By Chiara Ghetti, MD
Associate Professor of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
Dr. Ghetti reports no financial relationships relevant to this field of study.
It’s a new year, and how many of us have New Year’s resolutions to increase our exercise in 2017? Exercise classes at my neighborhood studio doubled in size this past week — likely because of many renewed hopes of fitness. My own personal dedication to movement and physical exercise has brought me a new appreciation of the capacity and interrelatedness of our human body and the maladies caused by lack of exercise. As a subspecialist in female pelvic medicine and reconstructive surgery, I struggle daily with how to best assist my patients in finding wellness and embracing a lifestyle that includes physical exercise. While exploring broad themes of exercise and obesity, this special feature will focus on physical activity in relationship to the pelvic floor.
There are numerous documented physical and mental health benefits to physical activity affecting overall well-being, health-related quality of life, and aging.1 A 2009 Cochrane review also concluded that exercise has a positive effect on body weight and cardiovascular disease risk factors in individuals who are overweight or obese, and that exercise improves health, even if no weight is lost.2 In 2010, the World Health Organization (WHO) published its recommendations for levels of activity for children, young adults, and older adults. It recommends that individuals 18 years or older should engage in at least “150 minutes of moderate-intensity aerobic physical activity throughout the week and for additional health benefits, older adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week.”3 The WHO lists physical inactivity as a leading risk factor for global mortality, following high blood pressure (13%) and tobacco use (9%) and equal to high blood glucose (6%).3 Increased inactivity is due in part to increasingly sedentary jobs and sedentary behavior at home and during leisure time, as well as inactive methods of transportation.
The rise in global inactivity undoubtedly is interrelated to the rapidly rising number of individuals who are overweight and obese. Worldwide in 2014, 39% of adults aged 18 years and older were overweight, and 13% were obese.3-5 Globally, a large proportion of the cost and health burden of obesity can be attributed directly to its associated comorbidities, specifically diabetes, cardiovascular heart disease, certain cancers, and musculoskeletal disorders.3,5 Globally, women are more likely to be overweight and obese than men. In the United States alone, 68.8% of adults older than 20 years of age are considered overweight or obese. The prevalence of obesity in the United States is 37% and is similar between men and women.6
We know pelvic floor disorders are very common; 25% of women report symptoms of urinary incontinence, fecal incontinence, or pelvic organ prolapse.7 The link between obesity and lower urinary symptoms and stress urinary incontinence has been well documented.8,9 Although obesity frequently is quoted as a risk factor for pelvic organ prolapse, its role is less clear, with only a few studies suggesting a positive association.9 Several studies have demonstrated the benefits of weight loss on urinary incontinence, with significant improvement in urinary incontinence symptoms seen following 5% reduction in body weight.9 In addition, several observational studies have shown improvements in urinary incontinence following weight loss surgery.9 It is unclear whether weight loss produces similar effects in obese older women with urinary incontinence.
Given these associations and the knowledge that physical activity can help decrease obesity, what is the relationship between physical activity and pelvic floor disorders? In 2016, Nygaard and Shaw reviewed the literature regarding physical activity and the pelvic floor.10 Most of the studies identified in their review included small numbers of subjects and were cross-sectional in design. The majority measured physical exercise by patient-reported questionnaire. With regard to urinary incontinence, the main findings indicated that urinary incontinence is frequent in women of all ages during physical exercise and more commonly is associated with high-impact activity. However, mild-to-moderate physical activity decreases the risk of developing urinary incontinence. As a corollary, there are studies documenting the negative effect of both stress and urge incontinence on women’s ability to exercise and to work. Nygaard found no association between exercise and prolapse; however, there are associations between strenuous occupational activities and prolapse. As our patients with prolapse describe, there can be an increase in degree of prolapse following short episodes of exercise, standing for long periods, or straining. Overall, data are limited regarding whether strenuous activity in youth can increase the risk of urinary incontinence or prolapse as an adult. Nygaard and Shaw concluded that most physical exercise is not harmful to the pelvic floor and there are many health benefits to exercise.
Middlekauff et al investigated the effect of acute and chronic strenuous physical exercise on pelvic floor muscle strength and support in nulliparous women.11 In this study, of the 70 nulliparous women enrolled, 35 were involved in habitual strenuous exercise and 35 were not. Participants involved in regular strenuous exercise were heavier, had lower percent body fat, and had higher handgrip strength. In both groups, maximal vaginal descent (defined as the greatest value of anterior, posterior, or apical support) increased, and vaginal resting pressure (measured using a perineometer) decreased. In neither group did maximal pelvic floor strength change significantly after exercise. The authors found that chronic strenuous exercise did not pose negative effects on pelvic floor support or strength, and although women in the strenuous exercise group had stronger grip strength, this did not translate into greater pelvic floor strength.
Suskind et al attempted to prospectively evaluate the relationships between body composition, muscle strength, and urinary incontinence in older women. In this prospective, community-dwelling, observational cohort study, the Health, Aging, and Body Composition study, 1,475 women aged 70-75 were enrolled. Urinary incontinence was assessed through structured self-report questions used in other larger epidemiologic studies. Body mass index (BMI), grip, and quadriceps strength also were assessed as well as walking speed, lean body mass, and whole body fat mass. The authors found that elevated BMI and greater adiposity are important risk factors for urinary incontinence in older women, as they are for younger women. The authors found that in this group of older women, women with a 5% or greater decrease in grip strength had higher odds of new or persistent stress urinary incontinence. Subjects had lower odds of new or persistent stress urinary incontinence if they demonstrated a 5% or greater decrease in BMI, another finding similar to studies in younger women. The authors concluded that in women ages 70 years and older, changes in body composition and grip strength over three years are associated with changes in stress urinary incontinence symptoms over time but not in symptoms of urge incontinence.
These studies point to the importance of physical exercise. However, we have yet to consider the effect of pregnancy and childbirth on exercise and the pelvic floor, as well as the cumulative effects of long-term obesity, core muscle weakness, and dysfunctional movement patterns alongside aging on the pelvic floor. Despite these many gaps in our understanding regarding exercise and the pelvic floor, physical activity is a strong modifiable risk factor that can significantly affect women’s overall wellbeing and quality of life as well as the risk of urinary incontinence symptoms. Despite my narrow scope of medical practice, my New Year’s resolution is to counsel and encourage every woman I see to increase her daily physical activity for both her fundamental and basic health, as well as for her pelvic floor.
- Lowe A, Gee M, McLean S, et al. Physical activity promotion in physiotherapy practice: A systematic scoping review of a decade of literature. Br J Sports Med 2016 Dec 21. pii: bjsports-2016-096735. doi: 10.1136/bjsports-2016-096735. [Epub ahead of print].
- Shaw K, Gennat H, O’Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database Syst Rev 2006; Oct 18;(4):CD003817.
- World Health Organization. Global recommendations on physical activity for health. Geneva, Switzerland: WHO Press; 2010.
- Mitchell S, Shaw D. The worldwide epidemic of female obesity. Best Pract Res Clin Obstet Gynaecol 2015;29:289–299.
- World Health Organization. Obesity Fact Sheets. Geneva, Switzerland: WHO Press; 2016. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/. Accessed Jan. 10, 2017.
- National Institute of Diabetes and Digestive and Kidney Diseases. Overweight and Obesity Statistics. 2012. Available at: https://www.niddk.nih.gov/health-information/health-statistics/Pages/overweight-obesity-statistics.aspx. Accessed Jan. 10, 2017.
- Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311-1316.
- Osborn DJ, Strain M, Gomelsky A, et al. Obesity and female stress urinary incontinence. Urology 2013;82:759-763.
- Greer WJ, Richter HE, Bartolucci AA, Burgio KL. Obesity and pelvic floor disorders: A systematic review. Obstet Gynecol 2008;112(2 Pt 1):341-349.
- Nygaard IE, Shaw JM. Physical activity and the pelvic floor. Am J Obstet Gynecol 2016;214:164-171.
- Middlekauff ML, Egger MJ, Nygaard IE, Shaw JM. The impact of acute and chronic strenuous exercise on pelvic floor muscle strength and support in nulliparous healthy women. Am J Obstet Gynecol 2016;215:316.e1-7.
- Suskind AM, Cawthon PM, Nakagawa S, et al; Health ABC Study. Urinary incontinence in older women: The role of body composition and muscle strength: from the Health, Aging, and Body Composition Study. J Am Geriatr Soc 2016; Dec 5. doi: 10.1111/jgs.14545. [Epub ahead of print].