What’s new with high intensity exercise and Prolapse (POP)? Let’s kick off Pelvic Organ Prolapse Awareness Month with a specific look at what current evidence suggests regarding the relationship between high-intensity exercise and prolapse. Not surprisingly, we don’t have much. However, we can start the month with a hopeful spin, the tide is turning. These needs are beginning to get some much needed attention! 

My How We’ve Grown!

In a scoping review by Giagio et al (2020), the authors noted a sharp increase in the number of studies on pelvic health in female athlete populations. Their search revealed 6 studies from 1990-1999, and 71 studies 2010-March 2020. However, a majority of that research (62/83 studies) explored urinary incontinence (UI), while only ONE was dedicated only to high intensity exercise and prolapse (POP). A recent narrative review by Bo et al (2023) searched databases from 1946-2022, and found only 8 studies that addressed POP (along with other pelvic health dysfunction) in relationship to physical activity. All 8 were found between 2016-2021. Again, it is good news that these questions are finally being asked! But clearly we are just getting started trying to understand this for our athletic and fit populations.

What’s New? Highs and Lows

The studies reviewed by Bo et al. (2023) looked at a variety of athletic and high-intensity exercise endeavors (running, CrossFit, Judo, triathlon, cheerleading, volleyball, and more). A history of pregnancy was a consistent risk factor for the development of POP symptoms in most of the studies. 

The highest prevalence of POP symptoms were noted amongst Olympic and Powerlifters at 23% (Skaug et al. 2022). However, most of the included studies found a much lower prevalence of POP symptoms reported by those that weight trained. Almeida et al.(2016) found that only 2.3% of amateur athletes who weight trained reported POP symptoms, while High et al. (2020) noted POP symptoms in only 3.2% of female CrossFitters. 

Wait, there’s more…

In addition, a large study found that only 14.4% of the 3934 participants, who reported a variety of activity levels, experienced prolapse symptoms (Forner et al. 2020). An important insight from this study was that symptoms were more prevalent among inactive women or those lifting lighter weights (<15 Kg), then those participants that lifted heavy (>50 Kg). The authors noted that vaginal deliveries and inactivity had the strongest associations with POP symptoms. Hello, this is huge. 

While these low numbers defy our historical understanding and expectations for POP symptoms and prevalence in those that regularly engage in weight training activities, we cannot take a victory lap just yet.

It is important to note that females with POP symptoms often remove themselves from these activities. Cook et al (2021) noted that 75% of those surveyed stopped or modified their fitness due to POP symptoms. Conversely, it has been proposed that global physical activities have a positive impact on the health of the pelvic floor (Bo and Nygaard, 2020, Leightner et al 2018). Forner’s 2020 results may support this idea, however, we still have a long way to go. 

So where do we go from here?

Our takeaways, or at least mine, are that these results, from Bo to Forner to Cook, continue to support that POP is multifactorial. Weight training and high-intensity exercise alone aren’t the bad guy, or the only bad guy. Often, our literature and clinical pathways seem to be asking either/or questions. Should we or shouldn’t we? Is weight training or physical activity a friend or foe of pelvic health?

However, the reality in the trenches is much more nuanced than that. More complex questions may help us start to tease out solutions that address that multifactorial, biopsychosocial nature of the relationship between high-intensity exercise and pelvic organ prolapse: 

• Forner’s 2020 study suggests that inactivity and lighter weights may have a more detrimental impact on pelvic health, and begs the question: have we unintentionally under-loaded folks in an effort to protect them from POP or other pelvic health dysfunction? (more on that here)
• Why does physical activity promote pelvic health for some, while it propels dysfunction for others? 
• Rather than focus only on the symptomatic folks, what can we learn from the large percentages of folks in these studies that had no symptoms of prolapse- it is HOW they are doing the exercises? Is it volume, speed, type? Is it genetics (fascia/collagen content? Levator hiatus width?).
• Could these protective efforts toward “safe” exercise added fears and kinesiophobia that impacted the decision making of those surveyed in Cook’s 2021 study to discontinue participation in their fitness of choice? (Some ideas of how to adapt vs abandon exercise)
• How does the lack of available guidance on a return to exercise after pregnancy impact these numbers? Would guidance have turned the tide for Cook’s survey participants? (Here is some guidance!)
• How does our lack of education of medical, rehabilitation, and fitness providers on the basics of pregnancy recovery and return to fitness impact their comfort with these topics, to improve their ability to engage athletes on these topics provide this guidance? (Some ideas here! Let’s coach this! 
• How can we improve our educational processes to change that professional trajectory?   

What’s Next?

Lots to consider as we move forward. But the good news is that we are moving forward. While the low prevalence of POP in these studies is encouraging, we need to absorb them broadly as we continue to gather more information. However, I do think that they support re-evaluation of the blanket premise that weight training leads to POP. Instead it moves us toward the consideration of more variables and asking deeper, more complex questions! Thus providing us with more entry points to make changes for our patients and clients, and can help us offer more hope! 

#educatedhope

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References

Giagio S, Salvioli S, Pillastrini P, Innocenti T. Sport and pelvic floor dysfunction in male and female athletes: A scoping review. Neurourology and urodynamics. 2021;40(1):55-64. doi:10.1002/nau.24564

Bø, K., Anglès-Acedo, S., Batra, A. et al. Strenuous physical activity, exercise, and pelvic organ prolapse: a narrative scoping review. Int Urogynecol J 34, 1153–1164 (2023). https://doi.org/10.1007/s00192-023-05450-3

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 pow- erlifters and Olympic weightlifters. J Strength Cond Res. 2022;36(10):2800–7. https://doi.org/10.1519/JSC.0000000000 003919.

Almeida MBA, Barra AA, Saltiel F, Silva-Filho AL, Fonseca AMRM, Figueiredo EM. Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: A cross-sectional study. Scandinavian journal of medicine & science in sports. 2016;26(9):1109-1116. doi:10.1111/sms.12546

High R, Thai K, Virani H, Kuehl T, Danford J. Prevalence of Pelvic Floor Disorders in Female CrossFit Athletes. Female Pelvic Medicine & Reconstructive Surgery. 2020; 26 (8): 498-502. doi: 10.1097/SPV.0000000000000776

Forner LB, Beckman EM, Smith MD. Symptoms of pelvic organ prolapse in women who lift heavy weights for exercise: a cross-sectional survey. International Urogynecology Journal. 2019;31(8):1551-1558. doi:10.1007/s00192-019-04163-w

Cook J, Frawley H, Dakic J, Hay-Smith J, Lin KY. Pelvic floor disorders in exercising women: impact on participation, symptom disclosure and screening. Journal of science and medicine in sport. 2021;24:S56-S56. doi:10.1016/j.jsams.2021.09.142

Leightner, Monika. “Evaluation of Pelvic Floor Kinematics in Continent and Incontinent Women during Running: An Exploratory Study.” Neurology and Urodynamics (2018); 37: 609-818. DOI: 10.1002/nau.23340