Pelvic Pain FAQs: Part 1

I see 40 patients a week, with roughly 50% of my patient’s coming to PT for some version of pelvic pain. Their pain varies wildly. Some have been in pain for years, some for months, some for weeks. Some have had a long history of surgeries, procedures and physicians visits while others have had very few or none. Some have vaginal pain, rectal pain or perineal pain while others have low back pain, abdominal pain or hip pain. I see men, women and a patients ranging in age from teenagers to nonagenarians.

My point is, they are all different. However, somehow, the same questions are on all of their minds. Below you will find the top three questions people ask me during a PT visit and my best effort to answer them. FAQ’s: Part 2 with questions four through seven to come next week!

  1. So, how long is this going to take?

This is the million dollar question. It’s on everyone’s mind at the start of physical therapy and I completely understand. The most honest way I can answer this question is this: it depends. I know that can be frustrating, but let me elaborate on what it may depend on.

When it comes to pain, recovery depends on many factors. It depends on how long you have been in pain, what your pain was originally caused by, what you have done to manage your pain in the past, how significantly your pain has impacted your life, how you’ve adapted to your pain and even how you feel about your pain.

Science has informed us how long we can expect tissue healing to take, bone healing and even how long nerves take to regrow. But often times pelvic pain is different. Sometimes we don’t know what caused it or what perpetuates it. Because of that, treating pelvic pain becomes a multifactorial process including everything from stretching and exercise to modifying diet, fluid intake, sleep and stress management.

Here is my attempt at giving you something more concrete: By the 4th-6th week of pelvic floor physical therapy, you should notice a change of some sort. It may be small, it may be incremental, but you and your physical therapist should be able to see some signs that your symptoms are moving in the right direction. This may differ from person to person, depending on any setbacks you experience or inconsistencies in your care, but that’s my attempt at a benchmark. If you go to PT at the interval your therapist determines is best and diligently follow your home exercise program, this should be enough time to notice some change. After that, you and your PT should be able to start setting some realistic goals for your particular case and your particular body.

2. What can even be done for this type of pain?

This is a big one on people’s minds when they start PT. It usually comes from a place of feeling like they have already tried everything: medication, surgery, diet, exercise, physical therapy, injections, etc. The one place they usually have not looked at or addressed yet is the pelvic floor.

Your pelvic floor muscles assist in controlling your bladder, bowels and sexual function. If these muscles are tight or weak, they can affect any or all of these symptoms, and they can cause pain. That’s where pelvic floor PT comes in. A pelvic floor physical therapist can use a physical exam including internal and external techniques to determine if your pelvic floor falls into the tense or weak category, or maybe both. Once they determine which muscles are affected, they can begin teaching you exercises to manage these impairments at home while providing manual therapy and other treatment tools in clinic.

Additionally, there are a number of changes in habit that can help reduce bowel, bladder or pelvic pain. For instance, ideal positioning when sitting on a toilet for bowel movements can help decrease pain while trying to empty, or decrease the need for pushing and straining which can also decrease pain. Knowledge is power. The more you know about your body and how these systems are meant to work together, the faster you can start helping your body heal.

3. How in the world did I develop a trigger point in my X?

X = vagina, rectum, abdomen, muscles surrounding tailbone, anal opening, vaginal opening,etc.

So many reasons. There are so many reasons you can develop a tense muscle in your vagina or rectum. You could ask the same question regarding how you’ve developed tension in your neck or back. Our pelvic floor is full of muscles, just like our back is.

Let me start by listing some reasons:

  • You had an infection at some point that caused your muscles to guard because of pain caused by the infection, and now they don’t know how to relax.
  • You had surgery and now the scar tissue is affecting the way your muscles function and move.
  • You and your body have been experiencing a lot of stress due to work or personal life and you’re not realizing how tense you are holding your glutes and pelvic floor.
  • You injured yourself at the gym and while you knew how to rest, ice, stretch and mobilize your knee, hip or back, you know very little about your pelvic floor and haven’t been able to give it the attention it needs to calm down and return to normal.
  • You have chronic ankle, knee, hip or back pain and don’t realize how your compensations during movement have affected your pelvis.
  • You took a 12 hour flight, fell asleep in a weird position, didn’t get up once, and don’t know how to stretch the right muscles.
  • You delivered a baby and your muscles haven’t returned to normal strength or length.

I can continue, but you see my point. Our muscles respond to injury, even if that injury is minor. When we wake up with inexplicable knee pain, we throw some ice on it, ask a friend what to do, and avoid going on a long run that day. When we wake up with inexplicable pelvic pain, we often don’t know what to do, and are most certainly not going to call up a friend and say hey my X (use X substitutes listed above) hurts.

When we add on that we also don’t know where these muscles are, how to activate them or what they do, it can leave people crossing their fingers and hoping it goes away until the pain gets strong enough that they decide to see a doctor. At that point, they’ve been in pain for quite some time and they’ve felt anxious about why there X is hurting for just as long. Pain is a cycle, and it needs to be broken. Understanding our bodies and what can contribute to this pain is an extremely important part of breaking that cycle.


-Rebecca Maidansky, PT, DPT

What To Expect From a Pelvic Floor PT Examination

In my previous post I touched briefly on what you may be able to expect from your first physical therapy appointment, but I wanted to dive in a bit further. Often times patients are very apprehensive when they walk through our doors for the first time. I see a lot of that concern wash away once they know what we’ll be doing that day. I thought I could ease some worried minds by shedding light on exactly what you can expect from your initial evaluation. Keep in mind that I am describing an initial examination at Sullivan Physical Therapy, and mileage may vary from clinic to clinic.

Before you even come in for an appointment, you will be asked to fill out some paperwork. Some of that will be insurance related and will help our wonderful front office staff get you the most out of your benefits. Some of it will be to give your therapist a little information about what you’re experiencing and what you’ve already done about it. We’ll also need a referral from your physician, but you can just have him or her fax it to us or bring it with you to your first appointment.

Now, to the good stuff. When you show up for your first appointment, your therapist will come get you from the waiting room and bring you to our private treatment room. The walls will likely be lined in hand drawn pictures of Napa to help put your mind at rest. Also because that’s where our Kimbelee Sullivan hails from. They’re very nice. You’ll like them.

Once we get back to the treatment room, you and your therapist will talk. This is a great time to ask any questions you have about pelvic floor PT and voice any concerns. This first part of your evaluation is called the subjective portion, or the talking portion. You’ll have a chance to tell us your story from beginning to end. Afterwards we’ll ask more questions about your bladder, bowels, sexual activity and pain in the pelvis to help us get the clearest idea of what’s happening with your pelvic floor and determine if there are any other affected areas that you hadn’t thought were connected. This can last anywhere from ten to fourty-five minutes depending on what you need and how much there is to cover.

After the subjective portion, we’ll be able to tell you what your physical examination will entail. The physical exam will be tailored to you and will differ based on what you’re experiencing and what your goals are. We may want to look at your lumbar spine to see if we think any of the symptoms are stemming from your back. We may want to strength test your hips and legs to see if we think weakness in your lower extremities is a contributing factor. We’ll look at pelvic alignment and abdomen if it seems necessary based on your symptoms and we may want to watch you squat, walk and pat your head and rub your belly at the same time. Kidding. Sort of.

Lastly, your physical examination may include an internal and external examination of your pelvic floor. An internal exam can be done vaginally or rectally for women and rectally for men. This part of our physical exam gives us a ton of information. It helps us determine whether your pelvic floor muscles are tight or weak and if you know how to use them correctly. It also helps us decide if they are a likely contributor to the pain or symptoms you’re experiencing. Our exams may be uncomfortable, but they should never hurt you and we want you to know that. If gynecological examinations have been painful in the past, know that we do not use a speculum or stirrups. We use a gloved, lubricated finger and we will not push through any intense pain or discomfort.

Like I said in my previous post, if you are uncomfortable with an internal exam, there are ways around it. I have seen patients and they have gotten better all without an internal exam. Don’t let fear of an exam stop you from getting PT care, because we can do our best to help even without this testing.

The physical exam will take up the majority of the remaining time of your first PT visit, but before you leave we will arm you with at least a few tips, tricks or exercises to start implementing over the following week or until your next appointment. This will be considered your home exercise program (HEP) and it’s a HUGE part of PT. We may see you once a week, maybe twice a week at absolute most. Our goal is to teach you little things you can start doing at home to make sure that you and your body are moving in the right direction between PT appointments.

And that is an initial evaluation with a pelvic floor PT at Sullivan Physical Therapy, folks. Thanks for reading! If you have any questions or comments, feel free to leave them below or email me at becky@sullivanphysicaltherapy.com.

Also, a couple of my amazing colleagues have an informative podcast called PT Below The Waist. If you want to hear a more about a pelvic floor evaluation, you can hear Jessica Chastka, PT, DPT and Jamille Niewiara, PT, DPT talk about it on episode 3! Or follow this link: https://soundcloud.com/ptbelowthewaist/episode-1

-Rebecca Maidansky, PT, DPT

What is Pelvic Floor PT?

The first question I start with during every initial evaluation is this: “So, what do you know about pelvic floor physical therapy?” I usually get a shrug, maybe an awkward laugh, or every once in a while the person I’m seeing it has googled it and their findings made them nervous. So let’s start off this blogs journey by demystifying the experience that is pelvic floor physical therapy.

Physical therapists are specialists in the way our bodies move and function and the way our muscles, ligaments and bones affect that movement and function. Pelvic floor physical therapists specialize further in the muscles that constitute the pelvic floor. The pelvic floor is the literal and figurative bottom of your body. It spans from your pubic bone to your tailbone and between your ischial tuberosities, or SIT bones. Spoiler alert: men and women both have it.

Because of where these muscles are located and how they are structured, they affect the function of your bladder and bowels as well as participation in sexual activity. They can also contribute to pain in the pelvis, back, hips and abdomen. These muscles, like all muscles, can be spasmed and tight or weak and ineffective. Often times they can be both tight and weak at the same time, but that’s a story for another post.

As pelvic floor physical therapists, our job is to determine how the muscles in your pelvic floor are affecting symptoms you’re experiencing like urinary incontinence, fecal incontinence, painful intercourse, prolapse, tailbone pain, vulvar and vaginal pain, diastasis recti, rectal pain, constipation… the list goes on and on.

When you see a pelvic floor physical therapist, your session will likely start with a lot of conversation to give us the best picture of what’s happening with your pelvic floor. All of that information will help guide our physical evaluation, which can include screening your lumbar and thoracic spine, hip mobility, lower extremity strength and control of your abdominals. It can also include a screen of your internal and external pelvic floor muscles, if you are comfortable with it at the time. It is important that if you’re not comfortable with a pelvic floor examination, you let your therapist know. An internal exam provides us with valuable information that helps get you better faster, but if we can’t look internally, we can still get information from other parts of your body and I never want that to be the reason someone shies away from getting help.

All of that information will help us determine whether you’re a good fit for physical therapy, a plan of action to start off managing your symptoms and getting you feeling better and ideally a rough estimate of how long we expect we’ll have to see you for results. At the very least, we can help you understand what’s happening in your body and how this very important bundle of muscles, that usually goes ignored, can be contributing to the concerns at hand.

Pelvic floor physical therapy typically includes a combination of exercise, of some sort, along with hands on manual therapy, of some sort. I say of some sort because often times when we hear of pelvic floor PT we think “kegels, kegels, kegels,” but in reality, kegels are not the best option for some conditions. Strengthening is a big part of pelvic floor physical therapy, but so is learning how to relax.

Physical therapy can include a lot of things. You may learn about how our bladder and bowels are supposed to function and tips to help yours function better. You may learn how to breathe better for your body and how to use that breathing to assist in a global relaxation of your pelvic floor and self. You may learn you’ve been doing that infamous kegel wrong all along AND how to do it correctly. Your physical therapy experience will be catered to you specifically, but can include: exercise, stretching, dietary modifications, fluid intake modifications, retraining your muscles to function better, biofeedback, meditation and lots of time for questions.

The quick and dirty is: If you have pain in your pelvis, bladder or bowel dysfunction and complaints regarding your sexual function, consider pelvic floor PT.

Thanks for reading! If you have questions or comments, please feel free to leave them below or email me at becky@sullivanphysicaltherapy.com.

-Rebecca Maidansky, PT, DPT

Let Me Introduce Myself

My name is Rebecca Maidansky and I am a pelvic floor physical therapist at Sullivan Physical Therapy in Austin, Texas. While working in this specialty, I have seen how difficult navigating the world of pelvic health can be for people. I have seen it affect their emotion and physical health, their livelihoods and relationships. I have seen people struggling for years in search of the right answers and the right help. HOWEVER, I have also seen those same people find the answers and treatment they’ve been searching for. I have seen those answers repair their professional and personal lives. That’s why I love pelvic floor physical therapy.

We ignore our pelvises. We abuse our pelvises and then when things go wrong it’s difficult to understand the cause or the answers we need. My goal for this blog is to help more people find more answers, faster. Did you know it takes the average woman 6.5 years to find help for pelvic floor dysfunction and men 4.5 years? I hope that over time these numbers change and I hope to be part of the movement that changes them.

Moving forward, I’ll be covering all things pelvic related. I’ll cover the basics of all things pelvis and try to break down the complex. If you’re interested in learning about pelvic pain, health and wellness, sign on to follow me on my journey to learn about all things pelvic related.

In the future, if you have specific topics you’d like to learn more about, let me know! If you have questions or comments, feel free to reach me at becky@sullivanphysicaltherapy.com or leave a comment below!