We dont give it the time of day, says pelvic floor physiotherapist Emma Brockwell. If you look at any journal on the hip, groin, pelvis, the pelvic floor is missing. Its wild how this muscle group has been ignored.
The pelvic floor supports the pelvic organs (the bladder, uterus and bowel), controls the bodys continence mechanisms and helps with core stability. It affects every womans daily life, including elite athletes and teenage girls. And it impacts men, too. Yet, apart from during pregnancy, the pelvic floor is barely talked about at all certainly not in the context of professional sport.
At Manchester City, however, after a few women players reported urinary incontinence (an involuntary leakage of urine) when doing a jumping warm-up exercise called pogos, it prompted questions about how representative that number was across the team.
Dr Rosie Anderson, physical performance scientist, and Emma Deakin, director of performance services, contacted Brockwell, who also works with Womens Super League clubs Chelsea, Arsenal, Aston Villa and London City Lionesses, and National Womens Soccer League side Washington Spirit. She aims to educate players and staff, assess players pelvic health and ensure pelvic floor work is integrated within their exercise programmes.
City found some players, for fear of leaking urine and the embarrassment caused, were modifying exercises, such as limiting the weight with which they squat in the gym. For the same reason, they were at times reluctant to jump and run at maximum intensity or drink fluids. They would go to the toilet frequently before a game, serving as a distraction from performance.
There is a psychological impact too. It knocks their confidence, says Brockwell. Anxiety and low mood are highly associated with pelvic floor dysfunction because of how it makes a woman feel. Recognising this within this sport is important, but knowing that and doing nothing about it is disastrous.
At Citys Etihad campus, The Athletic joined Anderson, Brockwell and Deakin as they bounce off each other, busting myths and trying to normalise the conversation about the pelvic floor so more women and girls can continue enjoying sport.
Pelvic floor dysfunction is an umbrella term for symptoms that occur when the pelvic floor isnt working optimally, says Brockwell. High impact sports such as football or rugby can be a risk factor. Symptoms may include pelvic organ prolapse; pelvic, coccyx, back, hip or groin pain, and urinary incontinence, even faecal incontinence.
But this is not just about high-profile players. Pelvic floor health has wide-reaching implications beyond football.
There is this common misconception that pelvic floor dysfunction only occurs if youve had a baby, youre older and perimenopausal (before the menopause) or postmenopausal (after the menopause), says Brockwell. The reality is that pelvic floor dysfunction can happen from girls as young as 12 or 13, all the way through their life cycle.
Its one of the main reasons we lose girls to sport. If theyre wetting themselves, its highly embarrassing and uncomfortable, so theyll stop playing.
And it is not only womens and girls pelvic floors which have been ignored.
I hazard a guess the mens side have a lot of pelvic floor issues, says Brockwell.
(Some mens) players will have repetitive groin issues, the majority of physios and doctors would not think to check their pelvic floor, adds Deakin. They could have avoided surgery or months out of the game because theyve been treating the wrong thing.
For sure, men experience urinary incontinence, says Brockwell. Erectile dysfunction can be a consequence of the pelvic floor not working optimally. But no one talks about these things, no one talks about penises, no one talks about vulvas. It becomes this taboo area that everyone is ashamed to talk about when its the epicentre of your body.
Pelvic health in the womens game is really cool because were doing it first. This is where the mens game can learn from us. We are like an untapped secret.
Among the female footballers Brockwell has worked with, the most common symptoms are stress urinary incontinence, and hip and pelvic pain. If you were to cough, sneeze, laugh, jump, tackle, head a ball, you might wet yourself, lose a few drops of urine or full bladder control, she says. It just depends on the severity of the symptoms.
The pain can often be musculoskeletal, but can also be related to gynaecological conditions such as endometriosis, which is when cells similar to the lining of the uterus grow outside the uterus, often on the ovaries, fallopian tubes, or other pelvic organs.
A 2024 study looking at the impact of pelvic floor dysfunction on women rugby players playing in the UK and Ireland highlighted that, as well as stress urinary incontinence and pelvic pain, faecal urgency and faecal incontinence are other symptoms to be considered when working with female athletes.
A study this year, Pelvic floor health and urinary incontinence in female soccer players, found that among 18 professional Spanish footballers, 50 per cent were leaking urine. That is massive, says Brockwell.
Adverts for incontinence pads or mothers passing on their experiences to daughters have warped societys perception of what is normal.
So many of the athletes we speak to have normalised that as part of being an elite athlete, says Brockwell. Its certainly a very common symptom but its not normal and not one they should have to put up with. The same applies to any woman exercising, whether that be recreationally or at the highest level.
As well as affecting physical performance, there is a mental impact too.
Its also a massive distraction, says Anderson. Youre not fully focussed on the game, decision-making might be impacted as a result.
City were the first high-profile club, three years ago, to announce their womens team would no longer wear white shorts as part of their home kit to help players feel more comfortable when on their periods. But the issue goes beyond menstruation the same concerns apply to urinary incontinence.
We had players stressing about what colour shorts they were wearing, says Deakin. If shorts are a lighter colour, it is more obvious to see if a player has leaked. The same applies to anyone wearing grey leggings rather than black, for example.
Especially the media attention on these players now, adds Brockwell. Ive spoken to quite a few who are incredibly self-conscious they are going to get snapped at the wrong moment when theres clearly urine on their shorts. That must be a horrible reality.
Around 18 months ago, Brockwell delivered an online education session to first-team players while Anderson was in the room.
Brockwell explained what the pelvic floor is, its role, what it looks like and what happens if its not working optimally. She also highlighted how the pelvic floor is intimately connected to the rest of the body. The hip muscles form part of the pelvic floor and attach closely to the groin muscles. Improving pelvic-floor function could help reduce groin injuries, which are prevalent in female footballers. The pelvic floor also relates to the lower back, the abdominal wall and the diaphragm which links to breathing. A weak pelvic floor could impact these areas of the body too.
This muscle that no one talks about, that causes embarrassment because of where it sits is just part of your body, and if we talk about it, we might be able to help not just symptoms of pelvic floor dysfunction but musculoskeletal injuries too, says Brockwell.
Another key takeaway was reducing the stigma around the treatment for pelvic floor dysfunction. Physio is one way to reduce symptoms. Like any other muscle, you can train the pelvic floor. If a player had a weak hamstring, a strengthening programme would be put in place; the same can and should apply to the pelvic floor. This framing was crucial for players to understand.
By the time you have read to this point, for example, you would have completed your pelvic floor exercises. It is important not to train the muscle in isolation, says Brockwell, who explains two sets of exercises to incorporate into a programme.
The pelvic floor is made up of slow and fast twitch fibres. To train the former, lie, sit or stand (the more upright you are, the harder it is to perform this initially), and squeeze as if trying to stop yourself weeing and passing wind. You should feel your perineum squeeze and lift. Aim to hold for up to 10 seconds holding works the slow twitch fibres and then relax the muscle.
To train the fast twitch fibres, you should again start by lying, sitting or standing, and quickly squeeze at the front and the back, and then slowly release. Repeat this up to 10 times. You may be doing your exercises incorrectly if you hold your breath or squeeze your bottom, or if after six to eight weeks any existing symptoms are not improving or are getting worse.
If this happens then you are not alone, says Brockwell. Many women struggle initially but this is when a pelvic health physio is recommended.
We should be encouraging girls and women to check this part of the body, the vulva, says Brockwell. We would encourage women to breast check for lumps and bumps.
Also look with a mirror at this part of that body. I cannot tell you how many women I see who have never looked at their vulva before. Its your body. Why havent you looked at it?
Its typically around pregnancy when you may have a look and say: Oh my God, what the hell is that? If you recognise that before going through these bodily changes, its empowering but it also removes anxiety. If there are changes to that area, we have to let the doctor know.
Indeed there was a lot of laughter among the Manchester City squad when all this myth-busting, as Anderson says, was going on. Predominately when there was an animated image of the female reproductive system, she adds.
I thought: Are they even taking this seriously?
But the players did. When they re-screened the squad, many more reported symptoms.
After the initial screening, players have the option to have a one-to-one session with Brockwell. She works with City twice a month, once in person and once online. Sharing their positive experiences encourages others, especially younger or shier players, to seek help.
Athletes who have leaked in the past, even after resolution, are nine times more likely to experience symptoms of pelvic floor dysfunction later in life, according to a 2010 study, so there is a degree of future-proofing at play, too.
This season there has also been a noticeable cultural shift in how players approach a once-taboo topic.
Its night and day, says Brockwell. Its amazing how different it feels even just talking to the players one on one. They say: Oh, yeah, thinking about it, I did wet myself last week so what are we going to do about it? Whereas prior to that it would have been: I dont care, Im not bothered about it.
They are bothered about it.
According to the aforementioned 2010 study, it takes within seven years to seek help for pelvic floor dysfunction. Deakin chimes in: Can you imagine that for any other symptom? Oh, my knee hurts, Ill wait seven years! Brockwell advises doing pelvic floor exercises even before symptoms occur.
Its never too late to seek help, she says, encouraging anyone to see their doctor first, who can then refer them to a pelvic health physio.
They shouldnt be embarrassed, says Brockwell. There are healthcare medical professionals who deal with this every day, its their bread and butter, all they talk about.
And it should be spoken about in everyday life.
This article originally appeared in The Athletic.
Manchester City, Premier League, Soccer, Women’s Soccer
2025 The Athletic Media Company