When to Treat Diastasis Recti in Postpartum Women
Physiotherapy is the first-line treatment for diastasis recti, and surgery should only be considered after a standardized 6-month abdominal core training program has failed in patients with functional impairment. 1
Initial Conservative Management
All postpartum women with diastasis recti should seek physiotherapy advice before resuming abdominal strengthening exercises. 2 The conservative approach should be attempted first, as it is effective for many patients and avoids surgical risks.
Exercise Guidelines
- Avoid abdominal strengthening exercises that worsen the condition, such as abdominal curls. 2
- Walking and appropriate aerobic exercise are beneficial and associated with decreased odds of developing diastasis recti. 2
- Exercise therapy focusing on recruiting the abdominal muscles has been shown to improve functional impairments. 3
Diagnostic Criteria for Treatment Consideration
Diastasis recti should be diagnosed at clinical examination using a caliper or ruler for measurement. 1 The diagnosis is established when the inter-rectus distance is >2 cm. 4
When to Consider Imaging
- Diagnostic imaging by ultrasound or other modality should be performed when concurrent umbilical or epigastric hernia or other causes of symptoms cannot be excluded. 1
- Computerized tomography can identify widening of the linea alba with abdominal hernia in severe cases. 5
Indications for Surgical Treatment
Surgery should be considered only when specific criteria are met. The largest width of the diastasis should be at least 5 cm before surgical treatment is considered. 1 However, surgery may be considered with smaller diastasis if there is pronounced abdominal bulging or concomitant ventral hernia. 1
Mandatory Prerequisites for Surgery
- At least 2 years should have elapsed since last childbirth and future pregnancy should not be planned. 1
- The patient must have functional impairment and have completed a standardized 6-month abdominal core training program without adequate improvement. 1
Urgent Surgical Indications
If severe diastasis recti remains in the postpartum period with abdominal hernia, it should be corrected to prevent concurrent complications including strangulation or incarceration. 5 Patients experiencing lower back pain, uro-gynecological symptoms, and discomfort at the level of the defect may warrant earlier surgical consideration. 4
Surgical Approach Selection
Plication of the linea alba is the first-line surgical technique. 1 Other available techniques include:
- Standard abdominoplasty with multiple wide longitudinal plications of the abdominal wall for severe cases with abdominal hernia. 5
- Minimally invasive laparoscopic repair combining Rives-Stoppa principles with plication of the posterior sheaths of the recti abdominis. 4
- Extensive plication of the anterior abdominal wall, sometimes with resorbable or nonresorbable mesh. 6
Patient Risk Stratification
Patients at high risk for diastasis recti include multiparous women, obese patients, and those with multiple previous operations. 6 These patients require closer monitoring and may benefit from earlier intervention with physiotherapy.
Common Pitfalls to Avoid
- Do not proceed to surgery without completing the mandatory 6-month physiotherapy program, as this is the evidence-based standard for determining surgical candidacy. 1
- Do not operate on patients planning future pregnancies, as this will likely result in recurrence. 1
- Do not delay surgical correction in severe cases with abdominal hernia showing signs of complications, as strangulation or incarceration can occur. 5
- The level of evidence varies across treatment recommendations, but the Swedish consensus guidelines provide the most structured approach to standardizing management. 1