Showing up to your first pelvic floor physical therapy visit takes a lot of guts. It’s not easy to seek help for issues that, for most, are extremely personal and often take a toll on self-confidence. Not to mention that it’s difficult to imagine how physical therapy – where you go for a knee injury or neck pain – will address things like urinary incontinence, constipation, and painful sex. And if you are like many others with pelvic floor issues, you have probably already been to countless providers and received solutions that left more to desire.

First things first: Take a deep breath and walk in with an open mind.

Pelvic floor PT will be different than your “typical” orthopedic PT, but includes a lot of the same foundations of treatment. As my good friend and colleague likes to say, “pelvic floor PT is like orthopedics in a cave.”

What if you have never been to PT before or when you did go, you didn’t even work with the same therapist every time? How “exposed” do you have to be? Can’t you just do kegels and be on your marry way? What is a pelvic floor anyway and what does it have to do with my vagina, penis, or rectum?

These are all VALID questions. Let’s break down the process of your first pelvic floor physical therapy visit – from the time you walk in, to the time you walk out – so you can feel more prepared and hopefully a little less nervous.

Meeting your physical therapist

At the very start, your physical therapist will introduce themselves and take you to a private treatment area. Brace yourself for small talk and icebreakers – it’s a PT special. Once you get settled in, your PT will shift the conversation towards why you are seeking PT and how they can begin to help you. This is otherwise known as the subjective evaluation.

An open conversation

When the subjective evaluation gets underway, your PT will most likely sit back and listen. This is a time for YOU to bring your concerns to the table and tell your story. Don’t worry about things be irrelevant or TMI! Frequently, even stories from childhood bring out a lot of critical information to determine where your issues are coming from. And in the pelvic floor PT world, there is no such thing as TMI – pee, poop, sex, desires, pain, body image ALL matter. If you need help getting the story out, your PT will chime in every now and then to ask questions like:

• How often do you urinate during the day/night? Do you have urgency, frequency, leaking, pain with urination?
• How often do have bowel movements? What is the typical consistency of your poop? Do you strain to empty?
• Do you have any unwanted pain with sexual activity or avoid certain parts? Do you have penetrative sex and does that contribute to symptoms? Are you able to orgasm?
• Have you had kids? What was your childbirth like? Did you have any tearing or other injuries? How was your recovery? Are you experiencing leaking, pelvic heaviness, core weakness, pain?

Physical Evaluation

Once you are finished with the story – and it’s okay if more comes up during the remainder of the visit – your PT will begin to make a hypothesis of where your symptoms are coming from. Now, as pelvic floor PT is like orthopedics in a cave, there are many areas of the body that can be taken into consideration when finding the drivers of your symptoms. These are some of the most common factors looked at while evaluating those drivers:

• Movement Patterns – What is your range of motion like? Do you squat with weight more on one side than the other? Do you avoid a painful area? What are your activities of choice – past and present?
• Posture – How do you like to stand or sit at rest and during particular activities? Do you sit most of the day or move around frequently? Does changing the way you stand or sit feel better or worse? What is the alignment like from head to toe?
• Breathing Strategies – Are you a chest breather or do you hold your breath? Do you know what the diaphragm is? What about at rest versus during activity? How about the way your ribcage moves?
• Musculoskeletal System – How do your muscles and joints play a role? What about strength in areas like your hips and core? Are there tender points that reproduce your pain? Does stretching or contracting make a difference? What relationships between your thighs, abdomen, hips, neck, jaw, pelvis contribute to symptoms?
• Neuromuscular System – Do your muscles coordinate well together? Can you activate muscles in the right sequence? How do those movement patterns affect your muscles and nervous system? Are there chronic stressors or triggers that contribute to your symptoms? Has chronic pain created more sensitivity in some areas more than others?

Some of this will be hands on, and some of this will be hands off. If you are uncomfortable with a particular portion or question, it’s okay to say so and come back to it at a later time. During the physical examination, there will be ongoing conversation about these tests and any findings.

The Pelvic Floor

Although this can still be considered part of the physical examination, it deserves it’s own section for a couple of reasons. One, it is a very personal and private examination that not everyone will be comfortable with or consent to on day one. Two, many of the items listed above can be viewed a bit differently from a pelvic floor perspective versus the more traditional “orthopedic” perspectives above. If you are open to a pelvic floor exam, your PT will give you privacy and ask you to undress from the waist down, providing you with a drape to cover.

• External Observations – How do your vulvar, vaginal, perineal, and anal tissues look? What movement can we see externally from a contraction and relaxation? Is there any scarring, redness, discoloration, etc?
• Internal Examination – What is the strength and muscle patterns of your pelvic floor contraction? Does the movement change with different breathing patterns or postures? Are there tender points within the pelvic floor? Are any of your symptoms reproduced with palpation to the pelvic floor? How flexible is your pelvic floor? Does your pelvic floor want to protect or tighten a lot? Is there any visible bulging internally?

It is extremely important to mention that the entirety of the pelvic floor examination is 100% optional, is only performed with your consent throughout, can be stopped at any time you choose. The ball is completely in your court.

Wrapping it Up

When the physical exam and pelvic floor exam (if consented) is finished, you will be given privacy again to dress, and your PT will return to discuss the entire exam with you. Your PT has likely not performed all of the tests mentioned above but has performed the highest prioritized to find the immediate drivers of your symptoms. Other testing will still be carried out through the next several sessions. Based on the test findings, your PT will explain what they found and what they believe to be the drivers. You will discuss the best plan of care moving forward based on this information.

• Treatment Expectations – What will the next visits involve? What are the goals for the next visits? What are the overall PT goals? What do you expect out of PT?
• Action Steps – What exercises will you work on until the next visit? Are there lifestyle modifications you addressed? How can you make changes right away? What is reasonable and realistic within your work/life schedule? How much time do you have?
• Referral to Other Providers – Will you benefit from seeing a medical specialists, acupuncturist, mental health therapist, massage therapist, nutritionist, etc? When should you plan to see those providers?
• PT Plan of Care – How often will you schedule pelvic floor PT? How long will visits be? Is this reasonable/realistic for you? If not, what compromises can be made?
• Remaining Questions – What else can be answered?

Pelvic floor physical therapy is designed for you to feel safe and heard. You are likely going through a difficult and life-changing experience, but PT is your path to recovery and there is light at the end of the tunnel. You are not alone through this. There will be ups and downs along the way. Your PT will help guide you through them, and give you the empowerment to overcome this situation. If you are currently looking for a pelvic floor physical therapist, give us a call today and we can help you find the right fit. Be well!

– Courtney Edgecomb, PT, DPT