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Having pelvic health problems presents patients with a dilemma.

“Do I fess up to a complete stranger that I am having problems with bladder, bowel and prolapse or do I continue to suffer with shame and in silence?”

Hopefully, with better awareness via social media channels and other communication modes, the word is getting out that pelvic health physios are well equipped to effectively treat these most private conditions.

But a common problem which is tricky to treat is when anxiety escalates the sensations that women are feeling and perhaps trick the brain into panic mode about their condition.

Photo of my book The User’s Guide to the Human Mind by Shawn T Smith 

Years ago I read a book called The User’s Guide to the Human Mind: (Why our brains make us unhappy, anxious and neurotic and what we can do about it) by Shawn T. Smith which helped me understand the impact of anxiety on my patients. It’s a great little book with practical advice and patient examples to clarify explanations.

Anxiety plays a huge part when patients have overactive bladder symptoms (bladder urgency or urge leakage), faecal incontinence (gas or bowel motion incontinence), vaginal prolapse or persistent pain conditions (dyspareunia -painful sexual intercourse; vulvodynia; endometriosis; anal pain) and we know that the stress hormones released with anxiety may make all these conditions worse.

In the book, Smith talks about the mind giving us things we don’t want – thoughts, feelings, memories, anxieties, moods and even physical sensations like a pounding heart or sweaty armpits. Sometimes it happens out of the blue.

Other times the mind goes into a tailspin because we have dragged it into a situation it hoped to avoid like a first date when rejection is a real possibility or something which is a common fear among humans: public speaking.

Other animals don’t posses this fear simply because they don’t make speeches. For all of you out there who are dog vs cat people (and it is a very definite love hate thing this: ‘I love dogs, no I love cats’), he makes a funny observation that dogs being pack animals would probably suffer public-speaking anxiety because placing themselves in the spotlight might affect their standing in the pack.

A poorly executed presentation on begging for table scraps could lead the other dogs to question the speaker’s competence. That could snowball into ostracism.

Cats being more solitary could probably deliver a speech with the confidence that arises from a complete disregard for social acceptance. (page 14,15)


Meme from Instagram

He goes through examples of irrational thinking – while he uses the example of public speaking we could just as easily substitute some of the conditions I treat every day: bladder urgency and leakage or the overactive bladder (OAB), faecal incontinence (FI); vaginal prolapse; painful intercourse. Let’s try and use his explanations for each of the categories.

All or none thinking ‘If I fail (which I must not do) at retrying sexual intimacy, then I am not worthy of love or respect’ .
Catastrophizing ‘I had my first faecal incontinence episode at those shops, I can’t face going there again’.
Focusing on the negative – ‘Because it is unacceptable for my bladder to misbehave and it often misbehaves my life is no good.
Disqualifying the positive – ‘When he says I look beautiful he is only being kind, I am really overweight and ugly’.
Minimisation – (I’ll bring it back to the giving a speech example): ‘If the speech goes well, it’s due to luck, if it goes poorly it’s because I’m completely incompetent’ .
Personalisation– ‘Everybody is looking at me, I must have soiled and there’s an odour’.

Once identified and put into words, evidence can shoot down irrational logic.

If all goes well, the mind backs down, as we realise thoughts don’t match reality. But the problem is an anxious mind doesn’t calmly defer to logic. (p17)

Smith reminds us how busy the mind can be, buzzing along at 500 thoughts per hour. Many people with busy minds would agree that it would be nice to walk away from the mind’s chatter. Tibetan monks talk about monkey thoughts. When these thoughts and this chatter becomes overwhelming, breath awareness……the good old belly breaths are good for calming things down.

Anxiety can be useful though – if you are in a dangerous situation then the body responses from anxiety can cause you to avoid that situation. Athletes can benefit from moderate levels of anxiety to improve performance, but problems happen when the mind tries to save our lives, when our lives really aren’t at stake. In large doses, anxiety (and depression) can be debilitating.

Another important thing to remember is thoughts are not facts.

Smith reminds us that thoughts are reasonably accurate representations of the world, but they can often be misleading and inaccurate. Even when the thoughts are accompanied by strong emotions, which can strengthen the illusion of credibility, the thought remains merely a thought.

Emotions do not turn thoughts into facts. (p40). Emotions tend to come with strong physical symptoms. Racing hearts, restless bladders, hair standing on end – we have no control over these experiences than the emotions that spawn them. (p44)

Psychologist Marsha Linehan suggests a useful exercise is to describe the emotional responses in words. For example someone experiencing fear before an exam might say: “I’m noticing my mouth is dry and my heart is beating fast” as opposed to “I’m going to fail my test, get kicked out of school and lose all my friends”. 

Applying this theory to say someone having repeatedly painful sex due to vulvodynia : “I feel my heart is racing, my legs and pelvic floor are gripping and I can’t breathe properly”.  This would allow them to identify the problem areas and concentrate on relaxing their adductor (inner thigh), abdominal and pelvic floor muscles and invoke some belly breathing, while visualising a comforting scene such as the rolling waves at the beach.

This may stave off the wave of anxiety, the release of cortisol and adrenaline and enable them to recognise what is happening for what it is. A combination of factors: memory  (failed experiences at pain-free intercourse); getting more ‘practised’ at this anxious response to the same situation and a non-relaxing pelvic floor.

Image of my book Teach Us to Sit Still by Tim Parks

In the book ‘Teach us to Sit Still’ by Tim Parks this sentence hit home powerfully with me when he said (p42) “It was true that my body and I weren’t the best of friends these days; we hardly communicated except through pain”. 

I think this is a common feature of persistent or chronic pain patients:  assessing what is really going on with their body, what caused that violent response, that unpredictable response – is hard because the only time these patients listen to their body is when there is a pain response. Not only are they not communicating well with their body, their brain gets better and better at producing the pain.

Increasingly I am encountering patients with profound anxiety about their level of prolapse. Anxiety about prolapse can be paralysing for women because it impacts on important things that they do in their life: playing with their children, exercising for fitness or jumping to help bone density.

If they are thinking about and constantly assessing their prolapse every day, this hypervigilance can exaggerate the representation of their prolapse on their sensory brain map, which further heightens their prolapse symptoms. Touching and feeling the area to assess the level of prolapse – even with a pessary, does this. As your thoughts tumble around, more cortisol and adrenaline worsens the sensations. Little can be said to placate the anxious mind. Even objective measurements cannot help.

What I related to with my patients and their pain issues, their overactive bladder issues, their belief about the stage their prolapse is sitting at or their faecal incontinence issue – is the belief that they cannot move forward until their thoughts and emotions are in order.

They are feeling stuck until their minds are under control. With unruly, over-protective minds, patients can spend a lifetime waiting until they feel they are ready to act or believe. (p49)

The book is full of gems of information and practical examples – I would recommend it to you to read to better understand the grip anxiety can have over you.

And to finish on a great quote from another book called The Alchemist by Paul Coelho:

‘The secret of life is to fall seven times and get up eight times.’
So no matter how compelling the sense of failure, incompetence or rejection may be, dust yourself off and get up and have a sense of self-belief and get on with “living the shit out of life” (Rob Cook – he broke his neck in a helicopter accident in 2009 and is confined to a wheelchair ever since.)

A great motto for 2022!