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

Turning 60 -a time for reflection?

 

mum and me

Me turned 6o, Mum 91!!, Jill photo-bombing in the background

What’s worse than turning 60? Well my Mum (who is 91) reckons it’s having the youngest child turn 60! I’d say she had a point except that everyone at my family party reckoned that Mum was spectacular – engaged, beautiful coiffured hair (the Queen copies her style – she is younger than Mum after all), and drove herself too and from the party – so independent in a rather exaggerated way.

So my new goal is to aim to be at my youngest child’s (Michael who is 25) 60th in 35 years, drive myself there, be able to remember my children’s names and still have hair!

family photo at 60th     cakes 60th

My kids and husband conspired to have a surprise party, but Bob folded under the pressure of keeping the secret and was looking much less stressed after he came clean on the birthday plans. I was instructed to do nothing and complied by going to one of my favourite pursuits at 5.15pm, (the witching hour for babies and party preparations when one realises there is way too much to do before the guests arrive) by going to a dance class at the studio with my second family- my dancing mates. As usual I left the dance class with a smile on my face and humming Michael Buble.

dancing class ailsa

(Just to let you know that this is Ailsa receiving some flowers and champers from me for being the most regular client at Studio194 since it opened on August 4th 2015. She has been to virtually every dance class and a Pilates class every Tuesday since we opened and she herself says she feels fantastic for all that dancing exercise (it’s not really exercise, its just fun) and Pilates under the watchful eye of Monique, (as one client described of Monique- “You can run but you can’t hide from Monique”)

But the best part about my birthday was, that everyone complied with my request to not give me a present and to rather give a donation to HADA. There may have been the odd bottle of beautiful champers, some glorious flowers or a dinner voucher to go along with the donation but people have been very generous to HADA. Now with recent stories in the media about a very well-known charity having considerable amounts of money siphoned off for dubious purposes, it is wonderful to know that when my kids, my mother, my friends and staff all donated to HADA, 100% went to funding operations to help women with fistulas and prolapse in Africa.

Recently I received an email of thanks from HADA showing the amazing work that the Medical Training in Africa crew are performing while utilizing the money raised below.

fistula repair operations July 2016

Hello friends,
Judith Goh, Hannah Krause, Jackie Smalldridge, GI Tan, John Taylor and I have just returned from Uganda, where we did a prolapse and fistula camp at Kagando hospital. Once again we were welcomed by a large group of ladies with big smiles and cheery dispositions – all the more so after we were able to help improve their previously desperate lifestyles. The ladies in the above photo have all had VVF repairs – as evidenced by their indwelling catheters running into their brightly coloured buckets. They are now dry – most of them having spent months to years being continually wet and smelly. Their joy is obvious!
We operated on 52 patients with prolapse, 29 patients with Vesico-Vaginal fistulas, 26 patients with Recto-Vaginal fistulas and 10 others with causes of incontinence requiring less major surgery. In addition, one patient presented with a large rectal prolapse, and one with a huge thyroid mass (she had a lump – just at the wrong end of her body!!). We were able to fund their operations by the general surgeon at the hospital. 19 patients were managed on the ward with conservative medical treatment for their incontinence (all after previous successful closure of their fistula).
The total cost of the camp was approximately AU$46,000. Thanks to your overwhelming generosity, we have been able to fund this camp and will be able to return to Kagando in December to conduct another prolapse and fistula camp.
These women are deeply grateful for your generosity and wish to thank you for changing their lives.
We will be heading off again in mid-December, and will keep you informed of our work.
Kind regards,
Barbara Hall

Now that is inspiring. I am way too sookie to go to Africa – worrying about silly things like parasites and the like but these devoted doctors head off 2, 3, 4 times a year and just completely change these women’s lives. Extraordinary!

So I reckon the least I can do is encourage friends and relatives to give a gift of giving.

Try and spread the idea. #giveagiftofgiving

While Tuesday 9th August was a very happy time, the period before was actually very sad with the passing of my sister’s partner, John O. I think sometimes in the hurley burley of life we can take things for granted and I know that John had much more living to do and felt cheated at losing his battle with cancer at only 68. And after listening to the tributes at his funeral from his family, friends and work colleagues, I know they feel cheated. What I know most is that every day my sister will miss her soul mate, who she sadly only met in later life – because they were truly a wonderful match, joined at the hip with their views on politics, social justice, Noosa and good food.

Whilst I have known John for 16 years, he was such a humble man, that I only really pieced together his life achievements once he actually passed away. His work with indigenous affairs in the Northern Territory, Alice Springs and Melbourne were at the coal face, the micro level- whilst still holding beliefs that the big picture issues must be addressed. When others were retiring at 65, John recognized that the young and disadvantaged needed a voice when facing drug charges and returned to study further to attain counselling accreditation and began a new career up at Noosa, while also soaking up some sun and walks on the sand with Lynne.

What I know is that Friday was a special day when John’s loved ones and friends gathered together – hugged, laughed, cried, listened to superb music – Cold Chisel, Leonard Cohen and the haunting music Bunyarra Mockva – The Voices of Red Heart as we watched the photographic memories. It was a special day which I know John would have loved.

Vale John O.

 

 

 

Global Pelvic Health Facebook Group Tackles Prolapse Rate!!

woman talking thru a megaphone

In a few weeks I will be presenting again to the general public on prolapse and every time I do one of these talks and I put that stat in and “50% of women over the age of 50 who have had a vaginal delivery will develop prolapse it still really impacts on me. Because when you think about the population of Australia 24 million- say 50% are female. And from the Bureau of Statistics, in 2011, 297,126 women gave birth to 301,810 babies in Australia. Onset of labour was spontaneous for 54.8% of women giving birth. Most women (67.7%) had a vaginal birth and, of these, 82.1% did not involve the use of instruments.

So it translates to an enormous number of women!

(Some other stats from that year: overall, 32.3% of women gave birth by caesarean section in 2011, a 0.7% rise from 2010. The caesarean section rate among first-time mothers was 33.2% in 2011. Among women who had already given birth at least once, 28.8% had had a previous birth by caesarean section.)1.

Now does this 50% figure have to be an inevitability or is it that we are letting down the women of Australia (and the US, UK Iceland, Africa etc etc) because we health professionals (physios, GPs, Obs and Gynaes, Urogynaecologists) are not educating enough and making a compelling argument about simple lifestyle factors and the preventative role of the pelvic floor in pelvic organ prolapse management?

If we had an orchestrated public health campaign (such as the highly successful ones about smoking and wearing seatbelts) in Australia, about prevention of prolapse such as the points listed below, could these targets be reached?:

  • Pelvic floor muscle strengthening to maximise the potential of the muscles following a vaginal delivery.
  • Matching downward forces of coughing, sneezing, bending, sit to stand etc by engaging the pelvic floor muscles first- known as ‘the knack’
  • Good bowel management such as the correct postures and dynamics for defaecation and appropriate consistency of the stool (yes bowels bring down prolapse!!)
  • Extol the virtues of more routine use of pessaries (to the medical fraternity) to allow women to be able relax to exercise and lift their children when they are toddlers
  • And another big one pelvic floor safe exercising.

On pelvic floor safe exercising– there is a lot of detailed research going on around the world about activities that raise intra-abdominal pressure, with debate as to whether some of the restrictions that physios like me talk about, are over-zealous. Restricting women from doing certain exercises needs to come with a caveat that it would be wise to have your risk assessed by a Continence and Women’s Health Physio depending on the strength of your muscles, the stretch to your ligaments or fascia or the damage to your pelvic floor such as levator avulsion, nerve damage or prolapse as a result of the vaginal delivery. If women were absolutely encouraged to exercise through their lifetime but in a safer way to minimise risk of further prolapse, to be fitted with a pessary to facilitate good support while exercising and to have regular yearly checks to monitor the state of the pelvic floor then I am sure those statistics could be lowered! I can tell you from years of experience that women feel angry when they realise the activities they have undertaken without any warning from their trusted instructor, have worsened their prolapse.

Now recently a number of us Women’s and Men’s Health Physiotherapists – otherwise known as #pelvicmafia – formed a new group called the Global Pelvic Health Facebook Group – driven by a desire to collaborate in a global way to tackle this worldwide phenomena of pelvic floor dysfunction – a silent yet manifestly common problem worldwide.

The goals of the group are to professionally challenge each other to improve outcomes for patients worldwide by:

  • sharing patient case studies;
  • distributing pertinent research articles;
  • highlighting clinical pearls and even
  • adding the odd artistic contribution such as seen in the photos below (yes we are a cultural lot!)

great-wall-of-vagina3-550x365

Great Wall of Vaginas MONA Gallery, Hobart

I think we as a new group could set targets like the scientists do with global warming- what if we set an aim to reduce this prolapse rate through public education by 10% in Australia by 2020; by 20% by 2025 and by 25% by 2030. How cool would that be if we as a new group actually got out there with megaphones (metaphorically) and literally blasted every media outlet with this message that simple manageable things like the knack; good bowel management and safely exercising (if it is warranted by proper assessment by a Women’s Health physiotherapists looking at objective data like is there a Levator Avulsion?, what is the GH+PB (genital hiatus plus perineal body length) measurement – does it fall into the risk dimensions for prolapse?; how much perineal descent is present on a curl up, cough with and without the knack?).

If these things were properly assessed and a judgement made and guidelines given to the women, the inevitable MAY NOT HAVE TO HAPPEN!!!!

Now another reason this may not have to happen is highlighted in this case presentation by a woman who has been touched in a very personal way by prolapse. Her name is Amy Dawes and she has given permission to give her real name as she is being very brave and ‘coming out’ about her issues. But as she says – “I don’t really feel brave, I feel like it’s my duty to be a voice”. This young women is extremely articulate and in fact is presenting her story at a medical conference soon, which is incredible, because the health professionals attending will be able to see the pain and suffering that happens with birth trauma and prolapse which raises it beyond just the ‘feeling of a bulge’ to how it impacts on all aspects of a women’s life. All too often, after health professionals see patient after patient, they get almost desensitized to the impact of these common occurrences and think women are being dramatic when they cry and stress about the changes to their once uncomplicated lives pre-vaginal birth (regarding exercise, controlling wees and bowel motions) when there is significant damage.

Here is Amy’s story:

In the lead up to the birth of my daughter in December 2013, I had become set on a natural birth, I wanted my daughter to get those important antibodies from the birth canal and after doing my calm birth course I was all set to breathe her out.

Except nothing can really prepare you for the pain. After 9 hours of laboring, vomiting and scratching the paint off our bathroom walls, the midwife on duty at the hospital finally said we could come in. I was desperate for the epidural I said I’d never get and 2 hours later relief was mine. When I was 10cms dilated we went to the next stage, an hour and a half of pushing and still no baby, that’s when we realised our girl wasn’t going to come into the world without help.

It came to an emergency decision between a caesarean section or high forceps, I wasn’t told the potential risks that lie with a forceps delivery and as my pelvic floor muscle was torn off the bone and my perineum cut, then torn (leaving me with a 3rd degree tear), they sent my new baby and partner out the room and ordered 2 units of blood, I lay there shaking and wondering whether I would die. The subsequent days where a morphine-induced blur until the unexpected afterbirth pains that came at night left me in agony, with every cramp I urinated in my bed, with no clue to what was happening- I just lay in a bed of urine. I was tied to a catheter for 5 days, I didn’t change a nappy till my daughter was a week old!

I could barely walk for around 4 weeks, much of that time was spent in bed, crying and wondering what I had done – my body now felt alien to me. However it wasn’t till my daughter was about 16 months old did I really feel the impact of the birth trauma.

Bio-feedback improved my faecal incontinence although without management I still have the odd accident. My biggest question then was ‘when would I be able to exercise like I used to?’ Exercise was a massive part of my life pre-baby – it was a huge part of my identity.

The obstetrician I was seeing said the physio (who had advised pelvic floor safe exercises) was just playing it a safe and that if I did prolapse then I could just get surgery after I’ve finished having kids.

I eased myself gently back into training and one day after a short run, I just knew something wasn’t right, a heavy feeling which I now know was as a prolapse. After examination from my physiotherapist, I was told that a bilateral levator avulsion was the cause and that’s when the bottom (literally) dropped from my world.

Not only would I no longer be doing the sports I loved but every day simple tasks that I once took for granted, like being able to lift up and cuddle my toddler, run, jump, sneeze, cough or perform basic functional movements like squatting and bending, became a constant source of worry – ‘have I made it worse’?

Yet I’m a mother running after a child all day long, how could I possibly avoid these tasks?

I felt completely alone, literally like I’m the only one with this and all at once overwhelmed by my bodies limitations. Here’s the thing with pelvic floor dysfunction, because you can’t see it, no one knows it’s there, so no one really knows how much you are suffering, yet my postpartum physiotherapist likened my injuries to that of being in a car crash- and some people thought I was lucky for not having a caesarean!

When I found out about my avulsion I felt like my quality of life was completely altered I found myself filled with anger, frustration, sadness and anxiety. I would revisit questions that plagued my mind -How can someone do that to my body? – damaging it beyond repair without informing me of the risks involved with forceps deliveries, LONG before I was in the delivery room.

When planning for a baby we certainly didn’t budget for the thousands upon thousands of dollars spent on doctors, physiotherapy, counselling and psychiatry.

A year after my initial diagnosis, I had a 3D/4D Ultrasound and I was able to visually review my bi-lateral avulsion and Stage 2 bladder and bowel prolapse. I have made the decision not to pursue surgery as it’s my understanding that prolapse surgery has a 30% risk of failure, however with a bi-lateral avulsion that risk increases to 80%. At the age of 35 I am not prepared to spend my time in and out of hospital. What concerns me is that surgery was viewed as the answer to my problems, where I feel that doing everything to avoid pelvic organ prolapse is more important than thinking surgery is the solution when it happens.

I never thought I would be able to make peace with what happened that December day, but I am thankful to be here now as a voice for so many who choose to suffer in silence. Pelvic floor dysfunction has serious power over everyday life, affecting all areas of your world and the people around you. Whilst I still think natural births are a beautiful thing, my wish is for women to have an opportunity to be provided informed consent about the risks involved with childbirth, especially forceps, so decisions don’t need to be made in emergency situations, without proper information, without informed consent.

Thank you Amy for your wonderful personal account and being brave enough to come out about it. With stories like these perhaps our global health target will be achievable as we spread the word about prevention to the next generation of mums and health professionals.

In response to Amy’s articles I have had a wonderful comment which deserves to be included in the article. It is from Liz Skinner a researcher and midwife who works with Professor Peter Dietz who has published around 200 articles on Levator Avulsion and is leading the conversation about birth choices for women.

Thank you so much Sue and Amy for this invaluable information and personal experience. I am at present working tirelessly with Prof Hans Peter Dietz and his team in Sydney to change clinical outcomes for women.
More women are bravely coming forward after forceps deliveries with these terrible injuries and despite the embarrassment they are realizing that change is imperative.

Childbirth is universally seen as a predictable and positive life experience despite women’s claims of pelvic organ prolapse, dyspareunia (pain having sex) and faecal and urinary incontinence after vaginal birth. Major pelvic floor dysfunction, often due to forceps use in labour, can affect 20-30% of primiparae. Such damage is rarely considered as compromising postnatal psychological health.

Traumatic vaginal birth, followed by the embarrassment and isolation that results from pelvic floor and anal injury, requires investigation as a major contributor to psychological problems post-partum. Such injuries are commonly dismissed as ‘trivial women’s issues’ and subsequent psychological symptoms confused with tiredness, pre-existing marital disharmony, postnatal depression (PND) or other psychosocial factors and treatment becomes inadequate. Unfortunately the literature on this topic is sparse and almost entirely ignores obstetric history.

Maternity services worldwide do not recognize pelvic floor dysfunction as a cause of mental health dysfunction regarding morbidities that impact women’s sexuality or lifestyle.

Findings in a study that examined the effects of vaginal birth trauma, mostly after forceps deliveries, noted postnatal mothers were not informed by clinicians that their genital area would be so damaged and many stated that ‘down there’ felt totally foreign, disgusting and changed beyond recognition. These women suffered from dissociation, avoidance, numbness, flashbacks, severe anxiety, panic attacks and nightmares from a traumatic delivery, sometimes years later, and often during sexual relations. Furthermore, decreased libido, dyspareunia, lack of intimacy and marital problems exacerbated women’s psychological consequences.

A great need exists to learn how to prevent women from sustaining somatic and psychological injuries by acknowledging their concerns and providing accurate diagnostic and therapeutic services.

Great words Liz and let’s keep these conversations building so outcomes can be changed!

#Globalpelvichealth #pelvicmafia #reduceprolapseincidence #spreadtheword #breakthesilence #pessariesarentjustforoldwomen

  1. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Chapter3202008

Soft targets with funding cuts- More silence!

deaf meme

I work in an area that despite extraordinary figures of prevalence (urinary incontinence 1 in 3 women leak urine; faecal incontinence 1 in 10 women soil or lose gas; 27% have pelvic pain including dyspareunia (painful sex); and the doosey of prevalence 50% of women over the age of 50 have prolapse) – it’s an area where the silence surrounding these most personal issues is at times almost deafening, mostly because of the shame, loss of dignity and the most personal nature of these issues. Yes things have improved significantly in the media, but still women find it hard to divulge.

But what about the area of disability? How’s the silence going in those areas?

I had to see a patient on July 1 who is deaf and requires a deaf translator for her physiotherapy appointment. My secretary tried to book a translator via NABS (the National Ausland Booking Service) and was told that as of July 1 there was no longer funding for translation services for Physiotherapy and other Allied Health appointments. When I rang the CEO of NABS she reported that they had had $1 million slashed from their funding as of 1/7/16. Something to do with the NDIS.

Did we hear anything about that in the last week of the election? Or anytime in the month from when NABS were notified by the Commonwealth? (Yes apparently one month’s notice is enough to plan and budget for a service that is so essential for deaf people.) Well I didn’t; the clients didn’t; my mother didn’t and she reads the newspaper from cover to cover!

Why? Well I reckon disability is a soft target. It’s pretty difficult for someone who is deaf and therefore not able to speak to complain and get up in arms about the funding cut. So what happened?

A 47 year old woman had to have her 70 plus (I wasn’t rude enough to ask her age) year old Mum come and translate for me and my patient- about some pretty personal stuff. How is that right? And what about my own liability having a non-professional translator translate for me? What if there is a malpractice call against me? (hypothetically speaking- her mum was fabulous and there was no risk in that situation of that happening).

Our practice also sees men with urinary incontinence, erectile dysfunction and pelvic pain- many men suffer these conditions and yet there is possibly even more silence amongst men in pubs, in mainstream media or general conversations because ……..well mostly because men’s health is a bit like that. Men don’t always prioritize their health and wives tend to be considered a little naggy if pushing for a health check or investigating some unusual symptoms. So often the problems have escalated and are more serious by the time they are addressed.

nagging wife

Whilst the silence is deafening around men’s health, it too is starting to get traction through organizations such as Andrology Australia, a unique program described as a ‘centre without walls’ that operates nationally and brings together health and education experts and organizations from across Australia to develop collaborative strategies to raise the awareness of male reproductive health disorders and their associations with chronic disease.

And yet in the last month Andrology Australia has received funding notice also. This invaluable service provides educational material on Men’s Health topics- yes one of those silent issues again. After 16 years (and 59 editions of The Healthy Male) as the only national body providing evidenced-based information, best practice support and education, and policy advice in the area of male reproductive health and associated conditions, the Federal Government has withdrawn ongoing funding for the program.

Andrology Australia is lobbying the government hard to reverse this decision for the sake of the health of Australian men.

andrology australai

Well now after this latest 2016 election, we have a perilous situation. All politicians will be on notice (hope none of the male ones get a men’s health illness….) and may be more responsive to public campaigns objecting to bad decisions that affect soft targets. I wonder how many health programmes that have received funding cuts could be funded if politicians could no longer double dip with their living away from home allowances- it’s not an insignificant amount of money when they pay ‘rent’ to their wife who owns the negatively geared house and then also claim the nearly $300 per night allowance for living away from home?

Keep on your toes and get upset when soft targets are hit.

Postscript to this blog. I was rung on Friday by NABS CEO and she let me know they were re-instating Physiotherapy and other Allied Health to be funded. I asked how could they afford to do that? And she said “I don’t know but we’ll take it one day at  a time”. Now that is a perilous way to have to run an organization.

 

The Art of Authenticity

On the day after the announcement of our election a couple of weeks ago, a patient and I had a discussion (whinge) about the state of politics in Australia. It was prophetic because I had been struggling to find the word (in my head when listening to the numerous shows I watch…the ABC news, 7.30 Report, Q & A) to describe what was missing in many areas of life these days, but particularly in politics- and as we were talking, the word I had been struggling to find, popped out of this patient’s mouth…Authenticity. I suppose the swinging door of Prime Ministers over the last 9 years, could have contributed to our cynicism with our politicians and their very apparent lack of authenticity. But in many walks of life there can be a superficiality, a lack of depth and understanding of others situation in life, a lack of empathy.

Take for example the NDIS. Often audience members in shows like Q &A (often older, white men) ask a question of a politician saying “With our current fiscal position, how can we justify the money being spent on the NDIS?” Now he obviously doesn’t understand that the NDIS could be something that HE HIMSELF may need in the future, if he had the misfortune of having a terrible accident that caused a head injury and subsequent neurological impairment and a loss of his ability to work. A perfect example of a complete lack of empathy for those in a less fortunate situation. As though providing assistance and funding for disability in the community is a luxury that our financially strapped nation can’t afford?! He hasn’t obviously heard of the saying….there but for the grace of God!

The definition of authentic is to be real or genuine, not copied or false; true and accurate; made to be or look just like an original.

Below is a photo of some very authentic women.

Hannah Judith and patient

Prof Judith Goh AO, Harriet and Dr Hannah Krause AO

The real reason for this post on authenticity is to let you know that Dr Hannah Krause has just been made an OFFICER (AO) IN THE GENERAL DIVISION OF THE ORDER OF AUSTRALIA in The Queen’s Birthday 2016 Honours List for distinguished service to medicine in the field of urology and gynaecology, particularly through surgical assistance to women in developing countries throughout Asia and Africa.

Now Hannah (and Professor Judith Goh) are a rare breed.

They work tirelessly all year to help women in Australia – here in Queensland- to achieve continence, to manage their prolapse and help with their pelvic and bladder pain and then…… when they go on holidays, to Africa, they do …….more operations- helping the desperate women of Africa who suffer the burden of a fistula. (You can see a list of the different camps and hospitals that they visit in Hannah’s list of volunteer work at the bottom of this blog) I have written about the work they do in numerous blogs, but it is so wonderful to see the public recognition of Hannah’s work with an AO!

A big congratulations Hannah. 

In case you feel like making their job a little easier- I will include a link to HADA, the organisation where you can donate directly to their work. Just make sure you nominate Medical Training in Africa. You may remember that six months ago (yes it is half way through this year already!!!) I announced as one of my New Years Resolutions, I was asking that the only presents I received this year were donations to HADA- as I had everything I needed and I am desperate to not get any more trinkets. Well it is going very well, particularly as I have also decided to give presents of donations as well to my family and staff. Now everyone who has received the gift of a donation to HADA so far, has been very gracious and said how nice (and I think they genuinely mean it) and I would encourage everyone to contemplate the thought of giving a donation, even as well as a smaller gift to someone, if you don’t want to make it the total gift.

Now let’s keep our chins up- there’s only 3 more weeks to go, in the longest election campaign of all time.

Let’s watch and see if our politicians can improve on their authenticity.

 

Hannah’s achievements 

Service includes: Urogynaecologist, Queen Elizabeth II Jubilee Hospital, since 2006.

Visiting Urogynaecologist, Greenslopes Private Hospital.

Committee Member, Queensland Branch, Continence Foundation Australia, current; Past Vice-President.

Volunteer Specialist, Fistula Camp, Kagando Mission Hospital, Uganda, since 2010;

Actively involved with training programs for local medical staff and volunteers.

Volunteer Specialist, Pelvic Floor Workshop, Cambodia, 2015.

Volunteer Specialist, Fistula and Pelvic Floor IUGA Workshop, Mankessim, Ghana, 2014.

Volunteer Specialist, Fistula Outreach, Mercy Ships, Conakry, Guinea, 2010;

Aberdeen Fistula Centre, Freetown, Sierra Leone, 2007;

Anastasis Fistula Outreach, Monrovia, Liberia, 2005.

Volunteer Specialist, Fistula Camp, HEAL Africa, Goma Democratic Republic of Congo, 2008-2011.

Volunteer Specialist, Bahir Dar Hamlin Fistula Centre, Ethiopia, 2007.

Volunteer Specialist, FistulaUnit, Dhaka Medical College Hospital, Bangladesh, 2003-2004.

Volunteer Doctor, Fistula Hospital, Addis Ababa, Ethoipia, 2009, 1997 and 1995.

Volunteer Doctor, Soddo Hospital, Southern Ethiopia, 1995.

(Makes my volunteering at tuckshop look a little ordinary).

200: It’s all about numbers today!

200 image 1

200 image 1

Blogs are usually about words but today, on this the first (1st) day of winter, the 1st of June, this blog is about numbers because THIS is my 200th blog. Yes, that’s correct – 200 blogs (articles about the bladder, bowel, pelvic floor, pelvic pain, men’s health, travel and a few other things like Italian toilets).  Goodness gracious (you may be saying) she’s got verbal diarrhea! How can you possibly continue to find things to write about the pelvic floor after this many years? But since I started the blog in July 2011 there has never been a time when I have thought ‘I’ve run out of things to say’.

Every day there are ideas that pop into my head from things patients say, from things I have learned and sometimes from things that have got me riled up. For me writing my blog is like knitting is, for people who are knitting fanatics (Elaine Miller) who would rather do knitting than perhaps the task at hand; or cooking for others who love to bake a cake, than fold the washing – they’ll always find time to knit or cook and the more mundane jobs go onto the backburner.

I am exactly the same with writing. It is a stress reliever and of course it gives me a chance to thumb my nose at my English teacher who desperately tried to make me fail Senior English! (You’ll read about her in my 100th blog). In fact it only seems like yesterday that I was writing my 100th blog and to think that here it is the 200th – well where have those years zoomed to?

fitpros1fitpros2

Marietta and I at the CFA Core Foundations day workshop

As this blog is about numbers, I thought I’d start by talking about the 120 Fitpros (Fitness Professionals) who attended the Core Foundations lectures Marietta Mehanni and I presented at The Mecure Hotel on Thursday. Honestly they were a fantastic, enthusiastic, attentive audience who have already gone out and started conversations about pelvic floor safe exercising with their clients. I received an email from a wonderful attendee on Friday who said:

Hi Sue, I attended the pelvic floor first seminar yesterday and let me say it was a godsend!!!!Not only did I gather soooo much new information and was highly impressed with the day, but I have openly discussed the topic with all of my clients since then (7 women in total) and can’t believe the results!!!!! Almost every one of them has experienced LBL (Light Bladder Leakage) and some of those ladies haven’t had children, and 1 has had a prolapse after her 2nd child AND didn’t think I needed to know that info! I actually couldn’t believe what my ears were hearing, and have instantly changed her training program (not that there was anything of huge concern). I can’t thank the Continence Foundation of Australia for putting this free event on; thank you Sue and Marietta – I found you both so professional and inspiring to listen to, and would be interested in a lot more further study!

Well I can tell you that email warmed the cockles of my heart! Such an immediate result from just a day of education! And that’s what’s so important about a Continence and Women’s Health physiotherapist’s job- it’s really all about education. A few simple facts about what is right and what is wrong with the bladder, bowel and pelvic floor and lots of improvement can happen- and to be honest pelvic floor unsafe exercising has actually educated and fed my family for the past 25 years. But that is changing and those Fitness Professionals and their enthusiasm and desire to learn and change their practices was absolutely heartening.

And don’t get me wrong we need to exercise!! Why?? Well let’s look at the numbers:

Physical inactivity is now identified as the fourth (4th) leading risk factor for global mortality and in older adults worldwide, around 3.2 million deaths per year are being attributed to inactivity. (World Health Organization: 2013 Diet and physical activity factsheet. 2014 Secondary diet and physical activity factsheet) Let’s look at obesity: 50% of adults in OECD countries are overweight and 18% of the adult population classified as obese. (World Health Organization (2013) Nutrition: “Controlling the global obesity epidemic”) And what do we know about physical activity? It’s a key determinant of energy expenditure, fundamental to energy balance and weight control. (WHO, 2014)

So if we need to exercise, how prevalent is pelvic floor dysfunction with varying degrees of physical activity?

Let’s look at the statistics: What is the prevalence of Urinary Incontinence across female life-stages?

Nulliparous elite athletes: 51 .9%   (Gymnastics main culprit 56%  Aerobics 40% (Thyssen2014)   Trampolinist 85% (Nygaard et al 1994) – What the……you are saying!!

Pregnancy related: Last trimester: Primips (first time mum) 48% Multips (had one or more babies) 85% (Morkved & Bo 2003) What the……you are again saying!!

Age related urinary incontinence: (Herschom et al 2003) 18-40: 25%; 48-54: 46% (Mishra et al 2010) Over 65: 55% Wow you could feel a bit out of it if you were dry (only joking).

So this incontinence thing is very prevalent! I could go on forever about prolapse prevalence, about pelvic pain prevalence but these are things for another blog.

Because in this, my 200th blog, I want to tell you about some other numbers. For all the 25 years I have been in private practice – it is only since last year that I have been computerized and we chose Cliniko to do our appointment system. Now the beauty of being computerized is that for the first time I now know exactly how many patients we see in any given time. So over the first twelve months of Cliniko, I have had a total of  1779 appointments of which 774 were new patients. I had to sit down after I delved into those stats because I felt a tad weary. 774 times in just 12 months I have told that beautiful bladder/bowel/prolapse/pelvic pain story ……… just as well I love talking!

And to just finish off this numbers blog -today the 1st of June was also my Father-in-law, Allan Croft’s birthday and today he would have turned 100 years old. He is still lovingly remembered by his children Dave, Helen, Greg and Bob and all his grandchildren and great grandchildren.

pa

Vale Pa

 

 

Nocturia- Really you are going to wake me again bladder?

What are the symptoms of nocturia?

Normally, you should be able to sleep six to eight hours during the night without having to get up to go to the bathroom. People who have nocturia wake up more than once a night to urinate. This can cause disruptions in a normal sleep cycle.

Nocturia may result from several different causes:

  • You produce a great deal of urine (more than 2 liters) a day (polyuria)
  • Your body produces a large volume of urine while you sleep (nocturnal polyuria)
  • You produce more urine at night than your bladder is able to hold (low nocturnal bladder capacity). This causes you to wake up at night because you need to empty your bladder.
  • A combination of nocturnal polyuria and low nocturnal bladder capacity (mixed nocturia)
  • Poor sleep: Some people who have poor sleep and awaken frequently will go to the bathroom whenever they awaken. Typically in these cases, it is not the need to void that awakens them.
  • sleep apnoea and nocturia

What are the causes of nocturia?

There are many possible causes of nocturia, depending on the type:

Causes of polyuria
  • High fluid intake
  • Untreated diabetes (Type 1 and Type 2)
  • Diabetes insipidus, gestational diabetes (occurs during pregnancy)
Causes of nocturnal polyuria
  • Congestive heart failure
  • Oedema of lower extremities (swelling of the legs)
  • Sleeping disorders such as obstructive sleep apnea (breathing is interrupted or stops many times during sleep)
  • Certain drugs, including diuretics (water pills), cardiac glycosides, demeclocycline, lithium, methoxyflurane, phenytoin, propoxyphene, and excessive vitamin D
  • Drinking too much fluid before bedtime, especially coffee, caffeinated beverages, or alcohol
Causes of low nocturnal bladder capacity
  • Bladder obstruction
  • Bladder overactivity
  • Bladder infection or recurrent urinary tract infection
  • Bladder inflammation (swelling)
  • Interstitial cystitis (pain in the bladder)
  • Bladder malignancy
  • Benign prostatic hyperplasia (men), a non-cancerous overgrowth of the prostate that obstructs the flow of urine
Possible causes of mixed nocturia

Any of the possible causes listed under nocturnal polyuria and low nocturnal bladder capacity

How is nocturia diagnosed?

To help your doctor diagnose nocturia, you can keep a fluid and voiding diary. This is a two-day record of how much you drink, how often you have to go the bathroom and the urine output, any medications you are taking, any urinary tract infections, and any related symptoms. Your doctor will review the diary in order to determine the possible cause(s) of and treatment for the nocturia.

Your doctor may ask you the following questions:

  • When did this condition start?
  • How many times do you need to urinate each night?
  • Is there a large or small volume of urine when you void at night?
  • Has there been a change in urination output (increase or decrease)?
  • How much caffeine do you drink each day, if any?
  • Does frequent urination during the night keep you from getting enough sleep?
  • Do you drink alcoholic beverages? If so, how much each day?
  • Has your diet changed recently?

In addition to reviewing your voiding diary, your doctor may order a urinalysis to examine the urine for infection.

Is nocturia treatable?

If you think you might have nocturia, see your physician. He or she may refer you to a urologist to treat the condition.

Treatment depends on the type and cause of nocturia. If sleep apnea is considered, you may be referred to a sleep specialist or pulmonologist.

Treatment options for nocturia may include:

Interventions:

  • Restrict fluids in the evening (especially coffee, caffeinated beverages, and alcohol).
  • Time intake of diuretics (take mid- to late afternoon, six hours before bedtime).
  • Take afternoon naps.
  • Elevate the legs (helps prevent fluid accumulation).
  • Wear compression stockings (helps prevent fluid accumulation).
  • compression stockings for nocturia

Medications:

  • Anticholinergic medications: reduce symptoms of overactive bladder
  • Bumetanide (Bumex®), Furosemide (Lasix®): diuretics that assist in regulating urine production
  • Desmopressin (DDAVP®): helps the kidneys produce less urine
    References

    © Copyright 1995-2016 The Cleveland Clinic Foundation. All rights reserved.

The Relationship between Mental and Physical Health

I asked Director and Principal Psychologist Christine Bagley-Jones of the Counselling and Wellbeing Centre, Woollongabba, to write a blog for me about the link between mental and physical health incorporating physical exercise. She and her team of psychologists help individuals, couples, families and organisations achieve social, emotional and physical well-being.

counselling and well being centre

By looking after your physical and your mental health, you can feel stronger, more competent and boost your self-esteem. Understanding the link between mind and body is the first step in developing strategies to reduce the existence of poor health of any form. Mental health is more than the absence of a mental health condition or illness: it is a positive sense of well-being, or the capacity to enjoy life and deal with the challenges we may face.

Mental health impacts each and every one of us.  We all have mental health, just as we all have physical health.   Mental health is not fixed. It is influenced by a range of factors, including our life experiences, workplace, social and economic conditions and of course our physical state.

Whatever attitude you have about your body and physical constitution, it will inevitably impact your mental health. This can have an effect on all areas of your life including your relationships, career, and aspirations. This is why it is so important to look after all of you.

A starting point for positive change may be as simple as embracing your exercise routine (including strengthening your pelvic floor and making the exercise pelvic floor safe if necessary) with an attitude of optimism and belief that you are doing your body a big favour.

Because ‘good’ mental health is essential for maintaining your physical health, at the Counselling & Wellbeing Centre we use an holistic approach. That is, we look after your mind, body and spirit. We can assist in resolving past issues, negative thought patterns, motivational issues and low mood. By utilizing a variety of proactive psychological therapies that suit you, we can get to the heart of the matter and assist with making lasting changes.

Thanks Christine for this blog. Mind and body are inexorably linked and it is important to do your best to work on both. At Studio 194 we offer dance, yoga, Pilates and a pain relaxation class- all amazing opportunities to fine-tune your body and if there are issues that you need help with, it sounds like the fantastic psychologists at Christine’s Counselling and Wellness Centre will be able to help.

amanda pilates

 Amanda Lee demonstrating Pilates 

nicoletta dancing

Nicoletta dancing up a storm

wilsons prom 1

Wilson’s Prom, Victoria. A beautiful vista to ponder!

Cancer: It’s never been a better time to exercise

runners

As you all probably know by now, the importance of exercise is something I talk about everyday. I write about it, tell my patients about it and, of course, promote it through my own exercise studio.

No matter what form of exercise it is, as long as it’s pelvic floor safe (if you have pelvic floor dysfunction) and gets you moving, the benefits are endless. I could talk for days about how exercise helps to decrease the impact of ageing, has a positive effect on mood and strengthens the body as a whole.

A feature on exercise and cancer on the ABC’s Catalyst program was a real eye-opener and revealed some wonderful research which could very well have the potential to drastically change the survival rates of those living with cancer.

A specialized gym attached to the  Edith Cowan University in Western Australia’s chemotherapy centre has been set up by Dr Robert Newton in the hope of proving that patients undergoing chemotherapy can immensely benefit from exercise.

Led by a team of exercise physiologists, patients attended the gym three times a week – most of them had their first session just hours after a round of chemotherapy.

Some patients who participated in the trial had their reservations at first, due to the way they were feeling after their chemo, but little by little, they saw the great benefits of exercise during their treatment. Measurements showed their muscle mass and strength had increased which is incredibly important during the treatment phase of cancer. Good circulation and muscle strength actually play a key role in helping the chemotherapy to work to its full potential.

Alongside the physical benefits, patients also reported less feeling of fatigue and a better overall mood and outlook on life. Once again, it seems like exercise is the real winner here.

Following amazing studies in recent years, exercise is said to double the chance of survival after cancer. This is fantastic news and is hopefully motivation for everyone undergoing treatment for cancer to gradually learn to love exercise again.

It’s stories like this that make me excited for my upcoming Gynae and Breast Cancer Rehabilitation Course at Studio194.

The course consists of one class each week running for an hour, for a total of 10 weeks. It’s run by physiotherapist and Pilates instructor Amanda Lee. The first five weeks have an education component, a gentle exercise component relevant to any specific weakness or pain the participant may have, and finally relaxation and breath awareness training.

The education component includes information about pelvic floor function, good bladder and bowel habits; the physical effects of radiation therapy and/or chemotherapy including managing the extreme fatigue that accompanies these treatments; good nutrition and healthy eating and an introduction to mindfulness.

The second five weeks will have an increased exercise component appropriate to the physical capability of the participants with the aim of building strength and vitality in the post cancer treatment phase.

The aim of the course is to help those recovering from cancer to not only survive, but thrive.

It’s such a great feeling seeing exercise so heavily promoted as a form of medicine these days. Hopefully in years to come, a specialised exercise program will become commonplace in hospitals for those undergoing treatment for cancer. In the meantime, we’ll continue to marvel at the work being done at Edith Cowan University and look forward to the future of cancer treatment.

Our Cancer Rehab Classes will commence when Amanda Lee comes back from her wedding in Bali at the beginning of July.

monique pilates AmandaLee

Pelvic Floor Health for Men – Magazine Article written by Amanda Lee

Amanda Lee is a Women’s Health and Musculoskeletal Physiotherapist and Pilates instructor who has been working at my physiotherapy practice and pelvic floor safe exercise studio, Studio194, since August 2015. She was asked to write an article on Men’s Health for a popular men’s magazine Men’s Muscle and Health and she did a fabulous job and it got printed in full with beautiful images. Well done to this young men’s mainstream magazine for embracing such a topic and well done Amanda for a great article! The article is below in italics.

AmandaLee

Do you work on your core strength at the gym? How about your pelvic floor? Before you think “I’m a dude, we don’t have those!” – think again. Your pelvic floor is actually part of your core. If you imagine your trunk as a cylinder, your diaphragm makes up the ‘lid’, your deep abdominal and back muscles make up the front and back, and your pelvic floor is the base. Now the chances are that unless something has gone wrong ‘down there’, you probably haven’t given your pelvic floor much of a thought (or even knew that it existed). However, having a basic understanding of the anatomy and the function of the ‘levator ani’ (the technical term for the pelvic floor) is key to maintaining health in the nether regions. Not only this, but your pelvic floor health can have immediate implications on your sex life (hello stronger erections and improved ejaculation control). So have I got your attention now?

To understand what is normal function and anatomy and how to gain optimal pelvic health, let’s talk about the things that can go wrong. This can include urinary symptoms, rectal symptoms, pain on sexual activity, abdominal and/or pelvic pain. Any of these symptoms can affect men of all ages, ethnicities and populations. Furthermore, as part of the ageing process, the prostate (walnut sized gland responsible for semen production situated between the bladder and the scrotum) can enlarge and cause urinary problems of increased urinary frequency and reduced urinary flow. Pelvic symptoms can also arise with long distance cyclists, due to compression of the pudendal nerve, the main nerve in the pelvis responsible for sensation, motor control and bladder and bowel function. Those who work in physically strenuous jobs or lift heavy weights repetitively at the gym can also be susceptible to pelvic floor weakness, hernias, haemorrhoids or rectal prolapse (when the lining of the rectum can relax and even protrude – yep, not pleasant). But enough of the stuff that can go wrong – what can you do to prevent these things happening? To be able to do this, we need to learn more about the pelvic floor.

So what exactly is the pelvic floor?

Stein-Illustration3 drawing of the male pelvic floor

Copied with permission from Amy Stein’s site

Your pelvic floor is a group of muscles attached to the base of your pelvis. Here it sits like a sling or hammock, supporting your pelvic organs (the bladder and bowels).   Along with the sphincter muscles of the front and back passages, the pelvic floor is responsible for maintaining urinary and faecal continence. They are like your arm or leg muscles, meaning you can actually switch them ‘on’ and ‘off’ at will and they respond to strength training. What makes it harder to know whether you are contracting them correctly is the fact that we can’t really see them when they work, which is where physiotherapists specializing in the pelvic floor can be of assistance.

How to ‘find’ your pelvic floor

Found yourself stuck in a lift full of people, with a sudden irrepressible urge to pass wind? The anal sphincter is part of the pelvic floor muscles and you will be familiar with using them in the above scenario or similar. Now how about engaging the pelvic floor muscles that are situated more at the front? This involves more of a visual assessment. Standing in front of a mirror (pants and underwear off), visualize stopping the flow of urine. Did you see your penis retracting and the scrotum lifting? University studies have shown that the most effective way of getting a good pelvic floor contraction is if men think of ‘shortening the penis’ and ‘lifting the testes’. So just think, ‘nuts to guts’ – which you find may happen automatically say, when you’ve run into freezing cold water at the beach!

Great, you’ve found it! So now what do you do with this newfound skill?

Having a strong pelvic floor helps with urinary leakage which can occur after prostate surgery for cancer, increased urinary frequency and/or urgency issues and with lower back pain. Research also shows that it contributes to stronger erections and more control with premature ejaculation.

Ok then, how do I strengthen the pelvic floor?

To strengthen your pelvic floor try doing a contraction at about 70-80% of a maximal voluntary contraction (MVC) and holding this for 10 seconds. Don’t worry if the contraction drops off before 10 seconds, but you can work towards getting stronger and practising to eventually hold for this long. Keep breathing while contracting and make sure you fully relax the abdominal and pelvic floor muscles between attempts. Aim for 10 repetitions of these, three times a day. The fibres that work to keep things from leaking when you cough, laugh, sneeze or lift something heavy are called the fast twitch ones. To train these, try doing 10 quick pulse contractions at 100%MVC a few times a day as well.

Don’t forget to relax

Importantly, you must balance all the tightening with some relaxation. Lots of pelvic pain problems (such as anal fissures and pudendal neuralgia) can be exacerbated by overly strengthening your abs and never letting your pelvic floor muscles relax. An overly tight pelvic floor can cause pain and tightness in the muscles and connective tissue (fascia) all around the pelvis in an ‘overflow’ effect, so exercises to stretch the gluteals, hip flexors, hamstrings, quadriceps and back muscles can relieve the tightness that may be exacerbating pain.

Healthy Bladder and Bowel tips every man should know:

  • Aim to drink about 2 litres of non-caffeinated fluid a day – this includes water, juices, soups etc. Caffeine, and alcohol especially, have a diuretic effect and can irritate the lining of the bladder, making you need to go to the toilet more.
  • Limit caffeine to about 3 cups a day, if no overactive bladder symptoms – Otherwise go completely decaf if you do have an overactive bladder.
  • Sitting position for emptying the bowels – Straining to pass a bowel motion or having stools stuck in the colon or rectum can cause painful anal and rectal conditions. Effective emptying of your bowels is improved by using some elevation under your feet (this recreates the ‘squat’ position which actually helps to open up the rectum). This can be as simple as using toilet rolls or a low footstool. Sit with the feet flat; lean forwards, elbows resting on knees, maintain a straight back, while looking forwards.
  • Abdominal muscle coordination to empty the bowels – To avoid straining (which puts too much stress on the pelvic floor and pelvic organs), let your abdominals relax, then gently bulge your tummy further out.
  • Maintain healthy looking stools – Yes, look at the finished product. Stools which should be formed and soft but easy to evacuate are achieved by maintaining a healthy diet, including plenty of vegetables and fruit, and a good fluid intake.

Male toilet position

 Biography

Amanda Lee is a Brisbane-based pelvic floor physiotherapist who sees patients for pelvic floor dysfunction, as well as other musculoskeletal injuries and conditions at Sue Croft Physiotherapy in Highgate Hill, Brisbane. She also runs pelvic floor safe Pilates classes at Studio194 at Highgate Hill. Being actively involved in various sports has led Amanda to be passionate about helping her patients’ return to function, and improve their quality of life.

Men's magazine cover amandas article men's health mag image2 men's health mag image 3

Fantastic work Amanda! And great find by my PR girl Rebecca who sourced the lead. Amanda is heading off to Bali to marry the love of her life Damien at the end of May and all of the staff at Sue Croft Physiotherapy wish them lots of laughter and happiness for many years to come and we are all praying the volcano stays sleeping for the next six weeks. xx

amanda and damien

 

 

Happy Mother’s Day 2016

judith-goh-celebrating

mothers day 2016

How lucky am I to be able to celebrate Mother’s Day with my Mum who at nearly 91, still drives herself to the function, is independent and engaging and has a better memory than all of us combined! May all those qualities be embedded deep in my gene pool and be ever present when I hit 91!

Speaking of embedding, I have been trying all night to embed a video I made today into this Mother’s Day blog – one following the theme from the previous two blogs on how important it is to relax your abdominal and pelvic floor muscles – but technology wins tonight as i just can’t make it happen. A young thing may help me tomorrow make it happen. They are very clever…young things!

The most important reason for this blog though is to report on the success so far of my 2016 pledge to encourage donations to HADA instead of people giving me presents for Mother’s Day, my birthday and Christmas. All my lovely family complied and gave to the Medical Training in Africa programme, which has three great outcomes: I think it’s is fantastic;the wonderful work that Judith Hannah Barb and Neroli do is supported; and there is no extra clutter in my house with ……things!

The other most amazing selfless act is my wonderful staff have also wanted to be a part of this pledge and instead of gift vouchers for their birthdays, they also have requested donations be made on their behalf.

Just think if more people made a conscious decision to do something like this!

If you would like to join in- this is the link to Professor Judith Goh’s HADA Medical Training in Africa programme.

judith-goh-celebrating

The smiles say it all. Their windfall is not a Gold Lotto win but the gift of Continence!

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