By Melissa Patrick, PT, DPT, RYT
Denise is an active 61 year old woman who enjoys spending time outside walking her dog, going to Zumba class and practicing yoga. When I met Denise, I could tell that she was energetic and lively but that her primary complaints of vaginal pressure were putting a damper on her lifestyle. I am happy to share her story of how she bounced back from struggling with symptoms of pelvic organ prolapse and utilized therapeutic yoga as part of her treatment plan to get there!
Denise visited me for the first time in the summer of 2021 when she found an increase in pelvic pressure after lifting her large Bernese Mountain Dog into the back of her car during March 2021. Denise described the sensation as ‘ballooning’ at the opening of her vagina, often made worse by walking, exercise and of course, lifting her furry friend. Denise had stopped most of her exercise routines for fear of her symptoms worsening and expressed worry that she may not be able to keep doing the activities that bring her joy.
Prior to coming to physical therapy, Denise was diagnosed by her gynecologist with posterior vaginal wall prolapse, also known as a rectocele. A rectocele occurs when the rectum protrudes through a weak posterior vaginal wall. Her doctor recommended kegels (pelvic floor muscle contractions) and also suggested pelvic floor physical therapy prior to trialing a pessary or surgical intervention. Not sure what a pessary is? We have you covered.
So what exactly was the reason for Denise developing a rectocele? And were kegels the answer to her problems?
Pelvic organ prolapse can occur for a variety of reasons, each of which may compromise the tissues of vaginal walls. Below is a list of risk factors, with Denise’s in bold. In her case, she had two vaginal deliveries that were both vacuum assisted and constipation, which I will talk more about later.
RISK FACTORS FOR PELVIC ORGAN PROLAPSE
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- Advanced age
- Greater parity
- History of vaginal delivery
- Instrument assisted vaginal delivery with forceps or vacuum
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- History of pelvic surgery
- Obesity
- Constipation
- Conditions that increase intra-abdominal pressure chronically (COPD, chronic cough)
When the pelvic floor muscles have weakened, as a result of many of the aforementioned risk factors, it is important to consider kegels as part of a treatment plan to strengthen the tissues that support the pelvic organs. However, kegels are not the ONLY answer. Keep reading to find out what else was included in Denise’s plan of care to address what we found during her assessment.
THE ASSESSMENT
To perform a prolapse assessment, the physical therapist will separate the patient’s labia using two fingers and have the patient bear down to see if tissue advances forward through the vaginal canal. Upon asking Denise to bear down with a closed glottis, the posterior vaginal wall protruded to the vaginal opening. This objective finding explains Denise’s report of ballooning and pressure at the vaginal opening and is considered a grade II rectocele.
When asked to contract her pelvic floor, Denise had a strength assessment of three plus out of five as graded with manual muscle testing, meaning a moderate degree of weakness. Pelvic floor muscles support the pelvic organs including the bladder, uterus and rectum. When the muscles are weak, they can contribute to prolapse because they are unable to support the pelvic organs.
Additionally, Denise presented with weakness of the abdominal muscles, which can contribute to weakness of the pelvic floor muscles. The transverse abdominis, your deepest core muscle, acts like a corset wrapping around the entire midsection. This muscle works together with the pelvic floor muscles and when we can properly contract the abdomen, it makes contracting your pelvic floor easier and more effective.
Based on my assessment, Denise and I discussed the following goals for her treatment plan:
- Use proper bowel habits (toilet posture, avoiding straining) and diet management to regulate bowel movements and avoid constipation.
- Accomplish appropriate motor control (ability to contract and relax) the pelvic floor muscles to improve overall strength and reduce prolapse.
- Establish a home exercise program, including therapeutic yoga postures, to alleviate and improve prolapse symptoms.
- Be able to resume exercise routine including Zumba with minimal complaints of prolapse symptoms
TREATMENT PLAN
Bowel Habits
While we were not able to change Denise’s gynecological history of vacuum assisted vaginal deliveries, we were able to tackle her constipation. Managing constipation is a main priority in treating pelvic organ prolapse. This is due to the fact that constipation causes increased strain on the pelvic floor muscles which ultimately weakens them. Additionally, increased abdominal pressure during straining to evacuate the bowels can also exacerbate prolapse. It may be that Denise’s chronic constipation was worsening her rectocele before coming to pelvic floor PT.
Denise also has Type II Diabetes. She reported that increases in her blood sugar could cause an increase in the need to strain with bowel movements. Denise understood the importance of managing her diabetes, to reduce constipation. Denise incorporated licorice, prunes and more olive oil into her diet, all of which supported a more smooth move. We discussed the importance of proper hydration and a high fiber intake to support healthy bowel movements, too. Of note, diabetes poses a risk for complications during surgery so, it was important for Denise to try and avoid surgical repair for her prolapse.
Motor Control
When I met Denise, she had started practicing kegels, as recommended by her gynecologist, and she felt like this was helping so far. However, as many women report, Denise was unsure if she was doing the kegels correctly. In fact, research shows that greater than 30% of women are performing kegels incorrectly. If you are practicing kegels, for any number of reasons, check with your local pelvic PT to ensure you are using your pelvic floor muscles correctly with good motor control!
Denise and I worked together for at least three appointments to fine tune her ability to contract the pelvic floor muscles with appropriate breathing mechanics and use of her transverse abdominis muscle. She practiced kegels in a variety of positions, up to 50 contractions per day, and was able to use her core muscles to help her get good pelvic floor contractions. Denise was starting to feel better around the fourth visit and she was only noticing her symptoms when walking her dog on the leash.
Therapeutic Yoga
A turning point for Denise in her treatment plan was the time in which we decided to incorporate therapeutic yoga. Therapeutic yoga is yoga instruction specifically tailored to meet the needs of an individual’s body – we use props like blankets, blocks, and bolsters to make postures accessible, enjoyable, and effective despite physical limitations. Because Denise already practiced yoga, she was eager to learn what postures could help reduce her symptoms and maybe even improve them.
I offered Denise yoga postures like supported bridges and legs up the wall (see below) in which we used props to elevate the pelvis. When the body is placed in inverted positions like these, it decompresses the pelvic floor muscles and can alleviate sensations of pressure or heaviness. Both of these yoga postures are wonderful to practice at the end of the day to decrease prolapse symptoms.
Additionally, inverted yoga postures can be great to get into to practice kegel contractions because gravity acts as an assistant to lifting the pelvic floor! Denise practiced supported bridge pose during pelvic floor endurance contractions, meaning she would hold a pelvic floor contraction for up to one minute while continuing to breathe in the inverted position. Denise found that the supported bridge pose allowed her to feel successful in practicing these longer holds of the pelvic floor muscles.
Caption: Supported bridge on a yoga block to alleviate pelvic pressure and improve kegel contractions
Caption: Legs up the wall to alleviate pelvic pressure and heaviness at the end of a long day on your feet.
Progress
Consistency is key when strengthening the pelvic floor – Denise was committed to her exercises daily and it showed! By the fifth visit, her pelvic floor muscle strength had increased to a four plus out of five on manual muscle testing and her complaints of vaginal heaviness and ballooning were less and less frequent. Her bowel movements had normalized and she wasn’t straining at all.
We continued to refine Denise’s breathing mechanics both with kegels as well as with lifting heavier things (like a big, furry dog). To reduce increased intra-abdominal pressure when lifting, it’s very important to do ‘Exhale on Exertion,’ meaning breathe out when you move! Exhaling lifts the diaphragm, supporting lifting of the pelvic floor, too. If we hold our breath when we’re lifting anything, it increases the pressure in the abdomen and can worsen prolapse symptoms due to increased strain through the pelvic floor.
Return to Exercise
By the sixth visit, Denise was holding her pelvic floor endurance contractions for a full minute seated and she had started to get back to Zumba dancing for up to 30 minutes before she would start to feel symptoms. She was thrilled to be able to finally get back to her dancing as it brought her significant joy! Additionally, Denise and I were able to practice therapeutic yoga together for a full hour without her having any increase in her symptoms.
By the seventh visit, Denise was lifting kayaks and furniture without any increase in symptoms – this was huge as Denise started to feel uninhibited in her active lifestyle. She even started swimming as the summer months progressed and didn’t have any increase in symptoms. We rounded out Denise’s care with a strong home program to target her core and glutes to ensure that the large muscle groups around her pelvis would support long term strength gains of her pelvic floor.
Upon discharge, Denise was beaming with excitement that she was able to return to the activities that she loved. Denise was now empowered with tools and tips to keep her pelvic floor strong, to reduce increased strain on the pelvic floor and to have smooth bowel movements. Denise expressed how much she was impressed by what she had learned in pelvic floor physical therapy and was grateful that we had taken a holistic approach addressing her diet, her movement patterns and even incorporating therapeutic yoga.
See below for what Denise had to say about her time receiving treatment with PHRC:
I was so grateful to have been referred to Melissa by my gynecologist. I had been experiencing discomfort due to a prolapsed vaginal wall. During my first visit Melissa and I spoke about my condition, and she talked me through everything that she would be doing which was a huge comfort!
With each different exercise, she would explain ahead of time so I would feel as comfortable as possible. She continued in this way with every session. After each session, Melissa sent me home with written exercises to practice. These were incredibly helpful.
Early on my sessions were weekly and Melissa always responded with positive progress because I was following her exercise regime. As we progressed, I would see Melissa every other week. Melissa also offered some optional yoga sessions which she guided me through. They were fantastic! I could then practice these yoga exercises at home.
Pelvic exercises have now become part of my daily life. I no longer need to have Pelvic PT but know that Melissa is there if I need her. I have gained so much strength and physically feel better since Melissa educated me! I do not think I will ever need surgery now that I have had Melissa’s professional help!
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.