Jo Willmott

Brief Outline:

Jo sees people with conditions such as stress and urge urinary incontinence, pelvic organ prolapse, painful sexual intercourse, and other urogynaecological conditions. She works with people to optimise their pelvic floor muscle function and provides education on good pelvic health. Jo has worked in pelvic health physiotherapy for over 15 years.

Background:

Jo is a Pelvic Health Physiotherapist.

Jo, a physiotherapist, discusses the importance of pelvic floor physiotherapy and what an appointment with a physiotherapist may involve.

As pelvic floor physios, we’re talking a lot about pelvic floor, and so firstly if our goal was to strengthen the pelvic floor and we know that with, with conditions like stress incontinence and prolapse, supervised pelvic floor strengthening, or pelvic floor training with a pelvic floor physiotherapist so a programme of pelvic floor strengthening, for around 50% of women will sufficiently improve their symptoms that they’re no longer sort of bothered by their symptoms. So we know that pelvic floor strengthening does work, you know, particularly in those conditions, and so a pelvic floor squeeze is when you’re tightening and pulling in around the vagina and back passage. So it might be like, it might, you might sort of imagine that you’re pulling in around the back passage, like you’re holding wind, and pulling up towards the so the pubic bone at the front, like you’re trying to stop yourself passing urine. And, and then relaxing and letting go. So it’s a squeeze and pull in around the vagina and back, back passage, and then a relax and let go. We do want to make sure that we’re isolating the pelvic floor muscles and not bringing in other muscle groups, so for example we don’t want to be squeezing our legs together. We don’t want to be clenching our buttock muscles, we want to be able to keep breathing nicely throughout and we don’t want to be overusing our abdominal muscles. So a little bit of gentle sort of core abdominal involvement is okay but not a lot of sort of abdominal work. So we’re trying to isolate those muscles without bringing in other muscle groups and we would then normally develop a programme of two different types of exercises. So want to do some quick squeezes, so an exercise would be just a nice strong squeeze and pull up of pelvic floor and then relax and let go. And we’d build up and ideally sort of build up, you know, to be able to do maybe ten of those in a row. And they’re really important for things like stress incontinence. If you cough or sneeze and, and leak, we want to be able to recruit those muscles quickly, so that if you felt a cough or squeeze, cough or sneeze coming on you could do a quick pelvic floor squeeze. We also want endurance in the pelvic floor muscles. We want them to be able to squeeze and hold and provide sort of, you know ongoing support. So we’d also develop an exercise programme where they’re tightening and pulling up the pelvic floor and holding, keeping breathing, really importantly. And so part of our examination we want to get an idea of how long someone can hold a pelvic floor squeeze for, again up to about 10 seconds. I think a lot of the time people think they are holding the pelvic floor and then we assess them actually find that the muscles fatigue quicker than they think. So with an endurance hold you want to be able to feel the pelvic floor squeeze and pull up, and then at the end of your hold you want to be able to feel it letting go as well, so that knowing that you’ve released that muscle and it’s not fatigued before then. So yeah, it would be a combination of quick squeezes, so squeezing and pulling up, relaxing and letting go plus some endurance holds where you’re squeezing and holding and breathing and then relaxing and letting go. And again, we might aim to do up to a ten second hold and up to ten of those in a row. And there’s good evidence to show that an exercise programme of three sets per day is, is, is what, you know can be quite sort of effective in improving those symptoms of sort of stress incontinence and prolapse, particularly.

I think a lot of people know about pelvic floor strengthening exercises, but that’s not necessarily the right thing for everyone. If you have, for example, pain, or painful intercourse or for some people it might be that their pelvic muscle, pelvic floor muscles they’re holding them tight. So the pelvic floor muscles are slightly high tone. Slightly tight. And actually might need to learn to relax the pelvic floor muscles.

So part of what we do is firstly assessing well, you know do you know how to do a pelvic floor squeeze. But also how well the muscles are functioning at the moment, how strong the muscles are, can someone squeeze and hold the muscles, can they actually relax and let the muscles go as well. And the best way to assess that is to do a vaginal examination. So that does involve sort of undressing from the bottom half, having a lie on a bed, we’d, you know we’d always give someone something to pop over them for, you know, for sort of dignity. And we’re having a look around the opening of the vagina, we’d like to check sensation, so check that the skin sensation is normal. We would ask someone to do a pelvic floor squeeze and see how well they can activate the muscles. What their technique is like. How well they relax the muscles. We might get them to cough or bear down to look for any signs of prolapse. And then we would again with their consent, insert a finger into the vagina, and that’s, we can then get an assessment of the tone of the muscles, again we can assess for any prolapse, and then we would go through more pelvic floor squeezes so really trying to get a good idea of how well they can squeeze and hold by being able to palpate the muscle, by sort of via the vaginal examination we can really assess how strong the muscle is, how well it squeezes, how well it holds, how well they let go.

Jo, a physiotherapist, describes what the pelvic floor is and the roles that it plays.

The pelvic floor is a sling of muscles that run from the pubic bone underneath to the tailbone. So it’s this sling of muscles underneath, and the muscles go around the urethra and the vagina, and around the back passage. And they sort of lift up underneath and help support the bladder, the uterus and the bowel. So they’re really important for maintaining our continence, so these muscles help sort of squeeze and close off around the urethra, and the vagina and the back passage, so they do help us control our bladder. So if you had a really full bladder and you felt that you were about to cough or sneeze, you might tighten your pelvic floor. They help control our bowels, so again if you felt that you were about to pass wind, you might tighten your pelvic floor and help control that. They provide support, they have a really important role in sexual function as well, so with sexual response. And so, a healthier pelvic, pelvic floor is important not only for control of bladder and bowel, so being able to hold on, but also emptying. So, when we go to the toilet to empty our bladder or to empty our bowels we need to be able to relax the pelvic floor as well. So really important roles in, in all of those areas.

Jo, a physiotherapist, describes what a hypertonic pelvic floor is, some of the symptoms, and how a physiotherapist might identify it.

The main thing to remember with the idea of hypertonic or over-active pelvic floor is that your pelvic floor muscles, like any other muscles in your body, so like your biceps or triceps or hamstrings, should be able to sort of squeeze and pull up, hold, and relax and let go, and also tolerate some degree of sort of gentle stress. And that should all be sort of comfortable. So, with hypertonic or over-active pelvic floor it tends to be that the muscles are held in more of a tense position and we’re not getting that relax and let go. That might be that you’re tending just to hold tension in the pelvic floor almost all of the time. Or it might be that your pelvic floor muscles sort of involuntarily tense or contract in response to some sort of- so for example in to penetration sort of with the vagina so that could be with intercourse, it could be with trying to insert a tampon, it might be with a smear test. So, you’re not sort of in control of that, your pelvic floor muscles are just tensing with that sort of penetration. But like I said it could be just that you’re holding these muscles in some sort of tension almost all of the time. And again, that’s not something that you’re necessarily in control of or aware of.

So, muscles that are tensing all the time can become painful. the way that might sort of manifest when it comes to sort of the pelvic floor muscles is that things like intercourse might become painful, you might struggle to insert a tampon or that might be painful. Like we said things like smear tests could be painful. But also, things like emptying your bowels. So, to be able to effectively empty your bowels, your pelvic floor muscles need to relax, and we want that sort of gentle degree of stretch in the pelvic floor muscles. So, you might struggle to empty your bowels, you might feel that you need to really push or strain to empty your bowels, you might feel that you can’t completely empty your bowels. So, all of those are potential signs that can be associated with that hypertonic or over-active pelvic floor.

We would always offer someone an examination of the pelvic floor, which is that vaginal examination that we sort of previously discussed. So, if someone sort of consented to that examination I might be able to get that information, so particularly by the sort of palpation, so inserting a finger into the vagina if it’s comfortable, if they can tolerate that, might give me an idea of whether there is that tension and-, tension in the pelvic floor, and if that palpation of the pelvic floor muscles is painful or uncomfortable.

Jo, a physiotherapist, highlights some of the options available for managing a hypertonic pelvic floor.

We want to optimise pelvic floor function. So, we’re looking at improving that relaxation in the pelvic floor muscles and that flexibility of the pelvic floor muscles, so there should be some movement in the pelvic floor muscles. There should- there should be some lift when you’re doing a pelvic floor squeeze. There should be a relax and let go and like we said the muscles should tolerate some degree of stretch. So, we want that movement and flexibility through the pelvic floor. So, how do we sort of work on that? So, we work on that with breath work. So, there’s a really important connection between the diaphragm and breathing and the pelvic floor. So, we might just start with looking at how someone’s breathing and particularly with a type of breathing called diaphragmatic breathing. So that would be one thing we would start with often quite early. We might look at some pelvic floor exercises, but not at a squeezing, holding, look at strengthening that squeeze, but really optimising how the let go is. So, looking at a gentle squeeze perhaps, but then a really good sort of let go. So, we might look at some pelvic floor exercises but there’s going to be a different focus to if we were doing strength work with someone.

So that’s what we might be looking at from an exercise point of view, as well as sometime other general stretches that we might look at. We might look at progressing to something, some work with vaginal dilators, potentially. So, a vaginal dilator is a small device, something similar to, looks like, so there’s different sizes and we might be starting with something that just is literally the size of a finger. It could be a kind of soft, flexible silicone or a harder, rigid plastic. And we might start doing some work with the vaginal dilators to look at using them to help some gentle stretch to vaginal tissues and to the pelvic floor muscles. So, it might be something that is inserted into the vagina to gently stretch. And that might gradually progress in terms of the size of the dilator, and that’s something that we might use to really work towards being able to manage penetration for example. So that’s another option and I think the main thing is that you’re always looking at a really individualised program.

But there are other things that might form a part of a program for managing over-active and hypertonic pelvic floor. There might be sort of talking therapy that’s involved, so you might see someone else to sort of look at exploring other reasons why that you might have these symptoms. Sometimes it might be to do also with the condition of the vaginal tissues, so for example in someone post-menopause, they can have slightly thinner, dryer vaginal tissues and they might look at using some vaginal estrogen. So, there’s definitely other aspects as well. But from an exercise science point of view, we would certainly you know start with looking at breath work and that pelvic floor relaxation and that pelvic floor flexibility.