MALE INCONTINENCE : A CRITICAL REVIEW OF THE LITERATURE

The aim was to identify and analyze studies on the quality of life and life experiences of men with urinary incontinence. Through critical review of the literature, data were analyzed using content analysis technique based on psychodynamic references. The results were grouped into two themes: Psychosocial lived experience aspects of men with urinary incontinence; Men’s lived experience in the management of urinary incontinence. Men with urinary incontinence experienced a low self-image along with a sense of social stigma associated to the image of a deteriorated body. Seeking treatment when the incontinence is mild and making use of psychological and social mechanisms to adapt to the urinary incontinence. The study shows that incontinent men to have low expectation regarding treatment due to the lack of knowledge about existing therapies and strategies to urinary loss control. DESCRIPTORS: Urinary incontinence. Prostatectomy. Men’s health. Nursing. Review literature as topic. INCONTINÊNCIA URINÁRIA MASCULINA: UMA REVISÃO CRÍTICA DA LITERATURA RESUMO: O objetivo foi identificar e analisar estudos sobre a qualidade de vida e vivência de homens com incontinência urinária. Por meio de revisão crítica da literatura, os dados foram tratados pela técnica de análise do conteúdo e analisados com base nos referenciais psicodinâmicos. Os resultados foram agrupados em dois temas: Aspectos psicossociais vivenciados por homens com incontinência urinária e Vivência dos homens no manejo da incontinência urinária. Os homens com incontinência urinária vivenciam sentimentos de estigma social associados à imagem de um corpo deteriorado. Procuram tratamento quando a incontinência é leve e buscam mecanismos psicológicos e sociais para se adaptarem à incontinência urinária. O estudo mostrou que os homens incontinentes tem baixa expectativa em relação ao tratamento devido à falta de conhecimento sobre as terapias existentes e das estratégias para controlar perda urinária. DESCRITORES: Incontinência urinária. Prostatectomia. Saúde do homem. Enfermagem. Literatura de revisão como assunto. INCONTINENCIA URINARIA MASCULINA: UNA REVISIÓN CRÍTICA DE LA LITERATURA RESUMEN: El objetivo fue identificar y analizar estudios sobre la calidad de vida y experiencias de hombres con incontinencia urinaria. Para la revisión crítica de la literatura, los datos fueron tratados con la técnica de análisis de contenido y analizados en las referencias psicodinámicas. Los resultados se agruparon en dos temas: Aspectos psicosociales vividos por hombres con incontinencia urinaria; La experiencia de los hombres en manejar la incontinencia urinaria. Los hombres incontinentes viven con sentimientos de estigma asociados con imagen de un cuerpo deteriorado. Buscan tratamiento cuando la incontinencia es pequeña y buscan mecanismos psicológicos y sociales para adaptarse a incontinencia. El estudio muestra que los hombres incontinentes tienen bajas expectativas cuanto a tratamiento debido a la falta de conocimiento sobre las terapias existentes y las estrategias para controle de la pierda de orina. DESCRIPTORES: Incontinencia urinaria. Prostatectomía. Salud del hombre. Enfermería. Literatura de revisión como asunto. 231


INTRODUCTION
Urinary Incontinence (UI) is a condition that affects both men and women, at all ages and cultural and socioeconomic status.][4] Studies of emotional and social domains on this subject show that fear, rage, shame and sleep disorders due to urinary loss as having negative impact on the Quality of Life (QoLand) that this negative impact is significantly higher in men than in women. 5] Male UI is becoming increasingly prevalent and its management has become a subject of increased interest for urologists, due to the rising elderly population and the risk factors associated, as bladder outlet obstruction, neurological disease and cognitive impairment, and the increase of surgical interventions for prostate cancer. 8ften the post prostatectomy incontinence PPI is a resulting morbidity of radical prostatectomy and may be caused by sphincter incompetence, bladder dysfunction, or both, or by overflow due to urinary retention. 9The PPI significantly compromises the lifestyle of men. 10 The frequency of studies that evaluate this subject indirectly implies that other causes for male UI are less important. 11fter prostatectomy, urinary loss is generally transitory, and the possibility of becoming continent progressively increased after 12-month follow-up. 12owever, when it continues for longer periods of time it may be considered a problem of difficult resolution that dramatically interferes in the QoL and compromises the physical, emotional, psychological and social aspects of the individual. 7,13he QoL domains of incontinent men, especially the emotional aspects, may be underestimated by health professionals due to the lack of information.UI is a factor that affects several domains of the QoL, thus, it constitutes a target in clinical research that indicates the importance of studying its physical, psychological and sociocultural domains, which must be equally considered for an appropriate and efficient treatment of male UI. 14 For that reason, the psychodynamic point of view, based on the comprehension that everything people say and do has meaning, 15 may help and to support a better understanding of the subject and assist the health professional on the identification, prevention and treatment of male UI.Thus, seeking the provide more comprehensive information to health professionals about psychosocial aspect of male UI, and offer to patients elements that contribute their adherence to treatment and improve the QoL, the purpose of this study was to identify and analyze studies in literature that discussed the quality of life and the life experience of men with urinary incontinence.

METHOD
The development of the review of the literature used four key databases: Lilacs (Latin-American and Caribbean Center on Health Sciences Information), Medline (International Database for Medical Literature), and Pubmed and Scholar Google.For the search, were used the descriptors: prostatectomy and urinary incontinence and quality of life.
Inclusion criteria were qualitative and quantitative studies written in Portuguese, Spanish and English; published from 2000 to 2010; focusing on the quality of life of men with UI and on the coping strategies of men with UI.
Results of the electronic searches identified and selected studies first according to their titles, followed by completely reading their abstracts which were evaluated and selected based on the aforementioned criteria.Reviews and original articles not related to the subject were excluded.
Next, were examined full text articles found at the bibliographic exchange service and at the library book collection of the Medical Sciences School of the University of Campinas (UNICAMP), at the CAPES' Electronic, Center of Journals through UNICAMP's Electronic Library, and at the Scientific Electronic Library Online (SciELO).
After reading published results, the set of collected material was studied using the content analysis technique, and the data analyzed based on the psychodynamic referential, 15 i.e., social and psychological domains.

RESULTS AND DISCUSSION
This paper discusses the 19 studies that met the criteria as established at the outset.The table 1 shows information about method and approaches the selected articles.The results highlight the relevance of understanding how UI affects the QoL of men, their life experiences when coping with it, and evidenced the existence of a reduced number of studies available in full text, focusing on QoL and coping strategies of Brazilian men with UI.
The reviewed articles point out UI as a traumatic experience that affects men's QoL and the search for medical treatment.To provide a better comprehension of the experiences of men with UI and the meanings attributed to male UI, the data were grouped by subject topics, by relevance and frequency, in which these were mentioned, resulting in two main categories: (1) Psychosocial experiences of men with UI, and (2) Men's experiences in the management of UI.This will be discussed in the section below.

Psychosocial experiences of men with urinary incontinence
Urinary incontinence and prostatectomy followed by sexual impotence have a significant impact on the social, psychological and physical domains of the QoL, and are directly related the meaning of UI symbolic representation.Lived experiences and the QoL seem to be in agreement with the concepts of continence and incontinence created by the subject, and the characteristics and frequency of the symptoms or the constant attempts to control UI. [3][4]14 Interestingly, male UI may be the determining cause of social and sexual interaction restrictions. Sties reviewed show that individual´s nature, associated with perceptions and reactions to experiencing UI, determine the extent of emotional conflicts and the difficulties faced in social life and in health self-perception.6 The more severe the UI symptoms are, the lower are the sexual desire and satisfaction.If these symptoms are mild the sexual life and the QoL is preserved.16 The anxiety caused by a urinary problem interferes in the QoL and restricts the family and social contact, which leads to feelings of loss of his life control.The shame, embarrassment and discomfort are reported due to the incapability of controlling their bladder in the presence of their relatives and friends.Furthermore, they have fear due to decreased ability in performing domestic and professional works.5,[17][18][19][20] Nevertheless, the implications of UI, as odor of urine and the wet clothing, affect the emotional, psychological and social wellbeing of these men, and they may to feel stigmatized person.Shame arises when the individual perceives one of his own attributes is in question, which may configure a disadvantage in life.It is considered a defect or flaw when compared to other people.For stigmatized people the society reduces opportunities and imposes the loss of social identity, resulting in a damaged self-image.And the men with UI need to publicly appear as a person who does not have the disease.21 It is possible that an incontinent person may try to keep his social identity as continent.If his problem is exposed, one´s social identity changes from normal to abnormal or socially unacceptable and will try to adapt in several ways, to somehow support this normality.14 The largest psychosocial impact of UI seems to be associated with physical and behavioral factors that may inflict emotional and social burdens as a threat to one´s social and personal identities.
Incontinent men are emotionally unprepared and suffer with the feelings of embarrassment and shame that interfere in their self-esteem.The lack of vigor affects work, interpersonal and intimate relations. 14,22Overall, society demands a person to have some level of control over the use and presentation of his body, a demand that may expand or contract due to psychological circumstances influenced by both social factors and physiological aspects. 23he body and identity integration starts at birth, when the human being realizes their incapability to control the release of urine as a normal condition.The simply acquisition of continence is an important event in the life.It is strong and influential and is present in core physiological processes of the organism.Likewise, the perception of one's own body as continent is deeply fixed to the core of each person. 24n this context, the experience of UI shows the nature and the way through which men understand and deal with this continence change in the body: at its best, as something irritating and, at its worst, as a devastating and embarrassing condition. 22ody image construction is continuously remodeled through an individual´s experiences, as it incorporates characteristic signs from one's whole life, and is constructed by intra and interpersonal relations, emotions and feelings within the individual, with others and the with environment. 23he body image is the unconscious memories of all relations experienced, and are alive, current and dynamic at the same time. 25he men with urinary loss can be hurt the masculine identity due to men interpretation on the relationship between the two functions of the male sexual organ, 27 the physiological and psychological association between the acts of passing urine and having sexual intercourse.Thus, in the presence of UI in men, the sense of masculinity, is affected. 22n this context, in order to hide the urinary loss and the use of a pad, change their dressing and life style.They frequently wear black pants, or bathing and changing clothes many times a day, and wear a diaper or pad to prevent visible wetness. 28The use of pads caused embarrassing and it may represent a threat to their masculinity. 13Considering that clothes become a part of an individual´s body image, the changing of clothes´ style can also mean change in attitude as an attempt to overcome the body image inflexibility. 24tudy showed that the men with UI who wear one pad a day consider themselves continent and have their QoL unchanged, while, those who require the use of two or more pads a day consider themselves incontinent, suffering and loss of QoL. 26 The smell of urine, at times associated with the visibility of wet pants, contributes to sense of being dirty, and can induces to stigmatized feeling, poor social relationships, low self-esteem, 17,19,28 and portends an old age, dementia and incompetence. 28he aging process also influences in the body perception.During this process the body image will adjust to his physical body changes. 29hen, a study indicated that the men perceive and describe UI as a degenerative process of the body as a consequence of advanced age. 23The age alone does not promote changes in body image, but the way in which the individual deals with his experiences. 29Ironically, UI and loss of other body functions during the aging process are feared as the beginning of independence loss because it is often an important factor towards the need for institutionalization. 5,7

The men's experience in management of urinary incontinence
[24][25][26][27][28][29][30] Interventions, treatment, and coping are supported by data of studies with women. 10Men look for treatment while the UI is still moderate or mild, in contrast to women, who expect the problem to get worse to seek professional help.
In terms of management, the European Association of Urologists (EAU) developed guidelines for male UI and recommends that conservative management in any treatment that does not involve pharmacological or surgical intervention and is considered to be simple and low cost and can be implemented at the primary care level. 31any conservative management interventions require a change of behavior, which is not easy to initiate or maintain.Though most patients with mild to moderate symptoms wish to try less invasive therapies first, patients with severe symptoms may need to be referred for specialized management. 8he drive to see a doctor is motivated by the need to confirm the diagnosis, mainly when the symptoms are recurrent. 5Individuals do not seek treatment when they believe the amount of urine leak does not compromise their domestic and professional activities; when they do not consider the incontinence as a serious or distressing problem; or because they do not know the causes and available efficient therapeutic options. 5,32The belief that UI is an inevitability due to prostate disease or that it is a natural consequence of aging, associated with the fear of institutionalization, prevents men from seeking for medical treatment. 3,23tudies reviewed pointed out that the meaning of UI for men is determined by the attitudes of seeking or not for help and is related to the impact of psychological, social and cultural lived experiences, along with the presence of symptoms and the lack of information.4][35] Even though these measures can be effective, they need to use pads causes an impact on the QoL mainly on sexual functioning. 2,20][24][25][26][27][28][29][30] Attempts to prevent their UI condition from becoming public, and to protect themselves, individuals plan to visit places that have restrooms; avoid activities that make the incontinence worse; remain alert since an unexpected urine leak may occur; and try to avoid mental turbulences with these protective measures. 23Consequently, the studies indicate it is need to use defensive mechanisms in the confrontation of the urinary problem.
Incontinent men use a language of strategic nature when handling UI symptoms and attitudes of self-discipline.Places where a restroom may not be found are considered 'danger zones', and from the moment the cause of the threat is identified individuals try to 'neutralize' the mechanism that may intensify the symptoms. 36he men may take advantage of the experienced situations and use social stigma for secondary purposes, such as an excuse for failure. 21trategies as psychosocial adaptive mechanism may be using by them, as an alternative to contain the physical symptom that UI causes.
Such mechanism is frequently used as a form of defending oneself from internal conflicts as a protection from stressing agents.It determines how each person reacts to stress situations.Additionally, people tend to develop mechanisms to adapt themselves with their internal world, where the threat from some psychological events may cause anxiety and existential anguish symptoms.And, this person may use repression and denial mechanisms for dealing with this conflicts. 36rom the moment men become aware of the consequences of prostatectomy, they show ability to adapt themselves to the adverse consequences of the procedure and to the experiencing of UI as an expected result of the surgery, the urinary symptoms will be accept naturally and will not change their QoL. 18Once it is not possible to maintain continence, the men begin a process of construction of a new understanding of 'self', moving towards acceptance of their incontinent body. 22ost men achieve continence through trial and error, using adaptations and strategies that were generally not taught by health professionals.Occasionally, negative feelings such as embarrassment due to their condition and attitudes of the health professionals, i.e., lack of information about the problem may be a barrier for the search for help. 32upport and information offered by health professionals do not seem to be poor.However, men who have gone through a prostatectomy state they have been informed regarding the usual complications of the surgery, but professionals sometimes forget to teach consistent and systematic strategies to cope with this complications. 37evices can be offered as means of achieving social continence prior to a definitive diagnosis and while a management plan is developed.Permanent continence products should be used only after exclusion of other methods of continence care.Product preference is related to lifestyle and severity of the incontinence.Different types of product for night time versus day time use and when going out versus staying in may be preferred. 8hus, whenever a male patient seeks help, health care professionals must consider his feelings of fear, anxiety, frustration, and rage, since UI sufferers generally do not spontaneously talk about their afflictions. 3

FINAL CONSIDERATIONS
For men, UI is the consequence of prostate disease and/or aging diseases.This review of literature on available full text research articles evidenced lack of studies aimed at evaluating the impact that strategies for minimizing the effects of UI have on QoL.In social life, incontinent men have the experience of stigmatized members.The feeling of loss of bodily function seems to be directly associated to the image of a damaged body, with consequent injure to their masculinity, i.e., to their sexual function.
The quantity of pads used every day may be associated to the QoL.In as much as the ability to control information about the self, in general is connected to social position and self-esteem.Concealing this urinary symptom so that are not perceptible to others may be vital as to being considered normal and avoiding stigmatization by the social group one belongs to.
The study shows that incontinent men seem to have low expectation regarding treatment.It may be due to the lack of knowledge about existing therapies and strategies.As a way of defending of stressful situations, the men with UI could make use of psychosocial adaptive mechanisms.Nevertheless, these men seek medical treatment even when the incontinence is mild, which is evidence that they consider it as a relevant problem.
Not all men who go through a prostatectomy experience UI, but it is important that they are aware of the consequences and of the effect that UI may have on their lives, as well as they should be aware of the fact that therapeutics may not be curative, but it will contribute to QoL improvement.
Studies also showed that health care professionals do not give the necessary attention to the psychological and social issues of male UI.On the other hand, the individuals may have varying responses to their urinary symptoms, and be reluctant to discuss UI and potential interventions with health care professionals.
Nursing holistic focus on patient care and QoL assessment includes the social and behavioral elements of stigma, factors especially relevant to determine the relationship between health and the QoL.Nursing assessment and care of patients with UI also provide a distinct opportunity to assess for potential consequences (e.g.low self-esteem, anxiety or depression).Therefore, nurses should direct sensitive queries about UI in their clinical assessments, provide information on the effectiveness of available treatments, and confiding in a healthcare professionals.This is important not only due to the social stigma, but essentially for the development of an empirical basis for health care practice.
Studies are necessary to determine the relationship between the types of coping used as strategies to mitigate UI impact in the QoL of men with UI, particularly in order to allow the choice of working interventions, both for the process of facing and handling the problem as well as to the establishment of indicators that allow the evaluation of outcomes.