“We don’t set a time limit,” says pelvic floor physical therapist Emma Brockwell. “If you look at your hip, groin and pelvis diaries, the pelvic floor is missing out. It’s incredible how this muscle group has been neglected.”
The pelvic floor supports the pelvic organs (bladder, uterus, and bowels), controls the body’s incontinence mechanisms, and aids in core stability. This affects the daily lives of all women, including elite athletes and teenage girls. And it affects men too. However, the pelvic floor is rarely talked about, except during pregnancy. Of course, it’s not even talked about in the context of professional sports.
However, several female Manchester City players reported urinary incontinence (the involuntary leakage of urine) during jump warm-up exercises known as pogos, raising questions about how representative the numbers were for the team as a whole.
Physical performance scientist Dr Rosie Anderson and performance services director Emma Deakin contacted Brockwell, who also works with Chelsea, Arsenal, Aston Villa and London City Lionesses in the Women’s Super League, as well as the Washington Spirit in the National Women’s Soccer League. She aims to educate athletes and staff, assess athletes’ pelvic health, and ensure pelvic floor muscle training is incorporated into their exercise programs.
City has discovered that some athletes have changed the way they practice, such as limiting the weight they can squat in the gym, for fear of leaking urine or embarrassment. For the same reason, they were sometimes reluctant to jump or run at maximum intensity or to drink fluids. They frequently went to the bathroom before games, disrupting their performance.
There are also psychological effects. “It crushes their confidence,” Brockwell says. “Anxiety and low mood have a lot to do with pelvic floor dysfunction when you think about how women feel. It’s important to be aware of this in this sport, but knowing it and not doing anything about it is disastrous.”
At City’s Etihad Campus, The Athletic joined Anderson, Brockwell and Deakin to challenge each other, bust myths and normalize the conversation about the pelvic floor so more women and girls can continue to enjoy sport.
“Pelvic floor dysfunction is a group of symptoms that occur when the pelvic floor is not functioning optimally,” Brockwell says. High-impact sports such as soccer and rugby may be a risk factor. Symptoms may include pelvic organ prolapse. Pain in the pelvis, coccyx, back, hips and groin, urinary and even fecal incontinence.
However, this is not just a problem for famous players. Pelvic floor health has far-reaching implications beyond soccer.
“There is a common misconception that pelvic floor dysfunction only occurs if you have had children, are older, and are perimenopausal (before menopause) or postmenopausal (after menopause),” says Brockwell. “The reality is that pelvic floor dysfunction can occur in girls as young as 12 or 13 and throughout their lifecycle.
“This is one of the main reasons we keep girls away from sports. If they pee, it’s very embarrassing and uncomfortable, so they’ll stop playing.”
And it’s not just women’s and girls’ pelvic floors that have been neglected.
“I would guess that men have more problems with their pelvic floor,” Brockwell says.
“(Some male) athletes will have recurring groin problems, but the vast majority of physiotherapists and doctors won’t think to check the pelvic floor,” Deakin added. “They were doing the wrong treatment and could have avoided surgery and months out of the game.”
“Yes, men experience urinary incontinence, too,” Brockwell says. “Erectile dysfunction can be a result of the pelvic floor not functioning optimally. But no one talks about these things, no one talks about the penis, no one talks about the vulva. When it’s central to the body, it becomes a taboo area that everyone is ashamed to talk about.
“Pelvic health in the women’s game is really great because we’re the first to do it. This is where the men’s game can learn from us. We’re kind of an untapped secret.”
Among the female soccer players Brockwell has worked with, the most common symptoms are stress incontinence and hip and pelvic pain. “Coughing, sneezing, laughing, jumping, tackling, or heading the ball can cause you to wet the bed, leak a few drops of urine, or completely lose bladder control,” she says. “It depends on the severity of the symptoms.”
The pain is often musculoskeletal, but it can also be associated with gynecological conditions such as endometriosis. Endometriosis is a disease in which cells similar to the lining of the uterus grow outside the uterus, often in the ovaries, fallopian tubes, and other pelvic organs.
A 2024 study examining the impact of pelvic floor dysfunction on female rugby players in the UK and Ireland highlighted that in addition to stress incontinence and pelvic pain, fecal urgency and incontinence are also symptoms to consider when working with female athletes.
A study conducted this year called “Pelvic floor health and urinary incontinence in female soccer players” found that 50% of 18 professional soccer players in Spain had urinary incontinence. “That’s a big deal,” Brockwell said.
Advertisements for incontinence pads and mothers sharing their experiences with their daughters have distorted society’s perception of what is normal.
“A lot of the athletes we talk to have it normalized as part of being an elite athlete,” Brockwell says. “This is certainly a very common symptom, but it’s not normal and it’s not something you should put up with.” The same goes for women’s exercise, whether it’s recreational or at the highest level of exercise.
Not only does it affect your physical performance, but it also has a mental impact.
“It’s also a huge distraction,” Anderson says. “You’re not fully focused on the game, which can affect your decision-making as a result.”
Physical performance scientist Dr Rosie Anderson leads Manchester City’s female athlete health program (Manchester City)
City were the first high-profile club to announce three years ago that their women’s team would no longer wear white shorts as part of their home kit, in a bid to help players feel more comfortable during menstruation. But the problem goes beyond menstruation; the same concerns apply to urinary incontinence.
“We were emphasizing what color shorts the players were wearing,” Deakin says. If the shorts are light in color, it will be more obvious if the player is leaking. The same goes for people who wear gray leggings instead of black, for example.
“Especially now with all the media attention on these players,” Brockwell added. “I’ve talked to quite a few people who are incredibly self-conscious that if they obviously had urine on their shorts, they would be snapped at the wrong moment. That must be a horrifying reality.”
About 18 months ago, Brockwell conducted online education sessions for first-team players while Anderson was in the room.
Brockwell explained what the pelvic floor is, what it does, what it does, and what happens when it’s not functioning optimally. She also emphasized how the pelvic floor is closely connected to the rest of the body. The hip muscles form part of the pelvic floor and are closely attached to the groin muscles. Improving pelvic floor function may help reduce groin injuries common in female soccer players. The pelvic floor is also connected to the lower back, abdominal wall, and diaphragm, which are involved in breathing. A weak pelvic floor can also affect these areas of your body.
“This muscle that no one talks about, this muscle that causes embarrassment because of its location, is just one part of the body. If we talk about it, we may be able to help with symptoms of pelvic floor dysfunction as well as musculoskeletal injuries,” Brockwell says.
Another important outcome is reducing the stigma of treating pelvic floor dysfunction. Physical therapy is one way to reduce symptoms. Just like any other muscle, you can train your pelvic floor. If a player has weak hamstrings, a strengthening program will be put in place. The same can and should apply to your pelvic floor. This framing was very important for players to understand.
For example, by the time you’ve read this far, you’ve probably completed your pelvic floor muscle training. It’s important not to train muscles in isolation, Brockwell says, explaining the two sets of exercises you should include in your program.
Manchester City women’s players train at the Joye Stadium in March (Martin Rickett/PA Images via Getty Images)
The pelvic floor is made up of slow-twitch and fast-twitch fibers. To train the former, lie down, sit down, or stand up (the more upright you are, the harder it is to do this in the first place) and tighten as if to stop peeing or wind from passing through. You should feel pressure and lift in your perineum. Aim to hold for a maximum of 10 seconds. Holding activates slow-twitch muscle fibers. Then relax your muscles.
To train your fast-twitch fibers, start by quickly tightening your front and back and slowly relaxing while lying, sitting, or standing. Repeat this up to 10 times. If you find yourself holding your breath or squeezing your butt, or if your existing symptoms don’t improve or get worse after 6 to 8 weeks, you may be doing the exercises incorrectly.
“If something like this happens to you, you’re not alone,” Brockwell says. “Many women struggle at first, and pelvic health physical therapy is recommended at times like this.”
“We should encourage girls and women to check this part of their body, their vulva,” says Brockwell. “We encourage women to check their breasts for lumps and bumps.
“Also, look at that part of your body in the mirror. I don’t know how many women have never seen their vulva before. It’s your body. Why haven’t you looked there?”
“Typically, before and after pregnancy, you might look at it and say, ‘Oh my god, what the heck is this?'” Being able to recognize these body changes before you experience them is not only empowering, but also relieves anxiety. Your doctor should be informed of any changes in the area. ”
Indeed, as Anderson puts it, there was much laughter within the Manchester City team as this “myth-busting” act took place. “Mostly when there were animated images of the female reproductive system,” she added.
“I thought, ‘Are they taking this seriously?’
But the players did. When the team was retested, more symptoms were reported.
After the initial screening, players will receive a one-on-one session with Brockwell. She works with Citi twice a month, once in person and once online. Sharing positive experiences will encourage others, especially younger and better athletes, to reach out for help.
A 2010 study found that athletes who experienced urinary incontinence in the past were nine times more likely to experience symptoms of pelvic floor dysfunction later in life, even after recovery, so they may have some future prospects.
This season also saw a notable cultural shift in how players approach once-taboo topics.
“It’s like night and day,” Brockwell said. “It’s amazing how different just talking to players one-on-one can make you feel. They say, ‘Oh yeah, by the way, I wet myself last week, what are we going to do?’ Before that, it would have been, ‘I don’t care, I don’t care.’
“They’re worried about it.”
According to the aforementioned 2010 study, it takes up to seven years to seek help for pelvic floor dysfunction. Dr Deakin agrees: “Can you imagine that with any other condition? ‘Oh, my knees hurt, I’ll wait seven years!'” Dr Brockwell advises doing pelvic floor exercises even before symptoms appear.
“It’s never too late to get help,” she says, recommending seeing your doctor first and then referring yourself to a pelvic health physical therapist.
“They shouldn’t be embarrassed,” Brockwell says. “There are medical professionals who deal with this problem every day. It’s their bread and butter and it’s all they talk about.”
And it should be talked about in everyday life.
