|Year : 2020 | Volume
| Issue : 2 | Page : 80-83
Effect of home-based pelvic floor muscle training based on the severity of incontinence on quality of life in women with stress urinary incontinence
Zarna Ronak Shah1, Priyanshu V Rathod2
1 SBB College of Physiotherapy, V.S.Hospital Campus, Ahmedabad, Gujarat, India
2 School of Physiotherapy, R.K.University, Rajkot, Gujarat, India
|Date of Submission||23-Apr-2019|
|Date of Decision||14-Oct-2019|
|Date of Acceptance||08-Apr-2020|
|Date of Web Publication||31-Dec-2020|
Dr. Zarna Ronak Shah
V.S. General Hospital, SBB College of Physiotherapy, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
BACKGROUND: The women of our country are different than any other developed or developing country due to its cultural, economic, and religious scenario. It has been observed that though stress urinary incontinence (SUI) is prevalent, Indian women tend to hide it and accept it very easily as a part of aging or consequences of delivery. They suffer in silence compromising their quality of life (QOL). They start avoiding attending social functions and gatherings. Even during household chores or during their working hours, they have to feel embarrassed because of leakage episodes. Compromised QOL affects women in many ways such as psychological and social. There is a strong need to work on these areas and prepare a protocol of exercise for such women so that their QOL can be improved.
AIM: The aim of the study was to evaluate the effect of pelvic floor muscle training (PFMT) based on the severity of incontinence on QOL in women with SUI.
METHODOLOGY: Seventy-three participants were recruited for an experimental study. Each participant was given 6 weeks of home-based PFMT based on the severity of incontinence which was decided by the Incontinence Severity Index. Pre- and post data were analyzed using SPSS 21.0. The outcome measure was the Incontinence Impact Questionnaire-Short Form score.
RESULTS: Wilcoxon test was used to compare the pre- and postdata for all the participants. Z = −6.86 with P < 0.001.
CONCLUSIONS: The home-based PFMT of 6 weeks given here was effective in improving QOL in female with SUI.
Keywords: Incontinence impact questionnaire-short form, pelvic floor muscle training, quality of life, stress urinary incontinence
|How to cite this article:|
Shah ZR, Rathod PV. Effect of home-based pelvic floor muscle training based on the severity of incontinence on quality of life in women with stress urinary incontinence. Physiother - J Indian Assoc Physiother 2020;14:80-3
|How to cite this URL:|
Shah ZR, Rathod PV. Effect of home-based pelvic floor muscle training based on the severity of incontinence on quality of life in women with stress urinary incontinence. Physiother - J Indian Assoc Physiother [serial online] 2020 [cited 2021 Sep 16];14:80-3. Available from: https://www.pjiap.org/text.asp?2020/14/2/80/305835
| Introduction|| |
Stress urinary incontinence (SUI) is the nonvolitional leakage of urine on effort or exertion, sneezing, coughing, or laughing. It is highly prevalent worldwide and also in India. According to most of the studies, the prevalence of urinary incontinence (UI) in women varies between 10% and 40%. In a survey done in Asia, the prevalence of UI in India was found to be 12%. A study done in Tamil Nadu in 2009 has estimated that among the 197 women surveyed, about 41 (20.8%) were found to have UI. Out of these 41 women, more than 50% had SUI.
UI influences females in social, physical, psychological, and sexual aspects. This adversely affects self-esteem and quality of life (QOL) of a female affected by it. Pelvic floor muscle training (PFMT) should be the first-line treatment for stress incontinence, as it has no serious adverse effects. However, the training needs proper instruction and close follow-up to be effective.
The women of our country are different than any other developed or developing country due to its cultural, economic, and religious scenario. It has been observed that though SUI is prevalent, Indian women tend to hide it and accept it very easily as a part of aging or consequences of delivery. They suffer in silence compromising their QOL. They start avoiding attending social functions and gatherings. Even during household chores or during their working hours, they have to feel embarrassed because of leakage episodes. Compromised QOL affects women in many ways such as psychological and social. There is a strong need to work on these areas and prepare a protocol of exercise for such women so that their QOL can be improved.
The aim of the study is to evaluate the effect of home-based PFMT based on the severity of incontinence on QOL in women with SUI. It has been hypothesized that home-based PFMT given in this study is effective in improving QOL in female with SUI. Procedure is described briefly in [Figure 1].
| Methodology|| |
This study is an experimental clinical trial which was conducted from January 2013 to December 2015. The data were collected from the department of obstetrics and gynecology of a tertiary care hospital and menopause health club of the city. The principal investigator has also conducted several awareness programs so that maximum participants can be enrolled from different parts of the city. The intervention was given for 6 weeks as a homebound program for one to three times in a day depending on the severity of incontinence.
The inclusion criteria were females with confirmed case of SUI and having slight, moderate, and severe incontinence as per the Incontinence Severity Index (ISI). The confirmation of the diagnosis was done by cough test. The primarily screened participants were made to perform cough test. The cough test was done with a full bladder. Participants were asked to cough in crook lying position, and urine leakage was observed. Leakage of urine while coughing indicates positive cough test. The exclusion criteria included prolapsed perineal organs, neurogenic bladder, pregnancy, acute urinary tract infection, and ISI score 0 (No incontinence) or 12 (very severe incontinence). The participants were divided into three groups depending on their severity of incontinence from their ISI score: slight, moderate, and severe.
The study has passed ethical clearance from the local ethics committee of college of physiotherapy in December 2012 (PTC/IEC/59/2012-13) under a broad titled study “Efficacy of Physiotherapy Management in Women with SUI.” The main trial has also been registered in the Clinical Trials Registry of India with reference no. CTRI/2016/12/007614.
The ISI scale is an ordinal scale which has two questions of the frequency of leakage and quantity of leakage. The principal investigator has translated the scale in Gujarati by the forward–backward–forward method. The score is calculated by multiplying two scores of two questions. The score ranges from 0 to 12, 0 meaning no incontinence and 12 meaning very severe incontinence. 1–2 score means slight, 3–4 means moderate, and 6–8 means severe incontinence. The scale has been validated by Sandvik et al., in 1993.,
The PFMT protocol depending on the severity is given as below:
- Five repetitions of general stretching and warm-up for the pelvic floor muscles and hip adductors (butterfly posture)
- Ten repetitions of voluntary pelvic floor muscle contraction with 5 s hold and 10 s rest, progress at 2 weeks to 10 s hold and 20 s rest
- Ten repetitions of isometrics of hip adductors and irradiation to the pelvic floor muscle with 5 s hold and 10 s rest, progress to 10 s hold and 20 s rest
- Five repetitions of transverse abdominis muscle contraction and pelvic floor muscle contraction simultaneously, 5 s hold and 10 s rest
- Cool down with slow stretching of the adductors and perineal muscles.
Along with this, few lifestyle modification advices were also given. They are as below:
- Educating women with severe (ISI = 6–8) incontinence to wear diapers
- Avoiding caffeine and excessive fluid intake
- Weight control exercises such as walking or jogging
- Asking them to go to void for every 2 h
- Ergonomic advices of lifting heavyweight (>5 kg), so that intraabdominal pressure does not increase much and thus avoiding instances of incontinence
- Performing PFMT whenever they find time, e.g., waiting at traffic signal.
The whole treatment was first given under supervision, and participants were explained properly. They were taught all exercises properly until they became independent in doing it. They were asked to carry the whole session at home depending on their ISI score. The participants who were slight incontinent (ISI = 1–2) were asked to perform one session a day, moderate incontinent (ISI = 3–4) two sessions a day, and severe incontinent (ISI = 6–8) three sessions a day. Pretreatment readings were taken at 1st day, whereas posttreatment readings were taken after 6 weeks.
Incontinence Impact Questionnaire (IIQ) is the most appropriate QOL questionnaire for SUI. IIQ-short form (SF) is a shortened version of IIQ and is strongly correlated (r = 0.97) with the long version. It shows a significant convergent validity with pad test and number of incontinence episodes. It is a simple and short questionnaire with seven questions related to activities of daily living (ADL), social participation, and emotions. The rating should be done from 0 to 3 ordinal scale (0 for “not at all,” 1 for “slightly,” 2 for “moderately,” and 3 for “greatly”). The average score of items responded to is calculated. The average, which ranges from 0 to 3, is multiplied by 33 1/3 to put scores on a scale of 0–100. Higher the score, more affected will be the QOL. The questionnaire was translated in mother tongue by the forward–backward–forward method and was verified by the HOD of the department of language.
| Results|| |
As all the data of this study are ordinal, nonparametric Wilcoxon test was applied to see the pre–post difference. SPSS 21.0 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) was used to analyze the data. P was kept at <0.05.
The subjects were divided into 3 groups based on their ISI score (Group 1– Slight, Group 2– Moderate and Group 3– Severe).
The above scattered [Graph 1] shows a positive correlation between ISI and IIQSF scores of all 73 participants. The Spearman's rho value for this correlation is 0.453 and P < 0.0001 showing a highly significant moderate positive correlation between ISI and IIQSF scores.
| Discussion|| |
The demographic details are given in [Table 1]. The mean of IIQSF before treatment was 27.3 and after treatment was 10.8 [Table 2]. This outcome totally depends on patient's perception about QOL. Many participants with more number of leakages had no QOL compromise as they somehow managed to do all ADLs and social activities. The emotional status was also quite stable of all participants as in Indian cultural setup; most of the females have accepted UI as part of their life. They think it is age-related problem and do not bother. This only made them silent, and they feel no problem at all. That is why with median leakage of 3 per week, the IIQSF score is only 27.3 pretreatment, which shows mild affection in QOL.
Cavkaytar et al. reported similar results after 2 months of home-based unsupervised Kegel exercises. Their exercise regimen included ten sets of contractions each day and every set included ten repetitions. Urinary Distress Inventory-6 (UDI-6) and IIQ-7 were used to determine the effects produced by Kegel exercises on the QOL of females having SUI. Kegel exercises caused a significant decline in IIQ-7 and UDI-6 scores in both SUI and mixed UI groups.
The improvement in the IIQSF score can be due to the decrease in frequency of micturition and leakage episodes and increase in pelvic floor muscles (PFM) performance. This was proven in other objectives of the broad study of “Efficacy of Physiotherapy Management in women with SUI.” The lifestyle modification advices have played a major role by educating women about timed voiding and ergonomic advices. They were also taught to wear diapers while going out.
UI causes affection of the patients' psychological, social, and physical domains, and its severity has an important role. There is a statistically significant moderate positive correlation between ISI and IIQSF scores (r = 0.453, P < 0.0001). This suggests that as the severity increases the QOL decreases. Higher score of ISI suggests higher severity, and higher score of IIQSF suggests worsened QOL. This correlation was done for all 73 participants.
There is no statistically significant difference found between all three groups of severity [Table 3]. The 95% confidence interval was 4.39–7.6 showing statistically significant difference pre- and posttreatment. The effect size was 15.23, may be because the three groups were unequal in number of participants, and there were only four participants in the most severe group.
|Table 3: Comparison between different severity groups for pretreatment-posttreatment difference|
Click here to view
There are certain limitations of the study. No intervention was given to reduce the intraabdominal pressure. Jogging was advised to reduce weight without checking their physical activity level which could have caused leakage episodes. Confirmation of SUI was made only clinically by cough test, and the urodynamic study was not performed due to financial issues. The compliance was not checked, and exercise adherence was not done with objective measurement. The number of participants in three different groups was unequal.
| Conclusions|| |
The home-based PFMT of 6 weeks given here was effective in improving QOL in females with SUI. This would help the physiotherapist to plan the severity-based protocol for women with SUI which they can be performed effectively at home. Improved QOL will overall help in improving the confidence level of the women with SUI and will reduce the participation restriction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]