Urogynaecological conditions: prolapse, bladder and pelvic floor problems

So prevention of pelvic floor problems is probably the big, the big kind of new phase of our speciality, in trying to work out how we prevent, because they are very common. We know that nearly half of women will develop some form of prolapse, incontinence, or pelvic floor problem. And nearly one in ten women will have surgery. So it’s clearly an epidemic or an endemic, and as we have an aging population becoming more common so trying to prevent it is, is, is really key. A lot of those things are simple: healthy living, maintaining an ideal body mass index, avoiding things that we know to trigger bladder, so things like caffeine for example, and certain environmental or dietary things can make the bladder worse. Maintaining pelvic floor, strengthen pelvic floor tone, so we all don’t bat an eyelid going to the gym to workout and make sure that we can run a marathon or, or undertake exercise classes, but we often neglect the pelvic floor. And when we talk about pelvic floor, we can kind of think of it as a group of muscles that act as a hammock for the bladder, the bowel and the vagina and just like any other muscle group whether it’s your cardiovascular fitness, or your abs, you can work out those pelvic floor muscles to try and prevent the development of prolapse and incontinence.

And then there are the kind of two big risk factors for pelvic floor problems; one is childbirth, and obviously that’s difficult because that’s something that a significant proportion of the population go through, and for most women undertaking a vaginal delivery, or a normal birth if you want to call it that, remains the safest option. But we do know that having a vaginal delivery significantly increases your risk of pelvic floor problems. But of course the alternative, a caesarean section, definitely doesn’t prevent you from getting a prolapse incontinence, and has its own set of risks. So often discussions about prevention veer into to how we manage childbirth and labour, but there’s a lot of other competing factors beyond the pelvic floor. And then sadly genetics, or bad luck. We know that you know that there’s a familial inheritance prolapse and incontinence which you can’t do anything about. And the other thing I didn’t mention as a cause is ageing, and of course we haven’t got anything, any treatments or solutions to the bad luck of ageing, which contributes to bladder symptoms and prolapse.

I am learning to live well with pelvic organ prolapse now and I have Grade 1 cystocele, rectocele and a uterine prolapse and I believe it was childbirth-related and also just a lack of support for postpartum rehab and recovery. It is funny when I talk to different health professionals, where it seems like a prolapse hot potato when you say it was probably because of these factors for my birth and people are quite quick to say actually it’s the pregnancy and the pressure of pregnancy and you’re an older mum but I think to my mind it’s very directly related to the birth experience I had. So I was, I had a few risk factors that put me more likely for developing prolapse. I was an older mum at 37, I had a larger than average baby but not, not massive. He was eight pounds six ounces so not, not huge and but I did have a very long pushing stage. I had a vaginal delivery. No instruments fortunately but I was on my back in a lithotomy position which wasn’t ideal and I ended up having an episiotomy which was I think necessary given the cascade of interventions I already had but again not ideal so that led to weakness in the pelvic floor.
 

It just yeah I know, it was very interesting when I was waiting to see the consultant when I was before I had my first operation for the rectocele and there was a lovely staff nurse in talking to me and it was before he came in and she was just chattering away and she was saying “So tell me how many babies do you have?” so I said “Oh I’ve had two” she said “And how big where they?” I said “Oh they were both nine pounder” I said “It was wonderful” I said “Because standard vaginal delivery absolutely no problems, a few stitches with my first” I said, “To be honest” I said “Shelling peas compared to a lot of my friends” and she was laughing and she said “Yes but you’ve got your problem now” and I said “Yes I have and that’s probably” she said “Well the new thinking is” and whether she was saying it I don’t know, she just said “ It’s the big babies that cause the problems, so you’ve had the brilliant birth but now the rectocele” the thinking is caused because the bigger the baby it contributes I’m not saying it causes, but it contributes to problems later in life.

I don’t think I suffered any other sort of problems until I had a hysterectomy, which would have been, oh when was that? That was probably about eight, ten years ago, when I did suffer a little bit from incontinence following that. I did get on top of that and it wasn’t too bad at all, in fact I don’t think it, once I got there it was okay. But then when was it, back in two thousand and-, beginning of 2019, so it’s a good two years or so ago, I started with a cough. And it wasn’t just a cough, it was a really, really, really bad cough. Cough, cough, cough, kept me awake at night, all sorts of things. I went to the doctor and I was put on inhalers and various things like that, and at that point in time again, the incontinence came back again. And I sort of mentioned it, but there wasn’t sort of, nobody sort of did anything or said anything and I just grinned and was bearing it. And I felt that probably it had just, all this coughing had just weakened my bladder. And so, I, as I say I put up with it.

Okay I started experiencing cystitis very regularly when I was about oh twenty, twenty or so and I went to see my GP, I was at university at the time and. I I can’t remember exactly but I I think they gave me some antibiotics or something. I I also, as the years went by, it, I got it more, you know, very regularly and then at some point somebody said to me, a GP said to me that it was often associated with intercourse. Then I sort of had a think about it and realised that that’s when I started being sexually active and that what’s when around about 20 and they definitely coincided and I found that very off-putting once I realised and also I knew that there was always the risk that I would have a period of cystitis which is very debilitating in the sense that your, you become unable to leave home or go far from a loo and it’s very uncomfortable and worrying and at some point I was asked to do mid-stream sterile urine samples and there was never really any indication of any bacterial infection.
 
So it was all a bit of a, bit of a problem really and nobody really suggested any, any solution that I would have just have to put up with it and in fact one GP I remember it clearly said to me, “Oh, you know, it’s one of those problems with women’s plumbing, it’s, it’s not a very good system” and I thought, ‘Oh that’s a [laughs] that’s a rather, a really helpful thing to say.’ And so from about the age of 20 until my mid-thirties or perhaps early thirties actually, I just had this recurrent problem and it didn’t, didn’t do anything very good for my married life because I got married when I was 25 and it made at times, made my life un unpleasant.

It’s so uplifting to think that, you know, something is happening, that, you know, that you’re, some, you know, people are on our side and, and trying to get things done. So, I’m really happy to do anything like this which is why I was determined to do it. I thought ‘I just do not want my own children, grandchildren, to deal with this when they get older’. Especially as we seem to be a bit susceptible in our family. So, you know, it’s I don’t, I mean, it must be something to do with hormones on the bladder lining or the, there’s a, they have, you have a layer apparently in your bladder, which is thick [coughs] whether or not there’s, you know, something to do with that or genetic thing, I don't know. But I thought, you know, if I’ve got my daughter and my granddaughter who have the same problem, despite all the precautions you brought up to follow, you know, hygiene wise, there’s still- and besides which the man in America said, “That’s nothing to do with it.” He said, you know, “Whether you wipe from front to back or not.” He said, “Otherwise everybody would have it, if that was a problem.” So, we’ve always been brought up to do the things properly, but they’ve still got it. So and I thought ‘well, it could be that the next one would be my lovely granddaughters, these lovely girls, you know, that might be faced with this and there might still be no help’. So, I’m very happy to do this.

I’ve been perimenopausal for five years and vaginal issues have been I don’t know, I’m quite sure how to quantify it, probably three years in maybe longer, longer I think, yeah I just wish I’d known more. I wish l because I think what my body was saying slowly was, you know, I need help particularly for the vagina vulva, it was slowly not functioning more and more, you know, it’s almost like more and more clues have been given to me and I haven’t, I haven’t responded to them, I haven’t taken heed and therefore I’m in quite a sorry state now, you know, it’s like an engine that’s just coming to an end, coming to a stop, to a halt more and more and you’re just not giving it what it needs.
 
Right.
 
You know, be it water or oil or whatever, what you’re not listening to it and you’re just, you’re just really taking it for granted and expecting it to work but also, you’re suffering in silence, you know, you’re suffering in silence.

Just become more aware of the symptoms of genitourinary syndrome of menopause how they might affect the bladder and the pelvic floor which can be another thing that’s related. There’s so much work being done in this area that, that we’re often when, when mentioning vaginal atrophy the bladder gets left out, so that’s a genitourinary syndrome of menopause is such a mouthful, so who wants to be saying that every time. So always ask, I would always say to any menopausal women who’s got bladder issues and they’re being linked in or referred into healthcare, ask whether there might be a relationship between low oestrogen and their bladder issues and that is so, so important. You know, whether it might be frequency, getting up in the night-time to wee irritation, painful bladder and just generally any sort of irritation and inflammation UTI’s if they’re getting recurrent UTI’s, ask if they might be, if they’re being treated and they’re not going away ask, what the reason, ask if it’s related to low oestrogen, ask whether it might be an embedded UTI for which different tests would be done, you know, not all healthcare practitioners are knowledgeable about that. Just, oh I don’t know, just always ask why, become informed.