Pelvic pain and pelvic floor disorders are common issues that, for many people, can be treated or managed with pelvic floor therapy.

What is pelvic floor therapy?

Pelvic floor therapy is a type of physical therapy that helps strengthen or relax pelvic floor muscles to prevent, treat or manage the symptoms of pelvic floor disorders. Through a combination of exercise and other nonsurgical treatments, pelvic floor therapy can help children and adults improve core stability and control over urination, bowel movements and sexual function.

The pelvic floor is a group of muscles and connective tissues that help support reproductive, colorectal and urinary tracts. This includes organs such as the bladder, uterus, prostate and rectum.

What conditions does pelvic floor therapy treat?

Pelvic floor therapy is used to treat conditions related to pelvic floor dysfunction. Typically, the dysfunction is related either to low muscle tone or high muscle tone.

Low tone or hypotonic pelvic floor dysfunction is caused by muscles that are more relaxed and looser than normal, which makes it harder to contract the muscles. Low-tone pelvic floor symptoms that can be managed with pelvic floor therapy include:

• Pelvic organ prolapse
• Stress incontinence
• Overactive bladder
• Anal incontinence
• Lower back, pelvic or tailbone pain
• Sexual dysfunction
• Vaginal laxity

High tone or hypertonic pelvic floor dysfunction is caused by muscles that are tighter and more restricted than normal, resulting in pain when trying to relax or stretch the muscles. High-tone pelvic floor symptoms that can be managed with pelvic floor therapy include:

• Pelvic floor myofascial pain – pain originating from tension or trigger points within the muscles
• Vaginismus – involuntary tightening of pelvic muscles making penetration during intercourse difficult or impossible.
• Dyspareunia – overactive pelvic muscles that make intercourse painful
• Vulvodynia – chronic pain in the vulvar area
• Erectile dysfunction or pain during an erection or ejaculation
• Inability to achieve orgasm
• Constipation as well as hemorrhoids and anal fissures caused by constipation

Pelvic floor therapy may also help manage the following conditions and their symptoms:

• Endometriosis
• Interstitial cystitis, or painful bladder syndrome
• Levator ani syndrome (a chronic pain condition)
• Pregnancy and postpartum issues

Who can benefit from pelvic floor therapy?

While women are more frequent recipients of pelvic floor therapy, anyone may benefit from it. Children can also have pelvic floor therapy, often to treat incontinence and related issues.

Not all pelvic pain is related to a pelvic floor condition. It is important to discuss your symptoms with your primary care doctor, gynecologist or urogynecologist. They will be able to help determine if the symptoms are related to a pelvic floor condition, and they will work with you on the diagnosis.

Typically, pelvic floor therapy can help people who have:

• Problems with urination and bowel movements such as incontinence, pain or constipation.
• Sexual dysfunction such as pain during intercourse, erectile dysfunction or inability to achieve orgasm.
• Pelvic pain and pain in the region, including tailbone pain and lower back pain.
• Menstruation issues, such as heavy bleeding, irregular periods and severe cramping.
• Issues during or after pregnancy, such as pelvic pain, incontinence and abdominal muscle separation. You don’t have to wait until these issues start — working with a pelvic floor therapist as early as the second trimester can help prevent certain problems from developing.
• Had or are planning pelvic surgery, such as surgery for cancer-related conditions, pelvic organ prolapse or gender-affirming care procedures. Pelvic therapy can help strengthen muscles before surgery as well as help with recovery after.

Who performs pelvic floor therapy?

Pelvic floor therapy is performed by pelvic floor therapists — rehabilitation therapists who have training and expertise in treating pelvic floor disorders. Most often, pelvic floor therapists are physical therapists, but occupational therapists and other clinicians may also practice pelvic floor therapy. Therapists with the highest level of training have completed a fellowship and/or a board or specialty certification in women’s health, pelvic rehabilitation or a related discipline.

Preparing for a Pelvic Floor Therapy Appointment

There are a few ways you can prepare for a pelvic floor therapy appointment:

• Make sure you are dressed in comfortable clothing that allows you to move your legs without being restricted.
• Your examination may include an external and internal portion, so it is important to make sure your groin and genital areas are clean.
• It can also be helpful if you have a list of questions or concerns to ask your therapist during the appointment.

What happens during pelvic floor therapy appointments?

At your first appointment, you will meet with a pelvic floor therapist who will ask you about your medical history, symptoms and concerns, as well as answer any questions you have.

After this initial discussion, the therapist will examine the pelvic area as well as evaluate your body mechanics to check for any abnormalities that match your symptoms. At any time, you can let your therapist know if you are feeling uncomfortable, and the therapist will make accommodations.

There are two main portions of your examination: an external and internal examination.

External Examination

During this portion of the exam, the pelvic floor therapist may assess the spine, hips, legs and feet, as well as your core strength, balance and movement patterns. They may ask you to perform certain movements that may help reveal muscle imbalances, weakness or other issues that could be contributing to your symptoms.

The therapist may also use their fingers to press the areas around the groin, inner thighs and abdomen to assess the pelvic floor and surrounding muscles. You may be asked again to move in a certain way or contract specific muscles so that the therapist can feel or see how they react.

Internal Pelvic Floor Exam

Your therapist may recommend an internal pelvic floor exam. They will explain why it is needed and what to expect, and you can always opt out if you feel uncomfortable.

During the internal examination, the pelvic floor therapist may insert one or two gloved fingers with lubrication into the vagina and/or rectum to feel the internal structures. This can help identify areas that are painful or tightened as well as determine internal organ positions, which can help explain your symptoms. You may be asked again to contract certain muscles so the therapist can assess their position and strength.

Sometimes, the therapist may use special equipment such as biofeedback and ultrasound to better see how the muscles respond when you follow the therapist’s instructions. The therapist may also use these methods if you have concerns about an internal pelvic floor exam.

Treatment Plan

The examination may last up to an hour, and the therapist will use the information they gathered to create a tailored treatment plan. The therapist will explain the findings, possible causes of your symptoms and recommended treatment options. You will have an opportunity to ask questions about the diagnosis and the treatment plan.

Therapy Sessions

After the examination, pelvic floor therapy sessions will be scheduled. Generally, you can expect to be working with a pelvic floor therapist for eight–12 weeks, with one or two sessions a week. The number and frequency of sessions varies, and may be adjusted based on your progress.

Pelvic Floor Therapy Treatments and Techniques

A pelvic floor therapy treatment plan may include medications, lifestyle modifications, exercises and other nonsurgical treatments.

Medications can be prescribed to improve bowel or bladder function or to reduce symptoms or discomfort.

Lifestyle modifications may include:

• Increasing or reducing fluid intake.
• Adjusting bowel or bladder routines.
• Consuming less food or drinks that irritate the bladder, such as caffeine and artificial sweeteners.
• Eating more food containing fiber, such as apples, berries, broccoli, Brussels sprouts and green leafy vegetables.
• Adjusting the amount of physical activity.

Exercise can help strengthen or relax pelvic floor muscles. The pelvic floor therapist will teach you exercise techniques to practice at home. Common pelvic floor physical therapy exercises include:

• Kegels
• Bridge pose
• Squats
• Pelvic tilts
• Bird dog pose
• Heel slides
• Marches or toe taps
• Happy baby pose
• Diaphragmatic breathing
• Pilates

Each person will be prescribed different types of exercises. Working with a physical therapist is important for selecting the exercises that work for you and understanding how to perform them correctly.

Other Pelvic Floor Physical Therapy Techniques and Devices

During pelvic floor therapy sessions, the therapist may use various treatment techniques and specialty equipment to find what works best for your symptoms. These techniques and devices may include the following:

• Manual therapy uses gentle pressure and massage techniques (external or internal) to help relax muscles and regain control.
  • Myofascial release is a hands-on stimulation of trigger points in the pelvic floor muscles to help release tension.
  • Soft tissue mobilization uses hands-on techniques to help treat soft tissue injuries, reduce pain and swelling, and remodel scar tissue.
• Functional dry needling works by inserting thin needles along trigger points to help reduce pain and restore normal muscle function.
• Biofeedback uses sensors to track muscle activity in real time, and can help with retraining muscles to loosen or tighten.
• Electrical stimulation uses mild electrical currents to stimulate pelvic muscles, which can help strengthen them or normalize nerve activity.
• Myofascial acoustic compression therapy uses focused sound waves to target deep tissues and muscles to help relieve pain and tension.
• Low-level laser therapy uses light to help heal muscles at a cellular level.
• Vaginal dilators are objects of varying diameter that can be used to gently stretch vaginal muscles and train them to relax while the dilator is inserted.
• Weight cones are small weighted objects that are inserted into the vagina or rectum to train the muscles by holding the objects in.