Between The Sheets: Sex & Pelvic Floor Dysfunction - 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 told me then I'd be speaking about this stuff out loud, I would have told you to give your head a wobble.

Helen

Hi. Welcome back. Whoever would have thought we'd be here talking about sex after pelvic floor dysfunction? Doing the deed, when all hell has broken loose. But we are, because it's important and because incontinence, prolapse, pelvic pain, birth injuries, birth trauma, to whatever degree, they all have this massive impact on relationships and intimacy, physically and mentally. It's not easy or obvious to know how to get help or where or even if you should, or how to feel good about yourself or how to communicate any of that to your partner. So it's just yet another thing that we really need to talk about, I think, and another thing you've asked me to talk about. And thankfully, there are people out there who can help and understand, and I mean really understand. One of them is Jilly Bond, who's a pelvic health physio based in Wales, with years of experience in this and a specialist interest in pelvic pain. We first spoke a few weeks before we recorded this episode and knew then that she was someone you would want to hear from.

Jilly

Pelvic health issues have a level of shame associated with them, which is just debilitating. It'll be, on average, six to eight years before people go to the doctor and say, ‘I'm leaking still after I've had my baby’,‘I'm still wetting myself when I go for a run’ or when I'm, you know, ‘I can't get through dinner without having to rush to the toilet.’ And that's for the stuff that's becoming a little bit more socially appropriate and acceptable to talk about with your friends, thanks to the Tena Lady campaigns and a lot more work like you're doing and more knowledge out there. But when it comes to intimacy, that has a whole level of shame attached and taboo attached to it, beyond incontinence or prolapse. And it tends to be that in all pelvic health settings, wherever you see a specialist pelvic health physio, you will always be in a private room with a door. And we all ask the same set of questions. We all ask about your bladder, about your bowel, about how everything's feeling in the vagina, or if you're a man, from the front end. And then we ask about intimacy. And they're not embarrassing questions,they're just ‘Are you achieving what you want to?’ Because everyone has sex in a different way and it doesn't mean penetration. It can be lots of different things. But from a women's female point of view, that tends to unlock a whole mass of problems that can occur that people have never had the opportunity to talk about with someone that knows about it and is really willing to listen, and all of these issues are so fixable, so remediable. I struggle to find in my mind anyone that we haven't been able to make progress, at least, if not really get them back to normal intimacy or intimacy that's fulfilling for them through treatment. It's like having a bad back, you know. We can get things moving.

Helen

And intimacy after childbirth, however that has gone, is always going to be interesting and a bit of a challenge. But then if you add birth injury, birth trauma, prolapse, incontinence, pelvic pain on top of that, it does feel like a massive mountain to climb. I think it's interesting, like, just that notion of when you get asked that in the consultation room or in the consultation with the physio, that's probably the first time that you've really been given permission to even consider it.

Jilly

Yeah, and people don't consider that it's not normal to go back to intimacy that is fulfilling. People think‘Well, I've just pushed this bus out’ and I've had, even if they've had, quote unquote, a normal delivery, that can be ridiculously traumatising for many women, especially during this pandemic, when they haven't got that support at those moments, apart from our great midwives that are doing the best they can. So to have even a standard medical delivery, that can leave you with abrasions or just small grazes, but even just swelling, pain, discharge that's different. You keep bleeding. You bleed a lot. Your pelvis still hurts as everything kind of fuses back together and then you've got the process of actually just looking after a small person. And from motherhood, from pregnancy to motherhood, you have this whole big change in focus from:‘How are you?’,‘Are you feeling the baby?’,‘How are you doing?’to suddenly:‘How is your baby?’ And you are irrelevant. And then add on top of that the kind of the burdens of a relationship, whoever your relationship is with, thinking, ‘Well, how am I ever going to go back to being me when I don't feel sexy and I feel a bit broken?’ So the psychological side of things is really quite challenging for a lot of people and that's...you know, within clinic we see that. So that the common issues that we have are from a standard delivery where again, I say, quote unquote, standard. There is no standard delivery from a medical point of view where we haven't seen any major trauma. And unfortunately, I'm who you end up seeing if you've had any kind of major trauma. So our normal deliveries... 

Helen

We'd all be very glad and very lucky to see you, Jilly.

Jilly

Oh, here we go! There are there are thousands of us in the country, so hopefully you get to see someone. But every woman should have a ‘mummy MOT’ or a post-natal checkup, where your pelvic floor is checked. We check your bladder, your bowel, your vagina, your pelvis, your abdominals, and then how you are with your relationship to intimacy. We don't expect you to be going back to it at a certain date because it's different for everyone. Some people's intimacy is very sporadic. Some people like a lot more intimacy. Some people's intimacy is intense, others isn't. It's about getting back to what you want to be doing at a time that you feel comfortable, and physios are there to support you in the same way that we would help you to get back to running or getting back to CrossFit after a baby. We'd show you the appropriate steps at the appropriate time. So a normal delivery, we'd look at all those things. But it may be that women have a lot of fears and really need to talk about what's happened in that process. And if it's safe to go back to having penetration by anybody or by the partner or by having any kind of foreplay outside, is that okay? If you've had an abrasion or a clitoral issue or a labial tear or something like that, or a perineal tear, and then we start seeing the issues. So if you've had an episiotomy, you might still be really sore from the episiotomy scar. And actually, quite often that tracks further up the side. I'm using my finger to demonstrate just because that's how we assess it. But we can feel for those stitches to make sure that they're well healed. You've got the fears around ‘Am I stitched? Am I healed? It's been six weeks.’ But sometimes people get wound infections. So all of that can be very sore and tender and actually remain sore and tender for quite a while. Then we have, kind of, the range of injuries that go up to much greater tears that involve the anal sphincter, where you might be having some anal incontinence or discharge as well. And that's a real tricky subject for women to broach because they come into a clinic going, ‘I can't sit down with my husband’,‘I can't go out for dinner with my partner’,‘I can't leave the house because I have this horrible incontinence from my back end.’ And it's beyond embarrassing. It's awful. It's truly debilitating. They want that fixed. They're not necessarily thinking about the next step of ‘And how can I perform in the bedroom?’ And if they have prolapses as well, there may not be pain, but there may be feelings that aren't normal, especially in that first six months as everything's getting stronger and getting past its swelling and calming down. So we have layers upon layers. You have the biological issues that can happen around delivery, but then the huge amounts of fear because we don't talk about it. Your mum doesn't sit down and say,‘Oh, well, I had anal incontinence for three months after my delivery and then I discovered I had a prolapse. I had a rectocele, but after I did my pelvic floor exercises and I had some coaching, that all went away. And then me and your dad managed to have sex again.’

Helen

No, that's not a conversation that I think I would probably want to have. Love you, mum, but still.

Jilly

No!

Helen

But you're right, like, the mental side of it, you're knackered, anyway, you're a new mum, you're looking after kids. And then I don'treally ever think that I considered what my own vulva looked like before I had my prolapse. And then afterwards, I was just a bit like, ‘I don't want to think about this. I don't want to think about this in relation to intimacy and that I might be wearing a pessary and let's not even let my head go there, because when my head goes there, then that is a mood killer. That is game over.’ And I guess that's just at the lighter end of the spectrum, like I don’t have all those...

Jilly

And that's the thing that people often say that, ‘Well, I've only got this.’ But you've got that and it's something that's awful because it's something you've never had to consider before, your bits falling out. They're not going to and we'll keep them in place and we know how to keep everything nice and secure. But those kind of questions like what do you do if you'vegot a prolapse and you've been given a pessary, which are, by the way, given to younger people. We don't put pessaries in 90 year olds anymore because they fall out. But yeah, what do you do when you've got a pessary or someone's given you a pessary, which has fixed your problem but hasn't really and you want to go to the gym? Where do you put it in when you get to the gym and you get changed or you want to go swimming? Do I wear it when I swim? Or what happens when it comes to intimacy? Is he going to feel it? Is she going to feel it? Is it going to move? Am I going lose it? So these are all the questions that, as pelvic health physios, we are very comfortable to navigate and often it will take a couple of sessions for someone to feel comfortable enough to say, ‘I want to do this with my other half. Is that okay? Am I going to damage myself?’ Or ‘How can I achieve this?’ And ‘Is this normal?’ And that's just about trusting the physio that you're with. But nothing in these consultations is off limits as regards to discussing intimacy.

Helen

Because we talked a little bit before, didn't we, about even the visual aspect of it? So the mental thing relating to how you feel about your own vulva and what it looks like. And we talked about you mentioned the Great Wall of Vagina, which I am now familiar with.

Jilly

Good. Good. What do you think?

Helen

It's incredible. Yeah, so for people who don't know, this is an art installation. It's plaster of paris moulds of lots of different people’s vulvas and vaginal entrances. And the artist is Jamie McCartney. And, yeah, I don't know, there must be hundreds of them, sort of side by side by side. And they're all so different. They're all so different.

Jilly

And they’re so beautiful. And the joy is that you can see older ladies, you can see younger people, you can see people with prolapses, people with jewellery, people with more hair, less hair. There's lots of wonderful things that you can see on this because it's normal bodies. And when we were talking about intimacy and problems before, and we were talking about this kind of the fact that, for women, 80% of sexual arousal is mental, and it's about feeling turned on, you know, let alone the fact that your hormones are telling you not to feel sexy when you've just had a baby, because it's about keeping the children that you've got alive so you don't get aroused as much and you don't get so much lubrication in that way. You know, we don't look at our vulvas when we're young and we all should, like we do breast checks, but we don't look at them. So then when something as huge and life-changing as having a child happens, it's difficult to know what's changed if you didn't know what was there beforehand. So the one that sticks in my mind is the lady whose child was four years old and she wanted to have a second child and she was referred to me because sex was painful. So through discussions through clinic, we worked out actually her issue was that she'd had a tear and was beyond traumatised by what that was because tearing of the most intimate part of you, but then also was incredibly ashamed of what she looked like. And what we did was she took pictures of her vulva safely in clinic, not uploaded to anyone but her. And we compared them to the great Wall of Vagina. And we just went through one by one by one, and by the end of that session, she was like, ‘Actually, it's quite pretty. It’s quite neat’. And we were able to discuss these things. But that's all about expectation. One of the really important things to know with pain is that pain is not always dependent upon tissue damage. Pain is a response of the body to protect somewhere that feels like it may need protecting because of tissue damage or the potential for tissue damage, and is based on predictions by your brain about what it thinks is going on. And that's really, really important to know that it's your brain making predictions. Now, most of the time, if it's your hand, if it's your arm, your knee, these predictions are quite accurate because you can see those bits. But when we start talking about your vulva, which you've never looked at, you've just gone through a massively emotional traumatic experience, which hopefully was positive, but we know that even the most positive experiences have trauma within them. You start having issues with that prediction being possibly much more negative, and then you're dealing with an area that you physically can't see because it's inside you, as well, within the vagina. So those predictions are not accurate, necessarily. And this is where we see the much more complex and beautiful side of pain with intimacy, which is where, you know, I'm a specialist within a specialist, so I deal with pelvic pain as what I do all day, every day when I'min work. And that's where we see the body is doing an amazing job of protecting you from what it predicts is happening. And that prediction is that you've got a tear or you've got more damage or something else going on, so it's going into spasm. So it hurts to have sex because all the muscles going to spasm. Yeah.

Helen

That’s incredible.

Jilly

Yeah. Yeah. The body is incredible.

Helen

So it's sort of relating what's happening in the bedroom just because it's that part, the same part of your body, with the trauma - or whatever you want to call it - that you went through when the baby came.

Jilly

Yeah. And it's the same process that we do when we learn to walk, because the body gets good at predicting how you're going to feel when you stand, which muscles it needs to use, but this time it's applying it to keeping you safe and keeping you alive. And those predictions aren't always true. So this lady that had serious pain with intimacy, it was all based on the predictions of her brain that were still going on about this tear still being there. But we got to the point where I could assess her and I could touch that tear where the scar was, and it didn't hurt her. And I was saying, right, so if that isn't hurting, then what's hurting? And she was... everything becomes very hypersensitive. So if you've ever had, like, a really bad cut, but the cut itself doesn't hurt, but all the skin around it does.

Helen

Right, okay.Yeah.

Jilly

Yeah. Why is that?

Helen

Don't know.

Jilly

Makes no sense, does it? Why would an area that's not injured or damaged hurt? It's there to say ‘Don't go any further because you'll damage yourself more.’

Helen

Yeah.

Jilly

So it's the same downstairs that can happen. So the skin of the vagina inside can become hypersensitive. So it's kind of, ‘Don't touch me. Don't touch me. You might damage me’, but really there's no damage to be had 99% of the time. Obviously in the early stages, postnatally, with tears and things, we need to give them three to six months to heal. And we can encourage that in the way the same way you would have a cut anywhere else in your body. You'll heal. It will get better. And if it's tense or tight, we need to help it relax. And a lot of the time that's the issue, is that it's kind of forgotten how to relax. It's doing so well at protecting you. The whole area needs to be soothed and calmed, and that's the key to getting intimacy back in any postnatal pelvis, is finding what the crux of the matter is biologically and psychologically.

Helen

And then if there is that sort of overtight pain, then that can be done through massage or...?

Jilly

Yep. Most physios will do a therapeutic assessment, which means that when we assess in the pelvis, when you have problems that are very ‘I leak when I do this, when I jump’, all the rest of it, we're looking at the muscles, we're looking at how strong they are, how far they move up and forwards can they resist, things like that. They're going to be strong enough to lift, but when we have pain, we won't do that. We'll say, ‘How does your body react to me, my finger touching you?So is it hypersensitive? Is it making predictions that I'm actually cutting you or hurting you?’ And a lot of people say, ‘Yeah, it feels like I'm cut, I'm raw inside after giving birth.’ But we can say, ‘Well, actually, you're really well healed. Your scar is well healed. Everything's nice and plump. It's soft, it's pink.’ You know, give all that reassurance and that starts to build better data upon which your brain can make these better predictions that are more accurate about what's going on. And so we see the pain come down over time. So it's a process of reassurance, education about what you look like, what you feel like, but also calming everything down. So we'll do these therapeutic assessments and physio should never hurt. And if you're in any pain postnatally, and someone touches you or does an assessment, and it hurts, they're not doing the right thing. You need to find another physio or you need to tell them to begin with that it hurts. But we'll calm the muscles down as well and we do lots of very gentle massage that you can also do yourself.It's not rocket science. It's just a bit of an awkward angle in the shower or the bath.

Helen

And that can make a difference?

Jilly

Yeah.

Helen

So that's the pain aspect. If there's people listening to this and for them, it's just like there's probably lots of things going on, but on a very practical level, maybe you can't even begin to contemplate intimacy because you leak poo or you leak wee. I mean, where do you even start with that? I think you mentioned earlier, you know, that's your priority, getting that sorted to a point.

Jilly

Yeah. You start with getting the problems fixed. So a very, very common, you know, one in three women will have incontinence at some point during life, postnatally or post menopause. And every single woman that I've ever met has had an impact on their intimacy in some form, because they're afraid that they smell and afraid that they'll wet themselves during intimacy. So people aren't getting back to normal foreplay, to normal other forms of intimacy, oral sex, those kind of things, because they just feel awful. The same with prolapse, the same with anal incontinence.So the first thing to know is that all the research that we have and the last count, I used to work for a journal, and the last count we had 82 randomised control trials showing pelvic floor physiotherapy and training is curative for more than 80% of people within incontinence. I think it was somewhere like 88%. So we know that three to five months of doing some pelvic floor exercises will get you dry from bladder incontinence or get you sorted from anal incontinence. If you've been doing it, cracking it out for three to five months yourself and nothing's changed, you need to make sure you see a physio to make sure A: you are doing it right, and B: is there anything else we can do to maximise or improve that? And I promise there's hundreds of things, so we know that we can solve those incontinence issues. And while we're doing that, while we're in the process of solving those incontinence issues, can we look at how your bladder is filling, how it's emptying? Can we try some tricks of the trade to make sure it's emptying fully before you have sex? So really simple things. So postnatally, we know a lot of women get small kind of stretches in the vaginal lining, so kind of mini prolapses. Everything can be a bit more fluid in how it moves inside and it's not so supported. So actually, just sitting on the toilet, not pushing down, but rocking forwards and backwards, massages that bladder over the tube in the middle, allowing any water that's caught in the corners to come out. So, again, nip into the toilet before you have sex. Granted, it's not brilliant if you're in the mood, but come on, let's be honest, if you've got a child, it's timetabled.We’re scheduling it in.

Helen

Spontaneity is just not really the thing, is it?

Jilly

No. Nap time sex. So you can nip to the toilet and just try and see if we can empty it fully, then that will give you more of an opportunity to feel calmer that actually no urine is going to leak out, but pushing down to strain to get poo or wee out before you have sex isn't helpful because that's going to put more pressure on the tissues in the middle. And we've also got loads and loads of brilliant little things that we can do from a bowel point of view to stop that happening. So we look at changes in your diet that are individualised to you, that can help it to make more formed stools or to help you shift during the day. So if you know that actually you're more likely to have sex in an evening or in a morning, whenever it is, can we work in a way that we know your bowel is always going to be empty then? And there are also certain medications. We can talk with the doctor that would firm up your stool a bit more, so it's not likely to fall out during these moments. Supportive devices, other things that you can pop there that, again, will give you this confidence to know that things aren't going to happen, which will allow you, over time, to continue with your treatment to get those primary issues solved. But in the meantime, you can go back to intimacy, if that's what you want to do.

Helen

And it's a staged process, isn't it? You're not going to fix all of these problems. It's not like there's a magic silver bullet. It's a little bit at a time of trying different things, I suppose.

Jilly

Exactly. And it's the same way that you'd think about going back to running. So if you were a runner before you had your baby and you really, really want to go back to your 5k or 10k, you're not going to go straight out six weeks postnatally and go, ‘Right, I'm going to do a 5k.’ You'd fall over wheezing in no time. It's the ‘Couch to 5k’ approach. A little bit of running, a little bit of walking, making sure that your pelvic floor can cope with it. And that's the same process with intimacy. So we take a much more staged approach to making sure that you feel in control, that you feel comfortable. So are you comfortable to be touched? That's the first stage. Not just intimately, but is there that intimate touch in your relationship already? And I would say most women that have a significant issue more likely with pain or a tear or a C-section that’s still sore that come into clinic will have, because they don't want to get to the point of sex, they'll be sitting on a different sofa. They'll be avoiding touching a bum in the kitchen when you're making a stir fry. That kind of intimate touch that's normal in a relationship, but signals that we're going to move towards having some intimacy later.So the first step is to get that...

Helen

No, I think that's so interesting and I think I'm going to put my hand up and say that I have probably done that at points and without even realising that that is what you're kind of doing in that situation. So the idea that you can just unpick that little by little, I think that's really a useful and helpful thing.

Jilly

And it's got to be led by you. So you've got to be comfortable. But the physio will have the skills and the tools to help you to find where you are and where is that grounded space that you are in right now and where would you like to get to? And we definitely come from a point of view, and hopefully I've reiterated that enough in this session, that sex isn't penetration, sex isn't man and woman. Sex is intimacy between two people. And regardless of who the physio sat in front of you is, they will help whoever you are to achieve whatever you want to do, which is normal for you. As long as it's legal and consensual then anything goes, as far as we're concerned. We're here to optimise your function. And the first step is saying, yeah, ‘Are you even getting any form of intimacy or holding hands? Is that something maybe that you would think about working on this week? Right. You can't hold his hand or her hand. Okay. Why?’‘Because I'm scared that actually they're going to be like, right, all over me in bed later and I've got my jumper and my dressing gown because I'm cold or I'm pretending to be cold and I'm wearing my socks and my gross pants so they don't come near me.’All of these signals have kind of ‘Stay away from me.’ Right, well, what do we need to put in place for you to feel safe enough to be able to take that first step? We'll carry on with our physio, we'll carry on with doing your pelvic floor exercises and looking at ways to support your anal incontinence and working forward with your diet and all these things that we do as part of your medical therapy treatment. What else do you need to do to feel safe? And, some of the time, that means working with some fantastic teams in the NHS. They're better than anywhere privately. And I work in both camps, I have worked in both camps, so I can say that comfortably. The NHS Psychosexual Services are brilliant. They are doctors and nurses and therapists that are trained in counselling around intimacy and problems with it.

Helen

Do you feel like there is a way to help everyone? Because I think, you know, some people must be feeling really desperate.

Jilly

Yeah. I've never come across a case that I've not been able to help them move forward in some way. And as I said...

Helen

With intimacy?

Jilly

With intimacy, yeah. In pelvic health, we see everyone that we can. We would see every single woman if we could, because these are the conversations that happen behind closed doors with your friends and aren't always real. Because even people, when you think you know loads about it and you've had a couple of babies and you've leaked for a while and you think you know what you do, and actually talking to someone about everything to do with your pelvic health, you might realise that there's a lot of it that can be changed. It is not normal to leak ever. It is not normal to pass stool ever, unless you want to. It's not normal to have any form of pain after you've had a baby. It's not normal to have no sensation. So a lot of women will go, ‘Oh, just, yeah, sex isn't the same. I can't come anymore.’ Well, that's not normal. Let's see if we can improve that. Let's see why that is. It shouldn't feel exactly the same as it did before, but it should feel pretty good.

Helen

And I think part of it as well is we have to believe that we deserve that. There's this whole rhetoric around where you've had a baby, what to expect, and that covers everything. Like, your body's changed, your mind's changed, your energy has changed, and your sex life will not be what it once was. But actually, we need to get past that a little bit and just believe that we deserve a little bit more than that. And actually, we deserve a decent sex life.

Jilly

Absolutely.

Helen

And there's a way to get back to it.

Jilly

Yeah. And there's so many simple steps, and the first step is the hardest. Getting to your GP and saying, ‘I've got a problem’, and you don't have to say to your GP, ‘I can't have sex in the way that we always used to. And that's straining our relationship.’ You just have to say, ‘I've got some leakage. I'm wetting myself and it's not got better’, which is socially appropriate. Get yourself to the specialists, get yourself to the gynaecologist or the physio. Tends to be the physio or the nurses that have got the hour to spend with you to really talk everything out.That's the space in which you can really explore it. One of the things I think is really important is that there's, culturally, a bit of a pushback about being super mum and having it all, you know, working career and being a mum and all the rest of it. This is not about that, you know. Having your body working is not about having it all and being over the top. It's just about having a basic human right. If men gave birth, then this would not be an issue. The whole of medicine is based on men and their bodies working well. If men, for some reason broke an arm when they were playing golf, then golf would be made safe. And it's the equivalent. We have these injuries to our bodies and we're just not treated for the injuries. But it's just like twisting an ankle or breaking an arm. You can get better from it.

Helen

So last week in the UK, the Health Secretary, Matt Hancock, said that, for generations, women have lived with a health care system that is designed by men for men. He was launching a consultation into the gender health gap. We don't know enough about conditions that only affect women, and the government is now asking women in England to share their experiences of healthcare services. I've done this myself. It's an online forum. I think it took me about 25 minutes. And it's a chance to have your say, right? I don't know where it's going to go, but it's a start. I'll put a link in the show notes as well as information about all the other things that Jilly and I spoke about in today's episode, which I really hope you found useful. Next time, we're going to hear from another stigma smasher - Peace, a mum who's been sharing her experience of nighttime leaking on Instagram as @baileysinspain. You've been listening to Why Mums Don't Jump with me Helen Ledwick. Let me know what you think. Leave me a review and please tell all your friends. You can find me on Instagram @whymumsdontjump or online at whymumsdontjump.com

Bye for now.