Pelvic Floor Problems 101 - Episode Transcript

Helen

Hi, I'm Helen, and this is Why Mums Don't Jump - busting taboos about leaks and lumps after childbirth. All the stuff that happens to your pelvic floor that no one ever talks about. Incontinence, prolapse, pelvic pain - problems that affect millions of women, one in three. I'm one of them. I have a prolapse. My pelvic organs fell out of place after the birth of my second child five years ago. And if you'd told me then I'd be speaking about this stuff out loud, I would have told you to give your head a wobble.

Welcome to episode two. I want to say thank you so much for an amazing response to the first episode last week. Honestly, it's been quite overwhelming. Obviously, going public with tales of a broken vagina, for one, but mainly just how much that's meant to people. I know there have been a few tears, but hopefully in a good way. I've read every message and I hear you and I'm really glad we found each other. As you know, I'm not an expert. I definitely don't have all the answers. I do not have it all figured out, but hopefully hearing other women's stories as well as from experts will help us all along the way.

So this episode is something like a crash-course in pelvic floor dysfunction with someone who does know much more about it than I do. Because, I don't know about you, but when I was pregnant, I knew very little about any of it. I knew the jokes about leaking when you sneeze or laugh, but I think...I just thought that if I ever had any problems like that, then I could just do a few pelvic floor squeezes and it would all go away. And I didn't have any problems after my first child was born, so it all came as a massive shock second time around.

And then when it did happen, after my son was born, I really struggled to find any sensible information - what was happening, why it was happening, the long term implications. I fell into a bit of an online rabbit hole, which just left me feeling confused and sometimes a bit sad, sometimes a bit scared. So I thought it might be useful to run through some of the more common problems and what help might be available.

I just think if something like this was available at the time for me, I think I would have learned a lot. I did learn a lot, in fact, by speaking to Katie Syrett, who is a women's health physio based in Manchester, here in the UK. In fact, she is my women's health physio. She's lovely, she's funny and she knows what she's on about. And before all this COVID business happened, she very kindly agreed to come over for a chat.

Helen

Hi.

Katie

Hi

Helen

Thank you so much for doing this.

Katie

It's a pleasure.

Helen

I was thinking about how we should start and I thought we could start when we met. So a couple of months ago, I came into your office about my prolapse and spent most of the appointment bawling my eyes out, if I remember rightly...

Katie

...which is very common.

Helen

Is it?

Katie

Yes very. Yeah.

Helen

I did feel a bit foolish, but I was just so...it was happy tears, because you gave me hope that I just hadn't really felt for a really long time, that I could make some progress and...move a bit.

Katie

Yes, I think it's an emotional area. It's an emotional area to talk to anyone about, whether it's a new diagnosis or an old one that you're still on a bit of a journey with. So I think, yeah, I do get quite a lot of tears, but hopefully, normally some happy ones.

Helen

Happy tears. It was. I was sitting there and I couldn't really speak, but I was trying to get out 'Happy tears. Happy tears.'

But yeah, so until I had to see...do we say, a 'women's physio' or a 'pelvic physio'? How do you refer to it?

Katie

So I tend to describe myself as a women's health physio, partly because there are lots of physios who do pelvic health stuff who also treat men, which isn't something that I've gone into. So I always want to make that distinction, partly because I just don't have those skills, really, and if a man approached me, I would refer them on to someone who definitely does have those skills.

Helen

So until I had my prolapse and I needed to see one, I never even knew that was a thing. So how did you get into it?

Katie

No. And again, it is quite a niche part of physio in that it's not really part of the basic training. The three year degree course doesn't particularly cover it. You don't do it as a standard sort of placement during your three year degree course. You could do it if you chose to, but it would be quite unusual.

So I became a physio. I just wanted to work in sport and massage, ideally some rugby players' or footballers' legs and then did that for a while and then just got a bit bored with it and kind of moved away from sport and then started to have my own family and suddenly went, 'oh, everything feels a bit different than it did before. I'm suddenly really interested in how this area works.' So that was the beginning of me wanting to learn more about women's health physio. So we always have to do lots of professional development as a physio, and I just took my professional development more down that route.

Helen

For me, when I found out about the prolapse. Never heard of it before. And a lot of the women I talked to now are in the same boat, Googling things we didn't even have the language for. And one of the things I really wanted to do is to try and get some good information out there, because I just found it really hard to find out any of the things that might be happening - what it meant, whether it could be fixed, so perhaps we could just talk a bit about the common things that people come and see you for?

Katie

I suppose a lot of the first line is probably if people have symptoms. So maybe that's some bladder or bowel incontinence, they sort of suddenly - the classic incontinence is leak when you cough or sneeze or laugh or jump or whatever. Or there's the urgency where you suddenly need the toilet and you can't really hang on. And that's just almost like the pelvic floor just hasn't got that endurance and just goes 'Argh, I can't hold on anymore.'

So those are the first, I suppose most common things that people go 'ooh, I can't do this' and hopefully someone suggests that they come and see a women's health physio. I would also say maybe the symptoms of a prolapse - so that feeling of heaviness or the discomfort, sometimes it can be discomfort and pain, alongside that, so people might come and see me. And then pain itself. So sometimes that tips over into overactivity in the pelvic floor and some more kind of chronic persistent bladder pain. And then I do see women with pregnancy related pain and issues and some pelvic floor problems.

And then I think I see women at different times in their lives as well. So again, the classic is you've just had a baby, you've had a vaginal birth, and things haven't perhaps gone according to plan. Or there's women who are much younger, perhaps before they've had children and often these are women who are quite fit and they're getting some leaking when they're running or lifting weights and that type of stuff. And then I'm getting another group of women who are coming through possibly during and after the menopause when they've had a big hormonal change and that can change the public floor issues all over again. So they've maybe had something from having children which they've managed, maybe not done another thing about, but it's never been that bad -they've just popped a Tena Lady on if they run, if they think that's enough- and then going through the menopause has changed things again, quite often.

Helen

Okay, that's really helpful to kind of get the overview because it is lots of different things and sometimes I guess you can have more than one thing together, can't you? Because I know a lot of people who have prolapse having incontinence and for some reason - maybe you can suggest a reason - I don't even know why, but I just don't really. Things aren't perfect but I just don't.

Katie

And it doesn't always come with symptoms. And sometimes when you read statistics about how many women have prolapses and blah blah blah, you often wonder are there women who have prolapses who because they haven't got any symptoms as such, and maybe they think 'Oh well, I've had a baby, of course it feels different', they haven't actually ever had it sort of officially diagnosed by anybody. So, yeah, I mean, some of it is just a bit of luck, partly of where the prolapse has gone. And there can be women who come in with those pelvic floor issues - incontinence and those sort of those symptoms - who actually haven't got a prolapse, but they've just got some weakness there, or some dysfunction.

Helen

I suppose one thing perhaps we should do...I didn't know what a prolapse was and yet now I just bandy it around as if everybody else does. Maybe, shall I tell you my understanding? And you can tell me if I'm right? (I'm not a physio or a doctor).

So the pelvic floor is kind of like this hammock of very clever, very important muscles and one of the things that it does is help to support your pelvic organs - your bladder, your bowel and your uterus, your womb. And if the pelvic floor gets weakened through pregnancy or childbirth or as you said, high impact exercise or various things, but I guess often: pregnancy, it can't support necessarily those organs as well anymore, and they all sort of fall down into the vagina?

Katie

Yeah, I mean, nowadays online there are some nice kind of graphics. I do often say to patients, don't Google image them because sometimes some of the images can be quite scary.

Helen

First thing I did. Scarred for life.

Katie

But I quite like some of the sort of more graphic - when I say graphic, I mean sort of almost like pictures - where they sort of describe this kind of hammock. The other thing that can happen is it's not just always a weakness within the pelvic floor, it can actually be sort of a structural change. So the pelvic floor is almost like the material of the hammock. And then you have got these sort of straps and they can also weaken, but they can stretch and they can tear.

Helen

That was the thing that I did not understand for a really long time. Cos I thought, I understood that my pelvic floor is weak. That's where things have fallen down. Get my pelvic floor strong again. They'll all go back up. But they don't. And that's probably because things that are attached from above have stretched and can't unstretch.

Katie

And that doesn't mean, well if they've gone, that's it and you're on the short road to surgery and that sort of thing. There is still stuff you can do to support the area around - there are probably loads of ligaments in your body that are stretched - but structurally you can't really change that, even with all the pelvic floor exercises in the world, really.

Helen

And I have no idea why someone would then have incontinence. As well as or instead of. Why does that happen?

Katie

So basically what the pelvic floor does is it's sort of loops of muscle that - this isn't exactly sort of anatomically correct - but they sort of come from the back and they loop round, in a woman, the three exit points. So when you contract your pelvic floor that basically sort of kinks the pipe. So it stops either the flow of urine or it stops something coming out of your bowel passage when you don't want it to, if it's not an appropriate time or whatever. So on the whole - well, this isn't always necessarily true, I suppose - but if it's weaker, you're not able to kink the pipe as efficiently at the times when you want to. So if it's not as strong as it should be, then that's why you'll get those sort of incontinence symptoms. Or if you have got that structural deficit from the ligaments, then it will drop down and in, and therefore you won't be able to control even if it gets stronger, you still have that weakness as you're trying to kink those pipes, almost because of the position that that pelvic floor is then sitting in.

Helen

And then, and the pelvic pain stuff? That's?

Katie

The pelvic pain, I mean, it can come from a number of things. Most commonly in women I see - who've got really long term sort of persistent pain- they've got overactivity in the pelvic floor. And the pelvic floor is incredibly intuitive. And often what's happened with the pelvic pain is sometimes it can come from maybe a birth trauma or lots of recurrent urine infections is often one of the things that can preempt that and start that. Sometimes even to do with some anxiety. And then there can be a bit of a link between other sort of more chronic conditions like fibromyalgia and that type of stuff as well. But often what's happening then is the pelvic floor is just almost constantly, imagine it's almost constantly on, and really no muscle should be on all the time. If you flexed your biceps for, I mean, more than a couple of minutes, you'd start to go, actually that hurts quite a bit and then you would let it go. No muscle is designed to be on all the time. But then it becomes a pattern because what happens then it gets fatigued, so it can't kink the pipe anymore. So you'll get leakage because the pelvic floor is exhausted. It's not available when you need it because it's too tight. And then it becomes a cycle of the anxiety around that tightens that public floor even more, and as I say, very commonly, treating that is quite a bit more complicated than you know. 'Oh, here's a few nice little pelvic floor exercises and a bit of glute work, and off you go. You'll be fine.' It's often looking a bit more deeply about, well, where is that pain? What are those triggers for that pain as well? And trying to work through some of those things with women.

Helen

Which brings me on to my next question about how fixable it is. So, Google Image, what is it? Next one, can it be fixed? Can it be healed?

Katie

I would say for most women I see, you can help their symptoms and mean that they can find some way of having the lifestyle that they want. And even if that isn't a fix forever - and at some stage you need to escalate things and have some conversations with surgeons and all that sort of stuff - I think you always want to feel that you've made that the last resort. But yeah, I would be disappointed if you couldn't make some kind of change to what's going on for them, symptom wise and discomfort wise.

Helen

And it seems like you need such a bespoke fix for everyone. And that, again, is something that just makes me really cross, because the advice, the official advice, is so black and white and certainly around prolapse, it was don't run, don't lift. Things that you just are doing anyway cos you've got a baby. You're lifting a baby in a car seat, which are heavy...

Katie

...And prams, which are heavy and you're lifting it into the boot. And that's one of the things that I do find really frustrating. I get quite a lot of women in my private work where they've been to see the GP, they've literally just had a baby. They can feel that things aren't right. Maybe it's a six-week-check, maybe it's another appointment. And the GP has often just sort of thrown out. 'Oh, well, yeah, it looks like you've got a prolapse. Just don't lift anything too heavy.'

And it's just...these poor women. And often then they will have raised a referral through to the NHS physio, which is great, but often there's a bit of a time waiting situation with that. Not always, but sometimes. So they come and often seek me out in a bit of a panic to go, 'Well, what does that not-lifting mean? Does that mean I can't lift my toddler? Does it mean I can't lift my shopping?' You know, and it's almost impossible not to lift as a human being, when you have young people in your life or really even at any other time.

So I often think with those women, I feel like a lot of my job is hopefully reassuring them that probably their insides aren't just going to fall out immediately, as soon as they lift the car seat once, but also giving them some strategies of how to do those things, because they are going to have to do those things. So there really is no point just saying don't lift because you're not really being realistic about what that woman's lifestyle is like. So actually, it's better to then give them some strategies about how to manage their breathing when they're lifting, or what muscles...apart from the pelvic floor, should they be looking at their glute muscles or their abdominal muscles, trying to get the teammates of the pelvic floor working really hard as well? And then they should be able to do normal day to day stuff.

Helen

What you've just said there, you've reminded me, the other thing, that it's been five years since I had my second child and had my prolapse, and it's only recently that I've really understood the importance of the muscles around the pelvic floor, the glutes, the thighs. I kind of knew about the core to a point. And it's just that idea, isn't it, that you're kind of spreading the load, aren't you? If you bulk up around that, then there's going to be less pressure ramming through your pelvic floor.

Katie

And I say to loads of my patients, your glutes, particularly your bum muscles, are like your pelvic floor's best friend. They're doing a lot around the time when you're using your pelvic floor during ordinary day to day movements. If you can get your glutes really strong, they're going to take, like you say, share that load. And actually, they are a bit more fit for it. They're much bigger. They can be massive...

Helen

Which is all the rage.

Katie

Which is all the rage. Yeah. Not just buy, like, the knickers from Primark. You actually have to put some effort in.

But yeah, actually, I would say that's the thing that I've definitely learned loads more about in the last few years and found really helpful. And I think, again, it gives a bit more of a focus to women to go, 'ooh right, I'm really doing something here.' And for lots of women, they want to exercise. So if you're saying, 'Well, actually, we can really do some exercise here, and it's going to help you pelvic floor', it's a win-win.

Helen

This has made such a big difference to my life in the past year, just feeling able to think that I can do things again and I am actually doing things, and just mentally and physically, I feel much better. So I feel like it's kind of a story of hope, in a way, for people who thought 'That's it. Game over.' I'm kind of, yeah, I can do things again.

Katie

And I think again, like we've talked about, we're always saying to men and women, 'Keep fit, exercise 30 minutes a day, be strong, get your heart rate up, blah, blah, blah.' And then we have this whole group of women where we go, 'Oh, actually, we're not sure.' And I think that's my big frustration with...not with all GPs, that sounds really terrible because it isn't just that. They've got a very short amount of time. It's not their area of expertise. But I do find sometimes these things are said quite sort of flippantly and quickly, and then not always followed up with a referral to a physio. And that's always a bit disappointing.

Helen

Yeah, you do read those kind of horror stories of just, 'Well you've had three kids, what do you expect? Off you pop.' It's so short sighted because these are often young working women. They've got so much to offer to society and they've kind of been sent away to just a dark corner somewhere, never to move again...

Katie

...Thinking that there's nothing. And once you've been told that kind of information, that can make people very fearful about doing things. And often then that fear actually taps into some pelvic floor dysfunction. Like we've talked about before. There is that element there of 'Things are wrong. It's broken.' All that really negative language that's so detrimental to your mental wellbeing and how you view your body.

And you know you are different after you've had a baby. If we're taking that group of women, particularly, everything isn't exactly where you left it, but I think anything where it feels like it's 'broken' is just such a negative thing. Sometimes as a physio, you spend quite a bit of time picking that apart and going, 'It's not...well it'll be better'.

Helen

What are your thoughts- sorry, I'm totally like, expecting you to have all the answers - on prevention? I know everyone's told during pregnancy, you must do your pelvic floor exercises, as if that's the kind of key to everything. Can you really prevent this stuff?

Katie

I don't know. And there is a bit more chat about this kind of thing. You know, should this be something that we're talking to young women about, before they're even thinking about having children? And so that they know what a pelvic floor exercise should feel like. How long, approximately, should you be able to hold the pelvic floor for? Also, should you be able to relax it? You now actually, the contraction is important, but the relaxation is as important, really. So maybe that's an area that would be nice to have some more research in, I would say.

Helen

You touched on it before. It's one of those subjects I think a lot of us just put our fingers in our ears and say 'La la la la la'. Menopause - what does that mean for our pelvic floors? Especially if they're already a bit knackered?

Katie

Yeah. So partly, some of the things that happen hormonally are, when you have that change in your hormones, they reckon that for women, we'll lose about 10% of our muscle power for every decade ongoing from that beginning of the perimenopause phase.

I know. Just another thing to add to the list.

Helen

And perimenopause, that's before?

Katie

Yeah. Just the beginnings of those hormonal changes.

Helen

And what age is that, roughly?

Katie

Well, mid 40s onwards, really. I mean, obviously some women can have it much earlier. So I often say to patients - I mean, this is very sort of basic - but you know, if you lose 10% of your biceps, you probably don't notice, but if you lose 10% of your pelvic floor, you might suddenly have gone from being very occasionally incontinent to suddenly going, 'Oh. Well, this is different to how it used to be.'

And I've definitely seen that in quite a lot of women in my work. Maybe it's just the women that I know now, because I myself am in my mid 40s. But I've definitely also seen women who haven't had children, who then have had changes during those menopausal years and afterwards, so that's the big thing. And then there's lots of other things that the hormonal changes that happen - sometimes it's some weight gain through those changes, and, again, that can change things. Some women get quite a lot of increased anxiety around the menopause and some of those changes, and I sometimes see that link, where things have changed for them, and the pelvic floor is just another thing to kind of be affected by that, really. But again, it's almost the most important time to be doing exercise, I would say.

Helen

And when you say exercise, you mean all kinds of exercise and not just pelvic floor exercise?

Katie

Yeah, definitely. There's loads of evidence to show that women from really, like, mid 30s onwards should be doing some strength stuff. It doesn't need to be high intensity body building weights at the gym, but doing some kind of body weight or resistance strengthening, some impact - a bit of impact stuff- is really important for your bone density.

So it's almost, again, another time when you don't want women to go, 'Well, I'm wetting myself, I'm going to just cut out a whole section of exercise.' What you really want is for them to go, 'I'm going to go and see if I can do something about it and carry on, and maybe even increase some of this exercise that I'm doing.'

Helen

Yeah. And I think that's something I hope to come back to a little bit further in the series, because I think there's a lot in menopause and the things that you might be able to do to help, and the things that we don't like to think about. But it's better to be prepared, isn't it?

Katie

I think so. And there's a lot of evidence about how women who know what could happen during menopause, their outcomes - once they've gone through the menopause - were so much better, because they didn't think they were going slightly insane. They did possibly go and get the right help because they thought, 'Ooh, I think this might be a sign of the menopause', rather than just backing away into that same dark corner.

Helen

And that feels like it's becoming less of a taboo as well.

Katie

Definitely, yeah. There's lots of really amazing women who are kind of shouting about it and writing brilliant books about it and articles. So I do think we're going, 'Oh no, actually, yeah, it's not ideal, but we're all going to go through it, so let's actually make it a better experience.' Definitely.

Helen

Yeah. When half the population is going through something, we may as well talk about it. Yeah, why not?

The other thing that I thought would be useful is, I see on forums sometimes, or on my Instagram, people get in touch and often they don't know what it involves to go and see a physio, and sometimes they're quite shocked when they have to get undressed. Or half undressed.

Katie

Yeah. And I do always try and pre warn people a little bit, because quite often you've had a bit of email contact, kind of back and forth a little bit first. And I will sort of...there'll be lots of questions and you'll probably be asked about your bladder and definitely your bowel and what's happening with those. So sometimes people are a bit like, 'You want to know about my poo?' and obviously what your symptoms are day to day, how that's impacting on your life. Sometimes we might ask about your sex life and that sort of thing, and then we would normally, ideally, do an internal examination, for most women. It is by far the best way to find out what's actually going on. It's the best way to find out what your pelvic floor is doing. Are you squeezing the right bit? What's the strength like? And then we can feed back about all that, actually, whilst you're doing it, which is really, really helpful. I would like to think that it's not too unpleasant and scary.

Helen

It's not. It's not. I mean, it's never like the most dignified thing to get your bottom half naked and have someone stick some fingers on it. Basically, it's what it is. But from my experience, it was definitely far less uncomfortable than a smear test, which is just fine. You have to get on with it. Cos there's no speculum involved...

Katie

...No, that's it. So it should be quite...and I would always say to women, there should never be any discomfort. And also, I think you've always had a bit of a preamble. I do feel, I think, as a physio, that's one of the things I like most about my job is I have time. So I have minimum half an hour with someone. You know you become a bit more comfortable. And there is always that opportunity to say, 'Actually, I don't think I'm ready this week. Can we come back and have another appointment?'

So it's good to know that that could be something that definitely happens when you go and see a physio. But A, it's not compulsory. I do have, occasionally, women who are just not comfortable at all. I've had a couple of women who've come in with really, really acute, persistent pain and actually doing an internal examination would have set off all kinds of pain signals and firing, and it just wasn't appropriate for a number of sessions for us to be doing any internal stuff. But, yeah, it is by far the best way.

Helen

One of the things I've found through all of this, I started on Instagram about a year ago, and even writing down some of these words - vagina, vulva, prolapse. I've found it really hard. I didn't realise how much I rely on euphemisms. And I'm kind of all right with that. Where do you stand on euphemisms?

Katie

Most people use them. I probably wasn't especially brave in teaching my children the real words. I mean I have pelvic floor models hanging around the house and I have talked to my children now, as they've got older, about the real words, but, yeah, I did completely wimp out with my small children and let them call them all sorts of random words.

Helen

I kind of think it's alright. I think part of the problem is when you put the word 'my' in front of it, it's ten times harder. I can say 'vagina', but if I have to say 'My vagina' then I'm much happier saying 'My bits' or whatever.

Katie

And I think if people are more comfortable...my job is to make people feel comfortable when they're in there. And if they want to call it all sorts of weird and wonderful words, then I can totally get on board with that. Because if that makes them feel more relaxed about how they're describing their symptoms, then I don't...I mean I would never correct anybody and go, 'I think you'll find that's actually called a vulva'! Because, like you say, I think maybe that just takes it down a notch or two for them and they just feel a little bit more at ease talking about these really personal things. If I'm picking away at, well, how often do you do a poo? And what's your sex life like? I don't mean, like the details, but how does it feel and all those things? If they want to use different euphemisms, then, yeah, I'm quite at ease with that.

And I don't think us necessarily using more anatomical words in day to day parlance would change this, particularly short term. Again, I think it would be good if girls knew where all the different bits were and that there were actually three holes, and that's always a bit of surprise for some people. So, yeah, I think it would be good if we knew a bit more about the anatomy, but, yeah, maybe we can just give it whatever names we fancy.

Helen

Baby steps. Baby steps. We'll get there.

Katie

Yeah, exactly.

Helen

I will get braver with the anatomical stuff, I promise. But, yeah, it's all a journey, isn't it? And I don't know about you, but I found that really useful. It's obviously not intended as medical advice, so do seek out your own professional help and do keep listening, because in the next episode, we're going to hear Ainsley's story. She's a mum to a toddler with a second baby on the way. And if you've seen the kids TV programme Digby Dragon, you may already know her as the voice of Fizzy. She's brilliant, she's down to earth, she's really honest about incontinence and prolapse. So don't forget to subscribe. Tell me what you think and spread the word. Tell a friend or spam or WhatsApp group. Lots of you have been posting on Instagram, which has been fantastic. Let's end the stigma. You've been listening to Why Mums Don't Jump with me, Helen Ledwick. You can find me on Instagram at Why Mums Don't Jump, or online at whymumsdontjump.com, where I'll put more information about the episodes. Bye for now.