Profile of physically active elderly women with urinary incontinence

1Universidade Federal Fluminense, Departamento de Educação Física e Desporto, Laboratório de Envelhecimento e Atividade Física – Niterói/RJ – Brazil. 2Universidade do Estado de Santa Catarina – Florianópolis/SC – Brazil. 3Universidade Federal Fluminense – Departamento de Educação Física e Desporto, Laboratório de Biodinâmica – Niterói/RJ – Brazil. 4Universidade Federal Fluminense – Laboratório de Pesquisa em Saúde e Enfermagem no Cuidado às Pessoas em Condições Agudas e Crônicas – Niterói/RJ – Brazil. Corresponding author: Gabriela Gonçalves Pereira da Silva | Rua Presidente Pedreira, 189/1004 | ZIP Code: 24210-470 – Niterói/RJ – Brazil | E-mail: silva.ggp@gmail.com Received: Nov. 3


INTRODUCTION
A frequently observed symptom in the elderly is urinary incontinence (UI).Defined by the International Continence Society (ICS) as any involuntary loss of urine, it is one of the major geriatric syndromes and has a multifactorial etiology 1 .
UI is classified into three main types: by effort (UIE), when preceded by increased intra-abdominal pressure (such as coughing, sneezing, laughter, physical activity); by urgency (UIU), with loss of urine preceded by voiding urgency; or mixed (UIM), when it occurs both by effort and by urgency 1 .
The relationship between physical activity and UI is still controversial.For some authors, non-sedentarism and regular practice of physical activities are understood as protective factors for the appearance of UI 2,4,9 , while promoting regulation of body weight, strengthening of muscles and maintenance of physical capacity 10 .On the other hand, vigorous physical activities are understood as an important risk factor 5 , especially those with high impact [11][12] , since they affect the pelvic floor muscles (PFM) and damage its sustentation, suspension and containment 13 .
As a limitation, however, most of these studies have as adults high-performance athletes, which makes this kind of comparison difficult.
Although many risk factors for UI are clear in the literature, little is known about the physically active elderly female population and its characteristics 13 .Therefore, it is relevant to investigate the profile of this population and to understand the factors associated with UI in this public, in order to direct specific actions through the practice of physical activities and health education

OBJECTIVE
To design the profile of active elderly women with UI in a program of physical activity according to sociodemographic characteristics, health conditions and life habits and conditions associated with urinary loss.

METHODS
This is a quantitative cross-sectional study.The sample was non-probabilistic of convenience, composed of elderly women attending a fall prevention program in the city of Niteroi, state of Rio de Janeiro, with a total of 167 people.This program has been developed since 2001 and aims to prevent falls through physical activities from the perspective of leisure, playfulness and intergenerationality 14 .Power, stretching and gym workshops are offered, each lasting 1 hour and 3 times a week in the morning and afternoon shifts.Currently, the program serves 167 adults and seniors of both genders, 90% of whom are elderly women.The class planning is based on the systematization of physical exercises and ludic activities focusing on the improvement of physical valences associated with fall events, such as balance, strength and flexibility 14 .In the strength workshop, activities are offered that contribute to the strengthening of large muscle groups; stretching exercises prioritize exercises that improve flexibility and promote greater range of movement for students; and in gymnastics activities are proposed that contemplate the objectives of both workshops previously described.
The sample was composed according to the inclusion criteria: i.To be enrolled in a project workshop; ii. Be woman; iii.Age 60 or older; iv.Reporting UI symptoms; and v. Agree to participate in the study.
As an exclusion criterion, the individual was not evaluated by medical determination or with a number of absences greater than four in the last month.
The data were self-referenced and collected through an individual interview using a semi-structured form, based on the literature and prepared by the researchers.The UI was evaluated through the International Consultation on Incontinence Questionnaire -Short Form (ICIQ-SF) 15 .It is a brief selfadministered questionnaire capable of qualifying urine loss in patients of both genders and its impact on the individual's quality of life 15 .The overall score ranges from 0 to 21 and is a result of the sum of the scores of questions 3,4 and 5.In this study, the elderly woman who presented a general score greater than or equal to 3 it was considered incontinent 6 .
The study variables include socio-demographic characteristics (age, marital status, race, schooling, live alone), health conditions and life habits (smoking, alcoholism, history of falls in the last 12 months, fecal incontinence, intestinal constipation, comorbidities, number of births, births ways, number of daily medications, water intake, nutritional status, type of activity practiced in the project) and conditions associated with loss of urine (UI classification, complaining time, nocturia, use of protector, frequency, quantity, type and situations of loss evaluated through ICIQ-SF 15 ).All the volunteers were considered active, since they perform at least 150 minutes of weekly activity moderate 16 in the project.The body mass index (BMI) was used to characterize the nutritional status and had as cutoff points: low weight ≤ 22 kg/m 2 ; adequate weight> 22 and <27 kg/m 2 ; and overweight ≥ 27 kg/m 2,17 .The classification of UI was due to the symptoms of urine leakage 1 reported in ICIQ-SF 15 .
Silva GGP; Krüger AP; Alves Junior ED; Gurgel JL; Camacho ACLF Nocturia was reported as a wake-up call one or more times at night to urinate or the recording of urination during one night's sleep 18

RESULTS
After applying the inclusion and exclusion criteria, the sample of this study (n=59) consisted of 35.32% of the student population of the project.It was observed that the age ranged from 60 to 89 years and had a mean of 71.4 years (standard deviation: 6.7).The sample presents 44.1% of its total in the age group between 70-79 years.The majority of the elderly women are widow (32.2%), white (59.3%), have completed high school (40.6%) and live alone (52.5%).
Regarding health data and lifestyle habits, the vast majority of women did not smoke (96.6%) and 57.6% did not drink alcohol.The majority did not suffer a fall event in the last year (64.4%) and did not have fecal incontinence Regarding cesarean birth, 50.8% (n = 30) had a negative history and 49.2% (n = 29) had already performed between one and three by this way.It is worth emphasizing that each woman can have a history of more than one type of birth There was a report of use of one to four medications daily in 57.6% of the sample, daily water intake of approximately 1L in 57.6%, overweight and adequate weight in 42.4% of the elderly in each of these two categories.Among the types of activities realized in the project, 45.8% of the sample practice stretching, while 28.8% do gymnastics and 25.4% exercise exercises.
Table 1 shows the results regarding conditions associated with urine loss.There was a predominance of UUI.There was a higher prevalence among those who report a loss of urine with frequency ≤ 1 time per week, which its claim to be a small amount.Those that report losses in large and

DISCUSSION
Considering the sample size (n = 59) and the total number of elderly participants in the project (n=167), it was verified that at least 35.42% are incontinent active elderly, which corroborates a study realized in the state of Santa Catarina ( SC) with active elderly women, in whom symptoms of urinary loss were present in 32.2% 13 .
The literature still presents few studies with investigations regarding the profile of physically active elderly with UI.
The most found ones are performed in the elderly (not necessarily active) or institutionalized in adults and in athletes of modalities with high level of impact.The prevalence of urinary UI in these studies varies between 8 and 60% 2,4-7 and depends, especially, on the age, gender, behavioral factors and life habits of the sample studied.
In this study, the highest concentration of incontinent active elderly women was between 70 and 79 years old (44.1%), which is close to that of a population-based study in the state of Minas Gerais, which had 42% of incontinents in this age group 2 .In a representative sample of the population of the city of Florianopolis (SC), half of the incontinents were between 60 and 69 years old 4 .As in other analyzes 2,4,13 , the prevalence of UI in older elderly people was lower in this study (13.5%).On the other hand, in a study realized in the state of São Paulo, the majority (30%) of incontinent elderly individuals with fragility criteria are 80 years old or older, followed by 19% between 70 and 79 years.Age is one of the main risk factors for UI 19 , since there is greater exposure to physiological and hormonal changes due to aging, as well as behavioral factors 5 .
Silva GGP; Krüger AP; Alves Junior ED; Gurgel JL; Camacho ACLF Those who report having completed high school represent the largest portion of the sample (40.6%).Studies indicate that low levels of schooling are associated with a higher incidence of UI [4][5]19 and that the absence of schooling is related to an 83% higher chance of having UI 2 . Thi fact can be justified by the lack or difficulty of access to health information that individuals with lower schooling face, which may lead to the naturalization of UI symptoms among the elderly 2 .Thus, health education is an important strategy to disseminate fundamental information for this population, since, besides enabling the search for preventive and therapeutic actions for symptoms of urine loss 4,19 , it provides better conditions to deal with the daily challenges arising from UI 2 .
Regarding smoking, values close to that of this investigation (3.4%) were found in SC 4 and in a university hospital in the state of Piaui 5 , where only 8.3% and 2.1% were smokers, respectively.Smoking is a habit of life associated with UI, since the greater amount of tobacco in the body leads to estrogen deficiency, in addition to increasing coughing events -which favors the recurrent increase of intra-abdominal pressure -, conditions that can lead to UI 7 .Despite this, smoking and alcohol consumption were not presented as a risk factor in research conducted with active elderly women 21 .
Falls are frequent events in the elderly and have UI 8 as a risk factor.Regarding this event, it is understood that incontinent patients are affected by musculoskeletal pelvic alterations that interfere negatively in the maintenance of postural balance and, associated with urinary urgencies, increased diuresis and nocturia, and environmental conditions, favor the occurrence of falls 8 .Despite this, 64.4% of the sample did not fall in the last year.It is believed that the physical activities practiced in the fall prevention project 14 help to maintain the functional independence of these elderly women, and that staying physically active reduces the risk of falls and institutionalization 8,10 .
Parity and birth ways stand out as risk factors for UI among women.The prevalence of these variables is influenced by biological, cultural and economic factors 19 and shows wide variations according to the sample profile.The study group had a higher frequency of women with one to three deliveries (71.2%) and at least one cesarean birth (49.2%), as observed in other studies 7,12 .On the other hand, other authors 5 obtained values close to 70% of women with normal birth history and 43.8% of the cesarean type.Thus, parity seems to exert a greater influence on the appearance of UI than birth ways.
In a study realized in SC 18 , a weak association between these variables was found, and it is stated that parity and birth ways do not increase the chances of UI, especially in the elderly population.There are studies that confirm parity as a risk factor 7 .Its point out that non-nulliparous women are 1.2 times more likely to have UI 12 and that having a history of ≥ 2 births, regardless by the way, increases the chance of having UI 20 by 67%.ICS advocates that both gestation and birth are risk factors for UI, and that the protective effect of cesarean does not persist after 50 years 1 .
Overweight is a characteristic of more than 40% of the sample.Studies indicate that overweight and obesity accentuate the intra-abdominal pressure exerted on the PFM, negatively affecting the mechanism of the urinary tract 2,5,19 , becoming determinant in the incidence and persistence of UI 7 .Despite this, overweight did not increase the chance of UI in research with active elderly women 13 , as well as in elderly in the community of Florianópolis 4 and Pelotas 19 (state of Rio Grande do Sul), where there was no relationship between UI and overweight variables.
Regarding the type of UI, the UIU had a higher prevalence (50.9%).This value corroborates other studies with elderly women 1,21 .In a study conducted with 20.000 Chinese women, it was found that age greater than 60 years increases the chance of developing UIU 22 twice.It is believed that the higher incidence of UIU in the elderly is justified by the structural alterations in the detrusor muscle from physiological aging 21 .
Although its are incontinent, only 32.2% of the sample makes use of some type of intimate protector, which may be related to the fact that the largest portion has symptoms of urine loss recently (64.4%), with low frequency (42.4%) and small amount (54.3%).On the other hand, almost half of the sample (45.7%) reported moderate or large urine loss.
Studies indicate that small urinary losses cause behavioral changes that ease the repetition of these events and avoid embarrassment to the patients 3,5 .Reduced water intake, dark clothing, choice of public places next to restrooms, selfresuspension of diuretic drugs, and refraining from leaving home, among others, may mask the initial symptoms and delay the search for professionals in search of specialized treatments 3,5 .
It was observed that a larger proportion of the incontinent elderly women (45.8%) practice stretching activities and a smaller proportion of them practice strength activities (25.4%).In addition, there are no cases of UIE among force practitioners.These results suggest that there is a relationship Profile of physically active elderly women with urinary incontinence between the type of activity practiced by the elderly women and the type of UI among them 23 .The practice of strength activities promotes the strengthening of the muscles of the lower limbs, abdomen, back and pelvic floor, favoring the reduction of UI symptoms 24 , which does not occur in stretching activities.
In Japan 25 , the UI status and habitual physical activity levels of 300 women with a mean age of 66. and that urinary urgency symptoms can be minimized regular physical exercise 21 .It is believed, therefore, that the regular practice of physical activities is a modifiable factor, since, besides favoring the reduction of episodes of urine loss, it influences the improvement of risk factors related to UI, such as hypertension, diabetes and polypharmacy 21 .
The limitations of this study are: restricted number of samples, classification of variables by self-report of volunteers, and lack of in-depth statistical analysis, elements that make it difficult to generalize the results.The relevance of this study is legitimate in that it is recognized that recent studies regarding the profile of active elderly women with UI are scarce and that this study adds data for this subject.
In view of this, it is recommended to realize other studies in order to deepen knowledge on the subject and direct specific actions for this public.

CONCLUSION
This study made it possible to design the profile of elderly women with UI and regular physical activity practitioners in a fall prevention program in Niteroi.Its are mostly elderly women between the ages of 70 and 79, widows, white women with a complete secondary level and living alone.Regarding the conditions associated with urine loss, incontinent elderly women report, in particular, moderate or large loss, with frequency less than or equal to once a week, and urgency characteristics.The profile of active elderly women with UI in this study resembles those found in the literature.
Some risk factors suggested by the literature were not expressive in this sample, such as smoking, last year's fall, fecal incontinence, intestinal constipation and polypharmacy.
It is suggested that the practice of physical activities allows the adoption of a healthier way of life, favoring the reduction of these variables.Thus, it is believed that the multidisciplinary health team plays a fundamental role in stimulating the adoption of healthy habits that suppress the occurrence of UI and other important comorbidities, especially in the elderly.In addition, the prevention and early treatment of UI is recommended in order to avoid the worsening of symptoms and the quality of life of those affected by it.
. The data were collected between July and October 2017.Data were tabulated and stored in the Office Excel 2010 program and imported into SPSS 17.0 software (Windows, Chicago, USA) for descriptive analysis by means of the calculation of absolute and relative frequencies.The research follows the recommendations of Resolution 466 of 12/12/2012 of the National Health Council and was approved by the Committee of Ethics in Research with Human Beings of the Federal Fluminense University on July 13, 2017 with opinion 2.172.240 and Certificate of Presentation for Ethical Appraisal (CAAE) 36677514.0.0000.5243.All the volunteers signed the Term of Free and Informed Consent and received a copy of the document.

(
84.7%) nor intestinal constipation (71.2%).The most significant comorbidities were hypertension (55.9%) and osteopenia or osteoporosis (64.4%).There was no report of Parkinson's disease and diabetes mellitus Parity characteristics and births ways are shown in Fig. 1.Nulliparous represented 22% (n = 13) of the sample and the number of births was more frequent among those who had already performed between one and three, representing 71.2% (n = 42) of the elderly.Regarding normal birth, 61% (n = 36) never performed this type of birth and 32.2% (n = 19) had between one and three births by this way.

Figure 1 .
Figure 1.Percentage distribution of number and birth ways of physically active elderly women with urinary incontinence (UI) (n = 59).Niteroi, Rio de Janeiro, Brazil, 2017

Table 2 .
Percentage distribution of types of urinary incontinence (UI) as to the type of activity practiced in physically active elderly women (n = 59).Niterói, Rio de Janeiro, Brazil, 2017.