Hypothesis / aims of study
There is a growing body of literature regarding female urinary incontinence which occurs in the context of athletic activities.
Since 1992 when the first study of urinary incontinence among elite female athletes was done, there have been 36 studies focused on incontinence during exercise, with a particular focus on elite athletes. These studies have consistently demonstrated that approximately 30% of elite college and Olympic athletes experience urinary incontinence during athletics [1]. Incontinence during athletics also occurs in the teenage years and affects 34% of competitive high school athletes who were surveyed [2]. High-impact sports (including trampoline, gymnastics, tennis, basketball, running) have rates as high as 80%. Low impact sports such as swimming, and golf have lower rates of incontinence [3].
In the 36 studies focused on urinary incontinence during athletics, a variety of instruments have been used to assess incontinence (e.g. ICIQ-SF, UDI-6, IIQ, OAB, BFLUTS, etc.). A number of other instruments have been used to measure the effect of incontinence on quality of life (I-QOL and KHQ). Still other questionnaires have been created to capture data about the type of sport and degree of engagement in the sport. Studies thus far have patched together these questionnaires to create a picture of urinary habits and severity of incontinence symptoms.
However, there is currently no single questionnaire that comprehensively and consistently is used to assess the key concepts related to urinary incontinence during athletics. Importantly, most instruments under-emphasize or do not acknowledge the role of bowel pattern on urinary function and only one asked about menstrual status. The purpose of this study was to provide a comparative analysis and discussion of the instruments used in prior studies and to identify the essential components of an optimal, comprehensive instrument designed for this population.
Study design, materials and methods
An exhaustive literature review of studies regarding urinary incontinence among female athletes was performed using the CINAHL, PubMed, and Cochrane databases and the search terms ‘urinary incontinence AND athlet*’. Thirty-six articles were found.
Only articles that focused on the prevalence and incidence of UI in female athletes were included. Articles that focused on the mechanism and theories behind UI were not included.
The questionnaires and instruments used in these studies were compiled and comparisons among the data they sought were made in a spreadsheet, including authors, year of instrument development, language, length of study, and the content of what the instrument was asking, including: demographics, obstetric history, menstrual status, bowel habits, bladder habits, incontinence during ADLs, incontinence during athletics, quality of life, and self-management strategies.
Questionnaires created by researchers were sought by email. One author provided a copy of the individualized questionnaire (with questions that supplemented standardized urinary incontinence instruments) used in her study. The authors sorted questions into groups to identify the major foci common across studies and created a critique of the advantages and disadvantages of the various instruments used.
Results
Among the 34 studies analyzed, 17 different instruments were used: 9 instruments focused specifically on UI symptoms and habits; 6 instruments were developed by investigators to focus on the relationship between athletics and UI; and two instruments focused on quality of life. Bowel symptoms were assessed in some studies, usually simply by asking about ‘constipation,’ while one study used the Rome III criteria. Of the 17 instruments analyzed, 12 were validated and 5 were not validated. Short forms of instruments were frequently used.
A wide variety of instruments used, and all of the studies combined a variety of instruments to obtain their desired data. However, there was not one tool that was consistently used across studies, nor one that could "stand alone" to assess all of the aspects of UI in athletics that the researchers were aiming to assess. A patchwork method using several instruments was required. One questionnaire (the EPIQ) was created with the goal of being used as a comprehensive assessment, however its length may have proven prohibitive to research use since it had not been used by any other researcher.
Interpretation of results
Previous studies of athletic urinary incontinence have used a variety of instruments which have inconsistently assessed a variety of key factors by patching together instruments which were designed as clinical screening tools (often in their short form) together with researcher-developed questionnaires about athletic engagement or sometimes quality of life questionnaires.
A wide variety of factors were measured across the 36 studies, with great variability of focus among studies and equally great variability of the incontinence instruments that were used. Only two of the 17 instruments used asked questions about bowel pattern. It is important to account for bowel habits because constipation may contribute to UI because of the dramatic effect that rectal pressure can have on the bladder. It is necessary to use a standard instrument such as the Bristol Stool Chart to ensure a standard assessment for constipation.
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.