Introduction

Urinary incontinence (UI) has been defined by the International Continence Society (ICS) as «a condition in which urine loss is a social or hygiene problem and is objectively demonstrated» [1]. This definition was amended in 2002 by ICS, then adapted as «complaint of any involuntary leakage of urine» [2,3]. UI is an involuntary loss of urine that can occur at any age and has multiple causes. Sometimes urinary incontinence can be associated with incontinence, urgent urination needs, prolapse or sexual dysfunction. UI has a considerable impact on quality of life and, due to its high frequency in the general population, constitutes a major public health problem with a strong economic impact [4]. This work aims to highlight the importance of  physical therapy in increasing the quality of life, improving or treating symptoms of women with urinary incontinence through static and dynamic reeducation methods. Biofeedback, electrostimulation and physical exercises are used to re-educate the pelvic floor muscles and help patients, by visualizing the perineal contraction on the screen, become aware of perineal muscle contraction and relaxation. They learn to control/train their corresponding muscle groups through increased awareness.

Literature Review

Urinary incontinence can be classified as SUI stress urinary incontinence, emergency urinary incontinence (IUU) or mixed urinary incontinence (IUM) [5]. SUI is defined as the involuntary leakage of urine during exertion, such as coughing, sneezing, laughing or physical activity. A sudden increase in abdominal pressure due to physical exertion puts pressure on the bladder, causing urine loss. The basic mechanisms responsible for this reaction are weak urethral support by the pelvic floor muscles and sphincter deficiency. IUU (commonly referred to as an «overactive bladder») is the involuntary leakage of urine associated with «urgency» [6] or a strong and sudden need to urinate. This incontinence is usually caused by involuntary contractions of the detrusor muscle of the bladder wall without the bladder necessarily being full. UUI can also be sensitive, i.e., it can be triggered by simple everyday events, such as the sound of running water, exposure to low temperatures or consumption of cold drinks [7]. The upper limit of urination during waking hours has been determined by the International Incontinence Society to be 7 urinations, although it may be higher in certain populations [8].

Urinary and faecal incontinence have a major impact ecologically, economically, health through urinary infections [9] and skin disorders [10] psychologically and socially through decreased quality of life. [11,12]. Most manufacturers of sorbents are looking for eco- responsible and effective solutions, but the large-scale use of sorbents has a significant negative impact on the planet.

The economic and social impact of incontinence is difficult to estimate, first of all, due to the lack of a real percentage of the incidence of this condition, of the direct costs (the cost of medical and therapeutic consultations, the costs of hospitalizations, absorbent protections…) and secondly , due to the indirect costs arising from incontinence: institutionalization of elderly people, absenteeism and performance at work, psychological disorders, depression [13]. Among athletes, it has been shown that there is an increased percentage of urinary incontinence, often poorly reported to the coach, parents or doctor. According to several studies, the percentage of exercise urinary incontinence among athletes or people who practice strenuous physical activities can reach a value between 28% and 80%. The sports with the highest risk are those that have repeated impacts with the ground: trampoline, gymnastics, hockey, ballet, jumping, etc. [14-18]. Pelvic floor dysfunction (PFD) is common after delivery, with approximately 30% of mothers experiencing urinary incontinence (IU) and 10% incontinence (AI) [19]. Urinary incontinence is sometimes associated with faucal incontinence, which is defined by the International Continence Society as the involuntary loss of faces or gas. Rectal contents (feces, gas) involuntarily pass through the anal canal and the patient is unable to postpone an evacuation until it is socially convenient. Attached to the definition, there is a time component of at least one month and an age of at least 4 years with previously achieved defecator control [20,21].

Depending on the circumstances fecal incontinence is classified as: passive incontinence (involuntary discharge without any awareness); incontinence by urgency (urgent needs and discharge despite active attempts to retain contents); faucal infiltration or «soiling» (leakage of faces often liquid, even after normal discharge) [22]. Urination emergencies, sexual dysfunction, pain, and pelvic organ prolapse (POPs) may also occurin association to the urinary or faecal incontinence. Between 40-91% of women in the first postpartum year may experience one or more of the perineal associated dysfunctions [23]. Prolapse symptoms (POPs) are a change from the normal sensation, structure, or function experienced by a woman relative to the position of her pelvic organs. Symptoms are generally worse at times whilst gravity could worsen prolapse (for example, after long periods of standing or exercising) and in certain cases more advanced even when gravity is not a factor, for example, in dorsal decubitus. Prolapse may be more prominent during periods of abdominal exertion, for example, during defecation [24].

Materials and Methods

The research addressed a number of 64 patients diagnosed with urinary incontinence (UI), respectively stress urinary incontinence (IUM), emergency urinary incontinence (IUU) or mixed urinary incontinence (IUM), sometimes associated with problems of pelvic statics (prolapsus), with faecal anal incontinence or gas. The patients presented this condition as a result of a vaginal birth, as a result of intense sports, due to hormonal deficiency during the peri-menopause period, multiple vaginal births, etc. The research participants were divided into 2 groups: 32 patients in the static group and 32 patients in the dynamic group. Patients come to the office under the guidance of family doctors or specialists in the region with a medical prescription for perineal re-education. This contains the patient›s diagnosis and in some cases the number of recommended sessions. However, most medical prescriptions leave the number of recommended sessions to the discretion of the physiotherapist depending on the evolution and particularities of the patient. In order to reach the aim of this study, the kinetotherapeutic means, the number and frequency of the sessions were selected in accordance with the medical antecedents, the motivation and the evolution of the patients.

The Criteria for the Inclusion of Patients in the Research Aimed at

1. Women with urinary incontinence with medical prescription for perineal re-education.
2. Patients who have given their consent for participation and data collection.
3. Patients who have completed at least 8 sessions.
4. The meetings were held within a maximum interval of 12 months.
5. The patients who completed the initial balance and the final balance.

Of the 312 patients who were presented to the clinic, 108 met criteria 1 and 2, whereas only 64 met all 5 criteria. The study was carried out between January 2022 and March 2023 in Minos, France, in the Kalta Physiotherapy Clinic using two electrostimulation and biofeedback devices Phenix Nano Physio, and the re-education materials necessary to perform the associated physical exercises. Intra-cavitation methods are performed using a Periform or Saint Cloud OVA vaginal probe, and the Anuform probe was used for anal re-education. To facilitate insertion of the probe and for electrical conductivity, a small amount of sterile water-based lubricating gel is applied to the electrodes of the probe before insertion. The physical therapy office is equipped with 5 individual rooms with a massage/ examination table and a gym. The materials used to perform physical exercises associated with intra-cavitation methods were mattress, gym-ball, bicycle, trampoline, treadmill, rope, stepper, half-sphere, proprioception balls.

Research Content

The research contains:

1. The patient›s initial questionnaire (personal data, weight, height, number of births, physical activities, etc., symptoms, Contilife questionnaire)
2. The balance sheet and the initial clinical examination performed by the physical therapist.
3. The patient›s progress sheet (information on the evolution of symptoms, the contraction force at each session and the recovery program used)
4. Final questionnaire of the patient (symptomatology, number and frequency of sessions and self-exercises, Contilife questionnaire)
5. Balance sheet and final clinical examination performed by the physiotherapist.

Recovery Methods Used

1. Manual reeducation at the first session for muscle strength testing and correct learning of abdomino-perineal contraction.
2. Electrical stimulation associated with biofeedback in a static semi-lying position on the examination table using a Periform plus or Saint Cloud OVA vaginal probe and the Phenix Nano device for the static group. Reeducation was achieved through the following therapeutic means: manual reeducation at the first session for awareness of perineal contraction and learning the abdomen o-perineal blockage, followed by pelvic floor training sessions through electrostimulation and intracavitary biofeedback, hypopressive training of the transverse abdominal muscles in a semi-lying or lying position.
3. Electrical stimulation associated with biofeedback and physical exercises with the help of a Periform plus or Saint Cloud OVA vaginal probe, the Phenix Nano device and the mattress, gym-ball, bicycle, trampoline, treadmill, rope, stepper, half- sphere for the dynamic group. The physical exercises associated

with the intracavitary method were progressive and adapted to each patient, the goal of the dynamic group was to gradually train the pelvic floor in the position or situation as close as possible to the real situation/similar to the moments of urinary loss in daily life.

1. Self-reeducation protocol at home with the help of physical exercises that involve the use of the following materials depending on the patient›s equipment or physical condition: mattress, gym-ball, bicycle, trampoline, treadmill, rope, stepper, half sphere, proprioception balls; perineal contractions can also be performed easily during everyday activities: at the office, in the car, climbing the stairs, walking, etc.
2. In the case of patients who have urinary incontinence associated with anal incontinence, the techniques mentioned above have been associated with anal electrostimulation and biofeedback sessions. They were performed with the Anuform anal probe and the Phenix Nano device.

The fast fibers are in proportion of 30% of the perineum muscles and it will be trained through strong and short contractions with an intensity of 80%-100% for a duration of 2-5 seconds. Slow fibers predominate in proportion to 70% because they ensure urinary and fecal continence through prolonged contraction of the urinary and anal sphincter. They will train with an intensity between 50%-70% for a duration of 5-15 seconds. Abdominal-perineal contractions are recommended to be performed on exhalation or in the case of prolonged contractions, if the patient feels the need, a nasal inhalation can be performed and emphasis will be placed on a prolonged oral exhalation as slowly as possible, resuming normal breathing during breaks. Each session lasts approximately 30 minutes.

Electrical Stimulation was Performed with the Following Frequencies

1. For slow fibers: the frequencies used were between 8 Hz

and 33 Hz with a wavelength between 320 and 740 μs.

1. For tonino-phase 2A fibers: the frequencies used were between 20 Hz and 40 Hz with a wavelength between 160 and 320 μs.
2. For 2B fast fibers: the frequencies used were between 40 Hz

and 80 Hz with a wavelength between 20 and 160 μs.

1. For bladder instability, the bladder inhibition program with a frequency of 5 Hz was used in conjunction with a biofeedback program that triggers the A3 Mahony reflex.
2. Biofeedback trained slow fibers and fast fibers through short maximal contractions and sub-maximal contractions holding 6-8 seconds using various combinations. Our study includes an SEM confirmatory factor analysis with Smart PLS. Statistical approaches such as confirmatory factor analysis (CFA) and path analysis are widely used in structural equation modeling (SEM) to investigate detailed relationships between variables.

Smart PLS is a software tool that provides a straightforward user interface for doing SEM analysis. It is designed primarily for Partial Least Squares (PLS) route modeling, which is a variance- based SEM approach. Researchers can use PLS-SEM to analyze the structural model (relationships between latent variables) and Smart PLS to evaluate the measurement model (reflective and formative indicators). Confirmatory Factor Analysis (CFA) is a statistical approach that assesses the measurement properties of a set of observable variables (indicators) and their relationships to latent variables (constructs). It is a confirmatory factor analysis approach in which researchers construct a hypothesized component organization based on theory or previous studies and then contrast it to the data that was observed. CFA is used to determine how well the proposed measurement model fits by examining the factor loadings, errors in measurement, and general model fit indices. Path analysis serves as a method for determining whether variables in a theoretical framework are causally connected. It allows researchers to assess both short- and long-term interactions among factors. Path analysis computes a number of equations for regression at the same time to examine the relationships between variables. Researchers may analyze the coefficients of the variables to determine the degree and significance of the directional relationships (paths) between them.

Results

The present research is structured on several levels, materialized by using research tools meant to provide a comprehensive perspective on urinary incontinence, focusing on the analysis of the impact of this phenomenon on the symptomatology and quality of life before and after physiotherapy treatment. The study uses the longitudinal method, providing a temporal image of this pathology, being applied research tools that allow the comparison of data, before and after performing kinesitherapy procedures. The analysis of the data shows some characteristics of patients (Table 1) thus, the average age of patients is 46.5 years, the youngest being 18 years and the oldest 78 years. The most common age throughout the sample is 57 years, in the dynamic group 54 years, and in the static group 57 years. The average BMI of patients is 25.9, the lowest BMI is 18 and the highest is 42.6. Next, we analyzed the relationship between BMI and symptomatology. It highlights the fact that the highest BMI values, above 30, often cause urinary incontinence associated with prolapse. The duration average of this pathology in the analyzed sample is 4 and a half years, most commonly women have this condition of 1 year, and the longest time for experiencing urinary incontinence is 42 years. The average of births per patient is 2, the number of births most commonly found in the static group is 2, and in the dynamic group is one. We notice that the number of births also influences the symptomatology, the highest values in terms of symptoms, presenting patients who gave birth to 3 children.

Results

The present research is structured on several levels, materialized by using research tools meant to provide a comprehensive perspective on urinary incontinence, focusing on the analysis of the impact of this phenomenon on the symptomatology and quality of life before and after physiotherapy treatment. The study uses the longitudinal method, providing a temporal image of this pathology, being applied research tools that allow the comparison of data, before and after performing kinesitherapy procedures. The analysis of the data shows some characteristics of patients (Table 1) thus, the average age of patients is 46.5 years, the youngest being 18 years and the oldest 78 years. The most common age throughout the sample is 57 years, in the dynamic group 54 years, and in the static group 57 years. The average BMI of patients is 25.9, the lowest BMI is 18 and the highest is 42.6. Next, we analyzed the relationship between BMI and symptomatology. It highlights the fact that the highest BMI values, above 30, often cause urinary incontinence associated with prolapse. The duration average of this pathology in the analyzed sample is 4 and a half years, most commonly women have this condition of 1 year, and the longest time for experiencing urinary incontinence is 42 years. The average of births per patient is 2, the number of births most commonly found in the static group is 2, and in the dynamic group is one. We notice that the number of births also influences the symptomatology, the highest values in terms of symptoms, presenting patients who gave birth to 3 children.

Table 1: Data on research participants.

Below are presented the number of hours per week of sports activities practiced by the research participants, the average being

2.7 hours per week, 2.5 hours per week for the dynamic group and

2.9 hours per week for the static group. The type of physical activity was analyzed according to the symptoms, so the respondents have a series of varied activities, most of them being oriented towards walking, biking, fitness, running and tennis. However, we notice that 33% of patients do not practice any physical activity and represent the highest share in terms of symptoms. It appears, however, that cycling has a major impact on urinary incontinence associated with gas incontinence. We also analyzed kinetic treatment (Table 2) according to the number of sessions performed, duration and frequency, whether exercises were performed at home and with what frequency. Frequency was measured from a scale of 1 to 5 (1=less than once a week, 2= once a week, 3= twice a week, 4= three times a week, 5= more than 3 times a week). The duration of a home reeducation session was measured on a scale of 1 to 4 (1 = less than 5 minutes, 2 = 5-10 minutes, 3 = 10-15 minutes, 4 = more than 15 minutes). Next, we analyzed the impact of urinary incontinence on the quality of life perceived by the respondents by applying a research tool to measure how the therapy positively impacted the daily life of the patients. Thus, a pre-test and post-test questionnaire was used to be able to observe how there were changes in the quality of life throughout the therapy.

Table 2: Information on kinetic treatment.

The analyzed data presents a general picture related to aspects of the personal life of the respondents such as the impact of IU on social, intimate, psychological and the quality of life (Contilife questionnaire). The calculation of the means at the initial and final testing was done on a scale from 0 (not at all) to 3 (strong impact) and on a scale from 0 (not at all) to 5 (strong impact) for the Contilife questionnaire. Contilife questionary describes daily activities, effort situations, self-image, emotional outing, sexuality and wellbeing. An increased difference in the scores obtained for all dimensions of life analyzed is observed. The symptoms that appear during various activities, such as playing sports, laughing, shopping, climbing stairs, etc., have a great impact at a social, intimate and psychological level, the patient developing different fears such as that of not being seductive anymore, of smells, of incontinence during sexual activity, soiling clothes, etc.

Correlation Between Variables

Analyzing the very strong positive correlation between activities and fears (0.937), activities and impact (0.868), fears and impact (0.873), according to the data in (Table 3), results in the model in (Figure 1), which represents the graphic expression that confirms that urinary incontinence decreases patients› quality of life. In this model the correlation coefficients are equal to the path coefficients (Table 3). Our model contains 3 variables: Activities, Impact and

Fears, each characterized by several items shown in (Figure 1). The Activities variable consists of 9 items (Figure 1), among which those with the highest weight are IU outside (LF=0.850), Shopping (LF=0.786), Sneezing and Laughing (LF=0.753), Extended Wait (LF= 0.625), Sports practicing (LF=0.622), Stairs climbing (LF=0.592), Lifting objects (LF=0.592) and UI in means of transport (LF=0.519). These represent the activities carried out by the patients in which the symptom of urinary incontinence occurs with a greater frequency. The Impact variable consists of 9 items (Figure 1), among which those with the highest weight are Straining (LF=0.844), Psychological Impact (LF=0.808), Social Impact (LF=0.799), Intimate Impact (LF= 0.782), Urinary control (LF=0.729), loss of patience (LF=0.622), Discouragement (LF=0.597), Obsession (LF=0.495), Use of absorbent pads (LF=0.490). Thus, we can analyze/observe to what extent the patients are affected by urinary incontinence. We notice that subtle or invisible factors such as Discouragement, Obsession, wearing absorbent pads are ranked last.

Table 3: Latent Variable Correlation.