LUTS (2015) 7, 22–26

ORIGINAL ARTICLE

Assessment of the Impact of Male Urinary Incontinence on

Health-Related Quality of Life: A Population Based Study
Hyoung Keun PARK,1 Sounghoon CHANG,2 Mary H. PALMER,3 Inja KIM,4 and
Heejung CHOI5∗
1
Department of Urology, School of Medicine, Konkuk University, Seoul, Korea, 2 Department of Preventive Medicine,
School of Medicine, Konkuk University, Seoul, Korea, 3 School of Nursing, The University of North Carolina, Chapel Hill,
North Carolina, USA, 4 Department of Nursing, Daejeon University, Daejeon, Korea , and 5 Department of Nursing,
Konkuk University, Seoul, Korea

Objective: To assess the impact of male urinary incontinence on health-related quality of life by population based
study.
Methods: A two-stage systematic sampling method was adopted. A total of 5830 men participated in this survey. Face
–to-face interviews were used to collect data. Urinary incontinence and symptom bother were measured with the
Urogenital Distress Inventory-6 (UDI-6). General health-related quality of life (QoL) was measured using EQ-VAS,
which evaluates the respondent’s self-rated health on a vertical visual analogue scale.
Results: The age-adjusted prevalence of Korean male UI was 5.5%. Incontinent men reported higher score of UDI-6
and lower score of EQ-VAS than continent men. Men with mixed urinary incontinence reported significantly lower
QoL than men with pure stress or urge incontinence.
Conclusions: Urinary incontinence affects men’s QoL negatively. In particular, mixed urinary incontinence has the
greatest impact on QoL.

Key words epidemiology, quality of life, urinary incontinence

1. INTRODUCTION
Urinary incontinence (UI) is a common but stressful
problem affecting the female population. Generally, its
impact on quality of life has been best characterized in
women. Indeed, recent studies have found noteworthy
decreases in the health-related quality of life (QoL) in
those women suffering from UI.1 – 3
However, UI is a problematic disease affecting not
only women, but also between 5 and 32% of men,
depending on how it is defined and the age and loca-
tion of the surveyed population.4 – 6 Additionally, UI is
an important contributor of reduced QoL in men espe-
cially following prostatectomy.7,8 Moreover, there is some
evidence to suggest that the negative impact of moder-
ate and severe UI on QoL is greater in men than in
women.9
Most studies on male UI have been performed
in patients undergoing radical prostatectomy or
transurethral resection of the prostate. Additionally,
while there have been a few general population-oriented
studies in Asian populations,6,10 none have studied how
symptoms of urinary incontinence affect the quality of
life of Asian men.
We recently performed a large population-based epi-
demiologic survey of urinary incontinence in Korean
men. The purpose of this study was to assess the impact
of male urinary incontinence on health-related QoL.
2. METHODS
A population-based epidemiologic survey was per-
formed in Korea in 2008. We have described the detailed
procedure of this study in a previous paper.11 A two-
stage stratified proportional systematic sampling method
was used so that the data accurately reflected the Korean
population. For the first step, a total of 1211 target areas
were selected through the proportional systematic sam-
pling in the Chungbuk area, 1 of 16 areas in Korean
territory. In the second step, 5–6 households were sam-
pled randomly within every selected area. Finally, a total
of 6279 households were selected, and all eligible men
in those households were interviewed. Eligibility criteria
included an age of 19 years or older and the ability to
communicate without any problems.
After obtaining informed consent, face-to-face inter-
views using a structured short form Urogenital Distress
Inventory-6 (UDI-6) questionnaire were performed to
∗ Correspondence: Heejung Choi, 322 Danwol-dong, Chungju, Chungbuk
380–701, South Korea. Tel: +82-43-840-3954; Fax: +82-43-840-3929. Email:
hjchoi98@kku.ac.kr
Received 30 May 2013; revised 3 September 2013; accepted 17 September
2013
DOI: 10.1111/luts.12043

© 2013 Wiley Publishing Asia Pty Ltd

 Impact of Male Urinary Incontinence on Health-Related Quality of Life
measure the presence of incontinence, its type and how
much it bothered the interviewee on a scale of 0 (not
at all) to 3 (greatly bothered).12 The UDI-6 question-
naire consisted of six questions relating to urinary fre-
quency, urge incontinence, stress incontinence, other
incontinence, hesitancy and pain or discomfort. Urge
UI (UUI) was defined as urine leakage related to the
feeling of urgency and stress urinary incontinence (SUI)
was defined as urine leakage related to physical activity,
coughing, or sneezing. Those who reported both UUI and
SUI were regarded as having mixed urinary incontinence
(MUI). Those experiencing involuntary urinary leakage,
but neither UUI nor SUI, were regarded as having ‘‘other
UI.’’ UDI score was calculated by the sum of UDI-6 item
score. Urinary symptom was defined as symptoms in
questions about urinary frequency hesitancy and pain or
discomfort. If a subject scored more than one point to the
question, the subject was considered as ‘‘having urinary
symptom’’.
General health-related QoL was measured using EQ-
VAS,13 which evaluates the respondent’s self-rated health
on a vertical visual analogue scale (VAS). The EQ-VAS
records the respondent’s self-rated health on a 20 cm
vertical, visual analogue scale with endpoints labeled
‘‘the best health you can imagine’’ and ‘‘the worst health
you can imagine.’’ Respondents are asked to rate their
overall health-related quality of life on a standard vertical
20 cm visual analogue scale (similar to a thermometer)
between 100 (best health imaginable) and 0 (worst health
imaginable).
The questionnaire was translated and revised by lin-
guists and clinicians and piloted in small group of par-
ticipants to test for overall acceptability and compre-
hensiveness. A total of 50 interviewers preformed the
interview. Interviewers were trained and educated about
urinary symptom and incontinence and we tried to make
interviewers qualified to judge the type of UI. Quality
control checks were performed on them. They distributed
the questionnaires to the subjects and after complet-
ing the questionnaire, they checked verbally whether
subjects understood the exact meaning of the questions
and the answers that the subjects supplied. The inves-
tigated population was divided into three groups: those
with continence and no urinary symptoms, those with
continence and with urinary symptoms, and those experi-
encing incontinence. The incontinence group was further
subdivided according to the type of incontinence experi-
enced: stress UI, urge UI, mixed UI, or other. The UDI-6
scores EQ-VAS score were compared between the groups.
Statistical analysis was performed using PASW ver.
17.0. One-way analysis of variance (ANOVA) was used to
compare intergroup variables. A P-value of < 0.05 was
considered statistically significant.
3. RESULTS
Of 6279 households contacted, 5831 men agreed to
participate in the survey yielding a response rate of
92.8%. The mean age was 50.0 years (±16.16) and
the weighted percentages of participants aged 19–44,
© 2013 Wiley Publishing Asia Pty Ltd
23
45–64, and 65 years and older were 52.2, 35.1, and
12.7%, respectively. The demographic characteristics of
study participants were described in previous paper11 and
Table 1.
A total of 426 men reported having urinary inconti-
nence. The age-adjusted prevalence of UI was 5.5%. The
prevalence of stress UI, urgency UI, and mixed UI were
1.1, 1.9, and 1.7%, respectively.
The mean score of health-related QoL as measured by
UDI-6 and EQ-VAS varied significantly different depend-
ing on the presence of incontinence (P < 0.001) (Table 2).
The mean UDI-6 score of the incontinence group was
significantly higher than that of the continence group.
Additionally, the mean EQ-VAS score of the incontinence
group was lowest, followed by the group with continence
with urinary symptoms, and the highest mean score for
continence without any urinary symptom group.
Within the incontinence group, UDI-6 mean scores
were significantly different depending on the type of
incontinence experienced (P < 0.001). Those with MUI
reported the highest scores (4.84 ± 4.80), followed
by those with UUI (1.93 ± 2.93) and those with SUI
(0.50 ± 1.22). In the case of EQ-VAS scores, men with
MUI (62.5 ± 21.3) reported significantly lower scores
than men with SUI (68.9 ± 18.6) or UUI (69.8 ± 17.9)
(P = 0.01) (Figs 1,2).
4. DISCUSSION
Urinary incontinence is associated with deteriorating
quality of life and has been related to dependence in
activities of daily living, depressed emotion and negative
affect.3 Indeed, one study has found that the quality of
life impairment due to incontinence is comparable to that
of other chronic medical diseases.14
Urinary incontinence has been documented as a well-
known and significant factor of reduced health-related
QoL and health utility in men. However, most studies
investigating male UI have been in patients who have
had prostate surgery7,8 and rarely include the general
population.2,3 Therefore, we performed a population-
based epidemiological survey investigating the preva-
lence of UI and its impact on QoL in men and we
TABLE 1. Demographic characteristics of the sample
Frequency†
Characteristics Level (%)‡
Age (years) 19–44 2353 (52.2)
45–64 2183 (35.1)
≥ 65 1295 (12.7)
Educational level Under high school level 2245 (30.0)
High school graduate 2206 (42.9)
College or higher level 1380 (27.1)
Marital status Currently married 4275 (67.1)
Never married 999 (24.2)
Others§ 557 (8.7)
Job Having a job 4333 (75.6)
No job¶ 1498 (24.4)
†Unweighted. ‡Weighted. §Including men who are bereaved or separated
or divorced. ¶Including college students and men in military service.
24 Hyoung Keun Park et al.
TABLE 2. Health-related quality of life (QoL) according to urinary symptoms and incontinence
Variables
Urinary symptom and Continencea
incontinence Continence with symptom(s)b
Incontinencec
a
Continence; b Continence with symptom(s); c Incontinence. UDI, urogenital distress inventory; UI, urinary incontinence. Symptom(s): symptom in UDI:
frequency, hesitancy, and pain or discomfort.
Fig. 1 Comparison of UDI-6 score according to type of incontinence
UDI-6 mean scores were significantly different depending on the type of
incontinence experienced (P < 0.001). Those with mixed urinary
incontinence (MUI) reported the highest scores (4.84 ± 4.80), followed by
those with urge urinary incontinence (UUI) (1.93 ± 2.93) and those with
stress urinary incontinence (SUI) (0.50 ± 1.22).
Fig. 2 Comparison of EQ-VAS according to type of incontinence. Men
with mixed urinary incontinence (MUI) (62.5 ± 21.3) reported significantly
lower scores than men with stress urinary incontinence (SUI)
(68.9 ± 18.6) or urge urinary incontinence (UUI) (69.8 ± 17.9) (P = 0.01).
described the prevalence of male incontinence in a pre-
vious paper.11 The prevalence of urgency urinary incon-
tinence (1.9%) in this study was lower than those of
previous other studies.2,5,6 The reason for the difference in
prevalence between this study and other reports might be
UDI score EQ-VAS score
Means (SD) P-value Means (SD) P-value
0.00 (0.00) P < 0.001 78.55 (14.31) P < 0.001
0.50 (1.20) a<b<c 74.47 (17.29) a>b>c
2.51 (3.82) 67.47 (19.79)
differences in population composition, questionnaire and
data collection method. For example, the proportions
of men aged 19–44, 45–64, and 65 years and older
were 52.2, 35.1, and 12.7%, respectively, in this study.
However, in a Japanese study,6 the entire study popula-
tion was over 40 years and the percentage of men aged
60 years old was more than 40%. When stratified by age,
our data showed similar urge UI prevalence (6.6%) in old
men (> 65 years old) in the previous paper.11 Also, direct
face-to-face interview might prevent male subjects from
freely telling about their embarrassing incontinent state
rather than mailing method of the US study.
The results of this study showed incontinent men
reporting significantly higher UDI-6 and lower EQ-VAS
scores compared to continent men, suggesting that UI
negatively affects QoL in men. These results are in
line with what has been reported in many studies of
women.1 – 3,15 – 18 Likewise, in men, Johnson et al.19 have
found a significant relationship between self-rated health
and UI in community-dwelling adults after adjustment
for age, co-morbidity and frailty. Roberts et al.20 have
also reported significant impacts on quality of life,
measured in terms of dissatisfaction with spending the
rest of one’s life with a urinary condition. These results
are consistent with ours.
Furthermore, we found that continent men with uri-
nary symptoms reported having a lower QoL than those
without any urinary symptoms. This indicates that other
urinary symptoms, such as frequency or difficulty in blad-
der emptying, also affect the QoL of men, consistent with
other reports.21,22
Several studies have reported that the impact of incon-
tinence on QoL may depend on its type.2,16,23,24 In studies
of women, UUI and MUI have been shown to have greater
impacts than SUI on general health-related QoL2,16 and
incontinence-specific QoL.23 In contrast, there is little
known about how different subtypes of UI affect QoL
in the male population. In the present study, those men
with MUI reported the highest UDI-6 scores, followed by
those with UUI and then SUI. Also, when QoL was mea-
sured by EQ-VAS, men with MUI reported significantly
lower QoL than men with SUI or UUI. The results of this
study indicate that MUI may have the greatest impact on
incontinence-specific QoL, as in studies of women.2,16,23
One recent study showed that men with mixed incon-
tinence or other-type incontinence bear a greater mental
health burden and report poorer health-related QoL.2
The results of this study support our findings that MUI
© 2013 Wiley Publishing Asia Pty Ltd
 Impact of Male Urinary Incontinence on Health-Related Quality of Life
was the incontinence type with the lowest reported QoL
scores. The unpredictable component of urge inconti-
nence episodes could be one explanation that MUI is the
type of incontinence associated with the lowest QoL in
men and women. Those with SUI can adapt their lifestyle
by, for example, avoiding heavy lifting or exercising,
thereby preventing situations that lead to involuntary
loss of urine.24 Wyman et al. have suggested that UUI
and MUI are particularly distressing, as patients cannot
predict incontinent episodes, and thus have less control
over their bladder symptoms.25
There was a difference in UDI-6 score between UUI and
SUI groups, while there is no difference in EQ VAS. That
discrepancy can be explained in that UDI-6 and EQ VAS
questionnaires have somewhat different purposes. UDI-6
showed how much subjects were bothered about uri-
nary symptoms including incontinence. So, UDI-6 results
showed that the UUI group felt their urinary symptoms
including urge incontinence were more uncomfortable
than the SUI group. The EQ-VAS showed general health-
related QoL and EQ-VAS results showed that the UUI and
SUI group showed similar general health-related QoL.
Although the degree of bother of urinary symptoms is
often correlated with general health-related QoL, that
was not always consistent and not with SUI and UUI
group in this study.
There are several limitations to this study. First, the
sampling was conducted in a single geographic area, albeit
a large probabilistic sample. Therefore, caution should be
taken when generalizing our results. Second, the incon-
tinence definition and classification used are fully based
on self-report according to questions, although the ques-
tions used in this study were from valid and reliable
questionnaires and consistent with ICS definitions.
Finally, as mentioned in the previous paper,11 Korean
validation test was not performed. However the ques-
tionnaire was piloted in a small group of participants
and interviewers were well trained so that the chance of
misunderstanding the questionnaire was minimized.
Despite these limitations, this study showed that
UI, as well as other urinary symptoms, affects the
QoL of men as it does women. In addition, men with
MUI reported the lowest general health-related and
incontinence-specific QoL.
Conclusively, our study showed that UI negatively
affects men’s health-related QoL in the general popu-
lation. For those men with incontinence, the MUI type
had the greatest impact on incontinence-specific and gen-
eral health-related QoL. Physicians should consider that
incontinence, especially urge urinary incontinence, can
lower the quality of life of men, and they should accord-
ingly develop management strategies for this condition.
Acknowledgement
This work was supported by Konkuk University.
Disclosure
The authors declare no conflict of interest.
© 2013 Wiley Publishing Asia Pty Ltd
25
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