WHO YOU CAN ASK TO SEE IN THE NHS
Women’s Health / Pelvic Health Physiotherapists
Predominantly the caseload which these physiotherapists see are outpatient based providing professional assessment, treatment and support to all of their patients with pelvic floor dysfunction symptoms. They also see inpatients typically to provide post-operative gynaecology rehabilitation and post-natal physiotherapy advice.
They see a variety of conditions, including but not limited to:
- Stress, urge or mixed urinary incontinence
- Perineal childbirth injury
- Pelvic organ prolapse
- Faecal incontinence
- Pelvic pain related to pelvic floor dysfunctions
All of the Pelvic Health physiotherapists uphold a highly professional standard and all have specialist post-graduate training in vaginal and anorectal pelvic floor examinations. They offer a sensitive and supportive service for patients with sometimes very personal and difficult symptoms.
Women’s Health Physiotherapists receive referrals from the GPs and consultants for the following:
- Childbirth injury
- Urinary incontinence including stress incontinence, urgency and frequency
- Pelvic floor dysfunction, including pain and sexual dysfunction
They receive referrals from the colorectal consultants for the following:
- Obstructive defaecation
- Anal Incontinence
To assess the best options for you, they will first examine you carefully, including an internal examination. They will then prescribe a set of pelvic floor exercises, tailored to address your specific problems. They may also prescribe other options including: pelvic floor stimulation, biofeedback, defecation dynamics and bladder training.
Because of their close working with other departments e.g. urogynaecology, physiotherapists are able to refer you to a consultant when needed, for example, if your symptoms have not improved after three months.
The perineal clinic is a specialised clinic for women who require follow up for perineal or pelvic floor problems following childbirth. They see women who have experienced third and fourth degree tears in order to assess the healing of the tear, to assess how the pelvic floor and bowel muscles are functioning, and to offer advice for delivery in subsequent pregnancies. These clinics are also able to see and advise women who have problems with perineal wound healing or infections, perineal pain, and persistent postnatal bladder or bowel symptoms.
What will happen at the clinic appointment?
You will be seen by a specialist consultant who will ask you some questions about topics including your most recent delivery as well as any other previous pregnancies, plus any bladder or bowel symptoms that you have. Depending on the reason for your attendance, an examination of the vagina and/or back passage will usually be recommended. You may also be offered a specialised ultrasound scan of the muscles around the back passage. This involves passing a small probe just inside the back passage. It might be slightly uncomfortable but is not painful. This scan gives important information about the healing of any tears that you sustained. If you do have any troublesome symptoms, you will be offered treatments and advice regarding these. Depending on your symptoms, you may be offered a follow up clinic appointment.
Pelvic Floor Clinics
These clinics offer a specialist pelvic floor assessment service, including endo-anal ultrasound, anorectal physiology, proctography and transit studies. Seven Pelvic Floor Society accredited clinics across the UK can be found on our interactive MASIC map.
They also offer advice and treatment for:
- bowel dysfunction, including biofeedback
- faecal incontinence
- irritable bowel syndrome
Effective treatment for complex pelvic floor disorders requires combined care from a multidisciplinary team (MDT) of surgeons, nurses, radiologists and physiotherapists.
At the Pelvic Floor MDT there is open discussion between everyone in the team and results are reviewed. This helps to provide ‘joined-up care’, giving patients the best possible chance of recovery.
When your doctor refers you to the pelvic floor clinic, you will first see a surgeon. The surgeon will ask questions relating to your symptoms to try to establish their underlying cause and will examine you. It is very likely that they will then refer you to other team members for investigation.
The next stage will vary according to your symptoms, but many patients will have a defaecating proctogram and transit study performed in the X-ray department by radiographers, with the results analysed by radiologists.
You may also have anorectal physiology and ultrasound, which is undertaken by nurse specialists and physiologists.
The team will often see if they can improve your symptoms with simple measures such as dietary changes, laxatives and pelvic floor exercises or pelvic floor retraining. Many people find that their symptoms are completely resolved by such measures. Much of this advice and help will come from specialist nurses.
A small number of people will be suitable for surgery for their symptoms, and they will receive counselling as to the advantages and disadvantages of surgery by their surgeon in clinic before being added to a waiting list.
A Urogynaecologist is an obstetrician and gynaecologist who has a special interest in pelvic floor problems such as urinary and bowel weakness/incontinence and vaginal/pelvic organ prolapse, as well as bladder and vaginal pain and other conditions e.g. urinary infections/recurrent cystitis.
Many, although not all, are subspecialists and have undertaken a two-three year training programme on top of their basic training in obstetrics and gynaecology and spend most of their time managing women with these problems – in particular doing investigations for bladder weakness such as urodynamics and offering a wide range of treatments within a multi-disciplinary team of nurses, physiotherapists, midwives, pain specialists, colorectal surgeons and urologists.
Urogynaecologists are also involved in teaching how to prevent birth injuries such as the ‘OASI Care Bundle’ www.rcog.org to midwives and obstetricians.
Many are involved in research to try and improve the results of treatment as well as prevention.
How a Urogynaecologist can help after birth injury:
Many Urogynaecologists will have dedicated clinics for women who have suffered a birth injury often with colleagues from the multi-disciplinary team. Many are with a colorectal surgeon, but there are also nurse/midwife clinics where a physiotherapist attends too.
Here time can be given to go through all the aspects of how the injury might have arisen and what can be done to treat the symptoms. The clinicians can also give advice on how to prevent another injury in a future pregnancy.
Treatments include physiotherapy, and advice on vaginal pessaries which can be worn to prevent leakage and prolapse.
In some cases, if these treatments don’t work, then surgery can be considered and the ‘pros and cons’ discussed.
The team can arrange support and counselling for women with mental health issues as a result of their birth injury.
How can I access my local Urogynaecology service?
The MASIC map shows centres around the UK where services can be accessed. This is for women who have had an OASI (obstetric anal sphincter injury) but will usually involve a Urogynaecologist too; a referral from your GP is best.
In addition there is much information for women via the British Society of Urogynaecology https://bsug.org.uk/pages/information-for-patients/111 and the International Urogynecological Association patient website www.yourpelvicfloor.org where there is a ‘Find a Provider’ service.
All should usually be able to provide you with information about the results of their surgery and feedback from women. You might also be invited to take part in clinical trials which might not just help you, but other women in the future too.
What questions should I ask my Urogynaecologist?
- It’s best to ask what is the problem and how has it happened, and what can your Consultant, and you, do to help.
- Explain how your symptoms affect your everyday life and which one troubles you the most. There are numerous relatively simple ‘self-help’ measures including avoiding drinks which might aggravate the condition (e.g. tea, coffee, fizzy drinks), weight loss and pelvic floor exercises (with a physiotherapist or specialist nurse), vaginal pessaries and medications.
- Ask what to do if that doesn’t work; what else is available, and how successful that is e.g. surgery outcomes and what are the risks?
- What if I do nothing?
- If planning another pregnancy, will it get worse? What can be done to prevent that?
- Are there support groups/other organisations that might help?
- Are there any clinical trials I can take part in?
Psychosexual therapy is the use of targeted counselling, or longer-term psychotherapy to help address sexual problems. It is a talking-based treatment and doesn’t involve touch such as massage.
Critically, psychosexual problems are emotional and/or psychological. But they can be caused by or lead to physical problems. This means that to understand psychosexual therapy properly, it is helpful to appreciate the interrelationship between physical and psychological.
Because of this, psychosexual therapy is highly specialised work that requires an in-depth knowledge of anatomy, physiology as well as pharmacology. All of which need to be integrated into a medical model and applied into a psychotherapeutic frame.
Physical Informing the Psychological:
For example, a physical effect of medical treatment might lead to changes in someone’s appearance. The person may be scared that others will be less attracted to them because of those physical changes. And in turn the person might develop psychological barriers to and a fear of intimacy. Those barriers and fears could negatively impact on relationships and sexual experiences. Whilst a medical professional would deal properly with the physical challenges faced, psychosexual therapy could be employed to tackle the related psychological problem.
Psychological Informing the Physical:
On the other hand, someone may have an emotional or psychological issue which ultimately manifests itself physically. A traumatic event such as rape could lead to severe emotional challenges from shame to deep insecurity. Those emotional challenges could then manifest themselves physically through, for example, erectile disfunction as the person inadvertently places barriers to stop physical intimacy. In this sort of situation, a medical professional would be able to rule out a physical cause (such as illness) for the tangible problem. And again, a therapist would be able to tackle the underlying emotional and psychological issues using psychosexual therapy. The hope in a scenario such as this is that resolving the emotional and psychological issues would then mean that the resulting physical problem would be resolved.
It is recommended that you see your GP for a referral to psychosexual therapy. In some areas of the UK they may be able to refer you to NHS-provided psychosexual services if that is the recommended treatment.