NA CONVIVÊNCIA DOS FAMILIARES CHILDREN WITH URINARY INCONTINENCE : IMPACT ON FAMILY MEMBERS COEXISTENCE

Objective: to identify factors that have an impact on the coexistence of family members of children with urinary incontinence. Method: bibliographic, descriptive, integrative review type study with search of articles in September 2017, in LILACS, BDENF, MEDLIN, and CINAHL databases. We considered the temporal cut from January 2012 to December 2017, using controlled and uncontrolled Health Science Descriptors (DeCS) in English and Portuguese. Results: we included 11 articles, published between 2012 and 2016, highlighting three categories: 1) The educational level of parents as an impact factor; 2) The impact on the quality of life of family members; and 3) The changes that impact on daily family life. Conclusion: urinary incontinence affects the family routine and can cause psychological disorders, such as stress, anxiety, and depression in children and their family members. There was a shortage of productions that related family members' perceptions of diurnal urinary incontinence and fecal incontinence to the parents' education level. The role of nurses working in pediatric urology was evident with respect to the importance of understanding family coexistence to contribute to the delineation of guidelines aimed at the education and understanding of caregivers' experiences. Descriptors: Urinary Incontinence; Family; Caregivers; Children; Enuresis; Urinary Incontinence Due to Stress. RESUMEN Objetivo: identificar factores que impactan en la convivencia de los familiares de niños con incontinencia urinaria. Método: estudio bibliográfico, descriptivo, tipo revisión integradora, con búsqueda de artículos en el mes de septiembre de 2017, en las bases de datos LILACS, BDENF, MEDLINE y CINAHL. Fue considerado el recorte temporal de enero de 2012 a diciembre de 2017, utilizando los Descriptores en Ciencias de la Salud (DeCS) controlados y no controlados en idioma Inglés y portugués. Resultados: se incluyeron 11 artículos publicados entre 2012 y 2016, destacándose tres categorías: 1) El nivel educativo de los padres como un factor de impacto; 2) El impacto en la calidad de vida de los familiares; y 3) Los cambios que impactan en el cotidiano familiar. Conclusión: la incontinencia urinaria afecta la rutina familiar y puede provocar trastornos psicológicos como estrés, ansiedad y depresión en los niños y en sus familiares. Hubo escasez de producciones que relacionaran la percepción de los familiares ante la incontinencia urinaria diurna e incontinencia fecal con el nivel escolar de los padres. Se evidencia el papel del enfermero que actúa en urología pediátrica con respecto a la importancia de la comprensión de la convivencia familiar, a fin de contribuir con el delinear de orientaciones sobre la educación y comprensión de las experiencias vividas por los cuidadores. Descriptores: Incontinencia Urinaria; Familia; Cuidadores; Niños; Enuresis; Incontinencia Urinaria por Estrés. Graduada em Enfermagem, Centro Universitário Euro-americano/UNIEURO. Brasília (DF), Brasil. E-mail: ivanda.matias0@gmail.com ORCID iD: https://orcid.org/0000-0002-1234-0921; Doutoranda em Enfermagem, Centro Universitário Euro-Americano/UNIEURO. Brasília (DF), Brasil. E-mail: cristiane.salviano@unieuro.com.br ORCID iD: https://orcid.org/0000-0002-0221-6011; Doutora (Pós-Doutora), Universidade de Brasília/UNB. Brasília (DF), Brasil. E-mail: martinsgise@gmail.com ORCID iD: https://orcid.org/0000-0002-4656-6195 ARTIGO REVISÃO INTEGRATIVA Oliveira IAMI de, Salviano CF, Martins G. Crianças com incontinência urinária: impacto... Português/Inglês Rev enferm UFPE on line., Recife, 12(7):2061-73, jul., 2018 2062 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i7a231376p2061-2073-2018 Sabe-se que a etiologia da incontinência urinária é multifatorial, sendo uma condição comum na infância, principalmente no contexto da assistência em uropediatria. A incontinência urinária é definida pela Sociedade Internacional de Incontinência Infantil (do inglês International Children’s Continence SocietyICCS) como perda involuntária de urina e subdivide-se em incontinência intermitente diurna e incontinência intermitente noturna, a segunda também é conhecida como enurese. Em termos epidemiológicos, a incontinência urinária noturna/enurese afeta de 20% a 30% das crianças com distúrbios comportamentais e a incontinência urinária diurna atinge entre 30% e 40%. Considera-se incontinência urinária noturna a micção involuntária durante o sono não associada a comorbidade, sendo problemática quando acomete crianças com cinco anos de idade ou mais. Segundo o Manual de Diagnóstico e Estatístico de Transtornos Mentais, a incontinência urinária encontra-se caracterizada entre as desordens comportamentais e emocionais associadas aos distúrbios de internalização, incluindo a depressão e a ansiedade. Nesse contexto, os cuidadores pessoas responsáveis pela saúde da criança passam a perceber a criança como vulnerável, uma convicção que aumenta os níveis de ansiedade e depressão nos familiares. A ansiedade pode ser influenciada pelos comportamentos aprendidos e pela observação e interação com os membros familiares próximos, podendo aumentar o risco de estresse psicológico dos familiares. Reconhece-se que o estresse psicológico influencia na maneira como os cuidadores se comportam e tratam as crianças com incontinência urinária. Nota-se que as formas de agressão psicológica e afetiva involuntárias mais aplicadas são brigas, constrangimentos e até mesmo agressões verbais e físicas como forma de punição. Discutiram-se tais ações em um estudo realizado no Brasil com 132 crianças diagnosticadas com incontinência urinária noturna. Evidenciou-se que 89% dos participantes sofreram algum tipo de agressão e 100% dos casos analisados pelo estudo constatou formas de agressão verbal, apontando a mãe (cuidadora) como a maior praticante das ações. Observa-se que o comportamento agressivo dos cuidadores pode agravar um quadro preexistente de saúde mental das crianças, que se justifica pela liberação exacerbada do cortisol (hormônio do estresse) desencadeando até mesmo um mecanismo de maior produção urinária, tal fato pode, ainda, acarretar problemas na conduta, sejam elas emocionais e de socialização entre pares. Encontram-se outros fatores de risco fortemente discutidos na literatura como as associações entre famílias numerosas e o baixo nível educacional e socioeconômico dos cuidadores, visto que mitiga-se a busca por ajuda nos serviços de saúde e pode influenciar na permanência da incontinência noturna até a vida adulta. Diante deste panorama geral sobre o tema estudado, sugere-se a adoção de estratégias de enfrentamento e comportamental para lidar com o estresse psicossocial dos cuidadores com o fundamento na prevenção de riscos relacionados à saúde mental das crianças, portanto, devem-se tratar os distúrbios comportamentais e emocionais simultaneamente ao regime terapêutico da incontinência urinária. Para transpor os desafios impostos pela condição da criança às famílias, espera-se que os cuidadores incorporem o regime terapêutico ao seu cotidiano e, portanto, coordenem com êxito as exigências do tratamento. Para tanto, muda-se a rotina familiar e anseia-se que a criança aceite os novos padrões de tratamento instituídos. Ademais, verifica-se uma escassez de intervenções na perspectiva familiar que envolva a natureza psicossocial da incontinência urinaria no contexto familiar, para entender os papeis e relacionamentos familiares no ambiente em que o regime terapêutico é manejado. Necessita-se de que os profissionais da saúde tomem decisões com o intuito de melhorar o engajamento dos familiares, buscando compreender como o envolvimento familiar contribui para o melhor controle da condição urinaria da criança. Diante do exposto, destaca-se a relevância de identificar os fatores que podem interferir no manejo familiar e nas intervenções terapêuticas aplicadas para a criança com incontinência urinária. ● Identificar fatores que impactam na convivência dos familiares de crianças com incontinência urinária. Estudo bibliográfico, descritivo, tipo revisão integrativa da literatura, realizada no mês de setembro de 2017, nas bases de dados investigadas, por meio do levantamento das INTRODUÇÃO

English/Portuguese J Nurs UFPE online., Recife, 12 (7):2061-73, July., 2018  2062  It is known that the etiology of urinary incontinence is multifactorial.This is a common condition in childhood, especially in the context of uropediatric care.Urinary incontinence is defined by the International Children's Continence Society (ICCS) as an involuntary loss of urine.It is subdivided into intermittent diurnal incontinence and intermittent nocturnal incontinence; the latter is also known as enuresis. Nocturnal urinary incontinence is considered to be involuntary urination during sleep, not associated with comorbidity, and problematic when it affects children aged five years or older. In this context, caregivers-individuals responsible for children's health-perceive that the children are vulnerable, which is a conviction that increases the levels of anxiety and depression in family members. 3Anxiety can be influenced by behaviors learned and by observation and interaction with close family members, which may increase the risk of psychological stress in family members. 3 is recognized that psychological stress influences the way in which caregivers behave and treat children with urinary incontinence.It has been observed that the most common forms of involuntary psychological and affective aggression are fights, constraints, and even verbal and physical aggressions as a form of punishment.Such behaviors were discussed in a study conducted in Brazil with 132 children diagnosed with nocturnal urinary incontinence.It was found that 89% of the participants had suffered some type of aggression and there were forms of verbal aggression in 100% of the cases analyzed by the study, pointing the mothers (caregivers) as the main responsible individuals for the actions. 4 is observed that the aggressive behavior of the caregivers may aggravate a preexisting mental health condition of the children, which is explained by the exacerbated release of cortisol (stress hormone), triggering even a mechanism of higher urinary output.This fact may also lead to behavioral problems, either emotional or affecting socialization among peers. 5There are other risk factors strongly discussed in the literature, such as the association between large families and the low educational and socioeconomic levels of the caregivers, given that the search for help in health services is reduced and this fact may influence the permanence of nocturnal incontinence until adulthood. 6,7,8ced with this general panorama of the subject studied, the adoption of coping and behavioral strategies to deal with the psychosocial stress of caregivers is suggested by addressing the bases for the prevention of risks related to children's mental health. 9herefore, behavioral and emotional disorders should be treated simultaneously with the therapeutic regimen for urinary incontinence.
In order to overcome the challenges posed by the children's condition to their families, caregivers are expected to incorporate the therapeutic regime into their daily lives and, therefore, successfully coordinate treatment requirements.To that end, the family routine changes and it is hoped that the children will accept the new standards of the treatments. 9 addition, there is a shortage of interventions in the family perspective that involves the psychosocial nature of urinary incontinence in the family context in order to understand the family roles and relationships in the environment in which the therapeutic regimen is managed.Health professionals should make decisions with the purpose of improving the engagement of family members, seeking to understand how family involvement contributes to better control children's urinary condition. 9 view of the above mentioned, it is relevant to identify the factors that may interfere in the family management and in the therapeutic interventions applied to the children with urinary incontinence.
• To identify factors that have an impact on the coexistence of family members of children with urinary incontinence.This is a bibliographical, descriptive and integrative review study conducted in September 2017, using databases by means of a survey of the scientific productions about the impact and behavior of the family members of children affected with any type of urinary incontinence.The integrative review is a research method that allows synthesizing the literature on a certain topic, allowing the

METHOD
English/Portuguese J Nurs UFPE online., Recife, 12 (7):2061-73, July., 2018  2063  inclusion of multiple studies with different methodological approaches.The aim is to obtain a more general conclusion and provide guidelines for further studies. 10e following steps were performed for the conduction of the present study: 1) Identification of the topic and selection of the research question; 2) Establishment of inclusion and exclusion criteria for the study; 3) Identification of pre-selected and selected studies; 4) Categorization of selected studies; 5) Analysis and interpretation of results; and 6) Presentation of the knowledge review/synthesis. 10e guiding question of this research was: Which is the available evidence in the literature on the factors that have an impact on the coexistence and behavior of family members of children with urinary incontinence?
The search for the studies was carried out in the following electronic databases: Latin American and Caribbean Health Sciences Literature database (LILACS); Specialized Bibliographic Database in the Nursing Area The inclusion criteria were articles in English, Portuguese, and Spanish, made available in full and published from January 2012 to December 2017 in the aforementioned databases, which were relevant to the object of study and the guiding question of the review.Duplicate publications, studies on relatives of children with neurological impairment or congenital malformation of the genitourinary and intestinal tract, dissertations, books, theses, case studies, papers presented at conferences, informative studies, literature reviews, and studies that did not correspond to the delimited search period in the databases and that did not address the topic of the present study were excluded. 10is way, the selection of the literature was performed by means of meticulous reading of the titles and abstracts of the original articles, available in full and online, that met the inclusion criteria mentioned.Still, they were submitted to the classification criteria of the Critical Appraisal Skills Program (CASP) to evaluate the quality of the selected articles. 11e process was carried out in three phases in order to choose the selected studies, namely: A) Selection of articles according to the combination of the descriptors associated with Boolean search (AND/OR) in the selected databases (Figure 1); B) Reading of the titles and abstracts of 204 articles corresponding to 141 in MEDLINE, 14 in LILACS, 27 in BDENF, and 22 in CINAHL (Figure 1), which resulted in a total of 13 articles selected for the study according to the inclusion criteria; and C) Reading of the 13 articles selected in full.Two articles that did not address the topic of the study were excluded. 10The selection process of the articles is illustrated in Figure 2.
English/Portuguese J Nurs UFPE online., Recife, 12(7):2061-73, July., 2018 2064 The extraction of data and synthesis of the studies included in the review were carried out using a descriptive tool elaborated in the Microsoft Word ® program, which included year of publication, country of origin, authors, titles, level of evidence/methodology of the studies, and main results of the included studies (Figure 3).
For the analysis of the level of evidence of the selected sample, we used the parameters that classify six levels of scientific evidence, namely: Level 1: evidence resulting from the meta-analysis of multiple controlled and randomized clinical studies; Level 2: evidence obtained in individual studies with experimental designs; Level 3: evidence of quasi-experimental studies; Level 4: evidence in descriptive studies (non-experimental) or with qualitative approach; Level 5: evidence in case or experience reports; Level 6: evidence based on experts' opinions. 10om the articles selected for this study, we obtained a final sample of 11 articles.
Regarding the year of publication, the period of greatest production of the studies occurred in 2015, with 36% (n = 4).There was one article published in 2012 and another in 2016, representing the smallest production of articles.Most of the studies were published in English (n = 10), and only one in Portuguese.Turkey was the country with the highest number of publications (n = 3), followed by the United Kingdom and the United States (n = 2 each).The other publications were from Japan, Sweden, Germany, and Brazil (n = 1 each).With respect to the methodological outline, it was observed that 10 articles had a quantitative approach and one article a qualitative approach, six articles were descriptive studies, three articles were casecontrol studies, and two articles were cohort studies.A summary of the studies selected for this review and their main results are presented in Figure 3.
There is a need of methodological quality of studies to support clinical practice, given that the use of more robust scientific

RESULTS
Total number of articles selected in the databases (204) MEDLINE ( 141) LILACS ( 14) BDENF ( 27 The family history of nocturnal urinary incontinence was a condition for the children to suffer more physical than verbal punishments.We used the concept of categorization of the topics according to the criteria for organizing the data collected in order to construct a set of categories (Figure 4). 12In the selected sample, the object of the studies was nocturnal urinary incontinence mostly in children and adolescents (90.9% = 10).The goal of using the published studies was to assess parental 15 and family members' 13,14,15,16,17,18,20,22,23 beliefs, the quality of life of family members, children, and adolescents, 13,17,18 psychological and behavioral factors, 19,21,22 and the methods of punishment used by the caregivers. 16,23It is worth noting that only one article addressed diurnal and nocturnal urinary incontinence in conjunction with fecal incontinence in children, 17 which indicates the scarcity of publications in this area.
After the construction of the categories, according to the publications selected, three thematic units were identified, namely: 1) Parents' educational level as an impact factor; 2) Changes that impacted on daily family life; and 3) Impact on the quality of life of family members/caregivers, which are discussed below.

 Parents' educational level as an impact factor
The parents' low educational level was discussed in the sample studies as a factor for a greater predisposition of difficulty in dealing with urinary incontinence. 14,18The mothers were the main caregivers, due to the fact that they experience in a more intensive way the daily life of their children and, in general terms, had a lower educational level in comparison to the fathers. 20These factors increase the risk for persistent urinary incontinence throughout the children's lives, especially for those that combine psychological factors and nocturnal urinary incontinence. 20,21It was observed that the educational level of the caregivers could also influence the way of dealing with the children, and verbal and physical punishment were common. 16n the present review, there was an evident relationship between caregivers' educational level and psychosocial factors, such as behavioral problems, hyperactivity, emotional difficulties, and peer relationship problems.Such behavioral findings were more frequently observed in children living with mothers of low educational level in comparison to children living with mothers with higher educational levels. 6Therefore, it can be suggested that low maternal education is a risk factor for adequate management of children with nocturnal urinary incontinence, given that the disorder is influenced by emotional and behavioral factors that promote the difficulty in cosidering and seeking healthcare. 6he late search for healthcare services 4 can be explained by the fact that the parents of children with nocturnal urinary incontinence do not regard this condition as a disease.This finding is similar to that found in studies that affirm the relationship between low educational level and reduced demand for medical care. 9In addition to the low educational level, the socioeconomic status of

DISCUSSION
English/Portuguese J Nurs UFPE online., Recife, 12(7):2061-73, July., 2018  2068  the family explains the reduced search for healthcare. 8However, this finding should be better investigated in further studies, given that this issue may not be related to education or social level, but to restricted access to healthcare, or even to the caregivers' work characteristics. 5n a study on parents' beliefs in the treatment of nocturnal urinary incontinence conducted with 216 subjects, 55% reported the search for medical care for their children with nocturnal urinary incontinence, and 36% believed in treatment efficacy. 15Also, in that study, it was observed that women with postgraduate level were more likely to seek medical care for nocturnal urinary incontinence in comparison to women with a low educational level.This was a direct impact factor in the early decision for the treatment of this morbidity. 15he prevalence of nocturnal urinary incontinence in countries such as Nigeria, Democratic Republic of Congo, Yemen, and Iran, considered to be in development, was about two to three times greater than the rates of developed countries with similar socioeconomic inequity.In comparison to developed countries, the rate of nocturnal urinary incontinence was higher and more severe.Youngest age, men, family history of nocturnal urinary incontinence, large families, ineffective prior treatment, as well as financial situation, individuals' role in the family, culture, beliefs and community resources are variables that will also contribute to the permanence of urinary incontinence. 8,24he literature points to nocturnal urinary incontinence as a condition that was more prevalent in children accompanied by caregivers of low educational and socioeconomic level, evidencing an important variation between social levels. 6,25It can be mentioned that this is an important variable to be investigated.It is suggested that the population affected by nocturnal urinary incontinence should be clarified and oriented in order to achieve better results of treatments.
In order to maximize patients' compliance with the treatment and education regarding the clinical management of the symptoms of urinary incontinence in the urological scope, nursing should be capable of offering holistic care to the patients, from the stage of user embracement in the specialized service to the meticulous evaluation of biological, psychological, social, and emotional risk factors.In addition, the nurses should explain the procedures necessary for diagnosis, discuss the concerns, and assist in care provided to the patients. 26

 Impact on the quality of life of family members/caregivers
Quality of life is measured as the way in which the individuals perceive their state of psychological, mental, emotional well-being, and socio-cultural values, i.e., how the impact of a disease and/or treatment is perceived. 18Urinary incontinence is a common disorder in childhood and significantly affects the daily family life, leading to a decreased quality of life of the caregivers with regard to the family psychosocial dimension. 13, A cort study conducted in the United Kingdom assessed the influence of psychological factors during early childhood on the risk of nocturnal urinary incontinence at school age.Through the application of two questionnaires, the Postnatal Depression Scale (EPDS) in Edinburg and the Emotionality Activity Sociability (EAS), the study found that mothers of children with nocturnal urinary incontinence had a probable diagnosis of maternal depression. 21nother study conducted with 139 children with nocturnal urinary incontinence assessed their mothers' quality of life using the following three scales: SF-36 ® Quality of Life Questionnaire; Self-Rating Depression Scale; and State-Trait Anxiety Inventory.It was found that the reduced vitality of the mothers for the management of nocturnal urinary incontinence, the greater burden of time and additional efforts, physical pain, and pessimism were associated with a possible masked depression and higher anxiety levels. 13,18aregivers' stress was pointed out as a predisposing factor that potentiates children's behavioral and emotional problems, such as low self-esteem and diminished self-image, and promotes a reduced family coexistence. 21- 2In the sample of the present study, there was only one article that addressed diurnal urinary incontinence, fecal incontinence, and nocturnal urinary incontinence associated with each other or individually.Among the study population, 34% had incontinence in a combined manner, with significant impairment in the psychological domain of the parents, who had increased anxiety and depression levels. 17Anxiety is an impact factor that causes impairment to parents and jeopardize their skills in parental practices, as well as the quality of family relationships. 14,22ccording to a cohort study conducted in Lithuania to assess the impact of maternal stress on the emotional and behavioral difficulties of children aged between four and English/Portuguese J Nurs UFPE online., Recife, 12(7):2061-73, July., 2018 2069 six years, the family environment during early childhood can influence health and wellbeing, and may also generate emotional and behavioral difficulties during the future life.Exposure to family stressors also leads to the release of stress hormone (cortisol), which triggers epigenetic changes, such as chromatin and DNA modifications, thus leading to changes in the metabolic pathways involved in the etiology of diseases. 7It is still unclear whether the presence of epigenetic triggers (stress) is related to the control of urination.This way, there is still a gap to be investigated in this area. 6 case study assessed 93 children with nocturnal urinary incontinence and found that the family members' perceptions regarding the children's emotional behavior did not match their own perceptions, because the children did not consider themselves different from their peers who did not suffer from nocturnal urinary incontinence.It is possible to consider lack of knowledge, given that the discrepancy in the children's perception of their condition indicates the existence of family isolation.The inefficient approach to the topic can interfere with children's well-being. 22larification on nocturnal urinary incontinence is essential, presenting it as a common childhood condition.Also, it should be stressed to the parents that with the advancement of the child's age, in most cases, the problem has a spontaneous resolution; however, comorbid conditions, such as psychological disorders, should be taken into consideration, because they can contribute to the permanence of urinary incontinence. 7,27 study on quality of life conducted with 87 children with nocturnal urinary incontinence and their mothers, assessed using the German version of the World Health Organization's WHOQOL-BREF quality of life assessment, which attributes a score to the factors influencing the quality of life, found that children and mothers scored their perceptions about quality of life differently. 18The same instrument was applied in a another study to a similar group and the mothers obtained a higher score for social relations.That study also pointed out greater social impairment for caregivers of children with nocturnal urinary incontinence. 17ocial isolation is a worrying factor for parents who deal with their children's nocturnal urinary incontinence.They feel lonely and fail to participate in community activities, because they consider urinary incontinence a taboo, and deprive their children of social interaction.Parents argue that protecting their children from family members, neighbors, and friends is an obligation, because it is a very personal matter and, this way, they avoid exposing their children. 14ocial exclusion can be harmful both to the children and their caregivers, and can aggravate the psychological factor during the maintenance of the incontinence condition.It is important to show that parents deprive their children of social life, because they feel that they are protecting them from embarrassment at school, among friends, and in the family.Such a protective attitude of the parents occurs due to the fear of discovering that their children have urinated in bed.They begin to hide these accidents by all possible means. 28This social impact is evidenced by the fact that children with severe nocturnal urinary incontinence exhibit difficulties in interacting with their peers, resulting in emotional isolation and difficult family relationships. 26onsidering urinary incontinence a dysfunction that affects the quality of life of the family members and the children, health professionals should establish a new healthcare approach in their practice, involving the relationship with the family members, as well as the perception of the disease of the children and the quality of care provided.Therefore, professional training in the field of pediatrics becomes necessary.Health professionals should be aware of the risks inherent to the health condition and to the physical and psychological suffering of the children and their caregivers. 29

Changes that impact on daily family life
In the selected literature, nocturnal urinary incontinence was the topic further investigated.This condition exhibits a gradual reduction as the children's age increases. 15,18,20arents believe that involuntary nocturnal urination is uncontrollable and try to understand the etiology of this condition, experiencing feelings of helplessness, concern, and annoyance.In addition, family social relationships are hampered by the fact that their children urinate in bed during the night; therefore, they avoid overnight visits.
It is common for parents to conceal the truth by keeping diapers as a strategy to deal with their children's condition, in addition to sharing management of tasks, such as performing hygiene and changing the sheets after their children have urinated in bed in an attempt to keep it dry. 14rom the perspective of the Dyadic Adjustment Scale (DAS), it was observed that the scores relating to affection were reduced in parents of children with nocturnal urinary English/Portuguese J Nurs UFPE online., Recife, 12 (7):2061-73, July., 2018  2070  incontinence. 30The studies assessed indicated the parents' difficulty in coping with family agreement in basic situations, which promotes less empathy between the fathers and the mothers and makes the family management difficult.The relationship between peers was seen as a risk factor for monitoring, supervision, and involvement with the children. 27If these relationships are negative, they can lead to children's suffering due to the lack of caregivers' control.This fact demonstrates the lack of other approaches in studies aimed at analyzing family coexistence in children with urinary incontinence, and the abilities of the families to manage the disease condition.
Parents wake their children up at night as a strategy to deal with nocturnal urinary incontinence.This procedure causes fatigue, both in the parents and the children, generating stress, irritability, conflicts, and frustrations.This fact even happens when using positive psychological reinforcement methods, such as rewards, which have no effect, causing feelings of anger and, consequently, threats toward the children.The observation of this behavior indicated parents' increased feelings of guilt related to their children's condition.  In ition, it is inferred that parents are more susceptible to psychiatric problems in the face of this reality, because they are disappointed by the lack of success in therapeutic interventions with the threats or rewards and, also, by the consequent obligation of maintaining the daily hygiene of the place, such as washing the sheets and removing odors from the rooms.Moreover, several interruptions of sleep at night may result in intolerant caregivers. 18,23he level of parents' intolerance has a significant impact on children with nocturnal urinary incontinence.As the children's age advances, this level of intolerance tends to increase. 19The level of caregivers' tolerance is considered to be a factor that causes child abuse, because it is believed that the children are guilty for bedwetting. 23Parents are extremely vigilant, but, due to the feeling of anger, they may choose punishments classified as mild (condemnation, threatening, deprivation of desires, humiliating the children in front of others) and severe (tapping softly, leaving the children wet, locking the children inside the house, tapping with the hands or a stick) as a treatment for nocturnal urinary incontinence. 16tudies conducted in the United States and France have found that most families used at least one method of punishment to manage their children's nocturnal urinary incontinence, and that this situation occurred repeatedly.Another important fact reported in the studies refers to the parents' experience regarding the diagnosis and family history of nocturnal urinary incontinence.This experience occurred concomitantly with verbal and/or physical punishment, thus increasing the incidence and repetition of these practices with their children. 18,23he literature shows that nocturnal urinary incontinence causes changes in daily family life and may give rise to maltreatment and punishment.In addition, inconsistence has a greater relationship with recurrent lower urinary tract infections and psychological changes.Parents and caregivers regard the condition of the children as normal and blame them for their urine losses and dirty clothing.This fact can lead to verbal and physical punishment and expose children to embarrassments. 4,9o treat the children, it was observed that parents use simple behavioral practices, such as restricting the intake of liquid before going to bed, disruption of sleep at night to go to the bathroom, and giving rewards that stimulate the children to stay dried.Such methods are considered satisfactory for the management of nocturnal urinary incontinence, but they become more effective when used concomitantly with the enuresis alarm therapy. 8ccording to a study on children and adolescents' perceptions, positive and negative situations, which induce actions to adapt them to their condition, may influence the care and treatment process. 29Proactive actions are collaborative attitudes of family members, such as health routine, communication, and treatment plan, which are associated with the lifestyle, the problem, collaboration, and mental support.Reactive actions are a significant change to achieve an established goal.Health professionals intervene to improve the management of the disease using the promotion and education of patients and their caregivers. 24he way in which the parents deal with these interventions is fundamental for the management of the children's condition.relationships and achieve a better and more effective therapeutic regimen. 9he literature points out other factors related to socioeconomic status and the presence of adversities, such as unemployed parents, financial difficulties, large families, and inadequate housing.This factors are regarded as having an impact on family life and as contributors to the permanence of nocturnal urinary incontinence, because there is a large increase in household expenses due to the multiple clothes washing and constant changing of bed sheets and mattresses. 13,15,21,30inary incontinence involves more than one physical disorder.It affects the family routine and can cause psychological disorders such as stress, anxiety, and depression in children and their caregivers.In general terms, caregivers feel powerless, worried, guilty, irritated, and intolerant when they have to manage urinary incontinence.
The low educational level of the parents was considered a risk factor, given that such a variable can lead children to suffer verbal and physical punishment.This fact poses a challenge to the practice of health professionals, especially nurses of pediatric urology.They should recognize the family members' ability to learn and guide the family as a whole to be engaged in specific educational actions for their children's condition and respect the particularities of each family member.
A gap to be filled is the need for scientific productions that relate the family members' perceptions of diurnal urinary incontinence and fecal incontinence to the parents' educational level, given that the primary role of nurses working in pediatric urology lies in the expanded understanding of the family context in which the children are inserted.

Figure 2 .
Figure 2. Flowchart of the selection and inclusion of studies for the review conducted in September 2017.Brasília, DF, Brazil, 2017.

Figure 3 .
Figure 3. Grouping of studies selected for the sample according to year of publication, country, author(s), title, level of evidence, and main results.Brasília, DF, Brazil, 2017.
Recent studies have shown that interventions involving the family improve the capacity to administer the treatment.Although parents are involved in the interventions, there is a deficiency in the family context, emphasizing the need for further studies centered on families and the psychosocial content of the intervention to involve roles and family English/Portuguese J Nurs UFPE online., Recife, 12(7):2061-73, July., 2018 2071 ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i7a231376p2061-2073-2018