Effect of Kegel Exercise on Improving Manifestations of Uterine Prolapse among Pre menopausal Women

Introduction

Uterine prolapse is a health concern affecting millions of women worldwide. When it defined by symptoms has prevalence of 3–6 % and up to 50 % when based upon vaginal examination (Barber & Maher, 2013). The mean prevalence in low-income countries is 19.7% (range 3.4%-56.4%) (Jokhio, et al., 2013) .However; A population based study (n = 2070) by UNFPA in Nepal found a prevalence of uterine prolapse were 10% included women had ‘something coming down in the vagina’ (Walker & Gunasekera, 2011). More recent studies from Ethiopia (Belayneh, et al., 2019 and Ballard, et al., 2016)and Tanzania (Masenga, et al, 2018) showed prevalence of UP based on symptoms included up to 64.6% based on clinical examination.

It defined as the descent of uterus and vaginal walls through vaginal canal. Uterus, move downwards due to anatomical or functional deformities of the tissues and ligaments that support the uterus (Memon & Handa, 2012).

Pre-menopause is an even a greater risk factor for uterine prolapse; it associated with profound reproductive and hormonal changes (Binjwala, et al, 2014). Also, additional risk factors associated with UP have been shown as; Birth weights, MOD (Mode of Delivery) and length of the second stage of labor (Walker & Gunasekera, 2011).

The symptoms of uterine prolapse depend on the degree of the prolapse. More significant uterine prolapse may cause pelvic pain or pressure. It may also interfere with sexual function (Hagen & Stark, 2011).

In a minimal prolapse, women may not develop any bothersome symptoms prolapse may be asymptomatic and require no treatment. Some women with a more advanced condition prefer observation to other treatments, but should be examined regularly (Buckler, 2017).

According to Priyanka, et al, (2010), the main symptom of uterine prolapse is seeing or feeling of bulging in the vagina. The presentation of symptom may be varying among individuals and it depends on the severity of prolapse. The association between childbearing and Uterine Prolapse (UP) giving rise to symptoms of pelvic floor dysfunction (PFD) (Elenskaia, et al, 2013).

Measures used for reducing the impact of uterine prolapse symptoms includes ; training of Kegel exercises and life style changes .These exercises strengthens levator ani muscle through muscular hypertrophy and stronger levator ani muscle improves support and reduces the burden imposed on the ligament (Berzuk & Shay, 2015) .

During the transition phase to menopause, the maternity nurse plays an important role in prevention of prolapse through giving the woman health education about diet, exercise and follow- up and its importance for early detection of any genital abnormalities (Vorvick, 2011).

Significance of the study

In Egypt and Arab countries half of the women had duration of UP more than 5 years and 6% of women had UP for more than 20 years. Overall more than 60% of women reported symptoms (Fitchett, et al, 2015).

Menopause is a consequence of age; there is a straight association between menopause and an increased risk for UP (Weintraub, et al, 2020 and Sze, et al, 2012). The hormonal changes in menopause cause a drop in the systemic estrogen concentrations, contributes to alterations in the composition and strength of collagen.This particular hormone helps keep pelvic muscles strong. Without it, premenopausal women at a higher risk of developing uterine prolapse (Alcalay, et al, 2015).

Conservative treatments for uterine prolapse during menopause for pre- menopausal women include; Pelvic Floor Muscle Training (PFMT), which used in cases of mild to moderate prolapse & may help to relieve symptoms (Bordman, et al., 2014). In addition, Kegel Exercise or PFMT is safe, effective and an inexpensive therapy. This highlights the need for using preventive measure includes Kegel exercise for the improvement of signs and symptoms of uterine prolapse; (Golmakani, et al., 2012, Binjwala, et al., 2015 & Priyanka, et al., 2015).    

Aim of the study

The present study was conducted to; evaluate the effect of Kegel exercise on improving manifestations of uterine prolapse among pre-menopausal women.

Research hypothesis

H1. Women who follow Kegel exercise training will have improvement in their manifestations of uterine prolapse than those who do not follow.

Subjects and Methods

Research design: Quasi-experimental research design (time series design) was utilized for the purpose of the current study.

Research Setting: The study was conducted at gynecological outpatient clinics at Minia University Hospital for Obstetrics & Pediatric and El - Minia General Hospital. Both hospitals offer care services to all women who have gynecological problems & living in Minia City districts and villages related to Minia Governorate.

Subjects:

Sample type: Purposive sample composed of 102 pre-menopausal women with 1^st, 2^nd degree uterine prolapse was recruited for the current study and divided equally by using simple random sample into study group (n=51cases) & control group (n=51cases) according to the following inclusion and exclusion criteria:

Inclusion Criteria:

• Age group ranged from 40-50 years.
• Educated women.
• Women who clinically diagnosed as uterine prolapse (1^st and 2^nd degree).
• Multipara women.

Exclusion criteria:

• Women with reproductive tract infection & urinary tract infection or any other gynecological complications.
• Women with 3^rd & 4^th degree uterine prolapse.

Sample Size: The determination of the sample size was based upon the flow number 340 pre-menopausal women (The attendants' rate of pre-menopausal women -in each clinic for both hospitals was estimated during 2017 before starting the study). Sample size was 102 & it was calculated by using the Isaac, S. & Michael, W.B. (2000) formula which is computed as (N = P x 30 / 100)

Description:

N = Sample size

P = Uterine prolapse prevalence in target population

N = 340 x 30/ 100 = 102 patients.

Tools of Data Collection:

Three tools for data collection were used in the present study:

Tool I (pre-intervention):

A Structured interviewing questionnaire was developed by the investigator to collect data and divided in to three parts;

Part (1): Personal data of women such as; (Age, marital status, residence, level of education……, etc).

Part (2): Obstetrics & gynecological history of women such as; (Gravidity, parity, mode of last deliveries……, etc).

Part (3): Medical history such as; (Medical diseases, problems resulting in increasing pressure in abdomen, problems associated with elimination……, etc).

Tool II (pre/ post intervention):

Pelvic Organ Prolapse – symptoms score (POP-ss)adopted from (Hagen, et al., 2004): 

This tool used & modified by the investigator to score the symptoms of uterine prolapse, it was a structured questionnaire included 7questions and modified into 10 questions. The total up the scores for Q 1 – Q 10 range 0-40 was calculated by summing the ten individual symptom responses. The best possible score would be 0 - meaning haven't been complaint of these symptoms at all , the moderate score would be 10- < 40 meaning that some of these symptoms bother woman all of the time, and the worst or severe would be 40- meaning that all of these symptoms bother woman all of the time.     

The investigators used this tool three times through the present study, the first time before intervention, the second time after 6 weeks from intervention and third one after 3 months from the intervention to evaluate the program effects after intervention as prolapse symptoms improved by compare the baseline symptoms scores before intervention with the symptoms after intervention.

Tool III ( pre/ post ):

Follow up evaluation sheet (dairy record)adopted from (Priyanka. et al, 2011 & Egyptian Journal of Hospital Medicine, 2017):

This tool was modified by the investigator in the form of dairy record to assess the frequency & duration of performance of Kegel exercise (compliance of women). Diary record was given to women in the study group to record their compliance of Kegel exercises at their homes. The investigator instructed them to document their compliance by put a circle for documenting frequencies of performing Kegel exercises through a day, time of relaxation / contraction and number of relaxation / contraction. The investigator followed up the study group after using this tool by them 3 times through the current study (The 1^st time after 1 month, the 2^nd time after 6 weeks and 3^rd time after three months from the intervention).

Supportive material:

It was designed by the investigator in form of handout (booklet) after revising extensive relevant literature review such as (Abrams, et al., 2012) & (Boyle, et al., 2014).It was written in a simple Arabic language & it was developed and supported with photos and illustrations to help the woman understanding the content of the booklet. This handout consisted of description about anatomy of female reproductive system, complete description about uterine prolapse, and complete description of Kegel exercises.

Validity & Reliability: The questionnaire was piloted on panel of 5 experts of Obstetrics and gynecological staff, and nursing professors who reviewed the instruments for clarity, relevance, comprehensiveness, understanding, applicability and easiness. Alpha Cronbach’s test was used to check the stability of the internal consistency of instrument.

Pilot study

It was carried out on 10% of the total study sample (10 pre-menopausal women). It was conducted to evaluate the applicability and clarity of the tools, assessment of feasibility of fieldwork and to detect any possible obstacles that might face the investigator and interfere with data collection. Necessary modifications were done based on contents for more simplicity and clarity. The subjects were not included to the actual sample.

Fieldwork:

After the conduction of the pilot study as well as the actual study, an official permission and consent was obtained from the dean of the Faculty of Nursing, as well as the Director of Minia University Hospital for Obstetric and Pediatric & El- Minia General Hospital & the head of internal medicine department at both hospitals. All women aged between 40-50 yrs who clinically diagnosed as uterine prolapse ( 1^st and 2^nd  degree) by the gynecologist was included in this study. Then the investigator was started to collect data through four phases included: 1) Interviewing; 2) Implementation; 3) Follow up and 4) Evaluation phases.   

(Interviewing phase):

At the beginning of this phase, the investigator visited data collection site from 9:00 Am to 1:00 Pm , for 2 days per week (Sunday and Tuesday). This phase was applied to control and study groups of pre- menopausal women.

The investigator held the first interview with each woman in the out patient gynecological clinics during examination by the doctor or after examination before leaving the clinics introduced her-self, Oral consent for participation in the study was obtained from selected pre-menopausal women for ethical issues & scheduled times and frequency of sessions and follow up, mobile phone numbers were saved to all selected women to assure adherence to the intervention.

The investigator collected data using the first, second and third tools from control and study group.The investigator asked pre- menopausal woman questions about their socio-demographic characteristics such as (age, marital status, ….ect), obstetrics and gynecological history included (Gravidity, parity, ….ect), and medical history included (Medical complaints, problems resulting in increasing pressure in abdomen, …..ect).

The structured interviewing sheet was filled by the investigator and she used the second tool (Pelvic organ prolapse – symptoms score (POP-ss) for assessing prolapse symptoms. Each interview took about 15 to 20 minutes for each pre- menopausal woman to be completed.

(Implementation phase):

The investigator conducted the educational sessions about Kegel exercise for pre- menopausal woman in the study group. The total number of Kegel exercise training sessions was 1 - 2 sessions (2 days/week) through 4 weeks varied according to understanding of each participant. Duration for each session was ranged from 20 to 35 minutes & it was conducted after organization with gynecologist in the outpatient clinics before the women left the clinic.   

The first session took about 20 minutes and at the beginning of this session, the investigator introduces her-self, explained the objective of the research; gave them an educational booklet about Kegel exercises and then illustrated the content of the booklet; through gave the women simple information about anatomy of the female reproductive system, anatomy of the female pelvis, and anatomy of pelvic floor muscles.

The second session (practical session) took about 25 minutes; the investigator gave the women a detailed explanation about Kegel exercise and helps the women to identify the correct muscle for Kegel training individualized by asked them to lie down on the bed in supine position with knees bent and focus on the perineal area and completely relax the perineal area. Then two fingers were put inside the vagina, and the woman was asked to contract her pelvic floor muscles just like when she holds the urine and she had to try to pull the investigator's finger upward and inward.

After identifying these muscles, the pre-menopausal women in the study group were asked to contract the pelvic floor muscles during examination of the vagina, and then after ensuring proper contraction of the muscle, they were asked to do these exercises twice daily,each time 15–20 times depending on their ability to contract their pelvic floor muscles for 5–10 s and relax for 5–10 s and repeating this exercise for 20 times (for 5 min). After 2 min of rest, they again had to perform this exercise for 3 times of 5 min. so that a total of 20 minutes of exercise is performed at each time. 

However, the investigator asked them to repeat exercise 1 to 2 times per day from the first day until one month, then (2-3 min) and repeated 1 to 2 times from the first day after one month post – intervention until two months and then (3-5 min) and repeated 2 to 4 times from the first day after two months post – intervention until three months.

The investigator used tool III (follow up sheet) which includes the duration of exercise per day, performing exercise according to training program and instructed them for recording their compliance at home. It was taken from them at the end every 4 weeks to ensure women's compliance.

However, control group of pre-menopausal women received routinely care from the hospital at out- patient gynecological clinics.

(Follow up phase)

The investigator used her telephone number for calling with women in the study group every 2 weeks to find out if they were regularly performing the exercises and have any other problems facing them to determine degree of her compliance with pelvic floor muscle exercises at home and checked women progress. However, the investigator calling women in the control group to ensure routine hospital care.

 (Evaluation phase)

Evaluation phase was done at pre intervention as a base data and after 6 weeks & 3 months at the outpatient gynecological clinic. The investigator interviewed pre-menopausal women in the study and control groups to assess the progress of uterine prolapse symptoms by using the second tool (Pelvic organ prolapse – symptoms score (POP-ss).

Results

Table (1): Distribution of pre-menopausal women regarding to their socio-demographic characteristics (n=102)

Table (1): There was no statistical significance difference between the two groups regarding to sociodemographics characteristics

Table (2): Distribution of Pre-Menopausal Women Regarding to Uterine Prolapse- symptoms Pre and Post Intervention (n=102)

Table (2) Shows that there were a highly statistical significant difference between both groups (study and control) at (P.value ≤ 0.000) regarding to uterine prolapse- symptoms post- intervention compared with no statistical significant difference at (P. value = 0.725) pre- intervention respectively

Table (3): Distribution of pre-menopausal women regarding to their degree of uterine prolapse symptoms (n=102)

Table (3): It reveals that there was a highly statistical significant difference between study and control groups regarding to degree of uterine prolapse symptoms post- intervention at (P value ≤ 0.002) after 6 weeks and at (P value ≤ 0.000) after 3 months compared with no statistical significance difference at (P value = 0.096) pre- intervention  respectively

Table (4): Relation between socio-demographic characteristics with uterine prolapse degree of symptoms among pre-menopausal women

Table (4):  It illustrates the relationship between sociodemographics characteristics with uterine prolapse symptoms. It was noticed that there was a highly statistically significant relation between the pre-menopausal women's uterine prolapse symptoms with their age and educational status at (P value ≤ 0.000) and statistically significant with their occupation at (P value ≤ 0.028).

Table (5): Relation between Problems resulting in increasing pressure in abdomen with uterine prolapse degree of symptoms among pre-menopausal women

Table (5): This table illustrates the relation between problems resulting in increasing pressure in abdomen with uterine prolapse symptoms. It was observed that there was statistically significant relation between problems resulting in increasing pressure in abdomen with uterine prolapse degree of symptoms at (P value ≤ 0.024) respectively

Table (6): Relation between uterine prolapse degree of symptoms with gravidity and parity among pre-menopausal women

Table (6): This table shows the relation between uterine prolapse degree of symptoms with gravidity and parity. It was, observed that there was a highly statistical significant relation between uterine prolapse degree of symptoms with gravidity and parity at (P value ≤ 0.001).