You probably fall into one of two groups of people: those who believe that incontinence in female athletes and physically ‘fit’ women is rare (it isn’t), or those who think that a ‘little’ incontinence during intense physical exertion is normal (it’s not).
Most people consider urinary incontinence to be a result of muscle weakness, injury, or aging. If you find yourself in a conversation about incontinence, I would hazard to guess that you’re talking with someone who has recently given birth to a child, has had their prostate removed, or who is elderly. Young and fit women typically don’t come to mind when you look at a box of incontinence pads. But urinary incontinence is common in athletes or otherwise physically fit women, including young athletes who have never given birth nor suffered a complicating injury. (And yes, you can find companies that market incontinence pads for running and exercise.)
Even female athletes who compete at the highest levels of sport suffer from a high rate of urinary incontinence, both during sport AND during day-to-day activities (ref 1). Urinary incontinence is also prevalent in fitness instructors, including Pilates teachers and yoga instructors, and at rates similar to that seen in other groups of athletic women (ref 2).
Could pelvic floor muscle weakness really be so common in these otherwise very fit women? Or could incontinence in female athletes have other causes as well?
Incontinence in Female Athletes vs Non-Athletes
The causes of incontinence in female athletes can differ from that of non-athletes, and this is important. If you are an athletic woman with incontinence you need to understand the underlying cause(s) of your incontinence before you can know how best to treat it. Misunderstanding the underlying cause of your incontinence can result in treatment that is ineffective or even harmful. As a case in point, Kegel exercises will actually worsen incontinence symptoms for some people.
Since there are multiple causes of incontinence in female athletes, and cause determines treatment, I think it is important to avoid using the umbrella term “Athletic Incontinence” to describe this diverse group of conditions. The definition of Athletic Incontinence is urinary incontinence that occurs exclusively during exercise. This isn’t a useful term because it doesn’t tell us anything about the underlying cause of the incontinence, and so it doesn’t inform treatment. For example: are we talking about a woman who has a weak pelvic floor that is just strong enough (for now) to prevent leakage during day-to-day activities, but that fails when she goes to a yoga class? She would be classified as having “Athletic Incontinence”, but how is this woman different from a woman who doesn’t regularly exercise and who experiences incontinence only when she sneezes? The underlying cause and treatment of incontinence may be identical for these women, so naming the first “Athletic Incontinence” is as unhelpful as naming the second “Sneeze Incontinence”. Furthermore, the umbrella of “Athletic Incontinence” would also capture the elite female athlete who only experiences incontinence during power lifting, and whose underlying cause and treatment of incontinence could differ greatly from the first two women.
So forget about the term “Athletic Incontinence” – grouping together different underlying causes of incontinence in female athletes is unhelpful. To understand the cause of your Athletic Incontinence and therefore how to treat it, we need to talk about Athletic Incontinence in terms of the four primary root causes of urinary incontinence in female athletes.
You may find the following background information on the pelvic floor helpful for understanding the causes of incontinence in female athletes – but you can skip it if you’d like.
A little background on your pelvic floor
Your pelvic floor is a group of muscles (Levator ani) and connective tissues (fascia and ligaments) that make up the floor of your pelvis. They provide a basement of support to the bladder and uterus, keeping things in their proper place and functioning normally. To have a look at this basement, see Figure 1.
The pelvic floor is also a vital component of your ‘inner core’, working alongside the main breathing muscle (diaphragm), deep back muscles (multifidus), and deep abdominal muscles (the transversus abdominus). When it’s functioning normally the pelvic floor helps the inner core to control pressure within the abdomen to stabilize the spine and torso to allow for body movement. Not only does your pelvic floor need to be functional on its own, it also needs to be functional in concert with the other components of the inner core for optimal movement during sport. Here’s an interesting video by physiotherapist Julie Wiebe where she explains the importance of this connection for movement:
In summary, here’s what your pelvic floor does for you:
- Assists with the mechanics of urination and passing bowel movements.
- Holds things in place, particularly your uterus and bladder. When these organs aren’t properly supported they start to drop downward in a condition known as ‘prolapse’.
- Helps you move your body safely and effectively by helping control intra-abdominal pressure as part of your inner core. Before you move your body the muscles of your inner core increase pressure within your abdomen to stabilize your spine and torso. This provides a foundation for the movement you are about to perform. These pressure changes can be automatic and imperceptible for some movements, such as when you lift your arms, or very obvious and conscious such as when you hold your breath, grunt, or slowly exhale when lifting a heavy weight off the floor.
- Assists with sexual intercourse function and pleasure (see our article on vaginal ‘tightness’ and the connection between pelvic floor dysfunction and painful intercourse).
Given the variety of roles your pelvic floor muscles play, women who suffer from urinary incontinence are, not surprisingly, more likely to also suffer other common symptoms of pelvic floor dysfunction such as low back or pelvic girdle pain, prolapse and dyspareunia (pain with intercourse).
With this background in mind, let’s discuss the four main causes of incontinence in female athletes.
Incontinence in female athletes usually occurs for one of four reasons (or some combination).
1. Some athletic women with incontinence have a genuinely weak pelvic floor
Pelvic floor weakness can occur in athletes and other otherwise physically fit women, even women who do a lot of ‘core’ strengthening (such as in Pilates, CrossFit, and Bootcamp-style fitness classes).
Being athletic, fit, or having a ‘6-pack’ of abs doesn’t mean that the pelvic floor muscles involved in controlling urination are equally (or sufficiently) strong.
There may also be other factors contributing to or underlying the pelvic floor weakness. Pelvic floor damage, incomplete recovery after child birth, medical conditions such as cancer and its treatment (see: pelvic floor and cancer), or a long-forgotten injury are some of the reasons for a weak pelvic floor in otherwise strong/athletic women. Even outwardly benign activities such as yoga may induce urinary leakage in women with a previously asymptomatic underlying condition (ref 3,4).
Pelvic floor muscles are notoriously difficult to strengthen because they can be notoriously difficult to ‘feel’. More than 30% of women are unable to contract their pelvic floor muscles correctly (ref 5). This means that your regular abdominal strengthening routine or other exercise probably isn’t strengthening these muscles effectively.
If you are a physically fit woman but you find yourself leaking during exercise AND during day-to-day activities (such as coughing, sneezing or laughing) it is likely that your pelvic floor muscles are genuinely weak. Other urinary symptoms you may be experiencing include needing to urinate more than 5-7 times a day, or feeling a need to urinate with great urgency – like you might not make it to the bathroom in time.
If you suffer from pelvic floor weakness the good news is that appropriate strengthening exercises can provide significant and lasting benefit (see more on this below).
2. Some athletic women with incontinence have an overactive pelvic floor
It might feel a little counter-intuitive, but having a pelvic floor that is very active all the time can be as problematic as one that has difficulty activating at all.
Excessive ongoing tightness or tone (sometimes called ‘hypertonicity’) of the pelvic floor can lead to chronic fatigue of the muscles and an inability to respond sufficiently to a sudden stressor such as a cough or sneeze. Maintaining a partial contraction of the muscles also means that the muscles have less additional room to contract when they are called upon – further reducing their ability to ‘squeeze’. Whether your muscles are weak or strong, overactivity reduces their function. This can be a root cause of incontinence in female athletes, but can also occur in non-athletes as well.
What causes an overactive pelvic floor? It’s not well understood, but contributing factors appear to include weakness or injury of core or low back muscles; stress; poor posture; or overloading your pelvic floor muscles with constant tightening (such as sucking in your abdomen all day long) or excessive pelvic floor exercising.
Symptoms of pelvic floor overactivity can include urinary leakage, an inability to fully empty the bladder, urinary urgency or slow flow. Other non-bladder related symptoms may also arise, such as pain with intercourse or tampon insertion; pelvic, lower back or lower abdominal pain; constipation; or pain with or difficulty emptying your bowels.
Treatment for an overactive pelvic floor involves learning how to relax your pelvic floor muscles, in addition to strengthening – but done in the right way. Performing the ever popular ‘kegels’ can actually worsen pelvic floor overactivity and resulting urinary symptoms. In this case ‘reverse kegels’ or other exercises may be more appropriate. Pelvic floor physiotherapy for hypertonicity can include pelvic floor relaxation exercises, breathing practice, pain education, internal massage of the muscles and connective tissue, and modification to training routines.
3. Some athletic women with incontinence have a strong pelvic floor, but an imbalanced inner core
Your pelvic floor muscles may not be strong enough to match the rest of your inner core.
Your pelvic floor muscles may be strong and functional, but your other inner core muscles may be even stronger. If you have strong pelvic floor muscles and a strong core, you are not likely to suffer from urinary incontinence in your day-to-day life. Good for you! However, if you have an inner core muscle imbalance you may still leak under intense physical load (such as explosive exercises). This may also happen if you have a strong pelvic floor but aren’t as skilled at activating it effectively during exercise.
If your pelvic floor is the weakest link in your inner core and you perform intense exercise that requires high intra-abdominal pressure such as powerlifting or CrossFit, your pelvic floor can ‘give out’ resulting in urinary leakage (and even defecation). You may have seen this confessional video that makes light of peeing during intense CrossFit workouts and competitions:
Feel free to pat yourself on the back for pushing hard, and for not being embarrassed by a little leakage. But incontinence isn’t ‘normal’ and it can be avoided. Learning appropriate pelvic floor pressure control during exercise and more specific pelvic floor strengthening can offer significant and lasting benefit.
If you think you fall into this group, and are also into CrossFit, you may need to modify your training, such as “training raw” rather than using support belts. Our own pelvic floor physiotherapists Katie Hauck and Jessica Metcalf have a special interest in Obstacle Course Racing and CrossFit themselves, being active competitors in the sport.
4. Some athletic women with incontinence suffer pelvic floor dysfunction due to exercise-induced damage
Simply put: your pelvic floor has been overburdened by the demands you’ve placed on it.
If you are one of these women, your pelvic floor is otherwise strong and functional, and you don’t suffer from day-to-day incontinence issues. But you still find yourself leaking during intense physical activities that require excessive pelvic floor endurance, namely activities that induce repetitive pelvic floor activation such as swimming, trampoline, repeated loaded jumping exercises such as in a high intensity bootcamp style class, gymnastics, and others.
This is not the same as simply having a weak pelvic floor that is just strong enough to prevent day-to-day leakage most of the time, but then fails when you go for a run or other moderate activity. If this sounds like I’m describing you, then you actually belong in category #1 above, where the pelvic floor muscles may be truly weakened.
It may feel like I’m splitting hairs here a bit. Is there really a difference between everyday women who leak during moderate exercise, and super-athletes who leak during higher intensity or loaded repetitive exercise? In either case the pelvic floor muscles are too weak to keep up with the demands of the activity, and strengthening them will help. But this distinction is worth making, because the underlying issue is different and, importantly, so is the treatment. Let me explain:
Physical activity may not always be beneficial for the pelvic floor
Although available clinic studies vary in their methods and conclusions, the bulk of the data clearly shows that urinary incontinence is at least as high in female athletes as in non-athletes, and probably higher. In fact, the higher-impact the sport is, the greater the frequency of urinary disorder, and women whose exercise involves the largest and most repetitive pelvic floor stresses (such as trampoline) appear to have the highest frequency of urinary incontinence (ref 6). This suggests that incontinence in these athletes may not just be a consequence of exercise-induced muscle fatigue, but may in fact be caused by their training. So it may not be a question of having a weak (#1 above) or overactive (#2) pelvic floor, or having an inner core muscle (or pressure control) imbalance (#3), it may be a question of physiological limits and resulting injury.
Some researchers hypothesize that prolonged intense physical activity “may overload, stretch and weaken the pelvic floor” (ref 7).
High-impact sport has been shown to increase the risk of urinary incontinence (ref 8), and in one study it was even shown to occur in a surprising 25% of young female athletes (average age of 20) who have not had children or other significant risk factor (ref 9). How can this be? Shouldn’t repetitive activation of the pelvic floor strengthen it rather than weaken it? Indeed, it has been shown that athletes whose sports repetitively activate their pelvic floor muscles tend to have larger pelvic floor muscles (which is a good thing). But these athletes also tended to have other physiological changes happening in their pelvic floor, such as changes in the position of structures such as the bladder that may be indicative of pelvic floor connective tissue deformation (ref 1). It’s probable that increased intra-abdominal pressure generated during physical activity that isn’t properly supported by the pelvic floor muscles may gradually stretch connective tissue (ligaments and fascia) thus potentially causing irreversible deformation, and resulting pelvic floor dysfunction (ref 10, among others).
Does this mean that women should avoid certain sports because they can be damaging to the pelvic floor?
Not at all. Many women athletes don’t suffer from urinary incontinence, so damage is not a foregone conclusion. Our own physiotherapists including pelvic floor physiotherapists Katie Hauck and Jessica Metcalf are avid Obstacle Course and CrossFit competitors themselves. Learning proper pelvic floor control during exercise is likely to be preventative, and those who do suffer from exercise-induced pelvic floor damage can be treated.
If you think you fall into this category, beneficial strategies for addressing your urinary leakage may include: strengthening; learning better pelvic floor control and activation during exercise; giving your pelvic floor opportunity to rest and recover (perhaps by incorporating more cross-training activities that aren’t as challenging to your pelvic floor); and using your pelvic floor as your limiting factor during training. For example, you could try to consciously train to the point of urinary leakage (but not past it), and gradually increase your training as your pelvic floor function improves. Addressing pelvic floor issues early in these athletes may also help to prevent further pelvic floor harm.
If it’s common, it must be normal.
Not so. I think I’ve stressed this point adequately, but if you still need more convincing look around: there are many high-intensity and high-performance athletes that do not have urinary incontinence. There are also many non-athletic women who have successfully recovered their pelvic floor function after significant injury and/or weakness.
Urinary incontinence in female athletes can be prevented
Contrary to popular belief, female athletes appear to be particularly at risk of developing pelvic floor disorders such as urinary incontinence. If you are a female athlete you should incorporate pelvic floor muscle training as part of your regular training routine. Doing so may help you reduce your chances of pelvic floor dysfunction and/or pelvic floor damage.
Urinary incontinence in female athletes can be treated
Urinary incontinence can be treated. If your pelvic floor muscles are weak, then strengthening them will help. If you are not using your pelvic floor adequately during sport, you can learn to. If your pelvic floor is overactive or overburdened, you can learn to relax, recover, and appropriately strengthen.
Consult with a certified Pelvic Floor Physiotherapist and with your doctor if you are experiencing a pelvic floor disorder. Pelvic floor physiotherapy is the recommended first line treatment for a wide range of pelvic floor disorders including urinary incontinence (ref 11), and it has also been shown to be effective at treating and preventing pelvic floor dysfunction in athletes (ref 12).
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