By: Rachel Gelman
Michelle is a 30 year old female referred by her gynecologist to us for pelvic floor physical therapy following the birth of her first child. Michelle had her son via vaginal delivery and she was roughly five months postpartum at the time of her evaluation with me.
She reports she had a second degree tear with “a lot of blood loss” which was repaired with stitches. She reports she experienced difficulty urinating after the delivery and the doctor had to insert a catheter. This catheter insertion sounded like it was a fairly painful and traumatic experience.
Her main reasons for coming to physical therapy were:
- Dyspareunia (pain with sex): She described this as a sharp pain with initial penetration that is in the perineum and around 6:00 in the vaginal opening. It can even be triggered if her husband touches her perineum. She usually cannot continue with sex once they start, but if they do try to continue the pain increases in intensity and feels like tearing. She has tried lubricants which has helped a little.
- Urinary Dysfunction: which included urinary hesitancy, difficulty emptying her bladder and urge incontinence. She reports a deviated stream that goes out at a 90 degree angle,” with difficulty emptying and having to double void with urination. She reported some episodes of urge incontinence and reported she would only leak small amounts of urine when it happened.
- Low back pain : She reported having low back pain that radiates into her hips that limited her ability to sit for more than five minutes and made it difficult to nurse her baby as this flared her back pain as well. She was back at work which required her to sit for longer lengths of time.
- Constipation:. She was taking colace daily due to constipation, was still pushing/straining with bowel movements. Having a bowel movement could relieve some of her low back pain. She did have a history of hemorrhoids during her pregnancy.
Her main goal for physical therapy at PHRC is to be able to have sex again, reduce her pain and understand how to work with and overcome her pain. She reported no medications at this time, other than colace as she was still breastfeeding.
The main findings from Michelle’s examination included:
- Significant scar tissue at the perineum that was hypomobile in all planes, tender to palpation and reproduced her symptoms.
- Moderate hypertonus of the superficial transverse perineal muscle which also reproduced her symptoms upon palpation.
- Increased (min–>mod) muscle hypertonus of the puborectalis, pubococcygeus and bulbospongiosus and ischiocavernosus muscles.
- Connective tissue restrictions suprapubically (minimal) and of the medial/posterior thigh (moderate) and bony pelvis (moderate). There were also trigger points in the adductors as well.
- Trigger points in the upper abdomen and muscles in the low back, primarily Quadratus lumborum, and these reproduced her low back pain.
- Impaired pelvic floor motor control. She was able to contract her pelvic floor with a ⅗ strength, but she had a delayed relaxation and a paradoxical contraction when instructed to bulge or lengthen her pelvic floor.
Based on her history and the objective findings I believe that as a result of the second degree tear during her delivery she developed significant scar tissue at the vaginal opening along with increased hypertonus of the superficial transverse perineal muscle. Since palpation of this area reproduced her symptoms, it seemed that this was most likely contributing to her pain with sex. The other musculoskeletal impairments could be contributing to her symptoms based on the muscles affected, their relationship to the pelvis and pelvic floor and that palpation of some of these structures reproduced her symptoms. The fact that she had impaired pelvic floor motor control could explain her incontinence, urinary hesitancy and constipation.
Based on these findings and my assessment I wanted her goals to include:
- Michelle will be able to have intercourse without pain.
- Michelle will report decreased severity of her low back pain by at least 50% to allow for improved sitting tolerance to better participate in work activities and with breastfeeding.
- Michelle will report no episodes of urinary incontinence.
The Plan & Treatment Highlights
I originally recommended Michelle be seen weekly for 8-12 weeks, yet I ended up only seeing her for a total of six visits. Treatment sessions focused on manual therapy techniques to decrease the myofascial impairments found upon the evaluation. This included myofascial release, myofascial trigger point release and connective tissue manipulation to allow for improved blood flow to the underlying tissue/muscles and improved tissue mobility. Manual release of the levator ani and urogenital diaphragm with emphasis on the transverse perineal, along with scar massage to the perineum, as this reproduced her symptoms and presented as the main driver of her presentation.
I instructed her in proper toilet position due to her difficulty lengthening her pelvic floor and her reports of pushing and straining with bowel movements which could further contribute to her hypertonic pelvic floor. I instructed her in performing myofascial release of the lower extremities using a foam roller due to the restrictions found on examination. I instructed her in the perineal/scar massage due the restrictions I found at the transverse perineal muscle and as the scar tissue in this area appeared to be the cause of her pain with sex which was her biggest concern.
After treating the myofascial trigger points in her low back she reported her symptoms had abated by the end of the treatment session. I instructed her in using a tennis ball in this area of her back at home so that she could do self myofascial release and maintain what was done during treatment. I also addressed the numerous trigger points in her upper abdomen and diaphragm. She reported she had “carried high” during her pregnancy and I observed that she was more of a chest breather. I instructed her in diaphragmatic breathing because I hypothesized that lack of mobility in her diaphragm could be impacting her pelvic floor as these two structures work in tandem. I noted her ability to relax her pelvic floor during treatment improved when she was doing the breathing exercises which supported my hypothesis.
As treatment progressed, she reported she had not had any episodes of urinary incontinence and was exercising more as her low back pain had also improved, but she had not attempted sex due to the fear that it would be painful. During the session we discussed the fear-avoidance cycle and how being afraid of pain could increase the likelihood that her brain would produce a pain signal. I discussed strategies to promote success and decrease the liklihood of pain with sex which included lubrication and positions to help passively relax the pelvic floor before and after sex.
She came in the following week and reported she implemented what we discused, and that they had sex and it was “awesome!” There was no pain with sex, her low back pain was improved and she was not having any leaking.
She continued to report improvements as her myofascial impairments resolved. She reported no low back pain, just stiffness, and reported no incontinence. She reported her urinary stream was “normal,” and that sex was still pain free and she was feeling more comfortable with it. She reported she was still taking colace, but it seemed like she was still taking it because she had been, not because she needed it.
Her last visit, she told me she was moving across the country, but she reported being symptom free, only having intermittent twinges of low-back pain.
Rethinking Postpartum Care Ted X Talk by Sara Reardon, aka The Vagina Whisperer