Pelvic Floor Dysfunction in Sport

The commonest presentation is stress urinary incontinence, meaning leaking on effort, and in athletes it is often confined to sport, so a woman who is dry all day may leak reliably on her third set of jumps. Urgency incontinence and overactive bladder present instead with a sudden compelling need to pass urine, and mixed symptoms are common.

Beyond leaking, ask about a sense of heaviness, dragging or a bulge, which suggests pelvic organ prolapse. Ask about faecal urgency or incontinence, which is more common than the literature implies and almost never volunteered. Ask about pelvic pain or pain with intercourse, which may point to increased tone rather than weakness. And ask what she has already changed, since pads, fluid restriction, avoiding particular sessions or dropping out of her sport all tell you how much this is costing her.

Categorisation drives everything that follows. At the first assessment, classify the incontinence as stress, urgency or mixed, and where symptoms are mixed, direct treatment at the predominant one, because first-line treatment differs between them.

A three-day bladder diary recording frequency, volumes, urgency, triggers and fluid intake is more informative than any single question in the consultation. A urine dipstick is undertaken in every woman presenting with incontinence, screening for markers of infection and for haematuria, with culture guided by her symptoms and the dipstick findings. Visible haematuria is investigated promptly: a suspected cancer pathway referral applies from the age of 45 where it is unexplained or persists after an infection has been treated, but a younger athlete still needs assessment rather than an assumption that her sport explains it.

Examine the abdomen, and undertake a routine digital assessment to confirm she can perform a pelvic floor muscle contraction before supervised pelvic floor muscle training is used. That assessment also grades strength and endurance and, importantly, establishes whether she can relax, which is what separates a weak floor from a tight one and changes the treatment entirely. Post-void residual measurement by bladder scan is reserved for suspected voiding dysfunction or recurrent urinary infection. Refer to a pelvic health physiotherapist where assessment or treatment is beyond the clinic, and refer on where prolapse is suspected or symptoms prove refractory.

Supervised pelvic floor muscle training of at least three months is first-line for stress or mixed incontinence, and the programme should comprise at least eight contractions performed three times per day. Supervision matters, because a substantial proportion of women contract incorrectly when instructed verbally alone, which is the point of the digital assessment beforehand. Perineometry and electromyographic biofeedback are not recommended as a routine part of that training.

For urgency incontinence or overactive bladder, bladder training for at least six weeks is first-line, alongside a trial of caffeine reduction and sensible fluid intake rather than fluid restriction. An antimuscarinic follows where bladder training alone is insufficient, and a beta-3 agonist, either mirabegron or vibegron, is used where an antimuscarinic is unsuitable, ineffective or not tolerated. Duloxetine is not offered as first-line treatment for stress incontinence. Vaginal oestrogen helps where there is urogenital atrophy, and constipation is treated, since straining loads the same system. Surgical options exist, are a specialist decision, and follow conservative treatment rather than replacing it.

Where tone is increased rather than reduced, the treatment inverts: down-training, breathing and relaxation work, and attention to bracing strategy, rather than more contractions. The evidence in athletes is thin, but the clinical logic is not, and prescribing contractions to a floor that cannot relax is a real way to make someone worse.

Athletes rarely need to stop. Load and technique are modified rather than abandoned, breathing and bracing strategy is reviewed, and session order is adjusted so that high-impact work is not done on an already fatigued floor. Energy availability is addressed where relevant. Intravaginal devices are not used for routine management, but occasional use to prevent leakage during exercise is a recognised exception and suits some athletes.

• •Current NICE guidance on urinary incontinence and pelvic organ prolapse in women sets out categorisation, the digital assessment, the pelvic floor muscle training and bladder training regimens, the position on duloxetine, and the exercise exception for intravaginal devices.
• •Systematic reviews report symptoms commonly in sports involving jumping and running, and substantial prevalence in nulliparous athletes, although estimates are heterogeneous.
• •A recent umbrella review questions whether broad sport classifications capture pelvic floor loading, so rankings by sport should be read with caution.
• •Reviews of elite female athletes identify pelvic floor laxity, bladder neck descent, muscle fatigue, hypermobility and low energy availability as possible associated factors.

• •Pelvic floor dysfunction is common in athletes, is under-reported, and is found only if you ask.
• •It is not confined to postpartum women, and nulliparous athletes in jumping and running sports are affected.
• •Categorise as stress, urgency or mixed first, since first-line treatment differs between them.
• •Supervised pelvic floor muscle training for at least three months is first-line for stress incontinence.
• •Bladder training for at least six weeks is first-line for urgency incontinence.
• •Do not assume weakness: a tight floor needs down-training, not more contractions.