|Year : 2021 | Volume
| Issue : 2 | Page : 102-106
Effect of core and pelvic floor muscle exercise on symptom severity and quality of life in women with stress urinary incontinence
Seemab Khan, Ronika Agrawal, Ayesha Syed
Department of Community Physiotherapy, M A Rangoonwala College of Physiotherapy, Pune, Maharashtra, India
|Date of Submission||27-May-2021|
|Date of Decision||28-Oct-2021|
|Date of Acceptance||05-Dec-2021|
|Date of Web Publication||12-Jan-2022|
Dr. Seemab Khan
M A Rangoonwala College of Physiotherapy, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Stress urinary incontinence (SUI) has been associated with a negative impact on quality of life in women which needs to be addressed. The commonly followed treatment includes only pelvic floor muscle (PFM) exercises with lack of importance given to the abdominal muscle strengthening.
Aims: The aim of the study is to find the combined effects of core muscle and pelvic floor exercises on SUI in women.
Study Setting and Design: This study was a single-group pre–post study design with females having SUI from communities of Pune city, India.
Subjects and Methods: Sixty females between 30 and 45 years of age experiencing SUI were recruited for the study. PFM exercises along with core muscle exercises were given as intervention for 5 days/week for 6 weeks. Outcome measures used were Revised Urinary Incontinence Scale (RUIS) and Urogenital Distress Inventory-6 (UDI-6), which were taken before and on completion of 6 weeks of intervention.
Statistical Analysis: Student's t-test was used to study the pre- and postintervention difference in the parameters.
Results: Significant improvement was noted in the symptoms of SUI as the value of the RUIS reduced from 7.75 ± 2.419 to 3.90 ± 1.100 (P = 0.0015). The quality of life as assessed by UDI-6 also improved significantly after exercise intervention with P = 0.0010.
Conclusion: The study showed a significant reduction in symptom severity of urinary incontinence and improvement in quality of life in females suffering from SUI.
Keywords: Abdominal muscles, Females, Pelvic floor muscles, Quality of life, Stress urinary incontinence
|How to cite this article:|
Khan S, Agrawal R, Syed A. Effect of core and pelvic floor muscle exercise on symptom severity and quality of life in women with stress urinary incontinence. Indian J Phys Ther Res 2021;3:102-6
|How to cite this URL:|
Khan S, Agrawal R, Syed A. Effect of core and pelvic floor muscle exercise on symptom severity and quality of life in women with stress urinary incontinence. Indian J Phys Ther Res [serial online] 2021 [cited 2022 Jun 30];3:102-6. Available from: https://www.ijptr.org/text.asp?2021/3/2/102/335665
| Introduction|| |
Stress urinary incontinence (SUI) is a condition in which there is involuntary loss of urine on activities which includes sneezing or coughing. In SUI, there is an association between physical exertion and urinary loss. Increased abdominal pressure triggered by physical exertion leads to increased intravesical pressure and exceeded intraurethral pressure. If these occur with absent or weak detrusor muscle, it causes urinary incontinence. The primary risk factors causing urinary incontinence are higher body mass index (BMI) of >22 kg/m2, type 2 diabetes, hysterectomy, parity, oral contraceptive use, smoking, etc.
Pelvic floor muscles (PFMs) provide support to the various pelvic organs. Their contraction is associated with tightening of sphincter and opening of vagina, anus, and urethra. Relaxation of these muscles causes passage of urine. PFM weakness is associated with reduced support to these organs causing incontinence. Deep abdominal muscle contraction will make the PFM co-contract, and coordinated action of pelvic floor and deep abdominals is more effective than specific strength training of the PFMs to enhance continence.
There are various advantages of PFM training like women intentionally learn to contract the PFM before and during exertional activities to prevent incontinence. The pelvic floor exercises help in bracing the pelvic floor which in turn improves and maintains the strength and endurance of these muscles., The transverse abdominal muscle and PFM co-contraction exercise intervention increases the thickness of the transverse abdominal and hence may be recommended to improve SUI in middle-aged women. PFM training promotes appropriately timed conscious PFM contractions which increase urethral pressure, improve support of the bladder neck, and prevent the urine leakage.
Urinary incontinence has an adverse effect on quality of life. It is not really a disease, but rather a symptom which has a physical and psychological effect on the patients, as it reduces self-confidence due to disability to control the bladder. It is an obstacle in maintaining good physical and social well-being and general fitness of the individual. It is also conceived as an ill-health which generates feeling of incense, distress, botheration, and depression.
As there has been a social stigma and privacy concerns related to urinary incontinence, many women do not seek treatment. It is important not only to educate women about the problem but also to encourage them to seek treatment and indicate that it is a treatable condition. As the core and pelvic floor exercises are easy to learn, they can be performed without the supervision of the therapist once learnt well. They don't require any special equipment and can be performed at any convenient time in either sitting or lying positions.
The commonly followed physiotherapy management includes only PFM exercises with lack of importance given to the strengthening of abdominal muscles. On comparison of isolated pelvic floor training, with a combined effect of pelvic floor and abdominal muscle training, the latter showed more improvement. Thus, the purpose of the study was to find the effects of core muscle exercise and pelvic floor exercise on severity of SUI and quality of life in women.
| Subjects and Methods|| |
The study was initiated after taking approval from the Institutional Ethics Committee. The study design of the trial was a single-group pre–post study which started with the recruitment of subjects who met the inclusion criteria from various outpatient departments and communities of Pune city, India.
The prevalence of SUI among young females was found to be around 35%, and confidence level was kept at 95% (P < 0.05). Thus, the calculated sample size required to include in the study was 34.9, which is a minimum number of subjects required to be included in the study, as a large number of dropouts were expected due to the social stigma of the condition. No dropouts were seen, thus 60 women were included between 30 and 45 years of age, experiencing self-reported urinary incontinence, with scores of 1–3 on questionnaire for female urinary incontinence diagnosis and those who were able to read and understand English, as this is a self-administered scale. Women suffering from urogenital dysfunction like cystocele, fistula in the bladder, pelvic cancer, and any recent abdominal, back, and pelvic surgery were excluded.
Written consent was taken and explanation about exercise program was given to all the participants, and all their doubts related to procedure and questionnaires were clarified. At preintervention, every participant was asked to fill two questionnaires, namely Revised Urinary Incontinence Scale (RUIS) and Urogenital Distress Inventory-6 (UDI-6). The RUIS is a short, valid five-item scale that can be used to assess urinary incontinence and to monitor patient outcomes following treatment. This instrument has good psychometric properties and can be considered by clinicians, researchers, and epidemiologists. The UDI-6 is a simple tool designed to assess the quality of life of individuals having urinary incontinence. Subjects were instructed to do PFM exercises and core muscle contractions in the stepwise manner as explained below:
- Step 1: Subjects were asked to be in a crook lying position with a pillow under the head. Relaxed breathing was given for 1 min, inhaling through the nose while exhaling through mouth
- Step 2: A biofeedback stabilizer cuff was placed under the lumbar spine. The cuff was inflated up to 40 mmHg. Maximal contraction of the transverse abdominal muscle was given by asking the subject to draw in the navel or lower abdomen toward the spine while breathing normally. The subjects were asked to breathe normally and maintain the baseline at 40 mmHg while maintaining the contraction for 10 s. If the pressure of the biofeedback stabilizer decreased during exercise, verbal feedback was given
- Step 3: PFM contraction was given by asking the subjects to tighten the muscles around the vagina and to lift them upward so as to hold the passage of urine
- Step 4: Coordinated contraction of both the transverse abdominal and PFMs was given by drawing in the lower abdomen and holding it followed by PFM contraction. Adequate rest period was given in between the steps.
This exercise protocol was given 5 days per week for 6 weeks. Dosage and progression of exercises was as follows: 1 set of 10 repetitions in 1st and 2nd weeks; 2 sets of 10 repetitions during 3rd and 4th weeks and 3 sets of 10 repetitions during 5th and 6th weeks.
The statistical software IBM SPSS statistics 20.0 (IBM Corporation, Armonk, NY, USA) was used for the analysis. Descriptive and interferential statistical analyses were carried out in the present study. Results on continuous measurement were presented on mean ± standard deviation (SD). p value < or = 0.05 was considered as statistically significant. Student's t-test was used to find the pre- and postintervention difference in outcome parameters.
| Results|| |
The mean age of the participants was 38.18 ± 0.040 years. Out of 60 subjects, 16 were between 31 and 35 years, 25 were between 36 and 40 years, and 19 females were 41–45 years old. The mean BMI of the participants was 29.6 ± 4.859 kg/m2, with 12 women having 23–24.9 kg/m2, 21 of them within the range of 25–29.9 kg/m2, and 27 females over 30 kg/m2.
[Table 1] shows the comparison of the RUIS and UDI-6 score values in terms of mean and SD before and after exercise using paired t-test. It was observed that mean values of RUIS score reduced significantly from 7.75 ± 2.419 to 3.90 ± 1.100 after the 6 weeks of intervention with P = 0.0015, while for UDI-6, the values change from 31.871 ± 10.542 to 17.149 ± 6.141 showing a significant improvement in quality of life of the female participants with P = 0.0015.
|Table 1: The Urogenital Distress Inventory and Revised Urinary Incontinence scores before and after intervention|
Click here to view
| Discussion|| |
The results of the study showed that after 6 weeks of intervention, the participants showed a reduction in severity of the stress incontinence as there was a decrease in the value of RUIS and UDI-6 scale for SUI. This indicates a reduction in the severity of symptoms and improved quality of life with the women suffering from SUI.
Pelvic floor exercises were reported almost 50 years ago which helped in improving strength, endurance, and reflex action of the pelvic muscles via recruitment as per Henneman's size principle. Strength training of pelvic floor shows many advantages like enhancing the total number of activated and impressive motor units and muscular hypertrophy. Pelvic floor exercises increase muscular strength and endurance and increase the reflex action of these muscles through fast-twitch fiber recruitment. Physiologically, pelvic floor exercises help in stimulation of fast-twitch fibers, and transition of the predominant type 1 fibers into type 2. Another study describing various treatment options for SUI believed that there is a relationship difference in various measures, such as increased strength of anal sphincter, increase in power of urethral pressure, and resistance closure, which helps to reduce incontinence. The effects of coordinated action of core and PFM exercise on SUI were investigated in a similar study which found that there is hypertrophy of muscles along with reduction in symptoms.
There are various proposed theories to explain the effectiveness of PFM training for SUI. Women learn to consciously precontract the PFMs before and during increase in abdominal pressure such as coughing and other physical activities for preventing incontinence. Strength training also helps in causing the hypertrophy of these muscles and improves the structural support.
It has also been postulated that there is an indirect effect of abdominal muscle training on pelvic floor strength. During inhalation, the diaphragm moves downward and there is anterior motion of abdominal wall. While in expiration, upward movement of diaphragm causes the posterior motion of abdominal wall, leading to increase in anteroposterior diameter of abdominal cavity which causes stretch on the abdominal muscles, leading to strong contraction of these muscles. During various functional tasks such as coughing, sneezing, lifting, nose blowing, and laughing, the coordinated recruitment of pelvic floor and abdominal muscles is seen leading to increase intra-abdominal. Pressure as this gives a feeling of urge to void. During these activities, the same recruitment pattern of pelvic floor, diaphragm, and abdominals is seen but with the difference in strength and power.
Combined exercises of pelvic floor and abdominal muscle significantly increase PFM strength, as proven by perineometer. There are certain neural and structural adaptations associated with increased PFM strength. There is also an increase in number and frequency of activation of motor units leading to increased volume and number of myofibrils causing hypertrophy.
Similarly, the results of another study also indicate that the transversus abdominis and the obliquus internus were recruited during all PFM contractions, which was helpful in reducing the symptoms of incontinence. Increase in the intra-abdominal pressure and supporting the pelvic organs can be coordinated with the theory that all the muscles around the abdominal cavity work together causing co-activation of the abdominal and PFMs. The authors also reported the co-activation of these muscles during lifting, coughing, and forced expiratory efforts, and also during the voluntary isometric contraction.
Modulation of increased intra-abdominal pressure is done by the increase in strength of contraction of various trunk muscles including diaphragm and generation of tension in thoracolumbar fascia. The effect of transverse abdominis training in treatment of urinary incontinence occurs via submaximal co-contraction of the PFMs during transverse abdominis contraction. Contraction of the core muscles may provide an efficient mechanism through which to initiate and train the contraction of the PFMs, particularly for patients who have difficulty in learning to contract the PFMs.
Quality of life is a significant predictor of health-seeking behavior among women with urinary incontinence. Improvement in quality of life of patients was reported after giving PFM training as it reduces the symptoms. Similar results were found by another author who concluded that PFM training has a major contribution in reducing the symptoms of urinary incontinence and also significantly improves physical, mental, and social functioning leading to improvement in the quality of life of the individual.
As the symptoms of incontinence reduce, there is a change in lifestyle of women that reduces social isolation and alienation, which helps in reducing the discomfort, mood deterioration and feeling of helplessness, changes in sexual activity, and even depression or anxiety disorder, having the positive effect on quality of their personal, social, and professional life. In addition to the improvement in described somatic symptoms, problems related to urinary iodine excretion which has a psychological impact are also reduced, thus improving patient's quality of life.
Thus, the findings of this study indicate that exercises of the abdominal muscles are beneficial in maintaining PFM coordination, support, endurance, and strength.
The study had few limitations. The strength of abdominal and PFMs was not quantified, however, improved quality of life and reduced symptom severity are indirectly associated with the strength. Only subjects who could comprehend English were included in the study. Further research with the larger sample size and addition of control group will be helpful to determine the effectiveness of the intervention in better way.
| Conclusion|| |
The study concludes that core and PFM exercise for a period of 6 weeks is effective in reducing the symptom severity and improving quality of life in females suffering from SUI. These exercises can be of benefit in the rehabilitation of females having symptoms of SUI.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Oliveira M, Ferreira M, Azevedo MJ, Firmino-Machado J, Santos PC. Pelvic floor muscle training protocol for stress urinary incontinence in women: A systematic review. Rev Assoc Med Bras (1992) 2017;63:642-50.
Danforth KN, Townsend MK, Lifford K, Curhan GC, Resnick NM, Grodstein F. Risk factors for urinary incontinence among middle-aged women. Am J Obstet Gynecol 2006;194:339-45.
Bø K. Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Med 2004;34:451-64.
Bø K, Herbert RD. There is not yet strong evidence that exercise regimens other than pelvic floor muscle training can reduce stress urinary incontinence in women: A systematic review. J Physiother 2013;59:159-68.
Jóźwik M, Jóźwik M. The physiological basis of pelvic floor exercises in the treatment of stress urinary incontinence. Br J Obstet Gynaecol 1998;105:1046-51.
Tajiri K, Huo M, Maruyama H. Effects of co-contraction of both transverse abdominal muscle and pelvic floor muscle exercises for stress urinary incontinence: A randomized controlled trial. J Phys Ther Sci 2014;26:1161-3.
Trantafylidis SC. Impact of urinary incontinence on quality of life. Pelviperineology 2009;28:51-3.
Luber KM. The definition, prevalence, and risk factors for stress urinary incontinence. Rev Urol 2004;6 Suppl 3:S3-9.
Bradley CS, Rovner ES, Morgan MA, Berlin M, Novi JM, Shea JA, et al.
A new questionnaire for urinary incontinence diagnosis in women: Development and testing. Am J Obstet Gynecol 2005;192:66-73.
Sansoni J, Hawthorne G, Fleming G, Owen E, Marosszeky N. Technical Manual and Instructions: Revised Incontinence and Patient Satisfaction Tools. New South Wales, Australia: Centre for Health Service Development, University of Wollongong; 2011.
Reuven Y, Yohay Z, Glinter H, Yohai D, Weintraub AY. Validation of the Hebrew version of the short form of the urogenital distress inventory (UDI-6). Int Urogynecol J 2017;28:1891-4.
Enoka RM, Stuart DG. Henneman's 'size principle': Current issues. Trends Neurosci 1984;7:226-8.
Menachem A, Alexander B, Martinec KS, Gutman G. The effect of vaginal CO2 laser treatment on stress urinary incontinence symptoms. Alma Surg 2016.
Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther 2004;9:3-12.
Neumann P, Gill V. Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:125-32.
Sapsford RR, Hodges PW. Contraction of the pelvic floor muscles during abdominal maneuvers. Arch Phys Med Rehabil 2001;82:1081-8.
Bø K, Mørkved S, Frawley H, Sherburn M. Evidence for benefit of transversus abdominis training alone or in combination with pelvic floor muscle training to treat female urinary incontinence: A systematic review. Neurourol Urodyn 2009;28:368-73.
Donahoe-Fillmore B, Chorny W, Brahler CJ, Ingley A, Kennedy J, Osterfeld V. A Comparison of Two Pelvic Floor Muscle Training Programs in Females with Stress Urinary Incontinence: A Pilot Study. Journal of Applied Research. 2011;11.
Radzimińska A, Strączyńska A, Weber-Rajek M, Styczyńska H, Strojek K, Piekorz Z. The impact of pelvic floor muscle training on the quality of life of women with urinary incontinence: A systematic literature review. Clin Interv Aging 2018;13:957-65.