This past weekend I was invited to teach second year medical students at the University of New England (UNE) in Maine. The experience inspired me for many reasons. One was that Friday was a gorgeous, nearly 60-degree day and UNE is located near Goose Rocks Beach in Kennebunkport, Maine. The photo is where I stopped for lunch before my talk.
The other, more important, reason was that because of my colleague, Dr. Frank Willard, medical students at UNE are learning about pain and how to manage it early on in their training. I was thrilled to have had the opportunity to lecture on the topic of Pelvic Pain during their Reproductive Unit!
The students were attentive and eager to learn about unique methods of pelvic pain treatment, such as physical therapy and acupuncture. Having the opportunity to influence developing doctors at a time when their minds are most open is hopeful. By encouraging interest in pelvic health starting early in medical training and across specialties, I believe the treatment of these issues will no longer be left entirely in the gynecologist’s realm.
The other, more important, reason was that because of my colleague, Dr. Frank Willard, medical students at UNE are learning about pain and how to manage it early on in their training. I was thrilled to have had the opportunity to lecture on the topic of Pelvic Pain during their Reproductive Unit!
The students were attentive and eager to learn about unique methods of pelvic pain treatment, such as physical therapy and acupuncture. Having the opportunity to influence developing doctors at a time when their minds are most open is hopeful. By encouraging interest in pelvic health starting early in medical training and across specialties, I believe the treatment of these issues will no longer be left entirely in the gynecologist’s realm.
There is evidence that interest in pelvic disorders is growing in my own specialty, Physical Medicine and Rehabilitation. This month my specialty’s academic journal, PM&R, published a study looking at female athletes and pelvic floor muscle strength (1). The authors examined 40 women aged 18-30 years of age. 30 of them were athletic (10 handball players, 10 volleyball players and 10 basketball players) and 10 were classified as nonathletic, since they didn't participate in regular exercise. The pressure generated during a maximum contraction of the pelvic floor muscles (the muscles surrounding the vagina and urethra) was measured with a device called a perineometer. This is basically a pressure gauge (see photo) that was placed in the vagina and the women were then asked to squeeze as hard as they could.
One might guess that the athletic women were better able to generate a pelvic floor muscle contraction due to being fitter and generally stronger. But this study found just the opposite. Athletes, especially those playing volleyball and basketball, involving a lot of jumping, generated lower perineal pressures on pelvic floor testing than nonathletic women. Also, lower pelvic floor pressures correlated with symptoms of urinary incontinence during sport. The activities that appeared to put them particularly at risk included the number of games played per year, strength training, and on court workouts, as opposed to abdominal exercises which were not correlated with low pelvic floor muscle pressures.
There has been some interest in this topic from a research perspective with evidence that female athletes may suffer high rates of pelvic floor muscle dysfunction. The risk appears mainly related to the degree of stress put on the pelvic floor muscle during their particular sport. For example, Bo et al found that 26.3% of female fitness instructors reported urinary incontinence (2), while Eliasson et al found that 80% of elite female trampolinists reported urinary leaking during activity (3). Another survey by Nygaard et al found that 7-38% of women who exercised regularly had problems with leaking (4).
Despite these high rates of urinary symptoms reported on anonymous surveys, female athletes (and women in general) tend to under report incontinence presumably due to shame and embarrassment. Maybe they talk to their girlfriends, mothers and sisters about this, but apparently not to their doctors. OK, so maybe this has to do with being embarrassed, but there are a lot of embarrassing things patients tell their doctors every day without hesitation. So, why so hush-hush when it comes to urinary incontinence?
Acceptance may be a big part of it. Could it be that women are indoctrinated at young ages to accept urinary incontinence as just another female annoyance? Certainly, this seems to hold true for older women or those who have born children. The “what do you expect, you’ve had x-number of children attitude”. Does this start so young that even female athletes accept urine leakage as a “normal” part of athletic participation? If so, that’s too bad. Excellent, non-surgical treatments for urinary incontinence do exist. In another study, strengthening of the pelvic floor muscles was shown to be effective in reducing symptoms of urinary incontinence (5).
Although pelvic floor physical therapy remains a less popular career choice for physical therapists, The American Physical Therapy Association (APTA) is working to change those statistics. Increasing effort is being dedicated toward recruitment of physical therapists into the field of pelvic health. Hopefully, we will see a rise in readily available treatments for urinary incontinence with awareness starting even at young ages in female athletes and non-athletes alike. After all, why accept symptoms as “normal”, when good treatments exist? The talk with a clinician may be well worth the initial embarrassment!
1. da Silva Borin LCM, Nunes FR, de Oliveira Guirro EC. Assessment of Pelvic Floor Muscle Pressure in Female Athletes. PM&R 2013; 5:189-193.
2. Bo K, Bratland-Sanda S, Sundgot-Borgen J. Urinary incontinence among group fitness instructors including yoga and Pilates teachers. Neurourol Urodyn 2011; 30: 370-373
3. Eliasson K, Larsson T, Mattsson E. Prevalence of stress incontinence in nulliparous elite trampolinists. Scand J Med Sci Sports 2002; 12: 106-110
4. Nygaard IE, Delancey JOL, Arnsdorf L. Exercise and incontinence. Obstet Gynecol 1990; 75: 848-851
5. Bo K, Hagen B, Kvarstein B, Larsen S. Female stress urinary incontinence and participation in different sport and social activities. Scand J Sports Sci 1989; 11: 117-121
One might guess that the athletic women were better able to generate a pelvic floor muscle contraction due to being fitter and generally stronger. But this study found just the opposite. Athletes, especially those playing volleyball and basketball, involving a lot of jumping, generated lower perineal pressures on pelvic floor testing than nonathletic women. Also, lower pelvic floor pressures correlated with symptoms of urinary incontinence during sport. The activities that appeared to put them particularly at risk included the number of games played per year, strength training, and on court workouts, as opposed to abdominal exercises which were not correlated with low pelvic floor muscle pressures.
There has been some interest in this topic from a research perspective with evidence that female athletes may suffer high rates of pelvic floor muscle dysfunction. The risk appears mainly related to the degree of stress put on the pelvic floor muscle during their particular sport. For example, Bo et al found that 26.3% of female fitness instructors reported urinary incontinence (2), while Eliasson et al found that 80% of elite female trampolinists reported urinary leaking during activity (3). Another survey by Nygaard et al found that 7-38% of women who exercised regularly had problems with leaking (4).
Despite these high rates of urinary symptoms reported on anonymous surveys, female athletes (and women in general) tend to under report incontinence presumably due to shame and embarrassment. Maybe they talk to their girlfriends, mothers and sisters about this, but apparently not to their doctors. OK, so maybe this has to do with being embarrassed, but there are a lot of embarrassing things patients tell their doctors every day without hesitation. So, why so hush-hush when it comes to urinary incontinence?
Acceptance may be a big part of it. Could it be that women are indoctrinated at young ages to accept urinary incontinence as just another female annoyance? Certainly, this seems to hold true for older women or those who have born children. The “what do you expect, you’ve had x-number of children attitude”. Does this start so young that even female athletes accept urine leakage as a “normal” part of athletic participation? If so, that’s too bad. Excellent, non-surgical treatments for urinary incontinence do exist. In another study, strengthening of the pelvic floor muscles was shown to be effective in reducing symptoms of urinary incontinence (5).
Although pelvic floor physical therapy remains a less popular career choice for physical therapists, The American Physical Therapy Association (APTA) is working to change those statistics. Increasing effort is being dedicated toward recruitment of physical therapists into the field of pelvic health. Hopefully, we will see a rise in readily available treatments for urinary incontinence with awareness starting even at young ages in female athletes and non-athletes alike. After all, why accept symptoms as “normal”, when good treatments exist? The talk with a clinician may be well worth the initial embarrassment!
1. da Silva Borin LCM, Nunes FR, de Oliveira Guirro EC. Assessment of Pelvic Floor Muscle Pressure in Female Athletes. PM&R 2013; 5:189-193.
2. Bo K, Bratland-Sanda S, Sundgot-Borgen J. Urinary incontinence among group fitness instructors including yoga and Pilates teachers. Neurourol Urodyn 2011; 30: 370-373
3. Eliasson K, Larsson T, Mattsson E. Prevalence of stress incontinence in nulliparous elite trampolinists. Scand J Med Sci Sports 2002; 12: 106-110
4. Nygaard IE, Delancey JOL, Arnsdorf L. Exercise and incontinence. Obstet Gynecol 1990; 75: 848-851
5. Bo K, Hagen B, Kvarstein B, Larsen S. Female stress urinary incontinence and participation in different sport and social activities. Scand J Sports Sci 1989; 11: 117-121
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