(long) Update, rectocele and acute lower back pain/wobbliness

Submitted by alphamom on May 22, 2009 - 9:41am
Body: 

Again, please move if this is an inappropriate forum. We could use a "new to this - still trying to find our way!" forum ;-)

I hurtled on to the list 3 weeks ago in the middle of an acute crisis with my rectocele, trouble with emptying but also very acute pelvic pain, lower back pain and wobbliness (the can't reach to wipe yourself or put on your own socks or find a tolerable sitting/standing position level of lower back pain).

I'm happy to say that crisis resolved with just 2 doses of vicodin to let all the clenched and spasming muscles settle. I've not had another acute episode since, just a few moderate lower back/pelvic days. Steps that seem to have made a big difference for me are 1) a daily dose of psyllium/metamucil (with more doses on days when my gut is feeling heavy) 2) going to a lighter/more liquid diet, at least during weekday daytimes, to keep my gut from getting so full and overtaxed and 3) wearing a maternity support belt all day, and especially when exercising. Just my old maternity support belt from my last pregnancy 9+ years ago was some help, but it had a tendency to fold and roll over and irritate my skin (it was fine to cling to and support a firm rounded pregnant belly years ago, but trying to support my flabbier, overweight belly now overwhelmed it . . . But I found a newer and firmer maternity support belt that's really working for me now, it's stiff enough to lift and support excess belly weight off my pelvic area, and to prevent jiggling or sloshing down to the pelvic area when I exercise on my stairstepper, even at highest intensity . . . I find both the weight off and the snug support in the pelvic area make me feel much better, more solid on my feet and youthful, like I'm supported in all my ache points and not wobbling on . . . The belt I have now is a Gabrialla elastic maternity belt, medium support, though I'm sure many stiff maternity belts would work just as well . . .

I did finally get the DVD and book. I'm very happy to have the DVD, to be able to add a whole body conditioning approach that won't itself further strain the pelvic area. I tend to do a 40-minute aerobic stairstepper routine and the 10-minute beginning WholeWoman stretching routine most days. (I lean forward in the higher intensity stairstepper bits to keep the pelvic organs supported, and the belt keeps everything locked down as well.) I think I'm mostly getting Christine's beginner routine, although especially the dance-inspired movements are new to me. The only ones I'm totally hopeless at are the stretches which - seated or standing - involve reaching hands over toward feet, I think its the back stiffness that keeps me from even approaching those positions halfway. I'm still working on posture and doing the stretches properly, but I have always been obtuse about recreating spatial movements and configurations with my own body. Hopefully it's helping even if not done perfectly.

The section in Christine's book about vaginal injury in childbirth (from Nichols & Randall) seem a perfect description of what happened to me. My second and last labor was totally unmedicated (with my first I had a bit of nubain to take the edge off labor pains). But it was precipitous . . . without any preliminary pushing at all, still a little while before my midwife was ready to clear me to go ahead and push, I had a sudden and irresistible urge to push, and I pushed with all my might. The baby came all the way down to crowning with that one long push, but I also felt everything slacken and collapse in that instant, my muscular tension and ability to mobilize my muscles was gone, an abrupt dropout which felt a lot like shock. My midwife said 'now stop! stop! let me clean up this field before the baby comes' and I said 'sure, I could wait all day, my muscles, the urge to push, it's all gone'. I just knew an irreversible change had happened. Once the midwife was ready we did get the baby out, but as she told me to push, none of the large, formerly tensed and powerful muscles contributed, they were totally nonresponsive and I felt like I was only mobilizing small, bystander muscles from beside the vagina, not behind it (if that makes sense). With the baby right there, she was able to basically pull her out herself with little muscular help from me . . . it then took much longer to get the placenta out than the the baby had, it felt like I was pushing forever but finding only a few pathetic muscles willing to help, the main ones had dropped out and wouldn't answer my call . . . but we were relieved when the placenta finally made it out intact, as I'd had a retained bit of placenta in my first childbirth. The midwife noted I had torn in the same place as with my first baby --- about where a medial episiotomy would be placed, though I never had one --- just a bit longer of a tear than the first time, and she stitched that up. But then, after all should have been over and rebounding, my muscles and uterus remained in shock and my uterus would not begin shrinking down, so I had an extensive postpartum hemmorhage that took most of the night to stabilize (with hours of hands in my uterus scraping out clots, fundal 'massage', IV pitocin to stimulate the uterus to contract --- both of my deliveries have ended this way, but the second took so much longer to stabilize, I lost half my blood volume and ended up anemic and wobbly-in-the-middle for several weeks).

I've had the cavernous vagina feeling ever since that childbirth, the feeling that I can only get any grip or leverage during sex in one position (on top, leaning backward). It's more than a feeling, and it's not just my own impression . . . it's apparent to DH as well (not just the openness, which he admits, and he could hardly miss the sliding out in other positions . . .) So sex has never really rebounded (in satisfaction) since that second baby, though the gut and lower back symptoms only arose more recently . . .

The description in Christine's book of the fascia not relaxing, and instead getting pushed down in a bulge ahead of the baby's head . . . that seems so right a match for what happened. It's basically what my surgeon says as well, that the fascia gets pushed down, detached or stretched, and then remains collapsed down near the introitus . . . and so I have a rectocele/vaginal wall weakness in the lower 1/3 of the vagina where the fascia no longer provides support. I am also still considering surgery, and am reading a current vaginal surgery textbook. What my surgeon proposes as a posterior repair is basically lifting up the fascia and re-attaching them to their natural attachments --- according to him (and he does not lack surgeon's arrogance) the posterior repair surgeries discussed in Christine's book --- foldover and plication of the rear fascia, or defect-specific repairs with mesh --- are outdated and dangerous (and I have seen him say so in his published works, that surgeons should no longer do these or at least should advise of their likely complications for, for example, painful sex, as part of gathering informed consent).

Sorry for the length --- I am still trying to get a grip on all this and appreciate any feedback.

alphamom

Christine

May 23, 2009 - 12:54pm

Hi Alphamom,

Thank you for this update, which is very thought provoking. I have a few comments.

First of all, I’d love to get Alemama’s take on your description of what you believe was the moment during birth that your muscles became “nonresponsive”, just because she has done this four times and is very close to her last experience. You do know it is the uterus pulling up with each contraction that essentially dumps the baby out. Once the levator muscles are completely open, can Any woman feel any control there? It seems very unlikely to me.

Although I have tried to make sense of and report the best of the ob/gyn surgical literature, some of their basic premises I believe are highly questionable. One is that fascia actually tears and breaks off from attachment points. The other is that the fascial layer can actually be identified and isolated off the back vaginal wall as one integral piece that can then be “repaired” and “reattached”.

The words of your surgeon, “lifting up the fascia and re-attaching them to their natural attachments” sounds like absolute nonsense and exactly the same sort of meaningless euphemism used by reconstructive surgeons throughout the decades. Perhaps you could obtain a more in depth description of the operation he proposes. To me, his description can only mean a colpopexy where mesh extensions are used to lift the back vaginal wall onto the sacrum. The true natural attachment points of the rectovaginal fascia are the uterosacral “ligaments”, which are nowhere near the sort of ligaments in your knee. Ultimately, everything is connected onto the spine and that is where all such colpopexy and rectopexy operations attach to.

Clearly, you have a large diastasis that has not closed, presumably because you have lived in spinal flexion all these years. Your pelvic floor is probably short and wide instead of long and narrow. It may take a long time (months, years - I really don’t know) to see progress, and there is also the chance that you may see none at all, although I believe the former. Try having sex in the posture - it really does make a difference.

Alphamom, it saddens me to squash your hope of a surgical “cure” and if that is the direction you want to take, we will be very supportive and interested in hearing every detail of your results. I only caution you that nothing sounds new here - they have been working on this problem since the late 1800s.

Christine

alphamom

May 23, 2009 - 5:09pm

Christine,

I am not a medical person, and this vocabulary is largely new to me, but the summary below is from the chapter on posterior vaginal reconstruction my surgeon referred me to as a good explanation of what he intends, and it gels with what he told me himself. Yes it is called "posterior vaginal reconstruction with bilateral vaginal uterosacral colpopexy" and yes the attachment points are to the uterosacral ligaments. My surgeon notes that he usually finds enough tissue present to complete the repair, but occasionally finds he must augment with a graft (porcine intestinal submucosal). This dissolves within the body within about 4 months, but serves as a temporary scaffold on which the body heals.

From Chapter 17 of _Advances in Reconstructive Vaginal Surgery_, ed Kovac & Zimmerman, pub. Lippincott, Williams & Williams, 2007:

"The goal of posterior pelvic reconstruction is to identify the specific pattern of apical separation of the rectovaginal septum and then successfully reestablish its continuity with the uterosacral ligaments and paracervical ring within the interspinous diameter. Reattachment of the rectovaginal septum to the superior fascia of the pelvic diaphragm repairs any pararectal defects. Central defects within the rectovaginal septum and distal separations of the rectovaginal septum from the perineum may be encountered occasionally and should be repaired in a site-specific fashion. . . .Site-specific techniques that identify damage to connective tissue elements and restore these structures to their normal anatomic relationships have the best long-term functional results [references] Permanent sutures should be used for all connective tissue reattachments with the exception of the introital portion of the perineum. Anatomically distorting midline plications are of historical interest only [references]. They do not restore normal anatomy and often result in permanent pain and sexual disability."

Then there is a much longer description of the surgery (this is a textbook for surgeons). Short summary: Expose the rectovaginal space . . . find the rectovaginal septum (with prescriptions for how to recognize it) . . . grab proximal edge with Allis clamps . . . description of the various common patterns of fascial damage, "transverse proximal margin displaced all the way to the perineum". . . or "an intact connection of the septum to the uterosacral ligament on one
side and a complete separation with a full-length pararectal defect on the side with the uterosacral disruption" . . . release adhesions . . ."Even in elderly patients, connective tissue does not atrophy significantly. When the rectovaginal septum is scarred and retracted within the rectovaginal space, the original complement of tissue is present. With careful and skillful surgical technique, most, if not all, of the original form of the septum can be recreated. The key to this entire exercise is identification and elevation of the proximal edge of the connective tissue continuous with the perineum. Meshes and bolsters are much more useful in anterior vaginal reconstruction than in posterior vaginal reconstruction. Restoration of vaginal depth is usually possible with available connective tissue posteriorly." . . . next, identify the uterosacral ligaments (landmarks, how to recognize, etc) "After identification is complete, a double-pass permanent suture is placed into each of these ligaments. Sutures are passed through the proximal edge of the rectovaginal sectum. When tied, these sutures complete a bilateral uterosacral colpopexy, suspending the rectovaginal septum to the uterosacral ligaments. This critical and necessary part of the surgery reestablishes the integrity of the suspensory axis of the vagina (DeLancey Level I) and its associated structures." . . . then 3 "central sutures at the level of the paracervical ring in order to repair the hernias" [rectocele and/or cystocele] . . . then site-specific repair of any evident central defects . . . then if needed repair of any pararectal
defect by reattachment to the arcus tendineus fascia pelvis, with permanent sutures [this is Delancey Level II]. . . "In posterior vaginal reconstruction, restoration of DeLancey Level I suspension should precede correction of DeLancey Level II lateral attachment. After these two levels of anatomy are corrected, DeLancey Level III distal fusion may be addressed if necessary. Surgical reconstruction should progress from proximal to distal. If the pelvic surgeon accounts for all normal connective tissue attachments in all of these segments, the best chance of good results will be attained . . . . An anatomically restorative repair that is permanent is the gold standard of pelvic reconstructive surgery."

I'm afraid you've now exhausted the level of detail I can provide!

My second labor was very different from my first, in that sudden and complete shock/nonresponsiveness of my muscles (or whatever they all are, technically), and in the failure to ever regain vaginal tone and caliber afterward, and that is why I feel so responsive to the idea that something 'broke' in that moment. Even at the time I felt, deeply, that something catastrophic had happened. I don't feel that I could have resisted that urge to push, though, even then I knew I was not clear to push but could only give in . . . so I feel no anger or blame.

Argh, I am having another acute pelvic pain day, I had naively hoped those might disappear now that I've been aware of the rectocele and proactively managing fiber, no straining, back support, posture . . . vicodin did allow me to go watch my daughter in two soccer tournament games, better than a day in bed or the ER . . . don't worry it's only the second time I've resorted to vicodin since this sorry saga began 7 weeks ago. Why are my crises always on weekends!?

I am still information-gathering and gathering data on my own healing/management, and still weighing surgical suffering versus nonsurgical suffering . . . and also still in the grieving stage that at 44 years old, both options suck more than anything I'd expected . . . and I remain aware that no matter what decisions I make, I will need to be more proactive and attentive to my pelvic health/support forevermore, I need lifetime good pelvic support habits . . .

alphamom

Christine

May 23, 2009 - 6:39pm

Well, it may be that there are a lot of assumptions being made here, but we really have no way of knowing without several studies on this type of reconstruction to refer to. The first is that there is indeed apical separation of the septum at all. And the different types of septum separations being described rings an all too familiar bell...

Oh yes...the different types of rectovaginal fascial “defects” - some central, some torn to the left, some transversely, described in pelvic surgery books from the nineties.

The posterior colporrhaphy was established in the last decades of the 19th century. Can you even imagine how much dissection in the name of research has gone on since? How in the world did they miss, until now, “apical separation” of the rectovaginal septum?

You are too new to all this to recall the “paravaginal defect repair”, which millions of women were being subjected to when STWW1 was being written. I asked the question then on our first website, “Although there are many illustrations of the alleged ‘paravaginal defect’, where are the actual photographs? Does the paravaginal defect even exist?” Sure enough, subsequent research began to question its validity and today you hardly hear of this surgery being performed.

Finally, be sure you are okay with the idea of a “double-pass permanent suture” being placed into each of the uterosacral ligaments, which carry nerve vessels off the spine.

I did enjoy the little nugget of information that, “Even in elderly patients, connective tissue does not atrophy significantly.” My greatest finds in surgery books were off-handed comments from observations such as these.

Don’t you think that if you had the sorts of structural breaks referred to by your doctor and in this text that your symptoms would’ve been severe all along since the birth of your last child nine years ago? Other than the looseness during sex and the unfortunate comment made by your gyn, it seems like you’ve managed well until very recently. Yes, of course they can pull your vaginal wall up and perhaps reduce your symptoms considerably. But at what cost and for how long? This sounds to me like a glorified colporrhaphy (they DO have to “expose the rectovaginal space”) and I would certainly look into the research before making any decisions.

Christine

alemama

May 23, 2009 - 9:59pm

I have been thinking on this post and the one you posted about 3 weeks ago Alphamom. I am going to start a reply right now and post as much as I can get in before I have to take care of the baby -who is fussy in the evenings recently (and of course during the daytime hours the other kids keep me busy). First- rereading your past posts I was reminded of how much pain you have been in- these acute episodes of pain. I wonder if you would be willing to give more information about this. When it starts, how it feels, how long it lasts, what relieves it, what you are doing when it comes on, etc....
Have you looked into PSD? and also do you suspect a diastisis of your central abdominal muscles?
I am guessing you still have the ovarian cyst, though it could be gone by now too. I am also guessing you are about to have another period pretty soon.
Your description of your vagina is interesting to me. It sounds like some PT wouldn't be a bad idea at this point- if you are not able to feel your muscles tighten in your perineum, anus, or introits. You may benefit from some kind of e-stim????
I have a complete unstitched tear from the introits back to the anus. I have retraction of the lavator-ani and bulbocavernosis muscles and if I go looking the opening of my vagina is shaped like an icecream cone- with the deep "V" shape. I share this in an attempt to make since of your "cavernous" feeling. Even with this unstitched tear and very large opening I still feel tight. When I insert a finger to check my cervix my finger is surrounded- I can push the on the anterior vaginal wall and get some space- or the sides or posterior wall- but I wouldn't use the term cavernous.
So what is going on? Could it be you are lacking tone in those muscles? I can hardly think that, since you are an active woman, up on your feet, exercising etc- those pelvic floor support muscles get used all the time. Could it be your rectocele is just so big your back vaginal wall has no support? and just where is this pain coming from anyway? Pain is so weird. Especially nerve pain. I can have a massage and the therapist will be targeting my neck and all of the sudden I feel a deep letting go behind my shoulder blade.

ok now about that birth. I can say that what you describe sounds really normal to me- As the baby starts to crown there is a numbness of the pelvic floor (beautiful really)- then having no urge to push is beneficial- the head gently stretches the perineum and you can give it as much time as you like as long as you feel the baby is safe (you could have no urge at all for hours and that would be fine- it will return)-The vagina's job is to relax and let the baby out (and support the baby's head applying pressure to assist the baby into a good birthing position- not to flex and push the baby out- most of the expulsion of the baby comes from the uterus and then from the mom increasing intra-abdominal pressure and bearing down if she chooses to do so. But the baby can come out with out this mom assisted pushing.
The next stage- birth of the placenta- can take hours to come on- with my last birth it was 2 and a half hours before I was able to get it out- rushing this process is unwise. It is good to give the uterus the rest it needs. I don't know if you could have prevented hemorrhage this way or not.
Sounds like you had a compromised perineum and a subsequent repair. I really do believe this greatly increases the chance of developing a rectocele.

I don't know. I wish I had some great feedback for you- I think you need to pin down this pain- get your bowels under control and then assess the rectocele situation. Get to know your vagina a little better- check out the bulge before you get out of bed in the morning- check it before, during and after using the bathroom. Start a journal where you list BMs, Pain, time of day, month etc., how you were feeling that day emotionally, where you are in your cycle, and what activities you did.

I do know that you are doing your research. You are questioning and learning- and if you do go the surgical route it will be with REAL informed consent.

alphamom

May 25, 2009 - 10:15am

Thanks for all of your insights, alemama.

I am not a reliably active person. Large parts of my day are sedentary, at a desk or computer monitor, with sustained flurries of on-my-feet presentation and of hustling kids off to various activities. Sometimes I settle into that, other times I do include deliberate exercise in my routine --- but typically only aerobic, endurance exercise, not a whole body muscle toning approach, because I've never felt very confident in a whole body approach that's not doing more harm than good. For the most part, since my kids were born, worrying about my own fitness and weight was what I deprioritized, to find the resources to manage their needs, my work, and an active family slate of activities. My weight has crept up over the years, ending at my end-pregnancy weight with my second, about 50 lbs higher than my mid-20s reliably sustainable weight. I go through bursts of instituting an exercise regimen, but it is mainly in response to episodes where I've suddenly felt unfit.

I did strain my back last fall, carrying a tall double load of laundry down stairs, a proper muscle strain that had very acute lower back pain and wobbliness for 1-2 weeks, then gradually healing stiffness and weakness for another 3-4 weeks (this was my first back injury). That and my gp's complaints about the vaginal wall continually collapsing on her while looking for IUD strings was one wakeup call. I've tried adding aerobic activity pretty consistently since then. I had already tried one of the kegel resistance devices and as I noted, I can only touch or squeeze it up very high, near the cervix. I did note some mild eventual improvement over weeks in the tension I could squeeze against, but again I only ever got any leverage with those very high muscles. It did often seem an irritant as well, causing spotting and congestion. And if I left off a few weeks and tried again (honestly, who has the extended private time for these activities?!) any gain was very temporary and lost. It may have been a recent push this spring to add classic abdominal exercises into my exercise routine, to try to work on the back weakness, that aggravated everything, I've dropped them and at least now feel safe with Christine's routine.

It seems that most of my pain involves muscle spasming or cramping in an unproductive way. My lower back pain and wobbliness are exactly as I felt when I injured my back --- but it lifts after a day or 2. To me it feels muscular, not in the joints --- and the ER doc did ask about and check my hip area joints (while I was wearing the maternity belt) and said they seemed fine. The pelvic pain is mostly in that left ovary/left crook of intestine area, though sometimes double-sided and in the worst case spasming across the front left to right. It feels like an engorged, full, crampiness. A hot bath can make all subside til I get out of the bath. A heating pad and large dose of ibuprofen can eventually make it subside, if I catch it early enough. All of it is usually present on first waking, and intensifies or fades after the first morning bathroom visit. The vicodin seems to always work, though it too takes some hours.

I'm afraid all this may be worsening because I'm in a long leadup to menopause that is getting more intense before it begins fading. My cycles seem to be getting shorter and more intense, with more virulent cramping (my pelvic cramping is much like I'd been starting to get with menstruation, I have a whole-abdominal area response to progestins it seems, and always get gut cramping). Previously I'd paid little attention to menstruation but recent months have seen more of a pattern of wake up during my period to severe cramping, take 3 ibuprofen and curl around a warm heating pad to try to get back to sleep, to sleep off the pain til the ibuprofen kicks in 2 hours later. That is probably the only sign I had in the months leading up to this big rectocele flair, which itself started at the tail end of a harsh week of menstrual cramping. I've also started getting midcycle spotting and fullness.

I've just recently had my long-term copper IUD out, and gone over to the nuvaring instead (and my body retains this, it's expanded into a flat wide ring, unlike tampons or yeast medication capsule which my body expels). This may attenuate some of the spotting, harsher cramping, etc, as it's like a birth control pill in attempting to shut down natural cycles.

I haven't done much self-inspection and probably should. I usually fall asleep and wake up next to my 9yo (bedtime reading and snuggling) in my bed. The gaping feeling is largely in the laying on my back position, even the kegel exercisers slide right out if I don't hold them in with my hand. When my back pain's present I find it hard to even reach down there, but I should make more of an effort . . . it's also hard to get the privacy to strip down and use mirrors, etc, behind closed doors . . .

I have lost 10 pounds in the 3 weeks since the ER incident.

Interesting what you say on the placenta and childbirth. With my first, I still felt much muscular tension and desire to push things out, until shortly after the baby's birth I heard the words "don't pull on that cord" followed y the news that I had to consciously relax everything to let the midwife put her hand through the cervix to fish out the placental fragments. Perhaps this made my (different) midwife and me too determined to get that placenta out fast the second time. With only 2 labor experiences, neither of which finished as prescribed, I guess normality is hard for me to judge.

Thanks again,

alphamom

Christine

May 25, 2009 - 11:09pm

Hi Alphamom,

I sort of fancy you as a scientist. Maybe it’s your general level of articulation or perhaps your readiness to peruse the medical literature that makes me think you have science somewhere in your background - or foreground.

In reading your last post, I allowed myself to carry this notion forward and wound up with a few thoughts I’d like to share in hope that you or some of the other women might find them useful. This is all predicated on *IF* you are indeed a scientist, and if you are not, then maybe there will be value here anyway.

What jumps out when I read your words is ***DATA*** and I would like to encourage you to see your pain as information as well. Pain is what our bodies have to alert us to disorder. This is how the body communicates and we, as good scientists, are supposed to pay attention to the data. As you know, no self-respecting scientist would cover up data and that is exactly what you are doing with the pain meds.

Something is causing your pelvis and lower back to signal a red alert, and it is your responsibility to listen and respond appropriately. No doubt just cause exists for such pain - an IUD and steroid-filled diaphragm would be enough to send me to the hospital - but so would years of sitting at a work station, and probably Ibuprofen too.

It is interesting that you can talk about “shutting down natural cycles” so casually - like that in itself wouldn’t be enough to cause a major pelvic revolt. I understand completely that you are a modern woman with a full workload to manage - but that doesn’t mean your pleistocene body is anywhere near ready to adapt to your lifestyle.

Instead of shedding a bunch of weight and feeling like you have to exercise like mad to fix all that’s going on in your body, my hope for you is that you’ll simply slow down and begin to listen.

Hugs and prayers,

Christine

louiseds

May 26, 2009 - 10:30pm

Hi Alphamom

My comment is much along the lines of Christine's perceptions, though I cannot match her technical knowledge. Her comments about pain as data ring true with me, along with advice about allowing your body to calm, and make more steady and slow changes, rather than doing one thing at a time to the extreme and expecting your body to be able to adapt quickly, then changing directions again.

One of the things I am learning is to look for the optimum region, the moderation region in all things. Constant fine-tuning instead of slash and burn will be much gentler on you as you run up to menopause. Likewise, exercising whole body, rather than individual parts, spreads the load, and spreads the benefit.

I am in a similar space, but now closer to menopause after a couple of years of hormonal upheaval and rebellion. It is as if there is a transition time in perimenopause, when the body does all sorts of weird things and small difficulties grow bigger, eg body pain and cramping. It is just like Transition during labour, the craggy peak after which it is hopefully mostly a downhill run. (Could I be so lucky? We'll see.)

Having said that, I am an all or nothing person by nature, not a steady plodder at all. Training myself to stop anything before the point of burnout or exhaustion is a constant effort, but I am finding that easing off a bit is good for me, when I can manage to accomplish it. Shades of grey are becoming my friend. Variety my mantra. Moderation my aim.

I have just been through a few days of unexplained body pain. It may have been the very soft mattress I was sleeping on, away from home. I am feeling better after a night in my own bed. Nothing worked to make the pain go away, then suddenly it stopped. That's not the first time. Go figure. Letting it be is sometimes the best treatment.

BTW, I had completely immobile pelvic floor muscles after my second birth. I did have some sessions of e-stim or something similar with a physiotherapist, a few weeks after leaving hospital. This seemed to wake up the nerves and get them firing again. Then I could get on with Kegels without further help and recovered completely.

I am also wondering if your body shape and/or size may be contributing to your difficulty with making the posture work, and stopping you from using the pelvic floor muscles for normal movement? If these muscles are asleep your body may be compensationg by using other muscles for normal movements. Depending on where we carry weight, it can change our centre of gravity and our posture changes, maybe not in a POP-friendly way. Lowering of the perineum can stretch and irritate the pudendal nerve. I wonder if it can also irritate or squash the nerves supplying the pelvic floor muscles?

Christine, your comments?

Cheers

Louise

kath333

May 27, 2009 - 9:16am

Hi alphamom,
I, too, would describe my vagina as "cavernous". When I insert a finger while lying down, my finger is surrounded by my vaginal walls. If I invert myself, though, and let everything fall upwards, my vagina is a big open space....my finger would be surrounded by nothing. Take a look at this study that discusses damage to portions of the levator ani.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2288794
here is a portion of the discussion:

"Clinicians have noticed the gaping introitus and enlarged hiatus present in women with prolapse7 for many years. The origins and insertions of the missing muscle (pubis and perineal body, vagina, and anal sphincter) are directly relevant to holding the perineal body, vagina, and anus closer to the pubic bones. Loss of this muscle portion may help explain why women with prolapse, known to have a higher incidence of levator ani muscle loss,2 have a larger genita hiatus.8"

I had an epidural, so I can't comment on sensation during birth...but I'm thinking that this is what happened to me. I'm seeing a neurologist soon to investigate pelvic pain I've been having since my daughter's birth a year ago. The pain (along with muscle twitching) has now migrated to my legs. I'm wondering if they will be able to see if any portions of my levator are missing (assuming they do an MRI).

kath333

Christine

May 27, 2009 - 4:25pm

Well, we could speculate about all sorts of possibilities for Alphamom’s pain, but only a qualified clinician could give a true diagnosis.

Even our emotions can set us up for pelvic pain, as renowned orthopedist, Andry Vleeming, states, “Emotional states can play a significant role in human function, including the function of the neuromusculoskeletal system. Many chronic pelvic pain patients present with traumatized life experiences in addition to their functional complaints. Several of these patients adopt motor patterns indicative of defensive posturing which suggest a negative past experience.”

I have no idea where Alphamom’s pain is coming from, but I do know that when we become far removed (whether from injury or habit) from our natural bipedal abilities to walk, run, bend, twist, reach, and sit on the ground, pain and limitation are inevitable consequences. So, we can learn the names of all our muscles - their points of origin and insertion - how they move and how they affect the structures around them. But outside of an educated and comforting therapist moving us this way and that to activate or deactivate one muscle group or another, the ultimate remedy for musculoskeletal pain is placing ourselves in proper alignment and moving through space in our evolved and adapted shape.

I want to caution readers to be very wary of “scientific” studies like the one Kath has linked us to. John DeLancey has given us decades of fancy diagrams and notions of pelvic floor “defects” and “dysfunction” - mostly based on misconceived anatomy. This guy has been funded for years with University dollars to come up with all sorts of wild and less-than-useful theories on prolapse. This study needs to be looked at with a very sharp eye before heading to the nearest urogynecologist and asking for reattachment of your pubococcygeus muscle!

First of all, click to enlarge and look at Figure 1. To me, it appears that her pelvic interior is lilting toward the right a bit so that her left side is more prominent in these images. She could be positioned squarely on the table, but her actual organs are not symmetrical and the right side is not fully visible. This reminds me of the old fairy tale, The Emperor’s Clothes....”Can’t you SEE the missing muscle?”

Figure 2 is one of his crazy models. Can you imagine the force (and horrific pain) that would have to occur to result in total avulsion of this much muscle? Figure 3 is equally perplexing, as not only is the pubococcygeus muscle missing, but so is the iliococcygeus that surrounds it! Such an unheard of injury would cause extreme disability and could hardly be considered a common cause of prolapse.

Figure 3 is a stunning example of anatomical misconception. The structure labeled “P”, for pubis is actually the clitoris. The fascia and ligament-covered pubic bones lie between it and the urethra. You can actually see the long legs of the clitoris, which continue to wrap all the way around the vagina underneath the bulbocavernosus muscles. It is said that male anatomic researchers have a difficult time accepting the fact that the whole clitoris is actually larger than the penis. As for the “missing muscle” in these pictures, I say, “Whatever, Dr. DeLancey”.

Christine

kath333

May 27, 2009 - 9:54pm

Thanks for your input, Christine. I can see that this may not be common defect among women who have given birth...but I haven't ruled out the possibility that it happened to me. My genital hiatus has increased in size tremendously (before giving birth my vaginal canal was so narrow that intercourse was uncomfortable, and now it is quite wide...as if there is nothing connecting my anterior and posterior walls). I have lost a LOT of muscle tone. I have a hard time believing that this is because I haven't been doing enough kegels (I'm sure you agree). Also, I have perineal descent. If I had an avulsion of a muscle that is anchored to my perineal body...maybe this could explain the descent??? What typically does cause perineal descent? Because of the epidural, I did not feel any pain at the time of the birth, but have had perineal and levator pain ever since the anesthesia wore off creating some disability. I am horrified at the thought of such an injury, but would not be surprised if it did happen. I hope I'm wrong! I am trying very hard to understand what is going on with my body, so that I can be pain-free. I'll keep you gals updated. Thanks again!
kath333

Karolka

May 28, 2009 - 4:28am

I can totally sympathize with those of you ladies who have a feeling of a cavernous vagina. When I insert my finger into it, it is not surrounded - I can feel the front and the back wall but bot the side walls (I need to insert two fingers to feel the side walls, which obvioulsy wasn't the case before the birth). The mussles surrounding my vagina must have got really stretched during birth and I don't expect them to get back to normal (I'm 9.5 months pp now), which makes me a bit sad. When on knees and elbows, there is a big empty space in my vagina:( Fortunately, my sex life has not suffered at all - I even get more sensation than before the birth and so does my husband. I don't have any pain either so that's good. Anyway, I'm still doing some Kegels (the right way) hoping that I can still shrink a bit:)

Christine

May 28, 2009 - 12:50pm

Dear Kath and Karolka,

There is no doubt that modern obstetric practice can set women up for serious and long term injury. Natural childbirth is not always injury-free under the best of circumstances, but the chances of serious injury are far less when our bodies are allowed to do what nature intended.

Another reality is that the mature, parous vagina is far different from what we knew as teenagers. It’s possible (and I only mean possible) that your anatomy is identical to Granolamom’s or Alemama’s, but your mind is telling you that it is pathological instead of just the way it is. I can tell you that your description, “When I insert a finger while lying down, my finger is surrounded by my vaginal walls. If I invert myself, though, and let everything fall upwards, my vagina is a big open space....my finger would be surrounded by nothing” is completely normal for a woman who has given birth.

Women are Very much influenced by what they read and hear from the medical establishment. I hear that influence, Kath, when you talk about your “tremendously” increased genital hiatus, etc. The more reputable surgeon-authors do not speak of “gaping” vaginas because they understand the anatomy of a child-bearing woman. However, we now have an entire industry of others convincing women that a mature vagina is a defective vagina.

Although I’m not a clinical practitioner and have not done these sorts of studies, I have looked deeply into the problem of prolapse. What I believe to be true is that most of the stretching of the levator muscles, the endopelvic fascia, and the vaginal walls happens at the ischial spines. The ischial spines are the limiting factor in the process of human birth and have greatly changed in both size and position as we have evolved. The good news is we can walk the graceful human walk AND birth large-headed offspring. The bad news is those ingenious points of attachment do stretch.

And there is absolutely nothing to be done about it surgically. Imho, that is why we never hear about this most obvious and reasonable cause of prolapse from gynecology, which is primarily a surgical practice. Every other sort of “defect” has been sought after, “identified” and “repaired” - yet they are all phantasmagories, except true maternal injury from instrumental delivery.

Okay, so we have this pelvic outlet that needs to be both wide and narrow. Through an amazing evolutionary process (which I believe included primordial dance where deep hip turnout was greatly utilized) most of us have the ability to birth vaginally. The ischial spines give just enough room for our beautiful big babies to squeeze through.

And what narrows the spines? Walking in natural human posture. Each time we take a step, the tailbone lifts and the sacrospinous ligament pulls the ischial spine toward the center, narrowing the pelvic “floor”. When we take a bigger step, it narrows even more. First on one side, then on the other the musculature and fascia are pulled toward the center. That is why, unlike quadrupeds, our ischial spines are very prominent and pointed inward toward the birth canal. Just walking pulls the ischial spines toward each other.

From the point of view of our true anatomy, the remedy for prolapse is not surgery, but simple human walking. The worse the prolapse, the more walking is needed with steps as large as you can make them. Of course, prolapse can get so bad that rehabilitation must begin slowly. Through the total-body effect of fascial sheets underneath our back muscles, we can add to this effect by making large movements with our arms as we walk.

My prolapse was low yesterday and I pushed my granddaughter in her stroller as I walked with the biggest stride I could do, all the while in the posture. It has been higher ever since.

Women will protest with all sorts of complaints and excuses why this doesn’t work for them, but someday there will be enough of us to verify what stands before our very eyes: that the truth is written in our anatomy.

Christine

louiseds

May 28, 2009 - 11:07pm

Christine, I am trying to visualise this stretching at the ischial spines. Do you mean that the spines move further during normal movement in a parous woman? Because the process of birth causes them to stretch further than they have in the past, and they never go back to their pre-birth positions? We are just looser in the abdomen and pelvis after giving birth (which is kinda like stating the bleeding obvious)? If this is the case, it looks like the ischial spines, and therefore the rest of the pelvic bones, are involved in a 'chicken and egg' scenario, along with all the tissues you talk about, that are parts of the body's stuctural system, whether they are in tension or compression at any time. The damaged tissues allow the bones to move around more, but it was the movement of the bones during the birth that caused the stretching. Hence the need to 'wind up' what we have to tighten the whole structure, rather than surgically tying up and chopping off the loose bits. Yes?

If this is the case we need to start looking at the stretching as successful, if sometimes unwelcome, adaptation and further maturity of the body, which sometimes extends to permanent damage. I, for one, was happy to be giving birth the second and third times with an already adapted body. Who would want the uncertainties of a first birth every time? I know it is not as simple as that but ...

It doesn't explain POP in women who have not given birth, but this description does give 'whole body' management even more emphasis, rather than exercising particular muscle groups in isolation. It makes me realise even more that POP is not a gynaecological condition, but one which is the canary in the mine for the need for a woman to attend to the way she uses her body.

Cheers

Louise

clavicula

May 29, 2009 - 7:45am

I can tell you that your description, “When I insert a finger while lying down, my finger is surrounded by my vaginal walls. If I invert myself, though, and let everything fall upwards, my vagina is a big open space....my finger would be surrounded by nothing” is completely normal for a woman who has given birth.

Exactly. I think too it is totally normal. Every mom I talked to reported this type of vagina... But I guess even your walls would be firm and tough, won't protect you from prolapse. I had a strong back vaginal wall, and few days ago it started to soften up and now I have a rectocele too. I am still said about it, but also thrilled how my body acts, how huge abdominal pressures forms us inside....I have to say it is (literally) freaking amazing!

Liv

Christine

May 29, 2009 - 12:26pm

I’ll respond further, Louise, when I have a bit more time - but wanted to tell you that I was referring specifically to the vaginal birth process when talking about tissues connected to the ischial spines stretching. Abnormal stretching of that area undoubtedly results from straining against the toilet seat - and all forms soft-chair sitting as well. C.

Karolka

May 29, 2009 - 12:42pm

My gyn also claims that this "type" of vagina is typical to women who gave birth and he said mine wasn't any different at all (he also did not notice my prolapses the last time he examined me (lying down)). I have no reason to complain, since my sex life has not been affected at all. In fact, I've noticed some positive changes:)

Thank you Christine for the thorough explanation. I'm looking forward to hearing more of it.