INTRODUCTION

Catherine Du Beau quoted that “Urinary incontinence not only causes great unhappiness but can also increase disability, social isolation, and health care costs” Urinary incontinence(UI) is defined by the International Continence Society as “a condition in which involuntary loss of urine which is objectively with such a degree of severity that it is a social and hygienic problem, and severely affecting quality of life(QoL).¹ A women may present at any stage of her adult life complaining of problem associated with bowel bladder or genital function. Problems are frequently multifactorial, involving one or more components- bladder, urethral and anal smooth muscles, urethral, anal and pelvic floor striated muscles and endopelvic fascia.²

UI causes embarrassment, loss of self- confidence which may lead to urinary tract infections, pressure ulcers and diseases of the perineal skin. The medical, social, psychological and economic implications of this condition lead to changes in standard of living and negatively affect the quality of life (QoL) in women. Feelings such as loneliness, sadness and depression are present in the incontinent woman life.³ The problem is more pronounced in India where woman usually do not seek treatment for their reproductive health problems and do not vocalise their symptoms.⁴ Although urinary incontinence and related symptoms can have substantial impact on quality of life , relatively few woman seek help from health care professionals, leading to high levels of unmet need for incontinence services. This is mainly due to misattributions of cause such as assumptions that symptoms are normal after child birth or in older age, and to a lack of awareness of available treatment options.⁵ Woman that present mild or moderate incontinence levels usually do not think about taking care, and the frequency for seeking treatment increases during the postmenopausal period, when the degree of urinary loss increases.³ Woman in India also has been reported to have more patience threshold for seeking treatment because of shyness, fear of surgery, lack of money, dependency on husband and non- availability of female doctors in the periphery.⁶ In addition to the effect of age ,other factors associated with urinary incontinence in multiple, large, population- based studies include parity, obesity previous hysterectomy or pelvic surgery, pulmonary disease, diabetes mellitus and nursing home admission or dementia.⁷ They also include the risk factors for UI are chronically increased abdominal pressure, chronic cough, constipation, occupational risk, urinary symptoms, childbirth, pregnancy, menopause, functional impairment, diuretic therapy, smoking and genetics.⁸Globally UI affects the quality of life at least one third of the woman.⁶ UI is a universal health problem amongst woman, with the prevalence varying from 8-45% in different studies. This wide variation may be due to different factors such as under reporting caused by shame and the belief that it is natural consequence of aging,¹ In a survey done in Asia, the prevalence of urinary incontinencein India was 12% .⁹ UI more common in women than in men and affects woman of all ages. Prevalence rate in woman between 15 and 64 years of age vary from 10% to 30% which increases with age.^3-5The prevalence of UI is significantly higher for individuals living in nursing homes, compared to community settings, with rates ranging from 43% to 77% .¹⁰

The effective management of stress urinary incontinence (SUI) requires knowledge of the pathophysiologic mechanisms behind the disorder, so understanding the anatomy and function of the pelvic floor and its supporting structures is important to provide proper treatment to a woman.Urinary incontinence (UI) is a frequent symptom that can affect woman of all ages, with a large range of severity. Is rarely life- threatening, but may seriously have an impact on the physical, psychological and social wellbeing of affected individuals.¹¹ It is one of the priority health issue recognized by WHO. This may occur as a result of a number of abnormalities of function of the lower urinary tract, or as a result of other illnesses, and these are likely to cause leakage in different situations.¹ There are various types of Urinary Incontinence: Stress, Urge, Giggle, Mixed, Overactive bladder, Nocturnal Enuresis and more. The most common type of incontinence is Stress Urinary Incontinence (SUI) with an estimated prevalence of 8-33%. SUI is defined as the involuntary loss of urine during physical exertion, e.g. coughing, sneezing, laughing, running.¹ SUI is most common type of incontinence among woman accounting for as much as 65% of all types of UI in woman. It is highest in young and middle aged group. There is a relative decrease with increasing age. History of woman with UI guides the investigation and management by evaluating symptoms, their progression and the impact of symptoms on lifestyle. Taking a history also allows the assessment of risk factors associated with the possible diagnosis. The relevant elements of history follow. A large portion of woman with urinary stress incontinence can be diagnosed from clinical history alone.^1,12 The history includes the frequency, voiding symptoms, post maturation symptoms. Along with the clinical history there are also several methods used to asses UI they are Perineometer, urinary diaries, pad- tests although they are common diagnostic assessments used in physical therapy. There are also various scales to asses quality of life in patients with UI.¹² The pregnancy, child birth and increase in age play a major role in developing SUI. Trupti N.  Bodhare, Sameer Valsangkar and Samir D. Bele  (2009) conducted a cross sectional descriptive study in Karimnagar, India. In a sample of 552 woman, 53 (10%) reported episodes of UI. The prevalence of UI showed significant association with increasing age (p<0.01)57% of them had stress incontinence, 23% had urge, 20 % mixed symptom of UI. The findings of recent survey on the prevalence of UI among woman show that while a third of the patients had find the lack of bladder control a definite bother, very few woman reached out for the medical assistance and even fewer of them knew which specialist to consult.¹³Conservative treatments, a nonsurgical therapy, it includes improving the way of living, bladder re- training, pelvic floor muscle exercises, biofeedback, vaginal cones and the electrical stimulation of pelvic muscles. Pelvic floor muscle exercises were first described as a possible treatment for urinary incontinence by Kegel’s in 1948. They are the most accepted method of reinforcing pelvic floor muscles and is a non- invasive management such that it does not involve the placement of any vaginal weights/ cones.¹⁴ The aim of pelvic floor muscle exercise is to strengthen the perivaginal and perianal musculature in order to increase a women’s control of urine leakage.¹⁵ In 1948 , Kegel’s reported that pelvic floor training produces a cure rate of 84% for woman with various types of incontinence. Rehabilitation of the pelvic floor muscle in form of Kegel’s exercises is done which helps in stabilizing the urethra by increasing the pelvic floor muscle strength. This traditional method brings about the contraction of only the pubococcygeus muscle.^16,17 Fast pelvic floor muscle contraction will clamp the urethra, thereby increasing the urethral pressure and prevent urinary leakage during abrupt increase in intra –abdominal pressure. The exercise does not require any instrument and can be done anywhere. It will also improve pelvic organ support. MRI and electromyography have demonstrated that the levator ani, the fossa ischioanalis, and the gluteus maximus are morphologically and functionally connected. And that the contraction of hip adductor and gluteus muscles facilitates the synergic contraction of pelvic floor muscles and striated urethral wall muscles. Woman with stress urinary incontinence show less strength in their abductor muscles and external rotators of hip compared with woman not having urinary incontinence.¹⁸ The synergism of hip muscles may reduce symptoms of stress urinary incontinence .This has to be shown to be based on postural changes, such as crossing the legs. It has been speculated that, the hip muscles are involved in continence mechanism and that their deficiency could destabilize the normal function of system.¹⁸

Need for the study

Stress Urinary Incontinence is extremely common problem that most woman experience at some point of their life. It causes enormous impact on physical, psychological and social wellbeing of affected individuals and also decreases the self confidence in many women. There are various treatments available for Urinary Incontinence to strengthen the pelvic floor muscles that include physical therapy, behavioural modifications and pharmacological interventions. Most of the studies have concentrated on the use and the effects of Conventional Therapy for Stress Urinary Incontinence and how useful it is for Strengthening Pelvic Floor Muscles. But there are fewer studies on the effectiveness of Progressive Resisted Exercises for hip muscles in Stress Urinary Incontinence. Hence the purpose of the study is to identify the effectiveness of Progressive Resistance Exercises for hip muscles and Pelvic Floor Muscle Training on the woman suffering from Stress Urinary Incontinence.

Research Question:

Will there be any difference in the pelvic floor muscle strength and the quality of life of female participants with Stress Urinary Incontinence when treated with pelvic floor muscle training and progressive resisted exercises for the hip muscles for the period of 8 weeks?

Aim of the study:

To find out the effectiveness of pelvic floor muscle training and progressive resisted exercises for strengthening of hip muscles in Stress Urinary Incontinence.

Objectives of the study:

   To determine the effectiveness of pelvic floor muscle training and hip muscle strengthening on strength of the pelvic floor muscle.

           To determine the effectiveness of pelvic floor muscle training, progressive resisted exercises of hip muscles and quality of life on patients with Stress Urinary Incontinence.

            To compare the effectiveness of pelvic floor muscle training and progressive resisted exercises for hip muscles and quality of life on patients with Stress Urinary Incontinence

Hypotheses:

Null Hypothesis (H₀):

There will be no significant difference in the pelvic floor muscle strength and quality of life of female participants with Stress Urinary Incontinence when treated with pelvic floor muscle training and progressive resisted exercises for hip muscles for the period of 8 weeks.

Alternative Hypothesis (H₁):

There will be significant difference in the pelvic floor muscle strength and quality of life of female participants with Stress Urinary Incontinence when treated with pelvic floor muscle training and progressive resisted exercises for hip muscles for the period of 8 weeks.