Pelvic floor physical therapy

Specialty of physical therapy

Pelvic floor physical therapy (PFPT) is a specialty area within physical therapy focusing on the rehabilitation of muscles in the pelvic floor after injury or dysfunction. It can be used to address issues such as muscle weakness or tightness post childbirth, dyspareunia, vaginismus, vulvodynia, constipation, fecal or urinary incontinence, pelvic organ prolapse, and sexual dysfunction. Licensed physical therapists with specialized pelvic floor physical therapy training address dysfunction in individuals across the gender and sex spectra, though PFPT is often associated with women's health for its heavy focus on addressing issues of pelvic trauma after childbirth.[1]

## Evaluating pelvic floor function

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Pelvic floor physical therapists perform an initial examination to determine the likely underlying muscular or nerve dysfunction causing a patient's symptoms. Therapists will manually examine muscles of the pelvic floor both externally and internally, palpating to locate trigger points of pain and guide patients to manually tighten or loosen muscles to assess tone and function. During this initial exam, PFPT must isolate the cause of dysfunction to one of two broader categories: low-tone or high-tone disorders. Low-tone disorders, such as stress-urinary incontinence, overactive bladder, pelvic organ prolapse, and anal incontinence, are caused by weakened muscles in the pelvic floor. High-tone disorders, such as pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia, are caused by overly strong or active muscles in the pelvic floor. While low-tone disorders can be addressed through exercises such as Kegels meant to strengthen the pelvic floor, high-tone disorders can be worsened by such exercises and must be addressed through other means such as biofeedback or dilation training.[1]

## Pelvic floor disorders treated with PFPT

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### Chronic pelvic pain

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Chronic pelvic pain (CPP) is an umbrella category of dysfunctions of the pelvic region associated with long-term discomfort, and includes diagnoses such as dyspareunia, vaginismus, vulvodynia or vestibulodynia, endometriosis, interstitial cystitis, chronic nonbacterial prostatitis, chronic proctalgia, piriformis syndrome, hip dysfunction, and pudendal neuralgia. Around 1 in 4 women and between 2% and 10% of men experience chronic pelvic pain, making CPP of high clinical relevance. Just as chronic pain is conceptualized elsewhere in the body, CPP is considered to have many underlying and interconnected causes, and therefore treatment is often interdisciplinary.[2] PFPT is considered to be a key element in the treatment of CPP, working to reduce pain or enhance function by normalizing pelvic floor muscle tone and endurance.[1]

### Sexual dysfunction

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Many disorders that cause chronic pelvic pain (CPP), such as dyspareunia and vaginismus, are associated with discomfort during intercourse. As a result, the treatment of CPP with pelvic floor physical therapy is often related to the treatment of sexual dysfunction.[2] In terms of dyspareunia, patients often suffer from overactive pelvic floor muscles (PFMs) that are also weak in strength. Pelvic floor physical therapy can help to both strengthen the PFMs as well as reduce the muscles’ resting muscle tone.[3] Pelvic floor physical therapy has also been shown to be effective in the treatment of erectile dysfunction (ED), providing a treatment avenue with less risk of complication than commonly prescribed medications or surgical interventions. Multiple randomized controlled trials have seen a range from modest to significant success with pelvic floor physical therapy treatments for ED. Research has also shown success in treating premature ejaculation with pelvic floor physical therapy, although the underlying reasons for this success are unknown. It is possible that PFPT helps address disorders such as ED and premature ejaculation simply because it enhances awareness and control over individual muscles or muscle groups in the pelvic region.[4]

### Urinary/fecal problems

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Passive muscular support and voluntary/reflexive contractions of the pelvic floor are important for maintaining continence during bouts of increase in intra-abdominal pressure like coughing, sneezing, etc.[5] Large, systematic reviews have shown that stress incontinence can be treated with high success using PFPT. The treatment of overactive bladder syndrome, a more complex disorder characterized by a larger range of symptoms, as well as fecal incontinence with PFPT has shown more modest success. There are benefits associated with pelvic floor physical therapy specifically in postpartum women including increasing muscle strength and endurance on top of decreasing the rate of urinary incontinence.[6] More research is needed to determine the best treatments within PFPT and/or interdisciplinary approaches to treatments for these disorders. Higher than average pelvic floor physical tone is thought to be a component of constipation, anismus, and irritable bowel syndrome (IBS). On the other hand, women who are postmenopausal, due to the decrease in estrogen production the muscles of the pelvic floor start to become thinner, dry, and are more susceptible to wear and tear. The decrease in strength causes an increase in urinary incontinence from the loss of urethral mucosa and tissue breakdown. This estrogen deficiency leads women to be more prone to stress urinary incontinence specifically, where any force that occurs in the body such as a sneeze can lead to urine loss.[7] In addition, research shows that it is more beneficial for women to train for longer periods (>12 weeks or ≥ 24 sessions) with shorter sessions (10–45 minutes). Those who accumulate a greater number of shorter sessions achieve a greater decrease in urine loss than those who participate in smaller number of longer sessions.[8] Because these disorders can be of unknown origin or may be caused by multiple lifestyles, genetic, and physical factors, PFPT may only be effective for some individuals with these conditions or may be most effective as part of a larger treatment plan.[4] New research is showing that, in addition to Pelvic Floor Physical Therapy (PFPT), using modalities like biofeedback and electrostimulation leads to higher success rates of treating incontinence symptoms by strengthening the pelvic floor muscles. This is most significant in women who are experiencing moderate to severe symptoms, such as leaking a little bit when one coughs to leaking a lot of urine frequently throughout the day. How does this work? During a session, a therapist would insert a small instrument into the patient's vagina or rectum. The muscle activity is then displayed on a screen and the patient is directed to contract their muscle to achieve good levels of activity. Electrostimulation can also be added to help the muscle contract optimally for training and strength. The instrument inserted into the rectum or vagina can stimulate the pudendal nerve to stimulate the pelvic floor muscles. [9]

### Benefits of prenatal and postpartum pelvic floor PT

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Women suffering from pelvic floor dysfunction and urinary incontinence due to "pregnancy and vaginal delivery have independently been proved to be the risk factors for the development of severe urinary incontinent as they could obviously weaken the pelvic floor muscle (PFM) strength".[10] About 1/3 of women post-childbirth struggle with urinary incontinence,[11] and women who attend PT can decrease the likelihood of developing urinary incontinence. However, this study concluded that women who had already experienced urinary incontinence in the early stages of pregnancy may not decrease urinary incontinence when using late-pregnancy pelvic floor PT.[11] Therefore, it may be advisable to seek out a pelvic floor PT in the early stages of pregnancy, before any issues one may encounter. Postpartum women, whether they delivered via cesarean section or vaginal birth, can significantly benefit from PFPT, because "women after childbirth, regardless of the type of delivery, [are at a] high risk of new and prolonged signs of pre-existing signs of pelvic floor muscle dysfunction".[12] C-sections are becoming more prevalent and those who received PT afterward improved pelvic floor muscle tone and strength and positively impacted their daily function and sexual activity at 6 months postpartum.[12] Various modalities can be done alongside typical physical therapy treatment for pelvic floor dysfunction and urinary incontinence, "such as biofeedback, electrical stimulation, or multi‐modal exercise programmes".[11][13] A study shows that long term treatment with electrical stimulation will increase the strength and endurance of the pelvic floor muscles, increase blood flow to the area to promote healing, and reduce pain or discomfort, all while contributing to urinary control. The study found that when electrical stimulation is combined with other techniques/treatments, the severity of postpartum urinary incontinence significantly decreases.[14] Pelvic floor training, specifically perineal massage, is associated with an improved childbirth experience. This modality was shown to decrease perineal pain, tearing and lower the rate of urinary incontinence. Perineal massage, if done during the second trimester of pregnancy has been proven to enhance perineal results, by lowering the risk of perineal tearing. Additionally, perineal massage performed during the first trimester of pregnancy can shorten the duration of labor. [15][16]

## References

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1. ^ a b c Wallace, Shannon L.; Miller, Lucia D.; Mishra, Kavita (December 2019). "Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women". Current Opinion in Obstetrics & Gynecology. 31 (6): 485–493\. doi:10.1097/GCO.0000000000000584. ISSN 1040-872X. PMID 31609735. S2CID 204703488.
2. ^ a b Bradley, Michelle H.; Rawlins, Ashley; Brinker, C. Anna (August 2017). "Physical Therapy Treatment of Pelvic Pain". Physical Medicine and Rehabilitation Clinics of North America. 28 (3): 589–601\. doi:10.1016/j.pmr.2017.03.009. PMID 28676366.
3. ^ Ghaderi, Fariba; Bastani, Parvin; Hajebrahimi, Sakineh; Jafarabadi, Mohammad Asghari; Berghmans, Bary (November 2019). "Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial". International Urogynecology Journal. 30 (11): 1849–1855\. doi:10.1007/s00192-019-04019-3. ISSN 0937-3462. PMC 6834927. PMID 31286158.
4. ^ a b Rosenbaum, Talli Yehuda (January 2007). "Reviews: Pelvic Floor Involvement in Male and Female Sexual Dysfunction and the Role of Pelvic Floor Rehabilitation in Treatment: A Literature Review". The Journal of Sexual Medicine. 4 (1): 4–13\. doi:10.1111/j.1743-6109.2006.00393.x. PMID 17233772.
5. ^ Wente, Karla; Dolan, Christina (March 2018). "Aging and the Pelvic Floor". Current Geriatrics Reports. 7 (1): 49–58\. doi:10.1007/s13670-018-0238-0. ISSN 2196-7865.
6. ^ Sigurdardottir, Thorgerdur; Steingrimsdottir, Thora; Geirsson, Reynir T.; Halldorsson, Thorhallur I.; Aspelund, Thor; Bø, Kari (March 2020). "Can postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial". American Journal of Obstetrics and Gynecology. 222 (3): 247.e1–247.e8. doi:10.1016/j.ajog.2019.09.011. ISSN 1097-6868. PMID 31526791. S2CID 202674386.
7. ^ Malinauskas, Ana Paula; Bressan, Elaine Fernandes Macedo; de Melo, Andrea Maria Zaher Rosa Pereira; Brasil, Cristina Aires; Lordêlo, Patricia; Torelli, Luiza (2023-07-01). "Efficacy of pelvic floor physiotherapy intervention for stress urinary incontinence in postmenopausal women: systematic review". Archives of Gynecology and Obstetrics. 308 (1): 13–24\. doi:10.1007/s00404-022-06693-z. ISSN 1432-0711.
8. ^ García-Sánchez, Esther; Ávila-Gandía, Vicente; López-Román, Javier; Martínez-Rodríguez, Alejandro; Rubio-Arias, Jacobo Á (2019-11-08). "What Pelvic Floor Muscle Training Load is Optimal in Minimizing Urine Loss in Women with Stress Urinary Incontinence? A Systematic Review and Meta-Analysis". International Journal of Environmental Research and Public Health. 16 (22): E4358. doi:10.3390/ijerph16224358. ISSN 1660-4601. PMC 6887794. PMID 31717291.
9. ^ Alouini, Souhail; Memic, Sejla; Couillandre, Annabelle (2022-02-27). "Pelvic Floor Muscle Training for Urinary Incontinence with or without Biofeedback or Electrostimulation in Women: A Systematic Review". International Journal of Environmental Research and Public Health. 19 (5): 2789. doi:10.3390/ijerph19052789. ISSN 1660-4601. PMC 8910078. PMID 35270480.
10. ^ Zhu, Hongmei; Zhang, Di; Gao, Lei; Liu, Huixin; Di, Yonghui; Xie, Bing; Jiao, Wei; Sun, Xiuli (January 2022). "Effect of Pelvic Floor Workout on Pelvic Floor Muscle Function Recovery of Postpartum Women: Protocol for a Randomized Controlled Trial". International Journal of Environmental Research and Public Health. 19 (17): 11073. doi:10.3390/ijerph191711073. ISSN 1660-4601. PMC 9517758. PMID 36078788.
11. ^ a b c Woodley, Stephanie J.; Boyle, Rhianon; Cody, June D.; Mørkved, Siv; Hay-Smith, E. Jean C. (2017-12-22). "Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women". The Cochrane Database of Systematic Reviews. 12 (12): CD007471. doi:10.1002/14651858.CD007471.pub3. ISSN 1469-493X. PMC 6486304. PMID 29271473.
12. ^ a b Kuravska, Yuliia; Aravitska, Mariia; Churpiy, Ihor; Fedorivska, Lesia; Yaniv, Olesia (March 2022). "Efficacy of correction of pelvic floor muscle dysfunction using physical therapy in women who underwent Caesarean section". Journal of Physical Education and Sport. 22 (3): 715–723\. doi:10.7752/jpes.2022.03090. ProQuest 2648269295.
13. ^ "What is pelvic floor therapy and do I need it?". Worth It PT: Pelvic Health & Physical Therapy. 9 August 2022.
14. ^ Chen, Yanzhen; Zhang, Feifang; Zheng, Pingwu; Cui, Dawei; Fan, Xufei (2025). "Postpartum Stress Urinary Incontinence: Current Advances in Non-Pharmacological Therapies". Archivos Españoles de Urología. 78 (1): 1. doi:10.56434/j.arch.esp.urol.20257801.1. ISSN 0004-0614.
15. ^ Schreiner, Lucas; Crivelatti, Isabel; de Oliveira, Julia M.; Nygaard, Christiana C.; dos Santos, Thais G. (October 2018). "Systematic review of pelvic floor interventions during pregnancy". International Journal of Gynecology & Obstetrics. 143 (1): 10–18\. doi:10.1002/ijgo.12513. ISSN 0020-7292.
16. ^ Li, Yuxuan; Wang, Chongkun; Lu, Hong; Cao, Linlin; Zhu, Xiu; Wang, Aihua; Sun, Ruiyang (2023-02-01). "Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis". International Journal of Nursing Studies. 138: 104390. doi:10.1016/j.ijnurstu.2022.104390. ISSN 0020-7489.