We prefer not to talk about a stool in the bathroom

Agnieszka Urazińska: Who is a urogynaecologist?

Ewelina Tyszko-Bury, an osteopath who also works in gynaecology and urogynaecology: Most often it is a gynaecologist or urologist who additionally trains in the field of urogynaecology. There is no separate specialisation in Poland, which is a pity, because the problems that such a specialist can help solve concern thousands of Polish women.

What are these problems?

A urogynecologist deals with the problems of urinary incontinence and the disturbance of the statics of the reproductive organs.

It is not easy to treat them, is it?

These are not simple health problems that can be treated with a pill. Sometimes months of exercise help. Sometimes surgical intervention is needed.

It’s even hard to talk about such problems!

One of the basic issues is that women are ashamed of their health problems, the urogynaecological ones. I had a patient who had been suffering from stress urinary incontinence for seven years before making an appointment.

Because these are problems related to organs considered intimate and closely related to physiological activities.

That’s right. In the case of organ prolapse, it may happen that, for example, the bladder or urethra fall into the anterior wall of the vagina. In both of these situations, a woman may experience stress urinary incontinence. This is a troublesome and unpleasant matter, because when a woman – let’s not be afraid of this word – pees during sudden exertion, i.e., while carrying a child, exercising, coughing or sneezing, the quality of life can really drop significantly. It is no longer just a matter of buying panty liners or pads that you wear permanently. It also involves unpleasant smell, a feeling of embarrassment in intimate situations. Urinary incontinence does not kill, but it does kill the comfort of life. One of my patients said that problems have led her to such a state that she does not see the joy of life at all.

But disorders of the statics of the reproductive organs do not just cause problems with physiological activity.

Sometimes the rectum falls into the back wall of the vagina, which is called a rectocele. When the situation is advanced, the patient may have problems with bowel movements. And the problems can reach the point that she has to palpate, pushing the rectum from the vagina side to make a bowel movement.

Vagina, anus, bowel movements – we really have a hard time discussing these kinds of things. Even with a doctor.

And I urge you with all my heart to overcome this shame. Because we can waste a lot of time completely unnecessarily. I just want to scream – women, stop being ashamed and let me help you. I even have a way to fight this embarrassment: think, ladies, that what makes you embarrassed and blush, for us – medical professionals – is obvious and normal. We hear about such health problems every day, for us they are medical issues, they do not cause embarrassment. We are committed to solving them and we really can help. In addition, this shame, omitting certain topics, carries a lot of risk, because it can cause serious health problems.

Can you give me a few examples?

Have you heard that when defecating it is good to put a stool under your feet?

I’ve heard something of the sort, but no details.

I’d love to explain. This 45-degree positioning of the hip joints in relation to the pelvis changes the tone of the puborectal muscle. It is attached to the pubic bone, extends behind the rectum and returns to the pubic bone. It may resemble a slingshot. It is very important because it seals the walls of the large intestine. It acts a bit like a funnel that pulls in the rectum and seals that part of the body when needed. But when you have a bowel movement, this muscle should be relaxed, and that is exactly what a proper position in the toilet is for. In a nutshell – thanks to this positioning, this physiological activity causes us the least effort. In this way, we should sit on the toilet so as not to harm ourselves.

Well, can you?

This excessive pressure can lead to rectocele. I had a patient who developed this problem because she had heard from childhood, before leaving the house, to use the toilet, to poop or pee “in advance”. Of course, her parents did it in good faith, but it backfired. Many of us have bad habits. From childhood, we should hear how to protect the statics of the reproductive organs, also in the toilet. Many women also have problems with micturition, i.e., urination. We often sit on the toilet and push, we increase the abdominal pressure. And anatomically, it should look like this: we sit down on the toilet, the pelvic floor muscles relax, there is a slight pressure from the abdominal pressure (not intensified by the patient), the bladder detrusor starts to work, the urethral sphincters relax. You do not have to “help” excessively, because you can harm yourself. Urinary urgency can be the result.

Meaning?

You often want to pee, you pee in small portions. I have patients who know all the toilets on their way to work. Urinary urgency is not always caused by improper toilet habits, so a diagnosis of an overactive bladder should be introduced, and even cytoscopy should be performed to exclude oncological problems. But keep in mind that poor toilet habits can also lead to urinary urgency.

Indeed, it would be worth talking about it more often.

Especially that urogynaecological problems are not an embarrassing rarity – they are common. Imagine that stress urinary incontinence is a problem for every third woman!

It often appears after giving birth, right?

A lot of patients have a problem after giving birth, more often when it is a natural vaginal delivery. However, pregnancy itself causes increased pressure in the abdominal cavity on the bladder, uterus and rectum, which can cause static disorders, and women – even if they have had a caesarean section – complain of stress urinary incontinence. Anyway, such a tendency can be inherited – ladies whose mothers and grandmothers also experienced such problems are more likely to have this problem. And when it comes to childbirth, statistically, urinary incontinence is most often the result of natural delivery. The way labour was conducted is very important. For me, as an osteopath, the protection of the perineum starts much higher – not at the very entrance to the vagina. It is not only a question of whether the incision is made, it is also a question of running the first and, above all, the second stage of labour. Rapid births, with extra oxytocin, are much more stressful for the body – which doesn’t mean they’re always bad. There are births where oxytocin should be administered for medical reasons. In obstetrics there is a conventional eleventh centimetre – sometimes when we reach full dilation, the contraction action stops a bit (in births without medical treatment). This is where the pelvic floor muscles have time to adapt and stretch before the baby’s head passes through. And in childbirth with an additional dose of oxytocin, this silencing is absent. And it’s a bit like with a turtleneck sweater: if you want to push your head through it quickly, it can get damaged. Therefore, it is worth examining the patient after childbirth for statics of the reproductive organs and checking the condition of her pelvic floor muscles.

Do we hope that the problem will disappear?

Often gynaecologists themselves confirm their patients in this. “This will pass, madam,” they say. Unfortunately, it will not pass by itself. It can only get worse, especially during the menopause, when oestrogen levels drop and collagen fibres weaken. It is worth dealing with the problem earlier. Some patients say that there is actually no problem, because urinary incontinence only happens to them. Well, when it happens, it’s a problem. Because when it’s not there, it doesn’t happen. It is worth checking what the cause is and it is worth fighting to remove it.

How long does a woman delay seeking help?

Statistically seven or nine years. Fortunately, something has changed in the subject, awareness is increasing, especially among young women. The Internet helps in this, because it is on the Internet that we often look for help first. And there, women find an indication that six weeks after giving birth, they should consult a gynaecologist who deals with urogynaecology, or a urogynaecological physiotherapist. And more and more patients come to such diagnostics – tests for the activity of the pelvic floor and the prolapse of the reproductive organs.

What if there is a problem?

We begin to act. Of course, it all depends on what the problem is. It would be best to perform a manual examination – gynaecological and the so-called Pelvic Floor Sonography (a type of urogynaecological diagnostics – ed.). We start by normalising the pressures in the body, we work to release structures that are tense and do not allow us to adopt the right posture. We recommend pelvic floor exercises to strengthen them. We teach patients how to perform such exercises. We have two types of fibres in the muscles of the pelvic floor – slow twitch, i.e., those that are supposed to support our organs, and fast twitch, i.e., protect when sneezing or rapid effort. The exercises should be for both types of muscles. Pessarotherapy also works well in the treatment of statics of the reproductive organs. Many patients use pessaries vaginally – that is, special cubes or tampons – to support the vaginal walls. Thanks to this, the problem does not worsen, because it is a supportive action and we can focus on exercise. There are situations in which training is the solution to the problem. And if that is not enough, then surgical treatment should be considered. However, strengthening the pelvic floor muscles is always recommended. Also as a prophylaxis.

You mean contact with your own body?

Most of us women have little contact with our bodies, which is a pity, because we lose the ability to help it. This is most often due to the fact that we did not have a model, nobody taught us, nobody guided us. Mindfulness of the body is extremely important. We will live with it for the rest of our lives, so maybe it is worth devoting more love to it. Be good to yourself. To do this, we also need to be aware of how to secure the pelvic floor. How to activate these intimate muscles while, for example, lifting a heavy object or sneezing. Even during physical exercise, especially when strenuous, it will be useful to protect the pelvic floor muscles. It is also worth using the toilet consciously.

Speaking of exercising, I have noticed a lot of pressure on young mothers to get back in shape quickly after giving birth. What do you say to this?

When I watch fitness celebrities advise women to do tabata and series of sit-ups right after the birth, I am terrified. After pregnancy, there is a period of a hormonal storm, women – especially those who breastfeed – have a decreased level of oestrogen, and connective tissue is flaccid after delivery. Physiology cannot be fooled. Yes, one woman may have a slightly flatter stomach than the other one. But fighting for a perfect figure two months after giving birth is bravado. Yes, physical activity is important, but it is worth introducing it gradually and appropriately! Take care of training the muscles for the pelvis. As an osteopath, I work manually with the body structure, also in postpartum women. I change the position of the pelvis, ribs, I normalise the pressure in the chest, abdomen and small pelvis. If necessary, I schedule pelvic floor muscle training. And if there is an opportunity, I explain to women that there are no taboos for a specialist.

What other problems do women who come to you for help have?

A lot of women have problems getting pregnant, so I work with women in terms of fertility. More and more women know that menstruation shouldn’t hurt. The answer “it’s just the way it is” is not enough, we are more and more aware.

Many of us believe that menstrual pain is the norm.

No. Find out what is causing the pain. It could be endometriosis. And here is the most common problem with diagnostics. This is an extremely broad subject. In any case, painful periods are not the norm. You can work manually to make this time comfortable. A lot can be done about painful periods. I would like you, women, to know that your periods don’t have to hurt, nor does intercourse. Take care of yourself and be good to each other.

Ewelina Tyszko-Bury, an osteopath who also works in gynaecology and urogynaecology

Author: Agnieszka Urazińska

Ilustracja: Marta Frej

The text was published in wysokieobcasy.pl on 17 July 2021