November 2018 Issue

Focus on Fitness: Exercising With Bladder Problems
By Jennifer Van Pelt, MA
Today's Dietitian
Vol. 20, No. 11, P. 56

November is National Bladder Health Awareness Month, sponsored by the Urology Care Foundation and the American Urological Association to educate the public about important bladder health issues. Bladder problems often are overlooked as a factor that can interfere with exercise; unfortunately, they're fairly common, especially urinary urgency and incontinence. Their effects on exercise may not be addressed with health care providers for a variety of reasons, including embarrassment or belief that one must just "grin and bear it." Unpredictable urinary leakage and urgency may cause some individuals to avoid public exercise or exercise in general. While urinary incontinence may occur more frequently with age and after childbirth in women, it also occurs in men and younger active individuals. How can your clients manage urinary incontinence and their exercise routine? And, what exercises are good (or bad) for bladder health?

According to the Urology Care Foundation (www.urologyhealth.org), urinary incontinence—the uncontrollable leakage of urine—affects one-quarter to one-third of Americans. There are two types of incontinence. In stress urinary incontinence (SUI), urine leakage occurs with abrupt pressure caused by sudden, forceful actions such as sneezing, laughing, coughing, and, yes, certain types of exercise or movements. The most common type of urinary incontinence, SUI is caused by weak or overstretched pelvic floor muscles and is more prevalent in women. Overactive bladder (OAB), the second type of urinary incontinence, involves a sudden and unignorable urge to urinate, as well as frequent urination during the day and night. OAB also is called urge incontinence, due to the "gotta go" feeling that can't be denied. According to the Urology Care Foundation, about 33 million Americans have OAB; it's more common in men with prostate problems and in postmenopausal women. Other causes of OAB include diet, medications, and neurologic conditions.

According to the Urology Care Foundation, estimates of urinary incontinence are likely low due to underreporting of the condition by those too embarrassed to seek care for it, especially in younger women. The foundation notes that 1 in 3 younger female veterans report OAB and/or SUI. Recent research found urinary incontinence in 36% of young female athletes across a wide variety of different sports; the athletes had a 177% greater risk of incontinence compared with sedentary women.1 A small study in female high school athletes found a similar prevalence of urinary incontinence (34%).2

SUI during sports and athletic activities has been dubbed "athletic incontinence." Unfortunately, recent studies also have found that certain types of exercise increased the prevalence of urinary incontinence in female athletes. Authors of a 2018 meta-analysis found much higher rates of urinary incontinence in female athletes performing high-impact activities (80%) such as running, basketball, and trampolining compared with low-impact exercise activities (5.5%).3 Urinary incontinence was 1.9-fold higher with high-impact exercise compared with medium-impact activities, and 4.6-fold higher compared with low-impact exercise. In high school–aged female athletes, higher rates of incontinence correlated with the number of seasons athletes participated in vigorous sports; athletes participating year-round in vigorous sports had the highest rates of incontinence during exercise, as well as when performing normal daily activities.2 In addition to impact sports, any sport that increases abdominal and pelvic floor pressure ("bearing down")—such as power/competitive weight lifting—also increases SUI risk. Though published research focuses on female athletes, male athletes also are affected by SUI, especially those participating in gymnastics, track and field events involving running and jumping, and power/competitive weight lifting.4

Managing Incontinence With Exercise
Any exerciser with urinary incontinence will benefit from pelvic floor muscle training, which is recommended as first-line treatment by the American Urological Association for both SUI and OAB.5,6 Also called Kegel exercises, after the physician who introduced them, pelvic floor exercises can be easily performed at home—or anywhere—to improve muscular strength around the bladder and urethra, thereby helping to reduce or prevent urinary incontinence. Pelvic floor physical therapy with therapists trained in pelvic floor rehabilitation may be recommended when supervision or more intensive therapy is required. The Urology Care Foundation provides an easy-to-understand, printable guide for pelvic floor exercises at www.urologyhealth.org/urologic-conditions/pelvic-floor-muscles.

Unfortunately, exercises may not fully resolve SUI and OAB issues, and additional treatments may be needed. Specially designed athletic shorts and pads can be worn during exercise to provide pelvic floor support and absorb urine leakage. Vaginal and urethral devices prescribed by a physician are another option. Lifestyle changes, such as dietary modifications (eg, eliminating caffeine, alcohol), bladder/voiding training techniques, and medications also may help. In more severe cases, surgery may be a viable option. Pelvic floor exercises can help when incontinence is caused by a neurologic condition, such as multiple sclerosis or Parkinson's disease, but additional disease-specific treatments also may be required to address incontinence.

Emerging research suggests that practicing yoga and Pilates may be beneficial for those with urinary incontinence. Recent small studies have reported that Pilates exercises can improve incontinence symptoms after prostatectomy and can reduce psychological symptoms, such as social embarrassment, in women with incontinence.7,8 Researchers presented study results at the 2018 American Urological Association meeting, reporting that three months of yoga reduced leakage by 76% in women with urinary incontinence.9 Ongoing studies are investigating the combination of yoga and Pilates with pelvic floor exercises.

From this brief review of published evidence on exercise and urinary incontinence, it's possible to summarize the following guidance for those exercising with SUI and/or OAB:

Don't be afraid to exercise. Obesity is a risk factor for urinary incontinence, so regular exercise is important for weight loss and healthy weight maintenance. If you fear leakage during exercise, start exercising from home before venturing out into public exercise venues.

Avoid exercises that make you bear down and performing exercises while holding the breath. Lifting handheld weights and using weight machines can still be done; just make sure to breathe properly and limit weight to light-to-moderate amounts.

Choose low- to moderate-impact activities that lengthen the spine and lift the chest, such as swimming and bicycling, thereby reducing pressure on the bladder.

Empty your bladder before exercise, and during if possible, to avoid leakage. Wear pads or padded clothing if needed.

Do pelvic floor exercises daily. Try combining them with certain yoga poses and/or Pilates movements.

With the availability of a wide variety of nonsurgical management and treatment options, your clients shouldn't have to suffer in silence with urinary incontinence.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.

References
1. Teixeira RV, Colla C, Sbruzzi G, Mallmann A, Paiva LL. Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis [published online April 13, 2018]. Int Urogynecol J. doi: 10.1007/s00192-018-3651-1.

2. Logan BL, Foster-Johnson L, Zotos E. Urinary incontinence among adolescent female athletes. J Pediatr Urol. 2018;14(3):241.e1-241.e9.

3. de Mattos Lourenco TR, Matsuoka PK, Baracat EC, Haddad JM. Urinary incontinence in female athletes: a systematic review [published online March 19, 2018]. Int Urogynecol J. doi: 10.1007/s00192-018-3629-z.

4. Bryan ST, Coleman NJ, Blueitt D, Kilmer NI. Bladder problems in athletes. Curr Sports Med Rep. 2008;7(2):108-112.

5. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of non-neurogenic overactive bladder (OAB) in adults: AUA/SUFU guideline. American Urological Association website. http://www.auanet.org/guidelines/incontinence-non-neurogenic-overactive-bladder-(2012-amended-2014). Updated 2014.

6. Kobashi KC, Albo ME, Dmochowski RR, et al. Surgical treatment of female stress urinary incontinence (SUI): AUA/SUFU guideline. American Urological Association website. http://www.auanet.org/guidelines/incontinence-stress-urinary-incontinence-(2017). Published 2017. 

7. Gomes CS, Pedriali FR, Urbano MR, Moreira EH, Averbeck MA, Almeida SHM. The effects of Pilates method on pelvic floor muscle strength in patients with post-prostatectomy urinary incontinence: a randomized clinical trial. Neurourol Urodyn. 2018;37(1):346-353.

8. Lausen A, Marsland L, Head S, Jackson J, Lausen B. Modified Pilates as an adjunct to standard physiotherapy care for urinary incontinence: a mixed methods pilot for a randomised controlled trial. BMC Womens Health. 2018;18(1):16.

9. Bankhead C. Yoga helpful for older women's incontinence. MedPage Today website. https://www.medpagetoday.com/meetingcoverage/aua/73033. Published May 22, 2018.

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