Perioperative Physiotherapy (PT) Management Following Gynaecological Surgeries

1. PRE-OPERATIVE PHYSIOTHERAPY (Prehabilitation)

Goals

• Optimise cardiorespiratory fitness before surgery
• Educate patient on post-operative exercises and precautions
• Establish baseline pelvic floor muscle (PFM) function
• Reduce anxiety, improve patient compliance

Key Interventions

Evidence note: Prehabilitation including PFMT before pelvic surgery is associated with better post-operative continence outcomes and faster recovery (Pauls et al., Female Pelvic Med Reconstr Surg, 2014, p. 334).

2. IMMEDIATE POST-OPERATIVE PHYSIOTHERAPY (Day 0–3)

Goals

• Prevent pulmonary complications
• Prevent DVT/VTE
• Restore circulation and early mobility
• Manage pain

Interventions

A. Respiratory Physiotherapy

• Breathing exercises: deep diaphragmatic breathing every 1–2 hours; 5–10 repetitions
• Incentive spirometry: reduces atelectasis after abdominal/pelvic surgery
• Assisted coughing: supported wound (pillow/hands over incision) to clear secretions without disrupting sutures
• Positioning: semi-recumbent (30–45°) to optimise lung expansion; regular position changes

B. Circulatory / DVT Prevention

• Ankle pumps: dorsiflexion/plantarflexion repeatedly from day 0 (every 1–2 hours)
• Leg circles and quadriceps sets in bed
• Early ambulation: typically within 6–24 hours post-op (Enhanced Recovery After Surgery — ERAS protocol)
• Compression stockings and pneumatic compression devices (in conjunction with pharmacological prophylaxis)

C. Early Mobilisation (ERAS)

• Sit out of bed on day 0–1 (laparoscopic) or day 1–2 (open/radical)
• Short-distance supervised walking progressing daily
• Reduces post-operative ileus, hospital stay, and risk of complications

D. Pain Management (in conjunction with medical team)

• TENS (transcutaneous electrical nerve stimulation) for incisional pain
• Positioning and support with pillows
• Education on analgesia timing before physiotherapy sessions

3. EARLY REHABILITATION PHASE (Days 3–6 / Inpatient to Discharge)

Goals

• Restore functional independence
• Introduce pelvic floor re-education
• Bowel and bladder retraining

Interventions

4. OUTPATIENT / HOME REHABILITATION (Weeks 2–12)

Phase-wise Progression

Phase 1 (Weeks 2–4): Tissue Healing & Awareness

• Pelvic floor muscle exercises (Kegel exercises): 3 sets × 10 contractions, hold 3–5 seconds, progress to 10 seconds
• Avoid high-impact activity (running, jumping)
• Walking programme — graded increase
• Core re-education: TrA, multifidus activation
• Bowel retraining: dietary advice, avoid straining, positioning (feet elevated, lean forward)
• Bladder training if urgency/frequency present — timed voiding, urge suppression techniques

Phase 2 (Weeks 4–8): Strengthening & Function

• Progress PFMT: longer holds (10 s), faster contractions, functional contractions
• Core strengthening: Pilates-based exercises, bridging, clam shells
• Light resistance training (lower extremity, upper body)
• Hydrotherapy if available
• Scar massage: circular and cross-fibre massage once wound fully healed
• Return to driving (typically 4–6 weeks, varies by surgery and country)

Phase 3 (Weeks 8–12+): Return to Full Activity

• High-load pelvic floor work: impact loading, functional tasks
• Graded return to sport and higher-impact activity
• Sexual rehabilitation counselling if dyspareunia present
• Return to work planning (varies: 2 weeks for laparoscopic to 6–8 weeks for open radical surgery)

5. CONDITION-SPECIFIC PHYSIOTHERAPY CONSIDERATIONS

A. Hysterectomy (Abdominal / Laparoscopic / Vaginal)

• Post-hysterectomy vault prolapse risk: PFMT reduces risk; avoid heavy lifting for 3 months
• Bladder dysfunction: common post-hysterectomy; bladder retraining, PFMT, urge suppression strategies

B. Pelvic Organ Prolapse (POP) Repair

• PFMT pre- and post-surgery critical; however, the OPTIMAL RCT (Barber et al., JAMA, 2014, p. 1023) found perioperative behavioural therapy + PFMT did not significantly improve quality of life vs surgery alone in apical vaginal prolapse — though PFMT remains standard of care for prevention of recurrence
• Post-repair: strict pelvic floor loading precautions for 6–12 weeks
• Avoid straining, constipation, heavy lifting, high-impact exercise for minimum 3 months
• Pessary use as alternative or adjunct to surgery may be included in PT advice

C. Anti-Incontinence Procedures (TVT / TOT / Colposuspension)

• Bladder retraining is central — structured voiding diary, timed voiding, urge suppression
• PFMT to maximise continence mechanism support
• Avoid straining or valsalva for 6 weeks
• Monitor for voiding dysfunction post-procedure; pelvic floor down-training if over-activity present

D. Gynaecological Oncology (Radical Hysterectomy, Debulking)

• Lymphoedema management: lymphatic drainage massage, compression garments, skin care if inguinal/pelvic lymph node dissection performed
• Neuropathic bladder: catheter weaning programme, bladder retraining
• Post-radiation effects: pelvic floor tissue fibrosis, vaginal stenosis — dilator therapy, scar tissue mobilisation, PFMT
• Fatigue management: graded aerobic exercise, pacing strategies (evidence supports exercise in cancer survivors)
• Psychological support: body image, psychosexual rehabilitation — PT works within multidisciplinary team

E. Laparoscopic Surgery (General)

• Shoulder-tip pain (referred from diaphragmatic irritation by CO₂): positioning — sit upright, walk early, heat therapy
• Trocar site pain: TENS, positioning
• Faster return to activity vs open surgery

6. PELVIC FLOOR MUSCLE TRAINING (PFMT) — Core of Gynaecological Rehab

Assessment

• Internal vaginal examination (by trained pelvic floor physiotherapist)
• Modified Oxford Scale (0–5) for PFM strength
• Real-time ultrasound for biofeedback (abdominal and transperineal)
• Manometry / perineometry

Standard PFMT Protocol

Functional Integration

• Contracting before cough, sneeze, lift ("the knack")
• Lifting technique (exhale with lift, avoid Valsalva)
• Bowel positioning: feet on footstool, forward lean, avoid straining

7. ENHANCED RECOVERY AFTER SURGERY (ERAS) — PT Role

1. Pre-op: prehabilitation, patient education
2. Day of surgery: early mobilisation 4–6 hours post-op
3. Day 1–2: supervised walking, breathing exercises, independence in self-care
4. Discharge planning: home exercise programme, outpatient PT referral

8. COMPLICATIONS PT AIMS TO PREVENT / MANAGE

9. DISCHARGE CRITERIA AND RETURN-TO-ACTIVITY MILESTONES

10. MULTIDISCIPLINARY TEAM INTEGRATION

• Gynaecologist / Surgeon — wound/healing precautions, activity restrictions
• Urogynecologist — bladder/bowel dysfunction co-management
• Continence nurse — catheter management, bladder diaries
• Oncology team — lymphoedema, fatigue, radiation effects
• Psychologist / psychosexual therapist — body image, sexual rehabilitation
• Dietitian — nutritional optimisation for healing and bowel health
• Occupational therapist — ADL adaptations

Summary of Evidence