Healthcare's best-kept secret - the pelvic floor (and why every therapist needs to know about it)

It always struck me as bizarre that sports medicine and musculoskeletal specialties deal with pain and dysfunction from head to toe in the human body, yet offer little health literacy or inclusion of the pelvic floor. Traditionally considered taboo and someone else’s remit, men and women with issues affecting the pelvic floor have largely suffered in silence. Thankfully, change is afoot, and healthcare is finally evolving. There is much more awareness, inclusion, and understanding of this unique body area and the role that it plays. For anyone playing catch up, the pelvic floor is a group of muscles spanning the base of the pelvic outlet in layers. While both men and women have a pelvic floor, the pelvic outlet is wider in females than in males and it also contains an extra orifice – the *vagina* \[1]. That’s right, we went there. We said the *‘V’ word*. Because just like *vulva*, or *vestibule*, the *vagina* is simply an anatomical term. It needn’t be embarrassing or taboo. Some of you will be long enough in the tooth to remember when the word ‘breast’ was taboo. However, with healthcare campaigns for breast cancer and breastfeeding, this term became an anatomical norm. We need to do the same for the pelvic floor and its related anatomy and physiology. **What does the pelvic floor do?** In both men and women, the pelvic floor serves to control the bladder and bowel (maintain continence), empty the bladder and bowel (voiding and defecation) and support sexual function (arousal and climax). In women, the pelvic floor also plays an important role in pelvic organ support. Remember that extra orifice I mentioned earlier…well this area is high risk for connective tissue laxity and defects meaning that the pelvic organs (bladder, uterus, rectum) can descend into the vaginal cavity causing symptoms of heaviness, pressure and a sensation of ‘something in the vagina’. **What are the signs and symptoms of pelvic floor dysfunction?** If the pelvic floor is not doing its job, any of its roles can become compromised. This may manifest in leaking from the bladder or bowel, inability to fully empty the bladder or bowel, pain ‘down there’, sexual dysfunction (compromised erection, dyspareunia, pain with climax) or heaviness and pressure in the vaginal region (for women) \[2]. A full list of sex-specific signs and symptoms of pelvic floor dysfunction can be seen in Table 1. *Table 1 - signs and symptoms of pelvic floor dysfunction in men and women* **Who gets pelvic floor dysfunction?** Pelvic floor dysfunction can affect any man, woman or child, however it is particularly problematic for women, especially during transitional life events, such as pregnancy/childbirth and the menopause \[1]. One in three women will experience pelvic floor dysfunction \[3] and for those that engage in sport, the prevalence of symptoms varies according to the load demands of the activity. For example 61% of netballers leak urine \[4], up to 43% of female rugby players leak \[5], and 32% of gymnasts experience incontinence \[6]. Structural changes associated with vaginal childbirth and aging, as well as lower levels of oestrogen to lubricate and bulk out the tissues can increase the odds of experiencing pelvic floor dysfunction. However, even young adolescent females can leak urine due to the load demands of their sport. For example, in athletics and gymnastics, stress urinary incontinence (the involuntary leakage of urine during activities involving high levels of intra-abdominal pressure) is commonly experienced. Yet no-one is doing anything about it. No one is screening. No one is signposting. No one is educating these younger athletes that pelvic floor symptoms are not to be expected and normalised. Or that they simply indicate that the sporting demands exceed the load capacity at the pelvic floor. If this was any other area of sports or MSK practice, would we settle for a load capacity that does not meet the demands of the sport?! **Why is this relevant to every therapist, no matter their discipline?** If a patient/client you are supporting has pelvic floor dysfunction, it will undoubtedly impact their engagement and progression with your rehabilitation, no matter the bodily region or complaint that you are treating. It is like a silent assassin working in the background, unbeknownst to you. For example, the 50-year-old woman with knee pain that you are trying to progress through weighted squats or progressive impact activities who is stalling or apprehensive and not making the expected headway may be stalled due to fear of heaviness, pressure or leaking and not necessarily capped by their knee pain or function. The competitive 15-year-old sprinter with hamstring tendinopathy may be inhibited more by the fear of leaking than the ability to push into their sprint. Layer that with the environmental considerations of access to toilet facilities (or lack thereof) where the athlete is training or engaging in rehabilitation, and you open a complex domain of biopsychosocial and environmental considerations that impact your patient’s presenting complaint. Further to this is the overlap between pelvic floor dysfunction and low energy availability. The latest IOC Consensus statement on relative energy deficiency in sport (REDs) \[7] recognised that urinary incontinence as a potential indicator of REDs. That is, where an athlete is expending more energy than they are consuming, non-necessary bodily processes will be de-prioritised, which is why females with REDs experience alterations or complete loss of their menstrual cycle as well as compromised bone health that carries an increased risk of bony stress injury. But did you know that the musculoskeletal and neuromuscular integrity of the continence mechanism may also be impacted? If you support female athletes and are screening them for REDs, recognising urinary incontinence as a potential sign is essential. Moreover, differentially diagnosing and clinically reasoning whether this leakage is related to REDs or caused by a dysfunctional pelvic floor should be part of our role. One of the most important reasons I believe that all therapists should be aware of and screening for pelvic floor symptoms, is because you may be that individual’s only chance to get these taboo symptoms recognised and addressed. As rehabilitation professionals, we have the opportunity to build therapeutic alliances with our clients. We get to spend time with them, build trust and engage in rapport. Therefore you may be the first person to introduce the topic of pelvic floor dysfunction and create a safe place for them to disclose symptoms. **Screening is easy!** Similar to screening for red flag, neurological, rheumatological or even psychosocial determinants of symptoms, we can easily screen for pelvic floor dysfunction. This carries no pressure or weight for therapists to know how to manage pelvic floor dysfunction if it is identified. Like red flags, neurological signs and the like, we screen to identify and signpost to the appropriately qualified professional (e.g., pelvic health physiotherapist, urogynaecologist or GP). Before you think this will create an extra need or more work, all you need to do is ask five simple questions. The PFD-SENTINEL \[8] is a sports-specific screening tool that is simple and user-friendly. For the faint-hearted therapist who doesn’t want to venture into using the ‘V’ words just yet, you can even hand the tool to your patient and have them tick what symptoms are present. Easy! \[Figure 1 - Section of PFD-SENTINEL screening tool. From: Giagio S, Salvioli S, Innocenti T, et al. PFD-SENTINEL: Development of a screening tool for pelvic floor dysfunction in female athletes through an international Delphi consensus, *British Journal of Sports Medicine.]* **Differential diagnosis – is it the pelvic floor, the hip or the groin?** Anyone assessing hip and groin pain should be aware of the pelvic floor in their differential diagnosis. The hip, groin and pelvic floor are anatomically linked. For example, the shared muscle represented by obturator internus as a lateral hip rotator AND as a lateral intrapelvic muscle of the greater pelvic floor) or the common bony insertion that the adductor muscles and pelvic floor connect to - the pubic bone. Frustrated by siloed thinking and practice, we put out a call to action in 2025 in the *British Journal of Sports Medicine* called ‘*Hiding in plain sight: the pelvic floor in hip and groin pain*’ \[9]. Further to this, my esteemed colleague Dr Helen McKeever presented a detailed overview of differentially diagnosing the source of hip and groin pain in a new scientific book chapter \[10]. **Individual reflection** As you read this I want you to consider whether you have ever screened for symptoms of pelvic floor dysfunction in the populations you serve? Did you already know that this was a potential issue that could be interfering with your rehabilitation success? Would you settle for reduced load capacity at any other bodily region if it was impacting your patient’s progression and quality of life? Did you ever consider that you may be the first or only person they disclose these intimate symptoms to? I call on you to be the difference that makes the difference and include the consideration of pelvic floor function in your clinical reasoning and practice. It is sure to elevate your game. **Want to learn more?** If you can’t tell by now, this topic is a huge passion area of mine. So, I edited an entire scientific textbook on it. *Sports Medicine and the Pelvic Floor – Science to Practice* was published in May 2026 and it has already achieved bestseller status in the Elsevier Life Sciences category and across multiple Amazon categories. Pitched to the non-pelvic health or fitness professional, it includes everything you need to know to include the pelvic floor within your sports medicine practice. Jack Chew even sat down to discuss this book with me on *Chewing it Over* if you want to find out more and even better…MSK Mag readers can access 30% off using discount code **BIOMED30** at Elsevier checkout if they purchase the *paperback* option only. \[Grainne’s new scientific textbook - Sports Medicine and the Pelvic Floor - Science to Practice. Elsevier. 2026] **References** 1\. LaCross JA, Ashton-Miller JA, DeLancey J. Chapter 2 - The female pelvic floor—anatomy, function, and the lifespan model. In: Donnelly GM, editor. Sports Medicine and the Pelvic Floor: Academic Press; 2026. p. 7-44. 2\. Donnelly GM, Moore IS. Sports Medicine and the Pelvic Floor. Current Sports Medicine Reports. 2023;22(3):82-90. 3\. NICE\_Guideline. Pelvic floor dysfunction: prevention and non-surgical management. National Institute of Clinical Guidelines. 2021;NG210. 4\. Gill N, Lin K-Y, Whitford E, Jeffrey S, Frawley H. The prevalence of urinary incontinence in nulliparous and parous adult netball players. Continence. 2025;13:101753. 5\. McCarthy-Ryan M PJ, Donnelly GM, Leahy K, Yeomans C, Liston M, et al. Urinary incontinence prevalence and risk factors in female Rugby Union players: A common health problem across four nations. . Under review 6\. Gram MCD, Bø K. High level rhythmic gymnasts and urinary incontinence: Prevalence, risk factors, and influence on performance. Scandinavian Journal of Medicine & Science in Sports. 2020;30(1):159-65. 7\. Mountjoy M, Ackerman KE, Bailey DM, Burke LM, Constantini N, Hackney AC, et al. 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2023;57(17):1073-97. 8\. Giagio S, Salvioli S, Innocenti T, Gava G, Vecchiato M, Pillastrini P, et al. PFD-SENTINEL: Development of a screening tool for pelvic floor dysfunction in female athletes through an international Delphi consensus. British Journal of Sports Medicine. 2023;57(14):899. 9\. Cooke R, Papadopoulou T, Weir A, Donnelly GM. Hiding in plain sight: the pelvic floor in hip and groin pain. British Journal of Sports Medicine. 2026;60(2):88. 10\. McKeever H. Chapter 9 - Differential diagnosis—Is it the pelvic floor, the hip, or the groin? In: Donnelly GM, editor. Sports Medicine and the Pelvic Floor: Academic Press; 2026. p. 221-40. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe