Pelvic floor dysfunction (PFD) is a collection of signs, symptoms and conditions affecting the pelvic floor and urinary incontinence (UI) is the most common type of PFD. Recent systematic reviews have indicated a higher prevalence of UI among female athletes compared to their non-athletic counterparts. To date, no review has been undertaken to investigate female athletes’ experiences of PFD. This review aims to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report elite female athletes’ experiences of symptoms of PFD.
Methods
The review protocol was registered in PROSPERO in August 2020. A systematic search was conducted in Embase, MEDLINE (OVID), Cochrane Library, CINAHL, PsycINFO and Web of Science for studies published in the English language reporting elite female athletes’ experiences of symptoms of PFD. This review included primary research studies that involved elite female athletes of any age or ethnicity.
Results
Of the 1922 citations retrieved in the search, 32 studies met the methodological criteria for data extraction and analysis. Five main themes emerged: (1) triggers for symptoms of PFD; (2) strategies adopted by athletes to manage/mitigate symptoms of PFD; (3) impact on QOL/daily life; (4) impact on performance; (5) impact on emotions.
Conclusions
The findings of this review suggest a need to further explore the experiences of PFD among elite female athletes and it is suggested that future research should adopt qualitative methods or incorporate a qualitative component.
Hinweise
*Please note: The findings from a preliminary search conducted in May 2020 were presented at the International Continence Society 2021 Conference, 14 to 17 October 2021, https://www.ics.org/2021. However, findings from the updated search conducted in January 2022 are presented in this submission and have not been presented or submitted elsewhere)
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Introduction
Pelvic floor dysfunction (PFD) is a collection of signs, symptoms and conditions that affect the pelvic floor [1]. Urinary incontinence (UI), the PFD most commonly experienced by women, is defined as a ‘complaint of involuntary loss of urine’ and is a common complaint in women of all ages. The most common types of UI include stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). The International Urogynecological Association (IUGA) and the International Continence Society (ICS) define SUI as the ‘complaint of involuntary loss of urine on effort or physical exertion (e.g., sporting activities), or on sneezing or coughing’ and UUI as ‘complaint of involuntary loss of urine associated with urgency’ [1]. Other symptoms of PFD include anorectal dysfunction (ARD), sexual dysfunction (SD), pelvic organ prolapse (POP) and pelvic pain [1, 2]. Many women find it embarrassing to discuss symptoms of PFD including continence problems with others and incontinence has been shown to negatively affect quality of life [3‐5].
Mendes et al. [6] conducted a systematic review of qualitative evidence regarding adult women’s experiences of UI. Findings from the 28 included studies were grouped into eight themes in the areas of: cultural and religious backgrounds; effect on daily activities/social roles; knowledge and nature of symptoms; experiences of UI and sense of shame; negative effects on intimacy, sexuality and sexual function; UI seen as consequence of pregnancy/childbirth, aging or religious punishment; strategies adopted by women affected by UI; meeting of care needs and women’s personal preferences. The authors concluded that the preferences and expectations of women with UI should be considered and that the provision of healthcare should be personal and tailored. A need for additional research to improve the understanding of the impact of UI on the quality of life (QOL) of younger women was identified [6].
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UI during exercise is not uncommon and a higher prevalence has been observed among athletes engaged in high-impact sports including running and jumping [7]. Rodríguez-López et al. [8] investigated the prevalence of UI in both female and male elite athletes and found an overall prevalence of 33% (45.1% in females, 14.7% in males) and that, whilst the prevalence of UI was 5.45 times greater in females, elite male athletes were also found to experience UI.
There have been a number of recent systematic reviews concerning PFD in female athletes [9‐14]. However, the main aim of these reviews has been the investigation of the prevalence of UI in female athletes. Almousa and Bandin Van Loon [9] included a secondary aim of exploring the knowledge and attitudes of female athletes regarding UI [9] and de Mattos Lourenco et al. [10] discussed strategies adopted by the athletes to manage their UI. The reviews differ somewhat in their inclusion criteria regarding age and parity, but they all concluded consistently that there was a higher prevalence of UI among female athletes compared to non-athletes. Engaging in high-impact sports [9, 10, 12, 14] with longer hours of training [9] appears to be commonly cited as risk factor for UI, but to our knowledge, no review has been undertaken to investigate female athletes experiences of PFD. Studies have found that experiencing UI during elite sports may be a predictor of UI in later life [15] and also that elite athletes have been identified as an understudied population in the research into PFD and, in particular, ARD and POP and physical activity [16].
Whilst a scoping review of the research literature revealed limited qualitative research into the area of PFD among female athletes, such research may, potentially, yield further information regarding the impact of the symptoms of PFD on the female athletes’ sporting activities and their daily lives.
Therefore, this review aimed to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report the experiences of symptoms of PFD in elite female athletes.
With the assistance of a medical librarian (DM), the electronic databases of Embase, MEDLINE (OVID), Cochrane Library, CINAHL, PsycINFO and Web of Science were searched, initially in May 2020 and subsequently in an updated search in January 2022 for studies that reported female athletes’ experiences of incontinence/symptoms of pelvic floor dysfunction. The search terms include the following: Wom?n, Femal*, urinar* continen* or incontinen*, Pelvic Organ Prolapse, Urinary leakage, leaking urine, vaginal wind, anal incontinen*, f?ecal incontinen*, Bladder leakage, bowel leakage, Flat* incontinen*, Physical* ADJ (activ* or inactiv* or exercise), recreational* ADJ (activ* or inactiv* or exercise), Exercis* ADJ (strenuous OR vigorous OR moderate)), Activit* ADJ (strenuous OR Vigorous OR moderate OR Leisure), sport*, Participat*.ti, ab., Modif*.ti, ab., Stop*.ti, ab., Adapt*.ti, ab., Change*.ti, ab., Limit*.ti, ab., Abandon .ti, ab., Ceas*.ti, ab., Barrier.ti, ab., Impact.ti, ab., Affect.ti, ab.
This review included primary research studies published in the English language that reported elite female athletes’ experiences of symptoms of PFD. Inclusion criteria were: (1) studies that involved female athletes of any age or ethnicity and studies that included both female and male athletes together when data on female athletes could be extracted; (2) studies involving female athletes who were considered to be at an ‘elite’ level. For the purposes of this review ‘elite’ could refer to athletic performance at regional/county/state level; sport/country-specific measures and university/collegiate, international and/or national level; training; professionalism; involved in talent development and (3) studies that reported the experiences of symptoms of PFD and how this affects activities of daily living or sporting activity or quality of life (QOL). This information could be gleaned from questions included in a quantitative survey or qualitative interview-based research. Exclusion criteria were: (1) studies involving only recreational or leisure-time exercisers; (2) editorial opinion articles, letters and commentaries and (3) studies that did not report on the experiences of symptoms of PFD.
Study selection and assessment of methodological quality
Two reviewers (ECQ and DD, ECQ and NF) independently screened studies using the inclusion/exclusion criteria based on titles, then abstracts and then full texts. Covidence software (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org) was used for the process of screening and identified agreement between reviewers. Disagreement between two reviewers was resolved by consultation with a third reviewer.
Thomas et al. [20] devised a 12-point quality assessment criteria checklist that facilitated assessment of quantitative, qualitative and mixed methods studies. Subsequently, Panda et al. [21] developed a modified version of this checklist that was used to assess the methodological quality of this reviews included studies. Each criterion was scored ‘1’ if met and ‘0’ if not met, and three categories of methodological quality were identified: ‘weak’ (scores 0–6), ‘moderate’ (scores 7–9) and ‘strong’ (scores 10–12).
Data extraction and data analysis
A double independent data extraction was conducted on the studies selected for inclusion (ECQ and DD, ECQ and NF).
Information was extracted and entered into a pre-designed extraction form in relation to the following study characteristics: authors; journal, year of study/publication, number of participants, participants’ characteristics, description of sport or athletic activity, methods of data collection, data collection instruments/tools, description of symptoms, methods of analysis and reporting of experiences concerning symptoms of PFD.
Information regarding athletes’ experiences of PFD was extracted from closed questions included in validated QOL instruments from closed questions and open-ended qualitative comments in questionnaires or from analysis of comments from focus group interviews.
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There was insufficient qualitative information to carry out a meta-synthesis of the findings regarding the reporting of experiences. Thematic analysis occurred by organising the findings into themes that were tabulated and then further analysed [22]. Descriptive themes were developed. An iterative process was repeated until the themes were considered to be representative and answered the research question.
Results
Selection and quality of the studies
A total of 1922 studies remained after deduplication, 123 were screened at full-text and 32 studies met the inclusion criteria (Fig. 1). Of these, three studies were of weak quality [23‐25], 28 studies were of moderate quality [8, 26‐52] and one was of high quality [53].
Descriptive analyses of the studies excluding information relating to the reporting of experiences
A summary of the study characteristics excluding the reporting of experiences is presented in Appendix 1. Studies were conducted in 14 countries and published between 1994 and 2021. Over half of the studies reporting on the experiences of PFD in the review were published within the last 5 years (56%, 18/32 studies) [8, 27‐29, 32, 36, 38, 39, 42, 45‐53]. Fifteen studies involved nulliparous participants [23, 24, 26, 27, 29, 31, 35, 37‐39, 41, 42, 44, 45, 53] and 15 studies included both nulliparous and parous participants [8, 25, 28, 30, 32‐34, 36, 40, 43, 46, 48, 50‐52]. Two studies did not report information on parity of participants [47, 49].
Thirty-one of the 32 studies used a quantitative design and only one study by Jácome et al. used a mixed methods design (questionnaire and focus group) [40]. None of the studies in this review used a qualitative design only and there was considerable heterogeneity in study designs. Seven studies utilised purposively designed questionnaires [30, 33‐35, 37, 43, 44] whilst the remaining 25 used or incorporated validated instruments. The most commonly used survey instrument was the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF), which was used in 13/32 (31%) of the studies [8, 26‐29, 31, 32, 38, 39, 42, 46‐48].
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UI was the most commonly reported symptom of PFD and reported in all 32 of the studies. Twenty-two studies specifically described the prevalence of UI according to type, with SUI reported as the most prevalent in 21/22 studies [8, 23, 24, 26, 28‐30, 32‐36, 38, 40‐43, 45‐48]. Mixed urinary incontinence (MUI) was reported as the most prevalent form of UI in one study by Cardoso et al. [27]. Anorectal dysfunction (ARD) was reported in nine studies with the prevalence of constipation/straining to defecate reported in all of these studies [8, 26, 28, 29, 31, 32, 34, 46, 47] and anal incontinence (AI) reported in four studies [26, 29, 46, 47]. The prevalence of sexual dysfunction (SD) was reported in two studies [26, 29], the prevalence of POP was reported in four studies [26, 29, 41, 46] and the prevalence of pelvic pain was reported in two studies [24, 45].
Experiences of pelvic floor dysfunction
Information regarding female athletes’ experiences of PFD was extracted from closed questions included in validated QOL instruments, from closed questions and open-ended qualitative comments in questionnaires and/or from analysis of comments from a focus group. The findings regarding the experiences of the athletes were grouped into five main themes (Table 1) and are summarised below. As previously mentioned, there was insufficient qualitative information to perform meta-synthesis of the findings.
Table 1.
Athletes’ experiences of PFD: triggers reported for symptoms of PFD, strategies adopted by athletes to manage/mitigate/report symptoms of PFD and impact on QOL/daily life, performance and emotions (NR = not reported)
Study
Triggers for symptoms of PFD
Strategies adopted by athletes to manage/mitigate symptoms of PFD
Second part of training sessions-86.67% (13/15) reported that it happened only in the second part of training Competition-38.6% (17/44) reported UI Second part of competitions-58.8% (10/17) UI only in the second part of competition
Majority of athletes did not speak to anyone about UI-84% (37/44)
Type of movement/activity in sport-SUI occurred most often among these athletes when performing “double unders” 67% (36/54) and “triple unders” 86% (48/56)
Strategies used by retired RS with UI during RS (survey 2)
Voiding before events-72% (46/64)
Voiding between events-71% (45/63)
Using containment, e.g. pads or tampons-38% (24/63)
Limiting fluid intake-20% (12/61)
Sought treatment for UI-0%
Only one female athlete identified that SUI was one of eight reasons for retiring from RS
Slight impact of UI on QOL-median ICIQ-UI-SF score in incontinent athletes was 4 (IQR 3–6), indicating a slight impact of UI on their overall QOL
Affected sports performance-some
athletes stopped participating in “double
unders” and “triple unders” events because of SUI
Attrition from participation in ‘double unders’ and ‘triple unders’ due to SUI was 6% in competition; 16% in practice
28% (39/138) of athletes connected leakage with specific exercise- high jumps or somersaults especially double ones
Training- athletes reported UI occurred more often during training (p = 0.022)
Coughing, laughing- (numbers not specified); on way to the toilet- (numbers not specified); during other physical activities- (n/n unspecified)
Protective pads- 78 % (45/58) competitive athletes (CG) used sanitary pads, and this was significantly more than recreational group (RG) 43 % (34/80) (p < 0.001)
Discussed their leakage- 72% (n = 99/138) of athletes (Competition Group & Recreation Group) had discussed their leakage with someone, most of them with friends, team coach or parents
Affected daily life-when experiencing UI during trampolining-36% (20/85) competitive athletes were affected in their daily life
61% (31/85) were affected psychologically
Affected sports performance-
12%, (n = 16/133) of athletes (Competition Group & Recreation Group) had stopped trampolining due to the leakage
Physical activity (PA)- slight UI on PA- in 6.14% sportswomen (n/n unspecified)
NR
Significant negative effect on QOL-
Significant negative correlation was observed between SUI and the overall I-Qol questionnaire score (r = 0.522, p < 0.001)
Affected sports performance- Significantly worse parameters were recorded in the group of sportswomen (r = 0.648, p < 0.001) in the I-QoL in sub-scales ‘avoidance & limiting behaviour score’
Embarrassment-
Significantly worse parameters recorded in the sportswomen in the I-QoL in sub-scales- psychosocial impact score & social embarrassment score (p < 0.001)
Jumping/legs apart (30%), Jumping with legs together (28%), Running (30%), Impact on floor during dismount/after flips 14%).
Daily Activities (excluded leaking ‘rarely’)
Coughing- 15%, sneezing- 6%, heavy
lifting- 3%, walking to the bathroom- 29%, sleeping- 6%, on hearing running water- 11%
Use of pad-
Only one woman stated that she wore a pad because of the urine loss
Discussed their leakage-(n/n unspecified)
Almost half of the athletes discussed the incontinence with a teammate, < 5% had discussed the UI with a trainer, coach, physician, nurse or family member
NR
NR
Embarrassment-
38% of the athletes felt embarrassed
Anxiety 22% describing anxiety, fear-6% expressed fear about the condition (n/n unspecified)
Athletes who leaked urine reported more hours of training/week (p = 0.008). For every additional hour of training, the risk of UI increased by 15.3% (2.9%–29.3%, 95% CI)
Use of pad-
None of the athletes disclosed use of any incontinence products or pads during exercise
Discussed their leakage/Sought treatment-
Only one athlete had discussed her UI with a health professional
None of players had received any treatment for UI
Several players 18% (9/51) were interested in receiving treatment for their urinary incontinence
Degree of bother associated with UI
% Of players who reported that UI was ‘not a problem/only a small problem’:
Training& Competition- - Most women with SUI reported UI during training- 91.5% (75/82)
and more than half during competition 56.1% (46/82)
Body mass index was the only factor found to have a significant positive association with SUI
Triggers for AI
Training and competition-
Gas AI- 89.1% (123/138) experienced leakage during training or competition
Liquid AI- 23.8% (14/59)
Solid AI- 15.4% (2/13)
Level of competition international level of competition was positively associated with AI
Time spent training:
AI-weightlifting training of <4 days per week had a significant negative association
Strategies to manage UI (n/82)
Use of pad-
54.9% (45/82) reported the use of pads to protect against visible leakage and 7.3% (6/82) used intravaginal tampon
Voiding before sports activity-
86.6 (71/82) voiding before training or competition
Restriction of fluids-
13.4% (11/82) decreased fluid intake
Performance of PA in restricted way-
19.5% (16/82) reported they would occasionally avoid training or specific exercises because of UL
Discussed their leakage/sought treatment-
25.6% (21/82) had never spoken about the condition with anyone
Pelvic floor muscle training (PFMT)-
42.8% (77/180) women did not know why and 44.4% how (80/180) to train the PFM
78.3% (141/180) women responded they would do PFM training to prevent or treat PFD if they knew how
Degree of bother associated with UI
ICIQ-UI-SF -Mean impact of UI on daily activities was 1.8 (SD: 2.0, range: 0–9), with 11 (12.2%) scoring ≥ 5
Degree of bother associated with AI
Of women reporting AI, the mean bother of accidental loss of gas, liquid and solid stool was 2.3 (SD: 2.5, range: 0–9), 2.0 (SD: 2.5, range: 0–9) and 2.2 (SD: 2.8, range: 0–9), respectively
The percentage of women scoring ≥ 5 on bother was
Gas AI- 15.9% (22/138)
Liquid stool- 15.3% (9/59)
Solid stool- 15.4% (2/13)
Affected sports performance –
87.8% (72/82)) of those with SUI reported a negative effect of UI on sports performance
Impact of SUI
Loss of concentration- 51% (42/82)
Fear of visible leaking- 59% (48/82)
Fear of Urine odour- 34% (28/82)
Embarrassment- 33% (27/82)
Negative effect on performance- 27% (22/82)
Feeling frustrated, annoyed or worried- 24% (20/82)
Type sport -Proportion of SUI was significantly lower in cheerleaders compared to artistic gymnasts (and team gymnasts (p < 0.001)
Type of movement/activity in sport (n = 210)
Running- 4% (8/201)
Jumping- 50% (101/201)
Take-off to a gymnastic or acrobatic element- 67% (135/201)
Land from a gymnastic or acrobatic element- 60% (121/201)
In air during a gymnastic or acrobatic element- 13% (26/201)
Trampoline or trampolette- 51% (103/201)
Training& Competition-
Most athletes with SUI reported leakage during training – 98% (198/201)
44.8% during competition (90/201)
Triggers for AI
Years with specialization in gymnastics/cheerleading was the only variable found to be positively associated with AI
Training and competition-
Gas- 87.6% (227/259) experienced leakage during training and/or competition: 38.2% (99/259) rarely, 35.1% (91/259) occasionally, 12% (31/259) often and 2.3% (6/259) all the time
Liquid AI- 22.3% (29/130) experienced leakage during training and/or competition; 18.5% (24/130) rarely and 3.8% (5/130) occasionally
Solid AI- 17.9% (7/39) reported leakage during training/competition, all experienced it rarely
Strategies to manage UI (n/201)
Use of pad-
28.4% (57/201) reported use of pads to protect against visible leakage and 4.5% (9/201) used intravaginal tampon
Voiding before sports activity-
66.7% (134/201) prevoiding training/competition
Restriction of fluids-
8.5% (17/201) decreased fluid intake
Performance of PA in restricted way-
22.4% (45/201) reported they would occasionally avoid training or specific exercises because of UL
Discussed their leakage/sought treatment-
26.4% (53/201) had never spoken about UI
13 (6.5%) had spoken with their coach and 12 (6.0%) with health care personnel, 115(57.2%) had spoken about UI with their teammates, 76 (37.8%) with friends and 40 (19.9%) with a parent
Pelvic floor muscle training (PFMT)-
0.9% (3/319) reported they did or had tried PFMT
41.4% (132/319) of the athletes had never heard about the PFM.
73.7% (230/319) women responded they would do PFMT to prevent or treat PFD if they knew how
12.2% (39/319) of the athletes reported that they had heard about the PFM from their coach, 10% (32/319) (from teammates, 19.1% (61/319) from health personnel and 16.9% (54/319) from other sources (friends, siblings or parents)
The mean self-rated knowledge of the PFM was 1.5 (SD: 1.7) of 10. Thirty-two (10.0%) knew how and 58 (18.2%) why to train the PFM
Impact on daily life associated with UI
ICIQ-UI-SF score mean impact of UI on daily activities was 2.5 (SD: 2.4, range: 0–10), with 46 (21.4%) scoring ≥ 5
AI
Of females reporting AI, mean bother of accidental loss of gas, liquid and solid stool was 3.0 (SD: 2.6, range: 0–10), 2.3 (SD: 2.3, 0–10) and 2.4 (SD: 2.4, range The number of athletes scoring ≥ 5 on bother 0–10) was respectively:
Gas AI – 26.6% (69/259)
Liquid stool- 15.4% (20/130)
Solid stool- 15.4% (6/39)
Affected sports performance –
82.6% (166/201) of those with SUI reported a negative effect of UI on sports performance
Impact of SUI
Fear of visible leaking- 66% (133/201)
Embarrassment- 65% (131/201)
Fear of Urine odour- 51% (103/201)
Fear of leakage happening- 39% (78/201)
Loss of concentration- 31% (62/201)
Feeling frustrated, annoyed or worried- 29% (58/201)
Negative effect on performance- 18% (9/201)
Making more mistakes -11% (22/201)
Impact of SUI
Fear of bowel leakage happening- 49% (13/)
reported that they sometimes or more often were worried about bowel leakage
38.3% (n = 173/452) experienced UI during training and/or competition as well as daily life
17.7% (80/452) experienced UI during training and/or competition but NOT in daily life
Type of movement/activity in sport-
High impact high repetition activities involving jumping and running activities most likely to cause UI - Jumping rope 39.16% (177/452), Double-unders 36.95% (167/452), Trampoline 25.00% (113/452), Running/Jogging 20.57% (93/452)
Activities least likely to provoke UI were low impact, body weight activities such as lunges
UI during high repetition sets- 28.7% (N = 60/208)
End of session
50% (30/60) indicated that UI was most likely to occur at the end of high repetition sets
Intensity-
28.2% (N = 59/208) of incontinent women reporting UI during heavy sets
Pelvic floor muscle training (PFMT)-
73.6% (n = 153/208) of participants who had experienced UI at some point had never undergone a pelvic floor assessment.
26% (n = 54/208) of women who reported UI at some point in their life were not confident in their ability to correctly perform pelvic floor exercises
Training and competition- 23.1% (111/480) had experienced ‘athletic incontinence’
17.9% of women (86/480) had been continent before commencing powerlifting now UI in training or competition but not during everyday activities (Type 1 athletic incontinence)
5.2% (25/480) had UI before commencing powerlifting but are now continent during everyday activities while continuing to experience UI during training or competition (Type 2 athletic incontinence)
Type of movement/activity in sport-
30.6% (147/480) experienced UI in competition during maximum lift attempts
40.4% (194/480) experienced UI in training during maximum lift attempts
12.5% (60/480) during sumo deadlifts
35.2% (169/480) during high repetition sets
End of session- 64.5% (109/169) stated UI worse at end of sets
Intensity- 79.3% (N = 134/169) indicated that UI was only an issue if the sets were heavy
Strategies to control or minimise UI were listed under the following headings (no. N = or % given):
Bracing related- Modifying technique, ± belt use, ± PFEs
16.2% (31/191) of weightlifters reported ‘type one athletic incontinence’
17.8%, (34/191) UI in competition i
25.7%, (49/191) UI in training 25.7%, (49/191)
Type of movement/activity in sport-
57.1% (40/70) experienced urinary leakage during high repetition sets
Max. effort lift in competition 16.8% (32/191)
Max. effort lift in training 24.6%, (47/191)
Wearing a belt provoked UI n 3.7% (7/191)
Intensity- 67.5% (27/40) of these women indicated that leakage was only an issue if the sets were heavy
End of session- 50% (20/40) who experienced UI during high repetition sets stated that the leakage was more likely to occur at the end of the set
Strategies to control/minimise UI (no. N =, % given)
Antibiotics for recurring urinary tract infections, yoga and Pilates, emptying bladder before training and frequent urination during training sessions/competitionsEngaging pelvic floor before lifting Focusing on breathing, bracing core before lifts, trying to not over brace, wearing a pad, using a tampon or avoiding the use of tampons, practicing pelvic floor exercises outside training, release work/massage, focus on pelvic mobility, core training, not overtightening belt, wearing dark-coloured clothing, maintain a low body mass, crossing legs before sneezing
Sought treatment- 24.3% (17/70) of those with UI had undergone a pelvic floor assessment
Pelvic floor muscle training (PFMT)- 77.1% (54/70) of those with UI stated that they were confident/very confident in their ability to perform pelvic floor exercises
NR
NR
NR
Key findings highlighted in bold
Theme 1: Triggers for symptoms of PFD
The first theme Triggers for symptoms of PFD was reported in 30/32 (94%) of the studies. ‘Competition, training and physical activity’ was the most common trigger reported in 26/30 studies [8, 25‐32, 34, 35, 37‐40, 43‐52]. In 7/26 studies [28, 30, 35, 49‐52], the PFD occurred at the end/latter part of the competition or training session. ‘Specific movements during activity (sporting and daily life)’ was the next most common trigger reported in 16/30 studies [8, 23, 32‐36, 40, 44‐47, 49‐52]. Being ‘on the way to toilet/sudden need to go to toilet’ was reported as a trigger in 5/30 studies [23, 33, 34, 40, 44] suggesting symptoms of mixed urinary incontinence (MUI).
Theme 2: Strategies adopted by athletes to manage/mitigate symptoms of PFD
The second theme Strategies adopted by athletes to manage/mitigate symptoms of PFD was reported in 23/32 (72%) of the studies. The ‘use of pads/containment strategies’ was the most commonly identified strategy reported in 16/23 studies [25, 27, 28, 32, 34, 35, 37, 41, 43‐48, 51, 52]. Fourteen of the 23 studies found that athletes ‘Discussed condition with others/sought help’. However, very few participants discussed/sought help for their PFD with a health professional [23, 25, 27, 30, 32, 34, 40, 43‐47, 51, 52]. ‘Increased frequency of urination/pre-voiding/voiding during events’ were strategies adopted by athletes in 10/23 studies [26, 32, 33, 35, 37, 40, 46, 47, 49, 52] and ‘fluid restriction’ was reported in 9/23 studies [25, 27, 32, 35, 37, 40, 46, 47, 51]. ‘Modification or avoidance of certain activities/movements’ was reported in 7/23 studies [23, 40, 46, 47, 49, 51, 52]. Pelvic floor muscle exercises/training (PFMEs/PFMT) was a strategy used by participants in 7/23 studies [25, 46, 47, 49‐52].
Theme 3: Impact of PFD on QOL/daily life
The third theme Impact on QOL/daily life was reported on in 18/32 (56%) of the studies. The findings were diverse. Hagovska et al. [39] described a significant negative correlation between athletes’ prevalence of SUI and overall I-Qol score, and Eliasson et al. [34] reported that, as a result of their PFD, 36% (20/85) of the trampolinists were affected in their daily lives and 61% (31/85) were affected psychologically. However, the majority of the studies (16/18) reported that, for most of the participants, PFD did not have a marked impact on the athletes’ QOL/daily life [8, 23‐25, 27, 31, 32, 38, 40‐42, 45‐48, 53].
Theme 4: Impact on performance
The fourth theme Impact on performance was reported on in 12/32 (38%) of the studies. One study reported that PFD ‘did not impact performance’ [27]. The remaining 11/12 studies reported that PFD had an ‘effect on some of the athletes’ performance’ [28, 32, 34, 36, 38‐40, 46‐48, 53] and 6 of these studies reported that some athletes had stopped an activity or limited their behaviour/activity in their sport [32, 34, 36, 39, 40, 43].
Theme 5: Impact on emotions
The fifth and final theme Impact on emotions was reported in 9/32 (28%) studies. The following negative emotions in some athletes were reported as a consequence of PFD: ‘embarrassment’ in 6/9 studies [31, 35, 39, 44, 46, 47]; ‘fear’ in 5/9 studies [38, 40, 44, 46, 47]; ‘concern/anxiety/worry’ in 5/9 studies [40, 44, 46‐48]; ‘annoyance’ in 4/9 studies [40, 46‐48]; finally, ‘frustration’ was an emotion reported by some athletes in in 3/9 studies [40, 46, 47].
Discussion
The primary aim of this review was to investigate the experiences of symptoms of PFD in elite female athletes. There was heterogeneity in study designs including a wide variety of athletic/sporting activity and most of the information regarding the athletes’ experiences came from quantitative research studies where the athletes’ experience of PFD was not the main focus. This was predominantly quantitative research involving questionnaires. Only one mixed methods study by Jacome et al. [40] included a qualitative component to elicit athletes’ experiences and this involved a relatively small focus group (n = 7). It is notable that > 50% of the studies were published within the last 5 years and this may indicate an increased interest in understanding the impact of PFD on athletes. Five main themes were identified and only three studies contributed findings to all five themes. Two of these were recent studies by Skaug et al., which, in addition to investigating prevalence, also investigated the impact and bother of PFD on powerlifters and weightlifters [46] and cheerleaders and gymnasts [47]. The third study was the mixed methods study by Jacome et al. [40].
Systematic reviews regarding female athletes and PFD to date have predominantly focused on the prevalence of UI in female athletes [9‐13]. As prevalence was not the main focus of the current review, the prevalence reported here was only that relating to those studies reporting elite athletes’ experiences of PFD and does not allow direct comparisons with previous reviews regarding prevalence of PFD in athletes.
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The fact that UI was reported in all the studies in this review was not surprising as UI is the most common form of PFD [54]. Similar to reviews by de Mattos Lourenco et al. [10] and Rebullido et al. [14], the ICIQ-UI-SF was found to be the most commonly utilised survey instrument. The prevalence and experiences of other forms of PFD including POP, ARD, sexual dysfunction and pelvic pain reported in the studies were also identified in this current review and it is notable that in all previous systematic reviews concerning athletes to date only the prevalence of UI was analysed. It is suggested that future systematic reviews should consider including the prevalence of other types of PFD to provide a more complete picture of PFD in these athletes. Bø and Nygaard [16] in a narrative review concerning physical activity and PFM function, identified AI and POP as understudied research outcomes.
This current review included only studies involving ‘elite’ athletes. Swann et al. [55], in a systematic review that aimed to evaluate how sports psychology research has defined elite athletes, identified eight broad categories of an ‘elite or expert athlete’. These included experience, international and/or national level, training, professionalism, involved in talent development, regional level, sport/country-specific measures and university. Williams et al. [56] suggested that for team sports, the recommendation for defining ‘elite' is that success in highly competitive leagues and competitive experience should be given priority over international experience. In this current review we used a definition of ‘elite’ based on the recommendations from the above literature. It remains difficult, however, to find a consistent definition of the term ‘elite’ as it refers to athletes. Almousa and Bandin Van Loon [9], in a systematic review investigating the prevalence of UI in nulliparous female athletes, highlighted that many studies failed to use level of sports (professional, amateur) to classify the participants.
The fact that ‘competition, training and physical activity’ was most commonly reported as a trigger for symptoms of PFD followed by ‘specific movements during activity (sporting and daily life)’ may not be surprising. Such activity may cause an increase in intra-abdominal pressure, impact the pelvic floor and is associated with SUI [1], the most prevalent type of PFD reported in this review. However, questions surrounding the effect of physical activity and exercise on the pelvic floor remain unresolved in the research literature and a need for further high-quality research to fill the gaps in knowledge concerning the role of strenuous physical activity in symptoms of PFD has been identified [16]. It is also be suggested that that future research regarding triggers for symptoms of PFD and when the symptoms occur in female athletes should be conducted as this may help inform the design of a pathway pelvic floor muscle (PFM) rehabilitation programme for such athletes.
In seven of the studies the PFD was reported as presenting in the second half/latter part of training or competition, and this may point to PFM fatigue. Previous research has suggested that, while some uncertainty remains regarding the extent to which PFM fatigue affects UI, the development and/or worsening of UI may be influenced by PFM fatigue [57‐59].
In this review the studies that reported on strategies adopted by athletes to manage/mitigate symptoms of PFD indicated that, whilst many athletes reported wearing pads, pre-voiding and restricting fluids, few appeared to seek attention from a health professional. Similarly, de Mattos Lourenco et al. [10] also reported strategies to prevent UI including use of pads, pre-voiding and limiting fluid intake and suggested that reasons why athletes do not discuss the condition or seek help may include the fact that they feel ashamed or perceived that it is normal or inevitable at their age. Another possible reason may be that the athletes consider that their use of some strategies such as pre-voiding may be sufficient to manage their UI. Interview-based, qualitative research may assist in investigating this issue further.
UI is a treatable condition. Recent research has shown that PFMT in young continent women resulted in improved muscle activation and pelvic floor muscle strength [60]. Findings of a Cochrane review [61] have shown that PFMT can cure or improve all types of UI but is most effective in SUI. Similar to the findings of other reviews, we suggest that it is important to provide education resources for athletes regarding symptoms and treatment options for PFD and educate the professionals (health professionals and coaches/trainers) involved with these athletes about the prevalence of PFD in athletes and increase screening for symptoms [9, 10, 12, 13].
In this current review the findings regarding the impact of PFD on female athletes’ QOL/daily life were quite varied and consequently no conclusion can be reached. Future research could include systematic reviews of UI and QOL in athletes and conducting qualitative research may deepen knowledge and understanding of the impact and experiences of PFD on female athletes’ QOL and daily life. UI has been shown to have a considerable impact on women’s lives [6] and have an adverse effect on QOL [3, 5]. A systematic review and meta-analysis on UI and QOL in both sexes reported that UI was associated with poor QOL, but an acknowledged limitation of the review was that only cross-sectional and case-control studies were included [4].
The fact that 11/12 studies reporting on the impact of PFD on performance reported that it had an effect and, that some athletes had stopped or limited their activity during their sport, is of concern. A need for further research to investigate the mechanisms causing PFD in athletes has been identified [38]. It would also be interesting to evaluate if athletes who limit their sporting activity because of PFD have considered seeking or have sought treatment for their symptoms. Further mixed-methods or qualitative, interview-based research may assist in investigating this issue in athletes.
Only nine (28%) studies in this review reported on the impact of PFD on the athletes’ emotions and there was limited information given in some of these studies. Embarrassment was the most frequently reported emotion followed by fear, concern and anxiety. It is important that athletes are educated regarding PFD and the treatment options available to help allay, mitigate and resolve some of these negative emotions surrounding UI. Mendes et al. [6] reported that UI is a condition that can involve embarrassment, stigma and distress in women. Once again, we suggest that further qualitative, interview-based research may assist in investigating the impact of PFD on the athletes’ emotions.
Limitations
Limitations of this review included the heterogeneity of the study designs, the inclusion of studies published in the English language only and that the prevalence reported in this review only referred to the prevalence of PFD in studies that reported on female athletes’ experiences of PFD. However, the main limitation of this review was the paucity of qualitative evidence that was available in the research literature concerning athletes’ experiences of PFD.
Conclusion
This review explored the experiences and impact of PFD in elite athletes and found a relative paucity of qualitative evidence. Five main themes were identified. Further qualitative and mixed methods, sports-specific research may serve to deepen knowledge and understanding of elite female athletes’ experiences and impact of PFD on athletes’ sporting activities and their daily lives and enrich the understanding of this condition in women competing at an elite level.
Recommendations for qualitative research include further investigating:
The impact of PFD on elite female athletes’ emotions
Why do many elite female athletes not discuss their PFD with others?
Triggers for PFD reported by elite female athletes
Strategies adopted by elite female athletes to manage/mitigate their PFD
Why do many elite female athletes not seek help from a health professional?
Do elite female athletes who limit their sporting activity due to PFD seek treatment?
Declarations
Conflicts of interest
None
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To investigate occurrence of symptoms of PFD among young female nulliparous athletes and nonathletes, paired by BMI. Also, influence of sport modality on occurrence and severity of urinary dysfunctions
Cross-sectional study
163 (67 athletes & 96 non-athletes, paired by BMI)
Volleyball, swimming, judo,
artistic gymnastics trampoline.
Nulliparous
Age range = 15 to 29 years
Mean age (± SD) years - athletes 18 (± 5), non-athletes 21 (± 4)
Questionnaire:
background information, sports practice and UI questions
Included questions extracted from ICIQ-UI-SF, ISI, FSFI, Rome III, ICIQ-VS
Descriptive statistics
Mann-Whitney test, chi-squared test, Fischer exact test, odds ratio
To evaluate the prevalence of UI in female elite athletes of different sports compared to age-matched controls and to investigate possible risk factors for UI
Cross-sectional study
N = 744 (372 elite athletes & 372 age-matched controls)
Variety (n = 28) Sub-divided
(G1 technical G2 endurance, G3 aesthetic
G4 weight
G5 Ball games, G6 Power
G7 gravity)
Nulliparous and parous
Age range = 15 to 48 years. Median age = 19 years for both athletes and controls
Questionnaire:
Section 1 - background information; Section 2 - medical, obstetric & gynaecological and UI history
To investigate the occurrence of urinary, anal, sexual and POP symptoms as well as symptoms originating from premenstrual syndrome in women who practice cheerleading
Cross-sectional study
N = 156 (78 cheerleaders & 76 nonathletes)
Athletes - high-performance cheerleaders, nulligravida, normal weight (BMI between 18.5 and 24.9 kg/m2)
Control group - nonathletic female university students
Nulliparous
Age range = 15 to 29 years, mean age (± SD) years - athletes 20.8 (± 2.3), non-athletes 21.9 (± 2.4)
Questionnaire:
background information, sports practice and UI questions
ICIQ-UI-SF
Questions extracted from KHQ, FISI, FSFI, ICIQ-VS, MSQ
Descriptive statistics
Shapiro-Wilk test (to confirm normality of data), Mann-Whitney test, odds ratio
a. UI - 26.9%
UI overall prevalence 26.9% (21/78)
UI - 47.6% (10/21) during training
SUI - 66.7% (14/21) was the most prevalent
UUI - 9.5% (2/21)
MUI - 23.8% (5/21)
b. ARD
AI - 62.8% (49/78) and was most prevalent symptom of PFD
To assess the prevalence of UI in elite athletes versus the general population and to analyse the condition of occurrence of urine loss
Survey- epidemiological athlete/
non-athlete study
N = 583 (157 elite athletes & 426 controls)
Athletes from volleyball, swimming, rugby, handball, basketball, football, 'other'. Controls from ‘Physicians & Occupational Networks’. Nulliparous and parous
Age range = 18 to 35 years Mean age (± SD) years - athletes 23.37 (± 4.5), non-athletes 25.06 (± 4.6)
Questionnaire:
A validated survey for use at a hospital clinic. Medical, obstetrical, gynaecological history, physical activities, including type of sports and duration of activities and UI
To investigate in young nulliparous female trampolinists hypothetical associations between the level of athletic performance and the volume of training with urine leakage
Cross-sectional cohort study
N = 22
Trampolinists, classified as elite and non-athlete. Nulliparous
Age range = 14 to 25 years, mean age (± SD) - 18.1 (± 2.4)
Questionnaire: background information, sports practice and UI questions
ICIQ-UI-SF
Descriptive statistics
Shapiro-Wilk test, Kruskal-Wallis H test, Spearman rank correlation test
To determine prevalence, impact and management of stress urinary incontinence (SUI) among rope-skipping (RS) athletes. First survey aimed at identifying
prevalence, impact and management strategies of SUI among current RS athletes. Second to determine whether SUI
contributes to athletes’ decisions to retire from RS participation
To determine the prevalence of UI in female collegiate athletes as compared to the prevalence in age-matched controls and to determine if there was a difference in the prevalence of UI among various sporting activities. Also examined strategies to prevent or manage UI in this population
To describe the occurrence of urinary leakage in young and mostly nulliparous women with a history of regular organised trampoline training as adolescents and to identify possible risk factors
Cross-sectional study
N = 305 [85 'competition' group (CG) & 220 'recreational' group (RG)]
Female ex-trampolinists in Sweden with licence for trampolining between 1995–1999
Nulliparous and parous
Median age = 21 (range 18–44) years
Questionnaire:
Questionnaire designed and validated for study of UI in young nulliparous/primiparous women
To establish the prevalence of SUI among elite female rugby union players within Australia. Study further analysed rates of SUI between participants playing in the forward and back positions, self-reported consequences of SUI on athletic performance during a game or training session and the percentage who believed SUI to be a reason for withdrawing from rugby union in the future
Cross-sectional study
N = 65
Elite female rugby union players from the Australian Rugby Union
To verify the effectiveness of the pelvic floor muscle rehabilitation programme (PFMRP) in female volleyball athletes, analysing the amount and frequency of urinary leakage
Experimental
N = 32 [16 experimental group (EG) & 16 control group (CG)]
Volleyball athletes with symptoms of SUI
Nulliparous
Mean age ± SD (range) years - EG 19.4 ± 3.24 (16–25); CG 19.1 ± 2.11 (17–26)
1.Questionnaire:
Baseline information
2. Pad test
3. Urinary diary assessment of frequency of UL
Descriptive statistics
Shapiro-Wilk, Student’s t-test, chi-squared test, Fischer exact test
a. UI
All participants in the study reported symptoms of SUI
To investigate the prevalence and risk factors for UI in rhythmic gymnasts and the impact of UI on performance and their knowledge of the pelvic floor and PFM training
Cross-sectional study
N = 107
Rhythmic gymnasts
Nulliparous
Age range = 12 to 21 years, mean age (± SD) years - 14.5 (± 1.6)
1.Questionnaire:
Background information, influence of UI on sports practice,
To determine the prevalence of SUI symptoms in sportswomen (high-intensity physical activity) and non-sportswomen (low-intensity physical activity), according to estimated intensity of physical activity in metabolic equivalents using the IPAQ questionnaire. Another goal was to identify relationships among SUI symptoms, intensity of PA & QOL
Cross-sectional study
N = 557 (270 sportswomen & 287 non-sportswomen)
Women from university sport clubs at national levels. No further detail regarding types of sport
Nulliparous
Mean age all (± SD) years 20.9 (± 2.8), sportswomen 20.7 (± 3.3); non-sportswomen 21.1 (± 2.3)
To investigate the prevalence of UI in a group of female athletes and to explore the impact on their lives by identifying their emotions regarding urine loss and techniques used to reduce UI episodes
Cross-sectional survey &
focus group
N = 106
Track and field athletes, basketball, indoor football
Nulliparous and parous
Mean age (± SD) = 23(± 4.4) years. Range not given. Inclusion criteria for age ≥ 18years and < 45years
1.Questionnaire:
(N = 106)
Background information/sports practice; UL characterisation; risk factors for UI
2. Focus group (N = 7) Non-directive manner, semi-structured guide
To measure and compare PFM strength in competition-level athletes and untrained women and evaluate the women's ability to contract the PFMs correctly and to explore frequency of SUI and assess the women's knowledge and awareness of PFMs
Case control study
N = 34 (18 athletes & 16 untrained women)
Various sports (handball, soccer, gymnastics, badminton, weightlifting, bootcamp, crossfit)
Nulliparous
Women, age range = 18 to 30 years. Mean age (± SD) years = athletes 24.2 (± 3.2), untrained 24.1 (± 2.9)
Nulliparous
1. Questionnaire:
Background information, exercise training, knowledge of PFMs
To determine the prevalence of the symptom of urinary incontinence during athletic endeavours among a group of nulliparous, elite college varsity female athletes
Questionnaire designed for the purpose of the study
Descriptive statistics
Student’s t-test, chi-squared test, Fisher exact test
a. UI - 49%
UI was reported by 49% (71/144) of the female athletes
28% (40/144) athletes admitted to at least one episode of UI while practicing or competing in their sport. Other bladder symptoms noted during competition included:
To determine whether women engaged in strenuous, provocative exercise are more likely to be incontinent in future life than similarly fit women who participated in less provocative exercise
Retrospective cohort study
N = 104
Ex-Olympian low-impact (swimming) and high-impact sports (gymnastics, track & field athletics). Nulliparous and parous
Mean age (range) years - low-impact group 42.4 (30–54), high-impact group 46.2 (30–63)
Questionnaire:
Questionnaire designed for the purpose of the study
Total of 35.8% (19/53) high-impact athletes (3 could not recall) and 4.5% (2/44) low-impact athletes, 4 could not recall (swimmers) reported having UI during their time as Olympians
Currently - SUI - 41.1% (23/56) high-impact athletes and 50% (24/48) low-impact athletes (swimmers) reported SUI currently
UUI - 33.9% (19/56) high-impact athletes and 16.7% (8/48) low-impact athletes (swimmers) reported UUI currently
To investigate the effects of pelvic floor muscles training in elite female volleyball athletes and whether it is an effective therapy for stress urinary incontinence
Randomised controlled trial
N = 13 athletes (7 in experimental group (EG) & 6 in control group (CG)
Volleyball athletes
Nulliparous
Mean age ± SD (range) years - experimental group 22.7 1± 4.99 (18–30), control group 21.83 ± 5.19 (18–31)
1.Questionnaire:
Questionnaire background sociodemographic and anthropometric data, KHQ
2. Pad test
3. Pelvic floor muscle strength measurement by perineometer
Descriptive statistics
Shapiro-Wilk test, Levene, M Box test, Student’s t-test, ANOVA
a. UI (SUI) - 61.5%
UI was reported by 61.5% (8/13) of the female athletes at initial evaluation (both CG & EG)
To determine the prevalence of SUI in a group of elite female endurance athlete. Also, to compare the SUI rates in the groups of female cross-country skiers and runners to determine whether the training weather conditions like temperature and humidity might also influence the prevalence of UI
Cross-sectional study
N = 112 Female endurance athletes (57 cross-country skiers and 55 runners)
Cross-country skiers
Runners
Nulliparous
Mean age (± SD) years = cross-country skiers 26.61 (± 4.41), runners 29.49 (± 6.02).
Questionnaire:
Short form of the UDI-6
Descriptive statistics
Chi-squared test
a. UI - 50%
UI was reported by 56/112 (50%) of the female athletes
SUI -45.54% (51/112)
UUI - 27.68% (31/112)
MUI - 18.75% (21/112)
Frequency - 58.04% (65/112)
Bladder-emptying problems - 33.04% (37/112)
e. Pelvic pain
pain or discomfort in lower abdominal or genital area 36.61% (41/112)
Overall - no statistically significant differences were noted between the groups
To determine the prevalence of urinary incontinence (UI) among elite athletes and to compare prevalence between sexes and across different sports modalities
Observational, cross-sectional study
N = 455 female athletes (total N = 754 elite athletes; females n = 455 and males n = 299)
To determine the prevalence of urinary incontinence among female university varsity rugby players. Secondary objectives are to understand when the incontinence occurred and to assess the degree of bother experienced
Cross-sectional study
N = 95
Female rugby players
Nulliparous
Mean age (± SD) years = 19.9 ± 1.8
Questionnaire:
Background information - age, height, weight and hours spent training was obtained
A specific rugby-related activity questionnaire was developed. Degree of bother, previous treatment, desire for treatment, when incontinence occurred and coping strategy
UDI -6
Descriptive statistics. Unpaired t-test
Linear regression
a. UI - 54%
UI was reported by 51/95 (54%) of the female athletes
SUI - 82% (42/51)
UUI - 39% (20/51)
Bladder-emptying problems - 16% (8/51)
e. Pelvic pain
pain or discomfort in lower abdominal or genital area 26% (13/51)
To investigate prevalence and risk factors for PFD powerlifters and Olympic weightlifters. Furthermore, to investigate the impact and bother of PFD and knowledge of the PFM
Cross-sectional study
N = 180 females (total N = 384 females n =180 and males n = 204)
Top national & international level male & female powerlifters & Olympic weightlifters
Nulliparous and parous
Mean age weightlifters SD (range) years - female lifters 31.0 weightlifters 10.7 (18–65)
(Males - 34.0 weightlifters 13.5 (18–84))
Questionnaire:
Background information - age, body mass index [BMI], parity, training frequency, level of competition, years specialising in sport, generalised hypermobility, straining at toilet, female athlete triad, knowledge of PFM
ICIQ-UI-SF
Questions from:
ICIQ-B for AI,
ICIQ-V for POP
LEAF-Q
Descriptive statistics
Shapiro-Wilks
Odds ratio (OR)
Logistic regression
a. UI female athletes - 50%
UI was reported by 90/180 (50%) of the female lifters
To investigate the prevalence of and risk factors for UI and AI in high-performance female artistic gymnasts, team gymnasts and cheerleaders and to investigate the bother of UI and AI, influence of SUI on sport performance and the athletes’ knowledge of the pelvic floor muscles (PFM)
Cross-sectional study
N = 319
(n = 68 artistic gymnasts, n = 116 team gymnasts, n = 135 cheerleaders)
Artistic gymnasts,
team gymnasts, cheerleaders
at the top national junior and senior level in Norway
To assess the prevalence of UI in federated female athletes (federative sports license). In addition to observing urine leakage in the study subjects according to the sport discipline of athletics and age, the methods of containment, the characteristics of leakage and the risk factors that may lead to UI were analysed. Biopsychosocial component of UI in this group of athletes was also analysed
Cross-sectional study
N = 63
Athletics
5 categories:
1.Long-distance running
2.Speed events 3. Middle distance races
4. Jumping events
5. Throwing events
Nulliparous and parous
Mean age ± SD (range) years –
30.78 ± 12.16 (18–61)
Questionnaire:
KHQ
ICQ-UI SF
Descriptive statistics
Chi-squared test
Student’s t-test
a. UI - 44.4%
28/63 women (44.4%) reported UI
SUI -89.3 %, (25/28) (25% reported coughing and sneezing and 64.3% reported coughing and sneezing during physical exercise)
To determine the prevalence of urinary and athletic incontinence and establish which activities and contexts were most likely to provoke urine leakage in women CrossFit competitors
Cross-sectional study
N = 452
Women CrossFit competitors
Nulliparous and parous
Mean age ± SD (range) years –
36 ± 9 (20–63)
Questionnaire:
Developed specifically for CrossFit participants. Focus on context in which UI occurred and exercises most likely to cause UI
ISI
Descriptive statistics
a. UI - 46%
46% (N = 208/452) of women experienced UI at some point in their life and 41.8% (N = 189/452) reported having experienced UI in the last 3 months prior to the study
To determine the prevalence of UI in competitive women powerlifters; identify possible risk factors and activities likely to provoke UI and establish self-care practices
Cross-sectional study
N = 480
Women powerlifters
Nulliparous and parous
Mean age ± SD (range) years –
35 ± 10 (20–89)
Questionnaire:
Background information
Questions to identify actions and events associated with UI, self-care strategies
ISI
Descriptive statistics
Kendall’s tau-b
Eta correlation coefficient
a. UI - 48.8%
48.8% (234/480) of participants in this study reported experiencing UI at some point in their lifetime
43.9% (211/480) had experienced UI in the 3 months prior to the study
Wikander et al. 2021B
Australia & other English-speaking countries (not specified) [52]
To explore multifactorial issue of UI in competitive women weightlifters focus on prevalence, risk factors and activities provoking UI. In addition to identify self-care strategies used by incontinent competitive women weightlifters. Finally, confidence in performing PFE & utilization of women’s health professionals
Cross-sectional study
N = 191
Women weightlifters
Nulliparous and parous
Mean age ± SD years- 35.92 ± 12 (20–89)
Questionnaire:
Questionnaire
Background information
Question to identify actions and events associated with UI, self-care strategies
ISI
Descriptive statistics
Pearson’s correlations
a. UI - 36.6%
36.6% (70/191) of women had experienced UI at some point in their life,
31.9% (61/191) reported having experienced UI during the previous 3 months
*BFLUTS = Bristol Female Lower Urinary Tract Symptoms Questionnaire; FISI = Fecal Incontinence Severity Index; FSFI = Female Sexual Function Index; ICIQ-UI-SF = International Consultation on Incontinence Questionnaire-Short Form; ICIQ-VS = International Consultation on Incontinence Questionnaire-Vaginal Symptoms; IIQ-7 = Incontinence Impact Questionnaire; IPAQ = International Physical Activity Questionnaire; I-QoL = International Quality of Life Questionnaire; ISI = Incontinence Severity Index; KAP = Knowledge Attitude and Practice; LEAF-Q = Low Energy Availability in Females Questionnaire; KHQ = King’s Health Questionnaire; MSQ = Menstrual Symptom Questionnaire; OAB-q = Overactive Bladder Questionnaire; POPQ = Pelvic Organ Prolapse Quantification; QUID = Questionnaire for Urinary Incontinence Diagnosis; Rome III = Rome III Questionnaire; 3IQ = Three Incontinence Questions Questionnaire
**PFD = Pelvic Floor Dysfunction; UI = urinary incontinence; SUI = stress urinary incontinence; UUI = urge urinary incontinence; MUI = mixed urinary incontinence; UL = urinary leakage; ARD = anorectal dysfunction; AI = anal incontinence; POP = pelvic organ prolapse; PFM = pelvic floor muscle; SD = sexual dysfunction)
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