By Jillian Cerda Ramos, PT, DPT, MFDc
*all names have been changed to maintain patient privacy
Introduction
Pregnancy is truly a life-changing event in more ways than one: bringing a baby into this world is no easy feat, and neither is the recovery process! Just like how each pregnancy is so different, each postpartum experience can be so unique too. Fortunately, pelvic floor physical therapy can help manage or treat a wide variety of conditions that are commonly seen after birth, including pelvic organ prolapse, urinary/bowel dysfunction, diastasis recti, and more.
However, there are times where surgery may be necessary to address conditions that develop from traumatic births. In such cases, pelvic floor physical therapy can help with the recovery process, as well as to improve symptoms that may arise as a result of these surgeries.
Read on to find out about Charli’s* postpartum journey through PHRC and how she was able to achieve her PT goals!
History and Chief Concerns
Charli is a 39 year old who came to PHRC with a chief concern of pain with penetrative sex. She had undergone a C-section with her first birth in 2016 and a forceps-assisted vaginal birth in 2019, from which she had sustained a grade 3C tear and uterine/bladder prolapse. She had previously seen another PHRC physical therapist following her 2019 VBAC, as she was also experiencing urinary frequency, urgency, and incontinence. After having very minimal improvement with PT, Charli underwent surgery for a hysterectomy, mesh procedure/urethral sling, and grade 3C repair in January 2020. While her symptoms of heaviness and urinary function improved, she noticed pain with intercourse after the surgical procedures, as well as notable pelvic muscle soreness and tightness that makes it tough to evacuate stool without massaging her perineum. To help improve scar tissue mobility, she also received two injections after the surgeries, which helped minimally with reducing pain during sex. Because of the COVID-19 pandemic, Charli was unable to attend PFPT in person immediately following the surgeries and procedures; she sought pelvic PT again in late summer of 2021.
Other notable considerations:
- Bowel function: history of hemorrhoids since her 20s
- Current exercise/activity levels: Exercises four to five days/week (runs 10-20 miles/week in 5-mile increments; HIIT classes two times/week)
- Stress level: moderate (five out of ten)
- Goal for PT: improvement in pain
Initial Findings
Upon initial evaluation, Charli presented with moderate-severe connective tissue restrictions throughout her lower abdomen (notably along her C-section scar), adductors, and bony pelvis (left > right). Her pelvic floor muscles (notably obturator internus and the levator ani group) presented with left > right moderate-severe muscle tension at baseline that was moderately tender to palpation; examination of the external anal sphincter revealed normal muscle tension. In terms of motor control, Charli had the most difficulty with performing pelvic drops and relaxing after any type of pelvic floor contraction.
Plan of Care and PT Goals
Given these findings, she appeared to be a great candidate for pelvic floor physical therapy (one time/week) to improve tissue mobility, decrease myalgia (muscle pain), and address deficits in motor control. Her physical therapy plan of care consisted of patient education, manual therapy, neuromuscular re-education, and therapeutic exercises. Charli was initially approved for 12 visits through her insurance provider.
Short term goals (two to four visits) for PT included:
- Charli will be independent with a home exercise program.
- Charli will demonstrate proper diaphragmatic breathing to facilitate pelvic floor relaxation.
- Charli will demonstrate proper pelvic drops independently x10 to facilitate pelvic floor relaxation.
Long term goals (12 visits) for PT included:
- Charli will be able to have at least 50% improvement in connective tissue restrictions throughout the medial thighs and abdomen.
- Charli will be able to evacuate without straining or requiring perineal massage.
- Charli will be able to tolerate penetrative intercourse with little or minimal pelvic pain at least 75% of the time.
Follow-up Sessions
During our follow-up sessions, Charli responded very well to manual therapy throughout the urogenital triangle, obturator internus, and levator ani muscle group bilaterally. She would notice improved levels of myalgia through these areas after treatment, which carried over between sessions over time. To help facilitate the gains we would make in pelvic floor tissue mobility and myalgia, we worked on pelvic drop mechanics to retrain her muscle to know how to lengthen and relax actively. Initially she required a moderate amount of verbal cues and was best able to feel the drops in a modified happy baby pose (JPG).
We also worked on scar tissue mobilization of her C-section scar, as scar tissue restrictions may be a contributing factor to pelvic pain. Because Charli also had moderate myofascial tension throughout her adductors that could be contributing to her symptoms, she benefited from manual therapy through these muscles, as well as self myofascial release (using a foam roller) and quadruped adductor rocks to improve tissue and hip mobility. Of note, she sustained an acute left groin injury from playing soccer just before her eighth visit, which had resolved by the following session.
Sometime between her third and fourth visit, Charli also began experiencing insidious onset of intermittent muscle tightness throughout her left low back which warranted attention, given that lumbar spine mechanics can influence pelvic floor mechanics due to its proximity. She responded well to a combination of MFD, stretching of the quadratus lumborum muscle, trigger point release, and spinal/hip mobility drills.
Outcomes
Charli met all of her short term goals and was able to perform diaphragmatic breaths and pelvic drops independently without any compensatory strategies or requiring any feedback. In terms of long term goals, tissue mobility throughout her abdomen, adductors, and bony pelvis region also improved, even after sustaining the acute left groin injury from soccer. She also noted decreased difficulty with bowel movements since starting PT. But most of all, Charli reported that penetrative sex was much less painful, especially around the area of the perineal repair, which was notoriously the most uncomfortable area for her–in fact, she began feeling improvements after her first visit! If she were to continue with PT, she would have been an appropriate candidate for less total visits at a decreased frequency to address any remaining tissue restrictions and discomfort; however, she made great progress overall and was also able to continue with her home program to self-manage her remaining symptoms.
Discussion and Conclusion
There are many factors that may have contributed to Charli’s overall success. First, it is important to acknowledge that there may be instances in which surgical interventions are necessary: with Charli, she recognized that her first round of pelvic floor physical therapy was only able to help with so much after such an involved vaginal birthing experience. Part of her success was getting the surgical interventions and procedures she needed. However, oftentimes, folks who undergo pelvic floor-related surgeries and procedures do not recover well or experience new symptoms after these interventions if they do not receive adequate rehabilitative care. Despite having to hold off PT due to the pandemic, Charli was eventually able to get the care she needed to reach her goals.
Part of what makes physical therapy successful is being able to zoom out of the affected area and determine what else may be contributing to symptoms. With Charli, she was essentially experiencing painful sex and difficulty with bowel movements because her pelvic floor was not able to move optimally. Her plan of care not only sought to improve the mobility and motor control of the pelvic floor itself but the surrounding areas as well. By determining the roles that her C-section scar, low back tension, and adductor/bony pelvis connective tissue restrictions played, Charli’s pelvic floor function greatly improved as well.
Postpartum recovery can be a long and taxing process, some more than others (especially when we throw a pandemic into the picture!). Know that, regardless of your experience, you don’t have to go at it alone–we at PHRC are here to help! If Charli’s story resonates with you, please do not hesitate to reach out to us.
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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.
Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page.
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