Teaching pelvic floor muscle exercise is like, really tricky

As a Women’s Health Physiotherapist I understand the challenge of teaching a woman to correctly contract and relax her pelvic floor muscles (PFMs).  The concern is not necessarily how strong the muscles are but how well they coordinate especially under high pressure situations.  Previous studies have confirmed the difficulty in teaching the correct technique and have assessed the effectiveness of verbal instruction, paper based resources, technology and various forms of biofeedback.  While these strategies are helpful, there are still some women who really struggle to ‘find’ these muscles.

Most of the studies exploring how to teach PFMT have been based in Western countries, predominantly with well-educated Caucasian women.  These women would have a fairly good understanding of their pelvic organs, anatomy and function.  Now, imagine teaching a woman to contract her PFMs who has no comprehension of her bladder, bowel or uterus and how the muscles work to support them.

One of the main reasons I started my PhD was after I discovered the informational handouts on PFMT in Nepal were incorrect.    Surprisingly, I found that many Nepali physiotherapists, doctors, public health workers and local health workers had been taught misinformation about PFMT.  This set me on a path to help develop new resources and educational workshops on conservative strategies to manage pelvic floor disorders.

Here are some of the examples I’ve been told on how PFMT has been taught to women in Nepal:

1. To stop-start the flow of urine when emptying your bladder
2. A supine double leg lift while breath holding
3. Pull your stomach in and breath hold for 10 seconds
4. Place your hand between your knees and squeeze them together
5. Tighten your bottom muscles

Misinformation about PFMT is a common problem globally as I have heard some of these descriptions from women in Australia.  Often when teaching women to squeeze their PFMs we demonstrate with one hand tightening around a finger.  I have been told several times that this confuses Nepali women as a few have gone home and performed their ‘PFM exercises’ with their hands by squeezing them around a finger.

One of the more effective ways of teaching women to find the correct muscles and technique is while performing a pelvic examination.  Asking a woman to squeeze around your finger while give some tactile cuing to the muscle helps her identify the correct muscles and contraction.  This strategy is helpful to women who can access a health professional for an individual assessment and treatment.  However, this is often impossible for many women in low resource settings.  In these settings, women rely on health education from paraprofessional health workers who are often not trained to perform a pelvic examination.

This problem lead me to explore the role of local health workers in providing education to women with symptomatic pelvic organ prolapse.  As part of my PhD I have developed an informational flipchart for local health workers to use and we are currently testing the effectiveness through a randomised control trial.

We can all agree that teaching PFMT is challenging whether in Nepal or Australia or anywhere in the world.  There are women from all countries and settings who face barriers in accessing individual care from health professionals.  Finding ways to reach these women to provide conservative treatment strategies for pelvic floor disorders is crucial regardless of how challenging it is.  So, let’s keep on keeping on…