Pelvic floor health and urinary incontinence (UI) are closely linked—and both significantly impact female athletes and active women. This blog explores the role of the pelvic floor in sport, the prevalence and effects of UI, and how targeted assessment and management by a Women’s Health Physiotherapist can support performance, recovery, and long-term wellbeing.
Pelvic floor muscles in sport
The pelvic floor muscles are made up of a group of deep muscles (levator ani) and hip rotator supporting muscles such as obturator internus and piriformis. These muscles help counteract the large ground reaction forces and increases in intra abdominal pressure that occur with sporting activities such as landing, jumping, running, bracing, tackling and lifting
weights.
These ground reaction forces can be between 1.6 and 2.5 times your body weight when running at a moderate speed, and inevitably, some of this force will go through the pelvic floor muscles. So it is essential that they are able to work in a strong and coordinated manner to maintain continence and protect our pelvic organs.
High impact exercise was found to have a 4.59 fold increased risk of pelvic floor dysfunction compared to low impact exercise.
Prevalence of urinary incontinence (UI) in women who play sport
One in three women across all levels of sport experience urinary incontinence, with elite athletes being three times more likely to develop urinary incontinence than recreationally active athletes The majority of elite athletes have mild UI symptoms, but one third have moderate to severe UI symptoms.
For example in basketball, rugby, tennis, hockey and netball, there are between 17-50% of women experiencing symptoms of UI. In trampolining, dancing and gymnastics, it is reported that between 40-80% of women experience UI symptoms, and when it comes to running, 58% of women report UI symptoms.
How pelvic floor symptoms impact sport
Unfortunately, 1 in 2 women cease sport participation due to pelvic floor symptoms. This is most commonly seen in basketball, netball, athletics and tennis.
39% of athletes report their pelvic floor symptoms negatively impact their performance, and many women report modifying their performance to try and reduce their pelvic floor symptoms. This may be done by:
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- reducing running speed, reducing jump height
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- lifting lighter weights
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- reducing frequency of sport
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- changing sport type to reduce impact on body
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- avoiding group classes to reduce embarrassment
Women reported that the main thing they do to minimise their UI symptoms was to reduce fluid intake prior to playing/training, which can then have a negative impact on their performance and recovery.
Despite how many athletes have UI symptoms, at a recreational level less than 30% have consulted a women's health physio, and at an elite level, this number drops to 10% consulting women's health physios.
What can a Women's Health Physio do to assess for pelvic floor dysfunction in a sporting athlete or recreationally active woman?
A vaginal exam performed by a women's health physiotherapist can assess:
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- Strength, coordination, timing, endurance and functional capacity of the pelvic floor muscles under load
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- A pelvic organ prolapse assessment to determine if there is other tissue
involvement contributing in the UI. Pelvic floor and prolapse assessment would ideally be done in a standing position as well as lying down.
- A pelvic organ prolapse assessment to determine if there is other tissue
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- Bladder and/or bowel diary assessment to better determine fluid intake habits and if this is contributing to the UI. Understanding fluid/food intake throughout the day can help us understand if the bowel and bladder are working optimally.
Risk factors for UI in nulliparous women
Research suggests that there is an increased risk of pelvic floor dysfunction in women who suffer with recurrent UTI's, constipation and low energy availability/eating disorder history
Currently the research does not suggest a correlation between Pelvic floor muscle dysfunction and generalised hypermobility, menstruation irregularity and previous surgery. There is still not enough research to suggest if training load and BMI have direct links to pelvic floor muscle dysfunction
Management with pelvic floor exercises
Pelvic floor muscle training for management of UI should focus on any deficiencies in strength, endurance, muscle activation or timing of muscle activation
Urinary incontinence management in the pre and postnatal period
Doing pelvic floor training during pregnancy has been shown to reduce the chance of UI in pregnancy and in the post natal period, as well as help to prepare for a vaginal birth, with links shown to a shorter first and second stage labour and decreased risk of perineal tears in those who did regular pelvic floor muscle training (individually assessed and prescribed by a physiotherapist).
In the postnatal period, healing times and return to exercise can depend of pelvic floor muscle and surrounding tissue function, which can be affected by vaginal birth injury as well as hormonal changes.
It can take between 8-12 months for natural recovery and healing to occur following a vaginal birth, and the tensile strength of a Caesarean scar is 75% recovered at 6 months post partum.
Keeping this in mind, post partum return to sport timeline should consider pelvic floor muscle function and passive tissue integrity, plus the following individual factors:
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- pregnancy history / delivery method/ birth related complications
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- exercise/sport load
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- physical health and well being of mother and baby
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- current physical capacity and prior training history
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- sleep and fatigue
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- nutritional intake
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- breast health
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- Muscle and joint function including - leg strength, abdominal muscle strength, presence of significant abdominal muscle separation, balance/proprioception
