Pelvis Problems: Athletic Urinary Incontinence

Hey again, Scarleteen readers! It’s Caitlyn the pelvic health PT here, back for another installment of Pelvis Problems. This time, we’re focusing on urinary incontinence (aka bladder leaks) during physical activity.

Ads on TV often give the impression that bladder leaks only happen to old ladies who’ve had a bunch of kids. However, urinary incontinence (UI) happens to people of all ages, genders, and activity levels. There are many different types of UI, but one of the most common types affecting young people occurs during physical activity and athletics – hence the term “athletic urinary incontinence."

Let me start by emphasizing that I use the title “athlete” broadly. Culturally, we’re often taught that “athletes” are very specific types of people: the NFL quarterback on that TV commercial, or the Olympic gymnast on the Wheaties cereal box. They look a certain way, live a certain way, and participate in just a few well-established sports. For this piece, I’d like to break away from this concept. If you physically move your body for the purpose of exercise, wellness, art, and/or joy, you’re an athlete. If you hike, dance, go to kickboxing classes, take your dog for jogs around the block, whatever – you’re an athlete.

Now that we’ve set the stage, let’s dive in and learn more about this common pelvis problem!

What is athletic UI, and how common is it?

A variety of pelvic floor dysfunctions can occur in athletes of all ages and genders. Today, however, we’ll be focusing on athletic UI, as it’s the most common complaint.

Medical organizations define urinary incontinence broadly as the involuntary leakage of urine. Athletic UI is a subtype of UI that occurs specifically when participating in sports or physical activities. Athletic UI has been identified in people participating in a wide variety of physical activities, from gymnastics and cheerleading to track & field to weight-lifting.

While athletic UI can occur regardless of one’s sex⁠ or gender⁠ , it is most common in people with vaginas. Compared to folks with penises, people with vaginas are nearly 5.5 times more likely to experience athletic UI. When compared with sedentary people, vagina owners participating in athletics are 177% more likely to experience UI.

Adolescent athletes with vaginas are most prone to a specific type of UI called stress urinary incontinence, or SUI. As the name implies, SUI occurs when the bladder and pelvic floor muscles are placed under stress. The high-impact forces of running, jumping, and other explosive movements all put stress on the pelvic floor.

Heavy lifting also challenges the pelvic floor: when you pick up something heavy, the pressure inside your abdomen naturally increases. This increased pressure creates a downward force on your bladder and pelvic floor.

Most forms of athletics and vigorous physical activity place stress on the pelvic floor in one or both of these ways. When these stresses overwhelm the capacity of the pelvic floor muscles, bladder leaks can occur. If you’re looking for more information on your pelvic floor and what it does, check out⁠ my article on the pelvic floor here!

UI is classified as athletic UI if the leakage occurs specifically while training for or competing in a physical activity/sport. Here are some estimates for the prevalence of athletic UI across various common sports:

Sport or Activity Percentage of participants with athletic UI
Track & Field 52% (F), 19% (M)*
Running 44%
Gymnastics & Cheerleading 67%
Rhythmic Gymnastics 32%
Soccer 50%
Basketball 35%
Volleyball 76%
Cross-country skiing 46%
Olympic weightlifting & powerlifting 50% (F), 9% (M)*

*These studies separated their analyses according to biological sex – i.e., athletes assigned female or male at birth.

Great, thanks, Caitlyn, you may be thinking. Now I know all the pelvic floor problems that sports and exercise can cause. But I don’t want to give up my activities! Am I just doomed to leak pee for the rest of my life?!?

Definitely not! I’m providing these stats solely to help readers understand how common this issue is. Fortunately, there are plenty of ways to improve athletic UI, which we’ll discuss later.

What causes athletic UI?

If you’re really active and strong, it can be hard to understand why you might develop athletic UI. Caitlyn, I’m working my muscles all the time at practice – how can my pelvic floor possibly be too weak to stop me from leaking?!?

Well…it turns out that it’s not quite as simple as brute strength. All the other things that help you in your athletic endeavors—flexibility, agility, endurance, coordination, etc.—are also important for the function of your pelvic floor.

You can think of your torso as a can of soda. The “walls” of this can are formed by different muscle groups.

  • Bottom of the can: the pelvic floor muscles (PFM)
  • Cylinder/sides of the can: the deep abdominals and the small stabilizing muscles of the spine.
  • Lid of the can: the diaphragm (the “breathing muscle” below the lungs)

In a perfect world, these muscles should work together in harmony to control the pressure inside the can and keep all the soda inside. In reality, though, this doesn’t always happen. Sometimes, imbalances between muscle groups and changes in internal pressure can overwhelm one part of the can so it’s no longer able to do its job. More often than not, the bottom⁠ of the can (the pelvic floor) is the part that gets overwhelmed.

As we discussed above, many physical activities increase stress on the PFM in various ways. Continent people (who don’t leak any pee) are able to automatically (unconsciously) activate their PFM to respond to these increased stresses.

If the PFM aren’t activating sufficiently or at the correct time, they are unable to keep the urethra⁠ —the tube where pee comes out—properly closed. Pee can then leak out of the partially open urethra, like soda leaking from a can with a hole poked in the bottom.

In order to keep the bottom of the soda can closed, the pelvic floor muscles need the correct combination of strength, agility, coordination, endurance, and flexibility. However, just like any other muscle group in the body, the pelvic floor muscles can develop imbalances.

Researchers who specialize in athletic incontinence have two competing hypotheses about the changes that occur in the pelvic floors of athletes*:

  1. The PFM become stronger and bulkier in response to athletic training. This increased strength creates better support for the pelvic organs, but it can also complicate activities that require the pelvic floor muscles to stretch and lengthen (like childbirth and some types of sex).
  2. The PFM become overstretched and overloaded by repetitive, high-intensity athletic activities. This can make things like childbirth easier, but it can also lead to leaks and other problems due to a lack of sufficient support.

*Note that the vast majority of this research centers on athletes who were assigned female sex at birth (AFAB). While these issues also affect their male-assigned counterparts (AMAB), there is less research regarding athletic UI in AMAB folks.

In fact, it may be a combination of both situations: AFAB athletes often have thicker, bulkier pelvic floor muscles, but also a wider opening between them (the levator hiatus). While bulkier muscles may be stronger than smaller ones, they also tend to be less springy and agile, and therefore less able to respond to sudden changes in pressure. (Imagine a muscle-bound bodybuilder who can barely touch their toes.) This combination of muscle stiffness and increased opening size may help explain why some athletes struggle with urinary leakage during training and competition.

However, these training-induced changes to the PFM aren’t the only contributing factors. Researchers have identified many other risk factors that can predispose people to athletic UI, such as:

  • Chronic constipation
  • A history of recurrent urinary tract infections (UTIs)
  • A family history of urinary incontinence
  • Eating disorders
  • Stiff arches in one’s feet

Among AFAB cheerleaders and gymnasts, additional factors may contribute, including:

  • Training 4 or more days per week
  • Age (UI is most common for athlete aged 16 & 17)
  • Straining/pushing to pee

How does athletic UI impact performance and quality of life?

Athletic UI, like most forms of involuntary leakage, can have a definite impact on mental health and confidence for those it impacts. People with athletic UI commonly report embarrassment, fear of leakage, and frustration related to their symptoms.

Athletes who leak report lower levels of self-esteem and decreased wellbeing compared to their peers who don’t leak. These athletes worry that leaks will be visible or will make them smell like urine. All of these side effects impact their overall quality of life and their participation in their chosen activity.

Some athletes report that leakage can cause them to lose concentration while participating in their sport. Reduced concentration can impair athletic performance and even increase the risk of injury

For some athletes who leak, the negative impacts of UI are so substantial that they choose to decrease participation or quit their sport(s) altogether. Decreased physical activity can then lead to all sorts of ill effects on both physical and mental health – we all know how important exercise and movement are for our health!

For these reasons, it’s very important that athletes have strategies to address and improve athletic UI. Let’s discuss treatment options next!

How can I improve athletic UI?

We’ve just discussed that staying active is important for your overall physical and mental health, so simply quitting athletics often isn’t the best choice. However, this doesn’t mean you have to just “put up” with athletic UI. I have good news: athletic UI can and does improve with some relatively simple interventions.

There’s no “quick fix” for athletic UI. Experts agree that surgery and/or medications are not the solution for athletes who leak during training and competition. That being said, there are other treatments that work, and they are less invasive and much lower risk than surgical or medical interventions.

Excuse me for a moment while I toot my profession’s horn: current research overwhelmingly supports pelvic floor muscle training (PFMT) as a front-line treatment for people* with athletic UI. Researchers who review the evidence for various medical treatments have awarded PFMT with a “Grade A recommendation” for addressing athletic UI. This is the highest level of recommendation a treatment approach can receive – basically, it means that PFMT is very effective!

Additionally, athletes who undergo PFMT typically experience more improvement in their symptoms than sedentary folks. Most of this data comes from research on elite athletes, rather than those participating at a more recreational level. In my clinical experience, however, I’ve found that people who regularly participate in any form of exercise tend to learn and progress more quickly with PFMT than inactive folks.

*Recall that the vast majority of current research on the treatment of athletic UI focuses primarily on athletes born with vaginal anatomy⁠ . As such, we must use caution when applying this information to people born with penises and the trans community.

What exactly is PFMT?

Perhaps you’ve heard the word “kegels”. This term was first used in the late 1940s by an American gynecologist (whose last name was—you guessed it—Kegel). He taught his patients to strengthen their pelvic floor muscles with repeated contractions. He found that this helped reduce urinary leakage and other pelvic floor problems. He coined the term “kegels” to describe these contractions, thereby cementing his place in medical history.

Nowadays, many people assume that kegels and PFMT are one in the same, but I beg to differ. Pelvic PTs often do teach pelvic floor muscle contractions, but we apply them in very specific ways to create comprehensive training programs.

Training the pelvic floor is just like training other muscles in the body: you need to work on strength, endurance, flexibility, agility, coordination, and more. Pelvic PTs teach people to contract, relax, and lengthen their pelvic floor muscles in a variety of patterns and body positions.

Once someone understands the basics of PFMT, we have them replicate these exercises during movements that simulate what they do during daily life. For athletes, this includes the movements they perform while participating in their chosen sport/activity. PFMT should be prescribed and dosed at a level that corresponds to an individual’s physical functioning and abilities.

Clinically, pelvic PTs will often combine PFMT with other interventions for maximum benefit. These may include breathing exercises, lifestyle/habit modifications, and techniques to improve movement quality while participating in their sport(s). In some cases, manual (hands-on) treatments can also be helpful to reduce tissue tension and address imbalances that impact the pelvic floor.

In short, a healthcare provider⁠ giving you a handout and telling you to “just do your kegels” does NOT constitute PFMT. For pelvic floor training to be maximally effective, it needs to be taught and prescribed by a pelvic rehab professional, not a pamphlet.

Where do I go for help with athletic UI?

If you’re looking for a pelvic PT near you, the Pelvic Rehab website is one great place to start: you can search by zip code to find professionals in your area. If you live far away from the nearest pelvic PT, don’t despair: more and more practices are offering fully remote and hybrid options for pelvic PT consults and care.

If you’re worried about cost, you can always ask about sliding scale payment options – many practices offer this and other options for folks with lower incomes. I’ve found that motivated people with athletic UI often only need a few visits to learn the basics and some progressions – then they’re able to continue their rehabilitation independently.

Side note: If you’re a minor, be sure to mention your age when scheduling. Many pelvic PTs are happy to work with teens, but they may require a parent or adult guardian to accompany you to appointments.

However you decide to proceed, remember: you are not alone. Athletic UI can and does improve with the right treatment – it’s one pelvis problem that has a definite cure!

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