**A Model of the Psychological Factors Conditioning Health Related Quality of Life in Urodynamic Stress Incontinence Patients After TVT**

Mariola Bidzan1, Leszek Bidzan2 and Jerzy Smutek3,4

*1Department of Clinical Psychology and Neuropsychology, Institute of Psychology, University of Gdansk 2Department of Developmental Psychiatry, Psychotic Disorders and Old Age Psychiatry, Medical University of Gdansk 3Department of Obstetrics, Medical University of Gdansk 4Pro-Vita Private Medical Center for Urinary Incontinence, Gdansk Poland* 

#### **1. Introduction**

130 Urinary Incontinence

Wyman JF, Burgio KL, Newman DK. Practical aspects of lifestyle modifications and

Xue Q-L. The Frailty Syndrome: Definition and Natural History. Clin Geriatr Med 2011; 27:

incontinence. Int J Clin Pract 2009; 63: 1117-91

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behavioural interventions in the treatment of OAB and urgency urinary

Urodynamic stress incontinence (USI) is the most common form of urinary incontinence (Thom, 1998; Lemack & Zimmern, 2000; Steciwko, 2002; Rechberger & Skorupski, 2005), accounting for about 50% of all patients with urinary incontinence (Foldspang & Mommsen, 1997; Rechberger, 2004; Rechberger & Skorupski, 2005). About 82% of USI patients are women (Kinchen et al., 2002, cited by Diokno, 2003; Rechberger, 2004; Barber et al., 2005). Approximately 63% of all women with urinary incontinence are diagnosed with USI, from 19% to 25% have urge urinary incontinence (UUI), while from 12% to 19% have a mixed form (Thom, 1998; Lemack, Zimmern, 2000; Steciwko, 2002; Rechberger, Skorupski, 2005). According to the International Continence Society, urodynamic stress incontinence is defined as the involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contr action (Abrams et al.., 2002; , Kata & Antoniewicz, 1999; Rechberger & Skorupski, 2005; Kobashi & Kobashi, 2006). It occurs when the increased pressure inside the abdominal cavity caused by a cough or hard physical exertion is accompanied by an involuntary release of urine (Rechberger & Skorupski, 2005).

USI in women is caused by the insufficiency of the apparatus that closes the urethra, and/or hypermobility of the vesico-connection, when bladder functions are completely normal (Milart et al., 2001). This means that the reason for USI lies in the weakening of the pelvic floor muscles, whose basic task is to hold up the organs located in the pelvis, including the urinary tract. Strong pelvic muscles keep the urethra closed until a conscious decision is made to urinate. When these muscles are weakened, the result is an inability to maintain a sufficiently tight hold around the urethra, so that any pressure exerted on the bladder caused by a movement of the diaphragm (e.g. a sneeze, a cough, a sudden exertion, walking

A Model of the Psychological Factors Conditioning Health

fields), vault support, pharmacotherapy, and lifestyle modification.

model of HRQOL determinants in USI.

group of patients.

**2. Material and methods** 

al., 2004).

Related Quality of Life in Urodynamic Stress Incontinence Patients After TVT 133

is recommended by the International Continence Society. What is assessed with the help of HRQOL is the impact of the illness and its treatment on the patient's quality of life, not including other, non-medical aspects. Treating the patient as an active subject, rather than a passive object, plays a major role in the evaluation process, which requires taking into consideration not only the objective results of medical examinations, but also the patient's own assessment (Brown et al., 1999; Swithinbank & Abrams, 1999; Shaw, 2002; Tamanini et

Depending on the etiology and severity of urinary incontinence, the treatment of this condition includes both surgical procedures and conservative methods, such as kinesitherapy, behavioral therapy, physiotherapy (including biofeedback, electrostimulation, and magnetic

Currently there are many (over 170) methods of surgical treatment of urinary incontinence. A particular surgical technique is selected individually for every given case. Patients with SUI constitute the main group qualified for the surgical treatment of urinary incontinence,. Currently, the TVT technique (tension-free vaginal tape) is a commonly used surgical intervention for SUI however there are other modificaitons of the procedure and tape that is also widely used with similar efficacy – TVTO, rectus fascial sling etc. This technique was developed in 1994 by Ulf Ulmsten from the Uppsala University Clinic, and has been practiced in Poland since 1999. TVT is a widely used method of surgical treatment thanks to its minimal invasiveness and morbidity, and particularly due to its superior recovery rate when compared to other frequently used methods (estimated at 88%) and relatively low cost (Włodarczyk et al., 2003; Konabrocka, 2006; Rechberger, 2006) These considerations, along with the fact that there is virtually no possibility of modifying this original technique (Rechberger, 2006), were the reasons for selecting patients subjected to TVT for developing a

The aim of this study was to create a model describing the HRQOL determinants in this

The initial population (N = 917) consisted entirely of patients treated in the period from 2002 to 2006 in the Pro-Vita Private Medical Center for Urinary Incontinence, in Gdansk, Poland. All these patients were subjected to a thorough diagnostic process for urinary incontinence, consistent with the standards of the International Continence Society (ICS), as follows:

1. A detailed patient history was obtained, to provide information concerning the nature of the urinary dysfunctions, possible congenital or neurological causes, history of urinary tract infections, and the course of treatment to date (drugs taken, hormone replacement therapy, surgical procedures). The history included a range of information that could have a bearing on the diagnosis of urinary incontinence, such as presenting complaint, past medical history including obstetric and surgical history, medications and social history (Abrams et al., 1988; Jensen et al., 1994; Abrams et al., 2002; Milart &

2. A detailed clinical examination was performed, which included the following elements: physical examination (focusing on the evaluation of the pelvic floor support);

Gulanowska-Gędek, 2002; Rechberger & Skorupski, 2005).

on an uneven surface) can lead to an involuntary release of urine (Dutkiewicz, 2002; Rechberger & Skorupski, 2005).

A typical feature of USI should incorporate the general similarity of symptoms in the day to day and the lack of nocturnal enuresis or nocturia. USI is thought to be caused by many different factors. Petros's Integral Theory (Petros, 2005), which is widely accepted, associates functional disturbances of the pelvic floor with structural disorders. The pelvic floor is formed by organs (the bladder with urethra, the vagina and the anus, the fascia and ligaments that bind them, the muscles). To simplify somewhat, the contracting muscles stabilize the organs in relation to the connective tissue elements, so damage to the ligaments and connective tissue can result in the lack of proper closure (manifested by urinary or fecal incontinence) or vaginal dysfunction, and the resulting symptoms and discomfort of which the patients complain.

Due to the considerable prevalence and nature of the symptoms, USI is a major medical and social problem. The intimate nature of the symptoms and their negative impact on daily functioning produces a significant mental burden for both the patients and their partners, and causes the frustration of many psychological, social and existential needs (Wyman et al., 1990; Wyman, 1994; Broome, 2003; Chiaffarino et al., 2003; Møller & Lose, 2005; Papanicolaou et al., 2005).

The scope of the psychological problems caused by the symptoms of USI is particularly large in advanced stages of the disease (Lagro-Janssen et al., 1992a; 1992b). Lalos et al. (2001) found that the life of persons with urinary incontinence changes dramatically, in respect to family life, vocational life, and social life (including the quality of life):


The lack of treatment, or the postponement of treatment until many years after the first symptoms appear, can have a major impact on the appearance of both physical and mental complications (Banach, 2004).

The problem of evaluating HRQOL in persons with urinary incontinence has been perceived by researchers and clinicians, for whom HRQOL has become in recent years an extremely important indicator of the psychological functioning of patients. An assessment of HRQOL is recommended by the International Continence Society. What is assessed with the help of HRQOL is the impact of the illness and its treatment on the patient's quality of life, not including other, non-medical aspects. Treating the patient as an active subject, rather than a passive object, plays a major role in the evaluation process, which requires taking into consideration not only the objective results of medical examinations, but also the patient's own assessment (Brown et al., 1999; Swithinbank & Abrams, 1999; Shaw, 2002; Tamanini et al., 2004).

Depending on the etiology and severity of urinary incontinence, the treatment of this condition includes both surgical procedures and conservative methods, such as kinesitherapy, behavioral therapy, physiotherapy (including biofeedback, electrostimulation, and magnetic fields), vault support, pharmacotherapy, and lifestyle modification.

Currently there are many (over 170) methods of surgical treatment of urinary incontinence. A particular surgical technique is selected individually for every given case. Patients with SUI constitute the main group qualified for the surgical treatment of urinary incontinence,. Currently, the TVT technique (tension-free vaginal tape) is a commonly used surgical intervention for SUI however there are other modificaitons of the procedure and tape that is also widely used with similar efficacy – TVTO, rectus fascial sling etc. This technique was developed in 1994 by Ulf Ulmsten from the Uppsala University Clinic, and has been practiced in Poland since 1999. TVT is a widely used method of surgical treatment thanks to its minimal invasiveness and morbidity, and particularly due to its superior recovery rate when compared to other frequently used methods (estimated at 88%) and relatively low cost (Włodarczyk et al., 2003; Konabrocka, 2006; Rechberger, 2006) These considerations, along with the fact that there is virtually no possibility of modifying this original technique (Rechberger, 2006), were the reasons for selecting patients subjected to TVT for developing a model of HRQOL determinants in USI.

The aim of this study was to create a model describing the HRQOL determinants in this group of patients.
