As a pelvic physiatrist by definition, my job is to provide rehab to the pelvis. The question that many patients have is when to start pelvic floor physical therapy and what that means. Before we get into that, let me explain the pelvic floor and the types of issues you may be facing. The pelvic floor is made up of muscles, tendons, and ligaments that are often overlooked which leads to fewer patients being directed to pelvic floor therapy. There are many women who hear the term pelvic floor and automatically start doing Kegel exercises. Kegels are an exercise that is used to strengthen a weak and underactive pelvic floor. Most people assume that pelvic health ends at Kegels. However, Kegels can actually worsen symptoms of a person who has an overactive pelvic floor.
Kegels are Just the Beginning
Let’s first get into underactive muscles a bit. Classically, you may have a friend who has confided in you over lunch about urinary leaking when running or doing jumping jacks after having children. I was one of those women. I had two kids back to back and had no pelvic floor rehabilitation in between. Just like many women, I was an overwhelmed mom and wanted to work out but didn’t have the time. Instead, I would use the restroom right before any high-intensity workouts. I even managed to train for a marathon but had to keep my bladder mostly on low to make sure I didn’t leak.
The other classic situation of underactive muscles is what you may have seen on television commercials. The majority of the world has accepted that urinary incontinence is a natural part of the aging process. However, there are so many conservative and non-conservative approaches to urinary incontinence, sexual dysfunction, fecal incontinence and bowel conditions related to underactive pelvic floor muscles. And Kegel exercises are just the beginning.
Finding your Kegels
Treating under-active muscles are a challenge because a great percentage of people don’t actually know how to do a Kegel correctly. Another hurdle is that the muscles of the pelvic floor are not seen, so they are easily forgotten, so continuity is less likely. When we have issues with knee pain, back pain, arm pain, etc. we are often directed towards physical therapy as a non-surgical intervention. Historically, medicine has revealed itself in layers—this is incredibly relevant in the field of pelvic pain. Physical therapists have been using their skill set to treat pelvic pathology for 20 years or so, and pelvic pain physicians have only started to bring their skill set into the field more recently. This synergy between the two fields is helping us to catch up and help patients who used to have few resources available to them.
The purpose of Kegels is to strengthen the pelvic floor. The first step is properly identifying your pelvic floor muscles. The ultimate goal is to squeeze and lift the muscles and then release the muscles back to resting level. Making sure to relax and rest in between the next Kegel. If you find yourself tensing your butt, back or leg muscles you are doing it wrong. A proper Kegel is meant to isolate the muscle, squeezing and lifting the three entrances to the vagina, urethra, and anus. I often tell patients to lift their muscles like they are holding in urination or stool. In this case, it is important not to push down or increase abdominal pressure because this can make the pelvic floor worse.
Do I Need Treatment?
Knowing the difference between under-active and overactive pelvic floor muscles dramatically changes the treatment options. This is why seeking a proper diagnosis is crucial. Overactive muscles are spastic, tight and contracted. The muscles are in spasm and often make sitting painful. This can also make intercourse uncomfortable or downright painful and can affect the bowels and bladder. For these patients, Kegel exercises would make the muscles tighter and aggravate their pelvic pain, so prior to strengthening it’s important to relax these muscles. These patients will present with pain during intercourse.
It might feel like they are dry (though might not be) or feel a twisting, stretching sensation during intercourse. They may also have pain with tampon insertion, to the point that they cannot insert it or it feels uncomfortable when they have it in. Patients with overactive tight muscles tend to have urinary urgency frequently and have urge incontinence. Having this urge any sooner than every 2-3 hours is too frequent. They may also have to urinate in the middle of the night. Women with overactive tight muscles may also be chronically constipated.
People are often confused with the definition of constipation. Constipation is a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces. Most people assume if they defecate once a day they are not constipated but that is not the case. If there is any straining or pushing to defecate this is also considered constipation. Treating overactive muscles are more difficult than underactive active muscles because there are two steps in treatment. The first is to make the muscles relaxed, and then to strengthen the muscles. A skilled pelvic physical therapist works manually on patients internally to help relax these muscles and to help avoid chronic constipation.
If you find yourself tensing your butt, back or leg muscles you are doing a Kegel exercise wrong.
What Happens in Pelvic Floor Rehabilitation Therapy?
As a pelvic physician, I have many tools in my toolbox to help assist in relaxing these tight spastic muscles. Especially when manual therapy is not enough. I work hand in hand with pelvic physical therapists to decrease muscle tension, improve circulation and muscle coordination. Biofeedback is often used during treatment and can be helpful to gain better awareness and control of these muscles. We do so by adding in a variety of medications including suppositories. We also try different procedures, including trigger point injections and hydrodissection nerve blocks. I spend a lot of my time trying to find the cause of their overactive muscle. I pride myself as an investigator searching for the answer byy digging into their past and finding clues that can help diagnose the patient and their pelvic floor disorder.
A pelvic physical therapist works one on one to help the patient identify their pelvic floor. They also create a home exercise program for the patient that includes a variety of different exercises to be done by the patient. Typically, the therapist will run through these exercises to make sure the patient is proficient in each type of exercise. There are many products that you may have seen on commercials, social media and women’s health stores including Kegel weights and personal trainer tools. Before jumping the gun and purchasing products, I always suggest patients reach out to a local pelvic physical therapist for proper examination to confirm the state of your pelvic floor muscles.
When to See a Pelvic Floor Specialist?
Many systemic conditions including endometriosis and adenomyosis can affect the pelvic floor. Additionally, conditions like colitis and interstitial cystitis tend to go along with pelvic floor dysfunctions. There are many other causes of pelvic floor dysfunction. These include labral tears, hernias and traumatic injuries to the pelvis (including unwanted sexual contact and injuries to the tailbone). If you find yourself having uncomfortable symptoms related to your bowel, bladder or sexual function, it may be time to seek the assistance of a pelvic floor rehabilitation specialist. The key to successfully treating pelvic floor dysfunctions is identifying the cause and implementing the correct treatment plan as well as patient education.