The lesson of “Standing Suzie” - Don’t be afraid to ask for a pelvic floor assessment.

*Suzie is not the patient’s real name, and some details have been changed for confidentiality. 

When I meet with patients who are pregnant, I suggest that when they have their post-delivery check up with their obstetrician at six weeks they ask for a pelvic floor discussion and assessment as needed. I do this because at this early stage of postpartum, it is possible to identify problems that can be resolved with physical therapy. If the patient doesn’t ask for this discussion, it’s unlikely that the doctor will raise the issue at all. This lack of communication is rampant, and quite often the physician does not know where to send the patient, or what type of physical therapy is required. The reasons for this breakdown in knowledge range from a lack of awareness overall to the way our healthcare system operates in the United States. The bottom line is that you must be your own and best advocate. If you feel pain, or wonder why you are incontinent or otherwise compromised, reach out and find a pelvic floor physical therapist who can help.

In France, every woman who delivers a baby is offered ten weeks of Women’s Health Physical Therapy.  They can either have biofeedback with an internal sensor or ten weeks of manual physical therapy. 

I think about one of my patients in particular, named Suzie, because if she had lived in France and received even just two weeks of physical therapy, the therapists would have found several issues following her second pregnancy and Suzie’s correction would have been much faster, avoiding many years of suffering.

Suzie’s story is one of undiagnosed pelvic issues that stemmed from asymmetrical vaginal muscles that had not healed properly, as well as diastasis and a mal-aligned tailbone. We found this out together, but only after Suzie overcame her fear of discussing her pain with anyone, after years of enduring that pain. 

Meeting Suzie 

Suzie had never had any rehab after the delivery of her daughter 14 years before, and she was never offered any pelvic floor physical therapy follow up.

A colleague had evaluated Suzie for puedendal nerve compartment syndrome, as Suzie’s initial complaint was: “I still can’t sit for more than 20 minutes, it’s too much pain.” 

When I met Suzie, she mentioned that she had partially dislocated her tailbone at the time of delivery of her second child, and I realized that not only did she have puedendal nerve crush injury, she also had coccydynia, or tailbone pain, which would have been directly related to an old fracture or dislocation. This could account for the ongoing pain she was feeling when she sat down.

But Suzie did not know whether it was an old fracture or a dislocation. I explained that dislocation of the tailbone is a consequential injury during childbirth and is rarely reduced or corrected. But if the pelvic floor becomes stretched beyond the tensile point, then there can be a fracture at the tailbone. 

At this point, I felt Suzie certainly had a weakened pelvic floor, but Suzie did not want any unnecessary examination of her pelvic floor, particularly her rectum.

The external examination

Given Suzie’s concerns, I asked if I could do an external examination of her tailbone, just to look at the angle to see if it was in good alignment, right to left, and in proper position, front to back.  She agreed and laid down on her abdomen. I assessed her tailbone, and its angle was incorrect and also tweaked to the right side. She had pain on that right side, in the muscle tissues between the tailbone and the sit bone, and said she typically sat on her left side sit bone to avoid this right side pain.

I suggested an internal rectal examination so that I could relocate the tailbone, but her fear of additional pain was too intense, and she declined. Instead, she agreed to an internal vaginal examination so I could see if there was an alignment issue. She sort of laughed, telling me that “penetration is impossible.” I explained, by flexing the top of my finger, that I would only insert my finger up to this first digit. 

The Internal Examination

In physical therapy, it is important to check the segments above and below the area of pain to make sure that nothing else is contributing to the misalignment. The body works like a chain, and if you fix one link, then the links above and/or below will be impacted. With regard to Suzie’s case, the pelvic floor starts at the pubic bone, wraps around to the tailbone, and then comes back. 

I knew that Suzie’s tailbone was tweaked out of midline, and I needed to check what was connected to the tailbone, to look for any other shifts. I examined her sacroiliac joint and lumbar spine, and both were positive indicators for obliquity.  

I found that the internal sides of Suzie’s vagina did not have equal sensation, and they did not contract and relax with equal speed. One side could contract and relax fairly normally, but the other side had a delay when it was time to relax. This is often not due to puedendal nerve cut, but rather it is due to a learned, protective response from pain. She also had a delayed response of her anal wink and cough reflex, which is a protective response in that the external anal sphincter closes to the stimulus. 

Considering our therapy options 

A typical therapy for weak pelvic floor muscles involves being in a supine position, which is “gravity eliminated” position.  But Suzie had pain in the tailbone and I could not have her lie on her back. Moreover, pelvic floor exercises generally are felt by lifting the perineal body (the part between the vagina and the anus) but since Suzie had such little sensation and awareness of her vaginal muscles, along with a negative feeling about anyone touching her rectum, I chose another approach.

Treating Suzie’s weak pelvic floor with abdominal core stabilizers 

The premise of pelvic floor training is the rule of three. In other words, none of the three core muscles can be activated in isolation. When one muscle fires, the other two automatically fire. It’s a cascade effect. 

I had Suzie focus on her transverse abdominus muscles, knowing the pelvic floor would come along for the ride. I chose a position on hands and knees with the Swiss ball under her abdomen (about 18” from the ground), so that her coccyx would not be compressed. 

With her stomach lying on the Swiss ball, she used the left side of her pelvic floor and left hip flexor to try to correct the tailbone that was pulling towards the right. I had her focus on curling her toes on the left foot (as if she was picking up a marble), to bring in more shortening on the left side because the right side needed lengthening and the left side needed shortening to realign the tailbone to midline. We set a 12-week treatment plan.

The unexpected finding: A diastasis

The internal examination revealed something I did not expect to find, a diastasis, or the separation of her abdominal wall. It was a significant diastasis – a 3 finger width split above the umbilicus compared to 1 ½ finger width split below the umbilicus. This finding explained a lot about her pain, and led me to plan an additional treatment modality to provide her relief.

But how did she have this split in her abdominal wall? She’d given birth to two babies. Both were normal, vaginal deliveries, and the second child was the delivery where she fractured or dislocated her tailbone. 

I explained this finding to Suzie by asking her to think of her diaphragm area and abdominal cavity as a box. The abdominal wall is the front of the box. Her loose abdominal wall is like a weakened, or caved-in front of the box. Its weakness forces the bottom of the box (or the pelvic floor) to stabilize more constantly and ultimately it breaks down itself.  For 14 years, this instability had been building up. But was it too late to help Suzie? Any muscle in the body can be strengthened, no matter how old or young the patient is, with proper training. If the muscle fires it can be hypertrophied as long as it is challenged two to three times a week for a duration of twelve weeks. 

After 12 weeks of treatment, Suzie’s diastasis and pelvic muscle inequity corrected. But she still felt pain when sitting. She eventually let me mobilize the tailbone, and the procedure took only a few minutes. To maintain the new alignment I asked her to sit on a pillow with a cut out in the sacrum for 2 days afterwards.  After those 2 days, she was relieved of tailbone pain. Subsequent visits showed that her pain had subsided entirely. 

When Suzie and I spoke about her journey, we realized that the lack of rehab and physical therapy after her second pregnancy was similar to breaking an elbow at the joint and just letting it heal on its own. The joints could heal in a crooked fashion, as her tailbone did. Taking the example further, living for 14 years with a crooked elbow joint would be terribly painful, similar to Suzie’s condition and the pain she felt when she sat. Of course, there’s a major difference in these scenarios. A physician would have seen the visible joint break in an elbow and recommended therapy immediately. But the vagina is not visible to the doctor, and it is taboo to discuss, and that is how Suzie wound up suffering with so much pain. If you are ever in pain, talk to a pelvic floor therapist, and begin a journey to recovery.