Pelvic Floor Dysfunction in the Female Athlete

High-impact activities are “those involving the performance of several jumps and actions related to maximum abdominal contractions” and clinicians classify them into three grades⁽³⁾: 

• Impact grade 3 (>4 times body weight, such as jumping activities);
• Impact grade 2 (2–4 times body weight, such as sprinting activities and movements involving rotation);
• Impact grade 1 (1–2 times body weight, such as light weight lifting); 
• Impact grade 0 (<1 times body weight, such as swimming).

The increase in intra-abdominal pressure exerts an impact force directly on the pelvic floor muscles (PFM)^(1,4,5). Running, jumping, and landing increase intra-abdominal pressure exerted onto the pelvic organs and tissues, making them susceptible to tissue failure or injury associated with PFD⁽⁶⁾.

“Pelvic floor dysfunction among female athletes is multifactorial…”

There are multiple possible reasons and mechanisms why high-impact activities may lead to PFD in female athletes. The first hypothesis is that athletes, under normal circumstances, should have strong pelvic floor muscles. Strenuous exercise may increase abdominal pressure, creating a simultaneous or pre-contraction of the PFM. This mechanism, in turn, may act as a stimulus during training of the PFM⁽⁷⁾. The second hypothesis contradicts the first, as a recent systematic review indicated that strenuous activity (which causes a chronic or repeated increase in abdominal pressure) may stretch, overload, weaken, and eventually lead to pelvic floor failure.
 
Researchers at the University of Porto in Portugal found that an incontinent group of athletes had a thicker pubovisceral muscle at the mid-vaginal level, contradicting the hypothesis that stress urinary incontinence (SUI) is associated with the displacement or strength of the PFM⁽⁸⁾. A decreased or delayed response of the pubovisceral muscle may explain these findings. The PFM thickens to counteract the decreased responsiveness of the sphincter urethrae. An extended sports training history may support the hypothesis of changes occurring in the intrafusal fibers⁽⁸⁾.

Clinical Takeaways

Routine screening: Proactive screening should be integrated into sports medicine assessments to identify at-risk individuals.
Comprehensive assessment: Clinicians should evaluate PFM strength and endurance, coordination, and contributing biomechanical factors such as kinetic chain imbalances, hormonal influences, and past medical history.
Individualized treatment: Management should be tailored to the athlete’s specific needs. 
Awareness: Athletes, coaches, and healthcare professionals must be educated on PFD symptoms, risk factors, and management options to reduce stigma and encourage early intervention.
Conservative management: Clinicians should prioritize non-surgical interventions and address contributing factors before considering surgical options for severe cases.

Alternatively, the high forces produced by high-impact activities may cause injury during transmission through the tissue. Should the affected tissue not be treated after injury, it may remain malformed and dysfunctional, increasing the risk of further dysfunction⁽⁹⁾. The dysfunction may lead to failure of the continence mechanism due to the muscular force transmission to the urethra being affected. In addition, the PFM may become fatigued due to the repeated intra-abdominal pressure experienced during the sporting activity, which may further lead to malfunctioning of the continence mechanism. 

“Early identification through screening, education, and athlete-centered management is crucial...”

Genetic predisposition has also been postulated to be a risk factor for PFD in female athletes, similar to the general female population. Furthermore, differences in individual athlete fatigue levels may impact their capacity to manage high-impact sports demands. Every female athlete may have a different personal fatigue level. When this fatigue level is reached, the continence mechanism may malfunction⁽¹⁰⁾.

There is a higher prevalence of leakage in athletes during training compared to during competition (95.2% vs. 51.2%). It is postulated that higher catecholamine levels during competition may be the reason for this. The catecholamine acts on the urethral α-receptors to maintain its closure during activities at the competition level⁽¹¹⁾. Moreover, low body mass index (BMI), low energy availability (RED-s), estrogen changes, and hypermobility joint syndrome may contribute to the development of PFD in female athletes. Lastly, the problem may occur in conditioned athletes at the muscle spindle level. Repeated or sustained increased intra-abdominal pressure may stretch or lengthen the pelvic floor muscles and affect the function and responsiveness of the intrafusal muscle fibers over time⁽¹⁾.

Clinical Implications

Educating healthcare professionals is the first critical intervention in improving the management of athletes with PFD. Coaches and clinicians must understand the signs, symptoms, and management options available to athletes to guide them appropriately if they report challenges and seek treatment. However, athletes are unlikely to report PFD symptoms. Therefore, screening is the best way to identify athletes at risk. Together with screening, preventative measures should also be taken in young female athletes, especially those with RED-s.

Pelvic floor dysfunction among female athletes is multifactorial, and conservative management is the first line of treatment. Clinicians should assess athletes for contributing factors and manage the whole athlete instead of only their presenting PFD symptoms. This may include factors such as imbalances in the closed kinetic chain or stabilizing mechanisms, muscle endurance, strength, other injuries or pain, medical factors, and genetic predisposition. A comprehensive assessment will identify contributing factors. This includes a detailed interview with the patient, establishing their medical and gynecological history.

In addition, clinicians can perform several physical tests, such as establishing the strength, tone, activity, control, and level of function of the PFMs and the surrounding muscle groups. Assessment may include manual palpation, rating scales such as the modified Oxford rating scale, testing with a perineometer or dynamometry, standardized questionnaires, electromyography, ultrasound, or another specialized bladder testing (such as urodynamics)⁽¹¹⁾. Importantly, PFM strength may not necessarily be the only factor to consider in athletes – although it cannot be ruled out until clinicians establish a differential diagnosis.

Addressing the contributing factors should be through a tailored and athlete-specific PFM training program, ensuring that the issue at hand (such as endurance, muscle control, strengthening of a lengthened muscle, amongst others) is being addressed and conservative management achieves optimal outcomes. In more severe cases, surgery might be indicated to restore normal bladder function.

Pelvic floor dysfunction in female athletes is a complex issue that is often overlooked despite its prevalence. Early identification through screening, education, and athlete-centered management is crucial for mitigating the long-term effects. Clinicians and coaches need to recognize the signs of dysfunction to provide appropriate, evidence-based interventions. Conservative treatments, like individualized pelvic floor muscle training, should be prioritized, with surgical options considered only in severe cases. Increasing awareness and proactive management can help female athletes maintain performance and pelvic health.

References

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11. Br J Sports Med. 2014 Feb;48(4):296-8. 
12. Neurourology and Urodynamics. 2021; 40: 1217-1260.