Family Practice Advance Access originally published online on July 13, 2006
Family Practice 2006 23(5):497-506; doi:10.1093/fampra/cml033
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The extent and severity of urinary incontinence amongst women in UK GP waiting rooms
a Department of General Practice, Cardiff University UK
b Boehringer Ingelheim Limited Berkshire, UK
c Health Research Associates, Inc. Seattle, Washington, USA
d Mid Yorkshire Hospitals Yorkshire, UK
e Bristol Urological Institute, Southmead Hospital Bristol, UK
f Department of Geriatric Medicine, University College London Hospitals UK
g Leicester General Hospital Leicestershire, UK
h Southern General Hospital Glasgow, UK
Correspondence to Dr Chris Shaw, Senior Research Fellow, Department of General Practice, Cardiff University, Maelfa Health Centre, Llanedeyrn, Cardiff CF23 9PN, UK; Email: ShawC{at}cf.ac.uk
Received 20 June 2005; Accepted 7 June 2006.
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Abstract |
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Introduction. Few women seek help for urinary incontinence. Subsequently, there may be many women accessing primary care services who would benefit from treatment or advice. If high levels of unexpressed need are present in this population, a more proactive approach to continence management may be appropriate, but the feasibility of this depends on an accurate assessment of the level of unmet need in this population.
Aim. To assess the prevalence of urinary incontinence in a female population attending primary care and the extent of treatment seeking in relation to level of need.
Methods. A cross-sectional survey of urinary incontinence of adult women attending primary care practices in West Yorkshire, London, Glasgow and Leicestershire during a 10- or 15-day period.
Results. Three thousand two hundred and seventy-three (54%) women responded. Twenty-one per cent reported stress urinary incontinence only, 3.5% reported urge incontinence only and 21% reported mixed stress and urge incontinence during the preceding month (9% had moderate or severe symptoms). Fifty-three per cent of these had not consulted a health care professional, which is equivalent to 1 in 20 of women in GP waiting rooms, most of whom have stress and urge incontinence (75%) or stress incontinence only (21%).
Conclusions. Nearly half of female primary care attendees had experienced incontinence during the preceding month, but only a minority had sought help. Even amongst the nearly 1 in 10 women with moderate or severe incontinence only about half had sought help. There remains considerable health decrement due to urinary incontinence in those not receiving help in a population readily accessible to primary care services.
Keywords. Help-seeking, incontinence, quality of life, treatment provision, women.
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Introduction |
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Urinary incontinence is a common problem in adult women, with the prevalence in European countries reported to be around 35%.1 Stress urinary incontinence (SUI), resulting from an increase in intra-abdominal pressure in the presence of weak pelvic floor muscles, is most common (37%) and urge urinary incontinence (UUI) or sudden uncontrolled contractions of the detrusor the least common (20%), with a presentation of mixed stress and urge incontinence (MUI) being of intermediate prevalence (33%).1 Estimates, however, vary owing to differences in sampling, definitions and procedures.2
Although urinary incontinence and related symptoms can have substantial impact on quality of life, relatively few women seek help from health care professionals, leading to high levels of unmet need for incontinence services.3 This is mainly due to misattributions of cause such as assumptions that symptoms are normal after childbirth or in older age, and to a lack of awareness of available treatment options.4 It has been suggested that primary care professionals are in a position to take a more proactive approach to incontinence treatment by screening for urinary symptoms in at-risk groups, such as the elderly, during routine appointments.5 Before practices develop services in this way, it is important to assess the resource implications by estimating the level of need within the target population of primary care attendees. Prevalence of urinary symptoms is likely to be higher in those accessing primary care services than prevalence estimates of conventional epidemiological studies would suggest, as there are high levels of co-morbidity in those with urinary symptoms.6 However, help-seeking and thus met need may also be higher in those already in contact with services, and so it is important to establish the prevalence of symptoms and also of current levels of help-seeking and treatment provision to gain a more accurate reflection of unmet need for continence care within routine primary care practice.
A successful case-finding approach to addressing high levels of unmet need would also rely on practitioners being equipped to provide appropriate treatment. However, the available evidence suggests that treatment provision in primary care is variable. Many GPs have received limited training on incontinence issues and have poor awareness of treatment options and services, with the result that some women who do seek help receive no treatment or advice.7,8,4 In addition, case finding in primary care would ultimately impact on secondary care services, but there is little systematic evidence concerning preferred treatment pathways on which to base estimates of the likely secondary-care resource implications.
This study aims to provide information that would inform the feasibility of a case-finding approach to continence care by identifying the extent of unmet need for incontinence care in a primary care population. More specifically, the study examines the prevalence of urinary symptoms in women who are accessing primary care services and identifies the level of help-seeking for urinary symptoms in this population, and the treatments received. The study explores the characteristics of incontinence in terms of the prevalence of different types of incontinence, and patient perceptions of severity and impact on quality of life. These factors influence women's decisions to seek help and so are important indicators of need. This information is, therefore, useful in a clinical situation in identifying those who are most likely to require services. An understanding of treatment provision illustrates how well services are currently meeting the needs of those seeking help.
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Methods |
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Sampling
The sample was recruited from women attending primary care practices for services during a period of either 10 or 15 clinic days, depending on recruitment location. Four locations were selected to cover a wide range of geographical and cultural variation within the English-speaking population and within the organization of health care provision. These included West Yorkshire, London, Glasgow and Leicestershire. In order to ensure a sizeable sampling frame, participating practices were required to have at least four primary care physicians and to serve a female population of about 4000. Multiple primary care clinics agreed to take part in the study (eight in West Yorkshire, seven in London, five in Glasgow and two in Leicestershire). Data were collected over 15 clinic days in Leicestershire and two practices in London and West Yorkshire. Data were collected over 10 clinic days in all other practices.
All adult women over the age of 18 years who entered the primary care practice to obtain health care services for themselves during the study period were invited to take part in the study by a trained researcher. After reporting to reception and taking a seat in the waiting room, the women were given a study pack containing an information sheet, a consent form and a self-completion questionnaire. Women who were unable to complete a questionnaire owing to visual impairments, or who could not read or write English, were excluded from the study. Any women who were obviously too ill to complete a questionnaire were not approached. Respondents could either complete the questionnaire whilst waiting to see the doctor or complete it later and return it in a prepaid envelope.
The questionnaire and definitions
The questionnaire requested information on the presence and severity of urinary symptoms, identification of the type of urinary incontinence, the impact of symptoms on quality of life, service use and treatment-seeking behaviours, parity and general health, and a minimum of demographic information.
Symptom frequency and bothersomeness in women with urinary incontinence was assessed using the Symptom Frequency and Bothersomeness (SFB) questionnaire.9 This identifies women with SUI, UUI and MUI. Eight items were designed to identify SUI, which included questions concerning urinary leakage on general physical activity or movement, during coughing or sneezing, when bending or lifting, when standing or sitting down, whilst walking, when using stairs, during strenuous activity and when laughing (SFB-SUI). One item identified UUI (do you lose control of your bladder before you get to the bathroom?). Each item requires a response on a six-point Likert scale of the frequency of each symptom (‘Never’ to ‘Always’) and also a response on a six-point Likert scale concerning the degree of bother experienced as a result of each symptom (‘Not at all’ to ‘Extremely’ bothersome). The time frame for this questionnaire was the preceding month. Both the symptom frequency and bothersomeness scales of the SFB have been found to be internally consistent and have high reproducibility in patients with stress, urge and mixed incontinence.10 Validity has been assessed by positive correlation with the SF36 physical component scale and the Incontinence Quality of Life (I-QOL) questionnaire.10
Those who responded positively to any one of the stress questions but negatively to the urge question were defined as having SUI, and similarly those who responded positively to the urge question but negatively to all of the stress questions were defined as having UUI. Those who responded positively to both stress and urge questions were defined as having MUI.
Other measures of severity of symptoms included questions of self-reported severity (mild, moderate, severe), incontinence frequency as number of times urine loss experienced per day/week/month and average amount of leakage during the last month (almost dry, damp, wet, soaked).
Condition-specific quality of life was measured using the I-QOL.11 This is a 22-item measure that uses a 5-point response scale (‘Not at all’ to ‘Extremely’) and can be scored as an overall quality of life score or as three subscales: Avoidance and Limiting Behaviours, Psychosocial Impacts and Social Embarrassment. Higher scores indicate higher quality of life. Questions focused on impact of symptoms at the time of filling in the questionnaire. This questionnaire has been shown to have good reliability, validity and responsiveness in men and women with stress, urge and mixed incontinence.11–13
Functional limitations were measured using an individualized and incontinence-specific scale (Scale for Activity Interference and Limitation: SAIL) that allows responders to identify the activities that are most important to them, along with an assessment of the degree of limitation experienced. Patients were asked to identify the five most important activities, to write them into the blanks in the question format box and then respond to a seven-point Likert-type scale expressing the degree of limitation experienced in that activity during the last 2 weeks (ranging from ‘Totally Limited’ to ‘Not at all Limited’). This has proved to be internally consistent and reproducible and has good convergent validity with the SF36 and the I-QOL.14
Statistical methods
The prevalence of indicators of need such as presence and severity of symptoms, type of incontinence, impact on quality of life, treatment seeking and treatment provision are presented as proportions of those who responded. The relationship between variables is explored for statistical significance using chi-square statistics.
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Results |
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Response
Seven thousand one hundred and fifty-one women were approached to take part, of whom 1087 were ineligible, giving an eligible sample of 6064. Three thousand two hundred and seventy-three (54%) agreed to complete a questionnaire (Fig. 1). The age group distribution of responders is shown in Table 1. A total of 61.8% of the sample lived in owned or mortgaged accommodation, 35.9% in rented, 0.5% in sheltered accommodation or residential care and 1.8% in other. The majority of the sample reported good or very good health (69%), with 10.6% reporting excellent health and 20.4% reporting fair or poor health.
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Prevalence
Table 1 shows the prevalence during the preceding month by age group in the different categories of symptoms. Overall, 45.7% reported urinary incontinence, with 21.5% having SUI, 3.5% having UUI and 20.7% having MUI.
The prevalence of SUI peaked in the 30- to 49-year age group (24.7%) whilst the prevalence of MUI peaked in the 50- to 59-year age group (31.9%). UUI, however, remained fairly constant across the age range, with an increase in the oldest group, although sample size in this group is small.
There was a statistically significant difference between the groups in severity of incontinence (
2 = 132.6, P < 0.001), which was a result of women with MUI reporting more severe incontinence than those with SUI or UUI. The majority of women with SUI (74.3%) and UUI (77.8%) reported monthly leakage, whereas the majority of women with MUI (59%) reported weekly or daily leakage. Combining all types of incontinence, 57.2% had monthly leakage or less often, 21.6% had weekly leakage and 21.2% had daily leakage (Fig. 2).
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Self-perceived severity was also significantly different between the groups (
2 = 88.6, P < 0.001), which resulted from a significant difference between all possible pairings (all P < 0.05) except for MUI and UUI. However, self-ratings tended to be milder than incontinence frequency measures would suggest. A total of 87.7% of women with SUI and 76.1% of those with UUI perceived their symptoms as mild compared with 61.3% of women with MUI (Fig. 3).
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Women with SUI reported having experienced their symptoms for an average of 63 months before the study, and those with UUI and MUI reported having experienced their symptoms over the past 42 and 69 months, respectively.
Impact on quality of life
Table 2 shows the mean scores on the condition-specific quality of life measures for women with different types of urinary symptoms. Women with MUI tended to experience more bother, higher impact on quality of life and more functional limitations than women with SUI or UUI. Those with UUI, in turn, had greater impact and bother from symptoms than women with SUI. However, impact on quality of life was also statistically related to severity of symptoms as measured by frequency of leakage (all significant at P < 0.001).
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Treatment seeking
A total of 15.8% of women with SUI, 32.3% of those with UUI and 33.7% with MUI had sought help for urinary symptoms during the preceding 12 months. Treatment seeking was related to severity (measured as frequency of leakage), with 37.6% of treatment seekers leaking monthly or less often, 25.9% leaking weekly and 36.5% leaking daily, whereas 63.6% of non-treatment seekers leaked monthly or less, 20.3% leaked weekly and 16.2% leaked daily (
2 = 62.9, P < 0.001). The relationship between severity and treatment seeking was also evident when self-perceived severity was considered (2 = 115.2, P < 0.001). Treatment seekers also reported higher impact on quality of life and greater functional limitation (Table 3).
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However, other factors are involved in the decision to seek help since differences in treatment-seeking rates persist between different types of urinary incontinence even amongst those with similar symptom severity. For example, in those with moderate or severe UUI, 59% seek help whilst in those with moderate or severe SUI only 40% seek help and in those with moderate or severe MUI 47% seek help (Table 4).
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Nine per cent (287 out of 3273) of women had moderate to severe urinary incontinence; 53% of these had not discussed their symptoms with a health care professional (nor intended to at the health care visit during which they were surveyed). Therefore, on the basis of symptoms only this represents a level of unmet need of 5% (153 out of 3273) of the population sampled, of whom 21% had SUI only, 75% had MUI and 5% had UUI (Table 4).
Treatment pathways
Table 5 shows the treatments received by women who had sought help for incontinence. Just over half of help-seekers received medication (52%). This was slightly higher in women with UUI than those with SUI or MUI. Few were referred to a specialist nurse (21.5%) or physiotherapist (17.3%). GPs gave information on pelvic floor exercises to 41% of women whilst 17% were referred to a physiotherapist. Just over half (56%) of the women who were recommended pelvic floor exercises by the GP had good compliance, carrying out exercises every day or most days, whereas 76.1% of women receiving pelvic floor exercise therapy by a physiotherapist carried them out most or every day. A total of 28.3% were referred to secondary care, mainly to urology or gynaecology clinics. Half of these received further tests, with around one-third having surgery (34.2%), and 26.6% were prescribed medication.
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Discussion |
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This study showed a high prevalence of urinary incontinence in adult women who are accessing primary care services, with just under half (45.7%) having urinary incontinence on a monthly basis. The majority of those had stress symptoms either alone (21.5%) or in combination with urge symptoms (20.7%).
Previous studies that have included women across the whole adult age range have reported prevalence of incontinence of 11.3,15 14,16 16,13 25,17 26,18 35,1 45,19 and 53.2%20. The definition of incontinence varies between studies. Those using definitions of any incontinence reported prevalence to be 25% or more, whereas those using more severe definitions reported lower prevalence. The present study used a definition of monthly incontinence in the previous month rather than ‘any’, and so the prevalence appears to be somewhat higher than those reported previously. However, it was expected that the prevalence rate in this population would be higher than that in a more general community sample, as the study sample focuses on women accessing primary care, some of whom are likely to have additional co-morbidity by virtue of being attendees in primary care. It is possible that this would yield a population with a higher risk for incontinence than the general community, but it could not be assessed as specific information on co-morbidity was not collected. However, responses are highly sensitive to the format of questions in self-completion questionnaires. In this particular questionnaire the temporal context (i.e. during the last month) was stated at the beginning of each set of questions with response categories of rarely, sometimes, often, and so forth on each question. It is possible that some women may have missed the monthly time frame, but it is most likely that the results obtained are a result of a combination of questionnaire framing and a high level of prevalence in this group.
The distribution of types of symptom also varies across studies, but it is a fairly consistent finding that SUI is the most common type of symptom, followed by MUI. The most recent study, which examined prevalence of symptoms in four European countries, reported the distribution of the different types of symptoms in the total sample to be 37% with SUI, 33% with MUI, 20% with UUI and 10% with other urinary incontinence.1 This compares with the percentage of urinary incontinence by type found in this study, which were 47% with SUI, 45% with MUI, 8% with UUI. The questionnaire used in this study had eight items identifying SUI compared with one item to measure UUI. Therefore, there is more opportunity to identify women with SUI, which may have exaggerated the differential in these proportions to a certain extent.
The pattern of symptomatology across the age range is consistent across studies,1,21,3 and this study is no exception in finding that there is a peak in the prevalence of stress symptoms around the menopause. The SUI group showed a peak in the 30- to 49-year age band, whereas the MUI group had a peak in the 50- to 59-year age band. As in other studies, UUI steadily increased across the age range.121
Women with MUI had greater impact on quality of life than those with UUI, who in turn had a greater impact on quality of life than those with SUI, and this was reflected in help-seeking behaviour, as those with MUI and UUI were more likely to seek help. It is likely that symptoms related to urgency have greater impact owing to the unpredictability of urine loss coupled with larger volume of loss and hence greater difficulty of management and concealment. Quality of life is an important aspect of felt need,21 and both the severity of symptoms and the impact on individual quality of life must be taken into account when considering treatment options. Although impact was significantly correlated with severity of symptoms, help-seekers who report high impact in the presence of mild symptoms should also be considered for treatment. GPs frequently tell women to return if symptoms get worse, but care should be taken to establish whether women are seeking treatment or reassurance, as they will often be reluctant to return, even if symptoms get worse.4
However, factors other than the patient's subjective experience of symptom impact may determine treatment-seeking behaviour. Even amongst those reporting a similar level of symptom severity, the level of treatment-seeking behaviour varies by the type of urinary incontinence. Whilst 59% of those with moderate or severe UUI seek help (based on self-reported severity), only 40% of those with moderate to severe SUI do so. Factors that might explain this difference may include the degree to which health care professionals screen for different types of urinary incontinence and the range and type of treatment options available to urinary incontinence sufferers, awareness of which may prompt consulting a health care professional. Qualitative studies have suggested that attributions of both cause and treatment availability influence decisions to seek help with the perception that nothing can be done to alleviate symptoms, or that the only treatment available is surgery, being strong barriers to help-seeking.4
Although the prevalence of symptoms was high in comparison with studies of population samples, the prevalence of help-seeking remained low with around one-third or less of the women in the different symptom groups having sought help. Also, many patients with relatively severe symptoms still do not seek help for urinary incontinence. Overall, about half of those with moderate or severe urinary incontinence and over half of those with daily episodes of urinary incontinence (Table 6) do not seek help. Previous studies have reported help-seeking as being around 8.8,19 20,22 12.8,20 and 25%1 of incontinent women. This demonstrates that although the present sample were accessing primary care services they were no more likely to consult about their symptoms than a general population sample. It can be assumed, therefore, that there are high levels of unmet need in women passing through the primary care system. This study suggests that 
5% of the primary care population have an unmet need for continence care, on the basis of symptom severity. Taking account of other, more complex factors that influence perceived need may increase this figure. In addition, the focus of this study on incontinence does not account for those who have debilitating symptoms of overactive bladder such as urgency or frequency but who manage to avoid incontinent episodes. Not reported as part of this study, a further 15% of the sample had symptoms of overactive bladder that would benefit from similar treatments to those for UUI.
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Around half of incontinent women received medication for their symptoms, but we have insufficient information in the present study to indicate the type of medication prescribed, and the appropriateness of the prescription. Certain drugs such as anticholinergics are useful in the treatment of urge symptoms, but there was no treatment available for SUI during the time frame23 beyond behavioural treatments, and so it is surprising then that the highest amount of prescribing was in the SUI group. However, it is possible that prescribing in this instance was for urinary tract infections, which may have been exacerbating their symptoms or, alternatively, off-label prescribing of anticholinergics. But also, the weighting of the questionnaire towards identification of SUI means that the typology of incontinence should be considered with caution.
Women with MUI were generally more likely to receive treatment, which may be a result of the greater severity of symptoms and impact on quality of life in this group. A total of 28.1% of women with MUI were referred to a specialist nurse compared with only 5.6% with SUI. Women with MUI were also more likely to receive pelvic floor exercises, both from their doctor and from referral to a physiotherapist, than women with SUI, and were more likely to be referred on to secondary care. A similar proportion of women with UUI were given pelvic floor therapies as those with MUI and SUI. Although it may be of some benefit, evidence of the effectiveness of pelvic floor therapy in women with urge symptoms is unclear, but its effectiveness has been demonstrated in SUI when compared with no treatment, and is generally considered first line treatment for stress symptoms.24
Compliance with pelvic floor exercises was greater when given by a physiotherapist. Previous work has recommended that pelvic floor therapy should be administered by professionals having specialist training to ensure that therapy is taught and monitored appropriately.24 The study did not collect information concerning the level of pelvic floor training provided by the GP, but appropriate monitoring is time-consuming to carry out during a routine surgery and is unlikely to have been carried out at the level of intensity provided by physiotherapists. Compliance with behavioural treatments are also likely to be poor in the longer term and would require further input from a health care professional to maintain any improvement, which is an added resource requirement.
In this study, the numbers receiving specific treatments were small and data collection was limited in the various symptom groups, and so it is not possible to look in greater detail at factors associated with treatment provision and the appropriateness of treatments. However, it would appear that there was little differentiation between symptom groups in the treatments given, with the preferred method of treatment being medication. Further research is needed to assess the basis for primary care physicians' treatment decisions as well as the resources available to treat incontinence in primary care. The number referred to specialist nurses was low but it is not clear that this service was available to all GPs in the study. Conservative treatments by specialist nurses have been shown to be effective, at least in the short term, in both men and women with symptoms of urinary storage disorder,25 and it is recommended that conservative treatment should be the first line treatment in women with SUI.24 Further data is required on the types of medication prescribed for the different types of incontinence and the rationale on which these prescriptions are based.
In conclusion, the prevalence of urinary symptoms was high in this population, with the majority having either SUI or MUI. Around 70% of the women attending primary care surgeries were experiencing symptoms, with just under a half having incontinence on a monthly basis. Treatment provision did not appear to be clearly defined or targeted. To undertake a case-finding approach would require clear treatment protocols with adequate resources, such as specialist clinics run by nurses trained in provision of behavioural treatments. The feasibility of this type of service provision needs to be assessed and piloted before primary care can address the health needs of women adequately. Further research is required to assess barriers to treatment provision from both a patient and a professional and service perspective. To ensure that primary care is adequately equipped to deal with this problem, further information is required concerning the knowledge base of professionals in primary care, barriers to treatment provision and selection, training needs and the development of assessment and treatment tools.
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Declarations |
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The data collection was funded by Eli Lilly and Boehringer Ingelheim Limited and carried out by Health Research Associates, Inc., Seattle, US. Writing of the paper was funded by Eli Lilly and Boehringer Ingelheim.
Contributions of authors: MM as director of Health Research Associates had overall responsibility for project management, ensuring agreement on design of the study, and liaison between the UK study coordinator, the investigators, research consultants and funders. RPA was lead investigator and site investigator for Yorkshire, with responsibility for negotiating ethical permissions, as well as contributing to the design of the study, and recruiting primary care practices. AW, CH and CM were lead investigators at each of the remaining geographical sites and were responsible for collaborating on the overall study design and recruiting appropriate primary care clinicians. DMB managed the data and carried out statistical analyses. PA and CS acted as research consultants and CS designed and wrote the paper in full. RDG represented the funders on the management group, monitored progress and research governance, thus acting as research sponsor. All authors contributed to interpretation of the findings and commented on drafts of the paper.
Ethics approval was sought from Wakefield MREC in West Yorkshire, in addition to LREC approval from each of the four sites involved in the study—West Yorkshire, London, Glasgow and Leicestershire.
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Notes |
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Shaw C, Gupta RS, Bushnell DM, Assassa RP, Abrams P, Wagg A, Mayne C, Hardwick C and Martin M. The extent and severity of urinary incontinence amongst women in UK GP waiting rooms. Family Practice 2006; 23: 497–506.
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1 Hunskaar S, Lose G, Sykes D, Voss S. (2004) The prevalence of urinary incontinence in women in four European countries. Br J Urol Int 93:324–330.
2 Thom D. (1998) Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type. J Am Geriatr Soc 46:473–480.[Web of Science][Medline]
3 McGrother CW, Donaldson MM, Shaw C, et al. (2004) Storage symptoms of the bladder: prevalence, incidence and need for services in the UK. Br J Urol Int 93:763–769.
4 Shaw C, Brady R, Allan R, Jackson C, Hyde C. (2001) Barriers to help-seeking in people with urinary problems. Fam Pract 18:48–52.
5 Peters TJ, Horrocks S, Stoddart H, Somerset M. (2004) Factors associated with variations in older people's use of community-based continence services. Health Soc Care Commun 12:53–62.[CrossRef]
6 Herzog A and Fultz N. (1990) Epidemiology of urinary incontinence: prevalence, incidence, and correlates in community populations. Urol 36:2–10.
7 Grealish M and O'Dowd TC. (1998) General practitioners and women with urinary incontinence. Br J Gen Pract 48:975–978.[Web of Science][Medline]
8 Roe B and May C. (1997) Effective and ineffective management of incontinence: a qualitative study with implications for health professionals and health services. Clin Effectiveness Nurs 1:16–24.
9 Garvart S, Bowman L, Buesching D, Patrick D, Martin ML. Development of the Symptom Frequency and Bothersomeness Scale for Stress Urinary Incontinence (SFB-SUI). ISPOR Seventh Annual International MeetingArlington VA, May 2002.
10 Grove A, Martin ML, Budhiarso I, Buesching D, Patrick DL. (1998) Usefulness of the symptom frequency/bothersomeness (SFB) scale in clinical practice. Qual Life Res 7:602.
11 Wagner TH, Patrick DL, Bavendam TG, Martin ML, Buesching DP. (1996) Quality of life in persons with urinary incontinence: development of a new measure. Urol 47:67–72.
12 Patrick DL, Martin ML, Bushnell DM, Yalcin I, Wagner TH, Buesching DP. (1999) Quality of life of women with urinary incontinence: further development of the incontinence quality of life instrument (I-QOL). Urol 53:71–76.
13 Patrick DL, Martin ML, Bushnell DM, Marquis P, Andrehasich CM, Buesching DP. (1999) Cultural adaptation of a quality-of-life measure for urinary incontinence. Eur Urol 36:527–435.
14 Bushnell DM, Martin ML, Patrick DL, Andrejasich C, Gore M. Development of an "Individually-Defined" Activities Limitation Scale. Sixth Annual Symposium of Contributed Papers on Quality of Life Evaluation—Drug Information Association (DIA)28–30 March 1999Hilton Head, South Carolina.
15 Roe B and Doll H. (2000) Prevalence of urinary incontinence and its relationship with health status. J Clin Nurs 9:178–188.[CrossRef][Web of Science][Medline]
16 Simeonova Z, Milsom I, Kullendorff A-M, Molander U, Bengtsson C. (1999) The prevalence of urinary incontinence and its influence on the quality of life in women from an urban Swedish population. Acta Obstet Gynecol Scand 78:546–551.[CrossRef][Web of Science][Medline]
17 Sandvik H, Hunskaar S, Seim A, Hermstad R, Vanvik A, Bratt H. (1993) Validation of a severity index in female urinary incontinence and its implementation in an epidemiological survey. J Epidemiol Commun Health 47:497.
18 Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. (2000) A community-based epidemiological survey of female urinary incontinence: The Norwegian EPICONT Study. J Clin Epidemiol 53:1150–1157.[CrossRef][Web of Science][Medline]
19 Yarnell JW, Voyle GJ, Richards CJ, Stephenson TP. (1981) The prevalence and severity of urinary incontinence in women. J Epidemiol Commun Health 35:71.
20 Harrison GL and Memel DS. (1994) Urinary incontinence in women: its prevalence and its management in a health promotion clinic. Br J Gen Pract 44:149–152.[Web of Science][Medline]
21 Perry S, Shaw C, Assassa P, et al. (2000) An epidemiological study to establish the prevalence of urinary symptoms and felt need in the community: the Leicestershire MRC Incontinence Study. J Public Health Med 22:427–434.
22 Dolan LM, Casson K, Ashe RG. (1999) Urinary incontinence in Northern Ireland: a prevalence study. Br J Urol Int 83:760–766.
23 Andersson KE, Appell R, Awad S, et al. (2002) Pharmacological treatment of urinary incontinence. In Abrams P, Cardozo L, Khoury S, Wen A (Eds.). Incontinence. 2nd International Consultation on Incontinence (2nd edn) (Health Publication Ltd, Plymouth) pp. 165–201.
24 Wilson PD, Bo K, Hay-Smith J, Nygaard I, Staskin D, Wyman J. (2002) Conservative treatment in women. In Abrams P, Cardozo L, Khoury S, Wen A (Eds.). Incontinence. 2nd International Consultation on Incontinence (2nd edn) (Health Publication Ltd, Plymouth) pp. 165–201.
25 Williams K, Assassa RP, Cooper NJ, et al. (2005) Clinical and cost-effectiveness of a new nurse-led continence service: a randomised controlled trial. Br J Gen Pract 55:696–703.[Web of Science][Medline]
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