After I had my second son, I came home from the hospital with a catheter bag. I was unable to pee on my own after delivery. Who even knew that was something that happens? As the nurse showed me how to change the “overnight bag” out for the “day bag,” she said, “See how small this is? You could wear a cute little skirt with that on your leg and nobody would ever know!”
I can tell you I was for sure not going anywhere with a pee-bag strapped to my thigh, and I certainly wasn’t going to wear a skirt, cute or otherwise, if I did. Thankfully, my issues cleared up within a few weeks, but I later learned as many as 17.9 percent of postpartum women report this challenge, and they aren’t all as lucky as me.
Urinary retention is far from the only unpleasant thing that happens to childbearing women. Millions suffer from damage to their nether-regions (some estimate as many as 50 percent of childbearing women experience incontinence), often struggling for decades just to continue daily activities. Turns out, there’s a whole medical field dedicated to preventing and fixing such problems: pelvic floor physical therapy.
Lara Henke, a physical therapist based in Pittsburgh, Pennsylvania, explains that women seek her services for everything from urinary leakage and fecal incontinence to pelvic organ prolapse and pain during intercourse, medical exams, urination, or bowel movements. But many more are simply dealing with these issues in silence.
“Women suffer through these challenges for years sometimes before seeking treatment,” Henke says. “The symptoms are often embarrassing, not something women typically bring up to their friends or even their physician.”
I’m pretty outspoken myself, but I sure didn’t tell many people about my catheter bag when they stopped by to bring casseroles.
Henke also sees women for muscle spasms or tissue restriction due to episiotomy or tearing, diastis rectis abdmonins (when the “6-pack” abdominal muscles fail to reattach after delivery), and scar care following cesarean surgery. “This is often an area that isn’t addressed by surgeons,” Henke says. “Once the incision heals, that’s kind of the end for them, but from a connective tissue standpoint, we see restricted tissue affecting muscles, circulation, tension on nerves.” In these cases, physical therapy can help women decrease their pain and improve their mobility and return to the same level of physical activity they enjoyed pre-pregnancy.
But first, women need to realize these issues are not normal and speak up to their care providers.
Another Pittsburgher, Suzie K., was 18 weeks pregnant with her second daughter when something disturbing happened. “I was in the shower, washing, and I felt something bulging out of my vagina,” she says. Since she’d delivered her first child at 35 weeks, Suzie feared that part of her placenta, or maybe even the baby, was falling from her body.
Instead, she was diagnosed with a rectal prolapse, something she was unaware could happen to young, pregnant women. Her care providers didn’t offer a lot of information beyond confirming that her lower colon was protruding, but they did refer Suzie to a pelvic floor physical therapist. “I had no idea there were different organs that could just drop out of a woman’s body,” she says. At home, Suzie began to research her condition, its causes, and what she might expect during treatment.
Henke says, “In physical therapy, we look holistically at the whole person, not just the pelvic floor function. During a comprehensive health screening, we ask a lot of questions that seem unrelated to the presenting symptoms in order to get a detailed picture of what might be impacting how the muscles activate and coordinate.”
During Suzie’s initial health screening, she learned that her labor with her older daughter, Abby, had probably led to her prolapse during this pregnancy. With Abby, Suzie had a fast, hard labor of under three hours and was instructed by her L&D (labor and delivery) nurse to push while lying on her back, pushing for 10-counts regardless of whether she felt the urge.
“My therapist told me that straining like that and not listening to my body can be a risk factor for issues like prolapse later in life,” Suzie says. Because she was pregnant, her therapist could only work externally, teaching techniques like muscle relaxation, proper lifting, weight restrictions, and focusing on posture.
Suzie switched her prenatal care to work with a midwifery group (supervised by Maternal Fetal Medicine) so that she’d be able to relax in labor and push in a position and rhythm that worked for her body. Suzie wound up birthing baby Lily in a seated position, pushing slowly and only when she felt the urge.
Around two months postpartum, Suzie was able to begin pelvic floor physical therapy sessions in earnest with weekly internal sessions on top of physical exercises. Henke explains that organ prolapse is caused by weakness in the musculature between the rectum and the vagina, so Suzie’s therapist spent the first few weeks focusing internally.
“Honestly, it wasn’t any more uncomfortable than a regular gynecological exam,” Suzie explained, describing how the therapist used trigger point therapy to work and massage the ligaments in Suzie’s pelvic floor. “It was definitely awkward,” she says, “but it felt better after each session.”
For many women, the thought of a physical therapist inserting her hand up their vagina becomes a barrier to seeking treatment. But not all women require internal examinations to correct their issues.
Salem, Oregon, mother Leah McMillan was about 20 weeks pregnant with her second child when she pulled her groin chasing her daughter, Violet, through the library. The next day, as she bent to change Violet’s diaper, Leah’s back seized and she found she couldn’t move. Several visits to the chiropractor later, and Leah was still complaining of pain to her neighbor, who happens to work as a pelvic floor physical therapist.
At the urging of her neighbor, Leah began PT while pregnant and during the course of her treatment learned that an initial injury lifting a bike trailer months earlier might have set off a chain of events leading to muscle weaknesses, eventually causing the pulled groin. When she first walked into the physical therapy gym, Leah felt nervous as the therapist escorted her to the back to a private room. “I thought, Oh god! What are they going to do to me?” she says, but she never required an internal exam.
The clinicians just wanted her to receive treatment in a private space where she completed exercises lying on a table. Leah says, “It was honestly more like massage therapy, with some pushing and pulling on my legs mixed in.” She was sent home each week with homework: cat/cow yoga poses, leg lifts—not the Jane Fonda kind, but slow and deliberate lifts focusing on engaging the thighs instead of the glutes—and squats holding on to the kitchen counter. Physical therapy exercises focus intently on the mechanics of each movement, so the exercises might seem simplistic at first until patients are really activating the correct muscles in the proper way.
As Leah began to feel better and better, she mentioned to her physical therapist that she’d had a cesarean section with Violet due to the baby’s sub-optimal positioning. She wondered if there was anything she could do to help prevent this and have a VBAC (vaginal birth after cesarean) with her second child. The therapist found one of Leah’s pelvic bones was slightly tipped and developed an exercise plan to help her keep everything aligned.
Henke explains that pelvic floor physical therapy can help get the pelvic joints in optimal alignment to most efficiently activate the muscles in that area, which can help smoothly deliver a baby. “We advise women about positioning during labor that might be best for their body type and specific orthopedic issues,” she says.
By the end of her pregnancy, Leah felt like her pain issues were fully resolved, but she was nervous to end treatment. “My therapist said, ‘you know, you don’t have to come in,’ but I kept making appointments just in case an issue would come up! I felt like this was a very proactive thing I could do to help my body feel better and stay strong for labor.”
When she did go into labor, Leah had very little back or groin pain and was able to birth baby Liam vaginally with no complications.
Women who enter pelvic floor physical therapy can expect weekly sessions lasting 45 minutes to an hour. Patients will get “homework” exercises to keep building strength between sessions. These sometimes go beyond squats and crunches—Suzie said her therapist encouraged her to work on some of the internal exercises at home with a dildo.
Most sessions will be completed in a private exam room, but many therapists develop a code phrase with clients who then go out into the main gym to work on exercises. For instance, Henke tells patients she wants them to “squeeze the muscles” when she’s referring to kegels and other tightening exercises for the pelvic floor.
Women seeking a pelvic floor physical therapist can consult the American Physical Therapy Association Section on Women’s Health. Therapists with advanced clinical specialist certification in pelvic floor issues are denoted with “WCS,” which stands for women’s clinical specialist. Women can ask if other therapists have had post-professional training specifically regarding pelvic floor muscle evaluation.
In some cases, pelvic floor problems appear relatively soon after childbirth. But often, women won’t experience issues like prolapse until many years later. Warning signs like pain during intercourse, popping joints, or even just a sense of pressure in the vagina or rectum can indicate trouble to come. Henke says, “If we can intervene early, we can prevent life-altering issues later in life.”