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SPORTS MEDICINE PELVIC FLOOR MUSCLES
TABLE 1: SYMPTOMS OF PELVIC FLOOR MUSCLE DYSFUNCTION (10) Affected system/structures Lower urinary tract
Symptoms
Urinary incontinence Urgency and frequency Slow or intermittent urine stream and straining
Feeling of incomplete emptying Vagina
Pelvic organ prolapse Bowel symptoms Obstructed defecation Functional constipation Faecal incontinence Rectal or anal prolapse
Sexual function and organs
Dyspareunia in women (painful intercourse)
Erectile and ejaculatory dysfunction (in men)
Orgasmic dysfunction (in men and women)
Pain responses
Chronic pelvic pain Pelvic pain syndrome
TABLE 2: MAXIMUM VERTICAL GROUND-REACTION FORCES IN DIFFERENT SPORTS
Event
Running Jumping
Landing from front somersault Lead foot in javelin throwing
Force (x body weight) 3–4
5 –12 9 9
Landing from double-back somersault 14 Landing in long jump
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women how to perform a trans-abs contraction to bring about contraction of their pelvic floor muscles (7). However, not all women co-activate their pelvic floor muscles during a trans-abs contraction, so while this technique may help initiate contraction of the pelvic floor muscles, it should not be used instead of a muscle-specific training programme (6,8,9).
PELVIC FLOOR MUSCLE DYSFUNCTION The symptoms of dysfunction are shown in Table 1.
THE PELVIC FLOOR AND FITNESS Symptoms of pelvic floor dysfunction – in particular urinary incontinence – are not widely reported among athletes. Yet epidemiological research has shown it to be prevalent. In one study of 35 female Swedish trampolinists (11), 80% leaked urine during training sessions on the trampoline, and 54% described that leakage as “embarrassing”. There is another explanation for this observation, however. Some believe there is a threshold for maintaining continence, so that any extreme rise in intra-abdominal pressure will go over this threshold even in people who are continent and would not otherwise experience urinary leakage. Therapists working with athletes should always consider
the potentially harmful effects that some sports may have on the pelvic floor complex – in particular the stretching of fascial supports. Specific pelvic floor muscle training should
be incorporated into the training schedule. Not surprisingly, different sports impose different stresses on the pelvic floor complex (12) as shown by the maximum vertical ground- reaction forces listed in Table 2.
An American study (13) examined 156 women of average age 19.9 who took part in competitive varsity athletics. None of them had children. The average prevalence of urinary incontinence they experienced while practicing or competing was 28%, and almost half of them experienced incontinence during their normal daily activities. A more recent study carried out in Danish sports clubs (13,14) supports these findings, showing that certain sports produced far greater levels of incontinence than others (Table 3). There is often a misconception that athletes have strong pelvic floor muscles. The assumption is that general physical activity loads the pelvic floor and that by simultaneous or pre-contraction before loading the pelvic floor muscles are exercised. However, the work of Karl Bo, Professor at the Norwegian University of Sport and Physical Education, demonstrates that the loading effects of many sporting activities will weaken pelvic floor muscles further and cause stretch to the supporting endopelvic fascia (15). Another misconception relates specifically to women,
whereby before having children they do not have any problems with their pelvic floor muscles. There is clear evidence that this is not the case (13).
PROTECTING THE PELVIC FLOOR MUSCLES First, it is important that the correct muscle is identified and exercised specifically. In the past many have advised the use of the “mid-stream stopping test” but there is still some confusion about whether or not women should actually be advised to “stop” their urine mid-stream. This is a good way to identify the action of the pelvic floor muscles – however confusion often arises when it is regarded as an exercise for the muscles, which it is not. This is because it is not sufficient to cause fatigue or overloading of the muscles and it will not therefore produce a strengthening effect. Other concerns relate to the interruption of the flow of urine and the chance that this could irritate the bladder, especially if irritative bladder symptoms are already present (16). Interrupting the
TABLE 3: PREVALENCE OF URINARY INCONTINENCE AMONG ATHLETES SPECIALISING IN DIFFERENT SPORTS (13,14)
Event (14)
Aerobics Athletics
Badminton Ballet
Basketball
Field hockey Golf
Gymnastics Handball Softball
Swimming Tennis Track
Volleyball Nygaard study (13)
– – – –
44% 32% –
67% – –
6%
50% 26% 9%
Thyssen study
40% 25% 31%
43% 17% –
0%
56% 21% 6% – – –
30% 25