Shankar Mishra, a person accused of urinating on a woman co-passenger on an Air India flight, denied his charges and told a Delhi Sessions Court that the woman urinated on herself. Mishra’s counsel told the Sessions Court that the complainant woman, a Kathak dancer, has a problem of incontinence, and that she urinated on herself, news agency ANI reported. 

“The complainant woman’s seat was blocked. It wasn’t possible for him (Mishra) to go there. The woman has a problem of incontinence. She urinated on herself. She is a Kathak dancer, 80% of Kathak dancers have this issue,” the counsel was quoted as saying by ANI. 

Urinary incontinence is the unintentional or accidental loss of urine, and is a common problem believed to affect millions of people. Whether dancers and similar artistes frequently suffer from urinary incontinence is a matter of debate. 

Padma Shri Awardee Kathak dancer Shovana Narayan called Mishra’s allegation against the Air India flight co-passenger the “weirdest reasoning” ever put forth. “I do not agree with it at all, I think it is the weirdest reasoning that has ever been put forth. Any peeing or not peeing is not related to any vocation at all,” ANI quoted Narayan as saying. 

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Here is everything you need to know about urinary incontinence.

The two most common types of urinary incontinence, or the loss of bladder control, that affect women are stress incontinence and urge incontinence, also called overactive bladder. 

Urine is made by the kidneys and stored in the urinary bladder, which has muscles that tighten when one needs to urinate. Urine is forced out of the bladder through a tube called urethra, when the bladder muscles tighten. In order to let the urine out of one’s body, sphincter muscles around the urethra relax. 

However, when the bladder muscles suddenly tighten and the sphincter muscles are not strong enough to pinch the urethra shut, incontinence can happen, causing a sudden, strong urge to urinate that one may not be able to control. 

Laughing, sneezing or exercising may lead to pressure, causing one to leak urine, according to the United States Department of Health & Human Services. 

If there is a problem in one’s nerves that control the bladder muscles and urethra, they could suffer from urinary continence. People with this problem may leak a small amount of urine or release a large amount all at once. 

Urinary incontinence affects twice as many women as men, probably because reproductive health events such as pregnancy, childbirth and menopause affect the bladder, urethra and other muscles that support these organs. However, urinary continence is not a normal part of ageing, and can happen to women at any age. 

The condition is more common in older women, probably because of hormonal changes during menopause. According to the Office on Women’s Health (OASH), US Department of Health & Human Services, more than four in 10 women aged 65 years and above have urinary incontinence. 

Types of urinary incontinence 

Stress incontinence is a condition in which urine leaks out when one’s bladder is under pressure, for instance, when one has a cough or laughs. Urge incontinence is a condition in which one’s urine leaks as they feel a sudden, intense urge to pee, or soon afterwards. People may have a mixture of both stress and urge urinary incontinence at the same time. This condition is often referred to as mixed incontinence. 

Other types of urinary incontinence are overflow incontinence, also called chronic urinary retention, and total incontinence, according to the National Health Service (NHS), England. 

When one is unable to fully empty their bladder, it causes frequent leaking, and this condition is called overflow incontinence. Total incontinence is a condition in which one’s bladder cannot store any urine at all, causing them to pass urine constantly or have frequent leaking.

Functional incontinence is a physical or mental impairment that keeps one from making it to the toilet in time, according to Mayo Clinic. For instance, if one has severe arthritis, they may not be able to unbutton their pants quickly enough. 

Causes of urinary incontinence

Different types of urinary incontinence occur due to different reasons. Stress incontinence occurs due to the weakening of or damage to the muscles used to prevent urination, such as the pelvic floor muscles and the urethral sphincter. 

Overactivity of the detrusor muscles, which control the bladder, results in urge incontinence. 

An obstruction or blockage in the bladder, which prevents it from emptying fully, causes overflow incontinence. 

A problem with the bladder from birth, a spinal injury, or a tunnel-like hole that can form between the bladder and a nearby area, called the fistula, can result in total incontinence. 

Factors which can increase the chances of urinary incontinence are pregnancy and vaginal birth, a family history of incontinence, increasing age, and obesity. 

Symptoms of urinary incontinence

The symptoms of urinary incontinence include the need to rush to the restroom and losing urine if one does reach the restroom in time, leakage of urine with movements and exercise, leakage of urine with coughing, sneezing or laughing, feeling of incomplete bladder emptying, constant feeling of wetness without sensation of urine leakage, pressure or spasms in the pelvic area, causing a strong urge to urinate, and urinating while sleeping.

People with urinary incontinence, especially older individuals, might suffer from lower urinary tract symptoms such as problems with passing urine, releasing a slow stream of urine, straining to pass urine, and stopping and starting as they pass urine, problems with storing urine, and problems after they have passed urine. 

Why urinary incontinence affects more women than men

Women are more commonly affected with urinary incontinence than men because reproductive events such as pregnancy, childbirth and menopause might affect the urinary tract and surrounding muscles. Also, the pelvic floor muscles that support the bladder, urethra, uterus and bowels might become weaker or damaged, resulting in incontinence. 

The muscles in the urinary tract are forced to work harder to hold urine until one is ready to urinate in cases where the muscles supporting the urinary tract are weak. Due to this extra stress or pressure on the bladder and urethra, leakage can occur. 

The female urethra is shorter than the male urethra, as a result of which women are more likely to suffer from urinary incontinence than men. Weakness or damage to the urethra in a woman is more likely to cause urinary incontinence because there is less muscle keeping the urine in until one is ready to urinate. 

Stress incontinence, urge incontinence and mixed incontinence are the most common types of urinary incontinence in women.

Do female dancers suffer from incontinence? Here is what an expert says

Some studies have claimed that female dancers and athletes might suffer from incontinence. Dr Kannan R Nair, Clinical Professor, Urology and Renal Transplantation, Amrita Hospital, Kochi, told ABP Live that the dance form of Kathak has nothing to do with incontinence.

“Dancing helps to achieve improved muscle tone of the pelvic muscles and helps prevent urinary incontinence. In terms of incontinence, dancers are better on average than the general population,” Dr Nair told ABP Live. 

He added that about 20 per cent of women above the age of 50 can suffer from stress incontinence, which occurs when there is increased pressure on the abdomen. “Usually, this condition progresses as age advances. Urge incontinence is a type of incontinence where someone experiences a strong urge to pee, but before reaching the restroom, may leak urine. Some patients may have abnormal communication in the urinary system which causes them to frequently suffer from urinary incontinence,” Dr Nair said.

How can urinary incontinence be prevented?

There are several ways of maintaining bladder health to prevent incontinence. “People can prevent incontinence through bladder training, exercises and proper bowel evacuation,” Dr Nair said. 

What research says about urinary incontinence in female athletes and dancers

Urinary leakage is common among elite athletes and dancers, particularly during training, and also during daily life activities, according to a study published February 2002 in the International Urogynecology Journal. An international team of researchers evaluated elite athletes and dancers in eight different sport and dance forms, including ballet, as part of the study. In order to determine the frequency of urinary loss in elite women athletes and dancers, the participants were asked to fill an evaluated questionnaire about urinary incontinence while participating in their sport or dance, and during daily life activities. 

According to the study, a total of 291 women with a mean age of 22.8 years completed the questionnaire. Of these, 151 women, or 51.9 per cent of the total number of women who completed the questionnaire, experienced urine loss. As many as 125 women faced the problem of incontinence while participating in their sport, and 123 women experienced the problem during daily life activities. 

The proportion of urinary leakage in the different sports, namely gymnastics, ballet, aerobics, badminton, volleyball, athletics, handball and basketball was 56 per cent, 43 per cent, 40 per cent, 31 per cent, 30 per cent, 25 per cent, 21 per cent, and 17 per cent respectively. 

According to the study, 44 per cent of the participants experienced leakage a few times while performing their sport, 46.4 per cent of the participants suffered from incontinence every now and then, and 9.6 per cent of the participants experienced the problem frequently. 

While performing daily life activities, 61.7 per cent of the participants experienced leakage of urine a few times, 37.4 per cent every now and then, and 0.8 per cent faced the problem frequently. 

Of the participants who experienced leakage of urine during a sport, 95.2 per cent suffered from urine loss while training, while only 51.2 per cent faced the problem during a competition. 

As many as 91 participants said they occasionally wore pads or panty shields because of urine loss, accounting for 60 per cent of the participants. 

As many as 13 participants had given birth, 40 women took oral hormonal contraceptive treatment, 14 women took medication for asthma, 10 women took non-steroidal anti-inflammatory agents, and one woman took insulin for diabetes. 

As many as 82 women had noticed the activities which were most likely to cause urine loss in them. For 71 women, jumping triggered urine loss, while seven women said running made them leak urine. 

Fourteen athletes, who accounted for 11.4 per cent of the participants, said they experienced urine loss without physical exertion. Ten participants claimed that they reduced their intake of liquids to reduce leakage. 

The study concluded that more than 50 per cent of the elite athletes and professional ballet dancers who participated in the research experienced urine loss during their sport or while performing daily life activities. 

The study stated that approximately one-third of the participants who had experienced urine leakage considered it to be a social or hygiene problem, and 60 per cent occasionally wore pads. 

The authors noted that “physical exertion seems to be a significant provocative factor” for incontinence. The study said that the frequency of regular urinary incontinence in a ‘normal population’ seems to be significantly higher than the findings in the population of elite athletes and dancers. 

Since jumping was found to be the activity that is mostly likely to trigger leakage, gymnastics, which involves many high-impact jumps, has the highest degree of leakage among different sports, the authors noted.

A significantly higher number of athletes experienced urine loss during training rather than competition (95.2 vs 51.2 per cent). According to the authors, this is an interesting finding that may be explained by the higher catecholamine levels during competition, compared to training. The urethra contains alpha receptors, and higher catecholamine levels during competition tend to keep these closed. Factors such as the ritual bladder and bowel emptying before a competition might be one of the reasons behind athletes and dancers suffering from significantly less urine loss during competition compared to training. 

According to a study led by I E Nygaard from the University of Michigan, 67 per cent of the gymnastics and 50 per cent of the tennis players who participated in the researchers experienced urine loss while participating in their sport. However, no golf players experienced the problem, and were completely dry during daily life activities. 

Meanwhile, 83 per cent of the tennis players and 53 per cent of the gymnasts experienced urine leakage during daily life activities. 

An editorial comment on the paper published in the International Urogynecology Journal said it seems the relatively high pressure generated by certain activities, especially jumping, is sufficient to overcome the continence mechanism in athletes and dancers. 

Study on urinary incontinence in female dancers of India

A study led by Arati Mahishale from the Kaher Institute of Physiotherapy, Belagavi, Karnataka, aimed to find the incidence of urinary incontinence in female dancers, compared to that in non-dancers of the same age group in Belagavi. The study, published in the Research Journal of Obstetrics and Gynecology in 2018, also aimed to find the correlation between urinary incontinence, and the type of dance, intensity of dance, and BMI of dancers. 

The different forms of dance in India are Bharatnatyam, Kathak, Odyssey, Kuchipudi, and Manipuri, among others. These are called eastern dance forms. Some of the popular western dance forms are hip-hop, locking and popping, jazz, salsa, tap dance, belly dancing, ballet, and cabaret.

The study said that the health problems of dancers are worthy of attention for several reasons, including the fact that most dancers begin training at a young age, as a result of which this can have a great impact on their future health. Also, the interplay of physical and aesthetic demands in dance may lead to various health issues. 

Dancers, similar to athletes, often suffer from specific conditions like amenorrhea (the absence of menstruation), disordered eating, osteoporosis and urinary incontinence. 

According to the World Health Organization (WHO), urinary incontinence is a widespread global disease and one of the last medical taboos to many people. Between 10 and 55 per cent of women belonging to the age group of 15 to 64 years suffer from stress urinary incontinence, the study said. 

The researchers screened a total of 124 participants for six months, 62 of which were screened at dance studios and competitive centres in and around Belagavi, while 62 individuals, who were non-dancers, were screened at the physiotherapy department. The participants belonged to the age group of 18 to 25 years. 

All the dancers were nulliparous, which means they had not given birth before or during the time of the study. 

Incidence of urinary incontinence in Indian female dancers

The study found that 22.5 per cent of female dancers had urinary incontinence. Of the 62 dancers who participated in the study, 14 reported suffering from urinary incontinence. They also said that they experienced urinary incontinence more in the colder months. 

In non-dancers, the incidence of urinary incontinence was 11.29 per cent. 

The incidence of stress, urge and mixed incontinence in dancers was 12.9 per cent, 8.06 per cent, and 1.61 per cent respectively.

What can lead to urinary incontinence in female dancers?

The authors noted in the paper that about 50 per cent of hip-hop dancers and 28 per cent of Bharatnatyam dancers showed a higher incidence of urinary incontinence compared to other dancers. This is because these dance forms demand movements which lead to increased flexibility of the lower limbs, eventually causing urinary incontinence. 

When dancers maintain certain postures for a longer period of time, they might suffer from urinary incontinence. For instance, Bharatnatyam dancers maintain a posture called Araimandi for long periods of time. This is a squatting position in which both the arms are extended for a long period of time, resulting in pressure in the lower tier of the pelvic support. This can subsequently lead to urinary incontinence. 

The parameter of body mass index was found to have a positive correlation with urinary incontinence in classical and western dancers. This is because a higher body mass index means a higher level of adipose tissue, which can cause vascular damage to pelvic floor muscles. This can eventually lead to the dysfunction of detrusor and sphincter muscles due to oxidative stress. 

Moreover, the duration of the training period was directly proportional to the risk of urinary incontinence.

The dancers who trained for six to 10 years showed the highest incidence of urinary incontinence due to overuse injuries, the study said. These injuries might have occurred due to the postures their dance forms demand, and eventually led to increased flexibility of the lower part of the body.  

As many as seven Bharatnatyam dancers, one Kathak dancer, two hip-hop dancers, and four participants performing western dance experienced urinary incontinence.  

The study said that urinary incontinence resulted in a reduced quality of life in dancers. Urinary incontinence also leads to depression, anxiety, reduced self-esteem and decreased self-confidence. 

The authors noted that female dancers might experience urinary incontinence due to the huge amount of time spent practising and performing, and also because of overuse injuries. 

The co-activation of abdominal muscles and pelvic floor muscles due to a rise in intra-abdominal pressure to stabilise lower limbs while maintaining fixed postures could also lead to urinary incontinence. 

In other words, repeated exposure to high forces on the pelvic floor muscles can increase the risk of urinary incontinence in female dancers.

The authors concluded that the first-of-its-kind study, conducted in an Indian scenario, contributes to the sparse scientific literature about the incidence of urinary incontinence in people performing different Indian dance forms. 

The authors also said that the study provides justification of how pelvic floor muscles weaken and lead to urinary incontinence in female dancers.

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