Physiotherapists working in the field of pelvic health help women with a range of conditions including bladder and bowel concerns, bothersome heaviness and discomfort associated with pelvic organ prolapse, persistent pelvic pain and sexual pain.

Pelvic health concerns are common throughout all stages of life, but can be particularly problematic during the childbearing years and after menopause.

1 in 2 women who have had a baby experience prolapse

1 in 3 women who have had a baby will wet themselves

1 in 5 women experience pelvic or sexual pain

1 in 10 women suffer from poor bowel control

Read this article for more pelvic floor health facts.

Nowadays, most people know that pelvic floor exercises (also known as ‘Kegels’) are recommended to treat a number of pelvic health conditions. However, the research shows that pelvic floor exercises are only effective if a suitably trained health professional, such as a pelvic health physiotherapist, supervises the program.

The world’s leading experts have recommended treatments provided by pelvic health physiotherapists (such as supervised pelvic floor muscle training and bladder training programs) as grade A recommendations (the highest level possible) for a number of conditions including;

  • For all pregnant women (even those who are fully continent) to prevent urinary incontinence during pregnancy and after childbirth,
  • As a first line treatment for any women experiencing urinary incontinence persisting three months after childbirth,
  • For all women, regardless of age, experiencing urinary incontinence,
  • To reduce symptoms of pelvic organ prolapse.

The research well and truly shows that seeing a pelvic health physiotherapist can help women improve, better manage and in many cases, completely cure their problem!

Pelvic Floor Anatomy

pelvic floor muscle diagram women

Your pelvic floor muscles sit between your pubic bone, coccyx (tailbone) and sitting bones, stretching like a trampoline across the base of the pelvis. These muscles support your pelvic organs – the bladder, bowel and uterus in women, and the urethra (front passage, from the bladder), vagina (birth canal, from the uterus) and rectum (back passage, from the bowel) all pass through this muscular sling.

Pelvic floor muscles play an important role in sexual function, bladder and bowel control, and pelvic organ support in women.

Common Pelvic Health (floor) Problems

  • Stress Urinary Incontinence
  • Urge Urinary Incontinence
  • Urinary Urgency
  • Urinary Frequency
  • Faecal / Flatal Incontinence and Urgency
  • Incomplete Emptying
  • Pelvic Organ Prolapse
  • Pelvic & Sexual Pain

For further information read our article on common pelvic floor problems.

Menopause and Pelvic Organ Prolapse

If you are going through the next stage of life as a woman, you might have felt a bulge in the vagina or had a routine smear and been told you have pelvic organ prolapse. It can be a difficult and scary time, and if you google pelvic organ prolapse some worrying images can be displayed. It is important to know that most pelvic organ prolapses are not like the ones you may see on the internet and most can be improved without surgery.

  • Why am I getting prolapse symptoms during menopause?
  • What is happening in my vagina?

Read the answers found in our blog article menopause and pelvic organ prolapse.

Pelvic Organ Prolapse after Childbirth

Being diagnosed with a pelvic organ prolapse can provoke mixed emotions, particularly if very little information is provided at the time of diagnosis or you have attempted self-diagnosis, and suspect you have the condition based on symptoms alone. The first year after having a baby can be particularly hard as improvements may be slow while your body heals from the amazing feat it just achieved – growing and bringing a whole new human into the world. If you suspect you have pelvic organ prolapse after childbirth, based just on your symptoms it is important to be assessed by a qualified practitioner. Symptoms such as heaviness in the pelvis or a bulge in the vagina can be common after having a baby and do not always mean you have a prolapse.

Women who are particularly active or want to start exercising after having a baby often find the changes in their pelvic floor difficult to process. There is inconsistent information and advice on the internet about what exercises are safe and not safe when you have a pelvic organ prolapse – it can be very confusing! To learn more about what exercises are safe with a pelvic organ prolapse and how a women’s health physiotherapist can help with pelvic prolapse please read our detailed article on Pelvic Organ Prolapse after Childbirth.

Pelvic Pain Conditions Explained

Pelvic, sexual and vulval pain are hidden problems and women often suffer in silence, or due to misdiagnosis, for years before they find help. They are very distressing problems and cause both physical and emotional suffering.

Common symptoms of pelvic pain:

  • Painful sex
  • Pain using a tampon
  • Pain with internal examination e.g. having a pap smear
  • Vulval pain with sitting or wearing tight clothing
  • Painful periods
  • Pain with bladder fullness
  • Generalised, persistent abdominal and pelvic pain
  • Coccyx (tailbone) pain

Persistent Pelvic Pain

Women with persistent pelvic pain (also known as ‘chronic pelvic pain’) experience some form of pain in the pelvis, which persists on most days for more than six months. It affects 15-25% of women and requires multi-disciplinary management for effective treatment – this means your physiotherapist will work with other health professionals in a team to help reduce your pain and improve your wellbeing.

For more information and resources, we have written a detailed article on Pelvic Pain Conditions Explained.

Painful periods and Endometriosis Advice

Should periods be painful?

It is common for some women or adolescents to experience discomfort during part of their period. Period pain is not normal when:

  • Pain starts before bleeding commences and/or extends past the first few days of your period
  • The pain does not respond to pain medications or the contraceptive pill
  • The pain is so debilitating it stops you from doing normal daily activities such as going to school or work.

What causes period pain?

Contributions to pain may include:

  • Muscle cramps from the uterus and surrounding pelvic muscles
  • Adenomyosis: when cells that normally line the uterus grow in the muscles of the uterus
  • Endometriosis: when similar cells that line the uterus are found outside of the uterus
  • A sensitised nervous system

For further advice please read our blog post on Painful periods and Endometriosis.

Vulvodynia Treatment Advice

What is vulvodynia?

Vulvodynia is a condition that at least 10 to 20% of women will experience at some point in their lifetime. It involves the nerves of the vulva (the area outside the vaginal opening) becoming sensitised, which commonly results in a sensation of burning, stinging, rawness, generalised pain or soreness in this area. Physiotherapists can provide advice and exercises to help retrain these nerves (to ‘desensitise’ them) and support the recovery of other muscles in the pelvis that may have been affected, such as your pelvic floor muscles.

The term vulvodynia is used to describe the persistent vulvar discomfort (lasting 3 – 6 months, but often years) when all other potential causes of the pain have been ruled out (such as infection) or the pain has persisted despite adequate management of the original cause (e.g. treatment of vaginal thrush). It can significantly impact quality of life for the many women who suffer with the condition, and is often misdiagnosed or inadequately managed.

Read more about Vulvodynia Treatment Advice.

Painful Sex Treatment Advice

menopause – if sex turns from pleasure to pain

Did you know that pain with sex – dyspareunia, is one of the most frequently reported symptoms of menopause? If sex is painful, women commonly have a reduced desire for sexual intimacy or reduced arousal too. Many women accept this as part of aging and just avoid having intercourse. However, there are ways to improve dyspareunia and to start enjoying sex again.

Why can sex become painful after menopause?

A common reason sex can become painful after menopause is due to the drop of the hormone Oestrogen. Oestrogen is important in the vagina and vulva to keep the tissues soft, lubricated and elastic. When Oestrogen lowers, the tissues can become more fragile and dry, this sometimes causes too much friction during vaginal penetration and the tissues get irritated. In some women, the pelvic floor muscles that surround the vagina and the vaginal opening tighten as a protective response to try and prevent further penetration. This tightening response can cause further discomfort, and if the muscles stay tight they can become sore from being over-active. If this continues women can develop anxiety or fear about having intercourse (sometimes this occurs on more of a subconscious level) and the nervous system can also become sensitised.

Read our blog post on Painful Sex Treatment for advice, tips on self management and how Physiotherapy can help.

What can cause Pelvic Floor Problems

Pelvic floor problems, such as urinary or faecal incontinence and pelvic organ prolapse can occur throughout the lifespan, but are more common at certain life stages. There are also certain lifestyle factors and associated health problems which may increase your risk further. You are more at risk of pelvic floor problems if you are:

  • Pregnant, or have ever had a baby
  • Currently or previously experiencing the menopause
  • An athlete with high training volumes particularly as a trampolinist or gymnast
  • A man who has undergone surgery for prostate cancer
  • A woman who has undergone gynaecological surgery such as a hysterectomy

You are at greater risk if you are:

  • Overweight, obese (body max index over 25)
  • Regularly lifting heavy weights at the gym or work
  • Straining when you use your bowels- such as with constipation
  • Coughing or sneezing often, which may be due to smoking, or respiratory disorders like asthma or hay fever
  • Currently or previously experiencing back or pelvic pain

Below is a list of risk factors:

  • Pregnancy and childbirth
  • The menopause
  • High training volumes/high impact
  • Following prostate surgery
  • Following gynaecological surgery
  • Overweight and obesity
  • Straining to use bowels
  • Chronic cough or sneeze
  • Low back and pelvic pain

Please visit our full blog post on what causes pelvic floor problems which details each risk factor and gives advice.

What Causes to Pelvic and Sexual Pain Disorders?

Pelvic, sexual and vulval pain are hidden problems and women often suffer in silence, or due to misdiagnosis, for years before they find help. They can be very distressing problems and cause both physical and emotional suffering. People with pelvic or sexual pain may have been diagnosed with vaginismus, vulvodynia, dyspareunia, endometriosis, pudendal neuralgia, painful bladder syndrome, irritable bowel syndrome, and often have a combination of these problems contributing to their individual pain experience.

Read our full blog post on What can cause Pelvic and Sexual Pain Disorders to find out how overactive pelvic floor, history of painful periods, irritable bowel syndrome or painful bladder syndrome may contribute to your pain experience.

Incontinence treatment options

The world’s leading experts have recommended treatments provided by pelvic health physiotherapists for incontinence, prolapse and pelvic pain. Read on to find out which treatments are available for your problem.

Pelvic Floor Muscle Training (PFMT)

As the pelvic floor is a group of muscles, just like those you can see on your legs or arms, they are trainable! Supervised pelvic floor muscle training (also known as Kegels) are recommended for all women, regardless of age to treat urinary incontinence. This is because experts have studied women like you and know that it is the best treatment available. We also know that regularly checking in with your pelvic physiotherapist is going to be much more effective than going at it alone. It is also essential that you are assessed before starting your program to ensure you are performing both the relaxation and contraction phases properly and that they program is individualized. You may need to work on different aspects of the training to improve speed, endurance, coordination, or relaxation.

Bladder training

Just like PFMT, bladder training has the highest recommendation for the treatment of urinary incontinence in women. Bladder training is a program that combines patient education, a voiding schedule, and strategies to control urgency or leakage such as bladder calming, distraction, relaxation and pelvic floor muscle contraction. This treatment tends to be favoured by pelvic physiotherapists for the treatment of urinary incontinence, frequency, urgency, or mixed urinary incontinence. Understanding how the bladder and brain work together to process all the incoming information is the first step to regaining control of your bladder problem.

Read our detailed blog article on Incontinence treatment options for in depth advice on:

  • Lifestyle advice
  • Continence pessary
  • Posterior Tibial Nerve Stimulation for Overactive Bladder
  • Medication
  • Surgery for continence

Pelvic Organ Prolapse treatment options

The world’s leading experts have recommended treatments provided by pelvic health physiotherapists for incontinence, prolapse and pelvic pain. Read on to find out which treatments are available for your problem.

Pelvic Floor Muscle Training

Pelvic floor muscle training also has the highest level of benefit according to experts at reducing symptoms in women with prolapse.

PFMT generally will not reduce the stage of prolapse (the physical position of the prolapse), but there is evidence that this training can lead to changes in muscle thickness and vaginal dimensions which may account for some of the symptom improvement. We also know that these exercises, when delivered by a trained pelvic physiotherapist are likely to prevent and improve prolapse symptoms in the longer term.

Lifestyle advice

You are at greater risk of developing POP if you are:

  • Overweight, obese (body max index over 25)
  • Regularly lifting heavy weights at the gym or work
  • Straining when you use your bowels- such as with constipation
  • Coughing or sneezing often, which may be due to smoking, or respiratory disorders like asthma or hay fever

For further advice, please visit our detailed blog post on pelvic organ prolapse treatment options.

Pelvic and sexual pain treatment options

The world’s leading experts have recommended treatments provided by pelvic health physiotherapists for incontinence, prolapse and pelvic pain. Read on to find out which treatments are available for your problem.

People with pelvic or sexual pain may have been diagnosed with vaginismus, vulvodynia, dyspareunia, endometriosis, pudendal neuralgia, painful bladder syndrome, irritable bowel syndrome, and often have a combination of these problems contributing to their individual pain experience. Nerve and muscle overactivity, particularly in the pelvic nerves and pelvic floor muscles, lead to a number of problems, including ongoing pain in the region from increased tension and an inability to relax the pelvic floor muscles in anticipation of penetration, causing problems with sex, and pain with tampon use and internal examinations with care providers.

Because your pain experience will be unique to you, treatment will also be very individualised based on the symptoms you are experiencing, your goals, and your medical history.

Your physiotherapist will work with you to determine the most appropriate management plan, this may include stretches, pelvic floor relaxation exercises, vaginal trainers as well as techniques for vulvar desensitisation and vulval care.

For more information about the ways which a pelvic physiotherapist may be able to help you please read our full blog on pelvic sexual pain treatment options.

The Multi-Disciplinary Approach to Pelvic Pain

Women with persistent pelvic pain (also known as ‘chronic pelvic pain’) experience some form of pain in the pelvis, which persists on most days for more than six months. It affects 15-25% of women and requires multi-disciplinary management for effective treatment – this means a number of health professionals work in a team with you to help you reduce your overall burden of pain and improve your wellbeing.

Your team of health professionals may consist of a:

  • Pelvic physiotherapist
  • Pain specialist
  • Psychologist
  • Dietician
  • Gynaecologist
  • GP

Read more about how a Physiotherapist can help in our blog post on the multidisciplinary approach to pelvic pain.

How do I do the pelvic floor exercises correctly?

Firstly, it’s important to understand that pelvic floor exercises, also known as kegels, are not recommended for everyone, and in fact can make certain conditions worse.

Women can develop overactive, tight and/or tender pelvic floor muscles, especially if they experience pelvic pain which may or may not relate to painful periods, pain with intimacy and sexual intercourse, as well as pain with the use of tampons or during vaginal examinations.

This is why it is essential that you have an evaluation from a trained pelvic physiotherapist prior to embarking on a pelvic floor exercise program.

Read our step by step guide on how to do pelvic floor exercises correctly.

Physiotherapy for Pelvic or Vaginal Surgery

Physiotherapists also play an important role in assessing patients pre and post operatively prior to a number of gynaecological surgeries including continence procedures, prolapse surgery and hysterectomy.

Did you know?

  • Hysterectomy is the most common female surgery
  • Up to 1 in 5 women will have surgery for prolapse or incontinence in their lifetime
  • The recovery period required after these surgeries can be up to 3 months and care must be taken to ensure your surgery has the best chance of success.

We know that:

  • A pelvic floor that functions well is important in ensuring your pelvic surgery and long term outcomes are optimal, however;
  • 1 in 2 women cannot effectively contract their pelvic floor when provided with written or verbal instruction alone.
  • 1 in 4 women will use a counter-productive technique, which can weaken the pelvic floor and the surgical sites further.

Read how Physiotherapy can help for Pelvic or Vaginal Surgery.

Bladder and Bowel Control Problems in Children and Adolescents

Pelvic floor physiotherapists with additional training in paediatric continence are skilled in working with your GP and/or specialist to assist your child and family to manage their bladder and/or bowel control issues.

Did you know:

  • 1 in 5 school-aged children in Australia will suffer from persistent bedwetting
  • Up to 20% of 4 to 6 year olds have bladder leakage during the day intermittently, and 3% wet during the day twice or more a week
  • Young children or adolescents can experience leakage of urine during sport, coughing, sneezing or laughing
  • At least 1.5% of school aged children experience leakage from their bowel
  • Physiotherapy can help improve these problems in many cases

Read how Physiotherapy can help with managing bladder and bowel control problems in children and adolescents.

Summary

There is strong evidence to support the role of pelvic floor physiotherapists with additional training in women’s and pelvic health to treat a number of conditions across all life stages – from more commonly known pelvic health issues affecting women such as incontinence and prolapse, to pelvic and sexual pain concerns and also for helping children and adolescents with bed wetting or other bladder/bowel control concerns.

We hope the information in this blog has been useful and should always be considered in conjunction with an individual assessment with your physiotherapist and/or other health care provider skilled in the area such as a GP or gynaecologist.

We would love to help you manage your concerns and get you back achieving your goals worry –free!

Author: Kate Phillips

Kate is the Clinical Director for ‘myPhysioSA for her’, and also works publicly at the Women’s and Children’s Hospital where she holds a position in the Women’s Health Physiotherapy Unit.

Kate has a special interest in women’s health and pelvic floor rehabilitation and has undertaken postgraduate study in these fields at the University of Melbourne.

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