June 2020
I attended a live interview with Dr. Sinead Dufour, Pelvic Floor Physiotherapist and co-author of the April 2020 Society of Obstetricians and Gynecologists of Canada (SOGC) updated guidelines for the treatment of urinary incontinence in women. She was accompanied by Dr. Carolyn Best, a Urogynecologist. These new guidelines are ground breaking because they emphasize conservative care, as opposed to non-conservative and more invasive interventions such as testing, surgery and medications. The guidelines address the treatment of the three most common types of incontinence: stress incontinence (leaking urine with exertion, sneezing or coughing), urge incontinence (leakage occurs with the urgent need to urinate), and mixed incontinence (a combination of stress and urge incontinence).
Dr. Dufour discussed the good evidence for conservative measures such as lifestyle modifications, which can include weight loss and dietary changes. Obesity, gut inflammation, constipation and caffeine intake can contribute to incontinence. Other interventions such as bladder training and pessaries (a soft, removable device designed for temporary use that is placed in the vagina to support the bladder and urethra) are also effective. The guidelines recommend that these measures are tried and exhausted before non-conservative treatment is considered.
The guidelines detail a comprehensive history and physical examination as a necessary first step in treatment. This serves to identify possible medical causes for incontinence that need to be addressed, or more complicated cases that warrant a different approach and/or specialized testing.
An important element of the new guidelines is the acknowledgement of the pelvic floor physiotherapist’s role. Pelvic floor physiotherapists can assess the functioning of the pelvic floor and tailor a pelvic floor muscle training (PFMT) program to a woman’s needs; be it for increased strength, endurance, power and/or relaxation. Research has shown that individualized and supervised PFMT is most effective, as opposed to generic, self-directed PFMT. The guidelines acknowledge that access to specialized pelvic floor physiotherapy is limited, and knowledge about PFMT needs to be improved among other health providers such as physicians, nurses, midwives, and physiotherapists. The guidelines explicitly state that “providing the patient with verbal instruction and written handouts does not constitute evidence-based PFMT” (p.510). In her teaching role at McMaster University, Dr. Dufour teaches family physicians how to assess pelvic floor strength. This knowledge alone helps health care providers identify whether there is too much tension or weakness in the pelvic floor which would indicate a referral for pelvic floor physiotherapy and PFMT.
Dr. Best explained that some women wait 1.5 years to see her after a referral is made. She sends a letter to the referring family physician recommending the patient be referred to a pelvic floor physiotherapist. This has been an effective way to reduce her waiting list because some of the women are successfully treated and never need to see her.
If something is not right with your pelvic floor, please see your physician to determine other possible causes for your symptoms. If the problem is muscular, or your physician is not sure, you can request a referral to a pelvic floor physiotherapist. (You can self-refer, but a physician’s referral will be required for private insurance). If you wish to self-refer, or your physician does not have a preferred provider, the Ontario College of Physiotherapists has a list of members and you can search by area of practice, giving you the option of choosing a physiotherapist by location, language, years of experience or other factors.
After years of suffering with a pelvic floor issue, I learned about pelvic floor physiotherapy in a Yoga for Pelvic Health course. I asked my family physician for a referral to the pelvic floor PT of my choice, and the rest is history! Now I use yoga to maintain the improvements in my pelvic floor functioning and help other women do the same.
I’m glad to see the new guidelines moving away from invasive therapy. Women need to be empowered with knowledge about their pelvic floor. It’s better for them and the health care system also benefits. Canada has a long way to go to catch up to countries like the U.K., France and Australia which provide pelvic floor physiotherapy to women pre and post-partum. The National Health Service (NHS) in the U.K. won’t cover bladder surgery until a pelvic floor physiotherapy assessment has been done. My hope is that governments will heed the evidence presented in these guidelines and provide OHIP coverage for pelvic floor physiotherapy.
References:
Dufour, Sinéad, Maria Wu. “Conservative Care of Urinary Incontinence in Women”, Journal of Obstetrics and Gynaecology of Ontario. Vol. 42, Issue 4, 2020, pp. 510-522. https://doi.org/10.1016/j.jogc.2019.04.009 Accessed June 26 2020.
Dufour, Sinéad and Carolyn Best. “New Guidelines for Urinary Incontinence”, Pelvic Health Professionals Guest Speakers, 27 May 2020.
Vandyken, Carolyn. “Biopsychosocial Model and Persistent Pain”, Pelvic Health Professionals Guest Speaker, 12 Dec 2019.
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