Summary
Introduction
Relative Energy Deficiency in Sport (RED-S) is a clinical syndrome that includes the
many complex health and performance consequences of low energy availability (EA) in
athletes, when there is insufficient caloric intake to meet exercise-related energy
expenditure and to support basic physiologic functions. There is a high prevalence
of urinary incontinence (UI) in female athletes and it is more common in female athletes
than non-athletes. The objective of this study was to determine if low EA is associated
with UI in a population of adolescent and young adult female athletes and to evaluate
for an association between sport categories and UI.
Material and methods
1000 nulliparous female patients, ages 15–30 years, presenting to a sports medicine
subspecialty clinic, provided informed consent/assent to participate in a cross-sectional
study involving a comprehensive survey, anthropomorphic measurements, and medical
record review. Low EA was defined as meeting ≥1 criterion: self-reported history of
eating disorder/disordered eating (ED/DE), and/or a high score on the Brief Eating
Disorder in Athletes Questionnaire (BEDA-Q), and/or a high score on the Eating Disorder
Screen for Primary Care (ESP). UI was assessed using questions adapted from the International
Consultation on Incontinence-Urinary Incontinence Short Form (ICIQ-UI-SF), questions
regarding timing of UI onset/duration, and a binary question regarding UI during sport
activities. A total of 36 sport types were included in the survey and sub-divided
into categories.
Results and discussion
Of the 1000 female athletes surveyed, 165 (16.5%) reported a history of experiencing
UI during athletic activities. ICIQ- UI-SF responses indicated that 14% (137/1000)
of the cohort experienced slight incontinence, 4% (35/1000) moderate incontinence,
and 2 athletes experienced severe incontinence. There was a significant difference
between UI categories in age (p = 0.01), low EA (p < 0.001), and sport category (p < 0.001).
Females who had low EA had twice the likelihood (OR = 1.97; 95% CI = 1.39 to 2.81;
p < 0.001) of UI compared to those with adequate EA, controlling for sports category
and menstrual dysfunction. Females who participated in high impact sports were 4.5
times more likely (OR = 4.47; 95% CI = 2.29 to 8.74; p < 0.001) to have had UI compared
to females who participated in ball sports, controlling for EA and menstrual dysfunction.
Conclusions
Summary TableCharacteristics of Female Athletes with Urinary Incontinence
| Entire cohort N = 1000 | Athletes with Urinary incontinence n = 165 (16.5%) | P-value | |||
|---|---|---|---|---|---|
| Freq. | (%) | Freq. | (%) | ||
| Low energy availability | 473 | (47%) | 99 | (20.9%) | <0.001 |
| Menstrual dysfunction | 449 | (45%) | 80 | (17.8%) | 0.31 |
| Sport category: | <0.001 | ||||
| High impact | 49 | (5%) | 18 | (36.7%) | |
| Ball/field | 356 | (36%) | 46 | (12.9%) | |
| Non-weightbearing endurance | 60 | (6%) | 6 | (10.0%) | |
| Aesthetic | 173 | (17%) | 25 | (14.5%) | |
| Resistance/power | 106 | (11%) | 23 | (21.7%) | |
| Running | 222 | (22%) | 44 | (19.8%) | |
| Technical | 34 | (3%) | 3 | (8.8%) | |
Keywords
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References
- The IOC consensus statement: beyond the female athlete triad--relative energy deficiency in sport (RED-S).Br J Sports Med. 2014; 48: 491-497https://doi.org/10.1136/bjsports-2014-093502
- IOC author consensus statement update 2018: Relative Energy Deficiency in Sport (RED-S).Br J Sports Med. 2018; 52: 687-697
- Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport.Br J Sports Med. 2019; 53: 628-633https://doi.org/10.1136/bjsports-2017-098958
- Prevalence and impact of urinary incontinence among female athletes.Int J Gynecol Obstet. 2011; 114: 60-63
- Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.Br J Sports Med. 2018; 52: 1586-1590
- Role of serum steroid hormones in women with stress urinary incontinence: a case–control study.BJU Int. 2017; 120: 416-421
- Lower urinary tract symptoms in women with benign joint hypermobility syndrome: a case–control study.International urogynecology journal. 2013; 24: 1553-1558
- Urinary incontinence and depression.J Urol. 1999; 162: 82-84
- Effect of age on urodynamic parameters of women with urinary incontinence.Beijing Da Xue Xue Bao Yi Xue Ban= J Peking Univ Health Sci. 2016; 48: 825-829
- Urinary incontinence and disordered eating in female elite athletes.J Sci Med Sport. 2019; 22: 140-144
- Prevalence of stress and urge urinary incontinence in elite athletes and controls.Med Sci Sports Exerc. 2001; 33 ([published Online First: 2001/11/02]): 1797-1802https://doi.org/10.1097/00005768-200111000-00001
- Prevalence study of stress urinary incontinence in women who perform high-impact exercises.International urogynecology journal. 2012; 23: 1687-1691
- Exercise and incontinence.Obstet Gynecol. 1990; 75 ([published Online First: 1990/05/01]): 848-851
- The development of the brief eating disorder in athletes questionnaire.Med Sci Sports Exerc. 2014; 46 ([published Online First: 2014/02/08]): 1666-1675https://doi.org/10.1249/MSS.0000000000000276
- Four simple questions can help screen for eating disorders.J Gen Intern Med. 2003; 18: 53-56
- Comparison of two questionnaires for assessing the severity of urinary incontinence: the ICIQ-UI SF versus the incontinence severity index.Neurourol Urodyn: Official Journal of the International Continence Society. 2009; 28: 411-415
- Validity and reliability of the international consultation on incontinence questionnaire-urinary incontinence Short form and its correlation with urodynamic findings.Urol J. 2012; 9: 685-690
- Reliability and validation of the international consultation on incontinence questionnaire in over active bladder to Persian language.Low Urin Tract Symptoms. 2015; 7: 99-101
- Validation of use of the international consultation on incontinence questionnaire-urinary incontinence-short form (ICIQ-UI-SF) for impairment rating: a transversal retrospective study of 120 patients.Neurourol Urodyn. 2013; 32: 974-979
- ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence.Neurourol Urodyn: Official Journal of the International Continence Society. 2004; 23: 322-330
- Participation in leanness sports but not training volume is associated with menstrual dysfunction: a national survey of 1276 elite athletes and controls.Br J Sports Med. 2005; 39: 141-147
- Health-related concerns of the female athlete: a lifespan approach.Am Fam Physician. 2009; 79 ([published Online First: 2009/03/28]): 489-495
- Vaginal laxity: a poorly understood quality of life problem; a survey of physician members of the International Urogynecological Association (IUGA).Int Urogynecol J. 2012; 23 ([published Online First: 2012/06/07]): 1435-1448https://doi.org/10.1007/s00192-012-1757-4
- Prevalence of stress incontinence in nulliparous elite trampolinists.Scand J Med Sci Sports. 2002; 12 ([published Online First: 2002/07/18]): 106-110https://doi.org/10.1034/j.1600-0838.2002.120207.x
- Urinary incontinence and other pelvic floor dysfunctions in female athletes in B razil: a cross-sectional study.Scand J Med Sci Sports. 2016; 26: 1109-1116
- Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis.Int Urogynecol J. 2018; 29 ([published Online First: 2018/04/15]): 1717-1725https://doi.org/10.1007/s00192-018-3651-1
- Prevalence of female urinary incontinence in crossfit practitioners and associated factors: an internet population-based survey.Female Pelvic Med Reconstr Surg. 2020; 26 ([published Online First: 2020/01/29]): 97-100https://doi.org/10.1097/SPV.0000000000000823
- The relationship between urinary incontinence and eating disorders in female long-distance runners.Rev Assoc Med Bras. 1992; 54 (2008) ([published Online First: 2008/05/29]): 146-149https://doi.org/10.1590/s0104-42302008000200018
- Muscular fatigue in the pelvic floor muscles after strenuous physical activity.Acta Obstet Gynecol Scand. 2007; 86: 870-876
- RED-S CAT. Relative energy deficiency in sport (RED-S) clinical assessment tool (CAT).Br J Sports Med. 2015; 49: 421-423https://doi.org/10.1136/bjsports-2015-094873
- Triathlete risk of pelvic floor disorders, pelvic girdle pain, and female athlete triad.Female Pelvic Med Reconstr Surg. 2016; 22: 373-376
- The mysteries of menopause and urogynecologic health: clinical and scientific gaps.Menopause. 2019; 26 ([published Online First: 2018/10/10]): 103-111https://doi.org/10.1097/GME.0000000000001209
- Urinary incontinence: the role of menopause.Menopause. 2014; 21 ([published Online First: 2013/09/26]): 399-402https://doi.org/10.1097/GME.0b013e31829fc68c
- Stress urinary incontinent women, the influence of age and hormonal status on estrogen receptor alpha and beta gene expression and protein immunoexpression in paraurethral tissues.J Physiol Pharmacol. 2018; 69 ([published Online First: 2018/05/18]): 53-59https://doi.org/10.26402/jpp.2018.1.05
- Oestrogen therapy for urinary incontinence in post-menopausal women.Cochrane Database Syst Rev. 2012; 10 ([published Online First: 2012/10/19]): CD001405https://doi.org/10.1002/14651858.CD001405.pub3
- Endocrine effects of relative energy deficiency in sport.Int J Sport Nutr Exerc Metabol. 2018; 28: 335-349
- Bone metabolic responses to low energy availability achieved by diet or exercise in active eumenorrheic women.Bone. 2018; 114: 181-188
- Low serum insulin like growth factor - 1 in patients with stress urinary incontinence.Int Braz J Urol. 2016; 42 ([published Online First: 2016/08/27]): 787-792https://doi.org/10.1590/S1677-5538.IBJU.2015.0453
- Changes in the quantity of collagen type I in women with genuine stress incontinence.Urol Res. 2000; 28 ([published Online First: 2000/12/29]): 323-326https://doi.org/10.1007/s002400000120
- Distribution of type I collagen morphologies in bone: relation to estrogen depletion.Bone. 2010; 46: 1349-1354
- The insulin-like growth factor system in bone: basic and clinical implications.Endocrinol Metab Clin N Am. 2012; 41 ([published Online First: 2012/06/12]): 323-333https://doi.org/10.1016/j.ecl.2012.04.013
- The association of serum testosterone levels and urinary incontinence in women.J Urol. 2018; 199 ([published Online First: 2017/08/30]): 522-527https://doi.org/10.1016/j.juro.2017.08.093
- Gastrointestinal complications associated with anorexia nervosa: a systematic review.Int J Eat Disord. 2016 Mar; 49: 216-237
- Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood.Pediatrics. 1997 Aug; 100: 228-232
- Urinary incontinence in elite nulliparous athletes.Obstet Gynecol. 1994; 84: 183-187
- Occurrence rates and predictors of lower urinary tract symptoms and incontinence in female athletes.Urologia Journal. 2010; 77: 139-146
- Prevalence of stress urinary incontinence in elite female endurance athletes.J Hum Kinet. 2014; 44: 91-96
- Urinary incontinence in physically active women and female athletes.Br J Sports Med. 2014; 48 ([published Online First: 2013/05/21]): 296-298https://doi.org/10.1136/bjsports-2012-091880
Article info
Publication history
Published online: January 30, 2021
Accepted:
January 28,
2021
Received in revised form:
December 24,
2020
Received:
August 21,
2020
Identification
Copyright
© 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
