Pelvic Pain Physical Therapy, Demystified

Like most things, you don’t realize how crucial your pelvis is until you experience problems with it. You need a healthy pelvic region to move comfortably, control urination and bowel movements, give birth and enjoy sex, among other things.

But 15 percent of women and a small percentage of men experience pelvic pain that interferes with their lives. If you’re one of those women or men, you have options, including medication and surgery. But first, consider pelvic physical therapy can help.

Pelvic Pain Symptoms

Let’s define your pelvic region: Your pelvis is located below your belly button 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. Pain from pelvis issues can occur anywhere from the belly button down 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. It also can feel like menstrual cramps.

If you have a pelvic problem, 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’re having any type of symptoms you should come in for an appointment,” UNC physical therapist Jennifer Harrington, DPT, says.

Pelvic Pain Physical Therapy in Action

“Pelvic floor physical therapy varies depending on a patient’s symptoms,” Harrington says. “Often it involves a combined treatment approach that includes a physical therapist, physician and sometimes a sex therapist and/or a psychologist or psychiatrist.”

The 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. If you’ve had physical therapy in the past, your therapist will discuss what worked and what did not. Then your therapist will do a physical assessment.

“During the physical assessment we will often examine your back, hips and abdomen,” Harrington says. “We will move your joints and press on your muscles to test muscle strength and muscle coordination. The last thing that we typically do is an internal assessment of the pelvic floor.”

The internal assessment is a well-lubricated vaginal or rectal physical exam.

“We insert a gloved lubricated finger into either the vagina or rectum to explore the muscles that are tucked up inside. We apply pressure to the various muscles and see if they are tender,” Harrington says. “We also check to see what the resting tone feels like. We are trying to assess if the muscles feel soft, supple and bouncy like they’re supposed to, or if they feel very tight and firm, which typically is painful for the patient. Oftentimes we’re able to reproduce some of the pain or create a different sensation that hasn’t been felt before but may be relevant to what’s causing your symptoms.”

Overcoming Hesitation About Therapy

For many women, the only doctor who has examined them in their private area is an OB-GYN, but a physical therapist’s assessment is different from a gynecologist’s.

“We typically don’t use a speculum, stirrups or other equipment. During our assessment, you lay on a table. When I’m initially first assessing you, I may look at the perineum to get a visual, and assess muscle coordination and skin integrity externally,” Harrington says. “But when I insert my gloved, lubricated finger, you are draped and covered up and I’m standing next to you. I’m talking to you as I’m feeling the muscles so I can read from your expression when something may be uncomfortable, which may be part of the main issue.”

Once your therapist knows what is causing your symptoms, he or she will work 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 the patient’s leg into a different position to help the muscles release. Everyone’s physical therapy sessions are individualized; internal work may be a large or a small portion of your session, depending on your specific needs.

“Many of our patients tell us that while it felt weird at first, they were surprised by how comfortable they ended up feeling during internal pelvic floor work,” Harrington says. “The assessment itself can be painful or uncomfortable, but the patient is always in control. You can always decline to have an internal assessment or end the assessment at any time. We’ll explain why we feel it’s important, but we won’t ever pressure you into doing anything that you do not want to do.”

Physical Therapy Results

Usually, when you start pelvic floor physical therapy, you may see your therapist once a week until your body starts responding to therapy. Then your appointments may be spaced out to once every two, three or four weeks.

“It completely varies and depends on how long you have had the pain, what causes the pain and your diagnosis,” Harrington says. “It could be a couple of sessions or as many as 20-plus. Once we feel like things are stable, we work toward having an official end to therapy.”

The majority of patients find some relief, Harrington says, either complete or partial. All patients leave pelvic physical therapy with more education about how to manage their symptoms moving forward.

“Everyone who goes through therapy has a much better understanding of their body,” Harrington says. “We educate people a lot. Patients leave feeling more empowered.”

Are you concerned about your pelvic health? Talk to your doctor. If you need a doctor, find one near you.