Vanderbilt experts explain pelvic floor physical therapy.
Pelvic floor physical therapy can help relax and strengthen the muscles of your pelvic floor. This in turn can help relieve pain in the pelvis and give you more control over your bodily functions. But many patients are hesitant at first when their health-care provider recommends this type of physical therapy to treat their pain.
Vanderbilt gynecologic pelvic pain specialist Dr. Lara Harvey, and pelvic floor physical therapist Jenn Emery explain why pelvic floor physical therapy is prescribed, what benefits it offers and what to expect from a session with a physical therapist.
What is chronic pelvic pain?
Chronic pelvic pain is defined by pain below the belly button and between the hips that lasts for at least six months. Sometimes chronic pelvic pain is constant; other times it may come and go. Many conditions can cause chronic pelvic pain. Some conditions causing pelvic pain in women are gynecologic, such as endometriosis or fibroids. Other causes can involve the gastrointestinal tract or bowel, including irritable bowel syndrome, diverticulitis, painful bladder syndrome, chronic kidney stones or injury to the nerves.
Chronic pain from any condition can be debilitating. It usually takes time to improve. It is important to diagnose the initial cause of the pain as well as secondary problems to get the best results. Often, we have to address several problems, including nerves that are not signaling correctly, chronic stress and pelvic floor myalgia (muscle pain) that develop in a response to living with chronic pain.
What are the pelvic floor muscles?
The muscles that make up the pelvic floor form a sort of bowl that holds up the pelvic organs. A woman can feel some of these muscles if she squeezes as if trying to stop a stream of urine. We don’t often think about these muscles when going about our daily lives if they are functioning normally. However, it is very common for women with chronic pelvic pain or with an injury to these muscles to develop pain and tension called pelvic floor myalgia. This can range from mild to so severe it can be debilitating. This disorder can also make it painful and difficult to have sex.
How do you diagnose pelvic floor myalgia (pain)?
A gynecologist familiar with the disorder can diagnose it with a physical exam in the office. The exam is internal. It consists of pressing on the various muscles through the vaginal wall to see if this triggers discomfort.
How does this therapy differ from a pelvic exam by a doctor?
Compared with a pelvic exam by a doctor or nurse practitioner, a pelvic floor exam with a physical therapist is more focused on the pelvic floor muscles, including assessment and treatment of weakness, tightness and causes of pelvic muscle pain.
What is pelvic floor physical therapy?
A therapist with specialized training in pelvic floor muscle dysfunction will evaluate how well the muscles in your pelvis are functioning. This exam is done in a private setting. The physical therapist will discuss your symptoms with you, including bowel and bladder habits and sexual function. The evaluation will also assess your breathing patterns, posture, and strength and mobility of your spine, hips and pelvis. This may include an external and/or internal pelvic floor muscle assessment to determine your strength, coordination, and tension of these muscles.
Female therapists usually do this, as some of the work is done vaginally. It can consist of a therapy called myofascial release, which aims to stretch and condition the abnormally contracted muscles.
This is not the same as kegel exercises, which some women have heard about. In fact, in many cases of pelvic floor myalgia, kegel exercise can make the condition worse. There are other techniques available as well, and a trained pelvic floor therapist will tailor a program to a patient’s needs. Often patients haven’t heard of this kind of therapy, and it may seem strange. However, many patients gain significant improvement from pelvic floor therapy. Typically it takes time to be effective and sometimes symptoms can get a little worse before getting better. You can imagine if you have a leg cramp, the first time you stretch it out can be a bit painful before it starts to really loosen up.
I’m nervous about what to expect. Is an internal exam necessary?
Treating pelvic floor dysfunction is possible without an internal exam. However, treatment can be tailored better to your condition with the information an internal exam provides. The purpose of the internal exam is to assess how the pelvic floor muscles are working. It can help identify whether those muscles are weak, overly tight and/or whether they are causing pain.
Ask the therapist to describe the exam in advance and discuss ways to help you feel more comfortable. During your visit you can stop the internal exam at any point.
What if the pelvic floor exam is too painful, or I’m on my period?
A pelvic floor exam is often less intense than a regular pelvic exam. The therapist typically uses a gloved finger rather than a speculum. If an internal exam is too painful, the therapist can assess the pelvic floor muscles externally. Pelvic floor exams can be completed while you are on your period unless you are having significant pain or cramping.
What kind of pelvic floor physical therapy will I have?
Before beginning physical therapy, the provider checks the back, pelvis and hips to determine range of motion, flexibility and strength, also assessing the internal pelvic floor muscles to see if they are in spasm, weak or uncoordinated. This helps the therapist design a treatment plan for you using one or more of the following:
- Exercise therapy. This involves stretching and/or strengthening the trunk and pelvic floor muscles, using exercises that may include diaphragmatic breathing and yoga poses, among others.
- Manual therapy. Massage techniques may be used to relax tension within muscles and desensitize painful scars.
- Biofeedback therapy. Biofeedback uses sensors to provide information (feedback) about your body. This feedback can help you learn how to relax and control your muscles.
- Electrical therapy. If your muscles are very weak, an electrical current may be used to stimulate them.
What are trigger points?
A trigger point is a sensitive, tight band within a muscle. Pressing on or contracting the muscle is often painful, and the pain may be located at the trigger point or could radiate to another area of the body. Trigger points can occur in any muscle. When they occur in the pelvic floor muscles, they can cause pelvic pain at rest or during bowel movements, pelvic exams and intercourse. An urgent need to urinate may also occur. Common treatments for trigger points include massage and applying sustained pressure to the trigger point to reduce tightness and pain. Relaxation training can also improve trigger points.
Is it common to use a dilator for trigger point release massage? What is a dilator?
Dilators are common tools for treating pelvic floor trigger points. They are inserted vaginally or rectally to allow direct massage of the trigger points. Your pelvic floor therapist can talk with you about whether a dilator could be helpful for you and can also teach you how to properly use the dilator.
Are pelvic floor exercises something I can do at home once I’ve been to a physical therapy session?
Your therapist will teach you exercises to do at home between physical therapy sessions. Some people only need two to four appointments, but most people have eight to 12 sessions to achieve the best possible improvement.
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