Potential Indicators of Low Energy Availability: Does Incontinence Offer New Insights? 

In 2023, the International Olympic Committee (IOC) expanded the Relative Energy Deficiency in Sport (REDs) conceptual health model to include urinary incontinence as a potential indicator of low energy availability (LEA).

Urinary incontinence refers to an involuntary loss of urine and can include stress urinary incontinence (leaks with physical exertion, sneezing, laughing, or coughing), urge urinary incontinence (leaks associated with urgent need to go to the bathroom), or mixed urinary incontinence (experiencing both).

Approximately 34.6% of female professional dancers between 18-41 years of age experience urinary incontinence. Amongst those that disclosed urinary incontinence symptoms, 31.9% reported urge urinary incontinence, 52.8% experienced leaks with coughing or sneezing, and 54.2% experienced leaking with physical activity and exercise.

Urinary incontinence is also highly prevalent in other artistic athlete populations including nulliparous aerialists (41.7%), rhythmic gymnasts (31.8%), and cheerleaders (26.9%), with stress urinary incontinence reported more commonly than urge or mixed urinary incontinence.

When surveyed, female aerial circus artists, gymnasts, and cheerleaders indicated that urinary incontinence impacted their performance in various ways, leading to stopping or reducing their training, loss of concentration, avoidance of certain skills, and/or worry about recurrence, odor, or leak visibility.

It is notable that a majority of the available prevalence data on urinary incontinence has been collected on young highly competitive athletes, including dancers, who have never been pregnant or delivered a baby. This is a valuable insight, as previously both history of pregnancy and advancing age have been considered primary risk factors for urinary incontinence.

In the absence of these commonly understood risk factors, additional variables need to be considered in high intensity athletic populations such as dancers and other artistic athletes.

REDs in dancers and athletes: Common Ground

The experience of urinary incontinence is not unique to dancers.

Female athletes across a broad range of sport populations experience high rates of urinary symptoms. High impact, high intra-abdominal pressures, and high load sport demands have been found to be potential variables in the prevalence of stress urinary incontinence, from 12.5% of rowers/canoers (low impact), 44% of runners (moderate impact and pressures), 82.4% in trampolinists (high impact), and 41.7% in Olympic and power lifters (high load and high intra-abdominal pressures).

In addition, connective tissue hypermobility is associated with urinary incontinence. This is an important consideration for dancers who typically present with higher rates of hypermobility.

In 2021, Whitney et al. noted that female athletes with LEA who competed in a variety of sports were twice as likely to experience urinary incontinence than those with adequate energy availability when sport type was not considered. When sport type was included, athletes with LEA that participated in high impact activities were 4.5x more likely to experience urinary incontinence.

Dancers regularly perform repetitive jumping and/or power moves involving high impact and intra-abdominal pressures in their training and performance. In addition, the rigorous training schedules, limited recovery, high stress environments that demand precision performance, and aesthetic expectations for dancers creates added risk for LEA. Taken together, this combination of variables may elevate the potential for urinary incontinence in dancers.

Connecting the Dots

The pelvic floor is the group of muscles seated in the bowl of the pelvis that play a primary role in the control of continence. While often understood and exercised as an isolated group of muscles (e.g. via Kegels or pelvic floor muscle training), the pelvic floor is a dynamic part of multiple muscular and physiologic systems.

As a muscle group, the pelvic floor works with the intra-abdominal pressure system and breath mechanics, coordinates with trunk and core musculature, interacts with connective tissue and ligamentous structures within the pelvis, and engages with nearby hip muscles to support high level activity demands. Thus the pelvic floor muscles are equally affected by low fueling with consequences similar to those experienced by other muscles and tissues in the body:

• Under fueled muscle has less strength, endurance, and glycogen stores to support physical activities.

• Under fueled muscles (including the pelvic floor) have a decreased training response.

• Decreased systemic estrogen due to LEA may have an impact on the passive support structures (e.g. connective tissue and ligamentous structures) of the pelvic floor.

• Low energy availability can contribute to constipation, which is a known predisposing variable to urinary incontinence issues (both stress and urge urinary incontinence).

It follows, then, that providers engaging the dance community should regularly screen for symptoms of urinary incontinence.

While the prevalence data reveals that this issue is common in the dance population, it may not represent the true burden and impact on daily life and performance due to under-reporting, symptom normalization among peers and teachers, and the lack of awareness of solutions.

As it relates to REDs in dancers, urinary incontinence could become an important early indicator of low energy availability in dancers, prior to menstrual irregularity or a career limiting bone stress injury.

While more research is needed, implementation of regular screening for pelvic health issues like urinary incontinence in dancers supports monitoring their overall health, establishing care pathways to address these performance-limiting symptoms, and may alert providers to screen for low energy availability and other components of the REDs in dancers health model.

Written by Brooke Winder, PT, DPT, OCS, CSCS and Julie Wiebe, PT, DPT

References

1. Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2023;57(17):1073-1097. doi:10.1136/bjsports-2023-106994

2. Winder BR, Lindegren K, Blackmon, M. Prevalence of Urinary Incontinence and Other Pelvic Floor-Related Symptoms in Female Professional Dancers. Journal of Dance Medicine and Science. 2023; 27(1): 50-55.

3. Winder BR, Heineman H, Scherb E. Prevalence and Impact of Urinary Incontinence and Other Pelvic Floor Symptoms in Female Aerialists. Journal of Women’s and Pelvic Health Physical Therapy. 49(1): 2-25; 35-44.

4. Gram MCD, Bø K. High level rhythmic gymnasts and urinary incontinence: prevalence, risk factors, and influence on performance. Scand J Med Sci Sports.

2020;30(1):159-165. doi:10.1111/sms.13548

5.Carvalho C, da Silva Serrão PRM, Beleza ACS, Driusso P. Pelvic floor dysfunctions in female cheerleaders: a cross-sectional study. Int Urogynecol J. 2020;31(5):999-1006. doi:10.1007/s00192-019-04074-w

6. Skaug KL, Engh ME, Frawley H, Bo K. Urinary and anal incontinence among female gymnasts and cheerleaders-bother and associated factors. A cross-sectional study. Int Urogynecol J. 2022;33(4):955-964. doi:10.1007/s00192-021-04696-z

7. Carvalhais A, Natal Jorge R, Bo K. 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(24):1586-1590. doi:10.1136/bjsports-2017-097587

8. Pires T, Pires P, Moreira H, Viana R. Prevalence of Urinary Incontinence in High-Impact Sport Athletes: A Systematic Review and Meta-Analysis. J Hum Kinet. 2020;73:279-288. Published 2020 Jul 21. doi:10.2478/hukin-2020-0008

9. Skaug KL, Engh ME, Frawley H, Bø K. Prevalence of Pelvic Floor Dysfunction, Bother, and Risk Factors and Knowledge of the Pelvic Floor Muscles in Norwegian Male and Female Powerlifters and Olympic Weightlifters. J Strength Cond Res. 2022;36(10):2800-2807. doi:10.1519/JSC.0000000000003919

10. Bérubé M-È, McLean L. The acute effects of running on pelvic floor morphology and function in runners with and without running-induced stress urinary incontinence. International Urogynecology Journal. 2023;35(1):127-138. doi:10.1007/s00192-023-05674-3

11. Whitney KE, Holtzman B, Cook D, et al. Low energy availability and impact sport participation as risk factors for urinary incontinence in female athletes. Journal of Pediatric Urology. 2021;17(3). doi:10.1016/j.jpurol.2021.01.041

12. Hodges PW, Butler JE, McKenzie DK, Gandevia SC. Contraction of the human diaphragm during rapid postural adjustments. J Physiol. 1997;505(2):539-548. doi:10.1111/j.1469-7793.1997.539bb.x

13. Hodges PW, Sapsford R, Pengel LHM. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362-371. doi:10.1002/nau.20232

14. Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A. Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing: a dynamic MRI investigation in healthy females. Int Urogynecol J. 2011;22(1):61-68. doi:10.1007/s00192-010-1240-z

15. Hodges PW, Richardson CA. Feedforward contraction of transversus abdominis is not influenced by the direction of arm movement. Exp Brain Res. 1997;114(2):362-370. doi:10.1007/pl00005644

16. Tuttle LJ, Autry T, Kemp C, Lassaga-Bishop M, Mettenleiter M, Shetter H, Zukowski J. Hip exercises improve intravaginal squeeze pressure in older women. Physiother Theory Pract. 2020;36(9):1007-1014. doi:10.1080/09593985.2019.1571142

17. Foster SN, Spitznagle TM, Tuttle LJ, et al. Hip and pelvic floor muscle strength in women with and without urgency and frequency-predominant lower urinary tract symptoms. J Womens Health Phys Ther. 2021;45(3):126-134. doi:10.1097/jwh.0000000000000209

18. Siess M, Steinke H, Zwirner J, Hammer N. On a potential morpho-mechanical link between the gluteus maximus muscle and pelvic floor tissues. Sci Rep. 2023;13(1):22901. doi:10.1038/s41598-023-50058-8

19. Rebullido, Tamara Rial PhD, CSPS; Stracciolini, Andrea MD, FAAP, FACSM. Pelvic Floor Dysfunction in Female Athletes: Is Relative Energy Deficiency in Sport a Risk Factor?. Current Sports Medicine Reports 18(7):p 255-257, July 2019. DOI: 10.1249/JSR.0000000000000615

20. Sorrigueta-Hernández A, Padilla-Fernandez B-Y, Marquez-Sanchez M-T, Flores-Fraile M-C, Flores-Fraile J, Moreno-Pascual C, Lorenzo-Gomez A, Garcia-Cenador M-B, Lorenzo-Gomez M-F. Benefits of Physiotherapy on Urinary Incontinence in High-Performance Female Athletes. Meta-Analysis. Journal of Clinical Medicine. 2020; 9(10):3240. doi:10.3390/jcm9103240.

21. Bosch-Donate E, Vico-Moreno E, Fernández-Domínguez JC, et al. Symptomatology and knowledge regarding pelvic floor dysfunctions and influence of gender stereotypes in female athletes. Sci Rep. 2024;14:11052. doi:10.1038/s41598-024-61464-x

22. Casey EK, Temme K. Pelvic floor muscle function and urinary incontinence in the female athlete. Phys Sportsmed. 2017;45(4):399–407. doi:10.1080/00913847.2017.1372677

23. Culleton-Quinn E, Bo K, Fleming N, Mockler D, Cusack C, Daly D. Elite female athletes' experiences of symptoms of pelvic floor dysfunction: A systematic review. Int Urogynecol J. 2022;33(10):2681-2711.

24. Dakic JD, Hay-Smith J, Cook J, Lin K, Frawley HC. Screening for pelvic floor symptoms in exercising women: a survey of 636 health and exercise professionals. J Sci Med Sport. 2023;26(2):80-86. doi: 10.1016/j.jsams.2023.01.008.

25. Popp KL, Bozzini BN, Reynoso M, et al. Hypothalamic-pituitary-ovarian axis suppression is common among women during US Army Basic Combat Training. Br J Sports Med. 2024;58(18):1052-1060. Published 2024 Sep 9. doi:10.1136/bjsports-2023-107716