1 Corrective Exercises for Diastasis Recti

Home , Pelvic floor

CORRECTIVE EXERCISES FOR DIASTASIS RECTI: Start your abdominal muscle training by learning how to brace your transverses abdominis.

1. Start on your hands and knees. Your hands should be directly under your shoulders, and your knees should be under your hips. Keep your back straight. Relax your abdominal muscles forward. Slowly and gently draw your abdominal muscles inwards towards your spine. Continue to breathe normally. Practice holding for 5 seconds and repeat 5 times.

2. To correct diastasis recti, begin by lying on your back with your knees bent. Cross your hands at your waist, or use a towel to wrap around your midsection, and begin to guide your stomach muscles together. Take a deep breath in, and as you exhale, contract your pelvic floor while you raise only your head off of the ground. While you lift, continue to pull your muscles together to start lessening the gap. Perform 10 repetitions of these exercises for diastasis recti three times per day.

3. Once you have stabilized your midsection and closed the gap, it should then be safe to try exercises for diastasis recti to further strengthen your abdominal muscles. On your own, you should begin to strengthen your transverse abdominis, or TVA, and pelvic floor. An example exercise that can help strengthen both is called a heel slide with belly scoop. Begin by lying on your back with your knees bent. Squeeze your belly toward your spine to activate your TVA. Tilt your pelvis up away from the floor as you slide the heel of one foot forward until your leg is almost straight. Slide the heel back in and repeat on the other side. Continue drawing your belly in and tilting your pelvis up as you perform 10 repetitions on each side. Only once your TVA and pelvic floor have strengthened should you begin to strengthen your outer abdominal wall, including the obliques and rectus abdominis.

4. Weight Loss is important and it’s a good idea to begin some form of aerobic exercise after pregnancy to regain general fitness and lose any excess body fat gained from pregnancy. You can start a gentle aerobic exercise program from 6 weeks after delivery of your baby. If you are breastfeeding, it is important to choose a form of exercise that is low impact and of moderate intensity. Research has concluded that exercise of low to moderate intensity will not affect production of breast milk or lactic acid build up. Ensure you are wearing a good fitting supportive bra. Aim for 45-60 minutes of aerobic exercise 3-5 days per week. Try walking, swimming, low impact aerobics, cycling etc. Remember the following simple formula: energy input (from food) must be less than energy output (from exercise) for weight loss. Stay hydrated by drinking an extra liter of water during your exercise session. Speak to a dietitian if you are concerned about your diet while breastfeeding.

5. Weight Training will assist with weight loss by increasing your metabolism. A simple weight training program can be performed at home that can include wall squats, lunges and pushups. Try the following after baby workout at home.

Wall Squats: Lean back into a wall or place your fitness ball against the wall and lean back into the ball so that your lower back is supported by the wall. Lower into a squat by bending your knees, keep your knees in line with your toes, push through your heels and return to the starting position.

6. Exercises to Avoid. Crunches, sit-ups, oblique twists combined with crunches. Refrain from doing anything that “jack-knifes” the body by pivoting at the hip & placing strain on the abdominals such as straight leg lifts or holds from lying on your back & some Pilates moves. In terms of every day movements, avoid lifting straight up from a horizontal lying position - always roll to your side & push up from there. Be careful when twisting & turning from the waist, keep thinking 'core' & pull belly button through to spine whenever you lift, twist or get up from lying, bending or crouching.

GENERAL VULVAR CARE Adapted from E Stewart MD

While you are seeking effective treatment for vulvar problems, here are some coping measures to relieve symptoms and prevent further irritation. Even when your symptoms are under control, these guidelines are recommended as a preventive strategy. ·

CLOTHING AND LAUNDRY • Wear all-white cotton underwear. • Do not wear pantyhose (wear thigh high or knee-high hose instead). • Remove wet bathing suits and exercise clothing promptly. Avoid exercise in tight synthetic clothes. Avoid thongs completely. • Wear loose-fitting pants or skirts. Take your underwear off when at home and go without underpants. • Use dermatologically approved detergents such as Purex or Clear, Arm & Hammer (Sensitive Skin), All Free and Clear. • Double rinse underwear and any other clothing that comes into contact with the vulva. • Do not use bleach or fabric softener on undergarments

SEXUAL INTERCOURSE • Use a lubricant that is water soluble, e.g., Astroglide, but be aware that it contains propyleneglycol (P.G.). A dab of cooking oil is fine if condoms are not used. • Ask your physician for a prescription for a topical anesthetic, e.g., Lidocaine gel 5% (this may sting for the first 3-5 minutes after application). • Apply ice or a frozen blue gel pack wrapped in one layer of a hand towel to relieve burning after intercourse. Frozen corn or peas in a small sealed plastic bag mold comfortably to vulvar anatomy. • Urinate (to prevent infection) and rinse the vulva with cool water after sexual intercourse. ·

PHYSICAL EXERCISE • Avoid exercises that put direct pressure on the vulva such as bicycle riding and horseback riding. • Limit intense exercises that create a lot of friction in the vulvar area (try lower intensity exercises like walking). • Use a frozen gel pack wrapped in a towel to relieve symptoms after exercise. • Enroll in a yoga class to learn stretching and relaxation exercises. • Don't swim in highly chlorinated pools. • Avoid the use of hot tubs.

EVERYDAY LIVING • Use a sitting cushion for long periods of sitting. • If you must sit at work, try to intersperse periods of standing (e.g., rearrange your office so that you can stand while you speak on the phone). • Learn some relaxation techniques to do during the day (The Relaxation and Stress Reduction Workbook by Davis, Eshelman and McKay or The Chronic Pain Control Workbook by Catalano and Hardin are recommended.

EXERCISE INSTRUCTIONS

ISOLATED CONTRACTION • Contract pelvic floor muscle and hold for _____ seconds • Rest for _____ seconds • Perform _____ repetitions Perform 2 times per day

BRIDGE • Contract your pelvic floor muscle and hold while lifting the buttocks off of the surface. • Relax while lowering your body down to the surface • Perform _____ repetitions Perform 2 times per day

PILLOW • Contract your pelvic floor muscle and hold for _____ seconds while squeezing a pillow between your knees at the same time. • Relax while moving your knees back to the starting position • Rest for _____ seconds

• Perform _____ repetitions Perform 2 times per day

EXERCISE BAND • Tie an exercise band around your thighs close to your knees • Contract pelvic floor muscle and hold for _____ seconds while separating knees against the resistance of the exercise band • Relax pelvic floor muscle while moving your knees back to the starting position • Rest for _____ seconds • Perform _____ repetitions Perform 2 times per day

QUICK CONTRACTIONS • Contract/Relax your pelvic floor muscle as rapidly as possible for 15 seconds. • Rest for 15 seconds • Repeat for _____ minutes Perform 2 times per day

HOME EXERCISE PROGRAM

TRANSVERSE ABDOMINIS ACTIVATION 1. Start the contraction from pubic bone upwards toward belly button. Think of zipping up a pair of jeans. 2. Start contraction, pulling up and in and do not go beyond the belly button. Keep the upper abdominals quiet. 3. Don't work for a really strong contraction. 4. This is a quiet stabilizing muscle that has more of an endurance function. Perform 10 repetitions

TRANSVERSE ABDOMINIS ACTIVATION WITH MARCHING 1. Start by lying on your back with your knees bent and arms by your side. 2. Engage TA so that your pelvis remains steady. 3. Lift one leg off mat to tabletop position (90 degrees at hip and knee). 4. Return your leg back to the mat. 5. Alternate lifting legs to the tabletop position. Perform 10 repetitions on each leg

TRANSVERSE ABDOMINIS

1. Breathing Inhale through the nose Exhale through pursed lips Exhale should be slightly longer than inhale Perform for a few minutes

2. TA Contraction Start the contraction from pubic bone upwards toward belly button Think of zipping up a pair of jeans Keep the upper abdominis quiet Don’t work for a really strong contraction This is a quiet stabilizing muscle that has more of an endurance function Perform 10 repetitions

3. TA Hold Start with the TA contraction and hold for as long as you can Keep breathing throughout the entire exercise Perform 10 repetitions of 5-10 second holds

4. TA with Leg Slides Start with the TA contraction and both knees bent Gently slide one heel along the table until your leg is straight and then pull it back up to a bent knee position. Repeat with the other leg The movement should be slow, and the most important part of the exercise is to keep the TA contraction Keep breathing throughout the entire exercise Perform 10 repetitions each side

5. TA with Knee Fall Out Start with the TA contraction and both knees bent Gently let one knee fall out to the side, only as far as you can keep the pelvis level Bring the leg back to the starting position. Repeat with the other leg The movement should be slow, and the most important part of the exercise is to keep the TA contraction Keep breathing throughout the entire exercise Perform 10 repetitions each side

NIGHTTIME BLADDER TRAINING

1. Limit fluids two hours prior to sleeping. If taking medications prior to bedtime. check with your physician if you can take the medications 1-2 hours earlier.

2. The first time that you wake during the night, try to first change positions to see. if the urge will resolve.

3. Perform slow relaxed breathing and make every effort to relax the muscles in the abdominal region and the bladder.

4. If the urge resolves, then try to go back to sleep.

5. If the urge remains and you are unable to relax, then remain calm and walk slowly to the bathroom to empty your bladder. Remember to apply the learned urge suppression techniques as you walk to the bathroom.

6. If you wake up multiple times at night, discuss with your therapist on how to slowly decrease the number of times you wake to empty your bladder.

7. Goal for nighttime voiding: ______times per night.

DAYTIME BLADDER TRAINING

These are suggestions for utilizing urge suppression to lengthen the time between voids.

1. Goal for daytime voiding: empty every _____ hours.

2. Set a goal each week on how to slowly lengthen the time between voids. Our goal for this week is - ______.

3. If you feel an urge to void, first think about the last time you voided and determine whether you need to delay the urge.

4. When choosing to delay the urge, first utilize the urge suppression techniques as instructed previously.

5. If you still have an urge after trying the various techniques – remain calm – slowly walk towards the bathroom as you continue to do slow relaxed breathing. Perform slow, submaximal pelvic floor contractions if it helps to suppress the urge.

6. Please be sure to slowly enter the bathroom, pull down clothing and sit. Everything should be done slowly to avoid the return of the strong urge and to avoid any leakage.

7. These techniques take practice to improve control of the urgency. It is best to practice these techniques at home first when you will not be as worried should you have a leakage episode.

BLADDER EMPTYING TECHNIQUES

This is a list of suggested techniques for bladder emptying. One or all of these may be helpful. Please utilize those techniques that work the best for you and discuss with your therapist.

1. With problems initiating a stream, sit as relaxed as possible. Begin slow, relaxed breathing: inhale through the nose and exhale through the mouth.

2. After the stream ends, sit for a few extra minutes and continue with the slow relaxed breathing to allow the muscles to completely relax and allow further emptying.

3. In standing, place your hands on your helps and firmly stroke your hands towards the bladder about 6 times to stimulate the voiding reflex. Then sit and place your hand one of top of the other above the pubic bone. Press firmly inward and downward to compress the bladder and expel any remaining urine. You can also slowly lean forward to further add pressure to the bladder.

4. Perform slow weight shifts to each side, forward and back. You can also try to slowly twist and bend forward.

5. It is important that these movements are slow and comfortable. There should not be any pain in your back, hips or shoulders.

6. Double voiding, wipe, stand up, jiggle around, sit down, lean forward and see if more comes out.

TOILETING TECHNIQUES FOR BOWEL MOVEMENTS (DEFECATION)

Using your belly and pelvic floor muscles to have a bowel movement is usually instinctive. Sometimes people can have problems with these muscles and have to relearn proper defecation (emptying) techniques. If you have weakness in your muscles, organs that are falling out, decreased sensation in your pelvis, or ignore your urge to go, you may find yourself straining to have a bowel movement. You are straining if you are:

• Holding your breath or taking in a huge gulp of air and holding it • Keeping your lips and jaw tensed and closed tightly • Turning red in the face because excessive pushing or forcing • Developing or worsening hemorrhoids • Getting faint while pushing • Not emptying completely and have to defecate many times a day.

If you are straining, you are actually making it harder for yourself to have a bowel movement. Many people find they are pulling up with the pelvic floor muscles and closing off instead of opening the anus. Due to lack pelvic floor relaxation and coordination the abdominal muscles, one has to work harder to push the feces out.

Many people have never been taught how to defecate efficiently and effectively. Notice what happens to your body when you are having a bowel movement. While you are sitting on the toilet, pay attention to the following areas:

• Jaw and mouth position • Angle of your hips • If your feet touch the ground or not • Arm placement • Spine position • Waist • Belly tension • Anus (opening of the anal canal)

AN EVACUATION/DEFECATION PLAN: Here are four basic points

1. Lean forward enough for your elbows rest on your knees. 2. Support your feet on the floor or use a low stool is your feet don’t touch the floor. 3. Push out of your belly as if you have swallowed a beach ball – you should feel a widening of your waist. 4. Open and relax your pelvic floor muscles, rather than tightening around the anus.

The following conditions may require modifications to your toileting posture:

• If you have had surgery in the past that limits your back, hip, pelvic, knee or ankle flexibility • Constipation

Your healthcare practitioner may make the following additional suggestions and adjustments:

1. Sit on the toilet a. Make sure your feet are supported b. Notice your hip angle and spine position – most people find it effective to lean forward or raise their knees, which can help the muscles around the anus relax. c. When you lean forward, place your forearms on your thighs for support.

2. Relax suggestions a. Breathe deeply in through your nose and out slowly through your mouth as if you are smelling the flowers and blowing out the candles. b. To become aware of how to relax your muscles, contracting and releasing muscles can be helpful. Pull your pelvic floor muscles in tightly by using the image of holding back gas, or closing around the anus (visualize making a circle smaller) and lifting the anus up and in. Then release the muscles and your anus should drop down and feel open. Repeat 5 times ending with the feeling of relaxation. c. Keep your pelvic floor muscles relaxed; let your belly bulge out. d. The digestive tract starts at the mouth and ends at the anal opening, so be sure to relax both ends of the tube. Place your tongue on the roof of your mouth with your teeth separated. This helps relax your mouth and will help to relax the anus at the same time.

3. Empty (defecation) a. Keep your pelvic floor and sphincter relaxed, then bulge your anal muscles. Make the anal opening wide. b. Stick your belly out as if you have swallowed a beach ball. c. Make your belly wall hard using your belly muscles while continuing to breathe. Doing this makes it easier to open your anus. d. Breathe out and give a grunt (try using other sounds such as ahhhh, shhhh, ohhhh or grrrr).

4. Finish a. As you finish your bowel movement, pull the pelvic floor muscles up and in. This will leave your anus in the proper place rather than remaining pushed out and down. If you leave your anus pushed out and down, it will start to feel as though this is normal and give you incorrect signals about needing to have a bowel movement.

ABOUT FECAL INCONTINENCE

Fecal incontinence is loss of control over bowel movements. Diarrhea is short-term loss of bowel control and can happen to anyone as an isolated event. Some people experience constant loss of gas (flatus) without awareness, which is called anal (gas) incontinence. Loss of bowel control can also occur as a result of:

• Childbirth or traumatic injury to the rectal are • Irritation or infection of the rectum, anus, or the surrounding area • Spinal cord injury • Brain condition such as head injury, stroke, or coma • Chronic constipation (can cause muscles of rectum/intestines to stretch and weaken) • Alzheimer's disease or other dementias

TREATMENT OPTIONS DEPEND ON THE CAUSE

Many people benefit from behavioral techniques and/or exercise. These include: • Exercises for the sphincters and pelvic floor muscles • Learning proper bowel health maintenance • Proper toileting positioning • Dietary factor management • Bowel retraining/Learning control techniques

SURGERY

Surgery may be needed to repair the muscle at the opening of the rectum. Another type of surgery is a colostomy. A colostomy attaches part of the colon to an opening in the wall of the abdomen. Bowel movements then pass through this opening instead of the rectum. They are collected in a bag outside the body.

MEDICATION

A person can usually control stool better when it is firm than when it’s loose or liquid. Sometimes taking medications to change the consistency of the stool can provide relief. Over-the-counter anti-diarrhea medications may include Imodium., and prescription medications may include Lomotil. These medications should be discussed with your physician prior to use.

INTRODUCTION TO BOWEL HEALTH

Diet and daily habits can help you predict when your bowels will move on a regular basis. The consistency and quantity of the stool is usually more important than the frequency. The goal is to have a regular bowel movement that is soft but formed.

TIPS ON EMPTYING REGULARLY

• Eat breakfast. Usually the best time of day for a bowel movement will be a half hour to an hour after eating. These times are best because the body uses the gastrocolic reflex, a stimulation of bowel motion that occurs with eating, to help produce a bowel movement. For some people even a simple hot drink in the morning can help the reflex action begin.

• Eat all your meals at a predictable time each day. The bowel functions best when food is introduced at the same regular intervals.

• The amount of food eaten at a given time of day should be about the same size from day to day. The bowel functions best when food is introduced in similar quantities from day to day. It is fine to have a small breakfast and a large lunch, or vice versa, just be consistent.

• Eat two servings of fruit or vegetables and at least one serving of a complex carbohydrate (who grains such as brown rice, bran, whole wheat bread, or oatmeal) at each meal.

• Drink plenty of water – ideally eight glasses a day. Be sure to increase your water intake if you are increasing fiber into your diet.

MAINTAIN HEALTHY HABITS

• Exercise daily. You may exercise at any time of day, but you may find that bowel function is helped most if the exercise is at a consistent time each day.

• Make sure that you are not rushed and have convenient access to a bathroom at your selected time to empty your bowels.

Fiber Table – Grams of Fiber in Food Food Products Serving size Grams of Fiber/Serving BREADS Whole Wheat 1 slice 2.11 White 1 slice 0.5 Rye 1 slice 1.72 CEREALS Oat Bran 1 oz 4.06 Wheat Bran 1 oz 10.0 Fiber One ½ cup 13.0 Shredded Wheat 1 oz 2.64 Corn Flakes 1 oz 0.45 Cheerio’s 1 1/3 cup 2.0 Oatmeal 1 oz 2.5 RICE Brown ½ cup 5.27 White ½ cup 1.42 SPAGHETTI Regular 2 oz 2.56 VEGETABLES (cooked) Broccoli ½ cup 2.58 Brussel sprouts ½ cup 2.0 Cauliflower ½ cup 2.6 Carrots ½ cup 3.2 Corn ½ cup 3.03 Eggplant ½ cup 0.96 Lettuce (raw) ½ cup 0.24 Baked potato (with skin) ½ cup 2.97 Spinach ½ cup 2.07 Squash ½ cup 2.87 Tomato (raw) ½ cup 1.17 Zucchini ½ cup 1.26 BEANS Green (canned) ½ cup 1.89 Kidney ½ cup 5.48 Lima ½ cup 4.25 Pinto ½ cup 5.98 FRESH FRUITS Apple (with peel) 1 medium 2.76 Banana 1 medium 2.19 Black/Boysenberries 1 cup 7.2 Grapefruit 1 medium 3.61 Grapes 1 cup 2.2 Nectarine 1 medium 3.14 Orange 1 medium 4.32 Pear (with peel) 1 medium 3.5 Prunes 3 3.5 Raspberries 1 cup 7.5 Strawberries 1 cup 3.87 Watermelon 1 slice 1.93

ABOUT CONSTIPATION

CONSTIPATION OVERVIEW

Constipation is the most common gastrointestinal complaint - about 4 million Americans experience constipation and make 2.5 million physician visits a year to get help for the problem. Constipation can occur when the colon absorbs too much water, the colon's muscle contraction is slow or sluggish, and/or there is delayed transit time through the colon. The result is stool that is hard and dry. Indicators of constipation include straining during bowel movements greater than 25% of the time, having fewer than three bowel movements per week, and/or the feeling of incomplete evacuation.

There are established guidelines (Rome II) for defining constipation. A person needs to have two or more of the following symptoms for at least 12 weeks (not necessarily consecutive) in the preceding 12 months:

• Straining in greater than 25% of bowel movements • Lumpy or hard stools in greater than 25% of bowel movements • Sensation of incomplete emptying in greater than 25% of bowel movements • Sensation of anorectal obstruction/blockade in greater than 25% of bowel movements • Manual maneuvers to help empty greater than 25% of bowel movements (e.g., digital evacuation, support of the pelvic floor) • Less than 3 bowel movements/week • Loose stools are not present, and criteria for irritable bowel syndrome are insufficient

COMMON CAUSES OF CONSTIPATION

• Lack of fiber in your diet • Lack of physical activity • Medications, including iron and calcium supplements • Dairy intake • Dehydration • Abuse of laxatives • Travel • Irritable Bowel Syndrome • Pregnancy • Luteal phase of menstruation (after ovulation, before menses) • Colorectal problems • Intestinal dysfunction

TREATING CONSTIPATION

There are several ways of treating constipation, including changes to diet and exercise, use of laxatives, adjustments to the pelvic floor, and scheduled toileting. These treatments include:

• Increasing fiber and fluids in the diet • Increasing physical activity • Learning muscle coordination • Learning proper toileting techniques and toileting modifications • Designing and sticking to a toileting schedule

STRETCHING THE PELVIC FLOOR MUSLCES NO DILATOR

SUPPLIES • Vaginal Lubricant • Mirror (optional) • Gloves (optional)

POSITIONING • Start in a semi-reclined position with your head propped up. Bend your knees and place your thumb or finger at the vaginal opening.

PROCEDURE

• Apply a moderate amount of lubricant on the outer skin of your vagina, the labia minora. Apply additional lubricant to your finger.

• Spread the skin away from the vaginal opening. Place the end of your finger at the opening.

• Do a maximum contraction of the pelvic floor muscles. Tighten the vagina and the anus maximally and then relax.

• When you know they are relaxed, gently and slowly insert your finger into your vagina, directing your finger slightly downward, for 2-3 inches of insertion.

• Relax and stretch the 6 o’clock position.

• Hold each stretch for _____ seconds and repeat _____ times with rest breaks of _____ seconds between each stretch.

• Repeat the stretching in the 4 o’clock and 8 o’clock positions.

• Total time should be _____ minutes, _____ x per day. Note the amount of time you were able to achieve and your tolerance to your finger in your vagina.

• Once you have accomplished the techniques, you may try them standing with one foot resting on the tub, or in other positions. This is a good stretch to do in the shower if you don’t need to use lubricant.

STRETCHING THE PELVIC FLOOR MUSLCES WITH A DILATOR

SUPPLIES • Vaginal Lubricant • Mirror (optional) • Gloves (optional) • Dilator

POSITIONING • Start in a semi-reclined position with your head propped up with knees bent, or in any position of comfort.

PROCEDURE

• Apply a moderate amount of lubricant on the outer skin of your vagina, the labia minora. Apply additional lubricant to the end of the dilator.

• Spread the skin away from the vaginal opening. Place the end of the dilator at the opening.

• Do a maximum contraction of the pelvic floor muscles. Tighten the vagina and the anus maximally and then relax.

• When you know they are relaxed, gently and slowly insert the dilator into your vagina, directing your finger slightly downward, for 2-3 inches of insertion.

• Relax and stretch the 6 o’clock position.

• Hold each stretch for _____ seconds and repeat _____ times with _____ seconds between each stretch.

• Repeat the stretching in the 4 o’clock and 8 o’clock positions.

• Total time should be _____ minutes, _____ x per day. Note the amount of time you were able to achieve and your tolerance to the dilator in your vagina.

• When ready, advance moving the dilator in and out of your vagina.

• Once you have accomplished the techniques, you may try them standing with one foot resting on the tub, or in other positions.

16 ABOUT VAGINAL DILATORS

WHAT IS A VAGINAL DIALATOR AND WHY DO I NEED ONE? • Vaginal dilators are silicone, plastic, or glass narrow cylinders used to help relax and release pelvic floor muscles. • Vaginal dilators are frequently helpful for individuals with pelvic pain, vaginismus, pudendal neuralgia, vulvodynia/vestibulodynia, and/or a history of sexual trauma. • Dilators/wands can also help individuals overcome anxiety, feet, and/or pain associated with touch at the opening or insertion inside the vagina by using the principles of desensitization; retraining your brain to overcome fear and/or anxiety that could also be contributing to pain. • Vaginal dilators come in sets with different sizes for gradual progression. You may or may not need to use all the sizes and can discuss your goals with your therapist.

HOW DO I USE A DILATOR? • Position yourself reclined, lying on your back with knees bent, feet apart, and head and neck supported. Use pillows to support knees if comfortable to allow full body relaxation. • Use diaphragmatic breathing to relax pelvic floor muscles: think about relaxing and lengthening pelvic floor muscles during inhale with a big belly breath, and keep it relaxed during the exhale. Use this time to increase awareness of pelvic floor muscle tension and release. Practice a few cycles of belly breathing for 2-3 minutes. • Starting with the smallest dilator, place a liberal amount of water-soluble lubricant, coconut oil, or lubricant of choice (avoid products containing glycerin, paraben, and propylene glycol) over the length of the dilator. You may also apply lubricant to vaginal opening to ease insertion. • Spread open vaginal lips (labia) and slowly slide the tip of the dilator in (use a mirror if necessary). Continue to slowly insert the dilator. You may feel burning and/or tightening as you guide the dilator in further, but you can pause at any time and focus on the following: o Breathing: Practice diaphragmatic breathing techniques, relaxing fully on every inhale o Relaxation: To aid in relaxation, add a gentle contraction (or kegel) of pelvic floor muscles once during exhale, and then continue to relax during inhale. o Lengthening: Visualize pelvic floor muscles lengthening downward o Stretching: Provide pressure to vaginal walls to stretch the opening outward o Space: Allow space between sit bones and think of opening outward. **Discomfort should not exceed 4/10 on your pressure/pain scale at any point and discomfort should gradually decrease during home session. If dilator has a vibratory option, this can be used to further relax pelvic floor muscles. • As you feel like you are able to accommodate to the dilator, you can use it to apply pressure to release and stretch your pelvic floor muscles. Apply even and constant pressure to tender or restricted areas. You can think of your vaginal opening as a pelvic clock and apply pressure to specific times on the clock as instructed by your therapist or as noted below. Total time should not exceed 10-15 minutes per day. • Gently remove the dilator and clean thoroughly with mild soap and water.

GOALS/NOTES FROM YOUR THERAPIST • Pressure to 2-5 & 7-10 o’clock for 20-30 seconds (avoid 12 & 6)

SOURCES: “Reviving Your Sex Life After Childbirth” by Kathe Wallace, PT, BCB-PMD “Guide to Using Vaginal Dilators, Part 1 by Tracy Sher, MPT, CSCS

17 VAGINAL DIALTORS

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18 URINARY RETENTION STRATEGIES

1. Privacy: comfort and privacy needed.

2. Sitting position: feet supported, PFM relaxed, do not rush, and do not push.

3. Relaxation: release PFM, deep breathe.

4. Forward lean: with cystocele, urine gets caught in pocket. Tip the pitcher to it into place where it can be emptied.

5. Crede’ Maneuver: add fist pulling into suprapubic area for more pressure during forward lean.

6. Double voiding: wipe, stand, jiggle around, sit down, lean forward, and see if more comes out.

7. Tapping: tapping over bladder may elicit detrusor contraction.

8. Stroking/Tickling: tickling over the sacral nerve roots stimulates pudendal nerve and the micturition reflex.

9. Whistling: sustained outward breath, increased intraabdominal pressure.

10. Pubic hair: pulling pubic hair can elicit detrusor contraction.

11. Cystocele: reduce cystocele manually prior to or during voiding to assist with emptying.

12. Vibration: one can use the Queens’ Square Bladder Stimulator or just manually vibrate suprapubic area to elicit detrusor contraction.

13. Valsalva Maneuver

14. Warm water pouring over perineum (to assist relaxation of PFM)

15. Timed voiding every waking hour and twice a night to shrink the bladder capacity.

19 BLADDER HEALTH

CONTINENCE DEPENDENTS ON MANY VARIABLES: 1. Urethral support 2. Pelvic floor muscle functioning 3. Anatomic configuration (organ stability) 4. Posture 5. Proper muscle length

WHAT IS CONSIDERED NORMAL? • Normal intake is 50-70 oz of water a day (or half your weight [in pounds] = number of ounces recommended). This ensures urine stays diluted enough so it does not get too concentrated and act as a bladder irritant (which can increase urgency). It is best to limit water an hour or so before bed time to avoid waking at night. • Normal output is 6-8x per day, 10-15 oz each time, or every 3-4 hours. As we age, we may need to pass urine more frequently, but no more than every two hours. Normal night time voiding is 0-1x per night. • Urine should flow in a steady stream, lasting 8-10 seconds without discomfort. No need to push or strain. • The bladder can typically hold about 15-20 oz of urine before it needs to empty. • Typical bladders, first sensation to void is between 5-7 oz or 40% of its “working volume”, first desire to void is at 70-75%. • An urge is a significant feeling that the bladder is stretching. This doesn’t necessarily mean the bladder is full. Tight pelvic floor muscles can mimic this sensation by putting pressure on the urethra or bladder. These signals can be controlled. • Normal bladder functioning is as follows: o Storing – pelvic floor muscles are in a semi-contracted state and bladder muscle is relaxed o Transition- recognition of fullness as bladder is stretching, nerves send signal to the brain that it interprets as an urge to go to the bathroom o Emptying – relaxation of pelvic floor muscles and contraction of bladder muscle

GOOD HABITS TO MAINTAIN BLADDER HEALTH

• Avoid consistently ignoring the urge to go to the bathroom >4 hours • Avoid hovering over the toilet (pelvic floor muscles are contracting rather than relaxing) • Avoid preventative voiding or going the bathroom “just in case”. This creates an increase in urge. • Maintain good fluid intake • Limit caffeine, citrus, aspartame, carbonated drinks, and alcohol these are bladder irritants. • Avoid constipation • Avoid rushed voiding: not allowing time for bladder to fully empty, no straining to empty the bladder • Lift with proper posture, bracing and avoid holding breath • Use diaphragmatic breathing during toileting to relax pelvic floor • Maintain optimal pelvic floor, abdominal, and leg strength, as well as cardiovascular endurance

URGE SUPPRESSION TECHNIQUES Objective: to change the brain and bladder relationship and assign brain over bladder control 1. Stop what you are currently doing and be still 2. Contract and relax pelvic floor muscles 3-5 times to quiet the bladder muscles and reduce urgency (small contractions may be more beneficial than large) 3. Take 3-4 diaphragmatic/belly breaths to relax your system 4. Distract yourself with an activity or relaxation for 5 minutes 5. Reevaluate urge; if you still need to go, slowly/calmly walk to the bathroom 20

URGE SUPRESSION TECHNIQUES

1. BE STILL a. Increased speed increases anxiety and increases sympathetic input to bladder which leads to leak b. Sit down – pressure on perineum inhibits the bladder 2. QUICK FLICKS a. Perform 4-5 quick flicks to utilize the reflex between the pelvic floor and the bladder 3. DIAPHRAGMATIC BREATHING a. Slow inhale and exhale decreases sympathetic input to the bladder and helps decrease urgency 4. DISTRACTION a. Count backwards from 100—by 7’s or from 20 by 3’s b. Visualize favorite time of place c. Autogenic training “I am in…control” with breathing pattern

BLADDER IRRITANTS

Reducing fluid intake will result in increase in concentration of urine which can irritate the bladder and cause an increase in urgency and related leaks

MOST IRRITATING IRRITATING TO SOME

• Coffee • Milk and milk products • Tea • Aspartame (artificial sweetener) • Caffeinated soda • Citrus fruits/juices • Alcohol • Tomato and tomato-based products • Medicines with caffeine • Spicy foods • Chocolate • Sugar/honey/corn syrup • Smoking

HELPFUL HINTS TO RELEASE PELVIC FLOOR MUSCLES

• Try to increase awareness of pelvic floor muscles by "checking in" with your pelvic floor throughout the day to see if you are holding/tightening the muscles. If you feel you are holding tension, try to release the muscles using the exercise above. • Find methods to improve your response to stress and reduce anxiety. The pelvic floor muscles can tighten with stress and worry without you knowing. Some methods you could try are: o Guided meditation apps such as Insight Timer, Calm.com, and Headspace, or other guided meditations on YouTube. Try to find meditations for relaxation or pain and do for at least 10-15 minutes per day to reduce anxiety associated with stress. o Mindfulness exercises such as the Five Senses Exercise. Use this exercise to quickly ground yourself in the present when you only have a moment. The goal is to notice something you are currently experiencing through each of your senses. § What are 5 things you can see? Look around and notice 5 things you haven't noticed before. Maybe a pattern on the wall or light reflecting off a surface. § What are 4 things you can feel? Maybe the pressure of your feet on the floor or the temperature on your skin. Or pick up an object and notice the texture. § What are 3 things you can hear? Notice all the background sounds you had been filtering out, such as air conditioning, birds chirping, or cars on the street. § What are 2 things you can smell? Maybe flowers, coffee, or cut grass. § What is 1 thing you can taste? Maybe sip a drink, or just "taste" the air. o Yoga: Try a gentle or restorative yoga class. You can also check out Yoga by Adriene on YouTube. She has a video on Yoga for Anxiety, Yoga for Stress Relief, among others. • Continue regular activity and exercise. A strong core helps take pressure off the pelvic floor. Ask your physical therapist about additional exercises to help develop your core. • Avoid constipation, use good lifting techniques, and focus on proper posture. This is to reduce unnecessary intrabdominal pressure that can cause stress on your pelvic floor.

Come with any questions to your next appointment. It can be difficult to find these muscles, so practice, consistency, and good techniques is the recipe for improvement. Your home exercise program will be progressed as you improve to incorporate other stretches and exercises to support physical therapy goals.

DIAPHRAGMATIC (BELLY) BREATHING

Find a comfortable lying or seated posture. If you are seated, try to avoid slouching. Feel free to close your eyes as you practice each part on this handout.

As you settle into your comfortable position. Scan your body and notice any tension in your body and try to relax these areas. Specifically bring your attention to your abdominal area and release any tension in this area. The stomach muscles should feel soft, relaxed, and supple.

Next, bring your attention to your breath. With each breath, try to create a visual in your mind or the action of your diaphragm muscle. As, you breathe in, the diaphragm moves downwards, flattening out, pressing down towards the abdominal cavity. As you breathe out, visualize it returning back up into its dome shape. Do this for a few breaths.

Then notice as you breathe in a feeling of expansion in the abdominal area; a filling of the belly with air. Maybe you can notice a sense of rising and falling of the belly. If you are not sure you can place your hands on top of your abdomen to reel it. If this doesn't work, place your hands at your sides of near the lower ribs, as you breathe in, you should reel an outward movement of your ribs into your hands. and then a gentle return back in on the breath out.

Relax your face, neck, and shoulders as you do this. See if you can keep the upper chest area from moving as you practice the belly breathing.

Continue to take in natural, smooth breaths. With each breath in, sense the expansion of the relaxed abdomen. With each breath out, feel the gentle return back in of the abdomen. Simultaneously, continue your visualization inhale and visualize the diaphragm moving downwards; exhale and visualize the diaphragm returning back up into Its dome shape. Maybe you can even sense the moment of your diaphragm within.

Continue to breathe like this for another 3-5 minutes, gradually taking in longer breaths, keeping them smooth and slow. At the end, take a moment to notice how this breathing exercise made you feel.

PELVIC FLOOR MUSLCE DOWNTRAINING/RELAXATION

Purpose: The muscles in our body have two primary goals for optimal function: strength and mobility. Not only do we want our muscles to be strong, we want them to move well. This means we want to avoid having "tight'' muscles, which don't allow our muscles to work well, and in our pelvic floor, tight muscles can lead to pain, urinary urgency and/or frequency, constipation, sexual pain or dysfunction, among other symptoms. Therefore, to relieve these symptoms, we want to learn how to release or relax our pelvic floor muscles. Once we gain the mobility we need; we can then focus on strength and coordination to gain optimal function for bowel, bladder, and sex, as well as core stability.

FINDING AND RELEASEING THE PELVIC FLOOR:

The pelvic floor muscles have surface and deep layers. Surface muscles surround the urethra, vagina, and anal openings. Deep muscles support the bladder, uterus, and rectum. These muscles attach to pelvic bones. For maximum release, it is helpful to imagine you are widening your sitting bones and moving the tailbone away from the pubic bone. You can also think of your vaginal canal opening or lengthening.

HOW DO I RELEASE MY PELVIC FLOOR?

To release your pelvic floor, start by lying on your back and take several calm, deep breaths. Now, when you breathe in, allow your belly to expand out, think of your pelvic muscles dropping toward your feet. Practice relaxed breathing with a mental picture of this drop and the bones widening to make space for the muscles at least 3 times per day for 1-5 minutes each session.

PELVIC FLOOR RELEASE EXERCISE

PELVIC FLOOR MUSCLE UPTRAINING/STRENTHENING

Start and end all exercises with diaphragmatic breathing for a few minutes to quiet the nervous system and encourage full body awareness. Start by lying on your back with knees bent and feet flat on surface, or in another comfortable, relaxed position. Place one hand on chest and one hand on abdomen to feel belly rise and fall. During inhale "belly hand" should rise and during exhale "belly hand" should fall. "Chest hand" should remain mostly unmoved.

1. SLOW CONTRACTIONS: On the exhale, contract pelvic floor muscles. Hold for _____ seconds, relax for _____ seconds, _____ repetitions _____x per day. 2. QUICK CONTRACTIONS: Contract pelvic floor muscles: Hold for 1-2 seconds, relax for 1-2 seconds _____ repetitions _____x per day. 3. PELVIC BRACE/KNACK: Before coughing, sneezing, laughing, nose blowing, lifting, rolling in bed, and/or changing positions; it is important to perform a pelvic floor muscle and abdominal contraction to offset the increased intraabdominal pressure placed on the urethra. A sneeze can be 70mph…whoa!

TIPS: While contracting pelvic floor muscles imagine “zipping up” closing anus, vagina, and urethra up to pubic bone using the same muscles that would stop the passage of gas or the flow of urine. It helps to think of an elevator and/or zipper for mental image.

**Make sure to FULLY RELAX your pelvic floor muscles after each contraction. Finish all exercises with a few diaphragmatic (belly) breaths**

Always be aware of posture: no slouching, pushing or straining. These increases pressure down on your pelvic organs.

Keep good body mechanics, especially with lifting: No breath holding, remember to lift with legs, squat or lunge instead of bending from the back, keep objects close to torso as possible, and do your “pelvic brace” every time! (See #3)

PELVIC FLOOR MUSCLE COORDINATION AND RELAXATION

Purpose: The muscles in our body have two primary goals for optimal function: strength and mobility. Not only do we want our muscles to be strong, we want them to move well. This means we want to avoid having "tight" muscles, which don't allow our muscles to work well, and in our pelvic floor, tight muscles can lead to pain, urinary urgency and frequency and incontinence, constipation, sexual pain or dysfunction, among other symptoms. Therefore, to relieve these symptoms, we want to learn how to both contract and relax our pelvic floor muscles in order to gain optimal function for bowel, bladder, and sex, as well as core stability.

Perform the following exercise at least 2-3 times every day.

CONTRACT/RELAX EXERCISE FOR PELVIC FLOOR

1. Diaphragmatic Breathing: Begin by taking slow, deep breaths for 1-5 minutes (see below).

2. Slow Contractions: Take a deep breath in. On the exhale, contract pelvic floor muscles: Hold for _____ seconds/duration of exhale, relax for _____ seconds/full breath cycles(s) for _____ repetitions.

3. Diaphragmatic Breathing: End by taking slow, deep breaths for 1-5 minutes (see below).

HOW DO I PERFORM DIAPHRAGMATIC BREATHING?

To relax your pelvic floor, start by lying on your back and take several slow, deep breaths. Now, when you breathe in, allow your belly to expand out and think of your pelvic muscles dropping toward your feet. Practice relaxed breathing with a mental picture of this drop and the bones widening to make space for the muscles.