Between 25-80% (1,2) of active females report that they leak urine during physical activities. There is increasing evidence that this condition has a negative impact on exercise habits, leading many to modify their training sessions or even to stop exercising (2). Conservative interventions have demonstrated effectiveness for the management of urinary incontinence (UI) in general populations (3), but less is known about the effectiveness of these interventions specifically for the alleviation of UI symptoms while performing physical activities. The aims of this systematic review were to describe and to synthesize the available evidence on the effectiveness of conservative interventions used to manage UI experienced by females during physical exercise.

This systematic review was guided by the Cochrane Handbook for Systematic Reviews and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and protocols. It was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022379138). With the assistance of a medical librarian, the search strategy was created for Medline based on PICO eligibility criteria developed by the team, then was adapted to the CINAHL, EMBASE, SciELO, LILACS and PEDro databases. The population consisted of females who reported symptoms of UI while participating in physical exercise, and the interventions involved any conservative treatment used to manage UI symptoms during exercise.  Any interventional study design in which a control group (e.g., no treatment or other intervention) was compared to an intervention group, as well as within-subject designs (i.e., baseline measures compared to post-intervention measures) were included. The outcome of interest was severity of UI signs and symptoms. An electronic literature search was performed in December 2022. The grey literature was searched through the Pro-Quest website. All retrieved articles were entered into the Covidence database and duplicates were removed. Two reviewers (MPR, MB) independently screened the titles and abstracts of retrieved articles for inclusion in the full text review. Studies were deemed eligible for inclusion if they met the pre-established PICO framework. Studies were excluded if the sample focused on pregnant females or those within the first postpartum year, if they were published in any language other than English, French, Spanish or Portuguese or if they presented secondary research data. Disagreements between the reviewers were solved through discussion. Full text review followed the title and abstract screening and was performed by the same two reviewers using the same approach. A custom data extraction sheet was developed by the team and pilot tested by the two reviewers using one included study before data extraction proceeded independently and in duplicate by the two reviewers. Extracted data included general publication information, study details, population characteristics,  intervention characteristics  and outcomes. The risk of bias of selected studies was assessed independently and in duplicate by the two reviewers (MPR, MB) using the Cochrane risk of bias tool (RoB2) for randomized trials or the Cochrane risk of bias in non-randomized studies of intervention (ROBINS-I). A narrative synthesis was used.

The PRISMA flow diagram is presented in Figure 1. A total of 3204 abstracts were initially retrieved, and ultimately, 16 manuscripts were included in the review. Most of the studies involved a general population of physically active women (n=5), followed by volleyball athletes (n=3) and female soldiers (n=2). Three studies did not specify what type of exercise the participants performed, and although the target population was active females/athletes, training frequency and intensity were poorly reported. Stress UI (SUI) was the most prevalent subtype of UI studied, but four studies described some women as having mixed UI (MUI) and one included those with urgency UI (UUI). Pelvic floor muscle training (PFMT) and intravaginal devices (pessary and tampon) were the most frequently investigated interventions (n=9 and n=5). An intraurethral device was explored in one study, and another study reported on a combination of electric stimulation, kinesiotherapy, and vaginal cones. PFMT study designs varied, with four randomized clinical trials (RCTs), three uncontrolled studies (within-subject designs), one case series, and one case report. PFMT protocols were tested as a stand-alone treatment (n=4) or combined with other modalities (n=5) including biofeedback, dietary recommendations, abdominal exercises, electrical stimulation, and vaginal cones. The PFMT protocols tended to be poorly described and varied in duration (from 1,5 to 6 months). Studies testing intravaginal devices (n=5) included different models of pessaries and tampons, and none were RCTs. Interventions were assessed mainly by questionnaires (n=11 of 16), pad test (n=9 of 16) and bladder diary (n=5 of 16), with a wide range of instruments used as well as how they were used (Table 1). 
 Both PFMT and pessary interventions were associated with improvement on questionnaires and less pad weight gain on pad tests administered during exercise compared to no intervention. Two studies found that tampons may have more satisfactory results than pessaries when considering pad weight gain. An intraurethral device also resulted in a significant reduction in pad weight while women participated in aerobic exercise, however findings after unsupervised use of the intervention were not described. Risk of bias was deemed high for all studies. Detection bias in the RCTs was mainly associated with poor fidelity between measurements and reported results. Confounding factors, missing data and poor fidelity between measurements and reported results led to risk of bias ratings ranging from serious to critical for the non-randomized studies. Limitations included a lack of detailed information on intervention protocols, improper use of statistical tests, and a lack of clarity in reporting outcomes (e.g., pad test measurements and confusing interpretation of questionnaires). In some studies, it was not clear if only women with UI were included, as the baseline pad weight gain in some participants did not appear to reflect leakage. Of the studies that included participants with symptoms of urgency, no subgroup analysis was performed to assess possible differences in treatment responses.

Conservative interventions for UI experienced during exercise include PFMT, pessaries, tampons, and intra-urethral devices. All appear to have some effectiveness. RCTs on PFMT have high risk of bias yet outcomes suggest that PFMT may be effective. Significant improvements were also observed in the studies that tested intravaginal devices, however tampons may be more effective than pessaries based on pad-test results and mechanical devices seem to be more effective in women with less severe symptoms. Data on the effectiveness of an intraurethral device are considered preliminary; medium- and longer-term outcomes are needed. 
There is a clear need for higher quality studies on conservative interventions for UI experienced during exercise, with better reporting on the details of the interventions themselves, as well as how outcome measures were selected, used, and interpreted. Subgroup information such as the subtype of UI, severity of symptoms, type of exercise performed, and training load need to be considered when interpretating the results.

Little is known about the impact of conservative interventions specifically on UI symptoms experienced during exercise. Although 16 studies were synthesized in this review, study heterogeneity did not allow for meta-analyses. Several methodological limitations were identified which impede the interpretation of results. Controlled randomized clinical trials with rigorous methodologies and judicious use of appropriate outcome measures are needed to provide better evidence for the use of conservative interventions for UI during physical activities.

Teixeira RV, Colla C, Sbruzzi G, Mallmann A, Paiva LL. Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis. Int Urogynecol J. 2018 Dec;29(12):1717-1725. doi: 10.1007/s00192-018-3651-1. Epub 2018 Apr 13. PMID: 29654349.
Nygaard I, Girts T, Fultz NH, Kinchen K, Pohl G, Sternfeld B. Is Urinary Incontinence a Barrier to Exercise in Women? Obstet Gynecol. 2005;106(2):307-314. doi:10.1097/01.AOG.0000168455.39156.0f
Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;2018(10). doi:10.1002/14651858.CD005654.pub4

Continence 7S1 (2023) 100940
DOI: 10.1016/j.cont.2023.100940