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Prolapse – A Case Study

As with many issues, often we aren’t sure if what we are experiencing is normal and expected, if it will just go away, or if we need to have it looked at. For many women who are pregnant and postpartum, this is made even more difficult as we are often told that symptoms we are experiencing are normal because “you’ve had kids” and that “this is just how it is now” which can delay effective treatment of these issues! Here you can see a case study on Prolapse, which outlines some of the issues that someone may experience.

The presenting symptoms:

A 31 year old woman attends the clinic mentioning a history of intermittent pelvic floor heaviness “feeling like things are falling down” and discomfort. She has noticed that the heaviness has been worse since starting back with weight lifting at her gym 1 month ago. She has two children ages 2 years and 4 months old.  She had continued to go to the gym throughout her pregnancy (symptom free), but notes she had reduced her weights somewhat during her third trimester.

She hadn’t returned to the gym until now, as her life has been quite busy since the delivery of her second child! No pelvic floor pain, urinary or fecal incontinence is reported.  She had felt like now was a good time in her life to return to the gym and is quite devastated at this setback. Going to the gym and working out had been an

important part of her life-mentally, socially and physically and she is worried she won’t be able to do any activity at all anymore.

She went to see her family physician as was concerned about her symptoms and was referred to pelvic floor physiotherapy for prolapse. She reports no symptoms first thing in the morning, but these progressively worsen as the day goes on.  Some days are better than others with her symptoms.  Lifting weights at her gym and lifting her children aggravate her symptoms.  She notes she did just get over a bad cold and had been coughing/sneezing quite a lot during the past month. She also identifies that she has always had issues with constipation.  Both of her deliveries were vaginal with no instrumentation (forceps or vacuum) or complications. She is currently breastfeeding.

Assessment and Treatment

The client was assessed with an internal pelvic examination by a pelvic floor physical therapist. A Grade 1 cystocele was found. (A cystocele means the prolapse was from the bladder descending into the wall of the vagina and a Grade 1 prolapse means the organ descent was halfway to the vaginal opening). The pelvic floor muscles were weak with a Gr. 2 strength (a weak squeeze and no lift of the pelvic floor muscles) and tight.

The client and the therapist worked together to increase her pelvic floor strength and coordination, as well as to optimize her intraabdominal pressure management systems. Toileting positions and discussion around constipation management were discussed and the client was able to implement these at home. Optimizing postures during breastfeeding and throughout the day were discussed to reduce strain on the pelvic floor and discussed on how to successfully get them implemented at home.  Education on anatomy of the pelvic floor and the pelvic organs/their supports as well as POP was provided which will help the client to take control and understand the why behind the recommendations.

Activity modifications were implemented but keeping her active was part of the plan and exercises were progressed as appropriate.  The client returned to her gynecologist for a pessary fitting to use intermittently during heavier weight lifting at the gym. She was seen in follow up 2 weeks after the initial assessment and then 1x/month for 6 months. She was able to return to her weight lifting and was symptom free with all tasks and activities at the conclusion of therapy, although her Grade 1 prolapse remained.

Have you been struggling with prolapse symptoms? Not sure if your symptoms could be part of prolapse, please feel free to contact us and we will help chat you through what you are experiencing as best we can.

Don’t delay start your road to recovery today!

Maja Stroh is a physiotherapist that has a particular interest in pelvic health and perinatal care. She graduated from the U of S MPT program in 2009 and has been working with pelvic health populations since 2013. Maja’s interest in helping her clients and spending quality time with her family has brought her to Warman Physio where she will be providing services in the Saskatoon and Warman locations.
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Pelvic Organ Prolapse – What is it? How does it happen? How do I know if I have it? How it is treated?

Pelvic Organ Prolapse (POP) occurs when one or more of the pelvic organs descend from its normal anatomical position from within the pelvic girdle. This can most commonly include the bladder, the urethra, the uterus or the rectum.

There are many types of prolapse, and these will have various names depending on the organ or organs that have descended or alternatively where the prolapse has occurred within the pelvic cavity.

The severity of the prolapse (how far the organ or organs have descended) will also likely be noted by your health care practitioner; usually on a scale of Grade 0-Grade 4 or stage 0- IV depending on the quantification system used. A prolapse can occur inside the pelvic cavity, or can protrude outside of the vaginal opening.  The higher the grade or stage of prolapse, the more the prolapse has descended towards or out of the vaginal opening. The severity of organ descent does not always correlate to symptom severity however. There are those who have minor objective prolapses when assessed by a health care provider but note significant prolapse symptoms, while others with more significant objective descent of the organs may have barely any symptoms at all.

The pelvic floor muscles, as well as the pelvic fascia/connective tissues support the pelvic organs. Repeated pressures from strain (which typically occurs on a relaxed pelvic floor) and valsalva (which is a forced exhalation against a closed glottis, mouth and nose) to these structures can worsen the descent of prolapse. 1

Some activities/conditions that can cause increased strain/valsalva to the pelvic floor and which are risk factors for POP are: vaginal delivery, having a chronic respiratory condition, as well as chronic constipation.2,3,4   Prolapse symptoms can worsen following activities such as heavy or repetitive lifting (like carrying children all day!!) Symptoms are often worse later in the day as the effects of gravity become more noticeable.

The symptoms of POP can vary. Some of these symptoms include heaviness or discomfort in the vagina, difficulty with constipation, difficulty emptying the bladder or bowel completely, urinary or fecal incontinence, difficulty with insertion of tampons, discomfort during sex, and irritation of exposed vaginal tissue.

The literature supports physical therapy and pelvic floor muscle training (PFMT) as an effective way to conservatively manage POP symptoms and severity of organ descent. 5,6   Physical therapy can help by giving clients strategies to help manage their intraabdominal pressure systems during activities that increase pressure and strain to the pelvic organs and pelvic floor such as lifting, carrying, coughing, jumping, sneezing, etc.  Often ‘The Knack’ is a technique taught where the client performs a pelvic floor contraction prior to an activity that would cause a significant increase in intraabdominal pressure to help decrease the strain to the pelvic floor.  A pelvic floor physical therapist will perform an internal pelvic exam to assess the strength and tone of the pelvic floor as well as grade the prolapse. If there are other issues found during the assessment such as incontinence or pain, those will also be addressed.  Education regarding toileting positions and evacuation techniques to decrease strain on the pelvic floor can be discussed. The physical therapist will also work with the client to help progress them back to their functional and fitness goals and how to modify tasks where needed.

For those whose POP symptoms continue to bother them despite doing some PFMT or those wishing to pursue sports where there may be increased pressures placed on the pelvic floor, a pessary may be a good conservative option. A pessary is a device that is placed in the vagina to help provide support and manage prolapse symptoms by preventing or lessening the descent of the pelvic organs. There are many different types of pessary available depending on the type of prolapse. Usually urogynaecologists, gynaecologists and nurse practitioners fit pessaries, however in some provinces pelvic floor physiotherapists are able to fit and follow these clients.

Others whom have more severe symptoms or severity of POP may choose surgery as an option. The type of treatment for prolapse will vary depending on the severity of the symptoms, the grade of prolapse, as well as client preference.

Conservative management and strategies learned with a pelvic health therapist can be helpful even for those that choose surgical management of their prolapse in resolving some of the pressure management issues that lead to POP.

Maja Stroh is a physiotherapist that has a particular interest in pelvic health and perinatal care. She graduated from the U of S MPT program in 2009 and has been working with pelvic health populations since 2013. Maja’s interest in helping her clients and spending quality time with her family has brought her to Warman Physio where she will be providing services in the Saskatoon and Warman locations.

 

 

 

 

 

Maja has a particular interest in the assessment and treatment of pelvic organ prolapse and is available in Saskatoon and Warman.

Our team consists of three pelvic health therapists to assist you including Maja, Kendra, & Haylie.

References:

  1. Tumbarello, J.A., Hsu, Y., Lewicky-Gaupp, C., Rohrer, S., & DeLancey, J.O. (2010). Do repetitive Valsalva maneuvers change maximum prolapse on dynamic MRI?. International Urogynecology Journal, 21 (10), 1247-1251.
  2. Mant, J., Painter, R., & Vessey, M. (1997). Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. BJOG: An International Journal of Obstetrics & Gynaecology, 104(5), 579-585.
  3. Whitcomb, E.L., Lukacz, E.S., Lawrence, J.M., Nager, C.W., & Luber, K.M. (2009). Prevalence and degree of bother from pelvic floor disorders in obese women. International Urogynecology Journal, 20 (3), 289.
  4. Fornell, E.U., Wingren, G., & KjOlhede, P. (2004). Factors associated with pelvic floor dysfunction with emphasis on urinary and fecal incontinence and genital prolapse: an epidemiological study. Acta obstetrician et gynecologica Scandinavica, 83(4), 383-389.
  5. Hagen, S., Stark, D. (2011). Conservative prevention and management of pelvic organ prolapse in women (Cochrane review).  Cochrane Database of Systematic Reviews, (12), CD003882.
  6. Li, C., Gong, Y., & Wang, B. (2016). The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. International urogynecology journal, 27 (7), 981-992.
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Welcome to the Team Maja Stroh!

We have been practically bursting waiting to be able to announce our newest physiotherapist to you! Maja Stroh is joining us and is starting with clients the week of March 11, 2019, and she already has her first clients booked in! As many of our new and current clients are aware, we have been very busy at the clinic since Shannon went on maternity leave and we have found Maja, the perfect therapist to join our Warman Physio family to help you help yourself!

Maja will be working out of both our Warman and Saskatoon locations, and has a specific interest in perinatal health.

 

Biography

Maja graduated from the University of Saskatchewan with a Bachelor of Science in Biochemistry in 2007. She went on to graduate at the same university with a Masters of Physical Therapy in 2009. Maja has been working as a physical therapist since 2009 in private clinic settings, both in Saskatoon and rural areas. Maja has experience in treating orthopedic based populations, as well as pelvic health clients. Her particular interest is in treating the prenatal and post-partum pelvic floor populations.

She considers continuing education a high priority as well as strives to provide the best evidenced based practices. She has completed a variety of post graduate continuing education courses. These include courses relating to pain management, her Level III for both the Upper and Lower Quadrant Orthopedic Division courses, as well as a variety of pelvic health continuing education courses/lectures. She plans to continue to advance her knowledge with treating pelvic floor populations by continuing with further pelvic health courses.

Maja loves spending time with her two young boys. Some of her other interests include, cooking, gardening, painting and camping/hiking.

Areas of Practice Interest:

*Pre-natal & Post-partum assessment and treatment

*General Orthopedics

*Urinary Incontinence

*Pelvic Pain

*TMJ Dysfunction

*Spinal Assessment & Treatment

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Headaches: an RMT Perspective

Headaches are one of the most common physical problems that many people live with on a frequent basis. Whenever a client presents with a headache or a history of headaches I really like to investigate to see how I can help improve their condition. Just asking a few simple questions might lead us to an idea of where these headaches may originate thus providing a better treatment. It’s important to note that in any case of concern with headaches clients are always encouraged to speak with their family physician. There are many different types of headaches and many may have some significant overlap.

When clients present with a head forward posture (think of the classic chin forward at the computer desk) we are going to consider additional techniques during treatment that will encourage a better and more optimal posture.

In a case dealing with referral pain to the temple area it might lead us to follow a trigger point pattern. When relieving tension in these areas with proper technique a client can experience what sensation we like to refer to as “melting”.

With many of these symptoms overlapping into tension headaches it’s necessary to inform clients on self-care to better their chances of decreasing headaches. Proper follow up for additional treatment is often recommended. Increasing water intake, suitable stretches and hydrotherapy techniques can all assist with your long-term outcome.

There is no “one-size fits all” program for stretching that will help headaches, as the muscles that need stretching will vary from one client to the next. You can never go wrong with changing up what position you are in frequently throughout the day!

For an appointment with Lauren you can check out the online booking or give us a call! To see what any therapist has available you can check it out as well!

Lauren has been working as a Massage Therapist in the Warman area since 2012 and sees a wide variety of issues from tension headaches, to scoliosis and much more. With a focus on health and optimal function, she is able to listen to what is going on and address the key muscles through a variety of techniques.
Her training has lead her to try and improve each individuals’ well-being by working through the areas at fault, but is also able to provide a relaxation massage where the focus is general relaxation and not specific tension release to correct pathology. She has specific training in and provides services for hot stone massage, which is a thermotherapy technique using both warm and cool stones to improve circulation and lymphatic function and prenatal massage.

 

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Potty Learning: Tips and Tricks to avoid the “Training” nightmare

Let’s put it out there from the beginning – the amount of stead-fast, hard research on what “actually works” to “potty train” kids is lacking. For this reason, I have taken the key factors and milestones that are seen clinically for readiness and complied some things for us to think more critically about related to “training” our kids.

First things first, I consider it potty learning. This is a crucial distinction to make as parents and caregivers. Training implies that there is something that the guardian must complete in order for kids to be successful at using the toilet. The shift in focus to being potty learning, is recognizing that no matter how hard you try, you cannot MAKE your child pee or poop in the toilet (I mean, have you tried to MAKE a toddler do anything? It’s not happening!)

“My child was on the potty two minutes ago and then they peed on the floor!”

We often get sucked into the cultural norms of having our children ‘potty trained’ by a certain age, but did you know that most children aren’t ready from a physical and mental perspective until closer to 3 or 4? Regardles, using the potty is a skill that needs to be developed and when attempted before the child is ready may lead to a variety of issues (constipation, later bed wetting and leaking problems, urgency and frequency issues, possible pelvic pain, etc).

For a child to be potty learned they must be able to complete all the components of toileting independently (pulling down/up pants/underwear, sitting on the potty, emptying the bladder and bowel, washing hands) and not only that but be able to recognize that the body needs to go, and leave enough time to get there, then coordinate the muscles of the pelvic floor to relax and empty the bladder and the bowel… phew! It’s actually pretty tough to get the hang of!

If a child is under the age of 3 and they learn that they can ‘hold’ their bowel/bladder they will often wait much longer between voids than inhibited voiding (this is what happens when children are in diapers as a newborn and infant) which can lead to bladder infections and constipation. Over time, bladder holding can lead to what is often referred to as a ‘weak’ bladder where the child needs to void frequently throughout the day (can’t drive more than an hour for your 4, 5, 6+ year old?)

You need to pee AGAIN? You just went to the bathroom!

A few things we want to think about specifically:
*having to guide (not nag, push, or pester) a child under the age of 4 (sometimes even older) to use the washroom is normal
*ensuring the child isn’t constipated before starting potty learning is essential (peanut butter consistency!)
*if it’s frustrating for you or the child likely now isn’t the right time

So what are some of the Potty Learning components?

From my perspective there’s three things kids need in order to potty learn:
~Physical readiness (can the bladder hold enough urine)
~Cognitive readiness (do they understand what their body is telling them with enough time to do what they need to do)
~Emotional readiness (this is whether they choose to actually go potty or not)

How much urine is in a miss? A dribble in underwear or a full bladder?

If it’s just a dribble they probably are ok to continue with underwear changes. If it’s a full bladder (and doesn’t get better quickly) I would say head back to diapers.

The tricky part is we often associate using the potty with being a big kid so if they aren’t ready they will become upset. HOWEVER, mom/dad/caregiver gets to decide underwear or diapers, and little gets to decide if they pee/poop in the potty or not. There is absolutely nothing you can do about when they pee or poop or where they do it.  Toddlers love control. So you give the little control: ‘ok, pee and poop need to go into the potty or into a diaper. If your body isn’t telling you when to go potty with enough time to get there then we need to wear diapers and that’s ok. We can try again later’
Wearing diapers also doesn’t mean they can’t go pee on the potty. They for sure still can! Tell them that too and celebrate pee in the potty ‘wow! You listened to what your body was saying, great job!’ (No big kid stuff)

If you have questions about potty learning, or want to learn more about normal continence and skill development, the clinic runs a Peds Pelvic Floor Workshop intermittently throughout the year, and I developed an online resource website plus e-book: Potty Learning Made Easy !

Haylie has been practicing pelvic health and focused in prenatal and post-partum care since graduating from the U of S MPT program in 2011. Officially adding to her practice pediatric pelvic floor therapy in 2017. She has been advocating for treatment for women, ensuring appropriate and effective care throughout pregnancy and post-partum, and helping all expecting and post-partum moms ultimately brought her to open her family-friendly clinic. At Warman Physio clients are encouraged to bring their infants and children to treatment. Warman Physio has been nominated as a finalist for the 2018, 2017, & 2016 WMBEXA, is a WMBEXA award recipient of 2017 New Business Award, and a finalist in the ABEX 2018, 2017 & 2016, and Haylie was recognized as YWCA Women of Distinction for Health & Wellness in 2017, and has been nominated for the 2019 SABEX and WMBEXA Awards.

 

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