Urinary incontinence in female athletes might be related to low energy availability


Urinary incontinence (UI) is a common experience for female athletes that can significantly impact their enjoyment of and participation in sports.

Previous studies have shown that female athletes who experience urinary incontinence are more likely to drop out of their sports.

Noting a large number of female athletes presenting with urinary incontinence, physicians in the Boston Children’s Hospital Female Athlete Program and the Department of Urology wanted to better understand the underlying factors that may contribute to the problem.

“We knew that low energy availability, which occurs when athletes don’t take in enough calories to meet the energy demands of their training, has been linked to a number of health and performance problems in female athletes,” says sports medicine physician, Kristin Whitney, MD, MA.

Such issues include menstrual dysfunction, poor bone health, cardiac and gastrointestinal problems, and decreased muscle strength and endurance – to name a few.

“We wondered if low energy availability might also be related to urinary incontinence, and what that could mean for our patients.” In a study lead by Kathryn Ackerman, MD, MPH, medical director of the Female Athlete Program, the team set out to explore this question.

Studying urinary incontinence in female athletes

The researchers conducted a cross-sectional cohort study of 1,000 female athletes between ages 15 and 30 who presented to Boston Children’s Sports Medicine Division for any reason. The comprehensive survey included questions about the athletes’ nutrition and general health, exercise and performance, self-reported history of disordered eating, and urinary incontinence during sports.

Of the female athletes surveyed, 16.5 percent reported urinary incontinence during athletic activity.

Athletes participating in high-impact sports such as running, cheerleading, and gymnastics were more than four times more likely to report urinary incontinence compared to other sport categories. However, no matter what sport they participated in, UI was far more prevalent in athletes with low energy availability.

The results of the study were published in the Journal of Pediatric Urology.

“We were able to discern that low energy availability is an independent risk factor for urinary incontinence across all sport categories,” says Whitney. “If you had poor nutrition and low energy availability, you’d be at high risk for urinary incontinence.”

Implications for female athletes

The results of this study could provide physicians opportunities to treat urinary incontinence more effectively. “It opens up a lot of doors and a lot of really great conversations between our Sports Medicine Division and our colleagues in the Department of Urology,” says Whitney.

The study could also have a positive impact on female athletes. Knowing urinary incontinence is a common issue that can be addressed in concrete ways could convince athletes discouraged by urinary incontinence to stay engaged in their sports.

“Sport participation is such a crucial component of young women’s development,” says Whitney. Benefits extend far beyond physical health to include mental health, personal development, and personal growth. “Anything that we can do to better understand and support young female athletes can help us help them grow up healthy, strong, and happy.”

Future research could look at running gait

The results of this initial study have generated several options for future research, including possible links between running gait and urinary incontinence. “Twenty percent of the runners we surveyed experience urinary incontinence,” says Whitney. The Division of Sports Medicine and its Injured Runner Clinic uses sophisticated running gait analysis technology to help runners improve the biomechanics of how they run. “Using this technology, we could look at things like whether modifying a runner’s landing patterns and the resulting ground reaction force could potentially modify their risk for urinary incontinence.”

Female Athlete Triad (Triad), an interrelated syndrome of low energy availability (EA), menstrual irregularity, and low bone mineral density. A broader, more comprehensive term was recently introduced by the International Olympic Committee: ‘Relative Energy Deficiency in Sport’ (RED-S). RED-S includes Triad, but also highlights the multiplicity of complex health and performance consequences of low EA and emphasizes that male athletes are also affected.

The syndrome RED-S refers to impaired physiological function caused by relative energy deficiency including menstrual function, metabolism, bone health, immunity, protein synthesis, and cardiovascular health. Low EA has independent negative effects on reproductive function and gonadal steroid production.

Urinary incontinence (UI) has many risk factors, including estrogen deficiency (which can be caused by low EA), depression, and participation in high-impact activities. A high prevalence of UI has been reported in female athletes participating in a variety of different sports.

To date, research evaluating low energy availability as an independent risk factor for UI has been limited, particularly in a young female athlete population. The purpose of this study was to evaluate the association of UI and low EA in adolescent female athletes.


1000 female athletes (ages 15–30 years) presenting to a sports medicine clinic completed a 476 question survey covering topics related to relative energy deficiency in sport (RED-S), including female athlete triad risk factors and athletic activity. For the purpose of this study, data was extracted from responses by subjects between 15–19 years of age.

Low EA was defined as meeting = 1 criterion: self-reported history of eating disorder/disordered eating (ED/DE), high score on the Brief Eating Disorder in Athletes Questionnaire (BEDA-Q), and/or high score on the Eating Disorder Screen for Primary Care (ESP).

UI was assessed through a modified form of the International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence (ICIQ-UI Short Form). Descriptive statistics are expressed as mean ± standard deviation and associations between EA status and UI queries were assessed by chi-squared analysis (cut off for statistical significance was defined as: p<0.05).


Of those who completed the survey, 70.8% were adolescents between 15 and 19 years of age. UI during athletic activities was reported by 14.4% of these athletes. Of those reporting UI, UI was significantly more common in those with low EA than those with adequate EA (54.9% vs. 45.1%, p=0.003).

Age was not associated with UI in this subset (p=0.83). The median onset of UI was 1–2 years prior to completing the survey and the median frequency of UI over the previous year was reported as weekly. There was no significant correlation between the presence of menstrual dysfunction and UI (p=0.104).


Our findings demonstrate that UI is a common problem among adolescent female athletes, occurring in 14.4% of 15-19 year old female athletes surveyed in this study. UI is more prevalent in adolescent female athletes with low EA in comparison to female athletes with adequate EA.

These findings are consistent with those previously observed in studies involving older populations of adult female athletes with eating disorders, where UI was more prevalent in those with low EA in comparison to controls with adequate EA. These findings suggest a potential place for genitourinary disorders in the constellation of impaired physiologic functions considered associated with low EA in athletes/RED-S, and offers a window into a commonly overlooked clinical problem impacting young female athletes.

reference link :https://journals.sagepub.com/doi/10.1177/2325967119S00115

More information: Kristin E. Whitney et al, Low energy availability and impact sport participation as risk factors for urinary incontinence in female athletes, Journal of Pediatric Urology (2021). DOI: 10.1016/j.jpurol.2021.01.041


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