PROFILE OF PATIENTS WITH URINARY INCONTINENCE IN A UNIVERSITY HOSPITAL OUTPATIENT CLINIC

Objective: to know the sociodemographic and clinical profile of people with urinary incontinence in an outpatient clinic of a University Hospital. Methods: cross-sectional study, using a semi-structured form with 63 women who were awaiting care at the gynecology and urology outpatient clinics, between the months of July and August 2019. The data were processed in the software Statistical Package for the Social Sciences – SPSS 20.0. Results: interviews were carried out with women aged between 19 and 77 years. Of these, 55.6% maintained an active sex life; 85.7% had pre-existing disease; 69.8% presented urinary loss when coughing, sneezing, smiling, putting on weight and/or making efforts; 12.7% need to urinate as soon as they feel like it; and 17.5% had loss of urine in both situations. About 35% sought consultation due to low bladder and/or loss of urine; 27% had 4 to 5 pregnancies. Among the risk factors associated with urinary incontinence, 28.6% had diabetes mellitus, 61.9% had arterial hypertension, 82.5% used continuous medication, 11.1% was obese, 34.9% reported constipation problems and 74.6% underwent pelvic surgery. Conclusion: it was concluded that all women in the study had more than one risk factor for developing urinary incontinence, reinforcing their multifactoriality, as well as the importance of a holistic and multiprofessional treatment. la incontinencia urinaria, el 28,6% tenía diabetes mellitus, el 61,9% hipertensión arterial, el 82,5% usaba medicación continua; El 11,1% eran obesos; 34,9% informó problemas de estreñimiento; El 74,6% se sometió a cirugía pélvica. Conclusión: Se concluye que todas las mujeres del estudio tenían más de un factor de riesgo para desarrollar IU, reforzando su multifactorialidad, así como la importancia de un tratamiento holístico y multiprofesional.


INTRODUCTION
The International Continence Society (ICS) defines urinary incontinence (UI) as the involuntary loss of urine.
Although considered a priority health issue, UI is underreported and underdiagnosed, with low professional recognition.
In 1998 it became part of the International Classification of Diseases (ICD), ceasing to be considered just a symptom and becoming a disease 1 .
According to the Sociedade Brasileira de Urologia (SBU), this condition affects around 400 million people worldwide, and in Brazil there are an average of 10 million people with incontinence 2 . Even though it is more common in women, it affects the population, regardless of sex, ethnicity or age. It has an increasing prevalence, as the population age increases [3][4][5] .
Among general population studies, the prevalence of UI varied between 25% and 45% in adult women, and in adult men there were publications with variations between 1% and 39%, with the proportion in women being at least twice as high when compared to men, that is, 2: 1. There is no standardization of tools and methods used in prevalence studies that define UI in practice, which can make the variation of prevalence wide, since it is still poorly established 6 .
In Brazil, there are few studies on the prevalence of UI, most of which are aimed only at women. Among the studies found, one conducted with adults from the urban population of Pouso Alegre, Minas Gerais, concluded that 20.1% of the general population has UI. Among women and men, the prevalence was 32.9% and 6.2%, respectively, with a proportion of approximately 5: 1 7 .
In Piauí, the prevalence of UI is not known, however a study carried out in 2016 with women in primary care in Teresina, showed that of the 306 study participants, 40.8% (125) were incontinent 8 . constipação e 74,6% fez cirurgias pélvicas. Conclusão: concluiu-se que todas as mulheres do estudo apresentaram mais de um fator de risco para desenvolver incontinência urinária, reforçando sua multifatorialidade, bem como a importância de um tratamento holístico e multiprofissional. Corroborating the aforementioned studies, the 2018 National Consensus on Urogynecology presented the prevalence of the most common types of UI, in which stress urinary incontinence (SUI) has a prevalence of 10 to 39%, with the highest rate, followed by mixed urinary incontinence (MUI) with 7.5 to 25%. Isolated urinary incontinence (IUI) is the least frequent and corresponds to 1 to 7%. The other causes of incontinence have an estimated prevalence of 1 to 7% 2 .
UI has a profound negative impact on the well-being and quality of life of people affected, which often leads to social embarrassment, reduced employment, decreased productivity at work, affects sexual life, in addition to presenting a significant economic and health burden 6 .
People with UI benefit when exposed to specific treatment through nursing interventions, however most people are unaware of this information because it is a poorly reported dysfunction in the health area and in the media, which makes it difficult to clarify and identify by the population of such condition 9 .
Thus, knowing the high prevalence of UI worldwide, as well as the interest in identifying the main aspects of people with UI attended at a public institution in Piauí, in order to develop actions with the population of the State, the following question arose: which is the sociodemographic and clinical profile of people with UI treated at the urology and gynecology outpatients of the University Hospital?
Thus, the study aimed to characterize the sociodemographic and clinical profile of people with UI treated at the gynecology and urology outpatients of Hospital Universitário. These data supported the development of educational technology for adults and will contribute to the development of care strategies to be provided to the population of the State, while also subsidizing the construction of an institutional protocol for outpatient care for people with UI. The population consisted of patients treated at the outpatient clinic for the specialties of gynecology and urology.
The sample was determined by the following inclusion criteria: men and women who were awaiting consultation for the specialties of gynecology or urology, aged 18 and over at the time of the interview, complaining of involuntary loss of urine. Exclusion criteria were: users who were waiting for care without a complaint of urinary loss and people with cognitive impairment that made it impossible to answer the form.
Were approached 339 patients who were awaiting consultations at the gynecology and urology services. Of these, 76 reported having symptoms of UI, but 13 people refused to participate. Thus, the sample consisted of 63 participants in total. Data were collected using a semi-structured form, previously validated by Benício (2018) 10  To conduct the interviews, the participants were initially approached about the existence or not of incontinence. If so, the patient was invited to participate in the research, and formalizations were carried out, explaining the objectives, Braga FCSAG, Benício CDAV, Bezerra SMG, Silva A, Costa AQ, Santos ES, Siqueira RMOT risks and benefits. In case of agreement, the participants were taken to a reserved space, such as doctor's offices or a waiting room. Then, they received more information about the study and, those who agreed to participate, signed the Free and Informed Consent Form.
The data were submitted to a typing process, using spreadsheets from the Microsoft® Excel® application version 16.0 and later exported to the Statistical Package for the Social Sciences-SPSS version 20.0. The sociodemographic, clinical profile and associated risk factors were presented in tables and described using absolute and percentage frequencies. Some clinical data were also outlined using descriptive statistics: mean and standard deviation.

Sociodemographic profile
Analyzing the sociodemographic profile of the 63 participants, all were female; with an average age of 52.1 ± 13.4 years; the majority being brown (77.8%), followed by black (9.5%) and white (7.9%). As for education, most had incomplete primary education (39.7%); in relation to occupation, 30.2% had a job, 27% were retired; and 12.7% did not perform any activity; with individual or family income of up to 1 minimum wage it was 55.6%; among those who had an income of up to 1 minimum wage, 43% supported 4 people. When asked about their marital status, the majority were married (63.5%), and the rest lived in a stable relationship or were single, both situations with 11.1%. Data shown in Table 1.

Clinical profile
According to Table 2, in the topic related to active sexual life, 55.6% maintained an active sexual life and 44.4% did not have sexual intercourse. Of these, 55.6% reported that UI did not interfere with sex life and 6.3% reported that it did.
Regarding the existence of a pre-existing disease, 85.7% had a disease in addition to incontinence.
When asked about the time he has been experiencing urine loss, it was possible to observe an average time of 5.8 ± 9.5 years, the shortest reported time was 0.16 years (2 months) and the longest 66 years, the median time was 3 years, that is, 50% started losing urine 3 years ago.
Regarding the loss of urine, the largest number of respondents, 69.8%, reported having loss when coughing, sneezing, smiling, putting on weight and/or making an effort; 12.7% need to pee as soon as they feel like it, otherwise they do it on clothes; and 17.5% had loss of urine in the two previous situations.
In the report of the participants regarding their main complaint for the consultation that day at the service, a low bladder and/or loss of urine stood out, with 34.9%, followed by an appointment for surgery or post-surgical return, with 17.5%.
As for the gynecological history, 41.3% had 1 to 3 pregnancies; 20.6% more than 6 pregnancies; and 11.1% never got pregnant. With regard to the occurrence of abortion, 39.7% reported having had at least one case of abortion.
Regarding the number and type of delivery per person, it is observed that, of the total participants, 11.1% had no delivery; 31.7% had 1 to 3 normal births and no cesarean section; 19% had 4 to 6 normal deliveries and no cesarean section; 7.9% had 7 or more normal births and no cesarean section; 15.9% had 1 to 3 normal births and 1 cesarean section; 4.8% Braga FCSAG, Benício CDAV, Bezerra SMG, Silva A, Costa AQ, Santos ES, Siqueira RMOT had 4 to 6 normal births and 1 cesarean section; 1.6% had 7 normal births and 1 cesarean section; 4.8% had 1 to 3 normal deliveries and 2 cesarean deliveries; and 4.8% had 1 to 3 normal deliveries and 3 cesarean deliveries.

Risk factors
As for the risk factors that may be associated with UI (

Sociodemographic profile
The study was carried out only with people who had UI and although there were attempts to collect it in the gynecology and urology outpatient clinics in search of information about both genders, the work was carried out only with women. It is believed that among the reasons are the fact that consultations in the gynecology sector take place daily in two shifts and in urology only three times a week, in a total of four weekly visits, and that it also serves women.
Another reason is the better acceptance of women to participate in research, and also because there are more women affected by this condition, in addition to being the public that most seeks health services.
It can be said that women use health services more than men. This statement is justified, in part, by the variations in the profile of health needs between genders, the main reasons being pregnancy and childbirth, and the greater interest of women in their health. 12 .
When age is analyzed, it can be seen that the majority has an average age of 52 years, which corroborates the literature on the subject, demonstrating a directly proportional relationship between age and UI, and this increase reaches its maximum level in middle age , with a prevalence of 30% to 40%, maintaining elevation as age increases 13 . In studies on prevalence, they presented statistically relevant data between the age group and the occurrence of UI, demonstrating that age alone does not cause incontinence, but induces structural and functional changes in the urinary system that predisposes to the problem 8,14 .
The study showed a greater number of brown women with UI symptoms, followed by black and white women, which corroborates the research that characterized the population of Piauí, with brown color as the most prevalent, in 72.9% of the population. This is reinforced by an important fact related to skin color, Brazil is a mixed country and the brown color is predominant 8,15 .
As for education, most had little time at school, having only incomplete elementary education, but there was a reasonable distribution across all levels of education. Regarding occupation, the majority worked in a job outside or at home, followed by retirees. Income with a higher percentage represented participants who earned between one and two minimum wages. Analyzing the percentage of people who are supported by this income, the individual distribution becomes low.  16 . This corroborates the characteristic presented in this research, with the majority of participants having an income below the Brazilian average. However, it is not possible to affirm in this study the relationship between economic condition and the presence of incontinence.

Clinical profile
The marital status of the interviewees showed that the majority live with a partner, married or in a stable relationship.
The findings showed that more than half have an active sex life, however a significant number of women who no longer have an active sex life can be perceived, even having a partner. Most reported that UI does not interfere with sexual life and a small percentage admit to impairment in this regard. This fact does not invalidate the importance of the problem and the need for interventions with these women.
One of the fields of life affected by UI is sexuality, which is rarely addressed, but involves the subjectivity of the human being in its social, cultural, ideological, beliefs and experiences, and can be affected, added to the sexual act itself, since it a late approach can have consequences such as a complete abdication of sexual life 17 .
Regarding the preexistence of some disease, the majority presented one or more diseases in addition to incontinence.
Diseases that in the literature demonstrate to be part of the risk factors for the individual to develop UI.
As for the reason for urinary loss, losses caused by coughing, sneezing, smiling, putting on weight and/or making efforts were predominant, these symptoms being more related to stress incontinence, which corroborates the studies on the subject, which had SUI as the most prevalent in all studies analyzed 4,7,8 .
SUI occurs due to the increase in intra-abdominal pressure without the previous perception of the urge to urinate.
With the increase in abdominal pressure and failure in the continence mechanisms when coughing, sneezing and lifting weight, urine loss occurs. Severity is also a relational factor with the amount of urinary loss 7 .
The study focused on participants who had UI symptoms. When asked about the main complaint for the consultation that day at the service, around 1/3 reported a low bladder and/or loss of urine, the rest were awaiting consultation for other problems and many, during the interview, did not they knew whether or not they valued the UI problem as something to be treated, although there was discomfort in the face of the condition presented.
The result is confirmed by the literature that shows the embarrassment of the participants when talking about the subject, leading one in three people who have incontinence not to seek health services for this reason, reinforcing the discussions on the subject, knowing that most of the time, people live with the problem for long years and evaluate it as normal 18 .
A study on the treatment of incontinence in elderly women reports that women perceive incontinence as being a natural process of aging and, due to lack of information, out of shame they do not seek the health service for the treatment of UI, therefore using , diapers or sanitary napkins as a method of care, which is worrying, as it can interfere with sexual life, physical and domestic activities and work 17,18 .
In the obstetric history, it is possible to observe the predominance of multiple pregnancies and vaginal deliveries, corresponding, respectively, to almost half of the first and most of the second. The sum of women who had four or more births represented an important number and of these, few had any cesarean delivery. Thus, the study corroborates other studies that show the impact of pregnancy and, mainly, of normal delivery as a predisposing factor for UI.
The research is consistent with other prevalence studies carried out that showed pregnancy as a risk factor, since the first pregnancy, increasing with the subsequent ones, and that normal birth increases the chance of developing incontinence.
In a population study on UI during pregnancy, the prevalence of UI during pregnancy was 14.7% in primiparous women and the likelihood of UI occurring varied significantly according to the characteristics of women, such as age, weight and Profile of patients with urinary incontinence in a university hospital outpatient clinic exercise physicists 19 . And with the occurrence of multiple pregnancies the predisposition to UI increases even more 20 . In other research it can be observed that the risk of developing UI is greater after vaginal delivery (71%) than after cesarean section, and the prevalence of UI over ten years, almost tripled after vaginal delivery compared to cesarean section 21 .

Risk factors
There are several risk factors known to be associated with UI, which were investigated in this study. An integrative review on UI prevention in elderly women reinforces that in addition to advancing age, other factors may predispose to the development of UI, which are: diabetes, obesity, smoking, menopause, diseases of the central nervous system, use of medications, restricted mobility , multiple vaginal deliveries, fecal impaction, psychic disorders, decreased tonus in the perineal region and alcohol use 21 . And it is these associated factors that increase the possibility of their occurrence.
In the study, one can observe the existence of one or more of these factors present in the research participants.
Arterial hypertension was identified in a significant amount in the study, whereas diabetes mellitus appeared in a smaller proportion. It can be seen in the study that patients with diabetes usually have hypertension and use one or more medications for one or both diseases. Studies on the prevalence of climacteric and on the characterization of incontinent women in a gynecology clinic also did not show, in their results, a significant relationship between the two diseases and UI 20,22 .
It was obtained a percentage of people who use caffeine and/or who underwent pelvic surgeries, followed by constipation problems, abdominal surgeries and obesity/overweight, to a lesser extent. Caffeine is a bladder irritant and products with the presence of the substance can increase the need to urinate. Intestinal constipation can affect urological function by compressing the bladder when stretching of the rectum occurs and by the effort made in the evacuation, which can cause injury to the pelvic muscles 20 . Gynecological surgeries and episiotomy can cause deformities in the pelvic floor, and overweight and obesity increase abdominal pressure. All of these factors can predispose to involuntary loss of urine 22 .
It is pointed out that the same participant has one or more risk factors for the development of UI. It is believed that an isolated factor does not lead to UI, but rather the sum of determining and conditioning factors. Which leads to reinforce multifactoriality for the presence of UI.
Regarding limitations, the study did not have a male sample, although the initial proposal was to encompass both genders. This was due to the reduced flow of male patients, the non-acceptance to participate in the research, as well as the time available to complete the study, which decreased the chance of conducting an interview with both genders and made it impossible to cross these data. Another factor that can be considered limiting was the performance of the study only with people who reported UI symptoms, not allowing the comparison of data between people without and with UI.
Further profile studies are recommended in Brazil and Piauí, with a larger sample size and with more variables to obtain information that can support new interventions and the implementation of services.
The study proved to be an important contributor to profile research, as it reinforces and increases information on the subject and its epidemiological aspects. It is also possible to observe the importance of knowing the profile of incontinent patients in the institution so that strategies for the care and treatment of this clientele can be developed, as well as subsidizing new works.

CONCLUSION
With the study it can be evidenced that the participants have as characteristics to be, mostly, brown, predominant color in this region of the country. With an average age of 52 years and with low schooling. Most have income, however they are responsible for the family's livelihood, which makes the per capita value low.
The largest number of women presented SUI, followed by MUI and IUI, respectively. Around 1/3 of these women sought outpatient services for the treatment of voiding dysfunctions, which demonstrates the demand for the treatment of UI in this institution.
Braga FCSAG, Benício CDAV, Bezerra SMG, Silva A, Costa AQ, Santos ES, Siqueira RMOT Most of the interviewees had multiple pregnancies, in addition to other risk factors that appeared significantly in the study, which were arterial hypertension, continuous use of medications, especially antihypertensive drugs, and have already undergone pelvic surgery. To a lesser extent, but still with a certain predominance, people with diabetes and using antidiabetic drugs appeared, with constipation problems and who have already undergone abdominal surgery.
Thus, it is possible to conclude that all women in the study had more than one risk factor for developing UI, reinforcing their multifactoriality, as well as the importance of a holistic and multiprofessional treatment.
When emphasizing the objective of knowing the profile of the patients, although with a small sample result, in view of the estimate of the population with this dysfunction, it presented satisfactory results and consistent with the existing literature, since the data referring to age, education, family income and race/color, as well as obstetric history and associated risk factors corroborate national and international studies carried out on the subject.
The number of women who have their sex life with some degree of interference due to UI, even in a not very significant amount in this study, should be valued, as well as the neglect in seeking treatment due to lack of knowledge about the problem and/or the possibility of treating it.