Pressure Management: From Heaviness to Hemorrhoids
Intra-abdominal pressure (IAP) management is a critical part of healthy bowel and bladder function and safe exercise across the lifespan. Intra-abdominal refers to the space between our diaphragm at the top and our pelvic floor at the bottom. This becomes even more essential to consider during pregnancy and postpartum when our system is vulnerable, and our ability to manage pressure effectively can be compromised. Some things that impact our ability to manage pressure well include lengthening of the pelvic floor and core muscles, Diastasis Rectus Abdominus (DrA), ligamentous laxity, hormones, and pain.
As our tissues lengthen during pregnancy, they become less responsive to pressure changes. The best example of this is the onset of Stress Urinary Incontinence (SUI); the term used to describe leaking urine with a cough, sneeze, laugh, jump, or even just being surprised. Each of these is an example of an increase in IAP. In a healthy well-coordinated system, an increased IAP should lead to a quick contraction of the pelvic floor muscles, closing off the sphincters and preventing leakage. When our pelvic floor muscles are lengthened, the muscle fibers can’t communicate as readily, and leakage can occur.
DrA is a natural phenomenon wherein the Rectus Abdominus heads, or two sides of the 6-pack muscles, stretch away from each other at the Linea Alba, a connective sheath running vertically along the midline of the belly. Though this is a natural part of pregnancy, it essentially creates a “crack” in the pressure management system. The Linea Alba is also where load is transferred across the abdomen, creating stability. When this separation occurs beyond its natural state, the abdominal wall is not as reactive as it was prior to pregnancy, so we lose some stability. Additionally, we need to direct pressure down in order evacuate our bowel and bladder. If there is a crack in the system, some of that directed pressure will escape, leading to less effective voiding. This can lead to straining to void, constipation, bowel or bladder retention, or worsening of hemorrhoids (another common sequelae of pregnancy) or even pelvic organ prolapse (POP).
This brings me to constipation. Though Progesterone peaks in third trimester, its presence from the onset of pregnancy contributes to slowed motility (the movement of waste through our colon). This is to ensure maximum nutrient exchange and uptake from our food; however, it also contributes to constipation. This means that now we must create excessive pressure to overcome the resistance to a bowel movement, and you can imagine that sitting on the toilet from prolonged periods, breath holding, and excessive straining, can again, contribute to all the afore mentioned risks of excess straining.
Ligamentous laxity that occurs during pregnancy, due to the presence of hormone Relaxin also plays a role in pressure management. This impacts our ability to transfer load efficiently across our joints. Consider how difficult it becomes to sit straight up in bed, stand up from a chair, let alone get off the floor. This is due to a combination of added weight, altered weight distribution, and loose joints! When we anticipate the challenge or pain associated with those transfers, our instinct is to hold our breath. But breath holding increases IAP, and makes everything we’ve already mentioned (DrA, SUI, POP, hemorrhoids – WORSE! AH!)
SO….WHAT CAN YOU DO ABOUT IT???
Here are some simple solutions that can make a WORLD of difference in how you manage pressure well throughout pregnancy. I know it’s an uphill battle, but just like in my previous post, a little mindfulness goes a long way.
1: EXHALE TO EXERT
Breath holding is the worst enemy of a happy pressure system. Breath holding with exertion, again, can contribute to urinary leakage, POP, overpressure on the rectum and sphincters contributing to hemorrhoids, and even make DrA wider. Simply breathing out during the hardest part of any movement (picking up a kid, a car seat, or a bag of groceries) relieves pressure somewhere safe and healthy, so that pressure doesn’t wreak havoc on our pelvic floor, low back, or core.
2: CONSTIPATION MANAGEMENT
If you don’t already look at your poop, you should start. Take a look at the Bristol Stool Chart. In a perfect world, we are always striving for our poops to be around a 4. They should be well formed and slide right out without too much effort or strain. Diet, medication, hydration, hormones, and well, life, can shift our optimal bowel routine. Bringing that back into balance in a huge factor in good pressure management. Here are some tips.
Drink plenty of water! A good goal is half your body weight in ounces. So, for 140lb person, about 70oz/day. I always suggest that is for a sedentary person at sea level, so if you are active or live at altitude, increase that as needed! Try to make that clean water without any artificial sweeteners or natural flavors.
Eat all the fiber. I love this high fiber foods list from the Mayo Clinic. Check in and see if you are meeting the recommended daily minimum and increase your daily intake beyond that in the presence of constipation.
Adding a magnesium supplement can also improve motility. I am a big fan of Calm. You can add this to water before bed and it should promote a morning bowel movement.
Colon massage is another great way to help your bowels along. I love the I L U technique.
Get a Squatty Potty. Even without one, propping feet on a stack of books, a garbage can, or a training potty works great! Just ensure that the knees are above the level of the hips to open “anorectal flexure” or put simply, make sure you’ve got a straight shot!
Avoid breath holding with strain. I recommend a breath called “releasing breath” which is the opposite of the “supportive breath or piston breath” I’ve mentioned in previous posts. This breath should be used to have a bowel movement. Instructions: place your hands on your belly. Inhale make the belly big; exhale press out into your hands and make the belly even bigger. This ensures that the pressure being directed down comes from the deep abdominal muscles, but the pelvic floor stays relaxed during strain. When we hold our breath to strain, or “valsalva” the pelvic floor muscles contract!
Exercise!!! Stay active and this will help your metabolism and motility.
Finally, if all else fails, it is ok to take a medication like Miralax or Colace short term. The risk of a worsening hemorrhoid, prolapse, DrA, etc. isn’t worth avoiding meds. Get your bowels moving so that pressure is well managed, and these things don’t have to worsen, or happen at all!
3: HEAVINESS OR PROLAPSE MANAGEMENT
Start with everything listed above. Additionally, spend time in the evening offloading the pelvic floor by raising it passively above the level of the heart. Examples of this include a forward fold, puppy pose or child’s pose, supported bridge, supported legs up the wall, happy baby, or bound angle.
Check out @yourhearthhealing for video demos! Hearth Healing IG