As many as 45% of elite athletes, including runners and triathletes, experience Stress Urinary Incontinence (SUI) during sport activity.

[i] A recent study found that 37.4% of triathletes reported SUI, 16% reported urge urinary incontinence, and 28% reported fecal incontinence.[ii] In addition, SUI can be a barrier to physical activity in 50% of women who report symptoms, meaning it also affects daily life.[iii] While common, it is often not discussed and rarely treated. One of the most common answers given when someone is asked if they have incontinence is, “No, only when I run or jump, which is normal”. SUI is never normal. This article will outline the causes of SUI and how physical therapy may help improved symptoms with running and sport activity.

The Pelvic floor is divided into three layers – superficial, middle and deep. These muscles have 4 main functions: support, bowel/bladder control, sexual function, stability. The middle layer, known as the urogenital diaphragm, helps to compress and close the urethra, much like a hose[iv]. The deepest layer of the pelvic floor muscles is known as the pelvic diaphragm. These muscles play a smaller role in urinary continence control and function more to support the pelvic organs and help balance intra-abdominal pressure. The muscles of the pelvic diaphragm are designed for endurance. When working properly, they help triathletes stay balanced and supported with sport activity.

The diaphragm, pelvic floor and abdominal muscles work as a team to balance intra-abdominal pressure. When one muscle group is over-used or over-developed, imbalances may occur. With imbalances, the muscles of the urethra cannot “keep the hose closed” and incontinence may result. Some activities that may affect this balance include: upper abdominal exercises such as crunches and sit-ups, running, jumping, breath holding with physical activity, prolonged sitting on a bike.

One of the misconceptions of SUI is that to prevent leakage while running is that you need to be contracting your pelvic floor the entire time. The pelvic floor is a dynamic group of muscles, which must load and lengthen to absorb the force downward with high impact loading. Imagine a trampoline that is sprung too tightly. If you jump on it, there is no bounce. Holding the pelvic floor muscles in a state of contraction has the same effect. Two potential dysfunctions may result: the pelvic floor muscles will give up, resulting in incontinence, or they may become chronically stiff hypertonic and could lead to pain.

When running the goal should not be about tightening the pelvic floor but controlling the loading and the impact on the muscles. Bad running posture may shift a lot of unnecessary weight onto the pelvic floor muscles and organs, creating imbalance. Keeping the abdominals tightly braced while running will also increase intra-abdominal pressure and excessively load the pelvic floor muscles. Breathing properly allows the diaphragm to expand and can dramatically decrease the abnormal pressure on the pelvic floor. With the proper muscle balance good alignment, and breathing, triathletes can minimize the risk of SUI with sport activity.

Physical Therapists are equipped with the knowledge to assess running mechanics, as well as bike fit. The first step to a healthy pelvic floor is making sure all of your muscles are able to do their best job. You may also benefit from instruction in how to properly use the pelvic floor muscles. Many people are familiar with Kegel exercises but this is not always the best way to use the pelvic floor muscles in the most efficient manner with activity. Learning how to incorporate these muscles’ actions into your existing workouts may be very helpful to prevent incontinence. If you are already experiencing symptoms, please seek help from a physical therapist who understands pelvic floor dysfunction. A good resource is: (Section on Women’s Health, APTA). Remember incontinence may be common but it is never normal.

This article was submitted by Anisha Drake DPT  from One on One Physical Therapy.

Anisha Drake joined One on One Physical Therapy after spending the last five years specializing in pelvic disorders. She is an expert in treating pelvic pain, post-prostectomies, urinary/fecal incontinence, constipation/ IBS, pelvic congestion, Interstitial Cysitis and endometriosis. Anisha knew she wanted to be a pelvic therapist when she realized how many people out there were looking for answers to their dysfunction, but weren’t sure what questions to ask and how to get the help they needed. Anisha’s email address is and more information can be found at

[i] Thyssen, 2002
[ii] Fitzgerald, et al AUGS 2014
[iii] Brown and Miller, 2001
[iv] Jevolesk JV, 2013