Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport

Abstract

Urinary incontinence is defined as “the complaint of any involuntary leakage of urine” and is a common problem in the female population with prevalence rates varying between 10% and 55% in 15- to 64-year-old women. The most frequent form of urinary incontinence in women is stress urinary incontinence, defined as “involuntary leakage on effort or exertion, or on sneezing or coughing”. The aim of this article is to systematically review the literature on urinary incontinence and participation in sport and fitness activities with a special emphasis on prevalence and treatment in female elite athletes. Stress urinary incontinence is a barrier to women’s participation in sport and fitness activities and, therefore, it may be a threat to women’s health, self-esteem and well-being. The prevalence during sports among young, nulliparous elite athletes varies between 0% (golf) and 80% (trampolinists). The highest prevalence is found in sports involving high impact activities such as gymnastics, track and field, and some ball games. A ‘stiff’ and strong pelvic floor positioned at an optimal level inside the pelvis may be a crucial factor in counteracting the increases in abdominal pressure occurring during high-impact activities. There are no randomised controlled trials or reports on the effect of any treatment for stress urinary incontinence in female elite athletes. However, strength training of the pelvic floor muscles has been shown to be effective in treating stress urinary incontinence in parous females in the general population. In randomised controlled trials, reported cure rates, defined as <2g of leakage on pad tests, varied between 44% and 69%. Pelvic floor muscle training has no serious adverse effects and has been recommended as first-line treatment in the general population. Use of preventive devices such as vaginal tampons or pessaries can prevent leakage during high impact physical activity. The pelvic floor muscles need to be much stronger in elite athletes than in other women. There is a need for more basic research on pelvic floor muscle function during physical activity and the effect of pelvic floor muscle training in female elite athletes.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Table I
Table II

References

  1. 1.

    Abrams P, Cardozo L, Fall M, et al. The standardization of terminology of lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21: 167–78

    PubMed  Article  Google Scholar 

  2. 2.

    Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. 2, update [96-0682], 1–154. Rockville (MD): US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Clinical Practice Guideline, 1996

    Google Scholar 

  3. 3.

    Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural history of urinary incontinence (UI). In: Abrams P, Cardozo L, Khoury S, et al., editors. Incontinence. Plymouth: Plymbrige Distributors Ltd, 2002: 165–201

    Google Scholar 

  4. 4.

    Norton P, MacDonald LD, Sedgwick PM, et al. Distress and delay associated with urinary incontinence, frequency, and urgency in women. BMJ 1988; 297: 1187–9

    PubMed  Article  CAS  Google Scholar 

  5. 5.

    Hunskaar S, Vinsnes A. The quality of life in women with urinary incontinence as measured by the sickness impact profile. J Am Geriatr Soc 1991; 39: 378–82

    PubMed  CAS  Google Scholar 

  6. 6.

    Bø K, Hagen R, Kvarstein B, et al. Female stress urinary incontinence and participation in different sport and social activities. Scand J Sports Sci 1989; 11(3): 117–21

    Google Scholar 

  7. 7.

    Nygaard I, DeLancey JOL, Arnsdorf L, et al. Exercise and incontinence. Obstet Gynecol 1990; 75: 848–51

    PubMed  CAS  Google Scholar 

  8. 8.

    Brown W, Miller Y. Too wet to exercise? Leaking urine as a barrier to physical activity in women. J Sci Med Sport 2001; 4(4): 373–8

    PubMed  Article  CAS  Google Scholar 

  9. 9.

    Bouchard C, Shephard RJ, Stephens T. Physical activity, fitness, and health: consensus statement. Champaign (IL): Human Kinetics Publishers, 1993

    Google Scholar 

  10. 10.

    Physical activity and health: a report of the Surgeon General. Atlanta (GA): US Department of Health and Human Services, Center for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 1996

  11. 11.

    Ashton-Miller J, Howard D, DeLancey J. The functional anatomy of the female pelvic floor and stress continence control system. Scand J Urol Nephrol Suppl 2001; 207: 1–7

    PubMed  Article  Google Scholar 

  12. 12.

    Lose G. Simultaneous recording of pressure and cross-sectional area in the female urethra: a study of urethral closure function in healthy and stress incontinent women. Neurourol Urodyn 1992; 11(2): 54–89

    Article  Google Scholar 

  13. 13.

    Wilson PD, Bø KH-SJ, Nygaard I, et al. Conservative treatment in women. In: Abrams P, Cardozo L, Khoury S, editors. Incontinence. Plymouth: Plymbridge Ltd, Health Publication Ltd, 2002: 571–624

    Google Scholar 

  14. 14.

    Bump R, Norton P. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998; 25(4): 723–46

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Bø K, Larsen S. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: classification and characterization of responders. Neurourol Urodyn 1992; 11: 497–507

    Article  Google Scholar 

  16. 16.

    Mørkved S, Salvesen K, Bø K, et al. Pelvic floor muscle strength and thickness in continent and incontinent nulliparous women. Neurourol Urodyn 2002; 21(4): 358–9

    Google Scholar 

  17. 17.

    Hahn I, Myrhage R. Bekkenbotten: bygnad, funktion och traning. Göteborg: AnaKomp AB, 1999: 39

    Google Scholar 

  18. 18.

    Bø K. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: methodological studies and clinical results [doctoral thesis]. Oslo: The Norwegian University of Sport and Physical Education, 1990

    Google Scholar 

  19. 19.

    Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol 1948; 56: 238–49

    PubMed  CAS  Google Scholar 

  20. 20.

    DeLancey J. Anatomy and physiology of urinary continence. Clin Obstet Gynecol 1990; 33(2): 298–307

    PubMed  Article  CAS  Google Scholar 

  21. 21.

    Miller J, Perucchini D, Carchidi L, et al. Pelvic floor muscle contraction during a cough and decreased vesical neck mobility. Obstet Gynecol 2001; 97: 255–60

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Peschers U, Schaer G, Anthuber C, et al. Changes in vesical neck mobility following vaginal delivery. Obstet Gynecol 1996; 88: 1001–6

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    Haderer J, Pannu H, Genadry R, et al. Controversies in female urethral anatomy and their significance for understanding urinary continence: observations and literature review. Int Urogynecol J Pelvic Floor Dysfunct 2002; 13: 236–52

    PubMed  Article  CAS  Google Scholar 

  24. 24.

    Peschers U, Schaer G, DeLancey J, et al. Levator ani function before and after childbirth. Br J Obstet Gynaecol 1997; 104: 1004–8

    PubMed  Article  CAS  Google Scholar 

  25. 25.

    Bump R, Hurt WG, Fantl JA, et al. Assessment of Kegel exercise performance after brief verbal instruction. Am J Obstet Gynecol 1991; 165: 322–9

    PubMed  CAS  Google Scholar 

  26. 26.

    Bo K, Talseth T. Change in urethral pressure during voluntary pelvic floor muscle contraction and vaginal electrical stimulation. Int Urogynecol J Pelvic Floor Dysfunct 1997; 8: 3–7

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Kegel AH. Stress incontinence and genital relaxation. Ciba Clin Sympos 1952; 2: 35–51

    Google Scholar 

  28. 28.

    Benvenuti F, Caputo GM, Bandinelli S, et al. Reeducative treatment of female genuine stress incontinence. Am J Phys Med 1987; 66(4): 155–68

    PubMed  CAS  Google Scholar 

  29. 29.

    Bø K, Larsen S, Oseid S, et al. Knowledge about and ability to correct pelvic floor muscle exercises in women with urinary stress incontinence. Neurourol Urodyn 1988; 7(3): 261–2

    Google Scholar 

  30. 30.

    Hesse U, Schussler B, Frimberger J, et al. Effectiveness of a three step pelvic floor reeducation in the treatment of stress urinary incontinence: a clinical assessment. Neurourol Urodyn 1990; 9(4): 397–8

    Google Scholar 

  31. 31.

    Bø K, Stien R. Needle EMG registration of striated urethral wall and pelvic floor muscle activity patterns during cough, valsalva, abdominal, hip adductor, and gluteal muscles contractions in nulliparous healthy females. Neurourol Urodyn 1994; 13: 35–41

    PubMed  Article  Google Scholar 

  32. 32.

    Peschers U, Gingelmaier A, Jundt K, et al. Evaluation of pelvic floor muscle strength using four different techniques. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: 27–30

    PubMed  Article  CAS  Google Scholar 

  33. 33.

    Sapsford R, Hodges P, Richardson C, et al. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn 2001; 20: 31–42

    PubMed  Article  CAS  Google Scholar 

  34. 34.

    Black NA, Downs SH. The effectiveness of surgery for stress incontinence in women: a systematic review. Br J Urol 1996; 78: 497–510

    PubMed  Article  CAS  Google Scholar 

  35. 35.

    Andersson K, Appell R, Awad S, et al. Pharmacological treatment of urinary incontinence. In: Abrams P, Cardozo L, Khoury S, editors. Incontinence. Plymouth: Plymbridge Distributors Ltd, 2002: 479–511

    Google Scholar 

  36. 36.

    Smith T, Daneshgari F, Dmochowski R, et al. Surgical treatment of incontinence in women. In: Abrams P, Cardozo L, Khoury S, et al., editors. Incontinence. Plymouth, UK: Plymbridge Distributors Ltd, 2002: 823–63

    Google Scholar 

  37. 37.

    Hay-Smith E, Bø K, Berghmans L, et al. Pelvic floor muscle training fur urinary incontinence in women. Available in The Cochrane Library [database on disk and CD ROM]. Updated quarterly. The Cochrane Collaboration; issue 3. Oxford: Update Software, 2001

    Google Scholar 

  38. 38.

    Bø K, Sundgot Borgen J. Prevalence of stress and urge urinary incontinence in elite athletes and controls. Med Sci Sports Exerc 2001; 33: 1797–802

    PubMed  Article  Google Scholar 

  39. 39.

    Nygaard I, Thompson FL, Svengalis SL, et al. Urinary incontinence in elite nulliparous athletes. Obstet Gynecol 1994; 84: 183–7

    PubMed  CAS  Google Scholar 

  40. 40.

    Nygaard IE. Does prolonged high-impact activity contribute to later urinary incontinence? A retrospective cohort study of female Olympians. Obstet Gynecol 1997; 90: 718–22

    PubMed  Article  CAS  Google Scholar 

  41. 41.

    Thyssen HH, Clevin L, Olesen S, et al. Urinary incontinence in elite female athletes and dancers. Int Urogynecol J Pelvic Floor Dysfunct 2002; 13: 15–7

    PubMed  Article  CAS  Google Scholar 

  42. 42.

    Eliasson K, Larsson T, Mattson E. Prevalence of stress incontinence in nulliparous elite trampolinists. Scand J Med Sci Sports 2002; 12: 106–10

    PubMed  Article  CAS  Google Scholar 

  43. 43.

    Sandvik H, Hunskaar S, Seim A, et al. Validation of a severity index in female urinary incontinence and its implementation in an epidemiological survey. J Epidemiol Community Health 1993; 47: 497–9

    PubMed  Article  CAS  Google Scholar 

  44. 44.

    Bø K, Stien R, Kulseng-Hanssen S. Clinical and urodynamic assessment of nulliparous young women with and without stress incontinence symptoms: a case control study. Obstet Gynecol 1994; 84: 1028–32

    PubMed  Google Scholar 

  45. 45.

    Hahn I, Milsom I, Ohlson BL, et al. Comparative assessment of pelvic floor function using vaginal cones, vaginal digital palpation and vaginal pressure measurement. Gynecol Obstet Invest 1996; 41: 269–74

    PubMed  Article  CAS  Google Scholar 

  46. 46.

    Gunnarsson M. Pelvic floor dysfunction: a vaginal surface EMG study in healthy and incontinent women. Lund: Lund University, 2002

    Google Scholar 

  47. 47.

    Nichols DH, Milley PS. Functional pelvic anatomy: the soft tissue supports and spaces of the female pelvic organs: the human vagina. Amsterdam: Elsevier/North-Holland Biomedical Press, 1978: 21–37

    Google Scholar 

  48. 48.

    Jørgensen S, Hein H, Gyntelberg F. Heavy lifting at work and risk of genital prolapse and herniated lumbar disc in assistant nurses. Occup Med (Lond) 1994; 44: 47–9

    Article  Google Scholar 

  49. 49.

    Fischer J, Berg P. Urinary incontinence in United States air force female aircrew. Obstet Gynecol 1999; 94: 532–6

    PubMed  Article  CAS  Google Scholar 

  50. 50.

    Davis GD, Goodman M. Stress urinary incontinence in nulliparous female soldiers in airborne infantry training. J Pelvic Surg 1996; 2(2): 68–71

    Google Scholar 

  51. 51.

    Hay J. Citius, altius, longius (faster, higher, longer): the biomechanics of jumping for distance. J Biomech 1993; 26Suppl. 1: 7–21

    PubMed  Article  Google Scholar 

  52. 52.

    Elser D, Wyman J, McClish D, et al. The effect of bladder training, pelvic floor muscle training, or combination training on urodynamic parameters in women with urinary incontinence. Nerourol Urodyn 1999; 18: 427–36

    Article  CAS  Google Scholar 

  53. 53.

    Dudley GA, Harris RT. Use of electrical stimulation in strength and power training. In: Komi PV, editor. Strength and power in sport. Oxford: Blackwell Scientific Publications, 1992: 329–37

    Google Scholar 

  54. 54.

    Vuori I, Wilmore JH. Physical activity, fitness, and health: status and determinants. In: Bouchard C, Shephard RJ, Stephens T, editors. Physical activity, fitness and health. Consensus statement. Champaign (IL): Human Kinetics Publishers, 1993: 33–40

    Google Scholar 

  55. 55.

    Bø K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999; 318: 487–93

    PubMed  Article  Google Scholar 

  56. 56.

    Indrekvam S, Hunskaar S. Side-effects, feasibility, and adherence to treatment during home-managed electrical stimulation for urinary incontinence: a Norwegian national cohort of 3198 women. Neurourol Urodyn 2002; 21: 546–52

    PubMed  Article  Google Scholar 

  57. 57.

    Norton P, Zinner N, Yalcin I, et al. Duloxetine versus placebo in the treatment of stress urinary incontinence. Am J Obstet Gynecol 2002; 187(1): 40–8

    PubMed  Article  CAS  Google Scholar 

  58. 58.

    Mørkved S, Bø K, Fjørtoft T. Is there any additional effect off adding biofeedback to pelvic floor muscle training? A single-blind randomized controlled trial. Obstet Gynecol 2002; 100(4): 730–9

    PubMed  Article  Google Scholar 

  59. 59.

    Lagro-Janssen A, Debruyne F, Smiths A, et al. The effects of treatment of urinary incontinence in general practice. Fam Pract 1992; 9(3): 284–9

    PubMed  Article  CAS  Google Scholar 

  60. 60.

    Resnick NM. Geriatric incontinence. Urol Clin North Am 1996; 23(1): 55–75

    PubMed  Article  CAS  Google Scholar 

  61. 61.

    Ostergaard D. The epochs and ethics of incontinence surgery: is the direction forward or backward? Int Urogynecol J 2002; 13: 1–3

    Article  Google Scholar 

  62. 62.

    Wall L. Innovation in surgery: caveat emptor. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: 353–4

    PubMed  Article  CAS  Google Scholar 

  63. 63.

    Hay-Smith J, Herbison P, Mørkved S. Physical therapies for the prevention of adult incontinence: a systematic review of randomised controlled trials. Melbourne: Continence Foundation of Australia, 2001

    Google Scholar 

  64. 64.

    Reilly E, Freeman R, Waterfield M, et al. Prevention of postpartum stress incontinence in primigravidae with increased bladder neck mobility: a randomised controlled trial of antenatal pelvic floor exercises. Br J Obstet Gynecol 2002; 109: 68–76

    Article  CAS  Google Scholar 

  65. 65.

    Mørkved S, Bø K, Schei B, et al. Pelvic floor muscle training during pregnancy to prevent urinary incontinence: a single blind randomized controlled trial. Obstet Gynecol 2003; 101: 313–9

    PubMed  Article  Google Scholar 

  66. 66.

    Chiarelli P, Cockburn J. Promoting urinary continence in women after delivery: randomised controlled tiral. BMJ 2002; (324): 1241–6

    Google Scholar 

  67. 67.

    Mørkved S, Bø K. The effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1997; 8: 217–22

    PubMed  Article  Google Scholar 

  68. 68.

    Sleep J, Grant A. Pelvic floor exercises in postnatal care. Midwifery 1987; 3: 158–64

    PubMed  Article  CAS  Google Scholar 

  69. 69.

    Hughes P, Jackson S, Smith P. Can antenatal pelvic floor exercises prevent postnatal incontinence. Neurourol Urodyn 2001; 20(4): 447–8

    Article  Google Scholar 

  70. 70.

    Kulseng-Hanssen S, Klevmark B. Ambulatory urethro-cystorectometry: a new technique. Neurourol Urodyn 1988; 7: 119–30

    Article  Google Scholar 

  71. 71.

    James ED. The behaviour of the bladder during physical activity. Br J Urol 1978; 50: 387–94

    PubMed  Article  CAS  Google Scholar 

  72. 72.

    Bø K, Hagen RH, Kvarstein B, et al. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: III. effects of two different degrees of pelvic floor muscle exercise. Neurourol Urodyn 1990; 9: 489–502

    Article  Google Scholar 

  73. 73.

    Sherman RA, Wong MF, Davis GD. Behavioral treatment of exercise induced urinary incontinence among female soldiers. Mil Med 1997; 162(10): 690–4

    PubMed  CAS  Google Scholar 

  74. 74.

    Pollock ML, Gaesser GA, Butcher JD, et al. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998; 30(6): 975–91

    Article  Google Scholar 

  75. 75.

    Miller JM, Ashton-Miller JA, DeLancey J. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc 1998; 46: 870–4

    PubMed  CAS  Google Scholar 

  76. 76.

    Constantinou CE, Govan DE. Contribution and timing of transmitted and generated pressure components in the female urethra: female incontinence. New York: Allan R Liss Inc., 1981: 113–20

    Google Scholar 

  77. 77.

    Glavind K. Use of a vaginal sponge during aerobic exercises in patients with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1997; 8: 351–3

    PubMed  Article  CAS  Google Scholar 

Download references

Acknowledgements

No sources of funding were used to assist in the preparation of this review. The author has no conflicts of interest that are directly relevant to the content of this review.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Prof. Kari Bø.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Bø, K. Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport. Sports Med 34, 451–464 (2004). https://doi.org/10.2165/00007256-200434070-00004

Download citation

Keywords

  • Urinary Incontinence
  • Pelvic Floor
  • Stress Urinary Incontinence
  • Pelvic Organ Prolapse
  • Duloxetine