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Postpartum Pelvic Pain: Be Like Sarah and Get PT 1st

In Pregnancy/Postpartum by pelv_admin5 Comments

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In mid-April, Fox News Health wrote an article on why postpartum moms need physical therapy.  (To see the article click here.)  As pointed out in the article, France, Netherlands, and Australia automatically provide postpartum moms with 6-12 pelvic physical therapy treatments. Meanwhile, here in the US postpartum moms are rarely told by their OB/GYNs to attend physical therapy. When a postpartum-related issue is brought up by a new American mom, it’s not uncommon for her doctor to respond with, “Well, you just had a baby.” This statement implies something like “You need to deal with it and eventually it might go away.” To illustrate the importance of pelvic physical therapy for postpartum moms, I would like to discuss Sarah’s case study. You’ll remember Sarah from the blog Coached Pushing vs. Maternal Pushing.  

 

When I initially saw Sarah she was a first-time mom who was 8 ½ months postpartum. Her main concern for attending physical therapy was pain with sex, medically known as dyspareunia. Sarah reported she delivered her baby vaginally. She stated she was in lithotomy position (on her back with her feet in the stirrups, like in the movies) and ready to deliver her baby when she felt a strong urge to push. She started pushing and the nurse had her stop. The nurse would not let her push until the doctor arrived, which was not until 20 minutes later. Sarah reported she pushed once and the baby arrived “fast.” She sustained a 3rd degree tear along the perineum, meaning that she tore from the perineal muscles down to her anal sphincter. Sarah stated she attempted intercourse once, sometime later, but stopped due to severe pain. During her evaluation with me, she described her pain as “like having razors” along the entrance of her vagina. She reported a “hard nodule” right at the entrance, which was painful during sex. Sarah had been unable to participate in sex due to this pain, and had felt discouraged about her plan to have multiple children. She had confided in her friend about her pain and her friend had encouraged her to seek pelvic physical therapy. That’s when she came to see me.

 

Pelvic Physical Therapy Examination and Assessment

  1. I checked her abdominal wall for a diastasis recti (separation of the abdominal muscles), because all postpartum women should be evaluated for this no matter what;
  2. I looked for connective tissue restrictions throughout the abdomen, suprapubic, bony pelvis, and medial and posterior thighs;
  3. I observed her vulvar tissues for any abnormalities, such as de-estrogenized tissue and hypertrophic scar;
  4. I palpated her perineum scar, checking for mobility and hypersensitivity;
  5. I palpated the muscles in her abdomen, medial thighs, buttocks, and pelvic floor for tightness and myofascial trigger points;
  6. I assessed her motor control of her pelvic floor muscles.

 

The reason why I assessed these particular components was because I wanted to know whether Sarah’s pain with sex was caused by muscle tightness, trigger points, and/or scar sensitivity. I also wanted to know whether any abdominal wall instability was contributing towards her pelvic floor dysfunction. The pelvic floor can compensate due to transversus abdominis (TrA) muscle weakness and a diastasis recti. Fortunately, Sarah did not have a diastasis recti, and her TrA muscle strength was normal. Her connective tissue was also normal, as was the muscle tone throughout her hips and buttocks.

 

What I did find with Sarah was scar tissue restrictions along the perineum where the tearing had taken place. The scar tissue was hypertrophic (raised), hypersensitive, and hypomobile (lacking movement). The “hard nodule” she was feeling during sex was this hypertrophic scar. Hypersensitivity to touch along the scar was contributing towards her pain. Guarding from this pain was contributing towards her pelvic floor muscle tightness, eliciting myofascial trigger points, which were then in turn creating more pain and feeding into the pain cycle.

 

Physical Therapy Treatment Plan

 

My initial treatment plan with Sarah was for her to come in once a week for 4-6 weeks for a session consisting of scar mobilization (breaking up scar tissue), myofascial trigger point release, Thieles massage, and neuromuscular re-education with emphasis on pelvic floor voluntary relaxation, combined with a home program. This home program initially consisted of perineal massage with scar mobilization and pelvic floor drops. We also discussed proper positioning for bowel movements (because I tell everyone about that), and why kegels were not appropriate for her.

 

On Sarah’s 3rd visit, I showed her husband how to do scar mobilization, since she expressed a preference for having her husband help. I also educated her husband on perineum massage prior to sex, in order to help decrease the discomfort Sarah was feeling with penetration.

 

On Sarah’s 4th visit, she reported that she had not been consistently having her husband help with scar mobilizations, and that she was having a hard time reaching the scar herself. We introduced a small dilator to help her with releasing the transverse perineal muscles and softening the scar tissue. In later visits, she reported being very consistent with the dilator.

 

Sarah completed a total of 11 pelvic physical therapy treatments. I saw her weekly for 6 visits, after which I re-evaluated her and came up with a new treatment plan. She reported a significant decrease in the pain intensity, from 9/10 to 1/10 on the pain scale. I spaced out her treatment to once every 2 weeks, as a result of the improvement in her symptoms, and her compliance with her home program.

 

On Sarah’s 10th visit, she reported having had sex regularly, however she had felt pain with initial penetration for the first 30 seconds each time. We continued with her treatment plan, and on her 11th visit, Sarah reported having had no pain with sex that week.
Sarah’s symptoms are all too common with postpartum moms, but as you’ve seen in this case study, physical therapy can help resolve these issues, and have a huge impact on a new mom’s quality of life. In my opinion, France, Netherlands, and Australia are doing it right: it’s time we in America caught up.

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.

Comments

  1. Thank you so much for this article. I teach fitness to pre and postnatal women, and I make a point of educating women about the great work Pelvic Floor PTs do for women. I will share this article with all my clients.

  2. Melinda,
    Thank you so much for sharing this case study! I’m a fellow PT who is just starting to dip my toes into this area of study as I am a new mother myself (and newer PT to boot). My interest in pelvic PT began in school but really grew once I became pregnant! We really can make a difference as PTs and need to change the way postpartum mothers are being cared for! I am so excited to pursue this area and look forward to being part of the change in treating postpartum mothers.
    I’ve started taking pelvic floor CEU courses to try to follow this new found passion. I would love any advice from someone experienced in this area. It’s not something that is offered anywhere near my location in FL and I really want to change that! It would be great to have some mentorship or someone to bounce things off of. It’s time to jump on board with the Netherlands, France, and Australia!

    1. Author Malinda Wright says:

      Hi Kristin,
      Thank you for your comment. It’s nice to hear from other physical therapist. If you’re looking for a PT who can help with mentoring, I recommend contacting Tracy Sher. She may be able to direct you towards a mentor. http://www.sherpelvic.com/
      Kindly,
      Malinda

  3. This condition destroyed my sex life and my marriage. Having enjoyed sex through my 20s, I had my children through my early to mid-thirties. I had post-partum scar tissue as described here; an operation to remove the ‘hard nodule’ about 18 months later, but no physiotherapy … I’d not even heard of such a thing.
    Now, 25 years on with no penetrative sex for 20 years or more (it seemed to get worse over time) my relationship is bitter and destroyed.
    Heart-breaking.

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