Diastasis Recti Abdominis and Pelvic Floor Dysfunction

Diastasis Recti Abdominis

Diastasis recti abdominis (DRA) is an impairment characterised by an increase in midline separation of the rectus abdominis muscles due to the widening and thinning of the linea alba (LA).[1][2] This separation results in an increase in the distance between the two rectus abdominis muscles, commonly referred to as the inter-rectus distance (IRD).[2] DRA is present when the IRD increases and exceeds normal values,[3] which can be measured at 1 or more regions along the LA.[4] It should be noted, that the increase in midline “separation” of the rectus abdominis muscles involves stretching of the LA rather than a true separation[5].

DRA can occur in both males and females, and across all age groups[6]. In infants, the separation between the rectus abdominis muscles can be congenital due to an abnormal alignment of fibre orientation within the LA or can occur as a result of decreased abdominal muscle activity[6]. In men, increasing age, significant weight fluctuations, weightlifting causing excessive increases in intraabdominal pressure (IAP), and/or inherited muscle weakness are all considered risk factors for the development of DRA[7]. DRA is most commonly recognised as a condition that is highly prevalent in pregnant and postpartum women[1], which can be explained by the expansion of the uterus to accommodate the growing fetus[6]. The expanding uterus causes the rectus abdominis muscles to elongate while altering their angle of attachment, which in conjunction with hormonal elastic changes of connective tissue[8], leads to the stretching of the LA resulting in an increased IRD, displacement of the abdominal organs, and a bulging of the abdominal wall[6]. During pregnancy, 33% of women present with an increased IRD by the second trimester[9], and 100% of these women present with an increased IRD by the end of the third trimester[10].

Clinically relevant anatomy

  • rectus abdominis muscles
  • external abdominal oblique
  • internal abdominal oblique
  • transverse abdominis
  • linea alba
  • lumbar multifidus
  • pelvic floor
  • diaphragm

Signs and Symptoms

  • Stomach bulge by umbilicus (usually below)
  • Stress urinary incontinence
  • Faecal incontinence
  • Prolapsed organs

Testing

The most traditionally used diagnostic method in clinical practice is the finger – width method, which primarily functions as a screening tool[11]. This tool is used to detect the presence or absence of DRA. If on palpation, the therapist can place two or more finger breaths (≈2cm) in the sulcus between the medial borders of the rectus abdominis muscles, the patient may present with diastasis recti abdominis[12].

In terms of measuring IRD, ultrasound imaging (USI) has been titled the gold-standard method to measure IRD non-invasively[13], displaying good inter-rater[14] and intra-rater reliability in the literature[15]. However, its daily clinical use may be limited due to cost, availability, and training[11]. A more clinically feasible alternative is the use of calipers, whereby the tips of calipers are fitted across the width of the separation[11]. Calipers are considered to be a reliable tool for measuring IRD at and above the umbilicus[11]. This was supported by Chiarello and McAuley (2013), who found that IRD measurements with calipers were similar to those taken with USI above the umbilicus.[16] Additional research is, however, needed to evaluate the potential of calipers relative to ultrasound imaging[11]. Other alternatives include computed tomography (CT scan) and magnetic resonance imaging (MRI), which are considered the method of choice when assessing the abdominal wall. However, neither are clinically feasible and both are expensive[11].

Treatment

  • Education to manage patient expectations, limit fear and anxiety
  • Postural correction
  • Exercises for transverse abdominis, multifidus, diaphragm and pelvic floor muscles
  • Although researchers suggest that external support, such as abdominal binding, should not be recommended as a primary rehabilitation technique for DRA to avoid reliance, in specific cases there may be benefits to its use when coupled with exercise[1]

Pelvic Floor Dysfunction

Anatomy

The pelvic floor is made up of a layer of muscles covering the bottom of the pelvis that support the bladder and bowel in men[17] and bladder, bowel and womb in women[18]. The structures that sit on top of the pelvic floor are known as our pelvic organs. These muscles run like a hammock from the front of the pelvis to the tailbone (coccyx) at the back, and side-to-side from one sitting bone to the other.[18]

The pelvic floor is a funnel-shaped structure covering the base of the pelvis from the pubic symphysis anteriorly to the coccyx posteriorly and stretches from one ischial tuberosity to the other. It consists of two main muscles, the levator ani, and the coccygeus[19].

  • The levator ani muscle is a broad thin muscle that is made up of a group of 3 muscles, pubococcygeus, puborectalis and iliococcygeus. The muscles join in the middle of the pelvis except at the prostrate in males and vagina and urethra in females.
  • Pubococcygeus originates from both sides of the body of the pubis lateral to the puborectalis muscle and anterior to the obturator canal at the tendinous arch. It travels posterior and medial to insert onto the perineum, coccyx and anococcygeal ligament.
  • Puborectalis is a U-shaped muscle that originates on both sides of the pubic body just lateral to the pubic symphysis. The muscle runs posterior and encircles the rectum so both sides join together. Some fibres join the external anal sphincter. The contraction of this muscle causes the anorectal junction to bend 90 degrees. This maintains faecal continence during contraction and enables defecation on relaxation. Some fibres may extend towards the urethra in both male and females and to the vagina in females, aiding with urinary continence.
  • Iliococcygeus originates from the ischial spines and posterior portion of the obturator internus. It travels posterior and medially and inserts onto the anococcygeal ligament and coccyx[20].
  • Coccygeus is also known as the ischiococcygeus muscle. It is a small muscle that makes up the posterior portion of the pelvic floor. It originates from the sacrospinous ligament and ischial spine and inserts on to the lateral borders of the inferior sacrum and superior coccyx[21].
  • Urogenital Diaphragm: deep transverse perineal, sphincter urethrae
  • Sphincters and erectile muscles of the urogenital and intestinal tract: external anal sphincter, bulbospongiosus, ischiocavernosus, superficial transverse perineal.

According to a research study by Migda et al. (2020), the use of high-frequency ultrasound (HFUS) provides an objective assessment of the structures of the vulva, vagina, and cervix[22].

For more information on the anatomy of the pelvic floor please visit: http://teachmeanatomy.info/pelvis/muscles/pelvic-floor/

Signs and Symptoms

Signs and symptoms of pelvic floor dysfunction include:

  • Pain or numbness during intercourse[23][24][25]
  • Ongoing pain in your pelvic region, genitals or rectum
  • A prolapse – may be felt as a bulge in the vagina (feeling or seeing a bulge or lump in or coming out of your vagina) or a feeling of heaviness, discomfort, pulling, dragging or dropping sensation[23]
  • Accidentally leaking urine when you exercise, laugh, cough or sneeze (stress incontinence)[26][24]
  • Feelings of urgency in needing to the bathroom, or not making it there in time[26]
  • Frequent need to urinate[26][23]
  • Difficulty emptying your bladder (discontinuous urination – stop and start multiple times) and bowels[26][23]
  • The feeling of needing to have several bowel movements during a short period of time
  • Constipation or bowel strains[25]
  • Accidentally passing wind[23]
  • Pain in your lower back that cannot be explained by other causes[23]
  • Prolapse is a common condition that can occur due to weak pelvic floor muscles in women. This occurs due to the womb, bladder, bowel or top of the vagina moving out of their normal positions and pushing into the vagina. This can cause pain and discomfort but can be improved with pelvic floor exercises and lifestyle changes[27]. Urinary incontinence has a direct relationship with pelvic floor muscles. These muscles tighten as a closure mechanism for the tube from the bladder to the exit (urethra) and weakness of these muscles can cause leaking and dribbling[28]

References

  1. 1.0 1.1 1.2 Dufour S, Bernard S, Murray-Davis B, Graham N. Establishing expert-based recommendations for the conservative management of pregnancy-related diastasis rectus abdominis: A Delphi consensus study. Journal of Women’s Health Physical Therapy. 2019 Apr 1;43(2):73-81.
  2. 2.0 2.1 Acharry N, Kutty RK. Abdominal Exercise With Bracing, A Therapeutic Efficacy In Reducing Diastasis-Recti Among Postpartal Females. International Journal of Physiotherapy and Research. 2015Nov;3(2):999–1005.
  3. Beer GM, Schuster A, Seifert B, Manestar M, Mihic‐Probst D, Weber SA. The normal width of the linea alba in nulliparous women. Clinical anatomy. 2009 Sep;22(6):706-11
  4. Lee D, Hodges PW. Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. journal of orthopaedic & sports physical therapy. 2016 Jul;46(7):580-9
  5. Hickey F, Finch JG, Khanna A. A systematic review on the outcomes of correction of diastasis of the recti. Hernia. 2011;15(6):607–14.
  6. 6.0 6.1 6.2 6.3 Michalska A, Rokita W, Wolder D, Pogorzelska J, Kaczmarczyk K. Diastasis recti abdominis — a review of treatment methods. Ginekologia Polska. 2018;89(2):97–101
  7. Cheesborough JE, Dumanian GA. Simultaneous Prosthetic Mesh Abdominal Wall Reconstruction with Abdominoplasty for Ventral Hernia and Severe Rectus Diastasis Repairs. Plastic and Reconstructive Surgery. 2015;135(1):268–76.
  8. Benjamin DR, Van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar 1;100(1):1-8.
  9. Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Jun 20:bjsports-2016
  10. Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy. 2015 Feb 1;20(1):200-5.
  11. 11.0 11.1 11.2 11.3 11.4 11.5 Van de Water AT, Benjamin DR. Measurement methods to assess diastasis of the rectus abdominis muscle (DRAM): a systematic review of their measurement properties and meta-analytic reliability generalisation. Manual therapy. 2016 Feb 1;21:41-53
  12. Noble E. Essential Exercises for the Childbearing Year. 2nd edition. Boston, MA: Houghton Miffilin; 1982
  13. Benjamin DR, Van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar 1;100(1):1-8.
  14. Keshwani N, Hills N, McLean L. Inter-rectus distance measurement using ultrasound imaging: does the rater matter?. Physiotherapy Canada. 2016;68(3):223-9
  15. Mota P, Pascoal AG, Carita AI, Bø K. Normal width of the inter-recti distance in pregnant and postpartum primiparous women. Musculoskeletal Science and Practice. 2018 Jun 1;35:34-7.
  16. Chiarello CM, McAuley JA. Concurrent validity of calipers and ultrasound imaging to measure interrecti distance. journal of orthopaedic & sports physical therapy. 2013 Jul;43(7):495-503
  17. Continence Foundation of Australia. 2018. Pelvic Floor Muscles in Men [online] [viewed 28 March 2018] Available from:https://www.continence.org.au/pages/pelvic-floor-men.html
  18. 18.0 18.1 Pelvic Floor First. 2016. The Pelvic Floor [online] [viewed 23 March 2018]. Available from:http://www.pelvicfloorfirst.org.au/pages/the-pelvic-floor.html
  19. Moore, K.L., Dalley, A.F. and Agur, A.M., 2013. Clinically oriented anatomy. Lippincott Williams & Wilkins
  20. Palastanga, N. and Soames, R., 2011. Anatomy and human movement, structure and function. Elsevier Health Sciences.
  21. Drake, R., Vogl, A.W. and Mitchell, A.W., 2009. Gray's Anatomy for Students E-Book. Elsevier Health Sciences
  22. Migda MS, Migda M, Słapa R, Mlosek RK, Migda B. The use of high-frequency ultrasonography in the assessment of selected female reproductive structures: the vulva, vagina and cervix.
  23. 23.0 23.1 23.2 23.3 23.4 23.5 Pelvic Floor First. 2017. Pelvic Floor First [online] [viewed 26 March 2018]. Available from: http://www.pelvicfloorfirst.org.au/pages/how-can-i-tellif-i-have-a-pelvic-floor-problem.html
  24. 24.0 24.1 Women's and Men's Health Physiotherapy. 2017. Leading the way in pelvic health [online] [viewed 28 March 2018]. Available from: http://www.wmhp.com.au/
  25. 25.0 25.1 Healthline. 2017. Pelvic Floor Dysfunction [online] [viewed 26 March 2018]. Available from: https://www.healthline.com/health/pelvic-floor-dysfunction#symptoms
  26. 26.0 26.1 26.2 26.3 NHS Choices. 2017. Living with incontinence [online] [viewed 28 March 2018]. Available from: https://www.nhs.uk/Livewell/incontinence/Pages/Livingwithincontinence.aspx
  27. NHS Choices. 2018. Pelvic Organ Prolapse Overview [online] [viewed 29 March 2018]. Available from: https://www.nhs.uk/conditions/pelvic-organ-prolapse/
  28. Male Pelvic Floor. 2012. Urinary Dysfunction and the Male Pelvic Floor [online] [viewed 29 March 2018]. Available from:http://malepelvicfloor.com/urinary.html