On a wall in a gym in south London, someone has written: “PB [personal best] with a bit of wee.” Who could have written it? A runner? A woman doing CrossFit who has been jumping rope? A powerlifter? Evidence shows that all these activities can trigger higher rates of urinary incontinence (UI) in women than other activities. (Men’s anatomy is different, so they are less prone to the problem.)
“Women pee. In my gym you see it all the time,” says Emily Westray, a 27-year-old civil servant in Sheffield who can bench press 75kg, deadlift 130kg and squat 115kg, while only weighing 57kg herself. She used to be a diver and gymnast and got into powerlifting two years ago. At first, she had no problem. And according to usual preconceptions, she shouldn’t have. She’s young and has never had children. Incontinence is supposed to affect women who have gone through childbirth, and the middle-aged and menopausal.
But when Emily deadlifted 100kg, something changed. “We record all our lifts so I have a video of it.” A man from her powerlifting gym was “spotting” her (standing behind her to make sure she didn’t drop the bar or come to harm). “He was wearing socks. And obviously on this video you can see me pee on the floor and his feet are really close to a puddle of pee. So we always joke that I peed on his feet.” Emily has no time for shame about peeing while lifting. It’s too common. She sees it as an inevitable part of lifting heavy and she knows that the biggest risk comes with the deadlift. “I was never embarrassed about it. It’s like, it happens. It means I worked hard.”
Some definitions: powerlifting and weightlifting both involve lifting heavy weights, but the elements are different. Powerlifting requires a deadlift, a squat and a bench press. Weightlifting is known for the “snatch” – lifting a barbell overhead – and the “clean and jerk” (where you can rest the barbell briefly on your shoulders) and is an Olympic sport. The pelvic floor is a group of muscles that, says the NHS, “help to keep your bladder, uterus, vagina and bowel in place”. When you need the toilet, you use your pelvic floor to stop the bladder leaking. You relax the muscles to pass urine. When this brake-and-release system doesn’t work properly, you get urinary incontinence (UI), which the International Society for Incontinence defines as a “complaint of involuntary loss of urine”.
I don’t complain about it, but I have it. I can no longer run downhill without my bladder leaking. Trampolining is out of the question without an incontinence pad. (Yes, I am doing pelvic-floor exercises and broke off from writing this to do my 3pm ones.) And, like many post-menopausal women who discover far too late that their bones have the density of an 80-year-old’s, I have taken up weightlifting. It’s not just the post-menopausal tribe who are lifting, though: nearly half the members of USA Weightlifting are now women. At the last International Weightlifting Federation world championships in Bogotá in 2022, 265 women competed, compared with 263 men. Anecdotally, some people think there are now more female powerlifters than male. I don’t plan to compete, and the weights I lift are puny compared with Westray bench-pressing the weight of her dad. But still I wonder: do I have a zero-sum choice? Will weightlifting to strengthen my bones weaken my pelvic floor?
UI and lifting “is a very topical area” at the moment, according to Dr Gillian Campbell, Gráinne Donnelly and Christien Bird, who are joint spokespeople for the membership association Pelvic Obstetric and Gynaecological Physiotherapy (POGP). It is also very sparse: anyone wanting to know about women’s health gets used to less research being available, but research into this particular topic is, according to POGP, “in its infancy”. What is known is that “elite athletes (in the absence of other risk factors, eg childbirth, obesity, etc) are more likely to experience UI than sedentary women”. One Norwegian study from 2020 found that athletes were three times as likely to leak as women who did little or no exercise. Some sports are more leaky than others. A meta-review in 2020 found that 75.6% of female volleyballers experienced stress incontinence (this is when you pee when you jump or sneeze; urge incontinence is when you can’t hold in urine when you need to go). The prevalence of UI, wrote the researchers, “may be a barrier to women’s participation in sport and fitness activities. Therefore, it may be a threat to women’s health, self-esteem and wellbeing.”
Kristina Lindquist Skaug, a researcher at the Norwegian School of Sports Sciences, north of Oslo, and one of the authors of the 2022 study, is one of the few academics to have taken an interest in the impact of lifting heavy weights on the pelvic floor. Her PhD had been on pelvic floor dysfunction but in running and jumping sports. She went on to do two studies on elite lifters in Norway, one entitled The Prevalence of Pelvic Dysfunction Bother. Skaug and colleagues found that 41.7% of the 180 female athletes who responded to a survey reported urinary incontinence and 87.8% “reported a negative influence on sport performance”.
Dr Rori Alter, who runs Progressive Rehab and Strength, a gym in Long Island, New York, quotes a 2018 study on high-level female powerlifters aged 18 to 35, which found that 74.5% experienced urinary incontinence while training. Most spoke to other women about it. Half spoke to their coaches. But only 7% talked to their doctors about it, even though 35% were distressed by it.
Inside the powerlifting and weightlifting community, Westray says, no one bats an eyelid. But when she shows her friends videos of her peeing while lifting, they tell her to go to the doctor. Cristina Rigden, 45, is a mother of five and a powerlifter from Herne Bay in Kent. When she started to leak while lifting, she duly approached her GP. “They referred me to a bed-wetting clinic. But I wasn’t wetting the bed,” she says. She had experienced incontinence after giving birth; what she calls “the stage of peeing when you sneeze”. But this was different. She’s not ashamed of it. “If I peed myself and there was a puddle of urine I’d just laugh and walk off.” In a competition, women aren’t penalised for peeing, although they are penalised if the weight scrapes their legs and draws blood. “If you wee yourself,” says Rigden, “you just rock on.”
Under online videos of female powerlifters and weightlifters peeing while lifting, the comments are predictable: “She shouldn’t be lifting if she can’t control herself.” “That weight is too heavy for her.” “That’s disgusting.” One sarcastic subheading in a blog about pelvic-floor issues reads: “Don’t lift too heavy … your vagina will fall out.” In 2010, Gian-Franco Kasper, the then head of the International Ski Federation, said on television that ski-jumping could cause a woman’s uterus to burst. In fact, neither ski-jumping or weightlifting mean your uterus will burst, although prolapse does happen. In Skaug’s study, 23% of lifters reported it.
And what about men? Because of their anatomy and where the urethra is, they are more likely to experience anal incontinence. In Emily’s words: “Boys don’t pee when they lift but they do poo.” But that’s not visible in a skin-tight singlet so it is even less addressed than the pee.
What is disgusting, says Alter, isn’t having urinary incontinence, but the reaction to it. There is no need for stigma. On the other hand she is emphatic that “it is common, but not normal”. I guess she would say that, as she is in the business of rehab and helping women who do have a problem. But the POGP says something similar. “It should not be accepted as a ‘price to pay’, but should be a trigger for a women to seek specialist help from a pelvic-health physiotherapist.”
I agree. But when I ask POGP what is going on anatomically when a woman deadlifts 125kg, the answer is: “We can’t say.” It depends on a woman’s particular load tolerance. “When women leak only during weight training like this, it means they have reached and exceeded their load tolerance. This is OK if it doesn’t cause the lady concern or distress and it doesn’t progress symptoms in any other way, eg they don’t start getting leakage during other activities. However, taking typical sports-med principles, when we exceed load tolerance in a region, we identify that we need to strengthen and train it.”
Alter agrees with this. For her and her team of coaches, the answer to peeing while lifting is to lift differently. “It is addressable,” she says. “We have something called stress recovery adaptation. If this was the first day you were lifting and I said: ‘Lift a hundred kilos’, and you’re not strong enough to do that, your weakest link would fail you. Your weakest link could be your back or your grip or it could be your pelvic floor. And if we had built up for that hundred kilos over time, your weakest link probably wouldn’t have failed.” If it was inevitable, she says, “everyone would pee while lifting”. If your grip fails, you can see that clearly, she says. But you can be leaking internally and not know it. By the time it gets to the point where there is urine on the floor, you’ve already failed. At that point, Alter says, you go back to a weight you can tolerate. “You lift without failing,” she says.
In a standing lift, there are techniques to aid a lifter to support the phenomenal weight. One is a Valsalva manoeuvre, which involves breathing in and pushing out the abdomen. Another is the belt, which increases the intra-abdominal pressure and braces the core. But maybe for women the belt is pressing in the wrong place. Maybe the Valsalva manoeuvre is adding to the pressure on the bladder. All of these maybes are because even the expert physios at POGP can only conclude that incontinence while weightlifting is “multi-factorial”.
Sarah Skoruppa is a 22-year-old farrier from Orchard Grove, Texas. When we talk over the phone, she is busy shoeing a horse. She started powerlifting three years ago because her job was giving her backache, and she happened to approach a coach who was a powerlifter. She discovered she was good enough to win third place in her age and weight category (junior 20-23, 75kg) at the US Powerlifting Association nationals in Las Vegas this year. When she began to pee while lifting, she was embarrassed. She didn’t have the acceptance of the powerlifting community around her as she trains at a commercial gym where there is only one other woman powerlifting. So she figured out how to manage it herself.
“One thing that is widely taught is to brace down, to put pressure on the pelvic organs. But now I also focus on bracing up. So I’m trying to pull my pelvic floor up then push myself down from the top.” Skoruppa hasn’t discussed it with her male coach. Instead she does what many female lifters do: she manages by using pads. Other women use tampons, which supposedly put pressure on the neck of the bladder to stop leaks, or they moderate their water intake (a bad idea). They find it distressing and embarrassing to have to constantly change their kit or pads. In the worst case, they drop out of the sport altogether.
The standard treatment for pelvic-floor weakness is to do Kegel exercises. Squeeze, squeeze, squeeze. But these strong women are athletes and it is unlikely that their pelvic floor is weak. Also, they don’t usually experience urinary incontinence in any other context except lifting weights. The pelvic floor can be strong, though, and still fail. When Skaug did a follow-up study that measured the pelvic floor before and after a lift, it showed that heavier weights didn’t really impact the pelvic floor more than lighter ones. “We don’t know why UI happens. Probably there is too much intra-abdominal pressure and the pelvic floor can’t respond. But we don’t have a way to measure it yet.”
Skaug is cautiously hopeful. She knows of four research groups working on this, and one is developing a probe that would enable better measurements. But for now, the message from the professionals at POCG is emphatic and clear: keep lifting. Keep running. Keep jumping. They have no evidence that lifting has any long-term damaging effect on the pelvic floor, and “in fact it’s likely to improve pelvic-floor load tolerance if approached in a graded way”. Nor do they know of evidence that sport or particularly weightlifting is a risk factor. A better word would be “aggravator”. But women should get professional help and not from a bedwetting clinic.
For amateur weightlifters like me, there is comforting news. A large online survey of recreational athletes found that they were no more likely to report pelvic-floor symptoms than non-athletes, even when they had been exercising at these levels for more than five years. There is still too much unknown about why heavy weights provoke pee, but POGP is still certain of one thing. “Given the huge overall benefits associated with taking part in exercise and in lifting weights, women should be encouraged to continue with sport.” And maybe soon the research will catch up, we will have a better idea of what’s going on down there, and why even these magnificently strong women get their PBs with a little bit – or a lot – of wee.
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