“Thanks for helping me so [that] I don’t pee at practice. You are the best!” writes my 16-year-old patient after being discharged from physical therapy. Urinary incontinence, “leaking urine” in common language, has recently been gaining attention in American culture. Kris Kardashian Jenner felt so strongly about her urinary incontinence that she became a spokeswoman for a urinary incontinence pad company. But urinary incontinence in a teenager? While it is more commonly known that women who have had children can potentially experience urinary incontinence, this sort of thing should not be happening in a teenage athlete who has never had kids, right? One would think. Let’s start with some of the basics.
The International Continence Society defines stress urinary incontinence as the “complaint of involuntary leakage on effort or exertion or with sneezing or coughing”. Prevalence of incontinence in females has been well documented in the literature over the years with some studies reporting up to 69% in the general population.1,6 This type of incontinence occurs due to the inability of the muscles and support structures in the pelvis to withstand pressure that occurs in the abdomen - known as intra-abdominal pressure - from activities such as a sneeze or cough or change in position (sit to stand). When the anatomical structure of the “core” is compromised (such as with pelvic organ prolapse or diastasis recti), this may lead directly to urinary incontinence, however, coordination of the diaphragm, pelvic floor, abdomen and back may also be disrupted as a result of or cause of these anatomical changes. This disruption of muscle synergy can also lead to stress urinary incontinence. Several risk factors for stress incontinence have been documented including increased age, being a female (who knew?), pregnancy and vaginal delivery, and physically strenuous work and exercise.
Recent research shows us that incontinence is not only highly prevalent in the female population as a whole, but that it also occurs in a young and athletic female population. In a study conducted in 2001, 41% of elite female athletes reported stress urinary incontinence at some point during their daily activities and/or sport. Nygaard et al, found that 28% of female college athletes reported at least one episode of incontinence while participating in their sport. Not all female athletes have incontinence, but sports that involve more impact are associated with increased leakage. This is the result of increased ground reaction forces passing through the body when landing after jumping and when shifting weight during pivoting movements. For example, one study found that female golfers reported no leakage but 67% of female gymnasts had some loss of urine during their daily activities. Leakage is reported at higher rates during competitions (as compared with practices), although one study reported 80% of female trampolinists experiencing leakage during training or competition.
So let’s return to the question of why my very young patient was leaking. There has been research and suggestions for the cause of urinary incontinence in female athletes. Research indicates that female athletes generally have stronger pelvic floor muscles when compared with the general population of women. Therefore, one would think that said strength would prevent loss of urine. However, there is a hypothesis that when athletes train, structural compromise - including damage to muscles, ligaments and connective tissue - may occur. This is based on the belief that higher level activities and repetitive stress on the pelvis causes overload and stretch weakness to these structures, ultimately leading to incontinence. Simply put, overuse of the structural supports for the bony pelvis (muscles, tendons and ligaments) causes them to become weak and fatigue more easily, less able to control for and modulate increases in IAP, and hence more prone to urine leakage.
How do we treat urinary incontinence in a highly trained athlete? Though not investigated specifically in female athletes, there have been several studies proving the effectiveness of a prescribed home exercise program consisting of pelvic floor muscle contractions (also known as Kegels) as treatment for incontinence. As previously mentioned, however, these muscles do not exist and operate in isolation - coordination of all neuromusculoskeletal components of the core must also be working properly to ensure continence. Therefore using an approach that seeks to identify the impairment(s) contributing the most to the athlete’s incontinence and addressing it through a combination of treatment methods (including core stabilization, stretching, and strengthening) is important. In addition to this, assessing body mechanics specific to the athlete’s sport, assuring that their core is functioning for the tasks they are completing and competing in on a regular basis, is a crucial component of treatment.
In recent years, healthcare professionals, and women in general, have broken down the wall of silence and shed some light on incontinence. With such alarming numbers of women affected by incontinence, the impact of these symptoms are difficult to measure. Consider the effects if a young female athlete avoids activity because of urine loss- the repercussions may be endless. For example, she may give up her sport, leading to inactivity. Inactivity has been clearly linked to increased weight gain, diabetes and depression. It is thus imperative to identify leakage in young female athletes early and to address it immediately to prevent progression of urinary symptoms.
Please share this with the female athletes you know and the people that care for and work with them. Let’s encourage them to speak up and maybe we can all contribute to reversing this trend before it becomes the norm.
Laura Robbins, PT, DPT Marathon Physical Therapy and Sports Medicine