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.

A miracle called: pooping!

“Pooping is a miracle!” That is what one of my colorectal physician friends told me once.  And he could not have been more correct.

Many of us do not have the luxury of feeling the urge for a bowel movement, making it to bathroom on a timely manner, or sitting down and having a bowel movement without straining and bending and pushing in each and every way.

Frequency of normal bowel movement can vary from three times a day to three times a week, without any straining and with feces that looks like type 3 or 4 on the Bristol scale.

According to Black and Ford (2018), “Chronic idiopathic constipation (CIC) is one of the most common gastrointestinal disorders, with a global prevalence of 14%. It is more common in women and its prevalence increases with age.”

Hard, pebble-like feces could be related to a slow-moving colon (slow transit), poor diet, medication, and certain diseases, to name a few. In other instances, the colon moves appropriately and constipation still exists. And then there are those people with CIC who also have dyssynergic defecation (DD). These people have difficulty passing their stool due to mechanical issues related to pelvic floor muscles, the nervous system in the area, and/or a lack of synergy between the abdominal muscles, pressure system, and pelvic floor muscles. More than half of the people who have constipation suffer from DD (Rao, Patcharatrakul, 2016).

Due to variabilities of the underlying causes that lead to symptoms of constipation and difficulty with bowel movements, it is extremely important that one does not get a generic treatment based on their symptoms (Patcharatrakul, Rao, 2018). A thorough and detailed history, review of systemic diseases, physical and digital exam, and use of imaging (anorectal manometry, ultrasound, MRI) is absolutely necessary for an accurate diagnosis and treatment protocol.

Many people with the diagnosis of DD have exhausted various common treatment protocols of using stool softener, laxatives and increasing fiber.  In fact, many report  having type 3 or 4 stool on the Bristol scale, once they can defecate.  Their problem lies on the inability to effectively pass the feces through.

Mechanically speaking, there needs to be a sufficient amount of intra-abdominal pressure in combination with relaxation of pelvic floor muscles and postural positioning to improve the ability to have a bowel movement.  With chronic constipation, this synchronized synergetic and coordinated function becomes compromised and people lose their ability to recognize the flaws in their effort to have an effective bowel movement.

Pelvic floor physical therapists have the skills to create a treatment plan that would include behavioral modifications, proper positioning, change in food and fluid intake, manual techniques, and biofeedback to re-educate individuals about proper and effective evacuation skills without straining, bleeding, and/or pain. In a study by Patcharatrakul, Valestin, Schmeltz, Schulze and Rao, from 127 subjects who had been diagnosed with DD, more than 60% improved their symptoms with biofeedback treatment (2018).  Biofeedback has been proven to be more effective than the use of laxatives and other modalities without having any side effects.

If you have exhausted many treatment options or just have started your journey with difficulty with defecation seek out pelvic floor physical therapy for a consult, you too deserve a miracle!

Hypermobility, pelvic pain, and pelvic organ prolapse: a cluster of symptoms

Joint hypermobility syndrome (JHS) describes an abnormal increase in the range of movement in different joints of the body. JHS is a hereditary condition and people often experience recurrence of sprains, strains, bruising, and/or dislocations as a result. Those who have the condition often notice its effects in their fingers, knees, or elbows. When the soft tissues are more lax and mobile, however, the same pliability applies to the skin and the support system of our internal organs. Furthermore, Ehlers-Danlos syndrome (EDS) refers to the group of disorders that consequently affect the different organs. The only proper way to diagnose EDS is to be evaluated in an extensive history-taking and physical examination that includes orthopedic, neurologic, and dermatologic analysis, to name a few.

In their article, Colombi, Dordoni, Chiarelli, and Ritelli (2015) discuss the clinical spectrum of JHS and EDS. The spectrum expands to include the skin, joints (including flat footedness, ability to do the splits, bending the thumb to the forearm, bending and touching hands to the floor), muscles, gastrointestinal system, urogenital system, cardiovascular system and neuropsychiatric symtoms (fatigue, disturbed sleep, anxiety, etc.).

In addition to understanding the breadth of the disease, recognizing the co-mobilities is beneficial to properly diagnosing JHS and/or EDS.

There have been several studies that show the correlation between hypermobility and gastrointestinal symptoms, including irritable bowel syndrome (IBS). One study found that those who suffer from the constipation sub-type of IBS show much higher symptoms of JHS. This could be due to the biomechanics of the connective tissue that lead to slower transit, or, movement, in the colon, also known as colonic inertia (Zweig, Schindler, Becker, van Maren, Pohl, 2018).

In another study by Castori, Morlino, Pascolini, Blundo, and Grammatico (2015), the gastrointestinal indicators of JHS/EDS were broken into structural anomalies (hernias, organ prolapse, intestinal intussusceptions) and functional alterations (recurrent abdominal pain, constipation/diarrhea, reflux).  

Postural tachycardia syndrome (POTS) and other cardiovascular conditions both at rest and sudden positions changes (orthostatic) has been shown to be more prevalent in those with EDS (Roma, Marden, Wandele, Fancomano, Rowe, 2018).

As with many others who have chronic conditions, recognizing the psychosocial function of a patient with JHS/EDS is highly important because people with these conditions generally do not respond to typical biomedical approaches (Baeza-Velasco, Bulbena, Polanco-Carrasco, Jussaud, 2018).

There is evidence that women with JHS could be more prone to pelvic organ prolapse. Pelvic organ prolapse occurs when one or more pelvic organs, which includes the bladder, urethra, uterus, vagina, rectum, and small bowel, droop or descend into the vaginal opening. Additionally, many women with JHS/EDS tend to suffer from pelvic floor muscle tightness and shortening, causing pain with the use of tampons, intercourse and/or in a pelvic exam. This could be explained by the fact that hypermobility in other parts of body causes the pelvic muscles to tense up for better postural support.

The physical therapists who specialize in pelvic floor rehabilitation have the expertise to perform a complete evaluation of the mechanical and musculoskeletal systems, enabling them to better understand complex diagnoses for conditions like JHS and EDS. Their skills allow them to create a sustainable, effective treatment plan that aims to make everyday life more functional and pain more manageable.

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.