What is Women’s Health Physiotherapy?

Women’s Health is an area of treatment interest that addresses a spectrum of issues related to women’s health and Pelvic Floor Dysfunction (PFD) including:

• Pain from c-section scars, episiotomies, or tears during child birth
• Endometriosis associated pain
• Pubic symphysis dysfunction  
• Sacroiliac joint pain.
• Sport related conditions
• Post surgical conditions
• Porstectomy
• Constipation
• Lower back pain
• Hip pain
• “Sciatica” pain  

How does the pelvic floor dysfunction (PFD) causes different conditions?

The pelvic floor is made of several layers of muscles that support the pelvic organs and form the birth canal and passages for urine and stool. Pelvic floor muscles along with abdominal and back muscles are called “core muscles”. Therefore they have an important role in core stability. These muscles need to be able to contract proper to demand e.g. keep us continent and be able to relax to facilitate childbirth, urination, bowel movements, and sexual intercourse.
Physiotherapy intervention is required when pelvic floor muscles are too weak, too tense, or not coordinated. Weakness in pelvic floor muscles might result in conditions including urinary or bowel incontinence, urgency and POP.

Increased tone in pelvic floor muscles can result in conditions such as urinary frequency, urgency, painful urination, incomplete emptying, constipation, low back pain, pelvic pain, vaginal pain, and pain during or after intercourse. In case of hypertonic pelvis floor muscles, the physiotherapy treatment will focus primarily on relaxing and normalizing the muscle tone.

How can pelvic floor rehabilitation help with Pelvic Organ Prolapse (POP)?

The pelvic floor muscles have an essential role in supporting uterus, bladder, and rectum. Weakness in soft tissue and muscles in pelvic floor might result in Pelvic Organ Prolapse (POP) that happens when the bladder, uterus, or rectum slips out of place down into the vaginal canal. POP is mostly caused by traumas such as childbirth, surgery, heavy and repetitive lifting, and hormones. There is growing evidence Pelvic Floor Physiotherapy is effective in reducing the prolapse and in preventing surgery. In cases of severe prolapse when surgery is recommended, pelvic floor physiotherapy before and after surgery is required to improve the pelvic floor function.

Symptoms of POP include: pelvic, vaginal or rectal pressure, feeling a bulge at the vaginal canal, bowel and/or urinary incontinence (stress/urgency), pelvic/abdominal/low back pain, difficulty emptying bowel and/or bladder and painful intercourse.

Physiotherapy Treatment for POP:

1. Pelvic floor re-training and exercises: Kegel exercises have been shown to improve strength in pelvic floor muscles. Biofeedback, real time ultrasound, and muscle stimulators can be used to assess and teach the patient how to strengthen pelvic floor muscles. Your physiotherapist will teach you how to use your pelvic floor proper to the demand in order for you to return to your daily normal activities without recurring symptoms.
2. Assessment low back and abdominal muscles as dysfunction of these muscle groups can contribute to PFD.
3. Core strengthening and stability exercises of lower back and abdominal muscles which play a supporting role in the strength of the pelvic floor
4. Education on relaxation, anxiety, stress, thoughts, and beliefs and how they contribute to sensation of pain in the pelvis.

In Severe cases when exercises do not fully improve the prolapse, the use of pessary is recommended. Pessary is an internal assistive device that supports and holds up the prolapse. Pessaries are easy to insert and remove. In severe cases where all the above therapies fail, surgery might be recommended.

How can pelvic floor rehabilitation help with dyspareunia, vulvar pain, vulvar vestibulitis, vulvar vestibulodynia, and vaginismus?

Some women experience pain during intercourse, medical exam or tampon use, and sometimes during activities such as sitting, or cycling. The cause of such pains is unknown; however, some times pain can trigger from yeast, bacterial, or fungal infection, injury to pain nerves, or psychological issues. Most women with these conditions have hypertonic (tense) pelvic floor muscles. 

In these cases, the focus of physiotherapy treatment will be on relaxation of the muscles and desensitization of painful areas. Your physiotherapist will teach you how to relax the pelvic floor muscles. Some times biofeedback is used to assist in relaxation of muscles. Internal manual therapy techniques will be used to relax the pelvic floor muscles, including trigger point release, and myofascial stretches. Other techniques include Treatment of pain in low back, hips and pelvis if present, relaxation and breathing techniques, Internal manual therapy techniques to relax the pelvic floor muscles, including trigger point release, myofascial stretches, scar massages, neural mobilisations, education on positioning and posture, and education on the use of vaginal dilators, pelvic floor educators or muscle stimulators to help with relaxation of pelvic floor muscles.

How can pelvic floor rehabilitation help during pregnancy?

During pregnancy the body goes through a huge change. The pelvic floor muscles and their supporting soft tissue can become stretched resulting in urinary or fecal incontinence or pelvic organ prolapse.

The most common symptoms during pregnancy and post-partum include incontinence, pelvic pain, low back pain or pelvic organ prolapse. Unlike what some women believe, these symptoms are NOT “normal” and are NOT a part of pregnancy or post-partum.

These symptoms are signs of pelvic floor dysfunction and need proper treatment. The research has shown 50% of all women who deliver a child will develop pelvic organ prolapse. Furthermore, the evidence shows that women, who experience stress urinary incontinence during pregnancy, or within 6 weeks after giving birth, are more likely to suffer from incontinence 5 years later. Also it has been shown that

Some of the symptoms you might experience during pregnancy are:

Incontinence or leaking urine/stool when laughing, sneezing, coughing, walking, lifting, etc.

1. Pain in pubic area, low back, groin, legs
2. Separation of abdominal muscles (bulging of the abdomen when you curl up from lying position)
3. Pain with intercourse

Your pelvic floor physiotherapist will help you prevent and recover from these symptoms properly and safely. You will be advised on pelvic floor strengthening and stability exercises, and you will be taught how and how much to activate the certain muscles proper to the task. Your physiotherapist will advise you on proper posture, positioning, movement modification, and how to perform daily tasks (e.g. sitting, lying, lifting, changing positions) safely. You will be directed on how to maintain a strong pelvic floor through your pregnancy and after.  Other techniques can include manual therapy techniques such as soft tissue release of the low back, hips and pelvis, fitting sacroiliac belts, and education on pain management.

How can pelvic floor rehabilitation help post-partum?

Some symptoms of PFD might arise post-partum no matter in you had a C-section or vaginal delivery. Childbirth can involve trauma to the pelvic floor, perineal tears and pudendal nerve injury. Symptoms such as incontinence, pelvic pain, low back pain or POP might begin during pregnancy and continue or exacerbate after delivery. These symptoms are NOT a normal part of post-partum and need to be treated properly.

Some of the symptoms you might experience post-partum are:

1. Incontinence or leaking urine/stool when laughing, sneezing, coughing, walking, lifting, etc.
2. Difficulty with emptying the bladder/bowel completely
3. Pain in pubic area, low back, groin, legs
4. Separation of abdominal muscles (bulging of the abdomen when you curl up from lying position)
5. Pain with intercourse or constant pain in low back, abdomen or pelvis.
6. Scarring from c-section
7. Feeling heaviness/bulging in vagina or rectum
8. Separation of abdominal muscles (bulging of the abdomen when you curl up from lying position)

The physiotherapy treatment include:

1. Pelvic floor re-training and exercises: Kegel exercises have been shown to improve strength in pelvic floor muscles. Biofeedback, real time ultrasound, and muscle stimulators can be used to assess and teach the patient how to strengthen pelvic floor muscles. Pilates exercises can be helpful in maintaining core strength as well. Your physiotherapist will teach you how to use your pelvic floor proper to the demand in order for you to return to your daily normal activities without recurring symptoms.

1. Education on body awareness and on how to engage specific muscles proper to the task (e.g. how to sit from lying, how to roll in bed, how to move in and out of the car, how to lift, etc.) and improves movement patterns and overall posture
2. Use of modalities such as of biofeedback, ice or heat, and electrical stimulation for pain management.
3. Use of manual therapy techniques to improve joint mobility and soft tissue flexibility.

How can pelvic floor rehabilitation help with Diastasis Rectus Abdominus (DRA)?

During pregnancy the abdominal wall as the stretches and can sometimes separate. The right and left rectus abdominus muscles join at the linea alba. Mostly in the third trimester of pregnancy when the abdominal muscles are the most stretched, the separation from linea alba might occur. This is called a diastasis rectus abdominus. You might notice a bulge down the centre of your abdominal muscles when you move your head up from lying on your back. You can also put your fingers into the space between your left and right rectus abdominus muscles across the midline of your stomach. DRA is often more prominent above umbilicus and it can extend to umbilicus and below umbilicus.

DRA along with the dysfunction/over stretch of pelvic floor and deep abdominal muscles (transversus abdominus) may lead to in low back pain, pain in symphysis pubis or pelvic girdle pain (PGP).

What can I expect from a pelvic floor physiotherapy session?

Your initial appointment might take from 45 minutes to one hour in length and will involve a detailed history and physical examination.  Your physical examination includes assessment on abdominal, pelvis and lumbar spine muscles. This assessment may possibly include an internal examination.  Internal examination is important for assessing the tone and strength of pelvic floor muscles, presence and severity of pelvic organ prolapse, and the presence of hypersensitive and tender spots in pelvic floor muscles.

After a thorough assessment, a customized treatment plan will be developed to target your special concerns. Follow up treatment appointments are 30 minutes in length.