Pelvic Floor Physical Therapy: What Is It & When Is It Needed?

Pelvic floor issues can wreak havoc on everyday life. Whether it’s leaking urine with a sneeze, overactive bladder, bowel incontinence or pelvic organ prolapse, these conditions can greatly affect self-esteem and how we manage our days.

Luckily, many treatments exist, including pelvic floor physical therapy, which can help women (and men!) work toward lessening or even eliminating symptoms.

We spoke with Dr. Emily Rutledge, a urogynecologist at Houston Methodist, about what pelvic floor physical therapy is, what happens during sessions and when it’s worth considering.

What is the pelvic floor?

The pelvic floor is the base of the body’s core area — the core muscles all work together to stabilize and keep the body in motion while protecting vital organs. The pelvic floor is made up of multiple muscles and connective tissues, and holds the bladder, bowel and reproductive organs in their correct positions.

The pelvic floor isn’t just about pelvic bodily functions, whether it’s urinating, defecating or sex, according to Dr. Rutledge.

“The pelvic floor is even involved in functions as simple as breathing," Dr. Rutledge says. "It coordinates itself with your diaphragm as you breathe in, and those muscles contract and relax in sync with your chest. We don’t even know it’s there most of the time.”

Like with most things, we typically don’t think of our pelvic floor function until something seems off.

What does pelvic floor dysfunction mean?

Pelvic floor dysfunction is an umbrella term, according to Dr. Rutledge. It can refer to several different and sometimes overlapping issues involving the pelvic floor muscles, pelvic support structures and the organ systems they affect.

“Pelvic floor disorders or dysfunction encompasses various types of urinary incontinence, stress incontinence or urgency incontinence, also sometimes called overactive bladder,” Dr. Rutledge says. “There can also be bowel incontinence, pelvic organ prolapse as well as sexual dysfunction and pelvic pain.”

In other words, pelvic floor dysfunction can show up as:

• Urine leakage

• Urgency or frequency

• Bowel control issues

• Pelvic prolapse symptoms such as feeling pressure or bulging at the vaginal opening

• Sexual dysfunction such as pain, erectile dysfunction and more.

People can have more than just one symptom or issue at a time.

Dr. Rutledge stresses that pelvic floor issues are extremely common yet may often go untreated because the matter is sensitive to people.

“We almost certainly underestimate how common these issues are because there are still a lot of barriers to people feeling comfortable talking about some of these topics,” she says. “There can be a lot of social embarrassment around these things.”

She also points out that while the issues are often associated with getting older and reaching menopause, symptoms can begin much earlier than many people expect.

“Young women are certainly not spared of this, especially urinary incontinence,” Dr. Rutledge says. “It can start during your 20s, 30s or 40s, particularly surrounding pregnancies and vaginal deliveries, but having a C‑section is not entirely protective of these issues. There is a lot of laxity and movement the pelvic area undergoes to accommodate a baby.”

Dr. Rutledge says that 40% or more of women will experience issues like this during their lifetime.

“Certainly, all of these issues start to become much more common as we age, but they are not necessarily normal or something that you have to tolerate,” she says.

RELATED: Lifestyle Changes to Reduce Your Risk of Prolapse

What is pelvic floor physical therapy? And how does it address pelvic floor issues?

Pelvic floor therapy (pelvic health physical therapy) is specialized physical therapy focused on addressing pelvic health issues. Much like the physical therapy one might do to rehab an orthopedic injury, it’s about strengthening and retraining the muscles and structures of the pelvic floor under the supervision of a physical therapist.

“The main goals of pelvic floor physical therapy are using non-surgical methods to address pelvic floor dysfunction and be able to optimize a patient’s quality of life,” Dr. Rutledge says. “We send a lot of patients to pelvic floor physical therapy, and we work together both before and after surgeries or help patients avoid surgery altogether.”

The physical therapists who treat pelvic floor issues are highly trained individuals that have completed advanced training specifically for pelvic health, Dr. Rutledge notes. This is extremely important because pelvic floor therapy often involves sensitive examinations.

“The physical therapists conduct vaginal exams to assess muscle strength and to assess pain,” Dr. Rutledge says. “We want to make sure that patients feel comfortable and confident in their therapy.”

Who is pelvic floor physical therapy for?

Dr. Rutledge makes clear: pelvic floor therapy is for anyone dealing with pelvic floor dysfunction.

“They take care of patients who have prolapse, all kinds of urinary incontinence, bowel incontinence, sexual dysfunction, pelvic pain and tight, tense or weak pelvic floor muscles,” Dr. Rutledge says.

While often thought of as a treatment for women, men can also benefit from pelvic floor physical therapy.

“Men also see pelvic floor physical therapists, so it’s not just us girls,” Dr. Rutledge says. “Men may not recognize pelvic floor issues since these symptoms can be associated with other health conditions.”

The pelvic floor can be tight, tense or weak in men as well — resulting in symptoms such as incontinence, scrotum, rectum or groin pain, or erectile dysfunction. Whereas women may be commonly concerned with issues with a weak pelvic floor, men more often deal with symptoms due to tight pelvic floors. A weak pelvic floor also can occur as a side effect from prostate cancer treatment.

RELATED: 6 Signs It's Time to See a Urologist

What happens during pelvic floor therapy?

During a typical first pelvic physical therapy session, Dr. Rutledge says the therapist will take a detailed evaluation, talking with you about your current health and symptoms. An internal exam may not take place on that first visit.

“The initial evaluation will include many questions, so the therapist makes sure they understand bowel habits, bladder habits and if there’s pain,” Dr. Rutledge says. “They’re going to go pretty far in on all of the details of what you're feeling.”

Being able to talk openly with a therapist about everything, from our sexual health to our exercise, eating and drinking habits, is a big part of the benefit, according to Dr. Rutledge.

“I don't always have the time to pick apart things to that degree with patients, so therapists really help us do some fact finding to understand what might be impacting a patient’s issue,” Dr. Rutledge says. “They might even just watch the patient walk around the room to look for anything in their hips or lower back that could be contributing to the patient’s issues. They may do an abdominal exam, as the core muscles may be tight and affecting pain.”

When it comes to internal assessment, it may or may not occur in the first appointment. It isn’t what women are usually accustomed to during a well-woman exam.

“The pelvic physical therapists often will do a vaginal exam, but they do not use a speculum to exam like you’re having a Pap smear,” Dr. Rutledge says. “It’s more a matter of feeling and asking patients to squeeze, seeing what their pelvic floor strength and coordination abilities are.”

What tools and techniques might a pelvic floor therapist use?

Dr. Rutledge notes pelvic therapists may use similar tools to those people associate with other physical therapy settings — like elastic exercise bands — along with exercises and techniques tailored to pelvic floor needs.

“They may recommend stretches and exercises that can help open up or relax the hips, or strengthen the core or back with elastic bands,” Dr. Rutledge says. “They will identify the areas of weakness just as an ortho physical therapist would and suggest treatment in a way that is functional for the problem.”

Kegels are important, but not always the first therapy

Kegels, probably the most well-known pelvic floor exercise, can be part of pelvic floor therapy for certain conditions, of course. Dr. Rutledge says the exercises are often misunderstood as being the first line in pelvic floor therapy, even though many individuals may be unable to do them or do them incorrectly.

“There are a good number of patients, that for whatever reason, be it age or just trauma, for whom the nerve function is not as good and they lose track of those muscles, as strange as it may sound,” Dr. Rutledge says. “They may be doing Kegels thinking they’re targeting the right muscles and they’re not.”

Pelvic floor physical therapists assess a person’s muscle strength and ability to do Kegel exercises before recommending them as a therapy.

Ultimately, whether or not Kegels are part of a pelvic physical therapy plan will come down to an individual's symptoms, the affected muscles and their current strength. 

More therapies pelvic floor therapists may use

• Bladder/toilet training

• Bracing and taping for pelvic and spinal alignment and pain reduction

• Custom at-home exercise plans

• Deferment techniques to help with urge suppression

• Transcutaneous electrical nerve stimulation (TENS)/Interferential (INF): Electrical stimulation for pain relief or muscle relaxation, to ease bladder urgency or increase muscle tone

• Home dilator use

• Manual therapy techniques to decrease bladder or bowel urgency, pain and constipation

• Nutritional and lifestyle counseling — diet can affect overactive bladder, for example

• Pelvic floor relaxation and coordination techniques to decrease urgency and improve bowel or bladder emptying

• Perineal biofeedback – computer graphs and audible tones show you the muscles you are exercising. It allows a therapist to measure muscle strength and individualize an exercise program

• Rehabilitative ultrasound – evaluates muscle and related soft tissue forms and function during exercise

• Sexual health counseling and position modification

• Posture and movement impairment alterations

‘Homework’ is where most progress happens

As someone who's been through pelvic PT herself, Dr. Rutledge reinforces the practical reality that therapists have limited time per visit, so progress depends heavily on what you do between sessions.

“I always tell patients that physical therapy work begins in the room with the therapist, but most of it happens at home,” Dr. Rutledge says. “The therapist only gets an hour with you and they’re checking your progress and adding in new therapies as needed. The rest of the work happens at home and success comes with being consistent.”

Where pelvic floor therapy fits in a treatment plan

For many patients with pelvic floor issues, Dr. Rutledge says physical therapy is one of the first treatment options. However, it can be used before or sometimes after surgery depending on various factors.

“It’s very rarely the wrong answer to try pelvic floor therapy,” Dr. Rutledge says. “But we do try to be realistic with patients about what it takes to find success in this therapy.”

Pelvic floor physical therapy isn’t for everyone, Dr. Rutledge acknowledges — someone may not enjoy doing the at-home plan or their symptoms may be too advanced for the therapy to be successful.

“Some people are just beyond the point where physical therapy will be beneficial because they need a more significant intervention,” Dr. Rutledge says. “You have to learn where that line is.”

For those with mild to moderate pelvic floor issues, it can be a way to address issues before trying medications or surgery.

“Many patients want to feel like they’ve exhausted their non-surgical options before considering surgery,” Dr. Rutledge says.

When is pelvic floor therapy needed?

Dr. Rutledge repeatedly returns to a single decision point for people experiencing symptoms: quality of life. If symptoms are changing what you do, where you go, whether you exercise, how you sleep or whether you socialize, that’s a valid reason to bring it up with your doctor.

“If someone stops running because they’re leaking when they exercise, or they stop socializing because you’re not sure if you’ll leak stool or urine, these are all reasons to be evaluated,” Dr. Rutledge says. “It’s not just quality of life; it becomes a quantity of life issue because we know loneliness affects our longevity. These aren’t superficial issues.”

Where to start if you’re curious about pelvic floor physical therapy

Dr. Rutledge says patients should remember they're not the first person to bring up these symptoms to their doctor. Many of us will have this experience in our lifetimes.

“There are whole fields of medicine that are totally dedicated to this,” Dr. Rutledge says. “I spend all of my time taking care of patients with these issues, so that just tells you how many people are struggling with this.”

She encourages readers not to be afraid to bring symptoms up to their provider — especially because clinicians across primary care, OB‑GYN and urology refer patients for pelvic floor support regularly.

“Don’t be afraid to bring it up to your provider,” Dr. Rutledge says. “Whether it’s to pelvic floor physical therapy or urogynecology, your doctor can get you to the right person. Our goal is improving quality of life and getting patients back to all the activities that they want to be able to do. That's our whole mission.”