Association between pelvic floor care practices and symptoms in female track and field athletes: a cross-sectional study

Introduction

Background

Maximal sports performance requires sustained physical effort that pushes anatomical structures and functions to their limits. These athletic routines, combined with some specific anatomical and physiological characteristics of women, may facilitate the development of pelvic floor dysfunctions (PFD). The female pelvic floor (PF) features a wider opening with lower muscle fiber density, and urethral support is provided by the anterior vaginal wall via fascial connections to the pubococcygeus muscle (1). In consequence, these PFD are notably more prevalent in female athletes compared to their male counterparts (2) and the sedentary population (3). According to the literature, one in three women participating in sports has experienced symptoms of urinary incontinence (UI), with even higher prevalence in disciplines such as track and field (4).

Beyond the physical demands of sport, daily practices are considered key factors that may either support PF health or contribute to its dysfunction. Previous studies have explored toileting habits in women with PFD, suggesting that early prevention and effective management strategies are essential(5,6). To investigate these habits, questionnaires typically assess behaviors related to micturition, defecation, the impact of UI on quality of life, specific types of urine loss, and other PFD such as female sexual dysfunction (FSD) and pelvic organ prolapse (POP) (3).

In the context of sport, some training routines that increase intra-abdominal pressure (IAP) are considered high-impact activities due to their association with PFD symptoms. Although these IAP increases produced in response to efforts and ground reaction forces are compensated to maintain the PF function, it might compromise the closure of the urethra (7) and the support capacity of the PF muscles (8). Repeated daily efforts may alter the physiological urethrovesical angle, contributing to PFD symptoms (2,9).

High-impact and heavy lifting activities generate significant ground reaction forces, which in turn elevate IAP (4). Jumping has been identified as the most frequent exercise associated with urine leakage, while movements such as trunk rotation and forward flexion have also been reported as triggers (2). Additionally, high training volume and intensity, along with low energy availability, have been suggested as risk factors for developing PFD (3).

Rationale and knowledge gap

Despite the specific daily demands that female athletes face in training and competition, no studies to date have explored their unique habits and their relationship not only with UI, but also with other PF symptoms associated with PFD, such as dyspareunia, anal incontinence (AI), and POP.

Objective

To describe the presence of habits related to PF care and to examine the associations between these habits and symptoms of PFD among female athletes in Spain. We hypothesize that unhealthy habits, particularly those related to urinary and fecal practices, are highly prevalent among female athletes, and even more frequent in those experiencing symptoms associated with PFD. We present this article in accordance with the STROBE reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-53/rc).

Methods

Study design

A cross-sectional observational study was conducted. Between May and August 2023, adult female athletes who train and compete in track and field in Spain completed an anonymous online questionnaire designed to assess habits related to PF care. In addition to behavioral data, the questionnaire collected sociodemographic, sport-related, and health-related information concerning PF function and symptomatology.

Participants

Female athletes with a sport license for track and field in Spain were invited to participate via email through their respective regional federations, clubs, and/or training groups. The survey was also disseminated via social media. Inclusion criteria require participants to train and compete in any track and field discipline, have a minimum of 2 years of experience in sport, and be at least 18 years old. The only exclusion criterion was the inability to adequately understand the questionnaire in Spanish, the official national language. At the time of the study, the total number of certified adult female athletes registered in Spain was approximately 31,000. Based on this population size, a minimum sample of 196 participants was calculated to ensure a 95% confidence level and a 7% margin of error, assuming a response distribution of 50%. A total of 281 athletes agreed to participate and completed the online questionnaire. The sample size was calculated using the formula for finite populations:

n=[N×Z2×p×(1−p)]÷[e2×(N−1)+Z2×p×(1−p)][1]

where N is the population size, Z is the Z-score for 95% confidence (1.96), p is the expected proportion (0.5), and e is the margin of error (0.07). Before being enrolled in the study, all participants were informed about the procedures of the research and provided written informed consent. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of University of the Balearic Islands (No. 124CER19).

Procedures

All participants completed an anonymous online questionnaire via the Jotform^® platform (www.jotform.com) (San Francisco, USA), with encrypted data protection enabled. The questionnaire was structured into five sections:

• Sociodemographic and sports-related data: included age, level of academic education, and years of experience in track and field.
• Health-related information concerning PF function: this section included: History of vaginal or cesarean delivery (yes/no); UI, assessed by confirming the first item from the International Consultation on Incontinence Questionnaire, validated in Spanish (10) (yes/no); AI, assessed through three items from the Wexner scale (solid, liquid, or gas anal leakage), validated in Spanish (11) (yes/no); POP, assessed by confirming the first item of the Pelvic Organ Prolapse Symptom Score questionnaire (12) (yes/no); dyspareunia, assessed by confirming the presence of pain during or after sexual intercourse, extracted from the Female Sexual Function Index, validated in Spanish (13) (yes/no); pelvic pain, assessed using a question based on the chronic pelvic pain definition by Moore and Kennedy (yes/no) (14). All items referring to potential PF dysfunctions were based on validated questionnaires, following an approach similar to that described by a similar study (7).
• Urinary habits (UHs): assessed through 11 items extracted from the toileting behavior (TB) scale (15).
• Fecal habits (FHs): assessed through 12 items adapted from the TB scale to evaluate anorectal behaviors (15).
• Sports habits (SHs): assessed through 7 ad hoc items developed by a team of experts, due to the lack of existing validated items related to sports practice.

Responses in sections 3 to 5 were dichotomized to indicate whether the athlete engaged in the behavior or not: “yes” (sometimes, frequently, or always) or “no” (never or rarely), based on the definition of a habit as a behavior performed with regularity (16). For each habit section, affirmative responses to unhealthy behaviors, defined as those considered detrimental to PF health, were summed to generate a score. Each unhealthy habit contributed one point to the total score, while healthy habits were not included in the sum, following the approach used in previous studies (16). This part of the questionnaire is shown in Appendix 1.

Statistical analysis

Prior to data collection, the face and content validity of the ad hoc SHs section of the questionnaire were assessed. Three physiotherapists specialized in PFD and one independent general practitioner participated in the expert review. Additionally, 15 female athletes completed the questionnaire to evaluate the appropriateness of the ad hoc items (17). To assess content validity, open-ended fields were included in each section to allow participants to provide comments and suggestions regarding the relevance and adequacy of the items. Face validity was evaluated based on participants’ feedback on clarity and comprehension. Internal consistency of the ad hoc items was assessed using Cronbach’s alpha coefficient, with values ≥0.70 considered acceptable, ≥0.80 good, and ≥0.90 excellent (18).

Descriptive statistics were used to summarize the data: means and standard deviations (SDs) for continuous variables, and frequencies and percentages for categorical variables. Normality of continuous variables was verified using the Shapiro-Wilk test, and no significant deviations were found. Given the binary nature of the main PFD symptoms, associations between symptoms and habits were analyzed using Chi-square tests. Specifically, the following relationships were examined: UI with UHs; AI with FH; and UI, AI, FSD, and POP with SHs. Differences in the total scores of unhealthy urinary and FH between athletes with and without UI and AI, respectively, were analyzed using independent samples t-tests. The 95% confidence intervals (CIs) were calculated for mean differences in the total scores of unhealthy UH and FH between groups, not for individual categorical items. Cohen’s d effect sizes (ES) were calculated to assess the magnitude of the significant differences between groups, interpreted as small (d=0.2), medium (d=0.5), large (d=0.8), and very large (d≥1.3) (19). Statistical analyses were performed using SPSS, version 20.0 (Chicago, IL, USA). A significance level of P<0.05 was used.

Results

Face validity and internal consistency of the SH section

The three experts confirmed that the items were appropriately interpreted and effectively measured the intended constructs. For face validity, 15 female athletes completed the questionnaire, and no modifications were required regarding clarity or comprehension. Internal consistency for the SH section was confirmed with a Cronbach’s alpha of 0.77, indicating acceptable reliability.

Characteristics of female athletes

During the study period, 281 female athletes (age: 35.2±11.8 years; years of sports experience: 13.3±9.2 years) completed the online questionnaire. The prevalence of PFD symptoms among participants was as follows: dyspareunia (61.6%), UI (52.0%), pelvic pain (41.6%), AI (16.0%), and POP (9.6%). A total of 171 participants (60.9%) were nulliparous. Regarding educational level, 75.8% of participants had completed university studies or held postgraduate degrees (Master’s or PhD).

UHs

Table 1 presents the UH reported by athletes and their association with UI. The most frequently reported UHs were UH1 (62.6%), UH3 (57.7%), and UH4 (48.0%), along with UH7 (76.3%) as a healthy habit. UI was significantly associated with UH2 (χ²=5.0, P=0.03, d=0.3), UH9 (χ²=7.7, P=0.005, d=0.3), UH10 (χ²=8.7, P=0.003, d=0.4), and UH11 (χ²=4.4, P=0.04, d=0.3), all of which were more frequently reported by athletes with UI compared to those without. No other significant associations were found between UH and UI (P>0.05). When considering the total number of unhealthy UH, athletes with UI reported significantly more unhealthy habits than those without UI (score: 4.3 vs. 3.4; mean difference: 0.9, 95% CI: 0.37–1.52, d=0.4, P=0.001).

FHs

Table 2 presents the FH and their association with AI. The most frequently reported FHs were FH1 (75.4%) and FH10 (49.1%), with FH7 (81.9%) identified as a healthy habit. AI was significantly associated with FH3 (χ²=8.6, P=0.003, d=0.4) and FH9 (χ²=6.7, P=0.01, d=0.3), both of which were more commonly reported by athletes with AI. No other significant associations were found between FH and AI (P>0.05). The total number of unhealthy FH did not differ significantly between athletes with and without AI (score: 3.9 vs. 3.3, mean difference: 0.6, 95% CI: −0.1 to 1.4, d=0.2; P>0.05).

SHs

Table 3 presents the SH and their association with PFD symptoms. All SH items were formulated as healthy habits. SH6 was the most frequently reported (38.4%), which refers to being mindful of posture to protect the PF during any effort (e.g., weight bearing, coughing, sneezing) to avoid the downward push on the perineum. In contrast, SH5, regarding the use of devices (such as tampons or vaginal umbrellas) to prevent symptoms or damage to the perineum during training or competition, was the least frequent (4.6%). SH7 was less frequently reported by athletes with AI (χ²=4.6, P=0.03, d=0.3), but more frequently reported by those with pelvic pain (χ²=6.7, P=0.01, d=0.3) and dyspareunia (χ²=4.0, P=0.046, d=0.2). Additionally, SH3 was more frequently reported by athletes with POP compared to those without (χ²=9.7, P=0.002, d=0.4).

Discussion

Key findings

The main findings of this study indicate that a high proportion of female athletes exhibit unhealthy toileting habits, particularly those related to premature voiding and defecation, such as attempting to urinate before training (>60%) or trying to defecate at home (>75%). These behaviors were more frequently reported by athletes with symptoms of PFD, including UI and AI, compared to those without symptoms. Athletes with UI reported a greater number of unhealthy UH, and those with AI reported more frequently some unhealthy FH. Although most SH showed no clear association with PFD symptoms, a few specific habits, like help-seeking behaviors and consulting about training, were more frequent among athletes with pelvic pain, dyspareunia, or POP.

Strengths and limitations

This study offers valuable insights into the toileting and sport-related habits of female athletes and their association with a broad spectrum of PFD symptoms, including UI, AI, dyspareunia, pelvic pain, and POP. One of its main strengths lies in the inclusion of a large sample of female athletes from track and field disciplines, a population often underrepresented in pelvic health research. The use of validated tools and expert-reviewed ad hoc items adds methodological rigor, and the focus on behavioral patterns beyond urinary symptoms provides a more comprehensive understanding of PF health in this population. However, several limitations must be acknowledged. Firstly, due to the cross-sectional design, causality cannot be established; athletes with symptoms may have adapted their daily practices in response to PFD, rather than those habits being the cause of their symptomatology. Secondly, the sample was limited to female athletes who train and compete in athletics, which restricts the generalizability of the findings to other sports modalities or population groups. Thirdly, data collection was based on a self-administered questionnaire. To avoid excessive length and participant dropout, only key items from validated questionnaires were selected to assess the presence of PFD symptoms. While this approach was practical, it limits the depth of clinical assessment, and the symptoms reported should ideally be confirmed through physical examination. Finally, the ad hoc scale for sport-related habits, although reviewed by experts and showing acceptable internal consistency, included only items framed as healthy behaviors. This design may have limited variability and reduced the ability to identify associations with PFD symptoms. Consequently, the lack of clear associations for most SH could reflect a measurement limitation rather than the absence of a true relationship. Future research should consider developing tools that capture a broader range of sports-specific behaviors, including potentially harmful practices.

Comparison with similar research

The findings of this study align with previous research that has highlighted the high prevalence of PFD among female athletes, particularly those engaged in high-impact sports. Reported rates of UI in this population vary widely, ranging from 6% to 80%, depending on sport modality, intensity, and measurement methods (20). Our observed prevalence of 52% falls within this range and supports the notion that UI is a common issue in track and field athletes.

Regarding dyspareunia and pelvic pain, our findings (61.6% and 41.6%, respectively) are notably higher than those reported in general female populations. A previous study found a prevalence of dyspareunia around 20.1% (21), while other authors reported pelvic pain rates between 15% and 24%, depending on age, culture, and country (22). These discrepancies may reflect the specific physical demands and IAP increases associated with athletic training.

Our results concerning toileting habits, particularly straining during voiding and defecation, are consistent with previous studies. A previous study identified straining behaviors in women with lower urinary tract symptoms (LUTS) (23), and another study reported that over 30% of women with UI engaged in muscular effort to shorten voiding time, contributing to increased IAP (24). Similarly, straining during defecation has been linked to POP and anorectal dysfunction (25), reinforcing our findings that athletes with AI reported unhealthier FHs.

The habit of delaying voiding until returning home, observed more frequently in athletes with UI in our study, has been associated with bladder over-distension, altered sensation, and increased risk of urinary tract infections (26,27). A previous study also linked this behavior to back pain, although our data did not confirm this association (28).

Hovering over the toilet during urination, a behavior reported by up to 85% of women using public toilets, was also observed more frequently among athletes with UI in our sample. Previous studies have shown that this posture can reduce urine flow and increase residual volume, although its impact on urodynamic parameters remains controversial (29).

In terms of help-seeking behavior, our findings suggest that athletes with symptoms such as pelvic pain, dyspareunia, or POP are more likely to seek professional support than those with UI or AI. This aligns with previous research indicating that leakage symptoms are often perceived as embarrassing rather than pathological (30).

Explanations of findings

The high prevalence of unhealthy toileting habits observed among female athletes in this study may be explained by the specific demands of high-impact sports and the lack of awareness regarding PF health. Premature voiding and defecation, such as urinating or defecating without urge before training, were among the most frequent habits. These behaviors may be adopted as preventive strategies to avoid leakage during physical activity, especially in athletes who have already experienced symptoms. However, such practices can disrupt normal bladder and bowel function and contribute to symptom persistence.

Other frequent habits refer to those involving straining during micturition, which can lead to difficulty initiating the urinary stream and increase the risk of PFD (31). This behavior often involves muscular effort to accelerate urination and reduce voiding time (32), which raises IAP.

Additionally, athletes with UI were more likely to delay voiding until returning home. Suppressing the urge to urinate may cause bladder discomfort, over-distension, altered bladder sensation, and increased risk of urinary tract infections (26,27). A previous study also linked this behavior to back pain, although our data did not confirm that association (28).

Hovering over the toilet during urination was another frequent habit among athletes with UI. This position increases PF muscle tension and may lead to incomplete bladder emptying. A study report reductions in flow of up to 21% and increases in residual urine volume of up to 149% (29). Although this behavior is widespread, its clinical relevance is still debated, and further research is needed to clarify its impact on bladder function.

Similar patterns were observed in athletes with AI. Premature defecation may be both a cause and a consequence of AI, as athletes may attempt to empty the bowel before training to avoid leakage. However, doing so without urge may reinforce dysfunctional bowel patterns. Straining during defecation, especially when accompanied by breath-holding, increases IAP and can damage the muscles or nerves involved in defecation.

In terms of SH, athletes with pelvic pain, dyspareunia, or POP were more likely to seek help from health professionals, while those with UI or AI were less likely to do so. This may reflect the perception that leakage is an embarrassing but non-serious issue (30), whereas symptoms involving pain or a sensation of bulging are more alarming. Public awareness campaigns have focused more on UI than other PFD (33), which may influence help-seeking behavior. A previous study found that women with POP were more likely to engage in PF muscle training and be informed about their condition (34).

Implications and actions needed

Overall, these findings suggest that many of the toileting and training behaviors observed in female athletes are habitual and potentially harmful, yet often go unnoticed or unaddressed because females are often uninformed about the effects of these practices. This highlights the need for increased education and awareness regarding PF care in female athletic populations.

Conclusions

A high proportion of female athletes reported urinary and FHs that may compromise PF health, particularly premature voiding, and these behaviors were more common among those with PFD symptoms.

Given that many of these practices are habitual and often overlooked, there is a clear need for targeted education and preventive strategies within athletic populations. Future research should focus on developing comprehensive tools to assess sports-specific behaviors, including potentially harmful practices, and on conducting longitudinal and interventional studies to clarify causal relationships and evaluate the effectiveness of preventive programs.

Acknowledgments

The authors would like to thank all the athletes who participated and completed the time-consuming questionnaire, as well as the teams and federations that assisted in its dissemination.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-53/rc

Data Sharing Statement: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-53/dss

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-53/prf

Funding: This study was part of a project funded by Consejo Superior de Deportes (Spain) and by “European Union NextGenerationEU/PRTR” (No. EXP_74607).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-53/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of University of the Balearic Islands (No. 124CER19) and informed consent was taken from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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