I have long wanted to share a post about pelvic floor health – especially since it’s an issue most of us deal with after pregnancy and child birth. It’s also a subject few talk about – many women feel embarrassed or don’t know where to go for help/don’t realize their symptoms aren’t normal.
Because I work in healthcare (in a non-patient care role, but specifically focused on obstetrics and gynecology), I knew a lot of the symptoms I was experiencing after my second child were not normal. I did see a pelvic floor specialist and had an evaluation to determine next steps. It’s not a topic that’s easy to talk about, but that’s why I wanted to write this post – because there is help for these common issues and many women just don’t know where to go or think it’s “not a big deal” and “is just a part of motherhood.”
Another topic that will be discussed in detail in this post is Diastasis Recti. I avoided ab exercises for a long time and tried a program to help repair Diastasis Recti when I was doing BBG. I was never formally diagnosed with it, but based on what I was feeling in my abs when I exercised and my very weak core, I do think I had at least a small separation.
(pregnant with Lincoln, a few weeks before my due date)
I reached out to three pelvic health experts to provide insight into the symptoms of pelvic floor issues, how they’re diagnosed, where to get help and what pelvic floor therapy entails. They also cover diastasis recti, which many women struggle with postpartum. I hope you find this post helpful!
- Olga Treko has a doctorate in physical therapy from the University of Hartford in Connecticut. Her undergraduate degree is in sports medicine, where she studied athletic training. She has a love for treating postpartum mothers and helping with their pelvic pain. She works alongside a wonderful urology and OB/GYN multidisciplinary team. She has a feisty and very active 19 month-old, which has lit a fire in her- she wants other women to have the knowledge and awareness during and after their post-partum journey. She also believes that “once a postpartum body, always a postpartum body” which means she treats women through different stages of their lives. You can find her on Instagram, here.
- Kailie Denham has been a physical therapist for 12 years. She has a bachelor’s degree in human biology and a doctorate in physical therapy from Eastern Washington University. She became interested in pelvic health, specifically women’s pelvic floor health, after having her daughter 3.5 years ago. She suffered all of the most common pelvic dysfunctions including stress urinary incontinence, diastasis rectum abdominus (DRA), umbilical hernia, cystocele (bladder prolapse) and pelvic pain. In a quest to heal herself, she decided to become a pelvic floor physical therapist exclusively to women and received training from Herman and Wallace Pelvic Rehabilitation Institute. She targets women who enjoy high-intensity exercise like CrossFit as this is what she enjoys, as well as women who have never been pregnant because there are ways to prevent and minimize what she has gone through. She wants to help pregnant women prepare their pelvic floors for the changes that take place during pregnancy and delivery. She also helps postpartum mothers who have been told leaking is normal and there is nothing but surgery to be done for a prolapse. She started her business, Her Physical Therapy and Wellness, in 2017. She sees women in her office, in their homes and remotely via video conferencing. You can find her on Instagram, here and on her website, Her Physical Therapy.
- Amber Mead has a bachelor of science degree in psychology with an associates as a physical therapy assistant and her certification as a physical trainer. She has taken countless continuing education courses on core strengthening and peri and postpartum care/strengthening. She has five years of experience treating patients in an orthopedic setting where she’s had the opportunity to treat many women during their postpartum recovery as well as women with pelvic floor dysfunction resulting from multiple pregnancies. Find her on Instagram, here. Amber works at Progressive Therapy Center in Miami.
I put together these questions and had each expert answer – I hope you will find this to be informative and helpful. If you’re experiencing these symptoms, know that help is out there!
When should women start thinking about pelvic floor health?
Olga: As soon as possible. If you are sexually active you should think about your pelvic floor health. If you’re thinking about conceiving, you should think about your pelvic floor health. If you are pregnant, just had a baby, post surgery, post sexual trauma, pre-menopausal and/or post-menopausal you should think about your pelvic floor health. I always say this to my patients “your pelvic floor does not discriminate against anything – that includes age.” On my schedule, I can have a 16 year old having difficulty inserting a tampon and a 96 year old with bladder pain.
Kailie: Women should start thinking about pelvic floor health before they become pregnant and before they start having signs and symptoms of pelvic dysfunction because we can prevent and greatly minimize problems. Adolescent teenagers who play high impact sports like gymnastics, volleyball, basketball or track may start leaking urine or discover they have an overactive bladder and pee all the time! They need to see a professional during this time! This is not normal.
Amber: I recommend women start thinking about their pelvic floor health prior to getting pregnant. Now what does that mean? Studies have shown that a strong pelvic floor and strong core reduce the likelihood for incontinence during and following pregnancy as well as decreased low back pain during pregnancy. What about the women who have already been pregnant or are currently pregnant? I recommend starting a strengthening program to help prevent these things – it’s never too late. When I was 25 weeks pregnant, I started to realize that I was having difficulty sneezing and laughing without peeing my pants, so at that point I started doing Kegel exercises, which fixed the problem within two weeks.
It seems like many women have issues with their pelvic floor after childbirth, but few talk about it – why do you think that is and why do you think women delay or do not seek care?
Olga: Childbirth in my mind, is the most natural physical trauma a woman’s body will endure. It is the equivalent to a traumatic MVA and yet we do not take it seriously. At your 6-week postpartum appointment, you have a 15 min check-up and you are told to resume all previous activity without a second thought. In parts of Europe, women are automatically give a scrip/order for Pelvic Floor Physio (PFPT) no questions asked, and it is up to the mom to follow-through. Knowledge and awareness are a huge part of why women do not seek a PF evaluation. As new mom, we also don’t have the resources and support in our community. I was also told by an MD once that there is not enough evidence-based practice to send a mommy to PFPT after childbirth. Cost and time is also a huge limitation – many insurance companies do not cover the specialty and we have to use special diagnostic codes to receive coverage. We are also told by our friends that “it’s normal” to feel a certain way after child birth. While that may be true to some extent- take for example, leakage, it is common for a women after child birth to have some leakage but it is not normal and something can be done with the right support and evaluation.
Kailie: The biggest reason women do not seek help for their pelvic floor issues is because there is a lack of education and belief by health professionals that leaking urine, for example, is normal! There is a lack of education and training on what the signs and symptoms of a pelvic floor dysfunction are, so when moms bring it up to their doctors, it is quickly dismissed as part of the postpartum healing process.
Amber: It’s so sad but I truly believe women don’t talk about these issues because to most it’s too embarrassing to speak of… no one wants to admit openly that they peed their pants just from something as simple as laughing or sneezing. I’ve worked with older women who suffer from incontinence at an early age secondary to childbirth and they said their mothers told them it’s not something that they speak of and to just deal with it, and unfortunately that’s the mentality still to this day. The other aspect of it is a lot of women say they just don’t have the time to seek help and it’s just not serious enough to follow-up with the doctor. I hate hearing this because it’s so simple to correct…all it takes is just a few exercises that we all can do while we’re waiting in the pick-up lines at school or while we’re waiting at a red light in traffic.
What are some common pelvic floor issues and what are the symptoms?
Kailie: The 4 most common pelvic floor dysfunctions and their symptoms are:
- Urinary incontinence: the unwanted leakage of urine. There are two types, stress urinary incontinence which is when you leak urine as a result of doing something. For example, leaking after coughing, sneezing, laughing, jumping, running etc. The other type is called urge urinary incontinence which means you get this overwhelming need to pee and you leak on the way to the toilet. Typically there is a trigger associated with it like hearing running water, seeing the toilet, a key in the door to unlock your house, walking into the store etc. Often you will also have an overactive bladder which means you pee more than 8 or so times in a 24 hour period. You should be able to hold your urine 3-4 hours at a time depending on caffeine intake, water intake etc.
- Diastasis Rectus Abdominis: DRA means there is a separation of the rectus abdominal muscles which are your “6 pack abs”. You will know you have this because you will see a dome or cone in your belly when you do a crunch or sit up in bed. It looks like an alien or your baby is trying to escape! Another sign is that you still look pregnant well after you have given birth even after losing all your baby weight. Sometimes, people refer to it as “the mommy tummy or pooch.”
- Prolapse: This is when one of your pelvic organs which are your bladder (holds pee) , uterus (holds baby if pregnant) or rectum (holds poop) falls out of place due to loss of muscle and or connective tissue support and these organs can fall out of the vagina hole. Symptoms are: a feeling of heaviness or fullness “down there,” a feeling like your insides are falling out, trouble fully emptying your urine or poop and having to “help” the process or seeing a bulge of tissue coming out of your vagina hole.
- Pelvic pain: This is an umbrella term for many different pain syndromes. Some of the most common are pregnancy related pelvic girdle pain which typically feels like an ice pick or sharp pain in your groin or pubic bone when you do activities where you stand on one leg. Another common type of pain is pain with sex. This can be upon initial or deep penetration. Pain may also be after sex. Another common pelvic pain symptom is bladder infection signs and symptoms like urgency, burning and pain but without confirmed infection. In this case when you have these symptoms without infection, it is typically the pelvic floor muscles that are to blame!
Olga: SUI (stress urinary incontinence) ; Dyspareunia (painful penetration) ; Prolapse (uterovaginal prolapse ; cystocele ; rectocele) ; OAB (overactive bladder) ; Vulvadynia (pain along the vulva). Symptoms: pain (pelvic / groin / back / abdominal region) ; pelvic pressure ; decrease in intimacy ; vaginal dryness ; painful intercourse ; leakage (urine & fecal).
Amber: The most common pelvic floor issues that we see are Incontinence, pelvic floor dysfunction, prolapse. Common symptoms can vary from low back pain, constipation, pain with sex, severe cramping/ muscle spasms, trigger points.
What are the solutions for these issues? Where can women seek an evaluation or get help?
Olga: Solutions are all dependent on your pelvic floor evaluation. I truly believe that every woman at some point would benefit from a pelvic floor evaluation. My reasoning behind that is that a PF evaluation by a PT is different than that of an OB/GYN or URO/GYN MD. Depending on insurance and provider, a woman may need a referral from her PCP/OB/UroGyn/Urologist/ColoRectal MD. The next step is finding a pelvic floor specialist. There are a lot of PT clinics that advertise having a women’s health specialist, but make sure you do your research, as not all PTs are trained in performing pelvic exams and I truly believe while it is not for everyone, a pelvic exam is necessary in truly determining what is going on with your pelvic floor function.
Amber: There are solutions! I always recommend to start with either your primary care physician or your OB/GYN. Express your concerns and the difficulties/symptoms you are experiencing – some doctors will recommend physical therapy – in that case, they will write a prescription for an evaluation and a specific treatment plan for pelvic floor strengthening.
What is the pelvic floor PT process like?
Olga: At your first PFPT (pelvic floor physical therapy) visit, the goal is to gather as much information about you, your condition, your symptoms and your limitations. The PF specialist will ask a lot of questions with the focus of better getting to know you and to assist in their goal-setting. This is the subjective findings. They will then go into a more detailed assessment of external and internal (if necessary) muscles which include your posture, flexibility, joint mobility and muscle strength. I personally do a detailed introduction of anatomy usually following subjective findings and prior to any objective measures taken. At the end, I go into detail what I expect from my patients, goals, and future plan of care. I usually see my patients once a week and depending on many factors – weekly, biweekly or once a month.
Kailie: In my practice, my evaluation is comprehensive and 2 hours long, which is rare. I always check for diastasis, l always check posture and breathing as they can both cause or exacerbate some of the problems. 95% of the time, I perform a pelvic floor muscles assessment. This is done via the vagina and my index finger only. There are no stirrups or speculum like with a pap smear. Everyone also gets some education with visuals from my pelvic models of where the pelvic floor muscles are, what they do and why there may arise problems. When I have remote clients, I cannot perform an internal evaluation but I can do a lot of education and evaluation via video conferencing to help my clients.
Amber: At this point, patients will come in with a prescription from their doctor and an evaluation will take place. Typically, the an evaluation lasts one hour and the PT will ask for a past medical history and most likely they’ll ask If you’ve ever been pregnant and/or delivered and how many children you have. At that point they’ll do what we call functional test and measures to look at your overall strength, mobility and assess any pain you may have. The PT will also ask what you’d like to see change, goals you’d like to achieve, problem areas which you would like to treat, etc. Once that’s established, the PT will create a specific strengthening program for each patient and demonstrate and teach the correct way to perform these exercises. Depending on the severity of the deficits, the PT may recommend sessions either 2 to 3 times a week to ensure that the patient is progressing and improving and fine-tune any part of their program If needed. Typically, the PT will incorporate a hands-on aspect as well and that could vary from soft tissue massage, stretching and mobilizations, if the PT feels it’s needed. Now for some patients who have a pelvic floor dysfunction you may have to see a PT who specializes in women’s health specifically for pelvic floor rehab. For women who suffer from pelvic floor spasms and/or triggerpoints it would be more appropriate to see a women’s health PT because they’re specifically trained to work on decreasing the pelvic floor spasms through manual therapy.
What is Diastasis Recti and how many women get it?
Olga: DR is the separation of the linea alba which is the ligament structure that holds your rectus abdominus muscle (wish is the top layer of the abdominal muscles) together. It is very important that patients understand that there are 4 layers of your abdominal muscles. The top layer is what is affected when there is a DR separation. It is very important that the deepest (4th) layer which is your supportive layer and also known as your Transverse Abdominal (TrA) muscle, is instructed in proper activation and isolation when treating someone with DR or PFD (pelvic floor dysfunction).
Kailie: Some research says 100% of pregnant women will get a diastasis. Most will heal theirs naturally but for those who don’t, research says they will need professional help from pelvic floor physical therapists to heal.
Amber: DR is known as abdominal separation of the rectus abdominis (which is very important for pelvic floor health because the rectus abdominis works together with the pelvis (pelvic floor) and lower back to help you move and transfer weight through the pelvic area). The chances of this happening or more commonly seen in women who have had C-sections, any type of abdominal surgery or a pregnancy with multiples.
How can Diastasis Recti be diagnosed? What are some signs a woman may have this?
Olga: A DR diagnosis must be completed by a trained individual and it is the assessment of the rectus abdominal muscle at 4 points going vertically at the center of the abdomen. The 4 points are bellow the sternum, above and bellow the umbilicus, and above the pubic symphysis. A women is asked to lay down, knees bent (is what I prefer) arms across the chest, the PT palpates the above areas and asks for the head to be lifted for the examination. Fun Fact: while in this position I palpate a mother’s rib cage and more often then none I can tell if one is breast feeding as the rib cage has a tendency to flair out. Patients love this. Also along the rib cage palpation if I do a down ward compression more often then none a patient will also feel increase in support and decrease in pain/discomfort.
Women will report abdominal weakness, abdominal bulge, and difficulty loosing weight along the abdominal region. With the weakness will come back pain and difficulty performing tasks. Some will see the separation when laying in bed and trying to pick there head up.
Kailie: it can be diagnosed by someone who has been trained. This may be a personal trainer with special training, physical therapist, midwife etc.
Amber: It can be diagnosed by either a physician or a PT. Typically what we’re looking for is a separation greater than two fingers. How this is determined the therapist has the patient lay on their back with their knees bent and feet planted, the physician or PT will place 2 fingers just above the bellybutton and then have them perform a crunch like maneuver and see if either the stomach peaks or creates a dip and if that valley or peak is greater than two fingers is how they diagnose it.
What should women with Diastasis Recti avoid?
Olga: Avoid any activity that will increase the separation. That includes getting in/out of bed, caring for your newborn or child and when performing strengthening exercises. My two exercises that are a no-no for me are planks and/or crunches or honestly any strengthening exercise that increases inter abdominal pressure. It will be difficult to maintain proper posture with DR so it is important that as a clinician you are also working on postural strengthening.
Kailie: There is no research that conclusively says “all women should avoid these 5 movements and you will avoid diastasis!” There is also no research that says, “do these specific exercises and heal your diastasis!” This is because all women move differently, their abdominal profile is different and so is the state of their pelvic floor muscles and it takes the pelvic floor muscles, abdominal muscles and breathing muscle, called the diaphragm to successfully heal a diastasis. You really need to be guided by a professional who can watch you move and tell you what movements you should avoid and what is safe! Some women shouldn’t do sit ups and others do them fine without making a diastasis worse. Sit ups cannot be avoided in everyday life, however, so if someone cannot do them safely, then a professional needs to give them a strategy to help minimize further separation.
Amber: Typically, there isn’t any pain involved with DR but I always recommend to follow what we call back precautions because the core is so weak. So what does that mean? That means no heavy lifting no twisting with heavy objects without first performing an abdominal brace to protect the core and the back and always keep the intended object close to the body (which is just good mechanics anyways).
How can women with Diastasis Recti repair it?
Olga: Proper evaluation is key. The best thing is to have a WH PT perform the evaluation. I have had many women that have been told by their doctor that the separation is not a big deal when it really has been. Luckily in these cases, the women did their own research and requested a PT evaluation. But I’ve had a few instances where separation was ignored during first pregnancy and only got worse during and after second pregnancy. Not all YouTube channels have correctly instructed exercises and at the end of the day, there is nothing better than a hands-on evaluation and instruction. What’s just as important as the actual separation, is the depth that comes with the separation. Ex. 1. A mother comes in with 3.5 finger width separation in the upper and lower umbilicus region, the depth is not bad, which means with proper exercise it should close up well. Ex.2. A mother comes in with 2 finger width separation same location with significant increase in depth (how deep my fingers go when I perform the test). I’m more worried about the second mother than the first. Because the fascia that is underneath the muscle is also affected during the separation – its integrity should also be evaluated. It used to be that a 2 finger width separation is “normal”. I still believe it to be true, but the underlying fascia integrity is just as important to me.
Amber: When we treat a patient for DR, we’re focusing on strengthening the deep core stabilizers. What does that mean and how does that work? A lot of people believe that to have a strong core, they need to strengthen their abs by doing hundreds of crunches – but that’s not necessarily what we want to focus on. The muscle of importance is called the transverse abdominal is which is a much deeper muscle in the core that helps to stabilize us. A strong transverse abdominis allows us to lift and carry heavier objects (i.e. our children) without putting a lot of stress through our back and our pelvic floor. Some simple exercises that we start with to name a few are posterior pelvic tilt with an abdominal brace (meaning we want to draw the bellybutton in towards the spine and upward), Pilates principal techniques like bridging and planks for more advanced patients.
What other information do you wish women knew about pelvic floor health?
Olga: I wish more than anything that women would be given the opportunity to see a women’s health or PFPT right after child birth. Especially after the first child. More often than not, I see women after their second, third or fourth child with PF symptoms that could have been prevented or minimized if they were only properly trained after their first pregnancy.
I wish women knew how common PF symptoms are and I wish they knew that something can be done and there are trained specialist that can help. I also wish they wouldn’t listen to their friends and family when they have symptoms and are told to blame it on the pregnancy. Many women are told “it’s normal, you just had a baby” or “it’s normal, you have five children” STOP mommas – IT IS NOT NORMAL, is it common? YES – but NOT NORMAL.
Kailie: All of the dysfunctions I listed are common but not normal. Thinking that time will heal or eliminate a symptom like incontinence will often make it worse vs. better because women intuitively do the wrong things thinking they are helping! I don’t know why but I see this across all my clients regardless of age, number of babies or even with those who have never had babies! Yes, women who never have babies can have all of the pelvic floor dysfunctions and I treat them all the time! Men can also have dysfunctions like a diastasis! When you tell your healthcare provider about your pelvic floor problems, do not take “it’s normal, give it time, you just had a baby” – they better give you a referral to a pelvic floor physical therapist! Not all physical therapists have this training and they will not be able to help you – they may make it worse! Also, surgery is NEVER the first line treatment! It is the last resort! Always!
Amber: When I was in my early twenties, I had intense cramping in my pelvic region which never seemed to subside on its own and physical activity just made it worse. I had seen many doctors who diagnosed me with everything under the sun. I finally followed-up with my GYN and she noticed that I had multiple trigger points in my pelvic floor and gave me a prescription for women’s health PT. The PT explained that I have too much tension in my pelvic floor and the muscles don’t know how to relax and we need to re-train them on how to relax she continued to explain that my core was very weak which caused my pelvic floor to work in overdrive. After weeks of therapy with emphasis on core strengthening and manual therapy to help decrease the tension in the pelvic floor, for the first time in two years I was able to get relief. That was seven years ago and I haven’t had any issues ever since! I think it’s important for every woman to know there’s no reason to live with these issues no matter how big or small and it’s great that we can come together as a community and talk about these issues so that women know there is help out there!
Thank you so much to Olga, Kailie and Amber for their insights and expert perspectives – I really appreciate your contributions!