Elena is a 35-year-old female who was referred to pelvic floor physical therapy by her ob/gyn with a diagnosis of prolapse. (Want more information on a prolapse diagnosis? Check out a detailed blog post on the topic here.)
Elena’s chief complaints stem from giving birth to her first child via vaginal delivery six months prior to her evaluation. After the delivery, she says she “felt something bulge out of her vagina.” However, at the time of her evaluation she no longer reports this feeling.
Following her delivery, Elena says she did Kegels to strengthening her pelvic floor muscles. She said she could tell her muscles were weak because she noticed that when she was urinating she was unable to stop the flow of her urine if she wanted to. Also, with sexual intercourse, she complained of “feeling swollen afterwards, but not having pain.”
Lastly, Elena reports that she has always had “problems with bowel movements”. She uses Colace, a stool softener, daily for hard stools, and occasionally has to manually evacuate stool with her finger. In addition, she says that she constantly has to strain to evacuate, even when her stool is soft.
Therefore, her main functional limitation is that she is unable to have a bowel movement without straining or resorting to manual evacuation.
Elena’s goal for treatment was to “do the right thing and take care of her body after childbirth.” However, after I learned of her history of bowel problems, establishing health bowel elimination became a primary goal.
Because Elena was postpartum, my assessment plan was fivefold:
- Check for a possible diastasis recti. A diastasis recti—a separation of the abdominal muscles—is a relatively common outcome of pregnancy; however, it can be problematic because it causes decreased abdominal support that compromises pelvic floor function and can contribute to prolapse.
- Evaluate the strength of her pelvic floor muscles in order to assess whether the muscles are adequately supporting the pelvic organs.
- Assess the amount of laxity in the vaginal wall. Laxity of the vaginal wall, which causes prolapse, could potentially cause the bowel symptoms Elena complains of.
- Check for any external or internal restrictions that are contributing to the weakness of the pelvic floor muscles. Specifically, I was looking for muscle hypertonus and/or trigger points in her levator ani muscle. The reason is that: restrictions in the levator ani can cause shortening of the pelvic floor muscles and hence cause the muscles to not activate fully and not fully support the pelvic organs.
- In addition, I planned to check her rectus abdomins muscles for trigger points. That’s because if a diastasis recti is present, I want to make sure that strengthening was indicated for these muscles as opposed to having to release any possible trigger points prior to strengthening.
Here’s what I found upon evaluation:
Elena has a type of vaginal prolapse called a “rectocele”. As you might recall from our previous post on the topic, a prolapse is a weakening of the pelvic floor muscles as well as tissues of the vaginal wall, which results in a bulging of one or more of the pelvic organs into the vagina. A “rectocele” is one type of prolapse, and it occurs when it’s the rectum that descends into the vagina. This finding would be the reason behind Elena’s bowel problems.
I did not find any restrictions in her pelvic floor muscles, thighs, or abdomen: therefore, I conclude that tightness is not contributing to the weakness of the pelvic floor muscles.
However, I did find that the patient has a one-finger diastasis recti from which I conclude that her abdominals are not contracting and supporting her pelvic floor optimally thus leading to increased pressure on the pelvic floor muscles likely causing an increase in her prolapse.
Also when I did a strength test of her pelvic floor muscles I found them to be weak (with a grading of 2/5, and the ability to hold a contraction for only four seconds total). What this showed me is that the patient’s pelvic floor muscles are weak and not optimally supporting her pelvic organs.
Without appropriate pelvic floor strength and motor control (the ability to contract, relax, and/or bulge the pelvic floor optimally), evacuating stool can be a problem, as it is for Elena. People often strain in response to this difficulty, which causes a forceful lengthening of the pelvic floor muscles and unnecessary pressure on the vaginal walls and supportive connective tissue. (The pelvic floor muscles, in combination with these tissues, are collectively responsible for pelvic organ support.) This pressure in turn compromises the integrity of the vaginal walls and supportive connective tissue, and decreases the support these tissues can provide, leading to prolapse. So, strengthening the pelvic floor muscles can help counteract the laxity in these tissues.
In assessing this patient, I conclude that her prolapse may have been present prior to childbirth due to the difficulty she has had over the years with chronic straining and bowel movements. To be sure, lifelong chronic constipation can lead to a rectocele; therefore, the patient may have had this impairment prior to the birth of her baby.
In addition, she may have had a cystocele, (a “cystocele” is a type of prolapse where the bladder descends into the vagina) or even an increase in her rectocele immediately after childbirth causing the bulging sensation that she complained of immediately after giving birth. However, she did not present with a cystocele at the time of her initial PT evaluation.
As for her other symptoms, she likely has a feeling of being swollen after intercourse due to vascular impairments. Vascular impairments involve changes to the arteries, veins, and capillaries and hence can cause swelling. Her pelvic floor weakness and diastasis are likely due to pregnancy and delivery; both are likely contributors to her prolapse symptoms, i.e. her original feeling of something bulging out of her vagina as well as her bowel symptoms, and should be addressed in order to prevent further prolapse. The impairment that can be treated with pelvic floor PT is the pelvic floor muscle weakness. In addition, certain lifestyle modifications can help Elena achieve her goals.
Initial Treatment Plan
I counseled Elena about using a stool for proper bowel elimination posture. Here’s what I told her: bringing your knees up higher than your hips (similar to a squatting position) will change the angle of your rectum making it easier to pass stool. It will also help to relax the pelvic floor muscles during evacuation.
In addition, I discussed “vaginal splinting” in order to support the laxity that I found toward the rectum. This will help improve bowel elimination. (“Vaginal splinting” is when you insert one or two fingers vaginally in order to provide support to the wall of the vagina, which when there is a prolapse has laxity. This is important because straining can worsen the prolapse.)
Also, I gave Elena a home exercise program, which included “quick flicks” (contracting and relaxing the pelvic floor muscles) and “four second holds” (these are endurance holds of the pelvic floor muscles, four seconds was the time I chose since that’s how long Elena could hold a contraction for) and diastasis recti correction in order to increase her abdominal and pelvic floor strength to better support her pelvic organs.
My goals for the patient are as follows:
Short Term Goals (two to three weeks):
- Patient will be independent with initial home exercise program to commence strengthening of her pelvic floor muscles.
- Patient will have the tools to help improve bowel elimination in order to decrease straining and prevent her prolapse from getting worse.
Long Term Goals (four to eight weeks):
- Patient will be independent with final home exercise program to strengthen her pelvic floor muscles and to prevent her prolapse from getting worse.
- Patient will eliminate straining to have a bowel movement.
I believe Elena’s goals to be reasonable because as her muscles increase in strength and she changes her lifestyle (vaginal splinting, not straining to have a bowel movement, using a stool to have a bowel movement, and lifting items without applying increased pressure to her abdominal muscles) she will be able to prevent her prolapse from worsening. Pelvic floor exercises and abdominal exercises will help increase her pelvic floor strength. Other providers that may be necessary to include in Elena’s treatment plan are a gynecologist to reassess her prolapse and discuss additional treatment options, such as a pessary or surgery.
Summary of Treatment:
Home Exercise Program that includes:
- Quick flicks x 30 (to increase strength of the pelvic floor muscles)
- Four seconds holds x 30 (to increase the endurance of the pelvic floor muscles)
- Diastasis recti correction x 30 (to help close the diastasis)
- Bowel elimination posture/splinting with her finger (to improve bowel elimination)
On Elena’s second visit, we reviewed her initial home exercise program and added “roll outs.” A “roll out” activates synergistic muscle groups of the pelvic floor to help improve a patient’s pelvic floor muscle endurance. (The external rotators of the hip and the transverse abdominus are both synergistic muscles of the pelvic floor.) Elena needed multiple verbal cues to perform endurance (the four second holds) and roll outs correctly.
On her third visit, she said it was still difficult to do her endurance (the four second holds) exercises at home and she noticed one incidence of stress urinary incontinence with lifting. After verbal cuing, she had improved ability to perform her home exercise program, and therefore roll ins were added to her home exercise program as well. A roll in is another exercise used to strengthen the pelvic floor.
On Elena’s fourth visit, she had a good understanding of her home exercise program. Her pelvic floor muscle strength had improved and also her endurance increased to seven seconds of being able to contract her pelvic floor muscles. Plus, her diastasis had improved; it was slightly less than one finger. Also Elena tried splinting with bowel movements with minimal help. I believe this did not help because of the degree of her prolapse (it was a grade II) and because of the chronic straining pattern she has had over the years.
Elena is beginning to increase her pelvic floor muscle strength and endurance in order to prevent her prolapse for getting worse. For improved bowel elimination, she will continue to try splinting and avoiding straining.
In addition, we discussed alternative treatment options for a prolapse such as a pessary or once she is done having children, surgery. The reason it is best to wait until after childbearing is finished is to ensure the prolapse does not reoccur necessitating further surgery.
Following four visits, Elena achieved her goals of becoming independent in her home exercise program so as to strengthen her pelvic floor muscles and not worsen her prolapse, and she was discharged from physical therapy with instructions to continue her home exercise program as well as her efforts to eliminate straining during bowel movements.