Aim: The aim of this study is to describe the meaning of urinary incontinence in female geriatric population who experience urinary incontinence.

Materials and methods: The study was conducted with 11 volunteer women chosen by using criterion sampling method among patients who were aged 65 and over and who applied to the Urogynecology unit in the Department of Obstetrics and Gynecology in Istanbul University Istanbul Medical Faculty between 1st November and 31st December, 2013. A qualitative methodology using thematic analysis was utilized to conduct the study. The data were collected through a semi-structured interview form with open-ended questions which were prepared by the researchers and which aimed to investigate the effects of incontinence. All the interviews were conducted using in-depth interview technique and the responses were tape recorded. The data were then coded, and the themes related to the topic were created with thematic analysis method.

Results: The participants mentioned the state of urinary incontinence as an embarrassing or secret situation rather than a disease, thus waited for years before seeking treatment. The themes emerged from the present study included “limitations in social activities”, “unable to be clean, unable to feel clean”, “unable to share with others”, and “unable to do religious obligations”.

Some of the participants stated that they did not want to travel long distances, and when they had to, they went with their husbands or children. They also stated that they did not want to be in social environments. Some other participants reportedly felt worried about not reaching the bathroom when they need to and thus having incontinence. They also felt worried that their incontinence would be noticed by others.

In conclusion, this study found that urinary incontinence caused embarrassment for women aged 65 and over; this feeling prevented them from seeking treatment for years.

Female, Geriatric population, Qualitative study, Urinary incontinence

Özkan SA, Ba?göl ?, Beji NK (2015) The Meaning of Urinary Incontinence in Female Geriatric Population Who Experience Urinary Incontinence: A Qualitative Study. Ann Nurs Pract 2(3): 1028.

UI: Urinary Incontinence

Due to estrogen deficiency, aging brings physiological changes such as lower urinary tract muscular atrophy, replacement of fatty tissue with muscle tissue, and decrease in the strong twitch of the pelvic floor muscles. These changes can cause involuntary leakage of urine, namely urinary incontinence [1-3]. Awareness of health professionals about incontinence increased with the increase in elderly population as well as their desire for the better quality of their life; urinary incontinence could cause loss of independence, limitations in social activities, anxiety, and social isolation [3-6].

In the literature, prevalence of urinary incontinence is shown 45% in elderly women in the world [7]. In their study conducted with 5467 women in Shanghai, Liu et al., (2014) found UI prevalence as 23.3% in women aged 20 and older; these proportions were found 35.3% in the 60-69 age group, 52.1% in the 70-79 age group, and 57.1% in the 80-100 age group. Ateskan et al., (2000) investigated 2000 elderly people aged 65 and over (1276 women and 724 men) and found urinary incontinence prevalence as 57.1% in women in Turkey [8].

Female geriatric population who experience urinary incontinence may develop dermatological problems such as dermatitis, skin infections, and pressure ulcer; and psychological problems such as depression, lack of confidence, guilt, sleep problems, sexual difficulties, and functional and psychological collapse [9]. All of these problems can cause elderly people to experience more dependency and inadequacy. The related literature indicates that women with urinary incontinence always worry about reaching the bathroom, they always need to carry and change clothes, and they try to hide this problem from their family and friends [10,11]. Besides, it is reported that women reduce their social and family relationships to minimum as they feel embarrassed or think they smell bad because of incontinence [9].

Studies indicate that most women with incontinence did not seek treatment due to having lack of knowledge, feeling embarrassed or considering urinary incontinence as a natural consequence of aging, which caused them to see a doctor when it was late and the problem got worse. Therefore, it is very important to make a holistic evaluation of the elderly population. The assessments must include pelvic physical examination, the presence of incontinence, and psychological and social well-being [11,12]. The views and experiences of elderly women who have urinary incontinence have never been investigated qualitatively in the studies conducted in Turkey so far.

Aim

The aim of this study is to describe the meaning of urinary incontinence in female geriatric population who experience urinary incontinence.

A qualitative methodology using thematic analysis was utilized to conduct the study.Eleven participants were chosen using convenience sampling method from Urogynecology Polyclinic of the Gynecology and Obstetrics department at a University hospital in Istanbul.

Depending on the symptoms accompanying the diagnosis and the type and phase of urinary incontinence after the diagnosis, the women who apply to the Urogynecology polyclinic of the hospital where the study was conducted have either surgical operation or conservative treatment options. The data were collected between 1st of November and 31st of December, 2013. As qualitative studies do not indicate a specific sample size, the present study was conducted with 11 volunteer women who were aged 65 and over. The inclusion criteria were being 65 or older, having experienced UI for at least 6 months, having a clinical diagnosis of incontinence, being conscious, and providing informed consent. The exclusion criteria were the presence of bladder pathology or dysfunction due to genitourinary fistula, pelvic irradiation, tumor, neurological conditions, and any kind of communication problems.

The data were collected through “Identification Form” which included information about women’s descriptive features (age, education level, number of pregnancies, and duration of experiencing urinary incontinence) and “Semi-structured Interview Form”. The semi-structured interview was specifically developed by the researchers to guide the data collection process and evaluated by the experts in the field. The interview form included 4 questions regarding the experience of urinary incontinence (When did your incontinence problem begin?, How did you feel?, How did this situation affect your life?, What did you do to cope with this problem?). The interviews were conducted using an in-depth interview technique with such questions as “Why?” and “Can you explain more?”. The interviews were conducted face to face, in a silent and comfortable room in the urogynecology polyclinic of the hospital. The questions were asked through semi-structured question forms. The participants were asked whether they had anything to add or change with a view to confirming and reviewing their answers. The participants’ original statements are presented in the findings section. The semi-structured interviews were tape recorded, written in computer, read and reread, and written in the Microsoft Word program. The interviews lasted approximately 25 to 30minutes, depending on the length of the responses given by the participants. Responses of the 11 participants who were interviewed were evaluated using “thematic analysis” method. This method is a systematic approach to the analysis of qualitative data. It was conducted according to the steps indicated in the related literature [13,14]. First, the participants’ voice recordings were transcribed (transcription) and then the thematic fields were formed in line with the responses given by all the participants. Transcribing was completed by the researchers. At the beginning of the thematic analysis, the notes about each interview were discussed. While listening to the audiotape recordings, the researchers read the transcriptions for several times. Thematic fields were redefined after reading and rereading, word counting (counter-examples) and checking alternatives that may mean the same; and data encoding was performed by two researchers, independently from each other. They were then reorganized by the two researchers with a view to increasing the internal consistency of the study. Following this, general themes that emerged were noted down. Reading the transcriptions for several times enabled the researchers to become familiar with the data and see the similarities in participant interviews more clearly. All aspects of the content were described by “open coding” of the repeated readings of the transcriptions. Similar categories with broad themes were created from the condensed content. The researchers coded the data under similar themes. The coding of data is an analysis process which dissects the data meaningfully. In the coding process, meaning is labelled or assessed to “chunks” of data [13,14]. The meanings of words are emphasized, not the words themselves. Following this, thematic categories are developed; here each code was organized into themes, which is a process known as categorizing. Categorizing involves the process of bringing together the data similar in content and meaning and then placing them into categories [13,14]. The coded sections of the interviews were collected and placed under appropriate themes. The process was repeated in the evaluation of each response.

Official permission was obtained from the Institutional Review Board. The women were informed about the study and those who agreed to participate were involved in the study. Verbal consent was obtained from each woman. Their names were kept confidential and they were referred according to the participant numbers instead of names.

Due to the nature of qualitative research, findings of the present study may not produce certain and generalizable results. However, they can produce examples, explanations and experiences which help us better understand the perceptions of any phenomena. They give nurses the opportunity to observe and define. Therefore, it is a very valuable research approach for professional nursing practices [14]. The most important limitation of the present study is that the results cannot be generalized. Besides, the study population comprised women who had chiefly been selected by their investigators and they all wanted to talk about their problem. This led to over-representation of women who felt less ashamed and were able to seek help more easily. A strong point in this study is that it included such a large and otherwise difficult to trace group of patients who were willing to participate and did not object to being videotaped.

Average age of the participants was 68,55±5,16, average number of children was 4,18±3,16, and average duration for experiencing urinary incontinence was 7,81±7,97 (4 women: 1-3 years, 3 women 4-6 years, 4 women 7 years and more). Four of the women were not literate, 3 of them were literate, 1 of them graduated from primary school and 3 of them graduated from high school.

The participants mentioned the state of urinary incontinence as an embarrassing or secret situation rather than a disease, thus waited for years before seeking treatment. The themes emerged from the present study included “limitations in social activities”, “unable to be clean, unable to feel clean”, “unable to share with others”, and “unable to do religious obligations”.

Theme 1

Limitations in social activities

In relation to the “limitations in social activities” theme, some of the participants stated that they did not want to travel long distances or be in social environments, carried pads or spare underwear with them, and felt worried about not reaching the bathroom when they need and thus having incontinence.

“I do not want to go to long distances, this case causes troubles. I am a very clean person, thus I do not want to go to places where I cannot reach the toilet easily. “…when I plan to go somewhere, I feel so irritated that I lose my sleep in the previous night…...” (P3).

“Sometimes they invite me somewhere far away from my home. The other day, they asked me to go when it was holiday, I could not go. It was far away. I went once and I was soaked on my way. It was terrible… I feel sad when I have incontinence, I feel embarrassed. Sometimes I stop on the way and do this (crossing her legs), I can go on walking only if incontinence stops (P6).

“I cannot go out; I cannot go for a walk for the fear that I would have urinary incontinence. I even have incontinence during the time I go to the supermarket and come back; I have incontinence while going up the stairs….” (P11).

Theme 2

Unable to be clean, unable to feel clean As for the theme “unable to be clean, unable to feel clean”, the participants stated that they felt dirty and smelly and were worried that the smell would be noticed by others. They also said that they coped with this problem by changing clothes frequently and using pads.

“I wear special underwear like a diaper, with snap crotch on one side, but it irritates and makes me sweat. It also causes itch. I cannot change it very often because I have pain in my knees….” (P4)

“I began to have this problem after menopause. How I hated myself…The smell was so intense that I even thought of committing suicide” “(P5).

“I do not want anyone to know me wet or dirty. I never go to someone else’s house to stay overnight….” (P8)

Theme 3

Unable to share with others

For the theme “unable to share with others”, some of the participants stated that they did not want to tell it to their children; they also did not want to share it with their husbands because the husbands would think that it was a natural consequence of aging. They felt worried about the probability their friends or neighbours would notice it.

“I live with my husband, but I haven’t shared it with him. He finds these kinds of things abnormal. He thinks I am old and nothing can be done. For instance, when I come here, I do not tell him that I am coming for incontinence… (P2).

“I felt bad when I told it to my daughter-in law, but what can I do? My knees hurt a lot, I cannot stand up and change my clothes, I even cannot change my socks”. (P9)

Theme 4

Unable to do religious obligations

In the “Unable to do religious obligations” theme, some of the participants stated that they became canonically unclean, could not perform prayers, and felt sorry because they were unable to do religious obligations.

“I always re-perform ablution when I have incontinence. When I do it frequently, I sometimes get ill.” (P1)

“I haven’t been able to perform prayers for a month… Last night, I had a bath and performed my prayers for evening prayer and night prayer. But I had incontinence and thus could not perform my prayer in the morning”. (P7)

“I perform prayers immediately after ablution. I perform ablution before each prayer time. It is difficult, but what else can I do?” (P10)

The present study has made an in-depth investigation of the meaning of incontinence in female geriatric population. Urinary incontinence should be taken into consideration because it is associated with long-term care, loss of independency, poor quality of life, limitations in social activities, and increased anxiety and social isolation especially in elderly population [4,6].

Although their quality of life is affected by incontinence, women do not seem to receive help. Some reasons for this behavior include perceiving incontinence as normal and a natural consequence of aging, being shy about talking about this problem, and feeling embarrassed [11,15-17]. Horrocs et al., (2004) point out that perceiving urinary incontinence as a shameful or secret situation rather than a disease and thus waiting for years before seeking treatment is an important barrier in reaching the health service [18]. Another study indicated that elderly women felt ashamed of incontinence, did not share it with anyone, and kept this situation like a secret [11].

Most women have to make some restrictive changes in their life styles in order to hide their incontinence problem (e.g. limiting fluid intake, avoiding going to places which do not have a toilet, refraining from physical activities, etc.). Some women with urinary incontinence problem develop an increasing isolation problem as incontinence limits their social activities and relationships [10].

In relation to the “limitations in social activities” theme, some of the participants stated that they did not want to travel long distances or be in social environments, carried pads or spare underwear with them, and felt worried about not reaching the bathroom when they need to and thus having incontinence.

Decreased social activities along with aging cause more problems with the involvement of urinary incontinence problem, which increases limitations and isolations of elderly people and thus has negative effects on their quality of life. Therefore, it is very important to examine incontinence and its effects, and to plan activities with the existing problem in elderly population.

Most women make detailed preparations in order to hide their incontinence problem; some examples include going to toilet before leaving home, using pads, and carrying spare clothes [10]. Besides, it is stated that women reduce their social and family relationships to minimum as they feel embarrassed or think they smell bad because of incontinence [6,9]. As for the theme “unable to be clean, unable to feel clean”, the participants stated that they felt dirty and smelly and were worried that the smell would be noticed by others. They also said that they coped with this problem by changing clothes frequently and using pads. Feeling constantly dirty or smelly and trying to be clean are behaviors that can cause psychological problems in time. Therefore, nurses should improve their patient education/consultancy in every area so that they can increase awareness about incontinence symptoms and treatments and eliminate individuals’ fears and misunderstandings [19].

 Most women see urinary incontinence as a social problem and taboo rather than a medical problem. Thus, they avoid talking about the problem [11,15], limit their social activities and interactions, and have dramatic decrease in their relationships especially with family members. In a number of the women, shame formed a reason why they could not talk to anybody about the incontinence, not even with the doctor [20], who indicates that incontinence causes social stigmatization [10].

For the theme “unable to share with others, some of the participants stated that they did not want to tell it to their children, they also did not want to share it with their husbands as the husbands would think that it was a natural consequence of aging. They felt worried about the probability their friends or neighbours would notice it. Majority of the women with incontinence did not seek treatment due to having lack of knowledge and embarrassment and seeing urinary incontinence as a natural consequence of aging, which caused them to visit a doctor when it was late and the problem got worse. Therefore, it is very important for health professionals to investigate the urinary symptoms as well, no matter for what health problem the patient has visited the health institution [21].

Beside their roles in diagnosis and treatment and monitoring/ control, nurses who aim at holistic care and who are responsible for more than clinical care have important responsibilities in developing continence and preventing incontinence [22]. While fulfilling these responsibilities, the continence nurse should consider elderly people’s need for information as well as their level of comprehension, cultural values, and religious beliefs [23].

Beside their roles in diagnosis and treatment and monitoring/ control, nurses who aim at holistic care and who are responsible for more than clinical care have important responsibilities in developing continence and preventing incontinence [22]. While fulfilling these responsibilities, the continence nurse should consider elderly people’s need for information as well as their level of comprehension, cultural values, and religious beliefs [23].

The authors would like to thank all the participants for their cooperation in this study

In conclusion, the present study found that urinary incontinence caused embarrassment in female geriatric population; they therefore limited their social activities, had to make an extra effort to be clean, and waited for years for treatment because they could not share the problem with others. Shortly, old women’s quality of life is affected due to this reason quite negatively. It is anticipated that the results will provide a way for nurses to examine urinary incontinence care from the women’s perspective

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