The stresses of a hidden epidemic

Described by many as a hidden epidemic, pelvic-floor problems affect about 45 per cent of women after childbirth, according to Don Wilson, a New Zealand-based professor of obstetrics and gynaecology.

"The lifetime risk of pelvic-floor dysfunction is 11 per cent of all women, most of whom have had children," says Prof Wilson, who will attend an international meeting of uro-gynaecologists in Dublin next week.

How best to deal with damaged pelvic-floor muscles will top the agenda of the International Uro-Gynaecology Association (IUGA) meeting, which will be attended by up to 2,000 uro-gynaecological specialists.

It is an opportunity for uro-gynaecological surgeons to discuss the latest surgical techniques used to treat prolapse of the uterus, bladder, bowel or vagina, as well as urinary and faecal incontinence. Most of these conditions are caused by damage to the pelvic-floor muscles during childbirth.

The Dublin meeting will also include a day dedicated to physiotherapy approaches to pelvic-floor damage, and a public awareness evening on pelvic-floor dysfunction.

Supporting the bladder
The pelvic-floor muscles are a band of muscles close to the vagina which support the uterus and bladder. They can be damaged during childbirth, particularly if the mother has a long second stage of labour or if forceps are used to bring the baby through the birth canal.

"Women who have an instrumental delivery [in which forceps or a suction cap are used] as opposed to an unassisted delivery are two to three times more likely to damage their pelvic-floor muscles," says Dr Declan Keane, an obstetrician and gynaecologist at the National Maternity Hospital in Dublin and a co-organiser of the IUGA meeting.

Antenatal and postnatal physiotherapy-led education, and exercise programmes to protect the pelvic-floor muscles before, during and after childbirth, are deemed to be the best approach to prevent incontinence or organ prolapse in later years.

“In Norway, women see a physiotherapist four times during their pregnancies and postnatally to help them keep good posture and to look after their pelvic-floor muscles,” says Keane.

In the UK, the National Institute of Health and Care Excellence recommends that women have supervised pelvic-floor exercises following childbirth. In France, women see a physiotherapist up to 10 times before and after childbirth.

In Ireland, the involvement of physiotherapists is often limited to one antenatal class. However, physiotherapists in private practice who specialise in women’s health here do teach women pelvic-floor exercises.

The problem is that not only are they tricky to learn – up to 50 per cent of women do pelvic-floor exercises incorrectly – but women must do two five-minute sessions a day for ever.

Incontinence and prolapse
Speaking about the increased demand for surgery for incontinence and organ prolapse, Keane says: "We won't do surgery as a first option but you need a motivated patient and a motivated physiotherapist to work together for between three and six months before you'll get significant improvement in the pelvic-floor muscles."

Maeve Whelan, a physiotherapist specialising in women's health, will speak at the IUGA meeting. She says research shows pelvic-floor muscle education and training can cure stress incontinence and prolapse in their early stages.

“We divide prolapses into four stages and physiotherapy works for stage one or two. Women should try physiotherapy first for stage three but when the prolapse has advanced to stage four, surgery is more likely to work.”

Whelan says up to 80 per cent of women will have pelvic-floor damage following the birth of their first baby.

“There has been some research to suggest that [giving birth lying on your side] can limit pelvic-floor damage. Also, research in midwifery has found that if a midwife puts her hand on the perineum during delivery, this can limit the damage.” Antenatal perineal massage is also recommended by midwives and physiotherapists.

Keane says that due to reduced levels of oestrogen, a woman’s pelvic-floor damage worsens as she ages.

“It’s a degenerative condition and as women live longer, we are seeing more cases of women coming for surgery. One in six women in the US will have surgery for incontinence or [organ] prolapse and up to 20 per cent of those will require further surgery,” says Keane. “Part of the problem here is that women want a quick fix and surgery gives them that option.”

A vaginal hysterectomy is the preferred option if a postmenopausal woman has a prolapsed uterus.

Surgery is also becoming popular for urinary stress incontinence, a condition in which women experience leakage of urine when coughing, sneezing, laughing or running.

“Surgery for incontinence is effective and safe, with low side effects. It involves the insertion of an artificial ligament midway along the urethra,” says Keane, who prefers to carry out surgery using spinal anaesthetic so bladder function can be fine-tuned during the procedure.

The biggest problem is that many women continue to suffer in silence, living with urinary stress incontinence or early-stage prolapse for years before doing anything about it.

Keane suggests that the National Cervical Screening Programme gives women the opportunity to have a pelvic-floor examination so that any signs of prolapsed or weakness of the muscles causing incontinence can then be further investigated.

Muscle-strength grading
Whelan suggests physiotherapists could teach GPs and nurses how to use the muscle-strength grading system to identify weakness in the pelvic-floor muscles.

Meanwhile, gynaecologists and obstetricians attending the IUGA meeting will debate the topic “This house believes instrumental delivery should be abandoned in favour of Caesarean section.”

Now, there’s a subject that many women will have a view on.