Urinary incontinence (UI) is highly prevalent in female athletes (FA). Approximately 36% of all FA have UI and they are three times more at risk of developing UI than sedentary females (2,3). The literature demonstrates that FA with UI experience negative emotions and report that UI has a negative impact on their sport performance. Some FA limit or even stop their sport due to their symptoms, yet few seek attention from health professionals. Pelvic floor muscle training (PFMT) has level 1A evidence to decrease urine loss during jumping, running or other sports and as such, is considered the first-line prevention and treatment for UI in FA (1). However, despite the safety and effectiveness of this available treatment, there exists an important gap between the prevalence of UI in FA and this population accessing proper management. Therefore, the aim of our study is to describe the awareness, attitudes and practices of Canadian sports and orthopedic physiotherapists regarding UI in FA through a national online survey.

A cross-sectional, mixed-methods, bilingual (English and French) survey was developed through a focus group of subject matter experts with deductive thematic analysis, followed by a sequential validation process using content validation ratio and clarity content validity index. The survey contained 41 questions, including demographic, qualitative and quantitative questions. The survey was then distributed online through LimeSurvey between April and June 2022 to Canadian sports and orthopedic physiotherapists treating FA. Participants were invited to take part in the anonymous survey via email and social media platforms through national and provincial physiotherapy professional associations and regulatory bodies. Quantitative data was analyzed using descriptive statistics and associative measures (Chi-squared, point-bismal correlation and Spearman’s correlation) and qualitative data was analyzed using inductive thematic analysis.

156 physiotherapists responded to the survey, in which 126 participants completed the entire survey. Fifty-eight percent of participants were aware that FA are 2.5 to 3 times more likely to develop UI than sedentary women, 58% were aware that FA may stop their sport due to UI and 41% were aware that some FA who experience UI consider it to have implications on their sport performance. As well, 90% of participants were aware that PFMT is the best known prevention and treatment of UI. In terms of attitude, 86% of participants agreed that UI is a topic that should be addressed in FA by their physiotherapists, 92% of participants agreed that UI during sport requires treatment and 80% of participants rated themselves completely or fairly comfortable about discussing UI with their FA. Despite participants being aware of UI in FA and believing that it is a physiotherapist’s role to treat UI in FA, only 27% of participants stated that they include strategies for the prevention of UI with their FA and only 37% of participants stated that they always or often screen their FA for UI. 
Important differences in prevention and screening practices were found between physiotherapists who had different levels of PF education. For instance, only 28% of participants with no PF education screened their FA for UI, whereas 55% of participants with PF continuing education screened for UI. Regarding prevention strategies, only 15% of participants with no PF education included prevention strategies for UI in FA, while 52% of participants with PF continuing education included prevention strategies. As well, 48% of participants with no PF education stated that they educate their FA regarding UI, with this number increasing to 93% in participants with PF continuing education. Furthermore, only 10% of participants considered the material covered in their physiotherapy degree sufficient to screen and educate their FA regarding UI. The vast majority of participants (90%), regardless of their level of PF education, believed that it is pertinent to gain further knowledge about the PF and related structures for their practice with FA. 
Furthermore, important gender barriers were identified pertaining to participants’ attitudes and practices regarding UI in FA. Only 37% of cisgender men educate regarding UI compared to 68% of cisgender women. Fifty-five percent of cisgender men versus 87% of cisgender women rated themselves as comfortable with discussing UI with their FA. Additionally, 60% of cisgender men believed their gender would negatively influence their approach to UI with FA, whereas 75% of cisgender women believed their gender would positively influence their approach.

This study showed that a majority of Canadian sports and orthopedic physiotherapists responding to this survey were aware of the high prevalence and impact of UI in addition to the efficacy of physiotherapy management for UI in FA. However, despite this awareness, very few participants screened for and implemented prevention strategies for UI in this population. The lack of screening and prevention practices may be due to participants lacking proper education regarding PF dysfunction. Additionally, this study demonstrated that having higher levels of PF education increased both prevention and screening practices in the survey participants. However, although participants did not feel equipped to screen and educate FA about UI, they were eager to gain further knowledge to better manage UI in this population. In addition, special considerations should address gender barriers, particularly regarding cisgender mens’ attitudes toward UI management in FA.

This study has highlighted gaps in the awareness, attitudes and practices as well as gender barriers regarding the management of UI in FA of orthopedic and sports medicine physiotherapists in Canada. Possible solutions to address these gaps include improving PF material in university entry-level programs, integrating PF education in sports physiotherapy curriculum and advocating for rigorous screening and referring practices in orthopedics and sports medicine physiotherapists treating FA. Addressing these gaps is essential to ensure proper management of UI in FA, to increase longevity of women in sports and to potentially improve sport performance.

Culleton-Quinn, E., Bø, K., Fleming, N., Mockler, D., Cusack, C., & Daly, D. (2022). Elite female athletes’ experiences of symptoms of pelvic floor dysfunction: a systematic review. International Urogynecology Journal, 33(10), 2681–2711. https://doi.org/10.1007/s00192-022-05302-6
Cardoso, A. M. B., Lima, C. & Ferreira, C. W. S. (2018). Prevalence of urinary incontinence in high-impact sports athletes and their association with knowledge, attitude and practice about this dysfunction. Eur J Sport Sci 18, 1405-1412, doi:10.1080/17461391.2018.1496146.
Teixeira, R. V., Colla, C., Sbruzzi, G., Mallmann, A. & Paiva, L. L. (2018). Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis. Int Urogynecol J 29, 1717-1725, doi:10.1007/s00192-018-3651-1.

Continence 7S1 (2023) 100903
DOI: 10.1016/j.cont.2023.100903