Pelvic health issues affect far more athletes than most people realize, yet they remain one of the least discussed aspects of sports performance and wellbeing. At Auckland Physiotherapy, our pelvic health physiotherapists work with athletes across all sports and levels - from recreational runners to elite competitors - helping them address conditions that significantly impact training, performance, and quality of life.

The silence around pelvic health problems often leaves athletes suffering unnecessarily, believing their symptoms are normal consequences of sport or childbirth, or feeling too embarrassed to seek help. Let's break this silence and explore the common pelvic health issues we see in sport, understand why they happen, and outline evidence-based solutions that can restore function and confidence.

Understanding Pelvic Health

The pelvic floor is a group of muscles, ligaments, and connective tissues forming a supportive hammock at the base of the pelvis. These muscles perform crucial functions:

• Support: Hold pelvic organs (bladder, bowel, uterus) in proper position
• Sphincteric: Control continence of bladder and bowel
• Sexual: Contribute to sexual function and sensation
• Stability: Work with core muscles to stabilize the spine and pelvis
• Circulation and Lymphatic: Support healthy blood and lymph flow in the pelvis

Just like any other muscles, the pelvic floor can become too weak, too tight, poorly coordinated, or injured - all of which can cause symptoms and functional limitations.

Common Pelvic Health Issues in Sport

Stress Urinary Incontinence (SUI)

What It Is: Involuntary leakage of urine during activities that increase intra-abdominal pressure - such as running, jumping, coughing, sneezing, or lifting weights.

How Common Is It? Research shows that 25-45% of female athletes experience urinary incontinence, with higher rates in high-impact sports. Studies of elite athletes find rates up to 80% in trampolining and gymnastics, and 50% in running and team sports.

Why It Happens:

• Repeated high-impact forces overwhelming pelvic floor muscle capacity
• Weak or poorly coordinated pelvic floor muscles
• Pregnancy and childbirth changes (though nulliparous athletes also experience SUI)
• Excessive intra-abdominal pressure generation during exercise
• Poor breathing patterns creating downward pressure on the pelvic floor
• Hypermobility or connective tissue laxity

Sports Most Affected: Running, CrossFit, gymnastics, trampolining, netball, basketball, volleyball, tennis, high-intensity interval training.

Impact on Athletes: Many athletes modify or stop activities they love. Some wear pads during training, limit fluid intake (which creates other health problems), or withdraw from sport entirely. The psychological impact - embarrassment, shame, loss of confidence—can be as significant as the physical symptoms.

Pelvic Organ Prolapse (POP)

What It Is: Descent of pelvic organs (bladder, uterus, or rectum) from their normal position due to weakened support structures. This can create sensations of heaviness, dragging, bulging, or visible protrusion.

Prevalence: While exact rates in athletes are unclear, studies suggest 40-50% of women who've had children have some degree of prolapse, many asymptomatic. Athletes who return to high-impact training too quickly postpartum have increased risk.

Why It Happens:

• Pregnancy and childbirth (vaginal delivery increases risk, but caesarean doesn't eliminate it)
• Chronic increases in intra-abdominal pressure from heavy lifting or high-impact activity
• Genetic predisposition and connective tissue properties
• Inadequate postpartum recovery before returning to sport
• Poor load management when returning to training

Symptoms: Sensations of pelvic heaviness or pressure, feeling of something "dropping down," visible or palpable bulge, difficulty emptying bladder or bowel, lower back ache.

Sports Most Affected: Weightlifting, CrossFit, running (particularly postpartum), gymnastics.

Pelvic Pain Conditions

What They Include:

• Persistent pelvic pain (pain lasting more than 3 months)
• Dyspareunia (painful intercourse)
• Vulvodynia (vulvar pain)
• Vaginismus (involuntary muscle spasm)
• Coccydynia (tailbone pain)
• Pudendal neuralgia (nerve pain in the pelvic region)

Why They Happen:

• Overactive, tight, or hypertonic pelvic floor muscles (common in athletes who "hold" or brace constantly)
• Previous trauma or injury
• Nerve irritation or compression
• Myofascial trigger points
• Psychological factors including stress, anxiety, or previous negative experiences
• Endometriosis or other medical conditions

Sports Most Affected: Cycling (saddle-related issues), rowing, horse riding, gymnastics, yoga (extreme positions).

Impact: Pain can occur during sport, interfere with sexual function, affect daily activities like sitting, and significantly impact quality of life.

Diastasis Recti and Core Dysfunction

What It Is: Separation of the rectus abdominis muscles (six-pack muscles) along the midline, most commonly occurring during pregnancy but also seen in heavy lifters and some male athletes.

Why It Matters for Pelvic Health: The abdominal wall and pelvic floor work as an integrated system. When abdominal integrity is compromised, the pelvic floor often compensates, leading to dysfunction, pain, or incontinence.

Symptoms: Visible bulging or doming along the midline with exertion, poor core stability, lower back pain, pelvic floor symptoms.

Sports Most Affected: Weightlifting, CrossFit, gymnastics, any sport requiring significant core strength.

Breathing Pattern Disorders

What It Is: Dysfunctional breathing patterns that create excessive downward pressure on the pelvic floor, often involving chronic breath-holding, bearing down, or paradoxical breathing.

Why It Matters: Poor breathing mechanics can create constant downward pressure on the pelvic floor, contributing to weakness, prolapse, or incontinence. Many athletes hold their breath during exertion, creating massive intra-abdominal pressure spikes.

Signs: Breath-holding during lifts, chest breathing rather than diaphragmatic breathing, inability to coordinate breathing with movement.

Breaking the Silence: Why Athletes Don't Seek Help

Understanding barriers to care helps us address them:

Normalization: Many athletes believe leakage during sport is normal or inevitable, particularly after childbirth. While common, it's not normal and is treatable.

Embarrassment: Pelvic health remains a taboo topic. Athletes feel uncomfortable discussing intimate symptoms.

Lack of Awareness: Many don't know pelvic health physiotherapy exists or that these issues are treatable.

Fear of Being Told to Stop Sport: Athletes worry they'll be advised to quit activities they love.

Minimization by Healthcare Providers: Some athletes report their concerns being dismissed as "part of being a mum" or "just do more Kegels."

The reality? Pelvic health physiotherapists are specialists who understand sport demands and work to keep you active while addressing symptoms.

Evidence-Based Assessment and Treatment

Comprehensive Assessment

Pelvic health physiotherapy begins with thorough assessment:

History Taking:

• Detailed symptom description and history
• Sport participation and training loads
• Pregnancy and birth history if relevant
• Bowel and bladder habits
• Sexual function (if relevant to symptoms)
• Previous injuries or surgeries
• Psychological factors and impact on quality of life

Physical Examination:

• Posture and movement assessment
• Breathing pattern evaluation
• Abdominal wall assessment (including diastasis recti check)
• Lumbopelvic and hip assessment
• Internal pelvic floor muscle assessment (with consent)

The internal examination allows direct assessment of pelvic floor muscle strength, tone, coordination, and presence of trigger points or pain. This is optional but provides valuable information that guides treatment.

Functional Testing:

• Sport-specific movements
• Load testing (jumping, running, lifting as appropriate)
• Pressure management assessment

Treatment Strategies for Stress Urinary Incontinence

Pelvic Floor Muscle Training (PFMT): The gold standard treatment for SUI, with strong research support showing 40-70% cure rates and significant improvement in most others.

Effective PFMT requires:

• Correct technique (many people contract incorrectly)
• Appropriate dosage (typically 3 sets of 8-12 contractions daily for 3-6 months)
• Progressive overload (increasing difficulty over time)
• Functional integration (incorporating into sport-specific movements)

The Knack: A timing strategy where you pre-contract the pelvic floor just before activities that cause leakage (like jumping). Research shows this significantly reduces leakage episodes.

Load Management: Modifying training loads temporarily while building pelvic floor capacity, then progressively increasing demands.

Breathing Coordination: Teaching proper breathing patterns that reduce downward pelvic pressure during exertion.

Whole-Body Strengthening: Addressing hip, core, and lower limb strength that supports optimal load distribution.

Pessaries: Medical devices inserted into the vagina that support pelvic organs. Research shows sports pessaries can effectively manage symptoms during high-impact activity while you build pelvic floor strength.

Treatment for Pelvic Organ Prolapse

Conservative Management:

• Supervised pelvic floor muscle training (shown to reduce prolapse symptoms and severity)
• Pessary use (can allow symptom-free sport participation)
• Load and impact modification during rehabilitation
• Whole-body strengthening programme
• Breathing and pressure management strategies

Surgical Intervention: Reserved for cases where conservative management doesn't provide adequate symptom relief. Post-surgical physiotherapy optimizes outcomes.

Return to Sport: Structured, progressive return to impact and loading. Research suggests 12 weeks minimum before returning to high-impact activity postpartum, often longer with prolapse.

Treatment for Pelvic Pain

Pelvic Floor Muscle Relaxation: For overactive muscles, treatment focuses on downtraining, relaxation, and stretching rather than strengthening.

Manual Therapy:

• Internal myofascial release to address trigger points
• External hip, lower back, and abdominal work
• Joint mobilization if indicated

Dilator Therapy: Progressive use of vaginal dilators for conditions like vaginismus or dyspareunia.

Pain Education: Understanding pain mechanisms and that pain doesn't always equal damage.

Stress Management: Addressing psychological factors that contribute to muscle tension.

Behavioral Modifications: Adjusting activities or positions that aggravate symptoms while working on underlying causes.

Treatment for Diastasis Recti

Functional Core Restoration:

• Teaching proper intra-abdominal pressure management
• Progressive core exercises emphasizing coordination over strength initially
• Breathing integration
• Gradual return to challenging exercises like planks, crunches, heavy lifting

Realistic Expectations: Some separation may persist, but function can be fully restored. The goal is effective core function, not complete gap closure.

Breathing Re-education

Diaphragmatic Breathing: Teaching proper breathing mechanics that create balanced pressure distribution.

Exercise Integration: Coordinating breathing with movement patterns (exhaling during exertion, for example).

Pressure Management: Avoiding excessive breath-holding or bearing down.

Sport-Specific Considerations

Running

Common Issues: Stress urinary incontinence, pelvic organ prolapse symptoms, pelvic pain.

Solutions:

• Pelvic floor strengthening with running-specific integration
• Gradual return-to-running programmes postpartum (typically starting 12+ weeks postpartum)
• Sports pessary use during runs while building strength
• Appropriate footwear and running surface selection
• Hip and core strengthening

Weightlifting and CrossFit

Common Issues: Prolapse symptoms during heavy lifts, stress incontinence during box jumps or double-unders, diastasis recti.

Solutions:

• Breathing and bracing strategies that reduce downward pressure
• Appropriate load progression
• Pelvic floor strengthening
• Exercise modifications (step-ups instead of box jumps initially)
• Strategic use of pessaries during training

Cycling

Common Issues: Pelvic pain, pudendal neuralgia, vulvar pain, numbness.

Solutions:

• Bike fit assessment and adjustment
• Saddle selection (wider, with pressure-relief cutouts)
• Padded cycling shorts
• Position changes during long rides
• Pelvic floor muscle relaxation if overactive
• Addressing hip and lower back mobility

Gymnastics and Trampolining

Common Issues: Very high rates of stress urinary incontinence, pelvic organ prolapse risk.

Solutions:

• Early pelvic floor strengthening (ideally before symptoms develop)
• The Knack timing strategy before high-impact movements
• Load management during heavy training periods
• Regular pelvic health check-ups

Prevention: Building a Resilient Pelvic Floor

Prevention is always better than treatment. Here's how to maintain pelvic health:

Include Pelvic Floor Training: Just like training other muscle groups, include pelvic floor exercises in your regular routine. Even 5 minutes daily makes a difference.

Breathe Properly: Never hold your breath during lifts or exertion. Exhale during the effort phase.

Progress Gradually: Avoid sudden jumps in training volume or intensity, particularly postpartum.

Maintain Healthy Body Weight: Excess weight increases pressure on the pelvic floor.

Manage Constipation: Chronic straining damages pelvic floor support. Address with adequate fiber, hydration, and proper toileting posture.

Postpartum Considerations: Return to sport gradually with professional guidance. The standard 6-week clearance doesn't mean you're ready for high-impact training.

Regular Check-Ups: Consider pelvic health assessment part of your athletic preparation, especially if planning pregnancy or experiencing any symptoms.

When to Seek Pelvic Health Physiotherapy

Consult a pelvic health physiotherapist if you experience:

• Any urinary or fecal leakage during sport or daily activities
• Sensations of heaviness, dragging, or bulging in the pelvic area
• Pelvic pain during or after exercise
• Pain with intercourse
• Feeling like you can't empty your bladder or bowel completely
• Lower back pain associated with core weakness
• Uncertainty about returning to sport postpartum
• Wanting to prevent pelvic floor issues before they start

Early intervention prevents minor issues from becoming major problems and allows faster return to full training.

What to Expect from Pelvic Health Physiotherapy

Specialized Expertise: Pelvic health physiotherapists have advanced training in pelvic anatomy, function, and dysfunction. We understand both the clinical aspects and the demands of sport.

Individualized Treatment: Cookie-cutter advice doesn't work. We design programmes specific to your symptoms, sport, and goals.

Empowerment: We teach you to understand your body, recognize warning signs, and manage your condition long-term.

Sport-Focused: Our goal is keeping you active. We work with you to modify, adapt, and progress training while addressing underlying issues.

Collaborative Care: We may work with your GP, obstetrician, sports physician, or other healthcare providers to ensure comprehensive care.

Breaking Stigma: Normalizing Pelvic Health Conversations

As pelvic health physiotherapists, we're passionate about changing the culture around these issues. Pelvic health should be discussed as openly as knee or shoulder injuries. Leaking during sport isn't a badge of honor or inevitable consequence of motherhood—it's a treatable condition.

By seeking help, speaking openly, and sharing experiences, athletes help break down stigma and encourage others to get the treatment they deserve.

Conclusion

Pelvic health issues affect countless athletes but remain undertreated due to embarrassment, lack of awareness, and misconceptions about what's normal. The reality is that these conditions are common, treatable, and should never force you to give up activities you love.

At Auckland Physiotherapy, our pelvic health physiotherapists provide specialized, evidence-based care in a comfortable, non-judgmental environment. We understand the unique demands athletes face and work to restore function, eliminate symptoms, and keep you doing what you love.

You don't have to suffer in silence. You don't have to accept leakage as normal. You don't have to give up sport. With appropriate assessment and treatment, most pelvic health issues improve significantly or resolve completely.

Experiencing pelvic health symptoms affecting your sport or daily life? Visit www.aucklandphysiotherapy.co.nz or contact Auckland Physiotherapy today to book a confidential appointment with our pelvic health physiotherapists.

Housed in the beautiful Foundation Precinct, sandwiched in-between Newmarket, Parnell & Remuera

This blog provides general information and is not a substitute for individual assessment. Pelvic health concerns require personalized evaluation and treatment. All internal examinations are performed with full consent and are optional.