Highlights
– Hatha yoga did not yield statistically significant improvements in sleep quality or wakefulness after sleep onset (WASO) compared to a general physical conditioning program.
– Over 55% of women with daily urinary incontinence (UI) report poor baseline sleep quality, underscoring the high morbidity associated with urological dysfunction.
– Nocturnal voiding frequency is a primary driver of sleep disruption; participants with two or more nocturnal voids had significantly worse sleep quality scores regardless of the intervention type.
– The study suggests that while movement is beneficial, the specialized mindfulness and restorative components of Hatha yoga do not offer unique therapeutic advantages for sleep in this specific clinical population.
Background: The Intersecting Burdens of Incontinence and Sleep
Urinary incontinence (UI) remains a pervasive and distressing condition affecting millions of women worldwide, with a particularly high prevalence among midlife and older adults. Beyond the immediate physical discomfort and social stigma, UI is frequently associated with significant sleep disturbances. These disruptions often stem from nocturia—the need to wake during the night to void—but may also involve generalized anxiety and discomfort related to the condition. Poor sleep quality in this population is not merely a nuisance; it is linked to increased risks of falls, cognitive decline, cardiovascular disease, and a diminished quality of life.
Integrative health practices, particularly Hatha yoga, have gained popularity as potential non-pharmacological interventions for both UI and sleep disorders. Yoga combines physical postures (asanas), controlled breathing (pranayama), and mindfulness-based relaxation. Proponents suggest that yoga may improve sleep by modulating the autonomic nervous system, reducing sympathetic arousal, and strengthening the pelvic floor musculature. However, there has been a lack of rigorous, comparative evidence to determine whether yoga provides benefits that exceed those of general physical activity. This secondary analysis of a randomized clinical trial aimed to fill this gap by comparing Hatha yoga directly with a time-equivalent physical conditioning program.
Study Design and Methodology
This study was a prespecified secondary analysis of a multicenter, investigator-blinded randomized clinical trial conducted between 2018 and 2022. The research was carried out across three sites in Northern California. Initially designed for in-person delivery, the interventions transitioned to videoconference formats following the onset of the COVID-19 pandemic, providing a unique look at the efficacy of remote integrative health delivery.
The study enrolled 240 women aged 45 to 90 years who reported at least one episode of daily urinary incontinence. Participants were randomized into two groups:
The Yoga Intervention
Participants in this arm engaged in a 3-month program consisting of twice-weekly 90-minute group sessions led by certified instructors. The curriculum focused on Hatha yoga techniques specifically adapted for older women and those with UI. In addition to the group sessions, participants were encouraged to perform at least one weekly self-directed practice session at home.
The Physical Conditioning Control
To control for the effects of physical activity and social interaction, the control group participated in a time-equivalent program. This intervention involved stretching, strengthening, and aerobic exercises that avoided traditional yoga postures or mindfulness-focused breathing techniques. Like the yoga group, this arm included twice-weekly group instruction and once-weekly self-directed practice.
Measurement and Endpoints
Sleep outcomes were evaluated using the Pittsburgh Sleep Quality Index (PSQI), a validated tool where higher scores indicate poorer sleep quality (scores >5 are generally considered indicative of poor sleep). Additionally, participants maintained a Pittsburgh Sleep Diary to track wakefulness after sleep onset (WASO). Nocturnal voiding frequency and incontinence episodes were documented through 3-day voiding diaries.
Key Findings: A Comparative Analysis of Efficacy
The study population had a mean age of 62 years and was racially diverse, including Asian (21.1%), Black (7.9%), and White (66.7%) participants. At baseline, the burden of sleep disruption was high: 55.4% of participants met the criteria for poor sleep quality, and 55.7% reported at least one nocturnal voiding episode per night.
Sleep Quality (PSQI) Results
Over the 3-month intervention period, both groups showed minimal changes in their PSQI scores. The mean change in the yoga group was 0.37 points (95% CI, 0.78 to -0.04), while the physical conditioning group saw a change of 0.66 points (95% CI, 1.07 to 0.25). The between-group difference was 0.29 points (95% CI, -0.28 to 0.86), which did not reach statistical significance. These results indicate that yoga was not superior to general exercise in improving subjective sleep quality.
Wakefulness After Sleep Onset (WASO)
Objective sleep diary data mirrored the PSQI findings. The yoga group experienced a mean reduction in WASO of 3.82 minutes, while the physical conditioning group saw a reduction of 6.97 minutes. The between-group difference of 3.16 minutes (95% CI, -2.84 to 9.16) was statistically insignificant. Both interventions appeared to provide a modest, albeit non-specific, benefit to sleep continuity.
The Impact of Nocturnal Voiding
A critical secondary finding was the powerful correlation between nocturnal voiding frequency and sleep quality, regardless of the assigned intervention. The estimated mean PSQI score was 5.83 among women with fewer than one nocturnal void per night, compared to 6.66 among those with two or more episodes per night (P = .02 for linear trend). This highlights that for many women, the physiological interruption of the sleep cycle due to bladder signals outweighs the potential relaxation benefits of yoga or exercise.
Expert Commentary and Clinical Implications
The findings of this study offer a sobering look at the limitations of mind-body interventions for specific secondary symptoms like sleep disruption in the context of UI. While yoga is frequently lauded for its holistic benefits, this data suggests that for sleep improvement, it may not be functionally different from other forms of low-impact physical activity.
Mechanistic Insights
From a physiological perspective, the lack of a superior effect for yoga may suggest that the ‘relaxation response’ associated with yoga is not sufficient to override the sympathetic nervous system arousal triggered by a full bladder or the physical act of waking to navigate to the bathroom. Furthermore, the physical conditioning group’s focus on stretching and strengthening might have provided similar benefits in terms of muscular fatigue and endorphin release, both of which facilitate sleep.
The Telehealth Transition
One notable aspect of this trial was the transition to videoconferencing during the pandemic. While this increased accessibility, it may have diluted some of the hands-on corrective aspects of yoga instruction or the specific ‘group energy’ often cited in yoga’s success. However, the fact that both groups performed similarly in both formats suggests that the results are robust across different delivery modes.
Study Limitations
As a secondary analysis, the study may not have been specifically powered to detect very small differences in sleep outcomes. Additionally, the participants were specifically recruited for UI, not for primary insomnia. Therefore, the results may not generalize to women whose sleep issues are unrelated to urological health.
Conclusion and Summary
In conclusion, this randomized clinical trial demonstrates that while physical activity—whether through Hatha yoga or general physical conditioning—can be part of a healthy lifestyle for women with urinary incontinence, yoga does not offer a unique advantage for improving sleep quality. The study reinforces the clinical reality that nocturnal voiding frequency is a dominant factor in sleep disruption. For clinicians, the takeaway is clear: while encouraging yoga for general well-being is appropriate, addressing the underlying frequency of nocturnal voids remains the most critical target for improving sleep in this patient population.
Funding and ClinicalTrials.gov
This research was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health.
ClinicalTrials.gov Identifiers: NCT04776720 (Ancillary Study of the Lessening Incontinence With Low-Impact Activity Study) and NCT03672461 (A Group-Based Therapeutic Yoga Intervention for Urinary Incontinence in Ambulatory Older Women).
References
1. Hough E, Goldstein LA, Subak LL, et al. Effects of Hatha Yoga vs Physical Conditioning on Sleep in Women With Urinary Incontinence: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2025;8(12):e2546499.
2. Subak LL, et al. Therapeutic Yoga for Urinary Incontinence in Women: A Randomized Controlled Trial. Annals of Internal Medicine. 2024.
3. Huang AJ, et al. Development of a group-based yoga therapy intervention for urinary incontinence in women. Female Pelvic Medicine & Reconstructive Surgery. 2019.
