Stress urinary incontinence in nulliparous female athletes - identifying causes using the physiotherapeutic process

Hypothesis / aims of study
High-impact sports like gymnastics, trampolining or handball increase the risk of developing stess urinary incontinence (SUI) for female athletes. The prevalence of SUI in female athletes varies depending on the type of sport practiced and the measurement method used. In some sports, such as trampolining, the percentage of those affected is up to 80% (1). Affected female athletes rarely talk about their symptoms due to shame and feelings of inferiority. They use strategies such as pads, wearing dark clothes, preventive urination, reduced fluid intake or even changing the type of sport they are practicing to cope better with their incontinence. These athletes often do not know where to go for advice and suffer from an impaired quality of life. (2)
The aim of this study is to identify aspects through the entire physiotherapeutic process that are connected to SUI in nulliparous female athletes from the perspective of Austrian physiotherapists to specify the physiotherapeutic examination, the physiotherapeutic diagnosis and the physiotherapeutic treatment in the future.
Study design, materials and methods
In this qualitative study to identify the causes of SUI in female athletes, five guideline-based expert interviews with physiotherapists from Austria were conducted between march and april 2023.The participants were recruited via the Austrian Pelvic Floor Society. They are freelancers and have been working in the gynecological field for at least two years. A further participation criterion was the treatment of at least one nulliparous female athlete with SUI. The physiotherapists participated voluntarily and signed a consent form prior the interviews. These were conducted and recorded via MS Teams, transcribed, and then deductively analyzed using framework analysis based on the physiotherapeutic process from physioaustria.
Results
The categories used were medical history, physiotherapeutic assessment, physiotherapeutic diagnosis, treatment and success control. The focus for answering the research question was on the physiotherapeutic diagnosis. The athletes treated by the physiotherapists trained at least 4 times a week in high-impact sports and were between 15 and 35 years old. The leakage of urine mainly occurred when the pelvic floor muscles of the athletes were fatigued after prolonged exercise and when a strong impulse (intraabdominal pressure) hit the pelvic floor. The experts agreed that a hypertonic pelvic floor and a reduced ability to relax these muscles are the main problems in the occurrence of incontinence in this patient group. This affects the closing mechanism of the urethra and the pelvic floor cannot exert the force it actually could. Due to a reduced coordination of the co-contraction of the pelvic floor and the abdominal muscles, the experts were able to determine that the abdominal muscles contract before the pelvic floor, which impairs continence. Two of the experts made an observation in relation to the female menstrual cycle and the occurrence of SUI. They found that urinary leakage occurred more frequently in the luteal phase of the menstrual cycle, when estrogen levels drop.
Interpretation of results
Current treatment strategies are primarily conservative and focus on behavioral changes, detonation of the pelvic floor muscles and pelvic floor training. If the potential causes are known, SUI in female athletes can be reduced by physiotherapeutic treatment. To prevent incontinence, education of athletes, coaches and health care professionals is needed. A program promoting awareness and control of the pelvic floor would be advantageous and targeted strengthening but also relaxing the pelvic floor muscles should be an integral part of training. (3) The study also encountered limitations. The interview guideline designed for conducting expert interviews provided a framework that may have overlooked certain relevant themes related to the topic. Some of the treated athletes described a gush-like loss of urine whereas others only mentioned a dribbling of urine. The cause of these differences could not be identified.
Concluding message
The study shows that physical aspects such as a hypertonic pelvic floor, fatigue of the pelvic floor muscles, hormonal fluctuations or a lack of coordination of the abdominal and pelvic floor muscles contribute to SUI during sports. SUI affects the quality of life of female athletes, but it often takes a long time for those affected to seek help. Therefore, awareness and preventative strategies should be created in future.
References
Almousa, S., & Bandin Van Loon, A. (2019). The prevalence of urinary incontinence in nulliparous female sportswomen: A systematic review. J Sports Sci, 37(14), 1663-1672. https://doi.org/10.1080/02640414.2019.1585312
Jácome, C., Oliveira, D., Marques, A., & Sá-Couto, P. (2011). Prevalence and impact of urinary incontinence among female athletes. Int J Gynaecol Obstet, 114(1), 60-63. https://doi.org/10.1016/j.ijgo.2011.02.004
Pires, T., Pires, P., Moreira, H., & Viana, R. (2020). Prevalence of Urinary Incontinence in High-Impact Sport Athletes: A Systematic Review and Meta-Analysis. J Hum Kinet, 73, 279-288. https://doi.org/10.2478/hukin-2020-0008