Understanding Pelvic Floor Disorders

Pelvic Floor Disorders

Understanding the signs, symptoms & causes of pelvic floor disorders

What are pelvic floor disorders (PFDs)?

pelvic floor disorders, pelvic pain, DRA, diastasis, women's health

First off, the pelvic floor is made up of a network of muscles and connective tissue that provide both structure and support of the pelvis and connecting joints, assist in urination and defecation and aid in sexual performance. The pelvic floor consists of three layers of muscle — the superficial perineal layer, the deep urogenital diaphragm layer and the pelvic diaphragm, including the levator ani muscle.

Pelvic floor disorders are any disorder affecting the pelvic floor, including urinary incontinence (stress and urgency), overactive bladder, pelvic organ prolapse (POP), and fecal or anal incontinence.1 Urinary incontinece and fecal or anal inconincen are best described as a loss of the body’s ability to control urination, defecation or flatulence. Pelvic organ prolapse is when the bladder, uterus or rectum drops from its normal place in the lower abdomen down into the pelvis.

How common are PFDs?

Pelvic floor disorders are fairly common, with studies showing that 23.7-34% of women have at least one PFD.2,4 Additionally, while 46% of these women had one PFD, 16%-33% of symptomatic women had two or more disorders.3 A study showed that although PFDs are common, only 25% of symptomatic women seek care.4

What are the signs and symptoms of PFD?

• Incontinence

  • This includes any amount of leaking urine, feces or even gas at any time

  • Whether you are leaking when sneezing, laughing, coughing, doing box jumps or any jumping, lifting heavy, and doing double unders, this is a sign of PFD

  • Frequent urination (more than 8 times in 24 hours) or urgency are also a sign of PFD

  • Pain with sexual intercourse, bowel movements or urination

    • This also includes constipation or feeling like you are not able to complete a bowel movement

    • Hemorrhoids - internal and external

    • Constipation

    • Pressure or pain in the lower abdomen and pelvis

      • This can include feeling like you have numbness, heaviness, bearing down sensation or bulging near the vagina

      • Low back, pelvic, SI and hip pain

        • All of the muscles of the body are interconnected. If you are experiencing pain in any of these areas it may actually be referred from the pelvic floor or referring to the pelvic floor

What are the contributors of PFD?

*Note I did not say CAUSE of PFD. I know we all want one cause, and therefore one treatment to cure PFD. Unfortunately, it is not always that easy as it is typically multi-faceted and has more than one contributing factor.*

Vaginal Birth

• A study showed that vaginal delivery increased the odds of pelvic organ prolapse but additional vaginal deliveries did not increase the odds of developing PFD.5,6,7

• Additionally, urinary incontinence is also associated with vaginal childbirth.5,8,9

• The risk of PFD is does not appear to be correlated with caesarean delivery as PFD has not been found to increase with a history of active labor or complete cervical dilation prior to cesarean delivery.6

Assisted Vaginal Birth - Episiotomy, instrumented delivery, etc.

• The use of instruments in delivery is associated with an increased risk of PFD. This includes the use of forceps or vacuum which significantly increases the risk of PFD and specifically POP.

• “Magnetic resonance images provide evidence that show that the pelvic floor regions experiencing the most stretch are at the greatest risk for injury, especially in forceps deliveries.”15 and “risk factors for pelvic floor injury include forceps delivery, episiotomy, prolonged second-stage of labor, and increased fetal size.”16

Obesity

• Handa found that obesity is not only a risk factor for incontinence but may also accelerate the progression.8

• Another study showed that weight loss from either diet or exercise can experience a “70% reduction in the frequency of total and urge UI episodes” with a 5-10% loss of body weight.18

Birth Weight

• A large birth weight has been shown to increase risk of pelvic floor dysfunctions.16,17

Levator ani injury

• Levator ani muscles have been shown to increase with long second stage, anal sphincter tear, and older maternal age.

• A study by Miller showed that at “seven weeks after delivery, 91% of women showed some form of musculoskeletal injury that involved the pubic bone or levator ani muscle: 66% had pubic bone marrow edema; 29% had pubic subcortical fracture; 90% had levator muscle edema, and 41% had low-grade or greater levator ani muscle tear.”10

What about muscle stretching?

During normal pregnancy, the pelvic floor muscles can stretch over 3 times the usual length to allow for the descent of the baby’s head.11,12

A study performed on rats showed that the pelvic floor muscle fiber length increases between 21-37% and the quantity of extracellular collagen matrix increases by 140% in the pelvic floor muscles. The collagen matrix is a normal protein that “may shield the muscle fibers from excessive mechanical strain during delivery by providing a parallel elastic element that limits fiber strain.”14 This study showed that the extracellular matrix remained elevated at 12 weeks postpartum but the fiber length returned to normal.

It’s easy to look at these numbers and think, “holy cow, my pelvic floor just stretched three times the usual length, that can’t be good,” but the body actually does this to help prevent pelvic floor dysfunction by allowing the pelvic floor muscles to open and move in preparation for the baby’s arrival. This is one reason that one thing we regularly say at BIRTHFIT is “slow is fast” because it takes time for the body to naturally heal.

What can I do about it?

While pelvic floor disorders are common, they are not normal and should not be minimized or ignored. If you are experiencing any sign or symptom of pelvic floor dysfunction, please reach out to a women’s health physical therapist near you. Not sure where to start? Check out these resources to find a local women’s health physical therapist near you. If you’re local, I’d love to help you on this journey!

• United States: http://www.womenshealthapta.org/pt-locator/ 

• Canada: https://www.pelviennewellness.com/apps/find-physio

References:

1. Hallock JL, Handa VL. The epidemiology of pelvic floor disorders and childbirth: an update. Obstetrics and gynecology clinics of North America. 2016;43(1):1-13. doi:10.1016/j.ogc.2015.10.008.

2. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, Spino C, Whitehead WE, Wu J, Brody DJ, Prevalence of symptomatic pelvic floor disorders in US women.Pelvic Floor Disorders Network. JAMA. 2008 Sep 17; 300(11):1311-6.

3. Gyhagen M, Åkervall S, Milsom. Clustering of pelvic floor disorders 20 years after one vaginal or one cesarean birth. Int Urogynecol J. 2015 Aug; 26(8):1115-21.

4. Rortveit G, Subak LL, Thom DH, et al. Urinary Incontinence, Fecal Incontinence and Pelvic Organ Prolapse in a Population-Based, Racially Diverse Cohort. Female Pelvic Medicine & Reconstructive Surgery. 2010;16(5):278–283.

5. Quiroz L, Muñoz A, Shippey SH, Gutman RE, Handa VL. Vaginal Parity and Pelvic Organ Prolapse. J Reprod Med. 2011;55(3–4):93–98.

6. Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Muñoz A. Pelvic Floor Disorders 5–10 Years After Vaginal or Cesarean Childbirth. Obstetrics & Gynecology. 2011 Sep;:1.

7. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG: Int J O&G. 2012;120(2):152–160.

8. Handa VL, Pierce CB, Muñoz A, Blomquist JL. Longitudinal changes in overactive bladder and stress incontinence among parous women. Neurourol Urodyn. 2014;34(4):356–361.

9. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women. BJOG: Int J O&G. 2013;120:1548–1555.

10. Miller, J., Low, K.L., Zielinski, R., Smith, A., DeLancey, J., and Brandon, C. Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol. 2015; 213: 188.e1–188.e11

11. Hoyte, L., Damaser, M.S., Warfield, S.K. et al. Quantity and distribution of levator ani stretch during simulated vaginal childbirth. Am J Obstet Gynecol. 2008; 199: 198.e1–198.e5

12. Lien, K.C., Mooney, B., DeLancey, J.O., and Ashton-Miller, J.A. Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol. 2004; 103: 31–40

13. Alperin, M., Lawley, D.M., Esparza, M.C., and Lieber, R.L. Pregnancy induced adaptations in the intrinsic structure of rat pelvic floor muscles. Am J Obstet Gynecol. 2015; 213: 191.e1–191.e7

14. New directions in understanding how the pelvic floor prepares for and recovers from vaginal delivery. Nygaard, Ingrid. American Journal of Obstetrics & Gynecology , Volume 213 , Issue 2 , 121 - 122

15. Ashton-Miller JA, Delancey JO. On the biomechanics of vaginal birth and common sequelae. Annu Rev Biomed Eng. 2009;11:163–176. PubMed PMID: 19591614. eng.

16. Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol. 1996;88(3):470–8. doi: 10.1016/0029-7844(96)00151-2.

17. Dietz HP, Wilson PD. Childbirth and pelvic floor trauma. Best Pract Res Clin Obstet Gynaecol. 2005;19:913–24.

18. Wing RR, Creasman JM, West DS, et al. Improving Urinary Incontinence in Overweight and Obese Women Through Modest Weight Loss. Obstetrics & Gynecology. 2010;116(2, Part 1):284–292.

19. Bump RC, Norton P. Epidemiology and Natural History of Pelvic Floor Dysfunction. Obstetrics and Gynecology Clinics of NA. 1998;25(4):723–746

*Disclaimer:

The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.

Diastasis Rectus- Navigating the Ins & Outs: Part 3

Diastasis Rectus- Navigating the Ins & Outs: Part 3 - Preventing & Treating a DRA

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Now that we know what diastasis rectus abdominis (DRA) is and the causes of DRA, it’s important to understand how DRA affects us and what we need to know before returning to the gym, studio, or running.

What can I do to prevent or heal DRA?

The movements and activities that heal a DRA are the same activities that prevent them. Here is a list of ways that may naturally prevent or heal DRA.

DNS, breathing, core exercises

1. BREATHE

   1. Creating appropriate intra-abdominal pressure (IAP) and using the diaphragm synergistically with abdominal musculature and the pelvic floor helps stabilize the body and decreases undue pressure on the abdomen that can cause DRA.

   2. It is through the breath and inhaling into all aspects of the abdomen including the lower pelvis, sides and low back that our core is stabilized. It is the stabilization with the breath and IAP and breathing into all aspects of the abdomen that creates a canister of stabilization.

   3. Another way to focus on the breath is to relax. Stop clinching your butt cheeks together, stop sucking in the abdomen and let the belly and butt relax and move freely with the breath.

1. Avoid movements that put undue stress on the abdominal musculature.

   1. This includes all exercises listed in the ineffective exercise section and it also includes any movement that causes tenting or coning of the abdomen (this is unique for each person)

   2. One thing that can cause unnecessary stress on the pelvic floor and abs is straining when you use the restroom. One way to avoid this stress is to avoid constipation. You may like to try the Squatty Potty to help ease the flow. If you are regularly constipated, please seek out medical advice.

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1. Mind your posture

   1. Neutral spine is key! We don’t want to be pulled into anterior pelvic tilt or posterior tilt as both put strain on the body in different ways.

   2. The goal is to keep your pelvic floor and your diaphragm aligned!

1. SLOW IS FAST

   1. Postpartum is forever and deserves to be respected. It’s not only OK to go slow, it is better in the long run! Going too fast too soon can actually slow down the healing process.

   2. Postpartum gives you an opportunity to slow down and allow your body to recover, rehabilitate, and rebuild.

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1. Restore your movements from childhood

   1. ALL babies are born with a DRA and it is through their normal childhood development that they naturally begin to close and close their DRA through movement.

   2. This is where Dynamic Neuromuscular Stabilization (DNS) in as it is based on ontogenesis- the natural growth & development we go through as children. We do purposeful movements that can naturally help to heal a DRA.

1. See a pelvic floor physical therapist

   1. Sometimes pain and discomfort can come from weak muscles and sometimes it comes from tight muscles. The key is knowing what you are working with so it can be treated appropriately. One great way to know what needs work is to see a women’s health physical therapist in your area!

   2. If you are in the Chicagoland area, reach out, I’d love to help!

*Disclaimer:

The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.

Diastasis Rectus- Navigating the Ins & Outs: Part 1

What is Diastasis Rectus Abdominis?

Diastasis Rectus Abdominis (DRA) is caused when the rectus abdominis muscles (two large, superficial, parallel bands of muscles commonly referred to as the 6-pack) become separated by a larger distance than normal. Diastasis recti occurs when the linea alba, a collagen structure of connective tissue, is no longer able to provide stability and appropriate tension.

In the pregnant or postpartum mom, DRA is commonly noticed when the abdominal muscles are firing in a non-optimal pattern. This is seen as “tenting” or “coning” of the abdomen that is often seen when women are going from lying down to sitting up or when exercising. Even at rest, DRA may be noticeable as it is commonly nicknamed “mummy tummy” or “mommy pooch” as even after a mom has lost the baby weight her stomach may not appear skinny due to a DRA.

How common is DRA?

According to a study, the prevalence of DRA decreased from 100% at 35 weeks gestation to 39% at 6 months postpartum.¹That means that 100% of women have some level of DRA in their third trimester. One study showed the prevalence of DRA above the umbilicus was 68% and 32% below the umbilicus. While there was no difference the DRA above the umbilicus, the DRA below the umbilicus was greater in women who had given birth more than once.⁶

It’s important to note that at 6 weeks postpartum 60% of mothers had a DRA, 45.5% at 5 months postpartum and 32.5% at 12 months postpartum.⁷ A different study showed that 36% of postpartum mom’s rectus abdominis remained abnormally wide at 5–7 weeks postpartum.¹¹

Furthermore, diastasis recti and pelvic floor problems tense to go hand-in-hand and 66% of women with a diastasis recti have some level of pelvic floor dysfunction whether it be inconinence or pelvic pain.^5,7

When can I check for a Diastasis Rectus?

Since almost all moms have some degree of abdominal separation, it is important to act as if you have a separation until at least 6 weeks postpartum. Remember, 60% of mothers have a DRA at 6 weeks postpartum and 32.5% continue to have a DRA after one year. It is safe to assume (and act/exercise as though) you have an abdominal separation until 6 months postpartum.

How do I measure for a DRA and what is normal?

Mota found that “palpation has sufficient reliability to be used in clinical practice.”² The following is how to palpate for a DRA and what is considered “normal” for a diastasis rectus abdominis.

First, lay on your back with your knees bent to a 45 degree angle with your feet resting gently on the ground. Next, make sure you are in a neutral position so your low back has a gentle curve and your butt is untucked.  Then as you exhale, gently lift your head and shoulders off the floor, tucking your chin and use your index finger and middle finger to measure based on the following palpation:

1. Location and width - there are three locations to palpate for a DRA and width is measured from side-to-side in fingertip width:¹⁰
   1. Just above the umbilicus: 2.7cm is normal (at most 2 fingertip widths)
   2. Midway between the pubic symphysis and the umbilicus: .9cm is normal
   3. Midway between the umbilicus and xyphoid process: 1.0cm
2. Depth or tension of the linea alba
   1. The linea alba is connective tissue and should be both strong and taut. There should be some natural flexibility but the tissue should resist the pressure of your fingers.
   2. If the linea alba is not able to optimally contract, you will feel as if your fingers are sinking in deeper when light fingertip pressure is applied.
   3. Depth can be measured as fingertip, knuckle or even finger depth or more specifically:
      1. Shallow: 0-3cm
      2. Medium: 3-6cm
      3. Deep: 6-7cm

*One other thing to look for as you lift your head is tenting or coning of the abdominal musculature. Although this is not specific to a diastasis rectus abdominis, it is commonly a sign that you are recruiting the wrong abdominal musculature and indicates instability that may need to be addressed.

How frequently can I check my DRA?

Not too often!  Checking too frequently can actually damage the tissue and weaken the muscles which makes the gap worse! If you “have to know” the most frequently you should check for a DRA is 4-6 weeks....give yourself time to heal from the inside out!

Keep an eye out for Diastasis Rectus- Navigating the Ins & Outs: Part 2 - The Causes of DRA

References:

1. Mota P, Pascoal AG, Carita AI, et al. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2015;20:200–5.
2. Reliability of the inter-rectus distance measured by palpation. Comparison of palpation and ultrasound measurements. Mota, Patrícia et al. Manual Therapy , Volume 18 , Issue 4 , 294 - 298
3. Corrêa MC, Corrêa MD. Puerpério. In: Corrêa MD, editor. Noções práticas de obstetrícia. 12ª ed. Rio de Janeiro: Medisi; 1999. p. 95-104.
4. Gilleard WL, Brown JM. Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Phys Ther. 1996;76(7):750-62.
5. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(3):321-8.
6. Rett, MT, Braga, MD, Bernardes, NO, & Andrade, SC. (2009). Prevalence of diastasis of the rectus abdominis muscles immediately postpartum: comparison between primiparae and multiparae. Brazilian Journal of Physical Therapy, 13(4), 275-280. Epub August 21, 2009.https://dx.doi.org/10.1590/S1413-35552009005000037
7. Sperstad JB, et al. Br J Sports Med 2016;0:1–6. doi:10.1136/bjsports-2016-096065
8. Boissonnault JS, Kotarinos KR. Diastasis recti I. In: Wilder E. ed. Obstetric andgynecologic physical therapy. New York: Churchill Livingstone, 1988:63–81.
9. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther 1988;68:1082–6.
10. Rath, A.M., Attali, P., Dumas, J.L., et al., 1996. The abdominal linea alba: an anatomo-radiologic and biomechanical study. Surgical Radiologic Anatomy 18, 281–288.
11. Coldron, Y., Stokes, M.J., Newham, D.J., Cook, K., 2007. Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual Therapy. Epub.

*Disclaimer:

The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.