Psychological perspectives in urinary incontinence: a metasynthesis

Introduction Urinary incontinence with co-morbid depression has been found to have a significant effect on quality of life. Examining the associations between the psychosocial factors related to urinary incontinence and mental health may help in improving the care for patients with these conditions. The aim of this research study is to explore the relationship between mental health status and urinary incontinence, focusing on the role of psychosocial factors. Materials and Methods A search of Medline, CINAHL and SCOPUS databases yielded 15 studies on the topic, and 10 studies were found to be in scope. A metasynthesis using Noblit and Hare’s approach of meta-ethnography was undertaken. This involved a number of steps including determining how studies are related and identifying major themes.


Introduction
Urinary incontinence with co-morbid depression has been found to have a significant effect on quality of life.Examining the associations between the psychosocial factors related to urinary incontinence and mental health may help in improving the care for patients with these conditions.The aim of this research study is to explore the relationship between mental health status and urinary incontinence, focusing on the role of psychosocial factors.

Materials and Methods
A search of Medline, CINAHL and SCOPUS databases yielded 15 studies on the topic, and 10 studies were found to be in scope.A metasynthesis using Noblit and Hare's approach of meta-ethnography was undertaken.This involved a number of steps including determining how studies are related and identifying major themes.

Results
Three psychosocial aspects of urinary incontinence appear to influence mental health status: living with, management of and attitudes about incontinence.Other smaller component themes included control, seeking help and personal beliefs.

Discussion
Psychosocial factors appear to mediate the relationship between urinary incontinence and mental health status.An increased awareness of the major psychosocial issues that can influence both incontinence and mental health may contribute to a better management of the condition as well as reduce the burden of the condition on individuals.

Conclusion
Incontinence and psychological wellbeing are intertwined and this adversely affects a number of aspects of life.Enquiring about the mental health status of those with incontinence should include an assessment of psychosocial factors to help reduce the burden of incontinence.To improve the management of these conditions, further research should investigate whether psychological issues precede incontinence or vice versa.

Introduction
Urinary incontinence with co-morbid depression has been found to have a significant effect on quality of life.Examining the associations between the psychosocial factors related to urinary incontinence and mental health may help in improving the care for patients with these conditions.The aim of this research study is to explore the relationship between mental health status and urinary incontinence, focusing on the role of psychosocial factors.

Materials and Methods
A search of Medline, CINAHL and SCOPUS databases yielded 15 studies on the topic, and 10 studies were found to be in scope.A metasynthesis using Noblit and Hare's approach of meta-ethnography was undertaken.This involved a number of steps including determining how studies are related and identifying major themes.

Results
Three psychosocial aspects of urinary incontinence appear to influence mental health status: living with, management of and attitudes about incontinence.Other smaller component themes included control, seeking help and personal beliefs.

Discussion
Psychosocial factors appear to mediate the relationship between urinary incontinence and mental health status.An increased awareness of the major psychosocial issues that can influence both incontinence and mental health may contribute to a better management of the condition as well as reduce the burden of the condition on individuals.

Conclusion
Incontinence and psychological wellbeing are intertwined and this adversely affects a number of aspects of life.Enquiring about the mental health status of those with incontinence should include an assessment of psychosocial factors to help reduce the burden of incontinence.To

Introduction
Urinary incontinence is not often considered without mentioning the associated psychological effects, such as psychological distress, depression and anxiety 1,2 .The International Continence Society takes great care, in its definition of urinary incontinence (hereon referred to as incontinence), to embrace its association with psychological and psychosocial factors 3 .An examination of mental health in combination with the psychosocial aspects of incontinence has generally been neglected [4][5][6][7][8][9][10] .
Many psychosocial factors associated with incontinence may be adversely impacted by depression.Incontinent people experiencing comorbid depression may be less likely to seek help for their incontinence, their quality of life may be lower, they may be more socially isolated, their perception of symptom severity may be greater and their use of health services may be less when compared to individuals with incontinence who are not depressed 1,[11][12][13][14][15][16] .We do not understand clearly how being depressed interacts with these psychosocial factors 17 .
Qualitative studies present one fruitful avenue to gain a better understanding of the relationships between incontinence, depression and psychosocial factors.Although a number of individual qualitative studies of these relationships have been undertaken, there has been no attempt yet to conduct a metasynthesis of the qualitative literature in this area.
Metasynthesis enables us to become more confident about using qualitative literature to fill the evidence gaps, as findings from a number of studies may become more conclusive after a synthesis is performed 18 .An advantage of this to the individual researcher is that an investigation can be further progressed rather than continuing to undertake smaller pieces of work that may elicit very similar findings 19 and broader perspectives may be achieved than that found by the individual researcher 20 .
One approach favoured by many researchers, possibly because its method is grounded in the originating paradigm of qualitative research 21 , is meta-ethnography 22 , which has its origins in educational research.It has often been applied across studies with diverse theoretical foundations 23  issues, worry, vulnerability, shame, paranoia and uncleanliness [28][29][30][31][32][33][34][35][36] .Three main psychosocial themes became evident from the literature as potential influences on the association between incontinence and mental health: day-to-day living with incontinence; the management of incontinence; and attitudes about incontinence (Figure 1).

Living with urinary incontinence
A first major theme emerged from the literature related to living with incontinence.This theme concerned relationships, particularly those of an intimate nature not only with a partner or spouse but also with friends, family; restrictions on activities; as well as overall quality of life.The nature of incontinence, with its complex issues in many different areas, means that, particularly when seeking help, those with incontinence do not know where to start discussing their problem 30 .Some papers described the problem in terms of its practical effects, but others concentrated on how the condition affected them emotionally.The greatest effect on quality of life appeared to result from coping with urgency 29 .The mental health of those with incontinence was affected on a day-to-day basis, and included depression, hopelessness, as well as anxiety.The exhaustion from broken sleep could compound such feelings.Some incontinent women also felt that their depression was making them ill in other ways 29 .
The effect incontinence had on relationships, both intimate and social, was a major issue.Avoiding any kind of sexual relationship, even with a longstanding partner was common.
'You can't be physically attractive if you are not clean' 29 .
'Aye it is terrible.Good job I don't have a man, my husband is dead.I am by myself.But it is really embarrassing' 29 .
It seemed, for those with incontinence, that not having an intimate relationship could be best for all

Search Outcome
Fifteen studies from 1993 until 2011 were identified.After reading through the articles, five were found to be out of scope; that is they did not provide discussions of incontinence and mental health status from the point of view of the person themselves (sometimes it was carer or health professional perceptions), they concentrated on service use, stigma or quality of life or they were not predominantly a qualitative study.
No previous studies were found that looked at the experiences of living with incontinence primarily from the perspective of mental health status.The studies focused on incontinence, and mental health issues arose as part of the examination.Table 1 summarises each article with regard to the sample, methodology, aims and finding of the study.
The quality of each of the included study was scrutinised using the Critical Appraisal Skills Program tool 24 .All included studies were found to sufficiently address all the criteria.
Using thematic analysis, each study included in the metasynthesis was initially read a number of times to identify overarching themes 25 .Once the major themes were determined, the studies were coded using Nvivo 9 26 .The results from the studies themselves were coded as themes and subthemes using a constant comparative method 27 .Then, the emerging themes from each of the studies were compared against each other, to examine important psychosocial aspects that mediated incontinence and mental health.

Results
Incontinence is associated with a number of psychological issues.Some of these issues are primarily defined as major mental health issues, such as depression and anxiety; there are also other psychological issues connected with incontinence such as embarrassment, fear, self-esteem the relationship between mental health status and incontinence in women, focusing on the role of psychosocial factors.

Materials and Methods
This work conforms to the values laid down in the Declaration of Helsinki (1964).The protocol of this study has been approved by the relevant ethical committee related to our institution in which it was performed.All subjects gave full informed consent to participate in this study.

Search Methods
Qualitative studies were sought that addressed incontinence and mental health, in either their aims or their findings.To maximise appropriate studies, broad search terms were used to encompass the full range of studies in this area.An electronic search of the Medline, CINAHL and Scopus databases was undertaken combining the terms (1) 'Urinary incontinence' as a MESH heading, and 'urinary incontinence', 'overactive bladder' or 'urethral syndrome' in the title or abstract, and (2) 'Depression', 'depressive disorder', 'mental health', 'social stigma', 'anxiety disorders', 'mood disorders' as a MESH heading, and 'depression', 'depressive', 'phobic', 'phobia*', 'mental health', 'stigma', 'stigmati*', 'fear', 'psychol*' or 'affective' in the title or abstract.To be included in the metasynthesis, studies need to be: concerned with some type of urinary incontinence, overactive bladder or lower urinary tract symptoms; observed from the respondent's own perspective; concerned with adult humans.Only articles written in English were chosen.Studies that included both women and men were included when particular themes concerning women were outlined.When searching for studies to include in this metasynthesis, we included those that concerned different types of incontinence, overactive bladder or lower urinary tract symptoms.
All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.concerned, particularly if partners commented on the smell or leakage during sexual relations 28,29,34 .However, lack of intimacy seemed to also increase tension in the household as well as negative feelings.'My husband says that I stink (muthra gadai) because of it.Sometimes he does not like to be near me.He no longer has sex with me.I am always worrying whether he sees other women.Then I feel sorry for myself.But who can help me with this?' (Renuka, 40 years) 31 .
As a result of the condition, a woman's body became irrelevant, that is she may no longer feel attractive, resulting in further self-esteem issues 30 .These themes illustrate the pressure for satisfactory relationships and intimacy, and this may contribute to poorer mental health in those with incontinence.
Major restrictions in many life activities also occurred because of incontinence, including the inability to exercise, especially aerobics or swimming.Running for the bus or playing Competing interests: none declared.Conflict of interests: none declared.

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript. All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
A number of other issues surrounded the management of incontinence.Coping referred to the management of urgency and preventing accidents 29 , but it also concerned the ability to just get on with life, by having various strategies to get through each day, including denial of the situation 30 .Having to be constantly aware of the situation was necessary but tiresome 28 .Avoiding activities that would lead those with incontinence into dangerous situations seemed to be a much used tactic, as well as the use of camouflaging clothing 29,35 .
' 29 Finally, behaviours that could lead to the person with incontinence to be seen as different were undertaken.These included the constant use of toilets at functions, frequent use of toilets at private residences when visiting, trying to avoid having accidents, avoiding intimate activities such as sex, or flying on planes, going for long walks and other activities, which led sufferers to become socially undesirable 32 .Not being in control contributed towards the level of anxiety.

Well I am going out tonight and I am sick [with worry]. I don't go out normally -I don't. Not even like say going to the doctor's, because if I have an 'accident' I will die.' ( female patient)
One important component of managing incontinence is help-seeking, specifically addressed in seven of the studies, and a major focus in five.Hagglund and Ahlstrom report that women felt 'wounded by health care staff'; they were not followed up in the provision of protective pads, particularly if they were younger 36 .In all studies, the theme of embarrassment with regard to help-seeking emerged 28,31,34 .Confidentiality and privacy were other barriers.A number of papers suggested that certain characteristics of the health practitioner could assist in encouraging help-seeking, such as the gender of the practitioner 31,33 , ethnicity 33 , or the type of health professional, both practical and psychological components.The practical management themes included planning, constant awareness, specific behaviours, avoidance of activities, barriers to adequate management and help-seeking.Psychological management themes included those of coping, disclosure, explanations of causes and control.
Management of incontinence was most commonly undertaken by planning.People with incontinence discussed 'designing their life around it' 29 , using protection, taking precautions or preventing accidents in a number of different ways [28][29][30][31][32]37 .
'I think to myself, when I get to the hill with the birch trees I'm not going to have to urinate, and when I get to the boulder, I can't hold myself any longer.But just quitting thinking about it, having someone along with me on the walk, then the thought doesn't enter my mind and I manage the walk, it is psychological' 34 Not disclosing their condition was one way that life could be made more bearable.Some people kept their condition hidden, even from their partners and family 28 .Others were worried that if they revealed their condition, even by using others' toilets, they would become stigmatized [30][31][32]34 . Furher, incontinence was particularly hidden for men, as it was seen as a woman's problem and as a private thing, not to be disclosed 35 .
'Because as long as nobody knewso in a way it was a problem.Didn't want my husband to find out.' 28 Control of one's incontinence could be construed either positively or negatively.Some women had only a minor problem that they had 'control over'; however, others saw their problem as something they could not control, leading to desperation, powerlessness and anger 28,36,37 .Some of those experiencing incontinence felt that it reflected a lack of control in their life more generally 30 , as they were not able to control their own bodily functions 35 .
with children was also restricted.The role as mother was interrupted because of incontinence.
'My little girl's eight now, and I can't run around and play with her.If she says 'race you,' I say 'no -you'll have to race your dad.' 28 .
Even coughing, sneezing or raising one's voice could cause an accident, and this was quite a problem in the public setting 28,30,37 .Social roles were greatly restricted: working, going to visit friends, going to the cinema or shopping 31 were all activities that were found to be problematic.Physical activity, appropriate social roles and social inclusion are important factors for good mental health, and it is evident that these were affected by incontinence.
A range of other feelings were also associated with incontinence, which in turn affected day-to-day living.These included embarrassment in discussing their condition with family, friends and care providers, which affected help-seeking behaviour 28,29,31,33,34 .The women experienced embarrassment when having to make frequent trips to the bathroom 32 .Experiences of associated shame with a problem of such a private nature contributed towards such feelings 35 .
Constantly aware, stressed and worried about having an accident and others finding out, or not being able to find a bathroom in time, weighed heavily on these people 28,29,31 .Fear also pervaded any sense of wellbeing that could occur, as there was always the chance of an accident or leakage 28,29,31 .For those with incontinence, the psychosocial aspects of day-to-day living adversely affected psychological wellbeing.

Management of urinary incontinence
Another consistent theme in the literature was the need for people with incontinence to 'manage' their condition.Managing  talked about more publicly, perhaps if there were a 'champion' with incontinence who wanted to share their experiences 33 .
If people with incontinence believed they were not in control of their own bodies, they could experience a kind of disembodiment, which led to low self-esteem, resulting in other problems either physical or psychological.Feelings of vulnerability developed from a lack of control in one's life 36 .
'But making light of it does not always work: I try to make a joke of it, but sometimes you've really got to feel down.You know, you get awful down.' 29 The impact of the condition had much to do with how those with incontinence perceived it.Did they accept the condition, or deny it?Did they think that their personality was such that they would not let it become a problem?Did they feel that it would get better, thus showing signs of hope?Positive perceptions such as these meant a reduced impact on life.
'Won't let it become a problem; it's not in my personality, will always find ways round it.' 28he opposite was also the case, where those who worried about incontinence, more likely to be impacted 28 .It was also evident that, once people got older and experienced other conditions, the impact of incontinence, in the scheme of things, was lessened 33,35 .Further, with women, as the role of women included both family and career duties, the problems of incontinence, and things that affected the women themselves, were less of a priority 34 .

Discussion
Incontinence is associated with poorer mental health 38 , and there are many psychosocial factors that mediate this relationship.Qualitative studies investigating incontinence are often concerned with particular aspects of the condition, such as quality of life or help seeking.
birth and having children since it didn't happen before that, it's a natural thing, it's nothing I could of done something about' 34 Many people with incontinence did not consider that it was actually a medical condition 30 .These attitudes affected their help-seeking behaviour, as well as perceptions about the condition 35 .Some of those with incontinence were very clear in the attribution of cause they gave to their condition so that they blamed themselves, believing they could have prevented it through pelvic exercise 28,36 .
At the other end of the continuum, the shame and embarrassment of incontinence meant for some that it was a taboo subject with stigma attached.It could not be discussed with friends and family.Those who were incontinent worried about the smell, having accidents and the frequency with which they visited the bathroom.They were often very concerned by what other people thought, and many spent much time concealing their condition 28,31,32 .The attitudes these women attributed to other people were often unfounded.
'If I go to someone's house and I have to go to the bathroom a lot, maybe it might not be the right time to go to the bathroom to pee, but since I have this weakness in my bladder, I have to go right away...I worry because I think other people are going to think 'what's wrong with her?Why is she going to the bathroom so much?'…It's truly not normal for someone to need to go to the bathroom so much!' (Hispanic woman) 32 The age of the affected person affected their attitudes, with younger people more likely to conceal their problem at all costs 36 .The taboo about incontinence also affected help-seeking behaviour 29,34,35 .Some women experienced stigma as a result of the relationship of incontinence to the genital area, as it was 'bad' or 'dirty', and needed to be concealed 30,31 .Others thought that it would be less of a problem if it was for example general practitioner 31,33 , nurse 33,34 or allied health professional 33 .
'You know, in our area, all the doctors are men.Then how can I discuss 'woman's stuff' with them.I feel embarrassed' 31 The women in the studies found that they were treated differently by different practitioners; however, overall they were not satisfied with the information and care that they had received.Problems such as these were regarded as barriers to helpseeking 35 .

Attitudes about urinary incontinence
People experiencing incontinence held a number of different attitudes along a continuum, from those who completely normalised their symptoms, to those that found the whole experience taboo.
At one end of the continuum, some women saw incontinence as a sequel to pregnancy and birth and accepted that it was inevitable 28,31 .Ageing was also cited as a reason for the problem, along with associated weakness of the body, previous surgery and medication use, as well as compounding chronic conditions 33,35 .Rationalising incontinence in this way made it a little easier to cope with it 34 .
If the symptoms of incontinence could be normalised in ways such as above, associated problems could be minimised 28 .Incontinence was not often mentioned as a disease or a health problem, and arguments were made that it was a normal state: 'I think it is a usual occurrence in women.It is not a disease.Child bearing, aging, heavy work may aggravate it' (Malini, 34 years, focus group discussion). 31t was taken for granted that incontinence was just a normal part of ageing or having children 33,35 , and it was also seen as a 'natural thing' 34 .
'I didn't bring this injury on myself, I've ended up with a bladder control problem, I associate it with giving perspective of their mental health status, the strength of this synthesis is it combines the evidence from a number of studies, enabling us to draw wider conclusions about our research questions.This metasynthesis indicates the importance of alleviating the psychological issues associated with incontinence, via a consideration of the major psychosocial aspects.If the condition is treated, taking into account the aspects of management, day-to-day living and attitudes, there may be reduced psychological burden and better outcomes for those with the condition.
Incontinent people experiencing co-morbid depression may be less likely to seek help for their incontinence, their quality of life may be lower, they may be more socially isolated, their perception of symptom severity may be greater and their use of health services may be less when compared to individuals with incontinence who are not depressed 1,[11][12][13][14][15][16] .Clearly, for the 30% of those with incontinence who also suffer from depression, an opportunity to reduce the burden of incontinence is presented, as treating depression may be more successful than treating incontinence 4,[39][40][41] .

Conclusion
Previous studies have described the relationship between incontinence and mental health, and poorer mental health is associated with a reduced help seeking.There have been no studies exploring the interaction of incontinence, depression and help seeking, a combination, which we would expect to be common.Additionally, few recent investigations have concentrated on the impact of mental health problems upon psychosocial issues that relate to incontinence such as on quality of life, management and coping behaviours, social connectedness and beliefs and knowledge of the condition, focussing more on risk factors such However, the impact incontinence has on mental health is part of a bigger story.The synthesis of studies in this area demonstrates that psychological factors mediate a number of other issues, such as help seeking, related to incontinence.
Three main psychosocial themesliving with, management of, and attitudes about incontinence-were identified from the nine studies analysed, with a number of subthemes falling under each of these areas.When the three main themes were examined in each study, key components emerged: how living with incontinence affected relationships and quality of life, the restrictions that occurred and the actual nature of the problem; how the management of incontinence included control, planning, coping and seeking help, and that the level of effect on one's life could be due to their own feelings about the condition; and attitudes about incontinence that included personal beliefs about aspects of the condition, such as the inevitability of it, and anxiety about, what other people thought.
The studies included in this metasynthesis also covered different population groups of people with incontinence, with variation by gender, age, ethnicity and whether or not help had been sought.Although some differences between groups, such as gender and ethnic groups, could be found, the similarities between such groups may enable more directed assistance for the management of incontinence and similar conditions, as these findings show that many of the practical problems of incontinence can have an impact on emotional problems, and taking care of the psychological wellbeing may reduce the burden of managing the condition and increase overall quality of life.
As no previous studies have been found that addressed women's experiences of living with incontinence primarily from the

Figure 1 :
Figure 1: Psychological factors influencing psychosocial issues in urinary incontinence

Table 1 Analyses of qualitative studies concerning incontinence and depression Author Date Country Condition, sam- ple, survey set- ting/methods Aim Questions Findings/main themes
Licensee OA Publishing London 2013.Creative Commons Attribution License (CC-BY) For citation purposes: Avery JC, Braunack-Mayer AJ, Stocks NP, Taylor AW, Duggan P. Psychological perspectives in urinary incontinence: a metasynthesis.OA Women's Health 2013 Jul 01;1(1):9 Competing interests: none declared.Conflict of interests: none declared.All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

Table 1 (Continued) Author Date Country Condition, sample, survey setting/methods Aim Questions Findings/main themes
Subthemes: living in readiness, making urine leakage comprehensible, accepting living with UI and being familiar with the situation.Licensee OA Publishing London 2013.Creative Commons Attribution License (CC-BY)For citation purposes: Avery JC, Braunack-Mayer AJ, Stocks NP, Taylor AW, Duggan P. Psychological perspectives in urinary incontinence: a metasynthesis.OA Women's Health 2013 Jul 01;1(1):9Competing interests: none declared.Conflict of interests: none declared.All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

Table 1 (
Continued) Licensee OA Publishing London 2013.Creative Commons Attribution License (CC-BY) For citation purposes: Avery JC, Braunack-Mayer AJ, Stocks NP, Taylor AW, Duggan P. Psychological perspectives in urinary incontinence: a metasynthesis.OA Women's Health 2013 Jul 01;1(1):9Competing interests: none declared.Conflict of interests: none declared.All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
incontinence had Licensee OA Publishing London 2013.Creative Commons Attribution License (CC-BY) For citation purposes: Avery JC, Braunack-Mayer AJ, Stocks NP, Taylor AW, Duggan P. Psychological perspectives in urinary incontinence: a metasynthesis.OA Women's Health 2013 Jul 01;1(1):9Competing interests: none declared.Conflict of interests: none declared.All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.