The Femina Physical Therapy Blog

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Written by: Ken Sinervo, MD, MSc, FRCSC, ACGE

Published: 13 March 2025

Last Updated: 13 March 2025

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Disclaimer: The decision to undergo surgery for endometriosis is a personal one, and outcomes can vary. There are no universal guarantees, and each patient’s experience is unique. It is essential to discuss all treatment options with a qualified healthcare provider. The information provided herein is for educational purposes only and does not constitute medical advice or establish a doctor-patient relationship.

EXCISION SURGERY FOR ENDOMETRIOSIS: POST-OPERATIVE PAIN EXPECTATIONS

Guest Post Author: Ken Sinervo, MD, MSc, FRCSC, ACGE

Endometriosis is a systemic, inflammatory disease affecting an estimated 200 million girls and women (Yi et al., 2021) and unmeasured amounts of gender-diverse individuals globally. Characterized by the presence of endometrium-like tissue found in other areas of the body (Taylor et al., 2021), the disease has been documented in virtually every organ system and commonly presents with a variety of subtypes and clinical manifestations. Endometriosis can lead to significant decline in the quality of life of those affected and carries a heavy financial burden on society. For many, surgical intervention is a pivotal step toward both diagnostic confirmation and alleviating symptoms, particularly Laparoscopic Excision (LAPEX). LAPEX is considered by many to be the ‘surgical gold standard’ of operative treatment. Understanding expectations following LAPEX is vital for managing recovery and setting realistic post-operative goals.

Understanding Laparoscopic Excision

Surgical excision of endometriosis is a meticulous technique that aims not only to alleviate pain but also restore normal anatomical structures and functioning. Utilizing cutting techniques, the excisional method allows for thorough removal of lesions ‘root to tip’ and the subsequent pathological examination to confirm a diagnosis. In our Center, we utilize the laser as a cutting tool to resect and remove the disease from all involved areas, preserving healthy tissue and surrounding structures. This precise approach minimizes damage to adjacent areas, promotes faster healing, and enhances overall outcomes for our patients. Studies have demonstrated that excision is more effective than placebo in reducing pain and improving quality of life in all stages of disease, and is generally preferred for its superior outcomes (Rathod et al., 2024). Others have demonstrated that excision is also perceived as superior to ablation* in most measures (Isaac et al., 2024).

In general, Minimally Invasive Gynecologic Surgery (MIGS) like Laparoscopy involves smaller incisions and may result in less postoperative pain, shorter recovery times, and reduced scarring compared to traditional open surgery. Though MIG surgery is considered ‘minimally invasive,’ it can be quite technically complex and vary significantly in terms of techniques, extent of disease treated, and individual patient circumstances. Pain and recovery expectations following excision surgery subsequently vary significantly among individuals and are influenced by numerous factors. Surgical technique, patient characteristics, pain management strategies, and other dynamics all play a role, and educating patients preoperatively can help healthcare providers set realistic expectations, enhance education, and improve overall satisfaction with outcomes.

To that end, excision of endometriosis can be challenging due to several factors, not limited to:

• Extent of Disease: Endometriosis necessitates careful planning and skilled surgical techniques, often undertaken in an interdisciplinary operative setting with a team from gynecology, colorectal, and other specialties.

• Surgical Precision: The complex nature of the disease means the surgeon(s) must be highly skilled in cutting out the lesion(s) from wherever they are present while simultaneously preserving healthy tissue and adjacent organs. This requires an extremely high level of expertise which can only be gleaned through advanced training and high volume experience.

• Potential Complications: Even ‘minimally invasive’ procedures carry risks, including but not limited to bleeding, infection, and damage to surrounding organs. Patients must be fully informed about the benefits and drawbacks of any surgery, all possible risks, expected outcomes, and potential complications. The surgeon must be fully prepared to address unexpected events during surgery, including those involving the bowel, bladder, or nerves, and ensure that any such occurrences can be managed safely, swiftly, and effectively.

• Individual Variability: Each patient's experience with endometriosis and their response to surgery will differ based on personal and specific factors including disease severity, overall health, previous treatments, and more.

It is essential to recognize the complexities involved in excision surgery and the importance of a truly skilled surgical approach to achieve the best, safest outcomes for patients.

Overview of the Post-Operative Recovery Process

The post-operative phase is a crucial one, and understanding expectations and management, especially of pain, is essential for successful recovery. The process varies depending on the type of surgery, the individual’s general health and underlying conditions, and various other factors which could complicate or lengthen healing. A comprehensive approach to recovery includes effectively managing pain, preventing complications, promoting mobility, and supporting overall well-being.

While recovery is generally quicker versus open surgery, patients will still experience pain and discomfort. The healing process is not linear, and post-operative pain may ebb and flow throughout the days and weeks following surgery. The recovery process involves several stages: 

Immediate Post-Surgery Phase (First 24-72 Hours)

• Hospital Monitoring: Vital signs, pain levels, and any immediate complications (such as bleeding or infection) are closely monitored.

• Mobility: Early movement, such as leg exercises or short walks, helps prevent blood clots and enhances circulation.

• Diet & Hydration: Patients may start with clear liquids before progressing to solid foods as tolerated.

• Pain Management & Realistic Understanding of Pain Expectations: This is crucial for patients undergoing any surgical procedure. It helps patients have a better sense on the level and duration of pain they may experience post-operatively. This knowledge can reduce anxiety and fear, and allows patients to mentally prepare for their recovery journey. Additionally, when patients are well-informed, they are more likely to communicate effectively about their pain levels, which is essential for timely intervention and support. 

Post-operative pain can vary significantly among individuals and may include:

• Incisional Pain: This is localized pain at the site of surgery, typically managed with analgesics.
• Referred Pain: Pain that may occur in areas distant from the surgical site due to nerve pathways.

Pain is typically measured using the Numeric Rating Scale, where patients rate their pain from 0 (no pain) to 10 (worst pain imaginable). However, this can vary based on the type of surgery and individual pain thresholds.

• Immediate Post-Op (0-24 hours): Patients generally experience the highest levels of pain immediately after surgery.
• 24-72 Hours Post-Op: Pain levels typically peak within this timeframe, followed by a gradual decrease. 
• Week 1-2 Post-Op: By the end of the first week, many patients report a reduced pain score, indicating transition from acute to more manageable pain.
• Week Two-Four: Most patients experience marked reduction in pain.
• Total healing can take 90 days or longer even after  a patient has resumed normal activity  levels, and patients may find that they experience painful periods for the first three cycles and/or have fatigue, transient pain, and other post-operatuve effects due to ongoing physical recovery, emotional stress, medication effects, overexertion, or sleep disturbances. It's important to listen to your body and consult your healthcare providers if symptoms seem disproportionate or persistent.

Effective pain management is a critical component of the recovery process, enabling patients to engage in rehabilitation activities and improve their quality of life post-surgery. Prioritizing pain control not only enhances recovery but promotes overall patient satisfaction. Depending on the case, this may involve opioid and/or non-opioid pain relievers, nerve blocks, anti-inflammatory medications and others. Pain levels can be influenced by various factors, including:

• Type of Procedure(s) Performed: The nature of procedures can significantly impact pain levels. More invasive surgeries, i.e., Video Assisted Thoracic surgery for lung endometriosis or bowel resection for invasive GI lesions may result in lengthier and higher pain levels compared to other LAPEX cases that do not involve such procedures.
• Individual Patient Factors: A patient’s pre-existing health and individual pain thresholds cannot be undervalued for their influence on how the patient experiences pain. Younger patients may recover faster, while older patients or those with chronic conditions may face additional challenges.
• Quality of Post-Operative Care & Monitoring: Effective post-operative care, including close monitoring and timely interventions, can significantly influence pain management outcomes and overall recovery. Patients should be educated on recognizing signs that indicate their pain may be excessive or not aligning with expected levels, such as increased intensity or changes in the character of pain. Clear guidelines should be provided to patients on when to reach out to healthcare professionals, including signs of complications or inadequate pain control.

Short-Term Recovery (First Few Weeks)

• Wound Care: Keeping the surgical site clean and dry reduces infection risk. Some patients may require drains, which must be managed properly.

• Activity Restrictions: Heavy lifting, strenuous activities, and excessive bending or stretching are discouraged. Frequent short breaks are encouraged. 

• Non-Pharmacological Approaches (Ice, Elevation): Complementary methods like applying ice/heat or using relaxation techniques can help alleviate pain and swelling. Ongoing assessment of pain levels allows for adjustments in pain management strategies, ensuring that patients receive the most effective care tailored to their needs.
• Monitoring Bowel & Bladder Function: Post-op constipation is common, especially with opioid use. Increased fiber intake, hydration, and gentle laxatives may help. Voiding concerns should be addressed with the surgeon at the post-operative visit, if not before as necessary. 

Mid-Term Recovery (Weeks to Months)

• Physical Therapy & Rehabilitation: Physical therapy plays a vital role in post-operative recovery, aiding in mobility, strength building, and pain reduction, ultimately facilitating a faster return to normal activities. Structured exercises with endometriosis- and pelvic pain-specialized PTs can be very helpful postoperatively to regain strength and flexibility and address secondary pain generators like pelvic floor dysfunction or others.
• Hormonal & Systemic Adjustments: For surgeries that involve post-operative medical therapy, hormonal changes may impact recovery.

Long-Term Recovery & Functional Restoration

• Emotional & Psychological Support: Depression and anxiety may arise post-surgery, particularly if chronic pain has been a longstanding issue. Support groups, therapy, and mindfulness practices can be helpful.

• Gradual Return to Normal Activities: Patients should pace themselves and listen to their bodies when resuming work, exercise, sex, and other routines.

• Always an important consideration, a balanced diet rich in protein, vitamins, and minerals is essential for postoperative healing, as it supports tissue repair, boosts the immune system, and promotes overall recovery.

• Follow-Up Appointments: Ongoing monitoring ensures healing is on track and complications are addressed.

Having a clear understanding of what to expect can lead to better adherence to pain management strategies, improve overall satisfaction with the surgical experience, and enhance cooperation between patients and their healthcare providers. Remember each patient’s recovery journey is unique, and a personalized plan - often involving a multidisciplinary approach - is essential for optimal outcomes.

Continued Post-Excision Pain: Is Something Wrong?

For many with endometriosis, LAPEX can provide significant relief. Some patients, however, can continue to experience pain long after the standard window of postoperative recovery. It is important to understand that excision is not a universal cure for endometriosis and that even removing all disease may not solve underlying issues for some individuals. It is also true that not all pain is from endometriosis. Persistent pain can stem from secondary pain generators and other factors such as surgical complications or underlying conditions that were not addressed during the procedure. Identifying the root cause for continuing symptoms is essential for effective management.

One major contributor to ongoing pain is secondary pain generators, which develop as a result of prolonged nerve sensitization, musculoskeletal dysfunction, or associated conditions. Central sensitization - where the nervous system remains in a heightened state of pain response even after the initial source is removed - can make post-surgical pain feel disproportionate. Pelvic floor dysfunction is also common, as chronic pain and inflammation from endometriosis can lead to muscle hypertonicity (tightness), which contributes to deep, aching pain, painful intercourse, and bladder or bowel dysfunction. In some cases, pain originates from nearby organs, such as the bladder (Bladder Pain Syndrome) or intestines (Irritable Bowel Syndrome), which can mimic endometriosis symptoms. Surgical complications may also play a role in continued pain. 

Adhesions, or bands of scar tissue that form between organs and tissues, can cause pain by restricting movement and function. While meticulous surgical techniques and barriers can minimize formation, adhesions can still develop and lead to pain or issues.

Nerve-related pain is another potential cause, particularly if surgical dissection involved areas near the pudendal, ilioinguinal, or genitofemoral nerves. Neuropathic pain - described as burning, shooting, or tingling – may result from nerve irritation or injury. 

In cases where incomplete excision occurs, residual endometriosis can continue to provoke inflammation and pain, particularly if deep infiltrating lesions remain in areas like the diaphragm or bowel.

Pain persistence may also be related to underlying autoimmune or inflammatory conditions that can exacerbate pain by amplifying the body's response to perceived threats.

A comprehensive post-surgical plan that includes Pelvic Physical Therapy, pain management, hormonal modulation if necessary, and/or lifestyle interventions including adequate nutrition is often appropriate to optimize recovery and reduce discomfort. Communication with your healthcare team is key. Patients should feel empowered to speak openly with their healthcare teams about their pain levels and any ongoing symptoms or concerns, fostering a truly patient- centered, collaborative approach to ongoing care and management.

In Conclusion

Understanding what to expect throughout the recovery process empowers patients, allowing them to navigate their journeys with greater confidence and a clearer perspective on their path to relief. Through thorough pre-operative education, effective pain and post-operative management strategies, and multidisciplinary, personalized care, healthcare providers can significantly improve outcomes in care. As we continue to explore the complexities of endometriosis management, it remains essential to support our patients in their recovery by providing them with the tools and knowledge necessary to enhance their quality of life, both immediately after surgery and for the long term.

Learn more from Dr. Sinervo and his team at The Center for Endometriosis Care

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Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. Lancet. 2021;397(10276):839-852.

Yi M, Wang S, Zhang X, et al. Linc-ROR Promotes EMT by Targeting miR-204-5p/SMAD4 in Endometriosis. Reprod Sci. 2023;30(9):2665-2679. 

Rathod S, Shanoo A, Acharya N. Endometriosis: A Comprehensive Exploration of Inflammatory Mechanisms and Fertility Implications. Cureus. 2024;16(8):e66128.

Isaac A, Kapetanakis T, Thibeault E, Chatburn L, Mackenzie M. Patient Perception and Experience of Laparoscopic Excision versus Ablation of Endometriosis: A Crowd-Sourced Comparative Evaluation of Symptom and Quality of Life Outcomes. J Minim Invasive Gynecol. Published online October 26, 2024. doi:10.1016/j.jmig.2024.10.014.

*The terms "ablation of endometriosis" and "endometrial ablation" sound similar but refer to completely different procedures with distinct purposes. Ablation of endometriosis is a surgical procedure often performed by those who are not trained in excision, as it requires less specialized skill and experience. The procedure burns or cauterizes lesions, but leaves deeper disease behind, leading to persistent endometriosis and ongoing symptoms. Endometrial ablation is a surgical procedure undertaken to destroy the uterine lining to reduce heavy menstrual bleeding. It is not among accepted treatments for endometriosis, and the procedures serve different purposes.

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Written by: Debbie Dy, PT, DPT

Published: 12 March 2025

Last Updated: 12 March 2025

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This article reviews information about Urinary Tract Infections (UTIs), understanding the link between UTIs and pelvic floor dysfunction, as well as how pelvic floor therapy can help. Recurrent urinary tract infections (UTIs) are common, especially among women, and can significantly impact quality of life. Emerging research suggests that pelvic floor dysfunction and hormonal changes, particularly during menopause, may contribute to recurrent UTIs, making physical therapy an effective alternative to frequent antibiotic use. By improving pelvic floor muscle coordination and addressing voiding dysfunction, physical therapy can help reduce UTI frequency and enhance overall urinary health.

Recurrent urinary tract infections (UTIs) are a common issue that we have seen more and more at our practice in recent years, particularly among women. You’ll seldom find a woman who hasn’t had at least 1 UTI in their lifetime, however, recurrent UTIs can significantly impact quality of life. Antibiotics are often first line treatments for acute UTIs. However, this can be problemsome with those dealing with recurrent UTIs, due to the frequent disruption of the gut microbiome, as well as the increasing risk of contracting antibiotic resistant UTI bacteria with repeated use.

The American Urological Association defines recurrent UTIs as “two separate culture-proven episodes of acute bacterial cystitis and associated symptoms within 6 months or 3 episodes within 1 year.”

Emerging evidence suggests that pelvic floor dysfunction may contribute to these recurrent infections. Addressing this dysfunction through physical therapy offers a promising alternative for reducing UTI frequency without antibiotic use, and for alleviating associated symptoms.

Understanding the Link Between Pelvic Floor Dysfunction and UTIs

The pelvic floor muscles play a crucial role in urinary function. Dysfunction in these muscles can lead to issues such as urinary incontinence (UI) and voiding dysfunction, which may increase the risk of UTIs. For instance, non-relaxing pelvic floor muscles can disrupt the normal flow of urine (think like kinking a garden hose), allowing bacteria in retained urine to remain in the urinary tract and potentially cause infections.

Recurrent UTIs and Menopause
The hormonal changes associated with menopause, particularly the decline in estrogen levels, can significantly affect the genitourinary system. This condition, known as genitourinary syndrome of menopause (GSM), encompasses a range of symptoms, including:

• Vaginal dryness and atrophy
• Increased urinary frequency and urgency
• Dyspareunia (pain during intercourse)

And notably…Recurrent UTIs

Estrogen plays a vital role in maintaining the health of the urogenital tissues. Its decline during menopause can weaken the epithelial lining of the bladder and urethra, impair the pelvic floor muscles, and disrupt the vaginal microbiota, all of which may increase susceptibility to UTIs.

A study published in the Journal of Menopausal Medicine emphasizes that addressing GSM through hormonal therapies and physical therapy interventions can significantly alleviate these symptoms and reduce the risk of recurrent infections.

Benefits of Physical Therapy in Managing Recurrent UTIs

Physical therapy aims to improve pelvic floor muscle function, which can:

• Enhance muscle coordination: Proper coordination of pelvic floor muscles ensures complete bladder emptying, reducing residual urine where bacteria can thrive.
• Address voiding dysfunction: Therapies targeting voiding dysfunction can prevent involuntary contractions of the external urethral sphincter during urination, promoting a healthier urinary flow.
• Reduce dependence on antibiotics: By addressing the root cause of recurrent UTIs, physical therapy may decrease the need for antibiotics, mitigating the risk of antibiotic resistance.

Physical therapists can provide treatment such as:

• Perform manual therapy on overactive pelvic floor muscles to improve voiding dysfunction and coordination
• Education on proper bladder habits and hygiene to reduce UTI frequency
• Provide referrals to menopause specialists to help sort out any hormonal dysfunction that may be leading to decreased health of urogenital tissues

Conclusion

Recurrent urinary tract infections (UTIs) are a common issue, particularly among women, and can significantly impact quality of life. Traditional treatments often focus on antibiotics; however, emerging evidence suggests that pelvic floor dysfunction and other factors, such as hormonal changes during menopause, may contribute to these recurrent infections. Addressing these underlying issues through physical therapy offers a promising alternative for reducing UTI frequency and alleviating associated symptoms.

Incorporating physical therapy into the treatment plan for individuals experiencing recurrent UTIs offers a conservative and effective approach to addressing underlying pelvic floor dysfunction. By enhancing muscle coordination and addressing voiding dysfunction, physical therapy can reduce the frequency of UTIs and improve overall urinary health. Individuals suffering from recurrent UTIs should consider consulting a pelvic health physical therapist to explore this treatment option. Suffering from chronic UTIs? Our highly trained staff of physical therapists are here for you!

References:

1. Divine, Kate PT, DPT, WCS; McVey, Lisa PT, DPT. Physical Therapy Management in Recurrent Urinary Tract Infections: A Case Report. Journal of Women's Health Physical Therapy 45(1):p 27-33, January/March 2021. | DOI: 10.1097/JWH.0000000000000189 
2. Kim, H. K., Kang, S. Y., Chung, Y. J., Kim, J. H., & Kim, M. R. (2015). The Recent Review of the Genitourinary Syndrome of Menopause. Journal of menopausal medicine, 21(2), 65–71. doi:10.6118/jmm.2015.21.2.65
3. Mareș C, Petca RC, Popescu RI, Petca A, Mulțescu R, Bulai CA, Ene CV, Geavlete PA, Geavlete BF, Jinga V. Update on Urinary Tract Infection Antibiotic Resistance-A Retrospective Study in Females in Conjunction with Clinical Data. Life (Basel). 2024 Jan 9;14(1):106. doi: 10.3390/life14010106. PMID: 38255721; PMCID: PMC10820678.

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Written by: Kasia Gondek, PT, DPT, CLT, CSCS

Published: 12 March 2025

Last Updated: 12 March 2025

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It is not uncommon for patients with autoimmune diseases to come see us because of difficulties with arousal, pain with sex or orgasms, and/or erectile dysfunction. This is because the chronic inflammation that occurs with autoimmune conditions impacts how nerves function, alters blood flow, and can make it difficult to sustain an erection or can cause vaginal dryness. Additionally, joint pain, muscle aches, and other pain symptoms associated with autoimmune diseases can make sexual activity uncomfortable or painful, and some autoimmune conditions can disrupt hormone balance, impacting sexual desire, arousal and overall sexual function. Autoimmune conditions like lupus, Sjogren’s syndrome, type 1 diabetes and rheumatoid arthritis are examples of systemic autoimmune diseases that can be associated with sexual dysfunction. 

One meta analysis and systematic review conducted by Minopoulou I, Pyrgidis N, Tishukov M, et al. in 2023 found that 63% of people with a systemic autoimmune rheumatic diseases (like lupus, Sjogren’s, and rheumatoid arthritis) have sexual dysfunction. They found that women with Sjögren's syndrome and systemic sclerosis reported the highest levels of sexual dysfunction.1

Additionally, “A 2024 meta-synthesis of 6 studies involving people with inflammatory arthritis conditions found that sexual function was impacted by pain, lower sexual desire, erectile dysfunction, fatigue, fluctuations in disease activity, altered self-image, and confidence in sexuality, with negative impacts on intimate relationships with partners.”2,3

What can pelvic floor therapy do to help my Autoimmune condition?

If you have been diagnosed with an autoimmune disease and notice that you have any symptoms of sexual dysfunction, our pelvic health physical therapists can help you! When a person comes to us with sexual dysfunction and also has an autoimmune condition, we take a thorough history of their symptoms, previous treatments, current medications, and current providers. We then conduct an orthopedic assessment that includes screening the spine, hips, legs and feet as well as any other body regions that may be impacted by the person’s condition. This may include observation of day-to-day movements such as bending over, reaching, squatting, walking, and balance. Additionally, we check range of motion and flexibility, muscle and soft tissue mobility and tender points, strength and muscle coordination. This is followed by a pelvic floor assessment which entails observation of pelvic floor muscle function, tissue health, and checking for any trigger points/ tenderness in the person’s pelvic floor muscles externally and internally depending upon the person’s comfort level at that time. The goal of these assessments is to determine what is driving the person’s sexual dysfunction and pain, and then targeting physical therapy treatment toward these areas. 

How long until I see results in physical therapy?

Each person’s physical therapy treatment plan is unique because no two people are exactly alike! In general, people will begin to see improvements in their pain and functioning in about four sessions, however the complete treatment plan duration does vary from person to person depending upon their symptoms, areas of treatment, and how long symptoms have been going on. 

Our pelvic health physical therapists are here to support you!

All of our physical therapists have specialized training in treating and healing pelvic pain, sexual dysfunctions, and the associated difficulties with day-to-day functioning that can go along with an autoimmune disease. Our goal is to provide compassionate, evidence-based, and effective treatments to help you feel and function at your best. Contact our office to start getting the care and support you deserve.

Sources: 

1. Minopoulou I, Pyrgidis N, Tishukov M, et al. Sexual dysfunction in women with systemic autoimmune rheumatic disorders: a systematic review and meta-analysis. Rheumatology (Oxford). 2023;62(3):1021-1030. doi:10.1093/rheumatology/keac457
2. Ackerman IN, Restoux L, Dobo B, Slater H, Ross MH, Briggs AM. Holistic Care for People Living With Chronic Musculoskeletal Pain: The Relevance and Importance of Sexual Function. Phys Ther. 2024;104(8):pzae083. doi:10.1093/ptj/pzae083
3. Restoux LJ, Dasariraju SR, Ackerman IN, Van Doornum S, Romero L, Briggs AM. Systematic review of the impact of inflammatory arthritis on intimate relationships and sexual function. Arthritis Care Res. 2020;72:41–62. doi: 10.1002/acr.23857.

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Written by: Anna Larson, PT, DPT

Published: 20 January 2025

Last Updated: 20 January 2025

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Physical therapy visits prior to childbirth, often called birth preparation or “push prep” visits, are essential and should be recommended to every pregnant human!

This article will cover:

• What is Birth Prep (or Push Prep)?
• Why do I need physical therapy to help with delivery of my baby?
• Do I need Birth Prep if I’m having a C-section?

What is Birth Prep (Push Prep) and what can I expect from my visits?

Birth preparation with our physical therapists is a program that gets you more comfortable during pregnancy and works on issues that have been identified to optimize your birth experience.

During these visits, your physical therapist will:

• Provide education to the expecting patient about the birthing process
• Alleviate any discomfort related to pregnancy
• Teach you how to get in touch with your pelvic floor muscles
• Provide tools and practices to help prevent severe perineal tearing
• Help prepare the birthing person for a better postpartum recovery.

Why should Birth Prep be included in my prenatal care?

The following are five key reasons why birth prep should be included in your prenatal care:

1. Education about Labor

Personally, this is one of my favorite parts of a push-prep visit. We get to take our time discussing what each of the stages of labor entail, helpful movements and positions for each stage of labor, and even how your birthing partner can help during this process. 

2. Relieves Common Pregnancy Discomforts

Pregnancy can cause a variety of aches and pains due to hormonal changes, the growing weight of the baby, and changes in posture. Some common issues include:

• Back pain
• Pelvic pain and pelvic girdle pain (PGP)
• Sciatica
• Neck and shoulder tension
• Carpal tunnel syndrome

Get ahead of the pain when it begins, not when you are postpartum and have a whole new human to take care of! Many of my patients are told, “your pain will just go away when you deliver the baby”. Sometimes this is the case, but many times aches and pains can linger or even get worse, and it is best to assess and begin to improve your pain and function in the prenatal period. Techniques such as manual therapy, therapeutic exercises, and posture correction can be helpful. 

3. Awareness of the Pelvic Floor

Labor and delivery requires significant physical effort, however, during actual labor, the pelvic floor just needs to get out of the way and let your uterus do its job! During our birth prep program, we teach you how to properly contract, and more importantly, relax your pelvic floor so that coordination of these muscles is automatic to you when the time comes! Physical therapy can also help you strengthen these muscles, as well as your core, back, and glutes to help through the rest of your pregnancy and with postpartum recovery.  

• Pelvic floor exercises (like Kegels) can help prepare the muscles for the pressure of labor and delivery, reducing the risk of incontinence both during pregnancy and after childbirth.
• Core strengthening enhances your ability to maintain posture and stability during labor and supports your changing posture during pregnancy.
• Lower back and hip strengthening helps reduce discomfort and improve mobility as the baby grows.

4. Reduces the Risk of Severe Tears During Labor

During a birth prep visit, we will teach you numerous techniques that have been proven in research to help decrease your risk of severe tearing – yay! Severe tears (grade 3 and 4) lead to more complications postpartum, and there is really no downside to incorporating these practices into your prenatal wellness routine. Some of these tools we will go through include:

• Optimal birthing positions to decrease your risk of tearing (Aasheim) through optimal labor positions.
• Breathing techniques both leading up to labor and during labor to decrease the strain on your pelvic floor
• Perineal massage, starting at 34 weeks pregnant have been shown to decrease the risk of severe tears (Beckman, Aasheim). While perineal massage is not a guarantee that you will not tear at all, it can help with the stretching sensation and discomfort of stretch of these tissues to help your body prepare for the sensation during vaginal child birth.

Your physical therapist can also provide instruction on specific birthing positions that will be best for you, depending on any injuries you are dealing with currently. For example, if you have labral tears in your hips, you would be advised on avoiding the classic lithotomy position (on your back with your hips and knees flexed past 90 degrees). 

5. Prepares You for Postpartum Recovery

While the focus during pregnancy is often on preparing for labor, physical therapy also plays an important role in preparing for postpartum recovery. Many women experience significant physical changes after childbirth, including pelvic floor dysfunction (such as incontinence of bowel and bladder), abdominal weakness, and poor posture due to the stress of pregnancy and delivery.

By strengthening key muscle groups and maintaining flexibility before delivery, physical therapy can reduce recovery time after birth, improve your strength, and decrease your chances of developing pelvic floor dysfunction, including incontinence. Additionally, it can aid in diastasis recti recovery, a condition where the abdominal muscles separate during pregnancy.

Will Birth Prep help me if I’m having a C-section?

Absolutely! As we discussed above, pelvic floor dysfunction can be identified while you are still pregnant. These issues can be addressed during pregnancy and lay down a better foundation for postpartum recovery. You can learn more about postpartum recovery after a c-section here.

So what are you waiting for??

Pregnancy is a time of immense change, and taking care of your body is crucial for both your well-being and that of your baby. Birth prep offers a range of benefits, from relieving common pregnancy discomforts to preparing your body for labor and helping you recover more quickly postpartum. If you’re expecting, consider adding a birth prep visit or two before your delivery. Your body—and your baby—will thank you! All of our therapists at Femina Physical Therapy are specialized to help you during your pregnancy and beyond, reach out to get started today! 

Resources

Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017;6(6):CD006672. Published 2017 Jun 13. doi:10.1002/14651858.CD006672.pub3

Beckmann MM, Garrett AJ. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. 2006;(1):CD005123. Published 2006 Jan 25. doi:10.1002/14651858.CD005123.pub2

Neta JN, Amorim MM, Guendler J, Delgado A, Lemos A, Katz L. Vocalization during the second stage of labor to prevent perineal trauma: A randomized controlled trial. Eur J Obstet Gynecol Reprod Biol. 2022;275:46-53. doi:10.1016/j.ejogrb.2022.06.007

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Written by: Debbie Dy, PT, DPT

Published: 20 January 2025

Last Updated: 12 March 2025

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Anorectal symptoms such as hemorrhoids, anal fissures, and anal pain are common during pregnancy and the postpartum period and can have a negative impact on one’s quality of life. They can be one cause of uncomfortable pain in the butt and anal area, but read on…there is hope!

This article will go over:

• Statistics related to hemorrhoids, anal and rectal pain during pregnancy
• Contributing factors to hemorrhoids, anal and rectal pain
• Birth Prep to improve your delivery experience
• How pelvic floor physical therapy can help!

HOW COMMON ARE HEMORRHOIDS DURING PREGNANCY?

Incidence of symptomatic hemorrhoids during pregnancy varies between 24-38%, increasing to 85% in the last trimester. Hemorrhoids are also very prevalent in the first 3 months postpartum, with the prevalence increasing with age and parity (the number of times you’ve delivered).

HOW DID I GET HEMORRHOIDS?

Many factors contribute to the development of hemorrhoids, including various musculoskeletal, hormonal and circulatory changes that occur during pregnancy.

• Increased intra-abdominal pressure compresses the pelvic veins, the inferior vena cava, and results in venous dilation (swelling or widening of the veins)
• Increased progesterone levels also lead to venous dilation and swelling
• Increased tension at symphysis pubis caused by high progesterone levels
• Physiological changes in blood volume that increases by 25-50% during third trimester 

Constipation increases the risk of hemorrhoids during pregnancy and prevalence of constipation in pregnancy by 11 to 38%.

Sex hormones are a large factor contributing to high rates of constipation in pregnancy, especially in the first trimester.

• Rising levels of progesterone cause relaxation of smooth muscle which leads to decrease in bowel motility.
  • This, combined with growth of the fetus prevents movement of feces through the bowel, making defecation mechanically difficult.
• Prolonged straining during defecation due to constipation leads to an increase in intra-abdominal pressure, contributing to hemorrhoids.

Other factors that contribute to the development of hemorrhoids:

• High body mass index (BMI)
• Iron supplementation
• Hypermobility associated with connective tissue disorders
• Low fiber and water intake
• Sedentary lifestyle 
• Higher number of pregnancies
• Increased anxiety and/or depression (due to nervous system effects)

Previous prolonged delivery, higher birth weight of more than 8.5 pounds, traumatic second stage of labor all additionally contribute to increased risk of postnatal hemorrhoids and anal fissures.

THE ROLE OF PELVIC FLOOR PHYSICAL THERAPY (PFPT)

Pelvic floor physical therapy for hemorrhoids, anal fissures and rectal pain focuses on relaxation of tight (or hypertonic/overactive) muscles, education on proper bowel mechanics and strategies to improve bowel movements, nervous system downtraining exercises (include Vagus nerve activation), restoring postural alignments, strengthening weak muscles and rehabilitating other aspects of the pelvic floor muscles. The pelvic floor muscles support the uterus, bladder, and rectum and when dysfunctional, can lead to developing hemorrhoids, anal or rectal pain. Pelvic Floor Physical Therapy can be instrumental in managing and alleviating hemorrhoid and other symptoms during and after pregnancy.

Benefits of Pelvic Floor Physical Therapy for Hemorrhoids

• Improved Circulation: Pelvic floor exercises can enhance blood flow in the pelvic region, reducing swelling and discomfort associated with hemorrhoids.
• Strengthening Pelvic Muscles: A stronger pelvic floor can improve management of intra-abdominal pressure, potentially preventing the development or worsening of hemorrhoids.
• Enhanced Bowel Function: PFPT can address constipation by promoting better bowel habits and reducing straining during defecation.

Teaching Optimal Labor and Delivery Positions

An often-overlooked benefit of pelvic floor physical therapy is the education it provides regarding labor and delivery positions. Prolonged labor can increase the risk of hemorrhoids due to sustained pressure on the pelvic floor region. Our physical therapists can teach positions that:

• Reduce the risk of prolonged labor by promoting effective pushing strategies.
• Minimize strain on the pelvic floor muscles, thereby decreasing the likelihood of developing or worsening hemorrhoids during delivery.
• Encourage proper alignment and relaxation to facilitate a smoother birthing process.
• Reduce risk of perineal tearing 

Conclusion

Hemorrhoids, anal and rectal pain are a prevalent issue during pregnancy and the postpartum period, influenced by factors such as age, multiple pregnancies, and constipation. Pelvic floor physical therapy offers a non-invasive, comprehensive approach to manage symptoms, prepare for labor, and protect pelvic health.

If you're pregnant or postpartum, consulting with a pelvic floor physical therapist can provide personalized strategies for symptom relief, improved bowel habits, and labor preparation, ultimately enhancing your comfort and quality of life. Contact us to get the support you deserve!

References:

1. Gülören, Gülbala PT, PhD, Çınar, Gamze Nalan PT, MSc, et al. Hemorrhoids, Anorectal Symptoms, and Related Risk Factors in Pregnancy and the Postpartum Period: A Follow-up Study. Journal of Women’s & Pelvic Health Physical Therapy 48(3):p 184-193, July/September 2024. | DOI: 10.1097/JWH.0000000000000308 
2. Longo SA, Moore RC, Canzoneri BJ, Robichaux A. Gastrointestinal conditions during pregnancy. Clin Colon Rectal Surg. 2010;23(2):80–89. doi:10. 1055/s-0030-1254294.
3. Bužinskiene D, Sabonyte-Balšaitienė Ž, Poškus T. Perianal diseases in pregnancy and after childbirth: frequency, risk factors, impact on women’s quality of life and treatment methods. Front Surg. 2022;9:788823. doi:10. 3389/fsurg.2022.788823