Tessa Loftus Physiotherapy   

Women's Health


Women's Health Physiotherapy deals with problems specific to women, due to our particular anatomy and physiology throughout the different stages of life. This is a relatively new field of physiotherapy, with few specialised practitioners in South Africa. This website will help you understand the pelvic floor, common conditions treated in physiotherapy, and advise you on options of treatment.


Understanding the Pelvic Floor


What is pelvic floor?

The pelvis is a bowl containing the bladder, uterus and the bowel. The sides of the bowl are made of bone and the floor of the bowl is made of muscle. This important muscle floor is made up of layers which stretch from the front to the back of the bowl. The muscle floor is commonly known as the pelvic floor. There are openings in the pelvic floor for the urethra (pipe from the bladder), the vagina (birth canal) and the rectum (back passage). The pelvic floor muscles support these internal organs, play an important role in urination and defaecation and sexual function.

Why must we keep the pelvic floor strong?

The pelvic floor plays an important role in maintaining urinary and faecal continence by helping keep the outlets from the urethra and the rectum closed until it is convenient to get to a toilet. A weak pelvic floor may not provide sufficient support for this process, resulting in leaking of urine on coughing, sneezing, laughing, straining or playing sport. This is known as Stress Incontinence. In some cases, there could also be leakage of faeces, and/or an inability to control the passing of gas from the rectum. Urge incontinence is the loss of urine with an urgent need to pass urine and may also be associated with a weak pelvic floor ("key in the lock", "don't make it to the toilet on time").
In addition, weakness may allow prolapse of the internal organs (aching, "falling out" feeling):
a)The uterus may move downwards through the vagina (prolapse), or
b)The bladder may bulge into the front wall of the vagina (cystocele), or
c)The rectum may bulge into the back wall of the vagina (rectocele).

Why do the pelvic floor muscles weaken?

Pelvic floor muscles may be weakened by:
a) Pregnancy and childbirth
b) Continual straining to open the bowels (constipation)
c) Persistent heavy lifting (e.g. nurses)
d) High impact sporting activities
e) A chronic cough (e.g. asthma, chronic bronchitis or smoker's cough)
f) Obesity
g) Inactivity/lack of general fitness
h) Changes in hormone levels at menopause

How can physiotherapy help?

Physiotherapy is often the first step taken to help correct pelvic floor disorders. By means of a simple and painless vaginal examination a physiotherapist can establish the strength, endurance, quality and structure of the pelvic floor. After a thorough assessment a unique exercise and bladder training programme for each patient can be developed. The aim is to strengthen the pelvic floor in order to provide greater support for the bladder, bowel and vagina, thus reducing symptoms. Many women may avoid the need for surgery and in others where surgery is unavoidable, a strong pelvic floor will provide the best possible chance of success in the years following the surgery.

If you think you suffer with any degree of stress or urge incontinence and/or you think you may be in the early stages of a prolapsed, cystocele, or rectocele it is important for you to discuss this with your doctor, midwife, or your local physiotherapist specializing in women's health. Your doctor may prescribe a simple exercise routine or will refer you to physiotherapy for a more detailed assessment and individual treatment plan or to a gynaecologist.

For a simple explanation of how to do Pelvic Floor Exercises, click here.

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Medication and devices

How can medication help?

Stress incontinence is very common during menopause, therefore Oestrogen therapy is often used as part of the treatment, and it is often given before surgery to improve the quality of the tissue of the pelvic floor. Oestrogen therapy can be given as tablets, as a skin patch, or as a hormone implant. It may also be given as a vaginal ring, or as a cream or tablet that is inserted into the vagina. In urge incontinence, the bladder becomes overactive, and will involuntarily contract before it is full and sometimes without warning, resulting in an urgent desire to get to the toilet. Certain medications may be prescribed to help "calm" the bladder.

How can devices help?

Intravaginal devices that are easy to insert support the bladder neck and can help prevent leaking. They are useful for women who leak in certain situations, such as when undertaking strenuous exercise.

Diagnostic tests and surgery

Your GP may refer you to a physiotherapist, gynaecologist or Urologist. Your Gynaecologist/ Urologist will help by running a series of tests in order to obtain a definitive diagnosis after which a decision can be made regarding the best course of treatment. It may mean that you require medication, physiotherapy, surgery or a combination of all of these.

Gynaecologists/Urologists will usually run a series of urodynamic tests to make an accurate diagnosis and to determine the cause and severity of the incontinence. There are various tests that may be used and each is carried out as an outpatient procedure.

There are various types of surgery used to correct stress incontinence:

Culposuspension: This is the current "Gold standard" operation and the most commonly used. It involves a major operation with an abdominal incision just above the pubic hair. The surgeon places sutures wither side of the bladder neck and elevates the bladder neck by tying these sutures to the inside of the bony pelvis.

Anterior Repair: This is a 'nip and tuck' procedure and is used for cystocele prolapsed and/or incontinence. The operation is performed through the vagina and no scars are visible afterwards.

A Sling procedure: This may be performed if other treatments haven't been successful. A small incision is made in the vagina and a strip of material is threaded through underneath the urethra. The material is then picked through another small incision in the abdomen and tied to a ligament inside the pelvis or the lining of the abdominal wall.

TVT Procedure: TVT is the newest urinary incontinence procedure, which continues to gain popularity due to it's encouraging 5 year results, minimal access and rapid recovery period. A Prolene mesh tape is inserted under the mid-urethra via the vagina and passed through the pelvic soft tissue to the abdominal skin, close to the bikini line. The tape is gently tautened so that it will provide support when the urethra is under strain during provocative activities such as cough, sneezing or physical exercise. The mesh remains in place permanently with the body tissues growing into it. Normal levels of activity can resume within weeks following the procedure.

Collagen injections: Injectable agents, such as collagen can be injected around the bladder neck to help keep it in a more closed position.