The current state of urinary incontinence among US women

Although many are aware that urinary incontinence (UI) is a prominent issue among women, the growing severity of this issue is not as publicized or acted upon.

Heidi Wendell Brown, MD

Ushma J. Patel, MD

To analyze real-world data of UI, Heidi Wendell Brown, MD, MAS, FACOG, Ushma J. Patel, MD, and co-authors conducted a study involving the 2015-2018 National Health and Nutrition Examination Survey (NHANES).¹ The results of this retrospective study serve as a major call to action for urologists and urogynecologists providing care for this condition. Brown is an assistant professor of female pelvic medicine & reconstructive surgery at the University of Wisconsin School of Medicine and Public Health, and Patel is a PGY-4 obstetrics and gynecology resident at the University of Wisconsin Hospitals and Clinics in Madison.

Please discuss the background for this study.

Patel: Dr. [Amy] Godecker, [PhD, MS,] who's one of the statisticians in the department and one of the co-authors for the study, met with me to go over my resident research interests surrounding urinary incontinence. So, we were looking up what the most recent updates for [this] data [were, and] came across the NHANES, which is this national database of rigorous information. [We] presented it to Dr. Brown, and at that time, we found that the last updates for urinary incontinence national data [came out in] 2004, which reported a prevalence of 49%. That was printed in 2007. We were thinking along the lines of increasing obesity [and] increasing age in the country and hypothesizing that the impact would be increasing urinary incontinence prevalence. So, we utilized the same database from the prior studies, which is the National Health and Nutrition Examination Survey, or NHANES, with the objective of figuring out what the actual prevalence of incontinence was in the US for adult women. And then, [we wanted] to further look at the level of bother, the frequency, and the severity, because that's underreported, I would say.

Brown: Population-based epidemiologic surveys are really the best way to ascertain the prevalence of a condition like urinary incontinence, where you're already collecting data from a national sample. You're not recruiting patients specifically to talk about their incontinence, so you know you can trust the prevalence rates. And we've seen pretty dramatic demographic shifts in terms of the aging population and the increasing obesity epidemic. So, we thought it was really important to try to update with a current snapshot of what's happening with urinary incontinence in women. We were just lucky that NHANES collected these data about urinary incontinence for the last 15 years, and we were able to analyze the most recent 4 to really give a snapshot of what's going on in our country right now with urinary incontinence.

What were the notable findings? Were any of them surprising to you or your co-authors?

Patel: In [this] study, we [found that] 61.8% of adult US women, which we say [are] 20 or older based off the way the data was collected, have urinary incontinence. And then we further estimated that with American community standards, which equates to 78 million American women with urinary incontinence, 40% of those have at least weekly urinary incontinence [and one] third of those are somewhat bothered or more bothered. When you look at severity, 27% have moderate or more severity, which equates to 28 million women. So, the data wasn't necessarily surprising because of what we had estimated with obesity and increasing aging population. But I think that the surprising part is that every person in the US has urinary incontinence or knows somebody that has urinary incontinence, and it's somehow still a restricted topic.

Brown: I think the most notable finding is that more than half of all adult US women experience urinary incontinence, and 1 in 5 experience moderate or more severe urinary incontinence. Even among women in their 20s, the prevalence of any urinary incontinence was greater than 1 in 3, and it was greater than two thirds among women in their 70s or older. I can't say that we, as urogynecologists, are surprised because we talk about this with women every day. But we certainly are happy to have these updated numbers to reassure our patients that they're not alone, that these conditions are common, but not normal, and that good solutions are available. Also, [we can] use the high prevalence in young women to reassure our young patients who sometimes feel like this is a sign that they're getting older that they're not alone, [and] that even in women in their 20s, 1 in 3 experience urinary incontinence.

How will these data continue to evolve in the future?

Patel: This is an exceedingly really prevalent condition and risk factors for the condition are growing. We mentioned the increasing population age and increasing [body mass index (BMI)], but we're also doing good things, like preventing primary cesarean delivery. That's been a new focus. So, it's hard to imagine that urinary incontinence prevalence won't remain this prevalent or increase, but my hope with this data is that it really underlines the seriousness of the matter and normalizes it too. [Also,] I hope that it allows mobilization of research funding into female urinary incontinence, and that it increases health care provider and community engagement to increase diagnosis and management of the topic. I think the real thing that would be amazing is if the trajectory of this was reversed from what we're seeing today.

How will these data guide your management of patients with urinary incontinence in the future?

Brown: I think these data mostly help with counseling—reassurance that patients aren't alone [and] that urinary incontinence is common but not normal—and debunking the misperception that urinary incontinence is a disease limited to old ladies. The increased odds of urinary incontinence, even among women with a BMI of 25 to 30, may actually help motivate patients to make behavior changes to improve weight. [It's] nice to see that we can say [that] even being in the overweight category is an increased risk. As you get into the obese and higher categories, the risk does increase, [but] even just tipping over from the normal BMI of 18 to 25 into the 25 to 30 [range] increases your risk. I also think that, based on the strong associations with anxiety and depression, we should continue to be vigilant about probing for the impact of symptoms, and consider incorporating brief validated screeners for depression and anxiety so that we can link those patients who need treatment back to their primary care providers for those services.

Patel: By the time patients come to specialty providers, we already know that they're having urinary incontinence. An important part of our work is to understand the level of bother [and] severity, [understand] patient lifestyle goals, provide education, and align them with the treatments that are there for them. I was [also] going to touch on the anxiety and depression part of it, Dr Brown, because that statistic is staggering. Other studies have [studied whether] it [is] anxiety and depression that leads to urinary incontinence or vice versa. You can easily see how either of those conditions could lead to each other, so that was the biggest part of it. These other things can lead to urinary incontinence, but the anxiety [and] depression part, even though we don't necessarily see it as a physical health condition, really is important.

What is the take-home message for the practicing urologist?

Brown: I think the biggest take-home message is that more and more women are going to need our help in the coming years, and very few of them seek care. Those who do often do so with primary care providers [(PCPs)] who may not be aware of all the solutions that we can offer. So, sharing this prevalence study with your local primary care referral network may be helpful to put it back on busy PCP's radars. [It's important that they know that] urinary incontinence is very common in women and that we're here to help. We're preaching to the choir. Urologists see women with urinary incontinence, but I think [you should consider] spreading the word to your local primary care referral base, [saying,] "Hey, think about this. It's really common in your patients." Also, [you should consider] incorporating screening for depression or anxiety in your patients who you're treating for urinary incontinence and doing that loop back to PCPs, which also helps your referrals.

Patel: Throughout my training, I have heard that urinary incontinence is under diagnosed [and] undertreated. So, now that we have this updated data, hopefully it gets out to primary health care providers to refer to the specialty providers—urologists, urogynecologists. We just need to be ready to meet the increase that we're going to see for caring for these women for a condition that's honestly been somewhat neglected.

Is there anything else your feel our audience should know about this topic?

Patel: The prevalence of incontinence is high and increasing. We recommend routine screening for all women for this condition as a part of preventive health care. If you're a woman out there who's experiencing urinary incontinence, you're not alone. And if you're bothered by this condition, then there's treatment out there for you.

Reference

1. Patel UJ, MD, Godecker AL, Giles DL, Brown HW. Updated prevalence of urinary incontinence in women. Female Pelvic Med Reconstr Surg. Published online January 12, 2022. doi:10.1097/SPV.0000000000001127