Ep 331 - Pelvic Organ Prolapse:"I Have a Client Who . . ."Pathology Conversations with Ruth Werner

0:00:01.4 Ruth Werner: Hello, I Have a Client Who listeners. Ruth Werner here, and I'm so excited to let you know that my library of online self-paced continuing education courses has just expanded. I now have a two-hour ethics course called, "A Doctor's note is not good enough, and what is better?" This NCBTMB, approved course goes into why a doctor's permission or approval or even a prescription doesn't provide the legal or safety protection you might think it does. Then we look at how to start useful conversations with healthcare providers that will actually get us to safe and effective massage for our clients with complex conditions. Visit my website at Ruthwerner.com for more information and to register for A Doctor's Note is Not Good Enough, and what is better?

0:00:52.1 Speaker 2: Introducing Back Jam, held online the first four Mondays in May 2023 and hosted by The Massage Mentor Institute. This is the fourth event in a series of workshops focused on a single region of the body. We've gathered the following industry leaders, Til Luchau, James Waslaski, Tom Myers, Diane Lee, Paul Kelly, Sue Hitzmann, Whitney Lowe, Aubrey and Allison Gowing, Allison Denney, Judith Aston, Benny Vaughn, Heath and Nicole Reed, and Ruth Werner. Sign up for the Back Jam, sponsored by abmp@themassagementorinstitute.com.

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0:01:43.3 RW: Hi, and welcome to I Have a Client Who, Pathology Conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice. And sometimes as we have all learned, that is harder than it looks. This episode is a little bit complicated and it brings up some scope of practice issues that might be a little iffy, and this is a great example of a situation where massage therapy might be helpful to the person living with the condition, but it is not a central answer to the problem.

0:02:46.9 RW: Before we start, I'd like to invite you to imagine something with me. And this applies to people assigned female at birth or assigned male at birth, but it is a bigger problem with females. So wherever you fall on that spectrum, imagine if you would please standing up and jumping or lifting something heavy or if you're like me, maybe coughing. Excuse me. And when you do this, you suddenly feel pressure and instability in your insides, like maybe your pelvic organs, the colon for guys, and any combination of the colon or uterus or bladder for women. All of that pushing hard against any weak spots or openings in the pelvic floor. And now I want you to take a deep breath and fight against it, contract every muscle that might help you to keep yourself together. Yes, your pelvic floor is contracting, but what else are you contracting. Your adductors, your glutes, your lower abdominals, and now think about having to do this all the time. Every day. Yikes, right?

0:04:02.5 RW: So here is today's story. Hi Ruth, how about an episode on how to support a client dealing with multiple pelvic organ prolapse while staying within a massage therapist's scope of practice. This client is 39, she's a mother of three. The youngest is five. She's had normal pregnancies and births, she's generally healthy and active, and while trying to get more physical activity after Covid shutdowns with strength training and yoga and running, she would end up tweaking her back every time for no apparent reason. She also started to feel the prolapse and went to her gynecologist. Her diagnosis was all three, her bladder, uterus, and colon are pro-lapsing with a pronounced rectocele present and not sure of a cystocele. Her first gynecologist has suggested surgery including hysterectomy with a mesh or sling.

0:05:00.7 RW: She is pursuing a second opinion and pelvic physical therapy sessions, but she's very frustrated that her body seems to be failing her. Much of my work with her seems to be helping her feel comfortable in her body and to help relax the muscles that are heavily over-compensating to help her feel confident that nothing will fall out. I'm working with her glutes, adductors, hamstrings and hip flexors, especially. Wow, so imagine feeling like your insides are falling out your bottom, because that is essentially what this person is dealing with. And okay, if you haven't relaxed yet, go ahead and let go of all those supportive muscles. Pelvic organ prolapse or POP, which is perhaps an unfortunate acronym, turns out to be a really common condition in people who were assigned female at birth, but there's a version for males as well.

0:05:58.8 RW: Some version of pelvic floor problems will affect about 25% of all women in their 40s and 30% of women in their 60s and up to half of all women in their 80s, but it's something we don't often talk about because it might involve problems with peeing, or problems with pooping, or problems with, biggest gasp of all, having pain-free sex. So, nice people don't talk about this, not even to their doctors, and that's a pity because there are a whole bunch of possible ways to treat this. So let's talk about pelvic organ prolapse, and to do this, I wanna give a shout out of appreciation to the office on women's health at womenshealth.gov, because their page on POP was clear, non-scary, extremely informative. This is exactly the kind of resource that might really help some clients who are wondering what in the world is happening to them.

0:07:02.7 RW: The basic factor in POP is weakening of the pelvic floor, and when this happens, and we'll get to possible contributors in a minute, when this happens the pelvic organs, which include the uterus and the bladder, and the colon in females, and just the colon in males, can drop down and maybe press through an opening. In men, this would be the anus, but in a women we're usually talking about the vagina. If you remember learning about hernias, remember an inguinal hernia at the inguinal ring, or maybe if the rectus abdominis splits or a hiatal hernia at those holes in the diaphragm. Well, this is essentially the same process, but the weak spot here is an opening in the pelvic floor. And guess what, there are a few different things that can go wrong with this complex of muscles and connective tissue. POP is one of a group of problems called pelvic floor disorders.

0:08:01.3 RW: Other pelvic floor disorders include urinary incontinence and fecal incontinence, and it is absolutely 100% possible for a person to have more than one type of pelvic floor disorder at any given time. With the label of POP specifically, there are some subtypes. When the bladder presses through, this is called cystocele, cyst means hollow organ and cele, spelled, C-E-L-E means a swelling or tumor or hernia. Cystocele is the most common type of pelvic organ prolapse. So now you can figure out what rectocele means, right? This is when the rectum, the collecting area at the distal end of the colon, bulges into the vagina. And the third subtype involves the uterus itself dropping down into the vagina. Sometimes this might also carry along a section of small intestine, which is called enterocele, entero refers to intestines.

0:09:01.6 RW: Pelvic floor dysfunction of one kind or another is really common, POP itself is less so, but it still affects about 3% of all women in the United States. Just about any adult can develop pelvic organ prolapse, but it is seen most often in people assigned female at birth, who have given birth vaginally and who are middle-aged or older. That said, it can happen for people who have had only C-section births, and the patient in today's story is only 39, definitely younger than the norm. Other contributors include being over 50, having a chronic cough. Oh, good. Here's another condition, I will make myself believe that I have. Also being overweight or having chronic constipation that causes straining during defecation. The hormonal changes that happen during menopause can help to weaken the connective tissue in the pelvic floor, so that is an issue too.

0:10:00.1 RW: And anyone with a connective tissue problem like Ehlers-Danlos syndrome or a handful of other similar disorders is going to have an increased risk for this to happen. How does the person know when there's a problem? Well, this condition doesn't have to be painful, it can cause a lot of disruptions. Women with pelvic organ prolapse may feel uncomfortable pressure during exercise or discomfort during sex, or it may be really hard to insert a tampon. They may feel or see a bulge from the vagina along with a feeling of fullness or pain or aching in the pelvis. It often gets worse as the day goes on, especially if the person is on their feet. Coughing or sneezing or having to lift heavy things can make it worse, and other signs of pelvic dysfunction, like urinary leaking or problems with bowel movements may develop too.

0:10:53.5 RW: The good news about POP is that there are about a bazillion treatment options. However, a lot of them are pretty invasive, but we start with diet, especially to counteract constipation and exercise to lose weight and quitting smoking because coughing makes this worse. Pelvic floor PT might be helpful too. And this is what the client in today's story wants to pursue. And if that all isn't sufficient, then a pessary, which is usually some kind of a circular or ring-shaped device made of silicone, can be inserted into the vagina to provide extra support. And if none of these improve the situation, then several different kinds of surgery have been developed, ranging from the insertion of a mesh sling to reshaping the vagina in various ways. By the way, this is not the same procedure as vaginal plasty that is meant to tighten the walls of the vagina.

0:11:51.2 RW: And there are also procedures to create new strong connections between the uterus and other pelvic structures like the sacrum or some ligaments, so it doesn't hang down into the vagina. And if the person is post-menopausal and doesn't plan on ever having penetrative sex again, then colpocleisis is a procedure that permanently closes the vagina. Can massage fix pelvic organ prolapse? Nope. Nowhere close. Can our work help to reduce the herniation of the colon or uterus or bladder? Not if we're staying within our scope of practice. To my knowledge, no massage law in this country allows manual therapy of the pelvic floor by massage therapists. So trying to move pelvic contents out of the vagina and back into place, not our call. But can our work improve the quality of life of clients who are living with this challenge? Sure.

0:12:48.8 RW: Remember the client in our story today is feeling so let down by her body. She's a healthy 39-year-old, she wants to be more active and what happens? Her insides are threatening to fall out. I can only imagine what this must be like. And one of the things I imagine is that it must be pretty hard for her to have a loving, appreciative relationship with her body, and that is one place massage therapy might help. Even if it's only for an hour once a week or however often, we can provide that oasis where it feels good to be us. I also really appreciate this massage therapist's special focus on those muscles that the client is using to try to maintain pelvic integrity. A lot of that is wasted effort that won't help her with those goals, but that can interfere with her fatigue and her quality of life.

0:13:45.0 RW: This client has some thoughts about how she wants to treat her situation, which is great, and it's really great that she even brought it up with her OB-GYN. I read one doctor's blog about this, in which she said that some of her patients were too embarrassed to bring it up with her, and so they pursued plastic surgery to refresh the vaginal walls. This is a procedure which is not risk-free, it costs thousands of dollars out of pocket and it does exactly nothing to address the problem of pelvic organ prolapse. And here's the thing I wanna remind us of, sometimes people share things about their health with their massage therapists that they don't share with their doctors. I bet many of us have had this situation and it can put us in a position to give some good advice, for instance, you don't have to put up with this and it could continue to get worse, and there are some good solutions. So please go see your OB and let them know what's going on.

0:14:48.1 RW: I know it sounds really easy to tell our clients to go see their doctors, and it's harder for them to actually do that, and I've even had a few I Have a Client Who stories come to me specifically about this kind of obstacle, but sometimes the situation has so much impact on a person's quality of life, and maybe all they need is a little nudge from a trusted provider, that's us. To help them feel like they deserve to feel better and to pursue ways to do that. Hey everybody, thanks for listening to I Have a Client Who, Pathology Conversations with Ruth Werner. Remember, you can send me your I Have a Client Who stories to ihaveaclientwho@abmp.com. That's I Have a Client Who all one word, all lowercase @ A-B-M-P dot com. I can't wait to see what you send me and I'll see you next time.

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