Pelvic Floor Physical Therapy

Objectives

  • Scope of Practice for Pelvic Floor Physical Therapy Landmarks and Significant Anatomy of the Pelvic Floor

  • Functions of the Pelvic Floor (PF)

  • Common PF Dysfunction:

    • Urinary incontinence

    • Constipation

    • Pelvic pain

    • Diastasis recti

  • Terminology Considerations:

    • Use “male” or “female” in reference to biological sex.

    • Consider using AFAB (assigned female at birth) or AMAB (assigned male at birth).

    • Discuss preferred pronouns with patients before evaluation.

What is Pelvic Floor Physical Therapy?

  • Definition: A non-surgical approach to rehabilitation of dysfunctions in the pelvis affecting bowel, bladder, sexual health, and pain complaints.

  • Therapeutic Approaches:

    • Behavioral strategies

    • Manual therapies

    • Modalities

    • Therapeutic exercise

    • Education

    • Functional retraining

Requirements to Become a Pelvic Floor PT

  • Required:

    • Interest in pelvic floor therapy

    • Completing pelvic coursework (Herman and Wallace, APTA)

  • Optional:

    • Pelvic floor clinical experience

    • Residency: 12-18 months with weekly mentorship

Certifications

  • ABPTS Women’s Health Clinical Specialist (WCS):

    • Complete 2000 hours of direct patient care or complete residency

    • Submit case reports

    • Pass a written exam

  • Herman and Wallace Pelvic Rehabilitation Practitioner Certification (PRPC):

    • Complete 2000 hours of direct patient care

    • Pass a written exam

  • CAPP-Pelvic and CAPP-OB:

    • Required continuing education

    • Submit case reports

Importance of Treating Pelvic Floor Dysfunction (PFD)

  • Statistics:

    • Women with incontinence: 2.3-2.5 times more likely to have frequent back pain.

    • 1 in 4 women experience PFD.

    • 10-20% of men experience PFD.

  • Implications:

    • Leads to surgical procedures.

    • Caused loss of healthcare dollars.

    • Affects productivity at work.

    • Decreases overall quality of life.

Anatomy of the Pelvic Floor

  • Musculature Attachments: 36 muscles attach to the sacrum or innominates, including:

    • Adductors

    • Gluteus muscles

    • Quadriceps

    • Obturators

    • Piriformis

    • Rectus Abdominis

    • Transverse Abdominis

    • Latissimus dorsi

    • Erector Spinae

Bony Landmarks of the Pelvis

  • Pelvic Clock:

    • 1,11: Ischiocavernosus

    • 2,10: Bulbocavernosus

    • 3,9: Superficial Transverse Perineal

    • 0: Perineal body

    • 12: Pubic symphysis inferior angle

    • 4,8: Levator ani; Pubococcygeus

    • 5,7: Levator ani; Iliococcygeus

    • 6: Coccyx

Layers of Pelvic Floor Musculature

  • Layer 1: Support bathroom activities

    • Superficial transverse perineal

    • Bulbocavernosus or bulbospongiosus

    • Ischiocavernosus

    • External anal sphincter

    • Perineal Body: Central point for superficial pelvic floor musculature.

  • Layer 2: Sexual funcion

    • Perineal membrane (thick, fibrous sheet of dense fascia)

    • Deep transverse perineal

    • Sphincter urethrovaginalis

    • External urethral sphincter

  • Layer 3: Deep supportive

    • Levator Ani:

      • Pubococcygeus

      • Puborectalis

      • Iliococcygeus

    • Coccygeus

Manual Muscle Testing for Pelvic Floor

  • Modified Oxford Scale (Laycock):

    • 0: No palpable contraction

    • 1: Trace (flicker or pulsation)

    • 2: Poor (contraction no lift)

    • 3: Fair (moderate contraction with posterior lift > anterior)

    • 4: Good (contraction with anterior, posterior, side wall compression)

    • 5: Strong (stronger lift and resistance against the posterior wall)

Functions of the Pelvic Floor

  1. Support

  2. Sphincteric

  3. Sexual

  4. Stability

  5. Sump pump

  6. Bonus: Impact on posture and breathing

Managing Pressures: Massery Soda-Pop Can Model

  • Relation of abdominal and erector spinae muscles in thoracic and abdominal cavities.

  • Specific muscles cooperate to modulate intra-abdominal and intra-thoracic pressures, crucial for maintaining upright posture (Massery et al, 2013).

Intra-Abdominal Pressure (IAP)

  • Primary muscles:

    • Intrinsic laryngeal muscles

    • Intercostals

    • Respiratory diaphragm

    • Abdominal wall

    • Paraspinals

    • Pelvic floor muscles

  • Breathing:

    • The respiratory diaphragm regulates pressure effectively.

    • Proper lung function relies on thoracic and abdominal pressure regulation.

    • Dysfunction in breathing frequently matches pelvic floor and low back dysfunction.

    • Breathing difficulties related to urinary incontinence and allergies more correlated with low back pain than inactivity or BMI (Smith et al, 2006).

Breathing Mechanics and Pelvic Floor Interaction

  • Main Components of Breathing:

    • Abdominal wall movement

    • Bibasal expansion of the ribcage

    • Upper chest motion

  • Interaction in Cases of Pain:

    • Increased vertical motion at the rib cage.

    • Breath Cycle:

      • Inhale: Diaphragm lowers; pelvic floor relaxes and lengthens.

      • Exhale: Diaphragm rises; pelvic floor contracts and elevates.

Movements Affecting the Pressure System

  • Understanding movements that directly influence intra-abdominal pressure dynamics and how they relate to pelvic floor dysfunction.

Common Pelvic Floor Conditions Treated

  • Bladder Dysfunction:

    • Urinary urgency/incontinence

    • Incomplete voiding

  • Bowel Dysfunction:

    • Fecal incontinence

    • Constipation

  • Pelvic Organ Prolapse

  • Sexual Dysfunction

  • Urogyn and prostate cancer

  • Pregnancy/Postpartum pelvic girdle pain

  • Pelvic Pain: interstitial cystitis, vulvodynia, chronic prostatitis, pudendal neuralgia, coccydynia

  • Diastasis Rectus Abdominis

Risk Factors for Urinary Incontinence (UI)

  • Pregnancy and childbirth

  • Hormonal deficiency (menopause, postpartum)

  • Pelvic surgery

  • Constipation

  • Obesity

  • Smoking

  • Excessive caffeine or alcohol consumption

  • Chronic cough/sneeze

  • Age: Greater than 50 in females, greater than 65 in males (important for boards)

Comparison: Stress Incontinence vs. Urge Incontinence

  • Stress Incontinence:

    • Involuntary urine loss during physical exertion (coughing, laughing, sneezing). (Affected by physical exertion)

  • Urge Incontinence:

    • Involuntary loss of urine preceded by urgency; may involve frequency of urination; often associated with overactive bladder.

Management Strategies

  • Stress Incontinence:

    • Pelvic floor muscle strengthening

    • Pressure management strategies (breathing mechanics, jump form, plyometrics, running program, use of pessary)

  • Urinary Urgency Management:

    • Behavioral training (bladder diary, identifying triggers)

    • Bladder retraining (increasing time between trips, consumption volumes)

    • Manual therapies (myofascial release, adductor release)

Bad Habits Affecting Bladder Function

  • Just in case (JIC) voiding

  • Semi-squatting/hovering over toilets

  • Interrupting voiding with pelvic exercises

  • Straining to void

  • Avoiding hydration fearing leakage

  • Habitual holding behaviors (e.g., by teachers or nurses)

  • Shy bladder syndrome: Fear of using public restrooms due to privacy or cleanliness concerns.

Bladder Irritants

  • Foods and drinks that may irritate the bladder include:

    • Alcohol

    • Carbonated drinks

    • Caffeine

    • Citrus fruits/juices

    • Tomatoes

    • Sweets

    • Chocolate

    • Dairy products

    • Artificial sweeteners

Use of Bladder Diary

  • Purpose: Track triggers of urination focusing on:

    • Food/drink irritants

    • Time of day

    • Activities

    • Urinary frequency/urgency

Constipation Definition and Statistics

  • Definition: Infrequent or hard to pass bowel movements; defined as fewer than 3 bowel movements per week.

  • Prevalence: Affects 15-20% of adults, with one-third over age 60.

  • Healthcare Cost: Leads to 2.5 million physician visits per year; $725 million spent on OTC laxatives annually.

Symptoms of Constipation

  • Hard stool

  • Excessive straining

  • Infrequent bowel movements

  • Bloating

  • Headaches

  • Bad breath

  • Decreased appetite

  • Flatulence

  • Depression

  • Reference to Bristol Stool Scale

  • Diarrhea

Treatment for Constipation

  • Dietary adjustments (increased fiber, fluid intake); referrals to nutritionists may be beneficial.

  • Optimizing defecation techniques (diaphragmatic breathing, reduced straining; use of Squatty Potty).

  • Manual therapies to enhance motility.

  • Relaxation practices and breath work.

Pelvic Organ Prolapse

  • Definition: Descent of one or more of the anterior vaginal wall, posterior vaginal wall, uterus, or apex of the vagina.

  • Symptoms:

    • Bulging

    • Pelvic pressure/heaviness

    • Low back pain

    • Bleeding, discharge, infection

    • Symptomatic improvement in gravity-reduced positions

    • Symptoms often worsen later in the day and improve with supine positioning.

  • Risk Factors:

    • Increased risk with each vaginal delivery

    • Use of forceps or vacuum in delivery

    • Collagen defects (Marfan syndrome, Ehlers-Danlos syndrome)

    • Hypermobility

    • Race (higher risk in Caucasian women)

    • History of pelvic surgeries

Treatment for Prolapse

  • Approaches:

    • Pelvic floor strengthening:

      • Progression from gravity-assisted to gravity-dependent exercises.

    • Breathing and pressure management.

    • Training of Transverse Abdominis (TrA).

    • Management of constipation (emphasizing no straining with bowel movements).

    • Pessaries for more complex cases.

Chronic Pelvic Pain

  • Definition: Pelvic pain lasting longer than 6 months, can occur in the lower abdomen, vulva/vagina, perineum, anus, penis, scrotum, testicles, or tailbone.

  • Associated Stats:

    • 1 in 7 women aged 18-50 experiences pelvic pain, accounting for 10% of gynecological consultations.

Common Conditions of Chronic Pelvic Pain

  • Coccyx pain

  • Sacroiliac pain

  • Pain during penetration

  • Pudendal neuralgia

  • Vulvar pain

  • Prostatitis

  • Post-hernia repair pain

  • Vaginismus

  • Dyspareunia

  • Perineal pain

Common Impairments Associated with Chronic Pelvic Pain

  • Limitations in prolonged postures (standing, sitting)

  • Sleep difficulties

  • Pain with bowel movements

  • Bladder dysfunction

  • Pain with insertion (tampon, gynecological exam)

Objective Findings

  • Tight and short musculature in the pelvic floor, pelvis, low back, and lower extremities.

  • Postural dysfunctions and coordination challenges in the pelvic floor.

  • Positive findings on Thomas test, FABER test.

  • Decreased lumbar spine range of motion.

  • Characteristic “pelvic pain posture” includes excessive lumbar lordosis and anterior pelvic tilt.

Treatment Approaches for Chronic Pelvic Pain

  • Manual therapy techniques.

  • Therapeutic exercise strategies including relaxation training and stretching.

  • Patient education regarding proper breathing and stress management.

  • Providing psychological and social support to patients.

  • Use of dilators or trigger point wands.

  • Biofeedback methods for improving coordination.

  • Note: Not all patients require Kegel exercises; for those with hypertonic pelvic floor, strengthening may exacerbate symptoms. Focus on relaxation and coordination first.

Use of Dilators for Pelvic Pain

  • Dilators are used for prolonged tissue stretching and allow for personalized circumference adjustments.

  • They are beneficial for tissue desensitization and promoting progressive movement.

Understanding Diastasis Recti Abdominis (DRA)

  • Definition: Separation of the rectus abdominis at the linea alba.

  • Prevalence Statistics:

    • At 21 weeks: 33.1%

    • 6 weeks postpartum: 60%

    • 6 months postpartum: 45.4%

    • 12 months postpartum: 32.6%

Examination of DRA

  • How to Examine:

    • Supine position, two fingers placed at midline.

    • Observe for bulging, sinking, or puckering; assess tissue tension changes.

    • Gentle pressure to locate rectus muscle borders.

    • Assess changes with abdominal curl up and if muscle activation (deep abdominal/pelvic floor) affects the gap.

  • Treatment for DRA:

    • Prevention strategy: Prenatal abdominal strengthening exercises can reduce DRA incidence.

    • External approximation methods (taping, binders).

    • Activation of deep abdominal musculature including TrA.

    • Strengthening low back and pelvic floor to support TrA function.

    • Progression to functional mobility exercises, incorporating lifting, squatting, bending etc.

Emotional Considerations in Pelvic Floor Therapy

  • Patient Communication: Many patients are uncomfortable discussing pelvic floor issues, which may impede treatment and delay seeking help.

  • Understanding Patient Trauma:

    • 46.8% of patients with pelvic pain report a history of sexual or physical abuse; 31.3% screen positive for PTSD.

    • Trauma can cause hyperactivity in musculature and fear responses, creating a barrier to open dialogue.

  • Therapist Responsibility:

    • Setting a tone of safety and understanding for patients.

    • Make patients feel safe, heard, and validated during discussions.

Tips for Discussing Difficult Topics

  • Your disposition affects the patient’s comfort; be open about your need for information.

  • Explain the examination process, ensuring you have consent.

  • Normalize discomfort during the conversation by discussing shared patient experiences with pelvic symptoms.

  • Always keep communication open: encourage patients to voice their concerns or uncertainties throughout the discussion.