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Body Changes in Pre- vs. Peri- vs. Post-menopause

Tue, 20 Oct 2026 16:31:52 GMT

Body Changes in Pre- vs. Peri- vs. Post-menopause

Content warning: Please be aware that we are talking about many body changes associated with perimenopause, including changes in body composition and fat distribution. Just a reminder that these changes & words are not "good" or "bad," and we want to avoid putting emotional attachment onto them as much as we can. But of course, learning how this time of life can affect your body is critically important to your health and sense of well-being! So please know this article contains some discussion of adipose tissue and calories, but not in a good or bad way, just as a way of discussing body changes.

Perimenopause brings about so many changes for any body with a vulva. Included in these changes are more shifts in how our bodies look and feel, very similar to what we experienced in puberty. The good news is that now that we are older, we are hopefully more prepared for these changes. And, it’s helpful to know that it’s not our fault if our bodies start to look and feel different in midlife!

There was a small, but excellent, study published in 2022 that investigated changes in body composition during midlife. This study divided 72 people with vulvas into 3 groups based on their ages and menstrual status:

Pre-menopausal (PRE): at least 35 y/o with regular periods
Peri-menopausal (PERI): at least 38 y/o with irregular periods (but no more than 12 months in-between cycles. REMEMBER - if you go 12 months without a cycle, then you are officially in menopause! )
Post-menopausal (POST): no periods for at least 12 months, none in the study were over age 60

The authors then looked at many differences between these groups, including:

body composition
adipose tissue distribution (basically, where our bodies store fat)
resting energy expenditure (how many calories your body burns at rest)
oxidation of adipose tissue during moderate-intensity exercise (how much we “burn” fat during moderate-intensity exercise)
menopause symptoms
lifestyle factors

The results? The authors found significant variances in the perimenopause time specifically that stabilized after menopause. Specifically, the perimenopause time was found to have the following as compared to both PRE and POST groups:

changes in body composition DESPITE having similar height, weight, BMI measurements, and even dietary intake (specifically - higher percent body fat)
greater adipose tissue deposits in the abdominal region (16% higher than PRE and 5% higher than POST)

After menopause, the following was found as compared to pre-menopause:

A significant drop in resting metabolic rate (fewer calories burned at rest)
A 31% decrease in oxidation rate of adipose tissue during moderate-intensity exercise (not burning as much fat for the same intensity of exercise)
A 7% decrease in estrogen (estradiol) levels. However, there was a 23% decrease as compared to perimenopause! This is a direct reflection of how much hormonal variance we experience during the PERI time.

Image credit: https://www.loyolamedicine.org/about-us/blog/menopause-facts-and-tips-to-help-you-through-it

So what's a person with a vulva to do?? The authors summarize their findings as such:

"Altogether, shifts in body composition and metabolism appear to peak during perimenopause and stabilize in post-menopause. This data highlights perimenopause as a critical window for interventions to prevent detrimental changes in body composition and metabolic health."

My BIG takeaway from this article is that the perimenopause time is a particularly volatile one, that will bring about body composition changes that have little to do with how much someone eats or exercises. So, being kinder to our own bodies during this time is important, as well as knowing that these changes DO level out after menopause. But, that perimenopause is a great time to start or continue a good exercise habit!

P.S.: The authors also recommended that post-menopausal women focus on exercises to build lean muscle mass (like resistance exercise), and exercises that would improve their oxidation of adipose tissue (like moderate- and high-intensity exercises). Sound like an exercise program we all know and love??? ��

Your pelvic health can change with hormones, too. Need support?

Pelvic Love Physio PTs are your local experts in all problems related to the pelvic floor! Please call or text us today at 309-431-1357 and we will be happy to answer all of your questions.

Reference:

Gould, L. M., Gordon, A. N., Cabre, H. E., Hoyle, A. T., Ryan, E. D., Hackney, A. C., & Smith-Ryan, A. E. (2022). Metabolic effects of menopause: a cross-sectional characterization of body composition and exercise metabolism. Menopause (New York, N.Y.), 29(4), 377–389. https://doi.org/10.1097/GME.0000000000001932

Perimenopause and Menopause 101

Wed, 14 Oct 2026 15:48:44 GMT

Perimenopause and Menopause 101

It's coming for anyone with a uterus! This midlife transition will affect all of us in various ways. Some will have a very long, very difficult transition; some won't hardly even notice it's happening; others will be forced into menopause via surgery or other medical treatments for various reasons. And, there is a LOT of misinformation out there regarding symptoms, treatment, and what to expect. Here's a primer on the basics, including how to best help yourself through the transition!

Menopause Definitions

What exactly is menopause?

The definition of menopause is simply that you have gone 12 consecutive months without any menstrual bleeding. That's it! So if you make it 11 months without a period, but then have 2-3 days of bleeding, your 12-month clock resets again. The average age this occurs to someone with a vulva is around 51 years.

What about perimenopause?

This is a very gray area. Technically it begins with "variability in the length of the menstrual cycle," and then ends 12 months after the last period (Lambrinoudaki 2022). So, not exactly helpful for anyone who already has an irregular cycle, or who is taking birth control or has an IUD, etc.

However, some definitions will place the start of perimenopause as whenever you experience a greater than 7-day change in the length of your cycles for two consecutive periods (Santoro 2020). For many people though, especially if they are not tracking their cycles closely, this will first show up as a missed period.

Of course, there are MANY other causes of missed periods that need to be considered, especially if you are less than 45 years old. These can range from thyroid dysfunction to polycystic ovarian syndrome (PCOS) to other hormonal disorders. Please talk to your doctor if this applies to you!

What about induced or surgical menopause?

Menopause can also come VERY quickly for some of us for various medical reasons. Typically this is either due to surgical removal of the ovaries (+/- the uterus) for various reasons, or chemotherapy/radiation for cancer. Unfortunately this is such an abrupt change for the body, that the consequences can feel more severe in the body and have longer-term implications than spontaneous menopause. Due to the depth and breadth of this topic I won't be able to discuss it in detail here. Hopefully if this has happened to you, you already have a close relationship with your doctor who is helping you manage this very abrupt hormonal change! And, the majority of the recommendations and information in this article will still apply to you.

Perimenopause

How do I know if perimenopause has started?

See above about the "definition" of perimenopause based on your menstrual cycles. If you aren't sure, you can also have some hormonal testing done. Especially if you are between the ages of 40-45 and you start noticing changes in your cycle, or feel like you are having perimenopausal symptoms, you can have your follicle stimulating hormone (FSH) levels checked. This typically isn't indicated if you are over 45, as we can assume you have begun the transition into menopause by then. Additionally, hormonal levels vary so wildly during perimenopause, that you need to remember your levels on any given day or just a snapshot in time. They are not necessarily good predictors of your overall hormonal trend.

If you are under 40 and feel like you are already experiencing the menopause transition, then you definitely need to talk to your doctor. You will want to be assessed for something called primary ovarian insufficiency (POI), which only affects 1% of people with vulvas of reproductive age. But if this happens to you, then you definitely need prompt diagnosis and medical management to help your body thrive into your later years!

How long does perimenopause last?

On average, this transition lasts between 4-8 years for most of us (NAMS).

What do perimenopausal symptoms feel like?

Of course I am sure you have heard a WIDE variety of symptoms that can be attributed to menopause. This is because we have estrogen receptors in so many areas of the body, and so many types of body tissues, that it affects almost all of your body systems. The most common symptoms to watch out for include:

-Vasomotor symptoms. These include hot flashes and sleep disturbances. This can lead to fatigue, insomnia, and irritability. The underlying reason for these symptoms is mostly rapid constriction and dilation of the blood vessels in response to the changes in hormone levels. Typically hot flashes start in perimenopause and can last 4-5 years after you are officially in menopause. And, one important thing to note, is that the severity of these symptoms is correlated with increased risk for heart disease and diabetes.

-Sleep problems. These can occur as a result of hot flashes/night sweats, but also independently of them, again due to hormonal fluctuations.

-Cognitive dysfunctions and mood disorders. You may notice your memory isn't what it used to be, poor concentration, or difficulty multitasking. This can also correspond with feelings of anxiety & depression, mood swings, and irritability.

-Genital changes. This is commonly termed "genitourinary syndrome of menopause," or GSM. This is a HUGE topic, but I will touch on the basics here. Basically, this means you may have a wide range of symptoms affecting the vagina, vulva, urethra, and/or bladder due to the decrease in estrogen. These symptoms can include irritation, dryness, burning, urinary frequency and urgency, recurrent urinary tract infections (UTIs), and pain and dryness during vaginal intercourse. Typically, these symptoms don't arise until you are later in perimenopause, but of course can start to show up earlier as well. The REALLY important thing to know is that these symptoms can be very easily treated with a topical estrogen cream. So little of this estrogen gets absorbed that it doesn't affect the rest of your body in a major way, or in the long-term. So if this is occurring to you, PLEASE talk to your doctor about topical estrogen! Most of the time, this is even safe to use in the setting of other medical conditions such as breast cancer.

Menopause

When do I need to worry about osteoporosis?

This is of course a big concern after you reach menopause, and even in perimenopausal times. You reach peak bone mass around age 30, and then see a progressive decline in bone mass at a rate of about 0.7%/year thereafter. In the year leading up to your final menstrual period, this bone loss dramatically rises. Up to the first 3 years of menopause, this bone loss is occurring at a rate of 5% per year. After 3 years, the rate of bone loss declines, gradually slowing to reach its pre-menopausal rate. Typically, you aren't recommended to start regular DEXA screenings for bone mineral density until after age 65, although of course you may need to start earlier depending upon your other health conditions or risk factors.

What about heart disease?

Heart disease is the dark horse of menopause that most people don't give enough consideration. Cardiovascular disease is the number one killer of people with vulvas in North America. And, after age 55, more than half of all deaths of people with vulvas are secondary to cardiovascular disease. You are at a higher risk for cardiovascular problems after menopause depending upon your smoking status, history of diabetes mellitus, blood pressure and levels of cholesterol.

Treatment

I have to admit, this is all very depressing. What can I do about any of it?

Good news! There is actually a lot you can do to decrease the severity of perimenopausal and menopausal symptoms. Just like in pregnancy, this life transition doesn't mean you are doomed to be miserable and "just have to deal with it." We'll touch briefly on medications, and then move quickly onto what is MOST in our control: exercise & movement.

How does hormone therapy help?

For many people, hormone therapy (HT) is a really great option! This is especially true if it is initiated less than 10 years after the onset of menopause, or before you are 60. It helps with so many symptoms:

-vasomotor symptoms, like hot flashes & night sweats

-genital changes, like vulvar atrophy and dryness

-prevents bone loss and osteoporotic fractures

-improves mood and wellbeing

-reduces risk of new-onset diabetes

-may reduce risk of cardiovascular disease (if initiated early after the menopause transition)

-may prevent cognitive decline (if initiated early after the menopause transition)

Is hormone therapy really safe? What about breast cancer risk?

Unfortunately, there is so much misinformation out there related to a very flawed study performed around 2002. This has caused a large number of people to suffer unnecessarily with menopausal symptoms due to misunderstanding of and misreporting on those study results. Here are the actual risks of HT that have been well-proven over time:

-the risk of breast cancer with HT is very small, and decreases after treatment is stopped. It is most prevalent in people taking estrogen AND progesterone, and is associated with longer duration of HT.
-oral HT, but not HT delivered via a skin patch, is associated with an increased risk of blood clots
-HT may cause a small increase in risk of stroke, more commonly with an oral vs skin patch route
-HT started after 60 years of age, or >10 years after menopause, does not have cardiovascular benefits, but also does not cause harm
-HT may increase the risk of dementia if started after age 65

What about non-hormonal treatments?

There are MANY other types of non-hormonal medications that can help with menopause symptoms if you wish to (or need to) stay away from hormone therapy. Some options include various types of antidepressants (SSRIs), gabapentin, clonidine, and oxybutinin. And there is certainly a lot of evidence (although not as good as HT) for complimentary/alternative therapies like phytoestrogens, yoga, acupuncture, mindfulness-based stress reduction, cognitive behavioral therapy, etc.

EXERCISE

I know that exercise can help, but what types of exercise are best?

The answer is yes, yes, and yes. Almost all kinds of exercise help! In fact, one article had this to say about exercise: "Physical exercise is the most powerful non-pharmaceutical fracture prevention strategy in postmenopausal women." (Shojaa 2020)

When we are talking about fracture risk specifically and improving bone mineral density, most of us have heard that resistance training is really important. Basically this would be any exercises that include joint movement that increase muscular strength. This can include lifting weights, using resistance bands, or any type of heavy object. However, it also includes body-weight exercises like squats, planks, or even walking. (I will mention though that walking-only programs don't seem to be sufficient to improve bone mass in your lower back, specifically.)

The most important aspect of exercise to improve bone density is that it needs to either be using equipment to provide the resistance, or it needs to be "closed-chain" for the body. Meaning, you are either standing up (feet on ground providing resistance/force), or your arms are pushing against the ground or a wall, etc to provide the resistance. So, that means exercises like swimming and biking don't "count" for bone density. They are great though for other types of menopause symptoms!

How much do I need to exercise?

To improve bone density in particular , the answer might surprise you! One systematic review and meta-analysis of 17 articles found that less is more when it comes to resistance training and improving bone density, specifically. They found that <2 sessions of resistance training per week actually produced superior results to 2 sessions or more per week! And, they found that doing resistance training with free weights was superior to using any type of "device." So basically - less is more, and you don't need any fancy equipment!

Does exercise help other menopause symptoms?

Yes! Exercise has been shown to help with hot flashes in particular. This is true for both resistance training and exercise such as yoga. And, yoga has been shown to improve overall quality of life during menopause in particular.

So, throw in some resistance training 1x/week if you aren't already, and consider adding in other types of exercise to help with menopause symptoms if you have time! And know you aren't going it alone - please talk with your doctor if you feel medication, especially hormone therapy, can help you feel better. ❤️

Navigating pelvic health changes during perimenopause or menopause? We can help.

Pelvic Love Physio PTs are your local experts in all problems related to the pelvic floor! Please call or text us today at 309-431-1357 and we will be happy to answer all of your questions.

References:

Flores, V. A., Pal, L., & Manson, J. E. (2021). Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment. Endocrine reviews , 42 (6), 720–752. https://doi.org/10.1210/endrev/bnab011

Kingsberg, S. A., Larkin, L. C., & Liu, J. H. (2020). Clinical Effects of Early or Surgical Menopause. Obstetrics and gynecology , 135 (4), 853–868. https://doi.org/10.1097/AOG.0000000000003729

Lambrinoudaki, I., Armeni, E., Goulis, D., Bretz, S., Ceausu, I., Durmusoglu, F., Erkkola, R., Fistonic, I., Gambacciani, M., Geukes, M., Hamoda, H., Hartley, C., Hirschberg, A. L., Meczekalski, B., Mendoza, N., Mueck, A., Smetnik, A., Stute, P., van Trotsenburg, M., & Rees, M. (2022). Menopause, wellbeing and health: A care pathway from the European Menopause and Andropause Society. Maturitas , 163 , 1–14. https://doi.org/10.1016/j.maturitas.2022.04.008

Nguyen, T. M., Do, T. T. T., Tran, T. N., & Kim, J. H. (2020). Exercise and Quality of Life in Women with Menopausal Symptoms: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. International journal of environmental research and public health , 17 (19), 7049. https://doi.org/10.3390/ijerph17197049

North American Menopause Society (NAMS): https://www.menopause.org/

Santoro, N., Roeca, C., Peters, B. A., & Neal-Perry, G. (2021). The Menopause Transition: Signs, Symptoms, and Management Options. The Journal of clinical endocrinology and metabolism , 106 (1), 1–15. https://doi.org/10.1210/clinem/dgaa764

Shojaa, M., von Stengel, S., Kohl, M., Schoene, D., & Kemmler, W. (2020). Effects of dynamic resistance exercise on bone mineral density in postmenopausal women: a systematic review and meta-analysis with special emphasis on exercise parameters. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA , 31 (8), 1427–1444. https://doi.org/10.1007/s00198-020-05441-w

Stool Leakage after Childbirth

Tue, 29 Sep 2026 21:41:53 GMT

Stool Leakage after Childbirth

By Stephanie Dillon, PT, DPT, WCS

Stool leakage, aka fecal incontinence, is one of the most distressing problems that a person who births a child can experience in my opinion. More than urine leakage, it can lead to increased embarrassment, shame, and even isolation as people are fearful to go out in the community. So, read on to see why this typically occurs, and what you can do about it.

What is fecal incontinence (FI)?

Similar to urinary incontinence, fecal incontinence is ANY unwanted passage of stool. This can be as small as a tiny bit of smearing in your underwear, to losing fully-formed stool. You can also be incontinent of gas (sometimes called flatal incontinence), where you lose gas when not expecting it.

Just a note about terminology here; sometimes FI is also referred to as AI (anal incontinence), or even ABL (accidental bowel leakage). While there can be very small differences in the medical literature on what these terms mean exactly, for the purposes of this article I'm just placing everything into one category - FI.

Why does FI happen?

There can be many reasons why someone may develop FI. It does happen in elderly people for a variety of reasons, but for the purposes of this article we'll be focusing on postpartum FI.

Postpartum FI almost always occurs from what is known as "obstetric anal sphincter injury," which is a mouthful! This is frequently referred to as OASI or sometimes OASIS (for injurieS). Basically all this means is that you had a birth-related tear in your anal sphincter, which is a series of concentric circular muscles that control the opening of the anus. As you can imagine, this tear creates weakness in the anal sphincter, and affects the ability of your sphincter to keep your rectum closed. So, stool and gas can then leak out when you don't want it to.

FI affects anywhere from 4-40% of people who give birth, but if you have an OASI, this more than doubles your risk of FI (increases risk by 2.66x).

Why does OASI occur?

There are many reasons why someone may tear through their anal sphincter during a vaginal childbirth. Typically it is either from natural tearing, or due to further tearing after an episiotomy. There are different grades of tearing as you may or may not be familiar with, so let's do a quick review.

Grade 1: tearing into the perineal skin but not into the perineal muscles. The perineum is the area between the vagina and anus.
Grade 2: tearing into the perineal muscles (halfway from vagina to anus), but not into the anal sphincter
Grade 3: tearing INTO but not fully THROUGH the anal sphincter. These can also be divided into 3a, 3b, and 3c depending upon whether or not the internal anal sphincter is torn, in addition to the external anal sphincter.
Grade 4: tearing through the anal sphincter into the rectum (the internal and external anal sphincters are fully torn)

So of course as you can imagine, people with grade 3 and 4 tears, or an OASI, are at the greatest risk for fecal incontinence.

How common is OASI?

This is where the data gets a little sticky. The average rate reported of OASI is pretty low, around 3.5% of all vaginal childbirths. However, some studies put the rate as high as 11%. And as you might imagine, the rates vary based on how much training the physician has had to recognize these types of injuries. Plus, really the bigger problem here is that many times OASI is not diagnosed at the time of birth (or under-diagnosed, meaning a grade 3 tear is actually a grade 4). As a result, estimates on the actual rate of OASI can be as high as 26%. This is something we'll talk about a bit later: how to diagnose this type of birth injury, and why it can be difficult to do at the time of delivery.

And, of course this rate can vary based on where you live. In the UK for example, there was a threefold increase in the incidence of OASI between 2000 and 2011. This meant 1 in 16 of first-time birthing persons were getting diagnosed with an OASI. Of course that was unacceptable, and so the UK did implement a nationwide strategy to decrease the risk of OASI, which we will talk about later.

What are risk factors for OASI?

There are many pretty well-established risk factors, including:

vaginal delivery using forceps or vacuum --> this is clearly the strongest risk factor across many studies over many years
first pregnancy
larger birthweight baby (over 8lbs has a slightly increased risk, over 9lbs a definite risk) & babies with larger heads
episiotomy, especially midline (straight down towards the anus) as opposed to mediolateral (on an angle more towards the thigh)
slight trend towards older age at delivery, especially 34-39 years
vaginal delivery after cesarean birth (VBAC)
procedures used to start/speed-up labor, such as amniotomy (breaking of water), and the use of oxytocin
longer duration of first stage of labor (contractions) and second stage of labor (pushing)

How is OASI diagnosed after labor?

Most of the time, this is accomplished through careful inspection of the perineum, vagina, and anus after delivery. In order for a thorough examination to take place, you need adequate lighting, exposure of the area, and pain relief for the birthing person. If there is any suspicion of an OASI (grade 3 or 4 tear), then a rectal examination should be performed to rule this in or out.

However, there is now some evidence to show that adding an ultrasound to this assessment can show an incidence of missed OASI by anywhere from 12-35%. Most commonly this type of ultrasound is either done essentially "through" (as in, on top of) the labia, called translabial ultrasound, or inside the vagina - transvaginal.

However, the gold standard for diagnosing a grade 3 or 4 tear is something called an endoanal ultrasound, where the probe is placed inside the anus. Despite sounding a little scary or uncomfortable (I'm sure it is uncomfortable to some extent!), this is usually well-tolerated, and gives us the best picture of what is going on with the anal sphincter. However, a recent 2023 study of 680 subjects who received an endoanal ultrasound immediately after birth in the delivery ward shows that it did NOT improve the ability to diagnose an OASI. The study's authors guessed this was mostly due to staff inexperience with using this type of ultrasound, as they were all performed by midwives. So, this may not be useful in maternity wards, but as I said after the fact it is the gold standard to diagnose OASI.

What can we do to prevent OASI during labor?

This is a little less-researched than the diagnosis of and risk factors for OASI. But, a summary of the American College of Obstetricians and Gynecologists (ACOG), plus the Society of Obstetricians and Gynaecologists of Canada (SOGC), recommendations on preventing OASI are below:

place a warm compress on the perineum during the pushing phase of labor
slow down the delivery of the baby's head, and instruct the birthing person not to "push" during the delivery of the head (relying upon uterine contractions alone)
perineal massage during the pushing phase of labor
avoid the routine use of episiotomy (hopefully no OBGYNs are doing this anymore!)
if episiotomy is needed, then use a mediolateral incision instead of midline
if assistance for delivery is needed (i.e. baby is in distress), choose vacuum over forceps

There is limited evidence to show that upright birthing positions (e.g. squatting, kneeling, hands-and-knees) vs. supine birthing positions (laying on your back) has a reduced risk of severe tearing. However, this evidence wasn't sufficient enough to make it into the American or Canadian guidelines for labor.

In the UK, as I referenced earlier, a nationwide program was implemented to reduce the rates of OASI. They were able to drop their OASI rates by 20% in just a 2-year period by implementing some of these techniques. They had a four-step program that included:

Counseling all prenatal birthing people on OASI risks starting at 32 weeks
Manual perineal protection with the doctor or midwife's hand directly on the baby's head and birthing person's perineum during delivery
Restricted use of episiotomy (and if needed a 60-degree mediolateral episiotomy was completed)
A vaginal AND rectal examination immediately after delivery to assess the extent of any tearing

If I end up an OASI, how is it best treated?

OASI injuries require a surgical repair. Most commonly, this is done by the OBGYN in the delivery ward. However, there has been more scrutiny of this in recent years, identifying that some surgeons are better-suited to repair these types of tears than others. A recent (small) 2023 study that specifically examined the skill of the surgeon found that only 4% of OASI repairs done by a skilled surgeon reported pelvic floor dysfunction after surgery, while a whopping 82% of those who had a less-skilled surgeon reported pelvic floor dysfunction post-operatively.

Minimally, you need good lighting and someone skilled in repairing the anal sphincter. A delivery ward is not the same as an operating theater, and yet most of the time these repairs are done in the delivery room, likely due to cost and accessibility of operating rooms at the time of birth. In many larger hospitals, a more-skilled GYN will be called in to repair the OASI, or they may even delay the repair until a urogynecologist or colorectal surgeon is available. You can delay these surgeries for 8-12 hours after birth without any negative consequences.

Many international governing bodies of women's health are now recognizing the repair of an OASI does really require extra training of whomever is repairing it. In my opinion they absolutely should not be done by GYN residents, plus they are definitely out of the scope of practice for midwives. Most of the guidance provided by these organizations are calling for more training in the surgeons who are performing OASI repairs, but stop short of recommending they are all done by a urogynecologist or colorectal surgeon. But if you have that option, definitely take it! And/or at least request a highly-trained GYN who has done many of these repairs to fix your OASI.

Yikes, if I had a 3rd or 4th-degree tear repaired by my GYN, should I be concerned?

Not necessarily. It really depends upon the skill of your GYN, and then whether or not you are having symptoms after surgery. And please don't misunderstand me - I am not trying to throw your (or any!) GYN under the bus here! It's just that GYNs have to wear so many hats, from well-woman care, to abdominal surgeries for things like endometriosis, to caring for a pregnancy and knowing how to delivery a baby vaginally or via C-section, to hormone replacement and care into menopause, etc. It makes sense that something as delicate as the anal sphincter may require more training & skill that some GYNs may possess.

So, basically, if you had a 3rd or 4th-degree tear (an OASI), and you are still struggling with stool leakage after 6 weeks postpartum, I would highly recommend you see a colorectal surgeon . They can do an endoanal ultrasound to determine the severity of your tear and the quality of the repair, and then see if a revision is warranted (basically if another surgery is needed).

If I had an OASI should I go to pelvic floor PT? Even if I am not having FI?

In a word, YES!! Pelvic floor PT can be incredibly effective for recovery from OASI in MANY areas of life, not just FI. I haven't discussed it much here, but OASI is also associated with issues like painful sex and even urinary incontinence too. Not to mention pelvic floor weakness since so much of the pelvic floor is torn with 3rd and 4th-degree tears. And, studies are showing that earlier referral to pelvic floor PT is better than later, even as early as 2.5 weeks postpartum.

Once your wound has healed and you no longer have stitches, also please perform perineal scar massage . It can go a long way in restoring both the strength of your pelvic floor, and in healing issues like painful sex.

So, if you had a 3rd or 4th-degree tear, or your friend did, PLEASE consider pelvic floor PT. It can spare you so much distress and additional symptoms as you age!

What if I am experiencing fecal incontinence that started after a vaginal childbirth, but I didn't have an OASI?

I would still recommend you see a colorectal surgeon, just to have the specialized endoanal ultrasound to rule out any undiagnosed tears. One small 2019 study found that you are more likely to have a missed OASI if you had a delivery with forceps or vacuum, an episiotomy, and an epidural. And that these people with missed OASI had both fecal and urinary symptoms, some that didn't show up until YEARS after delivery. These ranged from fecal incontinence (remember this can be anything from the loss of solid stool, to liquid stool, to just staining in your underwear), flatal incontinence (unable to control the passage of gas), fecal urgency (you know you need to have a BM and have to go RIGHT NOW), and even urinary incontinence.

What if I have fecal incontinence that is unrelated to childbirth?

If you have ever delivered a child vaginally, then I would still recommend you see a colorectal surgeon first before we assume that your anatomy is intact. Otherwise you may be chasing symptoms and treatments that won't help, since your anal sphincter may not be working properly!

If you only had C-sections or have not had children, then it's best to start with your PCP and/or a gastroentereologist (GI specialist). Of course, there are many non-pelvic floor reasons for FI! And some of these are something as "simple" as a GI bug that will resolve with antibiotics, or testing for food allergies. Or sometimes diseases such as Crohn's and ulcerative colitis can cause both fecal urgency and FI, so it can be good to see a GI specialist to rule these things out.

If you've had all of the above ruled out, then definitely get yourself to a pelvic floor PT ! Pelvic floor weakness can contribute to FI as well as anal sphincter weakness. A pelvic floor PT can also help you examine your bathroom habits, diet, and lots of other things that may be contributing to FI. Pelvic floor PTs can also help you figure out your diet, including increasing fiber to help bulk your stool, but seeing a dietitian can also help with diet-related FI.

If I had a vaginal delivery and ended up with an OASI, should I opt for a C-section next time?

This is a tricky subject, and definitely worth a detailed discussion with your OBGYN. The risk of a repeat OASIS with a subsequent vaginal delivery ranges from 3-10%, depending upon which studies you read. Whereas the risk of an OASI in a second delivery when there was not a OASI during the first delivery is only about 0.6-3.2%. So your risk is elevated, BUT, you also have to consider the risks of having a C-section . These include things like surgical injury to your uterus, bowels, and bladder; uterine infection; blood clots; and increased blood loss.

ACOG recommends you consider a C-section in subsequent pregnancies if you:

experienced fecal incontinence after your OASI repair
had complications such as wound infection, or a need for a repeat surgical repair
experienced psychological trauma as a result of the tear & repair, and would prefer a C-section the second time around

Changes in bowel control after childbirth? You’re not alone—and support is available.

Pelvic Love Physio PTs are your local experts in all problems related to the pelvic floor! Please call or text us today at 309-431-1357 and we will be happy to answer all of your questions.

References (many are open access!):

André, K., Stuart, A., & Källén, K. (2022). Obstetric anal sphincter injuries-Maternal, fetal and sociodemographic risk factors: A retrospective register-based study. Acta obstetricia et gynecologica Scandinavica , 101 (11), 1262–1268. https://doi.org/10.1111/aogs.14425

Committee on Practice Bulletins-Obstetrics (2018). ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstetrics and gynecology , 132 (3), e87–e102. https://doi.org/10.1097/AOG.0000000000002841

Harvey, M. A., Pierce, M., Alter, J. E., Chou, Q., Diamond, P., Epp, A., Geoffrion, R., Harvey, M. A., Larochelle, A., Maslow, K., Neustaedter, G., Pascali, D., Pierce, M., Schulz, J., Wilkie, D., Sultan, A., Thakar, R., & Society of Obstetricians and Gynaecologists of Canada (2015). Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair. Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC , 37 (12), 1131–1148. https://doi.org/10.1016/s1701-2163(16)30081-0

Huber, M., Larsson, C., Harrysson, M., Strigård, K., Lehmann, J. P., Nordin, P., & Tunón, K. (2023). Use of endoanal ultrasound in detecting obstetric anal sphincter injury immediately after birth. Acta obstetricia et gynecologica Scandinavica , 102 (3), 389–395. https://doi.org/10.1111/aogs.14514

Jordan, P. A., Naidu, M., Thakar, R., & Sultan, A. H. (2018). Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury. International urogynecology journal , 29 (11), 1579–1588. https://doi.org/10.1007/s00192-018-3601-y

Jurczuk, M., Bidwell, P., Gurol-Urganci, I., van der Meulen, J., Sevdalis, N., Silverton, L., & Thakar, R. (2021). The OASI care bundle quality improvement project: lessons learned and future direction. International urogynecology journal , 32 (7), 1989–1995. https://doi.org/10.1007/s00192-021-04786-y

Klokk, R., Bakken, K. S., Markestad, T., & Holten-Andersen, M. N. (2022). Modifiable and non-modifiable risk factors for obstetric anal sphincter injury in a Norwegian Region: a case-control study. BMC pregnancy and childbirth , 22 (1), 277. https://doi.org/10.1186/s12884-022-04621-2

Lua-Mailland, L. L., Yao, M., Wallace, S. L., & Propst, K. (2023). The Impact of Pelvic Floor Physical Therapy on Bladder and Bowel Function After Obstetric Anal Sphincter Injury. Urogynecology (Philadelphia, Pa.) , 29 (2), 234–243. https://doi.org/10.1097/SPV.0000000000001286

Marcellier, G., Dupont, A., Bourgeois-Moine, A., Le Tohic, A., De Carne-Carnavalet, C., Poujade, O., Girard, G., Benbara, A., Mandelbrot, L., & Abramowitz, L. (2023). Risk Factors for Anal Continence Impairment Following a Second Delivery after a First Traumatic Delivery: A Prospective Cohort Study. Journal of clinical medicine , 12 (4), 1531. https://doi.org/10.3390/jcm12041531

Serati, M., Ruffolo, A. F., Scancarello, C., Braga, A., Salvatore, S., & Ghezzi, F. (2023). When does oasis cause de novo pelvic floor dysfunction? role of the surgeon's skills. International urogynecology journal , 34 (2), 493–498. https://doi.org/10.1007/s00192-022-05205-6

Constipation During Pregnancy and Postpartum

Wed, 23 Sep 2026 14:48:26 GMT

Constipation During Pregnancy and Postpartum

Constipation especially during pregnancy can be such a huge problem. You already feel a lot of pressure, bloating, etc. in your stomach - and now you have a hard time pooping on top of it! Read on to find out why that happens, and what you can do about it.

What's the deal with constipation during pregnancy?

Constipation during pregnancy is SO common. In fact, it's the second-most common gastrointestinal disorder during pregnancy behind nausea and vomiting. 11-40% of pregnant people are constipated according to the official diagnostic criteria I outlined in previous articles. Most of the time, studies report a constipation rate of 30-40% as being most common. But if you ask pregnant people to self-report symptoms, as many as 61% will say they feel constipated! And yet, despite its commonness, it's woefully under-studied and under-treated.

Why do people become constipated during pregnancy?

There are so many contributing factors to the slowing down of your bowels during pregnancy. I'll provide a laundry list here:

high progesterone (especially in the first trimester) slows down gut motility, e.g. the ability of your colon to move your waste through your gut
relaxin slows small bowel contractions (peaks at end of first trimester but is present throughout pregnancy)
pressure of the pregnant uterus compresses/obstructs the colon in the third trimester
decreased physical activity because you feel crappy!
hormone changes cause increased water absorption in your colon, leading to hard, lumpy stools
medications, such as iron and some anti-nausea/vomiting meds have side effects of constipation
fluid loss from vomiting
maternal gut microbiome changes
reduced fiber and water intake (again, because you feel like crap, and/or have food aversions)
rectal pain from hemorrhoids or anal fissures (more on this later)

I will also add, although this isn't in the literature, that a growing belly means you can't use your abdominal muscles as effectively to push for your bowel movements (BMs) Plus, we know diastasis rectus abdominis (DRA) is a contributing factor to constipation, and 100% of pregnant people will have a DRA by week 35 of pregnancy.

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What are risk factors for constipation in pregnancy?

You are more likely to struggle with constipation while pregnant if any of the following applies to you:

decreased physical activity
being placed on bedrest
low fiber intake
decreased fluid intake
using iron supplements
pre-existing constipation
multiple pregnancies
previous C-section

Will my doctor order any tests to determine if I am constipated?

Most likely not. As with most other medical issues during pregnancy, we avoid putting a pregnant body through general medical testing as much as possible to avoid harm to the fetus. The only exception to this is bloodwork, as your doctor may want to check you for a low thyroid or diabetes. So, unless you have fecal impaction or have a severe obstruction of your colon, most of the time your doctor will just take your word for it that you are constipated.

What can I do about constipation in pregnancy?

First, the basics, as always! Make sure you are moving your body, getting plenty of fluid, and increase your fiber intake to higher than your typical levels. Of course, this all comes with the caveat that you are likely feeling crappy, so don’t push your body beyond its limits. Here are some basic recommendations:

drink at least 8 glasses of water/day
eat 25-40 grams of fiber/day
eat smaller, more-frequent meals in the second and third trimesters particularly

I will say though, at least one study does show that increasing fiber and fluid alone is not enough to reduce the symptoms of constipation during pregnancy. It is likely that the hormonal changes are so strong in the first and second trimesters in particular, that making changes to your diet isn’t enough to overcome the effects of these hormones. However, this same study did show that low fiber intake was linked to worse pregnancy outcomes. Specifically it was linked to C-section deliveries, prematurity, and/or fetal growth restriction. We do know that high fiber diets can reduce the risk of things such as high blood pressure and diabetes, which in a pregnant person can of course cause negative outcomes for the mom and fetus. So it is possible that eating a high fiber diet in pregnancy can have benefits beyond your bowels.

And, make sure you know how to sit on the toilet and “push” correctly for bowel movements. If not, please refresh yourself with my first constipation article! Small changes like a stool underneath your feet can make a big impact!

Plus, for most people, constipation is worst in the first and second trimesters. So one thing you can actually look forward to about your third trimester is possibly being less constipated!

If I’m good on fiber and fluid, what’s next?

As I said above, many times just upping fiber and water isn’t enough. The good news is that many of the same over-the-counter laxatives you can take when not pregnant are also safe for pregnancy. However, I will say that in general studies on supplements and medications in pregnancy are very sparse. The data that is there generally is of low quality with a high risk of bias. So, every person needs to talk to their OB/midwife, and weigh the benefits vs the risks of taking supplements or laxatives in their own bodies.

Here’s a run-down of some options:

Fiber supplements, aka bulk-forming laxatives: psyllium (Metamucil, or you can take this in pill form as psyllium husk), methylcellulose (Citracel), guar, calcium polycarbophil, pectin, and flax seed (ground or whole) are all generally safe and often effective in pregnancy. Fiber supplements do seem to be effective as compared to no intervention at increasing stool softness and frequency in pregnancy. However, stimulant laxatives are more effective than fiber supplements, but come with the risk of abdominal discomfort and diarrhea. And as always, if you are adding in fiber, do so slowly as too much in a short period of time can cause increased bloating and gas.
Osmotic laxatives: Polyethylene glycol (aka PEG or Miralax), lactulose, sorbitol, and glycerin are all options that are generally safe for pregnancy, as their mechanism of action is drawing more water into the colon. Osmotic laxatives are not well-absorbed by the intestine, so very little is absorbed into your bloodstream and thus not passed to the fetus. However, saline hyperosmotic laxatives are best to be avoided in pregnancy, as they can result in fluid retention.
Lubricants: the use of mineral oil and castor oil is best avoided in pregnancy as it can lead to reduced absorption of certain vitamins, and cause premature uterine contractions.
Stimulant laxatives: These can be a reasonable option if fiber and osmotic laxatives don’t do the trick. Senna and bisacodyl are the most common ones, and are minimally absorbed into your bloodstream. However, senna in particular has been linked to reports of fetal death at higher doses (4%) and has conflicting safety data. It also may cause an electrolyte imbalance if it ends up causing you diarrhea. And as I alluded to above, these work by causing intestinal cramping and so sometimes are not well-tolerated.
Stool softeners: Ducosate sodium, also known as Colace, is typically the first thing that is recommended by doctors for pregnant people. However, it’s well-known that ducosate sodium is found to be no better than placebo in very large, high-quality studies of the general population. So unfortunately, there really is no evidence to show that it works for anyone, regardless of pregnancy status. But since it’s generally well-tolerated without side effects, it is commonly recommended even though the evidence doesn’t support its use. I will say though, if you think it’s working for you, don’t stop it just because of this information! If you stop it and your constipation gets worse, definitely continue. But if you stop it and you don’t notice a change, you are best off trying something different.

What about postpartum constipation, and that typically-awful first bowel movement after delivery?

Ugh, that first BM after having a baby can be the. worst. This is regardless of delivery mode, because if you have a vaginal delivery (especially with tearing), the thought of pushing anything else out down there is terrifying! This is especially true if you are worried about tearing stitches. And for my C-section moms, your abdominal pain is so great that having to use those abdominals to push or create any force is pretty awful. Plus, pain makes your muscles tighten up, so even just trying to relax your pelvic floor to get your stool out is a tall ask.

The tough part about answering this question is that the evidence is VERY poor. A Cochrane review from 2020 only found 5 studies to review, and 4 of them were completed over 40 years ago. Which means also some of them studied supplements or drugs that we no longer think are safe for people who breast or chest feed. And the trials that were left are so small and the evidence so poor that really no great conclusions can be drawn from them.

I will say that especially for a vaginal delivery, if you try what is called “splinting” of your perineum , this may help. You take your fingers, or a wad of tissue paper, and push “upwards” slightly towards your head on your perineum (aka the area between your vagina and rectum). This can provide support to sore/lengthen/torn tissues, and give you some counterpressure to the “push” for the BM.

Additionally, the basics are KEY here. Lots of diaphragmatic breathing, relaxation, feet on a stool, and water/fiber to make your stool as soft as possible can be incredibly helpful.

Still have questions or need a little extra help with your bowel health?

Pelvic Love Physio PTs are your local experts in all problems related to the pelvic floor! Please call or text us today at 309-431-1357 and we will be happy to answer all of your questions.

References:

Nagaich, N., Sharma, R., & Nair, N. Gastrointestinal Diseases in Pregnancy; Diagnosis and Management. Gastro Med Res. 2(4). GMR.000544. 2019. DOI: 10.31031/GMR.2019.02.000544

Rao, S. S. C., Qureshi, W. A., Yan, Y., & Johnson, D. A. (2022). Constipation, Hemorrhoids, and Anorectal Disorders in Pregnancy. The American journal of gastroenterology , 117 (10S), 16–25. https://doi.org/10.14309/ajg.0000000000001962

Turawa, E. B., Musekiwa, A., & Rohwer, A. C. (2020). Interventions for preventing postpartum constipation. The Cochrane database of systematic reviews , 8 (8), CD011625. https://doi.org/10.1002/14651858.CD011625.pub3

Treatment of Functional Constipation

Wed, 16 Sep 2026 16:09:14 GMT

Treatment of Functional Constipation

Alright, let's dive into what is probably the biggest question about constipation - what can I do about it??

First of all, the basics. You NEED to make sure you are covering your bases with water and fiber before moving on to other types of treatments. I know, I know - especially if you have small people in your household who absolutely revolt at anything green, it can be hard to keep up your own fiber intake, or to be constantly making yourself additional/different food. But, if your fiber intake isn't great, then your success with any other type of treatment will be much poorer than it could have been otherwise! So, check out my first article on bowel function that covers these basics. I also have a little information on laxatives in my second article , which is likely the first thing your doctor will tell you to try. But, most laxatives are not meant for longer-term use. However, we do have pretty good evidence to show that polyethylene glycol (aka PEG or Miralax) is safe for up to 24 months of use. But, like I said in previous articles, I would MUCH rather that you get to the bottom of your constipation rather than take a laxative long-term! And, there are so many other options that also have really good evidence behind them that tend to get ignored, like PT.

Can I take fiber supplements to increase my fiber intake?

As always, before you decide to take any kind of supplement, it's best to talk to your doctor (or dietitian!) first.

You certainly can take a fiber supplement, but as with most supplements, it's always better to get what you need from actual food vs. taking a pill. Your body typically doesn't absorb or respond to something in a pill like it does in whole foods. And in the case of fiber, you may need to swallow A LOT of pills in order to boost your fiber intake significantly. This handout has great information on fiber in general (including a chart at the end about what you can eat for the most bang for your buck to increase your fiber), and does have a small part about fiber supplements as well.

I will say though, there is some good evidence that soluble fiber supplements (like psyllium husk) can help for both constipation and IBS, whereas insoluble fiber (like wheat germ) does not. However, we still don't have great long-term studies on this topic. And it's really important to note that any fiber supplement can initially increase gas and bloating, so fiber always needs to be started slowly! It's also important to note that fiber supplements can interfere with the absorption of certain medications, and so spacing them apart from your meds, plus drinking PLENTY of water with a fiber supplement, is really important. And also know that it might take a few weeks of regular fiber supplementation to notice an effect.

What about other supplements like probiotics, etc?

This gets into very sticky territory - again, it's recommended to consult your doctor. The best I can tell you is that so far, there isn't any great evidence that any one supplement besides fiber truly makes a difference for bowel dysfunction. And then of course, anything you put into your body can have side effects, especially if you are taking other prescription medications. A great summary can be found in this short slide presentation .

I will make a special note here though about magnesium, which does have some evidence behind it, and comes in many forms like the various Natural Calm powders. Magnesium is generally very safe, but can have side effects in certain settings as with kidney disease, so just make sure to talk to your doctor if this is something you are considering starting.

If I'm good on fiber and water, what's next?

Here's where I will admit I am 100% biased, but, I think everyone with functional constipation that is having trouble managing it on their own needs to see a pelvic floor physical therapist (PT)! We have SO many tricks up our sleeve that can be super helpful that are not medication-related. Give us a call at (309) 431-1357 today!

One note though is that if you do have slow transit constipation (refer back to my second article where I talk about this more ), then you likely will need some type of medication to help stimulate your colon to move your waste along. PT is most helpful for people with defecation disorders, but can still be somewhat helpful for slow transit too!

How can pelvic floor PT help with constipation?

There are SO many answers to this, but I will try to make it brief! First of all, we can help you figure out where your contributors to constipation may lie. Is it water, fiber, movement, how you are having your bowel movements, the timing of your meals, contribution from a DR or from pelvic floor dysfunction? Or any combo of those things! This is where PT can be really helpful, because we can look at the whole picture and make a lot of recommendations, vs. being stuck with "only" medication or surgical advice, for example.

So here's a few basic recommendations to tempt you into considering PT further :)

Don't hold your breath . Like, for real. I can't tell you how important it is that you are exhaling with the "push" for a bowel movement (BM)!! And, with this push your belly does need to slightly bulge outwards. You should not be pulling belly to spine when pushing for a BM! If you are a chronic breath-holder & abdominal-tightener, this can be really tricky to unlearn, but is absolutely vital. A PT can help teach you how to do this better.
HOW you sit on the toilet to have your bowel movement is also so, so important! I can't stress this enough, because it automatically helps you relax your pelvic floor without you having to do anything. I talked about this a little bit in my first article, and linked to this webpage that covers the basics.
If you have either a diastasis rectus abdominis (DRA)/umbilical hernia or prolapse, providing external support to those areas of the body can help! For DRA/hernia, placing your hands on your belly to have something to "push" against can be really helpful (or wearing an abdominal binder if you already have one). For prolapse, pushing up against the perineum (the area between the vagina and the anus) can be helpful. Or, if you have a rectocele in particular (the rectum is falling into the vaginal canal), then placing your finger inside the vagina and pushing back on the back wall of the vagina can also be incredibly helpful. There are also now devices you can purchase for this particular purpose, such as the Release and the Femmeze (not sure if you can buy the Femmeze in the US??)
Most of the time, people who have constipation have pelvic floor muscles that are too tense/tight, NOT too weak. Doing more Kegels or pelvic floor strengthening will not help! Learning how to RELAX your pelvic floor while you exhale (which is the opposite of what we do in MommaStrong - different purposes under different conditions!) is essential. Generally it takes pelvic floor PT to teach you how to do this.

What happens at a PT appointment?

First, lots of "exercise" training to coordinate your abdominals, pelvic floor, and breathing as I mentioned above. This is accomplished a lot of different ways, but will ALWAYS involve lots of training in deep breathing. And yes, generally a rectal exam is needed, but is much-preferable to a lot of similar medical tests that I outlined in my second article! And, we can absolutely skip the intra-rectal part if that isn't something you are comfortable with. We have lots of other tricks up our sleeve, including:

Biofeedback training. This can be done externally with superficial electrodes, or with internal vaginal or rectal electrodes. Basically it helps us see visually on a computer screen what your muscles are doing, and has LOTS of great evidence for helping with defecation disorders in particular. This is particularly effective for people that have a really hard time telling what their pelvic floor is doing, especially for learning to relax the pelvic floor.
Manual therapy & massage. This can be on your belly, using gentle massage to help stimulate the colon, or internal to the pelvic floor to help those muscles relax. You can also do abdominal massage at home, as there is also really excellent evidence this can be helpful too! You can either do the "I-Love-U" massage that we also use on infants, or massage in the direction that your stool moves through your colon from right to left.
Visceral mobilization. This is essentially an advanced version of the abdominal massage, where your PT will target the specific connections of fascia and ligaments around your organs. Not all PTs are trained in this, so if it's something that you would like to try, make sure to call and ask before booking an appointment!
Electric stimulation. TENS (transcutaneous electrical nerve stimulation) can be incredibly helpful for constipation, even for slow transit. It can be placed on the abdomen, over the sacral nerve roots, or at other acupressure-like points on other areas of the body to help the bowels.

If I don't have the time/money/energy for PT right now, what else can you tell me?

I have a lot of other great advice for you! All of this can also help if you are pregnant too, when your ability to take other supplements is limited.

Don’t skip breakfast. Having food hit your stomach in the morning helps “wake up” your digestive system, and lets the colon know more food is on the way. This stimulates your body’s gastrocolic (or emptying) reflex in order to make room for the new food. Bonus if you can drink something warm, and eat something high in fiber.
Eat regular meals at similar times each day. Your gastrocolic reflex also occurs after every meal, so eating regular meals is better than small snacks or grazing throughout the day. You can also try sitting on the toilet for 10 minutes about 20-30 minutes after every meal in order to take advantage of this emptying reflex. (Note: don’t strain if stool isn’t ready to come out. If nothing happens, get up and go about the rest of your day.)
Give yourself enough time to have a bowel movement in the morning, if possible. Your colon is 2-3x more active in the morning, and establishing a “routine” for having a bowel movement in the morning helps you become regular every day.
Don’t ignore the “call to stool.” If your body is telling you it’s time to have a bowel movement, try to respond if appropriate. Chronically delaying the urge to have a bowel movement not only disrupts the body’s way of knowing when you need to poop, it also increases the storage capacity of the rectum, further exacerbating constipation.
Keep regular bedtime and waking times (hahahaha....but, it is true that it helps). The bowels have their own circadian rhythm that gets disrupted when sleeping patterns are inconsistent.
Exercise regularly. More physical activity stimulates the body’s ability to move stool through the colon. There is evidence specifically that 20-60 minutes of exercise 3-5 days per week improves symptoms and quality of life for IBS.

What about if I'm pregnant or newly postpartum?

Some of these interventions aren't safe for pregnancy, so check out this article on constipation in pregnancy and postpartum! However, if you are pregnant, you can absolutely do all of the "behavioral" things I mentioned above (fiber, water, breathing, sitting on the toilet correctly, and then the last several bullets about eating and not ignoring the call to stool!).

Still have questions or need a little extra help with your bowel health?

Pelvic Love Physio PTs are your local experts in all problems related to the pelvic floor! Please call or text us today at 309-431-1357 and we will be happy to answer all of your questions.

References:

Bharucha, A. E., & Wald, A. (2019). Chronic Constipation. Mayo Clinic proceedings , 94 (11), 2340-2357. https://doi.org/10.1016/j.mayocp.2019.01.031

LaCross, Jennifer A. PT, DPT, PhD(c)1; Borello-France, Diane PT, PhD2; Marchetti, Gregory F. PT, PhD2; Turner, Rose MLIS3; George, Susan PT, DPT4. Physical Therapy Management of Functional Constipation in Adults Executive Summary: A 2021 Evidence-Based Clinical Practice Guideline From the American Physical Therapy Association's Academy of Pelvic Health Physical Therapy. Journal of Women's Health Physical Therapy 46(3):p 147-153, July/September 2022. | DOI: 10.1097/JWH.0000000000000245

Functional Constipation

Thu, 10 Sep 2026 15:26:55 GMT

Functional Constipation: Types and Diagnosis

Oof this is a big topic! So right off the bat, let's narrow our scope. And, if you missed my first article about �� talk (the basics of bowel function), you can check that out here .

This post will be about functional constipation . What do I mean by that? Basically this means there are no other medical explanations for your constipation. No IBS, Crohn's or Celiac, or really serious pathologies like cancer, etc. So before we dive in, let's review some major symptoms that would require you to contact your doctor ASAP to get some more serious diseases ruled out:

blood in the stool
a sudden change in bowel habits (especially after the age of 50 years)
anemia
unexplained weight loss
any bowel changes if you have a family history of colon cancer

How do I know if I have functional constipation?

For starters, your symptoms must be present for 6 months or more, and also you must have had some symptoms in the last 3 months. Then, you also need 2 or more of these:

straining for more than 25% of bowel movements (BMs)
lumpy or hard stools for more than 25% of BMs (refer back to my last article for the Bristol stool scale - these would generally be types 1-2)
sensation of incomplete emptying at least 25% of the time
fewer than 3 spontaneous BMs/week (spontaneous meaning without the use of laxatives or other agents to produce a BM)
a sensation of something blocking your rectum/anus for at least 25% of BMs
needing to "splint" your perineum (press a finger upwards against the tissue between your vagina and anus to help facilitate defection) or needing to put your finger in your rectum to help guide stool out for more than 25% of BMs (yes some people have to do this!)
loose stools rarely present without the use of laxatives
insufficient symptoms to diagnose IBS-constipation

Are there different types of functional constipation?

Yes! Functional constipation generally falls into two categories:

Slow transit constipation. Essentially this means that your intestines are not moving your waste along quickly enough through your colon. Symptoms include reduction in the urge to defecate, abdominal pain, and abdominal distension/bloating. This leads to hardened stool, as water from stool is lost as it moves through the colon. This hardened stool is slower to reach your rectum, and thus requires greater force to evacuate.
Defecation disorders. Sometimes called obstructed defecation, outlet dysfunction, or even a non-relaxing puborectalis, this essentially means you have lost the coordination/strength between your abdominals and pelvic floor that is needed to evacuate your stool. Generally you will experience a long toileting time to produce a bowel movement, a lot of straining, and sometimes the need to use manual assistance to empty the rectum.

Generally the big differentiator here is that with slow transit constipation, you feel like your stool is just sitting in your belly and not even making it to your rectum (you know you should go, but can go a long time without the urge to go). With defecation disorders, you know the stool is in your rectum and you have the urge to defecate, but you can't get it out.

And of course for some people, there can be a mix of these two things occurring at the same time.

How do I know if my constipation is slow transit or a defecation disorder (or both)?

Basically, there are a series of typically not-so-fun tests you can undergo. Typically these tests are ordered by a gastroenterologist or a colorectal surgeon (or a nurse practitioner or physician assistant in one of those offices), so you will need a referral to a specialist before having any of these tests. I'll give you a brief rundown of the options here.

For slow transit constipation:

This is the easiest/least-invasive test, commonly known as a Sitz-marker study. Basically it requires you to swallow a capsule containing 24 radiopaque markers. Then, via a series of abdominal x-rays, your doctor can tell how long it takes for those markers to move through your colon. Based on the method they prefer, they may ask you to:

Take one capsule, then have an abdominal x-ray 5 days later. The goal is to have less than 5 markers remaining in your colon.
Take one capsule on day 1, one on day 2, and then another on day 3. Then abdominal x-rays are taken on days 4 and 7. If you have more than a total of 68 markers left (out of the original 72) between the tests on both days, then you earn the diagnosis of slow transit constipation.

There are also newer tests in the works, like a wireless pH-pressure capsule you can take, but that requires some fancier monitoring equipment and I don't believe is used regularly yet.

For defecation disorders:

These tests are significantly more invasive and less fun than for slow transit. I'll outline them here, but also know in most states you can just make an appointment with a pelvic floor physical therapist (PT) who can also diagnose the same thing with an intra-rectal exam. A rectal exam is also not super fun, but when you read the rest of these you may want to take that option.

Rectal Balloon Expulsion Test: Basically you sit on a toilet-like object, have a balloon inserted into your rectum that is then filled with water, and finally you try to poop it out. If it takes you longer than one minute to expel the balloon, then you earn the diagnosis of a defecation disorder. HOWEVER, this test is not valid for anyone with prolapse or pelvic floor laxity.
Anorectal Manometry: This test is a measure of the pressure inside the rectum and anus, both at rest and when you use your pelvic floor muscles. It can also test your ability to sense when your rectum is full. Essentially you lay on your left side, have a catheter inserted into your rectum, and then that catheter is pumped with air. It can measure the pressure at various points along the rectum, and then also can measure what happens when you squeeze your muscles or try to bear down as if having a BM. For more details, check out this article . Many times this test is done at the same visit as the rectal balloon expulsion test.
Defecography : This test is generally done only if the anorectal manometry test results don't match up with your symptoms, or if your doctor suspects you have a large rectocele. This is a visual test to actually see what happens in your rectum when you try to poop. So as a result, it requires either a fluoroscopic x-ray or an MRI. Basically your rectum is filled with a barium paste (similar to the consistency of poop) so that the radiology technician can see the paste as you bear down to eliminate it. Then, you sit on a "special toilet" inside a specialized MRI or x-ray machine. You will try to eliminate the barium paste while a series of pictures is taken of your insides as you do so. For more of the lovely details, click here .

So, remember what I said about a rectal exam from a pelvic floor PT (1:1 in a private room) being possibly preferable to these types of tests (definitely not 1:1, and now you are trying to poop on command in front of strangers ��)?? Yeah...I'd take the PT exam any day!

What's the first step in treating functional constipation?

Generally, the basics you already know. If you tell your doctor you are constipated, they will generally tell you to increase water and fiber, and may recommend short-term use of laxatives (again, see my first article for fiber and water basics). However, this guidance will fail in about 50% of people. But on the other hand, then it means just basic info can help 50% succeed! The problem is that while constipation may be dietary-related for a lot of people, it doesn't get to the root cause of the constipation for many others. So, make sure your fiber and water intake are good first, and if that doesn't help, move on to some other treatments.

Also, long-term use of stimulant laxatives is NOT recommended (see this article for a full breakdown on types of laxatives). This is because then your body gets really used to relying upon the laxative to push your stool through your colon, rather than the colon doing the work itself. Stimulant laxatives are typically things like Ducolax and senna. Other types of laxatives, such as osmotic laxatives (lactulose, Miralax) and stool-softening laxatives (Colace, aka ducosate) do not have the same problems and are safe for long-term use. However, it is well-known that Colace is no better than placebo , so honestly, don't even bother in my opinion! And of course, with my PT hat on I'd rather have you get to the bottom of your constipation rather than just relying upon laxatives anyway.

If I'm already good on fiber and water, what's next?

I know this question probably applies to a lot of you! However, the answer to this is SO big that I needed to save it for another article. So, click here to read about treatment options for functional constipation.

Still have questions or need a little extra help with your bowel health?

Pelvic Love Physio PTs are your local experts in all problems related to the pelvic floor! Please call or text us today at 309-431-1357 and we will be happy to answer all of your questions.

References:

Bharucha, A. E., & Wald, A. (2019). Chronic Constipation. Mayo Clinic proceedings , 94 (11), 2340–2357. https://doi.org/10.1016/j.mayocp.2019.01.031 (the 2 last images come from this article as well!)

Constipation

Tue, 01 Sep 2026 16:03:46 GMT

Potty Talk ��

The famous book title says it all: everybody poops! And, a lot of people have problems with their poop. It’s a shame this isn’t talked about more openly, because there are so many simple things that can help if you are constipated in particular!

Let's start with the big one: how often should you poop?

Great question! And the answer might surprise you - typical frequency for bowel movements (BMs) is anywhere from 3x/day to 3x/week. So, most of us fall into "normal" on one end or the other. HOWEVER, I will say that I feel best if I poop every day, and I think the same is true for my patients! So I generally prefer myself and my patients to have a daily bowel movement at minimum.

What if you poop less than that?

Technically, then you would meet the guidelines of constipation. However, you can poop daily and still be constipated- it really depends upon how much stool you are actually getting out. Many people with constipation struggle with not getting very much poop out whenever they do sit down to poop, which may happen more often than not. The main rule of thumb is that you should NOT have to strain with your bowel movements. Yes you should have to push gently, or exert some effort, but generally your stool should come out easily. If you are holding your breath or pushing really hard, then most likely you are constipated too.

What if you poop more than that?

There is a chance you may have a different sort of bowel problem, such as irritable bowel syndrome. This is especially true if you are pooping frequently but only getting small amounts out. However, of course you can't diagnose IBS just by bowel frequency! But it can be one component of IBS. Other problems like stress and anxiety can also lead to an increase in bowel frequency, or people that have medical diagnoses like Crohn’s or Celiac disease also can have frequent BMs.

What about poop consistency?

This is the golden ticket! By seeing where you fall on the Bristol Stool Scale , you can learn SO much about your bowel health. The optimal stool type is a type 4, but type 3 is also pretty darn good. You are most likely constipated if you have types 1-2, or have diarrhea and/or fecal incontinence if you have types 5-7.

And, there is an excellent version of the Bristol scale that is for kids , but also I use it with my adults too sometimes just because it's fun. :)

Type 1 especially is really indicative of an overactive/hypertonic pelvic floor. These "rabbit droppings" mean that your pelvic floor muscles only relax JUST enough to squeeze a tiny bit of poop out, and then tighten back up again. In order to get nice type 3's and 4's, you need to be able to relax/elongate your pelvic floor for about 15-20 seconds.

How do I improve my stool consistency if I'm either a type 1-2 or a type 5-7?

The answers are actually very close to each other! Both types typically benefit from fiber. Insoluble fiber doesn't get absorbed by the body, but essentially helps push stool through your colon faster. So that can help types 1-2. Soluble fiber helps bulk stool and slows digestion, which thus can help types 5-7. Check out more info on soluble and insoluble fiber here .

Here is a great chart of how much fiber is in different types of foods. This way you can make some easy choices (sub peas for green beans, for example) to help boost your fiber intake.

And, especially for stool types 1-2, make sure you are drinking enough water! Water helps keep your stool soft and keep things moving. Aim for half your body weight in ounces, or until your pee is a pale, straw-colored yellow.

Does the squatty potty help?

Absolutely! The squatty potty is the million dollar idea we all wish we would have had, lol.

If you aren't familiar with it, they have very catchy ads you can watch . But basically the squatty potty is just a stool with a half-circle cut out in it. This way it can slide easily under your toilet when you are done, rather than take up extra space in your bathroom.

The idea is that by using a stool under your feet, you can elevate your hips higher than your knees while pooping. This helps your pelvic floor relax naturally, so then you have to exert less effort to eliminate your stool. This article also gives an excellent overview of the importance of toileting posture, among other things!

What about breathing?

Breathing is SO important for bowel movements! No matter your bowel issue (and even if you don't have any bowel issues per se), if you work on your breathing and use a stool underneath your feet, then you will poop so much more easily, I promise!

When you "push" to get your poop out, it's really important that you don't hold your breath. Instead, you want to exhale as you push.

It's also helpful to keep your belly distended a bit as you push, rather than do a "brace" or draw belly to spine. For kids, I often use the "bubble belly/bubble bottom" imagery. The idea is that if the belly is pushing out slightly, that helps the pelvic floor push down slightly, and then the rectum can open better to get your stool out. Give it a try!

Stay tuned for upcoming posts where we will talk more about specific bowel problems, especially ones that can develop as a result of pregnancy and childbirth. And, we’ll even dive into pediatric constipation, with some recommendations on how you can help your kiddos if they struggle with pooping too!

Still have questions or need a little extra help with your bowel health?

Pelvic Love Physio PTs are your local experts in all problems related to the pelvic floor! Please call or text us today at 309-431-1357 and we will be happy to answer all of your questions.

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:

6c77fa10

Body Changes in Pre- vs. Peri- vs. Post-menopause

Body Changes in Pre- vs. Peri- vs. Post-menopause

Your pelvic health can change with hormones, too. Need support?

Perimenopause and Menopause 101

Perimenopause and Menopause 101

Navigating pelvic health changes during perimenopause or menopause? We can help.

Stool Leakage after Childbirth

Stool Leakage after Childbirth

Constipation During Pregnancy and Postpartum

Constipation During Pregnancy and Postpartum

Still have questions or need a little extra help with your bowel health?

Treatment of Functional Constipation

Treatment of Functional Constipation

Still have questions or need a little extra help with your bowel health?

Functional Constipation

Functional Constipation: Types and Diagnosis ﻿

Still have questions or need a little extra help with your bowel health?

Constipation

Let's start with the big one: how often should you poop?

What if you poop less than that?

What if you poop more than that?

What about poop consistency?

How do I improve my stool consistency if I'm either a type 1-2 or a type 5-7?

Does the squatty potty help?

What about breathing?

Still have questions or need a little extra help with your bowel health?

Surgery for Diastasis Rectus Abdominis

Surgery for Diastasis Rectus Abdominis

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

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

Kinesiotape (KT) alone

KT alone or KT plus exercise

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

Visceral mobilization

Takeaways

What Makes You More Likely to Have a DRA?

What makes you more likely to have DRA?

What are the best exercises for postpartum DRA?

What are the best exercises

for postpartum diastasis rectus abdominis (DRA)?

What is Diastasis Rectus Abdominis/DRA?

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

Prolapse Surgery, Part 2

Prolapse Surgeries, Part II

Prolapse Surgeries, Part 1

Prolapse Surgeries, Part I

What are Pessaries, and How Do They Work?

What are Pessaries, and How Do They Work?

What are the Best Exercises for Prolapse?

What are the Best Exercises for Prolapse?

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

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

What is IAP?

Your pelvic floor and internal organs SHOULD move

How do I prevent IAP from becoming a problem?

What about deep abs and pelvic floor?

Who Gets Prolapse, and Why?

Who Gets Prolapse, and Why?

What Types of Prolapse are Most Common?

What About Postpartum Prolapse?

What Are the Risk Factors for Prolapse?

References:

Prolapse is Confusing!

Prolapse is Confusing!

Osteoporosis Part 2: How to build stronger bones through exercise

Osteoporosis Part 2:

How to build stronger bones through exercise

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

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

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

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

Osteoporosis Part 1:

What is it, and who is at risk?

What exactly is osteoporosis?

Who does OP affect?

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

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

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

Functional Constipation: Types and Diagnosis