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Pelvic Floor

What is the pelvic floor and how is affected during pregnancy?

The pelvic floor is a group of striated muscles which originate from the coccyx anteriorly and attach to the pubic bone posteriorly.¹ Their role is to provide constant tone and structural support for the pelvic organs² and to give conscious control over the bladder and bowel via the tightening and releasing of the sphincters. Additionally, the pelvic floor muscles provide support for the baby during pregnancy as well assisting with the birthing process. Due to the strain placed upon these muscles during pregnancy and childbirth, it is common for post-natal women to experience a loss of pelvic floor contractility, bladder-neck descent, increased bladder-neck mobility, pelvic organ descent and decreased urethral resistance.³ These changes are often associated with a number of pelvic floor disorders including urge urinary incontinence (UUI), stress urinary incontinence (SUI), overactive bladder syndrome, pelvic organ prolapse (POP) and anal incontinence. Incontinence holds a particularly high prevalence among postpartum women, with 33% of women experiencing incontinence during the first 3 months postpartum⁴.

What is the clinical presentation of pelvic floor disorders?

The clinical presentation of pelvic floor disorders will vary based on the type of disorder the patient presents with. Patients may report one or more of the following⁵:

• SUI - urine leakage when coughing, sneezing, laughing or during physical exercise
• UUI - an overwhelming sense of urgency when needing to micturate
• POP – bulging or a sense that something is “falling out” from the vaginal area
• Anal incontinence – loose stool beyond one’s control

How is the pelvic floor assessed?

Formal internal examination of the pelvic floor muscles can only be completed by physiotherapists who hold post graduate qualifications. This may include palpation of these muscles and the completion of strength/functional tests. Physiotherapists without post graduate qualifications are still able to assess the pelvic floor through palpation of the transversus abdominus muscle which often co-activates during pelvic floor muscle contractions⁶. Transabdominal real-time ultrasound can also be used as a non-invasive and valid method of visualising pelvic floor muscle activity⁷.

How can physiotherapy assist with pelvic floor related issues in post-natal women?

Following assessment of the pelvic floor, a physiotherapist will be able to prescribe post-natal women with pelvic floor muscle training (PFMT) in accordance with their level of strength and potential disorder. PFMT alone or in conjunction with other therapies has been shown to either cure or improve SUI in 97% of women⁸. Additionally, PFMT has been proven effective at reducing POP symptoms in women with a mild prolapse.⁹ After receiving brief verbal instructions, around 50% of women who attempt pelvic floor exercises perform them incorrectly, which can worsen pelvic floor function¹⁰. This further emphasises the necessity of a physiotherapist’s involvement and guidance when commencing PFMT. 

Diastasis of the Rectus Abdominal Muscle (DRAM)

What is DRAM?

DRAM is a separation of the abdominal muscles at the linear alba (LA), which is the fascia between the rectus abdominis heads .¹¹ As the abdomen expands during pregnancy, the LA must soften and expand in order to accommodate for the growing fetus. Possible causes of DRAM include the presence of hormones such as relaxin and progesterone which are produced during pregnancy leading to the softening of soft tissue structures, an increased anterior pelvic tilt/hyperlordosis and increased intra-abdominal pressure. 

What are the consequences of DRAM?

Without the dynamic stabilisation that the abdominal muscles provide, weakness in the abdominal wall can jeopardise trunk stability and mobility, contribute to back pain, compromise posture, hernia¹² and cosmetic defects. Additionally, there is some evidence to suggest that women with DRAM tend to have a higher degree of abdominal or pelvic region pain.¹³ Despite suggestions that DRAM may be associated with pelvic floor dysfunction, recent evidence has revealed that women who present with DRAM are not more susceptible to pelvic floor weakness, urinary incontinence or pelvic organ prolapse¹⁴.

How is DRAM diagnosed and assessed?

An adult is considered to have DRAM when they present with an ‘abnormal’ inter-rectus distance (width of the linear alba between the paired rectus abdominis muscles). A therapist is able to measure inter-rectus distance via palpation by placing fingers in the sulcus between the medial borders of the rectus abdominus muscles. A measurement of 2.5 fingers or more at, above or below the umbilicus is the current requirement for the clinical diagnosis of DRAM¹⁵. DRAM is considered to be ‘severe’ when a measurement of 4 fingers or more is obtained. A therapist will also observe ‘doming’ of the abdominal region and appropriate load transfer while the patient is completing a sit-up.

How can physiotherapy assist with the treatment of DRAM?

Fortunately, DRAM severity is markedly reduced naturally within the first 8 weeks post-pregnancy¹⁶, however physiotherapy can assist with this process. DRAM management begins with training of the ‘deep core’ which includes both the transversus abdominis muscles (TrA) and pelvic floor muscles. Use of the rectus abdominis muscles should be avoided until the patient is able to recruit TrA effectively¹⁷. Evidence has found that exercise programs, particularly those that included abdominal exercises, were effective at reducing inter-rectus distance^{18 19}. Treatment will also include patient-specific education, including advice regarding the avoidance of activities which increase intra-abdominal pressure such as heavy lifting and straining. Patients may also be offered compressive support garments if appropriate, which provide support to the lower back and abdomen while vulnerable.

Clinical Bottom Line

Pelvic floor disorders and diastasis of the rectus abdominis muscle are both highly common among post-natal women. If these conditions are suspected, physiotherapy assessment and intervention is likely indicated. Patients with pelvic floor disorders will benefit from specific pelvic floor muscle training while women with post-natal DRAM are likely to improve with a structured deep core and abdominal exercise program to reduce inter-rectus distance. 

References

1. The Continence Foundation. (2020). Pelvic floor muscles. Retrieved from  https://www.continence.org.au/pages/how-do-pelvic-floor-muscles-help.html
2. Myer, E. N. B., Roem, J. L., Lovejoy, D. A., Abernethy, M. G., Blomquist, J. L., & Handa, V. L. (2018). Longitudinal changes in pelvic floor muscles strength among parous women. Gynecology, 219(5), 482.e1-482.e7. doi:10.1016/j.ajog.2018.06.003
3. Van Geelen, H., Ostergard, D., & Sand, P. (2018). A review of the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques. International Urogynecology Journal, 29(3), 327-338. doi:10.1007/s00192-017-3540-z
4. Thom, D. H., & Rortveit, G. (2010). Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstetricia et Gynecologica Scandinavica, 89(12), 1511-22. doi: 10.3109/00016349.2010.526188
5. Chan, S. S. C., Cheung, R. Y. K., Yiu, K. W., Lee, L. L., Leung, T. Y., & Chung, T. K. H. (2013) Pelvic floor biometry during a first singleton pregnancy and the relationship with symptoms of pelvic floor disorders: a prospective observational study. An International Journal of Obstetrics, 121(1), 121-129. doi:10.1111/1471-0528.12400
6. Arab, A. M., & Chehrehrazi, M. (2010). The response of the abdominal muscles to pelvic floor muscle contraction in women with and without stress urinary incontinence using ultrasound imaging. Neurology and Urodynamics, 30(1), 117-120. doi:0.1002/nau.20959
7. Sherburn, M., Murphy, C. A., Carroll, S., Allen, T. J., & Galea, M. P. (2005). Investigation of transabdominal real-time ultrasound to visualise the muscles of the pelvic floor. Australian Journal of Physiotherapy, 51(3), 167-170.
8. Neumann, P. B., Grimmer, K. A., & Deenadayalan, Y. (2006). Pelvic floor muscle training and adjunct therapies for the treatment of stress urinary incontinence in women: a systematic review. BMC Women’s Health, 6(1). doi:10.1186/1472-6874-6-11.
9. Panman, C., Wiegersma, M., Kollen, B. J., Berger, M. Y., Lisman-Van Leeuwen, Y., Vermeulen, K. M., & Dekker, J. H. (2016). Two-year effects and cost-effectiveness of pelvic floor muscle training in mild pelvic organ prolapse: a randomised controlled trial in primary care. An International Journal of Obstetrics & Gynaecology, 124(3). doi:10.1111/1471-0528.13992
10. Bump, R. C., Hurt, W. G., Fantl, J. A., & Wyman, J. F. (1991). Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. American Journal of Obstetrics and Gynecology, 165(2), 322-329. doi:10.1016/0002-9378(91)90085-6.
11. Hills, N. F. (2018). Comparison of trunk muscle function between women with and without diastasis recti abdominis at 1 year postpartum. Physical Therapy, 891-896. doi:10.1093/ptj/pzy083
12. Cheesborough, J. E., & Dumanian, G. A. (2015). Simultaneous prosthetic mech abdominal wall reconstruction with abdominoplasty for ventral hernia and severe rectus diastasis repairs. Plastic Reconstructive Surgeries, 135(1), 268-276. doi: 10.1097/PRS.0000000000000840.
13. Parker, M. A., Millar, L. A., & Dugan, S. A. (2009). Diastasis rectus abdominis and lumbo‐pelvic pain and dysfunction‐are they related?. Journal of Women’s Health Physical Therapy, 33(2), 15-22.
14. Bø, K., Hilde, G., Tennfjord, M. K., Sperstad, J. B., & Engh, M. E. (2017). Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and Urodynamics, 36(3), 716-721. doi:10.1002/nau.23005.
15. Noble E. Essential Exercises for the Childbearing Year. 2nd edition. Boston, MA: Houghton Miffilin; 1982.
16. Coldron, Y., Strokes, M., Newham, D., & Cook, K. (2008). Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual Therapy, 13(2), 112-121. doi:10.1016/j.math.2006.10.001
17. Collie, M. E., & Harris, B. A. Physical therapy treatment for diastasis recti: a case report. (2004). J Sect Women's Health, 28(1), 11-15.
18. Sancho, F., Pascoal, A. G., & Mota, P. (2012). An ultrasound study on the effect of exercise on postpartum women inter-rectus abdominis distance. Journal of Biomechanics, 45(1), 493-494. doi:10.1016/S0021-9290(12)70494-3
19. Banerjee, A., Mahalakshmi, V., & Baranitharan, R. (2013). Effect of antenatal exercise program with and without abdominal strengthening exercises on diastasis rectus abdominis – a post-partum follow up. Indian Journal of Physiotherapy and Occupational Therapy, 7(4), 123-126.