Pelvic Floor Physiotherapy

Content warning: This post contains information regarding pelvic floor dysfunction and pelvic pain. If these subjects are upsetting for you, please prioritize your own well-being. Gynaecological exams can cause discomfort for those who have experienced trauma from clinical examinations (such as obstetrical or gynaecological violence, racism in healthcare settings, or transphobia in healthcare), as well as gendered/sexual violence outside of the healthcare setting. These experiences of trauma can impact sexual and reproductive health well after the events occur.


TLDR: Pelvic floor physiotherapy (PFPT) is a type of physiotherapy specifically for the muscles at the base of your pelvis – the pelvic floor muscles. PFPT can be useful for those dealing with pelvic floor dysfunction, incontinence, pelvic pain, and pelvic organ prolapse. Keep reading for in-depth information on what PFPT is and how it works!


In this post, we are going to go over everything you need to know about pelvic floor physiotherapy. This post was inspired by a community member who asked about pelvic floor muscle health in the anonymous submission box on our website (scroll to the bottom of our homepage to ask your question).


The topics we will cover include:

  • What is pelvic floor physiotherapy?

  • What can I expect in a pelvic floor physiotherapy session?

  • Medical and sexual history

  • Physical assessments

  • What happens after the exam

  • Exercises you can do at home: Kegels!

  • Finding a pelvic floor physiotherapist

What is Pelvic Floor Physiotherapy?

Pelvic floor physiotherapy (PFPT) is a specialized type of physiotherapy focused on restoring and maintaining the muscles in the base of your pelvis (see image below). PFPT is a recommended preventive approach for those who may be pregnant (now or in future) to prevent urinary/fecal incontinence (1), and for those experiencing genital pain (chronic or during sex). PFPT exercises, including Kegel exercises, can also be helpful in reducing pain and urinary incontinence after prostate cancer surgery (2). PFPT can also be helpful for sexual function, increasing sensitivity and arousal, power of orgasms, and/or reducing symptoms of erectile dysfunction (3). PFPT can include internal (through the vagina or rectum) & external manual manipulations of the pelvic floor muscles and ligaments to stretch, strengthen or relieve muscles (4). It can be especially helpful for pelvic floor dysfunction, incontinence, pelvic pain, and pelvic organ prolapse, as a low-risk and evidence-based treatment option (5, 6).



Pelvic Floor Dysfunction is an umbrella term for abnormal function of the pelvic floor and could be due to underlying anatomical abnormalities, disease, or physical injury. Dysfunction occurs when there is either too much (hypertonicity) or not enough (hypotonicity) muscle tone (5).

Pelvic Floor Dysfunction can impact urinary or bowel function and can cause pelvic pain. PFPT can assist in relaxing and lengthening pelvic floor muscles, in the case of hypertonicity. It can also help strengthen the pelvic floor muscles, in the case of hypotonicity.


Incontinence is the loss of bladder or bowel voluntary control, which leads to leaky fluids (which could be urine or fecal matter) (6). Stress urinary incontinence is urine leakage during laughing, coughing, sneezing or lifting (6). Not ideal! But not uncommon! Risk for incontinence is higher for those in larger bodies and increases with age. Pregnancy also increases the risk for incontinence and risk increases throughout the pregnancy (6). As you may imagine, this has implications on quality of life and mental health (7). People experiencing incontinence have reported negative impacts on their social life, everyday activities, sleep and sex life (7).


Pelvic pain is an umbrella term that can include chronic pain in genitals (e.g. vulvodynia) or pain during or after sex (dyspareunia), which can exist with other comorbidities such as endometriosis or interstitial cystitis (painful bladder). Up to 20% of women experience pain during sex, impacting the quality of sex life, relationships and mental health (8, 9). Oftentimes, it is difficult to seek help for a variety of reasons: embarrassment, normalizing pain, or bad previous experiences with healthcare. Our society tends to shy away from talking about pelvic and/or sexual pain and discredits the experiences of women and gender-diverse folks, especially racialized folks. This is particularly true for Black folks, whose pain is historically and systemically dismissed in healthcare settings (read Maisha Johnson’s article “I’m Black. I Have Endometriosis - and Here’s Why My Race Matters”). Invalidation of patient experiences can be perpetuated in healthcare offices and patients may not feel believed if they do report their symptoms. This is often a toxic feedback loop, in which healthcare practitioners may invalidate patients, leaving patients to doubt themselves or left alone in their pain, leading to underdiagnosis and undertreatment for those experiencing pelvic pain (9).


Pelvic organ prolapse occurs when organs in the pelvis (uterus, bladder, bowel) slip from their usual position into the vaginal canal. The prevalence of pelvic organ prolapse ranges from 2.9-12.1% (10). In postmenopausal women, the prevalence increases to 41% of patients with uteruses (10). Ultimately, pelvic organ prolapse is not uncommon! Most people do not show symptoms but those who do may experience bulging or a protrusion in the vagina (11).


PFPT is a first-line and evidence-based treatment option for various pelvic floor conditions (as listed above) in order to improve pelvic muscle strength, endurance, power, or relaxation (4 ; 6). It is a low-risk and relatively minimally invasive approach, with the aim to provide validation and relief to patients. However, there are mixed reports on the efficacy of PFPT for severe cases of pelvic organ prolapse or urinary incontinence that require surgical treatment (4).


What can I expect in a PFPT session?

  1. The talking phase: Medical & sexual history

  2. The physiotherapist will start by asking for a detailed history of your:

  3. Symptoms

  4. Sexual history, bladder and bowel health

  5. Daily physical activity routines

  6. This part is usually very detailed. You may have to fill out a form beforehand to answer these questions.

  7. Physical assessments

  8. Back, hips, legs - checking your posture, spinal movements, gait, pelvis, leg motion, and strength testing.

  9. How you breathe - checking your diaphragm, core and pelvic floor. They all work together so your breathing could impact the function of the pelvic floor.

  10. Muscle tension - checking around the pelvis and abdominal wall.

  11. External genital exam - checking skin and muscles for irritation, lesions, trauma, atrophy, etc. The perineum (space between vulva or scrotum and anus) is examined for prolapse.

  12. Other exams could include the cotton swab test to check if there is a pain response to a cotton swab against the vulva, which can give more information regarding vulvodynia and the type of pain you are experiencing.

  13. Internal genital exam

  14. Single-digit exam (1 finger) - checking for tenderness, tone, and spasms in the vagina, urethra, and pelvic floor muscles. May ask the patient to squeeze muscles (like a Kegel) for tone assessment.

  15. Bimanual exam - 1 or 2 fingers are placed into the vagina while gently pressing on your lower abdomen to check the uterus, ovaries and fallopian tubes.

During the exam, you should be lying comfortably on your back, covered with a sheet. Due to the sensitive nature of this exam and treatment, it is important to feel comfortable and respected. This might mean finding a PT with the same gender identity as you, or bringing a support person to your appointments. If at any point you are uncomfortable or in pain, it is completely your right to request a break or to stop! These feelings of discomfort are valid and your provider should be compassionate and understanding of your needs. The provider should give full disclosure and forewarning as to the next steps in the exams, providing you with information as to why each step is necessary. It is also important to note that pelvic floor exams do not necessarily need to include an internal pelvic exam - it is up to you! Additionally, if you are not comfortable in moving forward with any steps right away, you can always build up to them. The purpose of the internal pelvic exam is to provide more information regarding possible causes of dysfunction, but ultimately this treatment should be centred around you and individualized to your comfort level. :)


3. After the exam, the physiotherapist will suggest various treatments specific to what you need.

  1. Education: for example, learning about your own anatomy (e.g. using a mirror so you can observe the examination, depending on your own comfort), identifying the different muscles you will exercise, or lifestyle modification to reduce discomfort.

  2. May use biofeedback, dilators, electrical stimulation (see below for more info)

  3. Manipulations of the pelvic floor muscles - such as lengthening or releasing tension of muscles/ligaments through stretches or applying pressure.


Biofeedback is a technique that can help you identify the proper muscles to strengthen or relax. The PT may use a probe (inserted anally or vaginally) and abdominal sticky pads on the lower stomach or skin beside the vulva to indicate which muscles you are using. The PT will provide visual or verbal feedback so you can visualize how your muscles are working and self-correct as needed (12; 13).


Dilators have a misleading name as they are not being used to “expand” the vaginal canal. Rather, they are used to retrain soft tissues in/around the vagina to relax/lengthen, in order to relieve pain, spasms or hypersensitivity (14). Dilators come in various sizes (girth, length) and your PT should help fit you to the correct size. Dilator therapy involves lying in a semi- or fully-reclined position, adding a water-based lubricant to the dilator, inserting the dilator into the vagina as far as is comfortable, and holding the dilator in place for 10 minutes while applying gentle pressure downwards (15). Oftentimes, it is recommended to use dilator therapy daily and before penetrative intercourse.


Electrical stimulation is a good tool if you are unable to voluntarily squeeze the correct pelvic floor muscles. For example, if you keep hearing the word “Kegel” but for the LIFE of you, cannot figure out how to do it yourself. A small electrode can be placed in the vagina or anus to stimulate the correct muscles to contract. Therapy duration depends on your treatment plan with your healthcare team. Providing electrical contractions should help strengthen the pelvic floor muscles (16). An alternate form of electrical stimulation can be used by placing an electrode on your lower back (near your sacrum or tailbone). This activates your sacral nerve (which innervates the bladder) for urinary incontinence treatment (17).


Exercises you can do at home: Kegels!

A Kegel (pronounced kee-gull) is an exercise to strengthen the pelvic floor muscles. They can be helpful for anyone experiencing (or who wants to prevent) leaky fluids, or possibly increase sexual functioning. Popular culture usually designates Kegel exercises to those with vaginas, however, people with penises can also experience the benefits of strengthening pelvic floor muscles.


Individuals can also use various tools to help with their Kegel exercises, though there is limited research on these tools. One study recruited people with vaginas dealing with urinary incontinence and sorted them into two groups: the non-assisted Kegel group and assisted Kegel group (using the “Kegelmaster” tool). Both groups practised Kegels twice a day, 15 minutes per session, for 12 weeks. Both groups showed improvement in urinary incontinence and quality of life, but the groups’ improvements did not differ from one another (18). Meaning… Kegel tools or no tools, the exercises were helpful!


Kegel exercises are not dangerous, but like any other exercise, if you do it wrong it can lead to straining muscles or not exercising the correct ones (19). That is why learning about your anatomy and visiting a pelvic floor physiotherapist can be helpful!


Steps to kick-ass Kegels

  1. Empty your bladder/bowels.

  2. Find a comfortable position (laying down or sitting)

  3. Keep breathing (don’t hold your breath - remember your diaphragm and abs are connected to your pelvic floor, you want to keep it relaxed!)

  4. Find the right muscles - some visualization tips:

  5. Imagine you are preventing yourself from passing gas.

  6. Imagine stopping yourself from peeing mid-stream.

  7. Imagine suctioning a marble with a vagina or anus.

  8. Avoid flexing your abs, glutes, or legs.

  9. Hold the squeeze:

  10. Can start by holding it for 3 seconds, then rest for 3 seconds.

  11. As you get used to it, you can try holding for 10 seconds on/off. Repeat at least 10-15 times for 3 sets daily.


Finding a PFPT therapist

Check out the Women’s Health Division of the Canadian Physiotherapist Association for physiotherapists with training in pelvic health.


Media Resources

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References

  1. Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay‐Smith EJC. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev [Internet]. 2017 Dec 22 [cited 2021 Mar 17];2017(12). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486304/

  2. Post-prostatectomy incontinence: Etiology, evaluation, and management [Internet]. [cited 2021 Mar 17]. Available from: http://www.turkishjournalofurology.com/en/post-prostatectomy-incontinence-etiology-evaluation-and-management-13920

  3. What are pelvic floor exercises? [Internet]. nhs.uk. 2018 [cited 2021 Mar 17]. Available from: https://www.nhs.uk/common-health-questions/womens-health/what-are-pelvic-floor-exercises/

  4. Wallace SL, Miller LD, Mishra K. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Current Opinion in Obstetrics & Gynecology. 2019 Dec;31(6):485–93.

  5. Women’s Pelvic Health [Internet]. Pelvic Health Solutions. [cited 2021 Mar 17]. Available from: https://pelvichealthsolutions.ca/for-the-patient/womens-pelvic-health/

  6. Lawson S, Sacks A. Pelvic Floor Physical Therapy and Women’s Health Promotion. J Midwifery Womens Health. 2018 Jul;63(4):410–7.

  7. Ternent L, Vale L, Buckley B, Glazener C. Measuring outcomes of importance to women with stress urinary incontinence. BJOG: An International Journal of Obstetrics & Gynaecology. 2009;116(5):719–25.

  8. De Graaff AA, Van Lankveld J, Smits LJ, Van Beek JJ, Dunselman G a. J. Dyspareunia and depressive symptoms are associated with impaired sexual functioning in women with endometriosis, whereas sexual functioning in their male partners is not affected. Hum Reprod. 2016 Nov;31(11):2577–86.

  9. Sorensen J, Bautista KE, Lamvu G, Feranec J. Evaluation and Treatment of Female Sexual Pain: A Clinical Review. Cureus [Internet]. [cited 2021 Mar 17];10(3). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5969816/

  10. Bureau M, Carlson KV. Pelvic organ prolapse: A primer for urologists. Canadian Urological Association Journal. 2017 Jun 13;11(6S2):S125-30.

  11. Pelvic Organ Prolapse - American Family Physician [Internet]. [cited 2021 Mar 17]. Available from: https://www.aafp.org/afp/2010/0501/p1111.html

  12. Treating constipation with biofeedback for the pelvic floor - Harvard Health Blog - Harvard Health Publishing [Internet]. [cited 2021 Mar 17]. Available from: https://www.health.harvard.edu/blog/treating-constipation-with-biofeedback-for-the-pelvic-floor-2019051616638

  13. te Brummelstroete GH, Loohuis AM, Wessels NJ, Westers HC, van Summeren JJGT, Blanker MH. Scientific evidence for pelvic floor devices presented at conferences: An overview. Neurourol Urodyn. 2019 Sep;38(7):1958–65.

  14. Vaginal dilator exercises for psychosexual therapy. Oxford University Hospitals [Internet]. [cited 2021 Mar 17]. Available from: https://www.ouh.nhs.uk/patient-guide/leaflets/files/30804Pexercises.pdf

  15. Dilator therapy. Michigan Medicine [Internet]. [cited 2021 Mar 17]. Available from https://www.med.umich.edu/1libr/HealthyHealing/DilatorTherapy.pdf

  16. Publishing HH. More on strengthening the pelvic floor [Internet]. Harvard Health. [cited 2021 Mar 17]. Available from: https://www.health.harvard.edu/newsletter_article/more-on-strengthening-the-pelvic-floor

  17. Electrical Stimulation for Urinary Incontinence [Internet]. HealthLink BC. [cited 2021 Mar 17]. Available from: https://www.healthlinkbc.ca/health-topics/hw220147

  18. Kashanian M, Ali SS, Nazemi M, Bahasadri S. Evaluation of the effect of pelvic floor muscle training (PFMT or Kegel exercise) and assisted pelvic floor muscle training (APFMT) by a resistance device (Kegelmaster device) on the urinary incontinence in women: a randomized trial. Eur J Obstet Gynecol Reprod Biol. 2011 Nov;159(1):218–23.

  19. Kegels: The 30-second exercise that can improve incontinence and sex - UChicago Medicine [Internet]. [cited 2021 Mar 17]. Available from: https://www.uchicagomedicine.org/forefront/womens-health-articles/kegels-the-30-second-exercise-that-can-improve-incontinence-and-sex

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