urinary incontinence in athletes

What is the #1 issue facing female athletes, that they are too embarrassed to talk about….urinary incontinence in athletes. There is a lot of confusion surrounding urinary incontinence in athletes. Some of the most common questions we hear are: 

Sometimes, I pee with jumping. Is that normal?

NO

Is it common?

YES

Is there something we can do about it?

YES

When it comes to urinary incontinence in athletes, many women suffer in silence.

It is common that embarrassment, shame or a belief that it is normal stops women from seeking help for urinary incontinence. The goal of this article is to help improve awareness of urinary incontinence in athletes so women can seek the help they need to perform at the highest level.


How Common is Urinary Incontinence in Athletes?

Statistics show that between 25 – 45 % of women experience some form of urinary incontinence. This means that a large percentage of women involuntarily leak urine during activities. Sometimes an activity as simple as coughing or sneezing will elicit these symptoms. These symptoms interfere with workouts, social outings, and other daily activities.

There are three main types of urinary incontinence. Understanding the differences will help determine the most effective treatment approach for you.

pelvic floor muscles contributing to urinary incontinence in athletes
Pelvic floor muscles, illustration.

Stress Urinary Incontinence in Athletes (SUI)

SUI is the most common cause of incontinence in athletes. Athletes with SUI may experience leaking with jumping, lifting, running or any other activity that increases abdominal pressure.

When performing an activity like a squat, the pressure above the pelvic floor increases. This is due to many factors including the heavy load and the increased abdominal bracing needed to perform the task. As a result, the pelvic floor muscles, including the sphincters that control the flow of urine, must contract to counter the increased pressure from above. If they cannot generate enough force, or do not turn on at the correct time, leaking or stress incontinence may occur.

you can exercise with urinary incontinence in athletes

Pregnancy can contribute to a greater likelihood of SUI due to the increased pressure on the pelvic floor. It is also understood that menopausal state, aging, pelvic surgery, and obesity impact the incidence of incontinence.

The good news?

There are many things that you can do to improve the ability of your pelvic floor to do its job. Including seeking treatment from a physical therapist! We will discuss treatment options later in the article.

Urge Urinary Incontinence in Athletes (UUI)

This type of incontinence manifests as increased urgency and frequency of urination. It is the “gotta go right now” type of incontinence. Individuals who experience this type of incontinence may feel that they do not have enough time to get to the bathroom after an urge to urinate. They may use strategies such as “just in case voiding”, using the bathroom every time they pass one just in case they have to go later.

People with this type of incontinence may also benefit from physical therapy. This will be discussed further in a separate article.

Mixed Incontinence (MUI)

MUI is a combination of both SUI and UUI.


Does the Type of Exercise Matter?

weight training shouldn't settle for urinary incontinence in athletes

Running, jumping, weight lifting, sprinting … leaking?

If coughing and sneezing can cause incontinence, it is easy to imagine that high impact activities such as volleyball, weightlifting, or running can increase the risk of leaking.

This is correct. Stress urinary incontinence in athletes is common and the prevalence of SUI varies based on the type of sport.

A recent review including data from over 7500 women determined that the prevalence of SUI is significantly lower in individuals that perform lower impact activities. 58% of women who engage in high impact activities i.e. jumping activities (>4x bodyweight force) experience SUI compared to 12% of women who participate in low impact activities (light weight lifting).

Why is this important?

Incontinence is common and there are effective treatment approaches to decrease symptoms. You just have to know where to look. Leaking is something that no one wants to have to think about when training. It causes women and young females to shift some focus away from the sport.

One study found that 44% of high school volleyball players wear a pad during practice due to leaking. Another study found that 12% of female trampoliners quit the sport due to incontinence symptoms.

This is not okay!

There are effective treatment approaches that can help women understand and better control their body to continue to play and enjoy the sports that they love.

While ground reaction forces are a big factor, they are not the only factor. Sometimes, increased pressure from the abdominal cavity alone can cause SUI. This is the case with coughing and sneezing. A reported 15% of swimmers report SUI during practice. While there are not ground reaction forces, there is frequent, forceful abdominal contraction increasing stress on the pelvic floor.

No matter what the cause, increased pressure, that cannot be countered by the pelvic floor, may cause leaking. While it is common, it is not normal, and there are treatments that can help.


Treatment for Stress Urinary Incontinence in Athletes

There is plentiful research supporting the effectiveness of pelvic floor muscle training to improve stress urinary incontinence in athletes.

The pelvic floor is a made up of a group of skeletal muscles. These muscles help to support the organs in the pelvis and are therefore the VIP’s of SUI.

It is important to understand the demands that are being placed upon the pelvic floor. A runner who is experiencing leaking may not benefit from the same pelvic floor strengthening protocol that an Olympic Weightlifter does.

The reason?

Similar to training for a particular sport, the pelvic floor should be trained with consideration of the specific needs for that muscle group. Someone experiencing incontinence with long endurance activities or activities of daily living may benefit from more of an endurance approach to strengthening. For example, 30 sets of 10-second contractions of the pelvic floor daily to start with, then a gradual progression to performing these contractions during the provocative activity.

A power athlete such as a CrossFit athlete, volleyball player of weight lifter may need more of a strength/power approach. This may include a protocol that involves more repeated “quick” maximum contractions of the pelvic floor with relaxation in between. Just like training other muscles for particular athletic challenges, the pelvic floor should be strengthened with a focus on how it will need to perform for your sport.


Training Your Pelvic Floor

When it comes to muscle strengthening, it is important to progressively load the tissue that you are trying to strengthen. This is also true of the pelvic floor.

In order to best prepare the pelvic floor the type of force, it will encounter it is important to train the muscles to react to a similar force and in a similar position.

Usually, it is easiest to learn how to perform a proper pelvic floor contraction while lying on your back. This can be followed by a gradual transition to performing pelvic floor contractions in sitting, standing then sport specific activities.

Below is a basic outline of a progressive pelvic floor strengthening program. This should not take the place of working with a medical professional, but rather should be used as a guide for what to expect and tips to enhance your current program.

Lying

lying exercises for urinary incontinence in athletes

Try lying on your back with your knees bent. In order to activate your pelvic floor, think about turning on the muscles you would use to 1) keep from passing gas, 2) stop the flow of urine once the flow was started, 3) closing the vaginal and anal opening. A proper pelvic floor contraction will include the closing of these both openings and a lifting of the pelvic floor.

Once you have mastered the isolated pelvic floor contraction, or “Kegel”, while lying on your back you can try progressing the difficulty of the exercise. Turning on the adductors or gluteal muscles may help to synergistically enhance your pelvic floor contraction. Try lying on your back, knees bent, contracting your pelvic floor and squeezing a ball or yoga block between your legs.

Seated

Next move to the seated position. This is typically more challenging for people to master, but here are a few tricks for you.

Try sitting on a towel roll underneath your perineum. The perineum is the area of soft tissue that spans from between your sit bones and forwards toward the front of your pelvis. A proper pelvic floor contraction will lift the perineum off of the towel roll slightly. This is a great way to determine if you are doing the exercise correctly.

Do these exercises during your next Netflix binge, important meeting or commute. The best thing about this exercise is it is “sneaky” you can get them done everywhere.

Standing

Next, we move from seated to standing. Try activating your pelvic floor while standing at rest, or while holding a wall sit with a yoga block in between your knees. Once you have mastered the art of activating the PF in a stationary position, move on to functional movements.

Now try activating prior to squatting. Turn on your pelvic floor. You can use the “blow before you go” trick to help improve your pelvic floor contraction. Keep the pelvic floor active throughout the movement, pause, rest and repeat. See how many reps you can do before the pelvic floor starts to fatigue. Keep track and try to do more the next time.

From this stage try squatting with a weight or lifting a heavy object, going up and down the stairs with groceries, etc.

Sport Specific

The final stage may involve progressing to plyometrics, running, sprinting and other sport-specific movements to help you return to your sport without leaking. We can all jump for joy for that!

sport specific exercises for urinary incontinence in athletes

Why do you need a Pelvic Floor Physical Therapist?

1. To ensure correct exercise form

Many people struggle to correctly activate the pelvic floor during a Kegel exercise. They try to turn on all neighboring muscles with minimal recruitment of the pelvic floor. Many women are told to perform Kegels without proper instruction. If this is the case, you may be thinking you are strengthening the pelvic floor but not doing so correctly. A physical therapist can ensure that you are doing your pelvic floor strengthening exercises correctly.

2. To create a personalized treatment plan based on your sport-specific goals

A physical therapist can help guide you and create a specific treatment plan to achieve your goals. They will help you through the gradual progressions needed to achieve lasting results.

3. To examine contributing factors

Posture, alignment, and breathing can all affect the ability of the pelvic floor muscles to generate force. A physical therapist can evaluate the potential contribution of each of these factors and address them concurrently.

4. To be your advocate

Wonderful camaraderie, knowledge and a constant stream of nerdy pelvic floor PT jokes; what is there to not be excited about? A physical therapist can also communicate with your physician, coaches and other important players in your health and sport to optimize your treatment plan.  


Next Steps

If you or someone you know is experiencing SUI, do not hesitate to seek help. 

If you’re ready to schedule a physical therapy appointment, fill out the information below!


References

  1. Schettino MT, Mainini G, Ercolano S, Vascone C, Scalzone G, D’Assisi D, et al. Risk of pelvic floor dysfunctions in young athletes. Clin Exp Obstet Gynecol. 2014;41(6):671–6.
  2. de Mattos Lourenco TR, Matsuoka PK, Baracat EC, Haddad JM. Urinary incontinence in female athletes: a systematic review. Int Urogynecol J. 2018 Dec;29(12):1757-1763
  3. Eliasson K, Edner A, Mattson E. Urinary incontinence in very young and mostly nulliparous women with a history of regular organised high-impact trampoline training: occurence and risk factors. Int Urogynecol J. 2008;19(5):687–96.
  4. Schettino MT, Mainini G, Ercolano S, Vascone C, Scalzone G, D’Assisi D, et al. Risk of pelvic floor dysfunctions in young athletes. Clin Exp Obstet Gynecol. 2014;41(6):671–6.

Author Bio: Erin Cameron PT, DPT, CSCS

Dr. Erin Cameron Physical Therapist

Erin received her Doctorate in Physical Therapy from Northwestern University’s Feinberg School of Medicine. During her time in physical therapy school, she developed a special interest in treating patients with orthopedic injuries and promoting general health and wellness in people of all ages. She has since focused much of her continuing education on the treatment of runners and cyclists and patients with pelvic floor dysfunction.

She is an avid swimmer, cyclist, and runner and loves helping to maintain the health and improve the performance of endurance athletes.

While swimming at the University of Michigan she studied to obtain a Bachelor of Science in Movement Science from the School of Kinesiology. During her collegiate swimming career, she earned the following accolades: two-time CSCAA Honorable Mention Scholar All-American, three-time Big Ten Distinguished Scholar, team captain and the Michigan Leadership Academy Leader of Distinction award. Erin has dedicated much of her life to the sport of swimming.