Physiotherapist Lana MacDonald has been giving people instructions for physiotherapy exercises behind closed doors recently.
She has private, locked rooms at the brand new Reactive Health building in Stratford, P.E.I., where she examines and instructs people how to better use their pelvic floor muscles. Most of the exam involves a thorough questionnaire and demonstration of what the pelvic floor is and does.
And about 10 minutes of the one-hour pelvic health appointment is an internal exam.
"Imagine you're holding a blueberry at the opening of your vagina, then gradually squeeze upwards, like you're lifting it up to the top — like an elevator," she instructs patients, while gently tapping her fingers inside a patient to facilitate the pelvic floor muscles' contractions.
"You'll never look at blueberries the same again!" she says with a laugh.
Urinary incontinence is the top reason people, mostly women, seek pelvic floor help. For many, that means peeing a little, or a lot, when sneezing suddenly, coughing hard or laughing.
It's funny, but not really funny.
Stress incontinence is very common, especially in people who have carried and delivered babies. Some people can't run or jump without leaking. They need to strengthen their pelvic floor, which is like a hammock of muscles holding the uterus, bladder, etc. in place, and train it to activate more quickly.
Also very common is urge incontinence, where people feel a strong urge to pee many times in a day. This affects their day-to-day life, as they may need to always be close to a washroom.
Some people have pelvic pain or pressure because of organ prolapse, where the bladder, uterus or rectum collapse into the vaginal canal, sometimes protruding outside the body.
Pregnant people are coming for pelvic health wellness checks before and after a baby's birth.
Our objective is to avoid surgical intervention, if at all possible. And I would say in most cases we can. — Lana MacDonald
"Our role as a pelvic floor therapist is first to identify [what the problem is] ... we explain and educate them about it, then we train them how to use their pelvic floor muscles to help give those organs a little more support," she said.
MacDonald has been specializing in pelvic floor health for the last three years, as more specialized training became available to physiotherapists in the Atlantic region. It's now her full-time job, and she's very busy.
"[I] noticed that there was a gap in our profession, and in the area of obstetrics and gynecology, for women that were struggling with issues that probably could be helped by us and not necessarily have to go see a specialist if they didn't need to, considering that wait lists are so long for those visits," she said.
"It's conservative management ... our objective is to avoid surgical intervention, if at all possible. And I would say in most cases we can."
'It was frustrating'
Other physiotherapists on P.E.I. are taking the advanced training too — there are at least seven qualified right now, MacDonald said.
Paige Martin in Cornwall is one of them.
She had started treating Island women for pelvic health issues in 2018 after taking additional training, but found her wait list was getting long, as did other physiotherapists.
"It was frustrating as a woman to see other women in pain or with incontinence, waiting months on end to see somebody," Martin said. While on maternity leave with her second child, she decided to open her own women's health clinic, P.E.I. Pelvic and Breast Health, and since June she has dedicated full-time hours to that.
She sees women of all ages, from 18 to 80, who are "leaking" but most are of childbearing years or are menopausal or post-menopausal.
Why does the pelvic floor need to be retrained — why doesn't it just work? Hormonal changes can affect it, as can trauma such as childbirth. Even life stress can cause tension in the pelvic floor and interfere with its function, Martin said.
"I think prevention is the key to success in health care," Martin said. "I am encouraging women now to see a pelvic floor physiotherapist, whether it's myself or somebody else."
Besides dementia, incontinence is a major reason why people with vaginas are admitted to long-term care, Martin said.
"So if we can intervene earlier, preventatively, that would really help the long-term cost to our health care system and quality of life for our senior women," she said.
'A very big ego boost'
Both MacDonald and Martin say the response has been positive from the public and health-care system. Nurse practitioners and some family doctors are becoming more aware they can refer patients to a pelvic health physiotherapist before, or as well as, a gynecologist.
"By the time the women get in to see a specialist, sometimes it's one to two years' wait," said MacDonald. "They really should be seeing us before they get to that point."
"I really wasn't anticipating it being this busy," Martin said of her nascent practice. She's already planning to hire more specialized physiotherapists.
More people are talking more openly about incontinence or pelvic pain, which is driving awareness and willingness to seek help. In fact, MacDonald said most of the women who come to her have heard of her by word of mouth, from friends.
"It's a very big ego boost, I love it," said Martin of helping women who have been suffering silently. "It's very rewarding for me, because they are exceptionally happy — they feel that their quality of life has improved, they feel as though they can be more socially interactive, they don't have to worry about finding a toilet ... or limit their fluid intake."
"It's huge, because it's all these internal stressers that women are burdened with — it doesn't have to be their new normal," Martin said.
Martin and MacDonald say they'd like to see a future where pelvic health education and care is more readily and cheaply available to everyone. A one-hour session costs about $120-$150, and usually several sessions are needed. If you have insurance, a $500 per year stipend for physiotherapy can be eaten up quickly.
"I want it to be the new norm. I would love to see in our future in Canada that it is part of our public health care and women don't have to dig into their private insurance or private pocketbooks," Martin said.
"I see it as preventative medicine."
MacDonald has been working on a low-cost introduction to pre- and post-natal health, collaborating with a registered massage therapist, a social worker, a dietitian and certified personal trainer with special training in pre/post-pregnancy fitness. They charge $25 for a two-hour seminar "to make it financially feasible for those women who just cannot attend these services privately," she said. They've held two such session so far, and plan another in November.
"We still have a lot of education to do," she said, noting she talks to groups including P.E.I.'s nurse practitioners to educate them about what she and other pelvic health physiotherapists do.
Some people are nervous about the internal exam. MacDonald said it is preferable but not 100 per cent necessary, if people are opposed. (She can feel some of what she needs to externally.)
"It's just a group of muscles! Is really how we look at it," MacDonald said.
She sends patients off with a sheet outlining a series of pelvic floor exercises — their homework for the next month or so, different depending on the problem. MacDonald said in people with stress incontinence, if they do their work their leaking usually stops within three months or less.