unfamiliar place and avoid going to a place without a toilet, and it also showed significant differences between two groups ( syndrome: 58.5%, : 46.1%, Po.1) (Figure 1c). In daily life, relative risks to asymptomatic group of syndrome and were 11. and 2., respectively. In sexual life, relative risks to asymptomatic group of syndrome and were 4.6 and 17.5 No 33.7 Yes Figure 1 Effects of syndrome and urinary incontinence() on daily life. (a) Avoiding going out because of the voiding symptoms, (b) limiting water intake, (c) confirming where the toilet is before going out of the house. Yes, women ensured yes to corresponding symptoms. No; women ensured no to corresponding symptoms. *po.1. No

4 relative risk , respectively (Figure 2). Both the syndrome and incontinence groups experienced problems in daily and sexual life due to their voiding symptoms, and the syndrome group was at greater risk of such disruption (Po.1). Women with syndrome complain of repeated experiences of having to go to the toilet or of needing to void during intercourse. Possible confounders were controlled for by multiple logistic regression analysis (Tables 3 and 4). A history of urinary tract infection remained an independent predictor of sexual problems. In syndrome (OR ¼ 3.37, 95% CI ¼ ) and in (OR ¼ 2.77, 95% CI ¼ ), they were significantly and positively correlated with sexual problems or difficulties. After controlling of other factors, syndrome (OR ¼ 5.8, 95% CI ¼ ) and (OR ¼ 4.16, 95% CI ¼ ) were identified as significant predictors of sexual and daily life quality problems (Tables 3 and 4). Discussion daily life 4.8 Sexual dysfunction has a significant health impact and affects the QoL of many women. LUTS affect one s personal QoL, and many reports have revealed that LUTS in women is significantly correlated with deterioration in sexual life. Therefore, we should be concerned about the correlation between LUTS and the quality of sexual life not only upon the QoL. Approximately 2 million people worldwide suffer from, and less than 2% received treatment. The World Health Organization s (WHO s) conservative estimates are that the worldwide direct and indirect costs of exceed $16 billion annually. is a symptomatic term, and is defined by 3 sexual life syndrome Figure 2 Relative risks of disturbance to daily and sexual life for syndrome and urinary incontinence () compared to asymptomatic group. Data are corrected for age, occupation, residence, parity, and UTI history variables; *Po.1 Table 3 Multiple logistic regression analysis of problems or difficulties in sexual life Model OR 95% CI P-value 3 39 y y Salary Housewife Student Other UTI (reference ¼ No) o.1 Obstetric event (reference ¼ No) (reference ¼ No) o y y Salary Housewife Student Other UTI (reference ¼ No) o.1 Obstetric event (reference ¼ No) (reference ¼ No) o.1 Table 4 Multiple logistic regression analysis of syndrome and on daily activity and life quality Model OR 95% CI P-value syndrome 3 39 y y Salary Housewife Student Other UTI (reference ¼ No) o.1 Obstetric event (reference ¼ No) o.1 1 (reference ¼ No) o y y Salary Housewife Student Other UTI (reference ¼ No) o.1 Obstetric event (reference ¼ No) o.1 1 (reference ¼ No) o.1 symptoms of frequency, urgency, or urge incontinence. Although the incidence of is not well documented, Farrar et al 14 and Abrams 15 described the prevalence of as ranging from 8 to 5%, 161

5 162 and to depend on age. The usual prevalence of in premenopausal women is 5 %, and this increase with age to as much as 8% in the institutionalized incontinent elderly. 16,17 Even though its prevalence varies in study populations, and upon the inclusion criteria adopted, it certainly impacts QoL at a level equal to that of. Lapitan and Chye 18 investigated the prevalence of in 552 Asian women and it was 53.1%. In Korea, Korean continence society investigated the prevalence of syndrome in 25 men and women over age 4 by telephone interviews. 19 They reported that 3.5% of responders had at least one of the symptoms among urgency, frequency, or urge incontinence (men: 27.%, women: 34.%). In total, 7.9% of women had both urgency and frequency in their study. There is a few report on epidemiologic study of and LUTS in Korean women. 11,19,2 In their reports, we could find correlations between or LUTS and QoL. However, there is lack of data concerning the effect of syndrome on sexual life yet. Although is much less prevalent in the younger age groups, it probably has a more marked effect on the individual s personal life. We investigated the prevalence of syndrome in women in their 2s 4s, and found that it was 12.7%. This prevalence is higher than reported by any other study, perhaps because of the inclusion criteria used. In total, 19.2% of respondents had more than one experience of urge incontinence, and 5% were wearing a pad due to incontinence. Moreover, a history of UTI and a family history were found to correlate significantly with syndrome. Age, occupation, history of UTI, parity, and family history were also found to be related to. However, syndrome was found to interrupt daily life 11- fold versus asymptomatic women, and by 2.9- fold. These condition also interrupt sexual life: syndrome versus the asymptomatic group by 4.8:1, and versus the asymptomatic group by 3.9:1. These data are similar to the report by Shaw. 2 In his study, sexual relations varied depending on diagnosis. Those with detrusor instability (DI) were found to experience more difficulty than those with genuine stress incontinence (GSI). Several studies have reported on the impairment in sexual lives as a result of urinary symptoms. 1,21 25 Some reports have found that patients with urinary symptoms due to a combination of GSI and DI experience more sexual dissatisfaction than patients with GSI alone. 1,22,23 However, there is some debates as to whether urinary leakage occurs more commonly in DI than in GSI. We believe that LUTS are more important with respect to sexual activity and sexual satisfaction than urine leakage during intercourse. This study showed that women with syndrome complain of repeated experiences of having to go to the toilet or of needing to void during intercourse. However, we could not extract those factors most responsible for sexual problems in relation to sexual partner, sexual relations, and the sexual QoL. Walters et al 26 reported that women with DI experience more pain during intercourse and sexual-related problems. Women with syndrome often suffer from suprapubic pain or discomfort, dysuria and vulvodynia. 26 These symptoms may be aggravated during or after intercourse, and therefore they may negatively affect sexual life and reduce the quality of sexual life. In addition, women usually think of themselves as unattractive if they have to wear pads in bed. Moreover, women with GSI or syndrome show an increased tendency to be depressed due to their voiding problems. 27,28 Based on this fact, we suggest that a lack of self-confidence and a negative body image due to voiding symptoms are secondary causes of a subdued sexual life and the avoidance of sexual activity. This study has some limitations. First, even though our study is the first internet-based study concerning the sexual QoL in incontinence and syndrome in Korean young and middle-aged women, it certainly has disadvantage of not being able to confirm any of the data obtained. In spite of this limitation, we gave consequence to advantage of anonymity of the internet-based survey. Therefore, it offers more easier and safer access to get a sexual life related personal data. Second, we did not classify incontinence by type. However, we obtained meaningful data about the effects of and syndrome upon personal life and upon the subfactors related to the QoL. In particular, our data support the notion that syndrome has great bearing upon the sexual lives of women in their 2s 4s. Conclusion In this study, syndrome was found to cause a greater deterioration in a woman s sexual QoL than. Our results suggest that the symptoms of have a significant impact upon the sexual well being of the QoL of women in their 2s 4s. We urge that physicians pay more concern to sexual issues when managing patients. References 1 Sutherst JR. Sexual dysfunction and urinary incontinence. Br J Obstet Gynecol 1979; 86: Temml C et al. Urinary incontinence in both sexes: prevalence rates and impact on quality of life and sexual life. Neurourol Urodyn 2; 19: Clark A, Romm J. Effect of urinary incontinence on sexual activity in women. J Reprod Med 1993; 38: Hilton P. Urinary incontinence during sexual intercourse: a common, but rarely volunteered, symptom. Br J Obstet Gynaecol 1988; 95:

6 5 Field SM, Hilton P. The prevalence of sexual problems in women attending for urodynamic investigation. Int Urogynecol J 1991; 4: Shaw C. A systematic review of the literature on the prevalence of sexual impairment in women with urinary incontinence and the prevalence of urinary leakage during sexual activity. Eur Urol 22; 42: Abrams P, Blaivas JG, Stanton SL, Anderson JT. Standardization of terminology of lower urinary tract function. Neurourol Urodyn 1998; 7: Abrams P et al. Standardization of terminology of lower urinary tract function: report from the standardization subcommittee of the international continence society. Neurourol Urodyn 22; 21: Elving LB, Foldspang A, Lam GW, Mommsen S. Descriptive epidemiology of urinary incontinence in 3 women age Scand J Urol Nephrol 1989; 125: Malone-Lee JG. New data on urodynamics in the symptomatic elderly. Neurourol Urodyn 1988; 7: Choo MS et al. The prevalence of overactive bladder in Korea. Int Urogynecol J 21; 12, abstract S Jackson S et al. The Bristol female lower urinary tract symptoms questionnaire: development and psychometric testing. Br J Urol 1996; 77: Wagner TH et al. Quality of life of persons with urinary incontinence: development of a new measure. Urology 1996; 47: Farrar DJ et al. Urodynamic analysis of micturition symptoms in the female. Surg Gynecol Obstet 1975; 141: Abrams P. Detrusor instability and bladder outlet obstruction. Neurourol Urodyn 1985; 4: Moller LA, Lose G, Jorgensen T. The prevalence and bothersomeness of lower urinary tract symptoms in women 4 6 years of age. Acta Obstet Gynecol Scand 2; 79: Milsom I, Stewart W, Thuroff J. The prevalence of overactive bladder. Am J Manage Care 2; 6: Lapitan MC, Chye PL. The epidemiology of overactive bladder among females in Asia: a questionnaire survey. Int Urogynecol J 21; 12: Song HJ, Lee DH, Lee JY, Kim MJ. Epidemiologic study of urinary incontinence for Korean Women over 3 years old. J Korean Cont Soc 21; 5: Choo MS et al. Prevalence of stress urinary incontinence and bladder irritative symptoms in women: a community based survey. Korean J Urol 1999; 4: Bogren MA, Hvarfwen E, Fridlund B. Urinary incontinence among a 65-year old Swedish population: medical history and psychosocial consequences. Nurs Sci 1997; 17: Berglund AL, Fugl-meyer KS. Some sexological characteristis of stress incontinent women. Scand J Urol Nephrol 1995; 3: Hunt J, Moss J. Unwanted sexual experience and female urinary incontinence. Br J Health Psychol 1996; 1: Samuelson E, Victor A, Tibblin G. A population study of urinary incontinence and nocturia among women aged 2 59 years. Prevalence, well-being and wish for treatment. Acta Obstet Gynecol Scand 1997; 76: Temml C et al Urinary incontinence in both sexes: prevalence rate and impact on quality of life and sexual life. Neurourol Urodyn 2; 9: Walters MD, Taylor S, Schoenfeld LS. Psychosexual study of women with detrusor instability. Obstet Gynecol 199; 75: Vaart CH, Leeuw JR, Roovers JP, Heintz AP. The effect of urinary incontinence and overactive bladder symptoms on quality of life in young women. BJU Int 22; 9: Liberman JN et al. Health-related quality of life among adults with symptoms of overactive bladder: results from a U.S. community-based survey. Urology 21; 57: Appendix A Korean Overactive Bladder Syndrome Urinary Incontinence and Quality of Life Questionnaire 1. age ( ) years old 2. sex ( ) male ( ) female 3. Have you ever been attacked by acute urethral or bladder infections? ( ) yes ( ) no 4. Have you ever have problems with urinary frequency during period? ( ) yes ( ) no 5. Are there any of your parents who have any symptoms above? ( ) yes ( ) no 6. Do you feel headache, chest tightness or lower abdominal discomforts when you can t go to the toilet immediately?( ) yes ( ) no 7. Have you ever had a cerebrovascular accident? ( ) yes ( ) no 8. Have you ever had deliveries? ( ) yes ( ) no 9. Do you void more than 8 times a day? ( ) yes ( ) no. Do you wake up at night more than one times to void? ( ) yes ( ) no 11. Can t you hold your urge to void and do you have any experience of urinary leakage with urgency? ( ) yes ( ) no 12. Do you avoid drinking water or fluid due to your voiding problems when you go out? ( ) yes ( ) no 13. Have you ever have experience that you have to check where the toilet is when you go to an unfamiliar place? ( ) yes ( ) no 14. Do you avoid going to a place without toilets? ( ) yes ( ) no 15. Have you frequently feel sudden feeling to void? ( ) yes ( ) no 16. Does your voiding frequency interrupt your working? ( ) yes ( ) no 17. Do you leak urine when you cough, laugh, run or jump? ( ) yes ( ) no 18. Do you use any type of pad because of urine leakage? ( ) yes ( ) no 19. Do you have to empty your bladder before and after the intercourse because of your voiding problems? ( ) yes ( ) no 2. Have you ever have incontinence during the intercourse? ( ) yes ( ) no 21. Do your voiding problems make you to avoid or to feel difficulty on your sexual intercourse or sexual activities? ( ) yes ( ) no 22. Have you ever heard of the overactive bladder? ( ) yes ( ) no 23. Do you have any experience to see a doctor with your frequency as a kind of disease? (1) I don t think that it is a disease nor to see the doctor ( ) (2) I think it is a disease but never thought of seeing the doctor ( ) (3) I think it is a disease and ever thought of seeing the doctor to be treated ( ) (4) I have ever been treated ( )