**3. Relationship between urinary incontinence and sports and physical exercise**

#### **3.1 Physical exercises as a risk factor for stress urinary incontinence**

Authors do believe that high impact exercise can represent a risk factor to the development of stress urinary incontinence (Bump & Norton, 1998; Nygaard et al., 1994; Bo, 1992), however, studies and researches on the relationship between stress urinary incontinence and physical activities and sports are still quite rare and little is known about the impact of several exercises and sports on the pelvic floor. Previous studies showed two different hypothesis for the way high impact exercises affect the pelvic floor. One of them states that physical exercise may strengthen the pelvic floor muscles and, thus, help prevent stress urinary incontinence as it bolsters the muscles in charge of the continence. The second one, on the other hand, argues that physical exercises may overburden, strain and weaken the pelvic floor muscles and consider strenuous and high impact exercises (Bo, 2004b) as a risk factor for urinary incontinence. It is worth reminding that both hypothesis are related to young nulliparous elite athletes. Just the same, amenorrhea resulting from intense workout, eating disorders and/or both can foster urinary incontinence in athletes.

Some studies have associated urinary incontinence in nulliparous athletes with impact strength assimilation resulting from some activities. Long jumps allow the feet to touch the ground and may generate a maximum reaction force 16 times higher than body weight (Hay, 1993). This impact, a consequence of high impact exercises, may affect the continence mechanism by modifying the amount of strength transmitted to the pelvic floor. The shock transmission force, which occurs between the feet and the ground and is transferred to the pelvic floor, may foster incontinence in young nulliparous females, who do high impact exercises (Nygaard et al., 1996; Nygaard, 1997). Recently, O'Dell et al. (2007), analyzed the abdominal pressure during the use of hydraulic exercise machine; weight-lifting; floor exercises and jogging and comparing those exercise with abdominal pressure resulting from coughing in several individuals, the authors found out that, though different among subjects, the pressure on the pelvic floor during physical activities was lower than during coughing. Ree et al., (2007), verified that young nulliparous females with urinary incontinence symptoms showed fatigue in the PFM after performing strenuous physical activities for 90 minutes. According to the authors, studies about the impact of long term strenuous physical exercises on the pelvic floor among elite athletes should be carried out, once there has been a significant prevalence of stress urinary incontinence in this group (Bo, 2004a).

#### **3.2 Urinary incontinence prevalence in women**

#### **3.2.1 Athletes**

72 Urinary Incontinence

Fig. 1. Pelvic Floor Muscle -Source- Atlas of Human Anatomy(Frank H.Netter, 2010).

**3. Relationship between urinary incontinence and sports and physical** 

**3.1 Physical exercises as a risk factor for stress urinary incontinence** 

worsening of stress urinary incontinence.

**exercise** 

As mentioned earlier, stress urinary incontinence has lately been more frequently identified in physically active women. Though not conclusive, studies on this issue have reported that great effort and high impact exercises can enhance the chances for the development and

Authors do believe that high impact exercise can represent a risk factor to the development of stress urinary incontinence (Bump & Norton, 1998; Nygaard et al., 1994; Bo, 1992), however, studies and researches on the relationship between stress urinary incontinence and physical activities and sports are still quite rare and little is known about the impact of several exercises and sports on the pelvic floor. Previous studies showed two different hypothesis for the way high impact exercises affect the pelvic floor. One of them states that physical exercise may strengthen the pelvic floor muscles and, thus, help prevent stress urinary incontinence as it bolsters the muscles in charge of the continence. The second one, on the other hand, argues that physical exercises may overburden, strain and weaken the pelvic floor muscles and consider strenuous and high impact exercises (Bo, 2004b) as a risk Studies on the relationship between urinary incontinence, sports and physical activities and the prevalence of this condition in elite athletes date back from the 90s. Since then, they have gradually called the attention of professionals from different areas of expertise. As aforementioned, longitudinal systematic studies are still necessary, in order to identify the pelvic floor reactions while long term sports and physical activities are being performed, considering different intensities and frequencies. All the same, up until now, researches have indicated that urinary incontinence complaints are quite common among elite athletes. The examined studies showed 6% to 80% urinary incontinence prevalence among 12 to 22 year-old athletes, depending on which sport was practiced. Gymnastics, running and trampoline were the ones with the most urinary leaking complaints. (Bo, 2004b; Bump & Norton 1998; Eliasson et al., 2002; Jiang et al., 2004; Nygaard, et al., 1994; Nygaard et al., 1996;).

Nygaard et al., (1994), studied 156 athletes with an average age of 19,9 years; 28% said they had experienced urinary leaking while practicing a sport. The most frequently mentioned was gymnastics (67%), followed by basketball (66%), tennis (50%), hockey (42%), trekking (29%), swimming (10%), volleyball (9%), softball (6%) and, lastly, golf (0%). Jumping, high impact landings (or hitting the ground with high impact) and running were the physical activities with the highest incidence of urinary leaking. The jumping exercises with legs open, were a major complaint for 30% of the athletes, followed by tight-leg jumps (28%). In the same research, around 40% of the athletes reported urinary leaking while practicing

Incontinence: Physical Activity as a Supporting Preventive Approach 75

gymnastics and trekking. Swimming was considered a low impact sport, responsible for only 4.5% of the complaints. (Nygaard, 1997). All the same, the author concluded that high impact activities do not lead up to a significant urinary incontinence in the adulthood of the women belonging to the studied group. Actually, in a more recent retrospective study, authors investigated urinary incontinence complaint in 331 retired athletes as compared to a 640 female control group. Currently, 36.5% of the athletes complained about stress urinary incontinence and 36.9% of the control group had the same complaint. There was no meaningful difference between the two groups. Yet, after a more thorough and specific analysis on the athletes, the results indicated that urinary incontinence, when identified during the sports practice, can be a strong signal of future urinary problems in adulthood

Another issue, not less important and that must be taken into consideration in the complex relation of urinary incontinence prevalence among professional athletes is the much less studied eating disorder. This condition was detected in 20% of the athletes and only in 9% of the control group. As for stress urinary incontinence, it was reported by 49% of the athletes and by 38.8% of the control group. Urinary incontinence in women with eating disorders is likely to be associated with self-induced vomiting (a particular feature of such a disorder), which applies significant and repetitive pressure over the pelvic floor and, eventually, damages it. High impact sports practice without proper supervision might promote urinary incontinence in athletes with eating disorders (Bo & Borgen, 2001; Hextal et al.,1999). New researches should be carried out in order to identify the relationships between both urinary incontinent and eating disorder symptoms, considering different sports and physical

Similarly to the aforesaid about professional athletes, not until 2008 were studies and researches on urinary incontinence and sports and physical activities among non-athletes conducted. These few researches studied 18 to 65 year-old women, non-professional athletes, who mostly complained about incontinence while running and doing high impact sports; still, urinary leaking was also observed during everyday activities. Bo et al. (1989) observed a major difference between participants who practiced physical activities and those who didn't. Two different groups were compared: students whose major was physical education and others majoring in nutrition. (A=22.9; 19-59). Aspects such as age, childbirth and different physical exercises were considered. About 26% of the physical education students reported urinary leaking as compared to 19% of the nutrition students. According to the authors, this was not significant. However, when physical education students worked out more than three times a week, urinary incontinence prevalence increased up to 31%, a major difference when compared to the 10% presented by sedentary nutrition students. Nygaard et al., (1990) studied 326 women, 20-65 years old, (A=38,5) who exercised regularly; 47% had already noticed some kind of urinary leaking throughout life. In this study, no important connection was established between urinary incontinence and profession, educational background, weight, height or menopause. About 33% of the women reported incontinence while exercising. These women usually exercised three times a week during 30 to 60 minutes. Incontinence was most frequent while running; 38% of the women complained about urinary leaking while doing high impact aerobic exercises.

(Bo & Borgen, 2001).

activities

**3.2.2 Non-athletes** 

sports in high school and 17% in junior high school. Another study showed that the athletes also complained about urinary leaking not only during sports practice but also while performing every-day activities. The author identified that over half of 291 athletes, with an average age of 22.8 years, reported urinary leaking in both situations (Thyssen at al., 2002). It is interesting to mention that most of the athletes participating on this research, who complained about urinary leaking only while practicing sports, admitted it, happened only during practice and not during competitions. The authors believe this is probably due to "a ritual" of emptying the bladder and of drinking less liquid before competitions.

Urinary incontinence prevalence was also compared between a group of 660 athletes, belonging to a junior and senior national team (of 38 different sports) and a control group of 765 non-athlete females (Bo & Borgen, 2001). Their age ranged from 15 to 39 years. The majority was nulliparous, only 4% had had children. As for the non-athletes, one third had already given birth. Hence, data about childbirth must be taken into consideration and were more significant in the control group. There was no meaningful difference in the urinary incontinence prevalence in athletes and non-athletes: 41% and 39%, respectively. 27% of the athletes complained about urinary leaking while coughing, sneezing and laughing; 29% reported incontinence during physical activities and 15% during sudden moves or standing up.

The highest prevalence of urinary incontinence complaints during exercises was detected among trampoline professionals; 80% out of 35 nulliparous athletes, average age 15 (12-22 years old), complained about incontinence while jumping on the trampoline (Elliason et al., 2002). Athletes who complained about incontinence reported that urinary leaking was first noticed after two and a half years of practice. In this study, urinary incontinence was associated to the years of practice, age and duration and frequency of training. Incontinent athletes were older and had more frequent and longer trainings than athletes who had no symptoms of incontinence. During tests, incontinent athletes had more difficulty with voluntary voiding control by contracting the pelvic floor muscles than the other group with no incontinence symptoms. These athletes are likely to have been exposed to constant effort and impact; on the long run, due to the lack of training, the muscles responsible for continence lost their strength, leading up to urinary incontinence. In a more recent study, the same author (Eliasson et al., 2008) identified a high urinary incontinence prevalence in trampoline athletes (18-44 years old) during a competition. The author divided the athletes in two groups, according to the exercise intensity; 85 women performed high impact jumps and 220 performed low impact jumps. Among those who complained about urinary incontinence while practicing the sport, 76% still complain about the same symptoms; of these, 57% belong to the high impact jump group and 48% to the low impact jump group. The author also detected prospective reasons for urinary incontinence development in this group; similarly to his prior study (Elliasson et al., 2002), the author reported that the frequency and intensity of the exercises, age of first menstrual period, bowel obstruction and inability of voiding control were important factors for urinary incontinence. Hence, the practice of this sport (trampoline) without simultaneous and proper training for the strengthening of pelvic floor muscles may represent a risk factor for urinary incontinence onset, during and after the aforesaid practice.

A retrospective study including 104 athletes who were in the Olympics, in the 60s up until 1976, detected that 35% reported urinary leaking during high impact activities, such as gymnastics and trekking. Swimming was considered a low impact sport, responsible for only 4.5% of the complaints. (Nygaard, 1997). All the same, the author concluded that high impact activities do not lead up to a significant urinary incontinence in the adulthood of the women belonging to the studied group. Actually, in a more recent retrospective study, authors investigated urinary incontinence complaint in 331 retired athletes as compared to a 640 female control group. Currently, 36.5% of the athletes complained about stress urinary incontinence and 36.9% of the control group had the same complaint. There was no meaningful difference between the two groups. Yet, after a more thorough and specific analysis on the athletes, the results indicated that urinary incontinence, when identified during the sports practice, can be a strong signal of future urinary problems in adulthood (Bo & Borgen, 2001).

Another issue, not less important and that must be taken into consideration in the complex relation of urinary incontinence prevalence among professional athletes is the much less studied eating disorder. This condition was detected in 20% of the athletes and only in 9% of the control group. As for stress urinary incontinence, it was reported by 49% of the athletes and by 38.8% of the control group. Urinary incontinence in women with eating disorders is likely to be associated with self-induced vomiting (a particular feature of such a disorder), which applies significant and repetitive pressure over the pelvic floor and, eventually, damages it. High impact sports practice without proper supervision might promote urinary incontinence in athletes with eating disorders (Bo & Borgen, 2001; Hextal et al.,1999). New researches should be carried out in order to identify the relationships between both urinary incontinent and eating disorder symptoms, considering different sports and physical activities

#### **3.2.2 Non-athletes**

74 Urinary Incontinence

sports in high school and 17% in junior high school. Another study showed that the athletes also complained about urinary leaking not only during sports practice but also while performing every-day activities. The author identified that over half of 291 athletes, with an average age of 22.8 years, reported urinary leaking in both situations (Thyssen at al., 2002). It is interesting to mention that most of the athletes participating on this research, who complained about urinary leaking only while practicing sports, admitted it, happened only during practice and not during competitions. The authors believe this is probably due to "a

Urinary incontinence prevalence was also compared between a group of 660 athletes, belonging to a junior and senior national team (of 38 different sports) and a control group of 765 non-athlete females (Bo & Borgen, 2001). Their age ranged from 15 to 39 years. The majority was nulliparous, only 4% had had children. As for the non-athletes, one third had already given birth. Hence, data about childbirth must be taken into consideration and were more significant in the control group. There was no meaningful difference in the urinary incontinence prevalence in athletes and non-athletes: 41% and 39%, respectively. 27% of the athletes complained about urinary leaking while coughing, sneezing and laughing; 29% reported incontinence during physical activities and 15% during sudden moves or standing

The highest prevalence of urinary incontinence complaints during exercises was detected among trampoline professionals; 80% out of 35 nulliparous athletes, average age 15 (12-22 years old), complained about incontinence while jumping on the trampoline (Elliason et al., 2002). Athletes who complained about incontinence reported that urinary leaking was first noticed after two and a half years of practice. In this study, urinary incontinence was associated to the years of practice, age and duration and frequency of training. Incontinent athletes were older and had more frequent and longer trainings than athletes who had no symptoms of incontinence. During tests, incontinent athletes had more difficulty with voluntary voiding control by contracting the pelvic floor muscles than the other group with no incontinence symptoms. These athletes are likely to have been exposed to constant effort and impact; on the long run, due to the lack of training, the muscles responsible for continence lost their strength, leading up to urinary incontinence. In a more recent study, the same author (Eliasson et al., 2008) identified a high urinary incontinence prevalence in trampoline athletes (18-44 years old) during a competition. The author divided the athletes in two groups, according to the exercise intensity; 85 women performed high impact jumps and 220 performed low impact jumps. Among those who complained about urinary incontinence while practicing the sport, 76% still complain about the same symptoms; of these, 57% belong to the high impact jump group and 48% to the low impact jump group. The author also detected prospective reasons for urinary incontinence development in this group; similarly to his prior study (Elliasson et al., 2002), the author reported that the frequency and intensity of the exercises, age of first menstrual period, bowel obstruction and inability of voiding control were important factors for urinary incontinence. Hence, the practice of this sport (trampoline) without simultaneous and proper training for the strengthening of pelvic floor muscles may represent a risk factor for urinary incontinence

A retrospective study including 104 athletes who were in the Olympics, in the 60s up until 1976, detected that 35% reported urinary leaking during high impact activities, such as

ritual" of emptying the bladder and of drinking less liquid before competitions.

up.

onset, during and after the aforesaid practice.

Similarly to the aforesaid about professional athletes, not until 2008 were studies and researches on urinary incontinence and sports and physical activities among non-athletes conducted. These few researches studied 18 to 65 year-old women, non-professional athletes, who mostly complained about incontinence while running and doing high impact sports; still, urinary leaking was also observed during everyday activities. Bo et al. (1989) observed a major difference between participants who practiced physical activities and those who didn't. Two different groups were compared: students whose major was physical education and others majoring in nutrition. (A=22.9; 19-59). Aspects such as age, childbirth and different physical exercises were considered. About 26% of the physical education students reported urinary leaking as compared to 19% of the nutrition students. According to the authors, this was not significant. However, when physical education students worked out more than three times a week, urinary incontinence prevalence increased up to 31%, a major difference when compared to the 10% presented by sedentary nutrition students. Nygaard et al., (1990) studied 326 women, 20-65 years old, (A=38,5) who exercised regularly; 47% had already noticed some kind of urinary leaking throughout life. In this study, no important connection was established between urinary incontinence and profession, educational background, weight, height or menopause. About 33% of the women reported incontinence while exercising. These women usually exercised three times a week during 30 to 60 minutes. Incontinence was most frequent while running; 38% of the women complained about urinary leaking while doing high impact aerobic exercises.

Incontinence: Physical Activity as a Supporting Preventive Approach 77

2001; Nygaard et al., 2005), increasing sedentary habits and exposing the population to

On the other hand, encouraging physical activities can have a positive effect on incontinent women's attitude towards exercising. However successful urinary incontinence treatment was, women who had always exercised, continued doing so. Likewise, those who had never exercised before did not change their habits. According to information gathered from women who participated in the research, the more active ones looked for medical treatment because they wanted to lower and prevent urinary incontinence and, thus, keep up with their exercises (Stach-Lempinen et al., 2004).This attitude might be associated to a high motivation in doing physical activities. According to Bo et al., (1989), more motivated women tend to take urinary leaking for granted, while the less motivated ones make a big deal out of it. Professional athletes seem to be more motivated for sports and physical activities and perform more stressing exercises than those who practice sports leisurely. The first continue practicing, despite incontinence and other problems (Nygaard et al., 2005). Researches have found that women who did not quit physical activities because of urinary incontinence, worked out a way to prevent urinary leaking while exercising. Their usual strategies were: the use of sanitary napkins and diapers, emptying the bladder before practice and competitions, liquid ingestion restrictions, and choosing a different exercise to perform. This last strategy means that exercises which might facilitate urinary leaking (jumping, running) are avoided, and these women start to practice low impact sports, such as walking, biking and swimming (Nygaard et al., 1990; Thyssen et al., 2002). Besides these strategies, women studied by Salvatore et al., (2009) chose exercises to strengthen the pelvic floor muscles as a way to prevent incontinence during physical activities. These "adaptation" strategies, however, did not seem to be effective enough to prevent that they quit exercising. Several times, sanitary napkins cannot avoid urinary leaking and, after the

health conditions associated with sedentary life styles.

first incontinence, women tend to give up physical practice (Tata, 1998).

**4. Benefits of physical exercises for urinary incontinence** 

for their overall health.

**4.1 Pelvic floor muscle training** 

In a prospective study of 314 women with pelvic organ prolapse and stress urinary incontinence, the authors investigated if women who had undergone sacrocolpopexy surgery a year before, changed physical activities. One year after the surgery, 36% of the women increased the intensity of the exercises, 18% lowered and 47% kept the same intensity. The authors reported that most women who considered that the pelvic floor organ

However, it is worth saying that a few participants kept on limiting their physical activities, despite de surgery, due to fear of prolapse recurring and to their doctor's advice (Nygaard et al., 2007b; Nygaard et al., 2008).Bottom line, when women themselves limit the frequency and intensity of physical exercises, they drift apart from the benefits of a systematic practice

The most widely known exercises which prevent and treat urinary incontinence were created by Dr. Arnold Kegel in the fifities. This American gynecologist was the first to scientifically use exercises to strengthen the pelvic floor muscles in order to improve urinary

prolapse could prevent or restrict exercising changed their view after the surgery.

Another study including 3,364 women, 18 to 60 years old, detected that 1 out of 7 were incontinent while performing any kind of physical activity. (36). High urinary incontinence prevalence is also identified in women who belong to the US Army and US Air Force (Davis, 1999; Fischer & Berg, 1999). 31% out of the 563 female soldiers under observation complained about urinary leaking during physical and field drilling. Around 40% of them also complained about it during recreational activities. Aerobic exercises ranked highest in complaints (42%), followed by running (35%), weight-lifting (18%), jogging (21%), biking (8%), swimming (5 %) and lastly, golf (3%).

Salvatore et al., (2009) recently studied 679 female soldiers aiming to check urinary incontinence prevalence during recreational activities. The authors reported that stress urinary incontinence was detected in 14.9% of the subjects; out of this total, 31.7% complained about incontinence during sports practice and 10.4% considered their incontinence severe enough to limit or discourage their activities. The sport with the most complaints, (16.6%) was basketball, followed by running (15%). Body Mass Index and childbirth were connected to urinary linking. Also, data about studies on physical exercises and sports instructors were found. The first study with Physical Education teachers was done by (Santos, et al., 2009). We studied nulliparous students, 19 to 26 years old. 20.7% of them had already had urinary leaking before while practicing their sport and ranked it as a 2.3 leaking (in a scale of 0 to 10), being no problem at all and 10 being a severe problem). In this study, we came to the conclusion that, though urinary incontinence was quite frequent, the group didn't consider it a problem. More recently, 685 Pilates and Yoga instructors, with an average age of 32.7 years (18 to 68 years old) were studied; the authors identified a 26,4% prevalence of incontinence complaints. Among incontinent women, 15.3% reported urinary leaking during physical activities and 10.9% while sneezing or coughing. Hence, pelvic floor training is recommended not only for athletes and women who leisurely practice sports or physical activities, but also for instructors, coaches, trainers and teachers (Bo et al., 2011; Santos, et al., 2009.)

#### **3.3 Urinary incontinence impact on physical activity**

Unexpected and involuntary episodes of urinary leaking which may happen during physical activities may put incontinent women on an embarrassing and uncomfortable spot. According to studies, nearly 20% females give up (Nygaard et al., 1990) or limit their favorite sports and physical activities due to urinary incontinence. (Salvatore et al., 2009). A longitudinal study on female health (Australian Longitudinal Study on Women's Health- (ALSWH) reported that 27% females who practiced physical exercises showed urinary incontinence symptoms(> 40%were middle aged women and 16% were young or elderly); a percentage which supports previously discussed studies. Most incontinent women said they gave up sports practice due to their incontinence. According to the authors, the highest incidence of disengagement was among ≥ to 48 year-old women. Some authors consider that this might be even higher among women in the post menopause (Eliasson et al., 2002; Salvatore et al., 2009). Furthermore, the greater the concerns towards incontinence during exercise performances, the higher the frequency of urinary leaking episodes (Fultz et al., 2003) leading to an increase in giving up physical activities. More specifically, severe urinary incontinence symptoms strongly hamper the practice of physical activities, (Brown & Miller,

Another study including 3,364 women, 18 to 60 years old, detected that 1 out of 7 were incontinent while performing any kind of physical activity. (36). High urinary incontinence prevalence is also identified in women who belong to the US Army and US Air Force (Davis, 1999; Fischer & Berg, 1999). 31% out of the 563 female soldiers under observation complained about urinary leaking during physical and field drilling. Around 40% of them also complained about it during recreational activities. Aerobic exercises ranked highest in complaints (42%), followed by running (35%), weight-lifting (18%), jogging (21%), biking

Salvatore et al., (2009) recently studied 679 female soldiers aiming to check urinary incontinence prevalence during recreational activities. The authors reported that stress urinary incontinence was detected in 14.9% of the subjects; out of this total, 31.7% complained about incontinence during sports practice and 10.4% considered their incontinence severe enough to limit or discourage their activities. The sport with the most complaints, (16.6%) was basketball, followed by running (15%). Body Mass Index and childbirth were connected to urinary linking. Also, data about studies on physical exercises and sports instructors were found. The first study with Physical Education teachers was done by (Santos, et al., 2009). We studied nulliparous students, 19 to 26 years old. 20.7% of them had already had urinary leaking before while practicing their sport and ranked it as a 2.3 leaking (in a scale of 0 to 10), being no problem at all and 10 being a severe problem). In this study, we came to the conclusion that, though urinary incontinence was quite frequent, the group didn't consider it a problem. More recently, 685 Pilates and Yoga instructors, with an average age of 32.7 years (18 to 68 years old) were studied; the authors identified a 26,4% prevalence of incontinence complaints. Among incontinent women, 15.3% reported urinary leaking during physical activities and 10.9% while sneezing or coughing. Hence, pelvic floor training is recommended not only for athletes and women who leisurely practice sports or physical activities, but also for instructors, coaches, trainers and teachers (Bo et al., 2011;

Unexpected and involuntary episodes of urinary leaking which may happen during physical activities may put incontinent women on an embarrassing and uncomfortable spot. According to studies, nearly 20% females give up (Nygaard et al., 1990) or limit their favorite sports and physical activities due to urinary incontinence. (Salvatore et al., 2009). A longitudinal study on female health (Australian Longitudinal Study on Women's Health- (ALSWH) reported that 27% females who practiced physical exercises showed urinary incontinence symptoms(> 40%were middle aged women and 16% were young or elderly); a percentage which supports previously discussed studies. Most incontinent women said they gave up sports practice due to their incontinence. According to the authors, the highest incidence of disengagement was among ≥ to 48 year-old women. Some authors consider that this might be even higher among women in the post menopause (Eliasson et al., 2002; Salvatore et al., 2009). Furthermore, the greater the concerns towards incontinence during exercise performances, the higher the frequency of urinary leaking episodes (Fultz et al., 2003) leading to an increase in giving up physical activities. More specifically, severe urinary incontinence symptoms strongly hamper the practice of physical activities, (Brown & Miller,

(8%), swimming (5 %) and lastly, golf (3%).

**3.3 Urinary incontinence impact on physical activity** 

Santos, et al., 2009.)

2001; Nygaard et al., 2005), increasing sedentary habits and exposing the population to health conditions associated with sedentary life styles.

On the other hand, encouraging physical activities can have a positive effect on incontinent women's attitude towards exercising. However successful urinary incontinence treatment was, women who had always exercised, continued doing so. Likewise, those who had never exercised before did not change their habits. According to information gathered from women who participated in the research, the more active ones looked for medical treatment because they wanted to lower and prevent urinary incontinence and, thus, keep up with their exercises (Stach-Lempinen et al., 2004).This attitude might be associated to a high motivation in doing physical activities. According to Bo et al., (1989), more motivated women tend to take urinary leaking for granted, while the less motivated ones make a big deal out of it. Professional athletes seem to be more motivated for sports and physical activities and perform more stressing exercises than those who practice sports leisurely. The first continue practicing, despite incontinence and other problems (Nygaard et al., 2005). Researches have found that women who did not quit physical activities because of urinary incontinence, worked out a way to prevent urinary leaking while exercising. Their usual strategies were: the use of sanitary napkins and diapers, emptying the bladder before practice and competitions, liquid ingestion restrictions, and choosing a different exercise to perform. This last strategy means that exercises which might facilitate urinary leaking (jumping, running) are avoided, and these women start to practice low impact sports, such as walking, biking and swimming (Nygaard et al., 1990; Thyssen et al., 2002). Besides these strategies, women studied by Salvatore et al., (2009) chose exercises to strengthen the pelvic floor muscles as a way to prevent incontinence during physical activities. These "adaptation" strategies, however, did not seem to be effective enough to prevent that they quit exercising. Several times, sanitary napkins cannot avoid urinary leaking and, after the first incontinence, women tend to give up physical practice (Tata, 1998).

In a prospective study of 314 women with pelvic organ prolapse and stress urinary incontinence, the authors investigated if women who had undergone sacrocolpopexy surgery a year before, changed physical activities. One year after the surgery, 36% of the women increased the intensity of the exercises, 18% lowered and 47% kept the same intensity. The authors reported that most women who considered that the pelvic floor organ prolapse could prevent or restrict exercising changed their view after the surgery.

However, it is worth saying that a few participants kept on limiting their physical activities, despite de surgery, due to fear of prolapse recurring and to their doctor's advice (Nygaard et al., 2007b; Nygaard et al., 2008).Bottom line, when women themselves limit the frequency and intensity of physical exercises, they drift apart from the benefits of a systematic practice for their overall health.

### **4. Benefits of physical exercises for urinary incontinence**

#### **4.1 Pelvic floor muscle training**

The most widely known exercises which prevent and treat urinary incontinence were created by Dr. Arnold Kegel in the fifities. This American gynecologist was the first to scientifically use exercises to strengthen the pelvic floor muscles in order to improve urinary

Incontinence: Physical Activity as a Supporting Preventive Approach 79

and strengthening are concerned (Cammu & Nylen, 1998; Johnson, 2001; Pieber et al., 1995). However, studies available in literature do not reach an agreement, and as evidence is not strong enough, abdominal muscle training is not included in the treatment of urinary

The benefits of PFM training and strengthening could be seen when they were performed with no other technique (reference); or when combined with techniques such as biofeedback; electrical stimulation; with vaginal weight or cones; with the combination of two techniques, such as biofeedback + electrical stimulation; and also with the combination of three techniques: biofeedback + electrical stimulation + with vaginal weights and cones. More detailed data on the researches aforementioned can be found in publications by Neumann et al. (2006). Notwithstanding, no study linking PFM training and strengthening to a systematic exercise

Only a few researches in which training for the pelvic floor muscle strengthening has simultaneously occurred during sports practice were pointed out. As aforesaid, there is little knowledge about how pelvic muscles work during sports and physical activity practice. According to some authors, most physical activities do not involve pelvic muscle voluntary contraction during the performance of exercises which increase intra-abdominal pressure. Thus, women who exercise do not have stronger pelvic muscles than the ones who do not; actually, the more active women have reported greater incontinence while doing strong-effort and high-impact exercises than those who do not exercise regularly (Bo, 2004b). Athletes should be taught to contract those muscles previously or simultaneously to impact exercises and sports practice. Instructions on this matter are needed because previous studies indicated that one third of females either contract their pelvic muscles incorrectly or have difficulty with doing so. In three different studies, around 30% of female subjects reported inability to interrupt urinary flow (Bevenute et al., 1987; Bo et al., 1988; Kegel, 1952). This "inability" is associated with urinary leaking. After women were "taught" to contract their PFM while coughing, the authors noticed a significant incontinence reduction; still, no mention to whether women had the same training during sports practice was made (Brown & Miller, 2001). According to another study, 17 out of 23 women reported a decrease in urinary leaking during jumping and running, after exercising the PFM. All the same, just like the aforementioned study, it was impossible to identify if the PFM exercises were done during and simultaneously to sports practice (Bo, 2004a). More recently, researchers reported a reduction and even a suspension of incontinence complaints in 3 nulliparous athletes (29-33 years old). They had had training for strengthening PFM with specific exercises along with biofeedback; electrical stimulation and vaginal cones. Yet, though athletes were advised to work on the contractions at home every day, this instruction was not described simultaneously to their physical activity

**4.3 Systematic proposal of physical activities for women in general, including pelvic** 

Due to the lack of researches in Physical Education or of a multidisciplinary project which discussed a PFM strengthening exercise program and considering that physical exercises are likely to become a risk factor for urinary incontinence symptoms, we decided to create a

program outside the therapeutic context was identified during this review.

**4.2 Pelvic floor exercises during sports practice** 

and sports practice (Rivalta et al., 2010).

**floor exercises** 

incontinence (Bo et al., 2009).

incontinence mechanisms. These exercises improve the perineum muscle contraction, giving it more power (strong and fast), increase urethral compression against the pubic symphysis, increase intra-urethral pressure when intra-abdominal pressure is increased, help pelvic muscle hypertrophy and increase the volume of such muscles. Hence, structural support of this body area becomes more effective and prevents the urethra from descending when intra-abdominal pressure increases and, consequently, decreasing urinary leaking. Kegel (1948), observed that, apart from decreasing urinary incontinence, his exercises had positive effects on female sexual desire. His exercises are, therefore, based on the strengthening of the pelvic floor muscles (Palma & Ricetto, 1999). The pelvic floor muscles should support the viscera in the upright position and maintain urinary continence as well. So, they should be kept strong and in perfect condition. Still, in order to effectively perform these exercises, Levi-D'Ancona (2001) states that incontinent women should learn to contract and relax these muscles, once they are not usually used, and that many women have difficulties with their voluntary contraction (Moen et al., 2007).

Since Kegel first published the development of these exercises, they have been widely used and quoted in medical academic literature; however, as of then, it is also possible to find not only different techniques and systematization (that is, frequency, intensity, repetitions and associations) but also different instructions given to patients in scientific literature. According to theory on the development of exercises to treat stress urinary incontinence, the aim is to boost pelvic floor muscle (PFM) strength, coordination, speed and resistance in order to keep structures in an adequate position whenever there is an effort which causes intra-abdominal pressure increase and, thus, keeping a proper urethral closure strength. (Ashton-Miller et al., 2001).

In literature, it's possible to find different protocols to strengthen the pelvic floor through exercises. Most studies follow protocols with instructions based on quick and slow contractions, in 3 steps, ranging from 8 to 12 repetitions; isometric contractions with maximum contraction held for 6 to 8 seconds, 2 to 4 times a week. According to different authors, PFM strength increased after a period which varied from 4 weeks to 6 months. Another procedure used to strengthen the PFM is training only with isometric contractions with maximum contraction for a period of 6 weeks to 6 months. The study also advised women to perform the exercises at home; according to others, women had better attend weekly or monthly group training; some advise a doctor's appointment once in 6 months and others see no need for group training or appointment with a doctor. Most protocols or training methods were reported as positive for the improvement or cure of incontinence symptoms presented by some of the subjects of their studies. "Skill training" is also a procedure which may help strengthen and train the PFM; it implies the learning of motor skills which favor a more effective contraction time of the PFM before an activity that increases abdominal pressure followed by a possible urinary leaking (whenever there are injured and/or weakened muscles). Bo et al., have named this a motor learning approach. Though "skill training" has been quoted as useful for PFM training, few information on the specificity of these exercises have been made available. Other studies (Arvonen et al., 2000; Balmforth et al., 2004; Dumoulin et al., 2004; Hay-Smith et al., 2002; Parkkinen et al., 2004;) Turkan, 2005), even match up PFM strengthening exercises with "skill training", getting positive results, but as the reports don't follow a standard protocol, comparisons become invalid. The role of the abdominal muscles has also been discussed, as far as PFM training

incontinence mechanisms. These exercises improve the perineum muscle contraction, giving it more power (strong and fast), increase urethral compression against the pubic symphysis, increase intra-urethral pressure when intra-abdominal pressure is increased, help pelvic muscle hypertrophy and increase the volume of such muscles. Hence, structural support of this body area becomes more effective and prevents the urethra from descending when intra-abdominal pressure increases and, consequently, decreasing urinary leaking. Kegel (1948), observed that, apart from decreasing urinary incontinence, his exercises had positive effects on female sexual desire. His exercises are, therefore, based on the strengthening of the pelvic floor muscles (Palma & Ricetto, 1999). The pelvic floor muscles should support the viscera in the upright position and maintain urinary continence as well. So, they should be kept strong and in perfect condition. Still, in order to effectively perform these exercises, Levi-D'Ancona (2001) states that incontinent women should learn to contract and relax these muscles, once they are not usually used, and that many women have difficulties with their

Since Kegel first published the development of these exercises, they have been widely used and quoted in medical academic literature; however, as of then, it is also possible to find not only different techniques and systematization (that is, frequency, intensity, repetitions and associations) but also different instructions given to patients in scientific literature. According to theory on the development of exercises to treat stress urinary incontinence, the aim is to boost pelvic floor muscle (PFM) strength, coordination, speed and resistance in order to keep structures in an adequate position whenever there is an effort which causes intra-abdominal pressure increase and, thus, keeping a proper urethral closure strength.

In literature, it's possible to find different protocols to strengthen the pelvic floor through exercises. Most studies follow protocols with instructions based on quick and slow contractions, in 3 steps, ranging from 8 to 12 repetitions; isometric contractions with maximum contraction held for 6 to 8 seconds, 2 to 4 times a week. According to different authors, PFM strength increased after a period which varied from 4 weeks to 6 months. Another procedure used to strengthen the PFM is training only with isometric contractions with maximum contraction for a period of 6 weeks to 6 months. The study also advised women to perform the exercises at home; according to others, women had better attend weekly or monthly group training; some advise a doctor's appointment once in 6 months and others see no need for group training or appointment with a doctor. Most protocols or training methods were reported as positive for the improvement or cure of incontinence symptoms presented by some of the subjects of their studies. "Skill training" is also a procedure which may help strengthen and train the PFM; it implies the learning of motor skills which favor a more effective contraction time of the PFM before an activity that increases abdominal pressure followed by a possible urinary leaking (whenever there are injured and/or weakened muscles). Bo et al., have named this a motor learning approach. Though "skill training" has been quoted as useful for PFM training, few information on the specificity of these exercises have been made available. Other studies (Arvonen et al., 2000; Balmforth et al., 2004; Dumoulin et al., 2004; Hay-Smith et al., 2002; Parkkinen et al., 2004;) Turkan, 2005), even match up PFM strengthening exercises with "skill training", getting positive results, but as the reports don't follow a standard protocol, comparisons become invalid. The role of the abdominal muscles has also been discussed, as far as PFM training

voluntary contraction (Moen et al., 2007).

(Ashton-Miller et al., 2001).

and strengthening are concerned (Cammu & Nylen, 1998; Johnson, 2001; Pieber et al., 1995). However, studies available in literature do not reach an agreement, and as evidence is not strong enough, abdominal muscle training is not included in the treatment of urinary incontinence (Bo et al., 2009).

The benefits of PFM training and strengthening could be seen when they were performed with no other technique (reference); or when combined with techniques such as biofeedback; electrical stimulation; with vaginal weight or cones; with the combination of two techniques, such as biofeedback + electrical stimulation; and also with the combination of three techniques: biofeedback + electrical stimulation + with vaginal weights and cones. More detailed data on the researches aforementioned can be found in publications by Neumann et al. (2006). Notwithstanding, no study linking PFM training and strengthening to a systematic exercise program outside the therapeutic context was identified during this review.

#### **4.2 Pelvic floor exercises during sports practice**

Only a few researches in which training for the pelvic floor muscle strengthening has simultaneously occurred during sports practice were pointed out. As aforesaid, there is little knowledge about how pelvic muscles work during sports and physical activity practice. According to some authors, most physical activities do not involve pelvic muscle voluntary contraction during the performance of exercises which increase intra-abdominal pressure. Thus, women who exercise do not have stronger pelvic muscles than the ones who do not; actually, the more active women have reported greater incontinence while doing strong-effort and high-impact exercises than those who do not exercise regularly (Bo, 2004b). Athletes should be taught to contract those muscles previously or simultaneously to impact exercises and sports practice. Instructions on this matter are needed because previous studies indicated that one third of females either contract their pelvic muscles incorrectly or have difficulty with doing so. In three different studies, around 30% of female subjects reported inability to interrupt urinary flow (Bevenute et al., 1987; Bo et al., 1988; Kegel, 1952). This "inability" is associated with urinary leaking. After women were "taught" to contract their PFM while coughing, the authors noticed a significant incontinence reduction; still, no mention to whether women had the same training during sports practice was made (Brown & Miller, 2001). According to another study, 17 out of 23 women reported a decrease in urinary leaking during jumping and running, after exercising the PFM. All the same, just like the aforementioned study, it was impossible to identify if the PFM exercises were done during and simultaneously to sports practice (Bo, 2004a). More recently, researchers reported a reduction and even a suspension of incontinence complaints in 3 nulliparous athletes (29-33 years old). They had had training for strengthening PFM with specific exercises along with biofeedback; electrical stimulation and vaginal cones. Yet, though athletes were advised to work on the contractions at home every day, this instruction was not described simultaneously to their physical activity and sports practice (Rivalta et al., 2010).

#### **4.3 Systematic proposal of physical activities for women in general, including pelvic floor exercises**

Due to the lack of researches in Physical Education or of a multidisciplinary project which discussed a PFM strengthening exercise program and considering that physical exercises are likely to become a risk factor for urinary incontinence symptoms, we decided to create a

2009b)

Incontinence: Physical Activity as a Supporting Preventive Approach 81

1- hour classes were routinely given twice a week for a four-month period (Caetano et al,

Fig. 2. Pelvic Floor Muscle Exercises (By Artur Paulo Caetano & Nicholas Silva Caetano). Source: Caetano, A.S. et al.,(2004). Physical Activity Proposal for Stress Urinary Incontinent

After reviewing the data about the main relationships between urinary incontinence and physical activity and sports practice referred to in this chapter, we identified a high prevalence of urinary incontinence symptoms in women who exercise, significantly higher in young athletes; we also noticed that strong-effort and high-impact exercises are a major cause of incontinence complaints. Though literature is still inconclusive on this matter, these exercises seem to represent a risk factor for the development of urinary incontinence or are likely to aggravate pre-existing symptoms. Just the same, little is known about the pelvic

Women. Lecturas Educacion Fisica y Deportes [online journal] Available:

URL: http://www.efdeportes.com/efd76/mulheres.

**5. Conclusions** 

physical activity program with PFM exercises (Fig.2). It was first developed in 2003, and improved and applied to a female group afterwards, as part of a research. Its results showed a reduction of incontinence complaints and an improvement of participants' body image (Caetano et al., 2009b). This research project included specific exercises for PFM, plus proprioception exercises (to get a better perception of the pelvis), breathing exercises, recreational activities (such as games and plays), stretching exercises, warm-up exercises (aerobic activities), upper and lower limb, abdominal and gluteus strengthening exercises and relaxation exercises.

This research aimed mainly at creating strategies for the Physical Education professional to develop PFM strengthening exercises during physical exercise and sports practice with students who might or might not have complaints about urinary incontinence, in order to prevent or reduce its symptoms. The Physical Education professionals usually work at venues such as clubs, rehabilitation centers, gyms, schools, indoor or outdoor courts and companies; they also work as sports and fitness coaches for female professional athletes; this means their work involves a wide-ranging population group, which requires PFM exercises suitable to different ages as well as physical activities and exercises focusing on each individual's needs.

One of this systematization first concerns was to characterize the inclusion of PFM exercises in physical exercise and sports practice as a non-therapeutic action under the assumption that the engaged muscles also contain voluntary fibers, contracted according to the individual's will, the same way as upper and lower limbs, pectoral, abdominal, gluteus and calf muscles. The PFM contractions, however, can only be "felt", not observed. Thus, as these muscles are somehow "unknown", most women find it difficult to perform and sense the contractions. Given this, the first step to be taken by women, both, athletes and nonathletes, prior to PFM training, should include proprioception exercises so as to achieve a conscious "recognition" of those muscles and a complete cohesion of this area ("asleep" up until then) with the whole body, favoring the PFM training.

Pelvic Floor Muscles contractions can be obtained by specific procedures, in which these are the only exercised muscles; PFM can also be contracted simultaneously to other exercises which mainly focus on other muscles' strengthening. Simultaneity is handy, especially when there are strong-effort and high-impact exercises, whether competitively or leisurely. PFM simultaneous exercising is possible during body-building activities using specific equipment, free weight-lifting exercises, gym classes, mini-trampoline practice, steps, hydro-gymnastics; and aerobic exercises.

As aforesaid, though some procedures were created in order to help professionals to work with PFM contraction exercises, quite a few researches follow standardized guidelines. Both our proposal and our research follow the instructions published by the Association of Women's Health Obstetrics and Neonatal Nurses (Agency for Health Care Policy and Research, [AWHONN]). According to this protocol, PFM strengthening exercises should include 40 to 50 contractions per session, with a sequence of 8 to 12 slow and quick contractions, where contractions are slow and isometric, 5 seconds long at the beginning and lasting for 10 seconds later on. Long term and daily training can, however, allow more contractions per class or training session, which was detected during our research, in which

physical activity program with PFM exercises (Fig.2). It was first developed in 2003, and improved and applied to a female group afterwards, as part of a research. Its results showed a reduction of incontinence complaints and an improvement of participants' body image (Caetano et al., 2009b). This research project included specific exercises for PFM, plus proprioception exercises (to get a better perception of the pelvis), breathing exercises, recreational activities (such as games and plays), stretching exercises, warm-up exercises (aerobic activities), upper and lower limb, abdominal and gluteus strengthening exercises

This research aimed mainly at creating strategies for the Physical Education professional to develop PFM strengthening exercises during physical exercise and sports practice with students who might or might not have complaints about urinary incontinence, in order to prevent or reduce its symptoms. The Physical Education professionals usually work at venues such as clubs, rehabilitation centers, gyms, schools, indoor or outdoor courts and companies; they also work as sports and fitness coaches for female professional athletes; this means their work involves a wide-ranging population group, which requires PFM exercises suitable to different ages as well as physical activities and exercises focusing on each

One of this systematization first concerns was to characterize the inclusion of PFM exercises in physical exercise and sports practice as a non-therapeutic action under the assumption that the engaged muscles also contain voluntary fibers, contracted according to the individual's will, the same way as upper and lower limbs, pectoral, abdominal, gluteus and calf muscles. The PFM contractions, however, can only be "felt", not observed. Thus, as these muscles are somehow "unknown", most women find it difficult to perform and sense the contractions. Given this, the first step to be taken by women, both, athletes and nonathletes, prior to PFM training, should include proprioception exercises so as to achieve a conscious "recognition" of those muscles and a complete cohesion of this area ("asleep" up

Pelvic Floor Muscles contractions can be obtained by specific procedures, in which these are the only exercised muscles; PFM can also be contracted simultaneously to other exercises which mainly focus on other muscles' strengthening. Simultaneity is handy, especially when there are strong-effort and high-impact exercises, whether competitively or leisurely. PFM simultaneous exercising is possible during body-building activities using specific equipment, free weight-lifting exercises, gym classes, mini-trampoline practice, steps,

As aforesaid, though some procedures were created in order to help professionals to work with PFM contraction exercises, quite a few researches follow standardized guidelines. Both our proposal and our research follow the instructions published by the Association of Women's Health Obstetrics and Neonatal Nurses (Agency for Health Care Policy and Research, [AWHONN]). According to this protocol, PFM strengthening exercises should include 40 to 50 contractions per session, with a sequence of 8 to 12 slow and quick contractions, where contractions are slow and isometric, 5 seconds long at the beginning and lasting for 10 seconds later on. Long term and daily training can, however, allow more contractions per class or training session, which was detected during our research, in which

until then) with the whole body, favoring the PFM training.

hydro-gymnastics; and aerobic exercises.

and relaxation exercises.

individual's needs.

1- hour classes were routinely given twice a week for a four-month period (Caetano et al, 2009b)

Fig. 2. Pelvic Floor Muscle Exercises (By Artur Paulo Caetano & Nicholas Silva Caetano). Source: Caetano, A.S. et al.,(2004). Physical Activity Proposal for Stress Urinary Incontinent Women. Lecturas Educacion Fisica y Deportes [online journal] Available: URL: http://www.efdeportes.com/efd76/mulheres.
