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Prevalence of Lower Urinary Tract Symptoms in Pregnant Adolescents and the Influencing Factors
Journal Pre-proof Prevalence of Lower Urinary Tract Symptoms in Pregnant Adolescents and the Influencing Factors Arzu Aydin, Semra Kocaöz, Pınar Kara PII:
S1083-3188(19)30324-9
DOI:
https://doi.org/10.1016/j.jpag.2019.10.007
Reference:
PEDADO 2413
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 21 February 2019 Revised Date:
11 October 2019
Accepted Date: 16 October 2019
Please cite this article as: Aydin A, Kocaöz S, Kara P, Prevalence of Lower Urinary Tract Symptoms in Pregnant Adolescents and the Influencing Factors, Journal of Pediatric and Adolescent Gynecology (2019), doi: https://doi.org/10.1016/j.jpag.2019.10.007. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc. on behalf of North American Society for Pediatric and Adolescent Gynecology.
Prevalence of Lower Urinary Tract Symptoms in Pregnant Adolescents and the Influencing Factors
Article Type: Original Studies
Running Head: LUTS in Pregnant Adolescents
Arzu AYDIN1, Semra KOCAÖZ2, Pınar KARA3
1
MD, Bünyan State Hospital, Kayseri, Turkey
2
RN, PhD, Niğde Ömer Halisdemir University, Niğde Zübeyde Hanım School of Health,
Nursing Department, Department of Obstetrics and Gynecology Nursing, Niğde, Turkey 3
RN, MSc, Niğde Ömer Halisdemir University, Niğde Zübeyde Hanım School of Health,
Nursing Department, Department of Obstetrics and Gynecology Nursing, Niğde, Turkey
*Corresponding Author Prof. Dr. Semra KOCAÖZ Niğde Ömer Halisdemir Üniversitesi Niğde Zübeyde Hanım Sağlık Yüksekokulu, Hemşirelik Bölümü, Doğum ve Kadın Hastalıkları Hemşireliği ABD.,
Derbent Yerleşkesi, 51200,
Merkez/Niğde/TÜRKİYE Phone: +90 388 211 2838, Fax: +90 388 211 2813, E-mail: [email protected]
“This study was presented as as oral presentation at Third International Congress of Koru Pregnancy, Childbirth and Puerperium, 14-17 February 2019, Bolu, Turkey.”
Funding: No funding support was received for this study. The authors alone are responsible for the content and writing of this article.
Authorship Statement Authors have participated sufficiently in the work to take public responsibility for the content. AA, SK, and PK contributed to conception and design of study. AA and PK collected data from pregnant adolescents. SK and PK analyzed and interpreted the data. AA, SK, and PK drafted the article and revised it critically for important intellectual content. All authors have approved the final version to be published.
Word Account Abstract:250 Word Account Manuscript:3791 [Abstract:250, Main Text: 3541 (excluding references)] Table:4
Abstract Study Objective: To determine the prevalence of lower urinary tract symptoms (LUTS) and associated risk factors in pregnant adolescents. Design: A descriptive study. Setting: The obstetrics and gynecology outpatient departments of a training and research hospital in Turkey. Participants: 206 pregnant adolescents under the age of 19. Interventions: None. Questionnaire-based data and the Bristol Female Lower Urinary Tract Symptoms-Short Form (BFLUTS-SF) were collected from pregnant adolescents. Main Outcome Measures: Comparisons were made with independent samples t test, oneway ANOVA, Mann-Whitney U and Kruskal-Wallis tests, and Linear regression for the analysis of the potential risk factors. Results: The prevalence of at least one LUTS in pregnant adolescents was 78.6%. The prevalence of storage symptoms was more than those of urinary incontinence (UI) and voiding symptoms. Among LUTS, the prevalence of nocturia, urgency, frequency, bladder pain, and UI was 59.3%, 54.4%, 39.3%, 37.1%, 27.2%, respectively. 23.8% of pregnant adolescents with LUTS reported seeking treatment for LUTS in this study. The total median scores from the BFLUTS-SF increased with gestational week, but it no statistical significant difference was identified (p>0.05). According to the results of the linear regression analysis, daily coffee consumption, smoking, chronic coughing, constipation, and urinary tract infection history, were found to be associated with the total mean score on the BFLUTS-SF in pregnant adolescents. Conclusion: LUTS were found to be common among pregnant adolescents, with storage symptoms being the most frequently reported. Prenatal education could increase the number of adolescents who seek treatment, thereby improving the clinical course of LUTS.
Key Words: Adolescents, Pregnancy, Lower urinary tract symptoms, Prevalence, Risk factors
Introduction The anatomical, physiological and hormonal changes experienced during pregnancy affect the lower urinary tract of women1,2 and commonly cause lower urinary tract symptoms (LUTS).3-5 The prevalence of LUTS in pregnant women varies according to the symptom focused on, the definitions used, the population studied and the methodology applied.3,4,6-9 To the best of our knowledge, no studies that presenting the prevalence rate of at least one LUTS in adolescent pregnant women exist. The lower urinary tract dysfunction is reported to worsen by gestational week.5 Lin et al. have reported increasing rates for the symptoms of frequency, nocturia, stress urinary incontinence (SUI) and inability to completely empty the bladder as gestational age progresses in both primigravid and multigravid pregnant women.4 LUTS can occur for many reasons including pregnancy10 and together with the associated storage symptoms, they are reported to adversely impact women’s quality of life.11 Coyne, et al. have reported lower quality of life and higher anxiety and depression levels in women with LUTS.12 Even so, few women seem to seek help.7,13 The most common reasons for this are feelings of unease about talking to a physician about urinary symptoms, shame or hesitancy, and lacking the knowledge that the symptoms can be treated.14 Most women with LUTS who do not seek treatment develop incorrect strategies for self-care such as fluid restriction to avoid symptoms or decrease their frequency.15,16 There are in fact, preventive and therapeutic approaches that prevent LUTS development or decrease its severity in women.11 The presence of urinary incontinence (UI), which is one of the voiding symptoms of LUTS, during pregnancy is reported to increase the likelihood that the problem will continue
after the pregnancy, as well.17,18 Identifying and tracking consistent and noticeable LUTS related conditions in women from early pregnancy onwards is therefore important.1 Although a few studies have focus on LUTS symptoms in pregnant women at the national and international level.3,4,6-9 We did not come across any studies on the prevalence and risk factors of LUTS in adolescent pregnant women. LUTS could result in psychological problems compounding the trauma created by the pregnancy itself during the adolescent period, when physical, psychological and social changes are already being experienced. Adolescents’ lack of awareness regarding LUTS during pregnancy could cause them to be deprived of the required treatment. They could experience physical, social, psychological and sexual problems if their LUTS continue after pregnancy without receiving treatment. It is necessary to be aware of both the prevalence of LUTS in the adolescent pregnancy period and the relevant risk factors so that such problems can be prevented and effective treatment directed at the cause can be offered. This study was therefore conducted to identify the LUTS prevalence in adolescent pregnant women and their underlying factors. Materials and Methods The population of this descriptive study consisted of adolescent pregnant women who presented to the Obstetrics and Gynecology Outpatient Department of a public training and research hospital between 21 January and 19 July 2018 to undergo routine follow-up during pregnancy. No sample selection was conducted, and all pregnant adolescents who met the inclusion criteria were included in the study. Study inclusion criteria consisted of (1) being 18 or younger; (2) being married (official or religious ceremony); (3) presenting to the Obstetrics and Gynecology Outpatient Department to receive prenatal routine pregnancy care services; (4) having the ability to answer the questions, and (5) agreeing to participate in the study. The study province ranks 8th among Turkish provinces with the highest number of adolescent pregnancies according to the 2012 data of the Turkish Statistics Institute (51.5/1000).19 A
total of 206 adolescent pregnant women visited the Obstetrics and Gynecology Outpatient Department to receive health care services during the study period. None of them refused participation. This study was completed with 206 pregnant adolescents compatible with these criteria. The study data were collected using the “Data Collection Form” created by the researchers based on the relevant literature3,7,15,20,21 and the “Bristol Female Lower Urinary Tract Symptoms-Short Form (BFLUTS-SF)”. The data collection form consisted of four sections and contained a total of 38 questions regarding socio-demographics (such as age, educational level, perceived income, social security coverage, personal habits, body mass index (BMI), etc.) (9 questions); pregnancy and labor (last menstrual date, gravida, parity, the number of curettage and abortions, delivery type, difficult delivery, episiotomy, UI presence during pregnancy and after birth, spinal anesthesia, delivery of a baby weighing more than 4000 g, etc.) (14 questions); personal habits and chronic diseases (smoking; alcohol, water, soft drinks, coffee and tea consumption; the presence and frequency of constipation; and complaints of chronic coughing, diabetes mellitus, etc.) (7 questions); and urogynecologic history (urinary system disease, urinary tract infection history, previous urinary tract surgery, and history of UI in mother and/or sisters, Kegel exercises, treatment seeking behavior, etc.) (8 questions). The BFLUTS-SF was developed in 1996 by Jackson, Donovan and Brookes in order to investigate UI symptoms, other LUTS and their effects on sexual function and quality of life.22 The adaptation we used in our study was prepared by Güngör and Yalçın in 2005. The BFLUTS-SF consists of a total of 19 questions in the five sub-dimensions of storage, voiding, urinary incontinence, sexual function and quality of life. There is no questionnaire cut-off value for predicting whether LUTS is clinically present. The score range is 0 to 72, with higher scores indicating increased severity and perceived significance.23 The Cronbach alpha
value was 0.78 in the original questionnaire22 and 0.70 in the study by Güngör and Yalçın.23 The Cronbach alpha value of the questionnaire in this study was found to be 0.80. The study was conducted after obtaining ethics committee approval from the Niğde Ömer Halisdemir University Ethics Committee (decision no: 2017/12-04, date:30 November 2017) and written permission from the Directorate of Health and the hospital where the study was conducted. Before the data collection tools were used, the participants were informed on the subject by the researchers and verbal and written informed consent was obtained. The data collection tools were then administered to adolescent pregnant women between 09:00 and 16:00 during the week, between 21 January and 19 July 2018, at the Obstetrics and Gynecology Outpatient Department of the training and research hospital where the study was conducted. The data were collected by the researchers with the face-toface interview method. The study data were evaluated using the SPSS (24.0, IBM Corp., Armonk, NY) program. Numbers, percentages, arithmetic means, medians, standard deviations and minimummaximum values were used for descriptive statistics in the study. The Cronbach alpha value was used to assess the validity and reliability of the questionnaire. Parametric tests were used to compare the BFLUTS-SF scores and risk factors of the adolescent pregnant women as the sample size in the cells approached 30, according to central distribution theory. The Independent Samples t test and One-way ANOVA test were used when the assumptions were met and the Mann-Whitney U and Kruskal-Wallis tests when they were not. Linear regression analysis was conducted to evaluate the relationship between the scores of the adolescent pregnant women from BFLUTS-SF and the smoking, coffee consumption, constipation, chronic cough and urinary tract infection history variables. The statistical significance level was taken as p<0.05. Results
The mean age of the adolescent pregnant women was 17.66±0.61 and 67.5% were secondary school graduates. Two or more pregnancies were reported by 18.9% of the adolescents and 54.4% of the pregnant women were at the 28th gestational week or beyond. Among the adolescent pregnant women, 8.7% had experienced a miscarriage and 2.4% had had an abortion, while 9.2% had given birth once. Of those who had given birth, 68.4% had delivered vaginally. For 23.1% of the adolescent pregnant women who had delivered vaginally, labor had lasted over 24 hours and an episiotomy had been administered in 84.6%. Among the women who had given birth previously (n=9), UI had developed during the previous pregnancy of 5 and in the postnatal period of 2 women (Table 1). Among the adolescent pregnant women, 9.7% expressed that they consumed 500 ml or less fluid daily, 29.6% that they consumed coffee daily and 1.9% that they still smoked. Constipation was reported by 23.8% of the women, a chronic cough by 2.9%, urinary tract disease by 18.0% and a history of urinary tract infection (UTI) by 46.6% while 0.5% had diabetes. UI symptoms were present in the mother and/or sister of 20.4% of the adolescent pregnant women. Table 2 presents the distribution of LUTS symptoms in the participants. At least one LUTS involving urinary storage, voiding and UI symptoms was found to be present in 78.6% of the adolescent pregnant women. When urinary storage symptoms (77.7%) were investigated, 59.4% were found to have nocturia, 54.4% urgency, 37.1% pain in the bladder and 39.3% frequency symptoms. The prevalence of urinary voiding symptoms (25.7%) was 18.4% for hesitancy, 17.5% for intermittent urination and 11.2% for straining to urinate. Among the UI symptoms (35.9%), the prevalence of urge urinary incontinence (UUI), UI, SUI, unpredictable incontinence and nocturnal incontinence was 25.2%, 27.2%, 21.8%, 10.7%, and 2.9%, respectively. The LUTS was related to sexual function in 11.2% of the
adolescents and quality of life in 36.9%. The rate of going to a physician for the LUTS was 23.8%, and 22.8% had received treatment for this condition. Table 3 shows the distribution of the BFLUTS-SF score mean and medians obtained according to certain variables. The BFLUTS-SF score medians were found to be significantly higher in subjects who had a daily coffee consumption habit, chronic cough, constipation, urinary tract disease, history of UTI, and UI in the mother and/or sister (p<0.05). The BFLUTS-SF score medians were significantly lower in those who did not smoke compared to those still smoking or who had quit (p<0.05). Table 4 presents the Linear Regression analysis for the variables influencing the BFLUTS-SF scores of the adolescent pregnant women interviewed. This analysis revealed that the mean total score from the BFLUTS-SF was approximately 5 points higher in adolescent pregnant women consuming coffee compared to those who did not, in the presence of other variables (p<0.001). The BFLUTS-SF mean total score was approximately 20 points higher in those who had smoked and then quit compared to those who had never smoked (p<0.001) and 9.74 points higher for those who smoked (p=0.001). The mean BFLUTS-SF total score was also 8 points higher in pregnant adolescent women who suffered from a chronic cough compared to those who did not (p=0.001), 4.69 points in those with constipation compared to those without this condition (p<0.001) and 3.04 points higher in those with a UTI compared to those who did not have such an infection (p=0.001). Discussion LUTS is common in women and has a negative effect on the daily quality of life,12 and can develop due to the changes occurring in pregnancy.1,5,11 The vascular supply of the bladder increases due to the physiological, mechanical and hormonal effects of pregnancy; the bladder moves forward and upwards and becomes hypotonic, edematous and concave in shape; hypertrophy is seen in the detrusor muscle; changes occur in the neuromuscular and
connective tissues that surround the bladder neck and urethra and control their function; the growing uterus exerts pressure on the bladder and stretches the pelvic floor, and an increase in glomerular filtration rate and renal plasma flow are seen in accordance with the needs of the fetus.2 All these changes in pregnancy affect the lower urinary system and can result in the development of LUTS.1 The prevalence of LUTS in pregnant women varies according to the population in which the study is conducted, the measurement tools used for data collection, and the subsymptoms investigated.3,4,6-9 In a study conducted in Nigeria, LUTS has been reported to be seen during pregnancy in 89.2% of the women studied.9 A study from our country has reported that 81.6% of pregnant women experienced at least one LUTS. Our LUTS prevalence in adolescent pregnant women (78.6%) was lower than reported by these studies.7,9 The prevalence of LUTS is reported to increase with age in the literature.24 This could explain the lower prevalence of LUTS in our study.7,9 LUTS is grouped under the three main headings of urinary storage, voiding and postmicturition. Storage symptoms include increased daytime frequency, nocturia, urgency, bladder sensation, and various types of UI.24 UI was analyzed under a separate heading in the questionnaire we used in our study. In the literature, symptoms of storage have been reported to be more common than symptoms of voiding during pregnancy.3 In this study as well, symptoms of storage were more common than symptoms of voiding in the adolescent pregnant women. Frequency, urgency and nocturia are reported to be the most common types of LUTS in women during pregnancy.1 The prevalence of nocturia, urgency, frequency and pain in the bladder is reported to be 51.1-94.1%3,4,6-9, 10.4-34.1%3,6-9, 17.6-77.6%3,4,6-9, and 17.8-39.2%4,6,7, respectively, in studies on pregnant women conducted with various measurement tools. There was a higher prevalence of urgency in our study compared to that
in other studies,3,6-9 which could be due to the UTI history of almost half (46.6%) of our participants. UI is among the most commonly studied subjects along with the other symptoms of LUTS in adolescent pregnant women.25-28 A study among African-American teenage adolescents reported UUI in 55.0% and SUI in 69.0% during pregnancy,25 while one in Italy on pregnant women under 18 reported any type of UI at a rate of 18.2%.26 A Turkish study found UI to be present in 32.0% of the individuals aged 19 and younger.27 Our findings regarding UI prevalence in adolescent pregnant women are similar to those reported in that study.27 The voiding symptoms of LUTS include hesitancy, intermittent stream and straining.24 Adaji, et al. reported symptoms of hesitancy in 9.6%, straining in 3.9% and an intermittent stream in 13.2% of the pregnant women.6 Difficulty urinating was reported at rates of 14.0%, 15.3%, and 8.1%, respectively, in the studies by Balık, et al.7, Liang, et al.3 and Anzaku, et al.9 The high prevalence of voiding symptoms in our study could be due to the difference in study populations and the data collection tools used. It is reported that LUTS in women may affect medical, economic, social, physical, psychological and social weel-being negatively.29 LUTS also includes symptoms related to sexual intercourse.11,24 In our study, UI during intercourse was reported by 6.3% of the adolescent pregnant women and 9.2% stated that LUTS had an extremely detrimental effect on their life. We also investigated symptoms related to the quality of life in adolescent pregnant women in this study. Among the adolescent pregnant women, 20.4% stated that they had to change their underwear during the day, 9.7% restricted fluid consumption, 17.0% avoided going to places without a toilet, and urinary incontinence affected the daily tasks of 10.2% and the general life of 24.8%. We were unable to compare our findings with others as
we did not come across any other study on the LUTS components experienced as related to sexual function and quality of life in adolescent pregnant women. There are many treatment options for lower urinary tract symptoms. These treatment options for voiding, storage and postmicturition related LUTS include behavioral modifications such as management of fluid intake, pelvic floor muscle exercises and bladder training; lifestyle changes and pharmacotherapy.30 Although women experience many problems due to LUTS, only a small percentage seek treatment.13 None of the pregnant women in the study by Balık, et al. reported seeking treatment for LUTS.7 Although one of every four-five adolescents reported having sought treatment in our study, the rate of seeing a physician was not at the desired level. This indicates a lack of awareness regarding LUTS treatment among adolescents. High caffeine intake has been reported to be associated with detrusor instability.31 The consumption of caffeinated beverages also causes dehydration, diuresis and constipation during pregnancy and limiting their consumption is therefore recommended.5 The BFLUTSSF score medians were higher in the adolescents consuming coffee daily (p<0.05). Balık, et al. found no statistically significant relationship between tea and coffee consumption and being continent or incontinent in pregnant women but only investigated whether it affected the presence of UI.7 In contrast to the results of that study, we found that coffee consumption affected LUTS prevalence in adolescent pregnant women. Constipation is reported to be associated with the pelvic floor weakness in pregnancy.11 Bardino, et al.26 reported constipation to increase the risk of UI development 1.9 times in adolescent and young nulliparous women, while Barbosa, et al.28 similarly reported 1.6 times increase in UI risk with constipation in adolescent pregnant women in their case control study. Such study results11,26,28 also support our findings.
Smoking can cause coughing and increased pressure on the bladder.32 It is also reported to be a risk factor for LUTS development in women.11 Liang, et al.3 similarly reported a statistically significant difference between smoking and UI while Barbosa, et al.28 reported no significant difference between adolescent pregnant women with and without UI in terms of smoking. Another study found no increase in UI development risk with smoking in adolescent and young pregnant women.26 However, we found that the LUTS prevalence and symptom perception scores were 20 points higher in those who had quit smoking compared to those who had never smoked (p<0.001). The hormonal and mechanical changes during pregnancy can lead to the development of hydronephrosis and hydroureter, collecting duct dilatation in the urinary system and bladder hypotony. These changes increase the risk of UTI development following the resultant urinary retention.2 Certain urinary system diseases and UTI can result in the voiding and storage symptoms of LUTS.11 Dinç has reported a history of UTI to increase the risk of developing UI 3.8 times in pregnant women.27 In contrast, Bardino, et al. reported that a history of UTI did not increase the risk of developing UI in adolescent and young nulliparae.26 Linear regression analysis in our study showed that a history of UTI increased LUTS prevalence by approximately 3 points in our study (p=0.001). A relationship has been reported between the presence of urinary symptoms in women and UI in the mother.33 Another study from our country has similarly found a relationship between UI in pregnancy and the presence of UI in the mother or sister.17 The score means obtained from BFLUTS-SF were found to be significantly higher in adolescent pregnant women with UI in the mother and/or sister compared to those without such a history in our study (p<0.05). However, we did not find a statistically significant association between the presence of UI in the mother or sister and the mean BFLUTS-SF scores.
Labor is one of the well-known risk factors of LUTS.34 Lacerations of the urethra, vagina, cervix and vulva are common after vaginal birth. Severe lacerations are reported to be closely related to postnatal pelvic floor injury and UI.35 The damage to the neuromuscular and connective tissue surrounding the bladder and urethra and the muscles, fascia and nerves forming the pelvic floor during labor affect the lower urinary system. Forceps assisted delivery, the birth weight of the baby, an episiotomy and prolonged labor are reported as possible causes of damage to the nerves in the perianal region.2 However, we did not find a statistically significant difference between the BFLUTS-SF mean scores of the adolescent pregnant women who had or had not given birth. Excessive weight increases the risk of developing SUI by altering the bladder pressure in women.30,35 However, the relationship of obesity with LUTS other than SUI is not fully known.35 Zhang et al. have reported that a BMI in the 75th percentile or higher makes LUTS development 1.57 times more likely.36 We did not find a statistically significant relationship between the pre-pregnancy BMI and the BFLUTS-SF mean scores. Our study has some limitations. Our findings depend on the verbal self-reports from the adolescent pregnant women interviewed. The validity of the data is therefore affected by their responses to the questionnaire. Another limitation is that it is limited to the adolescent pregnant women visiting the training and research hospital in a single province in Turkey within a defined period. Our study results can therefore only be generalized to the study population. We also found it difficult to compare our study results with those of individuals of a similar age as there are very few studies on LUTS in adolescent pregnant women. Conclusion We found in this study that LUTS and symptoms of storage were common in adolescent pregnant women, but only one in four sought treatment. The severity of LUTS symptoms was found to increase in adolescent pregnant women who consumed coffee daily,
smoked, or those who reported a chronic cough, constipation or history of UTI. Health care professionals should keep these in mind to ensure the early detection and treatment of LUTS in adolescent pregnant women. Furtermore, adolescent pregnant women should be informed of the changes that may occur in the lower urinary system during pregnancy, the deviations from normal, and their prevention and treatment. They should also be provided training and counseling by healthcare professionals regarding the necessary lifestyle changes related to the risk factors affecting LUTS development. Acknowledgments The authors are grateful to all the pregnant adolescents in the study. The authors would also like to thank Research Assistant Nazlı TOTİK from the Department Biostatistics at Çukurova University for conducting the statistical overview of the study. Conflicts of Interest: None References 1. FitzGerald MP, Graziano S: Anatomical and functional changes of the lower urinary tract during pregnancy. Urol Clin North Am 2007; 34: 7 2. Kocaöz S, Eroğlu K: Conservative treatment methods of stress urinary incontinence during pregnancy and after vaginal delivery and roles of nurse: review. Turkiye Klinikleri J Nurs Sci 2009; 1: 94 3. Liang C-C, Chang S-D, Lin S-J, et al: Lower urinary tract symptoms in primiparous women before and during pregnancy. Arch Gynecol Obstet 2012; 285: 1205 4. Lin K-L, Shen C-J, Wu M-P, et al: Comparison of low urinary tract symptoms during pregnancy between primiparous and multiparous women. Biomed Res Int 2014; 2014: 303697
5. Ow LL, Le JK-S: Management of bladder dysfunction and LUTS during pregnancy. Curr Bladder Dysfunct Rep 2015; 10: 308 6. Adaji SE, Shittu OS, Bature SB, et al: Bothersome lower urinary symptoms during pregnancy: a preliminary study using the International Consultation on Incontinence Questionnaire. Afr Health Sci 2011; 11 Suppl 1: S46 7. Balık G, Güven ES, Tekin YB, et al: Lower urinary tract symptoms and urinary incontinence during pregnancy. Low Urin Tract Symptoms 2016; 8: 120 8. Sun MJ, Chen GD, Chang SY, et al: Prevalence of lower urinary tract symptoms during pregnancy in Taiwan. J Formos Med Assoc 2005; 104: 185 9. Anzaku AS, Mikah S, Utoo BT: Prevalence and determinants of lower urinary tract symptoms before and during pregnancy in a cohort of Nigerian women. Sahel Medical Journal 2014; 17: 96 10. Coyne KS, Kaplan SA, Chapple CR, et al: Risk factors and comorbid conditions associated with lower urinary tract symptoms: EpiLUTS. BJU Int 2009; 103 Suppl 3: 24 11. Takahashi S, Takei M, Nishizawa O, et al: Clinical Guideline for Female Lower Urinary Tract Symptoms. Low Urin Tract Symptoms 2016; 8: 5 12. Coyne KS, Wein AJ, Tubaro A, et al. The burden of lower urinary tract symptoms: evaluating the effect of LUTS on health-related quality of life, anxiety and depression: EpiLUTS. BJU Int 2009; 103 Suppl 3: 4 13. Sexton CC, Coyne KS, Kopp ZS, et al: The overlap of storage, voiding and postmicturition symptoms and implications for treatment seeking in the USA, UK and Sweden: EpiLUTS. BJU Int 2009; 103 Suppl 3:12 14. Welch LC, Botelho EM, Tennstedt SL: Race and ethnic differences in health beliefs about lower urinary tract symptoms. Nurs Res 2011; 60: 165.
15. Bilgic D, Kizilkaya Beji N, Ozbas A, et al: Coping and help-seeking behaviors for management of urinary incontinence. Low Urin Tract Symptoms 2017; 9: 134. 16. Anders K: Coping strategies for women with urinary incontinence. Baillieres Best Pract Res Clin Obstet Gynaecol 2000; 14: 355 17. Kocaöz S, Talas MS, Atabekoğlu CS: Urinary incontinence in pregnant women and their quality of life. J Clin Nurs 2010; 19: 3314 18. Güvenç G, Kocaöz S, Kök G: Quality of life in climacteric Turkish women with urinary incontinence. Int J Nurs Pract 2016; 22: 649 19. TUIK: Turkish Statistical Institute: Dünya Nüfus Günü 2013. Available at: http://www.tuik.gov.tr/PreHaberBultenleri.do?id=13663. Accessed June 12, 2019. 20. Coyne KS, Sexton CC, Thompson CL, et al: The prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK and Sweden: results from the epidemiology of LUTS (EpiLUTS) study. BJU Int 2009; 104: 352 21. Irwin DE, Milson I, Hunskaar S, et al: Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50: 1306 22. Jackson S, Donovan J, Brookes S: The Bristol Female Lower Urinary Tract Symptoms Questionnaire: development and Psychometric testing. Br J Urol 1996; 77: 805 23. Güngör F, Yalçın Ö: Comparison of the clinical and urodynamic effects of TVT and TVT-O in the treatment of stress urinary incontinence. (PhD Thesis), Istanbul: Istanbul Universities Institute of Health Sciences, Turkey, 2005, pp 42-44
24. Abrams P, Cardozo L, Fall M, et al: The standardisation of terminology in lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence Society. Urology 2003: 61: 37-49. 25. Lewicky-Gaupp C, Cao DC, Culbertson S: Urinary and anal incontinence in African teenaged gravidas during pregnancy and puerperium. J Pediatr Adolesc Gynecol 2008; 21: 21 26. Bardino M, Di Martino M, Ricci E, et al: Frequency and determinants of urinary incontinence in adolescent and young nulliparous women. J Pediatr Adolesc Gynecol 2015; 28: 462 27. Dinç A: Prevalence of urinary incontinence during pregnancy and associated risk factors. LUTS 2018; 10: 303 28. Barbosa L, Kühni D, Vasconcelos D, et al: Factors associated with urinary incontinence in pregnant adolescents: A case-control study. J Pediatr Adolesc Gynecol 2018; 31: 382 29. Bilgic D, Kizilkaya Beji N: Lower urinary tract symptoms in women and quality of life. Urological Nursing 2010; 4: 97 30. Bradway C, Coyne KS, Irwin D, et al: Lower urinary tract symptoms in women- a common but neglected problem. J Am Acad Nurse Pract 2008; 2: 311 31. Arya LA, Myers DL, Jackson ND: Dietary caffeine intake and the risk for detrusor instability: a case-control study. Obstet Gynecol 2000; 96: 85 32. Wesnes SL, Lose G. Preventing urinary incontinence during pregnancy and postpartum: a review. Int Urogynecol J 2013; 24: 889
33. Güngör İ, Kızılkaya Beji N, Onat Bayram G, et al: Lower urinary tract symptoms in women with and without urinary incontinence. Int J of Urol Nurs 2012; 6: 22 34. American College of Obstetricians and Gynecologists: Practice Bulletin No. 165 Summary: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol 2016; 128: 226 35. Elia G, Dye TD, Scariati PD: Body mass index and urinary symptoms in women. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: 366 36. Zhang W, Song Y, He X, et al: Prevalence and risk factors of lower urinary tract symptoms in Fuzhou Chinese women. Eur Urol 2005; 48: 309
TABLES Table 1. Socio-demographic and obstetric characteristics of the adolescent pregnant women interviewed Certain Variables Mean age ± SD, years Mean gravida ± SD Mean gestational Week ± SD Age group, n (%) ≤17 age 18 age Education level attained, n (%) Primary school Secondary school High school Gravida, n (%) 1 ≥2 Gestational week, n (%) ≤12th week 13-27 weeks ≥28th week Previous miscarriage, n (%) Yes No Previous abortion, n (%) Yes No Previously birth history (n=19), (%) Normal vaginal birth Caesarean section Laboring over 24 hours during vaginal birth (n=13), (%) Yes No Episiotomy (n=13), (%) Yes No UI history in previous pregnancy (n=19), (%) Yes No UI history in the postnatal period (n=19), (%) Yes No
Statistic 17.7±0.61 1.2±0.48 26.2±11.65 60 (29.1) 146 (70.9) 28 (13.6) 139 67.5) 39 (18.9) 167 (81.1) 39 (18.9) 31 (15.0) 63 (30.6) 112 (54.4) 18 (8.7) 188 (91.3) 5 (2.4) 201 (97.6) 13 6
(68.4) (31.6)
3 10
(23.1) (76.9)
11 2
(84.6) (15.4)
5 14
(26.3) (73.7)
2 17
(10.5) (89.5)
Table 2. The distribution of lower urinary tract symptoms in the adolescent pregnant women interviewed Lower urinary tract symptoms (LUTS) At least one LUTS (Storage+Voiding+Urinary Incontinence) Yes No Storage Symptoms Yes No Nocturia (≥2 times) Yes No Urgency Yes No Bladder pain Yes No Frequency Yes No Voiding Symptoms Yes No Hesitancy Yes No Straining Yes No Intermittent stream Yes No Urinary Incontinence Symptoms Yes No Urge urinary incontinence Yes No Urinary incontinence Yes No Stress urinary incontinence Yes No Unpredictable incontinence Yes No
n
%
162 44
78.6 21.4
160 46
77.7 22.3
122 84
59.3 40.7
112 94
54.4 45.6
77 129
37.1 62.9
81 125
39.3 60.7
53 153
25.7 74.3
38 168
18.4 81.6
23 183
11.2 88.8
36 170
17.5 82.5
74 132
35.9 64.1
52 154
25.2 74.8
56 150
27.2 72.8
45 161
21.8 78.2
22 184
10.7 89.3
Nocturnal incontinence Yes No Sexual Function Symptoms Yes No Sex life negatively affected by urinary symptoms Yes No Leakage during sexual activity Yes No Quality of Life Symptoms Yes No Changing outer clothing necessary Yes No Decreased fluid intake Yes No Daily tasks affected Yes No Avoid places without toilets Yes No Overall negative impact on life Yes No
6 200
2.9 97.1
23 183
11.2 88.8
19 187
9.2 90.8
13 193
6.3 93.7
76 130
36.9 63.1
42 164
20.4 79.6
20 186
9.7 90.3
21 185
10.2 89.8
35 171
17.0 83.0
51 155
24.8 75.2
Table 3. The distribution of the Bristol Female Lower Urinary Tract Symptoms-Short Form score means-medians obtained by the adolescent pregnant women interviewed according to certain variables Certain Variables
Total Score Median Min-Max
n
±SD
60
6.97±7.35
5.00
0-40
18 146 Educational level attainedb Primary school 28 Secondary school 139 High school 39 a Gravida
8.16±8.33
5.00
0-42
8.14±6.79 7.63±7.88 8.21±9.58
7.00 5.00 5.00
0-29 0-42 0-35
1
167
7.75±8.40
5.00
0-42
39
8.08±6.47
6.00
0-26
31 63 112
6.89±8.66 7.93±8.589 8.06±7.62
2.00 5.00 5.50
0-40 0-42 0-35
187
7.82±8.18
5.00
0-42
One birth Daily Fluid Intaked
19
7.68±6.94
5.00
1-26
≤ 500 ml
20
6.95±8.65
3.00
0-30
501-1499 ml 94 ≥1500 ml 92 Daily Coffee Consumptiona
7.11±6.96 8.72±8.93
5.00 5.00
0-35 0-42
61
11.80±10.05
8.00
0-40
145
6.13±6.39
4.00
0-42
197 5 4
7.02±6.83 29.80±10.11 19.50±15.16
5.00 34.00 18.50
0-40 6-35 17-42
6
18.83±14.00
16.50
5-42
200
7.48±7.63
5.00
0-40
Yes
49
13.12±8.90
12.00
0-40
No
157
6.15±7.02
4.00
0-42
Age Groupa ≤17
≥2 Gestational weekb ≤12th week 13-27 weeks ≥28th week Parityc No child bearing
Yes No Smokingd Never smoked Quit smoking Currently Smoking Chronic Coughc Yes No Constipationa
Test and p value t=-0.963 0.336
F=0.103 0.902
t=2.325 0.819
F=0.304 0.738
z=-0.405 0.685 χ2=2.284 0.319
t=81.134 <0.0001 χ2=16.858 <0.0001
z=-2.551 0.011
t=67.671 <0.0001
Urinary Tract Disease (n=183)a,e Yes
37
11.00
0-35
No 146 6.12±7.38 History of Urinary Tract Infection (n=200)a,e
4.00
0-42
Yes
8.00
0-42
96
12.65±9.23
10.59±8.68
No 104 5.12±6.60 3.00 Urinary Incontinence in Mother and/or Sister (n=175)a,e
0-40
Yes
42
12.33±9.88
8.00
1-40
No
133
6.18±7.00
4.00
0-42
t=48.297 <0.0001
t=176.904 <0.0001
t=54.627 <0.0001
a
Independent Samples t test was used. b One-way ANOVA test was used. c Mann-Whitney U test was used. d Kruskal Wallis test was used. e Responses such as “I don’t know” were excluded from the statistical analysis.
Table 4. The Linear Regression analysis for the variables influencing the BFLUTS-SF scores of the adolescent pregnant women interviewed Certain Variables Daily Coffee Consumptiona Present versus absent Smoking Quit smoking versus never smoked Smoking versus never smoked Chronic Cougha Present versus absent Constipationa Present versus absent History of Urinary Tract Infectiona Present versus absent Constant
B
SE
β
t
p
4.884
0.939
0.272
5.202
<0.001
19.991 9.747
2.525 2.793
0.408 0. 178
7.917 3.490
<0.001 0.001
8.178
2.313
0.182
3.536
0.001
4.698
1.019
0.239
4.610
0.001
3.049 1.857
0.888 0.636
0.185
3.434 2.919
0.001 <0.001
n=206, R=0.763, R2=0.582, Adjusted R2=0.564, F= 32.570, p<0.001 a: Independent variable, 0= Absent, 1=Present, B: Regression coefficient, SE: Standard error, β: Standardized regression coefficient.
S1083-3188(19)30324-9
DOI:
https://doi.org/10.1016/j.jpag.2019.10.007
Reference:
PEDADO 2413
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 21 February 2019 Revised Date:
11 October 2019
Accepted Date: 16 October 2019
Please cite this article as: Aydin A, Kocaöz S, Kara P, Prevalence of Lower Urinary Tract Symptoms in Pregnant Adolescents and the Influencing Factors, Journal of Pediatric and Adolescent Gynecology (2019), doi: https://doi.org/10.1016/j.jpag.2019.10.007. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc. on behalf of North American Society for Pediatric and Adolescent Gynecology.
Prevalence of Lower Urinary Tract Symptoms in Pregnant Adolescents and the Influencing Factors
Article Type: Original Studies
Running Head: LUTS in Pregnant Adolescents
Arzu AYDIN1, Semra KOCAÖZ2, Pınar KARA3
1
MD, Bünyan State Hospital, Kayseri, Turkey
2
RN, PhD, Niğde Ömer Halisdemir University, Niğde Zübeyde Hanım School of Health,
Nursing Department, Department of Obstetrics and Gynecology Nursing, Niğde, Turkey 3
RN, MSc, Niğde Ömer Halisdemir University, Niğde Zübeyde Hanım School of Health,
Nursing Department, Department of Obstetrics and Gynecology Nursing, Niğde, Turkey
*Corresponding Author Prof. Dr. Semra KOCAÖZ Niğde Ömer Halisdemir Üniversitesi Niğde Zübeyde Hanım Sağlık Yüksekokulu, Hemşirelik Bölümü, Doğum ve Kadın Hastalıkları Hemşireliği ABD.,
Derbent Yerleşkesi, 51200,
Merkez/Niğde/TÜRKİYE Phone: +90 388 211 2838, Fax: +90 388 211 2813, E-mail: [email protected]
“This study was presented as as oral presentation at Third International Congress of Koru Pregnancy, Childbirth and Puerperium, 14-17 February 2019, Bolu, Turkey.”
Funding: No funding support was received for this study. The authors alone are responsible for the content and writing of this article.
Authorship Statement Authors have participated sufficiently in the work to take public responsibility for the content. AA, SK, and PK contributed to conception and design of study. AA and PK collected data from pregnant adolescents. SK and PK analyzed and interpreted the data. AA, SK, and PK drafted the article and revised it critically for important intellectual content. All authors have approved the final version to be published.
Word Account Abstract:250 Word Account Manuscript:3791 [Abstract:250, Main Text: 3541 (excluding references)] Table:4
Abstract Study Objective: To determine the prevalence of lower urinary tract symptoms (LUTS) and associated risk factors in pregnant adolescents. Design: A descriptive study. Setting: The obstetrics and gynecology outpatient departments of a training and research hospital in Turkey. Participants: 206 pregnant adolescents under the age of 19. Interventions: None. Questionnaire-based data and the Bristol Female Lower Urinary Tract Symptoms-Short Form (BFLUTS-SF) were collected from pregnant adolescents. Main Outcome Measures: Comparisons were made with independent samples t test, oneway ANOVA, Mann-Whitney U and Kruskal-Wallis tests, and Linear regression for the analysis of the potential risk factors. Results: The prevalence of at least one LUTS in pregnant adolescents was 78.6%. The prevalence of storage symptoms was more than those of urinary incontinence (UI) and voiding symptoms. Among LUTS, the prevalence of nocturia, urgency, frequency, bladder pain, and UI was 59.3%, 54.4%, 39.3%, 37.1%, 27.2%, respectively. 23.8% of pregnant adolescents with LUTS reported seeking treatment for LUTS in this study. The total median scores from the BFLUTS-SF increased with gestational week, but it no statistical significant difference was identified (p>0.05). According to the results of the linear regression analysis, daily coffee consumption, smoking, chronic coughing, constipation, and urinary tract infection history, were found to be associated with the total mean score on the BFLUTS-SF in pregnant adolescents. Conclusion: LUTS were found to be common among pregnant adolescents, with storage symptoms being the most frequently reported. Prenatal education could increase the number of adolescents who seek treatment, thereby improving the clinical course of LUTS.
Key Words: Adolescents, Pregnancy, Lower urinary tract symptoms, Prevalence, Risk factors
Introduction The anatomical, physiological and hormonal changes experienced during pregnancy affect the lower urinary tract of women1,2 and commonly cause lower urinary tract symptoms (LUTS).3-5 The prevalence of LUTS in pregnant women varies according to the symptom focused on, the definitions used, the population studied and the methodology applied.3,4,6-9 To the best of our knowledge, no studies that presenting the prevalence rate of at least one LUTS in adolescent pregnant women exist. The lower urinary tract dysfunction is reported to worsen by gestational week.5 Lin et al. have reported increasing rates for the symptoms of frequency, nocturia, stress urinary incontinence (SUI) and inability to completely empty the bladder as gestational age progresses in both primigravid and multigravid pregnant women.4 LUTS can occur for many reasons including pregnancy10 and together with the associated storage symptoms, they are reported to adversely impact women’s quality of life.11 Coyne, et al. have reported lower quality of life and higher anxiety and depression levels in women with LUTS.12 Even so, few women seem to seek help.7,13 The most common reasons for this are feelings of unease about talking to a physician about urinary symptoms, shame or hesitancy, and lacking the knowledge that the symptoms can be treated.14 Most women with LUTS who do not seek treatment develop incorrect strategies for self-care such as fluid restriction to avoid symptoms or decrease their frequency.15,16 There are in fact, preventive and therapeutic approaches that prevent LUTS development or decrease its severity in women.11 The presence of urinary incontinence (UI), which is one of the voiding symptoms of LUTS, during pregnancy is reported to increase the likelihood that the problem will continue
after the pregnancy, as well.17,18 Identifying and tracking consistent and noticeable LUTS related conditions in women from early pregnancy onwards is therefore important.1 Although a few studies have focus on LUTS symptoms in pregnant women at the national and international level.3,4,6-9 We did not come across any studies on the prevalence and risk factors of LUTS in adolescent pregnant women. LUTS could result in psychological problems compounding the trauma created by the pregnancy itself during the adolescent period, when physical, psychological and social changes are already being experienced. Adolescents’ lack of awareness regarding LUTS during pregnancy could cause them to be deprived of the required treatment. They could experience physical, social, psychological and sexual problems if their LUTS continue after pregnancy without receiving treatment. It is necessary to be aware of both the prevalence of LUTS in the adolescent pregnancy period and the relevant risk factors so that such problems can be prevented and effective treatment directed at the cause can be offered. This study was therefore conducted to identify the LUTS prevalence in adolescent pregnant women and their underlying factors. Materials and Methods The population of this descriptive study consisted of adolescent pregnant women who presented to the Obstetrics and Gynecology Outpatient Department of a public training and research hospital between 21 January and 19 July 2018 to undergo routine follow-up during pregnancy. No sample selection was conducted, and all pregnant adolescents who met the inclusion criteria were included in the study. Study inclusion criteria consisted of (1) being 18 or younger; (2) being married (official or religious ceremony); (3) presenting to the Obstetrics and Gynecology Outpatient Department to receive prenatal routine pregnancy care services; (4) having the ability to answer the questions, and (5) agreeing to participate in the study. The study province ranks 8th among Turkish provinces with the highest number of adolescent pregnancies according to the 2012 data of the Turkish Statistics Institute (51.5/1000).19 A
total of 206 adolescent pregnant women visited the Obstetrics and Gynecology Outpatient Department to receive health care services during the study period. None of them refused participation. This study was completed with 206 pregnant adolescents compatible with these criteria. The study data were collected using the “Data Collection Form” created by the researchers based on the relevant literature3,7,15,20,21 and the “Bristol Female Lower Urinary Tract Symptoms-Short Form (BFLUTS-SF)”. The data collection form consisted of four sections and contained a total of 38 questions regarding socio-demographics (such as age, educational level, perceived income, social security coverage, personal habits, body mass index (BMI), etc.) (9 questions); pregnancy and labor (last menstrual date, gravida, parity, the number of curettage and abortions, delivery type, difficult delivery, episiotomy, UI presence during pregnancy and after birth, spinal anesthesia, delivery of a baby weighing more than 4000 g, etc.) (14 questions); personal habits and chronic diseases (smoking; alcohol, water, soft drinks, coffee and tea consumption; the presence and frequency of constipation; and complaints of chronic coughing, diabetes mellitus, etc.) (7 questions); and urogynecologic history (urinary system disease, urinary tract infection history, previous urinary tract surgery, and history of UI in mother and/or sisters, Kegel exercises, treatment seeking behavior, etc.) (8 questions). The BFLUTS-SF was developed in 1996 by Jackson, Donovan and Brookes in order to investigate UI symptoms, other LUTS and their effects on sexual function and quality of life.22 The adaptation we used in our study was prepared by Güngör and Yalçın in 2005. The BFLUTS-SF consists of a total of 19 questions in the five sub-dimensions of storage, voiding, urinary incontinence, sexual function and quality of life. There is no questionnaire cut-off value for predicting whether LUTS is clinically present. The score range is 0 to 72, with higher scores indicating increased severity and perceived significance.23 The Cronbach alpha
value was 0.78 in the original questionnaire22 and 0.70 in the study by Güngör and Yalçın.23 The Cronbach alpha value of the questionnaire in this study was found to be 0.80. The study was conducted after obtaining ethics committee approval from the Niğde Ömer Halisdemir University Ethics Committee (decision no: 2017/12-04, date:30 November 2017) and written permission from the Directorate of Health and the hospital where the study was conducted. Before the data collection tools were used, the participants were informed on the subject by the researchers and verbal and written informed consent was obtained. The data collection tools were then administered to adolescent pregnant women between 09:00 and 16:00 during the week, between 21 January and 19 July 2018, at the Obstetrics and Gynecology Outpatient Department of the training and research hospital where the study was conducted. The data were collected by the researchers with the face-toface interview method. The study data were evaluated using the SPSS (24.0, IBM Corp., Armonk, NY) program. Numbers, percentages, arithmetic means, medians, standard deviations and minimummaximum values were used for descriptive statistics in the study. The Cronbach alpha value was used to assess the validity and reliability of the questionnaire. Parametric tests were used to compare the BFLUTS-SF scores and risk factors of the adolescent pregnant women as the sample size in the cells approached 30, according to central distribution theory. The Independent Samples t test and One-way ANOVA test were used when the assumptions were met and the Mann-Whitney U and Kruskal-Wallis tests when they were not. Linear regression analysis was conducted to evaluate the relationship between the scores of the adolescent pregnant women from BFLUTS-SF and the smoking, coffee consumption, constipation, chronic cough and urinary tract infection history variables. The statistical significance level was taken as p<0.05. Results
The mean age of the adolescent pregnant women was 17.66±0.61 and 67.5% were secondary school graduates. Two or more pregnancies were reported by 18.9% of the adolescents and 54.4% of the pregnant women were at the 28th gestational week or beyond. Among the adolescent pregnant women, 8.7% had experienced a miscarriage and 2.4% had had an abortion, while 9.2% had given birth once. Of those who had given birth, 68.4% had delivered vaginally. For 23.1% of the adolescent pregnant women who had delivered vaginally, labor had lasted over 24 hours and an episiotomy had been administered in 84.6%. Among the women who had given birth previously (n=9), UI had developed during the previous pregnancy of 5 and in the postnatal period of 2 women (Table 1). Among the adolescent pregnant women, 9.7% expressed that they consumed 500 ml or less fluid daily, 29.6% that they consumed coffee daily and 1.9% that they still smoked. Constipation was reported by 23.8% of the women, a chronic cough by 2.9%, urinary tract disease by 18.0% and a history of urinary tract infection (UTI) by 46.6% while 0.5% had diabetes. UI symptoms were present in the mother and/or sister of 20.4% of the adolescent pregnant women. Table 2 presents the distribution of LUTS symptoms in the participants. At least one LUTS involving urinary storage, voiding and UI symptoms was found to be present in 78.6% of the adolescent pregnant women. When urinary storage symptoms (77.7%) were investigated, 59.4% were found to have nocturia, 54.4% urgency, 37.1% pain in the bladder and 39.3% frequency symptoms. The prevalence of urinary voiding symptoms (25.7%) was 18.4% for hesitancy, 17.5% for intermittent urination and 11.2% for straining to urinate. Among the UI symptoms (35.9%), the prevalence of urge urinary incontinence (UUI), UI, SUI, unpredictable incontinence and nocturnal incontinence was 25.2%, 27.2%, 21.8%, 10.7%, and 2.9%, respectively. The LUTS was related to sexual function in 11.2% of the
adolescents and quality of life in 36.9%. The rate of going to a physician for the LUTS was 23.8%, and 22.8% had received treatment for this condition. Table 3 shows the distribution of the BFLUTS-SF score mean and medians obtained according to certain variables. The BFLUTS-SF score medians were found to be significantly higher in subjects who had a daily coffee consumption habit, chronic cough, constipation, urinary tract disease, history of UTI, and UI in the mother and/or sister (p<0.05). The BFLUTS-SF score medians were significantly lower in those who did not smoke compared to those still smoking or who had quit (p<0.05). Table 4 presents the Linear Regression analysis for the variables influencing the BFLUTS-SF scores of the adolescent pregnant women interviewed. This analysis revealed that the mean total score from the BFLUTS-SF was approximately 5 points higher in adolescent pregnant women consuming coffee compared to those who did not, in the presence of other variables (p<0.001). The BFLUTS-SF mean total score was approximately 20 points higher in those who had smoked and then quit compared to those who had never smoked (p<0.001) and 9.74 points higher for those who smoked (p=0.001). The mean BFLUTS-SF total score was also 8 points higher in pregnant adolescent women who suffered from a chronic cough compared to those who did not (p=0.001), 4.69 points in those with constipation compared to those without this condition (p<0.001) and 3.04 points higher in those with a UTI compared to those who did not have such an infection (p=0.001). Discussion LUTS is common in women and has a negative effect on the daily quality of life,12 and can develop due to the changes occurring in pregnancy.1,5,11 The vascular supply of the bladder increases due to the physiological, mechanical and hormonal effects of pregnancy; the bladder moves forward and upwards and becomes hypotonic, edematous and concave in shape; hypertrophy is seen in the detrusor muscle; changes occur in the neuromuscular and
connective tissues that surround the bladder neck and urethra and control their function; the growing uterus exerts pressure on the bladder and stretches the pelvic floor, and an increase in glomerular filtration rate and renal plasma flow are seen in accordance with the needs of the fetus.2 All these changes in pregnancy affect the lower urinary system and can result in the development of LUTS.1 The prevalence of LUTS in pregnant women varies according to the population in which the study is conducted, the measurement tools used for data collection, and the subsymptoms investigated.3,4,6-9 In a study conducted in Nigeria, LUTS has been reported to be seen during pregnancy in 89.2% of the women studied.9 A study from our country has reported that 81.6% of pregnant women experienced at least one LUTS. Our LUTS prevalence in adolescent pregnant women (78.6%) was lower than reported by these studies.7,9 The prevalence of LUTS is reported to increase with age in the literature.24 This could explain the lower prevalence of LUTS in our study.7,9 LUTS is grouped under the three main headings of urinary storage, voiding and postmicturition. Storage symptoms include increased daytime frequency, nocturia, urgency, bladder sensation, and various types of UI.24 UI was analyzed under a separate heading in the questionnaire we used in our study. In the literature, symptoms of storage have been reported to be more common than symptoms of voiding during pregnancy.3 In this study as well, symptoms of storage were more common than symptoms of voiding in the adolescent pregnant women. Frequency, urgency and nocturia are reported to be the most common types of LUTS in women during pregnancy.1 The prevalence of nocturia, urgency, frequency and pain in the bladder is reported to be 51.1-94.1%3,4,6-9, 10.4-34.1%3,6-9, 17.6-77.6%3,4,6-9, and 17.8-39.2%4,6,7, respectively, in studies on pregnant women conducted with various measurement tools. There was a higher prevalence of urgency in our study compared to that
in other studies,3,6-9 which could be due to the UTI history of almost half (46.6%) of our participants. UI is among the most commonly studied subjects along with the other symptoms of LUTS in adolescent pregnant women.25-28 A study among African-American teenage adolescents reported UUI in 55.0% and SUI in 69.0% during pregnancy,25 while one in Italy on pregnant women under 18 reported any type of UI at a rate of 18.2%.26 A Turkish study found UI to be present in 32.0% of the individuals aged 19 and younger.27 Our findings regarding UI prevalence in adolescent pregnant women are similar to those reported in that study.27 The voiding symptoms of LUTS include hesitancy, intermittent stream and straining.24 Adaji, et al. reported symptoms of hesitancy in 9.6%, straining in 3.9% and an intermittent stream in 13.2% of the pregnant women.6 Difficulty urinating was reported at rates of 14.0%, 15.3%, and 8.1%, respectively, in the studies by Balık, et al.7, Liang, et al.3 and Anzaku, et al.9 The high prevalence of voiding symptoms in our study could be due to the difference in study populations and the data collection tools used. It is reported that LUTS in women may affect medical, economic, social, physical, psychological and social weel-being negatively.29 LUTS also includes symptoms related to sexual intercourse.11,24 In our study, UI during intercourse was reported by 6.3% of the adolescent pregnant women and 9.2% stated that LUTS had an extremely detrimental effect on their life. We also investigated symptoms related to the quality of life in adolescent pregnant women in this study. Among the adolescent pregnant women, 20.4% stated that they had to change their underwear during the day, 9.7% restricted fluid consumption, 17.0% avoided going to places without a toilet, and urinary incontinence affected the daily tasks of 10.2% and the general life of 24.8%. We were unable to compare our findings with others as
we did not come across any other study on the LUTS components experienced as related to sexual function and quality of life in adolescent pregnant women. There are many treatment options for lower urinary tract symptoms. These treatment options for voiding, storage and postmicturition related LUTS include behavioral modifications such as management of fluid intake, pelvic floor muscle exercises and bladder training; lifestyle changes and pharmacotherapy.30 Although women experience many problems due to LUTS, only a small percentage seek treatment.13 None of the pregnant women in the study by Balık, et al. reported seeking treatment for LUTS.7 Although one of every four-five adolescents reported having sought treatment in our study, the rate of seeing a physician was not at the desired level. This indicates a lack of awareness regarding LUTS treatment among adolescents. High caffeine intake has been reported to be associated with detrusor instability.31 The consumption of caffeinated beverages also causes dehydration, diuresis and constipation during pregnancy and limiting their consumption is therefore recommended.5 The BFLUTSSF score medians were higher in the adolescents consuming coffee daily (p<0.05). Balık, et al. found no statistically significant relationship between tea and coffee consumption and being continent or incontinent in pregnant women but only investigated whether it affected the presence of UI.7 In contrast to the results of that study, we found that coffee consumption affected LUTS prevalence in adolescent pregnant women. Constipation is reported to be associated with the pelvic floor weakness in pregnancy.11 Bardino, et al.26 reported constipation to increase the risk of UI development 1.9 times in adolescent and young nulliparous women, while Barbosa, et al.28 similarly reported 1.6 times increase in UI risk with constipation in adolescent pregnant women in their case control study. Such study results11,26,28 also support our findings.
Smoking can cause coughing and increased pressure on the bladder.32 It is also reported to be a risk factor for LUTS development in women.11 Liang, et al.3 similarly reported a statistically significant difference between smoking and UI while Barbosa, et al.28 reported no significant difference between adolescent pregnant women with and without UI in terms of smoking. Another study found no increase in UI development risk with smoking in adolescent and young pregnant women.26 However, we found that the LUTS prevalence and symptom perception scores were 20 points higher in those who had quit smoking compared to those who had never smoked (p<0.001). The hormonal and mechanical changes during pregnancy can lead to the development of hydronephrosis and hydroureter, collecting duct dilatation in the urinary system and bladder hypotony. These changes increase the risk of UTI development following the resultant urinary retention.2 Certain urinary system diseases and UTI can result in the voiding and storage symptoms of LUTS.11 Dinç has reported a history of UTI to increase the risk of developing UI 3.8 times in pregnant women.27 In contrast, Bardino, et al. reported that a history of UTI did not increase the risk of developing UI in adolescent and young nulliparae.26 Linear regression analysis in our study showed that a history of UTI increased LUTS prevalence by approximately 3 points in our study (p=0.001). A relationship has been reported between the presence of urinary symptoms in women and UI in the mother.33 Another study from our country has similarly found a relationship between UI in pregnancy and the presence of UI in the mother or sister.17 The score means obtained from BFLUTS-SF were found to be significantly higher in adolescent pregnant women with UI in the mother and/or sister compared to those without such a history in our study (p<0.05). However, we did not find a statistically significant association between the presence of UI in the mother or sister and the mean BFLUTS-SF scores.
Labor is one of the well-known risk factors of LUTS.34 Lacerations of the urethra, vagina, cervix and vulva are common after vaginal birth. Severe lacerations are reported to be closely related to postnatal pelvic floor injury and UI.35 The damage to the neuromuscular and connective tissue surrounding the bladder and urethra and the muscles, fascia and nerves forming the pelvic floor during labor affect the lower urinary system. Forceps assisted delivery, the birth weight of the baby, an episiotomy and prolonged labor are reported as possible causes of damage to the nerves in the perianal region.2 However, we did not find a statistically significant difference between the BFLUTS-SF mean scores of the adolescent pregnant women who had or had not given birth. Excessive weight increases the risk of developing SUI by altering the bladder pressure in women.30,35 However, the relationship of obesity with LUTS other than SUI is not fully known.35 Zhang et al. have reported that a BMI in the 75th percentile or higher makes LUTS development 1.57 times more likely.36 We did not find a statistically significant relationship between the pre-pregnancy BMI and the BFLUTS-SF mean scores. Our study has some limitations. Our findings depend on the verbal self-reports from the adolescent pregnant women interviewed. The validity of the data is therefore affected by their responses to the questionnaire. Another limitation is that it is limited to the adolescent pregnant women visiting the training and research hospital in a single province in Turkey within a defined period. Our study results can therefore only be generalized to the study population. We also found it difficult to compare our study results with those of individuals of a similar age as there are very few studies on LUTS in adolescent pregnant women. Conclusion We found in this study that LUTS and symptoms of storage were common in adolescent pregnant women, but only one in four sought treatment. The severity of LUTS symptoms was found to increase in adolescent pregnant women who consumed coffee daily,
smoked, or those who reported a chronic cough, constipation or history of UTI. Health care professionals should keep these in mind to ensure the early detection and treatment of LUTS in adolescent pregnant women. Furtermore, adolescent pregnant women should be informed of the changes that may occur in the lower urinary system during pregnancy, the deviations from normal, and their prevention and treatment. They should also be provided training and counseling by healthcare professionals regarding the necessary lifestyle changes related to the risk factors affecting LUTS development. Acknowledgments The authors are grateful to all the pregnant adolescents in the study. The authors would also like to thank Research Assistant Nazlı TOTİK from the Department Biostatistics at Çukurova University for conducting the statistical overview of the study. Conflicts of Interest: None References 1. FitzGerald MP, Graziano S: Anatomical and functional changes of the lower urinary tract during pregnancy. Urol Clin North Am 2007; 34: 7 2. Kocaöz S, Eroğlu K: Conservative treatment methods of stress urinary incontinence during pregnancy and after vaginal delivery and roles of nurse: review. Turkiye Klinikleri J Nurs Sci 2009; 1: 94 3. Liang C-C, Chang S-D, Lin S-J, et al: Lower urinary tract symptoms in primiparous women before and during pregnancy. Arch Gynecol Obstet 2012; 285: 1205 4. Lin K-L, Shen C-J, Wu M-P, et al: Comparison of low urinary tract symptoms during pregnancy between primiparous and multiparous women. Biomed Res Int 2014; 2014: 303697
5. Ow LL, Le JK-S: Management of bladder dysfunction and LUTS during pregnancy. Curr Bladder Dysfunct Rep 2015; 10: 308 6. Adaji SE, Shittu OS, Bature SB, et al: Bothersome lower urinary symptoms during pregnancy: a preliminary study using the International Consultation on Incontinence Questionnaire. Afr Health Sci 2011; 11 Suppl 1: S46 7. Balık G, Güven ES, Tekin YB, et al: Lower urinary tract symptoms and urinary incontinence during pregnancy. Low Urin Tract Symptoms 2016; 8: 120 8. Sun MJ, Chen GD, Chang SY, et al: Prevalence of lower urinary tract symptoms during pregnancy in Taiwan. J Formos Med Assoc 2005; 104: 185 9. Anzaku AS, Mikah S, Utoo BT: Prevalence and determinants of lower urinary tract symptoms before and during pregnancy in a cohort of Nigerian women. Sahel Medical Journal 2014; 17: 96 10. Coyne KS, Kaplan SA, Chapple CR, et al: Risk factors and comorbid conditions associated with lower urinary tract symptoms: EpiLUTS. BJU Int 2009; 103 Suppl 3: 24 11. Takahashi S, Takei M, Nishizawa O, et al: Clinical Guideline for Female Lower Urinary Tract Symptoms. Low Urin Tract Symptoms 2016; 8: 5 12. Coyne KS, Wein AJ, Tubaro A, et al. The burden of lower urinary tract symptoms: evaluating the effect of LUTS on health-related quality of life, anxiety and depression: EpiLUTS. BJU Int 2009; 103 Suppl 3: 4 13. Sexton CC, Coyne KS, Kopp ZS, et al: The overlap of storage, voiding and postmicturition symptoms and implications for treatment seeking in the USA, UK and Sweden: EpiLUTS. BJU Int 2009; 103 Suppl 3:12 14. Welch LC, Botelho EM, Tennstedt SL: Race and ethnic differences in health beliefs about lower urinary tract symptoms. Nurs Res 2011; 60: 165.
15. Bilgic D, Kizilkaya Beji N, Ozbas A, et al: Coping and help-seeking behaviors for management of urinary incontinence. Low Urin Tract Symptoms 2017; 9: 134. 16. Anders K: Coping strategies for women with urinary incontinence. Baillieres Best Pract Res Clin Obstet Gynaecol 2000; 14: 355 17. Kocaöz S, Talas MS, Atabekoğlu CS: Urinary incontinence in pregnant women and their quality of life. J Clin Nurs 2010; 19: 3314 18. Güvenç G, Kocaöz S, Kök G: Quality of life in climacteric Turkish women with urinary incontinence. Int J Nurs Pract 2016; 22: 649 19. TUIK: Turkish Statistical Institute: Dünya Nüfus Günü 2013. Available at: http://www.tuik.gov.tr/PreHaberBultenleri.do?id=13663. Accessed June 12, 2019. 20. Coyne KS, Sexton CC, Thompson CL, et al: The prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK and Sweden: results from the epidemiology of LUTS (EpiLUTS) study. BJU Int 2009; 104: 352 21. Irwin DE, Milson I, Hunskaar S, et al: Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50: 1306 22. Jackson S, Donovan J, Brookes S: The Bristol Female Lower Urinary Tract Symptoms Questionnaire: development and Psychometric testing. Br J Urol 1996; 77: 805 23. Güngör F, Yalçın Ö: Comparison of the clinical and urodynamic effects of TVT and TVT-O in the treatment of stress urinary incontinence. (PhD Thesis), Istanbul: Istanbul Universities Institute of Health Sciences, Turkey, 2005, pp 42-44
24. Abrams P, Cardozo L, Fall M, et al: The standardisation of terminology in lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence Society. Urology 2003: 61: 37-49. 25. Lewicky-Gaupp C, Cao DC, Culbertson S: Urinary and anal incontinence in African teenaged gravidas during pregnancy and puerperium. J Pediatr Adolesc Gynecol 2008; 21: 21 26. Bardino M, Di Martino M, Ricci E, et al: Frequency and determinants of urinary incontinence in adolescent and young nulliparous women. J Pediatr Adolesc Gynecol 2015; 28: 462 27. Dinç A: Prevalence of urinary incontinence during pregnancy and associated risk factors. LUTS 2018; 10: 303 28. Barbosa L, Kühni D, Vasconcelos D, et al: Factors associated with urinary incontinence in pregnant adolescents: A case-control study. J Pediatr Adolesc Gynecol 2018; 31: 382 29. Bilgic D, Kizilkaya Beji N: Lower urinary tract symptoms in women and quality of life. Urological Nursing 2010; 4: 97 30. Bradway C, Coyne KS, Irwin D, et al: Lower urinary tract symptoms in women- a common but neglected problem. J Am Acad Nurse Pract 2008; 2: 311 31. Arya LA, Myers DL, Jackson ND: Dietary caffeine intake and the risk for detrusor instability: a case-control study. Obstet Gynecol 2000; 96: 85 32. Wesnes SL, Lose G. Preventing urinary incontinence during pregnancy and postpartum: a review. Int Urogynecol J 2013; 24: 889
33. Güngör İ, Kızılkaya Beji N, Onat Bayram G, et al: Lower urinary tract symptoms in women with and without urinary incontinence. Int J of Urol Nurs 2012; 6: 22 34. American College of Obstetricians and Gynecologists: Practice Bulletin No. 165 Summary: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol 2016; 128: 226 35. Elia G, Dye TD, Scariati PD: Body mass index and urinary symptoms in women. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: 366 36. Zhang W, Song Y, He X, et al: Prevalence and risk factors of lower urinary tract symptoms in Fuzhou Chinese women. Eur Urol 2005; 48: 309
TABLES Table 1. Socio-demographic and obstetric characteristics of the adolescent pregnant women interviewed Certain Variables Mean age ± SD, years Mean gravida ± SD Mean gestational Week ± SD Age group, n (%) ≤17 age 18 age Education level attained, n (%) Primary school Secondary school High school Gravida, n (%) 1 ≥2 Gestational week, n (%) ≤12th week 13-27 weeks ≥28th week Previous miscarriage, n (%) Yes No Previous abortion, n (%) Yes No Previously birth history (n=19), (%) Normal vaginal birth Caesarean section Laboring over 24 hours during vaginal birth (n=13), (%) Yes No Episiotomy (n=13), (%) Yes No UI history in previous pregnancy (n=19), (%) Yes No UI history in the postnatal period (n=19), (%) Yes No
Statistic 17.7±0.61 1.2±0.48 26.2±11.65 60 (29.1) 146 (70.9) 28 (13.6) 139 67.5) 39 (18.9) 167 (81.1) 39 (18.9) 31 (15.0) 63 (30.6) 112 (54.4) 18 (8.7) 188 (91.3) 5 (2.4) 201 (97.6) 13 6
(68.4) (31.6)
3 10
(23.1) (76.9)
11 2
(84.6) (15.4)
5 14
(26.3) (73.7)
2 17
(10.5) (89.5)
Table 2. The distribution of lower urinary tract symptoms in the adolescent pregnant women interviewed Lower urinary tract symptoms (LUTS) At least one LUTS (Storage+Voiding+Urinary Incontinence) Yes No Storage Symptoms Yes No Nocturia (≥2 times) Yes No Urgency Yes No Bladder pain Yes No Frequency Yes No Voiding Symptoms Yes No Hesitancy Yes No Straining Yes No Intermittent stream Yes No Urinary Incontinence Symptoms Yes No Urge urinary incontinence Yes No Urinary incontinence Yes No Stress urinary incontinence Yes No Unpredictable incontinence Yes No
n
%
162 44
78.6 21.4
160 46
77.7 22.3
122 84
59.3 40.7
112 94
54.4 45.6
77 129
37.1 62.9
81 125
39.3 60.7
53 153
25.7 74.3
38 168
18.4 81.6
23 183
11.2 88.8
36 170
17.5 82.5
74 132
35.9 64.1
52 154
25.2 74.8
56 150
27.2 72.8
45 161
21.8 78.2
22 184
10.7 89.3
Nocturnal incontinence Yes No Sexual Function Symptoms Yes No Sex life negatively affected by urinary symptoms Yes No Leakage during sexual activity Yes No Quality of Life Symptoms Yes No Changing outer clothing necessary Yes No Decreased fluid intake Yes No Daily tasks affected Yes No Avoid places without toilets Yes No Overall negative impact on life Yes No
6 200
2.9 97.1
23 183
11.2 88.8
19 187
9.2 90.8
13 193
6.3 93.7
76 130
36.9 63.1
42 164
20.4 79.6
20 186
9.7 90.3
21 185
10.2 89.8
35 171
17.0 83.0
51 155
24.8 75.2
Table 3. The distribution of the Bristol Female Lower Urinary Tract Symptoms-Short Form score means-medians obtained by the adolescent pregnant women interviewed according to certain variables Certain Variables
Total Score Median Min-Max
n
±SD
60
6.97±7.35
5.00
0-40
18 146 Educational level attainedb Primary school 28 Secondary school 139 High school 39 a Gravida
8.16±8.33
5.00
0-42
8.14±6.79 7.63±7.88 8.21±9.58
7.00 5.00 5.00
0-29 0-42 0-35
1
167
7.75±8.40
5.00
0-42
39
8.08±6.47
6.00
0-26
31 63 112
6.89±8.66 7.93±8.589 8.06±7.62
2.00 5.00 5.50
0-40 0-42 0-35
187
7.82±8.18
5.00
0-42
One birth Daily Fluid Intaked
19
7.68±6.94
5.00
1-26
≤ 500 ml
20
6.95±8.65
3.00
0-30
501-1499 ml 94 ≥1500 ml 92 Daily Coffee Consumptiona
7.11±6.96 8.72±8.93
5.00 5.00
0-35 0-42
61
11.80±10.05
8.00
0-40
145
6.13±6.39
4.00
0-42
197 5 4
7.02±6.83 29.80±10.11 19.50±15.16
5.00 34.00 18.50
0-40 6-35 17-42
6
18.83±14.00
16.50
5-42
200
7.48±7.63
5.00
0-40
Yes
49
13.12±8.90
12.00
0-40
No
157
6.15±7.02
4.00
0-42
Age Groupa ≤17
≥2 Gestational weekb ≤12th week 13-27 weeks ≥28th week Parityc No child bearing
Yes No Smokingd Never smoked Quit smoking Currently Smoking Chronic Coughc Yes No Constipationa
Test and p value t=-0.963 0.336
F=0.103 0.902
t=2.325 0.819
F=0.304 0.738
z=-0.405 0.685 χ2=2.284 0.319
t=81.134 <0.0001 χ2=16.858 <0.0001
z=-2.551 0.011
t=67.671 <0.0001
Urinary Tract Disease (n=183)a,e Yes
37
11.00
0-35
No 146 6.12±7.38 History of Urinary Tract Infection (n=200)a,e
4.00
0-42
Yes
8.00
0-42
96
12.65±9.23
10.59±8.68
No 104 5.12±6.60 3.00 Urinary Incontinence in Mother and/or Sister (n=175)a,e
0-40
Yes
42
12.33±9.88
8.00
1-40
No
133
6.18±7.00
4.00
0-42
t=48.297 <0.0001
t=176.904 <0.0001
t=54.627 <0.0001
a
Independent Samples t test was used. b One-way ANOVA test was used. c Mann-Whitney U test was used. d Kruskal Wallis test was used. e Responses such as “I don’t know” were excluded from the statistical analysis.
Table 4. The Linear Regression analysis for the variables influencing the BFLUTS-SF scores of the adolescent pregnant women interviewed Certain Variables Daily Coffee Consumptiona Present versus absent Smoking Quit smoking versus never smoked Smoking versus never smoked Chronic Cougha Present versus absent Constipationa Present versus absent History of Urinary Tract Infectiona Present versus absent Constant
B
SE
β
t
p
4.884
0.939
0.272
5.202
<0.001
19.991 9.747
2.525 2.793
0.408 0. 178
7.917 3.490
<0.001 0.001
8.178
2.313
0.182
3.536
0.001
4.698
1.019
0.239
4.610
0.001
3.049 1.857
0.888 0.636
0.185
3.434 2.919
0.001 <0.001
n=206, R=0.763, R2=0.582, Adjusted R2=0.564, F= 32.570, p<0.001 a: Independent variable, 0= Absent, 1=Present, B: Regression coefficient, SE: Standard error, β: Standardized regression coefficient.