Since 1994 when the first study of urinary incontinence (UI) among female athletes was done, there has been a steadily increasing interest in this area of research. To date, 36 studies focus on urinary incontinence among female athletes, primarily elite athletes. Among the 34 studies focused on athletic incontinence, a variety of instruments have been used to assess key components of the athletic incontinence dynamic.  Most studies used urinary incontinence screening tools which were designed for use in general clinical work with women (e.g. ICIQ-SF, UDI-6, IIQ, OAB, BFLUTS) and ask about a variety of aspects of incontinence. Several studies assessed the effect of incontinence on quality of life (using I-QOL and KHQ). Some studies asked additional questions about bladder habits, menstrual status, self-management techniques.  A few asked about constipation. All of the studies added questions to assess the extent of athletic involvement. This method of patching together validated instruments and home-made questionnaires was used across all studies because no instrument existed which was designed for use with a population of female athletes. 

In a recent literature review performed by the authors, the 17 instruments used across these studies were compared and critiqued. Their advantages and disadvantages were discussed and the literature review concluded that a questionnaire designed to measure the key factors in urinary incontinence in athletics is needed and should include the best traits of the instruments reviewed in this study. The optimal instrument would include measures of: demographics, bladder habits and symptoms, bowel habits and symptoms, degree of involvement in athletics, high risk maneuvers and activities, menstrual status, obstetric history, incontinence during athletics, incontinence during activities of daily living, quality of life, and self management strategies. 

In response, the authors have developed a comprehensive instrument in order to consistently assess UI in athletics based on the following five categories: 1) urinary incontinence in athletics, laughter and activities of daily living 2) bowel and bladder habits 3) athletic participation 4) quality of life , and 5) health history.  This will allow for standard assessment and discussion of major concepts in future studies, and thorough screening in clinical settings.

The purpose of this paper is to describe the method by which this instrument was developed, validated and tested, and made available for broader use.

Based on a 2018 literature review by the authors which provided an analysis of the instruments used to assess UI, an instrument called the Athletic Incontinence Tool (AIT) was developed and tested, with the goal of including the best traits of the 17 instruments used in previous studies. Categories from previous studies included: demographics, bladder habits and symptoms, bowel habits and symptoms, degree of involvement in athletics, high risk maneuvers and activities, menstrual status, obstetric history, incontinence during athletics, incontinence during activities of daily living, quality of life, and self management strategies.

Once the instrument was created, the first step in establishing validity was to seek input from individuals who experience the UI during athletics. This included assembling a group of adult women, administering the instrument, and soliciting feedback about the content, language and format of the instrument. 

Because the instrument was planned to be used with an adolescent sample, a separate version of the instrument was developed and tested on adolescent girls in athletics, again soliciting their feedback for content, language and format. Particular attention was paid to language, with more emphasis on common language and less use of medical terminology. 

Both versions of the AIT were tested. The adolescent version was tested in a pilot study with high school varsity athletes and the adult woman version was tested in small groups of adult women, primarily runners. 

In the process of tailoring the language of the survey to the age groups, tailoring questions to athletic circumstances, and the authors' feeling of increased ability to ask about pregnancy in older age groups, and third version of the instrument was developed for college students. This allowed optimal phrasing of questions which reflect the likelihood of fewer sports played with greater intensity and the unique expectations of a college athlete's life. As with the adolescent and adult woman versions, the college athlete version was tested in a small sample of college athletes and feedback on format, language and content were solicited and used to make improvements. 

Content and construct validity were assessed and adjustments in questions were made to improve the instrument.

The Athletic Incontinence Tool in its current form contains 41 questions. 

questions about sensitive topics (such as question about surgery, trauma to the bladder, anus, vagina or pelvic floor) are addressed in the college athlete and in the adult woman version, but are excluded from the adolescent version so that IRB approval can be easily achieved for researchers. Similarly, questions about vaginal delivery, size of largest baby, and obstetric interventions like episiotomy or forceps are only included in the adult woman version. 

Several items were included in the instrument to fill a gap that many previous studies did not cover, including bowel habits and symptoms and unique circumstances when incontinence occurs (such as in hot weather, when crossing a finish line, running down hill). Importantly, an image of the Bristol Stool Scale is included in the instrument so that women can look at the scale while responding to questions about stool type. Questions about incontinence during activities of daily living are also included, specifically during laughter. 

There are options to skip sections if answers are negative (i.e. if symptoms of incontinence are not experienced) so that athletes who do not experience incontinence can meaningfully complete the instrument.

Feedback from the sample in a pilot study and from respondents who have taken the Athletic Incontinence Tool have been detailed and have been incorporated into the instrument to improve both reliability and validity. 
The Athletic Incontinence Tool is comprehensive and is thoughtfully designed with developmental level, language, and athletic context in mind.

The Athletic Incontinence Tool provides researchers interested in this area of study with a comprehensive and streamlined method assessing the key factors related to UI in athletics.