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

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:

Pain management and skill acquisition

Much of what pelvic health physiotherapists do each day relates to educating women and men in a variety of topics related to the pelvic floor. So people start with varying degrees of knowledge about say, urinary incontinence. Their current knowledge may have been acquired from their mother- “I have a weak bladder, my mother and her sister had a weak bladder, you will have issues unless you go to the toilet before you leave the house each day”. So this ‘fact’ is repeated over and over within earshot, as children grow up and it definitely sounds like gospel. It gets reinforced over the years – what your mother tells you is important and you dare not question it. The bad habit is entrenched and the ability to hold onto urine is diminished.

Many patients may have a pain issue with intercourse and any sexual intimacy. Their knowledge base surrounding sex may have acquired from their best friend, who read about intercourse in their older sister’s Cosmo and was the chief informant for the girls at school. They also may have gone to a highly religious school, where other messages about sex were preached regularly and layer upon layer of guilt regarding, even thoughts of premarital sex, were being laid down deep in impressionable brains. (‘Masturbation is a sin; you’ll go to Hell if you have sex before you are married’)

Medical people can even pass on dubious science about pain conditions. Men can be told they have prostatitis, when a more likely diagnosis may be an overactive pelvic floor causing pelvic pain, testicular and penile pain and even erectile dysfunction rather than an inflammation of the prostate.

So the point is education is very important and passing on that information and the way you do that as a health professional- is very important.

Why? Because adults are notoriously bad learners!

They may learn and understand about only 20% of anything you teach someone at an initial consultation.

Every week at our pain relaxation class, we present some Nuggets of Pain and Anxiety information – I usually create the one or two page information sheet which lasts just five minutes so that Martine Lange, one of my Women’s Health Physios and Pilates instructors can present it prior to the muscle and neurodynamic stretches, pelvic floor down-training, breath awareness and relaxation practice. After 23 weeks of preparing these, I have started to get the other physios at my practice to put their minds to coming up with some ideas for more important knowledge bombs. Amanda Quinn (nee Lee) who is another one of my Women’s and Men’s Health Physios (and also a Pilates instructor at Studio 194), came up with this fantastic Nugget from the masters of Nuggets, Dave Butler and Lorimer Moseley from their brilliant Explain Pain course. It is to outline the stages of learning information. This information was sourced from: Butler & L. Moseley Explain Pain course

Amanda’s Nugget for me:

According to Dr. Thomas Gordon, pioneer in teaching communication skills and conflict resolution (as well as a multiple Nobel Peace Prize nominee), the four stages of developing a skill set can be described below as:

Learning to manage your pain can be seen as a skill that needs to be developed – it is no different to committing to a new fitness program, learning a new language, getting your handicap down in golf… it requires time (patience), commitment and hard work. (http://fitnessontherun.net/imperative-learning-new-skill/) No one is pretending this is easy… why do you think we compare it to climbing Mt. Everest? Therefore being aware of the above stages of learning can help us better accept that it is a slow and frequently uncomfortable process.

Through hard work and persistence we can eventually hope to achieve the stage of ‘unconscious competence’. Remember, you are learning how to manage your pain through a pathway you have actually navigated countless times before when acquiring a new skill – it is no different. Don’t give up.

What is the other major benefit to learning a new skill with your health and how does it relate to pain?

Learning a new skill strengthens the connections between neurons and different areas of the brain, in fact the brain develops new pathways and synapses when learning and problem solving. This is evident when learning new movements. Exercise that involves dynamic, smooth and non-repetitive movement patterns eg. dance, yoga, certain martial arts, tai chi plus others can all help to navigate novel neuronal path ways and keep the body guessing.

It all comes back to bioplasticity.

Bioplasticity is what got you into this problem, but bioplasticity can get you out.

Dave Butler’s and Lorimer Moseley’s brand new book Explain Pain Supercharged has just been released and can I encourage any health professional working with patients who have pain, to purchase this book and enhance their repertoire of skills with these patients.

Thanks to Amanda for the inspiration for this blog on learning and I love the diagram as it can be applied to so many areas in our day educating on pelvic floor dysfunction.

 

 

Forty Years a Physio

Forty years ago Blondie’s first ever hit, “In The Flesh”, reached number two on the Australian Singles charts after it was played by mistake (instead of “X-Offender”) on the music show “Countdown” in 1977. (Well done Molly!) Tonight on the 7.30 Report there was an interview with Blondie, as she is touring Australia at present. She looks absolutely amazing – still pretty spectacular that she is performing, considering she is 71!

I loved Blondie in 1977 and she will always remain special for me, because soon after that hit of Blondie’s, I finished my Physiotherapy degree at The University of Queensland. I can’t remember the exact date but sometime close to the end of March 2017, I will have been a Physiotherapist for 40 years. Now you would think that was a long time and it might be time to give it away, but what I love about that fact is I am still completely invigorated by my profession and love getting up every day to go to work. To be honest the last forty years have literally flown by and it doesn’t seem daunting that I may work for another ten years and that is a testament to many things.

One reason I intend to work on is my area of interest – Women’s, Men’s and Children’s Pelvic Health – it is so diverse, so challenging and so rewarding – if you can help a patient with problems in the most private areas of bladder and bowel dysfunction; if you can help someone who suffers with pelvic pain or sexual dysfunction or if you can help someone with prolapse to exercise again, because they have been successfully fitted with a pessary, then work every day is indeed very satisfying.

Another reason I intend to work on for quite a while yet is I have gathered around me the most amazing group of Physiotherapists, Amanda, Jane, Kristen and Martine, who also treat conditions that affect pelvic health (as well having the added bonus that they are all excellent musculoskeletal physiotherapists) to help hand the baton on, when I do start to slow down. These enthusiastic and empathetic women also love their work and are constantly learning and acquiring skills to solve the complex problems that present every day to our practice.

The last and most important reason is I have fantastic longevity in my family – my wonderful mum is turning 92 this year – my father lived to 89 and my grandmother lived to 93. So hopefully I will be ‘plenty of years’ retired so I don’t want to give it all away too soon.

So to all the girls in my 1977 cohort- happy 40th year as a Physio and I hope there are many of you still working and spreading the magic of physiotherapy. #keepmoving #keepexercising #exerciseismedicine

Secret Women’s Business: The Big One

From time to time I have guest writers on my blog and someone (who is an actual writer but wishes to remain anonymous) has submitted this article to me.  I read it and found it interesting and decided to post it as it serves as a nice lead into a topic which I haven’t addressed with a blog and this topic certainly deserves one. It isn’t talked about very much and it may even sound rather uncomfortable. Some of you may squirm as you read this article and even not get to the end of the story, but I do encourage you all to see it through to the end.

To all my relatives – #embarrassmentalert.

Here is my guest bloggers article.

I guess it’s a particularly female thing. Maybe not often discussed. Somewhere along the line you realise you haven’t achieved this special physical feat. Let’s call it a goal. Well, at least you don’t think you have. You’re just not sure. Oh, you go through the motions. But no matter how experienced you are in the general ‘business’, no matter how much stamina or will you have, this goal seems tantalisingly unattainable. You just can’t get there.

Girlfriends who achieve one regularly assure you somewhat smugly that if you only ‘think’ you’ve reached this particular pinnacle, it’s a pretty sure bet you haven’t. As for ‘multiples’, gee, I’d be happy with just one.

I must admit it’s a little embarrassing to confess what I can’t help seeing as a failure at my age. It’s not like I haven’t been engaging in the activity for years. I just haven’t won the prize. I reckon I’ve come awfully close, but somehow am always left feeling dissatisfied. The build-up is intense, and then, and then …

In my case it’s not for want of trying. I reckon I try at least three times a week. I’m just not sure why I can’t actually make it happen. Perhaps it’s psychological. Do I feel too self-conscious about how I might look at the moment of success? I’m not the most physically coordinated person it’s true. And the whole thing is pretty undignified.

Still, apparently in this key moment, abandonment is the key. Give yourself over to the thing; just ride that wave – at least that’s what those in the know say.

It can be a dangerous business too. More than once I’ve bumped my head rather badly, which totally puts me off my game. I’ve strained my back too. On a couple of occasions, after much thrashing about, I’ve found myself facing the wall, completely disoriented and breathless.

Did I mention I’ve been trying this on my own? Could that be my problem? My technique must be missing something. Maybe there’s some kind of device I could plug in or strap on? Perhaps I should enlist the help of a partner – someone I can trust. Someone who can observe me as I strive and struggle and give feedback. Who knows? Maybe they could physically just tip me over at the crucial moment.

I’m fully aware that some women don’t stress – they simply fake it and lie about it to their girlfriends. But I’m afraid that’s not my style.

It occurs to me I may be overthinking the whole thing. After all I enjoy the overall experience leading up to this somewhat elusive end. The strokes, the physicality, the sheer feeling of exhilaration in my whole body and its movement.

Perhaps I should just be content with the pleasure I get from the rest of the exercise and give up on this heady release I’m seeking.

That’s the answer. Just stop trying so hard. I’ve decided finally, I’m not going to beat myself up about this anymore. Time to admit defeat and be satisfied with the status quo.

After all I’ve been swimming laps now on and off at my local pool for more years than I wish to admit. I’m an excellent, confident swimmer and I simply love the exercise.

So what’s the big deal about a tumble turn anyway?”

Now obviously my guest writer was having a bit of fun with us and that little article could have easily been about achieving an elusive orgasm. However the only difference is you can obviously openly chat about tumble turns, but unless you are at a Hen’s Night or in Grade 11 and have just read Dolly (I’m not sure what the equivalent mag is these days) and are asking your friends what is what, then women can’t easily find someone to discuss their orgasms with. But you can ask a Continence and Women’s and Men’s Health physio anything. We are used to discussing private matters related to pelvic floor dysfunction with care and professionalism and you can feel confident about privacy of any answers you give.

We do have to ask some difficult private questions – we have to ask about your voiding (weeing), frequency and your ease of passing a bowel motion, and it is important to ask women if they are sexually active; do they have pain with intercourse; do they lose urine with orgasm (coital incontinence) and if they are coming to see you with sexual dysfunction, asking about their ability to orgasm is a very important question.

Our role is also to educate about facts regarding orgasm. Many women discount a clitoral orgasm – like it doesn’t count if manual stimulation of the clitoris is involved. In fact only 30% of women are able to orgasm vaginally and 70% of women orgasm with clitoral stimulation only. (1) This article is quite comprehensive regarding the female orgasm if you would like to read more on it. Interestingly it was a female urologist Dr Helen O’Connor in Melbourne who made important anatomical discoveries about the size of the clitoris in 2005 completely turning Gray’s Anatomy description of the clitoris on its head! The article can be found in this link.

I also tell women that an important sex organ for women is their head (brain). There is a humorous YouTube clip on the difference between the male and the female brain and I think he pretty much sums it up accurately the cross wiring in women’s brains (that makes us able to multi-task so successfully). However, this cross wiring (metaphorically speaking), may contribute to the difficulties some women have in trying to achieve orgasm, in that many women find the busyness of their life and the anxieties and distractions of life diminishes their ability to orgasm. Financial worries, jobs unfinished, school reports, un-ironed clothes in the clothes basket – any or all of these things are liable to pop into a woman’s brain when she is having intimacy with her partner and in a second the intensity is lost and there’s no way she will achieve an orgasm. So clearing the head of distractions and setting the scene (minus the children in the house helps) enhances the prospect of achieving orgasm.

Learning that arousal is important, taking the necessary time with no rushing (which can be difficult with young children having daytime naps in the house) and using a good lubricant at any time can improve the enjoyment of intercourse and the potential for orgasm. If a woman is suffering with post-natal or post-menopausal vaginal dryness then discussing the use of a local oestrogen pessary or cream (twice a week) with your GP or specialist can significantly improve comfort and enjoyment.

Maintaining some libido can be an effort in itself and exhausted mothers and fathers can struggle to be bothered when some uninterrupted sleep holds far greater satisfaction than the prospect of sexual intimacy. But some time in the future, opportunities arise, the embers become low level flames and couples get back to enjoying sex as a part of their relationship, not as an obligation to be ticked off for the week. If there is ever any pain for the woman, it is important to ask a Continence and Women’s and Men’s Health Physio for assistance. With effective fear-reducing pain education and sensible advice depending on what has been found at assessment, dyspareunia can be significantly helped or cured. Dilators or a Therawand may be taught at the consultation by your Physio and used by the woman at home to help decrease any hypersensitivity and pelvic floor muscle soreness. As pain dissipates and pleasure and enjoyment returns, women can find significant help in achieving orgasm by experimenting with different sex toys such as vibrators. It can also help to venture into some romantic novels or light erotica,  -always sticking to your own comfort zone. Never do anything out of your comfort zone as it could make you have the opposite effect on your arousal.

   

Some tips:

  • Romance from the partners goes along way (even taking the rubbish out or vacuuming can amount to a significant romantic gesture in an exhausted woman’s eyes)
  • Offload the kiddies
  • Schedule intimacy just like you may schedule a pedicure- it is too easy to keep postponing it
  • Trial some different lubricants to see what is successful
  • Run away for a kid-free weekend to a romantic destination
  • Seek help sooner rather than later (here is the link to the APA’s Find a Physio website)
  • Keep your sense of humour with your partner around sex and keep communicating your needs and wants. Don’t assume they are mind readers.

International Women’s Day (IWD) 2017: #BeBoldForChange

As the title says- it’s International Women’s Day tomorrow on Wednesday 8th March and as the title instructs me to – I am going to #BeBoldForChange! That is the theme for this year’s International Women’s Day and being bold for change is a refreshingly demanding theme for us women.

Change is one of my favourite catch cries and in fact I wrote a blog about #change in 2011 when I first started writing blogs, because instituting lifetime change is what we Continence and Women’s and Men’s Health Physiotherapists have to inspire in women – we are obliged to encourage, cajole and nurture when we are educating women about managing problems with the pelvic floor. I liked my blog on #change so much (nothing like being a fan of your own writing) that I incorporated it into the conclusion of my books- because accepting and embracing change is how quality of life is maintained and improved in older age when there is increasing pelvic floor dysfunction.

But really I hear some (men) ask- why do we even have an International Women’s Day in this day and age? Is it still really necessary?

Well now in this digital age I have many virtual physio friends from the U.S. and if you read their posts in the lead up to the election and since the inauguration of Mr Trump (referred to from now on as DT), I feel they would say that the recognition and highlighting of IWD is more important than ever. Their dismay at the treatment and portrayal of women and girls during the past 8 months has been palpable because of the simply awful things that have been said and done to women. To the impressionable young girls in the US it must feel like a betrayal of their feminine being.

Not so far away, across the border in Canada of course is the complete antithesis of DT. And for all the women out there who love the other Justin (from hence known at TOJ) – here a reminder of Justin Trudeau extolling the virtue of the F word- feminism. What I find exhilarating when I listen to TOJ is his insistence that teaching young boys and men about feminism is as important as teaching young girls and women. #BeBoldForChange #Justin #swoon

Over the years, we in Australia have had our own awful disregard for the opinion and position of women in our political sphere and the workplace. Let me assure you, this meme below is not me being political. What is said in this meme may be something that many men may think to themselves – or not to themselves – they may actually articulate it at home, to their wives, or to their daughters, or in their workplace to their female employees or to their female friends.

tony-abbott

But this was said by Tony Abbott when he was only 21. He was young and obviously silly.

Of course, he later went on to become our Prime Minister and the Minister for Women in a Government that only had five women at the Cabinet table and where a man was the Minister for Women…… (It is interesting to read this full Liz Jackson interview  during the 2010 election, where the quote was from, and realize it feels like we are living in a parallel universe). Of course I am sure, now that Mr Abbott is considerably older and wiser, he has a completely different idea about the value that women bring to the Cabinet or business table and how important a female perspective on anything is (such as world peace; such as diplomacy and words before guns and bombs; such as seeing people for what they are – people rather than a religion- remember I am following the theme for IWD #BeBoldForChange so am being deliberately provocative.) Well I hope he does anyway.

So the purpose of these musings?

It’s to reiterate for any women or men who think otherwise- acknowledging International Women’s Day is important.

It’s to encourage women to keep strong and resilient in the face of prejudice and unfairness in the workplace.

And it’s to say to women #BeBoldForChange in every aspect of your life from your bladder and bowel dysfunction to challenging inequity when you see it.

And to finish on a positive note -thank you to one of my lovely Women’s Health colleagues Meggan (developer of a great app called Clock Yourself to help with balance maintenance and improvement) for finding this quote from E.B. White:

I arise in the morning torn between desire to improve the world and a desire to enjoy the world. This makes it hard to plan the day.
Make sure you spend International Women’s Day both improving and enjoying the world.

#BeBoldForChange #IWD2017 #Feminism #Feminismisnotadirtyword

 

 

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