A wee problem

• Alison Cameron
• June 6, 2008

Incontinence and weak pelvic floors can be a troubling issue for many women, but it needn't be, says pelvic physiotherapist Mary O'Dwyer.

"Trouble down below" has been written off for generations as one of the prices paid for being a woman. This attitude towards pelvic floor problems has led many women, particularly but not exclusively after childbirth or menopause, to simply readjust their expectations of life. For them it is normal to have continual discomfort and to consider laughing and coughing as high-risk activities.

For others, their unpredictable bladder takes over their life, with their whole world transforming into a landscape punctuated by toilets, always living in fear of being caught short.

Dr John Gullotta, who has a general practice in Marrickville and chairs the AMA's public health committee, says, "One in 20 women suffers from incontinence and many incorrectly think that it is normal and there is not much you can do about it." He explains that pelvic floor dysfunction is the most common cause of the two types of incontinence.

Stress incontinence is when you laugh or cough and urine escapes, while urge incontinence is the sudden and strong need to urinate, which sometimes cannot wait until you reach a toilet.

For Kirsten*, 36, incontinence wasn't an issue but she knew something was seriously wrong after the birth of her third child. "I felt fatigue and had a heaviness and ached around my vaginal area. I couldn't pick up my toddler and struggled carrying groceries."

There was also a disconcerting change in her physiology. "It's hard to describe but one of my friends who had a similar experience summed it up when she said she woke up one day and thought she had a penis! It was a bulge on the entry of the vagina."

This, she later discovered, was a prolapse, which is when a pelvic organ - bladder, bowel or uterus - bulges into the vaginal walls.

The pelvic physiotherapist she was referred to taught her pelvic floor exercises, also known as Kegel exercises. After she learned to strengthen her pelvic floor, the prolapse righted itself without the need for surgery. "I hadn't been able to even go for a walk in the evening because I was so uncomfortable. It was eating into the way I wanted to live my life," Kirsten says.

For pelvic physiotherapist Mary O'Dwyer, educating women was the driving force behind her new book, My Pelvic Flaw, which is based on 30 years of clinical and teaching experience.

"Women know they should do some exercises but don't know how to do them properly, so just hope that nothing goes wrong. That has been our approach for too many years," she says.

O'Dwyer says women after childbirth, after pelvic surgery and around menopause comprise the majority of those suffering pelvic problems but the young and the child-free are also at risk. "Teenage girls can develop problems and figures show that 28 to 52 per cent of elite female athletes have stress and/or urge incontinence."

The answer, O'Dwyer says, is to strengthen the pelvic floor through the exercises, which all women should perform daily whether or not they have problems. In her book, subtitled 'Preventing pelvic floor problems throughout life', she also recommends that parents become aware of their children's toilet habits. Constantly straining the bowel or habitually emptying the bladder before it is full can weaken the pelvic floor muscles and lead to problems later in life.

She also has a section warning women to be careful at the gym and to avoid lifting heavy weights or performing curl-ups. "It is up to women to be aware that when we train physically we need to train our pelvic floor and deep abdominal strength first."

For Margaret*, going to the gym was the last thing on her mind. At 73, all she wanted to do was play a game of bowls without having to constantly rush to the toilet. In 1990 she had surgery for a pelvic prolapse then two years ago had a re-occurrence.

"When I had my first child 50 years ago no one said anything about pelvic floor exercises. You just shelled them out like peas," she says.

When her male gynaecologist patronisingly dismissed her worries, Margaret was left feeling abandoned by the medical establishment.

"When you are my age you don't discuss it with anyone and I didn't know what to do," she says. It was only when she read an article on a pelvic physiotherapist she found the answer she needed.

After learning the exercises and being given a pessary from her new female gynaecologist, she saw results within weeks. "Life is wonderful now. I am back dancing three times a week, I play bowls, I walk and I swim."

Sarina Priori, a Sydney pelvic physiotherapist with more than 20 years' experience, recognises all too well the desperation that pelvic floor problems cause.

In extreme cases intercourse becomes very painful, while other women experience urine loss during sex.

"It can be devastating. I have had young women who just don't want to date or have had their relationships break down," she says.

At the other end of the age range, Priori stresses that you are never too old to exercise your muscles. "I have had 90-year-old patients."

According to Priori, there can be underlying causes of pelvic floor problems and constipation is a frequent culprit. "I often talk to women about adequate hydration and fibre intake as well as correct toileting positions and abdominal bracing without straining," she says.

For Priori, it is all the talk of wee and poo that often inhibits women from sharing their problems with friends but embarrassment can be overcome. "People tell me that when they start opening up about their pelvic floor other people open up too, and that is healthy."
* Surnames withheld.

Tips for a healthy pelvic floor
- Avoid heavy lifting.
- Perform pelvic floor exercises every day.
- Avoid constipation through diet and by drinking water.
- Try not to go to the toilet "just in case". Learn to wait until you have 250-300ml in your bladder. Learn the correct toilet position and avoid slumping and straining. 

Questions? Get answers in the pregnancy information and tips forum.

My Pelvic Flaw is published  by Redsok.