Pelvic Floor Physical Therapy

Pelvic health concerns, leakage of urine among them, are part of what Candace Cooley has treated across her years in women’s health, and treatment for them starts with anatomy. Picture a ring of bone at the bottom of the trunk, the hips, and across its lower opening a basket of muscle strung from the pubic bone in front to the sacrum behind and from side to side. That basket carries the uterus, ovaries, bladder and bowel, a physical therapist told NPR’s Life Kit. Working with the muscles of the belly it helps steady the spine, and it moves with every breath, lowering as the breathing muscle above it presses down and lifting again on the way out.¹

The FDA Office of Women’s Health credits this group of muscles and tissues with holding the pelvic organs where they belong, keeping urine and stool in until the right moment and contributing to sexual function, and names three ways they fail: they can be weak, tight or simply not work properly.⁴ A federal booklet on bladder control adds that ring shaped sphincter muscles keep the urethra closed while the pelvic floor holds the bladder up.⁶ Weak muscles cannot answer a sudden load. Tight ones cannot let go, and a muscle that never fully relaxes loses power too. The two problems call for nearly opposite work, and distinguishing one from the other is the first job of rehabilitation. The structure is described more fully under the pelvic floor.

Figure

Two ways the pelvic floor goes wrong

	Weak muscles	Tight or overactive muscles
Bladder	Leaking with a cough, sneeze, run or jump	Trouble starting the stream, a sense of incomplete emptying
Bowel	Leaking stool	Straining, constipation, hemorrhoids, thin stools
Sex	Less sensation, weaker orgasms	Pain with penetration or a tampon
Elsewhere	Prolapse, felt as heaviness or a bulge	Tailbone, deep hip or low back pain
Typical work	Strengthening, with quick and long held contractions	Breathing, posture, stretching and relaxation

How therapists assess and treat the two problems

Assessment is hands on. Sara Reardon, the therapist interviewed by NPR, says a qualified therapist should be trained to examine the pelvic floor muscles internally, rather than simply attaching a patient to a stimulation machine, and that treatment should mix exercise, manual therapy and education, with tasks to practice at home.² In every state, she notes, a person can see such a therapist for an evaluation without a physician’s referral, though insurance may still require one.¹ Weakness and tension can coexist; once tension is treated, she says, weakness is sometimes found underneath. She also cautions that the Kegel is only one exercise, and that telling every woman to do Kegels is like answering all back pain with sit ups.¹

For weakness, the familiar exercise is the Kegel, a squeeze of the pelvic floor that needs no equipment. Finding the right muscles is the hard part, and the bladder control booklet says a specially trained physical therapist can teach patients to locate and strengthen them; learning when to squeeze can also quiet the bladder spasms behind urge leakage.⁶ Reardon adds variety and timing: quick contractions and longer holds of five or ten seconds, done in different positions and during movements such as lunges and squats, plus a squeeze just before a cough or sneeze. She warns that habitual straining on the toilet can weaken the floor over time.² Weakness shows up as leaking with effort and as pelvic organ prolapse, in which the organs drop or push into the vaginal canal.¹

Figure

How the federal booklet teaches a Kegel

1. 01
   FindLocate the right muscles, for example by imagining stopping the passing of gas, and ask a clinician to check.
2. 02
   IsolateSqueeze only the pelvic muscles, without tightening the stomach or legs or holding the breath.
3. 03
   RepeatHold for a count of three, relax for a count of three, and build up the number of repeats.
4. 04
   VaryPractice lying down, sitting and standing, since all three positions build strength.
5. 05
   WaitImprovement in bladder control may take three to six weeks to notice.

Tightness is easier to miss. Overactive muscles can make it hard to start a stream or empty the bladder, cause straining, constipation and thin stools, make penetration painful, and send pain into the tailbone, hips and lower back.¹ The work here is relaxation and lengthening: deep breaths that let the floor descend, attention to posture and long sitting, stretches such as a deep squat or child’s pose, and at home a therapy wand or vaginal dilators.¹ The FDA office lists myofascial release, a form of physical therapy aimed at tension in the muscles and connective tissue, alongside Kegels as tools that improve tone and function.⁴

The extreme case shows how individual the work can be. A case report in PMC followed a woman whose hereditary spastic paraplegia left her pelvic floor in spasm, with pain during intercourse, constipation and difficulty emptying her bladder. Perineal massage helped little, and cold therapy was poorly tolerated. What worked was stretching, with an inflatable vaginal probe and exercises in a squatting position, which eased her pain, her bowel habits and her urinary stream.³ Because no set protocol existed for spasm caused by neurologic disease, the authors wrote, the plan had to be built around the patient.³

The range of normal

Pelvic floor symptoms are common enough to feel normal. A national survey of 1,961 women, announced by the National Institute of Child Health and Human Development in 2008, found pelvic floor symptoms in 23.7 percent overall. Age changed the picture sharply: 9.7 percent of women aged 20 to 39 were affected, against 49.7 percent of women past 80. Treatment, the institute noted, can include behavioral approaches and exercises that strengthen the muscles.⁷ Reardon puts the lifetime figure at one woman in three, including young women and women past menopause who never gave birth.² The bladder booklet notes that about half of adult women have leaked urine at some point, and insists that leakage is not a natural part of aging.⁶

Many women still treat it as normal. Nurses studying leakage in Ohio told WOSU Public Media that women hide it and adapt, giving up exercise, carrying spare clothes and planning outings around bathrooms, and listed physical therapy with biofeedback among the simple options they can be offered.⁵ Reardon frames the goal as making conversations about the pelvic floor ordinary, not its problems.¹ Not every pelvic symptom is muscular, though. Burning with urination can mean an infection, and a marked change in bowel habits calls for a medical evaluation, so other causes come first.¹ How much of a symptom is acceptable, and whether therapy, another treatment or watchful waiting fits, is for each woman to work out with a clinician who knows her. Leakage under strain, the commonest weakness pattern, has its own entry, stress urinary incontinence.