Elite female athletes’ experiences of symptoms of pelvic floor dysfunction: A systematic review

Introduction and aims Pelvic floor dysfunction (PFD) is a collection of signs, symptoms and conditions affecting the pelvic floor and urinary incontinence (UI) is the most common type of PFD. Recent systematic reviews have indicated a higher prevalence of UI among female athletes compared to their non-athletic counterparts. To date, no review has been undertaken to investigate female athletes’ experiences of PFD. This review aims to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report elite female athletes’ experiences of symptoms of PFD. Methods The review protocol was registered in PROSPERO in August 2020. A systematic search was conducted in Embase, MEDLINE (OVID), Cochrane Library, CINAHL, PsycINFO and Web of Science for studies published in the English language reporting elite female athletes’ experiences of symptoms of PFD. This review included primary research studies that involved elite female athletes of any age or ethnicity. Results Of the 1922 citations retrieved in the search, 32 studies met the methodological criteria for data extraction and analysis. Five main themes emerged: (1) triggers for symptoms of PFD; (2) strategies adopted by athletes to manage/mitigate symptoms of PFD; (3) impact on QOL/daily life; (4) impact on performance; (5) impact on emotions. Conclusions The findings of this review suggest a need to further explore the experiences of PFD among elite female athletes and it is suggested that future research should adopt qualitative methods or incorporate a qualitative component.


Introduction
Pelvic floor dysfunction (PFD) is a collection of signs, symptoms and conditions that affect the pelvic floor [1]. Urinary incontinence (UI), the PFD most commonly experienced by women, is defined as a 'complaint of involuntary loss of *Please note: The findings from a preliminary search conducted in May 2020 were presented at the International Continence Society 2021 Conference, 14 to 17 October 2021, https:// www. ics. org/ 2021. However, findings from the updated search conducted in January 2022 are presented in this submission and have not been presented or submitted elsewhere) urine' and is a common complaint in women of all ages. The most common types of UI include stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). The International Urogynecological Association (IUGA) and the International Continence Society (ICS) define SUI as the 'complaint of involuntary loss of urine on effort or physical exertion (e.g., sporting activities), or on sneezing or coughing' and UUI as 'complaint of involuntary loss of urine associated with urgency' [1]. Other symptoms of PFD include anorectal dysfunction (ARD), sexual dysfunction (SD), pelvic organ prolapse (POP) and pelvic pain [1,2]. Many women find it embarrassing to discuss symptoms of PFD including continence problems with others and incontinence has been shown to negatively affect quality of life [3][4][5].
Mendes et al. [6] conducted a systematic review of qualitative evidence regarding adult women's experiences of UI. Findings from the 28 included studies were grouped into eight themes in the areas of: cultural and religious backgrounds; effect on daily activities/social roles; knowledge and nature of symptoms; experiences of UI and sense of shame; negative effects on intimacy, sexuality and sexual function; UI seen as consequence of pregnancy/childbirth, aging or religious punishment; strategies adopted by women affected by UI; meeting of care needs and women's personal preferences. The authors concluded that the preferences and expectations of women with UI should be considered and that the provision of healthcare should be personal and tailored. A need for additional research to improve the understanding of the impact of UI on the quality of life (QOL) of younger women was identified [6].
UI during exercise is not uncommon and a higher prevalence has been observed among athletes engaged in high-impact sports including running and jumping [7]. Rodríguez-López et al. [8] investigated the prevalence of UI in both female and male elite athletes and found an overall prevalence of 33% (45.1% in females, 14.7% in males) and that, whilst the prevalence of UI was 5.45 times greater in females, elite male athletes were also found to experience UI.
There have been a number of recent systematic reviews concerning PFD in female athletes [9][10][11][12][13][14]. However, the main aim of these reviews has been the investigation of the prevalence of UI in female athletes. Almousa and Bandin Van Loon [9] included a secondary aim of exploring the knowledge and attitudes of female athletes regarding UI [9] and de Mattos Lourenco et al. [10] discussed strategies adopted by the athletes to manage their UI. The reviews differ somewhat in their inclusion criteria regarding age and parity, but they all concluded consistently that there was a higher prevalence of UI among female athletes compared to non-athletes. Engaging in high-impact sports [9,10,12,14] with longer hours of training [9] appears to be commonly cited as risk factor for UI, but to our knowledge, no review has been undertaken to investigate female athletes experiences of PFD. Studies have found that experiencing UI during elite sports may be a predictor of UI in later life [15] and also that elite athletes have been identified as an understudied population in the research into PFD and, in particular, ARD and POP and physical activity [16].
Whilst a scoping review of the research literature revealed limited qualitative research into the area of PFD among female athletes, such research may, potentially, yield further information regarding the impact of the symptoms of PFD on the female athletes' sporting activities and their daily lives.
Therefore, this review aimed to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report the experiences of symptoms of PFD in elite female athletes.

Study design and protocol registration
This systematic review complied with the 'Adapted PRISMA guidelines for reporting systematic reviews of qualitative and quantitative evidence' [17,18]. The review protocol was registered in PROSPERO in August 2020 and is available at https:// www. crd. york. ac. uk/ prosp ero/ displ ay_ record. php? ID= CRD42 02019 7330 [19].
This review included primary research studies published in the English language that reported elite female athletes' experiences of symptoms of PFD. Inclusion criteria were: (1) studies that involved female athletes of any age or ethnicity and studies that included both female and male athletes together when data on female athletes could be extracted; (2) studies involving female athletes who were considered to be at an 'elite' level. For the purposes of this review 'elite' could refer to athletic performance at regional/county/state level; sport/country-specific measures and university/collegiate, international and/or national level; training; professionalism; involved in talent development and (3) studies that reported the experiences of symptoms of PFD and how this affects activities of daily living or sporting activity or quality of life (QOL). This information could be gleaned from questions included in a quantitative survey or qualitative interview-based research. Exclusion criteria were: (1) studies involving only recreational or leisure-time exercisers; (2) editorial opinion articles, letters and commentaries and (3) studies that did not report on the experiences of symptoms of PFD.

Study selection and assessment of methodological quality
Two reviewers (ECQ and DD, ECQ and NF) independently screened studies using the inclusion/exclusion criteria based on titles, then abstracts and then full texts. Covidence software (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www. covid ence. org) was used for the process of screening and identified agreement between reviewers. Disagreement between two reviewers was resolved by consultation with a third reviewer.
Thomas et al. [20] devised a 12-point quality assessment criteria checklist that facilitated assessment of quantitative, qualitative and mixed methods studies. Subsequently, Panda et al. [21] developed a modified version of this checklist that was used to assess the methodological quality of this reviews included studies. Each criterion was scored '1' if met and '0' if not met, and three categories of methodological quality were identified: 'weak' (scores 0-6), 'moderate' (scores 7-9) and 'strong' (scores 10-12).

Data extraction and data analysis
A double independent data extraction was conducted on the studies selected for inclusion (ECQ and DD, ECQ and NF).
Information was extracted and entered into a pre-designed extraction form in relation to the following study characteristics: authors; journal, year of study/publication, number of participants, participants' characteristics, description of sport or athletic activity, methods of data collection, data collection instruments/tools, description of symptoms, methods of analysis and reporting of experiences concerning symptoms of PFD.
Information regarding athletes' experiences of PFD was extracted from closed questions included in validated QOL instruments from closed questions and open-ended qualitative comments in questionnaires or from analysis of comments from focus group interviews.
There was insufficient qualitative information to carry out a meta-synthesis of the findings regarding the reporting of experiences. Thematic analysis occurred by organising the findings into themes that were tabulated and then further analysed [22]. Descriptive themes were developed. An iterative process was repeated until the themes were considered to be representative and answered the research question.

Selection and quality of the studies
A total of 1922 studies remained after deduplication, 123 were screened at full-text and 32 studies met the inclusion criteria ( Fig. 1). Of these, three studies were of weak quality [23][24][25], 28 studies were of moderate quality [8, and one was of high quality [53].
Thirty-one of the 32 studies used a quantitative design and only one study by Jácome et al. used a mixed methods design (questionnaire and focus group) [40]. None of the studies in this review used a qualitative design only and there was considerable heterogeneity in study designs. Seven studies utilised purposively designed questionnaires [30, 33-35, 37, 43, 44] whilst the remaining 25 used or incorporated validated instruments. The most commonly used survey instrument was the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF), which was used in 13/32 (31%) of the studies [8, 26-29, 31, 32, 38, 39, 42, 46-48].
UI was the most commonly reported symptom of PFD and reported in all 32 of the studies. Twenty-two studies specifically described the prevalence of UI according to type, with SUI reported as the most prevalent in 21/22 studies [8, 23, 24, 26, 28-30, 32-36, 38, 40-43, 45-48]. Mixed urinary incontinence (MUI) was reported as the most prevalent form of UI in one study by Cardoso et al. [27]. Anorectal dysfunction (ARD) was reported in nine studies with the prevalence of constipation/straining to defecate reported in all of these studies [8,26,28,29,31,32,34,46,47] and anal incontinence (AI) reported in four studies [26,29,46,47]. The prevalence of sexual dysfunction (SD) was reported in two studies [26,29], the prevalence of POP was reported in four studies [26,29,41,46] and the prevalence of pelvic pain was reported in two studies [24,45].

Experiences of pelvic floor dysfunction
Information regarding female athletes' experiences of PFD was extracted from closed questions included in validated QOL instruments, from closed questions and open-ended qualitative comments in questionnaires and/or from analysis of comments from a focus group. The findings regarding the experiences of the athletes were grouped into five main themes (Table 1) and are summarised below. As previously mentioned, there was insufficient qualitative information to perform meta-synthesis of the findings.

Theme 4: Impact on performance
The fourth theme Impact on performance was reported on in 12/32 (38%) of the studies. One study reported that PFD 'did not impact performance' [27]. The remaining 11/12 studies reported that PFD had an 'effect on some of the athletes' performance' [28, 32, 34, 36, 38-40, 46-48, 53] and 6 of these studies reported that some athletes had stopped an activity or limited their behaviour/activity in their sport [32,34,36,39,40,43].

Discussion
The primary aim of this review was to investigate the experiences of symptoms of PFD in elite female athletes. There was heterogeneity in study designs including a wide variety of athletic/sporting activity and most of the information regarding the athletes' experiences came from quantitative research studies where the athletes' experience of PFD was not the main focus. This was predominantly quantitative research involving questionnaires. Only one mixed methods study by Jacome et al. [40] included a qualitative component to elicit athletes' experiences and this involved a relatively small focus group (n = 7). It is notable that > 50% of the studies were published within the last 5 years and this may indicate an increased interest in understanding the impact of PFD on athletes. Five main themes were identified and only three studies contributed findings to all five themes. Two of these were recent studies by Skaug et al., which, in addition to investigating prevalence, also investigated the impact and bother of PFD on powerlifters and weightlifters [46] and cheerleaders and gymnasts [47]. The third study was the mixed methods study by Jacome et al. [40]. Systematic reviews regarding female athletes and PFD to date have predominantly focused on the prevalence of UI in female athletes [9][10][11][12][13]. As prevalence was not the main focus of the current review, the prevalence reported here was only that relating to those studies reporting elite athletes' experiences of PFD and does not allow direct comparisons with previous reviews regarding prevalence of PFD in athletes.
The fact that UI was reported in all the studies in this review was not surprising as UI is the most common form of PFD [54]. Similar to reviews by de Mattos Lourenco et al. [10] and Rebullido et al. [14], the ICIQ-UI-SF was found to be the most commonly utilised survey instrument. The prevalence and experiences of other forms of PFD including POP, ARD, sexual dysfunction and pelvic pain reported in the studies were also identified in this current review and it is notable that in all previous systematic reviews concerning athletes to date only the prevalence of UI was analysed. It is suggested that future systematic reviews should consider including the prevalence of other types of PFD to provide a more complete picture of PFD in these athletes. Bø and Nygaard [16] in a narrative review concerning physical activity and PFM function, identified AI and POP as understudied research outcomes.
This current review included only studies involving 'elite' athletes. Swann et al. [55], in a systematic review that aimed to evaluate how sports psychology research has defined elite athletes, identified eight broad categories of an 'elite or expert athlete'. These included experience, international and/or national level, training, professionalism, involved in talent development, regional level, sport/country-specific measures and university. Williams et al. [56] suggested that for team sports, the recommendation for defining 'elite' is that success in highly competitive leagues and competitive experience should be given priority over international experience. In this current review we used a definition of 'elite' based on the recommendations from the above literature. It remains difficult, however, to find a consistent definition of the term 'elite' as it refers to athletes. Almousa and Bandin Van Loon [9], in a systematic review investigating the prevalence of UI in nulliparous female athletes, highlighted that many studies failed to use level of sports (professional, amateur) to classify the participants.
The fact that 'competition, training and physical activity' was most commonly reported as a trigger for symptoms of PFD followed by 'specific movements during activity (sporting and daily life)' may not be surprising. Such activity may cause an increase in intraabdominal pressure, impact the pelvic floor and is associated with SUI [1], the most prevalent type of PFD reported in this review. However, questions surrounding the effect of physical activity and exercise on the pelvic floor remain unresolved in the research literature and a need for further high-quality research to fill the gaps in knowledge concerning the role of strenuous physical activity in symptoms of PFD has been identified [16]. It is also be suggested that that future research regarding triggers for symptoms of PFD and when the symptoms occur in female athletes should be conducted as this may help inform the design of a pathway pelvic floor muscle (PFM) rehabilitation programme for such athletes.
In seven of the studies the PFD was reported as presenting in the second half/latter part of training or competition, and this may point to PFM fatigue. Previous research has suggested that, while some uncertainty remains regarding the extent to which PFM fatigue affects UI, the development and/or worsening of UI may be influenced by PFM fatigue [57][58][59].
In this review the studies that reported on strategies adopted by athletes to manage/mitigate symptoms of PFD indicated that, whilst many athletes reported wearing pads, pre-voiding and restricting fluids, few appeared to seek attention from a health professional. Similarly, de Mattos Lourenco et al. [10] also reported strategies to prevent UI including use of pads, prevoiding and limiting fluid intake and suggested that reasons why athletes do not discuss the condition or seek help may include the fact that they feel ashamed or perceived that it is normal or inevitable at their age. Another possible reason may be that the athletes consider that their use of some strategies such as pre-voiding may be sufficient to manage their UI. Interviewbased, qualitative research may assist in investigating this issue further.
UI is a treatable condition. Recent research has shown that PFMT in young continent women resulted in improved muscle activation and pelvic floor muscle strength [60]. Findings of a Cochrane review [61] have shown that PFMT can cure or improve all types of UI but is most effective in SUI. Similar to the findings of other reviews, we suggest that it is important to provide education resources for athletes regarding symptoms and treatment options for PFD and educate the professionals (health professionals and coaches/ trainers) involved with these athletes about the prevalence of PFD in athletes and increase screening for symptoms [9,10,12,13].
In this current review the findings regarding the impact of PFD on female athletes' QOL/daily life were quite varied and consequently no conclusion can be reached. Future research could include systematic reviews of UI and QOL in athletes and conducting qualitative research may deepen knowledge and understanding of the impact and experiences of PFD on female athletes' QOL and daily life. UI has been shown to have a considerable impact on women's lives [6] and have an adverse effect on QOL [3,5]. A systematic review and meta-analysis on UI and QOL in both sexes reported that UI was associated with poor QOL, but an acknowledged limitation of the review was that only cross-sectional and case-control studies were included [4].
The fact that 11/12 studies reporting on the impact of PFD on performance reported that it had an effect and, that some athletes had stopped or limited their activity during their sport, is of concern. A need for further research to investigate the mechanisms causing PFD in athletes has been identified [38]. It would also be interesting to evaluate if athletes who limit their sporting activity because of PFD have considered seeking or have sought treatment for their symptoms. Further mixed-methods or qualitative, interview-based research may assist in investigating this issue in athletes.
Only nine (28%) studies in this review reported on the impact of PFD on the athletes' emotions and there was limited information given in some of these studies. Embarrassment was the most frequently reported emotion followed by fear, concern and anxiety. It is important that athletes are educated regarding PFD and the treatment options available to help allay, mitigate and resolve some of these negative emotions surrounding UI. Mendes et al. [6] reported that UI is a condition that can involve embarrassment, stigma and distress in women. Once again, we suggest that further qualitative, interview-based research may assist in investigating the impact of PFD on the athletes' emotions.

Limitations
Limitations of this review included the heterogeneity of the study designs, the inclusion of studies published in the English language only and that the prevalence reported in this review only referred to the prevalence of PFD in studies that reported on female athletes' experiences of PFD. However, the main limitation of this review was the paucity of qualitative evidence that was available in the research literature concerning athletes' experiences of PFD.

Conclusion
This review explored the experiences and impact of PFD in elite athletes and found a relative paucity of qualitative evidence. Five main themes were identified. Further qualitative and mixed methods, sports-specific research may serve to deepen knowledge and understanding of elite female athletes' experiences and impact of PFD on athletes' sporting activities and their daily lives and enrich the understanding of this condition in women competing at an elite level.
Recommendations for qualitative research include further investigating: • The impact of PFD on elite female athletes' emotions • Why do many elite female athletes not discuss their PFD with others? • Triggers for PFD reported by elite female athletes • Strategies adopted by elite female athletes to manage/ mitigate their PFD • Why do many elite female athletes not seek help from a health professional? • Do elite female athletes who limit their sporting activity due to PFD seek treatment?   Table 2. (continued)