Scar tissue is an area of fibrous tissue that replaces normal skin after a surgery, injury, or pressure. This fibrous tissue is a result of our body's own mechanism for healing. There are generally three stages to scar formation:

Inflammatory phase: Our bodies produce increased blood flow in order to remove dead tissue to promote healing and reduce likelihood of infection.

Proliferation phase: New collagen and other substances are brought in to rebuild the site of injury and inflammation. Collagen lays down in an unorganized pattern, often leaving behind a bulky, fragile, and easily disrupted scar during this stage.

Remodeling phase: In order to strengthen the fragile scar, collagen is laid down in a more parallel orientation, which helps increase the strength of the scar. To promote this parallel orientation, the scar has to be stressed with proper loads, which may include massage, gentle strengthening, and stretching dictated by your Physical Therapist.

Scar tissue can lead to pain, decreased flexibility, and decreased joint motion. In the event of abdominal surgery, it can even cause adhesions between organs that can cause abdominal discomfort and digestive issues.

The good news is that physical therapy can help! Performing scar tissue mobilization can reduce tissue sensitivity, improve joint and muscle function, as well as digestion. Scar tissue mobilization helps muscles, skin, and organs to move freely and optimize their intended function. Your physical therapist can created a skilled program of strengthening, stretching, and scar tissue massage to reduce excessive fibrotic adhesions from impairing motion.

Here are some amazing tools that physical therapists at CTS can use to increase scar mobility:

The Edge Mobility Tool!

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The Moji tool!

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The Graston Technique tools!

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Cupping! 

Anna Ellenberger, DPT, MTC

For definitions of terms found in this article, see the end of the post.

Pelvic physical therapists specialize in treating bowel, bladder and sexual dysfunction. Conditions which are commonly treated include urinary incontinence, constipation, and pelvic pain. Pelvic pain may involve difficulties with rest positions, physical performance, and sexual function. Pelvic floor dysfunction is far more common and undertreated than many people realize. The transgender (trans) community is especially underserved in this area.

Pelvic floor physical therapy is necessary for trans people for three main reasons: bladder dysfunction due to limited access to restrooms, and chest and back pain related to binding and top surgery and post-operative care of the genital region. The following information will first provide relevant research in italics followed by clinical implications of the need for pelvic floor physical therapy with helpful additional information for healthcare providers when working with this population.

Compared to cisgender counterparts, transgender individuals had decreased likelihood of (Meyer, 2014):

Trans people as a whole are less likely to seek out healthcare professionals and when they do their experiences are negative, thus propagating the cycle of decreased healthcare involvement. It is essential that when treating this population, correct pronouns as well as correct terms for the patient's anatomy be used at all times, which simply involves asking the patient first and foremost their preferred name and pronouns, and if clinically indicated asking what terms they use to describe their anatomy.

The transgender population frequently experiences difficulty finding and using public restrooms (The 2015 U.S. Transgender Survey)

• 59% of transgender and gender non-conforming individuals have avoided using the bathroom in a situation where there is not a safe restroom available.


• 32% limited their liquid intake to avoid using the restroom.


• 8% reported urinary tract infections and other kidney issues due to avoiding restrooms.

We commonly see restricted or limited public restroom use in this population due to lack of a safe environment. Avoiding restrooms can lead to over-holding in the muscles of your pelvic floor which can lead to constipation, urinary incontinence and pain with sexual activity. Techniques such as diaphragmatic breathing, gentle stretching and utilizing biofeedback or real time ultrasound can be used to improve the coordination of pelvic floor muscles and restore optimal pelvic floor muscle function.

According to the National LGBT Health Education Center (2017):

• 48% of transgender women have had gender affirming surgery (breast augmentation and/or vaginoplasty)


• 41% of transgender men have had gender affirming surgery (bilateral mastectomy/top surgery, phalloplasty or hysterectomy)

Genital gender affirming surgery commonly results in pelvic floor dysfunction post-operatively (Kuhn, 2011):

• 47% reported voiding difficulties
   
• 24.6% had urinary urgency


• 23% had stress urinary incontinence


• 17% had urge incontinence

We see here that a high amount of the trans population undergoes major surgery involving the chest and/or genital region. While orthopedic physical therapy is helpful for treating back pain, pelvic physical therapy is beneficial post gender affirming surgery to avoid pelvic floor dysfunction post-operatively. Pelvic physical therapy can help decrease pain and voiding difficulties post gender affirming surgery by teaching patients relaxation and visualization, working on soft tissue massage to decrease adhesions and scar tissue and manage edema. Working with a pelvic floor physical therapist can help clients improve the strength and coordination of pelvic floor muscles for normal bowel and bladder function, pain-free sexual activity and easier dilation.

Definitions

• Transgender/trans: An umbrella term for people whose gender identity differs from the sex they were assigned at birth, and for those whose gender expression differs from what is socially or culturally expected of them. The term is not indicative of sexual orientation, hormonal makeup, physical anatomy or how one is perceived in daily life.
• Cisgender: A person whose gender identity matches the gender they were assigned at birth, i.e. not transgender.
• Gender Affirming Surgery: Any surgery performed on a transgender patient in order to more closely align their body to their mind. Surgeries for trans men include top surgery (bilateral incision or keyhole incision) metoidioplasty and phalloplasty, while surgeries for trans women include breast augmentation and vaginoplasty
• Binding: Compressing breast tissue to make the appearance of a flat chest, seen in trans men

References

1. R McDaniel, U Ossai. "Sexuality, Race And Transgender Health: Sexuality In Marginalized Populations". 2017. Presentation.
2. Meyer IH et al. Demographic characteristics and health status of transgender adults in select US regions: Behavioral risk factor surveillance system, 2014. 2017. Am J Pub HealthHerman JL.
3. Gendered restrooms and minority stress: The public regulation of gender and its impact on transgender people's lives. Journal of Public Management & Social Policy. 2013;19(1):65-80.
4. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. 2016.)
5. National LGBT Health Education Center. Improving Healthcare for Transgender People: Surgical Gender Affirmation. The Fenway Institute. http://www.lgbthealtheducation.org website. May 3, 2015. Accessed April 10, 2017.
6. Kuhn A, Santi A, Birkhäuser M. Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals. Fertil Steril. 2011;95(7):2379-82.

Rose Schlaff, PT, DPT