Adult womenʼs experiences of urinary incontinence: a systematic review of qualitative evidence protocol

Review question/objective The objective of this review is to identify the best available evidence on the experience of urinary incontinence by women. Background Urinary incontinence (UI) dramatically affects the physical, emotional, psychological and social aspects of and the quality of life of women who suffer from the condition. Men and women experience the consequences of UI independently of their age. Aging women are more affected by this condition.1 The significant increase in longevity in women from 73.2 in 1997 to 76.5 in 20072 contributed to the aggravation of UI rates. Currently, UI is an epidemic medical problem.3 Urinary incontinence is defined by the International Continence Society as involuntary urine loss, leading to social and/or hygienic problems. There are three common types of UI. Stress UI (SUI) refers to urine loss provoked by exertion. Urge UI refers to a constant sense of urgency to urinate. Mixed UI (MUI) refers to urine leakage resulting from SUI and urge UI.4 Approximately 200 million people worldwide are affected by UI. 5 Urinary incontinence rates vary according to the population studied and the type of UI that is analyzed. It is estimated that between 10% and 55% of females from 15 to 64 years of age are affected by UI; SUI has the highest prevalence.5 A multicenter study consisting of 17,080 subjects of both sexes was performed in multiple European countries6 to estimate the UI rate. The prevalence of UI was 44% in France, 42% in the United Kingdom (UK), 41% in Germany and 23% in Spain. Approximately only 24% of the women in Spain and the UK who were affected by any type of UI consulted a doctor regarding this condition. The search for medical support was higher in France (33%) and Germany (40%).6 The prevalence of UI in a study in China, with a sample of 19,024 women aged 20-99 years, was 30.9%.7 Among the women who visited a gynecological clinic in the United Arab Emirates, the prevalence of UI was 42.2%.8 These women reported that aspects of their lives most affected by UI were physical and social activities, and sex. Nevertheless, 50.5% of the women did not seek medical care. The hope for a spontaneous resolution of UI (61.9%), embarrassment at being examined by a clinician (35.9%), the belief that urine leakage is a normal occurrence (31.5%), and lack of awareness regarding the availability of treatment (23.9%) were the subjects' reasons for not seeking UI treatment.7 Other researchers reported that an average of 25% of women affected by UI seek medical treatment.6,9 Many efforts have been made to improve the quality of life of women with UI but these efforts need to include a better understanding of the degree to which women are affected by UI.1,10 There is evidence that UI seriously affects the daily life of women with this condition. The main difficulties associated with UI are related to the lack of an avenue for those affected by UI to share their UI problems and the stigma associated with the condition. As a consequence, the women experience difficulties establishing constructive interpersonal interactions with others experiencing similar problems. Women may experience fear and shame regarding UI. Typically, the consequences of this condition are experienced by these women alone, leading to isolation. Often this is because of the social stigma associated with UI.1 As a result, women often have difficulty seeking social support and treatment. The women affected by UI may experience restrictions in sexual, social, family and occupational activities as a consequence of this condition. Their self-esteem may also be affected, and financial problems could arise because of the effect of UI on work activities.11 The International Incontinence Society is of the view that the personal and social problems associated with UI can be demonstrated in an objective way. 12 Through a preliminary search of primary studies focusing on the experience of UI, international research on this topic was identified. Healthcare providers need to provide healthcare for women affected by UI through the best evidence available. The proposal to conduct this systematic review of qualitative evidence is timely to enhance understanding of the perspectives of women affected by UI. The identification of the similarities and differences in the experiences of women affected by UI from different cultures and social contexts can support and promote the implementation of evidence-based healthcare. A basic principle of evidence-based healthcare is ascertaining knowledge on the patient's perspective and incorporating this into the planning and implementation of healthcare. In this systematic review, the experiences of women will be considered, independent of their age, and from the physical, emotional, social and cultural perspectives. An initial search for sources was undertaken to determine whether a previous review addressing this question had been undertaken or was in progress. The Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports and the CINAHL databases were examined. No reviews, completed or in process of being conducted, focusing on the experiences related to female UI were found in these databases. A systematic review focusing on the experience of UI was undertaken and published in 2009 by Brazilian researchers.6 It was conducted using meta-ethnography in which the focus was primarily cultural perspectives. This systematic review will approach the topic more comprehensively and will include all the qualitative studies independently of the method used in the primary studies. This systematic review aims to include all aspects of the female experience of UI in addition research findings published after 2009.

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