Historically, physiotherapists have been known mainly for treating back and neck pain or running onto a football field when a player has sustained an injury. However, the emerging practice of “gender health” or “pelvic health” physiotherapy and, specifically, Women’s Health has recently garnered increased publicity. Many patients with pelvic dysfunction are suffering in silence, not aware that help is available. So we think it’s time that we devoted a little more space to the problems that no one wants to talk about.
What’s it All About?
Women’s Health physiotherapy can refer to the management of a very broad range of conditions, but most commonly it describes the treatment of any disorder of the pelvis or pelvic floor muscles.
The Pelvic Floor
The ‘pelvic floor’ is used to describe a group of muscles that run from the coccyx (tail bone) to the middle of the pubic bone, a cartilaginous joint known as the pubic symphysis. Their role is to support the internal reproductive organs, as well as the bladder and bowel, providing control for the latter.
The pelvic floor muscles can be stretched and weakened with any repetitive strain. This can occur, for example, due to chronic coughing (such as in cystic fibrosis or bronchiectasis), in pregnancy due to the increased load of a growing baby, or during childbirth – especially if any trauma is sustained or if an instrument assisted delivery is required.
A Women’s Health physiotherapist is qualified to provide expert treatment of pelvic floor weakness and dysfunction.
Since many people don’t know what Women’s Health physiotherapy is all about, here are 10 instances when you should see a Women’s Health Physio.
During pregnancy the body goes through numerous changes. As the baby grows, the hips widen to provide more room and also to prepare for labour and giving birth. A hormone known as Relaxin loosens the round ligaments supporting the pelvis to make it more flexible. These changes can cause sudden alterations in posture and resulting back and pelvic pain. Pelvic Girdle Pain is a common complaint amongst mothers-to-be, also known as Pubic Symphysis pain, stabbing pain in the middle of the pubic bone as the cartilage is placed under strain of a widening pelvis.
Pregnant women are also prone to back pain, either in their lumbar or thoracic region which can be due to increased spinal curvatures, excess weight and decreased activity.
Physiotherapists that specialise in Women’s Health are experts in treating these ante-natal complaints and help limit pregnancy musculoskeletal pain, while also advising on appropriate exercise during pregnancy which can help prevent complications and assist with weight loss post-birth. They can also provide education in the form of active birthing classes, advising on helpful positions to adopt during labour for both pain relief and to facilitate the progress of labour.
No matter what type of delivery, the size of the baby, or if any damage occurred to the pelvic floor, all mothers should be reviewed by a Women’s Health physio before being discharged from hospital. Some will also need further follow up treatment if they experience any complications.
Physios should assess that the pelvic floor muscles are activating correctly even though they will probably be quite weak initially. They should also assess if a rectus diastasis (a separation of abdominal muscles) is present. As the baby grows during pregnancy, the muscles can “split” and can remain this way after birth, this can cause poor core strength, back pain and a risk of developing an abdominal hernia; therefore an attempt should be made to close the gap through gentle exercise.
Many new mothers seek guidance from their physio on returning to exercise. Guidelines usually recommend six weeks post natural delivery or 12 weeks post caesarean section providing there have been no further complications. Unfortunately, labour doesn’t always go to plan and the pelvic floor can sustain damage either due to natural tears, instruments such as forceps or vacuum or an episiotomy. This damage often results in urinary incontinence which is discussed further in the next section and can be treated with ultrasound and pelvic floor strengthening.
Post-natal physio can also help treat caesarean section scars with connective tissue therapy on both the external scar as well as the underlying fascia. There are four layers of abdominal muscles as well as adipose tissue and fascia which are cut through during the procedure which can cause significant scarring.
Finally, postural changes can occur from carrying a growing baby, feeding, change in breast size, lack of activity and resulting deconditioning and these can all be treated with the help of a Women’s Health physio.
3. Urinary incontinence
There is a common misconception that incontinence is something normal that must just be accepted. While embarrassing and inconvenient, if left untreated it can also result in inactivity and social isolation. 1 in 3 women suffer from urinary incontinence and while it is common especially in women who have had children, it should not be considered as normal.
- Stress urinary incontinence occurs with coughing, sneezing, laughing, running, or jumping. The leaking of urine is caused by an increase in intra-abdominal pressure that occurs during these activities. The 1990s saw the introduction of a surgical procedure where a synthetic sling is implanted to support the urethra and prevent leaking.
- Urge urinary incontinence is the inability to “hold on” when the bladder becomes full or the sensation to pass urine occurs.
Both types are common in pregnancy, as the growing baby places more pressure on the bladder, and after birth, as the pelvic floor muscles are in a weakened state.
Physio treatment of incontinence consists of education around diet and hydration, bladder training, fluid monitoring, and advice on minimising caffeinated drinks, etc.
An internal examination may also be necessary; however this will only be done by an experienced, trained physiotherapist and only with your consent. A large part of treatment consists of pelvic floor muscle training, ensuring the muscles are activating correctly and with sufficient strength to support the bladder.
4. Post-gynaecological or abdominal surgery
Surgeries such as a hysterectomy or myomectomy can cause connective tissue adhesions and scarring. This can result in pelvic floor dysfunction and chronic pelvic pain. Patients who suffer from chronic pelvic pain, e.g., those with endometriosis, are often found to have overactive pelvic floor muscles which can cause urinary retention and constipation. Treatment of these patients is focused on relaxation, diaphragmatic breathing and pelvic floor down training (relaxation techniques)
5. Pelvic Organ Prolapse
This common condition affects a third of women who have had children. There is an increased risk of development in the obese population and those who undertake heavy lifting, as well as those with chronic constipation or chronic coughing. Prolapse can occur with either the bladder, bowel, rectum or uterus bulging down into the vagina and can vary in severity of symptoms. Patients will usually notice symptoms of a bulging sensation, back ache or abdominal discomfort.
Women’s Health physios can offer advice and fitting of pessaries which insert into the vagina to support the wall. Sometimes an oestrogen supplement is recommended, and surgical repair is considered if conservative approaches are unsuccessful.
Traditionally prolapse was repaired by suturing the connective tissue in the wall; however, this had a high rate of recurrence. Following on from the success of the sling to treat stress incontinence and the mesh used in hernia repairs, doctors began trialling mesh for the surgical repair of prolapse. The Therapeutic Goods Association started approving kits in 2003, but with little data as to the safety and efficacy of the procedure. Unfortunately, as there was no Medicare code generated for this specific surgery, it is impossible to know exactly how many women underwent a mesh repair of their prolapse; however it is predicted between 30,000 to 40,000 by 2017.
While the mesh repair has the advantage of a lower risk of prolapse recurrence compared to the suture procedure, the disadvantages are numerous. The mesh can rub or become exposed within the vagina which can result in pain and bleeding. Some patients experienced severe pain that persisted even once the mesh was surgically removed. Adverse effects have included urinary incontinence, chronic pain, pain on walking and during sexual intercourse and resulting relationship breakdowns. Most doctors in Australia stopped using mesh for prolapse repairs in 2012.
A Senate review was launched in 2017 with the report released in 2018 recommending that vaginal prolapse mesh repairs should only be done as a last resort, and that patients should be educated on risks of any adverse effects in order to give informed consent. Further audits were also to be done on the number of procedures conducted as well as providing patients who were suffering from symptoms with multi-disciplinary support.
Women’s Health physios may be able to assist ladies who are experiencing mechanical infertility due to pelvic adhesions. Pelvic dysfunction can be caused by trauma, inflammatory conditions and adhesions. One research study in Florida included patients who were both trying to conceive naturally or undergo IVF and underwent physio consisting of manual soft tissue mobilisation. The study used an outcome measure of becoming pregnant and reaching full term and observed that manual soft-tissue therapy facilitated fertility in these patient groups.
Physiotherapy provides a low risk, non-invasive and low-cost treatment for some causes of infertility with the primary goal being to decrease pain and increase mobility of the pelvic tissue.
7. Sexual dysfunction
It is not commonly known that physiotherapists are able to help treat sexual dysfunction. Rarely discussed, sexual dysfunction can often be due to anxiety, traumatic birth or instrument-assisted birth, pelvic pain or overactive pelvic floor muscles. Physio treatment focuses on relaxation techniques, mindfulness, lifestyle education and stress reduction. Patients are taught breathing techniques and self-massage to relax the pelvic floor muscles
8. Pelvic pain conditions
There are several causes of pelvic pain from various structures within the region:
An umbrella term, describing pain and discomfort in the vulva, lasting more than six months, with no obvious cause. Women’s Health physios can provide education on the physiology of pain, since sometimes vulvodynia is due to changes in the nervous system, and not from a mechanical source. Time will also be spent on stress and anxiety reduction techniques.
Pelvic floor muscle down-training is where women’s health physio is most important. Patients with pelvic floor muscle dysfunction often have higher resting tone and weaker, slower contractions. Down training can be an effective technique, often with the use of biofeedback.
Coccydynia describes pain around the coccyx (or tailbone). This is thought to be a symptom and not a diagnosis in itself. It typically affects patients when sitting and rising out of a seated position. If the pain is referred or radiating, it is usually due to a lumbar spine injury, whereas local pain is due to the coccyx itself. Treatment can include manipulation of the coccyx and massage of the surrounding muscles including the levator ani and coccygeus. Success can also be found with down training and relaxation of the pelvic floor muscles pulling on the coccyx. The invasive nature of these techniques requires specialised training.
Involuntary spasms of the vagina, sometimes caused by anxiety and previous trauma. Treatment again is usually with down training techniques. Dilators can sometimes be beneficial and focus is also placed on stress and anxiety reduction.
Sometimes referred to as pudendal nerve entrapment, this is an injury to the nerve supplying the ‘saddle’ region in both men and women, including the external genitalia and perineum. This condition is characterised by pelvic pain in sitting which increases during the day and is relieved by lying and standing.
Patients also frequently suffer from sexual dysfunction, difficulty passing urine and opening bowels. It is a neuropathic pain so often associated with burning or tingling, as well as numbness or pins and needles.
There are unfortunately no specific tests to diagnose pudendal neuralgia and it is treated with muscle relaxants, analgesics and anti-convulsants.
Physio treatment revolves around movement analysis to correct any poor patterns that may be contributing to the entrapment, as well as an assessment of ability to contract and relax pelvic floor muscles. Exercise programs are usually prescribed including yoga-based movement and strengthening.
9. Post-Cancer treatment
Cervical, ovarian, uterine and vulva cancers are often treated with surgery as well as pelvic radiotherapy, which can cause significant dysfunction to the surrounding region. While radiotherapy often causes vaginal constriction, surgery can stimulate menopause. Patients should have access to a Women’s Health physiotherapist to discuss any symptoms they are experiencing, including advice on lymphoedema prevention following lymph node clearance. It may even be as simple as wanting advice on returning to exercise in an attempt to lose weight following treatment.
Some of these physios also specialise in treating symptoms caused by breast cancer treatment which can require some patients to have prophylactic hysterectomies. Even in patients being treated for non-pelvic cancer, treatments can cause constipation, diarrhoea or urinary incontinence and they will benefit from seeing a physio as well.
During menopause, testosterone levels decrease, and muscle mass reduces which can significantly impact the pelvic floor muscles. There is a loss of skin flexibility and a potential decrease in libido. Treatment will often focus on advice and education, especially about exercise to improve or maintain muscle mass. It is recommended that women undertake a combination of aerobic and resistance exercise.
See a Women’s Health Physiotherapist
Women’s health physiotherapy is a rapidly growing discipline and this is in large part due to gradual destigmatisation. We believe it is critical to talk (and write) about sensitive problems. The issues outlined in this article are normal. They affect a huge number of Australian women and everyone should feel comfortable to seek treatment. So, book in with a Women’s Health Physio, get appropriate advice and take control today.