Often pain with intimacy is brushed off “oh you’ve had kids”, “just relax”, “have a drink and you’ll be fine”. If you have heard this rhetoric be the one to stop the narrative! Here we go through a case study on dyspareunia after having kids!

Case Study PD

What does it feel like?

A mom of two comes into the clinic, we will refer to her as PD. She is anxious and unsure of what to expect for her first appointment, but she knows she can’t continue to live like this. PD says that she started having pain with intimacy (specifically with intercourse also known as dysparuenia) after she delivered her first baby. It wasn’t bad then, just some burning and pinching right at the opening. It wasn’t too painful and didn’t stick around but definitely wasn’t pleasant.

Since having her second more trouble with intimacy began. PD recalls having some tearing during delivery with her second but she didn’t need a referral. Her and her partner have tried multiple times to be intimate but she has 8/10 pain. Her pain now is a pulling, burning, pinching at the opening and she also experiences sharp pains deep in her belly as well. PD has pain that persists after attempts at intimacy and it seems to be taking longer before it goes away now. She tells the therapist that she continues to attempt to be intimate for her partner and to see if it still hurts.

This all-too-familiar story doesn’t just happen just for women who have had children vaginally, but can also occur for women who have had c-sections as well as women without children. Let’s focus on this case and some of the possible reasons WHY this happens, what we can do about it, and how you can start your road to recovery TODAY! 

What Causes Pain with Intimacy?

There are many reasons why an individual may have pain during intimate encounters with their partner. In this instance PD is experiencing pain after child birth; which can be considered a trauma to the body. Since she had tearing during both her deliveries she will have scar tissue in the area that could be contributing. Couple this with the bodies natural response to pain (protect the area). The anticipation of pain causes the body to also move into a protective mode and it is a recipe for a pain cycle.

If you have pain with intercourse, a physiotherapy assessment could benefit you!

What does an assessment look like?

PD was seen for an assessment at the clinic where she was observed in how she moves generally through walking, squatting and bending movements. When evaluating her breathing PD had difficulty taking a deep breath down into the belly. The pelvic floor exam revealed a hypertonic/protective pelvic floor. At the time of the assessment she reported reproduction of “the pain”. The therapist was able to discontinue further evaluation while assisting PD in relaxing the muscles of the pelvic floor.

PD would be provided with a home program to improve deep breathing, pelvic floor muscle relaxation, and imagery/relaxation techniques to start.

Over the course of the next 3 months PD attended appointments at the clinic. Starting with once every 7-14 days, to stretching out as her symptoms improved. PD was thrilled with her improvements and adjustments to the home program and in-person techniques were made. These adjustments included home exercises and activity, discussion on optimal positions, and internal techniques as PD’s pain improved. After 6 appointments she reported being pain-free except when she was very stressed, but manageable with her home program. PD was also happy that the program also seemed to help with her light bladder leakage, and tailbone pain!

How long until I am better?

The recovery period usually varies from client to client, depending on the severity and frequency symptoms. Other factors include:

  • How long the pain has been present
  • Activity level
  • Ability to complete homework

Often with pelvic health issues resolution of straight forward cases occurs within 6-8 appointments. In some instances this could be shorter, and in others it could be longer.

Don’t delay! Schedule your assessment today to get started your journey to recovery!

Many people are aware that physiotherapy can help with injuries from sports or car accidents, but did you know there is physio that can help with your bladder problems? Not just any physiotherapist can assist you with your leaky bladder, we need to take a little bit of extra training to become a Pelvic Health Physiotherapist (PHPT). Depending on the courses that have been taken, PHPT can treat a variety of pelvic floor disorders including urinary incontinence.

There are a few different types of incontinence that pelvic health physiotherapy can address including stress urinary incontinence (leaking with cough and sneeze), urge urinary incontinence (leaking when rushing to the washroom), mixed urinary incontinence (a mix of stress and urge) and functional urinary incontinence (leaking due to other limitations).

In years past incontinence was an issue associated with an elderly woman who had likely had children at some point, and now we recognize that it is an issue not only in women, but men and children as well!

In some instances the leaking starts as just a small amount and only with certain activities, and in some instances it is a large amount and seeming to be all the time!

Stress Urinary IncontinenceLaughter is one of the frequent causes of stress incontinence

Usually occurs when intraabdominal pressures exceed the ability of our internal and external urethral sphincters to counteract these pressures on the bladder. This will happen most often during laughing, sneezing, coughing, lifting, or yelling. The muscles that control keeping urine in while the pressure around the bladder increases is our external urethral sphincters, a part of our pelvic floor musculature and they are under our control. When there is weakness in these muscle, possibly a problem with timing of the contraction of these muscles, or ‘bearing down’ vs ‘lifting up’, then some leakage can occur. Pelvic floor physical therapy can help by teaching techniques and strategies to get the best recruitment of the pelvic floor muscles and timing of the contractions with these increases in intraabdominal pressure.

 

Urge Urinary Incontinence

Developing urge incontinence on the way home or upon arrival is a common "key in the door" presentation

This leaking is associated with the increased urge to void without being able to make it to the bathroom in time. This may start with “photo finishes” and just making it to the washroom in time, to having the entire bladder empty at the first urge to void. Often a higher toned pelvic floor and/or overactive bladder may be the cause.  Pelvic floor physical therapy can help by teaching strategies for retraining of the bladder reflex responsible for the urge to urinate or by helping to decrease a higher toned pelvic floor with manual therapy techniques to the lumbosacral spine or pelvic floor and breathing/relaxation exercises.

 

Mixed Incontinence

As it sounds, this is usually a combination of the first two: stress and urge urinary incontinence. Depending on what the assessment finds, various techniques and strategies can be utilized by the pelvic floor physiotherapist to help address the issues. Each individual will get their own unique program no matter what type of issue they are coming in with, but this type in particular can have some very unique features for each client!

 

Functional & Overflow Incontinence

Generally will have leaking occur when there are other factors at play. Mobility or cognitive issues that prevent a person from making it to the bathroom in time are the biggest culprits  here. Physical therapists can help address mobility issues and provide manual therapy, teach exercises to help increase mobility, strength, balance as well as recommend certain mobility aids that can assist the client to reduce incontinence secondary to functional limitations. Often associated with the more elderly client, this can also affect younger individuals as well.

Photo by Cristina Gottardi on Unsplash - demonstrating one reason for functional incontinence (mobility issues)

Urinary incontinence can also be due to overflow incontinence.  The hallmark symptoms of this type of incontinence are frequent leakage of urine without the urge to void, or the inability to have normal volumes of urine. This is when the bladder remains full due to its inability to empty, which causes the urine to leak out when the bladder capacity is overfilled.  This type of incontinence is not a form that physical therapy typically addresses and NEEDS to be medically investigated first as there are a variety of medical reasons that may be causing this type of incontinence!

 

We have talked about what to expect in a pelvic health appointment before, and with these appointments as with all our assessments we get a detailed subjective history, followed by a scan exam of the low back, as well as an internal assessment of the pelvic floor is usually required in order to fully appreciate what is causing the urinary incontinence. This will help the therapist to formulate a treatment plan that will be individual and specific to each person being assessed. If someone is experiencing urinary incontinence and wishing to have this addressed by a pelvic health physiotherapist, no physician referral is required.

 

Have you been struggling with urine leakage? Not sure if your symptoms could be part of a pelvic health issue? Please feel free to contact us and we will help chat you through what you are experiencing as best we can.

Don’t delay start your road to recovery today in Warman or Saskatoon!

Maja Stroh is a physiotherapist that has a particular interest in pelvic health and perinatal care. She graduated from the U of S MPT program in 2009 and has been working with pelvic health populations since 2013. Maja’s interest in helping her clients and spending quality time with her family has brought her to Warman Physio where she will be providing services in the Warman location.

 

 

 

 

References:

 

The Canadian Continence Foundation <www.canadiancontinence.ca>

We have mentioned before about the predicament with completing ‘kegels’ (or the contraction phase of the kegel alone is what most end up doing). This has an inherent potential impact on labor and delivery.

Now there is new research out of the European Journal of Obstetrics & Gynecology and Reproductive Biology about the impact that there can be had when removing what is often referred to as ‘coached pushing’ during labor and delivery in addition to a few other key factors.

At Warman Physio we want to set women up for the best success possible during labor and delivery, and know that knowledge is power!

So let’s run through some of the background here.

The Facts From the Research

An article in Return to Now outlined the results from EJOG in a thought-provoking post. There is an 85% reduction in 3rd and 4th degree tears (the ‘worst’ of the available 1-4 scale) when women are not coached to push during labor. The amount of severe vaginal tearing was reduced from 7% to 1% within the study.

The researchers completed a review to determine what the main contributing factors were for third and fourth degree tears, and implemented a series of measures to try and reduce these risks.

Some of the risks include a larger than average baby, baby being born ‘face-up’, forceps use, previous perineal tear history, as well as maternal age and weight

This program is referred to as STOMP (Stop Traumatic OASIS Morbidity Project) and implemented within the hospital unit by the midwives and OB GYN teams over the following year. This program includes laboring in different positions to deliver the baby such as squatting, kneeling, and standing, as well as breathing through contractions instead of pushing and applying counter pressure to the perineum during delivery of the baby.

A total of 3902 vaginal deliveries occurred during the 1 year following the launch of full STOMP implementation, with the most significant and immediate results occurring in the first 5 months.

What Does This Mean?

We have seen before in a video demonstration how the uterus does it’s job to push a baby out, coached pushing is shown to lead to closure of the perineum on the descending baby. Allowing women to follow their instincts, without coached pushing, is proven to reduce severe perineal tearing. This will not eliminate all perineal tearing, but gives additional information into how we can best support mothers during labor and delivery.

Physiotherapists are uniquely positioned to assist with mothers during this phase of life, particularly pelvic floor physiotherapists.

Although seeing a pelvic health physiotherapist is not the standard of care here in Canada, there are many women choosing to see one prior to labor and delivery for a variety of reasons such as leaking, pelvic pain, pain with intercourse, and low back pain or sciatica among others. There is also a large trend to see women post-natally as well due to the same reasons in addition to injuries sustained during labor and delivery such as perineal tears.

 

How can Physiotherapy Help?

Pelvic floor physiotherapists, like those we have at Warman Physio, are able to provide prenatal evaluation of the pelvic floor muscles, coordination, and information on labor and delivery preparation activities. Many women will have been practicing kegels throughout their pregnancy since there still is a significant amount of mis-information regarding what is ‘best’… (remember, a tight pelvic floor isn’t really what we are going for, a functional pelvic floor is what we want!)

In Saskatchewan women are provided an immediate referral to physiotherapy if they have received a third or fourth degree tear (which is GREAT!), however, any woman who has been pregnant into the second trimester may benefit from seeing a pelvic floor therapist after delivering baby.

We have seen that in France, the standard of care is that every woman who has a baby is entitled to Pelvic Floor Physiotherapy appointments postpartum.

Reducing injuries during labor and delivery, and having research to support theoretical working knowledge is critical to advancing health and wellness for women of childbearing years.

Wonder if Physiotherapy can help you for labor and delivery? We recommend an appointment 32-34 weeks gestation. (For those with contraindications to a pelvic exam, we would complete various education and external assessment components).

 

Our Pelvic Health Therapists:

Kendra Usunier

Maja Stroh

Scott Golding

Haylie Lashta

 

 

 

 

At Warman Physio we have been working hard behind the scenes to get a secondary location going for all the clients that are unable to get out to Warman. We are pleased to announce that as of June 3, 2019 we will be located in Saskatoon!

To top it off, we are not only opening a second location, but we also have two NEW staff members to introduce to you!

Maja Stroh PT

First, our physiotherapist Maja Stroh!

  • Prolapse
  • Incontinence
  • Back pain
  • Sports Rehabilitation
  • General orthopedics

Maja is passionate about pelvic health and is always on the search to ensure that all angles are considered for every client. Her attention to detail and comprehensive exams ensure that you are obtaining the whole picture when you come in for any injury or issue.

 

We are also pleased to announce our RMT Signe Bone to the team in Saskatoon!

Signe has been working as a massage therapist for a number of years, and has always had a desire and drive to understand the human body from a very young age. She has been working in Saskatoon as an RMT as well as continuing her education in Prenatal Massage through Axiom Collage, and has begun her Visceral Manipulation through Barral Institute and Craniosacral Therapy through Upledger Institute. The areas of practice that Signe is most drawn to includes:

  • Prenatal & postpartum massage
  • General Injuries (whiplash, TOS, piriformis syndrome, etc)
  • Abdominal Health thorugh Visceral Manipulation
  • Critical Alignment Therapy
  • Cranial Sacral Therapy: CS1

Her love for learning and solving problems helps her provide the best care and treatment she can through working with her clients to better understand them as a person, not just as a body.

The schedule for physiotherapy assessment and treatment can be found HERE and to get on the list for booking for massage can be found HERE.

 

Spread the word and make sure you share this fantastic news with your friends! As per our vision – the Saskatoon location will be infant and child friendly, providing compassionate, comprehensive, and personable care to each and every client.

 

Location of the Saskatoon clinic is: 2543 Dudley St, Saskatoon

Lightning Crotch. Ouch! Our pubic symphysis is the point where the two halves of our pelvis meet in front – the bone at the top and front of the groin. For those that have had pubic symphysis dysfunction (PSD) or “lightning crotch” you well know that this can go from slightly irritating pain to WHAT IS GOING ON HERE! B(#%P! pretty quickly.

Commonly associated with pregnancy, we well know that individuals suffering with PSD can get to a point of despair and resignation that this pain will become a new normal; often because that is what we are being told about pain during pregnancy! “This is just part of becoming a woman” is a term I have heard yet again this past week from a client. I urge us to think of pain in pregnancy (any pain, but in this instance PSD), as something that although is common is not normal.

We wouldn’t tell someone who has just started running that has developed knee pain that “this is just part of becoming a runner – it will go away when you stop

 

There is research now that shows that pain in pregnancy can often be addressed with physiotherapy (1,2) – from PSD to back pain, and that staying active during pregnancy (3) has many benefits (which is hard to do when you are painful!). When there is pain, there is usually something we can do about it!

 

Case Study

An active mother of 28 comes into the clinic complaining of groin pain – it’s sharp, shooting, sometimes take your breath away pain that is getting progressively worse as her pregnancy continues on. She is only 26 weeks gestation and has been struggling with pain since about 16 weeks and finally decided to come to an appointment after talking with a friend about it. She is having difficulty rolling in bed (she tries squeezing her knees together because that is what she read on a few blogs on google) which has helped a little but not much, standing on one leg, and she sometimes notices popping and clicking with movement that really hurts as well. She tried kicking an empty laundry basket out to the side the other day and found that extremely painful as well.

Although there are many reasons for PSD, we will go through some of the things that may be found during a physiotherapy assessment of this type of pain

Assessment

Upon evaluation the client was clearly limping while they were walking, more on the right than the left leg, they had pain with standing on the right leg more than the left leg, and had difficulty bringing their knee toward their chest on both sides in standing. Generally speaking these individuals will have some restriction of movement on one side (same side as pain or the opposite – everyone is different!), significant muscle tightness of the inner thigh, and poor coordination of the gluteals. We also often see a change in posture – the individual may be hinging backwards (rib cage back over the pelvis), but there is a huge variation in the changes seen here depending on the underlying cause.

What can I do NOW?

In many instances our protective mechanisms related to pain may end up being one of the additional driving factors of our pain – your groin hurts, and when you hurt you tend to ‘protect’ the area (curling in) and the muscles around the area will tighten. Increased tension often doesn’t help serve us to feel better or less painful, but may drive a continued pain cycle! Squeezing the knees together to roll like in this instance, may help initially, but overall results in increased tension and often stops being helpful over a short period of time. Relaxing the muscles – particularly the inner thigh – and activating the gluts can go a long way to improving PSD pain. As always, an individual assessment is best, but when you are rolling over, try pushing yourself over with a bent knee (leg straight to the side you want to roll to), and spending some time in a ‘butterfly’ position.

At Warman Physio we have experienced physiotherapists that will use a variety of hands-on treatment while you are in-clinic, as well as home programming and exercises so that you can continue to help yourself to feel better between appointments!

PSD can be a draining, exhausting, and very painful experience for some people, and merely annoying, irritating, and minorly problematic for others. Let us help you, help yourself!

 

Haylie has been practicing pelvic health and focused in prenatal and post-partum care since graduating from the U of S MPT program in 2011. She officially added to her practice pediatric pelvic floor therapy in 2017. Haylie has been advocating for treatment for women, ensuring appropriate and effective care throughout pregnancy and post-partum, and helping all expecting and post-partum moms ultimately brought her to open her family-friendly clinic since opening in 2014. She now adds to this education and treatment provision her knowledge and experience in pediatric pelvic health providing workshops and presentations in addition to assessment and treatment. At Warman Physio clients are encouraged to bring their infants and children to treatment. Haylie was recognized as YWCA Women of Distinction for Health & Wellness in 2017, the ABEX Young Entrepreneur Award Recipient in 2018, and has been nominated for the 2019 SABEX and WMBEXA Awards.

 References:

  1. E Vermani et al (2009). Pelvic Girdle Pain and Low Back Pain in Pregnancy: A Review. World Institute of Pain. Volume 10, Issue 1 (60-71)
  2. E Richards, G van Kessel, R Virgara, & P Harris (2012). Does antenatal physical therapy for pregnant women with low back pain or pelvic pain improve functional outcomes? A systematic review. Nordic Federation of Societies of Obstetrics and Gynecology. (ahead of print)
  3. MF Mottola et al (2019). 2019 Canadian guideline for physical activity throughout pregnancy. British Journal of Sports Medicine. Volume 52, Issue 21