Strenuous work and exercise have been suggested as possible risk factors for pelvic floor dysfunction (PFD) in women (1). Female athletes/exercising women have three times the risk of experiencing urinary incontinence (UI) compared to non-exercising controls (2). However, most of these studies are in sports including running and jumping activities and there is sparse knowledge on prevalence and risk factors for PFD in female and male power- and Olympic weightlifters. These athletes train and compete with high external loads, often exceeding their own body weight, and the sports may therefor serve as a model to study heavy load and PFD. The aim of the present study was to investigate prevalence and risk factors for PFD in power- and Olympic weightlifters. Furthermore, to investigate impact and bother of PFD and knowledge of the pelvic floor.

This cross-sectional study addressed all male and female athletes of >=18 years of age, who had competed in at least one National Championship in power- or Olympic weightlifting in Norway in 2018/2019. Background data, symptoms of bladder/bowel and pelvic organ prolapse (POP), potential risk factors (age, BMI, parity, hypermobility, female athlete triad, straining on toilet, training frequency, years specializing in power- or Olympic weightlifting) and knowledge of the pelvic floor were collected via an electronic questionnaire. ICIQ–UI-SF, ICIQ-BS and ICIQ-V were used to assess PFD (3). Prevalence is reported as frequency and percentage. Risk factors for PFD was estimated by logistic regression analysis and reported as Odds ratio with 95% CI. P-value was set to 0.05.

One hundred and ninety-one female (response rate: 54.1%) and 204 male (response rate: 37.7%) power- and Olympic weightlifters answered the questionnaire. Eleven female athletes who reported ongoing pregnancy, history of surgery for UI/POP or neurological disease were excluded from the analysis. Mean age was 31.0 (SD: 10.7) and 34.0 (SD: 13.5) and mean BMI 26.1 (SD: 4.4) and 29.5 (SD: 4.0) for females and males respectively. Forty-nine (27.2%) of the females had given birth with mean parity of 2.2 (SD: 1.4, range: 1-9). Mean years of specializing in power- or Olympic weightlifting were 4.1 (SD: 3.6) for females and 10.1 (SD: 11.7) for males. Four or more days with weightlifting/week was reported by 143 (79.4%) of the females and 154 (75.5%) of the males. 
Prevalence of PFD is presented in Table 1. Among females, increasing age (OR: 1.03, 95%CI: 1.00-1.07, p = 0.03), increasing BMI (OR: 1.09, 95%CI: 1.01-1.18, p = 0.03) and being at risk of the female athlete triad (OR: 2.08, 95%CI: 1.02-4.23, p = 0.04) were shown to be significantly associated with SUI. Only occasional and daily straining on voiding was significantly associated with POP (OR: 2.44, 95% CI:1.07-5.55, p = 0.03 and OR: 9.49, 95%CI: 2.26-39.85, p = 0.02). No significant associations between expected risk factors and anal incontinence (AI) were found in females. In males, increasing age was significantly associated with AI (OR: 1.03, 95%CI: 1.00-1.07, p = 0.04). 
Seventy-four (90.2%) of the females reporting SUI or mixed urinary incontinence (MUI) experienced leakage during power- and Olympic weightlifting. Seventy-two (87.8%) reported negative effect of UI on sport participation. Fear of visible leakage (N=48, 58.5%) and loss of concentration (N=42, 51.2%) were the most common complaints. Accidental loss of gas was the most commonly reported type of AI, and 123 (89.1%) of the females and 105 (91.3%) of the males experienced leakage during sports. Twenty-three percent of the females reported symptoms of POP, but bother was low (mean: 1.0, SD: 2.1). 
Seventy-seven (42.8%) females and 150 (73.5%) males did not know why, and 80 females (44.4%) and 148 males (72.5%) how, to train the pelvic floor muscles. However, 141 (78.3%) females and 101 (49.5%) males responded they would do pelvic floor muscle training to prevent PFD, if they knew how.

As far as we have ascertained, this is the first study in power- and Olympic weightlifting including questions on AI and POP in addition to UI and targeting both men and women. We found high prevalence of both SUI, AI and POP in the female population and AI in the male population. Significant associations between SUI and increasing age, increasing BMI, risk of female athlete triad in females were found. Both BMI and age have previously been found to be associated with UI in female athletes, but results are inconsistent across different studies (2). High BMI scores in strength athletes is more likely to be a result of high muscle mass than overweight and obesity. Few risk factors, except age in males and straining on voiding in females, could explain the high prevalence of AI and POP respectively.
A limitation of our study is the low response rate with a possible selection bias. Small numbers in some categories may also have negatively influenced the regression models.

The prevalence of PFD was high in both female and male power- and Olympic weightlifters. Risk factors found to increase the odds for PFD were high age, high BMI and risk of female athlete triad for SUI, straining on voiding for POP in females, and high age for AI in males. Few athletes had any knowledge of the pelvic floor, supporting a potential for both prevention and treatment strategies.

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