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Incontinence and Sex – How do we get patients to tell us their problems?

24 January, 2013

Recently my lovely, wise GP and I were having a chat about catastrophising. We are all capable of catastrophising. I see the tendency in many pain patients and those suffering with bladder urgency. It’s easy to do when you are anxious as to whether you are going to cope with a function or outing when you have pain or an extreme feeling of imminent incontinence! My GP was telling me about an acronym he uses with patients suffering with depression to help work out what may have exacerbated their deterioration with the depression. He uses HALT as a checklist and teaches the patients to assess their state using the same.

H stands for hungry – are they eating properly?

A stands for angry– what is affecting their mood, family, friends, work?

L for lonely – are they connecting with their friends or leaving themselves isolated?


T for tired – are they getting enough sleep?

I thought that was a clever way to have a checklist of triggers for depression and I have kept it in my mind to apply a similar principle to pelvic floor dysfunction. Recently Aleeza Zohar, the Communications Manager at Jean Hailes Foundation, was highlighting the common complaint from GPs that their patients are not very forthcoming with their symptoms of incontinence, or sexual dysfunction or other pelvic floor dysfunction issues because of the embarrassment factor, and asked me what do I do?

Well, patients who come to see me have usually climbed the mountain of despair about their continence state by even making their first appointment to see me and are well and truly ready to ‘spill the beans’ on everything. Patients are usually very happy, and for those with lifetime constipation issues I would say, nigh on excited, when I question them closely about their bowel status and relieved to open up about sexual dysfunction. But I suddenly thought if GPs could have a similar acronym as the one my GP uses for his patients with depression, to follow for ensuring they ask the important questions at a woman’s PAP smear examination, then perhaps these problems would surface earlier.

I also asked Dr Hannah Krause, a (saintly) Brisbane Urogynaecologist was she aware of any such thing already in the medical training for GPs and she thought no and why not try and promote prevention at the coalface rather than waiting for the full blown prolapse or severe urinary incontinence to develop and definitely need surgery to correct it!

So my little prompter for GPs to ask at the PAP smear is PIPES. Somewhat appropriate given what the area looks like anatomically!

P stands for Prolapse. Now if all patients with minor vaginal wall laxity were alerted early to their slight prolapse then perhaps the conservative interventions would have a far greater chance of holding things at bay! Avoiding straining at stool by using the correct position and dynamics for defaecation, softening the bowel motion with soluble fibres or other products, always engaging in pelvic floor safe exercising (that is, no sit ups, curl ups, crunches, double leg lifts or full planks), regular pelvic floor muscle training and bracing (tightening your low tummy and pelvic floor muscles prior to increases in intra-abdominal pressure) – these are simple strategies to prevent worsening prolapse.

I stands for Incontinence. By questioning the patient as to whether they leak with cough or sneeze or with the urge to go will identify stress or urge incontinence. Stress incontinence has been shown in studies to be significantly improved and cured in 60-80% of patients. (Neumann P et al 2005 Physiotherapy for female stress urinary incontinence: a multicentre observational study, Australia and New Zealand Journal of Obstetrics and Gynaecology 45:226-232). Urgency and urge incontinence responds well to bladder retraining and modification of caffeine intake. These are simple conservative measures taught by a Continence and Women’s Health physiotherapist in one session.

P stands for PAIN. Chronic pelvic pain is seen in many patients attending a GP’s surgery. With a normal consultation where there is only 15 minutes to see the patient, it must be daunting to even think about delving into the question of “Do you have any pelvic/vaginal/bladder/ bowel pain. If the patient doesn’t come in specifically with that condition, then why the heck would you go fishing for it? Because chronic pelvic pain will get worse as the patient’s nervous system gets well practised at producing pain, (central sensitization) and with some time taken to ExplainPain, the patient can start to gain control over their condition and not feel so helpless. But it takes time and this is where the physios can help. Teaching the concept that the brain decides whether there is going to be pain or not really has changed our direction of treating the end organ and the peripheries to more the central sensitization nature of chronic pain.

E stands for exercise. Now exercise can mean pelvic floor exercises- the bread and butter of a pelvic floor physiotherapist- but as you can see we do far more than teach Kegals these days! But exercise is far more than that. There was an interesting article recently highlighting, that the UK’s Royal College of Physicians has just approved a report” Exercise for life: Physical activity in health and disease”. The report states: “There is evidence for the benefits of exercise in many forms of disease. It is effective, inexpensive, with a low side-effect profile and can have a positive environmental impact. Despite this, there remains a reluctance within the medical profession to use exercise as a treatment.” (Royal College of Physicians Exercise for life: Physical activity in health and disease. London RCP,2012). So, physiotherapists have a critical role in assisting GPs in this invaluable and essential treatment modality, as do exercise physiologists.

S stands for sex. I’ve learnt over the years never to assume anything about sex. I have patients in their 30’s who can take it, but mostly leave it, and patients in their 80s who are still having a satisfying sexual relationship. And therefore you should always ask the question and never assume someone is too old to be worried about pain or dryness with intercourse or a lack of libido. There is much to be offered to these patients by a Continence and Women’s Health Physiotherapist, even if it’s just reassurance that having intercourse is still possible and even beneficial if you have prolapse.

So I am putting my acronym PIPES out there, as a way to quickly evaluate the urogenital status of a woman, when having a PAP smear or even at a yearly general health assessment. I am sure many doctors have their own standard questions, but if it gives some GPs a reminder about asking those vital questions well it can only benefit the pelvic floor health of their female patients.



  1. Lisa Osborne permalink

    I truly appreciate your thoughts on this and I hope you or someone can make ths a standard of practice among OBGYN and Primary Care Doctors. If my OB had used this as a guide, and/or had some more knowledge, 16 yrs ago I would not have had to have “the works” (if it wasn’t tacked, tied, given support, it was simply removed) performed a couple of months ago at age 47.

    You see, my OB (16 yrs ago) knew I had the beginning of a prolapse and I even questioned him about what I was feeling, seeing, etc… He simply stated, “Some day you will need surgery to correct it, but not right now, don’t worry about it.” Not to mention the 3 additional OBs that I have had in the most recent 6 yrs. Had I known that to run, jump rope, excessive abdominal excercises, and do heavy weight lifting/training would accelerate my condition and even cause extreme damage, I would NEVER had made the choices I made. There are alternative ways to excercise and safety precautions that can be used when weight training, etc…

    Why are the doctors not taking responsibility for making us aware and being educated themselves instead of just patting us on the head and sending us out the door until it “gets bad” and NEEDS repair? I am angry…and I can’t do anything about the past. I will however, print your blog and give a copy to every doctor I meet until the standards include PIPES.

    Thank you Sue

    • Hi Lisa
      Thanks for your comments. Yes many patients are saddened when they discover that what they are doing to try and achieve ‘fitness’ is probably the cause of their worsening prolapse. Still the most important thing now is to do the correct thing by your surgery- look after it and only do ‘pelvic floor safe’ exercising, do your PFmuscle exercises, brace with increased IAP and use the correct posture and dynamics for bowels.

  2. Kath permalink

    Thanks sue
    I love the PIPES acronym. What a wonderful, positive way of highlighting to G P’s the benefits of women’s health physio. I will be contacting all my local gps with this.

  3. What a great article. This is one of those aspects where I find more women go to Cosmo for their sexual frustrations than an actual doctor. But shedding light on the issues and highlighting that it’s more common than many think is only going to help. Thank you!

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