Sports Med 2004; 34 (7): 451-464

REVIEW ARTICLE 0112-1642/04/0007-0451/$31.00/0

 2004 Adis Data Information BV. All rights reserved.

Urinary Incontinence, Pelvic Floor

Dysfunction, Exercise and Sport
Kari Bø
The Norwegian University of Sport and Physical Education, Oslo, Norway

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
1.1 Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
1.1.1 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
1.1.2 Prevalence and Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
1.1.3 Aetiology, Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
1.2 Pelvic Floor Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
1.2.1 Function and Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
1.3 Aim of the Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
3.1 Prevalence of Urinary Incontinence in Female Elite Athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
3.2 Pelvic Floor and Strenuous Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
3.2.1 Hypothesis One: Female Athletes Have Strong Pelvic Floor Muscles . . . . . . . . . . . . . . . . . 457
3.2.2 Hypothesis Two: Female Athletes May Overload, Stretch and Weaken the Pelvic Floor 457
3.3 Treatment in the General Female Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
3.3.1 Bladder Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
3.3.2 Electrical Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
3.3.3 Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
3.3.4 Oestrogen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
3.3.5 Pelvic Floor Muscle Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
3.3.6 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
3.4 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
3.5 Treatment of Elite Athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
3.6 Preventive Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
3.7 Role of Fitness Instructors and Coaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462

Abstract Urinary incontinence is defined as “the complaint of any involuntary leakage

of urine” and is a common problem in the female population with prevalence rates
varying between 10% and 55% in 15- to 64-year-old women. The most frequent
form of urinary incontinence in women is stress urinary incontinence, defined as
“involuntary leakage on effort or exertion, or on sneezing or coughing”. The aim
of this article is to systematically review the literature on urinary incontinence and
participation in sport and fitness activities with a special emphasis on prevalence
and treatment in female elite athletes. Stress urinary incontinence is a barrier to
women’s participation in sport and fitness activities and, therefore, it may be a
452 Bø

threat to women’s health, self-esteem and well-being. The prevalence during

sports among young, nulliparous elite athletes varies between 0% (golf) and 80%
(trampolinists). The highest prevalence is found in sports involving high impact
activities such as gymnastics, track and field, and some ball games. A ‘stiff’ and
strong pelvic floor positioned at an optimal level inside the pelvis may be a crucial
factor in counteracting the increases in abdominal pressure occurring during
high-impact activities. There are no randomised controlled trials or reports on the
effect of any treatment for stress urinary incontinence in female elite athletes.
However, strength training of the pelvic floor muscles has been shown to be
effective in treating stress urinary incontinence in parous females in the general
population. In randomised controlled trials, reported cure rates, defined as <2g of
leakage on pad tests, varied between 44% and 69%. Pelvic floor muscle training
has no serious adverse effects and has been recommended as first-line treatment in
the general population. Use of preventive devices such as vaginal tampons or
pessaries can prevent leakage during high impact physical activity. The pelvic
floor muscles need to be much stronger in elite athletes than in other women.
There is a need for more basic research on pelvic floor muscle function during
physical activity and the effect of pelvic floor muscle training in female elite
athletes.

1. Background or on sneezing or coughing”.[1] Urge urinary inconti-

1.1 Urinary Incontinence
1.1.1 Definitions
Urinary incontinence is defined by the Interna-
tional Continence Society (ICS) as: “the complaint
of any involuntary leakage of urine”.[1] The ICS has
emphasised that symptoms, signs and conditions of
urinary incontinence are separate categories. Symp-
toms are the subjective indicator of a disease or
change in condition as perceived by the patient,
caregiver or partner and may lead him/her to seek
help from healthcare professionals. Signs are obser-
vations by the physician including simple means to
verify the symptoms and quantify them. Simple
means can be the observation of leakage during
cough or pad tests. Conditions are defined by the
presence of urodynamic observations associated
with characteristic symptoms and signs and/or non-
urodynamic evidence of relevant pathological
processes, e.g. electromyogram (EMG), ultrasound
or magnetic resonance imaging (MRI).
Stress urinary incontinence (SUI) is the com-
plaint of “involuntary leakage on effort or exertion,
nence is the complaint of “involuntary leakage ac-
companied by or immediately proceeded by urgen-
cy”. Urodynamic stress incontinence is noted during
filling cystometry and defined as “the involuntary
leakage of urine during increased abdominal pres-
sure, in the absence of a detrusor contraction”.[1]
Mixed incontinence is the complaint of “involuntary
leakage associated with urgency and also with exer-
tion, effort, sneezing and coughing”.[1]
1.1.2 Prevalence and Consequences
Urinary incontinence is more common in women
than in men and may affect women of all ages.
Prevalence rates in women between 15 and 64 years
vary between 10% and 55%.[2,3] Only one-quarter of
these women seek help for the problem, but still the
approximate annual cost of the condition in the US
has been estimated at $US11.2 billion in the com-
munity and $US5.2 billion in nursing homes (1996
values).[2] The most common type of urinary incon-
tinence in women is SUI, followed by urge and
mixed incontinence.
Urinary incontinence is not a life-threatening or
dangerous condition. However, it is socially embar-
rassing and may cause withdrawal from social situa-

 2004 Adis Data Information BV. All rights reserved. Sports Med 2004; 34 (7)
Pelvic Floor, Incontinence and Sport 453

tions and reduced quality of life.[2,4,5] In the elderly, eries increase the risk). Other factors are less clear,
it is a significant cause of disability and dependency. such as strenuous work or exercise, constipation
SUI implies that urine loss occurs during increases with straining on stool, chronic coughing or other
in abdominal pressure. If the condition is present, it conditions that increase abdominal pressure chroni-
is therefore likely that urine loss will occur during
cally[3,13,14] Fantl et al.[2] stated that incontinence is
physical activity. Thus, sedentary women who are
less exposed to physical exertion may not manifest not a normal consequence of age. However, there
stress incontinence, although the underlying condi- are age-related changes in the urethra and the PFM,
tion may be present. SUI has shown to lead to anatomical and physiological insults to the lower
withdrawal from participation in sport and fitness urinary tract, and systematic disturbances (e.g.
activities[6,7] and may be considered a barrier for stroke) that may occur with aging. The association
life-long participation in health and fitness activities between oestrogen deficit and urinary incontinence
in women.[8] Hence, although urinary incontinence is not clear.[2,3]
itself does not cause significant morbidity or mortal-
ity, it may lead to inactivity. A sedentary lifestyle is
an independent risk factor for several diseases and
conditions, e.g. high blood pressure, coronary heart
disease, type 2 diabetes mellitus, obesity, colon and
breast cancer, osteoporosis, depression and anxie-
ty.[9,10]

1.1.3 Aetiology, Pathophysiology

The stress continence system has been described
as: (i) the urethral support system consisting of the
anterior vagina, endopelvic fascia, arcus tendineus
fasciae pelvis and the pelvic floor muscles (PFM);
and (ii) the sphincteric closure system consisting of
urethral striated muscle, urethral smooth muscle and
vascular elements.[11]
Lose[12] concluded that sphincter function de-
pended on site of the urethra, state of the urethra
(rest or dilatation), voluntary contraction of the
PFM, impact, posture and age. He also found that
the passive wall structure was of minor importance
in occlusion and that the bladder neck and mid-
urethra was influenced by a forceful voluntary clo-
sure mechanism. Women with urodynamic stress
incontinence had decreased closure forces in the
bladder neck and mid-urethra. He concluded that
urodynamic stress incontinence was a result of
weakening of one or more individual parts of clo-
sure mechanism and inability of other parts to com-
pensate.[12]
Well established aetiological factors include old- Fig. 1. The pelvic floor muscles are located inside the pelvis and
er age, obesity, gynaecological surgery, and preg- form a structural support for internal organs (reproduced from Hahn
nancy and vaginal childbirth (instrumental deliv- and Myrhage,[17] with permission).

 2004 Adis Data Information BV. All rights reserved. Sports Med 2004; 34 (7)
454
1.2 Pelvic Floor Muscles
The PFM consist of the pelvic and the urogenital
diaphragm. They are located inside the pelvis and
form the floor of the abdominal cavity (figure 1).
The PFM consists of a three-layer muscular plate
expanding from the pubic symphysis, along the
frontal sidewalls of the ileum towards the coccyx.
(figure 2). The muscles are innervated from S2–S4,
and have been measured to have a thickness of
approximately 1cm.[15,16]
1.2.1 Function and Dysfunction
The PFM contract constantly, except right before
and during voiding. In addition to this constant
firing of the muscles they can be contracted inten-
tionally. If any of these muscles contracts in isola-
tion, they would all act differently due to their
individual fibre direction. However, the only known
voluntary function of the PFM is a mass contraction
described as an inward lift and squeeze around the
urethra, vagina and anus.[19,20] Because of its loca-
tion inside the pelvis, the PFM are the only muscle
group in the body capable of giving structural sup-
Coccygeus m.
Pubococcygeus m.
Iliococcygeus m.
Rectum
Vagina
Urethra
Inferior fascia of Ischiocavernosus m.
urogenital diaphram
Bulbocavernosus m.
Deep transverse perineal m.
Superficial transverse
perineal m.
Levator ani m.
Coccygeus m.
External anal sphincter
Fig. 2. The pelvic floor muscles (reproduced from Bø,[18] with per-
mission).
 2004 Adis Data Information BV. All rights reserved.
Bø
port for the pelvic organs and the pelvic openings
(urethra, vagina and anus). Ultrasound and MRI
studies have shown that the PFM is ‘stiffer’ and has
a more cranial position in nulliparous compared
with parous women,[21,22] and in continent versus
incontinent women.[23]
During a voluntary contraction the PFM lift in-
wardly. The urethra closes and the PFM resist down-
ward movement, thereby stabilising the urethra[21,24]
Both Bump et al.[25] and Bø and Talseth[26] have
demonstrated that a correct voluntary PFM contrac-
tion increases urethral pressure. However, studies
from different countries have shown that >30% of
women are not able to contract the PFM even after
thorough individual instruction at their first consul-
tation.[27-30] The most common errors are to contract
hip adductor, abdominal and gluteal muscles instead
of the PFM. In addition, straining is a common error.
Bump et al.[25] showed that 25% of the women were
straining instead of performing the correct lift and
squeeze. They also found that only 49% were able to
perform a PFM contraction that effectively in-
creased urethral pressure. Contractions of other
muscle groups such as the gluteals, hip adductors
and abdominals cause co-contractions of the PFM in
healthy volunteers.[31-33] However, none of these
other muscles can act as a structural support to the
pelvic organs, prevent descent of the bladder and the
urethra during increases in abdominal pressure, or
increase urethral closure pressure by their own iso-
lated contractions. Lack of co-contraction or
delayed or weak co-contraction of the PFM may
lead to urinary and faecal incontinence, prolapse of
the anterior vaginal wall (cystocele), posterior vagi-
nal wall (rectocele), vaginal apex (enterocele) and
uterus, or pain and sexual dysfunction.[14]
1.3 Aim of the Review
The aim of the present article is to systematically
review the literature on urinary incontinence and
participation in sport and fitness activities with a
special emphasis on prevalence and treatment of
female elite athletes.
Sports Med 2004; 34 (7)
Pelvic Floor, Incontinence and Sport
2. Methods
This is a systematic review of the literature cov-
ering incidence, prevalence, treatment and preven-
tion of female urinary incontinence in sport and
fitness activities, with a focus on SUI. For epidemio-
logical studies, computerised searches on ‘Sport’
and ‘PubMed’ were done. Mesh words of ‘urinary
incontinence’ or ‘pelvic organ prolapse’ combined
with ‘exercise’, ‘fitness’, ‘physical activity’ and
‘sport’ were used. In addition, the chapter on epide-
miology from the 2nd International Consultation on
Incontinence (ICI), Paris, was consulted.[3] All stud-
ies found on prevalence and incidence were includ-
ed.
For treatment, the same computerised search was
conducted. In addition, a systematic review on sur-
gery,[34] overviews from the ICI meeting on pharma-
ceutical therapy,[35] surgery[36] and conservative
treatment,[13] a manual search of abstracts from ICS
Annual Meetings from 1984–2001 and the Coch-
rane library[37] were done. Only results from
randomised controlled trials are reported. As there
are few studies on prevention, a matched pair con-
trolled study on the effect of PFM training after
pregnancy is included. For treatment and preva-
lence/incidence studies reference lists of articles
identified were also reviewed to identify other use-
ful articles.
3. Results
3.1 Prevalence of Urinary Incontinence in
Female Elite Athletes
An overview of published studies on prevalence
of urinary incontinence in elite athletes is shown in
table I. Although there are anecdotal reports of
pelvic organ prolapse in young, nulliparous mara-
thon runners and weightlifters, no studies were
found on this topic. There is a high prevalence of
symptoms of both stress and urge incontinence in
young nulliparous as well as parous elite athletes.
Only one study has compared the prevalence of
incontinence in elite athletes with that of age-
matched controls. Bø and Sundgot Borgen[38] found
 2004 Adis Data Information BV. All rights reserved.
455
equal prevalence of overall stress and urge inconti-
nence in both groups. However, the prevalence of
leakage during physical activities was significantly
higher in the elite athletes.
None of these studies characterised incontinence
with urodynamic testing (simultaneous measure-
ment of urethral and bladder pressures during in-
crease in abdominal pressure) and it is therefore not
possible to confirm whether the leakage represents
stress, urge or mixed incontinence. However, in a
study by Sandvik et al.,[43] questions used in a survey
were validated against the diagnosis made by a
gynaecologist after urodynamic evaluation. The di-
agnosis of SUI increased from 51% to 77%, mixed
incontinence was reduced from 39% to 11%, and
urge incontinence increased from 10% to 12% after
urodynamic assessment. In another study of nullipa-
rous physical education students, six of seven who
underwent ambulatory urodynamic assessment
showed evidence of urodynamic stress inconti-
nence.[44]
As seen from table I, the question on inconti-
nence was posed in a general way with no time
restrictions (e.g. leakage during last week or month).
Eliasson et al.[42] is the only research group adding
clinical measurements to the study. They measured
urinary leakage in all elite trampolinists who report-
ed the leakage to be a problem during trampoline
training. The leakage was verified in all participants
with a mean leakage of 28g (range 9–56g) in a
15-minute test on the trampoline. PFM function was
measured in a subgroup of ten women accustomed
to wearing tampons. They were all classified to have
strong voluntary contractions.
Unlike the current ICS definition of urinary in-
continence, the former ICS definition required that
the leakage had to be considered a hygienic or social
problem. The reported prevalence is reduced when
this definition is used.[3] Nevertheless, a high pro-
portion of elite athletes reported that the leakage was
embarrassing, affected their sport performance or
was a social or hygienic problem. There is no report
of how many of the athletes sought help for their
problems.
Sports Med 2004; 34 (7)
 2004 Adis Data Information BV. All rights reserved.

456
Table I. Prevalence of urinary incontinence in female elite athletes

Study (year) Design Population/sample Response rate Question Results

(%)
Nygaard et Cross-sectional; postal All women participating in competitive 92 Have you ever 28% reported at least one episode of
al.[39] (1994) survey varsity athletics at a large US state experienced unanticipated urinary incontinence while practising or
university (n = 156). Mean age 19.9y ± urinary leakage during competing in their sport: gymnastics
3.3 (SD). Nulliparous participation in your sport, 67%; tennis 50%; basketball 44%; field
coughing, sneezing, hockey 32%; track 26%; volleyball 9%;
heavy lifting, walking to swimming 6%; softball 6%; golf 0%.
the bathroom, sleeping, 42% experienced urine loss during
and upon hearing the daily activities. 38% felt embarrassed
sound of running water?
Nygaard[40] Retrospective and Former US female Olympians 51.2 Do you now/did you while While Olympians: swimming 4.5%;
(1997) cross-sectional; postal (between 1960–76) participating in being an Olympian gymnastics/track & field 35.0%
survey gymnastics and track & field compared participant experience (p < 0.005). Now: swimming 50%;
with swimmers (n = 207). Mean age urinary leakage related to gymnastics/track & field 41% (NS)
44.3y (range 30–63y). Mean no. of feeling of urgency, or
years since beginning training = 30 related to activity,
coughing or sneezing?
Bø & Sundgot Cross-sectional, case- All female elite athletes on national Athletes: 87; Do you currently leak SUI: athletes 41%; controls 39%.
Borgen[38] control; postal survey team or recruiting squad in Norway (n controls: 75 urine during coughing, Range between sports: 37.5–52.2%.
(2001) = 660) and age-matched controls (n = sneezing and laughter, Urge: athletes 16%; controls 19%.
765). Age 15–39y. Parity: 5% in elite physical activity (running Range between sports: 10–27.5%.
athletes, 33% in controls and jumping, abrupt Social/hygienic problem: athletes 15%;
movements and lifting) or controls: 16.4%. Moderate/severe
with urge to void problem: athletes/controls 5%
(problems in reaching the
toilet without leaking)?
Thyssen et Cross-sectional; postal 8 Danish sport clubs (including ballet) 73.7 Do you experience urine 51.9% experienced urine loss during
al.[41] (2002) survey competing at national level (n = 397). loss while participating in sport or in daily life. 43% while
Mean age 22.8y (range 14–51y). 8.6% your sport or in daily life? participating in their sport: gymnastics
were parous 56%; ballet 43%; aerobics 40%;
badminton 31%; volleyball 30%;
athletics 25%; handball 21%;
basketball 17%
Eliasson et Cross-sectional; postal All 35 female Swedish trampolinists at 100 on survey; Do you leak urine during 80% reported leaking urine during
al.[42] (2002) survey; clinical national level between 1993–96. Mean 51.4 on pad trampoline training or trampoline training or competition and
assessment: pad test age 15y (range 12–22y). Nulliparous test; 28.6 on competition or daily life? sport. None leaked during coughing,
Sports Med 2004; 34 (7)

during trampoline strength sneezing or laughing. 51.4% reported

training (n = 18), measurement the leakage to be embarrassing. Mean
measurement of pelvic leakage on pad testing = 28g (range
floor muscle strength 9–56g)
(n = 10)
NS = not significant; SUI = stress urinary incontinence.

Bø
Pelvic Floor, Incontinence and Sport
There is limited knowledge about associated fac-
tors. In a study of college varsity athletes, Nygaard
et al.[39] found no significant association between
incontinence and amenorrhoea, weight, hormonal
therapy or duration of athletic activity. In a study of
former Olympians, they found that among factors
such as age, body mass index (BMI), parity,
Olympic sport group and incontinence during
Olympic sport 20 years ago, only current BMI was
significantly associated with regular stress or urge
incontinence symptoms.[40] Bø and Sundgot Bor-
gen[38] reported that significantly more elite athletes
with eating disorders had symptoms of both stress
and urge incontinence. Eliasson et al.[42] showed that
incontinent trampolinists were significantly older
(16 vs 13 years), had been training longer and more
frequently, and were less able to interrupt the urine
flow stream by voluntarily contracting the PFM than
the non-leaking group.
3.2 Pelvic Floor and Strenuous
Physical Activity
There are two opposing hypotheses about the
pelvic floor in elite athletes: (i) female athletes have
strong pelvic floor muscles; and (ii) female athletes
may overload, stretch and weaken the pelvic floor.
3.2.1 Hypothesis One: Female Athletes Have
Strong Pelvic Floor Muscles
The rationale would be that any physical activity
that increases abdominal pressure will lead to a
simultaneous or pre-contraction of the PFM, and the
muscles will be trained. Based on this assumption,
general physical activity would prevent and treat
SUI. However, women leak during physical activity
and they report worse leakage during high-impact
activities. No sports involve a voluntary contraction
of the PFM. Many women do not demonstrate an
effective simultaneous or pre-contraction of the
PFM during increased abdominal pressure. In nul-
liparas this may be due to genetically weak connec-
tive tissue, location of the PFM at a lower, caudal
level inside the pelvis, lower total number of muscle
fibres (especially fast twitch fibres) or untrained
muscles in those leaking.
 2004 Adis Data Information BV. All rights reserved.
457
To date, there is little knowledge about PFM
function in elite athletes. Bø et al.[44] measured PFM
function in sport and physical education students
with and without urinary incontinence and did not
find any difference in PFM strength. The increase in
PFM pressure during a voluntary contraction was
16.2cm H2O (SD8.7) in the group with SUI and
14.3cm H2O (SD8.2) in the continent ones. Howev-
er, this study was limited by its small sample size
and no strong conclusion can be drawn. Statistically
significant differences in PFM function and strength
between continent and incontinent women have
been shown in the adult population.[16,45,46] Bø (un-
published data) assessed PFM strength in four elite
female power lifters and compared them to 20 phys-
ical therapy students. Mean muscle strength during
voluntary contraction in power lifters was 22.6cm
H2O (SD9.1) and in the physical therapy students
19.3cm H2O (SD6.8) [not significant]. Only one of
the elite athletes in the above-mentioned ongoing
study had exercised the PFM systematically. She
reported to have trained her PFM regularly in order
to increase low back stability and abdominal pres-
sure during lifting. Her mean PFM strength was
36.2cm H2O. She was totally continent even when
competing in World championships, but so too were
those who had not trained the PFM.
3.2.2 Hypothesis Two: Female Athletes May
Overload, Stretch and Weaken the Pelvic Floor
Heavy lifting and strenuous work have been
listed as risk factors for the development of pelvic
organ prolapse and SUI.[3,13,14] Nichols and Mil-
ley[47] suggested that the cardinal and uterosacral
ligaments, PFM and the connective tissue of the
perineum might be damaged chronically because of
repeated increases in abdominal pressure due to hard
manual work and chronic cough. To date, there are
still little data to support the hypothesis. In a study
of Danish nursing assistants, it was found that they
were 1.6 times more likely to undergo surgery for
genital prolapse and incontinence than women in the
general population.[48] However, the study did not
control for parity and, therefore, it is difficult to
conclude whether heavy lifting is an aetiological
factor.
Sports Med 2004; 34 (7)
458
Twenty-six percent of women in the US Air
Force female crew, capable of sustaining up to 9G,
reported urinary incontinence.[49] However, more
women had incontinence off duty than while flying
and it was concluded that flying high-performance
military aircraft did not affect the rate of inconti-
nence. Davis and Goodman[50] found that nine out of
420 nulliparous female soldiers entering the air-
borne infantry training programme developed se-
vere incontinence. Hence, most women were not
negatively affected by this high-impact activity.
Hay[51] reported the maximum vertical ground
reaction forces during different sport activities to be:
3–4 times bodyweight for running; 5–12 times for
jumping; 9 times for landing from front somersault;
14 times for landing after double-back somersault;
16 times during landing in long jumps; and 9 times
bodyweight in the lead foot in javelin throwing.
Thus, one would anticipate that the pelvic floor of
athletes needs to be much stronger than in the nor-
mal population to counteract these forces.
To date, it has been concluded that there is no
evidence that strenuous exercise causes SUI or pel-
vic organ prolapse.[13] Although the prevalence is
high, most athletes do not leak during strenuous
activities and high increases in abdominal pressures.
However, from a theoretical understanding of func-
tional anatomy and biomechanics, it is likely that
heavy lifting and strenuous activity may promote
these conditions in women already at risk, e.g. those
with benign hypermobility joint syndrome. Physical
activity may unmask and exaggerate the condition.
3.3 Treatment in the General
Female Population
SUI can be treated with bladder training, PFM
training with or without resistance devices, vaginal
cones or biofeedback, electrical stimulation, drug
therapy or surgery.[2,3]
3.3.1 Bladder Training
Bladder training (bladder discipline, bladder drill
and bladder re-education) is an educational and
behavioural process used to re-establish urinary
control in adults by scheduled voiding. Bladder
training was first described by Jeffcoate and Francis
 2004 Adis Data Information BV. All rights reserved.
Bø
in 1966, and has been advocated mostly for urgency,
frequency and urge incontinence.[13] One study also
showed an effect for SUI.[52] However, the rationale
for effect on SUI is controversial and not easy to
understand. One might theorise that holding back
urine increases PFM activity. This modality has not
been tried out in exercise-induced stress inconti-
nence or in elite athletes. Most elite athletes would
empty their bladder before practice and competition.
Therefore, it is unlikely that any of them would
exercise with a high bladder volume. No adverse
effects have been reported after bladder training.
3.3.2 Electrical Stimulation
Electrical stimuli applied via a probe placed in
the vagina or rectum has been studied to treat SUI.
However, the effect of electrical stimulation on
muscle strength in general human skeletal muscles
remains controversial.[53,54] To date, the studies on
the pelvic floor are inconclusive.[13] Reported ad-
verse effects after electrical stimulation have been
pain, discomfort, vaginal irritations or infections,
urinary tract infections and diarrhoea.[55,56] In a Nor-
wegian study of 3100 women who had used electri-
cal stimulation, 51% reported one or more adverse
effects.[56] The most common adverse effects were
soreness/local irritation (26%), pain (20%) and psy-
chological distress. Most of the cases were mild.
3.3.3 Pharmacotherapy
Pharmacotherapy cannot treat anatomical factors
such as urethral support, vesical neck function, and
function of the PFM.[35] However, women with SUI
may have lower resting urethral pressure than age-
matched continent women, and resting urethral pres-
sure may respond to drug therapy via increasing
tone in urethral smooth or striated muscle and the
PFM. Drugs used in the treatment of SUI are α-
adrenoceptor agonists (ephedrine, norephedrine,
phenylpropanolamine), imipramine, clebuterol,
duloxetine and oestrogen.[35] There are few
randomised placebo controlled trials in this area,
and some concern about the adverse effects.[35]
Duloxetine, a selective inhibitor of serotonin and
norepinephrine reuptake, is a recent addition to the
pharmacological armamentarium.[57] In a double-
blind, randomised, placebo-controlled trial of 553
Sports Med 2004; 34 (7)
Pelvic Floor, Incontinence and Sport
women aged 18–65 years with a predominant symp-
tom of SUI, incontinence episodes were reduced by
41% in the placebo group compared with 54% for
duloxetine 20 mg/day (p = 0.06), 59% for 40 mg/day
(p = 0.02), and 64% for 80 mg/day (p < 0.001).
Compliance was 78% in the duloxetine group and
83% in the placebo group. Discontinuation because
of adverse effects increased with dosage: 5% for
placebo, and 9%, 12%, and 15% for duloxetine 20,
40 and 80 mg/day, respectively (p = 0.04). The most
common adverse effects were headache, nausea,
fatigue, dry mouth, insomnia, dizziness and menor-
rhagia.[57] The drug has not been tested specifically
for exercise-induced incontinence.
3.3.4 Oestrogen
The urethra has four oestrogen sensitive func-
tional layers: epithelium, vasculature, connective
tissue and muscle. The role of oestrogen in inci-
dence, prevalence and treatment of SUI is contro-
versial. Two meta-analyses of the effect have con-
cluded that there is no change in urine loss after
oestrogen replacement therapy.[35] Oestrogen given
alone therefore does not seem to be an effective
treatment for SUI. There is a higher prevalence of
eating disorders in athletes compared with non-ath-
letes, and these athletes may be low in oestrogen.[38]
However, most amenorrhoeic elite athletes would be
on oestrogen replacement therapy because of the
risk of osteoporosis. Oestrogen has adverse effects
such as higher risk of coronary heart disease and
cancer.
3.3.5 Pelvic Floor Muscle Training
Based on systematic reviews and meta-analyses
of randomised controlled trials it has been stated that
conservative treatment should be first-line treatment
for SUI.[2,13] The Cochrane review by Hay-Smith et
al.[37] concludes that PFM training is an effective
treatment for adult women with stress or mixed
incontinence, and consistently better than no treat-
ment or placebo treatments. Subjective cure and
improvement rates after PFM for SUI or mixed
incontinence reported in randomised controlled tri-
als vary between 56–70%.[37] Cure rates, defined as
<2g of leakage on pad tests, vary between 44–67%
in SUI.[55,58] Adverse effects have only been report-
 2004 Adis Data Information BV. All rights reserved.
459
ed in one study.[59] Out of 54 women, one woman
reported pain with PFM contractions, three had an
uncomfortable feeling during exercise and two felt
that they did not want to be continually occupied
with the problem.
3.3.6 Surgery
The first incontinence surgical procedure was
performed by Sims in 1852, and since then more
than 150 surgical procedures have been de-
scribed.[60] Generally, cure and improvement rates
after surgery have been reported to be above 80%.
However, Black and Downs[34] reported that out of
843 reports on the effect of surgery, only 11 were
randomised trials, 20 were non-randomised trials/
prospective cohort studies and 45 were retrospective
cohort studies. They concluded that the methodolog-
ical quality of the few prospective studies reporting
effectiveness of surgery for stress incontinence was
poor. This is supported by Smith et al.[36] stating that
the case selection for surgery is varied and often not
well described. Often pre- and postoperative evalua-
tion of urinary leakage is missing, and description of
surgical techniques and perioperative complications
are omitted. Long-term effectiveness of surgery de-
creases with time. Despite this, many reports only
include short-term follow up. As for conservative
treatment modalities, improvement and cure rates
are often reported together, and evaluation of impact
of complications after surgery is sparse. If a proce-
dure cures stress incontinence but creates retention
or urge incontinence, the surgery should not be
classified as successful.[36,61]
For sling operations, the risk of vaginal erosion
was found to vary between 0–16% and urethral
erosion from 0–5% in the literature.[36] De novo
detrusor instability occurred in 3.7–66% of cases
and procedures requiring sling revision or removal
ranged from 1.8–35%.[36] The newest surgery proce-
dure is the transvaginal tape (TVT) procedure. After
TVT operations, 3–15% of patients have been found
to have symptoms of de novo detrusor instability
and short-term voiding disorder has been found to
be 4.3%. Prolene mesh erosion seems to be rare, but
knowledge of long-term tolerability of the mesh is
lacking.[36]
Sports Med 2004; 34 (7)
460
Surgery may have a negative impact on the effec-
tiveness of later PFM training, while training has no
impact on future surgery. In two recent editorials,
Ostergaard[61] and Wall[62] have warned about the
widespread use of new surgical techniques before
there are high-quality randomised controlled trials
to show the effect and adverse effects. Currently,
there is no information to use in counselling women
about appropriate postoperative exercise. Some phy-
sicians request patients to refrain from all strenuous
activity, while others recommend no restrictions at
all. There are no reports of the effect of surgery in
young nulliparous elite athletes.
3.4 Prevention
There are no studies applying PFM training for
primary prevention for SUI. Theoretically, one
could argue that strengthening the PFM by specific
training would have the potential to prevent SUI and
pelvic organ prolapse. Strength training may in-
crease PFM volume, and ‘lift’ the levator plate to a
more cranial level inside the pelvis. If the pelvic
floor possesses a certain ‘stiffness’,[11,23] it is likely
that the muscles could counteract the increases in
abdominal pressures occurring during physical exer-
tion.
The few studies that have been published on
prevention have concentrated on training during
pregnancy or after childbirth.[63] In a group of conti-
nent primiparous women with bladder neck
hypermobility, Reilly et al.[64] showed a prevalence
of 19.2% with SUI in those who had trained during
pregnancy compared with 32.7% in the control
group. After PFM training during pregnancy,
Mørkved et al.[65] reduced the prevalence of urinary
incontinence by 14% during pregnancy, and 11% at
3 months postpartum. Both research groups showed
that continent women had significantly stronger
PFM than the incontinent ones. Both Chiarelli and
Cockburn[66] and Mørkved and Bø[67] have demon-
strated a significant reduction in the number of
women with urinary incontinence after PFM
strength training postpartum. Two studies did not
show any effect of PFM training during pregnancy
or after childbirth.[68,69] The interventions in these
 2004 Adis Data Information BV. All rights reserved.
Bø
two studies were, however, weak, as the programme
only consisted of one session with a midwife or a
physical therapist, respectively. There was no super-
vision or guiding of the training.
3.5 Treatment of Elite Athletes
The elite athletes have the same condition and
one would therefore assume that they would respond
to the same treatments as other women. However, to
this author’s knowledge there are no studies on the
effect of any treatment of SUI in female elite ath-
letes. In addition, there are methodological
problems assessing bladder and urethral function
during physical activity before and after treat-
ment.[70,71]
Bø et al.[55,72] and Mørkved et al.[58] used tests
involving high-impact exercise (running and jump-
ing) before and after treatment, and showed that it is
possible to cure or reduce urinary leakage during
physical activity. Bø et al.[6] demonstrated that after
specific strength training of the PFM, 17 of 23
women reported improvement during jumping and
running, and 15 during lifting. Significant improve-
ment was also obtained while dancing, hiking, dur-
ing general group exercise, and in an overall score
on ability to participate in different activities.[6]
Measured with a pad test with standardised bladder
volume during activities comprising running, jump-
ing jacks and sit ups, there was a significant reduc-
tion in urine loss from mean 27g (95% CI 8.8,45.1;
range 0–168g) to 7.1g (95% CI 0.8,13,4; range
0–58.3g), p < 0.01.[72] Mørkved et al.[58] demonstrat-
ed a 67% cure rate in a test involving physical
activity after individual biofeedback-assisted
strength training of the PFM. Sherman et al.[73]
randomised 39 female soldiers, mean age 28.5 years
(SD7.2), with exercise-induced urinary inconti-
nence, to PFM training with or without biofeedback.
All improved subjectively and showed normal read-
ings on urodynamic assessment after treatment. On-
ly eight subjects desired further treatment after 8
weeks of training.
Elite athletes are accustomed to regular training
and are highly motivated for exercise. Adding three
sets of 8–12 close to maximum contractions, 3–4
Sports Med 2004; 34 (7)
Pelvic Floor, Incontinence and Sport
times a week[74] of the PFM to their regular strength-
training programme does not seem to be a big task.
However, there is no reason to believe that they are
more able than the general population to perform a
correct PFM contraction. Therefore, thorough in-
struction and assessment of ability to contract is
mandatory. Since most of the elite athletes are nul-
liparous, there are no ruptures of ligaments, facias,
muscle fibres or peripheral nerve damage. There-
fore, it is expected that the effect would be equal or
even better in this specific group of women. On the
other hand, the impact and increase in abdominal
pressure that has to be counteracted by the PFM in
athletes performing high impact activities is much
higher than what is required in the sedentary popula-
tion. The pelvic floor, therefore, probably needs to
be much stronger in elite athletes.
There are two different theoretical rationales for
the effect of PFM training. Miller et al.[75] proposed
that women learn to perform a voluntary contraction
of the PFM before and during increases in abdomi-
nal pressure. Such a pre-contraction before cough-
ing reduces leakage by 98% and 73% during a
medium and deep cough, respectively.[75] However,
most published PFM training programmes do not
seem to have any emphasis on this voluntary con-
traction. The focus has been on regular strength
training. Kegel[19] first described the method in 1948
as ‘tightening’ of the pelvic floor. The rationale
behind a strength-training regimen is to increase
muscle tone and cross-sectional area of the muscles,
Table II. Role of fitness instructors and coaches in the prevention and treatment of stress urinary incontinence
Fitness instructors
Be aware and improve knowledge of the problem
Openness and information. Have brochures and anatomical models
available in the gym
Give alternative low-impact exercise to jumping and running. Avoid Establish cooperation with trained women’s health PT to teach
jumping jacks. Encourage continuing with regular exercises.
Recommend low-impact aerobics, swimming, bicycling, walking, Nordic
walking, step training
Add 2–3 sets of 8–12 close to maximum contractions of the pelvic floor Add 2–3 sets of 8–12 close to maximum contractions of the
muscles to any strength training programme
Inform participants that they may have consultations with women’s
health physiotherapist to learn and check their ability to contract
PFM = pelvic floor muscles; PT = physical therapist.
 2004 Adis Data Information BV. All rights reserved.
461
increase stiffness of connective tissue and thereby
lift the pelvic floor into a higher pelvic position.
It is unlikely that continent elite athletes or par-
ticipants in fitness activities think about the PFM or
pre-contract them voluntarily. A contraction of the
PFM most likely occurs automatically and simulta-
neously, or even before the impact or abdominal
pressure increase.[76] It seems impossible to volunta-
rily pre-contract the PFM before and during every
increase in abdominal pressure while participating
in sport and leisure activities. The aim of the training
programme therefore would be to build up the PFM
to a firm structural base where such contractions
occur automatically.
Elite athletes are young and mostly nulliparous,
and it is therefore recommended that PFM training
should be the first choice of treatment and always
tried before surgery. The leakage in athletes seems
to be related to high-impact strenuous activity and
elite athletes do not seem to have more urinary
incontinence than others later in life when the activi-
ty is reduced.[40] Therefore, surgery seems inappro-
priate in elite athletes who have incontinence only
during exercise and sport.
Most likely very few, if any, of the athletes have
learned about the PFM and one could assume that
none have tried to train them systematically. The
potential for improvement in function and strength
is therefore huge. PFM training has proved to be
effective when conducted intensively and with a
close follow-up in the general population.[37] It is a
Coaches
Be aware and improve knowledge of the problem
Talk about incontinence and prolapse as common conditions in
young, nulliparous female athletes. Use brochures and
anatomical models
and evaluate correct PFM contraction
pelvic floor muscles (or specific dosage prescribed from the
PT) to the athlete’s strength training programme
If PFM training has no effect contact urologist or
urogynaecologist
Sports Med 2004; 34 (7)
462
functional and physiological, non-invasive treat-
ment with no known serious adverse effects and it is
cost effective compared with other treatment modal-
ities. However, there is a need for high-quality
randomised controlled trials to evaluate the effect of
PFM strength training in female elite athletes.
3.6 Preventive Devices
Devices that involve external urinary collection,
intravaginal support of the bladder neck or blockage
of urinary leakage by occlusion are available and
have shown to be effective in preventing leakage
during physical activity.[13] A vaginal tampon can be
such a simple device. In a study by Glavind[77] six
women with SUI demonstrated total dryness when
using a vaginal device during 30 minutes of aer-
obics. For smaller leakage, specially designed pro-
tecting pads can be used during training and compe-
tition.
3.7 Role of Fitness Instructors and Coaches
Each person who conducts exercise training for
women has an important role in helping women of
all ages and fitness levels to prevent and cope with
urinary incontinence. Table II shows what fitness
instructors and coaches can do to help restore conti-
nence. Women or female elite athletes should be
encouraged to continue to conduct regular exercise
while training their pelvic floor. Low impact activi-
ties can be recommended for the general population.
4. Conclusion
SUI may be a barrier to women’s participation in
sport and fitness activities. Hence it may be a threat
to women’s health, self-esteem and well-being. The
prevalence among young, nulliparous elite athletes
varies between 0% (golf) and 80% (trampolinists).
The highest prevalence is found in sports involving
high-impact activities such as gymnastics, track and
field, and some ball games. There are no randomised
controlled trials or reports on the effect of any
treatment in female elite athletes. PFM training has
shown to be effective in randomised controlled tri-
als, has no serious adverse effects and has been
recommended as first-line treatment in the general
 2004 Adis Data Information BV. All rights reserved.
Bø
population. There is a need for more basic research
on PFM function during physical activity and the
effect of PFM training in female elite athletes.
Acknowledgements
No sources of funding were used to assist in the prepara-
tion of this review. The author has no conflicts of interest that
are directly relevant to the content of this review.
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Correspondence and offprints: Prof. Kari Bø, Norwegian
University of Sport and Physical Education, P.B. 4014, Ul-
levål Stadion, 0806 Oslo, Norway.
E-mail: kari.bo@nih.no
Sports Med 2004; 34 (7)