Volume 30, Issue 2 (4-2023)                   RJMS 2023, 30(2): 107-120 | Back to browse issues page

Research code: 99-3-3-19301
Ethics code: IR.IUMS.REC.1399.990
Clinical trials code: IRCT20201214049719N1

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Akbari N, Parsamoin L, Nikjooy A. The Impact of Vaginal Cone Along with the Knack Maneuver on the Severity of Incontinence and Quality of Life in Women with Stress Urinary Incontinence. RJMS 2023; 30 (2) :107-120
URL: http://rjms.iums.ac.ir/article-1-7379-en.html
MSc Student, Department of Reproductive Health &Midwifery, Iran University of Medical Sciences, Tehran, Iran , zohrep@yahoo.com
Abstract:   (760 Views)
Background & Aims: Urinary incontinence is defined as a complaint of any involuntary leakage of urine. This new definition includes a significant range of women who have rarely experienced accidental leakage events. As a result, some studies have estimated the prevalence of urinary incontinence at 60%. Stress urinary incontinence is the most common type of urinary incontinence and is a term used to describe involuntary urination during physical activity such as coughing, sneezing, laughing, or lifting heavy objects, etc., when the pressure inside the bladder exceeds the pressure. The urethral closure arrives, it is used. Numerous factors, such as sphincter dysfunction, pelvic floor muscles, connective tissues, or nerve structures, may cause or develop urinary stress incontinence. Approximately 4% to 35% of adult women worldwide suffer from stress urinary incontinence. Limited studies have been conducted on the prevalence of urinary incontinence in Iran. In the study of Rashidi., The overall prevalence of urinary incontinence in Iranian women was 46%. In the study of Bakui., Which studied the prevalence of postpartum urinary incontinence in women referring to health centers in Babul, the frequency of postpartum urinary incontinence was reported to be 19.4%. Urinary incontinence is a distressing condition emotionally, physically, socially, and economically. It has been shown to be associated with embarrassment, anxiety and depression and has a significant negative impact on quality of life. Despite the widespread impact of urinary incontinence on quality of life, only a small number of women seek treatment and most of them live in silence, so the disease is never diagnosed or treated. Because most women do not seek treatment in the early stages of urinary incontinence (for example, mild to moderate urinary incontinence), they eventually present with advanced symptoms (severe urinary incontinence), at which time there is an opportunity to prevent or help regress the disease. It is demolished. Given this situation, the need for appropriate prevention and treatment to reduce the negative impact of stress urinary incontinence on women's lives is clear, and most research on current therapies for the management of stress urinary incontinence seeks to improve patients' quality of life. Non-surgical interventions are recommended by the International Association of Incontinence as the first line of treatment for uncomplicated urinary incontinence in women. Pelvic floor muscle training is the basis of non-surgical treatment of urinary stress incontinence. This treatment is based on the hypothesis that training to identify and strengthen the pelvic floor muscles by increasing the support of the urethra and bladder and improving the function of the urethral sphincter muscle neutralizes the weakness of the pelvic floor muscles. The easiest way for women to train their pelvic floor muscles is to insert cone-shaped weights into the vagina and then contract the pelvic floor muscles to prevent the weight from falling out. On the other hand, the timing of pelvic floor muscle contraction, which is transmitted from the brain to the muscle by the nervous system, is an important factor in controlling urination. In other words, when there is a sudden increase in intra-abdominal pressure during sneezing, coughing, etc., the pelvic floor muscles must unconsciously and reflexively activate their rapid contraction fibers to prevent involuntary leakage of urine by neutralizing the increase in pressure, but In people with stress urinary incontinence, the coordination and timing of pelvic floor muscle function is impaired during increased intra-abdominal pressure, and the reflex and subconscious function of the pelvic floor muscles is impaired in response to a sudden increase in intra-abdominal pressure, which means that Although having strong muscles in the pelvis is necessary for proper contraction, a timely contraction is also necessary to prevent involuntary leakage of urine. In other words, a strong muscle that is not activated in time during an increase in intra-abdominal pressure cannot prevent urinary incontinence. Since the negative effect of urinary incontinence on daily activities and quality of life of women is very significant and women with more severe urinary incontinence and weaker pelvic floor muscles have lower quality of life, it is necessary to take measures to increase the contractile strength of pelvic floor muscles and promote health. Think of the urinary tract. Also, according to research, the result of cone therapy is recognizing and strengthening the pelvic floor muscles and does not play a role in the simultaneous action of rapid fibers of contraction of the pelvic floor muscles when increasing intra-abdominal pressure, if, as mentioned, the timing of urethral closure Timely contraction of the pelvic floor muscles is an important factor in controlling urination and should be considered. Therefore, it seems that in addition to strengthening the pelvic floor muscles with the vaginal cone, there is a need to train movement control strategies (control motor) to change the timing of pelvic floor muscle contraction and start their activity while increasing intra-abdominal pressure to the Knack maneuver (speed and coordination). It is said to be necessary to prevent involuntary leakage of urine. Miller et al. In their study justified the effect of the Knack maneuver as an immediate method and early response to pelvic floor exercise regimens that are widely used in women with stress urinary incontinence. Therefore, this study was performed to evaluate the effectiveness of vaginal cone with the Knack maneuver on the severity of incontinence and quality of life in women with stress urinary incontinence compared to the vaginal cone.
Methods: In this randomized controlled clinical trial that was performed in the pelvic floor dysfunction clinic of the Faculty of Rehabilitation Sciences, University of Iran, during the years 2021-2022, 76 patients with stress urinary incontinence were present who were randomly assigned to two groups of vaginal cones and were randomly divided into two groups: vaginal cone with the Knack maneuver and vaginal cone. Participants in both groups were finally accepted after an initial evaluation session. The initial evaluation included educating patients in plain language about the anatomy of the pelvic floor muscles, their proper contraction, and the benefits of therapeutic cones for the women participating in the study. Complete urine test (analysis and culture) to rule out participants' urinary tract infections, specific examinations of women in standard lithotomy with an empty bladder, and no vaginal bleeding. Pelvic visceral prolapse was also considered and the degree of each type was determined based on the POP-Q system, which is a standard approved by the International Continent Control Society and recorded in a special sheet. Grade 3 and 4 prolapses removed the sample from the study. Therapeutic interventions were performed for 12 weeks for both groups. The cone treatment protocol was common for both groups, and the intervention group received Knack exercises in addition to the cone treatment protocol. All patients before and after the intervention were evaluated for the severity of urinary stress incontinence due to increased intra-abdominal pressure and the number of involuntary leakage of urine with Urinary Diary, pelvic floor muscle contraction with Dynamometer and quality of life with Incontinence quality of life questionnaire. Paired and Wilcoxon t-tests were used for intragroup analysis and Independent Sample t-test and Mann-Whitney tests were used to compare the differences between the two groups.
Results: There was a significant difference between all values ​​before and after the intervention in each group (P<0.05). Also, comparison between treatment groups showed significant differences in quality of life (P=0.02), pelvic floor muscle contraction strength (P=0.00), urine leakage due to increased intra-abdominal pressure (P=0.01) and the number of leaks (P=0.01).
Conclusion: According to the findings of this study, the treatment of cone protocol with the Knack maneuver can be suggested as a treatment strategy for patients with stress urinary incontinence.
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Type of Study: Research | Subject: Midwifery

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