Restore Your Core: Diastasis Recti and Pelvic Floor Talks

Surgery for pelvic organ prolapse is a big deal. It is a big deal because you live in an age where you have many pathways to health, and don’t have to live with pelvic organ prolapse.Although surgery can be a viable, medically recommended option for many people, it is very invasive without a guaranteed outcome. Some people may find relief from their painful symptoms, yet, like many procedures, it can often require more intensive medical treatmenteven after the first surgery was performed. Surgery should be considered a last option when dealing with core, pelvic floor, or other related issues.

To be clear, our goal here at Restore Your Core is to strengthen your core and pelvic floor so you can live without surgery being a part of your story. Thousands of women use our program with amazing success as an alternative route to surgery because we work to restore function and integrity to the pelvic floor. However, we do not judge anyone’s choice to have surgery and we understand that sometimes it is the only choice! We support all choices so we would like to use this article to educate you on those choices. Please note, even if you decide on surgery, one year of pelvic floor rehab is very much recommended to prepare the body as it is a major surgery.

Table of Contents

How Do I Know if My prolapse is Severe? 

Surgery is for severe cases. So when are you considered severe? We strongly urge you to discuss it with your provider and get multiple opinions from doctors and therapists regarding your case. 

It is important to recognize that pelvic organ prolapse can involve one or more of your pelvic organs, including your uterus, bladder, and rectum. After injury to or the weakening of your pelvic floor muscles, your organs can drop into the wall of your vagina. We break down the different types of pelvic organ prolapse in other articles, but for your knowledge, we will include a list here:

• Bladder prolapse- Cystocele (The most common)
• Rectum prolapse- Rectocele
• Uterine Prolapse
• Vaginal Vault Prolapse
• Small Intestine Prolapse- Enterocele

How Do I Know What Stage My Pelvic Organ Prolapse Is?

Severity of Pelvic Organ Prolapse has to be diagnosed by your healthcare provider, but the general rule of thumb for staging is:

• Stage 1: Very minimal prolapse – organs still have a fair amount of support by the pelvic floor.
• Stage 2: Pelvic floor organs have begun to drop, but they are still contained inside the vagina.
• Stage 3: Pelvic floor organs have dropped to, or beyond the opening of the vagina.
• Stage 4: Pelvic floor organs have dropped completely through the vaginal opening.

What Happens if Prolapse is Left Untreated?

That is hard to know because some women have it for years and it can stay the same! However, for others, it can actually get worse. It can depend on a variety of factors, many might be out of your control: like tissue integrity and genes. Other elements, like movement and exercise choices are more in your control. Strengthening your pelvic floor can keep your organs from bulging further into the wall of the vagina without surgery.

Cystocele is the most common type of pelvic organ prolapse that occurs after vaginal childbirth. During a vaginal delivery, the pelvic floor muscles can be compromised as they stretch to make room for the baby to make its grand entrance into the world. The pelvic floor muscles are designed to hold up the organs of the pelvis. A severe enough breach in the system can cause a prolapse.

When these muscles are compromised, the organs are able to drift or “sag” down the path of least resistance until they bulge into the vaginal canal. It is important to know that there are many types of pelvic organ prolapse besides cystocele that will not be discussed in this article, but are listed below for educational purposes:

• Urethrocele or prolapse of the urethra
• Uterine prolapse
• Vaginal vault prolapse
• Enterocele or prolapse of the small bowel 
• Rectocele prolapse of the rectum

What causes a Cystocele? 

Cystocele (cysto- meaning bladder, -cele meaning pouching or herniating) is the downward displacement of the bladder that descends until the bladder bulges into the vaginal wall. This is sometimes referred to as “fallen bladder” or “prolapse of the bladder.” Though it is possible that cystocele occurs because of reasons outside of childbirth, such as genetic disposition, increased age or obesity, it is most commonly seen in women who have experienced a vaginal delivery.

How is a cystocele diagnosed? 

Methods of diagnosis depend on how much the prolapsed bladder has advanced from its usual position. 

The pelvic exam is used for the obvious prolapsed bladder. The provider may only need to do a visual exam of both the vaginal opening and the pelvis to spot the bladder in late staged prolapse (I’ll break down the stages for you momentarily). Typically this presents as a pronounced bulge in the vaginal canal or through the opening of the vagina. I strongly recommend doing this exam from a standing position. 

A voiding cystourethrogram may be used in less obvious cystoceles since the prolapsed bladder is not always visible In the vaginal opening in earlier stages of descent. Essentially, an X-ray is taken of the bladder while you urinate to capture the shape and placement of the bladder and vagina during the effort. Your provider will guide you through the preparation for this procedure, but there are typically no special precautions needed.

What are the symptoms of Cystocele? 

Symptoms of a cystocele vary from mild, moderate or severe depending on just how far that bladder has sagged from its usual position. 

Typically the first tell tale sign is a feeling of bulging in your vagina, heaviness, fullness, feeling of bubbles in your vagina and a change in your urine frequency/incontinence after a vaginal delivery that doesn’t improve over time. 

If it is more advanced you may be able to see the bulge formed by the bladder prolapse in the canal or vaginal opening. Heavy lifting, bearing down or straining during bowel movements may increase the feeling of pressure in the pelvic floor. Some women report feeling as if they are sitting on a ball. 

Rectocele Symptoms

A woman’s vagina is separated from her rectum by ligaments and tissues known as the rectovaginal septum. The tissues that line this wall are called fascia. At times, due to compromised pelvic health or pelvic injuries, a woman may experience a weakness of the vaginal wall and rectovaginal septum. When this occurs, a part of the rectum can bulge and protrude into the vagina. This is called a rectocele prolapse.

What is Rectocele?

Rectocele is a condition which causes the supportive tissues between the rectum and the vagina to weaken. This can occur due to excess pressure in the rectum, excess vaginal pressure, or excess intra-abdominal pressure leading to pelvic floor issues such as pelvic organ prolapse (POP). When this occurs, the separating tissues can herniate causing the front wall of the rectum to bulge into the vagina. This issue is also commonly called a posterior vaginal prolapse. Oftentimes, the prolapse is small and does not pose any painful symptoms or difficulties. However, in severe cases, the bulge may manifest outside of the vaginal opening and require surgical repair.

Signs and Symptoms of Rectocele

In many cases, someone may have a rectocele for a long period of time without noticing any symptoms.

In minor to moderate cases of symptomatic rectocele, someone may experience feelings of mild discomfort, pressure, or minor pain in the vaginal or rectal regions. This may be accompanied by a feeling of incompletion after bowel movements.

In moderate to severe cases, women with a rectocele may have an increased sensation of pain and discomfort in their vagina, rectum, or abdomen while pooping. This can be a result of the feces being pushed into the rectocele during a bowel movement. Women with moderate rectocele run a higher risk of constipation, painful intercourse, and lower abdominal and lower back pain. In severe cases, the rectocele can prolapse causing the tissue to protrude out of the vaginal opening.

Other symptoms of rectocele may include:

• A small bulge in the wall of the vagina
• Needing assistance of fingers to perform a bowel movement
• Pressure in rectum
• A feeling like an “air bubble” in the vagina
• Pain, discomfort, or feelings of looseness during vaginal intercourse

Other pelvic organ prolapse issues such as vaginal prolapse, uterine prolapse, rectal prolapse, or other issues with the pelvic floor.

Rectocele is a common condition many women may face without ever knowing it. Most often it is associated with postpartum issues, but it can affect women who have never been pregnant as well.

If you are experiencing severe issues such as: tissue bulging through your vaginal opening or constant struggles with constipation, it may be time to consult your doctor for a proper diagnosis. Generally a Urogyn is the best bet for diagnosis.

Rectocele Repair

Repair for a vaginal rectocele is pursued in order to correct the herniation or bulging of the bottom wall of the vagina. Symptoms of rectocele can become quite uncomfortable and painful over time. If left untreated, rectocele can lead to symptoms such as: the feeling of increased pressure or protrusion in the vagina or rectum, inability to defecate or feeling of incomplete emptying of the bowels, pelvic pain, and/or painful sex. Both non-surgical and surgical procedures for rectocele repair are only considered if symptoms become severe and inhibit daily life. Surgery for rectocele is typically performed transvagianally, yet, in some severe cases, may be completed both vaginally and abdominally.

Why Do I Need Treatment for Rectocele?

Treatment for rectocele can greatly aid in managing and reducing symptoms of rectocele or other forms of pelvic organ prolapse. In some cases, rectocele and POP may be undetectable until the condition has progressed in severity. A small rectocele is often unrecognized until a doctor notices it during a physical examination. In many cases, rectocele occurs alongside other pelvic organ related conditions. 

Treatment is designed to help reduce symptoms and heal any herniations, tears, or prolapses. Treatments include both surgical and non-surgical options. Although surgery for rectocele is often rare, in severe cases surgery may be your best option. Severe rectocele symptoms include:

• Bowels feeling full post defecation
• A noticeable bulge or protrusion in the vagina
• Inability to perform a bowel movement
• Rectal incontinence

Is Rectocele Repair Major Surgery?

Rectocele repair surgery is a major, out-patient surgery. A doctor will typically only recommend surgery for rectocele if at home exercise programs and / or physical therapy has not resolved the problem. The surgical procedure for rectocele removal is called posterior colporrhaphy which removes the herniated bowel from the wall of the vagina. Rectocele surgery is designed to:

• Ease pain and discomfort
• Minimally invasive transvaginal procedure
• Outpatient (usually released without needing overnight stay)
• Quick recovery time (2-3 weeks or less on average)

What is a Rectocele Repair Procedure?

The procedure for rectocele repair surgery is typically a straightforward process. The surgery is often performed through the vagina (transvagianlly.. The procedure is typically performed by a surgeon making a small incision along the posterior vaginal wall. Excess tissue along the herniation is removed and stitches are sewn around the tear sight. If the doctor notices any other forms of pelvic organ prolapse, he may resolve those issues as well during the procedure. Once complete, the vaginal incisions are stitched up and packed with gauze. Please speak with your doctor for more information on this process.

Rectocele Prolapse

Rectocele is a herniation of the tissue wall between the vagina and the rectum. Over time, this tissue wall - also known as the rectovaginal septum - can become weakened resulting in a pelvic organ hernia or pelvic organ prolapse. In this article we will discuss what a rectocele is, what the symptoms are, and how it can be treated.

What is a Prolapsed Rectocele?

A rectocele is a herniation, prolapse, or weakening of the rectovagianl septum (tissue wall between the rectum and the vagina). Rectocele is also commonly known as a posterior vaginal prolapse or a proctocele. This can occur as an isolated injury or gradual weakening of the tissues, or occur as a result of prolonged pelvic floor dysfunction. When the pelvic floor is weakened along with the ligaments and tissues between the vagina and the rectum, it can cause the vaginal and rectal walls to weaken and bulge leading very painful symptoms and other pelvic organ related issues. In severe cases, the vaginal or rectal walls can bulge and protrude from the vaginal opening.

Other types of Pelvic Floor Prolapse

There are several other types of pelvic organ prolapse that may present themselves in similar ways as rectocele:

• Cystocele, or anterior vaginal prolapse: occurs when a woman's bladder bulges into the vaginal wall
• Uterine prolapse: occurs when the uterine walls become weakened or unsupported and the uterus bulges into the vaginal wall.
• Rectal prolapse: occurs when the rectal wall is weakened and protrudes through the anus
• Vault prolapse: occurs when the vaginal vault (top of the vagina) bulges.

Pelvic prolapses can vary greatly in their severity and at times, different types may occur simultaneously.

What is the Main Cause for a Rectocele?

Although the exact cause of a rectocele is unknown, it is most commonly a result of a weakened pelvic floor and often goes hand in hand with excess pelvic pressure and intra abdominal pressure. A woman's pelvic floor can become weak after undergoing physically traumatic experiences such as: childbirth through vaginal delivery, difficulties with vaginal childbirth (if forceps or a vacuum were used, vaginal tearing, or an episiotomy). It is common for women to experience some form of pelvic floor or core weakness related issue postpartum. However, women who have never been pregnant can still develop a rectocele.

Other Causes of Rectocele

There are several other factors that may lead someone to develop a rectocele. Posterior pelvic organ prolapse can occur as a result of increased, intra-abdominal pressure. Outside of pregnancy, other causes of rectocele and increased pelvic pressure include:

• Chronic constipation
• Straining, difficulty in performing bowel movements
• Chronic cough, pneumonia, or bronchitis
• Hysterectomy
• Pelvic region surgery
• Improper heavy lifting techniques
• Obesity
• Age

Pelvic Floor Stretches

Persistent pelvic floor pain can be difficult to endure. Pelvic floor dysfunction issues can range between hyperactivity to pelvic organ prolapse. The result of both cases can lead to painful and embarrassing symptoms for both men and women. In this article, I will address helpful exercises and stretches that help free you of painful symptoms and aid in restoring pelvic floor and core function. To be clear, stretching is just one type of input into the pelvic floor system and is not the only thing you should do for a tight / tense pelvic floor. Downtraining your pelvic floor will require a variety of loads and inputs, stretching is one important one.

How to Stretch Pelvic Muscles

There are several ways you can properly stretch and engage your pelvic floor in order to reduce pelvic floor tension . One of the most beneficial and important techniques that I teach my clients is 3-D breathing – a pattern of breathing that uses the rib cage expansion rather than belly expansion for an effective and efficient strategy.

One of the key elements in resolving pelvic floor dysfunction and POP is breathing mechanics. In Restore Your Core, I spend a significant amount of time teaching my clients proper breathing mechanics. Often people don’t realize the way they breathe impacts the integrity of their core and pelvic floor. Yet, most of us do not even realize easily we can fall into improper breathing patterns.

Most people are belly breathers. This means that while inhaling, they’re extending their abdomen – focusing the tension in their belly. An Illustration of this would look like filling an oval-shaped balloon with water and squeezing the top creating a bulge. The exact same thing happens when you belly breathe. Bulging your gut strains your core and pelvic floor by increasing intra-abdominal pressure. This tends to cause muscle and organ damage in those regions. Our pelvic floor is not designed to handle a lot of consistent pressure and stress.

I spend a lot of my time with clients training them to 3-D breathe. 3-D breathing trains you to engage your diaphragm and rib cage while breathing. This means that instead of your belly extending as you inhale, your rib cage expands. Breathing in this manner reduces pressure in your core and pelvic region. Additionally, this technique encourages proper core response and engagement in your daily activities. Now that you understand proper breathing mechanics, it is time to learn how to properly stretch and exercise your core and pelvic floor.

Stretches for the Pelvic Floor:

Supine Pelvic Floor Stretch

Lying on your back, keep your knees bent and bring them toward your chest. Slowly extend your knees to the side to stretch the inner groin. Relax your pelvic floor and butt. Remain in this position for 5 to 10 breaths and relax.

Pelvic Floor Therapy

Pelvic floor therapy is recommended for conditions where the pelvic floor and core system is not functioning optimally. Pelvic Floor Dysfunction and its related conditions can be caused by many different things. These can include:

• Infections
• Pregnancy or childbirth
• Poor posture
• Trauma
• Chronic back pain
• Surgery

However, PFD can also seem to have no cause and present itself with a host of painful symptoms. In some women, the cause of PFD can be a result of postpartum diastasis recti. The pelvic floor is made up of muscles and other tissues which form a sling from the pubic symphysis to the tailbone. Many cases of PFD stem from a lack of sufficient support from the pelvic floor. These pelvic floor muscles assist in maintaining correct posture, abdominal and pelvic organ support, and aid in bladder and bowel control as well as sexual activity. If these muscles become overactive or overused (hypertonic), the results can be quite painful and function can decrease significantly. Less often, the pelvic floor muscles are hypotonic–lacking sufficient resting tension to perform their jobs. Yet, due to the complexity of the anatomy and functions of the pelvic region, the underlying cause of pain can be difficult to determine. In this case, the whole body must be treated and physical therapy including pelvic floor exercise can greatly aid in men and women in their healing process and recovery.

Why do I need pelvic floor therapy?

(POP) or pelvic organ prolapse is a type of pelvic floor dysfunction in which one or more pelvic floor organs (i.e. bladder, rectum, small bowel, uterus, etc) shift toward or down into the vaginal canal. This most commonly happens with conditions like diastasis recti, which create an imbalance of muscle and ligament tension supporting the pelvic floor; many people who have POP also have a DRA. Women who experience a pelvic organ prolapse sometimes describe the occurrence as feeling like a “stuck tampon,” a heavy pelvic floor, or as bubbles in the urethra. Some other symptoms present may include:

• constipation
• pelvic pain during sex
• urinary/fecal incontinence

Most fitness gurus try to educate their clients with core exercise routines that engage the pelvic floor and the core together. They believe that if you engage your core in any activity, you should also engage your pelvic floor. However, I believe there is a lot wrong with this routine and practice.

As a trained and educated professional, I never, ever attempt to teach pelvic floor muscles to engage in exercise. Rather, it is important to train the pelvic floor to lift and release appropriately depending on the exercise and the weight. This is what I teach in my 13-week program, Restore Your Core.

Is Pelvic Floor Repair Major Surgery?

Pelvic floor repair surgery is the most common surgery for pelvic organ prolapse. Pelvic floor repair is a broad term used to classify a variety of simple, surgical procedures for repairing the pelvic floor. The three surgeries for pelvic floor prolapse include anterior repair, posterior repair, and a hysterectomy.

Although Restore Your Core does not provide any surgical treatment for pelvic floor issues, my hope is that this article may answer any questions you may have regarding pelvic floor repair and the various procedures and treatments involved in getting you back to a healthy, active lifestyle.

What are the Symptoms of Pelvic Organ Prolapse?

Prolapse can affect several abdominal organs. These organs are said to prolapse if they descend into or out of the vaginal canal or anus. The medical terminology for these occurrences include:

• Cystocele: prolapse of the bladder into the vagina, the most common condition
• Urethrocele: prolapse of the urethra (the tube that carries urine)
• Uterine prolapse
• Vaginal vault prolapse: prolapse of the vagina
• Enterocele: Small bowel prolapse
• Rectocele: Rectum prolapse

What Causes Pelvic Organ Prolapse?

There are many factors that are thought to cause a prolapse. In most cases, anything that may apply or put increased pressure in the abdomen can lead to a pelvic organ prolapse. Some of the common causes may include:

• Pregnancy, labor, and childbirth are the most common causes
• Obesity
• Connective tissue disorders
• Respiratory problems with a chronic, long-term cough
• Constipation
• Genetic factors 
• Pelvic organ cancers
• Surgical removal of the uterus (hysterectomy)

Diastasis recti (weakened core, connective tissues)

Symptoms

The symptoms of a prolapse somewhat depend on which organ has descended. If you are suffering from a bladder prolapse, urinary incontinence may occur. If it is a rectal prolapse, constipation, painful bowel movements, and painful sex often occur. Lower back pain, painful sex, and bowel obstruction or incontinence tend to accompany a small intestine prolapse as well. If you are suffering from a prolapse of the uterus, you may also suffer from uncomfortable intercourse, incontinence, and lower back pain.

In some cases, there may never be signs of a prolapse or the presence of any painful symptoms. However, in others some women report symptoms ranging from:

• Pressure or sense of fullness in the pelvic area
• Lower back pain
• Painful sex
• Sensation of something falling out of the vagina
• Urinary incontinence or frequent urination
• Constipation
• Spotting or bleeding from the vagina

In cases where there may be a severe prolapse, POP symptoms may worsen. One may notice:

• Bulging of the vaginal region
• Needing manual assistance during a bowel movement
• Difficulty urinating, spraying stream of urine
• The need to lift the bulging vagina in order to urinate
• Urinary leakage during intercourse
• Recurrent UTIs or kidney infections

Pelvic Floor Specialist

Pelvic floor physiotherapists help women rehabilitate their pelvic floor region. The muscle groups within the core and pelvic region can be weakened by childbirth, surgery, genetics, heavy lifting, rapid weight gain, constipation, menopause, improper breathing mechanics, and more. These muscle groups aid in supporting the uterus, bladder, and bowels. They form a slinglike grouping from the pubic bone to the front of the tailbone at the back. Damaged or weakened pelvic floors can affect bladder and bowel control, leading to urinary and rectal incontinence or even pelvic organ prolapse.

At times, the pelvic floor can become overactive or hypertonic. This means that their pelvic floor muscles are overly tight and tense all of the time, even when they should be relaxed. Learning to relax and release the pelvic floor muscles (muscles contractions like the short contraction of the bulging of a bicep or long contraction, like the slow, contained stretching out of a bicep) will help ease overactivity. An overactive pelvic floor can cause many symptoms such as: back pain, pain during sex, heaviness or incontinence.

What is a pelvic floor specialist?

Doctors who specialize in pelvic floor dysfunction issues are called urogynecologists and physiotherapists. A urogynecologist will care for women with pelvic floor disorders by providing services that help evaluate pelvic floor health and provide primarily surgical treatments for pelvic organ prolapse. Their speciality covers the muscles, ligaments, connective tissues, and nerves within the uterus, vagina, bladder, and rectum.

A physiotherapist or Occupational therapist who specializes in pelvic floor treatment helps treat pelvic floor issues non-surgically. This is commonly done through exercise and manual therapy as well as extended education and advice on how to properly engage and strengthen your pelvic floor. Other specialists who aid in pelvic floor therapy include movement specialists and occupational therapists. Movement therapy can play a significant part in retraining the body toward correct posture, alignment, deep-tissue manipulation, and provide educational instruction on how the body works and how it heals.

What is involved in pelvic floor physical therapy?

Pelvic floor therapy most commonly involves exercises and education on how to properly engage and strengthen the pelvic floor. A specialist like a physiotherapist will help instruct their clients with a range of techniques ranging from:

• Breathing mechanics
• Therapeutic exercise & core building
• Pelvic floor realignment
• Proper posture
• Symptom treatment
• Physical education

Pelvic floor therapy seeks to instruct women in how their bodies work while also treating any conditions causing pain or embarrassing symptoms – like pelvic organ prolapse. When seeking treatment for pelvic floor dysfunction or POP, there are a few things you should keep in mind.

Pelvic Floor Disorder

Pelvic floor issues mostly occur when the pelvic floor muscles are lacking enough tone (hypotonic) or are too “tight” (hypertonic). Some people may experience weak pelvic muscles and core muscles from an early age. Others may not notice problems until after certain stages of life such as pregnancy, childbirth, or menopause.

Something many women may not realize is that when pelvic floor dysfunction is present, it is a result of over toned, too short pelvic floor muscles. The pelvic floor cannot function in this state. Think of it this way - you can contract muscles and make them shorter (as in a bicep curl) or you can contract it by making it longer (releasing a bicep curl). Strengthening your pelvic floor means loading it long (like a slow, controlled release of a bicep curl).

Overworking these muscles and connective tissues without learning how to properly engage the various muscle groups can keep you from relaxing them fully.

The most common reasons why someone may be suffering from pelvic floor dysfunction are:

Excessive pelvic floor tension

Pregnancy and birth

ongoing constipation and straining to empty the bowels

being overweight or obese if it contributes to excessive intraabdominal pressure

heavy lifting (e.g. at work or the gym)

a chronic cough or sneeze (e.g. due to asthma, smoking or hayfever)

previous injury to the pelvic region (e.g. a fall, surgery or pelvic radiotherapy)

growing older

Although it is hidden from view, your pelvic floor muscles can be consciously controlled and therefore trained, much like your arm, leg or abdominal muscles. A pelvic floor that is responsive to the varying loads placed on it keeps your organs functioning as they should--no more leaking pee when you sneeze. All people benefit from learning how to release and engage their pelvic floors, so that the pelvic floor reacts reflexively.

What are the symptoms of tight pelvic floor muscles? 

Symptoms vary from person to person. Some of the most common symptoms associated with pelvic floor dysfunction include:

Stress incontinence (sneeze pee)

Rectal incontinence

Incessant need to pee (urge incontinence)

Difficulty in emptying your bladder or bowel

A prolapse (in women, this may be felt as a bulge in the vagina or a feeling of heaviness, discomfort, pulling, dragging or dropping)

Pain in your pelvic region

Pelvic muscles spasms

Painful sex

Hypertonic pelvic floor muscles can result in painful and embarrassing symptoms. Pelvic pain and incontinence can be uncomfortable and embarrassing at best.. However, there are ways to begin releasing and integrating your pelvic floor muscles in order to gain back control over your body.

What Causes Pelvic Floor Dysfunction?

Pelvic floor dysfunction causes are still being researched. However, there are some common conditions that are linked with PFD and POP. Some of the common causes for the structure of the pelvic floor to weaken include:

Childbirth & postpartum related issues

Delivery trauma and more