Articles written by professionals from The Wellington Hospital for Healthcare Professionals.
Addressing the 'form' to improve the function of the pelvic floor
Too often in routine practice, for both primary and secondary care, we concentrate on specific diseases or disorders, rather than looking at the whole woman in front of us. Usually, the patient will present with a medical term rather than a list of symptoms, such as ‘I have a cystocele’ or ‘I was told by the practice nurse at my smear that I have a prolapse’. Only on closer questioning will symptoms such as urinary or defecatory issues, and occasionally sexual function, be discussed. However, there are usually one or two things that will underpin a generalised feeling of ‘not being quite right’ and having a sense of a urinary tract infection (UTI), The challenge is finding which problem can, if solved, have a knock on, positive effect on the whole.
These are often the result of some additional factors, especially in women who have had children. UTIs tend to persist for a while, recur once treated and are seriously debilitating. Untreated or low grade UTIs with acute flares can feature at the following times in a woman’s life:
Such infections can lead to interstitial cystitis and painful bladder syndrome, with any sexual contact potentially leading to pain and urinary frequency. These need careful investigation, eradication of persistent bugs and assessment of function and flow.
A poor urinary flow, determined with a flow meter or as part of a urodynamic assessment, together with a residual volume in the bladder, will predispose the particular patient to recurrent infections. The poor flow might be improved with elevating a cystocele, through inserting a ring pessary or performing an anterior repair of the vaginal wall. This particular problem will also respond to improving the urethral and vaginal mucosa with topical oestrogen (post menopause). By looking at more than just the residual urine, the whole area receives treatment, whilst other symptoms are also addressed.
Topical oestrogen in post-menopausal women can also reduce the incidence of UTIs. This is because it helps to ‘plump up’ the vaginal and urethral mucosa, making it more resilient. In addition to this, the sub-urethral vascular layer at the bladder neck (which is also hormone sensitive) will improve, and as it does, the closure pressure of the urethral sphincter may enable a feeling of greater security with continence.
Urinary incontinence affects up to half of all women at some stage of their lifes. The issue presents us with a problem to be solved, rather than an expression that this is ‘normal’ and an expected and natural consequence of having a family. The mobility of the bladder neck increases after pregnancy and childbirth, whether it is vaginal or abdominal. This mobility can be corrected with dedicated physiotherapy, followed by relatively simple surgery (mid urethral tape). But if the other symptoms of frequency, urgency, poor voiding and associated prolapse are forgotten, this can make the problems worse. As a result, careful history taking and investigation with urodynamics can highlight any other problems in patients presenting with more than one issue.
Physiotherapy has the advantage of improving the global tone of the pelvic floor. Although it is good practice to offer physiotherapy for stress incontinence before contemplating surgery, women can benefit in other ways. For example, whilst undergoing a course of physiotherapy for stress incontinence, many women find that other areas feel better.
Childbirth damage or strain after years of constipation can lead to posterior vaginal wall weakness; potentially further causing sexual dysfunction and defecatory problems. Even if there is not a complete resolution of symptoms after a course of physiotherapy, surgery will usually be easier and result in a better outcome, if the pelvic floor muscles are strong. Continued effort prevents atrophy of the muscles after the menopause and can improve sexual function, all of which maintains any improvement achieved by surgery.
So, we must look at caring for all aspects of women’s urogynaecological health as after investigation, improving the form or position of the pelvic organs within the pelvic floor can improve their function. Consequently, although each of these are small benefits, they can have a larger overall boost to a woman’s quality of life.
Pelvic floor, Mrs Joanne Hockey, Gynaecology, incontinence, urinary problems, interstitial cystitis, physiotherapy, pelvic organs, pregnancy
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