Ask An Expert: Postpartum Pelvic Floor Disorders

We are so thankful to UCHealth urogynecologists Kathleen Connell, M.D., and Marsha K. Guess, M.D., M.S., for answering our important questions about these important pelvic floor disorders SO many moms are dealing with.

Sometimes, women experience some unfortunate side effects from giving birth, including incontinence and prolapse. But there’s help for them.

There is a very specific sub-specialty of gynecology, called urogynecology, which deals with treatments of issues, which are called pelvic floor disorders. The most common of these disorders are urinary incontinence, pelvic organ prolapse and fecal incontinence.

  • Urinary incontinence is the accidental leakage of urine from the bladder.
  • Pelvic organ prolapse is when a pelvic organ, such as your bladder or uterus, drops from its normal place in your lower belly and pushes against the lower walls of the vagina.
  • Fecal incontinence is the inability to control bowel movements, causing stool (feces) to leak unexpectedly from the rectum,

Although a general OB/GYN or urologist may have knowledge about these problems, an expert in urogynecology is specially trained in this area and can offer further expertise.

Women often have questions if they are experiencing these disorders, so we asked two specialists for answers. UCHealth urogynecologists Kathleen Connell, M.D., and Marsha K. Guess, M.D., M.S., responded to some of these questions on postpartum incontinence and prolapse submitted by our community of moms. (Responses are indicated by each doctor’s initials).

Q. Ever since having my son four years ago, I can no longer do anything that requires jumping – such as jumping jacks, trampoline, or sometimes even jogging – without peeing. I often empty my bladder before doing these activities and continue to do Kegel exercises. What can I do about this? It is very embarrassing and frustrating!

MKG: Leakage problems and urinary incontinence are not uncommon after childbirth. In fact, childbirth is probably the biggest risk factor for developing these symptoms. UCHealth Ask An Expert:: Postpartum Pelvic Floor Disorders

KC: I want to stress that Kegel exercises are still important to do. A lot of times when people have stress incontinence, which is what you are describing, leakage happens during activities such as jumping, bending, hopping or running because of the pressure that gets put on the bladder. The pelvic floor muscles are a big part of the continence mechanism and support the urethra to prevent urine leakage when people are doing such activities. If performing Kegels on your own is not working to improve your symptoms, you might benefit from physical therapy to help strengthen those muscles further. It’s a great opportunity to work with a personalized trainer to make sure Kegel exercises are done correctly. 

MKG: Often times, people will report that they are doing Kegel exercises correctly but they really aren’t. Kegel exercises need to be treated like any other exercise — the pelvic floor muscles have to be conditioned in a fairly systematic way. For more detailed directions on how to do Kegel exercises properly, click here.

There are other support muscles that don’t sit within the pelvic floor but help to align the pelvic cavity that also are important and physical therapists, based on their level of expertise, are able to identify those additional muscles that can contribute to improvement of pelvic floor strength. 

Don’t be afraid to talk to your doctor about it – it’s nothing to be embarrassed about! If you have a primary care physician, you can mention it to that person or you can go and seek out care from a Urogynecologist. Also, if you bring it up, you may find that your mom, or sister or a friend has dealt with these conditions and you may be able to find some possible solutions from discussions with them. 

 

Q. I’m six months postpartum and when I exercise or run my pelvis still feels very sore afterward. Is this normal, and is there anything I should do?

KC: After childbirth, the pelvic bones are still coming together. The ligaments between the pelvic bones soften to allow for labor and delivery, so they can be a little bit loose in the first few months afterward.  It many instances women are only beginning to get back to their baseline with exercise at the six month mark and thus feelings of pelvic soreness after exercise can be expected. Since the exact cause of pelvic soreness can only be appreciated with a thorough history and exam, if you continue to experience soreness for a prolonged period of time after your delivery, you should make sure that your obstetrician is aware of what’s going on.

Sometimes doing physical therapy can help. All of the muscles, such as those in the abdomen, pelvis, hips and back, all work together. So, if there’s a tightening or a pulling in one area, sometimes that can misalign other areas. Women may also have pelvic floor spasms after delivery where they feel periods of tightness or soreness with exercise or intercourse. If it’s really bothering you to where you have a hard time exercising and it’s affecting your quality of life, it’s probably a good idea to check with your obstetrician to see if physical therapy may help.

Q. I have stage 3 bladder prolapse and stage 2 uterine prolapse that were diagnosed two years after my second child was born. I am now six weeks pregnant with my third child and already feel the cystocele descending more. I am 35 years old. What can I do to minimize further damage during pregnancy, during delivery, and postpartum?

KC: The first thing you can do is to talk with your OB/GYN about having a pessary fitting. A pessary is a small silicone ring that goes inside the vagina to give the bladder and uterus support. Up to the second trimester, women notice more prolapse during pregnancy because the uterus is still small, but heavier, so it descends more. Once the baby and uterus start getting bigger in the late second and into the third trimester, the uterus rests on the pelvic bones and uterine prolapse may not be as noticeable.  A pessary is a great option — it’s safe during pregnancy and we use it in patients that aren’t pregnant as well. We also use it postpartum to give the tissues support when women have bothersome prolapse after delivery. Keeping bowel movements regular and soft, to avoid constipation and straining, and avoiding heavy lifting also are good precautionary measures to take. 

During delivery, there aren’t any specific precautionary measures other than proper breathing and good pushing techniques to help minimize further damage. 

Post-partum is a critical time of healing for the stressed pelvic floor tissues that have endured labor and  delivery. Those first six to eight weeks, even the first three months, are considered the critical time periods where the tissue is “remodeling” – rebuilding itself and starting to recoil and go back up into the pelvis. So it’s hard to say if the prolapse will get worse or if it will stay the same or improve over time. Studies have shown that the most damage occurs with the first delivery and smaller amounts of damage may occur with each subsequent delivery, but it can vary greatly from person to person. 

MKG: Postpartum weight retention is also associated with prolapse. After delivery, we recommend that women get back to their original body mass index (BMI).

I worked with a physician in China and we looked at women throughout their pregnancies and examined them for prolapse during their third trimester of pregnancy and at six weeks, six months and one year after delivery and kept track of their heights, weights and BMIs.

At one year after delivery, there were significantly increased odds of having more vaginal wall laxity (larger bulge), for every one point increase in their BMI. Many of the women in our study were young and in their 20s, very slim (average BMI was 21) and this was their first delivery for all of the participants. While we don’t know for sure, it is possible that the effects would be even more dramatic for a population of women who were not starting off with a low or normal BMI, for those who are older and for those who have multiple deliveries, particularly since BMI, age and vaginal births are among the known risk factors for prolapse.   While we don’t know why prolapse happens in some people but not others, certainly childbirth is the No. 1 risk factor and then it’s compounded by aging, menopause, increased BMI and other factors like smoking and chronic straining. Hence, we recommend making it a goal to get back to your pre-pregnancy weight with healthy eating and exercise as soon as your obstetrician gives you the green light.

UCHealth Ask An Expert:: Postpartum Pelvic Floor Disorders

Q. What precautions and contraindications are there with uterine prolapse? Is there an exercise protocol to correct prolapse?

MKG: Kegel exercises are the known exercises that helps improve pelvic floor strength. And typically, with prolapse, with the uterus falling down, you don’t anticipate dramatic improvement in the degree of prolapse. Logically, if the muscle is hanging down, it’s not going to pull all the way back to its point of origin, but it may regress a little bit. 

What the data does show is if you do Kegel exercises and physical therapy, you can improve some of the symptoms associated with prolapse and prevent further descent of the organs. If someone has problems with constipation because of their prolapse, sometimes that can be improved with physical therapy. 

As far as precautions and contraindications go, even if you don’t have prolapse, there are things that aren’t associated with a healthy pelvic floor. We know that repeated heavy lifting, smoking and chronic constipation can be detrimental to having a healthy pelvic floor.

KC: Pilates has been shown in some small studies to help pelvic floor strength and symptoms of prolapse. There haven’t been any large randomized control trials yet, but there are centers across the country that are now starting to look at that. Strengthening the back, the core and the hip muscles along with the pelvic floor muscles is always helpful. 

Q. I’m 22 weeks pregnant with my third baby in four and a half years. I’m having major pelvic floor pain and pressure that my prenatal chiropractor said sounds like a potential prolapse. When I asked, my doctor she said it’s normal for my history, plus there’s nothing they can do anyway while I’m pregnant. I’m not suffering from incontinence but this is painful, and I’m nervous that I may be making it worse with everyday activities. Any ideas?

MKG: A pessary may be a potential option until the fetus grows large enough so the uterus is high enough so you’re not feeling the prolapse. However, this is a provider decision so this is ultimately at the discretion of your obstetrician as he or she may not feel that prolapse is the cause of these issues. 

KC: If prolapse isn’t the cause, round ligament pain could be a possible cause because around the second trimester when the uterus is expanding rapidly, it pulls on the round ligaments, which causes pain on both sides near the hip bones. Usually, with prolapse pain, patients feel pressure or can see or feel a bulge from the vagina. They may also have rubbing of the cervix or the bladder on their underwear because of the prolapse, and this may also result in some discomfort.

Postpartum Pelvic Floor Disorders Q&AQ. In addition to Kegel exercises, are there any other exercises or things you can do to strengthen your pelvic floor?

KC: As I mentioned before, Pilates has been shown to help because when people are doing exercises like Pilates, that are designed to strengthen the core, they are also focusing on the pelvic floor muscles, the buttocks and the back. Some people have a hard time isolating the pelvic floor muscles and there are different ways of what we call “biofeedback,” meaning there’s another signal that lets you know that you are performing the exercises correctly.

There are vaginal kits that can help strengthen the pelvic floor muscles. The most common one is called a vaginal weighted cone; it has small little ovules with different weights to them. You start with the lightest weight and when you put the cone inside the vagina, you have to squeeze the pelvic floor muscles to keep it inside. If you feel it falling out, you know that those muscles aren’t squeezing. As the muscles get stronger, you can increase the weight of the cone. There are other things on the market that are gaining popularity (and were included in the 2017 award show gift bags) that people can squeeze and use their digital device to confirm that they are using the correct muscles. 

There have been studies comparing Kegels vs. weighted cones vs. physical therapy. They all can work, but the key is consistency. It’s just like any other muscle. If you go to the gym once, you won’t get strong but if you use those muscles every day, even if it’s just for a few minutes at a time, then those muscles get stronger over time. 

MKG: If you aren’t getting better and you feel like you’re doing your Kegels, first, make sure you’re doing them correctly. Make sure you’re considering them an exercise – do reps and sets as you would any other exercise. If you still don’t see improvement, consider seeing a physical therapist. 

KC: We can’t stress enough how important Kegels, Pilates and physical therapy are for strengthening the pelvic floor. In Europe, postpartum women are automatically put into physical therapy programs because physical therapy gets those pregnancy-stressed muscles strong again. In this country, we have not paid attention enough to the pelvic floor muscles and how important they are to continence. We can do surgery to correct incontinence and prolapse in women, but if the muscles are not strong, patients are still going to have problems because that’s an integral part of the whole system.

For more information or to schedule an appointment with UCHealth’s urogynecology practices in Aurora or Lone Tree, call 720.848.2233 or visit uchealth.org/urogynecology.


Kathleen Connell, MD is a urogynecologist at UCHealth – University of Colorado Hospital and an Associate Professor at the University of Colorado School of Medicine. Dr. Connell received her medical degree from State University of New York Downstate Medical College of Medicine in 1996. She went on to complete a fellowship in Female Pelvic Medicine & Reconstructive Surgery in 2003 at the Albert Einstein College of Medicine/Montefiore Medical Center. In 2004, she was board-certified in Obstetrics and Gynecology and in 2013 became one of the first doctors in Colorado to become board-certified in Urogynecology.

Dr. Connell’s practice focuses on the female pelvic system with special medical interests in pelvic organ prolapse, incontinence, reconstructive pelvic surgery.

As a leader in the field of urogynecology, Dr. Connell participates in a number of professional organizations, including as a fellow of American College of Obstetricians and Gynecologists, and a member of American Urogynecologic Society and the Society for Gynecologic Investigation.

She is passionate about advancing scientific research in the field of female pelvic medicine, running the Anschutz Medical Campus science laboratory for University of Colorado Hospital where she leads the OB/GYN department’s clinical and translational research.

Dr. Connell’s own research focuses on the effects of aging and other women’s issues on pelvic support, with the ultimate goal of preventing pelvic organ prolapse and developing new treatment options.

Outside of her practice, Dr. Connell enjoys spending time with her husband and three children, traveling, hiking and skiing.

 

Marsha K. Guess, MD, MS is a urogynecologist at UCHealth – University of Colorado Hospital and an Assistant Professor at the University of Colorado School of Medicine. Dr. Guess received her medical degree from the University of California, Los Angeles (UCLA) School of Medicine in 1997. She went on to complete her residency in obstetrics and gynecology at UCLA, where she was the chief administrative resident. Dr. Guess then completed fellowship in the Female Pelvic Medicine and Constructive Surgery division at Albert Einstein College of Medicine/Montefiore Medical Center in the Bronx, New York. She also received from there her Master of Science, with distinction, in 2006.

Dr. Guess’s research interests include increasing women’s knowledge about pelvic floor disorders and understanding the pathophysiology of these conditions, particularly as they relate to pregnancy, childbirth and sexual dysfunction.

Dr. Guess has been the recipient of the Excellence in Teaching award on three occasions and has also been recognized for her commitment to community service. She has donated her time and efforts locally, as well as in Africa and Central America, where she has participated in medical missions treating underserved women who suffer with pelvic floor disorders.

She has been featured as one of U.S. News and World Report’s “Top Doctors,” has appeared on the “Today Show” and has had her research highlighted in The New York Times. In her spare time, Dr. Guess enjoys traveling, hiking, playing tennis and spending quality time with her family and her close circle of friends around the country.

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