6 Tricky Problems Caused By Constipation

Every time I meet a new patient, I ask them about their pooping. Sometimes this throws people off, and they’ll say “…but…I’m here for my shoulder” LOL jk, jk– I don’t treat people who have primary shoulder problems. Remember, pelvic floor problems are my jam! BUT, even when people have a “pelvic” problem (and I put it in quotes, because while I saw I specialize in the pelvis, the reality is that the pelvis is in the body so the whole body can impact the pelvis), they can struggle to see the connection between their bowel movements and their bladder leaks, painful sex, low back pain, prolapse– and more! The reality, however, is that what is happening with your bowel movements is ABSOLUTELY important for any pelvic problem we see. And, this is especially the case if someone struggles with constipation.

Why does constipation matter for pelvic health?

The reality is that the pelvis is not as big as you’d think. A full rectum that isn’t emptying well can press on the other structures around it (including the bladder and vagina, pelvic floor muscles and nerves around the pelvis) and can also stretch to an uncomfortable level and refer to the low back. Hard, dehydrated stool is also more difficult to empty, and can require more effort, placing increased pressure on the organs in the pelvis and the pelvic floor muscles themselves.

(c) Southern Pelvic Health, Do not use without permission

6 Tricky Things that Can Actually Be Caused or Worsened By Constipation

This is where things get interesting. Because of how close everything is, and how intricately the muscles are connected to defecation, people are often shocked at the things their bowel movements can be involved with. Let’s look at a few:

#1 Pelvic or Tailbone Pain

That’s right! Constipation can lead to worsening pelvic pain, or even be a primary cause to begin with. There are several reasons for this. First, when stool is in the rectum, it will put pressure on the puborectalis muscle, whose job it is to maintain the angle between the rectum and the anal canal, preventing leakage, and opening to allow for defecation. Typically, if the rectum fills, this will trigger a sampling response where literally your rectum allows a small amount of contents into the anal canal to determine– solid, liquid or gas? Then, it will trigger a reflex to facilitate defecation. If someone has harder stool with less forming together, they may not empty their bowels well, leading to stretching of the rectum. This will put pressure on the puborectalis muscle, which then can lead to increased muscle activation (hey, there’s more stool to hold back!), and ultimately, muscle irritation and overactivity. Pelvic floor muscle overactivity can lead to pain around the pelvis and into the tailbone and sacrum. And it’s a tricky cycle, because overactive muscles don’t stretch as well, making it harder to have a bowel movement, and the harder it is, the more the muscles become irritated.

#2 Pelvic Organ Prolapse

Prolapse occurs when there is a loss of support around the walls of the vagina and an organ (the bladder, rectum, small intestines or uterus) protrudes into the vagina. It can be very annoying and uncomfortable, and can lead to a feeling of a bulge in the vagina, heaviness in the pelvis, or pressure into the perineum or pelvis. Pregnancy and childbirth can be a big factor with prolapse due to a loss of connective tissue or fascial support, however, increased pressures on the pelvic floor over time can also play a role. I’ve seen this happen for people who worked in jobs that required extensive heavy lifting, when people are doing exercises that their bodies cannot really do well, and, yep– in cases of long-term constipation. Constipation leads to increased pressure on the pelvic floor and more effort required for emptying. So, when a person is constipated and has to strain more to empty, this can weaken the support around the vagina, and can ultimately be a big factor for people with prolapse. And the great thing– when we help this to improve, usually we’ll see the prolapse symptoms get better too!

#3 Painful Sex

Similarly to pelvic pain, overactivity in the pelvic floor muscles can be very involved when a person is dealing with pain during sex. Additionally, if their rectum is staying full with stool, this will put pressure on the vagina and decrease the space allowed for the vagina to stretch with insertion. So, you guessed it, optimizing constipation can make a difference for people having pain with sex.

#4 Low Back Pain

This one is very interesting! We already talked about how the pelvic floor muscles can become overactive if someone is dealing with constipation, and of course, this can be a factor with low back pain. However, the colon itself can also become very stretched when stool is backed up, and this will refer into the low back. This is surprisingly more common than you would think! I’ve seen many people dealing with long-term back pain that noticed a significant change (if not a cure!) by optimizing their bowel health. And this makes sense when we think about how organs can often refer to somatic structures around the body (Remember how a heart attack can present as shoulder pain? Kidney stones as low back pain?).

#5 Pudendal Neuralgia

I had to include PN in this group! The pudendal nerve runs through the pelvis so sits in very close proximity to the rectum. When a person strains and has difficulty emptying the bowels, this nerve can be stretched and irritated. Long term constipation can cause a person to develop pudendal nerve irritation, and if a person has pudendal nerve problems already (from an injury during surgery, cycling irritation, childbirth, or other), constipation will absolutely worsen their pain levels.

Häggström, Mikael (2014). “Medical gallery of Mikael Häggström 2014“. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008ISSN 2002-4436.
 Public Domain.

#6 Bladder Leakage

This one is always harder for people to grasp. Yes, constipation could be the reason you are leaking or it could be making your leakage much worse! This can happen for a few reasons. First, the pelvis is not that big. So, a full rectum could be pressing on the bladder putting it into a position where it is more likely to leak. Additionally, remember how the muscles get involved with constipation? Well, they’re important for the bladder as well! Overactive and irritated muscles do not work as well for the bladder so can often struggle with holding back urine.

So, what can you do if you’re struggling with constipation?

First, realize that you’re not alone. Constipation is the #1 GI complaint in the US for a reason, and there is SO much that can be done to improve this! So, don’t just deal with it. Don’t write it off as something “you’ve always dealt with” or something “that runs in my family” or anything else. Take steps today to help your body poop better, and I promise you– your world will be a happier place.

If you’re able, I would STRONGLY recommend my mini-course on overcoming constipation. In this class, Dr. Sara Reardon and I give you all of our big tips to help you poop better, and for $39 you can’t beat the value you’ll get in this class!

Check out these other articles I’ve written on pooping (yep, I write about poop a lot!) and hopefully this helps you get started!

Building a Stellar Bowel Routine

5 Ways to Help IBS

How to Poop

Dyssynergic Defecation (or When the Poop Won’t Come Out)

Happy Pooping!

~ Dr. Jessica

Holiday difficulties for your pelvic health & 5 tips to help!

Last week, my husband and I toted our 2 daughters to the clinic, and put up a Christmas tree, lights, a menora and a beautiful locally made wreath. We did the same to our house the week before, plus added the lights outside, stockings by the chimney, as well as the santa and snowmen collections (We’re BIG Christmas people– totally unabashedly Christmas obsessed!). Last night, we put those same little girls in the car with travel mugs of hot cocoa, and drove to a local lights show. And really, this is just the beginning of our holiday festivities.

Holiday ready at SPH! 🙂

Again, I love Christmas. But as you just saw above, holidays (like Thanksgiving, Chanukah, Christmas, or whatever you celebrate!) can lead to big changes in our day-to-day routine. These changes can bring us joy (or stress!), but can create major difficulties for people dealing with pelvic floor problems, like pain and constipation.

Why do holiday flares happen?

There are lots of reasons why the holidays can create unique challenges for people.

Stress:

I don’t have to tell you that for many people, the holidays are extremely stressful! Changes in routine, combined with added pressures (often placed by ourselves!), events, and financial difficulties can lead to lots of overwhelming feelings. This paired with spending time with family you may not see often (but hey, it’s a pandemic year, so we really shouldn’t be doing that– right?), can lead to people feeling incredibly stressed and overwhelmed. The pelvic floor muscles are known to be threat responders, so this can lead them to overactivate to guard and protect you against all of the stress. The challenge here is that protective pelvic floor muscles can often worsen symptoms like constipation, pelvic and lumbar pain, and incontinence.

Dietary Changes:

Turkey? Stuffing? Mashed Potatoes? Christmas Cookies? Pies? All the wine? I don’t know about you, but my holiday eating and my normal eating are quite different. This leads to us often getting less fresh fruits, veggies and natural fiber in our diets, and often getting way less fluid too. These dietary changes can make us more likely to develop constipation, and if you’ve worked with me, you know that constipation makes alllllll pelvic problems worse! Our habits can also lead to dehydration, as we exchange water for holiday drinks, and scurry around forgetting to get our fluid in.

Routine Changes:

For many of my patients, they’ve made progress by building habits that support healthy pelvic function. So, this may be an exercise routine they do in the mornings or at the end of the day. It could be taking a warm bath a few times per week with self-treatment. Perhaps it is doing a guided meditation before bed to relax their body. Perhaps it is something else entirely. But regardless, it can be really hard to keep these routines up over the holidays. This leads us to removing some of our self-care from our schedule, and without it, some of our symptoms can start to creep back up.

So, how can you make it through the holidays without worsening pelvic health problems? Well, I’ve got you my friend! Try these 5 tips!

Tip #1: Simplify your holidays

I get it, remember– BIG Christmas person! I’m not telling you to remove your traditions, and stop the things you love. But, I am encouraging you to prioritize what is important to you, and to remove pressures for what you think “should” be happening. Look at your schedule, your calendar, your family, and determine what naturally fits in. And if something doesn’t, gently let it go this year. Prioritize joy, family, and quality-time, and remove any pressures and obligations that you have placed on yourself.

Tip #2: Plan for healthy eating & hydration

I’m never going to tell you not to enjoy those delicious holiday meals, all the yummy pies and cookies, or the celebratory drinks. But, what I’m going to encourage you to do is to plan your day to make sure you’re also eating fresh fruits and veggies, getting adequate fiber, and getting adequate fluid. For many people, this means keeping one or two meals consistent during the day. So, for example, you might choose to have a salad for lunch, and keep yourself hydrated prior to having that turkey dinner that night. You may start your day with oatmeal and fresh berries, knowing that you have a big family lunch coming a little later. For bowel problems, this is especially helpful, as your colon LOVES consistency!

Tip #3: Create a daily stress-reducing routine

Stress can be one of the reasons symptoms tend to flare over the holidays, so I encourage people to be proactive in managing this! Some of my favorite stress-reducing routines include: warm baths with scented candles, guided meditations/relaxation, alone time with a cup of warm tea and journaling, yoga or tai chi, listening to binaural beats while you practice breathing exercises, and gratitude journals. Take some time to think about what feels relaxing and stress-reducing to you, then try to build that in to your day.

Tip #4: Prioritize your self-care

This one is hard as schedules get busy. But, as you plan your days and weeks leading up to the holidays, keep yourself in the equation. Think about the key pieces that are helping you right now, and make sure these stay in your schedule. This can mean keeping up with your exercise routine from your pelvic PT (ahem ;-)), making time to go outside for a walk or a job, waking up a little early to hop on your bike, or whatever it means for you. It’s really easy to let self-care go (believe me… I know), but when we do this, it hurts us and everyone around us. Being our best self means caring for ourselves. See this post on “Prioritizing Self-Care”

Tip #5: Treat flares with compassion

Despite trying these things (or not trying them), you may have a flare. Your symptoms may worsen. You may have increased pain or feel like you can’t poop. And I know it’s easy to go down the rabbit hole of despair. It’s easy to catastrophize, thinking things like, “I’m never going to get better!” “My body can’t even handle Christmas, I’m going to deal with this for the rest of my life.” “I’m headed for surgery…it’s just inevitable!” You get it. Maybe your brain has told you these stories. But, hear me when I say that while flares can feel incredibly overwhelming, they are just flares. So, take a slow, long breath, and let it go. See your flare for what it is– a flare. Recognize what likely caused it (oh yes, I haven’t been doing my exercises, and Aunt Betty was super stressful this year, and I don’t think I drank water for 3-days straight!), then gently make a plan to move forward. It may mean calling your pelvic PT to get an appointment, then jumping on your self-care plan, making some time for breathing and quietting your system, and taking some time for yourself away from Aunt Betty. Build your plan, and start taking steps in the right direction. You will get through this!

While the holidays can create challenges, there is so much beauty to our celebrations! I hope you and your family have a lovely, peaceful and joy-filled holiday season!

~ Jessica

5 Common myths about Pelvic Organ Prolapse

“I was just showering and reached down and suddenly noticed a bulge”

“I had no idea something was wrong until my doctor examined me and told me I have a stage 2 cystocele”

“I started feeling heaviness in my pelvis, then was wiping after I went to the bathroom, and noticed something was there!”

Pelvic organ prolapse impacts a lot of people. Some studies show that between 50-89% of people experience prolapse after vaginal birth (if they’re examined and someone is looking for it!), however, people can experience prolapse when they have never been through pregnancy or childbirth. Prolapse is one of the “scary diagnoses” as I tend to call them– not because I think it’s actually scary– I don’t– but because there is so much AWFUL information about prolapse out there. And when people suddenly learn about this, they dive deep into a rabbit hole of research, and often end up scared about what the future holds for them. BUT– I’m here today to tell you that: 1) Prolapse is actually very common and 2) there is so much you can do to help this problem!

To digress slightly– Working with people dealing with prolapse is a passion of mine, and I’m super excited to be teaching a LIVE class on managing pelvic organ prolapse with my friends and colleagues, Sara Reardon & Sarah Duvall. It’s going to be happening this Sunday at 4pm EST, and registration is limited! I hope you’ll join us for this awesome class! (Note: If you’re reading this after the event, and missed it– no worries! The recording will be available– just click the link above!)

What is Pelvic Organ Prolapse?

Before we jump into the myths surrounding prolapse, let’s talk about what it actually is. Pelvic organ prolapse refers to a loss of support around the bladder, uterus or rectum, and this causes descent one or more of these organs into the walls of the vagina. The organs themselves are supported by fascia, ligaments, connective tissues and… you guessed it! Muscles! So, how can loss of support occurs? Well, it could be due to straining of these tissues like would happen during pregnancy and childbirth, particularly if people have injuries during birth like stretch injuries to the nerves of the pelvis, tears in the connective tissue and fascia, or tears in the pelvic floor muscles themselves. This can also be due to chronic straining of the tissues that might occur with age, chronic lifting (with poor mechanics) or chronic coughing problems. Other factors like hormones, body size and joint hypermobility can also be involved.

What does prolapse feel like?

Maybe you’ve been diagnosed with prolapse, maybe you just think this is a problem you have, or maybe you know that you have this problem. Regardless, let’s chat about what prolapse can feel like. These are some of the things people who have prolapse can feel:

  • A bulge coming out of the vagina
  • Pressure in the pelvis or perineum
  • Lower back ache
  • Difficulty emptying the bladder
  • Difficulty emptying the bowels
  • Heaviness or a dragging feeling in the pelvis

Symptoms are often better first thing in the morning, then worsen as the day goes on (thanks so much gravity!). Symptoms vary person to person based on where they have prolapse and the severity of their prolapse.

So, now that we know what it is and what it can feel like, let’s jump into prolapse myths.

Common Myths Surrounding Pelvic Organ Prolapse

Myth #1: “You’ll likely need surgery at some point.”

I hear this one all the time. A well-intending physician tells their patient that they have prolapse, then follows it with, “we can fix that whenever you’re done having children” or something along those lines. While some people do end up needing surgery– particularly with more severe prolapse or if their prolapse is significantly impacting their function, many people are able to manage well conservatively with specific exercises or pessaries.

Myth #2: Prolapse is probably the cause of your pelvic pain, pain during sex, or genital pain.

So, you’ll see that I listed low back pain in the symptoms, but I didn’t list other types of pelvic pain. While I get that prolapse can look like it would be painful, it typically is not a painful condition. It’s an annoying condition, and can lead to behaviors that may cause pain (like constantly trying to grip your pelvic floor muscles to prevent things from falling down!). Prolapse can cause a back ache that worsens as the day goes on, and this is due to the ligaments around the organs stretching as the descent occurs. Additionally, the pressure/bulge can be uncomfortable, and people may feel like something is being pushed on during sex. That being said, we very often find that people have prolapse and something else going on when they are dealing with significant pain.

Myth #3: Because prolapse is structural, physical therapists likely won’t be able to help.

So first, support of the organs requires coordination of forces– ligaments and fascia are involved for sure, but muscles are also involved. All that aside, prolapse is a problem related to pressure management– so it matters what is happening at the pelvis, but also, what is happening outside of the pelvis that is impacting the pressure system.

Pressures within the intrathoracic and intraabdominal cavities can impact what is happening in the pelvis. Several muscles are involved in this pressure system, including the glottal folds at the top, the intercostal muscles, the respiratory diaphragm, the transverse abdominis muscle, the multifidus, and the pelvic floor muscles. These muscles work together in a coordinated way to help manage pressure and spread the load (so it is not funneled down to the pelvic floor).

Physical therapists help people with pelvic organ prolapse by helping them manage their pressure system as optimally as they can. This means looking at posture, spinal mobility, movement patterns, hip function, breathing habits, and so much more! It also means optimizing the function of the pelvic floor muscles. With this approach, we see good improvements. A Cochrane review of 13 studies in 2016 found that most people saw good improvements in their prolapse symptoms and their severity of prolapse on exam. A multicenter trial published in 2014 found that individualized pelvic floor training led to good improvement in symptoms and severity of prolapse.

Myth #4: Pessaries are for “old people”

Not true. Pessaries are amazing medical devices that help to support the walls of the vagina and can be very useful for reducing symptoms of prolapse. There are lots of different types of pessaries, and generally, people who wear them really find them to be helpful! In fact, this study found that 96% of the people who were appropriately fit with a pessary were satisfied and thought it helped with the severity of their symptoms.

Myth #5: If you have prolapse, you should never do certain exercises and movements so your problem doesn’t get worse.

I’ve said this before, and I’ll say it again– there are no bad exercises– BUT there may be times when certain exercises may not be optimal for you. Ultimately, the best thing to do is to work with a professional who can watch you move, watch you exercise, and see how you modulate pressure during these movements. Then, they will be able to make recommendations specifically for you– help you modify where you need to modify, observe your form during movement, and then strategize with you to make a plan to get back to whatever movements you would like to get back to!

If you’re experiencing prolapse, or you think this might be you– there is hope available! I’m very excited to be working with Sara Reardon and our special guest, Sarah Duvall to jump further into this topic in our upcoming class this Sunday 10/25 at 4pmEST on Managing Pelvic Organ Prolapse. Come join us LIVE and get all of your questions answered! If you can’t make the live, no worries!! A recording will be available.

What prolapse questions do you have? Let me know in the comments!

~ Jessica

LIVE Class Mon. 8/31: Easing Constipation

Did you know that 1 in 5 people struggle with constipation? 

Constipation is the #1 reason people seek a GI specialist. I write about pooping problems a lot. And for good reason– the bowels are something people often take for granted, until things aren’t working optimally.

The great news is that there is SO much you can do to help your bowel function! This Monday 8/31, Sara Reardon and I are teaching a LIVE 90-minute class on Easing Constipation

In this class you’ll learn: 

✅ What defines constipation and common contributing factors

✅ Pelvic floor muscle anatomy and how to use your muscles to help with defecation

✅ Dietary recommendations to help keep bowel movements soft

✅ Tips on managing constipation with prolapse (rectocele)

✅ Self-treatment techniques including building a bowel routine, optimal toileting posture, and breathing and relaxation exercises 

✅ BONUS Handouts on abdominal massage for constipation, proper toileting mechanics to facilitate emptying and more!!

You won’t want to miss this class! Registration for the LIVE class is limited, and we think this class will fill quickly! So be sure to secure your spot soon, and get your questions answered! If you can’t make the LIVE class, register now and receive access to the recording & all bonus content within 24 hours after the event! 

Register here! 

Hope to see you there! 

~ Jessica

Do you leak when you run? Try this!

I love running. To be honest, I’ve been out of a good running routine since Mary was born. She’s one now. I would like to change that. I’m scheduled (yes, my husband and I literally have to schedule everything with our crazy work weeks!) for a run this week and I’m thrilled.

As a pelvic physical therapist, my goal is always to help my support my patients in whatever exercise or fitness routine they enjoy. Sometimes, pelvic floor problems get in the way. I can’t tell you how many times I’ve heard things like: “I used to run all the time, but ever since I had a baby, I just can’t” or “I tried just wearing a pad while I was running, but I can’t get over the feeling that I’m making everything worse” or “I can run if I go first thing in the morning, empty my bladder before I leave, and then stop at the park on the way to go again.” Bladder leakage during running is ANNOYING. It can be so impacting to people, and for many, it can lead them to stop a movement or activity they enjoy, for the long-term.

5 years ago (has it really been that long!?!) I wrote on the topic, “Is running bad for the pelvic floor?” after receiving that question several times. Spoiler alert: There are times when it may be appropriate for someone to stop running for a period of time to retrain their body and regain their pressure modulating system optimization– however, running can be an excellent way for someone to exercise and move! There are no “Bad” exercises, just bodies that sometimes aren’t quite ready for them.

So, if you’re struggling with leaking every time you hit the pavement, what can you do?

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Let’s consider what happens during running, from a pelvic floor standpoint. Several studies in the past few years have demonstrated that the pelvic floor muscles are active during running. This study from 2017 used EMG electrodes at the pelvic floor muscles, and found that there was increased activation of the pelvic floor prior to heel strike and reflexive activation after heel strike during running. This is in line with what we know about the pelvic floor muscles. They play a crucial role in anticipating movement, preactivating, then have modulating force during movement based on the task at hand. And, this is protective. We would want the muscles to have varying levels of activation so that we can support ourselves during movement, support around the urethra, not leak.

What happens then when someone is leaking with running? We of course, want to say that this reflexive thing is not happening. This review did show some alterations in the way that those who leak contract vs. those who do not leak. However, this study found that the reflexive action was the same in those who leaked and those who didn’t. This one also found that patterns of engagement were the same. So, it is likely that there are sometimes differences, but sometimes not. And this seems in line with what we know about leaking. Leaking during running is a pressure system problem. So, to help it improve, we have to address the whole system– which includes the pelvic floor muscles, but not only the pelvic floor muscles. It makes sense that sometimes the issue is stemming from these muscles not activating at the right time, with the right force–but sometimes, the pressure problem is from something else.

How can we address the pressure modulation system?

First, we need to evaluate the system to see how the structures are functioning, and this includes looking at you– the full person– to see how you control pressure through your pelvis. So, we need to look at how you move from head to toe, then evaluate your running mechanics, then look more closely at your breathing pattern, your abdominal wall, and your pelvic floor muscles. Once we do this, we often have a clear idea of what is happening and can make a strategy to get this better.

So, my big Tip #1– Go see a pelvic floor PT–but make sure it’s someone who is trained at looking at the whole person and can really evaluate you well.

If you’re nervous about doing this, I feel you. It can be hard to talk to someone about very private things. And I totally understand that the idea of having an internal examination can be a barrier for some people. BUT, know that those of us living in the pelvic floor world talk about this stuff ALL THE TIME. You won’t surprise us. Seriously, we hear this stuff all day. And, if you don’t think you’re ready for an internal exam, that’s cool. Honestly, we don’t mind. There is SO much that can be done to help the pelvic floor and bladder leaks that can be done without an internal exam! If you want to learn more, give us a call. One of our doctors of physical therapy will be happy to do a virtual consult with you and get you started!

Ok, off my soap box… What else can you do to impact the pressure modulation system and decrease leakage?

Tip #2: Breathe!

This seems so simple. I know, you’re thinking, “Of course I’m breathing!” But, are you? Or are you going through a series of breath holds? Next time you run, pay attention, and keep your breath flowing in and out as you run. The diaphragm is the major pressure regulator of the body. So, we need to keep your breath moving so pressure is spread out!

Tip #3: Let your ribcage move!

Many people tend to run with stiffness, locking down their ribcage. This can funnel pressure downward toward the pelvic floor muscles leading to increased load, and potential leaking. Instead, relax your ribcage, let your arms swing and allow your trunk to rotate. This will actually turn on more of the muscles around your core improving the synergistic activation of your pressure modulating system.

Tip #4: Lean into the hills! 

When going up or down hills, it is easy to lean back to try to control the movement. This can alter the position of your ribcage over your pelvis which will impact your pressure control. Instead of doing this, lean into the hill as if you have a strong wind blowing against you (I love this visual I got from my friend & colleague, Julie Wiebe!). When going downhill, lean into the downhill and let yourself pick up a little speed instead of leaning back to slow down. Relax into the hill. Many of my patients find that doing this actually reduces the pressure they feel and can decrease leakage.

Tip #5: Get a running evaluation!

Running form matters, it really does! So, go see someone and have them take a look at your running form to offer you guidance on how you can optimize it! Be sure you’re using the best type of shoes for your foot as well! This can make a big difference! Awesome running stores in your area should be able to help you with this!

I hope this is helpful! What questions do you have about running and the pelvic floor? Ask away! We are here to help!

Have a great week!

~ Jessica

 

Clinical Expert Interview on Fecal Incontinence with Dr. Swetha Ramakrishnan

Clinical Expert InterviewsGood morning everyone!

This past week, I was so fortunate to sit down with Dr. Swetha Ramakrishnan to discuss fecal incontinence. Fecal incontinence is a MAJOR problem, impacting 7-15% of people. It is the #2 most common reason people are admitted to nursing facilities (guess what? #1 is urinary incontinence!) and it can happen in young and old alike. In fact, anal sphincter injuries are a common occurrence during vaginal birth (occurring in around 10% of vaginal births worldwide) and 9-24% of those people go on to develop anal incontinence.

At SPH, we use a multi-faceted approach to help people with bowel leakage which includes helping to optimize their stool consistency, facilitating a strong bowel routine, retraining digestive reflexes and encouraging functional pelvic floor muscle function (which does include that anal spinchters).

I’ve been treating colorectal conditions for over 10 years, and Dr. Rama and I have worked together for the past 5 years. She is an incredibly skilled, intelligent and kind provider with ATL Colorectal in the metro Atlanta area. I hope you enjoy our discussion on bowel leakage– what it is, why it happens, and the very important, what you can do about it!

If you have any questions, drop them in the comments below!

~Jessica

“Just the normal incontinence” and other common myths about pregnancy, birth, and beyond

At Southern Pelvic Health, we offer free 15-minute phone consultations for people to determine if pelvic floor physical therapy is the best next step in their health journeys. These consultations are awesome– they give us a chance to get to know the patient, give the patient a chance to ask any questions, and help us start building a partnership if physical therapy care ends up being their next step. For some, it is. And for others, it’s not. Sometimes we refer patients to their physicians or other specialists. Sometimes, we encourage them to wait before coming in for a procedure, surgery, or something else.

Recently, I spoke with a new mom experiencing some difficulties that happened after birth. As we were talking, I asked her if she was having any bladder leakage, or other bladder challenges. She said, “During pregnancy, I had the normal incontinence, and I do leak some now, but nothing unusual.” Let that sink in. Why is bladder leakage, ever, looked at as a normal thing? Spoiler alert: It’s actually not normal. And guess what? There is something you can do to help it. Even during pregnancy.

So, this inspired me to write a post on some of the common pelvic health myths around having babies.

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Myth #1: Bladder leakage is normal during pregnancy or after you’ve had a baby.

I already spoiled this one. It’s actually not. Common, yes. But not normal. During pregnancy, people can be more susceptible to leakage at certain times as the growing uterus changes the angle of the urethra, but the body should still be able to compensate, support the urethra, and avoid leakage. After having a baby, it can be normal to have some leakage in the first few weeks (depending on your birth), but then, it should improve. Continuing to leak after that initial healing period is actually not normal, and there is so much that can be done to improve this!

Myth #2: If someone is experiencing prolapse after having a baby they will eventually need surgery.

I hear this one a lot. Comments from well-meaning providers saying things like, “we’ll need to fix that when you’re done having kids.” So, let’s dispell a few myths. First, prolapse is SO common. Some studies have shown that up to 90% of people have some level of prolapse after birth (when checked on examination). This, of course, is going to be a much lower number when you look at people also having symptoms of prolapse. Prolapse is a pressure management problem impacting organ and tissue support. Organs and tissues are supported in the pelvis by fascia, ligaments, connective tissue and muscle. While we can’t necessarily change prior tissue damage via rehabilitation efforts, we can optimize muscles to improve the pressure system. And there is evidence that this reduces the stage of prolapse and improves the symptoms too! Additionally, there are other conservative options to help manage prolapse as well. Pessaries are wonderful support devices that can be used, and most people found them to be very helpful when we look at the research.

Myth #3: After having a baby, it’s normal for sex to be a little uncomfortable.

Pain is the body’s alarm system, produced by the brain to protect us. Pain is meant to evoke action on our part– to get us to protect the body, do something, to stop the “threat” from occurring. Sexual intimacy is meant to be pleasurable–before and after having a baby. Upon first returning to sex after birth, it can be normal to have a little bit of discomfort, HOWEVER, this should very quickly go away. If it persists, that’s a problem, and (you guessed it!), there is SO much we can do to make this better! Why does pain happen after birth? It can be a lot of reasons: scar tissue inhibiting the movement around the vaginal opening, decreased lubrication due to hormonal changes, musculoskeletal restrictions due to injury or dysfunction, and others! Read more on sex after baby here!

Myth #4: Low back or pelvic pain during pregnancy is just part of it.

Let me say it a bit louder for the people in the back: COMMON DOES NOT EQUAL NORMAL. Low back and pelvic girdle pain are indeed common during pregnancy, impacting anywhere from 4-84% (don’t you love those huge ranges we get in research) of pregnant individuals. While many cases resolve after birth, some people will continue to experience problems. Also, who wants to struggle with back and pelvic pain for months on end while they are pregnant? Not me, and I’m guessing not you. So, there is a lot that can be done to help this during pregnancy. Not surprising, research is mixed on the effectiveness of various techniques, and honestly, I think that is because treatment really needs to be individualized. Some tout “stabilization exercises” however, some studies have shown that most people with pelvic girdle pain actually have pelvic floor muscle overactivity— so of course, transverse abdominis and pelvic floor strengthening is going to make them feel worse! Key concept here- if you are pregnant and experiencing back or pelvic pain, go see someone who has specialized training in perinatal and pelvic floor care who can assess YOU (individually– not making assumptions!) and help make a plan to get you feeling better.

Myth #5: There’s nothing you can do about constipation during pregnancy.

Constipation during pregnancy is the worst! We can thank hormonal changes for that. While there’s not much we can do to change the hormones (nor would we want to!), we can do everything else to optimize our bowel habits and promote better bowel health. This includes learning the best way to sit on the toilet, proper mechanics for defecation, how to build a stellar bowel routine, and making dietary changes to promote better bowel function.

Myth #6: Do your Kegels, mama!

Surprisingly, this is actually false. While all pregnant individuals were told in the past to do kegel exercises to protect their pelvic floor muscles and optimize their births, we know now that not everyone actually needs pelvic floor strengthening. Remember, a large percentage of people actually struggle with pelvic floor tenderness and overactivity— especially if they are experiencing back/pelvic pain, or have pre-exisiting pelvic floor disorders. So, the best way to optimize pelvic floor function during pregnancy? Go get an exam, and have a skilled, specialist trained clinician help you get an individualized program for your pelvic floor.

Myth #7: There’s nothing you can do to really prepare your body for birth or prevent problems after.

Actually, there is emerging evidence that suggests we can do something to prevent problems like urinary incontinence, and other pelvic floor disorders. A recent Cochrane review (this is basically, the highest level of evidence we have) indicated that a targeted pelvic floor training program early in pregnancy actually decreased the risk of urinary incontinence during and after pregnancy. Exercise during pregnancy has also been shown to be safe and beneficial for the baby. Perineal massage has also been shown to be helpful in improving pelvic floor mobility and reducing perineal trauma during birth (particularly, during the first vaginal birth!). Want more info on preparing for birth? Check out our class on the topic! 

Myth #8: The only way to change your belly problems after having a baby is with surgery.

If you’ve been following this blog, you’ve probably read our recent 2-part series on diastasis rectus after birth (If not, check out part 1 & part 2!) Many people experience diastasis rectus during pregnancy and after birth, or may just feel laxity and a loss of support at their belly. Rehabilitation of the abdominal wall can be so hugely beneficial for these people (myself included– hello cesarean birth x 2!). Surgery can sometimes be an option, but really, this should be used after a person has exhausted conservative options. So, if you’re struggling with belly problems after birth, give us a call! Check out our DRA class in the meantime also!

Myth #9: You can jump right back in to whatever exercise you want after having a baby.

I guess technically this one is true. You can do anything you want. But, that doesn’t mean it’s a good idea. Having a baby can be very impacting to the abdomen and the pelvic floor muscles, and it’s best to build back up to desired exercises slowly and methodically. I always say I would much rather someone wait and slowly get back to exercise than to jump into strenuous exercise too quickly. I can’t tell you the number of patients I have seen who have had problems like pelvic organ prolapse, or other pelvic floor conditions after resuming really high intensity exercise without adequately preparing their bodies. I don’t tell you this to scare you– believe me, I want you to get back to EVERYTHING. I want you to be a strong mama who can rock exercise EVEN BETTER than you did before your birth. BUT, I think we need to be smart about it, ease into it, and learn how to self-asses our bodies to make sure we do the exercises that are most appropriate for us at the time.

Myth #10: Moms don’t need to see a pelvic PT if they don’t have problems after birth.

Did you all know the pelvic floor physiotherapy is actually the norm after birth in some European countries? And why shouldn’t it be? Birth is transformative and hugely impacting to the body! Why is rehab after an orthopedic surgery nearly required, yet moms are not even offered rehab after cesarean births or operative vaginal births? In my perfect world, I would love to see all parents given the opportunity to seek pelvic health care after birthing a baby. In fact, wanna know a little secret? I’m actually seeing my colleague (Dr. Kate Schenk, who is a rockstar!) for pelvic floor and abdominal wall rehab this week! You may be thinking, didn’t you have your baby a year ago, Jessica? Good point my friend. But, like many other moms, I decided to put myself on the back burner for a while…and a while turned into a few months…which then turned into a year. When we celebrated my little Mary Lynn a few weeks ago, I had a moment of, “what am I doing?!” and quickly contacted Kate to make my first appointment! I’ll write on my journey later, you can be assured of that. But, don’t be me. Put yourself first. I know it’s hard (believe me!) but self-care is actually not selfish, it’s self-less! (And reading my post on self-care from 3 years ago, I realize that this has clearly always been a struggle for me!) Recently, we actually took a close look at the ways we are caring for our pregnant and postpartum patients, and realized, we can do better! So, we started offering in-home prenatal and postpartum care! I am SO excited about this– to be able to reach people where they are, reduce their (and their baby’s) exposure to…ummm… “germs” in the community, and take away some of the stress of getting childcare to get out of the house!

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What else have you heard is “normal” for people during pregnancy and after birth? I know I didn’t hit all of the common myths out there! Let me know in the comments, and let’s keep the conversation going!

Happy Monday!

~ Jessica

Mother’s Day Specials!! My gift to YOU!

Good morning friends,

With Mother’s Day around the corner, we’ve been wanting to give back and help out the mothers in our community (around the country…around the world!) who are struggling in this interesting new normal. Figuring out managing caring for children, homeschooling, work/family obligations, all while trying to keep their families safe, sane, engaged. Let’s be honest, being a mom is the hardest, but most rewarding job ever!

To celebrate our mamas everywhere, we have a few discounted specials to roll out to you!

50% off first Virtual Pelvic Floor Consultation

Mother's Day Sale-2

First, we are offering 50% off a virtual pelvic health consultation  with one of our incredible pelvic floor specialists. Honestly, we’ve never discounted our services before, but I just felt like this was the right thing to do. So, for $97 you (or the mama you gift this to!) can receive a 55-minute virtual consultation. If you live in Georgia, this will be a pelvic floor physical therapy evaluation. If you don’t, our license won’t let us provide you with physical therapy, but we can still offer you a virtual coaching consultation.  So, if you’re struggling with any pelvic health problem– constipation? pain with sex? bladder leaks?– or if you need help recovering after children, getting back to exercise, or preventing problems in the future– this deal is perfect for you! Don’t miss out on this opportunity!!

20% Off Online Classes

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Along with this, we are offering 20% off our on-demand classes via the Southern Pelvic Health x The Vagina Whisperer partnership! Each of these classes is 90-minutes and covers SO much information, with great bonuses included! Classes are normally $39 each, so this is a nice discount to get some solid information!! (Gift idea: Consider a birth package for that pregnant mama in your life! Combine our birth prep class with a posptartum recovery class so that new mom has all she needs to rock her birth and after!) Be sure to use promo code MOM20 at checkout! 

These specials are only available through Monday May 11, so don’t delay!

Happy Mother’s Day!

~Jessica

Diastasis Rectus Abdominis (Part 2): How can you help it?

2 weeks ago, we chatted about what exactly is a diastasis rectus abdominus (DRA) and how to check to see if you have one. Today, we’re going to talk about how pelvic floor physical therapists evaluate a person with DRA, and what can be done to improve this. If you are struggling with support at your belly, I also hope you will join us for our upcoming LIVE class focused on this exact topic! Sara Reardon and I invited Sarah Duvall, an incredible expert, to join us for a 90-minute class on Diastasis Recti Rehabilitation. We took a lot of time to plan out this content, and I have to tell you all– this class is going to rock! The LIVE event is coming up Sunday May 3rd at 3pm EST, and it will be available after as a recording. We have a lot of great bonuses also– including handouts on exercises to get started and a lot more! Registration for the LIVE class is limited, so don’t wait to sign-up!

As we discussed previously, DRA involves an increased gap between the two bellies of the rectus abdominis muscle and a loss of support at the abdomen. Often times, people experiencing this will feel like they don’t have as much control or stability at their belly, and they may feel a bulging at their belly (some will even feel like they look pregnant when they aren’t!) We also discussed how to check to see if you do have a DRA. Now, let’s talk about how we approach making this better.

Your first visit 

When we first evaluate someone with a DRA, we always make sure we get a complete history of the problems and challenges they are experiencing. This includes discussing any pregnancies/births (if applicable), their pelvic health (yep– bladder, bowel and sexual function), musculoskeletal challenges, medical problems, and their fitness preferences and routines. Then, we discuss their diastasis and what is bothersome to them. Is it primarily the appearance or the knowledge that it is there? Are they also struggling with back pain or pelvic organ prolapse or other problems? Does their diastasis limit their ability to exercise or lift their children? Our goal here is to really have a complete picture on the challenges they are facing.

The exam

Next, we move into an examination. This can include many different parts. As a diastasis is a pressure system problem, we want to look at everything that could impact the system. This could include:

  • Movement patterns
  • Spinal mobility
  • Preferred postures/positions
  • Ribcage movement
  • Breathing patterns
  • Pelvic floor function (yep, sometimes people with DRA benefit significantly from a specific pelvic floor exam if they’re on board with it!)
  • Scar tissue mobility
  • Myofascial mobility at the abdomen and the back
  • Abdominal, hip, and pelvic motor control/strength

Each of these components can actually influence how much pressure is at the linea alba (between the two bellies of the rectus abdominis) and the control at the abdomen. If someone has decreased movement around their spine and ribcage, this can impact the fascia around the abdomen and contribute to widening at their midline. If they have less optimal breathing patterns, this could be funneling pressure where we don’t want it to go, instead of spreading the pressure out across the trunk and sharing the load.

Once we do a comprehensive evaluation, we develop a treatment plan to address the problems we found. This typically includes:

  • Improving global movement patterns
  • Improving breathing patterns (both in static postures and during movements/activities)
  • Restoring mobility and improving sensitivity at muscles and soft tissues (including scars)
  • Optimizing the pressure system
  • Retraining the abdominal wall

I want to talk a little bit more about how we can optimize the pressure system and retrain the abdominal wall.

Optimizing the pressure system

When improving DRA, it’s very important to keep the pressure system in mind. Pressure at the abdomen and pelvis depends on coordination of several muscles that work together in synergy. This includes the glottis, intercostal muscles, respiratory diaphragm, transverse abdominis, lumbar multifidis and the pelvic floor muscles. Mary Massery (who has contributed SO much to our understanding of these pieces) created an analogy of a soda pop can.

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In this analogy, the glottal folds are at the top, the pelvic floor muscles at the bottom, and the respiratory diaphragm in the middle. The intercostals, lumbar multifidus, and transverse abdominis are around the can. So, basically, these structures together work together to keep pressure spread out, leading to a strong and functional core. In the soda pop can example, the thin aluminum is pressurized on all sides, leading to a strong can that is difficult to break (Of course, this changes if the can is open or has a hole in it!)

So, in the case of a diastasis rectus, the pressure system is often not working optimally. Basically, pressure in many cases is funneled toward the belly, instead of being spread to all the structures, and this can contribute to gapping, bulging and a loss of support.

So, from a treatment standpoint, our goal becomes to optimize this system. We get to play detective and find out which of these structures are working well, and which need some assistance to do their job optimally. Then, we retrain this system, focusing on the natural synergy that should be present. When this is done well, we help the body learn to spread the load, decrease the funneling of pressure to the belly (or elsewhere) and thus, we improve what the person is experiencing at their abdomen.

Retraining the abdominal wall

After we improve the pressure system, we need to retrain all of the muscles in the abdominal wall. This further helps to improve the pressure system, but it also can assist in stimulating the fascia in the abdomen. Often times, retraining the abdomen starts by building the pressure system base like we discussed up above. This base– the pelvic floor- diaphragm- transverse abdominis- lumbar multifidus- base– is the key to what else we need to do to improve function at the abdomen. The transverse abdominis is particularly important. This muscle helps to tension the linea alba, which improves force transfer through this structure.

Next, we use breathing and awareness of muscles to retrain these muscles in a variety of movements, postures, and exercises. This can start as a simple progression– learning to activate these muscles while breathing and lifting an arm, then lifting a leg– and progressing from there.

We also teach self-awareness of the abdomen. So, this helps you identify how you manage pressure in your abdomen, and this is very important in making sure you are challenging your system, while still being able to control pressure (and not allow the pressure to funnel in your belly and produce coning and doming). As we progress in exercises, we ultimately want to retrain this system within the rest of the muscles in the abdomen, and this is fun, because we can be very creative and often help people progress toward things they did not think would be possible for them. So, can someone struggling with a diastasis eventually do planks? sit-ups? Abdominal crunches? What about pilates? Yoga? Barre classes? Most of the time, we can work together to help you reach the goals you want to reach. I really believe there are not “bad” exercises, but the key thing is determining the readiness of the person to do the exercise well, and ensuring that they can modulate pressure while doing the movement.

So, if you’re struggling with your belly…

Know, that there is hope. There is so much we can do to help restore stability at the abdomen and improve the way you move and transfer force through your belly. Come and join our upcoming class (or get the on-demand recording if you’re reading this later!) If you’re struggling, there can really be so much value to being evaluated by a pelvic health provider in person. So reach out! And if you need help finding a pelvic PT, check out this prior blog post to help you!

As always, reach out if you have questions!

~ Jessica

Diastasis Rectus Abdominis (Part 1): What is it? Do you have it?

If you’ve been pregnant before, you know the feeling of going out and having everyone comment on your beautiful belly. Of course, we all get the occasional, “wow, are you sure you’re not having twins?” “When are you due? You’re not going to make it there!” (And can we collectively just tell those people to leave us alone!!) BUT, the majority of the comments are, “you look amazing!” “Wow, she is really growing!” “How are you feeling? Congratulations on your baby!” Honestly, my own body self confidence was at a high during pregnancy.  But then, our sweet little love muffins are born. And society expects us to very quickly bounce back to our pre-baby state (and I have so many thoughts on that…because we just went through this transformative, incredible experience, that took nearly 10 months to build! And often times mamas are left alone to figure things out after birth).

As an aside, this was one of the BIG reasons that my friend and colleague, Sara Reardon, and I decided to partner together to create live & on-demand classes! We recognized that soooo many people are struggling with pelvic health problems. While individualized pelvic PT is so beneficial, it’s not always possible for people at the time they need it. For one…ummm…coronavirus/social distancing. But also, some people prefer trying to learn and work independently, may feel too nervous to discuss their problems with a provider, or may have a schedule/time constraints/financial constraints/geographical constraints that just don’t allow individualized care at the time they are wanting it. SO, these are our classes. We have 2 LIVE postpartum classes coming up– TOMORROW 4/14 is our “Postpartum Recovery After a Vaginal Birth” Class, and the following Wednesday 4/22 is our “Postpartum Recovery After a Cesarean Birth” Class (SO excited about this one as a mama of 2 Cesarean babies!). These classes are built for the consumer—BUT, if you are a health care provider, I can guarantee that you’ll learn a bunch also! We sold out before the start of our “Pelvic Floor Prep for Birth” class, so if you’re on the fence, register soon and reserve your spot!

Anyways…back to our topic at hand: Diastasis Rectus Abdominis.

The abdominal wall is stretched during pregnancy to accommodate the sweet growing munchkin, and in some cases (most cases, according to some research!), this leads to a stretching at a structure called the linea alba- the connection between the two sides of the rectus abdominis or “6-pack” muscle group. When this becomes larger than about 2 fingers in width, it is known as diastasis rectus abdominis (DRA). This is what it looks like:

Ultrasonography_of_diastasis_recti
Mikael Häggström, M.D. – CC0, obtained via Wikimedia Commons

The two “+” marks indicate each side of the lines alba, and you can see that it is wider than it likely was previously. Note, this is an ultrasound image of a 38 year old mom who had diastasis after her pregnancy. DRA is different than a hernia. When a hernia occurs, there is a defect that allows an organ or tissue to protrude through the muscle/tissue that normally contains it. So, someone could have a DRA and not a hernia. Or, they could have a DRA and a hernia. Make sense?

Diastasis rectus abdominis is common during and after pregnancy, and varies in severity. For some moms, they may not really realize it’s even there. Others may feel a complete lack of support at their belly, notice a bulge, or even worry that they still look pregnant.  A recent study published in 2016 found that among 300 women who were pregnant and gave birth, 33.1% had a DRA at 21 weeks gestation. At 6 weeks postpartum, 60.0% had a DRA. This decreased to 45.4% at 6 months postpartum and 32.6% at 12 months postpartum. So, basically, many pregnant folk get this, and while for some it gradually improves over time, for others it can persist.

The link between DRA and musculoskeletal dysfunction is not confirmed. A recent systematic review published in 2019 found “weak evidence that DRAM presence may be associated with pelvic organ prolapse, and DRAM severity with impaired health-related quality of life, impaired abdominal muscle strength and low back pain severity.” This makes a lot of sense to me. Conditions like pelvic organ prolapse and low back pain are complicated, but in some cases do have components related to pressure management. The abdominal wall is very crucial in helping to modulate intraabdominal pressure, so it makes sense that when it is not functioning optimally, a person could struggle with managing pressure well.

The intra-abdominal pressure system involves coordination between the respiratory diaphragm, low back muscles, transverse abdominis, and pelvic floor muscles. These muscles need to work together to control pressures through to abdomen and pelvis and create dynamic postural stability. When the abdominal wall has a loss of support, this system can be impacted and contribute to pressure problems like prolapse and low back pain. However, those diagnoses are complicated. There are many other factors involved (like connective tissue support, amongst other things), so this is why a comprehensive examination is often very beneficial. This is also why not everyone who has DRA has pain.

I think it’s important to note here, that for some people, their DRA may not be contributing to things like back pain or prolapse, but it may still be a huge problem for them. People can feel guilty about caring about the cosmetic component involved in some instances of DRA…you know…the pooch. But, you know what– if this matters to you, then it matters! Feeling confident and strong is so important! So, don’t let anyone tell you what is or isn’t important for you to care about!

So, how do you find out if you have a diastasis?

The best thing to do if this is sounding like you is to see a pelvic PT to be evaluated comprehensively. There are many different things that can contribute to a loss of support at the abdomen, so looking at the complete picture is the best option. We’re going to talk about some of those pieces and how we as pelvic PTs evaluate DRA in Part 2 of this blog series. However, there are ways you can examine yourself and find out if you have a diastasis rectus. First, lie down on your back with your knees bent.

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In this image, my two fingers are at my belly button, and my other hand is over the top, reinforcing what I feel.

 

Start by placing two of your fingers at your belly button. Next, lift your head and your shoulders up (like doing an abdominal crunch) and sink your fingers in, gently moving them back and forth to feel the sides of your rectus abdominis. Notice if your fingers sink in, and if you feel a gap between your muscles. Repeat this a few inches above your belly button, and again a few inches below your belly button. Also notice how you feel as you do this– do you feel tension at your fingers? Do your muscles feel strong? When you lift up, are your fingers pushed out or do they sink in? What do you notice? (This is great information for you to understand how much force you can generate through your “gap” and will be important as we start discussing how we treat this!)

How can you help a diastasis?

Well, the good news is that there is so much we can do to help improve diastasis, make your belly stronger, and help you feel better.  In part two of this series, we’ll discuss the ways pelvic PTs can best evaluate someone who has a diastasis, and the methodology we use to treat this problem. The method of treating this has changed over time, so I’m going to give you my best understanding of the research as it’s available today! Stay tuned to learn more!

Stay healthy during this time my friends– and wash your hands!

~ Jessica