Lisa Flanders, Registered Physiotherapist

Connecting you with your Pelvic Floor

Category: Pelvic Floor

Pelvic Floor Physiotherapy-What to Expect at Your First Visit, Part 1

Pelvic floor physiotherapy is a branch of orthopaedic physiotherapy with the focus being on the muscles, joints, tendons, bones and organs found in and around the vagina and rectum.

 

I encounter so many wonderful questions regarding the first visit with a pelvic floor physiotherapist and what to expect, that I compiled them into one place.

 

Below is a list of frequently asked questions about your first visit.

 

  1. What can be expected at my first visit?

 

At your first visit, you can expect a thorough health history.  Each concern you have will be addressed. A physical exam will be conducted including a postural and movement exam as well as a gentle abdominal examination. If you are comfortable, an internal evaluation will be completed.

 

Following the assessment, the findings of the exam will be discussed. You will be provided with a home exercise program and a treatment plan will be created.

 

  1. How long does the assessment take?

 

Each initial visit is scheduled for 60 minutes as there is a lot of cover. There will be ample time to answer all questions and address all concerns you may have.

 

  1. Will there be an internal evaluation?

 

Typically there is an internal exam at your first appointment as this is considered the gold standard for evaluating the pelvic floor. If you are not comfortable with an internal evaluation, we will work around this to design a treatment plan that is right for you.

 

  1. Is pelvic floor physiotherapy covered by OHIP or private insurance?

 

Unfortunately pelvic floor physiotherapy is not covered under OHIP (Ontario government). However, if you have private insurance, pelvic floor physiotherapy is covered by extended health benefits, it falls under your physiotherapy benefit.

 

  1. How many treatments will be required?

 

Everyone will respond to treatment differently. We will typically have follow up visits every 2-4 weeks. Typical number of treatments varies between 4 and 12. This will be discussed with you at your first visit following the assessment.

 

Stay tuned for part 2……

Singing and the Pelvic Floor

I love to sing! Only when no one can hear me, which often involves a solo party with my iPod or belting out tunes to a song on the car radio (yes I am that person at the red-light). When asked what type of music I like, my answer is whatever I can sing along with.

I am not a good singer and I am okay with that, however I started taking singing lessons with the goal of having confidence to get up on stage at a karaoke night. I won’t be quitting my day job anytime soon because I am mediocre at best (though my singing teacher is much more complimentary).

singing

I am a physiotherapist with an area of focus on the pelvic floor. I pride myself in my body awareness. I can contract individual muscles on cue and relax them just the same. I can flawlessly demonstrate an exercise and I have perfect sitting posture. What has been fascinating through my singing lessons and what inspired me to write this post is how much more I am learning about my body and connecting with areas where I hold tension.

I have learned that I hold my pelvic floor tightly in standing and consciously have to relax the muscles to allow a diaphragmatic breath before the notes come from my mouth. I have learned how to take fuller and longer breaths and command noise from my diaphragm. I have also learned that I am not tone-deaf and can actually hit some pretty high notes (I can hit them, but the sound is not nearly as pretty as what I hear on the radio). I leave every lesson feeling open, relaxed and slightly more connected with my body.

Breathing

An effective diaphragmatic breathing technique is essential to singing. Sadly I find that many people do not know how to breathe effectively. In our modern era, we have become a sedentary population who spend a third of each day sitting at desks. Desk-jobs and compression of the abdomen through poor posture is non-optimal for an effective breath. Further, and this applies especially to women, we suck our stomachs in or wear compressive garments to give the appearance of a flatter stomach, think of how difficult breathing becomes to inhale fully when we have compression across our bellies.

The Diaphragm and Pelvic Floor Role in Singing

As we inhale (long, slow and smooth breaths) our diaphragm contracts and descends to allow air to fill the lungs. This increases the pressure through the abdomen and that pressure has to go somewhere, hence a belly breath. Ideally, the pelvic floor will relax slightly to allow for this pressure as well. The long and full breath is what is needed to create beautiful sound out of the vocal chords and to hold notes without running out of air.

Initially I teach my clients breath work in a supine position (lying on the back). We focus on long, slow and smooth breaths. The focus is to imagine breathing into the pelvic floor.

For our muscles to be functional, they must be able to contract AND relax. Muscles that hold too much tension are not functional muscles. This can lead to pelvic pain, painful intercourse, hip dysfunction and stress urinary incontinence. If we learn to breathe more consciously, not only will pelvic pain decrease but overall stress levels will decrease as well.

I think I am going to start incorporating singing as a treatment technique into my physiotherapy practice.

A little side note: On my first lesson, my teacher asked me to think of a word that ends in ”ah” (based on Italianate vowels), without blinking I responded with “vagina”, I really am meant to be a pelvic floor physiotherapist.

A Pelvic Floor Physiotherapy Exam is NOT a Pap Test

I believe a big deterring factor from women seeking treatment from a pelvic floor physiotherapist is fear of the internal exam.

 

Nobody enjoys going for regular Pap test and though it is a necessary piece to overall health it is my least favorite part of the physical.

 

Pelvic floor physiotherapy is different and when I explain the differences to my patients I hear things like “oh that sounds so much better”.

 

Below are some of the main differences between a Pap test and an internal exam by your pelvic floor physiotherapist

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  1. You will not have your feet in stirrups.

 

It is awkward lying on your back, legs up in stirrups with your bum at the edge of the table. Traditionally called lithotomy position, it has been used in the medical world since early times. There are obviously benefits to being in this position from the doctor or medical teams perspective (good visual and physical access) however I find it leaves a level of vulnerability.

 

During your pelvic floor physiotherapy exam, there are no stirrups, the exam can be completed on your back or on your side (in the position that you are most comfortable) and I will be next to you at the table so I can see your face, explain each step in the process and watch for any facial cues to let me know you are not comfortable.

 

  1. Pelvic floor physiotherapists do not use speculums

 

The speculum is the plastic instrument (or if you remember the metal….) that is used to open the vagina to get a clear path to the cervix. Use of a speculum is never comfortable, however, they are a necessary part of the Pap test to allow a swab to taken without contamination from the vaginal wall.

 

During your physiotherapy exam this is not necessary (hooray!), as I want to be able to evaluate the walls of the vagina, the muscles and connective tissues what the tone feels like and the strength, endurance and symmetry of your contraction, the speculum would get in the way.

 

  1. You will not be asked to wear an awkward paper gown

 

The paper gown never fits, and I always lose the plastic belt that is provided to tie it around. When I move it shifts, leaving me feeling exposed.

 

I provide my patients with a soft flannel sheet to cover the lower body, allowing you to stay covered, comfortable and warm.

 

  1. You will not have to lie on table paper

 

The piece of paper designed to cover the exam table that is never wide enough. When I try to get up onto the table I shift it and it usually tears, leaving my bum exposed to the vinyl tabletop (which is cold).

 

During your visit to my clinic, I cover the exam table with a fitted sheet (soft flannel) that is removed and washed after each patient.

 

  1. You will remain in complete control

 

You always have the right to remove consent during any examination completed by your medical doctor or other health care professional. However many women will grin and bare the full Pap test, even if they are in pain or discomfort. Worse, some women will avoid them all together knowing the discomfort they feel.

 

At your pelvic floor physiotherapy exam, we will only complete what you are comfortable with on that day. This may mean only an external visual or it may be the full internal exam. I will talk to you during your visit to ensure you remain in complete control and feel comfortable for the duration of the visit.

 

Take home message

If you do need pelvic floor physiotherapy, know that it is not the same as a Pap test; don’t let fear, embarrassment or discomfort deter you from the treatment you require. Additionally, if you have not had a recent Pap test, I encourage you to make an appointment with your doctor, as it is a necessary part of your regular health checkup.

 

 

 

 

 

 

 

 

 

 

The Postnatal Pelvic Floor-Frequently Asked Questions Part 1

I have been encountering some great questions about the postnatal pelvic floor. Below is a list of the most common questions.

postnatal

Q: How long after delivery should I wait to see a pelvic floor physiotherapist?

 

I generally recommend waiting 6 weeks before having an internal vaginal examination; your body requires time to heal. However if you are experiencing low back or pelvic pain, seeing a physiotherapist sooner will be beneficial.

Q: I have Diastasis Recti, can pelvic floor physiotherapy help?

Diastasis Recti (or DRA for short) is a separation of the connective tissue that joins on the abdominal muscles. It typically occurs along the linea alba (connective tissue line attaching the ribs to the pubic bone). It is due to stretching of the abdominal tissue to accommodate your growing baby, however the tissue can remain stretched well after delivery.

 

The goal is support the connective tissue through control of transversus abdominus (deep abs). The transversus abdominus is part of the deep core system along with the diaphragm, pelvic floor and multifidus (deep back muscles); the whole system must work together to be functional.

 

Until you have been evaluated by a trained professional and it is determined that you have adequate deep core control, avoid abdominal exercises including planks, crunches and double leg lifts.

 

Q: Which exercises are best during the early postpartum period?

 

Everybody will respond differently in the early postpartum period (first 6-8 weeks) and you should return to physical activity at a pace that is right for your body. It is advisable to have an evaluation with a pelvic floor physiotherapist to ensure it is safe to return to activity, together you will discuss your goals and develop a plan that is right for you.

 

Generally low impact activities like walking and swimming are safe for the body in the early postpartum period.

 

Q: I had a Cesarean Section, yet I am still experiencing urinary leakage when I cough, I thought my pelvic floor would be okay?

 

During a cesarean section, the abdominal muscles, including transversus abdominus are cut to allow access to the uterus. Our deep core system must work together to be functional, therefore a dysfunction in one area can lead to a dysfunction in another, in this case in the pelvic floor.

 

Secondly, following a cesarean section, scar tissue is created as the incision heals. This may create restrictions in the deep core system, creating dysfunction to the system as a whole.

 

Q: When will I feel like myself again?

 

The immediate post partum period is considered to be 6-8 weeks. However, keep in mind that your body underwent a beautiful change over a 9-10 month period where your abdominal and pelvic floor organs shifted to accommodate your growing baby. It can take at least as long for you body to make the transition back.

 

Be patient, it’s hard work to grow and nurture a child. Working with a pelvic floor physiotherapist in your area that you connect with will help you reach your goals.

 

Stay tuned for part 2……

 

 

10 Reasons Why You Should See A Pelvic Floor Physiotherapist

The number one question I get asked is “How do I know if I should see a pelvic floor physiotherapist”. The short answer is that all pelvic floor dysfunction should be evaluated and if you are not sure, having an evaluation and the education that accompanies can be invaluable.

Below are my top ten reasons to see a pelvic floor physiotherapist.

  1. Connect (or reconnect) with your pelvic floor

I find so many people are disconnected from their private parts. However we use this area everyday!

Having a connection with your pelvic floor is necessary for optimal health and wellness. If you are pregnant, connecting with your pelvic floor will prepare the body for delivery. During childbirth the pelvic floor goes through a beautiful change but can leave the body can feeling disconnected, this is a great time to reconnect.

Understanding and being educated on how your pelvic floor works is the first step to connecting with it.

  1. Gain better bladder control

Running and exercising without leakage, decreasing the frequency of urination and sleeping though the night without waking to urinate are all concerns that a pelvic floor physiotherapist can help with.

 

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  1. Stop pelvic pain

Painful intercourse, pain with arousal, painful tampon use and tailbone pain are all concerns that can be treated by a pelvic floor physiotherapist.

  1. Improve your sex-life

If painful intercourse (both women and men) is interfering with your sex-life, a pelvic floor physiotherapist can help.

Additionally, a healthy pelvic floor can lead to stronger and more pleasurable orgasms.

  1. Manage the urgent need to urinate

Do you feel like you have to urinate the moment you get home or every time you are around running water? A pelvic floor physiotherapist will teach you to take control back over your bladder. You can read my story of an urgent bladder here.

  1. Decrease the heavy feeling in your vagina

If you feel heaviness (I usually describe this as the feeling like a tampon isn’t quite in properly) this may be due to a pelvic organ prolapse (the bowel, bladder or reproductive organs falling into the vagina). A pelvic floor physiotherapist can help.

  1. Relieve constipation

Constipation can come from many factors including diet and stress, but can also be related to a tense pelvic floor. Your physiotherapist will evaluate your muscles and can teach you to use them effectively. Toileting positions and education are necessary as well.

  1. Improve your core strength

The pelvic floor is part of the deep core system. The pelvic floor is at the bottom, diaphragm on top (breathing muscle), transversus abdominis at the front (deep abs) and multifidus at the back (deep back muscle). Optimal core function means the pelvic floor must also be functioning optimally.

  1. Decrease low back and pelvic girdle pain

The body is an interconnected system of bones, muscles and connective tissues. The pelvic floor has connections onto the bony pelvis, sacrum and tailbone meaning pain in the low back and pelvic girdle can have influencing factors from the pelvic floor itself.

  1. Have your questions answered in a safe, comfortable, compassionate environment

A pelvic floor physiotherapist is a highly trained, compassionate professional who has undergone additional training to assess and treat pelvic floor dysfunction.

If you still aren’t sure if pelvic floor physiotherapy is right for you, make an appointment to speak to a pelvic floor physiotherapist in your area, your questions will be answered and together you can determine the appropriate course of treatment that is right for you.

Take care of your pelvic health, your body will thank you!

Penguin Walking-An Urgent Bladder Story

Stigma surrounding the pelvic floor

There is a common state of thinking, that we shouldn’t discuss our private parts. Even the phrase “private parts” leads us into thinking that this is a secret that nobody else can know about.

Why is this a taboo topic? There is an assumption that as adults we should be toilet trained and be able to control our bladders. Accidental leakage and/or other bladder dysfunctions can feel embarrassing, as if we don’t have any control. The truth is one in 3 women will experience urinary incontinence in their lives and at least half of all women will experience some form of pelvic floor dysfunction. Interestingly, this is the same statistic as people who experience low back pain. I’m sure you have heard multiple people tell you about their back pain, but when was the last time one of your friends mentioned she peed her pants while trying to make it to the washroom?

You are not alone in this. Below is my story about struggles with urgency and urge incontinence.

Penguin walking

For as long as I can remember up until about 5 years ago, I struggled with something called urgency. Meaning an urgent need to urinate, like right now. Nearly every day I would be on my way home from school (and when I got a bit older this turned into on my way home from work) and I would sort of feel like I had to go to the washroom, but nothing I couldn’t hold. I would arrive home, and from the MOMENT I opened the door, the feeling would overtake me. I would resort to what I call a penguin walk to get to toilet before I peed all over. The penguin walk is where you hold your knees together and waddle as fast as you can toward the washroom.

penguinwalk

Now the thing is, this didn’t just happen at home, this happened whenever I sort of felt like I had to pee and then got within a 10 meter vicinity of a washroom. I always thought this was a bit weird, like my bladder knew I was close and it was prepping for evacuation. I also thought I was the only one that this happened to, none of my friends had ever mentioned a mad penguin dash to the bathroom.

I will also admit that there were a handful of occasions where I could not hold it and the penguin walk did not help; I leaked A LOT before making it to the washroom. As a teenage girl, I felt embarrassed, yet I would never admit to anyone that this was happening.

Fast-forward a few years. I was sitting in class for my first of many pelvic health courses in Montreal, QC. I was a fairly new graduate and eagerly awaiting to learn how to help people with bladder leakage. Within the first 15 minutes of the 4-day weekend, my wonderful instructor started talking about urgency and referenced putting the key in the door triggering some women’s bladders as a cue to pee. Could it be real I thought, is she reading my mind? Realization clicked in, as I looked around our small classroom and saw the look of familiarity across multiple participants’ faces and I realized I was not alone in this, it was called urgency and it was a common concern in many women.

What is urgency?

Urgency is any pressing need to urinate, often coming on very quickly. There is usually a trigger, something that sets the bladder off like getting home and putting your key in the door (sometimes called latch-key urgency) or being around running water. It can sometimes be related to a urinary tract infection so it is necessary to have your doctor rule out any sign of infection. It is often a miscommunication between our brain and our bladder. Our brain hears, “Oh I’ll just go when I get home” and as soon as we get home, key in the door our brain tells our bladder “You are home, time to go”.

For more information about urgency, incontinence and over-active bladder, click here.

First steps in taking back control over your urgent bladder

Start changing the way your brain thinks; remember, mind over bladder. Slow down and breathe. Instead of saying “I’ll go when I get home”, specify to your brain, “I will pee when my pants are pulled down and I am sitting on the toilet”. Altering your self-talk can be an important and necessary first step to overcoming urgency.

Either your medical doctor or pelvic floor physiotherapist should evaluate all forms of pelvic floor dysfunction, plus, ruling out other causes of urgency should be explored.

I am happy to report that I no longer have to penguin walk to the washroom and I am in full control of my bladder and urgency. The take-home message is that you are not alone! If you have ANY concerns related to your bowel, bladder or sexual function, I encourage you to speak to a healthcare professional or pelvic floor physiotherapist and learn how to take back control of your pelvic floor.