In this secondary analysis using baseline data from three RCTs, we found that QoL was decreased in women seeking care for UI using e-health, and that it was the severity of the leakage that had the highest impact on QoL. Type of UI also affected QoL, but not to the same extent. Lack of university education and comorbidity both had a negative impact on QoL, but age itself had no significant effect.
In our study, the mean ICIQ-UI SF score for all included women was 10.9, which corresponds to a moderate leakage [24], and the mean ICIQ-LUTSqol score was 34.9. Slightly lower scores were found in a survey from 2015 that included women in the age 45–60 years in the UK, France, Germany, and the USA, with unspecified subtypes of UI, who filled out a questionnaire via the Internet. These results showed a moderately severe leakage (overall ICIQ-UI SF score 8.7) with a mean ICIQ-LUTSqol score of 32.8 for the 1,203 participants. [26] Comparing to studies including women who sought care for their UI in ordinary ways, an RCT from urban parts of Malaysia, including baseline data from 120 women with SUI receiving non-surgical treatment for their UI, showed a mean ICIQ-UI SF score of 10.0 and a mean ICIQ-LUTSqol score of 39.0, giving it a slightly lower impact on severity, but slightly higher impact on QoL compared to our study population. [27] Moreover, an RCT including 600 women with newly clinically diagnosed SUI or MUI, conducted in centres providing continence care in the UK, showed slightly higher mean ICIQ-UI SF score (12.4), but still moderate severity, as well as somewhat higher mean ICIQ-LUTSqol score (42.9) compared to our study. [28] Thus, the level of severity was moderate in all the studies, but our study population experienced a slightly higher impact on QoL compared to the women in the survey, as well as a slightly lower impact on QoL compared to those who sought care for their UI in ordinary ways. These results could indicate the possibility to partly reach a new group of women that perhaps would not have sought care in ordinary ways, but still have a clear impact on their QoL.
Overall, the participants in our study saw the highest impact on QoL in the domains concerning physical limitations, role limitations (including household tasks and daily activities), and emotions. The women with UUI/MUI had more severe leakage and a higher impact on social limitations, emotions, role limitation, and sleep, than the women with SUI. We have found no other studies comparing SUI to UUI/MUI that considers the ICIQ-LUTSqol domains. However, in a study by Abrams et al. from 2015, the domains have been compared, with the participants divided into severity categories, and for the women with more severe UI, the greatest impact on QoL was shown in the domains social limitations and emotions. [26]
The regression analysis showed that in our population, the severity of the leakage was the factor that had the greatest impact on QoL, which, as other studies have shown the same result, was expected. A large study from 2007 on women seeking care in ways other than e-health, showed severity being the single most important predictor on QoL for women with UI, regardless of type of UI. [8] In another study from 2018 exploring the relationship between mental health, sleep, and physical function and type of UI and severity, it was shown that in 510 women seeking help for UI symptoms, severity of UI rather than type had the greatest impact on anxiety, depression, and stress. [29] In our study, it may at first sight look as though the type of UI is the most important factor since the adjusted beta is 2.5, while adjusted beta for severity is only 1.5. However, it should be borne in mind that type of UI is a dichotomous variable, where the increase can only take place once, while severity according to ICIQ-UI SF is a continuous variable that allows greater variation and thus a much greater potential impact on the ICIQ-LUTSqol score.
Strengths
To our knowledge, this is the first study to evaluate condition-specific QoL specifically in women with UI seeking care using e-health. One strength of this study is the relatively large number of participants, in combination with only a few missing values. Another strength is that the participants were actively seeking treatment, and thus represent a clinically relevant group. Moreover, the research group conducting the studies has solid clinical competence, and the diagnoses of SUI as well as UUI/MUI are well established. In the analyses, we were able to include many variables that possibly affect QoL, and we worked in close collaboration with statisticians. For easier comparison with other studies, we have used validated and recommended questionnaires to measure severity of UI and condition-specific QoL. [7, 22, 23]
Limitations
There are also some possible limitations in this study. There was a considerably smaller group of participants with UUI/MUI than with SUI (123 versus 373 women), and this might have affected the results. Also, 80.6% of the participating women had a university education, compared to 47% of all Swedish women aged 25–64 years in 2015, [30] and there is a risk that our population is not comparable to other women with UI in need of treatment. However, since e-health to date is mostly used by those with higher education [15], our population may well represent other women seeking care using e-health. Another limitation is that we were restricted to the data collected in the previous RCTs, and there might be other, for us unknown, factors that also influence the QoL of our participants. For example, psychological illness may have an impact on condition-specific QoL, but questions about anxiety and depression were only included in the baseline questionnaires in two of the three RCTs, and thus could not be further explored. Moreover, there is a risk that we underestimate the presence of comorbidity (e.g. endocrinological diseases etc.), especially in RCT three, by the definition used. The reason for our choice of definition was that different wording was used in the questions regarding prescribed medication and concurrent diseases in the three RCTs. The data concerning prescription drugs versus diseases in RCT one and three were comparable, and therefore prescribed medication was used as a marker of comorbidity. Finally, from the start of the first RCT to the third RCT, eight years have passed. During this time-span, the fast-growing field of e-health has developed rapidly, and this may have affected the results.
Clinical implications and future perspectives
The results in our study show that women with UUI/MUI and women with SUI, who seek care using e-health, have an impact on their condition-specific QoL, mainly related to severity, and not type, of UI. Since treatment of UI can decrease the symptom severity and therefore improve QoL, effective and easily accessible treatments for everyone with UI, regardless of subtype, is important. An individual assessment of each UI patient is also needed, with a careful assessment of the severity of their leakage to provide adequate help to them.
A considerable amount of research has been performed considering QoL in women with UI in general, but not specifically of those who seek medical care for UI through e-health. Our study contributes to new knowledge about this group of women, which may help to develop and improve this kind of treatment. Providing treatment using e-health could contribute to new and cost-effective ways to help women with UI, and lead to both financial savings and to increased QoL for the individual. Easily accessible self-management treatment programmes by Internet or mobile applications may facilitate the access to medical care for this group of patients and at the same time relieve pressures on primary care.
For future research, factors that separate this study population from those who seek care in other ways could be worth investigating further.