“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM ON KNOWLEDGE OF MULTIPARA WOMEN REGARDING MANAGEMENT OF STRESS INCONTINENCE IN SELECTED RURAL AREAS, BANGALORE.”

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Mrs. MARYKUTTY K.V

1st YEAR MSc NURSING

OBSTETRICS AND GYNAECOLOGICAL NURSING

JUPITER COLLEGE OF NURSING

No.225, NELAMANGALA

BANGALORE

2012-2013

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF

SUBJECTS FOR DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS / Mrs. MARYKUTTY K.V
1ST YEAR M.SC. NURSING,
JUPITER COLLEGE OF NURSING,
NELAMANGALA,
BANGALORE.
2 / NAME OF THE INSTITUTION / JUPITER COLLEGE OF NURSING,
NELAMANGALA,
BANGALORE
3 / COURSE OF THE STUDY AND SUBJECT / 1st YEAR M.Sc NURSING
OBSTETRICS AND GYNAECOLOGICAL NURSING
4 / DATE OF ADMISSION TO THE COURSE / 01-06-2012
5 / TITLE OF THE TOPIC
“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM ON KNOWLEDGE OF MULTIPARA WOMEN REGARDING MANAGEMENT OF STRESS INCONTINENCE IN SELECTED RURAL AREAS, BANGALORE.”

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Urinary incontinence is the unintentional passing of urine. It is a very common problem and is thought to affect millions of people worldwide. It is not clear exactly how many people are affected, but it is estimated that between three andsix million people in the UK have some degree of urinary incontinence. Urinary incontinence affects abouttwice as many women as men and becomes more common with age.1

There are two common types of urinary incontinence: stress incontinence (SUI) and urge incontinence (UUI). Stress urinary incontinence (SUI) is a common type of bladder control problem in women. It is characterized by uncontrollable leakage of urine with increased abdominal pressure. SUI is triggered by events such as coughing and laughing. In order to understand why SUI occurs, you must first understand the female urinary anatomy. Normally, the bladder has two functions. One is to store urine produced by the kidneys. The second is to contract and push out the urine through the urethra when it is convenient and socially acceptable to empty the bladder. The pelvic organs (the bladder, the vagina, the uterus and the rectum) are supported by a complex “hammock” of pelvic floor muscles and tissues. There is a circular muscle around the urethra, called the sphincter, which keeps the urethra closed during filling. The pelvic floor muscles help to support the sphincter muscle that keeps the bladder closed while it fills with urine.

When the bladder is full, it sends a message to the brain to empty. The bladder squeezes, the pelvic floor relaxes and urine comes out through the urethra. Therefore, the condition of the pelvic floor muscles has a direct effect on bladder control.

SUI occurs when abdominal pressure or “stress” is placed onthe weakened urethral sphincter or pelvic floor muscles. Bladder control also depends on stable communication between the brain and bladder. Therefore, damaged pelvic nerves, from obstetrical trauma for example, can affect the activity of the sphincter and pelvic floor muscles and also cause SUI.2

In women, physical changes resulting from pregnancy, childbirth, and menopause often contribute to stress incontinence. Stress incontinence can worsen during the week before the menstrual period. At that time, lowered estrogen levels may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels.3

Main manifestation of stress incontinence is leaking of small to medium amount of urine when you cough, sneeze, laugh, exercise, or do similar things.

Diagnosis of urinary incontinence in women may involve a physical exam, anultrasound, urodynamic testing, and tests including cystoscopy,urinalysis, and a bladder stress test. The doctor will also take a medical history and may recommend keeping a bladder diary.

Treatment of urinary incontinence in women may include behavioral or no pharmacologic treatments, like bladder training andKegel exercises, medication, biofeedback, neuromodulator, surgery, catheterization, or a combination of these therapies.4

6.1 NEED FOR THE STUDY

Urinary incontinence is an underdiagnosed and underreported condition with major economic and psychosocial effects on society. The direct cost of treating urinary incontinence in men and women of all ages was estimated at $26.3 billion in 1995.

The reported incidence of urinary incontinence varies considerably depending on the age of the study population, the study methods and the definition of the problem. A questionnaire studythat included women between the ages of 20 to 80 years, reported an overall prevalence for urinary incontinence of 53.2 percent. Even in younger women (between 20 to 49 years of age), the prevalence was 47 percent. In another study involving 2,763 postmenopausal women (mean age: 67 years), 56 percent reported urinary incontinence at least weekly.5

SUI, the most common type of UI in women, affects one in seven women worldwide. Nearly half of the women with urinary incontinence suffer from the symptoms of stress urinary incontinence (49%). Urge incontinence accounts for 22% of all incontinence and mixed incontinence accounts for 29% of all incontinence. SUI is more prevalent than other types of UI in younger and middle-aged women under 55 years.

Despite the high prevalence of SUI, many women are reluctant to discuss their condition with their partners, friends or even with healthcare professionals. Shame and embarrassment are the key deterrents of seeking help. In fact, more than half of women with SUI do not seek help from a healthcare professional. SUI can have a profound impact on women’s quality of life as the condition can result in embarrassment, psychological distress, social isolation and loneliness.6

A study was conducted to determine the prevalence, type and treatment behaviour of women with urinary incontinence in four European countries. Data were collected using a postal survey which was sent to 29,500 community-dwelling women aged > or = 18 years in France, Germany, Spain and the UK. Of the women who responded, 35% reported involuntary loss of urine in the preceding 30 days; stress urinary incontinence was the most prevalent type. The lowest prevalence was in Spain (23%), while the prevalence was 44%, 41% and 42% for France, Germany and the UK, respectively.the study concluded that Millions of women in Europe have urinary incontinence; the consultation and treatment rates were low.7

Studies show that 20.8% of women over the age of 15 have experienced stress urinary incontinence worldwide.8

The reported prevalence of stress urinary incontinence in India is about 12%.9

A study conducted on Women in the reproductive age group between 20 and 35 attending the Gynec and postnatal OPD at coimbatore revealed that The prevalence of incontinence was 18.6%. Incontinence was reported in 12.5% of primis as compared to 26.4% in multis. The incidence of incontinence rose as age advanced. Sixteen percent developed incontinence following LSCS whenever 19.8% developed incontinence after normal delivery.10

A cross sectional study was conducted to find out the frequency and associated obstetrical and gynecological risk factors of urinary incontinence in women. A total of 510 women (mean age of 35.4 year and parity 2.6) were studied. Out of the total women interviewed 234(45.9%) reported episodes of urinary incontinence. Urinary incontinence was found related to traumatic and operative vaginal births, pelvic organ prolapse, abdominal mass, smoking, obesity, old age and menopause.11

Researcher from her own experience and based on literature review felt a need to improve the knowledge of multipara mothers regarding management of stress incontinence. Hence a structured teaching programme is planned to improve the knowledge of multipara mothers.

6.2 REVIEW OF LITERATURE

Review literature is considered as an essential step of research processes. It involves the systematic identification, location, seriating and survey of return material that contain information on a research problem. The over all process review of literature is to develop a strong knowledge is to carry out a research and other scholarly education and clinical practice activities. It helps to determine the gaps consistencies and in consistencies in the literature about a particular subject under study.

A research literature is a written summary of the state of existing knowledge on a research problem. The task of reviewing research literature involves the identification, selection, critical analysis and written description of existing information on a topic.12

Review of literature guides the investigator to design the proposed study in a scientific manner so as to achieve the desired result, the literature for the present study been reviewed under following headings.

·  Review of literature on Behavior changes

·  Review of literature on Medication

·  Review of literature on Pelvic floor muscle training

·  Review of literature on surgery

Review of literature on Behavior changes.

H.M. Dallosso, C.W. Mc Grother, R.J. Matthews, M.M.K. Donaldson (2003 July) conducted a study on association of diet and other lifestyle factors with overactive bladder and stress incontinence in women. These researchers investigate the role of diet and other lifestyle factors in the incidence of overactive bladder and stress incontinence in women. Studies have suggested relationships between different aspects of lifestyle and symptoms of urinary incontinence, the researchers collected Baseline data on urinary symptoms, diet and lifestyle from 7046 women using a postal survey and food-frequency questionnaire. Follow-up data on urinary symptoms were collected from 6424 of the women in a postal survey 1year later. Logistic regression was used to investigate the association of food and drink consumption and other lifestyle factors with the incidence of overactive bladder and stress incontinence. In the multivariate model for the onset of an overactive bladder, there were significantly increased risks associated with obesity, smoking and consumption of carbonated drinks, and reduced risks with higher consumption of vegetables, bread and chicken. Obesity and carbonated drinks were also significant risk factors for the onset of stress incontinence, while consumption of bread was associated with a reduced risk. After the study the researchers concluded that there is a Causal association with obesity, smoking and carbonated drinks are confirmed for bladder disorders associated with incontinence, and additional associations with diet are suggested. Behavioral modification of lifestyle may be important for preventing and treating the stress incontinence.13

Sivalingam, FRCO G, K Y Loh, MMed (FamMed),( Oct 2006) conducted a study at International Medical University Malaysia, Jalan Rasah, Seremban. According to these researchers urinary incontinence is one of the important and common problem of the women population Behavioral therapy may benefit up to 60-75% of the patients. The therapy is usually long term and aim is for symptom control and better quality of life rather than curing the disease. Behavioral modification such as lifestyle changes, bladder re-training and prompted voiding can improve the quality of life and enhance self-esteem. Lifestyle modification should be started early in the course of treatment. These interventions are simple, inexpensive and do not cause significant adverse effects in managing urinary incontinence. Obesity, smoking and excessive alcohol intake must be addressed. The researchers concluded that without appropriate and timely management, urinary incontinence can lead to poor quality of life.14

Harvey Simon(Nove2012) at Harvard Medical school published a health guide regarding Stress incontinence and its management. According to the author Treatment depends on how severe your symptoms are and how much they affect your everyday life. Behavioral changes is one of the important management for the prevention of urinary incontinence, the changes include Drinking less fluid and Urinating more often to reduce the amount of urine that leaks. Avoiding jumping or running, which can cause more urine to leak and Making your bowel movements more regular by taking dietary fiber or laxatives to avoid constipation which can make incontinence worse. Avoiding alcohol and caffeine, which can stimulate the bladder and Avoiding food and drinks that irritate the bladder, such as spicy foods, carbonated drinks, and citrus fruits. 15

Christine Bradway, CS Gerontologic(1998) at University of Pennsylvania School of Nursing, conducted a study on Treating Women's Incontinence: Review of the Literature and Recommendations for Practice . According to these researchers Urinary incontinence is common and nurse practitioners are often the first professionals to evaluate and treat this condition. A growing body of literature exists that supports non-surgical treatment approaches for women with stress, urge, and mixed incontinence. This article reviews the existing literature regarding non-surgical treatment of incontinence in women, including behavioural therapies, pharmacologic interventions, self-care strategies, and prevention. The literature regarding non-surgical treatment mainly mention that behavioural changes are more effective and simple way of management which includes Drinking less fluid and Urinating more often to reduce the amount of urine that leaks. Avoiding alcohol and caffeine, which can stimulate the bladder.16

Review of literature on Medication

Mariappan P, Ballantyne Z, N'Dow JM, Alhasso AA(2005 Jul) conducted a study at Department of Urology, Western General Hospital, UK. According to these researchers Serotonin and noradrenalin reuptake inhibitors (SNRI) are good for stress urinary incontinence. The study included Nine randomized trials involving 3327 adults with predominantly stress urinary incontinence, randomized to receive duloxetine or placebo. Both arms in individual trials were comparable for various baseline characteristics. Treatment duration was between three weeks and 12 weeks. Duloxetine was significantly better than placebo in terms of improving patients' quality of life (WMD 5.26, 95%CI 3.84 to 6.68. P< 0.00001) and perception of improvement. Individual studies demonstrated a significant reduction in the Incontinence Episode Frequency (IEF) by approximately 50% during treatment with duloxetine. And suggested that duloxetine was better than pelvic floor muscle training alone in reducing IEF (P < 0.05) based on median percentage decrease in IEF per week. Although significant side effects were commonly associated with duloxetine, they were reported as acceptable and the researcher concluded that that duloxetine treatment can significantly improve the quality of life of patients with stress urinary incontinence.17

Moore K.( 2004 Jul) conducted a study at St. George Hospital, University of New South Wales. According to this researcher Duloxetine is a potent and balanced dual serotonin and norepinephrine reuptake inhibitor (SNRI) that enhances urethral rhabdosphincter activity and bladder capacity in a cat irritated bladder model. Whether this is beneficial in women suffering from stress urinary incontinence (SUI) has been investigated in one phase 2 and three phase 3 placebo-controlled clinical trials with very comparable inclusion and exclusion criteria and outcome variables.. Duloxetine 80 mg per day (40 mg twice daily) decreased the frequency of incontinence episode frequency (IEF) and improved incontinence-related quality of life (I-QOL) independent of baseline incontinence severity and also in patients awaiting surgery. The decrease in IEF and improvement in I-QOL were not due to more frequent voiding, as the mean time between voids increased. It can, therefore, be concluded that duloxetine 40 mg twice daily is a new and promising pharmacological treatment approach for women with stress urinary incontinence.18