Once a French woman has given birth she is offered free physical sessions to rebuild her pelvic floor. In Ireland, the need to exercise this area is barely addressed, often leading to ongoing issues with bladder control and less pleasure in sex. Sharon Ní Chonchúir reports.
How toned is your pelvic floor? If you live in France, it’s likely to be very toned. In Ireland, perhaps not so much.
The pelvic floor consists of muscles, ligaments, and tendons that support the pelvic organs. It plays two other vital roles in women’s bodies: it controls the flow of urine and increases pleasure in sex.
Post-pregnancy, every woman in France gets a prescription for 10 free physical-therapy sessions to rehabilitate her pelvic floor and abdominal muscles. These sessions take place between six weeks and three months after birth, to ensure that women’s pelvic floors recover from the exertion of pregnancy and labour.
But we rarely even discuss these matters here. Most of us view urinary incontinence as an old woman’s problem and if we ever have leakage, we’re too ashamed to tell anyone.
Yet urinary incontinence affects women of all ages, whether they have had babies or not. Always Discreet, one of a growing number of brands selling incontinence pads, carried out an online survey of 2,000 women in May 2019. Many complained of bladder leakage post-childbirth, but 64% of 18- to 24-year-olds said they had experienced it, too.
“It’s a massive problem that’s not confined to older women or women who’ve had babies,” says Helen Keeble, a clinical physiotherapist at Dublin’s Blackrock Clinic. She also runs a pelvic health physiotherapy practice in London. “It can happen to anyone when they’re sneezing, laughing, running, or doing exercise.”
Dr Cliona Murphy, chair of the Institute of Obstetricians and Gynaecologists, cites pregnancy, childbirth, and menopause as the main reason for weakness in women’s pelvic floors.
“Lots of women experience urinary incontinence in the first few days after childbirth,” she says.
The menopause and its hormone changes can also have an impact. “Falling oestrogen levels affect the vagina and bladder,” says Dr Murphy. “The skin isn’t as thick as it used to be and becomes more prone to cystitis and urinary tract infections. Tissue becomes laxer. The urethra is more exposed. All of this can lead to incontinence.”
There are other risk factors, says Maeve Whelan, a chartered physiotherapist with Milltown Clinic, in Dublin, and a specialist in women’s pelvic health.
“Urinary incontinence affects one in three women and one in nine men and is the main problem I treat in my work,” says Whelan. “In teens, it’s often because their muscles are too tight, and they have an overactive pelvic floor. In adults, pre-disposing factors include obesity, smoking, and even constipation.”
A new study by Glasgow Caledonian University establishes a link between urinary incontinence and our increasingly sedentary lifestyles. It found that women who had urgency incontinence (a sudden intense urge to urinate) sat for 19% longer than women with no incontinence issues.
Unlike the French, we seem to accept the inevitability of some leakage as we age. Look around any pharmacy and you’ll see shelves stocked with incontinence pads, washable pants, and EVB shorts that provide support to the pelvic and core areas. Many of these are marketed using middle-aged models who claim (perhaps not entirely convincingly) that you can still feel sexy while wearing them.
“Nobody should feel they have to spend the rest of their lives relying on these products,” says Keeble. “Incontinence is a common problem, but it’s not a normal one. There’s so much that can be done easily and quickly, no matter what your age. I have treated women in their 80s and they get better.”
Dr Murphy agrees. “In the past, women might have made do with pads, but, these days, they are living longer and doing more outside the home,” she says. “They want to continue dancing or golfing or whatever it is they do, and they should be able to. Not only is it great for their quality of life, but it benefits their cardiovascular and mental health, too.”
Whelan considers incontinence pads a short-term solution. “They are great stop-gaps while you get help to address the problem,” she says.
It starts with a visit to a physiotherapist. A Cochrane Review published in the European Journal of Physical and Rehabilitation Medicine in 2019 found that intensive pelvic-floor training with a physiotherapist resulted in 60% of women reporting a cure, or an improvement. They also reported better sexual function and an increased quality of life.
“Women need to do specific pelvic-floor exercises, but the trouble is that 50% don’t know how to do them correctly,” says Whelan.
Keeble urges caution when it comes to other exercise. “We all know that exercise can cause leakage, but we also know that impact exercise can strengthen the pelvic floor,” she says. “My advice to women is to start off at a low impact level and to build from there.”
Women are also likely to be given dietary advice as part of their treatment plan. “We tackle the simple things first,” says Dr Murphy. “Tea, coffee, and sparkling water can all lead to an overactive bladder, so we urge women to modify their intake of those. The same applies to citrus fruits and tomatoes.”
Training the pelvic floor muscles takes time. “After birth, most women will recover full continence after six weeks of exercises,” says Dr Murphy. “If the problem persists, they may need extra physiotherapy.”
Many women find it difficult to admit to having a problem with leakage, and struggle to reach out for this help. According to the Always Discreet survey, 29% of women aged between 18 and 65 who suffered from incontinence took a year or more to admit to themselves that they had an issue, let alone discuss it with another. 60% said they were too ashamed.
By the time they do reach out, the problem is more serious and may take longer to address. Most of the clients seen by Keeble, Whelan, and Dr Murphy follow a strengthening programme that takes anything up to 12 months to take effect.
“My programme requires them to do 20 to 30 long and 20 to 30 short pelvic floor exercises every day for the duration,” says Keeble. “It sounds like a lot, but in practice, it only takes a matter of minutes.”
Other options are considered if there’s still a problem after this course of exercise. “There are devices that electrically stimulate the muscles for women who have low-grade or no grade of muscle contraction,” says Whelan.
Medication can help. “Anticholinergics, which reduce bladder contractions, can help some women,” says Dr Murphy. “Topical oestrogen can also prove beneficial for menopausal women.”
Surgery is another option. “There was a procedure known as a vaginal mesh, which was implanted in the vagina to support the bladder and that had great results for incontinence,” says Whelan. “But some women experienced complications and the surgery has been banned, pending further investigation.
“There are still other surgical options available, as well as a procedure called urethral bulk by injection.”
While many women experience incontinence, there’s no reason why it should become a long-term problem. Neither should it become a reason for them to avoid exercise or put off sex for fear of leakage.
Yet, I wonder if most women know this. When I was pregnant three years ago, I read about the importance of pelvic-floor exercises. I tried to do them, but having spoken to the experts, I now think I was doing them incorrectly.
I don’t recall any member of the medical staff mentioning them after the birth. Whelan isn’t surprised by this. “The aim is for the physiotherapist to see every mother after birth and to offer a class during their postnatal period,” she says.
This could be why I missed out. To be honest, though, I was so overwhelmed by the birth that I don’t know if I’d have been able to listen to anything the physiotherapist said.
Whelan laughs at this. “In the initial few days after birth, most mothers have more on their minds than pelvic floor exercises,” she says.
Women should be told about the importance of pelvic floor training during pregnancy, not afterwards, says Whelan. “Pelvic-floor muscle training pre-birth, followed by six months of pelvic-floor exercises after birth, gives the best results.”
Keeble would like us to follow the French model. “If every single woman had access to a check-up by a physiotherapist, as they do in France, it would save millions in the long-term,” she says.
“All pelvic floors and abdomens should be screened at around eight weeks post-natal.”
In addition, she would like to see all women have a pelvic health check by the age of 35, whether they have had babies or not.
“A simple internal check carried out by a physiotherapist would take a matter of minutes, but could make a big difference to women’s health and quality of life,” she says.
However, Keeble says that age should not be considered when treating urinary incontinence. “I’ve treated thousands of women and I can’t recall anyone who wasn’t able to get dry in one way or another,” she says. “You don’t have to put up with this problem, because there are so many ways it can be improved. It’s never too late.”
“We may not be able to cure everyone entirely,” says Dr Murphy. “But we should be able to treat them, so that the problem no longer impacts on their day-to-day lives.”
For more information about the supports and services available in Ireland, visit www.oab.ie