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):
- Rachel will be independent with a home exercise program in two weeks.
- Rachel will have no instances of urgency with leaking to improve concentration at work
- 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):
- Rachel will have zero to two instances per week of leaking with laughing/coughing/sneezing to improve quality of life
- Rachel will be able to tolerate a 30 minute workout without leaking urine
- Rachel will be improve PF strength to three out of five to improve tolerate to high impact activities like jumping rope without leaking urine
- 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.
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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