Pelvic floor (PF) disorders are prevalent in exercising women, with one in every three women experiencing urinary incontinence (UI) during exercise (1). Forty-seven percent of women who experience UI symptoms stop/modify participation in sports; high-impact sports are most affected (2). Younger (18-25 years: 35%) and nulliparous symptomatic women (31%) also report sports cessation due to PF symptoms (submitted manuscript under peer review). Potentially, women may continue participation if health and exercise professionals identify and manage their PF symptoms. However, whether this is common practice is currently unknown. We aimed to (i) establish current practice for screening and managing PF disorders within sports/exercise settings (ii) and explore barriers/enablers to these practices amongst health and exercise professionals.

A cross-sectional online survey of health and exercise professionals working with women participating in any type or level of sport/exercise was undertaken. Eligible participants were registered, practising, Australian health professionals (e.g. doctors and physiotherapists) and practising exercise professionals (e.g. exercise physiologists and personal trainers). Participants were invited by sport/exercise organisations and professional bodies to participate in an anonymous, purpose-designed survey, administered using online software (Qualtrics). Survey items included demographic and professional characteristics and closed-response items on current practice for screening and management of PF disorders. Confidence and acceptability were evaluated using 10-point Likert scales (e.g. ‘0=not at all confident’ to ‘10=extremely confident’). A pre-specified list of perceived barriers/enablers for future practice was provided; free-text options were available for responses not listed. Data were analysed descriptively, and group comparisons performed using Chi-square tests.

Of 893 respondents, 636 were included. The most common reason for exclusion was not being a health or exercise professional (n=72). Participants with incomplete demographic and professional characteristics were also excluded (n=51). The majority of participants were female (86%). Respondents primarily included physiotherapists (39%), personal trainers/fitness instructors (38%) and exercise physiologists/scientists (12%) with a mean of 12 years of practice (SD: 9.7, range: 0-46). Many (77%) had accessed training specific to PF disorders, most commonly a lecture (53%), and 9% had a PF specific post-graduate qualification. Half never screened for PF symptoms and 23% screened only when they believed it to be indicated (Table 1). Pregnant/recently post-natal women (44%) were more commonly screened than younger women (18-25 years: 28%) or high-impact sports participants (32%). Chi-square analysis indicated that female professionals (54% vs 33% males; p=0.002) and health professionals (68% vs exercise professionals 37%; p<0.001) more commonly screened for PF symptoms. Participants who were more experienced (5-9 years: 27%; ≥10 years: 57%; p=0.01) reported screening more often than those with fewer years of practice (0-4 years: 16%). Of those who did screen, 50% did not use a standardised question or questionnaire. A majority (79%) used verbal rather than written questions. Common reasons for not screening included waiting for women to disclose symptoms (41%) and the absence of PF questions on screening tools (37%) (Table 1). Whilst 86% of participants were willing to include screening in the future, commonly cited barriers included a lack of training (41%), knowledge (39%), awareness of questions to ask (35%) and confidence (28%). Most participants (89%) agreed that PF questions should be included on pre-exercise screening questionnaires and annual screenings conducted in sports teams (77%).

If women revealed PF symptoms, 75% of participants referred to another health professional for management; most commonly to a PF (women’s health) physiotherapist (86%) and/or a GP (38%). Sixty-percent of health and exercise professionals prescribed PF muscle training (PFMT) using verbal instruction (90%) and reminding women to contract their PF muscles whilst exercising (56%) (Table 1). Of those who prescribed PFMT, 32% (n=59) individualised prescription following intra-vaginal PF muscle assessment; 60% (n=35) of those were physiotherapists with PF-specific post-graduate qualifications. Most (89%) participants agreed that PF symptom education should be provided to all exercising women, whether symptomatic or not. 
Enablers/support for screening and management of PF disorders in future practice included access to: patient resources, training, an appropriate screening tool, clear referral pathways and evidence-based management options (Table 2). The majority (79%) were interested in attending PF specific training via webinars or short courses.

One in two health and exercise professionals never screened exercising women for PF symptoms, despite existing evidence of high prevalence (1) and negative impact on participation (2). Health and exercise professionals reported waiting for patients to disclose PF symptoms first, but self-disclosure rates for PF symptoms are typically low. Overall, health and exercise professionals displayed a willingness to engage in future PF screening practice. This finding may be affected by selection bias, with participants who are motivated and willing to engage in screening and management for PF symptoms more willing to respond to the survey. Males and doctors were under-represented, despite efforts to target their recruitment. This may indicate a lack of interest, confidence or comfort regarding PF symptom screening and management. Further qualitative research may help to explore the experiences and attitudes of these groups.
Screening barriers may be reduced if health and exercise professionals are provided with standardised verbal questions/screening questionnaires to use. Including PF questions on an organisation’s pre-exercise and annual screening tools may also encourage health and exercise professionals to screen for PF symptoms. Of concern, at-risk groups such as young, nulliparous women and high-impact exercise participants are not being screened. Symptoms of UI in young athletes are a predictor of UI in later life (3). Educating health and exercise professionals on the indications for screening these at-risk groups may promote earlier symptom identification and management, allowing women to experience the benefits of lifelong exercise. Establishing a referral pathway to a PF specialist may also improve confidence in screening, by providing a management option when PF symptoms are disclosed.  Future research exploring the attitudes and preferences of exercising women towards screening and management of PF symptoms is required in order to guide acceptable future practice in sports/exercise settings.
Participants stated they would be willing to be involved in managing PF symptoms in exercise/sport settings if they had training to improve their skills in patient education and modifying exercise to avoid symptom provocation. Pelvic floor muscle training has been shown to be highly effective in managing PF symptoms. A majority of participants reported using verbal instruction to teach PFMT, either in an individual consultation or as part of a group exercise class. For many women, verbal instruction alone is insufficient to teach a correct PF contraction. Health and exercise professionals should be educated to refer to a skilled PF practitioner for individualised PF muscle assessment and management if symptoms are not resolving. 
There was a strong interest amongst participants to attend further training to improve knowledge of screening and managing PF disorders. Participants requested a mixture of online webinars and practical courses which would allow a board range of health/exercise professionals to upskill in this area including those in rural areas.

Exercising women were not commonly screened for PF symptoms. Health and exercise professionals were willing to screen and manage PF symptoms in the future. However, greater knowledge, access to training, appropriate screening questions and evidence-based management options are required to enable this practice.

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