Introduction
Neurogenic bladder refers to a dysfunction of the bladder, urethra, or prostate originating from neurological problems [1, 2]. This condition leads to urinary incontinence [3]. A stroke occurs in patients with spinal cord injury, Parkinson disease, and multiple sclerosis [3]. Neurogenic bladder prevalence is higher in women than in men [5], which leads to a decrease in self-esteem, depression [5], and a reduction in social activities [6]. This disorder, especially in young and middle-aged people of working and active age, is very harmful and reduces their quality of life (QoL) [7].
To increase the QoL of neurogenic bladder patients, there are several treatments, including drug treatments, Botox injection, and surgical treatment, which are not recommended as the first line of treatment due to their side effects and high cost [9, 10]. The treatment of choice for urinary incontinence in the neurogenic bladder is rehabilitation intervention, a way to teach bladder control [11].
Neurogenic bladder rehabilitation care is more accessible, less expensive, without complications, and can be easily taught to patients and families compared to other treatments [12]. Although nurses play an essential role in urinary incontinence rehabilitation interventions [11], many have little knowledge about it [12, 15]. Also, it is not easy to apply this knowledge in a clinical setting [16].
To solve nurses’ lack of knowledge, it is necessary to establish a proper protocol for nurses [17]. In this way, nurses can provide quality care for patients with urinary incontinence [17, 19].
Rehabilitation nursing interventions in urinary incontinence include drug prescription, bladder emptying training, pelvic muscle strengthening exercises, and clean intermittent catheterization [14].
Clean intermittent catheterization improves body image and self-confidence, increases independence, and improves the QoL of patients with neurogenic bladder by improving symptoms and signs of incontinence and urinary infection [20]. However, implementing rehabilitation care in women with neurogenic bladder has unique challenges, including the difficulty of catheterization in women. It is also much more difficult for women who are limited to moving with a wheelchair [21].
So far, few studies have been conducted concerning neurogenic bladder control methods [22-26], which have either examined men’s problems [27] or have been conducted on elderly menopausal women (and not necessarily with neurogenic bladder) [28]. At the same time, young and middle-aged women with neurogenic bladder face more challenges in fulfilling their social [29], marital, and occupational roles [8].
As a result, this study aims to investigate the effectiveness of the multimodal intervention of urinary incontinence rehabilitation nursing, including clean intermittent urinary catheterization, behavior therapy (determining the specific time of urination, delaying urination, adjusting diet, and taking medications) on the quality lives of young and middle-aged women with neurogenic bladder have been performed.
Materials and Methods
This research was a quasi-experimental study with a before-after design conducted from January to the end of February 2021 in Rafideh Rehabilitation Hospital, Tehran City, Iran.
According to the study of Lassen et al. [30], the sample size was calculated as 30, considering the type 1 error of 0.05, type 2 error of 0.20, and test power of 0.80, using Equation 1:



Subjects were selected from patients hospitalized in multiple sclerosis, spinal cord injury, and stroke departments using the available sampling method. The inclusion criteria include being young and middle-aged women 18-60 years old; having clean intermittent catheterization according to doctor’s orders; being literate; using WhatsApp application; having body mass index (BMI) less than 30 kg/m2; lacking a history of gynecological surgeries, being pregnant, a history of cesarean section, normal delivery in the last 6 months, pelvic organ prolapse, or spinal and cervical injuries; not consuming alcohol and drugs, not suffering from acute depressive disorder, not changing in the prescription of drugs effective on urinary incontinence during the last month (if used), the absence of diuretic blood pressure lowering drugs, the lack of active urinary tract infections. The exclusion criteria included sudden serious physical and mental illnesses during the study, unwillingness to continue participation, acute physical and mental conditions, and death of the subject during the study.
In the first stage, nursing interventions for the rehabilitation of urinary incontinence in patients with neurogenic bladder were developed and validated [31-33]. The intervention consisted of 2 dimensions: intermittent clean urinary catheterization and behavioral therapy (determining the time of urination, delaying urination, adjusting diet, and taking medications). Pre-test questionnaires (demographics and QoL in urinary incontinence) were completed in the second stage. The intervention included 7 individual and face-to-face sessions of 30 minutes daily in the first week. The third stage of follow-up of patients was one session per week (weeks two to six), and the post-test was done virtually using WhatsApp.
Using a demographic questionnaire, patients’ information about age, height, weight, education, marital status, number of family members, health insurance, employment status, monthly income, diagnosis during hospitalization, duration of illness, pregnancy and breastfeeding status, number of pregnancies, number and time of childbirth, alcohol and drug use, history of depression, history of surgery, active urinary infection, medications, symptoms of urinary infection (urine odor, burning sensation, pain during urination, abdominal pain, fever, presence secretions in the urine) of the patients were collected. Using the incontinence QoL questionnaire (I-QOL), the QoL of the samples was evaluated before and after the intervention. This questionnaire was designed in 1996 for the first time by Wagner et al. and examined the dimensions of the QoL of patients with urinary incontinence [34]. The validity and reliability of the I-QOL questionnaire were reviewed by Nojomi et al. [35].
According to the normal distribution of research variables confirmed by the Shapiro-Wilk test (P>0.05), parametric tests, such as a one-way analysis of variance and paired t-test, were used to analyze the data. Frequency, frequency percentage, and Mean and standard deviation were used to describe the demographic information of the study participants.
Results
In this study, there were 30 participants aged 17-44 years. Table 1 presents the distribution of participants based on demographic variables, disease pathology, and patients’ symptoms. According to the findings, 23 participants (76.7%) were under 35 years of age, 19 participants (63.3%) had a diploma level of education, and 16 participants (53.3%) were married. In addition, 16 participants (53.3%) were employed, and 23 participants (76.7%) had a monthly income of $ 45-140. In this study, 13 participants (43.3%) were not covered by health insurance. The subjects’ most common cause of neurogenic bladder disease was related to spinal cord injury and stroke with the same prevalence, i.e. 8 participants (26.7%), and the least common cause was MS with a plurality of 4 participants (13.3%). Also, the participants’ most common disease symptom was pain during urination, with a majority of 9 participants (30%) (Table 1).



In Table 1, the average scores of the QoL in people with urinary incontinence at the beginning of the study are compared based on subgroups of demographic variables. The QoL significantly differs based on age, marital status, occupation, cause of illness, and disease symptoms in the participants. According to the findings, the QoL is lower in people who are young; single; unemployed; with a spinal cord injury, a shorter diagnosis period, and less body odor.
Table 2 compares the QoL of patients before and after the intervention. The Mean±SD QoL total score of patients with neurogenic bladder disorder before the intervention was 46.46±11.07, which indicated a low QoL in patients. But after 6 weeks of educational intervention, the Mean±SD QoL total score in patients increased to 66.23±9.46, which was statistically significant (t=14.20, P<0.001). Also, a considerable increase in the average QoL scores was observed in all three subscales of the QoL questionnaire of patients with neurogenic bladder disorder. According to the results, the Mean±SD scores of the subscales of behavioral restriction, psychosocial effects, and social problems were respectively 17.86±3.98, 18.46±4.73, and 10.13±3.23 before the intervention, which increased to 24.23±3.25, 26.40±3.69, and 15.60±3.24 after the intervention, respectively. All of the changes were significant (P<0.001).






Discussion
This study aimed to investigate the effectiveness of multimodal intervention of urinary incontinence rehabilitation nursing, including intermittent clean urinary catheterization and behavioral therapy (determining a specific time to urinate, delaying urinating, adjusting diet, and taking medications) on the QoL of young and middle-aged women with bladder neurogenic.
Before the intervention, the QoL of women with neurogenic bladder was low. This finding is consistent with the results of the study by Fathian et al. [36], Tang et al. [28], and Guler et al. [37], who emphasized the low QoL of Iranian, Chinese, and Turkish women with neurogenic bladder. Factors such as the inability to control life, a decline in daily performance and physical health, lack of social connections, and sexual life lead to decreased QoL in patients with neurogenic bladder [3, 8]. However, after implementing the multimodal intervention of urinary incontinence rehabilitation nursing, the overall QoL of patients with neurogenic bladder increased significantly. The psychosocial effects and behavioral limitations caused by the disease decreased based on one of the three subscales of the QoL questionnaire. 
This finding was consistent with the study of Tang et al., during which it was found that continuous rehabilitation care intervention can significantly improve the QoL in patients with neurogenic bladder dysfunction in general and in the field of physical, occupational, and social functioning [26]. Fathian et al. also reported that teaching skills to adapt to the symptoms of the disease improves the QoL of patients with neurogenic bladder [36]. Other studies have also shown that pelvic floor and bladder strengthening interventions can improve urinary incontinence and increase patients’ physical performance and QoL [38, 39].
The destructive effect of urinary incontinence was investigated by Al-Shammari et al., and it was shown that 3.63% of patients were socially restricted [42]. For many women with neurogenic bladder, the opportunity to participate in many social gatherings and group activities and spend leisure time outside the home is simply lost because they cannot control their urination for more than 2 hours. Therefore, interventions that improve the condition of urinary incontinence in women will improve the QoL of patients in the social sphere [38, 39].
Another result of this study was reducing the disease’s mental effects and improving the patient’s QoL in the mental category. The fear of the sudden occurrence of urinary incontinence in the community causes many women to get anxious, worried, and fearful and suffer from a decline in mental health [8]. Therefore, to increase the QoL of patients with neurogenic bladder disorder psychologically, bladder control ability should be improved in patients [43]. 
In this research, by reviewing the literature and national and international guidelines and multi-specialty meetings, an attempt was made to select the most effective intervention to increase bladder control ability. In addition, during individual consultations and follow-ups after that, it was ensured that all subjects could use catheters and perform other interventions controlling urinary incontinence. Also, one of the important factors that lead to the success of treatment in patients with incontinence is the use of standardized training protocols that bring enough motivation and knowledge to the nurses who implement them [18]. In the current study, during a three-hour educational webinar, the educational content was evaluated, and the opinions of the nurses were received regarding its effective implementation.
Among the other results of the current study was the investigation of the QoL based on demographic variables. According to the findings, the QoL in younger, single, unemployed, spinal cord injury patients, shorter diagnosis period, and less body odor than in other patients.
One of the reasons that can lead to the low QoL of young people with a recent diagnosis is that, according to previous studies, the severity of symptoms in patients with neurogenic bladder decreases over time [44], and people with symptoms gradually find more adaptation to the disease [45]. In addition, middle-aged and elderly people consider urinary incontinence a part of the natural aging process. Unlike young people, they see it less as a health problem that needs treatment [46]. On the other hand, with the severity of symptoms of incontinence and lack of bladder control in patients, the manifestations of the disease, such as bad body odor, increase, and many social, occupational, and marital situations are lost [8] and the QoL of neurogenic bladder sufferers decreases [44]. Therefore, it is not surprising that single or unemployed people suffer from a lower QoL due to lacking social and family roles. In general, the results of the present study showed the effectiveness of multimodal rehabilitation nursing intervention on the QoL in young and middle-aged Iranian women with neurogenic bladder.
Conclusion
The current study investigated the effectiveness of rehabilitation nursing multimodal intervention on the QoL of urinary incontinence in patients with neurogenic bladder. The results showed an improvement in the patient’s QoL after 12 sessions of intervention and regular follow-up. One of the strengths of the current study was the use of a specific urinary incontinence QoL questionnaire. In addition, previous studies were only conducted on patients with neurogenic bladder disorder with the same cause. Still, in the current study, various patients participated, which is a better indicator for those with neurogenic bladder. Also, although many articles examined rehabilitation interventions in elderly women with incontinence, the present study focused on young and middle-aged women. The use of multimodal nursing intervention for urinary incontinence rehabilitation was another strength of the current research, which made the subjects implement various methods to control their incontinence. Finally, this study also has some limitations. In this study, only hospitalized patients were involved, so be careful in generalizing the results of the present study to other populations. Also, the short follow-up period in the current research denied the possibility of examining the long-term intervention results.

Ethical Considerations

Compliance with ethical guidelines
The proposal was approved and the code of ethics (IR.USWR.REC.1399.259) was obtained and approved by the Ethics Committee of the University of Rehabilitation Sciences and Social Health.
The dignity and rights of the patients were preserved. The principle of secrecy and keeping the subjects' secrets and keeping their information confidential was observed. Beneficially and non-harmfulness, no risk of health loss for the participants were observed even potentially. They were allowed to withdraw from the research whenever they wanted. The permission to stop the study was given to the client in case of any possible loss. Accessing the results of the study and benefiting from the interventions or methods whose usefulness has been shown in this study was created. Informed and free written consent was obtained from the samples. At the end of the study, educational pamphlets and content of Multidimensional Rehabilitation Nursing Intervention of Urinary Incontinence were made available to the wards of Rofeideh Rehabilitation Hospital.

Funding
This stduy was extracted from the master's thesis of Asieh Soghrati of the Nursing Department, University of Rehabilitation Sciences and Social Health.

Authors' contributions
Conceptualizatio, project management: Narges Arsalani; Methodology: Narges Arsalani, Shamaneh Mohamadi, Mohsen Vahedi and Hossein Ajami; Validation: Narges Arsalani, Shamaneh Mohamadi, Hossein Ajami, Asieh Soghrati; Analysis: Mohsen Vahedi, Narges Arsalani; Research and review: Narges Arsalani, Asieh Soghrati, Shamaneh Mohamadi; Sources: Narges Arsalani, Asieh Soghrati, Visualization: Narges Arsalani, Asieh Soghrati; Supervision: Narges Arsalani, Shamaneh Mohamadi. Writing the draft: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
Thanks to all the professors and officials of the University of Social Welfare and Rehabilitation Sciences and Rofeideh Rehabilitation Hospital, as well as the patients who helped us in the implementation of this research.
 

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