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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.
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.
An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.
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.
An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.
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 .
Urinary incontinence in very young and mostly nulliparous women with a history of regular organised high-impact trampoline training: occurrence and risk factors.
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.
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.
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.
Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
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 ).
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.
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)
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.
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).
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.
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.
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.
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. 2Prevalence of UI according to sports modality.
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.
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.
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.
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.
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.
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.
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.
Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
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.
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,
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,
Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
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,
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.,
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.
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.
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:
An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.
Urinary incontinence in very young and mostly nulliparous women with a history of regular organised high-impact trampoline training: occurrence and risk factors.
Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
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].
International Consultation on Urological Diseases: Evidence-based medicine overview of the main steps for developing and grading guideline recommendations.
What pelvic floor muscle training load is optimal in minimizing urine loss in women with stress urinary incontinence? a systematic review and meta-analysis.
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