Urinary incontinence

Urinary incontinence (UI) is the occurrence of involuntary leakage of urine from the bladder to the outside of the body. In other words, it occurs when someone urinates without making the conscious choice. Although both females and males can be diagnosed with urinary incontinence, pregnancy is one of the major causes of urinary incontinence in females (Fritel et al., 2015). As a result, urinary incontinence can have a major impact on the daily lives of many women. In particular, “It is physically debilitating and socially incapacitating, with loss of self confidence, feelings of helplessness, depression, and anxiety all related to its occurrence” (Chiarelli & Cockburn, 2002). As a result, the problem of urinary incontinence needs to be addressed by PT/AT’s because up to half of all females who bare children are affected by this issue (Fritel et al., 2015). By researching three articles, I hope to determine the effectiveness of pelvic floor muscle exercises in the prevention of urinary incontinence in post-partum females and; therefore, whether or not I would use this intervention in the clinic.
In order to obtain the research articles that are included in this paper, I used a few research databases. First, I used a resource called PEDro, which is an Australian research archive and online database that includes articles related to the field of physical therapy (Zafron, 2018). From PEDro, I found the article “Preventing urinary incontinence with supervised prenatal pelvic floor exercises: a randomized controlled trial” (Fritel et al., 2015). Additionally, I found the article “Promoting urinary continence in women after delivery: randomised controlled trial” (Chiarelli ; Cockburn, 2002). A different research database that I used to locate a research article was called PubMed. PubMed is a free online database that stores millions of peer reviewed articles that encompass a broad scope of the field of biology and medicine (Zafron, 2018). Using PubMed I was able to find the article “Postpartum pelvic floor muscle training and urinary incontinence: a randomized controlled trial” (Hilde, Staer-Jensen, Siafarikas, Ellstrom Engh, ; Bo, 2013).
Within a research paper, the author(s) usually include a section where they describe why they are about to preform their research. Additionally, it explains why performing the research is necessary to determine a specific question or hypothesis. This section of a paper is where you find the rationale for the study. Across all three of the research papers, the rationale was very similar. That is, each of the studies wished to see if pelvic floor muscle training affected the prevalence of urinary incontinence. However, there were a few specific differences in the rationale for a couple of the studies. Particularly, two of the papers wanted to determine the effect of a supervised training program (Fritel et al., 2015; Hilde et al., 2013). On the other hand, one of the studies wanted to determine if including an adherence education aspect to a non-supervised pelvic floor exercise program affected the prevalence of urinary incontinence (Chiarelli ; Cockburn, 2002).
Baseline measurements are data that researchers collect when they first begin an experiment with a group of participants. Then, once the experiment or trial is completed, the investigators are able to assess what the outcome is by relating the results to the baseline measurements. In the case of these three studies, the baseline measurements relative to were all taken at different times relative to their delivery date. However, two out of the three studies were similar in that they obtained baseline measurements post-partum. Specifically, one study recorded baseline information within 48 hours of the female giving birth (Chiarelli ; Cockburn, 2002). Also, another study obtained baseline information 6 weeks after the female gave birth (Hilde et al., 2013). Contrarily, an additional article chose to obtain baseline characteristics while the female was still pregnant. Specifically, in this study the authors obtained baseline data from the females during their second trimester of pregnancy (Fritel et al., 2015). Thus, two of the three articles began their randomised controlled trial after pregnancy, while the third began theirs during pregnancy.
Follow-up measurements are taken at various points after the experiment begins. Like stated earlier, these measurements can then be compared to baseline measurements to assess if the intervention resulted in some type of change. Two of the studies were similar in that they obtained follow-up measurements more than once. In particular, one study took follow-up measurements at 2 months postpartum and 3 months postpartum (Chiarelli ; Cockburn, 2002). The other study took follow-up measurements at 2 months postpartum 12 months postpartum (Fritel et al., 2015). On the contrary, there was a study that only recorded follow-up measurements once, which was at 6 months postpartum (Hilde et al., 2013). Although taking multiple measurements is very important in determining whether or not an intervention worked, it is also important to keep in mind the time interval between when the trial began and when the follow-up measurements were taken. Thus, when reading a paper it is crucial to determine if there was a sufficient amount of time between the start and end of a trial for the intervention to actually have an effect on the participants. Thus, although two follow-up measurements were obtained, I am uncertain weary about the short length of the trial that came to a conclusion after only 3 months (Chiarelli ; Cockburn, 2002).
Within any paper it is also important for the authors to include the exclusion criteria and why certain individuals were excluded. Therefore, when someone reads the paper, they know why certain groups were not included. Thus, it limits the amount of bias and also increases the credibility of the study. On the other hand, inclusion criteria are the characteristics that the researchers predetermine for the participants that they wish to include in their study (Sisto, 2018). A similarity in two of the studies was that they only included females who are pregnant with their first child or who have only given birth to once child (Fritel et al., 2015; Hilde et al., 2013). Therefore, my third article differed in that the females could have had any number of children prior to this trial (Chiarelli ; Cockburn, 2002). So, if my goal was to possibly use one of these interventions, the trial that allowed the females to have had any number of children in the past shows that it has a larger amount of external validity. That is, if I determine that the intervention is valid and reliable, I would possibly be able to use it on a broader population as opposed to the other two articles. Another similarity in two of the studies was that they only included females with or without UI before, during, or after pregnancy and had a vaginal delivery (Fritel et al., 2015; Hilde et al., 2013). On the other hand, the third article differed in that they included females that did not have UI before birth of the most recent child and also had an assisted vaginal delivery and/or high birth weight delivery (Chiarelli ; Cockburn, 2002).
A way that bias can be avoided in a research study is through the process of randomization and allocation concealment. Randomization is a process that ensures that there is an equal distribution of participants with certain characteristics in each group. Then, allocation concealment is another process that should be used which causes the person who is assigning each participant to either the intervention arm or control arm of the study to not have any idea what each participant is assigned (Doig ; Simpson, 2005).
A similarity across two of the articles was that they chose to perform randomization using a random computer generated sequence that randomized each participant to a specific group (Chiarelli ; Cockburn, 2002; Hilde et al., 2013). In contrast, the third article differed in that the authors chose to perform randomization using a pre-specified ratio of 1:1 (Fritel et al., 2015). Additionally, all three articles were similar in that they did have allocation concealment. In Hilde et al. (2013), allocation was concealed by having the participants exit the space where the assessors were located before telling the participant their specific allocation. In Chiarelli ; Cockburn (2002), allocation was concealed by giving the participants their allocation in a sealed opaque envelope, which they opened in private. Finally, in Fritel et al. (2015), allocation was concealed by putting it in sealed envelope and having an individual not involved in the outcome assessment give the envelopes to the participants. Again, these sealed envelopes were not accessible to the outcome assessors, who in this case were the obstetricians. As stated earlier, when research studies include these two aspects, it limits the amount of bias included in the study and therefore strengthens the credibility of the article. As a result, it is more likely that the intervention will be used on a patient that walks into my clinic if the paper is credible and the evidence is strong.
Although no two methods in any studies are going to be identical, two of the studies that I chose were similar in that they both included postpartum pelvic floor muscle training. So, in other words, for both of these studies, the females delivered their child and then they were randomized to either the intervention arm or the control arm at some designated time post-partum. Specifically, in Hilde et al. (2013), six weeks after delivery, the intervention group was taught proper technique and exercises that contract and relax pelvic floor muscles. Additionally, the intervention group went to exercise training classes for strengthening their pelvic floor on a weekly basis. Lastly, this group was told to perform their at-home daily exercise program. On the other hand, six weeks after delivery the control group was only taught how to contract the muscles in their pelvic floor. Then, both groups were assessed six months postpartum (Hilde et al., 2013). Likewise, in Chiarelli ; Cockburn (2002), the exercise intervention took place after the females gave birth. Thus, within 48 hours of delivery, the intervention group was given an exercise program that included pelvic floor muscle contractions, information/discussion of a booklet, and was taught about ways to increase exercise adherence. The intervention group was also re-evaluated 2 months postpartum. Contrarily, 48 hours after delivery, the “usual care group” was only given regular postnatal care and a brochure, which contained general information about the pelvic floor. Then, both groups were assessed 3 months postpartum (Chiarelli ; Cockburn, 2002). There was major difference in the methodology that Fritel et al. (2015) chose to use. In this study, the trial began even before the female gave birth. During the second trimester, the intervention group was assigned a supervised pelvic floor muscle-training regimen as well as written information on pelvic floor contraction and relaxation exercises. During the each of the supervised sessions, participants did things like “… standing contractions (5 minutes), lying contractions (10 minutes), and learning how to start a pelvic floor contraction just before exerting intraabdominal pressure (knack exercise)” (Fritel et al., 2015). On the other hand, during the second trimester, the control group was only given the written information on pelvic floor contraction and relaxation. Then, both groups were assessed at the end of gestation, 2-months postpartum and 12-months postpartum (Fritel et al., 2015).
The three articles that I chose were very similar in the way they each assessed their primary outcome. That is, all three assessed if their intervention resulted in a change using a type of self-reporting technique. Specifically, in Hilde et al. (2013) and Fritel et al. (2015), all of the women were assessed using a self-report questionnaire called the “International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form.” This form was the way in which the outcome assessors determined the primary outcome of these two studies, which was the prevalence of urinary incontinence in each of the females (Fritel et al., 2015; Hilde et al., 2013). The article by Chiarelli ; Cockburn (2002) was simlar in that the primary outcome was assess using a type of self-reporting technique; however, in this case the process of this assessment was by means of a telephone call. Furthermore, the interviewer was blinded to what group each women was a part of and also trained in this technique. Each individual women was asked the same set of questions and were asked to answer them using a validated scale for UI prevalence, UI severity and adherence to the pelvic floor exercise program (Chiarelli ; Cockburn, 2002).
There were similarities and differences across the three studies for what each concluded about the effect of pelvic floor muscle exercises in the prevention of urinary incontinence in females. A similarity is that two of the studies ended up rejecting their alternative hypothesis. Particularly, in Hilde et al. (2013), the outcome assessors determined that postpartum supervised pelvic floor exercises program did not decrease the prevalence of urinary incontinence six months after first-time vaginal deliveries (Hilde et al., 2013). Similarly, Fritel et al. (2015) also rejected their alternative hypothesis and concluded that the “Prevalence and severity of postpartum UI in primiparous women was not altered by supervised prenatal pelvic floor training compared with those who only received written instructions” (Fritel et al., 2015). Contrarily, the outcome of the paper written by Chiarelli ; Cockburn (2002) differed from that of the others. Notably, this was the only research paper that concluded that their alternative hypothesis was evident. Specifically, they stated that using both the physiotherapy intervention of pelvic floor exercises while also teaching the client principles of exercise adherence to the intervention program was effective at reducing the prevalence and severity of urinary incontinence (Chiarelli ; Cockburn, 2002).
So, upon taking into consideration all three of the research studies, I would not support the intervention of pelvic floor muscle exercises in the prevention of urinary incontinence in females unless the intervention included the aspect of teaching the patient adherence techniques for the intervention

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