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Urinary Incontinence in Female Athletes: Comparison with Impact in Sport and Athletic Energy Availability Status
Stuart B. Bauer, MD1, Kristin Whitney, MD2, Bryan Holtzman, MS3, Allyson Parziale, BA3, Pierre d'Hemecourt, MD3, Kathryn E. Ackerman, MD3.
1Boston Children's Hospital - Urology Department, Boston, MA, USA, 2Boston Children's Hospital -Sports Medicine Division, Boston, MA, USA, 3Boston Children's Hospital - Sports Medicine Division, Boston, MA, USA.

BACKGROUND: Female Athlete Triad (Triad) is a syndrome involving the interrelationship of low energy availability (EA), menstrual irregularity, and low bone mineral density. Relative Energy Deficiency in Sport (RED-S) is a consequence of low EA. Genitourinary disorders have not been investigated as potential components of RED-S. A high prevalence of urinary incontinence (UI) has been reported in female athletes participating in various sport activities. UI has many potential etiologies, including estrogen deficiency, ligamentous laxity, depression, participation in high-impact sport activities, and disordered eating/eating disorders. Research focusing on both sport type and degree of impact in sport, along with energy availability status as risk factors for UI, has been limited in young female athletes. Our aim includes evaluating the association of UI, with degree of impact in sport, volume/intensity of sport participation, and low EA in female athletes.
METHODS: Of 1184 nulliparous female athletes (ages 15-30 years) presenting to a sports medicine clinic between February and November 2017, 1,000 completed a 400+ questionnaire about RED-S. Low EA was defined by ≥ 1 criterion: self-reported history of eating disorder/disordered eating (ED/DE), high Brief Eating Disorder in Athletes Questionnaire (BEDA-Q), and/or high Eating Disorder Screen for Primary Care (ESP) scores. UI was assessed via the International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence (ICIQ-UI Short Form). Descriptive statistics were expressed as mean 1 STD and associations between EA status and UI queries were assessed by chi-squared analysis. RESULTS: 165 female athletes (16.5%) reported UI during athletics. These women were older than those without UI (19.52 3.72 years vs. 18.80 3.25 years, p=0.0225). Sport types were divided into running-centered, jumping-centered, non-impact, and resistance sports (weightlifting). UI prevalence was significantly higher among athletes involved in running-based (16.43%) and jumping-based (19.05%) compared to non-impact sports (11.02%), (p=.0007, and p=.0006, respectively). UI was more prevalent (15.56%) in weightlifting than non-weightlifting and non-impact athletes (11.02%), although not statistically significant (p=.0625). A significantly higher prevalence of UI existed among athletes with low (26.5%) versus those with adequate EA (14.3%) (p=0.0004). Median onset of UI occurred 1-2 years before completing the survey and median frequency of UI was weekly. No significant correlation existed between presence of reported menstrual dysfunction and UI (p=0.26). Athletes engaging in sports >15 hr/week, had a higher prevalence of UI compared to those participating less (p=<0.05). CONCLUSIONS: Our findings demonstrate UI is common among female athletes, ages 15-30 (prevalence 16.5%), presenting to a sports medicine clinic. UI occurred in running-based and jumping-based sports, and with higher exercise volume per week, confirming previous observations of UI in athletes with ED, and low EA compared to adequate EA. These observations offer a window into commonly overlooked clinical problems impacting young female athletes. They present opportunities for improved screening, prevention, and rehabilitation (of UI) by addressing underlying gait/landing biomechanics and pelvic floor PT. They suggest the potential for genitourinary disorders in the constellation of impaired physiologic functions associated with RED-S, highlighting the importance of nutritional intervention and adequate energy intake in young female athletes.


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