Exercise & Urinary Incontinence
Are Women at Gyms Increasing Their Risk?
When a woman has an initial consult at the gym, she is usually asked if she suffers from conditions such as diabetes, heart disease or asthma. As well as needing this information from a legal point of view, a personal trainer will take this into account when creating an optimal work out for that woman. A quick review of the literature shows that approximately 10% of women are affected by each of these issues. Although not life threatening, there is another major health issue that affects a much higher proportion of the female population which is very rarely asked about but should definitely be taken into account when creating an appropriate gym workout.
This issue is stress urinary incontinence (SUI), or the involuntary leakage of urine associated with an increase in intra-abdominal pressure, such as coughing, sneezing or exercise. Previous population based studies have shown that the proportion of women suffering from SUI is approximately one third. There are well researched risk factors associated with higher rates than this, such as pregnancy and childbirth, older age and menopause, obesity, lower back pain, chronic constipation, chronic coughing and regular heavy lifting. Research has also been done on elite athletes in high impact sports, and it has been shown that 20-80% of these female athletes suffer with SUI.
A study done in Western Australia looked at the prevalence of SUI in women who attend community-based exercise classes or gymnasiums. Of the 361 participants who completed the short survey, nearly half (49.3%) of them reported that they suffered from SUI. Although 43% stated that a fitness instructor had mentioned pelvic floor activation during a class, only 15.2% had been individually asked about it in an initial consult. What this study shows is that SUI is a very common issue in women attending gyms (seemingly more common than in the general population), however it is rarely screened for.
What this research suggests is that more resources need to go into educating fitness professionals on how to screen for this and other common symptoms of pelvic floor muscle dysfunction. Then, if a woman is identified as having these symptoms, or being at risk of developing them (i.e. after childbirth, after gynaecological surgery etc), the fitness professional needs to know how to advise that woman to seek help with long term management, and how to modify their training program in the meantime to prevent causing or worsening problems. The health professionals who are best placed to work
Regular exercise is extremely important, especially with the growing obesity crisis, and it would be tragic if an easily-avoided issue such as SUI was a barrier to exercise for women. However, women need to know that certain exercises are likely to increase the risk of pelvic floor dysfunction, including SUI and pelvic organ prolapse. It is recommended that women with pelvic floor dysfunction or in high risk categories should avoid high impact options such as boxing, running and jumping, heavy weights and high end ‘core’ and abdominal exercises such as crunches and double leg lifts, until they have a management plan in place for their pelvic floor muscle rehabilitation.
With the recent popularity of pilates, the term ‘core exercises’ has become widely spread. When taken in the true sense of the term, it should involve activation of the pelvic floor muscles and the deep abdominal muscles such as the transverse abdominus. In reality what are advertised as ‘core exercises’ in many gym programs are double straight leg raises and heavy medicine ball work that actually cause an over-recruitment of the superficial ‘power’ abdominal muscles such as the rectus abdominus and completely over-ride the more subtle, deeper muscles. These higher end core exercises can certainly be appropriate, but often need to be trained up to by proving you can correctly perform the lower loaded exercises first. When a Women’s Health Physiotherapist does a vaginal examination or a real time ultrasound assessment, the bearing down and bulging into the pelvic floor during the higher end 'core' exercises is often evident, and hence they would be detrimental to 'the core', not helpful. Externally this can also be obvious, with abdominal doming and breath holding occurring.
Women often only realize that they have been performing these exercises incorrectly when something goes wrong. This may be in the form of a musculoskeletal issue such as a lumbar disc injury, in the form of an abdominal issue such as an umbilical hernia, or in the form of a gynaecological issue such as a vaginal prolapse or urinary incontinence. All of these are essentially caused by the same issue – repetitive high intra-abdominal pressure that exceeds what can be matched by the deep supporting muscles such as the pelvic floor.
These issues, especially the gynaecological ones, may be able to be managed by conservative measures such as pelvic floor muscle training and heeding lifestyle advice on managing increases in intra-abdominal pressure. A large study done at the University of South Australia has shown that conservative management proved effective for 84% of women with mild to moderate SUI who received pelvic floor muscle training and lifestyle advice with a qualified Continence and Women’s Health Physiotherapist. The treatment was done over an average of five sessions. The 'cure' rate was still approximately 80% after 1 year, which is comparable to, or even better than, the 'cure' rate reported with surgery. There will be a proportion of sufferers for whom surgery is the only option, however conservative management should be considered in mild to moderate cases given that it is less invasive, less expensive and has much fewer side effects.
Pelvic floor exercises are often taught verbally, however studies have shown that this is not always adequate. In fact, one study showed that only 49% of women were performing an ideal pelvic floor muscle contraction after verbal instruction, with a quarter of the women performing a technique that could actually promote incontinence. Another study looked at women with incontinence and prolapse and found that more women were actually depressing the levator plate than were elevating it when cued to perform a pelvic floor contraction. Therefore, it is highly recommended that women have their pelvic floor assessed by a Continence and Women’s Health Physiotherapist who can assess them individually and give advice on correct muscle activation.
In summary, SUI appears to be very common in women attending gyms and exercise classes. Instead of allowing women to cease exercise because of this potentially embarrassing problem, effort needs to be put into education and prevention. Women performing exercises that increase intra-abdominal pressure like high end core exercises, high impact exercise, or heavy loaded exercise, should be screened for pelvic floor dysfunction and given information on both ‘pelvic floor friendly’ exercise options and how to seek guidance from a Women’s Health and Continence Physiotherapist so that they can work up to doing the higher level exercise that they wish to perform. The message that is so often promoted in the media that SUI is inevitable for women and that the answer is continence pads needs to be ignored and exercising women need to be encouraged to manage this issue in a healthier, more empowering way.