Why isn't having strong and well-functioning pelvic floor muscles important to us all? Why is leaking when we sneeze considered normal? And why is standing on the doorstep desperately trying to get the key in the door, and racing to the toilet before disaster strikes, something that we put up with?
We know that between 25% and 45% of women suffer with stress incontinence (Milsom and Gyhagen, 2019). In women it commonly occurs following childbirth and the menopause and, in men, following radical prostatectomy.
I have been a continence nurse specialist for 24 years and have loved every minute of it. Last year I wrote The Pelvic Floor Bible in a bid to reach far more people than I could ever dream of treating in person (Simpson, 2019). This led to meeting and making lots of new friends and colleagues along the way. These were people passionate about things such as pregnancy and childbirth, the menopause, men following prostate cancer surgery, constipation, sexual health, and so much more. I have also talked to pilates and yoga instructors who are in a perfect position to talk about and promote pelvic floor health and they are doing just that.
My plan is to make pelvic floor health normal, not something that we blurt out to our nurse or doctor when the situation is desperate, or discuss with our friends over a glass of wine and a giggle saying things such as: ‘I must sort this out, really I must.’
What can we do to motivate people to think that maintaining a strong pelvic floor is as important and as normal as cleaning our teeth?
We know that most pelvic floor dysfunction can be cured or, at the very least, better managed.
A recent Cochrane review (Dumoulin et al, 2018) concluded the following:
‘Based on the data available, we can be confident that pelvic floor muscle training can cure or improve symptoms of stress urinary incontinence and all other types of urinary incontinence.’
But despite this knowledge, many people do not do pelvic floor exercises regularly. However, it is never too late to start pelvic floor rehabilitation. As we are all living longer and are so much more active in our later years, it is even more vital that we maintain healthy bodies and that includes our pelvic floor. If you are young, then please don't think that this doesn't concern you. Think of what all that high-impact exercise that you enjoy so much is doing to you. A study looking at urinary incontinence in female athletes concluded ‘that sports practice increases the prevalence of urinary incontinence’ (de Mattos et al, 2018). This was also discussed by Heath et al (2014). High-impact exercises, such as trampolining cause the worst problems.
The most important three things to take away from this article are:
How to find your pelvic floor muscles
To locate your pelvic floor muscles, sit on any hard surface with your feet flat on the floor. Lean slightly forward with your vulval area in contact with the hard surface. With your hands on your thighs try to lift your vagina and anus away from whatever it is you are sitting on. If you cannot seem to connect with your pelvic floor, please seek help. Whatever you do, don't give up. To test which muscles to use, you can try to stop the flow of your urine midstream (men can do this too); this should only be used as a test to work out which muscles you are contracting and should not be done on a regular basis as it can be harmful to your bladder.
The better you understand how to use your own muscles, the better you can teach your patients.
How do we motivate everyone?
I am a fan of tools and gadgets. Some form of feedback is important. In our modern world we all like a quick fix. How many of you and your patients are addicted to a fitness tracker?
Here are some of the tools and gadgets that I use.
How to make it doable
Do your pelvic floor exercises when you are cleaning your teeth or when your alarm goes off in the morning. You need to associate it with something that is second nature so that it becomes a habit.
Pelvic floor health—not just about stress incontinence
Pelvic floor health is also linked with the following:
Overactive bladder
I am sure that many of you reading this article can relate to this.
The overactive bladder is either a frequent or urgent need to pass urine. This can lead to urge incontinence, meaning that the initial desire to pass urine becomes overwhelming, you simply can't hold on and you wet yourself. What is normal? We should pass urine six to eight times per day. So, if you notice your patients are going more often, please question why.
Why does overactive bladder and urge incontinence happen? Sometimes there is no reason, but the following can be triggers:
Pelvic organ prolapse
It is thought that about 50% of women over 50 have some degree of prolapse, although I suspect the figure is higher due to some women not wanting to tell anyone about it, and others with mild prolapse not knowing that they have one.
Pelvic organ prolapse has been described in the very earliest medical texts. One example from the time of Hippocrates (c. 460-377 BC) was to place half a pomegranate soaked in vinegar in the vagina to keep the prolapse in place (Mattimore et al, 2015).
A prolapse happens when the muscles and ligaments of the pelvic floor are weakened. As a result of weakened pelvic floor muscles and a weakened vaginal wall, one or more of the pelvic organs, most commonly the bladder, bulges into the vagina
Here are a few comments about pelvic organ prolapse from patients of mine:
‘It feels like I am sitting on an egg or a ball.’
‘I have stopped running as it feels so uncomfortable.’
‘I don't want to have sex; it's embarrassing with this prolapse there.’
Atrophic vaginitis
In atrophic vaginitis, the walls of the vagina start to thin and lose some of their elasticity, usually around the time of the menopause. It can be accompanied by vaginal dryness, pain during sex, urinary tract infections, itching and soreness of the vulva.
This is a hugely underreported problem. Please check for it and ask every woman that you examine, whether this is for a routine smear test or a catheterisation, if sex is sore, dry or downright painful, or have they stopped doing it altogether? A woman's sex life is not meant to be over due to lack of vaginal oestrogen. Vaginal oestrogen is available in three formats: a cream, a pessary or a ring, available on prescription from GPs.
Constipation
It has been reported that 50% of people with constipation have pelvic floor dysfunction.
Constipation can be caused by many things, including:
The Bristol Stool Chart (https://tinyurl.com/gnnjmwg) was created so that health professionals can explain with pictures what normal bowel movements are meant to look like.
Conclusion
This article has aimed to provide insight into pelvic floor dysfunction. I also hope that it inspires you to look after your own pelvic floor better and tell all your friends and patients how their pelvic floor is a vital and important part of their physical and emotional wellbeing.