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A PT's Guide To The Pelvic Floor for Female Athletes

by Rebecca Maidansky


Athletes are used to ignoring their injuries. They can get used to nagging knee pain, having to ice an ankle after a long run, forcing themselves into an ice bath if necessary. As physical therapists we’re constantly pleading with our athletes, trying to convince them that moderation is key for their recovery, or that they may need to scale it back in the short term to ramp up in the long term.

In our female athletes, specifically, there is one large part of the body that we’re forgetting to check in on the pelvic floor. Urinary leakage plagues long-distance runners and high-impact female athletes in epic proportions. Below, I will discuss the who, what, why, and what now, of urinary leakage in female athletes.

Who is affected?

“About 30% of exercising women experience urine leakage during at least one type of exercise.”1 This number rises as high as 80% when investigating the prevalence of leakage amongst high-impact female athletes, including gymnasts, dancers, and runners.

These numbers are not reserved for the elderly or postpartum populations. Studies that these symptoms affect all women, from teenagers in physical education class to elite, world-class athletes.

Other studies have specifically parsed out young, nulliparous female athletes. A 2017 study looked at women under the age of 45 who had never had children, finding that up to 20% experienced urinary incontinence, with numbers as high as 42% in runners with the same demographics.1 42% of young, female runners, who had never been pregnant, were experiencing leakage with running.

Other studies have looked at even younger girls and women. In 2007, Carls surveyed a group of female high school and college athletes regarding urinary symptoms with exercise. His results indicated that over 25% of the girls completing his surveys experienced urinary incontinence with exercise. Furthermore, the surveys showed that over 90% of those experiencing this had never reported their symptoms, and did not know treatment existed.2

Urinary leakage has significant effects on women’s quality of life, causing sports abandonment, depression, social withdrawal, decreased sexual function and pleasure, and damage to self-esteem. In a study by Lasserre et al, 51.8% of women reported that their incontinence had a negative impact on their quality of life.3 In order to help these girls and women stay active, both physically and as participants in their lives, we need a better understanding of how and why this may happen, and what we can do about it.

Why do women leak with exercise?

There are a number of risk factors for urinary incontinence. Those most widely acknowledged are old age, pregnancy, and delivery. However, research is starting to paint a different picture, of young women who have never been pregnant affected by these symptoms. Additional risk factors for urinary leakage have been uncovered, such as anxiety, childhood bedwetting, psychotropic medication, BMI, and high-impact exercise.

In large part, however, we’re still not sure why female high-impact athletes struggle with urinary incontinence in such significant proportions. Two theories are frequently cited in the research regarding exercise and the pelvic floor. Unfortunately, they are inconveniently diametrically opposed. The first argues that as we exercise, our pelvic floor gets stronger along with the rest of our body. The other theory states that as we exercise, the repetitive increase in intra abdominal pressure fatigues the pelvic floor, which over time leads to weakness. To make matters more confusing, studies have confirmed both theories.4,5

Furthermore, a third perspective argues maybe it’s neither of the above. Women who experience urinary leakage with high impact exercise frequently do not leak other daily activities. Maybe exercise is neither contributing to nor combatting urinary leakage, but high-impact exercise stresses their systems to the point of loss of control. Research has shown that oftentimes, women who leak during exercise will not actually leak at any other point in their daily lives. They will not experience leakage with coughing, sneezing, or laughing. Maybe for these women, the exercise in which they are participating simply illustrates the threshold of their pelvic floor strength and control.

Regardless of the cause, urinary leakage amongst female athletes is common and treatable. If we do a better job identifying girls and women struggling with these symptoms, we can let them know help exists. We can improve their confidence, their tolerance to exercise, and their self-esteem.

What is urinary incontinence?

Or, what causes urinary incontinence? Before we get into how to treat urinary incontinence, we need to understand that there is more than one cause. Understanding the difference between stress, urge and mixed incontinence is imperative to treating these symptoms correctly.

Stress incontinence occurs when someone loses control of their bladder with certain activities. These activities can be coughing, sneezing, laughing, walking, or in our case, running and jumping. With any of the above-listed activities, there is an increase in intra-abdominal pressure. If the increase in intra-abdominal pressure is greater than the pelvic floor can withstand, we can have an involuntary loss of urine. In these women, strengthening is important, but not just Kegels. We need to strengthen the entire pelvic girdle, including their hips, abdomen, and lower extremities.

Urge incontinence, on the contrary, is not necessarily related to weakness. Urge incontinence occurs when someone loses control of their bladder following a sudden, strong, and uncontrollable urge to urinate. These symptoms are frequently caused by muscular tension rather than weakness. These women may need stretching, relaxation, and breathing techniques, to down train a hypertonic muscle. Hypertonic pelvic floor, abdominal, external hip, and adductor musculature can all contribute to urge incontinence.

In reality, is it ever just one thing? In my clinical experience, urinary incontinence is typically a combination of both of the above, creating a third category, called mixed incontinence. Mixed incontinence, as I’m sure you can guess, is a combination of the two conditions previously mentioned. Treatment of mixed incontinence often requires a combination of strengthening and relaxation to resolve symptoms.

What else can help?

For all types of incontinence, healthy habits are important. Diet, water intake, bladder habits, breathing patterns, stress management, all play a role in managing these symptoms.

One of the first topics I discuss with my patients struggling with urinary control is bladder irritants. Bladder irritants do not necessarily harm the bladder, but they make urinary control more challenging. Each person is sensitive to different irritants, and to different degrees. Common irritants include carbonated drinks, artificial sweeteners, caffeine, alcohol, and spicy foods. I encourage these patients to decrease common irritants while increasing water intake.

Water intake is another important aspect of urinary control that I often address. When people leak, they’ll sometimes decrease their water intake in hopes of decreasing their leakage. While in the short term they may be moderately successful, decreasing water intake will further irritate their bladder, potentially irritating their symptoms further.

Urinary leakage is common, but that does not make it normal. Whether a woman’s leakage is caused by tension, weakness, or a combination of both, exercise should be the first option. Physical therapists know the body better than anyone else. If we ask the right questions, we can have a massive impact on these women’s quality of life.

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  1. Almousa, S. Bandin Van Loon, A. The prevalence of urinary incontinence in nulliparous adolescent and middle-aged women and the associated risk factors: a systematic review. Maturitas. 2018 Jan; 107:78-8
  2. 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 Feb; 27(1):21-4, 39.
  3. Lasserre A, Pelat C, Gueroult V, Hanslik T, Chartier-Kastler E, Blanchon T. Urinary incontinence in French women: prevalence, risk factors and impact on quality of life. Eur Urol. 2009 Jul; 56(1): 177-83.
  4. Goldstick, O. Constantini, N. Urinary incontinence in physically active women and female athletes. Br J Sports Med. 2013:0:1-5
  5. Kari, B. Sundgot, J. Prevalence of stress and urge urinary incontinence in elite athletes and controls. Med. Sci. Sports Exerc. 2001. 33(11): 1797-1802


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