Is physical activity influenced by urinary incontinence?

Transcription

1 BJOG: an International Journal of Obstetrics and Gynaecology May 2004, Vol. 111, pp DOI: /j x Is physical activity influenced by urinary incontinence? Beata Stach-Lempinen a, *, Clas-Håkan Nygård b, Pekka Laippala b, Riina Metsänoja b, Erkki Kujansuu c Objective To evaluate physical activity among urinary incontinent women seeking treatment and to assess the change of physical activity after treatment. Design Part of a prospective observational intervention study to examine the factors influencing the severity of urinary incontinence. Setting Tampere University Hospital referral unit. Population Eighty-two urinary incontinent women were evaluated in the baseline and 69 (84%) one year (mean 13 months, range 6 21) after treatment. Methods Physical activity was measured by self-report questionnaire and electronic motion sensor: Caltrac accelerometer worn by women for one week. The diagnosis and severity of urinary incontinence was estimated on the basis of urodynamics, pad test, diary and incontinence-specific quality of life measures. Treatment outcome was assessed according to objective parameters and patients satisfaction. Main outcome measures Physical activity at work, leisure and sport expressed in MET (metabolic unit) and kilocalories, change in physical activity after treatment. Results Twenty-one (25.6%) of all women reported exercise of more than three times per week. Incontinent women with the highest leisure time activity 6 MET (n ¼ 23, above 75th centile) were younger; they had less body mass index and greater urine leakage than others. One year after treatment, there was no change in any parameters of physical activities. Also exercise habits among women who were completely dry (n ¼ 37) after treatment were not changed. Conclusion Urinary incontinent women who seek treatment are as physically active as the normal population. Even after successful incontinence treatment, exercise habits do not change. INTRODUCTION Urinary incontinence affects millions of physically active women of different ages worldwide. The general opinion is that incontinent women modify their behaviour by wearing pads during exercise, changing or ceasing the exercise for fear of leakage and odour. 1 3 This impression however is not supported by facts. It is possible that intensity of sport or fitness habits has an effect on the treatment-seeking behaviour. For example, physically active women do not want to change their exercise habits and are unwilling to wear pads and actively seek relief for their problem. Except for a few epidemiological studies, 2,3 there a Department of Obstetrics and Gynaecology, South Karelia Central Hospital, Lappeenranta, Finland b Tampere School of Public Health, Biometry Unit, University of Tampere, Research Unit, Tampere University Hospital, Finland c Department of Obstetrics and Gynaecology, Tampere University Hospital, Finland * Correspondence: Dr B. Stach-Lempinen, Department of Obstetrics and Gynaecology, South Karelia Central Hospital, Valto Käkelän katu 4, FIN Lappeenranta, Finland. D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology is a lack of data about physical activities among incontinent women seeking treatment and how exercise habits change after treatment. This study had three major aims: Firstly, to measure the physical activity at work and in leisure time for incontinent women seeking treatment. Secondly, to describe the relationships between incontinence status (severity and pelvic muscle status), physical activity and quality of life and thirdly, to investigate whether physical activity changes after successful treatment. METHODS This study is part of an extensive, prospective clinical intervention study to examine the factors influencing the severity of urinary incontinence and the impact on healthrelated quality of life, parts of which have already been published. 4 6 The ethical committee of Tampere University Hospital approved the study, and written consent was given by the women at recruitment. One hundred and twenty-three consecutive women, referred to the Department of Obstetrics and Gynaecology at the Tampere University Hospital for symptomatic urinary incontinence between January 1996 and March 1997 were eligible for the study. Twenty-two were excluded according to predefined exclusion criteria.

2 476 B. STACH-LEMPINEN ET AL. Tampere University Hospital offers the medical service for the town of Tampere at a secondary referral level and for others at a tertiary referral unit. There is a well functioning physiotherapy unit specialised to treat urinary incontinent women. Exclusion criteria included: diabetic neuropathy, recently diagnosed cancer or other serious chronic conditions that may have resulted in neurogenic bladder dysfunction and patients who had undergone incontinence surgery in the last five years. Sixteen women did not wish to participate in the intervention study. The remaining 85 patients participating in the intervention study received a comprehensive clinical assessment consisting of a history and physical examination, urine culture, residual urine measurement, urodynamic evaluation, standardised 48-hour pad testing and frequency/volume chart. During bimanual gynaecological examination, the same doctor assessed by palpation the patients ability to detect and contract the pelvic muscles. We used a three-point scale based on the modified Oxford grading system: 1 ¼ no voluntary contraction is the equivalent of score 0 (nil) of the Oxford scale; 2 ¼ weak contraction is the equivalent of Oxford score 1(flicker of muscle contraction) and 2 (weak contraction). Score 3 (good contraction) is the equivalent of score 3 (medium: slight lift of examiner s finger, no resistance), 4 (strong: elevation of examiner s finger against light resistance) and 5 (very strong: elevation of examiner s finger against strong resistance) of the Oxford scale. 7 This was not validated. However, all women sent to physiotherapy underwent re-evaluation by palpation and assessment of pelvic muscle activity using biofeedback probe. The patients estimated the severity of their urinary incontinence using the visual analogue scale (a 10 cm line ranging from 0 not bothered by incontinence to 10 severely bothered) and by completing an incontinencespecific quality of life questionnaire (Urinary Incontinence Severity Score). These instruments have previously been validated and provided good reliability, validity and responsiveness to treatment among urinary incontinent women. 4 The Urinary Incontinence Severity Score questionnaire consists of 10 questions designed to assess the amount of leakage, the degree to which urinary incontinence affects aspects of women s daily lives and need to use pads. The responses are scored 0 2, yielding a total score between 0 and 20. The lower scores reflect better quality of life. Stress incontinence was diagnosed if the patient had a positive cough stress test with a comfortably filled bladder in the supine or standing position and filling cystometry revealed a stable detrusor. Urge incontinence was diagnosed when urine loss followed urgency associated with detrusor contractions exceeding 15 cm of water (idiopathic detrusor overactivity) or if we observed increased bladder sensation during filling cystometry, in the presence of urine leakage on a pad test greater than 8 g/24 hours and in the absence of stress incontinence. After accurate diagnosis was established, all patients were given conservative (n ¼ 53) or operative treatment (n ¼ 27) according to severity and type of urinary incontinence and based on the treatment protocols (below). Two patients did not want treatment because they felt improved after the first visit. Well-motivated women who had a weak pelvic floor muscle and had not been treated previously were referred to physiotherapy. The conservative treatment alternatives were pelvic floor exercises accompanied by electrostimulation in some cases. Bladder training and anticholinergic drugs were used for urge incontinence. Vaginal oestradiol 25 Ag twice weekly was prescribed for all patients who used neither local oestrogen nor hormone replacement therapy before the study. Surgical intervention (a sling operation) was undertaken in eight cases of low pressure urethra (MUCP <20 cm H 2 O). Colposuspension was done in 17 cases, one patient had a TVT and one had bone anchoring sutures. Data on physical activity was collected using two different measures: a valid and reliable self-report questionnaire which was used in Mini-Finland Study 8,9 and an electronic motion sensor Caltrac accelerometer. 10 The women were asked to assess physical activity at work during the preceding 12 months on a seven-point scale accompanied by illustrations and descriptions of the various types of work corresponding to each scale point. 11 The scale ran from 0 (not at work) to 6 (very heavy manual work). Each scale point was also evaluated using MET (metabolic unit) values from 1.5 MET to over 10 MET. One MET is defined as the energy expenditure for sitting quietly, which for the average adult is approximately 1 kcal kg 1 body weight hour 1. For example, a 2-MET activity requires two times the metabolic energy expenditure of sitting quietly. 12,13 Exercise during leisure was first graded into three levels: (i) little physical exercise, (ii) physical exercise in the connection with other hobbies or irregular physical exercise and (iii) regular physical exercise. As regards regular physical exercise, questions were asked about the type of activity or sport and about frequency, the duration and intensity, the latter being structured according to feelings of getting out of breath and of sweating. Each activity level was changed into a corresponding MET value. In calculating the MET value for regular exercise, the intensity of the activity was taken into account. For example, MET values for walking varied, depending on the intensity from 3 to 8 MET and for running from 7 to 12.5 MET. As regards exercise while going to work, questions were asked mainly in three categories: travel by motor vehicle, bicycle, or on foot during summer and winter separately. Exercise levels while going to work were also changed into MET values. The MET values were taken from many different studies. 8,12,14

3 URINARY INCONTINENCE AND PHYSICAL ACTIVITY 477 From the different MET values, it was possible to obtain the energy intensity at work, the highest intensity during leisure time, the mean of intensities while going to work, the sum index of these three intensities and the highest MET value from all activities. The Personal Activity Computer (Caltrac) is a small, portable accelerometer which measures vertical acceleration and deceleration of the body and translates motion into activity scores. It has shown a high test retest reliability and has demonstrated a strong relationship with several measures of energy expenditure in laboratory tests. 10,15 Patients wore the Caltrac attached to a belt for seven consecutive days except during sleep and registered the Caltrac scores in the diary. The physical activity was divided into three classes: 1 ¼ physical activity at work, 2 ¼ leisure time activity (normal living: daily chores, social activity, hobbies) and 3 ¼ sport/exercise. The activity mode in Caltrac showed the energy expenditure during physical activity expressed in kilocalories. Each time a new class of activity started women marked the scores in their diary. Therefore, from each individual woman, scores for total physical activity per week, specific scores for work, leisure and sport were obtained. Furthermore, we estimated the highest intensity of physical activity. Sixty-nine (84%) patients (52 with stress urinary incontinence and 17 with urge or mixed) were re-evaluated 6 21(mean 13 SD 3.0) months after treatment. This includes all surgical patients and 31 patients who underwent physiotherapy and 11 patients with pharmacological therapy. We asked during interview, patients to assess treatment outcome subjectively as cure, significant improvement, minor improvement or failure. Treatment effect was also assessed by change in 48-hour pad test, visual analogue scale and Urinary Incontinence Severity Score. Change of physical activity was evaluated by completing the questionnaire on the physical activity and having the patients wear the Caltrac for one week. One-way analysis of variance was used to test differences between groups defined by different amount of reported exercise in leisure time. Otherwise continuous data were tested by Mann Whitney U test and Wilcoxon test. Crosstabulated data were analysed with Pearson s m 2 test and odds ratio was used in the analysis. The limit for significance was set equal to Data analysis was carried out using SPSS/Win (Version 10.0). RESULTS Of the 85 women, 82 had objective evidence of urinary incontinence, 57 (67%) of them had stress incontinence, 14 (16%) had urge incontinence and 11 (13%) had a mixed condition. Three women (4%) had normal urodynamic findings with no clinical signs of UI. Women s characteristics are given in Table 1. Table 1. Patient characterization (n ¼ 82). No. (%) of patients Age (year): mean 52.1, range: (12.2) (51.2) (31.7) 70þ 4 (4.9) Duration of symptoms (years): median 7.5, range 1 40 <1 3 (3.7) (39.0) (40.2) 16þ 14 (17.1) Parity: median 2, range (4.9) (61) > 3 28 (34.1) Type of urinary incontinence Stress incontinence 57 (70) Urge or mixed incontinence (urge F stress) 25 (30.0) All 82 women correctly completed the questionnaire about their physical activity. During the pretreatment investigation, three of the Caltracs mechanically failed and nine women did not correctly fill the diary. Finally, there were data on 72 women available in the baseline. After treatment, all Caltracs worked but only 50 women properly completed the diary. From all patients, 26 (31.7%) were not at work, 20 (24.4%) working in occupations assessed as light or other sedentary work, 30 (36.6%) physically light standing or medium heavy work and 6 (7.3%) heavy or very heavy manual work. Eleven women (13.4%) reported little leisure time exercise, 34 (41.5%) exercised irregularly or in connection with other hobbies and 37 (45.1%) women exercised regularly. There were no differences between those groups in age, amount of urine leakage, parity and duration of symptoms, urodynamics parameters, frequency and quality of life scores. Women who exercised regularly had smaller body mass index (mean 26.0, SD 4.7) compared with those who exercised irregularly (mean 29, SD 5.4) or only little (mean 30, SD 4.9; one-way analysis of variance P ¼ 0.043). Twenty-one (25, 6%) of all women reported exercise of more than three times per week. Among those who exercised regularly, 16 (43.2%) exercised one to two times per week and 21 (56.8%) over three times a week. Fifteen (40.5%) reported exercising 1 hour at one time. Walking was the most popular kind of regular physical exercise among incontinent women, undertaken by 65% of women. The next were fitness gymnastics (46%), cycling (41%), swimming (32%) and cross-country skiing (27%). Incontinent women with leisure time activity above 75th centile (6 MET, n ¼ 23) were younger, they had less

4 478 B. STACH-LEMPINEN ET AL. Table 2. The patients characterisation and parameters of severity of urinary incontinence according to intensity of physical activity at leisure time. Highest intensity <6 MET (n ¼ 59, 72%) Intensity of physical activity at leisure time Highest intensity 6 MET (n ¼ 23, 28%) Age Median Range 25 75th centiles Body mass index Median Range 25 75th centiles Urine leakage (g/24 hours) Median Range 25 75th centiles Frequency n/24 hours Median Range 25 75th centiles Urinary Incontinence Severity Score Median Range 25 75th centiles Visual analogue scale Median Range 25 75th centiles Pelvic muscles, n (%) No detection 15 (25) 3 (13) Weak contraction 28 (48) 10 (43.5) Good contraction 16 (27) 10 (43.5) 1 P values based on Mann Whitney U test. 2 P value based on Pearson s m 2 test. body mass index and more leakage in the 48-hour pad test than others (Table 2). There were no differences between incontinence-specific quality of life measured by Urinary Incontinence Severity Score and visual analogue scale P scores. The contractility of pelvic floor muscles did not correlate with the intensity of the physical activity. Operated women had more severe leakage than those who were referred to physiotherapy [pad test, median (Q 25 Q 75 ) ( ) versus 26.6 ( ), P ¼ Mann Whitney test], but there were no differences between other parameters age, duration, deliveries, years of menopause and any parameters of physical activity. One year after treatment, there was no change in any parameters of physical activities parameters measured by Caltrac or assessed as MET on the basis of the questionnaires (Table 3). For clarity, not all the parameters of physical activities are shown. The physical activity of women, who reported only little or irregular physical exercise before treatment, did not increase. Also, physical activity habits among women who were completely dry (pad test negative, n ¼ 37) were not changed. There were no more regular exercisers among those objectively cured women, than among those who suffer from urine leakage (pad test >8 g/24 hours) (41% vs 36%, P ¼ 0.69, Pearson s m 2 test OR 0.80, CI ). We analysed all data separately for women with stress incontinence and those with urge (+mixed) and the results remained the same. DISCUSSION This is the first study measuring, by objective means, the physical activity of urinary incontinent women seeking treatment and the effect of treatment on the exercise habits. We found that urinary incontinent women who are referred to a specialised incontinence unit treatment were physically very active and that after successful treatment, exercise habits are unchanged. However, our study sample is small which might cause inability to detect differences in physical activity. Possible bias in our sample could also have arisen because not all women wore Caltracs and completed diaries especially in the post-treatment evaluation. The Caltrac sum reduction after treatment was Table 3. Comparison of changes in the baseline and post-treatment in pad test, quality of life scores and physical activity parameters according to patients satisfaction with treatment. Values are expressed in median (range 25th 75th centiles). P values are based on Wilcoxon ranked paired. At baseline Post-treatment P Cure/significantly improved (N = 42) Pad test (g/24 hours) 26.5 ( ) 3.0 ( ) <0.001 Visual analogue scale 8.0 ( ) 1.0 ( ) <0.001 Urinary Incontinence Severity Score 11.0 ( ) 2.0 ( ) <0.001 MET sum ( ) 9.0 ( ) 0.32 MET sport ( ) 3.8 ( ) 0.61 Caltrac sum (kcal/week) ( ) 3221 ( ) Caltrac sport (kcal/week) (30 977) 543 ( ) Sum of MET at work, leisure and sport. 2 Mean MET at sport. 3 Sum of Caltrac scores at work, leisure and sport. 4 Sum of Caltrac scores at sport.

5 URINARY INCONTINENCE AND PHYSICAL ACTIVITY 479 statistically significant (P ¼ 0.049) but might not be clinically significant. The results must therefore be interpreted cautiously. There were no differences in distribution of physical activity in women of working age (<65 years), by comparison with the normal Finnish population. 9 Almost half of our study population exercised regularly in their spare time and 25% reported exercise more than three times weekly. According to a recently published national health survey Health 2000 ( publications/2001/b2.pdf) about health and functional capacity of Finns, 25% of aged old women reported exercise at least four times per week. The same level of regular physical activity was reported in other developed countries, although a comparison between studies is very difficult because of variation in definition and study population. On the basis of the report from Behaviour Risk Factor Surveillance System in 2000, a total of 26.2% of adult Americans reported any type of physical activity for >30 minutes per day, >5 days per week or vigorous-intensity activity for >20 minutes per day, >3 days per week. 16 Contradictory data have been found on physical activity among urinary incontinent women. Recently, Brown and Miller 3 found that physical activity was impaired with increased urine leakage. Two previous studies did not find any association between urinary incontinence and physical activity among middle-aged women. 17,18 Nygaard et al. 2 studied 326 women (mean age 38.5) presenting to a private gynaecology office and found that 20% of incontinent exercisers stopped their exercise because of leakage, whereas 18% changed the way a specific exercise was done and 55% wore a pad during exercise. Only 35% had discussed their incontinence with a health care professional. In a general population study from Australia, 3 there was an association between incontinence and physical activity, such that women with more frequent urinary leakage were also more likely to report low levels of physical activity. According to epidemiological studies, women appeared to be very adaptive to their incontinence problem. It seems that there are different behaviours among incontinent exercisers. In those who cope women stop or change their exercise habits and/or wear pads and manage with leakage. The prevalence of regularly exercising women in our study did not differ from those reported in the general population, which can suggest that physically very active women who seek treatment want to continue their exercises and remain dry. Although we did not find a linear correlation between the amount of leakage and physical activity, physically very active women (MET >75 centile) had greater leakage and a lesser body mass index than more passive women. It is interesting that among the latter the level of quality of life impairment was the same as among very active women although inactive women had significantly less urine leakage. The impact of urinary incontinence on health-related quality of life is not directly related to the degree of urinary incontinence measured objectively. 1,19 As well as the type and amount of urine leakage, women s varying social and physical activities and mental state could play a role in their subjective assessment of severity of urinary incontinence and might affect seeking treatment. It is possible that for women who exercise very intensively, the amount of leakage is the most important factor impairing incontinence-specific quality of life. On the other hand, other factors could play an important role in the modification of quality of life of physically passive women. We have previously shown that major depression has more severely reduced incontinence-specific quality of life than the amount of urine leakage. 5 According to Nygaard s study, incontinent women prefer less energetic types of exercise (e.g. without jumping) which do not increase abdominal pressure. 2 The most common physical activities were the same as among the normal Finnish female population: walking, fitness gymnastics, cycling, swimming and cross-country skiing. The contractility of the pelvic muscle did not correlate with the level of physical activity. Perineometry, which we have not routinely used, would have given more accurate information of pelvic floor muscle strength, however, good correlation between digital palpation and perineometry has been reported. 20 Recent studies have shown that pelvic floor exercise is a very effective treatment for both stress and urge incontinence 21,22 that women of all ages need guidance as how to identify, exercise and use those muscles during fitness and aerobic training to prevent urinary incontinence and improve bladder control. There are many factors which modified the habits of exercise. The urine leakage has been considered as one of the evident restrictive factors. However, our results do not confirm that to become dry results in increase in physical activity. Independent of treatment outcome, physical activity did not change. One year after treatment, exercisers continued their sports and others were as passive as before even though they had become dry. Acknowledgements This study was performed at the Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland and South Karelian Central Hospital, Lappeenranta, Finland. The study was supported by grants from the Medical Research Fund of Tampere University Hospital and South Karelia Central Hospital, Finland. References 1. Norton C. The effects of urinary incontinence in women. Int Rehabil Med 1982;4:9 14.

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