Elite Female Athletes Show Higher Rates of Pelvic Floor Dysfunction and Dyspareunia - Avanti Rangnekar
October 31, 2024
Diane Newman hosts Avanti Rangnekar to discuss research examining pelvic floor dysfunction and dyspareunia in elite female athletes at the University of Pennsylvania. The study investigates whether rigorous athletic training contributes to increased incidence of pelvic floor dysfunction, particularly focusing on provoked vestibulodynia (PVD) and painful intercourse among NCAA Division I athletes in running and jumping sports. The findings indicate a higher prevalence of PVD and dyspareunia in elite athletes compared to age-matched populations, with significant associations between voiding dysfunction, pelvic pain, and dyspareunia symptoms. The conversation explores the study's methodology, including recruitment through the undergraduate program and the use of standardized assessment tools like the LURN-29 and GUPI indexes. The discussion highlights anatomical changes observed in these athletes through pelvic MRI and emphasizes the importance of studying urologic issues in young, active female populations.
Biographies:
Avanti Rangnekar, BA, MD Student, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Diane K. Newman, DNP, FAUNA, FAAN, Medical Director, Digital Science Press, Adjunct Professor of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Biographies:
Avanti Rangnekar, BA, MD Student, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Diane K. Newman, DNP, FAUNA, FAAN, Medical Director, Digital Science Press, Adjunct Professor of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Read the Full Video Transcript
Diane Newman: Welcome. I'm Diane Newman. I'm a nurse practitioner, and I'm an editor at UroToday. With me today is Avanti Rangnekar, and she's here today to discuss with us pelvic floor dysfunction and dyspareunia in elite athletes. I recently heard this presentation, and I thought it would be really of interest to you also. Welcome.
Avanti Rangnekar: Hi everyone. My name is Avanti Rangnekar. I'm a fourth-year medical student at the University of Pennsylvania, and today I'm going to be discussing our research, "Pelvic Floor Dysfunction and Dyspareunia in Elite Athletes." At a high level, this research explores whether the rigorous training experienced by elite athletes may be contributing to the increased incidence of pelvic floor dysfunction experienced in this population. And so, starting with a little bit of background here, provoked vestibulodynia, or PVD, refers to chronic pain in the vulvar area, specifically in the vestibule, and provoked by touch or sexual activity that occurs in the absence of another identifiable cause.
PVD is a leading cause of painful intercourse, or dyspareunia, and affects around 8 to 10% of women overall. This number significantly decreases to about 1 to 2% in women under the age of 25. One other known factor of PVD is pelvic floor muscular hypertonia, or excessive muscle tension in the pelvic floor. Studies have shown that elite athletes are at an increased risk for experiencing various types of pelvic floor dysfunction, including pelvic organ prolapse and fecal and urinary incontinence.
And so, given the link between pelvic floor hypertonia and higher rates of pelvic floor dysfunction in elite athletes, we raised the question: Could elite athletes also be at an increased risk for pelvic floor hypertonicity? And if so, could this result in higher rates of PVD and dyspareunia, particularly when combined with other urinary symptoms?
And so, to test this, non-pregnant females aged 18 to 25 who met elite athlete criteria—which we defined as participating in greater than 10 hours a week of an NCAA Division I running or jumping sport—were recruited from the University of Pennsylvania's undergraduate population. Athletes completed a detailed questionnaire that assessed demographics, exercise habits, medical history, as well as other urinary symptoms.
We used the Lower Urinary Tract Dysfunction Network Symptom 29 Index, or the LURN-29, to evaluate urinary symptoms, and the Genitourinary Pain Index, or the GUPI, to assess pelvic pain, including dyspareunia and PVD.
We compared LURN-29 scores and its subdomains using Mann-Whitney tests, and then used logistic regression to analyze the relationship between these scores and the likelihood of PVD and dyspareunia.
And so, 67 elite female athletes were included in our final study population, and among those, around five out of 67, or 7.5%, reported experiencing PVD, while 16.4%, or 11 out of 67, reported experiencing dyspareunia. Analysis of the LURN-29 scores that you can see here in Figure 1 revealed that higher scores in the subdomains of both voiding dysfunction and pain were significantly associated with experiencing dyspareunia.
Specifically, each increase in the voiding dysfunction score corresponded to a 46% higher chance of reporting dyspareunia with a p-value of 0.015. Similarly, higher pain scores were associated with a 64% increased likelihood of reporting dyspareunia with a p-value of 0.038. In contrast, and importantly, scores in the subdomains of incontinence, nocturia, and urgency showed no significant association with increased reporting of dyspareunia.
And so, in summary, our findings suggest that the prevalence of PVD and dyspareunia among female elite athletes—which in our study population we found to be around 7.5%—is notably higher than the 1 to 2% described in the literature for this age group, indicating that elite athletes are a potentially high-risk group for these symptoms.
Furthermore, PVD and dyspareunia are linked with specific urinary symptoms, including voiding dysfunction and pelvic pain, and these results can contribute to a larger theory that the demanding nature of elite athletics may in fact be contributing to pelvic floor dysfunction. We believe this could potentially be due to the mechanism of pelvic floor hypertonicity, or again, increased muscular tension in the pelvic floor. Moving forward, however, longitudinal studies are essential to establishing causality and better understanding some of the mechanisms at play. So, thank you very much for your time.
Diane Newman: Thank you so much. When I heard you present this, I found this really interesting. I have a few questions, though. How did you really recruit these athletes? I know that you went to the undergraduate program at Penn, but how? Did you just put up... whoever signed up came forward, or how did you do it?
Avanti Rangnekar: Yeah, we call this—our study population is considered a convenience sample. So, another colleague of ours, Dr. Zoe Gan, was actually doing some important work as well, looking at the anatomy of some of these athletes—the pelvic anatomy—and so we kind of borrowed from her sample. So, she put out an advertisement on the undergraduate campus asking elite athletes with urinary symptoms to volunteer.
And so, we were able to pull from that population and have them fill out a questionnaire that assessed our own study outcomes of interest.
Diane Newman: And what was the breakdown of the race-ethnicity of this group? Do you have that, the numbers?
Avanti Rangnekar: I don't quite have the breakdown of the race or ethnicity, but I will say some of the characteristics that I do know. Most of the elite athletes were runners; they were all between the ages of 18 and 25, non-pregnant females, nulliparous—so never had a child either. These women were also shown on pelvic MRI to have really significant functional and anatomic changes in their pelvic anatomy, which I'm happy to get into as well. And so, that's a little bit more of the detail of the breakdown of this population.
Diane Newman: So, maybe the result was because of their alterations in the pelvic anatomy then?
Avanti Rangnekar: Yeah, so Zoe—Dr. Gan—was able to find that a lot of these women had significant functional anatomical differences in their pelvic anatomy. So, many of these women had greater thickness and atrophy of the striated muscle of the urinary sphincter and superficial skeletal pelvic floor. And so, this is a very real issue for these young women.
Diane Newman: What about—do you have any history of their sexual activity, though? Because I would think that this must play into some of... as far as how active they were.
Avanti Rangnekar: So, we included a lot of questions around sexual intercourse and participation in sexual activity, using the Genitourinary Pain Index Score Questionnaire. However, I can't quite speak to the specific questions regarding frequency of sexual intercourse or other sexual activity for this population.
Diane Newman: The other thing I found of interest in some of your results was that you didn't see the correlation with these athletes and incontinence. As you know, the literature has been looking at elite athletes, as well as Olympic athletes—those that are gymnasts—because the amount of jumping and pounding that they do over their lifetime, and these can be young girls, but it's so many years they're practicing and performing that we do see stress incontinence. But you do not see that correlation with incontinence, right?
Avanti Rangnekar: So we didn't not see it. I think it's important to clarify our outcome of interest was looking at dyspareunia and pelvic floor dysfunction, specifically as it relates to provoked vestibulodynia, which are essentially sexual symptoms as they relate to urinary symptoms. So, I think the more accurate correlation, or lack of correlation, would be between those sexual symptoms—dyspareunia and incontinence—not so much these elite athletes experiencing incontinence.
It's well established that elite athletes, at baseline, have higher rates of incontinence and other sorts of symptoms of pelvic floor dysfunction. It's just whether or not those are necessarily associated with these sexual symptoms that we were interested in studying.
Diane Newman: Well, I hope you publish this, because I really want to see that data on the LURN.
Avanti Rangnekar: Yeah.
Diane Newman: We've used that in other research, so I'm really excited that you did use that, so that's really great. Thanks.
Avanti Rangnekar: Thank you.
Diane Newman: So, as a medical student, I was really impressed with your presentation, but also, why did you get interested in this? Why did you decide to be involved with the study?
Avanti Rangnekar: Yeah, so I think working with this team—Dr. Arianna Smith and Dr. Gan and Dr. Karen Michael—was really my first introduction into urology. So, I was very interested in specifically female urology and understanding some of the experiences that women face that are urologic in nature.
I think specifically this population—I found this study very interesting. I think traditionally there's a lot more acceptance around chronic pelvic pain in men, whether that's post-radical prostatectomy or with the issue of chronic pelvic pain. And for women, I think that issue is largely limited to urinary leakage after childbirth, for example. And so, the young, active population of women is largely understudied, and so I was very interested to dive deeper into this topic, and it essentially affirmed my interest in pursuing urology as a career as well.
Diane Newman: Well, that's really good. Well, thanks so much for presenting this, because I know it's going to be of great interest to our viewers. Thank you.
Avanti Rangnekar: Yeah, thank you.
Diane Newman: Welcome. I'm Diane Newman. I'm a nurse practitioner, and I'm an editor at UroToday. With me today is Avanti Rangnekar, and she's here today to discuss with us pelvic floor dysfunction and dyspareunia in elite athletes. I recently heard this presentation, and I thought it would be really of interest to you also. Welcome.
Avanti Rangnekar: Hi everyone. My name is Avanti Rangnekar. I'm a fourth-year medical student at the University of Pennsylvania, and today I'm going to be discussing our research, "Pelvic Floor Dysfunction and Dyspareunia in Elite Athletes." At a high level, this research explores whether the rigorous training experienced by elite athletes may be contributing to the increased incidence of pelvic floor dysfunction experienced in this population. And so, starting with a little bit of background here, provoked vestibulodynia, or PVD, refers to chronic pain in the vulvar area, specifically in the vestibule, and provoked by touch or sexual activity that occurs in the absence of another identifiable cause.
PVD is a leading cause of painful intercourse, or dyspareunia, and affects around 8 to 10% of women overall. This number significantly decreases to about 1 to 2% in women under the age of 25. One other known factor of PVD is pelvic floor muscular hypertonia, or excessive muscle tension in the pelvic floor. Studies have shown that elite athletes are at an increased risk for experiencing various types of pelvic floor dysfunction, including pelvic organ prolapse and fecal and urinary incontinence.
And so, given the link between pelvic floor hypertonia and higher rates of pelvic floor dysfunction in elite athletes, we raised the question: Could elite athletes also be at an increased risk for pelvic floor hypertonicity? And if so, could this result in higher rates of PVD and dyspareunia, particularly when combined with other urinary symptoms?
And so, to test this, non-pregnant females aged 18 to 25 who met elite athlete criteria—which we defined as participating in greater than 10 hours a week of an NCAA Division I running or jumping sport—were recruited from the University of Pennsylvania's undergraduate population. Athletes completed a detailed questionnaire that assessed demographics, exercise habits, medical history, as well as other urinary symptoms.
We used the Lower Urinary Tract Dysfunction Network Symptom 29 Index, or the LURN-29, to evaluate urinary symptoms, and the Genitourinary Pain Index, or the GUPI, to assess pelvic pain, including dyspareunia and PVD.
We compared LURN-29 scores and its subdomains using Mann-Whitney tests, and then used logistic regression to analyze the relationship between these scores and the likelihood of PVD and dyspareunia.
And so, 67 elite female athletes were included in our final study population, and among those, around five out of 67, or 7.5%, reported experiencing PVD, while 16.4%, or 11 out of 67, reported experiencing dyspareunia. Analysis of the LURN-29 scores that you can see here in Figure 1 revealed that higher scores in the subdomains of both voiding dysfunction and pain were significantly associated with experiencing dyspareunia.
Specifically, each increase in the voiding dysfunction score corresponded to a 46% higher chance of reporting dyspareunia with a p-value of 0.015. Similarly, higher pain scores were associated with a 64% increased likelihood of reporting dyspareunia with a p-value of 0.038. In contrast, and importantly, scores in the subdomains of incontinence, nocturia, and urgency showed no significant association with increased reporting of dyspareunia.
And so, in summary, our findings suggest that the prevalence of PVD and dyspareunia among female elite athletes—which in our study population we found to be around 7.5%—is notably higher than the 1 to 2% described in the literature for this age group, indicating that elite athletes are a potentially high-risk group for these symptoms.
Furthermore, PVD and dyspareunia are linked with specific urinary symptoms, including voiding dysfunction and pelvic pain, and these results can contribute to a larger theory that the demanding nature of elite athletics may in fact be contributing to pelvic floor dysfunction. We believe this could potentially be due to the mechanism of pelvic floor hypertonicity, or again, increased muscular tension in the pelvic floor. Moving forward, however, longitudinal studies are essential to establishing causality and better understanding some of the mechanisms at play. So, thank you very much for your time.
Diane Newman: Thank you so much. When I heard you present this, I found this really interesting. I have a few questions, though. How did you really recruit these athletes? I know that you went to the undergraduate program at Penn, but how? Did you just put up... whoever signed up came forward, or how did you do it?
Avanti Rangnekar: Yeah, we call this—our study population is considered a convenience sample. So, another colleague of ours, Dr. Zoe Gan, was actually doing some important work as well, looking at the anatomy of some of these athletes—the pelvic anatomy—and so we kind of borrowed from her sample. So, she put out an advertisement on the undergraduate campus asking elite athletes with urinary symptoms to volunteer.
And so, we were able to pull from that population and have them fill out a questionnaire that assessed our own study outcomes of interest.
Diane Newman: And what was the breakdown of the race-ethnicity of this group? Do you have that, the numbers?
Avanti Rangnekar: I don't quite have the breakdown of the race or ethnicity, but I will say some of the characteristics that I do know. Most of the elite athletes were runners; they were all between the ages of 18 and 25, non-pregnant females, nulliparous—so never had a child either. These women were also shown on pelvic MRI to have really significant functional and anatomic changes in their pelvic anatomy, which I'm happy to get into as well. And so, that's a little bit more of the detail of the breakdown of this population.
Diane Newman: So, maybe the result was because of their alterations in the pelvic anatomy then?
Avanti Rangnekar: Yeah, so Zoe—Dr. Gan—was able to find that a lot of these women had significant functional anatomical differences in their pelvic anatomy. So, many of these women had greater thickness and atrophy of the striated muscle of the urinary sphincter and superficial skeletal pelvic floor. And so, this is a very real issue for these young women.
Diane Newman: What about—do you have any history of their sexual activity, though? Because I would think that this must play into some of... as far as how active they were.
Avanti Rangnekar: So, we included a lot of questions around sexual intercourse and participation in sexual activity, using the Genitourinary Pain Index Score Questionnaire. However, I can't quite speak to the specific questions regarding frequency of sexual intercourse or other sexual activity for this population.
Diane Newman: The other thing I found of interest in some of your results was that you didn't see the correlation with these athletes and incontinence. As you know, the literature has been looking at elite athletes, as well as Olympic athletes—those that are gymnasts—because the amount of jumping and pounding that they do over their lifetime, and these can be young girls, but it's so many years they're practicing and performing that we do see stress incontinence. But you do not see that correlation with incontinence, right?
Avanti Rangnekar: So we didn't not see it. I think it's important to clarify our outcome of interest was looking at dyspareunia and pelvic floor dysfunction, specifically as it relates to provoked vestibulodynia, which are essentially sexual symptoms as they relate to urinary symptoms. So, I think the more accurate correlation, or lack of correlation, would be between those sexual symptoms—dyspareunia and incontinence—not so much these elite athletes experiencing incontinence.
It's well established that elite athletes, at baseline, have higher rates of incontinence and other sorts of symptoms of pelvic floor dysfunction. It's just whether or not those are necessarily associated with these sexual symptoms that we were interested in studying.
Diane Newman: Well, I hope you publish this, because I really want to see that data on the LURN.
Avanti Rangnekar: Yeah.
Diane Newman: We've used that in other research, so I'm really excited that you did use that, so that's really great. Thanks.
Avanti Rangnekar: Thank you.
Diane Newman: So, as a medical student, I was really impressed with your presentation, but also, why did you get interested in this? Why did you decide to be involved with the study?
Avanti Rangnekar: Yeah, so I think working with this team—Dr. Arianna Smith and Dr. Gan and Dr. Karen Michael—was really my first introduction into urology. So, I was very interested in specifically female urology and understanding some of the experiences that women face that are urologic in nature.
I think specifically this population—I found this study very interesting. I think traditionally there's a lot more acceptance around chronic pelvic pain in men, whether that's post-radical prostatectomy or with the issue of chronic pelvic pain. And for women, I think that issue is largely limited to urinary leakage after childbirth, for example. And so, the young, active population of women is largely understudied, and so I was very interested to dive deeper into this topic, and it essentially affirmed my interest in pursuing urology as a career as well.
Diane Newman: Well, that's really good. Well, thanks so much for presenting this, because I know it's going to be of great interest to our viewers. Thank you.
Avanti Rangnekar: Yeah, thank you.