Women's Football Hub

Blog: Pelvic Health – Let’s talk about it

Authors: Carolyn Kent MSK specialist Physiotherapist, Kate Leishman Advanced Practice Pelvic Health Physiotherapist & Chloe Evans Specialist Pelvic Health Physiotherapist

Pelvic floor dysfunction (PFD) refers to a group of signs or symptoms that affect the pelvic floor, this can include incontinence (urinary and anal), pelvic organ prolapse (PoP), pelvic pain, overactive bladder syndrome and sexual dysfunction (1)(2). There is evidence to show that female athletes are more at risk of PFD than non athletic females (3). There is also evidence to show that exercising women are 3 times more likely to experience urinary incontinence (4). However, we are still not able to state with certainty why one athlete in a sport will get PFD and another will not (2). It is important to point out that physical activity has many benefits for females and it can be protective against many diseases like cardiovascular disease, obesity, depression, cancer, diabetes mellitus, hypertension, and osteoporosis and can reduce the risk of premature death (5). In short, exercise is good for you overall and you should not stop exercising because you are concerned of the impact on your pelvic floor. You should however, seek input from a specialist if you have concerns about your pelvic floor. This could be a specialist Physiotherapist or nurse in the first instance. Remember that any female (and males) can experience issues with PFD regardless of age or whether you have given birth or not (2).

Is my sport considered high impact?

In the table below you can see football is rated as medium impact (6).

High impactMedium impactLow impact
Gymnastics, basketball, volleyball, high jump, trampoline, powerliftingTennis, running, karate, football, triathlonSwimming, cycling, walking

Stress incontinence, equipment and performance considerations

Only 32 published studies have looked at female equipment in football (7). Females have highlighted increased anxiety about the colour of their shorts especially during menstruation, and wearing white shorts has also been found to have a detrimental effect on team performance (8). Stress urinary incontinence is the most prevalent type of urinary incontinence, and is the involuntary leakage of urine during a period of increased intra abdominal pressure eg. cough, sneeze or physical activities. Athletes report that most urinary incontinence occurs towards the end of competition or training, and tend to wear a pad to manage leakage (9). Practitioners should be aware of this evidence especially if they are working with players with PFD, as equipment options and solutions should be discussed with the athlete.

How do we screen for PFD in athletes?

In 2023, a study was published in the British Journal of Sports Medicine that suggested a screening tool for PFD, it was called the PFD-SENTINEL screening tool. The PFD-SENTINEL is a screening tool which is seen as a first step towards early PFD identification and management, however, further studies are required to validate it (6). This means that it needs further testing to prove that it is effective at measuring what it says it measures (10).

The PFD SENTINEL has 2 sections. The first section screens the athlete for 5 symptoms (Urinary incontinence, Anal incontinence, overactive bladder syndrome, pelvic organ prolapse, pelvic pain).


The second section looks at the presence of 28 risk factors associated with PFD (BMI <18.5 or >30, history of giving birth, having a vaginal delivery, menopause, some medications (psychotropic medications, ACE inhibitors, diuretics), irregular menstrual cycle, hormonal therapy, history of urinary tract infections, family history of urinary incontinence or pelvic organ prolapse, constipation, nerve muscle or tissue disruption of the pelvic floor, pelvic surgery or radiation, diabetes mellitus, connective tissue disease, hypermobility syndrome, relative energy deficiency in sport (RED-s), eating disorders, other musculoskeletal disorders (back pain, hip pain), high impact sports, medium impact sports, age at start of training <14, years of training/sports practice ≥9, training hours/day ≥2, training hours/week ≥8, training frequency/week ≥4, high-level sports/athlete’s national ranking) (6).

How is it scored?

The authors proposed the following when scoring the PFD-SENTINEL

“Score A: direct referral to a PFD specialist should be encouraged if at least one symptom is reported. Only in the case that no symptom is referred, the clinician may proceed to the next section, named ‘total item score’.” (6)

“Score B: referral to a PFD specialist should be suggested if the total item score is ≥14 (50% of all items included).” (6)

“Score C: referral to a PFD specialist should not be suggested if the total item score is <14, which represents the 50% of all items included. Instead, continuous monitoring of the athlete’s health within a multidisciplinary team is indicated.” (6)

The full study on the PFD-SENTINEL is available here.

Conclusion

Athletes and exercising females can be at risk of PFD. Stress incontinence can be an issue when working with female athletes and equipment modifications may need to be discussed. Sports medicine staff working with female athletes should consider using the PFD-SENTINEL to regularly screen their athletes and onward refer if necessary, while being mindful that further validity studies are still required. Athletes should not stop participating in sport due to concerns about PFD but should discuss any concerns with a sports medicine team member.

Have something to contribute? Want to co-write a blog with us? Contact us info@womensfootballhub.com

References

  1. Culleton-Quinn E, Bø K, Fleming N, Mockler D, Cusack C, Daly D. Elite female athletes’ experiences of symptoms of pelvic floor dysfunction: A systematic review. Int Urogynecol J. 2022 Oct;33(10):2681-2711. doi: 10.1007/s00192-022-05302-6. Epub 2022 Aug 30. PMID: 36040507; PMCID: PMC9477953.
  2. Giagio S, Stracciolini A, Faigenbaum A, Pillastrini P, Rial Rebullido T. Infographic. Ten naked truths about the pelvic floor in athletes. Br J Sports Med. 2023 Dec 1;57(24):1583.
  3. Almeida MB, Barra AA, Saltiel F, Silva-Filho AL, Fonseca AM, Figueiredo EM. Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: A cross-sectional study. Scand J Med Sci Sports. 2016 Sep;26(9):1109-16. doi: 10.1111/sms.12546. Epub 2015 Sep 15. PMID: 26369504.
  4. Bø K, Nygaard IE. Is Physical Activity Good or Bad for the Female Pelvic Floor? A Narrative Review. Sports Med. 2020 Mar;50(3):471-484. doi: 10.1007/s40279-019-01243-1. PMID: 31820378; PMCID: PMC7018791.
  5. Miller, K.R., McClave, S.A., Jampolis, M.B. et al. The Health Benefits of Exercise and Physical Activity. Curr Nutr Rep 5, 204–212 (2016). https://doi.org/10.1007/s13668-016-0175-5
  6. Giagio S, Salvioli S, Innocenti T, Gava G, Vecchiato M, Pillastrini P, et al. PFD-SENTINEL: Development of a screening tool for pelvic floor dysfunction in female athletes through an international Delphi consensus. Br J Sports Med. 2023 Jul 1;57(14):899.
  7. Okholm Kryger K, Thomson A, Tang A, Brown N, Bruinvels G, Rosenbloom C, Carmody S, Williamson L, Datson N, Jobson E, Mehta R. Ten questions in sports engineering: technology in elite women’s football Sports Engineering. 2022 Jan;25(1). PMCID: PMC9667860.
  8. Krumer A. On the cost of wearing white shorts in women’s sport. Journal of Behavioral and Experimental Economics 2024;110:102214.
  9. Rzymski P, Burzyński B, Knapik M, Kociszewski J, Wilczak M. How to balance the treatment of stress urinary incontinence among female athletes? Arch Med Sci. 2020 Oct 21;17(2):314-322. doi: 10.5114/aoms.2020.100139. PMID: 33747266; PMCID: PMC7959087.
  10. Shah SS, Gvozdanovic A. Digital health; what do we mean by clinical validation? Expert Rev Med Devices. 2021 Dec;18(sup1):5-8. doi: 10.1080/17434440.2021.2012447. Epub 2021 Dec 12. PMID: 34845960.

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