The Effects of Pelvic Floor and Abdominal Muscle Training in Urinary Incontinence According to Severity

doi:10.21203/rs.3.rs-2729530/v1

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Research Article

The Effects of Pelvic Floor and Abdominal Muscle Training in Urinary Incontinence According to Severity

https://doi.org/10.21203/rs.3.rs-2729530/v1

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The aim of this study is to investigate the effect of incontinence severity on pelvic floor and abdominal muscle strengthening training in women with stress urinary incontinence (UI).

Sixteen patients with stress and mixed UI were included in the study. According to 24-hour pad test (24hPT), individuals were divided into two groups as group 1 (24hPT 4-20gr, mild group, n: 9) and group 2 (21g and above in 24hPT, moderate-severe group, n: 7). Pelvic Floor Muscle Training (PFMT) and Abdominal Muscle Training were applied to the groups for 6 weeks. Urinary incontinence, pelvic floor muscle strength measurement, quality of life, symptom, and the presence of pelvic floor dysfunction (PFD) were evaluated respectively using 24hPT, Electromyography (EMG) Biofeedback device, King’s Health Questionnaire (KHQ), Urogenital Distress Inventory (UDI-6), and Global Pelvic Floor Bother Questionnaire (GPFBQ). Evaluations were performed at the beginning and at the end of the physiotherapy program, and subjective improvement rate was determined.

After treatment, 24hPT values decreased in groups, but this decrease was only significant in group 2 (p < 0.05). The results obtained from this study showed that there was no difference between mild and moderate-severe groups in terms of having benefit from strengthening training to the pelvic floor and abdominal muscles.

It was proved that, an increase in pelvic floor muscle strength, and quality of life, a decrease in UI symptoms and PFD might be achieved with physiotherapy application regardless of the severity of UI, and improvements in subjective recovery rate were provided. NCT05549193, 22/09/2022, retrospectively registered

Rectus abdominus

Pelvic floor muscle training

Stress urinary incontinence

Quality of life

Biofeedback

Home exercise

According to the definition of the International Continence Association, urinary incontinence (UI) is an involuntary urine leakage that can cause social and hygienic problems which can be shown objectively. It is an important symptom of lower urinary tract (LUT) dysfunction [1].

Drug treatments, surgery and conservative treatment methods are used in the treatment of UI [2]. One of the conservative treatment options, within the scope of physiotherapy applications, pelvic floor muscle training (PFMT) is used alone or with other physiotherapy methods such as vaginal cones, biofeedback, electrical stimulation, etc. [3]. PFMT is the most widely recommended and applied physiotherapy approach and has A level evidence [4]. The purpose of PFMT is to improve the strength, endurance, and the coordination of the Pelvic Floor Muscles (PFM) and to increase the support of the proximal urethra and bladder neck [5]. The studies aimed to reduce the symptoms of UI and increase the effectiveness of the treatment by using PFMT with other physiotherapy approaches [6]. One of these approaches is exercise training especially synergist of PFM like abdominal muscles [7]. Studies combining PFMT with abdominal exercises have shown that it can reduce symptoms and improve quality of life (QoL) on stress UI (SUI) and mixed UI (MUI). [6, 8].

Strengthening the abdominal muscles can also strengthen the PFM due to the principle of force spreading [9]. Additionally, PFM cannot reach the optimum level of strength without combining the abdominal wall muscle training [10]. These results reveal that rehabilitating both deep abdominal muscles and PFM may be beneficial in women with UI [5]. However, studies have not reported the effect of combined exercises consisting of abdominal and PFMT on the severity of UI. Therefore, the aim of our study was to examine the effects of pelvic floor and abdominal muscle training on PFM activation, abdominal muscle strength, QoL, and the presence and severity of pelvic floor symptoms, according to the severity of UI in women with SUI and MUI.

Study design and participants

This was a single-center study consisting of two groups — mild UI, and moderate-severe UI—involving 16 women diagnosed with SUI or stress-predominant MUI. Participants were regular patients at the university outpatient urology clinic recruited and monitored by urologists and physiotherapists. The study was approved by the Ethics Committee (no: 24074710-604.01.01–44). All participants were informed about the study and signed the written consent form.

Patients presented with UI and referred for physiotherapy were included. Inclusion criteria were being female, over 18 years of age, having been diagnosed of SUI and stress-predominant MUI after urodynamic evaluation by the urologist. Exclusion criteria were currently taking medications for UI, having urinary tract infection, neurological disorders, pelvic organ prolapse (POP) stage > 2, pregnancy, a mental problem and/or been applied prior physiotherapy for UI.

Age, weight, and height were reported and Body Mass Index (BMI) was calculated (kg/m²) [11].

After clinical evaluation, patients were divided into 2 groups according to their incontinence severity as mild (group 1) and moderate-severe (group 2). The treatment program consisted of strengthening the abdominal muscles and PFMT and was applied to all groups.

Pelvic Floor Muscle Training

Pelvic floor muscle training was given as a home-based exercise program to increase PFM strength and endurance. Before starting the program, PFM was taught first schematically and then by biofeedback method. It was ensured that the patient learned the PFM. Fast and slow pelvic floor contractions were taught for both type 1 and type 2 muscle fibers. For slow contractions, it was asked to gradually contract in 5 seconds, wait at a maximum of 5 seconds and gradually relax in 5 seconds. For fast contractions, it was asked to contract at a maximum of 2 seconds and then to relax. Patients were asked to perform 10 slow contractions after every 10 rapid contractions. 10 fast + 10 slow contractions were accepted as 1 set exercise [12]. Subjects were asked to make 10 sets every day [13] for 6 weeks [12, 14].

Abdominal Muscle Training

Strengthening exercises for transversus abdominus (TrA) and internal obliques abdominus muscles were given as a home program and the details were written below:

Transversus Abdominus

Patients were in the crook lying position and were asked to contract their abdominal muscles strongly and statically. Fifteen repetitions were carried out; each one consisting of contraction for 10 s followed by relaxation for 20 s. After 15 repetitions, patients rested for 5 min. The sequence was then repeated for two sets of 15 repetitions [8].

Internal Obliquus Abdominus

Patients were in the crook lying position and were asked to contract their abdominal muscles strongly and statically and then try to touch the furthest point of their legs with their fingertips for 15 repetitions consisting of contraction for 10 s followed by a relaxation for 20 s. After 15 repetitions, patients rested for 5 min. The sequence was then repeated on the other leg [8].

Outcome Measure

Primary Outcome

Urinary Incontinence Severity

24-hour pad test was used to assess and standardize the severity of UI. The patients were informed before the test. The patients were told to change their pads every 4–6 hours and put the pads in an airtight locked bag to prevent the urine from evaporating. Since the pads should be weighed immediately after the evaluation, they were asked to do the test 1 day before the evaluation. Pads that were used for 24 hours were requested in a mouth-locked bag. 1 unused pad of the same type was requested. Urinary incontinence was determined by measuring the weight of the pad with precision scales (Isolab Laborgerate GMBH, Germany) before and after 24 hours. As a result of 24-hour pad test, 4–20 g was defined as mild, 21-74g as moderate, and > 75 g as severe UI [15].

Secondary Outcome

Evaluations were made at the beginning and at the end.

Pelvic Floor Muscle Activity

Muscle activity in electromyography was evaluated by EMG Biofeedback program of MMS brand Uro Solar Model urodynamics device (Medical Measurement Systems b.v. Netherlands). Superficial electrodes were used for the measurement. Electrodes were non-invasively measured by adhering 2 pieces to the right and left of the perineal body and 1 to the inner leg. EMG values were recorded. Evaluations were made with the patient in the lithotomy position. During the measurement, it was warned that the PFM should contract for 10 seconds and during contractions they should not contract the abdominal, hip and thigh muscles and hold their breath. For correct contraction, patients were asked to breath normally and then to squeeze and lift the pelvic floor as if preventing the escape of urine or flatus [16].

Abdominal Muscles Strength

Manual muscle test was used to evaluate abdominal muscle strength. It was started with the value 3, and patients that can make the value of 3 were examined with 3+, 4, and 5 values of the muscle. If the patients cannot make 3, 2, 1, and 0 values were examined [17]. All tests were performed the same physiotherapist according to standartised protocol.

Quality of life and symptom severity

King’s Health Questionnaire (KHQ) is a valid and reliable questionnaire used to assess the QoL specific to UI. It consists of two parts and 32 items [18]. Turkish version of the KHQ conducted by Kaya et al. was used [19]. UDI-short form was used to evaluate symptom severity score. It consisted of 6 questions and each question was scored between 0–3 points. If the scoring is high, the QoL is low [20]. Turkish version, which validity and reliability studies were performed by Cam et al was used [21]. Turkish version of Global Pelvic Floor Bother Questionnaire (GPFBQ) by Dogan et al [22] was used to determine how much PFD exists. The questionnaire consists of 9 questions, and if the scoring is high, the complaint is high [23]. To analyze the effects of UI in QoL three different measurement tool were used to evaluate in detail.

Treatment adherence

At the beginning of the treatment, an exercise follow-up form was given, and the patients were asked to mark it regularly. In the final evaluation, follow-up forms were obtained from the patients. During the treatment, the patients were followed up every week by phone. The compliance and continuity of the patients were followed closely. Patients who missed more than 2 treatments were excluded from the study.

Statistical Analyses

SPSS 14.01 package program was used. Descriptive statistics of quantitative (numerical) variables according to UI severity groups and frequency table of qualitative variables were created. Before starting the materiality tests, muscle activation and strength were examined with the Shapiro Wilk test for the normality of the variables of KHQ, UDI6, GPFBQ and subgroups, and the Levene test for the homogeneity of the variances. The t-test was used to evaluate the parameters (age, body weight, height, and BMI) that conform to the parametric test assumptions according to the UI severity groups, and the Mann Whitney U test was used to evaluate the non-compliant parameters (onset of the complaint, urination frequency, and parity). Numerical variables with normal distribution were shown as “Arithmetic mean ± Standard deviation”, and nominal and ordinal variables without normal distribution were shown as “median (minimum - maximum)”. The parameters were displayed as "Arithmetic mean ± Standard error". Two-way mixed ANOVA was used to analyze the variables evaluated before and after the treatment. Bonferroni-corrected simple effect analysis was used for the variables where the term interaction was significant. All statistical analyzes were evaluated according to p < 0.05 with minimum 5% margin of error.

G*Power Version 3.1.9.2 program was used to calculate the sample size. The type 1 error probability was calculated as a minimum of 16 patients using the criteria (a) = 0.05, power (1-b) = 0.80, and effect size = 0.38 in the study design, in which the differences of the relevant variables in different groups and sampling times were evaluated. In addition, as a result of the study, the power calculated according to the two-way mixed ANOVA test was found to be 81%.

Fifty women out of 61 meeting the criteria of inclusion were scanned. After a comprehensive evaluation, participants were divided into two groups according to their intensity of UI as mild UI (group 1, n:30, 60%), moderate and severe UI (group 2, n:20, 40%) (Fig. 1).

Insert Fig. 1 here please.

PFMT and abdominal muscle strength training were applied to both groups. 16 women (mean age 48,88 ± 12,80 years, BMI 30,79 ± 5,18 kg / m², average UI duration 8,09 ± 7,05 years) completed this study. In the remaining participants, there was no demographic difference between the groups (p > 0,05) (Table 1).

Table 1

Distribution of information about individuals by groups.
	Group 1 (Mild) (n:9)	Group 2 ( (Moderate-Severe) (n:7)	p
Age (years)	49,33 ± 10,58	47,57 ± 16,75	0,80
Body weight (kg)	75,78 ± 9,64	80,71 ± 10,83	0,35
Height (cm)	161,00 ± 9,17	157,71 ± 5,53	0,41
BMI (kg/m²)	29,44 ± 4,72	32,76 ± 5,84	0,22
Duration of UI (years)	7 (0,5–25)	5 (1–20)	0,83
Parity (n)	2 (1–5)	4 (0–8)	0,08
Urinary frequency	10 (5–15)	8 (5–15)	0,52
Kg: Kilogram, cm: Centimeter, BMI: Body Mass Index, m: Meter *<0,05

Insert Table 1 here please

Urinary Incontinence Severity

According to the results of the analysis, in the 24-hour Pad Test, the groups had significantly different values before and after the treatment. In the in-group comparison, the decrease in both groups was found to be significant. It was determined that the groups benefited differently from each other. In the comparison of the groups after the treatment, it was determined that the decrease obtained in the group with moderate-severe UI was higher (p < 0,05) (Table 2).

Table 2

Outcome variables in participants allocated to either mild UI or moderate-severe UI.
Parameter	Group	Time		P
Parameter	Group	Before Treatment	After Treatment	Group	Time	G*T
Pad Test	Mild	6,633 ± 16,156^B	3,233 ± 14,085^B	0,011	0,001	0,005
Pad Test	Moderate-Severe	86,914 ± 18,319^{a, A}	54,643 ± 15,971^{b, A}	0,011	0,001	0,005
General Average		46,774 ± 12,213	28,938 ± 10,647
PF Muscle Test	Mild	28,998 ± 5,820	40,812 ± 5,653	0,496	< 0,001	0,711
PF Muscle Test	Moderate-Severe	35,703 ± 6,599	45,809 ± 6,410	0,496	< 0,001	0,711
General Average		32,350 ± 4,399^b	43,310 ± 4,273^a
M. Abdominalis Upper Part	Mild	3,556 ± 0,269	3,889 ± 0,204	0,668	< 0,001	0,301
M. Abdominalis Upper Part	Moderate-Severe	3,286 ± 0,306	3,857 ± 0,231	0,668	< 0,001	0,301
General Average		3,421 ± 0,204^b	3,873 ± 0,154^a
M. Abdominalis Lower Part	Mild	3,722 ± 0,226	4,056 ± 0,254	0,630	0,009	0,245
M. Abdominalis Lower Part	Moderate-Severe	3,643 ± 0,256	3,786 ± 0,288	0,630	0,009	0,245
General Average		3,683 ± 0,171^b	3,921 ± 0,192^a
M. Obliquus Abdominalis Right Part	Mild	3,611 ± 0,197	3,889 ± 0,215	0,642	0,010	0,705
M. Obliquus Abdominalis Right Part	Moderate-Severe	3,500 ± 0,223	3,714 ± 0,244	0,642	0,010	0,705
General Average		3,556 ± 0,149^b	3,802 ± 0,162^a
M. Obliquus Abdominalis Left Part	Mild	3,667 ± 0,227	3,833 ± 0,234	0,755	0,030	0,535
M. Obliquus Abdominalis Left Part	Moderate-Severe	3,500 ± 0,258	3,786 ± 0,266	0,755	0,030	0,535
General Average		3,583 ± 0,172^b	3,810 ± 0,177^a
UDI-6	Mild	9,111 ± 1,190	5,667 ± 0,999	0,572	0,001	0,637
UDI-6	Moderate-Severe	8,714 ± 1,349	4,429 ± 1,133	0,572	0,001	0,637
General Average		8,913 ± 0,899^a	5,048 ± 0,755^b
GPFBQ	Mild	15,333 ± 3,248	8,889 ± 1,985	0,962	< 0,001	0,996
GPFBQ	Moderate-Severe	15,143 ± 3,682	8,714 ± 2,250	0,962	< 0,001	0,996
General Average		15,238 ± 2,455 ^a	8,802 ± 1,500 ^b
^#p < 0,05, a,b: Different letters on the same line represent a significant difference within the group. (p < 0,05), A,B: Different letters in the same column represent a significant difference between the groups. (p < 0,05), Group: Between the groups, G*T: Group cross Time, g: gram, Repeated measurements ANOVA. PF: Pelvic Floor, M: Musculus, UDI-6: Urogenital Distress Inventory-6, GPFBQ: Global Pelvic Floor Bother Questionnaire

Pelvic Floor Muscle Activation

For EMG-Biofeedback results, group timestamp interaction was not significant (p > 0.05), only time interaction was significant. It was determined that activation of PFM increased significantly after the treatment in both groups (p < 0.05) (Table 2).

Abdominal Muscle Test

In all measured abdominal muscles, muscle strength increased significantly after treatment in both groups (p < 0.05), and the difference in muscle strength was not significant between the groups (p > 0.05) (Table 2).

Pelvic Floor Dysfunction

According to GPFBQ, it was seen that there was no difference between the groups before and after the treatment (p > 0.05), and the scores after the treatment decreased significantly in both groups within the group (p < 0.05), (Table 2).

Insert Table 2 here please

Symptom Distress and QOL Scores

In UDI-6, it was observed that there was no difference before and after the treatment between the groups(p > 0.05) and the scores after the treatment decreased significantly in both groups within the group (p < 0.05), (Table 2). There was no difference between the groups except for the incontinence effect of KHQ, social limitations and severity measurements parameters (p > 0.05). Increased QoL was observed in all groups (Table 3).

Table 3

King Health Questionnaire results of the participants divided into mild and moderate-severe groups.
Parameter	Group	Time		p
Parameter	Group	Before Treatment	After Treatment	Group	Time	G*T
General Health Perception	Mild	41,667 ± 4,908	33,333 ± 5,455	0,752	0,018*	0,258
General Health Perception	Moderate-Severe	46,429 ± 5,566	25,000 ± 6,186	0,752	0,018*	0,258
General Average		44,048 ± 3,710^a	29,167 ± 4,124^b
Incontinence Impact	Mild	74,070 ± 7,849	62,958 ± 7,118^A	0,073	0,002*	0,032*
Incontinence Impact	Moderate-Severe	76,187 ± 8,899^a	28,569 ± 8,071^{b, B}	0,073	0,002*	0,032*
General Average		75,129 ± 5,933	45,763 ± 5,381
Role Limitations	Mild	42,589 ± 10,492	27,773 ± 8,584	0,814	0,021*	0,641
Role Limitations	Moderate-Severe	42,854 ± 11,897	21,426 ± 9,733	0,814	0,021*	0,641
General Average		42,722 ± 7,931^a	24,600 ± 6,489^b
Physical Limitations	Mild	49,998 ± 12,218	29,627 ± 7,029	0,804	0,005*	0,222
Physical Limitations	Moderate-Severe	59,521 ± 13,854	14,283 ± 7,970	0,804	0,005*	0,222
General Average		54,760 ± 9,236^a	21,955 ± 5,314^b
Social Limitations	Mild	13,579 ± 10,235^B	7,407 ± 4,820	0,178	0,008*	0,044*
Social Limitations	Moderate-Severe	42,856 ± 11,605^{a, A}	6,349 ± 5,465^b	0,178	0,008*	0,044*
General Average		28,217 ± 7,737	6,878 ± 3,643
Personal Relationships	Mild	9,258 ± 3,703	1,851 ± 1,399	0,140	0,131	0,131
Personal Relationships	Moderate-Severe	0,0001 ± 4,199	0,0001 ± 1,587	0,140	0,131	0,131
General Average		4,629 ± 2,799	0,926 ± 1,058
Emotions	Mild	33,330 ± 9,940	22,220 ± 9,997	0,414	0,039*	0,882
Emotions	Moderate-Severe	46,029 ± 11,271	33,331 ± 11,335	0,414	0,039*	0,882
General Average		39,679 ± 7,514^a	27,776 ± 7,557^b
Sleep/Energy	Mild	25,924 ± 10,904	14,812 ± 7,407	0,475	0,007*	0,223
Sleep/Energy	Moderate-Severe	42,856 ± 12,364	16,666 ± 8,399	0,475	0,007*	0,223
General Average		34,390 ± 8,243^a	15,739 ± 5,599^b
Severity Measures	Mild	31,850 ± 7,059^B	28,886 ± 7,363	0,208	0,009*	0,031*
Severity Measures	Moderate-Severe	56,187 ± 8,005^a,A	30,473 ± 8,349^b	0,208	0,009*	0,031*
General Average		44,019 ± 5,336	29,679 ± 5,566
Symptom Severity Scale	Mild	11,222 ± 2,646	4,889 ± 0,986	0,773	0,002*	0,744
Symptom Severity Scale	Moderate-Severe	11,143 ± 3,001	3,571 ± 1,119	0,773	0,002*	0,744
General Average		11,183 ± 2,000^a	4,230 ± 0,746^b
#p < 0,05, a,b: Different letters on the same line represent a significant difference within the group. (p < 0,05), A, B: Different letters in the same column represent a significant difference between groups. (p < 0,05), Group: Between the groups, G*T: Group cross Time, g: gram, Repeated measurements ANOVA.

Insert Table 3 here please

The results of the study showed that the combined physiotherapy program reduced the UI symptoms and PFD, increased PFM activation and QoL, improved individuals' perception of recovery of all participants regardless of the severity of UI. According to the results of this study, the mild and moderate-severe groups benefited similarly from the combined exercise program.

In the literature the severity of UI was used as a parameter to categorize in a study. Akbayrak et al. [24] divided 48 women with UI problems into 3 groups according to their UI intensity. The treatment protocol was consisted of Kegel exercises and interferential flow. As a result of the comparison between the groups according to the number of pads used daily, frequency of urination, the amount of UI and PFM strength, the treatment rate was found to be better in the mild and moderate UI group than in the severe UI group. In the current study UI severity and PFM activation were examined similar to the study of Akbayrak et al. but this study categorized individuals with UI complaints into 2 groups according to their intensity of UI as mild and moderate-severe, and the combined program consisted of the abdominal exercises in addition to PFMT.

The moderate-severe UI group benefitted from the treatment as much as mild UI group in the current study, while the severe group benefited less from the treatment program than the mild and moderate UI groups in the study of Akbayrak et al [24]. These differences between the results of two studies may be due to the differences in grouping criteria, assessment methods, and intervention protocols. Additionally, the different results may be because abdominal exercise program which was added to PFMT in both groups can support UI patients to release symptoms. Considering that adding abdominal exercises to PFMT program may provide extra benefits especially to severe UI patients.

The relationship of abdominal muscles with PFM was investigated [25]. It was found that the contraction of the deep abdominal muscles stimulated PFM to contract. The coordination of the PFM contraction with the deep abdominal contraction is found to be more effective than specific strength training of PFM [25, 26]. In another study, a synergistic activation between the deep abdominal muscles and PFM was reported [7]. Owing to the fact that there is a connection between PFM and abdominal muscles, abdominal muscle exercises were added to PFMT in the current study to improve the effects of UI in treatment protocol.

The effect of TrA training on UI treatment was explained in limited number of studies [7, 25, 26] as PFM activation occurred during the TrA contraction. In addition, submaximal co-contraction and PFM rehabilitation would not reach the optimum level without rehabilitation of the abdominal muscles [10]. In addition, in another study, it was shown that pelvic floor muscle function of women was highest in the maneuver consisting of contraction of the abdominal muscles, called the bracing maneuver [27]. These studies underlined that isolated PFM exercises would be insufficient in the treatment of UI, and when abdominal exercises were combined into the treatment, it would improve PFM activation.

Adding TrA training to PFMT did not have a significant additional effect in a study [28], A total of 62 women with postpartum SUI were compared in three different study groups, PFMT-electrical stimulation (ES), PFMT-ES-TrA training and control groups. This difference could not be explained, and the need for further study with a larger sample size was mentioned. In the current study, both groups achieved abdominal exercises, so the isolated effect of abdominal exercise could not be reported because the groups were organized on the basis of UI severity. However, in this study, a decrease in UI severity in both groups shows that combined exercises have effects on symptoms.

In another study [29], it was shown that women with UI have increased pelvic floor and abdominal muscle activity. This finding challenged the clinical assumption that UI is associated with decreased PFM activity and suggested that the coordination of PFM and abdominal muscle activity may be important in the treatment of this condition. In the current study, after the treatment program, the severity of UI was significantly decreased in both groups, mild and moderate-severe. Although abdominal muscle activation is thought to be beneficial, there is no consensus.

One study showed that more intensive and supervised programs are more effective than unsupervised programs [30]. Presumably, making more frequent appointments with the physical therapist will allow patients to become more familiar with the exercises and how to deal with the UI. In our study, 50 women were reached, but 16 were able to complete the treatment. It requires a long period of time for PFM to become stronger. This makes patient compliance difficult. The reason for this was that the women could not continue to comply with the treatment because the treatment duration was 6 weeks.

As it is known, incontinence has global effects on the life of the individual and negatively affects the QoL, daily life activities related to home and work [31], and recreational activities such as sports, travel, and sexual activities [32]. KHQ was commonly used as an assessment tool for QoL. The effect of global postural retraining and PFMT was examined in patients with SUI, and it was found that the QoL increased significantly in both groups [33]. In current study, the combined physiotherapy program was applied for 6 weeks, and the KHQ was used to evaluate the differences in QoL. After the treatment, except personal relationships in both groups, QoL increased. When groups were compered, QoL improved similarly except incontinence impact, social limitation, and severity measures. In this study, it was observed that the combined physiotherapy program increased the QoL in UI patients in many parameters similar to the other studies.

PFMT and abdominal muscle strengthening exercises may increase the tonus of PFM and control on pelvic organ prolapses. In a multicenter randomized controlled trial, it was demonstrated by the Pelvic Organ Prolapse Symptom Score results used in the study that PFMT resulted in a small but possibly significant reduction in prolapse symptoms [34]. In a cross-sectional study in which 198 women were examined, it was shown that 94 percent of the women had PFD after the first birth, by evaluating it with Pelvic Floor Bother Questionnaire [35]. It has been shown that the rate of PFD is very high in women and PFD decreases with PFMT. In this study, the presence of PFD was used to evaluate with GPFBQ. After the combined physiotherapy program, there was a significant decrease in the questionnaire scores in both groups. Regardless of severity, treatment has been interpreted to reduce PFD. However, using only the GPFBQ to evaluate PFD may be insufficient because it did not consist of all affects.

Limitations:

The treatment program was applied as home program to increase participation and compliance of the patients with UI. In addition, it was decided that the home program would be more appropriate since it may be difficult for the patients to come to the clinic every day for 6 weeks. In this way, it was concluded that the program was more applicable. The telephone calls and exercise diary were used to follow up the continuity. Despite all these efforts physiotherapist supervision can be more effective, so the results may be different in a face-to-face treatment plan.
The number of people who could complete the program was low because it required participation in the treatment program every day for 6 weeks. While the number of people included in the program was 50, there were only 16 people who could complete the program.
Pelvic muscle contraction could not be controlled by digitally as it is not possible in a home program.
The patient’s position may affect the results.
Manual muscle test was used to evaluate abdominal muscle strength. We would have liked to use more objective tests, but these were our possibilities.

In conclusion, not only the mild UI patients but also the moderate-severe UP patients benefitted from the combined (PFMT and Abdominal muscle strengthening) physiotherapy program by reducing the severity of UI and PFD, increasing PFM activation and QoL and improving the individuals' perception of recovery. Therefore, abdominal exercises may be thought to gain benefits especially in patients with moderate and severe UI as much as mild UI. In conclusion, even abdominal strengthening exercise with increased severity of UI may have additional improvements.

Acknowledgments

The authors are thankful to Department of Urology, Gazi University Faculty of Medicine, for providing opportunities to carry out our research studies. We also thank the many women who participated in the study.

Funding

No funding was received to assist with the preparation of this manuscript.

Author Contribution

All authors contributed to the study conception and design. Protocol and project development, data collection, data analysis, manuscript writing, literature review were performed by Havva Sumeyye Eroglu; data collection and literature review were performed by Emine Ipek Halatci; protocol and project development, data analysis, manuscript editing were performed by Ilke Keser; protocol and project development, manuscript editing, patient selection and medical consultant were performed by Ilker Sen. The first draft of the manuscript was written by Havva Sumeyye Eroglu and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Conflicts of interest

The authors declare no competing interests.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Gazi University (approval number: 24074710-604.01.01-44)

Consent to participate

Written informed consent was obtained from individual participants.

Consent for publication

Not applicable

Availability of data and material

The data that support the fndings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Code availability

Not applicable

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Figure

There is one figure. This figure shows how many participants were reached during the study, how many participants were excluded from the study, how many participants were included in the study, and how many participants completed the study. It also shows that the participants were grouped according to the severity of urinary incontinence (mild and moderate-severe) and received treatment.

Table

Table 1: This table shows that the participants grouped according to the severity of incontinence were similar between the groups in terms of age, body weight, height, Body Mass Index, Urinary incontinence duration, parity and frequency of incontinence.

Table 2: This table shows the comparison of the results of the Pad Test, Pelvic Floor Muscle Test, Abdominal Muscle Test, Urinary Distress Inventory-6 and Global Pelvic Floor Bother Questionnaire for the participants divided into groups according to the severity of urinary incontinence.

Table 3: This table shows the comparison of the results of the sub-headings of the King's Health Questionnaire of the participants who were divided into groups as mild and moderate-severe.

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The Effects of Pelvic Floor and Abdominal Muscle Training in Urinary Incontinence According to Severity

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Abstract

Figures

Introduction

Methods

Study design and participants

Pelvic Floor Muscle Training

Abdominal Muscle Training

Outcome Measure

Primary Outcome

Urinary Incontinence Severity

Secondary Outcome

Pelvic Floor Muscle Activity

Abdominal Muscles Strength

Quality of life and symptom severity

Treatment adherence

Statistical Analyses

Results

Urinary Incontinence Severity

Pelvic Floor Muscle Activation

Abdominal Muscle Test

Pelvic Floor Dysfunction

Symptom Distress and QOL Scores

Discussion

Declarations

References

Figure and Table

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