If you pee when you cough or sneeze, you might have a pelvic floor problem

Do you leak pee when you cough, sneeze, laugh or carry something heavy? Do you feel a heaviness "down there", like your insides are falling out? If you do, you might have a problem with your pelvic floor.

And you are not alone.

Specialists at the Singapore General Hospital (SGH) say they are seeing more people, mostly women, seeking help for these problems.

The hospital has a Pelvic Floor Disorders Service, which was set up in 2008 to be a one-stop, multi-disciplinary service, with experts from the fields of colorectal surgery, urology and obstetrics and gynaecology to diagnose and treat patients.

It is organising a free Zoom webinar on Saturday for people who want to find out more about these types of disorders. Already, more than 200 people have registered, and this might reflect changing attitudes towards what used to be an embarrassing problem sufferers rarely wanted to talk about.

Dr Cherylin Fu, director of the service and senior consultant in the hospital's colorectal surgery department, says the service sees about 100 new, and close to 300 follow-up cases, a year on average. The numbers represent a more than threefold increase from 2017.

She says: "The number of people with pelvic floor issues probably hasn't increased, but awareness has, and so has the willingness to seek treatment. And treatment is available.

"Older people are more active and they don't want to be bogged down by issues with incontinence. In the past, they would wear diapers. But nobody wants to do that these days.

"I have also been seeing younger patients, those in their 30s and 40s, in the last couple of years. They come in to check on their symptoms and want to know if they might get worse. People are not as shy as they might have been before."

The pelvic floor muscles run from the pubic bone in the front of the body to the base of the spine at the back. These muscles and ligaments do the important job of supporting the bladder, womb and bowel. They also help people hold their pee and poo, and improve sexual function.

Besides pregnancy and childbirth, other factors such as ageing and obesity can weaken the pelvic floor muscles.

Incontinence is one of the symptoms and so is uterine, bladder or rectal prolapse, when these organs sag and can protrude from the vaginal opening. That accounts for the heavy feeling down there.

Men, too, can have pelvic floor disorders and they make up 10 to 20 per cent of the cases the hospital sees. Their problems are usually to do with a tense pelvic floor, or a small number might suffer rectal prolapse from chronic straining when passing motion, or because of congenital reasons.

But pregnancy and childbirth are the main causes, and SGH says 46 per cent of pregnant women develop pelvic floor dysfunction after giving birth.

Some might have symptoms after childbirth, then develop more serious pelvic floor problems in their late 40s and 50s, when they menopause.

Dr Jason Lim, a senior consultant in the hospital's obstetrics and gynaecology department, says the muscles and ligaments become stretched during childbirth. The muscles recover, but the ligaments do not. Nerves might also become stretched and in the majority of cases, they recover, but for some women, they do not.

He adds that when women get older and menopause, the body produces less and less oestrogen, which he says is crucial for maintaining bulk and tensile strength in the muscles. That is why women shrink in size as they get older.

The earlier a woman starts thinking about the strength of her pelvic floor, the better.

"We have a clinic for post-natal mothers, where we start early rehabilitation of the pelvic floor, within six weeks of childbirth," he says. "If we start rehabilitation early, the rate of recovery is tremendously improved."

Dr Fu says it is never too early for women to do exercises that strengthen their pelvic floor muscles.

The mother of two says: "Women should be aware that once they get pregnant, things might go south. There's no harm doing these exercises from the first trimester. Once the child is delivered, the last thing on your mind is learning something new. You want the exercises to have become a habit."

Together with the exercises, the hospital also offers biofeedback treatment, a painless procedure using a machine with sensors that measure the pressure or contraction of the anal sphincter and pelvic floor muscles and display it as a graph or a diagram on the screen.

Patients can then see if they are engaging the right group of anal and pelvic floor muscles during the therapy and if they are contracting or relaxing the muscles adequately.

For patients with serious symptoms that conservative measures such as these cannot solve, there are other treatments.

Dr Lim says older patients with uterine prolapse, who may not be good candidates for surgery, might consider having a doughnut-shaped silicone ring inserted into the vagina, like a tampon, to hold the uterus in place.

"It acts as mechanical support and doesn't interfere with the patient's sex life. It has become quite popular. We do the insertion in the clinic, it's a 10-second job."

Surgery as an Option

There are also surgical solutions.

Dr Fu gives the example of rectopexy, for patients with prolapsed rectums. It involves pulling up the rectum and fixing it to the spine to prevent it from prolapsing again.

One of her patients, a 65-year-old, had this procedure done in 2018. The retiree went to Changi General Hospital because she had piles. During her consultation, she told doctors there she also had difficulty passing motion and would bleed. They referred her to the Pelvic Floor Disorders Service at SGH.

She says Dr Fu treated her piles problem and also sent her for a colonoscopy to rule out colon cancer and an MRI scan, which showed that she had a rectal prolapse. She was passing pebble-like stools and would feel the urge to pass motion again an hour after she last went.

She started taking stool softeners and did the pelvic floor exercises, but the problems persisted.

In November that year, she went for surgery. Since then, she has been fine.

"I have to be disciplined and take the softeners, drink more water and have vegetable, fruit and fibre," she says, adding that she still does those pelvic floor exercises. "But I no longer have to strain when I pass motion or worry about finding a toilet again after passing motion."

She urges sufferers like her to be frank with their doctors and to describe the symptoms they have.

"You'll know there are signs that something is not right," she says. "Discuss it with the doctors. If you keep quiet, then the problems progress."

Another patient, a 38-year-old sales manager, had rectocele, when the rectum bulges into the back wall of the vagina. She had difficulty passing motion after a hysterectomy in 2018 and even straining did not help. It came to a point where she would have to place her thumb in her vagina to push the stool out.

Dr Fu put her on stool-softening medication and she also had biofeedback treatment. Neither helped.

So, in June last year, she had surgery to strengthen the wall of her vagina, to stop the rectum from bulging into the vagina.

Recovery was not easy, says the mother of four, and she would have to go to the toilet often after the surgery. It took about two months for her to recover fully.

"Now, I go to the toilet normally," she says. "Although recovery was difficult, I don't regret it. I didn't know there was this condition, I just thought it was constipation."

Surgery, though, is not often the first option.

"Surgery is the last resort," Dr Fu says. "If we can fix the problem without surgery, we will do that for you."

Dr Lim adds: "This is not a problem one has to live with. There are solutions. Unlike cancer, this is not life-threatening. But people's lifespans are increasing. And we are talking about quality of life."

Pregnant women are encouraged to do exercises that strengthen their pelvic floor muscles from as early as the first trimester. PHOTO:ISTOCKPHOTO

Pay attention to the pelvic floor muscles

Signs that you have a weak pelvic floor

> When you pee or poo involuntarily when coughing, sneezing or carrying heavy objects.

> When you feel the urge to go to the toilet, but cannot hold it in before you get there.

> When you notice a bulge coming out of your vagina – this could be a uterine, bladder or rectal prolapse.
> When you feel fine in the morning, but develop a heaviness in the pelvic area as the day goes on.

> When you feel a vague discomfort “down there”, but it is not a sharp pain.

How to strengthen your pelvic floor muscles

Fast contraction

Tighten your pelvic floor as hard and as fast as you can, then relax completely. Do this 10 times one after another, at least once a day. You can do more sets of 10 repetitions throughout the day. You can do this lying down, which is the easiest way; sitting up; or standing up, which is the most difficult of the three positions.

Slow contraction

Tighten your pelvic floor gently and hold for five seconds. Gradually increase the holding time to 10 seconds over a month. Do this 1- times one after another, at least once a day. You can do more sets of 10 repetitions throughout the day. You can do this lying down, which is the easiest way; sitting up; or standing up, which is the most difficult of the three positions.

Other pointers

> See a pelvic floor physiotherapist for these exercises so that he or she can assess the level and strength of the individual pelvic floor muscles, followed by training of the exercises under direct supervision to ensure the manoeuvres are correct. He or she will prescribe a regimen of fast and slow contractions, depending on the status of the pelvic floor muscles. And this would be assessed over time to check for improvements, followed by increasing the difficulty level of the exercises to ensure continued improvements of the muscle.

> Breathe normally when doing the exercises, and relax your tummy, buttock and thigh muscles.

> Tighten your pelvic floor muscles before coughing, sneezing or lifting objects.

> Exercise regularly and keep your weight in the healthy range for your height.