January 21, 2019

Pelvic floor physical therapy: dispelling rumors, creating understanding


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.

Need help?

Vanderbilt Women’s Health provides care for women at all stages of their lives at locations across Middle Tennessee. Learn more here or call 615-343-5700.