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Physical Therapy for Men, Women, and Children. 803-716-9723
Vaginal birth is a major cause of pelvic organ prolapse and problems like urinary and fecal incontinence, known as pelvic floor disorders. Physical therapy is important for pelvic floor recovery after birth. To get the best results, rehabilitation should be based on a good understanding of the injuries, their biology, and the recovery process. Childbirth affects different parts of the pelvic floor in various ways.
How Childbirth Affects Pelvic Floor Disorders
Throughout a woman's life, various factors affect pelvic floor function, such as genetics, nutrition, and hormones. Some women naturally have a strong pelvic floor, while others have a weaker one. As women age, childbirth and other influences can cause damage. Lifestyle choices also matter; active women might strain their pelvic floor more than sedentary women. Symptoms appear when the pelvic floor's demands exceed its ability to function. Muscle strength and support structures are essential. Genetics and childbirth impact pelvic floor health, and aging can worsen the condition, leading to symptoms.
Pelvic Floor Disorders: Different Causes
Each pelvic floor disorder has unique causes. Recent research has disproven many long-held beliefs.
Pelvic Organ Prolapse
Pelvic organ prolapse is closely linked to childbirth, especially vaginal birth. It’s not just the number of births that matter, but having a vaginal birth itself increases the risk. Studies show that muscle tearing (avulsion) during vaginal delivery is a significant factor. About 55% of women with prolapse have muscle tears compared to 16% of women without prolapse.
Stress Urinary Incontinence
Stress urinary incontinence is primarily caused by weak muscles in the urethra and poor urethral support, resulting in lower urethral closure pressure, which is crucial for maintaining continence. This condition is common after childbirth, as women with stress incontinence have significantly lower urethral closure pressures compared to those without the condition. Additionally, injuries to the levator muscles can further contribute to stress urinary incontinence.
Fecal Incontinence
Fecal incontinence depends on factors like stool consistency, rectal capacity, and anal sphincter function. It occurs when the pressure in the anal canal is not enough to keep stool in. The internal and external anal sphincters, rectum, and puborectal muscle all play a role in maintaining continence.
Birth-Related Injuries
During pregnancy, the pelvic floor undergoes significant changes to accommodate childbirth, such as the increase in size of the levator hiatus area and the elongation of muscles around the birth canal. Connective tissues also become more stretchable to facilitate birth. Childbirth can cause various injuries leading to pelvic floor disorders, involving the vaginal high-pressure zone, perineal closure complex, and the levator ani muscles. Enlarged hiatuses in these areas are linked to prolapse, and not only muscle damage but also connective tissue changes play a role.
Levator Ani Muscle & Neuropathy
Neuropathy involving nerve injury to the levator ani and urethral sphincter is common during childbirth due to the significant descent of the pelvic floor, which can stretch or detach nerves from muscles. During vaginal birth, the levator ani muscle often stretches significantly and may tear in about 15% of women during their first birth, leading to long-term damage. Muscle recovery typically takes about six months post-birth.
Anal Incontinence Linked to Childbirth
Anal incontinence is linked to childbirth, particularly due to direct injury to the anal sphincter complex and pudendal nerve damage. Women with anal sphincter injuries during childbirth are at higher risk of developing fecal incontinence later in life.
Prevalence of Obstetric Anal Sphincter Injuries (OASIS)
Anal sphincter injuries from perineal trauma are common during childbirth. Anal sphincter injuries are more common in first-time mothers, those with larger babies, prolonged labor, or instrumental deliveries. Immediate repair reduces bleeding and pain. Postoperative care includes antibiotics, laxatives, and monitoring for complications like hematomas.
Role of Physical Therapists for Anal Sphincter Injuries
Physical Therapists play a vital role in managing anal sphincter injuries by examining for bruising, hematomas, and urinary retention soon after delivery. Follow-up examinations around 6-8 weeks postpartum help assess perineal and bowel symptoms, ensuring proper recovery.
Subsequent Pregnancy After Anal Sphincter Injuries
Women who had anal sphincter in\njuries in a previous pregnancy should be counseled about the option of elective cesarean birth to reduce the risk of recurrence. Studies show varying outcomes, and individualized care based on symptoms and diagnostic findings is recommended.
Pelvic Floor Muscle Training for Urinary Incontinence During Pregnancy
1. Can urinary incontinence be prevented by training the pelvic floor muscles before problems arise?
2. Can women at risk be identified early and benefit from prevention using pelvic floor muscle training?
Reviews on pelvic floor muscle training for preventing and treating urinary incontinence show inconsistent results. This could be due to different study inclusion criteria and various ways of classifying studies as prevention or treatment interventions. Some authors do not distinguish between prenatal or postpartum interventions, and there is often little focus on the dose-response issues in training protocols.
Prenatal Pelvic Floor Muscle Training
Women that participated in pelvic floor muscle training were significantly less likely to report urinary incontinence in late pregnancy and up to 3-6 months after delivery.
Women that had prenatal pelvic floor muscle training were significantly less likely to report urinary incontinence during pregnancy and up to 6 months postpartum.
Postnatal Pelvic Floor Muscle Training in Preventing or Treating Urinary Incontinence
No randomized control trials specifically focused on continent women for prevention of urinary incontinence.
For women that were incontinent postnatal, some randomized control trials showed varying results. However, some trials showed significant reductions in urinary incontinence symptoms after pelvic floor muscle training.
For women that had persistent postnatal problems, some randomized control trials showed a statistically significant reduction in urinary incontinence at 6 and 12 months after delivery with pelvic floor muscle training.
Optimal Dosage for Pelvic Floor Muscle Training.
There is a strong dose-response relationship in exercise training. The type of exercise, frequency, intensity, and duration, as well as adherence to the protocol, determine the effect size. Systematic reviews suggest that studies on pelvic floor muscle training are often small, underpowered, and of uneven quality. The most optimal dosage for effective pelvic floor muscle training remains unknown, but general strength training principles, emphasizing close-to-maximum contractions and at least an 8-week training period, are recommended. Studies that showed little or no effect often used inadequate training dosages or had high drop-out rates and low adherence.
Long-Term Effects for Pelvic Floor Muscle Training.
Long-term effects of pelvic floor muscle training are challenging to evaluate due to the likelihood of subsequent pregnancies and the cessation of organized training. Most trials showed that adherence to pelvic floor muscle training protocols diminished over time, with some studies reporting no long-term differences between intervention and control groups.
Recommendations for Effective Pelvic Floor Muscle Training for Urinary Incontinence
Sit on the edge of a chair or table and lift the pelvic floor by pulling up and contracting around the urethra, vagina, and rectum.
Squeeze hard enough to feel a slight trembling in the vagina.
Hold the contraction for 6-8 seconds, then relax without pressing downward.
Do 8-12 repetitions in three sets, three to four times a week.
Start with fewer repetitions if this is too difficult and gradually increase.
Use positions like sitting with legs apart, standing with relaxed buttock muscles, or kneeling on all fours to perform the exercises.
If unsure about performing the exercises correctly, contact a physical therapist specializing in women's health.
Anal Incontinence
Pelvic Floor Muscle Training During Pregnancy
While there is some indication that pelvic floor muscle training might help, particularly in women that have given birth more than once, the studies were not powered to evaluate anal incontinence specifically.
Pelvic Floor Muscle Training After Pregnancy
2001 study: Minimal reporting of anal incontinence, no significant difference between intervention and control groups.
2004 Study: Pelvic floor muslce training with biofeedback and/or electrical stimulation showed improvements in anal incontinence symptoms and anal sphincter pressures.
2014 study: Pelvic floor muscle training may reduce coexisting anal incontinence in women with urinary incontinence at 12 months postpartum, but differences did not persist long-term.
2017 study: Reduction in anal incontinence symptoms with regular pelvic floor muscle training.
2020 study: No significant differences in anal incontinence, but higher anal sphincter strength in the intervention group.
Limited evidence supports pelvic floor muscle training for preventing or treating anal incontinence postpartum, with some studies indicating benefits but often not sustained long-term.
Recommendations for Effective Pelvic Floor Muscle Training for Anal Incontinence
Early Management (up to 21 days postpartum): Promote pain-free, low-force pelvic floor muscle contractions, stool consistency management, and rest.
Management (3 weeks to 6 months postpartum): Pelvic floor muscle training, potentially combined with electrical stimulation, addressing pain management and stool consistency.
Beyond 6 months postpartum: Continued pelvic floor muscle training, addressing stool consistency, with potential inclusion of electrical stimulation.
The evidence on the effectiveness of PFMT for preventing and treating anal incontinence during pregnancy and postpartum is mixed and not conclusive. While some studies indicate potential benefits, especially when combined with biofeedback and electrical stimulation, the results vary, and long-term effectiveness is uncertain.
Genital Fistula
A genital fistula is an abnormal connection between two surfaces in the female genital tract. It can involve the bladder, ureters, urethra, or bowel. In developing countries, prolonged, obstructed labor is the main cause of genital fistulas due to limited access to medical care, poverty, and low medical literacy. The World Health Organization estimates that two million women worldwide suffer from untreated obstetric fistulas, often facing social ostracism.
In developed countries, pelvic surgery is the leading cause of genital fistulas, often due to surgical management of pelvic issues or radiation therapy for cancer. With the rise of advanced surgical techniques like laparoscopy, the incidence of fistulas may be increasing.
The formation of obstetric fistulas is primarily due to prolonged labor, where the baby's head presses against the mother's pelvis, causing tissue death and creating a fistula. The location and severity depend on the position of the fetal head and the duration of labor.
Types of Fistulas
1. Vesicovaginal Fistula: The most common type, making up about 80% of cases.
2. Rectovaginal Fistula: Rare on its own (5% of cases) but can occur with vesicovaginal fistulas.
Conservative Treatment:
Catheterization: Continuous bladder drainage for 2-3 weeks can help heal the fistula.
Increased fluid intake and perineal hygiene (sitz baths) aid in healing.
Surgical Treatment
Surgery is often required after conservative measures fail. The approach can be vaginal or abdominal, depending on the fistula's characteristics.
Postoperative care includes ensuring adequate hydration, a normal diet, early mobilization, and physical therapy to restore muscle function and address complications.
Physical Therapy
Physical therapy is vital for recovery, helping with muscle strength, mobility, and addressing issues like contractures and neuropathy. It also includes bladder training and education on managing incontinence.
Addressing genital fistulas involves specialized care, improved surgical training, and comprehensive support for patients. With these measures, women can achieve better health outcomes and reintegrate into society, overcoming the stigma and disability associated with this condition.
References: Bo, K., Berghmans, B., Mørkved, S., & Van Kampen, M. (Eds.). (2023). Evidence-Based Physical Therapy for the Pelvic Floor (3rd ed.). Elsevier.
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