Benefits of Physiotherapy on Urinary Incontinence in High-Performance Female Athletes. Meta-Analysis

troduction: High performance female athletes may be a risk group for the development of urinary incontinence due to the imbalance of forces between the abdomen and the pelvis. Pelvic oor physiotherapy may be a useful treatment in these patients.Objectives:(1) To identify the scienti c evidence for pelvic oor (PF) dysfunctions that are associated with urinary incontinence (UI) in high-performance sportswomen. (2) To determine whether pelvic oor physiotherapy (PT) corrects UI in elite female athletes.Materials and methods:Meta-analysis of published scienti c evidence. The articles analyzed were found through the following search terms: (A) pelvic oor dysfunction elite female athletes; (B) urinary incontinence elite female athletes; (C) pelvic oor dysfunction elite female athletes physiotherapy; (D) urinary incontinence elite female athletes physiotherapy.Variables studied:type of study, number of individuals, age, prevalence of urinary incontinence described in the athletes, type of sport, type of UI, aspect investigated in the articles (prevalence, response to treatment, etiopathogenesis, response to PT treatment, concomitant health conditions or diseases.Study groups according to the impact of each sport on the PF:G1: low-impact (noncompetitive sports, golf, swimming, running athletics, throwing athletics); G2: moderate impact (cross-country skiing, eld hockey, tennis, badminton, baseball) and G3: high impact (gymnastics,

type of sport, type of UI, aspect investigated in the articles (prevalence, response to treatment, etiopathogenesis, response to PT treatment, concomitant health conditions or diseases.Study groups according to the impact of each sport on the PF:G1: low-impact (noncompetitive sports, golf, swimming, running athletics, throwing athletics); G2: moderate impact (cross-country skiing, eld hockey, tennis, badminton, baseball) and G3: high impact (gymnastics, artistic gymnastics, rhythmic gymnastics, ballet, aerobics, jump sports (high, long, triple and pole jump)), judo, soccer, basketball, handball, volleyball). Descriptive analysis, ANOVA and meta-analysis. Results:Mean age 22.69 years (SD 2.70, 18.00–29.49), with no di erence between athletes and controls. Average number of athletes for each study was 284.38 (SD 373,867, 1–1263). The most frequent type of study was case-control (39.60%), followed by cross-sectional (30.20%). The type of UI was most often unspeci ed by the study (47.20%), was stress UI (SUI, 24.50%), or was referred to as general UI (18.90%). Studies on prevalence were more frequent (54.70%), followed by etiopathogenesis (28.30%) and, lastly, on treatment (17.00%). In most cases sportswomen did not have any disease or concomitant pathological condition (77.40%). More general UI was found in G1 (36.40%), SUI in G2 (50%) and unspeci ed UI in G3 (63.64%). In the meta-analysis, elite athletes were found to su er more UI than the control women. In elite female athletes, in general, physiotherapy contributed to gain in urinary continence more than in control women (risk ratio 0.81, con dence interval 0.78–0.84)). In elite female athletes, former elite female athletes and in pregnant women who regularly engage in aerobic activity, J. Clin. Med.2020,9, 3240; doi:10.3390 /jcm9103240 /journal/jcm

J. Clin. Med.2020,9, 3240 2 of 12 physiotherapy was successful in delivering superior urinary continence compared to the control group. The risk of UI was the same in athletes and in the control group in volleyball female athletes, elite female athletes, cross-country skiers and runners. Treatment with PT was more e ective in control women than in gymnastics, basketball, tennis, eld hockey, track, swimming, volleyball, softball, golf, soccer and elite female athletes.Conclusions:There is pelvic oor dysfunction in high-performance athletes associated with athletic activity and urinary incontinence. Eating disorders, constipation, family history of urinary incontinence, history of urinary tract infections and decreased exibility of the plantar arch are associated with an increased risk of UI in elite female athletes. Pelvic oor physiotherapy as a treatment for urinary incontinence in elite female athletes, former elite female athletes and pregnant athletes who engage in regular aerobic activity leads to a higher continence gain than that obtained by nonathlete women. Keywords:physiotherapy; urinary incontinence; high performance athletes 1. Introduction Urinary incontinence (UI) is de ned as the involuntary loss of urine [1]. When pressure inside the abdomen increases due to exertion, it is transmitted to the bladder causing the pressure within the bladder to be higher than in the urethra. For proper function of urination and urinary continence, intraurethral pressure must be higher than intravesical pressure both at rest and in activities that require e ort [2]. The urethra must be evaluated with physical examination and transvaginal ultrasound [3] to rule out disease such as diverticular or rare neoplasms [4]. The aim of UI treatment is to regain urinary continence. Treatment begins with conservative measures and changes to lifestyle, followed by pelvic oor (PF) physiotherapy and pharmacological treatments. If this fails, surgical treatment is considered [5]. PF exercises are a fundamental aspect of vesico-sphincter re-education treatments. They were initially proposed by J.W. Davis, although it was Arnold Kegel who described them in detail in 1948, since when they have been known as Kegel exercises [6]. If not performed regularly, the e ects of PF exercises may be lost in 10 to 20 weeks after they

[5]. PF exercises are a fundamental aspect of vesico-sphincter re-education treatments. They were initially proposed by J.W. Davis, although it was Arnold Kegel who described them in detail in 1948, since when they have been known as Kegel exercises [6]. If not performed regularly, the e ects of PF exercises may be lost in 10 to 20 weeks after they are stopped [7]. The decision over which PT technique to use should be based on the cause of the urinary incontinence and on the characteristics of the patient, such as learning ability, motivation, and adherence to treatment. Protocols should be followed which begin with the simplest and safest measures, and progress towards the most aggressive guided by pre-established therapeutic objectives (Garc½a-Mart½n, Del-Olmo-Cañas et al. 2005). Biofeedback (BFB) is a method for training pelvic oor muscle exercises by means of positive reinforcement. Through biofeedback we obtain information on the intensity and duration of pelvic oor muscle contractions [7]. The types of BFB most used on the PF are pressure and electromyographic, guided by visual, auditory or tactile stimuli [6]. Another technique is electrostimulation, which can passively enhance PF musculature through the activation of nerve and muscle bers by electrical or magnetic stimuli [6]. Ptaszkowskin et al. reported good results of stress or mixed urinary incontinence treatments by pelvic oor muscle stimulation with high-inductive electromagnetic stimulation using surface electromyography [8]. However, such treatments are not speci ed to have been applied to elite female athletes. The prognosis of UI depends on the type of UI, the age of the patient, past or concomitant illnesses, pregnancy, childbirth and the nature of frequently-performed activities [9]. High-performance female athletes are an at-risk group for UI. This nding could be due to the imbalance of forces in the abdomen and pelvis, which could lead to early alteration of the physiological urethrovesical angle in addition to leading to mixed urinary incontinence (MUI), primarily stress UI. Use of physiotherapy (PT) could prove bene cial in cases of UI in high-performance athletes, both in neuromuscular and fascial aspects, with repercussions on function and prognosis. Practicing various sports may also

in the abdomen and pelvis, which could lead to early alteration of the physiological urethrovesical angle in addition to leading to mixed urinary incontinence (MUI), primarily stress UI. Use of physiotherapy (PT) could prove bene cial in cases of UI in high-performance athletes, both in neuromuscular and fascial aspects, with repercussions on function and prognosis. Practicing various sports may also be associated with di erent positions of the pelvis or the cowork of synergistic muscles. This is a well-researched aspect in

J. Clin. Med.2020,9, 3240 3 of 12 menopausal women [10,11]. In our research, di erent types of sports practices were taken into account and an international medical expert in sports medicine (Dr Carlos Moreno) classi ed the di erent sports according to their impact on the pelvic oor. The objective of this study was to identify the scienti c evidence of association of pelvic oor dysfunction (PF) and urinary incontinence (UI) in high-performance athletes. In addition to determining if pelvic oor (FP) physiotherapy (PT) corrects UI in elite athletes. 2. Materials and Methods A meta-analysis of published scienti c evidence was performed. The ow chart shows how the analyzed articles were selected (Figure). The time limits of the search are from 1994 to 2019. The main search was carried out in the PubMed database, where the following searches were made. The rst search, pelvic oor dysfunction and elite female athletes returned seven articles. In the second search, urinary incontinence and elite female athletes, sixteen were found. The third search, pelvic oor dysfunction and elite female athletes and physiotherapy, returned zero results, but four articles appeared in Google Scholar. Finally, the fourth search, urinary incontinence and elite female athletes and physiotherapy, returned two results. Since some articles were repeated in these search results, a total of eighteen articles were found for analysis.J. Clin. Med. 2020, 9, 3240 3 of 12 types of sports practices were taken into account and an international medical expert in sports medicine (Dr Carlos Moreno) classified the different sports according to their impact on the pelvic floor. The objective of this study was to identify the scientific evidence of association of pelvic floor dysfunction (PF) and urinary incontinence (UI) in high-performance athletes. In addition to determining if pelvic floor (FP) physiotherapy (PT) corrects UI in elite athletes. 2. Materials and Methods A meta-analysis of published scientific evidence was performed. The flow chart shows how the analyzed articles were selected (Figure 1). The time limits of the search are from 1994 to 2019. The main search was carried out in the PubMed database, where the following searches were

pelvic floor (FP) physiotherapy (PT) corrects UI in elite athletes. 2. Materials and Methods A meta-analysis of published scientific evidence was performed. The flow chart shows how the analyzed articles were selected (Figure 1). The time limits of the search are from 1994 to 2019. The main search was carried out in the PubMed database, where the following searches were made. The first search, pelvic floor dysfunction and elite female athletes returned seven articles. In the second search, urinary incontinence and elite female athletes, sixteen were found. The third search, pelvic floor dysfunction and elite female athletes and physiotherapy, returned zero results, but four articles appeared in Google Scholar. Finally, the fourth search, urinary incontinence and elite female athletes and physiotherapy, returned two results. Since some articles were repeated in these search results, a total of eighteen articles were found for analysis. Figure 1. Flow chart of sample selection. In the eighteen articles on studies conducted on female athletes, both observational and intervention studies were included. In the selected articles, the following sports were found: noncompetitive sports (such as hiking), golf, swimming, track and field athletics, throwing athletics, cross-country skiing, field hockey, tennis, badminton, baseball, artistic gymnastics, rhythmic gymnastics, ballet, aerobics, jumping athletics (high, long, triple and pole jump), judo, soccer, basketball, handball, volleyball, and ex- athletes of various specialties. Each sport was assigned a code from least to greatest impact by an Figure 1.Flow chart of sample selection. In the eighteen articles on studies conducted on female athletes, both observational and intervention studies were included. In the selected articles, the following sports were found: noncompetitive sports (such as hiking), golf, swimming, track and eld athletics, throwing athletics, cross-country skiing, eld hockey, tennis, badminton, baseball, artistic gymnastics, rhythmic gymnastics, ballet, aerobics, jumping athletics (high, long, triple and pole jump), judo, soccer, basketball, handball, volleyball, and ex-athletes of various

J. Clin. Med.2020,9, 3240 4 of 12 specialties. Each sport was assigned a code from least to greatest impact by an expert in sports medicine (Doctor D. Carlos Moreno Pascual), and the sports were grouped in three categories corresponding to the three study groups. In each article we identi ed the resulting values of the investigated variables for athletes and controls. 2.1. Study Groups Three study groups were established according to the sports' impact on the PF: G1: low impact. This group included the following sports: noncompetitive sports, golf, swimming, running athletics, throwing athletics. Although some studies included running sports as moderate impact, our specialist physician in sports medicine, of international recognition (Dr. Carlos Moreno,) considered that the impact on the pelvic oor when running is low. G2: moderate impact. This group included the following sports: cross-country skiing, eld hockey, tennis, badminton, baseball. G3: high impact. This group included the following sports: gymnastics, artistic gymnastics, rhythmic gymnastics, ballet, aerobics, jumping athletics (high, long, triple and pole jump), judo, soccer, basketball, handball, volleyball. The specialty of ex-athletes was taken into account and, in articles which speci ed high performance, thus medium-high levels where weights are often used during training, these athletes were included in G3. For the meta-analysis, on the one hand, the type of sport performed by each female athlete included in the articles was taken into account. The type of sport was analyzed as a variable. Each sport analyzed was classi ed in one of the three groups of impact on the pelvic oor. In each article, the elite female athletes, and the subjects who acted as controls in the comparison, were identi ed. This allowed the multivariate analysis to be carried out, since many publications included various types of sports, it was necessary to analyze with the utmost rigor, disaggregating each sport, individualizing each elite female athlete and the female controls against which they were compared in each article. 2.2. Variables Studied For each article, we analyzed the scienti c studies to which they referred, which, in reviews and meta-analyses, may have been more than one. In each

of sports, it was necessary to analyze with the utmost rigor, disaggregating each sport, individualizing each elite female athlete and the female controls against which they were compared in each article. 2.2. Variables Studied For each article, we analyzed the scienti c studies to which they referred, which, in reviews and meta-analyses, may have been more than one. In each study the cases of both female athletes and female controls were analyzed, if they existed. The following variables were identi ed: (a)Type of study. The following types were distinguished: clinical case, bibliographic review, cross-sectional, cross-sectional plus case-control, meta-analysis, randomized trial. (b)Number of individuals participating in each study. (c)Age. (d)Proportion of urinary incontinence described in athletes. (e)Type of sport. (f)Type of urinary incontinence (UI). The following types were noted: general UI, stress UI (SUI), urge UI (UUI), mixed UI (MUI). For greater rigor in the typi cation of the class of urinary incontinence registered in the articles, we di erentiated between type of incontinence not provided (NP), from that speci ed as general incontinence: general UI. (g) response to treatment and etiopathogenesis. (h)Response to physiotherapy treatment. The following responses to physiotherapy were noted: investigated; not investigated. We assessed whether the response to physiotherapy treatment was superior to no physiotherapy treatment. The following responses to physiotherapy treatment were noted: not expressed; expressed and not superior; expressed and superior.

J. Clin. Med.2020,9, 3240 5 of 12 (i)Diseases or concomitant health conditions. The following were identi ed: No concomitant disease; family history of UI, cold environment, embarrassment about urinary incontinence, pregnancy, lower plantar exibility, eating disorders, constipation, history of urinary tract infections (UTI), levator ani muscle spasm, multiple conditions (family history of UI, constipation plus history of UTI). Cold environment means that the sport is practiced in a cold environment with a low temperature; it is not a disease, as in the case of no concomitant disease. Therefore, cold environment is just a concomitant condition. 2.3. Statistical Analysis The analysis was performed on the NSSS2006/GESS2007 automatic statistical calculator. Descriptive statistics, ANOVA (with Sche e's test for normal samples and Kruskal-Wallis for other distributions), and meta-analysis were used. Statistical signi cance was accepted forp<0.05. Stages of the analysis: rst the type of study was identi ed, then, within each study, the number of female athletes in each study, the type of sport, the number of controls for each sport.; then the variables studied were identi ed in each woman. A third step was to catalog the degree of pelvic oor involvement according to the sport studied (which classi ed the study groups). A nal step was to identify the result of the treatment received. The dependent variables were age, number of athletes, number of controls, treatment received and treatment result. The continuous variables were analyzed with one-way ANOVA and the categorical ones with Chi square. All variables were included in the multivariate analysis of randomized e ects. 2.4. Ethical Issues The study protocol with code PI2020 03 454 was approved by the Clinical Research Ethics Committee of the Salamanca University Assistance Complex (Comit² ’tico de Investigaciân con Medicamentos del Complejo Asistencial Universitario de Salamanca, Salamanca, 37.007 Spain). 2.5. Con icts of Interest The authors declare there are no con icts of interest. 2.6. Financing Funding for the study was provided by the Urological Renal Multidisciplinary Research Group (GRUMUR, Grupo de Investigaciân Multidisciplinar Urolâgico Renal) of the Salamanca Biosanitary Research Institute (IBSAL, Instituto de Investigaciân Biosanitaria de Salamanca, Salamanca 37007 Spain). 3.

Universitario de Salamanca, Salamanca, 37.007 Spain). 2.5. Con icts of Interest The authors declare there are no con icts of interest. 2.6. Financing Funding for the study was provided by the Urological Renal Multidisciplinary Research Group (GRUMUR, Grupo de Investigaciân Multidisciplinar Urolâgico Renal) of the Salamanca Biosanitary Research Institute (IBSAL, Instituto de Investigaciân Biosanitaria de Salamanca, Salamanca 37007 Spain). 3. Results Mean age of women in the studies was 22.69 years, SD 2.70, median 22.00, range 18.00–29.49 years, with no di erences between athletes and controls (p=0.9864). The mean number of athletes per study was 284.38, SD 373.867, median 144.00, range 1–1263. Mean number of controls was 85.49, SD 175.23, median 0.00, range 0.00–765.00. There were no di erences between G1, G2 and G3 in age, number of athletes studied in the articles, or number of control individuals (Table). The most frequent type of study was case-control (39.60%), followed by cross-sectional (30.20%). In G1, case-control studies and meta-analyses were more frequent, in G2 clinical cases and reviews were more frequent, and in G3 cross-sectional studies and randomized trials were more frequent (p=0.000002) (Table).

J. Clin. Med.2020,9, 3240 6 of 12 Table 1. Age, number of athletes studied and control women in the studies performed in G1, G2 and G3. Variable Group Mean SD Median Range p Age G1 23.37 3.32 22.00 19.00–29.49 0.8000 G2 22.35 2.94 21.35 19.90–26.61 G3 22.18 1.91 22.00 18.00–25.00 Number of athletes studied G1 470.91 517.04 150.50 24–1263 0.2470G2 146.67 78.83 144.00 57–291 G3 153.28 114.43 144.00 1–331 Number of control women G1 116.36 195.96 22.00 0.00–765.00 0.3840 G2 25.83 42.47 0.00 0.00–100.00 G3 72.64 174.98 0.00 0.00–640.00 G1: women engaging in sports with low impact on the pelvic oor. G2: women engaging in sports with moderate impact on the pelvic oor. G3: women engaging in sports with high impact on the pelvic oor. Table 2. Type of studies, type of urinary incontinence investigated, study objective and concomitant diseases or conditions in high-performance sportswomen. Variable G1 (n=22 *) G2 (n=6 *) G3 (n=25 *) p n % n % n % Type of study Clinical case 0 0 1 16.70 1 4.00 0.000002 Review 1 4.5 5 83.30 1 4.00 Transversal 5 22.7 0 0 11 44.00 Case-control 12 54.5 0 0 9 36.00 Meta-analysis 4 18.2 0 0 0 0 Randomized trial 0 0 0 0 3 12.00 Type of UI General 8 36.40 0 0.00 2 8.00 0.0120 SUI 3 13.60 3 50.00 7 28.00 MUI 4 18.20 1 16.70 0 0.00 NP 7 31.80 2 33.30 16 64.00 Study objective Prevalence 12 54.50 3 50.00 14 56.00 0.9600Treatment 3 13.60 1 16.70 5 20.00 Etiopathogenesis 7 31.80 2 33.30 6 24.00 Concomitant diseases or conditions None 12 54.50 5 83.30 24 96.00 0.0540 Cold environment 1 4.50 1 16.70 0 0.0 Embarrassment due to UI 1 4.50 0 0.0 0 0.0 Pregnancy 3 13.60 0 0.0 0 0.0 Less exibility 2 9.10 0 0.0 0 0.0 Eating disorder 1 4.50 0 0.0 0 0.0 Muscle spasms 0 0.0 0 0.0 1 4.00 Multiples diagnoses 2 100.0 0 0.0 0 0.0 G1: women engaging in sports with low impact on the pelvic oor. G2: women engaging in

This study analyzes the effectiveness of pelvic floor physiotherapy for urinary incontinence in elite female athletes.