Peeing When You Sneeze is Not a Rite of Passage
with Ramona Kieser

Have you walked down the aisles of a pharmacy lately? Or read a lifestyle magazine? Have you noticed how much effort is put into marketing incontinence pads to women? How often have you heard conversations between girlfriends joking about peeing themselves if they laugh too hard – as though it is a fact of aging or a consequence of having children? What if I told you that peeing when you sneeze is not inevitable and that common pelvic pain issues, some of which are extremely intimate to talk about, can be professionally evaluated and a treatment plan put in place.

My guest is Ramona Kieser who is here to share her experience as a practicing physiotherapist at Soper Physiotherapy in Sackville, New Brunswick. She has two European physiotherapy degrees and Canadian accreditation. Ramona is a certified lymphedema therapist, a pelvic health specialist, she’s one of my very best friends, and because I know her so well, I know she’s extremely passionate about women’s health. I asked her to describe what makes up the pelvic floor.

Ramona: “The pelvic floor, in summary, is a combination of muscles, and ligamenture, as well as fascia that supports the pelvic organs and their function, essentially.”

April: “And so both women and men have a pelvic floor?”

Ramona: “Yes.”

April: “And what organs, in that region, are supported by your pelvic floor?”

Ramona: “It’s your reproductive organs as well as bowel and bladder.”

April: “If I was coming to a physiotherapist and wanted to know more about pelvic floor treatment, what would be the scope of practice?”

Ramona: “We treat urinary dysfunction, we treat sexual dysfunction, anorectal dysfunction, pain disorders, and pelvic organ prolapse.”

April: “There is an idea that as we age, particularly as women, that sneezing or jumping, or even running and physical activities, and having a little bit of urine leakage is considered normal. Is that the case and is that what a lot of women would present themselves to you asking or looking for treatment or help with something like that?”

Ramona: “So urinary dysfunctions is definitely a big part of our practice. Urinary incontinence concerns 1 in 3 Canadians. 33% of women and 16% of men over the age of 40 experience urinary incontinence. There are different types of urinary incontinence that we see people for. What you are describing just now is referred to as stress urinary incontinence which is caused by an increase of abdominal pressure which then causes stress onto the pelvic floor and pelvic floor organs. To describe that as an activity it would be sneezing, coughing, laughing, jumping, running. Sometimes simple things like transfers, hence, getting up out of a chair or getting up out of bed, all of those things would put more stress onto the pelvic floor and could cause small leakage.

And then there is such a thing as an urge urinary incontinence, which is a different kind of beast, if you wish. The stress urinary incontinence responds to pelvic floor training, so a muscular approach, if you wish. An urge urinary incontinence needs bladder retaining. So, an urge urinary incontinence is defined as an inability to delay voiding when an urge is perceived. So, you have an urge and your bladder essentially empties all the way, so it’s usually characterized by a large amount of urine you lose whereas stress urinary incontinence is a small amount of urine that is lost.”

April: “So it’s not necessarily something that you have to live with for the rest of your life? There are ways to address it?”

Ramona: “Yes, very much so. In this society women are of the impression that, as you said before, it’s normal that those things occur, but unfortunately it prevents them from activities that they have been interested in and passionate about prior to the compromised function of their pelvic floor with regard to urinary dysfunctions and that is something you DO NOT HAVE TO LIVE WITH. There are treatment approaches, education is a huge part – we often are not aware as to why this is happening, what it includes, whether there are steps to take. So, the visit to the physiotherapist will be quite educational to how you’re made, what the functions are, how these things get injured, and what your options are for treatment and management.

Let’s say if the incontinence is due to a prolapse. Physiotherapy cannot impact the integrity of the vaginal wall once it has lost a certain amount of elasticity through, for example childbirth, but the physio can improve the competence of the pelvic floor musculature that then helps manage the urinary incontinence.”

April: “If I’m experiencing urinary incontinence or pelvic pain or one of the other issues you’ve described under the scope of practice of pelvic floor physiotherapy, and maybe I’ve talked about it with my girlfriends and they’ve said, ‘you know, you should really go see someone about that’, where would I start?”

Ramona: “Some people have a very good relationship with their GPs (General Practitioner or family doctor), there urinary incontinence patients are very commonly referred by GPs, whereas, at least in my experience, and I can really only actually talk about my clinical experience here, the patients with sexual dysfunctions or pain disorders will often be referred by the OBGYNs in the area as they are often already in treatment with an OBGYN and luckily the ones we have in this area are awesome at including us in the treatment for those disorders.”

April: “So you can see a physiotherapist without a referral. You can self-refer. You can pick up the phone or call and make an appointment? You do not need to go through the medical system necessarily?”

Ramona: “Yes, yes, definitely.”

April: “And if urinary incontinence is maybe the most commonly talked about, even if it’s among circles of close girlfriends, what else would be a topic that you would see very commonly in your practice?”

Ramona: “Probably THE most common problem I see at the clinic is dyspareunia, which is pain during sexual activity. About 10 to 15% of North American women suffer from dyspareunia.”

April: “That’s a huge number”.

Ramona: “It’s a very big number and that’s only the known statistics so it is something that is not as well discussed as urinary incontinence. But it’s quite, quite common.”

April: “It’s so private, right? It’s very difficult to talk about…”

Ramona: “Very, very. But the treatment is quite successful. So, people feel usually quite encouraged once they’ve had their first education session and understand as to why they are having these issues. It’s a little demystified after.”

April: “Is there a specific reason women would develop pain with intercourse?”

Ramona: “There are a whole bunch of reasons as to why one could present with dyspareunia. Either there is what we refer to as hypertonicity in the pelvic floor, which is just an increased tone in the pelvic floor musculature, or there could be scar tissue from previous operations or childbirth. People know about tearing in childbirth and episiotomies and those kinds of issues and they could cause trouble. Even the use of soap or fragrance in the vulvar area can cause irritation, which then may lead to pain at entrance, those kinds of things, yeah.”

April: “What steps would you walk women through if they were coming in for a pelvic floor consultation? What does a visit involve?”

Ramona: “What would it look like, type of thing? So, commonly, the first session is mainly talking. We chat for a really, really long time. There are lots of questions to be asked, lots of things to be discussed. Most women have an extensive history of issues that they’ve faced over so many years that will all be dug up in this interview. So, the interview takes up most of the first appointment. After the interview I commonly give the patient a tour, they will hold a mirror and I will explain the exterior environment of their pelvic area. It’s quite astounding how few women have actually had a look at they’re made of…”

April: “So an actual tour of your genitals?”

Ramona: “Yes. So I’m going to explain to them what are their labia majora, labia minora, I’ll show them how they’re made. I will explain to them in this process as to what is considered a normal environment, the changes they may see as they go through different stages in life, which of those are normal, which of those may need attention, so that they are able to self-assess and decide whether or not they may seek the assistance of a medical professional down the road.

It’s so much easier for men as their genitals are ‘out there’, and very visible.

I say to the women that I see, if there is something in the mirror in the morning that you detect on your face, a lesion or anything like that, you will pay attention to it. You will tend to it first in your own scope and if that’s not helpful you will talk to your GP about it, get a referral to a dermatologist, or whatever. Really the same attention is needed in our pelvic area. Our reproductive place is hugely important in the society. We wouldn’t exist if it weren’t for this area, and yet, women are quite shy to see whether they are healthy. So, that’s a big, big part of the fist session as well. And then, I usually continue with an internal exam and explain to them the things that I see with my hands, if there is a symptom reproduction, for example, in the pelvic pain patients, I will explain to them as to where this pain comes from. Let’s say it is due to a hypertonicity, so an increased tone in the pelvic floor muscles, I’ll explain to them why they feel that pain. It’s quite the same as people have shoulder pain from having suffered headaches or anything like that…”

April: “Stressful week…”

Ramona: “Stressful week, exactly, people tighten up in their shoulder musculature and any touch to those shoulder muscles is uncomfortable. That is very similar in increased tone of pelvic floor muscles, they are just not comfortable to touch, hence, in a situation of penetration, it would be very, very, very uncomfortable. So that would be just one example, I guess. Other examples include vaginal dryness, vaginal atrophy, all those things can be detected in an internal exam and pointed out to the patient. The patient is afterward quite able to understand why they’re having these symptoms, what they can do about these symptoms, how they can manage them, what additional help they may have to seek to manage these symptoms, whether they need certain ointments or medical intervention, future therapy sessions, home exercise, as well as other management strategies.

April: “Women must leave your office feeling hopeful.”

Ramona: “Yes, I’d say.”

April: “After what I’m sure what is a really emotionally trying period of time.”

Ramona: “They definitely feel empowered by having been educated. Understanding why they are in the situation they are in and taking the shame away, to be frank. There’s a lot of people with, in particularly, urge urinary incontinence live quite isolated because they do not understand their triggers for bladder emptying. They do not know how to manage the incontinence as it appears just random. They are very insecure in new environments when they have no idea where the next closest bathroom is. They need the security of knowing their environment, hence, they restrict themselves in their activities and do not like venturing. So, people leave the office in general…”

April: “Feeling hopeful, feeling FREE.”

Ramona: “Yes, if you want to phase it like that, hopeful in the sense of knowing there are ways to change their every day life and the quality of their every day life. Like a lot of young women that have had children are so busy with their new family structure and challenges of work and children and all of those kinds of things that they find very little time for self care but at the same time find themselves in situations where they want to pick up activities that they had taken part in prior to child birthing and they can’t. So, a visit to the physio would give them tools to work on at home and go back to things that they’ve liked before having children and help them in their work and family life demands and balance of all those things.”

April: “What does it feel like for you to be an integral part of improving women’s lives? Or do you think about it from that perspective?”

Ramona: “Well I guess you do think about it that way. Women’s health has always been close to my heart and it probably started out with treating women post cancer care for lymphedema treatment. And then my boss actually was a big part of choosing to go into pelvic health, he and his wife were quite supportive in me pursuing that interest. So, they were quite important in that choice and I have, I take pride, I guess, in being part of improving the quality of life in women because being a woman myself I know the demands that are put on us on a daily basis. And, you know, we are brought up to be caretakers, and have so few people around us who take care OF us when we are in need. We also have a tendency to keep performing even when we are in need, we override our own limits and put our health demands on hold. We will be at the end of the line when it comes to getting help. So, that is something I feel we really need to change. We are caretakers in so many aspects, whether that’s our children, whether that’s our elders, just organizing family life, that kind of thing. I feel like I am a place that women can come to and be looked after.”

April: “And I know you to be a very mothering personality. You a definitely a doula in the sense of mothering the mother when they come to see you as patients. And I thank you for your service to the community in that way. We are so lucky to have you here, because, the work that you do is really, really, really, important. It’s really valuable.”

Ramona: “Thank you. There’s more to be done, though, like, I think, as I said, we are only at the beginning of making this field grow, and even from my point of view, there is more to be done. I need to find ways to get the education of the patients, or of women, more easily available, not just through an appointment with a physio but finding ways to reach out to the community and educate in different kinds of ways, I guess, and make that more accessible.”

April: “Is there a component of preventative care in pelvic floor physiotherapy or, you know, what we’ve talked about so far is very much ‘an event has happened, I need help, here is a treatment plan that can help me’.”

Ramona: “It definitely has preventative components, let’s take the organ prolapse, the pelvic organ prolapse as an example. A rectocele, a common pelvic organ prolapse, in which women have a hard time with bowel movements. A common source of the problem would be tears in childbirth and episiotomies, but more so the tears, and the lack of management after. So often women will tear, but they’re not educated on how to take care of themselves with that tear and how to manage bowel movements when they are torn in the posterior vaginal wall. So, with an education on this with us being maybe referred to by the GPs or OBGYNs right after birth for a check up for education, we can change the degree of a rectocele, we can make sure it doesn’t worsen – because it does worsen if it’s untreated – we could definitely impact the degree of damage with proper education on how to empty after the trauma and how to not put more stress on the posterior vaginal wall.”

April: “Would you like it to be considered part of the routine – you know there is the magical six-week check up that many of us receive after we’ve given birth – should pelvic floor physiotherapy or a pelvic floor evaluation be part of that?”

Ramona: “I would say that would be amazing, yes, if we could. And I have women who know about pelvic health come to me and say, ‘okay, see where I’m at, am I healing fine?’ and I can give a couple of pointers as to what to watch out for…”

April: “So that in itself would be considered preventative care.”

Ramona: “That is preventative care, right there. Exactly. I mean, ideally, if I could wish for things, magically, we would be in the labour room with the whole team of other medical professionals. You know, looking out for the pelvic floor integrity and doing our part there, alongside the nurses and OBGYNs. That would be amazing. And maybe one day we’ll get there. The idea is already established and conversation is happening but it takes a long time to get trained in those specific areas and also to become part of that health care system in those situations.”

April: “Do you know if there are pelvic floor physiotherapists available in every province in Canada?”

Ramona: “I think there are, yeah. It’s just a matter of abundance. In the Maritimes they are not as abundant as Quebec or Ontario.”

April: “And they may be perhaps, more centered in larger urban centers. Is it something women might have to travel for?”

Ramona: “Well, being European, that question is a little tricky for me to answer because I find everybody here has to travel for everything, but, yes, they do have to travel a certain way. We definitely are not as abundant in the smaller communities, that’s for sure.”

April: “In the course of collecting histories and doing the initial interviews with women you must find that there is difficult subject matter. How do you deal with that?”

Ramona: “We do get a certain amount of training to deal with difficult situations in this field. I do refer patients that have non-physical trauma or problem areas to psychologists or sexologists to help them deal with that alongside physiotherapy. So, often, we do work in a multi-disciplinary team, if you wish, we have the OBGYNs on board, we have the physio and the psychologist work on one problem area of the patient.”

April: “What’s your favourite part of this whole practice?”

Ramona: “Of this whole practice…my favourite part really is when I can send my patients off and they are back to their every day life activities. They have a quality of life that they seek then I know I’ve done my job.

April: “Amazing. I really appreciate you taking the time today, because I know your schedule is crazy and we’ve been trying to pin this down for quite some time.”

Ramona: “So is yours, so is yours.”

April: “So I really do appreciate you sharing with me. It’s the intimate aspects of your personal practice here in Sackville, and thank you.”

Ramona: “Thank you for having me and thanks for everyone listening and spreading the word and helping each other. Thank you.”

April: “Yeah, it’s kind of like a sisterhood, when one woman goes to the pelvic floor physiotherapist and she tells her friends and then they all go and they all go and so forth…”

Ramona: “And a lot of the information, that is covered in the education, often people won’t have to come to see me if they have a friend or colleague share their experience. They may realize, ‘oh, this is a habit I have as well, and oh, better stop that, you know. Better stop the safety pee before bedtime, type of thing, because that’s not healthy, it’s not needed.’ That’s then not something they need to go and seek help for it’s just something they can do preventatively on their own by sharing a story, by sharing an experience and that’s really what  the hope of this podcast is too, to open up the conversation, take away some of the shyness on subject matters like this, and have us talk about them openly to change stigma, et cetera.”

April: “Do you know if there are books or resources that women could access, that they could read themselves, or is there an umbrella organization of pelvic floor physiotherapy?”

Ramona: “Well there is, you know, the women’s health department of the Canadian Physiotherapy Association, so that can be looked up online. And they will have resources on their site, they will have specialists you can seek in your area, that kind of thing. You will be able to find literature on pelvic pain, pain with intercourse. Help you pick lubricants, or, will help you pick a dilator set if you need one for self-treatment for a home exercise program, or that kind of thing. There are stores available, but largely in bigger cities, not so much in rural communities. Here we have to go online and be bombarded with all kinds of things we DO NOT want to actually have help with when we try to find online sources.”

April: “Okay, wonderful. And not wonderful.”

Ramona: “I have patients who come back and tell me all kinds of things like ‘oh god, like this and this and this….”

April: “Yeah, such is life on the internet, I suppose. So be careful what search terms you use.”

Ramona: “Exactly, very much so.”

April: “Thank you.”

Ramona: “You’re welcome.”

Additional links:

Physio Can Help:

Pelvic Floor Physios who carry Anointment Push:

The Ripple Effect Podcast

About the Podcast

April MacKinnon dives into how reframing our self-limiting beliefs and behaviours and bravely chasing our dreams, ripple out to change the world, one action at a time. And how, sometimes, it is the small moments in life that lead to a complete pivot in perspective, only to be found in hindsight. More about April »

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