Women’s Health: Pelvic Therapy

Pelvic What? Therapy?

We know, nobody wants to talk about “down there” and the many issues you can have or already experience. So instead, we will talk about it for you and let you know how therapy CAN help you! Warning – we are holding back nothing so you get the answers you need!

Can help with what? You may ask

Let us enlighten you!

Incontinence: This in when you are unable to hold urine or fecal matter. There are different types of incontinence including stress, urgency, overflow and total. The most common are urge and stress incontinence.

Prolapse: This is when your bladder, vagina, or anus start protruding and “falling” outside of you. You may feel a bump on the outside as you wipe and this is due to your internal organs beginning to drop.

Pelvic Pain: This can encompass a lot of people and symptoms and is primarily any pain you have in the lower abdomen. It may feel like cramping, stabbing, or tingling. It is typically from reproductive, digestive, or musculoskeletal systems being inflamed. It can also be called pelvic Inflammatory disease (PID).

Low back pain during pregnancy and post-partum: This is very common in pregnancy and is pain in the low back, Sacroiliac (SI) joint, and may also have pain down the leg causing sciatica.

Diastasis Recti: This is separation of the abdomen. It typically occurs after a quick weight gain, often associated with pregnancy.

Dyspareunia: Otherwise known as painful intercourse. It can also be associated with vulvodynia in which is pain around the vagina and vaginismus in which the vaginal muscles contract too much, typically felt more with pressure during intercourse and using the restroom.

No way therapy is able help with ALL that! I have been dealing with it for so long! How can it help? You may ask

The one thing all of these things have in common are “the pelvic floor”. The pelvic floor is consists of these muscles

  • Levator ani: pubococcygeus (pubovaginalis, puborectalis), iliococcygeus
  • Coccygeus/ischiococcygeus
  • Piriformis
  • Obturator internus

We know, big words, but these muscles are the basis of how we treat any pelvic floor dysfunction. As you can see in the picture above the pelvic floor is the “bottom of the bowl” with your hip and pelvis bones. As we discuss a few things, it is good to return to the picture as needed for reference. Typically with any of the issues mentioned above, the pelvic floor has some weakness and in the case of incontinence and prolapse, the weakness will be the worst.

So how do you strengthen the pelvic floor?

I am sure you have heard of Kegels before and may or may not try to do them on occasion. And when asked, how do you do a Kegel? You may answer “I pretend like I need to stop my urine flow”. This is good, however it does not completely entail the full pelvic floor. How I describe a Kegel to my patient’s is very direct, but it paints a good picture. Women have three holes “down there” that sit within the bottom of the pelvic floor bowl. If you just stop your urine flow to do a kegel you are only getting the front of the pelvic floor. What you want to do is try to pull all three holes up at the same time. A few good illustrations are 1. Think like you have the flu and have to run to the bathroom to make it on time. When doing this, we typically engage every bit of our pelvic floor to avoid an accident and 2. Pretend like you are sitting on some hot coals and the only way to avoid burning yourself is to pull the pelvic floor off the chair.

How many should I do?

When doing Kegels, don’t just do 30 all at once like you would for a normal workout routine. The pelvic floor needs to be engaged multiple times throughout the day so I recommend finding an activity you do often, i.e. checking facebook, checking emails, answering the phone, stopping at a stop light or sign, or changing and feeding you newborn, it can be virtually anything that is repeated throughout the day, and do one Kegel holding for 5 seconds, YES just ONE at a time. But if you are doing this activity 10-20 times a day, you are then doing 10-20 Kegels a day!

If all I have to do is Kegels, then why would I need therapy?

In addition to proper education and engagement of Kegels, we also look at pelvic alignment. Due to women’s hormones, the shapes of our pelvis, bearing children, and even the pressure during intercourse, our pelvis can become misaligned.

How do you fix it?

Using muscle energy techniques we can help correct the alignment of the pelvis. Muscle energy is a gentle technique that uses your muscle against the therapists’ gentle resistance to move the bones back to where they should be. There is no forceful thrust or manipulation involved and it should not be painful.

Can’t I just go to a chiropractor to fix the alignment?

Yes, you could, however in physical therapy we are correcting your hips using your muscles. When doing this, you are retraining the muscles to contract or to release depending on your goals, in order to keep the alignment. It takes fewer visits to achieve this when you use the muscles rather than a forceful manipulation.

And then what?

And then we stabilize and strengthen your core, pelvic floor, and hip muscles to keep the alignment. Using the muscles to realign the hips and then using the muscles around the hips to stabilize helps significantly to improve your outcome.

What types of diagnoses is this used for?

ALL of the conditions mentioned at the beginning of the article benefit from this!

  • Incontinence and prolapse is primarily weakness in the pelvic floor. You can do kegels all day long, however if your hips are out of alignment, it can cause one side of the pelvic floor to be stretched, the other to be contracted and tight. When this happens, the kegels are not as effective. So to make it worth your time to do the kegels, we correct the hips first. This is also beneficial after a surgery for prolapse bladder.
  • Pelvic pain and low back pain (associated with and without pregnancy) typically has some type of mal-alignment in the hips. Correcting the hips first allows us to strengthen the core, pelvic floor and surrounding hip muscles with better outcome.
  • Dyspareunia can be associated with tightness and difficulty relaxing the pelvic floor, weakness in the pelvic floor, and hip alignment. If the pelvic floor muscles are in constant spasm, it can pull on the hips affecting the whole structure. So with strengthening the pelvic floor and alignment, we teach relaxation of the pelvic floor as well.

And a few other treatments:

Myofascial release: In some instances the pelvic floor muscles become too contracted and tight and you may have difficulty relaxing completely. This can cause the issues of vaginismus effecting intercourse or even the pressure with wiping. In order to help with this we can do an external release of the pelvic floor in which we focus on allowing the muscle to go from a contracted state to relaxed state by gentle pressure and massage.

Biofeedback: Are you having trouble getting the concept of doing a kegel correctly or feel like you are not doing it at all? A biofeedback machine helps you see how well you are engaging those muscles. It uses a probe in the vagina and can also have a lead on the abdomen wall to give you feedback on how well you are contracting and how well you are relaxing those muscles as well.

Painful Intercourse: Physical therapy for this issue is a lot about education as well as focusing on the aforementioned strengthening and manual techniques. Remember ladies, men are like microwaves, you hit the start button and they are warmed up and ready but women are ovens, we need to be preheated. When we “preheat” our bodies are much more relaxed and ready, which in itself can decrease the pain.

Astym for scar tissue: Astym is a technique using some tools that can help to break up scar tissue. For women’s health we think of c-sections or multiple laproscopies in which scar tissue can build up around the abdomen. The tools can help the bottom to resorb the scar tissue and then with strengthening get you feeling strong and painfree again.

Whew! This is a lot….but we are almost done!

Lastly, I think physical therapy post-partum needs to be discussed. Women’s health physical therapy is not JUST incontinence or even pelvic pain. It CAN BE simply, you had a child via either vaginal deliver or c-section and you need help strengthening those pelvic floor and hip muscles again.

Think of what your body goes through from conception to child birth!

As the baby grows inside of you your ligaments soften and start to stretch in order for your hips to open up and make room for the baby. Not to mention, your abs begin to expand and there is a lot more pressure on the pelvic floor. Yes, some back pain, round ligament pain, pelvic pain is common in pregnancy, however pain where you have difficulty walking, standing, rolling in bed, can be helped while you are pregnant and it is 100% safe for you and the baby! We focus on the hip alignment, stabilization, and strengthening as mentioned above.

Next when baby is born vaginally, you are stretching every muscle in your pelvic floor and the hips are separating. Think of all the weakness that can occur just from the stretching! Some women may even encounter a pubic symphysis separation which can be very painful (p.s. therapy CAN help!).

If the baby is born via c-section, think of all the layers of muscles being cut! Surely there will be a lot of weakness just from cutting through the muscle and fascia. And imagine if it is your 2nd, 3rd, 4th, and so on c-section!

So what do I really need to take from all of this?


Most women don’t recognize physical therapy is an option for them! They think having incontinence can be “normal”, pelvic pain is “normal”, back pain from pregnancy is “normal” and they don’t recognize it doesn’t have to be normal anymore. Most women also believe physical therapy is just for incontinence, however we see many women that are fully continent but the issue is more with pain in the pelvis, pain during intercourse, or no pain at all and has a diastasis recti preventing them from getting back in shape and into their full workout routines.

Does any of this “down there” talk seem to be hitting close to home for you? If so seek out a physical therapist! You will be glad you did!

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