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Urinary Incontinence and Sport: First

and Preliminary Experience With a
Combined Pelvic Floor Rehabilitation
Program in Three Female Athletes
a a a
Massimo Rivalta , Maria Chiara Sighinolfi , Salvatore Micali ,
a b a
Stefano De Stefani , Francesca Torcasio & Giampaolo Bianchi
a
Department of Urology , University of Modena , Modena, Italy
b
Department of Public Health Sciences , University of Modena ,
Modena, Italy
Published online: 07 Apr 2010.

To cite this article: Massimo Rivalta , Maria Chiara Sighinolfi , Salvatore Micali , Stefano De Stefani ,
Francesca Torcasio & Giampaolo Bianchi (2010) Urinary Incontinence and Sport: First and Preliminary
Experience With a Combined Pelvic Floor Rehabilitation Program in Three Female Athletes, Health
Care for Women International, 31:5, 435-443, DOI: 10.1080/07399330903324254

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 Health Care for Women International, 31:435–443, 2010
Copyright © Taylor & Francis Group, LLC
ISSN: 0739-9332 print / 1096-4665 online
DOI: 10.1080/07399330903324254

Urinary Incontinence and Sport: First and

Preliminary Experience With a Combined
Pelvic Floor Rehabilitation Program in Three
Female Athletes
Downloaded by [University of Wisconsin Oshkosh] at 22:58 05 October 2014

MASSIMO RIVALTA, MARIA CHIARA SIGHINOLFI,

SALVATORE MICALI, and STEFANO DE STEFANI
Department of Urology, University of Modena, Modena, Italy
FRANCESCA TORCASIO
Department of Public Health Sciences, University of Modena, Modena, Italy

GIAMPAOLO BIANCHI
Department of Urology, University of Modena, Modena, Italy

A relationship between sport or fitness activities and urinary incon-

tinence (UI) previously has been described in women. We report our
preliminary experience with the use of a complete pelvic floor re-
habilitation program in three female athletes affected by UI. The
athletes were submitted to a combined pelvic floor rehabilitation
program, including biofeedback, functional electrical stimulation,
pelvic floor muscle exercises, and vaginal cones. After the scheduled
rehabilitation scheme, none of the patients reported incontinence,
nor referred to urine leakage during sport or during daily life. We
therefore conclude that UI that affects female agonistic athletes may
be effectively treated with this combined approach.

International medical literature has focused on the correlation among sports,

fitness activities, and women’s pelvic floor dysfunction: an association with
competition sports and UI was clearly evident (Bø, 2004; Carls, 2007;
Greydanus & Patel, 2002; Warren & Shantha, 2000). This occurrence rep-
resents a barrier to women’s participation in sport and fitness activities, and
results in a significant impairment in their quality of life (Carls, 2007). Until

Received 17 December 2008; accepted 9 September 2009.

Address correspondence to Dr. Massimo Rivalta, Department of Urology, University of
Modena, Via del Pozzo, 71, Modena 41100, Italy. E-mail: ri.max@hotmail.it

435
 436 M. Rivalta et al.

now there have been no randomized controlled trials on the effect of any
treatment for stress UI in female elite athletes (Bø, 2004): in this setting, we
introduce the role of a complete pelvic floor rehabilitation program, as a
noninvasive approach, in order to effectively treat this debilitating, chronic
condition. Since UI may relate to sport activity, a proper surveillance (gyne-
cologists, urologists, sports doctors, family physicians, trainers) is advised of
the competitive athletes.
Pelvic floor dysfunction is a major health issue for women, with a life-
time risk of 11% of women undergoing a single operation for UI, pelvic
organ prolapse, or both (Dooley, Kenton, & Cao, 2008). The prevalence of
UI in older adults living in the community is estimated to be as high as 30%,
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and studies have shown that incontinence increases with age. Studies on the
prevalence of incontinence show 18% to 46% of women 25 to 64 years old
report UI symptoms, while up to 15% to 37% of women older than 60 years
report incontinence symptoms (Dooley et al., 2008). Urinary incontinence
(UI) is the eighth most prevalent chronic medical condition among women
in the United States (Hu, Wagner, & Bentkover, 2004). In addition to the
significant social impact that UI has on a woman’s quality of life, data have
shown that this condition has a significant financial burden on individual
and national health care dollars. Estimates of annual direct costs of UI in
all ages in the United States were $10.3 billion in 1987 in reports by the
National Institutes of Health, $16 billion in 1995, and $19.5 billion in 2000
(Hu et al., 2004). Thus, this condition has a significant emotional and finan-
cial impact that continues to have an upward trend. Urinary incontinence
(UI) often is classified based on the inciting events that lead to the urinary
leakage. While definitions vary in the literature, the International Continence
Society defines three major subtypes of UI (Dooley et al., 2008): (1) stress
UI is the complaint of involuntary leakage upon effort or exertion, or upon
sneezing or coughing; (2) urge UI is the complaint of involuntary leakage
accompanied by or immediately preceded by urgency; and (3) mixed UI is
the complaint of involuntary leakage associated with the urgency and also
with exertion, effort, sneezing, or coughing. Evidence suggests that UI and
its subtypes differ across racial and ethnic groups (Dooley et al., 2008). A
wide range of risk factors has been identified in several studies; they can be
categorized into constitutional, obstetric, and gynecological risk factors. Age-
ing and hysterectomy are well accepted and described as risk factors in most
of the studies. Very few researchers, however, assessed exclusively young
adult and middle-aged woman, where the reported prevalence is 26–58%
(Peyrat, Haillot, & Bruyere, 2002).
The relationship between women’s UI and sport has been widely de-
scribed in the most recent literature (Bø, 2004; Carls, 2007; Greydanus et al.,
2002; Thyssen, Clevin, Olesen, & Lose, 2002; Warren et al., 2000). This
occurrence represents a barrier to women’s participation in sport and fit-
ness activities, and results in a significant impairment their quality of life
 Pelvic Floor Rehabilitation Program 437

(Carls, 2007). Actually, it was reported that up to 75% of the athletes

may experience urine loss while participating in their sport (Nygaard,
Thompson, & Svengalis, 1994). Of the sports studied, gymnasts and tennis
players reported a higher incidence of urine loss. The cause for inconti-
nence in athletes is thought to be multifactorial. Contributing factors include
inadequate abdominal pressure transmission, pelvic floor muscle fatigue,
and change in collagen or connective tissue. High-impact sports requiring
jumping and landing may place participants at greater risk for incontinence
because of the sudden increase in intra-abdominal pressure. Often this dys-
function goes under-reported or unreported. Health care providers need to
be made aware of such problems so they may be better addressed. In addi-
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tion to the risk factors identified earlier, the athlete who is amenorrheic or
having irregular menstrual cycles may have low estrogen levels. This also
can contribute to the development of incontinence. The importance of com-
pleting a directed detailed history cannot be overemphasized. Women may
need to be asked if they experience incontinence. Health care providers
should not leave it to women to report the problem.
Urinary incontinence (UI) 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
(Bø, 2004; Rovner, Wright, & Messer, 2008). The four major categories of
treatment are behavioral, rehabilitative, pharmacological, and surgical. Pelvic
floor rehabilitation (PFR) techniques represent the less invasive procedures,
and should be considered as the first-line therapy because of the efficacy
without side effects; furthermore, a surgical option is not compromised by
this approach (Rovner et al., 2008).
A complete PFR may include the following steps: biofeedback (BFB),
functional electrical stimulation (FES), pelvic floor muscle exercises (PFMEs),
and PFME using vaginal cones (VCs). During the last decades, international
medical literature has focused on the correlation among sports, fitness activ-
ities, and women’s pelvic floor dysfunction: an association with competition
sports and UI was clearly evident (Bø, 2004; Carls, 2007; Greydanus et al.,
2002; Warren et al., 2000).
We present a brief research report of preliminary findings with the use
of combined PFR treatment techniques (BFB-FES-PFME-VC) in three young
female athletes affected by UI.

MATERIALS AND METHODS

From January 2008 to June 2008, we evaluated three female nulliparous

athletes (mean age: 30.6 years; range: 29–33) experiencing urine loss during
sport and daily life. Mean body mass index was 21.4 (range 21–21.7), and
 438 M. Rivalta et al.

all of them were performing agonistic volleyball. Urinary incontinence (UI)

was defined as the need for pad or panty liner during sport or daily life.
The patients fulfilled a 48-hour voiding diary and underwent urody-
namic evaluation (Urobenchmark 200/3 SI.EM., Milan, Italy) pointing out
stress UI (mean abdominal leak point pressure: urinary leakage at 150 cm
H2 O abdominal pressure; mean maximum urethral closure pressure 70 cm
H2 O) without significant cystocele (grade 1 or less on Halfway system clas-
sification). Urine leakage during sport activity was reported in all the cases,
especially during jumping. All the athletes needed to use a panty liner during
training and competition; additionally, two of them use a preventive device
such as vaginal tampons in order to prevent or decrease leakage during
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high-impact physical activity.

None of the patients presented with cardiac pacemaker, pregnancy, or
urinary tract infection. Pelvic floor muscles were examined with urogyneco-
logic evaluation and with a puborectalis test (PC test) to document pelvic
floor muscle function and strength. The subjects experienced the combined
PFR treatment regimen (BFB-FES-PFME-VC) after signing an informed con-
sent with prior verbal explanation.
The steps for a complete PFR were as follows: (1) Functional electric
stimulation (FES) was performed for 20 minutes once a week for a period
of 3 months. Selected parameters included biphasic intermittent current with
frequency set at 50 Hz, pulse width of 300 µs, and an adjustable current
intensity (0–100 mA) reaching the most individually tolerable intensity of
stimulation that does not cause pain (Paradiso Galatioto, Pace, & Vicentini,
2007). “On time” ranged from 0.5 to 10 seconds, and “off time” ranged from
0 to 30 seconds. (2) Biofeedback (BFB) was conducted for 15 minutes, once
a week, for a period of 3 months. The special “Vaginal Combined Probe-
Coloplast” (same size for all the patients) was used for vaginal stimulation
and as a registering probe for both FES and EMG-BFB (Figure 1). It is made
of a longitudinal small and soft cylinder with four radial electrodes along
the probe itself. (3) Pelvic floor muscle exercises (PFMEs) were performed
alone. (4) Pelvic floor muscle exercises (PFMEs) using VCs, were performed
at home by the woman herself, after a preliminary stage with the urolo-
gist, accordingly to the Kegel protocol (Kegel, 1952); it requires at least
300 contractions a day of the PFM divided into six sessions, isolating PFM
contractions and eliminating coactivation synergies, alternating isotonic and
isometric exercises. Pelvic floor muscle exercises (PFMEs) were performed
also using VCs: three plastic cones with a metal interior that are identical in
shape and volume, but of different weights. The patient begins exercising
with the heaviest cone retainable in the vagina for 1 minute; once the cone
can be retained easily for 10 minutes, the patient starts exercising with the
next heaviest cone. Before moving on to a heavier cone, it is worth checking
that the cone can be retained during coughing, going up and down stairs,
and running.
 Pelvic Floor Rehabilitation Program 439
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FIGURE 1 A vaginal probe was used for vaginal stimulation and biofeeback.

The followup was carried out at 4 months, with urogynecologic evalu-

ation and a 48-hour voiding diary.

RESULTS

All the women completed the scheduled rehabilitation program, and their
compliance was verified throughout a weekly visit. The same skilled physi-
cian, who reported a satisfying relationship with all the women, performed
all the treatments. Patients reported pad or panty liner usage of 1–2 per
day at baseline. After the combined rehabilitation program, none of them
reported UI requiring device (pad or panty liner use), nor referred to urine
leakage during sport and fitness activities or during daily life. No side effects
or complications connected to the complete PFR were recorded.
The Pubococcygeus (PC)-test improved in all the athletes (Table 1).

DISCUSSION

The relationship between women’s UI and sport has been described widely
in the most recent literature (Bø, 2004; Carls, 2007; Greydanus et al., 2002;
Thyssen et al., 2002; Warren et al., 2000). Stress incontinence is the most
frequent form affecting the athletes, and it can be defined as “involuntary
leakage on effort or exertion, or on sneezing or coughing” (Bø, 2004). This
occurrence represents a barrier to women’s participation in sport and fitness
activities, and results in a significant impairment of their quality of life (Carls,
2007). To face this concern, several athletes are used to applying preventive
 440 M. Rivalta et al.

TABLE 1 The Pubococcygeus Test (PC-test) is Graded by the Modified Oxford Grading Scale
(Laycock, 1992).

Pubococcygeus test (PC-test)

Pubococcygeus test (PC-test) after 4 month of rehabilitation
at baseline program

Patient n◦ 1 2 5
Patient n◦ 2 1 5
Patient n◦ 3 2 5
Grade 0: no response.
Grade 1: flicker.
Grade 2: weak contraction.
Grade 3: moderate contraction, degree of lift.
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Grade 4: good contraction, against some resistance.

Grade 5: normal muscle contraction, strong, squeeze and lift.

devices such as vaginal tampons (Glavind, 1997) or pessaries to prevent

leakage during high-impact physical activity.
Actually, it was reported that up to 75% of the athletes may experience
urine loss while participating in their sport (Nygaard et al., 1994). Gymnasts
and basketball and tennis players are the most affected categories, with a
reported incontinence rate of 67%, 66%, and 50%, respectively. These finding
are consistent with those described in 2002 by Thyssen and colleagues,
who described an incontinence rate of 51.9% in a young female population,
mainly remarked upon as occurring during training but even in daily life
activities. The need for pads or panty shields was evident in 60% of their
series, especially when dealing with gymnastics, ballet, aerobics, badminton,
and volleyball.
Nygaard and colleagues (1996) explored the relationship between UI in
elite nulliparous athletes and force absorption on impact, as assessed by foot
arch flexibility. They concluded that the way impact forces were absorbed
may represent the potential aetiology for stress incontinence. The awareness
of how impact forces are transmitted to the pelvic floor can provide important
information about potential preventive interventions for UI and other pelvic
floor disorders, such as genital prolapse.
The effect of the treatment for stress UI on female athletes has been
mentioned only in international literature (Bø, 2004). Based on the experi-
ence that training of PFMs is effective in stress incontinent parous females
in the whole population (Bø, 2004), we decided to manage those athletes
with PFR. This approach has no serious adverse effects and has been rec-
ommended as a first-line treatment in the general population. A complete
rehabilitation program may include different steps such as FES, BFB, PFMEs,
and VCs, as previously suggested by Rovner and colleagues (2008).
The first step, BFB, derives from the combination of “biological” and
“feedback” (biological back action or sensory backcontrol), which expresses
the concept of a system capable of measuring physiological events that are
 Pelvic Floor Rehabilitation Program 441

not sufficiently appreciated consciously or have become so because of a

pathological process, allowing the subject to modify the events while at the
same time monitoring the results of his or her effort.
Biofeedback (BFB) acts in the early stage of rehabilitation programs,
in order to facilitate conscious awareness of the pelvic area and to achieve
an elective contraction of the pelvic floor muscles, particularly of the pub-
ococcygeus (PC): it provides the direct perception of the contraction and
quantification of its intensity via a visual or auditory signal. After its first
description (Kegel, 1951), positive outcomes with BFB were recorded in
60–80% of the reported series (O’Donnell & Doyle, 1991; Susset, Galea, &
Read, 1990).
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In recent years, even functional electrical stimulation has gained pop-

ularity and its indication extended to urology, as a result of improved un-
derstanding of the pathogenesis and diagnosis of pelvic floor dysfunction.
Its mechanism of action can depend on the indirect electrostimulation that
depolarizes the peripheral somatic motor fibers of the pudendal nerve with
a contraction of the urethral striated sphincter and the pelvic floor. Fur-
thermore, depolarization of sensory fibers of the pudendal nerve leads to a
reflex response, that is, contraction of the pelvic floor muscles, and inhibition
of an overactive detrusor. Besides these so-called peripheral effects, there
are also central effects that consist essentially of reorganization, coordina-
tion, and awareness of lower urinary tract and pelvic floor functions (Fall,
1984).
Furthermore, the use of PFMEs (with and without vaginal cones; Oláh,
Bridges, & Denning, 1990; Versi & Mantle, 1989) plays an extremely impor-
tant role in the conservative treatment of incontinence. A systematic review of
randomized controlled trials revealed strong evidence about PFME effective-
ness in reducing symptoms connected to stress incontinence and improving
the quality of life (Berghmans, Hendriks, & Bo, 1998). Such a technique acts
to advance the levator ani strength, as both a sphincter and a support for
the pelvic viscera. Slow-twitch fibers are responsible for the maintenance of
tone of the pelvic floor, thereby providing support to the pelvic viscera; the
fast-twitch fibers mainly are activated during elevations of intra-abdominal
pressure, such as coughing and sneezing. Kegel (1951), gynecologist and pi-
oneer of modern PFME, considered that the abnormal function of the pelvic
musculature (that he found in 30%–40% of women), could be caused in the
first place by a lack of awareness of the perineum, followed by a deficit
in neuromuscular coordination. In this way, a therapist’s task is to facilitate
learning or relearning of pelvic floor activity and sphincter automatisms and
not simple muscle strengthening in isolation (Di Benedetto, 2004).
To our knowledge, there are no randomized controlled trials on the
effect of any treatment for stress UI in female elite athletes (Bø, 2004): in
this setting, we introduce the role of a complete pelvic floor rehabilitation
program as a noninvasive approach to strengthen muscular support. Unless
 442 M. Rivalta et al.

the small number of patients enrolled, our data are remarkable and may
encourage further series to confirm these findings.

CONCLUSION

Since UI may relate to sport activity, a proper urogynecological surveillance

is advised in competitive athletes. Improved abdominal pressures together
with lack of levator ani support represent the basis of visceral descensus and
decreased abdominoperineal reaction, impairing, as a consequence, urinary
continence.
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PERSPECTIVE

Even if pelvic floor rehabilitation is recognized as a proven and effective

treatment for UI, the benefit of a complete rehabilitation program including
biofeedback, functional electrical stimulation, pelvic floor muscle exercises,
and vaginal cones, have been merely described. Stress UI, which affects a
great part of the female agonistic athletes, may be effectively treated with
this combined approach.
Trainers and physicians should consider this occurrence, and preventive
strategies on female athletes are required.

REFERENCES

Berghmans, L. C., Hendriks, H. J., & Bo, K. (1998). Conservative treatment of stress
urinary incontinence in women: A systematic review of randomized clinical
trials. British Journal of Urology, 82, 181–191.
Bø, K. (2004). Urinary incontinence, pelvic floor dysfunction, exercise and sport.
Sports Medicine, 34, 451–464.
Carls, C. (2007). The prevalence of stress urinary incontinence in high school and
college-age female athletes in the Midwest: Implications for education and pre-
vention. Urologic Nursing, 27, 21–24.
Di Benedetto, P. (2004). Female urinary incontinence rehabilitation. Minerva Gine-
cologica, 56, 353–369.
Dooley, Y., Kenton, K., & Cao, G. (2008). Urinary incontinence prevalence: Results
from the National Health and Nutrition Examination Survey. Journal of Urology,
179, 656–661.
Fall, M. (1984). Does electrostimulation cure urinary incontinence? Journal of Urol-
ogy, 131, 664–667.
Glavind, K. (1997). Use of a vaginal sponge during aerobic exercises in patients with
stress urinary incontinence. International Urogynecology Journal and Pelvic
Floor Dysfunction, 8, 351–353.
Greydanus, D. E., & Patel, D. R. (2002). The female athlete. Before and beyond
puberty. Pediatric Clinics of North America, 49, 553–580.
 Pelvic Floor Rehabilitation Program 443

Hu, T. W., Wagner, T. H., & Bentkover, J. D. (2004). Costs of urinary incontinence
and overactive bladder in the United States: A comparative study. Urology, 63,
461–465.
Kegel, A. H. (1951). Physiologic therapy for urinary stress incontinence. Journal of
the American Medical Association, 146, 915–917.
Kegel, A. H. (1952). Sexual function of the pubococcygeus muscle. Western Journal
of Surgery Obstetrics and Gynecology, 60, 521–524.
Laycock, J. (1992). Assessment and treatment of pelvic floor dysfunction. PhD thesis,
University of Bradford.
Nygaard, I. E., Glowacki, C., & Saltzman, C. L. (1996). Relationship between foot
flexibility and urinary incontinence in nulliparous varsity athletes. Obstetrics
and Gynecology, 87, 1049–1051.
Downloaded by [University of Wisconsin Oshkosh] at 22:58 05 October 2014

Nygaard, I. E., Thompson, F. L., & Svengalis, S. L. (1994). Urinary incontinence in

elite nulliparous athletes. Obstetrics and Gynecology, 84, 183–187.
O’Donnell, P. D., & Doyle, R. (1991). Biofeedback therapy technique for treatment
of urinary incontinence. Urology, 37, 432–436.
Oláh, K. S., Bridges, N., & Denning, J. (1990). The conservative management of
patients with symptoms of stress incontinence: A randomized, prospective study
comparing weighted vaginal cones and interferential therapy. American Journal
of Obstetrics and Gynecology, 162, 87–92.
Paradiso Galatioto, G., Pace, G., & Vicentini, C. (2007). Sexual function in women
with urinary incontinence treated by pelvic floor transvaginal electrical stimula-
tion. The Journal of Sexual Medicine, 4, 702–707.
Peyrat, L., Haillot, O., & Bruyere, F. (2002). Prevalence and risk factors of urinary
incontinence in young and middle-aged women. BJU International, 89, 61–66.
Rovner, E. S., Wright, C. J., & Messer, H. (2008). Adherence to the 1997 American
Urological Association guidelines for the surgical treatment of stress urinary
incontinence. Urology, 71, 239–242.
Susset, J. G., Galea, G., & Read, L. (1990). Biofeedback therapy for female inconti-
nence due to low urethral resistance. Journal of Urology, 143, 1205–1208.
Thyssen, H. H., Clevin, L., Olesen, S., & Lose, G. (2002). Urinary incontinence in
elite female athletes and dancers. International Urogynecology Journal and
Pelvic Floor Dysfunction, 13, 15–17.
Versi, E., & Mantle, J. (1989). Vaginal cones: A conservative method of treating
genuine stress incontinence. British Journal of Obstetrics and Gynaecology, 96,
752–753.
Warren, M. P., & Shantha, S. (2000). The female athlete. Baillière’s best practice &
research. Clinical Endocrinology & Metabolism, 14, 37–53.