How should I manage a patient with rectus diastasis who has recurrent abdominal swelling and cramp-like pain?

Management of Rectus Diastasis with Recurrent Swelling and Abdominal Cramps

Start with a structured 6-month physiotherapy program focused on abdominal core strengthening before considering any surgical intervention, as this is the first-line treatment for symptomatic rectus diastasis. 1

Initial Assessment and Diagnostic Confirmation

• Measure the diastasis width using a caliper or ruler during clinical examination to establish baseline severity 1
• Obtain diagnostic imaging (ultrasound or CT) to exclude concurrent umbilical or epigastric hernia that could be causing the swelling and cramping symptoms, as these conditions frequently coexist and require different management 1
• Rule out other causes of abdominal pain and distension including small intestinal bacterial overgrowth (SIBO), which can present with similar symptoms of bloating and cramping 2

The swelling and cramps may not be directly from the diastasis itself but from associated conditions. The correlation between anatomical abnormalities and symptoms is often weak, as functional disorders may underlie the presentation 3.

Conservative Management (First-Line Treatment)

Physiotherapy must be attempted for at least 6 months with a standardized abdominal core training program before surgery is considered 1. This approach is critical because:

• Exercise during the antenatal and postnatal periods can reduce diastasis width and prevent worsening 4
• Patients should avoid traditional abdominal curls and crunches, as these may worsen the separation 5
• Continue aerobic exercise such as walking, which is associated with decreased odds of developing or worsening diastasis 5
• Approximately 25% of patients will benefit from conservative therapies alone 3

For the cramping and swelling specifically:

• Address dietary fiber intake (both too little and too much can cause symptoms) and consider testing for SIBO if "wet wind" or excessive gas is present 2
• Consider antispasmodic medications for cramping pain 2
• Low-dose tricyclic antidepressants may help with chronic abdominal pain if it persists despite other measures 2

Surgical Criteria and Timing

Surgery should only be considered if ALL of the following criteria are met 1:

1. The diastasis width is at least 5 cm at its largest point (smaller diastasis may be considered only with pronounced bulging or concomitant ventral hernia) 1
2. Functional impairment persists after completing a standardized 6-month physiotherapy program 1
3. At least 2 years have elapsed since last childbirth and no future pregnancy is planned 1
4. Conservative management has failed to adequately control symptoms 3

Surgical Approach Selection

Plication of the linea alba is the first-choice surgical technique, as it has demonstrated high success rates with low recurrence and complication rates 1, 6. The approach can be:

• Open repair (most commonly via low abdominoplasty) with single or double-layer plication using permanent sutures 6
• Laparoscopic repair which shows comparable outcomes to open surgery with potentially faster recovery 7, 6

Both approaches have demonstrated:

• Low recurrence rates (generally <5-8%) 6
• Improvement in associated symptoms including low back pain, urinary incontinence, and quality of life 7
• Minor complications when they do occur 7

Important Pitfalls to Avoid

• Do not proceed to surgery without adequate conservative management trial - surgery is necessary in less than 5% of patients with abdominal wall disorders 3
• Do not assume the diastasis is causing all symptoms - investigate for concurrent hernias, SIBO, constipation, or other functional bowel disorders that may be the primary pain generators 2, 1
• Do not operate if future pregnancy is planned as this will likely result in recurrence 1
• Recognize that symptom improvement may not correlate with anatomical correction - counsel patients that surgery may not resolve all their complaints even if the diastasis is successfully repaired 3

Monitoring and Follow-up

• Reassess symptoms after 3 months of physiotherapy to determine if progress is being made 1
• If cramping and swelling worsen or new symptoms develop (fever, severe pain, vomiting), obtain urgent imaging to exclude bowel obstruction or other acute pathology 2
• Consider referral to gastroenterology if abdominal symptoms persist despite diastasis repair, as underlying visceral hypersensitivity or functional bowel disorders may require neuromodulators or brain-gut behavioral therapies 2