‘We women, after we’ve had babies, can be damaged so that we get incontinence and actually — I’ve never gone public about this — after my first child I could only go three yards before I peed my pants.’
These are the words of Dame Sally Davies, England’s chief medical officer, who last week, revealed she’d been virtually housebound for six weeks after the birth of her first daughter Olivia, now 26.
Dame Sally also said that even after all this time the issue was not completely sorted: ‘I’m still not as I would wish to be.’
Staggering: Roughly seven million women have some degree of incontinence, experts say
It was a brave admission from the most senior doctor in the country, and one that will have resonated with millions of women, many of whom live in silence with the shame of their condition. For Dame Sally’s comments have drawn the spotlight onto one of medicine’s last taboos.
‘It is a huge problem — around seven million women have some degree of incontinence — and it’s a hidden problem, because so many are too embarrassed to seek help,’ says Jeremy Ockrim, a consultant urologist at the Hospital of St John and St Elizabeth in London.
In fact, urinary incontinence is ‘considered significantly more embarrassing than depression or cancer, respectively’ according to a study in 2011 by the Medical University of Vienna in Austria.
It’s not just the embarrassment — incontinence can have a crippling impact on women’s lives. It doubles the risk of postnatal depression, reported the Journal of Obstetrics and Gynaecology in 2011.
In the same year a Norwegian study of more than 5,000 women aged 40 to 44 with incontinence found that a fifth had at least one major episode of depression in the previous year, according to the International Urogynecology Journal.
TOO ANXIOUS TO MAKE LOVE
‘I have seen women whose relationships have broken down as a result — who are so embarrassed they don’t have sex in case they leak,’ says Myra Robson, a senior pelvic health physiotherapist at the Lewisham and Greenwich NHS Trust.
‘I have treated women in their 30s who won’t go to their children’s school play or concert for fear of leaking.
Support: Dame Sally’s comments have drawn the spotlight onto one of medicine’s last taboos
‘Yet it is still such a taboo subject that women feel embarrassed asking for help.
‘I have had women in their 90s who’ve put up with it since they were 30 without seeking help or telling anyone about it.’
One UK-wide study found that nearly half of women surveyed at GP surgeries had urinary incontinence, but tellingly, only one in 20 with moderate or severe incontinence had sought help, reported the journal Family Practice.
Quite apart from the personal cost, urinary incontinence is estimated to cost the NHS over £233 million a year — on top of this are the many millions patients spend themselves, on products such as incontinence pads.
‘It destroys women’s lives and I find it so frustrating that we don’t do more to stop this happening in the first place,’ adds Myra Robson. Because much of this suffering is needless, as in a great many cases regular pelvic floor exercises can make incontinence entirely preventable.
‘We know that early intervention, where women start training early, helps prevent incontinence,’ says Jacque Gerrard, the Royal College of Midwives’ director for England.
This was confirmed by a review last year from the authoritative Cochrane research body that looked at 38 trials involving more than 900 women — the researchers concluded that offering women in early pregnancy a structured training programme of pelvic floor exercises (typically including the help of a physiotherapist) can help to prevent the onset of urinary incontinence.
MANY ARE JUST GIVEN A LEAFLET
The problem is that the level of instruction women are given about how to do pelvic floor exercises often falls woefully short.
‘At the moment what all too often happens is that new mothers are handed a leaflet as they leave hospital telling them to exercise their pelvic floor — at a time when they have a new baby and a hundred and one other things to consider,’ says Myra Robson.
‘But we have seen from studies that this is not effective — one found that 50 per cent of women doing pelvic floor exercise just from the instructions in a pamphlet were getting them wrong.’
Expensive: Urinary incontinence is estimated to cost the NHS over £233 million a year
And doing the exercises incorrectly can be almost as detrimental as not doing them at all, as it can cause even more incontinence, she says.
‘That’s because you may tense the muscles so much that the pelvic floor becomes hyperactive and puts too much pressure on the bladder.’
So how do we teach women to do it right? Myra Robson says ideally women would receive instruction during a consultation with a specialist physiotherapist: ‘but realistically there are just not the resources to make it happen.’
There is no doubt that actually being shown how to do the exercises helps. A 2010 study led by the University of Aberdeen found that pelvic floor training with either extra sessions or ‘biofeedback’ — where the woman’s muscles are tested electronically as she does the exercise, were the most effective treatment.
DON’T SUFFER – TREATMENTS DO MAKE A DIFFERENCE!
No worries about laughing or sneezing: Mother Vicki Williams, 44, from York
Women who’ve had children are a third more at risk of incontinence than women who haven’t, thanks to the impact this can have on the pelvic floor — a hammock of muscles that runs from the pubic bone at the front, to the spine, which supports the bladder, bowel and womb as well as the spine.
‘Just being pregnant puts the pelvic floor and the connected ligaments under a lot of strain — carrying a baby is like carrying around a bowling ball,’ says specialist urologist Jeremy Ockrim.
‘If the pelvic floor is strong it can make up for the stretching of the ligaments and take some of the strain but if it’s weak, then the neck of the bladder is not well-supported and it will leak urine under pressure, what we call stress incontinence.’
Laughing, coughing or even lifting something heavy can lead to leaking. Stress incontinence can often be accompanied by urge incontinence — a sudden desire to go — as the bladder suddenly spasms.
Risk factors for incontinence include having a big baby (over 8.8lb), forceps delivery and a prolonged labour, especially an extended second stage of labour when the baby’s head is deep in the pelvis, adds Tim Hillard, a consultant obstetrician and gynaecologist at Poole Hospital, and spokesperson for the Royal College of Obstetricians and Gynaecologists.
Incontinence can occur immediately after childbirth or during pregnancy itself — in other women it develops over time, especially around the menopause when the drop in oestrogen can further weaken tissues.
‘A weak pelvic floor also raises the risk of falls with age — if you’re incontinent you’re several times more likely to have a hip fracture, which can be potentially very serious for an elderly person,’ says Mr Ockrim. ‘It happens because you are rushing to the toilet, or are distressed after wetness.’
Pelvic floor exercises (see left) can be beneficial even after problems begin. Losing weight to help take pressure off the pelvic floor may also help, as can avoiding caffeine. ‘It’s a bladder stimulant, as is alcohol,’ explains Mr Ockrim.
The longer you leave it before getting help, the more likely you are to have a weaker pelvic floor, says specialist physiotherapist Myra Robson. ‘The menopause can affect muscle function, so some women may benefit from using oestrogen gel.’
If these measures don’t help then medication, duloxetine, can improve the muscle tone. It works only for as long as you take it and it can cause side-effects such as nausea. More invasive options include bladder bulking, where a filler or bulking agent is injected to bulk up the neck of the bladder so urine can’t leak out.
Vicki Williams, 44, a mother of one from York, had the treatment last October, after first developing problems when she started going to the gym four years ago.
‘As so as I had done a warm up — I would leak a bit and feel the need to go to the loo,’ says Vicki, an operating department practitioner at York hospital who is married to John, a warehouse manager (the couple have a 13-year-old son).
The treatment took about an hour. ‘I just had a local anaesthetic to numb the area before the injections. I haven’t had to think about sneezing or laughing since.’
However the effects can reduce over time leading to the need for more injections. Surgical options include inserting a plastic mesh to help hold the urethra in place — but as Good Health has highlighted, in some women the mesh can disintegrate, leading to crippling side-effects and its use is currently under review.
Another option is colpo- suspension which involves surgically lifting the vagina. ‘Essentially it puts the anatomy back to where it should be,’ says Mr Ockrim. This is specialist surgery; side-effects include repeated urinary tract infections.
FRENCH MOTHERS GET MORE CARE
In France, six weeks after giving birth, women are routinely sent for checks with a physiotherapist who actually checks their pelvic floor, with follow-up appointments for weeks afterwards.
‘For us it is normal to check the pelvic floor and to talk about the importance of a strong pelvic floor — there is no embarrassment — whereas here that is not the case,’ says James Turgis, a French physiotherapist and director of Mummy’s physio, a private London-based chain.
Myra Robson suggests particular attention should be paid to women who are at greater risk of urinary incontinence after pregnancy — women who have lots of stretch marks or hypermobility (as they may have issues with their collagen, which gives the tissue its strength).
‘They need to do extra protective exercises to prevent them from developing incontinence.’ Obesity has an impact as well.
‘Those women should be sent to specialists like me for intensive work during their pregnancy to help train their pelvic floor, but unfortunately they aren’t always.
HOW EXERCISE HELPS
Doing pelvic floor exercises can significantly reduce the risk of incontinence — and lead to an improvement if you already have it, says specialist physiotherapist Myra Robson. However, too often women aren’t exercising the right muscles.
To identify your pelvic floor, pull up and in as if you’re trying to stop passing wind and passing urine at the same time — pulling forward from the back passage.
There are different muscle fibres that make up the pelvic floor and each needs a slightly different version of this exercise, says Myra Robson. ‘Any woman new to pelvic floor exercise, or who has symptoms such as leaking urine when laughing, should do a set of these exercises three to six times a day.
‘This can be reduced to once a day when women feel they’re getting better at them or symptoms reduce.’
How quickly you see results varies — but, potentially, it could be in just weeks. You do need to persist with the exercises, adds specialist urologist Jeremy Ockrim.
‘The exercises give you more muscle tone to the pelvic floor, but as soon as you stop, you lose that tone.’
First do a maximum contraction and hold for ten seconds — then repeat ten times, leaving a gap of four seconds between each to allow the muscle to relax. Then do ten quick contractions at the rate of one per second.
Finally you need to squeeze as hard as you can and then let it go half way; then contract to that level ten times leaving 20-second gaps.
‘There are 6,000 births a year at the hospital where I work, and I work alone and part-time,’ she says. Indeed, a lack of specialist physio help is major problem.
The Uk was one of only three European countries to report a cut in the number of physiotherapists per 100,000 inhabitants between 2010 and 2015 according to Eurostat figures.
Under NICE guidelines published in 2015, women with incontinence should be offered three months of ‘supervised pelvic floor muscle training’ — ie, exercises with a physiotherapist.
At the time of publication NICE noted that women with incontinence ‘are often given a leaflet on pelvic floor muscle training but are not given additional support . . . As a result, many women who attend for specialist treatment have been incorrectly performing pelvic floor muscle exercises for many years with no improvement in their symptoms.’
Specialist pelvic physiotherapists will typically first check the strength of the pelvic floor — manually or using a probe — which is rated from 0 to 5. A score of less than three may lead to treatments to help to make pelvic floor exercises more effective (for instance using cones inserted into the vagina or electrical devices to help the muscles contract).
But in the UK there are only around 700 specialist pelvic physiotherapists (who’ve done postgraduate training in pelvic health). To put this in context there are more than 700,000 births in England and Wales each year — and one in three women will develop problems.
‘Specialist physiotherapy services make a huge difference to a woman’s health and quite simply, their quality of life, but access to them can be inconsistent,’ says Ruth ten Hove, head of research and development at the Chartered Society of Physiotherapy. ‘Some areas may provide good access whereas other areas may not provide enough.’
The reasons for this, they say, vary: in some places it will be due to a shortfall in the numbers of physios, whereas in others it may be due to a lack of awareness among GPs or women themselves that such services exist.
HELP OFTEN IN SHORT SUPPLY
The service offered to women can be hit and miss, adds specialist urologist Jeremy Ockrim. ‘GPs are overwhelmed trying to meet targets for heart disease and cancer, and incontinence has tended to get ignored as a low priority. In some areas doctors even have to limit the number of incontinence pads they give to these women — it’s an outrage really,’ he adds. Four years ago the Royal College of Midwives and the Chartered Society of Physiotherapists announced a joint venture to highlight the need for pelvic health to become ‘a key public health issue’.
They called for all women to be given accurate advice about pelvic floor exercises and an opportunity to discuss pelvic care with a healthcare professional — a midwife, physiotherapist or a GP. ‘Midwives doing antenatal checks and talking to a woman about her diet should be saying: “and are you doing your pelvic floor exercises,”’ says Jacque Gerrard.
But the message doesn’t seem to be getting through. Charity consultant Lyanne Nicholl, 37, was so scandalised by the lack of advice and care after having her son 2½ years ago that she’s organised a parliamentary roundtable discussion in May with the MP Rosie Duffield, health care professionals and charities to discuss the need to improve the postnatal care for women.
IT’S RUINED MY LIFE IN SO MANY WAYS, SAYS ONE BRAVE WOMAN
Sufferer: Maxine Cooper, 55, from Chester
‘If someone had told me about pelvic floor exercises during my pregnancies it would have saved me an awful lot of pain,’ says mother-of-two Maxine Cooper.
As she says bluntly: ‘Incontinence has ruined my life.’
When Maxine (left), who lives near Chester, had her children, now aged 27 and 31, the labour was uncomplicated and the babies were only around 6lb. But crucially, she says no one told her to exercise her pelvic floor.
Then ten years ago, Maxine, 55, an officer in the youth justice system, started to leak when she coughed or laughed. ‘When it first started I’d just feel a little trickle when I coughed or sneezed; I couldn’t run and would worry about laughing when I was out. But at that stage I could cope. However, within 12 months it was so bad it would happen when I was just walking and in the cold I would get sudden urges to go.
‘It makes you feel different about yourself — I felt old beyond my time and so embarrassed.’ After she eventually saw her GP a year later, she was referred for physiotherapy but this didn’t help. In 2010 she was offered a procedure to support the bladder using plastic mesh.
As Good Health has highlighted, some women have experienced crippling side-effects as a result of this procedure. Maxine was one. ‘Straight after I had it done I started bleeding and experiencing the most dreadful pain.’
‘To be fair it did stop my incontinence but now it’s been removed I’m back to the way I was — I cough and wet myself. I can’t be intimate with my partner as I’m too embarrassed. I’ve been through all this because no one told me to do my pelvic floor exercises.’
‘I got handed a leaflet after having my baby about pelvic floor exercises — when I hadn’t slept in days — and at that time it just didn’t mean anything.
‘I’ve been lucky in that I haven’t had a problem, but I have had friends who are leaking and accepting they are: it seems to be entrenched that yes we have babies and so we just have to put up with the incontinence, the painful sex, the mental health problems that can develop.
‘If men were in this situation and becoming incontinent far more would have been done by now,’ she says.
Adds Myra Robson: ‘We need to get the message out to women that incontinence is common but never normal.
‘We spend time telling women not to eat soft cheese during pregnancy but spend so little time warning them how important it is to care for their pelvic floor — and not doing so can have ramifications for the rest of their life.’
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