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

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. Incluíramse 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.

investigate the quality of life postpartum, the use of a generic health questionnaire in parallel to one specific for the determined condition has been recommended, in order to exclude the effect of morbidities often present, such as perineal pain and postpartum depression (6) .
According to the World Health Organization (WHO), the quality of life is a broad, multifaceted concept, which incorporates physical, psychological and social aspects and involves the perception of the individual regarding their condition, in the cultural context in which they live (16) .The HRQoL refers to the impact of an illness or injury on the different aspects of life (17) .
The investigation of the HRQoL of incontinent puerperae is of fundamental importance to verify the compromise that UI may generate in the diverse areas of life and to propose measures that can minimize this and contribute to improving the health and well-being of this population.The nurse must know the aspects of the HRQoL affected by postpartum UI, in order to provide targeted care to this population, implementing preventive strategies during the prenatal and postpartum periods.
Faced with this, the aim of this study was to evaluate whether postpartum UI compromised the HRQoL of women attending a public tertiary teaching hospital of the state of São Paulo, Brazil, and, if so, in what aspects.

Method
This is a case-control study conducted between May and December 2010, with women in the 90 days postpartum period, who attended the Obstetrics Outpatient Clinic of a public tertiary teaching hospital in the state of São Paulo, Brazil, for the postpartum follow up consultation.Women with urinary incontinence before pregnancy and those who had any of the following conditions were excluded from the study: twin pregnancy, the presence of: hypertension, diabetes mellitus, chronic obstructive pulmonary disease, neurological disease, urinary tract infection, renal calculus, previous history of pelvic surgery (excluding cesarean section), current treatment for UI and/or the use of medication that interferes with the function of the lower urinary tract.
The sample size was calculated to detect an odds ratio of 3.0 at a ratio of one case to three controls, assuming a significance level of 5% and a power of 80%, with the prevalence of exposure among the case group estimated at 20% (1) .The sample size calculation was estimated to be 74 cases and 222 controls.The case group (incontinent puerperae) and control group (continent puerperae) were identified by means of questions 3 and 4 of the International Consultation on Incontinence Questionnaire -Short Form (ICIQ-SF), validated in Portuguese (18) , which evaluates, respectively, frequency and quantity of urinary loss, making it possible to identify whether the person presents UI or not.The woman was included in the case group if she reported any frequency and/or quantity of urinary loss during the past four weeks, and the control group if she reported no complaint of urinary loss, considering the immediate postpartum period until the time of inclusion in the study.
For the socio-demographic and clinical data collection a questionnaire was prepared, which was submitted to content validity analysis, performed by three judges with experience in the areas of obstetrics and gynecology/or urogynecology.Some alterations in the questions and formatting were suggested, resulting in the final instrument.This was pre-tested with ten puerperae, which showed that no further modifications were necessary.
The instruments used for the evaluation of the HRQoL were the ICIQ-SF (18) , the KHQ (19) , and the SF-36 (20) , previously validated in Brazil.The ICIQ-SF is a self-administered questionnaire consisting of four questions, which qualify the urinary loss and evaluate the impact of UI on the quality of life through a scale, ranging from 0 (does not interfere) to 10 (interferes a lot), which aims to measure how much the loss of urine interferes in the daily life.The score is given by the sum of questions 3, 4 and 5, ranging from 0 to 21, and the higher the score, the greater the severity of urinary loss and impact on the quality of life (18) .In the present study, the Cronbach's alpha coefficient of this scale was 0.69.
The KHQ is a questionnaire that evaluates the perceived symptoms and the impact of the UI on different domains of quality of life.It consists of 21 questions divided into eight domains (General Health Perception, Incontinence Impact, Daily Activity Limitations, Physical Limitations, Social Limitations, Personal Relationships, Emotions, and Sleep and Energy) and two scales (Urinary Symptoms and Severity Measures).Scores range from 0 to 100 in each domain and the higher the score, the worse the quality of life related to that domain (19) .In the present study, the Cronbach's alpha coefficient of the total scale was 0.90, varying from 0.87 to 0.91.
The SF-36 is a generic instrument for evaluating the HRQoL, composed of a multidimensional questionnaire with 36 items encompassed in eight scales (Functional capacity, Physical Aspects, Pain, General Health Status, Leroy LS, Lopes MHBM. Vitality, Social Aspects, Emotional Aspects, and Mental Health).The possible score is from 0 to 100 in each domain and the higher the score, the better the evaluated health status (20) .In the present study the Cronbach's alpha coefficient for the total scale was 0.81, ranging from 0.77 to 0.81 in the eight domains.
Regarding the sociodemographic characteristics of the sample, the following variables were considered: age, race, marital status, schooling and income.The

Results
In the data collection period 441 women were approached.Of these, 97 were excluded due to not meeting the inclusion criteria.Included and excluded puerperae differed significantly (according to the Mann-Whitney test) regarding age (p<0.0001) and schooling (p=0.0496), with higher measurements among those excluded, and were similar regarding the length of puerperium (p=0.9870).A total of 344 women were, consequently, included, with a mean age of 25.9 years (SD=7.7,ranging from 13 to 45 years) and mean puerperium period of 52.3 days (SD=12.0,ranging from 12 to 87 days).The majority were non-white (65.7%), considered mixed race and black (there were no subjects in the categories Asian or indigenous), married (70.9%), had a mean of 9.9 years of schooling (SD=2.7,ranging from 05 to 18 years) and a mean monthly household income of approximately two minimum wages or R$1,212.50 (SD=773.5, ranging from R$200.00 to R$6,000.00).
The case and control groups differed significantly according to the chi-square test, with UI during pregnancy significantly more frequent (p<0.0001) in the case group (70.1%) compared to the control group (16.1%); birth, with a significantly higher frequency (p=0.0291) of multiparae within the case group (57.1%) compared to the control group (43.1%); and, according to the Mann-Whitney test, gestational age at birth, with means significantly higher (p=0.0365) in the case group (38.4,SD=2.6) than the control group (37.6, SD=3.2).
The other sociodemographic and clinical variables mentioned above were similar between the groups.
The data in Table 1 show the urinary incontinence characteristics in the puerperium.The mean of interference in the daily life, evaluated using a scale from 0 (does not interfere) to 10 (interferes a lot) of the ICIQ-SF was total score of the ICIQ-SF was 13.9 (SD=3.7,ranging from 06 to 20), which identified that the urinary loss in the puerperium, though generally of small quantity, is frequent, with a high impact on daily life.The respondent could indicate one or more situations of urinary loss, therefore, the total does not equal 100%.

The data in
clinical data related to the pregnancy and birth were obtained from the medical records of the puerperal or the newborn.The study was approved by the Research Ethics Committee of the institution (protocol No. 247/2010), following the current legislation in the country.The women who met the selection criteria were invited to participate in the study and, after they signed the Terms of Free Prior Informed Consent, the data collection was initiated.The questionnaires were completed in a selfapplicable manner by the respondents, however, they could seek clarification from the researcher when ever necessary.All the puerperae responded to the ICIQ-SF first.The case group responded to the sociodemographic and clinical data questionnaire, the KHQ and the SF-36, while the control group responded to the sociodemographic and clinical data questionnaire and the SF-36.The order of response to the questionnaires was nonconsecutive.Descriptive analysis was used, calculating the absolute and relative frequencies of the categorical variables and measures of position and dispersion of the continuous variables.To evaluate the adherence of the continuous variables to the normal distribution, the Kolmogorov-Sminov test was applied.The groups were compared according to their sociodemographic and clinical characteristics, using Pearson's chi-square or Fisher's exact test for the categorical variables and the Mann-Whitney or Kruskal-Wallis test for the continuous variables.As the domains did not present normal distributed, the Mann-Whitney test was used to compare the SF-36 scores between the case and control groups.The value of p<0.05 (a=5%) was adopted as the critical level for all tests and the SAS software (version 9.1.3,SAS Institute Inc., Cary, NC, USA, 2002-2003) was used for the data analysis.

( 19 )
underwent forceps deliveries.In relation to the previous births, 12.2% (42) had only cesarean delivery, 15.1% (52) only vaginal delivery (normal or forceps) and 18.9% (65) both.Episiotomy was performed in 23.8% (82) of the women and 17.2% (59) of them had some degree of perineal laceration.The women were around the 38 th week of gestation at the time of the birth (SD=3.1,ranging from 24 to 42) and had a mean of 02 living children (SD=1.0,ranging from 01 to 07).

Table 1 -
Characteristics of urinary incontinence in the puerperium (n=77), Campinas, SP, Brazil, 2010 *Measured by means of an analog scale (ranging from 0 to 10) †

Table 2 -
Scores of the KHQ domains in incontinent puerperae (n=77), Campinas, SP, Brazil, 2010The data in Table3presents the mean scores achieved in the ICIQ-SF and KHQ domains according to the type of UI.It was observed that women with MUI had significantly higher mean scores in the ICIQ-

Table 3 -
Scores of the ICIQ-SF and KHQ domains, according to the type of UI (n=77) -Campinas, SP, Brazil, 2010 Exact Test, urgency was associated with MUI and UUI (p<0.0001), but not SUI.The data in Table4describe the scores achieved in the SF-36 domains for the case and control groups.There was a significant

Table 4 -
Comparison of the mean scores obtained by the case and control groups in the SF-36 domains, Campinas, SP, Brazil, 2010 SD= standard deviation, Q1= first quartile, Q3= third quartile.* p value calculated using the Mann-Whitney test