WOMEN'S HEALTH
WOMEN'S HEALTH
Prevalence of Urinary Incontinence in Women
With Osteoporosis
Meena M. Sran, PT, PhD
BC Women’s Hospital and Health Centre, Osteoporosis Program, Vancouver BC
Simon Fraser University, Injury Prevention and Mobility Laboratory, Burnaby BC
Abstract
Objective: To investigate the prevalence and frequency of urinary
incontinence in women presenting to a specialist osteoporosis
clinic.
Methods: Participants included 412 female patients aged 22 to
94 years (mean 62 years) presenting to a hospital-based specialist
multidisciplinary osteoporosis clinic over one year. The presence
or absence of urinary incontinence, urgency without leakage, type
of symptoms (stress, urge, mixed) and frequency of urinary
incontinence were recorded.
Results: Sixty-seven percent of patients (277/412) reported some
symptoms of urinary incontinence, 23% reported no symptoms
and 10% reported urgency without any leakage. Of those who
reported some urinary incontinence, 51% reported symptoms of
stress incontinence, urgency, and urge incontinence. Almost 40%
of all patients (163/412) and 59% of those with any urinary
incontinence (163/277) reported leakage at least once per week.
Conclusion: The prevalence of at least weekly urinary incontinence
in this population is much higher than that reported in studies of
other older adult female populations. There is also a high
prevalence of incontinence accompanied by urgency in women
with osteoporosis. Based on these results and because urinary
incontinence can limit a woman’s ability to be physically active and
increase the risk of falls and fractures, screening for incontinence
should be a routine part of osteoporosis management. Clinicians
seeing patients for osteoporosis should consider the presence of
incontinence when prescribing exercise for bone health and fall
prevention.
Résumé
Objectif : Explorer la prévalence et la fréquence de l’incontinence
urinaire chez les femmes qui se présentent à une clinique
spécialisée en ostéoporose.
Méthodes : Les participantes consistaient en 412 patientes dont
l’âge se situait entre 22 et 94 ans (âge moyen : 62 ans) qui se
sont présentées à une clinique multidisciplinaire (en milieu
hospitalier) spécialisée en ostéoporose sur une période d’un an.
La présence ou l’absence d’incontinence urinaire, l’impériosité
sans fuites, le type de symptômes (à l’effort, par impériosité,
mixte) et la fréquence de l’incontinence urinaire ont été consignés.
Key Words: Osteoporosis, urinary incontinence, prevalence,
female, epidemiology
Competing Interests: None declared.
Received on October 3, 2008
Accepted on February 2, 2009
434 l MAY JOGC MAI 2009
Résultats : Soixante-sept pour cent des patientes (277/412) ont
signalé certains symptômes d’incontinence urinaire, 23 % n’ont
signalé aucun symptôme et 10 % ont signalé une impériosité sans
fuites. Parmi les patientes qui ont signalé une certaine
incontinence urinaire, 51 % ont signalé des symptômes
d’incontinence à l’effort, d’impériosité et d’incontinence par
impériosité. Près de 40 % de toutes les patientes (163/412) et de
59 % de celles qui présentaient une quelconque incontinence
urinaire (163/277) ont signalé au moins une fuite par semaine.
Conclusion : La prévalence de l’incontinence urinaire au moins
hebdomadaire au sein de cette population est beaucoup plus
élevée que ce qui a été signalé par les études menées auprès
d’autres populations de femmes âgées. Nous constatons
également une forte prévalence d’incontinence accompagnée
d’impériosité chez les femmes qui présentent une ostéoporose.
En fonction de ces résultats et puisque l’incontinence urinaire peut
limiter la capacité d’une femme à être physiquement active et
accroître le risque de chute et de fracture, le dépistage de
l’incontinence devrait systématiquement faire partie de la prise en
charge de l’ostéoporose. Les cliniciens qui offrent leurs services à
des patientes présentant une ostéoporose devraient envisager la
présence d’une incontinence au moment de prescrire un
programme d’exercice visant la santé osseuse et la prévention
des chutes.
J Obstet Gynaecol Can 2009;31(5):434–439
INTRODUCTION
rinary incontinence (UI) is the second leading reason
U for admission to long-term care1 and a top health pri-
ority for older women.2 The prevalence of UI increases with
age.3–5 Reported prevalence for weekly UI in older adult
women ranges from 21% to 28%3,5–7 and the economic cost
of UI in the United States is 16 billion dollars per year.8 Yet
only 25% of all women with UI seek help.9,10
Osteoporosis is also common in older adult women11 and
incurs high costs.12–14 Physical activity is an important part
of osteoporosis treatment aimed at maintaining bone
mass15 and reducing falls16–20 and should be prescribed for
all patients with osteopenia or osteoporosis. However, UI
can significantly limit a woman’s ability to be physically
active21 and is an independent risk factor for falls and low
trauma fractures in older women.22,23 The presence of UI
may dramatically influence exercise prescription and com-
pliance with exercise in women with osteoporosis, yet it is
 Prevalence of Urinary Incontinence in Women With Osteoporosis

not routine for physicians24 or other health care profession-

Table 1. Prevalence of UI
als to ask about incontinence, and it is typically only after
symptoms have been present for 6–10 years that women Presence/absence of UI n % of all patients
mention UI to a health care professional.25 The prevalence Any urinary incontinence 277/412 67.2
of UI in women with osteoporosis or osteopenia is not No urinary incontinence 91/412 22.8
known, nor is the prevalence in women presenting to an Urgency only, no leakage 41/412 9.9
osteoporosis clinic. Knowing whether UI is prevalent in
this population may help health care professionals “treat the
whole person,” and result in more woman-centred care. If
UI is prevalent in this population, then clinicians treating Table 2. Frequency of UI
individuals with osteoporosis may need to change their
% of all % of patients
practice to include routine screening for UI and referral for Frequency of UI n patients with UI
treatment, and to consider UI when prescribing exercise for
Once per day or more 69 16.5 24.5
bone health.
Twice in 3 days 41 9.9 14.8
For these reasons, this study was undertaken to investigate Once per week 54 13.1 19.5
the prevalence and frequency of urinary incontinence in Once per month 40 9.7 14.4
women presenting to a specialist osteoporosis clinic. Specif- < Once per month 73 17.7 26.3
ically, a self-administered questionnaire followed by
interview was used to assess (1) the presence or absence of
urinary incontinence, (2) the type of symptoms (stress, urge, by a physiotherapist at the end of the study period. The
mixed) and (3) the frequency of incontinence episodes, in most appropriate answer (once per week, twice in three
all new female patients presenting to the clinic over one days, once per day, once per month, or less than once per
year. month) was recorded on a standardized form. These ques-
METHODS tions are similar to those used in previous epidemiologic
studies3,4,6,26 and have been found to have good specificity,27
Data were collected in a multidisciplinary osteoporosis and accuracy similar to other, longer questionnaires.28
clinic over a one-year period (June 2007 to May 2008). To
be seen in this clinic, patients must be referred by their fam- Descriptive data were calculated. Data were expressed as
ily physician. In the clinic each new patient routinely the percentage of female patients who reported
receives a consultation with a physiotherapist, dietitian, 1. any UI (responded sometimes or yes, always to
physician and a nurse. questions 1 and/or 3)
Over the one-year period, 447 new patients were seen in the 2. no UI (responded never to questions 1 and/or 3)
clinic, of whom 414 (92.6%) were female. All except two
3. urgency only, without leakage (responded sometimes
female patients were included in this study, and all male
or yes, always to question 2 only)
patients were excluded. One female was excluded because
she was paraplegic and used an indwelling catheter; the Data were also expressed as a percentage of all female
other was excluded because she used a urostomy bag. Thus patients with any UI who reported
data for 412 female patients were included. 4. symptoms of stress UI only (responded sometimes or
Prior to attending the clinic, each patient received a stan- yes, always to question 1 only)
dardized questionnaire that included three questions about 5. symptoms of urge UI only (responded sometimes or
urinary incontinence, and each female patient was asked to yes, always to question 3 only)
complete this. The three questions were: (1) Do you leak
urine when you cough, sneeze, laugh, lift, jump, or run? (2) 6. urgency and symptoms of stress UI (responded
Do you rush to the toilet when you feel an urge? (3) Do you sometimes or yes, always to both questions 1 and 2)
lose urine when you rush to the toilet? Each question 7. urgency and symptoms of urge UI (responded
required one of three answers: (i) yes, always; (ii) sometimes; sometimes or yes, always to both questions 2 and 3)
or (iii) never. If the patient answered sometimes, or yes,
Finally, frequency of UI data were expressed as a percentage
always for question (1) or question (3), then the physiother-
of all female patients and of all those with any UI.
apist asked the patient to report how often they have even a
small amount of leakage. The data from the completed This study was approved by the clinical ethics review board
questionnaires were reviewed and entered on a spreadsheet of BC Women’s Hospital and Health Centre.

MAY JOGC MAI 2009 l 435

WOMEN'S HEALTH
Figure 1. Percentage of patients in each age group: 75 years and over (n = 71), 65–74 years
(n = 89), 55–64 years (n = 152), 45–54 years (n = 80), 35–44 years (n = 14), 22–34 years (n = 6)
Percentage of all patients
Age (years)
RESULTS
The 412 female patients ranged in age from 22 to 94 years
(mean 62 ± 12 years [SD]). More than 75% of patients were
over 55 years of age (Figure 1). Sixty-seven percent of
patients (277/412) reported some symptoms of UI, 23%
reported no symptoms of UI and 10% reported urgency
without any leakage (Table 1). Of the patients who reported
any UI or urgency without leakage, 75% had osteoporosis
based on bone mineral densitometry (BMD) or a history of
a low trauma fracture, while the remaining 25% had
osteopenia based on BMD.
Of those who reported any UI, 51% (143/277) reported
symptoms of stress UI, urgency, and urge UI (answered
sometimes or yes, always to all three questions). Sixteen per-
cent (45/277) reported symptoms of urgency and urge UI,
and 14% (39/277) reported symptoms of stress UI only or
stress UI and urgency. One patient reported symptoms of
urge UI alone and 10/277 reported symptoms of both
stress and urge UI (Figure 2).
Almost 40% of all patients (163/412) and 59% of those
with any UI (163/277) reported leakage one time per week
or more (Table 2).
Of these 412 female patients, one frequently had renal cal-
culi, one had multiple sclerosis, one had a history of bladder
cancer, and one had had an ovarian cystectomy 12 years
beforehand. In addition, 11 patients had a history of
anti-incontinence surgery or surgical procedures for pro-
lapse. Of these 11 patients, one had undergone two proce-
dures and another had undergone three. Ten of the 11
436 l MAY JOGC MAI 2009
continued to leak urine involuntarily; four had daily leakage,
one leaked twice in three days, three leaked once per week,
one leaked once per month, and one leaked less than once
per month. Six patients reported use of medication (five for
UI and one for overactive bladder), two patients had seen a
physiotherapist specializing in UI, one was waiting to see a
physiotherapist, and two reported routinely performing
pelvic floor muscle exercises.
DISCUSSION
In a population of women with osteoporosis or osteopenia
who presented to a specialist osteoporosis clinic, 67%
reported one symptom or more of UI, and almost 40%
reported experiencing UI once per week or more. The prev-
alence of at least weekly UI in this population of women
with osteoporosis or osteopenia is much higher than in pre-
vious studies of older adult women.3,5–7,29 Wetle et al.7
reported a 21% prevalence of weekly UI in women aged 65
or older; Hannestad et al. reported a 25% prevalence across
their whole population, and the prevalence reached 40%
only in individuals over 90 years of age. Jackson et al.29
reported a 21% prevalence of weekly UI in women aged
70–79. Brown et al. assessed women of a mean age very
similar to the current study but with coronary artery disease,
and reported a 28% prevalence of weekly UI.
These results therefore suggest that the prevalence of UI in
women presenting to an osteoporosis clinic is much higher
than the previously reported prevalence of UI in older adult
female populations. How the presence of osteoporosis
might increase the risk of UI is not known, but a previous

Figure 2. Type of urinary incontinence (UI) symptom(s) reported by all patients reporting any
UI (n = 277)
Percentage of all patients with any UI
Type of UI symptom(s)
study found self-reported osteoporosis to be associated
with disposable pad use (OR 2.01).30 Spinal curvature
(kyphosis/lordosis) associated with spinal osteoporosis
may also play a role. A previous study found spinal curva-
ture was related to pelvic organ prolapse,31 and sitting spinal
posture (slump or upright, with or without support) has
been shown to influence resting activity of the pelvic floor
muscles.32 Further, individuals with osteoporotic spinal
compression fractures may present with impaired pulmo-
nary function,33 which may in turn influence strength,
endurance and/or timing of the pelvic floor muscles.
The majority of patients with UI also reported rushing to
the toilet when they felt an urge (81.9%; Figure 2), while a
further 10% who did not report any UI reported rushing
(Table 1). Brown et al.23 reported that weekly or more fre-
quent urge incontinence increased the risk of falls and low
trauma fractures in older women. In addition, falls and UI
were in the top six disability-related priorities identified in a
survey of women’s health priorities, and fall-related injuries
incur enormous cost to the individual and the health sys-
tem.34 Further, the ability to maintain balance has been
found to be decreased in women with stress UI, compared
with continent women.35
The results of this study, specifically the high prevalence of
UI and UI accompanied by urgency in this osteoporosis
clinic population, indicate that screening for UI should be a
routine part of osteoporosis management. Higher levels of
physical activity are also associated with a reduced risk of
UI.36,37 Thus, enabling women to be more active is
Prevalence of Urinary Incontinence in Women With Osteoporosis
important for the prevention of both UI and osteoporotic
fractures.
A previous study found physicians who spent 15 minutes
with each patient and saw fewer patients per week were
more likely to screen for UI.38 In the specialist
multidisciplinary clinic in which this study was conducted,
each patient spends 45 minutes with a physician and is also
seen by a physiotherapist and a nurse, all of whom have the
ability to screen for and recommend appropriate treatment
for UI. Although this setting is favourable, practical time
constraints should not obviate screening for UI, and clinics
and practitioners must ensure that UI is addressed, because
patients are unlikely to describe UI spontaneously.25 A
method of routine screening, such as that used in this study,
is recommended. While UI screening is relevant for fall pre-
vention and exercise prescription in individuals with osteo-
porosis, it is also part of providing comprehensive care of
women’s health issues. In a large population survey, women
identified “being seen as a whole person” as their highest
psychosocial health priority. Importantly, women with UI
are more likely to suffer from depression and
low-self-esteem than women without UI.39 UI can result in
isolation from family and friends,40 and marital relation-
ships and sexual function are negatively affected in women
with UI.41
There is strong evidence for the use of supervised individ-
ual pelvic floor muscle training as a primary treatment for
UI in women.9,42–44 Clinical practice guidelines recommend
conservative management for UI in older women; a ran-
domized controlled trial of physiotherapy for UI in women
MAY JOGC MAI 2009 l 437
WOMEN'S HEALTH
with osteoporosis and UI in our centre is currently near
completion.
Poor recognition of patients who could benefit is prevent-
ing treatment of this prevalent condition.9,45 Whether or not
an individual will seek treatment for UI appears to be more
strongly linked to whether or not they perceive UI as a
problem46 than to the frequency of UI or the amount of
leakage.47 Patients may believe that UI is a normal part of
aging, and may be unaware of the consequences or recom-
mended treatment. This places greater importance on the
need for health care professionals to screen for UI and
advise patients of the evidence and recommendations. Edu-
cation by health care professionals, who may primarily be
seeing patients for conditions other than UI, may help
patients understand the importance of seeking treatment
for UI, which has been shown to have a significant negative
effect on overall health.48–52
The questions asked in this study regarding UI symptoms
are similar to those used in other epidemiologic stud-
ies,3,4,6,26 and have been shown to have fair accuracy and
good specificity,27 but further questions regarding which
activities were more or less of a problem may yield more
accurate results regarding the type of incontinence.28 The
questions used were found, in a previous study, to
over-report mixed UI that should have been diagnosed as
pure stress UI.27 From the perspective of clinical utility, if
knowledge of the type of UI (stress, urge, or mixed) will
alter the physician or other health care professional’s refer-
ral or treatment of the patient’s condition, then it would be
advisable to include more detailed questions regarding the
type of UI, as classifying the type of UI based on responses
to a questionnaire has shown acceptable accuracy.28 Of
note, the self-administered questionnaire and follow-up
interview used in this study were also chosen for their feasi-
bility, since the clinic’s protocol includes completion of a
self-administered questionnaire prior to the patient’s first
visit to the clinic. A validated interviewer-administered tool
is recommended for future studies. This study did not
investigate the prevalence of known risk factors for UI in a
population with osteoporosis, and a follow-up study may
provide additional insights. Finally, the frequency of
urgency alone was not assessed. Future studies might
include this variable given the potential relevance to the risk
for falls.
CONCLUSION
The prevalence of UI in this osteoporosis clinic population
was much higher than that reported in previous studies of
older adult women. This suggests a need for important
changes in clinical practice, particularly regarding screening,
referral, and education regarding the negative effect of UI
on health and evidence-based, effective, non-surgical, and
438 l MAY JOGC MAI 2009
surgical treatment options for UI in older adult women,
especially women with osteoporosis. Clinicians who are
seeing patients for osteoporosis should consider the pres-
ence of UI when prescribing exercise for bone health and
fall prevention.
ACKNOWLEDGEMENTS
The author is a Canadian Institutes of Health Research and
Michael Smith Foundation for Health Research Postdoc-
toral Fellow.
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