COMPARISON OF 4, 8 AND 12-WEEK KEGEL

EXERCISE WITH BIOFEEDBACK IN SYMPTOMS

ASSOCIATED INCONTINENCE, MUSCULAR
STRENGTH, AND QUALITY OF LIFE OUTCOME IN
WOMEN DIAGNOSED WITH STRESS URINARY
INCONTINENCE.

David Oktavianus, MD
Supervisor:
Surahman Hakim MD, OBGYN (C)

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

FACULTY OF MEDICINE UNIVERSITAS INDONESIA
 BACKGROUND
• Based on International Continence Society (ICS), stress urinary incontinence is
the complaint of any involuntary loss of urine on effort or physical exertion (e.g
sport activities) or on sneezing or coughing.1
Background • 2 theories on the mechanism of stress urinary incontinence:
80-90%
Intrinsic Sphincteric Deficiency2 10-20%
Objective Urethral Hypermobility3

Method

Result

Discussion

weakening of the pelvic floor muscles

Conclusion that support the bladder and urethra weakness of the urethral sphincter.

1. Delaney JOL. structural support of the urethra as it related to stress urinary incontinence; the hammock hypothesis. American journal of obstetrics and gynecology
1994;170:1713-20.
2. Herschorn S. Female pelvic floor anatomy: the pelvic floor, supporting structures, and pelvic organs. Reviews in urology 2004;6 Suppl 5:S2-s10.
3. Walters M, Karram MM. Anatomy of the lower urinary tract and pelvic floor. book, Clinical Urogynecology 1993:3-16.
 BACKGROUND

Kegel exercise or pelvic floor muscle training as the

first line conservative management, which is easy,
simple and effective.
Background
Dr. Arnold
Kegel (1948)
Objective
International Consultation on
Incontinence
Method

IUGA recommendation mentions ICI recommendation mentions that

Result
that practicing kegel exercise practicing kegel exercise twice a week, 3
twice a week, 3 sets of 8-12 sets of 8-12 maximal contractions 3
maximal contractions 3 times a times a day for 8- 12 weeks.
Discussion
day for 6 months.

Coclusion
Radzimińska A SA, Weber-Rajek M, Styczyńska H, Strojek K, Piekorz Z. The impact of pelvic floor muscle training on the quality of life of women with urinary
incontinence: a systematic literature review. Clin Interv Aging 2018;13:957-65
Marcos E Fernandez-Cuadros MFD-R, Maria Jesus Albaladejo-Florin. Manometric Biofeedback Effectiveness on Urinary Incontinence and Quality of Life: A Non-
Randomized Control Trial. Middle East J Rehabil Health In press(In press) 2017.
 BACKGROUND

• Duration variety of Kegel exercise induce the researcher to find the

effective duration of Kegel exercise. There are 2 parameters to evaluate
outcome, which are subjective and objective.
Background
Subjective (Questionnaire about urinary symptoms (UDI-6) dan Quality of
life (IIQ-7))
Objective
• Kashanian et al shows that there is a significant improvement in both
UDI-6 and IIQ-7 scores after 12 weeks of Kegel exercise (p=0.000).1
Method • Cavkaytar et al shows that there was statistically significant lower scores
in both IIQ-7 and UDI-6 before and after 8 weeks Kegel exercise
(p<0.001).2
Result
• Donahoe et al shows that there is statistically significant improvement in
both UDI-6 and IIQ-7 before, 4, 8, and 12 weeks (p<0.05).3
Discussion
1. Kashanian M AS, Nazemi M, Bahasadri S. Evaluation of the effect of pelvic floor muscle training (PFMT or Kegel exercise) and
assisted pelvic floor muscle training (APFMT) by a resistance device (Kegelmaster device) on the urinary incontinence in women.
European journal of obstetrics, gynecology, and reproductive biology 2011 Nov 1;159:218-23
2. Cavkaytar S KM, Topcu HO, Aksakal OS, Doğanay M. Effect of home-based Kegel exercises on quality of life in women with stress and
Coclusion mixed urinary incontinence. J Obstet Gynaecol 2015;35:407-10.
3. Donahoe-Fillmore B, Chorny W, Brahler C, Ingley A, Kennedy J, Osterfeld V. A Comparison of Two Pelvic Floor Muscle Training
Programs in Females with Stress Urinary Incontinence: A Pilot Study. Journal of Applied Research In Clinical and Applied Therapeutics
2011;11.
 BACKGROUND

Objective Improvement in pelvic muscle strength

• Bø et al shows that there was significant improvements in increasing
Background muscle strength after 6 months Kegel exercise (P < 0,001).1
• Yoon et al shows the benefits of Kegel exercises in significantly increasing
the peak pressure of pelvic muscles after 4 weeks and maintaining the
Objective
same level after 8 weeks. (P<0,001)2.
• Marcos et al shows that after 3 weeks of manometric-Biofeedback
Method protocol, the maximal and mean manometric values increased to 35 ±
20.85 and 7.45 ± 4.92 mmHg, respectively, all with statistical significance
(P < 0.001).3
Result

Discussion
1. Bø K. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? International urogynecology journal
2004;15:76-84.
2. Yoon HS, Song HH, Ro YJ. A comparison of effectiveness of bladder training and pelvic muscle exercise on female urinary incontinence. International journal of
Coclusion nursing studies 2003;40:45-50.
3. Marcos E Fernandez-Cuadros MFD-R, Maria Jesus Albaladejo-Florin. Manometric Biofeedback Effectiveness on Urinary Incontinence and Quality of Life: A Non-
Randomized Control Trial. Middle East J Rehabil Health In press(In press) 2017.
 Objective

The aim of this study was to evaluate the effect of

Background
Kegel Exercise for 4, 8, and 12 weeks on symptoms
Objective associated incontinence, muscular strength and
quality of life outcomes in women diagnosed with
Method
stress urinary incontinence.
Result

Discussion

Coclusion
 Method

Research Design

Background • Descriptive observational study

Place
Objective
• Cipto Mangunkusumo General Hospital
Sample recruitment
Method
• November 2018- June 2019
Result Sample exercise duration

• July 2019- September 2019

Discussion
Research sample

Coclusion
• All women suffering stress urinary incontinence in
 Sample Size

N= ( Z + Z ) S 2
X1-X2
= 19
Background

Objective N : sample size

Z : The probability of falsely rejecting a true null hypothesis is 1.96
(α=5%)
Method
Z : The probability of failing to reject a false null hypothesis (β)0.84
(α=10 %)
Result S : the standard deviation of the population being studied
X1-X2 : Difference in means

Discussion

Coclusion
 Inclusion

Women who
Background Women with want to
good cognitive document her
Kegel exercise
Objective

Method women with

women who
urinary
agreed to join
symptoms based
Result the study
on QUID >4
Inclusion
Discussion
criteria.

Coclusion
 Exclusion criteria

On medication
for
incontinence

60 minutes pad 1.Urinary tract

Background test < 2 gr infection

Objective

Exclusion
Method criterias
Uterine
Chemoradiation prolapse grade
3 and 4
Result

History of
Discussion urinary Incontinence
Surgery, such as Kelly
Low back pain
plication, urethral
sling and
Coclusion colposuspension
 DROP-OUT

• Subject can’t be contacted

1

Background • Subject don’t complete the activity book for 1 week.

2

Objective • Subject can’t attend > 2 times for biofeedback

3

• Subject unable to demonstrate the Kegel exercise

Method 4 independently.

Result
• Subject who are uncooperative.
5

• Subject who can’t complete the Kegel exercise for 12 weeks.

Discussion 6

• Subject who undergo the urinary Incontinence Surgery

Coclusion 7 during research.
 Sample recruitment

Suspect SUI
55 subjects

Background Inclusion Exclusion

35 Subjects 20 Subjects

Objective

Complete Kegel
Method Drop out
exercise
N=8
20 Subjects
Result
3 subjects with
LBP with Analyzed
1 Subject
Discussion 20 subjects
no
1 referral
Subject living
2 1
letter
far subject have
away
Subjects
urinary
refusedIncontinence
the
Coclusion Surgery
exercise
 1 step.
Background Slow exercise (slow-twitch muscle exercise)
Step: Contraction for 5 seconds and relax 10 second
5 times
Objective Lfast exercise (fast-twitch muscle exercise)
Step: Contraction for 2 seconds and relax 4 second
5 times
Method

Result

Discussion

Coclusion
 1st visit

Background
60.0
Every 2 weeks 40.0
20.0
Objective 0.0
Awal 4 mgg 8 mgg 12 mgg

Method
60.0
40.0
20.0
0.0
Result Awal 4 mgg 8 mgg 12 mgg

Every month

Discussion

UDI-6 IIQ-7
Coclusion
Background RESULTS
Objective

Method

Result

Discussion

Coclusion
 Maternal Characteristics Distribution
Subject Characteristics Frequency Percent
Age
31 – 55 years 12 60%
56 – 78 years 8 40%
Nutritional Status
Normoweight 1 5%
Overweight 6 30%
Background Obese 13 65%
Occupation
Moderate (Housewife) 12 60%
Objective Heavy (Nurse) 8 40%
Parity
Primigravid 2 10%
Method 2-3 Children 6 30%
>3 Children 12 60%
Obstetrical status

Result Cesarean section 1 5%

Vaginal delivery < 2 times 2 10%
Vaginal delivery > 2 times 17 85%
Duration of incontinence symptoms
Discussion
< 2 months 9 45%
2 – 5 months 11 55%
Degree of stress urinary incontinence
Coclusion
Mild 19 95%
Moderate 1 5%
 Comparison of on symptoms associated incontinence UDI-6 before, 4 , 8,
and 12 weeks Kegel exercise

Table 2. Median, minimum, maximum, and p-value of UDI-6

Improvements in the scores Median Min - Max p-value

Background UDI-6 before 50,0 29,1-66,6

UDI-6 4 weeks-Kegel exercise 33.3 12,5- 50,0 0.003
UDI-6 8 weeks-Kegel exercise 25,0 8,3-45,8 0.002
Objective
UDI-6 12 weeks-Kegel exercise 8,3 0-29,1 0.001
Wilcoxon -test
Method statistically significant if p <0.05

Friedman test < 0.001

Result
There is a significant difference in symptoms of incontinence (UDI-6)
at 4 weeks, 8 weeks and 12 weeks of Kegel exercises (p <0.05); (p
Discussion
<0.05); and (p <0.05).

Conclusion
 Comparison of on 60 minutes – pad test before, 4 , 8, and 12 weeks
Kegel exercise

Table 3. Median, minimum, maximum, and p-value of 60 minutes pad

test.
Variables Median (g) Min-Max (g) p-value

Background 60 minutes pad test pre-test 4,0 3,0-11,0

60 minutes pad test 4 weeks-Kegel exercise 2,0 1,0-8,0 < 0.001
60 minutes pad test 8 weeks-Kegel exercise 2,00 0-8,0 0.063
Objective
60 minutes pad test 12 weeks-Kegel exercise 1,00 0-6,0 <0.05
Wilcoxon -test
Method statistically significant if p <0.05
Friedman test < 0.001

Result
There is a significant difference in the comparison of the 60 minutes
pad test between before and 4 weeks of Kegel exercises (p <0.001) and
Discussion
the comparison of the 60 minutes pad tests between 8 weeks of Kegel
exercises and 12 weeks of Kegel exercises (p <0.05)
Conclusion
 Comparison of on slow-fiber muscle before, 4 , 8, and 12 weeks Kegel
exercise

Table 4. Median, minimum, maximum, and p-value of slow twitch muscle

strength.
Variables Median Min- Max p- value
Background
pre-test 23,0 7,0- 53,0
4 weeks-Kegel exercise 25,0 9,0- 60,0 0.556
Objective
8 weeks-Kegel exercise 30,0 7,0- 55,0 0.001
12 weeks-Kegel exercise 39,0 7,0- 89 0.001
Method Wilcoxon -test
statistically significant if p <0.05

Result Friedman test < 0.001

There is a significant difference in slow-fibers muscle strength between 4

Discussion
weeks, and 8 weeks (p<0.05). and There is a significant difference in slow
twitch muscle strength between 8 weeks, and 12 weeks (p<0.05).
Conclusion
 Comparison of on fast -fiber muscle before, 4 , 8, and 12 weeks Kegel
exercise

Table 5. Median, minimum, maximum, and p-value of fast- twitch muscle

strength.
Variables Median Min- Max p-value
Background
pre-test 18,0 4,0- 51,0
4 weeks-Kegel exercise 21 4,0-54,0 0,556
Objective 8 weeks-Kegel exercise 26 4,0-54,0 0,006
12 weeks-Kegel exercise 39 7,0-100,0 0,001
Wilcoxon -test
Method
statistically significant if p <0.05

Result Friedman test < 0.001

There is a significant difference in Fast fibers muscle strength between 4

weeks, and 8 weeks (p<0.05). and There is a significant difference in fast-
Discussion twitch muscle strength between 8 weeks, and 12 weeks (p<0.05).

Conclusion
 Comparison of quality of live (IIQ-7) before, 4 , 8, and 12 weeks Kegel
exercise

Tabel 6. Median, minimum, maximum, and p-value of IIQ-7

Improvements in the scores Median Min- Max p-value

Background IIQ-7 before. 52.3 4,7- 80.8

IIQ-7 4 weeks-Kegel exercise 33.3 4,7- 61.8 0,023
IIQ-7 8 weeks-Kegel exercise 19,0 4,7-33.3 <0.001
Objective
IIQ-7 12 weeks-Kegel exercise 4,7 0.0-28.5 0,003
Wilcoxon -test
Method
statistically significant if p <0.05
Friedman test < 0.001
Result
There is a significant difference in quality of life (IIQ-7) at 4 weeks, 8 weeks
and 12 weeks of Kegel exercises (p<0.01); (p<0.05); and (p<0.05).
Discussion

Conclusion
 DISCUSSION
Background

Objective

Method

Result

Discussion

Conclusion
 DISCUSSION

• The majority of population with urinary incontinence are in the 31-55-year

Background group (60%) and this is similar with Farid IA et al.1

• This study found that the majority of patients with urinary incontinence had
Objective
parity> 3 children (60%) with a history of vaginal delivery more than 2 times
(85%) and is also the same with Danforth et al.2
Method
• Trauma in labor is a factor influencing the occurrence of stress urinary
incontinence.
Result

Discussion

1. Farid IA. Prevalensi, Karakteristik dan Faktor Risiko yang Berhubungan pda Pasien Inkontinensia Urin di Poliklinik Ginekologi
Conclusion Menggunakan Questionnaire for Urinary Incontinence (QUID) versi Indonesia. 2017.
2. Danforth K, Townsend M, Lifford K, Curhan G, Resnick N. Risk factors for urinary incontinence among middle-aged women.
American journal of obstetrics and gynecology 2009 Feb 1;194:339-45
 DISCUSSION

• Obesity are related with the incidence of stress urinary incontinence, and
95% of population in this research are obese.
Background
• The degree of stress urinary incontinence in this research is mild around
95% and it shows that stress urinary incontinence has mild degree in 60
Objective
minutes pad test

Method

Result

Discussion

Conclusion
 Improvement of Subjective Symptoms

• In this study, there was a statistically significant change in urinary

incontinence (UDI-6) score from before exercise, and after exercise with
Background duration of 4 weeks, 8 weeks and 12 weeks (p = 0.003, p = 0.002; and p
= 0.001).
Objective
• It can be concluded that the improvement of urinary incontinence
complaints experienced by the subject began to be achieved since the
Method
4th week of Kegel exercises and improved with increasing duration of
exercise (up to 12 weeks).
Result
• Khasnian et al has the same result, that there is a significant difference
UDI-6 questionnaire scores before Kegel exercises and after Kegel
Discussion
exercises for 1 month (4 weeks) and 3 months (12 weeks) (p = 0,000).1

Conclusion
1. Kashanian M AS, Nazemi M, Bahasadri S. Evaluation of the effect of pelvic floor muscle training (PFMT or Kegel
exercise) and assisted pelvic floor muscle training (APFMT) by a resistance device (Kegelmaster device) on the urinary
incontinence in women. European journal of obstetrics, gynecology, and reproductive biology 2011 Nov 1;159:218-23
 Improvement of Objective Symptoms.
• It showed a significant difference between UDI-6 test results between 8
weeks and 12 weeks (p = 0.03); but no significant difference was found
between the test results before and after Kegel practice after 4 and 8
Background weeks (p = 0.063).

• The conclusion of this research is the improvement can be reached since

Objective
the 4th week of Kegel exercises and improved between Kegel exercises 8
and 12 weeks, although there was no change between Kegel exercises 4
Method
and 8 weeks.

Result • This result is in line with research by Golmakani et al, Lee HN et al and
Liu J et al who stated that there were significant differences in the results
Discussion of the bandage test between Kegel exercises 8 weeks and 12 weeks (p
<0.001).1-3
1. Golmakani N KN, Arabipoor A, Kerigh BF, Esmaily H. Behavioral Intervention Program versus Vaginal Cones on Stress Urinary Incontinence and Related
Conclusion Quality of Life: A Randomized Clinical Trial. Oman Med J 2014;1:32-8.
2. Lee HN LS, Lee YS, Han JY, Choo MS, Lee KS. Pelvic floor muscle training using an extracorporeal biofeedback device for female stress urinary
incontinence. Zhonghua Fu Chan Ke Za Zhi 2014;49:754-7.
3. Liu J ZJ, Wang H, Zhou Y, Zeng C. Effect of pelvic floor muscle training with biofeedback on stress urinary incontinence in postpartum and post-
menopausal women. Zhonghua Fu Chan Ke Za Zhi 2014;49:831-8..
 Improvement of Pelvic Floor Muscle
(Slow Twitch and Fast Twitch)

• There is a significant change in muscle strength statistically between

before exercise and after exercise with a duration of 8 weeks on fast
Background
muscle fiber (p = 0.006) and slow muscle fiber (p = 0.001); Significant
changes were also achieved after 12 weeks of Kegel training in fast
Objective
muscle fiber (p = 0.001).

Method • There were no significant changes between strength before training

and 4 weeks duration of training.

Result • The conclusion of this research is the existence of pelvic floor muscle
strengthening experienced by the subjects since the 8th week of Kegel
Discussion exercises and improves with increasing duration of exercise (up to 12
weeks).
Conclusion
 Improvement of Pelvic Floor Muscle
(Slow Twitch and Fast Twitch)
• Lee H, Liu et al also showed a significant increase in pelvic floor muscle
strength after Kegel exercises for 12 weeks.1-2

Background • There was an increase in muscle strength in the Lee H et al study from
baseline (19.6 ± 12.3cmH2O) and after Kegel exercise 12 weeks (25.0
Objective ± 13.5 cmH2O) which is significant (p <0.001). 1

Method

Result

Discussion
1. Lee HN LS, Lee YS, Han JY, Choo MS, Lee KS. Pelvic floor muscle training using an extracorporeal biofeedback device
for female stress urinary incontinence. Zhonghua Fu Chan Ke Za Zhi 2014;49:754-7.
2. Liu J ZJ, Wang H, Zhou Y, Zeng C. Effect of pelvic floor muscle training with biofeedback on stress urinary
Conclusion incontinence in postpartum and post-menopausal women. Zhonghua Fu Chan Ke Za Zhi 2014;49:831-8..
 Improvement of Pelvic Floor Muscle
(Slow Twitch and Fast Twitch)
• This result is similar with Fernandes-Cuadros et al , who found significant
differences in muscle strength between before and after Kegel training

Background for 3 weeks with biofeedback perineometer Myomed 932 biofeedback

evaluation (p<0.001).1
Objective • The Kegel exercise research program Fernandes-Cuadros et al, namely
rapid contraction exercises (3 seconds of contraction, 6 seconds of rest) for
Method 15 minutes and slow contractions (5 seconds of contraction and 10 seconds
of rest) for 15 minutes.1 This Exercise evaluates every twice a week.
Result

Discussion
1. Marcos E Fernandez-Cuadros MFD-R, Maria Jesus Albaladejo-Florin. Manometric Biofeedback Effectiveness on
Urinary Incontinence and Quality of Life: A Non-Randomized Control Trial. Middle East J Rehabil Health In press(In
press) 2017.
Conclusion
 Improvement of Quality of Life

• Significant improvement in quality of life between subjects before and

after Kegel exercises for 4, 8, and 12 weeks (p = 0.023; p = 0.000; and p
= 0.003).
Background
• The results of this study can be concluded that there is an
Objective improvement in the quality of life experienced by subjects since the 4th
week of Kegel exercises and improves with increasing duration of
Method exercise (up to 12 weeks).

• This study is in accordance with Kashanian et al who showed a

Result
significant difference between the IIQ-7 questionnaire scores in women
with urinary incontinence before undergoing Kegel exercises and after
Discussion
running Kegel exercises for 1 month (4 weeks) and 3 months (12 weeks)
(p = 0.000).1
Conclusion 1. Kashanian M AS, Nazemi M, Bahasadri S. Evaluation of the effect of pelvic floor muscle training (PFMT or Kegel exercise) and
assisted pelvic floor muscle training (APFMT) by a resistance device (Kegelmaster device) on the urinary incontinence in women.
European journal of obstetrics, gynecology, and reproductive biology 2011 Nov 1;159:218-23
 Duration of Kegel Exercise for 8 Weeks can Improve Stress Urinary
Incontinence.

• The results of this study indicate that there was a significant improvement
Background
in the objective symptoms of severity and a significant increase in muscle
strength after Kegel exercises for 8 weeks, even though improvement in
Objective
symptoms and quality of life had been seen since the 4th week.

Method

Result

Discussion

Conclusion
 Limitations of The Research.

• The limitation of this study is that the dropout rates of 7 subjects (27%) in
this study.
Background
• The efforts that have been made in this study are based on Sluijs EM et al by

Objective improving compliance in physical exercise; such as Extensiveness of

Instruction, patient demands, therapist-patient relationship, positive
Method feedback.1

• Another limitation of this study is that there was no analysis of confounding

Result variables In this study, because the number of samples was small, and this
confounding variable did not allow stratification.
Discussion

1. Sluijs EM KG, van der Zee J. Correlates of exercise compliance in physical therapy. Phys Ther 1993;73:771-82.
Conclusion
 Conclusion

• Improvements to subjective symptoms and the quality of life of women

Background
with pressure type urinary incontinence can be achieved with Kegel

Objective exercises 4 weeks and getting better with increasing exercise time.

• Improvement of objective symptoms and strengthening of pelvic floor

Method muscles of women with pressure type urinary incontinence can be
achieved with Kegel exercises for at least 8 weeks and improves with
Result increasing exercise time.

Discussion

Conclusion
Background

Objective

Method

Result

Discussion

Conclusion