Research

How can you tell if your pelvic floor is functioning as it should after your recent birth? How can your healthcare practitioner evaluate whether your pelvic floor has healed?

Title: Pelvic Floor Health Index: Initial validation of a practical postpartum tool for busy clinicians

Authors: Roxana Geoffrion, Sophia Badowski, Merry Gong, Gurkiran K. Mann, Manisha Tilak, Nicole Koenig, Terry Lee

Published November 2023

Summary prepared by: Kiran Mann

Pregnancy and childbirth can bring on or worsen symptoms of pelvic floor disorders. In the first few months postpartum, some women may therefore experience leaking of urine, stool or gas, a bulge in the vagina, pelvic pain or pain with sexual activity, decreased sensation, decreased sense of attractiveness and avoidance of intimacy with their partner. These symptoms should gradually resolve by 6 months after birth. If they persist and bother you, you should seek care.

To make it easier for you and for your family doctor, nurse practitioner, midwife, or any other healthcare professional, we created a screening questionnaire (survey) and showed it can reliably detect your pelvic floor issues. The Pelvic Floor Health Index (PFHI) is a 10-question survey with yes/no questions. You can take the survey yourself, or you can complete it with your healthcare professional.

In our research, we compared the PFHI with four other well-known longer validated questionnaires at several time points in a group of 74 participants who have recently given birth. The results on the PFHI closely matched those of the other questionnaires within the first 6 months postpartum. As expected, pelvic floor symptoms were worst right after birth, and slowly returned to baseline within the first year postpartum. Persistence of these symptoms may mean your pelvic floor has had significant stress and needs some extra help.

This survey is simple and takes about 30 seconds to complete. You are aiming for a NO answer to each of the 10 questions; this will give you an optimal score of 10/10.

If you have a score of less than 10, then we encourage you to speak to your family doctor for a referral to a pelvic floor health specialist (e.g. pelvic physiotherapist, sexual health counsellor, or urogynecologist).

What can reduce the number of bladder infections after pelvic surgery for prolapse/urinary leakage?

Title: Reducing urinary tract infection in female pelvic surgery: a retrospective cohort study

Authors: Gurkiran K. Mann, Nicole Koenig, Terry Lee, Roxana Geoffrion

Online Ahead of Print May 2023

Summary prepared by: Kiran Mann

Bladder infections (aka urinary tract infections or UTIs) are one of the most common infections in women. One of every two women will develop a UTI in her lifetime. If you have frequent painful urination, lower abdominal pain, and/or strawberry-red urine, chances are you have a UTI. However, you will need a urine culture to confirm.

Surgery for pelvic floor conditions, such as prolapse with or without urinary leakage, is also commonly needed but unfortunately puts patients at high risk for UTI, which can delay recovery.

We combined three methods known to decrease UTI around the time of surgery into a “bundle of care” and counted UTI’s before and after. Our bundle included:

1. testing every patient for a UTI within 2 weeks of surgery and treating with antibiotics to avoid going into surgery with a bladder infection;
2. discharging patients home with a catheter if they are unable to void the morning after surgery, with catheter removal in clinic the next day when they are much more likely to empty their bladder normally;
3. counselling every patient to take an appropriate daily dose of cranberry extract pills for 6 weeks after surgery (containing 36 grams of cranberries per day).

Before introducing our bundle of care, one in five women had UTI in the first 6 weeks after surgery. After we started using the bundle, our UTI numbers went down approximately three-fold, to one in fifteen women with UTI after surgery. We were also able to send patients home sooner. We plan to continue using our bundle and hopefully convince other clinicians to use it for their own patients around the time of pelvic surgery.

How are patients with tight and painful pelvic muscles using cannabis? What products are they willing to try?

Title: Cannabis use preferences in women with myofascial pelvic pain: A cross-sectional study

Authors: Emily C. Yang, Nicole A. Koenig, Merry Gong, Lori A. Brotto, Alasdair M. Barr, Terry Lee, Paul J. Yong, Roxana Geoffrion

Published June 2023

Summary prepared by: Emily Yang

Myofascial pelvic pain happens when muscles of the pelvic floor contract without your control and have trouble relaxing. This type of deep pain is extremely difficult to treat. From previous research, we know that cannabis is effective at reducing persistent pain elsewhere in the body, and that some patients with pelvic pain are already using various cannabis products for relief. In this study, we aimed to understand how our patients use cannabis or its derivatives and whether or not they are willing to use vaginal inserts and creams.

We collected information from 135 patients with myofascial pelvic pain across two clinics in Vancouver, British Columbia, using a detailed questionnaire that was designed by experts in pelvic pain and pharmacology. Over half of the respondents reported using cannabis products, with most users consuming it daily through oral intake or smoking. The most common reason they started using cannabis was because other recommended treatments did not work. Patients reported that cannabis was effective at relieving pelvic pain, improved their mood, sleep, and quality of life, and decreased their use of other pain medications. One third of patients experienced cannabis side effects, such as unwanted feelings of being high and decreased attention span.

Many patients who do not use cannabis expressed willingness to try it to treat pelvic pain. Overall, 3 out of 4 respondents were interested in trying gynecological cannabis products such as vaginal inserts, vaginal creams, and vulvar creams. The main reasons for not wanting to use cannabis for pelvic pain were lack of information and concerns about its side effects.

In summary, most patients who currently use cannabis for pelvic pain rate the effects positively, and many patients who do not use cannabis are willing to try it for pelvic pain relief. Whether or not patients have previously used cannabis, there is a large interest in cannabis products aimed specifically at treating pelvic pain. This calls for further research into how to use cannabis and its derivatives at a safe dose to treat pelvic pain without side-effects.

What can predict difficulties in bladder emptying after pelvic surgery for prolapse or urinary leakage?

Title: Risk factors for urinary retention after urogynecologic surgery: A retrospective cohort study and prediction model

Authors: Ethan Zhang, Jeffrey Wong, Nicole Koenig, Terry Lee, Roxana Geoffrion

Published April 2021

Summary prepared by: Ethan Zhang, Jeffrey Wong

Sometimes, women are unable to urinate for a short period of time after surgery for prolapse and/or urine leakage. If they are unable to urinate, they may need to keep a urinary drain (catheter) in their bladder for longer periods of time after surgery, or they may need to learn how to empty their own bladder intermittently, with a catheter at home. We wanted to know which women are at higher risk of this, so their surgeons can warn them ahead of time. Through reviewing the medical charts of 501 women who underwent pelvic surgery over six years at our hospital, we found that one of three women cannot urinate the day after surgery. While most women only required an extra day in the hospital to regain their ability to urinate, approximately one in ten had to go home with a urinary catheter. Women who went home with a catheter usually had it removed within one week.

The most important risk factor to increase women’s risk of bladder emptying difficulty after surgery was an inability to completely empty their bladder before surgery. We routinely measure how patients void when they first come to our clinic. If their bladder still contains more than 200 ml of urine after they try to empty, this means they will have 3-4 times the risk of this happening after their surgery as well.

Some other risk factors were also highlighted. These include the number of surgical procedures women undergo in the same operation, as well as whether they had a history of prior prolapse or urinary incontinence repairs. Based on this study, we were able to design a prediction model to help surgeons counsel their female patients at greatest risk for bladder emptying issues after pelvic surgery for prolapse and/or urine leakage.

Does psychological stress impact healing after surgery?

Title: Preoperative depression and anxiety impact on inpatient surgery outcomes

Authors: Roxana Geoffrion, Nicole A. Koenig, Meimuzi Zheng, Nicholas Sinclair, Lori A. Brotto,Terry Lee, Maryse Larouche

Published March 2021

Summary prepared by: Roxana Geoffrion

Mental health can affect physical health in many ways, including in surgery. Psychological stress can affect healing after surgery. Depression and anxiety are generally more common in women. Our study explored how depression and anxiety influenced recovery in both female and male patients who received surgical operations at our hospital over a 5-year period (2015-2020). Patients had various major surgeries, including cardiac, colorectal, ear nose and throat, general surgery, gynecological, orthopedic, plastic, urogynecological, urological and vascular. They all stayed in hospital at least one night after surgery.

We recruited just over 1000 patients and reviewed data from 486 female and 455 male patients. Before surgery, approximately one in ten patients had depression or anxiety. Male patients were generally in poorer health, had more complications and stayed in hospital longer after surgery when compared to female patients. People who exercised less, needed more help with basic daily activities, were more worried about the success of upcoming surgery or anticipated more pain had higher levels of depression before their operation. Depression and anxiety affected recovery in female but not in male patients. Females who were more depressed or anxious had more surgical complications, stayed in hospital longer and were readmitted to hospital for care more commonly in the first 30 days after surgery. Infrequent exercise and poor sleep quality also affected surgical recovery of female patients. If female patients were satisfied with the amount of information received about their operation beforehand, they tended to have less pain and use fewer pain medications. This was not true of male patients.

In summary, mental health plays a big role in recovery from surgery, and female patients are much more affected by depression and anxiety when compared to male patients.

Did cannabis legalization (Canada, 2018) change the way people use cannabis to help with pelvic pain?

Title: Recreational Cannabis Use Before and After Legalization in Women With Pelvic Pain

Authors: Roxana Geoffrion, Emily C. Yang, Nicole A. Koenig, Lori A. Brotto, Alasdair M. Barr, Terry Lee, Catherine Allaire, Mohamed A. Bedaiwy, Paul J. Yong

Published January 2021

Summary prepared by: Kiran Mann

Recreational cannabis was legalized in Canada on October 17, 2018. Many people use different types of cannabis for relief of pain. In women’s health, pelvic pain is a real concern, and difficult to treat. Some conditions, such as endometriosis, can lead to pelvic pain and pelvic floor muscle tightness. Endometriosis happens when the lining of the uterus (the tissue that builds up and sheds with each menstrual period) grows outside of the uterus and causes inflammation.

Since cannabis can cause muscles to relax, it may help with pelvic pain. However, some people may not want to put up with its side effects. Research on this is still ongoing. Through our study, we checked how legalization affected cannabis use in pelvic pain and endometriosis patients and how users were different from non-users.

We reviewed 3426 medical survey responses from patients with pelvic pain who were seen at an endometriosis clinic over several years, from 2013 to 2019. Before cannabis legalization in 2018, 13 of 100 women were using it for pain relief; after 2018, this number increased to 22 of 100 women. Cannabis users had more severe pelvic pain and worse depression, anxiety, and quality of life compared to non-users. We also found that cannabis users were taking various pain medications more often compared to non-users. After legalization, cannabis users were less likely to require strong daily pain medications when compared to pre-legalization users.

In summary, women increased use of cannabis for pelvic pain after cannabis legalization. We anticipate future studies will further explore the role, efficacy, and risks of various cannabis products for pelvic floor muscle relaxation in the context of pelvic pain.