Introduction – Let’s Talk About It!

I’m sure many of us have seen the recent bowel incident at the HYROX competition in Beijing. I’m not here to discuss or speculate about this particular incident or the athlete involved. However, it does bring attention to a topic that is rarely talked about openly: anorectal dysfunction and, in particular, anal incontinence (AI).

It is important to emphasise that a bowel incident during an event does not necessarily mean that an athlete is experiencing anal incontinence. Gastrointestinal symptoms or an isolated bowel incident during exercise can occur for many reasons, including diet, medication, supplements, and the physiological demands of intense exercise. Instead, I want to use this moment to open a broader conversation about anal incontinence in female athletes, a problem that often remains hidden despite its potential impact on sporting participation and quality of life.

So, what exactly are we talking about?

Anorectal dysfunction encompasses a broad spectrum of symptoms, including fecal urgency, incontinence, straining during defecation, constipation, a sensation of incomplete bowel evacuation, reduced rectal sensation, rectal prolapse, and rectal bleeding.

When discussing incontinence, it is helpful to distinguish between anal incontinence (AI) and fecal incontinence (FI). Anal incontinence is the broader term and refers to the involuntary loss of feces and/or flatus (gas). Fecal incontinence refers specifically to the involuntary loss of liquid or solid stool.

This distinction is important when looking at research in female athletes. Although the term “incontinence” may immediately make us think of stool leakage, many athletes reporting AI are actually experiencing the involuntary loss of gas rather than liquid or solid stool.

We often associate the pelvic floor muscles with urinary continence, but they also play an important role in maintaining anal continence. Together with the anal sphincters, the pelvic floor muscles contribute to continence through both passive and active mechanisms, while also being able to relax appropriately to allow the passage of stool during defecation. A pelvic health therapist (like me and my colleagues at Hela Kvinnans Klinik) can assess these muscles and their function.

Prevalence – how common is it?

A study by Forner et al. (2021), involving 1,379 women, reported a relatively high prevalence of anal incontinence (AI) in both CrossFit participants (34%) and runners (27.7%). In both groups, however, AI was predominantly related to the involuntary loss of gas, while stool leakage was less commonly reported.

Importantly, the researchers also compared athletes according to whether they had given birth vaginally or had never given birth (nulliparous). This distinction matters because vaginal childbirth is a recognised risk factor for pelvic floor dysfunction. Among women who had given birth vaginally, runners reported more symptoms of AI, as well as other pelvic floor symptoms, than CrossFit participants. In contrast, no differences were found between nulliparous runners and nulliparous CrossFit participants.

One strength of this study is its large sample size of 1,379 participants. However, because it was a cross-sectional study, the findings provide a snapshot at one point in time. While this type of research can identify associations and highlight potential problems, it cannot establish cause and effect. In other words, these findings alone cannot tell us that running causes AI or that runners are at greater risk of developing AI over time.

A systematic review by Culleton et al (2022) reviewed elite female athletes symptoms of pelvic floor dysfunction including studies reporting prevalence of anorectal dysfunction in 9 studies and anal incontinence in 4 studies.

Altogether these 4 studies reported a prevalence of AI. In the study by Almeida et al. (2016) participants, including athletes and non-athletes reported only symptoms of AI as the loss of gas. A cross-sectional study of cheerleaders and non-athletes found that anal incontinence (AI) was the most commonly reported symptom of pelvic floor dysfunction among the cheerleaders. When compared with non-athletic women, female cheerleaders were 2.3 times more likely to report symptoms of AI, suggesting that participation in cheerleading may be associated with a greater occurrence of these symptoms. When comparing these 2 groups in relation to loss of gas, cheerleaders were 2.1 times likely to be affected. This could be attributed to the repetitive high impact that cheerleaders are subjected to, challenging continence mechanisms such as strength, endurance, timing and coordination of the pelvic floor muscles. 

Interestingly, anal incontinence (AI) was also the most commonly reported pelvic floor dysfunction among both female and male powerlifters and Olympic weightlifters. Involuntary loss of gas was the most common form of dysfunction. What is particularly relevant for athletes is that these symptoms frequently occurred during sport: approximately 89% of women and 91% of men who reported accidental loss of gas experienced it during training or competition. Leakage of liquid or solid stool during sport was less common, but was still reported by some athletes. Although the average level of bother associated with AI was relatively low, around 15% of affected women reported a more substantial degree of bother. These findings highlight that anal incontinence is not solely an issue outside sport, it can occur during training and competition, even among strength athletes (Skaug et al., 2020).

What is particularly striking is how often anal incontinence occurred during sport itself. Among athletes who reported accidental loss of gas, almost 88% experienced it during training or competition, with most describing it as occurring rarely or occasionally. Leakage of liquid or solid stool during exercise was less common; approximately 22% of those reporting liquid stool leakage and 18% of those reporting solid stool leakage experienced these symptoms during training or competition. These findings demonstrate that anal incontinence can occur in the sporting environment. 

Ultimately, we still have much to learn about why anal incontinence occurs during exercise. Factors such as maximal effort, pelvic floor muscle fatigue, recovery, training experience and previous childbirth may all play a role, and future research needs to explore these factors more closely. Interestingly, the presence of similar symptoms in male athletes also suggests that childbirth alone cannot explain the problem. While we wait for more answers, there are practical steps athletes can take to support good bowel health—so, how can we keep our bowels happy?

Give Your Gut Some Love: Healthy Bowel Habits

What is considered normal:

• Frequency – a span from emptying 3x a week to 3x a day is considered normal.
• Consistency – as we aim for a passage of stool without effort or pain, stools should be soft, smooth and shaped like a sausage. Check out the Bristol Scale. 
• Effort – passing stool should only take a few minutes without heavy pushing or straining. If you find yourself sitting for a longer period of time, it’s better to get up and wait for the next signal for emptying.

Optimizing bowel movement:

• Hydration – water is the optimal hydrator. Depending on your lifestyle and maybe where you live, aim for 1-2L of water a day. 

• LISTEN TO THE SIGNAL – if your bowel is sending you an urge to empty, then try not avoid that signal, especially if you have issues with constipation. 
• Fiber and bulking agents are great to help soften your stool. A reminder is that hydration is going to be important. 

Triggers: 

• Medication
• Supplements
• Stress and anxiety 
• Hormonal fluctuations

IMPORTANTLY: 

If you are experiencing any change in your bowel movement, pain or blood in your stool, contact your doctor so that you get it checked out. 

By Mary-Lou Richards, leg. naprapat Advanced Clinical Practitioner in Pelvic Health

References:

Almeida, M.B.A., Barra, A.A., Saltiel, F., Silva-Filho, A.L., Fonseca, A.M.R.M. and Figueiredo, E.M. (2016) ‘Pelvic floor dysfunctions in female athletes’, Scandinavian Journal of Medicine & Science in Sports, 26, pp. 1109–1116. doi:10.1111/sms.12546.

Carvalho, C., da Silva Serrão, P.R.M., Beleza, A.C.S. and Driusso, P. (2020) ‘Pelvic floor dysfunctions in female cheerleaders: A cross-sectional study’, International Urogynecology Journal, 31(5), pp. 999–1006. doi:10.1007/s00192-019-04074-w.

Cleveland Clinic Available at: https://my.clevelandclinic.org/health/symptoms/17791-frequent-bowel-movements

Culleton-Quinn, E., Bø, K., Fleming, N. et al. (2022) ‘Elite female athletes’ experiences of symptoms of pelvic floor dysfunction: A systematic review’, International Urogynecology Journal, 33, pp. 2681–2711. doi:10.1007/s00192-022-05302-6.

Forner, L.B., Beckman, E.M. and Smith, M.D. (2021) ‘Do women runners report more pelvic floor symptoms than women in CrossFit®? A cross-sectional survey’, International Urogynecology Journal, 32(2), pp. 295–302. doi:10.1007/s00192-020-04531-x.

Skaug, K.L., Engh, M.E., Frawley, H. and Bø, K. (2020) ‘Prevalence of pelvic floor dysfunction, bother and risk factors and knowledge of the pelvic floor muscles in Norwegian male and female powerlifters and Olympic weightlifters’, Journal of Strength and Conditioning Research. doi:10.1519/JSC.0000000000003919.

Skaug, K.L., Engh, M.E., Frawley, H. and Bø, K. (2022) ‘Urinary and anal incontinence among female gymnasts and cheerleaders—bother and associated factors: A cross-sectional study’, International Urogynecology Journal, 33(4), pp. 955–964. doi:10.1007/s00192-021-04696-z.