What do we mean when we talk about pelvic floor dysfunction?
Pelvic floor dysfunction is usually associated with ongoing consequences of childbirth for some women. This includes three main groups of problems. The first is urinary incontinence (leaking urine), which affects about 30 percent of women over the course of their lives. Vaginal prolapse is second, with about an 11 percent lifetime risk of needing an operation to fix it. The third issue is bowel incontinence, which can be the result of a major tear during delivery, which happens in 3-5 percent of women.
What effect does this have on a sufferer’s physical abilities or quality of life?
They can have a devastating impact on women’s lives. If she has urinary incontinence, she may need to wear a pad to contain the leaky bladder, which is uncomfortable and embarrassing. She may limit her activities because of this – she may not be able to run around in the park with her kids. If she has a prolapse she may feel there is a lump coming out of her vagina, she may have difficulty emptying her bladder and bowel, and may be very uncomfortable if she has been on her feet all day. Incontinence is very socially disabling – never quite knowing when it’s going to happen. Understandably, these problems have a huge impact on self-esteem, and many women feel ashamed and embarrassed and alone because it is still a taboo subject in most cultures.
Are women who have had children more at risk?
Women who have vaginal deliveries are at risk of levator avulsion, where their pelvic floor muscles get damaged or “avulse” off the pubic bone. Their pelvic floor muscles are unable to do their job of maintaining a solid base of their core. It happens in 12 percent of normal births and 25 percent of births with forceps, and the women may be unaware of this. These women have a higher risk of developing a prolapse and urinary incontinence.
Describe the difference between the types of patients you saw 20 years ago and those you see now.
When I started in this field more than 20 years ago, most of the women I saw with prolapse were women in their 60s who had had many children (four or more) and who had had a lifetime of heavy lifting. They were often farmers or nurses. These days, I see many women in their 30s and 40s who have had their babies later in life and who are doing physical activities that are detrimental to their pelvic floor, and they are presenting to me with prolapse or urinary incontinence requiring surgery.
Given this, what are the risk factors you and others in your field have identified?
Some women have very strong family histories of pelvic floor dysfunction, which probably means that there is some genetic component to the type of collagen they are made of. Women with a high body mass index (BMI) are more likely to have pelvic floor issues because they have higher abdominal pressures from carrying around extra weight. Women who have gone through menopause (usually in their early 50s) often see a worsening of their symptoms then. Women who have had hysterectomies are more likely to develop prolapse in later life. Women who have had Caesarean deliveries are generally less likely to have these problems.
Do you think the fitness and sports industries in general are aware of the problem?
I think there is a huge variation in the quality. Some practitioners are excellent and are very aware of pelvic floor issues that their clients may have, but some may be too embarrassed to go there with their clients. Often at the first assessment at the gym the woman may fill in a health questionnaire. If she has had vaginal births, particularly with forceps, or a major perineal tear, or had a hysterectomy, or is over 50, or has a high BMI, then the fitness professional should be on alert for the fact that she may have significant weakness of her pelvic support and that she should be doing “pelvic floor safe” exercise.
So what advice should fitness professionals be giving?
The pelvic floor is the base of the “core”. Performing core exercises therefore requires activation of the pelvic floor muscles in order to protect the pelvic organs. But cueing a woman to “contract your pelvic floor” does not mean that she can do it. In fact, only 50 percent of women can do a pelvic floor contraction effectively when being examined by a pelvic floor physiotherapist or a gynaecologist. Often the women bear down rather than pulling up the pelvic floor muscles. If there is a levator avulsion, the muscle may not be able to work at all. You cannot tell by watching her whether she can or cannot do a pelvic floor contraction. Some women co-contract their pelvic floor muscles when they pull in their abdominal muscles, but plenty cannot. Advice to do more core strength exercises to strengthen the pelvic floor is not only incorrect but could actually make the problem worse.
What works then?
Only pelvic floor exercises can make the pelvic floor stronger! If the woman finds that she starts leaking urine with exercise or feels like things are falling out of her vagina, then this is an indication that she is exceeding the strength of her pelvic floor and needs to see a pelvic floor physiotherapist who can help her strengthen them. It is very difficult for the pelvic floor muscles to contract when they are stretched, and this happens when in a squat. It is when the pelvis is at its most vulnerable – think about it, that is how women give birth, it opens up the pelvis. Therefore, squats – particularly with weights – are not recommended for these women.
It’s a difficult and intimate issue to raise though, isn’t it?
Part of the problem is the relationship some fitness professionals have with their clients. Many women are too embarrassed to tell them that what they are doing is making them leak urine, for instance. Often personal trainers become friends with their clients and then do not want to let them down. I had a patient who, after three prolapse repairs, finally told her personal trainer that leg pressing 200kg was too much for her! Being pushed to do more is not always a good idea, and being competitive with each other in a group environment and being rewarded for going beyond fatigue is a common story I hear from my patients.
Aside from athletes and “over-exercisers”, who is presenting with these conditions?
The vast majority of my patients are normal women who want to get fit. They are likely to be doing high-impact exercise, and often getting pushed beyond fatigue, which can be inappropriate for their condition. Once pelvic floor muscles fatigue, the ligaments get stretched. Eventually the ligaments do not recover, and the woman might develop a prolapse or might start leaking urine. The other group of women who I see are post-natal women. They have given birth recently and have developed urinary incontinence or a prolapse. Medical bodies say that it can take a year to recover after a vaginal birth, and the recommendation is for occasional low impact exercise during this phase. Often they have the misconception that they should be able to get back to all their physical activities within months of giving birth, an impression often erroneously given to them by ill-informed fitness professionals. These new mothers’ pelvic floors are very vulnerable, remodelling and recovering from the stretching involved in a vaginal birth. They may also be breast feeding, which is making their tissues low in oestrogen and less strong.
What are the available treatments, and is there a permanent “cure”?
Pelvic floor physiotherapy with a trained physiotherapist who can examine the woman is likely to help with urinary incontinence and with early signs of a prolapse. There are mid-urethral sling procedures for urinary incontinence that are very effective. However, treating prolapse is a different story. Some women use ring pessaries in their vagina to support their prolapse, and others require surgery. Unfortunately prolapse surgery using the patient’s own tissue (native tissue repairs) have a 30 percent failure rate and so we should do all we can to prevent a prolapse happening in the first place.
What should sports bodies and fitness institutions be doing to raise awareness?
It is important to have “first, do no harm” as your motto. Education about the pelvic floor in women is vital. Women are entirely different from men when it comes to the pelvic floor, and this should be understood by all fitness professionals. Screening questionnaires are a good idea so you can tailor their program to meet their needs. Don’t assume that women can contract their pelvic floor muscles. Making it possible for women to discuss these issues with their fitness professionals may require a change of approach. “Longer, harder, faster” may be leading to lifelong problems for those women who get harmed by what they are doing for fitness. Pelvic floor safe exercise can achieve good results without causing harm in most cases.
What’s your advice to any woman concerned about this, or worried that she might already be at risk?
If possible, tell your fitness professional about it. If not, seek help from a pelvic floor physiotherapist or a urogynaecologist who can advise you. Please don’t put up with unpleasant symptoms.
Do you have to put your exercise regime on hold?
We also spoke to Bryce Hastings (Les Mills Head of Research and technical adviser) to collect his advice on the topic. He believes that while you certainly don’t want to exceed the capabilities of the pelvic floor muscles, being over cautious means you can miss out on the wider benefits of exercise. Hastings advises:
- Don’t shy away from discussing the pelvic floor issues with your fitness instructor, and consult a pelvic floor physiotherapist or a urogynaecologist if you are concerned.
- If you’re post-natal, focus on doing pelvic floor exercises to restore strength and control. Pick up some pelvic floor training tips from Diana Mills here.
- Avoid exercises that create stress incontinence (leakage of urine) until pelvic floor strength is restored.
- Recognize that the time it takes to recover from vaginal birth differs for all – while some women will be best sticking with low impact exercise for 12 months post birth, some may be able to slowly introduce more intense exercise sooner.
Dr Jackie Smalldridge is a specialist in obstetrics and gynaecology. She trained in England and currently practices in New Zealand. Jackie developed a special interest in urogynaecology with further training in the UK and USA; her area of expertise is in the management of urinary incontinence, prolapse, urodynamics and general gynaecology. She is actively involved in teaching medical students and trainee specialists and she is a member of several international societies of urogynaecology.
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