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Keywords:

  • chronic obstructive pulmonary disease;
  • elderly men;
  • prevalence;
  • stress incontinence;
  • urge incontinence

Abstract

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

Abstract:  This study investigated urinary incontinence in men with chronic obstructive pulmonary disease (COPD). A total of 244 community-dwelling men (mean age 66.5 years) diagnosed with COPD within the past 4 years were recruited from six hospital outpatient departments in central Japan. The prevalence of urinary incontinence was 10% according to the International Consultation on Incontinence criterion. Urine leakage among the 24 incontinent men was typically a small amount (75%) and occurred once a week or less often (58%). Fifteen (63%) of them reported urge incontinence while only two men experienced stress incontinence. On average they had urine leakage for 2.5 (SD 2.3) years and the majority (n = 19, 79%) developed the condition after diagnosis of COPD. The finding of higher prevalence of urge incontinence challenges the conventional view that COPD is associated with stress incontinence due to high pressure coughs.


Introduction

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

Chronic obstructive pulmonary disease (COPD) is a major cause of death and disability worldwide.1 It is characterized by a progressive irreversible air flow limitation with cigarette smoking being the principal risk factor.2 The burden of COPD has been increasing in many countries such as China and Japan because of high cigarette consumption.3

As COPD progresses, one of the associated clinical conditions, urinary incontinence, may become more common.4 The prevalence of urinary incontinence is known to be higher for women and increases with age.5 A community-based study of 1584 women aged 70–79 years reported that incontinence, at least once per week, was experienced by a quarter of the 209 women with COPD, and a 5.5-fold increased odds of stress incontinence was evident among this disease subgroup.6 Another cross-sectional study of 2398 elderly Italian people over 65 years suggested a higher risk of urinary incontinence in women with COPD (OR 1.5, 95% CI 1.1 to 2.1), but the prevalence of incontinence and associated sample sizes were not given.7

This study investigated urinary incontinence in community-dwelling men with COPD, which has never been documented in published reports. Unlike previous studies which focused on women, the present study ascertained the prevalence, type and characteristics of urinary incontinence among men with COPD, the findings of which are important for the prevention and treatment of this distressing condition.

Methods

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

Two hundred and fifty community-dwelling men with COPD were recruited from the respiratory outpatient departments of six hospitals in central Japan (Aichi, Gifu, and Kyoto prefectures). Inclusion criteria were: age between 40 years and above, and had COPD as the primary functionally limiting illness that was diagnosed by respiratory physicians within the past 4 years. A total of 244 participants were eligible after excluding six men with missing demographic details or incomplete pulmonary function testing. The study protocol was approved by the Human Research Ethics Committee of Curtin University (approval number HR 90/2005). Permission to recruit subjects and access to medical records were granted by the participating hospitals.

A structured questionnaire incorporating the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF)5 was given to assess incontinence and to collect demographic information. Each interview was conducted face-to-face by the first author in the absence of the respiratory physician in-charge. The purpose of the study was explained to each participant before obtaining their written consent. Confidentiality of the information provided, and the right to withdraw without prejudice, were ensured and maintained throughout the study. Meanwhile, clinical characteristics were retrieved from medical records. Severity of COPD was classified as mild, moderate, severe, and very severe, according to the Global Initiative for Chronic Obstructive Lung Disease criteria,8 with predicted forced expiratory volume in one second (FEV1) calculated using the Japanese Respiratory Society's Guidelines.9

The ICIQ-SF is a measure for evaluating the severity of urinary loss and condition-specific quality of life. The reliability, validity, and sensitivity of the instrument have been established,10,11 while linguistic validation of its Japanese version was completed.12 The questionnaire consists of three components to determine frequency, quantity, and impact of urine leakage.5 Frequency was categorized into 0 (never), 1 (about once a week or less often), 2 (two or three times a week), 3 (about once a day), 4 (several times a day), and 5 (all the time). Urinary incontinence was defined as a minimal amount of leakage of at least ‘once a week or less often’. Quantity was measured from 0 (none), 2 (a small amount), 4 (a moderate amount) to 6 (a large amount). The impact on daily life was scored on an incremental scale from 0 (not at all) to 10 (a great deal). The three component scores were then summed to yield a total score ranging from 0 to 21, which reflected the overall level and extent of impact of incontinence. The circumstances of incontinence were recorded via a separate self-diagnostic item, with urge incontinence defined as ‘leaks before you can get to the toilet’, stress incontinence defined as either ‘leaks when you cough or sneeze’ or ‘leaks when you are physically active/exercising’, whereas other incontinence referred to ‘leaks when you are asleep’, ‘when you have finished urinating and are dressed’, ‘for no obvious reason’, and ‘all the time’. Two questions were appended to the ICIQ-SF to find out how long the patient had the condition and whether treatment was sought.

Results

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

Of the 244 participants with mean age 66.5 (SD 6.8) years, the majority were married (87%), had high school or below education (80%) and retired (57%). A substantial proportion of men (22%) continued to smoke after diagnosis and 62% of them consumed alcohol on at least a monthly basis. The distribution of COPD severity was: mild, 17%; moderate, 39%; severe, 30%; very severe, 13%.

The prevalence of urinary incontinence was 10%. Table 1 shows the sample demographics by incontinent status. No statistically significant differences were found between the two groups. Table 2 presents the characteristics of the 24 incontinent men with COPD. Urine leakage was typically ‘a small amount’ (75%) and occurred once a week or less often (58%). The mean ICIQ-SF total score was 7 (SD 2.4) and very few men considered the condition to have interfered with their daily life to a great extent. The most common occurrence of urine loss was before reaching the toilet (n = 16, 67%). While 15 (63%) of the incontinent men sustained urge incontinence, two experienced stress incontinence, one had mixed and six reported other types. On average they had urine leakage for 2.5 (SD 2.3) years and the majority (n = 19, 79%) developed the condition after diagnosis of COPD. However, only two men consulted their physician for the incontinent problem.

Table 1.  Sample demographics of chronic obstructive pulmonary disease (COPD) men by urinary incontinence status
 With urinary incontinence (n = 24, 10%)Without urinary incontinence (n = 220, 90%)
Age68.9 (SD 5.8) years66.3 (SD 6.9) years
Body mass index22.1 (SD 4.6) kg/m221.9 (SD 3.4) kg/m2
Alcohol drinking
 Yes14 (58.3%)136 (61.8%)
 No10 (41.7%)84 (38.2%)
Smoking status
 Current smoker8 (33.3%)45 (20.5%)
 Never or ex-smoker16 (66.7%)174 (79.5%)
Marital status
 Single/divorced6 (25.0%)25 (11.4%)
 Married18 (75.0%)194 (88.6%)
Education
 High school or below20 (83.3%)175 (79.9%)
 College or university4 (16.7%)44 (20.1%)
Location
 Rural19 (82.6%)180 (82.6%)
 Urban4 (17.4%)38 (17.4%)
Retirement status
 Retired16 (66.7%)122 (55.7%)
 Not retired8 (33.3%)97 (44.3%)
COPD severity
 Mild6 (26.1%)36 (16.8%)
 Moderate10 (43.5%)84 (39.3%)
 Severe2 (8.7%)68 (31.8%)
 Very severe5 (21.7%)26 (12.1%)
Table 2.  Characteristics of chronic obstructive pulmonary disease (COPD) men with urinary incontinence (n = 24)
ICIQ itemn%
  1. ICIQ, International Consultation on Incontinence Questionnaire.

Frequency of leakage
 About once a week or less often1458.3
 Two or three times a week625.0
 About once a day28.3
 Several times a day28.3
 All the time00
Quantity of urine loss
 A small amount1875.0
 A moderate amount520.8
 A large amount14.2
Interfere with everyday life
 0 (not at all)312.5
 1–31666.7
 4–7520.8
 8–10 (a great deal)00
When urine leakage occurs (multiple responses)
 Before reaching toilet1666.7
 Coughing or sneezing00
 Physically active or exercising312.5
 After urinating and dressed416.7
 Asleep28.3
 Others520.8

Discussion

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

This study is the first investigation of the prevalence, type and characteristics of urinary incontinence in community-dwelling men with COPD. The prevalence estimate of 10% was comparable with the 7.8–13.0% reported for the Japanese elderly male population.13,14 Unlike cystic fibrosis where stress incontinence induced by coughing was prevalent in women,15 urge incontinence was more common (63%) among incontinent men with COPD. The finding challenges the conventional view that COPD is associated with stress incontinence, particularly that increase in abdominal pressure when coughing is assumed to cause the leakage of urine.4,7 Further research is needed to understand the reason and mechanism underlying urge incontinence in COPD men, so that appropriate treatment of the condition can be developed.

Within the context of a progressive disease that requires time-consuming remedy and rehabilitation, it is not surprising that most incontinent men with COPD did not perceive the condition had seriously impacted their daily life, as reflected by their mean ICIQ-SF score less than the cut off value of 8 for bothersome urinary incontinence.16

Several limitations should be considered when interpreting the findings. In this study, information on continence was obtained based on self report via the ICIQ-SF rather than objective measurements of urine loss, and seasonal alterations were not accounted for.17 Nevertheless, it is now recognized that the use of psychometrically robust self-completion questionnaires is a valid approach for assessing urinary incontinence.18 The ICIQ-SF has good measurement properties and encompasses all aspects of incontinence.10,11,18 Moreover, face-to-face interviews were conducted by the same investigator to help improve the accuracy of the responses and to eliminate inter-interviewer bias. The observed prevalence of incontinence can be inflated by the progression of benign prostatic hyperplasia (BPH) among the older men, especially after therapeutic treatment or prostatectomy,19 but information on BPH status was unavailable from the participants.

It appears that incontinence developed after the diagnosis of COPD (average duration 2.5 years), but the low number of patients seeking help is of concern. It is possible that the men were either embarrassed or unaware that the condition is treatable.20 With the increased disease burden as COPD progresses, education and regular assessment for urinary tract symptoms are needed. Addressing urge incontinence should become part of the routine management of men with COPD. Appropriate exercise and treatment involving urologists, therapists and respiratory physicians must be developed and incorporated within the rehabilitation program of COPD patients.

Acknowledgments

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

The authors are grateful to the following persons for assistance with the recruitment of participants: Drs Kondoh, Kimura, Nishiyama, Kato, Aso, Sakamoto, Yokoyama, (Tosei General Hospital, Aichi); Drs Hiramatsu, Matsumoto, Kojima, Takada, Watanabe, Shizu, Okachi (Komaki City Hospital, Aichi); Drs Ando, Shindo, Abe (Ogaki Municipal Hospital, Gifu); Drs Tanikawa, Aoyama, Honda, Hibino, Mizutani (Toyota Kosei Hospital, Aichi); Dr Son (Ichinomiya-City Municipal Hospital, Aichi); Dr Oga (Kyoto University, Kyoto).

References

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