Prevalence of Urinary Incontinence and Its Impact on the Quality of Life Among Women in Aseer region, Saudi Arabia

Prevalence of Urinary Incontinence and Its Impact on the Quality of Life Among Women in Aseer region, Saudi Arabia

Abstract

Background: Urinary incontinence. It affects millions of women worldwide. The objectives of this study were to measure the prevalence of urinary incontinence and the association with quality of life, physical, psychological, and social consequences of urinary incontinence Saudi women in Aseer region

Methods: A cross-sectional study was conducted from June to October 2024 in the Aseer region, Saudi Arabia. A total of 309 women participated in the study. Data were collected through a self-administered questionnaire, which included demographic information, the Urinary Incontinence Quality of Life Questionnaire (I-QOL), and health-related factors. Statistical analysis was performed using IBM SPSS Version 26.0, with chi-square tests and ANOVA used to identify associations between UI and various factors.

Results: The study found that 47.2% of participants experienced some form of UI. The prevalence was highest among older women (89.7% in those aged 50+), married or widowed/divorced women (65.3% and 66.7%, respectively), and those with multiple pregnancies (71.4% for four or more pregnancies). Other significant risk factors included menopause (84.0%), obesity (57.9%), and chronic diseases (53.6%). Women with frequent UI reported lower QoL scores, particularly in psychosocial impact, avoidance behavior, and social embarrassment, with statistically significant differences (p < 0.001).

Conclusion: UI is a prevalent issue among women in the Aseer region, significantly affecting their QoL. The findings highlight the need for targeted public health interventions, including awareness campaigns, early screening, and treatment strategies focused on high-risk groups. Addressing UI through lifestyle modifications, medical interventions, and community education can improve the well-being of affected women.

Keywords: Urinary Incontinence, Women’s Health, Urogynecology.

Urinary incontinence is the complaint of any involuntary leakage of urine It is categorized based on the situations that most commonly trigger the issue, Urgency urinary incontinence is the complaint of involuntary leakage accompanied by or immediately preceded by urgency. Stress urinary incontinence is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. Mixed urinary incontinence is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing. 1,2 The global prevalence of urinary incontinence (UI) in women varies considerably, affecting approximately 26% of women worldwide. 3 . In the United States, data from NHANES (2015–2018) revealed that approximately 62% of women experience UI and around 22% experienced moderate to severe UI. 4 The prevalence rate of urinary incontinence for women aged 45 to 60 in Brazil was 23.6%. Conversely, the prevalence rates among adult women (over 18 years old) in Germany, Denmark, and Norway were 48.3%, 46.4% and 18.7%. 5–7. Studies from European and North American populations report frequencies ranging from 8.5% to 58%. 8 . In the Middle East, prevalence rates range from 20% to 54%, 9,10 with Saudi Arabia-specific studies indicating rates between 30% and 41.4%. Specifically, the prevalence of stress urinary incontinence (SUI) was found to be 31.7%, urge urinary incontinence (UUI) 22.9%, and mixed urinary incontinence (MUI) 18.4%. Several studies have identified a wide range of factors significantly associated with urinary incontinence (UI), including obesity, high parity, menopause, hysterectomy, current use of hormone replacement therapy (HRT), urinary tract infections, chronic obstructive pulmonary disease (COPD), respiratory system diseases, heart disease, a history of pelvic surgeries, and alcohol consumption. Additionally, diabetes, hypertension, and tobacco use have also been linked to an increased likelihood of developing UI. 11–13 The prevalence of UI tends to rise with age, as demonstrated in the United Kingdom, where an estimated six to seven million people experience this condition. Among those affected, approximately 39.9% are between the ages of 55 and 64, and 15% are between 75 and 80, underscoring the condition’s growing impact on older adults. 14 While urinary incontinence (UI) is not typically classified as a severe physical disease or a direct threat to life, it influences women’s QoL in several dimensions, causing psycho-emotional changes and limitations such as physical, social, and sexual restrictions, as well as affecting daily activities. Researchers report that this impact is related to individual perceptions of the severity, type, and amount of urine leakage, as well as the cultural context in which women are situated. 15–17 The physical and social limitations stem from fear or shame of leaking urine in public, prompting women to avoid going out, attending parties, shopping, taking long trips, and participating in physical activities due to concerns about wet clothing, urine odor, or lack of nearby restrooms18. Many of these women only leave their homes when they know they will have easy access to facilities. According to the WHOQOL, 66% of affected women report QoL impairment, with UI having a greater impact on physical and social activities, trust, and self-perception. 19 Urinary incontinence . It’s affects millions of women worldwide, including those in Aseer, Saudi Arabia. However, research on urinary incontinence has primarily focused on other countries, leaving a gap in understanding the experiences of women in Aseer. This study aims to address this gap by investigating the impact of urinary incontinence on the quality of life of women in the region. The objective of this research is to explore the physical, psychological, and social consequences of urinary incontinence on the quality of life of women in Aseer, Saudi Arabia. By understanding the unique challenges faced by these women, appropriate interventions can be developed to improve their quality of life and overall well-being.

Methodology

Study population:

A cross-sectional descriptive study was conducted From June 1, 2024, to October

1, 2024, in Aseer region of southwestern SA. The study aimed at assessing the Prevalence of Urinary Incontinence and Its Impact on the Quality of Life. The target sample for this study comprises the female population of the Aseer Region.

Sample size:

The minimum required sample size to investigate the Prevalence of Urinary Incontinence and Its Impact on the Quality of Life Among Women in Aseer region was calculated using Epi-info software, version 7.2.2.6. With a confidence level (CI) of 95% and margin of error of 5%, and an expected frequency of 50%. The required sample size was determined to be 383 participants. We conducted a convenience sampling methodology to select our target population. Participants were recruited based on their availability, and efforts were made to include a diverse range of individuals to enhance the representativeness of the sample.

Data collection tool:

Data were collected through a self-administered anonymous questionnaire in Arabic created using Google Forms and distributed via various channels including social media platforms (Facebook and Twitter), messaging apps (email, WhatsApp, and Telegram), or through face-to-face. The questionnaire consists of three parts: The first part includes socio-demographic and personal data, including age, sex, residence (rural or urban), marital status (single, married, divorced, or widowed), working (employee or non-employee). Additionally, respondents were asked about any associated comorbidities and chronic diseases, including hypertension, thyroid issues, renal disease, liver disease, ischemic heart disease, chronic obstructive airway disease, cerebrovascular disease, and autoimmune diseases. The second part is the validated Arabic version of the Urinary Incontinence Quality of Life Questionnaire (I-QOL), which is a patient-reported outcome measure that specifically assesses the effects of urinary incontinence on various aspects of quality of life. The I-QOL comprises 22 items, each employing a five-point ordinal response scale where 1 = extremely, 2 = quite a bit, 3 = moderately, 4 = a little, and 5

= not at all. These items can be categorized into three sub-scales: Avoidance and

Limiting Behavior (8 items), Psychosocial Impacts (9 items), and Social

Embarrassment (5 items). To calculate the total, I-QOL score and the scores for the three sub-scales, the unweighted item scores are summed and converted to a 100point scale, with 0 indicating the most severe impact and 100 indicating no issues. This instrument has been extensively utilized and has been effectively validated for individuals experiencing urinary incontinence (UI). Anthropometric measurements: Waist circumference was measured by wrapping a measuring tape gently around the respondent's waist at the level of the top of the hip bone. Specific cutoff points of 102 cm for men and 88 cm for women were used to identify risk. The tape was positioned parallel to the ground and formed a complete circle around the trunk. Body mass index (BMI) was calculated using the formula: BMI = weight (kg) / height (m²). This involved dividing the body weight in kilograms by the square of the height in meters. BMI categories were defined as follows: a BMI below 18.5 classified as underweight, a BMI from 18.5 to less than 25 considered within the healthy weight range, a BMI between 25.0 and less than 30 indicating overweight, and a BMI of 30.0 or higher denoting obesity.

Data management and analysis plan:

The data collected from the study were analyzed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including frequencies and percentages, were used to summarize the demographic characteristics and responses of the participants. Chi-square tests were conducted to examine the associations between demographic factors (age, gender, marital status, educational level) and UI prevalence. The significance level was set at p < 0.05. One-way ANOVA was used to assess the impact of the frequency of urinary incontinence on quality of life domains, including Psychosocial Impact, Avoidance and Limiting Behavior, and Social Embarrassment. The mean scores and standard deviations for each quality of life domain were calculated and compared across different frequencies of urinary incontinence.

Ethics approval:

Participants were informed that their answers would be confidential and used only for scientific purposes. Ethical approval for the study was obtained from the relevant Ethics Research Committee prior to data collection, ensuring compliance with ethical standards. The research utilized validated instruments, including the King’s Health Questionnaire (KHQ) and the Urinary Incontinence Quality of Life Questionnaire (I-QOL), both recognized for their effectiveness in assessing the impact of urinary incontinence on quality of life.

Results

Table 1 presents the bio-demographic characteristics of 309 women in the Aseer region, Saudi Arabia. The age distribution shows that nearly half of the participants are aged 1829 years, with 151 women (48.9%). This is followed by 68 women (22.0%) aged 30-39 years, 61 women (19.7%) aged 40-49 years, and 29 women (9.4%) aged 50 years and above. Regarding marital status, 135 women (43.7%) are single, 150 women (48.5%) are married, and 24 women (7.8%) are divorced or widowed. In terms of employment, a significant majority of participants are unemployed, with 223 women (72.2%), compared to 86 women (27.8%) who are employed. Looking at the number of pregnancies, 147 women (47.6%) have never been pregnant, 20 women (6.5%) have been pregnant once, 26 women (8.4%) have been pregnant twice, 32 women (10.4%) have been pregnant three times, and 84 women (27.2%) have been pregnant four or more times. Regarding normal vaginal deliveries, 20 women (12.3%) have never had a normal vaginal delivery, 92 women (56.8%) have had between 1-3 deliveries, 44 women (27.2%) have had 4-6 deliveries, and 6 women (3.7%) have had more than 6 deliveries. For menopause status, 25 women (8.1%) are menopausal, while 284 women (91.9%) are not. Smoking habits show that 14 women (4.5%) are smokers, while 295 women (95.5%) are non-smokers. About the chronic diseases among the women, 113 (36.6%) have no chronic diseases, 82 (26.5%) are obese, 45 (14.6%) have chronic constipation, 29 (9.4%) have diabetes mellitus, 28 (9.1%) have recurrent urinary tract infections, 28 (9.1%) have chronic respiratory diseases, 24 (7.8%) have experienced back trauma, 20 (6.5%) have chronic cough, 10 women (3.2%) have undergone urinary tract surgery, 6 (1.9%) have neurological disorders, 6 (1.9%) have thyroid disorders, and 6 (1.9%) have other conditions.

Figure 1 illustrates the prevalence and frequency of urinary incontinence among women in the Aseer region, Saudi Arabia, over the past 12 months. The majority of respondents, 163 women (52.8%), reported never experiencing urinary incontinence. However, a significant portion of the population did experience incontinence to varying degrees: 63 women (20.4%) reported losing control of their urine once per month, and 48 women (15.5%) experienced it 2-3 times per month. Additionally, 23 women (7.4%) reported incontinence about once per week, and 12 women (3.9%) experienced it almost every day.

Table 2 presents the quality of life (QoL) scores among women in the Aseer region, Saudi Arabia. The Psychosocial Impact domain, which ranges from 1 to 5, has a mean score of

3.9 with a standard deviation of 1.0, representing 78.3% of the total possible score. The Avoidance and Limiting Behavior domain also ranges from 1 to 5 and has a mean score of

4.0 with a standard deviation of 1.1, accounting for 80.9% of the total score. The Social Embarrassment domain shows a mean score of 4.1 with a standard deviation of 1.1, covering 81.4% of the total score.

Table 3 presents the factors associated with urinary incontinence among women in the Aseer region, Saudi Arabia. There is a significant association between age and urinary incontinence (p = 0.001). The prevalence of urinary incontinence increases with age: 25.8% of women aged 18-29, 66.2% of women aged 30-39, 59.0% of women aged 40-49, and 89.7% of women aged 50 and above reported experiencing urinary incontinence. Marital status also shows a significant association (p = 0.001). Urinary incontinence is more prevalent among married women (65.3%) and divorced/widowed women (66.7%) compared to single women (23.7%). Employment status is significantly associated with urinary incontinence (p = 0.002). A higher prevalence is observed among employed women (61.6%) compared to unemployed women (41.7%). There is a significant association between the number of pregnancies and urinary incontinence (p = 0.001). Women who have had multiple pregnancies show a higher prevalence: 55.0% for one pregnancy, 69.2% for two pregnancies, 62.5% for three pregnancies, and 71.4% for four or more pregnancies. In contrast, 25.2% of women who have never been pregnant reported urinary incontinence. Also, NVD is significantly associated with urinary incontinence (p = 0.018). The prevalence increases with the number of normal vaginal deliveries: 50.0% for those who have never had a normal vaginal delivery, 66.3% for 1-3 deliveries, and 81.8% for 4-6 deliveries. Interestingly, 33.3% of women with more than six normal vaginal deliveries reported incontinence. Menopause status shows a significant association with urinary incontinence (p = 0.001). A higher prevalence is observed among menopausal women (84.0%) compared to non-menopausal women (44.0%). Body Mass Index (BMI) is significantly associated with urinary incontinence (p = 0.004). The prevalence of urinary incontinence is higher among overweight (58.3%) and obese women (57.9%) compared to those with normal weight (34.7%). Additionally, there is a significant association between chronic diseases and urinary incontinence (p = 0.003). Women with chronic diseases have a higher prevalence of urinary incontinence (53.6%) compared to those without chronic diseases (36.3%). On the other hand, smoking does not show a significant association with urinary incontinence (p = 0.376). The prevalence is 35.7% among smokers and 47.8% among non-smokers.

Table 4 shows the impact of Urinary Incontinence Frequency on Quality of Life Domains among Women in the Aseer Region, Saudi Arabia. Women who never experience urinary incontinence report the highest quality of life scores, with mean scores of 4.5 (SD = 0.6) for Psychosocial Impact, 4.6 (SD = 0.6) for Avoidance and Limiting Behavior, and 4.7 (SD = 0.6) for Social Embarrassment (p = 0.001). However, as the frequency of UI increases to once per month, the mean scores drop to 3.8 (SD = 1.0) for Psychosocial Impact, 3.9 (SD = 1.1) for Avoidance and Limiting Behavior, and 3.9 (SD = 1.1) for Social Embarrassment (p = 0.001). Further, women who experience UI 2-3 times per month report even lower mean scores of 3.1 (SD = 0.9) for Psychosocial Impact, 3.1 (SD = 1.0) for Avoidance and Limiting Behavior, and 3.1 (SD = 1.1) for Social Embarrassment (p = 0.001). Those experiencing UI about once per week have mean scores of 2.7 (SD = 0.9) for Psychosocial Impact, 2.9 (SD = 1.0) for Avoidance and Limiting Behavior, and 2.8 (SD = 1.1) for Social Embarrassment (p =

0.001). Lastly, women who experience UI almost everyday report mean scores of 2.9 (SD =

0.8) for Psychosocial Impact, 2.9 (SD = 0.8) for Avoidance and Limiting Behavior, and 2.7 (SD = 0.9) for Social Embarrassment (p = 0.001).

Discussion

The findings directly addressed the study’s objectives, focusing on the prevalence and QoL impact of UI among women in Aseer, Saudi Arabia. The results confirmed the hypothesis that UI is highly prevalent in the region and aligns with global patterns. Moreover, they highlighted the substantial physical, psychological, and social consequences of UI, as noted in the study’s introduction. the prevalence of urinary incontinence (UI) among women in the Aseer region of Saudi Arabia. Results revealed that almost half (47.2%) of participants experienced some degree of incontinence. The frequency of UI varied, with 20.4% of women experiencing it monthly, 15.5% reporting 2–3 episodes per month, and smaller numbers reporting weekly or daily occurrences. These findings confirm that UI is a widespread health issue in the region. The study further identified several factors associated with UI. Age emerged as a key determinant, with prevalence reaching 89.7% among women aged 50 and above. Marital status was also significant, with 65.3% of married women and 66.7% of divorced/widowed women experiencing UI compared to 23.7% of single women. Other risk factors included multiple pregnancies, with 71.4% of women who had four or more pregnancies reporting UI. Similarly, women with 4-6 vaginal deliveries showed a prevalence of 81.8%. Menopause was another important factor, with 84.0% of menopausal women affected. Chronic conditions such as obesity were strongly linked to UI, with 57.9% of obese women experiencing UI. The study highlighted the significant impact of UI on QoL. Women with frequent episodes of UI reported lower QoL scores in three domains: psychosocial impact, avoidance behavior, and social embarrassment. These scores declined as UI frequency increased, demonstrating the emotional and social challenges faced by affected women. The findings of this study align with and expand upon previous research examining urinary incontinence (UI) and its impact on women’s quality of life (QoL). The prevalence of UI in the current study was 47.2%, similar to reported rates from studies conducted in Saudi Arabia and other regions. For instance, Almutairi et al. (2021) found a prevalence rate of 41.7% among Saudi women 20, while studies in Omani and Iranian populations reported rates of 32.8% and

46%,21,22 respectively . However, the prevalence was higher compared to certain Western populations, such as Mallorcan women, where the rate was 24% .23 This difference may reflect regional variations in cultural norms, healthcare access, and lifestyle factors. In terms of risk factors, the current study corroborates findings from previous research emphasizing the role of age, parity, menopause, and obesity. Almutairi et al. (2021) and studies in Iranian populations similarly highlighted older age, multiparity, and menopause as significant contributors to UI prevalence 20,22. Additionally, the association between obesity and UI was consistently observed across studies, including those focused on obese populations where the prevalence reached as high as 88%24 . These findings reinforce the importance of targeted interventions addressing modifiable risk factors such as weight management. Regarding the impact on QoL, the current study aligns with global literature demonstrating that UI significantly reduces QoL, particularly in psychosocial and social domains. Studies by Steibliene et al. (2020) and Paes et al. (2016) also reported that women with UI experience higher levels of anxiety and depression, which negatively influence their overall well-being 25,26 . Additionally, the present study supports findings by Alshenqeti et al. (2022), which highlighted the emotional and social restrictions imposed by UI, especially in women reluctant to seek medical help due to stigma27. In the Middle Eastern context, Alquaiz et al. (2023) found a prevalence of 47.5% among Saudi women, with stress incontinence being the most common type. This matches the present study’s findings, highlighting the shared burden across different Saudi populations 28 . Xie et al. (2021) similarly emphasized the significant impact of aging, BMI, and lifestyle factors on UI prevalence in Chinese women29, which aligns with the role of these factors in the Aseer region . Moreover, studies on athletes and active populations, such as Hagovska et al. (2017), revealed that UI prevalence and QoL impact were substantial even in physically active groups, suggesting that UI affects diverse populations beyond the general public30 . Lastly, Steibliene et al. (2020) identified a strong association between UI, depression, and anxiety, which is consistent with the psychosocial burden highlighted in this study 25 . However, a notable difference emerges when comparing this study’s findings on help-seeking behavior. While the present study emphasizes a significant impact of UI on QoL, it does not explicitly address health-seeking behaviors, unlike Alshenqeti et al. (2022) and Al-Balushi (2020), who found low rates of medical consultation due to embarrassment and lack of awareness 27,31 . Future research should further explore this gap to better understand barriers to seeking treatment in the region. The findings directly addressed the study’s objectives, focusing on the prevalence and QoL impact of UI among women in Aseer, Saudi Arabia. The results confirmed the hypothesis that UI is highly prevalent in the region and aligns with global patterns. Moreover, they highlighted the substantial physical, psychological, and social consequences of UI, as noted in the study’s introduction. While global UI prevalence ranges from 8.5% to 58%, this study added valuable regional data, revealing prevalence rates consistent with prior research from the Middle East. It emphasized the severe impact UI has on daily life in Aseer, particularly regarding physical activity, social engagement, and emotional health. These findings validate the introduction’s assertion that UI significantly limits self-esteem and various life domains. Additionally, the study underscored the need for interventions tailored to the specific needs of women in Aseer. Public health strategies—such as awareness campaigns, prevention programs, and accessible treatments—are essential to mitigating the impact of UI. Addressing critical risk factors like age, menopause, chronic conditions, and childbirth can help healthcare providers develop more effective strategies to improve QoL. Ultimately, the findings bridge a crucial gap in regional knowledge, contributing meaningfully to both local and global research on UI.

A cross-sectional design was chosen for this study due to its efficiency in assessing the prevalence and impact of urinary incontinence (UI) within a defined population at a single point in time. This method aligns with the study’s objectives to identify the prevalence of UI, explore its associated risk factors, and evaluate its impact on the quality of life (QoL)

among women in the Aseer region. A self-administered questionnaire, including the validated Urinary Incontinence Quality of Life Questionnaire (I-QOL), was used to collect data while maintaining participant anonymity. The study faced challenges such as potential selection bias and low response rates from older participants, but these were addressed by using multiple distribution channels. A pilot study refined the questionnaire to improve clarity. Additionally, statistical analyses, including Chi-square tests and ANOVA, were employed to identify significant associations and differences across variables. The high prevalence of UI and its detrimental impact on quality of life (QoL) underscore the need for targeted public health interventions. Health care providers should focus on awareness campaigns to reduce stigma and encourage early treatment. Policymakers may consider adding routine UI screening to primary care visits, especially for at-risk groups like older, obese, and multiparous women. Educational programs on lifestyle changes, including weight management and pelvic floor exercises, should be developed, along with training for healthcare professionals in UI management. Future research could explore the progression of UI, the effectiveness of interventions, and the psychological impact of UI on Saudi women. This study has several limitations. The use of a convenience sampling method may have introduced selection bias by overrepresenting participants with internet access or those more willing to discuss sensitive topics. The cross-sectional design limits the ability to establish causality between risk factors and UI. Self-reported data may be affected by recall bias or underreporting due to the stigma surrounding UI. Cultural factors in the Aseer region may also influence the generalizability of the findings to other populations. For instance, the low smoking prevalence among women in this region limits the exploration of its potential impact on UI.

Conclusions

The study revealed that nearly half (47.2%) of the surveyed women in Aseer experienced some degree of UI, with prevalence increasing with age, as 89.7% of women aged 50 and above reported UI. Other significant risk factors included marital status, multiple pregnancies, menopause, obesity, and chronic diseases. The findings confirmed that UI negatively impacts QoL, particularly in psychosocial well-being, avoidance behaviors, and social embarrassment. Women with frequent UI episodes reported significantly lower QoL scores, highlighting the emotional and social burden of the condition. This study underscores the high prevalence of UI among women in Aseer and its profound impact on QoL. Addressing UI requires a multifaceted approach, including public health initiatives, routine screening, and improved access to treatment. This study contributes region specific insights to global UI literature and informs strategies to reduce its burden. Future research should address care barriers and evaluate intervention effectiveness.

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