Everything You Need to Know About Pelvic Floor Therapy

Starting with: what even IS the pelvic floor?

A few weeks ago, I started a chat thread asking for ideas for women’s health-related issues and questions people would like me to address here. There was a resounding interest in learning more about pelvic floor therapy — what it is, when to seek it, how it can help, how to find a good therapist, and more.

So today, I’m excited to be running this Q&A with pelvic floor physical therapist (and longtime Now What subscriber) Stephanie Dillon. Stephanie received her Doctor of Physical Therapy (DPT) degree from Washington University in St. Louis and has been treating people with pelvic health problems since 2012. She earned her board certification as a Women’s Health Clinical Specialist (WCS) in 2019. She is also the Physical Therapist Advisor for MommaStrong.

For me, the pelvic floor has long been a black box — what is it? What does it do? How does pelvic floor therapy work? How can you tell if you need it? So I started with basic questions, but we ended up having a long and fascinating conversation about all sorts of things, including, of course, Kegels!

Stephanie, let’s start with the basics: What is the pelvic floor? What does it do?

The pelvic floor muscles are a group of muscles that connect from your pubic bone in the front, all the way under the body to the tailbone in the back. They also extend to both sitz bones (the two bony bits at the bottom of your pelvis that you sit on). There are holes in your pelvic floor — the urethra and the vagina, if you’re female, and the rectum. The pelvic floor goes around all those openings.

The pelvic floor is a lot bigger than most people think. It controls your bladder and your bowels and your sexual function and can be involved in lower back pain or even hip pain. And it's a big piece of your core.

The pelvic floor muscles have the same properties as any other muscles in the body. They can be tight, they can be weak, they can have trigger points.

When I think of pelvic floor issues and pelvic floor therapy, I often think of pregnancy and postpartum recovery. How does pregnancy and childbirth affect the pelvic floor? Does it matter if you’ve had a vaginal birth versus a C-section?

When you're pregnant, the pelvic floor takes a lot of stress and load. Because there's basically a bowling ball sitting inside your pelvis.

Pregnancy affects the pelvic floor in terms of strength. It can get a little weaker. And then, especially if you have a vaginal delivery, any tearing that you have is through those muscles. That's why I and most pelvic floor PTs are super strong advocates for going to pelvic floor therapy, even just once, after having a baby. It’s so important to know what's happened to your body and what your muscle function is.

It’s still important for women who have had C-sections. That gets really overlooked. Because you do still spend nine months growing another human inside your body. There's still the pressure on the pelvic floor the whole time, plus then the incision through the abdominal wall can leave you with some abdominal weakness. Some people can have issues with their scars, with scar tissue becoming painful or really tight, and so then we can do a lot of work both on the abdominal wall and on the pelvic floor muscles, to make sure they're functioning like they should.

[Note from MWM: I wrote about C-section scar-related symptoms for The New York Times a few years ago; here’s a gift link.)

So during and after pregnancy, what tends to happen to the the pelvic floor? Does it typically become too tight? Or too loose?

It can go either way. If people are having leaking or painful sex or any kind of pelvic dysfunction, they tend to assume that they're weak, and then they start doing Kegel exercises. But a lot of the times they’re not weak, they’re actually tight. The pelvic floor actually kind of has too much tone or tension in it.

Generally, the problems that occur when the pelvic floor is overactive or too tight are things like painful intercourse, difficulty emptying your bladder all the way, and constipation. If you have too weak of a pelvic floor, the symptoms tend to be leaking urine, leaking stool or pelvic organ prolapse (that’s a drop in position of the bladder, bowels, uterus, or cervix, so that they’re falling in towards the vagina; sometimes people feel a bulge while wiping, or they feel heaviness or pressure in the pelvis).

But I will say it's really important not to assume that you're one way or the other based on your symptoms. Someone who has, for example, pelvic floor prolapse — if they're feeling a lot of heaviness or pressure in the vagina, they might counteract that pressure by over-engaging their pelvic floor muscles. And then they might read online that they just need to do Kegels. But that actually makes the problem worse. So the individual assessment is really important.

What kinds of symptoms might suggest that you would benefit from going to a pelvic floor PT?

I'd say number one is urine leakage. After pregnancy, the narrative out there is that a little bit of leakage is normal, and that is definitely not true. After that six to eight week mark postpartum, you really should be fully continent, and you should not be leaking, even with coughing and sneezing and jumping on a trampoline and stuff. If you're having any amount of leakage, that is not normal. We know from the science that pelvic floor therapy can be very helpful.

Painful intercourse is another thing that people put up with way too long. Any amount of pain with that can be indicative of overactive or tight pelvic floor muscles or prolapse. Pelvic floor physical therapy can really help.

Constipation, fecal incontinence (stool leakage) are the other things that pelvic floor PTs can really help with, too. And pelvic or lower back pain. With any type of pain around the area of the pelvis, the pelvic floor can definitely be involved, even if it may not be the primary source. Even gynecological conditions like endometriosis and PCOS (polycystic ovarian syndrome) — those kinds of gynecological pain syndromes, a lot of times, will also cause overactivity in the pelvic floor. So even though PTs can't help with the endometriosis part, we can help them with the associated muscle tightnesses and muscle dysfunctions. And we'll do a lot of abdominal wall treatment as well — hands on kind of treatment or core and abdominal strengthening.

That is a good segue to I was going to ask next: What might someone expect at a PT appointment?

There's definitely a lot of variation. First, pelvic floor physical therapists are still general PTs. We all graduate school as generalists, and the pelvic floor training is done postgraduate. We look at the pelvic floor within the context of the rest of the body. So you'll get a general assessment of posture. How well can you move around? What's your flexibility like? What's your core strength and your hip strength like? We work a lot on breathing, too. A lot of people are not breathing correctly, so we work on that, because that's tied to pelvic floor function as well.

Sometimes we do internal work, too — typically, one finger inside a vagina to check muscle strength endurance, and and then also to feel all the structures there to see if anything is tight or tender or painful. We can also assess for prolapse. And then some PTs can even fit pessaries, which are like little devices that go inside the vagina to help hold up the prolapse.

If the patient is having any bowel or rectal symptoms, we could also do a rectal exam. I'd say that's much less common, but it is part of our skill set, and it's something that we would do if it's indicated.

Let’s talk about Kegels for a minute, because you’ve brought them up a few times. They seem to be a go-to self-treatment for pelvic floor issues. Are they sometimes not helpful?

They're a conundrum, for sure. First of all, let's talk about the term, because they're named after a dead white guy, but they weren’t even invented by him. Margaret Morris was the first one to come up with the Kegel exercise, well before Arnold Kegel did.

So the key with Kegels, or any kind of pelvic floor exercise, is that they have to be done in the appropriate context. Most people, if they're doing Kegels, all they're doing is squeezing their pelvic floor as tight as they can. They're probably holding their breath, and they're probably doing them sitting down. And, of course, muscles don't function in one context, right? You have to be able to use your pelvic floor while you're breathing, and then be timing it with the breath. So for a lot of people who leak with coughing or sneezing or running or jumping, those things are big exhalations. So learning how to engage your pelvic floor on an exhale is actually really important and not something that most people do.

The other important context is body positioning. If people are having trouble with leaking or prolapse, it's mostly occurring while they're standing, and most people don't think to do Kegels while they're standing. So it's really important to learn how to engage your pelvic floor across all those different positions, and especially with exercises — like if you are doing core strengthening or squats or lunges or anything like that, you need to know how to engage your pelvic floor during those activities as well.

And it’s not just about the strengthening, it's about the relaxation too — so making sure you can fully let go and fully release the muscles in between the contractions, or maybe even take a few seconds to breathe and fully relax before you contract again. That relaxation and waiting period is also incredibly important. And it's something that most people miss.

So…. what’s the right way to do a Kegel?

The gold standard would be to be have an individual assessment by a pelvic floor PT, and I will just say — we're a lot better than going to the gynecologist. We don't use a speculum or stirrups or anything like that. It’s just one gloved finger in the vagina while you're squeezing and seeing how well you can squeeze, how long can you hold, how well can you relax, that kind of stuff.

But generally, if I'm trying to teach someone how to do it, there's a really cool trick you can use. Just roll up a towel and then sit on the towel long ways on your pelvis. It's basically going from pubic bone to tailbone, under your body while you're sitting there. The curve of the towel will match the curve of the pelvic bones. Then, if you're engaging your pelvic floor, doing a Kegel, you should feel the muscles lifting away from the towel. And then as you relax, they should fall back down towards the towel. That’s a helpful feedback mechanism to know if you're engaging the right muscles.

So the goal would be: can you engage the muscles and pull them away from the towel without squeezing other muscles? So you're trying not to squeeze your butt, squeeze your thighs, that kind of stuff, and to squeeze without holding your breath.

What’s the best way to find a pelvic floor PT? Are there accreditations we should look for? Is it typically covered by insurance?

You can ask your gynecologist or even primary care doctor, or you can search this or this online directory. Also, almost all major hospital systems typically have at least one pelvic floor physical therapist, but it may or may not be clear from their website. You may have to just call their rehab department and ask.

You don't need a referral from your doctor any longer to at least start PT, unless the clinic you are attending has a different internal policy.

No certifications are required to be a pelvic floor PT. If someone has one of these certifications or letters after their name, it means they have gone above and beyond to improve their skills to meet national standards of certification: CAPP-OB, CAPP-PF, WCS, PRPC.

If you go to a pelvic floor specialist but they don’t have the training to do an internal exam, that is a big red flag. It’s not always done on the first day, but the person you're seeing should have the ability to do it.

Insurance does cover pelvic floor physical therapy generally, but a lot of private clinics are out-of-network with all insurance companies. They will almost always provide a superbill you can submit to your insurance company to try to become reimbursed.

Also, you can typically use flex savings & health savings accounts (FSA/HSA) to pay for PT at these clinics, some will accept payment from companies like CareCredit. And many PTs (like myself) also hold a few pro bono and sliding scale spots for folks that may be on limited budgets.

Are there any other misconceptions you’d like to correct about pelvic floor physical therapy?

A big misconception that is only for women. Everyone has a pelvic floor. We can also see men and transgender and non-binary people. We can even see kids. We don't do internal exams on children, of course; the most common reason why a pelvic floor PT would see a kid is for prolonged bedwetting – if they're wetting the bed after, like age five. Pelvic floor therapy really is for everyone.