Behavioral therapy in the treatment of urinary incontinence: quality of life and severity

Introduction: Behavioral therapy (BT) is an association of techniques that aim to minimize or abolish urinary symptoms, including urinary incontinence (UI), through education about the health condition, changes in lifestyle and nutritional habits, and bladder training. Objective: To analyze whether there is a change in the quality of life and severity of UI after group behavioral therapy in women with UI. Methods: Prospective observational study conducted in a pelvic physical therapy public service. Women with UI of any etiology, over 18 years of age, who completed a protocol of four weekly group BT meetings as the first treatment option for UI were included. Outcomes (impact of UI on QoL and classification of UI severity) were assessed before, immediately after, and one month after BT using the King's Health Questionnaire (KHQ) and the Incontinence Severity Index (ISI). Results: Sample of 146 participants. A reduction in the impact of UI on QoL was observed in the KHQ domains: impact of UI, physical limitations, personal relationships, emotions, general health perception (p < 0.05) immediately after BT. After one month, there was a reduction in the UI impact domains, daily activity limitations, physical limitations, general health perception, emotions, and sleep (p < 0.05). In addition, there was a reduction in the classification of UI severity assessed by the ISI (p < 0.001). Conclusion: There was an improvement in QoL and a decrease in UI severity in women with UI who completed a BT group as the first treatment option.


Introduction
The International Continence Society (ICS) defines urinary incontinence (UI) as any involuntary urine loss, classified into three main categories according to symptoms. Stress urinary incontinence (SUI) is involuntary urine loss during exercise, or other types of effort, such as coughing or sneezing; urge urinary incontinence (UUI) is characterized by the urgency symptom that appears simultaneously with or just before incontinence; mixed urinary incontinence (MUI) occurs when involuntary urine loss is associated with urgency and effort. 1,2 Urinary incontinence harms people that suffer from it, impacting them psychologically, physically, socially, domestically, occupationally, and sexually. It negatively affects the quality of life (QoL) in these individuals. 3,4 In some cases, the dysfunction generates lifestyle, habitual, and daily activity changes because of the disturbing situations that it causes, which lead high levels of stress and feelings of vulnerability, that can cause social isolation. 5 Therefore, the ICS affirms that QoL evaluation should be included alongside clinical assessment. 6 Behavioral therapy (BT) consists of an association of techniques that aim to reduce or even eliminate urinary symptoms, including UI, through education about health conditions, changes in lifestyle and nutritional habits, and also through bladder training. As an UI treatment, BT can be applied alone or associated with other conservative approaches, such as training of the pelvic region muscles, drug treatment, or even surgery. 7 Behavioral therapy is developed based on health education, which involves the patient's perception of her own body and health condition, requiring adjustments related to habits and behaviors. 8,9 The changes include weight loss, avoiding some foods or beverages that are harmful to the bladder, regulation of intestinal function, drinking water correctly, and also a scheduled voiding  Patients who did not adhere to BT treatment were excluded from data analysis (attendance at a minimum number of meetings was required), as well as those who did not respond to the research questionnaires.

Group behavioral therapy
Behavioral therapy is the first stage of a physiotherapist treatment in the ambulatory clinic. The BT group is composed of up to ten patients, and occurs once a week for four consecutive weeks.
Each meeting has three stages: 1) 25 minutes for exhibition of themes; 2) ten minutes for dialogue between professionals and patients to respond to

Results
In total, 160 women were eligible to participate in the group BT, but 13 did not adhere to BT, and one of them did not respond to the questionnaires; the final sample was composed of 146 participants.
Mixed urinary incontinence was the most prevalent type (58%) (

Incontinence Severity Index (ISI)
To classify the severity of UI the ISI scale was used, which is a short instrument, composed of two questions about frequency and quantity of urinary loss. The final score, obtained from the multiplication of frequency and quantity scores, generates the UI severity classification: 1 to 2 = light, 3 to 6 = moderate, 8 to 9 = severe, 10 to 12 points = very severe. 13 Currently, this instrument is utilized in clinical and epidemiological studies;

Protocol adherence
Participant adherence was considered sufficient when they attended more than half of the total treatment, or at least three meetings. The attendance was weekly, verified by the researchers.  (Table 3).
Administration of the ISI scale identified a reduction in these women's UI severity, in the comparison between ISI-Q1 and ISI-Q2 (p < 0.001), also when comparing ISI-Q1 to ISI-Q3 (p < 0.001). Figure 1 shows a gradual "severe" and "very severe" categories decrease, and the growth of "moderate" and "light" categories, which are a consequence of the three questionnaire administration   Association, the UI treatment should start with BT and  In the present study, some factors could have interfered and made it harder to complete the questionnaires, such as the low educational level of the participants. Furthermore, as it is a reference service, many women live far from the health unit, which makes it harder for them to participate in all BT sessions. However, this study reflects the public service reality with good results using the chosen approach.
The present study naturally has its limitations for being observational in nature, without being able to compare BT effectiveness to a control group. The strengths are the sample size and the innovative BT approach in a group as a primary treatment option, before individualized physiotherapy.
The obtained results reaffirm the literature reports with people from different countries, 18,23,25,28 showing that BT can be implemented in a Brazilian health system context for women with UI. To enable the integration of group BT in a conservative UI treatment, we must face the challenge of encouraging people to join meetings in person, and also promoting healthy habit changes, making the participants more independent with their own treatment. However, after BT, it is necessary to identify those women who continue to require a multidisciplinary and individualized physiotherapy approach.

Conclusion
The reduction in the impact of UI on QoL was noticed in many KGH domains, as well as UI severity reduction on women participating in group BT, used as single intervention, as a first-line treatment option. The mentioned results were noticeable especially from a longer-term perspective, because the process includes changes in habits that naturally take time to be established.

Authors' contributions
The study was developed by RMC and SLN. ACRM and RMC were responsible for data collection, and ACRM and SLN for its analysis. All the authors contributed to the writing process and the article review, and also to final version approval.