Research: Sport, Pelvic Pain and Associated Symptoms
There is abundant research linking pelvic pain, and associated urinary tract symptoms, with various sporting activities. The studies reported on in this brief review are offered as a caution – particularly against excessive training and sport in early life.
In contrast however, with a few notable exceptions, evidence largely supports the benefits of athletic activities, and the negative long-term effects of inactivity.
Sport and CPP in Men: Pudendal Nerve Issues
Antolak et al (2002) report that chronic pelvic pain (CPP) syndrome is a puzzle that may be explained partly by pudendal nerve entrapment (PNE), which causes neuropathic pain. In men with PNE may involve aberrant development and subsequent malpositioning of the ischial spine as a result of excess athletic activity during youth. The changes appear to occur during the period of development and ossification of the spinous process of the ischium.
Common causative activities include “flexion activities of the hip (sitting, climbing, squatting, cycling, and exercising) induce or aggravate urogenital pain, chronic pelvic pain, or prostatitis-like pain.”
Specific sports incorporating these activities involving teenagers and/or young adults include: American football, weight-lifting and wrestling.
Antolak et al suggest that hypertrophy of the muscles of the pelvic floor among young athletes, causes elongation and posterior remodeling of the ischial spine, leading to the sacrospinous ligament rotating, so that the sacrotuberous and sacrospinous ligaments become superimposed over each other. During repetitive squatting activities, or during sitting and rising, stretching of the pudendal nerve occurs over the sacrospinous (SSp) ligament or the ischial spine, with shearing forces on the nerve.
The piriformis muscle may also be involved. Antolak et al note that: “The pudendal nerve exits the pelvis at the inferior aspect of this muscle. In the athlete, flexion and abduction of the thigh are common motions, and they may lead to hypertrophy of the piriformis muscle, causing compression of the pudendal nerve against the posterior edge of the SSp ligament. Pain that suggests this process includes … that induced during sports activity such as that of a baseball catcher (squatting and then rising to throw the ball – motions that require extension of the gluteus muscles and abduction and extension of the hip).” They suggest that the same principles be investigated in women with pelvic pain, in case their symptoms are “misdiagnosed and inappropriately treated.”
Cycling and Genitourinary Symptoms in Men and Women
Leibovitch and Mor (2005) have reported on bicycling related urogenital disorders. They note the following pertinent facts:
- The most common bicycling associated urogenital problems are nerve entrapment syndromes presenting as genitalia numbness, which is reported in 50-91% of cyclists reported on in the 62 articles evaluated, followed by erectile dysfunction reported in 13-24%.
- Other less common symptoms include priapism, penile thrombosis, infertility, hematuria, torsion of spermatic cord, prostatitis, perineal nodular induration and elevated serum PSA, which are reported only sporadically.
Andersen and Bovim (1997) applied a questionnaire to 260 participants in a Norwegian 540 km bicycle race.
Thirty-five of 160 responding males (22%) reported symptoms from the innervation area of the pudendal or cavernous nerves. Thirty-three had genital numbness or hypaesthesia after the race. In 10, the numbness lasted for more than one week. Impotence was reported by 21 (13%) of the males, lasting for more than one week in 11, and for more than one month in three.
Both genital numbness and impotence were correlated with weakness in the hands after the ride, a complaint that in some cases lasted up to eight months. It is suggested that changing hand and body position, restricting the training intensity, and taking ample pauses, may all be necessary to prevent damage to peripheral nerves.
LaSalle et al (1999) reported that the hardness of bicycle seats, and years of cycling, influence lower urinary tract symptoms in women. “The hardness of the bicycle seat increased the incidence of incontinence and other urinary symptoms in females….[possibly] related to the neurologic and vascular stress that hard seats produce on the perineal area.”
Sports That Appear to Increase Urinary Incontinence
Thyssen et al (2002) surveyed a total of 291 women with a mean age of 22.8 years. Of these 151 women (51.9%) reported having experienced urine loss, 125 (43%) while participating in their sport and 123 (42%) during daily life. The proportion of urinary leakage in the different sports was:
- Gymnastics – 56%
- Ballet – 43%
- Aerobics – 40%
- Badminton – 31%
- Volleyball – 30%
- Athletics – 25%
- Handball – 21%
- Basketball – 17%
The activity reported as being the most likely to provoke leakage was jumping.
Osteitis Pubis and Running
Strakowski and Jamil (2006) report on osteitis pubis, “an uncommon cause of pelvic pain in runners”. This condition presents insidiously with pain in the hip adductors aggravated by running or pivoting on one leg. The adductor muscles are usually noted as hypertonic, with pain on resisted hip adduction. Tenderness over the pubic symphysis will also be evident. Plain film radiographs commonly reveal sclerosis of the pubic bones, with occasional widening of the symphysis. (Harris and Murray 1974) Treatment includes use of NSAIDS and corticosteroid injections into the symphysis, along with stretching of shortened adductors.
- Andersen KV, Bovim G. Impotence and nerve entrapment in long distance amateur cyclists. Acta Neurol Scand, 1997;95(4):233-40.
- Antolak SJ et al. Anatomical basis of chronic pelvic pain syndrome: the ischial spine and pudendal nerve entrapment. Med Hypotheses, 2002;59(3):349-53.
- Brock G. Editorial. European Urology, 2005;47:286-7.
- Harris NH, Murray RO. Lesions of the symphysis in athletes. BMJ, 1974;4(5938):211.
- LaSalle M, Salimpour P, Adelstein M, et al. Sexual and urinary tract dysfunction in female bicyclists. J Urol, 1999;161:269.
- Leibovitch I, Mor Y. The vicious cycling: bicycling related urogenital disorders. European Urology, 2005;47:277-7.
- Strakowski J, Jamil T. Management of common running injuries. Phys Med Rehabil Clin N Am, 2006;17:537-52.
- Thyssen H et al. Urinary incontinence in elite female athletes and dancers. Int’l Urogynecology J, 2002;13(1):15-7.