What Exactly is Pelvic Physical Therapy?

I think it’s probably best to start with “what the heck is the pelvic floor?” Just like the rotator cuff, the pelvic floor is a group of muscles that work together for a common purpose. The pelvic floor spans the bottoms of the pelvis from the pubic bone to the tail bone like a hammock. There are three layers to the pelvic floor. The first and second layer (most superficial layers) contain the sphincter muscles that are responsible for urinary and bowel continence. The third (most deep) layer acts as support for the pelvic organs. As a whole, the pelvic floor works in conjunction with the diaphragm and abdominal muscles to stabilize the trunk. Sounds like a pretty important part of the body right? It is!

So what does pelvic floor dysfunction look like? Some people might not know they have pelvic floor dysfunction while others may have symptoms coming directly from their pelvic floor making it more obvious. Dysfunction of the pelvic floor can cause or contribute to low back pain, hip pain and sacroiliac pain. Symptoms related directly to the pelvic floor can include vulvar, testicular or scrotal pain; tailbone, pubic bone or sacroiliac pain; pain generated by scar tissue related to episiotomies, tearing during vaginal birth, cesarian surgery, or any other surgery involving sex organs; prolapse or the feeling of vaginal heaviness; urinary leakage or retention, pain with urination, excessive urination frequency or urge; fecal incontinence, pain with bowel movements, inability to hold farts in or hemorrhoids; pain with penetration, inability to orgasm and erectile dysfunction. What a long list! And I’m sure I have missed a few.

Some common diagnoses treated by pelvic physical therapists are: abdominal pain, anal spasm, bladder pain, coccygodynia, constipation, cystocele, diarrhea, diastasis recti, dysmenorrhea, dyspareunia, enterocele, fecal incontinence, fecal urgency, feeling of incomplete defecation or urination, flatulence, frequency of micturition (urination), hesitancy of micturition, interstitial cystitis, irritable bowel syndrome, low back pain, mixed incontinence (urge and stress), nocturia, nocturnal enuresis, overactive bladder, overflow incontinence, pain in hip, pelvic and perineal pain, poor/weak stream, piriformis syndrome, post-void dribbling, prostatitis, prostatodynia, pudendal neuralgia, radiculopathy, rectocele, sacrococcygeal disorders, sacroiliac disorders, scar conditions and fibrosis of skin, sciatica, splitting of stream, straining to void, stress fracture of pelvis, stress incontinence, symphysis pubis dysfunction, urethritis, urethrocele, urge incontinence, uterovaginal prolapse, vaginismus, vulvar vestibulitis, and vulvodynia.

Many people will look at this list and ask, can these issues really be fixed? Or worst, most people won’t feel comfortable asking. The answer is ABSOLUTELY YES! For most of these symptoms and diagnoses, the first step is seeing a pelvic physical therapist to see what conservative treatment can do to help improve your pain and/or function. Just like any other muscle in the body, the pelvic floor can be strengthened and stretched which can dramatically improve the quality of life of an individual with pelvic floor dysfunction. For some of these diagnoses it will be important to have a health care team to fully treat the problem. This might include an OBGYN, urologist, gastroenterologist, acupuncturist, psychologist, and/or general medicine doctor to ensure the dysfunction is treated from a lifestyle, anatomical, physiological and psychological perspective. No matter what the game changing intervention might end up being, its important to know there is something you can do about it!

Still weary? I understand that for most, talking about poop, pee and sex is awkward and uncomfortable but for a pelvic physical therapist, its like talking about the weather or what’s for dinner. Afraid of farting during your evaluation? It’s totally normal to feel that way but it’s also just as normal to fart a little. I’m serious! I recognize coming to pelvic physical therapy is inherently intimidating for many so to help ease any hesitations, here is what to expect at your first appointment: it starts with lots of talking and yes, clothes are still on at this point. In fact, clothes never need to come off if you don’t feel comfortable with it! There are plenty of external techniques to both diagnose and treat effectively. Discussion includes past medical history, current complaints and your individual goals. Then we move on to testing through functional movements, joint range of motion and muscle strength assessments. Since the pelvic floor is very connected to the low back, hip and sacroiliac joint, I start with an orthopedic screen of each of these first. I also look at management of pressure through breath and activation of the “core” because the pelvic floor is integrated with the diaphragm and abdominal muscles. If you feel comfortable, the internal evaluation of the pelvic floor is next. For this, you undress from the waist down but will have a sheet draped over you. I describe exactly what I am going to do before doing it and at any point, you can say “I’m done with this” or say “no thanks” to any of the techniques described. Internal assessment is best for measuring the strength of the pelvic floor, giving cues to increase coordination of the pelvic floor, assessing position of the coccyx, releasing trigger points within muscles of the pelvic floor and mobilizing scar tissue. But as I said before, external techniques are always an option if you just don’t want the internal stuff. As with every physical therapy evaluation, a musculoskeletal diagnosis is given, a plan of care is discussed and you will be given a home exercise program to get started on reaching your goals. At the end of your visit, I’m sure you will feel silly for being so nervous about going to one! It’s 100% worth your time, energy and a brief moment of feeling uncomfortable to improve your quality of life.

Q&A

  • I don’t live in Santa Cruz, how can I find a pelvic physical therapist in my area?
  • Do I need a referral from my doctor to see a pelvic physical therapist?
    • No. By law, a physical therapist is able to see you without a referral for 12 visits or 45 days. However, some insurances require a referral for coverage so if you are hoping to use your insurance, ask them first.
  • Do you treat men?
    • I do not treat men at this point but I do know people that do. Contact me for their information.
  • Do you treat transgender individuals?
    • I do but at this point, I do not have much experience in this area. I like to consult over the phone first in order to know whether it is a complaint/dysfunction/post-op that I am familiar with or whether I need to refer out.
  • I’m pregnant, can I come to pelvic physical therapy?
    • HECK YES! In fact, I encourage it! Even if you aren’t having any symptoms, there is a ton to do and talk about to prevent them. If you are already having pain or dysfunction, internal pelvic physical therapy isn’t indicated but external assessment and treatment are extremely effective.
  • How soon after delivery can an internal evaluation be performed?
    • There are a few exceptions but typically, 6 weeks.
  • Can I bring my baby to my appointment?
    • Definitely! I am used to the juggle of treating mama and keeping baby happy πŸ™‚
  • Can I get an internal pelvic evaluation or treatment when I am on my period?
    • Yes. It doesn’t effect my ability to either assess or treat.
  • When is an anal internal assessment indicated?
    • Never? Always? Whenever you want or don’t want? I only suggest internal anal when symptoms are specific to bowel/gas incontinence or pain because I know its not a hole a lot of people want a finger to go up. BUTT (haha) valuable information can come from an anal assessment no matter what the symptoms. On the flip side, its never 100% mandatory either.
  • If I have hemorrhoids, can an internal assessment be performed?
    • It depends. If the hemorrhoids are actively bleeding and/or painful, no. But if there are generally healing and not easily aggravated, yes.
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