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Incontinence and Bowel Management for Women, Men and Children.
Women’s Health Physiotherapist Brisbane, Australia.
Pelvic Floor Dysfunction Treatment.

PGAD- Persistent Genital Arousal Disorder

Persistent Genital Arousal Disorder is defined as the spontaneous, intrusive, and unwanted genital arousal (tingling, throbbing, pulsating) in the absence of sexual interest and desire. Usually any awareness of subjective sexual arousal is typically but invariably unpleasant. The arousal is unrelieved by one or more orgasms and the feeling of arousal persists for hours or days. (1) It is relatively uncommon, but I do worry there are women who don’t seek help and who suffer in silence with this condition and are much too embarrassed to speak of their misery. So the prevalence may be higher than we think.

Tragically, it is associated with death by suicide because of the anguish these women go through. It is a persistent pain disorder and unfortunately, if health professionals are not informed about it’s existence, women can be subjected to inappropriate comments and their discomfort dismissed, due to the lack of awareness of not only the condition itself, but that it is definitely able to be treated with good success.

I recently had a patient present with this condition, but fortunately because she recognised that something was seriously wrong, and because we can research very thoroughly on the internet ourselves these days, she found her symptoms on the net, saw that it was a persistent pain disorder and decided to be brave and seek treatment early. Her intervention was very early in the process unlike most women who go from pillar to post trying to get help after waiting perhaps for months and sometimes years to raise it with their doctor.

This patient is very articulate and has introduced PGAD beautifully in the beginning of her blog. Her story follows:

I have read many sad stories of women who have suffered in silence with the distressing condition known as PGAD which is typified by unrelenting, unwanted and intrusive arousal in the absence of fantasy or desire. What is worse, is that any attempt to relieve the arousal via masturbation is transient and the symptoms return almost immediately and usually more intense than before.

It’s a vicious cycle.

These women are not only at the mercy of their dysfunctional nervous systems but they battle shame, isolation and crippling social anxiety. Many health professionals are guilty of dismissing the symptoms, making off-handed comments or telling the patients that its all in their head. This only makes things worse for sufferers especially when you consider the immense courage it must take to even tell a doctor about it. For some women, the torment has become so bad that they have even taken their own lives.

I believe there are multiple causes for PGAD. There seems to always be an element of long term stress involved and also psychological or physical
trauma. Perhaps certain medications are to blame. In other cases, the compression or stimulation of nerves that innovate the pelvic area and
lower back send mixed messages to the genital organs.

When I first noticed my own symptoms, I was puzzled because I had always had low libido and I was post-menopausal at the time. I did not
understand the sudden intense and unprovoked arousal. Very quickly the sensations intensified to the point of constant discomfort and distress. Nothing seemed to help stop the aching tightness, urinary urgency and throbbing waves of persistent arousal with no release.

I could not concentrate or sleep or function properly. It was so distracting and upsetting that I avoided social interactions as I thought I must look like a cat on a hot tin roof. My anxiety would go through the roof and I despaired that life as I knew it was over. I decided to try and find an explanation on the internet and to my relief discovered the condition had a name – Persistent Genital Arousal Disorder or PGAD. I hoped that there may also be some kind of treatment to free me from this nightmare.

As I read articles from other sufferers, I began to wonder if my onset was due to compression of my tail bone from months of bed rest following several surgeries. I noticed my symptoms became much worse during my rehabilitation at the gym and in particular, those exercises that worked on the deep abdominals or inner thighs would send my pelvic floor muscles into spasm and lead to distressing persistent arousal. I also identified some other triggers such as prolonged sitting, cycling, driving, caffeine, alcohol and ongoing stressful situations. I needed to also avoid conflict if at all possible.

One of the sites I read was a blog on Persistent Pelvic Pain and as this seemed to be the link that my research kept referring to, I decided to come to see Sue who has a special interest in pelvic floor dysfunction and pelvic pain. She described to me the “Perfect Storm” of physical, emotional and psychological stressors that had combined to cause a breakdown in my body’s nervous balance. She taught me a lot of pain education – how to control my bladder, how to ‘sit like a man’ to help relax the muscles of the pelvic floor, inner thighs and abdominal muscles and most importantly how to breathe and do regualr body scanning to assist with relaxing key muscles. Moreover, the stretches and gentle pelvic exercises she showed me, which free up the nerves as they pass through the lower spine and pelvis, really made a difference. I have since noticed a marked improvement in my PGAD symptoms as well as improved bladder control and bowel function.

I understand that vigilance is the best defence against this terrible affliction. When I feel the symptoms starting, I know I have to immediately breathe and use distraction techniques and stretches to prevent a full blown flare. I surround myself with pictures of places or people who make me happy. I watch favourite tv shows or listen to music. Sometimes even a walk outside or a swim can break the cycle for me.

I am not sure if I will ever be entirely free from this exhausting condition, but I have learned to manage the symptoms and take back my life. My hope is that more research, treatments and understanding will help others to reclaim their sanity and reduce the impact of PGAD on their lives.

Enormous thanks to my patient for her story. It is one of the more difficult conditions to discuss with any health professional and I so appreciate her effort to write this blog for me, as it will help other women perhaps recognise their symptoms from the blog and seek help from a pelvic health physio. Imagine if a woman is having these symptoms and has no idea what is happening to her and reads this – they may be in a state of shock, like my patient was, that there was even such a thing as PGAD – but imagine her relief that treatment can work.

And the treatment is not complicated or difficult for the patient to undertake.

Breathing exercises – it sounds so nebulous and wishy-washy but there is good science behind doing belly breathing – after all it is a window into the drug cupboard in the body (2) (and the autonomic NS – namely the parasympathetic NS which releases dopamine, oxytocin and serotonin to down regulate the effect of sympathetic NS release of cortisol and adrenaline). (3)

Google a breathing gif to help train you to practise the breathing.

The stretches that my patient mentioned are designed to help relax and stretch the overly-switched on muscles, to help the nerves with their movement in the pelvis to ‘glide and slide’, to improve blood flow in the muscles and to provide movement and lubrication to the area. Here are just a couple but there are many more. To help this pain education ‘stick’ with the patients it helps to use metaphors such as the nerves are ‘gliding and sliding’ or ‘flossing and glossing’ – this is of course from the Explain Pain Masters– David Butler and Lorimer Moseley. (2)

Taken from Pelvic Floor Essentials 2018 Sue Croft (4)

The reason she had such a good improvement was her own detective work which meant she sought early intervention and was very receptive to the pain education. When this patient told me her story and we teased out the stressors that were happening for her at this time – together with the increased intensity of abdominal work at the gym and the prolonged somewhat awkward sitting – this was a classic perfect storm of factors colliding to trigger off her PGAD. The best part about her blog is the fact that she has recognised that she has to be mindful and respond when her body sends clues that her nervous system is upregulating again and intervene with her raft of proven strategies. She talks about vigilence – being mindful and responsive to the cues and clues that are there, but we don’t want hypervigilance as this tends to encourage fear-provoking behaviours that escalate the pain. For those wondering about her comment ‘to sit like a man’ here is a link to the blog to explain what that entails.

Sam Heughan plays Jamie Fraser in Outlander (SBS)

My final piece of advice is to please be brave and get help from a pelvic health physio if you are suffering with this difficult condition – don’t be embarrassed and definitely don’t suffer in silence. There are literally thousands of pelvic health physios world-wide!

#worldcontinenceawarenessweek #persistentpain #don’tsufferinsilence

(1) Lewis R et al (2010) Definitions/Epidemiology/Risk Factors for Sexual Dysfunction Journal of Sexual Medicine 7:1598–16071778 1598.

(2) Moseley L and Butler D (2017) Explain Pain Supercharged 

(3) Ma, X., Yue, Z. Qet al (2017). The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults. Frontiers in psychology8, 874. doi:10.3389/fpsyg.2017.00874

(4) Croft S (2018) Pelvic Floor Essentials

World Continence Awareness Week is approaching: First Aid for Bladders

Bev Killick for CFA

With World Continence Awareness Week (WCAW) looming on the horizon, I thought in this blog, I should set the scene with a brief overview of some quick things you can think about if you have urinary incontinence (for both women and men) and some of the first things to try to improve your continence state. But first a bit of introduction into this year’s WCAW. The Continence Foundation of Australia (CFA) are continuing this year with their theme of using humour to spread the message about treating incontinence.

This idea of using humour was first disseminated on a public forum by Elaine Miller, a Scottish Women’s Health Physio, who has performed for many years at the Edinburgh Fringe Festival and has made huge headway into getting incontinence into mainstream media and even into Parliament in Great Britain!

Elaine Miller

CFA have their own comedian, Bev Killick (tasked with the same job), who has recorded quite a few 15 second video grabs that are streaming on social media with the message of ‘doing regular pelvic floor exercises over your lifetime in order to treat any urinary incontinence’ needs to be a learned behaviour. But there is more to treatment of urinary incontinence than simply doing pelvic floor exercises.

Let’s look at some quick things to try in readiness for improving (and let’s hope for a cure for) your urinary incontinence.

Screening for a Urinary Tract Infection (UTI) should be a first step and this involves a trip to the GP for a request for a microurine (and the doctor can often get you to provide a midstream sample there and then and have it sent off). Many times increased urinary urgency and urge incontinence can be worsened if there is an infection. It also helps to check for the clarity of the urine (cloudy urine can signal infection) and colour (it should be pale yellow- the more concentrated the urine the more irritating for the bladder). If your urine is clear, a nice pale yellow, there is no odour and no stinging when you void or blood in your urine, then it is unlikely there is infection. 

Performing a 48 hour bladder diary to see what you can hold in your bladder is also important detective work to undertake with measured volumes preferably being between 350-500mls for the adult bladder. When we see our patients at Sue Croft Physiotherapy, we give everyone a container (which I call a witch’s hat but is technically called a speciman collector) to make measuring each urine void easier and since doing this many years ago I can honestly say we have about 95% return rate on the completed diary.

This bladder diary gives us an amazing amount of information – the capacity of the bladder; the degree of urge with each void (from nothing to busting); the spacing of the voids throughout the day; the number of urinary leaks and at what volume of the bladder; the number of voids at night and the amount of fluid voided through the day versus the night; the balance of your fluid input versus your fluid output; the types of fluid that you are drinking; the total volume of your intake; the times you are drinking etc.

Getting an ultrasound to see if you empty your bladder fully with voiding. Many times women believe they have urinary frequency when in fact they are not completely emptying their bladder fully which is why they have frequency. If you have a large residuals this can also lead onto recurrent urinary tract infections.

As we work through the weeks to WCAW, we will look at the different types of incontinence and some of the strategies you can employ to improve and ultimately cure urinary incontinence. If you have urinary incontinence, it can change how you feel about so many things: you can stop exercising; you can feel a whole range of emotions: shame, anxiety, sadness, depression; you stop socialising; you over-think about outings in general because you may be unsure about the location of the next toilet (did you know there is such a thing as a Toilet Map which actually locates where toilets are located?)

If you are suffering in silence with urinary incontinence, now is the time to seek help. The strategies we teach you are simple and easier than you think to implement and let’s face it – most pelvic health physios get into doing this work because of their own birthing experience and are actually living the dream of #pelvicfloordysfunction so they are empathetic, understanding and kind.

If you want to make a headstart on things prior to making an appointment with a pelvic health physio these things are comprehensively covered in my two books Pelvic Floor Essentials (if you haven’t had or not intending to have surgery) and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery (the surgical book). You can check them out on my book website.

 

 

 

Objective Measurements of Prolapse: What makes women anxious?

 

Whilst many scoff at this image, it is an excellent way to find out what women are complaining about (prolapse wise) when they stand up 

I am writing this long blog in response to an increased level of anxiety over the past couple of years in patients about their pelvic organ prolapse (POP).

Over the years much has changed in the way prolapse has been measured, reported and thought of by gynaecologists and other health professionals who see patients with prolapse. Women are now asking about their grade of prolapse and are constantly worrying about where their prolapse is sitting. Sometimes they are overly informed.

The POP-Q scoring system is a standardized method of assessing site-specific pelvic floor defects through nine measurements of the vagina and perineum obtained during a routine pelvic exam.(1)

The small wooden measuring stick called a POP-STIX which is a way to objectively measure prolapse and GH+PB. The small machine is a Peritron which allows us to benchmark the squeeze pressure for the woman from appointment to appointment

Another way is via 3D/ 4D (tomographic) ultrasound which allows an assessment of pelvic floor trauma such as levator avulsion injuries and hiatal ballooning. (The width and depth of defects are able to be measured or estimated, and the number of abnormal slices correlating with the likelihood of prolapse and symptoms of prolapse are assessed). (2)

Taken from Professor Peter Dietz site 

One of the positives and the negatives about prolapse diagnosis in 2019, is so much has changed about the level of knowledge that patients have about prolapse. Because of the internet, women can readily research information, but when they read the symptoms, they sometimes then panic that they have prolapse when they actually don’t or the degree of prolapse is not at a significant stage or their symptoms may be due to something else. The other isssue is that whilst they don’t actually have any prolapse yet, they may have a significant muscle trauma which may lead them to develop prolapse in the future and when they read about levator avulsion, it does lead to a lot of panic, anxiety and sometimes serious depression.

One of the critical things to acknowledge and respect is that it is inconceivable that the vagina is going to stay completely unchanged after a vaginal birth. You can see in the image below the tremendous stretch that happens when the baby’s head is crowning.

 The 1939 Dickinson-Belskie Birth Series Sculptures: Baby’s head crowning

But we know many women come through relatively unscathed. What is available to try and predict who is more likely to have issues with a vaginal birth and who isn’t?

There are many factors that affect the degree of change that occurs post-vaginal birth such as: your collagen make-up (do you have a collagen disorder such as Marfan’s or Ehlers-Danlos Syndrome (EDS)? – Although specific genetic predisposition has not been identified, a systematic review of genetic studies found that collagen type 3 alpha 1 was associated with POP (OR 4.79)(1)); the size of the baby’s head; the overall weight of the baby; your age with the first pregnancy (over 35 has an increased risk of pelvic floor dysfunction); any instrumentation that may be required to assist the baby out (with a forceps delivery there is a 40% chance of an avulsion injury). These factors are now able to be discussed with the obstetrician or midwife and the mother (and her partner) via a risk prediction model called UR-CHOICE.  Collaborators from a number of centres around the world, led by Eric Jelovsek, have developed UR-CHOICE, a scoring system to predict the risk of future pelvic floor dysfunction based on research looking at the many major risk factors. This research has followed up women at 12 years and 20 years after delivery and this scoring system together with the mother’s own preference, may help with counselling women regarding pelvic floor dysfunction prevention.(4, 5) 

UR-CHOICE stands for:

U –   Urinary incontinence before pregnancy.

R –    Race (ethnicity).

C –    Child. Bearing first child started at what age?

H –   Height. Mother’s height (if < 160cm).

O –   Overweight. Weight of mother, Body Mass Index.

I –     Inheritance. Family history of PFD (mother and sister).

C –    Children. Number of children desired.*

E –    Estimated foetal weight (baby weighing greater than 4kg).

*If caesarean deliveries are indicated this is important due to an increased risk of placenta praevia and accreta with increased number of caesarean deliveries.(5)

Discuss any factors you have on this list with your obstetrician to completely understand the implications.

I have also included a part of the conclusion from the Hallock study (2016) as this reinforces one of the issues with the vagina – the fact that it moves and responds to increased intra-abdominal pressure – the vagina is dynamic not static and rigid. It is also likely to change through the day depending on your activity levels (increased intra-abdominal pressure) and the degree of upright vs sitting/lying you undertake and it changes and adapts through pregnancy:

Recent studies have shown that the pelvic floor is a dynamic structure that adapts during pregnancy and delivery by expanding the levator hiatus, increasing elastase activity, and lengthening pelvic floor muscle fibers. Future studies with animal or imaging models will provide even more insight into these mechanics.” (3) 

Regarding your risk of prolapse if you look at the stats – up to 50% of women over the age of 50 who have had a vaginal birth will have some degree of prolapse in their lifetime. However many prolapses are asymptomatic for many years with only 15% of women being symptomatic at 20 years.(5) This is an important statement. Only 15% of women are symptomatic at 20 years after they had their babies.

Hallock also states that mild POP, defined as any degree of prolapse on examination is practically universal in older women, but women may not have symptoms unless prolapse is more severe. Thus, estimates of the prevalence of POP will be impacted by the threshold used to define the condition.

So my point in this article is having a prolapse need not be considered a devastating diagnosis. The degree of prolapse in any one woman can vary from day to day and from hour to hour within any given day depending on what they are doing. The significance health practitioners place on the degree of prolapse can vary depending on their experience and their deference to current research, which is that conservative management of prolapse should be the first line of treatment offered to a woman and that ‘watchful waiting’ is an important concept to consider for every patient. And some health professionals may fail to relay to the women that if you aren’t bothered by the prolapse, then you don’t necessarily have to rush into surgery to just correct the anatomy.

Over the years I have written many blogs about the preventative strategies available to treat prolapse. One of the most crititcal, is effective education. While it’s useful to know the state of your pelvic floor post-delivery, if you become paralysed by the fear of moving because of the state of your pelvic floor, it may have worse impact on your mental health, as well as your over-all physical health, if you are too scared to exercise and simply stop altogether. This can even lead to cardio-vascular problems in later life, bone density issues plus a risk of diabetes or obesity developing amongst others.

Therefore I believe it is important not to catastrophize about your prolapse as this will change your life if you become fearful about moving and exercising.

Many times women know that something has changed quite soon after a vaginal birth because they may have an episode of urinary incontinence or faecal incontinence. They may find out they have a small prolapse at their 6 week post-partum O&G check up or they don’t, because the doctor may not to want to worry them, because it is so mild. And so they then may discover it at their PAP smear two years down the track or not because the doctor thinks she may not cope with the news. And then, unfortunately much later still, the patient suddenly finds out when she can feel a lump after an intensive weights session when attempting to ‘get fit’ in a rush 10 years later.

This is where I think it should be manditory to see a pelvic health physio at 6-8 weeks post-partum regardless of the mode of delivery and any dysfunction that the patient may or not have. (The range of weeks is mainly due to a couple of things. When my daughter had her first baby, while I was visiting her in melbourne and I was attempting to do something like going for a shop with the baby, I was reminded that even at 6 weeks (and me not having had the baby) – it can be a big ask getting out to appointments – I had, not surprisingly, blocked out from my memory that first 12 weeks with your first baby. It takes effort to get ready and get all the paraphernalia associated with taking a baby out if they are a bit finicky and you are operating on zero sleep. Every time I see a girl at 6 weeks post-natal I congratulate them (in my head) on their achievement of getting it together and coming to see me. The second reason is if you’ve had a traumatic delivery you may be still be feeling sore/ weak/ wet/ heavy/ draggy from the vagina and having soiling etc.)

But it is also important for health professionals to keep the patient calm about the prolapse. When you see that research shows that after one vaginal delivery, a quarter to half of the women demonstrate a mild prolapse during the first postpartum year,(7) then maybe we health professionals need to be relaying a message to our patients that this laxity may never progress, especially if you are consistent with your exercises and the knack and we all be more accepting of mild prolapse (that is asymptomatic unless a lot of attention is drawn to it).

The Bio-psychosocial model by Butler and Moseley 2015- usually applied to pain management but can equally be applied to the emotional burden of prolapse

And this is where the Biopsychosocial approach may be applicable to treating patients with prolapse- to take the fear-provoking language, thoughts and behaviours out of the conversation with women with prolapse. This model takes into consideration more than just the biology (the anatomy of the vagina and pelvic floor – Where does the prolapse sit? What are the muscles like? What are the suspensory ligaments like?); it takes into consideration the psychology (How traumatised is the patient? and her partner? from the birth process? How supportive and understanding are the staff, the O&G of her feelings, her thoughts? after the birth of her baby. Is she showing signs of depression or PTSD?; and taking into account the social aspect – her family support, her work colleagues, her friends (who may be having absolutely no problems and is entertaining daily with cupcakes and lattes)?

The woman is more than her prolapse and every woman is an individual and her individual needs have to be respected, her narrative has to be heard, and if it’s a traumatic birth – just because 30 years ago women knew no better and seemed to ‘suck it up’ – doesn’t mean this denial of what the woman has gone through has to be perpetuated. The saying ‘but at least you have a baby‘ and completely disengaging with the process the woman went through to get the baby, causes a lot of grief for patients and that needs to be respected and validated.

This mandatory pelvic health assessment by a physio would allow the woman:

  • to have an accurate assessment of the muscle damage that may or may not have happened;
  • to be encouraged to work on the muscles that remain;
  • to learn about ‘the knack’;
  • to learn the correct defaecation dynamics and position (constipation and straining at stool can be asociated with prolapse);
  • to see if a pessary may be indicated to prevent worsening prolapse particularly in those early months and years when lots of heavy lifting is undertaken with babies, toddlers and their miriad of equipment;
  • to recover well from even a caesarean birth (learn good bladder habits, positioning for bladder and bowel emptying and address any other concerns)
  • to debrief about the birth with an understanding health professional.

With regard to this increasing anxiety and distress that many working with women with prolapse are seeing, increasingly research is now being undertaken looking at the emotional burden of women with prolapse.  Chiara Ghetti (2016) reports that they wanted to look at the emotional burden experienced by women with prolapse as “POP affects many areas of the woman’s life including social, psychological, occupational, domestic, physical and sexual.” They developed a condition-specific health-related quality of life (HRQOL) instrument, but acknowledged that the tool did not capture the complexity of women’s experience or to discern the impact of these conditions on her emotions and emotional well-being(8). Prolific researcher Ingrid Nygaard has undertaken some interesting research not only looking at the influences of intra-abdominal pressure and other influences on POP, but also the cultural context in which women experience changes and symptoms of POP.

Ghetti’s qualitative research I believe will be so validating for many women who have had a traumatic birth and I have directly taken the following from the article for this reason. These are things we hear every day in our clinic and it is so important to recognise the commonality of themes as described in the transcript. 

Transcript analysis revealed three main themes related to women’s emotional experiences:

  • emotions associated with the condition of prolapse,
  • communicating emotions related to prolapse
  • emotions relating to treatment.

Emotions Women Experience Associated with the Condition of Prolapse

Little to no emotions related to prolapse were described by some subjects. Their experiences were mainly limited to physical bother. In this group there were subjects whose prolapse had developed so quickly there experienced no emotion, while for others the prolapse had been such a longstanding problem it had just become normal part of life. Overall, the remainder of subjects collectively described a spectrum of feelings related to prolapse. Annoyance, frustration, and irritation were common themes, with one woman stating she was frustrated with having new worries. Others described unhappiness associated with the uncertainty of what was occurring and anger that this was happening to them.

Stronger emotions of depression, anxiety and sadness were described by some. Feelings of anxiety were often associated with a feeling of uncertainty of ‘something being wrong’. Several subjects also described concern and anxiety for the fear of having cancer. Others described anxiety about the change in their day to day routine because of the condition. This was often related to the incontinence symptoms they experienced.

Feelings of sadness were often associated with the thought of getting older. For others the sense of sadness was linked to a feeling of falling apart. Some women further elaborated on the feeling of falling apart, as a sense of brokenness or defectiveness, but did not directly associate it with a specific emotion. The feeling of brokenness and incompleteness surfaced also in a discussion of how prolapse affected the participant’s intimate relationships and how this made her feel. In a similar fashion, some described feelings of not being a whole woman.

Communicating Emotions Related to Prolapse

Overall women described a general difficulty in discussing their pelvic floor symptoms and their effects on daily life. Alongside identifying pelvic floor disorders as taboo, some women identified a sense of shame that made talking about their symptoms even more challenging. Women described secrecy surrounding pelvic floor disorders even amongst other women.

When asked specifically about talking to their gynaecologist or surgeon about their emotions, several subjects stated they had indeed spoken to their physician about their feelings. Of the subjects who had already addressed their emotions, one stated that her surgeon brought up the discussion; the other stated she started crying during her visit and her surgeon helped address her emotions. Other subjects were divided about whether to speak to their specialist about their emotions or not.

Others felt it was not a good idea to speak about emotions or mental health issues with a surgeon or physician. Some themes emerged about the responsibility of both patient and physician in discussing topics related to emotional well-being, with some having no expectation that a surgeon would discuss her well-being. In contraposition, others felt that physicians somehow just know how their patients feel.(8)

This qualitative research is so helpful for health professionals who may have become blasie about births and the ‘less than satisfactory state’ of the pelvic floor after the birth. Sometimes I think the more health professionals see, the more commonality is assigned to the cohort and the individual’s experience is somewhat diminished. This may lead to dismissing of the feelings the woman may be experiencing and this will add to their distress.

The good news is Nygaard’s qualitative research “will examine the cultural aspects of perceptions, explanations of pelvic floor support changes and actions taken by Mexican-American and Euro-American primiparas, emphasising early changes after childbirth. Summarising the projects’ results in a resource toolkit will enhance opportunities for dialogue between women, their families and providers, and across lay and medical discourses, with a view towards workable prevention strategies.”(7)

I hope this long blog is useful in allaying some fears, explaining some thoughts you may have had and explains some things that may have been said to you after your baby was born. Remember women have been having babies for millenia, but the research is relatively new and still evolving.

Me with Paddy 15/2/2017

(1) Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–17. [PubMed[]

(2) Dietz 2007 

(3) Hallock, J. L., & Handa, V. L. (2016). The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update. Obstetrics and gynecology clinics of North America43(1), 1–13. doi:10.1016/j.ogc.2015.10.008

(4) Sue Croft Pelvic Floor Essentials, Edition 3

(5) Jelovsek E, Chagin K, Gyhagen M, Hagen S, Wilson D et al (2018) Predicting risk of pelvic floor disorders 12 and 20 years after delivery Am J of O & G Vol 218, Issue 2 Feb: 222.e1-222.e19.

(6) Hagen S, Stark D, Maher C, & Adams E (2006). Conservative management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews (Online), (4), CD003882. 10.1002/14651858.CD003882.pub3.

(7) Nygaard IEClark EClark L, et al Physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery: a protocol for a mixed-methods prospective cohort study

(8) Ghetti, C., Skoczylas, L. C., Oliphant, S. S., Nikolajski, C., & Lowder, J. L. (2015). The Emotional Burden of Pelvic Organ Prolapse in Women Seeking Treatment: A Qualitative Study. Female pelvic medicine & reconstructive surgery21(6), 332–338. doi:10.1097/SPV.0000000000000190

Pelvic Health Physiotherapists can be found on the Australian Physiotherapy Association website under Find a Physio
Psychologists can be sourced on the Australian Psychology Association.

Men’s Health Issues

Men’s Health is a serious matter.

Men die because they are too embarrassed to seek help in a timely fashion about some of their most private issues.

With over 300 blogs written, it is somewhat embarrassing that I have only posted a handful of Men’s Health blogs. I have decided to rectify this today by at least bringing all the Men’s Health blogs that I have ever posted, together, into one blog (to make them easier to find) and I am also including some information about other significant Men’s Health conditions – some of which can be acutely embarrassing for teenagers and men when they occur. One in particular can have devastating consequences for men with pain and serious consequences for sexual intimacy.

These days we are better at talking about Women’s Health – incontinence, prolapse, vaginas, vulvas….these are all subjects which were never spoken about in the public domain even just 10 years ago, but thanks to the internet and the fact that we are more robust as a society, we can discuss these health issues much more readily. But with Men’s Health there is sniggering if the word penis is mentioned or immediately sexist jokes abound, or inuendo. It’s time to be more mature and realise the implications of not being open when discussing men’s health problems.

As you read through the rest of the blog there are many links within it so click on the links to go to the other resources.

The first link here is a great fact sheet produced by the excellent Men’s Health organisation called Andrology Australia on a subject which is rarely discussed – Foreskin Hygeine. But I particularly wanted to highlight a condition called Phimosis. Phimosis is when the foreskin of the penis is too tight, or the tip of the foreskin narrows and is unable to be pulled back to expose the head of the penis. Severe phimosis can cause pain when urinating, urinary retention (when the bladder is not completely emptied on urination), urinary tract infections and skin infection of the penis.

Older men with severe phimosis have a higher risk of developing cancer of the penis. Phimosis can cause severe pain with erections and sexual intercourse, causing injury to the foreskin with minor bleeding and infection. There is more detailed information in the link to the Andrology Newsletter. As you can imagine it is devastating for this condition to emerge as a young teen is starting to mature and perhaps pain and deformity can appear, of course worsened with erections. It is crucial to break the silence around this condition as it can be conservatively treated successfully in many cases, particularly if it is disclosed early to a health professional. Steroid cream application and teaching the patient tissue stretching techniques can sometimes cure the problem, but also sometimes circumcision may be necessary.

I was actually inspired to write about this due to a tragic story from BBC News about a mother who received an email from her son after he had tragically taken his own life due to this condition of Phimosis. The comprehensive story is graphic and take care as it may be triggering for some people who may have experienced the loss of a loved one through suicide. She was devastated as she knew nothing of the terrible health issues this problem created for him – he was too embarrassed to let his family know what he was going through.

Imagine that – because of the shame and embarrassment of a medical issue with his penis, he was unable to talk about it and this was the only way he could see to solve his problem. He sent the email detailing the shocking trauma he had been through (he was living in another country to his family) so she received it after his passing. In the email he begged his mother to publicise this issue – to bring awareness to the general public – to bring this condition out into the open.

If you are struggling with symptoms like this or other conditions regarding sexual activity, penile pain, testicular pain or other issues- it is important to seek help. We have two Pelvic Health Physios (Alex and Megan) who will be able to assess, educate about and treat these unpleasant symptoms.

The next link is in fact a link to some of the Men’s Health conditions we treat at Sue Croft Physiotherapy .

The first blog I wrote about Male Urinary Incontinence following Prostate Surgery was way back in 2013 called The Elephant in the Room – mostly because my lack of male blogs was the elephant in the room – I had written 73 blogs before I wrote the first blog for men.

Dr Joanne Milios (Physiotherapist and PHD Men’s Health)

A Men’s Health Physio, Joanne Milios, who has just received her PHD for her work looking at maximising recovery following prostate surgery was a guest blogger for my second men’s health article – it is longer than usual but well worth the read. I may be able to entice her to write a second blog for me now she is Dr Milios?!

The next link is an article which physio Amanda Quinn wrote for a Men’s Health Magazine. (Amanda worked with me at my practice for a couple of years-she has since moved back to Melbourne to work and be with family). It is a great article summarising many of the strategies including those for pelvic pain.

The final blog is one that I posted after attending a Stuart Baptist workshop on Men’s Health at the Continence Foundation of Australia‘s National conference in Sydney a couple of years ago. Stuart is a well-regarded Men’s Health Physio in Sydney and ran a comprehensive 3 hour workshop. Again it is quite a long blog so take your time.

Stuart Baptist

I would also like to point out two great Men’s Health Books by Craig Allingham another Men’s Health physio and author. One is the Prostate Recovery Map and the other the Prostate Playbook. I am hoping Craig will write me a blog about the two books and how helpful they will be in helping you if you have a diagnosis of prostate cancer or if you are embarking on the ‘watchful waiting’ journey.

If you are a man struggling with a pelvic floor pain condition, urinary urgency or incontinence, bowel issues or are facing prostate surgery it can be so daunting, but we have wonderful physios at our practice to help you with these conditions. There is no need to suffer in silence –ring the rooms (Ph: 07 38489601 or 0407659357 for an appointment or contact your nearest pelvic health physiotherapist who treats men if you are in a different city.

Spread the word!

Return to running after childbirth

 

One of the most requested desires from women after having their baby when they see us at our clinic, Sue Croft Physiotherapy (except for ‘I wish I could get a decent night’s sleep’) is When can I start running again?

Many women love running and use it for many reasons: recreational enjoyment; to exercise for fitness and many for their mental health. If they have had a smooth birth process, with minimal changes to their pelvic floor, then they may hardly give returning to running a thought – they just do it!

For others, who may have had a traumatic vaginal birth they realise there needs to be careful consideration of the pros and cons of returning to running. 

Recently there have been new guidelines written and published by three physiotherapists and these running guidelines are really the first comprehensive look at what should be taken into account when deciding whether and when to run again. You can click on the link above and enter your email and the guidelines will be sent to you. They have been written by three physiotherapists Tom Goom, Emma Brockwell (from the UK) and Grainne Donnelly (from Ireland). You can hear more about the guidelines from the authors themselves by listening to the Pelvic Health podcast by my friend and colleague Lori Forner

Over the years I have seen many, many girls addicted to running. It’s definitely seems to be one of those things that if you get the bug, it’s difficult to let go of (a little like me and chocolate). This was brought home to me when watching a story on (the brilliant) @Australian Story on our ABC. This particular episode grabbed my attention because of the determination of Mina Guli, a 48 yr old who decided to run 100 marathons in 100 days to draw attention to the growing global water crisis. It was excrutiating to watch toward the end, but it wasn’t her pelvic floor that let her down, but terrible hip pain. She basically ended up in a wheelchair due to stress fractures and pain, but just when she finally thought that her mission had to be aborted, suddenly the power of social media took the campaign in a totally different direction. The link to this episode is below. I won’t spoil the story.

https://www.abc.net.au/news/2019-04-29/how-mina-guli-change-the-world-one-step-at-time/10799874

But back to running after having a baby. There should be some real considerations prior to you commencing a return to running.

  • Have your pelvic floor thoroughly assessed by a Pelvic Health Physiotherapist (with an internal examination)
  • They will do objective measurements to assess the state of your pelvic floor (such as the dimensions of your genital hiatus plus the length of you perineal body and ask you to perform a valsalva)
  • They will assess the strength and integrity of your pelvic floor muscles (looking for indications that there may have been levator avulsion)
  • They will look at the distensibility of the pelvic floor
  • They will check for prolapse
  • After considerable education from your physio, teaching you the correct action of the muscles, how to brace them prior to increases in intra-abdominal pressure (called the knack), they will send you home to practise for a few weeks.
  • Once those strategies have been learned and implemented, they may discuss the value of being fitted with a pessary (once discussing with your urogynaecologist or Obstetrician and Gynaecologist as required) to give extra support with higher impact exercise such as running.

At our clinic, the next stage may be undertaking a Running Clinic. A number of my physiotherapists conduct these clinics – videoing you as you run on a treadmill and then taking you through some adjustments to things like breathing, stride length and how you are holding yourself. Then with correction, re-videoing you to show the more relaxed and improved style of running.

So think carefully before rushing back to running and I wouldn’t consider it until at least 3 months. A good time to get your pelvic floor assessed is at 6 weeks post-natal.

A greater explanation of the pelvic floor, bladder and bowel function, prolapse and pessaries and much more can be found in the latest edition (2018) of my book Pelvic Floor Essentials which can be purchased from the books website.

And in keeping with the theme of post-natal recovery, a big congratulations to the Duchess of Sussex and Prince Harry on the birth of Archie.  (I am rightfully placing her first in order, as he excitedly acknowledged how amazing she was with the whole birth process).

Meghan, Harry and Archie – I already love the name – very Australian to end it in ‘ie’

(Official photo released 9/5/19)

May is Pelvic Pain Awareness Month: Persistent pelvic pain information in one area

suecroftblog banner

My blog can be a useful resource for my patients (and for the general public). It’s like having a great big library of all the things I would love my patients to read at my finger tips. When we physios teach a vast amount of seemingly complex medical information in an hour to an hour and a half- its pretty certain that most adult learners will only be able to take in about 20% of what has been said during the consultation. That’s why every patient receives not only a copy of my book, but also an extensive handout plus some extra pages if there are specific tests I want them to undertake (for example- a simple corn or beetroot test to check their bowel transit time; or a handout on the causes of faecal incontinence- and if they have pelvic pain they get the normal pelvic floor dysfunction handout as well as a dedicated pain handout).

So there’s plenty of back-up reading.

Persistent pain is a big problem and I see more and more patients with sexual dysfunction caused by vaginal pain (vulvodynia, ‘vaginismis’, overactive pelvic floor muscles, post-op gynaecological surgery), endometriosis pain and generalized pelvic pain that is not resolving. I have written quite a few blogs on pain and there are some magical video blogs from Lorimer Moseley and David Butler of the NOI Group and the NSW Government which are freely available on the internet (heartfelt thanks to NOI/BIM/Lorimer/David and others) which I encourage my patients to look at after their consultation to reinforce what they have just learned.

Today I have decided to put all these blogs together in one place to make it easier to point patients to do some pre-reading prior to their first appointment. This is not compulsory though. There are many blogs within this link – you can choose to read one or all of them. (Or you can choose to read none of them and wait for the appointment).

If patients can pre-read that there is new chronic / persistent pain education to be covered prior to the appointment, then they are more likely to listen to what the physio is saying at the consultation rather than perhaps going into a state of shock when they hear those words…….

The brain decides whether you are going to have pain or not!’

Because if that piece of information is glossed over quickly, without good education, then what patients may hear is: ‘It’s all in your head’ and that is definitely not what good persistent pain education is all about.

So what I have done is list many of these different blogs/articles that I have written about pain below- read one, look at one video or eventually read them all. But it would be helpful if you could read at least something, or listen to at least one of the pain videos to get some understanding of what it is about before your first appointment.

The important thing to know is that 1 in 4 people with persistent pain will get a 50% pain reduction in their pain when pain education is included within their standard treatment. Lyrica is 1 in 6.8 patients for comparison. (1) So simply reading these blogs may give you some improvement in your pain condition.

The writing is going to get a bit stilted from here on….. but just click on the links to go directly to the blogs.

So here is my first blog ever on pain called “Persistent Pelvic Pain”

Here is the second blog called More on persistent pelvic pain”

The third blog is called “The art of conversation” and has an introduction on the placebo effect following a great show on SBS.

The fourth blog is called “Roadblocks to compliance”

The fifth link is to a one hour TED talk which Lorimer Moseley gave in Adelaide. This is very long and only look at it if you are really into reading and knowing as much as you can about pain.

The sixth link is a brilliant 5 minute video called “Understanding Pain” summarizing everything you need to understand about pain. The content in the video was a joint project between GP Access and the Hunter Integrated Pain Service in NSW.

And the seventh link is to a short video from David Butler on “The Drug Cabinet in the Brain”

The eighth link is another little gem called “Brainman stops his opioids” by Medicare Local, BIM, NSW Government Hunter District, Uni of SA, UW Medicine and NIH Pain Consortium on how to utilize pain relief without becoming reliant on opioids.

The ninth link is called ‘Sit like a Man’ and reminds us how to down-train the abdominal and pelvic floor muscles – one of our favourite Outlander characters helps us with this blog.

The tenth link is a great short video by Dave Butler on Smudging in the brain.

The eleventh link is another excellent video by Dave Butler on Thought Viruses.

The twelfth link is about the importance of good breath awareness.

The thirteenth link is a blog I wrote on managing social anxiety called Social Anxiety in Cats and Dogs.

The fourteenth link is a blog on Mindfulness in managing Anxiety.

The fifteenth link is a recent blog I wrote about the anatomy of the clitoris called “Masturbation is not a sin”.

There are also a number of excellent texts on understanding persistent pain.

I’ve mentioned Explain Pain’ by David Butler and Lorimer Moseley many times but another great patient directed book is called ‘Why Pelvic Pain Hurts’ by Adriaan Louw, Sandra Hilton and Carolyn Vandyken and of course my own books Pelvic Floor Essentials and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery have a chapter devoted to managing persistent pain.

So all of these blogs, links and books are designed to de-mystify persistent pain so we are no longer scared of pain, or moving, or having sex, or inserting a tampon, or whatever fears your pain is responsible for.

the lion and the daschound

Just like this daschy is not intimidated by this lion– in fact they are best friends- you too can not only learn to live with your pain, but hopefully conquer it so it becomes a part of your past. Here is a video which shows you Milo the dog and Bone Digger the lion interacting at GW Zoo, Wynnewood, Oklohoma. Bone Digger had problems walking when he was a cub and this pup was raised with him. They are now inseparable.

(1) Moseley, Butler 2017 Explain Pain Supercharged

Metaphors that ruin your life.

This is another one of those blogs where my close family members need to look away, if me talking frankly about sex is embarrassing for them. But I want them to remember that the silence around sexual dysfunction is massive and it is important that, as a health professional working with women and men with problems in this area, I need to cover this topic in my blog.

I have written previously about orgasm and sexual function in this blog here. Most importantly, it is imperative that if anyone out in the stratosphere is reading this and you have pain, uncertainty or questions about sexual function, then your local Pelvic Health Physiotherapist will be able to help you or refer you on to someone who can. Google for your nearest pelvic health physiotherapist.

Over the nearly 30 years I’ve been treating (mostly) women but some men for sexual dysfunction, one of the most destructive phrases or beliefs that keeps cropping up over and over is a common one which patients report from their Catholic (church or school) upbringing and probably from many other religions also and it is: “Masturbation is a sin”. 

That simple phrase has caused much angst for many women and men and their sexuality. This phrase must have been said and reiterated to these patients when they were young, vulnerable and impressionable because for many, it has caused them to deny themselves a lifetime of autonomy over their bodies. It has encouraged them to repress sexual feelings they have had and to feel guilty if they don’t ignore those sensations and feelings and actually decide to acknowledge them and do something about them by doing self-stimulation.

What it also has done is create mystery around how women can actually achieve orgasm and made women afraid to actually explore their own bodies with the view to learning what feels pleasurable and what doesn’t. This is an important skill for women to learn as they need to be able to tell their partner what feels comfortable and what feels uncomfortable or just plain hurts. This is another life-area where there is very little proper instruction – a lot like having a baby. I mean is anyone else absolutely incredulous (if you truly think about it) how little instruction is given to mothers and fathers about the most important task they will ever be given – here take this baby home and look after it……. FAROUT.

So in the ranking of important information we should talk much more about – how to orgasm and what is involved in having pleasurable pain-free sex is right up there because sexual dysfunction is a common cause of marital disharmony. If women (or men) can’t have pain-free sex and are too afraid/ embarrassed/ ashamed (yes shame is a common emotion women feel if they can’t have sexual penetration with their partner) to openly talk about it, seek help or counselling for it – then it sometimes causes relationships to fail, which then causes untold grief to families and particularly children.

Professor Helen O’Connell

Back to women learning about their clitoris (‘their’ being the operative word – it is an important part of every woman’s anatomy and belongs to her). The clitoris exists purely for pleasure. But sadly the clitoris is a mystery to many women and most men – and I am including some doctors in that broad statement. The interesting thing about the clitoris is that it wasn’t until 1998 that a female Australian Urologist, the now Professor Helen O’Connell, actually did detailed dissections and discovered the previous-held views on the true anatomy of the clitoris were completely misleading. A big fail in Grey’s Anatomy for many years! I’m not sure if all health professionals have caught up with this fact and still believe the clitoris is merely that (magic) button just above the urethra. Here is a great article about the anatomy of the clitoris by Dr Mark Blechner. 

Most of the components of the clitoris are buried under the skin and connective tissues of the vulva. It comprises an external glans and hood, and an internal body, root, crura, and bulbs; its overall size is 9-11 cm. (1) Therefore the clitoris is huge! Clitoral somatic innervation is via the dorsal nerve of the clitoris, a branch of the pudendal nerve, while other neuronal networks within the structure are complex. (1)

Image from an article by Mark Blechner (see full article linked above and at the reference below) 

Understanding about the power of the clitoris is important because when we are teaching women about how to manage persistent pelvic pain, we talk about the body’s own ability to administer some pretty powerful drugs of its own. This relates to the “The Drug Cabinet in the Body” and Dave Butler explains this very well in the linked 5 minute video. General exercise (walking, running, gym, netball, rowing, swimming, in fact, anything) releases some of the ‘drugs’ (such as serotonin, oxytocin and dopamine) in our bodies that helps with persistent pain management. But another excellent way to access the ‘drug cabinet’ in the body is via the clitoris and particularly apt if one has female sexual dysfunction (FSD).

Quite often women have pain with penetration – pain at the vulva or internally generated by their over-protective pelvic floor muscles, but have no pain around the region of the clitoris. This means that with a good lubricant, they are able to gently touch the clitoris for short periods of time and build up tolerance to the touch, release warm, fuzzy feelings and gain arousal to assist with dilator work or with penile penetration. This graded exposure to clitoral self-stimulation will also help with any feelings of guilt or shame that may be present. This can be used in conjunction with dilators (or trainers as they are sometimes called) and as progress is made, then with adding a gentle vibrator which can be purchased from here and here (from Pelvic Floor Exercise an online store for all things Pelvic Health)

For your interest, there has been a change in definition of Female Sexual Dysfunction (FSD) and the International Continence Society (ICS) went with the definitions from the DSM 5 (The Diagnostic and Statistical Manual of Mental Disorders fifth edition). The DSM 5 has combined disorders that overlap in presentation and reduced the number of disorders from six to three.

  • Hypoactive sexual desire disorder (HSDD) and female sexual arousal disorders (FSAD) have been combined into one disorder, now called Female Sexual Interest/Arousal Disorder (FSIAD)
  • The DSM-IV categories of vaginismus and dyspareunia have been combined to create Genito-Pelvic Pain/Penetration Disorder (GPPPD).
  • Female Orgasmic Disorder remains its own diagnosis
  • All diagnoses now require a minimum duration of approximately 6 months and are further specified by severity. (3)

There it is – Female Orgasmic Disorder all on a line by itself. Orgasmic dysfunction in women is the inability to achieve an orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm during any kind of sexual stimulation. They report (high) sexual arousal/excitement. (Prevalence 16–25% in 18–74‐year‐old women in US, Canada, Australia, Sweden but in 2 other studies from Nordic countries 80% of all sexually active women age 18–74, independent of age, report some degree of orgasmic dysfunction). (4)

One of the reasons there could be such high rates of female orgasmic disorder is women wracked with guilt. When girls and women are actively told by their church or their peers or their mothers/fathers that masturbation is a sin? It sounds so wrong. This statement makes it difficult for them to explore their bodies, to chat to someone about it – even their friends, because the knowledgable ones might be skiting about having three orgasms every night and that in itself is intimidating for someone who may barely know where their clitoris is.

Context matters with pain also.

Many women are able to wipe their perineum after they have urinated with no pain experienced at all around the vulva, but when they (or their partners) are attempting to touch this area to explore in a sexual way, it is then that they experience pain. This is an example of the brain believing there is a potential for danger associated with sexual intimacy. The evidence has been accumulated by the brain over the years and much cortisol and adrenaline has been released with every attempt at penetration or really any sexual intimacy. Even thinking about having sex can trigger off this sympathetic nervous system response (the fight- flight response). The brain perceives the threat even without any physical contact. And the response of the pelvic floor muscles is to become over-protective and women experience levator myalgia – the muscle tissues become sensitive and tender points are palpated in the muscles. History matters to the brain! Good and bad experiences leave their indelible impression in the brain. Memories are important and laying down new memories with positive experiences will be useful when moving forward with persistent sexual pain.

Finally after lots of explanations about the anatomy, persistent pain and the like, some resources to help you are important.

OMGYES (the link is here) is a website where you pay a one-off $49 for a lifetime subscription. It teaches about the art of orgasm. Warning: It is very graphic.

I have another blog which has many links within in it called: Persistent Pain Resources in One Area

I hope this frank blog will give you some strategies and the confidence to pursue some help from a pelvic health physiotherapist.

Below is a link to a TED talk on ‘The unknown greatness of the clitoris’ with Maria Røsok

. Enjoy……

 

 

(1) Pauls R 2015 Anatomy of the clitoris and the female sexual response Clinical Anatomy 376-384

(2) Blechner M 2017 The Clitoris: Anatomical and Psychological Issues, Studies in Gender and Sexuality, 190-200

(3) ICS Terminology Website: Rogers R, Thakar R, Petri E, Fatton B, Pauls RN, Morin M, Lee J, Kuhn A, Whitmore K. International Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for the Sexual Health in Women with Pelvic Floor Dysfunction. Int Urogynecol J,2018; Neurourol Urodyn,2018
(4) McCool et al (2016) Sexual Medicine Review Prevalence of Female Sexual Dysfunction Among Pre-menopausal Women: A Systematic Review and Meta-analysis of Observational Studies

 

DRAM Part 2: Exercises to do post-partum

Who are those two cutie-pies with me? (No Dior for me, that’s my mother’s top I’ve borrowed!)

I feel so sorry for Meghan at this stage of her pregnancy. I remember that in the last few weeks of my pregnancies, I was definitely not up for one or two photos of me and my (massive) pregnant belly, let alone one or two thousand! And I certainly never mastered walking in pencil thin stilettos in ordinary life, let alone pregnant life.

Nice sensible flats for me (action shot of Snoopy, the dog who was never still)

I would love to be a fly on the wall every morning as she gets out of bed and faces yet another round of engagements – there must be the occasional day when she’d love to say “Not today Harry- I just can’t do it!” But the time is fast approaching when there is going to be a fanfare and pronouncement of another Royal Baby arriving and another round of aghast amazement or outright belittling condemnation of however Meghan presents herself on the steps of the place where she’s just had the baby. It’s usually a lose-lose situation if you’re a young female Royal. I just for once wish everyone would give these women a break and just say Congratulations! instead of the usual negative palava.

When you look at the photos of us (the royal ‘we’) pregnant, you can see there is quite a strain placed on the abdominal muscles as the weeks close towards the end of pregnancy. We know the abdominal muscles are important for trunk movement, pelvic stabilization, and restraint of the abdominal contents (1)  – what an amazing adaptation to be able to stretch to such an extent and yet for many women, return to mostly what they were like originally. But sadly for some women there is significant separation and also micro-tearing of the fascia and skin which also contributes to a tummy which causes grief for the woman. The research is certainly pointing to the fact that ante-partum activity level may have a protective effect on DRAM and we know that exercise improves post-partum symptoms of abdominal separation. (1) Interestingly, research from Mota also highlights that women with DRAM were not more likely to report lumbopelvic pain than women without DRAM. (1)

The reason for this blog and pregnancy talk is that I promised a second follow-up blog to the DRAM blog that Martine wrote a few months ago and so I asked my Megan (Megan Bergman who works with me at Sue Croft Physiotherapy) to write Part 2.

Megan’s blog follows…

In a previous blog Martine explained diastasis or separation of the rectus abdominus muscles and some lifestyle tips for helping to manage this.  In clinic we have many women asking ‘what are the exercises I can do to flatten my tummy and can I get rid of the separation’?

When looking at these 2 questions it is important to understand a couple of concepts.

Firstly, separation is a normal adaptation of the abdomen to allow for the growth of a baby.  Every woman has a different pregnancy experience and different background which means that everyone’s restoration of function is different, and post pregnancy ‘normal’ may look quite different from pre-pregnancy. So we individualise treatment based on what we find at assessment. 

Secondly, you can achieve good strength and control through your abdominal canister even though the muscles may remain (slightly to moderately) separated. Many women have residual separation that you cannot see. What we are interested in is function

What do we mean by this?

If you imagine the two rectus abdominus muscles with a stretched piece of stiff tissue between them (the linea alba) that allows the muscles to sit out to the sides away from the midline of the tummy creating the separation.  If you contract the rectus muscles and draw them closer together that stretched piece of tissue will bunch up and become loose.  So, although your muscles are closer together, there is now loose tissue in between. This can be a point of weakness in the abdominal canister, and the rectus abdominal muscles do not contract as well as they should.  Additionally what many women will demonstrate is a doming effect in the abdomen (the two rectus muscles popping up in the middle). 

There is a deeper muscle called transversus abdominus (TA) which runs like a corset and pulls perpendicularly to the other abdominal muscles. The research is somewhat conflicting about the importance of TA with some studies reporting that a pre-contraction of the transversus muscle can generate tension in the linea alba which visually prevents the doming effect and functionally prevents looseness in the tissue (2). And yet other studies show that the inter-rectus distance (IRD) widens compared to rest along the length of the linea alba with the pre contraction of TA. Abdominal crunch has been considered a ‘risk exercise’ for development of diastasis recti but other studies have shown that the IRD narrows with a small abdominal crunch.

So what do we do?  We individualise the treatment. When we prescribe the early exercises we assess what does an exercise do to that patients tummy and say “Yay” or “Nay” to that exercise and then progress as the strength/IRD narrows/ function improves. This therefore means some may do a small crunch with a good positive effect and others may not. Some may activate TA and others won’t. 

How do we activate the transversus?

Imagine you are putting on a pair of jeans and you’ve forgotten to out your undies on.  As you do the zip up you are gently drawing in around the pubic hairline (to keep the hair away from the zip). In doing this contraction you notice a very gentle tightening in your lower abdomen but you can still breathe and your upper tummy is still relaxed.

In all exercises ensure you just keep breathing, (don’t breath hold) draw in the transversus and pelvic floor and then perform the movement (this allows the diaphragm to move up and the pelvic floor and abdominals to contract well). If you can do this and continue to breathe while exercising you can perform a wide variety of exercises.

The following exercises are gentle and slow in the early days but need to increase in speed, intensity and difficulty as you get stronger. These are for the early days.

Leg slides

Progress from TA activation to adding in alternate leg slides. 

Gentle head lifts

Lie on your back, gently tighten your low tummy, vagina, anus and gently in at belly button and bend one knee up at a time, so that both knees are bent. Then lift your head up and hold for 3 seconds and lower your head back down.

Pelvic rocking

Lie on your back, gently tighten your low tummy, vagina, anus and gently in at the belly button and bend one knee up at a time, so that both knees are bent. Slowly flatten your back into the bed by rocking your pelvis back, allowing your tummy to gently draw in. Repeat 3 to 5 times. Breathe and relax after this set.

Modified straight leg raise

Lie on your back, knees bent up, gently tighten your low tummy, vagina, anus and gently in at the belly button. Keeping your pelvis steady, draw your right leg to the chest and then straighten your leg out, holding the straight leg about 8cms (3 inches) off the bed/floor for a count of 3 and then go back to starting position. Repeat 5 to 10 times. As this becomes easier, do this exercise as described above but increase the number of straight leg raises to firstly 3 and then 5 if no discomfort. Remember always concentrate on the gentle tightening of your tummy and pelvic floor. Breathe and relax your muscles after this set. Look in a mirror for doming if you have that issue. Control it gently while continuing to breathe. 

Bent knee fall out

Lie on your back, with both knees bent up; gently tighten your low tummy, vagina, anus and gently in at the belly button; slowly lower your bent right leg to the side and slowly bring back upright again. Aim to stop your pelvis from rocking from side to side and check for doming as before. Repeat with the other leg. Do for 5 to 10 times. Breathe and relax after this set.

Modified clam

Lie on your side, with your knees bent and feet together, gently tighten your low tummy, vagina, anus and gently in at the belly button. Keeping your feet together, lift your top leg 8 cm (3 inches) off the other leg. Do not roll your pelvis backwards as you lift. Hold for 3 seconds and slowly lower down. Repeat with the other leg. Do 5 to 10 times. Your focus is on the abdominal muscles and pelvic floor in the beginning. Breathe and relax your muscles after this set.

 

Pelvic rocking in 4 point kneeling

Make sure you have enough tone in your abdominal wall before you go onto this gravity-dependent exercise. This is also a great postural stretch and is known as a ‘cat curl’. On all fours, hands under shoulders, knees under hips, maintain your lumbar curve, gently contract your low tummy, pelvic floor tension at the umbilicus and then stretch your back up, while dropping your head down – hold for 5 seconds then return back to the start position. Breathe and relax after this set. Repeat 5 to 10 times. 

Wall squat

Standing with your back against a wall, your feet are approximately 30 cm (12 inches) away from the wall. Most importantly, your heels should be under your knees so your lower legs are vertical. Gently tighten your low tummy, vagina, anus and gently in at the belly button and slowly slide your back down the wall 8cm (3 inches) and hold the position for about 5 to 10 seconds and then slide back up again. As the weeks go by you can increase the length of hold to strengthen your central muscles and your thighs. Do not go down to 90°. Do not do this exercise if you have knee pain. You can use a Swiss ball behind your back as well. Breathe and relax after this set.

Mini squat 

Stand tall with feet straight ahead and hands on hips. Gently tighten your low tummy, vagina, anus and gently in at the belly button and slowly bend to 45 to 60 degrees at hips / knee. Incline your trunk slightly forward, maintaining a gentle curve in the lower back. Squeeze gluts to come up – pushing through heels. Bring your trunk to upright and relax gluts and pelvic floor. Repeat 5 to 10 times. Once you are feeling stronger with this you can add some rotation and also weights.

There are many more exercises and progressions of these early ones to be performed when rehabbing your DRAM. If you aren’t sure and would like help finding your transversus muscle we have ultrasound at our clinic which allows you to see the muscle working and ensure you are doing the correct contraction. We also conduct one-on-one sessions in our small gym down stairs and then we have small group, Pelvic Health Physio-led strengthening sessions where your individual problems are assessed and then a programme prescribed. 

(1) Mota P, Pascoala A, Bo K (2015) Diastasis Recti Abdominis in Pregnancy and Post Partum period. Risk factors, functional implications and resolution. Current Women’s Health Reviews 11,59-67. Sourced 17/02/19 https://www.researchgate.net/publication/282271189_Diastasis_Recti_Abdominis_in

(2) Lee D, Hodges PW (2016) Behaviour of the Linea Alba During a Curl-up task in Diastasis Rectus Abdominus: An Observational Study. JOSPT 46(7): 580-589

Thanks Megan for this blog. These early exercises are designed to establish a response by the muscles to different pressures and movements through motor training. Initially you have to think carefully about switching the muscles on and give yourself biofeedback via a mirror, but eventually the muscles will respond in a more coordinated, background way.

You can see there is still some research to be done to clarify ‘which exercises actually do what’ to DRAM. Mota, in her comprehensive article, has summarised the situation: “There is an urgent need for more basic and experimental studies to understand the mechanisms of different abdominal exercises. In addition, high quality randomized controlled trials on the effect of different abdominal exercises to prevent and treat diastasis recti abdominis are warranted”. (1)

In the third part we will progress the exercises to harder, stronger, more functional exercises.

Ring the rooms on (07) 38489601 or 0407659357 if you would like an appointment with any of the physios who make coming to work such a pleasure for me. (Megan Bergman, Martine Lange, Jane Cannan, and Alexandra Schafer). Or if you have issues in another suburb or city, check out your local Pelvic Health or Women’s Health physiotherapist for help. You can search the Australian Physiotherapy Association’s website Find-a-Physio for names.

Please note all the illustrations for the exercises come from my books Pelvic Floor Essentials (2018) and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery. (2018)

And here are those two cuties all grown up and a new generation of cuties produced.

 

 

 

Some strategies to help deal with grief

Grief is something we all have to deal with at different times of our lives. Sometimes it starts with a pet dying or of course worse, a grandfather. If we are young, it’s difficult to understand what has happened and the people around us often have trouble talking about death and dying.

But grief can arrive when loved ones are lost if they break off relations with family members such between a mother and daughter/son or between sisters and brothers, sometimes with no real understanding of why the rift happened.

Another source of grief can be of a brilliant mind lost to dementia. What has gone before – the mind, the words, the relationships, the abilities – all become a blur as the identity of that person fades away to just become someone who is being cared for – that someone becomes a dementia sufferer, their previous life lost and sadly forgotten by so many.

Grief is a normal and natural response to loss. Grief allows you to gradually adjust to your loss and find a way of going on with your life without the person who has died/ broken off contact/ is unable to communicate or interact as before due to dementia.

The following is taken from two sources: On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages by Elisabeth Kübler-Ross and David Kessler (2014) and Bereavement support in your time of grief from The Royal Melbourne Hospital.

Elizabeth Kubler-Ross described the five stages of grief as:

  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance

DENIAL

Denial is the first of the five stages of grief. It helps us to survive the loss. In this stage, the world becomes meaningless and overwhelming. Life makes no sense. We are in a state of shock and denial. We go numb. We wonder how we can go on, if we can go on, why we should go on. We try to find a way to simply get through each day. Denial and shock help us to cope and make survival possible. Denial helps us to pace our feelings of grief. There is a grace in denial. It is nature’s way of letting in only as much as we can handle. As you accept the reality of the loss and start to ask yourself questions, you are unknowingly beginning the healing process. You are becoming stronger, and the denial is beginning to fade. But as you proceed, all the feelings you were denying begin to surface.

ANGER

Anger is a necessary stage of the healing process. Be willing to feel your anger, even though it may seem endless. The more you truly feel it, the more it will begin to dissipate and the more you will heal. There are many other emotions under the anger and you will get to them in time, but anger is the emotion we are most used to managing. The truth is that anger has no limits. It can extend not only to your friends, the doctors, your family, yourself and your loved one who died, but also to God. You may ask, “Where is God in this? Underneath anger is pain, your pain. It is natural to feel deserted and abandoned, but we live in a society that fears anger. Anger is strength and it can be an anchor, giving temporary structure to the nothingness of loss. At first grief feels like being lost at sea: no connection to anything. Then you get angry at someone, maybe a person who didn’t attend the funeral, maybe a person who isn’t around, maybe a person who is different now that your loved one has died. Suddenly you have a structure – your anger toward them. The anger becomes a bridge over the open sea, a connection from you to them. It is something to hold onto; and a connection made from the strength of anger feels better than nothing. We usually know more about suppressing anger than feeling it. The anger is just another indication of the intensity of your love.

BARGAINING

Before a loss, it seems like you will do anything if only your loved one would be spared. “Please God,” you bargain, “I will never be angry at my wife again if you’ll just let her live.” After a loss, bargaining may take the form of a temporary truce. “What if I devote the rest of my life to helping others. Then can I wake up and realize this has all been a bad dream?” We become lost in a maze of “If only…” or “What if…” statements. We want life returned to what is was; we want our loved one restored. We want to go back in time: find the tumour sooner, recognize the illness more quickly, stop the accident from happening…if only, if only, if only. Guilt is often bargaining’s companion. The “if onlys” cause us to find fault in ourselves and what we “think” we could have done differently. We may even bargain with the pain. We will do anything not to feel the pain of this loss. We remain in the past, trying to negotiate our way out of the hurt. People often think of the stages as lasting weeks or months. They forget that the stages are responses to feelings that can last for minutes or hours as we flip in and out of one and then another. We do not enter and leave each individual stage in a linear fashion. We may feel one, then another and back again to the first one.

DEPRESSION

After bargaining, our attention moves squarely into the present. Empty feelings present themselves, and grief enters our lives on a deeper level, deeper than we ever imagined. This depressive stage feels as though it will last forever. It’s important to understand that this depression is not a sign of mental illness. It is the appropriate response to a great loss. We withdraw from life, left in a fog of intense sadness, wondering, perhaps, if there is any point in going on alone? Why go on at all? Depression after a loss is too often seen as unnatural: a state to be fixed, something to snap out of. The first question to ask yourself is whether or not the situation you’re in is actually depressing. The loss of a loved one is a very depressing situation, and depression is a normal and appropriate response. To not experience depression after a loved one dies would be unusual. When a loss fully settles in your soul, the realization that your loved one didn’t get better this time and is not coming back is understandably depressing. If grief is a process of healing, then depression is one of the many necessary steps along the way.

ACCEPTANCE

Acceptance is often confused with the notion of being “all right” or “OK” with what has happened. This is not the case. Most people don’t ever feel OK or all right about the loss of a loved one. This stage is about accepting the reality that our loved one is physically gone and recognizing that this new reality is the permanent reality. We will never like this reality or make it OK, but eventually we accept it. We learn to live with it. It is the new norm with which we must learn to live. We must try to live now in a world where our loved one is missing. In resisting this new norm, at first many people want to maintain life as it was before a loved one died. In time, through bits and pieces of acceptance, however, we see that we cannot maintain the past intact. It has been forever changed and we must readjust. We must learn to reorganize roles, re-assign them to others or take them on ourselves. Finding acceptance may be just having more good days than bad ones. As we begin to live again and enjoy our life, we often feel that in doing so, we are betraying our loved one. We can never replace what has been lost, but we can make new connections, new meaningful relationships, new inter-dependencies. Instead of denying our feelings, we listen to our needs; we move, we change, we grow, we evolve. We may start to reach out to others and become involved in their lives. We invest in our friendships and in our relationship with ourselves. We begin to live again, but we cannot do so until we have given grief its time.

Another way to assess the impact of grief is to examine:

  • Feelings – shock, sadness, anger, guilt, loneliness, you may feel numb.
  • Thoughts- confusion and disbelief. You may dream about them or feel their presence. You may feel you’ll never get over their loss/their illness/ the changes in their mental state.
  • Physical reactions –sleep is affected, loss of appetite, tiredness, nausea or even chronic pain.
  • Behaviours- you may have no energy at all or feel like you need to do everything at once.

Suggestions to help:

  • Give time and be patient with yourself
  • Don’t make big life decisions
  • Don’t isolate yourself from family and friends
  • Allow people to help you
  • Self-care is important – eat well and exercise
  • Seek help if grief becomes overwhelming

This blog was prompted by the sad passing of Bernie – a father, grandfather and much-loved friend to many. Much love to Brenda, Kush and Barney and all their families. Everyone says that Bernie was a clever, thoughtful and generous soul who will be sadly missed by everyone.

Vale Bern.

 

 

International Women’s Day: The Whole Woman

This year’s theme for International Women’s Day (March 8th) is #BalanceforBetter and I can’t think of a better hashtag to represent what we pelvic health physiotherapists face every day, when in clinic treating patients who have pelvic floor dysfunction.

We have to assess the patient and use critical thinking, in conjunction with the patients’ wishes and desires, to work out what the patient can do every day, without over-thinking her every move and what the patient maybe should modify to prevent their problem worsening.

This is the dilemma.

We need to assess and treat – the Whole Woman.

Not just her pelvic floor. Not just her bladder. Not just her bowel. Not just any one part, but the whole of that woman who sits before us, pouring out her most vulnerable self; allowing us into her most personal corners of her being and giving us the privilege of hearing her story and giving us an insight into her personal nightmare. And let me reassure you – pelvic floor dysfunction for women can be a real living nightmare.

We have to treat her brain – her happiness, her thoughts, her anxieties, her beliefs to name a few.

We have to treat her cardio-vascular system and we do this by getting her back to exercise so her heart is strong and her blood vessels are pumping efficiently.

We have to treat her bones, her joints and her muscles in her body – again by encouraging her to exercise despite any changes that may have happened following pregnancy and childbirth.

And we have to treat her psyche – the very essence of her being a woman because a traumatic vaginal delivery may turn her female-world upside down affecting her sexuality, her confidence and her ability to do very basic things without feeling fearful and anxious.

We need to get the woman back in balance after the changes that pregnancy and childbirth bring to her.

Every day in our pelvic health practice we see patients who have a myriad of issues that arise as a result of a pregnancy, a vaginal delivery or a caesarean birth. Nowadays patients can easily access the same information about these issues as their physiotherapist or doctor. Many research articles are freely available on the internet and modern patients are very often good researchers.

Many are also very active on Social Media- they are members of many Facebook Groups that discuss childbirth issues and mothering problems – including all the joys, successes, heartaches and failures and can be very well-informed, but also absolutely terrified by what they have read.

Happy and oblivious! I was untrained in both baby caring and my bodily changes and I was a physio! And worse still, Facebook was not a thing

The patients arrive armed with pre-knowledge, primed with anxiety and fears and already have diagnosed many problems (that may not be even accurate, but the fears are difficult to let go of). Don’t get me wrong though, many of these Facebook support groups have been a lifesaver for women and brought them back from the brink.

Many arrive with complex problems that have completely trashed their former lives and because we focus on the ‘one day of labour’ instead of informing women about potential changes that can happen – women are completely unaware and not expecting these serious complications that have come out of left field for them. These patients can be sad….and bewildered………and angry at the same time.

Then because we see having the baby as the line drawn in the sand, rather than the beginning of the fourth trimester (more on that in a moment), women are handed this baby and sent home without due respect being given to any changes that have happened to their bodies.

Some women feel abandoned by the health system.

(The fourth trimester is a period described by expert Dr. Harvey Karp, an American pediatrician and children’s environmental health advocate, as the first three months of a baby’s life- a time when a newborn is adjusting to life outside of the womb. Many writers and commentators are now viewing the fourth trimester as a period of time for the mother to be ‘rehabilitated’ and as such are lobbying governments to fund regular visits to a pelvic health physiotherapist as a routine like they do in France).

 

Some of these women have played competitive sport.

Some are recreational joggers.

Some had hoped they would eventually kick a ball in the park with their child as they got to toddler status, without leaking urine (or gas or faeces).

Others had hoped to get back to sexual intimacy sometime before the child headed off to school.

Call me biased but I just don’t think governments and health funds take women’s health seriously.

Because if they did there would be serious attention and funding given to prioritizing the immediate period after having a baby like there is in France.

The evidence is clear. Pelvic floor dysfunction costs our economy a lot of money. Incontinence alone was estimated to cost the Australian economy $40 billion back in 2010. (Access Economics Report)

So if we want to indeed strive for #BalanceforBetter for women, we should become more vocal about financial support for mandatory assessment and treatment for every woman who has had a baby – regardless of the mode of delivery.

And if we want to indeed strive for #BalanceforBetter for women as they age, we should also become more vocal about incentivizing women to attend a pelvic health physiotherapist regularly every year through all the life-stages to encourage long-term adherence to pelvic health programmes. 

Today, while waiting on the phone to my health fund to enquire about the new (whiz-bang) changes to the name of my level of private health coverage (all $6025 per year for two of us) – now called Gold Level (I wanted to see if Silver, Bronze or Wood … would still keep me alive and kicking and cost substantially less) there was a pre-recorded message to lull me into a stupor (and thus rendering me oblivious to the length of the wait).

Instead the pre-recorded message made me angry.

My health fund was telling me that I was entitled to two visits to the dentist per year for a fully funded visit (absolutely nothing out-of-pocket) for an inspection, clean and scale – BECAUSE WE ALL KNOW HOW IMPORTANT DENTAL HEALTH IS TO OUR GENERAL HEALTH AND WELL-BEING! said the recording. This equates to $225 twice a year for every member on the coverage. No out-of-pocket expenses.

I was shouting back at the pre-recorded message: YOU KNOW WHAT? PELVIC HEALTH PHYSIOTHERAPY- GETTING YOUR BLADDER, BOWEL AND PELVIC FLOOR IN ORDER – IS PRETTY DAMN IMPORTANT TO YOUR GENERAL HEALTH AND WELL-BEING ALSO!!

Shouting at the pre-recorded message on the phone won’t get us anywhere.

What might help is to write to your parliamentarian (they are always all ears when there’s an election looming), ring your private health fund and ask them to record your complaint about this inequity (dental rebates versus physio rebates) and perhaps share this blog on Social Media.

Enough of expecting women to shut up and put up with pelvic floor dysfunction!

Here is the link to another blog I have written about this inequity.

#BalanceforBetter #pelvichealthphysiotherapy #treatthewholewoman #InternationalWomen’sDay #IWD2019

 

 

 

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