Hypothesis / aims of study
In the last two decades, obesity rates and sedentary behaviours have continued to steadily climb and are two of the greatest public health challenges facing women (1). It is therefore imperative to understand the barriers to exercise in women in order to increase exercise participation levels. Limited data from 15+ years ago (2, 3) suggest that urinary incontinence (UI) may be a potentially modifiable barrier to exercise in women, yet the degree to which women with UI perceive their symptoms or fear of symptoms to be a barrier, compared with other established barriers is unknown. Beyond UI, there have been no studies to date investigating the prevalence or significance of other pelvic floor dysfunctions (PFDs), such as pelvic organ prolapse (POP) or anal incontinence (AI) as barriers to exercise. The aims of this study were to explore the prevalence and impact of PFD (UI, POP and AI) as a barrier to exercise in a large sample of women who have either experienced pelvic floor symptoms during exercise or are fearful they might. We aimed to establish the significance of pelvic floor symptoms as a barrier amongst other known barriers to exercise in this group.
Study design, materials and methods
A cross-sectional study was performed via an anonymous, online questionnaire developed utilising Qualtrics software. Australian women with self-identified symptoms of PFD during exercise, either current, past or fear of PFD, were recruited via social media advertising, primarily Facebook and Twitter. The inclusion criteria were 18-65-year-old women, residing in Australia and not currently pregnant, breastfeeding or recently (6 months) post-partum. The survey was purpose-designed and validated questionnaires were embedded. To establish the presence and sub-type of UI, the grade A ICI-recommended, patient-administered screening tool Questionnaire for female Urinary Incontinence Diagnosis (QUID) was used. The Incontinence Severity Index (ISI) and questions from the Pelvic Floor Bother Questionnaire (PFBQ) were included to establish the severity and degree of bother. Selection of multiple PFD options was permitted. To investigate women’s perceived barriers to exercise we listed symptoms of PFD amongst 18 previously reported common barriers. Participants were asked to rate the extent the barrier stopped participation in preferred exercise using a 5-point Likert scale. Within the survey, questions on exercise barriers preceded questions on individually-identified pelvic floor symptoms. Descriptive statistics were used to analyse data. Those who did not complete the PFD validated questionnaires were removed from analysis.
From 5790 respondents a total of 4556 women aged 18-65 years (mean 41.90, SD 11.39) were included. Mean BMI was 29.9 kg/m2 (SD 7.3), 17.2 % were nulliparous, 82.8% parous. Prevalence of PFD in the survey sample was UI 87.2% (sub type prevalence: stress urinary incontinence 40.9%, urgency urinary incontinence 5.9% and mixed urinary incontinence 40.4%), POP 33.6% and AI 35.7%. The prevalence and impact of pelvic floor symptoms experienced during exercise are reported in Table 1. The most common pelvic floor symptom women had experienced during exercise was leaking urine (86.7%), which resulted in 40.5% stopping and 37.5% modifying their exercise participation. More than 70% of women who had experienced POP and 60.0% who had experienced symptoms of AI during exercise had stopped or modified their exercise. One in two women reported that stopping or modifying exercise bothered them moderately / greatly. 77.1% of women reported at least one barrier to exercise. The five most frequently reported barriers to exercise are reported in Table 2. Amongst all barriers to exercise, leaking urine was the most frequently selected barrier (60.3%). Identifying UI as a barrier to exercise, was most prevalent in the 26-45 years age group (50.9%) but was ranked in the top two barriers to exercise in all age groups. For women with symptomatic POP, 34.3% reported it a barrier to exercise and one in five reported it as a barrier to exercise often/all of the time. For women with AI 16.9% reported it a barrier to exercise. In women with POP, leaking urine and POP symptoms were two of the three highest ranked barriers to exercise participation, and in those with AI, UI was the top barrier, demonstrating that many women experience more than one symptom of PFD as a barrier to exercise.
Interpretation of results
Our results support earlier work (2), that for symptomatic women, UI is the highest ranked barrier to exercise, and this held true in a very large sample. As well as being highly prevalent, leaking urine resulted in significant impact, with one third of the women who identified it as a barrier reporting it stopped them participating in exercise often/all of the time. Due to the nature of the study it is possible that those with more severe or impactful symptoms were more likely to participate in the study. However, even women with slight UI severity perceived UI to be a barrier, with nearly half of those reporting it stops them exercising often/all of the time. UI was the highest ranked barrier in the age group representing the childbearing years, however it was also the most prevalent barrier in the youngest age category (18-25 years) indicating that screening and managing this condition is important even in younger athletes, and in nulliparous women. In women who reported past leaking urine whilst exercising, more than 75% reported it caused them to stop or modify their exercise activities in some way, which is higher than previously reported (3), demonstrating the growing magnitude of the problem. With sedentary behaviour and obesity rates rising, potentially modifiable barriers impacting exercise participation cannot be ignored. This study is the first to identify POP and AI as prevalent barriers with significant impact on exercise participation. Not only does PFD have a considerable level of impact, but women also report being significantly bothered by the effect of symptoms limiting exercise participation.