Pelvic floor physical therapy: Here’s why you need it and why it’s way more than kegels

by Casey Newman

If you’ve had a baby, you know… That first trip to the bathroom after delivery can strike as much fear in you as trying to walk a tightrope. You can thank your pelvic floor for that added anxiety. The muscles that helped you birth your baby, as well as pee (and poop), are part of your pelvic floor. And just like other muscles that have been injured or overused, your pelvic floor needs rehab too. Especially after a pregnancy. 

“Not a lot of people know about it, or they’ve heard of their pelvic floor and it’s just associated with Kegels and that’s it. And that is such a misconception,” explains Dr. Susan Facemire, a pelvic floor and women’s health specialist in Green. 

Pelvic health and pelvic floor health are much more than Kegels or dealing with leakage of urine. (Sidebar: Those ads for undergarments for leaky bladder you see everywhere? It’s not your bladder that’s leaking, it’s a problem with your pelvic floor muscles. Pelvic floor physical therapy can fix that.)

Though your pelvic floor muscles help you give birth, pee and poop, they also work as a unit helping to stabilize your core, lower back and connect all the way up to your head. Dr. Facemire notes that some people with pelvic floor dysfunction even experience teeth grinding issues.

Pregnancy can do a number on your pelvic floor. 

“[As your pregnancy progresses], there are a lot more potential contributors to either pain or urinary incontinence because that pelvic floor is having to add increased pressure,” Facemire says. “This can cause new complications or an exacerbation of issues that were there before. So when patients are coming to me and they are pregnant and are having issues, typically what we see most often is some kind of weakness or incontinence, but more so when a patient is pregnant, it is like a pubic dysfunction or pelvic dysfunction, whether it’s pubic girdle pain or low back pain sciatica.” 

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But just like postpartum mental health issues, pelvic health and pelvic floor physical therapy during pregnancy and postpartum need more awareness.

“Maternal care is abysmal. You go for your six-week checkup, and as long as your stitches are healing, or this is healing, and you have no major medical concerns, you’re fine,” Dr. Facemire says. “And that is a part of the healing process where therapy can play a crucial role in pelvic health, long-term health.”

Another thing you probably know as a new parent: You’re bombarded with messaging about “getting your body back after baby.” You don’t need to get your body back, said Dr. Facemire.

“Now you’re trying to embrace this new body that you have created and that has brought new life into this world, but in a very healthy way. It’s not about losing weight. It’s about being functional. It’s about being pain-free. So in that postpartum world, ideally as a pelvic floor physical therapist, what I would like to see is every patient.”

In other countries, when you go in for your first postpartum checkup, you’re automatically referred to a pelvic floor physio to help you go over what you can expect as you heal, evaluate for any dysfunction and develop a treatment plan. But in the U.S.? Most gynecologists have no idea about pelvic floor dysfunction or what to do about it. 

After I had my first daughter I had so much pain using the bathroom, sitting and even in my abdomen. My gynecologist wanted to refer me to a GI doctor and I even had one nurse practitioner tell me she had never heard of anything like what I was experiencing and that I might have cancer. Spoiler alert: I didn’t have cancer or a GI problem. My pelvic floor was dysfunctional. Really, really dysfunctional.

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Pelvic Floor Symptoms to Watch For

Pelvic floor dysfunction happens when you’re unable to correctly coordinate or relax the muscles of your pelvic floor to urinate, have a bowel movement or have sex. 

Other conditions besides pregnancy and childbirth can cause pelvic floor dysfunction including traumatic injuries to your pelvis, being overweight, advancing age, pelvic surgery or overusing pelvic floor muscles from frequent bathroom trips or straining.

Pelvic floor physical therapists treat a variety of problems: 

  • Pain
  • Painful sex
  • Weakness
  • Painful urination or bowel movements
  • Urinary or stool leakage
  • Pelvic organ prolapse
  • Diastasis recti (when your abdominal muscles split during pregnancy, but fail to close back together)

Despite what you may hear on TV or in ads, no amount of urinary leakage is normal, says Dr. Facemire.

“When someone is having leakage, it’s usually some kind of strength issue, but also a just pressure imbalance in the system. And that again relates back to, it’s not just the pelvic floor, so that’s why Kegels don’t work,” she said.

If you’re experiencing any of the above issues or think you might be, talk to your doctor about a referral to pelvic floor physical therapy. Or visit a clinic like Dr. Facemire’s that provides direct access to physical therapy services without a doctor’s referral. 

What to Expect During Your First Appointment

Pelvic floor physical therapy isn’t like your typical physical therapy appointment. Instead, it can resemble a trip to the gynecologist (but without the awkward stirrups or pain from a pap smear).

“If someone is pregnant, we don’t typically do an internal exam, but we will do a movement analysis and alignment analysis to kind of see where they’re carrying their center of gravity, how it looks as far as that rib cage and then breath mechanics. We’ll do some kind of external work to see if there are tight areas, especially low back, hips and glutes to see if manual work can help,” explains Dr. Facemire. “We’re looking at potential pain generators. What movements bring that pain and looking at the mechanical aspect of the pain or dysfunction, and then setting up a plan to address that and more.”

If you’re not pregnant, you’ll likely get an internal exam to assess muscle function, coordination and weakness in addition to movement and alignment analysis. 

“Does that mean we do an internal exam every time? No, but we can kind of delineate pain and weakness or the ends of that spectrum,” Dr. Facemire says. “Most people fall somewhere in between those, but it just depends on the main contributor. Is pain contributing to the weaknesses, the weakness contributing to the pain? We pull back the layers to guide our treatment course.”

Dr. Facemire and her patients work together to create a very safe space, working on the mental component of pelvic floor dysfunction as well.

“I very much try to approach it eclectically with stretching, meditation, strengthening all that manual work, self manual work. And that kind of feeds into the other big component of what we see on the mental health side,” she continues. “If it’s not something new after a pregnancy where we’re just kind of trying to restore some of that function. The other part of it that I see is a lot of chronic pelvic pain that’s due to trauma and trauma can be the birth trauma, can be from a botched surgery or rape or sexual abuse.”

If it’s been a while since you’ve had a baby, you can still benefit from therapy, says Dr. Facemire. She sees a lot of patients who leak urine when they do certain activities and have just accepted that as part of their lives.

“If you leak every time you did an activity when you were younger, and you’ve just avoided it for years and years, what I see that turn into is other things start hurting. So now you just have general aches and pains or your back hurts. You have sciatic pain and it may not be bad enough to seek medical treatment,” she said.

Read more about pelvic floor dysfunction here, or make an appointment to see Dr. Facemire at her clinic in Green.

Casey Newman is a mother of two from Green who depends on wine to get her through bathtime and bedtime. She is a maternal and women’s health advocate who volunteers with several birth and maternal rights organizations and has spoken to Congress members about issues affecting moms.

Photo: Dr. Anabel