Evaluation of the Capacity of the Pelvic Floor Muscle Exercise to

Improve Urinary Incontinence in Adult Women
Evaluation of the Capacity of the Pelvic Floor Muscle Exercise to
Improve Urinary Incontinence in Adult Women
Urinary incontinence (UI) can be a common or acute problem among adults,
especially elderly women in the society. Urinary inconsistency (UI)
mainly affects the geriatrician population where it negatively affects
their quality of life (Erwin, 2012, p. 171-218). The prevalence of the
urinary incontinence condition has been reported at a rate of 50-90 %
among this population. International Continence Society defined urinary
incontinence as an involuntary voiding with physical exertion or effort
such as sneezing or coughing (Haylen, 2010, p. 5-26). Currently, the
treatment practices for urinary inconsistent involves the management of
consequences (by providing the affected women with incontinence pads and
toileting assistance) of UI instead of focusing on the underlying causes
(Vinsnes, 2012, p. 45-50). However, the current study emphasize on the
effectiveness of pelvic floor muscle training (PFMT) in reducing the UI
among the community dwelling elderly and institutionalized women.
Different researchers have identified varying rates of UI in different
parts of the world. A cross sectional study of 1049 elderly women
identified a 76.2 % prevalence of UI (Firdolas, 2012, p. 221-226). The
study also identified that the most affected aspects of life include
emotional health and a feeling of frustration while in the public
places. In a similar study conducted in Pakistan Jokhio (2013, p.
121-156) established that 52 % of women with UI had leakage at least
once on a daily basis while 45 % reported a moderate effect of the
condition in life. Abrams (2002, p. 213–240) classified UI into three
categories namely urge UI, stress UI, and mixed UI.
Currently both invasive and conservative treatment approaches are used
in treatment of UI. The conservative treatments include physical
therapies, such as Pelvic Floor Muscle Training (PFMT) and cones
(Herbison, 2002, p. 1-4), Lifestyle intervention, behavioural training
such as bladder training. Moreover, pharmaceutical intervention (such as
anti-cholinergic) and invasive treatments include Anti incontinence
devices, surgery (minimally invasive sling operations), and absorbent
products (Shaikh, 2006, p. 1756 and Nabi et al, 2006, 572).
The present review aims at examining the effectiveness of the pelvic
floor muscles exercise (PFME) which is a repetitive contraction exercise
of the pelvic floor muscle to strengthen and support the perineal muscle
tone in the affected female population (Abrams, 2010, p. 213-240).
Aim of the study
This review aims at exploring the extent to which the pelvic floor
muscle exercise could improve UI in adult women.
Literature search strategy
Search strategies
Proper planning of the literature search and review ensures that the
information obtained is relevant to the topic of study and is the most
recent piece of information in a given field of study (Potter, 2010, p.
78-79). In addition, the selection of the suitable literature search
strategies helps the researcher in capturing the information that
satisfies all the objectives of the research project. The relevant
databases (such as MEDLINE, CINAHL, and Cochrane) and printed materials
were used to undertake the literature review in the current study.
However, only the published sources including the journals, books, and
trusted website contents in order to maintain the validity of the study.
The search engine review was optimized through the Boolean operations.
This was achieved through the use of relevant keywords (such as urinary
incontinence, pelvic floor muscle exercise, and adult women) of
different subtopics, nesting, and phrases (Gogtay, 2010, p. 517-518).
The key terms were obtained by subdividing the chapter into different
sub-topics, each of them addressing a different aspect of the main
topic. The relevance of the current study was maintained by reviewing
the most recent studies dated 2008-2009.
The aim of conducting the literature review is provide is to provide the
reader of the current research paper with the findings of the research
works done by other research (Potter, 2010, p. 78-79). Moreover, the
literature review helps the research in identifying the knowledge gaps,
which exists in the previous research works. The knowledge gaps may
exist in different forms including lack of consistency in the findings
provided in the previous research works the existence of flaws in the
design, methods data collection, sampling techniques, and interpretation
of the findings other research works being conducted in different
populations and the uncertainties of the findings of the previous
research works. The literature review helped in identification of the
currently known ideas and facts about the effectiveness of pelvic floor
muscle exercise in treatment and management of UI in women. This was
achieved by focusing on
Physical performance of PFME
Quality of life and patient satisfaction
Four Randomized Control Trials (RCTs) were considered during the
literature review where two of them emphasized on regular exercise and
the other two focused on an intensive program (Schaffer et al., 2012, p.
45-69). The randomization process was the basic strength of the studies
because it eliminates bias by giving each member of the study population
an equal opportunity of being selected (Stolberg, 2004, p. 2214-2228).
In the first group, a multicenter RCT study on 446 women after obtaining
approval from Institutional Review Board at each site, the data
coordinating centre. The sample of 446 was a suitable representation of
the study population and offered the benefit of reduced chances of
discovery failure and reduced wastage of resources resulting from
unnecessary large samples (Chenail, 2011, p. 1713-1726). The strength of
Schaffer et al. (2012, p. 45-69) work was the well-characterized
population in the prospective design and follow-up procedure. Moreover,
the study had a prospective design of the trial, which could give the
practitioner an overview to choose a convenient therapy for women with
different types of UI. However, the study had some weak points such as
short-term follow-up of improvement and satisfaction outcomes which make
the generalization unpractical.
Participants in control and experimental groups were similar in
demographic and medical characteristics on average of 50 years of age.
In a similar study Tak et al. (2012, p. 51-67) undertook a multicentred
RCT on 155 participants. The researcher invited the participants from 27
care centres in Netherlands via newsletter and direct mails. In total 20
out of 27 centres agreed to participate, the rest withdrew feared that
in cooperating with the group in this study, the workload for staff
members would be too much. The study subjects undertook the PFME, which
was followed by a three months assessment. This was followed by a second
study, in which the study subjects were assessed for six months in order
to establish the effectiveness of PFME in improving the quality of life
(Tak et al., 2012, p. 51-67).
The study participants were subjected to in a conditioning program while
the control participants were subjected to the traditional procedures
(such as provision of incontinence pads and toileting assistance) of
treating UI. The study subjects were assigned random numbers to avoid
personal identification. This was an appropriate ethical practice in
research because it protects the study participants from the public
identification during and after the research (Coleman, 2009, p. 48-63).
The in a conditioning program involved informing the subjects about the
procedure for PFME and the expected outcome. This was done to ensure
that the study subjects perform the exercise correctly and without
failing. The in-conditioning program helps the subjects in conforming
to the schedules of the exercise avoid contacting injuries, and
suitable body positioning to identify the target muscles (Industrial
Skills Council, 2012, p. 2-11). The data were provided by the
participating care centres.
The researchers used several tools of data collection including
interview, physical test, and questionnaire. The interview method of
data collection provides a relaxed atmosphere, which facilitates data
collection form the interviewee in an uninterrupted conversation
(Hancock, 2009, p. 16-27). In addition, the interview technique helps in
the enquiry for detailed information about the subjects’ feelings,
attitude, and behaviour.
The physical test, on the other hand, is an effective method of data
collection because it involves the direct observation of the subject
during the exercise. It offers similar benefits as direct observation
technique, which includes the evaluation of an ongoing process (Turner,
2010, p. 755-758). The use of questionnaires in the studies under review
was appropriate because they facilitated the collection of a large
amount of data, for the qualities of scientific and objective analysis.
All participants in the study were given verbal and written information
by care givers (Dumoulin, 2006, p. 746-753). The blinded measurements
were taken by trained students at baseline, in the middle and at the end
of the PFME program. The intervention, satisfaction, and improvement in
quality of life ware assessed using the Patient Satisfaction
Questionnaire at the end of the PFME program. The patient satisfaction
questionnaire (PSQ) has been used previously to assess the approval of
patients in a given therapeutic procedure. The study of psychometric
properties sounds in a randomly selected sample of 650 patients
indicated that PSQ are effective tools for the assessment of the quality
of care (Norea, 2005, p. 466-473). In addition, the study provided
evidence of time-based reliability of the PSQ in collecting and
recording of the patients’ response during the study.
The definition of success in this study was based on the response of “
much better” or “very much better” in a 7-point Likert scale
ranging from “very much worse” to “very much better”. The
7-point Likert scale has several limitations, which reduced the
reliability of the study. Fist, the use of scales in the study makes it
difficult for the researcher to determine the percentiles of the
subjects who agree and those who disagree with the effectiveness of a
given therapy (Geoff, 2010, p. 2-9). Secondly, the Likert approach does
not describe the population with an absolute sense because the results
of the study can only be compared across groups or similar samples over
a given period. Primary outcome and satisfaction were affected by
demographic variables (such as age, employment status, race, ethnicity,
and education) and clinical variables such as body mass index
(Minassian, et al., 2008, p. 324-331). Also alcohol consumption, smoking
status, parity, single or complex medical condition, menopausal status,
history of any pelvic surgery or treatment and quality of life measures.
The study identified that predictors of success and satisfaction could
be higher than other participant, in females with a college education or
higher (*p=0. 04). This was confirmed after the secondary analyses of
data also using the Patient Global Impression of Improvement. Those who
did not undergo urinary surgery (p=0. 04), postmenopausal (p=0. 03) and
patients with lower incontinence frequency (p=0. 01) (Rees, 2003, p.
247). The p-value in this case refers to the probability of obtaining a
test statistic similar to what would be actually observed under the
assumption that the null hypothesis is true (Thisted, 2010, p. 3-15). In
addition, the statistical significance values of 5 %, 1 %, and 0.1 %
respectively eliminate the doubt that would arise if the observed result
happened by chance (Morgan, 2010, p. 2-6). This is the indicator that
the researcher has statistically tested the results, particularly in
randomized control trials, to establish the probability that the
variation could occur by chance, and not the intervention. The most
common values used to indicate that the results are unlikely to have
happened by chance are, in increasing size of certainty that the results
are real differences –p <0.05, 0.01, 0.001.
The analysis was done twice to confirm the accuracy of the result in
evaluating the program through a final peer review of the manuscript,
but there was some room for bias to occur. However, the occurrence of
bias depends on the accuracy with which the hierarchy of multilevel
structure is reflected in the imputation model (Durrant, 2008, p. 8-17).
This structure helps in drawing a dictionary representation of basic
structures and classifications that underlie multilevel models. In
addition, the multivariate structures are effective in estimating the
missing multivariate data setting, categorical, and numerical variables
(Durrant, 2008, p. 8-17).
Effectiveness of PFME in Improving the quality of life and physical
The two researchers (Sherbun et al, 2011, p. 317-324 and Borello-France
et al, 2008, p. 161-169) used SPSS (Statistical Packages for the Social
Sciences) software to analysis their data. There are several benefits
that arose from the application of SPSS in analyzing the data instead of
conducting manual computation and analysis to arrive at rightful
conclusion. First, SPSS helped the researchers in ensuring effective
management of data. According to Blumenthal (2010, p. 7-15) the role of
SPPS is to help researchers in organizing data in an optimal
comportment. In addition, the software quickens the process of data
analysis compared to other techniques such as Excel spreadsheets. This
is because the SPSS program is designed to detect the location of the
case and variables automatically unlike the spreadsheets, which depends
on manual definition of the variable relationships. This increased the
reliability of the findings of the studies, which concluded that PFME is
effective in improving the physical performance of the affected women.
Secondly, the selection of SPSS in analyzing the data in the two
research works was a wise decision because the software gives better
organized outputs, which is clearly evident in the two papers
(Blumenthal, 2010, p. 7-15) SPSS, unlike other software, places the
output in different worksheets and has limited chances of overwriting
the information during the analysis. The impact created by this feature
of SPSS is to enhance the accuracy and comprehension of the output.
ANOVA and t-test are main outputs that were obtained from the data
analysis. Analysis of variants tests the mean difference between 3 or
more groups and compares how much the variability varies within the
groups as well as between them (Rees, 2003, p. 247. The research
indicates that only 28 women returned for the 6 month follow up.
However, application of the t-test assured that there was no significant
difference in the percentage reduction of UI episodes in the
intervention group. Some study subjects completed the 9-12 weeks
exercise while other underwent the 6 months follow-up exercise. Although
the research indicates that PFME is effective in management of UI, it is
clear that generalization may be difficult. This is because some study
subjects failed to adhere to the long-term exercise program.
Although SPSS software, ensures the accuracy of output there are some
potential limitations that may have affected the validity of the
results, but with the difficulty of detection. One of the major
challenges of the ANOVA analysis using the SPSS is that output does not
indicate the groups that differ statistically (Thisted, 2010, p. 3-15).
It is also evident that the two researchers did not perform the
follow-up test to detect the possibility of Type 1 error, which may have
resulted from the above limitation.
The researchers (Sherbun et al, 2011, p. 317-324 and Borello-France et
al, 2008, p. 161-169) assessed the effectiveness of the PFME on quality
of life by completing health related quality of life questionnaire in 3
stages: at home, at baseline and of intervention and at the followed up
12 months assessment using the pre-test, post-test design. However, the
difference in the latest assessment resulted from factors other than the
intervention because the participant was aware of the expected outcome
of research (Flanagan, 2009, p. 58-63). This study suggested no
significant change in quality of life although it obviously improves
physical performance. It is worth pointing here that PFME has profound
and positive impact in terms of reducing urinary incontinence. However,
the age-based generalization of the study findings cannot be made
because the study evaluated the effectiveness of PFME on elderly women
alone. Thus, it is not clear whether the exercise would have the same
effect on young women.
Price et al. (2010, p. 309-315) conducted a systematic review of the
literature from 1990-2010, all RCTs about the effectiveness of PFME were
included except, secondary data analyzing case, case reports, case
series and RCTS that did not report patient outcomes. In this review
extracting the data was carried out using standardized forms in all the
study stages such as sampling interventions, designs and outcomes. In
order to reduce bias, various strategies were implemented in
comprehensive literature search. PRISMA (preferred reporting items for
systematic review) (Moher et al., 2009, 7) was used as a standard
grading system to assure the quality of selected materials. The period
covered in this study (about 20 years) was sufficient to establish the
consistency of research works conducted on the effectiveness of PFME. In
addition, Price et al. (2010, 309-315) had an opportunity to evaluate
the knowledge gaps in all of the previous studies within the period
covered, thus making a valid conclusion about the effectiveness of the
PFME in improving the quality of life and physical performance of the
affected women (Flanagan, 2009, p. 58-63).
Hung et al, 2012 (p. 1030-1038) conducted a study, which indicated that
PFME is effective in improving the physical performance of women
suffering from UI. The researcher recruited 68 women aged 41 years via a
newspaper advert. The news paper advert offered the research an
opportunity to recruit study subjects from different parts. This reduced
the effect of bias that would have resulted from the recruitment of
subjects from one place (Hung et al, 2012, p. 1030-1038). During the
study, all participants were informed about the anatomy, physical
therapy, bladder hygiene and the correct way of conducting the PFM
exercise. Participants were recalled for adherence exercise after 4
months, and the percentage of adherence to PFME was categorized to 3
classes, high (80%), moderate (20%) and low (20%). This data and all
variable were analyzed. Variables, predictors and possible factors,
which could have any contributions, were defined by the researcher.
Although a four months period was reasonable to recall the subjects, a
six months period is most suitable to conduct the follow-up. This would
have extended period of evaluating the effectiveness of exercise in
improving the physical performance and quality of life of the study
subjects. Hung et al, 2012, (p. 1030-1038) in their study identified a
few limitations such as lack of accuracy of the home- based exercise.
Also, they defined the UI via self-reported data, rather than
urodynamics testing. There was unavailable chance of recall bias by the
participants after the 4-month program duration.
Chen et al. (2009, p. 367-373) established a direct correlation between
the Effectiveness of adherence to PFME exercise protocol. The study
revealed that there are many factors, which affect adherence to the PFME
and as a result of that, to the effectiveness of the intervention in
general. Most crucial elements are age, severity of health condition
social support, knowledge attitudes toward and perceived advantages of
the exercise (McCauley et al. 2005, p. 423-426). A survey looked at a
group of women with UI on a period of 12-week. Chen et al. (2009, p.
367-373) conducted a similar study by recruiting a sample of 152 women
suffering from UI. However, only 106 participants completed the
questionnaire and the informed consent form. The main weakness of the
study was the limitation in the training before initiation of the
program. This was the main reason for non-compliance with the PFME
procedure. Additionally, the study identified several factors, which act
as the main predictors of the participants’ adherence to the exercise
procedure. These factors include self efficacy (measure of the
patient’s ability to complete the exercise and accomplish the goals
set), improving attitudes towards PFME, perceived benefits of PFME, and
severity of passing urine. This study differed from the study by Hung
(2012, p. 1030-1038) because it established the insignificance of the
age factor in determining the adherence and the effectiveness of PFME.
Dumoulin et al. (2011, p. 746-753) conducted a research to with an aim
of establishing the effectiveness of PFME. The researcher divided the
study participants into four groups depending on the type of UI. This
would provide analysis of the results and help in verifying if the type
of UI (chronic and acute) determines the effectiveness of PFME (Erwin,
2012, p. 171-218). However, there were reports of improvement from women
who were physically strong and had taken regular check-up by a health
professional. The suggested regimen to achieve the best result of muscle
strength in order to manage the UI is a model using 8-12 contraction at
moderate velocity, a 1 to 2 minute rest between sets. The exercise
starts at a frequency of 2-3 times per week, which is then increased to
4-5 cycle followed by application of a 2-10% progress in load when a
woman is able to perform the current workload for 1-2 repetitions over
the targeted number (Durnolin et al. 2011, p. 746-753). Adherence to the
program depends on many factors, and each model has a different
adherence strategy. Dumoulin et al. (2011, p. 746-753) could not
identify the effect of self efficacy, improving attitudes towards PFME,
perceived benefits of PFME, and severity of passing urine in improving
compliance to the PFME procedure.
Participants in this program demonstrated a broad variation in
incontinence severity. In addition, several researchers established the
capacity of PFME to enhance the physical performance and quality of life
of the affected women. It is feasible to improve physical performance in
adult female by a group-based exercise, although it does not reduce in
UI, and the recorded reduction was less likely due to the intervention
(Tak et al. 2012, p. 51-67). Although the effectiveness of the PFME
program was fairly established in the SUI by strengthening PFM, yes the
maintenance of cured UI outcomes are uncertain. Moreover, the overall
result is not strong enough to be generalized to the real population due
to the limited sample size. Accordingly only 15 participant out of 25
provided exercise adherence information. That limits the conclusions
regarding the necessarily of counting the program in maintenance from
during follow-up intervals of 6 months or more. According to Chen et al.
(2009, p. 367-373) there are preliminary factors affecting the
self-efficacy. For instance, one of the significant positive influences
of PFME adherence is verifying the necessity of it in the overall
outcomes, in the UI management.
Hung et al. (2012, p. 1030-1038) in their cohort study provides that the
most significant the symptoms of leakage (higher score on the severity
Index at baseline) improvement of UI is expected after PFM
strengthening. The intensive PFME program is effective in reduction of
stress urinary incontinence signs in the elderly population. However,
aging is not a barrier to undergoing the program.
Dumoulin et al. (2011, p. 746-753) have no doubt that PFME has a
positive impact on managing SUI, although, they could not explain the
effective PFM exercise program. In comparison with other studies were
reviewed in this paper, considering the study design, existing
literature, tools of data gathering, analyzing system of data and result
producing, validity and reliability the conclusion of Price et al.
(2010, p. 309–315) work is the most proper one to be generalized to
the larger population. PFME is a recommended first line non-invasive
management program for different types of UI based on objective
evidence. The ideal recommended program should comprise minimum 8
contractions 3 times daily for at least 3 months duration with
maintenance exercise program (Price et al. 2010, p. 309–315). PFME
improves both the quality of life and personal physical performance in
women with UI however, there is a strong suggestion for more researches
to generalize the idea with more certainty around predictors affects the
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