It is well known that urinary incontinence (UI) affects several aspects of women’s quality of life. Currently, the World Health Organization (WHO) strongly recommends health approaches and research based on the biopsychosocial model, as proposed by the International Classification of Functioning, Disability and Health (ICF) (1). Functioning is a broad concept resulting from the interaction of components such as: health conditions, body function and structure, activity, participation, and personal and environmental factors. Functioning assessment is crucial as this approaches the real difficulties faced by patients. Based on the theoretical-conceptual framework of the ICF, the WHO developed the World Health Organization Disability Assessment Schedule (WHODAS 2.0) (2), a standardized tool for assessing functioning and disability across different cultures and different health conditions to understand the functioning of the individual and its dimensions. In this sense, the relationship between the types and severity of UI and the functioning of women with this condition is still unclear. The aim of the study is to explore functioning of women with UI by investigation how IU affects WHODAS domains and to verify whether there is a relationship between the types and severity of UI and functioning.

This is a cross-sectional observational study, with secondary analysis of data from a validation study of the Brazilian version of World Health Organization Disability Assessment Schedule (WHODAS 2.0) questionnaire in the 36-item version in women with UI (3). Women with urge, stress, or mixed urinary incontinence symptoms in the last month were included from different age groups, over 18 years old, and without cognitive disorders as assessed by the Mini Mental State Examination. Women with cognitive disorders, chronic pelvic pain of any etiology, severe pelvic organ prolapses, and urinary incontinence of neurogenic origin were excluded. Data collection was carried out from March 2020 to June 2022 at the Urogynecology and the Pelvic Physiotherapy outpatient clinics. Sociodemographic data, the type of UI, functioning and disability using the WHODAS 2.0, and the severity of UI using the Incontinence Severity Index (ISI) were evaluated. After obtaining the Free and Informed Consent Form, the instruments were applied through face-to-face interviews. The WHODAS 2.0 was translated to Portuguese and adapted for Brazil through a formal partnership with the WHO (3). The instrument consists of multiple-choice questions that assess the level of functioning in six domains of life: cognition, mobility, self-care, getting along, life activities and participation. The WHODAS 2.0 provides scores for each of the six domains and an overall (total) score, which can range from 0 to 100, where 0 means no disability and 100 means complete disability (2). For women with UI WHODAS presented excellent reliability (Cronbach's alpha = 0.8) and test-retest reliability (Intra-class coefficient = 0.87) in the total WHODAS score. The WHODAS scores is presented by means and standard deviation, minimum and maximum. ANOVA is used to compare means of WHODAS among types and severity of UI, with a significance level of 5%. This study obtained approval from the research ethics committee.

The sample consisted of 101 women, with a mean age of 50.87 (±10.32) years, with 65 (64.4%) women presenting mixed UI and 25 (24.8%) stress UI and 11 (10,9%) Urge UI. 54 (53.5%) women classified as having moderate UI severity. The mean total score of WHODAS was 16.3±17.95 points. The greatest impacts of UI were observed on mobility (22.95±25.46) and on social participation (22.56±22.36) domains of WHODAS (table 1). It was found that functioning does not seem to differ by UI type (Urge UI: 8,14±7,15; Stress UI: 13,73±17,72; Mixed UI: 18,67±18,92; p = 0,141). On the other hand, there is a relationship between UI severity and functioning. The WHODAS score increases with increasing UI severity (mild: 9,62±16,86; moderate: 11,75±14,37; severe: 18,6±13,67; very severe: 32,65±28,77; p = 0,001). We also observed the same pattern for WHODAS domains, except for interpersonal relationships domain (table 2).

We observed that women with UI may present different levels of disability. Mobility (moving and getting around) and participation (joining in community activities) are the domain with greater scores, thus greater disability. The incontinence type (urge, stress, or mixed) does not impact on functioning in our sample, but caution should be taken on interpretation of this results due to the imbalance of sample between groups.  On the other hand, we found that the worse UI severity, the greater impact on the functioning. The WHODAS assess functioning from the patient’s perspective and allowing for planning and application of patient-centered interventions from a biopsychosocial perspective as recommended by both the WHO. Also, this study with WHODAS for women with IU opens an important precedent to encourage implementing functioning in the context of the health care and rehabilitation research for women with pelvic floor dysfunctions.

We observed that UI may affect women's functioning, mainly mobility and social participation, independent of UI type. The WHODAS 2.0 was able to demonstrate greater impacts on the functioning of women with severe and very severe UI.

World Health Organization: International Classification of Functioning, Disability and Health (ICF). Geneva, Switzerland: World Health Organization; 2001.
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