Dr Adanna's Pelvic Floor Guide - 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.

Hi. Welcome back. How are you?

Funny story for you, not so funny for me. Definitely oversharing, right? So I've had a numb bum all week. My left buttock has been numb and I think it's because instead of doing the sensible thing and using a footstool when I'm on the loo, you know what I'm talking about. I've been using a pedal bin, which is really far too high for the job, and I think I've pinched a nerve from sitting like that.

So, as you know, I'm not a medical professional. I might be talking absolute nonsense and someone will definitely tell me if that's the case. But, yeah, consider this a warning. Use a footstool or a couple of toilet rolls, not a bin. Bad idea. That is your Public Service announcement for today.

This week, I bring you a chat with Dr Adanna Okeahialam, who's an obstetrics and gynaecology registrar with an interest in urogynaecology. And the reason I wanted to speak to her is because of an academic article that she co wrote last year, which I came across when I was writing the book. It's called 'Pelvic Floor Muscle Training: A Practical Guide'. It was published in the British Medical Journal and it's aimed at medical professionals to help them to understand how to advise women when it comes to pelvic floor muscle training, or Kegels, or pelvic floor exercises, which was really encouraging. And I would highly recommend having a look because it's really simple - a positive and practical change that will hopefully help loads of women when they do need help. But also surprising, right? Because how is this not already part of standard learning practise? So that's something I wanted to ask Dr. Adanna about.

Dr Adanna

People forget that pelvic floor problems affects around 15 million women in the UK. And, I mean, I was so surprised the fact that simple things like teaching women how to do pelvic floor exercise at home, like that guide wasn't already there, and something that affects women so much should really, really be researched more as well. And again, prior to...although now I'd say it's definitely more in vogue looking after pelvic floor muscle problems and also research into it and treatments surrounding it...but prior to this, it wasn't really something that researchers or clinicians were really that okay about. So it's definitely, definitely getting the interest it needs now. Definitely. And I thought by writing the pelvic floor guide that would at least help clinicians who probably aren't too well versed in how to offer women pelvic floor muscle exercise - particularly if they're not physiotherapists - a bit of a guide.

Helen

Yeah, and I guess it's for like GPs, midwives, health visitors? I don't know, all of that?

Dr Adanna

Exactly. And they might not necessarily get pelvic floor training within their training at all, or have ever seen that many people or patients with pelvic floor problems. So I just wanted to give them a guide that would hopefully make things easier for them, but also for patients to be able to use at home as well.

Helen

Yeah, sometimes you feel like you're in a bit of an echo chamber, so I'm never quite sure, but it does feel like things are changing to me. And I was so surprised when I was writing the book, like how little training people get in pelvic floor dysfunction. So if you go to your GP for your six week check or whatever, the idea that they may well never have been trained to do a vaginal examination, for example, may not have this basic grasp. So to know that that's out there to me is like good news. I think we can be positive about that.

Dr Adanna

No, definitely. I think especially with the Royal College of Obstetrics and Gynaecology making their position statement in February, I thought that was so important just to show Obstetrics and Gynaecology trainees that this is something that we really need to learn about. I mean, if you look at other countries, like France, for example, they have what they call a perineal rehabilitation service for all women after they had babies. So if other countries are doing it, I think the UK definitely needs to get on board and start doing things so there are better outcomes for women who've got pelvic floor dysfunction.

Helen

Yeah, I was really pleased to see that as well because - I'll talk about this now and then afterwards, let's get down back to some basics about what the public floor is and how it works and stuff - but while we're kind of here yeah, I was really pleased to see the Royal College of Obstetricians and Gynaecologists kind of promoting pelvic health education and pelvic health physiotherapy and the knowledge base for other kind of clinicians to offer this stuff. Because I think when I was first diagnosed with prolapse or whatever, I don't know, it seemed to me like it was a bit binary. It was like you either go down the surgery route or you go down like the physiotherapy or really just pelvic floor exercise route. And so the idea that that's sort of coming together now in a bigger picture... is that how you feel about it?

Dr Adanna

Yeah, definitely. I think it's just making people know that actually pelvic floor muscle exercises should really just be part of your lifestyle. You brush your teeth, you have a shower, it should just be something that is ingrained within you because it's really important to your life and outcomes, basically, so it's something you should really get on board with.

Helen

It's so hard to do, though.

Dr Adanna

I know

Helen

I've got that Squeezy App telling me three times a day, and some weeks I'm really good at it and some weeks I'm really not.

Dr Adanna

But I mean, you're doing something, which is good. That's the main thing, isn't it? It's not like everybody goes to the gym every day or twice a day, do they? So as long as you bring it as part of your lifestyle, that's the main thing.

Helen

That is very true. So, okay, let's try and do a little refresher for anyone, or for anyone who's new to it. So what is the pelvic floor? What are we talking about when we're talking about the pelvic floor?

Dr Adanna

So we're talking about a supportive structure which is mainly based of muscle, which helps support your bladder, your vagina and your anal canal as well. Like any muscle, it usually has a constant tone, but it will relax and contract voluntarily and involuntarily, particularly for moments where there's an increase in pressure in your tummy. For example, if you sneeze, cough, if you stand up, sit down, squat, to stop you from basically leaking, urine or stool, basically. It's also very important with your sexual function as well.

Helen

So it does loads of things!

Dr Adanna

It's a very intelligent muscle.

Helen

Yeah, it's really complicated, isn't it? And yet I had barely heard of one until it all went sideways.

Dr Adanna

It's just...I don't know. I'm glad things are changing now, definitely, but I mean, prior to that, it just wasn't something that people really were talking about. And then actually...back to sorry, the college statement. I mean, they said that 70% of women hadn't even seen a healthcare professional with regards to their symptoms, and the majority of the women who didn't was because they're embarrassed. And then if there's that culture of actually this is a shameful diagnosis, or something that's actually just normal part of childbirth, then clinicians are never going to see it. And then it's just a vicious cycle of nobody wants to attend a clinician, but then also clinicians, then not knowing how to manage these things.

Helen

Yeah, that's so true. And I talk about this a lot, but this idea that it's normal, it's out there with medical professionals, it's in the whole of society. We do it to ourselves, we think it's normal, so we ignore it, we're embarrassed about it anyway and we just try and get on. And in the last couple of weeks, actually, since the book was out, I've had a couple of emails from women in their fifties and sixties who have had problems for 30 years, and if they did try and get help, they were told it was normal. Off you go. And then lived, like with leaking and horrible things, and never known what it was and just thought that was it and lived with it for decades and it's so sad.

Dr Adanna

Exactly. That's something that I commonly see in my practise as well is that women will come in their fifties and their sixties, and actually, when you get to the crux of actually, when their symptoms started, it's been going on since they've had a baby and they just thought it was normal, or they were just a little bit embarrassed, too embarrassed to talk about it, and then just haven't come for years.

Helen

So going back to the practical guide, which what brought me to you in the first place, when we're talking about pelvic floor muscle training, what do we mean? Is it just kegels or pelvic floor exercises or whatever you want to call them?

Dr Adanna

So basically pelvic floor exercises are a way to strengthen, also give the muscle endurance, but also help with muscle relaxation as well. And I also say muscle relaxation because I think it's something people often forget about a lot, that you can make a muscle very, very strong, but that can also not be good in the long run, because the muscle then will not know how to relax and can leave you with things like pelvic floor pain and also sexual problems as well. So there are lots of ways you could do pelvic floor muscle exercises. I think the difficulty is that it's quite hard to learn just by verbal instruction. And actually a quarter women, although you can tell them how much to do pelvic floor exercises, may not be doing them correctly.

Helen

Is it a quarter? Right ok.

Dr Adanna

Yeah. So it's quite a significant number of women. And what I try and say is imagine that you're trying to hold in a wee and also hold in stool at the same time, or wind at the same time. Easiest way to do it is if you can sit down first and then lie down. So you can actually really concentrate on the pelvic floor muscles and try not to contract your abdominal muscles at the same time. And as you get more and more comfortable with them, you can then do them when you're walking around, do them when you're going from sitting to standing. You can involve them in functional exercises. Because I think that's important. The more and more you make pelvic floor exercises functional, the less likely you are to have symptoms in your normal and daily activities of living.

Helen

I think one of the things like hear often from women who are really underwhelmed with advice to do pelvic floor exercises, sometimes I think people can feel a bit fobbed off. You go to the doctor, maybe you're given a leaflet, you've got these, like you said, life altering problems going on and then you're given a leaflet to go and do pelvic floor exercises. But they do work, don't they? The evidence, the evidence is there, right?

Dr Adanna

The evidence is there. There was two big, what we call systematic reviews. So they're like the top quality evidence that clinicians and chief executives and health outcomes look at which basically showed that pelvic floor muscle exercises, women who do them in comparison to no treatment, saw a reduction in their symptoms by half or a cure. And then same with pelvic organ prolapse and also faecal incontinence. So there is evidence that it works. It's just sticking to it because you can do them here and there, but if you stick to them, you're more likely to see your symptoms improve.

Helen

It's so obvious when you think about it. But I think I've said this before, but...I sort of knew when I had the prolapse that it would be beneficial and I should do pelvic floor exercises. And I thought that I was doing them because I was just like doing them a couple of times a week. And then a physio sort of said to me, well, you wouldn't expect to get a six pack by doing a couple of squeezes.

Dr Adanna

No, exactly.

Helen

A couple of sit ups every now and then.

Dr Adanna

But it's a very good analogy, definitely. But I do say to women that I see that I know you can give people as many leaflets as they want, but actually I don't think it's that helpful. I think that if you find a good guide that can teach you, also reminders, like you said, the Squeezy App can be also helpful as well. But if you had a really good go and you just don't think your symptoms are getting any better, it's definitely important to go and see your general practitioner. Then they then come refer you to a urogynaecology service who often will have a physiotherapist as well.

Helen

Yeah. Because of course there's a spectrum of all these problems and the ways that they can affect women. And I guess pelvic floor exercises is going to be great for some people on that spectrum. And then it is not going to work for everyone, is it?

Dr Adanna

No, exactly. And there will be some number of women who, no matter how much they do pelvic floor exercises, will still benefit from further treatment. Be that with additional devices to supplement their pelvic floor muscle exercises, or if they need surgery, that option being there as well, or in the context of prolapse, even possibly a pessary, or if they're leaking urine, there are also some really good devices that they can use to try and prevent the leakage of urine. So there are lots of options available. It's just knowing that help is there and not being too embarrassed to seek it.

Helen

Totally. And there's a preventative effect as well, isn't there? Because I think it's always a hard one, because you're always like...because I think with a lot of these problems, certainly you're always like, oh, you blame yourself and you're like, what if I'd done this, what if I hadn't done that? What if I'd birthed better, what if I'd done more pelvic floor exercises? So it's sometimes a bit of a difficult one to hear, but on like a population level... we think these things can prevent problems?

Dr Adanna

100%. I was part of the NICE guideline committee that wrote the new guideline on prevention of Pelvic Floor Muscle Dysfunction. And what they found was that not only prevention of pelvic floor dysfunction can be done with pelvic floor muscle training but it's actually cost effective as well. So one thing they brought out of the guidance was to try and make sure that you can bring in pelvic floor muscle education within schools. Because actually, I think the younger you teach young girls, and even young boys about the importance of your pelvic floor, the more likely it's ingrained within them and they're going to seek help if they have problems later on and also employ methods to prevent them having problems. So the education is so important.

Helen

I agree so much. Often people say, oh, Helen, shouldn't we be telling people in pregnancy, shouldn't we be teaching people about all this? And then there's that whole, well, we don't want to scare people. What can happen? All this. I was like, no, we should be teaching it from the get go, from kids. Yeah.

Dr Adanna

Exactly. And I think it's important. I completely echo what you say about there's this fear about scaring people in antenatal classes and during birth, but I think that you have to appreciate that this is the woman's own body and they should be able to make an informed choice about their delivery and their labour process. So if you don't give someone all the information, then you're doing them a disjustice.

Helen

Can I be really nosy? I'm just imagining, like, do you have girlfriends, people around you who are having babies? Are they always like, Adanna, I want to ask you everything. Adanna, don't tell me anything.

Dr Adanna

Yes. I'm everyone's personal obstetrician and gynaecologist, for all my friends. But it's fine, that's what I'm here for.

Helen

They just leave you kind of quaking in their boots, but they leave informed and ready to make decisions. So, yeah, you mentioned the new guidance that came out in the last couple of years, and again, for me, you said it the guidelines for prevention and non surgical management.

Dr Adanna

Yeah. So conservative measures and non surgical management of pelvic floor dysfunction. So a big part of it was looking at the prevention.

Helen

Yeah. And I think I'm right in saying that's the first time anything like that has existed. So that feels quite significant and positive in itself, right? Just the fact of that existing.

Dr Adanna

Exactly. And it came off the back of the Cumberlege report, which just showed how many women were suffering after having invasive procedures for pelvic floor dysfunction

Helen

With the mesh. Yeah.

Dr Adanna

Exactly. So I do think it's so important this guideline was put out because it's really showing the public that prevention is key and there are conservative measures that can be done first before we think about going to surgery, because one in ten women will need to have surgery. But of those women, quite a few of them may need recurrent surgery or more invasive procedures. So we can actually prevent women from getting to that stage in the first place, the better.

Helen

It's really hard, isn't it? Because I think back to the first time when I got my consultant appointment after having the prolapse, and it's so shocking and sad and horrible, this thing that's happened to your body, and you feel so alien with it all, and all you want is a quick fix. I'm just like, this is horrible. I have a prolapse, please just fix me. Put it all back where it came from and let me just crack on as it was before. But I don't know. You must see women like that all the time. When they come to you, they're like, Adanna, please fix me. It must be difficult to explain what's going on, really.

Dr Adanna

And I think all clinicians, we really take into account the importance of informed consent. So as long as you are fully aware of all the risks and benefits of any management option, be that conservative, changing your lifestyle, surgical measures, and then you can sit down and make a decision.

Nothing is a quick fix because you need to think about the long term implications. And then actually, if somebody has thought about all the long term implications and still wants surgery, then unless there's a significant reason for us to say no, then that will be offered.

But we do have to make it clear that unless these management conservative measures are addressed, or your lifestyle is changed, for example, losing weight, stopping smoking, actually, I can do all the surgery in the world, but your symptoms are likely to come back.

Helen

And what would you say for women who've maybe got an appointment coming up with someone like yourself, a urogynaecologist? What advice would you give to them? What can they do to get the most out of that appointment? Because they've probably waited for months and months and months, right, to see you. What can they do, coming into that room, that will help you to help them?

Dr Adanna

Just making sure you've got a good timeline of your symptoms, when your symptoms started. I also say try and start your pelvic floor exercises, definitely. Even if you're not seeing a physiotherapist, just in the interim to seeing the consultant, the specialist or the physiotherapist, just because... if you've already started, that's less likely to delay your management.

And bringing somebody to advocate with, you can help. So a family member, you know a sister, a mum, somebody that can help you or be there to support you. Because I completely understand it can be embarrassing talking to somebody that you don't know about these intimate details, but sometimes having a friend or a family member there who's been with you through it can often help.

Helen

That's such a good idea. It's never occurred to me to bring someone, apart from to bring someone to look after the kids so that I can go in and have the appointment. But, yeah, that's such good advice and not wanting to talk you out of a job or anything, but if you could wave a magic wand, what's, like the one thing you wish women would know about when it comes to pelvic health that would fix it for generations to come?

Dr Adanna

Pelvic floor muscle exercises. Definitely. I'm one of with my friends, I'm always telling them that everybody needs to be doing their pelvic floor muscle exercises, just because, yes, we may feel fine now, but we don't know in years to come how our pelvic floor will be. So just bring it into part of your everyday life.

Helen

Yeah. And one of the complicating factors for me recently, especially, is there's kind of been a thing on Instagram. I spend a lot of time on Instagram. Recently it's like, kegel don't kegel, kegel don't kegel. And it's like, oh, it's such a confusing picture when you have these issues. You Google it, you don't know where to go. You get such conflicting advice. And now there's this whole kind of kegel v don't kegel thing. And I think it comes out of what you were talking about initially, about the fact that we have to learn to relax, use our pelvic floor in their full range. It's not all about tightening, tightening, tightening. And depending on what's going on with an individual, maybe you have to concentrate on one thing rather than the other.

Dr Adanna

Exactly. And I think that's a difficulty with social media. A lot of things we put out, and it's quite hard to decipher, what knowledge is correct and what knowledge is applicable to you. But like you said, with the pelvic floor, relaxation is just as important as contraction. So if you were to do a three second squeeze, it's important you do the equal amount of relaxation just because...any muscle, if it's overworking and it's too tense, then that's going to cause completely different symptoms than you started with.

And I do think if, for example, like I said, if you're really struggling with pelvic floor exercises, getting referred to, see if physiotherapist is helpful, because then they can properly examine you and see actually how tense or well, relaxed the pelvic floor is and actually how the tone of the pelvic floor is contributing to your symptoms.

Helen

Yeah, absolutely. I would love it if everyone just had physiotherapists on tap.

Dr Adanna

We need to move to France.

Helen

That is not a bad idea. Thank you to Dr Adanna Okeahialam. For me, that was a really interesting peek into what's going on behind the scenes when it comes to pelvic health. There's clearly a way to go. But if we're on the road to better informed professionals and more of a focus on pelvic health throughout our lives then I'll celebrate that and I'll put the links in the show notes to the papers that we've mentioned.

As ever, I'm not a medical professional. This isn't intended as medical advice.

The book. My book is called Why Mums Don't Jump: Ending the Pelvic Floor Taboo. And it's available now. If you've read it and you liked it please leave a review, because the algorithms apparently like that it helps other people to find it. If you've done that already, thank you. Thank you. Thank you.

You've been listening to Why Mums Don't Jump with me, Helen Ledwick. You can find me on socials @whymumsdontjump or online at whymumsdontjump.com. See you next week!