To the authors’ knowledge this is the first systematic review that aims to explore female athletes’/sportswomen’s ‘experiences’ of incontinence and pelvic floor dysfunction. Research has indicated that there is a higher prevalence of urinary incontinence (UI) and pelvic floor dysfunction among female athletes compared to non-athletes (1). Engaging in high impact sports at an elite level, coupled with longer hours of training, are commonly cited as risk factor for UI. 
In addition to identifying the prevalence, it is also important to gain an understanding elite female athletes’/sportswomen's experience of UI and pelvic floor dysfunction and the impact on their sporting activities and daily lives. 
This review aims to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings, from studies that report elite female athletes’/sportswomen’s experiences of incontinence/ symptoms of pelvic floor dysfunction.

Design: A systematic review (Prospero registration: CRD42020197330) 
Methods: The electronic databases of PubMed, Embase, MEDLINE (OVID), Cochrane Library, CINAHL, PsycINFO, Web of Science were searched up to May 2020. All quantitative, qualitative, and mixed methods primary research studies published in the English language that reported elite female athletes’/sportswomen’s symptoms and experiences of incontinence/pelvic floor dysfunction were included. Two reviewers independently screened studies based on titles and abstracts, then full texts. Disagreements were resolved by consultation with a third reviewer. Covidence software was used to screen and select studies. The methodological quality of included studies was evaluated using a modified version of Thomas et al’s 12-point quality assessment checklist (2), and studies were classified as being methodologically weak, moderate or strong. Studies evaluated to be methodologically weak were excluded.
This systematic review and meta synthesis complied with the ‘Adapted PRISMA guidelines for reporting systematic reviews of qualitative and quantitative evidence’ (3).

The search yielded 2,098 titles with 1,421 studies remaining after deduplication. A total of 97 studies were screened at full-text and 23 studies met the inclusion criteria. Following assessment of methodological quality, three studies were categorised as methodologically weak and subsequently excluded leaving 20 studies included for data extraction and analysis. Of these, 19 were of moderate quality and one was of high quality.  The studies were conducted in ten countries between 1994 and 2020.  Nineteen studies used a quantitative design (questionnaires; experimental; measurement) and one study used a mixed methods design (questionnaire and focus group). No study used a qualitative design only. Information regarding the impact of UI/pelvic floor dysfunction UI on elite athletes’/sportswomen’s sporting activities, quality of life (QOL), activities of daily living and experiences was extracted from closed questions included in validated QOL instruments or from closed questions and open-ended qualitative comments in questionnaires. Often this information was included in a study with a focus on prevalence of UI/pelvic floor dysfunction (n= 16 studies) or as part of an intervention or measurement study (n=4 studies). Some studies (n=5) did specifically include aims and objectives investigating the impact UI/pelvic floor dysfunction had on athletes’ QOL, sporting and daily life and the strategies employed by the athletes to manage their condition. Three core themes were identified in the analysis: 1) experience of symptoms of UI/pelvic floor dysfunction; 2) athletes’ strategies to manage/mitigate symptoms of UI/pelvic floor dysfunction, and 3) impact of symptoms of UI/pelvic floor dysfunction on athletes’ QOL and emotions. The key findings showed that UI was the most common pelvic floor dysfunction reported in the studies (prevalence ranging from 19.4% to 80%). Coping strategies reported by the athletes/sportswomen to manage/mitigate UI included voiding before training or competition, wearing pads and limiting fluid intake. Other symptoms of pelvic floor dysfunction commonly reported included fecal incontinence, pelvic organ prolapse and dyspareunia. Symptoms of pelvic floor dysfunction were found to adversely affect QOL and elicited emotions such as embarrassment and fear. Most athletes/sportswomen did not discuss their symptoms with anyone and did not seek treatment.

There appears to be a relative paucity of rich qualitative research evidence on elite female athletes’/sportswomen’s experiences of UI/pelvic floor dysfunction, and the impact on their sporting activities and daily lives. Only one of the included studies incorporated a qualitative component (focus group) in a mixed methods study. Whilst many athletes adopted strategies to manage/mitigate their symptoms of urinary incontinence, most did not seek advice or treatment. Pelvic floor dysfunction is a treatable condition and resources including information about the condition and treatment options should be made available to educate and support athletes/sportswomen.

Future research should adopt qualitative methods, or incorporate a qualitative component, which may deepen knowledge and understanding of elite female athletes’/sportswomen’s experiences and impact of UI/pelvic floor dysfunction on athletes’ sporting activities and their daily lives and enrich the understanding of this condition in athletes.

Bø K, Nygaard IE. Is Physical Activity Good or Bad for the Female Pelvic Floor? A Narrative Review. Sports Med. 2020 Mar; 50(3):471-484. doi: 10.1007/s40279-019-01243-1.
Thomas J, Sutcliffe K, Harden A, Oakley A, Oliver S, Rees R, et al. Children and Healthy Eating: A Systematic Review of Barriers and Facilitators. 2003, London. EPPI-Centre, Social Science Research Unit, Institute of Education, University of London
Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097.