Physical and Occupational Therapy

The Female Athlete’s Best Kept Secret

Urinary leakage in female athletes has been a well kept secret that has gotten very little attention. However, recent press regarding leakage during CrossFit workouts has created a flurry of activity on social networking sites. Female CrossFit athletes happily declared that they pee during a workout. A gynecologist offers her medical advice “It’s OK to pee during double- unders!” Peeing during a workout was offered as a badge of honor, a sign of intensity.


During the 2012 Olympics a female weight lifter from Ecuador leaked urine onto the floor during a lift. The story got some play on You Tube, not the kind of press she was hoping for on her Olympic quest. But, she was just the one we saw, the unlucky one who forgot her pad that day. It is almost a certainty that she was not the only elite female athlete that leaked during an event. It is a very common problem in high level (and not so high level) female athletes. 

Thyssen et al (2002) surveyed 291 elite female athletes competing in a variety of sports from basketball to ballet, regarding their history of urine loss during participation in their sport or day to day activities. 151 reported leakage of some kind. Of the 151, five discussed it with a medical provider, and only six got pelvic floor training. Only 4.6% actually sought and received treatment.

Several studies, Dockter et al (2007) Figures et al (2008) and Nygaard (1994), have looked at the incidence of urinary incontinence in college and older female elite and casual athletes. These studies consistently showed a 47-49% prevalence of urinary incontinence among these populations. In the college study, Dockter et al also reported the same incidence of incontinence among the control group of non- athletes.

The national average is that 1 in 3 women leak. However, peeing on yourself while working out is not a good thing, and incontinence is NEVER normal. Despite the prevalence, this issue is only recently beginning to be discussed. The message: You can workout and not leak. The proof: There ARE women who do CrossFit and other forms of high level fitness and do not leak.

Incontinence is just one way of identifying  a pelvic floor insufficiency. It is a signal that an imbalance in the deep core system exists. The deep core is a closed pressure system; an insufficiency in any component will impact the capacity of the whole. It is generally considered that athletes, especially elite athletes, have good core strength and support, however with this incidence of incontinence, the athletes’ actual core strength must be reconsidered.

Some effort has been made to understand the issue. Kruger et al ( 2007) looked at excursion of the bladder neck with a breath hold. (valsalva) in athletes. The bladder neck of athletes moved through a larger distance as compared to non- athletes. This was hypothesized to be a result of the consistent impact of running, and jumping. The athletes also had a thicker pelvic floor muscle and it was therefore assumed they also had improved capacity to recruit muscles. Perhaps, since they were not incontinent, this muscle thickness balanced the excessive bladder neck excursion. These athletes may not have been incontinent but they did complain of hip, low back or pubic pain? A pelvic floor imbalance in the deep core system can contribute to other issues as well. Pain, joint instability and incontinence are all just signals that the system as a whole needs attention.

What is the take away message from these athletes studies for recreational athletes and fitness enthusiast? The first studies should wake us up to the prevalence of incontinence among females who pursue fitness. The Kruger et al study gives us a window into what happens to pelvic floors that are asked to impact load repetitively, as they would for a committed runner. Add the effect of pregnancy and delivery pelvic floor strength, function, and fascial integrity and the situation could be even more striking in terms of excessive motion, lack of organ support, and added vulnerability to dysfunction.

For these folks out there treating female runners who present with back pain (a common pelvic organ prolapse complaint) or even knee pain due to instability at the hip, the understanding of what is happening at the pelvic floor while they are running or holding their breath during resistance training is critical. The closed pressure system of the deep core may have a fault that must be addressed. We must understand and acknowledge what we can not visualize in females that pursue fitness and sport, especially when evidence suggests weakness in core stabilization that places women at risk for future dysfunction.

A few insightful questions on your intake forms that may help to identify individuals who would benefit from further assessment or referral for physical therapy. Ask your patients any of the following: Do you experience unwanted leaking of urine with exercise or sport? Do you experience leaking of urine with lifting, sneezing, coughing, or laughing? Have you had any pregnancies? How many deliveries, and what type of deliveries? Can you retain a tampon? All of these questions give you some clues as to the capacity of the deep core pressure system as a whole. One other clue, if they complain of hip pain that has not responded to more conservative measures, the pelvic floor may be the culprit.

  1. Thyssen H H, Clevin L, Olesen, Lose G. Urinary incontinence in elite female athletes and dancers. Int Urogyecol J. 2002;13:15-17
  2. Dockter M, Kolstad AM, Martin KA, Schiwal LI. Prevalence of urinary incontinence: a comparative study of collegiate female athletes vs. non -athletic controls. JWHTP. 2007;31:12-17.
  3. Figures CC, Boyle KL, et al. Pelvic floor activity and urinary incontinence in weight bearing female athletes vs. non-athletes. JWHTP. 2008;32:7-11.
  4. Nygaard IE, et al. Urinary incontinence in elite nulliparous athletes. Obstet Gynecol. 1994;84:183-187.

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