How Does Pelvic Health Impact Performance: What Do We Know So Far? Asking for a Friend

Indirect effects create an added invisible (and sometimes visible) load for athletes

When I started trying to build bridges between sports medicine and pelvic health decades ago-it didn’t take long for me to recognize that if I could demonstrate a performance improvement as a result of addressing pelvic health needs...I’d have a huge IN. Medical, rehab, strength pros, and more importantly athletes themselves would be invested in strategies and solutions.

Clinical gains like heavier loads lifted and race PRs crushed while simultaneously resolving pelvic health issues shows value. However, demonstrating an association between performance and pelvic health via peer reviewed research holds added weight. We need both.

Quantifying the Impact

Efforts to quantify the impact of pelvic health issues on performance have been made. Data indicates that fit and athletic folks leave or modify their participation in physical activity due to pelvic health symptoms.

• 41% percent stop and 38% modify physical activity due to urinary incontinence (UI). (Cook et al. 2021)

• 75% of those with pelvic organ prolapse (POP) and 60% of those that report anal incontinence (AI) stop or modify exercise. (Cook et al. 2021)

• Urinary Incontinence was the most frequently named barrier to exercise in 18-55 year olds (reported over lack of time and musculoskeletal injury) (Dakic et al. 2022)

• Approximately 2/3 of those that reported POP or UI as an exercise barrier stopped exercising entirely. (Dakic et al. 2022)

Qualitatively Defining the Impact

While this suggests an impact on how intensely one might play or run, choosing an alternative activity, or that someone may stop participating entirely, it doesn’t get at the direct effect of pelvic health on how folks perform. To do that we had to look beyond quantifiable outcomes typically tied to performance like speed, load, PR, etc. Instead, we needed to get at it by looking at indirect variables such as the mental load of symptoms, the ongoing awareness of pelvic health symptoms or the evidence of something like a visible leak has on an athlete’s performance. How heavy was that extra load that athletes carried?

Turns out it’s a lot.

• Dancers reported loss of concentration, worries about visible leaks or odors, reduced training, and fear of re-occurance (Winder et al. 2025)

• Rugby players reported changing body positions during contact, changing techniques or speed in non-contact activities, and reducing weight training (McCarthy-Ryan et al. 2024)

• Rugby players also reported reducing training intensity, activity avoidance

  and loss of concentration during sport (Dakic et al. 2025)

• World Athletics U20 track and field athletes (multiple sports) reported loss of concentration, mistakes in performance, and adjusted movements to avoid discomfort (Giagio et al. 2025)

• Elite female athletes (multiple sports) reported embarrassment, fear, concern/worry, annoyance, and frustration (Culleton-Quinn et al. 2022; Giagio et al. 2025)

• Of the 41.7% of elite female power lifters and olympic weight lifting athletes that reported stress urinary incontinence, 87.8% reported that symptoms had a negative influence on performance. They cited similar concerns as reported above-loss of concentration, avoiding symptom triggering training activities, and visible leakage, etc. (Skaug et al. 2022)

Nevertheless, She Persisted

Cited studies quantifying fitness modifications and attrition have primarily been performed with recreational athletes. It is notable that in the elite athlete qualitative studies above, the tendency was for the athletes to carry-on and utilize coping strategies such as dehydration, use of pads, increased frequency urination during or pre-voids prior to training or competition (Culleton-Quinn et al. 2022; Skaug et al. 2022). Often, athletes assume pelvic health issues are to be expected in athleticism, are unaware of solutions, or haven’t had any practitioners inquire about symptoms (Dakic et al. 2023; Bosch-Donate. et al 2024)

While these strategies may somewhat address the invisible weight of some symptoms (visible leaks for example), they do not address how altering movement, avoiding training, or loss of concentration may impact competition preparation or game-day performance. In addition, it may be worth considering the injury vulnerability that may result from reduced training, on-field movement pattern changes, and reduced concentration.

We Are IN

While the current data suggests more of an indirect effect of pelvic health on performance, it is reasonable to suggest that this is our IN to start conversations (or bolster existing ones). Female athlete pelvic health is starting to gain a lot of attention, and now we have more information to help coaches, trainers, strength pros, and the sports med community understand the value of addressing pelvic health as a building block toward whole athlete health, performance, therapeutic alliance, and sport longevity.

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References

1. Cook J, Frawley H, Dakic J, Hay-Smith J, Lin KY. Pelvic floor disorders in exercising women: impact on participation, symptom disclosure and screening. J Sci Med Sport. 2021;24(Suppl 1):S56. doi:10.1016/j.jsams.2021.09.142

2. Dakic JG, Cook J, Hay-Smith J, Lin KY, Ekegren C, Frawley HC. Pelvic Floor Symptoms Are an Overlooked Barrier to Exercise Participation: A Cross-Sectional Online Survey of 4556 Women Who Are Symptomatic. Phys Ther. 2022;102(3):pzab284. doi:10.1093/ptj/pzab284

3. Winder BR, Heineman H, Scherb E. Prevalence and Impact of Urinary Incontinence and Other Pelvic Floor Symptoms in Female Aerialists. Journal of Women’s and Pelvic Health Physical Therapy. 49(1): 2-25; 35-44.

4. McCarthy-Ryan M, Perkins J, Donnelly GM, et al. Stress urinary incontinence prevalence and risk factors in female rugby players: a common health problem across four nations. BMJ Open Sport Exerc Med. 2024;10(1):e001832. Published 2024 Feb 6. doi:10.1136/bmjsem-2023-001832

5. Dakic J, Perraton L, Lindstrom J, Hain E, Chuah S, Stay S. The Hidden Challenge: Pelvic Floor Symptoms and Their Impact on Performance and Well-Being in Elite Female Rugby Players. Eur J Sport Sci. 2025;25(8):e70013. doi:10.1002/ejsc.70013

6. Giagio S, Adami PE, Bermon S, et al. Nearly half of 325 athletes reported pelvic floor symptoms: a cross-sectional study at the Lima 2024 World Athletics U20 Championships. BMJ Open Sport Exerc Med. 2025;11(3):e002564. Published 2025 Jul 25. doi:10.1136/bmjsem-2025-002564

7. Culleton-Quinn E, Bø K, Fleming N, Mockler D, Cusack C, Daly D. Elite female athletes’ experiences of symptoms of pelvic floor dysfunction: A systematic review. Int Urogynecol J. 2022;33(10):2681-2711. doi:10.1007/s00192-022-05302-6

8. Skaug KL, Engh ME, Frawley H, Bø K. Prevalence of Pelvic Floor Dysfunction, Bother, and Risk Factors and Knowledge of the Pelvic Floor Muscles in Norwegian Male and Female Powerlifters and Olympic Weightlifters. J Strength Cond Res. 2022;36(10):2800-2807. doi:10.1519/JSC.0000000000003919

9. Dakic JD, Hay-Smith J, Cook J, Lin K, Frawley HC. Screening for pelvic floor symptoms in exercising women: a survey of 636 health and exercise professionals. J Sci Med Sport. 2023;26(2):80-86. doi:10.1016/j.jsams.2023.01.008

10. Bosch-Donate E, Vico-Moreno E, Fernández-Domínguez JC, et al. Symptomatology and knowledge regarding pelvic floor dysfunctions and influence of gender stereotypes in female athletes. Sci Rep. 2024;14:11052. doi:10.1038/s41598-024-61464-x