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Incontinence and Bowel Management for Women, Men and Children.
Women’s Health Physiotherapist Brisbane, Australia.
Pelvic Floor Dysfunction Treatment.

Time Out

Sue timing out at Sunshine Beach

Time Out sounds like something I read in a book 25 odd years ago when a child, (who may not have been mine), tried to flush our cat down the toilet. It is supposed to be a circuit breaker, to stop the child from continuing down a path of destruction or bad behaviour such as screaming, punching their brother or …………………flushing a cat down the toilet.

But the Time Out that I am writing about is the type that refreshes the soul, clears the head and helps to press the re-set button. Getting away for a weekend or even a night has a remarkable effect on clearing out the cobwebs and if you somehow combine it with the ocean, then that really has a profound cleansing effect. So when thinking about what this week’s Nugget would be for our Pain Relaxation class (these Mondays come around remarkably quickly!), I decided to write about the value of scheduling some ‘time outs’ during the year, because we have snuck away to Sunshine for our own ‘time out’ escape this last weekend.

Work life balance is important when dealing with life’s stresses. If you don’t acknowledge the need for a break, for a change from routine and for different scenery, then you can feel overwhelmed with life’s round-a-about. When you relax, you give yourself permission to let go of worries for a while. Relaxing gives your mind and body time to recover from the stresses of everyday life.

Relaxation tips

Fit things into your day that help you unwind. For everyone it is different. Some ideas can include:

  • listening to music
  • going for a walk
  • coffee with friends
  • yoga
  • reading
  • watching TV

Find something that you enjoy and make a conscious effort to do that relaxing thing every day. In a busy work day, even 10 minutes of downtime can help you manage stress better. It can also help to have a place where you go to relax. This can be your bedroom, bathroom (maybe take a bath?), the garden, the verandah or a local coffee shop, a park or even the library– somewhere where you feel comfortable and secure.

Take a minute to breathe and regain control

We all take breathing for granted because it is something that happens without us being conscious of it. However, if you take a couple of minutes to concentrate on how you breathe, it helps to lower your heart rate and decreases any anxiety. When we are relaxed we take slower breaths which in turn helps us to feel calmer.

Breathing techniques

We have done lots on breath awareness, but revisiting our breathing techniques is the certain way to be able to ‘turn it on’ when it’s most needed. Just like we learn any new skill such as shooting goals, if you play netball or basketball, better breathing techniques can be learned.

Practise the tips, below, so that when life is hectic you can stop, take a moment and breathe. Breathing better will help your mind and body regain control of the situation.

  • Sit in a comfortable and supportive chair and place one hand on your chest and the other hand on your abdomen.
  • Breathe as you would normally but notice where your breath is coming from in your body.
  • Then concentrate on taking a belly breath and notice how your abdomen rises as you breathe in and falls as you breathe out.
  • Now bring your palms very lightly together and notice the warmth in your hands under your fingertips and palms. Take a moment to observe the intensity of that warmth.
  • Noticing is important, as it is a mindfulness activity which directly influences your heart rate and decreases your cortisol and adrenaline release. 

Bigger Time Outs

Bob at Sunshine National Park

These can include a morning hike through the nearest nature reserve (for us Brissie people Mt Cootha is close and a great short hike); a day trip to the nearest scenic outlook (Tamborine, Springbrook, Sunshine National Park) or stay a night or two and breathe in some sea air and just sit on the beach and listen to the peaceful rhythm of the ocean. Sometimes unexpected things happen on a Time Outs such as whale watching from the verandah of your accommodation.

Just breaking the routine and taking some time to chill reinvigorates and refreshes and most importantly gives you new memories to savour when you are at work.

My advice? Plan a time out soon!

This blog was written using the resource: http://www.yourmentalhealth.ie/mind-yourself/good-mental-health/feel-well/time-out/

Anger Management

There have been a number of incidents over the last couple of months that have led to me writing this blog on Anger Management. Anger is an emotion that comes up regularly in conversations I have with patients- they may be angry with their partners, their work colleagues, their health professionals – and it’s such a negative emotion which can sap an already depleted nervous system of any positivity. As a Women’s Health colleague pointed out- anger can also be a positive emotion when injustices occur and changes must be made to set things right. But why I am raising this issue and posting some anger management strategies is to assist those people where their anger is a negative in their life and they would like to address it with themselves or with someone in close proximity to them.

Social media is full of angry people. The apparent anonymity gives rise to a belligerence in replies that would probably never happen if people were conversing face to face. Facebook rants, Twitter tirades (most unbecoming of a US President methinks) and blog trolling are regular occurrences. Media ‘personalities’ – often white 50 something males – are very angry people and they can be responsible for some of the mob mentality that arises from talk-back radio, whipping up outrage and crushing moderate intelligent thought and conversation on topics.

One of the more public ones recently happened here in Australia, when the Qantas CEO Alan Joyce was giving a speech and a ‘gentleman’ walked up on stage and proceeded to smash a cream pie in his face.

Now to be honest Alan Joyce was never one of my favourite people because over the years he has made what seemed to be like some harsh decisions  about Qantas and staffing and maintenance of their planes which I felt I had an opinion on (based on what, I have no idea) but over recent times I have admired his public position on gay marriage and equal rights in this area, and he has been brave enough to vocalise it despite of his position as a CEO of a major company. Now this is apparently what riled the offender. He got so angry and indignant that he felt he had the right to go right up on stage while Joyce was presenting and push a cream pie in his face. I saw the news the next day and the offender was contrite and apologetic, but I did hear it wasn’t enough and Alan Joyce is going to press assault charges.

Every night on the news, there are also many instances of road rage – where someone upsets the other with a change of lanes or by driving at the speed limit (instead of over it) and next thing, a completely-over-the-top reaction – sometimes aggressively, violent response, with someone being hurt. Similarly horrific, there are regular instances of domestic violence, where wives and children most predominately suffer as a result of uncontrolled anger. So I decided to do some reading on anger management strategies and write a blog on it.

The information in this blog is taken directly from ‘Change Your Thinking’ by Sarah Edelman PhD (2006) without too much summarising because it is so good and it was important to not reduce the message on this increasingly necessary topic- this is a great book with topics including managing depression, overcoming frustration and anxiety strategies. I highly recommend it to you either if you are a patient or a clinician.

Anger is an emotion that we experience when we perceive that something is bad or unfair. In most situations anger is directed at other people or organizations, governments systems or even ourselves. Anger is often accompanied by the perception of threat where part of us feels unsafe.

Anger affects the way we behave. When we feel angry we may lose our patience or act on impulse. We may become aggressive and say things we later regret. Anger drains energy and interferes with our happiness and to have good relationships. Angry people may argue, attack, abuse, hit, blame or withdraw. This behaviour creates more problems than it solves. It can lead to physical violence, destruction of property or abuse of alcohol and drugs. Uncontrolled anger can lose your friends, break up your marriage, cause problems at work and cause you to become a social outcast.

An occasional burst of anger is not always a problem but it must be proportionate to the situation. However, long term, intense or frequent episodes can be a detriment to all aspects of our lives including the ability to feel good and to enjoy good relationships. Long term or frequent anger increases stress to organs of the body and increases blood pressure – thus increasing the risk of hypertension and heart disease.

Researchers have found that anger/ aggressive behaviour can be influenced by brain chemistry or defects within the brain. Negative childhood experiences may also affect the anger response.

Some people rarely express anger. This may be because they are well adjusted and have flexible expectations. On the other hand, lack of expression of anger may carry with it suppressed anger. This may manifest in passive-aggressive behaviour. They may be full of negative comments or subtly undermine others.

There is a belief that ‘letting out your anger’ is better than holding it in. If we are experiencing a brief episode of anger then physical activity – hitting a punching bag, gardening or going for a run – is a good way of release. Evidence shows that people often feel angrier after an explosive response – not less. More importantly, yelling is often hurtful to people we care about. We may feel guilty and remorseful afterwards.

STRATEGIES FOR MANAGING ANGER

Extingush the Fuse – Preventing an Angry Explosion

Although it may not always be possible to avoid getting angry, we can learn strategies to keep our anger in check and prevent it escalating: –

  • Learn the internal signals of anger arousal. You may become hot, flushed, your heart may start pounding, your hands may tremble or your jaw may clench. These are your clues to take control. Then use the ‘Stop – Breathe – Leave’ technique: –

Stop

Say the word ‘stop’ in your mind and visualise a stop sign or flashing rail crossing lights. This will short-circuit your automatic response and allow you to choose to respond differently. Go on to…

Breathe

Take in a few deep breaths to lower your anger arousal and distract yourself from the perceived injustice. Then…

Leave

Physically remove yourself from the situation. Leave the room or go for a walk. During the most testing period, this will keep you out of harm’s way or causing harm to others.

  • Once you have removed yourself from the situation, this will give you the opportunity to reflect. Ask yourself, ‘What is my goal here?’ Is it to get on with people? To have happy children? Avoid unnecessary stress? Enjoy the evening? Look after my health? Whatever the circumstance, focus on what really matters and recognize that getting angry stops you from achieving what really matters.

Reduce Your Physical Arousal

When we can reduce our level of anger arousal, our anger also receded. Here are some techniques: –

  • Exercise

Physical exercise allows us to use up reserves of energy that anger draws upon. Although our level of anger can rise during the actual exercise, it drops substantially afterwards and helps to relax. Vigorous exercise also releases endorphins which increase our sense of well-being. The exercise does not have to be pumping iron or punching a bag, equally effective is vigorous housework or digging the garden.

  • Diaphragmatic Breathing

I use belly breathing every day with my patients and myself for that matter. Belly breathing is calming and allows the brain to think more clearly and allows for easier processing of information. Place your hand over you tummy and as you breathe in feel your tummy rise up under your hand and then as you breathe out, your belly drops away.

Breathing gif to work with

  • Deep Relaxation

This is a physical state in which all our major muscles are extremely relaxed. As it is difficult to practice deep relaxation while we are angry, this technique is not suitable during an acute stage of anger. Use the methods above in the first instance. Practice deep relaxation as a maintenance tool which, when practised daily, reduces our potential towards becoming angry in the first place.

Dealing with Sustained Anger

Unlike explosive anger which is usually over in a few minutes, more sustained anger which does not fade quickly or after a night’s sleep, requires a long-term approach. Here are some strategies: –

  • Problem Solve

Whenever we perceive an injustice has occurred, it is sensible to think about actions we can take to redress it. Sometimes there is nothing we can do about it and we must accept the situation. At other times, we can resolve it through problem-solving. Even if we may not successful, it helps to know we tried our best and there is nothing more we can do about it.

When you find yourself feeling angry about a situation, ask yourself ‘What is the best action I can take to resolve this problem?’ You might be able to present a reasonable case to fight a traffic ticket. You might need to assert yourself to a builder who has left shoddy workmanship. You might discuss with your partner or housemate that you are unhappy that you are doing all the housework and ask they do their fair share. In many cases, taking some constructive action enables the problem to be solved.

  • Sometimes It Is Better to Let It Go

Sometimes we find ourselves in situations that are plainly unfair and there is nothing we can do to change them. Or we may recognize that our chances of achieving a fair solution is small and the cost of pursuing it is likely to be high. When we weight the chance of success against the cost of failure, it makes perfectly good sense to let it go. It may be best to practice acceptance. The acceptance affirmation below can be helpful in these situations: –

ACCEPTANCE

NOT HOW IT

Was

– Might have been

– Should have been.

NOT HOW

I wanted it to be

– Hoped it would be

– Planned it would be.

I ACCEPT THAT THIS IS HOW IT IS.

Now get on with my life in a positive way.

  • Give Yourself Some Stewing Time

At the outset of your anger resulting from a significant injustice, give yourself permission to stew for a while. Perhaps do some exercise, talk about it or even write a letter. As long as you don’t say or do things you’ll later regret, it is OK to experience the anger for that significant injustice for a few hours or days.

  • Talk About It (Ventilation)

The very process of talking about something that we feel angry or upset about can help us feel better. Sometimes all we need is to be heard and validated by a sympathetic, caring listener. Psychologists call this process ‘ventilation’. While talking to a third party can be helpful, sometimes speaking directly to the person we feel angry about is best by releasing accumulated anger and resentment and thus to feel better. It is not best to do this during an acute stage of anger when the risk of hostile confrontation is high.

  • Write a Letter

Sometime it is difficult to directly speak with the person who makes us angry either because the issue is too upsetting or we do not trust ourselves to remain calm. In this case, it might be better to express our thoughts on paper. This process gives us time to express ourselves coherently. While sending the letter helps the other person understand our position, sometimes just the process of writing helps us rationally evaluate the problem to the point where the letter might not need to be sent.

  • Thought Stopping

Thought stopping can be helpful in dealing with recurring ruminations that just won’t go away. Before you begin the process of stopping the unwanted thoughts, you need to prepare a pleasant fantasy that you will use to replace them. This pleasant fantasy might be memories of a good holiday, hugging a grandchild, a moment of past success, a beautiful place, a sexual fantasy, an inspiring person, an activity or hobby. To practise thought stopping, you need to catch yourself in the process of rumination and immediately shout out ‘Stop!’ either aloud or in your mind. Then turn your mind to that pleasant fantasy and focus on it for 30 to 60 seconds. If the unwanted thoughts return repeat as necessary. To be effective, thought stopping needs to be practised consistently for as long as the ruminations continue. At first this will happen many times per day but with practice, the unwanted thoughts will reduce and eventually disappear.

Choose to Let Go of Your Anger

Anger comes from the perception that important rules are being violated. When we feel angry, we tend to blame other people or external events. The truth is other people do not actually make us angry, they merely provide the stimulus. We make ourselves angry through our belief that things should not be this way.

Like all emotions, anger is generated by cognitions. Other people’s actions can anger us but whether or not we get mad depends on how we perceive what is happening in our world. Events that enrage some people, do not phase others.

Anger is different to most other unpleasant emotions in one important way – we instinctively want to hold onto it. If we have sustained anger, we need to ask, ‘do I want to hold on to this anger?’ Choosing to let go of anger may feel like we are letting a culprit off too lightly. Our sense of indignation can be a major obstacle to moving on. We have to ask ourselves – ‘who is suffering?’ Sustained anger can be painful and self-defeating. Anger does not hurt the other person – it hurts us. Even if we are able to make the other person uncomfortable by snubbing or bitching about them, chances are we are still suffering. Anger might be likened to drinking poison and hoping the other person will die. Why would we do it to ourselves?

  • The Cost / Benefit Analysis

Wanting to stay angry is one of the biggest obstacles to letting go of it. If we are not convinced we want to let go of the anger, do a cost / benefit analysis of maintaining the rage. Put pen to paper and under the headings of ‘Costs’ and ‘Benefits’ write down your thoughts. A benefit might be, ‘It feels right’ or ‘It gives me something to talk about with friends’.

Costs might be ‘It distracts me from thinking about more important things’, ‘I get churned up in the stomach’, ‘It stops me from getting a good night’s sleep’, ‘It makes me hard to live with’, ‘It is such a waste of time and energy’. After weighing up the costs and the benefits, this process might help us commit to whatever is necessary to let go of the anger.

  • Goal Directed Thinking

Anger can be self-defeating because it prevents us from getting the things we really want. These might include maintain a good relationship with our partner, being respected by our colleagues enjoying a night out or simply feeling happy and relaxed. It is not in our interests to feel this way.

  • Remember the vital question, ‘Does thinking this way help me to feel good or to achieve my goals?’

Identify and Challenge Anger Producing Cognitions

Anger is rooted in negative thinking. It is fuelled by being preoccupied with what has gone wrong or with assumptions about the bad intentions of others. One way to combat this negative syndrome is to maintain a constructive outlook about yourself and others.

Once we are motivated to work on letting go of our anger, we are ready to take the next step – to identify and challenge the patterns of thinking that makes us feel that way: –

  • The Shoulds

Of all the thinking patterns that contribute to human unhappiness, it is the ‘shoulds’ that are the most pervasive and unhelpful. ‘Shoulds’ play a major role in feelings of anger, resentment and bitterness. They reflect our expectations of how people ought to behave. Beliefs like ‘My husband should be able to communicate better’‘My friends should be more supportive’; ‘The trains should run on time’; ‘Pet owners should not allow their pets to make a mess of my garden’; The neighbours should keep their music down’ can cause us to feel angry if we hold them as absolute truths rather than preferences. This is because the world does not conform to our rules. Rigid expectations make us anger prone.

This is not to say that we should have no expectations of others or that we should accept unreasonable behaviour without challenging it. At times it is important to take an stand and do what we can to right the wrong.

However, it is important to be flexible and accept that in the real world, people will not always think the way we think.

  • The ‘Just World Fallacy’

A common expectation of an anger prone person is that of justice and fair play. The problem is that this expectation does not match what happens in the real world. Injustices exist in every society, every family and every work place. Perhaps we should be taught from kindy that many things in life are simply not fair and often there is nothing we can do about it.

Again, if there is something we can do to resolve an injustice, it is important to try. However sometimes there is nothing we can do about it. We can get angry or we can accept that we live in an imperfect world and focus on the things that are within our control.

  • Black and White Thinking

Anger often arises from black and white thinking. This is the tendency to see situations as either good or bad, right or wrong. It is the inability to see shades of grey that makes us prone to anger.

  • Injustice May Be Subjective

It is important to appreciate that although we may be strongly attached to our point of view, it is quite possible that it is not completely correct or definitive. Justice is often subjective. What is perceived as fair by one person, is not necessarily fair to another.

  • Blaming

Blaming goes hand in hand with anger and resentment. Some people spend all their lives blaming others for their own unhappiness. It fuels our anger and makes it hard to let it go. The blaming habit is strongly tied to our ‘shoulds’ – underlying assumption is that people who break our rules are bad.

As we can rarely punish others or control their behaviour so labelling them as idiots or creeps and demanding they should not be the way they are is a waste of our energy and it only makes us bitter.

We may still take action to resolve a perceived injustice but importantly we need to remember that we live in an imperfect world full of imperfect human beings.

When we can truly accept this we make life easier for ourselves.

  • Personalizing

Whenever someone acts unfairly, rudely or aggressively towards us, we might take offence because we perceive their behaviour as a personal attack. At times people will act in ways we do not like. But we don’t have to take it personally. It is not always about us. Consider, ‘Could this have happened to anyone in this situation?

  • Empathy

‘Forgiveness is not an occasional act. It is a permanent attitude.’ M. L. King Jr.

It is easy to feel anger towards people who say or do things we do not like. It is harder to understand them – their thoughts, their motives, their insecurities and their pain. Our anger often disappears when we can see the situation from the other person’s viewpoint.

Anger can turn to compassion. We can develop empathy towards almost any person when we can see their vulnerabilities and how things are for them. We are all trying to live on this planet using the resources we have developed over our lives. Resources are our: – cognitions, problem solving skills, social support, innate sense of security, self-worth and our ability to communicate and get on with other people. These resources are determined by two factors: – our life experiences; and our biology which includes reactivity to stress, intelligence, energy levels, physical strength, memory and our body’s chemicals that determine our psychological predispositions.

Some people are dealt a great hand both biologically and in their life experiences. As a result, they are well equipped to deal with life’s challenges. Others have been dealt a very meagre hand. For them life is a struggle. Their behaviours that appear to be unreasonable, selfish, stupid, neurotic often reflect the person’s limited resources with which to respond to life’s challenges. Understanding how it is for other people and why they behave the way they do does not mean we must like their behaviour. We may loathe it. However, it releases us from blaming and labelling them and enables us to stop taking it personally.

‘The reason to forgive is for your own sake. For our own health. Because beyond that point needed for healing, if we hold on to our anger, we stop growing and our souls begin to shrivel.’ M. S. Peck 

  • Behavioural Disputing

Behavioural disputing can be one of the most powerful techniques for letting go of anger or resentment towards someone.

The process is to go against our feelings and to treat perceived adversary in a friendly and reasonable manner – as we would treat a friend – through direct pleasant communication, friendly email or even a card. Changing our behaviour towards this person changes the dynamics between us and thus the way we feel. In most cases, they will respond in kind. We will feel more comfortable in their presence and they in ours. Most people respond positively to a peace offering but if this does not happen, we have lost nothing and we can enjoy the moral high ground, knowing we have behaved in a decent way.

  • Coping Statements

Coping statements are useful as reminders of our processes to quell anger when it resurfaces. Some examples are:-

  • Everyone behaves according to their own values and rules
  • People don’t have to do what I think is right
  • The world is not fair
  • If it’s beyond my control, let it go
  • Stay goal-focused-remember the big picture
  • Keep your cool and you’re in control
  • He/she is not perfect, and neither am I
  • People are just people. They are neither good nor bad.
  • Justice is in the eye of the beholder.

 

  • Communication

Good communication skills are our most valuable tool for solving problems, redressing injustices and getting on with people. Communicating with others when we feel angry can help us in two ways. Firstly, when we tell someone that they have done (or are currently doing) something that is a problem to us they may choose to change their behaviour. Secondly, the very process of communicating can sometimes make us feel better. Telling someone that we feel angry or upset over something that has happened can allow us to release a lot of anger. This is particularly the case if we speak directly to the person we feel angry with. If we can communicate in a calm, non-threatening manner, people sometimes validate what we say. This means that they express understanding for how we feel or acknowledge that we have the right to feel the way we do. Occasionally, they may even acknowledge that they did the wrong thing or apologize for their behaviour. Granted, this does not always happen, but in situations where it does, it is like salve to our wound. We can forgive and recover from almost any transgression when people are willing to acknowledge they were wrong or say that they are sorry.

Although it is usually appropriate to speak to the person who is directly involved, sometimes we may need to approach a third party who has the power to intervene. This is particularly the case when our initial approach gets us nowhere. So for instance, you might end up speaking to the school principal about the unsatisfactory behaviour of one of your child’s teachers or to the bank manager about the lack of service at your branch or to the foreman about the poor attitude of some of your fellow tradesmen.

Sometimes we may need to communicate in writing. This is usually necessary when we wish to make a formal complaint. We might also communicate in writing if there needs to be a record of our complaint or when we find face-to-face communication too difficult. Taking time to compose our thoughts on paper often results in clearer and more constructive messages. Whatever the circumstances, our case is strengthened with calm, rational communication, whether spoken or written. We are far more likely to get a favourable response when we are perceived as reasonable and conciliatory, as opposed to hostile, accusing or unreasonable.

Of course, even excellent communication skills do not guarantee that we will always get our needs met. Unfortunately, no system of communication in the world can ensure that other people will always do what we want; but constructive communication increases the likelihood of resolving problems and it helps us to keep people on side, enjoying healthy relationships that are based on mutual respect. Given that communication is such an invaluable resource, it is surprising how often we shy away from using it (‘It won’t work … what’s the use?’). Often it is because we feel uncomfortable bringing up an issue that involves a perceived injustice. The situation is already upsetting to us, and the possibility of an unpleasant confrontation may be extremely anxiety-provoking. It might seem easier to rationalize that talking about it will not work anyway. However, it’s important to keep in mind that communication does not necessarily result in conflict. Good communication involves sound judgement, negotiation and diplomacy, and very often leads to a reduction in tension and improved relationships.

IN SUMMARY

  • Anger is created by the perception that something is unfair, and is usually accompanied by feelings of threat or vulnerability. While it can sometimes motivate us to behave assertively or to solve a problem, anger has many negative consequences.
  • Acute, explosive anger is potentially harmful because it generates destructive behaviours and alienates other less intense but more sustained anger is also self-defeating because it drains our energy, impairs our relationships, makes us unhappy and can adversely affect our health. Different strategies are appropriate for dealing with the different types of anger.
  • Unlike other upsetting emotions, people often want to remain angry because they believe it is justified. However, anger hurts us more than the other. An important first step in releasing anger is to recognise the cost of holding onto it, and to make a decision to let it go.
  • Several cognitive strategies can help to release anger, including a cost/benefit analysis, goal-directed thinking, thought monitoring and disputing, empathy and coping statements. Accepting that injustice is unavoidable at times, and that ‘justice’ is sometimes subjective, can also help to release anger.
  • Behavioural strategies that are useful in the management of anger include problem solving and arousal reduction techniques, such as physical exercise and deep………… In addition, behavioural disputing choosing to behave in a friendly manner towards someone we resent-can be a powerful strategy for releasing anger. Utilizing effective communication can also resolve anger by lowering interpersonal tension.

A fantastic summary of anger management. Every chapter in Sarah Edelman’s book is thorough and most importantly manageable and practical for patients to implement.

World Continence Week: Incontinence is no Laughing Matter

It’s that time of the year again when the world celebrates World Continence Awareness Week. ‘Celebrates’ may sound like an unusual word to use when talking about issues such as urinary and faecal  incontinence, but it is important to confidently and loudly give a shout out about the conservative strategies to treat or manage the scourge of incontinence.

Incontinence makes people lose their confidence; it makes them anxious; it causes embarrassment; it makes you feel alone.

Well how lonely can you be when the figures are so staggering? One in three women leak urine; one in five have some faecal incontinence. That means if you have fifteen friends, five of them could leak urine and three of them might have faecal incontinence. In 2010, when the De Loitte Access Economics Report ‘The economic impact of incontinence in Australia’  (1) (which explores the current prevalence and economic impact of incontinence in Australia, and provides an outline of the future projected growth of this burden) was completed, it showed that 4.8 million Australians were currently living with incontinence and this prevalence of urinary, faecal and mixed incontinence is estimated to increase to over 6.4 million Australians by 2030.

You are not alone – it’s just that we as a community still have issues disclosing it. 

65% of women and 30% of men sitting in a GP waiting room report some type of urinary incontinence, yet only 31% of these people report having sought help from a health professional (2)

Why is that? Why as a community do we not encourage people to intervene early and seek conservative help from a Pelvic Health Physiotherapist to fix this problem?

Why don’t GPs say :’Hi Mrs So-and-So, did you know it’s World Continence Awareness Week? Do you have any issues you’d like to raise with me? I reckon Mrs So-and-So would be relieved that the ice had been broken and she could spill her guts about the fact she has stopped exercising because she floods; that she’s spending as much on pads as her daughter is spending on nappies for her grandchild; that she is constantly stressing about potential odour and that she has stopped going on outings with Probus because she’s worried if there will be enough toilet stops.

These are significant quality of life issues that can even turn women into agoraphobes. They make women change their career paths. They make women depressed.

We know education is a cornerstone of treating urinary incontinence and someone who does in fact succeed in making incontinence a laughing matter is Elaine Miller, a Women’s Health Physio and comedienne from Edinburgh, Scotland.

Elaine Miller doing her stuff

Elaine uses jokes and a comedy routine to impart facts and figures about incontinence. She has been a regular participant at The Edinburgh Fringe, at conferences and on talk shows. People listen when satire and humour is used to pass on information. I find it especially works well with memes – I could write a whole paragraph on something, but the words on a picture (which is all a meme is) are far more effective at driving home a point than a whole lots of words.

Humour also breaks down barriers. It makes things not seem so catastrophic. It shows us that we are all vulnerable – from the woman who works on the factory floor, to the CEO of a major company. Elaine is doing an amazing job at all these things because she is not only very funny, but her routine is evidence-based – which is what we should all demand from our health care professionals. If she could travel the country…even the world, spinning her yarns, women everywhere would come out of the woodwork and charge into their nearest (evidence-based) health practitioner and start making the quite simple changes that would significantly help and even cure their urinary incontinence.

Over the course of World Continence Awareness Week I will be posting advice and hints that will change your life. Make sure you keep following. What you do now you know, makes old age much more tolerable.

(1)  https://www.continence.org.au/pages/deloitte-report.html The Economic Impact of Incontinence in Australia, 2010                                                 (2) (Byles & Chiarelli, 2003: Help seeking for urinary incontinence: a survey of those attending GP waiting rooms, Australian and New Zealand Continence Journal).

The Robust Vagina

 

My Venetian glass perfume decanter

It is 33 years since I carried this little gem from Venice, Italy and through six more countries for another six weeks and then 16,531 kms back from London to Brisbane. This is a fragile, Venetian glass vase (well, perfume decanter) – of that there is no doubt. I bought it because it was/is beautiful and because on my first trip overseas, shopping was way too high a priority. As I have got older, I have realised what matters when you travel is the experience, the memories of the amazing food and to relish every image you create (on your iPhone) and imprint it on your brain so you can draw on it in moments of happiness, sadness, creativity, boredom or planning for the next trip.

I can still remember the anxiety each night, as I opened my suitcase to check that it had survived the rigours of the day. And I can intensely remember the triumph of getting it into our house in one piece – it was/is after all, a fragile Venetian glass vase (perfume decanter). Of that there is no doubt.

Sometimes women suffer pain in their vagina. It can hurt when they first try a tampon; it can be excruciating when they first have sex and there is nothing more devastating than when that pain only intensifies as the days, months and sadly, years go on. The pain can come on when there has been no pain before; for different reasons such as following a thrush infection, following gynae repair surgery, due to endometriosis or for no apparent reason.

For these women the vagina feels fragile – fragile like a Venetian glass vase.

Education is the cornerstone of persistent pain treatment. Pain science, which really we can no longer say is new, is well-researched and has the evidence base to ensure that it should be the first port of call when dealing with chronic pain. As mentioned in a previous blog, Melzack and Wall started this conversation on 1965. It is now 2017 – 52 years since that seminal paper. Since 2003, Butler and Moseley have Explain(ed) Pain brilliantly – so well, they have helped transform the lives of millions of people in pain around the world through their followers – physios, psychologists, OT’s, doctors and many other health professionals – who have joined their tribe of converts to the EP model of treatment for persistent pain and been able to change patients’ lives through education.

It can be a hard concept to accept. Every day, women say it’s hard to get their heads around, but adapting the EP model to pelvic pain does work (as well as treating any peripheral issues that will contribute to their pain).

An important part of my education of women with painful vaginas, is to explain that the vagina is not like a Venetian glass vase – it is, in fact very robust. 

The vagina, when aroused, can tolerate vigorous sex for a long time; and the vagina can deliver babies.

The vagina is very robust.

Many women relate to this image of fragility, when I ask them. When you have pain in your vagina, as each day moves forward, you have sought lots of treatment and nothing has improved – it just tends to get worse – this reinforces the belief and adds to the perception in your mind that the vagina is fragile.  As fragile as a Venetian glass vase.

But they especially like the new way to frame their thoughts on their vagina.

If we as health professionals can use language to transfer different meanings, different perceptions to the patient, then we are starting a different conversation about the vagina for that patient.

The vagina can be very robust – that is the new thought for the patient’s brain. 

When speaking of images and travel – look out for this new image below that will live imprinted in my brain after my next trip to Venice in September, on my way to the International Continence Society Conference in Florence from September 12-15th. The early-bird prices for this conference closes in two weeks, so make sure you check out the link and register asap. I am an ambassador for ICS and if you do decide to go based on this informative blog :-), don’t forget to mention my name when you are asked how you heard about the conference. (Thank you in advance!)

But the next photo you will see of this amazing sculpture called Support, by Lorenzo Quinn, depicting the effects of global warming on Venice in future years, will have me somewhere in the background.

Support by Lorenzo Quinn, Art Biennale, Venice 2017

(Climate change is real Mr President)

 

 

 

Embracing Change

As you know, I write a small nugget of information each week for our pain relaxation class at 6.15pm on a Monday night. This will be the 30th nugget, which is pretty amazing – where have those 30 weeks gone? I had another topic in mind for this week, but a blog by another physio – Sports Physio Adam Meakins– stimulated me to go back to my own Change blog (which I wrote in 2012 and has become a part of the final chapters in my books) and re-visit it and make some changes and use it for this week’s nugget at the pain class.

Embracing change (of your thinking, behaviour and your beliefs) is important, because if you won’t embrace change, then you probably won’t move forward with your chronic pain management. A comment on Adam’s thought-provoking blog by Pete Moore, who is himself a pain advocate who has created the Paintool Kit, also validated what Adam said. Why this is so crucial, is that Pete himself is a chronic pain sufferer, and he was giving the stamp of approval to the point that Adam was making in his blog was that “he  (Adam) will not waste his time and energy on any patient who thinks he should be more interested and invested in their progress and outcome than they are..”. Adam was directing his comments to his physio profession and other health professionals who risk (empathy) burn-out – listening to everyone’s pain stories can be exhausting and debilitating – and he was advocating for us to keep doing what we preach- exercising, taking a good break, socializing with friends and generally being mindful of self-care. I have to say that after 40 years of being a physio, I can relate to that and I am careful to keep leaving the desk looking untidy and heading to the gym and dance class as often as I can every day.

As usual, when I write these nuggets, then sometimes I decide it may be useful to post as a blog and so here it is.

‘Change is as inexorable as time, yet nothing meets with more resistance.’ Benjamin Disraeli

Change in our lives is an important concept to embrace. Whilst physios need to be skilled at encouraging, enabling and facilitating change in their patients, you as the patient / client need to understand that the biggest barrier to enacting better health outcomes, can often relate to inflexible thoughts about wanting to change how you do things, how you’ve always done things and what your belief is about what the right thing to do is.

Without an ability to embrace change in behaviour, beliefs and what are almost rituals – not much is going to improve with your condition, whether it be persistent pain, anxiety management and for that matter, things like sexual dysfunction and bladder / bowel issues (such as frequency, urgency, incontinence, constipation).

Rather than wishing for change, you first must be prepared to change.’ Catherine Pulsifer

Some of our thoughts, beliefs and behaviours are almost etched in stone, sometimes because our mothers have taught us these and handed them down from one generation to another; our church and religion has espoused some things; our girlfriends have told us; or because of what we read on social media or Dr Google. This makes them hard to let them go.

I think an important part of the change process is to:

  • Recognise there’s a problem
  • Acknowledge there’s a problem
  • Respect the process and seek help (with a health professional who will empower you with self-management skills)

‘Everyone can think of the one thing that would make life better for them. But people are not so quick to answer the second question: ‘What are you doing to make that change come true.’ Catherine Pulsifer

Life is busy and there seems no time for airy-fairy things like breathing training (tummy breaths, awareness of where your breathing is occurring, mindfully slowing it down, being aware of the rise and fall of your chest wall); like learning about mindfulness; like just switching off and listening to a playlist of calming music like a yoga playlist, or your other favourite artist and going for a walk in the fresh air. It may feel like it’s a waste of time or pointless, but these simple strategies can be life-changing for those with chronic pain and anxiety.

‘Never stop learning, like never stop changing and growing in your life – learning helps you adapt to change more easily.’

Pain science has itself changed – Ronald Melzack and Patrick Wall back in 1965 refuted the claim that there are specific pain pathways – how amazing that this work was way back then and yet this pain science is still being called new…..This has been elegantly explained in 2003 and updated in 2013 by Lorimer Moseley and Dave Butler in their book Explain Pain and expanded on in 2017 in their latest book Explain Pain Supercharged

Explain Pain Supercharged

Even 80 year olds can implement change – if you have the mindset that you can still learn new things and improve your situation. If you are fixed in your mindset and attitude then it will be hard to be inspired. Often what you will be taught is very simple – not rocket science.

‘You cannot change your destination overnight, but you can change your direction overnight.’ Jim Rohn

Sometimes the hardest thing to do is to open your mind. Your physiotherapist will open dialogue with some questions and listen (assess), empathise, educate, empower, nurture, cajole, encourage, console, praise – to help you on this journey, in a new direction, to a new destination, but if your mindset is fixed then it is almost impossible to change.

‘If you resist change, you will face challenges on a daily basis. If you consciously refocus your attitude to see the benefits of change, your outlook becomes positive and life becomes easier.’ Catherine Pulsifer

Meme sourced from (1) 

And most importantly:

‘No action, no change. Limited action, limited change. Lots of action – Change occurs.’ Catherine Pulsifer

This is the crux of all this change talk. What you put in will be reflected in your result, even if the pain is not entirely gone. Hopefully you have learnt new strategies to decrease the intensity/ severity of the pain; you have learnt to decrease the impact of the stress hormones of cortisol and adrenaline which up-regulate the intensity and increase the fear and catastrophizing that can accompany pain and anxiety conditions. Most importantly you have learnt the concept of self-management and empowerment – and decreased the reliance on some-one external to yourself. This will be liberating.

And now to finish, just because amongst all those change quotes I really like this as a good piece of life advice for all of us – to help us deal with the complexities of modern work and life:

‘To focus on the people who do not like you and the things you cannot change is like climbing an infinite mountain; instead focus on the people who love you and the things you can change and you will find you can move mountains’ 
Michelle Ghislaine Ambler.

Meme sourced from (2) 

(1) Meme sourced from https://www.google.com.au/search?q=change+meme+image&rlz=1C1CHBF_en-GBAU702AU702&source=lnms&tbm=isch&sa=X&ved=0ahUKEwji1dSQjoDUAhWCe7wKHf5hAGoQ_AUICigB&biw=1707&bih=723&dpr=1.13#imgrc=bEljCL1Y0TpiIM:

(2) Meme sourced from https://www.google.com.au/search?q=change+meme+image&rlz=1C1CHBF_en-GBAU702AU702&source=lnms&tbm=isch&sa=X&ved=0ahUKEwji1dSQjoDUAhWCe7wKHf5hAGoQ_AUICigB&biw=1707&bih=723&dpr=1.13#imgrc=hug4AHSXDMbHuM:

Update on local oestrogen use

I received a newsletter from HealthEd with an overview on Vaginal Atrophy and Sexual Function. If you have been prescribed local oestrogen please take note of the Take Home Messages below. I will attempt to get permission to post the whole document as it is very interesting with video inks from a variety of experts in the Menopause. For Women’s Health Physiotherapists who follow my blog, it is important to note the advice regarding application of local oestrogen.
For my patients, as you are aware, I have been encouraging you recently to dispense a small amount of Ovestin cream on your finger -halve one of the doses every second night as this means you lose less and you can avoid using the applicator (which is impossible to clean) and use a finger to apply. Squeeze the cream on your finger, insert low in the vagina – away from the cervix and be sure its on anterior wall and less deep– the half dose also means you don’t lose as much and this will be easier for any arthritic-fingered patients who were worried they couldn’t reach deep enough.
 
Vaginal Atrophy and Sexual Function
DR JOHN EDEN MB BS MD FRCOG FRANZCOG CREI
Dr John Eden is a certificated reproductive endocrinologist and gynaecologist. He is a Conjoint Associate
Professor at The University of New South Wales in Sydney. He is a visiting medical officer at the Royal
Hospital for Women, Sydney, Australia where he is Director of the Sydney Menopause Centre and the
Barbara Gross Research Unit
 
Take Home Messages
  • There is considerable data to support the use of topical oestrogens in urogenital atrophy.
  • Topical oestrogens should not be deposited deep in the vagina, but rather in the anterior portion, in order tominimise uterine exposure and to maximise the effect on the vulva, urethra and clitoral areas.
  • Oestrogen creams may be best used by abandoning the applicator all together and placed on a finger instead. This is then inserted inside the anterior vagina; some cream should also be smeared onto the vulval skin.
  • Patients who have had breast cancer should use nonhormonal moisturisers first and topical oestrogen as a last-resort.
  • Vulval dryness may respond to soap-free washes, using plain moisturisers on the vulva and intravaginal moisturiser products. Natural oils (such as coconut oil or olive oil) can be effective lubricants.
I will attempt to keep updating this.

Running blog

This is a real run as evidenced by the un-editable photo, but Jane liked the Story Bridge in the background, so in it goes.

 

 

 

 

 

In previous blogs I have been telling you about the new Running Clinic we have established at Sue Croft Physiotherapy and it has been going so well that I asked Jane Cannan (who along with Amanda Lee conducts the Running Clinics) to write an updated blog on the clinic. I love Jane’s passion which is clearly evident in her wonderful article. The other important thing is not only has Jane undertaken an Athletics Coaching Course Level One, she is a keen (obsessed) runner. Her Mother’s Day present to herself is running with three other friends 32 kms – just for fun…..as you do?!? Here is Jane’s blog. Enjoy!

The transition to motherhood made me a runner and I know I’m not alone. Something about the simplicity of putting one foot in front of the other while alone with my thoughts, that has served to calm my mind from the scrambling, juggling act of raising children. So when I come across a woman who is giving up running because they experience bladder or bowel leaks, my heart breaks and if this comes up in a physio consultation, I launch into problem- solving mode. Because, in many cases, it doesn’t have to be this way and there are a number of different reasons why it could be happening. In this blog I will explore the factors that contribute to bladder and bowel leaks and prolapse during running.

Regardless of the reason for leaks, my Number One message is to stop trying to maintain a pelvic floor hold while you are running. If leaks are due to a lack of strength or endurance, then trying to maintain a squeeze in these muscles will only lead to a sooner point of failure. Stand up now and gently contract your glutes (many of you will at some stage been told or considered whether your glutes are too weak), now maintain that gentle squeeze while you jog on the spot. It doesn’t feel very good does it?

For starters, you end up squeezing your butt harder than before, so you can still feel it, you end up changing what the rest of your leg muscles are doing, and if you kept that up for anything longer than a few seconds, you would probably get mighty sore in your butt cheeks! If you’ve ever tried that strategy to stop a bladder leak or a feeling of pelvic heaviness, I would hazard a guess that it didn’t work anyway. So please stop, it doesn’t make bio-mechanical sense, it doesn’t work and in actual fact, it can only make things worse.

If this is you and you want to break the habit, start by slowing down, trying a shorter run interval and focus on breathing. Draw the air deep into the lower parts of your lungs at the bottom of your rib cage. If you are over holding your tummy muscles, you need to let them go to let your ribs widen to bring the air in. Panic and rising fear have a nasty way of ruining a good run. You fatigue quicker, start feeling niggles, niggles become more intense and you start to wonder if you should listen to your “helpful” aunt who tells you that running is going to ruin your knees/back/feet/life.

Breathing not only helps the endurance of your pelvic floor, it is your tool to help curb the rising panic and fear. If you panic that you are going to leak (or get any unwanted symptom for that matter) and you stifle your breath, you will more than likely:

  • Tighten your pelvic floor
  • Tell your brain that you are under threat and need some protecting, so it will likely be that you further tighten your tummy and pelvic floor 
  • Your performance will feel worse than usual because you tried to do some cardiovascular exercise without breathing!

Many women after delivering a baby vaginally, will feel that their pelvic floor muscles aren’t what they were before and they are right…can we take a moment to give ourselves a pat on the back for listening to our bodies and hearing that something has changed!  The most significant change once the tissues have all healed is that pelvic floor timing is forever altered. Where before, the pelvic floor muscles would automatically engage before an activity of effort (cough, sneeze, bend over, lift something, jump, run etc), now the activity occurs before the brain and the pelvic floor has time to prepare for it. To improve this timing, we deliberately practice pre-contracting the PF muscles at the right time and during the right activities.

If you’re trying to improve your overarm throwing, you don’t just keep going through the action without releasing the ball, because without practising that fine timing, you could not expect to get better at hitting a target. In this case your arm will have enough strength and endurance to perform the action, but your lack of practice in timing the ball release will inevitably make your ability to coordinate a throw unsuccessful.

Every time I blow my nose or do glute strength activities, I make the timing count. Start with complete tummy and pelvic floor rest; prepare for the event (eg,nose blow, single leg bridge etc) by engaging your pelvic floor and lower abdominals; maintain that feeling throughout the event, task or movement (keep breathing if it’s a bridge or other exercise); then let it completely rest (relax) once the activity is over. In running, the moment when your foot strikes the ground, your glutes should act to absorb the impact and during this glute activation your pelvic floor should engage to support the downward jolt of your pelvic organs. But like all good technique, it requires deliberate and successful practice to make automatic (good motor training). So, if you’ve had a vaginal delivery and you want to run dry, please practice good pelvic floor timing in a variety of day-to-day activities, as well as in your gym sessions.

As much as I love running, it is not for everyone. There are certain pelvic circumstances for which running poses a great risk of pelvic organ prolapse. This is why at Sue Croft Physiotherapy we take care in our assessment so we can help you to know your level of risk.

  • Hiatus size – the gap in the muscles through which your urethra, vagina and rectum pass through. The bigger the size, the higher the risk of the bladder, uterus or bowel prolapsing through that gap.
  • Childbirth history – size of baby, progress through labour and amount of assistance (such as instrument deliveries especially forceps) may impact the degree of muscle damage.
  • Cervix descent on strain – this is a measure that we can re-assess over time to see if your chosen physical activity is causing structural problems.
  • Prolapse – a measure of the degree of pelvic organ descent, which we can monitor over time and assess for suitability for supportive devices such as pessaries which can be great at giving support and protecting existing prolapse.

The last piece of the jigsaw puzzle is a look at bladder function and habits. Certain circumstances can increase the risk of urinary leaks mid or post run. Going back to what I talked about in terms of pelvic floor endurance earlier, habits that lead to extra muscle requirements can pose an issue. Consider if you spent a significant portion of your day keeping your heels off the ground, then it would come as no surprise when during a run later that evening your feet and calf muscles don’t cope very well.  

A similar thing happens in people who over-hold their bladders. The normal bladder capacity is between 350-500mls. Some women have a habit of deferring bladder urge for far longer than they should, leaving their bladder to overstretch and get heavier and heavier. For starters, the pelvic floor has to now work under a higher load for a prolonged period of time which will impact endurance. In addition to this, the muscle of the bladder doesn’t respond well to overstretch and you can lose the awareness of fullness and incomplete emptying (notorious in teachers, nurses and hairdressers).

Another bladder factor that can increase the chance of urinary leakage is having an overactive bladder. This is one that makes deferring urges more difficult and the intensity of urgency harder to control. In contrast to the first bladder issue, this is characterised by an inability to reach a full bladder and more frequent trips to the toilet. Bladder training and using urge control techniques are the way to bladder control and your women’s health physio can guide you through this process.

So there you have it folks, the puzzle that runs through my head when I meet a woman wanting to run without prolapse risk or leaks…I love puzzles almost as much as I love running.

Jane completing her first marathon

Thanks Jane – a great blog. If you are reading this blog and want to see if you too, can start running or get back to running – or maybe you are running and you’re unsure if there are some issues that need addressing, give the secretaries a ring at the rooms and they can book you an appointment or you can book in online here. Remember the clinic is also open to male runners to be assessed by Jane or Amanda.

Don’t get us started on the brain advantages of running!

You can see what it did for Jane completing her very first marathon!

Amanda Lee also conducts the Running Clinics

Stiff, but not stiff stiff…

This is for all my relatives -and their friends and relatives – (and patients) to read who have bouts of stiffness. It really nicely explains various degrees of stiffness. Adam Is a Sports Physio who likes to debunk useless treatments. Enjoy.

Source: Stiff, but not stiff stiff…

Should it be classified as over-servicing if every woman who has a baby sees a Women’s Health physio?

I recently was interviewed on two occasions on two different days by two different journalists.

I was doing my spiel to them – giving statistics about urinary incontinence; giving the heads up on the prevalence of prolapse; and how many people with pelvic floor dysfunction are sitting in a doctor’s surgery and don’t disclose their problems ……with their GP. It was all riveting stuff – the journalists were engaged, shocked at the numbers I gave them and saying ‘Woh there’s so much of a story here!’

But then both of them said something that almost stopped me in my tracks.

Each of them, when I said I thought that every woman who has a baby, should see a Women’s Health physiotherapist……deserves to see a Women’s Health physiotherapist, said ‘Oh we don’t want an over-servicing situation’.

Now I had to keep talking, spruiking our worth, not lose a beat- but I was simmering away with this conversation going on in my head: What did she just say?’ And then, it happened again…….‘You’ve got to be kidding- she just said the same thing that journalist said last week?????’

Over-servicing! Women seeing a physio after pushing a baby out is classified as over-servicing? Have I been seeing so many women in this predicament, that I have a biased, distorted view of how important a post-birth consultation with a Women’s Health physio is? That in fact, women should just get on with looking after their baby and no need for individualised post-baby care for their bladder, bowel, vagina and pelvic floor.

Here is my argument stating the case for more routine individualised assessment and treatment for every woman after she has had a baby ……. regardless of the mode of delivery.

What follows is a wonderful image from Professor John de Lancey’s bio-engineering unit in America. It was created by the engineers based on the dimensions of a baby’s head, the size of the female pelvic outlet and the distensibility of the pelvic floor muscles. If you want to read the full article, here is the link. 

 

 

The biomechanical engineers conclusion? A vaginal delivery doesn’t seem to work!

There are many women who will attest to this. They will be the ones sitting awkwardly on a rubber donut cushion (don’t do this by the way) and an ice-pack at the same time. They will be the ones who are at play group with the women who have had the Caesar, who are sitting laughing at the jokes, while the vaginal delivery mothers still can’t sit without pain. They will be the ones who have just been told by their Women’s Health physio that they have had a significant birth injury and that is why they can’t feel their pelvic floor muscles working anymore.

These women might be faecally incontinent; they may have pelvic pain; they may be incontinent of urine or have prolapse.

Or have all of the above!

So I suppose the journalists would grant immunity to those women- they have definitely earned their visit to the Women’s Health physiotherapist.

They would be assessed, educated, counselled and supported for as many visits as the patient / and or the physio felt they required. For the majority of women it may be an initial long consultation of one to one and a half hours and then perhaps a month later, a half hour visit, and if recovery is going well, then a couple at the 3 and then 6 month mark.

But I believe all women deserve to see a Women’s Health physio in order to be reassured; to be well-educated about what is normal with the bladder and bowel and what might go wrong; the appropriate rehab of their abdominals; advice regarding any lingering pelvic or back pain; the importance of return to exercise, but also of appropriate rest. All of this without being made to feel guilty about over-servicing.

After all this is (sort of) the reality.

 

A 4kg watermelon

And what of the women who have had a Caesarean – but didn’t realise there was a problem going whenever they fancy to the toilet to pass urine? They get to 45 yrs of age and suddenly have frequency, urgency and urge incontinence, just because they didn’t get the opportunity to learn some basic facts about bladder and bowel control at a younger age after they had their baby. What if the woman had a vaginal delivery- there was no tear, no pain, she felt great and decided to go back to exercising at 3 weeks and started with some burpees and tractor tyre lifts and developed on a prolapse?

Every woman who has been pregnant and had a baby should be able to source the services of a Women’s Health physio and not have it labelled as over-servicing.

And for journalists, whose responsibility is to inform without judgement and to spread information without prejudice and fear mongering, I am interested why that word over-servicing was used? Is there a message from the Government – like from Medicare, from the health funds? Is it simply an unfortunate coincidence that two female journalists both used the same words within a week of each other? Or is childbirth so underrated that women are seen as weak if they are having problems? Are women just getting the short straw with their health? Or is the ignorance about the financial burden of urinary incontinence and the other consequences of pelvic floor dysfunction on Australia’s bottom FINANCIAL line so huge that the politicians haven’t seen it as a priority and the silence surrounding this burden for women continues?

Why is a dental check up every 6 months acceptable and rebated very handsomely by the health funds?  Does tooth decay create more quality of life issues than urinary and faecal incontinence?

France has recognised the importance of the pelvic floor following childbirth. Every woman is funded for ten (yes 10) visits to the pelvic floor physiotherapist. (I do wonder if sex and French men does have some role to play here- I may be wrong though.) Imagine in Australia, if when you walked out the door after having a baby, you picked up your Bounty bag (the sample bag of goodies from a variety of suppliers) and you also got a 10 pack of vouchers to the pelvic floor physio? Now that would be prioritising pelvic health!

The evidence is building about the importance of early intervention with the prevention of pelvic floor dysfunction. I have mentioned a couple of articles in my previous blog alluding to this. Incontinence of bladder and bowel are one of the leading cause of admission of older women (and men) to nursing homes. Our population is ageing and the future numbers will be staggering.

To me it is stating the bleeding obvious that this area should be appropriately and routinely funded and women should be demanding automatic routine follow-up for their daughters and sisters, before and after they have had a baby. The payback in the future, in savings for our economy, will make this investment in health public policy worthwhile.

 

 

 

 

PESSARY STORIES -YES! USING ‘SHOUTY’ LETTERS FOR A REASON

pessaries in situ

If it’s a phrase I’m really sick of hearing, it’s the one that many of my patients have had said to them by too many health professionals (and some of them are doctors):

     “There’s no point in having a pessary, pessaries are just for old ladies”.

Today’s blog is to refute that argument because it just isn’t true.

A pessary is a silicone or plastic device designed to help support prolapsing pelvic organs. The first pessaries date back prior to the days of Hippocrates and their use has been documented in early Egyptian papyruses. Throughout the centuries many unusual remedies have been used such as honey, hot oil, wine, fumes, succussion, leg binding and even pomegranates. In the middle ages, linen and cotton wool soaked in many different potions were used. As new materials were discovered, pessaries evolved and began to resemble those used today. Cork and brass were soon replaced with rubber and of course now medical grade silicone. (1)

Demonstration of Hippocratic succussion (From Appolonius
of Kittium)

Funnily enough, this is what many women feel like they want to do, to reduce their prolapse.

Pessaries are for any woman:

  • Whose anatomy (post vaginal delivery) can hold the pessary in a comfortable position, where the woman does not feel it and it effectively reduces her prolapse.
  • Who can be taught to self-manage the pessary (is cognitively sound; has a good memory; has the dexterity and finger strength to manage; can reach her vagina and feels comfortable inserting her fingers into her vagina to enable her, of course, to insert the pessary).
  • Who is able to have local oestrogen if she is post-menopausal (or if she is breast-feeding for that matter).
  • Of any age if they answer any of the previous statements.

Health professionals should not make blanket negative statements about pessaries without examining the patient and checking out the above criteria. It’s uninformed and obstructing a woman from trying a potentially, really successful, conservative option. Pessaries are amazing and life-changing………when they work. And there are many, many patients for whom they work if they get an opportunity to try them.

cube pessarysayco ring pessaries

There is now good evidence that screening for prolapse symptoms early, and in primary care, such as by the GP, there can be 40% symptom resolution with conservative measures and watchful waiting. (2) Now many blogs ago, I came up with an idea that the GP’s could be integral to early discovery of prolapse at the PAP smear. Using the acronym PIPES, when a woman is having her PAP smear, this could remind the GP of important things to screen for.

A simple checklist for GPs to check at every PAP smear

¤ P stands for prolapse – Vaginal, rectal.

¤ I   stands for incontinence – Urinary, faecal, gas.

¤ P stands for pain – Pelvic, abdominal, sexual.

¤ E stands for exercises- pelvic floor exercises; general physical exercise for bone density, weight management, stress and general ‘feel good’ management- (release of endorphins) -‘if you don’t move it you’ll lose it!’‘pelvic floor safe’ exercises.

¤ S stands for sex – pain, dryness, low libido, anxiety about the look, anxiety about doing damage, relationship issues.

There has been plenty of evidence about the value of pelvic floor muscle training (PFMT) as a part of the treatment package for managing prolapse (including correct defaecation position, the knack (bracing), and other lifestyle advice) and a recent meta-analysis demonstrated women who received PFMT showed a greater subjective improvement in prolapse symptoms and an objective improvement in POP severity. (3)

Defaecation Position taken from Pelvic Floor Recovery: Physiotherapy for Gynaecological Repair Surgery. Sue Croft 2014

Below are a couple of pessary stories. Women have written them in their own words. They have chosen their alias – but I have not changed anything. Please be aware these stories are to bring the value of pessaries into focus; and specialists such as Urogynaecologists and Gynaecologists and many Women’s and Men’s Pelvic Health Physiotherapists who are trained to fit pessaries, are able to assess if you are able to use a pessary in the short-term, medium term or longer term.

Ring Pessary: A Mother Journey 

Amanda, 34. Mother of 2 boys

About 10 days after my second unassisted, uncomplicated vaginal birth, I became aware of a heavy feeling inside my vagina. As someone who is well read and informed about the risks of prolapse, I had been extremely diligent between the birth of my two sons, seeing a specialist physiotherapist regularly to restrengthen my pelvic floor and then manage my second pregnancy as well as possible. I was therefore extremely surprised and quite devastated to suddenly feel the heaviness inside my vagina.

The feeling deeply troubled me and affected not only my physical ability to go about my day but also affected my sense of self and my confidence. I felt like my feet had been swept out from under me and that I was somehow not fully able to cope with the demands of caring for a vibrant toddler and a new born. I became increasing depressed and felt like I couldn’t cope.

I went to see Sue who diagnosed a Grade 1 uterine Prolapse with levator avulsion. Her solution, as well as continuing with my program of pelvic floor exercises, was a ring pessary which she fitted. I have not looked back. It gave me my life and my confidence back. I can’t describe what a difference it makes. It is easy to self manage and takes little time or effort.

Instead of being a constant strain and stress on my conscience, my prolapse has become something to be managed, but more as a part of my overall health. It’s a part of the background now, no longer the major strain that it was on my sense of self and my ability to function. I have my feet back under me again and I feel like along with my exercises, that the pessary will be a lifelong aid to maintaining my pelvic floor health. I am so glad to have avoided the risks and trauma of surgery and I genuinely encourage other women of all ages to give it a try before resorting to more drastic measures. Good luck!

What a beautiful, encouraging story. Thank you Amanda for sharing your journey.

Prolapse is devastating if women have not realised just how common a prolapse diagnosis is.

50% of women over the age of 50 who have had a vaginal delivery will have some degree of prolapse….YES SHOUTY LETTERS TIME AGAIN…….50% OF WOMEN OVER THE AGE OF 50 WHO HAVE HAD A VAGINAL DELIVERY WILL HAVE A VAGINAL PROLAPSE.

If I think about what has transformed many women’s lives- of all the things that a Pelvic Health physiotherapist does – I think fitting a pessary, when it works, is one of those amazing miracles. When a woman has a prolapse and can feel it all the time and then by simply inserting a pessary, she no longer feels the prolapse, no longer feels the drag, no longer feels the heaviness, can exercise with more confidence and isn’t constantly thinking about her prolapse every second of the day – well they are very happy patients.

Below is another story – Heather’s story – short, succinct and to the point!

I am 54 years of age and have had a bladder prolapse for a while now. I hated the bulging uncomfortable feeling. It was something I was always aware of and could never forget about my condition. After having been fitted with a  pessary for over six months now, it has made a huge difference. It is very comfortable, I don’t even know it is in place. It has never fallen out and I can do my usual safe exercises .  I don’t think about the pessary much, except when it is time to remove for cleaning which is once a week.  The only other thing I have to remember is to use Ovestin cream twice a week.  It has made a difference to my well-being, I am so glad I gave it a go.

Thank you Heather.

Don’t get me wrong. There are quite a few patients where we can’t make the pessary work, but if we try all types of pessaries and we can’t make it work, at least the patient feels they have given every conservative option a shot. Below is a case study about Sandra. I am writing her story to demonstrate how important ‘failing the fitting of a pessary’ can be!

Sandra had a significant vault prolapse. Her vault (she had a hysterectomy 10 years previously) was 5 cms out of her vagina. Her prolapse was obstructing her voiding, leaving her with sizeable residuals, so during the day when standing, she was hardly voiding more than 100 mls and when she lay down and reduced her prolapse, her volumes were much bigger. But she could never empty completely.

Sandra was adamant she didn’t want surgery when she presented to me.

She had quite good levator muscles on both sides and I felt there was a fair chance the pessary may work. But with pessaries, it is trial and error. We have fitting kits, which we sterilise and this enables the patient to be fitted and then cough, squat, jump, and then go for a long walk if all of those other challenges had not dislodged the pessary. So Sandra did this and she felt wonderful- the pessary reduced the prolapse and the heaviness was gone and she even voided and emptied with a minimal residual. But she went home and the next morning, when she passed a bowel motion, unfortunately the pessary dislodged. Despite using the correct technique for defaecation and many repeat attempts to use devices such as the Femmeze and hand support it just wouldn’t stay in with passing her motion.

Eventually, Sandra found this too much and having felt the relief from not having the prolapse dragging down, she then decided she would go ahead with the surgery. This is a wonderful exercise in exhausting every option, so the patient feels, of course, surgery is the next, correct option. With significant failure rates in the literature for gynaecological repair surgery (up to 30% for repair surgery; up to 80% if the patient has a bilateral levator avulsion), it is important the patient feels all conservative options have been tried.

And finally another story from Sally:

I had my last child 26 years ago. I had three 9lb babies, all very intelligent babies (with big heads). After my last baby I became aware that there was an unusual feeling (like a tampon was dislodged) that would come and go. I started to read and learn about pelvic floor dysfunction and became aware that I had developed a prolapse. I was religious with my pelvic floor exercises and the ‘knack’ and by using a tampon for heavy lifting or playing sport I managed to keep things at bay until last year.

I had turned 60 and started to feel a different feeling, a heaviness that I didn’t like. So I got fitted with a pessary and it IS like magic. I was told the most critical thing is to remove and wash the pessary weekly – and I had to sign a form promising I would do that! As if I’m not going to remember to remove the pessary every seven (7) days?!? Well very quickly I realised it is so comfortable, and I am so unaware that I have it in, that it is very easy to forget and lose track of time – those 7 days literally zoom by and are occasionally missed. My thoughts at the moment are that me and my pessary are going to be good friends for many years to come.

Thank you to all my patients who have contributed to this blog and all the others below.

And to all my patients who I have asked to write a story about their pessary journey, do not feel I do not need them anymore now I have posted this blog.

Every story is relevant to someone and if your story helps them understand and make an enquiry about this pessary option with their medical practitioner – and the more stories, then that is fantastic. So keep writing them and sending them – because each of them is a good learning opportunity.

(1) Shah SM, Sultan AH, Thakar R. The history and evolution of pessaries for pelvic organ prolapse.  Int Urogynecol J (2006) 17: 170–175 DOI 10.1007/s00192-005-1313-6

(2) Hagen, S. (2017) Should we screen for prolapse symptoms in primary care?. BJOG: Int J Obstet Gy, 124: 520. doi:10.1111/1471-0528.14067
(3) Li C et al (2015) The Efficacy of PFMT for pelvic organ prolapse: a systematic review and meta-analysis. International Urogynaecological Association Journal
Other blogs on prolapse:

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