Postpartum Urinary Incontinence is Common: Here’s How We Can Help

In Pregnancy/Postpartum by Lauren OpatrnyLeave a Comment

By Lauren Opatrny, PT, DPT, PHRC Berkeley & San Francisco

*all names have been changed to maintain patient privacy

 

Background

 

Rachel* is a 32 year old experiencing urinary incontinence after giving birth to her baby in December 2020. When she was eight months postpartum and still experiencing incontinence, her doctor referred her to pelvic physical therapy. Six weeks after giving birth via c-section, she began experiencing urinary leakage multiple times per day, which slowly improved over a few months, and then her progress plateaued. Upon initial evaluation, Rachel reported experiencing small amounts of urine leakage with coughing and laughing (stress urinary incontinence), as well as mild to moderate urinary urgency with occasional leakage on the way to the bathroom (urge incontinence). She also was experiencing mild to moderate discomfort with penetrative sex. She was mostly concerned about urine leakage with exercise. High impact and higher demand exercises would immediately result in leakage, including jumping rope, jump squats, deep squats, and jogging. She would also sometimes experience incontinence when hiking up or downhill when more fatigued. Prior to giving birth, Rachel loved participating in crossfit style workouts and never had incontinence. Her goals are to return to exercise without urine leakage and pain-free sex.

 

Other considerations:

  • currently breastfeeding
  • hiking one to two times per week for two to three miles, experiencing occasional leaking
  • current: mild strength training one to three times per week for ~20 minutes, always leaking 
  • prior to birth: combo strength and cardio, HIIT style, every other day, workouts are 20-60 minutes, no leaking

 

Objective findings

 

  • moderate to severe erythema (redness) of vestibule 
  • mild scar tissue restrictions of c-section scar
  • mild to moderate connective tissue restrictions of abdomen, bony pelvis, and medial thighs
  • moderate myalgia (muscle pain) of right and left levator ani and obturator internus
  • mild to moderate hypertonicity (muscle tightness) of levator ani muscle group
  • Diastasis Recti (abdominal separation): two finger width separation at umbilicus and below umbilicus 
  • Pelvic floor muscle strength: two out of five
  • Pelvic Floor muscle Endurance: four seconds
  • Repetitions: three before losing power
  • Quick flicks: two repetitions with good motor control, difficulty relaxing between contractions
  • Cough: absent pelvic floor co-contraction
  • Transversus Abdominis: present co-contraction, but weak and not consistent

 

Assessment, Plan, and Goals

 

Based on these findings, Rachel would benefit greatly from pelvic floor PT to reduce myalgia and hypertonicity, improve motor control, and improve strength and endurance of her pelvic floor. Her physical therapy plan of care consisted of patient education, manual therapy, neuromuscular re-education, and therapeutic exercise. She was approved for eight physical therapy visits, and we started with a frequency of 1x/week with a goal of reducing frequency to one time per week for two to four weeks as symptoms improved.

 

Short term goals (two to four visits):

  1. Rachel will be independent with a home exercise program in two weeks. 
  2. Rachel will have no instances of urgency with leaking to improve concentration at work 
  3. Tone and myalgia of obturator internus and levator ani will be 50% reduced to improve intimacy with partner

 

Long term goals (five to eight visits):

  1. Rachel will have zero to two instances per week of leaking with laughing/coughing/sneezing to improve quality of life
  2. Rachel will be able to tolerate a 30 minute workout without leaking urine
  3. Rachel will be improve PF strength to three out of five to improve tolerate to high impact activities like jumping rope without leaking urine
  4. Rachel will demonstrate improved PF endurance and motor control by 50% to improve tolerance to exercise

 

Follow-up Sessions

 

Manual therapy

First, we needed to address the hypertonicity and myalgia in Rachel’s pelvic floor muscles. She responded well to manual techniques including internal stretching of levator ani and obturator internus muscles bilaterally, and we saw consistent improvements visit to visit. We also addressed her scar tissue and connective tissue restrictions in her abdomen, bony pelvis, and inner thighs using a technique called skin rolling. It was important to improve the mobility of these tissues to ensure adequate blood flow not only to these tissues, but also to the surrounding muscles and nerves.

 

Neuromuscular Re-education

Addressing deficits in motor control, muscle activation, and coordination was a crucial component of Rachel’s treatment. Initially we worked on pelvic drop mechanics to retrain her muscle to know how to lengthen and relax actively, and we did this with diaphragmatic breathing in the happy baby pose. This was a great way for Rachel to continue decreasing muscle tightness and soreness between treatment sessions. We also worked on improving her coordination with “quick flicks,” which are small, quick kegels that emphasize the quick twitch muscle fibers of the pelvic floor. These types of contractions are especially important when experiencing stress urinary incontinence, because they improve the quick reaction-like contraction of the pelvic floor in the instance of a cough or sneeze. Rachel was also instructed to perform a kegel before coughing or sneezing (otherwise known as “the knack”) to help retrain the reflexive component of these muscles.  

 

Patient education

For Rachel, an important piece of her treatment was patient education including information on how breastfeeding affects the body and what can happen to vulvar tissues during this time. An area of the vulva called the vestibule can become red, dry, and irritated while breastfeeding, which can contribute to pain with penetrative sex. This is not a permanent change, and the integrity of the tissues improves once no longer breastfeeding. I provided Rachel with information on how she can manage these symptoms as she continues to breastfeed, such as using lubrication during sex, and consulting her doctor about using something like this, a natural moisturizer specifically made for vulvar tissues. 

 

Therapeutic Exercise

We initially began with supine trunk and hip stability exercises, which Rachel tolerated extremely well, so we quickly progressed to standing exercises. We worked on coordinating kegels with incline planks, modified mountain climbers, resisted side steps, and eventually mini hops with support. As I learned from Rachel, jump rope and “double unders” are an important and prevalent component of crossfit. Using some of the criteria from this guide [PDF], we incorporated key exercises to Rachel’s home program including single leg sit to stands, double leg mini hops, single leg hops, side shuffle, and squat jumps. The goal of these exercises was to strengthen and provide the necessary building blocks to eventually be able to perform jump rope without leaking.

 

Outcomes

 

  • mild erythema (redness) of vestibule 
  • no scar tissue restrictions of c-section scar
  • mild to no connective tissue restrictions of abdomen, bony pelvis, and medial thighs
  • no myalgia (muscle pain) of levator ani and mild of obturator internus
  • normal tone of levator ani muscle group
  • Diastasis Recti (abdominal separation): two finger width separation at umbilicus and one and a half finger width separation below umbilicus 
  • Pelvic floor muscle strength: four out of five
  • Pelvic Floor muscle Endurance: 10 seconds
  • Repetitions: 10 before losing power
  • Quick flicks: 10 repetitions with full relaxation at moderate to fast pace
  • Cough: present pelvic floor co-contraction
  • Transversus Abdominis: present co-contraction, good quality

 

As you can see above, Rachel’s objective measures improved from her initial evaluation. She met all of her short term and long term goals. Rachel had a total of six PT visits over 10 weeks (one initial evaluation and five follow-up sessions). After the first two treatment sessions, she reported no leaking with coughing or laughing, and pain with sex had significantly improved. She was very compliant with her home exercise program, and by her last treatment session she was able to perform HIIT style workouts at home including hopping and jumping activities without leaking! 

 

Discussion and Conclusion

 

There are many reasons why Rachel had success with pelvic floor physical therapy. First, we prioritized improving myalgia and tone of her pelvic floor muscles before focusing on strengthening. If a muscle is tight or painful, or both, the function of that muscle will be impaired. Rachel even mentioned that prior to starting pelvic PT, she had tried doing kegels but nothing improved. It was important to normalize tone and reduce soreness of her pelvic floor muscles to set them up for success once it was appropriate to incorporate strengthening. 

 

Additionally, we progressed and tailored the therapeutic exercises based on Rachel’s tolerance and specific goals. Rachel has a history of high intensity cardio and strength training, so it was important that her program incorporated the motor control training she needed, while still challenging her musculoskeletal system. It’s also important to recognize when an exercise or activity is too hard, and it can be helpful to have the guidance and expertise of a pelvic floor physical therapist to navigate the recovery process. Regardless of your experience after giving birth, just know that being able to return to the activities you love without urine leakage is possible! 

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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.

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