Physiotherapy to assist with pelvic health issues can cover a vast array of problems, including urinary or fecal incontinence, diastasis recti, dyspareunia, post-partum return to activity, pelvic organ prolapse, post-prostatectomy incontinence, and pelvic pain.
Specialized physiotherapy is becoming more established in the literature as a first-line of defense against incontinence and pelvic pain. Pelvic floor dysfunction can be caused by:
- Hypotonicity: contributing to stress incontinence and pelvic organ prolapse
- Hypertonicity: contributing to urgency, urge incontinence, chronic pelvic pain, dyspareunia, vaginismus, vulvodynia, pudendal neuralgia, interstitial cystitis, and chronic prostatitis
Kegels are not always indicated for pelvic floor problems. Sometimes they do more harm than good, and often they are NOT performed correctly. The Cochrane Collaboration 2010 concluded that physiotherapists with specialized training in pelvic floor rehabilitation (using internal examination to teach the exercises) should be the first line of defense, before surgical consultation, for stress, urge and mixed incontinence in women.
Our pelvic rehabilitation program will involve an exam of the muscles and connective tissues of the abdomen, buttocks and inner thighs, and often an internal exam to assess the tone, strength and endurance of the pelvic floor group of muscles. It has been said that assessing the pelvic floor without an internal exam is like an orthopaedic surgeon examining the knee through a pair of jeans—highly inefficient, and it would be difficult to determine how those tissues are working. An internal examination of the pelvic floor muscles is the gold standard. The individualized treatment may also involve:
- Comprehensive education
- Soft tissue release of internal pelvic floor muscles
- Muscle re-education
- Bladder retraining
- Strengthening of the pelvic floor muscles
- EMG/bio-feedback or electrical stimulation as required
Pelvic Floor Dysfunction
Dribbling or leaking is not a normal part of aging! Often the pelvic floor group of muscles is very weak with poor endurance, and can contribute to leaking involuntarily. Just doing Kegel exercises is often not enough, as the pelvic floor does not work in isolation. The right combination of strength, endurance, and control of these muscles is essential to improve continence. Whether you are a new mom who leaks when standing up or a woman in menopause who leaks a few drops with exercise, an individualized exercise program to fit your life is imperative to improve continence and get you back on track.
Pelvic Organ Prolapse:
Pelvic organ prolapse refers to the descending or drooping of any of the pelvic organs, including the bladder, uterus, small bowel or rectum. They may also be referred to as:
- Cystocele: A descent of the bladder into the vagina, the most common condition
- Uterine prolapse: descent of the uterus into the vagina
- Enterocele: Small bowel prolapse
- Rectocele: Rectum prolapse
Developing a prolapse is often due to putting increased pressure in the abdomen. Common causes can be pregnancy, labour and childbirth; obesity, chronic cough, hysterectomy and constipation. Symptoms of pelvic organ prolapse can range from a feeling of pressure/heaviness/fullness in the pelvis to an ache in the lower back, to feeling like something is falling out of the vagina. Some people report feeling no symptoms at all. Physiotherapy solutions would include specific and individualized exercises for strengthening the pelvic floor and other muscles that work together to support this region.
Diastasis Recti (DR) is a separation the rectus abdominis muscle that extends from the top to bottom of your abdomen. A DR often develops with pregnancy, and can settle on its own after 6-8 weeks post-partum, but sometimes it continues long after giving birth. It is also possible for a man with a larger abdomen to have a DR. Depending on the width and depth of your DR, there are specific exercises that should be done daily to allow these tissues to approximate, as well as other lifestyle modifications to consider while the abdominal muscles are improving.
Pelvic pain is pain in the lowest part of your abdomen and pelvis, and could be from several causes, including musculoskeletal sources. Musculoskeletal pelvic pain tends to be chronic, long-standing pain that could be dull or sharp, constant or intermittent, and mild, moderate or severe. Pelvic pain can sometimes radiate to your lower back, buttocks or thighs. Sometimes, you might notice pelvic pain only at certain times, such as when you urinate or during sexual activity. It has been more recently recognized that some pelvic pain, particularly chronic pelvic pain, can also arise from muscles and connective tissue (ligaments) in the structures of the pelvic floor. Occasionally, pelvic pain might be caused by irritation of nerves in the pelvis.
Physiotherapy to address the pelvic floor and surrounding muscles and tissues can be very helpful with:
It is an often painful disorder in which tissue that normally lines the inside of your uterus starts to grow outside your uterus, most commonly in the ovaries, bowel or the tissue lining your pelvis. In endometriosis, the endometrial tissue continues to thicken, breaks down and bleed with each menstrual cycle as it typically would, but now has no way to exit the body. The tissue surrounding it can become irritated and develop scar tissue and adhesions that my bind organs together. Treatment for endometriosis is usually with medications or surgery, but sometimes internal stretches and other pelvic floor muscle work can help with those adhesions and lessen pain. Generally, doctors recommend trying conservative treatment approaches first, opting for surgery as a last resort.
Painful intercourse can occur for a variety of reasons, and is defined as persistent or recurrent genital pain that occurs just before, during or after intercourse. This pain might be due to tightness of the superficial or deeper pelvic floor muscles and other tissues around that area. Physiotherapy including various massage techniques, muscle stretches, internal muscle work, and behavioural modifications can often be helpful to work though this pain.
The pudendal nerve branches off the very lowest part of the spine, and gives sensory and motor control to the perineum, external anal sphincter, sphincter muscles of the bladder and pelvic floor muscles. Irritation of the pudendal nerve could manifest as pain, itching, burning, or tingling and could extend into the groin, abdomen, legs, and buttocks.
Pudendal neuralgia can occur in men or women. Signs and symptoms can vary greatly between individuals, but could be:
- Pelvic pain with sitting, but improvement with standing or sitting on a toilet seat
- Discomfort with tight clothing
- Bladder and/or bowel symptoms (hesitancy, frequency, retention)
Physiotherapy for pudendal neuralgia would examine the pelvic floor, and other “core” muscles of the abdominals, lower back and hips to help with stretching and strengthening of any imbalances, neural mobilization techniques, possible trigger point release of the surrounding tissues.