Neurourology and Urodynamics 35:417–422 (2016)

Effect of Pelvic Floor Muscle Exercise on Pelvic Floor Muscle Activity and Voiding Functions During Pregnancy and the Postpartum Period Hatice Kahyaoglu Sut,1 and Petek Balkanli Kaplan2*

1

Faculty of Health Sciences, Department of Obstetrics and Gynecology Nursing, Trakya University, Edirne, Turkey 2 Department of Obstetrics and Gynecology, Istanbul Kemerburgaz University Medical Faculty, Istanbul, Turkey

Aims: The aim of this study was to investigate the effects of pelvic floor muscle exercise during pregnancy and the postpartum period on pelvic floor muscle activity and voiding functions. Methods: Pregnant women (n ¼ 60) were randomly assigned into two groups (Training [n ¼ 30] and Control [n ¼ 30]) using a computer-based system. Pelvic floor muscle strength was measured using a perineometry device. Urinary symptoms were measured using the Urinary Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and the Overactive Bladder Questionnaire (OAB-q). Voiding functions were measured using uroflowmetry and 3-day voiding diaries. Measurements were obtained at week 28, weeks 36–38 of pregnancy, and postpartum weeks 6–8. Results: Pelvic floor muscle strength significantly decreased during the pregnancy (P < 0.001). However, pelvic floor muscle strength improvement was significantly higher in the Training group compared to the Control group (P < 0.001). The UDI-6, IIQ-7, and OAB-q scores did not significantly change during weeks 36–38 of pregnancy in the Training group (P > 0.05). However, UDI-6, coping, concern, and total scores of OAB-q were significantly decreased during weeks 36–38 of pregnancy in the Control group (P < 0.05). The UDI-6 and OAB-q scores were significantly improved during postpartum weeks 6–8 (P < 0.05). Voiding functions were negatively affected in both groups, decreasing during weeks 36–38 of pregnancy and improving during the postpartum period. Conclusions: Pregnancy and delivery affect pelvic floor muscle strength, urinary symptoms, quality of life, and voiding functions. Pelvic floor muscle exercises applied during pregnancy and the postpartum period increase pelvic floor muscle strength and prevent deterioration of urinary symptoms and quality of life in pregnancy. Neurourol. Urodynam. 35:417–422, 2016. # 2015 Wiley Periodicals, Inc. Key words: delivery; muscle strength; pelvic floor; pregnancy; training; voiding function INTRODUCTION

Pregnancy and delivery may cause disorders in the pelvic floor including urinary incontinence (UI), fecal incontinence, and a prolapse of pelvic floor organs. For instance, UI rates during pregnancy range from 25% to 75%.1 Pelvic floor disorders significantly decrease pelvic floor muscle (PFM) strength. Moreover, age, parity, perineal trauma, and endocrine and neural factors also result in major losses in PFM strength.2 Pregnancy and delivery cause significant physiological changes in all organ systems and there is some limited information on the physiological changes that occur in the pelvic floor. However, their precise effects on pelvic organ support have not been established.3 As the uterus grows during pregnancy, pelvic organs are pushed downwards and PFMs are continuously exposed to stress and strain due to increased intra-abdominal pressure. This situation negatively affects pelvic support during pregnancy.4 Perineal ultrasounds conducted during the early stages of pregnancy have shown a downward displacement of the pelvic floor, a significant decrease in pelvic floor contractions, and increased bladder and urethral mobility. This is even more pronounced in the later stages of pregnancy.4–6 PFMs play an important role in UI and the thickness and strength of these muscles in continent pregnant women were higher than in those who suffered from incontinence.7 Kegel exercises are the most widely used method of improving PFM strength. This method was described by Arnold Kegel in 1948.8,9 The purpose of these exercises is to strengthen weakened PFM structure and function. Strengthening the PFM through Kegel exercises may solve incontinence problems without the need for surgical intervention. As a result, they can #

2015 Wiley Periodicals, Inc.

be used to prevent the development of UI during both pregnancy and the postpartum period. Several studies have examined the effect of PFM exercises on PFM strength during pregnancy and the postpartum period. However, few studies have examined the effect of PFM exercises on voiding functions during pregnancy and postpartum. In this study, we aimed to examine the effects of PFM exercise during pregnancy and the postpartum period on both the PFM strength and voiding functions. MATERIALS AND METHODS Study Design and Participants

This study was conducted as a randomized controlled design between September 2011 and August 2012 at the Urogynecology Unit of the Gynecology and Obstetrics Department of Trakya University Faculty of Medicine. Christopher Chapple led the peer-review process as the Associate Editor responsible for the paper. Potential conflicts of interest: Nothing to disclose. The study was presented as poster in 6th Congress of National Urogynegology in Istanbul, Turkey, in 23–26 November 2013. *Correspondence to: Hatice Kahyaoglu Sut, Assistant Professor, Trakya University, Faculty of Health Sciences, Department of Obstetrics and Gynecology Nursing, 22030-Edirne/Turkey. E-mail: [email protected] Received 20 June 2014; Accepted 1 December 2014 Published online 3 February 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22728

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Inclusion criteria for participants in this study were pregnant women who were in their third trimester (28th week) and over the age of 18 who were attending the Gynecology and Obstetrics Department of the University Faculty of Medicine. Exclusion criteria included pregnant women who had twin or high-risk pregnancies, urinary tract infections, prolapses, neuropathy, collagen tissue disease, neurological illnesses, diabetes mellitus, chronic pulmonary disease, a history of pelvic surgery, or had a high risk of early delivery. The sample size of the study was determined based on PFM strength. The effect size was calculated as 0.75 based on the de Oliveira et al. report.10 To detect the effect size with an a ¼ 0.05 rate and a minimum power of 80% (b ¼ 0.2) in a 2-sided test, the sample size was calculated as 29 patients for each group. However, we decided to examine 30 patients in each group in order to consider any missing data. Of the 122 pregnant women who were interviewed, 58 were excluded from the study for not meeting the inclusion criteria. The 64 remaining participants were randomly assigned into the Training or Control group using a computer-based system (two participants from each group dropped out during the follow-up). Ethics Considerations

The Trakya University Ethics Committee approved this study. The aims of the study were explained to the participants who agreed to participate in the study and written consent was obtained from all participants at the beginning of their interviews. PFM Training Program

Participants in the Training group were instructed by the researcher on how to perform Kegel exercises; however, no instruction was given to the patients in the Control group. Patients who were assigned to the Training group performed the exercise program by following these steps: (i) The bladder must be emptied prior to exercise; (ii) Exercises can be done in a supine or sitting position by bending the legs at the knee; (iii) Pelvic floor muscles should be contracted by pulling inward as with urine or gas output and held for 10 sec; (iv) Following 10 sec of contraction, the muscles should be completely relaxed; and (v) This contraction should be performed a total of 10 times. These sets of 10 contractions should be performed three times per day (e.g., morning, afternoon, and evening). Women who were assigned to the Training group were regularly called by telephone at two-week time intervals and reminded to do their exercises. Data Collection Instruments and Questionnaires

The patients’ characteristics (demographic-clinical) were collected. Perineometry, uroflowmetry, validated questionnaires (UDI-6, IIQ-7, and OAB-q) and voiding diaries were used to assess the effect of pregnancy and delivery on PFM activity and voiding functions. PFM strength was measured using a manometric perineometry device with a disposable vaginal probe. Voiding functions were measured using uroflowmetry (Voiding volume (ml), Flow time (sn), Qmax (ml/sn), Qmean (ml/sn)) and 3-day voiding diaries. Three validated questionnaires (UDI-6, IIQ-7, and OAB-q) were used to determine the level of urinary symptoms and quality of life (QoL) in patients. The UDI-6 consists of six items questioning urinary stress incontinence, detrusor overactivity, and nonbladder obstruction. The IIQ-7 consists of seven items that questioned how urinary continence during travel, social Neurourology and Urodynamics DOI 10.1002/nau

activity, and physical activity affects the patient and what impact it has on emotional health. Higher scores for the UDI-6 and IIQ-7 indicate a worse health status.11 The OAB-q consists of 25 QoL items that are assessed on a six-point Likert scale. The OAB-q subscales include coping, concern, sleep, and social interaction. The subscale scores and total score are summed and transformed into scores ranging from 0 to 100. A higher score indicates a better QoL.12,13 Measurements of PFM strength, urinary symptoms, QoL, and voiding functions were obtained at week 28, weeks 36–38 of pregnancy, and postpartum weeks 6–8. Statistical Analysis

A one-sample Kolmogorov-Smirnov test was used to test the normality distribution of the numeric variables. Training and Control groups were compared using an independent samples t-test for normally distributed data, and the Mann-Whitney U test for non-normally distributed data. Categorical variables were compared by Chi-square tests (Yates or Fisher) between the Training and Control groups. Differences in changes between the groups were compared with the Mann-Whitney U test. The Friedman test was used for comparison of the three measured values in each group. A P-value of 0.05 for all comparisons). Although a significant difference was not obtained (P ¼ 0.070), caesarean delivery in the Control group (60%) was higher than in the Training group (33.3%); consequently, the average number of vaginal deliveries in the Training group was higher (P ¼ 0.018). Comparisons of PFM strength are shown in Table II and Figure 2. PFM strength in the Training group during postpartum weeks 6–8 was significantly higher than in the Controls (P ¼ 0.002). PFM strength significantly increased in the Training group (P < 0.001); however, it was significantly decreased by weeks 36–38 of pregnancy in the Control group due to the pressure increase on the pelvic floor. PFM strength improvement in the Training group was significantly higher than the Control group (P < 0.001). A comparison of voiding functions between the groups is shown in Table III. Voiding volume, Qmax, Qmean in the Training group, and Qmean in the Control group differed significantly across the three measurements (P < 0.05). However, changes between groups were not significantly different (P > 0.05). A comparison of voiding diary data between the Training and Control groups across three days is shown in Table IV. Both the Training and Control groups’ frequency and urgency levels significantly decreased during the postpartum period compared with prenatal periods (P < 0.001). However, there was no significant difference between the groups (P > 0.05). The UDI-6, IIQ-7, and OAB-q scores for both groups are shown in Table V. In the training group, UDI-6, IIQ-7, and OAB-q scores

Effect of Pregnancy and Delivery on Pelvic Floor

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Fig. 1. Flow chart.

TABLE I. Demographic and Clinical Characteristics of the Training and Control Groups

Age, year BMI, kg/m2 Education None Primary school High school University Working status, yes Physical activity, yes Smoking status, yes Alcohol consumption, yes Caffeinated drink consumption, yes Gravidity Parity Abortion Number of vaginal deliveries Number of caesarean deliveries Delivery type Vaginal Caesarean Mean  Standard deviation; n (%).

Neurourology and Urodynamics DOI 10.1002/nau

Training (n ¼ 30)

Control (n ¼ 30)

P

30.0  6.5 29.9  5.7

27.2  6.3 27.7  5.0

0.100 0.110

1 (3.3) 18 (60.0) 9 (30.0) 2 (6.7) 5 (16.7) 17 (56.7) 1 (3.3) 0 (0.0) 15 (50.0) 2.8  1.5 1.2  1.1 0.3  0.6 0.9  1.2 0.3  0.5

2 (6.7) 20 (66.6) 5 (16.7) 3 (10.0) 6 (20.0) 17 (56.7) 7 (23.3) 0 (0.0) 11 (36.7) 2.3  1.7 0.8  1.1 0.3  0.7 0.4  0.8 0.4  0.7

20 (66.7) 10 (33.3)

12 (40.0) 18 (60.0)

0.619 0.739 1.000 0.052 1.000 0.297 0.057 0.051 0.799 0.018 0.620 0.070

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Sut and Kaplan weeks 36–38 of pregnancy in the Control group and significantly improved during postpartum weeks 6–8 (P < 0.05). DISCUSSION

Fig. 2. Pelvic floor muscle strength.

did not deteriorate during weeks 36–38 of pregnancy; however, they significantly improved during postpartum weeks 6–8 (P < 0.05 for all). Furthermore, the UDI-6 and OAB-q (coping, concern, and total) scores significantly deteriorated during

We sought to examine the effects of PFM exercises during pregnancy and the postpartum period on PFM strength and voiding functions. When we examined the literature on the effects of training on PFM strength, several studies reported that pregnant women who had performed PFM exercises increased their muscle strength.4,10,14–18 Consistent with these results, we observed a significant increase in PFM strength during pregnancy in the Training group; meanwhile, a significant decrease was observed in the Control group. During the postpartum period, PFM strength improvement in the Training group was significantly higher than in the Control group. Overall, PFM strength increased in the Training group and decreased in the Control group. We can therefore infer that the process of pregnancy decreases PFM strength. When we investigated the perineometric measurements in the Control

TABLE II. Comparison of Perineometric Pelvic Floor Muscle Strength (mV) Between the Training and Control Groups Training (n ¼ 30)

Control (n ¼ 30)

P

19.6  9.7 22.6  9.8a a,b 26.0  9.5

Effect of pelvic floor muscle exercise on pelvic floor muscle activity and voiding functions during pregnancy and the postpartum period.

The aim of this study was to investigate the effects of pelvic floor muscle exercise during pregnancy and the postpartum period on pelvic floor muscle...
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