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Q&A on women's health physiotherapy with senior physiotherapist Dr Rachel Bromley - ANSWERS BACK

(80 Posts)
HeatherMumsnet (MNHQ) Mon 11-Nov-13 11:45:24

Were running a Q&A on Womens Health Physiotherapy with Nuffield Health. Their senior Womens Health Physiotherapists will answer all your questions on musculoskeletal problems and issues with the bladder or pelvic floor. These might be antenatal or postnatal problems associated with pregnancy or childbirth, or gynaecological problems.

Dr Rachel Bromley is a senior physiotherapist. She qualified as a physiotherapist in 1992 and has been specialising in continence and womens health since 2005. She has recently completed a Masters Degree in Continence and Womens Health at Bradford University. Rachel is the clinical lead physiotherapist for Womens Health within Nuffield Health and as such teaches and mentors other physiotherapists within the company who have an interest in womens health and continence. Dr Bromley has had additional specialist training in the assessment and treatment of a variety of womens health conditions, including urinary stress incontinence, urgency, symptoms of prolapse, voiding dysfunction, pelvic girdle pain and other pregnancy related conditions.

Laura Haworth qualified from Cardiff University in 2004 with a BSc in Physiotherapy. She has worked in Australia and New Zealand. Back in the UK, Laura joined Pilates Art and completed her equipment and mat-based Pilates training through the APPI Institute. She worked in their Hampstead clinic for eighteen months and became part of the womens health special interest group, working towards developing a private womens health service. Laura joined Nuffield Health in 2011. Since January, she has been based at the Nuffield Health Wharf Medical Centre in Canary Wharf where she has been assisting in the development of the womens health service.

Post your questions to the experts before 18 November and well upload the answers to this thread on 27 November.

This Q&A is sponsored by Nuffield Health

Thank you v much for all your thorough answers smile

DoctorWhoPrefersToFlySolo Thu 28-Nov-13 01:16:50

thank you, thank you, thank you!!! smile

ChaffinchOfDoom Wed 27-Nov-13 21:25:42

thank you, lots of help.

domesticslattern Wed 27-Nov-13 20:35:24

Thank you, very interesting

Thank you for answering my questions.

NeverKnowinglyUnderstood Wed 27-Nov-13 18:44:00

thank you for your response.

HeatherMumsnet (MNHQ) Wed 27-Nov-13 17:23:55

The answers have now been posted. Thanks to everyone who participated in the Q&A.

nuffieldrachel Wed 27-Nov-13 17:16:42

Brittapie

Yesterday was my DD2's (my last baby) 4th birthday. I also had to stop mid dance in the evening (I do proper partner swing dancing, so I wasn't just randomly bouncing about) because the SPD pain was so bad.

I found that dangling one leg off a step, sort of hooking my foot under the step and pulling hard eased it a bit, but the only thing that allowed me to not be in awful pain was a lot of painkillers, which then meant I couldn't dance because I was too doped up.

Are there any other quick fixes that I can do to help when it gets bad? I have long term exercises, but I need things to do when I have got all dressed up, paid £13.50 to get in, there is a live band and a lovely slippy floor and I have a great lead to dance with. Then one movement, that usually would be fine, makes my pelvis go "crunch" and I have to stop. Because that is mega frustrating.

Long term exercises should hopefully stop this being a problem, however have you considered hands on physiotherapy? The physio would do an assessment of your pelvis and could perform some manual techniques to try and improve the alignment of your pelvis.

Alternatively you could try stretching your back and hips gently before going out dancing so that your muscles and joints are prepared for activity.

Unfortunately slippery floors are not great if are suffering from pelvic pain as it is often rotation and unsymmetrical movements that can flare up the problem.

It may be that over time as you muscles in your pelvic floor, gluteals and lower back improve, you can dance more easily with less pain
-Laura

nuffieldrachel Wed 27-Nov-13 17:16:11

jonicomelately

How the hell do I improve my posture? I am very badly designed with a small back and large chest. Unless you are built like this it's impossible to know how hard it is not to lean forward so sayi g keep your shoulders back won't help. Are there any garments I could use! I buy good bras too so please don't say that either. I am thinking the only solution is a breast reduction.

Without knowing the exact extent of you problem my advice would be try to make sure your back and shoulder are flexible as possible by doing regular stretches for example in a Pilates or yoga class. Whilst a support to hold your shoulders back may seem like a solution, what often happens is that the body relies on it to do all the work and the muscles can get weaker. You may find more benefit from doing some strengthening to your upper back muscles such as your lower fibres of trapezius which help to support your shoulder girdle and back. I would recommend you talk to you GP about making a referral to see a physiotherapist to see if there is anything they can do to help.
-Laura

nuffieldrachel Wed 27-Nov-13 17:15:54

PacificDogwood

Yes, my question is about high impact exercise as well:
If I take up running, is that likely to make things worse? Or better as I hope to improve core strength and lose a bit of weight? confused

And what about pelvic floor supports? Are they any good, which one would you recommend and should I wear one only when exercising or all the time?

Post natally ways to lose weight can include walking, swimming and cycling. If you have pain I would not recommend running as this could make the pain worse and it can also worsen any pelvic floor problems as jumping and impact can put stresses thorough the pelvic floor and cause leaking if the pelvic floor is not very strong. Pilates can be a good way to strengthen your core and pelvic floor muscles. If you have continence problems and these do not improve with core exercises you may benefit from visiting a women?s health specialist physiotherapist who can give tailored advice and a pelvic floor assessment as indicated.

Our muscles are designed to give support and therefore it is important that you first try and strengthen your pelvic floor muscles to help symptoms of urinary stress incontinence. If urinary stress incontinence remains a problem during high impact exercise, despite following advice and working hard to strengthen the pelvic floor muscles, there are various devices that can be worn inside the vagina during exercise that help to support the vaginal wall and bladder neck. However, these vaginal devices are not suitable for everyone and I would recommend that you consult a specialist women?s health physiotherapist to discuss your options.
-Laura

nuffieldrachel Wed 27-Nov-13 17:15:34

Mumzy

I have a degenerative disc condition and this has been getting worse with each of my 3 pregnancies. I've been told by my consultant to improve my core stability with regular Pilates sessions swimming. Are these the best ways to help my lower back pain

Pilates and swimming are great ways to strengthen your core muscles which include your deep tummy muscles, deep back muscle and pelvic floor. I would advise that you search for classes run by a clinical Pilates instructor as they will have a greater knowledge on injury and should ensure that you work at the correct level. Often these are physiotherapists so it is worth investigating before signing up.
-Laura

nuffieldrachel Wed 27-Nov-13 17:15:02

PavlovtheCat

I have had a microdiscectomy for an L5/S1 prolapse. I also have a slightly out of line vertebrae of the same area, probably the reason for the prolapse. I have had returning symptoms since the surgery in June of this year and have been told it may have re-prolapsed, awaiting MRI. Also told it could be nerve damage/scar tissue build up.

I saw a Nuffield Physiotherapist for three sessions while waiting forever for my NHS referral post surgery (still waiting) who have me some exercises in quite a tough regime to do to build core stability. I have worked to this, before return of leg pain. GP told me to stop. Physio had said here would be some residual pain and to work through it.

There is conflicting advice now and I don't know whether to proceed with exercise.

What is your view on continuing exercise with leg pain (sciatica) while the diagnosis is unclear (ie, it might be a re-prolapse, might be internal scarring, might be nerve damage from prior to surgery unlikely). And, can a nuffield physiotherapist give muscle massage to address back pain and muscle spasm while there is leg pain? Would this be beneficial?

I would advise that the exercises should not cause an increase in your back and leg pain ? an ache or a stretch type pain is ok but I would not advise any sharp pains and would agree with your GP to stop. The other option is to modify the number of repetitions and sets and to reduce these, or do your exercises less often. You have mentioned several potential diagnoses and I would rather not speculate on other potential causes until you have had the MRI scan and the results, otherwise this can just lead to more confusion. My general advice would be to try and keep gently active, swimming can often be a supportive way of exercising and I would avoid being in a position where your leg is straight but your body bent eg like when sitting in the bath, as this can aggravate leg symptoms.
Physiotherapists can do soft tissue massage as part of your treatment ? often this treats the symptoms rather than the cause, it can be helpful but often gives short term relief and therefore longer term strengthening your core may be the best option. There is no reason why this can not be done while you have leg pain and it is something you can discuss with your physio.
-Laura

nuffieldrachel Wed 27-Nov-13 17:14:43

theyoniwayisnorthwards

I have a large separation of the rectci after two big babies two years apart. I have had hugely conflicting advice from different sources about what to do about it and I'm worried about making it worse. My GP sent me for an X-ray which confirmed the gap is huge but she doesn't seem to know what to do about it. I bought a splint from a program called the tupler technique but another fitness instructor said no splinting. Where can I go for sound advice? I am waiting for an nhs physio appointment but would pay to see someone privately for some definitive answers.

The condition you are talking about is recti diastasis. There are three layers of tummy muscles, the deepest it the tranversus abdominus, then the obliques which cross over and then the rectus abdominus (our six pack muscles). Our six pack muscles are actual two three pack muscles with are joined together with connective tissue. During pregnancy a hormone is release which softens this connective tissue and allows the muscles to move apart as your baby grows. Usually this will return back to the normal position after the baby is born. In some people this does not completely return, but exercises that work your transversus abdominus and help with this. Surgery is an option to repair the gap in the muscles. This is usually only indicated in certain situations and can include if the gap is more than 3cm wide, if it is causing pain/discomfort and only if you have finished having all your children. The support I would imagine is only for a short period of time. Often this can be helpful as it can help support the stretched muscles and make it easier to exercise them. I would not recommend wearing a support long term as sometimes the body will rely on the support and the muscles underneath can get ?lazy? and not work as well. Exercises that work well are ones that strengthen the deep core muscles (the transversus abdominus) which I believe the Tupler Programme does with progression to more challenging exercises, only when you are ready. Strengthening exercises do tend to take a few months and do need to be done regularly to see the effects.
-Laura

nuffieldrachel Wed 27-Nov-13 17:14:02

ChaffinchOfDoom

Hi, I am 20 weeks pg with my 3rd,
I broke my coccyx in a fall while pg with no, 2 , and have occasional bad pain in lower back, not lately though
I am getting quite bad sciatic pain in my right hip/bum cheek area, and sometimes it is quite agonising meaning I limp or it hurts to sit on the loo. Also my right knee is getting sore, but I have a habit of folding my knees under me when watching TV, am trying to stop that..

as far as sciatic / pgp/ spd goes I know to be careful pushing supermarket trolleys, what else can I do to minimise pain?
I don't really want physio, there's no way I could afford private, and am worried they'd hurt my back worse. So I need day to day advice -
is it better to sit with legs straight, or to lie on settee, for example
Hip is particularly bad when I stand in kitchen to wash up, is this due to general bad posture, leaning on my right hip?

also generally are health spa masseurs trustworthy? again I feel like they could really ruin my back if I trusted them, consequently I have never tried a massage; is this needless worry or are they better avoided by someone with old back issues?

thank you

With regarding to the sciatic type pain you want to avoid things that have your legs out straight and your back bent such as sitting in the bath with your legs straight, or bending down without bending your knees, as this can put a stretch on the nerve and make the leg pain worse. I would advise you to sit up straight with your feet on the floor with a small cushion or rolled up towel in the small of the back. Ideally you want you hips to be higher than you knees. I would advise that you avoid any heavy or awkward lifting such as carrying the vacuum cleaner up stairs and if doing house work try and avoid too much repetitive twisting and bending movements.

If you are getting pain when standing then it may be that you are compensating and shifting your weight which is why you are getting hip pain. It may be advisable to reduce the amount of time you are standing for and take regular breaks and sit down.

You will need to find out if the massage therapist is trained to do pregnancy related massage and it may be a good idea to speak with him/her first to find out what training they have had.

Often massage and/or physiotherapy can be helpful. If you were to see your local NHS women?s health physio she would have experience with treating women during pregnancy and would know what positions to avoid. She would also take a detailed history and would be able to find out what movements made your pain worse. You do not need to struggle through your pain and you may find you can get a lot of relief from seeing a women?s health physio
-Laura

nuffieldrachel Wed 27-Nov-13 17:13:29

IamInvisible

I had severe SPD in my last pregnancy 17 years ago. I was wheelchair bound by the time the baby was born. I never managed to get rid of the crutches permanently afterwards. It was so bad my pelvis remained really unstable so I had the symphysis pubis fused 8 years ago. Unfortunately that failed, so was redone by another surgeon almost 6 years ago. I have since had both my SI joints fused too. Because of the ongoing pain and the fact that the screws from the front plates could be felt through the vaginal wall(sorry tmi) the front plates were taken out 2 years ago.

I am in severe pain and am unable to walk unaided. I have regular steroid and LA injections done into the SI joints, and I also have them done into multiple areas of my pelvis, including the SP, under GA. I have discovered I have an Acetabular labral tear in my left hip from a recent MRI, too. Recently it feels like the bottom of my pelvis has started flexing again.

The problem is from using crutches all the time, my wrists, hands, elbows and shoulders are really, really painful. Is there anything I can do to alleviate this?

The other thing is my leg muscles are wasted, and my knee caps are loose because of this according to my GP. I was sent to see yet another physio with the view of hydrotherapy, but he said that anything he did would cause me too much pain. I have seen so many physio's but no one knows what to do with me to help give my muscles a bit more strength. Is there anything that could be done to help me?

(Sorry its so long)

You sound like have had a really difficult time and have had conflicting advice. It may be that the physiotherapist you saw was not confident in treating you. I do not have all the details of your medical history, however I would argue that it would be you that would make the decision about how painful the hydrotherapy would be. Hydrotherapy can be a great option, the warm water helps to relax tight muscles and joints and the supportive nature of the water often allows you to do things that you can?t on dry land. I would recommend that you try and speak with the physio?s at the hydrotherapy pool and discuss trialling a few sessions to see how you get on.

The other alternative is trying a pain management approach where you would work a specialised team of physio?s, doctors and occupational therapists who work together to give you a more holistic approach. This may have been something you have tried before, but if not I would recommend you discuss with your GP what services are available in your local area.

From using your crutches for a long time, you may benefit from some physiotherapy to your shoulders and neck to relieve tension, teach stretches and build some strength in your arms. This should help alleviate some of the pain and can help teach you some management strategies.
-Laura

nuffieldrachel Wed 27-Nov-13 17:12:46

PinkStarStuck

Hello...I have had x3 babies since 2007, all of them fairly sizable - 8lb - 9lb 10oz. With all 3 pregnancies my stomach muscles have separated and I've needed to do quite a lot of work with a physiotherapist to get get them to (almost) meet in the middle.

I am pregnant with my 4th...is there anything that I can do to stop the separation happening again or at least to minimise it? Is there a special belt that I can buy easily in the country that I can put on PP to help, the NHS hospitals usually give out large tubie grip which IMO doesn't work as well as a pair of spanx!

My 2 younger babies were my biggest, but oddly enough with those 2 pregnancies I put on far less weight than with my first as I was on the go rather than sitting behind a desk as I was with my first pregnancy.

Any advice greatly appreciated...(and any tips on how NOT to look 6 months pg when I am 9 months pp...).

The condition you are talking about is recti diastasis. There are three layers of tummy muscles, the deepest it the tranversus abdominus, then the obliques which cross over and then the rectus abdominus (our six pack muscles). Our six pack muscles are actual two three pack muscles with are joined together with connective tissue. During pregnancy a hormone is release which softens this connective tissue and allows the muscles to move apart as your baby grows. Usually this will return back to the normal position after the baby is born. In some people this does not completely return, but exercises that work your transversus abdominus and help with this. During your pregnancy you can still do transverse abdominus exercises although this can get difficult as the baby grows. You can also try exercising your pelvic floor muscles which have a connection to the deep tummy muscles. I would recommend wearing the large tubigrip rather than supportive underwear - as it will give support but has more give. Postnatally supportive underwear would be ok to wear as long as it was comfortable. I would then recommend doing core stability exercises which work your pelvic floor and transversus abdominus, and not starting sit up until you can maintain a flat tummy without any ?bulging? when you do a sit up.
-Laura

nuffieldrachel Wed 27-Nov-13 17:12:07

ClearlyMoo

I have an ongoing lower back problem and my physio have me a Serola belt for sacoriliac joint stabilisation in very early pregnancy. I do Pilates fortnightly (one on one) and have a daily physio routine. I work long hours at a desk and sit in car for 2.5-3hrs/day. Recently I've been experiencing pain in my bottom (around my coxys) when I release pressure (ie stand up). Could this be linked to my sacroiliac issue? Do I need to go back and see physio?! Would wearing my belt help? Thanks very much in advance.

Pilates and general stretches are a great way to keep your lower back healthy and maintain your fitness through pregnancy. Sitting for long periods is not ideal even when you are not pregnant however during pregnancy one of the hormones released makes the ligaments around the pelvis soften and so there is more movement. This could mean that you are putting more load through your lower back and pelvis and coupled with the increased weight from the growing baby could give you symptoms of lower back pain.

I would recommend that you use a small cushion in the small of your back when sitting either at work, or in the car. I would also recommend that you stand up regularly and spend 5 mins in every hour away from your desk. This may mean you need to factor in a break in your car journey to stop your symptoms coming on. Gentle pelvic tilting can give your back and pelvis a stretch even when you are sitting and doing 5-6 of these at a time regularly throughout the day may help alleviate your symptoms or prevent them from coming on.

Support belts are usually more useful when you are moving around and not as much when you sit. I would advise you try the above modifications and if the symptoms do not improve or worsen to then return to your physiotherapist.
-Laura

nuffieldrachel Wed 27-Nov-13 17:10:11

Solo

I will be 50 early next year and have had two vaginal deliveries, the last one at the end of 2006. I had (double) continence problems for several years after the last birth (when I needed to go, I had to go quickly), but seem to have sorted that out somehow.
My GP whenever I have to have a vaginal examination is always telling me I have weak PFM's and to work on them. I find this really difficult to do for some reason. I also have part of my posterior wall sitting visibly at the entrance which the GP never mentions, so I assume it's part of the lack of muscle tightness and tone.
Is there anything I can do to sort this out? and how can I do the exercises that I find so difficult now? they didn't used to be!
I have not had a menstrual period for about 12 months either, so I presume it's all going to go south from now on, but I really don't want to become an incontinent old lady as my GP puts it!
I'm a couple of stones overweight if that's relevant.
Thank you.

If your pelvic floor muscles have become weak, it can be really tricky to locate where they are and therefore exercising them effectively becomes very difficult and demoralising. Pelvic floor exercises are very important as the pelvic floor not only helps to support your pelvic organs, but also helps to close off your bladder and bowel and improves sensation during sex. A pelvic floor contraction should feel like an inside ‘squeeze and lift’ – as if you were trying to stop yourself from passing wind or trying to stop a tampon from falling out. Pelvic floor exercises should never be done whilst you are having a wee, because it can interrupt the complex bladder mechanisms and make it difficult to empty your bladder properly. You can check if you are doing the squeeze properly by using a mirror to look between your legs – you should see your perineum (the area between your vagina and anus) moving inwards as you contract your pelvic floor. If you see any bulging you should stop trying to do the exercise and seek advice from a women’s health physiotherapist. They will be able to help you do the exercise properly. Aim to do up to 10 long squeezes (up to 10 seconds each), followed by 10 short squeezes about 3 times a day. Remember to build up your exercises gradually – start with what you feel comfortable with and gradually increase the length of time you squeeze for and the number of squeezes you do. Strengthening the pelvic floor can take up to 6 months, so don’t give up!

If you are really struggling to feel the squeeze, try again whilst lying on your side, or on your back with your knees bent. There is a device called the ‘Pelvic Floor Educator’ which fits inside the vagina. An indicator stick shows if you are correctly doing a pelvic floor squeeze and lift. Other devices, such as electrical stimulation units or weighted vaginal cones, can be very effective but are not suitable for everyone. I would therefore recommend that you seek advice from a women’s health physiotherapist before purchasing.

nuffieldrachel Wed 27-Nov-13 17:08:20

LetsFaceTheMusicAndDance

Also, before the op, I had no idea that I was putting myself at greater risk of prolapse and I do want to get back to lifting, running on a treadmill (at 1% incline for lower impact). What should I do to enable this? Should I try to swap the treadmill for a cross-trainer?

1 more question. How do I start sorting my abs out? After having a huge fibroid (5 months 'gestation' size) for 20 years, they need work!

Thank you.

We generally recommend that you avoid strenuous activity and lifting for the first 12 weeks after surgery, and then gradually build up your activity. It is sensible after any major gynaecological surgery to avoid activities that put a lot of pressure down onto the pelvic floor, for example heavy lifting, double leg lifts in the gym or straining on the toilet. It would be beneficial to have a couple of one-to-one sessions with a fitness instructor at your gym, to check that you are not doing any exercises that may cause harm – you will need to explain to them what you have had done! Using the treadmill is fine, but start at a steady walking pace (without an incline) and gradually build up. When doing abdominal exercises, avoid doing traditional ‘sit-ups’ – ask your fitness instructor to teach you exercises to work your deep tummy muscles and core.

nuffieldrachel Wed 27-Nov-13 17:07:43

LetsFaceTheMusicAndDance

I hope I'm not too late to post.

I had a sub-total abdominal hysterectomy 6 weeks ago. I've been doing my pelvic floor exercises regularly (thanks Gussigrips). How do I know if I'm doing them correctly?

You can check if you are doing your pelvic floor exercises properly by using a mirror to look between your legs – you should see your perineum (the area between your vagina and anus) moving inwards as you contract your pelvic floor. If you see any bulging you should stop trying to do the exercise and seek advice from a women’s health physiotherapist. They will be able to help you do the exercise properly. Aim to do up to 10 long squeezes (up to 10 seconds each), followed by 10 short squeezes about 3 times a day.

Remember to build up your exercises gradually – start with what you feel comfortable with and gradually increase the length of time you squeeze for and the number of squeezes you do. Strengthening the pelvic floor can take up to 6 months, so don’t give up!

nuffieldrachel Wed 27-Nov-13 17:06:28

pinkoneblueone

Please can I have some advice? My children are 9 and almost 5 I have trouble pooing and actually over eat so that I can go otherwise I get consytipated I eat lots of fruit and veg daily more than the 5 a day recommendation. I did none of the exercises recommended after pregnancy and have a fair amount of loose skin I have lost a lot 5 stone since january with change of diet and exercise and I was wondering if there are any exercises you would recommend to help me go to the toilet and get rid of the loose skin

There are a few things that may help you to empty your bowel more effectively. Firstly, try not to put off going to the toilet if you get the ‘urge to go’. Your position on the toilet is really important. The best position is sitting with your knees slightly higher than your hips – try raising your feet on a stool or a large book. Lean forward so that your elbows are resting on your knees, then relax your tummy and let it bulge out in front of you. Brace your tummy so that it can’t bulge out any further, relax your bottom and use a deep breath to increase the pressure in your abdomen. Gently push down towards your bottom. If you are not successful after 3 attempts, get off the toilet and try again later. Having a hot drink or walking around can help stimulate the bowel.

Well done for losing 5 stone – what an achievement! Unfortunately when skin becomes very stretched it loses its elasticity, and there aren’t any exercises that will shrink your skin. However, toning up your tummy muscles and doing some cardiovascular exercise to improve your general fitness will help to give you a more defined shape. Good luck!

nuffieldrachel Wed 27-Nov-13 17:05:41

mrscog

I had a ventouse delivery and a 2nd degree tear, I was very incontinent for the first few days but then it all got much better by 6weeks post partum and now DS is nearly 2 I have absolutely no coughing/sneezing issues at all - just one tiny issue left and it's this - first thing in the morning after my wee I find that after when I'm washing hands in warm water I always leak a bit more! It seems completely related to the warm water. Is there any explanation for this? I have a strong PF now, but I don't even get any warning - it dribbles out when I start washing. It's not a huge issue but one that intrigues me all the same!

Sometimes the bladder can overreact to certain stimuli, for example, running water, cold weather or seeing a toilet. This is known as ‘sensory urgency’. Doing a long pelvic floor squeeze whilst you are washing your hands will help to relax the bladder wall and close off the neck of the bladder so that you don’t leak.

nuffieldrachel Wed 27-Nov-13 17:04:17

Queenmarigold

I had an induction at 37 weeks with twins, one ventouse one forceps. Both good size babies, over 6.5lbs each. I have several issues:
1- sex is very painful, whatever position. Any penetration is excruciating.
2- episiotomy scar is painful. This is separate to the other pain and hurts during non sexual movement eg squatting.
3- loss of bladder sensation. My need to pee is not normal. I have small pelvic floor problems and can't run or do strenuous exercise without leaking urine.

What do I do?
I do my pf exercises and have been referred for ob-gyn appt for the sexual pain. Is there anything else? Babies now 10months old. I'm sick of it.

Having a ventouse or forceps delivery can cause internal damage to the delicate vaginal tissues as well as the pelvic floor muscles. Our bodies heal with scar tissue which isn’t as stretchy as normal tissue and can become over sensitive to touch. The gynaecologist will do an internal and external examination to check that the vagina and episiotomy have healed properly. If scar tissue is a problem, they may recommend that you see a specialist women’s health physiotherapist who will advise you how to desensitise and stretch the tight scar tissue to help make sex more comfortable. In the meantime it may help if you use a good vaginal lubricant (for example Sylk) and try to avoiding sexual positions where penetration is very deep.

If you have damage to the pelvic floor muscles and the connective tissue (called 'facia), you may be lacking support to the neck of your bladder. This will make you more likely to leak urine during coughing, sneezing or other strenuous activity. This is called urinary stress incontinence. The pelvic floor muscles need to work in 0.25 of a second to help stop a leak and can only do this if they are strong and well-coordinated. You can check if you are doing your pelvic floor exercises properly by using a mirror to look between your legs – you should see your perineum (the area between your vagina and anus) moving inwards as you contract your pelvic floor. If you see any bulging you should stop trying to do the exercise and seek advice from a women’s health physiotherapist. They will be able to help you do the exercise properly. Aim to do up to 10 long squeezes (up to 10 seconds each), followed by 10 short squeezes about 3 times a day. Remember to build up your exercises gradually – start with what you feel comfortable with and gradually increase the length of time you squeeze for and the number of squeezes you do. Strengthening the pelvic floor can take up to 6 months, so don’t give up!

nuffieldrachel Wed 27-Nov-13 16:58:36

NeverKnowinglyUnderstood

I have issues with my undercarriage.
my youngest child is now 7 and since he was born I have been unable to pass stools without manual excavation. My cervix sits at the opening to my vagina when I am upright but seems to slip back when I lie down, so each time I have spoken to the gp about it they have said it isn't good but nothing that needs extra help. GP said it was just one of those consequences of giving birth about having to manually excavate.
I am over weight by about 2 stones but find any level of cardio exercise uncomfortable, I walk alot but think to loose weight would need greater levels of cardio.
What am I asking??? not sure really, but I guess where do I go from here. I am nearly 40 and I can't imagine still having to do this when I am 80!

I think it would be sensible for you to ask your GP to refer you to a gynaecologist. Having to manually evacuate your bowels must be very distressing and needs investigating further. It you are aware of a lump at the entrance to the vagina, and have discomfort when exercising it is possible that you have a vaginal prolapse. Vaginal prolapses are very common and can be successfully managed either with physiotherapy to help strengthen your muscles, a pessary to support your vaginal walls, or surgical repair.

Whilst waiting to see a gynaecologist there are a few things that may help you to empty your bowel more effectively. Firstly, try not to put off going to the toilet if you get the 'urge to go'. Try to avoid being constipated – if you are passing very hard poo you may need something to soften it and make it easier to pass. Your GP or a pharmacist can advise you. Your position on the toilet is also really important. The best position is sitting with your knees slightly higher than your hips – try raising your feet on a stool or a large book. Lean forward so that your elbows are resting on your knees, then relax your tummy and let it bulge out in front of you. Brace your tummy, relax your bottom and use a deep breath to increase the pressure in your abdomen. Gently push down towards your bottom. If you are not successful after 3 attempts, get off the toilet and try again later. Having a hot drink or walking around can help stimulate the bowel.

nuffieldrachel Wed 27-Nov-13 16:56:09

breatheslowly

Could you comment on the statement "it's pregnancy, not birth that damages the pelvic floor".

It seems to be bandied about, but I had a great pelvic floor throughout pregnancy. The MW who was at my delivery said that I had unusually strong PF muscles. But a crap birth seems to have ruined my PF to the point that I am likely to need surgery at some time in the future.

Is there any truth in the statement or is it a way of deflecting women from requesting CS?

Unfortunately the female body is a bit of a design fault and there are many things that can damage the pelvic floor and make it weaker – coughing, smoking, straining to go to the toilet, abdominal surgery (including CS) and heavy lifting, as well as pregnancy and child birth, can all contribute to pelvic floor damage and weakness.

The good news is that, like any other muscle in the body, the pelvic floor can be strengthened. You can check if you are doing your pelvic floor exercises properly by using a mirror to look between your legs – you should see your perineum (the area between your vagina and anus) moving inwards as you contract your pelvic floor. If you see any bulging you should stop trying to do the exercise and seek advice from a women’s health physiotherapist. They will be able to help you do the exercise properly. Aim to do up to 10 long squeezes (up to 10 seconds each), followed by 10 short squeezes about 3 times a day. Remember to build up your exercises gradually – start with what you feel comfortable with and gradually increase the length of time you squeeze for and the number of squeezes you do. Strengthening the pelvic floor can take up to 6 months, so don’t give up!

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