What every mom needs to know about post-delivery pelvic floor injuries [PODCAST]

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Join us for an enlightening episode with Sarah Boyles, a urogynecologist, as we delve into the often overlooked topic of pelvic floor health post-delivery. While the joy of childbirth is celebrated, many women face concerns about delivery, including pain, labor duration, and birth plans. However, the pelvic floor—crucial for long-term health—is frequently neglected. Sarah sheds light on the prevalence of undiagnosed levator ani muscle tears, their long-term impacts, and the critical need for improved diagnostic and treatment practices.

Sarah Boyles is a urogynecologist.

She discusses the KevinMD article, “The overlooked impact of childbirth: hidden pelvic floor damage.”

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Transcript

Kevin Pho: All right, welcome to the show. Subscribe at kevinmd.com/podcast, then get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Sarah Boyles. She’s a urogynecologist, and today’s KevinMD article is “The overlooked impact of childbirth: hidden pelvic floor damage.” Sarah, welcome back to the show.

Sarah Boyles: Thanks so much for having me.

Kevin Pho: So go to kevinmd.com/podcast and search for Sarah’s name to hear her prior episode and story, but today let’s jump right into your most recent article about hidden pelvic floor damage, “The overlooked impact of childbirth: hidden pelvic floor damage.” What’s this article about?

Sarah Boyles: So after a woman delivers, obstetricians are trained to look for visible lacerations, right? We look for damage in the vagina. The most common ones are along the perineal body, and those are treated at the time of delivery. But we don’t standardly assess the pelvic floor muscles, so the levator ani, and look for damage and trauma to these muscles.

These muscles can be dramatically impacted during a delivery. They have to stretch, and the muscles that are closest to the vagina stretch three times their resting length, right? No other muscle can do that. And they frequently recover, but they don’t always recover. We think that about 19 percent of women have permanent damage to these muscles as they heal after delivery.

Kevin Pho: So what are some of the reasons in general why these muscles are overlooked?

Sarah Boyles: Well, one, you can’t really see them, right? I mean, they’re deep inside the pelvis. I think because we don’t see them and we were not trained to think about them, right? This is a part of your body that you just assume is going to work, right? Those pelvic floor muscles are attached to your sphincters, right? They keep you dry, they keep you clean, and they keep you from leaking stool and urine. And we just kind of assume that that part of the body is going to work, and we don’t frequently assess it.

So in other countries, for example, in France, women go to pelvic floor physical therapy after they deliver, and that’s the standard of care. In the United States, there’s some recommendation that you go if you have a traumatic delivery, right? So a third- or fourth-degree laceration. But we’re really waiting for a lot of women to have symptoms and present before we’re assessing these muscles and looking at what happened.

Kevin Pho: So how would these women present if they were to have any damage to the pelvic floor muscles after birth?

Sarah Boyles: So a lot of times it’s leaking urine; sometimes it’s leaking stool. It can be pain. Women who are very athletic, right? So women who are elite athletes will notice it, because the way their body works, the way their core works, is very different.

But one of the biggest risk factors that we see is that women that have damage to the pelvic floor during delivery are much more likely to develop symptoms later on in life. They’re much more likely to develop incontinence and prolapse as they age. And that’s one of the problems with this: A lot of times, the big symptoms that happen and the big problems are remote from that injury.

Kevin Pho: So what are some preventive measures that you would recommend before delivery and even after delivery to help prevent some of these symptoms?

Sarah Boyles: So those are things that we’re still trying to figure out, right? We’re trying to figure out how to risk-stratify women, to figure out which women are more likely to have a traumatic delivery. So women who are older, women that have large babies, so greater than 4,000 grams, or anticipated large babies, women who push for a long time, or women whose babies are not occiput anterior are much more likely to have damage to the pelvic floor. And the only way to kind of prevent it would be to move on to a cesarean section, and that’s a major surgery. So we’re working at developing risk stratification measures to figure out who is at the biggest risk, and there’s a lot of research that’s being done along that line.

There’s also some evidence to support doing pelvic floor muscle training before delivery, so during pregnancy. Those women who know how to exercise their pelvic floor and know how to relax their pelvic floor are less likely to have damage at the time of delivery.

Kevin Pho: Now, are these exercises Kegel exercises, or something similar to those?

Sarah Boyles: Yep, which I think is a little bit counterintuitive to people, because you would think that strengthening wouldn’t necessarily make a big difference. But it has been shown that if your pelvic floor is strong and you understand how to contract it and relax it, there is less damage that’s done at the time of delivery.

Kevin Pho: Now, for those listeners who may not be familiar with Kegel exercises, just give us a brief description of what they are.

Sarah Boyles: Yeah. So your pelvic floor muscles, so your levator ani, those muscles are a bowl, and they’re attached to your pubic bone, to your tailbone, and to your hips, and they support all of your organs. When you contract those muscles, you will feel the pelvic floor kind of elevate, so it contracts inward and upward. One way that people frequently test it is that if you contract your pelvic floor, it should cut off the flow of urine. If that happens, then you are contracting your pelvic floor correctly. Men have a pelvic floor too, but we talk about Kegel exercises a lot more in women. We don’t recommend that you contract it to stop the flow of urine regularly, because that can confuse some of your reflexes, but that’s one way to check it.

And so when we have women do pelvic floor exercises, it’s important that the exercises get harder over time, so you’re holding that contraction for a longer period of time, and that you’re doing it in different positions. It’s easier if you’re lying down and harder if you’re standing up. So the exercises that you’re doing should get more difficult over time, just like any other exercise routine. But you’re really contracting that muscle and holding it, and you want to hold it for up to 10 seconds. And then you do that 10 times, and ideally you would do three reps a day.

Kevin Pho: What are some common presentations of patients that you see in your clinic for people with pelvic floor damage? What are some common questions that referring physicians ask you to answer?

Sarah Boyles: I think the thing about the pelvic floor is that it’s frequently multifactorial, right? So I will see patients with leaking, and sometimes that leaking is because the pelvic floor is too tight. Sometimes it’s because it needs to be strengthened, right? And so when we’re examining patients, I’m always examining the musculature, and I’m always looking at the impact of hormones, right? Because hormones can definitely affect how these muscles work.

And I think there are definitely a lot of patients out there who have been working on their pelvic floor strength and have been doing a lot of things, and they’re not getting better. And sometimes that’s because they have had a levator injury, and they don’t have those muscles, right? Those muscles can avulse. They can pull off the pubic bone, and then they atrophy over time. And so they really don’t have the equipment to do the exercises that we’re asking.

I think, truthfully, a lot of people don’t like dealing with the pelvis and the pelvic floor. I think the most common question, or the most likely thing that I get asked, is, “Can you just figure this out, right? And figure out what’s going on?” Because they’re detailed conversations, and they’re not conversations that everybody is comfortable with.

I think the other question that I frequently get asked is, if you have someone who’s struggling with these issues and they’re postpartum, should you send them to a urogynecologist, or should you send them to pelvic floor physical therapy first? And I think that really depends on your local resources and your community. I think sending someone to pelvic floor physical therapy is absolutely a very reasonable thing to do first. And then in my community, if that pelvic floor physical therapist has any questions, or they feel like there are other things going on that they can’t answer, like poorly healing wounds, or they have questions about hormonal status, then they’ll send them to me. So either route is perfectly fine, depending on your local resources.

Kevin Pho: So talk more about your diagnostic strategy. Is it primarily clinical? Are there any specific tests, imaging studies, or dynamic studies that you would order to evaluate this?

Sarah Boyles: So if someone has a muscular injury, right, so they have a levator avulsion, you can feel it. You can palpate the muscle, and when the muscle isn’t there, you can feel it. So someone who’s experienced in this exam can tell on physical exam. There are also imaging techniques that you can do. You can do ultrasound, so you could do transperineal ultrasound to look at the muscles. You can also do MRI to look at the muscles.

So I base a lot of what I do on my clinical exam. I don’t routinely get imaging unless the clinical exam doesn’t make sense. Or sometimes I’ll do that imaging just to demonstrate it to the patient, right? And to help that patient kind of be more educated about their anatomy and how their anatomy is working. But most of the time, it’s clinical exam.

Kevin Pho: All right, let’s talk about treatment options. So once you are pretty sure that a patient has a pelvic floor issue, what is the range of treatment options that you would present to that patient?

Sarah Boyles: Yeah. So a lot of times it’s education, right, explaining to that patient kind of what they have, what’s going on, and why their body is functioning differently. We frequently do start with pelvic floor physical therapy and strengthening the muscle that the patient has, so that they recognize how to use their anatomy in the best way. And then after that, a lot of these patients benefit from a pessary, right, which is a device that goes in the vagina that can kind of hold things up, and that theoretically can help prevent prolapse from happening over time, or can help with incontinence, or can help with current prolapse issues as well. And then if someone has leaking or they have a prolapse, there are always surgical options that we can talk about.

Kevin Pho: All right, so talk about those surgical options and the prognosis for patients whose symptoms are bad enough to require surgery.

Sarah Boyles: So it’s such an interesting question. I recently was out to dinner with a friend of mine who is 50, who I’ve known since college, who is just this amazing woman. And in the course of our conversation, she said, “Well, I haven’t run for the last 20 years, since I had my second child.” And I think that’s a really common presentation, right? Someone starts leaking after their delivery, and they just assume that that’s normal. And while it’s common, it is absolutely not normal.

So especially for urinary incontinence and for bladder leaking, the cure rates after surgery are about 90 percent, with an additional 5 percent being much better. So the interventions that we can do can have a huge impact on quality of life. For prolapse, the cure rates with surgery are lower, and there is a risk of recurrence over time. And so sometimes people have multiple surgeries over time. But even with prolapse surgery, the cure rates are very, very high.

That doesn’t mean that everybody needs surgery. I mean, sometimes patients live with these symptoms very well, but other people don’t. And if it is impacting you, then it’s absolutely something that should be addressed and treated.

Kevin Pho: Going back to prevention, what do you typically recommend pregnant women do in terms of these exercises? Go into more detail about the regimen that you would recommend to women to prevent potential damage to their pelvic floor muscles.

Sarah Boyles: Yeah, so I actually think seeing a pelvic floor physical therapist while you are pregnant is a great idea, right? When you’re actually doing the exercises with a pelvic floor physical therapist, you get more benefit from it, right? And so if that is available to someone, then I absolutely think that you should see pelvic floor physical therapy during pregnancy, right?

But then the standard regimen for Kegel exercises is to do three sets of 10 contractions a day. For each contraction, usually we have women hold it for 3 seconds at the beginning, and then, in the end, you want to be able to hold it for 10 seconds, right? So you want to increase that. And when we have patients start doing them, we have you start doing them lying down, and then we have you do them sitting up, and then we have you doing them standing. So at the end, you’re doing three sets of 10 standing contractions a day. And it seems like a very simple exercise, right? But the benefit that people get from it over time is pretty tremendous.

Kevin Pho: So in primary care, and I’m a primary care physician, as you know, what are some signs, symptoms, or stories that would make me think that this patient may need a specialist like yourself?

Sarah Boyles: Yeah. So anyone who’s leaking after delivery, right, I think should see a specialist, whether that leaking is bladder leaking or incontinence, or stool incontinence. And I think it’s really important to ask those questions, because not everybody is comfortable bringing up that information, right? But it is so common that it should definitely be asked.

I think pain, right? So persistent pain after delivery should absolutely be evaluated. Sometimes that pain can be from muscle tearing, right? And you can even get pubic bone fractures after delivery, or osteomyelitis. So those are all things that are uncommon but can absolutely happen. So I think any type of leaking, any type of pain.

And then I think when people come and they say, “I just don’t feel right. I just feel like something’s different,” and they have a host of kind of very ambiguous symptoms, I think that those patients also need to be evaluated, right? Because sometimes it’s hard to find the words to qualify what is happening, right? And they just know it’s different. And that frequently is a sign of muscular damage after a delivery.

Kevin Pho: We’re talking to Sarah Boyles. She’s a urogynecologist. Today’s KevinMD article is “The overlooked impact of childbirth: hidden pelvic floor damage.” Sarah, as always, we’ll end with some of your take-home messages to the KevinMD audience.

Sarah Boyles: I really want everyone to think about the pelvic floor if someone comes in with ambiguous symptoms that don’t really make sense in the pelvis, because those are things that we can frequently treat, and they’re not symptoms that a lot of people are comfortable treating, and they definitely impact quality of life for women. So if you have someone with ongoing pain or just very ambiguous symptoms that aren’t making sense, I think that is a very important person to send on.

And then I think the benefit of pelvic floor strengthening and pelvic floor physical therapy before pregnancy, right, or before that first delivery, is something that we’re going to start prescribing more and more, because the benefits and the prevention are very clear.

Kevin Pho: Sarah, as always, thank you so much for sharing your perspective and insight. And thanks again for coming back on the show.

Sarah Boyles: Thanks so much. It was great to talk to you.

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