Introduction
The growth of aging population has now become a universal phenomenon, concerning to
developed and under developing countries alike.
The participation in the regular physical activity (aerobic and anaerobic exercises)
provides positive responses to healthy aging. The physical inactivity can be perceived
as a major public health problem, as being active drives down the locomotive system
limitations, promotes the maintenance of physical capacity and the autonomy of the
elderly Silva et al.[1 ] With the increasing life expectancy, it is needed to know the amplitude and mechanisms
of how physical exercises can improve the health, functional ability, quality of life
and independence among this population.
The regular physical activity aim is to improve cardiorespiratory, muscular, skeletal
systems, and to reduce the risk of non- communicable diseases. It is recommended that
adults from 18 to 64 years old should perform at least 150 minutes of moderate intensity
physical activity per week.[2 ] As per Ciolac,[3 ] the aging process cannot be avoided and a sedentary life might accelerate this process,
increasing the occurrence of chronic diseases. Moreover, the regular physical activity
practice improves the quality of life and increases life expectancy.
The urinary incontinence (UI) is a frequent complain among women, it can range from
32% and 64%. The most common type is the stress urinary incontinence (SUI) characterized
by involuntary urine loss on physical exertion or exercising, reflecting on her daily
routine, professional and sports activities Abrams et al.[4 ] Several factors might influence this condition, as age, medication (diuretics and
α-blockers), endocrine dysfunctions (diabetes), central or peripheral neuropathy (multiple
sclerosis), prolapse, pelvic floor denervation, obesity and smoking.[5 ] The urinary symptoms are also present in the transition from perimenopause to postmenopause.
The urinary tract trophic changes caused by hypoestrogenism increases the susceptibility
to infections, bladder filling disorders, dysuria, vaginal dryness, and dyspareunia.
The atrophy of urinary tract tissues can also increase the incidence of UI by the
presence of estrogen receptors and the common embryology of the bladder, urethra,
and vagina influencing the onset of UI symptoms after menopause.[5 ]
The UI leads to occupational, domestic and sexual activities restrictions, causing
discomfort that includes needing constantly panty liners to prevent urine leakage,
frequent changing of clothing, the odor of urine and skin rashes, affecting negatively
the quality of life.[6 ]
Functional and morphological aspects of the urinary bladder
There are functional differences among the several parts of the bladder. The ureterovesical
junction (UVJ) is the name that is assigned to the transition zone between the bladder
and the urethra, and it has an important role in the urine storage and voiding. Such
function is maintained by a synergistic process that engages central and autonomic
nervous systems, detrusor muscle and urethral sphincter.[7 ]
[8 ]
The urine storage occurs under low pressure, so bladder relaxes during the filling
stage. Disorders in the storage functions can lead to lower urinary tract symptoms
(LUTS), such as urgency, frequency and urge incontinence, caused by contraction of
the smooth muscle of bladder on this stage. The emptying requires coordination between
bladder contraction and urethra relaxation. Disorders in the emptying stage can lead
to voiding dysfunctions such as incomplete emptying of the bladder sensation on post
voiding. The LUTS rises significantly with age, irrespectively of whether they are
men or women, is a major problem for the elderly.[9 ]
The urinary bladder stores adequate volume of urine, allowing the accumulation of
volumes without increasing the intravesical pressure. Its muscle fibers spread in
every direction and once the intravesical pressure increases, the emptying happens
through the contraction of smooth muscle (detrusor muscle) and the relaxation of striated
muscle from external urethral sphincter, to allow the urination to occur.
The bladder wall is composed of three layers: the innermost layer, the mucosa, which
contains transitional epithelium tissue and is impermeable to urine; middle layer,
muscular, the most developed one and which made bladder to be known as a dense muscular
organ; and the outermost layer, adventitia, composed of connective tissue since serosa
is just found in the upper region of the bladder.[10 ] The muscular layer (detrusor muscle) consists in a central region of fibers arranged
in a circular configuration containing 3 irregularly arranged layers of smooth muscle,
intermixed with collagen fibers which makes difficult to distinguish the internal,
circular and external layers of the detrusor muscle. The contraction of this muscular
layer is related to urination reflex, as the muscle stretches out when the bladder
is filled with urine, and this condition affects the autonomic innervation, that is
under voluntary control. Thus, parasympathetic nervous system fibers are responsible
for urination reflex, they are located amongst the muscular fibers layers and are
responsible for bladder contraction. The sympathetic nervous system fibers are responsible
for bladder relaxation and compose a plexus on the adventitia, innervating the blood
vessels.[9 ]
The cells of external and internal layers tend to be arranged longitudinally and the
ones from middle layer circularly. The configuration of these fibers helps the tissue
architecture, enables a passive action on the tissue when under mechanical stretch,
facilitating to return to the original position; along with collagen cells, the elastin
cells are important for the maintenance of a regular tissue resistance.[9 ]
There is a high intercellular cohesion level that protects the bladder against the
excessive volume. The collagen concentration on the vesical wall is closely related
to the protection level available. The smooth muscle cells of the bladder help the
collagen production accordingly to the bladder wall distension triggers.[11 ]
The smooth muscles exhibit an extreme variability, not only in ultrastructural details,
but also in their contractile, regulatory, and electrophysiological properties and
in their sensitivities to drugs and neurotransmitters.[9 ]
The bladder extracellular matrix
The cells of a tissue are generally attached to a complex extracellular macromolecules
network known as extracellular matrix (ECM) that sets cells and tissues together,
providing an organized structure where cells can migrate and interact with each other
and also support most of the mechanical stress the tissue is exposed to.
The extracellular matrix (ECM) molecules are composed of two main classes of macromolecules:
glycosaminoglycans (GAGs) and proteins. The ECM protein components are also classified
in structural such as collagen and elastin and adhesive as fibronectin and laminin.[12 ]
[13 ]
The bladder ECM is composed of proteins, proteoglycans and GAGs that provides support
to bladder cells and components, playing an important role in protecting the urothelium
and in urine storage. The GAGs protective membrane (main chondroitin) that covers
the urothelial cells form a barrier against several toxic substances.[14 ]
Most of the bladder collagen is found in the connective tissue outside the muscle
bundles, in the perimysium. The main types of collagen found in the bladder are: collagen
type I that represents ∼75% of the bladder collagen, they are disposed in wavy shape
and under volumetric load they stretch and can become 3% to 5% longer; and collagen
type III that represents ∼25% of the bladder collagen, usually found around type I
collagen, widely distributed throughout the vesical wall. Collagen type II seems to
undergo conformational changes to adjust to the intravesical volume.[15 ]
During regular aging occurs elastic fibers fragmentation, a decrease in smooth muscle
cells, disarrangement and broadening of collagen and increase of amorphous ground
substance, causing the reduction of elastic properties in the urinary bladder.[16 ]
Aging and urinary incontinence
The UI is a usual issue on women aging, with prevalence of 17% to 24% in women over
65 years-old, and increase ∼75% in women above 75 years-old.[17 ]
Based on epidemiological studies, the occurrence of UI in elderly women is related
to diabetes, hypertension, and obesity.[18 ]
The correlation between the estrogen serum levels and the urogenital system atrophy
is directly related to the incidence of UI. However, as there is a clear relationship
between the higher prevalence of UI and age, so it is a huge challenge to establish
whether the prevalence is due to the estrogen decrease in menopause or part of the
regular aging process.[19 ]
Morphological, structural and histological studies over the urinary bladder found
weight increase, thickening of the bladder wall, thinning of the urothelial layer,
reduction of muscle mass and increase in collagen quantity and, therefore, disorders
in the bladder storage and filling processes.[20 ] Kitta et al.[21 ] analyzed how the ovariectomy in middle age and young adult female rats affects the
urinary continence mechanism during sneeze reflex and noticed apoptotic changes in
the urethral tissue. Hence, aging and estrogen deficiency affect baseline urethral
function and can induce SUI in postmenopause women.
Several factors can be the reason behind the filling disorders observed during aging,
including detrusor muscle fibrosis, and therefore, vesical contraction limitation,
collagen deposition, and accumulation. During aging process, the smooth detrusor muscle
progressively develops fibrosis by collagen deposition and may change the vesical
contractility, resulting in involuntary vesical contractions.[22 ]
The aging is also related to the reduction of urethral sphincter function in a woman,
a reduction on striated muscle cells in rhabdosphincter of humans and an increase
on urethral muscle fibers apoptosis.[23 ]
The dysfunctions on the pelvic floor muscle (PFM) are frequent and bring uncomfortable
problems including several conditions that affect the performance of daily activities,
sports, sexual and social activities, having consequences as urinary and fecal incontinence,
lower urinary tract abnormalities, sexual dysfunctions, pelvic pain and pelvic organs
prolapses.
The aging is a well-known factor that affects the PFM and lower urinary tract function
due to hormonal deficiency, is likely one of the causes of pelvic floor muscle dysfunctions
on elderly women, that can lead to pelvic organs prolapse and UI.[24 ]
[25 ]
The levator ani and the coccygeus muscle are connected to the pelvis inner surface
and along with the urogenital diaphragm muscles compose the pelvic floor muscles (PFM).
The levator ani consists of three main muscles: the pubococcygeus, the puborectalis
and the iliococcygeus.[26 ] The pubococcygeus and the puborectalis muscles have a U shape and arise from pubic
bone through both sides of midline and stretches behind the anus. They are formed
mainly by striated muscular fibers type I, which are important to maintain continuous
tone during resting state and keep the urogenital hiatus closed. The iliococcygeus
arises laterally from tendinous arch reaching the gap on the posterior part of the
pelvis, providing thereby support to the pelvic organs.[27 ]
The PFMs are functionally essential to maintain continence and pelvic support. Ultrasonography
studies shows that under the sudden rise of intra abdominal pressure (around 150 cmH2 O) the proximal urethra undergoes a displacement of the midsagittal plane close to
10mm, therefore the lower abdominal content is forced caudodorsally, due to a simultaneous
contraction of the diaphragm and the abdominal wall muscles. The bladder neck downward
move that is visible on the ultrasonography makes the surrounding tissues to move
downwards. The abdominal pressure is transversally transferred to the urethra, so
that its anterior wall is deformed toward the posterior, thereby helping to close
the urethral lumen and prevent urine loss caused by increased intravesical pressure.
The PFMs injury reduces the support layer and provides less resistance against deformity
while increased abdominal pressure, thus the urethral lumen closing is ineffective,
increasing the incidence of SUI.[27 ]
The muscles in elderly have around 35% less strength, exhibit mass loss and atrophy
mainly in type II fibers, when compared with a young adult.[28 ] These changes are not due to neural recruitment but to aging on muscle contractility.
Furthermore, if PFMs are damaged or the innervation is impaired, muscle contraction
will take even longer to make the same strength.[27 ]
[28 ]
The presence of estrogen receptors in the pelvic floor muscles means that the reduction
of this hormone concentration in the body can also promote changes in this musculature.[25 ]
[29 ]
Bocardi et al.[30 ] after observing the aging effect over PFM function and electromyographic activity
in healthy and nulliparous women from 18 to 69 years old, noticed no difference among
the several groups of different ages when comparing the pelvic floor function and
muscular strength. However, a low negative correlation was found between age and the
electromyographic activity of the pelvic floor muscles revealing the trend that higher
the age, lower the electromyographic activity of these muscles.
The pelvic floor is directly related to the urinary continence mechanism, as the muscular
function is better on physically active women.[31 ] Women that have UI usually exhibit pelvic floor dysfunctions. Strengthening these
muscles results in an efficient improvement in urinary losses.[32 ]
Method
A systematic bibliographical review that examined the influence of physical activity
on functional performance and on urinary incontinence among elderly women. The research
was performed by 2 (two) editors on articles from January 2000 to January 2017. This
study follows platform PRISMA8 protocols over articles selection and eligibility criteria.
The research was done on the following databases: Medline, Sports Disco, Pubmed, and
Scielo. In each database, these keywords were checked: urinary incontinence, postmenopause,
aging, physical activity, exercise, sport and fitness in Portuguese and its corresponding
term in English, with the Boolean operator AND. A manual search was also conducted
in all references mentioned in the articles selected for this study. The complete
PubMed database research strategy can be found in [Table 1 ]: The eligibility criteria were: aging women population, who performed a regular
physical activity for more than three months, there was no initial restriction regarding
publications quality. The shortlisted articles were fully analyzed ([Fig. 1 ]).
Fig. 1 Studies selection process flowchart, as per PRISMA check-list.
Table 1
Complete database research strategy
Keywords in English
Keywords in Portuguese
Physical activity OR exercises AND postmenpausal OR elderly OR aged OR older AND urinary
incontinence
Atividade física OR exercícios AND pós-menopausa OR mulheres idosas OR envelhecimento
AND incontinência urinária
Physical activity OR exercises AND postmenpausal OR elderly OR aged OR older AND stress
urinary incontinence
Atividade física OR exercícios AND pós-menopausa OR mulheres idosas OR envelhecimento
AND incontinência urinária de esforço
From the review of titles and abstracts, it was selected for fully reading the cross-sectional
and longitudinal randomized clinical trials, which includes a method for assessing
incontinence and/or functional performance, type of physical activity performed and
incidence of UI.
It was excluded repeated studies, protocols of articles recorded in databases, studies
involving pharmacological agents, noninterventional studies or those which didn't
specify the type of intervention performed.
Results
The electronic search identified 218 articles on Medline, Sports Disco, Pubmed and
Scielo databases, after removing the duplicates.
After reading the titles, 206 articles were excluded for they were not related to
the subject or for being unavailable. From fully reading 12 articles, 07 were selected.
The study aspects are described in [Table 2 ].
Table 2
Summary of included studies (n = 8)
Author, year
Type
Age
N
Population characteristics / intervention
Assessment method
Results
Moreno-Vecino et al.[33 ] (2015)
Transversal
> 65 years-old
471
Walking
ICIQ-SF** Fitness assessment
↑UI sedentary group (p = 0,08).
↓UI walking group (p < 0,01)
↑UI smaller the flexibility (p < 0,01)
Morrisroe et al.[35 ] (2014)
Transversal
60–93 years-old
248
20 minutes exercising 3X per week
ICIQ* Pedometer and physical performance
↑functional performance ↓UI symptoms (p < 0,05)
Tak et al.[48 ] (2012)
Randomized Controled Multicentric
Average of 84 years-old
155
85 intervention and 70 control
Group exercising on functional ability to use the toilet
Pelvic floor training
Physical performance questionnaire
Three-day voiding diary
↑functional performance has not been associated to the ↓of UI (p > 0,01)
Vinsnes et al.[39 ] (2012)
Randomized Controled Multicentric
> 65 years-old, average of 84,3 years-old
68
(TG n = 35 / CG n = 33)
TG: transfer, walk ability, balance, muscle strength, endurance and ADL training
CG – habitual care
24 hours Pad-Test
↓UI on TG (p = 0,03)
Virtuoso et al.[31 ] (2011)
Transversal
> 60 years-old
28 active on physical activities
11 inactive
Exercising the last 6 months
ICIQ*
↑UI in women who performs physical exercises (p = 0,288)
Townsend et al.[51 ] (2008)
Prospective cohort
37–54 years-old (average of 45,9)
−
Walking (35%), vigorous activities (18%) e calisthenic exercises (15%)
ICIQ*
↑physical exercises ↓UI
Danforth et al.[34 ] (2007)
Prospective cohort
54–79 years-old (average of 65,9)
2355
Walking (> 50%)
ICIQ *
walking ↓UI 26%
↑physical exercises ↓UI (p < 0,01)
Kikuchi et al.[18 ] (2007)
Transversal
>70 years-old
346
Exercising the last 12 months
ICIQ*
↑exercises ↓UI
Physical Activity and Urinary Incontinence in Elderly Women
Kikuchi et al.[18 ] assessed the relation between physical activity levels and UI in a population of
346 women over 70 years old. To be able to estimate the incidence of UI, the “International
Consultation Incontinence Questionnaire” (ICIQ) was applied. The results show a prevalence
of 34% of women having kidney failure. No correlation was found between high levels
of physical activity and reduction of UI. It is presumed that high impact activities
(like jogging and tennis), on which you have a significant increase of intra abdominal
pressure, can bring over SUI. Moreover, it is concluded that physical activity is
effective on primary and secondary control of UI because it reduces the risk of diseases
as diabetes, hypertension, obesity and pelvic floor disorders. Moreno-Vecino et al.[33 ] compared the relation between physical activity, body composition and UI in 471
women over 65 years old. The UI was evaluated through the “International Consultation
Incontinence Questionnaire - Short Form” (ICIQ-SF). The physical activity level was
evaluated using a set of 08 tests and the fitness index was calculated. Active and
sedentary behaviors were then recorded from standardized questionnaires. The UI was
found in 28% of the participants with higher prevalence in obese and lower physical
ability ones. There was a trend toward a higher level of physical activity and walking
once a day in women with no UI when compared with those with UI.
Danforth et al.[34 ] and Morrisroe et al.[35 ] evaluated the incidence of UI using the questionnaire which has the following question:
“In the last 12 months, how often have you had leakage or loss of urine?,” the answer
possibilities were: less than once a month, once a month, 2 or 3 times per month,
once a week, every day. Women that have the loss more than once a month were defined
as incontinence.
Morrisroe et al.[35 ] evaluated the fitness performance of Latin women in the United States, applying
the Guaralnik Short Physical Performace Battery for more than 60 years. To measure
the number of steps they take per day, it was given a pedometer to be used throughout
the day. It was shown that physical activity practice is related to lower incidence
of UI. The interventions made to improve physical performance may help to prevent
UI, as a better functional performance helps the toilet visits, thus keeping a vesical
control.
Virtuoso et al.[31 ] analyzed the UI incidence and perineal muscle function in 39 elderly women (over
60 years old) active and inactive in regular physical activity. For such they applied
the section “Atividade Física de Recreação, Esporte, Exercício e Lazer” from questionnaire
“Questionário Internacional de Atividade Física adaptado para idosos”,[36 ] where elderly women were considered as active in case they perform 150 minutes or
more of moderate or vigorous physical activity during a regular week. It was included
among the activities: aerobics, swimming, dancing, and bodybuilding. They also applied
a validated questionnaire[37 ] about the urinary tract dysfunctions symptoms and the definition of UI type (stress
or urge incontinence) as determined by the International Continence Society (ICS).
The participants were inquired making use of a 4 points rating scale (never, sometimes,
once a week, all the time or during daytime and nighttime). The pelvic floor function
was evaluated by digital palpation using the PERFECT scheme[38 ] and perineometry. The results show that physically active elderly women seem to
have better pelvic floor function than the inactive ones.
Danforth et al.[34 ] evaluated through a questionnaire, the relation between physical activity and the
risk to establish UI, in women between 54 and 79 years old. The women were inquired
about how much time they spend per week on physical activity, choosing from 0 minutes
to 11 hours or more and also indicating which activity was performed among: running,
swimming, dancing, aerobics, calisthenic exercises, squash, cycling or low-intensity
exercises like yoga (in or outdoor). From the results, they noticed that women that
performed walking presented 26% lower chance of UI compared with the those who performed
other activities (aerobics, running, cycling, dancing, water aerobics, among others).
There was no evidence of a relation between physical activity and emergency or mixed
UI. After prospective investigation they detected that moderate intensity of physical
activity, including walking, is associated with ∼20–25% lower chances of developing
UI.
Treatment and prevention of UI in elderly women
Vinsnes et al.[39 ] conducted a randomized clinical trial in 48 women over 65 years old for 3 months,
assessing the physical training effect on UI through training in the transfer, overall
muscle strength and walking training. Moreover, the group was advised on how to execute
daily activities, primarily how to carry weight and decubitus positioning since the
group consisted of home care nurses. The control group had 50 women. The evaluation
method to measure urinary loss before and after the intervention was the 24-hour pad
test. The results showed that urinary loss was significantly lower in the group under
intervention.
Tak et al.[43 ] conducted a multicentric randomized clinical trial with 192 institutionalized women
with an average of 84 years old, divided into two groups: intervention (n = 102) and control (n = 90). The selected women must have good cognitive and physical function to participate
in a program that included instructions on behavioral aspects of continence, exercises
to improve pelvic floor muscles, bladder, and physical performance. The program included
weekly group training for 30 minutes each, to improve the functional ability to use
the toilet in an independent manner. The exercises included: sitting and getting up
from chair and bed, upper- limb mobility and walking. The intervention was performed
by a physiotherapist specialized in pelvic floor musculature training, with experience
in group training and affinity with the elderly. The Physical Performance Test (PPT)
was applied. The involuntary urine loss was measured through the three- day voiding
diary. The reduction of UI was noticed in 40% of the intervention group and in only
28% of the control group. The frequency of urine loss episodes decreased in both groups
in six months (51% in the intervention group and 42% in the control group). The physical
performance improved in the intervention group and worsened in the control group during
the study. The physical performance improvement was related to joining in an exercise
program.
Discussion
The physical activity is an integral part of promoting healthy, active and independent
aging, and urinary complaints cannot be neglected, as it is established that women
can quit exercising if they experience urinary losses during the exercises, directly
affecting their physical fitness and functional performance.[40 ]
[41 ]
Individual strategies and training for UI control should be embraced and not allow
this symptom to be part of the women aging process since UI is one of the major public
health problems in aging, affecting negatively the life quality of this population.[18 ] The UI during physical activity is an obstacle that can hinder people from exercising,
mainly in women with more severe losses, increasing the possibility of inactivity
and obesity.[42 ]
The urine loss issue in young female athletes has been underestimated. Several studies
show increased risk of UI in this population and tends to be even worse over the years.[43 ] Approximately 30% of female athletes experience some urinary loss during exercise.[44 ] Young women who practice low-intensity exercise for at least 1 hour or more per
week, have less UI compared with the group of sedentary women.[45 ] However, studies that show correlation of UI and physical activity in elderly women
are limited, some studies include in its research only physical activity practice,[31 ]
[34 ] and some include an association between daily activities orientations and physical
activity (Vinsnes et al., 2012; Morrisroe et al., 2014). Elderly women who practice
low/moderate physical activity have lower UI complaints when compared with sedentary
women.[34 ] 25,33,49 Danforth et al. found a decrease in UI risk of 20 - 25% in elderly women
who walk, as well as active young women also have a lower incidence of UI.[46 ]
Sedentary women should be advised to participate in a low or moderate physical activity
program. The exercise program should be unconditionally embraced to prevent or reduce
urinary losses and enhance physical.[35 ]
[44 ]
The pelvic floor muscle exercising, when performed with the help of a qualified physiotherapist,
is an important factor both for the prevention and for the UI treatment, and it is
the first line therapy in women with UI.[32 ]
[47 ] The exercises for the pelvic floor muscles when associated with the regular physical
activity contribute effectively to UI reduction and should be embraced into physical
activity practice.[44 ]
[48 ]
Physically active women have a stronger pelvic floor. The women who participated in
a low-intensity exercise program for one hour or more per week had fewer UI complaints
compared with the nonparticipating group.[45 ] On the other hand, some high impact activities may increase SUI symptoms during
exercise. Therefore, it is recommended for this population to practice low or moderate
intensity exercises and it is advised to contract the pelvic floor muscles in every
situation of intra abdominal pressure increasing.[31 ] Nygaard and Shaw[46 ] suggest that women with some loss during exercise, carry out prevention strategies
such as emptying the bladder before activity. No association between physical activity
and UI is established, there is still the hypothesis that women with some loss should
avoid physical activity.[35 ]
Nygaard et al.[42 ] assessed the prevalence of UI in middle-aged women (from 39 to 65 years old) and
concluded that intense physical activity performed for more than 10 years may be associated
with a moderate increase in SUI. Thus, walking is an effective modality to be practiced
by elderly women to promote functional performance improvement, it has no negative
effects on UI and helps the overweight control and obesity[33 ]
[41 ] since weight reduction is associated with UI reduction.[49 ]
Hannestad et al.[45 ] found that the risk of severe incontinence among obese women was three times higher
than in normal weight women. Low or moderate physical activity helps maintain the
body weight, reduces body fat, decreases intra abdominal pressure, and strengthens
the pelvic floor.[33 ] There is, therefore, the hypothesis that women that practices physical exercises
have a lower body mass index, which may also contribute to the lower incidence of
UI complaints.
The multimorbidity contributes to a sedentary lifestyle and inactivity, so health
programs should include changes in women's lifestyles. These changes should include
weight loss, control of chronic diseases, maintenance of mobility and functional capacity,
and restoration of life quality.[50 ] Morrisroe et al.[35 ] found that the decline in health, obesity and low physical performance is associated
with a higher incidence of UI, and they associated the best physical performance to
the ability to easily move to the bathroom, reducing urinary losses.
This study has faced some limitations. The first was the lack of clinical trials proving
that elderly women that practice physical activity has a lower incidence of UI. Therefore,
in most of the studies, questionnaires were sent to assess the extent of the UI and
which physical activity they perform. Future studies should be conducted on elderly
women population to conclude which activity is most effective in preventing and controlling
UI.
