Exercise, fitness and the pelvic floor Kolding , Sept 2013

Kari Bø

Professor, PhD

PT, Exerc. Sci.

Norwegian School of Sport Sciences

Dept of Sports Med

The pelvic floor muscles

Pelvic floor muscles (PFM)

Piriformis

Ischiococcygeus

Iliococcygeus

M. Pubooccygeus•puborectalis•pubovaginalis•puboviseralis

Standring 2005

Leva

tor

ani

Coccygeus

Thickness: 8,0- 9,8 mm (Dietz et al 2005, Brækken et al, -09)

Levator hiatus

Optimal function?

• Forms a structural support (placement, cross sectional area, stiffness, hiatus opening)

• Prevent urethral descent

• Readiness for action

• Quick and strong co-contraction during/before increase in abdominal pressure

• Inhibition of detrusor contraction

• Ability to relax before and during voiding

Female pelvic floor dysfunction Bump & Norton 1998

• Urinary incontinence (30%)

• Fecal incontinence (11-15%)

• Pelvic organ prolapse (51%)

• Sensory and emptying abnormalities of the lower urinary tract

• Defecatory dysfunction (constipation)

• Sexual dysfunction (30%)

• Chronic pain syndromes (15%)

What can weaken connective tissue and pelvic floor muscles? Brubaker et al 2002

• Overweight: 55-60% of US population over 18 years of age!!! INACTIVITYINACTIVITY

• Constipation – straining with bowel motion

• Smoking – excessive coughing• Pregnancy and childbirth

(stretch/rupture of nerves, muscles, connective tissue)

• Pelvic surgery• Inherited weak connective

tissue• Strenous work/ heavy

lifting/sport (??)

General fitness activities?

• Physically active women report less UI (Milsom et al-08) – Selection bias

Hypothesis 1: Athletic women have strong PFM

• General PA increases PFM strength?

• Stretch and fatigue facilitate contraction?

• Co-contraction with other muscle groups and increase in intra-abdominal pressure?

Can general PA train the PFM?

• Exercise– horse back riding?

(22% UI Eliasson et al-04)– ballet ? (43% UI Thyssen

et al -02)

• Sexuality– Orgasm?– PFM strength and

mode of delivery did not affect sexual function (Baytur et al -05)

PFM strength in power lifters and controls Bø 2001, preliminary unpublished data

• 4 power lifters, mean age 23.5 years (SD 4.4)

• 19 controls, mean age 24.4 years (SD 2.4)

power lifters controls

22.6 cm H20 (9.1) ns 19.3 cm H20 (6.8)

PFM strength in athletes compared to controls Borin et al -13

• 10 volleyball: 4.4 mmHg (1.4)

• 10 basketball: 3.7 mmHg (1.4)

• 10 handball: 5.6 mmHg (1.4)

• 10 controls: 6.7 mmHg (1.9)

• Stat sign lower strength in volleyball and baskeballplayers compared to controls

• Moderate neg correlation (-0.51) between SUI and nocturia AND PFM strength

PFM morphology in female athletes and controls Kruger et al -05

• MRI in 10 athletes and 10 age-matched controls

• Results– No diff in size of pelvis– No diff in urogenital hiatus: 8.9 (9.5) vs 8.3

(11.4) cm2 p=0.2

– CSA of levator ani: 20% higher in athletes

• Prolonged labor?

Pelvic floor function in elite nulliparous athletes and controls Kruger et al 2007

• 24 nulliparous elite athletes (at least 5 years at national or international standard and involving high impact activity sport)

compared to 25 age and BMI matched controls• 3D/4D translabial ultrasound• Results

– Larger levator hiatus area on valsalva in athletes (21.5 cm2 (10.0) versus 14.9 cm2 (7.2)) p= 0.01

– Higher muscle diameter in athletes (0.96 versus 0.7 cm) p< 0.01

– Greater bladder descent on valsalva in athletes (22.7 mm (7.8) versus 15.1 mm (10.2)) p=0.03

– No signficant difference on hiatal area at rest or during PFM contraction

High prevalence of UI in women participating in regular PA

• Women with SUI– 2/3 of sedentary women report UI to be main reason for

withdrawal Bø et al -90• Sport students:

– 26% Bø et al-89• 33% of exercisers Nygaard et al -90• 40% of mid-age women exercising; 30% avoided sporting

activities Brown &Miller-01• 49% of exercisers Urwin & Urwin-03• 26% of group fitness instructors, same in Pilates/yoga Bø et

al -11• Nulliparous women attending gyms and controls

– 24.6% versus 14.3% Fozzatti et al-12

UI in female athletes

• 28% varsity athletes Nygaard et al -94

• 41%/16% elite athletes Bø & Sundgot- Borgen -01

• 52% athletes and dancers Thyssen et al -02

• 80% /51% of trampolinists Eliasson et al -02/05:

Anal incontinence Vitton et al J Women’s Health -11

• Questionnaire to 169 female high level sport participants (> 8 h/week) and 224 non intensive sport participants

• Anal incontinence: 14.8/ 4.9%– Flatus: 84%

• Urinary incontinence: 33.1/18.3%

• Intensive sport and BMI were significantly linked to anal and urinary incontinence controlled for age and births

Conclusion hypothesis 1: Does general PA train the PFM?

Physical activity does not seem to protect against UI

• Few studies on PFM strength

• No evidence that athletic women have stronger PFM

Hypothesis 2: PA may overload, stretch and weaken the PFM

Multifactorial model of athletic injury etiology Meeuwisse 1994

Predisposed athlete

Susceptible athlete

Injury

PFM anatomy

Connective tissue

Previous injury

Etniticity

Intr

insi

c ri

skfa

ctors

Eksposure to extrinsicrisk factors

Inciting event

Risk factors for injury Mechansim of Injury

ACUTE INJURIES

Acute injuries occur when tissue loading is sufficient to cause sudden irreversible deformation of the tissue Bahr et al 2004

Can high impact activities cause SUI? Larsen & Yavorek 2007

• 116 nulliparous women (80.6%), mean age 20.7 (19-24) examined with POP-Q and questionnaire before and after 6 weeks of summer military training

• Female paratroopers (n=37) singificantly more likely to have stage II prolapse (RR= 2.72) and worsening of their pelvic support regardless of initial prolapse stage (RR= 1.57)

• No association with UI and paratrooper training

Maximum vertical ground reaction forces during activity

(times body weight, in Hay -93)

• Running 3-4 • Jumping 5-12• Front somersault 9• Double back

somersault 14• Long-jump 16• Javelin throwing 9.1

(lead food)

IAP mmHg Faber-Hansen & Pedersen -86, Eie -71

• Lifing 305 kg: 400

• Sneezing: 100-125

• Valsalva: 83

• Ski-jumping (land): 67

• Double-sticking: 50

• Double leg-lift: 41

• Sit-up (rectus ab): 15

• Sit-up (obliques): 7-12

Increase in IAP during PA Weir et al 2006

• 30 women performed 3 reps of different activities with measurement of abdominal pressure (microtip rectal catheters)

• Results (median, min-max)

– Sit up 68 cm H2O (19.7-174.0)– Stand up from chair 70 cm H2O (36.0-229.0)

• Abd crunches, climbing stairs, walking on a treadmill, and many lifting acitivites did not increase abdominal pressure significantly more than standing up from a chair

IAP during exercise O’Dell et al 2008

• 12 healthy women, mean age 31.1 (20-51) measured by vaginal pressure in posterior fornix during cough and different exercises

• Results– Median cough 98.0 cm H2O– Lifting 45 pounds from floor 70.9 cm H2O– Jogging 54.0 cm H2O– All other exercise < 55 cm H2O– Abdominal exercise < 100 cm H2O, the same as

laughter, cough and bearing down in sitting position

– Holding breath/exhaling no influence on IAP during exercise

Daily activities

• 23 POP patients before and after surgery

• Vaginal pressure was 4-5 times higher during coughing/ valsalva than during lifting 2 and 5 kg

• Postopr care should focus more on treating chronic cough and constipation Mouritsen et al-07

Does one bout of strenuous general PA cause PFM fatigue? Lindland & Bø 2005

• Young nulliparous women with SUI symptoms.

• Muscle fatigue – maximal voluntary

contraction (MVC)

– vaginal resting pressure

– holding time

Intervention Lindland &Bø 200590 minutes interval training program

• Heavy strength training • High impact endurance

activities

ActivityMinute

sRunning 20

Jumps down from step-cases, jumping jacks, vertical jumps 5

Lounges 4

Jumps down from step-cases, jumping jacks, vertical jumps 5

Lounges 4

Jumps down from step-cases, jumping jacks, vertical jumps. 5

Lounges 4

Running down stairs 5

Squats 4

Running down stairs 5

Squats 4

Running down stairs 5

Squats 4

Results Lindland & Bø 2005

• 17% decrease in MVC

• No change in resting pressure or holding time

Overuse injuries

• Occur as a result of repeated overloading, each incidence of which, alone, is not enough to cause irreverisible deformation, but which when accumulated over time exceeds the tissue injury threshold Bahr et al

2004

Weaker PFM in female athletes? Borin et al 2013

• 10 volley, 10 basket, 10 handball and 10 controls

• Statistically sign difference between volley/basket and control

• Low PFM strength correlates with symptoms of UI

Long term effect of high impact PA

• 20 year follow-up of former olympians (1960-76), N= 104 (51%) Nygaard et al-97

– No difference in gymnasts / track & field or swimmers

• 15 year follow up of former elite athletes and controls in Norway Bø & Sundgot –Borgen -09

– Former elite athletes were not more likely to experience UI later in life compared to controls

– Former high impact activities did not influence prevalence of UI later in life

– UI early in life experienced during sport was strongly associated with UI later in life

Long term effect of high impact PA?

• 305 ex-tramponisits, median age 21 (18-44)

• 76% of women with leakage during trampolining continued to leak after ending competetive sport

• Prevalence of current leakage was higher in ex-trampolinists than in a reference group Eliassson et al 2005

Conclusion hypothesis 2: Does strenuous PA weaken the pelvic

floor?

?

It is possible...

Treatment and prevention in athletic women?

Does UI affect the athletes? Eliasson et

al 2005

• 305 athletes (response rate 60%) median age 21(18-44) with licence to compete in trampoline

answered questionnaire (Eliasson et al -05). – 61% UL when trampolining– 72% discussed it with someone– 35% affected in daily life– 53% affected psychologically– 12% stopped because of leakage

• 157 athletes Nimes, France answered questionnaire (low response%) (Caylet et al-05) – even small quantity of urine loss reported to be

embarrassing. 84% had not spoken about it

Effect of preventive devices Glavind -97

• 6 women with SUI, age 44-68 years

• Performed aerobic exercise for 30 minutes with and without vaginal sponge

• RESULTS: no leakage with sponge in situ

Effect of PFMT in athletes?• No RCTs

• 3 nulliparous volleyball players. PFMT++ for 3 mo – all cured Rivalta et al-10

• Case series of 7 sport students: – 6 of 7 cured, sign

improved PFM strength Roza -11

CONCLUSION (Bø, Sports Med,- 04, Milsom et al,

ICI -13)• Strenuous exercise is

likely to unmask UI

• Some evidence that strenuous exercise may cause pelvic floor dysfunction, BUT….

• More research is needed:

– heavy exertion as etiology?

– prevention and treatment?

– return to sport after childbirth?

Women’s Health: Exercise throughout a lifespan