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When Scars Become More of an Issue than Just Appearance

July 22, 2016

Scars and scar tissue are an inevitable bi-product of the healing process.  Without scar tissue, we would all die from infection with gaping open wounds.  While some scars can evoke a sense of pride and storytelling for some people, other types of scars can provoke bad memories, or even embarrassment for others.  Unwanted, scar lines can cause vanity issues but those who suffer from pain or sensitivity with thicker, reddened scars or pain from tissue under or deep to the scar, becomes more the search of how to rid yourself of the pain.  Usually visits to the doctor for painful scars will evoke the comment “everything seems to be healing well” which, in essence, they are, but sometimes too well.  Extensive abdominal surgeries, laparoscopic scars and even childbirth tissue trauma can be life events that can cause a variety of scars and compounding muscle weakness.   Scars themselves can be made through muscles, entrap small superficial nerves, become too thick by excessive lying down of cells that can cause pain.  Cesarean section scars that cut into abdominal tissue can create a host of unwanted symptoms such as abdominal sensitivity, bladder urgency and /or frequency, and even pubic bone pain or labial pain.  Perineal scars secondary to episiotomies or spontaneous vaginal tearing during the birthing process can form excessive amounts of scar tissue that cause sitting pain and inability to wear tight underwear or pants and can even create sexual dysfunction.  The postpartum period is supposed to be one of excitement and happiness over new beginnings, not the new distress or pain from cesarean and episiotomy scars.   

 

To understand how scars can cause pain and dysfunction, it is important to understand the physiologic process of how scars form. Your skin and fascia contain an important element called collagen that is laid down in an organized fashion much like a tic-tac-toe board. Normal fascia moves freely without many restrictions to allow our body to function pain free with optimal mobility. After a cut to your leg or arm, your body lays down granulation tissue made up of collagen in order to close the wound. However, our bodies are not always efficient at laying down this new collagen in an organized fashion. During what is called the “proliferation phase” of healing, the body will begin to lay down collagen in a haphazard form. Post the proliferation phase, the body will then try and organize this new collagen to the best of its ability for up to two years known as the “maturation phase.” 

 

Performing scar massage can help encourage the body to lay down collagen in a more organized fashion and reduce restrictions from the haphazard pattern of collagen being laid down during the proliferation phase.  It can also promote better organization of collagen during the maturation phase. Scar tissue can have the tendency to adhere to surroundings, restricting normal mobility and contraction of muscles and fascia, disrupt organ function, and cause constriction around nerves leading to symptoms distal from the scar. For example, scar tissue associated with a Cesarean section scar, given its size and location, can cause dysfunction of the abdominal muscles leading to low back and pelvic pain, disruption of bladder expansion leading to urinary urgency, and neuropathy of pelvic nerves such as the obturator nerve leading to loss of adductor (inner thigh) muscle function. In fact, one study reported pelvic adhesions in more than 1/3 of a sample of 308 women with a history of Cesarean delivery that were associated with chronic pelvic pain. Perineal scaring post vaginal tearing during childbirth or a planned episiotomy can cause dyspareunia (painful intercourse), pelvic pain, pelvic floor muscle weakness, or future fecal and stress incontinence when severe tearing occurs that may include the anal sphincter. Women who have episiotomies and spontaneous lacerations at birth report decreased sexual satisfaction post-birth versus those with an intact perineum post-birth. Massage to the perineum has been reported to cause increased vasodilation and blood flow, improve tissue elasticity, and decrease pain. Digital perineal massage during pregnancy at about 35 weeks’ gestation to prepare for birth may also potentially decrease the need for an episiotomy. Troubling health issues arising from post-birth perineal trauma is more common than you may think. One of the most common referrals to a postpartum perineal clinic recently formed during the first four years in the USA was history of a third or fourth degree perineal laceration that lead to urinary incontinence and pain.    

 

Luckily, physical therapists can be trained in soft tissue techniques to help prevent problematic scar tissue from forming and teach you self-care tools to prevent your scars from becoming a problem down the road. This can be typically done after approval from your doctor and the initial healing of the scar has occurred that commonly takes 6-8 weeks. Physical therapists specially trained in pelvic floor rehab can also address perineal scars internally and externally and provide pelvic floor muscle interventions to prevent future urinary or fecal incontinence in the future. The team at New Dimensions Physical Therapy consists of physical therapist with advance training in biomechanics of the body, hands-on orthopedics assessment and treatment as well as pelvic floor rehab beyond their doctoral degrees to help you return to normal life with no complications post-surgical or post- partum. Our team will also provide you with a home program to help you manage your scar symptoms once physical therapy is completed. 

 

References: 

 

Silva PD, Suarez SA. A Case of Disabling Urinary Frequency and Pelvic Pain Due to Postoperative Uterine Adhesions. WMJ. 2016. Feb;115(1):43-45 

 

Moro F, Mavrelos D, Pateman K, et al. Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section. Ultrasound Obstet Gynecol. 2015. Feb; 45(2):223-8. 

 

Hong B, Ko Y, Kim H, et al. Intrapartum obturator neuropathy diagnosed after cesarean delivery. Arch Gynecol Obstet. 2010. 282:349-350. 

 

Karacam Z, Ekmen H, Caliser H. The use of perineal massage in the second stage of labor and followup of postpartum perineal outcomes. Heath Care for Women’s International. 2012. 33:697-718. 

 

Beckmann NM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database for Systematic Reviews. 2003. Issue 4. ART NO.:CD005123. 

 

Brincat C, Crosby E, McLeod A. Experiences during the first four years of a postpartum perineal clinic in the USA. Int J Gynaecol Obstet. 2015.128: 68-71. 

 

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