As athletes, we do all the “little things”. It starts waking up early to get in a workout, fuel our bodies with the right nutrients, and stay after practice to work on that shot, routine, or pitch.  Tracking the mileage we’ve put on shoes, heading to the gym when no one is watching, and daydreaming of untapped potential. Heck, athletes even coach the body to be physically and mentally strong, powerful, and tough. This is done in the hope all these “little things” will turn into a “big thing”. A championship, a PR, or a completed race, aka a personal victory. So, if you were told, as an athlete, that you could be doing something more for your physical and mental well-being, would you say “yes”? If you were ignoring a vital group of muscles that are challenged daily with activity, would you want to know about them? If as a coach, you were told that you could be doing something more to build up an athlete’s confidence in practice and game, would you be eager to know more? Read on to learn more about pelvic floor dysfunction in athletes, and why you should care about your pelvic floor regardless of activities you are passionate about!

What is the pelvic floor? Why Does It Matter In Athletics?

A crucial and often under-recognized group of muscles, the pelvic floor, works to provide stability and support to the spine, pelvis, and organs of urination and defecation in both males and females. When the pelvic floor is not working properly, it can result in poor structural stability of the pelvis and spine as well as urinary leakage during activity and sport. Dysfunction of the pelvic floor is more often seen in female athletes, especially those participating in endurance and high-impact sports. A 2016 study found nearly 73% of trampolinists experience urinary incontinence during practice, followed closely by volleyball players, amateur soccer players, elite endurance athletes including long-distance runners and cross-country skiers, basketball players, and dancers. Wait a minute….did we just list nearly every mainstream sport? Yes, we sure did.

Calling all athletes, it’s time to start making the pelvic floor a part of the conversation. 

Let’s spend a minute breaking down exactly what the pelvic floor is, and its primary function. Sitting in between the two pelvic bones, this group of muscles supports the organs of urination, defecation, and sexual function, as well as provides stability to the hip bones and spine. As if that doesn’t sound important enough, the pelvic floor also works intimately with the diaphragm to control increases in intraabdominal pressure. Anytime we cough, sneeze, run, lift, bump, set, or spike, our pelvic floor is working. That’s right, as an athlete our pelvic floor is working every second of every game! And if it is not doing exactly that, we may experience stress urinary incontinence.

READ: THE FUNCTION OF THE PELVIC FLOOR

Urinary Incontinence

One of the most common signs of pelvic floor dysfunction is urinary incontinence which is defined as “the complaint of any involuntary leakage of urine”4. This definition can then be further broken down into a more specific stress urinary incontinence, which plagues female athletics. Stress urinary incontinence occurs when an increase in intra-abdominal pressure overcomes the strength of the pelvic floor, in which leakage then occurs. The prevalence of stress urinary incontinence in female athletics is alarming. In a comprehensive study that analyzed current health concerns for the female athlete, it was determined that stress urinary incontinence occurs in one-quarter of nulliparous young athletes – averaging at the age of 205. Of these female athletes, most experiencing stress urinary incontinence participated in gymnastics, basketball, and running and jumping sports. All these sports require tolerance to quick changes in intraabdominal pressure and load.

When looking at 480 female weightlifters, who challenge intraabdominal pressure without jumping, 48.5% reported experiencing urinary incontinence within their life with 23.1% experiencing incontinence related to athletics and 17.9% had been continent prior to beginning powerlifting but now experience incontinence6. If at this point you are thinking that stress urinary incontinence in sport is most common to young, recreational athletes or females that lift heavy weights, think again. When questioning three hundred and thirty-one former elite athletes, a study reported that 10.9% experienced stress urinary incontinence while competing in sport and presently 36.9% still reported signs and symptoms7. Simply put, recreational to elite, runners to weightlifters, 16-year-old to 54-year-old, we all have pelvic floors. And we all have pelvic floors that need to be prioritized.  

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The Impact of Urinary Incontinence On Athletic Performance

More concerning than the prevalence of incontinence within athletics, is the way in which incontinence can deter an individual from achieving their athletic goals and dreams. A study that analyzed the impact of urinary incontinence on high school and college athletes found that 25% of these athletes experienced incontinence with 90% reporting that they had never told anyone about the incontinence and had no knowledge of any preventative measures, with 16% of these participants reporting incontinence had a negative impact on their quality of life.

In another study that included 679 women, an alarming 10.4% of these women admitted to stopping participation in their favorite sport because of stress urinary incontinence, and 20% stated that they altered the way they practiced their favorite sport in an effort to reduce episodes of leakage. This is unacceptable. And as teammates, coaches, parents, and healthcare providers we need to protect our athletes’ confidence in both practice and play and consider the ways in which negative emotions associated with urinary incontinence can drastically affect an athlete’s physical and mental well-being.

LISTEN: Training The Mind In Rehab and For Sports Performance With Dr. David Meyer

So now what?

If an athlete acquires symptoms of a stress fracture, they may get referred to a doctor for some imaging. If an athlete has a sprained ankle, an athletic trainer can assist with taping and acute management.  A physical therapist with specialty training in the pelvic floor can provide specific exercises for athletes dealing with urinary leakage. Yup! You heard right! Physical therapists with training in the pelvic floor are highly equipped to assess and manage the athletic pelvic floor. A physical therapist will assess the endurance and strength of this group of muscles, assess the coordination of the pelvic floor with the core and diaphragm, and determine what plan of care is most appropriate for you! 

Learn How To Incorporate Med Ball Exercises Into Your Core Programming!

New flash…..pelvic floor contractions, aka Kegels, are not always the answer. And while appropriate for some, they are certainly not a “one size fits all” approach to the management of the athletic pelvic floor. A physical therapist managing the athletic pelvic floor should provide instruction as to WHEN and HOW to make your pelvic floor the most functional for your sport. This may include coordinating the pelvic floor to work with your breath. Are the diaphragm and pelvic floor working together as a team when the going gets tough on that final stretch of the race?

Diaphragmatic Breathing

Is the pelvic floor working appropriately with the other hip stabilizing muscles? As athletes, are we using our back muscles, core, glutes, and pelvic floor appropriately when cutting across the field?

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Bird Dog – Pelvic Floor 

Are we able to absorb increases in force with the pelvic floor? When we are jumping up for the spike, can we know that our pelvic floor is ready for the impact when we land back on court?

Lunge – Pelvic Floor

A physical therapist with specialty training in the pelvic floor can appropriately guide an athlete through the above exercises as well as many more! As athletes, we have the tools to manage a fracture and an ankle sprain. It’s time we start managing our pelvic floor, as well. 

Closing Thoughts

The pelvic floor is a dynamic and irreplaceable group of muscles that provide pelvic stability and support the organs of urination, defecation and sexual function. Despite their very important role, they often get overlooked when managing the overall health of an athlete. With poor management of the pelvic floor, athletes may experience urinary incontinence during practice, games, or both. Many athletes feel symptoms of urinary incontinence are normal and aren’t even aware that there are resources and healthcare providers that can assist in the management of incontinence! This is so valuable and so important for our athletes, as poor management of urinary incontinence has been shown to lead to feelings of embarrassment, lack of confidence, and even an exit from a loved sport. 

So, next time we are doing all the “little things”; next time we wake up at 5 AM to get out the door before the sun is up or stay after practice to work on that lay up, or open up our running journal to log some mileage, let’s consider our pelvic floor health to be an asset to our athletic journey, as well. After all, all these little things add up to big things. And maybe, just maybe, the health of our pelvic floor was the one little thing we didn’t know we were missing. 

Take Control of Your Core Performance

The outcome of a great core program is NOT a 6-pack but it if does happen we are sure you wouldn’t be upset! The core should be thought of as both a dynamic suitcase and an energy transfer center. The goal is to build a rock-solid suitcase for each aspect of the core and to improve its ability to transfer energy to and from the legs and arms.

References

1. Nygaard, I. Shaw, J. Physical Activity and the Pelvic Floor. Am J Obstet Gynecol. 2016 Feb; 214(2): 164–171.
2. Eickmeyer SM. Anatomy and Physiology of the Pelvic Floor. Phys Med Rehabil Clin N Am. 2017;28(3):455-460. doi:10.1016/j.pmr.2017.03.003
3. Gowda SN, Bordoni B. Anatomy, Abdomen and Pelvis, Levator Ani Muscle. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 11, 2021.
4. Abrams P, Cardozo L, Fall M, et al. The standardization of have shown to be effective in preventing leakage terminology of lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21: 167-78
5. Greydanus DE, Omar H, Pratt HD. The adolescent female athlete: current concepts and conundrums. Pediatr Clin North Am. 2010;57(3):697-718. doi:10.1016/j.pcl.2010.02.005
6. Wikander L, Kirshbaum MN, Waheed N, Gahreman DE. Urinary Incontinence in Competitive Women Powerlifters: A Cross-Sectional Survey. Sports Med Open. 2021;7(1):89. Published 2021 Dec 7. doi:10.1186/s40798-021-00387-7
7. 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(1):100-104. doi:10.1111/j.1600-0838.2008.00871.x
8. Carls C. The prevalence of stress urinary incontinence in high school and college-age female athletes in the midwest: implications for education and prevention. Urol Nurs. 2007;27(1):21-39.
9. Salvatore S, Serati M, Laterza R, Uccella S, Torella M, Bolis PF. 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(14):1115-1118. doi:10.1136/bjsm.2008.049072

About The Author

Lyndsay Centrowitz, PT, DPT

[P]rehab Writer & Content Creator

Dr. Lyndsay Centrowitz graduated from Colorado State University with a BS in Health and Exercise Science and a concentration in Sports Medicine. After multiple personal sports-related injuries and discovering a passion for healing through movement, Lyndsay attended Creighton University to receive her Doctorate of Physical Therapy. An avid runner herself, she has a particular interest in working with high school, recreational and elite endurance athletes and has undergone specialty training in pelvic floor rehabilitation to better serve her clientele. Additionally, Lyndsay is BSPTS C2 certified in scoliosis-specific exercise and has found a niche working with adolescents with scoliosis to improve overall spinal health.

No, you’re not seeing double! Lyndsay is an identical twin to Lauren Lynass, one of our [P]rehab rockstars. A native to Colorado, Lyndsay is an adventure seeker who loves to hike, camp and race her twin sister on the mountain trails. When the Portland rain hits, you can find her curled up with a good book and a cup of tea.

Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.