What are the attributes and barriers to care for college-aged women who have pelvic pain? This is a question asked by researchers who published an original article on the topic in the Journal of Minimally Invasive Gynecology. To complete the study, a random sample of 2000 female students at the University of Florida were sent an online questionnaire. Included in the questionnaire was basic demographic data, general health and health behavior questions, psychosocial factors, measures assessing different types of pelvic pain such as dyspareunia, dysmenorrhea, urinary, bowel, or vulvar pain, and information about barriers to care for pelvic pain and quality of life measures. A total of 390 women completed the survey, and the mean age was 23 years old. Most of the women in the sample identified as white, with 9.6% identifying as black or African-American. Most of the respondents had never been pregnant. The chart below lists some of the data.

Barriers to receiving care included difficulty with insurance coverage and providers’ “…lack of time and knowledge or interest in chronic pelvic pain conditions.” An interesting finding was that among the women who had pelvic pain, those who were sexually active reported lower scores on physical and mental health. Even among the women without pelvic pain, those who were sexually active reported lower mental health scores.

How can this study encourage us as pelvic rehabilitation providers? Can we reach out to providers and share the potential benefits of pelvic rehab care to decrease the burden on the patient in finding services? It seems that in addition to continually spreading the word that pelvic pain can be eased with rehabilitation efforts, we can provide the interest and knowledge in the subject so that the patient can feel validated and can be instructed in self-management tools.

Over the past 28 years, my pelvic floor has endured at least 20,000 miles of running, including racing on the collegiate level and then completing 10 marathons. Add to the high-impact sport two 8.1 pound natural childbirth deliveries 26 months apart, and you can imagine why I accepted the invitation to blog for this well-respected institute. One of my elderly patients once told me my uterus was going to drop out from so much running (which, thankfully, has NOT happened); however, I have to admit, urinary stress incontinence and frequent urination were unwelcome enough consequences! On the positive side, it all initiated my journey to understanding the pelvic floor.

In 2014, Poswiata et al used the Urogenital Distress Inventory (UDI-6) to assess how prevalent stress urinary incontinence may be among elite female skiers and runners. Of the 112 female athletes in the study, 50% reported leaking a small amount of urine. Coughing and sneezing provoked leakage for 45.54% of those women, indicating stress incontinence, and 58.04% of the women in the study reported frequent urination. Are those acceptable statistics? I would have to say no.

Research results can be comforting so athletes can be told they are not alone regarding a quite personal aspect of their lives. When I could supposedly empty my bladder, stand to wash my hands and have to go again, walk down the hall to put on my sneakers and go once again before heading out the door for a run, it was nice to know someone else was probably experiencing the same issue that morning. Just because it is common, though, does not make it “normal.” We are not meant to leak just because we stress our bodies beyond normal ADLs.

A very recent study by Luginbuehl et al (2015 July 21), just published online, attempted to explore the electromyography (EMG) activity of pelvic floor muscles with variable running speeds (7, 9, and 11km/h) over 10 steps. The highest pelvic floor muscle activity was recorded at 11km/h, which would sensibly suggest the muscles produce a greater contraction the faster someone runs. If a runner has developed a decreased ability to activate the pelvic floor muscles, stress urinary incontinence will likely become a highly irritating problem with fast running speeds over time. But how do they know, and where do they go?

Without health practitioners trained in rehabilitation of pelvic floor dysfunctions, consider how chronic an issue urinary stress incontinence would be for a large athletic population. So many women (and men) do not even recognize their leakage or frequent urination as treatable “issues” and never mention them to anyone. Often times, we are treating an athlete for a hip or lumbar injury and purposefully yet discretely have to ask the right questions and then educate the patient how some of their symptoms are secondary to pelvic floor deficits. Someone has to explain what is normal, and, better yet, someone HAS to make an effort to fix what is “broken” and restore the pelvic floor to a higher level of function. With the proper training, perhaps that someone can be you.

References:
1. Poświata, A., Socha, T., & Opara, J. (2014). Prevalence of Stress Urinary Incontinence in Elite Female Endurance Athletes. Journal of Human Kinetics,44, 91–96. doi:10.2478/hukin-2014-0114.
2. Helena Luginbuehl, Rebecca Naeff, Anna Zahnd, Jean-Pierre Baeyens, Annette Kuhn, Lorenz Radlinger (2015 July 21). Pelvic floor muscle electromyography during different running speeds: an exploratory and reliability study. Archives of Gynecology and Obstetrics. doi: 10.1007/s00404-015-3816-9.

Today we hear from Martina Hauptmann, PT, PMA-CPI, instructor of "Pilates for the Pelvic Floor: Pelvic Floor Dysfunction, Osteoporosis and Peripartum". Join Martina this September 19-20 in Chicago, IL to learn how to incorporate Pilates into your treatment plans!

Because the cost of staying in business is increasing and the insurance reimbursement rates are dropping, many physical therapy clinics are looking for cash based supplemental services (medically-orientated gym memberships, Pilates classes, yoga classes, durable exercise supplies etc). Offering Pilates as part of the physical therapy clinic’s therapeutic interventions will differentiate your clinic and may be marketed to physicians and the community to increase your clinic’s market share. Post rehabilitation, the offering of cash based Pilates wellness classes can increase the clinic’s bottom line, allowing for further rehabilitation of the client beyond the time frame allowed by insurances and improve retention of clients.

Pilates is a system and philosophy of exercises based on the work of Joseph Pilates (1883-1967) that focuses on precision and optimal alignment. This approach requires the client to focus her mind on the exercise in order to increase motor control. Women are attracted to the Pilates method because of its gentle but effective nature. Offering Pilates as part of your therapeutic offerings is a great marketing tool to physicians and to the community as well as an effective method for instructing specific muscle re-training.

My course will focus on the application of the Pilates method to women’s health issues: incompetent pelvic floor, hyperactive pelvic floor, chronic pelvic floor pain, pre-natal, post-natal and osteoporosis with small props. The course will utilize equipment that you may have in the clinic already (physio balls, foam rollers, resistance bands, small balls BOSUs and introduction to the Hooked on Pilates MINIMAX and HANDIBANDs).

The course specifically will incorporate Pilates exercises that increase the function of the pelvic floor via the intrinsic and extrinsic synergists of the pelvic floor muscles. Rationale for modified Pilates exercises for clients that exhibit hyperactivity in the pelvic floor muscles (Carriere & Feldt, 2006), pre-natal (ACOG, 2002) and osteoporosis (Sinaki, 1984 and Sinaki, 2002) will be discussed and modified exercises performed. Finally discussion of post-natal issues of lumbo-pelvic pain and pubic symphysis pain will be incorporated and specific exercises for these issues performed (Richardson and Jull, 1995).

This course has a heavy emphasis on exercise. Participants in this course will be able to utilize all instructed exercises immediately following the course. I hope to see you there!

References:
Carriere & Feldt (2006). The Pelvic Floor. Stuttgart, Germany: Georg Thieme Verlag.
American College of Obstetricians and Gynecologists (2002).
Sinaki, Mikkelsen (1984). Post-menopausal spinal osteoporosis: Flexion versus extension exercises. Arch Phys Med Rehab. Vol 65, Oct, 593-596.
Sinaki et al. (2002). Stronger back muscles reduce the incidence of vertebral fractures: A prospective 10 year follow-up of postmenopausal women. Bone. 30(6); 836-841.
Richardson, Jull (1994). Muscle control-pain control. What exercises would you prescribe? Manual Therapy. 1, 2-10.

An article promoting the beneficial role of a thorough clinical assessment was published last year in the Scandinavian Journal of Urology, and although the article is directed to medical providers, serves as an excellent summary for pelvic rehabilitation providers. Doctors Quaghebeur and Wyndaele describe a “four-step plan” that can help direct treatment efficiently, and that emphasizes the muscular and neurologic systems as potential referral sources. While you may not be surprised about several of the steps, you may find this article to be a useful tool, particularly for the terrific chart about neuralgia-type pain that you can find in the linked article.

Step 1 should include history taking with attention to information about the following:

- urinary frequency, urgency, and nocturia
- bowel habits
- sexual complaints and quality-of-life impact
- pain description with significant detail
- use of questionnaires

Step 2 emphasizes review of prior assessments and reports, including:

- imaging (x-rays, MRI, CT)
- lab work

Step 3 involves a thorough clinical assessment. This includes a neurologic assessment of the lumbosacral plexus, with evaluation of motor and sensory functions as well as reflexes. The nerves suggested for testing are the sciatic, iliohypogastric, ilioinguinal, genitofemoral, obturator, lateral cutaneous femoral, perineal and dorsal, and the medial, lateral, and inferior cluneal nerves. (An excellent chart listing each of these nerves and their dynamic tests is included in the article.) Of note in the chart is the lack of neurodynamic tests for the deep peroneal nerve, pudendal, perineal, dorsal nerve of the clitoris or penis, and the interior cluneal- these can be tested for symptom reproduction with direct palpation according to the authors. Other Step 3 tests are listed below.

- neurodynamics tension testing and nerve palpation
- EMG testing if needed
- evaluation for hernia (abdominal, inguinal, or femoral)
- exam of external genitalia (rash, secretion, abscess, fistula, atrophic disorders, signs of trauma, palpation)
- rectal and/or vaginal exam

Step 4 involves an extensive musculoskeletal system examination. This includes the spine, pelvic girdle, muscles, tendons, and pain points.

- spinal mobility (palpation, AROM, PROM)
- joint play of SI joints, pubis and sacrococcygeal joints
- muscular pain or other soft tissue pain reproduction

The physicians recommend a multidisciplinary team of providers including physical therapy. The true value of this article, from a rehabilitation standpoint, may be the emphasis on a thorough musculoskeletal examination as well as attention to recognizing neuralgias. We might utilize an article such as this to dialog with medical providers, or to assess our own “thorough” list of examination techniques. Herman & Wallace offers several courses which can benefit the practitioner seeking to gain new evaluation techniques. "Manual Therapy for the Lumbo-Pelvic-Hip Complex" is a great option which will be available this October 17-18 in beautiful Napa, CA.

Isa Herrera, MSPT, CSCS teaches the "Low-Level Laser Therapy for Female Pelvic Pain Conditions" course for Herman & Wallace. Join her on October 3-4 in New York, NY to learn about this new modality!

Physical therapists deal with chronic pain that can be problematic to treat and manage on a daily basis. There is an arsenal of tools, exercises and techniques at their disposal, but many times using a modality can help accelerate the pain-relieving process.

At my healing center in New York City, we treat an extremely difficult type of chronic pain loosely classified under the umbrella term "pelvic pain". Pelvic pain can express itself as sacroiliac pain, hip bursitis, symphysis pubic dysfunction, and vulvodynia. Chronic pelvic pain is sometimes perceived as a "woman's issue", but we treat both men and women who have suffered for years with their conditions. We are challenged to think outside the box to provide relief for these patients.

'Secret Weapon' for Pain

Chronic pelvic pain is very different from other types of pain because it's intimately connected to our emotional, spiritual and psychological states, and can involve many symptoms in the nervous, endocrine, visceral, gynecological, urological and muscular systems. It can be very difficult to treat, and can require from six months to one year of physical therapy, depending on patient presentation and history.

This lengthy course of treatment requires a fresh approach to therapy and modalities. When I started treating this population I had many difficulties when it came to controlling their pain and I had to think differently. Electrical stimulation and ultrasound were not working as well as I'd hoped, and were providing insufficient pain relief to these patients.

I needed a modality that, when incorporated with my pelvic pain treatment protocols, could help produce immediate and long-lasting pain-relieving effects. I needed a modality that could significantly decrease pain within one session, and that my patients could believe in because of the results.

Low-level laser therapy (LLLT) proved to be my secret weapon when treating women with chronic pelvic pain. (I frequently call it "light therapy", because many patients are put off by the term "laser.")

I have been successfully using light therapy for nearly ten years. It helps my patients keep their pain at bay, and many request that I use it as part of their therapy. Of course, light therapy is only as good as the therapist using it. You have to apply this modality correctly, and use the science properly to maximize results.

LLLT was approved by the FDA in 2002. At that time, the modality was hailed by the New England Patriots and the U.S. Olympic Committee, among others, for its ability to help top athletes quickly return from injury. Endorsements from these organizations piqued my interest and I decided to research its principles.

I realized that LLLT could be used on many levels. LLLT is unique: it is a cellular bio-stimulator and is used to increase vitality of cells as well as processes that occur within the cell. Not all lasers are "created equal," and you have to be careful with the type you purchase.

Principles that must be taken into consideration include wavelength in nanometers, power in milliwatts, and total energy delivered in joules. In my pelvic pain protocols, I use LLLT on sensitive and painful tissues that are unable to tolerate any heat production.

Many lasers claim to be great therapeutic lasers, but actually produce heat within the tissue and cells. Any heat production has the potential to harm cells and destroy them. Heat production indicates the delivery of too many joules of energy per cycle. The goal with LLLT is to stimulate health and vitality within the cell to produce effects such as pain relief, collagen synthesis, resetting nerve potential, anti-inflammatory effects, and endorphin production.

New Look at Modalities

LLLT has changed the way I treat all pain syndromes. It's had such a positive impact that I've created laser protocols for vulvodynia, scar and bladder pain. I also created a special class for the Herman and Wallace Institute class for physical therapists who treat chronic pelvic pain. I encourage any colleagues specializing in this population to investigate this remarkable modality and to attend the class in October. If you are looking for something different and a modality that will change the way you treat come and learn how to use if effectively.

Reema Thakkar, PT, DPT has been a practicing Physical Therapist in Manhattan since 2011, specializing in orthopedics and vestibular rehabilitation. Reema has offered to share insights about her journey into pelvic rehabilitation.

Working as a physical therapist for 4+ years in Manhattan, I soon realized the need for pelvic floor rehabilitation within the pre- and post- natal community, as well as the geriatric community. Much of our population did not even know that this type of rehabilitation was effective or even available. Others, were simply embarrassed by the topic altogether. I decided - a complete novice in this field - to attend a Herman & Wallace PF course and see what was available as a resource for me, and my patients.

"I can happily report that as more and more patients catch wind of what I’m working on, their interest spurs."

My first course was definitely overwhelming. I had studied beforehand, like any eager student would, but I still felt as though it was my first day of PT school and I was scared I would “break” the patient. The candor and wit, in which each topic was presented to us that weekend, completely eased my mind. The pelvic floor, like any other daunting body part we had studied through our careers as PTs, was equally as influenced by the pulls and strains of our daily lives…and the muscles and joints needed our help.

I returned from my course full steam ahead. I felt equipped to at least begin this journey with my patients, and decided to further pursue my pelvic floor education, already registering for a follow up course in a few months. One thing that was imperative to my pelvic floor pursuit, was understanding the confines of an outpatient clinic. Even with having curtains around, patients were far less inclined to open up about their dysfunctions despite this assumed level of privacy. I had to ensure to schedule in times where one on one care with a closed door was possible. Another imperative factor was studying ahead of time. Being new to this care, I had to have a prescription from the MD or an intake form from the patient beforehand in order to research the night before.

I am still in the process of mastering this flow of practice. However I can happily report that as more and more patients catch wind of what I’m working on, their interest spurs. I can’t say they have all come in for a pelvic floor evaluation, especially the older generation, but they are certainly opening up a dialogue and asking some questions – which is all I can hope for.

That being said, I am even more confident in my ability to help the patients in question. Since returning from my first class, my greatest successes have been working with an elderly woman with severe uterine prolapse and a middle aged gentleman suffering from urinary incontinence s/p inguinal hernia repair. I can gladly report that their quality of life has greatly improved since beginning this care and I can only hope to guide them further in this process, with further success.

Reema has been a practicing Physical Therapist in Manhattan since 2011, specializing in orthopedics and vestibular rehabilitation. Reema is currently pursuing further training in order to become a certified Pelvic Rehabilitation Practitioner.

The phrase “rectal prolapse” may be easily confused with the term “rectocele” yet they may be very distinct clinical presentations. A rectocele refers to a prolapse of the posterior wall of the vagina that allows the rectum to bulge forward towards the posterior vaginal wall. This condition occurs most often in women rather than men. A rectal prolapse is a protruding of the rectum itself outside of the anal verge or opening. An overview article published in 2013 in the Journal of Gastrointestinal Surgery provides information about the condition that may assist the pelvic rehabilitation provider with valuable clinical concepts. Prior to becoming a full external prolapse, an internal intussusception may occur (and observed on defecography) and progress to include an external mucosal prolapse. Rectal prolapse may occur with or without other conditions of pelvic organ descent such as a cystocele or uterine prolapse. Although the prevalence of complete rectal prolapse is low, and occurs more often in women or in elderly patients, interference with quality of life may be significant.

Symptoms can include pain, difficulty emptying the bowels, bloody and or mucous discharge, urinary incontinence, and fecal incontinence or constipation. Patients may also complain of a lump or a bulge in the rectum that may or may not improve following a bowel movement. A complete rectal prolapse can be described as a full-thickness protrusion of the rectum through the anus. A more serious consequence of this condition is strangulation of the bowel. Features of a rectal prolapse often include a redundant sigmoid colon, levator ani muscle diastasis, and loss of the vertical position of the rectum, according to the article.

Treatment of a rectal prolapse may include surgery. Prior to surgery, a physical exam, colonoscopy, anoscopy, and possibly manometry and defecography may be completed. The surgical goals are to correct the prolapse, improve any complaints of discomfort, and to resolve bowel dysfunction. Surgical approaches may include abdominal or perineal approaches, minimally invasive versus open surgery, and techniques can include posterior versus ventral and rectopexy with or without sigmoidectomy. For more details about the specific approaches for rectal prolapse repair, see the linked article. The authors of this overview article point out that because “…there is a paucity of data evaluating the effectiveness and appropriateness of the various surgical techniques…”, there is not one single management strategy for each patient.

Nonsurgical recommendations for management of a rectal prolapse include appropriate daily fluid and fiber, suppositories or enemas if needed, biofeedback training, and pelvic floor muscle exercises. A patient may benefit from education in all of these concepts, before and/or following surgery. Pelvic rehabilitation providers are well poised to offer conservative management in these conditions prior to and following any needed surgery.

To learn more about rectal prolapse and related dysfunctions, join Dr. Lila Abbate, PT, DPT, MS, OCS at Bowel Pathology, Function, Dysfunction and the Pelvic Floor this November in New York, NY!

Herman & Wallace faculty member Lila Abbate instructs several courses in pelvic rehabilitation, including "Coccyx Pain, Evaluation and Treatment". Join Lila this October in Bay Shore, NY in order to learn evaluation and treatment skills for patients with coccyx conditions.

Case studies are relevant reading for physical therapists. Reviewing case studies puts you into the writer’s brain allowing you to synthesize your current knowledge of a particular diagnosis taking you through some atypical twists and turns in treating this particular patient type. In JOSPT, August 2014, Marinko & Pecci presented a very well-written case study of two patients with coccyx pain. By then, I had already written my Coccyx course and couldn’t wait to see what the authors had written. I eagerly downloaded the article to see another’s perspective of coccyx pain and their treatment algorithms, if any, were presented in the article. How were the author’s patients different than mine? What exciting relevant information can I add to my Coccyx course?

I believe that coccyx pain patients have more long-standing pain conditions than other patient types. For the most part, the medical community does not know what to do with this tiny bone that causes all types of havoc in patients’ pain levels. Sometimes treating a traumatic coccydynia patient seems so simple and I am bewildered as to why patients are suffering so long - and other times, their story is so complex that I wonder if I can truly help.

The longer I am a physical therapist, the more important has the initial evaluation become. Our first visit with the patient is time together that really helps me to create a treatment hypothesis. This examination helps me to put together an algorithm for treatment. I now hear their story, repeat back their sequence of events in paraphrase and then I ask: do you think there is any other relevant information, no matter how small or simple, that you think you need to tell me? Some will say, I know it sounds weird, but it all started after I twisted my ankle or hurt my shoulder or something like that. I assure them that we have the whole rest of the visit together and they can chime in with any relevant details. Determining the onset of coccyx pain will help you gauge the level of improvement you can expect to achieve. Coccyx literature states that patients who have coccyx pain for 6 months or greater will have less chance for resolution of their symptoms. However, none of the literature includes true osteopathic physical therapy treatment, so I am very bias and feel that this statement is untrue.

The coccyx course is a very orthopedically-based which takes my love of manual, osteopathic treatment and combines it with the women’s health internal treatment aspects so that we are able to move more quickly to get patient’s back on the path to improved function and recovery. The course looks at patients from a holistic approach from the top of their head down to their feet. In taking on this topic, I couldn’t do it without honing into our basic observation skills, using some of my favorite tools in my toolbox: Hesch Method, Integrated Systems Model, and traditional osteopathic and mobilization approaches mixing it with our internal vaginal and rectal muscle treatment skill set.

Marinko LN, Pecci M. Clinical decision making for the evaluation and management of coccydynia: 2 case reports. J Orthop Sports Phys Ther. 2014 Aug; 44(8): 615-21.

Varicoceles are enlarged veins that occur in the scrotum. They can be common in adolescent boys and men, with an incidence rate of approximately 15%. Because up to 1/3 of men dealing with infertility have a varicocele, a repair of this venous herniation may be a first line treatment for male fertility. Varicoceles are sometimes referred to as feeling like a "bag of worms" due to the distended veins that coil through the area (the U.S. National Library of Medicine provides a useful illustration). Although varicoceles may be painless, they are thought to be symptomatic in up to 10% of men. Symptoms can be dull, aching, throbbing, and can worsen with physical activity. Conservative care includes scrotal support, limiting physical activity, and using anti-inflammatory medications.

Pelvic rehabilitation providers may work with a male patient who complains of scrotal pain, and who has a known diagnosis of a varicocele. If the patient is unsure of such a diagnosis, questioning the patient about prior discussions with his medical providers may reveal that he was told about “enlarged veins in the scrotum” or similar description. Visual inspection may reveal the tell-tale appearance of distended veins inside the scrotum, and palpation may reveal a significant difference among sides (unless both sides are involved of course.) Physical examination for a varicocele is usually completed in supine and standing positions and may be palpable with or without Valsalva maneuver. Keeping in mind that the differential diagnosis for pain in the scrotum can include medical conditions such as testicular torsion, epididymitis, inguinal hernia, testicular tumor, hydrocele, epididymal cyst, or sperm granuloma, patients who have complaints must see an appropriate medical provider to rule out such conditions. It is also possible for a patient’s condition to change or worsen if a period of time has passed, with communication with the referring provider recommended. Post-surgical complications that should also be considered are inguinal hernia repair for nerve entrapment or vasectomy.

Because of the nerves traveling in the same pathway as the involved veins, we can also consider the neural tension potentially created from the increased venous distension creating either (or both) compression and drag. Surgical options may be discussed by the medical provider, and these might include a microsurgical ligation or a varicolectomy. According to Park & Lee (2013) “A varicocelectomy should be considered in patients with no alleviation of their pain after conservative management, including resting, scrotal elevation, and nonsteroidal anti-inflammatory analgesics.” Conservative management is exactly where we can fit in as providers of pelvic rehabilitation. Including a condition such as a varicocele in our differential diagnosis and treating planning can further our success with patients.

Herman & Wallace offers it's popular Male Pelvic Floor Function, Dysfunction and Treatment course next month in Denver, CO. See you there!

References

Park, Y. W., & Lee, J. H. (2013). Preoperative predictors of varicocelectomy success in the treatment of testicular pain. The world journal of men's health, 31(1), 58-63.

Shridharani, A., Lockwood, G., & Sandlow, J. (2012). Varicocelectomy in the treatment of testicular pain: a review. Current Opinion in Urology, 22(6), 499-506.

Guidelines for the management of 3rd and 4th degree tears were updated and published last month by The Royal College of Obstetricians & Gynaecologists. The purpose of the guidelines are to provide evidence-based guidelines on diagnosis, management and treatment of 3rd and 4th degree perineal tears. These types of tears are also referred to as obstetric anal sphincter injuries, or OASIS. The authors acknowledge an increased rate of reported anal sphincter injuries in England that may in part be due to increased awareness and detection of the issue. In terms of classification of anal sphincter injuries, the following is recommended (note the different levels at grade 3:

- 1st degree tear: injury to the perineal skin and/or the vaginal mucosa
- 2nd degree tear: injury to the perineum involving the perineal muscles but not involving the anal sphincter.
- 3rd degree tear: injury to the perineum involving the the anal sphincter complex
- Grade 3a tear: Less than 50% of the external anal sphincter (EAS) thickness is torn.
- Grade 3b tear: More than 50% of the EAS thickness is torn.
- Grade 3c tear: Both the EAS and the internal anal sphincter (OAS) are torn.
- 4th degree tear: Injury to the perineum involving the anal sphincter complex (EAS and IAS) and the anorectal mucosa.

Risk factors for anal injury are also outlined in the guidelines, although the authors point out that accurate prediction based on the risk factors is not reliable. The noted risk factors are as below:

- Asian ethnicity
- Nulliparity
- Birthweight greater than 4 kg (8.8 lb)
- Shoulder distocia
- Occipito-posterior position
- Prolonged 2nd stage labor
- Instrumented delivery

Recommendations worth noting include Level A evidence that warm compression during the 2nd stage of labor reduces the risk of OASIS. A noted best practice recommendation is that “Women should be advised that physiotherapy following repair of OASIS could be beneficial.” Guidelines such as these from The Royal College of Obstetricians & Gynaecologists can help in creating common language and in making recommendations that improve communication and expectations between patients and providers.

If you are interested in learning more about anal tears, Herman & Wallace offers several courses which cover the topic. For postpartum care specifically, check out Care of the Postpartum Patient.