Behavioral therapy for urinary incontinence in India

The Role of Dynamic Neuromuscular Stabilization Exercises in Stress Urinary Incontinence Among Females Aged 18-40 Years

BACKGROUND AND OBJECTIVE

Stress urinary incontinence (SUI) is prevalent among females across various age groups, yet societal taboos and unawareness contribute to under-reporting and hinder effective management strategies. This study aimed to evaluate the efficacy of dynamic neuromuscular stabilization (DNS) compared to traditional Kegel exercises in females with stress urinary incontinence, focusing on assessing the impact of DNS on pelvic floor strength and core musculature activation to provide valuable insights into urinary continence management.

METHODOLOGY

This is a single-blinded, randomized trial with 90 females aged 18-40 years assessed perineometer readings, pelvic floor electromyography (EMG), and transverse abdominis activation via pressure biofeedback.

RESULTS

Significant improvements in pelvic floor strength and core musculature activation were observed in the DNS group compared to the Kegel exercise group. Perineometer values, EMG measurements, and pressure biofeedback unit readings demonstrated substantial enhancements post-intervention in both groups. Effect sizes, including Cohen's D and point biserial correlation coefficient, indicated medium to large effects favoring the DNS intervention.

CONCLUSION

DNS is superior to Kegel exercises for SUI management, emphasizing the importance of targeting core musculature. Future research should explore long-term outcomes and patient-reported measures for a comprehensive understanding.

Utility of opportunistic screening to assess the impact of urinary incontinence on quality of life and barriers to seeking treatment among women attending a tertiary healthcare centre in North India

INTRODUCTION

Urinary incontinence (UI) is a common but frequently neglected problem in females, significantly impacting their psychosocial health. The available estimates are an underestimation of a bigger problem. Thus, the study aimed to estimate the prevalence of UI, its associated risk factors, its impact on the Quality of life (QoL), and barriers to treatment-seeking behaviour in women attending tertiary healthcare centres.

METHODS

We conducted a cross-sectional study using an opportunistic screening among women visiting a tertiary care hospital in Punjab recruited using multi-stage systematic random sampling. UI was classified as Stress (SUI), Urge (UUI), mixed (MUI), and No Incontinence (UI less than once a week or a month or no complaints) using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). Bivariate analyses were done using the chi-square test to test the association between the dependent and independent variables. The predictors of UI were explored using univariable and multivariable binary logistic regression and depicted using Odds ratio with 95% confidence intervals. The impact of UI on Quality of Life (QoL) was assessed using the Incontinence Impact Questionnaire-Short Form (IIQ-7), and compared among the three UI types using One-Way ANOVA. Treatment barriers were explored using open-ended questions.

RESULTS

Of the 601 women, 19.6% reported UI (stress UI: 10.1%, mixed UI: 6.0%, and urge UI: 3.5%). There were significant clinical-social factors that predicted different types of UI. The UI depicted a significant effect on QoL across all domains of the IIQ-7 (total mean score: 50.8 ± 21.9) compared to women with no incontinence (0.1 + 1.9). The score was highest in women with MUI, followed by SUI and UUI. About two-thirds of the affected women never consulted a doctor and considered it a non-serious condition or a normal ageing process.

CONCLUSIONS

The present study found a high prevalence of UI through opportunistic screening across all the women's age groups with different conditions. Due to the associated stigma, clinicians should make every attempt to talk more about this, especially in women with medical conditions that can precipitate UI. Furthermore, the results call for generating more robust estimates through community-based screening studies.

Pelvic floor therapy program for the treatment of female urinary incontinence in Belize: a pilot study

Introduction

Urinary incontinence (UI) is highly prevalent in low- and middle-income countries (LMIC). Concurrently, the availability of surgical or conservative UI treatments in LMIC is limited.

Methods

We conducted a prospective feasibility study of Belize women with UI treated with pelvic floor physical therapy (PFPT) and education (PFE). Patients received individual PFPT/PFE over 2 days, consisting of biofeedback-enhanced PFMT in addition to behavioral, dietary, and general pelvic education. Patient completed a daily 6-month home regimen including 7 PFMT exercises (total 70 repetitions) comprising both endurance and quick flick exercises. Patients also performed comprehensive dietary and behavioral modification activities. Outcomes were assessed at baseline and 6-months, including validated symptom (ICIQ-FLUTS) and QOL (IIQ-7) questionnaires, and strength testing (PERFECT score, perineometry).

Results

Twenty-eight patients underwent baseline assessment. Four patients were lost to in-person 6-month follow-up, with two of these patients completing subjective assessment only by telephone. The mean (±SD) patient age, BMI, and parity were 50.0 (±10.0) years, 33.2 (±5.8), and 2.8 (±1.5). Provider assessment demonstrated patient comprehension of basic, endurance, and quick flick pelvic floor contractions in 28 (100%), 24 (86%), and 24 (86%) patients, respectively. At 6-month follow-up, significant improvements were seen across multiple validated questionnaire and strength measurement assessments. Median patient-reported improvement level was 7.0 on a 10-point Likert scale.

Discussion

Study patients demonstrated good understanding of PFMT/PFE and program completion was associated with significant improvements across a variety of subjective incontinence and quality of life outcomes, as well as objective strength testing.

Comparing the Efficacy of Dynamic Neuromuscular Stabilization Exercises and Kegel Exercises on Stress Urinary Incontinence in Women: A Pilot Study

Background and objective Stress urinary incontinence (SUI) is a prevalent condition affecting women of various age groups, significantly impacting their quality of life. To address this multifaceted issue, a comprehensive approach that goes beyond traditional pelvic floor exercises is needed. Dynamic neuromuscular stabilization (DNS) exercises, targeting the integrated spinal stabilization system, offer a promising alternative. Thus, this study aimed to compare the effectiveness of DNS exercises and Kegel exercises in managing SUI among women. Methods This single-blinded, pilot study involved 24 women aged 18-40 years with mild to moderate SUI. Participants were divided into DNS and Kegel exercise groups. Outcome measures included perineometer readings, electromyography (EMG) data, and the Urogenital Distress Inventory-6 (UDI-6). Statistical analysis compared baseline and 12-week data within and between groups, and rank-biserial correlation coefficient (r) as a measure of effect size in our study was calculated. Results At 12 weeks, the DNS group showed significant improvement in pelvic floor muscle strength compared to Kegel exercises (p = 0.005). Both groups had significantly enhanced pelvic floor muscle strength (p < 0.05). A significant change occurred for EMG average, EMG peak, and EMG maximum voluntary contraction (MVC) at 12 weeks (average p = 0.005; peak p = 0.001; MVC p = 0.009), with significant improvements in both groups (p < 0.05). For UDI-6, a significant difference emerged between the two groups at 12 weeks (p < 0.05), with significant improvements in both groups individually from baseline to 12 weeks (p < 0.05). The effect size "r" for all variables indicated a medium to large effect size, underscoring the substantial and significant impact of DNS exercises in managing SUI among women compared to Kegel exercises. Conclusion This study suggests that DNS exercises, emphasizing the coordinated activation of the diaphragm, abdominals, multifidus, and pelvic floor, may provide a more effective approach for managing SUI in women compared to traditional Kegel exercises.

Self-reported insomnia symptoms are associated with urinary incontinence among older Indian adults: evidence from the Longitudinal Ageing Study in India (LASI)

BACKGROUND

Insomnia and urinary incontinence (UI) are both diseases burdening older adults. However, the association between them has not been well elucidated. The purpose of this study is to assess the correlation between insomnia symptoms and UI in a large community-dwelling sample of older Indian adults.

METHODS

Data were from Wave 1 (2017-2018) of the Longitudinal Ageing Study of India (LASI). Male and female participants aged ≥ 60 years who provided complete information on insomnia symptoms, UI, stress UI (SUI), and covariates were included. Insomnia symptoms were identified by a report of: trouble falling asleep, waking up at night, or waking too early, ≥ 5 times/week. UI was defined by self-reported diagnosis. SUI was identified by self-report of involuntary urine leakage when sneezing, coughing, laughing, or lifting weights. Multivariable logistic regression analyses evaluated the associations between insomnia symptoms and UI and SUI. Stratified linear regression evaluated for interactions in prespecified subgroups.

RESULTS

Twenty-six thousand eight hundred twenty-one LASI participants met entry criteria. 2979 (11.11%) reported insomnia symptoms, 976 (3.64%) UI, and 2726 (10.16%) SUI. After full adjustment, insomnia symptoms were associated with both UI and SUI among males (OR 1.53; 95%CI 1.20-1.96 and OR 1.51; 95%CI 1.25-1.83) and females (OR 1.53; 95% CI 1.21-1.92 and OR 1.50; 95% CI 1.31-1.73). A significant interaction effect by age was observed between insomnia symptoms and SUI among both males (p = 0.048) and females (p = 0.042).

CONCLUSIONS

Insomnia symptoms were associated with UI and with SUI in both male and female older Indian adults. Further prospective study is called for to better characterize these associations and to explore underlying mechanisms.

Cognitive-behavioral therapy and urge urinary incontinence in women. A systematic review

INTRODUCTION AND HYPOTHESIS

UUI co-exists with numerous health conditions, having a substantial negative impact on health-related quality of life and mental health. Cognitive-behavioral therapy (CBT) could help patients manage these problems by changing the way they think and behave.

METHODS

We carried out a systematic review of the literature assessing the modalities and effects of CBT as a stand-alone strategy, without adding PFMT, on symptoms and clinical signs, in women with UUI. Our secondary objective was to report modalities and effects of CBT on health-related quality of life, psychological symptoms and patient-reported satisfaction. The PRISMA methodology was used to carry out this systematic review. A literature search was conducted in PubMed, PEDro, Web of Science and Cochrane Library databases from inception to December 2020. The PICO approach was used to determine the eligibility criteria.

RESULTS

Twelve papers were included in the present review which showed beneficial effects on both symptom severity (p < 0.05) and more subjective areas such as quality of life, psychological symptoms or patient satisfaction level (p < 0.05), respectively). However, results on the effectiveness of CBT on clinical signs remains conflicting.

CONCLUSION

Based on the available literature, this review suggested a high level of evidence for the effectiveness of CBT on symptom severity and a moderate level of evidence for the effectiveness of CBT on quality of life, psychological symptoms and patient satisfaction. However, we highlighted no evidence for the effects of CBT on clinical signs.

Treatment pathways traversed by polycystic ovary syndrome (PCOS) patients: A mixed-method study

BACKGROUND

This study was undertaken to explore the treatment-seeking pathways traversed by women with PCOS and elicit their behavior, experiences and perspectives regarding it.

METHODS

This concurrent mixed-method study was conducted on 18-40 years old women diagnosed with PCOS at the Gynecology outpatient department, PGIMER, Chandigarh, India. Of the 275 women, who were administered a questionnaire to elicit their treatment-seeking behavior, 62 willing participants were subjected to in-depth interviews. Quantitative responses were descriptively analyzed and presented as count, proportion, mean or median. Framework analysis was performed for the qualitative data. The findings of both types of data were triangulated to construct the pathways to treatment traversed by PCOS patients.

FINDINGS

Many (~45%) respondents had no information regarding PCOS. Only 9.1% received some information from their doctors. Though the internet was the primary source of information for 37.5% of respondents, they expressed dissatisfaction with the quality of information. Multiple health care agencies were consulted by most (85.8%) of the respondents. Allopathy was the preferred choice of treatment. The average delay in initiating the treatment was 3 months. The major reasons for this were ignorance, the concept of 'normality' and 'endurance'. Deviations from the normal self (like irregular-menstruation, obesity, hirsutism, infertility) were the concern that led them to consult a doctor. They were also dissatisfied with the treatment due to a late diagnosis, lack of relief, taboo, side-effects, expenses involved and the need for repeated laboratory tests. Participants' course of treatment was influenced by the interplay of individual, distress, health-system, and social-economic factors.

CONCLUSIONS

Women with PCOS were dissatisfied with the quality of the information and treatment received. There were treatment delays. The patients consulted multiple health agencies, including indigenous therapies, in the hope of relief. The findings provide an empirical basis on points to focus on for building better coping strategies for managing the condition.

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women

BACKGROUND

Pelvic floor muscle training (PFMT) is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed urinary incontinence (MUI) and, less commonly, urgency urinary incontinence (UUI).This is an update of a Cochrane Review first published in 2001 and last updated in 2014.

OBJECTIVES

To assess the effects of PFMT for women with urinary incontinence (UI) in comparison to no treatment, placebo or sham treatments, or other inactive control treatments; and summarise the findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (searched 12 February 2018), which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, handsearching of journals and conference proceedings, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with SUI, UUI or MUI (based on symptoms, signs or urodynamics). One arm of the trial included PFMT. Another arm was a no treatment, placebo, sham or other inactive control treatment arm.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials for eligibility and risk of bias. We extracted and cross-checked data. A third review author resolved disagreements. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. We subgrouped trials by diagnosis of UI. We undertook formal meta-analysis when appropriate.

MAIN RESULTS

The review included 31 trials (10 of which were new for this update) involving 1817 women from 14 countries. Overall, trials were of small-to-moderate size, with follow-ups generally less than 12 months and many were at moderate risk of bias. There was considerable variation in the intervention's content and duration, study populations and outcome measures. There was only one study of women with MUI and only one study with UUI alone, with no data on cure, cure or improvement, or number of episodes of UI for these subgroups.Symptomatic cure of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were eight times more likely to report cure (56% versus 6%; risk ratio (RR) 8.38, 95% confidence interval (CI) 3.68 to 19.07; 4 trials, 165 women; high-quality evidence). For women with any type of UI, PFMT groups were five times more likely to report cure (35% versus 6%; RR 5.34, 95% CI 2.78 to 10.26; 3 trials, 290 women; moderate-quality evidence).Symptomatic cure or improvement of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were six times more likely to report cure or improvement (74% versus 11%; RR 6.33, 95% CI 3.88 to 10.33; 3 trials, 242 women; moderate-quality evidence). For women with any type of UI, PFMT groups were two times more likely to report cure or improvement than women in the control groups (67% versus 29%; RR 2.39, 95% CI 1.64 to 3.47; 2 trials, 166 women; moderate-quality evidence).UI-specific symptoms and quality of life (QoL) at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT group were more likely to report significant improvement in UI symptoms (7 trials, 376 women; moderate-quality evidence), and to report significant improvement in UI QoL (6 trials, 348 women; low-quality evidence). For any type of UI, women in the PFMT group were more likely to report significant improvement in UI symptoms (1 trial, 121 women; moderate-quality evidence) and to report significant improvement in UI QoL (4 trials, 258 women; moderate-quality evidence). Finally, for women with mixed UI treated with PFMT, there was one small trial (12 women) reporting better QoL.Leakage episodes in 24 hours at the end of treatment: PFMT reduced leakage episodes by one in women with SUI (mean difference (MD) 1.23 lower, 95% CI 1.78 lower to 0.68 lower; 7 trials, 432 women; moderate-quality evidence) and in women with all types of UI (MD 1.00 lower, 95% CI 1.37 lower to 0.64 lower; 4 trials, 349 women; moderate-quality evidence).Leakage on short clinic-based pad tests at the end of treatment: women with SUI in the PFMT groups lost significantly less urine in short (up to one hour) pad tests. The comparison showed considerable heterogeneity but the findings still favoured PFMT when using a random-effects model (MD 9.71 g lower, 95% CI 18.92 lower to 0.50 lower; 4 trials, 185 women; moderate-quality evidence). For women with all types of UI, PFMT groups also reported less urine loss on short pad tests than controls (MD 3.72 g lower, 95% CI 5.46 lower to 1.98 lower; 2 trials, 146 women; moderate-quality evidence).Women in the PFMT group were also more satisfied with treatment and their sexual outcomes were better. Adverse events were rare and, in the two trials that did report any, they were minor. The findings of the review were largely supported by the 'Summary of findings' tables, but most of the evidence was downgraded to moderate on methodological grounds. The exception was 'participant-perceived cure' in women with SUI, which was rated as high quality.

AUTHORS' CONCLUSIONS

Based on the data available, we can be confident that PFMT can cure or improve symptoms of SUI and all other types of UI. It may reduce the number of leakage episodes, the quantity of leakage on the short pad tests in the clinic and symptoms on UI-specific symptom questionnaires. The authors of the one economic evaluation identified for the Brief Economic Commentary reported that the cost-effectiveness of PFMT looks promising. The findings of the review suggest that PFMT could be included in first-line conservative management programmes for women with UI. The long-term effectiveness and cost-effectiveness of PFMT needs to be further researched.

Nonantimuscarinic treatment for overactive bladder: a systematic review

The purpose of the study was to determine the efficacy and safety of nonantimuscarinic treatments for overactive bladder. Medline, Cochrane, and other databases (inception to April 2, 2014) were used. We included any study design in which there were 2 arms and an n > 100, if at least 1 of the arms was a nonantimuscarinic therapy or any comparative trial, regardless of number, if at least 2 arms were nonantimuscarinic therapies for overactive bladder. Eleven reviewers double-screened citations and extracted eligible studies for study: population, intervention, outcome, effects on outcome categories, and quality. The body of evidence for categories of interventions were summarized and assessed for strength. Ninety-nine comparative studies met inclusion criteria. Interventions effective to improve subjective overactive bladder symptoms include exercise with heat and steam generating sheets (1 study), diaphragmatic (1 study), deep abdominal (1 study), and pelvic floor muscle training exercises (2 studies). Pelvic floor exercises are more effective in subjective and objective outcomes with biofeedback or verbal feedback. Weight loss with diet and exercise, caffeine reduction, 25-50% reduction in fluid intake, and pelvic floor muscle exercises with verbal instruction and or biofeedback were all efficacious. Botulinum toxin A improves urge incontinence episodes, urgency, frequency, quality of life, nocturia, and urodynamic testing parameters. Acupuncture improves quality of life and urodynamic testing parameters. Extracorporeal magnetic stimulation improves urodynamic parameters. Mirabegron improves daily incontinence episodes, nocturia, number of daily voids, and urine volume per void, whereas solabegron improves daily incontinence episodes. Short-term posterior tibial nerve stimulation is more efficacious than pelvic floor muscle training exercises and behavioral therapy for improving: urgency, urinary incontinence episodes, daily voids, volume per void, and overall quality of life. Sacral neuromodulation is more efficacious than antimuscarinic treatment for subjective improvement of overactive bladder and quality of life. Transvaginal electrical stimulation demonstrates subjective improvement in overactive bladder symptoms and urodynamic parameters. Multiple therapies, including physical therapy, behavioral therapy, botulinum toxin A, acupuncture, magnetic stimulation, mirabegron, posterior tibial nerve stimulation, sacral neuromodulation, and transvaginal electrical stimulation, are efficacious in the treatment of overactive bladder.

The effect of pelvic muscle exercises on urinary incontinency and self-esteem of elderly females with stress urinary incontinency, 2013

Introduction:

Millions of women are afflicted with stress urinary incontinence. Urinary incontinence is mentioned as one of the geriatric syndromes, together with pressure ulcers, functional decline, falls, and low self-esteem. The aim of the present study was to determine the effect of pelvic muscle exercises on urinary incontinency and self- esteem of elderly females with stress urinary incontinency in Shiraz, Iran, 2013.

Material and Method:

In this interventional study, 50 old females aged 60-74 years were chosen among the members of Jahandidegan center, and they were asked to sign the informed consent form and complete the demographic questionnaire. Then, Quid questionnaire was used for choosing the type of incontinence in the elderly females. Next, the participants completed the ICIQ and self-esteem questionnaires. Then, they were randomly assigned to case and control groups. Each participant took part in 8 training classes. Finally, the subjects filled the ICIQ and self-esteem questionnaires before and 2 months after the intervention.

Result:

The results is shown that after the intervention, ICIQ score has a significant difference between the two groups (P=0.001). Also, after the treatment, self-esteem average scores of studied unit indicated a significant statistical difference in experimental group. In other words, the training sessions improved the score of self-esteem in the experimental group (P<0.001) versus control group (P=0.08).

Conclusion:

Pelvic muscle exercises were an empowerment mechanism for incontinent women in improving their quality of life and self-esteem, so recommended that such these exercising programs be used in elderly health care centers as a factor to improve health promotion of elderlies ’that are suffering from urinary incontinence.

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women

BACKGROUND

Pelvic floor muscle training is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed and, less commonly, urgency urinary incontinence.

OBJECTIVES

To determine the effects of pelvic floor muscle training for women with urinary incontinence in comparison to no treatment, placebo or sham treatments, or other inactive control treatments.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL) (1999 onwards), MEDLINE (1966 onwards) and MEDLINE In-Process (2001 onwards), and handsearched journals and conference proceedings (searched 15 April 2013) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials in women with stress, urgency or mixed urinary incontinence (based on symptoms, signs, or urodynamics). One arm of the trial included pelvic floor muscle training (PFMT). Another arm was a no treatment, placebo, sham, or other inactive control treatment arm.

DATA COLLECTION AND ANALYSIS

Trials were independently assessed by two review authors for eligibility and methodological quality. Data were extracted then cross-checked. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions. Trials were subgrouped by diagnosis of urinary incontinence. Formal meta-analysis was undertaken when appropriate.

MAIN RESULTS

Twenty-one trials involving 1281 women (665 PFMT, 616 controls) met the inclusion criteria; 18 trials (1051 women) contributed data to the forest plots. The trials were generally small to moderate sized, and many were at moderate risk of bias, based on the trial reports. There was considerable variation in the interventions used, study populations, and outcome measures. There were no studies of women with mixed or urgency urinary incontinence alone.Women with SUI who were in the PFMT groups were 8 times more likely than the controls to report that they were cured (46/82 (56.1%) versus 5/83 (6.0%), RR 8.38, 95% CI 3.68 to 19.07) and 17 times more likely to report cure or improvement (32/58 (55%) versus 2/63 (3.2%), RR 17.33, 95% CI 4.31 to 69.64). In trials in women with any type of urinary incontinence, PFMT groups were also more likely to report cure, or more cure and improvement than the women in the control groups, although the effect size was reduced. Women with either SUI or any type of urinary incontinence were also more satisfied with the active treatment, while women in the control groups were more likely to seek further treatment. Women treated with PFMT leaked urine less often, lost smaller amounts on the short office-based pad test, and emptied their bladders less often during the day. Their sexual outcomes were also better. Two trials (one small and one moderate size) reported some evidence of the benefit persisting for up to a year after treatment. Of the few adverse effects reported, none were serious.The findings of the review were largely supported by the summary of findings tables, but most of the evidence was down-graded to moderate on methodological grounds. The exception was 'Participant perceived cure' in women with SUI, which was rated as high quality.

AUTHORS' CONCLUSIONS

The review provides support for the widespread recommendation that PFMT be included in first-line conservative management programmes for women with stress and any type of urinary incontinence. Long-term effectiveness of PFMT needs to be further researched.