Behind the Clinic Door: A peek into a pelvic physical therapy appointment

Fiona McMahon, PT, DPT Joanna Hess, PT, DPT PRC, WCS

Everyone is talking about the pelvic floor now a days, which delights us at Beyond Basics to no end. We are finding that more and more folks are asking themselves if pelvic floor PT is right for them. Whether you found out from friends, a physician, or even the internet, you find that you are fairly certain that your mysterious symptoms are being caused by pelvic floor dysfunction. Everyone says to see a pelvic floor physical therapist, but the unknown seems daunting. We get it, the idea of someone addressing one of the most private parts of your body can be intimidating. Many of us, physical therapists at Beyond Basics find that after their first visit, many of our patients have commented that they wished they had come earlier and that the appointment was actually fun and informative, despite the nature of the problems. So what is pelvic floor physical therapy? What can I expect? Let’s dive deeper and get rid of that pesky mystery!

Who are pelvic health physical therapists?

Physical therapists (PTs) are experts in movement and function, which sounds like a pretty broad topic to be an expert in, and it is. After physical therapists graduate PT school (now-a-days at the doctoral level), they find their niche and specialize. You can find PTs working with high-level athletes, children, infants, people who are recovering from injuries, people with neurological conditions, and many other types of clients. Pelvic floor physical therapists specialize in the muscles, nerves and connective tissues that live between your legs, also known as the pelvic floor. They gain their expertise through a series of post-graduate continuing education classes, certifications, and training. Their training allows them to perform both internal and external pelvic exams, and broadens their knowledge of conditions which affect the pelvic floor. Sometimes, people who specialize in modalities like biofeedback or dilator therapy, advertise themselves as pelvic floor therapists, but do not actually have any hands on experience treating the sensitive and often reactive muscles of the pelvic floor. If you are seeking pelvic floor physical therapy, it is important to inquire about the experience and level of training your potential physical therapist has had in this specialty.

Physical therapists who specialize in the pelvic floor are a special breed. They have to integrate core concepts from nutrition, visceral health, orthopedics, and many bodily functions to find the best route to help their patients meet their goals. If you ask about our jobs, we love what we do because we get to help our patients move through a potentially isolating and limiting time of pelvic dysfunction. Our detective work puts together a puzzle composed of so many pieces to diagnose and treat dysfunction and eventually improve the quality of life for our patients.

What is pelvic health physical therapy?

Pelvic floor physical therapy, as the name might imply, treats the muscles that live between the tail bone and the pubic bone. What might not be so obvious is that in order to treat those muscles effectively, we usually have to treat other body parts like the hip, ribcage, abdomen, and even as far away as the head and feet! It’s honestly all connected and a good physical therapist will take time to explain why they may want to incorporate a body structure that feels very far away from the pelvic floor. We see a wide range of symptoms that can be generally grouped into: peeing, pooping, pain, pressure, and strength problems. We treat people across the lifespan. We at Beyond Basics take the delicate nature of our work very seriously. We are also competent in affirming care for all genders and those with history of trauma.

Urinary symptoms can include leakage, frequency, urgency, pain, difficulty initiating or completing, weak stream, and pain with urination. We usually think of urinary issues occurring in folks who have had babies. While pregnancy and childbirth can be factors in urinary dysfunction, we see urinary dysfunction occuring in all ages and all genders. The reason why can be varied but we love to get our detective’s hat on and start figuring it out. We have a literal (okay maybe not literal) ton of material on urinary dysfunction on our blog, so check it out!

Bowel symptoms can include leakage, constipation, frequency, urgency, hemorrhoids, and pain. As with all symptoms of pelvic floor dysfunction, the causes can be myriad. We as PTs have hacks to get you more comfortable immediately, while getting to the causes of your pelvic floor related bowel dysfunction, so poo problems can be a thing of the past.

Pain has complex contributions, so as physical therapists we look at the big picture and treat local and global musculoskeletal, visceral, and neural factors. We can use our skills to treat painful and spasmed muscles through hands on manual treatment, strengthening, lengthening, and lifestyle modifications. What really is our magic, is we partner with you to develop the skills, strength, life style modifications you need to control your pain and overtime reduce your need for physical therapy. We honestly love to work ourselves out of a job.

What’s a pressure system? We are! All humans have to regulate an internal pressure in order to keep their body, joints, and organs stable and secure, while not placing too much strain on our pelvic organs (uterus (if you have one), bladder, and bowel). Pressure system problems are associated with pelvic organ prolapse, diastasis recti abdominis, hernias, and overactive muscles. Our ability to regulate pressure can be disrupted by pregnancy and childbirth, muscle weakness and imbalance, as well as range of motion issues in our joints.

What happens during a pelvic health appointment?

When you first arrive at Beyond Basics, we have you get comfortable, so you can take your time to tell us your story. We want to know exactly what brought you in to see us, as well as any ideas you may have as to the cause of your symptoms. We also want to get a very clear sense of what your goals are and what is important to you. It is imperative that we are all striving towards a shared outcome.

After and during the time when you are telling us your story, we will ask follow up questions to get a true feel of what is going on as well as more information to guide us as we approach getting you to your stated goal. We may ask you questions, that on first blush, seem completely whack a do. You may be seeing us for pelvic pain, but you may get asked how many times in a week you poo, this is because there are many systems affected by the pelvic floor and the more we know about how those systems are affected, the better we can be at helping you. If you are truly surprised by a question, feel free to ask us why the answer matters and we will happily explain it to you.

Understandably the most daunting part of going to pelvic floor PT for the first time is the physical exam. The first thing we want you to know is that you are in control. We may recommend a certain type of exam, usually a vaginal or rectal exam is performed, but if that’s not something you want to do, that is TOTALLY OK. You can decide at any point whether or not to continue with an exam. We also have many ways to look at the human body. You will get a lot out of your exam, even if you do not wish to have internal or even a hands-on exam. Literally, no worries. The physical exam starts with observing how you move through your entire body, especially if there is a particular position, movement, or situation that provokes symptoms. Then we usually take a closer look at how your body moves in smaller segments, particularly at the spine, pelvis, and hips on a treatment table.

For most patients with pelvic floor dysfunction, we do an assessment of the external and internal pelvic floor muscles to evaluate and clarify the cause of the symptoms. This is similar, but different from an exam that you would have with an ob-gyn or urologist. As physical therapists, we are focused on the function of the muscles and nerves, not problems with the organs. Specifically, we look and examine the health of the external genitalia and activity of the superficial and deep pelvic floor muscles. In order to assess the deep pelvic floor muscles, we usually use one gloved finger through the vaginal or rectal canal to feel the tone, strength, and coordination of the pelvic floor. As with the rest of the appointment, everything we do requires your consent, especially with this part of the exam. We have many ways to find out more about the pelvic floor without an external or internal pelvic floor exam. We always implement trauma-informed care.

As a logistical point, when you come to a physical therapy appointment, bring clothes that allow for easy movement. If you have problems with a particular pair of shoes or using a brace, we will look at them. And if you have any relevant test results or prescriptions which can add to our clinical picture.

After we finish the exam, we ask you to get comfortable again in order to discuss next steps. Who knew you’d be so comfortable?! We take time to go through exactly what we found, how we can work on issues that could be affecting your symptoms, and leave you feeling like you know what’s going on and what to do about it. This part of the exam is so important, we want you to leave our office feeling empowered and like your plan will be doable for you and will help you.

What Happens Later On?

Every case is unique, but it is possible to generalize. You should see some degree of improvement within 4-6 weeks of consistent appointments and adherence to your homework. If you or your therapist notice that this is not the case, they may want to change tacts, or collaborate with partner’s from other disciplines, like allopathic medicine (traditional medicine), acupuncture, etc.,..

Physical therapists have unique sets of tools to help you get better. We can think of them in three main categories. 1.) Manual Therapy 2.) Neuroreducation 3.) Exercise. Therapists will titrate these 3 approaches into a perfect recipe for you. As you progress the recipe may change to serve the needs of your changing body. The ultimate goal is to work ourselves out of a job and make it so you feel so good, you don’t need to come back. Though you may be a lovely person, we want you better and out of our office.

You’re too much fun to spend all your time in physical therapy!

Okay, okay, but what are the three categories and what will my therapist actually do? Good question. Manual therapy means hands on therapy. This category as with the others listed is broad. A physical therapist may use massage and joint mobilizations to help your body move and feel better. In the pelvic floor world, this may mean that your therapist works internal vaginally and/or rectally to help get the pelvic floor muscles get out of painful spasm.

Neuroreducation sounds really fancy and it totally can be, but the basic premise is getting the body to learn to move differently. Neuro-re ed, as we call it can be as simple as working on adopting postures that are less stressful on the body, to the use of biofeedback to provide you with real time electronic feedback of how to use your muscles, including your pelvic floor muscles properly.

We all know what exercise is. Physical therapists will tailor exercise to best suit you and your goals. This may be working on a stretching program to get out of pain, to high intensity drills to allow you to go back to your sport of choice pain free and/or without incontinence. Again, we tailor this to you and your goals. If you want to be throwing lay-ups without peeing your pants great, if you want to sit for 1 hour at a restaurant without pain, also great. We can help you.

Again your chef… ahem I mean PT will work with you to conduct the perfect recipe for you and what you love to do.

Why do you need pelvic floor physical therapy?

Before coming to our office, most of our patients have seen many other specialists, usually finding some temporary, but incomplete relief. Pelvic floor physical therapy sits in a unique intersection with the ability to recognize and often treat muscular, neural, fascial, digestive, urinary, bowel, and sexual dysfunctions. When we can’t treat the dysfunction directly, within our scope of practice, we can usually refer to or team with another practitioner.

Many folks will benefit from pelvic floor physical therapy because the pelvic floor is so central to what we we do as humans, despite not many folks knowing about it!

Knowing what is normal function and what is not, can help you determine if you need pelvic floor physical therapy. We have many blogs written about urinary, sexual, pain, and bowel dysfunctions associated with pelvic floor dysfunction. But broadly speaking, pain is not normal. Incontinence is not normal. If you are experiencing these things, it is very likely that pelvic floor physical therapy will be an amazing boon to your well-being.

Many of our patients put off seeing a pelvic floor physical therapists. The reasons PT is put off are numerous including fear, and not having much time. If you can swing it, getting in sooner rather than later is nearly always the right move. Typically when dysfunction is caught early, it is much easier to unwind.

You should come to pelvic physical therapy for you, to get back to the life you enjoy and to take care of your body for years to come. Life is simply too precious to live it in pain.

Get help now from a pelvic floor therapist.

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