(FROM 2013) Recently my lovely, wise GP and I were having a chat about catastrophising. We are all capable of catastrophising. I see the tendency in many pain patients and those suffering with bladder urgency. It’s easy to do when you are anxious as to whether you are going to cope with a function or outing when you have pain or an extreme feeling of imminent incontinence!
My GP was telling me about an acronym he uses with patients suffering with depression to help work out what may have exacerbated their deterioration with this episode of depression. He uses HALT as a checklist and teaches the patients to assess their state using the same.
H stands for hungry – are they eating properly?
A stands for angry– what is affecting their mood, family, friends, work?
L for lonely – are they connecting with their friends or leaving themselves isolated?
T for tired – are they getting enough sleep?
I thought that was a clever way to have a checklist of triggers for depression and I have kept it in my mind to apply a similar principle to pelvic floor dysfunction. Recently Aleeza Zohar, the Communications Manager at Jean Hailes Foundation, was highlighting the common complaint from GPs that their patients are not very forthcoming with their symptoms of incontinence, or sexual dysfunction or other pelvic floor dysfunction issues because of the embarrassment factor, and asked me what do I do?
Well, patients who come to see me have usually climbed the mountain of despair about their continence state by even making their first appointment to see me and are well and truly ready to ‘spill the beans’ on everything. Patients are usually very happy, and for those with lifetime constipation issues I would say, nigh on excited, when I question them closely about their bowel status and relieved to open up about sexual dysfunction.
But I suddenly thought if GPs could use the idea of an acronym relevent to pelvic health (like my GP uses for his patients with depression) to ensure they remember to ask the important questions at a woman’s PAP smear examination, then perhaps these problems would surface and be addressed earlier.
So my little prompter acronym for GPs to use at the CST / PAP smear is the word PIPES. Somewhat appropriate given what the area looks like anatomically!
P stands for Prolapse. Now if all patients with early vaginal wall laxity were alerted to their slight prolapse then perhaps the conservative interventions would have a far greater chance of reversing and improving vaginal wall descent. Avoiding straining at stool by using the correct position and dynamics for defaecation, softening the bowel motion with soluble fibres or other products, always engaging in pelvic floor friendly exercising (exercises that are prescribed respecting the strength and status of the patients pelvic floor), regular pelvic floor muscle training incorporating functional exercising (such as bridging and superman exercises) and bracing (tightening your pelvic floor muscles prior to increases in intra-abdominal pressure) – these are simple strategies to prevent worsening prolapse.
I stands for Incontinence. By questioning the patient as to whether they leak with cough or sneeze or with the urge to go, or dribble after they have voided or with no apparent provocation at all, will identify which type of incontinence they are suffering from and this will determine the appropriate treatment regime. Stress incontinence (SUI) has been shown in studies to be significantly improved and cured in 60-80% of patients. (1) Urgency and urge incontinence (UUI) responds well to bladder retraining and other lifestyle modifications (such as reducing caffeine and alcohol intake). A post micturition dribble (PMD) or post micturition incontinence is helped by teaching the patient the correct voiding position and abdominal and pelvic floor muscle relaxation.These are simple conservative measures taught by a pelvic health physiotherapist in their first session.
Image of my Explain Pain Book – buy on NOI website
P stands for PAIN. Persistent pelvic pain is seen in many patients attending a GP’s surgery. With a normal GP consultation, where there is only 15 minutes to see the patient, it must be daunting to even think about delving into the question of “Do you have any pelvic / vaginal/ bladder/ bowel pain”. If the patient doesn’t come in specifically with that condition, then why the heck would you go fishing for it? But early interventions with persistent pelvic pain will potentially prevent the pain from getting worse. If left to be untreated for months, years, decades, the patient’s nervous system gets well-practised at producing pain, (central sensitization) and the pain escalates. Pelvic health physiotherapists use a range of strategies, including those based on the Explain Pain model and others to assist the patient to improve their pain condition and not feel so helpless.
E stands for exercise. Now exercise can mean pelvic floor exercises – the bread and butter of a pelvic floor physiotherapist – but as you can see we do far more than teach Kegals these days. But exercise is far more than that. There was an interesting article recently highlighting, that the UK’s Royal College of Physicians has just approved a report ”Exercise for life: Physical activity in health and disease”. The report states: “There is evidence for the benefits of exercise in many forms of disease. It is effective, inexpensive, with a low side-effect profile and can have a positive environmental impact. Despite this, there remains a reluctance within the medical profession to use exercise as a treatment.” (2) So, physiotherapists have a critical role in assisting GPs in this invaluable and essential treatment modality, as do exercise physiologists.
S stands for sex. I’ve learnt over the years never to assume anything about sex. I have patients in their 30’s who can take it, but mostly leave it, and patients in their 80s who are still having a satisfying sexual relationship. And therefore you should always ask the question and never assume someone is too old to be worried about pain or dryness with intercourse or a lack of libido. There is much to be offered to these patients by seeing a pelvic health physiotherapist even if it’s just reassurance that having intercourse is still possible and beneficial.
So the acronym PIPES can be a quick way to evaluate the urogenital status of a woman when having a PAP smear or even at a yearly general health assessment and could be used by any health professional to diagnose the problem and refer the patient on to a pelvic health physiotherapist.
If you want to learn more about your body and specifically the urogenital area then my books are available on my book shop site Pelvic Floor Recovery. (click on the link)
Happy Women’s Health Week
1. Neumann P et al 2005 Physiotherapy for female stress urinary incontinence: a multicentre observational study, Australia and New Zealand Journal of Obstetrics and Gynaecology 45:226-232).
2. (Royal College of Physicians Exercise for life: Physical activity in health and disease. London RCP,2012).