It is well established that a physically active lifestyle improves male pelvic floor health, with most literature investigating its protective benefits. Moderate-to-vigorous exercise has been shown to improve male pelvic health through systemic benefits, including peripheral arterial pressure regulation, improved nitric oxide production, glucose and lipid metabolism, endogenous hormonal control, and autonomic nervous system downregulation. 

With such broad systemic benefits, little consideration has been made toward the acute effect of exercise on the male pelvic floor. During exercise, intra-abdominal pressures (IAP) increase, with localised pelvic floor muscle (PFM) fast twitch fibres responsible for maintaining continence by increasing periurethral pressure. Acutely, these contractions may impair PFM contractility due to fatigue, although this musculoskeletal response is normal, and in fact required to improve PFM strength as a chronic adaptation (1,2). However, excessive exercise-induced stress imposed on the PFM by performing strenuous activity for longer periods, with limited account for recovery, may elicit unfavourable PFM outcomes in men, such as urinary tract symptoms. 

A dose-response relationship between exercise and urinary incontinence (UI) has been established in females, with increasing exercise intensity or volume resulting in a higher risk of incontinence (1,3). No comparable studies exist within the male population. Therefore, the question remains, to what extent does intensity or overall exercise volume influence PFM fatigue and increase risk of lower urinary tract symptoms in men? The aim of this review is to establish the prevalence of male lower urinary tract symptoms associated with increasing exercise levels.

A scoping review screening five electronic databases was undertaken in March 2024. The review adhered to the preferred reporting items for systematic reviews and meta-analyses extension for scoping review (PRISMA-ScR) reporting checklist. Keyword search terminology used the International Continence Society report on the terminology for sexual health in men with lower urinary tract and pelvic floor dysfunction. Further keyword and MeSH terms containing prevalence, male pelvic floor dysfunction, exercise and physical activity were also used. 

Eligibility criteria was determined by the mnemonic: population, concept, context (PCC). 

Participants: Males aged 18-65 years, without a history of benign prostate hyperplasia or prostate cancer. 
Concept: Reported urinary incontinence or lower urinary tract symptoms (LUTS). 
Context: Cross-sectional literature reporting UI or LUTS as a sample percentage. Males completing a minimum volume of ≥1000 metabolic equivalent of task (MET) minutes per week through vigorous physical activity defined by either:
•	MET activity score of ≥6 as per the Compendium of Physical Activities. 
•	≥80%HR max.

Six studies met the inclusion criteria, with reported rates of UI and LUTS varying between 3.8% and 18.8%. Three studies reported on high-impact exercise, two studies reported on a combination of exercise types, and one study reported on resistance-based exercise (Figure 1). 

There was considerable variability in reporting of exercise type, frequency, intensity, and volume. For comparative purposes, metabolic equivalent of task minutes per week was manually calculated, as per the following equation:

 Exercise frequency (days) X exercise session length (minutes) X MET activity score.

Literature reporting on multiple exercise types or numerical data in categorical fashion used minimum and maximum weighted averages to establish an unbiased average of irregularly sampled data (i.e., a frequency of 1-3 days, 4-5 days and 6-7 days had minimum weighted averages with the combined lowest values in each category [1, 4, 6 days], with maximum weighted averages using the highest value of each category [3, 5, 7 days]). Where a study reported on multiple exercise types (i.e., sport 1 [MET = 6.5], sport 2 [MET = 9.5] and sport 3 [MET = 11]), the smallest and largest MET values were used in the respective calculations for both the minimum and maximum average MET-minutes per week. This calculation was unable to compare reporting of each individual exercise variable, instead identifying a positive, dose-response relationship between MET-minutes per week and male lower urinary tract symptoms. Both minimum and maximum average calculations identified a positive dose-response relationship between MET-minutes per week and male UI and LUTS (R = 0.8625 vs R = 0.8675) (Figure 2).

A positive dose-response relationship between increasing MET-minutes per week and male LUTS and UI was identified. Our findings support previous literature indicating specific types of exercise may influence risk of male LUTS, with combined and low-impact exercise reporting the lowest prevalence of LUTS and UI. Literature investigating high-impact exercise, such as track and field (athletics), soccer and gymnastics, found a substantially higher prevalence, particularly during and after exercise, with up to 37.5% of symptomatic participants in one study reporting symptoms during exercise. However, this study and another that investigated high-impact exercise reported much higher training frequency (4.97 ± 1.33 days; 4.99 ± 1.26 days) and longer exercise sessions (3.07hrs ± 1.37; 2.42hrs ± 0.82). Further examination is required to understand the underlying mechanism in relation to these two exercise-related variables. 

The presence of LUTS during exercise indicates the possibility of slowed contractile speeds of the striated urethral sphincter (SUS) or lowered force generation capabilities to maintain continence during IAP increases. Throughout locomotion, the SUS reflexively contracts prior to heel strike, presumptively to maintain continence. These IAP increases brought on by high-impact exercise may cause a transient reduction of the PFM contractile ability with respect to both force generation and contractile speed. This acute fatigue response is exacerbated through high frequency training, leading to increases in PFM tone as a compensatory mechanism. Tonal changes may make PFM relaxation more difficult and further contributes to micturition difficulties. 

This fatigue mechanism likely occurs during low-impact exercise but to a lesser extent. Given the mechanism of producing increased IAP, closed-chain and low-impact exercise results in a lower volume of reflexive and volitional PFM contractions over the same MET-minutes per week. Secondly, relative IAP strain in a resistance trained population may be tolerated differently than individuals completing high-impact exercise. Complicating this hypothesis is that within the investigated high-impact exercise populations, no records of concurrent low-impact resistance training were documented. When competing at a national or international level, athletes commonly undertake a variety of exercise types, including high impact exercises and low impact resistance training within the one training program. 

Included literature failed to report on specific co-morbidities or exercise-related variables (e.g., frequency, intensity, type, volume) of participants reporting symptoms. Without this information, it remains difficult in determining the contribution of each variable.

Our results support a positive dose-response relationship of exercise and increased risk of male UI and LUTS. Whilst moderate levels of exercise provide systemic benefits, when intensity and volume rapidly increase and remains sustained, the protective effect of exercise appears to attenuate. Large variability in reporting methods between studies rendered difficulty in identifying the specific influence or interaction that exercise type, intensity or overall volume had on UI or LUTS.

Our results also shed light on the possibility that accumulated effects of residual fatigue induced by strenuous activity may increase urinary tract symptomatology in the long-term. Future research investigating these individual exercise-related variables that demonstrates causality of male pelvic floor muscle fatigue will further support or refute these findings.

Shaw JM, Nygaard IE. Role of chronic exercise on pelvic floor support and function. Current Opinion in Urology. 2017; 27(3):257-261.
Jacomo RH, Nascimento TR, Lucena da Siva M, et al. Exercise regimens other than pelvic floor muscle training cannot increase pelvic muscle strength-a systematic review. Journal of Bodywork and Movement Therapies. 2020; 24(4):568-574.
Silva AB, Sousa N, Azevedo LF, Martins C. Physical activity and exercise for erectile dysfunction: Systematic review and meta-analysis. British Journal of Sports Medicine. 2017; 51(19):1419-1424.

Continence 12S (2024) 101411
DOI: 10.1016/j.cont.2024.101411