EMHJ • Vol. 18 No. 10 • 2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Mismatch between Arab women’s preferences and options offered for treatment of stress urinary incontinence in the S. George,1 M.J. Hashim,2 M.H.S. Al Belooshi,3 R.S. Al Hebsi,3 A.A. Bloushi,3 S.A. Balfaqeeh 3 and A. Al Midfa 3

عدم التطابق بني ما تفضله النساء العربيات واالختيارات املقدمة هلن ملعاجلة َس َلس البول َالك ْريب يف اإلمارات العربية املتحدة سامي جورج، حممد جواد هاشم، مريم هندي شاكر البلويش، ريم سيف احلبيس، أمل عيل البلويش، ساره عيل بلفقيه، عاليه املدفع

اخلالصة: ُي ُّعد َس َلس البول الكريب من احلاالت الشائعة ًنسبيا، ويشكل ً عبئا ًثقيال من املعاناة مع أنه يمكن معاجلته بفعالية وبالقليل من اجلراحات غري الباضعة. ولكن ما تفضله النساء العربيات ملعاجلة هذا املرض غري معروف، والسيام من حيث رغبتهن يف إجراء اجلراحة. ويف هذا املسح الذي شمل 404 امرأة يف اإلمارات العربية املتحدة، أبلغت 99 امرأة عن سلسل البول الكريب، وأقرت 51% منهن عىل موافقتهن عىل إجراء اجلراحة. هذه 5 24 التفضيالت مل ترتبط بالعمر، أو عدد مرات الوالدة، أو التعليم، أو شدة َّالس َلس. إال أنه من بني امرأة التمسن االستشارة الطبية، ذكرت سيدات 38 29 فقط أن األطباء قد َع َر ْض َنعليهن املعاجلة باجلراحة. وشملت عروض العالج األخرى العالج باألدوية ) %(، ومتارين للحوض ) %(، ومتارين للمثانة )25 (.ومع %أن نصف النساء من اإلمارات العربية املصابات بالسلسل البويل الكريب يف هذه الدراسة رغبن يف إجراء اجلراحة، إال أن هذا النوع من املعاجلة مل يقدم إليهن عىل نحو روتيني.

ABSTRACT Stress urinary incontinence is a relatively common condition with a high burden of suffering that can be treated effectively with minimally invasive surgery. Treatment preferences for this condition in Arab women are not known, especially in regard to willingness to undergo surgery. In this survey of 404 women across the United Arab Emirates, 99 had self-reported stress urinary incontinence and 51% of these stated they would undergo surgery. This preference was not related to age, parity, education or severity of incontinence. However, of the 24 women who sought medical advice, only 5 recalled being offered surgical management by their physicians. Other treatments offered included medication (29%), pelvic exercise (38%) and bladder training (25%). Even though half of the Arab Emirati women with stress urinary incontinence in our study were willing to undergo surgery, this treatment is not being offered routinely.

Décalage entre les préférences des femmes arabes et les options thérapeutiques proposées pour traiter l'incontinence urinaire à l'effort aux Émirats arabes unis

RÉSUMÉ L'incontinence urinaire à l'effort est une affection relativement fréquente entraînant une souffrance importante qui peut être traitée efficacement par une intervention chirurgicale minimalement invasive. Les préférences thérapeutiques des femmes arabes affectées restent à élucider, en particulier par rapport à leur volonté de se soumettre à une chirurgie. Dans la présente étude portant sur 404 femmes des Émirats arabes unis, 99 souffraient d'une incontinence urinaire à l'effort autodéclarée et parmi celles-ci, 51 % affirmaient être volontaires pour choisir la chirurgie. Cette préférence n'était liée ni à l'âge, ni à la parité , ni au niveau d'études, ni à la sévérité de l'incontinence. Toutefois, sur les 24 femmes qui avaient consulté un médecin, seules 5 se sont souvenues avoir été informées par ce dernier de la possibilité d'une prise en charge chirurgicale. Des médicaments (29 %), des exercices du plancher pelvien (38 %) et une rééducation de la vessie (25 %) étaient les autres traitements proposés. La moitié des femmes émiraties de notre étude souffrant d'incontinence urinaire à l'effort étaient volontaires pour la chirurgie, mais ce type de traitement n'a pas été proposé systématiquement.

1Department of Obstetrics and Gynaecology; 2Department of Family Medicine; 3Faculty of Medicine & Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates (Correspondence to M.J. Hashim: [email protected]). Received: 03/08/11; accepted: 04/10/11

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Introduction (risk ratio 1.03 in 8 trials involving 599 interviewed in hospitals, primary health women) [5]. Minimally invasive sur- care clinics and local communities Although the prevalence of stress gery was associated with shorter op- based on non-random convenience urinary incontinence (SUI) and erating times and fewer postoperative sampling: any potential participants the burden of suffering caused by urinary complications. Furthermore, who were present were approached this condition among women has these operations can be performed as and invited to take part in the survey . been studied extensively, the treat- outpatient procedures under local an- The inclusion criteria were: wom- ment preference of these patients aesthesia with conscious sedation [6]. en age 30 years and above (since SUI has received minimal attention. It The quality of life has been shown to is generally related to childbearing is sometimes assumed that women improve with the minimally invasive and prevalence in younger women is from less-developed countries and tension-free vaginal tape procedure at much lower) and United Arab Emir- non-Western backgrounds may not 12 months follow-up, with a cure rate ates nationality. Due to the unique be aware that surgical treatment is of 87% [7].Treatment of SUI has ad- needs of our study and the lack of an option, or may not be willing to vanced significantly in terms of tech- a validated instrument in , a have surgery for this condition. Con- nique, success rate, non-invasiveness new questionnaire was developed via sequently, physicians may not be of- and safety [8]. multiple iterations and pilot tested in fering the full range of management Unfortunately, these remarkable Al Ain to assess the suitability of the options, especially to less-educated or advances in treatment do not appear questionnaire. The questions covered older women of certain ethnic origins. to have improved the community bur- demographic data, childbearing and Recent research in the Arabic- den of suffering from SUI. Whether medical conditions as well as specific speaking Middle East region has shown this is because of women’s reluctance questions about urine incontinence, that prevalence and morbidity of urinary to have surgery or to not being offered treatment options, attitudes and incontinence is comparable to that in this safe and effective option is un- healthcare-seeking behaviour. Most other parts of the world. The prevalence clear. For clinicians and public health questions were closed-ended with pre- reported in this region is over 20% in professionals, knowledge of women’s specified options. adult women [1]. awareness and preferences for man- In this study SUI was defined agement options are important in Arab Muslim women are particu- as “involuntary or accidental leak- discussing treatment choices and for larly distressed by SUI as it impacts age of urine with any increase in health education campaigns. As treat- on their ability to pray on a daily basis. intra-abdominal pressure such as with ment preferences and awareness of Embarrassment and misconceptions coughing, sneezing, laughing, exercise, effective operative management are about this condition prevents a large carrying heavy objects and bending, not known among Arab women, we number of women from seeking treat- regardless of its severity or social con- conducted this cross-sectional survey ment. A community-based survey in sequences”. among Emirati women. the United Arab Emirates found that Ethical approval was obtained from 69% of women did not seek medical Al Ain District Medical Research Eth- advice for urine leakage, leading to de- Methods ics Committee at Tawam Hospital, Al bilitating physical, psychological and Ain and the Faculty of Medicine and social burdens [1]. Women’s beliefs We developed a questionnaire and Health Sciences, United Arab Emirates about treatment options for inconti- conducted a cross-sectional survey to University, Al Ain. nence have been noted to affect help- assess the treatment preferences for seeking behaviour, including the fear SUI among women in the United Arab Statistical analysis of surgery and a perception of lack of Emirates. The survey was conducted Our study was powered to detect a effective treatments [2,3]. from June 2009 to March 2010 in 4 difference of at least 15% from the pref- However, the effectiveness of cities across the United Arab Emirates, erence for surgical treatment of 50% minimally invasive surgical techniques Abu Dhabi, Al Ain, Dubai and Sharjah. (minimum sample size 100 subjects; is fairly well established in urogynae- The cities were selected on the basis alpha 0.05; achieved power 82%; for a cology trials [4]. A systematic review of accessibility. After initial training 2-tailed, binomial, one-sample calcu- comparing minimally-invasive syn- sessions and a pilot phase, 6 medical lation). Data analysis was carried out thetic suburethral sling operations students from the United Arab Emir- using SPSS, version 18. We used 1-way with traditional suburethral slings ates University administered the ques- analysis of variance and nonparametric found them to be equally effective tionnaire. A total of 404 women were tests where appropriate. Two-tailed

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significance testing was used with sig- 99 had SUI as judged by self-reported with SUI said that the condition inter- nificance level 0.05. loss of urine with physical activity: 69 fered with performing their daily prayers women had leakage with coughing and and 41% said it caused them embarrass- 11 reported leakage with sexual inter- ment (Table 2). Severity of interference Results course (Table 2). with daily living varied from mild 32% Although 51% (50/99) of those (32/99) to moderate 25% (25/99) to Generalizability of the findings can with SUI indicated that they would severe 5% (5/99) (data missing for 4 be assessed from the background undergo surgery, only 20.8% (5/24) women). Coping strategies included characteristics of the participants of those who had consulted a doctor frequent changing of underwear (58 (Table 1). Education level and other recalled being offered surgery (Table 3. women) and wearing pads (23 women) demographic variables were used as Willingness to undergo surgery was not (Table 2). proxy to assess the representativeness. related to age, parity, education or sever- A range of educational backgrounds ity of incontinence (Mann–Whitney was captured in the our sample of 404 U-test, P > 0.05). Discussion women: 37 (9%) had undertaken Only 24 of the 99 women with SUI postgraduate education, 133 (33%) had sought medical advice (Table 3), We found that about half of our sam- had a college or university degree, with the rest feeling: shy or embar- ple of Emirati women with SUI were 119 (30%) had completed secondary rassed (9), ‘lazy’ (5), UI was not im- willing to undergo surgery but only school, 57 (14%) primary school and portant (20), or UI was normal part of about one-fifth of those who consulted 24 women (6%) had no formal educa- life (44) (data missing for 2 women). a doctor were offered surgical treat- tion (data were missing for the rest of Among the 24 women with SUI who ment. This is of concern given the high the women). did discuss the issue with physicians, prevalence of this condition and the As expected, compared with 50% (12/24) consulted gynaecolo- associated psychosocial morbidity. Our women who stated they did not have gists, 38% (9/24) urologists and 12% findings run contrary to the miscon- urinary incontinence, women with SUI (3/24) saw other specialties. Apart ception that women from a Middle were statistically significantly older (P = from surgical treatment, other options Eastern Arab background are unaware 0.003) (Table 1). prescribed were: medication 29% of treatment options or would prefer In our sample the prevalence of (7/24), pelvic exercise 38% (9/24) non-surgical options only. In particular, urinary incontinence was 26.4% and bladder training 25% (6/24). In age and education status do not seem (106/401 women; 3 of the participants some cases, more than 1 treatment was to affect the preference for surgery. were not eligible for inclusion), with a prescribed. These findings have not been reported substantial burden of suffering Among In our study, there was a significant in previous studies from this region to the 106 women with incontinence, psychosocial burden: 56% of women our knowledge.

Table 1 Comparison of women in the United Arab Emirates aged 30+ years with and without stress urinary incontinence (SUI) Characteristic Women with SUI Women without SUIa P-valueb (n = 99) (n = 305) Mean (SD) Mean (SD) Age (years) 42.5 (8.4) 37.8 (7.1) 0.003 Weight (kg) 77.0 (17.7) 72.2 (15.8) 0.82 BMI (kg/m2) 31.1 (7.4) 28.7 (6.0) 0.20 Level of educationc 2.3 (1.1) 2.4 (1.0) 0.62 No. of children 6.3 (3.5) 4.7 (2.8) 0.09 No. of vaginal deliveries 5.7 (3.6) 4.3 (2.9) 0.20 No. of instrumental deliveries 0.05 (0.2) 0.07 (0.3) 0.49 No. of C-sections after trial of labour 0.13 (0.3) 0.15 (0.5) 0.19 No. of C-sections without labour 0.37 (1.1) 0.19 (0.6) 0.79

aIncludes 7 women with non-stress urinary incontinence. bP-values for univariate general linear model (1-way analysis of variance) analysing 278 cases, adjusted R2 0.091. cLevel of education coded on a scale of: 5 = postgraduate training to 1 = no formal education. SD = standard deviation; BMI = body mass index; of C-section = caesarean section.

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Table 2 Burden of suffering in women in the United Arab Emirates aged 30+ years impact on prayers and personal life, with stress urinary incontinence and coping mechanisms correspond Issue No. of womena with previous reports from the region (n = 99) [14] and elsewhere [3]. The reluc- Cause for leakage tance of women to discuss this condi- With cough 69 tion with physicians has been reported With intercourse 11 in a community survey from With exercise 8 [15] with 32% of women with urinary On standing from a sitting position 8 incontinence seeking medical care With orgasm 2 compared with 27% in our study. The Impact on life reasons stated by the women in Lon- Interference with daily life 62 don were strikingly similar to those in Interference with prayers 56 the United Arab Emirates, including Embarrassment 41 embarrassment and acceptance as Noticed by spouse 11 part of aging, despite the differences in Coping strategy culture and society. Frequent changing of underwear 58 The limitations of our study include Wearing perineal pads 23 recall bias, use of a non-validated sur- Decreased fluid intake 13 vey instrument and non-probabilistic Avoiding physical activity 18 sampling.

aSelf-reported (loss of urine). Further research should assess clinical appropriateness of SUI treat- ments recommended by physicians in this region and qualitative research Table 3 Treatment awareness and preferences of women in the United Arab about perceptions of women in the Emirates aged 30+ years with stress urinary incontinence United Arab Emirates of treatment Awareness/preference No. of women (n = 99) options. Sought medical advice 24 Would undergo surgery 50 Conclusion Aware of effective treatment 44 Offered surgery by their physiciana 5 This study shows that Emirati Arab aOf those women who had sought medical advice. women with SUI are willing to un- dergo less-invasive surgical treatments but are offered these options relatively Previous research on treatment perhaps in line with our finding that a infrequently. Based on our findings we preferences of women with urinary in- limited number of treatments for SUI recommend that physicians engage continence elsewhere provides some were offered to Emirati women. We women in shared decision-making in validation to our findings. During deci- found that even though physicians are SUI treatment, offer the full range of sion making for urinary incontinence, offering a number of treatment options, options and avoid generalizing about 60% of women in a Norwegian sur- women may have a high willingness to limiting surgical options to women vey preferred an active role [9]. These have surgery, especially the less invasive from certain groups. women tended to be more educated, vaginal and laparoscopic approaches. single and younger. Knowledge of treat- Since cost–effective and minimally in- Acknowledgement ment options was mostly low among vasive surgical options are available as immigrant Moroccan and Turkish effective treatments for SUI [7,11–13], We would like to extend our thanks to women in a small qualitative study in the this finding is of concern from clinical all the medical students who helped Netherlands [10]. On the other hand, and public health perspectives. in the collection of these data from one-third of these women felt that their Our other findings on prevalence, the different cities in the United Arab physician had not taken them seriously, reluctance to seek medical help, Emirates.

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References

1. Rizk DE et al. The prevalence and determinants of health care- urinary incontinence. Acta Obstetricia et Gynecologica Scandi- seeking behavior for urinary incontinence in United Arab Emir- navica, 2007, 86:1370–1376. ates women. International Urogynecology Journal and Pelvic 10. Van den Muijsenbergh ME, Lagro-Janssen TA. Urinary incon- Floor Dysfunction, 1999, 10:160–165. tinence in Moroccan and Turkish women: a qualitative study 2. Koch LH. Help-seeking behaviors of women with urinary on impact and preferences for treatment. British Journal of incontinence: an integrative literature review. Journal of Mid- General Practice, 2006, 56:945–949. wifery & Women’s Health, 2006, 51:e39–44. 11. Valpas A et al. A cost-effectiveness analysis of tension-free 3. Hägglund D et al. Quality of life and seeking help in women vaginal tape versus laparoscopic mesh colposuspension for with urinary incontinence. Acta Obstetricia et Gynecologica primary female stress incontinence. Acta Obstetricia et Gyneco- Scandinavica, 2001, 80:1051–1055. logica Scandinavica, 2006, 85:1485–1490. 4. Gilleran JP, Zimmern P. An evidence-based approach to the 12. Ankardal M et al. Short- and long-term results of the tension- evaluation and management of stress incontinence in women. free vaginal tape procedure in the treatment of female urinary Current Opinion in Urology, 2005, 15:236–243. incontinence. Acta Obstetricia et Gynecologica Scandinavica, 5. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic 2006, 85:986–992. suburethral sling operations for stress urinary incontinence 13. Kuuva N, Nilsson CG. Long-term results of the tension-free in women. Cochrane Database of Systematic Reviews, 2009, vaginal tape operation in an unselected group of 129 stress CD006375. incontinent women. Acta Obstetricia et Gynecologica Scandi- 6. Kane AR, Nager CW. Midurethral slings for stress urinary incon- navica, 2006, 85:482–487. tinence. Clinical Obstetrics and Gynecology, 2008, 51:124–135. 14. El-Azab AS, Mohamed EM, Sabra HI. The prevalence and risk 7. Bakas P et al. Quality of life in relation to TVT procedure for factors of urinary incontinence and its influence on the quality the treatment of stress urinary incontinence. Acta Obstetricia et of life among Egyptian women. Neurourology and Urodynam- Gynecologica Scandinavica, 2006, 85:748–752. ics, 2007, 26:783–788. 8. Williams ER, Klutke CG. Stress urinary incontinence: the 15. MacKay K, Hemmett L. Needs assessment of women with uri- evolution of the sling. Expert Review of Medical Devices, 2008, nary incontinence in a district health authority. British Journal 5:507–523. of General Practice, 2001, 51:801–804. 9. O’Donnell M, Hunskaar S. Preferences for involvement in treatment decision-making among Norwegian women with

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