Bladder Leaks, Back and Pelvic Pain During and After Pregnancy

How often are back pain, a leaky bladder and pelvic pain viewed as part and parcel of pregnancy? Many of the physical symptoms accompanying pregnancy are simply accepted as being part of having a baby.

When women with signs of spinal, pelvic and pelvic floor dysfunction are identified during pregnancy, appropriate advice and treatment leads to a more comfortable pregnancy and reduced postpartum problems.

This article looks at pelvic floor muscles (PFM) during pregnancy and their association with urinary incontinence, back pain and pelvic girdle pain.

The International Continence Society recommends pelvic floor muscle training (PFMT) for women during pregnancy. Evidence for this recommendation shows that pregnant women without urinary incontinence, (UI) who do PFMT are 56% less likely to report UI in late pregnancy and 30% less likely to report UI, 6 months postpartum when compared with women who didn’t train their PFM. The PFMT women are half as likely to report faecal incontinence (FI) 12 months pospartum (1).

http://www.holditsister.com/content/recent-evidence-regarding-pelvic-floor-muscles-during-pregnancy

Pregnancy places significant stress on the abdominals and PFM. The PFM strength in pregnant women is weaker when compared with the PFM strength of women without children (2). Having UI before and during pregnancy increases the risk of UI postpartum (3). Weight gained during pregnancy is not associated with UI, rather the failure to lose weight 6 months postpartum is associated with UI (4).

Low back pain (LBP) is reported by 50-80% of pregnant women, affecting their performance or ability to engage in house and child duties and work performance. Along with PFMT, general exercise is recommended for pregnant women with LBP. This common condition is often present before pregnancy while pelvic girdle pain (PGP) develops during pregnancy and both can persist postpartum. LBP is more common in sedentary women when compared to active pregnant women. Those in physically demanding occupations have a higher risk of LBP. Women with LBP in the second half of pregnancy who took part in a pregnancy exercise program had less postural postpartum changes and severity of back pain (5).

What is recommended for LBP in pregnancy?

  • Targeted physiotherapy with postural and movement training
  • PFM training as muscles may be weak or uncoordinated from previous births
  • Water based exercises
  • Group exercise classes, acupuncture, massage, relaxation, daily rest
  • Garment/brace support

How does PGP differ from LBP in pregnancy?

Women with PGP have increased tension and pain in PFM when compared to pregnant women without PGP. These women don't do well with a general exercise or stability program and are typically made worse with PFM strength exercises. What's recommended for PGP -

  • Acupuncture for pain relief
  • A support garment/sacro-iliac belt may reduce pain
  • Relaxation therapy
  • Learning movement control
  • Individual treatment and specific exercise program

I'm currently treating several pregnant mums with pain in one or both sacroiliac joints, pubis, lower abdomen, hips and thighs. Their PFM are over-active with significant pain and trigger points referring pain to the lower back, buttock and lower abdomen. The internal space between the PFM is narrowed causing increased vaginal resting pressure, which is associated with a longer 2nd stage of labour. http://www.holditsister.com/content/can-pelvic-floor-muscles-be-too-tight-give-birth

Research shows women giving birth for the first time can reduce the risk of muscle tears and stitches by practicing regular perineal massage in the last four to six weeks of pregnancy (it does not always prevent tearing) (6). Some first time mums with PGP are using the Epi-No birth trainer from 35 weeks of pregnancy to stretch overactive PFM.

Treatment for PGP should be based on findings from individual examination and not lumped into the 'one exercise approach fits all' program (7).

What are the risks for developing low back pain (LBP) and pelvic girdle pain (PGP) during pregnancy?

  • Prior history of back pain
  • Prior trauma to the pelvis
  • Mixed evidence for those in physically demanding work, hyper-mobile joints and multi-parous
  • Mixed evidence for obesity (8)

The consequences of LBP/PGP during pregnancy can include

  • Poor psychological health and possible depression
  • Increased sick leave
  • Associated urinary incontinence
  • Limited mobility and involvement in activities
  • May need walking stick/wheelchair when severe
  • Increased bed rest
  • Limited mobility in labour
  • Reduced choices for birth positions
  • Need for increased analgesia/interventions with labour/birth
  • Risk of the condition becoming a chronic pain syndrome

Both LBP and PGP seldom receive the attention these painful conditions deserve during pregnancy. While Belly Bands, compression garments and belts may provide some relief, WH physiotherapists have a central role in assessing and treating the underlying poorly functioning PFM along with musculo-skeletal and movement assessment. Specific evidenced based tests, the PGP questionnaire and functional outcome measures will identify pregnant and postpartum women with PGP. Individual assessment guides the direction of treatment interventions, which aims to give skills for self-management.

References

  1. Hay-Smith J, Morkved S, Fairbrother K, Herbison G. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in ante natal and post natal women. Evid Based Med. 2009;14(2):53
  2. Resende A, petricelli C, Bernardes B, Alexandre S, Nakamura M, Zanetti M. Electromyographic   evaluation of pelvic floor muscles in pregnant and non pregnant women. Int Urogyn J. 2012 23:1041-1045
  3.    Bo, K. (2009). Does pelvic floor muscle training prevent and treat urinary and fecal incontinence in pregnancy? Nat Clin Pract Urol, 6(3), 122-123.
  4. Wesnes SL, Hunskaar S, Bo K, Rortveit G.Urinary incontinence and weight change during   pregnancy and postpartum: a cohort study. Am J Epidemiol.2010 Nov 1;172(9):1034-44. Epub 2010 Aug 20.
  5. Garshasbi A, Faghih Zadeh S.The effect of exercise on the intensity of low back pain in pregnant women.International Journal of Gynecology & Obstetrics, Volume 88, Issue 3, March 2005, Pages 271-275
  6. Beckmann MM, Garrett AJ. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005123. DOI: 10.1002/14651858.CD005123.pub2
  7. Stuge B. Tidsskr Nor Laegeforen.Diagnosis and treatment of pelvic girdle pain. 2010 Nov 4;130(21):2141-5. doi: 10.4045/tidsskr.09.0702.
  8. European Guidelines on diagnosis and treatment of pelvic girdle pain, 2008