In men and women with COPD the presence of urinary incontinence is associated with poorer quality of life
- Correspondence to
: Dr Diane K Newman
Division of Urology, University of Pennsylvania, 3rd Floor West Perelman Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USA;
Implications for practice and research
The combination of coughing, as a result of chronic obstructive pulmonary disease (COPD), and urinary incontinence (UI), can adversely affect quality of life.
Healthcare providers must actively screen for UI in patients who smoke, have a chronic cough and/or who are diagnosed with COPD, as early treatment may improve quality of life.
It is estimated that worldwide, over 200 million people are living with UI.1 UI is linked to an increase in social detachment, falls and fractures, depression, decreased ability to concentrate, increased anxiety, and admissions to nursing homes, resulting in immeasurable economic and quality-of-life deficits.1 It is also believed that chronic coughing secondary to smoking or COPD is a risk factor for developing UI. Coughing causes increased intra-abdominal pressure, which directly increases the pressure in the bladder. Usually, the sphincter muscle is able to contract tightly to avoid leakage of urine. However, it is felt that persons who cough repetitively weaken the ligaments of the pelvic floor muscles that support the external sphincter, and incontinence, specifically stress UI, can occur.
The authors used a descriptive survey design. A questionnaire survey was administered to 391 women and 337 men (aged 50–73 years) with COPD, to investigate the impact of cough and UI on quality of life. The questionnaire used for this study was the clinical COPD questionnaire (CCQ) which is a disease-specific questionnaire for patients with COPD. Data were collected between November and December 2007 as part of a larger project. The study was conducted in central Sweden and the questionnaire was mailed to patients identified as having a diagnosis of COPD.
A response rate of 68% was obtained. Of the women (n=193), 194 (49.6% CI 45% to 51%) reported UI. Of the men (n=337), 102 (30.3% CI 25.6% to 33.3%) reported UI. Both women and men with UI showed a significantly higher prevalence of symptomatic cough and phlegm production. Compared with women without UI, women who reported UI had a significantly higher burden of CCQ symptoms, functional and mental state. Men who reported UI had a significantly higher burden of CCQ symptoms compared with men without UI. Women with UI had lower physical state scores than women without UI. An interesting finding was that men and women with UI had a significantly higher body mass index (BMI) than those without incontinence.
This study by Hrisanfow and Hagglund provides much needed evidence-based findings on the relationship between COPD and UI. There is a paucity of research on this relationship.1–⇓⇓⇓5 A US population-based cohort of 2109 women aged 40 – 69 years, including racially and ethnically diverse participants, found an adjusted association between a change in continence status and COPD at baseline but not with other comorbidities.2 There is a significantly increased risk of UI among non-pregnant female heavy smokers, former and current, compared with women who have never smoked.3 ,4 A cohort study of 523 American women found that smoking before pregnancy compared with not smoking gave the highest independent risk for UI postpartum in multivariable analyses (OR=2.9, 95% CI 1.4 to 3.9).5 Therefore, if there is an association, avoiding smoking before pregnancy may reduce postpartum UI.
COPD is associated with chronic coughing that precipitates stress UI or worsens existing UI. As the authors indicated, physical factors caused by COPD play a role as they can increase the risk of the development of UI. Other symptoms of COPD, such as fatigue and shortness of breath which can impair mobility, may trigger an incontinent episode.
It is becoming more evident that pulmonary disease and smoking trigger coughing and coughing increases the pressure on the bladder and pelvis. This places an individual at increased risk of lower urinary tract symptoms (LUTS), and specifically UI. Healthcare providers need to be proactive in screening for LUTS in a patient with COPD.