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Prevalence of urinary incontinence among elite athletes of both sexes

Open AccessPublished:October 01, 2020DOI:https://doi.org/10.1016/j.jsams.2020.09.017

      Abstract

      Objectives

      To determine the prevalence of urinary incontinence (UI) among elite athletes and to compare prevalences between sexes and across different sports modalities.

      Methods

      This was a cross-sectional, observational study conducted in 754 elite athletes (455 women or girls and 299 men or boys). Participants completed a questionnaire to collect self-reported anthropometric measures, medical history and sport-related data, and the questionnaires International Consultation on Incontinence Questionnaire-UI Short-Form (ICQ-UI SF), Three Incontinence Questions (3IQ) and Incontinence Severity Index (ISI).

      Results

      According to replies to the ICQ-UI SF questionnaire, 33% of the athletes had UI at a mean age of 23.75 ± 7.74 years. Prevalences were 45.1% in female compared to 14.7% male athletes (p < 0.001) such that females were 5.45 times more likely to suffer this condition. In 59.9%, incontinence was stress UI. In 30.9%, UI was described as moderate to severe (according to ISI), and quality of life related to UI was scored 4.35 ± 2.98 out of 10 (ICQ-UI SF). 22.7% reported they had experienced urine leakage while training; in 40.5% this occurred when jumping, in 19.6% while running and in 20.2% in different situations.

      Conclusions

      The prevalence of UI observed in elite athletes was 33%. This prevalence was greater in females and also varied according to the sport practised.

      Keywords

      Practical implications

      • Elite athletes showed a high prevalence of UI. Although this prevalence was much higher in female athletes, this condition was also reported in men.
      • Only 9% of athletes who reported they had or had in the past had UI. This could indicate that urine leakage is often considered normal and a consequence of the demands of training.
      • 29.1% mentioned that they experienced urine loss during the competition season, suggesting possible effects on their performance.
      • The professionals involved in their training should be aware of the implications that UI may have. They should include pelvic floor muscle exercises in their training programs.

      1. Introduction

      Urinary incontinence (UI) is defined as the involuntary leakage of urine.
      • Haylen B.T.
      • de Ridder D.
      • Freeman R.M.
      • et al.
      An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.
      While not life-threatening, it is an embarrassing problem with a negative impact on quality of life (QoL ).
      • de Mattos Lourenco T.R.
      • Matsuoka P.K.
      • Baracat E.C.
      • et al.
      Urinary incontinence in female athletes: a systematic review.
      Incontinence affects both sexes, although a higher prevalence has been reported in women than men (51.1% versus 13.9%).
      • Markland A.D.
      • Richter H.E.
      • Fwu C.W.
      • et al.
      Prevalence and trends of urinary incontinence in adults in the United States, 2001 to 2008.
      Three types of UI have been defined: stress (SUI), urge (UUI) and mixed (MUI). SUI is the most prevalent form of UI in women (3%–58.4%) and is defined as a complaint of involuntary loss of urine upon effort or physical exertion, or on sneezing or coughing. It is usually attributed to weakened musculature of the pelvic floor.
      • Haylen B.T.
      • de Ridder D.
      • Freeman R.M.
      • et al.
      An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.
      • de Mattos Lourenco T.R.
      • Matsuoka P.K.
      • Baracat E.C.
      • et al.
      Urinary incontinence in female athletes: a systematic review.
      • Markland A.D.
      • Richter H.E.
      • Fwu C.W.
      • et al.
      Prevalence and trends of urinary incontinence in adults in the United States, 2001 to 2008.
      Several risk factors for UI have been identified in the general population including, vaginal delivery, older age, obesity, diet, urinary infection, hormone disorders and chronic bronchitis .
      • Markland A.D.
      • Richter H.E.
      • Fwu C.W.
      • et al.
      Prevalence and trends of urinary incontinence in adults in the United States, 2001 to 2008.
      In persons who practice sport, its prevalence varies as it seems to depend on the intensity of exercise, movements and impact on the ground.
      • Eliasson K.
      • Edner A.
      • Mattsson E.
      Urinary incontinence in very young and mostly nulliparous women with a history of regular organised high-impact trampoline training: occurrence and risk factors.
      • Bø K.
      Urinary incontinence, pelvic floor dysfunction, exercise and sport.
      In these individuals, the main cause is thought to be a rise in abdominal pressure followed by abdominal muscle contraction in the absence of prior pelvic muscle contraction.
      • Bø K.
      Urinary incontinence, pelvic floor dysfunction, exercise and sport.
      According to a recent metaanalysis,
      • Teixeira R.V.
      • Colla C.
      • Sbruzzi G.
      • et al.
      Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis.
      the mean prevalence of UI is 36.1% (95% CI 26.5% –46.8%), ranging from 19.4%
      • Poświata A.
      • Socha T.
      • Opara J.
      Prevalence of stress urinary incontinence in elite female endurance athletes.
      to 76%
      • Fozzatti C.
      • Riccetto C.
      • Herrmann V.
      • et al.
      Prevalence study of stress urinary incontinence in women who perform high-impact exercises.
      However, it should be taken into account that these data refer only to all-level female athletes. Female professional athletes seem to carry an around 3 times greater risk of UI compared to non-active women.
      • Da Roza T.
      • Brandão S.
      • Mascarenhas T.
      • et al.
      Urinary incontinence and levels of regular physical exercise in young women.
      Among these, high impact sports have been associated with a higher UI prevalence than low impact exercise activities (80% versus 5.56%).
      • de Mattos Lourenco T.R.
      • Matsuoka P.K.
      • Baracat E.C.
      • et al.
      Urinary incontinence in female athletes: a systematic review.
      Such high impact sports are likely to generate higher intraabdominal pressures, leading to pelvic floor muscle weakness,
      • Da Roza T.
      • Brandão S.
      • Mascarenhas T.
      • et al.
      Urinary incontinence and levels of regular physical exercise in young women.
      morphological and functional changes in ligaments and connective tissue,
      • Fozzatti C.
      • Riccetto C.
      • Herrmann V.
      • et al.
      Prevalence study of stress urinary incontinence in women who perform high-impact exercises.
      or an increased diameter of the levator hiatus.
      • Kruger J.A.
      • Dietz H.P.
      • Murphy B.A.
      Pelvic floor function in elite nulliparous athletes.
      Therefore, the general belief that physically fit women have a stronger pelvic floor due to regular exercise preventing the development of UI should be questioned further.
      • Almousa S.
      • Bandin Van Loon A.
      The prevalence of urinary incontinence in nulliparous female sportswomen: a systematic review.
      Some authors have reported the presence of UI in athletes as young as 15 years .
      • Almeida M.B.
      • Barra A.A.
      • Saltiel F.
      • et al.
      Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: a cross-sectional study.
      • Carvalhais A.
      • Natal Jorge R.
      • Bø K.
      Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
      It should be mentioned that the American College of Sports Medicine
      Female athlete issues for the team physician: a consensus statement—2017 update.
      fails to consider UI among the conditions specifically affecting women.
      To date, numerous studies have addressed the topic of UI in several sports codes.
      • Almeida M.B.
      • Barra A.A.
      • Saltiel F.
      • et al.
      Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: a cross-sectional study.
      • Carvalhais A.
      • Natal Jorge R.
      • Bø K.
      Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
      • Eliasson K.
      • Larsson T.
      • Mattsson E.
      Prevalence of stress incontinence in nulliparous elite trampolinists.
      However, few epidemiological studies have shown the prevalence and risk of having a UI in elite athletes, and we lack data comparing this condition according to sex. Hence the main objective of the present study was to determine the prevalence of UI among elite athletes. We also examined whether differences exist between men and women and between different sports codes practised by this large cohort of athletes.

      2. Materials and methods

      This was an observational, cross-sectional study conducted in Spain over the period December 2018 to May 2019. Athletes were recruited via the Madrid institutions: Agencia de Protección de la Salud en el Deporte (AEPSAD, Agency for the Protection of Health in Sport), Federación Española de Atletismo (RFEA, Spanish Federation of Athletics) and Centro de Alto Rendimiento Deportivo (CAR, Centre for High-Performance Sport). Also, via these centers, we contacted the presidents of national sports federations so that they could help with the recruitment of athletes. Finally, 837 athletes were contacted and 754 elite athletes selected for this study. According to Spanish law participants had a valid certificate of Deportista de Alto Nivel (DAN; high-level athlete) and/or Deportista de Alto Rendimiento (DAR; high-performance athlete ).

      Royal Decree 971/2007, of July 13, on high-level and high-performance athletes Ministry of Education and Science «BOE» no. 177, of July 25, 2007. BOE-A-2007-14231. https://www.boe.es/buscar/pdf/2007/BOE-A-2007-14231-consolidado.pdf.

      Exclusion criteria were: (1) being pregnant at the study start or in the past year, (2) being under 14 years, and (3) an inability to adequately understand instructions in Spanish. The study protocol adhered to the tenets of the Declaration of Helsinki.
      • General Assembly of the World Medical Association
      World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.
      All data were anonymous and confidential in line with new European data protection
      Regulation (Eu) 2016/679 of the European Parliament and of the Council of April 27.
      and Spanish LOPD norms.

      Organic Law 3/2018, of December 5, on the Protection of Personal Data and guarantee of digital rights.

      The study received approval by the Review Board of the Universidad Camilo José Cela, Madrid, Spain. All participants gave their consent to participate after having been informed of the study's objectives and procedures.
      Data were collected through an online survey supervised by researchers. A questionnaire containing four main sections was administered to collect the following information: (1) Anthropometric data, age, gender, weight and height; (2) Medical history, common diseases, constipation, urinary infection and gynecological data; (3) Sports practice, discipline, years of experience, criteria for consideration as an elite athlete, and training volume; (4) UI data, type, severity and social impact according to International Urogynecological Association (IUGA) and International Continence Society (ICS)
      • Haylen B.T.
      • de Ridder D.
      • Freeman R.M.
      • et al.
      An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.
      recommendations, as assessed through the following validated questionnaires:
      International Consultation on Incontinence Questionnaire-UI Short-Form (ICIQ-UI SF). This questionnaire determines if a subject has UI, and if so, its frequency, severity and whether there are impacts on QoL.
      • Espuña Pons M.
      • Rebollo Alvarez P.
      • Puig Clota M.
      Validación de la versión española del International Consultation on Incontinence Questionnaire-Short Form. Un cuestionario para evaluar la incontinencia urinaria [Validation of the Spanish version of the International Consultation on Incontinence Questionnaire-Short Form. A questionnaire for assessing the urinary incontinence].
      Three Incontinence Questions Questionnaire (3IQ). Three questions are used to define whether a subject has had UI in the last 3 months, its type and trigger situation (stress, urge or no physical activity).
      • Treszezamsky A.D.
      • Karp D.
      • Dick-Biascoechea M.
      • et al.
      Spanish translation and validation of four short pelvic floor disorders questionnaires.
      • Brown J.S.
      • Bradley C.S.
      • Subak L.L.
      • et al.
      The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence.
      Incontinence Severity Index (ISI). This consists of two questions about a subject's frequency of urine leakage (5 levels) and how much urine is lost (4 levels) described as none, drops, small splashes, or more. This index classifies incontinence severity as: slight, moderate, severe or very severe.
      • Twiss C.
      • Triaca V.
      • Anger J.
      • et al.
      Validating the incontinence symptom severity index: a self-assessment instrument for voiding symptom severity in women.
      Using the program for epidemiological analysis from tabulated data (EPIDAT 3.1), sample size was calculated as a proportion of finite populations considering a 95% confidence level to estimate an expected prevalence of 50% in a total population for each of the groups DAN and DAR, for a 5% accuracy of the study. In the Resolution of December 19, 2018, the Spanish Sports Council (Consejo Superior de Deportes) reported 1524 DAN for 2018 and, according to data reported by each Federation and Autonomous Community, in that year there were 3123 DAR. Thus, the estimated minimum sample size was of 650 elite athletes, 307 DAN and 343 DAR.
      All statistical tests were performed using the package IBM SPSS Statistics v. 26.0. Data are provided as the mean and standard deviation along with 95% confidence intervals (CI). When appropriate, data are provided as percentages. The Shapiro Wilks test was used to check the normality of data in the sample. Between sexes, means were compared using the Student t-test and proportions by the Chi-squared test. The estimated odds ratio (OR) and 95% confidence interval for the OR were analyzed through the risk estimate of crosstabs. Further, bivariate correlations among variables were assessed through Pearson's coefficient. The level of confidence was set at 95% and significance at p<0.05.

      3. Results

      The mean age of the 754 elite athletes enrolled was 23.04 ± 7.16 years; 60.3% were women or girls (n = 455) and 39.7% men or boys (n = 299) (Table 1). Of the 455 female athletes, 97.6% were of fertile age, 1.8% were premenopausal and 0.7% menopausal. In 98.2% (n = 447), menarchy onset was at 13.2 ± 1.70 years. Of the 455 female athletes, 42 had been pregnant and the rest were nulliparous. Females showed higher frequencies of urinary infection and constipation than males. Both the male and female athletes showed similar trends in their sports practice with the exception that women reported they trained more days per week (p = 0.002) and more months (p = 0.025); they had also been elite athletes for longer (p = 0.024) than the men (Table 1).
      Table 1Sociodemographic, anthropometric, medical history and training volume data.
      Overall (n = 754)Females (n = 455)Males (n = 299)p Value
      p value belonging to initial comparability of the baseline values between gender (based on t-test results).
      p value belonging to initial comparability of the baseline values between gender (based on Chi Square test results).
      CharacteristicsMeanSD (95%CI)MeanSD (95%CI)MeanSD (95%CI)
      Sociodemographic, anthropometric and medical history
      Age (years)23.047.16 (22.5–23.5)23.187.10 (22.5–23.8)22.817.26 (21.9–23.6)0.489
      Weight (kg)64.4413.64 (63.4–65.4)59.3510.85 (58.3–60.3)72.1913.84 (70.6–73.7)<0.001
      Height (cm)170.6410.9 (169.8–171.4)166.0710.19 (165.1–167)177.597.87 (176.7–178.4)<0.001
      Urine infections
       Yes (n, %)25033.2%21485.6%3614.4%<0.001
      p value belonging to initial comparability of the baseline values between gender (based on Chi Square test results).
       No (n, %)50466.8%24147.8%26352.2%
      Constipation
       Yes (n, %)8110.7%6074.1%2125.9%0.005
      p value belonging to initial comparability of the baseline values between gender (based on Chi Square test results).
       No (n, %)67389.339558.7%27841.3%
      Training characteristics
      Starting competition age (years)15.704.92(15.3–16.0)15.965.37 (15.4–16.4)15.304.11 (14.8–15.7)0.072
      Years of experience as elite athlete3.413.43 (3.1–3.7)3.703.60 (3.2–4.1)3.013.13 (2.5–3.4)0.024
      Training
       Hours/day3.061.43 (2.9–3.1)3.061.47 (2.9–3.2)3.071.37 (2.9–3.2)0.921
       Days/week5.141.22 (5.04–5.2)5.261.11 (5.1–5.3)4.971.33 (4.8–5.1)0.002
       Months/season9.711.96 (9.5–9.8)9.851.86 (9.6–10.04)9.52.08 (9.2–9.7)0.025
      Rest between training
       Hours14.6311.1 (13.7–15.4)14.709.99 (13.6–15.7)14.5412.51 (13.04–16.03)0.990
       Weeks/year3.532.03 (3.3–3.6)3.622.02 (3.4–3.8)3.402.05 (3.1–3.6)0.166
      SD, standard deviation; CI, confidence interval; kg, kilograms; cm, centimeters.
      a p value belonging to initial comparability of the baseline values between gender (based on t-test results).
      b p value belonging to initial comparability of the baseline values between gender (based on Chi Square test results).
      Based on the ICQ-UI SF scores (Table 2), 33% (n = 249) of the athletes had UI at a mean age of 23.75 ± 7.74 years. Around 70% of those with incontinence were under 25 years: one participant was 14 years old (33.3%), 5 were 15 years old (19.2%), 11 were 16 years old (28.2%), 15 were 17 years old (20%) and 23 were 18 years old (34.8%). Of 33% of the athletes who reported UI, 82.3% were women and 17.7% men (p < 0.001) (Fig. 1). 45.1% of the female elite athletes indicated they had had UI compared to 14.7% of the men, the difference being significant (χ² [1] = 69,28; p < 0.001). Women also showed a 5.45 (95%CI = 3.55–8.35) times greater risk of having UI. However, this risk was not greater in those who had been through a pregnancy (χ² [1] = 3.16; p < 0.055). There were no significant differences (p = 0.626) between nulliparous and parous women as half of the women who had been pregnant and 45% of the nulliparous women mentioned they had had UI. Women showed a 6 times higher risk of urinary infection and two times higher risk of constipation than men. Athletes had higher odds of UI if they had constipation (OR = 2.69) or a history of urinary infection (OR = 2.21). However there no was correlation with weight. Frequencies of urine leakage in both sexes were once a week in 59.7%, more than three times per week in 25.6% and daily in 14.7%. In around 15% of the participants, urine losses were described as moderate or abundant. The mean score for some impact of UI on QoL was 4.35 ± 2.98 points out of 10.
      Table 2Urine leakage characteristics.
      Overall (n = 754)Females (n = 455)Males (n = 299)p Value
      p for comparisons in baseline variables between genders (Chi-squared test).
      n%n%n%
      ICIQUI SF Presence of UI
      24933%20582.3%4417.7%<0.001
      ICIQUI SF Frequency
       Once a week10513.9%8681.7%1918.1%<0.001
       2−3 times per week456%3986.7%613.3%
       Once a day162.1%1487.5%212.5%
       Several times in a day91.2%444.4%555.6%
       Constant10.1%1100%00%
      ICIQUI SF Amount of urine lost
       None51468.2%25449%26051%<0.001
       Small amount20226.8%16983.7%3316.3%
       Moderate amount354.6%3085.7%514.3%
       Large amount30.4%266.7%133.3%
      3IQ
       UI19726.1%16885.3%2914.7%<0.001
       SUI11859.9%11194.1%75.9%
       UUI3819.3%2771.1%1128.9%
       MUI2814.2%2485.7%414.3%
       Other UI136.6%646.2%753.8%
      ISI
       Slight13669%11584.6%2115.4%0.629
       Moderate5628.4%4885.7%814.3%
       Severe52.5%5100%00%
      Leakage while training
      Yes (n, %)17122.7%15691.2%158.8%<0.001
      No (n, %)58377.3%29951.3%28448.7%
      Trigger for leakage while training
       Lifting weights169.5%1487.5%212.5%0.023
       Running3319.6%3090.9%39.1%
       After running95.4%777.8%222.2%
       Jumping6840.5%68100%00%
       After jumping42.4%4100%00%
       Trunk rotation21.2%2100%00%
       Forward flexion21.2%150%050%
       Several of the above3420.2%3088.2%411.8%
      Training period
       Rest31.7%3100%00%0.444
       Precompetition4023.3%3792.5%37.5%
       Competition5029.1%4386%714%
       Several of the above7945.9%7493.7%56.3%
      SD, standard deviation; CI, confidence interval; ICIQ‐UI SF, International Consultation on Incontinence Questionnaire-Urinary Incontinence Short-Form ; 3IQ, Three Incontinence Questions Questionnaire; UI, urinary incontinence; SUI, stress urinary incontinence; UUI, urge urinary incontinence; MUI, mixed urinary incontinence ISI, Incontinence Severity Index.
      a p for comparisons in baseline variables between genders (Chi-squared test).
      Fig. 1
      Fig. 1Prevalence of urinary incontinence among elite athletes.
      UI, urinary incontinence; ICIQ‐UI SF, International Consultation on Incontinence Questionnaire-UI Short Form; SUI, stress urinary incontinence; UUI, urge urinary incontinence.
      The 3IQ indicated that 92.4% (n = 182) of those with UI according to ICQ-UI SF had suffered urine leakage over the past 3 months. These losses were attributable to SUI in 59.9%, UUI in 19.3%, MUI in 14.2%, and to other causes in the remaining 6.6% (Table 2).Of the athletes who indicated they did not have UI in the 3IQ questionnaire, 25.7% stated they did experience urine leakage during training (χ² [1] = 265.56; p < 0.001). Further, 12.3% of the athletes who considered they did not have UI and 60% of those who admitted they had had UI on some occasion, stated they had experienced some urine leakage in the past 3 months (χ² [1] = 28,759; p < 0.001).
      The ISI scores indicated that among athletes with UI (n = 197), 3% described their condition as severe (27.2 ± 10.8 years), 28.4% as moderate (26.89 ± 9.7 years) and 69% as slight (23.05 ± 7 years) (Table 2).
      In response to the question “Do you think you have or have had UI?”, only 9% (n = 68) of the 754 elite athletes mentioned they presently had this condition, and 13.3% (n = 100) indicated they had had UI at some time. However, 22.7% (n = 171) reported they had experienced urine leakage while training; in 40.5% this occurred when jumping, in 19.6% while running and in 20.2% in different situations (Table 1). In the female athletes, weak correlation was detected between UI and days of training per week (r = 0.104; p = 0.028), hours of training per day (r = 0.113; p = 0.017) and negative correlation emerged with weeks of rest in a year (r = −0.109; p = 0.029). No association was observed between UI and years of sports practice, or hours of practice per day. In male athletes, no correlation was found between UI and training volume or frequency (p > 0.05). Most participants (45.9%, n = 346) practised athletics, followed by soccer (8.4%, n = 63) and gymnastics (7%, n = 53); the remaining athletes undertook other sports (Fig. 2). The sports in which UI was most often detected were: rugby (80%), swimming (57.1%), hockey (43.5%), karate (45.5%) athletics (40.5%), orienteering (40%), and dancesport (40%). Within athletics, a greater percentage of urine leakage was observed in the disciplines mountain running (100%) and sprints (71.4%). Within gymnastics, a prevalence of 32.1% of UI was detected, with 100% of trampolinists and 41.2% of rhythmic gymnasts describing they experienced urine leakage.
      Fig. 2
      Fig. 2Prevalence of UI according to sports modality.

      4. Discussion

      The main objective of our study was to determine the prevalence of UI among elite athletes and to examine this condition in this large cohort of elite athletes. Thirty-three percent of the athletes suffered UI (females 45.1%, males 14.7%). In effect, according to our data, the risk of UI was 5.45 times greater in women than men. Moreover, UI was reported by almost 50% of the female athletes and 20% of the male athletes at a relatively early age (20–30 years of age). Urinary incontinence has been scarcely addressed in men and even less in sport. Thus, UI should be considered a clinical condition that affects athletes of both sexes.
      Carvalhais et al.
      • Carvalhais A.
      • Natal Jorge R.
      • Bø K.
      Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
      undertook a similar study with the same validated questionnaires in a group of athletes in Portugal, comparing their findings between athletes and non-athletes. They concluded that the prevalence of UI was 29.6% in female elite athletes and the odds of having UI were three times higher than in controls. Their participants were women only and were younger than our athletes. This age difference could perhaps explain the higher prevalence of UI in women found in our study.
      As reported in the Portuguese study,
      • Carvalhais A.
      • Natal Jorge R.
      • Bø K.
      Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
      constipation and history of urinary infection were here associated with UI and can be described as modifiable risk factors for UI susceptible to monitoring as prophylactic measures. Other risk factors are body weight and pregnancy, according to which the evidence the prevalence of UI increases proportionally.
      • Danforth K.N.
      • Townsend M.K.
      • Lifford K.
      • et al.
      Risk factors for urinary incontinence among middle-aged women.
      • Abrams P.
      • Khoury S.
      International Consultation on Urological Diseases: Evidence-based medicine overview of the main steps for developing and grading guideline recommendations.
      However, most of our athletes were very young and the effects of increased body weight on the pelvic floor muscles are likely not evident until later in life. A recent systematic review showed that the mean prevalence of UI in nulliparous athletes was 40.6% ± 21.9.
      • Almousa S.
      • Bandin Van Loon A.
      The prevalence of urinary incontinence in nulliparous female sportswomen: a systematic review.
      Our rate was similar at 45% of nulliparous women. While pregnancy and delivery have been described as the main risk factors for UI in women, we found no differences between our nulliparous and parous female elite athletes. This can be attributed to the young age of our study population as only 10% of the women had undergone a pregnancy.
      The prevalence of stress UI was the type of UI most frequently experienced by athletes, around 60% (66.1% in females; 24.1% in males). Texeira et al.
      • Teixeira R.V.
      • Colla C.
      • Sbruzzi G.
      • et al.
      Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis.
      detected a lower prevalence of stress UI (44%). This is the most frequent form of UI in women and has a direct relationship with physical effort such as that involved in high impact physical activities.
      • Bø K.
      Urinary incontinence, pelvic floor dysfunction, exercise and sport.
      • Couderc A.
      • Gabbett T.J.
      • Piscione J.
      • et al.
      Repeated high-intensity effort activity in international male rugby sevens [published online ahead of print, 2019 Jan 22].
      The present finding of urine leakage when running, jumping and other situations, support the hypothesis that UI is related to an increase in the forces directed toward the pelvic floor during physical activity.
      • Bø K.
      Urinary incontinence, pelvic floor dysfunction, exercise and sport.
      • Carvalhais A.
      • Natal Jorge R.
      • Bø K.
      Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
      • Eliasson K.
      • Larsson T.
      • Mattsson E.
      Prevalence of stress incontinence in nulliparous elite trampolinists.
      This reinforces the idea of how important it is that coaches, physiotherapists, and other professionals involved in maximizing the performance of athletes include pelvic floor muscle exercises in an athlete's training regimen, as such exercises are effective in preventing and managing UI.
      • García-Sánchez E.
      • Ávila-Gandía V.
      • López-Román J.
      • et al.
      What pelvic floor muscle training load is optimal in minimizing urine loss in women with stress urinary incontinence? a systematic review and meta-analysis.
      In the present study, over 38 different sports were recorded. The modality showing the greater prevalence of UI was rugby, in which 80% reported urine leakage. This sport is characterized by repeated bursts of high intensity exercise, running spurts and bruising,
      • Couderc A.
      • Gabbett T.J.
      • Piscione J.
      • et al.
      Repeated high-intensity effort activity in international male rugby sevens [published online ahead of print, 2019 Jan 22].
      increasing forces directed toward the pelvic floor. The second largest incidence of UI was observed for swimming. Although in water sports the body is partially immersed in water and therefore ground reaction forces have no impact on the pelvic floor,
      • Carvalhais A.
      • Natal Jorge R.
      • Bø K.
      Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
      Almeida et al.
      • Almeida M.B.
      • Barra A.A.
      • Saltiel F.
      • et al.
      Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: a cross-sectional study.
      also noted a high incidence of UI among swimmers. Carvalhais et al.
      • Carvalhais A.
      • Natal Jorge R.
      • Bø K.
      Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
      argued that the torsion and rotation movements characteristic of this sport could trigger UI. As another explanation for UI, Dornowski et al.
      • Dornowski M.
      • Makar P.
      • Sawicki P.
      • et al.
      Effects of low-vs high-volume swimming training on pelvic floor muscle activity in women.
      proposed that a reduced training volume of increased intensity induced signs of fatigue affecting the electrical activity level of the pelvic floor muscles in female athletes. Within a single sport, we were also able to observe significant differences in rates of UI as for example in the disciplines athletics and gymnastics. Athletics was the highest reported sports in the respondents (45.9%) and 40.5% of those athletes reported that they had experienced UI. Among the gymnasts, 32.1% indicated they had had UI. Only 2 trampolinists completed the questionnaires and both reported UI. In agreement with the findings of others,
      • Almeida M.B.
      • Barra A.A.
      • Saltiel F.
      • et al.
      Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: a cross-sectional study.
      trampolinists show a high prevalence of UI. This occurs during somersaults and difficult or exhausting exercises.
      • Eliasson K.
      • Larsson T.
      • Mattsson E.
      Prevalence of stress incontinence in nulliparous elite trampolinists.
      In the present study, we included rhythmic, artistic and aerobic gymnastics which featured UI rates of 20–41.5%. Of note, was the high prevalence of UI observed here in the sports orienteering (40%) and sailing (33.3%).
      Responding athletes had a mean UI-related QoL score of 4.35/10, and 30.9% of participants described their condition as moderate to severe. According to Jácome et al.,
      • Jácome C.
      • Oliveira D.
      • Marques A.
      • et al.
      Prevalence and impact of urinary incontinence among female athletes.
      UI can have a negative impact on the quality of life of females athletes. Given the impact of UI on the day to day life of an elite athlete, having UI is likely to compromise performance. It should be highlighted that more than half of the population surveyed here were high competition athletes (Olympics, International and European competitions) determining that much of their day is given over to training. Further, competition results could well be affected, since as many as 29.1% of these high-competition medalists indicated they experienced urine leakage during competition periods. Besides having an impact on their performance, athletes may experience feelings of concern and frustration that urinary leakage might be noticed by their peers.
      • Jácome C.
      • Oliveira D.
      • Marques A.
      • et al.
      Prevalence and impact of urinary incontinence among female athletes.
      However, most athletes never discuss problems of urine leakage with anyone or seek treatment
      • Jácome C.
      • Oliveira D.
      • Marques A.
      • et al.
      Prevalence and impact of urinary incontinence among female athletes.
      Professionals involved in their training should be aware of the implications of UI and if necessary refer them for physiotherapy support.
      Thus, adequate preventive and/or therapeutic strategies for UI need to be adopted in athletes. First, we need to examine an athlete's training volume. The present data seem to indicate that the factor weekly training hours has an effect on the development of UI, while this relationship was not as clear for hours per day or years of training. The key point seems to be in the break between workouts and weeks of rest in a year. Elliasson et al.
      • Eliasson K.
      • Nordlander I.
      • Larson B.
      • et al.
      Influence of physical activity on urinary leakage in primiparous women.
      proposed that a different personal fatigue threshold exists for each female athlete, and that when this is breached the continence mechanism may be affected.
      Our study provides other data that merit some reflection. Only 9% (n = 68) of the athletes reported they had or had had UI. Despite this, through the use of validated questionnaires we observed an UI prevalence of 33% (n = 249), and 22.7% indicated they experienced urine leakage while training. This discrepancy could reflect the great lack of knowledge about UI in sports, and that sometimes an athlete may consider that urine leakage is normal and a consequence of the demands of training. We certainly feel that this condition deserves more attention so that the athlete is made more aware of this condition.
      The strength of our study lies in its large sample size, our inclusion of male athletes and sports disciplines that have not been previously considered in studies on this topic, along with our use of three questionnaires of proven validity for assessing UI. The questionnaires were validated in Spanish, except for the ISI questionnaire, which was translated by the authors. Its limitations are the use of these questionnaires as the only tool in the absence of clinical and/or urodynamic tests to confirm the presence of UI. In addition, self-reported questionnaires are influenced by recall bias. This bias was minimized by collecting the data under the supervision of the researchers. Finally, the number of participants in some of the sports disciplines was too small for valid comparisons of UI prevalence rates.

      5. Conclusions

      The findings of our study reveal a 33% prevalence of UI among elite athletes of mean age 23.75 ± 7.74 years. The prevalence of UI in female elite athletes was 45.51%. Although women were 5.45 times more likely to have UI, 14.7% of the male elite athletes surveyed also reported they suffered this condition.

      Financial support

      This study has received financial support by Royal Spanish Athletics Federation (Real Federación Española de Atletismo) , through grant del Spanish Sports Council (Consejo Superior de Deportes) .

      Ethical approval information

      The study received approval by the Review Board of the Universidad Camilo José Cela, Madrid, Spain.

      Data sharing statement

      Data are available upon reasonable request.

      Acknowledgments

      We thank Carlota Castrejana, General Secretary of Royal Spanish Athletics Federation, and Enrique Lizalde, Chief of Department of Health and Sports in Spanish Agency for the Protection of Health in Sports. Both helped us get the sample. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation, and statement that results of the present study do not constitute endorsement by ACSM.

      Appendix A. Supplementary data

      The following is Supplementary data to this article:

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