“I had a c-section, so my pelvic floor is totally fine.”

“I had a c-section, so my pelvic floor is totally fine.” Probably not.
Patients who have undergone vaginal delivery and are working with me to eliminate postpartum symptoms such as urinary leakage, pain with intercourse at the site of tearing, or prolapse will sometimes say “I wish I would have just had a c-section , then I wouldn’t have all of these problems.” Well…yes and no. They may not have presented in exactly the same way, but I think, when it comes to coping with symptoms postpartum, the grass is always assumed greener on the other-method-of-delivery side.
For individuals who have undergone a c-section, sometimes I feel that postpartum recovery education is even less available (if that could be possible). There are many symptoms that we see in these moms that are very treatable, even years down the road but everyone seems to think that because they had a surgical procedure, they just have to deal with the aftermath. False.
Symptoms commonly reported:
1) Problem: The scar itself may be painful and restricted or is unsightly
Fix : we can perform scar massage to decrease restrictions and alleviate pain, while desensitizing the skin, sometimes even (as a bonus) getting clothing to fit better and get rid of that shelf-like appearance over the scar.
2) Problem: The individual feels like they have no abdominal strength, or they have back pain

Insight/Fix: Again, we’ll work through scar tissue while teaching the patient to properly activate abdominal musculature in the proper manner . Once abdominals can work as they were prior to surgery, those muscles can support the spine, thereby resulting in decreased back pain with activities and safe return to exercise.

3) Problem: Bladder frequency and urgency, leakage
Insight/Fix: This one is actually often overlooked as having anything to do with caesarean history. Very frequently, we find significant scar tissue deep to the visible scar. What you can see is really just the tip of the iceberg. Those deep aspects can become wrapped around the area of the bladder, limiting the bladder’s ability to fill well and causing bladder spasms. This can make it feel like you have to pee all the time or actually contribute to bladder leakage when it feels like you have to pee. Manual work to the scar and bladder can often make a huge impact in these symptoms.

4) Problem: Painful intercourse
Insight/Fix: if the uterus or deep aspect of vaginal canal are also restricted or have scar tissue wrapped around them, the scar can actually be a large contributing factor to painful intercourse.
A mix of internal and external manual therapy can alleviate this pain.

Take home points: A caesarean is not a routine procedure. It involves lots of disruption of the musculature and tissue throughout the area and forms significant scarring that can cause numerous abdominal and pelvic symptoms. See a pelvic floor physical therapist to assess your scar and find out what can be done to help you heal fully.

 

The “Evil Triplets” of Chronic Pelvic Pain

The “Evil Triplets” of chronic pelvic pain include endometriosis, interstitial cystitis/painful bladder syndrome, and pudendal/levator neuralgia which are called triplets because they frequently can occur together.
Endometriosis is a condition where the endometrial lining of the uterus grows outside the uterus. This abnormal tissue growth occurs most commonly in the tissue lining the pelvis. This condition can cause chronic pelvic pain, dyspareunia, scar tissue formation, and fertility issues.
Interstitial cystitis/painful bladder syndrome is often characterized by pelvic pain, pain with intercourse, urinary frequency, and urinary urgency that is not associated with an active infection.
Pudendal/levator neuralgia is frequently associated with tenderness and pain to tissues about the pudendal nerve, changes to tissue texture, decreased tissue blood supply, and muscle weakness and atrophy.
What can be done about the “Evil Triplets?” Physical therapy treatment of pelvic pain frequently includes an assessment of a variety of structures including the spine, pelvis, abdomen, and lower extremities. Alignment, range of motion, muscle strength, muscle extensibility, and connective tissue mobility is frequently assessed. Physical therapy treatment may include manual treatment such as trigger point release, neuromuscular re-education, relaxation techniques, therapeutic exercise, and physical therapy modalities. Patient care for this population frequently involves a cross-disciplinary approach.

Endometriosis: The Invisible Illness End

Endometriosis: The Invisible Illness
Endometriosis is this big long word which means that tissue similar to what normally lines the uterus is now growing outside of the uterus in places like the abdominal and pelvic cavity. The issue arises when this tissue begins to form implants/adhesions. Endometriosis affects nearly 1 in every 10 women and is one of the top three causes of female infertility.
To give you a visual: Imagine all the organs present in the abdomen and pelvis. Now think what it would look like if someone put something really sticky in there in little spots; it starts to stick things together. Those organs and tissues wouldn’t want to move very well. Every time you move, have a bowel movement, have sex, eat a meal, exercise to intensely, it pulls on all these sticky spots and creates pain. The interesting thing is someone with more severe endometriosis may not have any pain and someone with mild endometriosis may have extreme pain; in other words, there is no correlation to the severity of the disease and the symptoms someone will experience.
Researchers have a lot of theories about what causes this special uterine tissue to end up outside of the uterus but they are just theories; no one has been proven but some are more supported than others. Regardless, these women are living with potentially a load of symptoms. These symptoms can range from abdominal pain, pelvic pain, pain with intercourse or bowel movements, urinary urgency, constipation, extreme fatigue, pain in the hips/legs, low back pain, etc. Many women experience a worsening of their symptoms in relation to their menstrual cycle. Unfortunately, it usually takes 10+ years for women to receive an accurate diagnosis. During this time these women are seeing a bunch of doctors, working and attending to their daily life demands, fighting fatigue and pain, and getting told their tests are normal try this-or-that but nothing affects their pain. There are several treatment options ranging from conservative management-medications-surgical intervention that can be determined by an endometriosis specialist. Part of this plan should include pelvic floor physical therapy as it can address many of the symptoms stated earlier and also address tension and restrictions that have likely built up from years of pain and change in movement patterns.
This is a brief on endometriosis and by no means does it hit the depths of this disease. A good amount of information has been gained in the last several years but more is needed to help these women get the care they need. March is National Endometriosis Awareness month. Maybe you’ve heard, maybe you have not; maybe you know someone, maybe you do not; maybe this is you, maybe it’s not. If it is you, reach out to your local pelvic floor physical therapist with questions, for help, or relief and advocate for yourself and the ones you love.

Lubrication

I’m going to get right to the point. You should probably be using lubrication during sex. Seriously, it makes sex less painful and more enjoyable. Even if you feel that you have enough natural lubrication during sex but you still have pain during intercourse it may be beneficial to try using lubrication. A study published in the Journal of Sexual Medicine stated that most women that had painful intercourse reported using lubrication was a moderately effective strategy when it comes to addressing their symptoms.1 (Only moderately effective? That’s where your pelvic floor physical therapist comes in!)
So, you’re on board to try a lubricant, but which one should you try? There are SO many out there, some better than others.
Right away, I would say steer clear of anything with glycerin, parabens, or fragrances. Glycerin can cause that burning sensation that you feel during intercourse, it isn’t always the culprit, but sometimes it is and changing your lubricant will give you a better idea of what is causing your pain. Parabens are a hot topic when it comes to the safety of its use in products. Parabens are used to extend the shelf life of the produced and it’s also antimicrobial. However they pose risks for other long term side effects, although there is little to no evidence to support it. Lubricants contain small doses of parabens but they do pose a risk of irritation (as do fragrances), so it might be best to avoid them altogether.
It also depends on the situation in which you are using lubrication. Are you suing dilators, toys, condoms? In bed or in the shower? (Yes you can/should use lube in the shower). There are 3 main types of lubricants – silicone, water, and oil. They are all safe to use but some are better in certain situations.
Over all, water based lube is probably the most widely recommended. This is because they are safe to use with latex contraception and silicone toys/dilators. However, water based lubricants tend to dry quicker than silicone based lubricants and sometimes have to be reapplied more frequently. You also cannot use water based lubricant in the shower/bath because it will wash away. If you feel like you need a more substantial lubricant, a silicone-based lubricant might be the one for you. It is safe to use with latex condoms, you can use it in the shower/bath, and it will last longer than water based lubricant. However, you cannot use it with silicone toys or dilators because it will break down the dilator, making it easier for it to hold bacteria. Oil – such as coconut or olive oil is a good lubricant to use if you are not using latex contraception, as it will break down the latex.
There are so many options! Which one should you choose? Talk to your pelvic floor physical therapist, they will help guide you in the right direction. It all depends on your priorities and preferences. In general, silicone lubricants are a good choice because they are the most “slippery”, but it’s a good idea to have a water based lubricant as well if you have a silicone toy or dilator.
1. To Lube or Not to Lube: Experiences and Perceptions of Lubricant Use in Women With and Without Dyspareunia

To belly band or not to belly band?

That’s the question! And it’s a good one. Those with a diastasis recti (DRA) or a separation of their abdominal muscles are probably asking themselves this question. Let’s start with what is a belly band? A belly band is an abdominal brace that is used to approximate the muscles to decrease their separation. Why is that important? When there is a gap between the abdominal muscles it puts them on a stretch, which makes it difficult for the muscles to contract properly. The abdominal muscles function best when they are running straight from the rib cage to the pubic bone. Not only are the muscles not as strong but this can create a bit of abdominal pooching.
So we want the abdominal muscles to be strong and we know that they are strongest when there is no separation between them. The muscle that we want to strengthen is the transverse abdominus (TrA) because tightening this deep core stabilizer brings the other abdominal muscles together, decreasing their separation. You activate this muscle without thinking when doing normal tasks like walking or moving your arms and legs. Sometimes after child birth, this muscle needs to be retrained, and your therapist may work with you on contracting your TrA before specific movements or exercises. If you have a diastasis recti, talk to your therapist about what exercises are right for you!
Now, back to the belly band. (To be fair, there are many different types of braces for a DRA, like the FitSplint, your physical therapist can help you decide which one is right for you). What the brace does is it brings the muscles closer together so that when you do use your abdominal muscles they are in the right place and will function appropriately. This should help you feel stronger when your need to use your abdomen to perform activities like daily chores or exercise. Using your abdominal muscles in the position that they should be in (with no gap) teaches the muscles to stay in that position.
Not everyone needs a belly band or a FitSplint to correct their DRA. It can depend on the severity of the DRA and relating symptoms. Ask your therapist if some sort of abdominal brace is appropriate for you!

Making Sense of Your Menstrual Cycle…

Menstrual cycles can vary greatly from one woman to the next, but by becoming more in tune with your cycle, you can gain a better understanding and appreciation of the way your body feels and acts. The best way to accomplish this is by tracking your menstrual cycle for 2-3 months through a journal or computer/phone application. You can track things such as the first day your period, how long your period last, time of ovulation, any symptoms you feel around the time of your period, and how you feel throughout your cycle both physically and emotionally. The following information is an example based off of a typical 28 day cycle.
The first day of a woman’s period is considered day 1 of her cycle, and bleeding for 3-7 days is considered normal. Due to the rise in estrogen and testosterone that occurs during the first 1-2 weeks of the cycle, specifically around day 3, a woman will likely feel more energy, more confidence, and more focused during this time. This might be a time she feels more inclined to take a risk such as having a difficult conversation, making a new friend, or challenging herself to grow professionally, academically, or athletically.
Just prior to ovulation, there is a surge in hormones that might present as a boost in energy, thus a time a woman feels she can get a lot accomplished. During ovulation, which typically occurs around day 14-15, women will feel an increase in sex drive, feel more attractive, and feel more courageous compared to other points in the cycle.
After ovulation, there is a drop in testosterone and an initial drop in estrogen, although estrogen does return to a medium level for the remainder of the cycle. This is the time progesterone dominates. Because of this, throughout week 3 and into the early part of week 4, a woman might feel the need for some down time. This can present as a desire for bonding time with close female friends and/or alone time to rest and reflect through reading or journaling. This would also be an ideal time to plan something creative, such as an art project one has been wanting to take on.
Lastly, during the latter part of week 4, it is very important to nourish the body through self-care, diet, and sleep/rest. This will help to decrease potential PMS symptoms leading up to the next period. By taking the time to learn your body’s menstrual cycle, you will gain a better understanding of why you are feeling certain ways throughout the month. Additionally, you may even choose to navigate your life differently based on where you are in your cycle in order to achieve your highest potential.

Menstrual Cup

Menstrual cup…yes, that’s right! The menstrual CUP. Now you may or may not have heard of them, but they are eco-friendly, feminine hygiene products that you can use in the place of tampons or pads. They are typically made of silicone and are typically ~5-6 cm long (including the stem).

So why would you even consider using a menstrual cup? Some of the pros are that you can wear them for 10-12 hours, without worrying about leakage or bacteria that could lead to Toxic Shock Syndrome. They are reusable, you wash them 2-3x a day, and according to a distributor’s websites they can last from 1-3 years, saving you money on feminine hygiene products. They typically run $20-30 per cup. It softens with body heat so it is meant to form to your body, allowing people who have difficulty inserting tampons use something besides pads.
What are the cons? For one thing, taking them out the first time seems to be the hardest part about using the menstrual cup. It stays inside the vagina by placing light suction and pressure on the vaginal walls. It is meant to be taken out easily, but from some of the blog posts I have read online, this is sometimes not the case. Some women are bearing down to remove the cup and this is something that, we as physical therapists would like you to avoid! This puts stress and strain on the pelvic floor muscles as well as surrounding ligaments and fascia that support your pelvic organs. In order to avoid bearing down, it is suggested to break the seal before removal. A suggestion from Divacup.com is that the cup may be too high if you are having a hard time removing it. Not everyone has trouble using the menstrual cup, but it is something that seems to require practice.
There are many different types of menstrual cups. Diva, MeLuna, MoonCup and LadyCup are all popular brands that you can find online. Most of these have 2 different sizes, one meant for women who have not had children, and one meant for women who have. MeLuna has several different sizes and a way to calculate what size you should wear online. However, just because you have had a child, doesn’t mean the larger size is the one for you! It depends on the condition of your pelvic floor muscles. Talk to your pelvic floor physical therapist and ask if the menstrual cup is right for you and how to use it.