The involuntary leakage of urine caused by effort, physical exertion, or increased intra-abdominal pressure while sneezing or coughing is known as stress urinary incontinence (SUI). Female urinary incontinence (UI) affects 200 million women worldwide, with a median prevalence of SUI ranging from 15% to 35% (Haylen et al., 2010).
The leading cause of SUI is weak urethral support due to the pelvic floor muscles’ (PFM) weakness and intrinsic sphincter insufficiency. The SUI occurs when the intra-abdominal pressure exceeds the pressure of the PFM contraction and the urethral sphincter, so the PFMs cannot hold against this increase in pressure and leakage of urine occurrence (Ghaderi & Oskouei, 2014).
Stress UI is common among postmenopausal women due to estrogen deficiency, which causes many problems and symptoms that start to occur gradually after the onset of menopause, in which the PFM strength and function decline (Fritel et al., 2012). The drop in estrogen after menopause may cause symptoms of pelvic floor dysfunction, such as UI, reduction in PFM tone, and reduced blood circulation to the urinary–genital tract, causing weakness and atrophy (Robinson et al., 2013). Also, there is a decline in urinary sphincter pressure with less control and support for the pelvic organs, which leads to more frequent urination times (Khanjani & Khanjani, 2017). Although the etiology of SUI is still poorly understood, among the main risk factors are age, pregnancy, and childbirth. Pregnancy and childbirth are potent causes of female UI, so that they exert a considerable impact on the level of population UI prevalence. In an individual woman, the effect seems to be cumulative and long lasting but fades with age (Foldspang et al., 1992).
Stage I SUI is known as a urinary leak during coughing, sneezing, or lifting heavy objects. Patients with Stage II SUI are those who engage in less strenuous physical activity, such as walking and turning from sitting to standing. UI occurs without physical strain in Stage III SUI (Ingelman-Sundberg, 1952; Stamey, 1980).
Exercises for the PFM are the most widely prescribed first line treatment method, particularly for Stage 1 SUI. Schröder et al. (2010) have emphasized the positive outcomes of this conservative treatment, suggesting that it is an effective noninvasive treatment for mild Stage 1 SUI. Because of the increased muscle mass, these exercises help to stabilize the urethra. Positive outcomes are only achieved after approximately 6–8 weeks of consistent exercise and manifest themselves in a higher quality of life evaluation.
There is a reciprocal relationship between aerobic capacity and the activity of the PFMs in healthy adult women (Jürgensen et al., 2017). Aerobic exercise is sometimes known as “cardio” exercise that requires the pumping of oxygenated blood by the heart to deliver oxygen to working muscles. Aerobic exercises increase the body’s capacity to absorb, deliver, and utilize oxygen. Adults aged 18–64 years should do at least 150–300 min of moderate-intensity aerobic physical activity throughout the week for health benefits (e.g., walking and cycling; Ozemek et al., 2018).
Pelvic floor muscles do not function as an independent entity. Depending on the level of physical strain, their function is supported by other synergistic muscles, among them abdominal muscles (musculus abdominis) and thigh adductors (musculus adductor femoris). In addition, some activity of the gluteus maximus muscle (musculus gluteus major) was observed simultaneously with PFM tension (Ptak et al., 2017). The postural and stabilizer muscles, such as the abdominal and adductor muscles, are well employed during aerobic exercise. Moreover, the PFM, responsible for the voluntary urinary continence mechanism, is also considered stabilizers and postural muscles, and can be reflexively activated during physical exercise. The PFMs are extremely important for the continence mechanism and, in addition, act as a powerful pelvic stabilizer (Jürgensen et al., 2017).
Purpose of the Present Study
General exercise training strengthens the pelvic floor. The impacts during exercise could lead to a co-contraction of the PFM, creating an acute indirect training effect (Bø et al., 2018). This may reduce the levator hiatus area, which is defined as the space between the inferior pubic rami and the puborectalis component of the levator ani muscle, by causing hypertrophy and shortening of the surrounding muscles, thereby lifting the pelvic floor and the internal organs into a higher pelvic location. Theoretically, such morphological changes could reduce the risk of SUI (Bø, 2004). The objective of this study was to determine the effect of aerobic walking exercise on SUI in postmenopausal women.
Hypotheses of the Study
The literature data on this subject are very recent and there is a shortage of knowledge in the kinesiology field on incontinence (Caetano et al., 2007). We hypothesize that aerobic exercise and PFM training would improve PFM strength and reduce symptoms of SUI when compared with usual care only in postmenopausal women with SUI.
Method
Participants
During routine checkups, 40 Egyptian women were identified as eligible candidates for the study. Their ages ranged between 50 and 60 years old. The mean age of the women who provided data for the 12-week follow-up (n = 30) was (M = 53.7, SD = 6.5) years. The qualifying examinations for the study were performed at the Gynecology outpatient clinic of Kasr Al-Ainii University Hospital, Cairo. The eligibility criteria in the study were women with SUI (Stage I) as assessed by the gynecologist, previous vaginal delivery with episiotomy was 2–3 times, natural cessation of menstrual periods for at least 12 months, and body mass index (BMI) <30 kg/m2 where kg was the participant’s weight in kilograms and m2 was their height in meters squared. They all led a sedentary lifestyle as they were not currently participating in a formal exercise program and were asked to participate. Exclusion criteria included previous incontinence surgery, urinary urgency, concurrent medical care for UI, urinary tract infection, and neurologic or psychiatric disorders.
Materials
Myomed Biofeedback
Myomed biofeedback is a reliable and valid instrument. Hence, this device can be used in clinical trials and in practice for assessing PFM strength (Sigurdardottir et al., 2009). It consists of a vaginal electrode of the proper size connected to the main unit by a rubber tube. It was used to evaluate PFM strength through measuring vaginal closure or squeeze pressure. The participants were in a supine posture with their hips and knees bent at approximately 90° during the tests. “On command, contract your PFMs as much as you can, keeping your abdominals, thighs, and buttocks relaxed; and, on command, relax your entire body,” they were told. Each participant could observe the graph of the electrical activity of these muscles on a computer screen simultaneously with the exercises. Before assessment and before the start of the week-long program, 2–3 sessions of EMG biofeedback familiarization were given to each participant to watch how their muscles contracted and relaxed (Szumilewicz et al., 2019).
The Revised Urinary Incontinence Scale
The Revised Urinary Incontinence Scale (RUIS) is a short, reliable, and valid scale for evaluation of UI and its response to treatment (Sansoni et al., 2015). It consists of five questions. For example, how often do you experience urine leakage? to calculate the urinary score. The total RUIS score is determined by adding each question’s score. A possible score range of 0–16 is obtained by adding the scores for each of the five questions. A score of 0–3 indicates that the patient has no UI. A score of 4–8 indicates mild UI, a score of 9–12 indicates moderate UI, and a score of 13 or higher indicates severe UI (Sansoni et al., 2015).
The Borg Rating of Perceived Exertion Scale
The Borg Rating of Perceived Exertion Scale is a subjective method for measuring the intensity level of physical activity. Perceived exertion is a measure of how hard the activity is for the participant during exercise and is based on the physical sensations (e.g., increased heart rate, respiration or breathing rate, sweating, and muscle fatigue) a person experiences during physical activity or exercise. The scale ranges from 6 (no exertion at all and/or very light) to 20 (maximal exertion and/or very hard; Borg, 1982). The ratings of perceived exertion has been shown to be a valid measure of exercise intensity and physiological exertion during various forms of exercise (Chen et al., 2002).
Procedures
In this study, participants were selected through convenience sampling and interviewed after approval of the Faculty of Physical Therapy, Cairo University Ethics Committee (reference number: P.T.REC/011-4/2017). Seven refused to participate and three females were excluded as they did not meet the study’s inclusion criteria. Therefore, 30 females were enrolled in the 12-week intervention trial. Thirty (100%) of these women completed the 12-week intervention trial (see Figure 1).
—The CONSORT flowchart of participants. CONSORT = CONsolidated Standards of Reporting Trials; UC = usual care group; TMT = aerobic walking exercise group.
Citation: Women in Sport and Physical Activity Journal 30, 1; 10.1123/wspaj.2021-0022
—The CONSORT flowchart of participants. CONSORT = CONsolidated Standards of Reporting Trials; UC = usual care group; TMT = aerobic walking exercise group.
Citation: Women in Sport and Physical Activity Journal 30, 1; 10.1123/wspaj.2021-0022
—The CONSORT flowchart of participants. CONSORT = CONsolidated Standards of Reporting Trials; UC = usual care group; TMT = aerobic walking exercise group.
Citation: Women in Sport and Physical Activity Journal 30, 1; 10.1123/wspaj.2021-0022
All participants for the study provided a participant information sheet describing the study and providing sufficient information for them to make an informed decision about their participation in the study. Each participant was specifically informed that participation in the study was voluntary and that she might withdraw from the study at any time and that withdrawal of consent did not affect her subsequent medical assistance and treatment.
Participants were assigned randomly to either the UC group (pelvic floor training only; n = 15) or the TMT group (pelvic floor training in addition to aerobic walking exercise; n = 15). Before the study, a researcher who was not involved in the participants’ recruitment, evaluation, or treatment, used a random number series to randomize the participants. The treatment allocation was concealed inside sealed, opaque envelopes that were numbered sequentially. Women were asked not to reveal their randomized group to assessors or caregivers.
Pelvic floor muscle strength was the primary outcome of this study, measured by Myomed biofeedback. The secondary outcome was assessed by the revised UI score. The evaluations of both groups were conducted before and after treatment completion (12 weeks) by physiotherapists blinded to the groups.
Treatment Protocol
Pelvic Floor Muscle Training for Both Groups (UC and TMT)
During the initial instruction sessions, participants were given verbal instructions on the correct PFM exercise technique to ensure a full contraction and relaxation cycle was implemented. The pelvic floor muscle training consisted of 30 min of initial therapist supervised guidance on how to contract the PFMs. Women were instructed to perform eight to 12 maximum voluntary pelvic floor contractions, maintaining them for approximately 6–8 s, followed by three or four quick contractions, pausing for 6 s between contractions. All contractions were performed in a lying back position with legs bent and relaxed on the mat. For 12 weeks, pelvic floor muscle training was conducted twice a week (Pereira et al., 2013). Adherence to performing pelvic floor muscle training was captured through the number of appointments attended.
Each participant in both groups (UC and TMT) was asked to repeat her own exercise program as a home routine on the other alternate days. Participants were instructed and directed to perform five sets of PFM exercises per day, with 10 contractions per set, aiming to hold for a duration of 10 s, with an equal rest time, providing a total of 50 contractions per day. All participants kept an exercise diary, indicating the date and time at which they completed their exercises for the 12 weeks of the intervention.
Aerobic Exercise for the TMT Group
Before the aerobic training session, participants undertook a separate familiarization session, where they were introduced to the aerobic exercise protocol and all measurement procedures. For a total of 10 min, the TMT group was subjected to a global stretching program (upper limbs, lower limbs, and spine with two repetitions and 30 s of stretch maintenance in each segment for a total of 10 min) as a warming-up exercise (Bandy & Irion 1994).
A treadmill (Track Star, Incheon, Korea) was used for walking aerobic exercise. All participants are allowed to hold a support bar as needed. Training intensity was based on a combination of heart rate based on the maximum heart rate percentage: 208− (0.7 × age; Tanaka et al., 2001), and the perceived exertion rate determined by the Borg scale (Williams, 2017). The heart rate was recorded with a Sport Tester (Polar RS400; Polar Electro Oy, Kempele, Finland). All participants began walking at a 0% slope and a speed of 0.8 km/hr, increasing by 0.3 km/hr every 30 s until they reached a walking speed that corresponded to a perceived exertion of 11–13 on the Borg scale and 60% of the participants’ age predicted maximal heart rate (mild exercise intensity). The rate of perceived exertion and heart rate was recorded every 5 min. Participants walked for 30 min and were constantly observed by a physical therapist while walking on the treadmill. Light stretching for 10 min was done to go back to the original state. Aerobic training on a treadmill was performed two times per week for 12 weeks.
Statistical Analysis
Based on the research objectives and previous studies conducted on the same topic, considering α of .05, power of 80%, variance of 1.5, and an effect size of 0.18 SDs, a 30-woman sample size (15 in each group) was determined for the current study (Ghoniem et al., 2008; Harvey et al., 2001). After data collection and management, statistical characteristics of dependent variables were presented as arithmetic means, SDs, and interquartile range. The normal distribution of variables was verified with the Shapiro–Wilk test. Because a t test is required for small samples, it was employed to determine whether there were any differences within or between the two groups in the increase in the PFMs after the intervention. The Mann–Whitney U tests and the Wilcoxon signed-rank test were used to detect group differences in RUIS scores as the data were nonparametric. To adjust for multiple comparisons, Bonferroni adjustment was used and p value <.0125 was assumed to be statistically significant. The IBM SPSS Statistics for Windows (version 19.0; IBM Corp., Armonk, NY) was used for data analysis. We hypothesized thatthere would be a significant difference between the pretest and posttest scores of postmenopausal women with regard to management of SUI after administering aerobic walking and PFM exercises. Comparisons were performed using a paired t test and a Wilcoxon signed-rank test for variables measured pretreatment and posttreatment within the same group. Also, there was a significant difference between posttest levels of SUI among the UC and TMT groups. Comparisons between the two groups were done using the unpaired t test and the Mann–Whitney U test. Cohen’s d was used for within-group comparisons, where values of 0.20, 0.50, and 0.80 represent small, moderate, and large effect sizes (Cohen, 1988).
Results
The general characteristics for UC group were age (M = 55.6 years, SD = 3.4), BMI (M = 26.91 kg/m2, SD = 1.77), and the number of vaginal deliveries was (M = 2.06, SD = 1.56). In TMT, the age (M = 54.26 years, SD = 2.91), BMI (M = 26.35 kg/m2, SD = 2.7), and the number of vaginal deliveries was (M = 2.20, SD = 1.34).
At randomization, there were no statistically significant differences between participants assigned to either the UC group or the TMT group with respect to age, BMI, and number of previous vaginal deliveries (p = .250, p = .500, and p = .660, respectively; see Table 1).
Patients’ Demographic Data
| UC group | TMT group | |||||
|---|---|---|---|---|---|---|
| M | SD | M | SD | t value | p value | |
| Age (years) | 55.6 | 3.4 | 54.26 | 2.91 | 1.15 | .250 |
| Weight (kg) | 86.3 | 7.6 | 84.38 | 9.23 | .61 | .540 |
| Height (cm) | 159.6 | 4.53 | 160.26 | 4.75 | −.39 | .690 |
| BMI (kg/m2) | 26.91 | 1.77 | 26.35 | 2.7 | .67 | .500 |
| Number of previous vaginal deliveries | 2.06 | 1.56 | 2.20 | 1.34 | .73 | .660 |
Note. Values are expressed as mean ± SD; p > .0125, not significant. BMI = body mass index; UC = usual care group; TMT = aerobic walking exercise group.
PFM Strength Measured by Myomed Biofeedback
Before treatment, there was no difference between the two groups regarding PFM strength as measured by Myomed biofeedback. There was a significant increase in PFM strength in the posttest state in the UC group (M = 49.4 mmHg, SD = 5.34, p = .011, d = 0.647) and the TMT group (M = 55.46 mmHg, SD = 7.67, p = .010, d = 0.745) compared with the pretreatment condition. The value of PFM intensity in the TMT group increased statistically significantly after the intervention relative to the corresponding value in the UC group (p = .010) as shown in Table 2.
Mean Values of PFM Strength (in mmHg) for Both Groups (UC and TMT) Before and After Intervention
| PFM strength | UC group | TMT group | t# value | p value | ||
|---|---|---|---|---|---|---|
| M | SD | M | SD | |||
| Before treatment | 39.13 | 5.18 | 37.8 | 4.85 | .72 | .470 |
| After treatment | 49.2 | 5.34 | 55.46 | 7.67 | −2.59 | .010 |
| t## value | 3.70 | 2.57 | ||||
| p value | .011 | .010 | ||||
Note. Values are presented as mean ± SD. UC = usual care group; TMT = aerobic walking exercise group; PFM = pelvic floor muscle.
#Unpaired t test. ##Paired t test; p < .0125, significant.
The RUIS Preintervention and Postintervention for Both Groups (UC and TMT)
Regarding RUIS between groups, no statistically significant difference in its mean value was observed between UC and TMT groups before treatment. When comparing the RUIS value before and after treatment in each group separately, there was a statistically significant decrease in RUIS in the UC group (median [interquartile range] = 8 [11–6], Z = 3.45, p = .011, d = 0.566), and the TMT group (median [IQR] = 6 [8–5], Z = 3.49, p = .001, d = 0.652) after treatment. The RUIS mean value was significantly lower in the TMT group than in the UC group after treatment (U = 63.5, p = .011) as shown in Table 3.
The IQR Values of RUIS in the Two Studied Groups (UC and TMT) Before and After Intervention
| RUIS | UC group | TMT group | U value# | p value |
|---|---|---|---|---|
| Before treatment (IQR) | 12 (14–10) | 12 (13–10) | 97 | .512 |
| After treatment (IQR) | 8 (11–6) | 6 (8–5) | 63.5 | .011 |
| Z## value | 3.45 | 3.49 | ||
| p value | .011 | .001 |
Note. IQR = interquartile range; UC = usual care group; TMT = aerobic walking exercise group; RUIS = Revised Urinary Incontinence Scale.
#U value, Mann–Whitney test. ##Z value, Wilcoxon signed rank; p < .0125, significant test.
Discussion
According to this research, the TMT group, treated with aerobic walking exercise and PFM training, showed a significant improvement in their PFMs and RUIS. To our knowledge, our study is the first to examine the effect of aerobic walking exercise on SUI among postmenopausal women. The results obtained in this study aligned with those of Jürgensen et al. (2017) who showed that PFM functionality was closely related to aerobic capacity in apparently healthy women without SUI. Increasing intra-abdominal pressure during aerobic exercise triggers a reflex contraction of the PFMs, enhancing the overall condition of these muscles.
The relationship between PFM function and aerobic capacity reinforces the importance of submaximal exercise programs, which should be combined with specific interventions to preserve these muscles’ integrity and to improve UI (Schnelle et al., 2002). It can be argued that aerobic exercise has the potential to strengthen the PFMs during activity and thereby improve pelvic floor support in the same manner that exercise strengthens other skeletal muscles (Shaw & Nygaard, 2017). In this study, mild physical activity, represented by walking, appears to decrease the risk of UI. In cross-sectional analyses, current leisure activity is associated with lower odds of SUI; conversely, lack of exercise increases these odds (Nygaard et al., 2015).
For some women, engaging in moderate exercise may improve PFM function compared with sedentary women. This fact adds to the growing body of evidence that promoting physical activity is critical for population health. Exercise can enhance pelvic floor function in addition to its many other well-known benefits, as it has the potential to improve or maintain some aspects of physical fitness, including aerobic capacity, muscular strength and endurance, flexibility, and body composition (Garber et al., 2011; Gonçalves et al., 2018).
The current study also showed a significant improvement in PFMS and RUIS in the UC group who received pelvic floor exercise treatment. This finding was supported by Radzimińska et al. (2018), who reported that PFM training is the most effective conservative management for older women with SUI. Exercises for the PFM are the most widely prescribed first line treatment method, particularly for Stage 1 SUI. Also, a systematic review by Neumann et al. (2006) demonstrated that pelvic floor exercise was effective in the treatment of SUI, reaching a cure rate of 73%. Similar to our findings, Mørkved and Bø (1997) found that a specially designed postpartum PFM exercise course is effective in increasing PFM strength and reducing UI in the immediate postpartum period. Moreover, Fitz et al. (2012) reported improvement in SUI regarding PFM strength following the first 8 weeks of performing pelvic floor exercises. Moreover, voluntary PFM contractions force the urethra against the symphysis pubis posterior aspect, causing an intraurethral pressure mechanical increase. Consequently, during a rise in intra-abdominal pressure, a positive urethral closure pressure is preserved, leading to a negative closure pressure correction, which is commonly seen in stress incontinence patients (Thüroff et al., 2011).
Limitations of the Study
Certain limitations of the present work are: first, the small sample size, which affects the degree to which the results can be extrapolated beyond the study sample. The sample size estimate was calculated to detect pre–post differences within groups and was based on data from a study that included a different population. Second, data on fluid intake volume and type among participants was not collected during the study. Third, in the future, the thickness of the PFM could be assessed before and after intervention using ultrasound. Fourth, obtaining exercise adherence from a self-report diary presents another study limitation. Asking women to return the diaries weekly over the 12-week period may have increased the quantity of adherence. Furthermore, data on maximum heart rate during aerobic exercise were not reported and this should be investigated in future work.
Conclusion
The effectiveness of pelvic floor strengthening exercise in the management of SUI is well established. Our results demonstrated that aerobic walking exercise with PFM training is more effective than PFM training only in increasing PFM strength and in reducing urine loss in postmenopausal women with SUI.
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