1. Pelvic Floor Physical Therapy
Jamie Justice, PT, WCS
Creative Therapeutics

2. Defining pelvic floor therapy
What does pelvic floor therapy mean to you?
Subspecialty of orthopedics allowing physical therapists to objectively assess function of the pelvic floor muscles
Diagnoses commonly treated
Bowel incontinence Osteoporosis
Constipation Urinary incontinence
Pediatric pelvic health Voiding dysfunction
Male pelvic health Pregnancy related pain
Chronic pelvic pain Postpartum pain and weakness
Pelvic organ prolapse

3. Changing perception of PFPT
Standard is 4 hours of lecture in DPT program to introduce students to this specialty
No interest in being a pelvic floor therapist – No Problem!
Should be responsibility of every orthopedic therapist to understand the function of the pelvic floor, even if you don’t treat it
Know red flags and when to refer to a PFPT

4. let’s define the core
What does the
core mean to you?

5. The unstable house
The core or pelvis is the foundation . A crack in the foundation leads to problems with:
Local Muscle Activation
Remote muscle imbalances
Alignment problems
Balance
Agility
Overuse in extremities
Urinary incontinence and prolapse

6. Local or anticipatory core muscles
Coordinated action will produce central stability
Functional synergy

7. Pelvic floor and respiratory synergy
Parallel movement of the respiratory diaphragm and pelvic floor
Inhalation- diaphragm drops and pelvic floor elastically loads
Exhalation- Diaphragm and pelvic floor recoil
Teamwork: Intra-abdominal pressure
What could cause a restriction around the balloon?

8. Pelvic Floor anatomy

9. Urogenital Triangle Bulbocavernosus Ischiocavernosus
Superficial Transverse Perineal
Innervation from perineal branch of pudendal nerve S2-4
Slow and Fast Twitch
Assists more with bladder and bowel function
Assists with sexual function

10. Anal Triangle External Anal Sphincter
Innervated by Inferior Rectal and Perineal Branch of Pudendal Nerve S2-4
Responsible for 20% resting tone
Internal Anal Sphincter
Innervated by ANS
Responsible for 80% resting tone
Attaches the perineal body to the anococcygeal ligament

11. Pelvic diaphragm Iliococcygeus Coccygeus Pubococcygeus Puborectalis
Pubovaginalis
70% slow twitch
Carries weight of abdominal and pelvic organs
Prevents constant strain on visceral ligaments
Innervation from Nerve to Pelvic Diaphragm S3-4; may also include perineal branch pudendal nerve

12. Gateway into the local system
The Diaphragm
PFM turned on before the abdominals every time and matched the load
PFM turned on quicker when cue of diaphragmatic breath was done with a Kegel versus without
Transverse abdominis turns on with increased activation of the diaphragm. (Hodges et al 2000)

13. Why is the pelvic floor so important?
Sphincter control
Stability
Sump pump
Sexual function
Support

14. Pelvic Floor Dysfunction
Condition
Description
Symptoms
Normal PFM
PFM contracts and relaxes on command and in response to changes in IAP
Normal urinary, bowel and sexual function
Underactive PFM
PFM unable to contract when needed
Urinary or fecal incontinence, pelvic organ prolapse
Overactive PFM
PFM is unable to relax and may contract during defecation, voiding, vaginal penetration
Obstructing voiding, constipation, dyspareunia, pelvic pain
Non-functioning PFM
No PFM palpable
Any symptom may be present
An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Floor Dysfunction

15. Specific dysfunctions treated with pelvic floor therapy
Stress urinary incontinence
Do you leak with coughing, sneezing, running, jumping
Urgency/urge urinary incontinence
Do you have strong urgency and have a hard time making it to the bathroom in time
Do you leak the closer you get to the bathroom
Do you get an urge or leak with any triggers, such as coming home, turning on water?
Voiding Dysfunction and Urinary Retention

16. Specific dysfunctions treated with pelvic floor therapy
Pelvic Organ Prolapse
Cystocele
Uterine Prolapse
Rectocele
Vaginal Vault Prolapse

17. Specific dysfunctions treated with pelvic floor therapy
Urogynecological Pain
Dyspareunia
Vaginismus
Vulvodynia
Painful Bladder Syndrome (Interstitial Cystitis)
Dysuria
Adhesions

18. Specific dysfunctions treated with pelvic floor therapy
Chronic Pelvic Pain
Pain persisting longer than 3 months; visceral source of pain ruled out
Pain may be in lower pelvis, abdomen, perineum, vagina, rectum, coccyx, buttocks
May be accompanied with urinary and bowel dysfunction
Associated with pelvic floor muscle overactivity
Pudendal neuralgia
Need to find what the driver of this pain is – musculoskeletal, neural, central sensitization, visceral

19. Recognizing Musculoskeletal Pain
Visceral
Somatic
Dull, aching, crampy, burning
Deep, squeezing,
Diffuse, vague
Systemic effects
Unaffected by position
Dull, aching, constant, gnawing
Stabbing, sharp, throbbing
Specific location
Alters with position
Aggravated by movement
(Steiner 2004)

20. Questions to screen patients for pelvic floor dysfunction
Do you have pain with sitting?
Do waistbands/jeans aggravate your pain?
Are you sexually active? Is intercourse painful?
Does your patient have to go to the bathroom before, during and after treatment?
What is your gynecological history? Vaginal childbirths? Pelvic surgeries?

21. Pelvic Floor examination
Verbal and written consent
External observation and palpation
Intravaginal or intrarectal muscle examination
Response of pelvic floor to diaphragmatic breathing, contracting abdominals, bearing down,
Qualification of strength of a Kegel contraction
Qualification of ability to relax
Assessment of any myalgia, tone, trigger points, myofascial restrictions, scar tissue

22. Spotting pelvic Floor Dysfunction WITHOUT PALPATING THE PELVIC FLOOR
Assess during core activation and strengthening
Butt gripping
Breath holding during TVA activation
Teeth gritting, jaw tensing
Overuse of obliques
Ribcage elevation and depression with exercise – poor lateral movement
Diastasis rectus abdominis

23. Treatment For Pelvic Floor Dysfunction
Manual therapy
Modalities
Neuro re-education of voluntary action of the pelvic floor
Neuro re-education of the anticipatory core
Motor strategies for posture and functional movement training
Addressing muscle imbalances

24. Manual Therapy
Intravaginal or intrarectal trigger point release, myofascial release
External connective tissue mobilization to perineum, ischiorectal fossa, pelvis, abdomen
Visceral mobilization
Muscle energy and mobilization for pelvic and sacral obliquity

25. Modalities Biofeedback or Surface EMG Electrical Stimulation
Balloon Catheter Retraining

26. Pelvic Floor Re-education
Kegels
Cue to shut off flow of urine and lift the beans
Always train with breathing, are you contracting on the inhale or exhale?
Cue to feel relaxation
Very subtle contraction
Look for breath holding, compensation in glutes, obliques

27. Turning on the Core with Posture
Where is ribcage in relation to pelvis?

28. Tricks To Train the Pelvic Floor During functional exercise
Ski jump position
Pursed lips open mouth exhalation
Turn feet in and out
Lift your arches (S2)
Cue Kegel with lifting the beans during core work
Work Synnergists

30. Resources
Talasz et al. Phase–Locked Parallel Movement of Diaphragm and pelvic Floor During Breathing and Coughing- A Dynamic MRI Investigation in Healthy Females. Int Urogynecol J ; 22:61-68.
Hodges PW, Gandevia SC. Changes in Intra-abdominal Pressure During Postural and Respiratory Activation of the Human Diaphragm. J Appl Physiol. 2000; 89(3):
An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Floor Dysfunction. Neurourology and Urodynamics. 2010; 29:4–20.