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Incontinence in the female athlete.

Readers beware: We’re about to get real, up close, and personal.

Are your running tights black to hide pee that leaks when you run and jump?

Do you carry a long sleeve to cover your bum after runs?

Do you wear a pad, or insert a tampon to minimize leaking?

Are you part of the peezing, peeing and sneezing at the same time, club?

Were you advised to stop the sport you love to avoid the leak?

Don't be embarrassed. You’re not alone.

Did you know:

1 in 3 women experience incontinence.

Fit, female athletes that don't have children fight incontinence too.

Stress urinary incontinence (SUI) does not discriminate!!

Thyssen studied 150 elite female athletes, mean age 22, that have not had children. 51% of women report daily leakage during sport. This is higher than national average for postpartum woman. 20% of these women left sport due to leaking, and only 4%, or 6 women, sought help. This is not OK. We have solutions. Women don't have to leak, or leave their sport due to leakage. A physical therapist, trained in women’s health can help.

Are you kegeling all day, everyday, and still leaking?

If you’re tired of leaking, keep reading.

Muscles work SPECIFIC to how you train it. If you’re prepping for a 1rep max, like a cough or sneeze, then keep kegeling, but if you’re participating in running, jumping, high intensity intervals, double under-ing, training for a marathon, or crossfitting, then the kegel will likely fall short and you’re likely still experiencing leakage.

The load demands of certain sport are much greater than the strength and endurance that developed during an isometric, static hold muscle contraction, kegel. So why are we only kegeling to control continence during sport? In fact, too many kegels can result in an overuse injury of pelvic floor muscles resulting in pelvic pain during sex, or when inserting a tampon, and nobody’s got time for that! We’ll keep that for another blog post...

In order to stop leaking, we need to strengthen and train the deep, anticipatory core central stability system to work in a coordinated fashion. The pelvic floor does not work alone in controlling continence. The pelvic floor works in coordination with your breathe control, and core stability. This "system" is considered your "deep core."

The deep core system consists of the 4 component parts:

1) Diaphragm 2) Transverse Abdominis 3) Pelvic Floor and 4) Multifidus.

A quick lesson in anatomy:

  1. Diaphragm: large muscle that spans the bottom of the ribs which controls breathing.

  2. Transverse Abdominis: the bottom most layer of the 3 layers of abdominals. THE ONLY layer that encapsulates the entire waist from back to front, top to bottom. I like to think of it like a corset. The major support of your spine.

  3. Pelvic floor: 3 layers of muscle acting as a sling to support and stabilize the pelvic organs.

  4. Multifidus: A very thin muscle deep in the spine, it spans three vertebral segments, and works to stabilize the joints at each segmental level to minimize degeneration of the joint structures, and promote central stability for distal mobility and power.

The system works as a “piston” that follows the respiratory cycle. When you inhale the diaphragm lowers, pressing into the stomach, and the stomach pressing into the pelvic floor increasing pressure and creating an elastic load that is released with exhaling allowing elastic recoil to release and promote stability. It is the dynamic balance of breathe, pressure, and movement that produce stability and control continence. There is no static hold. I hope you can see how an isometric kegel falls short.

We must consider different demands on the system based on activity performed, and build goal specific programs to stabilize the deep, core and pelvic floor to stop leakage. The system is referred to as the “deep” or “anticipatory” core because of its ability to turn on in a predictable, consistent way to prepare for movement, optimize function, and reach peak performance.

Is your core prepared for the demand of your fitness goal?

Let’s go through a quick self-check of the 3 basics:

1) Alignment

2) Breath control

3) Improving responsiveness of stability strategies based on demand of the task

Step 1: Postural alignment.

Proper alignment optimizes availability of muscles to work. All muscles have a length tension relationship, and operate best from a neutral, midrange position. If alignment is poor, the athlete does not have access to strength, and cannot produce stability.

Problem: Poor posture in adolescents and young women. Pregnancy posture in adult women.

Solution: Think of ribs as a bell, and the pelvis as a bowl. Ensure the bell is not tilted up or down. Ensure the bowl is not tilted forward or back. Try to align the opening of the bell with the opening of the bowl. This is optimal alignment for your deep core to properly function.

Step 2: Controlled, Balanced Breath

Step 2 is dependent on successfully mastering step 1. The diaphragm muscle controls breath. Poor posture will shift the diaphragm muscle from a neutral position making it difficult to coordinate full, balanced breathe. This results in breathe holding, chest dominant breathing. Breath holding is most common, and increases intra-abdominal and pelvic pressures. Chest breathing is second most common resulting in decreased pressures and the inability to utilize elastic recoil of the pelvic floor to produce stability and prepare for impact. Both lead to leakage.

Problem: Breathe holding, chest breathing, abdominal gripping.

Solution: Align the opening of your bell over the opening of your bowl and find a full, balanced breathe. While inhaling, think of expanding 360 degrees, simulating an umbrella. During the exhale think of collapsing the umbrella down to the handle.

Step 3: Matching the task to the demand.

Research reveals continent women have more efficient, balanced, task and demand appropriate muscle activation compared to women who leak. Women who leak tend over recruit the pelvic floor too forcefully, they breathe hold, grip their abdominals, and activating from the outside in vs. the inside out. This strategy increases abdominal pressures increasing pressure on the pelvic floor causing leakage. Women who leak have difficult producing a precise, responsive contraction required during simple daily tasks, and sport activity.

Problem: Attempting to align, breathe, and control leakage the on first attempt to sprint, jump rope, or box jump.

Solution: Don't expect too much too soon. You must be able to assume neutral alignment, and have the ability to coordinate breath at rest, before coupling with movement, and powerful exercise. Start with slow, controlled movements and build as if you would increase weight during a lift, or speed during a run. Keep in mind it is more difficulty to perform during high speed, high impact, and endurance activities. Have patience. Practice makes perfect. Seek out professional help if needed. Remember a physical therapist, trained in women’s health can help.

Final Word

This is a lot to take in and a problem many of us secretly deal with. You are not alone and there are actions you can take to fix this problem. If you have questions, want to speak with a professional, or just want to learn more, please reach out!

Author Bio:

Dr. Erika Patterson, PT, DPT, OCS

Dr. Patterson is a Doctor of Physical Therapy, APTA board certified Orthopedic Clinical Specialist,

with advanced certifications in manual therapy, dry needling, RPR, and specializes in Endurance & Multi-Sport Athletes.

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