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 10-15% of women are affected by each of these issues (AIHW 2015). 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 percentage of women suffering from SUI is approximately one third (AIHW 2015). 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 (Koelbl et al 2013). 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 (Bo 2004, Caylet et al 2006).
Exercise and Urinary Incontinence – are women attending gyms aware of the risks?
A recent, as yet unpublished, study done in Western Australia by McKenzie et al, looked at the prevalence of SUI in women who attend community-based exercise classes or gymnasiums.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.
How do we combat this issue?
What this research suggests is that more resources need to go into educating gym and exercise class participants and instructors on both pelvic floor exercises and what constitutes ‘pelvic floor friendly’ exercise. The Continence Foundation of Australia (CFA) has launched an initiative called Pelvic Floor First (PFF), which includes a website created specifically for this purpose. Less than 10% of the participants in the aforementioned study had heard of this website, despite the best marketing efforts.
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. The PFF website states that pelvic floor friendly exercise includes low impact cardiovascular options such as cycling or swimming, resistance exercises that don’t cause breath holding, and basic ‘core’ muscle exercises such as leg lift sitting on a ball or modified plank exercises. They recommend 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.
How can women get assistance regarding pelvic floor exercises and ‘Pelvic Floor Friendly Exercise?
Gynaecological issues such as incontinence and pelvic organ prolapse may be able to be managed by conservative measures such as pelvic floor muscle training and heeding lifestyle advice on avoiding 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 (Neumann et al 2005). 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 (Bump et al 1991). 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 (Thompson and O’Sullivan 2003). 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.
Let’s fix this problem and keep women exercising safely in gyms!
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 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. 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.
Bo K. Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport. Sports Medicine. 2004;34(7):451-64.
Bump RC, Hurt WG, Fantl JA, Wyman JF. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. American Journal of Obstetrics and Gynecology. 1991;165(2):322-7
Caylet N, Fabbro-Peray P, Marès P, Dauzat M, Prat-Pradal D, Corcos J. Prevalence and occurrence of stress urinary incontinence in elite women athletes. Canadian Journal of Urology. 2006;13(4):3174-9
AIHW.gov.au. [database on the Internet] 2015, Pages on: Incontinence in Australia, Diabetes, Cardiovascular Health.
Koelbl H, Nitti V, K. Baessler, S. Salvatore, A. Sultan, O. Yamagughi. Committee 4: Pathophysiology of Urinary Incontinence, Faecal Incontinence and Pelvic Organ Prolapse. . In: (Eds) IAPea, editor. Incontinence: . 4th Edition 2013 ed: 5th International Consultation on Incontinence by the ICS,; 2013. p. 255-330
McKenzie S et al, (as yet unpublished), Stress Urinary Incontinence is highly prevalent in recreationally active women attending gymnasiums or exercise classes.
Neumann PG, K. Grant, R. Gill, V. Physiotherapy for female stress urinary incontinence: a multicentre observational study. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2005;45(226-232)
Thompson J, O’Sullivan P. Levator plate movement during voluntary pelvic floor muscle contraction in subjects with incontinence and prolapse: a cross-sectional study and review. International urogynecology journal and pelvic floor dysfunction. 2003;14(2):84-8