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Strengthening The Pelvic Floor Muscles

A correct pelvic floor muscle contraction involves two parts: squeezing around the pelvic openings and lifting upwards. However, many people struggle with this. Studies show that over 30% of women can't contract their pelvic floor muscles correctly on their first try, even with instructions.

Several factors make pelvic floor muscle contractions difficult:

pelvic floor muscles are located inside the pelvis, making them hard to see or feel.
Most people haven't learned how to contract these muscles.
The muscles are small and harder to control voluntarily.
People often associate these muscles with activities like going to the bathroom.

Learning to contract pelvic floor muscles correctly can be broken down into five steps:

Understand: Knowing where the pelvic floor muscles are and how they work.
Search: Being able to locate the pelvic floor muscles within the body.
Find: Getting confirmation and guidance from a physical therapist to correctly identify the muscles.
Learn: Practice contracting the pelvic floor muscles correctly, with feedback from a physical therapist.
Control: Work on performing controlled and coordinated pelvic floor muscle contractions.

Physical Therapist Teaching Tools

Feedback and motivation are crucial for learning. Pelvic floor physical therapists are specially trained experts in pelvic floor anatomy and can provide valuable feedback on the strength and correctness of pelvic floor muscle contractions. Physical therapists use various tools to teach how to correctly perform pelvic floor muscle contractions:

Verbal Instructions: Explaining the function of the pelvic floor muscles and how to contract them correctly. A common verbal example is "squeeze and lift."

Visual Aids: Using drawings and anatomical models to show where the pelvic floor muscles are located.

Physical Demonstrations: Helping the client feel a correct pelvic floor muscle contraction and being able to identify the difference between contracting and relaxing other muscles.

Imagery: Describing the contraction as a lift, like an elevator moving upwards, to help visualize the movement.

Direct Physical Contact: Guiding the client in sensory feedback such as sitting on an armrest or edge of a table to feel the contraction in their perineum.

Strength Training for Pelvic Floor Muscles

The pelvic floor muscles are similar to the other muscles in the body and can get stronger with regular exercise. The goal of strength training is to make muscles stronger and more functional by making them bigger and improving how well they work together. This involves doing exercises that follow the basic rules of strength training.

When strength training any muscle, the muscles become thicker and stronger, which improves how quickly and effectively they contract. Connective tissue around the muscles also gets stronger and more elastic, supporting the muscles better.

Key Concepts in Muscle Strength

Muscle Strength: The maximum force a muscle can produce.
Repetition: One complete movement of an exercise.
Set: A group of repetitions done without stopping.
Maximum Voluntary Contraction (MVC): The strongest contraction you can make.
Muscle Size: Bigger muscles are usually stronger.
Muscle Length: Muscles work best at an optimal length.

Speed of Movement: Faster movements usually produce less force.
Neural Control: How well your brain can activate the muscles.

Neural Adaptations: Early strength gains are often due to the brain getting better at activating the muscles.
Muscle Hypertrophy: Over time, muscles get bigger and stronger with consistent training.

Strength Training Guidelines

Muscle Endurance: High repetitions (15-20) with low weight.
Muscle Power: Moderate repetitions (8-12) with moderate weight.
Muscle Strength: Low repetitions (1-6) with high weight.
Frequency: Train each muscle group 2-3 times a week.
Intensity: Use a weight that is challenging, aiming for around 60-80% maximum strength.
Volume: Total work done in a session, week, or month.
Rest: Take breaks of 2-3 minutes between sets to recover.

Pelvic Floor Muscle Recommendations

The American College of Sports Medicine suggests the following for general strength training:

Target major muscle groups.
Do 8 to 12 slow and controlled contractions near maximum effort.
Perform 1 to 3 sets per exercise.
Exercise 2 to 3 times a week.
Adjust your routine over time to keep improving.

Key Factors to Increase Muscle Strength

There are three main principles to focus on when increasing muscle strength: specificity, overload & progression, and maintenance.

Specificity

Exercise affects the muscles that are targeted. For example, arm exercises make the arms stronger. To make the pelvic floor muscles stronger, it is important to do exercises that directly work those muscles. Activities like running and jumping don’t improve pelvic floor muscle strength if the muscles aren’t responding correctly to the added stress. It’s important to balance the load on the pelvic floor muscles to avoid overstretching and weakening them. Even though some other muscles may contract together with the pelvic floor muscles, this doesn’t always happen in people with pelvic floor muscle problems, so specific pelvic floor exercises are necessary.

Overload & Progression

To get the pelvic floor muscle stronger, the muscles need to be overloaded by making the exercises harder. This can be done by adding weight, increasing the number of repetitions, or shortening the rest periods. For pelvic floor muscle training, this can be tricky. One idea is to start with a position that can be held for a minute, then gradually increase to more difficult positions as strength increases. It's advised to be careful, as holding contractions too long can cause discomfort. Also, it is important to breathe normally to avoid dizziness or headaches. More research is needed to find the best ways to progress pelvic floor muscle training, but starting with basic contractions and gradually making them harder is key.

Maintenance

Once muscle strength is built, it is important to keep exercising in order to maintain the strength. Stopping exercise leads to a loss of strength, but the rate of loss depends on factors like age and the length of previous training. Even if the frequency of workouts is reduced, maintaining the intensity can help keep strength gains. For pelvic floor muscle strength, regular maintenance exercises are important. Some studies suggest training at least once a week can help maintain strength for a long time.

Common Mistakes When Training Pelvic Floor Muscles:

Arching the back
Sucking in the stomach
Using inner thigh muscles
Contracting outer abdominal
Contracting hip muscles
Pressing the buttocks together ("bridging")
Holding breath
Inhaling deeply

Recommendations for physical therapists when training pelvic floor muscle contractions:

Ensure the patient can perform the exercise correctly.
Encourage the patient to contract their muscles as hard as possible.
Progress to longer and faster contractions.
Hold contractions for 3 to 10 seconds.
Do Pelvic floor training every day.
If possible, introduce eccentric contractions (lengthening the muscle under tension).
Explain that strength improvements come in stages, with the biggest gains at the start.

Types of Pelvic Floor Muscle Training

In 1948, Kegel was the first to report that pelvic floor muscle training was effective in treating female urinary incontinence. Despite his reports of cure rates higher than 84%, surgery quickly became the preferred treatment. It wasn't until the 1980s that interest in conservative treatments like pelvic floor muscle training resurfaced. This renewed interest likely arose from increased awareness among women about incontinence and health, the cost of surgery, and the complications and relapses reported after surgical procedures.

Although many systematic reviews and consensus statements have recommended pelvic floor muscle training as the first choice for treating urinary incontinence, many surgeons still prefer minimally invasive surgery over pelvic floor muscle training.

This skepticism towards muscle training might stem from:

a lack of understanding of exercise science and physical therapy
doubts about the evidence supporting muscle training's effectiveness
concerns about the long-term effects
beliefs that women are not motivated to perform muscle training regularly.

Recently, mid-urethral sling surgery has come under scrutiny due to concerns about long-term complications. In the UK, the use of synthetic mid-urethral slings has been paused following a 2020 parliamentary review. The review concluded that while many women had successful outcomes, the lack of reliable information on complications meant that some women suffered significantly.

The NICE (2019) guidelines concluded that pelvic floor muscle training is as effective as surgery for about half of the women with stress urinary incontinence. Given the risks associated with surgery and the lack of adverse events with muscle training, they recommend three months of supervised pelvic floor muscle training as the first-line treatment for stress urinary incontinence and mixed urinary incontinence.

Rationale for Pelvic Floor Muscle Training

There are four main theories on how pelvic floor muscle training may prevent and treat stress urinary incontinence:

Theory 1: Women learn to contract their pelvic floor muscles before and during an increase in intra-abdominal pressure to prevent the pelvic floor from descending.

Intentional contraction of the pelvic floor muscles before and during an increase in abdominal pressure lifts the pelvic floor and squeezes around the urethra, vagina, and rectum. Studies using ultrasonography and MRI have verified this lift. This voluntary counter-bracing contraction has been named "the Knack" and has been found to reduce urinary leakage during coughing 73% to 98.2%.

Theory 2: Women perform regular strength training over time to build up the stiffness and structural support of the pelvic floor.

Intensive strength training of the pelvic floor muscles might build structural support, elevating the levator plate and enhancing the pelvic floor muscle's stiffness. This would help prevent pelvic floor descent during increased abdominal pressure. Ultrasound studies showed that women who completed a 12-week muscle training program reduced bladder neck mobility and increased urethral cross-sectional area. Another study reported increased thickness and volume of the striated urethral sphincter after muscle training, along with reduced incontinence episodes.

Theory 3: Pelvic floor muscles are trained indirectly by contracting the internal abdominal muscles, especially the transversus abdominus (TrA) muscle.

It is possible to train the pelvic floor muslces indirectly by training the Transverse abdominus muscle. This is because the pelvic floor muscles are part of the abdominal capsule, which includes the lumbar vertebrae, respiratory diaphragm, TrA, and pelvic floor muscles. Several studies have shown co-contraction of the pelvic floor muscles with abdominal muscle contractions in healthy women.

Theory 4: Functional training involves women performing pelvic floor muscle contractions during daily tasks like lifting or sneezing.

Some physical therapy practices include teaching patients to co-contract the pelvic floor muscles during all daily activities. This approach aims to develop an automatic function to prevent incontinence. One study found this method effective compared to general diet and exercise advice. However, it remains unclear if this functional training alone is enough to prevent incontinence during more complex activities like running or dancing.

Research Evidence for Pelvic Floor Muscle Training

Key points summarized:

Many women struggle to contract their pelvic floor muscles correctly. Around 30% can't do it on their first try, and 25% might strain instead of squeezing and lifting.
Randomized control trials have shown that pelvic floor muscle training is more effective than no treatment for stress urinary incontinence.
Combining pelvic floor muscle training with devices like vaginal cones or biofeedback does not necessarily improve results compared to pelvic floor muscle training alone.
The best outcomes are seen with regular supervised training.
Pelvic floor muscle training often improves symptoms rather than completely curing stress urinary incontinence, with short-term cure rates ranging from 20% to 75%.

With Biofeedback

Biofeedback involves using an external sensor to give feedback on body processes to help improve muscle function. Although some women find biofeedback helpful, studies show that pelvic floor muscle training without biofeedback is also effective.

With Vaginal Weighted Cones

Vaginal cones are weights inserted into the vagina, which require the pelvic floor muscles to contract to keep them from slipping out. Although these may be effective, many women find them uncomfortable and have low compliance.

Other Programs (Yoga, Pilates, "Core training")

Programs like yoga, Pilates, and other core training exercises have been studied for their effects on stress urinary incontinence. None have proven to be better than or add significant benefits to pelvic floor muscle training.

For example, a study on yoga showed improvement in incontinence frequency, but it was not significantly better than control exercises.

Hypopressive Exercise

A study was conducted where 90 women with stress urinary incontinence were randomly divided into two groups.

One group did pelvic floor muscle training
The other group did hypopressive exercise

Both groups did their exercise program for 12 weeks. The pelvic floor muscle training group had better results in reducing the number of leakage episodes over seven days, as well as greater improvement in pelvic floor muscle strength as compared to the hypopressive exercise.

Group Training vs. Individual Training

Studies have compared group and individual pelvic floor muscle training. Both types of training include teaching women how to correctly contract their pelvic floor muscles. Results show that group muscle training is as effective as individual training for treating female urinary incontinence. In a well-designed study, women who did group training had similar results to those who did individual training, with a significant reduction in leakage episodes.

Motivation and Adherence

Motivation and sticking to the exercise program are important for success. Many factors, like proper teaching and a supportive environment, help women stay committed to muscle training programs. Some studies use strategies to improve adherence, like reminders or apps, but results vary. Overall, creating a positive and enjoyable training environment is crucial.

Pelvic Floor Muscles Training Alone

For people who haven't trained before, any exercise can improve function. Including pelvic floor muscle training in fitness programs for women is beneficial. Studies show that the actual pelvic floor muscle training, not other exercise concepts like yoga or Pilates, makes the difference. However, many women need proper instruction to do pelvic floor muscle exercises correctly. Incorrect contractions can reduce the effectiveness of general programs.

Physical activity includes any movement of the body made by skeletal muscles that increases energy use beyond resting levels. It is a key factor in health for people of all ages and can be adjusted to fit individual needs. Research has shown that exercise can act like medicine, helping with many diseases and health conditions. Physical activity can happen in different parts of life, like at work, during travel, doing chores, or as part of hobbies and sports. Exercise training, a type of physical activity, is usually done regularly and with a goal in mind, such as getting fitter, stronger, or healthier.

According to the Physical Activity Guidelines Advisory Committee (2018), regular physical activity has many benefits. It lowers the risk of dying from all causes, heart disease, high blood pressure, type 2 diabetes, and certain types of cancer, like breast and colon cancer. It also helps prevent dementia, anxiety, and depression and reduces the chances of falling and related injuries. Physical activity can improve how you think, your quality of life, sleep, and bone health. It can also help control weight and improve physical function. For people who already have a chronic illness, staying active can lower the risk of developing new conditions, slow disease progression, and improve daily life. Staying active throughout life is essential for good health and well-being.

The pelvic floor, however, is unique. There’s debate about whether physical activity, especially intense exercise, helps or harms it.

Here are two opposite ideas about how physical activity affects the pelvic floor:

Hypothesis 1: Exercise strengthens the pelvic floor.
This idea suggests that impacts during exercise might stretch and tire the pelvic floor muscles (PFMs), causing them to get stronger. The movements during exercise could make the PFMs contract, providing a training effect. These changes might lift the pelvic floor and internal organs, reducing risks of urinary incontinence (UI), anal incontinence (AI), and pelvic organ prolapse (POP). However, these changes might also make childbirth more difficult because they could limit the space for the baby to descend.

Hypothesis 2: Exercise weakens the pelvic floor.
This theory argues that physical activity increases abdominal pressure and ground reaction forces. If the PFMs aren’t strong enough to handle these forces, they could become overstretched and weaker. This could lead to a higher risk of UI, AI, and POP but might make childbirth easier.

Impact of Exercise on the Pelvic Floor

Bø and Nygaard (2019) reviewed studies on how certain exercises affect the pelvic floor. Exercises like strength training and weightlifting can cause short bursts of high intra-abdominal pressure (IAP) but have low ground reaction forces. On the other hand, high-impact activities, like jumping, involve significant ground reaction forces and smaller increases in IAP.

Interestingly, research shows mixed results about which exercises are safest for the pelvic floor. A study by Tian et al. (2018) found no differences in IAP between recommended "safe" exercises and discouraged ones, such as ball rotations, lunges, push-ups, and squats. Other studies suggest that everyday movements, like standing up from a chair, can create more IAP than some restricted activities, such as sit-ups or lifting light weights (O'Dell et al., 2007; Yamasato et al., 2014). Coughing typically generates even higher IAP than most exercises (Bø and Nygaard, 2019).

Ground reaction forces also impact the pelvic floor. For example, running creates forces 3-4 times a person's body weight, while jumping can multiply this force by 5-12 times. Gymnasts landing from flips can experience forces as high as 16 times their body weight (Hay, 1993). These forces must be absorbed by the pelvic floor muscles (PFMs), which may strain them over time.

Measuring the effects of exercise on PFMs is challenging. Tools often have errors due to device movement, interference from surrounding muscles, or difficulty separating IAP from PFM responses (Bø and Nygaard, 2019). Despite these challenges, some studies have provided insights:

Short-Term Effects: In one study, a single 90-minute high-impact workout reduced maximum PFM contraction by 17% but did not change resting pressure or muscle endurance (Ree et al., 2007).
Habitual Exercise Effects: Another study found no changes in PFM strength after one bout of strenuous exercise in CrossFit athletes or light exercise in recreational controls. However, both groups showed a slight decrease in vaginal resting pressure (Middlekauff et al., 2016).

The evidence on whether athletes have stronger or weaker PFMs is unclear. For example:

Weaker PFMs: Volleyball and basketball players were found to have weaker PFMs compared to non-athletes, which correlated with higher symptoms of urinary incontinence (UI) (Borin et al., 2013).
Stronger PFMs: High-impact athletes had stronger PFMs than non-athletes in another study (de Araujo et al., 2015).

Most studies show no clear differences in PFM strength between athletes and non-athletes (Bø and Nygaard, 2019). More research is needed to understand how physical activity affects the pelvic floor, particularly in women without pelvic floor dysfunction.

Prevalence of Urinary Incontinence in Women Participating in Fitness Activities

Stress urinary incontinence (SUI) happens when urine leaks during physical activity (Haylen et al., 2010). Sedentary women may not notice SUI as often since they aren’t as active, even though they might still have the condition. SUI can discourage women from participating in sports and fitness activities, creating a barrier to lifelong exercise (Bø et al., 1989a; Nygaard et al., 1990). While SUI itself isn’t life-threatening, it can lead to inactivity, which increases the risk of many diseases (Pedersen and Saltin, 2015; WHO, 2002).

Studies comparing active and sedentary women show mixed results. Some suggest that active women experience less incontinence, but this may be because women with SUI stop exercising (Brown et al., 1996; Danforth et al., 2007). However, other studies report higher rates of UI in women who exercise, especially in those who do high-impact activities or attend gyms. For example, Fozzatti et al. (2012) found that 24.6% of women attending gyms reported UI compared to 14.3% of non-exercisers.

Adding general physical activity, such as running and jumping, to pelvic floor muscle training (PFMT) does not seem to improve UI outcomes, as shown in a randomized controlled trial (Luginbuehl et al., 2019).

Urinary Incontinence in High-Impact Female Athletes

High-impact sports, like running and jumping, show a higher prevalence of both SUI and urgency urinary incontinence (UUI) in athletes compared to less active women (Bø and Nygaard, 2019). Systematic reviews conclude that athletes are 3.5 times more likely to experience UI than non-exercisers (De Mattos Lourenco et al., 2018).

Some studies used clinical measurements to confirm leakage. For instance, Eliasson et al. (2002) measured urinary leakage in elite trampolinists during training. All participants reporting leakage showed a mean loss of 28 grams during a 15-minute test. Athletes often describe leakage as embarrassing and disruptive to performance, but most do not discuss the issue with anyone (Caylet et al., 2006).

Urinary Incontinence in Female Strength Athletes

Research on strength athletes is limited, but studies show a significant prevalence of UI. In Australian female powerlifters, 37% reported leakage during lifting, though only 11% experienced leakage during daily activities (Wikander et al., 2019). In Norway, 50% of female powerlifters and weightlifters reported UI, with 41.7% experiencing SUI. Many felt this negatively impacted their performance (Skaug et al., 2020). Similarly, 44.8% of female athletes in USA Weightlifting and CrossFit reported leakage during specific exercises like double-unders, running, and front squats (Rohde et al., 2020).

Key Takeaways

Urinary incontinence is common in women who engage in fitness activities, particularly high-impact or strength-based sports. While exercise provides many health benefits, it can also highlight or worsen pelvic floor dysfunction. Further research is needed to understand how different types of exercise impact pelvic floor health and how to better manage UI in active women.

Prevalence of Anal Incontinence in Female Elite Athletes

There is less research on anal incontinence (AI) compared to urinary incontinence (UI) in female elite athletes. Studies suggest the following prevalence rates:

14.8% of athletes aged 18 to 40 reported AI, compared to 4.9% in non-intensive active women. Most cases involved flatus (passing gas) (Vitton et al., 2011).
28% of female triathletes in an online survey reported AI (Yi et al., 2016).
Among Brazilian sport club members, 64.6% reported AI, with no significant difference between athletes and controls (Almeida et al., 2016).
80% of strength and Olympic weightlifters reported AI, with over 70% experiencing gas leakage only (Skaug et al., 2020).

Prevalence of Pelvic Organ Prolapse in Female Elite Athletes

Pelvic organ prolapse (POP) is less studied in athletes but is known to affect certain populations:

Heavy lifting may contribute to POP. Danish nursing assistants were 1.6 times more likely to undergo surgery for genital prolapse and incontinence, though this study didn’t control for childbirth history (Jørgensen et al., 1994).
A study on 56 women undergoing POP surgery found that physical activity had mixed effects on POP stages. After engaging in activities like walking and stair climbing, 26% of participants experienced an increase in their POP stage, while 70% maintained the same stage (Ali-Ross et al., 2009).
In military training, women in paratrooper training were significantly more likely to develop stage 3 prolapse after six weeks of intense summer training (Larsen and Yavorek, 2007).
Among female triathletes, 5% reported POP symptoms (Yi et al., 2016). No POP symptoms were reported in a study of 67 Brazilian athletes (Almeida et al., 2016).
In strength sports, 23.3% of female powerlifters and Olympic weightlifters reported a sensation of a vaginal bulge (Skaug et al., 2020).

Summary

Although less common than UI, both AI and POP affect a notable percentage of female athletes, particularly those involved in high-impact or strength-based sports. There is an urgent need for more research to understand the mechanisms, risk factors, and prevention strategies for these conditions in women who exercise regularly.

Prevalence of Urinary and Anal Incontinence in Male Athletes

There is very little research on urinary incontinence (UI) and anal incontinence (AI) in male athletes, which may indicate that these conditions are less commonly reported or remain a taboo topic among men.

Urinary Incontinence: In a study by Bø et al. (2011), only 2% (3 out of 152) of male group instructors reported UI, and the leakage was unrelated to physical activity.
Anal Incontinence: A Norwegian study of 204 male powerlifters and Olympic weightlifters found a prevalence of 9.3% for UI and 61.8% for AI, with most cases of AI involving gas leakage. The men reported minimal bother from the condition (Skaug et al., 2020).

Prevention of Pelvic Floor Dysfunction in Athletes

There are no studies specifically testing pelvic floor muscle training (PFMT) as a primary prevention method for UI, AI, or pelvic organ prolapse (POP) in athletes. However, theoretical evidence supports the idea that strengthening the pelvic floor muscles could prevent these conditions.

Benefits of PFMT: Research shows that PFMT can increase muscle thickness, reduce muscle length, decrease the levator hiatus area, and lift the levator plate in women with POP (Brækken et al., 2010). These changes could help stabilize the pelvic floor during activities that increase intra-abdominal pressure (IAP) or involve ground reaction forces.
Optimal Pelvic Floor Positioning: If the pelvic floor is in an optimal position, excessive downward movement or opening of the levator hiatus, urethra, vagina, or rectum may be prevented. This could reduce the need for pre- or co-contraction of pelvic floor muscles during physical exertion.

Preventive Devices

Several devices are available to help manage pelvic floor dysfunction during physical activity:

Vaginal Devices: A simple tampon or similar device can prevent urinary leakage during activities. In one study, six women with SUI experienced total dryness during 30 minutes of aerobics using a vaginal device (Glavind, 1997).
Protective Pads: Specially designed pads can be used to manage smaller leaks during training or competition.

Conclusion

While male athletes report lower prevalence rates of UI and AI than female athletes, more research is needed to understand these conditions in men. For both men and women, PFMT and simple preventive devices may offer effective strategies to reduce leakage during physical activity, but further studies are essential to confirm their benefits.

Treatment of Stress Urinary Incontinence in Elite Athletes

Stress urinary incontinence (SUI) in elite athletes can be addressed through several treatments, including pelvic floor muscle training (PFMT), bladder training, biofeedback, electrical stimulation, drug therapy, or surgery. However, due to the high physical demands placed on their pelvic floor, elite athletes may require stronger and more conditioned pelvic floor muscles (PFMs) compared to non-athletes.

Pelvic Floor Muscle Training (PFMT)

Effectiveness: PFMT is considered the first-line treatment for SUI and mixed urinary incontinence (MUI). Systematic reviews and meta-analyses have demonstrated its effectiveness, with subjective cure and improvement rates reaching up to 70% in randomized controlled trials (RCTs) (Dumoulin et al., 2017; Hay-Smith et al., 2011).
Research Findings: Studies show significant improvement in urinary leakage during physical activity, including high-impact exercises like running and jumping, after PFMT (Bø et al., 1990; Mørkved et al., 2002). For example, one study reported a reduction in mean urine loss from 27g to 7.1g during standardized activities (Bø et al., 1990).
Athlete-Specific Challenges: While elite athletes are highly motivated and accustomed to training, they often lack knowledge about the pelvic floor and PFMT techniques. Proper instruction and assessment of PFM contractions are essential for effective results (Gram and Bø, 2020; Skaug et al., 2020).

Bladder Training

Bladder training may involve using frequency-volume charts to improve toileting behaviors. Many elite athletes already empty their bladders before training and competition, reducing the likelihood of exercising with a full bladder (Fozzatti et al., 2012).

Surgery

Surgery is not recommended for young, nulliparous athletes as their symptoms are often tied to high-impact activities and may improve when these activities are reduced later in life. PFMT should always be tried before considering surgical options (Dumoulin et al., 2017; NICE, 2019).

Oestrogen Therapy

The role of oestrogen in treating SUI is controversial. Local oestrogen therapy may provide some benefit, but systemic hormone replacement therapy may worsen UI (Andersson et al., 2017). For athletes with low oestrogen levels, due to conditions like amenorrhea, replacement therapy may be used primarily to prevent osteoporosis rather than directly treat SUI.

Preventive Devices

Preventive devices, such as tampons or vaginal supports, can help prevent urinary leakage during physical activity. For example, Glavind (1997) found that women with SUI remained dry during aerobics using a vaginal device.

Clinical Recommendations

Education: Provide information about pelvic floor function, dysfunction, and PFMT to fitness instructors and athletic coaches.
Preventive Devices: Recommend the use of tampons or other devices to prevent leakage during physical activity.
PFMT Programs: Follow general PFMT guidelines for female elite athletes to address SUI and POP.

Conclusion

SUI is a common issue among young, nulliparous elite athletes, particularly those in high-impact sports like gymnastics, track and field, and ball games. While PFMT has shown significant benefits, more research is needed to understand pelvic floor function during physical activity, as well as the effects of PFMT on UI, AI, and POP in both female and male athletes. Ensuring athletes are equipped with proper knowledge and training tools is essential to improving their health, performance, and quality of life.

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References: Bo, K., Berghmans, B., Mørkved, S., & Van Kampen, M. (Eds.). (2023). Evidence-Based Physical Therapy for the Pelvic Floor (3rd ed.). Elsevier.

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