Clinical Consult

Each month, questions with a common theme will be selected and answered comprehensively by one of our Steering Committee members. Previously answered questions will be archived each month for your reference. If you wish to submit a question, click here.

This Month's Question:

Several studies have found that women athletes more often experience SUI during sporting activities than nonathletes in the same age group. Why do women athletes experience SUI, and what are the most effective treatment options for this population of women?

Response by Diane K. Newman, RNC, MSN, CRNP, FAAN, posted 04/22/2005:

Urinary incontinence is often regarded as a problem with older women, although studies have shown that women of all ages can be affected.^1,2 A common form of urinary incontinence is stress urinary incontinence (SUI), which is the loss of urine during an increase in intra-abdominal pressure during activities such as coughing, sneezing, or exercising.² Known risk factors for SUI are inherently weak connective tissue and pelvic floor muscles (PFMs), pregnancy, vaginal delivery, obesity, and aging.³ Female athletes who experience SUI often do not have these conventional risk factors but may still experience SUI episodes during strenuous exercise.^1,4 It is thought that the repetitive downward abdominal pressure experienced during physical exertion can unmask SUI. What is not known is which sports are most likely to unmask urine leakage.

Nygaard and colleagues¹ studied a group of 144 female college students engaged in athletic competition (average age 19.9 years) and found that 40 athletes (28%) reported urine loss while participating in their sport. Activities most likely to provoke SUI were gymnastics (67%), tennis (50%), basketball (44%), and field hockey (26%). The researchers concluded that factors involved in the failure of continence mechanisms may include inadequate abdominal pressure transmission, PFM fatigue, and changes in connective tissue or collagen. Running, jumping, landings, and dismounts create sudden increases in abdominal pressure. The PFMs must be able to contract forcefully and rapidly to withstand the constant deceleration of the abdominal viscera on the pelvic floor caused by repetitive jumping or running.¹ Similar results were found by Thyssen and colleagues⁵ in their cohort of 151 elite athletes reporting SUI, in which gymnasts had the highest prevalence (65%) followed by dancers (43%) and those doing aerobics (40%).

Bo and Borgen's study³ of 572 athletes (average age 21.5 years) and 765 nonathletes who served as controls (average age 24.2 years) showed that the overall prevalence of SUI was 41% in the athletes and 39% in the control group (not significant). However, 29% vs 22%, respectively, experienced SUI during physical activity, which was a significant difference (P=.009). In a review of the data available to date, Bo² concluded that it is not possible to confirm that high-impact activity itself can cause connective tissue or PFM damage, and no conclusive evidence has shown that strenuous exercise causes SUI or pelvic organ prolapse. Based on functional anatomy and biomechanics, it is more likely that heavy lifting and strenuous activity may promote these conditions in women already at risk. Physical activity may trigger and exaggerate the condition; however, more basic research is needed to understand the function and role of the pelvic floor during strenuous activity.

In 3 large cohorts of Australian women (14,792 aged 18 to 26 years, 14,200 aged 45 to 53 years, and 12,624 aged 70 to 75 years), Brown and Miller⁶ found that 13%, 44.7%, and 15.9%, respectively, of those who reported leakage said that they leaked urine when they played sports or exercised. Consequently, 38%, 27.5%, and 6.7%, respectively, said they avoided sporting activities because of leaking urine. Other athletes used self-management strategies, such as voiding before they exercised and wearing pads. The researchers therefore recommend that healthcare professionals, coaches, and trainers address the issue of urine leakage and refer women with SUI to a clinician for treatment. Also, it is recommended that women urinate prior to beginning the sports activity as the chance of involuntary urine loss may be less if the bladder is empty and that foods and beverages that promote natural diuresis (caffeinated products) be avoided.

Therapies for exercise-induced SUI include PFM exercises, intravaginal devices (eg, tampons, pessaries), urethral devices, and perineal pads, panty liners, and other absorbent pads. A study by Nygaard⁷ showed that women lost significantly less urine while exercising (40-minute, standardized aerobic sessions) when wearing either a tampon or pessary.^4,8

Finally, although no drugs are currently approved for treating SUI, neuropharmacology is one strategy for improving SUI. The role of the central nervous system (CNS) in controlling nerve activity is currently being studied. Targeting serotonin and norepinephrine receptors in Onuf's nucleus has been shown to increase the pudendal nerve efferent activity. Duloxetine, a dual serotonin and norepinephrine reuptake inhibitor, potentiates these physiologic effects, thereby enhancing the CNS's natural continence control mechanism.⁹ Although not approved by the US Food and Drug Administration for the treatment of SUI, duloxetine has been shown in clinical trials to reduce the frequency of stress urinary incontinence episodes in women.¹⁰

References

1. Nygaard IE, Thompson FL, Svengalis SL, Albright JP. Urinary incontinence in elite nulliparous athletes. Obstet Gynecol. 1994;84:183-187.

2. Bo K. Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Med. 2004;34:451-464.

3. Bo K, Borgen JS. Prevalence of stress and urge urinary incontinence in elite athletes and controls. Med Sci Sports Exerc. 2001;33:1797-1802.

4. Dunn M, Brandt D, Nygaard I. Treatment of exercise incontinence with a urethral insert: a pilot study in women. Physician Sports Med. 2002;30:45-48.

5. Thyssen HH, Clevin L, Olesen S, Lose G. Urinary incontinence in elite female athletes and dancers. Int Urogynecol J. 2002;13:15-17.

6. Brown WJ, Miller YD. Too wet to exercise? Leaking urine as a barrier to physical activity in women. J Sci Med Sport. 2001;4:373-378.

7. Nygaard I. Prevention of exercise incontinence with mechanical devices. J Reprod Med. 1995;40:89-94.

8. Newman DK. Stress urinary incontinence in women. Am J Nurs. 2003;103:46-55.

9. Thor KB. Targeting serotonin and norepinephrine receptors in stress urinary incontinence. Int J Gynaecol Obstet. 2004;86(suppl 1):S38-S52.

10. Dmochowski RR, Miklos JR, Norton PA, Zinner NR, Yalcin I, Bump RC; Duloxetine Urinary Incontinence Study Group. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol. 2003;170:1259-1263.