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The prevalence of overactive bladder and its impact on the quality of life: A cross-sectional study

The prevalence of overactive bladder and its impact on the quality of life: A cross-sectional study ARAB JOURNAL OF UROLOGY https://doi.org/10.1080/2090598X.2023.2221403 ORIGINAL ARTICLE The prevalence of overactive bladder and its impact on the quality of life: A cross-sectional study a b c a b Shrouq Qudah , Mohammad Abufaraj , Randa Farah , Abdulrahman Almazeedi , Ali Ababneh , b d e e Mazen Alnabulsi , Ayman Qatawneh , Dana Hyassat and Kamel Ajlouni a b School of Medicine, The University of Jordan, Amman, Jordan; Division of Urology, Department of Special Surgery, Jordan University Hospital, Amman, Jordan; Department of Internal Medicine, School of Medicine, Jordan University Hospital, Amman, Jordan; d e Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Jordan, Amman, Jordan; The National Center for Diabetes, Endocrinology and Genetic (NCDEG)/The University of Jordan, Amman, Jordan ABSTRACT ARTICLE HISTORY Received 25 March 2023 Objective: Overactive bladder (OAB) is a common condition affecting both men and women Accepted 30 May 2023 and has been shown to affect the quality of life. We conducted this study to estimate the prevalence of OAB, and to incorporate symptom severity, symptom bother and health-related KEYWORDS quality of life (HRQL) in the assessment of OAB and evaluate associated factors. Overactive Bladder; quality Methodology: A total of 940 participants were categorized into non-OAB and OAB using the of life; urge incontinence Overactive Bladder Symptom Score (OABSS). HRQL and symptom bother were measured using the Overactive Bladder Questionnaire – Short Form (OAB-q SF). Descriptive analyses and multivariable regression analyses were performed. Results: The prevalence of OAB among our population was 27.4%. Patients with older age (Odd ratio [OR] = 2.26, 95% confidence interval [CI]: 1.6–3), higher body mass index (BMI) (OR = 2.6, 95% CI: 1.8–3.8), comorbidities (OR = 2.6, 95% CI: 1.9–3.5) and history of recurrent urinary tract infection (UTI) s (OR = 1.9, 95% CI: 1.4–2.6) were significantly associated with increased risk of OAB (p < 0.001). The mean OAB symptom bothers score was 35.7 + 22.9 and increased significantly across OAB severity groups (p < 0.001). The mean HRQL score was 73.3 + 22 and a significant decreased across OAB severity groups (p < 0.001). All OAB symptoms showed significant positive correlation with increased symptom bother (p < 0.001) in addition to significant inverse correlation with HRQL (p < 0.001). Conclusion: OAB is a prevalent condition in our population and the associated symptoms negatively affect HRQL. In this study, the detrimental effect is not exclusive to UUI and can be attributed to the other elements in the symptom spectrum of OAB. Screening for OAB should be considered during routine clinical visits using validated and reliable measures for early detection of symptoms and possible modification of risk factors to improve the outcome. Introduction management [7]. Yet, rates in seeking healthcare remains low [8]. Studies investigating treatment Overactive bladder (OAB), as defined by the interna- seeking behavior have shown that individuals tional continence Society (ICS), is a complex of symp- affected with OAB misinterpret their urinary symp- toms characterized by the presence of urgency with toms as a normal part of aging [9] or lack awareness or without urinary incontinence (UI), and often with about the availability of treatment [10]. Coping stra- frequency and nocturia, provided the absence of underlying infections or pathologies [1]. OAB is an tegies including fluid restriction, physiotherapy and the use of absorbent pads to adapt with the urinary extremely common urological disease affecting both symptoms have also been shown to interfere with men and women [2]. OAB adversely affects the qual- daily and social activities [9,11]. OAB forms ity of life, throughout the physical, mental, emo- a significant financial burden and was estimated to tional and sexual domains [2–5]. While UI has been the forefront in research in evaluating health-related contribute to a direct cost of 1.2–2.7 trillion in 2008 quality of life (HRQL), other investigators demon- [12]. In the United States, the health care costs were strated that bother and HRQL can be significantly 2.5 times higher in OAB patients compared to their counterparts [13]. In addition to health care, OAB has influenced by urgency [3,6], even more than UI. The been estimated to have an indirect economical cost symptomatic definition of OAB helps in establishing of 841 million dollars by adversely impacting work an initial diagnosis which has allowed for early CONTACT Mohammad Abufaraj dr.abufaraj@gmail.com Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman 11942, Jordan © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. 2 S. QUDAH ET AL. productivity [14]. Despite the highest predicted bur- survey was self-administered with a trained health- care personnel present to provide any non-influential den of OAB to be in Asia [12], data surrounding OAB assistance, if requested. Study participants filled out remains scarce in Jordan. The focus has mainly been a data sheet regarding socioeconomic and demo- directed towards UI [15], or OAB among women graphic information (age, sex, marital status, house- aged ≥40 [16]. Consequently, we aim to assess the hold income), as well as health-related and lifestyle prevalence of OAB among men and women characteristics which included questions about the aged ≥18, provide an insight on the extent of symp- presence of any comorbidities such as: diabetes, tom bother, as well as integrate quality of life as an hypertension, anxiety or depression, and history of outcome measure in the assessment of OAB. recurrent UTIs. Weight and height (for body mass Secondarily, we aim to evaluate associated factors, index (BMI) calculation), smoking status, fluid, and and explore trends in treatment seeking behaviors caffeine intake were also obtained. The Overactive among affected individuals. Bladder Symptom Score (OABSS) was the diagnostic tool of choice in our study. The OABSS was devel- oped and validated to quantify OAB symptoms, as Materials and methods defined by the ICS, using four questions asking about the occurrence frequency of: urinary urgency, day- Patients and settings time frequency, nocturia, and urge urinary inconti- This was a cross-sectional study performed at the out- nence (UUI) over the past week. Each reported patient clinics of Jordan University Hospital (JUH); answer is designated a score, and the resulting sum a tertiary hospital and The National Center for score can range from 0 to a maximum score of 15; Diabetes, Endocrinology and Genetic (NCDEG); higher scores on the OABSS were also indicative of a healthcare center, both located in Amman, the capi- higher OAB symptom severity [17]. In 2019, a reliable tal city of Jordan. Data was collected between and valid Arabic version of the OABSS was produced October 2021 and January 2022. The necessary sample [18], allowing for the assessment of OAB symptoms size was calculated by projecting an estimated preva- in Arabic-speaking populations. Accordingly, we uti- lence of 25%, to achieve a 95% CI, and a margin of error lized the Arabic version and categorized our study of 5%. Assuming a response rate of 60%, we concluded participants into two groups (OAB and non-OAB) that our sample should constitute 860 individuals. depending on their OABSS sum score. OAB was Conservatively, data collection was continued until defined as a total score ≥ 3, and a score on the 1000 participants were reached. urgency question ≥ 2 (urgency occurring once a week or more). This was in accordance with the Inclusion and exclusion criteria ICS that integrated urgency as a key characteristic in Inclusion criteria instated the participants to be ≥18 the OAB symptomatic definition [1]. Additionally, the years old, capable of understanding the questionnaire OAB group was subcategorized into mild OAB (total and providing consent. Generally, all those who had score ≤ 5), moderate (6–11), and severe (≥12). Any any neurological disorder (i.e. Multiple Sclerosis/ individual who met the criteria for OAB and scored ≥ Parkinson’s/spinal cord injury/stroke) and who 1 on the urge UI questions was considered to have reported a recent urinary tract infection (UTI) (current OAB with UI. In our study, OAB without UI is referred UTI or UTI within the past month) whether clinically to as OABdry and OAB with UI is referred to as diagnosed or self-reported as ‘burning or painful sen- OABwet. For the evaluation of HRQL and symptom sation upon urination’, current renal stones, recent bother, we utilized the Overactive Bladder urological surgery (within the last six months), history Questionnaire – Short Form (OAB-q SF). The OABq – of urological cancer and radiotherapy were considered SF is a valid and reliable condition-specific instru- ineligible to proceed with the survey analysis . ment that consists of 19 items divided into two Additionally, female participants with pelvic organ pro- parts; six items asking about OAB symptom bother lapse (either self-reported or clinically diagnosed), cur- and 13 items asking about OAB impact on different rent pregnancy, history of gynecological cancer and HRQL domains (sleep, social, concern and coping) male participants who had benign prostatic hyperpla- over the past month [19]. All 19 items were desig- sia (BPH) diagnosed clinically or receiving medications nated to a Likert scale ranging from a score of 1 to 6. were excluded from the study. The results of the questionnaire were interpreted and transformed from crude scores into a value out of 100. For symptom bother, higher scores were sug- Measurements gestive of increased symptom bother as opposed to Participants were first introduced to the purpose of the HRQL where higher scores were suggestive of the study and the nature of the questionnaire. a better outcome. The questionnaire was translated Following this, a written consent was obtained to to the Arabic language, prior to administration, proceed with the completion of the survey. The ARAB JOURNAL OF UROLOGY 3 according to the Good Practice Guidelines [20], 2021) and the IRB at the National Center for Diabetes where linguistic and cultural integrity were ensured. and Endocrinology and Genetics (NCDE) . Participants Healthcare seeking behavior was explored by asking were assured confidentiality of information. participants if they had ever sought medical advice regarding their urinary symptoms, had been pre- Results viously diagnosed with OAB or if they had received treatment. Respondents who had received treatment Reliability of measures were asked to specify the type and state of treatment The OABq – SF showed good reliability and internal (i.e. behavioral, pharmacotherapy/current, previous). consistency; Cronbach alpha for six items measuring the degree of bother was 0.88, for 13 items measuring Statistical analysis the HRQL was 0.95 and for the entire questionnaire (19 All analyses were performed using Stata version 14. items) was 0.96. For the OABSS, Cronbach alpha Data were first inserted into an Excel spreadsheet, was 0.77. and the exclusion criteria, mentioned above, was implemented. Descriptive statistics using frequencies and percentages were used to express categorical vari- Baseline characteristics ables. Continuous data were expressed as means ± SD A total of 1,125 participants were recruited. and medians with IQR following the normalcy of their Following the exclusion criteria, 185 participants distribution. Chi square tests and Mann-Whitney U test were found ineligible for further analysis providing were performed to determine the association with a response rate of 83.5%. The final number of eligi- OAB. Logistic regression was performed and odds ble study participants was 940. Table 1 shows the ratio with 95% CI were produced. Following the unad- baseline characteristics and association with OAB. justed regression, all factors that reached statistical Overall, the median age of the respondents was significance (p < 0.05) were fit into the final logistic 43 years, female to male ratio was 1.1, 62.5% were model. Multivariable linear regression analysis was per- married, 54.2% were non-workers, housewives or formed for symptom correlation with bother and retired and the household income was > 500 (JDs) HRQL. P value < 0.05 was considered significant. among 512 individuals (54.4%). The majority Regarding reliability of study instruments, Cronbach (77.5%) had received an education level equivalent alpha ≥ 0.70 was used to define good internal to college or higher. Smoking was reported in consistency. 28.6% of study individuals while caffeine intake (i.e. coffee, tea) was reported in 89.8%. More than Ethical considerations half of the study participants (66.9%) had an aver- The study was approved by the Institutional Review age fluid intake of less than 2500 (mL). The pre- Board (IRB) of the Faculty of Medicine and Jordan sence of comorbidities, previous history of renal University Hospital at The University of Jordan (309/ stones and previous history of UTIs were observed Table 1. Baseline characteristics of 940 study participants. Overall Non-OAB OAB Baseline characteristics n = 940%) n = 682 (72.6%) n = 258 (27.4%) p value Age, median (IQR) 43 (30) 39 (30) 50.5 (22) <0.001* Age group+ < 40 436 (46.4) 362 (83) 74 (17) <0.001* >40 504 (53.6) 320 (63.5) 184 (35.5) Gender Male 446 (47.4) 348 (78) 98 (22) <0.001* Female 494 (52.6) 334 (67.6) 160 (32.4) Marital status Married 588 (62.5) 399 (67.9) 189 (32.1) <0.001* Single/divorced/widow 352 (37.4) 283 (80.4) 69 (19.6) Education Elementary school 38 (4) 26 (68.4) 12 (31.6) 0.8 Secondary school 173 (18.4) 126 (72.8) 47 (27.2) College and higher 729 (77.5) 530 (72.7) 199 (27.3) Employment Currently employed 449 (47.8) 304 (67.7) 145 (32.3) 0.01* Retired/housewives/unemployed 379 (40.3) 287 (75.7) 92 (24.3) Income+ <500 JD 428 (45.5) 296 (69.2) 132 (30.8) 0.03* ≥500 JD 512 (54.5) 386 (75.4) 126 (24.6) BMI+ <25 289 (30.7) 238 (82.4) 51 (17.6) <0.001* 25–29 335 (35.6) 243 (72.5) 92 (27.5) ≥30 311 (33) 198 (63.7) 113 (36.3) Smoking (Yes) 269 (28.6) 200 (74.4) 69 (25.6) 0.4 Fluid intake+ <2500 629 (66.9) 468 (74.4) 161 (25.6) 0.07 >2500 311 (33) 214 (68.8) 97 (31.2) Caffeine intake (Yes) 845 (89.9) 605 (71.4) 240 (28.4) 0.05 Medical Comorbidities (Yes) 495 (52.6) 316 (63.8) 179 (36.2) <0.001* Previous UTI 340 (36) 217 (63.8) 123(36.2) <0.001* Previous renal stones 85 (9) 55 (64.7) 30 (35.3) 0.09 4 S. QUDAH ET AL. in 52.6%, 9%, and 36.1% of the study population, 0.4–0.9) and income > 500 (OR = 0.7, 95% CI: 0.5–0.9) respectively. were significantly associated with decreased odds of OAB (p = 0.01, p = 0.03, respectively). On the other hand, educational level, smoking, caffeine intake as Prevalence of OAB well as fluid intake did not reach statistical significance. We found that the overall prevalence of OAB was For the multivariable regression model, gender, BMI, 27.4% (258), 22% among men and 32.4% among presence of comorbidities, and history of recurrent women. Almost half of the OAB patients (51.2%) had UTIs remained significantly associated with increased OAB with the highest prevalence (28%) among the wet risk of OAB (p < 0.05). Considering the pertinent effect eldest age group (≥70 years) and lowest (4.5%) in the of fluid intake, it was included in the final regression youngest age group (18–29). model despite not yielding prior statistical significance, In women with OAB, 56.8% had urge UI compared this showed that fluid intake > 2500 (mL) might to 41.8% of men with OAB (p = 0.01). Mild OAB was increase the odds of OAB (OR = 1.39, 95% CI: 0.9–1.9) observed in 36.4% of affected individuals, moderate with p-value of 0.05, yet not statistically significant in OAB in 12.7% while 50.7% had severe OAB. our analysis. Factors associated with OAB OAB symptoms, severity, degree of bother and Results of the regression model are shown in Table 2. HRQL We performed bivariate regression analysis and found that age (Odd ratio [OR] = 2.26, 95% confidence inter- Among all respondents, nocturia (defined by the ICS val [CI]: 1.6–3), higher BMI (OR = 2.6, 95% CI: 1.8–3.8), as ≥ 1 voids per night) was the most common symp- presence of comorbidities (OR = 2.6, 95% CI: 1.9–3.5) tom (n = 650) followed by urgency (n = 455), frequency and history of recurrent UTIs (OR = 1.9, 95% CI: 1.4–2.6) (n = 211) and lastly urge UI (n = 179) (Figure 1a). Since were all significantly associated with increased risk of the diagnosis of OAB in our study entailed the pre- OAB (p < 0.001 for all). Additionally, men as compared sence of urgency, we aimed to also explore the pre- to women, and those who were single, divorced or valence of the other spectrum of symptoms. Nocturia widowed as compared to those who were currently remained the most common symptom (n = 241) married had two times decreased odds of OAB (Figure 1b). (p < 0.001 for both). Employment (OR = 0.6, 95% CI: Table 2. Logistic regression analysis for factors predictive of OAB. Variable OR (95% CI) P value AOR (95% CI) P value Age (ref. <45) ≥45 2.26 (1.6–3) <0.001* 1.13 (0.7–1.7) 0.5 Gender (ref. female) Male 0.5 (0.4–0.7) <0.001* 0.5 (0.3–0.7) 0.001* Marital status (ref. Married) Single/divorced/widowed 0.5 (0.3–0.7) <0.001* 1.3 (0.8–1.9) 0.1 Educational level (ref. Elementary) Secondary 0.7 (0.3–1.7) 0.5 College/University or higher 0.7 (0.3–1.5) 0.4 Income (ref. <500) >500 0.7 (0.5–0.9) 0.03* 0.7 (0.5–1) 0.05 Occupation (ref. Unemployed/retired/housewife) Employed 0.6 (0.4–0.9) 0.01* 1.2 (0.8–1.7) 0.3 BMI (ref. <25) 25 - <30 1.7 (1.2–2.5) 0.01* 1.6 (1.03–2.56) 0.05 ≥30 2.6 (1.8–3.8) <0.001* 1.8 (1.1–2.9) 0.01* Fluid intake (ref. <2500) ≥2500 1.3 (0.9–1.7) 0.07 1.39 (0.9–1.9) 0.05 Caffeine intake (ref. none) Yes 1.6 (0.9–2.8) 0.05 Smoking (ref. non-smoker/Ex-smoker) Smoker 0.8 (0.6–1.2) 0.4 Comorbidities (ref. none) Yes 2.6 (1.9–3.5) <0.001* 1.86 (1.2–2.8) 0.01* History of recurrent UTIs (ref. none) Yes 1.9 (1.4–2.6) <0.001* 1.6 (1.1–2.2) 0.01* reference, OAB: Overactive bladder BMI: body mass index, UTIs: Urinary Tract Infections. + 2 Age expressed in years; BMI expressed in Kg/M ; Income expressed in Jordanian Dinars (JDs); fluid intake measured in mL. *Statistically significant P value < 0.05. ARAB JOURNAL OF UROLOGY 5 Figure 1. Frequency of OAB symptoms (a)among general population, (b) among OAB group. Table 3. The Impact of OAB severity on degree of symptom bother and HRQL. OAB, n = 258%) No OAB Mild, n = 94 (36.4) Moderate, n = 32 (12.4) Severe, n = 132 (51.16) P value Symptom bother (mean + SD) 8.9 ± 11.4 21.1 ± 11.9 34.3 ± 16.4 46 ± 24.4 <0.001* HRQL (mean + SD) 94.9 ± 9.1 83.7 ± 15.1 69.7 ± 22.5 66.7 ± 23.2 <0.001* OAB: overactive bladder; HRQL: health-related quality of life. *Statistically significant P value < 0.05. Table 3 illustrates the scores of symptoms bother mean ± (SD). Symptom bother significantly increased and HRQL measured by the OAB-q SF and expressed as from those without OAB and across OAB severity Table 4. Linear regression analysis of OAB symptoms contribution to symptom bother and HRQL as measured by the OABq. 2 2 Multivariable linear regression for HRQL (Adjusted R = 0.56) Multivariable linear regression for symptom bothers (Adjusted R = 0.56) β co. efficient (95% CI) P β co. efficient (95% CI) P Frequency −6.8 (−8.5 - −5.15) <0.001* 5.9 (4.4–7.7) <0.001* Nocturia −3.6 (−4.5 - −2.7) <0.001* 4.4 (3.5–5.4) <0.001* Urgency −4.02 (−4.7 - −3.2) <0.001* 4.9 (4.1–5.7) <0.001* Urge Urinary Incontinence −4.09 (−5 - −3.1) <0.001* 6.1 (5.1–7.1) <0.001* Age −0.05 (−0.09 - −0.004) 0.03* 0.005 (−0.04–0.05) 0.8 Gender 0.57 (−0.89–2.04) 0.4 −1.4 (−2.9–0.06) 0.06 HRQL: health-related quality of life. *Statistically significant P value < 0.05. 6 S. QUDAH ET AL. groups (p < 0.001). For those without OAB, the calcu- Milsom et al. [10] conducted telephone interviews in lated mean ± (SD) was 8.9 ± 11.4 while the highest France, Germany, Italy, Spain and Sweden, and the symptom bother was observed in severe OAB (mean reported prevalence was 16.6% (range, 12% − 22%). ± (SD) = 46 ± 24.4) (Table 3). Regarding HRQL, In Korea, the overall prevalence was 12.2% (10% in a significant decrease was noted with the increase in men and 14.3% in women) [24]. In Germany, Canada, OAB severity (p < 0.001). For those without OAB, HRQL Sweden, Italy and the UK, Irwin et al. [25] reported that mean ± (SD) was 94.9 ± (9.1), compared to 66.7 ± (23.2) the prevalence of OAB was 11.8% (10.8% in men and in those with severe OAB. 12.8% in women). In light of the above mentioned, multivariable linear We also observed higher prevalence in those ≥40 regression was performed to explore the correlation of years with overall prevalence of 36.4% (30.8% in men each symptom with the degree of bother and HRQL and 41.3% in women). while accounting for the role of age and gender, as Epidemiological studies can use different definitions illustrated in Table 4. All OAB symptoms showed sig- of OAB and although many studies utilized the 2002 nificant positive correlation with increased symptom ICS definition [1], criteria to establish the diagnosis, bother (p < 0.001) in addition to significant inverse targeted populations (in terms of region, gender, and correlation with HRQL (p < 0.001). For increased symp- age), type of survey administered, and the implemen- tom bother, urge UI had the highest correlation (β = ted methodology can be different and explain the 6.1, 95% CI: 5.1–7.1, p < 0.001), while decrease in HRQL prevalence variance. The higher prevalence reported had the highest correlation with daytime frequency in the current study can be explained by the regional (β = −6.8, 95% CI: −8.5 - −5.15, p < 0.001). difference. This is supported by Erwin et al. [12] who reported that the highest number of individuals affected by OAB are in Asia. Evidently, our results Healthcare and treatment seeking behavior similarly compared with other epidemiological studies In those with OAB, 18% sought medical advice regard- conducted in Asia [26,27] where OAB was found in 29.9% of men and 51.4% of women. The attributable ing their urinary condition of which 40% received treatment and 42.5% were diagnosed with OAB. All cause for the higher prevalence in Asia in these studies those who had received treatment reported the use remained indefinite; however, cultural, social, eco- nomic and hygienic differences were suggested [26]. of pharmacotherapy. Among those, 52.6% were cur- Furthermore, Edwan et al. [16] reported that among rently treated and 47.4% had discontinued their treatment. women residing in Jordan aged ≥40 years, the preva- lence of OAB was 58.8% with approximately half experiencing urge UI. The significant prevalence differ - Discussion ence among genders, can be explained by the anato- mical differences and obstetrics history in women. In To the best of our knowledge, this is the first study our study, the overall prevalence of UUI among men conducted in Jordan that explores OAB prevalence in was 9.1% (41.84% of those with OAB) and 18.2% both genders while incorporating broad age groups among women (56.25% of those with OAB). Our results with assessment of HRQL. Clinical characteristics of are in line with previous literature regarding urge UI those affected were evaluated and the following being more common in women [2,22–24]. were significantly associated with increased risk of Nonetheless, these high numbers can be justified by OAB; female gender, increased BMI, presence of our broad definition of UI; participants who reported comorbidities and history of recurrent UTIs. In an episode of UI once a week or less up to those who patients with OAB, nocturia was the most common reported 5 episodes a day were all included in the symptom in both genders. Symptom bother signifi - category OABwet. We anticipate a lower prevalence if cantly increased with the increase in OAB severity the diagnosis of UUI required more frequent episodes. and HRQL significantly decreased with the increase Studies concerned with male UI have estimated in OAB severity All OAB symptoms significantly cor- a prevalence of 3.1% to 12.7% highlighting that the related with increased symptom bother and prevalence increases with age. Shamliyan et al. And decreased HRQL, but frequency and urge UI had Diokno et al. have also reported that among men the highest correlation. experiencing UI, UUI is the most common type affect - In this study, the prevalence of OAB was 27.4% (22% ing 44% of incontinent men [28,29]. In the UREPIK in men and 32.4% in women) which was comparable study, Boyle et al. [30] concluded that 89% of men self- to many studies [21–23]. In China, Taiwan and South reported leakage of urine occurring at least once Korea [4], the prevalence was 20.8%. Among men and a week compared to 34% of men who reported 3 or women residing in Poland [21], the prevalence was more episodes per week. This adds to our agreement 26.8% and 39.5%, respectively. In the United States, that our high prevalence can be justified by the num- the prevalence was 43% in women and 27% in men ber of incontinent episodes. Lastly, risk factors for [23]. Other studies showed lower prevalence of OAB, ARAB JOURNAL OF UROLOGY 7 incontinence including age [28,29], diabetes [28] and all OAB symptoms and comorbidities were self-reported BMI were also apparent in the OABwet group where and therefore can be over or underestimated. In addition, 51.2% were aged 60 years or older, 55.38% had the measures utilized depend on recall from the prior a BMI ≥ 30, and 68.2% had diabetes. week for the OABSS and prior month for the OABq – SF In a meta-analysis that evaluated risk factors for OAB; subjecting the information to recall bias. Moreover, and increase in age, and BMI were significantly associated despite following a stringent exclusion criteria, sampling with increased risk of OAB while higher educational might not be representative of the general population as level was significantly inversely correlated [31]. The data were collected in hospital setting. increased risk of OAB with higher BMI, in our study, was in agreement with other reports [32] that explained Conclusion the association by the increased intraabdominal pres- sure causing pelvic floor disorders attributable to con- OAB is a prevalent condition in both men and women. sequent repetitive pedundal nerve injury. In addition, OAB was significantly higher in women; however, the higher BMI has an increased link with other comorbid- prevalence of OAB and urge UI among men should not ities including diabetes which contributes to bladder be overlooked. OAB is a bothersome condition that has dysfunction [31–33]. In our study, the prevalence of a significant adverse impact on HRQL. Our results deno- comorbidities including diabetes, hypertension, anxiety, tive that this detrimental effect is not exclusive to urge UI depression and recurrent UTIs was significantly higher and can be attributed to the other elements in the symp- in the OAB group, this was also in line with the current tom spectrum of OAB. We found the following factors to literature [3,4,9]. Our results showed possible associa- be associated with OAB: Gender, increasing BMI, pre- tion between increased fluid intake (>2500 mL) and risk sence of chronic diseases, and history of recurrent UTI. of OAB. In a systemic review to identify the role of fluid Screening for OAB should be considered during routine intake modification on OAB symptoms, the results var- clinical visits for early detection of symptoms and possi- ied and while some studies showed that decreasing ble modification of risk factors to improve the HRQL. fluid intake can significantly reduce OAB symptoms Implementing validated and reliable measures for the and vice versa, others reported no correlation [34]. assessment of OAB aids healthcare providers in optimiz- Since individuals with OAB are adopting coping beha- ing their evaluation and treatment. viors that include fluid restriction [9,11], proper evalua- tion is required, to avoid disposing them at higher risks Acknowledgments of dehydration and UTIs [34]. Across prior reports, OAB has proven to be We are grateful to the participating patients and their a bothersome condition. In our study, the degree of families for their kind collaboration. bother significantly increased with OAB severity, which perspectively , increased as the number of symptoms or Disclosure statement their episodes amplified. Our findings were supported by Irwin et al. [35] who outlined that the highest per- No potential conflict of interest was reported by the centage of individuals reporting bother was of those author(s). affected by urgency and five or more of lower urinary tract symptoms (LUTS). Other studies have also demon- ORCID strated that bother is significantly correlated with the frequency of symptoms and severity of OAB [4,5,21]. Our Mohammad Abufaraj http://orcid.org/0000-0002-6603- results were also in line with those of Milsom et al. [3] 6319 Randa Farah http://orcid.org/0000-0003-1638-9017 and Coyne et al. [6], where the OAB-q SF was utilized in both for the evaluation of bother and HRQL. Similarly, HRQL was better in those without OAB compared to Data availability statement those affected. and bothersome OAB had the most substantial decrease in HRQL scores observed as com- Raw data were generated at Jordan university hospital. Derived data supporting the findings of this study are avail- pared to those with OAB who did not report bother. able from the corresponding author MA on request. The strength of the study includes being carried out in accordance with the ICS 2002 definition, allowing for standardized assessment of OAB prevalence. We also Ethical considerations used validated and reliable measures to establish OAB The study was approved by the Institutional Review Board diagnosis, determine the degree of bother and impact on (IRB) of the Faculty of Medicine and Jordan University HRQL. The exclusion criteria eliminate many underlying Hospital at The University of Jordan. 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The prevalence of overactive bladder and its impact on the quality of life: A cross-sectional study

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ARAB JOURNAL OF UROLOGY https://doi.org/10.1080/2090598X.2023.2221403 ORIGINAL ARTICLE The prevalence of overactive bladder and its impact on the quality of life: A cross-sectional study a b c a b Shrouq Qudah , Mohammad Abufaraj , Randa Farah , Abdulrahman Almazeedi , Ali Ababneh , b d e e Mazen Alnabulsi , Ayman Qatawneh , Dana Hyassat and Kamel Ajlouni a b School of Medicine, The University of Jordan, Amman, Jordan; Division of Urology, Department of Special Surgery, Jordan University Hospital, Amman, Jordan; Department of Internal Medicine, School of Medicine, Jordan University Hospital, Amman, Jordan; d e Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Jordan, Amman, Jordan; The National Center for Diabetes, Endocrinology and Genetic (NCDEG)/The University of Jordan, Amman, Jordan ABSTRACT ARTICLE HISTORY Received 25 March 2023 Objective: Overactive bladder (OAB) is a common condition affecting both men and women Accepted 30 May 2023 and has been shown to affect the quality of life. We conducted this study to estimate the prevalence of OAB, and to incorporate symptom severity, symptom bother and health-related KEYWORDS quality of life (HRQL) in the assessment of OAB and evaluate associated factors. Overactive Bladder; quality Methodology: A total of 940 participants were categorized into non-OAB and OAB using the of life; urge incontinence Overactive Bladder Symptom Score (OABSS). HRQL and symptom bother were measured using the Overactive Bladder Questionnaire – Short Form (OAB-q SF). Descriptive analyses and multivariable regression analyses were performed. Results: The prevalence of OAB among our population was 27.4%. Patients with older age (Odd ratio [OR] = 2.26, 95% confidence interval [CI]: 1.6–3), higher body mass index (BMI) (OR = 2.6, 95% CI: 1.8–3.8), comorbidities (OR = 2.6, 95% CI: 1.9–3.5) and history of recurrent urinary tract infection (UTI) s (OR = 1.9, 95% CI: 1.4–2.6) were significantly associated with increased risk of OAB (p < 0.001). The mean OAB symptom bothers score was 35.7 + 22.9 and increased significantly across OAB severity groups (p < 0.001). The mean HRQL score was 73.3 + 22 and a significant decreased across OAB severity groups (p < 0.001). All OAB symptoms showed significant positive correlation with increased symptom bother (p < 0.001) in addition to significant inverse correlation with HRQL (p < 0.001). Conclusion: OAB is a prevalent condition in our population and the associated symptoms negatively affect HRQL. In this study, the detrimental effect is not exclusive to UUI and can be attributed to the other elements in the symptom spectrum of OAB. Screening for OAB should be considered during routine clinical visits using validated and reliable measures for early detection of symptoms and possible modification of risk factors to improve the outcome. Introduction management [7]. Yet, rates in seeking healthcare remains low [8]. Studies investigating treatment Overactive bladder (OAB), as defined by the interna- seeking behavior have shown that individuals tional continence Society (ICS), is a complex of symp- affected with OAB misinterpret their urinary symp- toms characterized by the presence of urgency with toms as a normal part of aging [9] or lack awareness or without urinary incontinence (UI), and often with about the availability of treatment [10]. Coping stra- frequency and nocturia, provided the absence of underlying infections or pathologies [1]. OAB is an tegies including fluid restriction, physiotherapy and the use of absorbent pads to adapt with the urinary extremely common urological disease affecting both symptoms have also been shown to interfere with men and women [2]. OAB adversely affects the qual- daily and social activities [9,11]. OAB forms ity of life, throughout the physical, mental, emo- a significant financial burden and was estimated to tional and sexual domains [2–5]. While UI has been the forefront in research in evaluating health-related contribute to a direct cost of 1.2–2.7 trillion in 2008 quality of life (HRQL), other investigators demon- [12]. In the United States, the health care costs were strated that bother and HRQL can be significantly 2.5 times higher in OAB patients compared to their counterparts [13]. In addition to health care, OAB has influenced by urgency [3,6], even more than UI. The been estimated to have an indirect economical cost symptomatic definition of OAB helps in establishing of 841 million dollars by adversely impacting work an initial diagnosis which has allowed for early CONTACT Mohammad Abufaraj dr.abufaraj@gmail.com Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman 11942, Jordan © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. 2 S. QUDAH ET AL. productivity [14]. Despite the highest predicted bur- survey was self-administered with a trained health- care personnel present to provide any non-influential den of OAB to be in Asia [12], data surrounding OAB assistance, if requested. Study participants filled out remains scarce in Jordan. The focus has mainly been a data sheet regarding socioeconomic and demo- directed towards UI [15], or OAB among women graphic information (age, sex, marital status, house- aged ≥40 [16]. Consequently, we aim to assess the hold income), as well as health-related and lifestyle prevalence of OAB among men and women characteristics which included questions about the aged ≥18, provide an insight on the extent of symp- presence of any comorbidities such as: diabetes, tom bother, as well as integrate quality of life as an hypertension, anxiety or depression, and history of outcome measure in the assessment of OAB. recurrent UTIs. Weight and height (for body mass Secondarily, we aim to evaluate associated factors, index (BMI) calculation), smoking status, fluid, and and explore trends in treatment seeking behaviors caffeine intake were also obtained. The Overactive among affected individuals. Bladder Symptom Score (OABSS) was the diagnostic tool of choice in our study. The OABSS was devel- oped and validated to quantify OAB symptoms, as Materials and methods defined by the ICS, using four questions asking about the occurrence frequency of: urinary urgency, day- Patients and settings time frequency, nocturia, and urge urinary inconti- This was a cross-sectional study performed at the out- nence (UUI) over the past week. Each reported patient clinics of Jordan University Hospital (JUH); answer is designated a score, and the resulting sum a tertiary hospital and The National Center for score can range from 0 to a maximum score of 15; Diabetes, Endocrinology and Genetic (NCDEG); higher scores on the OABSS were also indicative of a healthcare center, both located in Amman, the capi- higher OAB symptom severity [17]. In 2019, a reliable tal city of Jordan. Data was collected between and valid Arabic version of the OABSS was produced October 2021 and January 2022. The necessary sample [18], allowing for the assessment of OAB symptoms size was calculated by projecting an estimated preva- in Arabic-speaking populations. Accordingly, we uti- lence of 25%, to achieve a 95% CI, and a margin of error lized the Arabic version and categorized our study of 5%. Assuming a response rate of 60%, we concluded participants into two groups (OAB and non-OAB) that our sample should constitute 860 individuals. depending on their OABSS sum score. OAB was Conservatively, data collection was continued until defined as a total score ≥ 3, and a score on the 1000 participants were reached. urgency question ≥ 2 (urgency occurring once a week or more). This was in accordance with the Inclusion and exclusion criteria ICS that integrated urgency as a key characteristic in Inclusion criteria instated the participants to be ≥18 the OAB symptomatic definition [1]. Additionally, the years old, capable of understanding the questionnaire OAB group was subcategorized into mild OAB (total and providing consent. Generally, all those who had score ≤ 5), moderate (6–11), and severe (≥12). Any any neurological disorder (i.e. Multiple Sclerosis/ individual who met the criteria for OAB and scored ≥ Parkinson’s/spinal cord injury/stroke) and who 1 on the urge UI questions was considered to have reported a recent urinary tract infection (UTI) (current OAB with UI. In our study, OAB without UI is referred UTI or UTI within the past month) whether clinically to as OABdry and OAB with UI is referred to as diagnosed or self-reported as ‘burning or painful sen- OABwet. For the evaluation of HRQL and symptom sation upon urination’, current renal stones, recent bother, we utilized the Overactive Bladder urological surgery (within the last six months), history Questionnaire – Short Form (OAB-q SF). The OABq – of urological cancer and radiotherapy were considered SF is a valid and reliable condition-specific instru- ineligible to proceed with the survey analysis . ment that consists of 19 items divided into two Additionally, female participants with pelvic organ pro- parts; six items asking about OAB symptom bother lapse (either self-reported or clinically diagnosed), cur- and 13 items asking about OAB impact on different rent pregnancy, history of gynecological cancer and HRQL domains (sleep, social, concern and coping) male participants who had benign prostatic hyperpla- over the past month [19]. All 19 items were desig- sia (BPH) diagnosed clinically or receiving medications nated to a Likert scale ranging from a score of 1 to 6. were excluded from the study. The results of the questionnaire were interpreted and transformed from crude scores into a value out of 100. For symptom bother, higher scores were sug- Measurements gestive of increased symptom bother as opposed to Participants were first introduced to the purpose of the HRQL where higher scores were suggestive of the study and the nature of the questionnaire. a better outcome. The questionnaire was translated Following this, a written consent was obtained to to the Arabic language, prior to administration, proceed with the completion of the survey. The ARAB JOURNAL OF UROLOGY 3 according to the Good Practice Guidelines [20], 2021) and the IRB at the National Center for Diabetes where linguistic and cultural integrity were ensured. and Endocrinology and Genetics (NCDE) . Participants Healthcare seeking behavior was explored by asking were assured confidentiality of information. participants if they had ever sought medical advice regarding their urinary symptoms, had been pre- Results viously diagnosed with OAB or if they had received treatment. Respondents who had received treatment Reliability of measures were asked to specify the type and state of treatment The OABq – SF showed good reliability and internal (i.e. behavioral, pharmacotherapy/current, previous). consistency; Cronbach alpha for six items measuring the degree of bother was 0.88, for 13 items measuring Statistical analysis the HRQL was 0.95 and for the entire questionnaire (19 All analyses were performed using Stata version 14. items) was 0.96. For the OABSS, Cronbach alpha Data were first inserted into an Excel spreadsheet, was 0.77. and the exclusion criteria, mentioned above, was implemented. Descriptive statistics using frequencies and percentages were used to express categorical vari- Baseline characteristics ables. Continuous data were expressed as means ± SD A total of 1,125 participants were recruited. and medians with IQR following the normalcy of their Following the exclusion criteria, 185 participants distribution. Chi square tests and Mann-Whitney U test were found ineligible for further analysis providing were performed to determine the association with a response rate of 83.5%. The final number of eligi- OAB. Logistic regression was performed and odds ble study participants was 940. Table 1 shows the ratio with 95% CI were produced. Following the unad- baseline characteristics and association with OAB. justed regression, all factors that reached statistical Overall, the median age of the respondents was significance (p < 0.05) were fit into the final logistic 43 years, female to male ratio was 1.1, 62.5% were model. Multivariable linear regression analysis was per- married, 54.2% were non-workers, housewives or formed for symptom correlation with bother and retired and the household income was > 500 (JDs) HRQL. P value < 0.05 was considered significant. among 512 individuals (54.4%). The majority Regarding reliability of study instruments, Cronbach (77.5%) had received an education level equivalent alpha ≥ 0.70 was used to define good internal to college or higher. Smoking was reported in consistency. 28.6% of study individuals while caffeine intake (i.e. coffee, tea) was reported in 89.8%. More than Ethical considerations half of the study participants (66.9%) had an aver- The study was approved by the Institutional Review age fluid intake of less than 2500 (mL). The pre- Board (IRB) of the Faculty of Medicine and Jordan sence of comorbidities, previous history of renal University Hospital at The University of Jordan (309/ stones and previous history of UTIs were observed Table 1. Baseline characteristics of 940 study participants. Overall Non-OAB OAB Baseline characteristics n = 940%) n = 682 (72.6%) n = 258 (27.4%) p value Age, median (IQR) 43 (30) 39 (30) 50.5 (22) <0.001* Age group+ < 40 436 (46.4) 362 (83) 74 (17) <0.001* >40 504 (53.6) 320 (63.5) 184 (35.5) Gender Male 446 (47.4) 348 (78) 98 (22) <0.001* Female 494 (52.6) 334 (67.6) 160 (32.4) Marital status Married 588 (62.5) 399 (67.9) 189 (32.1) <0.001* Single/divorced/widow 352 (37.4) 283 (80.4) 69 (19.6) Education Elementary school 38 (4) 26 (68.4) 12 (31.6) 0.8 Secondary school 173 (18.4) 126 (72.8) 47 (27.2) College and higher 729 (77.5) 530 (72.7) 199 (27.3) Employment Currently employed 449 (47.8) 304 (67.7) 145 (32.3) 0.01* Retired/housewives/unemployed 379 (40.3) 287 (75.7) 92 (24.3) Income+ <500 JD 428 (45.5) 296 (69.2) 132 (30.8) 0.03* ≥500 JD 512 (54.5) 386 (75.4) 126 (24.6) BMI+ <25 289 (30.7) 238 (82.4) 51 (17.6) <0.001* 25–29 335 (35.6) 243 (72.5) 92 (27.5) ≥30 311 (33) 198 (63.7) 113 (36.3) Smoking (Yes) 269 (28.6) 200 (74.4) 69 (25.6) 0.4 Fluid intake+ <2500 629 (66.9) 468 (74.4) 161 (25.6) 0.07 >2500 311 (33) 214 (68.8) 97 (31.2) Caffeine intake (Yes) 845 (89.9) 605 (71.4) 240 (28.4) 0.05 Medical Comorbidities (Yes) 495 (52.6) 316 (63.8) 179 (36.2) <0.001* Previous UTI 340 (36) 217 (63.8) 123(36.2) <0.001* Previous renal stones 85 (9) 55 (64.7) 30 (35.3) 0.09 4 S. QUDAH ET AL. in 52.6%, 9%, and 36.1% of the study population, 0.4–0.9) and income > 500 (OR = 0.7, 95% CI: 0.5–0.9) respectively. were significantly associated with decreased odds of OAB (p = 0.01, p = 0.03, respectively). On the other hand, educational level, smoking, caffeine intake as Prevalence of OAB well as fluid intake did not reach statistical significance. We found that the overall prevalence of OAB was For the multivariable regression model, gender, BMI, 27.4% (258), 22% among men and 32.4% among presence of comorbidities, and history of recurrent women. Almost half of the OAB patients (51.2%) had UTIs remained significantly associated with increased OAB with the highest prevalence (28%) among the wet risk of OAB (p < 0.05). Considering the pertinent effect eldest age group (≥70 years) and lowest (4.5%) in the of fluid intake, it was included in the final regression youngest age group (18–29). model despite not yielding prior statistical significance, In women with OAB, 56.8% had urge UI compared this showed that fluid intake > 2500 (mL) might to 41.8% of men with OAB (p = 0.01). Mild OAB was increase the odds of OAB (OR = 1.39, 95% CI: 0.9–1.9) observed in 36.4% of affected individuals, moderate with p-value of 0.05, yet not statistically significant in OAB in 12.7% while 50.7% had severe OAB. our analysis. Factors associated with OAB OAB symptoms, severity, degree of bother and Results of the regression model are shown in Table 2. HRQL We performed bivariate regression analysis and found that age (Odd ratio [OR] = 2.26, 95% confidence inter- Among all respondents, nocturia (defined by the ICS val [CI]: 1.6–3), higher BMI (OR = 2.6, 95% CI: 1.8–3.8), as ≥ 1 voids per night) was the most common symp- presence of comorbidities (OR = 2.6, 95% CI: 1.9–3.5) tom (n = 650) followed by urgency (n = 455), frequency and history of recurrent UTIs (OR = 1.9, 95% CI: 1.4–2.6) (n = 211) and lastly urge UI (n = 179) (Figure 1a). Since were all significantly associated with increased risk of the diagnosis of OAB in our study entailed the pre- OAB (p < 0.001 for all). Additionally, men as compared sence of urgency, we aimed to also explore the pre- to women, and those who were single, divorced or valence of the other spectrum of symptoms. Nocturia widowed as compared to those who were currently remained the most common symptom (n = 241) married had two times decreased odds of OAB (Figure 1b). (p < 0.001 for both). Employment (OR = 0.6, 95% CI: Table 2. Logistic regression analysis for factors predictive of OAB. Variable OR (95% CI) P value AOR (95% CI) P value Age (ref. <45) ≥45 2.26 (1.6–3) <0.001* 1.13 (0.7–1.7) 0.5 Gender (ref. female) Male 0.5 (0.4–0.7) <0.001* 0.5 (0.3–0.7) 0.001* Marital status (ref. Married) Single/divorced/widowed 0.5 (0.3–0.7) <0.001* 1.3 (0.8–1.9) 0.1 Educational level (ref. Elementary) Secondary 0.7 (0.3–1.7) 0.5 College/University or higher 0.7 (0.3–1.5) 0.4 Income (ref. <500) >500 0.7 (0.5–0.9) 0.03* 0.7 (0.5–1) 0.05 Occupation (ref. Unemployed/retired/housewife) Employed 0.6 (0.4–0.9) 0.01* 1.2 (0.8–1.7) 0.3 BMI (ref. <25) 25 - <30 1.7 (1.2–2.5) 0.01* 1.6 (1.03–2.56) 0.05 ≥30 2.6 (1.8–3.8) <0.001* 1.8 (1.1–2.9) 0.01* Fluid intake (ref. <2500) ≥2500 1.3 (0.9–1.7) 0.07 1.39 (0.9–1.9) 0.05 Caffeine intake (ref. none) Yes 1.6 (0.9–2.8) 0.05 Smoking (ref. non-smoker/Ex-smoker) Smoker 0.8 (0.6–1.2) 0.4 Comorbidities (ref. none) Yes 2.6 (1.9–3.5) <0.001* 1.86 (1.2–2.8) 0.01* History of recurrent UTIs (ref. none) Yes 1.9 (1.4–2.6) <0.001* 1.6 (1.1–2.2) 0.01* reference, OAB: Overactive bladder BMI: body mass index, UTIs: Urinary Tract Infections. + 2 Age expressed in years; BMI expressed in Kg/M ; Income expressed in Jordanian Dinars (JDs); fluid intake measured in mL. *Statistically significant P value < 0.05. ARAB JOURNAL OF UROLOGY 5 Figure 1. Frequency of OAB symptoms (a)among general population, (b) among OAB group. Table 3. The Impact of OAB severity on degree of symptom bother and HRQL. OAB, n = 258%) No OAB Mild, n = 94 (36.4) Moderate, n = 32 (12.4) Severe, n = 132 (51.16) P value Symptom bother (mean + SD) 8.9 ± 11.4 21.1 ± 11.9 34.3 ± 16.4 46 ± 24.4 <0.001* HRQL (mean + SD) 94.9 ± 9.1 83.7 ± 15.1 69.7 ± 22.5 66.7 ± 23.2 <0.001* OAB: overactive bladder; HRQL: health-related quality of life. *Statistically significant P value < 0.05. Table 3 illustrates the scores of symptoms bother mean ± (SD). Symptom bother significantly increased and HRQL measured by the OAB-q SF and expressed as from those without OAB and across OAB severity Table 4. Linear regression analysis of OAB symptoms contribution to symptom bother and HRQL as measured by the OABq. 2 2 Multivariable linear regression for HRQL (Adjusted R = 0.56) Multivariable linear regression for symptom bothers (Adjusted R = 0.56) β co. efficient (95% CI) P β co. efficient (95% CI) P Frequency −6.8 (−8.5 - −5.15) <0.001* 5.9 (4.4–7.7) <0.001* Nocturia −3.6 (−4.5 - −2.7) <0.001* 4.4 (3.5–5.4) <0.001* Urgency −4.02 (−4.7 - −3.2) <0.001* 4.9 (4.1–5.7) <0.001* Urge Urinary Incontinence −4.09 (−5 - −3.1) <0.001* 6.1 (5.1–7.1) <0.001* Age −0.05 (−0.09 - −0.004) 0.03* 0.005 (−0.04–0.05) 0.8 Gender 0.57 (−0.89–2.04) 0.4 −1.4 (−2.9–0.06) 0.06 HRQL: health-related quality of life. *Statistically significant P value < 0.05. 6 S. QUDAH ET AL. groups (p < 0.001). For those without OAB, the calcu- Milsom et al. [10] conducted telephone interviews in lated mean ± (SD) was 8.9 ± 11.4 while the highest France, Germany, Italy, Spain and Sweden, and the symptom bother was observed in severe OAB (mean reported prevalence was 16.6% (range, 12% − 22%). ± (SD) = 46 ± 24.4) (Table 3). Regarding HRQL, In Korea, the overall prevalence was 12.2% (10% in a significant decrease was noted with the increase in men and 14.3% in women) [24]. In Germany, Canada, OAB severity (p < 0.001). For those without OAB, HRQL Sweden, Italy and the UK, Irwin et al. [25] reported that mean ± (SD) was 94.9 ± (9.1), compared to 66.7 ± (23.2) the prevalence of OAB was 11.8% (10.8% in men and in those with severe OAB. 12.8% in women). In light of the above mentioned, multivariable linear We also observed higher prevalence in those ≥40 regression was performed to explore the correlation of years with overall prevalence of 36.4% (30.8% in men each symptom with the degree of bother and HRQL and 41.3% in women). while accounting for the role of age and gender, as Epidemiological studies can use different definitions illustrated in Table 4. All OAB symptoms showed sig- of OAB and although many studies utilized the 2002 nificant positive correlation with increased symptom ICS definition [1], criteria to establish the diagnosis, bother (p < 0.001) in addition to significant inverse targeted populations (in terms of region, gender, and correlation with HRQL (p < 0.001). For increased symp- age), type of survey administered, and the implemen- tom bother, urge UI had the highest correlation (β = ted methodology can be different and explain the 6.1, 95% CI: 5.1–7.1, p < 0.001), while decrease in HRQL prevalence variance. The higher prevalence reported had the highest correlation with daytime frequency in the current study can be explained by the regional (β = −6.8, 95% CI: −8.5 - −5.15, p < 0.001). difference. This is supported by Erwin et al. [12] who reported that the highest number of individuals affected by OAB are in Asia. Evidently, our results Healthcare and treatment seeking behavior similarly compared with other epidemiological studies In those with OAB, 18% sought medical advice regard- conducted in Asia [26,27] where OAB was found in 29.9% of men and 51.4% of women. The attributable ing their urinary condition of which 40% received treatment and 42.5% were diagnosed with OAB. All cause for the higher prevalence in Asia in these studies those who had received treatment reported the use remained indefinite; however, cultural, social, eco- nomic and hygienic differences were suggested [26]. of pharmacotherapy. Among those, 52.6% were cur- Furthermore, Edwan et al. [16] reported that among rently treated and 47.4% had discontinued their treatment. women residing in Jordan aged ≥40 years, the preva- lence of OAB was 58.8% with approximately half experiencing urge UI. The significant prevalence differ - Discussion ence among genders, can be explained by the anato- mical differences and obstetrics history in women. In To the best of our knowledge, this is the first study our study, the overall prevalence of UUI among men conducted in Jordan that explores OAB prevalence in was 9.1% (41.84% of those with OAB) and 18.2% both genders while incorporating broad age groups among women (56.25% of those with OAB). Our results with assessment of HRQL. Clinical characteristics of are in line with previous literature regarding urge UI those affected were evaluated and the following being more common in women [2,22–24]. were significantly associated with increased risk of Nonetheless, these high numbers can be justified by OAB; female gender, increased BMI, presence of our broad definition of UI; participants who reported comorbidities and history of recurrent UTIs. In an episode of UI once a week or less up to those who patients with OAB, nocturia was the most common reported 5 episodes a day were all included in the symptom in both genders. Symptom bother signifi - category OABwet. We anticipate a lower prevalence if cantly increased with the increase in OAB severity the diagnosis of UUI required more frequent episodes. and HRQL significantly decreased with the increase Studies concerned with male UI have estimated in OAB severity All OAB symptoms significantly cor- a prevalence of 3.1% to 12.7% highlighting that the related with increased symptom bother and prevalence increases with age. Shamliyan et al. And decreased HRQL, but frequency and urge UI had Diokno et al. have also reported that among men the highest correlation. experiencing UI, UUI is the most common type affect - In this study, the prevalence of OAB was 27.4% (22% ing 44% of incontinent men [28,29]. In the UREPIK in men and 32.4% in women) which was comparable study, Boyle et al. [30] concluded that 89% of men self- to many studies [21–23]. In China, Taiwan and South reported leakage of urine occurring at least once Korea [4], the prevalence was 20.8%. Among men and a week compared to 34% of men who reported 3 or women residing in Poland [21], the prevalence was more episodes per week. This adds to our agreement 26.8% and 39.5%, respectively. In the United States, that our high prevalence can be justified by the num- the prevalence was 43% in women and 27% in men ber of incontinent episodes. Lastly, risk factors for [23]. Other studies showed lower prevalence of OAB, ARAB JOURNAL OF UROLOGY 7 incontinence including age [28,29], diabetes [28] and all OAB symptoms and comorbidities were self-reported BMI were also apparent in the OABwet group where and therefore can be over or underestimated. In addition, 51.2% were aged 60 years or older, 55.38% had the measures utilized depend on recall from the prior a BMI ≥ 30, and 68.2% had diabetes. week for the OABSS and prior month for the OABq – SF In a meta-analysis that evaluated risk factors for OAB; subjecting the information to recall bias. Moreover, and increase in age, and BMI were significantly associated despite following a stringent exclusion criteria, sampling with increased risk of OAB while higher educational might not be representative of the general population as level was significantly inversely correlated [31]. The data were collected in hospital setting. increased risk of OAB with higher BMI, in our study, was in agreement with other reports [32] that explained Conclusion the association by the increased intraabdominal pres- sure causing pelvic floor disorders attributable to con- OAB is a prevalent condition in both men and women. sequent repetitive pedundal nerve injury. In addition, OAB was significantly higher in women; however, the higher BMI has an increased link with other comorbid- prevalence of OAB and urge UI among men should not ities including diabetes which contributes to bladder be overlooked. OAB is a bothersome condition that has dysfunction [31–33]. In our study, the prevalence of a significant adverse impact on HRQL. Our results deno- comorbidities including diabetes, hypertension, anxiety, tive that this detrimental effect is not exclusive to urge UI depression and recurrent UTIs was significantly higher and can be attributed to the other elements in the symp- in the OAB group, this was also in line with the current tom spectrum of OAB. We found the following factors to literature [3,4,9]. Our results showed possible associa- be associated with OAB: Gender, increasing BMI, pre- tion between increased fluid intake (>2500 mL) and risk sence of chronic diseases, and history of recurrent UTI. of OAB. In a systemic review to identify the role of fluid Screening for OAB should be considered during routine intake modification on OAB symptoms, the results var- clinical visits for early detection of symptoms and possi- ied and while some studies showed that decreasing ble modification of risk factors to improve the HRQL. fluid intake can significantly reduce OAB symptoms Implementing validated and reliable measures for the and vice versa, others reported no correlation [34]. assessment of OAB aids healthcare providers in optimiz- Since individuals with OAB are adopting coping beha- ing their evaluation and treatment. viors that include fluid restriction [9,11], proper evalua- tion is required, to avoid disposing them at higher risks Acknowledgments of dehydration and UTIs [34]. Across prior reports, OAB has proven to be We are grateful to the participating patients and their a bothersome condition. In our study, the degree of families for their kind collaboration. bother significantly increased with OAB severity, which perspectively , increased as the number of symptoms or Disclosure statement their episodes amplified. Our findings were supported by Irwin et al. [35] who outlined that the highest per- No potential conflict of interest was reported by the centage of individuals reporting bother was of those author(s). affected by urgency and five or more of lower urinary tract symptoms (LUTS). Other studies have also demon- ORCID strated that bother is significantly correlated with the frequency of symptoms and severity of OAB [4,5,21]. Our Mohammad Abufaraj http://orcid.org/0000-0002-6603- results were also in line with those of Milsom et al. [3] 6319 Randa Farah http://orcid.org/0000-0003-1638-9017 and Coyne et al. [6], where the OAB-q SF was utilized in both for the evaluation of bother and HRQL. Similarly, HRQL was better in those without OAB compared to Data availability statement those affected. and bothersome OAB had the most substantial decrease in HRQL scores observed as com- Raw data were generated at Jordan university hospital. Derived data supporting the findings of this study are avail- pared to those with OAB who did not report bother. able from the corresponding author MA on request. The strength of the study includes being carried out in accordance with the ICS 2002 definition, allowing for standardized assessment of OAB prevalence. We also Ethical considerations used validated and reliable measures to establish OAB The study was approved by the Institutional Review Board diagnosis, determine the degree of bother and impact on (IRB) of the Faculty of Medicine and Jordan University HRQL. The exclusion criteria eliminate many underlying Hospital at The University of Jordan. 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Journal

Arab Journal of UrologyTaylor & Francis

Published: Jan 2, 2024

Keywords: Overactive Bladder; quality of life; urge incontinence

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