Evaluation of the Prevalence of Urinary Incontinence Symptoms in Adolescent Female Soccer Players and their Impact on Quality of Life
Eduardo Filoni1,2*, Fátima F Fitz2, Alexandre Silva3 and José M Filho1
1Department of Science of Health, State University of Campinas (Universidade Estadual de Campinas), Brazil
2Departament of Physcal Therapy, University of Mogi das Cruzes (Universidade de Mogi das Cruzes), Brazil
3Departament of Physcal Therapy, Cruzeiro do Sul University (Universidade Cruzeiro do Sul), Brazil
Submission: March 15, 2018;Published: May 24, 2018
*Corresponding author: Eduardo Filoni, Department of Science of Health, State University of Campinas (Universidade Estadual de Campinas), Campinas, SP, Avenida Milton 180, Vila Galvão, Guarulhos-SP, CEP: 07063-120, Brazil, Tel: +55 (11) 996299437; Fax: +55 (11) 23585954; Email: email@example.com
How to cite this article: Eduardo F,Fátima F F, Alexandre S,José M F. Evaluation of the Prevalence of Urinary Incontinence Symptoms in Adolescent
Female Soccer Players and their Impact on Quality of Life. J Yoga & Physio. 2018; 5(1): 555655. DOI:10.19080/JYP.2018.05.555655
The object of the study was to evaluate the prevalence, reliability and severity of symptoms of urinary incontinence (UI) in adolescent female soccer players and the impact of those symptoms on quality of life. The present work is a cross-sectional study of 59 female adolescents divided into a group of athletes (35) and control group (24). The International Consultation on Incontinence Questionnaire -Short Form (ICIQ-SF), the pad test and King’s Health Questionnaire (KHQ) were used for evaluation. The athletes displayed 62.8% positivity the pad test and the ICIQ-SF, whereas the control group exhibited 25% positivity. In terms of quality of life, the athletes exhibited a score of 35.2 in the General Health domain, 37.3 in the Emotions domain and 26.5 in the Sleep/Energy domain. In the present study, a high prevalence of UI symptoms was found in soccer athletes, with moderate reliability between the pad test and the ICIQ-SF; mild UI was found in both groups.
Urinary incontinence (UI) is defined by the International Continence Society (ICS) as any involuntary loss of urine. Specifically, one of the symptoms is stress urinary incontinence (SUI), which is the involuntary loss of urine while coughing or sneezing or during physical exercise .
In terms of risk factors for UI, women who have had a vaginal delivery exhibit an approximately six times higher probability of UI compared with nulliparous women . However, although vaginal delivery is one of the greatest risk factors for the development of UI, a high prevalence has also been shown among young and nulliparous women [3-5].
A review of the literature showed a UI prevalence of 28% to 80% among participants in high-impact sports, such as artistic gymnastics, hockey and ballet . There is no doubt that physical exercise has diverse beneficial effects on health; however, there is evidence that high-impact sports can result in an alteration of intra-abdominal pressure that affects the pelvic organs, thus inducing SUI during sports training or competitions [7,8].
Bo  and Eliasson et al.  have evaluated the prevalence of UI among artistic gymnasts, dancers and trampolinists, observing a higher prevalence of UI in sports activities that are considered to have a high impact on the pelvic floor compared with low-impact activities.
Full diagnosis involves a variety of procedures ranging from anamnesis to specific UI-evidencing tests. Anamnesis and medical history reflect the patient-reported symptoms. The physical exam allows muscular function evaluation via digital palpation or specific equipment, including a pneumatic device and electromyography [3,11,12]. Urinary loss can be evaluated with the pad test, which quantifies leakage in stress situations and the severity of urinary symptoms [1,13,14]. The one-hour pad test, which is validated by the ICS, classifies a loss of 1.1 to 9.9g as mild, a loss of 10 to 49.9g as moderate and losses greater than 50g as severe .
Questionnaires can be used to detect and measure UI’s negative and comprehensive interference with the woman’s health, which triggers restrictions in the sexual, domestic, occupational and social domains, the latter of which includes
physical and/or sports activities . Among the most often
used questionnaires are the Incontinence Quality of Life (I-QoL)
questionnaire, the Incontinence Impact Questionnaire -Short
Form (IIQ-7) and King’s Health Questionnaire (KHQ) .
Considering the growing number of female athletes who
play soccer, a high-impact activity, and the lack of epidemiologic
studies in the literature that evaluate UI in soccer, the objective
of the present study was to evaluate the prevalence, reliability
and severity of UI symptoms among adolescent female soccer
players and the impact of UI symptoms on quality of life.
A cross-sectional study was performed with 59 female
soccer players and non-soccer players aged between 11 and 19
years. Participants were included if they were nulliparous, nonpregnant
adolescent soccer players and adolescents who did not
practice any sports. Adolescents who did not agree or did not
obtain permission from their guardian to participate in this study
were excluded. The adolescents were recruited and divided into
two groups: a group of athletes, composed of 35 amateur soccer
athletes, and a control group, composed of 24 adolescents who
did not practice any sports. All of the participants’ guardians
signed the informed consent form according to the Resolution
196/96 of the National Health Council. The project has been
approved by the Research Ethics Committee (283.986).
Personal data were collected using a standard form for sample
characterization. Subsequently, the International Consultation
on Incontinence Questionnaire (ICIQ-SF) was administered to
evaluate UI severity by qualifying and quantifying urinary loss.
The questionnaire is composed of four questions that evaluate
the frequency, severity and impact of UI, plus a set of eight selfdiagnosis
items related to the UI causes or situations that the
patients have experienced. The ICIQ-SF score is based on the sum
of the scores of questions 3, 4 and 5 and is classified as follows:
mild UI, 1 to 5 points; moderate UI, 6 to 12 points; severe UI, 13
to 18 points; and very severe UI, 19 to 21 points .
As a further tool for evaluating the prevalence and severity
of urinary loss, the one-hour pad test, standardized by the ICS,
was used . All of the athletes took the test at a set time and
date before they began their training. One day prior to the test,
the participants received a kit containing a bottle with 500ml
of water at room temperature, a sanitary pad that had been
previously weighed with an electronic precision-weighing
balance (Shimadzu BL3200H) and instructions on the activities
they would perform. On the day of the test, the athletes were
instructed to urinate two hours before performing the test.
They were then instructed to wear the sanitary pad and
subsequently ingest 500ml of water within 15min. During the
subsequent 30min, the participants performed the following
exercise protocol: walk and jog for 15min; sit down and stand
up 10 times; cough 10 times; pick up objects from the floor for
1min; run on the same spot for 1min; and, finally, wash hands
for 1min. After the exercises, the sanitary pad was immediately
removed. According to ICS recommendations, individuals who
exhibit leakage of up to 1g are considered continent; hence, the
pad test was considered positive when the final weight of the
sanitary pad exhibited a 1.1-g urinary loss . After urinary loss
was assessed with the pad test, the Brazilian version of the KHQ
was administered. The KHQ consists of 30 questions divided
into nine domains: health perception, incontinence impact, role
limitations, physical limitations, social limitations, personal
relationships, emotions, sleep/energy and severity measures.
All of the answers are assigned numeric scores, which are added
up and evaluated by domain. The values are then calculated
using a mathematical formula to obtain the quality of life score,
which varies from 0 to 100, with higher scores representing
worse quality of life .
First, the data were tabulated and analyzed using simple
descriptive statistical analysis. Student’s t test was performed to
assess the differences in UI symptoms and quality of life between
the athletes and the control group. Fisher’s exact test was used
to compare the positivity of urinary symptoms between the
Considering the two variables used for the UI observation
(the pad test and ICIQ-SF), Cohen’s kappa coefficient was used
to assess agreement; values above 0.75 represent excellent
agreement, values below 0.40 indicate low agreement, and
values between 0.40 and 0.75 indicate moderate agreement. The
correlation of the variables age, training frequency and time of
training with respect to the ICIQ-SF score was assessed using
Pearson’s correlation test. Values between zero and 0.39 were
considered weak correlation, values between 0.40 and 0.69 were
considered moderate correlation, and values between 0.7 and 1.0
were considered strong correlation. All statistical analyses were
performed with α <0.05, and the statistics software packages
PASW statistics 18.0 and Excel 2010 were used.
The sample was composed of a group of athletes that
included 35 adolescent amateur soccer players aged 12 to 19
years (15.6±2.0) with a body mass index (BMI) between 12.4 and
25.9Kg/m2 (20.9±2.2), and a control group of 24 adolescents
not practicing any sport and aged 11 to 19 years (14.8±2.4) with
a BMI between 16.4 and 24.7Kg/m2 (20.4±2.68). There was a
statistically significant difference between the groups for the
variable age (p=0.008).
Table 1 displays the social and urinary characteristics of
the athletes and the control group. The athletes had practiced
their sport for between six and nine years (3.1±2.6), performing two to five weekly trainings (3.1±1.3) with an average workload
of (3.1±0.8) hours of training per week. Table 2 itemizes the
prevalence of UI in the evaluated groups. Specifically, the athletes
exhibited 62.8% positivity for both tests (the pad test and the
ICIQ-SF), whereas the control group exhibited 25%. There was a
statistically significant difference between the groups using both
evaluation tools (p =0.007). The degree of agreement between
the pad test and the ICIQ-SF was assessed using Cohen’s kappa
coefficient and was classified as moderate agreement (0.45)
aFisher’s exact test
ICIQ-SF: International Consultation on Incontinence Questionnaire- Short Form
Cohen’s kappa coefficient =0.45.
The severity of urinary loss was measured using the ICIQ-SF
and the one-hour pad test. According to the severity classification
based the ICIQ-SF, mild UI (from 1 to 5 points) could be observed
in both for the athletes group, which exhibited an average score
of 3.2 (±3.2), and for the control group, which had an average
score of 2.0 (±3.6). There was a statistically significant difference
between the groups (p=0.027). For the pad test, the athletes
exhibited an average urinary loss of 1.7g (±0.7g), whereas the
average urinary loss of the control group was 2.1g (±0.8g). There
was no statistically significant difference between the groups (p
A moderate correlation (r =0.45) between age and urinary
loss was observed among the athletes. Regarding the correlation
between the frequency of weekly training or the time of training
in years and the severity of urinary loss, as assessed by the
ICIQ-SF, the athletes exhibited a moderate correlation for the
frequency of weekly training (r =0.44) and a weak correlation
with time of training (r =0.34). There was no correlation between
the variables age, time of training or frequency of training and
the severity of urinary loss, as assessed by the one-hour pad test.
Regarding quality of life, the athletes exhibited an average
score of 35.2 (±22.7) in the General Health domain compared
with an average score of 20.8 (±18.8) for the control group.
Further, the control group exhibited a higher average score
compared with the athletes in the domains Incontinence Impact,
Physical Limitations, Emotions, Sleep/Energy and Severity
Regarding the impact of urinary symptoms on the quality
of life, as assessed with the KHQ, Student’s t test revealed a
statistically significant difference between the athletes and
the control group on all domains with the exception of General Health (p=0.14), Incontinence Impact (p=0.27) and Personal
Relationships (p=0.65; Table 4).
The results of the present study reveal a 62% prevalence of
UI symptoms among adolescent nulliparous soccer athletes. In
a review of the literature, a 28% to 80% prevalence of UI could
be observed among participants in high-impact sports, such as
artistic gymnastics, hockey and ballet . The authors Bo 
and Eliasson et al.  evaluated the prevalence of UI among
artistic gymnasts, dancers and trampolinists and observed a
higher prevalence of UI in sports disciplines that are considered
to have a high impact on the pelvic floor compared with lowimpact
sports. Although these studies did not use the same
methodology or sampling and examined sports, both studies
point to a UI prevalence above 54% among the athletes.
In the present study, the control group exhibited a UI
prevalence of 25%. Some studies relate the presence of UI to other
urinary disorders, such as bladder pain and urinary infection.
This could explain the UI prevalence in the control group, given
that urinary infection and bladder pain was observed in 58.3%
and 25% of the adolescents, respectively.
The ICS emphasizes that UI must be demonstrated
objectively, which is possible using the one-hour pad test.
Specifically, this test evaluates the presence of UI and quantifies
the severity of urinary symptoms . In the present survey, the
prevalence and severity of UI were evaluated using the onehour
pad test and the ICIQ-SF. As stated above, the pad test is
very specific in its evaluation of the presence and severity of UI,
whereas evaluation based on questionnaires requires careful
interpretation of the results. There was a statistically significant
difference between groups in the ICIQ-SF evaluation; the athletes
exhibited higher severity (p =0.027). The pad test evaluation,
however, exhibited no statistically significant difference between
the groups (p =0.309). Bo & Sundgot Borgen  found the SUI
symptoms in 41% of the elite athletes who were evaluated using
a questionnaire. Another study of young nulliparous physical
education students showed an SUI prevalence of 38% according
to a questionnaire, and six of the seven students who underwent
urodynamic evaluation exhibited sphincter incompetence .
The factors that contribute to UI in young and nulliparous
women are not yet fully elucidated. Weak connective tissue,
combined with high-intensity and high-impact activities, may
contribute to this condition . Bo & Sundgot Borgen 
reported an increased prevalence of athletes with UI and a
relationship with eating disorders. This association between UI
and eating disorders may arise because eating disorders cause a
lack of appropriate nutrients, which in turn favors the reduction
of the strength and resistance of the pelvic floor muscles. The
agreement between the pad test results and those of the ICIQ-SF
in evaluating the prevalence of UI was assessed using Cohen’s
kappa coefficient. A moderate agreement (0.45) between the
applied evaluation scales could be observed.
Franco et al.  found that the ICIQ-SF is easy to administer
and that there is a good agreement between this questionnaire
and the one-hour pad test results for women with UI. The two
tests incorporate both the severity of symptoms and the quality
of life variables; thus, we recommend using these tests as a
routine procedure in clinical practice. Pereira et al.  have
used the pad test as a comparative tool to validate an evaluation
questionnaire specific for UI called the Incontinence Severity
Index (ISI); the researchers found satisfactory reliability, internal
consistency, reproducibility and validity, indicating agreement
between the pad test and the ISI. Liebergall Wischnitzer et al.
 demonstrated agreement between the pad test results
and a subjective evaluation questionnaire for UI, using it as a
complementary tool to evaluate UI severity.
In the present study, we hypothesized that age, time and
weekly hours and frequency of training were correlated with
UI severity. According to the ICIQ-SF, the correlation between
age or the frequency of weekly training and UI severity in the
athletes was moderate, with r =0.45 and r =0.44, respectively,
whereas the correlation with the time of training in years was
weak, with r =0.34.
Eliasson et al.  have associated time, duration and
frequency of training with the presence of urinary symptoms.
According to the authors, the longer the time, duration and
frequency of training, the higher the prevalence of UI in athletes
practicing high-impact sports. As opposed to the present study’s
findings with respect to the correlation between age and UI, the
studies by Bo  and Eliasson et al.  revealed no statistically
significant correlation between age and UI.
Knowledge about the perineal region and the dysfunctions
that can afflict it is a basis for a good treatment performance and
preventing dysfunctions . In the present study, approximately
88% and 75% of young nulliparous women in the athletes group
and the control group, respectively, were knowledgeable about
UI symptoms. The level of education favors these findings, given
that the majority of the studied population had completed
elementary school, i.e. approximately 68% of the athletes and
91% of the control group.
According to some studies, women with UI report physical
limitations, such as restrictions in practicing sports and carrying
objects, and changes in social, occupational and domestic
activities that negatively influence their emotional state and
sex life. Further, UI can provoke social and hygienic discomfort
related to the fear of urinary loss, the smell of the urine, the need
to use protection (sanitary pads) and the more frequent need
to change clothes [24,25]. Incontinent athletes avoid ingesting
liquid prior to trainings and competitions, which ultimately
affects body hydration, a fact that must receive special attention
to avoid health problems .
Numerous tools have been used to evaluate the impact
of UI on the quality of life of affected women. In the present
study, quality of life was evaluated using the KHQ, which has been
translated and adapted into Portuguese . Regarding the
General Health domain, the athletes exhibited an average score
of 35.2 (±22.7), and the control group exhibited an average score
of 20.8 (±18.8). For the domains Incontinence Impact, Physical
Limitations, Social Limitations, Emotions, Sleep/Energy and
Severity Measures, the control group exhibited a higher average
score than the athletes did.
The low impact on quality of life observed here could be
explained by the fact that the severity of urinary symptoms
was relatively low. According to Jácome et al. , urinary
incontinence negatively influences quality of life and has a
negative impact on sports performance. Ree et al.  affirmed
that young nulliparous women exhibit a 17% reduction of the
mean maximum voluntary contraction after 90 min of strenuous
exercise, indicating muscular fatigue of the pelvic floor and
showing the importance of specific training for these muscles.
Structural and functional changes can occur in the lower
urinary tract over the course of these women’s lives because of
the risk factor exposure to which they submit themselves. As
mentioned above, these changes can lead to the development
of urinary symptoms, including UI. Thus, it is of paramount
importance to assess the risk factors and study the prevalence of
symptoms in a particular population, such as adolescent soccer
players, to allow for a preventive gynecological evaluation and
the development of sensory-motor training and pelvic floor
awareness programs to prevent or minimize the symptoms in
The present study shows a high prevalence of UI symptoms
among athletes, with medium reliability between the ICIQ-SF and
the pad test as assessed using Cohen’s kappa coefficient. Mild
SUI was observed in both groups, as assessed by the pad test
and the ICIQ-SF. In terms of quality of life, the domains General
Health, Emotions and Sleep/Energy, which are considered to
have the highest impact on the quality of life, had the highest
scores among the athletes.