Journal of Sports Sciences

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The prevalence of urinary incontinence in

nulliparous female sportswomen: A systematic
review

Sania Almousa & Alda Bandin Van Loon

To cite this article: Sania Almousa & Alda Bandin Van Loon (2019): The prevalence of urinary
incontinence in nulliparous female sportswomen: A systematic review, Journal of Sports Sciences,
DOI: 10.1080/02640414.2019.1585312

To link to this article: https://doi.org/10.1080/02640414.2019.1585312

Published online: 01 Mar 2019.

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JOURNAL OF SPORTS SCIENCES
https://doi.org/10.1080/02640414.2019.1585312

PHYSICAL ACTIVITY, HEALTH AND EXERCISE

The prevalence of urinary incontinence in nulliparous female sportswomen:

A systematic review
Sania Almousaa and Alda Bandin Van Loonb
a
Faculty of life Sciences and Education, University of South Wales, Wales, UK; bCobián Clinic, Corunna, Spain

ABSTRACT ARTICLE HISTORY

Urinary incontinence is the complaint of involuntary loss of urine and is a social and hygienic problem. Accepted 7 February 2019
While pregnancy and delivery have been described as etiological factors, observational studies show
KEYWORDS
that urinary incontinence is also prevalent in nulliparous female athletes. Therefore, the general belief Athlete; sports; pelvic floor;
that physically fit women have stronger pelvic floor muscles preventing them from developing urinary nulligravid; high impact
incontinence may be questioned. The aim of this study was to systematically review studies investigat-
ing the prevalence of urinary incontinence in nulliparous female athletes. The electronic databases
Medline, Embase, Cinahl, and Cochrane Library were systematically searched for eligible studies. Two
independent researchers assessed the quality of the included studies and extracted the data in
a standardised data extraction spreadsheet. Twenty-three studies were included in this systematic
review. The urinary incontinence prevalence measured during sport activity varied from 5.7% to 80%.
Urinary incontinence prevalence differs based on the type of sport. Trampolinists were found to have
the highest prevalence of urinary incontinence. The findings suggest that urinary incontinence occurs
often in female athletes, especially those involved in high impact sports. Future studies should
investigate the mechanisms by which high impact sport activities may affect pelvic floor muscles
leading to the development of urinary incontinence.

Introduction with the occurrence of UI as a condition and its treatment

options (Silva & Lopes, 2009; Taylor, Weir, Cahill, & Rizk, 2013).
Urinary incontinence (UI) has been defined as the complaint of
Although pregnancy and delivery have been described as
involuntary loss of urine, and occurs worldwide with a prevalence
the main risk factors in women for the development of UI,
of 13.9% in males, and 51.1% in females (Markland, Richter, Fwu,
epidemiological studies report that female athletes who are
Eggers, & Kusek, 2011). The two most common UI types are stress
nulliparous experience UI episodes too (Carls, 2007; Meyer,
urinary incontinence (SUI) and urge urinary incontinence (UUI)
Schreyer, DeGrandi, & Hohlfeld, 1998; Solans-Domènech,
(Agarwal et al., 2014). SUI is defined as the involuntary loss of
Sánchez, & Espuña-Pons, 2010; Thorp et al., 1999). More spe-
urine on effort or physical exertion (sporting activities), or on
cifically, it has been demonstrated that female athletes often
sneezing or coughing, and UUI as the involuntary loss of urine
have leakage episodes while engaged in their sporting activ-
associated with a sudden compelling desire to pass urine (Haylen
ities (Da Roza, Brandão, Mascarenhas, Jorge, & Duarte, 2015).
et al., 2011).
Therefore, the general belief that physically fit women have
UI has a significant impact on quality of life due to feelings
a stronger pelvic floor due to regular exercise preventing the
of embarrassment, and fear of odour and distress leading
development of UI should be questioned further.
affected women to distance themselves from social and physi-
Physical activity is related to general health, and UI is consid-
cal activities (Hägglund & Wadensten, 2007; Papanicolaou,
ered a barrier to exercise for incontinent women, especially those
Hunskaar, Lose, & Sykes, 2005). The economic cost of UI is
with severe leakage, as they accidentally lose urine during work-
also a substantial issue. It has been reported that in the
outs (Brown & Miller, 2001; Nygaard et al., 2005; Papanicolaou
United States each patient pays on average over $900 per year
et al., 2005). Incontinent women are more than twice as likely to
on resources used for “routine care” (absorbent pads, diapers,
be inactive as continent women (Nygaard et al., 2005).
protection and laundry) (Subak, Van Den Eeden, Thom,
Two previous literature reviews (Goldstick & Constantini,
Creasman, & Brown, 2007). However, despite its high preva-
2014; Heath et al., 2014) and two systematic reviews (De
lence and its negative impact on people’s lives, UI still remains
Mattos Lourenco, Matsuoka, Baracat, & Haddad, 2018;
a taboo issue and is not always reported (Carls, 2007). It has
Teixeira, Colla, Sbruzzi, Mallmann, & Paiva, 2018), one with
been found that 60.6% of women believe that UI is considered
meta-analysis have been conducted; however, they included
taboo and that it is more embarrassing than depression or
both parous and nulliparous female athletes. There is no
cancer, and that less than 30% of incontinent women discuss
systematic data on the prevalence of UI in nulliparous female
it or seek help for it (Elenskaia et al., 2011; Hannestad, Rortveit,
athletes. Pregnancy and delivery have been described as the
& Hunskaar, 2002). In addition, some women are still unfamiliar

CONTACT Sania Almousa sania.almousa@southwales.ac.uk Faculty of life Sciences and Education, University of South Wales, UK
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 S. ALMOUSA AND A. BANDIN VAN LOON
main risk factors for UI; therefore, by including only nullipar-
ous participants, we exclude these factors. An accurate estima-
tion of UI prevalence in nulliparous female athletes and an
exploration of the attitudes toward UI will increase awareness
of the problem in this population and hence may ultimately
lead to the development of prevention strategies. Furthe
rmore, valid UI prevalence measurements may improve the
accuracy of sample size calculation in future studies.
Therefore, the aims of this study were: primarily, to system-
atically review studies investigating the prevalence of UI in
nulliparous female athletes; and secondary, to explore female
athletes’ knowledge of and attitudes toward UI.
Methods
The Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement was used (Liberati et al., 2009).
Data sources and searches
A search of the literature was performed to identify eligible
studies using the following electronic databases: MEDLINE (via
PUDMED), CINAHL (via EBSCO), EMBASE (via OVID), and
Cochrane Library. These databases were utilised to search for
relevant articles from their inception to March 2018. A variety of
keywords and combinations of them were used to search for
relevant articles (Appendix). The following search terms were
used: urinary incontinence; stress incontinence, sports, athletes,
leakage; pelvic floor; high impact; urinary dysfunction; preva-
lence; epidemiology; nulliparous; and nulligravid. Filters were
used only to report studies with human subjects. Logic Boolean
functions were used to establish the search algorithm. In addi-
tion, truncation was used to capture the variations. The electro-
nic search was then supplemented by manual searches of the
reference lists of these articles. Also, a search of Google Scholar
was conducted for the identification of further relevant papers.
Study selection
Specific criteria were applied to the articles to ensure the
studies used were relevant and of a high quality. The studies
were included if: (1) they reported UI prevalence in nulliparous
female athletes, or provided sufficient data from which these
figures could be calculated; (2) they were original primary
studies; any other form was excluded. Any review study, case
report, or current concepts was also excluded. No restrictions
on the language applied.
In cases of mixed study populations (parous and nullipar-
ous), study authors were contacted and asked for split results,
and only the findings of the nulliparous athletes were
recorded and included. In cases of incomplete information in
potentially relevant studies, the authors were also contacted.
When an author did not respond or was unable to provide the
relevant data, the study was excluded. In cases where the
sample comprised of both female and male athletes, only
the female data was included. Abstracts from conferences
were not reviewed for inclusion because of their limited avail-
ability in the electronic databases.
Initially, the titles and abstracts were screened by the two
researchers independently. Full text copies were obtained for the
selected studies to assess for eligibility and the reference lists were
scanned for further relevant articles. Any disagreements that arose
between researchers were resolved through discussion.
Data extraction and quality assessment
Data extraction was carried out by the two researchers indepen-
dently, using a predesigned and standardised form to record
information and data. The methodological quality assessment
of the included studies was conducted by the two researchers
independently, using a modified tool by the ʺNational Heart,
Lung and Blood Instituteʺ (NHLBI) (https://www.nhlbi.nih.gov/
health-topics/study-quality-assessment-tools). The NHLBI is a
quality assessment tool designed for observational studies
including systematic reviews. It contains essential aspects to
evaluate the internal and external validity. This tool includes 15
items and each item received 1 point based on the answer YES
and 0 points for NO/Not Reported (NR). When there was insuffi-
cient information in the article to permit a judgment for an item,
then the item was given a score of zero (0 points). Further details
are given for each item to help guide assessment.
The criteria were as follows: 1. Was the research question,
hypothesis or objective in this paper clearly stated; 2. Was the
study population clearly specified and defined; 3. Was the parti-
cipation rate of eligible persons at least 80%; 4. Were all the
subjects selected or recruited from the same or similar popula-
tions; 5. Were inclusion and exclusion criteria for being in the
study prespecified and applied uniformly to all participants; 6.
Was a sample size justification, power description, or variance
and effect estimates provided; 7. Did the study use an acceptable
case definition; 8. Was the timeframe sufficient so that one could
reasonably expect to see an association between independent
and dependent variables if it existed; 9. Were the independent
variables clearly defined, valid, reliable, and implemented con-
sistently across all study participants; 10. Did the study use the
same method of data collection for all the participants; 11. Were
the dependent variables clearly defined, valid, reliable, and
implemented consistently across all study participants; 12.
Were the outcome assessors blinded to the exposure status of
participants; 13. Was loss to follow-up after baseline 20% or less;
14. Were key potential confounding variables measured and
adjusted statistically for their impact on the relationship between
independent and dependent variables; and 15. Did the study use
appropriate statistical analysis.
The quality scores ranged from 0–15 points. Studies were
classified as being of poor quality when the score was ≤6 points,
fair quality when the score was 7–9, very good quality when the
score was 10–12, and high quality when the score was 13–15.
Data synthesis and analysis
Descriptive statistics were used to summarize the data includ-
ing the mean, the range, and the standard deviation (SD) in
relation to prevalence. The mean prevalence rates were calcu-
lated for each type of UI.
 JOURNAL OF SPORTS SCIENCES 3

Results The age of the included participants ranged from 12 to 45 years

old. The female athletes were gathered from high schools,
The databases identified 2539 results (Figure 1). A total of 23
universities, national and international sports teams, and sports
studies are included in this review and are presented in the Table 1.
clubs. The sample sizes varied from 18 to 503. The quality of
Twenty studies included only nulliparous female athletes
two studies was considered poor, eleven fair, seven very good,
(Almeida et al., 2016; Alves et al., 2017; Bø, Stien, Kulseng-
and three excellent.
Hanssen, & Kristofferson, 1994; Carls, 2007; Da Roza, Brandão,
The prevalence of UI (defined as any leakage) in nulliparous
Mascarenhas, et al., 2015; Dockter, Kolstad, Martin, & Schiwal,
athletes was found by twelve studies to vary from 14.3% to 80%
2007; Eliasson, Larsson, & Mattsson, 2002; Elleuch et al., 1998;
(mean 40.6%; SD 21.9). The prevalence of SUI reported by fifteen
Fozzatti et al., 2012; Hagovska et al., 2017; Kruger, Dietz, &
studies varied from 10.3% to 61.1% (mean 31.6%; SD 17.4). Twelve
Murphy, 2007; Ludviksdottir, Hardardottir, Sigurdardottir, &
studies reported the prevalence of UI during sport as ranging from
Ulfarsson, 2018; Nygaard, Thompson, Svengalis, & Albright,
5.7% to 80% (mean 43.5%; SD 22.9). The prevalence of UUI was
1994; Nygaard, Glowacki, & Saltzman, 1996; Parmigiano et al.,
found to be between 6.1% and 49.5% (mean 22.4%; SD 17.5). The
2011; Pozo-Municio, 2007; Rolli & Frigeri, 2016; Reis, Câmara,
highest prevalence was reported in trampolinists. The prevalence
Santos, & Dias, 2011; Santos, Caetano, Tavares, & Lopes, 2009;
for trampolinists ranged from 72.7% to 80% (during sport activity).
Schettino et al., 2014). Three studies included a mixed sample
Three studies reported that the movements which provoke
of nulliparous and parous women (Jácome, Oliveira, Marques,
leakage during sports are: jumping with legs apart and jumping
& Sá-Couto, 2011; Poświata, Socha, & Opara, 2014; Yi, Tenfelde,
with legs together, running, dismount landings or flips, new som-
Tell, Brincat, & Fitzgerald, 2016) where, in two of these, the
ersaults and difficult exercises, double somersaults, jumps and
prevalence was reported separately and in the third study, the
large leaps (dancing), balancing, and vigorous tap dancing
authors had to be contacted to provide further details regard-
(Eliasson et al., 2002; Nygaard et al., 1994; Pozo-Municio, 2007).
ing the prevalence of UI in the nulliparous participants, to
It was recorded that 50%- 92% of athletes had never dis-
which they complied (Poswiata, Socha, & Opara, 2014). One
cussed the problem with anyone (Carls, 2007; Elleuch et al.,
study included a mixed sample of females and males but the
1998; Nygaard et al., 1994; Pozo-Municio, 2007). 6.3% – 65.1%
results were presented separately, where all women were
of athletes reported that UI affects their life negatively and
nulliparous (Pozo-Municio, 2007).
they consider UI a social or hygienic problem (Bø,
The studies were conducted in the following countries: the
Stien, Kulseng-Hanssen, & Kristofferson, 1994; Carls, 2007; Da
USA (5), Brazil (6), Poland, Portugal (2), Italy (2), Iceland, France,
Roza, Brandão, Mascarenhas, et al., 2015; Eliasson et al., 2002;
Spain, New Zealand, Sweden, the Slovak Republic, and Norway.
Nygaard et al., 1994; Schettino et al., 2014).

Figure 1. Selection process of articles.

 4

Table 1. Summary of included studies.

Prevalence Response Prevalence of UI Prevalence of UI by
Study N Age Type of sports Method of UI rate during sport activity sport Quality
Bo et al. (1994) 34 18–27 Physical educational Interview SUI: 38% 91.9% NR NR Fair
students
Nygaard et al. (1994) 144 19 ± 3.3 Gymnastic Basketball Questionnaire* 42% 92% 28% Gymnastics 67% Fair
Tennis Basketball 44%
Volleyball Tennis 50%
Golf Field hockey 32%
Field hockey Track 26%
Swimming Swimming 6%
Softball Volleyball 9%
Track Softball 6%
Golf 0%
Nygaard et al. (1996) 47 18–20 Gymnastic Basketball Questionnaire* NR NR 54% Gymnastics 70% Poor
Volleyball Softball Field Hockey 60%
Field hockey Softball 54%
S. ALMOUSA AND A. BANDIN VAN LOON

Volleyball 50%
Basketball 33%
Elleuch et al. (1998) 105 15–33 Gymnastics Basketball Questionnaire* SUI: 60% NR SUI: 62.9% Fair
Volleyball Handball UUI: 32.3%
Arts martial Swimming
Track and field
Eliasson Larsson, & Mattsson 35 12–22 Trampolinists Questionnaire* 80% 100% 80% Very Good
(2002)
Pozo-Municio (2007) 27 15–21 Dancers Questionnaire* SUI: 48.1% 100% 33.3% Very Good
Dockter et al. (2007) 109 18–25 Basketball Softball Questionnaire* SUI: 46.8% NR 40.7% Basketball: 18.2% Fair
Volleyball Cheerleading UUI: 29.6% Softball: 41.7%
Soccer Volleyball: 42.9%
Track and field Cheerleading: 22.2%
Soccer 50%
Track and field: 58.3%
Carls (2007) 86 14–21 Basketball Volleyball Revised Bristol female lower urinary tract NR 50.3% SUI: 28% Fair
Track symptoms questionnaire
Softball
Cheerleading
Weightlifting Pom Pom
dance
Kruger et al. (2007) 24 19–39 High impact activity sports Questionnaire* SUI: 12.5% NR NR Poor
UUI: 8.3%
Santos et al. (2009) 58 19–26 Gymnastics Questionnaire* 20.7% 61.1% 15.5% Swimming 50% Fair
Weightlifting SUI: 10.3% Running 11.1%
Running UUI: 8.6% Basketball 16.6%
Basketball Mixed: Handball 20%
Volleyball 1.7% Gymnastics 3.3%
Swimming Water aerobics 25%
Handball Weight lifting 8.3%
Soccer
Walking,
Water aerobics
Step aerobics
Rope Jumping
Bike riding
Tennis
(Continued )
Table 1. (Continued).
Prevalence Response Prevalence of UI Prevalence of UI by
Study N Age Type of sports Method of UI rate during sport activity sport Quality
Reis et al. (2011) 20 17–25 Basketball Questionnaire* NR 25.3% SUI: 40% Basketball 50% Fair
Volleyball Volleyball 30%
Jácome et al. (2011) 96 null 23 ± 4.4 Athletics (running, sprinting jumping) Questionnaire* 39.6% NA
(For the whole the Basketball
sample) Indoor football
NA Very Good
Fozzatti et al. (2012) 244 20–45 High impact sports ICIQ-SF SUI: 24.6% NR 5.7% Very Good
Da Roza, Brandão, 22 14–25 Trampolinists ICIQ-UI-SF SUI: 13.6% 91.6% 72.2% Excellent
Mascarenhas,
Jorge and Duarte (2015)
Poświata et al. (2014) 85 Runners: Cross country skiers and Questionnaire* SUI: 37.6% NA NR Running 35% Fair
29.49 ± 6.02 Runners Short form of urogenital distress Cross country skiers
Cross country inventory (UDI-6) 40%
skiers:
26.61 ± 4.41
Schettino et al. (2014) 105 ≥16 Volleyball Questionnaire* 65.7% 100% NR Fair
(21.96 ± 5.6) SUI: 29.5%
UUI: 49.5%
Parmigino et al. (2011) 148 >13 (15.4 ± 2.0) Soccer ICIQ-SF 18.2% NR NR Very Good
Handball
Basketball
Wrestling
Judo
Track and field
Swimming
Boxing
Almeida et al. (2016) 67 15–29 Volleyball ad hoc survey Questionnaire* 52.2% NR NR Volleyball 43.5% Very Good
Swimming (based on questions from ICIQ-SF, ICIQ- Judo 44.4%
Judo VS, Incontinence severity index (ISI)) Swimming 50%
Artistic Gymnastics Artistic Gymnastics,
Trampoline and Trampoline
88.9%
Yi et al. (2016) 177 35–44 Triathletes Epidemiology of prolapse and SUI: 24% NA NR Fair
(For the whole incontinence questionnaire (EPIQ)
sample)
Hagovska et al. (2017) 503 18–35 High impact exercises Questionnaire* UI: 14.3% 71.2% NR Excellent
ICIQ-SF SUI: 13.5%
Overactive Bladder Questionnaire MUI: 0.79%
Urinary Incontinence Quality of Life Scale
International Physical Activity
Questionnaire
Rolli and Frigeri (2016) 60 Average 19.6 Basketball Questionnaire* 50% NR NR Fair
Diary
Pubococcygeus test
Ludviksdottir et al. (2018) 18 18–30 Handball Questionnaire* SUI: 61.1% NR 61.1% Handball & football Very Good
Soccer ICIQ-SF 66.7%
Gymnastics Weightlifting: 50%
Weightlifting
JOURNAL OF SPORTS SCIENCES

Badminton
Boot camp/CrossFit
(Continued )
5
 6
S. ALMOUSA AND A. BANDIN VAN LOON

Table 1. (Continued).
Prevalence Response Prevalence of UI Prevalence of UI by
Study N Age Type of sports Method of UI rate during sport activity sport Quality
Alves et al. (2017) 245 18–40 Swimming Rowing ICIQ-SF UI: 22.9% NR NR Excellent
Cycling Kings Health Questionnaire SUI: 13.9%
Pilates UUI: 6.12%
Dance MUI: 2.9%
Volleyball
Basketball
Tennis
Athletics
Gymnastics
Judo
CrossFit
SUI: stress urinary incontinence; UUI: urge urinary incontinence; MUI: mixed urinary incontinence; UI: urinary incontinence; NR: No reported; ICIQ-SF: International Consultation on Incontinence Questionnaire-Short Form; *
used an investigator-designed questionnaire.

Preventive methods and strategies to disguise and handle
UI were reported by nine studies. These included pads, fre-
quent visits to the toilet before and during sporting activities,
wearing black clothes, practising alone and avoiding laughing
(Almeida et al., 2016; Dockter et al., 2007; Eliasson et al., 2002;
Fozzatti et al., 2012; Nygaard et al., 1994; Pozo-Municio, 2007;
Rolli & Frigeri, 2016; Santos et al., 2009; Schettino et al., 2014).
The main methods were the use of pads during training, and
emptying the bladder before exercising.
Four studies recorded how informed athletes were regarding
UI and the pelvic floor. One study reported that 89.9% of the
athletes were not familiar with the occurrence of UI as
a condition (Parmigiano et al., 2011), another that 73.3% were
unfamiliar with UI and the function of the pelvic floor (Rolli &
Frigeri, 2016), and two others that 80.8% −91% had either not
received any pelvic floor education or had never heard of pelvic
floor muscle exercises (Carls, 2007; Dockter et al., 2007). In
Dockter et al. (2007) study, the 19.2% of the athletes who had
received information on pelvic floor muscle strengthening exer-
cises reported that they had got it from media sources.
A positive correlation was identified in four studies (Alves
et al., 2017; Da Roza, Brandão, Mascarenhas, et al., 2015;
Eliasson et al., 2002; Hagovska et al., 2017) between UI and
years of training, and volume of exercise. It is reported that the
female athletes with UI had practised for more years, and
more hours per week, and more frequently compared to
those who did not have UI. However, Elleuch et al. (1998)
did not identify any association between UI and hours of
training (Elleuch et al., 1998). Two studies which included
trampolinists reported that the athletes’ symptoms started
after beginning trampoline practice (Da Roza, Brandão,
Mascarenhas, et al., 2015; Eliasson et al., 2002).
Discussion
Our results show that the prevalence of UI in female nullipar-
ous athletes during exercise ranges from 5.7% to 80%. The
prevalence rates differ according to the types of sports. The
highest prevalence of UI was observed in trampolinists.
Previous systematic reviews investigated UI in female ath-
letes, but they included nulliparous and parous athletes (De
Mattos Lourenco et al., 2018; Goldstick & Constantini, 2014;
Heath et al., 2014; Teixeira et al., 2018). In our review, we
included only nulliparous athletes as our aim was to establish
the prevalence of UI in sportswomen and to examine whether
UI is related to sport. By not including parous athletes, the
main risk factors of pregnancy and childbirth were excluded.
There are two suggested hypotheses regarding pelvic floor
strength in athletes. One supports that athletes normally should
have strong pelvic floor muscles, as strenuous exercising increases
abdominal pressure, which may lead to a simultaneous or pre-
contraction of the pelvic floor muscles, which may act as a training
stimulus (Ree, Nygaard, & Bo 2007). Based on this theory, female
athletes should be protected from leakage.
On the other hand, there is an opposing second hypothesis
which supports the view that strenuous activity may overload,
stretch and weaken the pelvic floor due to the chronic and
repeated increase of abdominal pressure; this theory agrees
with our findings.
JOURNAL OF SPORTS SCIENCES 7
Da Roza, Brandão, Oliveira, et al. (2015) have examined the
anatomical differences in the pelvic floor of nulliparous female
athletes with and without UI. They found that the incontinent
group had a thicker pubovisceral muscle at the mid-vaginal
level, suggesting that SUI is not associated with the strength
or displacement, but with the decreased response or delayed
reaction of the pubovisceral muscle. As the pubovisceral and
the sphincter urethrae muscles are part of the diaphragm, Da
Roza, Brandão, Oliveira, et al. (2015) hypothesize that the
muscle becomes thicker to try to counteract decreased
responsiveness of the sphincter urethrae (Da Roza, Brandão,
Oliveira, et al., 2015). The delayed response could occur due to
alterations in the intrafusal fibers as a consequence of many
years of sports training (Da Roza, Brandão, Oliveira, et al.,
2015).
Prior work has also supported that pelvic floor muscle
strength is not related to leakage. More specifically, Bo et al.
(1994) examined pelvic floor muscle strength in continent and
incontinent nulliparous female sports students, and did not
identify any difference. Similarly, Da Roza, Brandão, Oliveira,
et al. (2015) evaluated and compared the pelvic floor muscle
strength between continent and incontinent nulliparous female
athletes and also did not identify any difference. Nevertheless, it
is questionable why not all female athletes develop UI, and why
they remain continent after years of practising their sports.
We found that high impact sportswomen such as trampo-
linists have the highest UI prevalence rate among those
included in the study. A potential explanation may be that
high impact activities produce higher forces, and that large
forces are transmitted through tissue, where an injury may
occur. The remodelled tissue after repair may be malformed
and dysfunctional (Southon, 2008). This can create difficulties
in transmitting muscular forces to the urethra; and the con-
tinence mechanism fails to work effectively (Southon, 2008).
Some sporting activities have very large forces. Landing on
the heel following a long jump generates a maximum ground
reaction force of up to 16 times the body weight (Hay, 1993). It
is possible that these forces transmit to the pelvic floor, and
put stress on it. Trampolinists’ movements such as shifts in
direction, lead to changes in the velocity of their body mass. If
this is combined with a long period of practice, the pelvic floor
can come under immense stress (Eliasson et al., 2002).
Some athletes mentioned that they experience leakage only
during their sport activities and not during their daily lives.
Repeated intra-abdominal pressure during sport may fatigue the
pelvic floor, and this may reduce the effectiveness of the conti-
nence mechanism. This theory is supported by Ree, Nygaard, and
Bo (2007) study, which observed fatigue of the pelvic floor muscles
after strenuous exercise in nulliparous females with SUI.
A decrease in collagen in the pubovesical ligament has
been linked to the development of UI (Keane, Sims, Abrams,
& Bailey, 1997). It has been noticed that collagen levels in the
tissue of nulliparous premenopausal women with SUI are
lower than in those without UI (Keane et al., 1997). Collagen
is an important fibrous protein which provides strength and
elasticity, and is mainly located in the connective tissues
(DeLancey & Starr, 1990). Ulmsten, Ekman, Giertz, and
Malmstrom (1987) found that women with SUI had a 40%
lower total concentration of hydroxyproline (the fundamental
8 S. ALMOUSA AND A. BANDIN VAN LOON
component of collagen) in the rectus fascia compared to
continent women. Abnormal collagen can affect connective
tissue, and consequently SUI could occur because the reduc-
tion in collagen weakens the paraurethral support (Falconer,
Ekman, Malmström, & Ulmsten, 1994; Keane et al., 1997). The
combination of the transmitted large forces with the lower
collagen levels makes the pelvic floor more vulnerable to SUI.
Genetic predisposition has also been connected with SUI
development. Chen et al. (2005) suggest that elastin remodel-
ling may be important in the molecular aetiology of SUI, as
they found that genes involved in elastin metabolism were
expressed differently in the vaginal tissue of women with SUI.
Finally, it may also be possible that a different personal fatigue
threshold exists for each female athlete, and that when it is
overcome the continence mechanism may be affected
(Eliasson, Nordlander, Larson, Hammarström, & Mattsson, 2005).
Our results reveal that a high number of athletes have not
discussed their UI with a health professional or with their
coaches. This data is consistent with that from previous stu-
dies conducted within the general population, where few
incontinent women seek help. This may be connected to the
fact that many female athletes are simply not familiar with the
occurrence of UI or with pelvic floor muscle exercises. This
suggests that coaches should be more conscious of UI pre-
valence in female athletes in order to better inform them. It is
also essential that health care providers be aware that nulli-
parous women can also have urinary incontinence and that
the relevant screening procedures can be implemented. This
may help to uncover hidden UI in female athletes from which
the necessary education and treatment strategies can be
offered.
Our findings differ from the two recent systematic reviews
probably due to the fact that we included only nulliparous
female athletes. Also, Teixeira et al. (2018) only included stu-
dies that were published after the year 2000 and only female
participants over of 18 were included. We did not have any
limitation on the publication date or age of the participations.
This study was not limited to studies published only in
the English language, avoiding potential language bias;
however, limitations of this review should be noted. This
was not a statistical meta-analysis (quantitative synthesis)
but a descriptive epidemiological summary of UI prevalence
(qualitative synthesis). A meta-analysis was not performed
because of the methodological heterogeneity of the studies.
There was variability in the design of the included studies;
and the questionnaires used for collecting data differed
between studies; some of them were investigator-designed
questionnaires which used different definitions and termi-
nology to identify the occurrence, frequency and severity of
UI, without being assessed for validity. Some of the ques-
tionnaires had more emphasis on UI and may have failed to
capture the various types of UI. This may have created
response bias and inaccurate reporting. Also, the frequency
and the severity of UI episodes were difficult to report in
this systematic review because each study classified the
rates differently. In addition, some studies provided a UI
prevalence rate from many different sports and not sepa-
rately for every sport thereby making it difficult to analyse
further, the prevalence of UI for each sport. Therefore, there
is a need for further research using validated protocols to
study the prevalence of UI, the different types of UI and
overall, to quantify its impact on the QOL. In addition, future
prevalence studies should be more attentive in following the
standardised definitions proposed by the International
Continence Society.
The quality score of the studies varied. Most of the studies
failed to take into consideration the level of sport, the number
of training hours undertaken, and years of training. Studies did
not classify their participants based on the level of sports
(professional, amateur). Therefore, we could not examine
whether the prevalence rates of UI were different between
professional and amateur athletes. Further studies will have to
explore the differences in UI rates at different levels of sport
and examine whether the amount of training hours has an
effect on the development of UI. In addition, future research,
including samples of female athletes with similar sport char-
acteristics such as the level of sport, training hours, years,
intensity, may be required in order to gain satisfactory conclu-
sions about the prevalence of UI within different sports and
between different levels of sport.
Our findings support the need for further research to better
establish the sports-specific prevalence of UI in nulliparous
women of different sports and levels, with validated tools in
which the issues of selection bias and response rate are care-
fully considered, in order to obtain comparable results.
Conclusion
It demonstrated that there is a high prevalence of UI in nulli-
parous athletes, particularly those involved in higher impact
sports. Future work should therefore examine the mechanism
by which long-term high impact activities affect the pelvic floor,
and whether there is a way to prevent the development of UI in
female athletes. Attention should be given to the fact that
fewer than half of the athletes discussed their leakage with
a professional or team coach, and have referred to feelings
embarrassment. Τhis means that either female athletes are
unaware of UI and its potential treatments or that UI is still
a taboo. Either way, we still have a long way to go.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This research received no funding.
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