Fit Splint

“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:

  • 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.

  • 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.

 

  • 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.

 

  • 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.

 

 

Endometriosis

There can be many factors as to why someone might experience pelvic pain. Injury, scar tissue, past surgeries, or even overly contracted pelvic floor musculature may be the culprit. Endometriosis is also a diagnosis that can sometimes be overlooked as a factor in pelvic pain and pelvic floor dysfunction. Endometriosis is a condition where the inside lining of the uterus, the endometrium, be found on other areas of the abdominal cavity outside of the uterus. Endometrial tissue has been found in some women to be on the ovaries, fallopian tubes, peritoneum, bladder, bowels, rectum, and in some studies even in the eye! Now, how did it get there, you ask? Researchers and still investigating how this might be the case, but a working theory is that this tissue gets displaced during fetal development, or the activation of certain genes, a science called epigenetics, later on in child or adulthood.

Endometrial tissue is unique in that it is receptive to normal cyclical hormonal changes of the menstrual cycle and bleeds and sheds every month. This process works just as designed when this tissue is inside of the uterus and has a way to exit our body through the vagina. When endometrial tissue is found in areas outside the uterus, however, it cannot be eliminated which can create irritation and inflammation to the surrounding tissues or organs. Over time, this can create scar tissue or adhesions throughout the abdominal cavity, causing pain and inflammation.

Common symptoms of endometriosis include painful, debilitating periods. Not just gentle cramping that makes you reach for a heating pad or your nearest ibuprofen, but unable to get out of bed, go to work, or engage with family or friends type of pain. Heavy bleeding or clotting, fatigue, excessive abdominal bloating, painful bowel movements, constipation, painful sex or bladder urgency and frequency or infertility are also potential symptoms for endometriosis.

Women who have endometriosis may wait anywhere on average from 6-11 years from first symptoms to final diagnosis. Diagnosis can be challenging as surgery is currently considered the gold standard, meaning physicians must look at the tissue via small cameras inserted through the abdomen in order to be diagnosed. Current treatments to assist in reducing symptoms for endometriosis include hormonal birth control and surgery via excision or ablation. Other treatment modalities such as acupuncture, modifications to diet and exercise, yoga, meditation and mindfulness practice, self care routines, and pelvic floor PT may be helpful in management of pelvic pain from endometriosis. Communicating with your doctor and other providers of your health care team allow for the best plan to be created based on what your specific needs are.

 

 

 

Optimizing the Digestive System

A proper functioning digestive system acts as a good barrier to undigested food particles, bacteria, mold, and yeast. Additionally, it allows for optimal nutrient absorption. If our digestive system is not functioning properly, one could experience digestive complaints such as heartburn, difficulty swallowing, bloating, abdominal pain, gas, and diarrhea and/or constipation. Additionally, one may experience symptoms of food sensitivities including eczema, headaches, sinus infection, difficulty with weight loss or weight gain, allergies, and asthma.

 

There are a variety of reasons our digestive system may not be functioning at an optimal level. The good news is there are certain lifestyle modifications one can begin to make in order to improve the function. Below are 3 suggestions you can begin to incorporate into your life to optimize digestion.

 

  1. Our brain and gut work together, therefore, the sight of food alone can trigger thoughts in the brain that trigger a stress response. When eating under a stressful environment, our body does not produce the digestive juices, saliva, and digestive enzymes necessary to help digest and absorb food. On the other hand, when we eat in a relaxed environment and feel pleasure with eating, these responses do occur. Due to this, it is important to eat in an environment that is calm and relaxing and to prepare our foods in a way that appeal to us – this includes the look, smell, and taste of our foods.
  2. Adequate chewing is necessary to ensure our food is broken down into small enough pieces for our body to absorb. Smaller particles are absorbed into our system at a faster rate than larger particles. Additionally, larger particles may get eliminated before they are absorbed. This means one could be eating nutrient rich foods, but not receive the benefits of those nutrients if they are eliminated prior to absorption. Research shows chewing each bite of food 40 times is optimal, especially for harder foods like nuts.
  3. General stress management is important for many aspects of our lives. As far as digestion goes, general stress can interfere with our ability to produce enough stomach acid, which helps us to properly absorb and digest various nutrients, vitamins, and minerals. Therefore, stress management is key for proper digestive functioning. Incorporating simple stress management strategies, such as meditation and deep breathing, can be very helpful to ensure optimal digestion.

 

Walking

Going on a walk can be a great activity for self care and has multiple benefits for our health. It is great for our heart and lungs, helps build bone density and safe for our joints, gets us outdoors in the fresh air, reduces time spent in front of a screen, helps us relax, clears our mind, and just plain and simply gets us moving. Researchers recommend getting 30 minutes of brisk walking in most days of the week, meaning you can still talk to a friend while you are walking, but maybe not sing and dance. If walking 30 minutes is too difficult to do at once, break it up by starting at 8-10 minutes and slowly increase your time.

How you walk can be just as important as the walking itself. Is your posture rounded through your shoulders with your head down, or are you upright, head and shoulders back, with a smile? Studies have shown your posture can effect the things you remember, and potentially your mood. Mindful walking, taking in the scenery, feeling your body move, and focusing on your breath can decrease mental stress and improve quality of life.

Having trouble finding time to incorporate walking into your daily routine? Try scheduling it at the same time each day. If this is challenging to do, here are some other useful tips to get those steps in.

-Take the stairs instead of the elevator whenever you have the opportunity

-Park at the back of the parking lot when you go to the store

-walk your dog

-get off public transport one stop earlier

-have your ride share driver drop you off at the end of your block.

You might find asking a friend or neighbor to walk with makes it more enjoyable and helps to keep you accountable. Writing a log or keeping track of your activity can also help with making self care happen and meeting your self care goals.

Cyclist’s Syndrome

Cyclist’s Syndrome, or Pudendal Neuralgia, is a diagnosis involving pain or sensory changes (numbness, tingling) around the pudendal nerve distribution. Women are not the only ones that can be affected with pelvic pain, as this can involve regions around the penis, testicles or anal opening in men. It can no doubt effect a person’s quality of life, impacting bladder, bowel, and sexual function as well as someone’s ability to sit for extended periods of time. Pudendal nerve pain can be exacerbated by sitting, driving, exercise, bowel elimination or having a full bladder, and can be alleviated by lying down, sitting on a toilet seat, or standing.

PN is commonly referred to as Cyclist’s syndrome due to the amount of time spent in a bike saddle, which can compress or irritate braches along the path of the pudendal nerve with repetitive compression or irritation from the repetitive nature of hip flexion required from cycling. Prolonged cycling on an ill fitting bike seat in this position can cause those nerve branches to become irritated.

As we described above, pain is not the only identifier of pudendal neuralgia. It can also present with bladder dysfunction such as urinary urgency, frequency, pain with bladder filling, burning with voids, or sensation of incomplete emptying. Bowel symptoms can include anything from pain, to difficulty eliminating, or even incontinence. Sexual function can be affected including pain with erection, ejaculation or orgasm, erectile dysfunction or persistent arousal. With the amount of symptoms pudendal neuralgia can present with, it’s easy to see how PN can be quite challenging to receive an accurate diagnosis.

PN can be challenging to treat, but not impossible to manage. Pelvic floor PT can be one tool to assist in normalizing muscle tone or reducing nerve irritation on the pudendal nerve, as it has a close relationship to the pelvic floor. Having a team of providers focusing on a multidisciplinary approach is essential for thorough treatment of PN. Medical management with medication, suppositories, nerve blocks, surgical decompression or ablation are some options in addition to pelvic floor PT. Dry needling can also be a tool utilized during PT visits to reset the pudendal nerve and assist with reduction in symptoms.

COMPLETE BLADDER EMPTYING

Emptying your bladder shouldn’t be difficult, right? It’s a skill that our body, like breathing, doesn’t need to learn; it just happens from the time we are born. But what happens when this skill, which is so engrained into our unconscious behavior and innate need, suddenly becomes different, difficult or even painful.

Incomplete bladder emptying can cause us physical and emotional discomfort. It can feel unsatisfying, uncomfortable, and draw all of our attention to our bladder. It can interrupt our lives, having to get up from our desk more often and thus taking more time to complete a task, interrupt our favorite movie, or even limit how far of a run we wish to go on due to fear of not having a restroom near by.

If this sounds like you, no need to worry or cause any more pain or suffering, as there are some strategies you can try to help assist in feeling that relieving “empty” feeling, as well as physically emptying most of the urine out of your bladder.

Regardless of how long your symptoms have been hanging around, other comorbidities, and your diagnosis, these techniques are generally safe and appropriate to use, regardless of what may be the root cause of your symptoms.

The first thing you can try doesn’t take much effort at all. Deep breathing is a tool that comes in handy in so many situations, but essential for us to be and feel relaxed. Taking deep breaths through the belly, feeling the belly rise and fall as you inhale and exhale, allows the pelvic floor to relax. This is essential during and after you void to ensure your pelvic floor is as relaxed as possible. Sitting on the toilet correctly can also assist in complete voids. Use a small stool or trashcan to prop your feet on, and try to avoid hovering, standing, or crouching on the toilet (men, I’m talking to you, too!). You can bring your elbows to your knees to lean forward, or even press on the bladder gently after you feel finished to make sure nothing else comes out.  You can even stand and sit back down, or rock front/back or side to side after finishing to give your bladder every opportunity to empty.

If you are still having difficulty emptying, in addition to these techniques above, pelvic floor PT may help to gentle release tension and/or restriction around the bladder, urethra and pelvic floor that may be the culprit to your symptoms. Talk to your doctor about pelvic floor PT to see if these techniques are right for you.

 

Dilator

Let us shed some light on a topic that some people may find uncomfortable when first given the opportunity to begin a dilator program.  Do not be intimidated. It is not meant to be a sex toy. Beginning a dilator program is one of the most effective tools pelvic floor physical therapist use to address pelvic floor muscle tension. What is a dilator program? The purpose of the dilator program is to stretch pelvic floor muscles that are tight as well as to train an individual to not associate pain with penetration. It can help women tolerate gynecological exams, tampons, and intercourse. Dilators are cylindrical devices that are tapered off at the end. They come in varying sizes, with the smallest size similar to an index finger. A patient typically goes up to the size similar to their partner’s girth. Some pelvic floor physical therapists may advise patients to go up to a dilator slightly bigger than their partner’s girth. Reason being if a woman can tolerate a dilator bigger than her partner’s girth and length, then intercourse should be a piece of cake, especially since she will ideally be aroused and lubricated during intercourse.

There are cases where women tell their physicians that they are experiencing pain with intercourse and unfortunately, sometimes patients are easily dismissed. They are told it is in their head, they just need more lubrication, or go buy a sex toy. Some women purchase a dilator program but are not given proper instructions on how to use it or how to progress. If used improperly, these women will have a negative experience using it and they will think it does not work.

The key to a dilator program is to go slow and at one’s own pace. Again, a dilator program is used to allow one to disassociate pain with penetration. Thus, if a woman goes too aggressively, pushes too hard, and gets frustrated, her body will reject it. Patients are recommended to use their dilators without pushing it beyond mild pain. A dilator is meant to be used daily for about 10-30 minutes. There are 3 components. The first step is to be able to insert the dilator into the vagina until there is about 2 inches of the dilator outside of the body. If only the very tip of the dilator can be inserted without experiencing more than mild pain, then just stop right there. Hang tight and wait for the pain to dissipate or pain to reduce to mild pain. If the full 10 minutes passes and the pain does not reduce, then that is ok. Try again next time. The next component is to be able to rotate the dilator along the sides of the vaginal muscles to stretch tight and sensitive areas that need to be worked out. If a sensitive area is found, apply some gentle pressure until the pain dissipates or if more than 90 seconds have lapsed. Applying pressure for more than 90 seconds should be avoided due to restricting blood flow. Finally, the last step is to be able to move the dilator in and out to simulate the friction involved in intercourse. Once all 3 steps have been completed and the patient feels mild to no pain while using the dilator, she is ready to move up to the next dilator size. The transition to the next dilator size can range from 1 day to several weeks for some individuals. It does not matter how long it takes to progress, as long as it is within the pace of that individual. DON’T be intimidated. DO ask questions.