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Keywords:

  • prevalence;
  • risk factor;
  • self-perception;
  • urinary incontinence

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Appendices

Background: Urinary incontinence (UI) is a common problem in adults, especially among the elderly. We examined the prevalence and risk factors of UI and potential factors hindering individuals from seeking treatment for UI among a community-dwelling population aged over 40 years.

Methods: Data were collected by mailing a 23-item urinary incontinence questionnaire to a random sample of community-dwelling individuals aged 40–75 years (n = 3500) in seven towns of Shiga Prefecture, Japan. Collected data were then used to estimate the prevalence of UI and to provide information regarding subtypes of UI, knowledge and self-perception about UI.

Results: The overall response rate was 52.5%. Prevalence of UI for male and female respondents were 10.5% and 53.7%, respectively. The incidence of urge incontinence increased as age increased in the male group. In women, stress incontinence was prevalent at all ages and the incidence of urge incontinence increased over 70 years of age. Urinary incontinence was more likely as activities of daily living limitations and cystitis increased. Women with a history of hysterectomy or diabetes mellitus and men who had stroke were at increased risk for UI. Of those who reported UI, only 3% had ever consulted doctors or other health care professionals concern- ing it, 25% recognized their condition as a disease and 38% considered it curable by appropriate treatments. In addition, 63% regarded UI as an unavoidable consequence of aging, 63% con- sidered their condition was embarrassing and 54% were reluctant to seek treatment from a health professional.

Conclusions: Although UI is common among community-dwelling individuals over 40 years of age, the majority of affected individuals remained untreated due to lack of knowledge and/or a negative perception of UI. Thus, community education on UI may be needed to increase the number of UI patients who receive treatment.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Appendices

Urinary incontinence is a common problem in adults, especially among the elderly, with 1.6–49% of elderly individuals in the community experiencing difficulty with urinary control.1 Diokno et al. reported that 30.0% of respondents (18.9% of men and 37.7% of women) had experienced incontinence within the previous 12 months in a population-based sample of 1955 non- institutionalized elderly in the US.1 Despite the fact that most affected elderly individuals have had their incontinence symptoms for years, less than half of them have sought treatment from a health professional, as reported by the NIH Consensus Conference on Incontinence.2 Many problems are related to misinformation or lack of information about incontinence and its treatment and include the possibility that older people may accept urinary incontinence as a normal part of aging and therefore deem it not worth mentioning to health professionals. It has been reported that many patients with incontinence are not treated successfully, at least in part due to patient underreporting.2,3

The present study was conducted in a rural community in which the health care providers have attempted to treat urinary incontinence.

In this community, which is poorly informed regarding urinary incontinence, we investigated the prevalence of urinary incontinence and factors potentially hindering community-dwelling people aged over 40 years with incontinence from seeking treatment.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Appendices

Before the present study was conducted, a health education programme, including information about urinary incontinence, had been performed through local newspapers and public lectures.

Data were collected by mailing a 23-item anonymous urinary incontinence questionnaire to a random sample of community-dwelling individuals aged 40–80 years (n = 3500) living in seven towns in Shiga Prefecture, Japan (58 182 inhabitants). Collected data were then used to estimate the prevalence of urinary incontinence and to provide information regarding subtypes of urinary incontinence including general history (marital status, history of disease, surgical history, medication and parity). Urinary incontinence was considered present if the question ‘do you suffer from involuntary loss of urine?’ was answered yes. The type of incontinence was diagnosed from answers to the questionnaire: An answer of yes to ‘do you ever leak urine when you cough, sneeze, or laugh?’ was taken to indicate stress urinary incontinence. An answer of yes to ‘do you often have difficulty holding your urine until you can get to a toilet?’ was urge incontinence. If both answers were yes, mixed incontinence was diagnosed. In our study we also evaluated the association between incontinence and medical conditions or factors previously reported to be associated with incontinence including diabetes mellitus, stroke and activities of daily living. We also included questions concerning knowledge and self-perception regarding urinary incontinence and their willingness to seek clinical consultation in cases in which an episode of urinary incontinence was reported.

Conditions associated with urinary incontinence were entered into backward elimination logistic regression to construct a multivariable model, with urinary incontinence as the dependent variable. Results of the model are reported as odds ratios with 95% confidence intervals. All calculations were done by SPSS (SPSS Inc., Chicago, IL, USA).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Appendices

Of the 3500 individuals to whom the questionnaire was mailed, 1836 participated in the study (52.5% response rate). Among these 1836 study participants, 1786 individuals who responded to all questions were evaluated. The respondents exhibited the following demographic characteristics: 54% were female; the respective mean ages in men and women were 59.3 and 57.5 years; 24% were 40–49 years of age, 27% were 50–59 years of age, 32% were 60–69 years of age and 17% were 70 years of age or older; 3% lived alone, 20% lived with a spouse only and the remaining 77% lived with others. Of 818 male respondents, 10.5% reported at least one episode of urinary incontinence within the last year. For the 968 female respondents, urinary incontinence was reported at a higher rate (53.7%). Tables 1 and 2, which summarize subtypes of urinary incontinence based on urinary symptoms, show that: (i) the incidence of urge incontinence (urge + mixed) increased as age increases in the male group; (ii) for females, stress incontinence was prevalent at all ages; and (iii) the incidence of urge incontinence (urge + mixed) was increased in female respondents aged over 70 years. In addition, we are currently examining potential correlates of urinary incontinence including health and functional problems. Variables for males and females significantly associated with prevalence of incontinence are shown in Table 3 and Table 4, respectively. Individuals are more likely to be incontinent as activities of daily living limitations and cystitis increase. Women who have had a hysterectomy or were suffering from diabetes mellitus were at increased risk for incontinence, with odds ratios of 1.59 and 2.55, respectively (Tables 4,5). Men who had suffered a stroke were at increased risk for incontinence, with an odds ratio of 7.12 (Tables 3,6).

Table 1.  Urinary incontinence in male respondents
AgeContinent Incontinent Total
  UrgeStressMixed
40–49171 (20.9%) 7 (0.9%) 2 (0.2%) 0 (0%)180 (22.0%)
50–59184 (22.5%) 6 (0.7%) 4 (0.5%) 3 (0.4%)197 (24.1%)
60–69249 (30.4%)22 (2.7%) 4 (0.5%) 6 (0.7%)281 (34.3%)
70–128 (15.6%)28 (3.4%) 1 (0.1%) 3 (0.4%)160 (19.6%)
 732 (89.5%)63 (7.7%)11 (1.3%)12 (1.5%)818 (100%)
Table 2.  Urinary incontinence in femal respondents
AgeContinent Incontinent Total
  UrgeStressMixed
40–49 97 (10.0%)13 (1.3%)109 (11.3%)37 (3.8%)256 (26.4%)
50–59124 (12.8%)12 (1.2%)103 (10.6%)40 (4.1%)279 (28.8%)
60–69158 (16.3%)25 (2.6%)83 (8.6%)18 (1.9%)284 (29.4%)
70–69 (7.1%)17 (1.8%)33 (3.4%)30 (3.1%)149 (15.4%)
 448 (46.3%)67 (6.9%)328 (33.9%)125 (12.9%)968 (100%)
Table 3.  Factors significantly associated with prevalence of incontinence (univariate analysis) for males
 VariableOdds ratioP value
Age40–49
 50–591.340.51
 60–692.440.02
 70–794.750.0001
Stroke(–)
 (+)7.120.0001
Angina(–)
 (+)2.762.44
Diabetes(–)
 (+)1.240.59
Cystitis(–)
 (+)3.650.003
Unable to(–)
change clothes(+)17.40.02
Unable to walk(–)
outside(+)4.360.04
Table 4.  Factors significantly associated with prevalence of incontinence (univariate analysis) for females
 VariableOdds ratioP value
Age40–49
 50–590.760.12
 60–690.490.0001
 70–790.710.098
Stroke(–)
 (+)1.30.69
Angina(–)
 (+)0.860.8
Diabetes(–)
 (+)2.550.025
Cystitis(–)
 (+)1.950.0001
Hysterectomy(–)
 (+)1.590.019
Unable to walk(–)
outside(+)3.780.039
Table 5.  Results of logistic regression analysis with urge incontinence as the outcome for females
 VariableN%CoefficientSE of odds ratioOdds ratioP value95% confidence interval
Age40–4920652.9
 50–5922745.40.3020.1930.7390.1170.506–1.079
 60–6924134.40.760.1950.4680.00010.319–0.685
 70–7910232.40.8540.2540.4260.00080.259–0.700
Cystitis(–)48736.1
 (+)28952.6–0.6730.1511.9610.00011.459–2.635
Hysterectomy(–)67740.8
 (+)9752.6–0.4770.2181.6110.0291.051–2.469
Constipation(–)18544.3
 (+)59141.60.110.1690.8960.51660.642–1.250
Table 6.  Results of logistic regression analysis with urge incontinence as the outcome for males
 VariableN%CoefficientSE of odds ratioOdds ratioP value95% confidence interval
Age40–491783.9
 50–591903.20.2270.566–0.7970.690.262–2.418
 60–692718.1–0.7690.4452.1580.0840.902–5.165
 70–7915617.9–1.6760.4385.3440.00012.263–12.619
Cystitis(–)77036.1
 (+)2552.6–1.1210.5183.070.0311.111–8.475
Constipation(–)819.9
 (+)7147.70.2720.3980.7620.4940.349–1.661

Of 606 individuals (86 men and 520 women) who reported urinary incontinence, at the time of this study only 3% had ever consulted with doctors or other health care professionals concerning it. Twenty-five percent of individuals with symptoms of incontinence recognized their condition as a disease and 38% considered it curable with appropriate treatment. In addition, 63% accepted urinary incontinence as an unavoidable consequence of aging. Sixty-three percent felt their condition embarrassing and 54% were reluctant to seek treatment from a health professional. Fifty percent didn’t know where to seek treatment for their problem (Table 7).

Table 7.  Self-perception of urinary incontinence
Image for urinary incontinence%
Condition as a disease25
Curable disease38
Condition as a consequence63
of aging
Embarrassing condition63
Hesitation to consult health(36:male, 54:female)
professionals
Nowhere to consult50

The majority of individuals with incontinence remained untreated due to lack of knowledge. According to responders, the source of information is the media, television (63%), newspapers (47%), magazines (30%) and less often the specialist (6%). Although 60% of respondents use well-known protective systems such as pads and panty liners, the main therapeutic modalities such as exercise, drugs and surgery are not very well known (10%) in the community.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Appendices

In previous studies, the prevalence of urinary incontinence in the community ranged from 9 to 45%.4 Our finding was also in this range but our response rate (52.5%) was lower than in any other location such as the United States and Europe, even though information on incontinence was provided to the community before our study began. Our study might have been undertaken in a community where awareness of urinary incontinence was low. In Japan in contrast with USA/Europe, there has been little systematic research involving random sampling in a postal survey. If future surveys are to be carried out in Japan, our experience suggests that information is very important.

Previous reports showed that urinary incontinence is associated with diabetes mellitus,5 stroke,6,7 and decrements in activities of daily living.8 Our study demonstrated that women with urinary incontinence were five times as common as men in the community we studied. Stress incontinence in females is very prevalent (33%) and related to diabetes, cystitis and posthysterectomy status. Urge incontinence is the most prevalent problem in males (6.9%), due to prostatic symptoms and is associated with stroke and cystitis. These results indicate that patients with diabetes or stroke should be given information about urinary incontinence by medical staff.

In order for people to obtain primary care for urinary incontinence, it is necessary for them to have easy access to health professionals and/or urologists. Norton found that 60% of patients had delayed seeking treatment for more than 1 year from the time their UI symptoms became severe.9 Brocklehurst found that more than 80% of incontinent men and women aged 30 and over had consulted their general practitioner (GP), but this was in a population with prevalence as low as 4% (men) and 9% (women).10 Burgio et al. found a prevalence of 27% among middle-aged women and that 26% of affected women had sought help.11 Seim et al. reported a prevalence of 29% among women aged 20 or over in a rural community, 20% of whom had consulted health professionals.12 Although most Japanese women have had their incontinence symptoms for years, 54% hesitate to visit urological clinics and only 3% of them had consulted a doctor for such symptoms.

Our study also showed urinary incontinence is considered a normal consequence of aging and a non- therapeutic condition (63%). Holst and Wilson also found that 81% of their sample of community-dwelling women did not seek help for regularly occurring incontinence because they did not see the condition as abnormal and that 10% had not sought help due to a low expectation of the benefit of treatment.13

Many women prefer to buy incontinence aids such as sanitary towels without first contacting health professionals. Our most important findings are that community residents have a poor understanding of urinary incontinence and that correct information about urinary incontinence must be given to them.14 In addition, detailed questionnaires might play an important role in screening for urinary incontinence prior to a urodynamic study.15

In conclusion, our study confirmed that urinary incontinence is a common condition in community-dwelling individuals aged over 40 years and that stress and urge incontinence are most prevalent in women and elderly individuals, respectively. However, the majority of individuals with incontinence remained untreated due to lack of knowledge and/or negative perception of urinary incontinence. These results thus indicate that community education on urinary incontinence is needed to increase the number of UI patients who receive treatment.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Appendices

This study was supported by the LACADIA Health and Welfare Foundation for Senior Citizens and the Social Department Foundation for Senior Citizens, Japan.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Appendices
  • 1
    DioknoAC, BrockBM, BrownMB, HerzogAR. Prevalence of urinary incontinence and other urological symptoms in the non-institutionalized elderly. J. Urol. 1986; 136: 10225.
  • 2
    Consensus Conference. Urinary incontinence in adults. JAMA 1989; 216: 268590.
  • 3
    Urinary incontinence in adults. NIH Consensus Development Conference. J. Am. Geriatr. Soc. 1990; 38: 26572.
  • 4
    SamuelssonE, VictorA, TibblinG. A population study of urinary incontinence and nocturia among women aged 20–59 years. Prevalence, well-being and wish for treatment. Acta Obstet. Gynecol. Scand. 1997; 76: 7480.
  • 5
    UedaT, YoshimuraN, YoshidaO. Diabetic cystopathy: Relationship to autonomic neuropathy detected by sympathetic skin response. J. Urol. 1997; 157: 5804.
  • 6
    GriffithsDJ, McCrackenPN, HarrisonGM, MooreKN. Urinary incontinence in the elderly: The brain factor. Scand. J. Urol. Nephrol. 1994; 157 (Suppl.): 838.
  • 7
    SkellyJ, FlintAJ. Urinary incontinence associated with dementia. J. Am. Geriatr. Soc. 1995; 43: 28694.
  • 8
    DioknoAC, BrockBM, HerzogAR, BrombergJ. Medical correlates of urinary incontinence in the elderly. Urology 1990; 36: 12938.
  • 9
    NortonPA. Prevalence and social impact of urinary incontinence in women. Clin. Obst. Gynecol. 1990; 33: 2957.
  • 10
    BrocklehurstJC. Urinary incontinence in the community analysis of a MORI Poll. Br. Med. J. 1993; 306: 8324.
  • 11
    BurgioKL, MatthewsKA, EngelBT. Prevalence, incidence and correlates of urinary incontinence in healthy, middle-aged women. J. Urol. 1991; 146: 12559.
  • 12
    SeimA, SandvikH, HermstadR, HunskaarS. Female urinary incontinence-consultation behaviour and patient experience: An epidemiological survey in a Norwegian community. Family Prac. 1995; 12: 1821.
  • 13
    HolstK, WilsonP. The prevalence of female urinary incontinence and reasons for not seeking treatment. NZ Med. J. 1988; 101: 7568.
  • 14
    SchulmanC, ClaesH, MatthijsJ. Urinary incontinence in Belgium: A population-based epidemiological survey. Eur. Urol. 1997; 32: 31520.
  • 15
    Kirschner-HermannsR, ScherrPA, BranchLG, WetleT, ResnickNM. Accuracy of survey quetions for geriatric urinary incontinence. J. Urol. 1998; 159: 190311.

Appendices

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  9. Appendices

Appendix I.

Questionnaire

Please answer the questions below by circling the appropriate answer or filling in the spaces provided.

Preliminary Question

If the person completing this questionnaire is the person whose name is indicated on the envelope please circle reply 1. Otherwise please indicate your relationship to the said person.

1. Addressee 2. Grandparent 3. Parent 4. Brother or sister 5. Son

6. Daughter 7. Daughter-in-law 8. Son-in-law 9. Other

Q1. Where is your current place of residence?

Q2. Please complete the following information about your age and sex.

(A) Sex

1. Male 2. Female

(B) Age

Q3. What is your height in cms?

Q4. What is your weight in kgs?

Q5. Please indicate if you have ever suffered from any of the illnesses given below. If so, please indicate the year concerned.

A. Cerebral apoplexy 1. Yes 2. No

B. Myocardial infarction 1. Yes 2. No

C. Diabetes 1. Yes 2. No

D. Fracture of thigh bone 1. Yes 2. No

E. Herniated disk 1. Yes 2. No

Q6.1. Have you ever been diagnosed as having cystitis?

1. Yes 2. No

If your answer to the above question is Yes then please answer the following question.

Q6.2. Have you experienced a recurrence of your cystitis?

1. Yes 2. No

Q7. Have you undergone any of the following operations? If so, please indicate the year in which the operation took place. (If you have undergone the same operation on more than one occasion, please indicate the most recent date.)

A Gynecological operation (for females only) 1. Yes 2. No

B. An operation on the large intestine 1. Yes 2. No

C. An operation on the small intestine 1. Yes 2. No

D. Spinal surgery 1. Yes 2. No

E. Brain surgery 1. Yes 2. No

F. Others 1. Yes 2. No

Q8. Have you always been careful to participate in some kind of regular physical exercise such as walking or jogging for the sake of your health?

1. Yes 2. No

Q9. Please choose the response that describes the current composition of your household.

1. Living alone

2. A couple living together

3. A two-generation family (with your children)

4. A two-generation family (with your parents)

5. A three-generation family

6. Living with brothers or sisters

7. Living with a housekeeper

8. Other ( )

Q10. Please indicate to what extent you are able to perform the following tasks.

A. Meal preparation 1. I can do it by myself

2. I can do it with a little help

3. I am completely unable to do it without help

B. Excretion 1. I can do it by myself

2. I can do it with a little help

3. I am completely unable to do it without help

C. Changing clothes 1. I can do it by myself

2. I can do it with a little help

3. I am completely unable to do it without help

D. Walking about in the house 1. I can do it by myself

2. I can do it with a little help

3. I am completely unable to do it without help

E. Going out 1. I can do it by myself

2. I can do it with a little help

3. I am completely unable to do it without help

Q11.1. Do you have a tendency to suffer from constipation?

1. Yes 2. No

If your answer to the above question is Yes, please answer the following question.

Q11.2. What are you doing to control your constipation?

(Please circle as many answers as appropriate.)

1. I use laxatives

2. I use enemas

3. I do nothing

4. Other ( )

Q12. Please circle the type of receptacles used when urinating (please mark all receptacles used).

1. Western-style toilet

2. Japanese-style toilet

3. Portable toilet

4. Urine bottle

5. Pad

6. Diaper

7. Catheter

8. Other ( )

Q13. Have you ever taken care of the needs of an elderly or handicapped person?

1. Yes 2. No

Q14. (for women only) Please indicate the number times you have given birth (including still births).

Q15. Please select the response which corresponds most closely to your experience of the symptoms described.

(A) How often has urine leakage occurred while you were unaware of it?

1. Never 2. Seldom 3. Sometimes 4. Very often

(B) How often has urine leakage occurred while you were going up or down a slope or stairs?

1. Never 2. Seldom 3. Sometimes 4. Very often

(C) How often has urine leakage occurred when you coughed or sneezed?

1. Never 2. Seldom 3. Sometimes 4. Very often

(D) How often has urine leakage occurred when you were carrying something heavy?

1. Never 2. Seldom 3. Sometimes 4. Very often

(E) How often has urine leakage occurred while you were doing work involving water (washing up, etc.)?

1. Never 2. Seldom 3. Sometimes 4. Very often

(F) How often has urine leakage occurred because you haven’t been able to get to the toilet in time?

1. Never 2. Seldom 3. Sometimes 4. Very often

(G) How often has urine leakage occurred while you were sleeping?

1. Never 2. Seldom 3. Sometimes 4. Very often

(H) How often have you experienced urination of excessively long duration?

1. Never 2. Seldom 3. Sometimes 4. Very often

(I) How often have you experienced pain while urinating?

1. Never 2. Seldom 3. Sometimes 4. Very often

(J) How often have you felt that you still needed to urinate after urination had finished?

1. Never 2. Seldom 3. Sometimes 4. Very often

(K) On what other occasions have you experienced urine leakage? Please write in the box below.

Recently, there has been a lot of talk about incontinence. Please answer the following questions.

Q16.1. Have you ever heard anything about incontinence?

1. Yes 2. No

If your answer to the above question is Yes, please answer the following question.

Q16.2. From what source did you hear about incontinence? Please indicate as many of the following responses as applicable.

1. Television

2. Newspapers

3. Magazines

4. A doctor

5. A hospital nurse

6. Welfare center or welfare worker

7. A nurse on house call

8. A home helper

9. A drug store

10. Nursing goods store

11. A friend or acquaintance

12. Other ( )

Q17. Please indicate which of the following things, associated with incontinence, you are aware of?

(A) Care goods

1. Incontinence pads

2. Incontinence pants

3. Portable toilets

4. Catheters

(B) Medical concerns

5. Incontinence outpatient care

6. Surgical treatment

7. Medication

(C) Others

8. Pelvic exercises (incontinence exercises)

9. Others

10. I know nothing about it

Q18. What impression do you have concerning the following incontinence-related questions?

(A) Do you think you will recover from incontinence?

1. Yes 2. No 3. Don’t know

(B) Do you think that talking to other people about incontinence is embarrassing?

1. Yes 2. No 3. Don’t know

(C) Do you think incontinence is directly attributable to your age?

1. Yes 2. No 3. Don’t know

(D) Do you have any hesitation in consulting the Urology Department?

1. Yes 2. No 3. Don’t know

(E) Do you think that incontinence is preventable?

1. Yes 2. No 3. Don’t know

(F) Do you know where you can go to get advice concerning incontinence?

1. Yes 2. No

(G) Do you think incontinence is an illness?

1. Yes 2. No 3. Don’t know

The questions below are to be answered by those people who are currently suffering from incontinence.

Q19. Please indicate what action you take to deal with your incontinence by circling one or more of the items below.

1. I use incontinence pants

2. I use a pad

3. I wear a diaper

4. I use a sanitary napkin

5. I use a towel or face cloth

6. I use a gauze handkerchief

7. I do nothing in particular

8. Other ( )

Q20. In which of the following ways has your everyday life changed due to incontinence?

1. You have started suffering from depression

2. You don’t get enough sleep

3. It’s become difficult to go out

4. Traveling has become difficult

5. Socializing with friends has become difficult

6. You have stopped lifting heavy things

7. You feel you are becoming a nuisance to people

8. You stopped work because of incontinence

9. You have to change your underwear more recently

10. You have become less sympathetic

Q21. Do you think you’d like to do something about your incontinence problem?

1. I think I’d like to do something about it

2. I haven’t thought about it

3. I thought there was nothing that could be done about it

Q22. Presently, are you receiving any medical treatment?

1. Yes, I am being treated by the Urology Department

2. Yes, I am being treated by a doctor other than in the Urology Department

3. No, I am not receiving any treatment or guidance

4. Other ( )

Q23.1. Before receiving treatment did you consult anyone?

1. Yes 2. No

If your answer to the above question is Yes, please answer the following question.

Q23.2. Who was this person?

1. A Urology Department doctor

2. A doctor outside the Urology Department

3. Welfare worker

4. A nurse

5. Home helper

6. Other ( )