We live in a different time. I remember when chat rooms and meeting people from the internet was the plot line for a Lifetime movie. Now, we get in cars driven by strangers and fall in love via sophisticated algorithms and profile pictures. What a time to be alive! It is pretty apparent that technology plays a huge role in our lives. Since I live in the tech mecca of San Francisco, I am surrounded by techies and have connected with several start-ups that specialize in a field that I hold very near and dear to my heart: sex! At first, I thought that I had discovered a small niche in the tech community; now I know that technology and sexual health have quite the relationship, one that is more extensive than you might guess.

 

These days, the role of technology in sex is so much more than online pornography, although that market is still booming (or so I’ve heard). First, there is a whole wide world of alluring apps. There are apps, such as Kindu and Undercovers, that allow you and your partner to find new sexy things to try together. Think R-rated truth or dare, but sans slumber party with the added bonus of being able to potentially play on your commute! There are apps that give you ideas for new sex positions to try or even places to try them in. Finally, there are the obvious hook-up dating apps, including some that help you find a third (or fourth) should you be in the mood for some late night company.

 

Then there are some apps with not-so-carnal intentions, such as Tabú, a start-up that I have recently become involved with as a “sexpert.” And yes, my parents are “so proud.” Tabú helps promote sexual education via an app that allows its users to post questions and receive answers from their peers, as well as “sexperts,” who have been approved by Tabú as being knowledgeable in the field of sexual health. Tabú also has a college ambassador program to allow college students to provide quality sex education via campus workshops . Per Mia Davis, the founder of Tabú, “the goal of Tabú is to empower ‘millennials’ to take control of their sexual health. We understand that misinformation is rife in sexuality, and to truly break down the myths and taboos, we need to provide young people with answers. We believe that to open up a dialogue, we need to approach young people where they are – their phones, social media, and for college students, on their campuses.”  With more and more people using smartphones and apps to interact, having resources to provide solid education to people is crucial. And education can be as simple as knowing about your own body. As you know, I am a big advocate for getting to know yourself, which I discussed at length in this post. Luckily, there are many apps that allow people to learn all about their sexual health and health in general. Certain apps, such as Clue and Glow,  allow people to track their menstrual cycle, ovulation and other details relating to fertility. Some, such as Pelvic Track, even allow individuals to track symptoms related to pelvic floor dysfunction, such as pain and incontinence.

 

Some apps even connect with other devices to help improve pelvic floor motor control ( like a fitbit for your vagina). Here is one example. Another company, Lioness, has developed a “smart” vibrator that helps users to better understand how they experience sexual pleasure. The vibrator pairs with an app that provides biometric data about how quickly the user becomes  aroused and how long it takes to orgasm. The app allows the users to share this information with their partner. Some other vibrators on the market even allow your partner to control the device from afar via their cell phone! This can be useful for long distance relationships or for patients with pelvic pain who cannot tolerate penetration but still want sexual intimacy with their partner.  

 

Intimacy is a key word. Smartphones and laptops have almost become a silent partner for most of us. It brings us information from other people that makes us feel like we are in constant contact without having any real contact at all. This brings me to one of the downsides of the internet and technology in general: everyone has access to it and can therefore contribute content. I frequently see patients who — terrified after reading about someone who was bed bound with pelvic pain for five years  — ask, “Will that happen to me?” The thing I remind my patients is that it is impossible to know who  your new internet “friend” really is. The person writing could be a thirteen year old teen who thinks it is hilarious to post in forums for people with chronic pain. Why? We may never know. Just like Pokemon-Go’s popularity, some things may never make sense. Just like the person who posted that he cured himself with some wonder-herb and is living the pain-free dream. Maybe he did, and that is great, but that doesn’t mean he has a medical background or any knowledge about your unique history and symptoms. In other words, Basically why should internet user #10065 be trusted to give you advice? The internet is not the end-all, be-all of information. I mean, Dr. Google didn’t even go to medical school! However, you can find a lot of well researched information online. Please refer to Liz’s post on determining what articles are legitimate.  Yes, the internet can create great communities as a way to form support groups of people who share similar experiences, but remember to, always take information with a grain of salt.

 

Now, if you think the present world of sex and tech is amazing, wait till you hear what the future holds. Love and sex with robots may be here sooner than we think. I wonder, will the legalization of robot marriage be a future debate topic? Will 3-D printed robot babies be the new norm? The ethical and philosophical questions that go along with a robotic romance are endless, and if I am brave enough, I may explore it in a later post (or while watching Westworld). Sex-bots may still be in the future, but this sweet virtual reality sex jumpsuit is currently available in — surprise — Japan! While these developments make me question what this means for the future of intimacy and relationships, virtual reality and robots may have a positive impact on controlling STD/STIs and unplanned pregnancies. Furthermore, this type of technology may let you discover your own wants and needs  without the pressure of a (human) partner being present.

 

As a provider, I find the potential future impact of technology on sexual health both fascinating and at times frightening. Someday, will I be treating patients who can’t have sex with their robot husbands? Or will I be treating robots which have such advanced Artificial Intelligence that they have chronic pelvic pain and are unable to function as “human beings?” But what scares me is this: what if I already am?

By Admin

 

During pregnancy and the postpartum period, many women suffer from both functional and cosmetic issues caused from the widening of the abdominal wall from stretch and pressure generated from the growing uterus. This stretching can result in a separation of the rectus abdominis muscle, known as a diastasis recti (DR).  Diastasis recti occur in approximately 66% of women in their third trimester of pregnancy ¹, many of which continue to suffer even 1-year postpartum, despite physical and occupational therapy or exercise programs designed to close this gap. In addition to the pregnant/postpartum population, others can suffer from this as well, including athletes, babies, and even patients who have undergone laparoscopic surgery such as hysterectomy, endometriosis, and prostatectomy.

 

Malinda wrote a great blog all about DR that you can read here that discusses functional limitations a DR could impose, how to check for it, and some basics on how to close it. This blog will focus on the ongoing debate of what researchers and clinicians believe is the best way to rehabilitate diastasis recti.

 

Is it really important that there is a wider gap than before pregnancy or surgery? Should we focus on crunches, abdominal bracing, or surgery? What should be done when exercise is not enough? And ultimately, how does one know when someone may require surgical intervention?

 

Anatomy of diastasis recti

 

The rectus abdominis is what we commonly think of as our six-pack muscle that connects from our sternum all the way to our pubic bone. We have two of them, one on the right and one on the left, that are separated by a dense band of connective tissue known as the linea alba. The linea alba is made from a continuation of our internal obliques, external obliques, and the transverse abdominal muscles.

 

What is the function of our abdominal muscles?

 

The function of the abdominal musculature is to resist changes in intra-abdominal pressure (IAP), and transfer forces between our right and left sides during movement such as lifting our legs, twisting, etc. When there is a widening of these muscles and the linea alba becomes lax, we lose this ability, and it is possible that we may experience low back pain, weakness, pelvic girdle pain, urinary incontinence, and in time, even pelvic organ prolapse may occur.

 

What is normal?

 

In general, there is debate about how wide the inter-rectus distance (IRD) can be, and researchers have performed imaging in cadavers, as well as in women who have not had children (nulliparous), to determine what is “normal.” How wide and at which points to measure vary in the literature, and currently there is no international consensus in the best way to measure. Most recently, there was a study performed on nulliparous women that suggested a normal linea alba should be less than 15mm at the xiphoid level, 33mm at 3 cm above the umbilicus and 16mm at 2 cm below the umbilicus.³

 

The Debate

 

Most physical and occupational therapistss, trainers, and exercise programs that currently exist tend to focus on closing the gap between the rectus abdominis muscle bellies. At PHRC and many other clinics, we teach patients to pull the bellybutton to the spine (a draw-in maneuver that activates our transverse abdominis muscle also called a TrA contraction) and then with a towel wrapped around the widest part of the gap, do a mini abdominal crunch which activates the rectus abdominis muscle bellies and pulls them closer together. It has generally been thought that the TrA contraction will draw the muscle bellies of the rectus abdominis together and improve stability of the core, while abdominal crunches alone have been considered a risk for the development of DR. ⁴

 

The Research

 

There was a recent journal article released from the Journal of Orthopedic and Sport Physical and Occupational Therapy (JOSPT) that actually looked at the effect of a drawing-in maneuver (or TrA contraction) and the abdominal crunch in its ability to decrease the IRD.  Surprisingly, it showed that doing a draw-in maneuver caused a slight widening of the IRD, while the abdominal crunch in both the gestational period (during pregnancy) and postpartum periods showed a narrowing of the IRD ² – which has been the focus of rehab!

 

This was interesting because like I said before, abdominal crunches tend to not be the exercise of choice and have been thought to be a risk factor for DR. This also led to the question – does closing the gap really matter as much as we previously thought?

 

Technically, we do not just have patients do a draw-in maneuver, nor do we have them just do crunches or sit ups to correct the DR, we actually teach them a very specific way to do this correction exercise, and it involves a combination of the two exercises. In a very recent study by Diane Lee and Paul Hodges, they did look at what happens at the IRD with an abdominal crunch alone, and an abdominal crunch with pre-activation of the transverse abdominis muscle or a “draw-in” maneuver. What they found was that doing a draw-in maneuver with a crunch decreased the narrowing of the IRD compared to what would occur with an abdominal crunch alone. This still technically does not close the DR as well as we’d like, but it does increase the tension on the linea alba, which they propose is necessary to support the abdominal contents and to transfer force between the two sides of the abdominal wall.⁵

 

Currently, the goal of rehabilitating a DR is to reduce the IRD. This is based on the assumption that closing the gap will restore the function of the core and improve cosmetic appearance.  Lee and Hodges showed the opposite in their study, and demonstrated that while we are closing the gap, we are creating more laxity or distortion on the linea alba, which makes us less likely to restore the function of our abdominal wall; this will lead to potentially poorer cosmesis of the abdominal wall.

 

What to do now?

 

It seems that closing the gap may not matter as much as we previously thought, and instead of focusing on the width of the gap, we should be focusing on optimizing the functional ability of our abdominal wall to generate enough tension to stabilize us in order to perform the activities we do on a regular basis and this will vary individually.

 

If you suffer from a DR and have not been assessed by a physical and occupational therapists, start there! During their evaluation, the physical and occupational therapists will be able to identify functional and structural impairments that may be contributing to ongoing symptoms, and can either help you to continue to improve your function, or have the resources to refer you to a surgeon if conservative approaches have been exhausted.

 

Below is a list of criteria that would identify a good surgical candidate, your physical and occupational therapists can help determine if you would benefit from a surgical consult. To find out more about pregnancy and postpartum physical and occupational therapy, visit our website or our Pinterest page.

 

Who actually needs surgical intervention?

 

According to Dianne Lee, the criteria for referral to a surgeon are summarized below:

1.     The woman should be at least 1 year postpartum and has failed appropriate therapeutic approaches to restore function, resolve lumbopelvic pain and/or urinary incontinence.
2.     The inter-recti distance is greater than mean values, and the abdominal contents are easily palpated through the midline fascia.
3.     Multiple vertical loading tasks reveal failed load transfer through the lumbopelvis.
4.     The active straight leg raise test is positive, and the effort to lift the leg improves with both approximation of the pelvis anteriorly, as well as approximation of the lateral fascial edges of rectus abdominis.
5.     The articular system tests for passive integrity of the joint of the low back and/or pelvis (mobility and stability) are normal.

 

 

References:

1.     Diastasis Rectus Abdominis & Postpartum Health Consideration for Exercise training: http://dianelee.ca/article-diastasis-rectus-abdominis.php

2.     Mota P, Pascoal AG, Carita AI, Bo K. The immediate effects on inter-rectus difference of abdominal crunch and drawing-in exercises and during pregnancy and the postpartum period. J Orthop Sport PhysTher. 2015; 45(10):781-788.
3.     Beer GM, Schuster A, Seifert B, Manestar M, Mihic-Probst D, Weber SA. The normal width of the linea alba in nulliparous women. Clin Anat. 2009;22:706-711. http://dx.doi.org/10.1002/ ca.20836
4.     Blanchard PD. Diastasis recti abdominis in HIV-infected men with lipodystrophy. HIV Med. 2005;6:54-56. http://dx.doi. org/10.1111/j.1468-1293.2005.00264.x
5.     Lee D, Hodges PW. Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. J Orthop Sports Phys Ther. 2016;46(7):580-589.

By Shannon Pacella, DPT, PHRC Lexington

 

The pelvic floor is a phrase used very frequently here on the blog as well as in our clinics, but to those unfamiliar with this area of the body, it may still be this illusive mystery. I want to break down the pelvic floor into each of the muscles it is comprised of, in order for you to get a better grasp of what’s going on down there.

 

If you are partial to 3D visuals and videos, you can Take a Tour of the Pelvic Floor.

 

The pelvic floor is comprised of multiple layers of muscles that close off the bony frame of the pelvic outlet and are key in supporting the pelvic organs. To quote from our previous blog post: A Cock in the Hen House: A look inside the Male Anatomy, “Although the external anatomy is different, all the other internal muscles that make up the pelvic floor are the same for men and women. The muscles sit in the pelvis like a muscular bowl, providing support to the organs of the pelvis and assisting in bowel, bladder, and sexual function. In women, the pelvic floor supports the uterus, the bladder, and the colon. In men, the pelvic floor supports the prostate as well as the bladder and the colon.”

 

 

First let’s discuss the bones that make up the pelvis/pelvic girdle. The pelvic girdle is a basin-shaped ring of bones connecting the vertebral column to your femurs. The pelvic girdle contains and protects the pelvic organs and allows for attachment of the pelvic floor muscles.

 

 

The pelvic girdle is comprised of:

 

• Ilium: the largest pelvic bones – when you put your hands on your hips you are touching the ilium.
• Ischium: the part of the pelvis that you sit on (aka sit bones).
• Pubis: the front part of the pelvis that joins both sides together via the pubic symphysis.
• Sacrum: the sacrum attaches to the ilium via the sacroiliac (SI) joint.
• Coccyx: also known as the tailbone, and attaches to the lower part of the sacrum.

 

 

Now that you have some reference material, let’s go through each muscle one by one:

 

• Bulbospongiosus: in men, this muscle runs along the underside of the base of the penis and forces blood into the penis during erection, and aids in ejaculation. In women, this muscle runs from the clitoris to the perineum along each side, constricts the vagina, and forces blood into the clitoris.

• Ischiocavernosus: attaches from the pubic symphysis to the ischial spine on each side, and forces blood into the penis and clitoris during erection.

• Superficial & Deep Transverse Perineal: this muscle has superficial (thinner band) and deep (broad) fibers that run underneath the perineum – the space between the anus and vagina (in women) or base of penis (in men). Supports the prostate and vagina.
• Ischiococcygeus (aka Coccygeus): attaches from the tendinous arc of the ischial spine to the lower sacrum and coccyx. Moves the coccyx forward and supports the pelvic viscera.
  

 

 

• Levator Ani is a group of muscles (highlighted above in red) comprised of:
  • Pubococcygeus: attaches from the pubis to the lower sacrum and coccyx.
  • Iliococcygeus: connects with pubococcygeus muscle and attaches to the coccyx.
  • Puborectalis: wraps around the rectum to form a muscular sling.

• External Anal Sphincter: attaches to the tip of the coccyx and surrounds the anal canal. This muscle closes the anal orifice.

• Obturator Internus: attaches from the pubis and ischium to the femur, helps to turn your hip outward (lateral/external rotation). *Fun fact: tightness and/or trigger points in this muscle can refer pain to the coccyx/tailbone.

• Piriformis: muscle deep in the buttocks (underneath gluteals), attaches from the sacrum to the femur, also works to rotate the hip outward (lateral/external rotation). Tightness in this muscle can be linked to sciatica (nerve pain down the back of the thigh), due to its proximity to the sciatic nerve.

 

Whew! That was a lot of information to get through! Now that you have a better understanding of what the pelvic floor looks like, let’s go over some ways this complex area of the body may lead to pelvic floor dysfunction in men and women.

 

Pelvic Pain

• Vaginal/penile/scrotal/perineal or anal pain

• Tailbone/sacroiliac joint/pubic symphysis pain
• Pain that interferes with sitting and exercise
• Pain that radiates to the abdomen/buttocks/thighs

 

Urinary Dysfunction

• Urinary urgency, frequency, and hesitancy
• Urinary retention
• Pelvic organ prolapse & incontinence  
• Decreased force of urinary stream
• Pain/straining with urination

 

Bowel Dysfunction

• Constipation
• Fecal Incontinence
• Pain/straining with bowel movements

 

Sexual Dysfunction

• Pain with intercourse/penetration
• Pain post ejaculaton

 

I hope this helped to give you a better understanding of the pelvic floor anatomy.

 

 

 

References:

1. Carriere B, Feldt CM. The pelvic floor. Germany: Georg Thieme Verlag; 2006.
2. Netter FH. Atlas of human anatomy. 6th ed. Philadelphia, PA: Elsevier Inc.; 2014.