Incontinence is the uncontrolled loss of urine, gas or stool. Incontinence may be due to activities that increase pressures in the abdominal canister such as running, coughing, jumping, lifting or laughing. It may be accompanied by a strong sudden urge – if it cannot be controlled, then leakage occurs.
This includes problems such as voiding frequency, voiding hesitancy, pain or burning with urination, a sensation of incomplete emptying, frequent night-time voiding, seemingly recurrent UTIs, or pain in the bladder. Bowel and gut dysfunction can include chronic constipation, hemorrhoids, IBS, or defecation dyssynergia (when the anal sphincter contracts instead of relaxes during attempted bowel movement – also known as anismus).
Pelvic organ prolapse occurs when there is a shift in the optimal position of the pelvic organs. Fascia and ligaments that suspend the organs in place may become lax or torn. This causes the organs to lose support from above. If the pelvic floor muscles are compromised, it can result in lack of pelvic support from below. These factors, coupled with poorly managed pressures in the abdominal canister result in a downward descent of the pelvic organs towards the vaginal entrance.
Diastasis Rectus Abdominis (DRA) is technically defined as a separation of the rectus abdominis (6 pack) muscle. However, the most current research indicates that a DRA is less about a separation and more about the integrity of the connective tissue that lies at the midline of the abdominal wall. This tissue is called the linea alba and it should have a certain amount of tension to it. It should be able to transmit forces and help counteract pressures generated in the abdominal cavity.
During pregnancy the abdominal wall expands, the rectus muscles move apart to make room for the baby, and the the linea alba softens, stretches, and gets thinned out. These adaptations are normal. However, for a variety of reasons in some people, the linea alba does not return to it’s usual state after pregnancy is over. The tissue remains lax and unable to generate tension. This decrease in abdominal wall integrity, coupled with non-optimal alignment and inability to manage intra-abdominal pressures, can compromise the entire function of the inner core unit. Issues can “show up” anywhere in the body – such as back pain, incontinence, prolapse, decreased sports performance, or a distended looking belly (which is the most common complaint among post-partum moms).
The inner core unit is comprised of four main muscle groups that work synergistically: the transversus abdominis, the diaphragm, the multifidus, and the pelvic floor. These muscles turn on in advance of movement to provide a stable and controlled platform for movement. Correct core training involves engaging all these muscles in the right sequence, to the right degree, and in anticipation of movement.
The pelvic girdle consists of 3 joints – the left sacro-iliac joint, the right sacro-iliac joint and the pubic symphysis. Imbalances or asymmetry of the bony pelvis (usually due to imbalanced muscular forces or tensions) can lead to pain at one, two or all three joints. Generally speaking, this is called pelvic girdle pain. There are various types of pelvic girdle pain (PGP) and it’s important to understand what is contributing to PGP so that treatment is effective.
Changes to the abdominal canister, increases in maternal weight, shifts in the centre of gravity, increased volume of blood – these are just a few factors that can cause muscular aches and pains during pregnancy as the body tries to find a new way of orientating against gravity. Upper or lower back pain, sciatica, restless legs, varicose veins, increased pelvic pressure, vulvar varicocities, pain in the tailbone, groin, hip or pubic pain, changes to walking pattern, general feeling of muscle fatigue – can all occur during pregnancy. It is important to get these things checked out so they do not become the ingrained pattern during the busy years of motherhood.
Wrist pain, upper or lower back pain, postural changes, muscle tension or weakness, persisting pelvic girdle pain are some of the common orthopaedic complaints in the months following childbirth.
The pelvic girdle, pelvic floor, uterine muscle, and inner core are all intimately involved during childbirth. The pelvis is baby’s first cradle and it’s orientation during pregnancy and childbirth can impact labour and delivery. The job of the pelvic floor is gently yield and open during labour. Therefore a flexible and compliant pelvic floor, along with a strong one, is ideal. Because many pelvic health conditions result from pregnancy and childbirth, prevention of dysfunction is a huge goal of pelvic floor physiotherapy prenatally. The goal is to decrease excessive strain and manage pressures on the pelvic floor during labour and delivery. Minimizing perineal tears and preventing pelvic floor avulsions is also a major focus of prenatal physiotherapy.
A caesarean section is major abdominal surgery that can take additional time to recover from post partum. Returning to normal mobility, regaining abdominal wall function, promoting a well healed and mobile scar, optimizing the health of the deeper layers of connective tissue, normalizing sensation in the lower abdominal wall – these are some of the goals of physio post c-section.
Return to a pain free life is possible! To heal from pain, physiotherapy treatment focuses on the pelvic tissues and more importantly, on the central nervous system since it is ultimately responsible for modulating the pain experience. Persistent pain in the pelvic region is pain that has been present for over 3 months. Official diagnoses or terms include:
- dyspareunia (painful intercourse)
- vulvodynia (generalized pain in the vulvar region)
- vestibulodynia (specific pain in the vestibule region of the vulva – also known as vulvar vestibulitis)
- clitroidynia (pain in the clitoral region)
- primary or secondary vaginismus (involuntary spasm of pelvic floor muscles with penetration attempts)
- coccydynia (pain in coccyx or tailbone)
- endometriosis (pain caused by endometrial tissue outside of the uterus)
- painful bladder syndrome (hypersensitivity and inflammation of the lining of the bladder wall – also known as interstitial cystitis)
- levator ani syndrome or proctalgia fugax (tension or spasm in a major group of muscles that make up the pelvic floor)
- pudendal neuralgia or pudendal nerve entrapment (irritation or compression of a major nerve supplying the pelvic floor muscles)
- persistent genital arousal disorder (unwanted and painful arousal of the genitals triggered by sexual or non sexual stimuli)
- other types of pain due to hormonal changes, menopause, abdominal or pelvic surgery, internal scar tissue, gut or bladder dysfunction, pelvic girdle pain, hip labral tears, myofascial or connective tissue dysfunction, trauma, or hypertonicity of pelvic floor muscles
Regardless of the location or nature of the pain, a bio-psycho-social approach is necessary for the effective treatment and ultimate elimination of pain. We focus on the whole person, not just the part.
Abdominal or pelvic surgery may be necessary or elective. It includes surgery to address incontinence, pelvic organ prolapse, or removal of cysts, fibroids, other growths, or adhesions. It may be an endometrial ablation or to surgery repair a diastasis recti. Interestingly, hysterectomy is one of the top 5 performed surgeries in Ontario (C-sections being number 1). When it comes to irreversible procedures, the risks, benefits, alternatives, success and failure rates, and general outcomes of surgery must be carefully evaluated before making the decision. Make sure you are well informed.
Pelvic floor physiotherapy treatment prior to surgery may help to delay or prevent surgery all together. Just as in any other situation (such as an ACL repair or knee replacement) going into pelvic surgery with as robust of a system as possible will lead to better post-surgical outcomes. Pre-operative physiotherapy is therefore recommended to maximize the state of the pelvic region prior to surgery. Post-operative physio is equally important for regaining optimal function and hopefully to prevent the need for future surgeries.
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Please check out the general learning page for articles, downloads, and links on various conditions, and links to various topics. Feel free to share them with your patients. If you are interested more in- depth research, you can download and read the journal articles below.