Long term post-operative care following continence surgery

After 6 weeks

Once 6 weeks has passed, then some patients relax and think it is all behind them and they can get on with their life as before. However, it is crucial that precautions continue forever to ensure longevity with your surgery.

Rules to observe for after 6 weeks

At the gym:

Never do anything resembling a sit-up, curl-up or crunch. See below for a list of safe exercises to do at the gym.
Never do double leg lifts or a full plank. A plank from the knees is safe as long as you brace first and feel no downward strain.
Never lift heavy weights. Do not lift over 15 kilos for the rest of your life .
Never use machines at gyms where you are in a scrunched position with your feet on a plate and pushing the heavy weights with your feet.
Avoid rowing machines and any machines that increase your intra-abdominal pressure.
Take care in pilates, yoga and stretching classes to avoid crunches.

Caution

When coughing, sneezing or vomiting. you must where possible use hand support or sit on the edge of a table or chair to stop the tremendous forces which push downwards onto your pelvic floor.

Caution with such illnesses as:

Flu
Flare up of asthma
Chronic cough such as in bronchiectasis, chronic bronchitis
Hayfever
Vomiting bug

Fig 27. Leg press

At home or in the gym it is important to assess what is the load being placed on your pelvic floor and therefore your surgical repair, before you tackle any new exercise offered to you by a personal trainer, an exercise DVD, a pilates instructor or yoga teacher. Make sure you tell them you have had pelvic floor surgery. (If you have a male trainer and feel embarrassed you can always say you have a bad back!)

You have invested a lot of time and money in your operation, so own it – and take responsibility for your actions and be strong enough to say no to fitness leaders if it doesn’t feel right to do the exercise they have prescribed (Fig 27).

Many women inquire about lunges – unfortunately much of our housework involves bending to lower levels. The lunge, as seen below (Fig 28) is good for strengthening your core, your thigh muscles and for training you to get to lower objects through your knees, not by bending over at your lower back. Don’t ever put bar bells or a weighted vest on your shoulders as this is unnecessary and dangerous load for your repair.

See below for a list of safe abdominal exercises that may be commenced to strengthen your core safely. Start with small numbers and review each day how you are feeling after doing a set of exercises and increase accordingly.

Back to general exercise and sport

If you play high impact sports such as basketball or netball or love jogging or running you can slowly transition from commencing at 6 weeks to participation at 12 weeks. You are allowed to recommence pelvic floor exercises one month post-operatively but remember right from the beginning, you are allowed to recruit your deep abdominal muscles and should be bracing to protect with all movements.

Walking

When you start walking again always walk in ever increasing circles around the block with your house at the centre, so you are never too far away from home. Therefore, if you get any drag, ache or heaviness, you can easily turn around and come back home quickly. The old saying ‘there is no gain without pain’ definitely does not apply in this situation. If you feel discomfort after the activity you have undertaken, then slow down, shorten the distance you have walked, halve the time you took..….there is no hurry, you have the rest of your life to regain any lost fitness!

Netball or Basketball

If you play higher impact sports such as netball or basketball, start back slowly and playing only one or two quarters initially, will ease you back into it. Again if you feel heavy drag or ache then stop immediately. For some women, especially those who have already had a prolapse re-occur after surgery, they may never play again.

Cycling

When cycling, avoid riding up steep hills, keep to the flat until well healed. Using a well padded seat cover will help with buttock discomfort. Standing up and cycling puts considerable downward forces on the operation. Take great care with too high intensity and resistance on the bike in ‘spin classes’ at the gym.

Swimming

After 6 weeks you can go swimming, if that is something you enjoy. Flutter kicking lengths of the pool, ‘deep water walking’ forwards and backwards, aqua aerobics (same rule no double leg lifts or any high resistance exercises) and swimming lengths of other general strokes are all useful and safe forms of exercise. If you have any sacro-iliac joint pain, then breast stroke kick or frog kick may stir up that pain.

Rowing, Outrigger Canoeing, Kayaking

These water sports have gained immense popularity recently and they can all place a heavy load on the pelvic floor repair. Even if you are fanatical about bracing, the lifting of the sculls/boats before and after almost surely will preclude you from going back to rowing.

Following repair surgery, pay attention and stop if the exercise feels as though it is pushing in a downward direction.

Safe Abdominal Exercise

Every weekend there seems to be another article in the newspaper on how to acquire a set of six pack abdominals. As you are now aware, you are unable to do any ‘sit-up’ type exercises, therefore it is important to have a list of safe abdominal exercises to use if attending a gym or doing a home exercise programme. The Continence Foundation of Australia, in a joint collaboration with the Fitness industry, have a new initiative called Pelvic Floor First campaign. The aim of the project is to reduce the number of women (and men) who experience pelvic floor dysfunction as a result of inappropriate exercise regimes. So hopefully soon everyone will be as aware as you are now, about doing the correct exercises at the gym.

Now you are at week 6, you can commence the following exercises. Gentle tensioning, not strong in-drawing with the chest puffed up, is what we are looking for. With all the following exercises you are to concentrate on the lower tummy and pelvic floor, not on what the legs are doing. All these exercises can be performed in bed or on a floor mat. Start by doing 1 or 2 repetitions of all the exercises and over the days and weeks slowly build up to 10 each. You can pick and choose between these exercises. You do not have to do all of them at any one time.

1. Transversus abdominis and pelvic floor

Lying on your back, knees bent up, gently contract your low tummy and pelvic floor muscles. Hold for 5 seconds while continuing to breathe.(See page 9).

2. Pelvic Rocking

Some back conditions may be irritated by this exercise. If it hurts, stop. If it doesn’t proceed gently. Lying on your back, with your knees bent up, gently contract your low tummy and pelvic floor, tilt the ‘small of your back’ into the bed, hold for 3 seconds and rock back to the start position. (As performed in hospital see page 70). Do not hold your breath.

3. Ski Squat (Fig 31):
Standing with your back against a wall, your feet about are about 30 cm (12 inches) away from the wall. Most importantly, your heels should be under your knees so your lower legs are vertical. Gently contract your low tummy and pelvic floor, and slowly slide your back down the wall 8cm (3 inches) and hold the position for about 5 to 10 seconds and then slide back up again. As the weeks go by you can increase the length of hold to strengthen your core and your thighs. Do not go down to 90°. Do not do this exercise if you have knee pain.

4. Progression of modified straight leg raise:

As this becomes easier, do the exercise as described below but increase the number of straight leg raises you do to firstly 3 and then 5 if no discomfort. Remember always concentrate on the gentle tightening of your lower tummy and pelvic floor.

5. Bridging (Fig 33)

Lie on your back, with your knees bent up, gently contract your low tummy and pelvic floor; then tighten your gluteal (buttock) muscles and then slowly lift your bottom up 10 cm (4 inches) and hold for 3 seconds, then slowly lower down. (Repeat 5 to 10 times)

6. Bridging Progression

As you become stronger lift and lower without touching the bed 3 times and then rest for 3 seconds and repeat. (Do 5 to 10 times).

7. Bent knee fall out (Fig 34)

Lie on your back, with your knees bent up; gently contract your low tummy and pelvic floor; slowly lower your bent right leg to the side and slowly bring back upright again. Aim to stop your pelvis from rocking from side to side. Repeat with the other leg. (Do for 5 to 10 times).

8. Core stability abdominal exercise (Fig 35)

Lie on your back as usual, gently tighten your low tummy and pelvic floor. Holding a light weight (maximum 5kg in each hand) with both hands. Slowly raise and lower weight in a controlled fashion, first from line of abdomen up to shoulder line (see diagram) and then from shoulder to back over your head. Start with 2 or 3 and build up slowly to 10 in each direction.

9. Modified Clam (Fig 36)

Lie on your side, with your knees bent and feet together, gently tighten your low tummy and pelvic floor. Keeping your feet together, lift your top leg 8 cm (3 inches) off the other leg. Do not roll your pelvis backwards as you lift. Hold for 3 seconds and slowly lower down. Repeat with the other leg. (Do 5 to 10 times). If performed correctly, this is a good exercise for the pelvic floor.

10. Balance, abdominal and coordination exercises (Fig 37)

On all fours, hands under your shoulders, knees under your hips, maintain your lumbar curve. With your head in a neutral position, gently contract your low tummy and pelvic floor, lift your right arm out in front, hold for 3 to 5 seconds. (You can get someone to place a soft ball in the middle of your back and see if you can stop it from rolling off your back). Repeat with your left arm.

Back to all fours and gently contract your low tummy and pelvic floor muscles and lift your right leg out straight out behind you and hold steadily for 3 to 5 seconds and lower. Repeat with the left leg. Start by performing 2 exercises with each limb and then as you get stronger build up to 5 and then 10. Then, when feeling good core strength and quite controlled in each exercise then you can lift your right arm and left leg together, hold for 3 to 5 seconds and repeat with left arm and right leg.

11. Ball Exercises (Fig 38):

Balance work on a gym ball is great for your core muscles. Make sure your hips and knees are at right angles and your low tummy and pelvic floor are gently contracted. Start by holding your upper limbs at 90° and then lower and raise back to start position. Do 2 to 3 and increase the number daily. Another ball exercise is to try lifting one leg 3cm (1 inch) off the ball without your pelvis shifting or the ball rolling. Do not do any sit up, curl up or crunches on a ball.

A word about travelling

If you have a holiday planned following your surgery it always best to wait until at least 6 weeks post-op for a number of reasons. Check with your surgeon for advice.

Deep Vein Thrombosis – Anyone who has had surgery is at higher risk of developing a deep vein thrombosis post operatively so the longer the time before long haul flights the better.
Heavy lifting – Naturally when travelling interstate and particularly overseas this involves lifting baggage which may place unwanted strain on the recent repair surgery. So again, the longer time frame from the operation the better chance of the good fibrosis to form and assist with holding the surgery in a good position.
Constipation – Many women tend to find that travel often causes constipation and straining to pass a bowel motion will risk damage to your operation. So the longer the time post op the stronger the surgery is likely to be.
Travel tummy and bowel bugs – anyone can get a ‘bug’ and have violent vomiting and diarrhoea which will place great strain on your operation.

So for all of these reasons I have prepared a travel checklist with ideas which will be helpful in dealing with these situations. There is a checklist below which you can photocopy and tick off, prior to departing to make sure you have thought of everything when packing.

Travel Checklist

Travel light– when packing be ruthless, remembering that once you have had gynae repair surgery you shouldn’t lift over 15 kilos for ever.
Always have a ‘pull-along’ bag with wheels and if travelling with someone, see if they can lift the bags for you. If you have to do it, always remember to brace prior to lifting the bags.
Pack airline travel socks or alternatively if you have your calf TEDS from hospital you may like to put those on under your long pants.
Keep your legs and ankles moving on the plane. Every 30 minutes while awake pump your ankles up and down, do foot circling, tighten your thigh muscles & squeeze your buttock muscles. Walk the aisles. Adhere to airline recommendations regarding prevention of deep vein thrombosis (DVT’s.)
Talk to your GP about packing medications for diarrhoea and vomiting and use hand support if vomiting to stop pelvic floor descent.
Travel in loose comfortable clothing. No tight waistlines as these tend to increase your risk of bloating and wind discomfort.
On the plane, eat lightly and avoid all caffeinated drinks as they are diuretics and will cause you to go more frequently to the toilet.
Drink plenty of water to keep well hydrated as this is important with prevention of DVT’s.
Avoid drinking alcohol on the flight if possible or keep it to a minimum– it is a diuretic and can increase the risk of DVT’s.
If prone to constipation with a long haul flight, then prior to flying it can be helpful to have a glycerol suppository (page 48) either the night before or early in the morning, knowing that you have had a good evacuation of your bowels prior to flying.
To help prevent constipation with travelling, ensure that you pack any fibre supplements or bowel medications that you are using at home. If you don’t use fibre at home it can be helpful to take it when travelling, as your diet and fluid intake can be deficient on holidays
Try to sit properly with bladder and bowels when using the plane toilet…..never easy!

The previous are pages extracted from the book “Pelvic Floor Recovery – A Physiotherapy Guide for Gynaecological Repair Surgery” by Sue Croft Physiotherapist.

Link to Sue’s book page is:
http://www.pelvicfloorrecovery.com/

Sue’s web site link is:
http://suecroftphysiotherapist.com.au/

Disclaimer: this information is intended as a guideline only and reflects the consensus of the author/s, at the time of publication. The sources used are believed to be reliable and in no way replace consultation with a health professional.