During pregnancy the female body goes through dramatic changes including hormonal changes impacting connective tissue, postural changes due to the change in centre of gravity, widening of the rib cage, increase pressure downward on the pelvic floor, often a change in bladder and bowel function. In some women these changes can lead to pelvic girdle pain, pain with intercourse and sometimes vaginal heaviness and incontinence. The good thing is there is so much that can be done to manage and treat these symptoms, to optimise the function of their changing body.
Physiotherapy can help with:
Pregnancy aches and pains including; hips, lower back, Pelvic Girdle Pain (PGP), ribs, abdominal muscles
Pelvic floor assessment and exercise prescription
Preventing the likelihood of incontinence and prolapse
From 35 weeks gestation physio can assist with birth preparation. The pelvic floor can stretch up to 3 times its resting length during a vaginal delivery and by preparing the body and the pelvic floor, we can help reduce the risk of damage on the pelvic floor during birth. This is done by:
Teaching optimal positions for labour and birth
Down training the pelvic floor including breath work, teaching you how to relax the pelvic floor and teaching you perineal massage (to decrease the risk of grade 3 and 4 perineal tearing)
Teaching effective pushing techniques
Postnatal physiotherapy appointment is recommended from 6 weeks postpartum (However if you have any concerns or pain prior to this please come in sooner). A comprehensive birth history will be taken and you will also be able to voice any concerns you may have.
Assessment will include:
Abdominal muscles to determine abdominal separation
Pelvic floor muscle assessment to assess any birth injuries and level of strength and endurance
Pelvis assessment and any other musculoskeletal concerns including rib, upper back and wrist pain
From the assessment we are able to:
Guide an individualised exercise program focusing on abdominal and pelvic floor rehab
Treat pelvic floor related conditions such as incontinence, prolapse, painful intercourse, anal sphincter tears, episiotomy recovery
Teach scar massage if necessary (abdominal or perineal) to decrease sensitisation in the area
Provide return to exercise guidance to meet your goals
URINARY INCONTINENCE
Urinary incontinence is any involuntary loss of urine. There are two common type of incontinence:
Stress Urinary Incontinence (SUI)
The leaking of urine with activates where there is an increase in abdominal pressure, such as coughing, sneezing, laughing, jumping and changing positions. This is often due to a defect in the connective tissue that supports the bladder and urethra and weakness of the pelvic floor muscles. Physiotherapy is considered the first line of treatment for SUI with 70 – 90% of women reporting their symptoms significantly improved or completely resolved following a targeted pelvic floor training program.
Urge Urinary Incontinence (UUI)
The involuntary loss of urine associated with a sudden, strong urge to urinate. Most people’s bladder will slowly stretch as it fills with urine and as it stretches you will get a desire to need to urinate, however you could normally hold if you need to. Sometimes the bladder can spasm and send a sudden, strong urge to the brain that it needs to empty, even when often it isn’t full. Some people may experience leaking as their bladder spasms and they to rush to the toilet, this is called Urge Urinary Incontinence.
Physiotherapy treatment of incontinence:
Physiotherapy will assess what factors are causing your incontinence and devise an appropriate treatment program to address and manage the symptoms and the problem, often including pelvic floor muscle training
Address any constipation and poor toileting habits that may be impacting your incontinence
Bladder re-training
Look at breathing mechanics, lifting techniques and any other appropriate biomechanical factors
In some cases a pessary may be fitted to help manage symptoms while working on the above factors
OVERACTIVE BLADDER (OAB)
An overactive bladder is the frequent and sudden urge to urinate that may be difficult to control.
This can result in:
Urinary urgency
Urinary frequency
Nocturia (going to the toilet >2x overnight).
Frequently associated with urge incontinence
Common causes:
Pelvic floor weakness or overactivity
Chronic constipation
POP
Low oestrogen
Bladder irritants (caffeine, artificial sweeteners, carbonated drinks, dehydration)
Assessment includes a detailed history of symptoms and other health conditions and medications, ruling out any infection or inflammation and commonly completion of a bladder diary.
Physiotherapy treatment of OAB:
Physiotherapy will always liaise with relevant health care practitioners to help manage symptoms
Addressing modifiable risk factors such as weight reduction, bladder stimulants
Ensuring good bowel habits and avoiding constipation
Bladder education along with bladder retraining and drills
Pelvic floor muscle training
Breath work
PELVIC ORGAN PROLAPSE
The symptomatic descent of one or more of the anterior vaginal wall, the posterior vaginal wall, and the apex of the vagina (Cervix/uterus) or vault (cuff) after hysterectomy.
The pelvic organs include the bladder, uterus and bowel which are held together by two support systems; the pelvic floor and the endopelvic fascia and ligaments.
Prolapse can occur if the pelvic floor is weak or injured, usually along side with some fascial damage, meaning the pelvic organs descend into the vaginal cavity.
The research tells us that between 40-50% of women over 50 will have some degree of prolapse. It also tells us that 1:2 women postnatal will experience prolapse symptoms.
Things that can cause pelvic organ prolapse:
Chronic constipation
Pregnancy and birth
Heavy lifting with poor technique
Post menopause
Genetics
Symptoms include:
Vaginal heaviness
A lump or bulge at the entrance of the vagina
Difficulty emptying bladder or bowels
Low back pain
Painful intercourse
Physiotherapy can help manage prolapse symptoms by:
Identifying the type and severity of the prolapse
Provide lifestyle modifications to manage pressures on the pelvic organs
Pelvic floor muscle training
Defecation dynamics
Pessary information and fitting
Your physiotherapist will work with your GP, Gynaecologist or Surgeon for optimal management strategies.
VAGINISMUS
The involuntary contraction of your pelvic floor muscles, when attempting to insert something (tampon, finger, penis) into the vagina causing pain or discomfort.
Primary: It has always been painful
Secondary: Vaginal penetration was possible without pain, however is no longer for different reasons.
Can affect all women, most commonly younger women, and women postnatal (especially after caesarean section). The causes are multifactorial but can include:
Skin conditions
Hormonal factors
Muscular (increased tone)
Psychological (trauma,
Chronic pain
Physiotherapy management may include:
Identifying the pain drivers – this is really important to be able to optimally treat your pain.
Pelvic floor muscle release
Dilator therapy
External pelvic muscle manual therapy to help decrease dysfunction around the pelvis
Exercise and stretching prescription
Breath work
Physiotherapy management is often working in conjunction with your GP, psychologist or sex therapist.
BOWEL DYSFUNCTION
Common bowel dysfunction:
Constipation
Diarrhoea
Faecal or flatal incontinence
Haemorrhoids and anal fissures
Prolapse (rectoceal) – compromise to the fascial support between the vagina and rectum. Can cause difficulty emptying bowel contents
Lack of rectal sensation
Over distended rectum/megacolon
IBS
Physiotherapy assessment may include:
A detailed history of symptoms and other contributing factors
Vaginal or rectal examination
A bowel diary to track your bowel habits
From the assessment we will be able to devise an individualised program to address your issues. This may include:
Education on contributing factors
Lifestyle and diet advice
Education on defecation dynamics
Pelvic floor muscle and anal sphincter muscle training
Pelvic floor muscle release
This is all alongside working with any other health practitioners including, dietician/nutritionist, colorectal specialist.
CHRONIC PELVIC PAIN (CPP)
Chronic pelvic pain is pain in your pelvic region that is felt most days and lasts for more than six months. Women with CPP often complain of symptoms such as pain with emptying bladder or bowel, pain or discomfort with sexual intercourse. CPP affects between 15-25% of women and more common in young women.
The cause of CPP is complex and can have a variety of contributing factors including:
Health conditions including inflammation and infection
Sensitisation of the central nervous system
Psychological factors including emotions, how you perceive your pain and its affect
Social factors such as relationships and support networks
Physiotherapy aims to gain a detailed history of your pain, symptoms and health history to understand the complexity of your pain and therefore will be able to devise appropriate treatment plan.
Medical management can include surgery to remove adhesions (endo) and hormonal control. Non-surgical management can involve pain management, improving bladder and bowel function and lumbo-pelvic input to pain.
Physiotherapy management includes:
Pain education and management
Improving bladder and bowel function
Down training any pelvic floor muscle tightness
Addressing and improving any lumbo-pelvic input to pain
Physiotherapy will always work alongside any other health practitioners that may be involved in your care or referral to the appropriate services.
ENDOMETRIOSIS
A condition where cells, similar to those that line the uterus, are found in other parts of the pelvis and organs and sometimes in other areas of the body. This can result in painful periods, CPP, pain passing bowel movements and infertility.
Symptoms (vary from person to person) can include:
Painful periods
Chronic pelvic pain
Pain passing a bowel motion
Infertility
However, sometimes can women with endo can also be completely asymptomatic. The extent of the severity of the endometriosis does not always correlate with the severity of a woman’s symptoms.
Diagnosis will include a thorough history of symptoms and medical history and test results.
Although physiotherapy cannot ‘fix’ or change your endo, it can assist in pain management including:
Pain education
Breathing to assist in down regulating central nervous system drivers of pain,
Normalising pelvic floor function which can often have an input into pain and
Educate and manage normal bladder and bowel function
Dilator therapy
Manual therapy treatment for thorax, lower back, pelvis and hips
Exercise advice
DYSPAREUNIA (PAINFUL INTERCOURSE)
A superficial or deep pain experienced in the vagina or pelvis, during or after sexual intercourse.
Painful sex can affect all women, most commonly younger women, and postnatal women (particularly after caesarean section). The impact dyspareunia can have on a woman and her relationships can be huge, so we understand how important it is to listen to a women’s concerns and begin to help her understand her pain a little better.
The causes are multifactorial but can include:
Skin conditions
Hormonal factors
Muscular (increased tone)
Psychological (trauma and sexual abuse)
Chronic pain
Endometriosis
Physiotherapy management may include:
Identifying the pain drivers to be able to optimally treat your pain.
Pelvic floor muscle release and down training
Dilator therapy
External pelvic muscle manual therapy to help decrease dysfunction around the pelvis
Exercise and stretching prescription
Breath work
Physiotherapy management is often working in conjunction with your GP, psychologist or sex therapist.