Pelvic Physical Therapy

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By Dr. Jessica Reale, PT, DPT, WCS

I had never heard of pelvic physical therapy prior to beginning my doctoral program at Duke University. I remember very clearly when I first learned that some physical therapists did “that.” One of my fellow students had completed a small half-day observation at a local clinic, and excitedly told us all about his day watching the “Pelvic PTs.” We were blown away. We had always assumed physical therapists treated back pain, helped patients after surgery, worked with people who had strokes…but pelvic pain? Urinary incontinence? Sexual dysfunction? This was shocking and new.

Not surprisingly, I was not the only person surprised to hear of this *new* specialty. Over the past 10 years, I have worked with thousands of patients, and SO many of them had never heard of pelvic PT before it was recommended to them. This is improving though! In fact, when I first wrote this article, I would say nearly 90% of my new patients had not heard of pelvic PT. Now, it’s more common that people have heard “something”—maybe read an article online? Heard about something from a friend? But, that being said, there are a TON of misconceptions people have about my profession. I thought it would be helpful to share a few of the top misconceptions with you today.

  1. The only people needing to see a Pelvic PT are women after childbirth.

The interesting thing about this one, is that of the patients I treat, only about 10-20% are post-partum women! The other 80-90% includes young (with our youngest being 4 years old) to old (with our oldest being over 95) people experiencing a big variety of symptoms, like: urinary incontinence, difficulties in urination, bowel incontinence, constipation or difficulty having a bowel movement, abdominal pain, low back/SI pain, sexual dysfunction, abdominal/pelvic pain or coccyx pain, vaginal or rectal pain, penile or testicular pain, scar-tissue related difficulties, pre/post surgery, and much, much more.

  1. Pelvic PTs do not treat men.

False. We treat many men. All people have pelvic floor muscles, so all people can have pelvic floor problems. At my practice currently, around 20% of the patients I see are men, however, this varies a lot per practice. Some of the common diagnoses we see in men include chronic prostatitis, penile and/or testicular pain, tailbone pain, post-prostatectomy incontinence, sexual pain, constipation or difficulty emptying bowels, fecal leakage, bladder pain/interstitial cystitis, and urinary dysfunction. This could go on though, to include so much more! 

  1. If a person is leaking urine, they definitely need kegel exercises (pelvic floor strengthening).

Ah yes, Kegel exercises. This really is a very common misconception I often have to fight with my patients. Urinary incontinence is a failed system, not just a failed muscle. From a musculoskeletal standpoint, a person needs a well-functioning pelvic floor muscle group, abdominal muscles, hip muscles, respiratory diaphragm and low back muscles. People need strong, but flexible muscles that tighten when they need to and relax when they need to. If a person has a shortened, irritated pelvic floor, they may have just as much difficulty holding back urine as the person with a weak pelvic floor. It is important to trust your physical therapist to prescribe the specific exercises necessary to help YOU. Pro Tip: If you have bladder leakage and notice that your leakage gets worse when you are doing kegels, you probably have an overactive pelvic floor! Start trying to lengthen, open, and relax your pelvic floor—or better yet—go see a pelvic PT for an evaluation. 

  1. If a person has tried “kegel exercises” and they did not work, Pelvic PT won’t be able to help them.

Now that you read the one above, you know this isn’t true! As a Pelvic PT, I take great offense to this statement… I mean, honestly, do you think I would need a doctoral degree, 100+ hours of additional continuing education, and a board specialization to teach a person Kegel exercises? How boring would it be to teach Kegels all day! That all to say, rehabilitation for the pelvis is much more involved than simply strengthening a muscle group. First, many people (including most people with pelvic pain conditions!) do not actually need pelvic floor muscle strengthening. In fact, many people actually have overactive pelvic floor muscles and need lengthening and relaxation to be an emphasis in their care. Pelvic PT focuses on restoring function—improving muscular support and motor control around the pelvis, improving behavioral/dietary habits, and re-training body movements to allow for optimal organ and structural function. And that’s really just a snippet of what we do! 

  1. If your mother/grandmother/great-grandmother also had constipation/urinary incontinence/diarrhea/etc., then it must be genetic and can’t be helped.

Also, not true! Now, I won’t say there aren’t genetic components which may cause a person to be more likely to experience certain conditions than others—but that being said, there is always something that can be done to help! It is important to work with a team of healthcare professionals which could include physicians, nurses, physical therapists, psychologists, nutritionists and other providers to ensure a person gets comprehensive and holistic care to achieve optimal health.

  1. People can major in “physical therapy” and become a pelvic PT right after they graduate.

This actually used to be true. Many years ago, physical therapy was, indeed, a bachelor’s degree program. However, the profession has changed so much in the past 20-30 years. Currently, most practicing physical therapists have a Masters or Doctoral degree in physical therapy (although some clinicians who are more seasoned may still have a Bachelor’s degree in physical therapy), and the majority of the current educational programs in physical therapy in the United States are doctoral programs. In order to specialize in pelvic PT, a person should have an entry level degree as well as attend continuing education to gain the knowledge and clinical skills necessary to treat this complex population. This equals a total of 7 years of formal education (for doctoral trained clinicians) after high school as well as significant amounts of continuing education. (Note: I say “should” here because, unfortunately, there are people out there who jump into treating people with pelvic floor problems without actually having adequate training to do this well. This is why I encourage all patients to ask about educational and training background!)

  1. 7If a person has already had surgery OR is planning to have surgery, pelvic physical therapy won’t help them.

The truth is that physical therapists usually work very closely with surgeons to help patients achieve optimal recovery. Surgery will often correct an anatomical problem, but it is important to have improved muscular control and function to help a person attain optimal outcomes after surgery. Research has shown that physical therapy prior to and after surgery can improve patient outcomes as well as reduces the need for future surgery.

  1. A physical therapist doing vaginal or rectal exams is weird and NOT conventional.

Physical therapists specialize in working with the musculoskeletal and neuromuscular systems of the body. The pelvic floor muscles run around the opening of the urethra, vagina and rectum. There are many ways we can assess the pelvic floor muscles—through watching movement/function, external examination and observation, and most directly (and comprehensively) through an internal examination. This examination is performed with one gloved finger inserted into the vaginal or rectal canal. Although this may seem “untraditional” to some, there is a strong anatomical basis for the exam, and it is well supported in current medical research. That being said, a skilled pelvic physical therapist will partner with their patient to determine the best examination and treatment approach for them, based on their current problems, preferences and comfort level. So, if a patient feels uneasy about an internal examination, we can modify our approach based on what they want. 

  1. If a person has a “medical cause” of his/her pain, physical therapy will not help.

Often times, certain diagnoses can have musculoskeletal involvement. For example, if a person has endometriosis which has caused significant pelvic pain they will often have severe trigger points, connective tissue restrictions, and muscular restrictions in all of the muscles around the pelvis. In many cases, if the endometrial tissue is removed via excision surgery, but the soft tissue restrictions remain, pain may persist. All that to say, a multidisciplinary approach to pain tends to be the most optimal to help people achieve the best recovery.

  1. A person’s habits (eating, drinking, etc) are not related to pain, urinary or bowel dysfunction.

This may seem obvious, but this thought is more common than you would think. Many people believe that if they have had certain habits for a long time, it cannot be related to the problems they are experiencing. Unfortunately, that is not the case. Often times, habits such as fluid intake, dietary habits, activity preferences, and movement strategies can strongly influence a person’s symptoms—even if the symptoms are new. It is important for your physical therapist to evaluate all of your habits to help you understand the steps you can take to improve your health.

I hope this information was helpful for you today! What were some misconceptions you had about pelvic physical therapy? Let us know in the comments below!

Written by: Dr. Jessica Reale, PT, DPT, WCS

Dr. Jessica Reale is a physical therapist and board-certified specialist from Atlanta, GA. She owns Southern Pelvic Health, a specialty pelvic health practice that serves all people with pelvic floor problems in the metropolitan Atlanta area. Dr. Reale is a faculty member and curriculum architect with the Herman & Wallace Pelvic Rehabilitation Institute and has educated hundreds of health care providers across the country on pelvic health topics. Additionally, she is passionate about educating the community and hosts courses on pelvic health topics through a partnership with Sara Reardon, PT, DPT, WCS. She authors www.jessicarealept.com, where she writes articles on all topics related to pelvic health. Note: This article was originally written by Dr. Reale in 2013, and published via the Proaxis Therapy Pelvic Floor Team’s Blog. The content of this post was updated in June 2020 by Dr. Reale for Nancy’s Nook.