Pelvic floor symptoms in 746 female field hockey players in Australia. A retrospective survey

Abstract

Objective

To explore the proportion of female field hockey players who experienced urinary incontinence (UI) and pelvic floor symptoms, and the impact their symptoms have on their participation and healthcare-seeking behaviour.

Methods

We employed a retrospective study design utilising an anonymous survey to address the study aim. Female field hockey players aged 14 and above who participated in the 2023 winter competition in Australia at any level were eligible to participate in the study. We collected demographic data, the Questionnaire for Urinary Incontinence Diagnosis (QUID) and the impact of pelvic floor symptoms on participation. Demographic data were reported as proportions, with all data analysed at the cohort level and stratified based on primary age group competition (Juniors, Seniors, Masters).

Results

746 females consented to answer the survey about pelvic floor function with an average age of 33.6 years (range 14–74). One in four participants reported some kind of UI, however; just 30 % of females with symptoms saw a health professional for their symptoms. Frequency of symptoms increased by level of competition (i.e., more frequent in Masters compared to Juniors or Seniors). Most females who reported symptoms (∼50 %) during exercise did not change their participation; however, 22 %–36 % modified or stopped their activities.

Conclusion

Symptoms of UI in female field hockey players are frequent, with the majority not seeking health care assistance for their symptoms. Therefore, education programs focused on UI management strategies such as early identification and healthcare referral should be prioritised within female field hockey.

Key points:

• •One in four female field hockey players reported some form of urinary incontinence (UI), and the majority had not sought health care for assistance with their symptoms.
• •Symptoms were more frequent in Masters players (aged 35+ years) than Seniors (any age) or Juniors players (aged 18 years).
• •Education programs focused on UI risk factors and management strategies should be prioritised within female field hockey.

1. Introduction

Field hockey is a high-impact, fast-paced, multidirectional team field sport participated in by ∼1 % of the Australian population [1]. It is also the number one sport in the country for equal participation between boys/men and girls/women [1] and is played by people of all ages, from young children to people over 65 years old [1,2]. Growing and retaining girls and women's participation in sport is a key focus of the Australian government, implementing the “Play our Way” program in 2024 with a key focus on understanding and addressing barriers to sport and physical activity participation [3,4].

Pelvic floor symptoms [5] have been identified as a significant barrier to participation for women in sports [6], with symptoms identified in active adolescents as young as 14 years old [7,8]. Pelvic floor dysfunction is used as an overarching term to describe a number of disorders and symptoms which are characterised by impairment of the pelvic floor muscles, with urinary incontinence (UI) one of the common symptoms of pelvic floor dysfunction [5]. UI can be diagnosed as stress (SUI) (involuntary loss of urine on effort or physical exertion e.g., coughing, sneezing, exercise), urge (UUI) (involuntary loss of urine associated with urgency) or mixed (MUI) (a combination of stress and urge UI) [9,10].

Pelvic floor symptoms impact participation for woman athletes of all ages [6], where one in two women stop exercise due to symptoms [6,11], and high-impact sports result in greater cessation [6,11]. This is hypothesised to be due to the increased load on the pelvic floor through increased intra-abdominal pressure, or repetitive ground reaction forces during high–impact activities [12]. Engaging in a sport with higher impact and external forces (e.g., ball and stick sports), such as field hockey, may increase the risk and frequency of these symptoms [8]. Meta-analyses have shown that woman athletes are more likely to suffer from UI compared to their non-athletic peers [11,13].

Despite women athletes being more likely to experience UI than women non-athletes [11,13], screening for pelvic floor symptoms is uncommon [14]. Studies have reported that only up to approximately one third of women with UI symptoms have reported this to a health professional [15], with many athletes not disclosing symptoms, or seeking specialised care. This may leave a large proportion of symptomatic women untreated and may negatively influence their mental health [16] as it is known to inhibit their physical activity participation [6,14], increasing their risk of other non-communicable chronic diseases (such as diabetes and cardiovascular disease) [17,14]. Despite these factors, there is a paucity of research exploring the prevalence and impact of pelvic floor symptoms in woman athletes across different sports. Such information would facilitate targeted education and resource allocation to assist in identifying, preventing, and managing UI to address barriers to participation for women and girls. Therefore, the aim of the study was to explore the proportion of female field hockey players who experienced UI and pelvic floor symptoms, and the impact that symptoms have on their participation and healthcare seeking behaviour.

2. Methods

2.1. Study design

We employed a retrospective study design utilising an anonymous survey to address the study aim. Development and reporting of this study was guided by the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [18,19]. The pelvic health questions included in this study were embedded in a larger field hockey injury surveillance survey [20].

2.2. Ethics and consent process

Ethical approval was granted by the La Trobe University Human Ethics Research Committee (HEC24138) with participants providing informed implied consent. As the study included adolescents aged 14 to 17 (in addition to adults), adolescent participants were required to correctly answer three questions based on the participant information sheet during the consent process. This was completed to ensure underage participants demonstrated they had read the participant information sheet and were informed of the study's aims and outcomes prior to participating in the survey and thus did not require parental consent to participate in accordance the 2023 Australian National Health and Medical Research Council national statement on ethical conduct in human research.

2.3. Development and testing

Survey questions were collated by four physiotherapists (ECB, MCH, MGK, ES) guided by existing literature [6]. Testing of survey questions and branching logic were carried out by the same authors, two of whom are current female field hockey players (ECB, ES). The larger surveillance survey asked between 28 and 104 questions (depending on branching). This study extracted demographics and 20 pelvic floor questions (Appendix 2).

2.4. Data collection

Data collection took place between May 8th to 31st 2024 with the survey administered via Research Education Data Capture (REDCap) [21,22]. Female field hockey players aged 14 and above who participated in the 2023 winter competition in Australia at any level were eligible to participate in this study as a component of a larger injury surveillance project. Branching was employed from the larger survey to include only participants who self-selected “female” when asked sex assigned at birth. People who were registered with Hockey Australia during 2023 and consented to receive advertising emails from Hockey Australia were invited to participate via email. Hockey Australia advertised the survey via social media (Instagram, Facebook and X), where field hockey players could click on a link to access the survey. Participation was voluntary; if participants changed their mind during completion, they could simply close the survey. Given the sensitive nature of the pelvic floor questions, participants were asked for an additional opt-in to answer these at the time of consent. Participants were offered to enter a draw to win AUD$500 worth of recovery products for completing the survey.

2.5. Outcome measures

Demographic data were collected, including age, playing level (elite (national level), top state level or other (club/community), field position (goalie, defender, mid-fielder or striker) and years playing field hockey. Participants were asked to identify the primary age group competition they participate in, i.e., Junior (age 14 to 18), Senior (any age bracket) or Masters (age 35 and above). It should be noted that a player being 18 years old or less does not automatically constitute them being a Junior player, they can (and often) primarily compete in the Senior competition.

The six item Questionnaire for Urinary Incontinence Diagnosis (QUID), was used to identify the presence and type of UI [23,24]. Respondents rank the frequency of UI symptoms as ‘none of the time’; ‘rarely’; ‘once in a while’; ‘often’; ‘most of the time’; ‘all of the time’; or ‘I do not wish to disclose’ (scores of zero to six were given) across six questions. Questions one to three are combined to make a stress score, where positive responses contribute to a diagnosis of SUI (response ≥4 out of 15) [23,24]. Questions four to six are combined to make an urge score (≥6 out of 15), where positive responses contribute to a diagnosis of UUI [23,24]. The QUID has been shown to have good validity in making SUI and UUI diagnoses with sensitivity and specificity of 0.85 and 0.71 for SUI, and 0.79 and 0.79 for UUI, respectively [24]. A diagnosis of MUI would be given for responses across stress and urge categories. Participants who met the diagnostic criteria were subsequently asked ‘Have you seen any health professionals about your pelvic floor symptoms?'.

Impact of pelvic floor symptoms on participation was measured by asking participants about the type of pelvic floor symptoms they experienced whilst exercising (e.g., UI, urgency, anal incontinence and pelvic organ prolapse), and what impact these symptoms had on participation. Questions included were adapted from other published literature in active populations [25,6,26]. Response options included: ‘continue exercising in the same way despite the symptoms’; ‘modify the way I exercise’; ‘stop doing certain types of exercise’; or ‘I do not wish to disclose’.

2.6. Data analysis

Data management and analysis were conducted following previously defined methods for anonymous survey designs [27]. All data was exported to an Excel CSV file and imported into R (R, R Foundation for Statistical Computing) for analysis and visualisation. Response duplication was assessed via repeated IP addresses, with data from duplicates removed where the IP addresses and demographic/playing data matched. Responses from the same IP address but differing demographic information/playing data, were considered independent responses (e.g., members of the same family). As the questions were not compulsory, all data were exported and analysed with omitted responses classed as “missing/not answered”, participants were also given the option to opt out of answering any question. All data were analysed at the cohort level and stratified based on primary age group competition (Juniors, Seniors, Masters). Demographic information relating to age, competition level, playing position, and years of participation in field hockey was reported as counts and proportions. Responses to the QUID were reported descriptively, with the participants meeting the diagnostic criteria of SUI, UUI and MUI reported as counts and proportions. Access to healthcare for those diagnosed with SUI, UUI and MUI was defined by the response to the question ‘Have you seen any health professionals about your pelvic floor symptoms?'. Response to the effect of pelvic floor symptoms on participation were also subsequently reported descriptively as proportions.

3. Results

We had 870 female participants complete the injury surveillance survey, of which 746 consented to answer the survey about pelvic floor function. Demographic characteristics are available in Table 1. Fifteen players reported being pregnant during the 2023 playing season, and 23 reported returning to play in 2023 following pregnancy.

Table 1.

Characteristics of female field hockey players.

n, %	Cohort	Primary competition age group
		Juniors	Seniors	Masters
	n = 746	n = 89	n = 583	n = 74
Age, years	33.6 (12.3)	15.5 (1.2)	34.0 (13.9)	52.4 (9.7)
	[14.0 to 74.0]	[14.0 to 18.0]	[14.0 to 72]	[35.0 to 74]
Playing level
Elite (national level)	n = 76, 10.2 %	n = 20, 22.5 %	n = 48, 8.2 %	n = 8, 10.8 %
State	n = 148, 19.8 %	n = 17, 19.1 %	n = 127, 21.8 %	n = 4, 5.4 %
Community/club	n = 522, 70.0 %	n = 52, 58.4 %	n = 408, 70.0 %	n = 62, 83.8 %
Position
Goalie	n = 68, 9.1 %	n = 11, 12.4 %	n = 49, 8.4 %	n = 8, 10.8 %
Defender	n = 246, 33.0 %	n = 21, 23.6 %	n = 201, 34.5 %	n = 24, 32.4 %
Midfield	n = 224, 30.0 %	n = 28, 31.5 %	n = 176, 26.9 %	n = 20, 27.0 %
Striker	n = 208, 27.9 %	n = 29, 32.6 %	n = 157, 26.9 %	n = 22, 29.7 %
Years participating in hockey
0–1 year	n = 15, 2.0 %	n = 0, 0 %	n = 11, 1.9 %	n = 4, 5.4 %
> 1–2 years	n = 17, 2.3 %	n = 5, 5.6 %	n = 11, 1.9 %	n = 1, 1.4 %
> 2–5 years	n = 56, 7.5 %	n = 17, 19.1 %	n = 36, 6.2 %	n = 3, 4.1 %
> 5–10 years	n = 185, 24.8 %	n = 55, 61.8 %	n = 123, 21.1 %	n = 7, 9.5 %
>10–20 years	n = 207, 27.6 %	n = 12, 13.5 %	n = 186, 31.9 %	n = 9, 12.2 %
>20 years	n = 266, 35.8 %	n = 0, 0 %	n = 216, 37.0 %	n = 50, 67.6 %

Age is reported as mean (standard deviation), [range], all other data are reported as counts and percentages.

One in four participants experienced UI symptoms, with SUI being the most frequent (15.4 %) (Table 2, Fig. 1). UUI and MUI were present in 3.6 % and 6.0 % of participants, respectively (Table 2). Overall, UI symptoms and each sub-type were most common in the Masters players (Table 2). Only 30 % of participants who reported symptoms meeting SUI, UUI and MUI diagnostic criteria had sought healthcare for their symptoms, including no Junior players (Table 2). Regarding the frequency of symptoms, 3.5 % reported experiencing SUI ‘often’ or more, 2 % for UUI and 2.5 % for MUI (Fig. 2).

Table 2.

QUID and healthcare utilisation results.

	Cohort n = 746	Juniors n = 89	Seniors n = 583	Masters n = 74
Stress urinary incontinence only n, % of group	n = 115, 15.4 %	n = 4, 4.5 %	n = 93, 16.0 %	n = 18, 24.3 %
Sought/seeking healthcare for their symptoms: n, % of those with SUI	n = 37, 32.2 %	n = 0, 0 %	n = 32, 34.4 %	n = 5, 27.8 %
Urge urinary incontinence only n, % of group	n = 27, 3.6 %	n = 4, 4.5 %	n = 18, 3.1 %	n = 5, 6.6 %
Sought/seeking healthcare for their symptoms: n, % of those with UUI	n = 3, 11.1 %	n = 0, 0 %	n = 3, 16.6 %	n = 0, 0 %
Mixed urinary incontinence n, % of group	n = 45, 6.0 %	n = 4, 4.5 %	n = 37, 6.3 %	n = 4, 5.4 %
Sought/seeking healthcare for their symptoms: n, % of those with MUI	n = 16, 35.5 %	n = 0, 0 %	n = 13, 35.1 %	n = 3, 75.0 %
Total n, % of group	n = 187, 25.1 %	n = 12, 13.5 %	n = 148, 25.4 %	n = 27, 36.5 %
Sought/seeking healthcare for their symptoms, % of total	n = 56, 29.9 %	n = 0, 0 %	n = 48, 32.4 %	n = 8, 29.6 %

QUID = The Questionnaire for Urinary Incontinence Diagnosis, n = number of participants, % = percentage, SUI= Stress Urinary Incontinence, UUI= Urge Urinary Incontinence, MUI = Mixed Urinary Incontinence.

Fig. 1.

Itemised response frequency for the 6 questions of the Questionnaire for Urinary Incontinence Diagnosis (QUID) for the entire cohort and by primary competition age group. Data for all 746 participants reported.

Fig. 2.

Impact of pelvic floor symptoms on exercise participation. Data for all 746 participants reported.

A breakdown of the impact of pelvic floor symptoms on exercise participation for the cohort is outlined in Fig. 2, with data for each primary competition age group provided in Appendices 1a-c. More than one third of participants had experienced UI or anal incontinence (accidental loss of control of bowel or passed wind) during exercise, and 10 % reported symptoms of pelvic organ prolapse. Most participants (45 %–72 %) who reported pelvic floor symptoms continued to exercise the same way despite there presence (Fig. 2). While a small proportion (5.7 %–6.9 %) of symptomatic participants stopped certain types of exercise (Fig. 2).

4. Discussion

This is the first study to explore UI and pelvic floor symptoms exclusively in field hockey players. The proportion of UI in female field hockey players was 25.1 % with the results highlighting that UI may be more common in Masters players, yet 13.5 % of junior players also experienced symptoms. SUI was the most common UI diagnosis (15.4 %), followed by mixed (6 %) and lastly urge (3.6 %). A small proportion of participants had to modify (3.2–9.9 %) or stop (0.8–2.5 %) exercise due to their symptoms. Overall, approximately one-third of symptomatic females sought healthcare, with no junior players seeking healthcare for their symptoms.

Having UI during competitive sport is strongly associated with UI later in life [28]. The Australian Department of Health and Aging reports that up to 40 % of females experience some form of incontinence [29], while a systematic review of pelvic floor symptoms in exercising females reported that those in high-impact sports are more likely to be affected (58 % experienced UI alone [30]). Our study found lower rates of UI, which may result from younger participants in our cohort, or the retrospective nature of the survey administered.

4.1. UI in junior players

Thirteen and a half per cent of the participating junior players reported the presence of UI, although it is possible that this value may under-represent the presence of UI in adolescents due to the mechanism-based questions of the QUID [23]. Consideration of cross-contextual aspects of incontinence (such as UI associated with laughing and daily activities) may increase engagement and understanding in adolescents [31]. In addition, a higher proportion of Junior participants in this study reported being ‘unsure’ about their experience of pelvic floor symptoms during exercise compared to Seniors or Masters athletes. These findings suggest a lack of knowledge and awareness in this population and may further under-represent the presence of UI in adolescents. Developing targeted education for adolescent athletes may increase awareness of pelvic floor symptoms and ensure that the true prevalence of this is accurately captured.

No Junior players sought healthcare for their symptoms. Their reasons for this were not collected as a component of the study. However, previous research has indicated that reasons for not seeking healthcare for pelvic floor symptoms are multidimensional and can include, the perception that UI is normal [32], embarrassment [32], or lack of awareness and knowledge of available treatment options [33]. Previous research has reported a desire from adolescents to understand more about their pelvic health [23]. Developing education that addresses symptom recognition and barriers to disclosure and accessing treatment may lead to improved outcomes in an adolescent cohort [33].

4.2. Healthcare seeking

There is level 1 evidence that pelvic floor muscle training should be offered as first-line management of UI in females [34,35,11]. Despite this, only one third of our participants with symptoms sought healthcare, consistent with previous literature [14]. Lack of knowledge about UI and possible treatment options, and shame or embarrassment to discuss symptoms, have been shown to contribute to female players not seeking help [36]. This may be further confounded with elite-level athletes also being less likely to report symptoms than recreational athletes [37,38]. Our findings highlight the need for a more proactive approach to prevention, early identification, and management strategies in field hockey players. For example, only 32 % of health and exercise professionals routinely screen for UI [14]. Increasing routine screening as standard practice will identify symptomatic individuals sooner and improve awareness amongst individuals. Screening tools have been recently developed for use in athletic populations; however, these require further validation [39].

Providing female athletes, such as field hockey players, with accessible information on UI and its management may help increase awareness and comfort in seeking assistance. Educational programs in schools or community sports clubs could help adolescents and young women recognise UI symptoms and understand the referral pathways and care options that are available [33]. Among medical staff, fostering a safe environment where athletes feel comfortable discussing symptoms may improve referral rates and open dialect with athletes, facilitating health [14].

4.3. Limitations

Our study has limitations that require acknowledgement and consideration when interpreting the results. Firstly, the study was a retrospective survey, therefore increasing the likelihood of recall and misclassification bias in the observed results. It also should be noted that the study was advertised as an injury surveillance survey; thus, there is a chance that people experiencing an injury or symptoms were more likely to participate, creating selection bias. As a result, data was reported as proportions of respondents and not with statistical hypothesis testing due to the chance of overestimating effect sizes. Given the retrospective nature of the survey, questionnaires that measured UI and the impact of pelvic floor symptoms on participation were condensed to limit recall bias. These questionnaires allowed identification of specific symptoms, but did not allow a broader range of pelvic floor symptoms to be explored. Future research exclusively dedicated to this aim should consider using outcome measures that capture information about a broad range of pelvic floor symptoms [40,41,42], their impact on participation [26], and use tools that have been developed specifically for athletes [39].

Secondly, we did not collect data relating to previous pregnancy(ies), delivery method(s) and additional pelvic floor presentations. As such we are unable to explore the effect of pregnancy on the reporting of pelvic floor symptoms and UI in field hockey players. In addition, we did not include male athletes in the study. Inclusion in this study was based on self-reported sex assigned at birth and not self-described gender identity; we therefore refer to our cohort as female athletes not girls and/or women. We have referred to women/woman athletes only in relation to other studies. Pelvic floor symptoms and UI are not exclusive to female athletes and are prevalent in male athletes [43]. Future research should explore the effect of pregnancy and mode of delivery on pelvic floor symptoms and UI in field hockey players and explore the prevalence of symptoms in male players.

Finally, we did not complete an a priori power calculation, with the survey distributed to all registered players (who agreed to receive marketing emails from Hockey Australia). However, a post hoc power calculation with a Slovin's formula (total population 46,282 registered female players, 5 % margin of error, 95 % confidence interval) highlights that a minimum of 381 respondents is required to be considered representative, a sample size which was exceeded in the study.

5. Conclusion

This is the first field hockey specific survey to measure the frequency of UI in female players. One in four female field hockey players reported some form of UI, and the majority had not sought health care for assistance with their symptoms. The frequency of UI symptoms and lack of health professional seeking in our cohort demonstrates the need for prevention, early identification, and management strategies to be prioritised within female field hockey players.

Roles and responsibilities

Conceptualisation: ECB, MCH, MGK, ES.

Development of survey: ECB, MCH, MGK, ES.

Ethics: ECB, MCH, MGK.

Survey rollout: ECB.

Data analysis: MGK.

Data interpretation: MGK, ECB, SM.

Drafting: MGK, ECB, SM.

Final manuscript: All.

Funding

Nil.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following is the Supporting Information to this article.