INVITED COMMENTARY

Pelvic Floor Dysfunction in Female Athletes: Is

Relative Energy Deficiency in Sport a Risk Factor?
Tamara Rial Rebullido, PhD, CSPS1 and Andrea Stracciolini, MD, FAAP, FACSM2

reproductive systems (7). Low-energy

Abstract availability in female athletes may play
Due to the unique demands of sport participation on the body, female a role in the development of PFD such
athletes are at increased risk for pelvic floor dysfunction (PFD) and relative as urinary incontinence, fecal inconti-
energy deficiency in sport (RED-S). A high number of female athletes suffer nence, and pelvic organ prolapse. In-
from PFD, especially urinary incontinence. Several biomechanical and phys- deed, nutritional factors have been
iological risk factors may play a role in the development of PFD in female identified as a predisposing causal factor
athletes. RED-S has been shown to be associated with PFD. The goal of this of PFD (8,9). The complex nature and
commentary is to discuss RED-S as a risk factor for PFD and propose a impairment of physiological functions
mechanism for this relationship. by these unique health problems affect-
ing female athletes might suggest an asso-
ciation between the two syndromes.
Introduction To date, research evaluating RED-S as an independent risk
Pelvic floor dysfunction (PFD) is a nonspecific term encom- factor for PFD is scarce. Current findings, nonetheless, dem-
passing a variety of conditions including urinary incontinence, onstrate that those athletes with low-energy availability have
fecal incontinence, pelvic organ prolapse, pelvic pain, and sex- increased odds of urinary incontinence than those without energy
ual dysfunction. The prevalence of urinary incontinence among deficiency. A significant correlation between eating disorders and
female athletes of different sport modalities has been shown to urinary incontinence was found in a group of 37 female long-
be 36%, making female athletes almost three times more likely distance runners (10). Additionally, a cross-sectional study of
to experience urinary incontinence when compared with non- 372 elite female athletes and 372 age- and sex-matched nonath-
athletic females (1). Despite the high prevalence of PFD in fe- letes found that athletes with disordered eating were three times
male athletes, this condition has received limited attention more likely to present with urinary leakage than athletes with-
from sports medicine clinicians. The stigma and embarrassment out disordered eating (11). Urinary incontinence also has been
surrounding pelvic concerns leads many female athletes to found to be more prevalent in adolescent female athletes (15
avoid seeking adequate care for this condition. Female athletes to 19 years of age) with low-energy availability compared with
involved in physically demanding training or sports that place those with adequate levels of energy availability (12). A signifi-
an emphasis on “weight,” such as track and field, gymnastics, cant prevalence of PFD especially urinary incontinence (37%),
or dance have been found to have high rates of PFD (1–3), as anal incontinence (28%), and pelvic girdle pain (18%) was
well as an increased risk for low-energy availability (4–6). described in a population of 311 adult female triathletes
Relative Energy Deficiency in Sport (RED-S) is a syndrome (13). Almost one in four of these triathletes screened positive
consisting of health and performance impairments resulting for at least one component of the female athlete triad (i.e.,
from low-energy availability (3). RED-S has both short- and amenorrhea, osteoporosis, eating disorder). However, the au-
long-term effects on many systems of the body, including the thors found no significant association between the female
endocrine, central nervous system, musculoskeletal, and athlete triad and PFD (13).
In this article, we present RED-S as a potential independent
1
International Hypopressive & Physical Therapy Institute, Vigo, SPAIN; and risk factor for PFD and propose a hypothetical pathophysio-
2
Division of Sports Medicine, Boston Children’s Hospital, Harvard Medical logical model linking low-energy availability to the impair-
School, Boston, MA ment of the pelvic floor function in female athletes.
Address for correspondence: Andrea Stracciolini, MD, FAAP, FACSM,
Division of Sports Medicine, Department of Orthopedics, Boston Children's Anatomy
Hospital, 300 Longwood Ave, Boston, MA 02115; E-mail: The concept of pelvic floor as a whole is composed of several
Andrea.stracciolini@childrens.harvard.edu. structures and functions (8). Anatomically, the pelvic floor is a
1537-890X/1807/255–257
complex structure situated in the pelvic cavity. It is composed
Current Sports Medicine Reports of the levator ani and ischiococcygeus muscles, urogenital
Copyright © 2019 by the American College of Sports Medicine diaphragm, external genitalia, pelvic viscera, sphincters, and

www.acsm-csmr.org Current Sports Medicine Reports 255

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
pelvic connective and neurological tissue. As part of the mus-
culoskeletal system, the pelvic floor plays a crucial function in
continence, parturition, sexuality, stabilization of the sacroiliac
articulation, as well as breathing and posture (2). Moreover,
the pelvic floor supports the viscera of both the abdominal
and the pelvic cavity. Weak levator ani musculature, neuro-
logic compromise, and fascial support detachment can collec-
tively reduce pelvic floor support and consequently result in
PFD, such as urinary incontinence or pelvic organ prolapse
(9). Hence, PFD results from different combinations of ana-
tomical, physiological, reproductive, and lifestyle factors, in-
cluding nutrition across the lifespan (8).
Pathophysiology
Neuromuscular
The physiology of female athletes with PFD includes a com-
plex interaction of neuromuscular, biomechanical, morpho-
logical, hormonal, and nutritional risk factors (2). In the
case of female athletes, it has been suggested that the stress
and impact of strenuous exercise can weaken and fatigue the
pelvic floor (1,2). RED-S has recently been shown to affect
many systems of the body, including the neuromuscular system,
exhibited as decreased muscle strength, decreased glycogen
stores, and decreased endurance performance (3). Consequently,
proper activation of the pelvic floor musculature may be af-
fected in female athletes with RED-S. The female continence
mechanism is determined by proper structure, function, and
communication between the central and peripheral nervous
systems, urothelium, detrusor and urethra muscle, and pelvic
floor musculature. The urethral sphincter muscle contributes
to the maximal closure of the sphincter during high-impact
activities that load the bladder, such as jumping, running, or
landing. As such, neuromuscular weakness of the urethral
support closure mechanism can lead to involuntary urine
leakage during physical exertion.
Stress urinary incontinence is the most prevalent PFD found
in female athletes (1,2). The lack of energy available for
proper skeletal muscle function during training and competi-
tion may result in muscle glycogen depletion, leading to pelvic
floor neuromuscular fatigue, and poor intramuscular and
Figure: Theoretical model of pelvic floor dysfunction and low-energy availability in female athletes.
256 Volume 18  Number 7  July 2019
Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
intermuscular coordination. In elite female athletes, neuro-
muscular fatigue of the pelvic floor musculature was observed
during strenuous training and sport competition (14). When
the supporting connections of the pelvic floor are weakened
through increases in mechanical loads and intraabdominal
pressure, in addition to pelvic floor neuromuscular imbal-
ances and fatigue, the urethral closure mechanism also may
be adversely affected.
Nutrition
Vitamin D is a micronutrient essential for musculoskeletal
health, strength, and function. Pelvic floor skeletal muscle effi-
ciency, which is crucial for urethral function, may be compro-
mised when vitamin D concentrations are deficient (9,14).
Levator ani and external urethral sphincter muscles are both
striated skeletal pelvic floor muscles whose cell nuclei contain
the vitamin D receptor (15). Therefore, vitamin D insufficient
concentrations likely could impact the contractility and func-
tion of the levator ani, extrinsic urethral sphincter, and exter-
nal anal sphincter. However, available research examining the
relationship between PFD and vitamin D nutritional status is
still limited. One report found that the prevalence of urinary
incontinence and pelvic floor disorders was significantly
higher in women with vitamin D insufficiency (15). Others re-
ported a similar trend for fecal incontinence, although these
findings were not statistically significant (16).
Endocrine
The endocrine sequelae of RED-S, including hypothalamic
dysfunction and menstrual irregularities, could be viewed as
another predisposing factor for PFD in female athletes. Ath-
letes with low-energy availability may experience alterations
in normal sex hormone concentrations and function (17). It
is well established that low-energy availability leads to men-
strual cycle disruption, reproductive system suppression, and
to functional hypothalamic amenorrhea in females (7). One
of the effects of the functional disruption of pulsatile hypotha-
lamic gonadotropin-releasing hormone secretion, which oc-
curs in hypothalamic amenorrhea, is a decrease in systemic
estrogen levels. In fact, estrogen receptors have been identified
in all major supporting structures of the pelvic floor (18).
Invited Commentary
Therefore, the hypoestrogenic state present in female athletes
with RED-S, may increase the risk of PFD by influencing the
connective tissue properties and the overall neuromuscular
functionality of the pelvic floor.
Conclusions
The epidemiological profile of PFD and RED-S supports a
relationship between the two clinical entities in female ath-
letes. The underlying pathophysiology, including increased
pressure on the pelvic floor structures with strenuous exercise,
neuromuscular dysfunction related to muscle energy store de-
pletion, and nervous system impairment, also supports an as-
sociation (Fig.). PFD may have a negative impact on sports
performance, and at the extreme, prematurely terminate a fe-
male athletes’ sports career. Sports medicine clinicians need to
be aware of PFD and the proposed association with RED-S in
female athletes in order to promote timely and effective evalu-
ation and treatment. Future research should continue to ex-
plore this relationship.
The authors declare no conflict of interest and do not have
any financial disclosures.
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