Jump to content

Urinary Incontinence in Athletes

What is Urinary Incontinence

The unintentional voiding or loss of urine is known as urinary incontinence (UI).[1] [2] Stress urinary incontinence (SUI) occurs with increases in abdominal pressure during activities such as squatting, lifting weights, exertion, sneezing, and/or coughing, and is the most common type of incontinence.[1] [3] SUI is 2-4 times more likely in women compared to men and is typically experienced in postpartum or post-menopausal women. However, recent studies indicate young nulliparous athletes also show increased rates of SUI,[1] with high performance female athlete’s part-taking in high-impact sports considered to be at the greatest risk for developing SUI.[2] High impact sports are defined as sports where 2 feet are off the ground at the same time, which encompasses jumping sports, as well as running.[4]

Clinically relevant anatomy

See Urinary Incontinence

Why does it happen

During exertional activities, abdominal pressure increases and is transmitted through the bladder which causes bladder pressure to increase higher than urethral pressure. With a dysfunctional pelvic floor (PF), these pressure changes can cause leakage.[1] Currently, there are two competing hypotheses in regards to the cause of SUI in athletes. One hypothesis is that physical activity strengthens pelvic floor muscles (PFM) leading to increased tone, overactivity of the muscles, and changes in biomechanics of the PFM.[4] [5] The overactivity of PFM may result in increased frequency, and eventually lead to UI.[1] [5] Secondly, the PF may be weakened due to overload and stretching of the PFM.[1] [4] High impact sports, where jumping or a repetitive flight phase where both feet are off the ground, as seen with running, is associated with intra-abdominal pressure increases which can overburden the PFM.[5] [6] This mechanism can cause a predisposition to the symptoms of SUI in athletes.[6] It is suggested that a continence threshold exists and if this threshold is exceeded, either due to duration or intensity, this can cause PFM fatigue without muscle damage and may explain the reason why athletes experience SUI.[6]

Risk Factors

Alves et al, has divided risk factors for UI into three main categories:

  1. Predisposing factors, which include genetics and family history of UI;
  2. Promoting factors, such as sports participation
  3. Aggravating factors which include obesity or high BMI, and vaginal delivery[6][7]

When speaking particularly of risk factors for the athletic population, the type of sport has a large impact on development of SUI, which is especially noted in high impact, high intensity sports with large ground reaction forces.[4] [5][6] Training volume, eating disorders, and decreased foot arch flexibility are also associated with increased likelihood of SUI.[2] [4][6] A history of urinary tract infections and constipation also increase an athletes risk for developing UI.[2]

Prevalence

Prevalence of UI in female athletes is reported to be on average between 25% and 29%.[1][2] [6]At the high end of the spectrum, up to 80% of trampolinists display signs of SUI, which is the highest prevalence of any sport.[3] [4]

Clinical presentation

UI affecting athletes is unique, as athletes only experience symptoms during their athletic endeavours.[1] The most common triggers of SUI in athletes reported in a systematic review by Culleton-Quinn et al were physical activity training and competition.[8] Importantly, episodes of incontinence at a young age due to athletics is not associated with an increased risk of UI later in life compared to non-athletes nor does high impact vs low impact sport predispose on to UI later in life.[3][5]

Diagnosis

Clinical diagnosis is completed using the patient’s subjective history, as well as external and internal examination.[9] The PF and surrounding muscles are palpated for elasticity, tone, tenderness and pain. Voluntary contractions and relaxation techniques are performed and assessed.[9] With information from these assessments the physiotherapist can make an informed clinical diagnosis.

Treatment

Conservative treatment measures include changes to lifestyle, pelvic floor physiotherapy (PFPT) and pharmacological interventions.[2] Changes to lifestyle include treating contributing factors such as eating disorders, atrophy, obesity and also reducing caffeine and alcohol intake, as well as smoking cessation.[4] Many athletes report wearing pads, voiding prior to competition and even restricting fluids to combat SUI during competition.[8] Ensuring an athlete voids before training and competition is a strategy that is often employed as a means to help minimize symptoms of SUI.[1][4] Avoiding excessive fluid intake may also be an option, although caution is required when limiting fluids as dehydration is a concern, especially within the athletic population.[1][4] The purpose of PFPT is to regain strength, power and endurance in the muscles of the pelvis, increase the structural support, and improve overall resting tone within these muscles.[9] [10] PFPT is recommended as first line treatment as it is minimally invasive, low-risk, and effective in reducing or curing the symptoms incontinence, as well as reducing episodes of leakage.[2][9][11] Muscle pain, weakness and PFM dyssynergy are general focuses for treatment.[7] The optimal load and program parameters for PFPT in the athletic population are currently unknown, and typically protocols for PFM training are not well defined.[10][11] However, strengthening the muscles of the PF have proven to be beneficial for improving symptoms of SUI, including reducing episodes and quantity of leakage.[11] Kegel exercises are a particular type of PF exercises employed in PFPT to improve muscle tension and blood supply to the PFMs.[1]

Biofeedback (BF) is a specific treatment technique used in PFPT. This technique involves using self-control measures to regain control over physiological processes in the body, it can also provide useful information on PFM contractions regarding duration and intensity.[1] Through visual and/or auditory cues from the BF system, the patient is able to monitor contractions which may help to isolate muscles of the PF in order to produce improved PFM activation.[9][12] Vaginal dilators or weighted cones are another option for PFPT, and similar to biofeedback, the use of these devices produces better contractions and isolation of the PFM.[9] Research has shown cone-shaped weights to be an effective treatment strategy for SUI, although no difference has been reported between other non-weighted PFPT treatments such as exercising the PF or muscle stimulation.[13] Some individuals report weighted cones to be uncomfortable, and as no further benefits have been shown, this treatment should be chosen based on the individual’s response to the intervention.[13] Pharmacological treatment is also a potential option to assist with symptoms of UI;[4] however, athletes are not typically exposed to pharmacological interventions due to the unique nature of their symptoms only occurring during physical activities.[1]

If conservative treatment options fail, surgery may be considered for some individuals, although this is atypical for young elite athletes, where such procedures would be unnecessary and unsuitable for their circumstances.[4] These surgeries may include a pubovaginal sling, retropubic suspension and periurethral injections.[2][4]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Joseph, C., Srivastava, K., Ochuba, O., Ruo, S. W., Alkayyali, T., Sandhu, J. K., Waqar, A., Jain, A., and Poudel, S. (2021). Stress Urinary Incontinence Among Young Nulliparous Female Athletes. Cureus, 13(9), e17986. https://doi.org/10.7759/cureus.17986
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Sorrigueta-Hernández, A., Padilla-Fernandez, B. Y., Marquez-Sanchez, M. T., Flores-Fraile, M. C., Flores-Fraile, J., Moreno-Pascual, C., Lorenzo-Gomez, A., Garcia-Cenador, M. B., and Lorenzo-Gomez, M. F. (2020). Benefits of Physiotherapy on Urinary Incontinence in High-Performance Female Athletes. Meta-Analysis. Journal of clinical medicine, 9(10), 3240. https://doi.org/10.3390/jcm9103240
  3. ↑ 3.0 3.1 3.2 Bø, K., and Sundgot-Borgen, J. (2010). Are former female elite athletes more likely to experience urinary incontinence later in life than non-athletes?. Scandinavian journal of medicine and science in sports, 20(1), 100–104. https://doi.org/10.1111/j.1600- 0838.2008.00871.x
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Goldstick, O., and Constantini, N. (2014). Urinary incontinence in physically active women and female athletes. British journal of sports medicine, 48(4), 296–298. https://doi.org/10.1136/bjsports-2012-091880
  5. ↑ 5.0 5.1 5.2 5.3 5.4 de Mattos Lourenco, T. R., Matsuoka, P. K., Baracat, E. C., and Haddad, J. M. (2018). Urinary incontinence in female athletes: a systematic review. International urogynecology journal, 29(12), 1757–1763. https://doi.org/10.1007/s00192-018-3629-z
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Alves, J. O., Luz, S. T. D., Brandão, S., Da Luz, C. M., Jorge, R. N., and Da Roza, T. (2017). Urinary Incontinence in Physically Active Young Women: Prevalence and Related Factors. International journal of sports medicine, 38(12), 937–941. https://doi.org/10.1055/s-0043-115736
  7. ↑ 7.0 7.1 Casey, E. K., and Temme, K. (2017). Pelvic floor muscle function and urinary incontinence in the female athlete. The Physician and sportsmedicine, 45(4), 399–407. https://doi.org/10.1080/00913847.2017.1372677
  8. ↑ 8.0 8.1 Culleton-Quinn, E., Bø, K., Fleming, N., Mockler, D., Cusack, C., and Daly, D. (2022). Elite female athletes; experiences of symptoms of pelvic floor dysfunction: A systematic review. International urogynecology journal, 33(10), 2681–2711. https://doi.org/10.1007/s00192-022-05302-6
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Wallace, S. L., Miller, L. D., and Mishra, K. (2019). Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Current opinion in obstetrics and gynecology, 31(6), 485–493. https://doi.org/10.1097/GCO.0000000000000584
  10. ↑ 10.0 10.1 Bø K. (2004). Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work?. International urogynecology journal and pelvic floor dysfunction, 15(2), 76–84. https://doi.org/10.1007/s00192-004-1125-0
  11. ↑ 11.0 11.1 11.2 Dumoulin, C., Cacciari, L. P., and Hay-Smith, E. J. C. (2018). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. The Cochrane database of systematic reviews, 10(10), CD005654. https://doi.org/10.1002/14651858.CD005654.pub4
  12. ↑ Kopańska, M., Torices, S., Czech, J., Koziara, W., Toborek, M., and Dobrek, Ł. (2020). Urinary incontinence in women: biofeedback as an innovative treatment method. Therapeutic advances in urology, 12, 1756287220934359. https://doi.org/10.1177/1756287220934359
  13. ↑ 13.0 13.1 Herbison, G. P., and Dean, N. (2013). Weighted vaginal cones for urinary incontinence. The Cochrane database of systematic reviews, 2013(7), CD002114. https://doi.org/10.1002/14651858.CD002114.pub2
Retrieved from "https://www.physio-pedia.com/w/index.php?title=Urinary_Incontinence_in_Athletes&oldid=375431"