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Surgery for Diastasis Rectus Abdominis

Tue, 31 Mar 2026 16:43:00 GMT

Surgery for Diastasis Rectus Abdominis

Yikes, this is a big topic! While there is still a lot that is unknown about who is appropriate for surgery, there is more and more research showing that surgically repairing a diastasis recti (DRA) can actually improve DRA-related symptoms. Here's what we know.

1. Surgery for DRA is successful in terms of very low recurrence rates of the DRA.

Amazingly, most of the surgical literature only looks at surgical complications (infections, seromas - pockets of fluid, etc) and recurrence rates. Improvement in function or appearance is reported very rarely if at all! So we have a long way to go there, but at least we know that surgery is very successful for DRA repairs. Most studies report no recurrences of DRA out of hundreds of patients, with very few studies reporting one recurrence (Mommers 2017).

2. Patients should be given a trial of PT prior to considering surgery.

How long the trial should last is up for debate, but most studies include a 3-6 month trial. Plus, most will not consider surgery until 1 year postpartum, and the patient needs to be certain they are done having children. It has been shown to be possible to carry pregnancies to term successfully following DRA repair, but with more pain and discomfort in the abdomen reported, as well as a return of the DRA during pregnancy that resolved afterwards (Swedenhammar 2021). Frequently when discussing with other PTs, many will recommend at least 12 months of conservative rehab & core exercise before considering surgery.

3. In patients that have not been successful with PT, surgery can improve many outcomes that matter to patients.

This is especially true for physical function, but not necessarily for appearance. In one study of 60 subjects (Olsson 2019), at one year post-op 98% self-reported improved abdominal function after surgery, and 76% showed improvement on endurance tests of the back and abdominal muscles. 37-47% reported an improvement in incontinence depending upon the survey used, while interestingly 8-13% reported worsened incontinence. However, across the board quality of life scores were improved, and reached a level equal to or greater than the general population. And, all of these improvements were maintained at 3 years post-operatively as well (Olsson 2021).

Another study of 86 subjects (Emanuelsson 2016) showed improved quality of life, better objective abdominal strength, and improved perception of abdominal strength as well at one year post-op. Interestingly, these functional improvements were maintained at 3 years post-op, but only 29-39% reported satisfaction with their appearance at that time (Swedenhammar 2021).

4. The type of DRA repair does not seem to matter at this time.

In all of the references below, many different types of surgeries are compared against one another. They don't show any difference in outcomes, although some authors will make arguments for certain types of surgeries over others, based on things like the extensiveness of the surgery.

The takeaway?

If a DRA is not improving despite PT & consistent attempts at core rehabilitation for at least 3-6 months, and the patient is at least 1 year postpartum, surgery can be considered. The recovery is typically extensive from these surgeries, with an abdominal brace usually being worn for 12 weeks, and no heavy physical exercise for 12 weeks as well. But, sometimes surgery is the right answer, and it certainly never hurts to get a consultation.

Whether or not insurance will pay for DRA repair is another can of worms, as most of the time DRA repair is considered "cosmetic" by insurance companies. So that is another consideration and area of research the patient will need to undertake. But hopefully as the research catches up on reporting more functional outcomes, insurance coverage for DRA repairs will change too!

References:

Emanuelsson, P., Gunnarsson, U., Dahlstrand, U., Strigård, K., & Stark, B. (2016). Operative correction of abdominal rectus diastasis (ARD) reduces pain and improves abdominal wall muscle strength: A randomized, prospective trial comparing retromuscular mesh repair to double-row, self-retaining sutures. Surgery , 160 (5), 1367–1375. https://doi.org/10.1016/j.surg.2016.05.035

Mommers, E., Ponten, J., Al Omar, A. K., de Vries Reilingh, T. S., Bouvy, N. D., & Nienhuijs, S. W. (2017). The general surgeon's perspective of rectus diastasis. A systematic review of treatment options. Surgical endoscopy , 31 (12), 4934–4949. https://doi.org/10.1007/s00464-017-5607-9

Nahabedian M. Y. (2018). Management Strategies for Diastasis Recti. Seminars in plastic surgery , 32 (3), 147–154. https://doi.org/10.1055/s-0038-1661380

Olsson, A., Kiwanuka, O., Wilhelmsson, S., Sandblom, G., & Stackelberg, O. (2019). Cohort study of the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life. BJS open , 3 (6), 750–758. https://doi.org/10.1002/bjs5.50213

Olsson, A., Kiwanuka, O., Wilhelmsson, S., Sandblom, G., & Stackelberg, O. (2021). Surgical repair of diastasis recti abdominis provides long-term improvement of abdominal core function and quality of life: a 3-year follow-up. BJS open , 5 (5), zrab085. https://doi.org/10.1093/bjsopen/zrab085

Swedenhammar, E., Strigård, K., Emanuelsson, P., Gunnarsson, U., & Stark, B. (2021). Long-term follow-up after surgical repair of abdominal rectus diastasis: A Prospective Randomized Study. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society , 110 (3), 283–289. https://doi.org/10.1177/1457496920913677

What if Exercise Alone Isn't Enough to Heal DRA?

Tue, 31 Mar 2026 16:35:20 GMT

What if exercise alone isn't enough to heal DRA?

Sometimes despite our best efforts, exercise isn't enough to improve diastasis rectus abdominis, aka DRA. Recent studies have been done on other treatment options, alone or with exercise, in an effort to further improve DRA. Let’s run down the list of other things you can try if your DRA isn’t improving enough only with exercise!

TL;DR? Taping your abdominal wall in addition to performing core strengthening exercises can help DRA. Adding electrical stimulation (NMES, or neuromuscular electrical stimulation) to the abdominal wall while doing exercises can also show improvements. And, visceral mobilization (aka massage to the connective tissue that holds up your inner organs) can also help! Not sure what any of that stuff is? Read on below! And know that at Pelvic Love Physio, we are proficient in all of these methods to help you heal your DRA!

Kinesiotape (KT) alone

One small randomized controlled trial (Ptaszkowska 2021) of 24 women did show statistically-significant improvements in DRA width after wearing KT for 48 hours, as compared to a control group that used cloth surgical tape. However, there was no long-term follow-up to see if this effect lasted longer than after the tape was removed.

KT alone or KT plus exercise

Another small randomized controlled trial (Tuttle 2018) split up 30 participants into four groups: exercise alone, KT alone, exercise + KT, and a control group. They were followed for 12 weeks. The taping group wore the tape for 4-7 consecutive days, then took a 2-4 day break, then applied the tape again. The exercise group only did transverse abdominis contractions (abdominal bracing) WITHOUT pelvic floor activation (Kegel) in several positions. These positions included laying on their backs, on their sides, on hands and knees, and in sitting. They did 10 repetitions in each position, 4-5x/week. The KT + exercise group did both of the previously-described procedures, and the control group maintained their normal activity levels. The results? The biggest improvements in DRA were seen in the exercise only group and the exercise + taping group, with no difference between those groups. The taping alone group did show some improvements that were above the minimal clinically important difference (MCID) as described in previous research, but did not reach statistical significance in this study.

Neuromuscular re-education (NMES) alone or NMES plus exercise

NMES is the use of electrical stimulation to help improve the function of weak or underactive muscles. It's not comfortable to say the least! But it can be helpful in certain situations. In this study (Kamel 2017), a group of 60 women was split into two groups: exercise alone, or exercise + NMES (no control group). Each group did the same abdominal strengthening exercises 3x/week for 8 weeks; mostly variations on crunches/curl-ups, but also included some breathing and bracing exercises. Both groups showed statistically-significant improvements across several measures, including width of the DRA. However, the NMES group outperformed the exercise-only group on almost all measures (including width of DRA). If you are interested in trying NMES for your DR, this does need to be done in a PT’s office. And pelvic health PTs are the experts in abdominal wall rehab!

Visceral mobilization

A case series of 3 patients was recently reported in 2021 by Kirk and Elliott-Burke. All patients received at least 4 treatments of various types of visceral mobilization, which is mobilization of the fascia (connective tissue) that surrounds the internal organs. The authors theorize that changes in the uterus size and shape during pregnancy and postpartum recovery places tension on the fascia around it. This tension can increase stiffness in different layers of fascia within the abdomen, thus placing tension on the abdominal wall. By normalizing the tension of the fascial layers inside the abdomen, the abdominal wall then can restore itself to a normal position (e.g. improve/resolve a DRA). In these cases, the primary intervention was visceral mobilization, with minimal exercise interventions specific to each patient. The patients received 6-12 visits in a timespan ranging from 18 weeks to 26 months. All three patients showed complete resolution of their DRAs, plus either resolution of or significant improvement in bladder, bowel, and lower back pain complaints. Additionally, these three women maintained their changes from 6-16 months after discharge.

Takeaways

While none of these methods are fool-proof, all show somewhat promising preliminary results in the treatment of DRA. And all can be performed by us at Pelvic Love Physio! Call or text us today at 309-431-1357 if you have been struggling to heal your DRA, and need a little extra help. We are here for you!

References:

Kirk, B., & Elliott-Burke, T. (2021). The effect of visceral manipulation on Diastasis Recti Abdominis (DRA): A case series. Journal of bodywork and movement therapies , 26 , 471–480. https://doi.org/10.1016/j.jbmt.2020.06.007

Kamel, D. M., & Yousif, A. M. (2017). Neuromuscular Electrical Stimulation and Strength Recovery of Postnatal Diastasis Recti Abdominis Muscles. Annals of rehabilitation medicine , 41 (3), 465–474. https://doi.org/10.5535/arm.2017.41.3.465

Ptaszkowska, L., Gorecka, J., Paprocka-Borowicz, M., Walewicz, K., Jarzab, S., Majewska-Pulsakowska, M., Gorka-Dynysiewicz, J., Jenczura, A., & Ptaszkowski, K. (2021). Immediate Effects of Kinesio Taping on Rectus Abdominis Diastasis in Postpartum Women-Preliminary Report. Journal of clinical medicine , 10 (21), 5043. https://doi.org/10.3390/jcm10215043

Tuttle, L.J., Fasching, J., Keller, A.P., Patel, M., Saville, C., Schlaff, R., Walker, A., Mason, M., & Gombatto, S.P. (2018). Noninvasive Treatment of Postpartum Diastasis Recti Abdominis: A Pilot Study. Journal of Women's Health Physical Therapy, 42 , 65–75.

What Makes You More Likely to Have a DRA?

Tue, 31 Mar 2026 16:23:05 GMT

What makes you more likely to have DRA?

Here’s the good news: there has been a LOT of new research on diastasis rectus abdominis (DRA) within the last few years. The bad news is that the studies are all so different from one another, and many can’t even agree on what the cut-off is to diagnose DRA, or how even to measure it in the first place! This makes it incredibly hard to generalize results, as you can imagine! But, some trends are emerging, including data on risk factors for developing DRA.

What are the most common risk factors for DRA?

Here's a short-ish list:

Pregnancy, and especially more than one pregnancy (this is a big one that shows up consistently across the board)

C-sections, especially more than one

Diabetes

Larger babies, >9lbs

Excessive amniotic fluid

Age (interestingly, most studies show a HIGHER incidence of DRA with increasing age, while others show LOWER)

And of course, everyone's love-to-hate: BMI. This really relates not to BMI generally, but to the theory that carrying increased weight in your midsection will put more pressure against the abdominal wall. I might consider buying into this once I see 1) research that specifically correlates higher waist circumference with DRA, and 2) that decreasing waist circumference actually helps improve DRA. So far we don't have evidence for either of those things.

Childcare responsibilities and repeated heavy lifting may also play a role, but the jury is still out on those two.

If I have a lot of these risk factors, will my DRA never heal?

Absolutely not! And let’s be clear: everyone who is pregnant will develop a DRA by week 35 of pregnancy. Everyone . The key here really is how long it takes your body to recover from that DR after the baby is out of your belly.

I am hopeful that this knowledge may help some people who are struggling with DRA and have these risk factors realize that it's not their fault! And, may eventually lead us to figure out why some people struggle with DRA for so long after birth, while others do not.

References (most are open access!):

Cavalli, M., Aiolfi, A., Bruni, P. G., Manfredini, L., Lombardo, F., Bonfanti, M. T., Bona, D., & Campanelli, G. (2021). Prevalence and risk factors for diastasis recti abdominis: a review and proposal of a new anatomical variation. Hernia : the journal of hernias and abdominal wall surgery , 25 (4), 883–890. https://doi.org/10.1007/s10029-021-02468-8

Iqbal, M., Hussain, T., Khalid, F., Ali, M., Ashraf, I., & Nazir, T. (2020). DIASTASIS RECTI ABDOMINIS AND ITS ASSOCIATED RISK FACTORS IN POSTPARTUM WOMEN. PAFMJ , 70 (5), 1535-38. Retrieved from https://pafmj.org/index.php/PAFMJ/article/view/5600

Kaufmann, R. L., Reiner, C. S., Dietz, U. A., Clavien, P. A., Vonlanthen, R., & Käser, S. A. (2022). Normal width of the linea alba, prevalence, and risk factors for diastasis recti abdominis in adults, a cross-sectional study. Hernia : the journal of hernias and abdominal wall surgery , 26 (2), 609–618. https://doi.org/10.1007/s10029-021-02493-7

Sperstad, J. B., Tennfjord, M. K., Hilde, G., Ellström-Engh, M., & Bø, K. (2016). Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. British journal of sports medicine , 50 (17), 1092–1096. https://doi.org/10.1136/bjsports-2016-096065

Wu, L., Gu, Y., Gu, Y., Wang, Y., Lu, X., Zhu, C., Lu, Z., & Xu, H. (2021). Diastasis recti abdominis in adult women based on abdominal computed tomography imaging: Prevalence, risk factors and its impact on life. Journal of clinical nursing , 30 (3-4), 518–527. https://doi.org/10.1111/jocn.15568

What are the best exercises for postpartum DRA?

Thu, 26 Mar 2026 22:58:39 GMT

What are the best exercises

for postpartum diastasis rectus abdominis (DRA)?

There is SO much research on & so many recommendations out there for postpartum DRA ( diastasis rectus abdominis) treatment . Over the years, it's gone something like this:

You should do sit-ups!
No wait - don't even think about doing a sit-up - they are terrible for DR!
No actually - sit-ups ARE bad, but you can do curl-ups and use your hands or a towel to the two halves of the rectus abdominis together
Actually, you should ignore the rectus abdominis altogether and focus on deep abdominal and pelvic floor rehab!

It's enough to make your head spin!! Fortunately, there were two systematic reviews published on this very topic not too long ago, one in 2021 by Gluppe, Engh, and Bo , and then one in 2022 by Berg-Poppe et al . Both of these articles tried to obtain the answer to the VERY elusive question about which exercises are best for postpartum DR.

So, what did they find about exercise for DRA?

Both reviews, not surprisingly, came to the same conclusion about the studies that are out there about DRA. Most of those studies are not of great quality, and it’s also VERY difficult to generalize results due to the variety of methods used to both assess and treat DRA. But the main finding across all studies? Core strengthening exercises DO help improve DRA!

Are some core exercises better than others for DRA?

The surprising answer seems to be - all core exercises help, regardless of the type! And there is never any one type of exercise that is proven to worsen DRA. Let me say that again....there is not any one type of exercise that a person with DRA should never do. It is not supported in research that exercise worsens DRA!

Really?? I thought for sure that sit-ups and planks were bad for DRA.

The answer to this really comes down to the fact that like most things in life, the answer lies in the gray of the “in-betweens,” versus a black-and-white “yes or no.” For DRA especially, it really comes down to how you are doing the exercise instead of what you are doing. So absolutely, if you have a large DRA and haven’t done any foundational deep abdominal work, then starting out with sit-ups would be terrible for you. Or if you focus on keeping your plank as low as possible and holding as long as you can without actually thinking about when your abdominals may be fatiguing, yes that could be harmful too.

But as long as you start out with a good foundation of learning how to activate your deep abdominals properly, and how to BREATHE while doing abdominal work, then you can work up to crunches and planks safely again!

What about pelvic floor strength - does that have any impact on DRA?

There is even disagreement across studies on the importance of including pelvic floor exercises in DRA rehab....as of this writing, adding pelvic floor exercises to DRA rehab doesn't seem to improve the outcome as compared to when pelvic floor exercises are NOT included.

So, what are the takeaways from this data?

It's generally agreed upon when pelvic health PT s are surveyed that activating the deeper layer of your core and pelvic floor FIRST is really important, essentially to get your “inner life vest” working again. Focusing on breathing is also important - please don’t EVER hold your breath while doing abdominal work! But then, layering any other exercises on top of that "inner life vest" of muscle activity is absolutely ok. Many of the studies included in these reviews had exercises like planks, Russian twists, sit-ups and reverse sit-ups. And guess what? The participants all still showed improvement in their DRAs!

What are some general recommendations for what you should and shouldn’t do while exercising with a DRA?

First of all, you want to make sure that your glutes and midback (scapular stabilizers) are active before you start a lot of intensive abdominal work! Your abdominals attach onto both your ribcage and your pelvis, so if these areas of the body aren’t stable, then your abs don’t stand a chance. You also need to have a good “neutral spine” posture, with your ribcage stacked over your hips. Plus, making sure the ribs aren’t super flared is also really important!

Once your glutes and midback are awake & your posture is better, then you can do any abdominal exercises that feel good for your body, as long as you meet these criteria:

Perform an abdominal brace (belly to spine) WITHOUT flaring your ribs, do your Kegel, and maintain at least the abdominal brace throughout the exercise
Don’t hold your breath
Don’t allow the middle part of your belly to “cone” or “dome” up towards the ceiling

If you find yourself doing any of these things with abdominal exercises, then the exercise is too hard for you. You either need to modify the exercise to an easier version where you can control those things, or just stop working out for the day and try again another time when your muscles aren’t fatigued.

Still confused, or want an individual assessment to make sure you are doing everything correctly?

If you've been asking, "Where can I find a diastasis rectus specialist near me ?" contact us at 309-431-1357 to schedule an appointment or to ask some questions!

References:

Berg-Poppe, Patti PhD; Hauer, Michaela BS; Jones, Cassandra BS; Munger, Mattison BS; Wethor, Cassidy BS Use of Exercise in the Management of Postpartum Diastasis Recti: A Systematic Review, Journal of Women's Health Physical Therapy: January/March 2022 - Volume 46 - Issue 1 - p 35-47. doi: 10.1097/JWH.0000000000000231

Gluppe, S., Engh, M. E., & Bø, K. (2021). What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta-analysis. Brazilian journal of physical therapy, 25(6), 664–675. https://doi.org/10.1016/j.bjpt.2021.06.006

What is Diastasis Rectus Abdominis/DRA?

Thu, 26 Mar 2026 01:18:57 GMT

What is Diastasis Rectus Abdominis? Aka DR/DRA/Di-recti?

It goes by so many names it can be confusing: diastasis rectus abdominis, diastasis recti, di-recti, diastasis, or some people will even just call it an “ab separation.” Plus you can shorten the name to DRA or DR too! So what exactly is diastasis recti? Let’s talk about allll of it, and along the way we’ll dispel a LOT of myths associated with di-recti.

I’ve read a lot about DR causing the dreaded “mommy belly” and am pregnant with my first. What is a good pregnancy exercise plan to prevent diastasis recti?

This is a great question, and gets right to the first myth that we need to dispel about DR. Diastasis recti will occur to everyone while they are pregnant by at least week 35 ! A 2018 study even found that the abdominal separation in pregnancy can range from 4.4cm to 8.6cm at weeks 35-41 of pregnancy , and the most-common definition of DR is anything greater than 2.0cm. And thank goodness that you do develop a DR while pregnant - otherwise your abdominal muscles might rip, or the baby wouldn’t be able to grow big enough to survive outside of the womb.

Oh no! So there’s really no exercises I can do to prevent diastasis recti while pregnant?

There is nothing you can do to completely STOP a DR from developing, but there is plenty that you can do to help improve your core strength and decrease the effects of a DR while pregnant! We have plenty of evidence to show that exercise during pregnancy can help reduce the size of a DR , prevent the development of urinary incontinence , decrease your risk of things like needing a C-section or having a preterm delivery , and improve the speed of your postpartum recovery . If you have questions about the safety of exercising in pregnancy, check out this link for FAQs on exercise in pregnancy, and this link for more specifics in a scholarly article (the Committee Opinion on “Physical Activity and Exercise During Pregnancy and the Postpartum Period” from the American College of Obstetricians and Gynecologists, aka ACOG).

Ok, so can you explain a little more about what a DR is exactly? I don’t think I understand it all.

Absolutely - this is a common source of confusion for most people! So, most of us know about the abdominal “six pack” muscle - aka the rectus abdominis. This is the highly-visible muscle in the center of the abdomen that creates a six pack in people who do a lot of sit-ups. As you’ll notice, to create the “six pack” effect there are two vertical lines of muscle, which are the right and left halves of the rectus abdominis. And in-between them is something called the linea alba. The linea alba is fascia, or connective tissue, that helps join the right and left halves of the abdominals together. It’s made up of fibers from ALL of your abdominal muscles, including the rectus abdominis, your external and internal obliques, and even your transverse abdominis! The linea alba is what lengthens, or stretches, during pregnancy to allow the baby to grow. So, it is also what creates the phenomenon of diastasis recti.

Oh wow, so then how do I know if/when I have a DR during pregnancy or postpartum?

This is another great question without a very clear answer. Clinically, the most-commonly accepted definition of DR is a separation between the two halves of the rectus abdominis (also known as the “inter-recti distance”) of greater than 2.0cm. Other signs are visible “coning” or “doming” of the middle of the belly with activities like coughing, sitting up from a reclined position, or when lifting anything heavy. At MommaStrong, we don’t recommend checking your own belly for a DR, as it’s difficult to know what you are feeling. Plus, there isn’t agreement on the best way to assess for DR anyway, and a self-check tells me nothing about how you are actually using your abdominals during daily activities!

When can I expect a DR to resolve postpartum?

Again - a wonderful question and one that we don’t have a ton of research on! Generally-speaking, if an abdominal separation hasn’t resolved by about 8 weeks postpartum, then we would say the abdominal wall likely needs extra help to recover. However, it is very common for a DR to persist for many months after pregnancy - this study found that a DR persists at 6 months postpartum in 45% of people, and even at 12 months postpartum in 33%. But good news - there’s a lot you can do to correct a persistent DR! You can see a pelvic/women’s health physical therapist , or do exercise programs designed for postpartum recovery like MommaStrong .

But I can expect my abdominal separation to return to zero, right?

No! This is another very common myth. No one ever has a zero-centimeter separation between their rectus abdominis muscles, even if they’ve never been pregnant! A 2022 systematic review and meta-analysis found the width of the linea alba ranges from 0.2cm-1.2cm in women who had never been pregnant. Since we don’t know what your particular separation was prior to pregnancy, it’s hard to say what width of the linea alba is “normal” for you. So, we like to rely more upon functional goals, like being able to care for your baby without increased lower back or pelvic pain, be able to cough and sneeze without leaking pee, and do core exercises without seeing any abdominal coning or doming. Plus, as you work to strengthen your core, the width of your gap may actually increase, and that’s ok! We care much more about the function of your abdominal wall that the gap in-between two sets of muscles.

Awesome, so I need to get started on core strengthening now then! What core exercises are safe for pregnancy and postpartum DRA?

This is a great question with a bit of a complicated answer! During pregnancy, core exercises do need to be modified a bit. Your best bet is to either see a pelvic health PT for an evaluation, or follow a trusted exercise program like MommaStrong . For postpartum exercises, check out the next article in this series!

References: (in order of appearance in article)

Fernandes da Mota, P. G., Pascoal, A. G., Carita, A. I., & Bø, K. (2015). Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy , 20 (1), 200–205. https://doi.org/10.1016/j.math.2014.09.002

Mota, P., Pascoal, A. G., Carita, A. I., & Bø, K. (2018). Normal width of the inter-recti distance in pregnant and postpartum primiparous women. Musculoskeletal science & practice , 35 , 34–37. https://doi.org/10.1016/j.msksp.2018.02.004

Chiarello, Cynthia M. PT, PhD1; Falzone, Laura A. PT, MS2; McCaslin, Kristin E. PT, MS3; Patel, Mita N. PT, MS4; Ulery, Kristen R. PT, MS5 The Effects of an Exercise Program on Diastasis Recti Abdominis in Pregnant Women, Journal of Women's Health Physical Therapy: Spring 2005 - Volume 29 - Issue 1 - p 11-16

Davenport, M. H., Nagpal, T. S., Mottola, M. F., Skow, R. J., Riske, L., Poitras, V. J., Jaramillo Garcia, A., Gray, C. E., Barrowman, N., Meah, V. L., Sobierajski, F., James, M., Nuspl, M., Weeks, A., Marchand, A. A., Slater, L. G., Adamo, K. B., Davies, G. A., Barakat, R., & Ruchat, S. M. (2018). Prenatal exercise (including but not limited to pelvic floor muscle training) and urinary incontinence during and following pregnancy: a systematic review and meta-analysis. British journal of sports medicine , 52 (21), 1397–1404. https://doi.org/10.1136/bjsports-2018-099780

Syed, H., Slayman, T., & DuChene Thoma, K. (2021). ACOG Committee Opinion No. 804: Physical Activity and Exercise During Pregnancy and the Postpartum Period. Obstetrics and gynecology , 137 (2), 375–376. https://doi.org/10.1097/AOG.0000000000004266

Wadhwa, Y., Alghadir, A. H., & Iqbal, Z. A. (2020). Effect of Antenatal Exercises, Including Yoga, on the Course of Labor, Delivery and Pregnancy: A Retrospective Study. International journal of environmental research and public health , 17 (15), 5274. https://doi.org/10.3390/ijerph17155274

https://www.acog.org/womens-health/faqs/exercise-during-pregnancy

Wang, Y., & Wang, H. (2022). Systematic review and meta-analysis of the inter-recti distance on ultrasound measurement in nulliparas. Journal of plastic surgery and hand surgery , 1–7. Advance online publication. https://doi.org/10.1080/2000656X.2021.2024555

Lee, D., & Hodges, P. W. (2016). Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. The Journal of orthopaedic and sports physical therapy , 46 (7), 580–589. https://doi.org/10.2519/jospt.2016.6536

Prolapse Surgery, Part 2

Mon, 20 Jan 2025 19:36:28 GMT

Prolapse Surgeries, Part II

This article is a follow-up to a Part 1 article I wrote on prolapse surgeries, where I covered a lot of FAQs about who needs surgery and why. In this article, we'll cover the nitty gritty of surgeries, including the different types of surgeries and recovery times, etc. We won't rehash what I mentioned last time, so if you have questions about who might need surgery, and how successful surgery generally is or isn't, please revisit the past article!

What types of prolapse surgeries are there?

There are two types of surgeries. For most people who are patients at Pelvic Love and who are reading this article, they will have a type of surgery that preserves the ability to have vaginal intercourse. There is another type of surgery that closes off the vagina, but then of course after that, you are no longer able to have intercourse. So that is typically reserved for elderly people with vaginas, as this type of surgery has the highest cure rate for prolapse. But of the types of surgeries that leave the vaginal canal open, there are many options depending upon the type of prolapse.

Does surgery vary based on the type of prolapse?

Yes! For bladder prolapse, the most common type of surgery is called anterior colporrhaphy . In this procedure, the front wall of the vagina underneath the bladder has sutures placed in it to help reinforce the original position of the bladder.

For rectocele (rectal prolapse into the vagina), the most common type of surgery is a posterior colporrhaphy . This also involves placing sutures on the backside of the vaginal wall to help keep the rectum in place. Sometimes this is also done in combination with a repair of the perineal body (the area between the vagina and anus), aka perineorrhaphy.

What about uterine/cervical prolapse?

This gets a little tricky. Many times, if you are done having children and your prolapse is more advanced, you may be advised to have a hysterectomy . However, there are other options that will allow you to keep your uterus. These surgeries are a little more complicated to explain, but if you click this link , you'll find them explained well. Basically they all involve some method of re-suspending the uterus and the cervix by using either stitches or mesh (NOT the mesh that is involved in so many lawsuits!).

If you do opt to have a hysterectomy, then as you may imagine, this can place you at a higher risk of bladder and/or bowel prolapsing (if they have not already done so). The uterus takes up a fair amount of space inside the pelvis, so if you remove it, that leaves empty space for other organs to fall into.

If I do have a hysterectomy, what are my options to avoid future issues with prolapse?

This is the one topic for which I will drag out my soapbox. If you do have a hysterectomy, and it is an option for you, I would HIGHLY recommend your surgeon re-suspends the vaginal vault as part of your surgery . The vaginal vault is the apex of the vagina, and where the vagina is sewn shut after the uterus/cervix is removed. Many surgeons will just stop here and allow the top of the vagina to essentially scar in place. However, as you can imagine, when you remove a major internal organ, then you are also removing (or slackening) a lot of ligaments & fascia that support that organ and others! So this places the top of the vagina at a much higher risk from prolapsing in the future, and/or the bladder and bowel falling into the vagina.

Please note, these "extra" steps to support the top of the vagina during a hysterectomy are not available to everyone . They do require more time under anesthesia, potentially greater skill from your surgeon, and the structures the vaginal vault is being sutured to are still intact. For example, I had a friend that had severe endometriosis and had a hysterectomy at 40 years old as a result. Her endometriosis was so advanced, and so many lesions had to be removed from inside the pelvis, that this didn't leave her surgeon with an option for a good place to suspend her vaginal vault. So even though I would recommend you discuss this with your surgeon, it's not an option for everyone.

What are the options for suspending the vaginal vault after hysterectomy?

There are many places from which the vaginal vault can be suspended after the uterus/cervix are removed. There are too many to go into detail in this format, but all have their pluses and minuses. The main options are the uterosacral ligament , sacrospinous ligament , and the sacrum itself . More general information can be found in this handout .

What is recovery like after these types of surgeries?

Every surgeon is different, but here are some general guidelines for recovering from a hysterectomy or prolapse repair. And YES, many times there is more than one repair being done at a time! Or a hysterectomy may be combined with an anterior and/or posterior vaginal wall repair, for example.

Most often, you will have a catheter in place for anywhere from 8-24 hours after surgery (potentially longer for a bladder repair). And generally, your hospital stay is very short.

Typically you need to take anywhere from 2-6 weeks off work. Around 2-3 weeks you can resume driving and taking short walks. And no sex (vaginal penetration) is allowed for 6 weeks.

It's also important to remember that because these are very delicate tissues, they are not fully healed for THREE MONTHS. So, for quite some time you will likely have restrictions on heavy lifting.

Have even more questions about your pelvic floor in general, or prolapse specifically? Here are two great websites for more info on all kinds of pelvic floor-related issues, not just prolapse:

International Urogynecological Association handouts

American Urogynecologic Society fact sheets

References:

All information contained in this post is aggregated from the handouts linked throughout the text.

Prolapse Surgeries, Part 1

Mon, 20 Jan 2025 19:34:11 GMT

Prolapse Surgeries, Part I

Whew, surgery for prolapse is a big topic. So much so that I'm splitting it into two articles to avoid overloading your eyeballs and brains! Today we'll spend time discussing the whys and who's surrounding surgery. Then next time we'll get into the details of types of surgeries, recovery times, etc.

If I have prolapse, do I definitely need surgery?

In a word, no. Or at least, most likely not. I wanted to get this question out of the way first, because I think prolapse can be a very scary diagnosis when you are first told you have it. Then, your brain (or at least mine!) jumps to the most extreme outcome, which would be surgery. As we discussed in a past article about the best exercises for prolapse, pelvic floor muscle training and core strengthening can be a really effective treatment for prolapse. It can relieve your symptoms, delay/prevent the need for surgery, and potentially even reduce the grade of your prolapse. Plus, pessaries are another great non-surgical option that can prevent or delay the need for surgery too (if the idea of a pessary is new to you, check out my past article on pessaries). So, especially if you are newly diagnosed with prolapse, don't jump to the thought that you will have to have surgery someday!

Who does need surgery for prolapse?

Indications for prolapse surgery are the following:

Significant "bother" of symptoms (vaginal heaviness/pressure, associated bowel/bladder symptoms, difficulty/pain with intercourse, etc)
"Failed" a good trial of conservative treatment - PT/pelvic floor muscle training, pessaries, etc. that does not satisfactorily resolve symptoms
Completed childbearing
Typically more-advanced prolapse grades (3-4), unless with lesser grades the symptoms are severe and not responding to conservative treatment

If your prolapse is mild (grade 1-2), you are going to have more children, or have other medical conditions that would make surgery difficult, then you can/should avoid it! Typically the biggest differentiator regarding the need for surgery is if the prolapse extends beyond the hymen, or external to the vagina. Conservative treatment is less likely to be successful (but not always, of course!) in cases where the prolapse is external to the vaginal opening. More often than not, surgery will eventually be needed to resolve symptoms. But, that doesn’t mean a good trial of conservative treatment isn’t a good idea!

How common is prolapse surgery?

It is pretty common, at least with age. If you have a uterus/vagina, you have a lifetime risk of 11-20% of undergoing surgery for prolapse or stress incontinence. By age 80 the risk is 20%.

How successful is prolapse surgery?

It is very successful, especially in the short term! Success rates are generally around 80-90%, especially within the first 2 years following surgery. However, it is true generally that the further away you get from surgery, the more likely your prolapse may return. And we don't have a lot of high-quality studies that follow people after prolapse surgeries beyond 2 years (many stop around 6-12 months).

The other caveat here is how we define "success." There is a BIG difference between restoring your anatomy (i.e., reducing the organ back to its original position, and having it stay there) and improving your symptoms. Around 5 years post-op, the majority of repairs will have "failed" in terms of anatomy. Meaning that if someone did a vaginal examination, the prolapse will have returned (although potentially not to the same degree that it was present before). However, even in these cases, the symptoms are still reported to be much better, and happiness with surgery outcomes is still high. So this is further proof that the degree of prolapse isn’t always equal to the severity of symptoms and that more research is definitely needed.

Why do prolapse surgeries fail?

There are a lot of reasons. The biggest one is that the tissues surgeons are trying to repair are very delicate. There's a really fine line between suspending an organ via it's own ligaments, or using mesh, with just enough tension vs. using too much tension. So it's always a balance between fixing the original problem without causing further complications.

The other is that many times, the original cause of the prolapse has not been corrected. As I discussed at length in my intra-abdominal pressure article, prolapse really is a top-down problem more than a bottom-up problem. In fact, one recent study that looked at outcomes 5 years after prolapse surgery found no difference between those who did and did not do post-operative pelvic floor muscle training (Jelovsek 2018). Essentially, pelvic floor muscle training did not stop the prolapse from returning. So if you still are doing a lot of heavy lifting, have continued constipation, or are just genetically predisposed to having prolapse, there is a high likelihood it will return because there is still a lot of top-down pressure on your internal organs.

It's important to note though, as I stated above, generally, your symptoms still remain improved even if the prolapse itself returns post-operatively. Although of course, some people will need to have a second surgery. This is also why it's best to delay surgery for as long as possible.

Should I have prolapse surgery?

This is obviously a very personal decision, and depends upon a lot of factors! I think the biggest takeaways here are that you should try PT, pelvic floor & core exercises, and/or pessaries first. Pelvic Love also fits in well with these exercise recommendations, and has some specific videos for prolapse! All of these things are recommended to be the first-line interventions for prolapse and can help the majority of people who are living with prolapse. If that doesn't work for you, or for whatever reason your surgeon determines surgery is the best route right away, then definitely consider it.

It can be very successful, especially for symptom improvement! As with any surgery though, I would always recommend getting at least 2 opinions before deciding to move forward. And I would highly recommend at least one of those opinions come from a urogynecologist or colorectal surgeon depending upon your needs.

The next article will discuss different options for prolapse surgeries, so be sure to check that one out!

References:

Bureau, M., & Carlson, K. V. (2017). Pelvic organ prolapse: A primer for urologists. Canadian Urological Association journal = Journal de l'Association des urologues du Canada , 11 (6Suppl2), S125–S130. https://doi.org/10.5489/cuaj.4634

Dumoulin, C., Hunter, K. F., Moore, K., Bradley, C. S., Burgio, K. L., Hagen, S., Imamura, M., Thakar, R., Williams, K., & Chambers, T. (2016). Conservative management for female urinary incontinence and pelvic organ prolapse review 2013: Summary of the 5th International Consultation on Incontinence. Neurourology and urodynamics , 35 (1), 15–20. https://doi.org/10.1002/nau.22677

Jelovsek, J. E., Barber, M. D., Brubaker, L., Norton, P., Gantz, M., Richter, H. E., Weidner, A., Menefee, S., Schaffer, J., Pugh, N., Meikle, S., & NICHD Pelvic Floor Disorders Network (2018). Effect of Uterosacral Ligament Suspension vs Sacrospinous Ligament Fixation With or Without Perioperative Behavioral Therapy for Pelvic Organ Vaginal Prolapse on Surgical Outcomes and Prolapse Symptoms at 5 Years in the OPTIMAL Randomized Clinical Trial. JAMA , 319 (15), 1554–1565. https://doi.org/10.1001/jama.2018.2827

Weintraub, A. Y., Glinter, H., & Marcus-Braun, N. (2020). Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse. International braz j urol : official journal of the Brazilian Society of Urology , 46 (1), 5–14. https://doi.org/10.1590/S1677-5538.IBJU.2018.0581

What are Pessaries, and How Do They Work?

Mon, 20 Jan 2025 19:29:33 GMT

What are Pessaries, and How Do They Work?

Pessaries can be awesome, and they can also be really frustrating. But for many people with prolapse, they can be real game-changers! They can improve your symptoms immediately, delay/prevent the need for surgery, and allow you to get back to activities that would normally cause leakage or discomfort. But like any treatment there are upsides and downsides, so let's dive in.

What are pessaries?

Pessaries are prosthetic devices (like orthotics) that are placed inside the vagina to support the internal organs. They come in MANY shapes and sizes depending upon which organ(s) need(s) support, and what symptoms need improving. They are generally made of silicone but can be made of other medical-grade materials too.

My favorite analogy about pessaries is that they are like a sports bra for your internal organs! So there is no shame in needing to use one, especially for higher-impact activities. And just like a sports bra, they don't make the surrounding muscles weaker, they just provide you a little lift right where you need it.

Fun fact, pessaries have been around since at least 400 BC. People used to put ALL kinds of things inside vaginas to support the internal organs...my favorite is half a pomegranate soaked in wine as described by Hippocrates!

What can pessaries help with?

Pessaries help lift organs back toward their original position when they have started to shift due to pelvic organ prolapse. But, pessaries also help control symptoms typically associated with prolapse, like urinary incontinence and pelvic pressure.

One of the number one indications for a pessary also is stress urinary incontinence, which most people don't know! So even if you only have stress incontinence with exercise, but don't necessarily have a prolapse, a pessary can still help you.

Most of the time we think that pessaries are just helping to decrease symptoms while the pessary is in place. But, there is some emerging evidence to show that regular pessary use can actually improve the grade of the prolapse. This is because the pessary can reduce the strain on the prolapsed organ's ligaments, and then over time those ligaments may shorten and provide better support to the organ.

Do they really work?

Yes!! Pessaries have a high acceptance rate of over 70% (Vasconcelos 2020). And it's been established in multiple studies that pessaries in combination with pelvic floor muscle training is very effective, more so than either alone (Bugge 2020). Plus, once they are fit well, pessaries generally are a good long-term option. 60% of people are still using their pessaries after 2 years from the initial fitting (Mao 2019).

The combo of pessaries and pelvic floor exercises can really make sense when you think about the pressure that a prolapsed organ can place on the pelvic floor. If you always have something pushing down against a muscle you are trying to work, it will be much harder for you to engage/activate that muscle. So, with a pessary in place, your pelvic floor can engage much better and get stronger more easily than without it!

Are pessaries helpful for all types of prolapse?

Not necessarily - this is the big bummer about pessaries. Pessaries can be incredibly effective for bladder and uterine prolapse. However, for rectoceles (rectum falling into the vagina), pessaries are very hard to fit and much less effective. This is because most pessaries for the bladder and uterus will pop in place by sitting behind the pubic bone. The pubic bone and pelvic floor will act like a little "shelf" to help hold it in place. But, for the backside of the vagina (the rectum), there isn't anything for the pessary to rest against.

It doesn't mean that if you have a rectocele you can't find a pessary that works for you, but just remember that it might be a longer and more frustrating process than average. And in the end, you may decide you are better off without a pessary than with one.

Who might need a pessary?

A pessary can be helpful for you if you:

have pelvic organ prolapse
have stress incontinence
do not need or do not want to have surgery
need surgery but are unable to undergo surgery for medical reasons, or because you aren't done having children yet (and yes you can use pessaries while pregnant!)

Who may not do well with a pessary?

If you fit any of these criteria, a pessary may not be for you:

are a smoker
have a shortened vaginal length from radiation or any other medical procedures
have had prior vaginal surgery
have had a pelvic floor avulsion during childbirth (not a typical tear, but where the pelvic floor muscle is pulled off the pubic bone)
have fragile vulvar tissues or are otherwise prone to skin breakdown

Aren't pessaries just for old ladies?

Absolutely not! Anyone can use a pessary at any age and at any stage of prolapse. As we've discussed before, the stage/severity of prolapse and the symptoms of prolapse don't necessarily match. So some people have very minimal prolapse with very severe symptoms, while others can have advanced prolapse with little to no symptoms. So, especially if you've already worked on your pelvic floor, go to PT, etc etc ,and are still struggling with prolapse and/or stress incontinence symptoms, a pessary may be really helpful for you.

The bonus to being younger and using a pessary is that it typically means you’ll have an easier time inserting and removing the pessary on your own. Some older people, or generally people with arthritis or limited mobility, can’t reach their vagina well. Or, they may have trouble with the finger dexterity needed to put the pessary in or take it out. So if you don’t live with arthritis or limited mobility and only have symptoms with exercise, you can put the pessary in for exercise and take it out when you are done. Or you can remove it for intercourse and put it back in afterward without a big hassle. And some pessaries you can even leave in for intercourse depending upon their shape and size.

How do I insert them, and what do they feel like?

Pessaries are really similar to menstrual cups and discs in this manner as most of them are very flexible. You typically squeeze them between your fingers, slide them in vertically, and then they pop into place behind the pubic bone. Once they are inserted, you shouldn't feel them.

Other types of pessaries that are called "space-filling" pessaries (like cube pessaries) rely on suction to stay in place. These do not compress in your hand. So those you push up into the vaginal canal like a tampon, and then they will stay in place on their own.

What about cleaning?

This is a great question and you may get different advice depending upon your sources! The difference here really relies upon whether or not you can insert and remove your pessary on your own. If you are able to do so, then it's recommended you take it out and clean it with soap and water about 1-2x/week. However, I've also heard the argument that if you are only doing it 1-2x/week you are likely to forget! So every day may be best. And if you do have sex with it in, you need to take it out and clean it afterward.

If you cannot remove it on your own (especially if you have arthritis in your hands, or otherwise have some limitation with upper extremity mobility), then you do need to visit your doctor once every 3 months to have it removed, cleaned, and re-inserted.

Where and how do I get a pessary?

Most gynecologists (GYNs) have the ability to fit pessaries. However, depending upon their individual experience they may not feel comfortable fitting all types of pessaries, or may not have a lot of options for you to choose from. So, as I've said in previous posts you may want to see a urogynecologist if you have trouble fitting your pessary, or don't do well with the one your GYN gave you.

The good news is that PTs can now fit pessaries too! However, this is very new to the PT scope of practice (at least in the US), so not many PTs are offering this service yet. But if you think about it, it makes sense for PTs to fit pessaries. We have the luxury of spending more time with patients, so we can make sure to get the exact right fit. Plus since we have more space we can usually have you stand up, walk around, even jump or run, etc to make sure it stays in and is comfortable. And we already have experience with things like foot orthotics, so this is just like a foot orthotic for your vagina! I'm excited to see more and more PTs be able to offer this service to their patients.

Most of the time pessaries are covered by insurance, but like most things in women's health care, this can be variable. So if you have questions about coverage, make sure to discuss it with your provider, or even better call your insurance company ahead of time.

Bottom line

Pessaries often get a bad rap or are not thought of for most of us who are younger with prolapse and/or incontinence. But they can be SO helpful, and really should be the first line intervention after pelvic floor exercise/PT for prolapse and stress incontinence! They are pretty cost-effective (certainly less than surgery and PT), don't limit your future options (unlike surgery), and can always be removed and/or changed in size if they become uncomfortable. In fact, it's pretty normal to have to change sizes over time if you use a pessary long-term.

Want even more info? Check out some great handouts on pessaries by different urogynecological professional organizations here and here .

References:

Bugge, C., Adams, E. J., Gopinath, D., Stewart, F., Dembinsky, M., Sobiesuo, P., & Kearney, R. (2020). Pessaries (mechanical devices) for managing pelvic organ prolapse in women. The Cochrane database of systematic reviews , 11 (11), CD004010.

https://doi.org/10.1002/14651858.CD004010.pub4

Mao, M., Ai, F., Kang, J., Zhang, Y., Liang, S., Zhou, Y., & Zhu, L. (2019). Successful long-term use of Gellhorn pessary and the effect on symptoms and quality of life in women with symptomatic pelvic organ prolapse. Menopause (New York, N.Y.) , 26 (2), 145–151. https://doi.org/10.1097/GME.0000000000001197

Vasconcelos C, Gomez M, Geoffrian R ,et al. Pessary evaluation for genital prolapse treatment: From acceptance to successful fitting. Neurourology and
Urodynamics. 2020;39:2344–2352.

What are the Best Exercises for Prolapse?

Mon, 20 Jan 2025 19:07:46 GMT

What are the Best Exercises for Prolapse?

There are a LOT of recommendations out there - “do this one exercise to fix your prolapse!” Or, “NEVER do this exercise!” It can be confusing, and frankly overwhelming. So now we are going to take a deep dive to try to answer these questions: what exercises are safe for prolapse, or what are the best exercises to manage prolapse? And, probably the most common question: what should I AVOID if I have prolapse?

Pelvic floor muscle training is where it's at

I spent a lot of time last article talking about the importance of managing intra-abdominal pressure (IAP). Prolapse is truly more of a top-down issue than a bottom-up one! But after you are better at managing your IAP and not holding your breath, then the first-line intervention always recommended in the literature is pelvic floor muscle training.

Notice I keep saying "pelvic floor muscle training," NOT just Kegels. There isn't anything wrong with Kegels, but hopefully, as a Pelvic Love patient, you know that working your pelvic floor goes well beyond just Kegels! We want the pelvic floor to be dynamic and responsive like a trampoline, not hard and stiff like concrete. So working on both strengthening AND relaxing the pelvic floor, longer holds AND quicker flicks, applying pelvic floor muscle activation to exercise AND daily tasks, etc. is all important!

Here are some of the benefits of pelvic floor muscle training when you have a prolapse:

improvement prolapse symptoms (pressure, heaviness, etc) especially in those with mild to moderate prolapse
in prolapse grades 1-3, reduction of the grade of the prolapse
reduction of the long-term risk of hospital-based treatment for prolapse (i.e. surgery)

How much pelvic floor muscle training is enough?

This is the million-dollar question, right? Fortunately for prolapse in particular, we do have some decent evidence on how long it takes to see changes with pelvic floor muscle training.

2 weeks is enough to start to notice a change in symptoms
6 weeks will show a more marked improvement in symptoms
16 weeks may be needed to show improved pelvic floor muscle bulk
6 months may be required before a change in the grade of prolapse is seen
After 6 months, the frequency of exercise can be decreased to maintain strength gains, or you can just incorporate the pelvic floor into other exercises

Are there specific recommendations for pelvic floor muscle training?

In a word (or two :), not really. There isn't enough evidence to say how many sets and repetitions of pelvic floor exercises you need to do. But there are some general guidelines to follow, like:

work on your pelvic floor in multiple positions: laying, sitting, standing, squatting, etc
choose at least 2-5 days/week to focus on pelvic floor exercises
do this for at least 16 weeks

And then, don't forget about your core as well! Core stabilization, when added to a regimen including pelvic floor muscle training, can also improve prolapse symptoms. So this basically means, don't forget to incorporate abdominals, multifidus (lower back muscles), breathing, etc. while also working on your pelvic floor! This is basically everything we already do at Pelvic Love Physiotherapy and Wellness!

What about different positions just to get some relief from the prolapse symptoms?

Many people with prolapse will find that laying in a position with the pelvis elevated, or even doing exercises in this position, is really helpful. Basically by elevating the pelvis you are using gravity to help reduce your organs back to their original position. And then, with the organs not putting so much pressure on your pelvic floor, you will have an easier time activating your pelvic floor too!

So some of these positions can include:

laying on your back with your bottom elevated on pillows or a wedge (basically a supported bridge)
bridges
laying down with legs propped on a chair or up the wall (this doesn't technically elevate your pelvis, but can relieve some pressure on the pelvic floor)

So what should I NOT do if I have prolapse?

As with almost all questions similar to this (such as: what exercises are bad for DR?), it's more about HOW you are doing the exercise vs. WHAT you are doing. And of course, it depends. It depends upon the grade of prolapse, it depends upon how much control you have of your pelvic floor (or not), it depends upon how bad your symptoms are, etc.

If prolapse is a new diagnosis for you, we do recommend you avoid impact exercises until you have good control of your pelvic floor, and you know that impact won't exacerbate your symptoms. But once your pelvic floor is strong and still responsive, you have your breathing and abdominals coordinated well with all exercises across all positions, and your symptoms are minimal - you can go back to doing just about anything you want! People have even successfully gone back to higher-level weight lifting, running marathons, etc. with prolapse. The key is managing that intra-abdominal pressure that I talked about last week, and keeping up your pelvic floor strength. Once you have a handle on your IAP and your pelvic floor is working well, the world is your oyster.

Sometimes to return to higher-level activities, you may need a little extra help for your prolapse, such as wearing a pessary. It can be inserted for exercise and then removed when you are finished (if you choose not to wear it all of the time). And pessaries are exactly the topic we cover in the next article! So definitely check that one out.

References:

Fenocchi, L., Best, C., Mason, H., Elders, A., Hagen, S., & Maxwell, M. (2023). Long-term effects and costs of pelvic floor muscle training for prolapse: trial follow-up record-linkage study. International urogynecology journal , 34 (1), 239–246. https://doi.org/10.1007/s00192-022-05272-9

Kashyap, R., Jain, V., & Singh, A. (2013). Comparative effect of 2 packages of pelvic floor muscle training on the clinical course of stage I-III pelvic organ prolapse. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics , 121 (1), 69–73. https://doi.org/10.1016/j.ijgo.2012.11.012

Özengin, N., Ün Yıldırım, N., & Duran, B. (2015). A comparison between stabilization exercises and pelvic floor muscle training in women with pelvic organ prolapse. Turkish journal of obstetrics and gynecology , 12 (1), 11–17. https://doi.org/10.4274/tjod.74317

Wang, T., Wen, Z., & Li, M. (2022). The effect of pelvic floor muscle training for women with pelvic organ prolapse: a meta-analysis. International urogynecology journal , 33 (7), 1789–1801. https://doi.org/10.1007/s00192-022-05139-z

What Does Intra-Abdominal Pressure Have to Do with Prolapse?

Mon, 20 Jan 2025 19:02:21 GMT

What Does Intra-Abdominal Pressure Have to Do With Prolapse?

So far in this series of articles we’ve spent a lot of time talking about what prolapse is exactly, who gets it, and why. It is definitely true that the underlying issue for pelvic organ prolapse is weakness of the connective tissues that help hold up your internal organs, and many of those things are out of your control. But of the things that ARE in your control, they all come down to the same variable: intra-abdominal pressure (IAP) !

What is IAP?

IAP is the increased pressure that we create inside our abdomen during physical tasks that either helps push things up and out our nose/mouth (sneezing, coughing, laughing, etc) or down and out your rear end (bowel movements and passing gas). IAP is a necessary part of life; we use increased IAP to our benefit anytime we sneeze or blow our nose, have a bowel movement, cough or laugh, etc.

So, I want to be clear that all IAP is NOT bad, as you need it for everyday tasks! The problem becomes when people are increasing IAP as a substitution for lack of core strength, to give them extra “oomph” when lifting or carrying heavy things, or to help put more pressure on their bowels to eliminate their stool if they are constipated. As you can imagine, if you are chronically increasing the pressure inside your abdomen when you really shouldn’t be, this can definitely cause or contribute to your internal organs being pushed out of position.

In order to talk about when increasing IAP is and isn’t helpful, we’ll need to do a quick review of breathing mechanics.

Your pelvic floor and internal organs SHOULD move

With every breath you take, your body does an awesome and intricate dance between your diaphragm, abdominals, and pelvic floor. As you inhale, your diaphragm pushes downwards in order to help fill your lungs with air. This creates increased IAP, which then pushes the belly slightly outwards, and the internal organs and pelvic floor slightly downwards. Then as you exhale, the diaphragm relaxes and elevates as you expel air from your lungs. In turn, this helps pull the pelvic floor and internal organs upwards, and helps the abdominals relax or fall back towards your center. If you want to see this movement in action check out this breathing gif or this abdominal and pelvic floor movement gif .

This amazing coordination happens with every. single. breath. that you take! So hopefully this should help illustrate why we always coordinate brace/blink/rocket on the exhale. Coordinating your belly and pelvic floor with the exhale helps keep your IAP low, and naturally helps your body activate your abs and pelvic floor. You can also imagine why prolapse is linked to chronic lung conditions like asthma and COPD, or why you may have worsened prolapse (or incontinence!) with an illness that causes excessive coughing/sneezing.

This is also why we don’t want people to get in the habit of holding their breath while exercising or engaging in everyday activities. And it’s also why we don’t want someone to ONLY focus on engaging/strengthening their pelvic floor, and never focus on relaxing it. Your diaphragm gets rigid when you hold your breath, and thus puts a lot of pressure on your internal organs below (illustrated in the second pic). It also doesn’t allow you to properly engage your abs or pelvic floor.

The same goes for an overactive pelvic floor - too much rigidity in the pelvic floor doesn’t allow for the natural movement your diaphragm and abdominals should have while breathing, and can cause you to take shorter, shallower breaths. This tension may create more tension in your pelvic organs & fascia, contributing to their descent. In this, and in most cases, motion is lotion!

How do I prevent IAP from becoming a problem?

In a word, EXHALE! When you exhale fully your IAP is at its lowest. This is due to the natural coordination between your pelvic floor, diaphragm, and abdominals as mentioned above. When the diaphragm elevates and empties your lungs fully of air, it encourages the pelvic floor and abdominals to draw inwards. This provides better support for your internal organs too.

This doesn’t mean that it’s always terrible to hold your breath, or you should be scared of taking a deep inhale that causes your belly to bulge a bit and pelvic floor to push downwards/outwards. As explained above, your pelvic floor and internal organs NEED to move. The fear that some people develop after a prolapse diagnosis that prevents them from never fully relaxing their abs and pelvic floor is just as bad as someone who never engages them. Life is all about balance!

So, get into the habit of exhaling with any tasks that might increase IAP. This would include lifting anything heavy (from that big bag of dog food to your 20lb infant plus car seat), pushing/pulling anything heavy (heavy grocery carts, moving furniture, etc), light weight-lifting, etc. A special note here for moderate to heavy weights - sometimes this does require you to INCREASE your IAP in able to lift weights safely. If this applies to you, please make sure to work with a personal trainer or other certified fitness professional who can teach you safe techniques for heavier weight lifting.

What about deep abs and pelvic floor?

Yes, it’s even better if you can coordinate your deep abs (belly brace) and pelvic floor (Kegel) with the exhale during these everyday life tasks! But, the good news is there is a "cheat" if that’s too hard to coordinate (looking at you, the mom with 3 under 5 who has two toddlers asking her 5 million questions while she's lifting the baby out of the car). If you can at least coordinate the exhale during moments of increased IAP, the rest of your muscles will follow. The main point here is that you do not hold your breath with any of these activities.

It is also true that some people with prolapse will have INCREASED tension in their pelvic floors, not decreased tension. If you know that is you, then you can ease up on the blink/rocket with increased IAP. But, doing the brace would still be helpful!

Next article we’ll dive more into exercises for prolapse, so be sure to check that one out!

Reference:

Talasz, H., Kremser, C., Talasz, H. J., Kofler, M., & Rudisch, A. (2022). Breathing, (S)Training and the Pelvic Floor-A Basic Concept. Healthcare (Basel, Switzerland), 10(6), 1035. https://doi.org/10.3390/healthcare10061035

Who Gets Prolapse, and Why?

Mon, 20 Jan 2025 18:59:10 GMT

Who Gets Prolapse, and Why?

Please note: this post has a brief mention of body weight and obesity.

The prevalence of pelvic organ prolapse is one of my favorite things to talk about. Prolapse is SO common, and not enough people know that! Here are some statistics associated with the risk of prolapse (Weintraub 2020):

3-50% of people with vulvas have prolapse
50% of people with vulvas who have been pregnant have prolapse, as do 50% of menopausal people
Prolapse increases with age, but prolapse can even be seen in people in their 20s

These statistics illustrate why it can get confusing when discussing prolapse because different studies define it differently. The biggest difference between the studies is whether or not the participant has symptoms. Is the study looking at people with symptoms of prolapse like pelvic pressure/heaviness, or difficulty emptying bladder or bowels? Or is the study relying upon an actual diagnosis by a medical professional from completing a vaginal examination?

The prevalence of prolapse that does NOT cause symptoms is much higher than that of prolapse that causes symptoms. Some studies will show prolapse occurs in only 3-10% of people with vulvas who have symptoms (ACOG & Abrams), while others show a 94% rate of prolapse if you are talking about grade 1 prolapses that do not cause any symptoms at all (Braekken 2015). In fact, I want to highlight a joint statement by the American College of Obstetricians and Gynecologists (ACOG) and the American Urogynecologic Society (AUGS):

“Mild descent of the pelvic organs is common and should not be considered pathologic. Pelvic organ prolapse should only be considered a problem if it is causing prolapse symptoms (ie, pressure with or without a bulge) or sexual dysfunction or if it is disrupting normal lower urinary tract or bowel function.”

So, if you have a mild prolapse especially (grade 1), try not to get too worried! If you need a review on the grades or prolapse, please check out my article Prolapse is Confusing!

What Types of Prolapse are Most Common?

This is also where the literature is really interesting, and shows more truths that are not discussed often. In people who are diagnosed with prolapse, these are the rates of the different types of prolapse seen: (Abrams 2017)

Cystocele (bladder) 16-25%
Rectum (rectocele) 13-19%
Uterus 5-14%

And of those, the vast majority have grades 1 or 2 prolapse. But guess what….. 65% of people with prolapse have some grade of prolapse of all 3 organs.

That’s right - unfortunately, when one organ starts to fall, the rest tend to come with it. This is especially true of the uterus. The uterus and cervix are kind of like the roof of the house of your vagina. And once the roof starts to fall in, it tends to take the walls with it.

What About Postpartum Prolapse?

This is also incredibly common, and again not discussed often. Durnea 2014 found these rates in a smaller study of 202 people with vulvas who were one year postpartum after their FIRST baby:

89% had uterine prolapse
90% had cystocele
70% had rectocele

And again, the majority of these study participants had prolapse in multiple compartments. Plus, 80% had no symptoms as the majority of these were grades 1 and 2. And, the majority of these participants also were young - 78% were under the age of 34.

The study didn’t do any long-term follow-up, so my suspicion is that these conditions likely improved over time as the demands of childcare were less, and the participants returned to their pre-partum levels of strength and activity.

What Are the Risk Factors for Prolapse?

This is another one I love to talk about, because it helps to realize that developing prolapse is largely out of an individual person’s control. The main “cause” of prolapse is a weakening of the fascia and ligaments that help hold up your internal organs. Your pelvic floor strength, or lack thereof, can contribute to prolapse, but typically is not the primary problem.

Here is a non-exhaustive list of risk factors:

Having a vagina is number one (a larger space in the pelvis required for childbirth also means more space for organs to change position)
Being pregnant, especially more than once (parity)
Vaginal childbirth, especially pushing more than 2-3 hours or the need for forceps/vacuum
Genetics/family history
Connective tissue disorders (joint hypermobility)
Menopause specifically, as well as simply aging
Pelvic trauma/injury
Heavy lifting
Chronic constipation/straining
Lung disorders or chronic coughing
Poor nutrition
Smoking
Higher body weight/mass due to pressure placed on the internal organs (please note: in the graphic it does say “obesity,” which is not our choice of words)
Race/ethnicity
Hysterectomy

Hopefully this helps pull back the curtain a bit on why you may have prolapse (if you do), and help you realize that it’s not your fault. Make sure to check out the next article that discusses intra-abdominal pressure, which is really the link behind all of these issues, and is the key to avoiding making your prolapse worse!

References:

Abrams,P, Cardozo, L, Wagg, A, Wein, A. (Eds) Incontinence 6th Edition (2017). ICI-ICS. International Continence Society, Bristol UK, ISBN: 978-0956960733.

American College of Obstetricians and Gynecologists and the American Urogynecologic Society, & INTERIM UPDATE: This Practice Bulletin is updated as highlighted to reflect the US Food and Drug Administration order to stop the sale of transvaginal synthetic mesh products for the repair of pelvic organ prolapse. (2019). Pelvic Organ Prolapse. Female pelvic medicine & reconstructive surgery , 25 (6), 397–408. https://doi.org/10.1097/SPV.0000000000000794

Braekken, I. H., Majida, M., Ellström Engh, M., & Bø, K. (2015). Can pelvic floor muscle training improve sexual function in women with pelvic organ prolapse? A randomized controlled trial. The journal of sexual medicine , 12 (2), 470–480. https://doi.org/10.1111/jsm.12746

Durnea, C. M., Khashan, A. S., Kenny, L. C., Durnea, U. A., Smyth, M. M., & O'Reilly, B. A. (2014). Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal primiparous women. International urogynecology journal , 25 (11), 1463–1470. https://doi.org/10.1007/s00192-014-2382-1

Prolapse is Confusing!

Mon, 20 Jan 2025 18:58:17 GMT

Prolapse is Confusing!

If you've been diagnosed with, or ever suspected that you have, pelvic organ prolapse, I'm certain it brings up a million questions for you. Will my bladder eventually fall out of my vagina? Will having sex make it worse? Do I need surgery? What about having more kids, returning to exercise and running, etc etc??

These are all FANTASTIC questions that typically don't get explained very well by the person who diagnoses you with prolapse, or by doing your own internet research. And, most of these difficulties originate with the fact that prolapse is not just one diagnosis. There are so many different organs that can prolapse, and so many different grades of prolapse, that it can be incredibly confusing. So today, let's start with the basics: what is prolapse, and how do we diagnose and grade it?

What is Prolapse?

The definition of prolapse is when "an organ or organs in the pelvic cavity shift downward out of their normal position." (Palm 2017)

What are the Types of Prolapse?

Vaginal prolapse can occur from the bladder (cystocele), the rectum (rectocele), the uterus/cervix (apical or uterine prolapse), the small intestines (enterocele), or the vaginal vault (vaginal vault prolapse only happens in individuals who have had a total hysterectomy).

It's also important to note that similar to a hernia, the “bulge” created by a prolapse is the organ pushing the vaginal wall downwards or outwards. As a result, the tissue you are actually seeing or feeling is the vaginal wall, not the organ itself. So no, your bladder or bowel will not just fall out one day! The only exception to this is cervical/uterine prolapse, where you will actually feel or see the cervix if it gets low enough. But, I promise that still won’t fall out one day either!

You can also have prolapse outside of the vaginal canal - the urethra can descend from its original position towards the vulva (urethrocele), or the lining of the rectum can prolapse outside of the anus (rectal prolapse). {NOTE: this is why language is important; many people will talk about a "rectal prolapse" when they really mean a rectocele. Rectal prolapse external to the anus requires surgical correction - no amount of pelvic floor exercises will help.}

WHEW that's a lot. So, before you freak out and worry about just exactly how many of your organs will eventually fall out of your vagina (haha), let's talk about grading and statistics!

How do we Grade Prolapse?

This is super important. - not all prolapses are created equal! There is a VERY big difference between minor prolapses (the bladder just slightly bulging into the vagina) vs major prolapses (the cervix or uterus being external to the vagina).

There are a few different grading scales out there, but here are the most common grades:

Prolapse is less than halfway to the opening of the vagina
Prolapse is more than halfway to, or AT the opening of the vagina
Prolapse is EXTERNAL TO the opening of the vagina
Maximal descent of the entire organ outside of the vagina

The good news is that prolapse is a slowly progressing condition. So no, you won't go from a grade 1 to a grade 3 overnight. Grade 4 students are rare, especially in higher-income countries. Typically it takes years for prolapse to worsen, if it does worsen at all. In upcoming posts we'll talk about what does and doesn't cause prolapse, and if you do have prolapse what you can do to help it get better (or at least not get worse).

Who Can Diagnose Me with Prolapse?

This is also an excellent question with a very nuanced answer. Your gynecologist (GYN) can do so, but the prolapse specialists are truly urogynecologists (urogyns) or in some cases colorectal surgeons, particularly for rectoceles. A pelvic floor PT can also diagnose you with prolapse, but we can't say with certainty which organ is prolapsing - we typically talk more about which wall of the vaginal canal is bulging. A pelvic floor PT also typically can do a more detailed assessment than your GYN, as we also can assess people in standing positions. Sometimes prolapses are tricky to see when you are laying flat on your back, so a standing examination can be very useful!

If someone is concerned about their prolapse diagnosis, I do typically recommend they seek a consultation with a urogynecologist. This usually occurs when they have been told they don't have a prolapse when they think they do, or have been blindsided with a diagnosis of higher-degree or multiple-organ prolapse when they were unaware. A urogyn can do a much more detailed assessment of prolapse than a GYN can, and they are also experts at fitting pessaries or performing corrective surgeries. More on this in upcoming posts! But if you are curious, you can look up a urogyn close to you or a colorectalsurgeon (for rectoceles or rectal prolapse).

I will say also that typically fancy imaging studies are not needed to diagnose prolapse. They can be used in certain cases, for example, if you have constipation and a rectocele, there is a special test that can be done to see how much of your rectum is falling into the vagina when you are bearing down to pass stool. But, this is definitely the exception rather than the rule. Usually, the examination done in the office is all that is needed.

What Else Should I Know About Pelvic Organ Prolapse?

Voices for Pelvic Floor Dysfunction

Association for Pelvic Organ Prolapse Support

International Urogynecological Association patient information leaflets

American Urogynecological Association patient fact sheets

Reference:

Palm, S. (2017). Pelvic Organ Prolapse: The Silent Epidemic (3rd ed.). POP Publishing and Distribution.

Osteoporosis Part 2: How to build stronger bones through exercise

Thu, 10 Mar 2022 23:53:36 GMT

Osteoporosis Part 2:

How to build stronger bones through exercise

If you missed my first article on osteoporosis (OP), make sure to go back and check it out! That article explains what osteoporosis is, and who is more at risk for being diagnosed with OP. This article will focus more on the evidence behind building stronger bones with exercise, and thus lessening the effects of osteoporosis. Of course there are also a lot of nutritional recommendations for OP, but that is beyond our scope of practice. Please consult your doctor or dietitian for more information on how nutrition can help OP!

What types of exercise are best to improve my bone strength (aka bone mineral density - BMD) if I have osteoporosis?

Basically, a combination of exercise is best. We know for sure that weight-bearing (WB) exercises help build bone density, which means any type of exercise that is putting weight through your bones. So for your legs and spine, this would be any upright/standing exercises. For your arms and upper trunk, this would be anything that puts weight through your arms like planks or push-ups (yes, even the version on the wall!).

The cool thing is that we also see these improvements in BMD with any type of resistance exercise: free weights, dumbbells, resistance bands, etc. The sky is the limit! And of course, we know generally that people with OP are at a higher risk for falls and broken bones as a result of those falls. So including some balance training and aerobic exercises are recommended as well.

How often do I need to exercise to see improvements in my bone health?

Studies indicate that to achieve an increase in bone mineral density, the frequency of training should be 2–3 times per week for 30–60 minutes, depending on the intensity. Twelve weeks’ duration is the minimum to see increases in BMD.

Is there any research showing the benefits of certain types of exercise?

Absolutely! Here’s a short list:

Aerobic weight-bearing exercises: walking, stair climbing, jogging, dancing, and Tai Chi have all been shown to be beneficial for bone health (note: walking alone isn’t enough to improve BMD unless paired with another type of exercise!)
Resistance training: especially focused on the glutes, lower back, and upper body
Hi-intensity resistance and impact training (HiRIT): HiRIT has the potential to be better at improving bone density as it is more intense than low-impact exercise, and has been shown to be safe in postmenopausal people with vulvas who have osteopenia and osteoporosis
Balance/coordination exercises: can reduce fall risk and thus fracture risk
Whole-body vibration: this is a therapy intervention in which the whole body is vibrated to activate mechanoreceptors that help improve bone growth
Aquatic therapy (exercise in a pool): exercise in the pool is often tolerated better by older adult patients, plus a review found that it can be successful in maintaining BMD

This is all so fascinating! So how can physical therapy help?

A physical therapist (PT) can help make an individualized exercise program for you. This will take into account the location(s) in which you have OP, and any associated muscle weaknesses or tightness that need to be addressed. Plus, a PT can also help you “dose” your exercise appropriately - finding that “just right” amount between too little and too much. And then of course, your PT can also give you exercises to either relieve any current pain that you have, or prevent you from developing pain later on!

References:

Dressendorfer, R, BscPT, PhD, and A, MPT Callanen. “Osteoporosis and Exercise.” CINAHL Rehabilitation Guide, edited by DhSc, MSPT, PT Richman S, Aug. 2021. EBSCOhost, https://search.ebscohost.com/login.aspx?direct=true&db=rrc&AN=T709163&site=eds-live

National Institutes of Health (NIH) page on osteoporosis diagnosis, treatment, and steps to take: https://www.niams.nih.gov/health-topics/osteoporosis/diagnosis-treatment-and-steps-to-take

Osteoporosis Part 1: What is it, and who is at risk?

Wed, 23 Jun 2021 22:56:39 GMT

Osteoporosis Part 1:

What is it, and who is at risk?

We have all heard of osteoporosis, probably especially as it relates to older people with vulvas. But what is it exactly, and who gets this disease? We dig down into the details to help you understand what osteoporosis is, and who is more likely to have it. Then check out my next article for more information on how to build stronger bones through exercise!

What exactly is osteoporosis?

“ Osteoporosis (OP) is a systemic skeletal disease indicated by very low bone mineral density (BMD), which is generally defined as values 2.5 standard deviations or more below the average BMD for young adults.” (Dressendorfer 2021)

That's a mouthful! Basically, OP means that you have less density in your bones, and to get a clinical diagnosis of course we had to put a cut-off limit as compared to "normal." So the values this definition is referencing are the values that you would get if you had a DEXA screening.

Who does OP affect?

OP mostly affects postmenopausal people with vulvas over the age of 50. And it affects 54 MILLION adults in the US over the age of 50, and in the E.U. it affects 22 million people with vulvas and 5.5 million people with penises! And, the WHO has identified OP as one of the 10 most important conditions affecting the entire human race. Plus, "OP is a 'silent' risk factor for fragility fractures (i.e., fracture with minimal trauma). Fractures of the hip, spine, or wrist are common in persons with OP, especially postmenopausal women and adults older than 65." (Dressendorfer 2021).

That’s so many people! So who is at greater risk for OP?

There are many risk factors that can lead to the development of OP. Dressendorfer 2021 had a great summary, found below:

Premenopausal osteopenia (T-score for BMD of –1.0 to –2.5)
Sex: Females > males
Race: Whites and Asians are at higher risk
Older age (≥65 years-old)
Small frame, very low BMI
Loss of body height (more than 1.5 inches or 3.81cm)
Previous fracture: Having one fracture doubles the risk of having another
Genetics
Activity level: Insufficient weight-bearing (WB) exercise and excessive exercise training without adequate nutrition
Medications associated with bone loss
Premature menopause (before age 45 years) increases risk
Poor dietary habits associated with increased risk
Medical conditions that promote bone loss
Modifiable lifestyle factors that increase risk, like tobacco use, 3 or more alcoholic drinks per day, and prolonged sedentary behavior

Oh wow. So if I have some of those risk factors, what can I do about it?

There are many medications of course to help with OP, but that is outside of my scope of practice. So I will mostly focus on physical activity from here on out. Namely, it’s important that any exercise interventions for OP are prescribed appropriately, and are completed under the guidance of a physical therapist or personal trainer. But, we know that there are NO exercises so far that have been shown to be harmful to anyone with OP! Even high-intensity exercise can be safe for postmenopausal people with vulvas, when it is appropriately recommended.

That’s so cool! So what types of exercise are best?

This is such a BIG topic that we had to split it up into two articles! So please check my next article titled “Osteoporosis Part 2: How to build stronger bones through exercise” for more information!

Reference: