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

Prostatectomy: PF muscle training programme pre-operatively

This is taken directly from The Prostate Foundation of Australia (with permission from Dr Joanne Milios).

It is entitled: A pelvic floor exercise program starting before prostate surgery improves the recovery of urinary continence” Dec 2019. It has been written by Wendy Winnall, a scientific writer for PCFA to summarise the excellent research by Jo to obtain her PHD.

Dr Joanne Milios

Pelvic floor muscles control the bladder and the flow of urine.

Exercising these muscles can help men regain control over urine flow after prostate surgery. New research from Australia has defined an effective pelvic floor exercise program that starts before surgery. Surgery to remove the prostate gland usually leads to temporary incontinence – loss of control of urine flow. For most men this gradually improves over time. But unfortunately, some men suffer long-term incontinence after their prostate is removed.

Leaking of urine after surgery happens because some of the muscles involved in bladder control are removed with the prostate. Before surgery, it is difficult to predict the amount of urine that will leak. Leaking often happens unexpectedly, together with coughing, sneezing or exercise. Some men even leak urine during orgasm. Urinary incontinence is an issue that disrupts everyday life and causes a great deal of distress to these men and their partners.

One way to improve urinary control is by exercising pelvic floor muscles. The pelvic floor is a round layer of muscles at the base of the pelvis. These muscles support organs such as the bladder and large intestines (bowels). They help to control the bladder as well as erections. It’s important to learn how to exercise the pelvic floor muscles correctly. This will give the best results for improving control over urine flow. PCFA has a brochure that describes pelvic floor exercises for men having prostate surgery. However, seeing a physiotherapist who specialises in pelvic floor muscles will be the best way to learn these exercises.

Research into pelvic floor exercises for men having prostate surgery
Many trials have been run to determine effective pelvic floor exercise programs for men having prostate surgery. Even though randomised controlled trials have been done, the results have been mixed. 45 trials testing pelvic floor exercises for prostate surgery were compared in a rigorous review process in 2015. Some studies support the benefits of pelvic floor exercises, whereas others suggest that urinary continence improves over time with no added benefit of exercise. One of the problems with the past research is mixed methodology. There was too much variation in the type of exercise program, the volunteers who joined the trials and the way the programs were assessed. For instance, continence (no leakage) was defined as less than 10g leakage, use of 1 pad or less, or 0 g leakage in different studies. In other words, different studies used different definitions of continence, which probably contributed to different results between studies.

This extensive Cochrane review calls for large, rigorous, randomised controlled trials to test pelvic floor exercise programs. They recommend assessing quality-of-life and pad weights to test the success of these programs. Australian researchers have been using these recommendations to determine the best pelvic floor exercise programs to help men having surgery for prostate cancer.

Australian pelvic floor exercise research
A new Australian study has defined a pelvic floor exercise program specifically for men having surgery to remove their prostate. The trial was led by physiotherapist Dr Jo Milios as part of her PhD studies through the University of Western Australia. Men joining this trial were referred by their urologist before surgery to remove their prostate gland. These men did not have urinary incontinence before surgery and had no previous radiotherapy or hormone therapy.

The Australian trial tested a new pelvic floor muscle training program focused on activating different types of muscles fibres. Both slow-twitch and fast-twitch muscle fibres are specifically targeted. Slow-twitch fibres contract slowly and can be used for long periods of time. Fast-twitch fibres contract quickly. They work at high-speed but tire easily.

The study tested the new training program by comparing it to a similar program performed by a control group. 50 men who volunteered for the study were randomly allocated to the new program. Their results were compared to those from 47 men allocated to the control program. The muscle training programs started five weeks before surgery and continued for 12 weeks afterwards. Both programs started with two sessions of instructions from a physiotherapist for pelvic floor exercises. Men were asked to focus on a muscle called the anterior urinary sphincter, shown in previous studies to promote men’s urinary control. Men were then provided with a daily training program.

Men in the control group were given instructions according to current clinical practice. They performed 3 sets of exercises each day with 10 contractions for each (done in the sitting, standing and lying positions). Men in the new program group performed exercises targeting slow and fast-twitch muscles. They did 6 sets of pelvic floor exercises each day, all in the standing position. Each participant did not know which group they were in.

Men tend to leak in upright postures, especially during actions such as sit-to-stand and walking. So it makes sense to train men in the postures they will need in the recovery process and long-term. I also combined the traditional slow twitch fibre (long hold) training with the fast twitch training of the pelvic floor muscles in times of stress e.g. cough/sneeze/lifting…essentially, what is required for continence in everyday life.” – Dr Jo Milios

To measure urinary continence (bladder control), men were asked to weigh their pads and report any leakage of urine. Continence (no leakage) was defined as having no increase in pad weight due to urine leakage over a 24 hour period. This was measured at 2 weeks, 6 weeks and 12 weeks after surgery. There were more men reporting no leakage in the group who used the new exercise program compared to the group using the old program. At each time interval, the average pad weight was less for men using the new exercise program.

The researchers also used a survey called EPIC-CP to ask the men in the trial how much urinary incontinence was bothering them. At two weeks after surgery the men in the control group reported significantly worse quality-of-life related to urinary issues than the men who used the new exercise program. But at 6 and 12 weeks after surgery the effects on qualityof-life, as measured by this survey, were similar between the two programs.

“For men newly diagnosed with prostate cancer, the research indicates that preparation prior to treatment is the critical difference to minimising the impact of post-operative urinary incontinence. I designed the new protocols based on what I had learnt clinically over 15 years and a cohort of more than 3000 individuals undergoing surgery. By commencing pelvic floor muscle training in a standing position, as soon as possible after a prostate cancer diagnosis, the lead-in time to surgery can be maximised.” Dr Jo Milios.

PCFA recommends men planning surgery for prostate cancer consult with a pelvic floor physiotherapist. The results of this study indicate that doing this before surgery may be beneficial.

Thanks to Jo for permission to share this article via my blog – if you are interested in getting help pre or post op prostatectomy please contact the rooms on (07) 38489601 and Megan Bergman or Amanda Waldock will help you.

Recalibration, reframing valued activities and reconceptualization

Resciesa looking towards The Dolomites, 2019

Recalibration, reframing valued activities and reconceptualization: the title of this blog sounds like I am going to write about our new life post COVID. What will it mean? Where will we be? What will we be doing? What’s going to be our future? (And I am being metaphorical here- I am talking about the bigger picture).

I chose this photo from our last European trip because it aligns with my thinking about the title. That trip to Seceda certainly recalibrated our thinking about overseas holidays. From then on, our trips were always going to involve mountains and we were going to try and avoid cities. And we hadn’t even contemplated in our wildest dreams something like Coronavirus! We made the decision based purely on the beauty, solitude and majesty of mountain scenery. We had decided it was our happy place. (We were also fairly confident our children felt the same and if we chose some place special they would leave the city of almost 9 million and join us in a tiny Italian/Swiss village for a holiday). 

But the phrase I wrote this blog around is actually taken from a recent article called: ‘What influences patient satisfaction after a TKA (which stands for a Total Knee Arthroplasty or what we know as Total Knee Replacement)? A qualitative investigation. (Klem, N et al 2020)

Now I am not going to analyse this article here, but it is defintely worth reading- especially if you are contemplating surgery for your knee or your hip- but when this article was posted on Facebook by a physio in one of the myriad of groups I belong to – it just hit my like a ton of bricks. I love this phrase.

Recalibration, reframing valued activities and reconceptualization.

This is what we pelvic health physios do every day when treating women, men or children with continence issues, prolapse problems or persistent pain. Through education we recalibrate their body functions – the most personal, private bits of their day. We tease out their story, collect data (like from their bladder diary) and then use this to rejig the system. 

We have to change up their thinking about the old ideas, beliefs and habits (some which have persisted since childhood when their mother taught them) and reframe the patients’ thinking into a new direction. We have to drag them (sometimes screaming) out of their comfort zone with their bladder – stopping them from going so often to the toilet to teach their bladder how to store better.

We have to reframe their valued activities when they have persistent pain with intercourse with their partner. This mostly may be temporary, but for some it might be forever and we also may have to reframe the partner’s expectations and bring them along on the journey. We may have to point out the beauty of intimacy without penetration if penetration causes agony and tears. 

The Ohnut – available from Pelvic Floor Exercise (Fiona Rogers online site)

For every single patient we reconceptualize what their new work life, social life and family life will be like in their new post-treatment era. We give them the confidence to set goals they thought were unachievable; to have hope when they thought all hope was lost and the ability to understand that fear mustn’t dominate their thinking. 

And all of that applies directly to what is happening to our lives through COVID19. 

As a society we must recalibrate, reframe valued activities and reconceptualize what the future will be. 

Lots of people feel this time is a wake up call – a chance to very literally stop and smell the roses. Others can’t adapt to the imposts on our freedoms. There is indignation about closed borders to Queensland – but there would be indignation if they opened them and COVID started to spread like wildfire through our community. We have to be patient. Like Nelson Mandella. Like Anna Frank. Like those who have been in detention for SEVEN years.

And those borders aren’t really even that closed. There are exemptions on compassionate grounds. There are exemptions on work grounds and exemptions to seek out health appointments. Ask the authorities if you want to cross the border.

But I have colleagues and family who live in countries who can’t even comprehend how we have done what we have done in Australia. As of today Australia has 7,079 confirmed cases of COVID19 and 100 deaths. The United States 1,501,876 confirmed cases and 90,203 deaths. The United Kingdom has 248,822 confirmed cases and 35,341 deaths.  

Sobering statistics. 

And I for one am grateful that we have strong leaders who are copping the criticism and being cautious as we enter our flu season. We don’t want to look back in horror and wonder why we rushed back from lockdown. 

As you read this, if you haven’t yet downloaded the COVIDSafe app could I ask you to contemplate doing it? If your aunty or grandchild or mother or best friend get a diagnosis of Coronavirus, you’ll be wanting the experts to be able to trace every possible carrier of this insidious virus. That’s what the app can do. Nothing else. 

Stay safe, keep washing your hands and be grateful for our sunshine, our health professionals and our scientists.

And until we can get back to some mountains, here is some more mountain spam. That was a beautiful day. 

Mont Blanc, 2017

(1) Klem, Nardia-Rose BSc (Physio) (Hons); Smith, Anne Postgrad Dip Sports Physio, BAppSci(Physio), MBiostats, PhD; O’Sullivan, Peter Dip Physio, Grad Dip Manip Ther, PhD, FACP; Dowsey, Michelle M. BHealthSci, MEpi, PhD; Schütze, Robert MPsych(Clin), PhD; Kent, Peter BAppSc(Chiro), BAppSc(Physio), Grad Dip Manip Ther, PhD; Choong, Peter F. MBBS, MD, FRACS, FAOrthA, FAAHMS; Bunzli, Samantha BPhty (Hons), GradCert Res Methodology, PhD (May, 2020): What influences patient satisfaction after a TKA (which stands for a Total Knee Repalcement)? A qualitative investigation.  Clinical Orthopaedics and Related Research: May 12, 2020 – Volume Publish Ahead of Print – Issue –doi: 10.1097/CORR.0000000000001284

An Overactive Bladder: Urinary frequency, urgency and urge incontinence

   

Knowing where the next toilet is hiding is the bane of your life if you have an overactive bladder. Especially in our new #Coronvirus life where many public toilets are locked off to the general public – women and men must be really struggling.

I was reminded of this when we went for a giant walk yesterday in my home town, Brisbane, from Somerville House, across the Goodwill Bridge, along a brand new walkway called The Mangrove Walkway, under the freeway where there’s a new exercise area, past Parliament House, through the Botanical Gardens, along another new walkway over the river in front of Riverfront Place, then back through the Botanical Gardens, back over the Goodwill Bridge and to the car.

     

It was a 10,000 stepper walk that took a couple of hours. And what was interesting that in that whole time we were out walking we only walked past one set of toilets.

In the good old days (pre-COVID19), when we were travelling overseas, we often ended up buying a coffee or a spritzer/beer at a cafe just so we could use their toilet, because toilets are as rare as hen’s teeth in Europe and the UK.

You may remember another blog regaling my struggle to maintain continence after a train trip to Brighton where there was no toilet on the train and when we arrived at Brighton, all but two of the toliets were blocked off and the queue to the remaining two was resembling the opening of ticket sales to the Rolling Stones concert. Needless to say I survived and my dignity remained intact – but I remember I was conducting a messenger conversation with some friends back in Australia to keep myself distracted and not thinking about the toilet.

Distraction is just one of the methods that can work well when you have an urgent bladder urge and there is no toilet available. Other ‘urge control’ strategies are toe curling, squeezing your glutes (your butt cheeks), crossing your legs, pulling in your low tummy or strangely relaxing your tummy (try each and see which works better for you), gently engaging your pelvic floor muscles and finally belly breathing.

Toe curling to help turn off the urge (yes I got to go to have a pedicure yesterday for the first time in 3 months)     

These strategies are useful to help you build up your bladder capacity by deferring, but when you are as full as you can tolerate and you sense: “If I take a step I am going to lose it all”, then defer the urge once more and use the time to walk slowly to the toilet, breathing and perhaps counting your steps as you go along.

Doing a bladder diary to check your bladder capacities across two days is helpful in determining how much work you need to do to build up your bladder holding ability.

Other strategies such as pelvic floor exercises (they may help to calm down the smooth muscle pump of the bladder but also sometimes doing too strong a pelvic floor contraction this may make your urgency worse); and even having local oestrogen up the vagina can help overactive bladder symptoms – discuss this with your doctor.

Managing your bowels well is also an important strategy for an overactive bladder. A loaded rectum or even lots of gas and bloating can make it harder to hold onto a decent capacity, so things like sitting with correct postures to empty your bowels and the correct dynamics of defaecation and avoiding foods that give you excessive bloating will be helpful.

Another helpful strategy is using TENS (stands for TransCutaneous Electrical Stimulation) over the tibial nerve (see the application of the electrodes below) to provide some neuromodulation. Your pelvic health physiotherapist will teach you how to use the TENS unit.

It is always important to have a bladder ultrasound before and after you void to make sure you are emptying your bladder completely. If you have a largish residual and you are not aware of this, you may try to wrongly build up your voided capacity when in fact your bladder emptying needs addressing.

An ultrasound can check whether the bladder is emptying properly. Use this position to try to empty completely

Anyway, what is the moral of this blog?

  • The Brisbane City Council needs to install more public toilets around the city.
  • An overactive bladder can be significantly improved by a Pelvic Health Physiotherapist – make sure you get some help.
  • Medications can help also – but discuss with your GP, gynaecologist, urogynaecologist or urologist about the best drug of choice as there is increasing, emerging evidence that long-term use of many of the drugs used to help the urgent bladder are implicated with dementia. (The drugs that cross the blood-brain barrier are the ones to watch out for.)

And finally walking everywhere allows us to stop and ponder life. On our regular walks, we’ve discovered new things that have been built, new outdoor art which is refreshing and beautiful, found things we never knew existed and just observed things.

I wanted to be this bird. He’d had a swim and there he was just sitting on a log in the Brisbane River, drying his wings, oblivious to the pandemic. If you can believe the theories, we should all be doing this to get our daily dose of Vitamen D – which appears to be useful with this damn COVID!

Six Weeks of Telehealth: Update for posterity!

 

Week Six of Telehealth consultations. This is an update for the future to look back on and reflect on these unusual times.

Thursday 7th May, 2020 had some highs and lows.

After 6 weeks of waiting we received our Job Keeper payments. This is a giant high for Bob and myself after weeks of stress and anxiety- farout what a relief! If anyone hasn’t received their Jobkeeper payment and they have applied for it, please be aware it is quite complex to fill out all the forms and you may have missed a step if you haven’t received a payment by now.

The joy was somewhat tempered by the fact that on that same day, I also had a one hour conversation with a representative from HCF – one of the Private Health Insurance (PHI) companies – regarding their requirement that they had a new form for us to fill out if their patients were to receive a rebate on their Telehealth physiotherapy appointments.

This was the proverbial straw to break the camel’s back.

There’s been so many curve balls and hoops to jump through EVERY DAY since COVID19 imploded all around the world. In the beginning I could have easily curled up under the dining room table with my blankey and given up. It all seemed a bit overwhelming.

But gradually each day, with a lot of lists and extremely able staff and husband (who has in fact become an IT guru), we have managed to claw our way back up to peek out from the quick sand and see a future as a practice again. We have classes streaming each day, we are turning peoples’ lives around with Telehealth and even seeing the occasional patient again face-to-face.

We had started to breathe.

And then we get an email from HCF with the news that we have to fill in yet another form if our HCF patients are to be given a rebate from their private health insurance (PHI) – their very expensive health insurance, even though the services anyone can access and receive a rebate from their PHI have been almost non-existent since COVID19 started. Not just give them a Tax Invoice with a special Telehealth code like every other health fund required. No, a two page form had to be filled in by each physio who treated the patients.

I decided when I read this email that I was going to ask HCF to explain to me why all Allied Health Practitioners had this extra burdon placed upon them when no other health fund was doing it. Firstly the number the email gave to ring on just rang and rang and rang- no robot even picked up. After 2 calls totalling 45 minutes each went by with absolutely zilch pick-up, I decided to do what usually gets a swift response from the other major offenders in the category of “Ridiculously Impossible To Get Through To”- Optus and Telstra – I decided to send a Tweet.

Two days later and HCF tweeted back and asked for my phone number.

To cut a long story short – on Thursday 7th May, Kieran from HCF rang me and politely listened to me for about an hour, as I educated him on the complexities of Telehealthing my patients with pelvic health conditions – to say his straight hair may have been curly when I’d finished is an understatement. And I told Kieran that myself and my physios were often physically and emotionally exhausted after an initial consulation with a complex patient and the very last thing any of us need to do or should be required to do is fill in another form.

The patients currently get a detailed Tax Invoice with an Item number, and the cost, their name and address, the physios name and provider number – an extremely detailed invoice. Our patients also get a 14 page set of notes, a specipan for their bladder diary, a copy of one of my books, a specific homework page tailored to their specific problems and then get sent links to videos which I have done to explain the things that they would normally see if they were physically in the room. We are trying very hard to make this Telehealth experience worthwhile and as good almost as being face-to-face. My reaction to this requirement from HCF is they don’t trust us Allied Health Professionals.

It’s funny after all the things that have been testing us all in these strange times, why some things really get your goat.

The internet has been atrocious at times, the mobile phone reception has gone caput, our income has dropped by 60%, the amount of actual change that has had to be enacted to make this all be effective in about 10 seconds flat has been massive…..and yet the meanness of this Health Fund towards the hard working Allied Health Providers who are literally (almost) killing themselves to help HCF clients, beggers belief.

If I were a HCF customer I would ring them to ask them why are you doing this to our caring Allied Health Professionals?

(It would be probs be impossible to get through to anyone though.)

 

 

Endometriosis Part 1

It is surprising that I am up to Blog Number 339 and I have never written anything about Endometriosis. I apologise unreservedly to the 1 in 10 women who suffer with the persistent pain / fertility issues that Endo presents them with. In these COVID19 times, I have staff who have less patients and more time to sit down and collaborate to write some blogs and so together, Megan, Amanda and myself have compiled this blog on Endometriosis. It is so big that I am splitting it into a couple of blogs for your reading pleasure. We have used multiple sources for this information and these references are listed below.

Endo is something that women have suffered with in silence for generations. You will see that it often takes 6 to 10 years to diagnose it. I work in the area of persistent pain and yet it has taken me nine years to get around to writing this blog. (This is actually embarrassing now- it took me the same length of time to compile this blog as it takes for some poor young woman to get it diagnosed and get help). But hopefully this is starting to change. Funding is starting to emerge from the government and leaders in the area of persistent pain management such as Dr Susan Evans are bringing programmes into the schools alerting young girls that period pain is not normal and you need to seek treatment earlier rather than later to manage any pain.

Here we are now in these strange COVID19 days. You are reading this blog about endo pain.

You know you have it because of a recent (or past) diagnosis.

Or you are wondering if you have it because of what you are reading – your symptoms are fitting the description written in the blog.

Do you wait and continue to suffer pain month after month because it is difficult, if not impossible to see a specialist endo gynaecologist or pain specialist? Or do you decide to book a Telehealth appointment with a pelvic health physiotherapist to learn some pain science and start to master your pain?

Even if your physio cannot do an internal examination, I know she will listen to your pain story, tease out any stressors, educate you about persistent pain and give you coping strategies to assist any pain symptoms, to help the pain with intercourse or minimise your monthly period pain. David Butler and Lorimer Moseley, two leading Australian pain researchers, have written many books on the management of persistent pain (the Explain Pain series) and they tell us that the pain science evidence reveals that 1 in 4 persistent pain patients will get up to 50% improvement in their pain symptoms simply with good pain science education. (1)

So this first blog is setting the scene to help you understand endometriosis:

Endometriosis is a chronic, benign, oestrogen-dependent inflammatory disease which includes the presence and growth of dysfunctional endometrial-like glands and stroma often with reactive fibrosis and muscular metaplasia outside the uterus (2). It affects 1 in 10 Australian women, usually commencing in teenage years with symptoms becoming more noticeable with each menstrual period. The progression usually follows one of two paths:

  • Women who have severe period pain and are otherwise completely well; for these women an operation to remove the endometriosis is usually helpful
  • Women whose pain starts with their period but then progresses to occurring most days of the month. This can include pain in the vagina, bladder, bowel, pain with intercourse, bloating, or migraines. For this group, a laparoscopy to remove endometriosis is usually only part of the solution. Their pain is more complex. The good news is that you still can fully expect to achieve a life with less pain with the right mix of physiotherapy, lifestyle change, diet, medications and pain education

What is happening in the body for someone with endometriosis?

When you look at the current literature regarding the pathogenesis of endometriosis you can see that what causes it is still a matter of considerable research and debate. Stem cells, dysfunctional immune response, genetic predisposition and aberrant peritoneal environment may all be involved in the establishment and propagation of endometriotic lesions. (2) There is still considerable work to do with the understanding this disease.

Endometriosis lesions are found in the pelvis covering the side walls and on the surface of the uterus, ovaries, fallopian tubes, bowel, cervix, vagina, bladder and lining of the pelvis. These areas of endometrial-like tissue do not bleed like the endometrium but are full of nerves – it may be this that causes pain or the chemical substances that can irritate or scar the tissue around them. 

The original and best established theory by John Sampson (retrograde menstruation) was that the menstrual bleeding which normally flows out of the vagina is shed to the abdominal cavity via the Fallopian tubes and as it couldn’t leave the body it formed lesions of endometriosis in the pelvis. Retrograde menstruation happens for many women who do not have endometriosis so this theory doesn’t fit with all cases. Several other theories have been suggested. 

Brosens and Benagiano suggest that it starts with bleeding from the uterus of girls just after they are born that passes into the abdomen and remains there until puberty when they fire up.(3) Another theory – the coelomic metaplasia theory states that embryonic cells from the Müllerian ducts persist in ectopic locations. At puberty, stimulated by estrogens, they grow to build up endometriotic lesions. According to genetic scientist Nyholt endo is a heritable, hormone-dependent gynaecological disorder. What is known is that oestrogen is the driving force of endometrial proliferation which is why it commences with menstruation and usually subsides when women go through menopause.

Endometriosis lesions come in many colours, shapes and sizes when seen via laprascopy.

  • Red lesions-contain many blood vessels and may be the first stage of endometrisis.
  • Clear lesions look like tiny bubbles, early endo and difficult to see
  • Black lesions – endometriosis irritates the peritoneum around it causing scarring. The black colour is due to trapped blood turning black
  • White lesions occur when the scarring blocks bood vessels and leaves a thick white scar
  • Endometriomas or chocolate cysts ar larger lumps of endometriosis that grow inside an ovary
  • Peritoneal windows or pockets on laparoscopy look like oval dents in the surface (4)

In about 20% of women with endometriosis, it will inflitrate into pelvic structures (bowel, bladder, the vagina and uterosacral ligaments) – it is called deep infiltrating endometriosis (DIE). This form of the disease often causes more destruction of the normal anatomy and is generally significantly more difficult to remove and results in adhesions between organs.

There is also evidence that endometriosis has elements of central sensitization via persistent nociceptive (danger) input from endometriotic tissues resulting in increased responsiveness at the dorsal horn of the spinal cord which processes input from the affected areas (viscera and somatic tissues).(5). This is important when considering the treatment strategies that physiotherapists use in managing pain.

Although the condition affects a large percent of the female population, diagnosis and treatment can be difficult. In Australia, the average length of time between onset of symptoms and diagnosis is about six years, longer in other countries. This is largely due to the fact that endometriosis symptoms can also result from other conditions, therefore it can be difficult and time consuming determining the cause of someone’s symptoms.

How is it diagnosed?

More recently ultrasound (U/S) has a good sensitivity and specificity for endometriomas (83% and 89%, respectively) is able to show us a picture of different pelvic organs and is an increasingly important investigation as preparation for surgery for DIE. U/S can also be helpful to look for other conditions such as fibroids in the uterus or ovarian cysts that are unrelated to endometriosis, but may be causing other pelvic problems. High-resolution magnetic resonance imaging (MRI) with bladder, vaginal, and rectal contrast has been a breakthrough in recent times.

A laparoscopy is ‘keyhole’ surgery during which they look inside the abdomen for the presence of endometriosis and is usually required to show the full extent of the endo. This is gold standard in endometriosis diagnosis. It is recommended that you see a specialist endo surgeon for removal of lesions as this first clearance increases your chance of good results with future pain. However, there is only so much that surgery can do for pain, and having too many laparoscopies can actually worsen pain. Your doctor may explain that sometimes non-surgical treatments are a better option for your particular pain. 

It is important to note that the degree of symptoms experienced by a patient does not reliably correspond with the degree of endometriosis found at laparoscopy. At times women with mild symptoms of endometriosis have been found to have a lot of lesions at the time of surgery, whereas other women with severe symptoms have a normal pelvis (no endometriosis present).

What are the symptoms?

Symptoms vary from woman to woman, with some showing no symptoms at all. Common symptoms include:

  • Intermenstrual bleeding (bleeding between periods)
  • Painful periods (Dysmenorrhea)
  • Pain with intercourse (Dyspareunia)
  • Painful defaecation (Dyschezia)
  • It’s also common for women with endometriosis to have other conditions including Irritable Bowel Syndrome or Painful Bladder Syndrome
  • Infertility – although most women with endometriosis do become pregnant, and you should definitely use contraception if you aren’t ready for a pregnancy

Period pain can be caused by endometriosis or by the uterus, or both.  The uterus contracts to help shed the endometrial lining during a period. The body produces substances called prostaglandins that stimulate these contractions and also have an inflammatory effect. A higher concentration of these prostaglandins is linked to more severe pain.

Period pain can be quite severe in teenagers who do not have endometriosis. This pain usually occurs during the first one to two days of the period and is relieved by the oral contraceptive pill or period pain medication. On laparoscopy, the pelvis looks normal and this pain usually eases after having a baby.

Severe period pain in younger women is becoming a more significant problem. Two generations ago, our grandmothers were having their first baby at around 20 years of age and spending a lot of their younger years pregnant or breastfeeding.  Now many women are delaying having children or choosing not to have children. This means that they are having more periods, and if they have endometriosis, more pain as endometriosis pain tends to worsen with each period.

Adapted from the Endometriosis Myths and Facts Endometriosis Australia: Created by Amanda Waldock

Click on the image to see a larger version of it

Risk factors

There are some factors that seem to increase the likelihood of developing endometriosis including:

  • Family history of endometriosis
  • Menstrual patterns – including menarche at an early age (first period), longer length of periods (>7days), shorter cycle (regularly less than 27 days between periods) and heavier periods
  • Reproductive history – fewer or no children (as pregnancy and lactation reduce number of periods)
  • Immune function – having autoimmune conditions like asthma, allergies, rheumatoid arthritis or multiple sclerosis
  • Obstructive menstrual outflow – such as congenital abnormalities or a narrow cervix could increase retrograde menstruation
  • Environmental toxins – research has found dioxins may imitate oestrogen or compromise the immune system and contribute to endometriosis

Endometriosis and other health conditions

Women with endometriosis are 2.5 times more likely to have irritable bowel symptoms, and there is also an association between endometriosis and bladder pain syndrome (BPS).  It has also been found that women with endometriosis or dysmenorrhea (painful periods) can develop hyperalgesia (increased sensitivity), inflammation and overactivity in abdominal and pelvic floor muscles. There will be treatment strategies for IBS, reducing overactive muscles and managing BPS in the Treatment Blog coming soon.

The cross over effect of these conditions and symptoms explains how the pain can start in one tissue, organ or muscle and then spread throughout the pelvis. The cross over effect is caused by convergence. Nerve supply to the organs and muscles comes from the spinal cord and each segment of the spinal cord can supply several tissues.  This means that nerves from several tissues converge into one segment or nerve root to travel together up the spinal cord. Simply put, convergence means that inflammation in one organ or structure can cause inflammation or hyperalgesia in other organs which are supplied by the same nerve root. (Known as viscero-visceral hyperalgesia). This same concept can be applied to the musculature: inflammation in an organ can cause hyperalgesia and overactivity in muscular structures supplied by the same nerve root.

Some good websites for endometriosis

Endometriosis Australia

www.endometriosisaustralia.org

Pelvic pain Foundation of Australia

www.pelvicpain.org.au

Jean Hailes

www.jeanhailes.org.au/health-a-z/endometriosis

NICE Guidelines for management of Endometriosis

https://www.nice.org.uk/guidance/ng73?fbclid=IwAR0wJR31r-5VSH0ZKu2iOqVv8ZyffLitQxvhDZmaqY1e6aMjvaxPi215w5M

Australian Government National Action Plan for Endometriosis

https://www1.health.gov.au/internet/main/publishing.nsf/Content/58AD1EF08402AC9FCA2582D5001A271E/$File/National%20Action%20Plan%20for%20Endometriosis.pdf?fbclid=IwAR2xUcDfWUtHNTPnUw4snCEm3v3Bzt60byMsHOVJ1jMGMk1WU1VGG2oNthY

Queensland Endometriosis Support Group

https://www.qendo.org.au/

If you want an excellent, comprehensive book to learn more about Endometriosis, I highly recommend Dr Susan Evans book Endometriosis and Pelvic Pain. I will be reviewing Susan’s book in a future blog. We sell it on our website – if you would like to purchase it then click here.

 

Part 2: The treatment options will come in the next couple of days.

If you want to BOOK AND APPOINTMENT TO GET HELP CLICK ON THIS LINK. Don’t delay any longer- seek help!

References

(1) Moseley and Butler (2017): Explain Pain Supercharged 

(2) Lagana A et al (2019)The Pathogenesis of endometriosis: Molecular and cell biology insights. Int J Mol Sci

(3) Rolla E (20919) Endometriosis: Advances and controversies in classification, pathogenesis, diagnosis and treatment

(4) Evans. S and Bush. D (2016). Endometriosis and pelvic pain. Adelaide, South Australia. Dr Susan F Evans Pty Ltd.

(5) Zheng, P., Zhang, W., Leng, J., & Lang, J. (2019). Research on central sensitization of endometriosis-associated pain: a systematic review of the literature. Journal of pain research, 12, 1447–1456. https://doi.org/10.2147/JPR.S197667

Australian Government Department of Health (2018). National Action Plan for Endometriosis. Available at: https://www1.health.gov.au/internet/main/publishing.nsf/Content/58AD1EF08402AC9FCA2582D5001A271E/$File/National%20Action%20Plan%20for%20Endometriosis.pdf?fbclid=IwAR2xUcDfWUtHNTPnUw4snCEm3v3Bzt60byMsHOVJ1jMGMk1WU1VGG2oNthY

Endometriosis Australia. Endometriosis Research. Available at : https://www.endometriosisaustralia.org/research

Hallam, T (2020). WHTA – Advanced Pelvic Floor. Pelvic Pain Genitourinary and Anorectal Pain disorders.

Jean Hailes. Endometriosis. Available at: www.jeanhailes.org.au/health-a-z/endometriosis

National Institute for Health and Care Excellence. Endometriosis: Diagnosis and management NICE guideline [NG73] 2017. Available at: https://www.nice.org.uk/guidance/ng73?fbclid=IwAR0wJR31r-5VSH0ZKu2iOqVv8ZyffLitQxvhDZmaqY1e6aMjvaxPi215w5M

Parasar, P., Ozcan, P., & Terry, K. L. (2017). Endometriosis: Epidemiology, Diagnosis and Clinical Management. Current Obstetrics and Gynecology reports, 6(1), 34–41. https://doi.org/10.1007/s13669-017-0187-1

Pelvic Pain Foundation of Australia. 2019. Available at: www.pelvicpain.org.au

Women’s Health Queensland Wide Inc. Endometriosis Fact Sheet. Available at: https://womhealth.org.au/conditions-and-treatments/endometriosis-fact-sheet

 

 

 

 

 

 

 

 

 

 

 

 

COVID19 IN 2020

New Yorker cartoon about blogs: In case you can’t read it:

“I had my own blog for a while, but I decided to go back to just pointless, incessant barking”

I have been so busy responding to the Coronavirus crisis and the effect on my practice – the changeover to Telehealth and all the ramifications of such tumultuous times- that I completely have had no time to write a blog for weeks now.  I love writing blogs and sometimes will shirk my pressing ‘to-do’ list in favour of writing a blog. Complete weariness and exhaustion has meant that I just couldn’t do it.

But this time- this new Coronaviruslife is so significant, so monumental, so extraordinary and dare I say it, so unprecedented – that it definitely must continue to be recorded for posterity in my blog. When I read my blogs in the future, and look back on this history in the making, I want to remember some of the incredible moments that were defining in the COVID19 story.

I think it has been a PR disaster from the beginning. If it were a brand, the mixed messaging about it would mean the brand would have probably taken a dive and failed from the beginning. The understatement about it being like a mild flu which still perpetuates in some groups to this day; the belief that it only caused problems for ‘the elderly’. Apparently ‘the elderly’ is the group over 60 yrs – BC (Before Corona) I was thinking that me being 60 was the new 40; the constant changing of the rules about social distancing, what you can shop for (if only I loved doing jigsaws). But here we are nearly at Easter, looking at our curve taking a dive for the better and our population is mostly sucking it up and changing their behaviours. And most importantly there have been gigantic lifelines sent out to business, the newly unemployeed, the parents needing childcare (yes it’s free for the moment) and many other groups by the government, which have allowed many to breathe a little easier about the future.

Is it hard? You betcha it is. Australia has the best beaches in the world and you can’t so much as pause on them to ponder the view. We are renowned for our gatherings around the barbie, but they are banned. It appears that our internet is groaning under the weight of activity – which is weird when you think about it to be honest. We all have computers chugging away whether we are at work or at home working so I don’t quite understand why it is SO bad (it is BAD but I’m refusing to whinge).

Closed beach at Bondi (Photograph: Jessica Hromas/The Guardian)

But there are some amazing things happening.

The memes, for example, keep us chuckling when we might feel like crying; my staff send me a joint email which lifted me back up, when I felt the weight of the problem causing my knees to buckle; out of the blue, a gesture of such kindness to me from a leader in our field, in response to my Facebook comment about a glitch in the ATO system, potentially causing us a cash flow problem; and finally an intervention from our Federal member Graham Perrett (clever Bob thought to send him an email about the problem) solving the said glitch the very next day – we had the sort of phone call from the ATO we’d all like to get saying: “You’ll get your money”.

All of those things I wanted to record for posterity because I don’t want to forget how in times of adversity, kindness rises to the top.

I also wanted to report about Telehealth.

It is going well in the sense we are still helping people solve their problems.

Is it perfect? Well if we’d love to do an internal examination to check for levator avulsion, or test pelvic floor muscle strength, or teach about bracing so the woman could feel the descent when she coughed followed by the stability when she performed the knack, or do a bladder ultrasound to check for any residual urine on emptying the bladder………well we can’t.

But we have become innovative and we have designed even better ways to teach, which we may continue to use when we can see patients face-to-face. I know we will be able to offer more regional appointments via Telehealth AC (After Corona) because we will be excellent at it. We are streaming classes – lots of classes- pain/anxiety management and relaxation classes; strength and balance classes; movement classes, a dance class and soon a men’s health pain management class.

Jane doing her PhysioFitness class

The attendees are mostly overjoyed and grateful that we are trying hard to produce these classes. If they knew just how many hours Bob is putting into the structures and implemetation of the IT to make this happen they would be staggered. I thank all my staff for being so flexible and embracing of the situation. And the secretaries! They have been tireless in converting patients to Telehealth appointments. It is quite a spiel they have to do ……. every single time!

Some other moments to remember:

  • Tom Hanks and his wife Rita Wilson aquired Coronavirus in Australia while filming a-yet-to-be-titled film by Baz Luhrmann about Elvis Presley
  • Peter Dutton, our Minister for Home Affairs got it and in his absence the biggest boat we ever had to our shores released 2700 passengers unchecked at our border and released COVID19 widely into our community. As of 4th April, 11 people had died and 620 poeple had aquired coronavirus from the Ruby Princess.
  • Pink, Prince Charles and Boris Johnson have or have had corona. Today 7th April, Boris was admitted to hospital and then very quickly Intensive Care. I hope when I read back on this blog, Boris survived this disease. He was very cavalier in the early days and has sadly paid a very high price.
  • COVID19 has corona-ed our economy. It is probable that we will enter into a recession. Economists have dire predictions of a depression worse than The Great Depression of 1929. I hope that this is not true and that the measures that our leaders are taking will save the country from that consequence.

And finally in this blog I want to quote Professor Hugh Montgomery, an English professor of medicine and the director of the UCL Institute for Human Health and Performance at University College London.

On the 7.30 Report tonight he said:

‘COVID19 has been presented as a very bad flu. It really isnt- it’s as different from the flu, as Ebola is from an ingrown toe nail.’

‘It’s a very different disease. It might present with flu-like symptoms -achy, breathless, temperatures. But around day 10-12, the patients get an increased drive for oxygen. This air hunger and breathlessness – sometimes they are aware of it, sometimes they are not. We see them blue and panting and they do not realise how sick they are or how high their CO2 is or how low their oxygen saturations are. Sometimes they need supplemental oxygen, sometimes CPAP, sometimes they need ventilating. It is a serious disease.’

Remember what he said: ‘Its as different from the flu, as Ebola is from an ingrown toe nail.’

#staysafe #washyourhands

 

#Stayathome #FFS #sorrynotsorryforswearywords: #newCoronalife

The message should be clear!

#stayathome!!

But it’s not clear.

It’s contorted.

If you had a wedding planned – tell the guests to come in the #activewear and you can have double the number (10 not 5). Just tell them there’ll be some burpees thrown in – possibly more effective after the sculling of the Prosecco- to comply with the instruction that apparently boot camp attendees are exempt somehow from #spreadingthevirus (#not – this is a nonsense and beggars belief)??

Could I suggest that you look at the following information which is looking at the raw data.

“The success or failure of Australia’s coronavirus fight relies to a remarkable degree on just one thing, new modelling has found. And that thing is whether individual Australians now follow official advice -and just stay home. The data comes from a complex model of how COVID-19 could spread in Australia, which finds: Coronavirus will continue to spread virtually unchecked unless at least 8 in10 Australians stay home as much as possible. If that slips even slightly-to seven in 10 people-the fight to ‘flatten the curve’ will be lost. ” (1)

This article above, together with the fact that India (a nation of 1.3 billion people) has gone into a 3 week lockdown, has led me to make the extraordinarily difficult decision to see our last face-to-face patients today (25th March, 2020) and go 100% Telehealth for the next 3 weeks at a minimum. After a sleepless night – and disappointment that we weren’t ordered to go into lockdown by our PM last night- I made the call myself.
I would have done this much earlier, but I have 10 staff (whom I love and I am very concerned about their financial position) to consider. But the brave decision by India and the state of Australia’s ever-increasing curve made it crystal clear for me at the crack of dawn.

We will be available for Telehealth consults and have online bookings. We will soon be live-streaming exercise classes for a nominal fee. Check out our website (soon) for details.

Another thing: If it is recommended that we wash our hands for 20 seconds, then if your physio has recommended you do pelvic floor exercises (or that you relax your pelvic floor and belly breathe regularly through the day if you have a pain condition) then marry those two things together (hand washing and pelvic floor mindfulness we will call it) and when we ‘come out the other side’ your pelvic floor will not have suffered for the #lockdown!

And finally: For all of those couples who are contemplating (freaking out) 24/7 ‘internment’ with their partners (and children) please note that Bob and I will be offering Telehealth counselling about how to survive and come out of #lockdown still together. As you may or may not be aware we have worked and lived together 24/7 for the last 18 years of our 44 year relationship. We have much wisdom and knowledge to share and for an exhorbitant fee (to cover 10 staff on reduced wages) we will get you through this nightmare!

And #stayhealthy , #stayhappy and #stayathome

Restoring trust in your pelvic health #newCoronalife

Most of what I do every day relies on restoring trust to our patients’ bodies.

Trust that their bladder will hold and not let them down at the back door or in the (extremely) long queue at the checkout (these crazy COVID19 days).

Trust that they can hold their gas when they get into a crowded lift on the way up to their hotel room.

Trust that as another period approaches their pelvic floor muscles won’t revert back to their usual overprotective ways that causes pain and magnifies anxiety.

Trust that the newly fitted pessary will hold their prolapse up.

Trust in our bodies is important because it promotes stability and confidence, happiness and joyfulness with life. It enhances freedom to move and exercise, to have pain-free sex and to concentrate on the fun things in life. But what happens when you have a spanner thrown in the works by something like the novel coronavirus called COVID19?

You hear increasingly worrying news about illness rates in other countries and then you realise we are about a week behind those countries. A little bit of anxiety creeps into your thinking. You see a social media post about a shortage of toilet paper and then you remember a story your mother told you about the job given to her by her father during the Great Depression (cutting the newspaper into squares and popping a small hole in the corner for some string to tie it together- yes this is a real story). A bit more panic sets in, which further accelerates your anxiety. Then you head to Coles, Woolies, Aldi and IGA and there is no toilet paper to be found anywhere.

Definitely not my toilet

You have faecal urgency and have been known to have accidents so the fear is real for this patient. This fear generates more cortisol and adrenaline, which in turn causes the bowel to be very reactive and makes the urgency even worse.

Before we know it there is a full scale calamity unfolding both in the whole world and in this lady’s life. Her body is letting her down and she no longer trusts it to behave safely.

Trust extends further in our lives. We need trust in the mechanisms that keep our society running smoothly. We need trust in all levels of government. We need trust that the health system will be able to withstand the pressure of the tsunami of patients if COVID19 takes off. We need trust that the financial system is robust and can bounce back after this is all over.

Most importantly we need trust that basically humans will behave in a humane and kind way.

But what can you do?

Individually try and use this strange time to your advantage. Over the years everyone at different times has felt the pressure of too much work, too much socialising, too much lecture preparation, too much Committee-ing and no absolutely no down-time. Not a minute. And certainly if you take a minute – you are usually plagued with guilt that you should be doing something, anything on your To Do List.  so why not write a bucket list of #jobstodoinlockdown

Here is my #Coronalifebucketlist:

  • Tidy desk (I did this today and I am very pleased with the before and after).

Achieved prior to #lockdown #impressive

  • Delete the 21,989 emails in my inbox (you think I am exaggerating……..I promise you I am not. I am definitely an email hoarder)
  • While on my computer – try and learn how to save a Powerpoint without saving it 40 times thereby completely choking the storage on my computer. Then delete all unnecessary Powerpoints. (Similarly with Word documents)
  • Tidy up my many ‘desks’ that I have ‘home offices’ set up at.
  • Delete the photos from my Iphone that I do not need on there (I have even more trouble deleting photos from my iPhone, than emails).

This is truly embarrassing

  • Clothes culling (some may call it #MarieKondo-ing but I’m going to run with #Coronakondo-ing). As each child has left I have spread my clothes amongst all the wardrobes in their bedrooms. In my #preCoronalife, when I was trying to be a good #climatechangewarrior I was embracing the #recyle #reuse #reduce and not buying any new clothes. So I couldn’t possibly contemplate throwing any clothes out just in case my size changed from my current-sized wardrobe, back to a previous weight (ranging from size 8 – such as my wedding dress to size 16 at the height of my #chocolateasastressreducer phase). But with some #lockdowntime on my hands possibly it’s time to let go of some oldies!
  • Clean out the children’s belongings (this is actually a test to see if they ever read my blogs – I couldn’t possibly ever let go of their numerous trophies, china dolls, cricket bats)
  • Read some (not pelvic floor related)books. I read a lot. I read journel articles, new pelvic floor-related books, pain and anxiety management books, Facebook stories, Twitter trending stories. Alot of reading. At Christmas time I read fiction and non-fiction (but non-pelvic floor related non-fiction) books and I love it. Give me a good book and I lose track of time and meal preparation and can knock a good book over in a day. But that happens but once a year – at Christmas time. I also have been known to buy a lot of books hoping I will read at other times of the year, so I have plenty of great books ready and waiting once all the chores above are ticked.
  • Get plenty of exercise. We will walk the streets while we are allowed to. We have a treadmill at work and a stationary bike at home which we will utilise if we get to the stage that Italy is at (please no). We are also in the process of setting up some exercise classes which we will be live streaming into your homes should you subscribe to keep everyone sane and healthy. We know that we need a tip-top immune system to not fall in a heap if we get Coronavirus. I too will love doing the classes my staff will be doing for us.

But seriously I am truly hoping I get no time to do these #Coronalifebucketlist things because I am hoping Jane, Martine, Megan, Amanda and myself will be absolutely flat out with appointments via our new treating medium called #Telehealth to restore everyones’ trust in their bodies.

What more perfect time to get control of your bladder, bowel, pelvic pain or prolapse, but when you are in #lockdown and can truly give time and attention to your body – to fine-tune it and problem-solve why it has been letting you down? We are so savvy with computers these days. We spend an inordinate amount of time on them – why shouldn’t we treat your pelvic floor dysfunction ‘virtually’?

For many years now we have been doing phone consults for regional patients who can’t make it back to Brisbane for their follow-ups. This will be better because we will have video capability. So much of what we do is education. We teach you about what is normal for your bladder, bowel, pelvic floor and what goes wrong. Or if it is a pain condition, we teach you what is persistent pain and how to treat it, and beat it. How to get back to living the fullest life you can.

Now many may ask about the important internal examination. There are lots of ways to teach you about the state of your pelvic floor. Of course it’s not ideal to not be able to examine you, but SO MUCH can be learned via good, thorough education and that is what we pride ourselves on at Sue Croft Physiotherapy. Much can be also taught to Mums and Dads to help their children who may have a pelvic health condition. Men’s health problems can be successfully treated with a #Telehealth consultation.

So if you would like a phone consultation or a video appointment with us ring one of my secretaries on (07) 3848 9601 or 0407659357 and book one in. Being able to book Telehealth (or phone) consults online yourself will also be available very soon.

Now finally, what about #trust in our public institutions? 

I think we trust our medical profession and our scientists. They are doing a stellar job.

Our teachers at the warfront with no possibility of social distancing and in the firing (spray) line of every sneeze and cough deserve a medal.

Our state leaders seem to be stepping up. South Australia have incredible testing procedures for COVID19. Tassie and NT are plain old shutting the borders. Victoria, WA and Queensland have consisitent messaging and their numbers appear to be stabilising. NSW? Well who doesn’t love a #Bonditan?

At a National level? The messaging is confusing, disjointed and at times I feel despair. I have 10 employees and if we are going into #lockdown – what is going to happen to us all? Boris Johnson (United Kingdom PM) has offered all citizens 80% of their pay if their employer can’t keep paying them when there is no income. Seriously, I would cry if we had that offer from our Government. The relief would be enormous for me and my staff.

But I am not waiting for such an offer. I am encouraging you all to embrace your #newCoronalife and attend to your pelvic health deficiencies via a #Telehealth appointment with one of my girls or myself. Let’s hope we talk soon. Stay healthy. Keep moving and exercising. Don’t despair. And most importantly, keep on the lookout for funny #Coronalifememes

 

Recognising that sexual intimacy is an important part of faith for women

International Women’s Day 2020 Post

All my physiotherapists at different times have been asked to contribute to my blog by writing an article on some aspect of pelvic floor dysfunction for me. Today is the turn of my newest staff member, Amanda Waldock. Amanda is settling in beautifully at my practice after coming back from the UK, where she worked in London in pelvic health. I recently bought quite a lot of books on different issues related to sexual intimacy and Christianity and I asked Amanda to have a quick read of the books and give a short summary of their subject matter. One of the recurring barriers for women are the conflicted thoughts they have regarding intimacy.

We have copies of the books at the rooms but if you like the sound of a particular book then they were easily secured from Amazon.

Here is Amanda’s first blog for me:

Sexual wellbeing is an essential part of a person’s overall wellbeing. However sexual difficulties are often not discussed and therefore go untreated. For women these include:

  • Painful intercourse – known as dyspareunia, vulvodynia or vaginismus with 1 in10 women suffering with painful sex
  • Lack of Libido – 4 in10 women have poor libido
  • Anorgasmia – 1 in 3 women find it difficult reaching orgasm

(See https://www.racgp.org.au/afp/2017/januaryfebruary/lets-talk-about-sex/ for more details)

Although the statistics are high for these conditions, we also know it takes women (and men) a long time to seek help about these concerns.

We pelvic health physiotherapists at Sue Croft Physiotherapy, believe that sexual wellbeing should be high on the agenda. We are able to see how sexual difficulties impact an individual, their partner and their relationship. It is a very important aspect of one’s quality of life and needs to be given more attention.

Although it is important to speak to a medical professional (such as GP, gynaecologist or pelvic health physiotherapist) about these conditions, sometimes having reading resources you can turn to in the comfort (and privacy) of your own home, and at your own pace, can be a helpful adjunct to seeing a trained professional.

Dealing with sexual concerns can also be confronting and confusing with other factors such as religious, cultural and social beliefs being thrown into the mix.

For this reason, I have compiled a list of books we have in clinic at Sue Croft Physiotherapy along with a brief overview to help steer you in the right direction when looking for information on intimacy, sex, arousal and a whole lot more.

Christian Perspective

Hot, Holy and humorous by J. Parker

This book is a complete guide to Sex and Intimacy from a Christian perspective. Parker discusses everything from cultivating romance in your relationship, defining “Christian Sex”, tips for the physical side of things, but also refers to lower desire and other issues that may crop up. The focus of this book is on that fact that God designed humans to be sexual and that enjoying a sexually satisfying relationship is within his plan.

Bonus – Hot, Holy & Humorous is also a blog!

Parker has a blog full of resources as well! With over 850 blog posts ranging from the Bible’s perspective of sex to romancing your spouse and specific sexual techniques. The blog also answers readers specific questions and new blog posts are being added weekly.

Intimacy Revealed by J. Parker

This is a practise book for a year. 52 devotions, one for each week, which provide Bible passages, application, questions and a prayer that aim to shed light on God’s gift of marital sex. This book provides a scaffolding for you to think deeply about you and your partner’s sexual relationship and place this into the context of your life, and faith.

The Good Girl’s Guide to Great Sex by Sheila Wray Gregoire

A Christian place to turn to find answer to the most intimate and embarrassing questions. It aims to show people that sex isn’t just physical, but also an emotional and spiritual experience. Chapters include (but are not limited to) – How Good Girls Think about Sex, Lighting Fireworks and Learning to Make Love, Not Just Have Sex. This book is dotted with words from other women sharing their experiences.

Modern Scientific Approach

Come as You Are by Dr Emily Nagoski

This book takes the focus of the science of Sex and the surprising truths about what does work to maximize a woman’s sexual wellbeing. This book aims to teach you that although we are all made up of the same physical parts, no two people are the same. That we need to focus on “Turning on the ons and turning off the offs”, taking control of the context or environment and that unlike men, women’s desire is often more responsive rather than spontaneous.

The Come as You are Workbook by Dr Emily Nagoski

This is the companion to ‘Come as You Are’ which aims to bring together activities, prompts and thought-provoking examples to provide practical, evidence-based tools to enhance your personal sexual wellbeing. It is the perfect way to take the information learnt in ‘Come as You Are’ and expand on it to further understand yourself and your sex life.

Holistic/ Spiritual Approach

Women’s Anatomy of Arousal by Sheri Winston

This book is separated into three sections and talks about all things from spirituality, personal energy to chakras. The first focus on the history of female sexuality, how things have changed over time and how thing have gone wrong throughout time, specifically hiding and under-valuing female sexuality. The Section 2 focuses on the physical anatomy of a woman and pleasure, while Section 3 ties it all together providing practical tools to expand your sexuality.

Let us know if you have read any of the following and have any thoughts or if you have any suggestions for our bookcase.

Thanks Amanda for this summary. I know that many women will be pleased to see that there are some reading books available to them to help them expand their knowledge and gain comfort from the recognition of their faith.

 

Mon Repos Turtle Centre,near Bundaberg,Queensland

Twenty five years after our first attempt at seeing the turtles of Mon Repos we struck gold when we ventured to the brand new Turtle Centre at Mon Repos, Bundaberg. Our road trip this weekend was triggered by my son who has been closely involved with the design of this new iconic building by Kirk.

The new Turtle Centre at Mon Repos by Kirk (Architects)

Our first trip in 1994 to check out the turtles was an exciting trip in a hired camper trailer with all the kids (aged 8,5,2 years) having croup so badly that we actually took our humidifier and had it going all night! The midgies which were shocking also kept us on our toes and we didn’t come close to seeing a turtle laying or a hatchling hatching. There was nothing much formal organised to see the turtles- or if there was we didn’t find out about it (remember this was pre-google days).

Fast forward to 2020 and we had definitely prioritized seeing this new magnificent building. But we soon found out that seeing the turtles requires some forward-planning as there are limited numbers of tourists taken out on the sand each night and these book out months and months ahead. But we had a weekend looming with everyone free to go and so it was on. After searching websites and phoning to beg for seven spaces on the tour for the 8th, the lovely lady at Mon Repos Turtle Centre suggested we check out all the tour companies and see if they had any spare spots and sure enough Bundaberg Coaches came through with the goods. Seven spots for the Saturday night and better still, the ticket price included a pick-up from our accommodation to Mon Repos and return to the accommodation after the turtles sighting.

Some may say that driving to Bundaberg for an overnighter was too much, but we headed off for the four and a half hour drive at the crack of dawn on Saturday and arrived in good time and no discomfort- definitely achievable for a weekend. We stayed at Don Pancho Resort which weirdly was where (Bob believes) we stayed on another family holiday (but of which I have no recollection). It was very reasonable and very pleasant and most importantly you can stay there just for one night which made the whole trip very inexpensive. The young ones headed off to The Bundaberg Rum Distillery and the oldies and the babies headed for a session of beach and rockpool time. There were plenty of crabs and miniature fish to keep everyone entertained and then a big session at the great pool back at the Don Pancho.

Thousands of baby fish in the rockpools kept everyone excited

After an attempted (and failed) afternoon nap time the bus arrived for the pick up at 6.20pm and off to the centre we went. On the way we spotted some wallabies which added to the excitement. The all-important allocation of groups at the Turtle Centre desk revealed we had really scored by booking with a tour group because, despite purchasing the tickets only 6 days before, we were in Group 2 – the second group to go out and meant we didn’t have to wait until (potentially) 2am to see the turtles. There were around 300 people all patiently waiting for their turn to go down to the beach, carefully guided by a National Parks Ranger (we had Loz- she was great). There are lots of great audio-visual displays and plenty of things to keep the littlies entertained during the Big Wait.

Some Advice:

  • Definitely eat before you go, as the cafe only has drinks and the (inevitable, inedible) packaged pies and sausage rolls and limited baguettes.
  • You MUST take waterproof coats or ponchos if there is any threat of rain as you are not allowed to take umbrellas out onto the beach.
  • You MUST wear joggers on the beach to walk to see the turtle action and the walk could be 800-1000 metres in the PITCH DARK.
  • Really for this reason, you have to be fairly steady on your feet. You can’t see where you are going and the beach might be quite steep and with soft sand making it difficult to walk on.
  • No lights are allowed (including just the light of a mobile, mobile flashes with photos, torches or head lamps) as it may affect the natural process of the turtles that you have come to observe, whether it be turtles laying eggs or hatchlings making their way to the water after hatching from their eggs. But you will be given opportunities to take photos with lighting provided by the Rangers.
  • While there are plenty of tables and chairs for you to wait at, definitely take a good book to read and a thermos of tea/coffee and snacks to keep you awake if you don’t have young kids with you, as the cafe shuts at 8pm. It is a perfect time to catch up on some reading and the wait will be significant if you are not in Group 1 or 2. If you have young kids, they love the interactive room and as we were group 2 the ranger took us in to an auditorium, gave us a great talk and then some nice videos about turtles to look at after Group 1 went out to be taken to the beach. There is sand at the bottom of the auditorium with some giant turtle models that kept the 2 year olds entertained (when the beautiful video didn’t).

Our wait was around an hour and our ranger came and stopped the video and said there is action happening with a loggerhead turtle coming in to lay eggs. We headed out in the gentle drizzle (and very moody but slightly worrying distant lightning) and very carefully followed the ranger out on the boardwalks.

Did I say it is very dark? With intense cloud cover, rain and no lighting you have to hope the builder did a good job on laying the planks on the boardwalk. All the kids (and there were quite a few) were incredibly brave with none of them whinging about the dark. I think they were all filled with excitement about the upcoming reveal.

We walked along the beach and came to where the most incredibly beautiful (and enormous) loggerhead turtle was in the process of laying her eggs.

Oblivious to the large audience, she went about her business of laying 124 eggs!

She was unperturbed about her large audience and there was great excitement in our group when the ranger announced she was a brand new, previously untagged loggerhead. It was her very first time at Mon Repos. Loggerhead turtles usually start their reproductive years at age 30 and then lay eggs for around 40 years – and when they come back to nest they lay up to 6 clutches over a 12 week period. Each clutch of eggs is around 120 eggs and our girl laid 124 eggs! Unbelievable. It was so fantastic watching her and realizing she started her journey 30 years before as a hatchling and then came back to Mon Repos to complete the circle of life. We all felt very privileged to witness this beautiful experience. The rangers tagged her and that was something she didn’t particularly enjoy and she took off back to the ocean at a great rate of knots. But that tagging is vital to the researchers who work at Mon Repos in helping track the turtles and monitor their numbers.

But it got better. The researchers at Mon Repos know that they have a two hour window once the eggs are laid by the turtle to move the eggs to a nearby hatchery. This hatchery has sun protection and is closely monitored by rangers to ensure the eggs have the best chance to survive things like the hotter sand due to our increasingly hotter weather because of climate change.

The ranger carefully digs the eggs out after the turtle has returned to the water and then they get moved to the hatchery which is shaded

And you may ask – how did all those eggs make it to the hatchery?

Michael with the 3 eggs he moved

Yes all the people in the group got to move the eggs into the newly dug holes – another unbelievable experience which I didn’t know was coming. We all lined up and took our turn and because she laid 124 eggs some of us got a second go and I took 5 eggs to the hatchery. So moving.

After everything that had happened the group was on quite a high but it was about to get even better. We were making our way back to the boardwalk when we were all ordered to immediately stop because there in front of us were 8 little straggler hatchlings randomly walking down to the ocean.

 

A close-up of the hatchling 

I suddenly decided that night that when we retire it may be worth having some months up at Mon Repos volunteering to help the researchers across the turtle season. This is such a fantastic weekend trip. Don’t be put off by the drive up but maybe allow 2 or 3 nights as there is lots to do including just chilling looking at the beautiful water.

One of the lovely rangers at the Turtle Centre    Side View and the Outdoor Education Centre

 

 

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