Volume 59, Number 10

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2004
by Lippincott Williams & Wilkins CME REVIEWARTICLE 28
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total
of 36 AMA/PRA category 1 credit hours can be earned in 0. Instructions for how CME credits can be earned appear on the
last page of the Table of Contents.

Exercise and Urinary Incontinence

in Women
Kanli Jiang, PhD,* Joseph M. Novi, DO,† Suzanne Darnell,‡ and
Lily A. Arya, MD§
*Medical Student, University of Pennsylvania, Philadelphia, Pennsylvania; †Fellow, Division of
Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pennsylvania; ‡Medical Student, University of Minnesota Minneapolis,
Minnesota; and §Assistant Professor, Department of Obstetrics and Gynecology, Division of Urogynecology
and Reconstructive Pelvic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania

Urinary incontinence is a common problem in women and may significantly impair their quality of
life. Although women often report stress urinary incontinence during exercise, current data indi-
cates that most types of exercise are not a risk factor for the development of urinary incontinence.
However, certain extreme high-impact sports such as parachute jumping may cause pelvic organ
support defects that result in stress urinary incontinence. Eating disorders also increase the risk of
urinary incontinence in athletes. Overall, women should be encouraged to pursue physical activity
that will benefit their general health without the risk of development of urinary incontinence later in
life. Women athletes should be counseled about the increased risk of urinary incontinence with
ultra high-impact sports and eating disorders.
Target Audience: Obstetricians & Gynecologists, Family Practitioners
Learning Objectives: After completion of this article, the reader should be able to list the most common
types of urinary incontinence, to outline the risk factors for the development of urinary incontinence, and
to describe the pathogenesis of exercise-associated urinary incontinence.

Urinary incontinence is a common problem affect-
ing women of all ages. It is defined by the Interna-
tional Continence Society as “the complaint of any
involuntary leakage of urine that is objectively de-
monstrable and is a social and hygienic problem” (1).
The prevalence of urinary incontinence ranges from
5% to 54% depending on the definition used and the
population studied, with a mean prevalence of 28%
(2). The most common type of female urinary incon-
tinence is stress urinary incontinence, affecting 50%
of all incontinent women. The next most common
type is mixed incontinence (32%), followed by urge
Reprint requests to: Joseph M. Novi, DO, Fellow, Division of Urogy-
necology and Reconstructive Pelvic Surgery, Department of Obstetrics
and Gynecology, University of Pennsylvania, 5 Penn Tower, 3400
Spruce Street, Philadelphia, PA 19104. E-mail: jnovi@obgyn.upenn.edu.
The authors have disclosed no significant financial or other
relationship with any commercial entity.
717
urinary incontinence (14%) (2). According to the
International Continence Society, stress urinary in-
continence is “the complaint of involuntary leakage
of urine on effort or exertion, or on sneezing or
coughing”; and urge urinary incontinence is “the
complaint of involuntary leakage of urine accompa-
nied by or immediately preceded by urgency” (1).
Mixed incontinence describes the coexistence of both
symptoms. Urinary incontinence impacts many as-
pects of a woman’s life, including health, psychoso-
cial, occupation, and leisure (3).
RISK FACTORS FOR URINARY
INCONTINENCE
Multiple risk factors have been found to be asso-
ciated with urinary incontinence. These include age,
718 Obstetrical and Gynecological Survey
parity, vaginal delivery, obesity, race, and lifestyle
factors.
Age
Several studies have identified increasing age as a
major risk factor in the development of urinary in-
continence. A recent review of the literature showed
that there are 2 distinct peaks in the prevalence of
urinary incontinence, one in the fifth decade of life,
and the second in the eighth decade (2). The preva-
lence of significant urinary incontinence increases
from the second to the eighth decades (2).
Pregnancy-Related Factors
Almost 32% of women report stress urinary incon-
tinence during pregnancy and most tends to be new
onset (4). It has been shown that women who report
stress urinary incontinence during their first preg-
nancy and those who develop stress incontinence
during the immediate postpartum period are at high
risk for persistent stress urinary incontinence 5 years
later (3). Other independent obstetric risk factors of
urinary incontinence are multiparity and vaginal de-
livery (2,3). Forceps-assisted vaginal delivery may
be an additional risk (5). Data regarding the impact
of the size of the baby, fetal head, and the length of
second stage of labor on the development of urinary
incontinence are controversial (3).
Obesity
Increased body mass index (BMI) has been estab-
lished as an independent risk factor for the develop-
ment of urinary incontinence. It has been shown that
with each unit increase in BMI, there is a 5% increase
in the odds of having urinary leakage (6).
Race
After adjusting for known risk factors such as age,
parity, and BMI, several studies have demonstrated
that white race is a significant risk factor for the
development of stress urinary incontinence (2,3,7).
In 1 study, black race was a significant predictor of
urge incontinence (odds ratio [OR], 2.6; 95% confi-
dence interval [CI], 1.45–4.80) (7).
Diet
In a large longitudinal study, daily or more fre-
quent intake of carbonated beverages was found to be
a risk factor for stress urinary incontinence (OR,
1.62; 95% CI, 1.18–2.22) (8). Interestingly, in the
same study, daily bread intake was found to be as-
sociated with a reduced risk of stress urinary incon-
tinence (OR, 0.76; 95% CI, 0.61–0.96). High caf-
feine intake has also been associated with a higher
risk of urge urinary incontinence (OR, 2.4; 95% CI,
1.1–6.5) (3,9). No statistically significant correlation
between urinary incontinence and alcohol intake has
been reported (2). One study has shown that eating
disorders such as anorexia nervosa were associated
with increased risk of all urinary symptoms, includ-
ing urgency, frequency, nocturia, stress and urge
urinary incontinence (10). This observation has also
been reported by Bo et al., who noted an increased
prevalence of stress urinary incontinence in athletes
with eating disorders (P ⫽ 0.03) (11).
Smoking
Smoking has been shown to be a risk factor for
both stress and urge urinary incontinence. In 1 study,
women with detrusor instability were more likely to
be current smokers than control subjects (9). Women
smokers have also been reported to have a 2.5-fold
increased risk for developing stress urinary inconti-
nence than control subjects (12).
Exercise
Women commonly report stress urinary inconti-
nence during physical activity; however, it is not
clear whether exercise is a causative factor in the
development of stress urinary incontinence.
The purpose of this article is to review the litera-
ture regarding the role of physical exercise in the
etiology of urinary incontinence.
EXERCISE AND INCONTINENCE
Prevalence of Incontinence in Exercising
Women
Nygaard et al. reported in 1990 that as many as 30%
of women complain of urinary leakage during physical
activity. The highest rates were reported in high-impact
activities such as running (38%) and high-impact aer-
obics (36%). The mean age of women in that study was
38.5 years (13). A subsequent study by the same au-
thors showed that exercise-associated incontinence is
also a common problem in much younger, nulliparous
women (mean age, 19.9 years) with as many as 28%
reporting stress urinary incontinence during exercise
 Exercise and Urinary Incontinence Y CME Review Article 719

(14). A more recent study in 2002 by Eliasson et al.
described similar findings in nulliparous elite trampo-
linists with 80% reporting involuntary leakage (15).
Thus, there appears to be a high prevalence of stress
urinary incontinence in women who participate in high-
impact exercise.
Exercise as a Risk Factor for Incontinence
Several studies have been published in the last few
years comparing the rate of urinary incontinence in
women who exercise and those who do not. These
results are summarized in Table 1.
A 1990 study by Nygaard et al. reported that there
was no difference in the prevalence of urinary incon-
tinence in women who exercised and nonexercisers.
However, this study was limited by a small sample
size.
In 1997, the same group performed a retrospective
cohort study comparing the rate of urinary inconti-
nence in women who participated in low-impact
(swimming) and high-impact (gymnastics and track
and field) sports. A group of 104 female former
Olympians who had competed in these sport events
were identified. They were asked to recall urinary
incontinence when they were actively competing in
their sports and also to report current symptoms of
urinary incontinence. Women who participated in
high-impact sports reported a higher rate of urinary
incontinence while they had been actively competing
than those in low-impact sports. However, rates of
current urinary incontinence were not statistically
different in these 2 groups of women (41.1% vs.
50.0%). This study suggests that women actively
competing in high-impact sports report higher rates
of stress urinary incontinence than those active in
low-impact sports. Importantly, this disparity does
not appear to persist later in life (16).
In a large prospective study involving 660 elite
athletes and 765 nonathletes, Bo et al. reported no
significant difference in the prevalence of stress or
urge urinary incontinence between cases and control
subjects. In this study, urinary incontinence was di-
agnosed by a standardized questionnaire and a clin-
ical interview. Athletes were divided into different
sport groups, including technical, endurance, es-
thetic, weight-dependent, ball games, power, and
gravity. In addition, data on eating disorders were
collected using Diagnostic and Statistical Manual of
Mental Disorders, 4th edition, criteria. There was no
statistically significant difference in the prevalence
of stress or urge urinary incontinence between ath-
letes and control subjects (41% vs. 39% with stress
urinary incontinence and 16% vs. 19% with urge
urinary incontinence, respectively). However, the
prevalence of stress urinary incontinence (49.5%)
and urge incontinence (20%) in athletes with eating
disorders was significantly higher than in healthy
athletes, 38.8% (P ⫽ 0.003) and 15% (P ⫽ 0.048),
respectively.
A small study was conducted by Davis et al. in
1996 investigating the role of ultra high-impact
sports such as parachute jumping in the development
of urinary incontinence. In this study of 512 female
soldiers in an airborne infantry unit, 9 previously
continent women reported severe urinary inconti-

Table 1
Relationship between exercise and urinary incontinence
Mean age
Author Year Design Subjects N (years) Prevalence of UI Comments
Control Exercise P
Nygaard 1990 Cross-sectional Female volunteers 326 38.5 N/A 30% NS Small number of
controls
Davis 1996 Case series Airborne infantry 9 21–34 N/A 9 with severe UI N/A UI confirmed with
trainees urodynamics
Nygaard 1997 Retrospective Former female 104 46.2 N ⫽ 48 N ⫽ 56 NS Control women
Cohort Olympians were low-impact
sports Olympians
v. 42.4 50.0% 41.1%
Bo 2001 Case-control Elite athletes v. 1425 21.5 N ⫽ 765 N ⫽ 660 No objective
non-athletes measurements
for UI
v. 24.2 SUI (39%) SUI (41%) NS
UUI (19%) UUI (16%) NS
UI ⫽ urinary incontinence; SUI ⫽ stress urinary incontinence; UUI ⫽ urge urinary incontinence; N/A ⫽ non-applicable; NS ⫽ non-
significant.
720 Obstetrical and Gynecological Survey
nence on completion of training. Objective testing
revealed that 3 of the 9 women had urge urinary
incontinence and 6 had stress urinary incontinence.
On physical examination, the 6 women with stress
urinary incontinence showed evidence of bladder
neck hypermobility, anterior vaginal wall prolapse,
and loss of urine with Valsalva maneuvers. Interest-
ingly, 5 of them could recall a specific traumatic
event associated with a parachute jump after which
her urinary incontinence began. All 5 recalled a pain-
ful feeling in the pelvic region at the time of the
incident. All 6 opted for surgical intervention at
which time the pubocervical fascia was noted to be
separated from the pelvic side wall (17). Despite the
small size of this study, it appears that activities that
predispose women to pelvic organ support damage
could be a risk factor for urinary incontinence.
Pathogenesis of Exercise-Associated
Incontinence
Stress urinary incontinence commonly reported
during physical activity is likely the effect on the
normal continence mechanism of excessive increases
in intraabdominal pressure that occur during exer-
cise. Normally, when intraabdominal pressure rises
during coughing or exercise, continence is main-
tained because this pressure increase results in direct
mechanical compression of urethral sphincter against
the supporting endopelvic fascia of the vagina (18).
This effectively closes the urethral sphincter. It is
possible that during high-impact sports such as vig-
orous running, gymnastics, or intense aerobics, intra-
abdominal pressure rises high enough to allow intra-
vesical pressure to exceed intraurethral pressure.
This excessive rise may overwhelm even a normally
functioning continence mechanism, leading to stress
urinary incontinence. It seems unlikely that even
high-impact sports result in direct physical damage to
the urethral support system (16). However, extreme
high-impact sports such as parachute jumping may
cause direct physical damage to the pelvic floor such
that separation of the pubocervical fascia from the
pelvic side wall occurs (17). This would result in
poor support of the bladder neck with consequent
bladder neck hypermobility and stress incontinence.
The high prevalence of urinary incontinence in
women athletes who also have eating disorders is
harder to explain. In 1992, Bump et al. postulated
that urinary incontinence in smokers may be the
result of the damaging effect of nicotine on the
endopelvic fascia (12). It is possible that the lack of
appropriate nutrients, as may occur in women with
eating disorders, might also weaken the endopelvic
fascia and lead to an increased risk for urinary in-
continence. Furthermore, women with eating disor-
ders that involve self-induced vomiting may be sub-
jecting the pelvic floor and endopelvic fascia to
significant repetitive pressures might have a cumu-
lative negative impact on these structures.
CONCLUSION
Current data on the role of exercise in the devel-
opment of urinary incontinence is limited. Existing
studies are compromised by retrospective design and
failure to control for confounding factors such as
diet, hormonal factors, and BMI. Additional prospec-
tive studies are required to fully evaluate the role of
exercise in the development of urinary incontinence.
Nevertheless, based on existing literature, it is pos-
sible to draw some conclusions. Health problems
reported in women athletes include an increased in-
cidence of sports-related injuries, arthritis, and men-
strual disturbances (19). As a result of its potential
for serious social and psychologic impacts, the high
prevalence of urinary incontinence associated with
physical activities deserves special attention. Based
on our review of the available data, it appears that no
causal relationship has been identified between most
forms of exercise and the development of urinary
incontinence. However, extreme high-impact sports
may increase the risk of developing urinary inconti-
nence by causing direct damage to the pelvic organ
support structures. Additionally, women athletes who
have eating disorders are at high risk for urinary
incontinence even if they participate in less intense
exercise.
Regular and moderate exercise is known to promote
cardiovascular health, weight control, muscle strength,
bone density, as well as psychologic health. In light of
our present knowledge, we recommend that women be
encouraged to pursue physical activity that will benefit
their general health. They should be counseled about
the increased risk of urinary incontinence with ultra
high-impact sports. All women should be encouraged to
maintain normal eating habits and body weight to aid in
preserving continence.
REFERENCES
1. Abrams P, Cardozo L, Fall M, et al. The standardisation of
terminology in lower urinary tract function: Report from the
Standardisation Sub-committee of the International Conti-
nence Society. Urology 2003;61:37–49.
2. Minassian VA, Drutz HP, Al-Badr A. Urinary incontinency as a
worldwide problem. Int J Gynecol Obstet 2003;82:327–338.
 Exercise and Urinary Incontinence Y CME Review Article
3. Holroyd-Ledue JM, Straus SE. Management of urinary incon-
tinence in women: Scientific review. JAMA 2004;291:986–995.
4. Viktrup L, Lose G, Rolff M, et al. The symptom of stress
incontinence caused by pregnancy or delivery in primiparas.
Obstet Gynecol 1992;79:945–949.
5. Arya LA, Jackson ND, Myers DL, et al. Risk of new-onset
urinary incontinence after forceps and vacuum delivery in
primiparous women. Am J Obstet Gynecol 2001;185:1318–
1323.
6. Sampselle CM, Harlow SD, Skurnick J, et al. Urinary inconti-
nence predictors and life impact in ethnically diverse perim-
enopausal women. Obstet Gynecol 2002;100:1230–1238.
7. Graham CA, Mallett VT. Race as a predictor of urinary incon-
tinence and pelvic organ prolapse. Am J Obstet Gynecol
2001;185:116–120.
8. Dallosso MM, McGrother CW, Matthews RJ, et al. The asso-
ciation of diet and other lifestyle factors with overactive blad-
der and stress incontinence: A longitudinal study in women.
BJU Int 2003;92:69–77.
9. Arya LA, Myers DL, Jackson ND. Dietary caffeine intake and
the risk for detrusor instability: A case-control study. Obstet
Gynecol 2000;96:85–89.
10. Hextall AS, Majid L, Cardozo K, et al. A prospective controlled
study of urinary symptoms in women with severe anorexia
nervosa [Abstract]. Neurourol Urodyn 1999;18:398–399.
721
11. Bo K, Borgen JS. Prevalence of stress and urge urinary in-
continence in elite athletes and controls. Med Sci Sports
Exerc 2001;33:1797–1802.
12. Bump RC, McClish DK. Cigarette smoking and urinary incon-
tinence in women. Am J Obstet Gynecol 1992;167:1213–
1218.
13. Nygaard I, DeLancey JOL, Arnsdorf L, et al. Exercise and
incontinence. Obstet Gynecol 1990;75:848–851.
14. Nygaard IE, Thompson FL, Svengalis SL, et al. Urinary incon-
tinence in elite nulliparous athletes. Obstet Gynecol 1994;84:
183–187.
15. Eliasson K, Larsson T, Mattsson E. Prevalence of stress in-
continence in nulliparous elite trampolinists. Scand J Med Sci
Sports 2002;12:106–110.
16. Nygaard IE. Does prolonged high-impact activity contribute to
later urinary incontinence? A retrospective cohort study of
female Olympians. Obstet Gynecol 1997;90:718–722.
17. Davis G, Goodman M. Stress urinary incontinence in nullipa-
rous female soldiers in airborne infantry training. Journal of
Pelvic Surgery 1996;2:68–71.
18. Delancey JOL. Structural support of the urethra as it relates to
stress urinary incontinence: The hammock hypothesis. Am J
Obstet Gynecol 1994;170:1713–1723.
19. Warren MP, Sjantha S. The female athlete. Bailliere’s Clinical
Endocrinology and Metabolism 2000;14:37–53.