This article originally ran June 6, 2018, and was updated April 11, 2024.
Like most things, you don’t realize how crucial your pelvis is until you have problems with it. You need a healthy pelvic region to move comfortably, control urination and bowel movements, give birth and enjoy sex.
About 15 percent of women of childbearing age (and a smaller percentage of men) in the United States report having chronic pelvic pain that interferes with their lives, but the number could be higher, as people may not be asking for help.
“There’s a cultural hush-hush about these body parts and a lot of embarrassment about the unknown,” says UNC Health physical therapist Erika Johnson. “A significant number of people are seeking care for these issues, and you’re not alone.”
If you’re experiencing pelvic pain or issues with incontinence, you have options, including medication and surgery. For many people, specialized physical therapy can help. Johnson explains the process of pelvic floor physical therapy.
Pelvic Pain Symptoms
First, let’s define the pelvic region: Your pelvis is below your bellybutton and above your hips and thighs and includes the hipbones, the sacrum (the bone at the base of the spine, between the hipbones) and the tailbone. Your pelvic floor muscles are at the bottom of the pelvis and hold the bladder, bowel and uterus in place, and these muscles relax to allow you to urinate or defecate. These muscles also form the bottom of your abdominal core, which is why they can affect your ability to move comfortably. Pain from pelvic issues can occur anywhere from the bellybutton to the knees.
Pelvic pain can be constant or intermittent. The type varies widely but can include heavy aching, sharp or shooting pain, and burning pain in the vulva or vagina either with or without penetration, such as during sex or a gynecological exam. It can feel like menstrual cramps.
If you have a pelvic floor issue, you might deal with urinary urgency, significant constipation or diarrhea, bowel urgency or frequency, and urinary leakage with coughing, laughing or sneezing. People with pelvic issues also may have episodes of fecal incontinence, which is losing control of your bowel movements, and frequent, involuntary passage of gas. Pelvic issues can lead to sexual dysfunction, including pain with intimacy, difficulty achieving an orgasm, or anorgasmia, the inability to reach an orgasm.
If you recently had a baby, Johnson advises asking your obstetrics provider about pelvic floor physical therapy, even if you’re not experiencing any symptoms.
“All postpartum people can benefit from a few visits to a pelvic floor physical therapist,” she says. “You need to rehab the muscles that were used during pregnancy and delivery.”
Starting Physical Therapy for Pelvic Pain
The pelvic floor physical therapy process starts with an evaluation by a physical therapist, who will take a medical history to determine what might be contributing to your pain, including any relevant surgeries or injuries.
“The medical history intake touches on a lot of issues, and it’s common for a person to come in for one concern only to realize how much their pelvic floor is affecting something else,” Johnson says. “That’s why the initial visit will include lots of education on anatomy and how the pelvic floor interacts with the rest of the body.”
You’ll also have a physical examination at your initial visit, including an assessment of how the back, hips and abdomen look and feel, and an internal assessment. During the internal assessment, the physical therapist inserts a gloved, lubricated finger into either the vagina or rectum.
“We’re looking to see how the muscles of the pelvic floor are moving and working in coordination with other muscles,” Johnson says. “We’re checking for strength and endurance and seeing where there’s tension or discomfort.”
This internal assessment is different from a gynecologic exam, as the physical therapist doesn’t put you in stirrups or use a speculum. You are dressed from the waist up, and your bottom half is covered.
“We use the information from your medical history and physical examination to create an individualized program for you that meets your goals and addresses the issues we find,” Johnson says. “That’s when we can determine how often and how long you might need to be seen and what specific education and retraining may be necessary.”
What Happens During Pelvic Floor Physical Therapy
Your visits with a pelvic floor physical therapist will depend on your needs and goals, but Johnson says that everyone can expect to receive education about the workings of their pelvic floor muscles.
“We want people to understand how their pelvic floor influences the reason they came in, whether that’s pain or incontinence,” she says. “When you know how and why the pelvic floor muscles have caused an issue, then you’re able to integrate exercises into your daily activities that will significantly improve your quality of life.”
Depending on your pelvic floor issue, your sessions might include the therapist working on your pelvic floor muscles externally or internally—again, with gloves and lubrication. The therapist may apply pressure to the pelvic floor muscles and may move your leg into a different position to help the muscles release. You may also receive biofeedback to retrain pelvic floor muscles or have therapy devices inserted into your vagina to stretch and relax the pelvic muscles.
Because physical therapy sessions are individualized, internal work may be a large or a small portion of your session, depending on your specific needs. You might learn breathing exercises that can help with pain or exercises and stretches that engage the pelvic floor and core muscles. You may also discuss lifestyle changes, such as avoiding foods or drinks that cause irritation when you void or strategies for controlling the urge to urinate or defecate.
At the end of each session, you might be given a few things to work on at home. “We try to be cognizant of what a person’s day looks like and integrate activities into what they’re already doing,” Johnson says. “You might have a few exercises to do, or you might be tracking your trips to the bathroom for bladder and bowel retraining.”
Pelvic Floor Physical Therapy Results
With pelvic floor physical therapy, your therapist will help you meet your goals, whether that’s less pain with intercourse or fewer episodes of incontinence. Johnson says the average person is seen eight to 12 times, though for you it could be more or less depending on your needs.
“It’s a little different from therapy for your knee, where you might be seen twice a week,” Johnson says. “It’s more common to be seen less frequently over a longer period of time.”
If you find you aren’t meeting your goals, your physical therapist can provide you with options for next steps, including other conservative approaches with a different specialist or surgery.
But no matter what happens, you should leave pelvic floor physical therapy with more education about how to manage your symptoms moving forward.
“There’s a real power in having knowledge about this area,” Johnson says. “Even if you only have an initial visit, we hope you leave knowing more about your pelvic floor and how you can be more comfortable.”
If you’re concerned about pelvic pain, talk to your doctor. Need a doctor? Find one near you.