Vanderbilt experts explain the pelvic floor physical therapy, how it can be beneficial and what to expect.
There has been a lot of discussion in the news about the purposes of pelvic floor physical therapy and the proper uses of it for a patient. Many patients are initially hesitant when the therapy is brought up as part of treatment plan. Vanderbilt gynecologic pelvic pain specialist, Lara Harvey, M.D., MPH, and board-certified specialist in women’s health physical therapy, Tiffany Priest, PT, DPT, WCS, explain why pelvic floor physical therapy is prescribed, what the benefits can be and what to expect from a session with a physical therapist.
What is chronic pelvic pain?
Chronic pelvic pain is defined by pain below the belly button that lasts for at least six months. Many conditions can cause chronic pelvic pain. Some conditions that cause pelvic pain in women are gynecologic, like endometriosis and fibroids. Other causes include irritable bowel syndrome, diverticulitis, painful bladder syndrome, chronic kidney stones or nerve injuries.
Chronic pain from any condition can be very debilitating. It usually takes time to improve. It is important to diagnose the initial cause of the pain as well as secondary problems to get the best results. Often, we have to address several problems including abnormally signaling nerves, chronic stress and pelvic floor myalgia that develop in a response to living with chronic pain.
What are the pelvic floor muscles?
The muscles that make up the pelvic floor are a sort of bowl that holds up the pelvic organs. A woman can feel some of these muscles if she squeezes as if trying to stop a stream of urine. We don’t often think about these muscles when going about our daily lives if they are functioning normally. However, it is very common for women with chronic pelvic pain or with an injury to these muscles to develop pain and tension called pelvic floor myalgia. This can range from mild to so severe it can be debilitating. This disorder can also make it painful and difficult to have sex.
How do you diagnose pelvic floor myalgia (pain)?
A gynecologist familiar with the disorder can diagnose it with a physical exam in the office. The exam consists of pressing on the various muscles through the vaginal wall to see if this triggers discomfort.
What is pelvic floor muscle therapy?
The best treatment for pelvic floor myalgia is pelvic floor physical therapy. Female therapists usually do this as some of the work is done vaginally. It can consist of a therapy called myofascial release, which aims to stretch and condition the abnormally contracted muscles. This is not the same as kegel exercises, which some women have heard about. In fact, in many cases of pelvic floor myalgia, kegel exercise can make the condition worse. There are other techniques available as well, and a trained pelvic floor therapist will tailor a program to a patient’s needs. Often, my patients haven’t heard of this kind of therapy, and it seems a little strange. However, I have had many patients return from pelvic floor therapy and tell me it has changed their lives. Typically it takes time to be effective and sometimes it can get a little worse before it gets better. You can image if you have a leg cramp, the first time you stretch it out can be a bit painful before it starts to really loosen up.
How can physical therapy help me with a pelvic floor problem?
Physical therapy can help you relax and strengthen the muscles of your pelvic floor. This, in turn, can help relieve pain and give you more control over your bodily functions.
What kind of physical therapy will I have?
Before we begin physical therapy, we check the back, pelvis and hips to determine range of motion, flexibility and strength. We also assess the internal pelvic floor muscles to see if they are in spasm, weak or uncoordinated. This will help us design a treatment plan just for you using one or more of the following:
- Exercise therapy. This involves stretching and/or strengthening the trunk and pelvic floor muscles, using exercises that may include diaphragmatic breathing and yoga poses, among others.
- Manual therapy. Massage techniques may be used to relax trigger points within muscles and desensitize painful scars.
- Biofeedback therapy. Biofeedback uses sensors to give you information (feedback) about your body. This feedback can help you learn how to relax and control your muscles.
- Electrical therapy. If your muscles are very weak, we may use an electrical current to stimulate them.
I’m nervous about what to expect. Is an internal exam actually necessary?
Treating pelvic floor dysfunction can occur without an internal exam, but the treatment recommendations can be more accurately tailored to your condition with the information from an internal exam. The purpose of an internal exam is to assess how the pelvic floor muscles are working. It can help identify whether the muscles are weak, overly tight, and/or whether they are a cause of pain. Ask the pelvic floor therapist to describe the exam beforehand, and discuss ways to help you feel more comfortable. During the appointment, you may stop the pelvic exam at any time and for any reason.
What if the pelvic floor exam is too painful or I am on my period?
A pelvic floor exam is often less intense than a regular pelvic exam; the therapist typically uses a gloved finger rather than a speculum. If an internal exam is too painful, the therapist can assess the external muscles around the vaginal opening. Pelvic floor exams can be completed while you are on your period unless you are having significant pain or cramping.
How does pelvic floor physical therapy differ from the pelvic exam a doctor does?
Compared to one with a physician or nurse practitioner, a pelvic floor exam with a physical therapist is more focused on the pelvic floor muscles, including assessment and treatment of weakness, tightness and causes of pelvic muscle pain.
What exactly are trigger points?
A trigger point is a sensitive, tight band within a muscle. Pressing on or contracting the muscle is often painful, and the pain may be located at the trigger point or could radiate to another area of the body. Trigger points can occur in any muscle. When they occur in the pelvic floor muscles, they can cause pelvic pain at rest or during bowel movements, pelvic exams and intercourse; urinary urgency may also occur. Common treatments for trigger points include massage and applying sustained pressure to the trigger point to reduce tightness and pain. Relaxation training can also improve trigger points.
Is it common to use a dilator for trigger point release massage? What is a dilator?
Dilators are common tools for treating pelvic floor trigger points. They are inserted vaginally or rectally to allow direct massage of the trigger points. Your pelvic floor therapist can talk with you about whether a dilator could be helpful for you and can also teach you how to properly use the dilator.
Are the internal exercises something I can do at home once I’ve been to a therapy session?
Your pelvic floor therapist will give you exercises to do at home between physical therapy sessions. Some people only need two to four appointments, but most people have eight to 12 sessions to achieve the optimum amount of improvement.
This post was written by:
- Lara F. Harvey, M.D., MPH, completed her undergraduate degree in anthropology from the University of South Carolina. Raised in McMinnville Tennessee, she graduated from Vanderbilt Schools of Medicine and Public Health in 2010 and completed residency training at Beth Israel Deaconess Medical Center. She returned to Vanderbilt for a fellowship in minimally invasive gynecologic surgery and is currently an Assistant Professor in the Department of Obstetrics and Gynecology.
- Tiffany Priest, PT, DPT, WCS, CLT is a pelvic floor physical therapist at Vanderbilt University Medical Center. She earned her clinical doctoral degree in physical therapy from Washington University in St. Louis, and she is a board-certified specialist in women’s health physical therapy. She provides patient care at Vanderbilt Orthopaedic Institute and Osher Center for Integrative Medicine.
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Pelvic floor physical therapy treats pain, weakness, and dysfunction in the pelvic floor muscles. When these muscles are functioning well, they allow blood flow to connective and muscle tissue, helping improve mobility.
The goal of pelvic floor physical therapy is to restore a higher level of mobility, movement, and healthy function. In cases of pain or discomfort, we will work to identify muscle trigger points and tight connective tissues that may be causing the problem.
Doctors have regarded physical therapy to improve symptoms of pelvic floor dysfunction as an effective, non-invasive treatment approach for decades. At MOTION PT Group, our physical therapists incorporate a variety of non-surgical, painless treatment approaches to retrain the pelvic floor muscles that help control bladder, bowel, and sexual function. Learning to strengthen and relax pelvic floor muscles not only improves function but often reduces the pain or discomfort you may have been experiencing.
During pelvic floor therapy, we teach you exercises to stabilize and strengthen your core, or the major muscles that stabilize the trunk, including the pelvic floor, abdominal, back, and diaphragm. This also involves re-training and strengthening your pelvic floor muscles.
Your therapist will determine which muscles are overly tight and teach you exercises to stretch these muscles to improve coordination and mobility. We will also teach you postural exercises, relaxation techniques, and diaphragmatic breathing that can improve symptoms and your overall health and sense of well-being.
The specific treatment approach we recommend for your needs will depend on your symptoms. To improve some symptoms, you will need to relax and lengthen pelvic floor muscles, while other symptoms will require you to strengthen those muscles.
Our therapists will also work with you on behavioral modifications, including dietary and lifestyle modifications that will relieve symptoms and improve your quality of life.
Importance of Pelvic Floor Physical Therapy
The pelvic floor consists of a layer of muscles that stretches from the pubic bone to the tailbone in both men and women. Pelvic floor muscles and connective tissue support the bladder, bowel, and prostate in men and the bladder, bowel, vagina, and uterus in women.
In both men and women, pelvic floor muscles help control bladder and bowel functions and are involved with sexual function and pleasure. In pregnant women, pelvic floor muscles provide support for the fetus and must relax during the natural birthing process.
Pelvic floor muscles work by contracting and relaxing to control bowel and bladder functions. For example, pelvic floor muscles must contract to avoid incontinence and relax to allow for urination and bowel movements. Individuals can experience dysfunction when their muscles are either contracting too strongly or too weakly, contributing to incontinence, constipation, pain during intercourse, or pain in the lower back, pelvic region, genitals, or rectum. Pain and dysfunction can also be caused by trauma to the pelvic floor due to surgery, childbirth, some medical procedures, or prior history of physical abuse.
Symptoms of Pelvic Floor Dysfunction
According to the Cleveland Clinic, one or more of the following symptoms may indicate pelvic floor dysfunction. If you have any of these symptoms, be sure to discuss them with your doctor.
- Frequently needing to use the bathroom. You may also feel you need to ‘force it out’ to go or you might stop and start many times.
- Constipation, or a straining pain during your bowel movements. Up to half of the people suffering long-term constipation may have pelvic floor dysfunction.
- Straining or pushing really hard to pass a bowel movement. You may also find yourself changing positions on the toilet or using your hand to help eliminate stool.
- Leaking stool or urine (incontinence)
- Frequent or painful urination
- Feeling pain in your lower back with no other cause
- Feeling ongoing pain in your pelvic region, genitals, or rectum. Pain can occur with or without a bowel movement.
Some symptoms and conditions related to pelvic floor dysfunction differ between men and women.
In men, pelvic floor dysfunction may contribute to groin pain, problems with ejaculation, or erectile dysfunction, meaning the inability to get or maintain an erection during sex.
Prostatitis is an infection or inflammation of the prostate which may present symptoms similar to pelvic floor dysfunction, but usually resolves on its own or is treated with antibiotics.
In women, pelvic floor dysfunction may compromise reproductive health by affecting the uterus and vagina and may contribute to pain during sexual intercourse.
Either men or women with pelvic floor dysfunction may experience stress urinary incontinence (SUI), or the leakage of urine when they cough, laugh or sneeze. However, the condition is more common in women, with about 35% of all women experiencing SUI during their lives.
What Causes Pelvic Floor Dysfunction?
While there are no definitive answers on the causes of pelvic floor dysfunction, experts believe the condition may be related to one or more of the following:
- Strain on muscles and tissues when giving birth (especially during long labor)
- Vaginal childbirth
- Interstitial cystitis (also known as “painful bladder syndrome”)
- Obesity
- Traumatic injuries to the pelvic area (like a car accident)
- Pelvic surgery
- Nerve damage
- Chronic coughing
- Chronic constipation
- Weightlifting
- High-impact exercise (like running)
- Overuse of pelvic muscles (frequent urination or bowel movements or chronic straining)
- Aging and menopause
What to Expect at Your First Physical Therapy Session
We understand that pelvic floor dysfunction issues can be highly personal, and you may feel nervous and even fearful about what to expect. We want to reassure you that our physical therapists are compassionate, highly trained professionals who have extensive experience working with pelvic conditions. They will take the time to answer all your questions and explain each step thoroughly.
At your first appointment, your physical therapist will do a comprehensive assessment in order to design the most effective treatment plan for your situation.
Pelvic floor physical therapy aims to restore mobility and movement and reduce pain. During your exam, the therapist will assess your posture, breathing pattern, strength, and flexibility of your spine, hip, and abdominal to determine contributing factors.
Our goal is to identify the probable cause (or causes) of your pelvic floor dysfunction. The more information you can provide us about your symptoms, the more quickly we can determine the issue. We encourage you to bring detailed notes about your symptoms, including anything that worsens or relieves the pain, to the session.
During your visit, your therapist may ask you to move around in order to assess certain functions, so dress comfortably. Throughout this and every visit, we encourage you to ask questions and provide feedback.
Our initial assessment includes the following:
- An in-depth review of your medical history
- A thorough evaluation of your symptoms
- An evaluation of areas that are tight, painful, or dysfunctional
- A complete physical examination
During the exam, we will ask you to stand, walk, and sit so we can pinpoint potential posture or joint issues that may be affecting the pelvic floor muscles. We will also evaluate whether bone or muscle problems in your lower back, hips, sacroiliac joint, buttocks, or thighs may be placing undue stress on your pelvic floor muscles, causing dysfunction or pain.
Your physical therapist will also perform a physical examination. In some cases, this may include an internal exam. Our therapists have received specialized training in pelvic floor muscle dysfunction. We understand you may feel uncomfortable about this examination process, so we conduct each step slowly and deliberately. This upfront effort can provide valuable information in identifying muscle and strength-related issues that are causing your discomfort or dysfunction.
Your physical therapist will proceed slowly and explain what to expect with each step of the exam. We encourage you to ask questions. You can pause the exam at any time.
How Many Sessions To Expect
It’s important to think of sessions of pelvic floor physical therapy as more of a marathon than a sprint. While the first session of treatment marks an important step in making a full recovery, you should not expect any issues to be completely resolved following it. In reality, it most likely takes between six to eight hour-long sessions before you start experiencing relief. Although this may seem like a long time, it is much better than not seeking treatment and prolonging pain and discomfort for months.
The Benefits
Before choosing a rehabilitation regimen, patients will often like to weigh the pros and benefits of the recommended service. At MOTION, our team knows how beneficial pelvic floor physical therapy can be for patients. That is why we hope you consider taking this route when the issues you are facing start to become unmanageable. After reaching out to our team and starting your sessions of care, you can expect to reap a number of benefits including:
- Reduced pain levels.
- Increased range of motion.
- Improved sexual function.
- Mitigated risk of developing chronic pain.
- Corrected urinary and bowel patterns.
Treatment Modalities and Tools for Pelvic Floor Dysfunction
Physical therapy to treat pelvic floor dysfunction often includes both internal and external therapy. We understand you may be nervous at the prospect of internal therapy, so we won’t proceed until you are ready.
There are a variety of external manual therapies and treatment tools we may incorporate into your treatment plan. For example, your physical therapist may do manual therapy to stabilize your pelvis and increase the mobility of skin, muscle, and fascia before using other treatment modalities.
External Manual Therapies
- Trigger point release is a manual therapy to relieve chronic pain. Trigger points are sensitive areas in the muscle or connective tissue that are painful when pressed. Trigger points may cause pain in the pelvic area. To relieve painful trigger points, your physical therapist will apply gentle, firm pressure by hand or by using a tool.
- Visceral mobilization is a gentle manual release technique to help restore normal movement to internal organs, such as the stomach, bladder, liver, urethra, prostate, and intestines, to reduce pain and restore function.
- Connective or scar tissue release breaks up scar tissue that may be causing stiffness, desensitization, or pain. Besides gently breaking up the tissue, the therapy stretches and relaxes surrounding muscles.
- Skin rolling is similar to trigger point release because it identifies restricted or painful areas in the body, muscular adhesions, and scar tissue. The therapist will massage those areas to release muscle tension, reduce pain, and improve flexibility.
- Joint mobilization improves the range of motion of the joint and may reduce pain.
Treatment Tools, Exercises, and Techniques
- Biofeedback is commonly used to retrain pelvic floor muscles. This pain-free procedure uses special sensors to monitor pelvic floor muscles as you try to relax or clench them. The sensors provide feedback to your therapist about which specific muscles you need to strengthen to gain sensitivity and better control over pelvic floor muscle function.
- Pelvic floor exercises, also called Kegel exercises, work to strengthen pelvic floor muscles as you contract and relax them. Kegels are especially helpful in cases of stress urinary incontinence (leaking urine when you cough, laugh, or sneeze). Regularly practicing Kegel exercises can also improve your sexual health and pleasure by relaxing vaginal muscles, improving blood circulation to your vagina, and increasing vaginal lubrication.
- Weighted vaginal cones are devices of increasing weight that you insert into your vagina and use pelvic muscle contractions to hold in place. Initially, you may try to hold the cone in place for about 15 minutes, twice a day, gradually increasing the duration as your muscles become stronger.
- Electrical stimulation therapy delivers a painless electrical impulse through electrodes placed vaginally, anally, or on your skin. The mild electrical stimulation treats muscle weakness, pain, spasms, and swelling by causing muscles to contract and release. Portable units are available to treat at home. Treatment time varies depending on the protocol and device used but typically takes 10 to 20 minutes or longer. You may also be asked to use an electrical stimulator in combination with prescribed exercise or the application of heat or ice. Your physical therapist may recommend one or more electrical stimulation devices to improve your symptoms of pelvic floor dysfunction.
- Therapeutic ultrasound in physical therapy differs from a diagnostic ultrasound, although both can provide some information as to how your pelvic floor muscles are functioning. In physical therapy, the primary purpose of an ultrasound is to provide deep heating to soft tissues like muscles, tendons, joints, and ligaments in order to reduce inflammation, increase circulation, and decrease pain.
- Vaginal dilators help relax the vaginal canal before pelvic exams and intercourse, retrain muscles in and around your vagina, and prevent or improve scar tissue damage during childbirth, surgery, or radiotherapy. The dilators progress in size as the vaginal wall relaxes and expands. These are for home use.
- Relaxation techniques such as meditation, yoga, acupuncture, deep breathing, and other techniques help calm the mind and body, reducing pain, emotional distress, and other symptoms.
- Medications to keep your bowel movements soft and regular are often useful during treatment for pelvic floor dysfunction. Your primary doctor will recommend the over-the-counter or prescription medications appropriate for you. Because pelvic floor muscle spasms may be causing you pain or discomfort, your doctor may prescribe a muscle relaxant to prevent your muscles from contracting.
Interstitial cystitis
Interstitial cystitis (IC) is a pelvic floor disorder characterized by recurring pelvic pain, pressure, or discomfort in the bladder and pelvic region and is often associated with frequent urination and urgency, according to the Interstitial Cystitis Association.
Interstitial cystitis (IC) is often mistaken for a urinary tract infection because the symptoms are similar. However, IC is not an infection that can be cured by antibiotics. In fact, it is a chronic, painful bladder disorder that can be treated through various interventions but not cured.
As with many other people suffering from pelvic floor dysfunction, those with IC may have overly tight or overly weak muscles, muscle spasms, pain trigger points, or “referred pain.” Referred pain means the pain in one part of the body is actually caused by the injury, disease, or dysfunction of another organ or body part.
A study published in the Journal of the American Osteopathic Association found internal and external myofascial physical therapy provided significant relief to almost 60 percent of participants with IC and pelvic floor pain.
For individuals struggling with IC, physical therapy may be a beneficial alternative to more invasive procedures if recommended by your doctor.
You Can Assist in Your Own Recovery
There is a lot you can do on your own to speed up and maintain your recovery. The following self-care practices can not only keep your recovery from pelvic floor dysfunction on track but can also improve your overall physical and mental health and quality of life.
- Regularly practice home exercises, including stretches, as recommended by your physical therapist.
- Regularly perform Kegel exercises if recommended.
- Avoid pushing or straining when urinating or having a bowel movement.
- Commit to a healthy living plan, including good nutrition, sufficient water intake, a healthy sleep schedule, regular fitness exercise, and mind-body practices like yoga, meditation, positive thinking, deep breathing, and relaxation techniques. A warm bath can relax your muscles and improve blood circulation.
- Regular home use of devices recommended by your physical therapist, including electrical stimulator, biofeedback machine, dilator, or vaginal cones.
- You or your partner can perform self-massage, as taught by your physical therapist.
Pelvic floor issues can be an anxiety-provoking topic. Don’t let embarrassment or stigma stop you from seeking the care that you need to live a fulfilling life. At MOTION, we work hard to create a safe and welcoming environment where you can receive treatment from non-judgmental professionals. We can also help facilitate difficult or stressful conversations with family and loved ones who may be able to assist you with your care and recovery.
Why MOTION?
Since 2015, MOTION’s licensed therapists have provided transformative physical, occupational, hand, and work injury therapy services to clients of all ages.
Recently, we have added the treatment of post-COVID syndrome to our list of services. There are many challenges facing those who have been discharged from COVID-19 treatment, including fatigue, pain, muscle wasting, decreased endurance, decreased respiratory function, and depression. We have designed a post-COVID treatment program to address those issues and more.
At MOTION, our mission is to improve the lives of every client as we help them get back to what moves them. We’re always guided by our values of compassion, empowerment, integrity, and teamwork, which we pledge to embody through our care.
Knowing that each client has unique needs, we take extra time to listen and answer questions. MOTION appointments last 40 minutes on average, which is longer than the typical PT session. Longer sessions allow our therapists to provide more one-on-one time with each client. MOTION also offers in-clinic care and telehealth.
Once you complete your initial plan of care, we want to help you stay on track. Consider enrolling in our Wellness@MOTION program, which includes annual wellness checkups, certified yoga, custom orthotics, ergonomic assessments, strength and conditioning, and golf performance (TPI).
Contact us today to schedule an in-clinic or telehealth appointment.
