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Prevalence and treatment modalities

Pelvic floor disorders in physically active women and female athletes

Gynäkologie & Geburtshilfe | Urologie & Andrologie
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<p class="article-intro">There is an increasing interest in physical activity and sport for adolescent girls and young adults worldwide. This is especially true for female athletes as the benefits of an active lifestyle are well documented. During the last three decades a tremendous increase in female sports participation has been witnessed at all levels. The belief that urinary incontinence (UI) is mainly a problem of the elderly and parous women has been prevailing in our society. However, recent studies have shown that young, physically fit, nulliparous women also suffer from UI. The term female pelvic floor dysfunction can be applied to a wide variety of clinical conditions, including UI.</p> <hr /> <p class="article-content"><p>There is an increasing interest in physical activity and sport for adolescent girls and young adults worldwide. This is especially true for female athletes as the benefits of an active lifestyle are well documented. During the last three decades a tremendous increase in female sports participation has been witnessed at all levels. The belief that urinary incontinence (UI) is mainly a problem of the elderly and parous women has been prevailing in our society. However, recent studies have shown that young, physically fit, nulliparous women also suffer from UI. The term female pelvic floor dysfunction can be applied to a wide variety of clinical conditions, including UI.</p> <h2>Common medical problems in the female athlete</h2> <p>Female athletes are more prone to certain sport-related problems compared to men. Musculoskeletal problems more common in female athletes include patellofemoral pain syndrome and anterior cruciate ligament tears, as well as bone stress injuries, among others.<sup>1</sup> One of the most important medical problems that can occur with female athletes is the female athlete triad.<sup>2</sup> It is a medical condition often observed in physically active and athletic females that involves the interrelationships among spectrums of energy availability, menstrual function and bone mineral density, that may have clinical manifestations of: (1) low energy availability with or without disordered eating or eating disorders, (2) menstrual dysfunction and (3) low bone mineral density, increased fracture risk, and/or osteoporosis. All female athletes are at risk of the female athlete triad, regardless of body build or sport. Nonetheless, the condition is most common in young female athletes in sports which focus on a thin and lean physique as is commonly seen in endurance sports, or in sports in which there is subjective judging. Low energy availability and inadequate caloric intake appear to be an underlying causative factor in the female athlete triad.<sup>2</sup><br /> The increased participation in sports at all levels has alerted the medical profession to other medical problems occurring in active and athletic women. Included in these problems is loss of bladder control as well as pelvic floor disorders (PFDs). In order to meet today&rsquo;s society standards of beauty, girls become over-aware of their appearance and wanting to be &laquo;fit&raquo; often includes well-developed abdominal muscles. However, intra-abdominal pressures that occur during many abdominal strengthening exercises, as well as in certain sports, result in an increase of the pressure on the pelvic floor, and can often increase the problem of UI.</p> <p>Physically active women are more likely than sedentary women to experience UI. This is especially true for those competing in high-impact sports. Elite athletes, or physically active individuals who participate in high-impact sports are at increased risk for developing PFDs. Links between compromised pelvic floor health and strenuous exercise are reported in the literature. Certain exercise in particular can maintain pelvic floor health.<sup>3</sup> There are two opposing hypotheses on how strenuous exercise or hard work might affect the pelvic floor: (a) physical activity may strengthen the pelvic floor muscles (PFM) and (b) physical activity may overload, stretch and weaken the pelvic floor.<sup>4</sup></p> <h2>Prevalence and related risk factors</h2> <p>The prevalence of UI associated with exercise and sport ranges from 20 to 52 % with women participating in higher impact sports at greater odds of experiencing UI compared to those at lower levels of impact.<sup>5, 6</sup> Athletes, in general, are at higher risk to develop UI, loss of gas, and sexual dysfunctions, either practicing highimpact or strong-effort activities. However, UI is a prevalent condition in women whether they exercise professionally or not. It is reported in a large variety of sports and may interfere with everyday life or training, leading athletes to compromise their performance or risk compromising it. De Mattos and colleagues<sup>7</sup> aimed to assess the prevalence of UI in female athletes and to determine whether the type of sport might also influence UI. In their systematic review, a prevalence of 5 to 56 % of UI was found in low-impact activity to 80 % in trampolining. These data suggest that certain sports and physical activity practices not only increase the prevalence of UI but that the type of activity performed also has a major influence on the disorder. The type of sports played can have a major impact on the risk of developing PFDs and UI. Bourcier has developed a classification of risk to the pelvic floor musculature related to the level of impact of the sport.<sup>8</sup> The classification described risk related to the amount of pressure generated on the pelvic floor (Table 1).<br /> Differences in pelvic floor muscle among athletic and non-athletic women have been observed. The examination of the pelvic floor musculature by various imaging techniques has demonstrated differences among athletes compared to controls. Researchers have shown that perineal pressure is decreased in female athletes compared to non-athlete women.<sup>9</sup> A lower perineal pressure correlates with increased symptoms of UI and PFDs. Using a novel wireless intra-vaginal pressure transducer, intra-abdominal pressure was measured during diverse activities in a laboratory. Findings indicate variability in intra-abdominal pressure amongst individuals doing the same activity, especially in activities that required regulation of effort.<sup>10</sup> Women have a &ldquo;continence threshold&rdquo; which corresponds to the amount of time which the pelvic floor muscles can withstand efforts and repetitive impacts. If the &ldquo;threshold&rdquo; is exceeded, these muscles are fatigued and lose their efficiency, especially if they have not been prepared for these conditions. Fatigue of the pelvic floor muscles might be the reason why women with symptoms of UI often describe that leakage starts only after several incidents, such as repetitive jumps. This indicates that the continence control system weakens after repetitive stresses. Other researchers<sup>11</sup> have suggested that a series of introductory Pilates exercises, mat exercises and six reformer activities can be implemented in women desiring a low intra-abdominal pressure (IAP) exercise routine and are unlikely to be problematic. In an ideal situation the regulation of pressure within the abdomen happens automatically: the muscles of the core work together in a good coordination. If any of the muscles of the core are weakened or damaged, this coordinated automatic action may be altered. If this occurs repeatedly over time the pelvic organs are strained. Furthermore, overactive bladder (OAB) is a common condition during running and has a significant impact of quality of life on female recreational runners. Researchers have found that as many as 30 % of female runners have experienced incontinence while running.<sup>12</sup><br /> Unfortunately, a large number of affected women decide to stop their sport or exercise when experiencing problems. The main reason is often pure embarrassment. It is the responsibility of healthcare providers who work with physically active and athletic women to become familiar with these problems and the right treatment options.</p> <p><img src="/custom/img/files/files_datafiles_data_Zeitungen_2018_Leading Opinions_Gyn_1803_Weblinks_lo_gyn_1803_s55_tab1.jpg" alt="" width="1419" height="454" /></p> <h2>Therapeutic options</h2> <p>Given the fact that UI is not generally a progressive disease, conservative therapies play an integral part in the management.<sup>13&ndash;15</sup> There is currently a variety of treatment options for female patients, ranging from conservative to surgical procedures, among the different options offered. In general, some may be proposed as being beneficial to female athletes as well. The different components of conservative management include lifestyle changes, pelvic floor muscle training (PFMT), biofeedback, vaginal cones, electrical stimulation, and mechanical devices.</p> <p><strong>Behavioral therapies</strong><br /> Clinicians should offer behavioral therapies<sup>16,17</sup> (e.g. bladder training, bladder control strategies, PFMT, fluid management) as first-line therapy to all patients with OAB. Behavioral treatments are a group of risk-free tailorable therapies, which improve individual symptoms by changing patient behavior or the patient's environment. There are two approaches based on changing voiding habits with bladder training or focusing on PFMT to improve techniques for urge suppression. Both require the active participation of the patient. Fluid restriction has also been recommended in the treatment of OAB as excessive fluid intake can exacerbate symptoms. Conversely, extreme fluid restriction produces concentrated urine, which has been postulated to be a bladder irritant, leading to frequency, urgency, and urinary tract infections. Female athletes with OAB should try moderately restricting fluid intake as applicable to their sport and health. Sports medicine physicians working with the athlete can help to monitor and suggest optimal regimes to avoid dehydration, while minimizing problems with urinary leakage.</p> <p><strong>Pelvic floor muscle training (PFMT)</strong><br /> Arnold Kegel<sup>18</sup> was the first to report PFMT to be effective in the treatment of female UI and pelvic organ prolapse (POP). Today there is a huge body of evidence from randomized controlled trials and systematic reviews concluding that PFMT is effective in the treatment of stress urinary incontinence (SUI) and mixed urinary incontinence in women.<sup>19, 20</sup> The premise is that strong LA (levator ani) muscle contraction will improve urethral closure and pelvic organ support. Since the LA muscle consists of both type I (slow twitch) and type II (fast twitch) muscle fibers, specific strength training exercises can affect type II muscle fiber size through hypertrophy. Thus, strengthening type II fibers of the LA muscle could aid in maintaining continence specifically, strengthening and coordination of the motor control of muscles that form the abdominal cavity walls and function as stabilizing the core by interacting with the transversus abdominis (TrA) via coordinated contractions between the pelvic floor muscles and the TrA which occurs in normal trunk activities. The pelvic floor muscles need to be much stronger in elite athletes in certain sports than in other non-athletes. During low levels of activity, the fatigue-resistant slow twitch-fibers are predominately activated. When activity increases, fast-twitch fibers are also recruited. This highlights another difference between training athletes and training non-athletic women with UI. As the core is increasingly incorporated in yoga, Pilates and other techniques, PFMT can be taught. We recommend that PFMT be taught in a general exercise class with a former assessment of ability to perform a correct contraction. It can then be taught in smaller classes to offer a wide range of programs for the beginners to the advanced participants.</p> <p><strong>PFMT with biofeedback (BF)</strong><br /> Vaginal, anal sensors or surface EMG electrodes have been used to make patients more aware of muscle function, and to enhance and motivate patient efforts during training.<sup>21</sup> A correct PFM contraction was defined as an inward movement and squeeze around the urethra, vagina and rectum, but almost 25 % of women are unable to initially contract their pelvic floor muscles correctly. These women contract the gluteal, hip adductors, or abdominal muscles, or are bearing down.<sup>21, 22</sup> The vast majority are sportswomen who have had the constant abdominal muscle recruitment involved in their physical activities. In the early stages of sessions, the woman must perform minimal EMG activity of the abdominals in avoiding to push or to do a Valsalva. The second teaching process aims to demonstrate how the LA must be contracted before and during increased IAP. This technique is called the &ldquo;perineal blockage before stress technique&rdquo; or most commonly the &ldquo;Knack maneuver&rdquo;.<sup>23, 24</sup> A quick, strong and welltimed PFM contraction can compress the urethra and prevent the leakage during an abrupt or sustained increase in IAP. We have implemented a new technology in a pilot study which is now ready for full deployment. On the basis of this concept, we developed the &ldquo;MAB Program&rdquo;<sup>25</sup> using sports equipment (rowing machine, treadmill, body training machine) which provides a muscular framework that protects internal organs by involving the pelvic floor and core musculature (Fig. 1).<br /> Perineal ultrasound can be used to detect and quantify LA activity. Women who had previously been instructed in PFMT have been shown to be more likely to contract the LA properly. The real-time information provided by ultrasound imaging has been proposed as a possible source of BF that can be valuable during PFMT and abdominals. It presents the unique benefit of ultrasound BF and outlines basic gaps in the current knowledge base with respect to these topics. Ultrasonography can be used as a noninvasive method to identify the change in pelvic floor muscle strength with exercise training.<sup>26</sup></p> <p><strong>Devices: vaginal cones, pessaries and obturators</strong><br /> Vaginal weights are cone-shaped and sold in sets of progressive increments. They are believed to promote correct PFM contraction (through feedback sensed about cone slippage) and enhance PFM strength (through progressive resistance training). The patient receives a set of vaginal weights of identical shape and different volume but of increasing mass. As part of a progressive resistance program, women insert a weight intra-vaginally and are instructed to attempt to retain it by contracting the pelvic muscle for up to 15 minutes at least twice daily.<sup>27</sup><br /> An extensive range of mechanical devices have been described for the treatment of pelvic organ prolapse. Vaginal pessaries are extremely effective at managing SUI if they are fit properly and managed by frequent removals and regular checkups. The reviews of trials<sup>28</sup> found that using mechanical devices might be better than no treatment, but the evidence is weak. There was not enough evidence to recommend any specific type of device or to show whether mechanical devices are better than other forms of treatment such as pelvic floor muscle training.</p> <p><strong>Electrical stimulation (ES)</strong><br /> ES is another potential option for management of UI in physically active and athletic women. It uses natural pathways. Its efficacy relies on a preserved reflex arc, with complete or partial integrity of the pelvic floor muscle innervation.<sup>29</sup> The treatment is given in a health-care professional&rsquo;s office. Lately small stimulation machines that deliver an electrical current are becoming more common making home use the goal. Neuromuscular electrical stimulation (NMES) is now available for patients unable to contract the muscle itself, as well as for those suffering from UI. Some stimulators are simplified and have preset stimulation settings (frequency, amplitude and duration) targeting different dysfunction. Home-based ES is as effective in the treatment of UI as outpatient clinic-based ES with significant improvement in objective and subjective parameters.<sup>30</sup><br /> Some electrodes are designed for placement in the vagina or in the anus, other electrodes are coated with conductive adhesive and attach to the skin of the pelvic floor (Fig. 2). A non-invasive electrical stimulation with no probe exists that can deliver NMES via a pair of lycra cycling shorts. It is possible that adding ES to other treatments such as PFMT may be beneficial. Until recently ES was only possible through direct application or electrical current. However, new devices utilizing a pulsed electromagnetic field have been developed, which may achieve a similar affect. Extracorporeal magnetic stimulation<sup>31</sup> generates a magnetic field via a magnetic coil attached underneath the surface of the seat. The patient sits fully clothed with the perineum in the middle of the seat.</p> <p><strong>Surgical approach for UI in sportswomen</strong><br /> However, for women who do not want to receive or have insufficient improvement following conservative therapy a variety of surgical treatments is possible.<sup>32</sup> The introduction of mid-urethral slings has changed the decision process for surgical treatment and is likely a factor in the increase in the rate of anti-incontinence surgery. There is a significant body of research to support its use in sub-urethral polypropylene slings, including more than 15 years of experience in the USA and nearly 20 years of experience in Europe. There are several types of mesh kits for the treatment of SUI on the market. Time for recovery varies but we recommend that to limit activities for a full 6 weeks after surgery and to avoid any activity which will unduly increase the intra-abdominal pressure. For sportswomen we have recently proposed a specific &ldquo;postsurgical pelvic floor rehabilitation program&rdquo; in order to reduce the risk of repeat prolapse after prolapse repair.<sup>33</sup></p> <p><img src="/custom/img/files/files_datafiles_data_Zeitungen_2018_Leading Opinions_Gyn_1803_Weblinks_lo_gyn_1803_s56_fig1+2.jpg" alt="" width="2150" height="1041" /></p> <h2>Conclusion</h2> <p>PFDs are common in physically active women and female athletes, especially in the latter participating in moderate and high intensity exercise and sports. There is great need to document the acute and chronic effects of exercise and sport participation on the pelvic floor. Such information is important as expert consensus suggests that long-term, elevated IAP predisposes women to PFDs. Based on our experience with the management of young female athletes we can attest that there are rewarding and promising treatment options for women suffering from PFDs.<br /> Generally, the PFM needs to be stronger in elite athletes of certain sports than in non-athletic women. As a first-choice treatment the combination of BF with pelvic core workout in association with ES could represent a good choice of treatment for such a population. Furthermore, the use of anti-incontinence devices can prevent leakage during high impact physical activity.<br /> It should be stated that exercise and sport promote good health-related outcomes and should be encouraged. We would recommend that women affected by these symptoms should seek medical help from a healthcare professional in this field. Sports medicine providers should become familiar with these PFDs and UI as well as the management options for physically active women and female athletes.</p></p> <p class="article-footer"> <a class="literatur" data-toggle="collapse" href="#collapseLiteratur" aria-expanded="false" aria-controls="collapseLiteratur" >Literatur</a> <div class="collapse" id="collapseLiteratur"> <p><strong>1</strong> Female Athlete Issues for the Team Physician: a consensus statement-2017 Update. Med Sci Sports Exerc 2018; 50(5): 1113-22 <strong>2</strong> Nattiv A et al: The female athlete t riad. American College of Sports Medicine position stand. Med Sci Sports Exerc 2007; 39: 1867-82 <strong>3</strong> Nygaard IE et al: Physical activity and the pelvic floor. Am J Obstet Gynecol 2016; 214: 164-71 <strong>4</strong> McKenzie S et al: Stress urinary incontinence is highly prevalent in recreationally active women attending gyms or exercise classes. Int Urogynecol J 2016; 27: 1175-84 <strong>5</strong> Postwiana A et al: Prevalence of stress urinary incontinence in elite femal endurance athletes. J Hum Kinet 2014; 44: 91-6 <strong>6</strong> Da Roza T et al: Urinary incontinence and levels of regular physical exercise in young women. Int J Sports Med 2015; 36: 776-80 <strong>7</strong> De Mattos Lourenco TR et al: Urinary incontinence in female athletes: a systematic review. Int Urogynecol J 2018 Mar 19; doi: 10.1007/s00192- 018-3629-z. [Epub ahead of print] <strong>8</strong> Bourcier AP: Final general discussion. In: Bock G, Whelan J (eds): Neurobiology of incontinence. John Whiley, London 1990; 151: 318-22 <strong>9</strong> Borin LC et al: Assessment of pelvic floor muscle pressure in female athletes. PMR 2013; 5(3): 189-93 <strong>10</strong> Shaw JM et al: Intra-abdominal pressures during activity in women using an intra-vaginal pressure transducer. J Sports Sci 2014; 32: 1176-85 <strong>11</strong> Coleman TJ et al: Intra-abdominal pressure during Pilates: unlikely to cause pelvic floor harm. Int Urogynecol J 2015; 26: 1123-30 <strong>12</strong> Paul S: Is it common to have a leaky bladder while running? Runner&rsquo;s World 2010 Nov 24 <strong>13</strong> Ghaderi F et al: Physiotherapy for women with stress urinary incontinence: a review article. J Phys Ther Sci 2014; 26(9): 1493-9 <strong>14</strong> Adams SR et al: Pelvic floor physical therapy as primary treatment of pelvic floor disorders with urinary urgency and frequency-predominant symptoms. Fem Pelv Med Reconstr Surg 2015; 21(5): 252 <strong>15</strong> Birolli A: Effective, clinically feasible and sustainable care interventions to promote pelvic floor rehabilitation. 16<sup>th</sup> Physiotherapy Round Table, I.C.S. Florence 2017; Workshop 1 <strong>16</strong> Burgio KL: Current perspectives on management of urgency using bladder and behavioral training. J Am Acad Nurse Pract 2004; 16(10 Suppl): 4-7 <strong>17</strong> Gormley EA et al: Diagnosis and treatment of overactive bladder in adults: AUA/SUFU Guideline. J Urol 2012; 188: 2455-63 <strong>18</strong> Kegel AH: Progressive resistance exercise to the functional restoration of the perineal muscles. Am J Obstet Gynecol 1948; 56: 238-48 <strong>19</strong> Dumoulin C et al: Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2014; (5): CD005654 <strong>20</strong> Rivalta M et al: Urinary incontinence and sport: first and preliminary experience with a combined pelvic floor rehabilitation program in three female athletes. Health Care Women Int 2010; 31(5): 435-43 <strong>21</strong> Bourcier AP et al: Biofeedback therapy. In: Pelvic Floor Disorders. Elsevier 2004, pp 297-310 <strong>22</strong> Henderson JW et al: Can women correctly contract their pelvic floor muscles without formal instruction? Female Pelvic Med Reconstr Surg 2013; 19(1): 8-12 <strong>23</strong> Bourcier AP: Pelvic floor rehabilitation. Int Urogynecol J 1990; 1(1): 31-5 <strong>24</strong> Miller JM et al: Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19(6): 773 <strong>25</strong> Bourcier A et al: Urinary incontinence in physically active sportswomen. Pelvic floor dysfunction: investigations and conservative treatment. Rome, CESI; 1999: 9-17 <strong>26</strong> Tosum OC: Assessment of the effect of pelvic floor exercises on pelvic floor muscle strength using ultrasonography in patients with urinary incontinence: a prospective randomized controlled trial. J Phys Ther Sci 2016; 28(2): 360-5 <strong>27</strong> Vural M et al: Vaginal cone therapy in patients with stress urinary incontinence. Arch Gynecol Obstet 2013; 288(1): 99-103 <strong>28</strong> Ghadeer AS et al: Pessary use in stress urinary incontinence: a review of advantages, complications, patient satisfaction, and quality of life. Int J Womens Health 2018; 10: 195-201 <strong>29</strong> Fall M et al: Electrical stimulation. A physiological approach to the treatment of urinary incontinence. Urol Clin N Am 1991; 18: 393-407 <strong>30</strong> Ugurlucan G et al: Comparison of home-based and outpatient clinic-based intravaginal electrical stimulation for the treatment of urinary incontinence. Minerva Ginecol 2014 Aug; 66(4): 347-53 <strong>31</strong> Goldberg RP et al: Extracorporeal electromagnetic stimulation therapy. In: Bourcier AP et al (eds): Pelvic floor disorders. Elsevier 2004, pp. 291-6 <strong>32</strong> Dmochowski RR et al: Female stress urinary incontinence update panel. J Urol 2010; 183(5): 1906 <strong>33</strong> Bourcier A: Prise en charge de l&rsquo;incontinence chez les athl&egrave;tes f&eacute;minines et les professionnels du sport. Congr&egrave;s Sport &amp; P&eacute;rin&eacute;e, Paris 27-28 Sept 2018; Abstract #1</p> </div> </p>
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