By: Rachel Gelman, DPT
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.
Objective Findings
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.
The Assessment
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.
Additional Resources:
Rethinking Postpartum Care Ted X Talk by Sara Reardon, aka The Vagina Whisperer
Why all new moms deserve postpartum physical therapy
Katie’s Crib: Get to Know Your Pelvic Floor
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.