Tumble lines & leaking? Or tuck jumps & a tight pelvic floor?

Do you leak urine when you run, jump or land?

Are you scared that you will leak urine during training or a routine?

Do you feel a lump / bulge sitting in the vagina?

Why are female athletes at a higher risk?

Female athletes (gymnasts, trampolinists, track athletes) are at more risk of urinary incontinence than women who do not engage in high impact exercise (tai chi, yoga, swimming) (Nygaard et.al, 2016). Stress incontinence is defined as the “involuntary loss of urine on effort or physical exertion, or on sneezing or coughing” (IUGA / ICS Terminology Report, 2010).

67% of female gymnasts reported urine leakage during training

In a study of young female athletes, nearly 1/3rd reported urine loss while participating in their sport.

Gymnasts reported the highest rate of urine leakage (67%), followed by:

- basketball 66%

- tennis 50%

- field hockey 42%

- track 29%

- swimming 10%

- volleyball 9%

- softball 6%

- golf 0%.

Two-thirds of the women who noted urine loss during athletics were incontinent more often than rarely. There was no association found between incontinence and amenorrhea (missed menstrual cycles), weight, hormonal therapy, or duration of athletic activity. Activities most likely to provoke incontinence included jumping, high-impact landings, and running. 17% of the women first noted incontinence during their sport while in high school and junior high school, respectively (Nygaard, et.al.2016).

A study of elite female trampolinists (age range 15 – 22 years) showed that 80% of the trampolinists reported involuntary urinary leakage, but only during trampoline training. The leakage started after 2.5 (range 1 - 4) years of training (Eliasson, K.et. al, 2002).

The support system – muscles and fascia

The pelvic floor is a group of muscles in both men & women which sit like a hammock between the pubic bone, tailbone and seat bones. The role of the deep pelvic floor muscles is to support the position of the bladder & bowel (& uterus in women). The superficial muscles keep closed around the sphincter and vagina to maintain urinary & faecal continence. Fascia is a layer of connective tissue (similar to Glad – wrap) which also helps to hold the bladder, uterus and vagina in place. When the pelvic floor muscles lift, the fascia tightens and pulls the neck of the bladder closer to the pubic bone, keeping it shut and maintaining continence.

Over time, strenuous physical activity, particularly high – impact exercise, can cause the bladder neck to gradually drop past the fascia and muscle that work together to keep it closed – leading to urinary incontinence.

High – impact exercise can also increase the intra – abdominal pressure (IAP) (pressure within the abdominal region) and may, over time, place repetitive strain on the muscles and fascia of the pelvic floor (Rao, et.al, 2006). At rest, the IAP is 40cmH20. A full sit up can generate 128cmH20, jumping 153cmH20, and a cough can be up to 199cmH20! (Shaw et.al, 2014)

One misconception of pelvic floor function is that to prevent leakage while exercising is that you need to be contracting your pelvic floor the entire time. The pelvic floor is a dynamic group of muscles, which must load and lengthen to absorb the force downward with high impact loading. If you jump on a trampoline that is too tight, there is no bounce. Holding the pelvic floor muscles in a state of contraction has the same effect. Two potential dysfunctions may result: the pelvic floor muscles will give up and stop supporting the fascia - resulting in incontinence, or they may become chronically overactive.

The effects of being “too flexible”

Athletes who are very flexible may have benign joint hypermobility syndrome (BJHS). The basic pathophysiology of BJHS is due to an underlying abnormality in collagen where the ratio of type III to type I collagen is increased (Child, 1986). This means that tissue is more stretchable, which may result in generalised tissue damage. BJHS usually presents with a variety of musculoskeletal problems ranging from joint subluxation to tendosynovitis. It may also affect multiple other systems, including the musculotendinous pelvic floor (Mastoroudes, et.al, 2013). Repetitive bouncing and stretching has the potential to stretch the fascia and ligaments supporting the bladder, bowel and uterus.

Pelvic Floor Overactivity

Muscle strength is not equal to tonicity - you can have strong muscles, but at same time, they can have high or even low tonicity / stiffness.

Symptoms of overactivity of the pelvic floor include:

- constipation

- incomplete emptying of the bowels

- pelvic pain

- low back pain

- coccyx pain

- vaginismus

- urinary incontinence

- incomplete emptying of the bladder

- slow flow of urine

- hesitancy or delayed start of urine stream

- urinary urgency

What can be done about it?

See your Pelvic Floor Physiotherapist! We are specially trained in the assessment, diagnosis and treatment of individual pelvic floor disorders. The goal should not be about tightening the pelvic floor the whole time, but controlling the loading and the impact on the muscles. Do the muscles relax when you need to open your bowels, insert a tampon, and urinate? These activities should be pain – free. You may also benefit from instruction in how to properly use the pelvic floor muscles – strengthening or relaxation of the muscles depends on each individual.

Remember, stress incontinence may be common, but it is not the “price you have to pay” to continue high – impact sport.

References:

Child AH (1986) Joint hypermobility syndrome: Inherited disorder of collagen synthesis. J Rheumatology 13:239–46.

Eliasson K1, Larsson T, Mattsson E. (2002). Prevalence of stress incontinence in nulliparous elite trampolinists. Scand J Med Sci Sports.12(2):106-10.

Haylen BT, de Ridder D, Freeman RM et al (2010) An International Urogynaecological association (IUGA)/ International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 21:5–26

Nygaard, Ingrid and Shaw, Janet. Physical activity and the pelvic floor., expert review. American Journal of Obstetrics & Gynaecology, February 2016

Mastoroudes, H. (2013). Lower urinary tract symptoms in women with benign joint hypermobility syndrome: a case–control study. International Urogynecology Journal 24 (9):1553–1558.

Shaw, J. (2014). Intra -abdominal pressures during activity in women using an intra-vaginal pressure transducer. Journal of Sports Science. 32(12): 1176–1185.

Rao, LCP, Chaudhry,CR & Kumar, LCS. (2006). Abdominal Compartment Pressure Monitoring - a simple techniques. MJAFI,Vol. 62, No. 3.