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Common (medical) testing of the bowel -what the tests involve and why they are done

Colonoscopy

How is it performed?

A colonoscopy involves passing a long, thin, flexible tube (a colonoscope) which has a tiny camera on the end, through the anus to look inside the rectum and colon (lower part of the bowel). Before having a colonoscopy, the patient will be given strict instructions on bowel preparation beforehand to clear bowel contents, which will usually include fasting, drinking a bowel prep and the use of an enema. They will generally be under moderate or deep sedation during the procedure. While a colonoscopy can just involve looking inside the colon and rectum, often a biopsy (typically of a polyp), is taken for further laboratory analysis or an internal haemorrhoid may be banded during the procedure. This video shows the procedure in animated form.

Why is a colonoscopy performed?

A colonoscopy is typically done to look for any abnormalities in the rectum and colon. This can include haemorrhoids, polyps (which can be harmless but are sometimes pre-cancerous), cancers, diverticulitis, Crohn’s disease, or ulcerative colitis. Typically, a colonoscopy will be performed to investigate reasons for the patient’s particular signs or symptoms (e.g. if they have bleeding, chronic diarrhoea, or pain, to see if an obvious cause can be found). Colonoscopies are also performed as a screening investigation (e.g. if the patient has a strong family history of bowel cancer, or if they have a past history of disease themselves).

How are the results presented?

Vaginismus leaves many women in pain and avoiding sex, but it can be treated

Recently our practice principal and clinic director, Alison Wroth, was interviewed by ABC news journalist Grace Burmas.  Well done, Grace, for shining a light on a sensitive and distressing issue that is common to many women’s experience.

ABC article –

Navigating pain for women can be a twisted maze of questions, referrals and specialists, but amid the ever-growing list of diagnoses lies a silent condition that is experienced by many.

It’s called vaginismus.

Six months ago, Sophie*, 22, started to endure painful sex with her long-term partner.

“It’s just like a heavy pressure,” she said.

“I thought it was because I left it too long, like a month between intercourse, but then that shouldn’t really change anything.

“I was looking for answers with the gynaecologist being like ‘it must be PCOS’ (polycystic ovarian syndrome), but PCOS doesn’t actually cause pain.

” I think I was just looking for a reason because I didn’t want it to be vaginismus.”

What is vaginismus?

Vaginismus is when vaginal muscles involuntarily contract in anticipation of penetration.

It causes immense pain or discomfort during intercourse, physical examinations or inserting a tampon and is psychologically triggered.

Those triggers vary greatly, from a general fear of penetration, to medical conditions like endometriosis, to a past trauma such as sexual assault or a distressing childbirth.

Equal to the physical pain can be the emotional toll it takes on women, the isolation they feel and the pressure it places on their relationships.

“The anxiety that came with it, because one time would be painful and then if you’d leave it for too long, it would just build up in my head more than anything,” Sophie said.

A cycle of pain

She thinks of vaginismus as a cycle, where one painful experience builds fear for the next time, which feeds the muscle tension and leads to more pain.

“My boyfriend doesn’t feel like I want to be intimate with him, which I do, and then I had to explain to him I get anxious because of the pain, not because of the situation,” she said.

“It’s so tiring having the conversation, it’s exhausting.”

The prevalence of the condition is blurry but health professionals, like sexologist Melissa Hadley Barrett, believe the numbers are much higher because of under-reporting.

“In a clinic like mine it’s between five and 17 per cent … but in the general population, they say between one and six per cent,” she said.

“It’s just not something people talk about, so people don’t know that it even exists until they come across it.”

Ms Hadley Barrett helps women and their partners work through the condition, which she said takes time but is achievable with a comprehensive approach and open communication.

“The partner often blames themselves and I think it’s about getting them to understand that it’s nothing they’ve done, it’s just the person has anxiety around having pain in general,” she said.

“You’re not going to touch a hot oven if it burns you.”

Ms Hadley Barrett said a lot of women try to work around the symptoms of vaginismus instead of seeking professional help.

Like many women’s health issues, knowing where to go can be overwhelming — and there’s often a cloud of shame surrounding sexual complications.

Finding the trigger

Pelvic floor physiotherapist Alison Wroth said along with a psychological approach, health professionals can work to retrain and relax the pelvic floor muscles.

“It’s thought that the pelvic floor muscles have a protective response … it makes sense to think if a woman is feeling unsafe, that these muscles would tense,” she said.

Ms Wroth helps her clients understand what the initial trigger may be and how to address that fear emotionally and then physically.

“I think it’s really confronting to go and see someone about this part of the body,” she said.

“Sometimes even in taking a really thorough history, we don’t really get to what the initial onset was, but we can still work with the body and how it’s responding now.”

Seeking help can be hard

Sophie is yet to seek professional help, because of the barriers a lot of women face when dealing with pain and complex health complications.

“It always puts me off because of the amount of money it costs and it’s intimidating, I don’t know I’ll just cry, but I think it’s worth it,” she said.

“It’s been months of trying to fix it myself, which is not happening.

However difficult treating vaginismus may seem, there is hope in overcoming the condition, Ms Wroth said.

“I’m constantly amazed at humans and the complexity of systems that are all working together just to keep us functioning in the body, and how quickly they can change if that person is ready, with the right practitioners to help them,” she said.

ABC News: Women speak out about birth trauma and poor pelvic health care in public system

It found that three months after giving birth:

• one in three women struggle to control their bladder
• one in 10 suffer faecal incontinence and
• one in two experience pain with sex

Valerie Slavin, a midwifery researcher at Griffith University who led the project, says pelvic injury isn’t being addressed because the health system doesn’t ask women about their symptoms.

And she says until we start systematically collecting national data about the problem, women will continue to suffer.

‘No-one mentioned prolapse’

The first time Samantha Coughlan became aware of prolapse was when she did an internet search about what she was feeling.

She was out walking with her husband a few weeks after the birth of her first child when she says she felt like her insides were falling out.

Previous studies have estimated half of all women who have given birth experience some degree of prolapse — a condition in which one or more of the pelvic organs drop into the vagina — but there is no clear national data.

That’s despite her daughter being delivered using forceps to pull her through the birth canal, which led to a severe vaginal tear. Both are linked with a higher risk of pelvic floor dysfunction.

The Melbourne mum had given birth in a public hospital, where she was told if she had any problems she could go on a waitlist to see a physiotherapist.

Unwilling to wait, she found a private women’s pelvic physio.

Four years later, Samantha still struggles with activities that strain her pelvic floor, including lifting her kids.

“I want to be that fun mum who jumps on the trampoline … and goes down the slide, but I can’t physically do it,” she says.

The former schoolteacher also experiences urinary incontinence when she coughs or laughs.

“That’s actually stopped me going to work.

“It’s not worth the embarrassment.”

          Samantha Coughlan still struggles with activities that strain her pelvic floor, including lifting her kids. (ABC News: Mary Lloyd)

Women’s health physiotherapist Lyz Evans runs a clinic in Sydney and says physical birth injuries can be catastrophic.

Women might avoid exercise, leaving the house because they’re not sure where the next bathroom is and intimacy with their partner, she says.

A ‘hidden epidemic’

The ABC has heard from nearly 4,000 women as part of the Birth Project.

Hundreds of women described devastating pelvic injuries and expressed dismay with the standard of care in the public system.

Many said they resorted to spending thousands of dollars seeing specialist physios in the private sector.

Access to publicly available pelvic physiotherapists across Australia varies from state to state and between urban, rural and remote areas.

Ms Evans believes the rate of pelvic floor trauma is higher than acknowledged and can be dramatically reduced if women were given access to pelvic floor physio before and after giving birth.

Physios can help prevent birth trauma by working with women during pregnancy to assess their risk of pelvic injury and help prepare their pelvic floors for labour.

They also help women recover from birth using pelvic floor muscle training and guidance on how to safely return to activities such as exercise.

The Australian Physiotherapy Association (APA) is calling on the federal government to provide all women with five Medicare-funded sessions with a pelvic physiotherapist during their child-bearing year.

Catherine Willis, chair of the APA’s advisory council, says this will help women prevent and recover from birth trauma.

“The cost of five physiotherapy appointments for women birthing in Australia has a much better economic value than the future interventions that they might need, including surgery, and also the inability to return to work due to their pelvic floor symptoms.”

Ms Willis says she’s seen women in their 60s and 70s who have endured pelvic floor problems since the first time they gave birth.

“That’s really sad to think that possibly for 30 or 40 years they’ve been putting up with these symptoms.”

‘Holding women back’

Emma Elder’s second pregnancy put twice as much strain on her body, but sessions with a physio made it a much better experience than her first.

After delivering twins it took her only a few months to return to running and jumping.

Following her first pregnancy, it took two years.

“I found [pelvic physio] extremely beneficial, not just for my recovery, but also for the preparation for birth,” she says.

Several months after giving birth to her first baby, which caused a severe vaginal tear, she was dismayed she couldn’t skip, jump or lift weights at the gym without wetting herself.

“I had to make sure that I was always carrying a spare change of clothes,” she says.

Unwilling to accept a weak pelvic floor as an inevitable and irreversible consequence of childbirth, she spent thousands of dollars on private physios and now wants that available to more women.

“I think this issue really holds women back,” says Emma.

‘What we don’t measure, we can’t improve’

Dr Slavin says one of the reasons women aren’t getting access to better pelvic care is that the scale of the problem is not known.

Australia has a clinical care standard for the 3 per cent of women who deliver vaginally and experience a tear that extends into the muscle of the anus.

Many more women than that experience life-altering pelvic injuries, but there is currently no way to evaluate how many women are affected and no national standard for the care they should receive.

Dr Slavin wants to see the public health system routinely collect data from women about their experience of pelvic floor disorders, as well as the model of care and procedures used during their delivery.

She believes that will drive improvement in maternity care.

“What we don’t measure, we can’t improve on,” says Dr Slavin.

Assistant Minister for Health Ged Kearney says she would be interested in discussing better data collection with her state counterparts.

“Collecting data is an incredibly important part of improving our health system,” she says.

Experts say women will continue to suffer until Australia starts collecting national data about pelvic injuries.(ABC News: Mark Leonardi)

Ms Kearney says many women have told her they don’t feel their experience has been heard and want birth trauma to be taken seriously.

Both Samantha Coughlan and Emma Elder think the first step towards this is rejecting the stigma of talking about pelvic disorders.

“I would love other women to know that there’s nothing to be ashamed of,” Samantha says.

“We need to talk about it so we can make things change.”

Understanding Your Core – Article for Ostomates Magazine 2022

Vaginismus