Hormones During Pregnancy

• Pelvic health physiotherapy addresses conditions related to pregnancy and postpartum, prolapse in menopause, and prostate issues.

Pregnancy

• Significant hormonal changes occur during pregnancy to support the developing fetus.

Hormone Changes and Roles

• Human Chorionic Gonadotropin (HCG): Produced by the placenta, HCG levels rise in the first trimester, possibly contributing to nausea and vomiting.
• Prolactin: Produced by the pituitary gland, it stimulates milk production for breastfeeding.
• Human Chorionic Somatomammotropin: Produced by the placenta, provides nutrition to the fetus and stimulates milk glands in the breasts.
• Estrogen: Produced by the ovaries and placenta, it develops female sexual traits and maintains a healthy pregnancy.
• Progesterone: Produced by the ovaries and placenta, it thickens the uterine lining for the implantation of a fertilized egg.
• Relaxin: Produced by the corpus luteum, ovaries, and placenta, it relaxes muscles, joints, and ligaments to prepare for childbirth.

Pelvic Girdle Pain (PGP)

• PGP is pain in the posterior and anterior pelvic girdle during pregnancy.
• Pelvic joint mobility increases in the last three months of pregnancy and the first three months postpartum in women with PGP.
• 60-70% of women report some degree of PGP by late pregnancy.
• Increased estrogen and relaxin lead to reduced connective tissue stiffness, potentially causing PGP.
• PGP is linked to pelvic floor muscle (PFM) weakness.

Sacroiliac Joint (SIJ) Dysfunction

• The SIJ fibrous apparatus loosens during gestation to prepare for birth.
• SIJ dysfunction results from increased weight, posture changes, increased abdominal pressure, and laxity of pelvic structures, along with hormonal changes.

Symphysis Pubis Pain (SPP)

• SPP is pain felt over the pubic symphysis, with relaxation of the pubic symphysis structures due to hormone activity and biomechanical factors.
• Perinatal dilation of the symphysis by 3–5 mm is physiological, typically returning to normal within five months.
• Increased symphyseal width is found in women experiencing severe SPP.
• 2.3% of women report SPP during pregnancy, with 7-25% experiencing it postpartum.

Treatment of PGP Includes

• Exercise to strengthen muscles around the pelvis, including the gluteals, hips, abdominals, and pelvic floor.
• Education about the causes and risk factors, benefits of physiotherapy intervention, and avoidance of aggravating activities and postures.
• Bracing with a pelvic belt or support garment to reduce pain and maintain function and physical activity.
• Manual therapy techniques, such as soft tissue release.

Round Ligament Pain

• Round ligament pain is felt as sharp pain over the lower, lateral abdominal wall due to the stretching of the round ligaments as the uterus grows during pregnancy.
• It occurs when the round ligament contracts and tightens too quickly when trying to hold the uterus still, typically due to sudden, rapid movements.
• Treatment involves education on the role of the round ligament, triggers for pain, how to avoid these triggers, and abdominal bracing.

Exercise During Pregnancy

• RANZCOG recommends that women without contraindications should participate in regular aerobic and strength conditioning exercise during pregnancy because there is no evidence that exercise will harm the developing fetus.
• Benefits of exercise during pregnancy include prevention and management of gestational diabetes (38% decreased risk), pre-eclampsia (41% decreased risk), and gestational hypertension (39% decreased risk).
• Exercise can also prevent excessive pregnancy weight gain and improve psychological well-being.

Labour

Stages of Labour

• First Stage: Starts when the cervix softens and opens, completing when the cervix is dilated to around 10 cm.
• Second Stage: Period from full cervical dilation to the birth of the baby.
• Third Stage: Starts after the baby is born and finishes when the placenta and membranes are delivered.

Vaginal Delivery and Obstetric Anal Sphincter Injury (OASI)

• Anterior perineal trauma has little morbidity, posterior perineal trauma can cause complex damage.
• Perineal tears are classified from 1st to 4th degree based on severity and location.
• OASI refers to 3rd and 4th degree perineal tears.
  • 1st degree tear: Shallow tear to the skin only.
  • 2nd degree tear: Tear to the skin and underlying muscles.
  • 3rd degree tear: Tear through perineal muscles and anal sphincter.
  • 4th degree tear: Tear through anal sphincter to anal canal and mucosa.
• Risks of perineal tears include: first vaginal birth, Asian ethnicity, baby greater than 4 kg, forceps or vacuum delivery, prolonged 2nd stage of labour, midline episiotomy, and baby shoulder dystocia.
• Approximately 40% of first-time mothers sustain a second-degree perineal tear, 7.4% sustain an OASI, and 8.7% an episiotomy.
• OASI increases the risk of fecal incontinence.

PFM Damage During Vaginal Delivery

• Vaginal childbirth increases the risk of pelvic floor disorders later in life.
• Stress, urinary incontinence, and pelvic organ prolapse are strongly associated with vaginal childbirth and parity.
• The exact mechanism of injury associating vaginal delivery with pelvic floor disorders is multifactorial, including mechanical and neurovascular injury to the pelvic floor.
• Risk factors for PFM damage include: babies 4kg or larger, parity (2 or more babies), long 2nd stage of labour (greater than 1 hour), increasing maternal age (30 years or older at first vaginal delivery), and instrumental delivery (especially forceps delivery).
• Vaginal delivery has been identified as a risk factor for levator injury, particularly to the pubococcygeal muscle.

Postpartum

• Postpartum, women are in a hypoestrogenic state, induced by birth and associated amenorrhea and breastfeeding.
• This results in thinning of the vaginal mucosa, vulvovaginal atrophy, and an increased risk of stress urinary incontinence (SUI).
• Women may experience diastasis rectus of the abdominal muscles (DRAM).
• Women are at increased risk of soft tissue injuries, especially in the first 12 weeks postpartum due to hormonal changes.

Diastasis of the Rectus Abdominus Muscle (DRAM)

• DRAM is a stretching of the linea alba, with an abnormal widening of the gap between the two medial sides of the rectus abdominis muscle (increased inter-recti distance - IRD).
• An IRD of 34mm at 3cm above the umbilicus is considered normal post-natally.
• In clinical practice IRD is normally measured with finger width, with one finger equivalent to approximately 1cm.
• Thought to be associated with increased estrogen levels during pregnancy, resulting in increased connective tissue extensibility and stretch to the abdominal wall from the growing uterus.
• 31.5% of women have a DRAM of 2-3 finger widths at three months postpartum.
• Associated with impaired abdominal strength, larger IRD the more abdominal function was negatively impacted.
• Women with DRAM have a lower capacity to generate trunk rotation torque and perform sit-ups.
• Growing consensus suggests DRAM is a normal part of pregnancy that women's bodies are naturally designed to do.
• Treatment involves restoration of PFM and abdominal muscle function, strength, and control.
• Recovery of DRAM should not be rushed and involves abdominal muscle training.
• Includes education on care of abdominal musculature post-natally with functional tasks and the use of abdominal support.

Exercise Recommendations in the Postpartum Period

• Continue exercise for physical and psychological health benefits, but be mindful of the increased risk of soft tissue injury.
• Low-impact and low-resistance exercise options are needed.
• Avoid swimming or water immersion in a public pool due to the risk of infection to the perineum, vagina, or uterus.
• Avoid exercise where the pelvis is lifted higher than the heart, due to the increased risk of air embolism until 6 weeks postpartum.
• Exercise can be increased to include progressive resistance and cardiovascular exercise, swimming, and elevation of the pelvis and wide leg postures with exercise.
• High-impact exercise and increased resistance exercise may recommence based on individual assessment considering any ongoing pelvic pain, DRAM, and PFM dysfunction.
• Abdominal exercise during the first 12 weeks postpartum should concentrate on core activation and strengthening and minimize stress on the PFM.

Menopause and Pelvic Organ Prolapse (POP)

• Menopause is defined as the last menstrual period, diagnosed after 12 consecutive months without menstruation with the average age of onset at around 51 years.
• Associated with adverse metabolic and bone changes increasing the risk of cardiovascular disease and osteoporosis, as well as urogenital symptoms.
• Reduced estrogen and progesterone levels predispose women to decreased bone density, increased central adiposity, and reduced PFM strength.
• Postmenopausal women need to participate in regular physical activity, focusing on muscular strength, balance, falls prevention, PFM training, cardiovascular exercise, and resistance training.

Pelvic Organ Prolapse (POP)

• POP is a gynecological condition where pelvic organs herniate into the vagina due to biomechanical failure of pelvic tissues.
• Risk of POP is increased by vaginal delivery, instrumental vaginal delivery, parity > 2 deliveries, birthweight > 4kg, increasing age, high body mass index, levator defect, and levator hiatal area.
• Women with levator ani defects are twice as likely to show clinically significant POP and experience recurrence after pelvic surgery.
• Two-thirds of parous women have anatomical evidence of POP, only 12% are symptomatic.
• POP causes significant physical and psychological morbidity and impacts quality of life, becoming more common with aging.
• The lifetime risk of surgery for POP in the general female population is 11.1%.
• Risk factors include: demographics (age, postmenopausal status), obstetric factors (parity, vaginal delivery, instrumental vaginal delivery), pelvic surgery, bowel dysfunction, connective tissue disorders, lifestyle factors (obesity, smoking, high-impact exercise, physically strenuous occupation), and genetics (family history, race).
• POP is subcategorized according to the compartment of descent: cystocele (anterior wall herniation), rectocele (posterior vaginal wall descent), and vaginal vault prolapse (descent of the uterus, cervix, or apex of the vagina).
• Stages of prolapse refer to the severity and extent of the descent of the uterus or other pelvic organs into the vaginal canal: staged I to IV depending on descent relative to the hymen.

Physiotherapy Treatment for POP

• Involves PFM training and lifestyle advice.
• Level 1 evidence and grade A recommendation for PFM training as first line treatment for POP to improve symptoms and severity.
• PFM training increases PFM thickness and elevates the bladder and rectal ampulla, improving PFM strength and endurance.

Lifestyle Advice for POP

• Exercise: Appropriate exercise choices depend on a woman's level of fitness, history, co-morbidities, and interests.
• Must consider cardiovascular fitness, lower limb and pelvic girdle strength, and resistance training.
• Bowel advice: Prevent straining and reduce pelvic floor loading through education on defecation dynamics and positioning, and fluid and fiber advice.
• Modify activities that increase POP symptoms; suggest positioning to reduce POP.
• Implement strategies to reduce BMI, high body fat is an independent risk factor for POP.

Vaginal Pessaries

• Pessaries are intravaginal devices designed to provide support to the vaginal walls in women with POP, fitted by physiotherapists with specialized training.

Radical Prostatectomy (RP)

• Prostate cancer is the most commonly diagnosed cancer in Australia, estimated that one in six males will be diagnosed by the time they are 85.
• A radical prostatectomy is a surgical procedure for the complete removal of the prostate, most commonly performed to treat prostate cancer with the average age of diagnosis being 70 years old.

Surgery for Prostate Cancer

• All techniques used to remove the prostate aim to be nerve sparing techniques.
• Most common surgery is radical prostatectomy with retropubic or robotic-assisted laparoscopic prostatectomy.

Post Operative Issues

• Urinary incontinence and erectile dysfunction.
• UI post prostatectomy most commonly occurs as SUI but may also be UUI. It is often the worst immediately after surgery and improves over time.
• Causes of post op UI include anatomical factors (shortened membranous urethra, bladder neck funneling, intrinsic sphincter deficiency) and pathophysiological factors.
• Recovery of sexual function may take up to two years or more after surgery and may not be complete with possible causes including anatomical (neurovascular bundle damage), pathophysiological, and psychosocial factors.

Physiotherapy Treatment Post Surgery

• Physiotherapy assists in education, pelvic floor muscle training, and exercise guidance to recover from side effects such as urinary incontinence and erectile dysfunction.
• Strengthening the pelvic floor muscles before a prostatectomy improves post-prostatectomy urinary continence, post-micturition dribble and erectile function.
• PFM training continues post RP.
• PFM training results in hypertrophy and strength and endurance increases in the levator ani, EUS, and bulbospongiosis and should include optimization of contraction patterns and functional training.
• "The Knack" is an effective tool.
• PFM training assists in increasing penile rigidity, and maintenance of erection.
• Bladder training maintains bladder compliance and volume.
• Penile rehabilitation post RP is important for maintenance of vascular and cellular integrity with the use of erection enhancing medications.
• Physiotherapy treatment for ED involves PFM training, discussion and encouragement of sexual intimacy, and education on vacuum erection devices (VED).
• VED maintain penile tissue length during the rehabilitative phase, encourages blood flow to the penis, and maintains the connective tissue extensibility.

Outcome Measures

• Client improvement and treatment effectiveness is measured using standardized, validated clinical outcome measures.
• Including: Pelvic Girdle Questionnaire (PGQ), Pelvic Organ Prolapse Symptom Score (POP-SS), International Index of Erectile Function Questionnaire (IIEF), and International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF).