What does Pelvic Health Physiotherapy look like?

What types of conditions are commonly seen by a pelvic health physio?

Pelvic health is a very broad area, and there are many conditions that can be related to the pelvic floor muscles, and improved with strengthening, relaxation and release, or education on how to reduce strain on the pelvic floor. 

I often see individuals with stress incontinence or pelvic organ prolapse, which may be related to pregnancy or giving birth, but could also be related to sport or performance. These issues are common with things that repetitively strain and weaken the pelvic floor. In performance sports such as trampolining, gymnastics, dance and aerial arts (particularly aerial silks), there are high impacts on the pelvic floor which could lead to strain.  

Furthermore, performing artists often suffer from hypertonic pelvic floor muscles (too much tension as a result of chronic holding patterns or habitual clenching). This can lead to a range of pelvic health issues, including incontinence, constipation, and pelvic or sexual pain. This is common in dancers, circus artists, actors (particularly those playing an intense role), and the focus for treatment for these clients is based around pelvic floor down-training to reduce tension and optimise muscle function. 

What happens in a Pelvic Health Physiotherapy appointment?  

Pelvic health physiotherapy appointments are very different to musculoskeletal physiotherapy appointments, as we are discussing details that are of a much more sensitive nature and can often feel embarrassing for patients. Therefore, an important part of a pelvic health appointment is making sure the patient is comfortable, and their concerns are acknowledged and validated. 

With this in mind, in an initial pelvic health appointment, I start by taking a detailed history on the patient’s current concerns, including bladder, bowel, and sexual function in the context of their daily activities, exercises and goals.

Our pelvic floor muscles are internal muscles, and we can’t see or feel them from outside the body. Therefore, I first explain to patients where the pelvic floor muscles are situated, and their function, using a model of the pelvis and pelvic floor. 

Assessment of the pelvic floor muscles can be tricky, as they lie internally. After explaining the anatomy and physiology of the pelvic floor, I then discuss with my patients options for pelvic floor assessment, including internal vaginal or rectal examination if indicated. I will only perform an internal examination on a patient if they are comfortable with it, and after explaining in detail each component of the examination and what it will involve, therefore gaining informed consent. Internal examination provides us with the most information about the pelvic floor, as we are able to assess the pelvic floor muscle strength, tone/tension, and if there is any laxity, as well as teach the patient how to perform a correct pelvic floor contraction. 

Despite being the most accurate form of assessment, internal examination is quite invasive, and many people may feel uncomfortable with this. Therefore, we can also use assessment techniques such as external visual assessment of the vulva or anal sphincter, external palpation through underwear around the vagina or anus, or real-time ultrasound over the lower abdomen. Ultrasound assessment is the least invasive option, and can be helpful when teaching people how to correctly activate the pelvic floor muscles, however, it is not able to tell us any information about how strong or tight the pelvic floor muscles are.

Each person's management plan will be different and will depend on their condition, their activities, goals, and motivation. I aim to tailor my treatment to each individual patient, ensuring I provide them with information and advice that they understand, and create a rehabilitation plan which is effective but also achievable. This may include anything from pelvic floor and other exercises to help strengthen the area, to taking 20 minutes out of a day to have a cup of tea and read a book to encourage relaxation. I will also outline a plan for ongoing management that is closely tailored to them and will help them to achieve their goals. Follow up appointments allow me to review how you have been going, see how your condition is improving, and progress your rehabilitation or adjust it if needed. The number of appointments required varies significantly depending on type of condition and severity, compliance, how much support the patient needs, how fast or slow the condition takes to improve, how well they are able to self-manage. Generally I aim to see patients for a 2 week follow up after the initial appointment to check how the management plan is going, reassure or modify, and then 2-4 weekly, spacing out to every 6-8 weeks when someone is mostly self-managing, until they have achieved their goals.

Being able to manage or resolve pelvic floor issues that often significantly impact someone’s life, is such a powerful part of my job as a pelvic health physiotherapist. Seeing how my patients re-build their confidence and re-engage in activities or exercise they had stopped due to pelvic floor dysfunction, is inspiring, and I feel so privileged to be able to make such a meaningful difference in people’s lives.