**2. Urinary incontinence**

Urinary Incontinence was first seen as a disease by the International Classification of Diseases (ICD/WHO) in 1998; up until then, it was treated as a symptom. The International Continence Society currently defines urinary incontinence as "a complaint of any unintended urinary leaking" (Abrams et al., 2003). It is estimated that 200 million people across the world show some sort of urinary incontinence. Its incidence is twice as higher in women, due to anatomic reasons, hormonal changes and as an after-effect of pregnancies and baby deliveries which can relocate and weaken the pelvic muscles. (Simeonova et al., 1999). According to Ortiz (2004), one out of 4 women has already had an episode of urinary leaking. When considering the kind of population under study (features such as age, professional activity, incidence of chronic diseases, menopause), the kind of diagnosis applied, and the definition used during the investigations, urinary incontinence prevalence may range from 10% to 55% in 15 to 64 year-old females (Hunskaar et al., 2004). About 38% of elderly females urinary leaking intense enough to be classified as a "urinary incontinence problem" within this group (Nygaard et al., 2007a). Just the same, the greatest incidence of urinary incontinence typically occurs in the years prior to or after the menopause, reaching its highest peak in 45 to 49 year-old women. Despite this high prevalence, less than 50% of these female patients look for medical treatment. Reasons for this might be as complex as shame and/or embarrassment and the belief that urinary incontinence, simply comes along with the ageing process (Mullins & Subak, 2005).

Not only does urinary incontinence imply medical consequences, but high expenses and negative emotional effects as well. It has been shown that this condition demands a cost which might range from 16 to 26 billion dollars a year, including days off at work and the use of sanitary napkins and diapers (Hu et al., 2004). Emotional damages can be even more devastating, as most incontinent women hardly ever share this problem and usually prefer to deal with it on their own, "silently". About 80% of women with severe urinary incontinence show symptoms of depression, high anxiety and low self-esteem, including loneliness and sadness. Moreover, the embarrassment and shame that come along are responsible for their quitting social activities and sports as well as for their lack of sexual interest (Fultz et al.; 2003; Norton et al.; 1988), which might exacerbate negative emotions and feelings.

Among the different types of urinary incontinence, the most commonly identified are stress urinary incontinence, urge-incontinence and mixed incontinence. The first is most frequently seen in 25 to 49 year-old females. Mixed urinary incontinence is more common in middle-aged women (40 to 60 years old) while urge-incontinence is mostly identified in elderly women (Minassian et al., 2003). Stress urinary incontinence appears to be more frequent in physically active female, those who practice sports and/or exercise regularly.

#### **2.1 Stress urinary incontinence**

Guyton & Hall (1997), characterize two main phases in urination: bladder filling or storage is the first, when there is an increase in the bladder wall pressure above limits; the voiding (urine flow) reflex occurs in the second phase, when the bladder is emptied and there should be a conscious signal of urinary urge. It is an autonomous reflex, integrated in the spinal cord which can be inhibited or facilitated by cortex centers or by the brainstem. In

Urinary Incontinence was first seen as a disease by the International Classification of Diseases (ICD/WHO) in 1998; up until then, it was treated as a symptom. The International Continence Society currently defines urinary incontinence as "a complaint of any unintended urinary leaking" (Abrams et al., 2003). It is estimated that 200 million people across the world show some sort of urinary incontinence. Its incidence is twice as higher in women, due to anatomic reasons, hormonal changes and as an after-effect of pregnancies and baby deliveries which can relocate and weaken the pelvic muscles. (Simeonova et al., 1999). According to Ortiz (2004), one out of 4 women has already had an episode of urinary leaking. When considering the kind of population under study (features such as age, professional activity, incidence of chronic diseases, menopause), the kind of diagnosis applied, and the definition used during the investigations, urinary incontinence prevalence may range from 10% to 55% in 15 to 64 year-old females (Hunskaar et al., 2004). About 38% of elderly females urinary leaking intense enough to be classified as a "urinary incontinence problem" within this group (Nygaard et al., 2007a). Just the same, the greatest incidence of urinary incontinence typically occurs in the years prior to or after the menopause, reaching its highest peak in 45 to 49 year-old women. Despite this high prevalence, less than 50% of these female patients look for medical treatment. Reasons for this might be as complex as shame and/or embarrassment and the belief that urinary incontinence, simply comes along

Not only does urinary incontinence imply medical consequences, but high expenses and negative emotional effects as well. It has been shown that this condition demands a cost which might range from 16 to 26 billion dollars a year, including days off at work and the use of sanitary napkins and diapers (Hu et al., 2004). Emotional damages can be even more devastating, as most incontinent women hardly ever share this problem and usually prefer to deal with it on their own, "silently". About 80% of women with severe urinary incontinence show symptoms of depression, high anxiety and low self-esteem, including loneliness and sadness. Moreover, the embarrassment and shame that come along are responsible for their quitting social activities and sports as well as for their lack of sexual interest (Fultz et al.; 2003; Norton et al.; 1988), which might exacerbate negative emotions

Among the different types of urinary incontinence, the most commonly identified are stress urinary incontinence, urge-incontinence and mixed incontinence. The first is most frequently seen in 25 to 49 year-old females. Mixed urinary incontinence is more common in middle-aged women (40 to 60 years old) while urge-incontinence is mostly identified in elderly women (Minassian et al., 2003). Stress urinary incontinence appears to be more frequent in physically active female, those who practice sports and/or exercise regularly.

Guyton & Hall (1997), characterize two main phases in urination: bladder filling or storage is the first, when there is an increase in the bladder wall pressure above limits; the voiding (urine flow) reflex occurs in the second phase, when the bladder is emptied and there should be a conscious signal of urinary urge. It is an autonomous reflex, integrated in the spinal cord which can be inhibited or facilitated by cortex centers or by the brainstem. In

**2. Urinary incontinence** 

with the ageing process (Mullins & Subak, 2005).

and feelings.

**2.1 Stress urinary incontinence** 

order to maintain urinary continence, the bladder must be complacent capable of storing hundreds of milliliters in volume, the urethra must be preserved and in a normal position, innervations must be intact, which is crucial for the sphincters integrity. A properly long urethra is also important, as it allows urethral mucosal coaptation which mechanically prevents the flowing of urine or the voiding. (Wei et al., 1999).

However, the female urinary continence mechanism is also supported by a healthy perineum structure, such as muscle and fascias (tissues) which provide structural framework for the internal organs as well as the closure of the pelvic opening. (Ashton-Miller & DeLancey, 2001). The perineum comprises all soft tissues that circle the pelvis and keep viscera in the upright position. In a simplistic analogy, the pelvic floor is compared to \*the foundations of a house, the diaphragm would be the ceiling and the abdominal muscles would make the front and side walls, while the spinal muscles and cord would make the back walls" (Grosse & Sengler, 2002). The pelvic floor muscles encompass three different layers (or plans), known as deep, middle and superficial. All layers, but the superficial, have voluntarily active muscle parts which can help keep continence when proper and supervised training takes place.

The deep layer consists of the main pelvic diaphragm, comprised by two muscles: the levator ani and the ischiococcygeus. The outward section of the levator ani is called elevator, its sphincter-like (consists of two hammock-like muscles – the pubococcygeus and the iliococcygeus) and has the support of the ischiococcygeus muscles; the inward section is formed by the pubovaginal and puborectal muscles. For the physical trainer, the levator ani is crucially important, as the pelvic floor muscle strength and quality can be improved by exercising this muscle.

The layer in the middle has three muscles: two deep transverse and the external urethral sphincter. The latter has the shape of a ring, circles the mid-third of the urethra and plays a fundamental role in the maintenance of continence. It's made of non-fatigable slow fibers which form the intra-urethral section plus a group of stretched muscles formed by slow fibers, fast and strong but highly fatigable fibers, called peri-urethral section. Despite being formed by striated fibers, the external sphincter is always in a state of contraction, helping to keep the pressure in a balanced level; in addition, it helps eliminate involuntary urinary flow as urinary needs can be controlled by strong and quick contractions.

Stress urinary incontinence is classified as the involuntary urine leaking as a result of physical exercises, physical efforts, sneezing and/or coughing (Abrams et al., 2002). It occurs when the urethral sphincter cannot withstand the urinary flow resulting from physical activities that increase intra-abdominal pressure; whenever a weakness or flaw occurs in the pelvic floor, there is an incorrect pressure transmission for the physical efforts, thus damaging the urinary continence mechanism and leading up to an unintended urinary leaking. This kind of incontinence is probably due to anatomic reasons; hypoestrogenism; after-effects of baby deliveries and pregnancies which might relocate and weaken the pelvic floor muscles. Other causes of stress urinary incontinence in women are: obesity; chronic diseases; gynecological surgeries; bowel obstruction; caffeine ingestion; smoking; hereditary reasons; medicinal drug ingestion (for example, alpha-adrenergic) and physical exercises.

Incontinence: Physical Activity as a Supporting Preventive Approach 73

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,

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,

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.,

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

eating disorders and/or both can foster urinary incontinence in athletes.

2004a).

1996;).

**3.2.1 Athletes** 

**3.2 Urinary incontinence prevalence in women** 

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

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 worsening of stress urinary incontinence.
