Stress urinary incontinence (SUI) is a complaint of involuntary loss of urine during effort or physical exertion, or during sneezing or coughing [1]. SUI is frequently a symptom during pregnancy and in the postpartum periods.  However, it also affects women in sport [2]. High prevalence of SUI has been shown in sports involving running and jumping but there is sparse knowledge on women participating in strength sports [2]. The aim of this study was to identify the scope of the problem of SUI in women participating in strength sports, movement patterns that elicit SUI, and the impact on quality of life in female athletes with SUI.

This study followed a mixed methods design, with a quantitative survey and qualitative focus group interviews. The International Consultation on Incontinence Questionnaire on Urinary Incontinence Short Form (ICIQ-UI-SF) was sent to women who are United States citizens, age 18-65, and members of USA Weightlifting (USAW), USA Powerlifting (USAPL), and/or United States CrossFit affiliates [3].  In addition to the ICIQ-UI SF, several demographic questions were added to the survey: age, body mass index (BMI), sport preference (USAW, USAPL, CrossFit, or a combination), number of pregnancies, number of delivery(ies),  type of delivery(ies), vaginal tears during labor and delivery, frequency and duration of exercise sessions per week, and perceptions of leakage in and outside of training. Polychoric and Spearman correlations were conducted for survey analysis. A logistic regression was performed to estimate predictors of the likelihood of women experiencing urine leakage with exercise. Wald chi-square tests were used to calculate odds ratios for each outcome. Following the survey, respondents were able to volunteer to participate in two focus groups for qualitative data. Eight women participated in the focus groups.

Three hundred forty-two respondents completed the online survey (5% response rate); the largest representative was from Olympic weightlifting members (n=239). A majority of respondents (n=226, 65.5%) reported leaking once per week or more often. When responding to “when does urine leak?” a majority of respondents (n=154, 44.8%) reported leakage during physical activity and exercise. There was a moderate positive correlation between parity and the interference of urine leakage with everyday life (r=.336, p<.001) and between urine leakage during exercise and urine leakage outside of exercise (r=.397, p<.001),  as well as urine leakage during exercise and interference with everyday life (r=.683,  p<.001).  There was also a weak, but statistically significant correlation between hours per week of physical activity and urine leakage outside of exercise (r=-.122, p=.024).  Sport preference was the only statistically significant predictor of urine leakage with exercise (OR 1.227 {95% CI 1.04-1.45}, p=.01), as shown in Table 1. Multiparity was the only statistically significant predictor of urine leakage outside of exercise (OR 1.402 {95% CI 1.00-1.94}, p=.04), as shown in Table 2.  Qualitative reports demonstrated feelings of embarrassment, frustration, and hopelessness with urine leakage during and outside of exercise. Women reported double-unders, deadlift, running/jumping, front squats, cleans, and push press as the primarily offending movements during exercise that cause leakage during exercise.  Main barriers to quality of life included adjustments to or elimination of training exercises, feelings of annoyance/irritation, and that urinary leakage is an acceptable side effect of training. Women stated that if provided education about pelvic floor muscle training they would use it, but only once the urinary leakage episodes became severely bothersome. Qualitative results show that while women have negative motions surrounding SUI, they are also not comfortable asking for more resources beyond pelvic floor muscle training from their physicians.

Quantitative results are similar to those found in previous studies that SUI is an issue within female athletes [2]. Due to the poor response rate (5%) it is not possible to generalize to the female strength population. This is one of few studies that specifically examined female athletes involved in strength sports. Qualitative results support the need for additional research examining each of these strength sports individually to truly identify the scope of the problem and the manner in which women choose to address SUI.

Parous women are more likely to report SUI than nulliparous women. Parity and hours of training per week are linked to urine leakage both during and outside of exercise. Despite negative feelings of shame, embarrassment, and frustration, women accept SUI as a side effect of training, and are hesitant to ask for more from their physicians beyond pelvic floor muscle training information. Additional research is needed to examine each strength sport individually.

Haylen BT, Freeman RM, Swift, SE, et al. The International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) and grafts in female pelvic floor surgery, Neurourol Urodyn, 2010; 30(1), 2-12.
Bø K, Nygaard IE. Is physical activity good or bad for the female pelvic floor? A narrative review. Sports Med, 2019; doi:10.1007/s40279-019-01243-1
Avery, K, Donovan, J, Peters, TJ, et al. ICIQ: A brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn, 2017; 23, 4, 322-330.