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Urinary incontinence and rectus diastasis

The association between urinary incontinence and rectus diastasis would have been unthinkable only fifteen years ago: physiotherapists would never have considered the pelvic floor muscles in their treatments for lower back pain, and would have discouraged the use of abdominal muscles in patients with urinary incontinence. Today, the paradigm has completely changed - and this, we must admit, is partly due to the fact that General Surgeons began to take an interest in diastasis of the rectusThe pelvic floor muscles are considered part of the abdominal muscle complex, and they are recognised as having a dual function: that of helping to maintain trunk stability on the one hand, and urinary and faecal continence on the other.

It is well known that simple pelvic floor rehabilitation (e.g. with the Kegel exercises) is not sufficient to prevent urinary incontinence in the long term in women after vaginal delivery; on the other hand, as early as 1984 Gordon et al. had shown that, non-specifically, physical activity can prevent the onset of incontinence, thus highlighting the role of muscles other than those of the pelvic floor in the control of continence.

Anatomy of the pelvic floor

rectus, pelvic floorAs always, to understand the relationships between urinary incontinence and rectus diastasis it is essential to know, at least in broad terms, the anatomy, which is rather complex, of the pelvic floor.

The pelvic floor is a funnel-shaped structure consisting of muscles that insert into the lower portion of the walls of the pelvis, separating the pelvic cavity from the perineum.
There are two main 'holes' in it: the urogenital hiatus, anterior, through which pass the urethra and, in women, the vagina; and, behind this, the rectal hiatuscrossed by the anal canal. Between the two hiatuses is a particularly dense fibromuscular structure, called perineal bodywhich functions as an insertion zone for various muscles, including the elevator muscle of the anus.
The latter is one of the two muscles that make up the pelvic floor. In fact, it is more correctrectus, pelvic floor say it is a complex consisting, on each side, of three musclesThe first is the muscle puborectalwhose function is to bend the anal canal forward; some of its very important fibres, called prerectal fibresThey form a kind of sling that flanks the urethra in men and the urethra and vagina in women: these fibres are of fundamental importance in preserving urinary continence, especially under stress. The second pelvic floor muscle is the pubococcygeuswhich, arising from the pubis, runs alongside the puborectalis muscle and inserts posteriorly on the coccyx and ano-coccygeal ligament. The third muscle, which is thinner, is theiliococcygeuswhich arises from the ileum (one of the bones that make up the pelvis), runs alongside the pubococcygeus muscle and inserts on the coccyx and anococcygeal ligament. Of the three muscles, the iliococcygeus is the true 'elevator' of the anus: by contracting it raises the pelvic floor and the anal canal.
The coccygeal muscle is the smallest and most posterior muscle of the pelvic floor, being located behind the elevator of the anus.

Although we have 'anatomised' the pelvic floor, describing it muscle by muscle, in reality it is rather to be considered as a single functional musculoskeletal unit composed of muscles and ligaments. The first thing to be said about its function concerns the role of familiarity in the development of pelvic floor insufficiency: that is, to put it simply, women with a mother who suffered from pelvic organ prolapse have a statistically higher probability of developing it themselves. Why? There are many factors identified in the literatureand one of these is an error in the synthesis of collagen type IIIexactly as in diastasis of the rectus. And here we might begin to identify a first element of relationship, at the molecular level, between urinary incontinence and rectus diastasis. But let us move on.

Urinary incontinence and rectus diastasis: what we know

The role of the pelvic floor is to maintaining urinary and faecal continence e support the abdominal organswhich, due to gravity, tend to prolapse. Therefore, the pelvic floor muscles must react quickly to any change in intra-abdominal pressure (which tends both to push down the organs and to 'squeeze' both the bladder and the bowel, favouring the elimination of urine and faeces), indeed: they must be able to react first that intra-abdominal pressure varies. In fact, the pelvic floor muscles constitute a fundamental anti-gravity muscle unit of the organismTheir continuous activity in this regard has been well demonstrated for some time. It is well known, regarding the relationship between abdominal muscle contraction and pelvic floor muscles, how the contraction of the latter causes a contraction of the oblique muscles (especially the internal oblique) and the transverse muscle of the abdomen; and, in a completely specular manner, that a contraction of the abdominal muscles themselves causes a contraction of the pelvic floor.

Hence the pradigma that the pelvic floor muscles form part of the muscular system that controls trunk stabilityIt is known that alterations in other muscles of this system (such as, for example, the muscles of the abdominal wall) can affect the tone of the pelvic floor muscles: a reduction in the latter, for example, is found in women with chronic low back painas a consequence of the reduced activity of the transverse muscle of the abdomen in these patients. H. M. Bush et al. at the conclusion of their detailed study on the relationship between chronic low back pain and urinary incontinence, they write that "...there is a significant association between chronic low back pain and stress urinary incontinence. It is reasonable to conclude that it is important that all muscles of the trunk, including the pelvic floor muscles, act in a co-ordinated manner both to ensure posture control and to prevent the occurrence of low back pain and stress urinary incontinence".. To further confirm this Sapsford et 2001, showed that a weakness of the abdominal wall muscles, the cause of that 'bulging' abdominal (i.e., of that swelling of the abdomen) - which is also always observed in patients with diastasis of the rectus - causes a reduction in the activity of the pelvic floor muscles and the appearance of pelvic floor dysfunction, which can give rise to urinary (and, less frequently, also faecal) incontinence. These authors conclude that abdominal muscle exercise helps to cure these conditions. In fact, a reduction in the tone of the muscles of the abdominal wall, and in particular of the transverse muscle of the abdomen, is almost always reflected in a reduction in the tone of the pelvic floor muscles, with the appearance of vaginal heaviness and urinary urgency and incontinence. Always Sapsford and Coll, in 2012They observed how the contraction of the muscles of the abdominal wall (particularly the deeper muscles, the external oblique and the transverse) is associated with an increase in urethral pressure, contributing to the mechanism of urinary continence.

Summing up, what can we say at this point about the relationship between urinary incontinence and rectus diastasis? As is well known, with the mechanisms we have already highlighted in a previous articlein patients with diastasis of the rectus the tone of the muscles of the anterolateral wall of the abdomen, and in particular the oblique and transverse muscles, is significantly reduced. A few lines ago we wrote that abdominal muscle exercise can be helpful in regaining lost tone, but we were referring to healthy patients, without evidence of diastasis: it is the common experience of many 'diastasised' patients that with common abdominal muscle exercises rectus diastasis, and its symptoms, worsen - and thus, in a sort of vicious circle, also worsens the tone of the abdominal muscles. The only type of physical activity that can help to partially recover abdominal muscle tone is hypopressive gymnasticsHowever, this recovery is partial if the diastasis is not surgically repaired.

This explains, in conclusion, the relationship between urinary incontinence and rectus diastasis: from urinary incontinence, diastasis of the rectus, pelvic floor, pelvic floor, hypopressive gymnasticssince the muscles of the abdomen and pelvic floor constitute a functional unit which controls the posture, the breathing and the mechanisms of urination and defecation, the loss of tone and control of the abdominal wall muscles, and in particular the external oblique and transverse, due to diastasis causes a reduction in the tone of the pelvic floor muscles: this results in a reduction of urethral pressurewith a feeling of urinary urgency and appearance of stress urinary incontinence. This is why urinary incontinence is so common in patients with diastasis of the rectus, and why the diastasis repaircombined with hypopressive gymnastics as both pre- and post-operative physiotherapy, is an integral part of the treatment of urinary incontinence in such patients.

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