tag:theconversation.com,2011:/ca/topics/pelvic-organ-prolapse-3698/articlesPelvic organ prolapse – The Conversation2022-11-22T19:05:09Ztag:theconversation.com,2011:article/1930192022-11-22T19:05:09Z2022-11-22T19:05:09ZChoosing a caesarean birth to ‘protect’ your pelvic floor? Here’s why that won’t necessarily work<figure><img src="https://images.theconversation.com/files/494368/original/file-20221109-22-oxq0fy.jpg?ixlib=rb-1.1.0&rect=9%2C36%2C5997%2C3971&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-practicing-yoga-600w-1109877887.jpg">Shutterstock</a></span></figcaption></figure><p>It’s commonly understood that having a baby can be a primary cause of later pelvic floor problems, such as bladder leakage. While giving birth can be a very special and joyful time, it can sometimes be difficult returning to day-to-day activity postpartum. </p>
<p>About one in three women who have had a baby experience <a href="https://www.continence.org.au/information-incontinence-english/one-in-three-women-who-ever-had-a-baby-wet-themselves">urinary incontinence</a>. A similar proportion will have <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/vaginal-prolapse">prolapse symptoms</a> like vaginal heaviness or bulging.</p>
<p>You might guess that choosing a caesarean section – that is, a surgical birth via the abdomen – rather than a vaginal birth could be a sensible way to avoid such symptoms. You could assume doing so would avoid any direct stretching and trauma to the pelvic floor muscles. </p>
<p>However, it’s not that simple. It turns out pregnancy itself, <a href="https://www.sciencedirect.com/science/article/pii/S2590161321000181?via%3Dihub">regardless of the mode of delivery</a>, is a significant risk factor for pelvic floor dysfunction.</p>
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Read more:
<a href="https://theconversation.com/pessaries-are-still-a-taboo-topic-but-these-ancient-devices-help-many-women-187083">Pessaries are still a taboo topic – but these ancient devices help many women</a>
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<h2>Under pressure</h2>
<p>During pregnancy, there is a rapid increase in pressure and strain on the pelvic floor from the growing baby and increasing fluid load. Add to this a <a href="https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/1471-0528.16559">high likelihood of constipation</a> during and after pregnancy causing straining that further weakens already stretched muscles. </p>
<p>A growing belly also stretches and weakens the <a href="https://www.thewomens.org.au/health-information/pregnancy-and-birth/a-healthy-pregnancy/the-abdominal-muscles#:%7E:text=This%20is%20called%20'core%20stability,uterus%20rests%20forward%20onto%20them.">muscles of the abdominal wall</a> and changes our posture, impacting core stability and the function of the trunk and pelvis. </p>
<p><a href="https://www.sciencedirect.com/science/article/pii/S1028455914001697">Changes in hormones</a> during pregnancy soften our muscles, tendons and ligaments to allow the pelvis to widen during labour and delivery. This reduces the stability of the pelvic floor and supporting tissues. </p>
<p>So the risk for pelvic floor compromise is already there – well before any type of delivery. </p>
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<a href="https://images.theconversation.com/files/494372/original/file-20221109-20-mrjzfp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman hold newborn baby" src="https://images.theconversation.com/files/494372/original/file-20221109-20-mrjzfp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/494372/original/file-20221109-20-mrjzfp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/494372/original/file-20221109-20-mrjzfp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/494372/original/file-20221109-20-mrjzfp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/494372/original/file-20221109-20-mrjzfp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/494372/original/file-20221109-20-mrjzfp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/494372/original/file-20221109-20-mrjzfp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">After caesarean surgery you shouldn’t lift anything heavier than your baby until the six-week check.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-images-half-african-thai-600w-1922320169.jpg">Shutterstock</a></span>
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<a href="https://theconversation.com/why-you-shouldnt-make-a-habit-of-doing-a-just-in-case-wee-and-dont-tell-your-kids-to-either-167628">Why you shouldn't make a habit of doing a 'just in case' wee — and don't tell your kids to either</a>
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<h2>Other risk factors</h2>
<p>Add to this other non pregnancy-related <a href="https://www.nature.com/articles/s41598-022-13501-w">risk factors</a> for pelvic floor weakness such as: </p>
<ul>
<li>being a woman (our widened pelvis and extra gap in the muscles for the vaginal canal compromise pelvic floor strength)</li>
<li>being overweight</li>
<li>previous pelvic surgery</li>
<li>advancing age</li>
<li>ethnicity and genetics</li>
<li>family history of incontinence, prolapse and connective tissue disorders</li>
<li>participation in repetitive high impact sports like dancing, CrossFit and running </li>
<li>repetitive heavy lifting (occupational or with sports like weightlifting)</li>
<li>a history of excessive coughing, sneezing or vomiting</li>
<li>constipation and straining. </li>
</ul>
<p>It’s a long list of contributing factors to pelvic floor dysfunction that don’t have anything to do with having a vaginal or caesarean delivery. </p>
<p>That said, a vaginal delivery (particularly a difficult one) does add risk factors. This is especially <a href="https://journals.sagepub.com/doi/full/10.2217/WHE.13.17">true if</a>:</p>
<ul>
<li>the baby is large (weighing more than 4 kilograms) on delivery</li>
<li>instrumental assistance is required, especially forceps</li>
<li>the second stage of labour (the pushing phase) is <a href="https://www.tandfonline.com/doi/abs/10.1080/00016340801899008">longer than an hour</a></li>
<li>muscle damage or high-grade perineal tearing (<a href="https://www.thewomens.org.au/images/uploads/fact-sheets/Perineal-tears-third-and-fourth-degree.pdf">damage</a> to the tissues between the vagina and the anal sphinter) occurs. </li>
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<p>A caesarean is certainly not the “easy way out” either. <a href="https://www.nhs.uk/conditions/caesarean-section/recovery/">Recovery from a C-section</a>, even a planned one, can be challenging as it is major abdominal surgery. It means avoiding lifting anything heavier than your baby for six weeks, not driving until medically cleared, reduced mobility, and incision pain. As with any surgery, it carries the risk of complications such as infection, reaction to the anaesthetic, surgical injury and blood clots. </p>
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Read more:
<a href="https://theconversation.com/playing-games-with-your-pelvic-floor-could-be-a-useful-exercise-for-urinary-incontinence-182431">Playing games with your pelvic floor could be a useful exercise for urinary incontinence</a>
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<a href="https://images.theconversation.com/files/494370/original/file-20221109-23-mviuk5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="pregnant people on exercise mats" src="https://images.theconversation.com/files/494370/original/file-20221109-23-mviuk5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/494370/original/file-20221109-23-mviuk5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/494370/original/file-20221109-23-mviuk5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/494370/original/file-20221109-23-mviuk5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/494370/original/file-20221109-23-mviuk5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/494370/original/file-20221109-23-mviuk5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/494370/original/file-20221109-23-mviuk5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Exercise classes designed for pregnancy are a good idea.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/group-young-pregnant-women-lying-600w-1809776566.jpg">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/7-ways-to-reduce-perineal-tearing-during-childbirth-176670">7 ways to reduce perineal tearing during childbirth</a>
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<h2>Birth planning with your pelvic floor in mind</h2>
<p>There are pros and cons to <a href="https://www.nature.com/articles/s41598-020-78625-3">both modes of delivery</a> when considering potential long-term impacts on function. Individualised counselling with your medical provider during pregnancy is highly recommended, as everyone’s personal risk factors, circumstances and preferences are unique. </p>
<p>Using a <a href="https://www.ajog.org/article/S0002-9378(17)31205-X/fulltext">risk calculator tool</a> may be a useful starting point when discussing with your care team whether a vaginal or caesarean birth may be more suitable for you. </p>
<p>If you are planning a vaginal delivery, there are a few things <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8983111/">research shows</a> can reduce your risk of pelvic floor injury and dysfunction: </p>
<ul>
<li>maintain a healthy <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5406235/">body weight</a></li>
<li>practice <a href="https://www.pelvicfloorfirst.org.au/pages/pelvic-floor-muscle-exercises-for-women.html">pelvic floor exercises</a> during pregnancy, under the guidance of a suitably trained professional such as a pelvic floor physiotherapist </li>
<li>participate in supervised exercise classes specifically tailored for pregnancy and pelvic floor awareness</li>
<li>start <a href="https://www.qld.gov.au/health/children/pregnancy/antenatal-information/looking-after-yourself-and-your-baby/perineal-massage">perineal massage</a> from 35 weeks of pregnancy to improve muscle flexibility and blood flow</li>
<li>adopt <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002006.pub3/full">upright positions</a> for labour and delivery if it feels right and is safe and comfortable, which may allow for gravity assistance, more efficient contractions and a widened pelvic outlet</li>
<li>push when you <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8983111/">feel urges</a> rather than following “directed pushing” from others</li>
<li>use a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8983111/">warm compress</a> on the perineum during crowning to relax the muscles</li>
<li>a mediolateral <a href="https://theconversation.com/episiotomy-during-childbirth-not-just-a-little-snip-36062">episiotomy</a> (planned cut to the perineal muscles) with <a href="https://www.sciencedirect.com/science/article/pii/S030121151930332X">forceps-assisted deliveries</a> rather than allowing uncontrolled tearing towards the anal sphincter muscles. This is not the same as a <a href="https://theconversation.com/episiotomy-during-childbirth-not-just-a-little-snip-36062">midline episiotomy</a>, which carries <a href="https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/episiotomy/art-20047282#:%7E:text=A%20midline%20incision%20is%20easier,is%20more%20difficult%20to%20repair.">different risks</a>. </li>
</ul>
<p>Whether you choose to birth vaginally or via caesarean is a decision that is very personal and involves many factors. Due to unforeseen complications, sometimes this decision can be taken out of our hands so it is beneficial to be well-informed on both options. </p>
<p>Regardless of mode of delivery, it’s important to learn how to <a href="https://www.continence.org.au/who-it-affects/women/female-pelvic-floor-muscles">effectively exercise your pelvic floor muscles</a> for prevention and treatment of pelvic floor symptoms such as incontinence and prolapse. Today’s a great day to get started. </p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CYoldnCJztB","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
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Read more:
<a href="https://theconversation.com/men-have-pelvic-floors-too-and-can-benefit-when-they-exercise-them-regularly-184451">Men have pelvic floors too – and can benefit when they exercise them regularly</a>
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<img src="https://counter.theconversation.com/content/193019/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mischa is the Founder and Principal Physiotherapist at Pelvic Fix Physiotherapy. She is affiliated with CQUniversity as a Sessional Lecturer, Curtin University as a Physiotherapy Clinical Supervisor, and Queensland Health as a Senior Women's Health Physiotherapist.</span></em></p>It turns out pregnancy itself, regardless of mode of delivery, is a significant risk factor for pelvic floor dysfunction. And there are other risks that have nothing to do with babies.Mischa Bongers, Sessional Lecturer, CQUniversity AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1870832022-08-23T02:18:37Z2022-08-23T02:18:37ZPessaries are still a taboo topic – but these ancient devices help many women<figure><img src="https://images.theconversation.com/files/480485/original/file-20220822-22-j0vkv.jpg?ixlib=rb-1.1.0&rect=1497%2C14%2C7335%2C3308&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/dressed-woman-wants-pee-600w-2143814309.jpg">Shutterstock</a></span></figcaption></figure><p>A vaginal <a href="https://www.yourpelvicfloor.org/media/vaginal-pessary-for-pelvic-organ-prolapse-english-1.pdf">pessary</a> is a removable device inserted in the vagina to support its walls or uterus (support pessary) or for bladder leakage (continence pessary). </p>
<p>Pessaries have been around for a very long time, the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0301211503006511">oldest</a> known pessary – as described by the ancient Greek physician Hippocrates – was a pomegranate soaked in vinegar! </p>
<p>Nowadays, pessaries are made from silicone which is non allergenic, long lasting, pliable and can be sterilised. Some are worn continuously for weeks, months or years with appropriate maintenance, while others are inserted as needed. </p>
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Read more:
<a href="https://theconversation.com/vaginal-birth-after-caesarean-increases-the-risk-of-serious-perineal-tear-by-20-our-large-scale-review-shows-173249">Vaginal birth after caesarean increases the risk of serious perineal tear by 20%, our large-scale review shows</a>
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<h2>What they are good for</h2>
<p>There are many <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320/">types</a> of vaginal support pessaries with (mostly) descriptive names: ring, Gellhorn, donut, cube, C-POP and more. At least two models of continence pessaries – branded <a href="https://contiforminternational.com/">Contiform</a> and <a href="https://coowee.me/">Coo-Wee</a> – are relatively new on the market as well as the continence <a href="https://www.researchgate.net/figure/ncontinence-ring-and-incontinence-dish-courtesy-of-Milex-web-site_fig1_225762597">ring and dish</a>. </p>
<p>Continence pessaries are used for stress urinary incontinence or “light bladder leakage” that occurs with coughing, sneezing or exercise. These act to support the urethra, as can a vaginal tampon, and can prevent leakage in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9119894/">up to 60%</a> of women. They are especially useful if leakage is predictable, such as when a woman goes to the gym or out for a jog.</p>
<p>Vaginal support pessaries can be effective for <a href="https://www.continence.org.au/who-it-affects/women/prolapse">prolapse</a> (a type of hernia or weakness of the vaginal walls and ligaments that allow the uterus, bladder, or bowel to descend to or beyond the vaginal opening). If successfully fitted, pessaries can help <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004010.pub4/full">60% to 70%</a> of women with these problems. There is improvement in the feeling of a vaginal bulge or tissue protrusion, improvement in bladder emptying and bladder leakage and urgency, sexual frequency and satisfaction. About 50% of women who have a vaginal birth will have some prolapse and up to <a href="https://journals.lww.com/greenjournal/Fulltext/2014/06000/Lifetime_Risk_of_Stress_Urinary_Incontinence_or.9.aspx">20%</a> will go on to have surgery during their lifetime.</p>
<p>Pelvic floor muscle training in the early stages can improve symptoms as can vaginal estrogen in women after menopause. A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320/">pessary</a> can be an alternative to surgery or used while women are delaying (such as in between pregnancies) or waiting to have surgery.</p>
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<a href="https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="diagram of pessary and prolapse" src="https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=233&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=233&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=233&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=293&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=293&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=293&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">One example of a pessary and how it can be fitted to help prolapse.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-vector/pelvic-floor-prolapse-type-uterine-600w-1484216528.jpg">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/why-you-shouldnt-make-a-habit-of-doing-a-just-in-case-wee-and-dont-tell-your-kids-to-either-167628">Why you shouldn't make a habit of doing a 'just in case' wee — and don't tell your kids to either</a>
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<h2>The downside</h2>
<p>Pessary use can have a downside too. Side effects may include vaginal discharge or odour or vaginal bleeding. These side effects generally occur after many months or years of continuous use and contribute to discontinuation. </p>
<p>An <a href="https://pubmed-ncbi-nlm-nih-gov.monash.idm.oclc.org/19906018/">Australian study</a> reported only 14% women continued long term use of pessaries mainly due to these side effects and the need for long term maintenance. </p>
<p>But a pessary can “buy time”. Theoretically, pessary use can help prevent worsening of prolapse.</p>
<p>A pessary for longer wear is usually fitted in clinic. Generally, all gynaecologists are trained to fit a pessary as are specialised pelvic floor physiotherapists and continence nurse specialists. Women often require a trial of more than one size or type to find the “best fit”. Sometimes a pessary can’t be fitted, is uncomfortable or falls out. This can occur when the vaginal length is short after previous prolapse surgery or hysterectomy, the vagina has a wide opening or the muscles are very weak.</p>
<p>Support pessaries can be self-managed by women who are willing to do this regularly in the same way they might manage a tampon, menstrual cup, or diaphragm contraceptive device. Sexually active women may choose to remove the pessary prior to intercourse; however, this is not essential for all types. </p>
<p>If not self-managed, pessary follow up is needed every six to 12 months, when the device is removed, cleaned, and reinserted or a new one inserted. </p>
<p>There are rare but serious complications like fistula (an opening between vagina and bowel or bladder) and impaction where an anaesthetic or surgery is required to remove the pessary.</p>
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Read more:
<a href="https://theconversation.com/playing-games-with-your-pelvic-floor-could-be-a-useful-exercise-for-urinary-incontinence-182431">Playing games with your pelvic floor could be a useful exercise for urinary incontinence</a>
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<h2>Some future models</h2>
<p>Recently, there is some research and development occurring in adding <a href="https://www.medicaldesignbriefs.com/component/content/article/mdb/pub/features/applications/40042">personalised</a> or “smart” capabilities to the vaginal support pessary such as electrical stimulation therapy or pressure biofeedback such as <a href="https://www.ncbi.nlm.nih.gov/books/NBK565181/">already exists</a> for pelvic floor training devices.</p>
<p>Acceptance of pessaries is variable and often related to prior knowledge and appropriate <a href="https://pubmed-ncbi-nlm-nih-gov.monash.idm.oclc.org/26829346/">counselling</a>. </p>
<p>There is a lack of knowledge and awareness regarding how common pelvic organ prolapse and urinary incontinence are. We often hear women express embarrassment, shame or fear but many suffer in silence. The main barrier to seeking treatment is the perception that prolapse or incontinence are inevitable parts of childbirth and ageing.</p>
<p>Prolapse and urinary incontinence can have a negative impact on a woman’s physical, <a href="https://www.researchgate.net/profile/Javier-Pizarro-Berdichevsky/publication/301795538_Association_between_pelvic_floor_disorder_symptoms_and_QoL_scores_with_depressive_symptoms_among_pelvic_organ_prolapse_patients/links/59dd6741aca272b698e19388/Association-between-pelvic-floor-disorder-symptoms-and-QoL-scores-with-depressive-symptoms-among-pelvic-organ-prolapse-patients.pdf">emotional and social wellbeing</a>. Women experiencing any pelvic floor dysfunction can speak to their GPs, gynaecologists, or <a href="https://www.ugsa.com.au/home">urogynaecologists</a> (gynaecologists specialised in management of prolapse and incontinence). </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-pelvic-organ-prolapse-9097">Explainer: what is pelvic organ prolapse?</a>
</strong>
</em>
</p>
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<img src="https://counter.theconversation.com/content/187083/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Rosamilia is Clinical Associate Investigator for studies receiving funding from NHMRC, Past research grants from Boston Scientific, American Medical Systems. Astellas. She has had an expert witness role. None of this funding is related to pessaries.
She is affiliated with and member of International Urogynecological Association, Urogynaecological Association of Australia, Continence Foundation of Australia and International Continence Society.</span></em></p><p class="fine-print"><em><span>Mugdha Kulkarni is a member of International Urogynecological Association & Urogynaecological Association of Australia.
</span></em></p>They are rarely talked about but vaginal pessaries can give women freedom and security if they have prolapse or urinary incontinence.Anna Rosamilia, Adjunct associate professor and urogynaecology & pelvic reconstructive surgery, Head Pelvic Floor Unit at Monash Health, Monash UniversityMugdha Kulkarni, Consultant Urogynaecologist, Pelvic Floor Unit, Monash HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/954442018-06-14T20:38:33Z2018-06-14T20:38:33ZShould all women do pelvic floor exercises? We asked five experts<figure><img src="https://images.theconversation.com/files/216067/original/file-20180424-94149-16edwtn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doing them properly is key. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p><a href="https://www.continence.org.au/pages/key-statistics.html">Over a third</a> of Australian women suffer from urinary incontinence, and it’s estimated at least <a href="https://womhealth.org.au/conditions-and-treatments/genital-prolapse-fact-sheet">half of women</a> who’ve had more than one child have some degree of genital prolapse. </p>
<p>Pelvic floor disorders affect many women, and <a href="https://www.thewomens.org.au/health-information/pregnancy-and-birth/a-healthy-pregnancy/the-pelvic-floor">health professionals often recommend</a> exercising the pelvic floor muscles in order to keep them strong to reduce symptoms and prevent disorder.</p>
<p>We asked five experts if all women should be exercising these muscles regularly. </p>
<h2>Five out of five experts said yes</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=99&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=99&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=99&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=125&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=125&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=125&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><strong><em>Here are their detailed responses:</em></strong></p>
<p><iframe id="tc-infographic-265" class="tc-infographic" height="400px" src="https://cdn.theconversation.com/infographics/265/a8d28f39b496b1a291906a67fa31edf2fbe09e89/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
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<p><em>If you have a “yes or no” health question you’d like posed to Five Experts, email your suggestion to: alexandra.hansen@theconversation.edu.au</em></p>
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<img alt="" src="https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>Disclosures: Hannah Dahlen has received funding from the NHMRC and ARC. Victoria Salmon receives funding from the UK National Institute for Health Research (NIHR). The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.</em></p><img src="https://counter.theconversation.com/content/95444/count.gif" alt="The Conversation" width="1" height="1" />
If you haven’t had kids you probably haven’t given much thought to your pelvic floor muscles. But 5 out of 5 experts say all women should regularly exercise them.Alexandra Hansen, Deputy Editor and Chief of Staff, The Conversation AUNZLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/944032018-04-04T08:10:29Z2018-04-04T08:10:29ZNot all vaginal implants are a problem and treating them the same puts many women at risk<figure><img src="https://images.theconversation.com/files/213103/original/file-20180404-189830-7ufdlf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Around on in five women might need surgical treatment for prolapse or urinary incontinence.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Last week, a <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MeshImplants">Senate Committee</a> investigating the impacts of “transvaginal mesh implants” on women in Australia handed down its report, with 13 recommendations. The implants are medical devices surgically inserted to prevent prolapse and urinary incontinence - conditions that affect many women over their lifetime, with around 20% <a href="https://www.ncbi.nlm.nih.gov/pubmed/24807341">requiring surgical</a> treatment.</p>
<p>The inquiry was the result of many <a href="http://www.abc.net.au/news/2017-05-31/more-women-mesh-implant-side-effects-than-thought-experts-say/8572840">women coming forward</a> reporting <a href="http://www.abc.net.au/news/2017-05-31/how-a-vaginal-mesh-implant-destroyed-maessens-life/8573878">serious side effects</a>, such as chronic pain and trouble walking, after vaginal mesh surgery. Recommendations included that these medical devices are to be used only “as a last resort”, that each mesh implant be registered, patient counselling and decision-making, surgeon training and better reporting of adverse events. </p>
<p>Proposals to improve outcomes for patients by implementing stricter standards in training, audit, research and monitoring of medical implants are welcome. However, the Senate has lumped together incontinence and prolapse devices, considering them all to be “transvaginal meshes”. </p>
<p>Only the prolapse devices are problematic, while those used for incontinence are safe and evidence-based procedures. Conflating the two confuses women and may lead them to seek snake-oil type treatments that have no evidence base, and can be risky.</p>
<h2>Different devices</h2>
<p>Prolapse is when pelvic organs – such as the bladder, bowel or uterus (womb) – fall through the vagina. Stress urinary incontinence is involuntary urine leakage with activity such as sport, coughing or even walking. Both conditions are types of pelvic floor dysfunction, but the surgery and medical devices used to treat them are different.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/urinary-incontinence-can-be-a-problem-for-women-of-all-ages-but-there-is-a-cure-49365">Urinary incontinence can be a problem for women of all ages, but there is a cure</a>
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</em>
</p>
<hr>
<p>Despite many <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MeshImplants/Submissions">submissions to the inquiry</a> from clinical bodies, the Senate committee has been unable to distinguish between midurethral mesh slings (used for urinary incontinence) and transvaginal mesh (used for prolapse). The first is a mesh tape placed under the urethra like a sling for support. The second are sheets of mesh placed under the bladder, or in front of the bowel, to stop prolapse and prevent recurrence.</p>
<p>Midurethral slings in Australia have been associated with complaints in around equal numbers to mesh used for prolapse, but proportionately most problems have been seen with prolapse. This is because an estimated 120,000 sling operations have <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MeshImplants">been performed</a>, compared to only around 30,000 prolapse mesh procedures.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many women who had mesh surgery for pelvic prolapse have experienced significant pain, bladder injury and incontinence.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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</figure>
<p>There is <a href="https://theconversation.com/common-surgery-for-vaginal-prolapse-can-lead-to-complications-review-shows-54559">still clinical uncertainty</a> and insufficient data on indications for use and best practice when it comes to the mesh used to treat vaginal prolapse. A <a href="http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD012079/abstract">review of several studies</a> found that the artificially grafted mesh had more problems than benefits, and the women who underwent the operation had high rates of needing repeat surgery due to mesh exposure, bladder injury and urinary incontinence.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/common-surgery-for-vaginal-prolapse-can-lead-to-complications-review-shows-54559">Common surgery for vaginal prolapse can lead to complications, review shows</a>
</strong>
</em>
</p>
<hr>
<p>Midurethral slings, however, have an <a href="https://www.ncbi.nlm.nih.gov/pubmed/26130017">excellent track record</a> and are the <a href="https://www.ncbi.nlm.nih.gov/pubmed/23563892">most researched incontinence procedure</a> in history. Midurethral slings have been recognised by every national and international medical or regulatory organisation as the treatment of choice for stress urinary incontinence in patients who have failed conservative management, such as pelvic floor exercises.</p>
<h2>There are riskier procedures</h2>
<p>The Senate also tasked the Australian Commission on Quality and Safety in Health Care with carrying out many of its recommendations. The commission recently <a href="https://www.safetyandquality.gov.au/our-work/transvaginal-mesh/status-of-commission-guidance-february-2018/">published guidelines</a> for hospital credentialing of surgeons to perform transvaginal mesh procedures for urinary incontinence and prolapse. </p>
<p>Along with many sensible recommendations on training and audit, the commission determined that surgeons needed to perform:</p>
<blockquote>
<p>a minimum of ten surgeries for stress urinary incontinence (either mesh or non-mesh) each year. </p>
</blockquote>
<p>This is not ten midurethral slings – the procedure for which the whole guideline was designed – but any surgery for stress incontinence.</p>
<p>There is no requirement from the commission that such procedures have proven efficacy and safety. This means that, in theory, a completely non evidence-based treatment such as vaginal laser could be claimed as a continence procedure. Vaginal laser is essentially a cosmetic laser treatment, for which there is absolutely no scientific data for any effect in patients with urinary incontinence.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaginal-mesh-controversy-shows-collective-failure-of-the-tga-and-australias-specialists-78605">Vaginal mesh controversy shows collective failure of the TGA and Australia's specialists</a>
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</em>
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<hr>
<p>Along with the Senate’s recommendation that mesh be used as a “last resort”, this suggests patients should be offered less effective procedures, such as an <a href="http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003881.pub4/abstract">injection therapy</a>, or <a href="http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD001755.pub2/abstract">big abdominal operations</a>, with <a href="https://www.ncbi.nlm.nih.gov/pubmed/28479203">more complications</a> and no better efficacy, simply because they don’t involve mesh.</p>
<p>We have already seen a <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1111/ajo.12445">reduction in continence surgery</a> over the last several years, which could be related to adverse mesh publicity. This has not been replaced by an increase in conservative management. Rather Australian women are now continuing to suffer with their incontinence. And there is a risk they will turn to expensive “snake oil” treatments, such as <a href="https://splinternews.com/vaginal-rejuvenation-stem-cell-therapy-is-probably-bogu-1793859971">vaginal rejuvenation therapy</a>.</p>
<p>We anticipate further patient anxiety and poor outcomes if the system doesn’t guarantee patients receive evidence-based care. We have the data on midurethral slings so we can’t compromise access to the safest and most effective surgical treatment for their stress incontinence.</p><img src="https://counter.theconversation.com/content/94403/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer King is the Chair of the UroGynaecological Society of Australasia.</span></em></p>Mesh surgery for urinary incontinence is effective and extensively studied, while the mesh used in pelvic prolapse is problematic. But the Senate has conflated the two, which will confuse women.Jennifer King, Honorary Clinical Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/786052017-06-06T19:21:24Z2017-06-06T19:21:24ZVaginal mesh controversy shows collective failure of the TGA and Australia’s specialists<figure><img src="https://images.theconversation.com/files/172197/original/file-20170605-20608-1x1wfgp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hundreds of women have complained of adverse reactions from transvaginal mesh implants.</span> <span class="attribution"><a class="source" href="https://unsplash.com/search/older-women?photo=_EKlFRXUuvg">Anna Noack/Unsplash</a></span></figcaption></figure><p>Australian women are coming forward with <a href="http://www.abc.net.au/news/2017-05-31/how-a-vaginal-mesh-implant-destroyed-maessens-life/8573878">stories of the negative impacts on their lives of transvaginal mesh implants</a>, medical devices surgically inserted to prevent pelvic organ prolapse. </p>
<p>A recent <a href="http://www.abc.net.au/news/2017-05-31/more-women-mesh-implant-side-effects-than-thought-experts-say/8572840">Australian consumer group</a> survey reported more than 700 women said they had a mesh implant that had caused adverse effects. These included incontinence, severe chronic pain, problems walking, painful intercourse and even marriage breakdown. In the United Kingdom, hundreds of women are <a href="http://www.bbc.com/news/health-39567240">taking legal action</a> against the National Health Service and the makers of mesh implants. </p>
<p>The <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MeshImplants">Senate is conducting an inquiry</a> into transvaginal mesh implants in Australia. The questions the inquiry aims to answer include why there is no accurate record of how many meshes have been inserted in Australia, and how we can guarantee safer introduction of new products in future.</p>
<p>So, how did we get to a place where hundreds of Australian women have allegedly had this surgery leading to lifelong complications? </p>
<h2>A history of transvaginal mesh</h2>
<p>The pelvic floor is a group of muscles in the pelvic area that support the bladder, vagina and rectum. About 50% of women who have had children <a href="http://www.ajog.org/article/S0002-9378(00)53840-X/abstract">experience pelvic floor dysfunction</a>. As many as 20% <a href="https://www.ncbi.nlm.nih.gov/pubmed/24807341">will require surgery</a> for these conditions.</p>
<p>Pelvic floor dysfunction includes prolapse (falling through) of pelvic organs, such as the bladder, bowel or uterus (womb), through the vagina. It also includes stress urinary incontinence, which is involuntary urine leakage with activity such as sport, coughing or even walking.</p>
<p>The surgery and the medical devices used differ between these two conditions.</p>
<p><strong>Stress incontinence</strong></p>
<p>In the late 1990s, <a href="https://www.ncbi.nlm.nih.gov/pubmed/7618052">an innovative treatment</a> for stress incontinence was introduced. This involved a <a href="https://www.thewomens.org.au/health-information/continence-information/urinary-incontinence/">permanent synthetic sling, called a mid-urethral sling</a>, placed under the urethra (the tube through which urine travels from the bladder) to give it support. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The mid-urethral sling is placed under the urethra for support.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>By 2002, the mid-urethral sling became the most frequently performed incontinence surgery in Australia. This was <a href="https://www.ncbi.nlm.nih.gov/pubmed/12114234">because doctors saw</a> the procedure was equivalent to, or better than, alternative procedures. The blood loss and operating time were less and recovery times were shorter than older procedures. </p>
<p>This clinical experience was later <a href="https://www.ncbi.nlm.nih.gov/pubmed/14981369">confirmed in large trials</a>. But while we waited for the results of these, which were published from 2004 onward, many women gained from a highly effective and safe operation, demonstrating the benefits of the innovation.</p>
<p><strong>Pelvic organ prolapse</strong></p>
<p>Traditional surgery for pelvic organ prolapse involved repairing the torn connective tissue with sutures. This was called vaginal repair. Unfortunately, this <a href="https://www.ncbi.nlm.nih.gov/pubmed/9083302">surgery was associated</a> with a <a href="http://www.ajog.org/article/S0002-9378(01)99389-5/abstract">high rate of the prolapse</a> recurring.</p>
<p>Following the success of the sling tape in stress incontinence, and of mesh use for hernias, doctors and manufactures looked to <a href="http://www.ejog.org/article/S0301-2115(00)00341-9/abstract">introduce a mesh</a> product to treat vaginal prolapse. This involved sheets of mesh being placed under the bladder, or in front of the bowel, to stop prolapse and prevent recurrence.</p>
<p>The <a href="https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.nsf&docid=2349C2AAB6E8898ECA2577DD0001C16B&agid=(PrintDetailsPublic)&actionid=1">Therapeutic Goods Association (TGA)</a> approved a variety of transvaginal mesh kits for pelvic organ prolapse from 2003. As with the mid-urethral sling four years earlier, little supporting data on the safety and efficacy of these kits was initially available. </p>
<p>Due to a lack of detail in the Medicare codes used to record the surgeries, we are unable to accurately determine how many women underwent surgery. I estimate that around 150,000 tapes for stress urinary incontinence and between 30,000 and 40,000 transvaginal meshes for pelvic organ prolapse have been performed to date.</p>
<h2>Problems with vaginal mesh</h2>
<p>Since the introduction of transvaginal mesh, long-term trials and <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012079/abstract">reviews have demonstrated</a> it has some advantages over traditional vaginal repair. These include reduced symptoms of prolapse and need to operate again. But the mesh kits also have disadvantages. </p>
<p>The mesh rubs or <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012079/abstrac">becomes exposed in the vagina</a> in as many as 14% of cases. For some women, the exposure has no symptoms, but others experience bleeding, discomfort and painful intercourse. </p>
<p>At least half of the women in the studies reviewed needed surgery to treat the exposed mesh and sew over the vaginal tissue. The surgical correction is relatively straightforward and is generally successful. </p>
<p>Another problem is <a href="http://www.ajog.org/article/S0002-9378(10)02270-2/abstract">vaginal and groin pain</a>, which affects 3-4% of women. Sometimes multiple surgeries are required to remove large portions of the mesh. The pain <a href="https://www.ncbi.nlm.nih.gov/pubmed/26506159">persists in as many as 25% of women</a>, even after mesh excision, and may become chronic and disabling. Some find it difficult to maintain employment and intimate relationships. </p>
<h2>What regulatory bodies did</h2>
<p>Following reports of these complications, the <a href="https://www.fda.gov/downloads/medicaldevices/safety/alertsandnotices/ucm262760.pdf">US Food and Drug Administration</a> (FDA) <a href="http://www.mdedge.com/obgmanagement/article/63461/fda-alert-transvaginal-placement-surgical-mesh-carries-serious-risks">issued alerts</a> in 2008 and 2011 that the mesh carried serious risks. Many transvaginal mesh kits were voluntarily removed from the market. Most doctors in Australia stopped using the mesh for prolapse from 2012.</p>
<p>While the evidence of the benefits of the mid-urethral sling for urinary incontinence is overwhelming, <a href="http://journals.lww.com/co-urology/Abstract/2004/11000/Trans_obturator_tape_procedure____inside_out_or.3.aspx">some changes to the tapes</a> were introduced from 2005 to decrease adverse events. The TGA approved these new mini-slings (or obturator slings) and specialists used these without evidence confirming whether they were safer or more effective than the traditional mid-urethral sling.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Disabling vaginal and groin pain can be a complication of vaginal mesh implants.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>In 2015, an <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006375.pub3/abstract">extensive Cochrane review</a> showed 2-3% of women developed significant groin pain after surgery with the obturator slings. It also showed the obturator slings were not as effective as the traditional slings at the five-year mark. But the obturator slings were quicker to perform and had less bladder injury than the traditional mid-urethtral slings. </p>
<p>In 2016, specialist groups such as the Urogynaecology Society of Australia and the Australian College of Obstetricians and Gynaecologists undertook <a href="http://www.ugsa.org.au/data/MUS_Presentations/3.UGSA_MUS_SUI_treatment_Read-Only.pdf?COLLCC=3602805463&">educational courses and later issued statements</a> cautioning doctors about using the new slings.</p>
<p>Many of the affected women have asked how procedures could be performed on them when the full benefit-to-risk profile of the intervention was not yet known. It can be argued doctors wanted to provide new and better options. But, in hindsight, innovation and patient safety could have been far more closely aligned. </p>
<p>This could have been achieved if both the TGA and the specialists themselves had more thoroughly evaluated transvaginal meshes by ensuring these were used under the oversight of medical ethics committees. The well-established practice of performing large trials under the guidance of an ethics committee encourages innovation while ensuring patients are properly informed of the possible benefits and risks of the innovation. </p>
<p>While some Australian hospitals took this precautionary step, the fact it did not happen uniformly is a collective failure of both the TGA and specialists. </p>
<h2>Next steps</h2>
<p>The Senate review will evaluate how sponsoring manufacturers interact with doctors performing surgical interventions, and how the broader medical community and public are educated about new interventions. </p>
<p>It is hoped the inquiry will inform the general community, doctors and industry of a clear and transparent pathway that balances the need for innovation and the responsibility for protecting patients.</p>
<p>Finally, while waiting on the inquiry’s deliberations, women should remain confident mid-urethral slings used for stress incontinence are an excellent intervention. Those undergoing prolapse surgery should also be reassured that highly trained specialists will carefully evaluate and perform surgery without the need for transvaginal mesh. </p>
<p>Those affected by ongoing complications associated with transvaginal mesh can be reassured Australian specialists are leaders in the management of these problems. Not only were we among the first in the world to report large trials that evaluated transvaginal mesh, we’ve also reported on the safety, technique and efficacy of mesh-removal procedures for vaginal pain in peer-reviewed publications.</p>
<p>We are fully supportive of the women who have experienced complications of transvaginal mesh. We look forward to working collaboratively at a national and local level, under the auspices of the Senate enquiry, to ensure we learn from the mistakes made when introducing transvaginal mesh into clinical practice. </p>
<hr>
<p><em>Further information is available on the websites of the <a href="https://www.ranzcog.edu.au/Womens-Health/Patient-Information-Guides">College of Obstetricians and Gynaecology</a> (RANZCOG) and the <a href="http://www.ugsa.org.au/pages/patient-information.html">Urogynaecology Society of Australia</a> (UGSA).</em></p><img src="https://counter.theconversation.com/content/78605/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Maher does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Regulatory bodies approved some medical devices to treat pelvic organ prolapse and urinary incontinence before having data to prove their safety and efficacy.Christopher Maher, Associate Professor, Urogynaecology Royal Brisbane and Women's and Wesley Hospitals Brisbane, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/764402017-04-25T08:09:25Z2017-04-25T08:09:25ZPelvic floor training in pregnancy could help prevent the need for ‘barbaric’ vaginal mesh surgery<figure><img src="https://images.theconversation.com/files/166517/original/file-20170424-12629-b1cu81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Exercises can help women's pelvic floor health during pregnancy and after birth.</span> <span class="attribution"><span class="source">COLLATERAL/www.shutterstock.com</span></span></figcaption></figure><p>For millions of women, childbirth is a somewhat daunting yet thoroughly rewarding process. In the western world, many years of medical research and professional experience mean that women have access to expert care before, during and after birth. However, there is still one matter that is not being addressed enough during pregnancy: pelvic floor health. Women often do not realise, and are not properly informed, that something can be done to reduce the risks of pelvic floor problems in pregnancy and after childbirth.</p>
<p>The pelvic floor muscles lie across the base of the pelvis, supporting and holding the bladder, uterus and bowel in position. They also help to control the bladder and bowel. Pregnancy and childbirth can cause problems such as weakness, overstretching and tears in the pelvic floor muscle, due to increased pressure. </p>
<p>Weakening or damage may result in inability to control <a href="http://www.nhs.uk/conditions/Incontinence-urinary/Pages/Introduction.aspx">bladder</a> or <a href="http://www.nhs.uk/conditions/incontinence-bowel/Pages/Introduction.aspx">bowel</a> movements, resulting in incontinence. Muscle weakness can also contribute to <a href="http://www.nhs.uk/conditions/Prolapse-of-the-uterus/Pages/Introduction.aspx">pelvic organ prolapse</a>, which is the bulging of one or more of the pelvic organs, such as the uterus, bowel and bladder, into the vagina.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/166536/original/file-20170424-25594-1nsx2hy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/166536/original/file-20170424-25594-1nsx2hy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=480&fit=crop&dpr=1 600w, https://images.theconversation.com/files/166536/original/file-20170424-25594-1nsx2hy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=480&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/166536/original/file-20170424-25594-1nsx2hy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=480&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/166536/original/file-20170424-25594-1nsx2hy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=603&fit=crop&dpr=1 754w, https://images.theconversation.com/files/166536/original/file-20170424-25594-1nsx2hy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=603&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/166536/original/file-20170424-25594-1nsx2hy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=603&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Weakening or damage to the pelvic floor can lead to incontinence or prolapse.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/female-pelvic-floor-labeled-157672304?src=inic3UbLdsbFHl5NKxTmkA-1-3">Alila Medical Media/www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Urinary incontinence is a common problem, affecting <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/595439/CMO_annual_report_2014.pdf">over 5m women</a> in the UK alone. Between <a href="http://www.icud.info/incontinence.html">30-50% of women</a> will experience some leaking of urine during or after pregnancy. And, according to one study, up to three out of four women still experience symptoms <a href="https://www.ncbi.nlm.nih.gov/pubmed/25846816">12 years after giving birth</a>.</p>
<p>Incontinence can make women feel <a href="https://www.ncbi.nlm.nih.gov/pubmed/22924517">shame and embarrassment</a>, which stops them from seeking help. It is normalised in UK society, with many women believing that incontinence is an unavoidable consequence of having children, further stopping them from accessing treatment. They are exposed to media images of female incontinence as normal and inevitable: young women are portrayed as accepting the condition in adverts for absorbent products, accompanied by tag lines such as “<a href="http://www.lightsbytena.co.uk/the-oooops-lounge/tv-advert/">Oops moments happen. C’est la vie</a>.”</p>
<h2>Prevention rather than treatment</h2>
<p>When women do seek help for pelvic floor problems they are offered treatment according to the severity of their symptoms. Pelvic floor muscle training (PFMT) is a first line treatment. <a href="http://pogp.csp.org.uk/">PFMT</a> involves pulling up the pelvic floor muscles by pretending to hold in wee or stopping passing wind. The muscles can be strengthened by regularly doing a series of long and short holds. For example, squeezing these muscles slowly ten times in a row, then doing ten fast squeezes and repeating this three times per day.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/LMiNq_ai1hU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>In more severe cases, surgery may be offered, which can include insertion of mesh through the vagina, to provide extra support when repairing weakened or damaged tissue. </p>
<p>However, vaginal mesh surgery has <a href="https://theconversation.com/common-surgery-for-vaginal-prolapse-can-lead-to-complications-review-shows-54559">more problems than benefits</a>. It has been called <a href="http://www.telegraph.co.uk/news/2017/04/18/800-sue-nhs-barbaric-mesh-implants-cause-agonising-pain/">“barbaric”</a> and recently led to <a href="http://www.bbc.co.uk/news/health-39567240">more than 800 women suing the NHS</a> over complications with it such as permanent pain, and an inability to walk, work or have sex.</p>
<p>So why aren’t we focusing more on women’s pelvic floor health in pregnancy, to try to avoid these conditions developing?</p>
<p>Evidence shows that PFMT can help prevent and treat incontinence in pregnant women or women who have recently given birth. In fact, research has found that women having their first baby who performed PFMT were about <a href="http://www.cochrane.org/CD007471/INCONT_pelvic-floor-muscle-training-for-prevention-and-treatment-of-urinary-and-faecal-incontinence-in-pregnant-women-and-women-who-have-recently-given-birth">30% less likely</a> to experience incontinence up to six months after delivery. There is also increasing <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32109-2/abstract">evidence</a> that PFMT may prevent symptoms of pelvic organ prolapse and could reduce the uptake of further treatment.</p>
<p><a href="https://www.nice.org.uk/guidance/cg62?unlid=6487027412017312201739">UK guidelines for antenatal care</a> recommend midwives offer information about pelvic floor exercises at a pregnant woman’s first appointment. However, for PFMT to be effective it needs to be delivered through a <a href="https://www.ncbi.nlm.nih.gov/pubmed/21820536">structured, supervised training programme</a>. Simply giving out information on its own is rarely enough to support people to carry on exercising long term. </p>
<p>Women have reported that the information they received about PFMT in pregnancy was <a href="https://www.ncbi.nlm.nih.gov/pubmed/17126457">insufficient</a>, and they weren’t told about the importance of pelvic floor health. They did not understand why they had to do the exercises or how to do them correctly. The information was not clearly linked to the role of the muscles in reducing the risk of incontinence or pelvic organ prolapse so many women did not think PFMT was worth doing.</p>
<p>Evidently, more <a href="https://www.rcm.org.uk/sites/default/files/CSP-000924_RCM.PDF">could and should be done</a> to improve the quality and delivery of PFMT information during the antenatal period. Incontinence and prolapse do not need to be taboo, but nor should they be normalised as part of the consequences of childbirth and pregnancy. </p>
<p>PFMT during pregnancy presents an opportunity to prevent long-term, debilitating pelvic health problems and may reduce the need for further medical or surgical intervention. But for this to happen, women need to understand the benefits, know how to do it and feel that PFMT is realistic and doable in their daily lives.</p><img src="https://counter.theconversation.com/content/76440/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Victoria Salmon is a member of the Chartered Society of Physiotherapy and the Pelvic, Obstetric and Gynaecological Physiotherapy (POGP) professional network. Victoria receives funding from the UK National Institute for Health Research (NIHR). The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.
</span></em></p><p class="fine-print"><em><span>Rachel Jarvie receives funding from the UK National Institute for Health Research (NIHR). The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.</span></em></p>Women need to be given more information about pelvic floor health during and after pregnancy.Victoria Salmon, Research Fellow in Women's Health, University of ExeterRachel Jarvie, Research Fellow in Women's Health, University of ExeterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/493652016-02-11T19:01:30Z2016-02-11T19:01:30ZUrinary incontinence can be a problem for women of all ages, but there is a cure<figure><img src="https://images.theconversation.com/files/109586/original/image-20160129-27156-le0h63.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Urinary incontinence is often seen as a degrading condition and women can feel too ashamed to seek help.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>This article is part of our series examining women’s hidden health conditions. You can read about endometriosis, menopause and other pieces in the series <a href="https://theconversation.com/au/topics/womens-health-series">here</a>.</em></p>
<hr>
<p>Urinary incontinence is urine leakage from a loss of bladder control that mainly affects women after childbirth. But it can happen to anyone. Around <a href="http://www.continence.org.au/pages/key-statistics.html">37% of Australian women</a> have some form of the condition compared to 13% of Australian men.</p>
<p>Mild incontinence is <a href="http://onlinelibrary.wiley.com/doi/10.1002/(SICI)1520-6777(1999)18:6%3C567::AID-NAU7%3E3.0.CO;2-F/abstract">the most common form</a>, affecting about two out of three sufferers. This is where small amounts of urine leak out onto clothing a few times a week and require a light pad or pantyliner to catch the flow. </p>
<p>Moderate to severe incontinence is less common and affects about a third of sufferers. Women need to use a specific incontinence pad (with absorbent gel) and change it more than once or twice daily. This might not be enough though, and they may get accidental wetting through to their clothing even if using the pad.</p>
<p>Whatever form it takes, <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442455815">the impact of incontinence</a> can be debilitating and women are often too embarrassed to seek help from their doctor. This is unfortunate as there is more likelihood of a cure for those who receive treatment at an earlier point.</p>
<h2>Stress and urge incontinence</h2>
<p>There are <a href="http://www.medicalobserver.com.au/medical-news/female-urinary-incontinence">two main forms of urinary incontinence</a>: stress incontinence and urge incontinence. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=462&fit=crop&dpr=1 600w, https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=462&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=462&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=581&fit=crop&dpr=1 754w, https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=581&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=581&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A urethra is like a hose.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/aboutamy/9393569695/in/photolist-fj5v1c-oP3Dyz-dFeJuJ-euAJrh-u1XZbc-87sDPW-87sDYY-ejHu9E-CyG8VV-brQmQ9-bQXhyT-4zD86w-3kDmhH-6sVPNv-6qsCeC-feetQ-6GiGDD-6qsCtY-8znEb9-6tfyr2-6zYu1t-6zYtEF-6qaaSK-AHq7JC-rJG7n4-3kDkup-7pSaM-7QVd9S-6gdkBM-Ha6vs-4xxAXw-om5m7i-87EWG3-7jE2oQ-b3cg3R-7YSN8X-c9aPVj-4SoZ7b-bL3xu4-dgMWHL-91RmJq-4Ftxuo-nC9ecZ-87m66u-tQo36f-84iNCt-bwfnjh-wxwyB8-bCMxkg-pQYPHR">Amy Stanley/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>In stress incontinence, urine leaks out during coughing, sneezing, laughing, or exercising. People with this condition have weak pelvic muscles around the urethra, which are overwhelmed during times of physical stress. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/8041527">About 28% of young women</a> who engage in high-impact sports - such as gymnastics, basketball and tennis - develop stress incontinence.</p>
<p>The second form, urge incontinence, is a desperate need to go to the toilet due to spasms in the bladder muscle. Sometimes this results in leaking. People often go to the toilet more than eight times a day, and get up to go more than once at night.</p>
<p>There’s another form called overflow incontinence, which is actually more common in men who have an enlarged prostate gland. It partly blocks the urethra so a pool of residual urine builds up in the bladder and leaks out when capacity overflows. </p>
<p>The problem is rare in women and happens when the bladder has <a href="https://jeanhailes.org.au/health-a-z/bladder-bowel/prolapse-bladder-weakness">prolapsed or dropped down</a> into the vagina. This can block off the urethra, leading to incomplete emptying with overflow leakage.</p>
<h2>Incontinence across the ages</h2>
<p>Women are more prone to incontinence because their urethra is very short (only 4 cm) while the male’s is quite long (11 cm). If you imagine a garden hose, the shorter it is, the more likely water from the tap is to leak out. In a longer hose, the tap water might stop flowing before it reaches the end.</p>
<p>About a third of women <a href="http://www.alswh.org.au/who-is-involved/students/9-who-is-involved/28-dr-pauline-chiarelli-s-studies">who have had children</a> suffer from incontinence at some point. Adolescent girls and older children also experience urine leakage, mainly in the case of bed wetting. This is due to an overactive bladder and <a href="http://www.ncbi.nlm.nih.gov/pubmed/8944518">affects about 4%</a> of children between five and 12.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=441&fit=crop&dpr=1 600w, https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=441&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=441&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=554&fit=crop&dpr=1 754w, https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=554&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=554&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Weak pelvic muscles around the urethra can lead to stress incontinence.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>Bed wetting gradually declines during adolescence, but urge and stress <a href="http://www.ncbi.nlm.nih.gov/pubmed/22704114">incontinence persist</a> in up to 10% of women. Incontinence then becomes more common after menopause as women <a href="https://jeanhailes.org.au/health-a-z/bladder-bowel/prolapse-bladder-weakness">produce less oestrogen</a> which weakens ligaments and pelvic floor muscles supporting the urethra. </p>
<p>Obesity <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866035/">increases the likelihood</a> of incontinence too, as abdominal fat puts pressure on pelvic floor muscles. Likewise, constipation and repeated straining to pass a bowel motion weakens these muscles, <a href="http://www.ncbi.nlm.nih.gov/pubmed/20346050">increasing the risk</a>. </p>
<p>Other factors influencing incontinence include urinary tract infection, which is <a href="http://www.ncbi.nlm.nih.gov/pubmed/18238968">known to worsen</a> its prevalence and severity. Anxiety also contributes to symptoms with studies showing 28% to 32% of women with <a href="http://www.ncbi.nlm.nih.gov/pubmed/22068320">urge incontinence</a>, and 22% with stress incontinence, suffer from anxiety.</p>
<h2>Treatment options</h2>
<p>Urinary incontinence implies lack of control which leads to feelings of shame and reluctance to seek help. As one <a href="http://www.ncbi.nlm.nih.gov/pubmed/15621220">study showed</a> 55% of women who wore pads for incontinence had not consulted a general practitioner in 12 months. </p>
<p>This is unfortunate as treatment options have advanced enormously in the last 20 years. If a patient seeks treatment when leakage is mild, it’s much more likely <a href="http://www.ncbi.nlm.nih.gov/pubmed/12955342">to be successful</a>. The more severe the incontinence, the more difficult and expensive it is to treat.</p>
<p>First-line therapy for stress incontinence is pelvic floor muscle training by a specialist continence physiotherapist, which doesn’t require a doctor’s referral. This has a 65% likelihood of cure for mild, and <a href="http://www.ncbi.nlm.nih.gov/pubmed/12842055">35% for moderate, incontinence</a> with no side effects or risk.</p>
<p>If this doesn’t work, there are two kinds of <a href="http://link.springer.com/article/10.1007/s00192-007-0519-1">vaginal ring pessaries</a> available to support the urethra. These are particularly useful for women who only leak with active sports or gym classes.</p>
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<p>The final option is to have an operation. The most widely performed is one where a mesh tape is placed under the urethra like a sling for support. About 93% of women <a href="http://www.ncbi.nlm.nih.gov/pubmed/10426241">are found to be</a> cured three years after having the surgery and it shows good long-term results.</p>
<p>For urge incontinence, first-line therapy is training to increase bladder capacity. <a href="http://www.australianprescriber.com/magazine/29/1/22/4">A tablet or patch</a> that reduces bladder spasms is prescribed alongside training for at least three to six months.</p>
<p>Urge incontinence after menopause is treated with vaginal oestrogen cream that helps <a href="http://www.ncbi.nlm.nih.gov/pubmed/23076892">strengthen the urethra</a> and enhance bladder capacity. </p>
<p>About 40% of women who don’t respond to these are found to <a href="http://www.ncbi.nlm.nih.gov/pubmed/24844724">have a low grade infection</a> of the bladder, known as cystitis. More treatment options are being developed for this. For instance, a <a href="http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=12613000285752&isBasic=True">randomised trial is currently underway</a> exploring bladder-specific antibiotics together with a muscle spasm reduction tablet for urinary incontinence. </p>
<p>No woman should have to suffer urinary incontinence in silence or shame. The above treatments are not difficult, but they require a professional to steadily work through the options to find the right cure for each woman.</p>
<p><em>Specialist continence physiotherapists can be found at the <a href="https://www.physiotherapy.asn.au">Australian Physiotherapy Association’s</a> website and at the <a href="http://www.continence.org.au">Continence Foundation of Australia’s</a> website.</em></p><img src="https://counter.theconversation.com/content/49365/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Moore receives funding from the NHMRC, the Bupa Research Foundation and the Australian Bladder Foundation.</span></em></p>Women with urinary incontinence are often too embarrassed to seek help from their doctor. But there is more likelihood of a cure for those who receive treatment at an earlier point.Kate Moore, Professor, Obstetrics and Gynaecology and Head of Department of Urogynaecology, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/209772013-12-09T14:39:25Z2013-12-09T14:39:25ZRegular pelvic floor exercises help a very common problem<figure><img src="https://images.theconversation.com/files/37148/original/s8rbkpjt-1386339721.jpg?ixlib=rb-1.1.0&rect=1%2C3%2C1022%2C680&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">And hold.</span> <span class="attribution"><span class="source">Relaxing Music</span></span></figcaption></figure><p>Women who have had children are often advised to do exercises to tighten their pelvic floor muscles. The <a href="http://www.nhs.uk/chq/Pages/1063.aspx?CategoryID=52&SubCategoryID=146#close">muscles run</a> from the pubic bone at the front of your body towards the back and help support your bladder and control when you urinate.</p>
<p>As you get older, these muscles can also weaken, and pelvic organ prolapse is a common disorder. This is when the bladder, womb or bowel moves downwards from its normal position because the muscles or ligaments aren’t supporting it as they should. It can lead to pain, discomfort and less enjoyment in life. Problems with the bladder – both difficulty passing urine or incontinence – the bowel and having sex can be embarrassing and debilitating. Prolapse and bladder problems often co-exist but they aren’t always related.</p>
<p>We don’t know the exact number of women with prolapse. This is because women don’t always come forward because they are embarrassed, but also because studies measure prolapse in different ways – some record symptoms, others actually measure how far your anatomy has dropped from its normal position but which may not always be accompanied by symptoms. </p>
<p>According to <a href="http://www.ncbi.nlm.nih.gov/pubmed/12066091">one large study</a> about 40% of women older than 50 had some degree of prolapse when examined. About 11% of women undergo surgery for urinary incontinence or prolapse in their lifetime, <a href="http://www.ncbi.nlm.nih.gov/pubmed/9083302">and 7%</a> for prolapse alone. In England, <a href="http://www.hscic.gov.uk/hes">about 29,000</a> prolapse repairs were done between 2010 and 2011, at a cost of around £60m.</p>
<p>All of this suggests that the problem is common – but there are things that can be done to help. Pelvic floor exercises have been recommended but evidence of their effectiveness has been limited. But a study we carried out with 447 women suggested that women reported fewer symptoms at six and 12 months if they had been involved in a personalised programme of pelvic floor muscle training than if they had been in the control group.</p>
<h2>Pelvic floor muscles exercises</h2>
<p>You can pull in your pelvic floor muscles by pretending to hold in your wee or stop yourself passing wind. Once located, the muscles can be trained by regularly doing a series of long and short holds. For example, you might squeeze these muscles slowly ten times in a row, then do ten fast squeezes.</p>
<p>The exercises can be built up over time, and in our study we aimed for women to achieve ten long muscle holds for ten seconds, and up to 50 fast contractions three times per day. It does take some time to start to see the effect, but after a couple of months they did start to feel a difference.</p>
<p>Consulting a professional, such as a pelvic floor physiotherapist, as well as giving you the correct exercises, can also help you understand more about the anatomy and function of pelvic floor muscles and the types of prolapse, and offer support. They will perform an internal assessment of the muscles to ensure correct exercise technique and provide an individualised exercise programme.</p>
<h2>Risky business</h2>
<p>There are a number of reasons why women develop a pelvic organ prolapse. The main one is childbirth, which is associated with a higher risk of prolapse in later life. The more children you deliver, the greater the risk. Other obstetric factors could also play a part. Caesarean sections, for example, might be protective compared to vaginal delivery, while the use of instruments such as forceps during the delivery may increase risk. </p>
<p>Women can also have a genetic predisposition to prolapse, and heavy lifting or a physically strenuous occupation can contribute.</p>
<p>Treatments for prolapse include surgery and conservative (non-surgical) management, which includes the pelvic floor exercises, lifestyle changes (such as weight loss), and vaginal pessaries (a support device worn inside the vagina to push the prolapse up to restore normal anatomy).</p>
<p>Choice of treatment depends on the severity of the prolapse and its symptoms, and the woman’s general health and preferences. Conservative treatment is generally considered for women with a mild degree of prolapse, those who wish to have more children, the frail or those unwilling to undergo surgery. These therapies are less expensive, carry lower risk and don’t stop you having further treatment such as surgery later on. It is also the main form of management used to help women with this condition. </p>
<p>While we reported better results for women who’d done exercises in a follow up after a year, we still don’t know whether in the longer term it prevents women from having to go on to surgical procedures. What we do know is how common prolapse is and what could help. It really is nothing to be embarrassed about. </p><img src="https://counter.theconversation.com/content/20977/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Hagen receives funding from the Chief Scientist Office, Scottish Government Health Directorates.</span></em></p>Women who have had children are often advised to do exercises to tighten their pelvic floor muscles. The muscles run from the pubic bone at the front of your body towards the back and help support your…Suzanne Hagen, Programme Director in Nursing and Midwifery, Glasgow Caledonian UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/90972012-09-11T01:38:27Z2012-09-11T01:38:27ZExplainer: what is pelvic organ prolapse?<figure><img src="https://images.theconversation.com/files/15315/original/y34qg4vf-1347327330.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Little is known about pelvic organ prolapse because its symptoms are incredibly embarrassing for women.</span> <span class="attribution"><span class="source">Meghana Kulkarni</span></span></figcaption></figure><p>Millions of Australian women experience a pelvic organ prolapse, but they suffer in silence. This hidden epidemic is a well-kept secret and few people in the rest of the community know anything about the condition.</p>
<p>One in four Australian women have one or more symptoms of pelvic organ prolapse. The most common one is urinary incontinence. Half of all women over 50 who’ve had children will suffer urinary incontinence, mainly because of pelvic organ prolapse. Considering these statistics, three generations of women in a family may potentially be affected at any given time – the new mum, her mum and her grandmother.</p>
<h2>What is it?</h2>
<p>Pelvic organ prolapse is when the muscles and ligaments supporting a woman’s pelvic organs weaken and the organs (bladder, bowel and or uterus) in the area slip out of place (or prolapse) into the vagina. The major cause is vaginal birth, but ageing, heavy lifting, chronic constipation, chronic asthma and obesity exacerbate it. Giving birth by caesarean section doesn’t prevent pelvic organ prolapse or urinary incontinence because pregnancy itself is a major contributor.</p>
<p>Pelvic organ prolapse results from damage to the three support structures of the pelvic organs – the suspensory ligaments, pelvic floor muscles and fibromuscular tissue surrounding the vaginal walls. These support structures are injured by overstretching during pregnancy and tearing during the birthing process. </p>
<p>The nerves that enable the muscles to function can also be damaged in these processes. And using forceps during delivery, prolonged second-stage labour, large infant birth weight and episiotomy (cut to assist delivery) all contribute to the injury sustained during the birthing process as well.</p>
<p>The main symptoms of pelvic organ prolapse are urinary and bowel incontinence, sexual problems and an uncomfortable feeling of bulging in the vaginal area. These symptoms may be experienced during pregnancy, following childbirth or may only manifest many years later, particularly after menopause.</p>
<h2>A secret shame</h2>
<p>The reason so little is known about pelvic organ prolapse in the community is that these symptoms are incredibly embarrassing for women.</p>
<p>No one likes losing control of their bodily functions or discussing it with friends, let alone talking to the general public about it via the media. But the impact of incontinence on the quality of life and daily functioning can be severe. Indeed, it’s comparable to the effects of having a stroke or dementia.</p>
<p>Women suffer anxiety about not being able to get to a toilet when needed, or coughing or sneezing and wetting themselves in public. This can easily lead to social isolation as they retreat from everyday activities to the safety of their own home. (The advent of the smart phone has made life a little easier with “loo locator” applications.)</p>
<h2>Prevention and treatment</h2>
<p>Preventive measures include daily pelvic floor exercises and treatment can range from the use of a pessary (a device inserted into the vagina to support the uterus) to reconstructive surgical repair operations that provide support to vaginal walls, damaged pelvic floor muscles and over-stretched ligaments in more severe cases.</p>
<p>An Australian <a href="http://www.ncbi.nlm.nih.gov/pubmed/20966694">study showed</a> 19% of women in the general population have a lifetime risk of having surgery for pelvic organ prolapse or incontinence. Up to one third of these women will have subsequent operations because of failed surgery.</p>
<p>To improve outcomes, meshes similar to those used in hernia operations have been adapted for repairing damage leading to pelvic organ prolapse. These provide improved support for pelvic organs but they’ve introduced a new set of problems – infection, exposure of the mesh into the vaginal wall, bladder or bowel and shrinkage of the mesh causing pain and painful sex. And they can require another operation to correct. Some companies have recently withdrawn their product from the market because of these unacceptable complications.</p>
<p>Non-permanent biological collagen-containing materials have also been used for pelvic organ prolapse surgery, but these often fail due to their degradation by normal body processes and repeat surgery is required. And, while permanent or non-permanent meshes provide structural support to the pelvic organs, they don’t repair the support structures damaged during pregnancy and childbirth or block the ageing process.</p>
<h2>Steps in a promising direction</h2>
<p>My research group is currently working with urogynaecologists and scientists at CSIRO to develop a tissue-engineering approach to repair the vaginal wall tissues damaged by processes leading to pelvic organ prolapse. Our work focuses on using a woman’s own mesenchymal stem cells (a type of adult stem cell found in bone marrow, fat, and in the uterine lining, which is known as endometrium). Endometrium is a highly regenerative tissue that grows each month and is shed at menstruation.</p>
<p>Mesenchymal stem cells can produce connective tissues cells – fat, bone, cartilage, smooth muscle, and tendon – and have healing properties when transplanted into the human body. They promote blood vessel growth and tissue repair, reduce inflammation, prevent excessive fibrosis, and promote adult stem cells in the body to proliferate and produce new tissue. All these processes help repair injured tissues.</p>
<p>Combining endometrial mesenchymal stem cells with new mesh materials to treat pelvic organ prolapse has the potential to regenerate damaged pelvic tissues and provide a more durable solution for the condition. It’s currently being tested in pre-clinical animal models and is most likely about five years away from being generally available.</p>
<p>This condition should not be suffered in silence and the more awareness raised about this common, but invisible problem, the sooner there will be better solutions available for women. </p><img src="https://counter.theconversation.com/content/9097/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caroline Gargett receives funding from the National Health and Medical Research Council, The CASS Foundation and Monash IVF Research & Education Foundation, and has previously received funding from Australian Stem Cell Centre, Royal Australian and New Zealand College of Obstetricians and Gynaecologists and a variety of philanthropic organisations.</span></em></p>Millions of Australian women experience a pelvic organ prolapse, but they suffer in silence. This hidden epidemic is a well-kept secret and few people in the rest of the community know anything about the…Caroline Gargett, Deputy Director of The Ritchie Centre and head of Women's Health Theme at Monash Institute of Medical Research, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.