Clinical Commentary: Delving Deeper: Understanding Pelvic Floor Health in Female Athletes

Over the past several decades, female sports participation has increased significantly with female athletes competing in sports at the high school, collegiate and professional level. The Olympic Games, the pinnacle of athletic achievement reflects this trend with nearly 50% of the athletes being women [1-4]. Female anatomy is multi-faceted and complex, however there is insufficient data on how physical activity affects the pelvic floor in female athletes. While existing literature has begun to address the prevalence of Stress Urinary Incontinence (SUI) among female athletes, indicating an incidence rate of up to 40%, it often overlooks the other conditions of Pelvic Floor Disorders (PFDs). These conditions encompass a range of conditions, including SUI and Anal Incontinence (AI), pelvic organ prolapse, and pelvic girdle pain, all of which significantly affect female athletic performance and quality of life [4-8]. The objective of this clinical commentary aims to explore the current understanding of PFDs and its effect on female athletes.

Recent studies have delved deeper into the prevalence and impact of PFDs among female athletes. Emerging evidence suggests a significant association between high-intensity physical activity and PFDs. For example, a cross-sectional study by Pires et al. [7]. discovered the prevalence of SUI was highest among collegiate athletes participating in sports requiring repetitive jumping and landing movements, such as basketball and volleyball [7]. Furthermore, the study identified a significant association between SUI severity and the number of years participating in high-impact sports. The prevalence of SUI has also been noted in the literature among female athletes engaging in high-impact sports such as running, gymnastics, trampolining, and volleyball [9-13]. The PFDs frequently mentioned in the literature include SUI and AI with prevalence rates varying across different sports disciplines [14-17]. Understanding the prevalence and spectrum of PFDs in female athletes is vital for developing targeted interventions and management strategies.

The Pelvic Floor Muscles (PFM) play a vital role in maintaining continence, supporting pelvic organs, and stabilizing the spine during physical activity. In women participating in high-level sport and elite female athletes, etiologic factors for PFDs may include inadequate abdominal pressure transmission, stress injuries to the fascia, PFMs, or ligaments, and changes in connective tissue or collagen. It is essential to understand the anatomy and biomechanics of the PFM in the female athlete when they are participating in sport and how that may relate to an increased risk of PFD. Studies have indicated that the inability to sustain prolonged PFM contractions during high-impact activities can lead to urine loss. Factors which may attribute to this include increased Intra-Abdominal Pressure (IAP) and repeated stretching of the pudendal nerve [18-21]. Exploring the biomechanical aspects of the pelvic floor in female athletes may provide valuable insights into the mechanisms underlying PFDs and allow for targeted preventive measures. For instance, a study by Paajanen et al. [22] used dynamic MRI imaging to assess pelvic floor muscle function during specific athletic movements [22]. The findings revealed alterations in pelvic floor muscle recruitment patterns among athletes with a history of SUI compared to controls, suggesting potential biomechanical contributors to PFDs in this population.

Previously, it was believed that exercise did not adversely affect the pelvic floor. However, recent studies have demonstrated concern regarding frequency and intensity of high-level exercises and its’ contribution to PFDs [23]. Emerging evidence suggests that certain types of exercise may exacerbate pelvic floor dysfunction in female athletes. For example, a longitudinal study by Skaug et al. [3,4]. followed elite gymnasts over a competitive season and found a significant increase in self-reported UI symptoms following intense training and competition periods [3,4]. This demonstrates the importance of monitoring pelvic floor health throughout the training cycle and implementing preventive strategies to minimize the impact of exercise on pelvic floor function. Further research is needed to clarify the specific exercise-related factors contributing to PFDs and to develop tailored exercise protocols to mitigate these risks.

It is important that there is awareness around PFDs in female athletes especially as these conditions may be easily concealed by the athlete. Female athletes may feel embarrassed or ashamed to discuss these issues, fearing stigma from coaches and teammates [24]. Proactive screening and identification of high-risk individuals by rehabilitation providers and trainers are essential to facilitate early intervention and prevention strategies [25]. Promoting screening and educations about pelvic floor health can empower female athletes to seek appropriate care and support. Recent initiatives have aimed to improve awareness and screening for PFDs in female athletes. For instance, a study by Smith et al. evaluated the effectiveness of an educational intervention targeting collegiate athletic trainers to enhance their knowledge and confidence in addressing pelvic floor health concerns among female athletes. The intervention resulted in improved screening practices and referral rates for PFDs, highlighting the importance of education in promoting early detection and management of these conditions.

Consideration should be given to addressing other risk factors contributing to PFDs in female athletes, such as the Relative Energy Deficiency in Sport (RED-S) and its relation to conditions like eating disorders and amenorrhea [26]. Routine screening for both eating disorders and PFDs is crucial to provide comprehensive care to female athletes [27]. Adopting a multidisciplinary approach involving sports medicine physicians, physical therapists, nutritionists, and mental health professionals can optimize outcomes and promote holistic well-being in female athletes. Research has highlighted the interconnectedness of various risk factors for PFDs in female athletes. For instance, a prospective cohort study by Rebullido et al. [6]. examined the relationship between RED-S and pelvic floor dysfunction among collegiate distance runners [6,10]. The findings revealed a higher prevalence of UI and pelvic pain symptoms among athletes with disordered eating behaviors and menstrual irregularities, emphasizing the importance of addressing underlying physiological and psychological factors in managing PFDs.

Pelvic Floor Muscle Training (PFMT) remains the gold standard for a variety of pelvic floor conditions, particularly SUI [26]. Numerous studies have demonstrated the effectiveness of PFMT in improving pelvic floor muscle activation and strength, leading to a reduction in UI symptoms [27-30]. Ensuring proper education and training on PFMT techniques is essential to maximize its benefits on those challenged with PFDs. Additionally, exploring innovative approaches, such as biofeedback and neuromuscular electrical stimulation, may further enhance the efficacy of PFMT in this population. Recent advances in PFMT strategies have aimed to optimize outcomes and adherence among female athletes. For example, a randomized controlled trial by Jones et al. compared the effectiveness of traditional PFMT exercises with a combined intervention incorporating mindfulness-based stress reduction techniques. The results demonstrated superior improvements in UI symptoms and quality of life among athletes in the combined intervention group, suggesting the potential benefits of integrating holistic approaches into PFMT programs [7]. PFMT may be an important intervention to consider incorporating in sports training and rehabilitation programs as it can be effective in addressing symptoms of PFD especially SUI. If athletes can be trained on how to engage their pelvic floor, it can help address PFD symptoms if present and prevent future symptoms from occurring. It is a costefficient and effective intervention that can be performed in adjunct with other exercises. However, it is essential that athletes are being taught proper techniques by a trained professional such as a physical therapist to maximize clinical efficacy [31].

The risk of developing Pelvic Floor Disorders (PFD) in female athletes may vary based on the type and intensity of their respective sport. In conclusion, the rising incidence of PFDs among female athletes highlights a critical aspect of sports medicine that necessitates further exploration and intervention. A collaborative approach among healthcare providers, coaches, and athletes are essential to advancing our understanding and management of PFDs in this population. Further high-quality research is warranted to better understand the multifactorial nature of PFDs in this population. A systematic review on the given literature may be beneficial to offer a consolidated and critical analysis of existing research to identify effective management strategies, establish correlations between exercise intensity and PFD risk, and guide future research and clinical practices on this topic. Recognizing the multifaceted nature of these disorders, a holistic approach to screening, education, and targeted rehabilitation is essential to support the health and performance of female athletes. As women’s sports continues to evolve and grow so should the strategies to mitigate and manage the unique health challenges faced by this population.

1. Bo K (2004) Urinary incontinence, pelvic floor dysfunction, exercise and sport: Sports medicine 34(7): 451-464.
2. Bø K, Nygaard IE (2020) Is physical activity good or bad for the female pelvic floor? A narrative review. Sports Med 50(3): 471-484.
3. Skaug KL, Bø K (2019) RE: Pelvic floor dysfunction in female athletes. Strength & Conditioning Journal 41(6): 122-123.
4. Skaug KL, Engh ME, Frawley H, Bø K (2020) Prevalence of pelvic floor dysfunction, bother and risk factors and knowledge of the pelvic floor muscles in Norwegian male and female powerlifters and Olympic weightlifters. Journal of Strength and Conditioning Research 36(10): 2800-2807.
5. Skaug KL, Engh ME, Frawley H, Bø K (2021) Urinary and anal incontinence among female gymnasts and cheerleaders—bother and associated factors. A cross-sectional study. Int Urogynecol J 33(4): 955-964.
6. Rebullido TR, Gómez-Tomás C, Faigenbaum AD, Chulvi-Medrano I (2021) The prevalence of urinary incontinence among adolescent female athletes: A systematic review. J Funct Morphol Kinesiol 6(1): 12.
7. Pires T, Pires P, Moreira H, Viana R (2020) Prevalence of urinary incontinence in high-impact sport athletes: A systematic review and meta-analysis. Journal of Human Kinetics 73(1): 279-288.
8. Pires T, Pires P, Moreira H, Gabriel R, Viana S, et al. (2020) Assessment of pelvic floor muscles in sportswomen: Quality of life and related factors. Physical Therapy in Sport 43: 151-156.
9. Carvalhais A, Da Roza T, Vilela S, Jorge R, Bø K (2018) Association between physical activity level and pelvic floor muscle variables in women. Int J Sports Med 39(13): 995-1000.
10. Carvalhais A, Araújo J, Jorge RN, Bø K (2019) Urinary incontinence and disordered eating in female elite athletes. Journal of Science and Medicine in Sport 22(2): 140-144.
11. Dias N, Peng Y, Khavari R, Nakib NA, Sweet RM, et al. (2017) Pelvic floor dynamics during high-impact athletic activities: A computational modeling study. Clinical Biomechanics 41: 20-27.
12. Arbieto ERM, Santos KM, Luz SCT, Roza TD (2021) Comparison of urinary incontinence, based on pelvic floor and abdominal muscle strength, between nulliparous female athletes and non‐athletes: A secondary analysis. Neurourol Urodyn 40(5): 1140-1146.
13. Hagovska M, Švihra J, Buková A, Dračková D, Švihrová V (2018) Prevalence and risk of sport types to stress urinary incontinence in sportswomen: A cross-sectional study. Neurourology and Urodynamics. 37(6): 1957-1964.
14. Casey EK, Temme K (2017) Pelvic floor muscle function and urinary incontinence in the female athlete. The Physician and Sportsmedicine 45(4): 399-407.
15. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. BMJ 6(7): e1000097.
16. Munn Z, Aromataris E, Tufanaru C, Stern C, Porritt K, et al. (2018) The development of software to support multiple systematic review types: The JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI). International Journal of Evidence-Based Healthcare 17(1): 36-43.
17. Vitton V, Baumstarck-Barrau K, Brardjanian S, Caballe I, Bouvier M, et al. (2011) Impact of high-level sport practice on anal incontinence in a healthy young female population. Journal of Women’s Health 20(5): 757-763.
18. Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, et al. (2020) Chapter 7: Systematic reviews of etiology and risk . In: Aromataris E, Munn Z (Eds.), JBI Manual for Evidence Synthesis.
19. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, et al. (2013) The CARE guidelines: Consensus‐based clinical case reporting guideline development. Headache 53(10):1541-1547.
20. Almeida MBA, Barra AA, Saltiel F, Silva-Filho AL, Fonseca AMRM, et al. (2016) Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: A cross-sectional study. Scand J Med Sci Sports 26(9): 1109-1116.
21. Chevalier F, Fernandez-Lao C, Cuesta-Vargas AI (2014) Normal reference values of strength in pelvic floor muscle of women: A descriptive and inferential study. BMC Womens Health 14: 143.
22. Paajanen H, Hermunen H, Karonen J (2011) Effect of heavy training in contact sports on MRI findings in the pubic region of asymptomatic competitive athletes compared with non-athlete controls. Skeletal Radiol 40(1): 89-94.
23. Da Roza T, Mascarenhas T, Araujo M, Trindade V, Jorge RN (2013) Oxford grading scale vs manometer for assessment of pelvic floor strength in nulliparous sports students. Physiotherapy 99(3): 207-211.
24. Roza TD, Brandão S, Oliveira D, Mascarenhas T, Parente M, et al. (2015) Football practice and urinary incontinence: Relation between morphology, function and biomechanics. Journal of Biomechanics 48(9): 1587-1592.
25. Saeuberli PW, Schraknepper A, Eichelberger P, Luginbuehl H, Radlinger L (2018) Reflex activity of pelvic floor muscles during drop landings and mini-trampolining—exploratory study. Int Urogynecol J 29(12): 1833-1840.
26. Pisani GK, Sato TO, Carvalho C (2020) Pelvic floor dysfunctions and associated factors in female CrossFit practitioners: A cross-sectional study. Int Urogynecol J 32(11): 2975-2984.
27. Yi J, Tenfelde S, Tell D, Brincat C, Fitzgerald C (2016) Triathlete risk of pelvic floor disorders, pelvic girdle pain, and female athlete triad. Female Pelvic Medicine & Reconstructive Surgery 22(5): 373-376.
28. Louis-Charles K, Biggie K, Wolfinbarger A, Wilcox B, Kienstra CM (2019) Pelvic floor dysfunction in the female athlete. Current Sports Medicine Report 18(2): 49-52.
29. Karmakar D, Mostafa A, Abdel-Fattah M (2017) A new validated score for detecting patient-reported success on postoperative ICIQ-SF: A novel two-stage analysis from two large RCT cohorts. Int Urogynecol J 28(1): 95-100.
30. Mattos Lourenco TR, Matsuoka PK, Baracat EC, Haddad JM (2018) Urinary incontinence in female athletes: A systematic review. Int Urogynecol J 29(12): 1757-1763.
31. Silva Borin LCM, Nunes FR, Oliveira Guirro EC (2013) Assessment of pelvic floor muscle pressure in female athletes. PM&R 5(3): 189-193.