Prevalence of urinary incontinence and knowledge of pelvic floor muscle training among older women in a Nigerian suburban community

Abstract

Background:

Urinary incontinence (UI) is a highly prevalent condition in women with a profound influence on their well-being and quality of life. Pelvic floor muscle training (PFMT) is a widely accepted conservative management of incontinence. Adequate knowledge of PFMT can enhance the ability of individuals to perform them effectively unsupervised.

Objectives:

This study aimed to determine the prevalence of UI and knowledge of PFMT among older women in a selected suburban community in Nigeria.

Design:

A cross-sectional design.

Methods:

This study consecutively recruited 121 older women (65 years and above) with a mean age of 68.59 ± 4.94 years in Nnewi North LGA Anambra state, Nigeria. The International Consultation on Incontinence Questionnaire Short Form and an adopted pre-tested questionnaire were used to assess the prevalence of UI and knowledge of PFMT. Data was analyzed using Statistical Package of Social Sciences (SPSS) version 26 Descriptive statistics, and the chi-square test was utilized with significance determined at an alpha level of 0.05.

Results:

The results revealed that 33.88% of the respondents experience UI, and 3.3% of them have heard about PFMT. There was significant association between prevalence of UI and number of pregnancies (χ² = 11.16, p = 0.03) and children (χ² = 9.77, p = 0.04). There was no significant association between the prevalence of UI and level of education (χ² = 4.20, p = 0.12) and knowledge of PFMT (χ² = 0.48, p = 0.42). There was no significant association between knowledge of PFMT and number of pregnancies (χ² = 04.25, p = 0.37), and number of children (χ² = 4.02, p = 0.40). There was a significant association between knowledge of PFMT and level of education among the participants (χ² = 7.46, p = 0.02).

Conclusion:

The study showed a significant prevalence of UI and poor knowledge of PFMT in older women. Health professionals should sensitize older women in hospitals and care homes on the benefits of PFMT to improve their knowledge of PFMT.

Keywords

prevalence knowledge urinary incontinence pelvic floor muscle training older women Nnewi

Introduction

Urinary incontinence (UI) widely impacts healthcare resources utilization, health-related quality of life, productivity, and economic consequences.^1,2 Although UI traditionally affects women, evidence shows it affects both sexes.³ In women, the occurrence of UI is linked to age, as its prevalence tends to increase with age, and physiological changes associated with ageing in women contribute to its higher impact.⁴ Other identified etiologies include obesity, smoking, physical inactivity, extended periods of inactivity, poor perceived health, and chronic illnesses such as diabetes, hypertension, and chronic obstructive pulmonary disease.³

Researchers have shown a growing interest in investigating UI prevalence among women. Stickley et al. found a prevalence of 37% in European women,^5,6 whereas studies conducted in the United States, such as that by Suskind et al. reported a prevalence of 14% among older females.⁷ Similarly, in Asia, studies by Bijani et al. in Babol, Iran, and Morowatisharifabad et al. in Yazd, Iran, revealed prevalence rates of one-third and 62.2%, respectively, among older adult women.^8,9 In Africa, Gallas et al. estimated the prevalence of UI in women to be 45.3%.¹⁰ Despite UI being often overlooked in Nigeria, studies such as that by Badejoko et al. have shown significant prevalence rates among Nigerian women.¹¹ For instance, in a study of women attending general outpatient clinics in southwest Nigeria, 73.8% of women with UI did not consider it a reason to seek medical intervention, possibly due to perceptions of UI as a normal part of ageing or the social stigma associated with the condition. Given that lower incidence was seen more frequently in industrialized nations, differences in the prevalence across these countries may be related to cultural views of the populace toward UI as well as regional variations in healthcare access and awareness.

The International Continence Society advocates pelvic floor muscle training (PFMT) as the primary approach for managing UI in women.¹² Kegel initially introduced PFMT in 1948 as a cornerstone technique for enhancing pelvic floor muscle strength and recruitment.¹³ Physiotherapy interventions aim to enhance muscle contraction strength, re-educate abdominal muscles through exercises, devices, and techniques, thus bolstering the muscles necessary for maintaining urinary continence.¹⁴ Consequently, PFMT is recommended for enhancing strength, endurance, and muscle coordination.¹⁵ Over time, research has shown its effectiveness in both supervised and unsupervised programs. Individuals can participate in these exercises with or without the guidance of a physiotherapist, depending on their access to healthcare professionals. However, limited knowledge of these exercises may hinder individuals from adopting them for prevention or management purposes. Therefore, the purpose of the study is to ascertain the prevalence of UI among older women in Nnewi North Local Government Area, Anambra State, and their knowledge of PFMT.

Methods

Study design and settings

This study used a cross-sectional design and enrolled community-dwelling older women aged 65 years and above in Nnewi between October and December 2023. Nnewi is a bustling commercial and industrial city located in the North Local Government Area of Anambra State, southeastern Nigeria. This manuscript was followed the STROBE guidelines.

Participants, sampling and sample size

The study participants comprised older women who live independently within the community, without requiring assistance for daily activities, and who do not have any mobility conditions but excluded institutionalized individuals, those needing mobility assistance, those with severe cognitive impairment, debilitating illnesses or conditions potentially influencing urinary continence. Additionally, participants who had undergone pelvic floor surgery or interventions were excluded. A convenience sampling technique was employed consecutively until the predetermined minimum sample size of 121 as determined using G power software version 3.1.92 was reached. The test family was configured as Exact, employing a statistical test for proportions: the sign test (binomial test). The power analysis type was specified as sensitivity, with input parameters including a probability error of 0.05, an effect size of 0.3, and a desired power of 0.95 with an alpha level of significance set at 0.05.

Procedure for questionnaire development and data collection

Ethical approval was obtained from the Ethical Review Committee of the Faculty of Health Science and Technology, College of Health Sciences and Technology, Nnamdi Azikiwe University, Anambra State, Nigeria (FHST/REC/023/00150), before the commencement of the study. We enlisted participants who fulfilled the inclusion criteria from various locations including markets, churches, and meeting places. They were briefed on the study’s objectives, and their written informed consent was obtained. Initially, we distributed the adapted questionnaire and instructed participants to select the most suitable response. Subsequently, the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) was administered, prompting participants to choose the option that best described their current situation. Following data collection, any queries were addressed, and participants were educated on the significance and advantages of PFMT, along with proper exercise techniques.

To ensure the content validity of the self-structured questionnaire, we had a panel of experts in Physiotherapy and women’s health review the adopted questionnaire. These experts assessed the questionnaire for its clarity, comprehensiveness, and alignment with the research objectives. We incorporated their feedback and recommendations into the questionnaire design.

Following the expert review, a pilot testing phase was conducted to validate the questionnaire and identify any necessary corrections or modifications. The pilot study included a small sample of 30 individuals similar to the target population. The participants in the pilot test were asked to complete the questionnaire, and their feedback was collected regarding the clarity of questions, potential ambiguities, and overall comprehensibility. We further excluded these participants from the study. Based on the feedback and insights obtained during the pilot testing phase, the questionnaire was refined and finalized. Any ambiguities or issues identified during the pilot testing were addressed to ensure that the questionnaire was clear, reliable, and suitable for the intended research.

Research instrument

The study utilized the following questionnaires:

The ICIQ-SF The ICIQ-SF was developed in 1998 under the sponsorship of the World Health Organization to evaluate UI in women (Supplemental Appendix 2).¹⁶ It serves multiple purposes including screening, summarizing causes of UI, and facilitating patient-clinician discussions. The questionnaire assesses frequency and bother of leakage, protection use, amount of leakage, interference with daily life, social and sexual activities, and overall quality of life. Development involved principal factor analysis and analysis of validity, reliability, and responsiveness. Relationships with other UI instruments were evaluated through correlation analysis, showing weak to moderate agreement with different measures. Reliability was good, with “moderate” to “very good” stability in test-retest analysis and a Cronbach’s alpha of 0.95.¹⁶ The scoring criteria involve summing scores from the first three items to generate a total score ranging from 0 to 21, indicating greater symptom burden with higher scores. The last item serves as a self-assessment of perceived causes of incontinence.

A self-structured questionnaire, adapted from Sato-Klemm et al., was employed to evaluate knowledge and practice regarding PFMT in spinal cord injury patients (Supplemental Appendix 1).¹⁷ This questionnaire comprises three sections:

• Section A inquired about sociodemographic details such as age, sex, marital status, number of pregnancies and children, and highest level of education.

• Section B consisted of seven yes/no/unsure multiple-choice questions aimed at exploring knowledge regarding PFMT. Additionally, there were fill-in-the-blank style questions to assess respondents’ knowledge regarding how they perceive access to PFMT and its purpose.

• Section C included yes/no/unsure multiple-choice questions regarding whether participants had been informed about PFMT by a healthcare practitioner and if they had ever engaged in PFMT. Participants indicating the practice of PFMT were further questioned about their program parameters and perceived benefits.

Statistical analysis

The data underwent analysis utilizing Statistical Package for the Social Sciences (SPSS) version 26.0. Descriptive statistics including percentages, frequency tables, charts, and measures of central tendency and variability (mean and standard deviation) were employed to summarize the data and present the findings as suitable. Additionally, the chi-square test was utilized to assess the association between UI prevalence, knowledge of PFMT, and sociodemographic factors, with significance determined at an alpha level of 0.05.

Results

Sociodemographic profiles of the participants

A total of 121 married females with a mean age of 68.59 ± 4.94 years participated in this study. More than half (53.7%) of the participants had above four pregnancies and children respectively. More than half (60.3%) of the participants had at least a secondary level of education (Table 1).

Table 1.

Sociodemographic profiles of the participants.

Variable	Categories	Frequency	Percentage
Number of children	1	10	8.3
	2	10	8.3
	3	14	11.6
	4	22	18.2
	5 and above	65	53.7
Number of pregnancy	1	10	8.3
	2	10	8.3
	3	14	11.6
	4	22	18.2
	5 and above	65	53.7
Education	Primary	48	39.7
	Secondary	61	50.4
	Tertiary	12	9.9

Prevalence of UI and knowledge of PFMT among the participants

The prevalence of UI among the participants was found to be 33.88%, as illustrated in Figure 1. Only four participants (3.3%) were aware of pelvic floor muscle, PFMT, and Kegel’s exercise (Table 2).

Figure 1.

A pie chart showing the prevalence of urinary incontinence among the participants.

Table 2.

Knowledge of the participants on pelvic floor muscle, pelvic floor muscle training, and Kegel’s exercise.

Variable	Knowledge (f (%))
Variable	Yes	No
Pelvic floor muscle	4 (3.3)	117 (96.7)
Pelvic floor muscle training	4 (3.3)	117 (96.7)
Kegel’s exercise	4 (3.3)	117 (96.7)

Association between prevalence of UI and number of pregnancies and children, level of education, and knowledge of PFMT among the participants

There was a significant association between prevalence of UI and number of pregnancies (χ² = 11.16, p = 0.03) and children (χ² = 9.77, p = 0.04). There was no significant association between the prevalence of UI and level of education (χ² = 4.20, p = 0.12) and knowledge of PFMT (χ² = 0.48, p = 0.42) among the participants (Table 3).

Table 3.

Chi-square test showing the association between prevalence of urinary incontinence and number of pregnancies, number of children, level of education, and knowledge of pelvic floor muscle training.

Variable	Category	Urinary incontinence status (f (%))		χ²	p
Variable	Category	Continent	Incontinent	χ²	p
Number of pregnancies	1	5 (62.5)	3 (37.5)	11.16	0.03*
	2	9 (75.0)	3 (25.0)
	3	7 (53.8)	6 (46.2)
	4	20 (95.2)	1 (4.8)
	5 and above	39 (58.2)	28 (41.8)
Number of children	1	6 (60.0)	4 (40.0)	9.77	0.04*
	2	8 (80.0)	2 (20.0)
	3	7 (50.0)	7 (50.0)
	4	20 (90.9)	2 (9.1)
	5 and above	39 (60.0)	26 (40.0)
Level of education	Primary	29 (60.4)	19 (39.6)	4.20	0.12
	Secondary	40 (65.6)	21 (34.4)
	Tertiary	11 (91.7)	1 (8.3)
Knowledge of pelvic floor muscle training	Yes	2 (50.0)	2 (50.0)	0.48	0.42
Knowledge of pelvic floor muscle training	No	78 (66.7)	39 (33.3)

significant at p < 0.05.

Association between knowledge of PFMT and number of pregnancies and children and level of education among the participants

Knowledge of PFMT had no significant association with number of pregnancies (χ² = 4.25, p = 0.37) and number of children (χ² = 4.02, p = 0.40). There was a significant association between knowledge of PFMT and level of education among the participants (χ² = 7.46, p = 0.02) (Table 4).

Table 4.

Chi-square test showing the association between knowledge of pelvic floor training and number of pregnancies and children, and level of education among the participants.

Variable	Category	Knowledge of pelvic floor training (f (%))		χ²	p
Variable	Category	Continent	Incontinent	χ²	p
Number of pregnancy	1	1 (12.5)	7 (87.5)	4.25	0.37
	2	1 (8.3)	11 (91.7)
	3	0 (0.0)	13 (100.0)
	4	0 (0.0)	21 (100.0)
	5 and above	2 (3.0)	65 (97.0)
Number of children	1	1 (10.0)	9 (90.0)	4.02	0.40
	2	1 (10.0)	9 (90.0)
	3	0 (0.0)	14 (100.0)
	4	1 (4.5)	21 (95.5)
	5 and above	1 (1.5)	64 (98.5)
Level of education	Primary	1 (2.1)	47 (97.9)	7.46	0.02*
	Secondary	1 (1.6)	60 (98.4)
	Tertiary	2 (16.7)	10 (83.3)

Significant at p < 0.05.

Discussion

This study aimed to assess the prevalence of UI among older women in a Nigerian suburban community, and their awareness of PFMT (Kegel’s). The findings revealed a UI prevalence of 33.88%, which appears lower compared to rates reported in similar studies.^17–26,32 However, this discrepancy could potentially be attributed to biases introduced during data collection, where respondents may have provided socially acceptable responses or underreported their symptoms to avoid embarrassment.

However, in the study of the prevalence of incontinence in older women, the lowest prevalence of UI was reported in Asia at 10% indicating that their result may be influenced by the fact that Asian participants are more ethnically conservative regarding delicate personal health concerns.²⁶ The results may also have varied due to racial, environmental, socioeconomic conditions, and cultural differences among countries. The relatively high prevalence obtained in this study shows the need to investigate and follow up on the results. The significant impact of this condition on the sociopsychological aspect of older female adults,²⁷ highlights the need for special attention and screening for UI in treatment and care programs in the country. We recommend further longitudinal studies to better understand the true prevalence of UI through extended monitoring periods. In addition, further studies should consider employing more definite diagnostic criteria or procedures for UI.

Pregnancy and childbirth can strain pelvic floor muscles and weaken sphincter muscles, potentially leading to UI.²⁸ In additio, works of literature suggest that the number of pregnancies plays a crucial role in the progression of UI, with the prevalence becoming more pronounced with each additional delivery. For instance, Akkus and Pinar found that UI prevalence was 25.3% for participants with no history of pregnancy, 37.1% for those with one pregnancy, and 79% for those with more than one pregnancy.²⁹ This study found a significant association between the prevalence of UI and the number of pregnancies and children. This finding aligns with research conducted by Akkus and Pinar which reported a correlation between UI prevalence and the number of pregnancies (p < 0.05).³⁰ Similarly, Mahmoud et al. observed a significant association between UI prevalence and participants with 4–10 deliveries compared to those with 0–3 deliveries.³⁰ However,³¹ reported no statistically significant association between UI and the number of pregnancies. This discrepancy may be attributed to variances in the availability of antenatal and healthcare services across different countries, potentially lowering the risk of UI post-pregnancy.

One unaddressed factor in this study that may have influenced this finding is the inclusion of other variables that could impact the relationship between pregnancy and UI, such as potential variations in the duration, and mode of delivery, as well as individual differences in pelvic floor muscle tone, genetics, and pre-existing conditions such as obesity or pelvic organ prolapse. Additionally, access to antenatal care, postnatal rehabilitation programs, and healthcare services can vary between populations, potentially affecting the management of pelvic floor health and mitigating the risk of UI. Cultural attitudes toward pregnancy-related healthcare and UI may also play a role, in influencing reporting tendencies and healthcare-seeking behaviors. Lastly, lifestyle factors such as physical activity levels, diet, and socioeconomic status could impact pelvic floor health and urinary continence outcomes following pregnancy. Future studies should consider these multifaceted influences crucial for comprehensively understanding the relationship between pregnancy and UI prevalence.

Pelvic muscle exercises, targeting the enhancement of pelvic floor muscle strength, power, endurance, relaxation, or a combination of these factors, have demonstrated efficacy across all types of UI.^13,32,33 These exercises comprise routines that can be easily performed at home without requiring expert supervision, often recommended as a convenient home-based program. Many researchers support the significant role of education in health, as individuals with higher levels of education typically exhibit better health outcomes. This includes improved health-seeking behaviors and a greater inclination toward lifestyle modifications.

In the present study, a significant association was found between knowledge of PFMT and the participant’s level of education (χ² = 7.46, p = 0.02). Kilic et al. supported this finding in their study, showing that a higher level of education correlates with greater awareness of pelvic floor function, pelvic floor dysfunction, and PFMT.³² Mbada et al.’s research indicated that the majority of their participants (68.2%) who had a tertiary level of education exhibited good knowledge of PFMT.³⁴ However, the majority of participants in our study (96.7%) reported no previous information about PFMT. The disparity in findings could be attributed to the fact that our study was conducted among women in a suburban Nigerian community, the majority of whom had attained only a secondary level of education (50.4%), and unlike the compared studies conducted in a clinic setting. Additionally, only a small proportion of participants (3.3%) were aware of PFMT and Kegel exercises. In contrast, Moustafa et al. reported in their study on total knowledge about PFMT in women aged 18–65 that 13.8% of women had a good level of knowledge, whereas 64.1% of them had a poor level of knowledge.³⁵ This difference may be because their study population included younger female adults who may have greater exposure to information due to increased use of internet facilities and information technology.

This finding implies that there is a significant gap in awareness and education regarding pelvic floor health and the management of UI among the study population. This lack of awareness may contribute to underreporting of symptoms, delayed diagnosis, and inadequate management of UI. Moreover, without knowledge of pelvic floor muscle exercises, affected individuals may miss out on a cost-effective and non-invasive intervention for improving bladder control and reducing UI symptoms.

The strength of this study lies in its investigation of awareness of PFMT among the participants, the study offers insights into the gaps in knowledge and education regarding UI management among this population. On the other hand, one limitation in this study is the potential for biases introduced during data collection, such as respondents providing socially acceptable responses or underreporting symptoms. Additionally, the study’s focus on a specific demographic within a single geographical area may limit the generalizability of its findings to other populations. It is also worth noting that the study solely focused on older women, whereas UI also affects men. Recommendations for future research include conducting longitudinal studies with extended monitoring periods to better understand the true prevalence of UI, employing more definite diagnostic criteria or procedures, and considering multifaceted influences such as variations in pregnancy-related healthcare access and cultural attitudes toward pelvic floor health. Additionally, future studies should consider including male participants to provide a comprehensive understanding of UI prevalence and awareness across genders.

Because UI has a major impact on women’s health and quality of life, it is important to understand and treat UI. Many related health hazards, including skin irritation, infections, and pressure sores from extended moisture exposure, can result from UI.^36-38 These frequently require the use of absorbent materials, which can be expensive and add to a person’s continuous financial concerns.³⁹ Furthermore, having to use these products can be embarrassing and socially stigmatizing, which discourages people from engaging in social and physical activities.³⁹ This seclusion can worsen mental health issues, such as anxiety and sadness. We can empower women to manage and perhaps lower the occurrence of UI by increasing education and understanding of PFMT, which will improve their general health, cleanliness, economic well-being, and quality of life.

One practical recommendation to enhance awareness of PFMT is to implement community-based educational workshops or seminars specifically focused on UI management and PFMT techniques. These sessions, led by healthcare professionals or trained educators, can provide accurate information about the importance of pelvic floor health, demonstrate PFMT exercises, and address any misconceptions or concerns participants may have. These workshops could be integrated into various healthcare settings such as antenatal visits, postnatal care services, and immunization clinics, where women can learn about PFMT alongside routine healthcare appointments. Additionally, organizing women’s health workshops or including dedicated booths at health fairs or community events can further disseminate information about PFMT to a broader audience. In addition, flyers and pamphlets can be distributed during such events to provide participants with tangible resources for ongoing reference and reinforcement of PFMT knowledge.

If properly trained, individuals can perform PFMT independently without the guidance of a physiotherapist. It is consequently essential that frontline healthcare workers receive training in order to instruct the public in these exercises. To ascertain the gaps and opportunities for development to improve this, a research evaluating the expertise and use of PFMT recommendations among healthcare professionals is necessary. Moreover, raising awareness through campaigns will encourage medical practitioners to suggest this training.

Conclusion

In conclusion, the prevalence of UI among older female adults in Nnewi North Local Government Area, Anambra State, is relatively high. Additionally, their knowledge of PFMT is poor. There exists an association between the prevalence of UI and the number of pregnancies and children among participants. However, no significant associations were found between the prevalence of UI and the level of education or knowledge of PFMT. Similarly, no significant associations were observed between the prevalence of UI, educational attainment, and awareness of pelvic floor training among the participants. Lastly, there was no significant association found between awareness of pelvic floor training and the number of pregnancies, number of children, and educational attainment among the participants. The implementation of community-based educational workshops or seminars specifically focused on UI management and PFMT techniques is recommended.

Supplemental Material

sj-pdf-1-whe-10.1177_17455057241276255 – Supplemental material for Prevalence of urinary incontinence and knowledge of pelvic floor muscle training among older women in a Nigerian suburban community

Supplemental material, sj-pdf-1-whe-10.1177_17455057241276255 for Prevalence of urinary incontinence and knowledge of pelvic floor muscle training among older women in a Nigerian suburban community by Uzoamaka Nwakaego Akobundu, Mmunachiso Stephanie Onuzulu, Sochima Johnmark Obiekwe, Christopher Olusanjo Akosile, Jovita Ada Daniel, Mmaduabuchukwu Joseph Nwankwo and Ogochukwu Mary-Theodora Ochiabuto in Women’s Health

Footnotes

Acknowledgements

The authors are grateful to all the participants of the study.

Declarations

ORCID iD

Sochima Johnmark Obiekwe

Supplemental material

Supplemental material for this article is available online.

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