Skip to content

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

Bisacodyl suppositories are not glycerol suppositories

Glycerol suppositories and Bisacodyl suppositories

This is a short blog to alert people about the hazards of walking onto a pharmacy and getting a substitute suppository when the brand recommended is out of stock. I had a patient who had significant bowel emptying dysfunction and who was straining quite a lot report that she had gone to the pharmacy to purchase the suppository that can be helpful to achieve better evacuation without straining. She reported that the pharmacist did not have any glycerol suppositories in stock – the commonly recommended ones that colorectal surgeons suggest. The pharmacist suggested Bisacodyl suppositories instead.

She used one of the Bisacodyl and reported distressing symptoms that then made her very uncomfortable- burning all around the perineum and constant ongoing bowel urges all day, with a feeling that she could’t control her bowels if the urge hit.

One of the things I ask my physios to do is to be aware of what some of the things we talk about actually feel like. All of them who have done pessary courses have tried a pessary so they understand what patients may feel (they may not need them but they still get to trial it). Of course, as I tell all my patients, I use a pessary for my prolapse and due to my own pelvic floor dysfunction, experience the day-to-day delights of childbirth. I have always tried any product that I may suggest to my patients will be helpful so I understand the ramifications of it.

So when this patient reported these unpleasant symptoms – I thought it essential I test it out….she wasn’t lying. It was extremely unpleasant with the generalized burning and the ongoing constant urges through the day.

Glycerol suppositories are NOT Bisacodyl suppositories.

Deeds not words

Aussie Bushfires, 2019/2020

There are many people directly involved or affected with this current Australian fire catastrophe. Some are very busy fighting the fires, organizing the firefighters, coordinating the helicopters and planes, saving lives, tending to the sick and burnt, feeding the hungry and rallying the troops. But there are now around 25 million people living in Australia, plenty of whom are not directly involved or affected by the fires – some with the smarts in science, the weather, the climate, economic nous, organisational skills, business entrepreneurs and so on.

If my house had burned down in an event which had never, ever been seen before, would I want to wait a respectful period of time before a think tank was established to sort this mess out? A gathering of brilliant minds to come up with many ideas to combat this catastrophe?

No way.

I would want…no expect…that there would be an emergency declared (this IS an emergency – if you are worried about calling it a #climateemergency then just call it any old emergency but this is what an emergency looks like)!

Respectfully, there is not a second to be wasted. The first fires started on 4th September, 2019 in Queensland with 50 fires in various regions throughout my state. The iconic Binna Burra Lodge was decimated. One of Australia’s longest-established nature-based resorts, Binna Burra Mountain Lodge was founded in 1933 by Arthur Groom and Romeo Lahey. These two pioneering conservationists shared a vision to create a place where people could stay and experience the beauty of the Lamington National Park rainforest. (1)

That is not a typo. Binna Burra was destroyed by a bushfire and it is in a rainforest.

We damn well need to get our sh*t together and get a plan. As many people have said, this is like a war. And it should be treated as such.

We need army generals with good planning skills to organize this bunch of nerdy, smart people who have NO VESTED INTERESTS. And there must be no politicians allowed. They unfortunately proven themselves over 10 years to be incapable of rising above the politics and think of Australia’s long term future. We don’t need politicians. Shane Fitzsimmons has shown himself to be a real leader, but we need him to stay where he is.

But I bet there are many many ‘Shane Fitzsimmons’ out there. Clever, calm leaders who can work this mess out. And there can’t be any financial constraints on this battle- there wouldn’t be if it was war- the generals would say: ‘We need this’ and the politicians would say: ‘Here you go’.

We need health professionals to advise about how to prevent a catastrophic overloading on our already stretched health services. How to get around the calamitous air quality? What will our future be like if we are forced to stop exercising outside because the putrid air is dangerous to inhale? How will our children enjoy their childhood if they are locked inside – never allowed to breathe the air outside, run and skip and play with gay abandon.

What do you think the people who have been affected so horrifically by these fires would think about this idea? I believe they would be relieved, heartened, grateful, excited that something was finally happening and did I say relieved? Very relieved….

Did you know there is actually a Fire Centre in the Uni of Tasmania? The Director is David Bowman (a fire scientist).

Professor David Bowman

He says that climate change and weather driven processes have to be confronted. We have to stop allowing politicians attempting to distract us from where the real action is- the fact is the bush is drying out and the weather is hotter and there’s danger ahead and we have to get on top of it. And it is driven by humans.  Trying to frame these recent fires as criminality is just plain wrong- pathological lighting of fires is very small percentage of fires. Lightning strikes and lightning from within the fires themselves cause the majority of fires.

Why do I keep writing out of my scope? Why do I keep bleating on about this issue? ** Because it affects us all and is life-changing!

Will this little boy ever be the same? The day he drove the boat with his family in it away from the cataclysmic fires at Mallacoota will be etched on his brain forever. He’s about three years older than my grandson. What a nightmare for him.

PHOTO: Allison Marion took this photo of her son Finn as they joined the exodus from Mallacoota

If this isn’t an emergency…… well I don’t know what is. The army evacuating Mallacoota residents, January 2020

What should we want as citizens of Australia?

Real action by our Government. Set up a think tank and fund it with our surplus. We are losing BILLIONS AND BILLIONS of dollars ($$$) in tourist dollars, let alone the dreadful damage to houses, infrastructure and our citizens’ lives by not addressing the elephant in the room #climatechange

We want deeds not words.

And when do we want it? NOW!

(Embrace the future. Let go of the past. It’s ok to change tack. There needs to be immediate establishment of renewable energy industries in coal towns and regions. Give every coal worker a job in renewables. No jobs will be lost. Leave the coal in the ground. And it will be healthier work for the current coal workers. And establish another think tank to sort out the water crisis. And this is another definite politician-free zone. There is something rotten in the water management area of Australia.)

(1) https://www.binnaburralodge.com.au/about/

** And because I want a record for my grandchildren that I cared about their future and I spoke up.

A Merry Christmas and Happy New Year blog in not so merry or happy times

Bush fires Australia 2019   Exhausted volunteer fire fighters 

Everyone knows this has been a terrible spring and summer in Australia for drought and bushfires and to be honest it almost feels disrespectful to those suffering in fire regions to be having fun and relaxing at the beach with the family (like I am) when fire is raging all around the country and people are suffering. The pictures tell the story and I just can’t imagine what it’s like for these families who have had their past erased and their futures plunged into uncertainty by these catastrophic and unprecedented fires.

We all know what it means to be an Australian in tough times – the ANZAC spirit is often quoted – qualities which include endurance, courage, ingenuity, good humour, mateship, being resilient under extreme pressure and having a ‘she’ll be right mate‘ attitude. But sometimes I feel our politicians take advantage of these qualities and quite frankly, these amazingly brave firefighters and just ‘ordinary’ citizens who live in these regions suffering under extremely dangerous and overwhelming conditions, need a break.

The army was called in immediately after unprecedented floods in Brisbane in 2011. I remember saying to my mum who lived on the northside: “Yeronga is literally like a war zone“.

 

The army was immediately ‘deployed’ to all the flood zones

I felt distressed at the damage in my suburb, but relieved and almost guilty at the same time as our house was unaffected by water inundation. The only discomfort we had was we had no power for 5 or 6 days. It was in fact a special family time when we played board games around the camping light and binge-watched a TV series each night on the computer until it died and then we’d recharge it the next day as we had power at my rooms at Highgate Hill. There was only one round-about way into Yeronga and you had to plan your routes if traveling to family members who lived out of the ‘war zone’.

Our shops at the end of our street 2011

There was mud and enormous piles of rubbish built out of the memories and lives of our neighbours; there were helicopters circling overhead; and army trucks and soldiers everywhere pitching in with the ‘mud army’ (other Brisbane residents unaffected by the floods who came out of the woodwork to help their fellow citizens) to get people’s lives back in order.

The famous Brisbane mud army that rose to the challenge the floods created

The council were incredible – getting trucks to remove the rubbish from the streets to a local park area and then magically taken away and then within a week, some order felt like it was restored.

The houses at the end of our street suffered badly- people’s lives exposed wet and muddy on the footpath

I have read where some poor people have endured both floods and bushfires and they have commented that whilst they have lived through devastating floods, these bushfires were much worse, as everything has been completely erased, including the surrounding environment and the animal life that lived there. Worse still they were terrified they could be caught in the fire and burned alive. It was bad enough reading reports of the bushfire residents hearing screaming wildlife as the fires ravaged the landscape.

These survivors of these bushfires must be traumatized.

They have to be suffering psychologically as well as emotionally and financially.

How fortified would they feel if the army arrived to help?

How strengthened would their resolve be if every day on the news they saw their elected representatives travelling the country dishing up food to weary firefighters, shaking their hands and thanking them for their amazing bravery.

But wait- how could they see that? They probably don’t have power due to the fires. They don’t have TVs or living rooms anymore. They don’t have lounge chairs or platters to put their cheeses on.

God how desolate must they feel?

How relieved would they feel if they had a promise from their government that significant financial help will be provided. Personally, I am happy to give up our budget surplus to help these people through these disasters. I’ve taken a poll – all my family agree. They would understand that this is a necessary burden to our economy to give these people some hope for their future. If their villages are rebuilt and they are compensated, this will be a boost to the local economy and the national economy.

These bushfires are wrecking Australia’s bottom line and our brand. They are trashing our reputation as a tourist destination. Getting on top of them quickly and restoring faith in the ability of our leaders to lead is paramount.

It isn’t enough to say Aussies are strong folk. They’ll pick themselves up and get on with life. Whole villages have been decimated. Schools, shops, maybe even physio practices have disappeared off the face of the earth. I can’t imagine what it must be like.

There has been much criticism of the behaviour of our Prime Minister. I expect many Australians are disappointed and many others, directly affected by the fires, are feeling abandoned and others are angry. I think those affected by the fires wish he could walk in their shoes – feel their sense of loss, fear, anxiety and abandonment.

But I think he is conflicted. He has got himself trapped in a corner with nowhere to go because he has made so many strong comments about coal, climate change and the surplus and he has contested opinions about climate change to deal with within his own party about climate change and it’s impact on our environment.

Backed into a corner with nowhere to go

But it is never too late. Don’t feel trapped. It’s OK to change your tone and your opinion in the middle of an argument. People respect you for listening to the science and looking at the evidence that there is much money to be earned in alternatives to coal. It’s OK to leave the coal in the ground and forget about it – forever!

And the fact is – there is no need anymore to actually say: ‘I believe in climate change’.

It’s like saying I now believe the Earth is not flat!  Believe it or not there was actually a time when the belief was that the Earth was indeed flat. Our children may not have heard that fact – the fact being that there was a time when the inhabitants of Earth thought it was flat. It sounds ridiculous now doesn’t it?

And this is what will be said in years to come about climate change. Since the seventies, scientists and vested interests in coal production have known about the effect of carbon emissions on the warming of the climate. The link below is to an excellent short video from Dr Karl that I commend to you to listen to.

Dr Karl – Do you believe in climate change?

I have always believed there are some things that should be exempt from government decision-making. And the impact and effect of climate change on the Australian natural environment and the potential future extinction of so many native animals, insects and amazing natural wonders like the Great Barrier Reef, should definitely make the list.

It should be left to an expert panel of climate scientists, farmers, economists, innovators, business leaders, researchers and experienced negotiators and mediators. It must be represented equally in gender. Get the brain storming going. Lock the doors until they sort it out.

The plan must have strong parameters:

The coal towns must be promised that every job in coal will be replaced with viable work in renewables and other industries which will be created. (We don’t even know what these things will be – they are still trapped in the innovative, clever brains of our scientists waiting for research funding from the government).

The farmers have to be consulted and listened to. They are at the coalface of climate change.

First nations peoples must be involved. Their skills in managing the Australian bush must be utilized. They know the land and the bush.

Why not utilize the manpower left abandoned on Manus Island. I am sure they would relish the opportunity to show that they can be useful members of our Australian community.

Let’s think out of the box. Let’s go off tangent. Let’s declare any vested interests and leave those people out of the decision-making.

And why you might ask is a pelvic health physio writing this blog?

Because I am a health professional who sees the burden of our changing climate on our health and fears for the effect of the smoke and pollutants on the respiratory system of those with asthma, bronchiectasis, chronic hayfever and other similar conditions. All that coughing and sneezing -it is a serious problem for pelvic floors believe me! I worry about a time when we may not be able to exercise outdoors anymore and the deleterious effect on our health – compromised cardio-vascular system, diminished brain health and bone density to name a few.

I am a grandmother who wonders what the future will bring for my children and grandchildren. What will be the extent of species extinction?

I am a citizen of the world and we are a part of the global community, not isolated and disrespectful of other countries and communities.

Because I write a blog and therefore I can.

But I hope it will open a dialogue, not shut down conversation or cause discontent. We must take this scary ‘new normal’ seriously.

Most importantly, I want to know when I am 90 and look back at what I have thought about or how I have acted on this climate emergency in 2019, that I didn’t choose to not ruffle feathers or upset friends, relatives or the public by saying nothing. I will know that I have tried to make a difference beyond my own individual choices such as plastic use, choosing to reuse, recycle or reduce and other ways to reduce our carbon footprint.

#climatechangeisreal

#theearthisnotflat

#believethescience

Merry Christmas and a Happy New Year and may our new decade bring us new direction and strong effective governance.

Here’s a great pelvic floor friendly exercise: Walking netball? Yes really!

Ladies playing Walking Netball 

Recently I had a patient who, when I asked about her exercise that she is currently doing or would like to do, told me about Walking Netball!?!  Now we are a netball family and in all my years sitting around netball courts, I have never heard about it. I actually couldn’t imagine such a thing and then if there were such a thing, how would it really work? This patient wrote a little paragraph about it and then to my surprise (or is it that Facebook and Instagram have a wifi link to my brain waves -see Years and Years on SBS – a great, but rather worrying show with Emma Thompson about our future) walking netball posts started to appear in my feed…..

Here is a image of the amount of activity someone on Instagram posted the very next day that her Fitbit recorded while she was playing walking netball. Looks like a lot of moving.

Here is my patient’s paragraph.

My friend Sue had been asking me to join Walking Netball.  When younger (much) I played basketball and thought that the Walking Netball would be a bit tame. Well, I was ‘hooked’ from my first game.  Actually I was exhausted, but soon built up fitness.

Special rules apply – NO RUNNING – NO JUMPING – NO DEFENDING UP CLOSE.  If off balance, bounce the ball or take a step. Be aware of players with a disability and help newcomers. The objective is to provide exercise while being aware of creating a safe environment.

I felt welcome from the first game and soon was part of a great group of ladies.

Thanks for sending this in JS and I hope my pelvic health colleagues will remember this when offering pelvic floor friendly sports and activities to their patients who have significant pelvic floor compromise and need to modify their exercise. When I checked out Netball Queensland about walking netball, this was on the site and seemed appropriate to lots of things in life.

“The hardest part about Walking Netball is being brave enough to walk through the door, but once you do, you will be welcomed by lots of smiles and a bunch of new friends. I encourage people of all ages to come and try Walking Netball.”  Rhonda Newton, Walking Netball Coordinator, Netball Qld 

Some links:

Netball Qld Walking Netball

Netball NSW Walking Netball

 

A patient story – a holistic approach to managing urinary frequency, urgency and urge incontinence (also known as the Overactive Bladder)

Treating Overactive Bladder problems involves many strategies – I liken it to the many slices in a big apple pie.

I recently saw a patient who was at her wits’ end with her urge urinary incontinence – one of the symptoms of a condition called the Overactive Bladder (OAB). The other symptoms are urinary frequency, urgency and nocturia. She had tried physiotherapy and medication and came reluctantly to see me because her urogynaecologist had insisted she come. When patients come to see me and they say they have had physio, I always make them sit through the education again, because the most important part of what pelvic health physios do each day is educate the patient in an easy-to-understand way about the pathophysiology of their condition.

I find that often patients ‘hear’ the education the first time from their therapist and they sometimes are not quite ‘listening‘- it sounds like a lot of words that involve them making changes to long-held behaviours and beliefs and so they inadvertently switch off. So it isn’t that the first physio isn’t doing the right thing – it could be that the patient wasn’t ready to hear it. The second time around, with some emphasis on the importance of self-empowerment, patients are often more receptive and ready to ‘run’ with their treatment programme.

So here is T’s patient story. Thank you for your thoughts T – everyone learns from patient stories.

As you know, I had already been dealing with this incontinence for three years before my first consultation. I had tried several medications as well as physiotherapy, but could not seem to get on top of it.  I saw no light at the end of the tunnel. After our first treatment session, I decided I needed a more pro-active attitude and I had a clearer vision of what I needed to do myself to help fix this problem and I understood more about this condition which helped me plan a path ahead.

I started with the exercises you gave me (** see below) and went back on the Betmiga 25mg at night. By taking the medication at night I started getting a better nights sleep for one thing, as I was getting up several times a night. I had previously been given Endep for night-time, but found I was too tired the next day to do anything. 

I then started walking because I had more energy, so I was walking four kilometres a day. That meant I started losing weight and pretty soon six kilos dropped off over 3 months!  

During this process I looked at what food and drinks were triggers for my condition. I was amazed to discover things like a vitamin C tablet would cause me want to visit the toilet more. I gave up coffee and tea, and even the decaf. I stopped eating anything with caffeine in it, especially chocolate. I also never touch alcohol or carbonated drinks, as they are huge triggers for me as well as any citrus fruits drinks.

I started drinking more water and concocted my own version of a healthy drink each morning to start the day with.  The more I drank the less I actually felt that urge not the opposite, so I no longer had those trips to the toilet that produced 50mls! 

I also use my TENS machine every day.

Image from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730708/

I still wear a liner when I leave the house but no longer need thick pads. When I’m just at home I don’t wear anything which is amazing. Another side effect of all this is my bowel works more regularly and I’m never constipated anymore! 

I know I’ll always have to do the work and keep to my list of ‘can’t haves” but it’s worth it to have a lifestyle free from stress and worry about my bladder condition.

I now can see how by taking control myself and attacking the problem from several angles my life has changed so much since my first visit.

Thanks T. A nice inspirational summary for other women (and men) suffering with overactive bladder (OAB) symptoms. You can see why patients can be reluctant to fully embrace a programme because -as for T- there can be a lot of ‘nice’ things in life that may be provoking the bladder.

(**) The exercises I gave T were urge deferral using urge control strategies, pelvic floor exercises including relaxing the PF and abdominal muscles and the breathing exercises to help her stay calm for when the urge suddenly arrived.

T also had been offered another treatment by her specialist and asked me about the research results on success with this treatment (stimulating the posterior tibial nerve with a needle). She wanted to know this because it was quite a commitment (number of visits to the specialist rooms) and quite expensive ($200 per treatment but it is reimbursed quite handsomely by Medicare. A TENS unit costs around $70-$100 plus the visit to the physio but then you continue at home with the treatment yourself).

When I looked at the research for T, the needle stimulation of the posterior tibial nerve results were similar to the application of the external sticky electrode with the TENS machine. Studies suggest applying the TENS electrodes over the posterior tibial nerve (this technique is called TTNS) daily for 20-30 minutes and this has a positive impact within 4-6 weeks on bladder holding capacity. TTNS has minimal side effects and it is safe for the large majority of people to implement.

If you have these issues and are feeling despondent with your OAB then get your notes out from your physio and revise them or you can purchase my book for $20 plus postage as a little Xmas present for yourself. Think of all the extra savings you may have from not requiring such thick pads anymore!

Electrotherapy for urinary retention (NOUR)

The following blog is from one of my physios Martine Lange who attended a brilliant course run by Fiona Rogers, who is a pelvic health physiotherapist who owns an online pelvic health supplies business called Pelvic Floor Exercise. Fiona has been taking her one day course around Australia this year and is on the road next year to New Zealand and the UK. If you are a physiotherapist working in pelvic health I strongly recommend this course to you for its completeness and evidence base.

Non-obstructive urinary retention (NOUR), when it doesn’t respond simply to positional adjustment (see below), can be frustrating for therapists to treat and patients to live with, as it can often mean recurrent urinary tract infections and urinary frequency.

Position for voiding from Pelvic Floor Essentials (2018) by Sue Croft

Martine undertook Fiona’s course in July 2019 and immediately had a patient with this condition and had great success with implementing this treatment strategy as you can see in her account following.

TENS unit (image from Pelvic Floor Exercise online website)

The TENS (Trans-cutaneous Electrical Nerve Stimulation) machine has been used for years as a treatment for different aches and pains, in particular lower back pain. However, research is mounting that the humble TENS machine may actually be a viable treatment option for a number of bladder conditions such as OAB, persistent pelvic pain conditions (bladder pain syndrome, vestibulodynia, male pelvic pain), obstetric labour, faecal incontinence, period pain (primary dysmenorrhea) and what today’s blog is about which is non-obstructive urinary retention (NOUR).

NOUR refers to incomplete emptying of the bladder without any physical blockage. Often the reason for incomplete emptying maybe muscular (maybe the pelvic floor muscles or urethral sphincter muscles do not relax well) or it could be related to other conditions in the area, such as lichen sclerosus or lichen planus, cystitis, post-partum or post-operative complications.

The TENS machine is a small hand held device that emits an electrical current via 2-4 sticky electrodes which are attached to the skin. The sensation is of a tingling/ pins and needles type of feeling when it’s turned on. The machine is able to be adjusted in both frequency and intensity so that it gives a strong but comfortable sensation. This sensation tends to be calming for the nerves being stimulated, thus reducing both pain as well as reducing over-activity of the target nerves. Whilst we are not sure on exactly the mechanism of action of the neural stimulation, research does seem to indicate both a local effect on the organs and peripheral nerves as well as a central effect in the brain.

Using the TENS machine over the nerves that also supply the bladder and pelvic floor muscles has been demonstrated to improve symptoms of OAB (overactive bladder), BPS (bladder pain syndrome) as well as NOUR. The TENS electrodes are positioned to stimulate the posterior tibial nerve down near the ankle (this has a neuro-modulatory effect on the bladder and pelvic floor as they have the same spinal origin).

Image from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730708/

Most studies suggest applying the TENS electrodes over the posterior tibial nerve (this technique is called TTNS) daily for 20-30 minutes has a positive impact within 4-6 weeks on bladder emptying, holding capacity, as well as on pain. TTNS has minimal side effects and it is safe for the large majority of people to implement.

As a case example I have a 40-year-old female patient with a 3-year history of urinary retention who had tried many things including urethral dilatation, self-catheterisation, bladder stimulating machines and correct bladder emptying positions. After a 4-week trial of TTNS she had halved her urinary retention volume and reduced her urinary frequency. After 10 weeks whilst she still felt somewhat incomplete in emptying, in clinic she actually had no residual volume on emptying.

It is important if you do have urinary retention, that it is properly investigated to rule out obstructive causes. Once that is given the all-clear, it is possible to start management such as correct position for bladder / bowel emptying, knowledge and understanding of good bladder habits, good pelvic floor muscle coordination and if they have not resolved the retention we can utilize TTNS to speed up the recovery process.

Thanks Martine – a great summary for us to remember and also thanks to Fiona Rogers for her great course and online shop.

As we head towards Christmas, and we have raging bush fires in Australia – consider purchasing Christmas presents from sites that support regional areas in Australia. The hashtag #buyfromthebush will find you lots of regional Australian businesses that are often supplementing the income of primary producers, so if you need some presents think about supporting these businesses. https://www.instagram.com/buyfromthebush/

Another useful Christmas present, particularly for women (even if I do say so myself) are either of my books – Pelvic Floor Essentials (if you haven’t had any surgery) and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery. You can purchase my books from my website Pelvic Floor Recovery books .

Another fantastic Christmas present is to do something altruistic and kind by donating to HADA – a charity which supports the wonderful fistula and prolapse repair work that Professor Judtih Goh and Dr Hannah Krause are undertaking in Africa every 3 months. The link is here. 

The forgotten pessary

I love pessaries for prolapse management. I wear a pessary for my own prolapse (perhaps oversharing a bit there) and fitting pessaries have been a great adjunct to all the other things (pelvic floor muscle training, engaging your PF muscles prior to increases in intra-abdominal pressure, lifestyle changes, excellent bowel management -correct position, defaecation dynamics and a Goldilocks consistency bowel motion – not too soft, not too hard, but just right) that we pelvic health physios teach to patients to empower them to keep everything where it should be while they are exercising or to support their prolapse.

There has been an explosion of talk on social media about pessaries in recent times. The beauty of that is that whereas only a couple of years ago barely anyone nobody knew what a pessary was, now every patient who has prolapse seems to have read about them already and they are asking would a pessary help them? The problem with that is that sometimes the girls who may benefit most from wearing a pessary, because they have suffered a serious muscle injury at childbirth (called levator avulsion), are the ones who can be difficult to fit with a pessary because of that significant injury, but it is definitely worth trying.

Illustration showing a levator avulsion injury

It can take multiple attempts with different styles/sizes of pessaries and this can be frustrating and disappointing for the patients. Persistence and perseverance is important with pessaries. Sometimes if you wear one type of pessary for a while and you are doing all those treatment strategies I outlined above, the prolapse can actually improve sufficiently to then mean a less bulky pessary or smaller sized pessary can be fitted.

But a warning: Pessaries need to be taken seriously.

There are rules that need to be adhered to. You need to follow the instructions of your treating pelvic health physiotherapist.

  • These include regularly taking the pessary out to rest the vaginal tissue if you have been fitted with a silicone self-managing pessary. The length of time depends on the type of pessary and the status of the patient’s vaginal tissue. For some women it may be every night; others every second night; some every seven nights and for the Gynaecologic pessary – they have just received TGA approval to be left in for 28 days before needing removal.
  • The pessary needs to be washed once it is removed in a liquid soap and dried and stored in some type of plastic container with a lid while it is out (we have had a spate recently of dogs discovering the pessary on a side table and chewing it to bits – which is definitely not good for the dog if they ingest it and is an expensive toy for the dog).
  • The pessary must be replaced every 12 months (this is the manufacturer’s advice and must be followed).
  • If the patient has self-referred rather than being sent by a medical practitioner, they need to see their GP for a speculum check and bi-manual examination as soon as possible after being fitted with a pessary and return yearly to their GP for a speculum check.
  • They must return for an appointment with their treating physio at between 2 weeks to 4 weeks after fitting to make sure all is going well and then yearly to get their replacement pessary and a check of their muscles, bowels, bladder function and general exercise programme.
  • It is important to continue with all the conservative strategies as mentioned above (especially pelvic floor muscle training and the knack so you maintain good strength in your muscles, especially if you eventually have to have surgery).
  • While it can be normal that the pessary causes increased vaginal discharge, you must visit your GP if there is bloody discharge (obviously not if it is a period) or smelly discharge as there may be an infection (bacterial vaginosis).
  • If you are menopausal you should discuss the use of local oestrogen with your GP as the risk of vaginal tissue erosion is increased with a pessary (which is why you require a regular yearly speculum check with your GP or a gynaecologist or urogynaecologist).
  • At our practice we get you to read our instruction sheet explaining all about the pessary and with all the above precautions and then get you to sign the form saying you understand about some critical factors (the new pessary 12 monthly, the speculum check 12 monthly and seeing your GP if there is blood or smelly discharge) and you will stick to those rules.
  • We also keep a log of all pessaries that we fit at the practice. We now attempt to audit the log every year to help our patients remember to come back and to remember to get a new one yearly. This is why you may get a call from our secretaries prompting you to return as there can be some significant issues if you don’t.

When a pessary fits well, it can be very easy to forget about it and it is for this reason that I have written this blog. The forgotten pessary is concerning. This is one reason why a patient who has dementia can only be fitted with a pessary if they have a designated carer who is taking them to a doctor 4-6 monthly for a pessary check, removal, wash, speculum check and re-insertion. This type of pessary is a PVC one (rigid pessary) and can stay in for longer periods of time and not usually removed by the patient (some younger women are able to self-manage a rigid pessary themselves and therefore it can be taken out and washed in a similar manner to the silicone ones).

Lately some incidents with pessaries have prompted me to write this blog.

The first one involves a lady who had her first pessary fitted in 2011 and who returned in 2014 for her next replacement one (but still had her old one at home). She unfortunately went on for the next few years using the pessary, not taking it in and out as often as she should have and forgetting about the important rules (this was before we instituted a regular audit). Sometime in these ensuing years this lady has found the original pessary and thought she didn’t have a pessary in and put this pessary in. Recently the patient rang up needing an urgent appointment because she felt uncomfortable and thought her pessary was no longer holding her prolapse, as she had heaviness, discomfort and drag. I was overseas at the time and despite there being other physios at my practice who could see her, she elected to wait for me to return. By the time I saw her, she no longer had the severe discomfort but definitely knew she needed a new pessary so arrived at the appointment.

After a chat about her history (and then a reminder about how important it was in future to definitely come yearly to get a new pessary), I examined her and found she actually had two pessaries in. The drag and heaviness she had experienced was probably an episode of bacterial vaginosis, which her body had been able to sort out itself (well done body), because those symptoms had completely resolved. We were both pretty shocked and I made her an urgent appointment at her GP who performed a speculum check and thank goodness gave her the all clear. This can so easily happen because a good fitting pessary can’t be felt and is too easily forgotten sometimes! I told her that I would like to write a blog about this because it would be a good learning blog for other patients and she consented to me telling this story.

The second event was a GP rang asking me to see a patient who had a cube pessary in, which had been fitted by a doctor, but the patient had not been removing it at all, had not returned for a new one and it was now disintegrating. The GP removed the pessary, the lady is starting on local oestrogen and then in a few weeks time she will be coming to be fitted for a new pessary and perhaps a different type of pessary from a cube.

So the moral of the story?

Take your pessary seriously.

Be vigilant about the rules.

Be aware of how long you have had your pessary in and how long you have owned it.

See the practitioner who inserted the pessary yearly for renewal and a revision of all the important conservative strategies and have a yearly speculum check with your GP or specialist.

Put reminders in your phone and a good idea can even be gradually moving the date of your renewal closer towards your birthday so you can more easily remember it if that is a problem for you.

And here are some reminders of what a pessary may allow you to do exercise wise.

Sue hiking at The Matterhorn Paradise Glacier Trail 2019

  

Yoga class at my old studio  Jane Cannan finishing her first marathon

Photos kindly supplied by Nadine Brown, Pelvic Health Physio who loves boxing

 

 

Listening through all the noise of life

Life is very busy these days. Thanks to the internet we can fit in about twice as much as we used to be able to do, but still feel guilty about what we haven’t done. Busyness makes us exhausted and also means we don’t prioritize our own self-care. We literally stop listening to our bodies!

We let things like sleep slip – going to bed to late, going to bed with a busy brain and being too tired to get up and write that amazing idea down which then means you lie awake hoping it will be locked into your memory, which further delays sleep and of course you wake in the morning oblivious to that amazing thought.

We can’t find time to shop for healthy food, so we eat on the run and often too much of the inflammatory foods like sugars which then make us feel terrible (and probably result in unwanted weight gain).

We are often dealing with family stresses and pressures and this can result in a sympathetic nervous system which is chronically switched on releasing adrenaline and cortisol which are detrimental to our body’s metabolism.

We never get to play and have fun – we have to say no to a movie night or the simple pleasure of reading a novel because the housework has to be tackled because we are working so hard through the day

We never get time to feel bored and just do nothing which is a useful activity to let the brain and body regenerate and relax.

We let things like general exercise slip which is critical for maintaining good muscle mass, bone density, cardio-vascular fitness and good brain health.

We don’t prioritize specific exercises such as our pelvic floor exercises or pelvic floor relaxation exercises or pelvic stretches whatever may be required to help any pelvic health problems we may have.

So take some time to listen to your body, hear what it’s saying.

Do you have trouble getting to sleep, staying asleep or do you snore? The answer is to review your caffeine intake (caffeine is a stimulant and can affect your ability to get off to sleep); seek help from a sleep physician who will assess whether sleep apnoea is contributing to your sleep issues; have a notebook and pen beside your bed to write down that amazing idea; and assess what best sends you off to sleep – is it reading a light novel or is it using your phone. Whilst many advise not using screen time in bed, for many it is a way to get tired and fall asleep – after all for many this is their new way of reading.

Getting ready for my sleep apnoea test

Do you feel sluggish including with your bowels? The answer is find the time to buy healthy foods, prepare in a healthy way and cut down on the inflammatory foods – biscuits, chocolates, soft drinks and alcohol. Treat your body like a temple and worship fresh, whole foods, simple foods not fast foods. Add fibre to your diet and use the correct positioning and dynamics for defaecation to evacuate completely and without effort.

 

Bowel evacuation position and baked eggplant with humus and pomegranate

Do you have too many thoughts and no idea as to how to sort them out? With regard to stresses and pressures – ‘control the controllables’ (1). There are some things that are under your control – like many listed here in this blog, but there are many that are reliant on the actions of others and are out of your control and these are the ones that are often the cause of the constant release of cortisol and adrenaline that actually stuff up your (calm, clear) thinking. Write lists of things you can do that may help the things out of your control, but come to terms with the reality that many times others have agendas that you could never predict and there is no solution at the present moment. Try not to dwell unduly because this is having an effect on your health – particularly your mental health.

Always schedule some play and fun as this is the way into your parasympathetic nervous system which helps to release the calming hormones of dopamine, oxytocin and serotonin. If you are twenty something it might mean a coffee date with some girlfriends or (safely) jumping off some rocks; if you are thirty something with kids it might mean a date night with your partner (and no kids); if you are fifty something it might mean discovering the joy of hiking in the mountains; if you are sixty something it might mean minding the grandchildren and totally immersing yourself in their conversations and delightful innocence that is so rare to see in grown-up life. And if you are seventy something it may be joining a club (bridge, bowls, book) and having that regular commitment out of the house. If you are older, it doesn’t mean you don’t get to enjoy pleasures – it often means your pleasures are simpler, but you must never stop trying to pursue them.

Some twenty and thirty somethings having some fun and play

 

Hiking and grandchildren – the joys of the fifties and sixties

And as for feeling bored and just doing nothing (without guilt) that is a tricky one- particularly if you are a woman, we seemed to be wired to use every moment, of every day, otherwise we feel like we are wasting time. But it is a skill I have no answers for because this is my biggest hurdle.

Do you have stiffness when you wake in the morning? The answer is keep moving and move more – not resting more and sitting more. Explore ways to fit in incidental exercise. Expand your horizons with exercise – think about new things to try that you feel are beyond you. Seek help from those who are trained in that activity to achieve your new goal or return to a much-loved pursuit after an injury or a birth. Remember, you are never too old/stiff/immobile/weak to start moving again.

 

Dance is a great new activity/exercise to start

Do you forget to do your specific exercises – such as pelvic floor muscle training (PFMT), pelvic floor muscle relaxation or pelvic nerve stretches? If you start leaking urine again, recommence your exercise and behavioural modification programme to get you back on track; if you feel pain return – acknowledge it, be proactive with the strategies that helped your pain before and then let go of any fear about the pain. 

What that equates to is listening to your body through all the noise of living.

The hardest thing in life is being consistent with things – whether it’s eating healthy, sleep hygiene or commitment to an exercise programme. And sometimes your body is literally yelling at you, but you are not listening. You are using band-aid measures to keep stopping up the gaps and making do, whereas if you truly stopped and paid attention and implemented things that you have learnt, your body would respond and repair and revitalize and renew.

So if you can relate to some things in this blog, take the opportunity to assess what changes you can make and little steps – introduce them one at a time.

Post-script:

The idea for this blog came from two places. One was a lady who virtually announced to me the framework of the blog. She was doing well, then she got busy. She knew there were things going wrong, “her body was yelling at her”, but she felt she was too busy to do what was required of her (do her exercises, sleep better, eat better, exercise regularly etc etc). And so she made an appointment to come back so I could tell her (what she actually knew, but it made her accountable to someone which she said she needed).

The second one was from a segment on The Drum, an ABC Current Affairs show at 6pm weeknights about a new book called The Woman Who Cracked the Anxiety Code: the Extraordinary Life of Dr Claire Weekes by Judith Hoare.  This new book about this amazing doctor, Claire Weekes, highlights her life and that she was perhaps the mother of Acceptance therapy – ACT which stands for Acceptance Commitment Therapy. She herself had problems with heart palpitations which she took years to understand what was causing them. If you read the link to the article you can understand more of the history.

When she ceased engaging so intensely with her symptoms, her heartbeat returned to normal.The keyword was “acceptance”.The turnaround was swift. If Weekes had been devastated by her lack of understanding of what ailed her, she now felt exhilarated, liberated by an explanation from what had been incomprehensible suffering. With this new understanding, she regained control. Here she learnt that panic and anxiety played a medley of dissonant bodily tunes, from breathing, swallowing and digestive difficulties to headaches, dizziness and muscle fatigue among many others. Weekes’ treatment protocol was just six words: face, accept, float, let time pass. She had a gift for discerning the relationship between the mind and the body – what was clinical illness and what were symptoms driven by fear and anxiety. Understanding fear and its relationship to physical illness had become a mission.” Read the rest of this edited extract from The Woman Who Cracked the Anxiety Code: the Extraordinary Life of Dr Claire Weekes by Judith Hoare (Scribe, $40), out October 1 in the link above.

Bob off to crack the macadamias with his followers (Great Gma’s grass has turned brown during our Brisbane ‘winter’)

(1) Many thanks to Michelle Lyons for this – I am not sure where she got it from.

Sicily, Scopello and The Tuna Factory

The iconic Tuna Factory at Scopello, Sicily

This is the last installment in my travel blogs about our trip to catch up with our children who live in London. This last weekend was in Scopello, Sicily. Bob and I first of all left Geneva (after the train trip from Zermatt) and flew into Palermo, hired a car and then headed off to look around Sicily for a few days before the kids arrived on Thursday at Scopello. A heads up about car hire in Sicily. I have established three essential rules.

  1. Never hire from a big name company (Hertz, Europe Hire, Avis etc) because the queues at Palermo Airport for those companies were ENORMOUS. We hired from Italy Car Rentals and there was no queue, the car hire rate was cheaper and the car was fine.
  2. ALWAYS, ALWAYS, ALWAYS pay the added amount each day to have zero dollars excess because it is virtually impossible to not have some car damage in Sicily because of the narrow roads, very tight parking and (crazy) Italian drivers. We had to get our car parked for us at one hotel in Castelmola and the car got brought back to us with a new scrape but as we had paid the extra charge we could relax and not worry.
  3. As from the previous blog, always use a normal credit card for any deposit or car hire charge rather than a debit card or cash travel card otherwise you will have the full amount deducted and your real money will be unable to be accessed.

The first town we headed to was Agrigento, the Valley of the Temples. It was strikingly arid, poor and there was garbage dumped literally everywhere and anywhere by the side of the roads on the drive down to Agrigento.

Extraordinary the way all freeway pullover spots are dumping grounds for rubbish!

On the way to Agrigento we called in at a natural wonder called the Turkish Steps or Scala dei Turchi. The photos do not do it justice.

This is a rocky cliff on the coast of Realmonte in Southern Sicily. The steps are formed by marl, a sedimentary rock with a characteristic white colour and there is a beach area close, with a restaurant with an amazing view to the steps. Here we had a beautiful Italian lunch with a view to die for and the food was pretty good also.

   

Lumie di Sicilia Ristorante, Turkish Steps

Beautiful seafood dishes

We then drove onto Agrigento and seeing the magnificent Greek temples in very good condition was certainly worthwhile and if you go late in the afternoon, then you see a glorious sunset with the temples and ruins lit up at night, which gives a hauntingly beautiful aspect to the scene.

 

Statue of Zeus              Archaeological Site of Agrigento

View from our hotel in Agrigento with a view of the Valley of the Temples

The next day we headed to a very small village called Castelmola perched high on the mountain above Taormina. We had originally planned to stay at Taormina, but we were worried about the terrible parking situation in there and so changed to the elevated village of Castelmola. It was such a good move. It was peaceful and quiet and with spectacular views across to Mt Etna and the hills beside.

Castelmola perched above Taormina The long walk down passing some quaint buildings

The first day we walked down from Castelmola to Taormina down hundreds of steps. My quads were definitely shaking by the end of the walk. We explored the village, checked out the pottery shops and had a lemon granita and generally we were so relieved that we could escape back up to the quiet of Castelmola at the end of the day.

   

View to beaches from Taormina Botanical Gardens and a cute alleyway in Taormina

Lemon Granita was delicious A statue in the Taormina Botanical Gardens which encapsulated me at the end of each day

We caught the local bus back up there for 1.8 euro and admired the spectacular view from the bus on the winding trip. Our room in Castelmola had a beautiful view of Mt Etna which had been obscured by cloud all day but then suddenly at midnight she revealed herself and gave a special display, which we later heard did not happen all of the time!

   

After the cloud hiding the top of Mt Etna lifted at midnight the fiery display was revealed 

The following day we saw the beauty of Mt Etna for the first time.

 

Mt Etna and a panorama of the rolling hills opposite Castelmola from Hotel Villa Sonia 

The next day we caught the local bus to the funicular in Taormina to take us down to a beach below called Isola Bella. There are a number of beaches along the coastline, but our hotel had an arrangement with the place we chose, so the beach lounge and umbrella were 10 euros each for the day. There is a cafe with food and drinks which were very reasonably priced and there’s something special about walking up to bar and ordering food and drinks and especially more granita and then lying back on a lounge to read a book.

This is a typical rocky beach which really requires special plastic rock walkers to enable beach walking or swimming without looking ridiculous and suffering enormous pain. Unfortunately I didn’t see the guy selling them for 5 euros until we left the beach, but I bought a pair for the next stage of our holiday at Scopello which also has only rocky beaches.

Scopello was our final destination in Sicily and we saved the best for last. Its a tiny village with the BEST town square where you could easily stay for a month and just relax and do nothing. When you buy drinks at the bar above, the lovely waiter brings you ‘presents’ of free food and I’m not talking about a bowl of chips but delicious slices of pizza, calzone and yes there were some chips. In the afternoon after a long, hot day walking to and from the beach, the square is in deep shade and the big comfy lounge chairs just swallowed you up.

 

The bar which was so enticing and Jimmy and Mike kicking back at the end of the day.

The place we stayed at Scopello was Pensione Tranchina and my daughter had stayed twice before and had been raving about the hospitality and especially about the beautiful breakfasts. Marisin Tranchina (the owner) greeted us like we were family and as we arrived before Sophie it was very special. She guided us to our room (which she called Sophie and Jimmy’s room – thanks Soph for making the ultimate sacrifice) and it did have a verandah with a view to die for and was spacious and extremely comfortable.

Sue, Marisin and Sophie outside the beautiful Pensione Tranchina and the view from our room

The breakfast was all fresh produce grown or produced by locals – honey and fresh ricotta, sour dough bread baked on the premises, juiced fruits of all types and home-made jams and cakes. Yum. Marisin also has a five course dinner available at night where you start with a welcome wine outside the front door of the Pensione and meet the other guests and then move in to eat a seafood feast. They also cater for vegetarians and we all were very well fed that night.

Seafood feast about to be devoured

Fortunately there are kilometers to be walked before the beaches are accessed, so many calories are burnt during the day, allowing not only for enormous meals to be consumed, but also many gelatis.

A little bit of magic at Scopello

Matching Budgie Smugglers at Scopello and a pair of daredevils in Budgies

We walked the National Park the next day and it was hot (searingly hot) and I almost threw in the towel and gave up, but thank goodness we reached a beach and I staggered down and fell in the amazing water and revived myself enough to continue the rest of the day’s walking. The coastline is rugged and spectacular, but I have to say I will never whinge about the climb up from Sunshine Beach again after the hills of Scopello.

We bid Marisin and Pensione Tranchina farewell and drove off to a small village called Erice – an historic town in the province of Trapani in Sicily – to fill in some time before the airport and we were lucky enough to chance upon some time trials for racing cars at the top. People may have planned for 12 months to make sure they made this event and sometimes when you are travelling you come across these priceless moments.

 

Erice racing car time trials

After the excitement of the racing cars (and traversing the extreeemely narrow roads up and down the mountain, we arrived at the airport to go our separate ways. Airport farewells are always sad, but we were so lucky to have had some precious time with our kids and cherished every moment. Facetime, Whatsapp, Messenger and Skype calls allow us to see our faraway loved ones (for free) but they haven’t mastered the feel of a hug and that’s why we spend their inheritance and travel for 24 hours to see them. Hugs are special and irreplaceable.

So ends our 2019 trip. Now it’s back to bladders, bowels and the like and dreams of 2020.

View from the rooftop garden of our Rome hotel (which made up for the stinky bathroom and kitchen)

 

 

 

 

 

The elusive Matterhorn

As promised, there has been plenty of holiday spam and today’s blog is no exception. It’s hard to play catch-up with writing when you are partying every night with your close family (living distant), so I am here is Rome writing in the dark, staring at this beautiful coppola to play catch up with my writing for the last couple of weeks so I don’t forget this beautiful holiday.

The view of the Mausoleum of Augusta, Rome from the rooftop veranda of our accommodation

So back-tracking to the beginning of September, the next set of mountains after Ortisei were the mountains surrounding Zermatt including the (elusive) distinctive Matterhorn, used by a much-loved chocolate as its inspiration. I am of course talking about Toblerone and while we consumed plenty of it while we were visiting, the weather precluded the obvious gag-photo but we tried.

Zermatt is a lovely village which is car-free with only small electric vehicles allowed in the streets of the town.

We had a change of weather after some brilliant sunny weather in The Odle Mountains and despite having a room with normally a perfect Matterhorn view, it was unfortunately shrouded in cloud for most of the weekend we were there and we only caught the glimpse below of the majesty of The Matterhorn one evening at 7pm. It was very exciting.

The Matterhorn peaking out from behind the clouds

On our first afternoon after arriving via train, we caught the gondola up to Furi to see the Hanging Bridge – a suspension bridge which I very bravely walked over. (I have a terrible fear of heights and especially when there are holes in the walking bit and rushing water underneath). We walked down to Zermatt in light rain which was not unpleasant and the walk was through beautiful forests.

Prior to arriving in Switzerland we had purchased a Swiss Rail Pass which entitles you to half price tickets on all the gondolas and trains, but they are still very expensive, especially with our (rubbish) dollar at the moment. But honestly we ate at The Co-op (a grocery store where we bought delicious BBQ chicken and salad for 10 CHF) so we could spend the money on the gondolas and rail trips because that’s what is so beautiful about Switzerland – seeing the mountains so very close up.

The second day we caught the Matterhorn Glacier Paradise Gondola up to the top – and like so often in the Alps we got to the top and there was a collective gasp from the 10 or so people in the gondola as we saw the panorama at the top – a ring of spectacular snow-clad mountains and then just as quickly (or before I could whip the phone out and catch the photo of it) it was shrouded in clouds.

After the obligatory hot chocolate at the top, we caught another gondola back down to Trockener Steg and then walked down the Matterhorn Glacier Trail to Schwarzsee. This was a huge walk (with lots of up as well as down) but the magnificence of the mountains surrounding was so worth the hard work of hiking. For a normal speed of good hikers it should have taken 2.5 to 3 hours but it took me (us) 4 hours, but again I would totally recommend it. There was some scrambling on loose rock but it was generally relatively manageable.

That was steeper than it looks

There was a time I could have thrown in the towel on that walk, but I pulled my big girl pants on and socks up when we bumped into a family coming in the opposite (and seemingly much more difficult way) with twin babies – each parent had one in a baby carrier and two other young children – say 4 and 6 years – all walking confidently and happily. Needless to say I finished the walk with much greater gusto after that.

Zermatt village from above

The third day we caught the Gornergrat Train attempting to get to the top, but the weather was very cold and snowing and the train couldn’t run because of iced-up wires so we got off the train half way up at Riffelberg and had a hot chocolate waiting for the crews to sort out the iced-up wires and allow the train to keep going. (This is where some bad luck – or negligence on my part – stepped in because that’s where I lost my Qantas Travel card and unfortunately I didn’t realise until I was about to step onto the train to Geneva as we were leaving later that afternoon).

The scenery at the top of the Gornergrat was spectacular. It was minus 4 degrees (-4C) and snowing and whilst the Matterhorn was shrouded in cloud, the Gorner Glacier was visible in all its glory. The trouble when you are mixing up a holiday with snowing weather and sunbaking weather it requires a wide assortment of clothes and whilst I was cursing carting around all that winter gear for the majority of the holiday, I was grateful this particular day for all the warm clothes I had packed.

Gornergrat

We caught the train back down – we had vacillated about spending the money on this as it was 98 CHF for 2 people which was half price on our Swiss Rail Card and the webcam view was terrible while we were deciding whether to go- swirling cloud and low visibility – but when we eventually got there is was truly spectacular and totally worth the trip.

We left Zermatt vowing to come back again one day to see The Matterhorn in all its glory and added it to the list of magnificent mountains we have NOT seen due to cloudy weather. But as my son says that’s the beauty of mountains – they are unpredictable and glorious.

A gobsmacked cat of Scopello

The final blog will be about beautiful Scopello and Roma. The end of the holiday is nye.

Beautiful Scopello

 

 

 

%d bloggers like this: