INTRODUCTION:

Urinary incontinence is defined as any involuntary leakage of urine¹. It is one of the most common health problems among women of all ages, with an increase in prevalence with aging². It is estimated that 25% to 45% of women, of different ages throughout the world suffer from involuntary urine leakage, while 9% to 39% of women over 60 years of age report daily urinary leakage³.

Furthermore the leakage of urine results in severe consequences for the quality of life of the women affected⁴.

Urinary incontinence are of Stress incontinence, Urge incontinence, Overactive Bladder, Functional Incontinence, Overflow Incontinence, Mixed incontinence. Stress urinary incontinence is the most common of these all⁵. Normally pelvic floor muscles contraction compress the urethra and avoids urine leakage which results in an increase intra-abdominal pressure i.e. coughing, sneezing, jumping, walking and lifting⁶. Urinary incontinence is characterized by lower urinary tract symptoms (LUTS) which include both storage and voiding problems⁷. Over flow incontinence is caused by a hypotonic bladder, bladder outlet obstruction or other forms of urinary retention⁸.

Pelvic floor muscle exercises used to strengthen the pelvic floor muscles and there by prevent or manage urinary incontinence strengthening⁹. The term over active bladder is often used to describe urinary incontenence¹⁰. Pelvic floor muscles training is effective therapy for urinary incontinence¹¹. Pelvic floor tensing has been used to treat and prevent urinary and faecal incontinence¹². However the only known voluntary function of the pelvic floor muscles is a mass contraction best described as an inward lift and squeeze around the urethra, vagina and rectum¹³. Because of its location inside the pelvis the PFM is the only muscle group in the body capable of giving structural support for the pelvic organs (urethra, vagina, and rectum^14,15. The bladder connects to the urethra, the tube through which urine leaves the body¹⁶. Incontinence will occur if your bladder muscles are not strong enough to hold back urine¹⁷. Behavioural treatment also includes kegel exercises to strengthen the muscles that help hold in urine¹⁸. The predominant mechanisms underlying the development of the impairment of glucose tolerance and diabetes mellitus is represented by the stimulation of gluconeogenesis and development of insulin resistance in associated with the occurrence of an impairment of insulin secretion by the pancreas¹⁹. The concomitant occurrence of different metabolic syndrome associated with the increase and predominance of visceral adipose tissue significantly participates in the pathogenesis of insulin resistance and consequently the development of diabetes mellitus²⁰. The behavioural therapy is effective and proved by 1991 VIRGINA IN US had taken females in the age group and proved 50% are effective.

Some studies concentrate on physician assessment of incontinence severity while other look more at the patient experimental report. Incontinence related quality of life may be associated with more than a simple index frequency and amount of urinary leakage. Incontinence is a chronic condition and the impact this condition has on a woman’s life is valuable.

PROCEDURE:

This was an experimental study design with pre and post type. The study was conducted in the outpatient physiotherapy department in ACS medical college and hospital and took nearly 4 months to complete the study (Jan 2018 – April 2018). 45 samples were selected from 60 volunteers based on the inclusion criteria only females and clinically diagnosed diabetes mellitus and in the age group of above 40 years and below 60 years are included exclusion those with males are excluded and non-cooperative patient and in the age group below 40 and above 60 years are excluded.

Once the study get approved from IRB REG. NO: IV C- 050/PHYSIO/IRB/2017-2018. The 45 samples were divided into three group by the lottery method where three coloured chits where (green, blue, red) drawn and each falls to respective groups. Group received pelvic floor muscle training and group B received yoga and group c received cognitive behavioural therapy for 8 weeks. The samples will be full explained about the study and the questioners to be filled. They were then asked to fill the consent form in acceptance to participate in study which is clearly signed by the samples and therapist. Initially demographic details like age, sex, height, weight, were collected assuring confidentiality of the same. Group A exercise (Hip adductor roll, supine hip roll, bridges with hip roll, transverse abdominal contraction, hip abduction roll, hook lying roll, side taps, hamstring curl, wall push up, oblique abdominal curl, low step up, wall squat, seated leg raise, kneeling push up, wall and floor hover, camel pose cow pose standing forward bend, bridge pose extension).Group B exercise (chair pose, triangle pose, squat pose, malasana, reclined bound angle). Group C cognitive behavioural therapy is used to treat urinary incontinence. The bladder training stretched as it fills to bring back into normal pattern to less often be passing. The treatment is improving the overactive bladder it helps hold more urine so need not to go frequently and increase length of time between visits to the toilet help measure a process. The study of the pre and post-test measurement are taken and compared by using questionnaire for urinary incontinence diagnosis and incontinence severity index.

DATA ANALYSIS:

The collected data were tabulated and analysed using both descriptive and inferential statistics. All the parameters were assessed using statistical package for social science (SPSS) version 24. One Way ANOVA includes of following tests (Tests of Homogeneity of Variance, ANOVA, Robust Equality of Means, Post Hoc test Tukey HSD) (multiple comparison) was adopted to find statistical difference between three groups.

TABLE- 1 Comparison of Pre Test QUID score using Test of Homogeneity of Variance and One way ANOVA Test between Group A, Group B and Group C

TEST	GROUPS	MEAN	S.D	df1	df2	F-VALUE	SIGNIFICANCE
QUID	GROUP-A	4.666	.487	2	42	1.05	.359*
	GROUP-B	4.400	.507	2	42
	GROUP-C	4.533	.516	2	42

TABLE- 2

TEST	GROUPS	MEAN	S.D	df1	df2	F-VALUE	SIGNIFICANCE
QUID	GROUP-A	2.133	.743	2	42	23.68	.000***
	GROUP-B	3.600	.507	2	42
	GROUP-C	2.600	.507	2	42

Comparison of Post Test QUID score using Test of Homogeneity of Variance and One way ANOVA Test between Group A, Group B and Group C

TABLE – 3 Comparison of Pre Test QUID score using One ANOVA multiple comparison Post Hoc Tukey HSD Test between Group A, Group B and Group C

MULTIPLE GROUP COMPARISON		MEAN DIFFERENCE	STANDARD ERROR	SIGNIFICANCE
GROUP A	GROUP B	.26667	.18402	.326*
GROUP A	GROUP C	.13333	.18402	.750*
GROUP B	GROUP A	-.26667	.18402	.326*
GROUP B	GROUP C	-.13333	.18402	.750*
GROUP C	GROUP A	-.13333	.18402	.750*
GROUP C	GROUP B	.13333	.18402	.750*

TABLE – 4 Comparison of Post Test QUID score using One ANOVA multiple comparison Post Hoc Tukey HSD Test between Group A, Group B and Group C

MULTIPLE GROUP COMPARISON		MEAN DIFFERENCE	STANDARD ERROR	SIGNIFICANCE
GROUP A	GROUP B	-1.46667*	.21773	.000***
GROUP A	GROUP C	-.46667	.21773	.093**
GROUP B	GROUP A	1.46667*	.21773	.000***
GROUP B	GROUP C	1.00000*	.21773	.000***
GROUP C	GROUP A	.46667	.21773	.093**
GROUP C	GROUP B	-1.00000*	.21773	.000***

TABLE- 5 Comparison of Pre Test ISI score using Test of Homogeneity of Variance and One way ANOVA Test between Group A, Group B and Group C

TEST	GROUPS	MEAN	S.D	df1	df2	F-VALUE	SIGNIFICANCE
ISI	GROUP-A	9.533	1.684	2	42	0.98	.907*
	GROUP-B	9.666	1.676	2	42
	GROUP-C	9.400	1.594	2	42

TABLE- 6

TEST	GROUPS	MEAN	S.D	df1	df2	F-VALUE	SIGNIFICANCE
ISI	GROUP-A	5.066	0.703	2	42	25.15	.000***
	GROUP-B	8.533	1.597	2	42
	GROUP-C	7.400	1.594	2	42

Comparison of Post Test ISI score using Test of Homogeneity of Variance and One way ANOVA Test between Group A, Group B and Group C

TABLE – 7 Comparison of Pre Test ISI score using One ANOVA multiple comparison Post Hoc Tukey HSD Test between Group A, Group B and Group C

MULTIPLE GROUP COMPARISON		MEAN DIFFERENCE	STANDARD ERROR	SIGNIFICANCE
GROUP A	GROUP B	-.13333	.60334	.973*
GROUP A	GROUP C	.13333	.60334	.973*
GROUP B	GROUP A	.13333	.60334	.973*
GROUP B	GROUP C	.26667	.60334	.898*
GROUP C	GROUP A	-.13333	.60334	.973*
GROUP C	GROUP B	-.26667	.60334	.898*

TABLE – 8 Comparison of Post Test ISI score using One ANOVA multiple comparison Post Hoc Tukey HSD Test between Group A, Group B and Group C

MULTIPLE GROUP COMPARISON		MEAN DIFFERENCE	STANDARD ERROR	SIGNIFICANCE
GROUP A	GROUP B	-3.46667	.49846	.000***
GROUP A	GROUP C	-2.33333	.49846	.002***
GROUP B	GROUP A	3.46667	.49846	.000***
GROUP B	GROUP C	1.13333	.49846	.071**
GROUP C	GROUP A	2.33333	.49846	.002***
GROUP C	GROUP B	-1.13333	.49846	.071**

RESULTS:

On comparing Mean values of Group A, Group B and Group C on Pre Test QUID score, it shows no significant difference in the Mean values at P> 0.05.

On comparing Mean values of Group A, Group B and Group C on Post Test QUID score shows significant difference in the Mean values, but Group A shows 2.13 which has the Lowest Mean value is more effective than Group C at 2.60 and followed by Group B at 3.60 (P ≤ 0.001). On comparing Mean values of Group A, Group B and Group C on Pre Test ISI score, it shows no significant difference in the Mean values at P> 0.05.

On comparing Mean values of Group A, Group B and Group C on Post Test ISI score shows significant difference in the Mean values, but Group A shows 5.06 which has the Lowest Mean value is more effective than Group C at 7.40 and followed by Group B at 8.53 (P ≤ 0.001).

DISCUSSION:

In this experimental study subjects urinary incontinence was treated with pelvic floor muscle yoga and behavioral therapy. A total of 60 samples were selected among them 15 were not cooperated due to their personal problems. Finally 45 subjects were included in this study. They were divided into three groups. Group A were given pelvic floor muscle training. Group B were given with yoga. Group c were given with behavioral therapy. This study was conducted for the duration of 4 months and it was given for 45 minutes/day.

Data analysis was carried out after collecting data for the two outcome measures (QUID, ISI) in all the three groups.

Urinary incontinence is a problem tackled by majority of females and is found to be related with diabetes mellitus, present study evaluated the effect of pelvic floor muscle exercise in diabetic women with complaint of urinary incontinence. Although there is no significant evidence to make strong recommendations about the best approach for the pelvic floor muscle training helps in treating and reducing the risk of urinary incontinence²². Wang proposed the subjective improvement rate of overactive bladder for pelvic floor muscle training as 51.4%, 50.0%, and 38.2% respectively even the pelvic floor muscle training is recommended as a first line of treatment for urinary incontinence because of its ease of usage and patients preference²³. However as concluded by Hay –Smith in a study that followed women who completed a supervised pelvic floor muscle training program 5 years later, 70% were still exercising at least once a week and 70% had no leakage on coughing showed that of those being successfully treated after a pelvic floor muscle training program had undergone surgery 10 years later²⁴. Pelvic floor therapy requires special training to be effective. The long term follow up of physical therapy results is essential in reaching conclusions on the effectiveness of the interventions. All of the selected studies that included a long term follow up evaluated pelvic floor muscles training²⁵. It is known that it is necessary to continue the exercise in order to maintain the benefits of pelvic floor muscle training. Although most of the previous researches were conducted on non-diabetic population but the results may generalized for diabetic population too because of the involvement of same muscle and mechanism of urinary incontinence as is involved in non-diabetic women²⁶. An important question is whether PFM rehabilitation programs first need to focus on the pre-contraction during physical stressors in order to eventually obtain an automatic PFM Co-contraction during increases in abdominal pressure. Some authors suggest that this is one way to build automatic function²⁷. Hence, one could postulate that building up muscle strength and changing muscle morphology (via permanent elevation of the levator plate into a higher location inside the pelvis, increasing muscle volume, strengthening bony connective, and more effectively recruiting motor neurons) may lift and tighten the structural base made up by the pelvic floor, thus making an automatic co-contraction possible. When a correct PFM contraction is learned, and the structural base is built up, combinations of TrA and the PFM may be one way to increase progression and enhance automatic function²⁸. In contract to the need for a strong maximum contraction to build up muscles strength, the automatic co-contraction needed for everyday life once a structural than timing²⁹. Compared with a strong voluntary contraction, this co-contraction is barely perceived, and may be due to the PFM being located in an optimal anatomical location. However, some women need stronger support than others. e.g weight lifters, gymnasts and others performing heavy lifting, strenuous work, and high-impact activities³⁰. Again, if structural support is optimally located inside the pelvis and the connective tissue is strong, only a little downward movement will occur during a rise in abdominal pressure: the PFM is “stiff and the urethra and bladder base is kept in place³¹. The study concluded that the prevalence of urinary incontinence among the four groups of females was higher in patients with diabetic followed by vaginal delivery than lower segmental caesarean section and finally in hypothyroidism. The urge incontinence was more prevalent than the stress incontinence and it shows that it has an impact in the quality of life. Clinicians should be aware of the secondary complication after normal or caesarean delivery and patients on medication for thyroid and diabetic and advise them to perform urinary incontinence exercise in daily routine³².

CONCLUSION:

This study reveals that there was a significant difference in the subject who under gone pelvic floor muscle training, yoga, and cognitive behavioural therapy. On comparing the mean values of pre and post-test was a significant difference in the QUID and ISI. It has been concluded that the diabetic women with urinary incontinence can get benefit from kegel exercises commonly known as pelvic floor muscle training. Supervised pelvic floor muscle training for 4 months was found to be particularly helpful for reducing stress incontinence.

At the end of the study there was a significant decrease in pelvic floor muscle training, preventing various risk factors of urinary incontinence.

AUTHORS CONTRIBUTION:

All authors have contributed equally.

CONFLICT OF INTEREST:

Conflicts of interest: none.

ETHICAL CONSIDERATIONS:

The manuscript is approved by the Institutional Review board [IRB REG. NO: IV C- 050/PHYSIO/IRB/2017-2018.] of faculty of physiotherapy. All the procedures were performed in accordance with the ethical standards of the responsible ethics committee both (Institutional and national) on human experimentation and the Helsinki Declaration of 1964 (as revised in 2008).

DECLARATION OF PATIENT CONSENT:

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

FUNDING:

This is a self-funded study.

REFERENCE:

1. Abrams P, Andersson KE, Birder L, Brubaker L, Cardozo L, Chapple C, et al. Fourth International Consultation n incontinence Recommendation of the international scientific committee: evaluation and treatment of urinary incontinence, pelvic organ prolapsed and fecal incontinence. Neurourol Urodyn. 2010; 29(1):213-40.

2. Temml C, Haidinger G, Schmidbauer J, Schatzl G, Madersbacher S. Urinary incontinence in both sexes: prevalence rates and impact on quality of life and sexual life. Neuroural Urodyn. 2000; 19(3)259-71.

3. Buckley BS, Lapitan MCM; Epidemiology committee of the fourth international consultation on incontinence, Pairs, 2008. Prevalence of urinary incontinence in men, women, and children – current evidence: findings of the Fourth International consultation. Urology. 2010; 76(2)265-70.

4. Dedicacao AC, Haddad M, Saldanha MES, Driusso P, Comparison of quality of life for different types of female urinary incontinence. Rev Bras Fisioter. 2009; 13(2):116-22.

5. Kim, Y., Kwak, Y. Urinary incontinence in women in relation to occupational status. Women Health. 2016 Feb 6:1-18.

6. Shaw, C. Stress urinary incontinence in women. Primary Health Care. 2004; 14(5), 27-31.

7. Haylen BT, de Ridder D, Freeman RM et al. An International Urogynecological Association (IUGA)/International continence society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010; 29(1):4-20

8. Smith DR, Tanagho EA, Mc Aninch JW. Smith’s general Urology, 17^thed.New York: Lange medical books/McGraw-Hill: 2008.Fam pract 2001; 18(1):48-52

9. Phelan, S., Kanaya, A. M., Subak, L.L., Hogan, P. E., Espeland, M.A., Wing, R. R., and Brown, J. S. Prevalence and risk factors for urinary incontinence in overweight and obese diabetic women action for health in diabetes (Look AHEAD) study. Diabetes care. 2009; 32(8), 1391-1397.

10. Abrams P, Birder L, et al. Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn 2010; 29(10 :213-240.

11. Hay smith E, BO K, Berghmans LC, Hendriks HJ, de Bie RS, Van Waalwijk van Doorn ESC: Pelvic floor muscle training for urinary incontinence in women. Cochrane Library, Oxford.2001 health publication Ltd, Plymouth, pp 571-624

12. Mantle J (2001) Physiotherapy for incontinence. In: Cardozo L, Staskin D (eds) Textbook of female urology and urogynecology. London: Isis Media Ltd, pp 351-358.

13. Bo K, Lilleas F, Talseth T, Hedlund H (2001) Dynamic MRI of pelvic floor muscles in an upright sitting position. Neurourol Urodyn 20: 167-174

14. Ashton-Miller J, Howard D, DeLancey J (2001) the functional anatomy of the female pelvic floor and stress continence control system. Scand J Urol Nephrol Suppl 207:1-7.

15. Chen Y, Chen GD, Hu SW, Lin TL, Lin LY. Is the occurrence of storage and voiding dysfunction affected by menopausal transition or associated with the normal aging process? Menopause.2003; 10(3):203-8.

16. Ricci NA, Dias CNK, Driusso P. The use of electrothermal and phototherapeutic methods for the treatment of fibromyalgia syndrome: a systematic review. Rev Bras Fisioter.2010; 14(1); 1-9.

17. Sousa JG, Ferreira VR, Oliveira RJ, Cestari CE. Avaliacao da forca muscular do assoalho pelvic emidosas com incontinence urinaria. Fisioter Mov.2011; 24(1):39-46.

18. Durrant J, Snape J. Urinary incontinence in nursing homes for older people. Age Ageing.2003; 32(1):12-8.

19. Kegel AH (1952) Stress incontinence and genital relaxation.Cibaclin Sympos 2:35-51.

20. Cammu, H., Van Nylen, M., and Amy, J. A 10-year follow –up after kegel pelvic floor muscle exercises for genuine stress incontinence. BJU international.2001; 85(6), 655-658.

21. Jeanette S. Brown, MD, and Janis Luft, NP, MSN et al 24, 2015 urinary incontinence in individuals with diabetes mellitus.

22. Hay-smith E, Herderschee R, Dumoulin C, Herbison GP. Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women. Cochrane Database syst Rev.2007 Dec 7; (12):CD009508.

23. Alex C. Wang, Ya-Ying Wang, Min-Chi Chen. Single-blind, randomized trial of pelvic floor muscle graining, biofeedback-assisted pelvic floor muscle training, and electrical stimulation in the management of overactive bladder. Urology.2004;63(1):61-6

24. Hay-smith E, Bo K, Berghmans L, Hendriks H, deBie R, van Waalwijk van Doorn ESC pelvic floor muscle training fur urinary incontinence in women.2001 Neurourol Urodyn 9:436-437.

25. Polackwich AS, Li J, Shoskes DA. Patients with pelvic floor muscle spasm have a superior response to pelvic floor physical therapy at specialized centers. JUrol 2015; 194:1002-6.

26. Rizk DE, Fahim MA. Ageing of the female pelvic floor: towards treatment a la carte of the geripause. Int urogynecol J Pelvic Floor Dysfunction. 2008; 19(4):455-8.

27. Kolcaba, k., Dowd, T., Winslow, E., and Jacobson, A. Kegel Exercises. American Journal of Nursing. 2000; 100(11), 59.

28. Pollock M L, Gaesser GA, Butcher JD, Despres JP, Dishman R K, Franklin BA, et al (1998). The recommended quantity and quality of exercise for developing and maintaining cardio respiratory and muscular fitness and flexibility in healthy adults. Med Sci Sports Exerc 30:975-991.

29. Howard D, Miller J, De Lancey J, Ashton-Miller J (2000) Differential effects of cough, valsalva, and continence status on vesical neck movement. Obstet Gynecol 95:535-540.

30. Roehrborn CG, Rosen RC. Medical therapy options for aging men with benign prostatic hyperplasia: Focus on alfuzosin 10 mg once daily. ClinInterv Aging 2008; 3(3):511-524.

31. Nix jw, Carson CC. Medical management of benign prostatic hypertrophy. Can J Urol 2007 (Suppl 1):53-57.

32. V Rajalaxmi, P Sutharsika, C.V Senthilnathan, G Yuvarani, SS Subramanian, Prevalence of Urinary Incontinence among Females with Vaginal Delivery, Lower Segmental Cesarean Section, Diabetic and Hypothyroidism and Its Impact on Quality of Life, Journal of Clinical and Diagnostic Research. 2018 July, Vol-12(7): QC05-QC08

Received on 23.04.2019 Modified on 15.05.2019

Research J. Pharm. and Tech. 2019; 12(10):4618-4622.

DOI: 10.5958/0974-360X.2019.00794.7