Pelvic Floor Clinic (Module 5): The Next Step

If you have watched the last 4 modules, you
now know more than the average person about the pelvic floor and its issues. We hope you are able to better understand
what is happening to your own body. We also hope that you have identified specific
things that only you can do to improve your symptoms. And we hope you have a clearer idea about
what your options for treatment are and what you would like to pursue. You can review these modules at any time. We also encourage you to look at some of the
additional educational segments we have created for our patients – on topics like pelvic
floor muscle rehabilitation, intermittent self-catheterization, pessaries, constipation
and more. The objectives for this final module are: 1. To review and summarize treatment options
for prolapse, bladder and bowel
management issues 2. To ensure you understand your role in improving
the symptoms you are having 3. To help you to consider and select your direction
for ongoing care, if needed 4. To help you understand what to expect in the
clinic you are attending Now, I would like you to reflect on the pelvic
floor issues that are bothering you – the reasons that compelled you to review these modules. For some of you, the issue is clear and only
consists of one main thing. For others, there may be a few things going on. It is important to decide which problem is
the greatest bother to you – which problem you want to focus on first and look for solutions. As mentioned earlier, some solutions are up
to you as only you can make the changes necessary for improvement. However, some solutions require medical appointments
and ongoing treatment. We will now summarize the treatment options
for all the issues. We will try and help you consider and select
which area is a priority for you and where you want to go with it. You may want to review previous modules so
you are clear on what your options are. Pelvic organ prolapse affects up to half of
all women and can be mild to severe. You may recall that the front wall of the
vagina – with the bladder behind it – may prolapse or fall down towards the vagina. This is the most common type of prolapse that we see. The uterus can come down from on top or the
vault of the vagina can sag down if you have had a previous hysterectomy. As well, the back wall can also prolapse forwards
towards the vagina. It is normal to have some laxity and movement
within the vagina after having children, but prolapse can develop to the point that it
may cause some symptoms that are affecting you. All of the options listed here – pelvic
floor muscle training, protecting your pelvic floor in all your daily activities, using
a pessary or surgery – may help with your prolapse symptoms. To clearly recall any of these, please review
module 2. How do you decide what to do? Prolapse is something most women do not know
much about, in spite of how common it is. You may or may not be experiencing symptoms. If you are noticing prolapse symptoms, think
about how much of a bother these symptoms are to you in your daily life. If you do have some prolapse, but it really
is not a concern or a bother to you at all right now, you may choose to do nothing but carry on. However – it is very important to prevent
your prolapse from becoming more severe. Now that you know what may make it worse,
be very careful with things like chronic coughing, straining with bowel movements, weight gain,
heavy lifting, high impact activities and so on. Keep your pelvic floor muscles well trained
so they will assist in supporting your abdominal canister and its contents. You may know you have prolapse, and “Yes”,
sometimes it does bother you. You are concerned that it may worsen, and
rightly so. Would you like to try a pessary to help support
the prolapse? You may try the pessary and decide against
it – that is perfectly acceptable. Or – it may work well for you. If your tissues are dry, you may want to use
vaginal estrogen. Making the tissues healthier can alleviate
the feeling of prolapse for some women. The other alternative you may be considering
is surgery which is a big decision. The surgeon that you meet with should be open
and honest with you in terms of the risks and possible outcomes. OR – you may want to wait and watch. Your prolapse may not worsen if you are diligent
with training and using your pelvic floor muscles and being careful with things that
aggravate it. It may improve to the point that it is no
longer a bother. Some of you are experiencing a lot of discomfort
from your prolapse. You may have symptoms such as pressure, heaviness
and bladder and bowel problems that are difficult to deal with. You may even have tried a pessary in the past
and find it is no longer the solution you want to live with. Perhaps you have had surgery that has failed
over time. You can retry a pessary that might be a long-term
solution for you. You may want to meet with a surgeon to discuss
a surgery that will fix the prolapse. Whatever you decide, it remains your responsibility
to keep your pelvic floor muscles trained and to modify lifestyle behaviours that will
allow you to have optimal and long-term success with either the pessary or surgery. Lastly, you may never notice any signs or
symptoms of pelvic organ prolapse. Please remember that 50% or more women do
develop prolapse at some point in their lives from various associated factors – pregnancy,
weight gain, constipation and so on. You can prevent prolapse from becoming an
issue for you by being careful with all these things. Now lets consider the bladder issues. One third to one half of women deal with bladder
leakage problems at some point in their lives. The two most common types of urinary incontinence
are stress and overactive bladder OR urge incontinence and many women have a bit of
both called mixed incontinence. Stress incontinence is the leakage of urine
with pressure on your bladder from activities such as running, coughing, sneezing and jumping. There are four options to consider when dealing
with stress incontinence – training your pelvic floor muscles to prevent leakage by
holding the urethra closed, wearing a pessary to prevent leakage, a surgical intervention
like a mid-urethral sling or bulking agents, or by focusing on healthy bladder habits that
allow your bladder to function at its best. You may want to review these options in more
detail by looking at module 3 again. Do you have stress incontinence? If you do, consider how much if affects your
quality of life or lifestyle. If you don’t leak at all, or only a wee
bit, it is important that you maintain your control by keeping your pelvic muscles trained
and working for you. Always practice “the knack” – squeeze
and hold before you cough or sneeze, lift, etc. – and prevent any minimal leakage from
worsening in the future. If you do leak, and it is a bother – again,
consider your options. The very first focus is to strengthen and
train your pelvic floor muscles to be there to tighten and hold your urethra closed with
any activity that puts pressure on your bladder. An incontinence pessary may
be a simple option for you. You don’t know how well it may work until
you are fitted and try it over time. Surgery may also be an option to think about. And as always – practice healthy bladder
habits. If stress incontinence is a major problem
for you, your options remain the same. You need to train your pelvic floor muscles
to work for you and use healthy habits. You may be leaning a little more to trying
a pessary or pursuing a surgical solution. You might want to review about the 2 types
of surgical approaches that are used for stress incontinence in module 3. The other common bladder issue is overactive
bladder, when the bladder contracts suddenly without warning, making it impossible or difficult
to make it to the bathroom without leakage. You may be running to the toilet frequently. There are some different treatment options here. Pessaries and surgery are
not considered as options for OAB. However, note that we now have urge control
techniques, bladder retraining and the use of some medications to help control the urge to void. Once again, you might want to look back for
more information on overactive bladder in module 3. Do you experience severe urgency, frequency
or leakage from overactive bladder? If you do – does it interfere with your
quality of life or your lifestyle? Think about this. If this does not happen to you, or is very
rare, you may want to keep your pelvic floor muscles strong, be careful with what you eat
and drink and in general, keep good control over your bladder habits so it never becomes
a full-blown issue. If overactive bladder is a concern for you,
definitely work hard on all these things. We recommend that you reduce bladder irritants
completely and see if you can note an improvement. If your bladder is controlling your life and
you find you are always running to the bathroom and planning your daily errands around bathroom
stops, you may want to give bladder retraining a try. Also, your doctor or specialist may provide
you with prescriptions for drugs that relax your bladder so that you have better control. Using a bladder diary will help you to track
your progress. Again, there are no surgeries for overactive
bladder, and pessaries are generally not used. Mixed incontinence treatments options include
everything we have just talked about. It is helpful if you analyze which issue is
worse – stress incontinence OR urgency and frequency – and focus on those things first. Review module 3 on urinary incontinence to
clarify what you can do if you have overflow incontinence, functional incontinence or nocturia. In module 4, we talked about bowel management
problems and strategies to deal with them. If you have issues with bowel control – hard
dry stools that are hard to eliminate, or anal leakage issues, definitely review module 4. If these issues are not a problem for you,
you must be careful to ensure that they never will be . Dealing with bowel evacuation issues generally falls in these categories – using healthy
bowel habits, including proper positioning, changing your food intake to eliminate possible
irritants or adding specific foods with fibre, ensuring your anal sphincter is working properly
so you have better control and possibly seeing physiotherapists trained to help with these issues. Review module 4 to help remember the specific
things that may help you. Are you finding that it is hard to manage
your bowels – with needing to strain to move them or perhaps difficulty controlling
or holding them? Is it affecting your life and frustrating
or concerning you? –If not, excellent. Make sure your bowel habits and food and fluid
intake help keep it this way. Make sure your ability to hold stays strong! If you must answer yes – it is a worry – be
very deliberate with the options for treatment, including your bowel habits, position on the
toiler, diet and fluid and your pelvic floor muscles. You may want to look up the private physiotherapists
trained in these issues for additional help. If it is big issue for you, you must take
very seriously all these suggestions, including possible medications that may help. You may be a candidate for our clinic physiotherapists
who are experts in dealing with these issues. If you choose to come to our clinic for a
clinical appointment with any of the team members, your medical history form that you
will fill in and bring in is an important part of the visit. We rely on the information that you give us
to help us understand the issues you have. The medications that you take can also help
us understand your medical issues, and also to check if any of these medications may be
affecting your symptoms. A bladder/bowel diary is very helpful to us. We so appreciate it when you come in with
a completed diary, as it clearly shows us how often you are peeing, how much, how much
and what you drink and so on. The bladder diary is a very useful tool for us. After a review of your information, you can
expect to be asked for a urine sample for us to check and it may be done on a uroflow
chair – a special toilet that measure certain aspects of your urine flow. Then we check how much urine remains inside
your bladder after you void, with a hand-held ultrasound bladder scanner applied to your
tummy that gives us this amount. Routinely we will exam your bottom, especially
on the first visit. We check the health of your vaginal tissues,
we check for prolapse and we check if you able to properly contract your pelvic floor muscles. We even give you a score out of five on the
intensity of your contraction. Some of our patients, not all, may have other
specialized testing in our clinic. This would be booked and you would return
on another date. Some patients in our clinic may have urodynamic
testing, a specialized test done to help understand how your bladder is functioning. This may be important if you are going on
to surgery, or if your symptoms are unclear and we need to better assess the bladder’s functioning. This is done by certain well-trained clinicians
using specialized equipment. Cystoscopy is another test that the surgeons
perform, where they examine the inside of your bladder with a telescope designed to
fit into your urethra and bladder. Neither test requires any sedation. The urodynamics test takes up to an hour and
the cystoscopy about half an hour. Because the Calgary clinic has different team
members, the one best suited to your problem and your needs will be the
one you see when you come in. It may be a nurse, a surgeon or urogynecologist,
a family doctor or nurse practitioner or a physiotherapist. All team members have special training to
deal with the needs of our patients. Our team of nurses see many of our new patients
for their first assessment and pelvic exam and they do the pessary fittings and follow-ups
for those who want pessaries to help with their prolapse or stress incontinence. They also may be the ones doing your urodynamics
or helping with cystoscopies. The urogynecologist will see you if you would
like to be evaluated for a surgery to help your pelvic organ prolapse or incontinence
issues, or to be assessed and treated medically. They will also see patients that have any
other type of pelvic floor issue that is complicated or less common and possibly not discussed
in these modules. A family doctor and nurse practitioner generally
see our patients who have overactive bladder symptoms and may prescribe
medications to assist you. You may be referred to a clinic physiotherapist
if your pelvic floor muscles are extremely weak or extremely tight. As well, some women with severe constipation
or anal incontinence may also be referred to them. I would like to emphasize that it is critical
that you must let us know if you cannot be present for a scheduled appointment. Due to the busyness of our clinic and the
demand for appointments, every appointment spot is valuable. Sometimes it may be necessary to cancel and
rebook an appointment for reasons beyond your control. If this happens, it creates a vacant spot
that we could offer to another patient so please give us as much notice as possible. Cancelling more than once makes us wonder
if you are really motivated to attend our clinic and thus, we may require a new referral
in order to be seen. Now we ask that you think about all the information
you have received in these modules and consider what your next step might be – what type of
treatment you are most interested in at this This overview reviews which treatment options
must be done by yourself and those that require an appointment – they are indicated in red. Pause the video to look at this closely. In Calgary, in the package you received by
mail, there was a letter and a medical history form that you must now find and fill out. In addition, there is a form on the website
that we require you to download, print and complete before your first clinic visit – the
“Bladder and Bowel Diary”. We ask that you complete these forms and bring
them with you to your first appointment. Answer every question on the medical history
form fully and accurately. Please find and fill in the list about all
your prescribed and over the counter medications, along with the dosages. Bring this form and your list to your appointment. Find the “Bladder/Bowel Diary” form on
our website, in the “Health Information” section. Read the instructions carefully and fill it
out over 3 days, not necessarily in a row. Bring this completed form to your first appointment
as well. Once again, we remind you that your role is
critical – there are many things we have indicated that may help your issues that only
YOU can do. We cannot eat or drink for you – you make
those decisions daily. The same goes for your bladder and bowel habits,
the strength and ability to use your pelvic floor muscles to help you, activities you
are involved in and your weight. All these things were factors in potentially
causing these issues and are factors in potentially helping them. The final take home thoughts from this module
are here – can you understand what pelvic floor issues are the most bothersome for you? Are you clear about the things that only you
can do to improve your symptoms? Do you know what type of treatment options
apply to your issues? And have you filled out your forms so that
you can bring them to your first appointment? Remember that your direction for care can
always change after you are seen in the clinic –that will all be discussed after you are
fully examined and we have a good conversation with you. We really hope that these modules have been
interesting for you and have challenged you to do what you can to improve your pelvic
floor symptoms. You can view them again and again, if necessary. We are continuing to create additional supplementary
modules that explain certain topics in greater detail and they are found on the website menu. There are also education information sheets
that you can download and print with information that reinforces what we have said on these
modules. One more thing that would greatly help us is if
you download and complete the module feedback form. This allows you to provide some feedback to
us about these modules. We will consider carefully all the feedback
you provide for us. This form can be mailed or faxed to us, or
brought to the clinic at any time. The next 2 slides contain links that you can
use to search for more information on other websites. Their focus is indicated beside them. Good luck to all of you!