ORIGINAL ARTICLE

Genitourinary symptoms and their effects on quality of lifein women with uterine myomas

Murat Ekin & Huseyin Cengiz & Emine Öztürk &

Cihan Kaya & Levent Yasar & Kadir Savan

Received: 13 September 2013 /Accepted: 29 November 2013# The International Urogynecological Association 2013

AbstractIntroduction and hypothesis This study was designed to de-termine the presence of genitourinary symptoms and theireffects on quality of life (QOL) in women with uterinemyomas.Methods A total of 145 women with ultrasonography (US)diagnosis of anterior myoma were divided into two groupsaccording to myoma size: (1) those ≤5 cm (n=75), and (2)those >5 cm (n=70). The control group comprised previouslymatched 94 women with a normal-appearing uterus on US.Study participants answered the Urogenital Distress Inventory(UDI-6) and the Incontinence Impact Questionnaire (IIQ-7).Pelvic examination was performed, and urinary symptomswere recorded. The chi-square test and Fischer’s exact testwere used to compare qualitative data. The Kruskal–Wallistest and Dunn’s test were used to compare groups. Statisticalsignificance was set at P <0.05.Results The frequency of genitourinary symptoms was sig-nificantly higher in women with myomas, including stressurinary incontinence (SUI), urgency, frequency, urge urinaryincontinence (UUI), and dyspareunia. SUI and mixed urinaryincontinence (MUI) were the most common symptoms asso-ciated with myoma size. Total UDI-6 scores were significantlyhigher in women with myomas than in control patients(P<0.0001). UDI scores associated with UI and obstructivesymptoms were higher in women with myomas >5 cm than inother women. IIQ scores regarding physical activity, travel,

and emotional health were significantly higher in women withmyomas >5 cm than in other women (P<0.001).Conclusions Urinary tract dysfunction is associated with an-terior myomas, increasing in association with myoma size,and significantly affects QOL.

Keywords Urinary symptoms . Uterinemyomas .

Incontinence Impact Questionnaire . Urogenital DistressInventory . Quality of life

Introduction

Uterine myomas are benign, monoclonal tumors of thesmooth muscle cells of the myometrium. Although myomasare rarely associated with mortality, they may cause signifi-cant morbidity and affect patients’ quality of life (QOL)because of various symptoms such as abnormal uterine bleed-ing and pelvic pain. They can also cause acute or chronicpressure or pain against the bladder. In such cases, the patientmay experience lower back pain and frequent urination [1].Few studies have examined the association between myomasand genitourinary tract dysfunction. Moreover, these studiesfocus on symptom improvement, such as urinary frequency,nocturia, and urgency, after treatment with either agonadotropin-releasing hormone agonist or uterine artery em-bolization [2, 3]. Self-reported stress urinary incontinence(SUI) and acute urinary tract obstruction have also beenreported in various studies [4, 5]. Patients with myomasinfrequently complain of urinary symptoms and are infre-quently questioned on this subject by physicians, which canlead to delay in treatment and decreased QOL. The objectiveof this study was to evaluate urinary symptoms and their effecton QOL using the validated Urogenital Distress Inventory(UDI-6) and the Incontinence Impact Questionnaire (IIQ-7)in women with uterine myomas for quantitative analysis.

M. Ekin :H. Cengiz (*) : E. Öztürk :C. Kaya : L. YasarBakirkoy Dr. Sadi Konuk Teaching and Research Hospital, TevfikSağlam Street, No: 11, ZuhuratbabaBakirkoy Istanbul, Turkeye-mail: obstetrik@gmail.com

K. Savanİstanbul Kemerburgaz University, School of Medicine,İstanbul, Turkey

Int Urogynecol JDOI 10.1007/s00192-013-2295-4

Material and methods

The study was approved by the Institutional Review Boardand Local Ethics Committee and was conducted at our outpa-tient gynecology clinic from December 2011 to April 2012.The aim of the study was presented to all women with anultrasound (US) diagnosis of anterior uterine myomas, andwritten informed consent was obtained from participants. Todistinguish accelerating factors for the development of SUI,women with neurological diseases, diabetes, arterial hyperten-sion, thyroid dysfunction, symptomatic pelvic organ prolapse(POP), obesity, history of operative vaginal deliveries, andmyomas in locations other than the anterior uterine corpus,were excluded from the study.

One hundred and forty-five women were consecutivelyrecruited and divided into two groups according to myomasize. The first group consisted of women with myomas ≤5 cm(n=75) and the second of women with myomas >5 cm (n=70). The control group comprised 94 previously matchedwomen who attended our department for a scheduled annualgynecological visit and were found to have a normal-appearing uterine myometrium on transvaginal US examina-tion. The control group had no history of endometriosis,

adenomyosis, or uterine myomas. All US examinations wereperformed by the same expert physician (HC) using a VolusonE6 US scanner (GE Medical Systems, Milwaukee, WI, USA)with a 4–9MHz vaginal probe. Uterine size was calculated bythe mean of the measured vertical and horizontal diameter ofthe myoma.

The women also completed two validated questionnaires:the UDI-6 and the IIQ-7, the former of which screens forstress, irritative, and obstructive symptoms, and the latterhow these symptoms affect QOL with regards to physicalactivity, travel, social relationships, and emotional health [6].

All women underwent a pelvic examination and werequestioned by an expert physician regarding the presence ofurinary symptoms, including SUI, urgency, urge urinary in-continence (UUI), nocturia, increased daytime frequency, analincontinence (AI), and dyspareunia. SUI was defined as in-voluntary leakage of urine on effort, exertion, sneezing, orcoughing. UUI was defined as involuntary leakage of urineaccompanied by or immediately preceded by urgency. Mixedurinary incontinence (MUI) was defined as involuntary leak-age associated with urgency and effort, exertion, sneezing, orcoughing. Increased daytime frequency was defined accord-ing to the woman’s perception of voiding too often during the

Table 1 Comparison of women with myomas and controls in frequencies of genitourinary symptoms

Controls Myoma≤5 cm Myoma >5 cm P value

Patient characteristics (mean ± SD)

Age (years) 41.9±9.2 42.31±6.29 43.83±6.18 0.062

Parity 2.2±1.8 2.12±1.3 2.30±1.23 0.485

C/S 0.24±0.5 0.23±0.5 0.20±0.6 0.200

BMI 26.8±1.9 26.1±0.8 25.9±1.0 0.506

Frequencies of genitourinary symptoms [n (%)]

SUI 30 (31.9) 42 (56.0) 56 (80.0) 0.0001

MUI 10 (10.9) 19 (25.3) 22 (31.4) 0.01

Urgency 27 (28.7) 34 (45.3) 30 (42.9) 0.027

Increased daytime frequency of voiding 47 (50.0) 59 (78.7) 60 (85.7) 0.0001

UUI 7 (7.4) 6 (8.0) 5 (7.1) 0.571

Nocturia 10 (10.6) 15 (20.0) 18 (25.7) 0.082

AI 1 (1.1) 0 (0) 0 (0) 0.664

Dyspareunia 4 (4.3) 11 (14.7) 12 (17.1) 0.001

Symptom-related scores of the UDI-6 questionnaire (mean±SD)

Irritative symptoms 1.86±1.82 2.64±1.75 3.09±1.75 0.0001

Median (IQR) 1.5 (0−3) 2 (1−4) 3 (2−4.25)Urinary incontinence 0.79±0.97 1.19±1 1.7±1.13 0.0001

Median (IQR) 0 (0−2) 1 (0−2) 2 (1−3)Obstructive symptoms 1.2±1.66 2.23±1.65 2.94±2.3 0.0001

Median (IQR) 1 (0−1) 2 (1−3) 2 (1−4)Total 3.78±3.61 6.04±3.49 7.73±3.85 0.0001

C/S cesarean sections, BMI body mass index, SUI stress urinary incontinence,MUImixed urinary incontinence, UUI urge urinary incontinence, AI analincontinence, UDI Urogenital Distress Inventory, SD standard deviation, IQR interquartile range

Bold indicates statistical significance

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day. Nocturia was defined as waking during the night at leastonce to void. AI was defined as involuntary loss of flatus orliquid or solid stool [7].

Statistical analyses were performed using NCSS 2007 Sta-tistical Software (Kaysville, UT, USA). The sample size wascalculated with the assumption that the prevalence of myomaswas 20–30 % of the population. To provide 80 % power of0.05, it was calculated that 70 participants would be adequatein each group. For univariate analyses, continuous data werereported as the median [interquartile range (IQR)] and mean ±standard deviation (SD). The Kruskal–Wallis test and Dunn’stest were used to compare groups. The chi-square test andFischer’s exact test were used to compare qualitative data.Statistical significance was accepted at a P value of <0.05.

Results

There was no significant difference in mean age, parity, num-ber of previous cesarean deliveries, and body mass index

(BMI) between women with myomas and control patients.Mean myoma diameter was 4.3±0.5 (SD 3.2−4.9) and 7.0±1.1 (SD 5.1−9.6) in myomas ≤5 cm and >5 cm, respectively.Frequency of genitourinary symptoms was significantlyhigher in women with myomas, including SUI (P<0.0001),urgency (p<0,027), daytime frequency (P<0.0001), MUI(P<0.0001), and dyspareunia (P<0.001), than in the controlgroup. Total UDI scores were also significantly higher inwomen with myomas (P<0.0001) (Table 1). SUI (56–80 %)and MUI (25–31 %) were the most common symptoms asso-ciated with increasing myoma size (Tables 1 and 2). UDIscores were related to UI, and obstructive symptoms werehigher in women with myomas >5 cm; P<0.0001) (Table 3).Total IIQ scores regarding physical activity, travel, socialrelationships, and emotional health were significantly higherin women with myomas compared with controls (P<0.001)(Table 4); IIQ scores regarding physical activity, travel, andemotional health were significantly higher in women withmyomas >5 cm (Table 5).

Table 3 Symptom-related scores of women with myomas and controlpatients from the UDI-6 questionnaire

UDI-6 Irritativesymptoms

Urinaryincontinence

Obstructivesymptoms

Total

Control patientsvs patients withmyoma ≤5 cm

0.003 0.007 0.0001 0.0001

Control patientsvs patients withmyoma >5 cm

0.0001 0.0001 0.0001 0.0001

Myoma≤5 cmvs >5 cm

0.102 0.005 0.046 0.007

Dunn’s test

UDIUrogenital Distress Inventory

Bold indicates statistical significance

Table 4 QOL-related scores of the IIQ-7 questionnaire in women withmyomas and controls

IIQ-7 Controlpatients

Myoma≤5 cm

Myoma>5 cm

P value

Physical activitymedian (IQR)

1.96±2.34 1.67±2.24 3.06±2.63 0.0021 (0–4) 1 (0–3) 3 (0.75–4.5)

Travel median (IQR) 0.82±1.06 0.69±0.75 1.29±1.21 0.0140 (0–2) 1 (0–1) 1.5 (0–2)

Social relationshipsmedian (IQR)

0.28±0.63 0.56±0.81 0.71±0.9 0.0030 (0–0) 0 (0–1) 0 (0–1)

Emotional healthmedian (IQR)

0.83±1.3 0.95±1.44 1.93±1.92 0.0010 (0–1) 0 (0–2) 2 (0–3.25)

Total median (IQR) 3.88±4.31 3.85±4.15 6.99±5.8 0.0012 (0–8) 2 (0–6) 7.5 (1–11)

Values are in mean±SD

QOL quality of life, IIQ Incontinence Impact Questionnaire, IQR inter-quartile range, SD standard deviation

Table 5 QOL scores of women with myomas and control patientsaccording to the IIQ-7 questionnaire

IIQ-7 Physicalactivity

Travel Socialrelationships

Emotionalhealth

Total

Control patientsvs patients withmyoma ≤5 cm

0.505 0.928 0.007 0.519 0.638

Control patientsvs patients withmyoma >5 cm

0.003 0.011 0.0001 0.0001 0.0001

Myoma≤5 cmvs >5 cm

0.0001 0.004 0.289 0.001 0.001

Dunn’s test

QOL quality of life, IIQ incontinence impact questionnaire

Bold indicates statistical significance

Table 2 Association between genitourinary symptoms and myoma size

SUI Urgency Increaseddaytimefrequencyof voiding

MUI Dyspareunia

Control patientsvs patients withmyoma ≤5 cm

0.002 0.026 0.0001 0.012 0.018

Controls patientsvs patients withmyoma >5 cm

0.0001 0.06 0.0001 0.001 0.006

Myoma≤5 cmvs >5 cm

0.002 0.764 0.269 0.415 0.683

Dunn’s test

SUI stress urinary incontinence, MUImixed urinary incontinence

Bold indicates statistical significance

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Discussion

The effect of uterine myomas on bladder function remains along-standing enigma, and the purpose of this study was toevaluate urinary symptoms and their effect on QOL using thevalidated UDI-6 and IIQ-7 questionnaires in women withuterine myomas in a quantitative assessment. In two previouspopulation-based studies performed in Turkey, UI was foundin 36–44% of women aged 40–45 years [8, 9]. These findingsare consistent with those of our control group.

Few studies have evaluated urinary symptoms in womenwith uterine myomas [4, 10]. Dragomir et al. [4] reported a7 % increase in SUI associated with uterine myomas, andincreased self-reported SUI is related to a uterine myoma sizeof at least 4 cm.Waetjen et al. [10] investigated the associationbetween uterine myomas and SUI in a population-based epi-demiological study of 3,302 women aged 42–52 years. Theyfound an association between uterine myomas and stress,urge, or mixed UI. In our study, we evaluated genitourinarysymptoms using objective, validated UDI-6 and IIQ-7 ques-tionnaires. We believe that validated questionnaires have im-proved the results of the study concerning subjective com-plaints and determination of the effects of the increase inmyoma size in relation to QOL. Total UDI-6 scores weresignificantly higher in womenwith uterine myomas comparedwith control patients. UDI-6 scores associated with UI andobstructive symptoms increased relative to myoma size. IIQ-7scores regarding physical activity, travel, and emotional healthwere also significantly higher in association with myoma size.We observed that SUI and MUI were the most commonsymptoms to increase according to myoma size. A high rateof SUI found in women with myomas was also reflected instress symptom scores in the UDI-6 and physical activityscores in the IIQ-7. There are a few case reports of acuteurinary retention due to uterine myomas [5, 11, 12]. In ourstudy, obstructive symptom scores on the UDI-6 were alsohigh in those with myomas.

We excluded women with myomas in locations other thanthe anterior uterine corpus. Similar to Haney et al. [13], wehypothesized that uterine enlargement due to the presence ofanteriorly localized uterine myoma may cause SUI bycompressing the urinary bladder. Pelvic congestion due touterine pressure may also influence bladder innervations, caus-ing lower urinary tract symptom. In our recently publishedstudy evaluating genitourinary symptoms in women withadenomyosis, we confirmed this theory with our findings ofincreased SUI, urgency, daytime frequency, UUI, anddyspareunia [14]. Limitations of the study reported here werethe undetermined cultures of urine samples and lack of educa-tional status as a demographic variable. None of our partici-pants had acute symptoms of cystitis that may attenuate thislimitation. The community served by the hospital has generallymoderate educational status, and all participants were literate.

In conclusion, women with anterior uterine myomas had asignificantly higher frequency of genitourinary symptoms, in-cluding SUI, urgency, daytime frequency, UUI, and dyspareunia.We also found that the degree of urinary tract dysfunction wasassociated with the size of the uterine myoma. We suggest thatany pathology resulting in uterine enlargement may predictgenitourinary symptoms, and such women should be carefullyscreened to identify any effects on their QOL.

Conflicts of interest None.

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