Beyond assault: sexual trauma and the pelvic floor

WARNING: This post includes experiences and rhetoric relating to sexual assault, sexual violence, PTSD, and physical repercussions of sexual trauma.

Not a day passes without us hearing about another case of sexual assault. While I don’t like to get political, it’s important to talk about these subjects, especially in light of today’s confirmation. The past few weeks have been disheartening, but it is encouraging to see that we, as a society, are paying a closer attention to this subject. Sexual assault is one of the most unreported crimes due victims’ belief that their report(s) will not be validated or deemed credible.

As for my own personal experiences as a pelvic floor physical therapist and an educator, I encounter individuals with histories of sexual abuse and trauma on a weekly basis. This extends outside of the clinical setting; when I teach other clinicians, there is always at least one person in the room that shares a personal story related to abuse.

Whether the incident of abuse/trauma occurred in childhood/adolescent ages or adulthood (for example, among men and women in military), sexual dysfunction and chronic pain conditions are often common side effects. Bornefeld-Ettmann et al., (2018) reported of signs of post-traumatic stress disorder (PTSD) as directly related to sexual dysfunction among those who have experienced childhood sexual abuse (CSA).

Female adults with a history of CSA not only have problems with sexual desire and arousal, they may also suffer from complex cognitive complications, such as increased sympathetic nervous system activation (the fight or flight system), shame, guilt, low self-esteem and poor body image (Pulverman, Kilimnik & Meston, 2018).

It is important to understand that a variety of other chronic pain diagnoses could be associated co-morbidities of the sexual trauma. In a large-scale retrospective study by Cichowski, et al., (2018) on military women veterans, this assertion was explored and validated. The women in the study suffered from a variety of conditions such as irritable bowel syndrome, chronic pelvic pain, back pain, dyspareunia (painful sexual intercourse), joint pain, fibromyalgia, chronic abdominal pain, and headaches.

Pelvic floor dysfunction, such as vulvodynia and other sexual dysfunction, become the integral part of treatment when survivors are seen by pelvic floor physical therapists. These therapists, myself included, have special training to address many of the above physical disorders, confirm that the signs and symptoms the individual is experiencing are indeed from a deeper root, and subsequently provide a safe environment for these patients to reach their optimal physical (and mental) strength.

As mentioned in my previous blog posts, pelvic floor-related issues (pain, urinary/fecal incontinence or other related issues, and/or sexual dysfunction) are not gender specific. Men and women suffer silently from these issues, regardless of the origin of problem. I am proud to work with amazing people, many who are survivors of assault – they have each made me stronger and I will forever believe them, support them, and help them reach the goals they want to achieve in physical therapy and life itself.

The state of postpartum pelvic floor: pleasure or PTSD?

Most health care providers choose their profession because they love to care for and help others.  I certainly have the most fulfillment when my patients can live their lives without any physical restrictions.  I admit that we all fall short on doing the right thing at all times and sometimes we fall in the rot of doing the work “routinely” and/or an overwhelming schedule makes us lose focus.

Sometimes, quite simply, things don’t go right.

There are consequences, however.  These flaws effect “the human” on the other side of the equation.   Those that we want to help, become the victim of the broken system of care.

In my opinion, the post-partum moms are one the most underserved group in the medical system.

They have been promised this perfect experience of giving birth and delivery.  They have planned and weighed every option and created a birthing plan that is aligned with their beliefs and wishes.

Every consult, every test, every advice for better eating, sleeping, and education is to ensure that the nine months of pregnancy produces an optimal outcome:  a beautiful healthy baby! However, if the new mom is not getting the support that she needs, how would the family function?

A recent study, evaluated the psychological effects of the traumatic vaginal delivery when the pelvic floor muscles (PFM) were confirmed damaged by way of 3D and 4D imaging. Forty women were given open-ended questions regarding their experiences before, during and after pregnancy.  Their responses were as follow for the following ten categories: lack of prenatal education (29/40); no information provided on potential morbidities (36/40); conflicting advice (35/40); traumatized partners (21/40); long-term sexual dysfunction/relationship issues (27/40); no postnatal assessment of injuries (36/40);  multiple symptoms of pelvic floor dysfunction (35/40); “putting up” with injuries (36/40); symptoms of posttraumatic stress disorder (PTSD) (27/40); dismissive staff responses (26/40) (Skinner, Bryanne, Barnett & Hans, 2017).

At least once or twice a week I consult a new mom that asks me,” why didn’t someone tell me that I could have pelvic floor damage?”.  I agree, knowledge is power! There are many women who have babies without any issues at all.  Pelvic floor physical therapists, such as myself, only see those who have acquired an injury.   But, knowing about possible risk factors and knowing that there are things that can go wrong during and after delivery could be scary, but, less traumatizing if anticipation was there.

Equally, women with C-section scars, experience tension along the scar site, decreased sensation and often a fragile sense of vulnerability due to weakness of the abdominal wall and other symptoms related to an abdominal surgery.  Both groups of women, report of decreased quality of life due to physical and psychological effects.

As health care providers we are responsible to educate and provide the support necessary   to ensure every new mom feels whole again after giving birth.

As a woman, I encourage other woman to ask for help when things don’t feel right.  When it comes to other aspects of life, we are encouraged not to “put up” with what is not right.  Do not put up with pain, or incontinence or fatigue or sadness… are not ok until you  return to full health, both physically and emotionally, even if your baby is in college!

Therefore, it is never too late to address the lingering issues postpartum.  If you have issues with incontinence, weak and stretched abdominal muscles or pelvic pain or even if you just think you could be better, don’t put it off or dismiss yourself.  Seek advice from your primary care, gynecologist, or see a physical therapist that specializes in pelvic floor rehabilitation.   There is hope, and things can be a lot better, but not until you take the first step.

Diastasis of Rectus Abdominis Muscles

Diastasis of the rectus abdominis muscles (DRA), or separation of the abdominal wall, is different from abdominal or umbilical hernia.  The linea alba, or the connective tissue that connects the rectus abdominis (8 packs), thins which leads to laxity of the abdominal muscles.

It is seen in men and women and despite the lack of supportive evidence, it is considered to be a significant contributor to chronic back pain .  In the study by Doubkova et al.(2018), 77% men and 45% of women with DRA had experienced low back pain.

Also, pelvic related issues, such as incontinence, pain and organ prolapse, have also been shown to be related to poor abdominal support.  In this article more than 66% of women (average age of 52) who presented with DRA also had support related pelvic floor dysfunction.

When the abdominal muscles function optimally, they support the abdominal organs, maintain proper posture and create stability for the pelvis and spine.  This perfect design achieves the proper abdominal pressure that is needed to maintain bowel/bladder function and preserve continence with higher impact tasks such as lifting, jogging, coughing, sneezing and laughing.   While there is conflicting reports and minimal scientific support of the direct connection between DRA and low back pain and pelvic issues, clinically and functionally speaking, these symptoms are often seen along with the presence of DRA.

DRA is most commonly associated with pregnancy and some believe that up to 100% of pregnant women experience some degree of abdominal separation during pregnancy.   Even though most women show improvement in their pelvic related issues in the early postpartum phase, one third of women who experienced urinary incontinence immediately postpartum and improved, experience urinary incontinence 5-7 years later.  This was explained to be related to poor movement strategies that they adapt to due to poor abdominal support.  Read more here.

In recent years, there has been a flood of information (not all correct) on what to do about the abdominal bulging that many men and women experience with movement and/or activities that increases the abdominal pressure.   There have been many exercise regiments that mainly focus on closure or approximation of the DRA.

In this study available treatment methods were analyzed and it was concluded that there is not one method that showed significant change in the signs and symptoms of DRA.   Tension of the linea alba is needed to transfer force across the abdominal muscles in presence of tasks that increased intra-abdominal pressure (i.e. jogging, lifting, coughing, or sneezing). Ultrasound imaging has shown that when the deepest layer of abdominal muscles activate before a task is done, the proper tension is created and therefore less stress is transferred to low back and pelvic organs.  This translates to improvement in symptoms of low back pain, pelvic pain, incontinence and pelvic organ prolapse.

Many experienced pelvic floor physical therapists utilize their musculoskeletal expertise along with state of the art technology (real time ultrasound) to train men and women  who suffer from pelvic related issues or those who may not have responded to traditional low back rehab protocols.