To Women on the Sidelines…

Posted on Wed, 24 Oct 2018 

by Angela Growse, PT FCAMPT

To the women on the sidelines of their life:  I see you there.  Cheering madly but not out on the field.  Organizing food, ferrying children or friends to events, and yet, not the one signing up for the race, doing the star jump into the pool, or dancing with abandon at the wedding – because what if…?

It starts early for some women.  Maybe her periods are really heavy, or make her so sick she misses days of school each cycle.  No one talks about it so perhaps she thinks,  “this is what everyone goes through.” Maybe her breasts are large and heavy so jumping and running are painful or awkward because she’s never had a properly fitting bra.  The mall lingerie stores don’t make a 32 F so she makes do with a DD but her back and shoulders hurt before she’s 20.

In her 20’s and 30’s maybe she finds her best methods for managing menstruation and gets a great fitting bra. Then comes the next round.  She’s less worried about menstrual mishaps and embarrassing breasts. Now she’s running the gauntlet of childbirth to menopause. Incontinence, pelvic organ prolapse, painful intercourse, vaginal dryness. It’s the era of “You’ve had kids, what did you expect?”, “Peeing when you laugh is normal” and “You are ageing now, this is all a part of menopause. You should go on hormones!”. 

Whether the voices are internal, coming from friends, people in society or health care providers – too often the full spectrum of options available to you aren’t shared, known, or explored.

Research Opportunity

As a pelvic health Physiotherapist, I see you in my office.  Booking in because a friend or your doctor said there may be help for your current dilemma, but unpacking your story all the way back to that first period.  I hear you and I really do get it.   I’ve heard all the misinformation, the shame, the rationalizing, the hiding, and the avoiding.  When you feel like you are the only one, or that what you’ve got is as good as it will get.  I see you standing on the sidelines because it seems safer than being the woman who smells like pee at the gym.

“Well, I only leak a little.”

“I don’t want to have surgery!”

We’ve all seen the ads on TV showing women of a certain age finally out dancing around because they are wearing a pad for their light bladder leak or “LBL” – a cute acronym to make incontinence easier to sell as “normal”.  It gets the word out about incontinence but only in the way of adapting to what is already the case and does not explore what could be!  My husband loves it when these ads come on. He watches for little wafts of smoke to come off my ears in frustration.  Maybe you are the one in the group with the “tiny bladder” who always has to pee.  Or you identify as having a “nervous bladder”.  These are all great stories we tell ourselves, but they aren’t a fixed physiological state.  So much of what we experience in this arena is malleable, open to suggestion, and heavily influenced by social experience.

What I’ve learned from the hundreds of women I’ve treated and thousands I’ve spoken with is that there are major gaps in our collective knowledge. Two of biggest taboo issues I treat are incontinence and pelvic organ prolapse and they are loaded with misinformation and shame.

Incontinence:

Incontinence is ANY amount of urine, feces or gas that you can’t control at any time.  Even 1 drop.   That’s right. One drop.   People can experience stress incontinence  - those leaks when you jump or laugh, urge incontinence – wherein the need to go comes on so strongly you can’t make it to the toilet before you start to pee – or mixed. The statistics suggest that 1 in 4 Canadian/US women are dealing with incontinence.   When reading that statistic however you have to consider how much goes unreported.  How many women have actually been asked by their primary health care team if they leak when they laugh or can’t hold in gas?  How many of our female friends and family members know they leak and accept it as part of life after kids or menopause and therefore don’t seek further help? 

So much of incontinence is a brain game.   Stress incontinence can often be managed by learning to balance the pressures within the abdomen and working on the timing of the pelvic floor. The pelvic floor is part of the anticipatory core system which means it doesn’t need to contract very much, but it needs to happen before you actually move, load, jump etc.  This aspect can get lost after surgery, childbirth or even low back pain and it can be retrained.  Urge incontinence is heavily influenced by hydration levels and external triggers; think of how you feel around running water, seeing your front door at the end of the day, or just before an exercise class starts.  So much of what I do in a day is brain retraining, and we are all capable of new learning and neuroplasticity!

Prolapse:

Pelvic organ prolapse is often the least talked about.  It’s when the ligaments and connective tissue supporting the bladder, urethra, uterus, or rectum lengthen under strain over time and these organs start to drop into the pelvis and bulge into the vaginal canal. Patients describe a heaviness or feeling that something is dropping out of the vagina.  You don’t have to have been pregnant to develop prolapse – chronic constipation is one of the worst offenders.  Having a baby or two does increase your risk of developing prolapse but again, genetics can play a big role here.  Why does someone develop significant prolapse after one child and another woman has 5 babies and no prolapse? Women post-hysterectomy can even get vaginal vault prolapse!

Bladder lift surgeries (if it’s just the bladder – it could be the uterus or rectum too) should be an end consideration – yet this is often not seen as the case.  They have a history of “failing” after a couple of years too. Why?  Well, you can fix stretched out support ligaments but if you don’t address all the reasons it’s getting stretched out it’s going to happen again.

With both incontinence and prolapse, women need to consider the big picture.  Hydration has a huge role to play in reducing urgency and even stress incontinence – yet most people reduce their fluid intake if they leak.  What you drink can be as influential as how much.  Constipation is a huge enemy with prolapse.  Inefficient breathing, habitual postures, prolonged standing, repetitive lifting or wide leg squatting can also be big factors. (Think of new parents, nurses or kindergarten teachers who do this all day.)   Balancing the pressure in your abdomen is a key component of rehabilitation and function. If you tend to grunt when you lift or get out of a chair, hold your breath as you lift or mostly breathe in your upper chest, chances are you are creating excess downward pressure on your pelvic organs and pelvic floor many times throughout the day.

And of course, the pelvic floor muscles play a big role.  These work like a sports bra for your pelvic organs.  You can’t have a breast lift and never wear a bra again and expect them to stay there!  Your pelvic floor has to have enough tone, strength and good timing to provide the necessary support.  

What about Kegel exercises?  Won’t those fix it all? Sometimes doing Kegels can make things worse.  The pelvic floor muscles can be and are commonly too tight, or working is a shortened state, and so death gripping your pelvic floor is only going to make them more dysfunctional. Think of lifting weights or trying to run with a hamstring cramp.  Things are not going to go well.  Most patients are doing way too many Kegel exercises or doing them inefficiently.  Even for clients with very weak pelvic floor muscles, the most I might prescribe in a day is 30 reps.  Certainly not 200! Pelvic floor physiotherapists are trained to directly assess the state of your pelvic floor muscles via a vaginal or rectal exam and teach you how to use them properly. Remember these muscles have been designed to work without you really having to think about them so it’s hard to know when things aren’t going as well as they could.  

The good news is bodies are really resilient and almost everyone can be taught how to progressively lift heavy weights and manage the demands of work and daily life within minimal symptoms. It just takes some detective work and some coaching to progressively expose your body to meet your activity demands with efficiency!

Adore Your Pelvic Floor - Bladder Leakage Program

But what if all the lifestyle modifications and pelvic floor rehab aren’t enough?  Surgery is absolutely the right option for many women whose connective tissue can no longer provide enough support.  In spite of the hype, the pelvic floor can’t do it all alone.  This is why even women considering surgery should be assessed to address the whole spectrum of reasons why they are experiencing leakage or prolapse.   Your pre-habilitation can be just as important as your post-surgery rehabilitation.

Surgery usually means being unable to lift for 6 weeks and involves a significant amount of recovery time.  This is not practical for most women with young kids or those not done having them.  Work considerations play into this as well. 

So if surgery doesn’t make sense right now – what else is there to do? 

A pessary can be a really viable option for lots of women experiencing prolapse. It’s a device inserted in the vagina and designed to support your pelvic organs.  They come in a wide variety of shapes and sizes and it can take a few tries to get the right fit.  It has a bit of a stigma of being the answer for the advanced elderly set who are no longer surgical candidates, but there has been an important shift in recent years.  Younger women who aren’t ready for or don’t want to consider surgery are great candidates for these devices that provide support to the pelvic organs and can help reduce the sensation of prolapse or assist with stress incontinence.   In Ontario, gynecologists  (and in a few rare cases – pelvic floor physiotherapists) assess and fit women for a pessary.  The cost of the appointment is covered by OHIP but the cost of the device is not.  A pessary can be worn 24/7 or it can be used intermittently. Some of my clients only wear their pessary for long runs, or 12-hour work shifts when they know they are likely to be symptomatic by the end.    Products like Impressa or Uresta offer options for managing stress incontinence without the need of a gynecologist referral and are worth trying to see if it makes a difference. 

For those with prolapse and truly weak pelvic floor muscles, a pessary worn regularly for 6 weeks or so can lift the weight off the pelvic floor and allow those muscles to strengthen properly.

Why do we care so deeply about this issue?  It’s true that incontinence or prolapse won’t kill you, but they both change the way you participate in life.  Also, one drop of incontinence, or mild to moderate prolapse after childbirth while bothersome now, can become a bigger issue after menopause, and for the elderly who live at home incontinence can be a predictor of frailty, increased length of hospital stay, and even mortality.  We also care because we have great evidence that pelvic floor physiotherapy should be the first line of intervention in stress urinary incontinence, and we are well trained and positioned to also deal with all the other aspects of pelvic health.  We also have the time.  Appointments are one on one usually, and they can range from 30 to 60 minutes long which means we have time to dig deep and unpack those misconceptions, find out what’s important to a patient and help them get back what they value in life.

We’re also in a unique place these days.  Social media can be the best and the worst at the same time. Most of us know the ugly side, but a big positive that I see is the community it creates around these sensitive issues.   Someone will bravely post about postnatal leaking or prolapse, and in most cases, I’ve been privy to,  there is an outpouring of really great information about where to get real help.  This is one of the few areas in health care where there has been a major handing up vs. handing down of information. Women of childbearing age are getting the right information and help early, and then they are sending in their own mothers to address some of what they have been living with for decades.   Prolapse and incontinence are both really common, but not normal.  The sidelines can be a lonely place, but women are great at being a village for each other.   Friends don’t let friends smell like pee.

Click Here to learn more about opportunities to participate in research in London seeking to improve Stress Urinary Incontinence in Women.

 

Angela Growse, PT FCAMPT

Rebirth Wellness Centre

 

About Author:

Angela Growse is an Orthopaedic and Pelvic Floor Physiotherapist at Rebirth Wellness Centre in London Ontario and proud mother of two. Angela provides multidisciplinary care in her practice to optimize health and wellness in both pregnancy and everyday life for women and men in Southwestern Ontario.  Angela received her Masters of Science in Physiotherapy from McMaster University and has been a member of the College of Physiotherapists of Ontario since 2003.  As a Fellow with the Canadian Academy of Manipulative Physiotherapists (FCAMPT) she has engaged in many years of advanced orthopaedic clinical reasoning and manual therapy skills and is currently an instructor with the national training program. Angela also holds a Certificate of Contemporary Medical Acupuncture and is a Certified Pelvic Health Physiotherapist.   Her treatment considers the body as a whole within the context of how we move through our day, not solely focusing on the area patients are struggling with. Patients are invited to be an active participant in their rehab with the goal of helping men and women to regain independence in their health.

References:

Chiarelli, P. E., Mackenzie, L. A., & Osmotherly, P. G. (2009). Urinary incontinence is associated with an increase in falls: A systematic review. Australian Journal of Physiotherapy, 55(2), 89-95. doi:10.1016/s0004-9514(09)70038-8 

Damián, J., Pastor-Barriuso, R., López, F. J., & Pedro-Cuesta, J. D. (2016). Urinary incontinence and mortality among older adults residing in care homes. Journal of Advanced Nursing, 73(3), 688-699. doi:10.1111/jan.13170

Dumoulin, C., Hay-Smith, J., Habée-Séguin, G. M., & Mercier, J. (2014). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: A short version Cochrane systematic review with meta-analysis. Neurourology and Urodynamics, 34(4), 300-308. doi:10.1002/nau.22700

Holroyd-Leduc, J. M., Mehta, K. M., & Covinsky, K. E. (2004). Urinary Incontinence and Its Association with Death, Nursing Home Admission, and Functional Decline. Journal of the American Geriatrics Society, 52(5), 712-718. doi:10.1111/j.1532-5415.2004.52207.x

John, G., Gerstel, E., Jung, M., Dällenbach, P., Faltin, D., Petoud, V., Rutschmann, O. T. (2013). Urinary incontinence as a marker of higher mortality in patients receiving home care services. BJU International, 113(1), 113-119. doi:10.1111/bju.12359

Leung, F. W., & Schnelle, J. F. (2008). Urinary and Fecal Incontinence in Nursing Home Residents. Gastroenterology Clinics of North America, 37(3), 697-707. doi:10.1016/j.gtc.2008.06.005

Mørkved, S., & Bø, K. (2013). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: A systematic review. British Journal of Sports Medicine, 48(4), 299-310. doi:10.1136/bjsports-2012-091758

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