Long before I knew anything about pelvic health as a physical therapist, I was 19 years old and at the peak of my athleticism running cross- country for a division one school. In my last half mile of my races, I always gave it my all to the point I felt like I lost entire control of my body. Like clock work, some urine would start running down my leg. I always had my token extra pair of shorts to change into shortly after I crossed the finish line. It was not an uncommon occurrence among my teammates. It was something no one really talked about, but if brought up, we just laughed and said it happens to all of us sometimes.

These conversations may not be as uncommon in groups of female athletes as we might think. In fact, leaking urine may become a “badge of honor” or laughable matter to some athletes. Reebok CrossFit recently was criticized for uploading a viral YouTube video that was perceived by some that peeing during workouts is not a large concern.

Every athlete in the above video is describing symptoms of stress urinary incontinence (SUI). SUI is defined as the involuntary leakage of urine with exertion such as coughing, sneezing, laughing, lifting, jumping, or any form of exercise.¹ Weak pelvic floor muscles are a common cause of SUI but other causes of SUI include pelvic floor muscle damage, hypermobility of the urethra, too much repetitive straining such as pushing over a toilet, chronic cough, neurological damage, and a decrease in estrogen during menopause.²

Examples that you may be experiencing SUI as an athlete are:

-If you leak urine during a squat

-If you jump during sport and notice urine leakage

-If you find urine on your underwear after a run.

You do not have to be a post- partum woman or considered in your later years to have SUI. SUI can affect any age bracket ranging from teenage girls to women over the age of 65. Female athletics has drastically increased in the past 20 years. Now more then ever, females are heavily participating in sports. In a study of 86 high school and college athletes, 28% reported SUI during sport and 92% of those with urinary incontinence never reported their symptoms.¹³ Another study that included 144 college varsity athletes, showed 28% of them also reported SUI during sport, with the most prevalent sport being gymnastics.¹ The most common activities to produce leaking were jumping, high impact landings, and running. SUI can become a large embarrassing problem, especially for sports involving minimal tight clothing like gymnastics and figure skating.¹

Two common risk factors for SUI if you are a female athlete, are intensive exercise and eating disorders or a combination of both. SUI in eating disordered athletes has been shown to be significantly higher than in healthy athletes.¹⁴ The “female athlete triad” can occur with overtraining and poor nutrition related or non related to disordered eating. If you are experiencing increased fatigue with workouts, irregular menstrual periods, or increased stress fractures you should seek appropriate medical care due to possible problems with the female athlete triad.⁵ All of the above factors can increase your risk of developing SUI.

Female Athlete Triad: ⁵

One of the most common coping strategies used by female athletes for SUI is use of protective pads. Frequent toilet visits and limiting fluid intake are also common coping mechanisms. Frequent toilet visits may lead to increased urinary frequency that can cause the addition of urge incontinence and be disruptive during practice sessions. Limiting fluid intake may be dangerous for athletes training hard in hotter environments by putting them at risk for dehydration or other heat related events.¹

The pelvic floor muscles have to be able to accept loads appropriately as part of a larger support system in order to prevent leakage of urine. The demands of high- level sports can cause pelvic floor muscle fatigue and a repetitive increase in intra-abdominal pressure. If your pelvic floor muscles are already weak, the additional demands of high- level sports can cause urinary leakage.¹⁶ Perineal pressure has been found to be decreased in female athletes versus non- athletes in a sample of 40 women ranging 18-30 years of age. Lower perineal pressure may be related to increased urinary incontinence symptoms and pelvic floor dysfunction.⁷

If you are experiencing involuntary leaking of urine during daily activities, with sports, or with straining, pelvic floor rehabilitation by a women’s health physical therapist should be considered a first line approach with treating your SUI symptoms.¹ There is strong evidence to support pelvic floor muscle training is an effective treatment for SUI.⁸⁹ Appropriate pelvic floor muscle retraining exercises can be provided to increase the strength and endurance of the pelvic floor muscles during high- level demands of sports and work outs. Combining pelvic floor muscle retraining in combination with techniques to decrease intra-abdominal pressure and external pelvic and core strengthening can also decrease SUI in athletes. Training behavioral habits by instructing on fluid and dietary modifications and voiding intervals if needed may be part of treatment.¹ The team of physical therapists at New Dimensions Physical Therapy are trained in the above techniques for treating SUI in female athletes. SUI does not have to be the hidden problem among female athletes but rather a very treatable problem by conservative care.

Lila Abbate PT, DPT, MS, OCS, WCS

Andrea Wood, PT, DPT

References:

1. Heath, A, Folan S, Ripa B, et al. Stress urinary incontinence in female athletes. . J WomensHealthPhys Therap. 2014; 38(3):104-109

2. Figuers, C. C. (2010). Physical therapy management of pelvic floor dysfunction. In Women’s health physical therapy. (Kindle Edition ed.). Baltimore, Philadelphia: Lippincott Williams and Wilkins

3. Carls C. The prevalence of stress urinary incontinence in high school and college-age female athletes in the Midwest: implications for education and prevention. Urol Nurs. 2007; 27(1): 21-24, 39

4. Bo K, Borgen JS. Prevalence of stress and urge incontinence in elite athletes and controls. Med Sci Sports Exerc. 2001;33(11): 1797-1802

5. Rauh M, Barrack M, Nichols J. Associations between the female athlete triad and injury among high school runners. Int J Sports Phys Ther. 2014; 9(7): 948-958

6. Brody, L., & Irion, J. (2010). The female athlete. In Women’s health physical therapy. (Kindle Edition ed.). Baltimore, Philadelphia: Lippincott Williams and Wilkins.

7. Borin LC, Nunes FR, Guirro EC. Assessment of pelvic floor muscle pressure in female athletes. PMR. 2013; 5(3): 189-193

8. Bo K. Pelvic floor muscle training in treatment of female stress urinary incontinence, pelvic organ prolapse and sexual dysfunction. World J Urol. 2012; 30 (4): 437-443

9. Dumoulin C, Hay-Smith J, Habee-Sequin GM, et al. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: a short version Cochrane systematic review with meta-analysis. Neurourol Urodyn. 2015; 34(4): 300-308