Hypothesis / aims of study
Uterine leiomyomata, although predominantly benign, can give rise to a wide variety of gynaecological symptoms, most notably menorhaggia and abdominal bloating, and including lower urinary tract symptoms and incontinence.
Our study aims at establishing the prevalence of overactive bladder syndrome in patients with fibroids in our population, and exploring the correlation between the size and location of fibroids with the severity or otherwise of urinary symptoms.
Study design, materials and methods
50 women who had been referred for ultrasound due to possible benign uterine pathology and found to have uterine fibroids, were identified in consecutive order. Their consent to participate in the study was sought. Patients were asked a series of demographic questions and questions related to their urinary habits, including any issues with urinary incontinence. The participants were asked to complete a questionnaire aimed at establishing the time of onset of incontinence, the severity of their symptoms and the affect this has on their Quality of Life. Participants were also asked whether they had stress incontinence, urge incontinence, mixed incontinence, frequency and urgency. Furthermore, those women who reported any type of incontinence were identified and a clinical correlation between the size and location of the uterine fibroid/s and their incontinence symptoms was sought.
Results
50 Caucasian women were recruited, with a mean age of 43 years. All patients were found to have at least one uterine fibroid of varying dimensions and location within the uterus.
22 patients reported lower urinary tract symptoms related to urinary incontinence .Of these, 10 patients reported mixed incontinence, 5 stress incontinence and 7 overactive bladder symptoms. Frequency was the predominant symptom overall, present in 20 patients (91%), followed by urgency in 15 patients (68%). Of the 7 patients with overactive bladder symptoms, all reported urgency as the most bothersome symptom.
Interpretation of results
Lower urinary tract symptoms were reported in 44% of women in our study population. Urinary incontinence is present in 30%, with mixed incontinence predominant. 14% had overactive bladder symptoms.
The overactive bladder subgroup had either intramuscular or sub-serous fibroid, varying between 4.6 cm3 to 12.2cm3 in volume. The locations were various and a positive correlation between the size and location and severity of OAB symptoms could not be established. Similar findings were also noted in patients with mixed incontinence. In the stress incontinence subgroup, 3 out of 5 patients had an anterior wall fibroid larger than 6 cm3. Several studies have reported an association between anterior uterine wall fibroids and lower urinary tract symptoms (1). This relationship cannot be ascertained in our study due to limitations in sample size.
It is well established that both the presence of leiomyomata and urinary incontinence are independent risk factors associated with a decreased QOL. Whilst all patients reported a decreased QOL, this was substantially worse in those with incontinence episodes. The interrelationship of these factors needs to be established.
Interestingly, most women initially presented complaining of menorrhagia or abdominal bloating. Incontinence is still grossly under-reported as women are too embarrassed to seek help.
Whilst a mass pressure effect is considered as the primary cause of lower urinary tract symptoms due to fibroids, hormonal, vascular and neurogenic causes have also been proposed as possible underlying pathophysiological mechanisms. There is conflicting evidence in the literature regarding the association between lower urinary tract symptoms and fibroid volume and position. Our study also reflects this. Some studies have however shown improvement in incontinence symptoms when fibroids were either embolized or surgically removed (3).