Prevalence, Risk Factors, and Impact on Quality of Life Due to Urinary Incontinence Among Palestinian Women: A Cross-Sectional Study

Introduction: Urinary incontinence (UI) is a common condition that affects females with variable incidence. Factors like age, obesity, weak pelvic floor, and pregnancy contribute to UI pathogenesis. Our study aimed to determine the prevalence of UI and identify associated risk factors. Methods: A cross-sectional study recruited females aged 18-65 attending primary health care (PHC) centers. The collected data included demographic information and questionnaire scores for urinary incontinence diagnosis (QUID), International Consultation on Incontinence Questionnaire-Urinary Incontinence (ICIQ-UI), and Incontinence Impact Questionnaire-Short Form (IIQ-7) scores. Results: Three hundred and eleven females met our inclusion criteria, with 162 (52.1%) participants aged ≥ 42 years. Approximately 41.5% were college/university graduates, and 23.2% had an education level less than high school. Moreover, 108 (34.7%) participants were smokers, 223 (71.7%) drank coffee, and approximately 212 (68.2%) drank tea. Only 125 (40.2%) participants engaged in exercise at variable frequencies, and most of them exercised once per week. Approximately 27.3% of the participants had chronic medical illness with hypertension or diabetes mellitus (40 (12.9%) or 25 (8%), respectively). Stress urinary incontinence (SUI) was found among 152 (48.9%) participants, while urgency urinary incontinence (UUI) was found among 114 (36.7%) participants. Age ≥ 42, marital status, low educational level, unemployment, lack of physical activity, and chronic medical illnesses were significantly correlated with both SUI and UUI. There was a strong correlation between UI and the severity of symptoms and between UI and quality of life (QoL). Conclusion: The prevalence of UI is relatively high among Palestinian women. Many factors contributing to UI included age, marital status, the presence of other chronic medical diseases, and a lack of physical activity. Early detection and diagnosis are necessary to provide effective treatment and improve UI symptoms and QoL.


Introduction
The International Continence Society has defined urinary incontinence (UI) as the complaint of involuntary loss of urine [1].Several types of urinary incontinence have also been described, and at most, our study focused on stress urinary incontinence (SUI) and urgency urinary incontinence (UUI).
SUI is a condition characterized by the involuntary loss of urine during physical exertion, such as sneezing, coughing, or engaging in sporting activities, and is not related to psychological stress, whereas UUI has been described as the involuntary loss of urine associated with urgency [1].The factors contributing to UI include advanced age, chronic cough, connective tissue disorders, constipation, heavy lifting, menopause, obesity, pelvic floor trauma, pregnancy, and smoking.Previous pelvic surgeries can also lead to neuromuscular damage [2,3].
Studies from different countries highlight the prevalence and risk factors for UI among women.In Jordan, more than half of the participants experienced SUI, emphasizing the need for early diagnosis and treatment [3].Chinese studies revealed diverse prevalence rates associated with UI and age, BMI, malnutrition status, education, and medical conditions [4,5].In France, nearly one in four women visiting family physicians exhibited UI symptoms, with age, BMI, and parity influencing severity [6].A Tunisian study showed that 45.3% of women experienced urinary or anal incontinence, citing risk factors such as postpartum urinary incontinence, menopausal status, arterial hypertension (HTN), nurse occupation, and constipation [7].In Saudi Arabia, multiple studies have presented diverse findings on the prevalence of UI.The overall prevalence of UI ranged from 41.1% to 56.6% across different studies [8][9][10][11][12].Specifically, SUI rates were noted at 15.4%, 20%, and 3.3% in individual studies [9,12,13].Furthermore, various studies have reported that UUI has been acknowledged by roughly less than a third of affected women.[8,9,11].
Moreover, UI is a common and distressing condition that significantly affects the QoL of young females.Studies have shown that SUI can cause social and sexual limitations [14].Pelvic exercises that strengthen the pelvic floor muscles are also known to prevent SUI [15].Additionally, SUI and UUI can be managed through both medical and surgical interventions [16,17].
Our group has published several papers about lower urinary tract symptoms (LUTS) and UI among different cohorts of patients in Palestine [18][19][20][21][22].This was a national study investigating the prevalence of UI and the factors that influence it.

Study design and setting
This was a cross-sectional study in which females attending primary health care (PHC) centers in the West Bank were recruited.Convenience sampling was employed in this study, and the data were collected between April 2022 and December 2022.

Study population, sampling procedure, and sample size calculation
The research participants were women who were attending PHC clinics.The sample size of 300 was determined by using an online Raosoft sample size calculator.This calculation resulted in a convenient sample with a confidence level of 95% and a margin of error of 5%.

Inclusion and exclusion criteria
The inclusion criteria were females aged between 18 and 65 who attended PHC centers.The exclusion criteria were patients with urinary tract anomalies, documented or symptomatic urinary tract infections, medications that affect urinary bladder function, a history of chronic neurological disease, or a history of or current major psychiatric illness.

Data collection instruments
The data collection instrument utilized was a questionnaire in the Arabic language organized into four sections as outlined below:

Demographics and Clinical Data
Age, employment status, marital status, and education level were included.Smoking status, caffeine intake, medication use, history of previous pelvic surgeries, presence of chronic medical illness, physical activity, number of both vaginal and cesarean deliveries, number of delivered babies above 4 kg, and age at first delivery were also collected.

The Questionnaire for Urinary Incontinence Diagnosis (QUID)
The Questionnaire is a 6-item survey designed to assess UI symptoms [23].It was developed and validated specifically to differentiate between stress and urge UI.It consists of 6 questions.The stress score is calculated by summing the responses to items 1, 2, and 3, while the urge score is determined by summing the responses to items 4, 5, and 6.The intensity of each symptom is classified on a scale from 0 to 5.

International Consultation on Incontinence Questionnaire-Urinary Incontinence (ICIQ-UI)
The ICIQ-UI short form [24] is a questionnaire for evaluating the severity, frequency, and impact of UI on QoL in both sexes in clinical and research practices worldwide.The total score represents the sum of all symptoms, with an overall score of 21 and greater values indicating increased symptom severity.

Incontinence Impact Questionnaire, Short Form (IIQ-7)
The IIQ-7 [25] is a tool specifically designed to evaluate the influence of UI on an individual's QoL.The assessment focused on four key areas: physical activity, travel, social relations, and emotional well-being.Symptom severity was graded on a scale from zero to three, with zero indicating the least severe and three indicating the most severe.The maximum IIQ-7 score achievable is 21, and a higher score corresponds to a more significant impact on QoL.The Cronbach alpha coefficient was employed to validate this tool, demonstrating an impressive internal consistency of 0.98 [26].

Ethics approval and consent to participate
The study protocol, encompassing access to and utilization of clinical information, received approval from the Institutional Review Boards (IRBs) of An-Najah National University; the IRB approval number is Med.August, 2022/22.The research adhered to ethical standards established by the Human Experimentation Responsible Committee (at the institutional and national levels) and the Helsinki Declaration.All participants provided verbal informed consent for their involvement in the study, and they were informed about the study's objectives and their potential contribution to UI research before giving consent.

Statistical analysis
The information was analyzed utilizing version 21 of the Social Sciences Statistical Package (IBM-SPSS).Continuous variables are presented as the means and standard deviations, while categorical variables are expressed as frequencies and percentages.Correlations were assessed using the Pearson test.To evaluate the significance of differences between categorical variables, the chi-square test or Fisher's exact test was employed as appropriate.Differences in means between categories were tested using the Kruskal-Wallis test followed by Bonferroni-Dunn post hoc analysis or the Mann-Whitney test.A p-value less than 0.05 was considered to indicate statistical significance.
c Statistically significant values were calculated using Fisher's exact test.

TABLE 3: Associations between ICIQ-UI scores and demographic and clinical data
Data is represented as Median (Q1-Q3) and Mean rank: b Statistically significant values were calculated using the Mann-Whitney U test.
c Statistically significant values were calculated using the Kruskal-Wallis test.

CVD: Cardiovascular diseases
Incontinence Impact Questionnaire (IIQ-7) The greater the IIQ-7 score was, the greater the impact of urinary incontinence on QoL.Age ≥ 42 years was significantly correlated with the IIQ-7 score, with a median of 57.08 (23.78-66.6)(p<0.001).Widow females, those with less than a high school education, and retired females had higher IIQ-7 scores, with mean ranks of 192.56, 209.39, and 212.00, respectively (p<0.001).The IIQ-7 score was greater among females who did not exercise, with a median of 52.32 (16.65-66.6)(p<0.001).Moreover, there was a positive correlation between the IIQ-7 score and chronic medical diseases; CVD, HTN, and DM participants had higher scores, with a mean rank of 68.33 for CVD, 49.70 for HTN, and 45.60 for DM (p=0.001).Smoking status, drinking of coffee, drinking of tea, and prior pelvic surgery did not reach statistical significance (Table 4).

Correlations Between the Severity of Urinary Incontinence (ICIQ-UI), Stress UI, Urgency UI, and IIQ-7 Scores
There was a strong correlation between SUI and the severity of incontinence measured by the ICIQ-UI (r=0.855)(p<0.001).Furthermore, there was a statistically significant correlation between the severity of IIQ-7, UUI, and the severity of UI (r=0.796 and r=0.812; p<0.001, respectively) (Table 5).

Discussion
The present study investigated the demographics and clinical characteristics of female participants, their correlation with different types of UI, and the impact of UI on their QoL.The findings provide valuable insights into this cohort's prevalence and risk factors associated with UI.
Our study showed that SUI was prevalent among 152 (48.9%) participants, while UUI was found among 114 (36.7%) participants.These findings are consistent with those of previous studies in which the incidence of SUI was 55.1% in the Jordanian cohort [3], while a Tunisian study showed 40.3% UUI, 24.6% SUI, and 19.9% mixed UI [7].Other studies have shown that variations in UI prevalence and risk factors would vary depending on different cultural or geographical contexts [27].
The majority of participants were aged 42 years or older, with more than half of the sample falling into this age group.This finding aligns with age-related trends in UI incidence [28][29][30].Marital status was significantly correlated with SUI and UUI incidence.Married females exhibit a greater likelihood of UI, possibly due to factors such as pregnancy and hormonal changes [31][32][33].In an American study, multiparity was identified as a significant risk factor for SUI compared to uniparity or nulliparity.Complicated labor was significantly more strongly associated with UI than uncomplicated labor [32].
Smoking status, which was not significantly different in our study, was strongly associated with SUI according to previous studies, with a reported relative risk ranging from 1.8 to 2.92 [34][35][36].Physical inactivity correlates with an increased incidence of both SUI and UUI, underscoring the role of exercise in pelvic floor strength and UI risk reduction [37].
Educational level correlates with UI, as lower educational levels are associated with higher incidences of SUI and UUI, emphasizing the importance of targeted educational interventions to improve awareness and promote early intervention for UI [38].Employment status is linked to SUI and UUI, with a higher prevalence among unemployed females, aligning with previous research on unemployment as a UI risk factor [39,40].Chronic medical conditions, HTN, and DM were positively correlated with SUI and UUI, consistent with previous findings identifying these conditions as UI risk factors [41,42].
Tea consumption was significantly correlated with higher ICIQ-UI scores, suggesting an association with the impact of UI on QoL.The caffeine content in tea, approximately one-third of that in coffee, prompted the exploration of other components potentially associated with lower urinary tract dysfunction [34,43].Prior pelvic surgery is associated with higher ICIQ-UI scores, indicating a greater impact on QoL, possibly through structural or functional changes in the pelvic region [44].
Factors such as not engaging in exercise, HTN, and DM were associated with higher IIQ-7 scores, indicating a greater impact of UI on daily activities.Managing these modifiable risk factors may positively influence the overall impact of UI on daily life [18,45,46].

Strengths and limitations of our study
This study marks the first exploration of the prevalence and severity of urinary incontinence in Palestinian females.However, the cross-sectional design limits our ability to establish a cause-effect relationship, introducing potential biases.Thus, longitudinal studies could establish causality between identified risk factors and UI for future research direction.Additionally, we do not have BMI data for all patients, as many women in our countries are unwilling to declare their weight for research purposes.

Conclusions
Our study revealed a notable prevalence of UI, particularly SUI and UUI, among Palestinian females in the West Bank.Age, marital status, education, employment, physical activity, and chronic medical conditions were identified as significant factors correlated with both SUI and UUI.The strong association between these factors and the severity of UI symptoms underscores the complexity of this condition.These findings advocate for targeted interventions addressing modifiable risk factors to enhance prevention and management strategies, ultimately improving the overall QoL for affected Palestinian women.

TABLE 2 : Associations between stress and urgency incontinence scale scores and demographic data
Data is represented as Frequency (%)

TABLE 4 : Associations between the IIQ-7 score and demographic and clinical data
2024atistically significant values were calculated using the Mann-Whitney U test2024Abushamma et al.Cureus 16(4): e57813.DOI 10.7759/cureus.578138 of 12 c Statistically significant values were calculated using the Kruskal-Wallis test

TABLE 5 : Correlations between the severity of urinary incontinence and stress UI, urgency UI and IIQ-7 scores
*Correlation is significant at the 0.01 level (2-tailed). *