The mean prevalence of stress urinary incontinence (SUI) in European women is 35% (1). Two thirds of women suffering from SUI reported a negative impact on quality of life since the involuntary urine leakage affects their physical and psychosocial well-being while putting a burden on their economic situation (2). Furthermore, SUI is associated with anxiety disorders. SUI is the most common reason for a referral to a nursing home (3). As the risk for SUI increases with age, the current demographic change in the population’s age structure observed in many resources-rich countries will yield an increased prevalence of SUI. Thus, SUI implies a substantial economic burden on the health care and social services of many European countries. For example, from the health care insurance perspective, direct medical and direct non-medical costs of SUI amounted over one billion Euro in Germany in the year 2011 while another billion Euro was spent for SUI-related care and accommodation in nursing homes. The economic burden of SUI in Switzerland is, as yet, not well reported.
Therefore, the aim of this study was to estimate the health status and the health costs of women with SUI living in a German speaking part of Switzerland.

This cost-of-illness study (COI) was embedded in a Randomized Controlled Trial (RCT) exploring the effect of two pelvic floor muscle (PFM) training protocols, one including standard physiotherapy and one additionally focusing on involuntary reflexive PFM contractions in women with SUI. This COI study took a societal perspective while a bottom-up approach was applied. Health status as well as cost data were collected using a self-reported diary during the 16 weeks of physiotherapy intervention period. The diary included: 1. questions on demographics (plus modified 20-min Pad test (g) and Oxford grading (scale 0-5), 2. health and quality of life related questions (the European Quality-of-Life-5Dimensions-5Levels questionnaire (EQ-5D-5L)) and general health questions to assess comorbidities, 3. questions on all direct medical (e.g. treatment costs), direct non-medical (e.g. incontinence aids), and indirect costs (e.g. absenteeism) occurring during the 16 weeks of intervention phase and 4. questions on mental stress on a scale ranging from 0 (no mental stress) to 10 (maximum mental stress). Participants were asked to report units consumed and unit prices separately over this period. If participants did not mention unit prices, prices provided by the Swiss Federal Office of Public Health or the billing service tariffs of the University Hospital were used for cost calculations. Intangible costs (e.g. stigma) were omitted. All costs were reported in 2018 in CHF. To ensure validity of the self-reported data and the imputation from the extracted data in the spreadsheet, data were checked independently by two additional researchers. The EQ-5D-5L questionnaire was analyzed using the EQ-5D-5L crosswalk index value calculator with social UK tariff, yielding a health utility score. Descriptive statistics were used to analyze the demographic and the cost data. A frequency analysis was conducted for the comorbidities, for the direct (medical and non-medical) health care unit consumption and for the indirect cost of productivity losses.

Thirty-seven participants volunteered in this COI study. Mean age was 52.4 years (SD: 8.9). Baseline means of the Pad and the Oxford grading test were 8.51 g (SD: 14.47) and 2.88 (SD: 0.83) respectively. About 95% of the patients with SUI had at least one comorbidity. Two participants had 10 comorbidities. The most commonly reported problems were back (54%) and joint (32%) problems. Allergies (46%), episodes of depression (24%) and insomnia (19%) were reported. During these 16 weeks 51% of the participant consulted a medical doctor (1 to 10 visits), 43% a specialist (1 to 16 visits) while 41% consumed alternative medicine treatments (1 to 12 visits). The prevalence of drug consumption was 70% (1 to 9 different drugs). Incontinence aids were used by 65% of the participants. Furthermore, 11% reported to be less efficient while working and 30% less physical active because of the SUI. One participant had less social contacts because of SUI. SUI-related mental stress was mentioned by 59.5% (range: 1 to 9) of the participants while absenteeism due to SUI was not reported. The calculated mean health utility score in this sample was 0.916 (SD: 0.114). The average health costs during the 16-week period were CHF 2256.- (range: 504.- to 11712.-). The average direct medical costs paid (partially) by the general health insurance were CHF 1641.- (range: 445.- to 11337.-). All participants had 9 sessions of pelvic floor physiotherapy during their intervention phase (costs: CHF 445.- per participant). On average, a participant of this sample spent CHF 404.- (range: 0.- to 9320.-) for the specialist, CHF 245.- (range: 0.- to 1535.-) for the physician and CHF 274.- (range: 0.- to 7000.-) for surgery.

The prevalence of comorbidities observed in this present study was comparable to values reported in studies that have assessed comorbidity and COI in obese females of a similar age group. However, participants with BMI <30 kg/m2 were not included in the current study. This present COI study was embedded in a RCT. One inclusion criterion was “fit for exercise”. However, 33% of the volunteers reported SUI-related limitations of their physical activity. It is well documented that low physical activity is related to more comorbidity. This illustrates the important public health impact of SUI. In this sample of women with SUI, a high utility index score (0.916) was observed. This finding can probably be explained by the RCT inclusion criteria “fit for exercise”. Another reason may be that the EQ-5D-5L questionnaire has shown good properties for the use in severe disorders. Perhaps SUI does not fulfill this criterion and perhaps the use of other quality-of-life questionnaires (e.g. SF36) may be more appropriate in such a sample of women with SUI. The average health care cost observed in this present sample of women with SUI over the 16-week period was CHF 1641.-. Extrapolating this 16 week period cost to a yearly cost yielded CHF 4924.-, about 22% higher as compared to the average per capita health care cost (CHF 4047.-) of the general Swiss female population of similar age group in 2017. Due to the socio-demographic development of the Swiss population, an upward trend of health care costs in females is to be expected.

The high economic burden of SUI requires cost-effective preventive actions and clinical treatments. Physiotherapy is recommended by the International Consultation on Incontinence (ICI) as first-line therapy in the treatment of all forms of female urinary incontinence since its effectiveness could be shown. Consequently, physiotherapy could contribute to a reduction in the cost of health care. Therefore, in Switzerland the cost-effectiveness of physiotherapy programs in this patient group should be investigated.

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Hampel C et al. Understanding the burden of stress urinary incontinence in Europe: a qualitative review of the literature. European Urology. 2004;46:15-27.
Graf von der Schulenburg JM et al. Gesundheitsökonomie und Qualitätsmanagement. Thieme Verlag 2007;12(05): 301-309.