Fit following Surgery advice and exercise following gynaecological surgery

Getting help

If you have any difficulty with the exercises in this booklet, or find that your symptoms are not improving, ask to be referred, or if available, refer yourself to a physiotherapist with experience in treating women with pelvic floor muscle problems.

To find your nearest specialist physiotherapist visit:

pogp.csp.org.uk

or contact:

POGP administration Fitwise Management Ltd. Blackburn House Redhouse Road Bathgate West Lothian EH47 7AQ

T: 01506 811077 E: info@fitwise.co.uk

Women with complex needs

If your ability to follow the advice in this booklet is affected by any health problem we suggest that you contact your local specialist women’s health physiotherapist, who will be able to assess you and offer specific alternatives, suitable for your needs.

Other relevant booklets are available from: pogp.csp.org.uk

Glossary as the words occur in the booklet

vagina - a muscular tube from the external genitalia (labia and vulva) to the end of the uterus (cervix)

laparoscopy - examination of the pelvic contents by laparascope (camera) through a small incision below the umbilicus (belly button)

pelvic floor muscles - the group of muscles spanning the base of your bony pelvis, held in place by ligaments which support the pelvic organs. Pelvic floor muscle exercises / Kegels will help keep these muscles strong

urinary catheter - a tube put into your bladder to drain the urine (wee)

bladder - where urine is stored until you go to the toilet to pass water/ have a pee

perineum - the area between the back passage and the vagina

anal incontinence - uncontrolled leakage of wind or stool

pelvic organs - the bladder, bowel or uterus which drop downwards in a pelvic organ prolapse

intra-abdominal pressure - an increase in the pressure in the tummy which causes strain downwards onto the pelvic floor muscles

uterus - the hollow organ in which a foetus / baby develops in pregnancy (sometimes called the womb)

transverse abdominals (transversus abdominis) (TA) - the deepest abdominal muscle running across the front of the lower tummy working with the lower back muscles to support the spine

neutral spine - when the lower back is midway between a tucked and arched position

Introduction

This booklet is a general guide for women following gynaecological surgery. Your operation may have been performed through your abdomen (tummy), your vagina (birth canal) or via laparoscopy (keyhole surgery). Rates of recovery will vary and may depend on your age, lifestyle and fitness level before the operation.

This booklet will advise you how to:

•    Move easily and rest comfortably after your operation

•    Exercise to prevent chest and circulatory problems

•    Exercise the abdominal and pelvic floor muscles

•    Regain your previous level of fitness following surgery

It is advisable to practise your exercises before you go into hospital, as it helps to prepare for your operation. It is important that you and your family understand that although the outside scar can heal very quickly, it takes longer to heal on the inside; allow yourself time to recover fully.

The Day of your Operation

It is beneficial to get out of bed and sit for a time, as well as walk short distances as soon as you are able to.

Circulatory exercises in sitting and lying

• Until you are back to full mobility, do these every few hours 
• Sitting    upright,    take    a    deep    breath    in,    feeling    the    lower    ribs      move out sideways. Repeat 4 to 5 times, every hour and every time you wake up. A pillow across your tummy may help if you feel that you need to cough.
• Move    your    feet    and    ankles    up    and    down    for    30    seconds     
• In    sitting,    bend    and    straighten    your    knees    (one    at    a    time)    for 30 seconds

How to get out of bed 

• Roll    onto    your    side
• Push    up    with    your    hands 
• Lower    your    feet    over    the    side    of    the    bed  
• If    you    have    abdominal    stitches,    you    may want to give some extra support by holding onto your tummy with a rolled towel or your hands as you come may want to give some extra support by holding onto your tummy with a rolled towel or your hands as you come forwards

Toilet Advice 

Going to the toilet

You may have a urinary catheter in your bladder after your operation. When you fi rst try to empty your bladder on your own, make sure that you sit down properly on the toilet. If you hover over the toilet seat your bladder may not empty properly. Take your time and try to relax.

It is important to drink normally (1.5 to 2 litres per day), and water is best. This will help your bladder and bowels to work well. You should pass urine every 3 to 4 hours throughout the day. Avoid going to the toilet to pass urine ‘just in case’. If you are having difficulty passing urine or you have any altered sensation of the need to go, it is important that you tell your doctor immediately. 

Moving your bowels

It is important to avoid constipation as this puts extra unnecessary pressure on your pelvic fl oor muscles and operation site. Eating plenty of fruit, vegetables and fi bre It is important to avoid constipation as this puts extra unnecessary pressure on your pelvic floor muscles and operation site. Eating plenty of fruit, vegetables and fibre can help. Also, make sure that you are drinking enough fluids. 

• Do    not    strain
• Sit    fully    on    the    toilet    seat:    do    not    ‘hover’
• Have    your    feet    apart    and    raised    up    on    a    stool/ support, with your arms resting comfortably on your thighs
• Keep    your    tummy    relaxed;    don’t    tighten    your    abdominals   
• Avoid    breath-holding;    try    to    have    a    relaxed    breathing    pattern   
• A    slight    bearing    down    will    help    the    stool    to    open    the    back    passage    for    the    bowel movement but do not ‘push, push, push’!
•  Some    women    may    find    it    helpful    to    between the back passage and the vagina) by applying some pressure
• Some    women    may    find    it    helpful    to    support the perineum (the area between the back passage and the vagina) by applying some pressure with a clean hand or pad, when emptying their bowels, particularly if you have had vaginal stitches emptying their bowels, particularly If you feel constipated, or have an increased need to strain when passing a bowel motion, talk to your doctor about medications that may help.

Pelvic Floor Muscle (PFM) Exercises (Kegels)

Your pelvic floor muscles span the base of your pelvis. They:

• keep    your    bladder    and    bowel    closed    (stop    urinary    or    anal incontinence)
• help    with    sexual    function    and    pleasure
• help    with    the    stability    of    the    pelvic    and    lumbar    joints
• support    your    pelvic organs helping to prevent prolapse  

Your pelvic floor muscles need to be strong, but they also need to work in the right way at the right time.  It is important that you get these muscles working again after your operation to help with recovery and to prevent problems in the future. Once the catheter has been removed and you are able to pass urine on your own, start exercising them gently, even if you have stitches underneath. 

Imagine that you are trying to stop yourself from passing wind at the same time as trying to stop passing urine. You should feel a squeeze and a lift inside the vagina. Do not hold your breath. Do not clench your buttocks.

Pelvic floor muscle exercises (sometimes called Kegels) should include long squeezes as well as short, quick squeezes. You should aim to work the muscles until they tire and do the exercises regularly to help the muscles become stronger and more effective.

Long squeezes

• Tighten    your    PFM,    hold    them    tight,    then    release    and    let    them    fully    relax.    How    long can you hold the squeeze?
• Repeat    the    squeeze    and    hold    until    the    PFM    tire.    How    many    times    can    you    repeat the squeezes?

Short squeezes

Quickly    tighten    your    pelvic    floor    muscles,    then    immediately    let    them    go    again.    How many times can you do this quick squeeze before the muscles tire?

Always    let    the    muscles    fully    relax    after    each    squeeze

Pelvic Floor Muscle Exercises

• Aim    to    do    10    long    squeezes,    holding    each    for    10    seconds,    relax    the    muscles    for 10 seconds then do 10 short squeezes
• You    may    need    to    start    with    ‘little    and    often’    if    you    find    that    you    can    only    hold    the squeeze for a short time, or only do a few before the muscles tire
• You    should    do    your    PFM    exercises    at    least    3    times    a    day.    Starting    in    lying    and    sitting positions and progressing to standing and active positions such as walking and bending
• Build    up    your    exercise    routine    gradually    over    the    weeks    and    months.    If    your    muscles were weak, you should notice an improvement in 3-5 months. Then keep up the practise to maintain the improvement 

The Knack

Draw up and tighten your pelvic floor muscles before any activity that increases the intra-abdominal pressure (coughing/ sneezing/ laughing/ bending) to help the pelvic floor muscles resist the downward movement of the pelvic organs including the uterus.

PELVIC FLOOR EXERCISES ARE FOR LIFE - TRY AND DEVELOP A DAILY PELVIC FLOOR MUSCLE EXERCISE ROUTINE

Abdominal Exercises

Finding and exercising your abdominal muscles

The deepest abdominal muscles are called Transverse Abdominals (TA) and they work together with the other abdominal muscles and your pelvic floor muscles to support your back and help with good posture.

It is important to get the basic TA contraction right. It is not always easy - seek help if you are finding it difficult. (If you are finding lying on your back uncomfortable this exercise can be adapted to a side lying position).

1. Lie    on    your    back    with    your    knees    bent,    feet on the fl oor/bed and relax into the fl oor/bed

2. Find neutral spine - neither too tucked nor too arched

3.    Lay    your    hands    on    your    lower    abdominal    muscles    (as    shown)

4.    Breathe    in    gently    allowing    your    tummy    to    rise.    As    you    let    the    breath    out,    keep    your back and ribs relaxed while drawing in your lower tummy (at the navel/ belly button level) towards the spine. You will probably feel the muscles under your fi ngers tense up. Keep the spine in the neutral position and the pelvis still

5. Keep this contraction in the deep abdominals for 2 or 3 breaths and then relax fully

This is the muscle to use for support when you are being physically active with bending, lifting, standing for a period of time.

Further Exercises

Basic abdominal exercises:

1. Pelvic tilt

Do a basic abdominal contraction, drawing up your pelvic fl oor muscles at the same time, and fl atten your lower back into the fl oor/bed allowing your pelvis to tilt. Hold this position for a few seconds while you breathe normally, and then relax. Repeat a few times.

This exercise may also be useful for relieving trapped wind and backache after your operation.

2. Knee Rolls 

Do a basic abdominal contraction, keeping your back still on the bed, and your knees and feet together, slowly let both knees go to one side. Bring them    back    to    the    middle    and    relax. Repeat the basic abdominal contraction and do the same exercise to the left side. 

3. One leg stretch

Do a basic abdominal contraction, drawing up your pelvic fl oor muscles at the same time then gently slide one heel away from you, keeping the heel in contact with the fl oor/bed. Do not hold your breath. Repeat for the other leg. 

Progressing your Exercises

Alternate knee bends

Do a basic abdominal contraction and draw up your pelvic floor muscles. Keeping your spine in neutral, bend your hip and float your knee up as far as is comfortable. Hold for a short count then lower your foot to the fl oor with the abdominal muscles staying active. Do not hold your breath. Repeat for the other leg and do on alternate sides for several repetitions. 

Single knee fallout

Do a basic abdominal contraction and draw up your pelvic floor muscles.  Allow one knee to gently fall to the side away from midline keeping both feet on the fl oor. Do not let    your    pelvis    roll    or    move.    Let    the    knee    lower    as    far    as    you can keeping the pelvis still then return the knee to the midline position keeping the abdominals active throughout the movement. Relax the abdominals and pelvic fl oor muscles before repeating the exercise on the other side. 

Bridging

Do a basic abdominal contraction and draw up your pelvic fl oor muscles.  Starting in a lying position on the floor, very gently curl the pelvis inwards starting from the tailbone and bit by bit roll your spine away from the fl oor to create a bridge above the floor. Imagine that you are lying on a strip of velcro peeling yourself away from it. Gently roll back to start position. You may feel that you do not get very far at fi rst but don’t worry it will feel easier with practise. 

Healing and Return to Activity

Recovery from your operation varies from person to person. Your return to normal activity should be gradual.

Up To 6 weeks

This is when the initial healing takes place. The wound needs time to heal on the inside, even if it appears healed on the outside quite quickly.

• Avoid    standing    still    for    long    periods    (30    mins    or    more),    particularly    in    the    early    days post-op
• Avoid    heavy    lifting    e.g.    hoover,    full    kettle,    bag    of    groceries 
•  Start    your    pelvic    floor    muscle    exercises    and    early    abdominal    exercises    in    the    Further Exercises section: Pelvic tilt / Knee rolls / One leg stretch
• Daily    walking,    starting    with    short    distances    and    building    up    gradually 
• Remember    to    listen    to    your    body,    and    stop    if    anything    is    uncomfortable    

6 to 12 weeks 

• Try    low    impact    exercises    such    as    swimming,    cycling,    low    level    pilates,    a    crosstrainer, more vigorous walking or gentle aerobics. Make sure that any vaginal discharge or bleeding has stopped before you do
• If    you    are    exercising    with    an    instructor    make    sure    that    you    tell    them    that    you    have had a recent gynaecological operation

12 weeks +

• You    will    need    to    wait    at    least    three    months    before    you    start    more    physically    active exercise including high impact activities and competitive sports. However, some exercises that need ‘heavy straining’ may need to be avoided for life. You should ask your Specialist Women’s Health Physiotherapist for specific advice, and potentially a pelvic floor muscle assessment, especially if you have had an operation for prolapse 

Driving

It may be some time before you are ready to drive, depending on the type of surgery that you have had. This varies from person to person, so you need to check with your doctor, and also with your insurance company regarding what your policy allows.

Physically, you need to be comfortable and able to:

• Wear    the    seatbelt    comfortably
• Press    a    brake    pedal    hard    enough    for    an    emergency    stop;    practise    this    whilst    stationary first
• Turn    to    look    over    your    shoulder,    and    turn    the    steering    wheel    without    pain

Sexual Activity

The right time to resume sexual activity will vary from person to person. You may want to wait at least 3 to 4 weeks before resuming sexual intercourse, but be guided by how ready and comfortable you feel. Make sure that any bleeding has stopped. Take your time and use adequate lubrication if needed. If you feel that this is too soon, then wait until you are ready. 

Useful Websites 

• Royal    College    of    Obstetricians    and    Gynaecologists    (RCOG): https://www.rcog.org.uk/en/patients/patient-leaflets/recovering-well-fromgynaecological-procedures/
• NHS    Choices    - http://www.nhs.uk/pages/home.aspx
• POGP    -    Booklets    such    as:    The    Mitchell    Method    of    Simple    Relaxation    available    to download at pogp.csp.org.uk
• Various    apps    such    as:    Squeezy    -    the    NHS    Physiotherapy    App    for    pelvic    floor    muscle exercises