Incontinence and Pelvic Organ Prolapse in the Perinatal Populations: Translating Best Practices
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[00:00:50] Melissa Dessaulles: So thank you everybody for joining us. We are looking forward to this webinar. We're gonna cover the topic of incontinence and pelvic organ prolapse in the [00:01:00] perinatal population. I am your host for today. I am, my name's Melissa Dessaulles. I'm a physiotherapist. I'm located in Kelowna, BC and I myself, host of a podcast called The Pelvic Floor Project, and I'm very passionate about any type of teamwork in healthcare collaboration. And so when Sarah and Alicia asked me to join this project, I was very keen.
[00:01:25] Dr. Sarah Lea: Do you want me to speak briefly to the Pregnancy for Professionals? If you'd like to, I'm happy to do it, but I feel like you might offer some more insights.
[00:01:32] Sure. I'm super happy to do it. So I'm Dr. Sarah Lea, that's a picture of me and my kids. And I'm a family doctor that does sub-specialized care in, maternity as well as addiction medicine. But this is my maternity hat that I'm wearing today. And my colleague and Alicia and I came together because we actually started a patient-focused resource called she found motherhood focused at women and people who identify as women that are pregnant and newly parenting to provide evidence-based up to date information.
[00:01:59] And [00:02:00] during that journey we started reaching out to other allied providers like physiotherapists, dieticians, midwives, doulas. And we realized how much we as physicians didn't know, and how much expertise other providers have, and how much we can learn from one another. So that burst, haha, pun intended pregnancy for professionals, which is meant to be like an interdisciplinary learning hub so that we really can learn from one another and, Pull on our strength to provide the best care we can for patients and, not just necessarily wing it. So that's who I am and why we're here. And I'm gonna turn it back to Melissa. Thanks Melissa.
[00:02:39] Melissa Dessaulles: Yeah. Thank you so much. So I was obviously game when they asked me to join because anytime we, we talk about some type of collaboration I am, I'm all for that. So really quick housekeeping. I think Sarah's gonna add in your chat the initial survey that we're asking you to fill out before the webinar, so less than a minute. And then there'll also be one at the completion [00:03:00] just to gain some information as to what type of information people are wanting to hear about. We have some designated Q and A time afterwards with the speakers. And then just a reminder, please do sign up for the newsletter just so that you have access to recordings and future events. All of these events are also hosted in a podcast where you'll see regular episodes coming out. So without further ado, I wanna tell you about our amazing speakers today. I've had the pleasure of talking with both of them on my podcast before, both a wealth of knowledge and also eager to work holistically with other healthcare providers.
[00:03:39] Dr. Roxanna Geoffrion, located in Vancouver. She's a practicing urogynecologist, an associate professor at UBC in Vancouver. Research interests in patient education, knowledge translation in the area of the pelvic floor. And you'll have to check out her initiative that she started with some other healthcare providers [00:04:00] called Be Pelvic Health Aware. They have a website and all sorts of information that is meant to help patients understand some of their symptoms. I just recently did a podcast episode with one of her colleagues on UTIs, and so there's some great whiteboard animations that help people understand, so you can use those as a care provider to share information with your clients.
[00:04:23] Dr. Sinead Dufour is a physiotherapist in Ontario and a clinical professor at McMaster. She herself is also involved in lots of research. She's a leader in our field as a physiotherapist, helping us practice with evidence-based care. I don't even know where to start. Sinead, you've done so much work with our profession on, in, on topics like collaborative healthcare, pregnancy related, pelvic girdle pain, and you're also a clinician and mentor, a lot of other physiotherapists and sit on different committees.
[00:04:55] And I appreciate both of you taking the time to be here. We've got a [00:05:00] a big topic to cover. So what we were asked to cover is evidence-based practice when it comes to pelvic organ prolapse and incontinence. And so we have put together a presentation. The ladies have, I shouldn't say a presentation, a discussion planned to discuss how we are guided to practice when it comes to these very common symptoms that women experience after birth in the, in specifically vaginal birth. So we'll talk about everything from conservative management to surgical management and what the evidence suggests about when to implement. So are you okay, Roxana, if I start with you and I ask you to set the stage first, just describing how do you describe to patients or new moms in, what are some of the things that change in the pelvis and the related structures during a vaginal birth? Just so people can picture some of the things [00:06:00] that happen.
[00:06:01] Dr. Roxana Geoffrion: Sure. Thank you so much, Melissa, for that kind introduction, and I really look forward to our hour together. So in terms of if we're talking about vaginal birth, we have to just take a step back and think about pregnancy as well. So during pregnancy, really there are a lot of adaptations that prepare the maternal body for birth and that include many that we do understand a little bit and some that we don't understand at all. We know that there's a huge influence of hormones. That's the most obvious change. We know that hormones, female hormones raise significantly. We know that a woman or female patient produces in her pregnancy, more estrogen than a woman produces in her whole lifetime. And so that's gotta do something to the pelvic area and the ligaments and the structures and the connective tissues. And so we know that influence increases vascularity to the womb increases connective tissue [00:07:00] elasticity and prepares the body for birth. However, we do also know that during vaginal birth there's a a tremendous amount of stretch and different risk factors that predispose women to having more difficult births.
[00:07:15] And we see that in the context of emerging pelvic floor disorders. In the first year postpartum, there are a lot of these symptoms that occur that actually start in the third trimester of pregnancy. So we know that certain things like urinary incontinence, fecal incontinence, pelvic organ prolapse happen increasingly and give women symptoms in late pregnancy being as common as one out of two patients experiencing some sort of pelvic floor symptom. And that kind of mirrors what happens a little bit later in life as well. And after vaginal birth some women will have no symptoms at all, but many will have various confusing symptoms that are either persistent from the third trimester or new and they, they include leaking [00:08:00] of urine, leaking of stool, sexual dysfunction, as well as various difficulties with body image and psychological troubles. And so we certainly look back at vaginal birth and try to establish some risk factors to almost try to have a crystal ball and predict what will happen and how to best support these patients moving forward.
[00:08:19] Melissa Dessaulles: Anything to add Sinead as a physiotherapist?
[00:08:23] Dr. Sinéad Dufour: Yeah what I would just add to that, I thought that was a really great succinct kind of summary, but I would also add from a PT perspective, when we look at some of these like modifiable risk factors in terms of, what are some things in play that seem to help the pelvic floor or, the pelvic structures in general fare better after.
[00:08:44] One of the consistent pieces is exercise. We know that when people are exercising and staying fit and they're managing their weight well, that they seem to fare better. And as a PT it's important kind of for us to think about sometimes there [00:09:00] might be a variety of reasons when someone actually is pregnant.
[00:09:03] That might actually have them not exercising as much, right? So if they're just starting to get these symptoms that actually might make them exercise less and then that then is a risk factor for some of these other things that happen then in the birth that they're gonna fare not as great after. But also other things around like pain and the pelvic girdle and other pieces can be other really big reasons why people stop exercising and even bring in some of those other kind of psychosocial pieces that Roxana touched on briefly, but just like around fear and some of these other pieces.
[00:09:37] And it's all part of it as we're really trying to. Promote optimal pelvic health like through this perinatal care period, acknowledging, yes, there's some of the structural change that's happening across the board, but we don't have these issues in people that are lingering a hundred percent of the time.
[00:09:55] So there definitely are things we can do and intervene on some really great [00:10:00] effective conservative care strategies, some of which sometimes just education can go a long way.
[00:10:06] Melissa Dessaulles: And I think it's important just based on what you're both describing, that, it's important to normalize some of these symptoms that people experience after just given all of the anatomical changes that happen. And I think that with this there's, this pendulum is swung from no information to a lot of information, a lot of it being very fear-based, I think. And people coming out of their birth kind of feeling like, oh my gosh, I have prolapse or I have incontinence. I must have done something wrong, or I must have drawn the short straw or something like that. But I think just in the importance of explaining the anatomy and explaining why some of this happens, but as you say, Sinead also too, that there's so many things that we can do. I wonder let's start with incontinence. Let's start with incontinence and talk about one of the number one symptoms that people might experience after a vaginal birth. Let's double click on that a little bit. And I wonder if you wanna [00:11:00] start then, Roxana, in describing kind of incontinence, how do you describe that to your clients? When someone comes in, postpartum and is experiencing continence what do you say to them?
[00:11:11] And then I want to get into, some of the options that they have because, I do think as we talk about incontinence and prolapse, that we think about conservative management progressing to surgical management and in the case of talking with a client, if you were an orthopedic surgeon we don't see the same management happen if someone has knee pain, we don't go straight to, you must go see the orthopedic surgeon first and have surgery. But we do tend to think of this way in the women's health world sometimes, is that if you have any symptoms, you must need a surgery. Will you talk a little bit about that? Cause I'm sure a lot of your clients come to you with that thought that I'm here because you are a surgeon and I must need surgery. So I've asked you many questions in that statement, but let's start with [00:12:00] when someone comes to you that it's experiencing incontinence, what's your explanation and where might you start?
[00:12:06] Dr. Roxana Geoffrion: Sure. Thank you. And so urinary incontinence is first of all a very common concern, and it is a quality of life issue. So we've tried many times, both in the pregnant and the non-pregnant population to objectify this with pad tests and diapers we use and, number of incontinence episodes. But I think what people need to mostly remember is that it becomes a problem if it bothers them and if it changes what they do in their daily life.
[00:12:33] And this is definitely not a life-threatening condition. It's really purely a quality of life issue. And as the population is increasing and quality of life becomes increasingly important and our longevity increases for sure, we're going to see many more of these conditions.
[00:12:49] Back to urinary incontinence. It really, it's really mainly divided into two main ones. So stress incontinence, which is incontinence with coughing and sneezing [00:13:00] and downward pressure on the bladder, as well as urgency incontinence, which is leaking of urine with an inability to defer a strong urge and leaking on the way to the bathroom.
[00:13:10] And so in the third trimester frankly, right after the as in any, at any other life point, stress incontinence is more common than urge incontinence. And that's what will bother younger active women mainly with daily activities, with exercise and so on. So there is a normal spectrum for sure. A lot of one out, like I said, one out of two women in the third trimester and right after birth will experience some stress urinary incontinence. But there is also the fact that we don't quite understand what that normal spectrum is. So we don't necessarily have established milestones or some sort of average number of leaks and so on to explain what normally happens and how fast people recover.
[00:13:57] It is just so multifactorial. [00:14:00] And so we have to be really careful about calling it a normal symptom postpartum versus a real dysfunction because we don't quite know how to make an objective. I don't know. I'm not sure we ever will be able to. Again it's a quality of life issue.
[00:14:14] So if it bothers women, then they come in for for management and. Perhaps I should keep the management for a little bit later, or would you like me to go over conservative and surgical options now?
[00:14:26] Melissa Dessaulles: Yeah, why don't you start, and Sinead, feel free if you have like visuals that you want to, because I think you'll both be talking about some of the same points here. So if you have visuals that you both want to allow people to see, then go ahead cuz I think Roxana's comments here will compliment what slides you have.
[00:14:42] Dr. Sinéad Dufour: Yeah, I'll go ahead and put the slides up, Roxana, while you start and then I'll piggyback off some of the things you said.
[00:14:50] Dr. Roxana Geoffrion: Sure. So usually again, we try to see how much of a bother this is for women.
[00:14:56] A lot of times we don't necessarily we can initiate some [00:15:00] conservative options immediately. And, surgery, like you said, is really end of the line. We don't really necessarily even approach it at the first visit. So as you can see here from from Sinead's slide, really, we start talking to women about lifestyle intervention, pelvic floor muscle training, bladder training as well as some aids such as vaginal devices for biofeedback and so on. And I'm sure Sinead you can go into more detail about your options on your slide, but really the first thing we tell women when they come in with that is are you exercising your pelvic floor? Are you doing your kegel exercises? Sometimes we take a bladder diary, how often do you avoid, what kind of bladder irritants are you ingesting? And that all helps us direct them with conservative management.
[00:15:47] Melissa Dessaulles: And so obviously the people that you are seeing right now Roxana are coming from a family doctor. So these people first have gone maybe to their family doctor, they've mentioned this symptom, [00:16:00] and then they're seeing you. Is that the typical, is that the typical presentation for you?
[00:16:07] Dr. Roxana Geoffrion: It, it really varies. So it, sometimes I also get referrals from OBGYNs directly without passing through family medicine. But in the first year postpartum, we have to think about who women might see. So they will see their OBGYN at six weeks. And then there's a bit of a vacuum of care, really because women get busy with the care of a newborn and don't necessarily think that this is dysfunction. So going back to that, everybody tells them it's some sort of transient dysfunction and it's not necessarily important at the moment. And they get busy with caring for children and. Just frankly getting some sleep at night. And so they, they don't necessarily seek care. But those who do they would, yes, they would perhaps see their family doctor. Sometimes they actually see a physio, a pelvic physiotherapist. They self-refer and see someone in the community and then they circle back to a gynecologist because of some more [00:17:00] special concerns or when they're resistant to conservative management.
[00:17:03] Melissa Dessaulles: Any, anything to provide more detail with this Sinead as a physiotherapist point of view, because we're often involved in a lot of the conservative management as well.
[00:17:14] Do you wanna to, is there anything you'd like to go into more detail on this?
[00:17:18] Dr. Sinéad Dufour: Yeah, absolutely. So one thing I would say which is just a point I communicate to my clients, but also in some of the teaching that I do, is that, we do have to understand also this concept of spontaneous recovery as well. You alluded to the fact before, Melissa, that in ways, if we've birthed a baby and there has actually been a degree of like legitimate soft tissue injury that's occurred through that process, right? It's understandable that when we injure structures, we're gonna need sometimes some opportunity for some spontaneous recovery and then maybe rehabilitation, right? Hence why our big message is to get this early conservative care going. [00:18:00] But what we oftentimes will see with some clients is that they will come see us and say, after I first birthed my baby, I was having like tons of leaking, lots of issues. But you know what? I'm eight weeks postpartum now, and actually in the last couple weeks, like I haven't had any.
[00:18:14] And there is some data that exists that's been duplicated in a couple of studies indicating that if urinary incontinence symptoms are lasting beyond the fourth trimester beyond those first 13 weeks post-birth like there hasn't been that full spontaneous recovery. That it's unlikely without some specific rehabilitation that's going to continuously to spontaneously, cure itself, at all.
[00:18:40] So studies have shown that it's more likely that these folks will have continued symptoms at five to seven years post. So I think that's something for our colleagues working in this space is when clients are continuing to have symptoms past that time, probably there's not gonna be the spontaneous recovery to really [00:19:00] ameliorate that. And and that's when it's gonna be, I would argue even more important to get onto some of these tools. What I did, what just wanna mention about lifestyle interventions is that there has been more research in this area more recently and some of our more recent guidelines capture actually even aspects around, diet, weight management, fluid intake, fiber intake, some of those pieces. And the thought is around, yes, we know there's this big connection between our bowel function, constipation, straining with incontinence, right? Not only in terms of straining behaviors and what that might be doing down into some of those pelvic structures, but even thoughts of, bowels that are full of that fecal matter, how that might be really irritating to the bladder. It's from that perspective, but even just more data around, diets that are a little bit more anti-inflammatory and higher in fiber. So I just wanted to make that comment. And then I also wanted to make a comment [00:20:00] about the pelvic floor muscle training piece because this is also going to come up in our conversation around prolapse.
[00:20:07] And, there are many times, and I'm sure Roxana, you've experienced this too, where an individual comes forward and they really feel like they've already done pelvic floor muscle training and that intervention has failed or it hasn't worked. But actually what they have done doesn't at all constitute what an evidence-based pelvic floor muscle training protocol is, right?
[00:20:34] So they might have read some or, oh, just do kegels, but the way in which they're actually enacting that in themselves really doesn't at all align with what the evidence would show. We would expect a really good improvement. We know we need some degree of. An individual sort of understanding that basic anatomy, understanding sort of the lifting motion of what the pelvic floor does, having some proper kind [00:21:00] of queuing to try to get that function.
[00:21:02] Understanding that, yes, we need to contract and lift these muscles. We need to know how to let them go. We need to understand that there's fast switch fibers, slow twitch fibers, that these muscles communicate in a very synergistic way with the breathing diaphragm, the transversus abdominis, right?
[00:21:19] There's some of these other layers. Really are rather straightforward and don't take a lot of time to put into care. But many people aren't getting those pieces and they believe they've done pelvic floor muscle training and it hasn't worked. And then I think that's what makes them feel like their only option is going to be, surgery was someone like Roxana, for example.
[00:21:41] So I'm sure we'll come back to pelvic floor muscle training again and how that needs to be a little bit more nuanced. But that is something that I did wanna say. And then also wanted to mention too, that yes, we have our foundational care strategies that are actually really effective.
[00:21:56] We have level one evidence for many of these things, as you can [00:22:00] see, but we've also had an opportunity over the last few years through technologies emerging and frankly through the Covid Pandemic that sort of has Really, accelerated the use of technology and even virtual care.
[00:22:14] And we can feel pretty confident that we have some good data to support the integration of those tools. But again, as long as there's some individualized tailoring and there is a, healthcare provider at the helm who's helping to guide the integration of all those menu of options.
[00:22:33] Dr. Roxana Geoffrion: Thank you so much for bringing up the pelvic floor muscle training and how women actually perform these muscle exercises. I just wanted to point out that the best time to really learn how to train your pelvic floor muscles are, is on an intact pelvic floor. So meaning if we can just take back educating patients how to perform pelvic floor muscle training exercises.
[00:22:58] To their teenage [00:23:00] years, to, I don't know, the first time they get a pap smear or something like that. It's been shown that female patients who come in and for some other reason and they get some simple verbal instruction in how to do Kegels, actually do them correctly if they're on an intact pelvic floor.
[00:23:16] Whereas patients who experience dysfunction after birth or when they're in their third trimester pregnancy, that is not a good time to learn pelvic floor muscle exercises on their own because three outta four of them will actually not lift the pelvic floor, but rather push, so do the opposite motion where it's actually damaging to their pelvic floor.
[00:23:35] So if we can find a way to, to teach young teenage girls how to perform these pelvic floor muscle exercises, I think that's the first prevention we need to think.
[00:23:47] Melissa Dessaulles: And I think I listened to you and I think so many people I think would say everything about the pelvic floor is very mysterious. And I try hard with everybody to make parallels to a different area of the body. And what you've just said, I think is [00:24:00] similar to why we do prehab before we have a knee surgery. Why people want to go into their surgery, having the most range of motion and strength and awareness and a plan after, because incontinence.
[00:24:12] Is after all a symptom, just like knee pain is a symptom. And I think you would never take knee pain and say everybody needs the same thing for your knee pain. I think everybody knows, if I go to physiotherapy, if five of my other friends are going to physiotherapy, we're probably not all doing the exact same thing about our knee pain.
[00:24:30] And that's what all these things that you've listed are options basically with the amount of, what does the evidence say about them. But. Options. And I think we all field a lot of questions around, should I use the Perifit or should I do kegels or should I be relaxing my pelvic floor, or should I be doing some jumping exercises?
[00:24:50] It depends, I think is what Sinead said. And it takes very much an individualized assessment and treatment plan to decide, because there are options, just like there are [00:25:00] options for someone's knee, it's not just as simple as tightening and relaxing your knee over and over again. That's going to get you back to running or soccer.
[00:25:07] It's one small thing is to work on the strengthening, but there's so many other pieces to the puzzle that need to be addressed to return to the function that's desired by the person. So I think you've laid this out nicely just to describe what are the options. There are no black and white answers.
[00:25:24] But these are all options that can come before a surgical intervention. Have I captured that? Yeah. Yeah. And so actually, can I just really quickly ask a question because this is something that a lot of newer physios asks me too. They say the local physician in town or the local gynecologist has asked if I have biofeedback can you guys speak? That is a big topic right now in the area of pelvic health and that do we need to just refer to physiotherapists that have biofeedback? I know that's a big question, but can you, that's a question that a lot of providers, I think have questions around. Sinead, will [00:26:00] you just touch on that? You have briefly, but will you make that answer a bit more clear for people?
[00:26:05] There's a lot of talk around, do I need to go to someone that has biofeedback.
[00:26:09] Dr. Sinéad Dufour: Okay. So I think part of this comes back to the really astute point Roxana made before that when we're dealing with people after the fact with pelvic floors that are now compromised, it sometimes is a lot harder for us to really get things going.
[00:26:25] So as far as biofeedback is concerned, yes, we have traditionally had these kind of more cumbersome units that in clinic that we can. In ways, any of us as clinicians using our own hands, cuz that's typically actually how we do assess the structures of the pelvis. That is a form of biofeedback, right?
[00:26:45] A form of input into the system. You're communicating with the individual. Do you feel this? Can you feel that? Okay? Now I want you to think about really get your brain connected with where you feel the sensation of my hand, right on this tissue. Try to [00:27:00] think about lifting that up, okay? Now try to coordinate that with your breathing.
[00:27:03] Okay? And we are there as the medium for the biofeedback, right? So would I say that for many people, particularly if their pelvic floor isn't very, Really do need a bit of that to make sure that yes, they're connecting well and to make sure that you're giving them the feedback that what they're sensing in their body, they're actually doing the right thing.
[00:27:28] Yes. I feel like a high proportion of people benefit from that. Does everyone need that? That certainly hasn't been my experience. That's not really what the literature would suggest, but do a high proportion really benefit from that? Yes, but I conceptualize biofeedback beyond just those traditional units.
[00:27:47] I consider what I'm doing with my own hands and engaging in providing that feedback also as a form of biofeedback, but I'd be curious to see what Roxana's perspective is.
[00:27:59] Dr. Roxana Geoffrion: [00:28:00] Yeah. So thank you for that. I absolutely agree with you that a pelvic examination is key here. And as gynecologists, we are trained to assess the strength of the pelvic floor muscles with simple digital examination. So that just involves placing a finger in the vagina and then asking the patients to squeeze around and determining whether indeed there is a component of lift and strength to the contraction, and how long that contraction lasts. As opposed to some degree of. Pushing out. There's also a component of relaxation to the muscle.
[00:28:34] So does the muscle lift and stay there? And or does it relax adequately with prompting? And, we are nowhere near pelvic physiotherapists in assessing these muscles. But the simplest thing we can do is just rate the strength of this contraction on a simple scale from zero contraction to five five being extremely strong to the point where you can't pull your examining finger out, and then zero being absolutely nothing and everything else in [00:29:00] between.
[00:29:00] And so if my sort of the way I send patients to physiotherapy for specifically biofeedback is if they have zero pelvic floor muscle contractions. So if I cannot elicit any sort of lift in the muscles through simple prompting in, during pelvic exam in the office or if they have such severe pelvic floor muscle spasm that it's difficult to examine them internally, and they would benefit from some sort of bi external electro biofeedback to show just how tight those muscles are.
[00:29:33] Melissa Dessaulles: And then obviously for the sake of time, we can't go into too much detail on any one topic. But Roxana, will you speak to then, cuz we wanted to make sure we captured in this webinar that there's so many options for conservative care before we move down to the continuum of to this side of the continuum that is surgical intervention.
[00:29:51] Would you say then that, I think more and more as we go through time, our practice in the area of women's health is becoming a bit more focused on [00:30:00] conservative care. But would you say then that's obviously again, a discussion that you have between you and the individual client as far as, bothersome and quality of life. And you go through some of these conservative options before you entertain the idea of surgery.
[00:30:16] Dr. Roxana Geoffrion: Oh, absolutely. Yes, definitely. So there's a wide range of conservative options that we address with patients, and we always need to understand as providers what their goals are. So somebody who just wants to leak less so she can go for walk in the forest with her dog for an hour versus somebody who wants to not leak at all during a marathon are two very different goals that we definitely need to understand before we can provide any treatment options. So that conversation always goes into it. That being said, we always ask them to try conservative methods before going on to surgery. I'd always say that surgery is really the end of the line.
[00:30:57] Melissa Dessaulles: And I'll talk about this. I'll bring this up again when we're in our q [00:31:00] and a to talk about some of the barriers to some of these conservative care options.
[00:31:04] But let's shift our focus a little bit to pelvic organ prolapse just in the interest of time and talk a little bit about, given that we have so much stretch that our pelvis so much change and stretch that our pelvis and the walls of the vagina go through in the case of a vaginal birth, it's no wonder that women experience symptoms or signs of prolapse postpartum.
[00:31:29] Roxana, can I ask you to do the same thing when it comes to this? Will you describe about a visual of what's happening to the vaginal walls and why prolapse happens?
[00:31:40] Dr. Roxana Geoffrion: Of course. Yeah. So prolapse is one of those pelvic floor disorders that we see quite commonly as urogynecologists. The same risk factors apply, so urinary incontinence and prolapse.
[00:31:50] So share risk factors. They. These conditions often come together. So we definitely need to ask about both and treat around [00:32:00] both. One can produce the other and the other way around. So they're very interconnected. 80% of women have more than one pelvic floor symptom. So prolapse happens when the muscles, ligaments, and connective tissue of the pelvis have stretched out and haven't regained their normal elasticity.
[00:32:18] And that produces the the bladder, the bowel, as well as the uterus and the vaginal walls to collapse. Normally bladder and bowel are very dispensable organs, so they rely on the vaginal walls and the ligaments of the uterus to keep them on the place. And when those stretch out or become torn during the process of birth or other risk factors the bladder and the bowel can collapse into that, that bulge into the vagina.
[00:32:43] And then you get pelvic organ prolapse. And similar to urinary incontinence it's a quality of life issue. So we know that postpartum, if you examine women at one year postpartum, let's say about three out of four will have some element of prolapse that [00:33:00] providers see. Three out of four is a big number, but really it's not bothersome.
[00:33:05] It's not, they don't, they women are not even aware that it's there. So it's inconsequential and does not need to be treated. And so again, you establish with women whether this is a bulge that's bothersome, that produces pressure, that bothers with with intercourse or other sexual activities.
[00:33:22] And then you again, talk about various forms of treatment ranging from conservative to surgical.
[00:33:29] Melissa Dessaulles: Sinead, I don't know if you have anything to add as a physiotherapist. I think you can relate in that most of the clients that come to see us it's definitely a pathologized term right now in, in just they're looking again, black or white, do I have it or not? And can this cure me? And I think it's important, a lot of our education is around what happens to the structures and what we are able to provide as physiotherapists. But what else, what other kinds of things? We're really trying to shout from the rooftops and, a certain degree of prolapse is normal after we have such stretch to our vaginal walls. Anything to [00:34:00] add from a physio point of view?
[00:34:02] Dr. Sinéad Dufour: Yeah, the only thing I would add to that is also just to acknowledge just the pressure system kind of component with prolapse that I think is PTs. We tend to spend a little bit more kind of nuanced time on that. We do know that established risk factors for prolapse again, are the constipation, the straining behaviors, and the sort of persistent mismanagement of these pressure systems.
[00:34:26] So we want people to understand that there's a whole host of kind of comprehensive things we can be doing to try to restore some of that structure and relationship. And there's lots that can be done. So that's just one thing I wanted to mention. And then the other thing I just wanted to mention too is just this concept of like you're saying, The term normalize Melissa, and I think tied into part of that is so people don't get so fearful and catastrophize. Yes. Because that's oftentimes what we see I think is PTs, someone coming in and a client saying, oh my [00:35:00] gosh, I felt a bit of heaviness and I started Googling, and they are so terrified. And it's to acknowledge that sometimes you can have a symptom of a little bit of pressure and it's not necessarily this major architectural issue of their tissues.
[00:35:15] What we know clearly about prolapse is very similar to what we see in other sort of conditions in health, but it's not a linear relationship in terms of I have this severity of symptoms and that correlates with this degree of compromise of my structure. We don't see that. We see that some people can really have very strong.
[00:35:38] Sensory symptoms that are very debilitating for them. And then when we go on into check, we see quite minor deficit from like our traditional staging perspective, and then we can have the opposite. We can have an individual where it seems, wow, the structure seems really like from an architecture perspective, there's some [00:36:00] compromise, and we might wanna be suggesting they consult with someone like Roxana to know options of surgery or a pessary, cuz things are really along. But they're saying, oh, that, no, that doesn't bother me. This is fine. That's another thing we have to understand. It's also not this linear relationship.
[00:36:18] There's lots of things we can do. There's lots of things that will contribute to the state of relationship with those structures. Intraabdominal pressure is one of them, so we always wanna make sure we're really queuing our clients into understand that process. But also that symptoms of bothersomeness don't necessarily correlate with the state of the structure. So I think sometimes that's important so people aren't catastrophizing.
[00:36:42] Melissa Dessaulles: And I'm seeing a lot, we have, we're lucky to have so many new young gynecologists in, in Kelowna here that are sending a lot of people to physiotherapy. So I get a lot of these referrals, someone coming in saying I'm here because I saw my gynecologist.
[00:36:57] She says, I have some prolapse, and she has [00:37:00] suggested that I try physiotherapy and she mentioned something like a pessary and I don't want to use a pessary. So I think again a lack of information and I have some resources that I can share. I did an episode with a gynecologist once on pessaries, so I'll make sure I put that in the resources.
[00:37:17] But Roxana, can you talk a little bit about this talk a little bit about, cuz I'm sure you two are doing a lot of these referrals too, Yes. I acknowledge you have some changes to your anatomy. I suggest you try physiotherapy and maybe a pessary down the road. Will you speak to that topic a little bit? Because I think this is another time where we used to think prolapse equals surgery.
[00:37:39] Dr. Roxana Geoffrion: That's. There, there is a lot of information out there and some of it is confusing. I completely agree. And it has exploded over the past decade and women are looking more and more for information online. And so the education piece is very important. And I think one aspect that's often forgotten is they think that, A pessary is going to be a life [00:38:00] sentence. And they have to wear it all the time and they're, this is going to be their new best friend. It's really not true. And so sometimes, women come in and they say I really experience incontinence, or a little bit more pressure when I go to the gym. And that's a perfect example on of a patient who can be fitted with a pessary so that they can use it just when they go to the gym. And, that will be completely fine for that kind of patient.
[00:38:25] The other area of research that's emerging is using pessaries as prevention for worsening of pelvic organ prolapse. Wearing a pessary thinking about a lifestyle where, you may be lifting more in the beginning of the day or you're going for groceries or you're helping someone move, and that's going to make you lift a lot of heavy boxes. And, should you be wearing a pessary, it's a bit like a crutch for prolapse, just to support that structure so it doesn't stretch out anymore. And pessary use can be situational but it can also be all the time if needed. And,[00:39:00] women wear, we used to wear caps and diaphragms, wear tampons wear IUDs. So it, it's certainly just providing some education and normalizing this pessary idea. And we certainly all have seen many patients who use pessaries for many years and never need surgery.
[00:39:19] Melissa Dessaulles: Sinead, will you talk a little bit about, because this is definitely something I think as as physios, you mentioned, pelvic floor, muscle training will come into this.
[00:39:26] Pessaries will work with physicians, or nurse practitioners or whoever else in the communities fitting the pessary to work with the client. Pelvic floor muscle training to support the pessary as well. Lifestyle interventions, like you mentioned constipation, helping them lift more effectively or without having so much downward pressure.
[00:39:46] All sorts of things, but I think something I don't use a lot of is external support. And will you talk a little bit about you see a lot of marketing around external support for prolapse management. Will you speak to that point?
[00:39:57] Dr. Sinéad Dufour: Yeah. So I have [00:40:00] imaged here, it's a particular company I'm not associated with the company at all, but it's an example of a style of external compression that there is definitely not as high level of evidence for, these external supports as there is for a pessary for sure. And so I'm very transparent about that actually with my clients in terms of like giving them a sense of these are the more tried true higher levels of evidence.
[00:40:27] These are other options, but some people can find them very helpful, particularly those folks who they just aren't interested from their own preference perspective that we have to respect. I'm having anything intravaginally done. And so it's lower it's lower evidence, but there is some evidence that symptoms of prolapse, so these tools have not been shown to actually change, the staging of the tissue. They have rather been shown to change the symptoms of prolapse. [00:41:00] And there has been, some small studies done on these tools. So I have started to utilize these tools or at least make people aware of them, of this kind of external compression wear that can be used, when someone is pregnant or in the postpartum period.
[00:41:14] There's different companies, there's different styles and just make them aware of their options. And what I can say is definitely a very high proportion of my clients really have communicated back and said, that was really helpful. I just felt like I was more secure to do my workouts. I was more inclined to exercise. And we know that exercise in and of itself is a really helpful thing when it comes to pelvic floor dysfunction, right? Even if we think about the data across the board, you made the comment about knee pain and knee injuries before. If we look at the data around knee braces for whole variety of knee issues, The data is pretty mixed across the board. Half the data kind of shows it's doing something helpful. Half the data shows knee braces don't do [00:42:00] anything. And then when you really distill it and look at it and see what outcomes are most consistently seem to justify the use of the knee braces? It isn't around it doing something structurally for the tissue.
[00:42:12] It's around the individual feeling more confident and less scared and more supported to move. And actually I think that's what we're seeing with this type of a tool. So I think when these tools are studied more probably we will see, their strength of evidence kind of creep up a wee bit. But definitely as far as really empowering someone to have tools that reduce their symptoms, that keep them active in doing some of the other things that are our frontline options, an external support can be a nice menu option for some people.
[00:42:46] Melissa Dessaulles: And I think that kind of summarizes, the suggestions or the evidence here or the, conservative down along the line to surgical management talk is that at the end of the day, your goal is to look at each individual, [00:43:00] their symptoms, the bothersome, the quality of life, and give them options for conservative management before surgery.
[00:43:06] But sometimes everybody's bothersome skills different. Some people are okay if they leak, some people will do anything to not have surgery. Other people would be mortified to have one drip. And so I think just knowing that there are options, but I think I listen to this and think how beneficial all of these conservative options even before you have a surgical intervention.
[00:43:26] Because I always tell people that a surgery won't change your habits. A surgery won't change your muscle. The surgery can change your structures, but but it's your habit changing or your strengthening or your global strength that it can't change. And so either way, a lot of these conservative management options seem to be a good idea beforehand to consider anyway. And I'm seeing a lot of those that are coming as a referral saying, I have an upcoming surgery and my physician suggested I, I come here first so that I can have a bit of a plan going into it to improve [00:44:00] my outcome after we're just getting close to the end of our time. I wanna make sure that we leave enough time for questions. And just maybe some take home messages. Is there anything that I have a couple things, but I just wanna open it up to either of you first. Any take home messages that you want to make sure that people take away from this?
[00:44:22] Dr. Sinéad Dufour: So I can maybe just jump in first is one of the things I think that's really important to know is that, if we're looking at the research, it really is showing actually that when we have these behavioral components to our care plan really fostering what we would call self-management support, that actually is when you know the care seems to be much better.
[00:44:46] So even to give a bit of an example, if we look at some of the newer technologies that have come on the market, claiming to, really rehabilitate, restore the pelvic floor, if we even compare an option that has an [00:45:00] intravaginal biofeedback component that connects up to a Bluetooth phone, for example, Perifit, that was something that was mentioned at the beginning. Yes. The Perifit has a bit of a biofeedback to give you a sense of you're connecting and releasing these muscles correctly and maybe a little bit of motivation to do these exercises the way the technology is set up, but isn't really providing a comprehensive educational program that's based on principles of behavior change. Whereas there's some other applications that exist that don't have an intravaginal biofeedback component, but just the app is very based on principles of behavior change and the data is clear that those are much more effective. So I think all the while as yes, we're having this individually tailored approach, we really do wanna be thinking of that concept of empowering the client and having some of these behavior trained sort of principles within our care plan.
[00:45:58] So that was just one thing that [00:46:00] I wanted to punch through, cuz with a lot of the mentorship I do with PTs. I still find that's a bit of a shortcoming in some standard PT training across the board as PTs still really want to be very kind of prescriptive of exercise. They wanna do lots of manual therapy to release the pelvic floor and they're missing some of the other components and doing the manual therapy. It's not to say that might not be helpful, but as far as the evidence goes, that's very low grade on the list, right? So we just wanna be making sure we're including these things that are much more likely to create more global change in health creation in the whole pelvis.
[00:46:42] Melissa Dessaulles: Anything that you can think of, Roxana, that you wanna make sure that you people have as a take home message from this or a summary?
[00:46:49] Dr. Roxana Geoffrion: Absolutely. Yeah. Whenever I talk to patients I think as healthcare professionals, we are definitely in the business of dispelling myths. And whenever I talk to my patients, I try to remind [00:47:00] them to not get distracted by all the information out there and to not become mystified by the pelvic floor. And I just present them with a range of simple options. Pelvic floor disorders are exceedingly common and there are many tested therapies that you can try and there's no, there isn't, unfortunately just one medication to cure your ailment. In this particular case, it's a wide range of options.
[00:47:22] Think of it as, going shoe shopping. Why restrict yourself to sandals? Keep an open mind and explore the options out there and then keep coming back. These are chronic conditions. There is no good cure. Surgery is not, that is definitely not a cure. It actually, it often fails. And the worst thing is when somebody comes in and they've had three prolapse surgeries and they don't understand the concept of a pessary. And so there are options out there. Some of them are evidence-based and we as healthcare professionals are here to help them navigate through this confusing world.
[00:47:54] Melissa Dessaulles: Yeah, and I think that, you describe that, the importance of [00:48:00] educating yourself. Sometimes those visits with our provider are short. It's just a matter of finding the right type of evidence. I think about some of the whiteboard animations on your website, or I try to make sure I do make sure in all my podcast episodes are based on evidence and I interview the researchers or interview the expert in their field, but finding a way to ask your provider which information should I seek out. But I think we all need to educate ourselves as the clients too, so that when we do show up to an appointment, we understand what options are being presented to us because we recognize that no two people will choose maybe the same option first. So I think that's on us as the client as well. Sarah, I know you were going to help me with the chat a little bit. Do you wanna see if anybody has any questions right now or maybe you do? I have some if nobody else does.
[00:48:47] Dr. Sarah Lea: I see two questions. So the first question is is there a list, and I'm not sure the community, but I would think this could be community or province wide, but if there's a list of practitioners that fit pessaries and will follow wondering if there's any pelvic [00:49:00] floor physios or nurse continents, advisors that, that do it. And do all gynecologists do it? Cuz I know that can be a concern in our community as well. Like where can you access pessary support?
[00:49:10] Melissa Dessaulles: Roxana, do you have that answer?
[00:49:12] Dr. Roxana Geoffrion: Yeah. So, within BC the rules have changed a little bit, so you can only have a pessary fitting it's if it's been recommended by a physician. Nurse continence advisors have actually gone into trouble from fitting pessaries without the recommendation of a physician. I am not sure about pelvic physiotherapists and their particular rules. This brings a really good point. We're actually working at creating a little we've created a map of pelvic physiotherapists across BC for our website, www.bpelvichealthaware.ca. And I think that our next project is going to be to build a little map of where providers can send patients for pessary fittings. And, if you are a family doctor and recommend a pessary, that's completely fine. An NCA or a pelvic physiotherapist could do it. But as a, as an a nurse, you cannot send someone else for your [00:50:00] patient for a pessary fitting by another nurse or nurse continence advisor. It has to come through a physician in BC at the moment.
[00:50:06] Dr. Sarah Lea: Thank you. And are you able to say that website again and I'll put it in the chat?
[00:50:10] Dr. Roxana Geoffrion: Absolutely. It's www.bpelvichealthaware.ca all in one word, ca. And that gives you a map of pelvic physiotherapists in BC at the moment. But we're working on a similar map for pessary fittings.
[00:50:26] Dr. Sarah Lea: Amazing. Thank you. And there was one more question. We got one minute. So let's see how we can do it. How concerned should we be about asymptomatic prolapse slash incontinence that is not bothersome at the moment, but it's becoming more bothersome in the future, like getting, as we move towards menopause?
[00:50:43] Dr. Sinéad Dufour: I'm happy to just give my perspective first, but then Roxana, please buddy up your perspective. So again, a lot of the times clients when they seek my care it sometimes it's from a healthcare provider sort of [00:51:00] recommendation, but a lot of the times people actually just self seek my care. And actually I would say that is probably characteristic in the Ontario context of many pelvic health PTs. A good proportion of the people coming to see them have self-selected to see them. So if someone has self-identified, I have this issue, I've been managing with it fine. But it's starting to get a bit worse.
[00:51:23] And you know what? I'm just maybe anticipating or fearful it's going to get to a point where then I won't be able to manage it well. I would argue that's actually a really great time to be seeing someone rather than it really is down the line and then it can just be a matter of sometimes as simple as one.
[00:51:41] Thorough consultation to help them understand their body, to help them understand all the different factors, some of which are gonna be unique to them, to help them to understand all their options. And in many instances, these issues can actually really turn around, or the volume can be turned around very [00:52:00] quickly. So I would almost really be encouraging to people to think if they're on that track, where something's just starting to dial up in volume. Chances are it will continue that way unless they have some insight in terms of how to change directions and it can be as simple as one really thorough session with a care provider who has some understanding in this.
[00:52:24] So that would be my advice. It's not a big concern, but there's probably a ton that they can actually do to help themselves and change the trajectory. So it's probably well worth, a touch base point with a care provider.
[00:52:37] Dr. Roxana Geoffrion: And I completely agree with that for sure.
[00:52:39] Dr. Sarah Lea: Thank you. And I think that was it for all of the questions. Thanks to you both. I'll turn it back over to Melissa to wrap things up.
[00:52:47] Melissa Dessaulles: Yeah, I I really appreciate you both taking the time. I know we had a big topic we needed to cover in a short period of time, and I had thought let's just think of this as a bird's eye view because these are big [00:53:00] topics that I think there's a lot of confusion around, and I think we've done a good job of capturing the fact that there are options. It's not black and white for everybody. But I do, I think people are realizing that surgery is not the only option for some of these women's health related issues that come sometimes as a result of childbirth. And so I obviously welcome any of your feedback in the questionnaire that you'll be receiving because it lets us know what you want to know more about so that we can tailor these webinars to you so we look forward to your feedback and thank you both again for your expertise and in helping me really chisel down the most important pieces to talk about today.
[00:53:38] Dr. Sinéad Dufour: Thank you so much for having me. I think this is a really important conversation, so I'm just happy that it's gonna get out to more people. So thank you.
[00:53:46] Melissa Dessaulles: Yeah. And we're gonna have every people listening, from doulas, dieticians, physiotherapists, physicians, everybody you know, is going to be different types of practitioners will listen to this. And I think that it's helpful. We all come at it [00:54:00] from a different angle, but just helping understand, the options out there in conversation and just providing some education. We, we all can stand to learn from each other, can't we?
[00:54:11] Dr. Sinéad Dufour: Yeah, absolutely.
[00:54:13] Melissa Dessaulles: All right. Thank you everybody so much.
[00:54:14] Dr. Roxana Geoffrion: Thank you so much for organizing this, Melissa. Thank you all.
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