(Stroke. 2000;31:886.)
© 2000 American Heart Association, Inc.
Original Contributions |
Prevalence and Impact of Urinary Symptoms Among Community-Dwelling Stroke Survivors
From the Division of Medicine for the Elderly, Leicester General Hospital (K.R.B., S.M.P.); Division of Medicine for the Elderly, Glenfield Hospital (J.F.P.); and the Department of Epidemiology and Public Health, Leicester University (S.I.P., C.S., H.D., R.P.A., K.W., C.J.), Leicester, England. Dr Castleden is a professor emeritus of Leicester University.
Correspondence to J.F. Potter, Division of Medicine for the Elderly, Leicester University, The Glenfield Hospital, Groby Road, Leicester, LE3 9QP, England. E-mail jp34{at}leicester.ac.uk
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Abstract |
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Background and Purpose—To establish prevalence of urinary symptoms among community-dwelling stroke survivors and how these symptoms affected lives of these survivors compared with a nonstroke population.
Methods—The present study was a community-based postal survey
in Leicestershire community, UK (that excluded institutional settings),
that was designed to track stroke, urinary, and bowel symptoms and the
effect of such symptoms on relationships, social life, daily
activities, and overall quality of life. Subjects included 14 600
people who were living in the community and 
40 years of age, randomly
selected from the Leicestershire Health Authority Register.
Results—A 70% response rate was achieved with the return of 10 226 questionnaires. Prevalence of reported stroke was 4% (n=423). Prevalence of urinary symptoms was 34% (n=3197). Overall, stroke survivors had a higher prevalence of symptoms than the nonstroke population (64% to 32%, respectively). These symptoms were reported to have more of an effect on the lives of the stroke survivors compared with the nonstroke population even when adjusted for age and sex differences. This reported impact was not related to the stroke per se but to the severity of the urinary symptoms.
Conclusions—These data show a high prevalence of urinary symptoms among community-dwelling stroke survivors. These symptoms were reported to have considerable impact on the lives of stroke survivors, which needs to be taken into account in future research and clinical practice.
Key Words: prevalence • quality of life • stroke • urinary incontinence • urinary symptoms
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Introduction |
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Research has shown a high prevalence of urinary incontinence among stroke survivors.1 2 3 Rates in hospitalized stroke patients have been reported between 32% and 79% at time of admission, 25% and 28% at discharge, and 12% and 19% some months after the stroke.4 In comparison, prevalence of urinary incontinence in the general population is 6%5 6 and in older people, between 11% and 29%.7 8 9 Not only is the prevalence of urinary incontinence in the community higher in those
65 years of age, but it
increases significantly in those in their 80s and is associated with a
higher risk of death.7 9 However, these reports focus
solely on the symptom of urinary incontinence, whereas other urinary
symptoms (frequency, urgency, nocturia, pain, and straining) may be
equally or more important for determination of the impact of urinary
symptoms on the lives of stroke survivors as well as the nonstroke
population. Few data specifically address the effect of urinary
symptoms on the lives of stroke survivors, and to date, no information
compares stroke survivors with a nonstroke population. Therefore, the
aim of the present study was to address these gaps in the
literature on urinary symptoms and their effect on the lives of stroke
survivors in the community. |
Subjects and Methods |
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An epidemiological, community-based postal survey was performed with a random sample of 14 600 Leicestershire residents
40 years of
age. The sample was derived from the Leicestershire Health Authority
register, although residents living in institutional settings
(residential homes, nursing homes, hospital settings) were excluded.
The present study forms part of the Leicestershire Medical Research
Council (MRC) Incontinence Study, which assesses the prevalence and
incidence of urinary symptoms in adults 40 years of age. With the use of a standardized questionnaire developed by the Leicestershire MRC Incontinence Study team, data were collected for 9 months, from October 1996 to June 1997. Respondents were asked about previous stroke, urinary, and bowel symptoms and the effect of these symptoms on several domains of their lives before they were invited to take part in the trial. These "impact" questions were derived from a review of the literature and focused on areas of life shown to be affected by urinary incontinence.10 11 12 13 Demographic data and questions on general health and medical conditions were also collected.
Definition of Stroke
The postal screening question used to determine whether a person
had ever had a stroke was that developed by O’Mahony et
al.14 The exact wording was as follows: "Have you ever
had a stroke (sometimes known as cerebral hemorrhage, cerebral
thrombosis, brain hemorrhage, subarachnoid
hemorrhage, cerebrovascular accident or a mini-stroke or
TIA)?" This question was reported to have a high degree of
sensitivity (95%) and specificity (96%).
Definitions of Urinary Symptoms
Urinary symptoms explored were urinary incontinence, urgency,
frequency, nocturia, straining, and pain. These were decided on after
exploration of the literature and discussion among clinical
specialists. Six clinically significant urinary symptoms were defined
as follows: Urinary incontinence:
Leakage several times a month or more or leakage most of the time when
a person laughs, coughs, or
exercises. Urgency: Overwhelming need
to pass urine or difficulty holding urine most of the time when a
person feels the urge to go. Frequency:
Passing urine 
1 times per hour during the daytime.
Nocturia: Getting up at night to pass urine 2
times. Straining: Having to strain to
pass urine "most of the
time." Pain: Feeling pain in the
bladder "most of the time."
Definitions of Impact of Urinary Symptoms
"Impact" was defined as the effect of urinary symptoms on a
range of physical, functional, and psychosocial domains. Severity of
impact in each domain was recorded as "a lot," "a little,"
or "not at all" (see Appendix
). In a broader sense, impact was also
defined as whether a subject felt symptoms were a severe or moderate
problem and whether the subject used pads, appliances, or aids as a
means of managing these symptoms.
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Statistical Methods
Responders and nonresponders (who were excluded from further
analysis) to the stroke question were compared by Mann-Whitney
U test for age (continuous variable) and
2 tests for sex (binary variable).
Comparisons between the stroke and nonstroke population on binary and
nominal variables (ethnicity and general health) were made with
2 tests. Confounding factors, such as age,
sex, and disability in the relationship between stroke, urinary
symptoms, and impact of those symptoms have been examined with
multivariate logistic regression models and
2 tests.
In the univariate analysis, missing data were
excluded on individual variables; therefore, different denominators
are reported for each variable. A small number (n=36) of
respondents were excluded from analysis because they did not
report any clinically significant urinary symptoms but did indicate
that these symptoms had "a lot" of impact on quality of life.
Fifteen percent (n=471) of respondents who reported experiencing
clinically significant urinary symptoms were excluded from
multivariate analysis because of missing data
on 1 of the 8 impact questions (3% had missing data on all 8
questions). To ensure that exclusion of missing data did not inflate
differences found between the stroke and nonstroke samples, further
analysis was performed to include respondents with missing data
on 1 of the impact questions in the logistic regression model.
However, the results reported in the present article remained
unchanged by further analysis.
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Results |
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Response Rate
Of 15 904 questionnaires mailed, 1304 (8.2%) were excluded because the person no longer lived at the address, had moved to a residential or nursing home, or was deceased. Of the remaining 14 600 questionnaires mailed, 10 226 were returned (70%); of these, 10 121 (99%) could be analyzed. Response rates were lowest in the youngest and oldest age groups (ie, 40 to 49 years and
80 years) and
slightly lower in men. Analysis has been performed on 9963
individuals who responded to the stroke question (excluding 1.5%
missing data).
Comparison of Responders and Nonresponders
Nonresponders to the stroke question were compared with
responders, and although no significant sex differences were found,
nonresponders were significantly older (P<0.0001).
Forty-four percent of nonresponders were male compared with 46% of the
responders. Mean age of nonresponders was 67 years (range,40 to 98
years) compared with the mean age of the responders, 60 years (range,
40 to 99 years). However, mean age of the nonresponders was lower than
those who had had a stroke and slightly higher than those who had not
(mean age, 71 and 59 years, respectively).
Comparison Between Stroke and Nonstroke Population
Fifty-three percent of the stroke sample was men compared with
45% of the nonstroke sample (P<0.005). Stroke survivors on
a whole represented a significantly older group than the
nonstroke population (mean age, 71 versus 59 years). Stroke survivors
also reported their general health to be poorer than the nonstroke
population: 63% of stroke survivors compared with 23% of the
nonstroke population rated general health as either fair or poor. A
larger proportion of the stroke group reported having difficulties with
daily activities (difficulties with getting around the house or
dressing, or having a long-term health problem that affects daily
activities): 66% and 24%, respectively (Table 1).
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Prevalence of Urinary Symptoms Among Stroke and Nonstroke
Population
Overall, 34% of respondents reported 1 clinically significant
urinary symptom (n=3197), and prevalence of reported stroke was 4%
(n=423). Prevalence of stroke with urinary symptoms in the whole
population was 2.5% (n=249). The stroke group reported a significantly
higher prevalence of urinary symptoms than the nonstroke population,
64% (n=249 of 391) compared with 33% (n=2948 of 9071;
P<0.0001). Prevalence of specific urinary symptoms among
community-dwelling stroke survivors was as follows: nocturia, 49% (199
of 409); urinary incontinence, 33% (127 of 382); urgency, 19% (78 of
403); frequency, 15% (62 of 410); straining, 3.5% (14 of 402); and
pain, 2.5% (10 of 397). All were found to be significantly more
prevalent in the stroke than the nonstroke population (Table 2). Even when age and sex were controlled
for, in a multivariate logistic regression model, the
difference in prevalence was found to be significant (odds ratio [OR]
2.45; 95% CI 1.96 to 3.06). When disability was introduced into the
model, people who reported disability were 2.89-fold more likely to
experience urinary symptoms than those who reported no difficulties
with mobility (OR 2.89; 95% CI 2.60 to 3.20). All 4 explanatory
factors (sex, age, stroke, and disability) were significant
contributing factors to reports of urinary symptoms. A quadratic term
for age was also added to the model because it significantly improved
the fit; stroke survivors were 1.77-fold more likely to experience
urinary symptoms than the nonstroke population (OR 1.77; 95% CI 1.40
to 2.24).
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Comparison of Stroke and Nonstroke Subjects Who Experienced
Urinary Symptoms
When subjects who experienced urinary symptoms were examined, 49%
of stroke survivors with symptoms versus 38% in the nonstroke
population were found to be men. Stroke survivors who experienced
urinary symptoms had a mean age of 72 years versus 64 years in the
nonstroke population. Similarly, stroke survivors who reported urinary
symptoms reported more difficulties with daily activities than the
nonstroke population (78% compared with 41%), which suggests a
higher level of disability in this population (Table 1
).
Reported Impact of Urinary Symptoms in Stroke and Nonstroke
Subjects
In univariate analysis, more stroke survivors
with symptoms reported significant impact on lifestyle than did the
nonstroke population (Table 3). For
example, urinary symptoms affected sleep in 23% of stroke survivors
compared with 9% of the nonstroke population. Twice as many stroke
survivors than nonstroke subjects felt that their urinary symptoms were
a moderate-to-severe problem (83 of 246 and 470 of 2897, respectively;
P<0.0001). More than 3 times as many stroke survivors with
symptoms used aids to help manage urinary symptoms (22% or 45 of 206
compared with 6% or 126 of 2119; P<0.0001), and 24% (46
of 189) of stroke survivors reported using pads to cope with urinary
symptoms "most of the time" compared with 9% (197 of 2114) of
nonstroke subjects(P<0.0001). Overall, nearly twice as many
stroke survivors with symptoms reported a lot of impact on 1 of the 8
impact questions (Appendix) compared with nonstroke subjects with
symptoms (31% or 65 of 208 compared with 16% or 406 of 2518;
P<0.0001) (Table 1).
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When age and sex were controlled for by use of a multivariate logistic regression model, with a lot of impact as the outcome, analysis still showed that stroke survivors were 2.40-fold as likely to feel that their urinary symptoms had an impact on their lives than were subjects who had not had a stroke (OR 2.40; 95% CI 1.74 to 3.30). Surprisingly, neither sex nor age was found to be significant in this relationship. When disability was introduced into the relationship, only stroke and disability were found to be significant: for disability, OR 3.03 and 95% CI 2.44 to 3.77; for stroke, OR 1.73 and 95% CI 1.24 to 2.41.
This higher prevalence of reported impact in stroke survivors may be
explained by the severity of urinary symptoms, because the stroke
survivors experience more-severe symptoms. For example, a higher
percentage of stroke survivors, 26% (59 of 228), reported daily
urinary incontinence compared with 14% (396 of 2805) of the nonstroke
population (P<0.0001), and 6% (14 of 227) of stroke
survivors compared with 1% (31 of 2783) of the nonstroke population
reported that the amount of urine lost left them soaked
(P<0.0001). Multivariable analysis with
logistic regression was performed to further investigate the level of
severity of symptoms and their influence on reported impact (Table 4). These data highlight that the severity of the urinary
symptoms, not the stroke per se, influences whether a person feels an
impact on quality of life. Stroke survivors have a high prevalence of
urinary symptoms, which are reported to be more severe than those of
the nonstroke population. Twice as many stroke survivors with urinary
symptoms reportedly experienced 3 symptoms compared with the
nonstroke population (26% and 13%, respectively;
P<0.0001). Disability was also shown to influence whether a
person felt an impact (OR 1.67; 95% CI 1.26 to 2.20). Although again
stroke survivors reported higher levels of disability, once disability
entered the model, the presence of stroke was not significant (OR 1.23;
95% CI 0.79 to 1.93). However, the number of urinary symptoms
experienced may also influence the level of impact those symptoms are
felt to have on a person’s life.
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Discussion |
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There has been a dearth of good epidemiological data on the prevalence of urinary symptoms in a community-dwelling population of stroke survivors. We believe this to be the first article that examines the prevalence of clinically significant lower urinary tract symptoms in community-based stroke survivors.
Current literature on the prevalence of urinary incontinence in stroke survivors has reported it to be between 12% and 79%,15 16 17 18 19 20 21 22 23 24 with the highest prevalence derived from an assessment in hospital at the acute stage.18 These studies derived their samples from people admitted to hospital and subsequently may form a sample of people who experience more severe urinary symptoms (eg, daily urinary incontinence). Prevalence estimates among stroke survivors are extremely variable because of the different definitions of urinary incontinence used and the different points in time when urinary incontinence is measured. However, these estimates suggest that significant numbers of stroke survivors with incontinence are discharged into the community and that little may have been done to address treatment needs while in hospital or that effectiveness of such treatment was short-lived. Daily incontinence may be well managed in terms of pads, regular toileting, and structural management of incontinence on hospital wards by professional staff. However, after discharge, a stroke survivor or carer may find this problem more difficult to manage and, therefore, might feel considerable impact on his or her life.
Brocklehurst et al16 have argued that urinary incontinence
is a transient symptom for most stroke survivors who experience this at
time of admission to hospital. However, the present study shows
that a large percentage of community-dwelling stroke survivors
experience this symptom. Overall, 33% of community-dwelling stroke
survivors reported experiencing urinary incontinence several times a
month or more, and 17% reported daily incontinence. This prevalence is
similar to that reported by Tilvis et al,7 who found that
37.6% of stroke survivors experienced incontinence. Urinary
incontinence was found to be most common in hospitalized patients or
those with severe depression, previous stroke, or dementia. Urinary
incontinence is more prevalent with age,7 8 9 but the high
prevalence of incontinence in the stroke population cannot be
attributed only to age. These data have shown a still-significant
difference in prevalence between stroke survivors and the nonstroke
population. Our prevalence estimate would have been much higher had we
included subjects institutionalized in residential and hospital
settings. A census of adults 65 years of age who live in residential
and nursing home settings reported a prevalence of urinary incontinence
of 21.5%.25 Such reports varied depending on the setting,
and the prevalence was found to be highest in nursing homes
(29.7%).25 Prevalence of urinary incontinence among
stroke survivors in residential care was not reported.
The present study has considered not only urinary incontinence but also other urinary tract symptoms. Urinary incontinence is one of several urinary symptoms that affect quality of life. For example, nocturia and consequent loss of sleep might have more of an impact on quality of life than incontinence. Thus, it is important to include other urinary symptoms (nocturia, frequency, urgency, pain, and straining) when investigating impact on quality of life.
The present study has also compared stroke survivors and a nonstroke population in a community setting and has found that a high percentage of stroke survivors report clinically significant urinary symptoms. Although confounding factors such as advancing age, sex, and disability will inevitably affect this relationship, when controlled for, stroke was still found to be independently associated with a higher prevalence of urinary symptoms.
A high proportion of stroke survivors in the community are experiencing >1 clinically significant urinary symptom. This finding has not been highlighted before, given that previous research has tended to focus on urinary incontinence alone. Further research into when urinary symptoms begin in relation to the stroke would be valuable to assess the cause of symptoms within this population. Such research could provide an insight into the progression of urinary symptoms (for example, under what conditions a person who gained bladder control after stroke might develop this symptom again some months or even years later).
The impact that urinary symptoms have on quality of life is especially important to decisions regarding level of treatment and types of care that stroke survivors living in the community need. Urinary symptoms that are considered severe according to clinical definition (for example, if the patient leaks urine continuously or gets up 4 times per night to pass urine), may not necessarily be considered by the patient to have a huge impact on quality of life.
Although no previous research that specifically examines the impact of urinary symptoms in a stroke population has been reported, the literature provides data on the general impact of urinary incontinence on the lives of women. These data suggest that about one third perceive incontinence to be problematic.26 27 28 Between 1% and 5% of the population report some restrictions to daily activities that can be attributed to urinary incontinence.26 27 28 Our study has shown that age, sex, disability, and severity of symptoms have the greatest impact and that once these symptoms are considered, little difference is seen between stroke and nonstroke populations with symptoms.
It might not be surprising that people who have had a stroke tend to be older and more disabled and, therefore, experience more-severe levels of urinary incontinence and other lower urinary tract symptoms. A clinician might hypothesize that as a result of other health comorbidities, a stroke survivor’s health priorities, or felt impact, might not include urinary symptoms. However, the present study suggests that, in stroke management, urinary incontinence should be seen not only as a diagnostic indicator but as a symptom that can have considerable impact on lifestyle.
The present study has not examined the type or severity of stroke, which invariably influences the presence of urinary incontinence. It has not investigated drug use, which again may influence the presence of urinary symptoms. For example, community-dwelling stroke survivors might be prescribed diuretics, which would influence frequency of nocturia. The present study has not differentiated between stroke survivors who experience urinary symptoms before stroke and those who experience them at or after stroke. However, regardless of severity of stroke and drug use, the present data have shown that community stroke survivors have reported high levels of impact of urinary symptoms on quality of life that need to be addressed.
Conclusions
The present study has found a high prevalence of urinary
symptoms among community-dwelling stroke survivors that cannot be
attributed only to sex, age, or disability. Although stroke survivors
with urinary symptoms were more likely than people who had not had a
stroke to report an impact on quality of life, impact was not related
to the stroke per se but to severity of urinary symptoms experienced.
The stroke group also reported more severe symptoms. Research now needs
to focus on improving patient quality of life by treating or managing
urinary incontinence and other lower urinary tract symptoms, given that
this does not appear to have been a main focus of stroke management to
date.
Studies are also needed that test the hypothesis of Barer29 that achieving continence or dryness in social situations could lead to more-favorable stroke outcomes overall. Research now needs to address how improvement of continence can be achieved, the impact of continence on a stroke survivor’s quality of life, and the temporal relationship between the incidence of urinary symptoms and stroke. The effect that achievement of stroke survivor continence would have on carers of the stroke survivors who are experiencing clinically severe urinary symptoms is also an important area that needs investigation. As the present study has suggested, urinary symptoms are perceived to be a problem to stroke survivors. We now need to find treatments that would be effective within this group. We argue that the first step is to evaluate existing interventions for urinary symptoms and apply them specifically to a stroke population.
Appendix
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Acknowledgments |
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The present work was supported by the MRC Incontinence Study and the NHS R&D Stroke and Incontinence Study. We would also like to thank all members of the MRC Incontience Study team and Bradley Manktelow.
Received October 19, 1999; accepted January 6, 2000.
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