After Pelvic Floor Reconstruction

Thinking Long-Term

By Lizanne Pastore, PT, MA, COMT
Appeared in the February, 2013 issue of Quality Care®

The decision to undergo pelvic reconstructive surgery to correct pelvic organ prolapse (POP) can be difficult. Women often wait years dealing with symptoms of POP before they commit to surgery. Aside from decreasing symptoms of prolapse, a desired outcome of pelvic floor reconstruction is for the woman to be able to return to her active life. Likely, the surgeon has provided some information about do’s and don’ts, but this is usually related to immediately post-surgery.  Most pelvic floor surgeries require an initial 6 to 8 week rest period —keeping activity very light—no sexual intercourse, no heavy lifting, no running etc.

But after the initial rest period, then what? Are there activities to avoid or limit? How much is “too much” to lift?  Should anything be avoided altogether? Medical literature tells us that 30% of women may require a second surgery at some point in the future due to failure of the first or because of another pelvic problem.1 Yet, there is little information on improving outcomes in order to prevent another surgery. Most surgeons use a common-sense approach in advising their patients, and if a woman has specific questions or concerns, she is always advised to ask her surgeon. The surgeon has the best understanding of how the procedure went and in what shape the woman’s pelvic tissues are.

The primary cause of POP is trauma to the pelvic floor muscles (PFM,) connective tissue or “fascia” and ligaments. These structures become unable to support the pelvic organs. The majority of women undergoing surgery sustain tissue injury from childbirth trauma.  More rarely, women may develop severe prolapse due to extreme increases in intra-abdominal pressure (IAP) for other reasons.  Examples include illnesses that cause chronic coughing or performing frequent Valsalva maneuvers (straining) such as with chronic constipation.

In attempting to identify risk factors and make post-surgical recommendations, research has determined that indeed, the two things that increase IAP and vaginal pressure (VP) the most are coughing and Valsalva maneuvers.2,3,4 Most of these studies compared pressure measurements during everyday activities like supine lying, standing, lifting, running, coughing and straining. According to the research, many things increase IAP; just getting out of bed will mildly increase IAP, as will lifting moderate weight and running. One study went so far as to say that many post-surgical guidelines are “needlessly restrictive.”5 The researchers found that in subjects without pelvic floor problems tasks such as lifting eight to 20 pounds off a counter, lifting 13 pounds from the floor, walking briskly, performing crunches all produced no more increase in IAP than getting out of a chair. They summarized that “how lifting is done impacts intra-abdominal pressure.” The good news is, that the research, found that unless a woman has a chronic cough condition or habitually performs Valsalva maneuvers, everyday stressors like standing, walking, lifting normal weight, sexual intercourse and running should be okay post pelvic surgery.

Women seen by a specially trained pelvic physical therapist (PT) after surgery are taught strengthening exercises and postural strategies, as well as how to lift correctly. If risk factors are present the woman may need extra help to learn how to care for her pelvic floor during stressful activities, this may include diet counseling and information on sexual positions to limit stress to the PFM. Here is a list of some things PT’s might teach their patients post surgery:

  1. Posture: PFM works best when the spine, pelvis and hips are in good alignment. If a woman’s back is too rounded, the normal bony structure of the pelvis can’t act to support the pelvic organs as intended. If the back is too arched, the pelvic muscles can become overstretched and strained. Normal spinal posture is a simple and effective way to support the pelvic organs. Learn how to maintain good posture with your normal daily activities, such as sitting at a computer, lifting, squatting etc.
  2. Diet: To avoid constipation and straining (Valsalva) with bowel movements, drink plenty of water, eat a balanced, healthy diet with whole grains and fresh vegetables and learn about soluble and insoluble fiber. If constipation exists, it needs to be assessed to determine the type of constipation, and then be properly treated.
  3. Toilet Posture: We know that the vast majority of people evacuate their bowels best when in a squatting position. Most modern toilets don’t accommodate for this. Try placing a phone book or two under the feet to elevate the legs. Or try this device, which allows for a nice squatting position when on the toilet:  spine in neutral, but hips flexed and knees above the hips.
  4. Restful Rescue Poses: There are excellent resting positions that utilize gravity to encourage organs to “reposition” back into the pelvic cavity. Here’s one: lie on your back and place a pillow or small wedge under the pelvis to invert your pelvic region. Place pillows under your knees as well and one pillow (or none) under the head. It’s a lovely position to rest in, and for those doing a strengthening program, it’s a great position for that too. If you want to go all out, place a heating pad over your tummy, turn the lights low, play soothing music and rest for a blissful 20 minutes or so. 
  5. Biomechanical Considerations for Sexual Intercourse: Let’s face it, the majority of women going through POP surgery are sexually active. Sex must be addressed and often it’s the PT who spends the time with the patient and can make the best recommendations. For example, if a woman has pain with vaginal penetration, she may need to perform special stretching exercises to open the vaginal introitus and the PT can advise on intercourse positions that will least stress the PFM. Menopausal women may also need to discuss additional local estrogen and lubricant with your surgeon or physical therapist.
  6. Pelvic Bracing: This is a technique of co-contracting one’s lower abdominal muscles, deep back stabilizing muscles, with the PFM. When done correctly it can limit the stress on the pelvic organs during activities of increased IAP, like lifting or squatting. It sounds complicated but it’s really not. Women should learn to do this in any position. First, attend to your PFM by giving them a gentle squeeze (feel the perineum lift) followed immediately by a relaxation (feel the perineum release down.) Starting from a relaxed place, gently draw the PFM upward as you gently draw the navel inward. Imagine you are trying to lift your vagina like an elevator as you feel your lower tummy gently flatten. Do this gently, not full force. You should be able to breathe normally as you do this. You’ll feel the two muscle groups acting together to tighten the lower belly and “brace” the pelvic floor. The deep back muscles should activate when you do this providing posterior support simultaneously. Hold this co-contraction for a few seconds then release. If you have trouble with this, seek out a pelvic floor PT in your area to help you learn. Learning how to brace during functional activities sometimes requires a bit of training, so again, seeking a specialist may be indicated if you are someone who has risk factors.
  7. Pelvic Floor Muscle (PFM) Strengthening: Often called “Kegels,” PFM strengthening involves exercising the PFM by contracting them for short or long periods of time—usually from two to four seconds to train the “fast twitch” muscle fibers, and five to 30 seconds to train the “slow twitch” muscle fibers.  Sometimes these exercises are done in conjunction with other muscle groups. The muscle fibers of the pelvic floor are 70% slow twitch and only 30% fast twitch. This means that the PFM are much better at endurance events than brute strength activities. They act more as supportive postural muscles; however we occasionally need a quick strong contraction to avoid leaking with a sneeze.  Correct PFM strengthening incorporates exercises for both types of muscle.

Some women actually do too much exercise and develop tight, painful muscles. Sometimes, after a pelvic surgery, a woman might actually feel “tight” or “tense” inside. This is from the surgery, not because the muscles magically strengthened from the procedure. If after surgery you have symptoms of pain (either at rest or with an activity like sex), urinary urgency or frequency, then tell your doctor. Kegels would not be appropriate for you. If this is the case be sure to talk to your doctor for other options, such as biofeedback.

Other women need to exercise to develop more muscle tone and strength. The trick is to ensure there is balance between strength and flexibility. If you are still leaking or feel weak, then strengthening may be helpful.

Physical therapists with a pelvic floor specialization are trained to assess the whole person to determine an appropriate exercise routine, and women are advised to be evaluated before undertaking a rigorous strength program.

References:
1Olsen AL, Smith VJ, Bergstrom JO, Colling JC & Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997; 89(4): 501-6.
2Int Urogynecol J Pelvic Floor Dysfunct. 2007 Aug;18(8):943-8. Epub 2007 Jan 18. Vaginal pressure during daily activities before and after vaginal repair. Mouritsen L, Hulbaek M, Brostrøm S, Bogstad J
3Int Urogynecol J Pelvic Floor Dysfunct. 2007 Dec;18(12):1481-9. Epub 2007 May 22. Vaginal pressure during lifting, floor exercises, jogging, and use of hydraulic exercise machines.  O'Dell KK, Morse AN, Crawford SL, Howard A.
4Am J Surg. 2008 Mar;195(3):401-3; discussion 403-4. doi: 10.1016/j.amjsurg.2007.12.014. Are postoperative activity restrictions evidence-based?  Guttormson R, Tschirhart J, Boysen D, Martinson K.
5Obstet Gynecol. 2006 Feb;107(2 Pt 1):305-9.  Postoperative activity restrictions: any evidence?  Weir LF, Nygaard IE, Wilken J, Brandt D, Janz KF.