Features

No more shame

08 March 2019

You can give invaluable help to mothers about two problems they often just resign themselves to living with – stress urinary incontinence and pelvic organ prolapse, finds journalist Rima Evans

Pelvis iStock

Celebrities are starting to open up about a subject many women prefer to shy away from – stress urinary incontinence (SUI) after having a baby. Actress Nadia Sawalha broke the taboo on talk show Loose Women in 2017, admitting she wet herself live on air once while trampolining (Hunt, 2017). Nadia highlighted a message increasingly being promoted by health professionals that ‘it’s so important that as women, we do talk about it because you don’t have to accept it. There are so many things you can do’.

In fact, SUI and another issue related to pelvic floor health, pelvic organ prolapse (POP), are problems community practitioners can encourage women to be honest about and seek help for.

 

Stress urinary incontinence

SUI is when urine leaks out at times when the bladder is under pressure, for example, when someone coughs or laughs (NHS, 2016). It is usually the result of the weakening of, or damage to, the muscles used to prevent urination, such as the pelvic floor muscles and the urethral sphincter (NHS, 2016).

Swati Jha, vice-chair of the British Society of Urogynaecology and consultant gynaecologist and subspecialist urogynaecologist at Sheffield Teaching Hospitals, says it’s a relatively common problem that increases with age. ‘Other risk factors include childbirth, obesity, menopause, and drinking a lot of caffeine-based drinks.’

It is the most common type of urinary incontinence in pregnant women, and affects 59% of pregnant women in the UK (Sangsawang and Sangsaswang, 2013).

Meanwhile, a University of Helsinki study found that vaginal delivery is associated with an approximately two-fold increase in the risk of SUI compared to caesarean section (Tähtinen et al, 2016). However, Amanda Savage, specialist physiotherapist and public relations officer for the Pelvic, Obstetric and Gynaecological Physiotherapy (POGP) professional network, warns: ‘A caesarean is not entirely protective, as carrying the weight of a pregnancy alone causes pelvic floor stretching.’

While it’s a widespread condition, SUI is still shrouded in shame and embarrassment. An NCT poll in 2016 revealed that almost four in 10 women said they were even self-conscious speaking about incontinence issues with a healthcare professional (NCT, 2016).

Women are suffering in silence, agrees Amanda, despite SUI having a hugely negative impact on daily life. ‘Women worry about leaking and whether it shows or smells. So, it can make them withdraw socially. Activities, such as running, playing with their children or lifting them up may cause leakage. So too can coughing, sneezing, laughing and jumping. Often, people become anxious about knowing where the nearest toilet is, which again puts them off going out. Women describe how they feel unclean or ashamed about not being dry. Having to wear pads is also a taboo.’ However, she adds: ‘Women don’t have to live with this or assume it’s just what happens after childbirth. This is a very solvable problem and that’s a message CPs are vital in promoting.’


 

Pelvic Exercise iStock
The wonders of physiotherapy

Kegel exercises are the single biggest activity that can make a difference to prevention or treatment of POP and SUI, says Swati Jha.

While women can do these on their own, the motivation or ability to do them can be significantly enhanced if a physiotherapist is supervising. ‘Supervised Kegel exercises are always going to be better than where someone is just given an information leaflet to read,’ she says.

Health visitors or community nurses can signpost to specialist physiotherapy services, says Amanda Savage. In some areas women can even self-refer, so a CP could advise where that’s the case. ‘One of the problems with pelvic floor exercises is that it’s easy for women not to be doing it right,’ says Amanda. ‘A physiotherapist can offer proper guidance, and they will feel where the pelvic floor muscles are and check the exercises are being done correctly.’


 

Pelvic organ prolapse

The NHS describes POP as when one or more of the organs in the pelvis slip down from their normal position and bulge into the vagina (NHS, 2018). It can affect the uterus, bowel (rectocele), or bladder (cystocele) it says, and happens as a result of a weakened pelvic floor that can’t hold the organs in place firmly.

The risk factors are similar to those of SUI, so include pregnancy and childbirth (multiple births, a vaginal delivery or a long difficult labour or having a large baby increase the risk), ageing and menopause, and being overweight or obese. Family history, having a hysterectomy, constipation, a chronic cough or a job that requires a lot of lifting are additional causes (NHS, 2018).

POP is thought to affect 40% of women over 50 in the UK; the same study highlights that physiotherapists were ‘treating significantly more women with prolapse than a decade before: 36% versus 14% treated more than 50 women per year in 2002 and 2013 respectively’ (Hagen et al, 2016).

Amanda questions whether this represents a real increase. ‘It could be that rates are increasing or that we are now just asking the right questions and capturing the data.’

Swati agrees it is being reported more, although she says that rates are likely going up too because of the increase of risk factors, such as obesity and life expectancy. Nevertheless, Swati says, loss of vaginal support is thought to be seen in ‘up to 70% of women who have had children’.

‘Though it’s not to say all those women will see any symptoms or require treatment,’ she adds.  

'While pelvic organ prolapse is not serious or life-threatening, it doesn’t mean women should be ready to put up with it’

POP comes with a feeling of discomfort, with symptoms dependent on the organ that is prolapsing. ‘If it’s the bowel prolapsing, people describe feeling pressure in their vagina area when their bowel is full then feeling better when they have emptied their bowel,’ Amanda says. ‘If it’s the bladder that’s prolapsing, women may be able to feel something soft and bulging at the vagina opening. It can be frightening, though it’s not necessarily painful. With a uterus prolapse, it can make people feel like they are sitting on an egg or experience a sensation of heaviness or dragging. And while it’s not serious or life-threatening, it doesn’t mean women should be ready to put up with it.’
 

Taking a direct approach

CPs can be of huge help to women suffering either of these conditions, first by recognising the symptoms and then by offering reassurance that both health problems are common but treatable and, of course, nothing to feel ashamed about.

Amanda advises listening out for subtle cries of help. ‘Often, it can be hidden in a joke to hide embarrassment. Or there may be hints that activities are being limited. CPs should be alert to these signs so they can encourage the mother to take them seriously.’

What about those women who won’t even hint at a problem because they are too embarrassed? Swati says directly broaching the subject by just asking whether they are experiencing problems can help break the taboo. ‘It opens the way for a conversation to get more detail about the extent of the problem. For SUI, it’s necessary to find out how often they experience problems or how bothersome it is. If it’s happening once every fortnight that may be less of a problem then if, say, leakage is happening every day, all day and it’s curbing activities.’

In the case of POP, it’s key to assess whether a referral to a GP or secondary care is necessary. ‘If a woman says she can feel a lump protruding from the vagina and it’s there all the time, a referral should be made,’ advises Swati.

Most times a CP can advise on treatment, and for both conditions pelvic floor or Kegel exercises are the first step.

In new draft recommendations published last year, NICE suggested that a programme of supervised pelvic floor muscle training for at least 16 weeks be the first option offered to women (NICE, 2018).

‘Pelvic floor muscle training is a well-researched, effective and successful treatment for stress incontinence and is highly recommended as a first step to managing symptoms of prolapse too,’ says Amanda. ‘Women who practise daily pelvic floor exercises can see an improvement in their strength and then in their symptoms in 12 weeks to six months. Research also shows that if you exercise your pelvic floor when pregnant there is less likelihood of leakage afterwards. So, it’s an opportunity for CPs to mention this if the woman is planning another pregnancy or is already pregnant.’

Women who exercise their pelvic floor muscles efficiently are six times more likely to report SUI as cured or improved than those who don’t exercise (Dumoulin et al, 2018).

 

Wider health factors

Lifestyle is an important issue to raise too. ‘CPs should talk to the person about maintaining a healthy weight and a diet that will prevent constipation – high fibre in many cases but not all,’ says Amanda.

For SUI, encourage cutting down caffeine-based drinks and consuming two litres of fluid a day, says Swati.  

There are a range of products available that CPs could benefit from being aware of. Vaginal pessaries to support and hold organs in place, for example, can be effective for POP but are underutilised, according to Amanda. ‘A CP would have to refer their patient to a GP to find out more, but it’s still useful to mention it as another option.’

Pessaries are available for incontinence, says Swati. So too is equipment, such as pelvic floor toners, although these ‘are no more effective than standard physiotherapy with no devices’, she says.

Ultimately, there are surgical options for treating both problems but they should be considered last resort. ‘There are huge risks. In any operation there is a one in 20 risk of complication. It shouldn’t be taken lightly,’ Swati explains.

It’s much preferable to promote the benefits of Kegel exercises – which have a high success rate with zero risk – and leading a healthier life.’ 


Pop prevalence

According to a survey, pelvic organ prolapse is thought to affect 40% of women over 50 in the UK

Hagen et al, 2016

Resources

  • Clear information on pelvic floor exercises and how to do them at bit.ly/NHS_pelvic_floor
  • The Pelvic, Obstetric and Gynaecological Physiotherapy (POGP) is affiliated to the Chartered Society of Physiotherapy. You can signpost mothers to the website at bit.ly/POGP_booklets
  • RCOG patient information can be found at bit.ly/RCOG_POP  
  • The Pelvic Floor Society supports research and monitors standards for treatment at thepelvicfloorsociety.co.uk

Image credit | iStock


 

References

Dumoulin C, Cacciari L, Hay-Smith EC. (2018) Pelvic floor muscle training for urinary incontinence in women. See: https://www.cochrane.org/CD005654/INCONT_pelvic-floor-muscle-training-urinary-incontinence-women (accessed 20 February 2019).

Hagen S, Stark D, Dougall I. (2016) A survey of prolapse practice in UK women’s health physiotherapists: what has changed in the last decade? International Urogynecology Journal, 27: 579-85. See: ncbi.nlm.nih.gov/pmc/articles/PMC4819739/ (accessed 13 February 2019).

Hunt A. (2017) Nadia Sawalha admits personal struggle with ‘unsexy’ health problem. Woman & Home. See: womanandhome.com/life/news-entertainment/nadia-sawalha-incontinence-205955/ (accessed 20 February 2019).

NCT Survey. (2016) Breaking the taboo of incontinence after childbirth. See: nct.org.uk/about-us/news-and-views/news/breaking-taboo-incontinence-after-childbirth (accessed 13 February 2019).

NHS. (2018) Overview: Pelvic organ prolapse. See: nhs.uk/conditions/pelvic-organ-prolapse (accessed 13 February 2019).

NHS. (2016) Overview: Urinary incontinence. See: nhs.uk/conditions/urinary-incontinence (accessed 13 February 2019).

NiCE. (2018) Guideline Urinary incontinence and pelvic organ prolapse in women: management (draft for consultation). See: nice.org.uk/guidance/gid-ng10035/documents/draft-guideline (accessed 13 February 2019).

Sangsawang B, Sangsawang N. (2013) Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. International Urogynecology Journal 24(6): 901-12. See: ncbi.nlm.nih.gov/pubmed/23436035 (accessed 20 February 2019).

Tähtinen RM, Cartwright R, Tsui JF, Aaltonen RL, Aoki Y, Cárdenas JL, El Dib R, Joronen KM, Al Juaid S, Kalantan S, Kochana M, Kopec M, Lopes LC, Mirza E, Oksjoki SM, Pesonen JS, Valpas A, Wang L, Zhang Y, Heels-Ansdell D, Guyatt GH, Tikkinen KAO. (2016) Long-term impact of mode of delivery on stress urinary incontinence and urgency urinary incontinence: a systematic review and meta-analysis. European Urology 70(1): 148-58. See: europeanurology.com/article/S0302-2838(16)00156-1/pdf (accessed 20 February 2019).

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