Urinary Incontinence in Athletes and Exercise: More Common Than You Think

Urinary incontinence is a common problem affecting women in general and even more common among female athletes. If you have urine leakage while exercising, you’re far from alone. Exercising females in many sports experience urinary incontinence. At the same time, it’s something of a hush-hush phenomenon, perhaps because many find it embarrassing. This article looks at urinary incontinence in exercising females, what causes the problem, and what you can do about it.

What Is Athletic Incontinence?

There are several types of urinary incontinence, including the following:

  • Urge incontinence – when you experience urine leakage during or soon after a sudden and intense urge to pee.
  • Stress incontinence is when urine leaks out during physical movement, when your bladder is under pressure or during prevalence of stress. It might happen when you jump, lift something, or even cough or sneeze.
  • Overflow incontinence – your bladder leaks urine frequently or even constantly because it doesn’t empty completely.
  • Mixed incontinence – when you experience a combination of other types of urinary incontinence, most often urge incontinence and stress incontinence.

Urinary incontinence affects both sexes, but females experience it to a much higher degree than males. In a 2011 US survey, 51% of participating females reported urinary incontinence, compared to 14 % of participating males.1

Major risk factors for urinary incontinence include vaginal delivery, age, obesity, diet, repeated urinary infections, hormonal issues, and chronic bronchitis.

Females who exercise regularly experience urinary incontinence more frequently than sedentary women, even when they are not in any of these risk groups. In particular, females who participate in high-impact activities, with plenty of running and jumping, have up to eight times higher risk of urinary incontinence than non-exercising females of the same age.2 The majority of these young female athletes not experience urinary incontinence in their everyday life or when they cough or sneeze, but only when they exercise. Therefore, some researchers find that the term athletic incontinence better describes what female athletes experience.3

This article mainly focuses on athletic incontinence, not urinary incontinence in general, although there is, of course, a considerable overlap.

A 2018 meta-analysis found a high prevalence of urinary incontinence in female athletes in many different sports.4 The researchers also noted that, compared to sedentary women, active women had a 177% higher risk of urinary incontinence. The meta-analysis looked at female athletes regardless of their training level and experience, but the more advanced you are, the higher your risk for urinary incontinence.

Elite female athletes are often at a high risk.5 Among professional athletes, urinary incontinence is more or less common, depending on the type of sport. Female athletes engaging in low-impact sports, sports without running or jumping, report fewer problems with incontinence during training or competition. Only 6% experience athletic incontinence. Compare that to the 80% of females competing in high-impact sports, like trampolining, at a high level.

Females who lift are no exception. A comprehensive survey of 134 competitive female powerlifters show that more than 40% at some point experienced urinary incontinence during training or competition.6 Only 11% of them reported urine leakage during everyday activities outside of powerlifting. One study looking at female CrossFit classes found that more than 80% of the women experienced problems with urine leakage.7 Urinary incontinence does not seem to be that prevalent among competitive female CrossFit-athletes, but we’re still talking about more than 40%.8

In summary, urinary incontinence is a widespread problem, both among females in general and to an even higher degree among females who exercise.

What Causes Athletic Incontinence?

The two most common causes of female urinary incontinence are pelvic floor dysfuntion as in weak pelvic floor muscles or an overactive, overloaded pelvic floor.

Sure, you work out hard in the gym or on the track, but that does not necessarily translate to a strong pelvic floor. When you perform regular gym exercises, it doesn’t keep up with your legs, back, or biceps. Your pelvic floor consists of muscles stretching from your pubic bone to your tailbone and from one of your sitting bones to the other, almost like a hammock. If your pelvic floor muscles aren’t strong enough, targeting them with dedicated exercises helps prevent urine leakage and incontinence Pelvic floor exercises have no serious side effects and are a good first course of treatment if you experience urine leakage, even if studies documenting the effectiveness usually look at untrained women.9

By strengthening your pelvic floor, you learn to control those muscles when you need them, like when you lift something or exercise, thus preventing urine leakage. They also grow in size when you train them, much like how other muscles react to strength training. That gives you permanent structural support of your pelvic organs without having to think about it consciously.10

However, weak pelvic floor muscles are not necessarily the root cause of your problems if you’re already physically active. One study found stronger pelvic floor muscles in incontinent female athletes compared to their continent counterparts.11 All of the women experiencing athletic incontinence had complete control of their pelvic floor. That indicates that some other reason than a weak pelvic floor or failure to control it properly might be causing the issue.

Female athletes report more significant or more frequent urine leakage towards the end of their workouts or competitions.12 Even when their pelvic floor muscles are strong enough, they might not have sufficient endurance to withstand prolonged and exhausting training sessions.

The leading physical cause of urine leakage is an increase in abdominal pressure, followed by a contraction of the abdominal muscles without activating the pelvic muscles first.13 In other words, you lift or exert yourself, and your abdominal pressure increases. However, you haven’t adequately flexed the muscles supporting your uterus or, in this context, your bladder, first.

When you’re lifting weights, your intra-abdominal pressure increases significantly, and the heavier the weight, the higher the pressure.14 Lifting just 5 lbs increases your abdominal pressure significantly, which is nothing compared to the weights you use in the squat, deadlift, or bench press. Also, many lifters use a lifting belt and hold their breath to improve stability.15

The combination of high intra-abdominal pressure and a heavy load strains the pelvic floor muscles. It is probably one of the reasons why experienced female lifters experience incontinence during training and competition more often than inexperienced lifters. Even though their pelvic floor might be stronger, they also lift much heavier weights, exposing it to greater forces.

Recent research introduced the concept of a “continence threshold,” the time your pelvic floor can withstand the demands of your training or the repeated impacts of running and jumping. When you pass that threshold, the pelvic floor muscles become exhausted, weakened, and less effective, especially if you haven’t prepared them by exercising them specifically.

Training intensely and frequently might lead to your pelvic floor being in a constant state of exhaustion. In that case, exercises that relax the proper muscles are likely more helpful than exercises that further exhaust them. In other words, identifying the cause of the problems is essential to treat them properly.

According to another hypothesis, frequent high-intensity physical work or exercise causes micro-damage to the pelvic floor muscles or stretches them out too much, making them incapable of controlling your bladder when it’s under pressure.16 However, there is not much scientific support for this hypothesis.

Low Energy Availability and Athletic Incontinence

Low energy availability, meaning you don’t eat the number of calories you need to meet your training demands, is closely associated with several problems related to health and performance in exercising females. We’re talking about the female athlete triad, with menstrual dysfunction, weaker bones, gastrointestinal issues, and muscular weakness and endurance.

Recently, a cohort study with 1,000 female participants between the age of 15 and 30 identified low energy availability as an independent risk factor for athletic incontinence.17 The researchers found that, as expected, young athletes participating in high impact sports with a lot of running and jumping often reported athletic incontinence. However, they also noticed that urine incontinence was much more prevalent among women with relative energy deficiency, women who didn’t eat enough regardless of activity or sport. So, if your diet isn’t on point or you don’t eat enough calories, you increase your risk of athletic incontinence. Correcting that might be a good first course of action if you’re having problems with urine leakage. If nothing else, eating enough benefits your health and training in so many other ways. Of course, low energy availability as a result of an eating disorder might require professional help to deal with.

Read more: Performance Nutrition: Eating for Exercise Excellence

How Do You Manage Athletic Incontinence?

As we said before, identifying the underlying reason for athletic incontinency is a good starting point. If your pelvic floor muscles are too weak, you can expect improvements or even solve the problem by strengthening them with the proper exercises. However, if your pelvic floor is in some kind of overtrained state, where it can’t handle the stress of your training, maybe you need to learn how to relax it and let it recuperate more between workouts.

In both cases, it’s all about controlling your pelvic floor muscles. Gaining that control isn’t always easy. We’re not talking about muscles you can see and feel the same way as when you flex your biceps. A physical therapist specializing in women’s health can identify the problem, help you control your symptoms, and give you a course of action with the proper exercises.18 19 20

As an athlete, you benefit more from physical therapy compared to untrained women with urinary incontinence.21

A training program for urinary incontinence should be adapted to your individual body. Therefore, it’s probably better to seek professional help than to experiment on your own. It’s not dangerous or harmful to do pelvic floor exercises without professional guidance, and there are no serious side effects. However, if you embark on a pelvic floor strengthening program without the need for one, you might not notice any improvements in your condition either. Health care providers like a physical therapist or sports medicine physician focusing on women’s health can adapt the training to your needs and help you relax the pelvic floor muscles instead if that’s the proper course of action in your specific case.

In general, pelvic floor exercises are effective in managing urinary incontinence. Unfortunately, no randomized controlled studies look at female athletes specifically. It’s a conclusion based on the overall female population. Of course, it’s reasonable to expect the same results in athletes, but as with your other muscles, you shouldn’t train the same way regardless of your needs and goals. It’s risk-free, though, so feel free to try an exercise program for pelvic floor training if you, for any reason, don’t want to seek professional help.

You can find basic instructions for pelvic floor training at the US National Library of Medicine website.22 There are also many other more or less comprehensive general guides to help you strengthen the muscles controlling your bladder both during everyday life and during a training session. The only problem is that they are just that: general, not necessarily the optimal approach for you.

Conclusion

Urinary incontinence and urine leakage are prevalent among female athletes and females who exercise in general. It’s a common issue in many sports, but women who engage in running, jumping, and lifting report urine leakage to a higher degree. Here at StrengthLog, we focus primarily on strength training, but athletic incontinence affects women in most, if not all, physically demanding sports.

Even though this article provides you with the reasons for athletic incontinence and what you can do about it, my main hope is that it helps spread awareness of this phenomenon. If you’re experiencing urinary incontinence, you are far from alone. Also, it’s not something to be ashamed of. Unfortunately, shame is one of the main reasons preventing women from seeking help. It’s not something you talk about.23 Now that’s a shame. There is help to be had. Urinary incontinence means a lower quality of life, both in your daily life and during training and competition. Also, it’s a source of frustration and worry for many women living a healthy lifestyle. I hope this article can improve awareness of how common athletic incontinence actually is and make the issue less problematic and taboo.

References

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  3. ]Rev. Bras. Ginecol. Obstet. 39 (09), Sept 2017. Athletic Incontinence: Proposal of a New Term for a New Woman.
  4. International Urogynecology Journal volume 29, pages 1717–1725 (2018). Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis.
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  6. International Urogynecology Journal volume 30, pages 2031–2039 (2019). Prevalence of urinary incontinence in women powerlifters: a pilot study.
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  10. Int Urogynecol J Pelvic Floor Dysfunct. Mar-Apr 2004;15(2):76-84. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work?
  11. International Urogynecology Journal volume 30, pages 693–699 (2019). Assessment of abdominal and pelvic floor muscle function among continent and incontinent athletes.
  12. ]Arch Med Sci 2021;17(2):314–322. How to balance the treatment of stress urinary incontinence among female athletes?
  13. Sports Medicine volume 34, pages 451–464 (2004). Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport.
  14. Am J Obstet Gynecol. 2008 Mar;198(3):306.e1-5. Intraabdominal pressure changes associated with lifting: implications for postoperative activity restrictions.
  15. Journal of Strength and Conditioning Research: August 2013 – Volume 27 – Issue 8 – p 2338-2345. The Valsalva Maneuver: Its Effect on Intra-abdominal Pressure and Safety Issues During Resistance Exercise.
  16. ]Sports Medicine volume 34, pages 451–464 (2004). Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport.
  17. J Pediatr Urol. 2021 Jun;17(3):290.e1-290.e7. Low energy availability and impact sport participation as risk factors for urinary incontinence in female athletes.
  18. Supplement to the Dutch Journal of Physical Therapy, Volume 121 · Issue 3 · 2011. Guideline for Physical Therapy in patients with Stress urinary incontinence.
  19. Journal of Physical Therapy Science 2014 Volume 26 Issue 9 Pages 1493-1499. Physiotherapy for Women with Stress Urinary Incontinence: A Review Article.
  20. Synopsis in the Management of Urinary Incontinence. Physiotherapy in Women with Urinary Incontinence.
  21. J Clin Med. 2020 Oct; 9(10): 3240. Benefits of Physiotherapy on Urinary Incontinence in High-Performance Female Athletes. Meta-Analysis.
  22. Pelvic floor muscle training exercises
  23. Int J Gynaecol Obstet. 2011 Jul;114(1):60-3. Prevalence and impact of urinary incontinence among female athletes.
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Andreas Abelsson

Andreas has over 30 years of training experience and is a highly appreciated writer and educator on exercise, fitness, and nutrition. Few people stay more up to date and have a better grasp of the field of exercise science than Andreas.