Diastasis Recti Abdominis and Pelvic Floor Dysfunction

Diastasis recti abdominis

Diastasis recti abdominis (DRA) is an impairment characterized by an increase in midline separation of the rectus abdominis muscles due to the widening and thinning of the linea alba (LA).[2][3] This separation results in an increase in the distance between the two rectus abdominis muscles, commonly referred to as the inter-rectus distance (IRD).[3] DRA is present when the IRD increases and exceeds normal values,[4] which can be measured at 1 or more regions along the LA.[5] 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.[6] DRA can occur in both males and females as well as across all age groups.[7] 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.[7] 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.[8] DRA is most commonly recognized as a condition that is highly prevalent in pregnant and postpartum women,[2] which can be explained by the expansion of the uterus to accommodate the growing fetus.[7] 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,[9] leads to the stretching of the LA resulting in an increased IRD, displacement of the abdominal organs, and a bulging of the abdominal wall.[7] During pregnancy, 33% of women present with an increased IRD by the second trimester,[10] and 100% of these women present with an increased IRD by the end of the third trimester.[11]

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.[27] 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.[28] In terms of measuring IRD, ultrasound imaging (USI) has been titled the gold-standard method to measure IRD non-invasively[9], displaying good inter-rater [23] and intra-rater reliability in the literature. [25] However, its daily clinical use may be limited due to cost, availability, and training.[27] A more clinically feasible alternative is the use of calipers, whereby the tips of calipers are fitted across the width of the separation.[27] Calipers are considered to be reliable tool for measures of IRD at and above the umbilicus.[27] This was supported by Chiarello and McAuley (2013), who found that IRD measures with calipers were similar to those taken with USI above the umbilicus[29], however, additional research is need to evaluate the potential of calipers relative to ultrasound imaging.[27]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, both are not clinically feasible and are expensive.[27]

Treatment

Education to manage patient expectations, limit fear and anxiety

Postural correction

Exercises for transverse abdominis, multifidus, diaphragm and pelvic floor muscles, Transverse Abdominis, multifidus, Pelvic Floor Muscle and diaphragm

Although researchers suggest that external support, such as abdominal binding, should not be recommended as a primary rehabilitation technique for DRA to avoid reliance, there may be benefits to its use, coupled with exercise, in specific cases.[2]

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 [6] and bladder, bowel and womb in women[7]. These structures that sit on top of the pelvic floor are known as our pelvic organs. The 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 [7]

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.[8]

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 on the pubic body just lateral to the pubic symphysis. The muscle runs posterior and encircles the rectum so both side join together. Some fibers join the external anal sphincter. CThe cntraction of this muscle causes the anorectal junction to bend 90 degrees. This maintains facal continence during contraction and enables defecation on relaxation. Some fibers may extend towards the urethra in both male sand females and to the vagina in females, aiding with urinary continence.

Iliococcygeus originates from the ishial spines and posterior portion of the obturator internus. It travels posterior and medially and inserts onto the anococcygeal ligament and coccyx. [9]

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 inferior sacrum and superior coccyx.[10]

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 research study (2020), the use of high-frequency ultrasound (HFUS) provides an objective assessment of the structures of the vulva, vagina, and cervix[11].

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

Signs and symptoms

Pain or numbness during intercourse.[25][22][24]

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.[25]

Accidentally leaking urine when you exercise, laugh, cough or sneeze (stress incontinence).[24][27]

Feelings of urgency in needing to the bathroom, or not making it there in time.[27]

Frequent need to urinate.[25][27]

Difficulty emptying your bladder (discontinuous urination – stop and start multiple times) and bowels.[25][27]

The feeling of needing to have several bowel movements during a short period of time.

Constipation or bowel strains.[22] Accidentally passing wind.[25]

Pain in your lower back that cannot be explained by other causes.[25]

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 [30]. 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.[29]