One of my colleagues Sue Croft is a a Brisbane Physiotherapist with a special interest in pelvic floor dysfunction including urinary incontinence, prolapse, bowel management and pelvic pain for women, men and children. Below are a couple of articles that she has written that really hit a nerve with me. I would like to thank Sue for allowing me to post these articles on my website. For further information on Sue Croft or to read more of her blog posts please visit: https://suecroftphysiotherapistblog.wordpress.com/
Having written blogs on Change and Confidence, today I have decided to write about Acceptance. I think, as you can see from some of the stories that I have written about in my blogs, that there are many unhappy ladies dealing with these issues of prolapse, incontinence – both urinary and faecal – frequency, urgency, pelvic pain and so on. Whilst education about the strategies to significantly improve many of the symptoms they are suffering is empowering – some patients really struggle with the less than perfect results that they can obviously be left with.
There is a lovely quote by George Orwell that says…’Happiness can exist only in acceptance’. And I think once every avenue has been explored, no leaf unturned – meaning the patient has done and is doing everything you have asked of them; they are the best exerciser, the best deferrer, have the best posture etc and do all these things daily and they still have residual issues, then I truly believe acceptance is what they are missing.
By acceptance I don’t mean give up and wear a pad – although I am a great believer in wearing a pad to ensure you still go for the walk, run around with the grand kids and in general keep active. Wearing a pad also gives some women the confidence to defer and hold on, safe in the knowledge that they won’t leak and embarrass themselves out in public.
By acceptance I mean that sometimes……many times, women are changed by their birth trauma or their operation – changed forever and that coming to terms with these changes -by accepting their new situation – can be cathartic and unburdening for the woman. Accepting that brisk walking can be as pleasurable as running; that cycling releases as many endorphins as 100 crunches; that swimming builds muscle bulk and tones as successfully as pumping iron – and will perhaps lift the happiness bar up to new heights.
There is much to give us anxiety in our mad, hectic lives today and one of the newer fields of study these days is Mindfulness and Work-Life Balance. In fact one of my dear friends Dr Anne Poulsen is an Occupational Therapist who runs workshops on this very subject. The pursuit of happiness (that sounds like a good name for a book) is very important and causes great despair for many of us these days.
And I don’t think our politicians these days are good role models in this area. The frenetic pace of our leaders these days is exhausting to watch. Personally I would like to see less sod turning and cycling/swimming/ running and more photos of them sitting at their desks running the country. How do they read or write anything when they are always at the opening of this or that.
Anyway back to acceptance. Coming to terms with the changes that have happened to your body and learning to re-love yourself is as important as doing 30 pelvic floor exercises a day. Being happy doesn’t mean that everything is perfect. It means that you’ve decided to look beyond the imperfections.
Today I saw two patients who have sort of encapsulated everything I wanted to get across when I wrote this blog on Change back in January. I have changed the patients names for the obvious reasons. The first lady, Nancy, had a serious urethral sphincter injury from childbirth, actually pushing out the balloon holding the catheter in situ during labour. She loved her running and has been devastated that this very serious injury is causing her significant leakage with just simple walking, let alone with the high impact of running. She has an important job and the leakage issues have been very stressful for her. I have encouraged her over the last couple of months to think about a different form of exercise such as cycling, which will be kinder to her bladder and pelvic floor but still be capable of releasing the endorphins to deal with her hectic life.
Today was her third visit – after her second visit there was hardly any improvement in her leakage and she was very dispirited. But we talked about Change and the mindset needed to go about something like giving up running and today she came back and reported that the leakage was much better (albeit with a Contiform in) and most importantly she had bought two mountain bikes and she, her husband and her baby were really enjoying their new exercise/ family outing!
The second lady, Monica has a new and different sport – pole exercising- which she has equally loved and been devastated when I have suggested it isn’t compatible with her pelvic floor dysfunction. She presented with dramatic drag, ache and heaviness following a hysterectomy and after assessment I said I felt she would have to give up the pole work. She went away, tried the strategies such as pelvic floor muscle training, bracing (engaging her pelvic floor prior to increases in intra-abdominal pressure), regular use of a super tampon to act like a splint and defaecation dynamics and came back saying after a month and said the drag and pressure was significantly better.
She was still very emotional about her loss….and it is a loss when you have found something you adore and which gives you such strength, empowerment and stress release and achieved a high level of skill over five years and you are advised to let it go. But she has bravely decided that it wouldn’t be sensible to go back to it because of the tremendous downward forces pole dancing / exercising has on the fascia and muscles of the pelvic floor.
So lets re-visit the Change blog
Last night my son was busy making a special farewell card for Jane, a colleague at his work who was leaving. Interestingly his theme of the card was Change- lots of ‘change ‘ quotes over the front of the card – which got me thinking about how crucial my skills in encouraging, enabling and facilitating change in my patients actually is. For without change in behaviour, beliefs and what are almost rituals not much is going to improve with people’s incontinence, frequency, urgency and other bladder and bowel conditions.
“Rather than wishing for change, you first must be prepared to change.” Catherine Pulsifer
Well by contacting a Women’s and Continence Physiotherapist the client has taken the first step – which for some people is like climbing Everest. Admitting there are continence issues is a big thing – it’s a personal thing – and they have moved beyond wishing for change to the next level.
But unless patients have heard from a friend about what is involved when they come to see a Continence and Women’s Health Physiotherapist, they are often surprised at the amount of education that is involved in the consultation. What’s more they are shocked (and sometimes appalled) at some of the things they are learning!
Change to decaf?! Change from hovering (to void…wee)?! Change from going just in case?! Change from straining for bowels every time?! You have got to be kidding. Some of these behaviors are almost etched in stone, mainly because our mothers have taught us these and handed down from one generation to another.
“Everyone can think of the one thing that would make life better for them. But people are not so quick to answer the second question: ‘What are you doing to make that change come true.” Catherine Pulsifer
No one likes to leak urine but we are also keen for things to be done to us, or for there to be a tablet to take, or an operation to be offered. Changing old bad bladder habits takes willpower, exercise, discipline, letting go of the easy old way – things that are definitely not easy and comfortable. But interestingly patients are tickled pink when their hard work starts to pay off and they can hold on longer, they are drier and they regain some sense of control with their bladder!
“Change is as inexorable as time, yet nothing meets with more resistance.” Benjamin Disraeli
How do you empower patients to make these changes? Well certainly not by ordering them to do it! I say to patients – I will give you the information, teach you the science… But you are an adult and have to be the one to make the decision about the intervention. Try the decaf for a month and assess – is there improvement in the amount of leakage, the degree of urgency, the severity of the frequency? And if there is then you make the change.
“Never stop learning, like never stop changing and growing in your life – learning helps you adapt to change more easily.”
Even 80 year olds can implement change – as long as they have the mindset that they can still learn new things and improve their situation. If they are fixed in their attitude then it will be hard to inspire them. But that comes back to the therapist – we have to sell this message that what we are teaching is not rocket science -although it does involve maths (angles of how you should sit for defaecation and emptying your bladder) and physics (counteracting forces from above, such as with cough and sneeze, with a force from below…contracting your pelvic floor muscles).
“You cannot change your destination overnight, but you can change your direction overnight.” Jim Rohn
We as therapists have to nurture, empower, cajole, encourage, listen, console, praise – in order to help the patient on this journey in a new direction to their different destination.
“If you resist change, you will face challenges on a daily basis. If you consciously refocus your attitude to see the benefits of change, your outlook becomes positive and life becomes easier.” Catherine Pulsifer
Patients often relapse and sometimes a refresher such as a short return visit and re- reading their handout and book, can easily bring them back to where they should be. They are often relieved that some minor refocusing, such as encouraging more pelvic floor exercises, remembering the concept of bracing, changing their general posture as well as their posture for defaecation and voiding, some local oestrogen if it’s required – can return them to a continent state.
“No action, no change. Limited action, limited change. Lots of action – Change occurs.” Catherine Pulsifer
Ah the crux of all this change talk. What you put in will be reflected in your result ( mostly………. this is for all those hard-working patients who do struggle to conquer their incontinence). The pelvic floor muscles thrive on attention (unless there has been some levator avulsion or significant nerve damage) and getting into a routine of daily pelvic floor exercises will make a difference. Kari Bo, A physiotherapy researcher, has shown that the levator hiatus – the internal dimensions of the vagina- can be decreased and prolapse elevated ( to a certain extent and of course depending on the severity of the prolapse ) from a programme of pelvic floor muscle training. So don’t delay – start today, make the first step. Contact your local Continence and Women’s Health Physiotherapist today and learn how to contract those muscles correctly.
And now to finish, just because amongst all those change quotes I really like this as a good piece of advice for all of us – to help us deal with the complexities of modern work and life:
“To focus on the people who do not like you and the things you cannot change is like climbing an infinite mountain; instead focus on the people who love you and the things you can change and you will find you can move mountains.”
Michelle Ghislaine Ambler.
PESSARY STORIES -YES! USING ‘SHOUTY’ LETTERS FOR A REASON
If it’s a phrase I’m really sick of hearing, it’s the one that many of my patients have had said to them by too many health professionals (and some of them are doctors):
“There’s no point in having a pessary, pessaries are just for old ladies”.
Today’s blog is to refute that argument because it just isn’t true.
A pessary is a silicone or plastic device designed to help support prolapsing pelvic organs. The first pessaries date back prior to the days of Hippocrates and their use has been documented in early Egyptian papyruses. Throughout the centuries many unusual remedies have been used such as honey, hot oil, wine, fumes, succussion,leg binding and even pomegranates. In the middle ages, linen and cotton wool soaked in many different potions were used. As new materials were discovered, pessaries evolved and began to resemble those used today. Cork and brass were soon replaced with rubber and of course now medical grade silicone. (1)
Demonstration of Hippocratic succussion (From Appolonius of Kittium)
Funnily enough, this is what many women feel like they want to do, to reduce their prolapse.
Pessaries are for any woman:
Whose anatomy (post vaginal delivery) can hold the pessary in a comfortable position, where the woman does not feel it and it effectively reduces her prolapse.
Who can be taught to self-manage the pessary (is cognitively sound; has a good memory; has the dexterity and finger strength to manage; can reach her vagina and feels comfortable inserting her fingers into her vagina to enable her, of course, to insert the pessary).
Who is able to have local oestrogen if she is post-menopausal (or if she is breast-feeding for that matter).
Of any age if they answer any of the previous statements.
Health professionals should not make blanket negative statements about pessaries without examining the patient and checking out the above criteria. It’s uninformed and obstructing a woman from trying a potentially, really successful, conservative option. Pessaries are amazing and life-changing………when they work. And there are many, many patients for whom they work if they get an opportunity to try them.
There is now good evidence that screening for prolapse symptoms early, and in primary care, such as by the GP, there can be 40% symptom resolution with conservative measures and watchful waiting. (2) Now many blogs ago, I came up with an idea that the GP’s could be integral to early discovery of prolapse at the PAP smear. Using the acronym PIPES, when a woman is having her PAP smear, this could remind the GP of important things to screen for.
A simple checklist for GPs to check at every PAP smear
¤ P stands for prolapse – Vaginal, rectal.
¤ I stands for incontinence – Urinary, faecal, gas.
¤ P stands for pain – Pelvic, abdominal, sexual.
¤ E stands for exercises- pelvic floor exercises; general physical exercise for bone density, weight management, stress and general ‘feel good’ management- (release of endorphins) -‘if you don’t move it you’ll lose it!’; ‘pelvic floor safe’ exercises.
¤ S stands for sex – pain, dryness, low libido, anxiety about the look, anxiety about doing damage, relationship issues.
There has been plenty of evidence about the value of pelvic floor muscle training (PFMT) as a part of the treatment package for managing prolapse (including correct defaecation position, the knack (bracing), and other lifestyle advice) and a recent meta-analysis demonstrated women who received PFMT showed a greater subjective improvement in prolapse symptoms and an objective improvement in POP severity. (3)
Defaecation Position taken from Pelvic Floor Recovery: Physiotherapy for Gynaecological Repair Surgery. Sue Croft 2014.Below are a couple of pessary stories. Women have written them in their own words. They have chosen their alias – but I have not changed anything. Please be aware these stories are to bring the value of pessaries into focus; and specialists such as Urogynaecologists and Gynaecologists and many Women’s and Men’s Pelvic Health Physiotherapists who are trained to fit pessaries, are able to assess if you are able to use a pessary in the short-term, medium term or longer term.
Ring Pessary: A Mother Journey
Amanda, 34. Mother of 2 boys
About 10 days after my second unassisted, uncomplicated vaginal birth, I became aware of a heavy feeling inside my vagina. As someone who is well read and informed about the risks of prolapse, I had been extremely diligent between the birth of my two sons, seeing a specialist physiotherapist regularly to restrengthen my pelvic floor and then manage my second pregnancy as well as possible. I was therefore extremely surprised and quite devastated to suddenly feel the heaviness inside my vagina.
The feeling deeply troubled me and affected not only my physical ability to go about my day but also affected my sense of self and my confidence. I felt like my feet had been swept out from under me and that I was somehow not fully able to cope with the demands of caring for a vibrant toddler and a new born. I became increasing depressed and felt like I couldn’t cope.
I went to see Sue who diagnosed a Grade 1 uterine Prolapse with levator avulsion. Her solution, as well as continuing with my program of pelvic floor exercises, was a ring pessary which she fitted. I have not looked back. It gave me my life and my confidence back. I can’t describe what a difference it makes. It is easy to self manage and takes little time or effort.
Instead of being a constant strain and stress on my conscience, my prolapse has become something to be managed, but more as a part of my overall health. It’s a part of the background now, no longer the major strain that it was on my sense of self and my ability to function. I have my feet back under me again and I feel like along with my exercises, that the pessary will be a lifelong aid to maintaining my pelvic floor health. I am so glad to have avoided the risks and trauma of surgery and I genuinely encourage other women of all ages to give it a try before resorting to more drastic measures. Good luck!
What a beautiful, encouraging story. Thank you Amanda for sharing your journey.
Prolapse is devastating if women have not realised just how common a prolapse diagnosis is.
50% of women over the age of 50 who have had a vaginal delivery will have some degree of prolapse….YES SHOUTY LETTERS TIME AGAIN…….50% OF WOMEN OVER THE AGE OF 50 WHO HAVE HAD A VAGINAL DELIVERY WILL HAVE A VAGINAL PROLAPSE.
If I think about what has transformed many women’s lives- of all the things that a Pelvic Health physiotherapist does – I think fitting a pessary, when it works, is one of those amazing miracles. When a woman has a prolapse and can feel it all the time and then by simply inserting a pessary, she no longer feels the prolapse, no longer feels the drag, no longer feels the heaviness, can exercise with more confidence and isn’t constantly thinking about her prolapse every second of the day – well they are very happy patients.
Below is another story – Heather’s story – short, succinct and to the point!
I am 54 years of age and have had a bladder prolapse for a while now. I hated the bulging uncomfortable feeling. It was something I was always aware of and could never forget about my condition. After having been fitted with a pessary for over six months now, it has made a huge difference. It is very comfortable, I don’t even know it is in place. It has never fallen out and I can do my usual safe exercises . I don’t think about the pessary much, except when it is time to remove for cleaning which is once a week. The only other thing I have to remember is to use Ovestin cream twice a week. It has made a difference to my well-being, I am so glad I gave it a go.
Thank you Heather.
Don’t get me wrong. There are quite a few patients where we can’t make the pessary work, but if we try all types of pessaries and we can’t make it work, at least the patient feels they have given every conservative option a shot. Below is a case study about Sandra. I am writing her story to demonstrate how important ‘failing the fitting of a pessary’ can be!
Sandra had a significant vault prolapse. Her vault (she had a hysterectomy 10 years previously) was 5 cms out of her vagina. Her prolapse was obstructing her voiding, leaving her with sizeable residuals, so during the day when standing, she was hardly voiding more than 100 mls and when she lay down and reduced her prolapse, her volumes were much bigger. But she could never empty completely.
Sandra was adamant she didn’t want surgery when she presented to me.
She had quite good levator muscles on both sides and I felt there was a fair chance the pessary may work. But with pessaries, it is trial and error. We have fitting kits, which we sterilise and this enables the patient to be fitted and then cough, squat, jump, and then go for a long walk if all of those other challenges had not dislodged the pessary. So Sandra did this and she felt wonderful- the pessary reduced the prolapse and the heaviness was gone and she even voided and emptied with a minimal residual. But she went home and the next morning, when she passed a bowel motion, unfortunately the pessary dislodged. Despite using the correct technique for defaecation and many repeat attempts to use devices such as the Femmeze and hand support it just wouldn’t stay in with passing her motion.
Eventually, Sandra found this too much and having felt the relief from not having the prolapse dragging down, she then decided she would go ahead with the surgery. This is a wonderful exercise in exhausting every option, so the patient feels, of course, surgery is the next, correct option. With significant failure rates in the literature for gynaecological repair surgery (up to 30% for repair surgery; up to 80% if the patient has a bilateral levator avulsion), it is important the patient feels all conservative options have been tried.
And finally another story from Sally:
I had my last child 26 years ago. I had three 9lb babies, all very intelligent babies (with big heads). After my last baby I became aware that there was an unusual feeling (like a tampon was dislodged) that would come and go. I started to read and learn about pelvic floor dysfunction and became aware that I had developed a prolapse. I was religious with my pelvic floor exercises and the ‘knack’ and by using a tampon for heavy lifting or playing sport I managed to keep things at bay until last year.
I had turned 60 and started to feel a different feeling, a heaviness that I didn’t like. So I got fitted with a pessary and it IS like magic. I was told the most critical thing is to remove and wash the pessary weekly – and I had to sign a form promising I would do that! As if I’m not going to remember to remove the pessary every seven (7) days?!? Well very quickly I realised it is so comfortable, and I am so unaware that I have it in, that it is very easy to forget and lose track of time – those 7 days literally zoom by and are occasionally missed. My thoughts at the moment are that me and my pessary are going to be good friends for many years to come.
Thank you to all my patients who have contributed to this blog and all the others below.
And to all my patients who I have asked to write a story about their pessary journey, do not feel I do not need them anymore now I have posted this blog. Every story is relevant to someone and if your story helps them understand and make an enquiry about this pessary option with their medical practitioner – and the more stories, then that is fantastic. So keep writing them and sending them – because each of them is a good learning opportunity.
View the full article with pictures here: https://suecroftphysiotherapistblog.wordpress.com/