Prevalence and impact of urinary incontinence among female athletes

The point prevalence of stress incontinence among young adult Jordanian women based on activity levels

BACKGROUND

Stress Urinary incontinence (SUI) is a common condition among women of all ages. The point prevalence of SUI among young adult Jordanian women is less explored.

OBJECTIVES

To examine the point prevalence of SUI among this sample based on activity level, and whether the affected women have shared their complaints with healthcare providers and/or received education related to UI.

METHODS

This was a cross-sectional survey-based study. Participants with diseases that affect the control of micturition were excluded. The International Consultation on Incontinence Questionnaire-UI Short-Form was used to calculate the point prevalence of UI. The Tegner activity scale was used to classify participants based on their physical activity levels. The participants reported whether they shared their complaints with a healthcare provider or received education about this health problem.

RESULTS

Five hundred women (median age = 20 years, BMI = 22) participated (118 competitive athletes, 192 recreational, and 190 sedentary). The overall point prevalence of SUI was 14% (n = 61). A chi-square test of independence showed a significant difference in the point prevalence of SUI between women with different activity levels, χ2 (12) = 12.07, p < 0.01. The point prevalence of SUI among competitive athletes, recreational women, and sedentary women was 21%, 8%, and 11%, respectively. None of those with SUI have shared their complaints with healthcare providers or received education related to SUI.

CONCLUSION

SUI is prevalent among young adult Jordanian women, with the highest prevalence observed in those engaged in competitive athletic activities. The affected women refrain from disclosing their SUI-related concerns to healthcare practitioners and lack sufficient knowledge about this health issue.

Pelvic Floor Muscle Training Interventions in Female Athletes: A Systematic Review and Meta-analysis

CONTEXT

Athletes are almost 3 times more at risk of experiencing urinary incontinence (UI) than sedentary women, with prevalence rates varying from 10.9% in low-impact sports such as cycling to 80% when engaging in high-impact sports such as trampoline gymnastics. To treat UI, pelvic floor muscle (PFM) training (PFMT) is recommended as a first line of treatment.

OBJECTIVE

The aim of the present study was to perform a meta-analysis of the available literature on the efficacy of PFMT interventions in young, nulliparous female athletes.

DATA SOURCES

A literature research was conducted using PubMed, Sport Discus, and Web of Science.

STUDY SELECTION

The inclusion criteria were studies with PFMT intervention in female athletes or recreationally active women. Interventions could be carried out for treatment or prevention of pelvic floor dysfunctions.

STUDY DESIGN

Systematic review with meta-analysis.

LEVEL OF EVIDENCE

Level 5.

DATA EXTRACTION

A descriptive analysis of the articles included in the systematic review was carried out. Meta-analyses could be performed on 6 of the included articles, evaluating the maximal voluntary contraction (MVC) of the PFMs, the amount of urinary leakage (AUL), and the vaginal resting pressure (VRP). Random-effects model and standardized mean differences (SMD) ± 95% CI were reported.

RESULTS

The meta-analysis showed that PFMT produced a significant increase in MVC (SMD, 0.60; 95% CI, 0.11 to 1.08; P = 0.02) and a significant reduction of AUL (SMD, -1.13; 95% CI, -1.84 to -0.41; P < 0.01) in female athletes. No effects were shown in VRP (SMD, -0.05; 95% CI, -1.27 to 1.17; P = 0.93).

CONCLUSION

PFMT is shown to be effective in increasing PFM strength and reducing urine leakage in female athletes, being a powerful tool to prevent and treat pelvic floor dysfunction in this population.

Prevalence of urinary incontinence in nulliparous Indian sportswomen

Introduction

A common gynaecological problem among women that leads to a negative impact on quality of life and causes distress is the involuntary loss of urine which is addressed as urinary incontinence (UI). Females involved in playing various types of sports perform high-intensity activities which can serve as risk factors for UI and pelvic organ prolapse. According to the available literature, there is a scarcity of information regarding data on the prevalence of UI in Indian female athletes. Therefore, the purpose of the present study was to evaluate the prevalence of UI in nulliparous Indian sportswomen.

Methodology

For a duration of 6 months, a cross-sectional study was carried out in various sports centres across the states of Telangana, Maharashtra, Gujarat, and Delhi. A total of 560 nulliparous Indian female sportswomen were involved based on the selection criteria. The various sports involved were malkhamb, kabaddi, kushti, weightlifting, gymnastics, basketball, badminton, and athletics. All the participants were provided with a questionnaire for female UI diagnosis (QUID), which was the primary outcome measure.

Results

Out of 560 women enrolled in the study, the highest prevalence was found for stress urinary incontinence (SUI), consisting of 126 (22.5%) women, followed by mixed urinary incontinence (MUI), involving 49 (8.8%) women, and urge urinary incontinence (UUI), including 47 (8.4%) women. Additionally, the prevalence of UI was highest in obese and overweight Indian sportswomen. Moreover, the highest prevalence of SUI among women was for weightlifting, whereas for UUI and MUI, malkhamb and kushti sports were the most prevalent, respectively.

Conclusion

The present study concluded that the highest prevalence among nulliparous Indian sportswomen was for SUI, followed by MUI and UUI. Additionally, weightlifting sport showed the highest prevalence for SUI, followed by malkhamb for UUI and kushti for MUI. The prevalence of UI in Indian sportswomen is important as it imparts knowledge and awareness among women and benefits professionals in designing appropriate preventive and rehabilitative protocols for curtailing such problems in the near future.

Self-reported reproductive health of retired elite women's footballers: a cross-sectional study

Objectives

The primary objective of this study was to describe the self-reported reproductive health of retired elite women's footballers with specific reference to menstrual function, pregnancy and motherhood, contraceptive use and pelvic floor function.

Methods

An electronic survey was disseminated to women's footballers (18 years or older) who had retired from elite football within 10 years of completing the survey.

Results

69 respondents completed the survey (mean age 35.8 years, mean age at retirement 30.3 years). One-third of participants self-reported experiencing at least one episode of amenorrhoea (>3 months without menstruation) for reasons other than hormonal contraceptive use or pregnancy. Three participants (mean age of 41 years, range 30-54) reported having reached menopause at the time of the study. 54 (78.3%) participants were not using any form of contraception. 17 (24.6%) of the participants are mothers (range 1-3 children). 51 of the participants (73.9%) had never been pregnant, and the majority of those who had been pregnant (86.7%) became pregnant in less than 2 years following the onset of desire for pregnancy. Four of the retired players gave birth during their playing career, and the mean time to return to competitive matches following delivery was 22 weeks. The mean Pelvic Floor Distress Inventory-20 score for participants was 72.

Conclusion

These insights can be used to inform future efforts to promote positive reproductive health outcomes for current, former and future women's footballers. Research efforts should focus on improving the understanding of how to effectively support women's footballers in the perinatal period. Best practice guidelines on the use of menstrual cycle monitoring and pelvic health support would improve standards of care for women's footballers. Stakeholders should consider gender-specific postretirement care for women's footballers.

Urinary Incontinence in Female Athletes: A Systematic Review on Prevalence and Physical Therapy Approaches

Urinary incontinence (UI) is an involuntary leakage of urine and is classified as stress, mixed, or urge. It is more common in females due to anatomical and physiological body differences. Moreover, the literature remarks an evident presence of UI with high-intensity physical activities. Therefore, the present integrative systematic review focused on the studies aimed at investigating the prevalence of UI in nulliparous sportswomen, studies illustrating sport-specific prevalence of UI, and studies demonstrating the impact of physical therapy intervention on UI. A literature search was carried out systematically on electronic databases consisting of Cochrane and Google Scholar databases from 2018 to December 2023. The keywords utilized to perform the literature search and include relevant articles consisted of "urinary incontinence," AND "nulliparous," AND "sportswomen," OR "female athletes," AND "physical therapy". A total of nine studies were included in the present systematic review. The quality assessment of the studies was performed by using a measurement tool to assess systematic reviews (AMSTAR 2) scale, and the Mixed Methods Appraisal Tool was used for cross-sectional and randomized controlled trial studies. The data extracted included first author and year of publication, study design, sample or number of individuals involved in the study, age range of the participants, type of UI, type of sports involved, purpose of the study, methodological part, outcome measures derived, conclusion, and quality assessment of the studies. The review concluded that nulliparous athletes, especially those participating in high-impact activities, have a significant prevalence of UI. In addition, the physical therapy intervention consisting of pelvic floor muscle training (PFMT) along with education about pertinent pelvic anatomy was mostly performed on female athletes for the prevention and management of UI.

Is the Elite Female Athlete's Pelvic Floor Stronger?

Background: Exercise can stress the pelvic floor muscles (PFMs). This study sought to assess the strength of the PFMs according to the level of physical exercise. Methods: An analytical observational study was carried out using digital palpation and dynamometry measurements to assess PF strength. Healthy nulliparous women were stratified according to physical exercise (physically active and sedentary) and level of physical exercise (elite, amateur, and sedentary). Results: Fifty-four women were analyzed, with a mean age of 25.64 (5.33) years and a BMI of 21.41 (2.96) kg/m2. Differences in the passive force and strength were observed between both groups of women (p < 0.05), and the strength was around two times higher in physically active women (p < 0.05). The strength was similar between elite female athletes and sedentary women (p > 0.05), but statistical differences were found with amateurs (p < 0.05). The PFM strength (p = 0.019) of elite female athletes (0.34 N) was almost half that of amateurs (0.63 N) and twice as strong as that of sedentary women (0.20 N). However, these differences were not significant using digital palpation (p = 0.398). Conclusions: Women who exercise generally have greater PFM strength than women who do not exercise. Physical exercise could strengthen the PFM; however, the high intensity demanded by high-level sports does not seem to proportionally increase the strength of the PFMs.

Women's preferences for pelvic floor screening in sport and exercise: a mixed-methods study integrating survey and interview data in Australian women

OBJECTIVES

One in two women experiencing pelvic floor (PF) symptoms stop playing sport or exercising. The study examines the perspective of women with PF symptoms to inform acceptable screening practices within sport and exercise settings.

METHODS

Explanatory, sequential, mixed-methods design. Phase 1: survey of 18-65 years, symptomatic, Australian women (n=4556). Phase 2: semistructured interviews with a subset of survey participants (n=23). Integration occurred through connection of phases (study design, sampling) and joint display of data.

RESULTS

Findings are represented in three threads: (1) 'women (not) telling'; a majority of women had told no-one within a sport or exercise setting about their PF symptoms due to shame/embarrassment, lack of pelvic health knowledge and not wanting to initiate the conversation, (2) 'asking women (screening for PF symptoms)'; women endorsed including PF symptom questions within existing sport and exercise screening practices but only when conducted in a respectful and considered manner and (3) 'creating safety'; professionals can assist women to disclose by demonstrating expertise, trustworthiness and competency. If health and exercise professionals are provided with appropriate training, they could raise pelvic health awareness and promote a supportive and safe sport and exercise culture.

CONCLUSION

Women with PF symptoms support health and exercise professionals initiating conversations about PF health to normalise the topic, and include PF symptoms among other pre-exercise screening questions. However, women should be informed on the relevance and potential benefits of PF screening prior to commencing. Safe screening practices require building trust by providing information, gaining consent, displaying comfort and genuine interest, and being knowledgeable within one's scope of practice to the provision of advice, exercise modifications and referral as appropriate.

Prevalence and Normalization of Stress Urinary Incontinence in Female Strength Athletes

ABSTRACT

Mahoney, K, Heidel, RE, and Olewinski, L. Prevalence and normalization of stress urinary incontinence in female strength athletes. J Strength Cond Res 37(9): 1877-1881, 2023-Strength training is increasing in popularity in women but is also a potential risk factor for stress urinary incontinence (SUI). There is potential for normalization of SUI in sports with high rates of SUI. Pelvic floor physical therapy is an effective treatment for SUI in both athletes and nonathletes, but female strength athletes may not be aware of this option. Our study sought to assess prevalence, normalization, rates of treatment, and preferred sources of information about SUI in female strength athletes. A novel cross-sectional survey was distributed online through social media groups dedicated to female strength athletes with 425 women responding within 4 days. Statistical significance of results was assumed at a 2-sided alpha value of 0.05. 43.5% of athletes experienced incontinence with daily tasks, 59.1% experienced incontinence with normal strength training, and 50.2% experienced incontinence during competition. Of the athletes who experienced incontinence, 61.4% did not have incontinence before starting their sport and only 9.4% had ever sought treatment. 67.9% of all athletes surveyed believed that urinary incontinence was a normal part of their sport. Our findings indicate that SUI is common in female strength athletes and may be a consequence of the sport itself. Normalization of SUI is common, and few athletes seek treatment.

Effect of cognitive-behavioral therapy on sexual self-esteem and sexual function of reproductive-aged women suffering from urinary incontinence

INTRODUCTION

Patients with urinary incontinence may fear sexual activity due to the unpredictability of urine leakage during intercourse. Given the effective role of cognitive-behavioral therapy in correcting negative thoughts and attitudes, this study was aimed to investigate the effect of cognitive-behavioral therapy on sexual self-esteem and sexual function of reproductive-aged women suffering from urinary incontinence.

METHODS

This study was a randomized controlled clinical trial conducted on 84 reproductive-aged women (18 to 45 years old) with urinary incontinence who referred to Health Centers of Dezful, Iran. After random allocation, the participants were divided into two groups of intervention and control (n = 42). The intervention group attended eight 45-min sessions of cognitive-behavioral therapy, while the control group received only routine interventions. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the Scale of Self-Esteem Index for Women-Short-form (SSEL-W-SF), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12) were completed before, immediately after, and 4 weeks after the end of the intervention by patients in both groups.

RESULTS

The overall scores of sexual self-esteem and sexual function immediately and 4 weeks after the end of the intervention showed a statistically significant difference in the intervention group compared to the control group (p < 0.001). Also, the results showed that in women with urinary incontinence, an increase in the sexual self-esteem score is associated with an increase in the sexual function score (r = 0.9), p < 0.001).

CONCLUSION

Cognitive-behavioral therapy was found to increase sexual self-esteem and improve sexual function in reproductive-aged women suffering from urinary incontinence.

Electromyographic Activity of the Pelvic Floor Muscles and Internal Oblique Muscles in Women during Running with Traditional and Minimalist Shoes: A Cross-Over Clinical Trial

The study aimed to investigate the effects of footwear on the electromyographic (EMG) activity of pelvic floor muscles (PFMs) and internal oblique (IO) muscles during running at different speeds. The study also aimed to explore the correlation between EMG activity of PFMs and IO muscles and participants' morphological characteristics. Ten nulliparous female runners were included in the study. The participants ran for 90 s at speeds of 9, 11, and 13 km/h wearing both traditional and minimalist shoes. EMG outcomes were presented as a percentage of maximum voluntary contraction (%MVC). Comparative analysis was conducted using the Wilcoxon rank test. Correlational analysis was performed using the Rho-Spearman correlation coefficient. The %MVC for the IO muscles was significantly lower when using minimalist shoes compared to traditional shoes (p = 0.04). No statistically significant differences were found for the PFMs (p > 0.05). The study also observed large correlations between age and %MVC of the PFMs and IO muscles (rho = -0.64; p = 0.04). Minimalist shoes decreased the activity of IO muscles in female runners. However, no significant differences in EMG activity of PFMs were found when comparing traditional and minimalist footwear. The long-term effects of minimalist footwear on EMG activity of PFMs and IO muscles, as well as their relationship to morphological characteristics, require further investigation.

Urinary Symptoms and their Impact on Young Women's Sexual Function and Quality of Life

Sexuality and urinary function have received scarce research attention in younger women. In this cross-sectional survey study, prevalence, type, severity, and impact of urinary incontinence (UI), and its relationship with sexuality was investigated in 261 nulliparous women aged 18-27 (M = 19.08 years). Modules of the International Consultation on Incontinence Questionnaire and the Female Sexual Function Index assessed UI, sexual function, and quality of life. Thirty percent of the sample experienced UI, and 26% reported sexual function problems. A significant small negative correlation was found between UI and sexual lubrication (p = .017). Forty-three percent of participants in the total sample reported that they were bothered by urinary symptoms, and 13% avoided sexual activity due to urinary symptoms. Of those classified as incontinent, 90% were bothered by their symptoms. Urinary symptoms are impactful on the quality of life and sexual lives of young women, but despite their high prevalence, they remain a largely understudied and undertreated issue in this age group. Further research is crucial for improving awareness and access to treatment for this underserved population.

Experience of Playing Sport or Exercising for Women with Pelvic Floor Symptoms: A Qualitative Study

BACKGROUND

Women participate in sport at lower rates than men, and face unique challenges to participation. One in three women across all sports experience pelvic floor (PF) symptoms such as urinary incontinence during training/competition. There is a dearth of qualitative literature on women's experiences of playing sport/exercising with PF symptoms. The purpose of this study was to explore the lived experience of symptomatic women within sports/exercise settings and the impact of PF symptoms on sports/exercise participation using in-depth semi-structured interviews.

RESULTS

Twenty-three women (age 26-61 years) who had experienced a breadth of PF symptom type, severity and bother during sport/exercise participated in one-one interviews. Women played a variety of sports and levels of participation. Qualitative content analysis was applied leading to identification of four main themes: (1) I can't exercise the way I would like to (2) it affects my emotional and social well-being, (3) where I exercise affects my experience and (4) there is so much planning to be able to exercise. Women reported extensive impact on their ability to participate in their preferred type, intensity and frequency of exercise. Women experienced judgement from others, anger, fear of symptoms becoming known and isolation from teams/group exercise settings as a consequence of symptoms. Meticulous and restrictive coping strategies were needed to limit symptom provocation during exercise, including limiting fluid intake and careful consideration of clothing/containment options.

CONCLUSION

Experiencing PF symptoms during sport/exercise caused considerable limitation to participation. Generation of negative emotions and pain-staking coping strategies to avoid symptoms, limited the social and mental health benefits typically associated with sport/exercise in symptomatic women. The culture of the sporting environment influenced whether women continued or ceased exercising. In order to promote women's participation in sport, co-designed strategies for (1) screening and management of PF symptoms and (2) promotion of a supportive and inclusive culture within sports/exercise settings are needed.

Urinary Incontinence in Parous Women Practicing Non-Extreme Competitive Sports Compared to the General Population

INTRODUCTION AND OBJECTIVE

This cross-sectional study aimed to compare the prevalence of urinary symptoms in physically active females to the general population represented by medical staff.

MATERIALS AND METHODS

We conducted a survey utilizing the UDI-6 questionnaire on women playing catchball for at least one year and training twice a week or more in an official Israeli competitive league. The control group consisted of women practicing medicine (physicians and nurses).

RESULTS

The study group consisted of 317 catchball players and the control group consisted of 105 medical staff practitioners. Both groups were similar in most of the demographic characteristics. Urinary symptoms represented by UDI-6 scores were higher in women in the catchball group. Frequency and urgency symptoms were common in women playing catchball. Stress urinary incontinence (SUI) was insignificant between the groups (43.8% in the catchball group and 35.2% in the medical staff group, p = 0.114). However, severe symptoms of SUI were more common in catchball players.

CONCLUSIONS

The rates of all urinary symptoms were higher in in catchball players. SUI symptoms were common in both groups. However, severe symptoms of SUI were more common in catchball players.

Can running influence women's sexual function?

INTRODUCTION AND HYPOTHESIS

Studies have shown that athletes have three times increased risk of urinary incontinence compared to non-athletes, in addition to anal incontinence and sexual dysfunction (SD). This study aimed to assess the sexual and pelvic floor muscle (PFM) functions and to compare these variables among female athlete runners with and without SD and to identify predictive factors that may be associated with sexual function among the athletes.

METHODS

Cross-sectional study including 90 female runners, who ran ≥ 20 km/week for at least 6 months, had had sexual intercourse in the last 4 weeks and were > 18 years old. PFM function was assessed by vaginal palpation and manometry. Women also answered the International Consultation on Incontinence Questionnaire-Short Form to investigate presence of urinary incontinence. Sexual function was assessed by Female Sexual Function Index (FSFI); total scores ≤ 26.5 were considered to indicate SD. The scores of each FSFI domain and the total score were compared individually between each predictor using simple linear regression. In addition, multiple linear regression analysis was performed.

RESULTS

Athletes with SD presented lower PFM strength. The results of the multiple linear regression analysis among all the predictor variables, FSFI domains and total score show that the Modified Oxford Scale is a predictor for the desire, excitation, lubrication, orgasm, pain and total score domains.

CONCLUSIONS

Female runners with lower PFM strength presented worse sexual function regardless of age, parity, BMI and running practice time.

Urinary Incontinence in Elite Female Athletes

PURPOSE OF REVIEW

To summarize the current understanding on the epidemiology, pathophysiology, and management strategies of urinary incontinence (UI) in female athletes, highlighting findings specific to nulliparous elite athletes.

RECENT FINDINGS

UI occurs in about 20-50% of female athletes of all ages and parity status, around 40% for younger nulliparous athletes, and is more prevalent in high-impact sports. Possible contributing factors to UI in female elite athletes include pelvic floor laxity and bladder neck descent, pelvic floor muscle fatigue, low energy availability, and hypermobility syndrome. In female elite athletes, urinary symptoms negatively affect quality of life, although the effects of symptoms on exercise participation are not well understood. Current management strategies are primarily conservative and centered on behavioral modifications and pelvic floor muscle physiotherapy. UI in female elite athletes appears to be multifactorial. Clarifying how individual factors influence UI in this population will inform athlete counseling, prevention, and treatment strategies.

Prevalence of Urinary Incontinence and its Relationship With Sociodemographic and Obstetrical Variables Among Omani Women

Objective

Urinary incontinence (UI) is defined by the International Continence Society as any complaint of involuntary urine leakage. This research study highlights the prevalence, types, and associated factors of UI among women in Oman.

Methodology

A descriptive cross-sectional design was used to collect data using purposive sampling technique from 400 women between 20 and 60 years; who were attending outpatient department of a referral hospital in Oman. Women were assessed using the Questionnaire for Urinary Incontinence Diagnosis to determine the type of UI. The severity and the impact of UI in women were assessed using the female urinary tract symptoms module (ICIQ-UI-SF). Descriptive statistics were used to determine the prevalence and type of UI, and the Chi-square test was used to find the association between UI and sociodemographic and obstetrical variables.

Results

In our study, 28.25% of the women belonged to the age of 50-59 years. The point prevalence (per 1000) of UI among Omani women who were between 20 and 60 years was 44%. In the women who had UI, the majority were having stress UI (41.6%). In the women who had UI, the severity of UI, according to the ICIQ-UI-SF scoring, 15.2% of the women had slight, 50.3% had moderate, 33.1% had severe, and only 1.3% had very intense.

Conclusion

Understanding the prevalence of UI in every community and associated factors is essential for the policy makers and healthcare providers to consider the early diagnosis, prevention, health promotion, and management of UI.

Urinary Incontinence Among Elite Track and Field Athletes According to Their Event Specialization: A Cross-Sectional Study

Background

Physical effort in sports practice is an important trigger for urinary incontinence (UI). Among high-impact sports, all track and field events require continuous ground impacts and/or abdominal contractions that increase intra-abdominal pressure and impact on the pelvic floor musculature. However, studies to date have not taken into account the specific sports tasks that elite track and field athletes perform according to the competitive events for which they are training.

Methods

This cross-sectional study describes the prevalence, type, and severity of UI among elite track and field athletes considering their event specialization and training characteristics. A total of 211 female and 128 male elite track and field athletes answered an online questionnaire including anthropometric measures, medical history, training characteristics, and UI symptoms. To determine self-reported UI, the International Consultation on Incontinence Questionnaire-UI Short-Form (ICIQ-UI-SF) was used. To determine UI type and severity, the incontinence questionnaire and incontinence severity index were used, respectively.

Results

The ICIQ-UI-SF showed that 51.7% of female and 18.8% of male athletes had UI, with stress UI (SUI) being the most frequent type (64.4%) for female and urge UI for male athletes (52.9%). Of athletes who were not identified as having UI according to the questionnaires, 24.6% of female and 13.6% of male athletes experienced urine leakage during training, mainly during jumping. Although training characteristics (experience, volume, and resting) were not related to UI, female athletes specializing in vertical jumps showed significantly lower UI prevalence compared to those specializing in horizontal jumps (χ² [1] = 4.409, p = 0.040), middle-distance running (χ² [1] = 4.523, p = 0.033), and sprint/hurdles events (χ² [1] = 4.113, p = 0.043). These female athletes also displayed the lowest training volume. No differences were shown for males (p > 0.05).

Conclusions

Over half of the elite track and field female athletes have self-reported UI, especially SUI, and prevalence is higher when considering urine leakage events during training. Training characteristics and specialization were not related to UI identified by questionnaires, but female athletes specializing in vertical jump events showed the lowest prevalence and training volume. Males showed significantly lower prevalence, without correlation with their specialization. Sport professionals should increase UI detection among elite athletes and design-specific approaches that consider their physical demands to make visible, prevent, or improve pelvic floor dysfunction in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00468-1.

Urinary Incontinence in Competitive Women Weightlifters

ABSTRACT

Wikander, L, Kirshbaum, MN, Waheed, N, and Gahreman, DE. Urinary incontinence in competitive women weightlifters. J Strength Cond Res 36(11): 3130-3135, 2022-Urinary incontinence has the potential to diminish athletic performance and discourage women from participating in sport and exercise. This study determined the prevalence and possible risk factors for urinary incontinence in competitive women weightlifters. This research was a cross-sectional, survey-based study completed by 191 competitive women weightlifters. The frequency and severity of urinary incontinence was determined using the Incontinence Severity Index. Urinary incontinence was defined as an Incontinence Severity Index score >0. The survey questions focused on risk factors, the context and triggers for urinary incontinence, and self-care strategies. Approximately, 31.9% of subjects experienced urinary incontinence within 3 months of completing the survey. Incontinence Severity Index scores were significantly correlated with parity ( r = 0.283, p = 0.01) and age ( r = 0.216, p = 0.01). There was no significant correlation between the Incontinence Severity Index score and the number of years participating in any form of resistance training ( r = -0.010, p = 0.886) or weightlifting ( r = -0.045, p = 0.534), body mass index ( r = 0.058, p = 0.422), or competition total ( r = -0.114, p = 0.115). The squat was the most likely exercise to provoke urinary incontinence. Although the number of repetitions, weight lifted, body position, and ground impact may increase the likelihood of urinary incontinence occurring during a lift, it is difficult to determine which factor has the greatest influence. Some self-care strategies used by competitive women weightlifters who experience urinary incontinence, such as training while dehydrated, have the potential to diminish athletic performance.

Elite female athletes' experiences of symptoms of pelvic floor dysfunction: A systematic review

INTRODUCTION AND AIMS

Pelvic floor dysfunction (PFD) is a collection of signs, symptoms and conditions affecting the pelvic floor and urinary incontinence (UI) is the most common type of PFD. Recent systematic reviews have indicated a higher prevalence of UI among female athletes compared to their non-athletic counterparts. To date, no review has been undertaken to investigate female athletes' experiences of PFD. This review aims to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report elite female athletes' experiences of symptoms of PFD.

METHODS

The review protocol was registered in PROSPERO in August 2020. A systematic search was conducted in Embase, MEDLINE (OVID), Cochrane Library, CINAHL, PsycINFO and Web of Science for studies published in the English language reporting elite female athletes' experiences of symptoms of PFD. This review included primary research studies that involved elite female athletes of any age or ethnicity.

RESULTS

Of the 1922 citations retrieved in the search, 32 studies met the methodological criteria for data extraction and analysis. Five main themes emerged: (1) triggers for symptoms of PFD; (2) strategies adopted by athletes to manage/mitigate symptoms of PFD; (3) impact on QOL/daily life; (4) impact on performance; (5) impact on emotions.

CONCLUSIONS

The findings of this review suggest a need to further explore the experiences of PFD among elite female athletes and it is suggested that future research should adopt qualitative methods or incorporate a qualitative component.

BRAZILIAN OLYMPIC FEMALE ATHLETES’ MULTIDISCIPLINARY CARE: AN OBSERVATIONAL STUDY

ABSTRACT Introduction: Female participation in sports had reached a milestone in 1972 when a constitutional amendment was implemented to ensure equal opportunities for men and women. Since then, the percentage of participants in competitive sports has grown. In 1992, an association was made between three disorders related to female athletes called the “Female Athlete Triad”. After that, much has been studied about this and other particularities of female athletes. Objective: To identify the professionals who follow-up Brazilian female Olympic athletes and the association between a multidisciplinary approach and athletes’ knowledge about gynecological issues related to the practice of sport, i.e., female athlete triad, urinary incontinence, and weight control concerns. Methods: This observational study was conducted in Rio de Janeiro, Brazil, in 2016, during the Olympic Games. It included 120 female members of the Brazilian teams. A self-applied questionnaire, validated and adapted from the pre-participation gynecological evaluation of female athletes, was used to evaluate their multidisciplinary follow-ups, weight control concerns, and knowledge about the Female Athlete Triad and urinary incontinence. Results: The athletes practiced 28 different sports. For 66%, it was their first participation in Olympic Games; 56% were unaware of the female athlete triad, 77% indicated weight concerns, and 52% were on a diet. The use of diuretics or laxatives or vomiting was reported by 11%; 67.5% were aware that sports are a risk factor for urinary incontinence, and 40% had already experienced urine loss. Decreased sportive performance was mentioned by 31%. Several athletes presented multidisciplinary follow-ups psychological (83%), nutritional (96%), and gynecological (83%). Conclusion: Brazilian Olympic athletes sought multidisciplinary follow-ups during the Olympic cycle; however, participants’ knowledge of sports-related issues remains limited. An orientation program regarding the above conditions is needed for female athletes and the professionals working with them to improve health and performance. Evidence Level IV; Cross-sectional observational study.

Urinary and anal incontinence among female gymnasts and cheerleaders-bother and associated factors. A cross-sectional study

INTRODUCTION AND HYPOTHESIS

Artistic gymnastics, team gymnastics and cheerleading are sports including high-impact activities. It is presumed that the athletes' pelvic floor must be functioning well to prevent urinary (UI) and anal incontinence (AI) during sports. The aim of this study was to investigate the prevalence and risk factors for UI and AI in female artistic gymnasts, team gymnasts and cheerleaders; the influence of UI and AI on daily living and sport performance; and the athletes' knowledge about the pelvic floor muscles (PFM).

METHODS

All female athletes ≥ 12 years of age competing in ≥ 1 National Championship in artistic gymnastics, team gymnastics or cheerleading in 2018/2019 were invited. International Consensus on Incontinence Questionnaires were used to assess the prevalence/bother of UI and AI.

RESULTS

Among the 319 gymnasts and cheerleaders who participated, the prevalence of UI and AI was 67% and 84%, respectively. Age, training ≥ 4 days/week and straining to void were significantly associated with stress urinary incontinence (SUI) and years of training with AI. Eighty-three percent of athletes with SUI reported a negative effect on sports performance, 22% would occasionally avoid training or specific exercises because of leakage, and 28% used pads for protection. Forty-one percent of the athletes had never heard about the PFM, and 74% reported an interest in PFM training to prevent/treat UI or AI.

CONCLUSIONS

UI and AI were prevalent in female gymnasts and cheerleaders, and SUI negatively influenced sport performance. The athletes' knowledge about the PFM was limited.

Prevalence and factors associated with urinary incontinence in female crossfitters: A cross-sectional study

OBJECTIVE

To determine the prevalence and factors associated with urinary incontinence (UI) in female crossfitters.

METHODS

This is a cross-sectional study. Data were collected using assessment forms: Knowledge, Attitude and Practice survey for young female athletes; Incontinence Severity Index; and International Consultation on Incontinence Questionnaire for UI. Descriptive analysis was conducted to obtain absolute and relative frequencies, means and 95% confidence intervals (95% CI). Multivariate analysis was carried out to determine the association between UI and sociodemographic, gynecological-obstetric, and anthropometric variables, associated morbidities, previous history and physical activity.

RESULTS

Prevalence of UI, in the 189 included volunteers, was 38.6% and the most frequent type was stress UI (69.9%). A total of 72.6% of incontinent women reported urine loss during CrossFit training. Knowledge (53.4%) and attitude (86.2%) regarding UI were generally adequate, while prevention, management and treatment were inadequate (96.3%). The predominant characteristics of UI were frequency of once a week or less (74.0%), in small amounts (86.3%), mild intensity (57.5%) and slight impact on quality of life (64.3%). In multivariate analysis, no variable was significantly associated with UI.

CONCLUSIONS

The prevalence of UI in female crossfitters was 38.6%. The factors investigated did not contribute to the development of UI.

Leg stiffness and muscle power vs manometer in sportswomen with symptoms of stress urinary incontinence

BACKGROUND

Pelvic floor muscle training can cure or alleviate stress urinary incontinence. This study aimed to evaluate maximum voluntary contractions of the pelvic floor muscle in sportswomen and verify the association with leg stiffness and muscle power, both maximal and submaximal.

METHODS

The sample consisted of 41 sportswomen between 18 and 42 years of age. Pelvic floor muscle strength was measured by the manometer. The sportswomen were instructed to perform 3 maximum voluntary contractions of the perineum, held for 3 seconds. Maximal and submaximal leg stiffness and muscle power were measured with a force platform, in two conditions: 1st condition was the sub-maximal, double leg hop test, which was performed allowing sportswomen to self-select their preferred frequency and 2nd condition was the maximal double leg hop test, which was performed asking athletes to maximize hop height and minimize contact time on the top of the force platform for 6 consecutive hops.

FINDINGS

Maximal and submaximal leg stiffness values increase with increasing age, weight, height, and body mass index, showing positive and significant (p <0.05) or close correlations. There are strong positive correlations between maximal and submaximal leg stiffness (r = 0.759) and between maximal and submaximal muscle power. Maximum voluntary contractions values decrease with increasing leg stiffness: the correlation is significant with maximal leg stiffness.

INTERPRETATION

Maximum voluntary contractions values decrease with increasing leg stiffness and increase with increasing muscle power values. If the training program aims to increase muscle power, it may also increase maximum voluntary contractions.

Influence of sports groups on the risk of stress urinary incontinence in sportswomen

OBJECTIVES

To evaluate sports groups on the risk of stress urinary incontinence (SUI) in sportswomen and its impact on their quality of life.

STUDY DESIGN

Cross-sectional study. The group consisted of 249 sportswomen with a mean age of 22.18 ± 6.11 years. We used the International Physical Activity Questionnaire (IPAQ), the International Consultation on Incontinence Questionnaire (ICIQ-UI), the Overactive Bladder Questionnaire (OAB-q) and the Quality of Life Assessment Questionnaire Concerning Urinary Incontinence (Contilife) were used for evaluation. We divided the sports into the following six groups: 1. Functional mobilization sports (FMS); 2. Strength sports (SS); 3. Aesthetic-coordination and sensory-concentration sports (ACS); 4. Heuristic-individual and martial arts (HIS + MAS); 5. Heuristic-collective sports with a hockey stick (HCS-A); and 6. Heuristic-collective sports with a ball (HCS-B).

RESULTS

The symptoms of SUI according to the ICIQ-UI SF were 1.80 ± 2.93. The estimate of the relative risk (OR) of developing SUI was most significant in the FMS group (OR = 1.96, 95% CI: 1.04-3.68; p < 0.03). Other sports groups did not pose a significant relative risk of developing SUI and had a lower incidence of SUI. In SS was OR = 0.77, in EKS, OR = 0.69, in (HIS + BS), OR = 1.26, in (HKS-A) was OR = 0.63, in (HKS-B) was OR = 1.02. There were no significant differences between the groups in the overall score of the Contilife, which assesses quality of life.

CONCLUSION

The Functional mobilization sports group had a 1.96 times higher risk of SUI compared to that in other sports groups.

Low energy availability and impact sport participation as risk factors for urinary incontinence in female athletes

INTRODUCTION

Relative Energy Deficiency in Sport (RED-S) is a clinical syndrome that includes the many complex health and performance consequences of low energy availability (EA) in athletes, when there is insufficient caloric intake to meet exercise-related energy expenditure and to support basic physiologic functions. There is a high prevalence of urinary incontinence (UI) in female athletes and it is more common in female athletes than non-athletes. The objective of this study was to determine if low EA is associated with UI in a population of adolescent and young adult female athletes and to evaluate for an association between sport categories and UI.

MATERIAL AND METHODS

1000 nulliparous female patients, ages 15-30 years, presenting to a sports medicine subspecialty clinic, provided informed consent/assent to participate in a cross-sectional study involving a comprehensive survey, anthropomorphic measurements, and medical record review. Low EA was defined as meeting ≥1 criterion: self-reported history of eating disorder/disordered eating (ED/DE), and/or a high score on the Brief Eating Disorder in Athletes Questionnaire (BEDA-Q), and/or a high score on the Eating Disorder Screen for Primary Care (ESP). UI was assessed using questions adapted from the International Consultation on Incontinence-Urinary Incontinence Short Form (ICIQ-UI-SF), questions regarding timing of UI onset/duration, and a binary question regarding UI during sport activities. A total of 36 sport types were included in the survey and sub-divided into categories.

RESULTS AND DISCUSSION

Of the 1000 female athletes surveyed, 165 (16.5%) reported a history of experiencing UI during athletic activities. ICIQ- UI-SF responses indicated that 14% (137/1000) of the cohort experienced slight incontinence, 4% (35/1000) moderate incontinence, and 2 athletes experienced severe incontinence. There was a significant difference between UI categories in age (p = 0.01), low EA (p < 0.001), and sport category (p < 0.001). Females who had low EA had twice the likelihood (OR = 1.97; 95% CI = 1.39 to 2.81; p < 0.001) of UI compared to those with adequate EA, controlling for sports category and menstrual dysfunction. Females who participated in high impact sports were 4.5 times more likely (OR = 4.47; 95% CI = 2.29 to 8.74; p < 0.001) to have had UI compared to females who participated in ball sports, controlling for EA and menstrual dysfunction.

CONCLUSIONS

UI during athletic activities is a common problem among nulliparous adolescent and young adult female athletes, occurring in 16.5% of female athletes surveyed. UI was significantly associated with low EA across all sport categories. Sport type was significantly associated with UI, with the highest impact sport group demonstrating a higher prevalence and symptom severity compared to other sport categories.

Pelvic floor evaluation in CrossFit® athletes and urinary incontinence: a cross-sectional observational study

Athletic urinary incontinence is characterized by urinary loss during sports practice. This condition occurs in the case of CrossFit®, a modality based on high intensity training and functional movements, it can also be considered as having a high impact on the pelvic floor. This study aimed to compare the force and the contraction capacity of the pelvic floor musculature and urinary incontinence between female CrossFit® practitioners (AG) and non-practitioners (CG). We performed a cross-sectional observational study in the period from December 2018 and May 2019. Complaints of urinary incontinence was assessed by the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF); the functional evaluation of the pelvic floor was performed by digital palpation; resting tone, maximum voluntary contraction, fast contractions and sustained contraction of the pelvic floor muscles was tested by electromyography. The prevalence of urinary incontinence was significantly higher in AG compared with CG (p < .001). Nevertheless, we did not find significant differences between the two groups for functional assessment and electromyographic parameters. The AG presented a prevalence 60% of UI, while CG only 9,5 (p < 0,001). Considering this point, tailored prevention strategies seem mandatory in this population, in order to allow early identification and management of urinary incontinence.

Prevalence of Pelvic Floor Dysfunction, Bother and Risk Factors and Knowledge of the Pelvic Floor Muscles in Norwegian Male and Female Powerlifters and Olympic Weightlifters

Skaug, KL, Bø, K, Engh, ME, and Frawley, H. Prevalence of pelvic floor dysfunction, bother, and risk factors and knowledge of the pelvic floor muscles in Norwegian male and female powerlifters and Olympic weightlifters. J Strength Cond Res XX(X): 000-000, 2020-Strenuous exercise has been suggested as a risk factor of pelvic floor dysfunction (PFD). Powerlifters and Olympic weightlifters compete with high external loads. To date, knowledge of PFD in these athletes has been sparse. The aim of this study was to investigate prevalence, risk factors, and bother of PFD in powerlifters and Olympic weightlifters and their knowledge of the pelvic floor muscles (PFM). All athletes aged ≥18 years competing in ≥1 National Championship in powerlifting or Olympic weightlifting in 2018/2019 were invited. The International Consensus on Incontinence Questionnaires were used to assess PFD. One hundred eighty women and 204 men participated. The prevalence of urinary incontinence (UI), anal incontinence (AI), and pelvic organ prolapse in women was 50.0, 80.0, and 23.3%, respectively. Stress UI (SUI) was reported by 41.7% of the women and 87.8% reported a negative influence on sport performance. The prevalence of UI and AI in men was 9.3 and 61.8%. In women, increasing body mass index was significantly associated with SUI (odds ratio [OR]: 1.09, 95% confidence interval [CI]: 1.01-1.17) and international level of competition (OR: 3.27, 95% CI: 1.32-8.07) and weightlifting ≥4 d·wk (OR: 0.26, 95% CI: 0.08-0.86) with AI. In men, increasing age (OR: 1.03, 95% CI: 1.00-1.07) and frequently straining to void (OR: 4.84, 95% CI: 1.02-22.94) were significantly associated with AI. Forty-three percent of the women and 74% of the men did not know why and 44.4 and 72.5% how to train the PFM. In conclusion, the prevalence of PFD was high, and the athletes had limited knowledge of the PFM.

Stress Incontinence during Different High-Impact Exercises in Women: A Pilot Survey

The aim of this survey was to investigate the prevalence of stress urinary incontinence (SUI) among women (primigravida, multigravida, and nulligravida) in high-impact exercise groups—CrossFit, kickboxing, and boot camp. Incontinence Survey was modified to an anonymous online questionnaire. A total of 17 participants, 64.2% reported at least some urinary leakage during exercise. About 85.7% of participants in each of the 3 high-intensity exercise groups exercised >3 h/week. There was no significant difference in the likelihood of urinary leakage between participants who have had at least 1 pregnancy and those who had never been pregnant. CrossFit group were significantly more likely to report urinary leakage than those in the kickboxing and boot camp groups combined (p = 0.023). The participants did not exhibit typical risk factors, as they were premenopausal, active, and had an average body mass index within the normal range. This pilot survey indicates that all women those who do high-impact exercises are susceptible to stress urinary incontinence (SUI), and that CrossFit poses a greater risk for SUI in terms of more jumping resulting in increased intra-abdominal pressure and ground reaction forces compared to others. Our pilot study indicates that a higher risk of SUI during high impact exercises may exist associated with previous pregnancy but also in nulliparous women.

Rug-pee study: the prevalence of urinary incontinence among female university rugby players

INTRODUCTION AND HYPOTHESIS

The goal of this study was to determine the prevalence of urinary incontinence among female university varsity rugby players. Secondary objectives were to understand when the incontinence occurred and to assess the degree of bother experienced. It is postulated that female rugby players may have higher rates of urinary incontinence due to the high-impact activities involved in training and competitions.

METHODS

Data was collected via a self-administered, anonymous questionnaire.

RESULTS

A total of 95 athletes were included in the survey results. Urinary incontinence was experienced by 51 of the 95 (54%) players. Of the 51 athletes who reported leaking urine, 90% leaked urine when competing in a rugby game and 88% of players leaked when being tackled or hit. Despite the high prevalence of urinary incontinence, most players reported they were not bothered or only slightly bothered by their urinary leaking. Several of the players (18%) were interested in receiving treatment for their urinary incontinence.

CONCLUSION

The prevalence of urinary incontinence among varsity female rugby players is 54%, which is consistent with rates among other high-impact sports. Surprisingly, the majority of these women are not bothered by their incontinence and most are not interested in treatment for this condition at this time.

A feasibility study of the physiotherapy management of urinary incontinence in athletic women: trial protocol for the POsITIve study

Background

Urinary incontinence (UI) affects up to 40% of adult women within the UK, and pelvic floor muscle training can be effective as a treatment. The prevalence of UI is higher in athletic women than in their sedentary counterparts, but there is little research into reasons for this or into treatment within this population.

The aim of this study is to investigate the feasibility of conducting a future randomised controlled trial of physiotherapeutic management of UI in athletic women.

Methods

This is a mixed methods study with three distinct but related phases.

Phase 1: Semi-structured interviews with health care professionals in the community will explore current management practices of UI in women and particularly in female athletes in order to inform the control arm of a future study. It will also establish community health care professionals’ understanding of pelvic health physiotherapy.

Phase 2: Athletic and regularly exercising women recruited directly from gyms and sports clubs will undergo a course of physiotherapy to manage UI. This will establish study recruitment, eligibility, consent, attendance, attrition, and data completion rates. It will provide information regarding appropriate clinical venues and outcome measures to use for this patient group.

Phase 3: Semi-structured interviews with purposefully selected participants from phase 2 will investigate participant satisfaction with recruitment procedures, the intervention, outcome measures and the venues. Further, we will collect data regarding the use of a smartphone ‘app’ for adherence and monitoring of home exercises and participants’ beliefs around randomisation in a future study. We will explore the impact of UI on life and sport in more detail.

Discussion

This study will establish the ease and acceptability of recruiting athletic women directly from gyms and sports clubs and identify attrition rates. It will also explore the acceptability of the intervention, clinical venues and outcome measures. Data collected will be used to inform a future randomised controlled trial.

Trial registration

NCT03986411 (clinicaltrials.gov). Registered on 14 June 2019

Prevalence of Urinary Incontinence in High-Impact Sport Athletes: A Systematic Review and Meta-Analysis

The aim of this study was to systematize the scientific evidence that assessed the prevalence of urinary incontinence in female athletes and determine which modality is most predisposed to stress urinary incontinence. From September to December 2018, a systematic literature search of current interventional studies of stress urinary incontinence of the last ten years was performed using PubMed, EMBASE, Scopus and Web of Science databases. The methodological quality was assessed by the Downs and Black scale, while the data collected from the studies were analyzed through meta-analysis. Nine studies met the eligibility criteria, meaning they included reports of urinary incontinence in different sports. The meta-analysis showed 25.9% prevalence of urinary incontinence in female athletes in different sports, as well as 20.7% prevalence of stress urinary incontinence. The most prevalent high impact sport was volleyball, with the value of 75.6%. The prevalence of urinary incontinence can be high in female athletes, with high-impact sports potentially increasing the risk for stress urinary incontinence. Further research is needed regarding the potential risk factors related to the onset of urinary incontinence.

Frequência de incontinência urinária em mulheres praticantes de crossfit: um estudo transversal

RESUMO O objetivo deste estudo foi verificar a frequência de Incontinência Urinaria (IU) em mulheres praticantes de Crossfit. Realizou-se um estudo de corte transversal com mulheres que praticavam Crossfit há, pelo menos, 6 meses ininterruptos, com idade entre 18 a 35 anos e frequência de treino de, no mínimo, três vezes por semana. Foram aplicados questionários de avaliação individual compostos por dados sociodemográficas, antropométricos e esportivos, além do International Consultation on Incontinence Questionnaire - Short Form (ICIQ-UI-SF), para identificar a presença de IU. Também por meio do ICIQ-IU-SF foram identificados a frequência e quantidade de perda de urina e interferência da IU na qualidade de vida (QV) das mulheres incontinentes. Essas mulheres também responderam a um questionário acerca da gravidade da IU. A amostra total do estudo foi de 50 mulheres, das quais 10 (20%) apresentaram IU. A maioria das mulheres incontinentes apresentou IU de gravidade moderada e de interferência leve na QV. Ademais, observou-se associação entre ter histórico de IU e apresentar IU (RP=5,33; IC95%=1,41 a 20,10). Diante do exposto, conclui-se que a frequência de IU em mulheres praticantes de Crossfit foi de 20%, sendo a IU, em sua maioria, de gravidade moderada e de leve interferência na QV.

Assessment of pelvic floor muscles in sportswomen: Quality of life and related factors

OBJECTIVES

To evaluate Maximum Voluntary Contraction (MVC) of the Pelvic Floor Muscles (PFM) in sportswomen, to observe the urinary symptoms and their impact on the Quality of Life (QoL).

DESIGN

Observational cross-sectional study.

SETTING

Gyms and teams in the North of Portugal.

PARTICIPANTS

Sportswomen (n = 197).

MAIN OUTCOME MEASURES

The measurement was performed using a manometer. The sportswomen were instructed to perform 3 MVC of the perineum, held for 3 s. The Kings Health Questionnaire (KHQ) was used to evaluate urinary symptoms and the QoL of the sportswomen.

RESULTS

Age significantly influenced (p < 0.05) the QoL in all domains. An increase in BMI was also significantly associated with a decrease in the QoL. MVC values had a highly significant effect on the overall QoL and all domains, including a reduction in urinary symptoms. The weekly time of physical activity was associated with a better QoL in symptomatology. The practice of high-impact activities decreased the QoL (compared to low-impact activities). The vaginal resting pressure values ranged from 1.60 to 59.80 (24.34 ± 11.00).

CONCLUSIONS

Age, BMI and high-impact sports appear to be the leading factors that promote the onset of SUI, which in turn decrease the QoL in sportswomen. There was a positive association between MVC and weekly time of physical activity in the QoL.

Is Physical Activity Good or Bad for the Female Pelvic Floor? A Narrative Review

More women participate in sports than ever before and the proportion of women athletes at the Olympic Games is nearly 50%. The pelvic floor in women may be the only area of the body where the positive effect of physical activity has been questioned. The aim of this narrative review is to present two widely held opposing hypotheses on the effect of general exercise on the pelvic floor and to discuss the evidence for each. Hypothesis 1: by strengthening the pelvic floor muscles (PFM) and decreasing the levator hiatus, exercise decreases the risk of urinary incontinence, anal incontinence and pelvic organ prolapse, but negatively affects the ease and safety of childbirth. Hypothesis 2: by overloading and stretching the PFM, exercise not only increases the risk of these disorders, but also makes labor and childbirth easier, as the PFM do not obstruct the exit of the fetus. Key findings of this review endorse aspects of both hypotheses. Exercising women generally have similar or stronger PFM strength and larger levator ani muscles than non-exercising women, but this does not seem to have a greater risk of obstructed labor or childbirth. Additionally, women that specifically train their PFM while pregnant are not more likely to have outcomes associated with obstructed labor. Mild-to-moderate physical activity, such as walking, decreases the risk of urinary incontinence but female athletes are about three times more likely to have urinary incontinence compared to controls. There is some evidence that strenuous exercise may cause and worsen pelvic organ prolapse, but data are inconsistent. Both intra-abdominal pressure associated with exercise and PFM strength vary between activities and between women; thus the threshold for optimal or negative effects on the pelvic floor almost certainly differs from person to person. Our review highlights many knowledge gaps that need to be understood to understand the full effects of strenuous and non-strenuous activities on pelvic floor health.

Lower urinary tract and gastrointestinal dysfunction in sportswomen: a systematic review and meta-analysis of observational studies

INTRODUCTION

The aim of this review was to assess the prevalence of gastrointestinal (GI) and lower urinary tract symptoms (LUTS) in sportswomen having high intensity training and to determine whether the type of sport might also affect LUTS and GI symptoms.

EVIDENCE ACQUISITION

A systematic review of the literature was performed by searching PubMed, CINAHL, Cochrane Library and Web of Science up to November 2018. The search strategy included several keywords concerning pelvic floor disorders, urinary dysfunction, bowel dysfunction, sportswomen, and elite sports. Inclusion criteria were studies of women who performed any kind of sport with a prevalence of LUTS and/or bowel symptoms without any restriction for age, sport modality or frequency of training. Outcomes were prevalence of LUTS and GI symptoms and meta-analyses and moderator analyses to identify risk factors for the occurrence of these symptoms in female athletes.

EVIDENCE SYNTHESIS

During the search, 1263 records were screened, 31 of which met the methodological criteria for qualitative analysis and 5 for meta-analysis. Sportswomen during daily activity showed a threefold higher risk to develop urinary incontinence (UI) than controls (OR 3.13; 95% CI: 2.39-4.00). No differences were found stratifying data for UI types. Cumulative prevalence rates were: 58.7% of all kinds of UI (daily life together with sport time), 32.8% at rest (during daily life out of sport time), 36.3% during sport time; 23% of stress urinary incontinence (SUI) during sport time versus 38.6% at rest; 11% of urge urinary incontinence (UUI) during sport time versus 17.8% at rest; 11.9% of mixed urinary incontinence (MUI) during sport time versus 20.7% at rest. Prevalence rates of GI symptoms before sport time were 57.6%, during sport competition 35.2% and 58.2% after competition.

CONCLUSIONS

All the analyzed studies showed bias. This meta-analysis indicated that competitive sport activities represent a risk factor for urinary incontinence and gastrointestinal disorders. To prevent urinary leakage athletes should be instructed to strengthen the pelvic floor muscles.

Urinary incontinence: Pelvic floor muscle and behavioral training for women

Primary care NPs play a significant role in recognizing and implementing strategies for urinary incontinence (UI) management. The American College of Physicians recommends pelvic floor muscle and behavioral training as initial treatment for UI. This article provides practical tips that can help improve urinary continence.

High level rhythmic gymnasts and urinary incontinence: Prevalence, risk factors, and influence on performance

Urinary incontinence (UI) is common among exercising women, but no studies have been found in rhythmic gymnasts. The aims of the present study were to investigate the prevalence and risk factors for UI in rhythmic gymnasts and the impact of UI on performance. This was a cross‐sectional study including all rhythmic gymnasts competing at the highest national and international level in Norway. One hundred and thirty‐three gymnasts from 22 sports clubs were invited to participate. Background data and possible risk factors were collected via electronic questionnaires. UI was assessed by Urinary Incontinence short form (ICIQ‐UI SF). The "Triad‐specific self‐report questionnaire" was applied to assess the female athlete triad. Joint mobility was assessed by Beighton score. Logistic regression analysis was used to assess possible risk factors. One hundred and seven nulliparous rhythmic gymnasts (80.5% response rate) from 21 sports clubs, with mean age of 14.5 (SD 1.6) years, participated in the study. Thirty‐four (31.8%) reported UI with 21 (61.8%), 3 (8.8%), 6 (17.6%), and 4 (11.8%) reporting stress, urgency, mixed urinary incontinence, and leakage for no obvious reason, respectively. BMI, hypermobility, menarche, disordered eating, and hours of training were not found to be risk factors for stress urinary incontinence. Twenty‐four gymnasts with UI (70.6%) reported incontinence to influence sports performance; 10 (29.4%) reported to be afraid of visible leakage and 5 (14.7%) that the leakage would happen again. Seventy‐four (69.1%) had never heard about the pelvic floor. In conclusion, UI is common in rhythmic gymnasts and may influence sports performance.

Urinary incontinence among competitive rope-skipping athletes: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

The purpose of this study was to determine the prevalence, impact and management of stress urinary incontinence (SUI) among rope-skipping (RS) athletes.

METHODS

A cross-sectional observational study was employed. Survey #1 (current athletes): RS athletes aged ≥13 years attending a national RS competition (183) were invited to participate. The primary outcome was the prevalence of SUI during RS (yes/no question). Secondary outcomes included SUI interference with RS (Likert scale, 0-10), quality of life (ICIQ-SF), and the prevalence and bothersomeness of SUI for each RS event (un-validated sport-specific questionnaire inspired by the IIQ-7). Survey #2 (retired athletes): retired RS athletes were invited to complete an online questionnaire to identify whether SUI contributed to their retirement from RS.

RESULTS

Survey #1: 56% (103 out of 183) of athletes responded. Athletes were predominantly girls of adolescent age, normal weight, menarchal, and nulliparous. Seventy-five percent of the girls (67 out of 89) and 7% of boys (1 out of 14) reported SUI during RS, mostly when competing "double-unders" and "triple-unders." Twenty-one percent (14 out of 67) of affected girls indicated a moderate or greater interference of SUI with RS, although the median impact of SUI on their overall quality of life was slight. Female athletes managed SUI with containment products, fluid limitation, and timed voiding. Survey #2: one of the 77 respondents (74 females, 3 males) indicated that SUI contributed to their retirement from RS.

CONCLUSIONS

Similar to other high-impact sports, female RS athletes experience a relatively high rate of SUI while participating in RS, which may lead to decreased quality of life.

Pelvic floor laxity: A not so rare but unrecognized form of daytime urinary incontinence in peripubertal and adolescent girls

INTRODUCTION

Stress urinary incontinence (SUI) is common among older multiparous females but rarely reported in active, young girls.

OBJECTIVES

Our hypothesis is: physically active adolescent females develop pelvic floor laxity demonstrable on upright VCUG. Our objectives are to (1) increase awareness of SUI in young females, (2) test our hypothesis with an upright VCUG, and (3) report effectiveness of step-wise management.

STUDY DESIGN

A retrospective review was performed of nulliparous girls with only SUI seen from 2000 to 2015, who were evaluated with upright voiding cystourethrography (VCUG) (bladder descent defined as ≥2 cm drop of bladder neck below pubic ramus at capacity). Data collection included level of physical activity, physical examination, BMI and Z-scores, urodynamics, management, and treatment response. Standard urotherapy (SUT) (timed voiding, proper diet, adequate fluids, bowel management) and biofeedback therapy (BFT) was initiated. Fisher exact test was used to calculate 'p' values.

RESULTS

Thirty-three females (median age 15.1 years, range 5.5-20.3) were identified who underwent an upright VCUG; 20 had bladder neck descent (Fig.). Of these 20, 15 (75%) were involved in strenuous activity, whereas only three of 13 (23%) without descent engaged in intense athletics. No differences were noted in median BMI and Z-score with strenuous activity (21.1 (15.2-26.7) and 0.31 (-0.9-1.94)), respectively, versus patients without (21.3 (15.8-33.5) and 0.62 (-0.0-2.38)). Average follow-up for all was 16.6 months (range 0.4-102.2). Of 20 demonstrating bladder neck descent, three did not complete therapy and were lost to follow-up. Only six of these 17 became dry. Of the remaining 11, eight underwent surgery: Burch colposuspension (5), fascial sling (2), Coaptite to the bladder neck (1), and an artificial urinary sphincter (1). This latter girl had a failed Burch colposuspension 1 year previously. All surgical patients are dry. Of 13 without bladder descent on VCUG, five did not complete therapy and were lost to follow-up. The remaining eight were managed non-surgically; seven were fully dry at last follow-up. Overall, 13 of 25 (52%) achieved dryness. SUT and BFT were more effective in those without, than in those with bladder descent (87.5% vs. 35.3%, p = 0.0302, Fisher exact test).

DISCUSSION AND CONCLUSIONS

Physically active, nulligravid girls with SUI can be efficaciously diagnosed on upright VCUG. They should be considered for non-surgical therapy but will likely require bladder neck elevating surgery. Non-surgical therapy works for those with minimal bladder descent on cystography.

Clinical and MRI changes of puborectalis and iliococcygeus after a short period of intensive pelvic floor muscles training with or without instrumentation : A prospective randomized controlled trial

PURPOSE

This study evaluates the impact of a 3-week period of intensive pelvic floor muscles training (PFMT), with or without instrumentation, on clinical and static magnetic resonance imaging (MRI) changes of puborectalis (PR) and iliococcygeus (IL) muscles.

METHODS

24 healthy young women were enrolled in the study and 17 achieved the 9 sessions of 30 min training exercises and conducted all assessments. Participants were randomly assigned in two training groups: voluntary contractions combined with hypopressive exercises (HYPO) or biofeedback exercises combined with transvaginal electrical stimulations (ELEC). Clinical and T2-weighted MRI assessments were realized before and after training.

RESULTS

Modified Oxford Grading System (MOGS) scores for left PR and perineal body significantly increased in the two groups (p = 0.039, p = 0.008), but MOGS score for right PR significantly increased only in HYPO (p = 0.020). Muscle volumes of right and left IL significantly decreased (p = 0.040, p = 0.045) after training as well as signal intensities of right and left PR (p = 0.040, p = 0.021) and thickness of right and left IL at mid-vagina location (p = 0.012, p = 0.011).

CONCLUSIONS

A short period of intensive PFMT induces clinical and morphological changes in PFMs at rest suggesting a decrease in IL volume and adipose content of PR. Although the results suggested that an intensive non-instrumented PFMT is as effective as an instrumented training, future controlled studies with greater sample sizes are needed to establish the relative and absolute effectiveness of each of the two interventions.

Female sexual function and urinary incontinence in nulliparous athletes: An exploratory study

OBJECTIVES

To estimate the prevalence of Female Sexual Dysfunction (FSD) and Urinary Incontinence (UI) symptom in nulliparous athletes and analyze the risk factors for these dysfunctions.

DESIGN

A cross-sectional study.

SETTING

The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF) and the Female Sexual Function Index (FSFI) were applied to assess the UI and the FSD.

PARTICIPANTS

50 athletes with ≥18 years old.

RESULTS

We found a prevalence of 48% of UI and 44% of FSD among nulliparous athletes. The rate of athletes having concomitant FSD and UI was 24%. We found a significant difference between high and low impact sports in the ICIQ-UI-SF score (p = 0.028). Hours of training (p = 0.007; R² = 0.21) was found to be a risk factor for UI. Incontinent athletes demonstrated a Relative Risk of 2.7 to develop sexual desire problem when compared to the continents (p = 0.04; 95% CIs: 1.50-4.89).

CONCLUSIONS

This study found a high prevalence of both UI and FSD among nulliparous athletes. Furthermore, nulliparous athletes practicing high-impact modalities are the most susceptible to UI. The hours of training per day was considered a risk factor to develop UI, and incontinent athletes have more chances of showing difficulties in sexual desire.

Urinary incontinence among adolescent female athletes

BACKGROUND

A collection of studies have demonstrated that approximately one-third of female nulliparous athletes experience urinary incontinence during their athletic activities. Contributing factors of incontinence that have thus far been the focus of study include type of sport, duration and intensity of athletic activity, use of hormonal contraception, and weight. There has, as yet, been a notable underemphasis on several other factors which influence incontinence, including bowel pattern, urinary habits, and menstrual status. The purpose of this pilot study was to describe the urinary habits and frequency of incontinence among adolescent female athletes. A secondary purpose was to identify factors associated with incontinence.

METHODS

To investigate these factors, a questionnaire was completed by 44 female high school athletes. Descriptive statistics were used, including means and percentages to answer the first purpose of our study. Chi-square tests and effect sizes were employed to determine the magnitude and statistical significance of the differences. The second research purpose was tested using correlations and logistic regression. Approval was obtained for this study from the Dartmouth Hitchcock Medical Center Committee for the Protection of Human Subjects.

RESULTS

There is an even higher rate of athletic incontinence (34.15%) among high school female athletes surveyed in this study than in previous studies of college age athletes. The more seasons athletes are engaged in vigorous exercise, the higher the rate of incontinence in athletics as well as during laughter and activities of daily living (ADLs). A habit of voiding more than six times per day was associated with incontinence.

CONCLUSIONS

Athletic incontinence is common among adolescent female athletes. Athletes who compete four seasons of the year have higher rates of all types of incontinence (athletic, laughter, and during ADLs) than athletes who compete during fewer seasons of the year. Avid participation in vigorous exercise may be a risk factor not only for athletic incontinence but also incontinence during laughter and ADLs. Several areas of findings warrant further research, including the impact of hot weather on incontinence and increased incontinence with particular body positions or athletic maneuvers.

Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis

Urinary incontinence (UI) is any involuntary loss of urine. In female athletes, physical exercise may be a risk factor for UI because of increased intra-abdominal pressure generated during high-impact exercises, which overloads the pelvic organs, predisposing them to UI. This is a systematic review of the prevalence of UI in female athletes in different sports. A search for articles was carried out in the PEDro, Scopus, Cinahl, PubMed, LILACS, SciELO, Science Direct, Web of Science, Embase, and Cochrane databases as well as a manual search of the references of studies already published on the subject with the keywords "athlete," "urinary incontinence," and "women" in Portuguese and English. Only articles published from 2000 to 2016 were included. Observational studies assessing the prevalence of UI in female athletes were selected. Methodological quality was assessed using the Downs and Black scale, and the data collected from the studies were analyzed through meta-analysis. Eight studies met the eligibility criteria. Meta-analysis showed a 36% prevalence of UI in female athletes in different sports, and compared with sedentary women, the athletes had a 177% higher risk of presenting with UI. There is a higher prevalence of UI in female athletes compared with sedentary women. There have been reports of UI in different sports.