Urogynaecological conditions: prolapse, bladder and pelvic floor problems

I think some sort of self-referral to physio. I don’t need to see a surgeon at this point. I’m happy to wait for surgery. I don’t even know if I want surgery but self-referral to a specialist women’s physio who’s got the expertise to help me with the pessaries, to tell me whether or not I need the oestrogen cream, you know, just - and they’re such low level things. Surgery’s a huge expensive thing. I don’t understand why the NHS isn’t prioritising first level care really, I really can’t get my head round it and I think I should have had access to that within six weeks really as a minimum and it shouldn’t be, I can self-refer if I have a knee for a foot problem, for a wrist problem, for a hand problem, I can go and I can be seen within two weeks. Why can’t I self-refer for a prolapse? It just doesn’t make sense to me, but they won’t take the referral.

I personally think that, if a woman at her six-week check shows signs of having a prolapse, there should be an automatic referral to physiotherapy and you should be seen by a physiotherapist within a timescale and you should be given an intensive course of physiotherapy, which is probably a lot to ask. I know things cost a lot of money but I do feel like, if you’re going to correct prolapses through physiotherapy, the only way you can do that is when they’re at very early stages and by having intensive physiotherapy very quickly so a twelve week programme of weekly visits to the physio. Very early on would probably actually help things get corrected instead of saying, “Come back in six months’ time. Come back in six months’ time.” And by that time, you know, you’re stage three prolapsed.

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.

I think the best time was when I went to see the physiotherapist. Because I felt like she really understood me, that she listened to what I was saying. And she asked me lots of questions, you know relevant questions, and she gave me lots of information and she answered all my questions. And she, I felt like she, she was sort of on the same wavelength in that she didn’t want to talk about the sort of drastic, you know like she wasn’t talking about starting with operations, she was sort of about the, the, starting with pelvic floor exercises and then you know going on from there, starting with just me being able to help myself but then if that doesn’t work then there’s this we can try and that we can try, you know. And being operated on was a very last resort which was exactly how I was feeling as well.
 
So that was really good, I just felt she had a really good understanding of my difficulties, and she was very positive about what could be done, and she also, it wasn’t just a one-off appointment, she said, you know, come back and if you’ve got more questions, ‘cos the first time you, you know when you ask loads of questions and then you go away and then quite often you think, ‘Oh why didn’t I ask this or that?,’ you know. So it’s always good to go back and, and also she gave me loads of exercises to do and it’s good to go back and know that you’re doing them properly and that, see if there’s been any improvement or not, and just to have, that just felt like proper care, it felt like you know it was, it felt hopeful and encouraging and it felt like it was more of a two-way conversation than just me being told what I should do, or what’s gonna happen or something like that.

My first physio was a nightmare if I’m honest and it, as a result I did actually end up going to counselling so she just showed no empathy or kindness, she was very factual. I know you have to be factual, but she was, this was very much how she kind of said things so the first-, there were a few things that kind of really stand out about it. One of which obviously I was saying there, she was asking about sex, not having sex and I just didn’t feel like I wanted it and she’s like, “Oh it’s okay, you just have to get back on it,” and I was like, “What does that mean, you know, I don’t, how do you do that?’ I don’t, I’m so lost now,’ I didn’t, I don’t, I think I lost myself as well within the whole process as well and so she said about coming off contraception which I because I was on the pill and I did because she said, “Oh yeah then it will just kind of come back,” and it’s like ‘Oh right, okay,’ so I just did that and her bedside manner was not very kind I suppose or it wasn’t, it wasn’t unkind, I think it was more empathy towards it because obviously you’re going in there, it’s quite, it’s quite daunting, it’s quite embarrassing. I wasn’t really expecting the physio that I had. I mean, I’ve had physio before from sport injuries and I just assumed, whether I didn’t read the letter properly I don’t know, but obviously it was internal physio and I found it quite intrusive.
 
The second physio, it wasn’t patronising or anything like that but she just, she just made me feel comfortable. I don’t know how she done it, she just made me feel comfortable. She didn’t do anything physically different to what the first physio done, she was still examining, examining me internally, it was just her way she did it and explained it, I think. Where the first physio was very direct and very blunt and this is it, it’s like black and white. Whereas sometimes you need that pink and fluffy because it’s quite undignified, when you have, when you know you’re pregnant, it does become undignified because everyone has to look up there, you know, everyone you kind of that bit kind of goes out the window.
 

And it, I was also told, from six weeks, to go away, do pelvic floor exercises, that will sort you out, you’ll be fine only to find in my first physio appointment that I actually cannot do a pelvic floor exercise correctly, which is probably not helped the fact that things have got worse with my prolapses because I’ve been working for two years on them but not been working correctly so I feel like if I’d been offered the help maybe sooner. I would have discovered that I wasn’t doing them correctly and I may not have got to the point that I’ve got to with my prolapses, so yeah.
 

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.

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.

And so I’ve had a hypertonic pelvic floor can cause issues with urinary retention, so I went along, I had a lot of pelvic pain, and so I went along to a women’s health physio, which was something else that I had to finance privately, and she’s been working on trying to release the tissues with internal massage basically, it’s fairly, fairly invasive, it’s not particularly pleasant either. So, she’s been doing some internal massage with me and some, I’ve had some acupuncture with her, and also, I’ve had she recommended I buy a therapy wand, so I can do a little bit of some massage myself in between sessions, just to try and free up the tissues, and soften them so that my bladder sits in a better position. And it isn’t, you know it isn’t quite so, the flow is better, my urethral flow is better.
 
You said that’s a little bit uncomfortable?
 
Yes, it’s uncomfortable because, and also, it’s, you have to have trust in the therapist because obviously they’re working internally, they’re massaging internally, so it’s, it can be a bit painful, and also it’s embarrassing I suppose.

I mean you go in and it’s not about them telling you what to do. They take a full history, they explain all how it all works, they were we did diary exercises about bladder and bowel and all that kind of stuff and then had a proper discussion about what the various options might be. It was much more of a holistic approach, so it wasn’t just pelvic floor exercises, it was diet, it was exercise, it was the pelvic floor stuff and I felt that I was being listened to. I felt that my views were valued and that we were working together to try and seek the best solution we could so that that for me works really well. I don’t want to be just told what to do. I want somebody who’ll talk me through what the options are and what the implications are of the various things that, that we might try so that for me works really well.