Internal Pelvic Floor Physical Therapy Explained.
Authored by Dr. Maryssa Steffen, PT, DPT, Board-Certified Pelvic Health Specialist
Internal pelvic floor physical therapy
is a type of modality used by trained, board-licensed physical therapists, to assess and treat pelvic floor dysfunction. Each therapist at Bodyful PT has more than 5000 hours of experience treating pelvic floor dysfunction, for all ages and genders, using internal and external pelvic floor techniques.
Internal pelvic health treatment can be part of a comprehensive physical therapy assessment to get to the root cause of symptoms. Often, this part of the diagnosis and treatment process is after breathing and posture analyses and treatments for the diaphragm, abdomen and hips.
Because the pelvic floor muscles connect to the hips and are integrated into breath and posture support, you will likely benefit from internal pelvic floor work after you can start to feel your breath and core support in a way that changes your symptoms and improves body awareness.
When you are grounded in the center of your breath, your pelvic floor muscles may be more accessible to your awareness and curiosity. This is the beginning of changing your symptoms and empowering you in your healing practice.
After your informed consent, your therapist may offer internal pelvic floor therapy. At Bodyful PT, we prioritize comfort and communication. We consider your temperature, body position, and emotional state during this personal and vulnerable work. Your safety and comfort matters.
Expect resources for grounding and check-ins to assure that the pacing, duration, and type of touch is therapeutic for you.
If you are experiencing pelvic health symptoms and it is limiting your movements and functions, it may be necessary to assess the pelvic floor muscles. An assessment of these muscles helps to rule out hypothetical PT diagnoses by your therapist.
For example, a healthy muscle group is not too sensitive to touch, it can tense and relax voluntarily, it is coordinated with other muscles and joints necessary for daily functions, it is flexible, and it is strong. A doctor of physical therapy is arguably one of the most trained providers to diagnose movement dysfunction and anatomical issues necessary to get you on a path towards improving your joyful engagement in activities and exercise.
During an internal pelvic floor examination, your pelvic floor muscles are gently explored to rule out issues that may contribute to your symptoms. You will be offered feedback from the therapist to start to train your body awareness and necessary coordination.
What does “internal” mean for a pelvic floor examination?
The pelvic floor muscles are layers of muscles around the pelvic floor sphincters and the bowl of muscles that supports the pelvic organs. To assess and treat these tissues and to train pelvic floor exercises and relaxation, the therapist can use tactile feedback and gentle manual therapy techniques to support your pelvic muscles and to address the root cause of your symptoms.
You may have heard of “biofeedback.” Biofeedback comes in a few different forms. You may have heard of using sensors on your skin to track muscle activity with a visual readout, or surface EMG.
Biofeedback is also available when the skilled pelvic floor therapist uses visual and tactile assessments and offers you real time auditory and touch feedback during your responses to cues for pelvic floor exercises. Mirror feedback and self touch are also options.
Pelvic floor muscles, front view, with the psoas and inner thigh muscles.
Superficial pelvic floor muscles with the pubic bone and tailbone.
What can you expect during the pelvic examination process?
It will include more than just pelvic floor muscles.
The pelvic PT examination starts with an assessment of the pelvis, including gently palpating the lumbosacral and sacroiliac joints, abdominal muscles, iliopsoas and piriformis muscles, the hip joints, abdominal viscera, and bladder, for any sensitivities or reproduction of symptoms.
If indicated, we can also rule out a diastasis recti (separated abdominal muscles) and abdominal/inguinal hernias.
As described in this comprehensive guide to pelvic PT, we also assess your posture, breathing, and core and hip strength.
The external pelvic floor tissues are observed for signs of irritation, scars, hemorrhoids, or pelvic organ prolapse, a vulvar assessment for possible hormonal contributing factors, and to screen for dermatological conditions. Auditory and visual cues for endurance hold, relax, breathe, and isolation of the pelvic floor muscles are also introduced.
Once you are ready and curious about the internal work, pelvic floor exercises including coordination with breath, strength, power, balance of engaging all pelvic floor muscles on the right and left side, front to back, and superficial to deep, post-”squeeze” relaxation ability, fast and slow muscle contractions, and flexibility of the tissues, are introduced.
You are also gently screened for any tenderness to palpation or reproduction of symptoms and therapeutic manual therapy skills are used to reduce the discomfort.
What are pelvic floor therapy benefits?
Many studies, and years of clinical experience, have shown that some people may struggle with performing pelvic floor exercises in a way that is most beneficial for them. For example, you may have been told to squeeze your pelvic floor muscles, or “kegel,” as strongly, as often, and for as long as you can. You may not have learned how to coordinate it with breathing nor practiced how to fully relax the muscles after squeezing. For some, these general instructions to “kegel” can worsen their symptoms.
Most of the time, the root cause of pelvic floor dysfunction comes from coordination and relaxation issues. What this means can vary per person, depending on their symptoms and goals for integrative pelvic health.
What are the expected outcomes of internal pelvic floor therapy?
If your issues come from strength limitations, like how to stop urine leakage while coughing, then expect to have specific strengthening exercises tailored to your needs. And, believe it or not, posture influences leakage with coughing.
Your prescribed exercises optimize the quality of movement and body awareness needed to get to the root of your symptoms.
If indicated, your pelvic floor exercises will also include diaphragm strengthening, abdominal activation to support your spine and visceral organs, and squatting and balance exercises.
What are the conditions treated?
Stress urinary incontinence - preventing urine leakage during coughing, sneezing, laughing, lifting, jumping, and running.
Urinary urge incontinence - preventing leakage during a strong urge to urinate. This commonly happens while you are running to the bathroom, or trying to find a bathroom, with a strong urge.
Overactive bladder - also known as painful bladder syndrome, interstitial cystitis, or causes of bladder pain without infection
Pelvic organ prolapse - rectocele, uterine prolapse, vaginal vault prolapse, urethral prolapse, cystocele, rectal prolapse, mild pelvic organ prolapse, and how to fix a prolapse without surgery.
Pain with sex - cis-male, cis-female, trans, or intersex, if you experience symptoms with sexual appreciation, pelvic floor therapy can help. Common complaints and concerns include burning sensation during and after sex, including symptoms with arousal, external stimulation, penetrative sex, and orgasm.
Bladder symptoms - bladder pain without a current infection, burning sensation after urinating but no infection, and “why do I feel like I have to pee after I already peed?”
Bowel function - constipation treatment, IBS treatment, abdominal bloating, and rectal pain and pressure. Pelvic PT is typically very successful with how to empty bowels completely.
Pelvic pain - there are many muscles, nerves, and fascia in the pelvis and any of these structures can cause symptoms, including how to relieve sit bone pain, tailbone pain with sitting and standing, psoas muscle pain symptoms, sciatica, pudendal neuralgia, and round ligament pain.
Prenatal and postpartum pelvic floor therapy - manual therapy techniques are offered to relieve pain and safe exercises are prescribed by a pelvic floor specialist. You can receive treatment for mild pelvic organ prolapse.
Perimenopause and postmenopause - safe exercises for bone strengthening and warm up prescription for cardiovascular exercise. Safe exercises after hysterectomy.
So, internal pelvic floor therapy uses diagnostics to find the cause of symptoms and pelvic floor dysfunction.
What is pelvic health treatment?
Internal pelvic floor physical therapy treatment techniques include:
Pelvic floor relaxation. You may be cued on diaphragmatic breathing, learn positions and postures that improve your ability to relax your pelvic floor muscles voluntarily, and how to fully relax your pelvic floor muscles after you “kegel.”
Pelvic floor strengthening exercises. Strengthening your pelvic floor muscles will almost always include coordination with breath support, integration with posture, and activation with your core and hip muscles. Expect progressions to include your entire body and application to daily functions.
Manual therapy. If you are tending to scar tissue, are experiencing pelvic pain, or have tight muscles, gentle approaches to manual therapy may be indicated. Manual therapy techniques are used to train your brain to connect to faulty habits, to learn how to engage with a muscle differently, to improve blood and lymphatic flow to the tense or restricted tissues, and to improve resting tone and flexibility.
Pelvic floor coordination training. You may need to learn how to time the activation of your muscles to prevent urine leakage during coughing, for example. Coordination training can also help with mild pelvic organ prolapse self-management.
Electromyographic biofeedback may be useful for visual learners who are not comfortable with touch, but it does not offer any information about the strength and isolation of muscles. Studies show that surface EMG for the pelvic floor offers no additional benefit compared to a skilled continence therapist for cis-women with urinary incontinence.
Frequently asked questions:
“Why is the pelvic therapist asking so many questions during the first visit?”
Anyone will have “impairments.” For example, you may have heard of “good” or “bad” posture, “flat feet,” “tense neck,” “curved back” or “flat back,” “how to breathe correctly,” “strong core,” and the list goes on and on. There are some muscles that are sore on almost everybody. There is no conclusive evidence about a one-size-fits-all ideal posture or amount of pelvic floor muscle “strength.”
There is a lot of noise out there and it can be challenging to identify the information that is appropriate for you. Do you “avoid hormone replacement therapy for menopause,” or “do not lie on your back during pregnancy?”
As Board-licensed medical professionals, pelvic floor physical therapists ask questions to cluster your symptoms into patterns and to start to hypothesize your diagnosis and streamline the physical therapy and movement exam. Since anyone can have “impairments,” it would take several hours to collect data. Instead, your answers to the questions begin to tailor what tests to use and which ones would not be necessary.
Also, you will begin to learn how to ask yourself the same questions when you are finding the cause of your symptoms on your own. The questions will likely lead you to the solutions your body needs.
Can you treat pelvic floor dysfunction without an internal pelvic floor therapy?
YES! If your jaw, neck, abdomen, breathing patterns, hips, and sustained postures are tense or restricted, then your pelvic floor is MOST LIKELY also tense and contributing to dysfunction and symptoms. Many people benefit from abdominal and diaphragm manual therapy, and prescribed restorative and corrective exercises and resources at home, to decrease tension patterns that ultimately benefit that pelvic floor.
Is it OK to have internal pelvic floor therapy if I am on my period?
Yes. If you are on your period, you can still keep your appointment, as long as you can drive yourself to the clinic and walk comfortably. If you have symptoms during your period, but you are functional enough to get yourself to the clinic, your therapist can better understand what causes your symptoms if it is cyclically menses-related.
Do you treat men and trans-folks?
Yes. Pelvic floor dysfunction is possible in anyone. Posture, breathing, hip mobility, core strength, and pelvic floor coordination are some of the factors we consider, and these factors are gender inclusive.
