Women’s Health and Pelvic Floor Physical Therapy is a highly specialized area of Physical Therapy that requires advanced and substantial additional training for a physical therapist in this niche discipline. Less than one percent of all physical therapists specialize in pelvic floor dysfunction. This is a new direction in physical therapy that is becoming increasingly popular due to its success. 1 in 7 women suffers from pelvic pain at some point in their life. They end up going to multiple specialty doctors looking for answers and getting nowhere. This pain affects every aspect of a woman’s life, including going to the bathroom, sitting, walking, having sex, and wearing a tight pair of jeans that can put pressure in the wrong places.
Here at Action Physical Therapy, we specialize in and successfully treat women with pelvic pain and incontinence. Please refer them to us if you have any of the symptoms described or know someone who does. We are there not just to treat the patients but to make a difference in their lives.
Please read the following article, and if it pertains to you, please contact us at 215-947-3443 to schedule an appointment.
Why It Hurts Down There
What you need to know about pelvic-floor dysfunction
Published in www.prevention.com in April 2014
Understanding Pelvic Floor Dysfunction
By Sari Harrar
The pain began as a weird twinge, like an odd muscle pull where her groin and pubic area meet. “Within a few days, my vagina felt like it was on fire,” says Lisa, a 36-year-old New Jersey mother of two and human resources executive who paddleboards and scales the tough routes at her local climbing gym on weekends. “I’m a strong, confident woman. But the pain was beyond excruciating. At one point, I ended up curled in a ball at work, sobbing.”
It was the summer of 2012, and Lisa trudged from one doctor to the next—11 in 1 month—to find out the elusive source of the pain. But the doctors—urologists, gynecologists, the emergency room doctor she saw when she thought her insides were imploding—found nothing wrong. Tests for infections came back negative. Rounds of antibiotics, antivirals, and antifungal drugs were useless. A psychiatrist hinted at hidden marital discord (“So not true,” she says); a gynecologist speculated about genital warts (“I’ve been faithfully married for 15 years, so imagine what I said to my husband after that misdiagnosis—I’m still apologizing”). At one point, the pain was so horrific. She begged one doctor to remove her vagina.
It was as though the very thing that made her a woman had declared war on her. Worse, she had no idea how to fight this intimate enemy, one that was quickly swallowing the life she knew. “I’m an extremely positive person,” Lisa says, “but I felt like my independence and feminine identity were being stripped away. I hated the moment I woke up every morning, searching for how intense the pain was going to be, wondering if I’d get through work and be able to spend time with my kids and husband or end up just lying on the couch again.”
Then, as she sat in yet another doctor’s waiting room, a book caught her eye. It was Heal Pelvic Pain, by physical therapist Amy Stein. Lisa began reading, finding a familiar set of symptoms and a phrase that in her pilgrimage from doctor to doctor she’d never heard: the pelvic floor. This melon-size web of muscles, ligaments and exquisitely sensitive nerves is at the bottom of the pelvic region. It supports the uterus, bladder, colon, and rectum; stabilizes the pelvis, trunk, and hip joints; and plays a role in everything from orgasm to continence. And, as Lisa learned as she read, if something goes awry, it can refer searing pain to a bewildering array of organs and tissues.
Ancient healing traditions regard the area below the navel as the seat of the life force, what’s known in Chinese medicine as qi. Today it’s one of the hottest frontiers in women’s health.
Lisa finally got her diagnosis—pelvic-floor dysfunction—though only after she talked her urologist into writing her a referral to a pelvic-floor physical therapist. This is a relatively new breed of practitioners—with a PT, not an MD, after her name—who has expertise in fixing what goes wrong in the crowded organ, muscle, and skeletal systems in male and female pelvises.
For a condition that seems so hard to diagnose, PFD is surprisingly common. By some estimates, it affects one in four American women, who might call it by a different name while aware of the pain. In some, like Lisa, PFD manifests as pain in the vulva. Doctors may call it vulvar vestibulitis, an inflammation of vulvar tissue. In other women, it’s a bowel disorder, endometriosis, interstitial cystitis (chronic pain or tenderness in the bladder), or lingering or episodic hip, back, or abdominal pain (in addition to these Five Reasons For Pelvic Pain).
The confusion is understandable: Since the pelvic floor connects the upper and lower body, the pain can be a moving target, shooting up to the back or down to the feet and darting everywhere in between. Doctors unfamiliar with PFD may wind up diagnosing the problem with the same narrow thinking as the blind men from the old Indian fable, describing an elephant based only on the parts they could feel.
“Often, doctors see the symptoms in the affected organ or joint and treat that rather than finding the real cause,” says Amy Stein, DPT, a pelvic-floor physical therapist in New York City, whose book set Lisa on the path to a diagnosis. “They try to treat just the vulva pain or the bladder pain, constipation or incontinence, or urge to pee all the time, out-of-balance hip joints or the back pain. But when you miss the cause, you can’t really fix the problem.”
The cause can be a bit of a dog’s breakfast itself. Both weak and strong muscles and muscles that are too tight—yes, those built up by faithfully doing the Kegel exercises gynecologists urge women to do—can lead to pelvic-floor pain. Loss of muscle mass with aging and hormonal declines in menopause are among the culprits, affecting the fast-twitch and some slow-twitch fibers that help control urination, defecation, and the relaxing or tightening of the vagina. The result: In your 50s and 60s, your risk of PFD nearly triples. Although men do have pelvic-floor disorders, largely as a result of injury or surgery, being a woman is the greatest risk factor for all the obvious female reasons: Pregnancy and childbirth can stretch pelvic muscles out of shape, leading to pelvic-organ prolapse - the dipping and even protruding of the uterus, bladder, urethra, and rectum into the vaginal vault, which itself may weaken and collapse. Giving birth boosts your chances of developing one of the myriad pelvic-floor issues by 18% if you’ve had one child and 32% if you’ve had three, according to data from the Herman & Wallace Pelvic Rehabilitation Institute, a well-respected Seattle-based pelvic-floor-therapy training center.
Tight, shortened muscles can also trigger painful tension and spasms in the pelvis the same way they can cause a charley horse in your calf. You may be unwittingly holding tension in your core, doing Kegels when you shouldn’t (or doing them wrong, as 50% of women do), or involuntarily tensing your muscles when you have menstrual cramps or other pain. Injuries related to childbirth, surgery, or an accident (like falling on your hip or tailbone) may also play a role. Having a cesarean or hysterectomy can leave behind adhesions and scars that exacerbate the problem. Obesity is also a risk factor.
In Lisa’s case, her pelvic-floor muscles were clenched into tight knots. “Childbirth, my habit of holding my stomach in, a tailbone injury as a child, even riding on the seesaw with my daughter may have contributed,” she says. “The tight muscles translated into intense pain in my vulva.”
Her treatment, like that of so many other women with PFD, didn’t depend on drugs, surgery, or even doctors. The physical therapist who diagnosed her relaxed the tension with internal and external massage, among other treatments, and gave her home exercises that Lisa still does today if she has a (rare) relapse.
PFD is gaining recognition among pelvic-pain specialists, gastroenterologists, colorectal doctors, urologists, gynecologists, and urogynecologists, who are part of a relatively new specialty in which practitioners have expertise in both bladder and pelvic health. The first step to relief is a pelvic-floor evaluation, followed by specialized physical therapy.
This kind of exam, which either a PT or an MD can perform, will feel familiar. “It’s a lot like the gloved internal check your gynecologist does, although we focus on muscle function,” says Holly Tanner, PT, DPT, a pelvic-floor physical therapist in Seattle and curriculum director for the Herman & Wallace Institute. (In fact, experts are urging gynos to pay more attention to these muscles.) “Part of the exam is performed with one gloved finger in the vagina or rectum to check muscles,” she says. The therapist will look for tenderness, pain, and any tension in the muscles and if they’re weak or strong. “But we also look from the outside to see if you can tighten and lift the pelvic floor and relax it, too,” she says.
“This should be the frontline treatment for all sorts of pelvic pain,” says urogynecologist Colleen Fitzgerald, MD, medical director of the Chronic Pelvic Pain Program at Loyola University in Chicago, where she treats patients and conducts research. “If you’re not seeing a specialist who understands the impact these muscles have in causing pain or making it worse, you may not be getting the best care. Less than half of the women who would benefit from a pelvic-floor evaluation are getting one.”
While there are helpful drugs and even surgical solutions to some pelvic-floor problems, new research shows that physical therapy plus home routines work better for many women than either alone. In a 2014 study of nearly 800 women with PFD, University of Missouri researchers found that most saw incontinence, constipation, and/or pain improve by at least 80% with pelvic-floor physical therapy. This combo can ease nearly 60% of serious bladder pain in women and about 50% of vulva pain. Kegels - contracting and relaxing the pelvic floor muscles - can dry up incontinence for up to 85% of women, say Norwegian researchers who reviewed 19 studies in 2013. People with lower-back pain got extra relief when they added pelvic-floor exercises to back exercises and ultrasound in another study.
Other treatments include massage-like work inside the vagina by a therapist to release scars, adhesions, and tight spots, with biofeedback to help train a patient to tighten and relax the muscles herself. “It’s not weird,” Lisa says. “The exam and treatments are very professional—and when you’re looking for relief, you’re so grateful that someone is helping to find the cause. When you start to feel the tight, painful spots inside you release, it’s wonderful.”
You’ll also go home with a list of daily exercises, including Kegels for weak pelvic-floor muscles and stretching and relaxation exercises that target tense pelvic-floor muscles and those attached to them, like the hip flexors and glutes. For some conditions, such as uterine prolapse, pelvic-floor work may follow corrective surgery. If your pain is intense, you may continue to take pain meds or muscle relaxants—some of which can be delivered directly to tense muscles via suppository—as you begin physical therapy, then find you can taper off as pain recedes.
Even if you don’t believe in qi, anatomically speaking, the pelvic floor is the center of your physical power and balance, keeping both sides of your body moving effortlessly in partnership. If the muscles tighten or lose mobility, they can cause your pelvic bones to torque, twisting your spine out of alignment. That’s what happened to Alexandra, a Washington, DC, lawyer in her mid-50s who struggled for years with what she described as severe back pain.
Her doctors told her that her sacrum (a triangular bone at the base of the spine) and her sacroiliac joint (twin kidney-shaped bones between the sacrum and the largest pelvic bone) had rotated, twisting her spine and all the attached muscles and ligaments like a wrung-out dishcloth. Conventional physical therapy and drugs, muscle relaxants, and cortisone shots barely touched her pain.
Then a therapist she was seeing recommended she consult a pelvic-floor physical therapist, too. It turned out that scar tissue and adhesions from a hysterectomy had tensed and stiffened Alexandra’s pelvic-floor muscles, pulling her pelvic bones off-center. Months of pelvic-floor therapy and at-home exercises released tight spots and strengthened weak muscles. “No jokes about it; therapy can be pretty painful,” she says. “But it worked. I can walk to a coffee shop, sit at my desk, and go shopping without pain.”
While the regimen works, it’s not always done in one session. Lisa had a couple of scary pain relapses but never again ended up sobbing at work. She went back for more PT and continued her home exercises. So far, no more fire down below.
“My life is back to normal,” she says. “I stretch a couple of times a week. I maintain an insane schedule. I rock-wall climb, hike, paddleboard, and wear tight, skinny jeans with heels to dance my heart out with my girlfriends, which is something I was terrified I would never be able to do again.”
Better Than Kegels
Once considered the essential strength-training move for fixing or avoiding incontinence (and boosting sexual pleasure), Kegel exercises, if done wrong, do very little or can actually cause trouble. “If your pelvic floor is tight, Kegels will make it tighter,” says pelvic-floor physical therapist Amy Stein, DPT. “Plenty of women should focus on relaxing their pelvic-floor muscles instead to help fix or prevent overactive muscles.”
Add Kegels if your muscles are relaxed and weak, says Holly Tanner, PT, DPT. You can assess muscle function yourself. If you can completely stop your urine midstream, your pelvic floor muscles are probably fairly strong, she says. If not, weakness could increase your risk of incontinence. “Do this check no more than once a month = and never use it as a form of exercise,” she says. “It can affect muscle coordination.”
To do Kegels correctly, sit or lie down in a quiet place. Inhale and tighten the muscles around your urethra, bladder, and rectum as if you were trying to hold back intestinal gas and stop the flow of urine at the same time. (Don’t tighten the muscles in your abs, hips, butt, or legs.) Hold for 10 seconds, then relax completely as you exhale. Repeat up to 10 times.
The Pelvic-Floor Drop
This relaxing move is the right choice if you have signs of tightness such as pelvic pain, constipation, or pain with sex or have to push to empty your bladder—and for everybody who wants to cut their risk of tightness, says Amy Stein, DPT. “Do it every morning and throughout the day to release tension,” she says. The move: Sit, stand or lie down in a quiet place. Relax your whole body with some deep, calm breaths. Then take a long, deep breath, and as you exhale, imagine your breath pressing down and out through your pelvis and your muscles relaxing and dropping. Don’t push. Aim for the same feeling you get when your urine stream starts to flow when you go to the bathroom.
If you’re experiencing pain or leaking, a pelvic exam is worth it, and health insurance often covers the cost. Find a trained pelvic-floor PT via the American Physical Therapy Association website or the Herman & Wallace Institute’s practitioner directory. Learn about related conditions such as interstitial cystitis through the Interstitial Cystitis Association and the International Pelvic Pain Society.