As much as it may be something we don't like talking about, stress urinary incontinence [SUI] is something that many women will deal with at some point during their lives. Urinary incontinence can be defined as a complaint of involuntary leakage of urine, and affects between 10-55% of women between the ages of 15 to 65. Stress urinary incontinence is specific to experiencing leakage when exerting in ways which increase intraabdominal pressure. One of the risk factors that increases the likelihood of experiencing SUI, is participating in high impact physical activities, or activities that involve heavy lifting. SUI is also recognized as a detriment to women's participation in physical activity, as the stigma and embarrassment surrounding leakage in some cases may be enough to discourage participation.
Although I am in no way a pelvic health expert, I am an athletic therapist and as a woman myself, I want to do my part to educate and normalize the experience of SUI to support women in sport. Today I want to talk about what the pelvic floor is and how it plays a role in SUI, coping strategies for the physically active and next steps following the onset of SUI.
Posture, Positioning, Pressure and the Pelvic Floor
Although I am not a pelvic health specialist, I frequently have clients strengthen the inner unit core (which includes the pelvic floor) when dealing with low back pain, disc injuries, pelvic instability and more. Typically when people think of the core, they think of the big guys; the rectus abdominus (6-pack abs) and the obliques. But these muscles are prime movers of the trunk, and their key purpose is not spinal stability. The stabilizers lie deeper, and are used to create pressure within the abdominal cavity and around the spine to provide functional support. The transverse abdominus, diaphragm, multifidus and the pelvic floor work together to create support, and in the case of the pelvic floor it works to lift the lower abdominal contents, including the bladder, upwards. Relaxation of the pelvic floor also allows us to release the bladder when we wish to urinate.
The pelvic floor acts as a sling that supports the contents of the abdominal cavity, and in women, the larger opening of the pelvis, the need of muscles to relax during child birth and other factors increase the likelihood of experiencing SUI. Just as with any other muscle, there are ideal ways to train the pelvic floor to contract and as always, quality repetitions are far more productive than large quantities of poor contractions.
Although most of us are familiar with the word "kegels", some research has shown that many women activate the muscle in the opposite direction that is desired, ultimately creating a negative effect on urinary continence. Additionally, there are cases in which the pelvic floor is actually too tight, and once again performing more strengthening exercises is only going to worsen the problem. When it all comes down to it, proper evaluation and direction from a qualified professional is the best way to improve upon pelvic floor dysfunction, and I highly suggest finding a reputable practitioner if you are struggling with SUI.
In some ways it can seem like there's no winning with the pelvic floor; too tight or too weak, we might leak! And the even more frustrating part, is that the muscles of the pelvic floor need to perform actions on both ends of the spectrum to do their job. What I mean by this, is that we require the pelvic floor to maintain a strong contraction to support the body when it is producing large amounts of external force, and we require it to relax voluntarily when we wish to use the washroom or to pass gas. As with most things, it can be difficult to find a happy medium, and when the pelvic floor fails us during bouts of physical activity, we are left with leakage.
Stress Urinary Incontinence and Physical Activity
From the information I typically see surrounding the pelvic floor and SUI, it seems as though the most common demographic in which we see SUI includes women who have given birth, and post-menopausal women. The idea behind this being, that post-menopausal women experience a loss of muscle mass and weakening of muscles including the pelvic floor, and that women who have recently given birth have created trauma at the level of the pelvic floor, altering its tonicity and function. But in researching this topic, I found that physically active women, even those who have never given birth still deal with SUI. In an Australian study investigating SUI in recreationally active women in a gym setting, it was found that 49.3% of women (aged 18-83) experienced slight to moderate leakage during exercise. Furthermore, a meta-analysis (examination of many studies of the same topic to determine overall trends) of 670 studies involving 1,714 participants showed that female athletes have a 177% higher chance of experiencing SUI as compared to sedentary women. But if we associate physical activity with improved strength, how does this make sense?
As previously stated, quality contractions are crucial when it comes to training muscles, and although we can easily be told to engage the pelvic floor, what the heck does that mean? In the Australian gym study, it was found that although women who worked with trainers in some regard were made aware of the importance of pelvic floor control, they were not screened for risk factors of SUI and were not recommended pelvic floor friendly exercises where it may have been beneficial. Although cuing pelvic floor contraction was not the main purpose of this study, I would imagine that use of strong verbal cues may have been variable in this population.
In doing my own research, I visited four web pages concerning pelvic health that simply indicated that it is important to engage, or to lift the pelvic floor to strengthen and provided no recommended sets or repetitions. It was only once I clicked the link from Sydney Advanced Physiotherapy that I was able to find a list of multiple verbal cues to aid in performing proper pelvic floor exercises. If there is one thing I am sure of as a therapist, it is that not all cues work the same for each individual, and it was disappointing for me to find such little variation in cuing information for pelvic floor strengthening on most sites. And to really make this clear, telling someone how to contract a muscle by saying "contract the muscle" is not helpful if they don't know how to do so! We have to find ways to provoke the contraction without just saying "CONTRACT". Additionally, the lack of recommendations regarding sets and reps was astonishing, particularly since in recent years it has been shown that it is not beneficial to perform more than 3 sets of 15 reps of a pelvic floor contraction each day, as over strengthening may provide as much harm as not strengthening at all.
Support Strategies and Next Steps
As I said before, if you have been struggling with SUI and it is impacting your daily life, please seek professional help! If you don't know where to go, your family doctor is always a great start, and from there you may receive referrals to pelvic health specialists, urologists and the like. In the studies I reviewed, it was often found that women struggling with SUI during activity would actively void the bladder before exercise, make sure to engage the pelvic floor, wear a pad to the gym and wear dark pants to hide leaks just in case. The downside of some of these strategies, is that they may actually negatively impact the ability of the pelvic floor to prevent incontinence.
In seeing a professional, they will be able to determine the cause of your SUI, recommend physical therapy and therapeutic exercise, help you decide if the use of a pessary or incontinence tampon is a good option, or in extreme cases refer for surgery. At the end of the day, SUI during physical activity is incredibly common and should not be regarded as shameful! In normalizing this condition in athletic populations, we can work together to keep women active and provide opportunities to seek professional support. Interested in learning more? Check out the list of articles reviewed for this post, as well as links to pelvic health specialists located in Calgary. Don't let the fear of the leak keep you away from physical activity!
Kristen Huber BaKin, CAT(C)
Owner, The Gentle Athletic Therapist
Pelvic Health Calgary
Optimum Perinatal Health (for those who are pregnant, or post-partum)
References
R.V. Texeira, et al. (2018). Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis. International Urogynecology Journal. 29, 1717-1725. Web: https://link.springer.com/article/10.1007/s00192-018-3651-1
C., Fozzatti, et al. (2012). Prevalence study of stress urinary incontinence in women who perform high-impact exercises. International Urogynecology Journal. 23, 1687-1691. Web: https://link.springer.com/article/10.1007/s00192-012-1786-z
S. McKenzie, T. Watson, J. Thompson and K. Briffa. (2016). Stress urinary incontinence is highly prevalent in recreationally active women attending gyms or exercise classes. International Urogynecology Journal. 27, 1175-1184. Web: https://link.springer.com/article/10.1007/s00192-016-2954-3
K. Bo. (2004). Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Medicine. 34, 451-464. Web: https://link.springer.com/article/10.2165/00007256-200434070-00004
Urinary incontinence surgery in women: the next step. (2022). https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/in-depth/urinary-incontinence-surgery/art-20046858
What is stress urinary incontinence?. (2022). https://www.urologyhealth.org/urology-a-z/s/stress-urinary-incontinence-(sui)#Medical_Devices
Pelvic floor muscles in women. (2022). https://www.continence.org.au/who-it-affects/women/female-pelvic-floor-muscles
Pelvic Floor First. https://continence.my.salesforce.com/sfc/p/#A0000000KUc9/a/5K0000002xDC/pC824jUoNeNPvPJLFoZzyrFBX0v702SAzxdkCc2GxGY
Activating Your Pelvic Floor with Guided Visual Imagery: 8 Verbal Cues.
How many kegels should you do a day?. https://www.pelvicexercises.com.au/how-many-kegels-should-you-do/?v=3e8d115eb4b3&c=e38de74562d1