SEARCH

SEARCH BY CITATION

Keywords:

  • urinary incontinence;
  • epidemiology;
  • multinational study;
  • men

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. APPENDIX

OBJECTIVES

To report the results of the prevalence and health status associated with male urinary incontinence (UI) in a population-based, multicentre study in four countries, and to assess the epidemiology of this condition.

SUBJECTS AND METHODS

A standard questionnaire asking about frequency and amount of urine loss, use of pads and stress incontinence, was used to measure the prevalence of UI among men in four countries (Boxmeer, The Netherlands; Auxerre, France; Birmingham, UK; and Seoul, Korea). Self-reported urinary leakage was also recorded, with details of visits to the doctor for the symptoms. The samples were selected randomly from population registers of men aged 40–79 years, which provided representative samples in each community.

RESULTS

In all, 4979 men responded; from incontinence symptom scores, 7.3% of men aged 40–79 years in Auxerre, 16.3% in Boxmeer, 14.4% in Birmingham and 4.3% in Seoul reported mild to severe UI. On a self-reported question, 14.8% and 14.5% of men in Birmingham and Boxmeer thought that they had urinary leakage, compared with 7.5% and 7.1% of men in Auxerre and Seoul, but typically the reported incontinence was leaking drops of urine a few times a week. Of men with urinary leakage in the three European centres, 25.9% visited the doctor with this problem, compared with only 9.0% of men in Seoul. Of men in the European centres, 5.9% used pads at least occasionally, compared with only 1.6% of men in Seoul. UI was age-related and the reporting of it varied among centres, with 14.4% of men in Birmingham and 12.7% of men in Boxmeer aged 40–49 years reporting mild to severe UI, compared with 5.2% in Auxerre and 1.9% in Seoul. Among men aged 60–69 years the corresponding percentages were 13.7% in Birmingham, 22.6% in Boxmeer, 9.2% in Auxerre and 8.0% in Seoul.

CONCLUSIONS

UI is more common in older men and relatively uncommon among younger men. Some men reported no problems on the symptom questionnaire but replied positively to a direct question. Surprisingly many men wear protective pads at least occasionally as a result of their problem. UI appears to be a problem for men and which remains largely untreated; this may partly be a result of cultural differences.


Abbreviations
UI

urinary incontinence

OR

odds ratio

BII

BPH Impact Index.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. APPENDIX

There are several fundamental problems to consider when assessing the epidemiology of urinary incontinence (UI) [1]. First, there is no common definition of UI and every study has used its particular definition; second, there is little information about the aetiology of UI; and third, little attention is paid to the severity of the condition. Accurate details of the population incidence and prevalence are unavailable [2] and existing studies are hampered by the lack of a common definition of the type of UI and the severity of the symptoms. Previous studies in Belgium [3], Italy [4], Sweden [5], UK [6] and USA [7,8] have reported a widely different prevalence of UI, of 2.8–28%, depending on the definition of UI, with higher rates reported for leakage over a longer period and in older men.

UI may be common in elderly men; there is little population-based epidemiological information available using the same definitions over several centres. The specific objectives of the UREPIK study of male UI were to investigate the prevalence using the same instrument in four centres, assessing also why, in similar circumstances, some men seek medical assistance and others do not.

SUBJECTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. APPENDIX

The full details of the survey methods, population sampling, statistical analysis and response rates were reported previously [9]. UI was assessed using the total score from four questions (listed in the Appendix) which asked about frequency and quantity of urinary leakage, the use of pads and stress incontinence [10]. The score was 0–14, with high scores indicating the presence of a problem. Groups were defined as 0–2 (none), 3–6 (mild), and 7–14 (severe). Severe and frequent UI was defined using the responses to the individual questions (Appendix). If the man reported losing urine more than three times a week and either the urine loss was a small stream or more, or he always or almost always had to wear pads, then he was said to have severe and frequent UI. Self-reported UI was also assessed by asking subjects directly if they currently had urinary leakage which was defined as some lack of control over bladder function which caused urine leakage at times. The bother associated with general urinary symptoms was measured using the BPH Impact Index (BII) [11,12]. The UI score with this index was combined to obtain mild to severe incontinence with bother, UI score ≥ 3, and BII 4+0.

The agreement between the different measures was assessed using κ[13] and its CI [14]; perfect agreement corresponds to a coefficient of 1.0 and 0 indicates chance agreement only. The relationship between UI and age and other factors, e.g. marital status and physical activity, was estimated using weighted logistic regression. The results are reported in the text as odds ratios (OR) and 95% CI. Physical activity was recorded as either the response to ‘How would you describe your level of physical activity during work hours?’ or ‘How would you describe your level of physical activity during leisure time?’ The UI score was dichotomised rather than using linear regression, as the normality assumption required in the linear regression was violated because the score had a skewed distribution. All statistical calculations were conducted using software (Statistical Analysis System, SAS Institute Inc, Cary, NC, 1996).

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. APPENDIX

The prevalence of mild to severe UI was 14.4% in Birmingham and 16.2% in Boxmeer, with lower rates in Auxerre (7.3%) and Seoul (4.3%) (Table 1). Severe and frequent UI was much less common, at 1.6–3.6%, and similar to mild or severe UI with bother, at 1.2–4.4%. There was substantial agreement between mild to severe UI and self-reported urinary leakage, with a κ of 0.63 (0.60–0.67). Among men reporting no leakage, 95.2% had a score of 0–2 while in men with leakage, 31.3% had a score of 0–2. The agreement between severe and frequent UI and self-reported urinary leakage was poor, with a κ of 0.30 (0.25–0.34), as only 21.4% of men reporting leakage had severe and frequent UI. The UI was age-related and the reporting of it also culturally related (Fig. 1).

Table 1.  Response rates and urinary incontinence, and the self-reported urinary leakage and severity of leakage, with responses to two of the four questions about UI, consulting a doctor for the problem, and medication
VariableAuxerreBoxmeerBirminghamSeoul
  1. A simple random sample was selected in Birmingham but age-stratified samples in the other centres. Adjusting the Birmingham response rate to mimic the same age stratification as the other centres gives an estimated response rate of 53%; 179 men in Birmingham completed a short version of the questionnaire without full information on UI, giving an overall response rate of 60% in Birmingham.

Response rate, %  28  72 42*  68
N with UI data121712339901360
UI score, %
0–2  92.7  83.8 85.6  95.7
3–6   6.9  14.8 13.0   4.1
7–14   0.4   1.5  1.4   0.2
Self-reported urinary leakage, %   7.5  14.5 14.8   7.1
Consulted doctor for leakage, %   1.7   3.8  3.9   0.6
Severe and frequent UI, %   1.6   3.6  2.5   2.1
Mild/severe UI and bother, %   2.3   3.5  4.4   1.2
No. with self reported urinary leakage  95 200139 135
Question 1, %
Never  13.1  10.1 10.2  10.3
< 3/week  53.2  57.3 54.4  84.0
≥ 3/week  33.6  32.7 35.3   5.7
Question 2, %
Never   8.0   4.4  8.9   8.3
Drop  77.6  76.4 75.6  74.1
Stream or worse  14.3  19.2 15.4  17.6
Doctor and medication, %
Saw doctor  23.3  26.4 26.9   9.0
Prescription medication  22.8   9.7 17.6   8.7
Prescription or non-prescription  23.7  13.4 21.1  13.9
image

Figure 1. The percentage (95% CI) of men (a) with a urinary incontinence score of ≥ 3 and (b) who wear pads at least occasionally, by age and centre (Auxerre, green closed circles; Boxmeer, light green open circles; Birmingham, red closed squares; Seoul, light red open squares).

Download figure to PowerPoint

Mild to severe UI increased with age in all centres but with different slopes (P = 0.002). The age gradient was steeper in Seoul and shallower in Birmingham. Adjusting for centre and age, the reporting of mild to severe UI was related to marital status (P = 0.05). Men with a partner were less likely to report mild to severe UI (OR 0.76, 0.55–0.99). There was no evidence that mild to severe UI was related to physical activity at work (P = 0.21), at leisure (P = 0.50), or smoking status (P = 0.30). Severe and frequent UI was lower in Auxerre (P = 0.007), increased with age (P < 0.001) and was less common among men with a partner (OR 0.40, 0.25–0.66). We estimated that 6.8% and 3.8% of married men in Boxmeer and Birmingham aged 75 years had severe and frequent UI.

Self-reported urinary leakage was higher in Birmingham and Boxmeer than in Auxerre and Seoul (P < 0.001; Table 1). Among these men, 76% reported that they only leaked a drop, a consistent result in all four centres. In the European centres 34% leaked urine at least 3 or 4 days a week and 89% at least once a week (Table 1). Self-reported urinary leakage increased with age (P < 0.001) at the same rate in all centres, and was lower in married men (OR 0.70, 0.53–0.92).

Among the 569 men with self-reported urinary leakage, the odds of visiting the doctor because of this symptom increased with age (P < 0.001) and varied among the four centres (P < 0.001); in the three European centres, 25.6% visited the doctor with leakage, compared with only 9.0% of men in Seoul (Table 1). Among men with severe and frequent UI the percentages seeing a doctor were Auxerre (16.7%), Boxmeer (54.8%), Birmingham (47.4%) and Seoul (17.6%). The respective percentages among men with mild to severe UI with bother were 40.9%, 77.5%, 54.5% and 25.0%.

The odds of visiting the doctor also increased with the severity of the UI symptoms (P < 0.001). For a man with a severe UI score of 7–14 the age-adjusted OR of going to the doctor was 8.93 (3.45–23.05) compared with a man with a symptom score of 0–2. However, the bother associated with urinary symptoms was a more important determinant of visiting the doctor than was the level of the symptoms. Adjusting for country, age and UI score, the odds of visiting the doctor increased with decreasing health status (BII) score (P < 0.001), but adjusting for country, age and bother there was no effect of the UI score (P = 0.34). There was no influence of living with a partner on the odds of visiting a doctor (OR 1.01, 0.53–1.94). In Auxerre and Birmingham, a larger proportion of men with self-reported UI received medication than in Boxmeer and Seoul (Table 1).

In Birmingham there was only a moderate increase in the rate of using pads with age, increasing from 8.0% of men aged 40–49 years to 10.4% of men aged 70–79 years (Fig. 1). The overall rate of using pads was similar in Boxmeer and Birmingham, but the rate of increase with age was steeper; in Seoul and Auxerre the rates of using pads were much lower.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. APPENDIX

Comparing epidemiological studies of male UI is problematic because there are no recognized ‘short’ instruments. Self-reported urinary leakage was used in a several studies [4,6,7,15], and questionnaires eliciting information about the amount of leakage and frequency in others [8,16–19]. The new ICSmaleIS questionnaire [20] is welcomed.

Among population-based surveys with age groups similar to those in the present survey, estimates of prevalence range from 3% of men reporting at least one episode of UI during the year preceding the interview [4] to 5% with UI according to the Bristol LUTS questionnaire, reporting 17.3% and 26% with moderate to severe incontinence [8]. In a community study of men aged 40–79 years, 23% of men report dribbling and 14.5% reported wet clothing [21]. The present estimates of prevalence in Birmingham and Boxmeer are at the lower end of this range for severe and frequent UI (3%), and mild to severe UI with bother (4%), but towards the middle at 17% when considering only mild to severe UI irrespective of bother. The differences in prevalence are associated with terminal dribbling. The prevalence of UI, by all measures, is age-related and we report a similar gradient to those in other studies [5]. Severe UI involving frequent loss of larger amounts of urine is much less common, but we estimated that 6.8% and 3.8% of married men in Boxmeer and Birmingham aged 75 years have severe and frequent UI.

The present study is one of the largest and uses the same instrument to measure male UI in several different settings. The comparisons show possible cultural differences in the reporting of UI which may reflect true differences in the rate of UI among men. They also show cultural differences in seeking treatment Response rates and cultural issues must be considered when interpreting the results; the former was poor in Auxerre and low UI was reported there, and in Seoul. We cannot exclude cultural differences or interviewer effects in Seoul; from Table 1 there is a suggestion that there may be under-reporting of frequency among men reporting leakage. However, when using the IPSS [22] there were no interviewer or cultural effects in Seoul compared with the European centres [9]. The higher prevalence estimates from Birmingham and Boxmeer than in Auxerre are consistent with differences associated with high volumes of liquid consumption over a long period, associated with beer and tea, especially as responses among men with self-reported leakage were all internally consistent among the three European centres.

The rates of mild to severe UI and self-reported urinary leakage were relatively high among men aged 40–49 years in Birmingham and Boxmeer. Also, the age gradient was lower in Birmingham than in the other three centres. This is not likely to be solely a problem of over-reporting of UI, as the data were internally consistent with the use of pads. There is a possibility of sampling bias, particularly in Birmingham where the response rate was strongly aged-related, and younger men with symptoms might be more likely to respond, but not so much in Boxmeer, where the response rate was much higher.

There was good agreement between the assessment of mild to severe UI and the self-reported urinary leakage. The main lack of complete agreement was in men who reported that they have urinary leakage but only leak a few drops of urine on some days each week: the cause appears to merit further investigation. Men do not appear to express any bother with terminal dribbling and about three-quarters of European men self-reporting leakage reported terminal dribbling. Exclusion of dribbling from the definition of UI leads to a large reduction in the prevalence.

Surprisingly many men reported wearing protective pads or having to change their underwear at least occasionally as a result of their UI. The trends with age and the differences among the centres are consistent with the reporting of UI and leakage.

A low percentage of men reported discussing this issue with their doctor, even though the men thought that they had urinary leakage. The analysis showed that age and centre were both determinants of seeking medical advice for this condition, and that men in Seoul do not seek medical advice as readily as men in the three European centres. Even in Europe, only a quarter of all men with urinary leakage go to the doctor. The most important determinant of seeking medical advice is not the severity of the symptoms but age and the impact that these symptoms have on daily activities (bother) [23,24], although other studies found no association with bother [25,26].

The discrepancy between reported symptoms and seeking medical advice was large; there is a need for better health education of this topic. A major implication of these findings is that UI is a relatively large problem in men in some centres and which remains untreated to a large extent. While some of this discrepancy may be a result of cultural differences among the centres there is also a large proportion which cannot be explained by such differences. There is clearly a need for a more detailed investigation of the epidemiology of UI in men.

ACKNOWLEDGEMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. APPENDIX

This contribution of Peter Boyle, Chris Robertson and Chiara Mazzetta to this research was within the framework of support from the Associazione Italiana per la Ricerca sul Cancro (AIRC) (Italian Association for Cancer Research). The study was funded by an unrestricted research grant from GlaxoWellcome.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. APPENDIX

APPENDIX

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. APPENDIX

Incontinence questions, response grades and scores; modified from [10].

1. How often do you leak urine? (score 0–4)

Never

Once a week or less

More than once but less than three times a week

More than three times a week but not every day

Every day

2. How much urine do you leak each time? (score 0–4)

Never

Only a drop

A small stream

Enough to make my pad or clothes wet

So much that it soaks or even leaks through my pad

3. How often do you wear pads or sanitary napkins (or change underwear) for your urine loss? (score 0–3)

Never

Occasionally

Almost always

Always

4. Does urine leak when you cough or sneeze? (score 0–3)

Never

Occasionally

Sometimes

Most of the time.