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

The Sleep Apnoea and Dementia link: Get yourself checked pronto!

The sacrifices I make in the name of health prevention – plastering a photo of me in my pj’s ready for my sleep study on the internet!

It’s taken me over two years to write this blog on my own sleep apnoea diagnosis and subsequent treatment. I’ve been keen to do it but other blogs kept popping up and I just never got around to it. We know there is a strong link with nocturia and sleep apnoea, but at the gym today as I was watching the news, there was yet another headline about how sleep apnoea and dementia are linked and I was compelled to get off my butt and finally do it.

My story started when Bob (husband) decided to go to a sleep specialist a few months after we returned from our overseas trip in late in 2016. He had been struggling every night to stay awake much past 7pm and he felt like he had never got over his jet lag – and that was after 4 months. As I was sitting in with Bob at the respiratory physician’s appointment and she was asking him all the relevant questions, I had this overwhelming feeling that I should have been seeing her – not Bob!

Sleep apnoea, which means failure to breathe during sleep, can be obstructive or non-obstructive.

Non-obstructive or ‘central’ apnoea occurs when the brain fails to signal the breathing muscles that it’s time to get active.

In obstructive apnoea (also abbreviated to OSA standing for Obstructive Sleep Apnoea), breathing fails because of a relaxed airway that fails to open up despite the brain’s insistence. Eventually, sometimes after more than a minute without breathing, the brain sounds its alarms urgently enough to jolt the muscles of breathing back into action. Sometimes this wakes the sleeper, but more often the periods of apnoea and gasping serve only to rob sleep of its restful and restorative quality. A respiratory infection or excessive alcohol use can also interfere with breathing during sleep. Chronic and severe apnoea, however, is a prolonged, debilitating condition. (1)

After we sorted Bob (booked his sleep study) I chatted to the physician and she suggested that rather than coming to see her first, I just book straight in for a sleep study and after the study, come then to see her with the results. So Bob had his sleep study and got a clean bill of health and I went to Greenslopes Sleep Unit and they dressed me up (see photo at the top of the page) and I went back home to do my home sleep study. Like everyone, I naturally doubted I would sleep a wink trussed up as I was with the wiring and monitors, but it went swimmingly as I went to bed at 9.15pm and woke up at 6am having slept through the night without budging.

A week later I went to the doctor to read the results. It wasn’t pretty.

It had shown I had stopped breathing 27 times every hour; the longest pause in my breathing was 51 seconds and my oxygen saturation had dropped to 73% (it should be in the high 90’s). I was shocked to say the least. And so started the process of being assessed and fitted with a CPAP machine. CPAP stands for Continuous Positive Airways Pressure and is administered via a machine and a rather overwhelming mask and tubing – honestly my worst nightmare. More on that later. When working out mask types that are the most comfortable and give the best seal and pressures required to stop the sleep apnoeas, you have to go into hospital for the sleep study to trial their CPAP machine. I started with the nasal prong mask – and for me it was not good. It was quite uncomfortable. Then I moved onto the small half mask just over the nose, leaving the mouth free. My oxygen sats were much improved and the mask seal was good. The next step is to hire a CPAP machine for 4 weeks, returning weekly to assess the vital signs that these clever machines are able to report back to the team.

The first weeks were difficult because I suffer badly with claustrophobia. The first time I became aware of my ‘claustrophobia affliction’ was when I was about 19 and my mother paid for a single sleeper for my return train trip home from visiting my grandmother Dolly, who lived in Wollongong. The conductor diligently set up my bed at around 9 pm – but I lasted only half an hour before I called him again to return it to a seat. You see your face ends up about 6 inches away from the ceiling of the compartment and that freaked me out. This ‘claustrophobia affliction’ presented itself again on the first night we set up our campervan bed in Brighton on our first trip overseas together in 1984. Bob had taken quite a while to get it sorted (instructions were hard to come by) and again about 30 minutes after settling in, I literally jumped out of the bed and dived out of the van gasping for air. Again, my face 6 inches away from the roof was impossible for me to tolerate.

So you can understand that placing that mask over my head every night was my worst nightmare. I almost had to be asleep before I could tolerate it on – which is quite hard to master. Get the mask on and not fall asleep before that happened. By the end of week 2, I declared I just couldn’t do it. I had decided I was going to soldier on slowly destroying my brain cells without a CPAP machine.

And literally just then, the ABC News came on. Carrie Fisher, who played Princess Leia in the Star Wars series, had sadly died on a plane trip of sleep apnoea! I was shocked. I had never ever heard of sleep apnoea as a cause of death out loud on TV before. And just when I was being a complete idiot and denying the seriousness of my predicament, there it was – headline news.

I pulled up my Big Girl Pants and said get over your ‘Claustrophobia Affliction’ and make the bloody thing work – and I did and now my most favourite sleep companion (next to Bob) is my CPAP machine. From that moment it all went swimmingly. I suddenly had no trouble coping with it and my pressures, sats and mask fit were all stable and I proudly went back for my final visit to the team at CPAP Select at Greenslopes to buy my own machine. Luckily for me they had just had a brand new release of a Resmed Travel CPAP machine.

Resmed Travel Machine compared to the usual one

This machine is tiny compared to the one I thought I would have to buy and being much more portable than the big one I had been trialing would be great for our travels. It was a bit dearer at that time but I do believe they have come down in price these days. I am literally addicted to my machine now. I love it. I sleep completely through the night, never getting up anymore through the night and wake up refreshed and with clarity of thought (not that I really realized this until I had been using it for a few weeks). One night about a year ago we had a blackout and I literally thought I can’t go to sleep tonight until that power comes back on. I was scared to sleep flat without it.

It is very simple to set up and below is a You Tube video showing you how to use it.

So why as a Pelvic Health Physio do I think is it so important to get yourself checked?

The following is taken from an article by Park E et al (2015) Relationships between Nocturia, Obstructive Sleep Apnoea and Quality of Sleep.
As I mentioned earlier in this blog nocturia, the condition of waking up to urinate one or more times during the night, is common in adults, with a reported prevalence of 53%. However, the potential contribution that leads to sleep disturbance is less well acknowledged. Nocturia has been reported to be an independent predictor of self-reported insomnia with a 75% increased risk and of sleep quality reduction with a 71% increased risk.
Many causes of frequent nocturnal awakening to void have been described in the adult population.
These include:
  • decreased bladder capacity,
  • reduced glomerular filtration rate and nocturnal polyuria due to decreased arginine vasopressin,
  • incipient diabetes,
  • sleep-disordered breathing, such as, obstructive sleep apnoea (OSA),
  • congestive heart failure and/or diuretics use,
  • benign prostatic hypertrophy in men 
  • vaginal atrophy with consequent reduced sphincter control in women. 

Nocturia has been reported to be more severe in patients with OSA, and it is a well-researched end-organ symptom of OSA. It is found to be frequently associated with nocturia: 81% (17/21) women with OSA versus 40% (4/10) control women without OSA. The mechanism responsible for a higher prevalence of nocturia in OSA patients could be due to a reduced ability to concentrate urine during night sleep.

OSA is a condition characterized by repetitive episodes of complete or partial upper airway obstruction, which causes negative intra-thoracic pressure and consequently increases venous return to the heart. As a result, the right atrium and ventricle are distended, which receives wrong signaling of fluid overload, and the consequent release of brain-type atrial natriuretic peptide (ANP) from cardiac atria and ventricles. The secretion of anti-diuretic hormone (ADH), which is increased at night to promote the absorption of sodium and water from collecting tubules, is subsequently inhibited and this eventually leads to decreased urine concentration and consequent polyuria during night sleep.

In a study, diluted night-time urine was noted in 80% (16/21) of OSA patients, whereas it was noted in only 30% (3/10) of the control group. Numerous studies have reported reduction in nocturia after continuous positive airway pressure (CPAP) treatment in OSA patients, which supports the idea that OSA itself induces nocturia. However, despite the well-known pathophysiologic link between nocturia and OSA described above, the importance of nocturia has not been emphasized sufficiently in the context of screening for OSA. (The section in italics is taken directly from this article) (1)

But a second important reason is that people with sleep apnoea have been shown not only to have impaired memory and executive function, but also biomarker changes that are associated with Alzheimer’s disease. The results of several studies suggest that OSA might be a reversible cause of cognitive impairment and dementia, and that treatment of OSA, particularly in the early stages of AD, when patients are still largely independent, may decelerate dementia progression. (2) This particular article collected all available published clinical data and analyzed them through a quantitative meta-analytical approach. A quantitative meta-analysis suggests that the aggregate odds ratio for OSA in AD vs. healthy control was 5.05 and homogeneous. This reflects that patients with AD have a five times higher chance of presenting with OSA than cognitively non-impaired individuals of similar age. 

And this is why I personally feel getting a sleep study should be a routine consideration once women are post-menopausal, especially if they snore, if they suffer with nocturia and if they feel exhausted initially on waking. There is a validated questionnaire called TANGO which is an easy check list with questions to see which domains are affected.

I hope through my own personal journey of sleep apnoea, I have de-mystified getting a CPAP machine and encouraged a few of you, if not quite a lot of people, to have their sleep study and when the results are not good, take the next step of trialing a CPAP machine.

It is definitely worth looking after your brain.

Now my next goal. Get to bed before midnight more often! 

(1) Taken directly from: Park E et al (2015) Relationships between Nocturia, Obstructive Sleep Apnoea and Quality of Sleep, Sleep Medicine Research (SMR) 6(1): 28-34

(2)Emamian, F., Khazaie, H., Tahmasian, M., Leschziner, G. D., Morrell, M. J., Hsiung, G. Y., … Sepehry, A. A. (2016). The Association Between Obstructive Sleep Apnea and Alzheimer’s Disease: A Meta-Analysis Perspective. Frontiers in aging neuroscience8, 78. doi:10.3389/fnagi.2016.00078

 

Prolapse and Pessaries – all blogs in one area (well most of them)

Gathering similar blogs together under one banner helps when I am referring patients to particular topics for reference material. I did it a long time ago with the majority of my Pain Management blogs and recently did it with my Men’s Health blogs. 

So today I decided to group all my prolapse and pessary blogs together so they are quicker for patients to access.

Pelvic organ prolapse (POP) is common with up to 50% of women who have had a vaginal delivery having some form of prolapse, but only 15% are symptomatic 20 years later. If you become aware that you have prolapse there is so much you can do to increase your chances that the prolapse won’t progress to the point that you may be bothered by it and ultimately need surgery. Early intervention, such as is written about in the blogs below, can be helpful and allow you to continue to lead an active life with the types of exercise you want to do.

Learning how to correctly activate your pelvic floor muscles is the first step and seeing a Pelvic Health Physiotherapist can help de-mystify how to contract them. Many women have found out they have a levator avulsion injury and don’t really understand what are the implications of that. This blog describes what an avulsion injury is. 

However in recent times there has been increasing anxiety about the diagnosis of prolapse and I have written a blog about just this to try and help put things into perspective. When you are anxious, cortisol and adrenaline is coursing through your body all the time and this in fact may actually accentuate what you are feeling in your vagina – like with pain there can be a central sensitization effect with prolapse. So in your learning journey about your prolapse, reading this one about keeping your perspective about any diagnosis of prolapse is important.

This 2011 blog was the first one I posted highlighting research that showed that pelvic health physiotherapy should be the first line of treatment.

This next blog talks about not feeling that it’s essential to commit to surgery just because there is prolapse – that Grade 2 prolapse often doesn’t change much over the years and that it may be the new normal for a woman who has had a vaginal delivery.

This blog is the first in a series of five blogs designed to cover all possible facets of prolapse management. Step 1 Prolapse Management

This blog is Step 2 Find Yourself a Prolapse Mentor

This is Step 3 in the Prolapse series: Pelvic floor muscle training, bracing (the knack) and functional training

This is Step 4: Managing your bowels well 

And finally Step 5: Keep moving but keep your exercise friendly for the status of ‘your’ pelvic floor

This one is a good reminder about how to be mindful around the house with some of the chores we do if you have significant prolapse or especially are inn the early days post-op.

There are many blogs about pessaries in the over 300 blogs that I have written on pelvic floor dysfunction, but this one has a bit of the history of pessaries and how they can be a game-changer for a woman with prolapse.  

This blog has a wonderful story in it by Amy Dawes who has set up the Australasian Birth Trauma Association, a charity which is there to support women who have had a traumatic birth experience.

This pessary blog has more on the history of fitting pessaries in Australia.

Many women are keen to know if they can run with prolapse and many times you can, mostly if there is a pessary in to support the prolapse. But this needs to be assessed by a Pelvic Health Physio and recently some new guidelines have been released on the return to running post-partum which have been included in this blog.

So if you have prolapse (or think you may have prolapse) and want to understand more about what prolapse means, how to activate your pelvic floor muscles correctly and how to embark on a pelvic floor muscle strengthening programme then ring our practice at Highgate Hill, Brisbane on (07) 38489601 or mobile 0407659357 or email to admin@suecroftphysiotherapist.com.au and our secretaries can book you in with one of our talented physios seen below. You can also search the APA website for Find a Physio or the Continence Foundation of Australia register for the name of your nearest Pelvic Health Physiotherapist.

World Continence Awareness Week: Its all about the supervision of pelvic floor exercises!

If you follow my blog, you have heard the sad tale about me making the hard decision to close my pelvic floor inspired exercise studio (at Gladstone Road, Highgate Hill) at the end of 2018. This came about because in November 2017, there was a decree from the Australian Government that a number of complementary medicine categories would no longer be able to be covered by the Private Health Insurance companies. This is what the Government had decided as part of the linked advice above.

“Rules will be made to remove natural therapies from the definition of general treatment under section 121-10 of the Private Health Insurance Act 2007. Insurers will then not be able to offer benefits for these therapies as part of a complying health insurance policy.”

Three of these natural therapies included Pilates, Yoga and Tai Chi. There are many others but when I wrote the blog about this change, I was mostly addressing the restriction on Pilates. I wish to address this change again because I have just returned from a wonderfully inspiring weekend conference run by one of our leading Pelvic Health Educators, Taryn Hallum, updating the most recent research in all things Pelvic Health and some of the evidence has again got me all worked up about the changes implemented in just April 2019.

Jane Cannan, one of our Pelvic Health Physios

Pilates is one form of exercise. It is a name that the general public was familiar with and many physiotherapists had clinics with Pilates within the name of their practice, as they offered classes as an opportunity for patients to progress beyond just individual treatment. The word Pilates (named after Joseph Pilates who described the series of exercises) has a high recognition factor with the general public, who associate Pilates with strengthening exercises; understand that it helps with balance and coordination and that it is synonymous with perhaps posture, guided movements and set recognized exercises.

This dramatic decree from the government was quite incredible coming at a time when the slogan #exerciseismedicine was trending on Twitter and Instagram and that research was popping up everywhere saying exercise was the answer to most medical ailments!

And this dramatic decree was the nail in the coffin for my studio at Gladstone Road, Highgate Hill.

My studio was my dream – the opportunity to have a place where patients with pelvic floor ‘needs’ – maybe prolapse, urinary or faecal incontinence or pelvic pain – all things that can stop a conversation should one raise it over drinks at the bar in mixed company (in fact topics that are the focus of World Continence Awareness Week) could go and be supervised with their exercising and have their pelvic floor as the focus. The studio was definitely a wonderful add-on for our practice which is predominantly pelvic health-focused and one for which I had yearned for years.

I loved my studio. And that decree killed my dream. (Well until I created a small space at my rooms in Hampstead Road because my patients demanded we do something as they missed it so much.) The health funds would pay an amount towards the classes and this small subsidy would help the patients be able to afford to come regularly to the studio to exercise.

I really couldn’t understand the logic behind this decision.

Exercise is good for preventative health reasons. Bone density. Obesity. Diabetes. The Heart. The Lungs. The Brain. The Pelvic Floors (especially the pelvic floor). Really all the bits of our body are helped with exercise (but especially the pelvic floor and wait and see at the end of this blog about the evidence for supervision of pelvic floor muscle training in a class setting). Do government decision-makers not read Instagram or the Readers Digest? Of course the real medical literature is full of articles proclaiming the Wonder of Exercise, but I don’t expect public servants or the health department or the Health Minister to be all over research articles. But I would have thought some of them may have had a woman in their lives that loves their exercise. You see gyms, Pilates studios, yoga classes are all dominated by women. Women predominantly attend these health-promoting venues because they have read about the wondrous things that happen when you exercise.

Our yoga was loves at the studio

But what stirred up this hornet’s nest of annoyance again this weekend of learning and updating was the number of recent research papers that show that supervised training of the pelvic floor in classes and group sessions is better than assessing and teaching pelvic floor muscle training to a woman and then sending them home to do a home exercise programme. It appears that women need the supervision, the motivation, the inspiration, the dedication that a pelvic health physio supervised class gives them. Needless to say we will be looking at ways to increase the opportunity for women to attend more sessions in our Hampstead Road exercise space and ways to prompt them more in their home programme.

Now the good news is that very soon after the April introduction of this new decree – and after some dedicated lobbying from our professional organisation The Australian Physiotherapy Association– the Health Minister Greg Hunt reversed the decision as long as the P word is not mentioned – P doesn’t stand for preventative even though any exercise is preventative for so many things. P doesn’t stand for P*ssed off even though there’s a stack of physios, Pilates instructors and women who love their Pilates and have seen drastic declines in their numbers attending, who definitely are. P stands for Pilates – yes the actual word Pilates cannot be mentioned in any advertising, signage or handouts. And of course it must be a physio who is supervising the classes. There is unfortunately still one health fund who has refused to follow the decision of the health minister.

Enough whinging. Now the important message.

It’s World Continence Awareness Week. Ladies – do your pelvic floor exercises. Be motivated, be enthusiastic. Be regular in the initial phase and then integrate them into an exercise routine if you can. Make it count.

And what is your reward you ask?

Compared with no treatment or inactive control treatments, women with Stress Urinary Incontinence (SUI) who were in the Pelvic Floor Muscle Training (PFMT) groups were 6 times more likely to report being cured or improved. PFMT 72% Placebo/Control 11.4% (Doumoulin et al 2018)

The success rate for PFMT for SUI varies between 60-75% when performed in the outpatient setting under the supervision of a physiotherapist. (Fitz et al 2017).

In this World Continence Awareness Week, get yourself off to your nearest Pelvic Health Physio and be assessed and get in-training!

And below is our class space at Hampstead Rd with room for four people to the class. Ring (07) 38489601 if you want to try a one-on-one or group session.

 

Also for those ladies who used to come to dance, we are still doing dance every Thursday at 4pm at 194 Gladstone Road, Highgate Hill with Ash King. Again ring if you want to book in.

The thing I miss most about my little studio was it created a community – bureaucracy will never understand community though. 😦

The definition of Community: Our lovely dance ladies -we still congregate and chat, laugh and dance every Thursday at 4pm 

 

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

 

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