WASHINGTON, DC — Pelvic floor disorder symptoms are extremely common in female triathletes, a Web-based survey suggests.

"Many doctors may not think this population would be at risk for pelvic floor disorders, but from our small study — with understandable limitations — we found that it may be more common than in the general population," said Johnny Yi, MD, a urogynecologist from Aracea Women's Care, Centura Health, Porter Adventist Hospital, in Denver.

In fact, 1 in 3 female triathletes reported symptoms of pelvic floor disorders, including stress urinary incontinence, anal incontinence, and nondisabling pelvic girdle pain. In addition, 1 in 4 had at least 1 component of female athlete triad, which consists of low energy (with or without disordered eating), menstrual disturbances, and low bone mineral density.

"I would urge doctors, especially primary care physicians and OB/GYNs, to ask questions and refer these women to urogynecology to discuss pelvic floor health, especially before they take on a rigorous exercise regimen," Dr. Yi told Medscape Medical News.

He presented the survey results here at the American Urogynecologic Society and International Urogynecological Association 2014 Scientific Meeting.

Urinary incontinence, which is prevalent in high-impact sports, such as gymnastics and track and field, has not been looked at in female triathletes. Significant pain can arise from the impact on the pelvic floor and pelvic girdle. Moreover, an endocrinologic consequence of female athlete triad is a hypoestrogenic state similar to menopause, and little is known about the effect on the pelvic floor of coupling high-impact activity with the potential for a hypoestrogenic state in young otherwise healthy women, Dr. Yi explained.

Incontinence and Pain

The 311 female triathletes surveyed were asked about demographic characteristics and medical history, and completed 3 questionnaires: the Epidemiology of Prolapse and Incontinence Questionnaire; the Pelvic Girdle Questionnaire; and the Female Athlete Triad Questionnaire, which has been endorsed by the National Collegiate Athletic Association for use in screening female athletes.

The women were 35 to 44 years of age, with an average body mass index of 22 kg/m². Nearly all (90%) were white, and 20% were menopausal. At the time of the survey, 82% of the respondents were training for a triathlon.

Triathletes are very interesting patients. They're obviously highly motivated people.

Of the 46% who had children, 95% had had vaginal deliveries. In this respect, the cohort is quite different from the general population in the Western world, where rates of caesarean delivery typically exceed 25% to 30%, noted session moderator Stephen Jeffery, MBChB, head of the Department of Urogynecology and Pelvic Floor Reconstruction at Groote Schuur Hospital and the University of Cape Town in South Africa.

"That tells you a lot about this group of women. Triathletes are very interesting patients. They're obviously highly motivated people," Dr. Jeffery told Medscape Medical News.

The overall prevalence of stress urinary incontinence was about 37%, but it was significantly more common in parous than in nulliparous women (approximately 55% vs 23%; P =.001).

The overall prevalence of anal incontinence was also about 37%, but there was no significant difference in prevalence between parous and nulliparous women.

Urgency urinary incontinence was reported by about 16% of respondents, and pelvic organ prolapse — also more common in parous women — was reported by about 5%. Training mileage and intensity were not associated with pelvic floor disorder symptoms.

Symptoms greatly bothered about 20% of women with urinary incontinence or pelvic organ prolapse and 30% to 50% of those with anal incontinence.

On the 100-point Pelvic Girdle Questionnaire, 18% of respondents reported pelvic girdle pain, but most of it was nondisabling; the mean score was 38. The pain was evenly distributed between the right and left sacroiliac joints, and was less common in the pubic symphysis. Women with urinary and anal incontinence had higher scores, Dr. Yi reported.

Of the 80% who completed the Female Athlete Triad Questionnaire, 1 in 4 screened positive for at least 1 of the 3 components; 22% had low energy, 24% had menstrual disturbance, and 29% had low bone mineral density. Eight percent screened positive for all 3 components. "We were surprised by how commonly this was reported," he said.

No association was found between pelvic floor disorders and female athlete triad.

The study findings are surprising and raise several important questions, Dr. Jeffery told Medscape Medical News.

"What's interesting to me is the physical impact of the high-intensity training, and how that's affecting the pelvic floor. The big question with regard to pain is, are they overtraining?"

Dr. Jeffery, who himself has competed in the Ironman Triathlon, said "it speaks very much to how we rehabilitate these patients. Incorporating a woman's health physiotherapist into their care would be a good first start."

He noted that the nearly 40% rate of anal incontinence was particularly surprising and worrisome, especially because a previous study showed that it takes an average of 5 years for patients to report fecal incontinence to a physician. This should be "high on your radar" when treating these women, he advised.

He said he would have liked to have seen information on bone mineral density. In addition, Dr. Yi didn't mention that these women often develop vitamin D deficiency, despite training outdoors, because they typically cover themselves with sunblock, Dr. Jeffery told Medscape Medical News.

He pointed out that much has been written about the impact of bicycle riding on male fertility, but there is little information on women. "The average Ironman bike ride is 3 to 5 hours," he said. "It would be an extremely interesting study."

With this research, Dr. Yi and colleagues have "provoked a lot of thinking around this group of people who, in my opinion, are a very interesting bunch," Dr. Jeffery told Medscape Medical News.

Dr. Yi has disclosed no relevant financial relationships. Dr. Jeffery has received speaker fees, travel grants, surgical training, and/or support to run local workshops from Boston Scientific, Bard, Coloplast, Karl Storz, and Covidien.

American Urogynecologic Society (AUGS) and International Urogynecological Association (IUGA) 2014 Scientific Meeting: Poster OP028. Presented July 24, 2014.


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