Going public

Hearing patients say ‘but isn’t this normal?’ when discussing their incontinence issues is something Tarryn Lawrence, APAM, experiences regularly.

Working in an advanced role in the women’s, men’s and pelvic health physiotherapy service at Logan Hospital, Tarryn often challenges long-held perceptions that urinary incontinence is normal, and that the problem can only be corrected with surgery. It is her job—and her passion—to show patients how physiotherapy interventions can help them achieve their goal of becoming dry.

‘Overwhelmingly, I see people who have been experiencing incontinence for a long time. Sometimes, I’ll see a woman who is in her 60s who has had incontinence since she had her babies when she was in her 20s—so she’s been dealing with it for decades,’ Tarryn says.

‘They’ll say “I thought that because I’ve had a baby this was just a normal part of life now”. I think that is why a lot of people hold off on getting help until they reach a point where it is really impacting on their lives.

‘Where I work, our referrers are really on the ball. As soon as someone mentions they have incontinence they’re referred straight to us … in the community there are lots of barriers such as cost of seeing someone if they’re not able to go publicly, and potentially their referrer not knowing that physio is a good evidence- based option for management of incontinence.’

The primary contact Pelvic Health Clinic at Logan Hospital services patients referred by a GP, doctor or midwife or who come from the hospital’sgynaecology, urology and colorectal surgery waitlists. These patients are aged from 16 all the way through to men and women in their 80s and 90s who are experiencing incontinence issues.

Men are put in contact with the service usually after they’ve hadtheir prostate removal surgery for prostate cancer, while the acute women’s arm of the service sees the perinatal and postnatal population. Many patients have little understanding of the role physiotherapy can play in treating their incontinence and are often unsure how a physio can help them, Tarryn says.

‘A huge part of what we do is education, because not all urinary incontinence is the same, it’s not all caused by the same thing. We do the appropriate in-depth questioning to find out exactly when the incontinence happens, which is important for knowing what your treatment option should be and then what kind of education you’ll provide,’ Tarryn says. ‘If it’s a stress incontinence issue then your advice might be more around exercises…you’d do different things for stress incontinence than you will do for urge incontinence or overflow incontinence.

‘Then in terms of management there’s a lot that we can do from activity-modification advice, from pelvic floor muscle training point of view, from even there are pessaries that can be used to help with continence as well.’

Education also plays a vital role in helping patients know who to see to treat their incontinence, what questions to ask of their treating clinician and what their best treatment options are. For physiotherapists unfamiliar with treating incontinence, this can mean knowing the right questions to ask the patient or client before you, and then taking appropriate steps to follow up and refer on when necessary.

‘It’s not as scary as it first seems. Often it’s part of the questions you’ll ask patients and when they say “oh yes, actually I do have incontinence” it’s knowing what to do and taking that next step and not just saying “oh okay” and writing it down on your assessment form,’ Tarryn says. ‘It is so important to follow up on it because sometimes even just for someone to admit that they’ve got the problem can be a big thing. If you do not feel like you can treat it appropriately then refer onto someone who has some training in incontinence management. Don’t be afraid to ask more questions about it; ask them when it’s a problem for them and get a bit of that background before referring on.’

Tarryn, who is the chair of the APA Women’s, Men’s and Pelvic Health Queensland committee, says she was drawn to work in the area of pelvic health after undertaking her student placement on the maternity ward at the Mater Mothers’ Hospital.

‘I’ve always had a love of this clinical area. You really can make a difference in people’s lives, particularly with incontinence,’ Tarryn says.

‘If you can help someone participate in the exercise that they want to be able to do without leaking, that’s huge. If they love running but they haven’t been able to do it because they leak and you can help them get back to running, that can be life changing.

‘I’ve had patients who have had more of a problem with urinary urgency and urge incontinence where they’ve needed to go to the toilet five times in an hour so they won’t go on that family holiday, they won’t go to that music concert, they won’t go to anything because they’re so worried about having an accident when they’re out. When you can help someone get their life back to normal, that’s really rewarding.’ 

Privately speaking

Most people might know an older man who was once very active, loved heading out to watch their grandchildren play sport or enjoyed playing a round of social golf, and then for no apparent reason began to suddenly withdraw and make excuses to stay at home, says Thomas Harris, APAM, a private practitioner at Target Physio in Brisbane.

This inexplicable departure from normal behaviour may well be a sign of that person experiencing incidents of urinary incontinence.

Men sometimes build a wall of silence around their incontinence issues, Thomas says, and may opt to handle the problem themselves rather than seek treatment. It’s a subject unlikely to find its way into men’s general conversation, and many men who experience incontinence will never discuss it with family or friends. Thomas cites an example of one patient, pre COVID-19, who went to extraordinary lengths to conceal his looming prostatectomy surgery.

‘This man was telling family and friends that he and his wife were going on holidays for a number of months. He basically stopped his wife from shopping locally, instead she was driving about 50 minutes away to shop. They were isolating at home well before isolating at home was happening,’ Thomas says.

‘He didn’t want anyone to know. He was extremely fearful of what his outcome was going to be incontinence- wise, so instead he was telling everyone they were going overseas. And his wife eventually said “this is stupid, I don’t care if you tell everyone that I’ve been unwell but I’m going to see my sister and have coffee.” But that was his way of dealing with it.’

Having worked with a lot of incontinent men, particularly those diagnosed with prostate cancer and who have gone on to have a prostatectomy, Thomas says addressing the physical aspects of the condition are as important as the emotional ones. Prostate cancer is the most commonly diagnosed cancer in men, and those undergoing radical prostatectomy can experience severe urinary leakage for some time afterwards. Many patients are simply not physically and emotionally prepared for this outcome, find it highly distressing and, as a result, may employ poor coping mechanisms, Thomas says.

‘There’s still this widely held conception that men don’t leak. It’s a fallacy to say that because men don’t give birth they don’t have incontinence issues and they don’t really need to worry about pelvic floor training. But we know that in the general community, men still experience incontinence, even those who haven’t had prostate surgery,’ Thomas says.

‘When they do experience urinary incontinence they either don’t want to talk about it or they try to ignore it. Often they will say to me things like “Oh if I’d known that something could have been done, I would have done something earlier.” And a lot of men are not searching for help on the internet because they’d rather just find ways to hide the problem themselves.’

Thomas says getting pre-prostatectomy patients onto a pelvic floor muscle exercise program as soon as possible prior to surgery can have a big impact on the level of incontinence experienced post-surgery. He says a trial by Jo Milios (see article page 36) showed that pre- and postoperative pelvic floor muscle training at the right intensity and frequency had produced positive results in patients becoming drier sooner.

Urologists sparing a bit more urethra during surgery as well as a more collegiate approach by allied healthcare professionals around the patient in the early stages of diagnosis were also having a more positive impact on urinary continence in this patient cohort, he says. 

‘Typically, I consult with these men before their surgery and help with the education and pelvic floor training side of things,’ Thomas says. ‘In conjunction with that is helping them deal with the emotional and physical fallout that occurs when they are incontinent. Particularly if they come out [of surgery] worse than they expected. Then it’s all about offering support and reassurance, as well as encouraging training, training and more training. And then implementing a few other different strategies along the way.’

He says physiotherapists can significantly help people experiencing urinary incontinence, and a good outcome for patients is something Thomas finds extremely rewarding. Challenges arising from the COVID-19 pandemic have seen Thomas and many other practitioners turn to telehealth as a solution; the online application was helpful in maintaining continuity of treatment with most of his patient cohort, Thomas says.

‘Telehealth is capable of helping out the blokes in the bush in terms of online capabilities. It’s something we need to keep working more towards and try to get a bit more education on, particularly for rural GPs and specialists. Online telehealth is definitely an option for these blokes, it’s far better than them being told to look things up on YouTube,’ Thomas says.

‘I usually ask them “have you YouTubed the male pelvic floor?’ and typically they have encountered some American guy that’s had two million views on YouTube with terribly outdated information. It is important to keep reminding them that the longer something’s been on YouTube the more views it gets and the more it goes to the top of the list. It’s going to take years for the new stuff to get to the top of the list.’

Recently Thomas featured in a webinar about urinary incontinence that was produced for the Prostate Cancer Foundation of Australia (pcfa.org.au). The webinar featured Thomas, a general practitioner, a urologist and a prostate cancer nurse being interviewed by a newsreader specifically for men diagnosed with prostate cancer and their partners. On behalf of the Movember Foundation, a supporter of the Prostate Cancer Foundation of Australia, Thomas also gave a talk to Genie Health Solutions, which runs software packages for urologists, on his experiences with men clinically.

Thomas also regularly speaks to members of many service club meetings such as Rotary, the Lion’s Club and Men’s Shed about urinary incontinence.

‘I think we are slowly getting more awareness. In my experience with these patients, they don’t like jargon. Recently I provided an online lecture for Griffith University and during that lecture I highlighted that in terms of communicating with men, you let them lead with whatever language they want to use. If we’re talking and they call their penis their “old fella”, I’ll do the same. If they want to use “penis”, I’ll use “penis” or any other random nickname—and I’ve heard a lot over the years.’

The lessons learned

In many rural and regional parts of the country, where time often seems at a standstill, 10 years have seen a huge change in the ability of patients to access physiotherapy services for pelvic health issues in at least one area, Orange, in the central west of New South Wales. It is here that Charles Sturt University lecturer Kerstin McPherson, APAM, has seen an uptake of physiotherapists treating patients for pelvic health complaints, urinary incontinence among them, in the last decade.

‘Maybe 10 years ago there were very, very few physios who had the experience or the desire to work in this area. And if you look just over the last 10 years, the clinicians have upskilled in the area,’ Kerstin says. ‘Even though there are a lot of patients with need, there’s also a lot of physios who are really taking to this area of practice. Clinical practice has really changed.’ 

Kerstin is completing a PhD with Dr Irmina Nahon and Professor Gordon Waddington at the University of Canberra, and as part of that she is exploring the physiotherapy curriculum design around women’s, men’s and pelvic health physiotherapy for entry-level physiotherapists at Australian universities.

‘It’s quite interesting, because, when you design a physiotherapy course there’s no set guidelines saying you must cover this, you must cover that in this area of physiotherapy. There’s all the Physiotherapy Practice Thresholds to guide the curriculum but it doesn’t cover exact content,’ Kerstin says.

‘Different universities do different things in terms of covering content, so it’s about making sure students have got some anatomy knowledge, that they know where the pelvic floor is, how it links to the rest of the body and what incontinence is. They may not be able to treat it, as they need more postgraduate skills, but knowing what it is, is really important. And I think if we can get students interested in the area and establish guidelines for what universities should cover, then that will set the students up for the APA career framework, which is something that I’ve been also been involved with.’

Kerstin says that many students start with little understating that women’s and men’s pelvic health physiotherapy is such a diverse area of practice, and may have a perception or belief that urinary incontinence is an ‘old people thing’.

‘If you talk to students, they’ll say “there’s nothing you can do,” or “I didn’t even know that was an area of practice”,’ Kerstin says.

‘Men’s health is an expanding area of practice, and students are so surprised that this would be an area that physios would do something with, especially in terms of erectile dysfunction. So, it is important to reach all students early to teach them that this is an area where you can have a huge impact and improve people’s quality of life.

‘I think it is important for the students to know that physiotherapists can have a huge impact upon someone’s life by changing their continence.

Having the skills in how to have the conversations and recognising symptoms is important for all physiotherapists so they can refer onwards to physiotherapists with the skills to the manage the conditions,’ she says. 

Why asking one question can be so important

The tremendous impact that incontinence can have on Australians of all backgrounds and ages—and the role that physiotherapy plays in helping to manage both bladder and bowel leakage—are the focus of the Continence Foundation of Australia’s Laugh Without Leaking Campaign, which is supported by the APA.

More than six million Australians report being incontinent of either urine, faeces or flatus or a combination of these three. These symptoms can have a significant impact on quality of life and make simple activities such as going to work, spending time with friends or exercising difficult.

The consequences can be social isolation, embarrassment and increasing morbidity. While these symptoms are common they are not normal, and it is important that people understand how to access suitable help. It is also vital to know that incontinence affects women, men, children and people of indeterminate sex alike—we can’t assume that the 18-year-old male standing in front of us is always continent.

With appropriate training, physiotherapists can offer thorough assessment and management of incontinence via lifestyle measures, pelvic floor muscle training—which has Grade A, Level 1 evidence for improving urinary incontinence—and bladder retraining.  Physiotherapists can also assess and offer modifications to activities that cause incontinence, such as exercise, sexual intercourse and work-related tasks. Physiotherapists work in conjunction with medical specialists, general practitioners, nurses, psychologists, dietitians and occupational therapists (to name a few) in order to improve the lives of people with incontinence every day.

Even during the coronavirus pandemic we are still helping our clients via telehealth, and we can use standardised questionnaires, bladder and bowel diaries, online resources and friendly support to make gains. This increasing utilisation of telehealth will be of great benefit to our rural and remote communities in the future as well, and the APA continues its campaigning of both politicians and health funds to support this.

Ongoing research is necessary for providing answers to incontinence, and it’s great to see physiotherapists involved in this area, particularly with men’s health.

So don’t forget to screen your clients for symptoms of incontinence—it’s as easy as asking ‘do you or have you ever had any issues with controlling your bladder or bowel?’ And then refer on to a women’s and men’s pelvic health physiotherapist.

>> Cath Willis, APA Women’s, Men’s and Pelvic Health Group National Chair