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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.4 São Paulo Aug. 2012
The impact of urinary incontinence of the lives of wives of men with incontinence: an integrative review*
Mariana Bezzon BicalhoI; Maria Helena Baena de Moraes LopesII
by the University of Campinas (UNICAMP), Faculty of Medical Sciences. Campinas,
SP, Brazil. firstname.lastname@example.org
IIRN. Associate Professor, University of Campinas (UNICAMP), Faculty of Medical Sciences, Nursing Department. Campinas, SP, Brazil. email@example.com
Male urinary incontinence has been related to several factors, among which benign prostatic hyperplasia and prostate cancer treatment are highlighted. Urinary incontinence has negative effects on patients as well as on their relatives and caregivers. In the present study, an integrative review was performed with the purpose to identify the impact that urinary incontinence has on the lives of the patients' partners. The article survey was performed on the following databases: CINAHL, EMBASE, SCOPUS, MEDLINE, and PubMed. Articles were included if they were written in Portuguese, English or Spanish, and excluded if they did not mention the patients' wives. The final sample was comprised of 15 articles from seven countries. The articles were distributed into the following categories: Psychological Distress, Fatigue, Change in Sex Life, and Limitations on Social Life. The category Psychological Distress was present in all articles and was rated as having the most impact on these women's lives.
Descriptors: Men; Urinary incontinence; Spouses; Quality of life; Nursing care
Male Urinary Incontinence (UI) has been related to various factors. Those considered to be the most important are old age, benign prostatic hyperplasia (BPH), treatment for prostate cancer, physical and mental impairment, and some diseases prevalent among elderly individuals such as stroke and Parkinson's disease, in addition to medication and surgeries potentially capable of causing reduced pelvic muscle tone and/or capable of causing nerve damage(1).
BPH affects about 10% of men above the age of 30 and is observed in 90% of individuals older than 90 years of age(2). Prostate cancer is the most frequent neoplasia among men and affects about 18% of men up to the end of life with obvious negative implications for their lives(2).
Both transurethral resection for treating BPH and prostatectomy to treat prostate cancer can cause complications, among which erectile dysfunction, urinary incontinence and bladder problems stand out. These complications can affect the patient's quality of life (QoL) and functional condition, while also potentially affecting the individual's self-esteem and intimate aspects related to couples. Among the complications, UI is the most afflictive. In many patients, incontinence improves after some days, weeks or months without intervention, however, a small number of patients do not experience improvement(3).
The negative impact of UI includes the emotional, social, and economic spheres both of the incontinent individual and his friends, family members and caregivers. Therefore, it represents a challenge for health workers to seek alternative forms to approach and treat the problem, which is constantly underestimated, especially in the nursing field(1).
Male urinary symptoms negatively affect the quality of life of wives. The relationship between the husband's symptoms and the interference of these symptoms in the lives of women differ in various countries; the impact is influenced by culture and different perceptions(4).
Hence, the planning of care to be provided to the couple should be based not only on scientific knowledge but also on the characterization of their context, focusing on their perceptions and experiences. These issues are not addressed in Brazilian studies and are seldom explored in papers published in other countries.
Considering the preceding discussion, an integrative review was conducted to identify the impact of UI on the lives of partners of incontinent men, that is, repercussions on their physical and mental health, as well as their sexual and social lives, in order to support health workers to develop care planning focused on their needs, and also to guide future investigations in the theme.
The integrative review is a specific review method that synthesizes theoretical and empirical literature in order to deepen understanding of a given topic or health problem(5). The researcher analyzes relevant studies seeking grounding for decision-making and evidence to improve clinical practice.
The stages recommended by the literature were followed in this integrative review(5).
First stage: Identification of the problem
The following questions guided the study: What is the impact of UI on the lives of the partners of incontinent men? What are the repercussions for their physical and mental health, and also on their social and sexual lives?
Second stage: Literature review
A bibliographic search was performed with publications up to November 2010 through the databases CINAHL, EMBASE, SCOPUS, MEDLINE and the research service at the National Library of Medicine on the PubMed databases. The descriptors for Medical Subject Headings (MeSH) and the Boolean operator "AND" were used and resulted in the following combinations: Urinary Incontinence and Male and Spouses and Quality of Life. The descriptors were used in Portuguese, English and Spanish. Only papers written in Portuguese, English or Spanish were considered for analysis. Those not including the perceptions of the partners of men with UI were excluded from the analysis. The databases were searched using the Electronic Information Access Program and the Capes Periodicals Portal in the search system of the Electronic Library at the State University of Campinas (UNICAMP).
Third stage: Data evaluation
The papers were evaluated through reading the full text, which should focus on the report of the spouses concerning the condition of their husbands and the extent such a condition interfered in the partner's and in the couple's quality of life.
Fourth stage: Data analysis
The selected studies were analyzed and the problems experienced by the spouses of incontinent men, reported in these papers, were grouped into categories that define the impact of urinary incontinence on the lives of spouses of incontinent men. The categories were selected according to the study's objective and the material found in the papers, aiming to evaluate the impact of urinary incontinence on the wives' emotional, sexual, physical and social spheres.
Content analysis or a specific theoretical framework was not used because the information present in the papers did not allow this type of analysis. Hence, the data are discussed based on literature only.
Fifty stage: Presentation
A synthesis of the findings is presented in Table 1 and analysis was based on the established categories.
Forty papers were found in searching the databases. Of these, 25 were excluded for not addressing the spouses. Hence, 15 papers were analyzed.
A synthesis of the results is presented in Table 1. The studies were published between 2001 and 2009. At the time of data collection, studies addressing the subject were found only in this period.
The studies originated in seven countries: the United States of America, the United Kingdom, Norway, Sweden, Greece, Israel and South Korea, though most studies are from the United States.
The problems experienced by spouses of incontinent men and reported in the studies were grouped in the following categories: Psychological distress, Fatigue, Altered physical life, Limited social life.
The spouses of men with urinary symptoms feel more anguish than do their husbands(6-12). The source of such anguish is lack of information, fear of the unknown, fear of the future, concern related to their partner's treatment(8,10,13-14), and fear of a cancer diagnosis, surgery and its side effects(4,9).
Women also reported: despair(4,9,12), stress(6-7,14-15,17,19), feelings of guilt(6), fear(4,6,8), anger(6,12), bitterness(6), sense of abandonment(6), anxiety(6-7,12,15-16). The urinary problems of husbands are associated with their spouses' anguish and low QoL(16). Uncertainty concerning the disease causes concern (8,10,13-14,16-17) and depression in the wives(7,12,15-18).
The spouses felt tired during the day due to sleep disorders (4,17,19). They woke up one or two times during the night due to the husband's symptoms of nocturia(4,17,19). Insomnia was mentioned in only one paper(14). Fatigue was also associated with care provided to husbands and increased responsibilities were reported to negatively affect these women's QoL(6,14,16).
Changed sexual life
Urinary symptoms and erectile disorders changed the couple's sexual life making it unsatisfactory(4,11,17,19).
Limited social life
Couples end up becoming isolated in their social life due to urinary symptoms(4,15-16,19).
UI after a prostatectomy is a complication that is difficult to treat and causes a deep negative impact on one's QoL, triggering psychological problems such as anxiety, insomnia, and depression as well as complications such as infections in the urinary tract, dermatitis, and embarrassment, affecting the man's self esteem(20).
In most of the studied papers, UI was reported to be a result of the prostate cancer treatment, which affected the lives of patients and their spouses, potentially compromising the QoL of both.
The wife's quality of life affects the patient's quality of life(21-23) in the same way a negative evaluation of the disease is associated with the couple's reduced quality of life(22). The husband's negative evaluation in relation to the disease is associated with their partner/caregivers' responsibilities that may cause them stress and fatigue. For these reasons, women feel physically, mentally and emotionally exhausted(16).
They report that psychological distress expressed by feelings such as guilty, anger, fear, isolation, depression, abandonment, and anxiety are more harmful to their lives and their daily functions than the physical demands(6).
Concern over urinary symptoms is milder in men with UI than for their spouses(10). For this reason, as the husband's symptoms become more severe, the worse the spouses' mental health becomes(9).
The partners experience some kind of morbidity as a consequence of their husbands' condition. The most common are psychological burdens, unsatisfactory sexual life, limited social life, and sleep disorders associated with the husbands' urinary loss such as nocturia, urge incontinence, and nocturnal enuresis.
Studies show that the impact on the lives of spouses of incontinent men is influenced by factors such as age. Older spouses (more than 65 years of age) experience less disruption in their plans and, therefore, face the care responsibility less negatively over the years. They feel more satisfied with their caregiver role than younger women. However, the physical vulnerability experienced by older spouses exposes them to the risk of physical weakness, worsening health problems and consequent mortality(6). Also, social isolation, fewer family resources and the effects of comorbidities, may cause anguish because these are more frequently observed among elderly wives(16).
This is a particularly relevant aspect in terms of public health, considering that the prevalence of male UI increases with age. That is, with the increased population of elderly individuals, there will be more men with UI and more women will suffer additional harm to their health when their partners become incontinent. Additionally, the fact that the impact caused by male UI on the health of their partners is an issue neglected by the health services; care is usually focused only on the incontinent individual.
Some men more easily accept UI as a consequence expected from a prostatectomy, while anxiety experienced by others due to the urinary loss limits social contact(24). Restricted social contact, in turn, leads to the perception that one's personal life is out of control due to a reduced number of activities(25).
However, despite the adverse effects of UI on one's quality of life, most men adapt to the adverse consequences because a prostatectomy is essential to prolong their lives(26). On the other hand, it is important to keep in mind that even though most patients manage to adapt to these consequences, it does not mean that the symptoms are not important or can be easily controlled. Hence, treatment for postprostatectomy-related UI should be initiated at the time surgery is being planned and continue until the patient is able to control his incontinence(27). Given the impact of male UI on wives, nursing care should be extended to them and involve them in this care plan.
These findings have clear implications for both healthcare delivery and teaching. Given the prevalence and scope of such a condition, nurses should learn this subject in the beginning of their formal education and not only in specialization programs. If nurses in general were better prepared to care for incontinent people, the problems accruing from this condition could be prevented, improved or controlled, avoiding suffering not only for patients but also for their partners and families.
Psychological distress was identified in all 15 papers included in this review, Fatigue was identified in five, Altered Sexual Life and Social Isolation were each found in four studies. Despite cultural differences and differences in perception, all the papers show that male UI negatively affects the lives of their partner-caregivers.
The papers found in Spanish and Portuguese, originating from Latin American countries, were excluded because they did not mention spouses, showing the need for further studies in these countries to represent different cultures.
One of the limitations of this study is the databases that were not included in the search, as well as theses, dissertations and papers published in conference proceedings. There were also restrictions in relation to the language, since papers were limited to those written in English, Portuguese and Spanish.
Male UI negatively affects the lives of wives, especially in emotional, sexual and social terms, with the psychological distress it causes being of particular note. Based on these findings, interventions should be proposed and implemented in clinical practice to help couples cope with such an experience, to minimize these effects in their lives, especially in the routines of caregivers.
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Received: 04/07/2011 *
Excerpted from the term paper "Impacto da incontinência urinária
na vida de esposas de homens com incontinência: uma revisão integrativa",
University of Campinas (UNICAMP), Faculty of Medical Sciences, Nursing Department,
* Excerpted from the term paper "Impacto da incontinência urinária na vida de esposas de homens com incontinência: uma revisão integrativa", University of Campinas (UNICAMP), Faculty of Medical Sciences, Nursing Department, 2010.