Journal of Midwifery & Women’s Health www.jmwh.

org
Review

Pelvic Floor Physical Therapy and Women’s Health Promotion

Samantha Lawson, CNM, WHNP-BC , Ashley Sacks, PT, DPT

Pelvic floor dysfunction is defined as abnormal function of the pelvic floor and includes conditions that can have significant adverse impacts on
a woman’s quality of life, including urinary incontinence (stress, urge, and mixed), fecal incontinence, pelvic organ prolapse, sexual dysfunction,
diastasis recti abdominis, pelvic girdle pain, and chronic pain syndromes. Women’s health care providers can screen for, identify, and treat pelvic
floor dysfunction. This article examines the case of a woman with multiple pelvic-floor-related problems and presents the evidence for the use of
pelvic floor physical therapy (PFPT) for pregnancy-related pelvic floor dysfunction. PFPT is an evidence-based, low-risk, and minimally invasive
intervention, and women’s health care providers can counsel women about the role that PFPT may play in the prevention, treatment, and/or
management of pelvic floor dysfunction.
J Midwifery Womens Health 2018;00:1–8  c 2018 by the American College of Nurse-Midwives.

Keywords: gynecology, postpartum care, preventive health care, primary care, midwifery education

CASE SUMMARY concerns but wishes to avoid medication and delay surgery
A.B., a 32-year-old woman, gravida 2, para 2, presents for until she is certain she is done having children.
an annual gynecologic examination. She was last seen for A.B. is diagnosed with midline grade II cystocele and
her 6-week postpartum visit 18 months ago, after her sec- rectocele, stress urinary incontinence, and diastasis recti
ond normal spontaneous vaginal birth. She jokes that she abdominis. The midwife discusses lifestyle changes that
has been “falling apart” since her last birth and reports she may alleviate her symptoms and reviews her treatment op-
is “quite a bit bothered” by the sensation of “something tions. She is referred to a pelvic floor physical therapist for
falling out” that has worsened during the last couple of pelvic floor muscle training.
months. A.B. tells her midwife that she saw a gynecologist
this past year, per her mother’s recommendation. She states INTRODUCTION
that she was diagnosed with “some kind of prolapse,” and
Well-woman, preconception, and antepartum visits are all op-
she also mentions some persistent pelvic, perineal, and low
portunities for women’s health care providers to identify risk
back pain. She declined surgical intervention, and she was
factors for adverse health and initiate measures to promote
told that a pessary would likely not be effective. She expe-
health and prevent disease across the life span. These interac-
riences urinary incontinence with exercise, and she denies
tions are ideal times for identifying pregnancy-related pelvic
strong urinary urges, fecal incontinence, or constipation.
floor disorders, but this opportunity for prevention and early
She does report dyspareunia, specifically pain with initial
intervention is often missed.1
and deep penetration.
Pelvic floor dysfunction is defined as the abnormal
A.B. does not smoke, drink, or use recreational drugs,
function of the pelvic floor, and it may be caused by structural
and her body mass index (BMI) is 19.5 kg/m 2 . She does
abnormalities, underlying disease, or physical trauma. Health
not have any other significant medical or surgical prob-
care providers may recognize pelvic floor dysfunction as a
lems, and she reports her mother had a complete hysterec-
condition, such as urinary and fecal incontinence, pelvic
tomy for “these same kinds of problems.” Her maternal
organ prolapse, sexual dysfunction, diastasis recti abdominis,
health history is significant for a third-degree laceration
pelvic girdle pain, and chronic pelvic pain.2 Risk factors for
that was repaired after her vaginal birth 4 years ago but was
prepregnancy pelvic floor dysfunction are primarily modi-
otherwise uncomplicated. She had no perineal laceration
fiable and include smoking, frequent vigorous exercise, high
during the birth of her second child, and she is no longer
BMI, and high hip circumference.2 The greatest risk factor for
breastfeeding.
postpartum pelvic floor dysfunction is prepregnancy pelvic
Her physical examination reveals a midline cystocele
floor dysfunction, although birth by forceps and third-degree
and rectocele that both extend one cm past the hymenal
perineal lacerations are clinically significant risk factors.2
ring, and a 5-cm wide diastasis at her umbilicus. Umbili-
Pelvic floor dysfunction adversely affects a woman’s quality
cal hernia is absent. She reports pain that is 5 of a maxi-
of life and overall well-being. Medical and surgical treatment
mum of 10 with speculum placement and bimanual exam-
methods are not without risk, and these options may be
ination, she has minimal strength when asked to perform a
further limited during pregnancy and breastfeeding.
Kegel contraction, and she leaks urine when asked to cough.
Pelvic floor physical therapy (PFPT) is evidence based
She verbalizes interest in treatment for her pelvic floor
and minimally invasive, can be used during pregnancy and
breastfeeding, and may be offered as a first-line treatment
choice to women experiencing pelvic floor dysfunction. This
Address correspondence to Samantha Lawson, CNM, WHNP-BC. Email: article reviews the evidence that supports PFPT for treating
SamanthaALawson@gmail.com pregnancy-related pelvic floor dysfunction.

1526-9523/09/$36.00 doi:10.1111/jmwh.12736 
c 2018 by the American College of Nurse-Midwives 1
PELVIC FLOOR ANATOMY genital sensation, continence, and orgasm, and the disruption
Understanding the structure and function of the pelvic floor of its function may significantly impact quality of life. Mic-
aids the provider in the assessment, diagnosis, and manage- turition, defecation, and normal sexual function, which are
ment of pelvic floor dysfunction.3 The pelvic floor is made the result of coordination between the pelvic floor and the
up of a sling of muscles, ligaments, and fascia that support autonomic nervous system, may be disrupted when the mus-
the bladder, rectum, and reproductive organs. The bony pelvic culoskeletal structures of the pelvic floor are injured or not
girdle includes the 2 innominate bones and the sacrum, and functioning normally.
these structures form the bony framework that surrounds and
anchors the pelvic floor.3 The innominate bones are made of PELVIC FLOOR PHYSICAL THERAPY
the ilium, ischium, and pubis. The innominate bones articu-
late with each other anteriorly at the pubic symphysis and with Dysfunction of the pelvic floor sling subsequently results in
the sacrum posteriorly at the sacroiliac joints. The coccyx ex- the dysfunction of the structures that depend on its support.
tends from the sacrum and serves as an attachment for various PFPT targets the muscles, nerves, ligaments, connective tis-
ligaments and tendons. The bilateral sacroiliac joints are sta- sue, lymphatic system, and joints inside and around the pelvic
bilized by multiple ligaments anteriorly and posteriorly; how- girdle and focuses on addressing mobility and function.5
ever, musculoskeletal changes during pregnancy may stretch Pelvic floor physical therapists use internal or external manual
and stress these ligaments, causing posterior sacroiliac joint therapies such as myofascial release, connective tissue manip-
pain. The pubic symphysis is reinforced by ligaments on all ulation, and joint and scar tissue mobilization. Manual ther-
sides as well; however, this cartilaginous joint can be a source apy uses palpation to loosen spastic muscles and lengthen
of pain or discomfort as it is subjected to much mechanical tightened tissue to provide relief from pain. Therapies such
stress as it relaxes and widens during pregnancy.3 as neuromuscular electrical stimulation and biofeedback use
The musculature of the pelvic floor contains 2 basic layers. technology to help women gain functional awareness of the
The bulbospongiosus, ischiocavernosus, internal and external pelvic floor, better coordinate muscle contractions, and im-
urethral and anal sphincters, and superficial and deep trans- prove endurance to promote maximal functioning. Physical
verse perineal muscles constitute the most superficial layer of therapists are experts in the treatment of musculoskeletal dis-
the pelvic floor. These muscles help control bladder, bowel, orders, and they combine neuromuscular reeducation and pa-
and sexual function and can frequently be injured during tient education to optimize outcomes and improve quality of
childbirth. The deep layer of pelvic floor muscles—containing life.5 These therapies do involve intravaginal and intrarectal
the levator ani, coccygeus, and surrounding fascia—make up assessment, examination, and treatment, so a woman may ap-
what is known as the pelvic diaphragm. The levator ani in- preciate this anticipatory guidance prior to accepting a referral
cludes the pubococcygeus, puborectalis, and iliococcygeus to PFPT.
muscles, which are innervated by sacral nerve roots S3-S5.
Education and Certification
The pubococcygeus, the most anterior component of the le-
vator ani, functions primarily to maintain pelvic floor tone Additional education and training are not required for phys-
and support pelvic viscera. The iliococcygeus is located most ical therapists to provide PFPT. Although pelvic floor and
posteriorly and contributes the voluntary control of urination. women’s health topics are a required component of graduate-
The puborectalis sits below the pubococcygeus and forms a level physical therapy education, curricula vary by institution,
U-shaped sling around the rectum, and its fibers interdigitate and many physical therapists practicing PFPT seek out ad-
with the external anal sphincter.3,4 The coccygeus is a triangle- ditional training. The 2 institutions in the United States that
shaped muscle that attaches at the ischial spines and inserts on offer additional education and certification opportunities for
the lower sacrum and upper coccygeal bones. It functions to physical therapists and health care professionals are listed in
support pelvic viscera and stabilize the sacroiliac joint.3 The the table of resources at the end of this article (Appendix 1).
perineal body is a dense mass of connective tissue between Both organizations maintain a directory of certified pelvic
the vagina and anus, where multiple muscles, tendons, and floor therapy providers and offer continuing education op-
sphincters come together to support the pelvic floor. Injury to portunities and/or online and traditional classroom courses
the perineal body during childbirth may contribute to pelvic for physical therapists and other licensed health care prac-
organ prolapse.4 Muscles of the pelvic walls include the obtu- titioners, including physicians, nurses, nurse practitioners,
rator internus and piriformis, both of which function to later- nurse-midwives, physician assistants, chiropractors, and oc-
ally rotate the extended hip and abduct the flexed hip.3 cupational therapists. Practitioners must know if pelvic floor
The pelvic floor supports the reproductive organs against rehabilitation falls within their state-specific scope of prac-
changes in intraabdominal pressure by maintaining a constant tice. Certification requires obtaining additional education,
state of tone.4 The levators may be voluntarily contracted (as meeting requirements for direct patient care, and passing a
occurs during Kegel exercises), but dysfunction may occur if certification examination.
these muscles are hypertonic or hypotonic. The levator ani
muscles relax briefly and intermittently during voiding, defe- STRESS URINARY INCONTINENCE
cating, and birth.4 The pudendal nerve, emerging from the
Urinary incontinence is categorized as stress, urge, or mixed
sacral plexus at S2-S4, innervates the clitoris, superficial pelvic
incontinence based upon symptoms (Table 1). Stress urinary
floor muscles, the urethral sphincter, the anus and external
incontinence is defined as urine leakage that occurs with
anal sphincter, and the perineum.3 It plays a critical role in
physical stress on the bladder such as laughing, coughing,

2 Volume 00, No. 0, xxxx 2018

 Table 1. Definitions of Pelvic Floor Dysfunction Disorders
Disorder Definition
Stress urinary incontinence Involuntary loss of urine on effort or physical exertion or on sneezing or coughing
Urge urinary incontinence Involuntary loss of urine associated with urgency
Mixed urinary incontinence Involuntary loss of urine associated with urgency and also with effort or physical exertion or on
sneezing or coughing
Pelvic organ prolapse The descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or
the apex of the vagina (vaginal vault or cuff scar after hysterectomy)
Uterine or cervical prolapse Observation of descent of the uterus or uterine cervix
Vaginal vault (cuff scar) prolapse Observation of descent of the vaginal vault or cuff scar after hysterectomy
Anterior vaginal wall prolapse Observation of descent of the anterior vaginal wall, most commonly because of bladder prolapse
(cystocele) or prolapse of the urethra (urethrocele)
Posterior vaginal wall prolapse Observation of descent of the posterior vaginal wall, most commonly because of rectal protrusion into
the vagina (rectocele)

Source: Haylen et al.24

sneezing, or lifting.6 Weak pelvic floor musculature may con- very effective.16 Antimuscarinic drugs are recommended for
tribute to hypermobility of the bladder, or there may be intrin- women with urge incontinence.
sic weakness of the urethral sphincter, and either may cause Surgery is acceptable to treat stress urinary incontinence,
involuntary loss of urine with physical exertion and increased but continence rates may decrease over time after surgery.6
intraabdominal pressure. Assessment of stress urinary incon- Risk factors associated with lower long-term success include
tinence may also include asking how often a woman leaks age, menopausal status, and prior continence surgery.17
urine and whether the leak is a small or large volume.
The prevalence of stress urinary incontinence in the
Management
general population ranges from 30% to 60% in middle-
aged women and increases with age.7 During pregnancy, PFPT is effective for prevention and treatment of stress uri-
as many as 60% of parous women may report stress uri- nary incontinence in pregnancy and the postpartum period
nary incontinence, and the prevalence and severity increase and is recommended by the International Consultation on
throughout the course of the pregnancy.8 The prevalence Incontinence as the first-line treatment for women across
of postpartum stress urinary incontinence ranges from 9% the life span experiencing stress, urge, or mixed urinary
to 45%,9 and although symptoms frequently improve dur- incontinence.18,19 PFPT helps women manage incontinence
ing the first year after childbirth, women with incontinence because effective contraction of the pelvic floor musculature
during pregnancy are at an increased risk for postpartum (prior to and during exertion) raises the pelvic diaphragm in
urinary incontinence as well as incontinence that persists a forward and upward direction, compresses the urethra, and
beyond the postpartum period.8 Women with stress uri- increases urethral pressure, thus preventing urinary leakage
nary incontinence are also at an increased risk for anxiety with urge or stress.11 Although PFPT is effective for preven-
and depression as well as decreased sexual satisfaction, de- tion of stress urinary incontinence, it is most successful when
creased participation in physical activities, and poor self-rated supervised training is conducted, high adherence to the exer-
health.10,11 cise protocol is maintained, and close follow-up is provided.20
Initial treatment for stress urinary incontinence includes This need for adherence to a training program is challeng-
lifestyle modifications, among them weight loss, reduc- ing, as studies have shown that few antepartum and post-
ing consumption of bladder irritants (alcoholic, caffeinated, partum women exercise regularly as recommended without
and carbonated beverages), preventing constipation, quitting supervision.21,22 Patient counseling may include the recom-
smoking, normalizing fluid intake, and eliminating fluid in- mendation that the pelvic floor be exercised effectively and
take in the hours before bedtime.12,13 Women may be in- regularly to increase strength, as is the case for any muscle
structed to maintain a voiding diary and implement blad- group; improve motor control; and, subsequently, reduce uri-
der training strategies, such as scheduling voids. Although nary leakage. The effect of any training program will fade over
there are no medications approved by the US Food and time if it is not maintained.20
Drug Administration for treating stress urinary incontinence, Women who can perform strong pelvic floor contrac-
duloxetine (Cymbalta) is used in Europe. Two systematic tions and are highly motivated to follow recommendations
reviews found that duloxetine, a serotonin-norepinephrine are more likely to benefit from unsupervised PFPT; nonethe-
reuptake inhibitor, reduced incontinence episodes and in- less, the current practice of recommending suboptimal PFPT
creased quality of life; however, one in 3 women reported ad- (low-dosage or unsupervised training, ie, advising a woman
verse effects.14,15 Alpha-adrenergic agonists are no longer rec- to do more Kegels at her 6-week postpartum visit) may lead
ommended for the treatment of stress urinary incontinence some women to believe they have attempted PFPT without
as they, too, have a high rate of adverse effects and are not success.20 These women may feel less inclined to reattempt

Journal of Midwifery & Women’s Health r www.jmwh.org 3

PFPT with more optimal dosage and supervised training and Table 2. Assessment of Pelvic Organ Prolapse
opt for more invasive treatment methods instead. It is impor- Pelvic Organ Prolapse Quantification System
tant to teach women how to make the Kegel more purpose-
Stage Description
ful, specifically by using it during functional activities during
which they experience leakage. The success of PFPT depends 0 No prolapse
on several factors, and seeing a pelvic floor physical therapist I ⬎1 cm above the hymen
likely yields better results than individual use of Kegels only. II ࣘ1 cm proximal or distal to the plane of the hymen
A systematic review of 18 trials involving 1281 women III ⬎1 cm below the hymen, but protrudes no farther
found that women who underwent PFPT reported improved
than 2 cm less than the vaginal length
quality of life because of improved incontinence and satis-
faction with PFPT treatment. They also leaked urine less of- IV Complete eversion of the lower genital tract
ten, lost smaller amounts of urine, emptied their bladders Source: Haylen et al.24
less often, and reported improved sexual outcomes.11 Four
trials within this systematic review examined the relation-
ship between PFPT and stress urinary incontinence. Women injury and/or dysfunction as well as genetic predisposition.4
with stress urinary incontinence who underwent PFPT were PFPT may help women strengthen and better control the le-
8 times more likely to report cure than women in the control vator ani muscles that function to support the weight of ab-
group (46/82 [56.1%] vs 5/83 [6.0%], respectively; risk ratio dominal and pelvic contents against increased intraabdomi-
[RR], 8.38; 95% CI, 3.68-19.07) and 17 times more likely to nal pressure.4 Pelvic organ prolapse affects between 5% and
report cure or improvement (32/58 [55%] vs 2/63 [3.2%], re- 10% of women and is strongly associated with parity, obesity,
spectively; RR, 17.33; 95% CI, 4.31-69.64).13 and hysterectomy. It is a common condition as women age,
It is not known how long benefit from participating in as uterine prolapse occurs in 40% of women aged older than
PFPT lasts, but adherence to treatment is believed to improve 50 years.25 Women often report bulge or pressure symptoms,
both symptoms of stress urinary incontinence and the dura- constipation, incomplete emptying of bowels, urinary incon-
tion of the benefits.11,20 There is insufficient evidence to sug- tinence, overactive bladder symptoms, or difficulty voiding;
gest that adding PFPT to other active therapies (vaginal cones however, the severity of symptoms does not correlate with the
or pessaries, behavioral therapies, pharmacologic therapies) stage of prolapse, and some women may be asymptomatic.26
is beneficial7 ; however, it is appropriate to try PFPT as a first- Prolapse symptoms may interfere with daily activities, in-
line conservative treatment for stress urinary incontinence, as cluding negatively affecting exercise, sexual functioning, and
it may cure or improve symptoms and quality of life so that body image.27 Treatment is indicated for symptomatic women
more invasive treatment options may be delayed or avoided and may be individualized based on symptoms and patient
altogether. preferences.
PFPT may also be used in the antenatal and postnatal pe- Treatment methods for pelvic organ prolapse include ex-
riods to prevent stress urinary incontinence. A systematic re- pectant management and the use of pessary, surgery, and
view of 22 trials found that pregnant women without prior pelvic floor muscle training. Expectant management is a rea-
stress urinary incontinence who were randomized to super- sonable option for women who are able to tolerate their symp-
vised PFPT were less likely than women randomized to no toms and wish to avoid treatment. Pessaries are intravaginal
PFPT (or usual antenatal care) to report stress urinary in- devices that attempt to alleviate symptoms by restoring the
continence up to 6 months after birth (RR, 0.71; 95%, CI pelvic organs to their normal position.23 They are also a con-
0.54-0.95).18 Providers may consider recommending PFPT to servative treatment option; however, success rates with pes-
prevent the onset of stress urinary incontinence during preg- sary use range from 41% to 86%, and younger women may be
nancy and in the postpartum period. When used optimally, less satisfied with using a pessary.28 Factors associated with
PFPT is also effective for improving symptoms of urge and unsuccessful pessary fitting include higher BMI and inactive
mixed urinary incontinence.11 or underactive pelvic floor muscles.28
Surgery may be indicated for women experiencing symp-
PELVIC ORGAN PROLAPSE tomatic prolapse who have failed or opted out of conservative
therapies. There is an 11% to 19% lifetime risk for women un-
The International Urogynecologic Association and the Inter- dergoing surgery for pelvic organ prolapse, and there is a re-
national Continence Society define pelvic organ prolapse as operation rate of up to 30% after the initial surgery.29–31
“the descent of one or more of the anterior vaginal wall, pos-
terior vaginal wall, the uterus (cervix) or the apex of the vagina
PFPT Management of Pelvic Floor Prolapse
(vaginal vault or cuff scar after hysterectomy).”23 A prolapse
may involve the anterior vaginal wall (cystocele or urethro- Unlike the evidence supporting the use of PFPT for stress
cele), the posterior compartment (rectocele or enterocele), or urinary incontinence, the evidence about the effect of PFPT
the apical compartment (uterine or vaginal vault prolapse).6 on pelvic organ prolapse symptoms is somewhat less clear.
Prolapse may be assessed and graded using the International By strengthening the pelvic floor muscles, PFPT improves
Continence Society Pelvic Organ Prolapse Quantification support for pelvic organs in response to changes in intraab-
system (Table 2).24 dominal pressure.32 Should surgical repair be necessary, this
The etiology of pelvic organ prolapse is multifactorial presurgical physical therapy may prevent the need for surgi-
and likely a result of pelvic floor or pelvic connective tissue cal revision. PFPT may also teach women proper techniques

4 Volume 00, No. 0, xxxx 2018

for bearing down with constipation, as well as optimal body objective and subjective improvements in prolapse symptoms,
mechanics to reduce the amount of stress on the pelvic floor. but it does not predict or always prevent the need for further
Randomized trials that have evaluated use of PFPT for treatment.35 Women with more severe prolapse or more both-
treating women with pelvic floor prolapse have demonstrated ersome symptoms are more likely to seek further treatment
a small but clinically relevant improvement in both pelvic or- after PFPT.34 Counseling may include informing women that
gan prolapse and bowel symptoms when women adhere to PFPT is a reasonable treatment option and that a pelvic floor
PFPT treatment.33,34 A meta-analysis of 13 trials concluded physical therapist may assist in setting treatment goals to ad-
that pelvic floor muscle training was associated with a greater dress the bothersome prolapse symptoms, despite not being
improvement in prolapse symptom scores; therefore, a trial of able to completely resolve the prolapse.
PFPT is likely appropriate as it may improve symptoms and
presents very little risk for harm.35 Prolapse symptom scores
were used to assess subjective changes in prolapse symptoms, DIASTASIS RECTI ABDOMINIS
and pelvic floor prolapse stages were used to assess changes Diastasis recti abdominis is a condition in which the 2 rectus
in severity of the disorder. The study authors found that muscles are separated by an abnormally wide distance; how-
women who underwent PFPT reported a greater improve- ever, although the distance that is considered to be abnormal
ment than women in the control group in prolapse symptom is undetermined, an inter-rectus width of greater than 2 cm
scores (mean difference −3.07; 95% CI, −3.91 to −2.23) and (at the umbilicus or 4.5 cm above or below the umbilicus) is
demonstrated an objective improvement in pelvic floor pro- recognized as a widened diastasis.41,42 Diastasis recti abdomi-
lapse severity (RR 1.70; 95% CI, 1.19-2.44).35 nis occurs when there is a weakening of the linea alba fas-
The randomized trial by Panman et al found that PFPT cia and is not an abdominal wall hernia. It may be diagnosed
was superior to expectant management in that women who during a physical examination when the woman raises her
underwent PFPT had a 12.2-point increase (95% CI, 7.2-17.2; head and abdominal contents protrude into a weakened linea
P ⬍ .001) in the score on the validated Pelvic Floor Dis- alba as a result of increased intraabdominal pressure. Diasta-
tress Inventory.36 In one randomized controlled trial, 39% of sis recti abdominis persists in approximately 33% of women
women with pelvic organ prolapse receiving PFPT reported at 12 months postpartum.43
improved sexual function compared with 5% of women in the The physiologic changes of pregnancy, specifically in-
control group (P ⬍ .01). Specifically, some women reported creasing pressure applied by an enlarging uterus and the
increased control, better strength and awareness of their pelvic displacement of abdominal organs, can have a nonoptimal
floor, improved self-confidence, and resolution of pain with impact on the structure and function of the abdominal can-
intercourse.37 Improvement in sexual function was noted in ister. Dysfunction of the rectus abdominis may contribute
the women who demonstrated the greatest increase in mus- to lumbopelvic instability and postural changes, resulting
cle strength (r = 0.43, P ⬍ .01) and endurance (r = 0.27, in discomfort with movement, low back pain, sacroiliac or
P = .01).37 pubic symphysis pain, or exacerbation of existing pelvic
A subsequent Cochrane systematic review concluded that floor dysfunction.42 Research does not indicate, however,
PFPT is effective for improving pelvic floor prolapse symp- that women with diastasis recti abdominis experience more
toms and severity.38 PFPT may be effective for women with lumbopelvic pain, pelvic organ prolapse, or urinary incon-
only mild prolapse and may also improve sexual function in tinence than women without diastasis recti abdominis.43,44
some women with pelvic organ prolapse.38 These small im- Some women may express concern about the cosmetic ap-
provements in prolapse symptoms may be of great signifi- pearance of the diastasis, whereas others may inquire about
cance to women and could be an impetus to delay or forgo how soon they can resume an exercise regimen or whether
surgery.33 After PFPT, women may choose to proceed with abdominal exercises will reduce the inter-rectus space. Dias-
more invasive measures with the confidence that conserva- tasis recti abdominis may also be corrected surgically through
tive therapy was insufficient and that surgery is the appro- abdominoplasty or laparoscopy.41
priate choice. It appears that there are subgroups of respon-
ders and nonresponders, and identifying the characteristics of
Management of Diastasis Recti Abdominis
who may respond to PFPT is beyond the scope of the current
research.38 Exercise appears to be beneficial for diastasis recti abdomi-
Based on this body of research, PFPT is recommended nis. A systematic review found that exercise during the ante-
as the first-line treatment for women with pelvic organ pro- natal period reduced the presence of diastasis recti abdominis
lapse (Grade A Recommendation)32 ; however, more research by 35% and suggested that diastasis recti abdominis may be
is needed to understand what PFPT regimens are most effec- reduced by exercising during the ante- and postnatal periods
tive in managing pelvic organ prolapse, the cost-effectiveness (RR, 0.65; 95% CI, 0.46-0.92).42 The implications of this re-
of PFPT in the treatment of pelvic organ prolapse, and how view are limited, as there is little high-quality literature on the
long benefits persist after treatment.39 For women undergo- subject of exercise and diastasis recti abdominis, and more re-
ing surgery for the treatment of prolapse, it is unclear whether search is needed to determine what exercise regimens are best
adding perioperative PFPT to surgery is superior to surgery for reducing diastasis recti abdominis.42 Physical therapy may
alone.40 address diastasis recti abdominis by improving postural con-
Health care providers may inform women that it is diffi- trol and core stabilization through the training and use of the
cult to predict how well they may respond to PFPT. This ther- transverse abdominis and pelvic floor musculature, thus pre-
apy increases muscle strength and endurance and results in venting overuse of the rectus abdominis.

Journal of Midwifery & Women’s Health r www.jmwh.org 5

 Dysfunction of the abdominal canister and related com- lacking in the graduate education curricula of nurse-midwives
pensatory measures also contribute to pelvic girdle and low and midwives, advanced practice nurse practitioners, and
back pain. For women experiencing diastasis recti abdomi- physician assistants; and reimbursement may be challenging
nis, pelvic girdle pain, or low back pain, pelvic floor physical to navigate, insurance companies may not cover all treatment
therapists can assess the myofascial integrity and function of modalities, and co-pays may be a barrier to patient access. In
the structures of the abdominal canister, as well as how other addition, there is a lack of resources to appropriately teach
joints may be interrupted as a result of this dysfunction.45 patients, no standardized treatment protocol to guide clinical
Physical therapists can teach women with these conditions op- practice, and no standard for long-term follow-up care.48 The
timal strategies for restoring function by correcting misalign- first step in addressing these barriers must include address-
ment of the pelvis, teaching proper patterning of the transver- ing health care provider knowledge deficits about the benefits
sus abdominis and pelvic floor muscles, and providing of PFPT.
postural and movement retraining for activities such as stand-
ing, bending, single-leg loading, and squatting.45
CONCLUSION
It is important that women understand that physical ther-
apy will not completely reverse or close a diastasis recti ab- Increased health care provider knowledge about the benefits
dominis; however, education may highlight the benefits that of PFPT may benefit women and their families. As health pro-
accompany evaluating and restoring the function of the ab- motion and disease prevention are a priority in the health
dominal canister. care field, it is in a health care provider’s best interest to
use a treatment method that maximizes patient outcomes
IMPLICATIONS FOR PRACTICE
and minimizes risk. Health care providers may do this by
screening for disorders that would benefit from PFPT, refer-
Based on the literature supporting PFPT for the prevention ring women to PFPT in a timely manner, and educating pa-
and treatment of urinary incontinency and pelvic floor dys- tients about PFPT in a way that cultivates hope and reduces
function, women may be advised to perform PFPT during anxiety.
pregnancy and the early postpartum period, provided that A.B.’s case represents a sequence of events and inter-
they are able to correctly isolate and adequately contract their actions with health care providers that is shared by many
pelvic floor muscles.46 Providers can include screening for women. After her referral to PFPT, A.B. was seen by a pelvic
prepregnancy and antenatal pelvic floor dysfunction at the floor physical therapist for 3 visits, and she reported im-
initial prenatal visit and again at the 6-week postpartum visit.1 provements in her symptoms of stress urinary incontinence,
Women’s health care providers should routinely ask women pelvic organ prolapse, and dyspareunia. Ultimately, A.B.’s in-
about the onset or exacerbation of pelvic floor dysfunction be- surance provider changed and PFPT was no longer an af-
cause women may not volunteer this information, and they fordable option for her, but she hoped that adhering to her
can then provide education about the signs and symptoms at-home physical therapy regimen would continue to yield
to report as well as the modifiable risk factors that women results.
can address to decrease their risk of developing or worsen- Pelvic floor dysfunction is not an acceptable normal result
ing pelvic floor dysfunction. Empowering women to address of pregnancy and birth, and medication or surgery does not
modifiable risk factors (avoiding smoking and constipation, need to be presented as a first-line treatment when a safer, less
maintaining a healthy BMI, adhering to PFPT) and make in- invasive option is available. Although A.B.’s history suggests
formed decisions about their treatment for pelvic floor dys- there were several missed opportunities for PFPT interven-
function is in line with the philosophy of care that women tion over time, her case also represents an opportunity for the
have a right to self-determination and active participation provider to provide education and counseling about PFPT as a
in their health care.1 Education may include the risks and conservative, evidence-based treatment option for her pelvic
benefits of, as well as the alternatives to, medical and surgi- floor dysfunction.
cal interventions, and low-risk treatment modalities such as
PFPT should be included. Extensive education and instruc-
tion about PFPT cannot reasonably be completed in a 10 to AUTHORS
20 minute office visit; therefore, individuals with these dis- Samantha Lawson, CNM, WHNP-BC, is a recent graduate
orders or symptoms may benefit from referral to a pelvic from the University of Utah’s Nurse-Midwifery & Women’s
floor physical therapist so that intensive regimens, sufficient Health Nurse Practitioner program. She will be practicing
education, and support may be provided to ensure optimal full-scope midwifery in the US Air Force.
outcomes.20,47
Ashley Sacks, PT, DPT, is a physical therapist at the University
Barriers to Use of Utah and is certified through the Herman & Wallace Pelvic
Institute to treat pelvic floor dysfunction, including rehabili-
Despite the evidence supporting the effectiveness of PFPT, tation for pregnant and postpartum women. She also serves as
it is not commonly used as a first-line treatment for pelvic the Utah State Representative for the American Physical Ther-
floor dysfunction in the United States.19,48 There are several apy Association Section on Women’s Health.
potential reasons for this: more research is needed to better
understand the long-term benefits of PFPT, the most effec-
tive training regimens, and barriers to patient adherence; ed- CONFLICT OF INTEREST
ucation about conservative pelvic floor dysfunction may be The authors have no conflicts of interest to disclose.

6 Volume 00, No. 0, xxxx 2018

ACKNOWLEDGMENTS 2013: summary of the 5th International Consultation on Incontinence.
Neurourol Urodyn. 2016;35(1):15-20.
The authors would like to thank Emily Hart Hayes, CNM, 20.Mørkved S, Bø K. Effect of pelvic floor muscle training during
WHNP, and Scott Christensen, MBA, APRN, ACNP-BC, for pregnancy and after childbirth on prevention and treatment of uri-
their guidance and support in the writing of this manuscript. nary incontinence: a systematic review. Br J Sports Med. 2014;48(4):
299-310.
21.Bø K, A H Haakstad L, Voldner N. Do pregnant women exercise
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Appendix 1: Resources for Providers

Herman & Wallace Pelvic Rehabilitation Institute

Provides continuing education courses, as well as a practitioner directory.
https://hermanwallace.com/practitioner-directory
American Physical Therapy Association (Section on Women’s Health)
Offers a Physical Therapist Locator, resource directory, continuing education courses, educational materials for patients, and the
Journal of Women’s Health Physical Therapy.
http://www.womenshealthapta.org
The International Continence Society
An international, multidisciplinary professional organization that prioritizes education, research, and advocacy as they pertain to
pelvic floor health. Of note, the International Continence Society publishes joint reports with the International Urogynecologic
Association that standardize the terminology used to describe pelvic floor dysfunction.
https://www.ics.org/
The Pelvic Guru
Includes several resources for professionals, including courses, mentoring, and a free pelvic floor anatomy review guide. This
website offers educational materials for patients, access to a blog featuring articles about PFPT, and private support groups on
social media for new mothers and women experiencing pelvic pain.
http://pelvicguru.com/

8 Volume 00, No. 0, xxxx 2018