Introduction
The female athlete is still seen as a specialist population in educational material, meaning female considerations, such as pelvic floor dysfunction (PFD), are not commonly taught to sports medicine practitioners, and there is limited access to in-depth information. This is surprising given that current estimations for the prevalence of PFD in female athlete populations range from 23% to 80% depending on the symptoms explored (1). From a biological perspective, it is widely reported that females are not small males and do not produce movement patterns that are scaled down versions of their male counterparts (2,3). Unfortunately, current understanding within sports medicine is based on research primarily involving male athletes (4) and sports organizations are only recently beginning to develop appropriate policies and education to support female athletes (5–7). Therefore, it is essential that sports medicine practitioners are upskilled in female athlete health and in particular, knowledge regarding the anatomy and physiology of the pelvic floor and its associated dysfunctions. The aim of this article is to describe the anatomy and function of the pelvic floor, outline the types and rates of PFD, discuss evidence-based management and treatment options, and raise awareness of perinatal bodily changes. Further, the role of the pelvic health practitioner and their relevance to sports medicine will be discussed alongside insight into new research to inform best practice and encourage multi- and interdisciplinary collaboration. Finally, recommendations for sports medicine practitioners and organizations will be made to support them in optimizing female athlete care.
The Pelvic Floor
An Overlooked Muscle Group
The pelvic floor muscles (PFMs) are overlooked within many specialities of health care, including sports medicine (8–10). These muscles are frequently left to the specialities of obstetrics, gynecology, urology, and colorectal, with many physicians deeming them to be someone else’s concern. For example, several established sports medicine reports on groin pain (11,12) do not even mention the PFMs, despite proximity to the structures of focus. Not only do the PFMs and groin muscles share the same bony attachment, the pubic bone, but the obturator internus muscle serves as part of the PFM group and as a lateral hip rotator (Table 1). Such shared attachments and dual muscle function highlight the relevance of considering the PFMs within the differential diagnoses of lumbar, pubic, groin, or hip pain (13–16). In addition, traditional return-to-sport frameworks lack female specific considerations and the inclusion of pelvic floor specialists (e.g., gynecologists or pelvic health physical therapists) within the multidisciplinary team (17). Yet, the call for recognition of PFM related symptoms within sports medicine has been established for more than a decade (8,18–25). In recent years, however, there has been greater recognition that symptoms of PFD such as pain, incontinence, or pelvic organ prolapse, negatively influence sports performance and ability to train (1,26,27). This recognition is stimulating increased interest in the need to consider the PFMs within sports medicine.
Table 1 -
The pelvic diaphragm and beyond — anatomic origins, insertions, innervation, and function of the comprising pelvic floor muscles.
| Muscle |
Origin |
Insertion |
Innervation |
Function |
| Pubococcygeus |
Posterior pubic bone and ATFA |
Anococcygeal ligament and coccyx |
S3 to S5, direct innervation from sacral nerve roots |
Forms part of the levator ani group and maintains pelvic floor tone in upright position |
| Iliococcygeus |
Ischial spine and ATFA |
Anococcygeal raphe and coccyx |
S3–4 |
Forms part of the levator ani group and voluntary control of urination |
| Puborectalis |
Pubic symphysis |
Pubic symphysis |
S3–4 |
Forms part of the levator ani group and raises the pelvic floor |
| Coccygeus |
Ischial spine |
Lower sacral and upper coccygeal bones |
S4–5 |
Reinforces the posterior pelvic floor and support of fetal head |
| Piriformis |
Anterior sacrum |
Posterior-surface of greater trochanter |
L5, S1 to S2 via nerve to piriformis |
Lateral rotation, abduction of thigh, and retroversion of pelvis |
| Obturator Internus |
Pelvic surface of ilium, ischium, and obturator membrane |
Posterior surface of greater trochanter |
L5, S1 to S2 via nerve to obturator internus |
Lateral rotator of thigh |
Anatomy and Physiology of the Pelvic Floor
The pelvic floor (Figure) consists of muscles and connective tissues (ligaments and fascia) that work together to form a structural sling of support to the base of the pelvic outlet to: i) support the pelvic organs, ii) prevent urinary or fecal leakage, iii) facilitate emptying of the bladder and rectum, and iv) enable sexual function (24,28). This sling of soft tissue is enclosed by the bony scaffolding of the pelvis, formed by two innominate bones that articulate with the sacrum posteriorly and each other anteriorly. The coccyx is an extension of the sacrum, which acts as an important ligamentous and tendinous anchor (29).
;)
Figure: Pelvic floor anatomy. Reprinted with permission from Pelvic Guru®, LLC/Pelvic Global.
The PFMs are comprised of a combination of type 1 (slow-twitch, 66%) and type 2 (fast-twitch, 34%) muscle fibers that are organized into superficial and deep layers (30). The superficial PFMs consist of the bulbospongiosus, ischiocavernosus, and superficial and deep transverse perineal muscles. The deep PFMs lining the inner walls of the pelvis include the levator ani (puborectalis, pubococcygeus, and iliococcygeus) and coccygeus that, along with the endopelvic fascia, form the pelvic diaphragm (Table 1) (29). Of note, the puborectalis forms a U-shaped sling around the rectum, medially and continuous to pubococcygeus, and its sphincter-like action pulls the anorectal junction forward, contributing to the continence mechanism. The perineal body is located between the vagina and anus. This is a site where the PFMs and sphincters converge to provide support to the pelvic floor (29).
The PFMs function through a constant state of muscular activity, maintaining continuous, coordinated and responsive contraction and relaxation to task, alongside passive support from the surrounding tissues and fascia (29,31). For example, in response to increases in intraabdominal pressure, the female PFMs reflexively contract in an upward and forward motion closing the vagina, urethral sphincter, and anal sphincter (29). This action is important for maintaining continence. Relaxation of the PFMs occur briefly and intermittently during the processes of normal micturition and defecation. Micturition occurs when the bladder wall detrusor muscle contracts, and the urethral sphincter relaxes through involuntary autonomic nervous system control. Simultaneously, the PFMs voluntarily relax (32). The coordination of these muscular actions is essential to maintain urinary continence and allow for micturition. Therefore, structural integrity of the muscles and connective tissues, range of motion, innervation, and resting tone are essential components for maintaining optimal PFM function.
Physiology of the Pelvic Floor during Movement
Current understanding of the behavior and functionality of the PFMs is that they respond to movement-related load in an anticipatory and reflexive manner (31). In activities such as running and jumping, studies have demonstrated that there is a lengthening of the PFMs and feed-forward muscle activation prior to an individual making impact with ground. This is then followed by reflex PFM activity in response to impact (33–36). Although the evidence is conflicting regarding the role and speed of response of PFM activity and PFD, such as incontinence (36–38), the anticipatory and reflexive activation during movement has been consistently reported.
The Dysfunctional Pelvic Floor
Types of PFD
Anything that impacts the natural behavior of the PFMs can lead to PFD and symptoms such as pain, reduced pelvic organ support or compromised continence, voiding, and defecation. As such, PFD is an umbrella term that encompasses several diagnoses. Specifically, the following are all examples of PFD: urinary incontinence, fecal incontinence, pelvic organ prolapse, voiding dysfunction, obstructive defecation, dyspareunia, vaginismus, and vulvodynia.
Prevalence of PFD in the General Population and in Athletes
PFD can present in adolescence (39–43), nulliparous adult athletes (42,44–46), and males (1,44,47). However, it is most associated with transitional periods during the female lifespan, such as pregnancy and menopause (39,48) in which the prevalence has been demonstrated to be as high as 32% and 59%, respectively (48).
Numerous epidemiological studies have highlighted an association between sport and the development of PFD (1,18,42,43,49,50), where the prevalence of PFD is much higher than the general population. For example, approximately 50% of female powerlifters and Olympic weightlifters have urinary incontinence (1,49), 80% have anal incontinence, and 23% have pelvic organ prolapse (1). Urinary incontinence has been more widely researched, with prevalence rates for several sports reported, such as 32% in rhythmic gymnastics (51) and 76% in volleyball (52). Therefore, urinary incontinence varies by sport and this also may be the case for other types of PFD, but data are needed to confirm this theory.
It is acknowledged that the reported prevalence figures for PFD show a large range throughout the literature due to varying case definitions, recruited populations, and study methodologies (53). The prevalence of urinary incontinence in athletes is often quantified using general, but validated questionnaires, such as the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (54,55) and the Incontinence Severity Index (56). However, more recently sport-specific questions about leaking urine have been used (57,58). When general and sport-specific questions are used, half of female athletes deny having urinary incontinence on validated questionnaires, but report leaking urine during sports training (57). This means reported urinary incontinence rates within athletic female cohorts may underestimate the actual occurrence of it. There are several possible reasons that may account for denying incontinence which apply for both urinary and fecal incontinence: 1), the taboo and embarrassment associated with leaking, 2) athletes assuming it is normal to leak, 3) the reporting mechanism (e.g., to who, how the question was asked).
The majority of sports injury surveillance studies do not report any occurrence of incontinence in male or female athletes, which is probably due to predominantly focusing on time-loss health problems. Sports medicine practitioners should be aware that PFD can present at any point across the female lifespan, but athletes in transitional periods appear to be at the greatest risk. They also should be cognizant that athletes may deny symptoms of incontinence in a brief screening questionnaire. Furthermore, symptoms of PFD often coexist. For example, mixed urinary incontinence is often a component of female athlete PFD (54). Therefore, we recommend that sports medicine practitioners undertake a more specific continence history, educate athletes to “denormalize” leaking, consider recording non-time-loss health problems, such as PFD and screen for mixed urinary incontinence, symptoms of pelvic organ prolapse, and sexual dysfunction rather than only considering stress urinary incontinence.
Other Factors Involved in PFD
A common misconception with symptoms of PFD is that the cause is always due to the PFMs being weak. In contrast, the PFMs may be tight, maintaining a prolonged and heightened recruitment and resulting in compromised function (46). Furthermore, such hypertonic, tight PFMs are reported to lead to decreased circulation, localized hypoxia, and ischemia which can all lead to pain (59,60). Pain can present at rest, during palpation of the PFMs or saddle region, during voiding or defecation, during sexual activity, or during sports specific performance or training. Evaluation by a gynecologist and/or pelvic health physical therapist is the recommended step to clinically reason whether muscles are hypertonic or weak and identify what the underlying cause may be.
Wider physiological factors such as vaginal lubrication are also important to consider. There are several periods during a female’s lifespan which can lead to compromised vaginal lubrication and associated connective tissue atrophy, such as postpartum (especially if lactating) and during the transition into menopause (39). Vaginal dryness leads to increased risk of urinary tract infections, vulvovaginal pain, and compromised PFM function (39). Addressing atrophic vaginal tissues with treatments such as localized topical estrogen or organic vaginal moisturizers is important, especially in athlete populations where the aim is to facilitate their ability to continue training and competition (61).
Red Flags, Cautions, and Onward Referral
As with any speciality in health care, screening for signs and symptoms of serious medical pathology is essential (62–64). Table 2 outlines red flag signs and symptoms that sports medicine physicians and wider multidisciplinary members should be aware of, including specific symptoms for gynecological pathologies, such as ovarian cancer (39). For specific signs, symptoms, and recommendations for screening and managing suspected gynecological (ovarian, endometrial, cervical, vulval, vaginal), urological, and lower gastrointestinal tract cancers (colorectal, anal) refer to The National Institute for Health and Care Excellence Guidance 2021 on Suspected Cancer: recognition and referral (65).
Table 2 -
Red flag signs and symptoms.
| Red Flag |
Signs and Symptoms |
| Potential serious pathology |
Pelvic masses
Neurological signs and symptoms including, but not limited to, cauda equina: reduced saddle sensation, loss of urinary urge, loss of fecal control, widespread neurological signs and symptoms
Suspected cancer (bladder, bowel, cervical, vulva) — screen for established cancer related signs including unremitting night pain, night sweats, unexplained mass/growths, skin lesions, weight loss or gain, neurological signs. In addition, be aware of gynecological-related symptoms including excessive abdominal bloating, feeling of fullness early with eating, and unexplained vaginal bleeding
Persisting vaginal bleeding
Persisting urinary retention or any postpartum urinary retention |
| Indicating onward referral for specialist management |
Psychosexual trauma
Suspected endometriosis
Fistula
Suspected dermatological presentations, e.g., lichen sclerosis
Missed or poorly healing obstetric anal sphincter injury
Heavy, painful, or clotting menstrual bleeding |
| Other potential medical sources of presenting symptoms of PFD |
Urinary tract infection
Thrush or bacterial vaginal infection
Diabetes
Sexually transmitted infection
Inflammatory bowel or bladder issues |
Further to ruling out serious pathology, awareness and differential diagnosis between simple presentations of PFD and more complex presentations should be considered. For example, stress urinary incontinence or mild pelvic organ prolapse may be considered to be simple clinical presentations, whereas painful bladder syndrome (66), voiding dysfunction (46), or underdiagnosed dermatological conditions (e.g., lichen sclerosis) (67) could be considered complex. Such complex clinical presentations indicate onward referral for specialist and/or multimodal investigation and management.
Risk Factors for PFD
There are several modifiable and nonmodifiable risk factors for PFD (Table 3) (39,43,50,51,68–70). Modifiable risk factors can be categorized as general (e.g., higher body mass and long-term constipation) and sport-related (e.g., activities involving higher impact or intensity), while nonmodifiable risk factors can be categorized as general (e.g., age and family history), pregnancy related (e.g., higher age in pregnancy and increasing parity), and labor related (e.g., assisted deliveries and perineal trauma). For athletes, the sport itself is a modifiable risk factor. Female athletes report competition, training, and physical activity as the most significant triggers for their symptoms of PFD, followed by specific movements during their sport (54), such as impact-related activities (e.g., running, jumping) and strenuous activities (e.g., powerlifting) (57). It is important that sports medicine practitioners are aware of these risk factors, particularly when advising women on possible management and treatment options.
Table 3 -
Modifiable and nonmodifiable risk factors for PFD.
| Risk Factor Type |
Category |
Risk Factor |
| Modifiable |
General (39) |
A body mass index over 25 kg·m−2
Smoking
Low physical activity levels
Constipation
Diabetes |
| Sport-related (43,50,51,68,69) |
Impact sports
Strenuous exercise
Higher intensity activities
RED-S |
| Nonmodifiable |
General (39,44,51,68,70) |
Age (risk increases with increasing age)
Family history of urinary incontinence, overactive bladder, or fecal incontinence
Female sex
Gynecological cancer and associated treatments
Gynecological surgery (such as a hysterectomy)
Fibromyalgia
Chronic respiratory disease and cough (chronic cough may increase the risk of fecal incontinence and flatus incontinence) |
| Pregnancy (39) |
Being over 30 yr when having a baby
Having given birth before their current pregnancy |
| Labor (39) |
Assisted vaginal birth (forceps or vacuum)
A vaginal birth when the baby is lying face up (occipitoposterior)
An active second stage of labor taking more than 1 h
Injury to the anal sphincter during birth |
The Impact on Daily Living and Sports Participation
The impact of PFD on daily living varies but often includes negative consequences to social life and self-perception (71). There are also associated consequences to an individual’s mental health such as increased risk of depression (72), anxiety, and psychological morbidity (73).
The impact of PFD within a sporting context is reduced performance and withdrawal from sport (1,54). There are also long-term health problems associated with sport-related PFD, as it has been shown that elite athletes experiencing urinary incontinence at a young age are more likely to report symptoms in later life (70,74). At a recreational level, PFD could lead to women not reaping the health benefits of regular physical activity because symptoms of urinary incontinence or the sensation of vaginal heaviness may cause them to stop exercising (26,27,58). Symptoms of PFD also are one of the biggest concerns and barriers for women returning to exercise following childbirth (58,75). Consequently, the cost of both inactivity and urinary incontinence are suffered by women and society (17,26), highlighting the importance of pelvic health awareness and rehabilitation (24,70) as part of a public health priority within sports medicine.
The Perinatal Athlete
The Need for Perinatal Sports Medicine
The perinatal period refers to the time in which a person is pregnant up to the first year postpartum (76). In 1984 only 23% of the athletes participating in the Olympic Games were female, but this rose to nearly half (49%) of the participating athletes in 2021 (24,77). Meanwhile the 2022 Commonwealth Games featured the highest number of female athletes competing who were also mothers. In addition, an increasing number of athletes across all sports are of prime reproductive age (20s and 30s). Yet many athletes report feeling confused about what they can or cannot do in relation to sports specific training during the perinatal period. Moreover, many still feel that they must make a choice between entering motherhood or continuing in their performance career (21). Part of the difficulty in making such a choice is the lack of standardized support and guidance for perinatal athletes (8). Therefore, there is an urgent need for knowledge and upskilling of sports medicine practitioners (20) and creation of supportive policy from sports organizations.
A Unique, at-Risk Population That Is Underserved
Beyond the sex specific differences, the perinatal transition brings about further, widespread physiological, and psychological changes, including abdominal and PFM lengthening and strain, generalized deconditioning, fluctuations in breast size, lactation, changes in body mass, compromised sleep quality, and hormonally altered environments (8,78). Symptoms of PFD may first present during pregnancy, where the weighted prevalence of urinary incontinence is understood to be 41%, increasing as weeks of gestation progress (53). Symptoms of PFD also are prevalent in the general postpartum population, with at least one in three at risk of leaking from their bladder, regardless of mode of delivery (79,80). When the perinatal bodily changes are combined with the PFMs being exposed to high loads, such as during impact-related sports activities, the risk of PFD may increase. However, appropriate injury surveillance systems have not been developed and implemented to adequately monitor the prevalence of PFD within perinatal athletes. Consequently, the actual risk to perinatal athletes is unknown.
Despite the acknowledged widespread bodily changes during and after pregnancy including the risk for PFD, postpartum rehabilitation is not standardized nor routine. Women can usually access services, for example a pelvic health physical therapist, if their symptoms are bothersome enough. However, awareness of the role of the pelvic health physical therapist within the multidisciplinary team is not consistent and provision of pelvic health physical therapists varies across different regions. Moreover, health care across the world continues to exist in silos (23,81), whereby specialities such as sports medicine and elite athlete care are considered separate to female and perinatal health care. We argue that sports medicine practitioners are well placed to support the perinatal athlete because postpartum recovery should be evaluated with the same clinical rationale as injury rehabilitation. Specifically, a graded approach to activity with progressive loading as tolerated should be implemented.
Alongside sports medicine practitioners applying their knowledge and skillset to support perinatal athletes, sports organizations also must do more. Policies should be created to enable athletes to continue their sporting careers throughout motherhood, screening measures should be implemented, and education provided to an athlete's support team regarding the management of perinatal considerations. For example, appropriate risk assessments should be used by support teams to consider and plan around the technicalities of athletes training while having dependent young children or the logistics of breastfeeding while returning to training and competition (6). Sporting organizations therefore have an urgent need to improve their understanding of perinatal health and how they can appropriately support perinatal athletes.
The perinatal athlete is a unique presentation. Unlike return-to-sport following an injury, the transition into motherhood offers an opportunity to anticipate the expected bodily changes and prepare for them, offering a favorably proactive approach (6,8). For example, pregnant continent women who engage in PFM training are 62% less likely to experience urinary incontinence in late pregnancy and have a 29% lower risk of urinary incontinence 3 to 6 months postpartum (82). In addition, minimizing deconditioning by engaging with sport (where it is safe to do so) while pregnant increases the odds of returning to sport postpartum (58). While return-to-sport frameworks exist to guide return-to-sport following injury (17), it is only recently that focus has turned to the perinatal athlete (20,21,23,83) and a population specific return-to-sport framework has been developed (8).
The 6 Rs Framework
The 6 Rs Framework is a postpartum specific return-to-sport framework. It is informed by the biopsychosocial model (84) and represents a progression of steps that include sports medicine and female specific considerations relevant to the transition into and beyond motherhood (8). The 6 Rs stand for ready, review, restore, recondition, return, and refine. Perinatal women can progress or regress through the framework, allowing for their individual needs to be addressed with the overall objective to achieve and maintain return-to-sport and safeguard their long-term ability to engage in their sport (8). The framework is underpinned by a whole-systems approach with the safety of the mother and baby forming the overarching concern. A whole-systems approach refers to considering the entire athlete and all their bodily systems within an applied biopsychosocial context of care. It is the removal of working in anatomical silos to provide harmonious, multidisciplinary care for the athlete.
A pelvic health evaluation is an essential part of the 6 Rs framework. Routinely monitoring signs and symptoms of PFD is recommended as athletes progress through the framework. If, at any point, a perinatal athlete presents with PFD there are several management and treatment options available. These will be discussed below and also can be applied to the general population.
Managing and Treating PFD
Self-Management Techniques
Altering sporting habits by reducing exposure to high-impact activities or to the time spent performing the sport may reduce the symptoms of PFD. Some female athletes may look to modify or change their sporting activity (26). However, for many athletes this may not be an option because they prefer to maintain their sporting habits or are financially dependent on them. Consequently, individualized and movement specific PFM training should be factored into athlete management.
Many athletes try to manage symptoms of PFD by altering their bladder emptying behavior and fluid intake, which can lead to the development of further presentations of PFD (54). For example, an athlete presenting with simple stress urinary incontinence may try to manage this by restricting fluid intake and frequently emptying their bladder before and during training, resulting in the development of urinary frequency, urgency, and incontinence. It is therefore important that evidence-based guidance is provided to athletes regarding maladaptive bladder behaviors and best practice approaches, e.g., PFM training.
Strength and Conditioning for the Pelvic Floor
Like other muscle groups in the body the PFMs can be targeted with strength and conditioning. In support of strengthening as a treatment option, there is consistent evidence that PFM training can improve the symptoms associated with PFD as well as producing physiological changes, such lifting the pelvic floor, reducing the levator hiatus area, and inducing PFM hypertrophy (39,85–87). These encouraging findings alongside the high prevalence rates and the negative impact of PFD, indicate that focused strength and conditioning of this muscle group should be undertaken as part of all female athlete training programs. Importantly, both research and clinical experience have highlighted that more than 44% to 70% of females are not recruiting their PFMs correctly (87,88). As a result, supervised PFM assessment and training is recommended as the first line management for symptomatic women (31,39,86). This emphasizes the importance of having a pelvic health physical therapist as part of the sports medicine multidisciplinary team who can conduct the PFM assessment and training.
The principles of strength and conditioning for the PFMs align with the established sports medicine concepts of individualization, specificity, overload, and progression (89). Load tolerance also needs to be considered (90). This means that the level of PFM training needed depends on the individual athlete, alongside the type of sport undertaken. For example, faster movements and lifting heavier weights have higher intraabdominal pressures than slower movements and lifting lower weights (91). Athletes may present with stronger PFMs compared with nonathletes, but their muscles may still be too weak or respond too slowly to counteract the intraabdominal pressure changes during the strenuous activity of their specific sport (24). It is important that parallels are drawn from sports medicine physician knowledge and expertise of muscle strength and conditioning, to offer guidance on PFM training to the athletes that they serve (24,92). The following cues may offer useful prompts to help athletes understand PFM training: “imagine you are stopping gas escaping,” “close your anus,” “stop the flow of urine,” or “imagine closing a zip from your back passage to front passage.” In addition, athletes should not be clenching the surrounding lumbopelvic muscles or holding their breath while targeting their PFMs.
Training for the PFMs should aim to target both fast twitch and slow twitch fibers. Rapid maximum voluntary contractions will target fast twitch fibers and slower endurance holds will target slow twitch fibers. Therefore using exercise prescription principles female athletes should engage in focused PFM training of one to two repetitions of ballistic PFM recruitment alongside three sets of 8 to 12 sustained close to maximum PFM contractions repeated three to four times per week (24). This can be built into a wider training program; however, some athletes may find PFM training more achievable when implemented as a daily habit whereby they engage in three sets of 8 to 12 sustained PFM contractions plus one to two ballistic repetitions everyday (31). Furthermore, there are ample digital applications that could be considered useful within Femtech (93) to prompt reminders and reinforce educational components of PFM training directly from an athletes smart phone or device (94,95).
Adjuncts and next Step Intervention for PFD
For some athletes, symptoms of PFD may never be fully resolved with conservative management, or they may wish to manage bothersome symptoms while they engage in a course of rehabilitation. In these circumstances, there are several adjuncts to PFM training which may offer relief of symptoms such as silicone pessaries, urethral support devices, and compression garments. Pessaries offer support to the tissues supporting the internal pelvic organs, which may be lax and predispose the athlete to symptoms, while urethral support devices specifically target support to the urethra (96–98). Compression garments targeting the lumbopelvic region are a relatively new concept but may be able to optimize PFM function (99–102). Women report perceived reductions in symptoms when using compression garments for lumbopelvic pain (103), stress urinary and/or fecal incontinence (101,102), and symptoms of pelvic organ prolapse (100). However, few studies have assessed the biomechanical impact of compression garments (99), meaning further research is warranted.
For a small number of athletes, conservative treatment and adjuncts for PFD will not be effective and onward referral to a (uro)gynecologist for the next step intervention is required. Depending on individual presentation, options range from urethral bulking agents (104) to surgical repair of pelvic organ support or a sling to support the bladder neck and continence mechanism (105). As with any invasive procedure, thorough multidisciplinary risk-benefit analyses with athlete centered decision making is important to identify whether surgical intervention is best indicated during or after their performance career. For example, surgery during their performance career will result in time loss from training and an inability to perform while undergoing rehabilitation, as well as carrying the risk of symptom recurrence due to their sporting demands. These needs must be considered together with the potential negative impact that experiencing PFD symptoms can have on sporting performance and quality of life.
Practical Recommendations
Based on the sections discussed we make the following recommendations for sports organizations and sports medicine practitioners in managing the pelvic floor and perinatal athlete:
- Conduct a specific incontinence history
- Educate athletes to de-normalize leaking
- Consider red-flags relevant to the female athlete and symptoms of PFD
- Recognize modifiable and nonmodifiable risk factors for PFD
- Screen for symptoms of PFD beyond urinary incontinence
- Consider recording non time-loss health problems in injury surveillance systems to include PFD
- Facilitate access to self-management techniques, strength and conditioning options, and adjuncts for managing and treating PFD via athlete education and signposting as required
- Expand the multidisciplinary sports medicine team to include access to PFM specialists such as (uro)gynecologists and physical therapists
- Create supportive perinatal athlete policy and guidance within sporting organizations
- Apply the 6 Rs framework (a perinatal specific return-to-sport framework) to proactively manage perinatal athletes
- Ensure postpartum athletes have the option to access a pelvic health evaluation
Further resources on how to manage and support the perinatal athlete are provided in the supplementary content file https://links.lww.com/CSMR/A139.
Conclusion
In summary, the pelvic floor is often overlooked and a greater understanding of its physiology, dysfunction, risk factors, and management is needed within sports medicine. We have made several practical recommendations to aid sports organizations and sports medicine practitioners in managing the pelvic floor and supporting the female, and specifically the perinatal, athlete. In particular, a proactive approach using the 6 Rs framework should be used and a pelvic health evaluation postpartum should be accessible for athletes returning to sport.
Funding Disclosures/conflicts of interest: The authors declare no conflict of interest and do not have any financial disclosures.
Figure used with permission from Pelvic Guru®, LLC/Pelvic Global. Illustration title is 'Hip short rotators, inferior view, pelvic floor of body with vulva (#G-Art4)'. Year of Copyright - 2019. Copyright retained by Pelvic Guru®, LLC/Pelvic Global.
References
1. Skaug KL, Engh ME, Frawley H, Bø K. 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.
J. Strength Cond. Res. 2020; 36:2800–7.
2. Moore IS, Goom T, Ashford KJ. Gait re-training for performance and injury risk. In: Blagrove RC, Hayes PR, editors.
The Science and Practice of Middle and Long Distance Running. Oxon (UK): Routledge; 2021. p. 185–206.
3. Williams EMP, Petrie FJ, Pennington TN, et al. Sex differences in neck strength and head impact kinematics in university rugby union players.
Eur. J. Sport Sci. 2021; 1–10.
4. Cowley ES, Olenick AA, McNulty KL, Ross EZ. “Invisible sportswomen”: the sex data gap in sport and exercise science research.
Women Sport Physical Activity J. 2021; 29:146–51.
6. UK Sport PREGNANCY GUIDANCE and Support for UK Sport Funded Athletes 2020. [cited 2022 August 27]. Available from:
file:///C:/Users/Owner/Downloads/1%20UKSportPregnancyGuidanceAthletesFINAL%20Interactive%20(1).pdf.
7. Australian Government. Australian Institute of Sport Female Performance & Health Initiative: Australian Sports Commission. [cited 2023 January 9]. Available from:
https://www.ais.gov.au/fphi.
8. Donnelly GM, Moore IS, Brockwell E, et al. Reframing return-to-sport postpartum: the 6 Rs framework.
Br. J. Sports Med. 2022; 56:244–5.
9. Dakic JHSJ, Cook J, Lin K, Frawley H. Abstract 52: Screening and management of pelvic floor symptoms in exercising women: online survey of 636 health and exercise professionals. Melbourne, Australia: International Continence Society (ICS).
https://www.ics.org/2021/abstract/52; 2021.
10. Cook J, Frawley H, Dakic J, et al. Pelvic floor disorders in exercising women: impact on participation, symptom disclosure and screening.
J. Sci. Med. Sport. 2021; 24:S56.
11. Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes.
Br. J. Sports Med. 2015; 49:768–74.
12. Falvey EC, Franklyn-Miller A, McCrory PR. The groin triangle: a patho-anatomical approach to the diagnosis of chronic groin pain in athletes.
Br. J. Sports Med. 2009; 43:213–20.
13. Unverzagt CA, Schuemann T, Mathisen J. Differential diagnosis of a sports hernia in a high-school athlete.
J. Orthop. Sports Phys. Ther. 2008; 38:63–70.
14. Décary S, Longtin C, Naye F, Tousignant-Laflamme Y. Driving the musculoskeletal diagnosis train on the high-value track.
J. Orthop. Sports Phys. Ther. 2020; 50:118–20.
15. Battaglia PJ, D'Angelo K, Kettner NW. Posterior, lateral, and anterior hip pain due to musculoskeletal origin: a narrative literature review of history, physical examination, and diagnostic imaging.
J. Chiropr. Med. 2016; 15:281–93.
16. Thorborg K, Reiman MP, Weir A, et al. Clinical examination, diagnostic imaging, and testing of athletes with groin pain: an evidence-based approach to effective management.
J. Orthop. Sports Phy. Ther. 2018; 48:239–49.
17. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern.
Br. J. Sports Med. 2016; 50:853–64.
18. Salvatore S, Serati M, Laterza R, et al. The impact of urinary stress incontinence in young and middle-age women practising recreational sports activity: an epidemiological study.
Br. J. Sports Med. 2009; 43:1115–8.
19. Goldstick O, Constantini N. Urinary incontinence in physically active women and female athletes.
Br. J. Sports Med. 2014; 48:296–8.
20. Davenport MH, Ray L, Nesdoly A, et al. We're not superhuman, we're human: a qualitative description of elite athletes' experiences of return to sport after childbirth.
Sports Med. 2023; 53:269–79.
21. Davenport MH, Nesdoly A, Ray L, et al. Pushing for change: a qualitative study of the experiences of elite athletes during pregnancy.
Br. J. Sports Med. 2022; 56:452–7.
22. Donnelly GM, James ML, Coltman CE, et al. Running during pregnancy and postpartum, part B: How does running-related advice and guidance received during pregnancy and postpartum affect women's running habits?
J. Women’s Health Physical Therap. 2022; 46.
23. Donnelly GM, Rankin A, Mills H, et al. Infographic. Guidance for medical, health and fitness professionals to support women in returning to running postnatally.
Br. J. Sports Med. 2020; 54:1114–5.
24. Bø K, Nygaard IE. Is physical activity good or bad for the female pelvic floor? A narrative review.
Sports Med. 2020; 50:471–84.
25. Brown WJ, Miller YD. Too wet to exercise? Leaking urine as a barrier to physical activity in women.
J. Sci. Med. Sport. 2001; 4:373–8.
26. Dakic JG, Cook J, Hay-Smith J, et al. Pelvic floor disorders stop women exercising: a survey of 4556 symptomatic women.
J. Sci. Med. Sport. 2021; 24:1211–7.
27. Dakic JG, Hay-Smith J, Cook J, et al. Effect of pelvic floor symptoms on women's participation in exercise: a mixed-methods systematic review with meta-analysis.
J. Orthop. Sports Phys. Ther. 2021; 51:345–61.
28. Herschorn S. Female pelvic floor anatomy: the pelvic floor, supporting structures, and pelvic organs.
Rev. Urol. 2004; 6 Suppl 5(Suppl 5):S2–s10.
29. Eickmeyer SM. Anatomy and physiology of the pelvic floor.
Phys. Med. Rehabil. Clin. N. Am. 2017; 28:455–60.
30. Quartly E, Hallam T, Kilbreath S, Refshauge K. Strength and endurance of the pelvic floor muscles in continent women: an observational study.
Physiotherapy. 2010; 96:311–6.
31. Okeahialam NA, Oldfield M, Stewart E, et al. Pelvic floor muscle training: a practical guide.
BMJ. 2022; 378:e070186.
32. Rocca Rossetti S. Functional anatomy of pelvic floor.
Archivio Italiano di Urologia e Andrologia. 2016; 88:28–37.
33. Moser H, Leitner M, Eichelberger P, et al. Pelvic floor muscle displacement during jumps in continent and incontinent women: an exploratory study.
Neurourol. Urodyn. 2019; 38:2374–82.
34. Leitner M, Moser H, Eichelberger P, et al. Evaluation of pelvic floor muscle activity during running in continent and incontinent women: an exploratory study.
Neurourol. Urodyn. 2017; 36:1570–6.
35. Leitner M, Moser H, Eichelberger P, et al. Evaluation of pelvic floor kinematics in continent and incontinent women during running: an exploratory study.
Neurourol. Urodyn. 2018; 37:609–18.
36. Koenig I, Eichelberger P, Luginbuehl H, et al. Activation patterns of pelvic floor muscles in women with incontinence while running: a randomized controlled trial.
Int. Urogynecol. J. 2021; 32:335–43.
37. Smith MD, Coppieters MW, Hodges PW. Postural activity of the pelvic floor muscles is delayed during rapid arm movements in women with stress urinary incontinence.
Int. Urogynecol. J. Pelvic Floor Dysfunct. 2007; 18:901–11.
38. Kharaji G, Nikjooy A, Amiri A, Sanjari MA. Proprioception in stress urinary incontinence: a narrative review.
Med. J. Islam Repub. Iran. 2019; 33:60.
39. NICE. Pelvic floor dysfunction: prevention and non-surgical management. 2021.[cited 2023 January 9]. Available from:
https://www.nice.org.uk/guidance/ng210/chapter/Recommendations.
40. Arbuckle JL, Parden AM, Hoover K, et al. Prevalence and awareness of pelvic floor disorders in female adolescents seeking gynecologic care.
J. Pediatr. Adolesc. Gynecol. 2019; 32:288–92.
41. Parden AM, Griffin RL, Hoover K, et al. Prevalence, awareness, and understanding of pelvic floor disorders in adolescent and young women.
Female Pelvic Med. Reconstr. Surg. 2016; 22:346–54.
42. Schettino MT, Mainini G, Ercolano S, et al. Risk of pelvic floor dysfunctions in young athletes.
Clin. Exp. Obstet. Gynecol. 2014; 41:671–6.
43. Rebullido TR, Gómez-Tomás C, Faigenbaum AD, Chulvi-Medrano I. The prevalence of urinary incontinence among adolescent female athletes: a systematic review.
J. Funct. Morphol. Kinesiol. 2021; 6:12.
44. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery.
BJOG. 2000; 107:1460–70.
45. Carvalhais A, Da Roza T, Sacomori C. Pelvic floor in female athletes: From function to dysfunction. In: Brandão S, Da Roza T, Ramos I, Mascarenhas T, editors.
Women's Health and Biomechanics: Where Medicine and Engineering Meet. Springer International Publishing; 2018. p. 145–53.
46. Louis-Charles K, Biggie K, Wolfinbarger A, et al. Pelvic floor dysfunction in the female athlete.
Curr. Sports Med. Rep. 2019; 18:49–52.
47. Eberman LE, Liberi V, Liberi KH. Pelvic pain and pelvic floor dysfunction in male athletes.
Int. J. Athletic. Therapy Train. 2011; 16:8–12.
48. Hallock JL, Handa VL. The epidemiology of pelvic floor disorders and childbirth: an update.
Obstet. Gynecol. Clin. N. Am. 2016; 43:1–13.
49. Wikander L, Kirshbaum MN, Waheed N, Gahreman DE. Urinary incontinence in competitive women powerlifters: a cross-sectional survey.
Sports Med. Open. 2021; 7:89.
50. Carvalhais A, Natal Jorge R, Bø K. Performing high-level sport is strongly associated with urinary incontinence in elite athletes: a comparative study of 372 elite female athletes and 372 controls.
Br. J. Sports Med. 2018; 52:1586–90.
51. Gram MCD, Bø K. High level rhythmic gymnasts and urinary incontinence: prevalence, risk factors, and influence on performance.
Scand. J. Med. Sci. Sports. 2020; 30:159–65.
52. Pires T, Pires P, Moreira H, Viana R. Prevalence of urinary incontinence in high-impact sport athletes: a systematic review and meta-analysis.
J. Hum. Kinet. 2020; 73:279–88.
53. Moossdorff-Steinhauser HFA, Berghmans BCM, Spaanderman MEA, Bols EMJ. Prevalence, incidence and bothersomeness of urinary incontinence in pregnancy: a systematic review and meta-analysis.
Int. Urogynecol. J. 2021; 32:1633–52.
54. Culleton-Quinn E, Bø K, Fleming N, et al. Elite female athletes’ experiences of symptoms of pelvic floor dysfunction: a systematic review.
Int. Urogynecol. J. 2022 Oct; 33:2681–711.
55. Ibinaeva IS, Apolikhina IA, Makhmedzhanova FN, Muslimova SZ. ICIQ-SF questionnaire in women with urinary incontinence.
Urologiia. 2012; 38–42.
56. Klovning A, Avery K, Sandvik H, Hunskaar S. Comparison of two questionnaires for assessing the severity of urinary incontinence: the ICIQ-UI SF versus the incontinence severity index.
Neurourol. Urodyn. 2009; 28:411–5.
57. Rodríguez-López ES, Acevedo-Gómez MB, Romero-Franco N, et al. Urinary incontinence among elite track and field athletes according to their event specialization: a cross-sectional study.
Sports Med. Open. 2022; 8:78.
58. Moore IS, James ML, Brockwell E, et al. Multidisciplinary, biopsychosocial factors contributing to return to running and running related stress urinary incontinence in postpartum women.
Br. J. Sports Med. 2021; 55:1286–92.
59. Grinberg K, Sela Y, Nissanholtz-Gannot R. New insights about chronic pelvic pain syndrome (CPPS).
Int. J. Environ. Res. Public Health. 2020; 17:3005.
60. Pastore EA, Katzman WB. Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain.
J. Obstet. Gynecol. Neonatal. Nurs. 2012; 41:680–91.
61. Edwards D, Panay N. Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition?
Climacteric. 2016; 19:151–61.
62. Maselli F, Palladino M, Barbari V, et al. The diagnostic value of red flags in thoracolumbar pain: a systematic review.
Disabil. Rehabil. 2022; 44:1190–206.
63. Ramanayake RPJC, Basnayake BMTK. Evaluation of red flags minimizes missing serious diseases in primary care.
J. Family Med. Prim. Care. 2018; 7:315–8.
64. Sizer PS Jr., Brismée JM, Cook C. Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain.
Pain Pract. 2007; 7:53–71.
65. NICE. Suspected cancer: recognition and referral NICE guideline [NG12] 2021. [cited 2023 January 9]. Available from:
https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer.
66. Huffman MM, Slack A, Hoke M. Bladder pain syndrome.
Prim. Care. 2019; 46:213–21.
67. Kirtschig G. Lichen sclerosus—presentation, diagnosis and management.
Dtsch. Arztebl. Int. 2016; 113:337–43.
68. Dimpfl T, Jaeger C, Mueller-Felber W, et al. Myogenic changes of the levator ani muscle in premenopausal women: the impact of vaginal delivery and age.
Neurourol. Urodyn. 1998; 17:197–205.
69. Rebullido TR, Stracciolini A. Pelvic floor dysfunction in female athletes: is relative energy deficiency in sport a risk factor?
Curr. Sports Med. Rep. 2019; 18:255–7.
70. Bø K, Sundgot-Borgen J. Are former female elite athletes more likely to experience urinary incontinence later in life than non-athletes?
Scand. J. Med. Sci. Sports. 2010; 20:100–4.
71. Corrado B, Giardulli B, Polito F, et al. The impact of urinary incontinence on quality of life: a cross-sectional study in the metropolitan city of Naples.
Geriatrics (Basel). 2020; 5:96.
72. Mazi B, Kaddour O, Al-Badr A. Depression symptoms in women with pelvic floor dysfunction: a case-control study.
Int. J. Women's Health. 2019; 11:143–8.
73. Bogner HR, Gallo JJ, Swartz KL, Ford DE. Anxiety disorders and disability secondary to urinary incontinence among adults over age 50.
Int. J. Psychiatry Med. 2002; 32:141–54.
74. Eliasson K, Edner A, Mattsson E. Urinary incontinence in very young and mostly nulliparous women with a history of regular organised high-impact trampoline training: occurrence and risk factors.
Int. Urogynecol. J. Pelvic Floor Dysfunct. 2008; 19:687–96.
75. James ML, Moore IS, Donnelly GM, et al. Running during pregnancy and postpartum, part A: why do women stop running during pregnancy and not return to running in the postpartum period?
J. Women’s Health Physical Therap. 2022; 46.
76. Garcia ER, Yim IS. A systematic review of concepts related to women’s empowerment in the perinatal period and their associations with perinatal depressive symptoms and premature birth.
BMC Pregnancy Childbirth. 2017; 17:347.
77. L’Heveder A, Chan M, Mitra A, et al. Sports obstetrics: implications of pregnancy in elite sportswomen, a narrative review.
J. Clin. Med. 2022; 11:4977.
78. Donnelly GM, Brockwell E, Rankin A, Moore IS. Beyond the musculoskeletal system: considering whole-systems readiness for running postpartum.
J. Women’s Health Physical Therap. 2022; 46:48–56.
79. Moossdorff-Steinhauser HFA, Berghmans BCM, Spaanderman MEA, Bols EMJ. Prevalence, incidence and bothersomeness of urinary incontinence between 6 weeks and 1 year post-partum: a systematic review and meta-analysis.
Int. Urogynecol. J. 2021; 32:1675–93.
81. Mills H, Atkinson L, Olander E, et al. Bump start needed: linking guidelines, policy and practice in promoting physical activity during and beyond pregnancy.
Br. J. Sports Med. 2020; 54:764–5.
82. Woodley SJ, Boyle R, Cody JD, et al. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women.
Cochrane Database Syst. Rev. 2017; 12:Cd007471.
83. Deering RE, Christopher SM, Heiderscheit BC. From childbirth to the starting blocks: are we providing the best care to our postpartum athletes?
J. Orthopaedic Sports Physical Therap. 2020; 50:281–4.
84. Truong LK, Bekker S, Whittaker JL. Removing the training wheels: embracing the social, contextual and psychological in sports medicine.
Br. J. Sports Med. 2021; 55:466–7.
85. Hoff Brækken I, Majida M, Engh ME, Bø K. Morphological changes after pelvic floor muscle training measured by 3-dimensional ultrasonography: a randomized controlled trial.
Obstet. Gynecol. 2010; 115(2 Pt 1):317–24.
86. Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.
Cochrane Database Syst. Rev. 2018; 10:Cd005654.
87. Díaz-Álvarez L, Lorenzo-Gallego L, Romay-Barrero H, et al. Does the contractile capability of pelvic floor muscles improve with knowledge acquisition and verbal instructions in healthy women? a systematic review.
Int. J. Environ. Res. Public Health. 2022; 19:9308.
88. Ornö AK, Dietz HP. Levator co-activation is a significant confounder of pelvic organ descent on Valsalva maneuver.
Ultrasound Obstet. Gynecol. 2007; 30:346–50.
89. Kasper K. Sports training principles.
Curr. Sports Med. Rep. 2019; 18:95–6.
90. Gabbett TJ. How much? How fast? How soon? Three simple concepts for progressing training loads to minimize injury risk and enhance performance.
J. Orthop. Sports Phys. Ther. 2020; 50:570–3.
91. Shaw JM, Hamad NM, Coleman TJ, et al. Intra-abdominal pressures during activity in women using an intra-vaginal pressure transducer.
J. Sports Sci. 2014; 32:1176–85.
92. Constantinou CE, Govan DE. Spatial distribution and timing of transmitted and reflexly generated urethral pressures in healthy women.
J. Urol. 1982; 127:964–9.
93. Wiederhold BK. Femtech: digital help for women's health care across the life span.
Cyberpsychol. Behav. Soc. Netw. 2021; 24:697–8.
94. Sudol NT, Adams-Piper E, Perry R, et al. In search of mobile applications for patients with pelvic floor disorders.
Female Pelvic Med. Reconstr. Surg. 2019; 25:252–6.
95. Jaffar A, Tan CE, Mohd-Sidik S, et al. Persuasive technology in an mHealth app designed for pelvic floor muscle training among women: systematic review.
JMIR Mhealth Uhealth. 2022; 10:e28751.
96. Al-Shaikh G, Syed S, Osman S, et al. Pessary use in stress urinary incontinence: a review of advantages, complications, patient satisfaction, and quality of life.
Int. J. Women's Health. 2018; 10:195–201.
97. Duenas-Garcia OF, Shapiro RE, Gaccione P. Safety and efficacy of a disposable vaginal device for stress urinary incontinence.
Female Pelvic Med. Reconstr. Surg. 2021;27:360–4.
98. Jonasson AF, Bryder K, Sthengel E. A vaginal inlay for reduction of stress urinary incontinence: outcome of a randomized clinical trial and four user acceptance studies.
Ther. Adv. Urol. 2021; 2021:8822186.
99. Ninomiya S, Saito I, Masaki K, et al. Single-arm pilot study to determine the effectiveness of the support power of underwear in elevating the bladder neck and reducing symptoms of stress urinary incontinence in women.
Low Urin Tract Symptoms. 2014; 6:81–7.
100. Milner M, Gamble M, Barry-Kinsella C. Covid-19, pelvic health, and women’s voices: a descriptive study.
Continence. 2022; 1:100012.
101. Szkwara JM, Milne N, Rathbone E. A prospective quasi-experimental controlled study evaluating the use of dynamic elastomeric fabric orthoses to manage common postpartum ailments during postnatal care.
Womens Health (Lond). 2020; 16:1745506520927196.
102. Okayama H, Ninomiya S, Naito K, et al. Effects of wearing supportive underwear versus pelvic floor muscle training or no treatment in women with symptoms of stress urinary incontinence: an assessor-blinded randomized control trial.
Int. Urogynecol. J. 2019; 30:1093–9.
103. Szkwara JM, Hing W, Pope R, Rathbone E. Compression shorts reduce prenatal pelvic and low back pain: a prospective quasi-experimental controlled study.
Peer J. 2019; 7:e7080.
104. Hoe V, Haller B, Yao HH, O'Connell HE. Urethral bulking agents for the treatment of stress urinary incontinence in women: a systematic review.
Neurourol. Urodyn. 2021; 40:1349–88.
105. NICE. Urinary incontinence and pelvic organ prolapse in women: management. 2019. [cited 2023 January 9]. Available from:
https://www.nice.org.uk/guidance/ng123/chapter/recommendations.
