The concept of pain and pain management and treatment keeps coming up for me. It is arguably the most common presenting complaint in my practice and one I am seeking to expand my knowledge on.

I want to recap the most salient points I have learnt about thus far.

1. Pain is real.

Your pain experience is yours alone. no one can fully understand it, measure it, define it- but you. And if you are experiencing it then it is very, very real.

2. Pain CAN change.

Pain is described as being noviplastic in nature. That means it can change over time. It can get worse, but it can also get better. It is not a static construct that defines your existence.

3. The pain experience matters.

Imagine 2 scenarios involving you stubbing your toe:

A) rushing to get showered after a poor night’s sleep and big argument with a loved one. The water has just turned cold, you’ve run out of shampoo and as you reach to get the refill you bang your toe against the washroom door.

B) You are strolling down a sandy path towards friends waving to you from the beach. You are holding your favourite drink in one hand while taking in a beautiful sunset. Your foot catches on a wooden post lining the path and your big toe takes the brunt of the impact.

Same force, different scenarios- which toe hurts more?

Instinctively, we say option A.

Because what else is going on always impacts the pain experience.

4. Pain that has lasted for more than 12 weeks is classified as persistent pain.

Central processing changes have started taking place. That means that the brain is magnifying sensations in order to protect you. Actual tissue damage is no longer the main issue, instead pain is a means of communicating perceived threat or danger.

5. Seek out practitioners that will discuss multiple contributing factors to your pain experience.

They will ask what pain means to YOU and how it impacts your life and ultimately what goals you want to set for yourself.

6. Sensory integration is a strategy that helps re-introduce normal touch and tolerance to pressures and movements through the tissues.

Nerves, muscles, connective tissue all need to re-learn ‘normal’ The aim is to restore this function using pleasurable touch, allowing your brain and body to lower their defenses.

Ask your PT about sensory integration if you are experiencing persistent pain. 

Schedule you appointment with me today.

Join me  as I unveil the secrets of menopause in this presentation. With a pinch of humor and a dose of respectability, we’re breaking down barriers and empowering women to embrace this transformative stage of life.

Menopause is underspoken about. There are a lot of myths around it and it has very negative connotations. With our longer life expectancy we have to remember that we are going to live arguably half of our life post-menopausally. That’s why it’s important to know what to expect. In this video Dr. Daniela Steyn and I discuss how you can thrive through menopause.

A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence  and to treat pelvic organ prolapse to maintain the location of organs in the pelvic region. It can also be used to administer medications locally in the vagina or as a method of contraception.

Early use of pessaries dates back to the ancient Egyptians, as they described using pessaries to treat pelvic organ prolapse.[3] The term ‘pessary’ itself, is derived from the Ancient Greek word ‘pessós’, meaning round stone used for games. The earliest documented pessaries were natural products. For example, Greek physicians, Hippocrates and Soranus, described inserting half of a pomegranate into the vagina to treat prolapse.[3] It was not until the 16th century that the first purpose-made pessaries were made.[5] For instance, in the late 1500s, Ambroise Paré was described as making oval pessaries from hammered brass and waxed cork. Nowadays, pessaries are generally made from medical grade silicone.

POP (pelvic organ prolapse)

POP occurrence is cited to occur in 30-50% of parous women.(1,2,3)

three main types occur:

•                     A cystocele, where the bladder (or urethra) deviates into the vagina,
•                     A rectocele, where the rectum deviates into the vagina and
•                     A uterine prolapse, where the uterus (cervix) deviates into the vagina. 

I purposefully use the word ‘deviate’ as the web of connective tissue supporting the pelvic organs can become stiff in response to injury and cause altered orientation of organs. It is not only a vertical movement that can happen but a shift into any direction. Addressing these restrictions, especially in the post partum population can significantly affect prolapse presentation. 

Let’s review THE VAGINA:

Length of a normal vagina (7-10 cm) from the hymen to the posterior fornix.

The size varies with age, estrogen level, number of deliveries, genetics.

It is inclined posteriorly, from the vestibule to the cervix.

The anterior wall is about 3 cm shorter than the posterior wall because of the position of the cervix.

The folds on the walls are called rugae of the vagina and they contribute to its elasticity.

The mucosa is covered with a layer of erectile and muscular tissue.

Quite vascularized, irrigated by the vaginal artery and innervated by the pudendal nerve

Normal PH of the vagina is 3.8-4.5

Vaginal support

(according to John De Lancey)

In the distal third of the vagina, the vaginal walls attach to the structures around the paracolpium without the paracolpium itself. Anteriorly, the vaginal wall fuses the urethra and attaches on the tendinous arch of the pelvic fascia.

Posteriorly, the vagina fuses at the perineal body (that is maintained at the ischial pubic rami by the perineal membrane. ) And laterally, it is attached directly on the LA (levator ani)

Damage to the distal third of the vagina causes a urethrocystocele or a rectocele.

If the posterior vaginal wall is stretched, and if the rectovaginal fascia is torn or damaged, it might not be able to prevent the rectum from moving forward and a rectocele could form.

A large rectocele could mask stress urinary incontinence.

Uterocele: We can see or touch the cervix during the vaginal exam

Evaluation of the patient in standing position is important to evaluate the degree of prolapse.

POP is most often related to once- off trauma or repeated strain to the pelvic structures overwhelming muscular and connective tissue support. Examples of the former include prolonged 2nd stage in labour and vaginal birth with surgical assistance from forceps or episiotomy.  Cumulative trauma such as breath- holding, repeated heavy lifting with a poor technique, straining when having a bowl movement/constipation and persistent coughing are all common culprits.

Other risk factors include parity (slows down after 2 babies), age, family history of POP and obesity

Presenting complaints include a sense of heaviness or bulging, ‘sitting’ on an egg, the sense of a tampon falling out, delayed initiation of voiding or altered stream and, occasionally back ache.

29% women who have had a 1st surgery will have a second one Beck RP 1983,

50% women with SUI have a POP (anterior) Jackson S et al 1997

Caucasian women (5,4-11%) are more affected by POP than Black and Asian women (0.6-2%).

I put this slideshow together to address some of the most common queries I hear about menopause and peri-menopause. It is intended to empower women to make informed choices and also give an opportunity to reframe  the menopause experience.

Menopause has been heavily pathologized,  a midlife ailment that need to be medicated and treated. Advertisements show women in distress over symptoms, while the words grumpy, fat and bitchy are synonymous with this life stage. And yet this concept of it being a disease is only really prevalent in the west, with the degree of bothersomeness correlating with higher socio-economic status. The more we adulate youth, the more disruptive the symptoms seem to be. 

Eastern cultures, on the other hand, tend to venerate older women, making them leaders and matriarchs. Pillars of the society that are looked up to. Often these cultures and their languages do not even have words for hot flushes and night sweats.

Ladies, peri-menopause can be such a key opportunity to look at your overall health and well being. We get notifications from our body that things are in flux. It’s an opportunity to get our hormones checked out and re-asses food intake and poop output. 

I want to move away from the notion that our body somehow fails us from the mid 40’s onwards. No, it’s talking and communicating with us and I want to encourage the art of listening to it.

We are a generations that will live half its life post-menopausally!!

Let’s do well so that we can empower the women and girls coming after us.

I will be discussing menopause through a bio-psych social lens, highlighting compounding factors that may negatively or positively impact this life transition.

Menopause is the term for the one year anniversary of the last period. It is a moment in time.

Before that moment you are in peri-menopuase, after that moment you are post-menopausal.

The mean age for menopause is 51 years of age.

Peri-menopause

• Can last 2-10 years , most women experience +- 3 years associated with hormonal imbalances
• Periods less regular, lighter bleeding 
• hot flashes

A study presented at the 2019 conference of the North American Menopause Society found night sweats were linked to cognitive dysfunction in menopausal women, decreasing the ability to pay attention and perform higher-level thinking tasks.

Another found a direct link between the frequency and persistence of hot flashes and cardiovascular events later in a woman’s life. If you, or a friend, are really battling with hot flashes, a visit to your GP for a stress test may well be really beneficial.

Estrogen comes in 3 forms. By far the strongest form is oestradiol which is secreted by your ovaries in your fertile years.

The form of estrogen secreted in the menopausal years called estrone. It is formed in the adrenal glands and fatty tissue (adipose tissue) and to a much lesser degree in the ovaries.

High estrone levels may increase the growth of breast cancer and uterine cancer especially in obese women.

Decreasing levels of estrogen impacts heart health, brain health, bone health negatively

In peri-menopause and menopause hormone ratios change:  

The ratio of the 3 estrogen forms to each other changes as well as the ratio progesterone 

Thyroid: T3, T4, TSH

Vitamin D3 levels

Cortisol

Cholesterol  HDL and LDL 

 Fluctuations in any of these levels may lead to symptoms of lowered energy, weight gain, changes in hair growth etc.

A complete hormonal profiling done by ND may be advisable.

 The adrenal fatigue theory suggests that prolonged exposure to stress could drain the adrenals leading to a low cortisol state. The adrenal depletion would cause brain fog, low energy, depressive mood, salt and sweet cravings, lightheadedness, and other vague symptoms.

Many women assume that the concerns they have at peri-menopause and beyond are to do with low estrogen. And while this is kind of true- estrogen and progesterone both decrease and they not decrease at the same rate leaving with you with are relatively higher level of estrogen.  We call this relative estrogen dominance.

It is often experienced by women in their 40’s and a key feature is heavy , painful periods.

Other symptoms may  include,

• irritability,
• weight gain,
• bloating and  swelling
• tenderness in your breasts
• fibrocystic lumps in your breasts
• decreased sex drive
• irregular menstrual periods
• increased symptoms of premenstrual syndrome (PMS)
• mood swings.
• headaches.

These features mimic peri-menopausal symptoms and are often brushed off as such.

If these symptoms are familiar to you,  it may be a good idea to consult with a naturopathic doctor.

Most meat we buy is filled with hormones and antibiotics and can drive this estrogen dominance. Plant-based protein is a great way to meet protein requirements, increase fiber intake and keep gut bacteria happy to ensure good stool formation.

Xeno oestrogens are similar to estrogen but have a negative effect on the body. They are found in plastics, herbicides, household cleaners, personal care products and cosmetics and the birth control pill. 

Hormones aside,  the fifth decade can have some psychosocial triggers that can cause stress of its own. 

This stress can exacerbate menopausal symptoms.

 Children are often moving out of the house, some people retire or are caring for ailing parents. Change is difficult and can often trigger low mood and and/or feelings of anxiety. 

It is also  important to honour that menopause itself bring about feelings of grief: loss around childbearing, body changes, sexuality, and aging. 

All of these impact the HPA(hypothalamic pituitary adrenal) axis- our stress system axis.

This axis intertwines your hormones with your nervous system and attempts to regulate out mood and energy levels.

This is a key area to investigate further if you’re feeling overwhelmed and stressed.

Urogynecological Considerations: The Pelvic Floor and More. 

In Menopause the uterus, cervix and ovaries decrease in size. Notably the clitoris also becomes smaller and may contribute to the decreased arousal women report. Stimulation of the clitoris may not lead to the same degree of arousal that it did previously.

(on a side note, the clitoris has about 8000 nerve endings, double as much as the penis)

The fat in the labia majora and the mons pubis decreases and pubic hair becomes sparse.

Cervical mucus decreases until they disappear completely

The genitourinary syndrome of menopause (GSM) is a new term that describes various menopausal symptoms and signs including not only genital symptoms (dryness, burning, and irritation), and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function, but also urinary symptoms (urgency, dysuria, and recurrent urinary tract infections). 

45 to 63 % of menopausal women report symptoms.

These symptoms are all directly linked to decreased estrogen levels and these changes reduce elasticity of the vagina, increase vaginal pH, lead to changes in vaginal flora, diminish lubrication, and increase vulnerability to physical irritation and trauma.

Factors that can contribute to excess oestrogen in the body are poor clearance via the liver and colon. Gut health and good bowel function are key factors to look at.

How often are you having BM and how well is your liver functioning? Remember, alcohol and medication all need to be broken down in the liver so it may not be effectively clearing excess estrogen.

To minimize this impact and transition through menopause more easily we need to look at the four pillars of health.

Get tested!!!

So what now:

Seek professional advice and or discuss your most bothersome symptoms

Is it depression?

Is it anxiety? Is it anger, rage, fatigue, brain fog.

Start with one small manageable change that looks like self care. Not another to do list item.

Movement:

It is probably the most important aspect as it modifies all the other pillars

It is beneficial for stress management which in turn helps us make better food choices (as we do not   waste the effort we put into exercising)

It lowers circulating cortisol levels which has been shown to contribute to fat deposition along the waist

It can help moderate hot flashes as it has a beneficial effect on the thermoregulators in our body.

It builds/maintains muscle mass.

It slows down the loss of bone density.

It improves our cardio vascular function. 1 in 2 women will experience a cardiovascular event in their lives and it is the biggest killer of women.

It is good for mental health.

Restorative: Breathing, walking, yin yoga.

Strength training: Bone, joint, tendon health- glut med and max development 

Nutrition:

The foods that we eat can either nurture or harm our gut bacteria.

Highly processed and refined, sugary foods drive inflammation in our system and exacerbate the symptoms of altered oestrogen levels and contribute to auto-immune diseases and cancer.

Our body eliminates excess oestrogen via the gut- well formed, daily poops are essential.

Choose a diet based on the Mediterranean one to optimize nutrition and help form good stool.

• Minimally processed vegetables, fruits and whole grains in season.
• Oily fish, eggs and nuts and seeds as protein sources.
• Lots of water.

Stress management:

• Where are your stress levels at?
• What strategies work and which ones can you incorporate on a daily basis.
• Walking, chatting with a friend, sipping a favourite drink, playing with a dog, stroking a cat…. Doing something that sparks JOY.

Sleep:

• What is your sleep like? Interrupted?
• By what, when?
• Sleep hygiene: no screens 2 hours before bed, no phones near your bed, dark room, breathable fabrics.

Notes for prolapse and pessary webinar 21 April 2022

Good evening ladies!!

Thank you so much for joining me on this webinar or catching the replay!

My name is Gerda Hayden and I am a pelvic health PT working out the WOMB (the WORLD of my baby) in Burlington, Ontario. It’s a perinatal care clinic with a holistic multi-disciplinary approach.

I have a special interest in prolapse and prolapse care through the entire life span, so was really excited when the team at Corelife asked me to give a talk on the subject.

You will find my contact details at the end of this presentation so please do not hesitate to reach out!

We will look at the prolapse presentation, some contributing or risk factors and then talk about management, including pessary use.

I want to emphasise that these are principles and not a one size fits all approach. A million Kegels are not the answer to addressing prolapse!!

Before explaining what prolapse is, I’m going  to take  a moment to reframe our understanding of  anatomy as it shapes our prolapse experience.

For a long time we considered the bones to be a stack of rigid blocks stacked on top of each other.

And the muscles and tendons and organs were essentially draped in between and over the bones. We moved as result of forces, pulleys and levers acting on the bones .With that model in mind any pelvic organ movement is considered a collapse, or a linear downward movement, a falling down of the tissue.

Our understanding of anatomy has fundamentally changed though and we are now realising that instead we demonstrate a model more like this image here. It’s called a tensegrity model, where the muscles and fascia, the elastic components are constantly pulling, while the bones, the rigid components, are pushing. And if all the parts are optimally organized we have this dynamic balance, where the rigid structures don’t touch and everything has lots of wriggle room. So we can move freely in all kinds od different directions and positions and the forces are transmitted in many ways all of the time.  We can move freely, do complicated yoga positions, stand on our head and have babies.

We are self-suspended within our elastic components, most notably the fascia which connects everything to everything.

It’s these elastic elements that allow minute alterations and responses to internal pressures and the external world we move in.

Now, when these tissue elements have sustained and injury, the tissue tends to be a bit stiffer and cause some restrictions in movement.  In the pelvis these restrictions can occur after tissue injury with birth. This can mean that the soft squishy organs, the bladder, the uterus and the rectum are not optimally aligned and they are the pulled against the vaginal wall which we then experience as a prolapse. 

So to recap, it’s not a downward falling, it’s a pulling of tissue that occurs.

Now that we have addressed the mechanism of prolapse, let’s chat about the different types of tissue changes you may present with.

The top left shows the ideal position of the organs suspended within their connective tissue web. (Except that the connective tissue isn’t shown)

Top middle shows movement of the bladder or cystocele. In practice I find the bladder is often deviated to the Left after a vaginal birth.

Top right shows a rectocele. In practice I find these occur with perineal body restrictions.

Bottom left shows a hysterocele, womb movement, and the findings in practice are more of a cervic pulled to the right or left.

The bottom pictures on the right depict anatomy after a hysterectomy and what can happen if the vaginal vault deviates.

So, lets look at the risk factors

We have some acute ones, mainly to do with birth and some  as result of sustained or repeated forces onto the pelvic floor.

In response to these occurrences, we get some connective tissue changes, generally tissue becomes stiffer- less flexible and less able to optimally suspend itself. And thus suspend the pelvic organs/

The tissue is impaired , not just always ‘weak’

So, lets look at the risk factors

We have some acute ones, mainly to do with birth and some  as result of sustained or repeated forces onto the pelvic floor.

In response to these occurrences, we get some connective tissue changes, generally tissue becomes stiffer- less flexible and less able to optimally suspend itself. And thus suspend the pelvic organs/

The tissue is impaired , not just always ‘weak’

So what are the symptoms of prolapse.

Women report a sense of dragging, heaviness, bulging, difficulty initiating urination

Or a sense that , and I’m parapharsing’ something isn’t ‘quite right down there’

The most cited prevalence is fairly high at 50%, but only 15% are SYMPTOMATIC after 20 yrs.

The threshold at which prolapses ae diagnosed is not clearly defined in the literature.

Prevalence rates are actually fairly inconclusive, as it depends on the practitioner’s threshold of reference. Your midwife, family Dr, OBGYN etc May or MAY not give you a diagnosis, based on what their perception of prolapse is.

We are recognizing that the vaginal tissue is very elastic and that some degree of organ movement is to be expected after birth and also with significant changes to intra=abdominal pressure.

Grading or staging of prolapse is also being debated, so I tend to work with a women’s perceived degree of bother. Using a questionnaire.

Management: how do we saftely get active with POP

• Modifying risk factors: pregnancy PT care, informed birth choices
• Addressing tissue  changes: scar tissue, adhesions, organ deviations THROUGHOUT The body.

I assess breath strategies, standing posture as well as sit to stand and walking to determine and address any restrictions

• supervised pelvic floor muscle training: this can be either strengthening or Lengthening depending on the findings. The 2019 return to running guide gives a framework for understanding what the strength, endurance, co-ordination and lengthening capacity of the pelvic floor should be for optimal tissue support. Our pelvic floor act like trampolines cushioning impact and should feel like that too on palpation.
• We are optimizing postural pre-activation control as well as larger mover muscles strength and endurance
•  guidance related to 

    -Intrabdominal Pressure management

    -General movement 

    -Diet

•  Pessaries

So, regardless of when your prolapse has presented, be it post partum, or peri-menopausally or anywhere in between, I’ll start with IAP management.

IAP is the term given to the increase in pressure in your abdomen in response to movement. The connective tissue elements respond to these pressure changes. 

One of the activities that increases IAP the most has actually been found to be sit to stand! And we all do that OFTEN throughout the day.

Managing IAP well can have huge benefits for optimizing pelvic floor function. ( I won’t get into all the anatomical details here..), suffice to say

 I highlight breath strategies with moving and lifting as well as good toileting positions.

When it come sto considering actual vaginal tissue integrity, I consider the elasticity and resilience of the organ.

If tissue appears thin or sensitive, I also consider either a hyaluronic acid cream or some vaginal estrogen to optimise collagen health.

Finally, I also need to consider what else is going on in a 24 hr period.

What nutrients are being consumed- are they predominantly inflammatory or anti-inflammatory as that influences our overall well-being and are also the building blocks the body uses to repair themselves

Sleep: how much are you getting and what is it’s quality

Movement: what were you doing, what are you doing currently, what do you want to get to?

We brainstorm types, amount and what exercise resonates with you. I have very few taboo exercises, rather I’d modify what you enjoy doing. Cause if you don’t enjoy it, you’re not going to do it!!

Stress: what is your perception of the degree of stress you are under and what startgies do you choose to deal with your stress? For so many women running is more  a mental headspace thing than just an exercise.

And sometimes we get about 80%there and some movements remain uncomfortable.

And then we can talk pessaries!!

A pessary is a prosthetic device that can be inserted into the vagina to support its internal structure

There are two main types of pessary: support and space-filling. They come in many different shapes and sizes to fit a woman’s individual anatomy. They are all usually made from medical-grade silicone, which makes them durable and resistant to absorption.

The most commonly used support pessary is the ring pessary with support. This is because it fits a large majority of women and can be used at all stages of pelvic organ prolapse.

The most commonly used space-filling pessary is the Gellhorn pessary. This has a broad base with a stem that comes in different lengths so that it will also be able to fit most women.

Fitting is a trail and error exercise with the aim of finding  a pessray that supports but is  not felt once inserted.

Squatting, walking, sit to standing and toileting are all trialed  and once the correct device has been found, a medical professional needs to sign off on any contra-indications, before the device is ordered.

Possible complications

Vaginal or urinary infection:

▪ If there are signs or symptoms of infection, you must remove your pessary and consult your doctor.

▪ Candida, bacterial infection or urinary tract infection are the most commonly seen and require a diagnosis and the appropriate treatment.

Bleeding:

Erosion, ulcers, laceration and  inflammation of the vaginal mucosa are more common if the pessary fits too tightly or if the mucosa is atrophied or not healthy. Bleeding may also occur if the pessary was forgotten inside the vagina.

It will require you not no wear the pessary during medical treatment

Incarceration: when the pessary is stuck in the mucosa and cannot be removed 

(Do not try to remove it, it will bleed!! ) You will be referred to your doctor or gynecologist)

Migration: when the pessary moves from the vagina to the bladder or

the rectum and creates fistulas

these risks are mitigated however by suggesting frequent removal of the pessary to allow the vaginal wall time to repair itself.

I re-evaluate the pessary annually to determine fit, comfort and possible wear and tear of the silicone.

And there we have it ladies.

Caring for the device

If you are comfortable removing and reinserting your own pessary, you may remove the pessary once or twice a week. Once removed, clean it with mild soap and warm water and then rinse before replacing it. You doctor may prescribe a vaginal estrogen cream to apply inside your vagina while the pessary is out to prevent irritation.

Pessaries can fall out if you strain. If you can, try not to bear down during bowel movements. If the pessary does fall out, you can reinsert it after you clean it.

Many women find insertion easier when they are standing up with one foot resting on a stool. It’s important to use plenty of water-based lubricant for insertion.

If you aren’t comfortable removing and reinserting your own pessary, your doctor will set up follow-up visits for you to come and it done in the office. Frequency of visits can range from monthly to every three months, depending on your needs.

When to see a doctor

A pessary can occasionally cause some complications:

• Foul-smelling discharge. This could be a sign of a condition called bacterial vaginosis, which is an imbalance in the natural bacteria found in your vagina.
• Irritation and even damage inside the vagina.
• Bleeding.
• Passing a small amount of urine during exercise or when you sneeze and cough. This is called stress incontinence.
• Difficulty having sexual intercourse.
• Urinary tract infections. Initial signs of this may be difficulty urinating, feeling unwell, or a high temperature.

It’s important that you see your doctor if you develop any signs of these complications, as they are usually very treatable.

Listen to the podcast HERE.

WHO AM I? MEET YOUR PELVIC HEALTH PHYSIOTHERAPIST

My name is Gerda Hayden and I am a pelvic health physiotherapist, practicing out of the World of My Baby or WOMB in Burlington, Ontario. I am trained neuro-musculo-skeletal or ‘normal’ physiotherapist but have completed specialised training as a pelvic health physiotherapist which allows me to further assess women via their vagina and/or rectum if that is indicated.

I completed my studies in South Africa and worked in various multi-disciplinary practices, the largest one of which focused on athletes. It was here that I became most aware that we were viewing women, often and inadvertently, as small men. Menstrual cycles and vaginal and bowel or bladder complaints were at best minimised or completely disregarded, and I realised that there was a real need for more pelvic floor specialists to address these concerns.

I did my pelvic health post graduate qualifications while being pregnant with my first son and started a women’s health practice when he was 6 months old.

We then immigrated to the UK, where I had my 2nd son and arrived in Canada in early 2017 where I met my mentor Sinead DuFour and started my journey at the WOMB. It is a perinatal care facility that aims to support  women in a very holistic manner.

I have an interest in the perimenopausal space so I really do see a wide range of women. From young competitive athletes to women planning their fertility journey to pregnant and post partum women as well as post menopausal ladies.

WHAT IS PELVIC HEALTH PHYSIOTHERAPY?

Pelvic health physiotherapy looks at the role the pelvis and its contents and tissue are playing in pelvic complaints and overall well-being.

The pelvic floor is made up of muscles, connective tissues, nerves, ligaments and supports the pelvic organs while also facilitating good voiding of the bladder. It allows good sexual functioning and is part of the postural control mechanism.

The muscles run from the coccyx or tailbone all the way to the pubic bone and into the sides of the pelvis.

It is also implicated in good gut health, which we are now understanding is crucial to our immune response and hormone regulation due to its role in voiding of bowel movements.

As a physiotherapist I am really intrigued by the muscular aspect. Broadly speaking the pelvic floor can be underactive, essentially under-supportive, and present with complaints such as prolapse or stress urinary incontinence. On the other side we can classify the pelvic floor as overactive. Presenting complaints are then more along the lines of painful intercourse ( a sense of hitting a wall) , constipation or urinary urgency and frequency.

And then we can also encounter some asymmetries, or co-ordination issues as well as injuries to the pelvic floor.

WHAT CONDITIONS CAN PELVIC HEALTH PHYSIOTHERAPY ADDRESS?

I’m going to unpack all these complaints a bit more, but really want to reiterate that as much as I am focusing on pelvic complaints, I am very mindful and aware of the fact that I am working with a woman whose entire health matters. Her perception of her concern, her overarching well-being, her sleep quality,  her stress resilience and nutritional status:  ALL of it matters and that conversation takes up just as much time as  unpacking the pelvic details.

So let’s unpack those complaints a bit more.

Urinary incontinence

Urinary incontinence is the unintentional loss of urine. Stress incontinence happens when physical movement or activity — such as coughing, laughing, sneezing, running or heavy lifting — puts pressure (stress) on your bladder, causing you to leak urine. Stress incontinence is not related to psychological stress. Stress incontinence is much more common in women than in men.

Stress incontinence occurs when the muscles and other tissues that support the urethra (pelvic floor muscles) and the muscles that control the release of urine (urinary sphincter) weaken.

The bladder expands as it fills with urine. Normally, valve-like muscles in the urethra — the short tube that carries urine out of your body — stay closed as the bladder expands, preventing urine leakage until you reach a bathroom. But when those muscles weaken, anything that exerts force on the abdominal and pelvic muscles — sneezing, bending over, lifting or laughing hard, for instance — can put pressure on your bladder and cause urine leakage.

Your pelvic floor muscles and urinary sphincter may lose strength because of:

Childbirth. In women, tissue or nerve damage during delivery of a child can weaken the pelvic floor muscles or the sphincter. Stress incontinence from this damage may begin soon after delivery or occur years later.

Contributing factors

Other factors that may worsen stress incontinence include:

• Illnesses that cause chronic coughing
• Obesity
• Smoking, which can cause frequent coughing
• High-impact activities, such as running and jumping, over many years

Risk factors

Factors that increase the risk of developing stress incontinence include:

• Age. Physical changes that occur as you age, such as the weakening of muscles, may make you more likely to develop stress incontinence. However, occasional stress incontinence can occur at any age.
• Type of childbirth delivery. Women who’ve had a vaginal delivery are more likely to develop urinary incontinence than women who’ve delivered via a cesarean section. Women who’ve had a forceps delivery to more rapidly deliver a healthy baby may also have a greater risk of stress incontinence. Women who’ve had a vacuum-assisted delivery don’t appear to have a higher risk for stress incontinence.
• Body weight. People who are overweight or obese have a higher risk of stress incontinence. Excess weight increases pressure on the abdominal and pelvic organs.
• Previous pelvic surgery. Hysterectomy in women and surgery for prostate cancer in men can weaken the muscles that support the bladder and urethra, increasing the risk of stress incontinence.

Stress incontinence is different from urgency incontinence and overactive bladder (OAB). If you have urgency incontinence or OAB, your bladder muscle contracts, causing a sudden urge to urinate before you can get to the bathroom. ( I will address this later in the talk)

A lot of women will present with mixed urinary incontinence which is a combination of SUI and UI.

Prolapse

Another symptom of decreased pelvic support is prolapse. It is often abbreviated to POP for ‘pelvic organ prolapse’ and is the term given to the medical condition in which pelvic organs descend from their normal positions within the pelvic cavity.

It is a common problem reported in as many as 1 in 2 women. 

Generally, three main types occur: 

• A cystocele, where the bladder (or urethra) descends into the vagina,
• A rectocele, where the rectum descends into the vagina and 
• A uterine prolapse, where the uterus (cervix) descends into the vagina.

POP is most often related to repeated strain on the pelvic structures and occurs typically when the pelvic floor muscles are not providing optimal support.  So, causes of both strain and pelvic floor damage are triggers of POP. Examples include prolonged 2nd stage in labour, vaginal birth with surgical assistance from forceps or episiotomy, cumulative trauma such as breath- holding, repeated heavy lifting with a poor technique, straining when having a bowel movement and/or persistent coughing are all common culprits. 

The most common complaint is of a sense of heaviness, especially towards the end of the day. Other complaints include the sense that something is protruding from the vagina or the feeling of ‘sitting on a ball’. Incomplete emptying or difficulty initiating urination are also often mentioned.

Symptoms vary according to the organ involved.  Pain can be a part of the picture but oftentimes the pain is related to other aspects of pelvic dysfunction .

Degree of perceived bother is one of the key aspects I look at. How much does the prolapse impact your activities of daily living and your quality of life. I make this point because there is a lot of debate around whether we should even quantify ‘minor’ prolapses since a degree of tissue laxity is evident in most postpartum and perimenopausal women.

Conservative care strategies are considered the first line management for POP.  Research shows that supervised pelvic floor muscle training, guidance related to general movement and diet and the use of adjunct devices called pessaries are very effective. 

I also consider hormonal changes in my practice. We know that low estrogen levels contribute to tissue laxity, shrinking and drying of tissue and this can exacerbate symptoms.

This is where working with a hormone literate GP can be really beneficial. The GP can prescribe estrogen supplementation to optimise tissue function. Local estrogen comes in the form of a vaginal tablet, creams or gel or a ring pessary. 

In addition to pelvic floor muscles training, lifestyle counselling is a powerful way to manage POP symptoms.  Again these will be tailored to meet your needs but generally revolve around these four principles:

Pacing  Posturing  Planning  Practising

If standing aggravates symptoms, try and do the bulk of standing activities earlier in the day and pace yourself while doing them. Intersperse standing with other positions such as sitting or lying.  Bridges are a great exercise for prolapse for many reasons, one being the posture that takes all gravity and downward motion off the pelvic organs and the pelvic floor. 

Avoid unnecessary lifting and lugging and use aon organ supporting strategy when doing these tasks. The key is to not hold your breath and to have your pelvic floor working.  Simply exhaling through a task like lifting can achieve this.  We call this “blow before you go”. 

Ensure a diet high in fruits and vegetables (lots of fibre) and a good toileting position to avoid straining.

When you feel the urge to have a bowel or bladder movement, head to the bathroom. Good toileting positions include having your knees higher than your hips – you can rest your feet on yoga blocks, on rolls of toilet paper, on the steps toddlers use for reaching the sink – as long as your knees are comfortably higher than your hips. Practice ‘opening’ and relaxing your pelvic floor: take a deep breath and go ‘GRRRRR!!’ Now take another deep breath and go ‘SSSHHH!!’ Which did you find the most ‘opening’ for your pelvic floor? Try making that noise the next time you have a bowel movement! It will help move things ‘down and out’ without stressing your pelvic floor. Now, put those steps together; sit on the toilet, knees higher than your hips. Lean forwards resting your elbows on your thighs. Make your noise (‘Grr’ or ‘Shh’ – whichever works best for you). When you are finished, do a pelvic floor contraction (close the opening around your anus and lift up and in) This signals to your brain that you are all done.

In some cases a pessary or vaginal supports can help undergird pelvic organs. They are used in conjunction with exercise and can be fitted for once off use or more permanently.  

External support such as hideaway (a garment with elastic straps that allows for support over the perineum up to the pubic bone)

Internal assistance, such as Impressa (one time use bladder support), Uresta (silicone device for SUI) and silicone pessaries (silicone devices both for SUI and prolapse)

Pessaries are being used a lot more in younger women. I liken them to a sports bra for your vagina or a pair of reading glasses. They can be used only for bothersome activities such as running, skipping or doing a weight lifting class and then removed. This decreases the risk of adverse outcomes such as infection, abrasion and migration- (perforation of the vaginal wall and movement to other areas of the body).

So that concludes an overview of underactive pelvic floor structures.

Overactive Pelvic Floor

If we consider the overactive pelvic floor, the symptoms are usually not quite as apparent.

Vaginally, women will report a degree of resistance with inserting sanitary ware or with penetration. Both initial and deeper. Some state that they can shift or change position to ease the discomfort, while for others any form of penetration is uncomfortable.

A more holistic look at the sexual history experience and any trauma is obviously necessary but generalised heightened tension and stress levels can point to some upregulation the muscles.

This can be explained by the nerve supply to the pelvic floor structures. The majority is innervated by the pudendal nerve which is also under autonomic nervous system control.

So when we experience stress the pelvic floor muscle will usually tighten in response. Similar to clenching our jaw or bracing our shoulders.

The local up-regulation response is addressed with cognitive (top down), somatic (bottom up) as well as mindfulness strategies. 

Bladder-wise, overactive bladder is another common presenting complaint.

Overactive bladder

Overactive bladder (OAB) is a condition where there is a frequent feeling of needing to urinate to a degree that it negatively affects a person’s life. The frequent need to urinate may occur during the day, at night, or both. If there is loss of bladder control then it is known as urge incontinence. More than 40% of people with overactive bladder have incontinence. Conversely, about 40% to 70% of urinary incontinence is due to overactive bladder. Overactive bladder is not life-threatening, but most people with the condition have problems for years.

 The cause of overactive bladder is unknown.

Risk factors include obesity, caffeine, and constipation. Poorly controlled diabetes, poor functional mobility, and chronic pelvic pain may worsen the symptoms. People often have the symptoms for a long time before seeking treatment and the condition is sometimes identified by caregivers. Diagnosis is based on a person’s signs and symptoms and requires other problems such as urinary tract infections or neurological conditions to be excluded. The amount of urine passed during each urination is relatively small. Pain while urinating suggests that there is a problem other than overactive bladder. 

Specific treatment is not always required. If treatment is desired pelvic floor exercises, bladder training, and other behavioral methods are initially recommended. Weight loss in those who are overweight, decreasing caffeine consumption, and drinking moderate fluids, can also have benefits. Medications, typically of the anti-muscarinic type, are only recommended if other measures are not effective. They are no more effective than behavioral methods; however, they are associated with side effects, particularly in older people. Some non-invasive electrical stimulation methods appear effective while they are in use. Injections of botulinum toxin into the bladder is another option. Urinary catheters or surgery are generally not recommended. A diary to track problems can help determine whether treatments are working. This bladder diary gathers information about type and quantity of fluid consumed, frequency of voiding and if and how much urine was lost.

Common bladder irritants include alcohol, caffeine, citrus, sweeteners and processed foods.

Overactive bladder is estimated to occur in 7-27% of men and 9-43% of women. It becomes more common with age. Some studies suggest that the condition is more common in women, especially when associated with loss of bladder control. 

 In layman’s terms overactive bladder can be irritated by ‘peeing just in case’. Voiding before leaving the house, when arriving at a destination or when asked to go to the washroom by your girlfriends at a party.

The normal feedback loops between brain, bladder and pelvic floor are changed and the bladder becomes relatively overactive.

When the pelvic floor is overactive it can itself irritate the bladder and contribute to overactivity.

The behavioural strategies that we address are the bladder irritants, as revealed in the bladder diary, and concepts around the fact that the bladder and pelvic floor are inversely proportional to each other.

When the bladder contracts the pelvic floor has to relax and conversely, when the pelvic floor contracts, the pelvic floor has to relax.

So when an urge is felt, contracting the pelvic floor will decrease the degree of sensation felt- either enough to defer the void or to allow time to get to the washroom without rushing and leaking.

If we further distract attention by asking for tricky mental tasks like counting backwards from 100 in 7’s, reciting telephone numbers, recipe ingredients or whatever takes concentration we can decrease the urge even more effectively.

If necessary, a timed voiding schedule can be instituted to get to 2-3 hours between voids.

Constipation

A very common concern for women is constipation. Gut transit times and gut motility can be slower in women, but the aim is still to pass at least one daily sausage-shaped bowel movement with ease.

Faeces is waste matter and need to be eliminated for optimal health. Especially hormones can be reabsorbed into the bloodstream affecting the balance the body is trying to achieve.

Pelvic floor overactivity can impact the required relaxation for an effective bowel movement, so addressing optimal toileting behaviour and positions is crucial.

When you feel the urge to have a bowel movement, head to the bathroom. Good toileting positions include having your knees higher than your hips – you can rest your feet on yoga blocks, on rolls of toilet paper, on the steps toddlers use for reaching the sink – as long as your knees are comfortably higher than your hips. Practice ‘opening’ and relaxing your pelvic floor: take a deep breath and go ‘GRRRRR!!’ Now take another deep breath and go ‘SSSHHH!!’ Which did you find the most ‘opening’ for your pelvic floor? Try making that noise the next time you have a bowel movement! It will help move things ‘down and out’ without stressing your pelvic floor. Now, put those steps together; sit on the toilet, knees higher than your hips. Lean forwards resting your elbows on your thighs. Make your noise (‘Grr’ or ‘Shh’ – whichever works best for you). 

When you are finished, do a pelvic floor contraction (close the opening around your anus and lift up and in) This signals to your brain that you are all done.

Further to these common concerns I work with women on their fertility journey as well as in pregnancy.

Pelvic Girdle Pain

Pubic symphysis dysfunction or more correctly, pregnancy related pelvic girdle pain is the discomfort experienced along the pubic symphysis, groin or sacro-iliac joints.

Pelvic girdle pain is a protective output by the brain to get you to move a bit more mindfully and take things easier in general.

To decrease the perceived threat response, aim to move a bit more slowly and symmetrically (think getting into and out of a car, and turning over at night) and do some gentle pelvic tilting before you get up /change position.

Birthing

Another cornerstone of my approach is reviewing evidence based birthing strategies. This pertains to labouring and birth positions as well as breathing strategies to optimise pelvic floor outcomes.

(Can give more details if this comes up in discussion)

Postnatal care

This is perhaps the most popular time I connect with women. 

I consider the kind of birth and birth experience the woman has had and evaluate the abdominal wall and pelvic floor.

DRA

There is a lot of talk about DRA, Diatsis Rectus Abdomins in the media.

In this condition the load transfer capacity of the midline connective tissue is impeded, causing the abdominal contents to bulge out and making the tummy look much bigger than it is.

Traditional abdominal activity can exacerbate the situation.

We need to approach the abdominal wall as part of a unit of muscles that control posture.

Your diaphragm, pelvic floor, lower abdominal wall and muscles supporting the spine. 

Thus functional position and posture such  as sleeping and breastfeeding are considered. 

Further, the 4th trimester is a period of time in which the body is prioritising healing and its new homeostasis . Again, sleep, nutrition, support and stress resilience will all play crucial roles in optimising the outcomes.

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