Pelvic floor symptoms a barrier to sport and exercise

The image shows a running woman with a cloud of red smoke behind her.

Pelvic floor symptoms a barrier to sport and exercise

The image shows a running woman with a cloud of red smoke behind her.

Research shows that women experiencing pelvic floor symptoms like urinary incontinence may reduce or even stop their participation in sport and exercise but screening and education may help them access the help they need to keep going.

On average, one in three women leak urine when they exercise, although the rate varies depending on whether they are engaged in low-impact exercise or high-impact sports.

Other pelvic floor (PF) symptoms, such as anal incontinence or pelvic organ prolapse, are also experienced by women participating in sport and exercise, whether they are elite athletes or exercising for health and recreation.

A recent study led by physiotherapist and researcher Dr Jodie Dakic APAM at Monash University has shown that almost one in two Australian women experiencing PF symptoms during sport or exercise stop participating in a form of sport or exercise.

The study was funded in part by a Physiotherapy Research Foundation Seeding Grant awarded to Jodie in 2017.

Her findings are based on a survey of 4556 Australian women aged 18 to 65 with self-identified pelvic floor symptoms, which focused on establishing the impact of PF symptoms on exercise participation (Dakic et al 2021) and identifying PF symptoms as an often overlooked barrier to participation (Dakic et al 2022).

Overall, 46 per cent of the surveyed women stopped participating in exercise activities due to PF symptoms, while more than 50 per cent modified their activities.

Among women participating in high-impact sports and exercise, 42 per cent stopped participating in that sport or exercise.

‘It’s a significant number. We found that it affected women across all age categories, including 18–25-year-old women, which was surprising,’ Jodie says.

‘In those younger women, and in women who hadn’t had children, one in three were also stopping a form of sport or exercise due to the pelvic floor symptoms they were experiencing.

‘That’s a substantial period of the life span to be missing out on the benefits of physical activity.’

She says the sheer prevalence of PF symptoms in women participating in sport and exercise was a surprise to her, even after working with professional female athletes for more than a decade.

‘We often associate pelvic floor symptoms with the postnatal period.

‘As physios we need to be aware that women of all age groups—from young women who haven’t had children to pregnant, postnatal and menopausal women—are experiencing the impact of symptoms on their sport and exercise,’ Jodie says.

The study found that PF symptoms affected women’s participation in sport and exercise in different ways.

Some women modified their exercise—for example, by reducing the intensity or moving to a lower impact form of exercise.

‘A lot of women said they didn’t feel comfortable exercising in group settings because they were worried that other people might find out about their symptoms,’ Jodie says.

The frustration and anxiety associated with PF symptoms also affect women’s overall wellbeing, Jodie notes.

Many women employed coping strategies such as reducing fluid intake, making multiple trips to the toilet to empty their bladder before exercise or only working out at certain times of the day.

‘We already know there are a lot of barriers to exercise and this is another hurdle that women have to overcome,’ she says.

Alongside the survey of women with PF symptoms, Jodie and her colleagues surveyed 636 health and exercise professionals—including physiotherapists, personal trainers, fitness instructors and exercise physiologists—to look at practices and attitudes in relation to screening for PF symptoms in exercising women (Dakic et al 2023a).

The findings showed that only 23 per cent screened women for PF symptoms and then only when indicated—most commonly, in women who were pregnant or returning to exercise after giving birth.

High-risk groups such as young athletes competing in high-impact sports were not commonly included in PF screening practice.

Jodie says the issue may be even worse than the data shows.

Because participants were self-selected, those who were already engaged in PF screening may have been more willing to respond.

The vast majority (more than 85 per cent) of survey respondents were women. For male exercise and health professionals, the researchers suggest that lack of interest, confidence or comfort regarding PF symptom screening could be at play, limiting participation in the survey.

However, the survey did show that participants were willing to include PF screening in their practice—for example, in pre-exercise screening questionnaires that are commonly used to identify other health issues such as injuries, asthma or high blood pressure.

‘They wanted a screening tool to use in the clinic or the gym.

‘They wanted access to referral networks and to resources and education that they could provide to their players, patients and clients so they could provide an appropriate response.

‘And they felt that they needed those things in order to have the confidence to implement the screening,’ Jodie says.

Following these results, Jodie and her colleagues went back to their original cohort of women with PF symptoms to ask a small subset whether they would feel comfortable disclosing their symptoms in a sports and exercise environment and how this might be achieved.

Just over a half of the women surveyed said they would be willing to discuss their symptoms in a sports and exercise setting if asked.

However, interviews revealed that women considered many factors when deciding whether they are comfortable to discuss symptoms of such a personal nature.

Women were surprised that PF questions weren’t already included in other pre-exercise health screening questionnaires, saying it would help to normalise the conversation as a genuine health concern (Dakic 2023b).

‘One of the main reasons they hadn’t told anybody was because no one had asked them and it’s a challenging conversation to initiate.

A lot of women said, “I’d like the health professional or the exercise professional to initiate the conversation.” But they wanted it to be done in a carefully considered, supportive and safe manner,’ she says.

Overall, the researchers found that a majority of women had not told anyone about their PF symptoms due to shame or embarrassment, a lack of knowledge about PF disorders and available treatments and not wanting to initiate the conversation.

They endorsed including PF symptoms within existing sports and exercise screening practices as long as it was done in a supportive, safe and respectful manner by appropriately trained health and exercise professionals.

Jodie says the research team has now started working with professional sports organisations and governing bodies to raise awareness of pelvic health in female athletes and active women.

‘We’re trying to do that in two ways.

‘One is providing education to the exercising women, teaching them about their pelvic floor health and the common symptoms and helping them to understand what treatment options are available,’ she says.

‘The other thing we’re doing is working with sporting organisations and with groups such as the APA and Sports Medicine Australia to try to educate the professionals who are working with the women.’

The team has worked with the Australian Institute of Sport to develop education modules, fact sheets and infographics on PF health for female athletes, their coaches and sporting and other support organisations.

Jodie and her colleagues are investigating the feasibility of PF muscle training for female athletes in high-impact sports that involve repetitive jumping, landing, lifting and tackling.

They are also looking more closely at the less well understood PF symptoms and disorders, including leaking gas or stool, pelvic pain and pelvic organ prolapse, to identify their prevalence, impact and risk factors across sports such as rugby, AFLW and hockey.

‘People are starting to realise that this is something that affects female athletes but we need a lot more research in this space to be able to understand exactly why these symptoms are happening at such a high prevalence and what the best management is for athletes who are under high-impact loads to reduce or cure those symptoms,’ Jodie says.

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Course of interest:

Women’s Pelvic Health Level 1—Part B 

>> Jodie Dakic received a PRF Seeding Grant in 2017 for this study.

>> This research was also supported by funding from the Australian Bladder Foundation managed by the Continence Foundation of Australia.


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