Why Do Up To 50% Of Female Athletes Leak Urine?
Urinary leakage is incredibly common amongst female athletes with prevalence increasing amongst those who participate in high impact activity. A 2018 review by Lourenco et. al. found that athletes who do high-impact activities had a 1.9 fold increase in prevalence of urinary incontinence as compared to those in "medium-impact” activities. Another 2018 study by Texeira et. al. found that athletes had a 177% higher risk of experiencing urinary incontinence than their sedentary counterparts.
So what’s the deal? In this blog post we’re going to tackle the biggest myth around leakage, outline why leakage happens more in female vs male athletes, talk about two of the biggest things contributing to leakage in athletes and what athletes can do to get their leakage under control.
The biggest myth about urinary incontinence is that only pregnant and postpartum people leak.
Urinary incontinence is a diagnosis that impacts all genders, ages and demographics. All we need to do to disprove this is look to the literature. Evidence has found surprisingly significant prevalence of leakage amongst children, teenagers and college students as well as older adults, both male and female, who have never been pregnant.
While pregnancy and vaginal childbirth are risk factors for urinary incontinence, so are constipation, chronic coughing, menopause and smoking. You do not have to be pregnant or give birth to experience urinary incontinence.
Why does urinary incontinence happen more in female athletes than their male counterparts?
Urinary incontinence is more prevalent amongst people with female anatomy. In the pelvic floor of a person with a vulva, there’s a structure called the levator hiatus. The levator hiatus is a structural opening in the pelvic floor that allows the vagina, rectum and urethra to pass through the musculature. This opening creates a structural weakness in the muscles that control bladder, bowel and sexual function, increasing the risk of dysfunction in these systems.
Like mentioned previously, pregnancy and vaginal birth are two additional risk factors impacting those with vulvovaginal anatomy. Global weakness, common following pregnancy and birth, further perpetuates these symptoms.
Two of the biggest factors contributing to leakage in female athletes
We can’t do much about having a levator hiatus, but there are factors we can modify to reduce the risk of urinary incontinence. Two of the biggest factors we can influence are global weakness and pressure management issues.
Global weakness
Your glutes, core, back, hip, ankle and foot muscles support your pelvic floor in doing its job of controlling your bladder, bowel and sexual function. When you have weakness in these surrounding muscle groups, your pelvic floor has to take on more of the burden with less support, contributing to symptoms like leakage during sports
Let’s break down how this happens. Weakness in these surrounding muscles can cause changes to movement mechanics. The way an athlete moves while participating in sports impacts the amount of ground reaction force generated when landing from jumping tasks. For example, landing flat footed will send greater force and shock up your leg to your knee, hips and pelvic floor whereas a slow, controlled landing will be softer on all your joints and pelvic floor included.
With reduced hip and ankle control, a runner can generate up to 7 times their body weight in force traveling through their body with each step. Minor changes to form and strength in surrounding muscles can slash that force to 2-3 times bodyweight. Imagine the difference in toll on your pelvic floor after a 5 mile run.
Pressure management
The inability to appropriately manage intraabdominal pressure is a big factor behind urinary incontinence for female athletes. Let’s start by defining intraabdominal pressure and how it works.
Intraabdominal pressure is the pressure within your abdomen. It’s always there, at rest and during activity. It’s normal for intraabdominal pressure to rise when we lift something heavy and drop when we set that weight down. This pressure fluctuates with all activities, including running, jumping, dancing and weight lifting.
When the pressure from within the abdomen rises, the muscles surrounding the abdomen have to activate to meet that force. The muscles that push back on this rise in pressure include your abdominals in the front, your paraspinals in the back, your diaphragm at the top and the pelvic floor at the bottom. Because pressure likes to move in the direction of least resistance, it’ll move towards the body’s point of failure. If the pelvic floor is the weak link, this pressure rise can cause urinary incontinence.
What can we do to reduce leakage while participating in sports?
Though urinary incontinence is common, it’s also treatable. Learning to manage your abdominal pressure and building strength can make a huge difference in leakage symptoms. Here are a few ways to get started:
Exhale on exertion
Exhaling on exertion helps with pressure management and tends to be the most impactful for weightlifters and athletes that participate in sports that require big bursts of power. Get started by exhaling during the push of the movement. For instance - while squatting - inhale on the way down and exhale on the push to standing.
This breath pattern will allow pressure to escape through the mouth instead of the pelvic floor, reducing leakage. While weight lifters may need to reduce the amount of weight they’re lifting while practicing this technique, starting at a lower weight can help manage symptoms and allow for slowly building back up.
Build strength
For runners and endurance athletes, strength training is often overlooked. For these athletes, adding in hip, glute and core strengthening can make all the difference. Training single leg strength in movements like a step up or single leg deadlift as well as heavier weighted movements like squats and hip thrusts are a great place to start building lower body strength. Adding in core and plyometric training can be a helpful next step, too!
See a pelvic floor PT
Athletes are all different, with a unique set of strengths, weaknesses, prior injuries and goals. Training needs to be tailored to the athlete for maximum efficiency. Treatment of symptoms needs to be tailored, too. If you’re ready to get dry while you participate in your sport and improve your overall performance, pelvic floor PT can help.
Want to learn more about how our team of experience pelvic and orthopedic physical therapists can help you? Call 512-766-2649 or send us a message to set up your free phone consultation here.
This post was written by Dr. Rebecca Maidansky, PT, DPT, owner and founder of Lady Bird Physical Therapy. Rebecca is a pelvic floor physical therapist in Austin, TX and founded Lady Bird Physical Therapy in 2019. She is the creator of Birth Preparation and Postpartum Planning, Baby Steps Fitness and the head writer and editor of The Pelvic Press.
Rebecca is a passionate writer and vocal advocate for pelvic health and the importance of improving access to perinatal care. She believes strongly that many common pregnancy pains and postpartum symptoms can be eased or even prevented with basic education and care.
She created this blog to help all birthing people manage common pregnancy pains, prepare for birth and recover postpartum.