We sat down with Dr June Tan Sheren, GP from Osler Health who sees a lot of women patients and the fantastic team at Physio Down Under who specialize in women’s health physiotherapy. We wanted to raise some of the questions women often don’t talk openly about – urinary incontinence and pelvic prolapse – and hear from the experts!
What exactly do we mean by ‘urinary incontinence’? Are there different types?
Dr June: Urinary incontinence is the unintentional or accidental passing of urine.
There are four types of urinary incontinence, namely:
- Stress incontinence – leakage of urine occurring when the bladder is under pressure, for example when you cough, sneeze, laugh, run, exercise or lift weights. This is the most common type of urinary incontinence and is usually the result of weakened pelvic floor muscles, often associated with pregnancy, natural childbirth, pelvic organ prolapse, menopause, obesity and surgery.
- Urge incontinence – urine leaks when you feel a sudden, intense urge to pass urine, resulting in “not being able to reach the toilet in time”. This is due to overactivity of the detrusor muscles which control the bladder.
- Overflow incontinence – frequent leaking of urine occurring in chronic urinary retention, when you’re unable to fully empty your bladder. This can be due toobstruction or blockage in the bladder, for example from pelvic organ prolapse; or neurological conditions like stroke, spinal cord disease, dementia, diabetic neuropathy, or post-delivery or post-surgery where the bladder is unable to fully empty.
- True incontinence – where the bladder cannot store urine at all leading to constant or frequent leakage, for example from a congenital abnormality of the urinary tract,spinal injury, or fistula (a false passage) rarely occurring after vaginal delivery, Caesarean section or gynaecological surgery.
Some women have a mixture of both stress and urge incontinence also known as mixed incontinence. Factors that increase a woman’s chances of urinary incontinence include pregnancy and vaginal birth, obesity, family history of incontinence, menopause and increasing age.
Is urinary incontinence common in perimenopause or menopausal women? When do you most often see women?
Dr June: Urinary incontinence is the main symptom of genito-urinary syndrome of menopause (GSM), a condition affecting the female genital and urinary tract due to low oestrogen during and after menopause, and affects more than 50% of postmenopausal women. According to recent data, urinary incontinence affects women twice as often as men, occurring in about 20-30% of young women, 30-40% in middle age and up to 50% of women in old age.
Physio Down Under: We see women across all stages of life, but it is most often after childbirth and during peri and post menopause that we see those with bothersome urinary incontinence. Studies show that 1 in 3 women develop stress urinary incontinence as a result of pregnancy and childbirth, whereas urge incontinence and mixed incontinence become more common as women go through menopause.
When do you know when to seek help? Where should you start?
Dr June: If you are pregnant or just had a baby, or had recent surgery to the pelvic area, you may experience temporary urinary incontinence due to weakening of the pelvic floor which should mostly recover. If the incontinence is persistent or severe, or if you have not had a recent pregnancy or surgery and are experiencing incontinence, it is advisable to seek help from a healthcare professional. A good starting point would be your Family Doctor / GP who will assess the type of incontinence, ask about other symptoms and determine the possible causes. He or she may run a urine test for you to rule out a urinary tract infection. We can then liaise with physio’s like the team at Physio Down Under who specialize in these types of concerns.
Physio Down Under: Urinary incontinence is common but not normal. Some studies show women take on average 5-7 years to mention pelvic floor complaints to their physicians, and there are lots of different reasons for their delay in seeking help. Unfortunately, some women have long held beliefs that urinary incontinence is an expected consequence of childbirth and that little can be done to treat or cure it. Some women feel understandably embarrassed to mention it, and many wait until their symptoms have worsened to the extent that it severely affects their quality of life, such as stopping exercise due to urinary leakage or limiting their social interactions due to fear of not having easy access to a toilet.
At Physio Down Under, we are passionate about educating and empowering women about their pelvic health as early as possible, preferably even before symptoms develop. Commonly, we start that process when women come for a pre-conception or pre-natal check-up. However, as Dr June mentioned above, if urinary incontinence is noted for the first time during peri-menopause, it is important to rule out any underlying medical reasons. Like many other health problems, we often see better outcomes if women don’t wait too long before seeking solutions. Having said that, it is never too late to seek help!
What can be done to help?
Dr June: There are many treatment options available depending on the type of incontinence, the severity, and the underlying causes. In general, non-surgical treatments are known to work well and they include:
- Lifestyle changes – losing weight; cutting down on bladder irritants like caffeine, alcohol and sodas.
- Pelvic muscle rehabilitation under the guidance of specialist physiotherapists such as the team from PDU
- Bladder training, where one is taught by the doctor or physiotherapist to resist the urge to void and gradually increase the intervals between voiding.
- Medications such as vaginal oestrogen in menopausal and postmenopausal women can be very helpful especially in conjunction with physiotherapy.
- Vaginal pessary – a small device worn inside the vagina to prevent leakage can be very effective if fitted by a trained professional such as a specialist physiotherapist from Physio Down Under.
Surgery may be recommended for women with severe incontinence that is not improving with non-surgical methods of treatment.
Physio Down Under: Physiotherapy offers a variety of treatments for urinary incontinence, and these will vary depending on the type and severity of incontinence.
Pelvic floor muscle training has been shown to improve or cure a significant percentage of women with stress, urge and/or mixed incontinence. Research has shown that up to 40% of women perform an incorrect pelvic floor muscle contraction when only given written or verbal instruction, which unfortunately can lead to more harm than good. Some women hold excessive tension in their pelvic floor muscles, which will present as weak muscles, but the exercise treatment approach is different than that given to a woman whose muscles are low tone and weak.
A qualified women’s health physiotherapist can assess the pelvic floor muscles with a gentle and pain free pelvic floor examination and devise an individualised exercise programme to address each woman’s needs and goals.
Alongside pelvic floor exercises, these are some of the frequently used treatment modalities:
- Postural alignment
- Breathing and intra-abdominal pressure management
- Deep abdominal, hip and spinal muscle training
- Electrical muscle stimulation
- EMG biofeedback
- Imaging ultrasound biofeedback
Physiotherapy effectiveness and duration of treatment varies considerably for each woman, but with a good degree of compliance and consistency, results can be seen between 3-6 months.
Please explain more about vaginal pessaries?
Physio Down Under: A vaginal support pessary is a silicone or pvc device that is inserted into the vagina. It is designed to relieve prolapse symptoms and/or urinary incontinence by offering mechanical support of the pelvic organs. It can be compared to a splint supporting a hernia or a sports bra for your organs. Pessaries come in many different styles and sizes, and choosing the right one is dependent on many different factors including the type and stage of a woman’s prolapse.
Pessaries were traditionally used in post-menopausal, non-sexually active women. They were inserted by a gynaecologist and left in for an average of 6 months when the woman would return to the gynaecologist, the pessary would be removed, cleaned and reinserted as long as there were no signs of vaginal erosion.
At Physio Down Under we teach our patients to self-manage their pessaries which means they learn to independently insert and remove their pessaries. This reduces the risks associated with wearing a pessary (like vaginal erosion), and gives a woman complete control over when she wants to wear her pessary. For example, some women will only wear a pessary for exercise, others on weekends when they are busier, others daily.
For many women with bothersome prolapse symptoms, a pessary can be a life changing treatment by immediately relieving prolapse symptoms, allowing them to actively participate in their activities of daily living and regain their quality of life. Wearing a pessary has also been shown to delay or avert the need for prolapse surgery.
A pessary, along with pelvic floor muscle training, should be considered as a first-line treatment for all women presenting with prolapse.
What is pelvic organ prolapse? How would I know?
Dr June: Pelvic organ prolapse occurs when one or more of the organs in the pelvis slip down from their normal position and bulge into the vagina. It can be the womb (uterus), bowel, bladder or top of the vagina that prolapses. This occurs when a woman’s pelvic floor muscles, ligaments and vaginal wall weaken and stretch, often due to post-menopause and aging, being overweight, childbirth or a prior hysterectomy.
In some cases, women may not have symptoms and may not know they have a prolapse until they are examined by their doctor, for example during a Pap smear test. In others, pelvic organ prolapse can cause:
- A feeling of heaviness around the lower abdomen and genitals
- A dragging discomfort in the vagina
- A feeling of a lump coming down in the vagina or seeing a bulge coming out of the vagina
- Discomfort or numbness during sex
- Difficulty passing urine, increased urinary urge and frequency, or stress incontinence
- Difficulty passing motion
Are there various types of prolapse?
Physio Down Under: There are 4 main types of prolapse:
- The bladder bulging into the front wall of the vagina (cystocele)
- The womb bulging into the vagina (uterine prolapse)
- The bowel bulging forward into the back wall of the vagina (rectocele/enterocele)
- The top of the vagina sagging down in some women after hysterectomy (vault prolapse)
It is possible to have more than one of these occurring at the same time.
The severity of a prolapse is classified on a scale of 1 to 4, 4 being the most severe where the prolapse is completely outside of the vagina.
What is the treatment for pelvic organ prolapse?
Dr June: A prolapse that is mild, uncomplicated and not causing any symptoms may not need medical treatment, but lifestyle changes are advised to prevent worsening of the prolapse. These include losing weight if one is overweight, avoiding heavy lifting, and taking measures to avoid constipation and straining.
If the prolapse is more severe and/or is causing symptoms, it is advisable to seek treatment early. Useful treatment options include:
- Pelvic floor rehabilitation – therapy and exercises guided by your pelvic floor physiotherapy specialists
- Vaginal pessaries for support – very effective when properly fitted by a trained health professional or specialist physiotherapist from Physio Down Under. It is inserted into the vagina and left in place to support the vaginal walls and pelvic organs.
- Vaginal oestrogen in menopausal and postmenopausal women. By improving the health of the lining of the vagina, oestrogen can help reduce the discomfort from a prolapse and also helps to protect the vaginal wall in women using vaginal support pessaries. Vaginal oestrogen is available in Singapore on prescription as a tablet for insertion and as a cream.
Surgery may be recommended in cases of severe and/or complicated prolapse, or where conservative methods of treatment have been unsuccessful.
What type of treatment a woman needs depends very much on her symptoms, her stage of life, the type and severity of the condition, and her preferences. Treatment needs to be individualized with careful consideration of all these factors when discussing treatment options with your doctor and physiotherapist.
How does physio assists the treatment for pelvic organ prolapse?
Physio Down Under: Women’s health physiotherapists are trained to provide conservative management of prolapse which includes pelvic floor muscle training and lifestyle modifications.
Pelvic floor muscle training can include:
- A programme that is individualised to each patient – it usually involves doing a combination of quick squeezes and longer holds being performed 1-4 times per day
- Electrical stimulation
- Vaginal cones
Some women present with overactivity of PFM’s which we often see in women who are symptomatic of a vaginal bulge as they are constantly gripping their pelvic floor muscles to try minimise the bulge sensation. These women would initially require down training and relaxation of their pelvic floor muscles, not strengthening.
Lifestyle management can include bowel management, as constipation can be associated with prolapse symptoms. In particular straining while having a bowel motion can cause an excessive increase in intra-abdominal pressure, resulting in perineal descent, and it’s this action that should be avoided. We teach women defecation dynamics which basically means we teach them how best to poo!
Some women with prolapse will present with some issues with passing urine, for example dribbling urine when they stand up after passing urine, experiencing a slow urine stream or not feeling completely empty after passing urine. Women’s health physiotherapist are trained to help manage these symptoms with various techniques.
Many women who come to see us with prolapse symptoms are nervous to return to exercise, for fear that they will make their prolapse symptoms worse. As women’s health physiotherapists we are able to guide our patients with regards to what are ‘pelvic floor safe’ exercise. We also always work with our patients towards achieving their goals whether that is as simple as lifting their toddler without worrying about their prolapse or being able to play tennis or go for a run.