Victoria
I am a physiotherapist. I started off in musculoskeletal outpatients, and then trained in pelvic health physiotherapy. I'm a pelvic health physiotherapist at heart. I've just been seconded to do a transformation fellowship which will help me develop on my leadership and project management skills and I'm going to be working with the women's and children's division.
 
Maya
Why did you choose to specialise in pelvic health?
 
Victoria
I don't think I even went to the pelvic health lectures at university because they were optional, and I just thought I'm not going to do that. I was doing my junior rotations, and I really liked the outpatient setting, then I did a rotation in women's health, but it was more musculoskeletal – treating pregnant women with back pain, pelvic girdle pain, things like that. When I joined Northwick Park Hospital, I was keen to develop those skills. The outpatient department offered an opportunity to do both musculoskeletal and pelvic health which I think is the perfect blend.
I firmly believe that I'm a good pelvic health physiotherapist because I have that musculoskeletal background, but I also think that I'm an even better musculoskeletal clinician because I've got that pelvic health background. I have this affinity for talking to women and I really enjoy working with women and women’s problems – talking to somebody about personal matters like incontinence or sexual dysfunction, that they're often scared to talk about – and being able to help. Having the opportunity to create an environment where women could tell me some of their most personal and intimate things, and I'd be able to help them with that and educate them about their bodies, is one of the reasons I fell in love with pelvic health.
 
Maya
Which urological conditions are most often referred to you?
 
Victoria
I mainly get my referrals from the urogynaecology clinic, so that is mainly bladder dysfunction (stress incontinence, urge incontinence or overactive bladder) or prolapses. I haven't trained in treating bowel conditions, although I would like to move on to that as they can be very closely linked. For example, constipation can really affect somebody's bladder function and their pelvic floor.
I do have additional knowledge about constipation and pelvic pain. I was approached by one of our endometriosis consultants who had heard that physiotherapists can help to manage endometriosis. That was the first I had heard of it, so I researched it and spoke to some amazing pelvic health physiotherapists and pain physiotherapists. There is more and more research coming about the role that physiotherapists can have in helping women with persistent pain from endometriosis, using a more holistic approach with the biopsychosocial model. We set up the first physiotherapy clinic for direct referral of people with endometriosis and got some interesting data out of it which was presented at the European Society for Gynaecological Endoscopy 33rd Annual Congress (27–30 October 2024, Marseille, France), which was very exciting.
 
Maya
Can you talk me through your typical day as a pelvic health physiotherapist?
 
Victoria
Generally, I see two to four new patients a day. New patient slots are about 45 minutes long and follow-ups are about 30 minutes long. Once a week, I sit on the urogynaecology multidisciplinary team (MDT) meeting, which comprises the urogynaecology consultants, urogynaecology specialist nurse, one of the admin team and me. We meet on Teams so that we can check notes and talk about the patient from multiple angles and then come up with the best treatment pathway for each patient. As I'm a manager, I also have some admin time as well as appointments.
 
Maya
In the MDT meeting are you talking about all your patients or just those with complex presentations?
 
Victoria
It is the more complex patients. It is also a great resource for me to learn more about the surgeries, about the different interventions that could be offered because then I can speak to the patient about these. It can be a good way to improve the patient experience on our pathway as patients may have questions about their treatment options after leaving their consultant appointment. I can go over their options again and discuss it from a holistic point of view which helps them make the right decision for them. Sometimes patients are added to the surgery waiting list but also referred to physiotherapy, a lot of patients do well with physiotherapy and feel they don’t need the surgery. Sometimes patients are struggling to see the progress they need with physiotherapy alone so I can get them an appointment back with the consultant or nurse specialist to discuss other options.
 
Maya
Do you mainly see new patients in clinic, or do you also have follow-up patients?
 
Victoria
I like to have a mixture of new patients and follow-ups. I spend quite a lot of a new patient appointment taking the subjective history, with the woman telling me the problems they've been experiencing. This can help me work out the different things that might be contributing to their symptoms. So even though a lot of the session is ‘just’ talking, if I'm asking ‘tell me about how much you're drinking and what types of drinks you are having’, if she's having six cups of tea or coffee a day then I can educate her that caffeine is a stimulant for the bladder, so she could either try some decaffeinated drinks or cut out caffeinated drinks. So, you get that opportunity to do the treatment and education at the same time as working out why they are having a problem with their bladder.
After I've done the history, I usually try and offer an internal examination. With their consent, this involves inserting a finger into the vagina to check the strength of the pelvic floor. Some people ask how accurate that can that be, but it allows me to understand how strong the muscle is in terms of stopping urine, how long she can hold a contraction and how quickly she can contract.  The pelvic floor muscles need to react to sudden movements like jumping, coughing or sneezing. In the past few years, I've been working on coordinating the pelvic floor with breathing: a lot of women can't maintain a contraction unless they hold their breath, which means they leak when they cough or sneeze but also the contraction is never as strong as it could be.   
Once I've got the information from these examinations, I can give them a programme of how to do the pelvic floor exercises correctly, some bladder training techniques and healthy habits for the bladder.
 
Maya
What would you typically do with your follow-up patients?
 
Victoria
In the follow up I always ask how them to give me an idea of how much better they are feeling, usually as a percentage. It's a good way for me to gauge because every woman feels very different, but if someone comes back and says I've tried those things and I'm starting to feel maybe 30–40% better, I think ‘great! what can we focus on more now to get that percentage higher?’. Normally if the pelvic floor wasn't working well in the first session, patients often like us to recheck their technique. In the second session, I make sure that they are doing the exercises correctly, and check if they've got stronger or the coordination has improved. We sometimes go through the bladder training again, making it a bit more specific to the individual. I like the patient to lead the session with them telling me what symptoms are bothering them the most so that my advice and treatment is tailored to the things that are important to them...
 
Maya
How often would you typically see these women?
 
Victoria
It depends. If somebody cannot contract their pelvic floor at all, we sometimes use an electrical stimulator device. This is a probe that is inserted into the vagina, which gives a tingling sensation that can help try and recruit the muscles, so the woman can join in with the squeeze that the machine is trying to elicit. I send them away with that machine and get them to practise for a couple of weeks, then come back and I can retest them. If the pelvic floor is working but needs a little bit more help I might see them again in 2 weeks’ time. If there is good technique, but it's weak, I might leave it 4 weeks so that they can really work on it every day and then in a month's time we can see if that's made any difference.
 
Maya
And you would typically see them for 3–6 months and then discharge them?
 
Victoria
To be honest, it's more about how much better they are getting.
I see a lot of patients once or twice and they feel much better after some reassurance, advice about how to manage their symptoms and checking that they are doing their pelvic floor exercises correctly, so one or two sessions is enough. More complicated cases might take 3–6 months where they're needing my guidance and then we'd be deciding whether physiotherapy has helped them? The National Institute for Health and Care Excellence (2019) guidelines on management of urinary incontinence and pelvic organ prolapse in women say that you should be doing physiotherapy style exercises, bladder training, things like that for 3–4 months before you decide this has or hasn't helped.
In terms of best practice guidelines, I strongly believe that evidence informed practice is crucial. Between 70 and 80% of women with a low grade prolapse never need to have surgery if they do their pelvic floor exercises and look after the other factors that contribute to prolapse. A lot of women think that they have only one option, but I'd love patients to know that they don’t have to have surgery, there are other things to try.
 
Maya
What is the one thing you wish patients knew about their pelvic health?
 
Victoria
What is normal. So many patients tell me about their bladder habits and think that it's normal, for example, to leak after they have had a baby. And that is not normal. Perversely, because there are a lot of adverts about managing incontinence it's normalising it, ‘OK, I'll just wear a pad’. Some women are happy with that but I would love them to know that there might be something that they could do to help reduce that incontinence. What is a normal bladder? What are normal drinking habits? What are normal bladder habits? And when should I go and see a physiotherapist? I have women who are so embarrassed by their incontinence and they've been hiding it for years. Most patients that I see have been experiencing symptoms for years before they even get the courage to go and see their GP, whereas, if they'd come earlier we could have nipped this in the bud.
 
Maya
If I was experiencing urinary incontinence, where could I go and read about it or how I would seek help?
 
Victoria
The Pelvic, Obstetric and Gynaecological Physiotherapy website (https://thepogp.co.uk/) is a fantastic resource with so much information. They also have a recite function so that if English is not your first language, it will translate the website for you into any language, or if you are visually impaired, it can read it out to you. You can also find a physiotherapist through that website, and your GP should be able to refer you to a pelvic health physiotherapist.
 
Maya
What's the most satisfying part of your job as a pelvic health physiotherapist?
 
Victoria
The obvious thing of getting patients better. A lot of patients cry in my session because incontinence, prolapse and sexual dysfunction can be very overwhelming as it's so personal. Talking about those things is a bit of a release. I am glad that I can create an environment in my clinic that allows women to freely open up and talk to me about their most intimate problems and give them a space to cry. I always tell them ‘this is a safe space. You can say anything you like in here, whether we're talking about bladder, bowel or sexual dysfunction’. I feel proud about the environment that I create in my clinic.
 
Maya
You mentioned the MDT meeting earlier. Would you normally work with these MDT members on a day-to-day basis?
 
Victoria
Not day-to-day, but I meet with the gynaecology consultants on a weekly basis. We did a project where I worked in their clinics and saw the patients on their list as well. We found that 60% of patients that were referred to the urogynaecology clinic waited a year or so for their appointment but could have seen a physiotherapist first. If the GP had referred them to a pelvic health physiotherapist straight away, they might have been sorted by the time their urogynaecology consultant appointment came around and it would have saved time for the patient, so we're hoping to build on that. As far as working with the rest of the team, they are very approachable and we work well together as we put the patient at the heart of everything we do. Sometimes women find it hard to do pelvic floor exercises when the prolapse feels heavy so I contact the urogynaecology nurse to arrange for a pessary and that can help support the prolapse and make the exercises easier. We try and maintain a good level of communication and we talk very openly and freely to each other. I work with a lovely team.
 
Maya
Is there one thing you wish other healthcare professionals knew about pelvic health physiotherapy?
 
Victoria
That we don’t just deal with muscles. Physiotherapy is very holistic, so we always ask patients about how the symptoms affect their social life and how it is affecting them psychologically. It is also important to understand that if someone is really stressed with their life situation, going through a difficult time with family or finances, that can have an effect on the bladder.
I feel quite lucky that most of my patients get better because there are a lot of lifestyle factors that can influence these things. I talk about that a lot with patients, but I say that they are not always easy. You know, if you love your tea, and I'm asking you to give up tea or give up caffeine, you have to have a balance. So sometimes I will say ‘OK, if you're drinking six cups of tea, could you change that to decaf? Would you be prepared to change that to decaf and see how it goes?’ And some people say ‘yes, that's fine’, and others say ‘absolutely not, I'm knackered and I need the caffeine’. Well, then I say, OK, well, instead of having six cups, could you cut it down to three and just be prepared that your bladder might be a bit more overactive after each cup? Helping patients with that awareness and understanding of their habits and their body helps patients make their own decisions and find the balance to suit them.

Find out what excites Victoria about the future of pelvic physiotherapy?

Maya
What excites you about the future of pelvic physiotherapy?
 
Victoria
I think it's the scope that physiotherapy can have. In the NHS at the moment there is a lot more buzz around allied health professions coming into advanced practice roles. As a physiotherapist, I could train to become an independent prescriber so I could prescribe some of the bladder medications rather than asking a doctor to prescribe. I could learn to put in pessaries rather than refer them to the nurse. In musculoskeletal physiotherapy there are injection courses and imaging courses that we can do to try and help people get earlier diagnosis and treatment. The future for all allied health professions looks bright. If we start doing things that traditionally used to be the doctor's role, patients can get diagnosis and treatments faster and that allows doctors to do the more complex interventional aspects at which they are highly skilled.