Special report: 'There was urine flying through the air' - the incont…
archived 23 Feb 2022 08:43:09 UTC
ByFiona Tomas23 February 2022 • 7:00am
Pelvic-floor dysfunction can be mentally and physically debilitating CREDIT: Custom image
Laura Gallagher Cox remembers the moment as if it was yesterday. She was 15, competing at a national trampolining meet, and putting the final touches to the routine she would perform minutes later.
Out of nowhere, as she landed from a jump, she wet herself.
“It completely destroyed my warm-up,” reflects the Briton, 32. “I felt embarrassed. I went to the loo and sorted myself out and changed my leotard. People probably knew what had happened.”
Unknown to her at the time, it was Gallagher Cox’s first real experience of stress incontinence, the accidental loss of urine through physical exertion.
In female athletes, the problem commonly occurs when the pelvic floor – a group of muscles and ligaments with important functions, such as pelvic-organ support – is damaged over time. It commonly occurs in athletes from high-impact sports that involve running, or jumping as in netball or gymnastics, where constant and excessive downward pressure is placed on the pelvic floor to the extent it becomes too tight.
The issue is particularly endemic in trampolining, where research has shown incontinence to be prevalent in as many as 80 per cent of female athletes.
“When we land from a jump, we put about 16 times our body weight through the trampoline,” explains Gallagher Cox. “In terms of peeing, the worst time for it seems to be the younger girls just coming into puberty. I’ve been at competitions where I’ve seen girls pee as they take off – when they do a double back somersault you’ll genuinely see urine flying through the air.”
Gallagher Cox, who represented Great Britain at last summer’s Tokyo Olympics, counts herself as one of the lucky ones – incontinence never became a real problem during her senior career. But the humiliation of leaking as a junior has left a psychological impact that verges on unhealthy.
“I go to the loo about five times per session,” she says. “I don’t drink very much during training, so when I get advice from the nutritionist and you have to drink X amount or this type of drink and you’re like, I just can’t do that.”
Laura Gallagher Cox represented Great Britain at the Tokyo Olympics CREDIT: GETTY IMAGES
Her British team-mate Izzy Songhurst started experiencing incontinence issues aged 13. More than a decade later, she still wears pads in her leotard, and can go through as many as four in a session. “If you’re having a bad day, you do worry about whether your pad is showing through the back of your leotard or if it’s coming out the side,” says Songhurst, a former European and world junior champion. “It causes a bit of uncomfortableness and anxiety, which can obviously be distracting and can throw you off.”
Urinary incontinence is often talked about in the context of pregnancy and childbirth, which can weaken a woman’s pelvic floor. But, such is the taboo around leaking, it is rarely discussed in the context of elite sport, let alone in wider society.
When a photographer captured France’s 2004 Olympic gymnastics champion Emilie Le Pennec urinating during the World Championships in 2005, the images ended up plastered across porn and fetish websites. The same fate happened to Ecuadorian weightlifter Maria Alexandra Escobar Guerrero, who leaked while attempting a lift at the London 2012 Olympics. Instead of prompting a frank and open discussion about sportswomen being at risk of incontinence, both were ridiculed in the media.
A decade on and the subject continues to be seen as a taboo. Several major sporting governing bodies declined or ignored repeated requests from Telegraph Sport to discuss the extent to which their athletes were prone to stress incontinence, including any measures they were taking to help those impacted.
“Women are supposed to have a menstrual cycle – blood is supposed to come out of them once a month,” says Baz Moffat, a women’s health coach at The Well HQ who specialises in pelvic-floor education.
“You’re not supposed to wet yourself. You’re not supposed to leak urine, especially if you’ve not had a baby.”
Maria Alexandra Escobar Guerrero competing at London 2012 CREDIT: GETTY IMAGES
Research has shown that pelvic-floor dysfunction and incontinence should not be solely viewed “as mums’ issues”, as Moffat puts it. Female athletes are, in fact, at a 177 per cent higher risk of presenting with urinary incontinence symptoms than sedentary women, with those involved in high-impact sports such as volleyball, athletics, basketball, rugby, football, cross-country, skiing and running all affected.
“The assumption is that you leak because you have a weak pelvic floor,” adds Moffat. “There’s this ‘keep doing your pelvic-floor exercises’ message but, actually, for many sportspeople, it’s about relaxing the pelvic floor and the down training, which sportspeople are pretty bad at.”
Urinary tract infections are another sign that the pelvic floor is too tight due to its inability to let go of urine, which stays in the urethra.
“The pelvic floor is a dynamic muscle which should move with your breathing,” adds Moffat. “Every muscle needs to have a range of movement that it works through and if all you’ve done is tighten and tighten your muscles, that’s not a healthy state for your connective tissue to be in.”
The issue is widespread in gymnastics. One academic paper revealed that the entire French gymnastics team experienced leakage during the 2016 Rio Olympics, while a 2021 study published in the International Urogynecology Journal found that out of 319 gymnasts and cheerleaders surveyed, two thirds suffered urinary incontinence.
Moffat knows of parents whose gymnast daughters have even started wetting the bed, their pelvic floor overtrained and overtight through the consistent core work, while the stigma around incontinence has been intensified by sexual abuse scandals that have rocked the sport.
PELVIC FLOOR DYSFUNCTION EXPLAINED
The pelvic floor is a group of muscles and ligaments which stretch from the pubic bone to the tail-bone, supporting the pelvic organs and preventing incontinence (the involuntary loss of urine or faeces). The pelvic floor helps to control bladder and bowel function when pressure is exerted through running, jumping and squatting - or even laughing, coughing and sneezing. An athlete’s pelvic floor must be stronger to counteract excess force through their body during high-impact exercise.
It is thought that sportswomen are at risk from a tightened pelvic floor because their pelvic and core muscles are constantly switched ‘on’ without time to relax and let go. Another hypothesis is that athletes are training their bodies so hard their pelvic floor can’t keep up.
Larry Nassar, the convicted paedophile doctor for the United States gymnastics team, twice shut down police probes into his sexual abuse after claiming his assaults on victims were medically legitimate “pelvic-floor therapy”. This type of treatment uses internal vaginal soft tissue manipulation, or massage, to relieve pelvic pain by accessing muscles that cannot be accessed any other way, and gave Nassar an easy cover story that allowed him to become a predatory abuser.
In other sports, the scale of stress incontinence and the prevalence of tight pelvic floors is only just starting to be understood – and in the case of Wales Rugby – tackled. After conducting a player questionnaire among the Wales women’s squad during the first Covid-19 lockdown, Jo Perkins, the team’s head physio, discovered incontinence was leading to huge performance implications.
“When I started working with the team in 2019, it was more chats of, ‘Oh, well, I pee myself’ or ‘I have horrendous abdominal pain when I reach my maximum speed’, or ‘It’s painful putting tampons in’. These all come under the umbrella term of pelvic-floor dysfunction,” says Perkins.
“If you’ve got pain or you’re leaking, all that pressure is going the wrong way, so you won’t be able to push as hard in the scrum or tackle and jump effectively. Our stats showed that, actually, the girls were leaking more through jumping, rather than tackling.”
After launching its first set of professional full-time contracts this year, the Welsh Rugby Union began a pioneering partnership with “fem tech” brand Elvie to improve players’ pelvic-floor knowledge. Every player has a smart kegel trainer, a device that is vaginally inserted and helps with pelvic-floor training. It links with an app, and players can monitor their pelvic-floor strength as it contracts and releases.
“The app is really good at telling players whether they are squeezing effectively and how much they are squeezing,” explains Perkins. “It gives you real time feedback. What we’re finding with a lot of the girls is that it’s the release that’s really difficult.”
With the rise of fem tech – the umbrella term for software, services and products focusing on women’s health – expected to exceed £40 billion within the next decade, there are an increasing number of products to help sportswomen deal with incontinence. But, according to Moffat, who conducts pelvic-floor health workshops, there is not an off-the-shelf one-fits-all solution.
“My approach to women and their bodies is they need to know what they need to be doing,” she says. “Just doing a set of pelvic-floor exercises at home will work for some people brilliantly. Nothing is perfect for everybody.
“My recommendation would always be to just go simple first of all and try doing pelvic-floor exercises on your own. Women have no clue how to do pelvic-floor exercises – they’ve never been taught properly – so that’s a challenge. If that’s the case, I would go and find a women’s health physio first who can teach you how to do them properly and also teach you what exercises you need to be doing.”
Having seen specialists for her own pelvic-floor problems, Songhurst has found breathing techniques to relax her core which have helped, but she has reached a point where she is simply managing her leakage. “I kind of accept it’s going to be a thing for the rest of my career,” says Songhurst, who is targeting the Paris 2024 Olympics. “I’m open to trying things if someone suggests how to help.”
By simply talking about urinary stress incontinence, she and Gallagher Cox are making a major contribution to breaking the taboo.
“It’s so normalised after pregnancy,” adds Songhurst, “but why isn’t it normalised in sport?”
