Impact of urinary incontinence on the quality of life of individuals undergoing radical prostatectomy

ABSTRACT Objective: to assess the level of urinary incontinence and its impact on the quality of life of patients undergoing radical prostatectomy. Method: cross-sectional study carried out with prostatectomized patients. The data were collected from the following instruments: sociodemographic questionnaire, Pad Test, International Consultation on Incontinence Questionnaire - Short Form and King Health Questionnaire. Data were submitted to descriptive and bivariate statistical analysis. The level of significance was set at 0.05. Results: a total of 152 patients participated, with a mean age of 67 years. Among incontinent patients, there was a predominance of mild urinary incontinence. Urinary incontinence had a very severe impact on the general assessment of quality of life in the first months and severe impact after six months of surgery. The greater the urinary loss, the greater the impact on the quality of life domains Physical Limitations, Social Limitations, Impact of Urinary Incontinence and Severity Measures. Most participants reported no erection after surgery and therefore did not respond to the question of the presence of urinary incontinence during sexual intercourse. Conclusion: the present study evidenced the occurrence of urinary incontinence after radical prostatectomy at different levels and its significant impact on the quality of life of men, which reveals the need of interventions for controlling it.


Introduction
Prostate cancer (PC) is the most incident in the male population, with the exception of non-melanoma skin cancer. The possibilities of treatment are surgery, radiotherapy and hormonal therapy. These options can cause undesirable effects, such as erectile dysfunction, loss of libido and urinary incontinence (UI), which also imply emotional changes, although temporarily (1)(2) .
Radical prostatectomy (RP) is the gold standard treatment option for localized PC cases (3) . However, post-RP UI (PRPUI) may have a significant impact on men's quality of life (QoL) (3)(4) .
PRPUI is more severe in the early postoperative phase. However, continence recovery may occur within the first three to six months or belatedly (one year or more), as described in a meta-analysis that evaluated the effectiveness of exercises for pelvic muscles in the control of PRPUI (2) . Therefore, the male population may present different levels of urinary loss over time after surgery.
In turn, this problem may generate feelings of low self-esteem, anxiety, and depression that are usually present in men after surgery because of the uncertainty about how to deal with those undesirable effects (3)(4) . A review that analyzed 19 studies concerning male UI identified that the different perceptions and reactions experienced determine the extent of emotional conflict, the difficulties faced in life and the self-perception of health (5) . The association of physiological, psychological and behavioral factors related to urinary control influences the QoL of prostatectomized men (3,5) .
Health-related QOL is a multidimensional construct that involves relevant aspects of the patient's life, such as the health status in general, symptoms related to the treatment of the disease, physical capacity, psychological state and social factors (6) . In this context, prostatectomized men require attention and care regarding factors related to UI that impact their QoL.
As strategies for assessing the physiological ability to control urinary continence, there are the objective tests, such as urodynamic study, Pad Test and exercise test, which classify the degree of UI by the quantification of urinary loss (7) .
However, these parameters do not assess the impact of UI on the psychological and behavioral aspects from the patient's perception. Therefore, questionnaires were designed to evaluate the subjective aspects of urinary dysfunction that may influence QoL (7) . The use of these instruments allows comparing the effects of different existing therapies and strategies to control urinary loss, an essential factor to optimize the actions not only of nurses but also of the whole multiprofessional team (8) .
Among the existing instruments for evaluation of the QoL associated with UI, we can mention the International Consultation on Incontinence Questionnaire -Short Form (ICIQ-SF) and the King Health Questionnaire (KHQ), both translated and validated for the Brazilian context (9)(10) . The concomitant use of these questionnaires becomes relevant as the ICIQ-SF provides a brief and general assessment of the impact of UI on QoL while KHQ provides an assessment of the impact of UI on different QoL domains related to the physical, social and emotional aspects (9)(10) . The sample size was calculated from the population of men seen at the institution in a two-year interval, equivalent to 242 men, 5% of margin of error and a 95% confidence level, which resulted in a minimum size of 149 individuals (11) .
Participants were selected from the following inclusion criteria: adults having been submitted to RP in an interval of two months to two years, since studies point to a high rate of PRPUI reported from the second month after RP that may last up to two years (12) ; preserved locomotor, visual, hearing and swallowing ability; and cognitive ability assessed through the Mini Mental State Examination (13) .
Patients using an indwelling bladder catheter (IBC) and reporting UI prior to surgery were excluded. In order to objectively quantify the urinary loss, we used the one-hour Pad, a resource validated and recommended by the International Continence Society (ICS) (14) . The test consists of placing a penile absorbent pad next to the external urethral meatus, which will be weighed on a high sensitivity scale after the interval of one hour. During this interval, patients are initially asked to drink 500 milliliters of water and wait at rest for 15 minutes. Then, they are subjected to a protocol that simulates activities of daily living. Finally, after one hour, the penile absorbent pad is removed, which allows the assessment of urinary loss by different sources -effort, urgency and overflow (14) . Urinary losses are classified as insignificant -losses up to 1 gram (g); mild loss -between 1.1 and 9.9 g; moderate loss -between 10 and 49.9 g; and severe loss -above 50 g. The Pad Test quantifies but does not distinguish the mechanism that led to this urinary loss (14) .
To evaluate the impact of UI in different domains of QoL, considering the physical, social and emotional aspects, we used the KHQ instrument, which presents Cronbach's α coefficient of 0.7 in its original version (9) . In the present sample, the instrument presented Cronbach's α coefficient of 0.9, which means high reliability. The instrument consists of 21 questions organized in ten domains and another nine related to the symptoms of UI, as well as a space for the patient to report any other problem associated with the functioning of the bladder. Thus, for all answers, numerical values are assigned, summed and evaluated by domain, obtaining a score that varies from zero to 100, in which the higher the value obtained, the worse the QoL (10) .
In order to complement the information obtained by KHQ, the ICIQ-SF instrument was also used for a general and brief evaluation of the impact of UI on QoL. The ICIQ-SF is a short, self-administered questionnaire composed of four questions that assess the frequency, severity and impact of UI, as well as eight items related to the causes and situations of UI experienced by the patient. The instrument was developed in the English language and in 2004 it was validated in the Portuguese language, presenting high psychometric capacity and Cronbach's α coefficient of 0.9 (9) . In the present sample, the instrument presented Cronbach's α coefficient of 0.8. The total score is obtained by adding the scores of questions three, four and five, with values varying from zero to 21, considering that the higher the score obtained, the worse the QoL.
Thus, the impact on QoL is classified according to the score: no impact (zero point); mild impact (one to three points); moderate impact (from four to six points); severe impact (from seven to nine points); and very severe impact (10 or more points) (9) .
Data were processed and analyzed using the

Results
The study sample consisted of 152 patients, it was observed that the G1 presented a higher mean UI (5.7grams ± 13.7), followed by G3 (2.0 grams ± 3.7) and, finally, the G2 (2.0 grams ± 3.7). In turn, the difference was not statistically significant between the groups (p = 0.310). Table 1 shows the UI classification by weight of absorbent pad. In the classification of incontinent patients, the mild UI category is the most frequent among patients in the three groups, and severe UI is the most prevalent among G3 men (4.5).
In the analysis of the impact of UI on QoL by ICIQ-SF, G1 presented a mean of 9.6 (± 5.5), classified as very severe, G2 6.9 (± 5.5) and G3 7.   difference of G1 in relation to G2 (p = 0.020) and G3 (p = 0.021), that is, the QoL due to Severity Measures of UI (use of absorbent pads, limitation of fluid intake, need for changing wet underwear, shame, urine odor) is worse in the first six months after surgery.  The item "UI during sexual intercourse" was not answered by 119 participants (78.3%), since they reported not having sexual intercourse due to the absence of erection.  (2,12,15) , however, no studies were found describing the classification of the most frequent UI levels in this period.   Among patients with postoperative period of two to six months, UI had a very severe impact on QoL according to ICIQ-SF, whereas among patients with more than six months after surgery (G2 and G3) the impact on QoL was severe. Similar data were found in a Brazilian study that obtained an average of 10.6 points in the general QoL of incontinent post-RP patients in the third postoperative month and an average of 9.2 points in the sixth month, thus classifying the impact as very severe (15) .
Regarding the QoL domains Impact of UI, Limitations of Daily Activities and Social Limitations, there was a greater impact in these domains in patients between two and six months postoperatively compared to those with more than six months to one year. In this sense, PRPUI significantly compromises the lifestyle of men. Anxiety caused by urinary loss interferes with QoL, restricts social and family contact, and generates feelings of loss of control of life. Patients report shame and discomfort due to the inability to control the bladder in the presence of their relatives and friends or for having to wear a diaper or having to change it out of home. There are also patients who do not wear a diaper daily, but always carry it for safety in their bag when they leave home, afraid of urinary leakage due to some physical effort (16) . UI, besides provoking feelings of loss of masculinity (16) , also threatens the decline in professional performance and household chores (5) .
The results of the study indicated statistical significance in the difference between groups for the impact of UI in the field of UI Severity Measures (use of absorbent pads, limitation of fluid intake, need for changing wet underwear, shame, urine odor), being more severe in the first six months. The literature corroborates this finding and points to a higher impact of UI in the QoL during the first months after surgery, mainly due to the need to use absorbent pads and the feeling of shame, with spontaneous and progressive improvement over time (2,5,16) .  (17) .
Regarding the positive correlation of UI with the domains Physical and Social Limitations, it is possible to point out that acts resulting from the intensity of urinary loss, such as urine odor and wet clothes, affect the emotional and social aspect of these men because they feel stigmatized, generating an impaired self-image (5) . Such situation changes the lifestyle of these men, who start to take several baths a day, wear dark clothes, limit their physical activities for fear of urinary leakage, and even tend to isolate themselves (5) .
It is important to consider that part of the impairment of mental well-being that affects QoL is related to the lack of social support, as well as to the fear associated with psychological and affective relationships, especially fear of being abandoned by wives, reported by at least half of patients (18) .
These results reinforce the need for health professionals to reflect and act on the problem in order to organize care that guides men with UI in a welcoming and individualized way, within the framework of the altered physical and psychosocial aspects.
The most prevalent UI symptoms at different post-PR periods in all groups were urinary frequency, nocturia, and urinary urgency. These symptoms are characteristic of detrusor overactivity and when associated with sphincter dysfunction represent the cause of 23% to 42% of cases of PRPUI (19) .
Sphincter dysfunction may be developed by bladder devascularization or denervation, or by inflammatory changes related to surgery, or as a result of vesicourethral reflex activation (19) .
Among the symptoms classified as "very little present", the finding referring to the item "UI during sexual intercourse" was not answered by the majority of the participants (78.3%) due to the absence of an erection. Corroborating with the results found, researchers identified a rate of 83% (15) and 85% (20) of patients with erectile dysfunction. RP can reduce erectile function in up to 60% of patients undergoing surgery within two years (21) . During the surgical procedure, the vascular-nerve bundles and the smooth muscle can be affected, thus compromising the penile erection (4) . Researchers have identified that surgery negatively affects sexual function causing a significant impact in the social domain regarding the evaluation of post-RP QoL (15) .
Another study also reinforces this finding by pointing out that the impact on erectile dysfunction goes beyond the physical aspect and affects psychological and relationship aspects (20) .

Conclusion
The results showed that the urinary loss