Original Article

Rev. Latino-Am. Enfermagem 2012 Mar.-Apr.;20(2):346-353 www.eerp.usp.br/rlae

Urinary incontinence in the puerperium and its impact on the health-related quality of life1

Lígia da Silva Leroy2 Maria Helena Baena de Moraes Lopes3

This case-control study evaluated whether UI in the puerperium compromises the healthrelated quality of life (HRQoL) and if so, in which aspects. The study included 344 women (77 case group and 267 control group) up to 90 days postpartum, who were attended the Obstetrics Outpatient Clinic of a public teaching hospital, for the postpartum follow up consultation. A socio-demographic and clinical data questionnaire formulated and validated for the study, the International Consultation on Incontinence Questionnaire - Short-Form (ICIQ-SF), the King’s Health Questionnaire (KHQ) and the Medical Outcomes Study 36 Item Short Form Health Survey (SF-36), were applied. The mean score of the ICIQ-SF was 13.9 (SD: 3.7). The case group presented high mean scores in the domains Impact of the Incontinence, Emotions, Daily Activity Limitations and Physical Limitations, of the KHQ. The groups differed significantly in the domains Physical Aspects, Pain, General Health Status, Vitality, Social Aspects and Mental Health of the SF-36. It is concluded that UI significantly affects the physical and mental health of puerperae. Descriptors: Urinary Incontinence; Postpartum Period; Quality of Life.

1

Article extracted from master’s thesis “Incontinência urinária no puerpério: fatores de risco e impacto na qualidade de vida” presented to Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Brazil.

2 3

MSc, Universidade Estadual de Campinas, Brazil. Free lecturer, Associate Professor, Departamento de Enfermagem, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Brazil.

Corresponding Author: Lígia da Silva Leroy Rua São Pedro, 188 Centro CEP: 18540-000, Porto Feliz, SP, Brasil E-mail: [email protected]

347 A incontinência urinária no puerpério e o impacto na qualidade de vida relacionada à saúde Trata-se de estudo caso-controle que avaliou se a incontinência urinária (IU) no puerpério compromete a qualidade de vida relacionada à saúde (QVRS) e em quais aspectos. Incluíram-se 344 puérperas (77 casos e 267 controles) com até 90 dias pós-parto, que compareceram ao ambulatório de obstetrícia de um hospital público e de ensino, para revisão pós-parto. Aplicou-se questionário formulado e validado para o estudo, o International Consultation on Incontinence Questionnaire – Short -Form (ICIQ-SF), o King´s Health Questionnaire (KHQ) e o Medical Outcomes Study 36 – Item Short Form Health Survey (SF-36). O escore médio do ICIQ-SF foi 13,9 (dp=3,7). Casos apresentaram pontuação média elevada nos domínios impacto da incontinência, emoções, limitações de atividades diárias e limitações físicas do KHQ. Os grupos diferiram significativamente nos domínios aspectos físicos, dor, estado geral de saúde, vitalidade, aspectos sociais e saúde mental do SF-36. Conclui-se que a IU afeta significativamente a saúde física e mental de puérperas. Descritores: Incontinência Urinária; Período Pós-Parto; Qualidade de Vida.

La incontinencia urinaria en periodo de posparto y su impacto en la calidad de vida relacionada a salud Estudio caso-controle ha evaluado se la incontinencia urinaria posparto afecta la calidad de vida relacionada a salud y en que aspectos. Serán incluidas 344 mujeres (77 casos y 267 controles) hasta 90 días posparto que asistieron a la Clínica de Obstetricia de un hospital de público y de enseñanza. Fue aplicado cuestionario formulado y validado, el “International Consultation on Incontinence Questionnaire – Short -Form” (ICIQ-SF), “King´s Health Questionnaire” (KHQ) y “Medical Outcomes Study 36 – Item Short Form Health Survey” (SF-36). La media del ICIQ-SF fue 13,9 (DP: 3,7). Casos tenían altos puntajes en los dominios del Impacto de la Incontinencia, Emociones, Limitaciones de las Actividades Diarias y Limitaciones Físicas del KHQ. Los grupos presentaron diferencias significativamente en los dominios Aspectos Físicos, Dolor, Estado General de la Salud, Vitalidad, Aspectos Sociales y Salud Mental del SF-36. Se concluyó que la incontinencia urinaria afecta de manera significativa la salud física y mental de las madres. Descriptores: Incontinencia Urinaria; Periodo de Posparto; Calidad de Vida.

Introduction Urinary incontinence (UI) in the puerperium has been reported as a hygiene problem

UI (SUI)(1,8-14), followed by mixed UI (MUI)(1,8,12) and urge

, which interferes with

UI (UUI)(1,8,12). In general, urinary loss is infrequent(9-10,14)

work, with the social and sexual lives of the women(1), and

and in small quantities(10,13-14). The impact of the UI varies

can have a negative impact on the health related quality

according to age, type of UI, differences in coping skills

of life (HRQoL)(3). Urinary incontinence, defined as “the

and quality of social support(5). Incontinent individuals

complaint of any involuntary loss of urine” , can affect

may present anxiety, depression, isolation and social

people of all ages(5). During pregnancy, the prevalence of

exclusion(5). Urinary incontinence may cause suffering

UI ranges from 36%

and incontinent women face difficulties in dealing with

(1-2)

(4)

(6)

to 58%

(7)

and in the puerperium

rates are described from 27%(8) to 33%(9), depending on the time frame and methodology of the studies

this complaint(15).

. The

The puerperium is a period in which diverse

most common type of UI in the postpartum period is stress

physical and psychological modifications occur. To

(9-10)

www.eerp.usp.br/rlae

348

Rev. Latino-Am. Enfermagem 2012 Mar.-Apr.;20(2):346-53.

investigate the quality of life postpartum, the use of a

(continent puerperae) were identified by means of

generic health questionnaire in parallel to one specific

questions 3 and 4 of the International Consultation on

for the determined condition has been recommended, in

Incontinence Questionnaire - Short Form (ICIQ-SF),

order to exclude the effect of morbidities often present,

validated in Portuguese(18), which evaluates, respectively,

such as perineal pain and postpartum depression .

frequency and quantity of urinary loss, making it

According to the World Health Organization (WHO), the

possible to identify whether the person presents UI or

quality of life is a broad, multifaceted concept, which

not. The woman was included in the case group if she

incorporates physical, psychological and social aspects

reported any frequency and/or quantity of urinary loss

and involves the perception of the individual regarding

during the past four weeks, and the control group if she

their condition, in the cultural context in which they

reported no complaint of urinary loss, considering the

live(16). The HRQoL refers to the impact of an illness or

immediate postpartum period until the time of inclusion

injury on the different aspects of life

in the study.

(6)

.

(17)

The investigation of the HRQoL of incontinent

For

the

socio-demographic

and

clinical

data

puerperae is of fundamental importance to verify the

collection a questionnaire was prepared, which was

compromise that UI may generate in the diverse areas

submitted to content validity analysis, performed by

of life and to propose measures that can minimize this

three judges with experience in the areas of obstetrics

and contribute to improving the health and well-being of

and gynecology/or urogynecology. Some alterations in

this population. The nurse must know the aspects of the

the questions and formatting were suggested, resulting

HRQoL affected by postpartum UI, in order to provide

in the final instrument. This was pre-tested with ten

targeted care to this population, implementing preventive

puerperae, which showed that no further modifications

strategies during the prenatal and postpartum periods.

were necessary.

Faced with this, the aim of this study was to evaluate

The instruments used for the evaluation of the

whether postpartum UI compromised the HRQoL of

HRQoL were the ICIQ-SF(18), the KHQ(19), and the SF-

women attending a public tertiary teaching hospital of

36(20), previously validated in Brazil. The ICIQ-SF is

the state of São Paulo, Brazil, and, if so, in what aspects.

a self-administered questionnaire consisting of four questions, which qualify the urinary loss and evaluate

Method

the impact of UI on the quality of life through a scale, ranging from 0 (does not interfere) to 10 (interferes a

This is a case-control study conducted between

lot), which aims to measure how much the loss of urine

May and December 2010, with women in the 90

interferes in the daily life. The score is given by the sum

days postpartum period, who attended the Obstetrics

of questions 3, 4 and 5, ranging from 0 to 21, and the

Outpatient Clinic of a public tertiary teaching hospital

higher the score, the greater the severity of urinary loss

in the state of São Paulo, Brazil, for the postpartum

and impact on the quality of life(18). In the present study,

follow up consultation. Women with urinary incontinence

the Cronbach’s alpha coefficient of this scale was 0.69.

before pregnancy and those who had any of the

The KHQ is a questionnaire that evaluates the

following conditions were excluded from the study: twin

perceived symptoms and the impact of the UI on different

pregnancy, the presence of: hypertension, diabetes

domains of quality of life. It consists of 21 questions

mellitus,

disease,

divided into eight domains (General Health Perception,

neurological disease, urinary tract infection, renal

Incontinence Impact, Daily Activity Limitations, Physical

calculus, previous history of pelvic surgery (excluding

Limitations, Social Limitations, Personal Relationships,

cesarean section), current treatment for UI and/or the

Emotions, and Sleep and Energy) and two scales (Urinary

use of medication that interferes with the function of the

Symptoms and Severity Measures). Scores range from

lower urinary tract.

0 to 100 in each domain and the higher the score, the

chronic

obstructive

pulmonary

The sample size was calculated to detect an odds

worse the quality of life related to that domain(19). In the

ratio of 3.0 at a ratio of one case to three controls,

present study, the Cronbach’s alpha coefficient of the

assuming a significance level of 5% and a power of

total scale was 0.90, varying from 0.87 to 0.91.

80%, with the prevalence of exposure among the case

The SF-36 is a generic instrument for evaluating the

group estimated at 20%(1). The sample size calculation

HRQoL, composed of a multidimensional questionnaire

was estimated to be 74 cases and 222 controls. The

with 36 items encompassed in eight scales (Functional

case group (incontinent puerperae) and control group

capacity, Physical Aspects, Pain, General Health Status,

www.eerp.usp.br/rlae

Leroy LS, Lopes MHBM.

349

Vitality, Social Aspects, Emotional Aspects, and Mental

meeting the inclusion criteria. Included and excluded

Health). The possible score is from 0 to 100 in each

puerperae differed significantly (according to the Mann-

domain and the higher the score, the better the

Whitney test) regarding age (p