By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
Dr. Ghetti reports no financial relationships relevant to this field of study.
SYNOPSIS: Sedentary behavior is associated with more severe symptoms of nocturia and nocturnal enuresis in women with urinary incontinence.
SOURCE: Chu CM, Khanijow KD, Schmitz KH, et al. Physical activity patterns and sedentary behavior in older women with urinary incontinence: An accelerometer-based study. Female Pelvic Med Reconstr Surg 2019;25:318-322.
The main objective of this study was to examine the relationship between physical activity, sedentary behavior, and the severity of urinary symptoms in community-dwelling women with urinary incontinence (UI). A secondary objective was to determine the feasibility of measuring physical activity using an accelerometer in this population and examining the correlation between objective accelerometer-based data and self-report measures.
This study is a secondary analysis of a cross-sectional, prospective study measuring the risk of falls in older women with UI. Subjects were recruited from three community centers and were included if they were 65 years of age or older, lived independently, were able to ambulate, and had moderate-to-severe UI (defined as a score of 6 or greater on the International Consultation on Incontinence Questionnaire [ICIQ]–UI Short Form), and were not actively seeking treatment. Subjects were excluded if they were receiving treatment for their urinary symptoms.
Subjects completed validated measures and physical functional testing in their home. Primary outcomes included: 1) incontinence severity measured by the ICIQ-UI score; 2) nighttime urinary symptoms as measured by the Nocturia, Nocturnal Enuresis and Sleep-interruption Questionnaire; 3) physical activity as measured by the Physical Activity Scale of the Elderly (PASE), a validated self-report questionnaire (scored 0-400, with a higher score indicating greater activity); and 4) physical activity as measured by waist-worn, tri-axial accelerometers for one week. The authors examined the relationship between physical activity/sedentary measures and urinary symptoms using univariable linear regression for continuous variables, and t-test and Wilcoxon rank sum test for categorical variables. They investigated the relationship between self-reported physical activity (PASE total score) and accelerometer-based activity data using Spearman correlation.
This analysis included data for the 35 of 37 subjects with accelerometer data. Subjects had a median age of 71 years, the majority were obese, they had severe UI based on ICIQ-UI score (median score, 12.8; range, 7-19), and they used incontinence products (71%). Half of the women reported mixed incontinence. Sixty-eight percent reported nocturia twice nightly, 97% reported it once nightly or more, and 50% reported nocturnal enuresis. Subjects wore the accelerometer for mean of eight days of the assigned seven days (range, 4–12 days). The total activity time measured by accelerometer was about three hours and constituted mainly low-intensity activity; self-reported activity also was predominantly low-intensity activity. As a corollary, accelerometer data indicated a median of 74% of time was spent in sedentary behavior.
The authors reported significant associations between low activity and lower urinary tract symptoms. In particular, low step counts were significantly associated with higher UI severity scores (P = 0.02). Low activity affected nighttime symptoms, with low step counts significantly associated with greater numbers of nocturia episodes (P = 0.02). Shorter duration of moderate to vigorous physical activity was significantly associated with greater numbers of episodes of nocturia (P = 0.001), severity of nocturnal enuresis (P = 0.04), and greater use of incontinence products (P = 0.04) consistent with worsened urinary incontinence.
COMMENTARY
The main finding of this study is that, in this sample of community-dwelling women with UI, sedentary behavior is very common, and low levels of physical activity are associated with worsened urinary symptoms.
By successfully implementing the use of accelerometers in this older population, the authors found that sedentary behavior is associated with worsened incontinence severity, nocturia, and nocturnal enuresis.
As clinicians caring for elderly women, this study reminds us that physical activity may play an important role in affecting not only women’s overall functional capacity, but possibly in reducing lower urinary tract symptoms. It is difficult to interpret the relationships between exercise and UI fully. Does exercise maintain pelvic floor strength in these older women? Perhaps sedentary women have bothersome urinary leakage and are less interested in activity. The small sample size and design of this study do not allow an answer to this question. However, there is a small and growing body of scientific literature regarding the relationship between physical exercise and pelvic floor function.
In 2004, Bo et al proposed two competing hypotheses1: that general exercise training strengthens the pelvic floor vs. general exercise training overloads and weakens the pelvic floor. The research has resulted in conflicting findings, with studies showing that physical exercise increases, decreases, or has no impact on pelvic floor strength. Nygaard et al found that mild to moderate physical activity decreases the odds of having or developing UI.2 Since exercise unmasks UI, leaking during exercise is very common. Exercise may worsen leakage for women with incontinence. Pelvic organ prolapse also has been associated with a history of strenuous activity.
In their review, Nygaard et al concluded that the existing literature suggests that most physical activity does not harm the pelvic floor, and that mild to moderate activity may decrease the risk of urinary incontinence. In addition, exercise provides numerous other health benefits for women. The present study suggests that a sedentary lifestyle is associated with increased urinary incontinence and, in particular, increased nighttime urinary symptoms, both of which significantly affect quality of life in aging women.
It is important to encourage all our patients, older patients particularly, to stay physically active and to remind them about the health benefits of exercise. Activity provides many physical and mental health benefits and, as such, is a strong modifiable risk factor. Exercise contributes significantly to overall well-being and health-related quality of life in aging adults.3 In 2018, the American Medical Association (AMA) published revised exercise recommendations, stating that adults should “get at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity, or a combination of both, preferably spread throughout the week.” Further, the AMA recommends muscle strengthening activity at least twice per week, and states that adults can gain additional benefits by being active for at least 300 minutes.4 The World Health Organization makes the same recommendations.5 Nocturia and nocturnal enuresis are difficult conditions to treat, but women who stay active may be less likely to experience them. While there is still much research to be done to understand the relationship between physical activity and pelvic floor function, is it possible that the connection between physical activity and nocturia can provide an additional lifestyle benefit by improving both bothersome nighttime voiding and overall general health?
REFERENCES
- Bø K. Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Med 2004;34:451-464.
- Nygaard IE, Shaw JM. Physical activity and the pelvic floor. Am J Obstet Gynecol 2016;214:164-171.
- Lowe A, Gee M, McLean S, et al. Physical activity promotion in physiotherapy practice: A systematic scoping review of a decade of literature. Br J Sports Med 2016; Dec. 21. doi: 10.1136/bjsports-2016-096735. [Epub ahead of print].
- Piercy KL, Troiano RP, Ballard RM, et al. The physical activity guidelines for Americans. JAMA 2018;320:2020-2028.
- World Health Organization. Physical Activity and Adults. Available at: https://www.who.int/dietphysicalactivity/factsheet_adults/en/
Sedentary behavior is associated with more severe symptoms of nocturia and nocturnal enuresis in women with urinary incontinence.
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