Pelvic floor physical therapy is one of only two recommendations in the 2022 AUA Guidelines for IC/BPS.(1,2) Patients who have tight, sensitive painful muscles should immediately be referred to physical therapy for physical therapy. Why? Researchers and clinicians have long noted tight pelvic floor muscles in patients struggling with IC/BPS. Muscles can become tense (aka the “guarding reflex”) in patients who struggle with bladder pain, UTI, chemocystitis, endometriosis or fibroid tumors. It can occur as a result of pelvic injury (i.e. falling on the tailbone), childbirth injury or surgery (i.e. hysterectomy, bladder suspension). Patients with a history of athletics (i.e. bike riding, football, gymnastics, ice skating, horseback riding) are particularly susceptible to pelvic floor tension over time.
When the tension is prolonged, painful trigger points and muscle dysfunction occurs which can then make urination, defecation and sexual relations difficult and/or painful. Tight muscles also restrict blood flow (aka ischemia) to the bladder and surrounding tissues.
In 2012, a randomized multicenter clinical trial found that pelvic floor myofascial massage was remarkably successful at reducing symptoms, including pain, urgency and frequency. (3)
The AUA suggests:
Appropriate manual physical therapy techniques (e.g., maneuvers that resolve pelvic, abdominal and/or hip muscular trigger points, lengthen muscle contractures, and release painful scars and other connective tissue restrictions), if appropriately-trained clinicians are available, should be offered to patients who present with pelvic floor tenderness. Pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided. Standard (Evidence Strength Grade A).
How do you know if you have pelvic floor dysfunction (PFD)?
The classic symptom of PFD is difficulty starting urination. If you have to wait five, ten, fifteen seconds or longer before you can release urine, this suggests that your muscles may be struggling to relax. Pain with intimacy and/or chronic constipation are also common symptoms. Some patients report a pulling sensation or pushing sensation after hysterectomy, often the result of spasms in the levator ani muscles. Physical therapy is remarkably successful in reducing muscle tension and, for many patients, provides a complete resolution of their symptoms. Learn more in the ICN PFD Information Center
What does a physical therapist do?
During your first visit, the therapist will do an overall assessment of your muscles. They will look for tension patterns in your legs, pelvis, lower back and abdomen. They will measure your leg length to determine if one is longer than the other. They usually watch how you walk up and down and hallway to see if you are limping, favoring one side over the other, walking abnormally, etc. They will ask if they can perform a brief internal examination. Why? Because some pelvic floor muscles lie deep within the pelvis and cannot be touched through the skin. For women, this will be performed through the vagina and, for men, the rectum.
Tell your therapist about your symptoms and history. Are you an athlete? If yes, what are your sports or current workouts? Have you had any pelvic trauma or pelvic surgeries? Hysterectomy? Do you remember falling? Did you ever break your tailbone? Were you a victim of rape or abuse? Do you have any sharp pain? Where? Do you have pain that refers down your leg? Do you experience any fluttering or feeling as if you are sitting on a cell phone on vibrate? Your goal is to help them visualize and then study the muscles in your pelvis.
If they touch a muscle and trigger pain, this is what we call your “hallelujah” moment. Immediately ask them what they are touching. Your goal is to walk out of that appointment with the names of the muscles that are dysfunctional. The physical therapist should provide a variety of stretches and exercises designed to relax, lengthen and loosen tight pelvic floor muscles at home. Ideally, you will work with a physical therapist for several sessions and then slowly begin to do work at home. Many patients are taught to use a glass wand or dilator to perform internal massage at home.
What if I don’t want internal work?
Many patients are surprised to discover that pelvic floor physical therapy is done internally. Yes, it can be embarrassing. Yes, it can feel awkward. But research shows it is also remarkably successful at reducing symptoms. Muscles require “hands on” work. With their fingers, the therapist will gently follow the length of the muscle to help it relax and release. If they find trigger points, they may gently massage it. And they are always watching your face to determine if you are hurting or uncomfortable. Be vocal. Let them know how it feels.
If you are a victim of sexual abuse and cannot or do not want to tolerate internal examinations, you are not alone. Please tell the therapist your history. Their goal should be to work with you over time until you become more comfortable and develop trust. Many patients can eventually have internal work done and experience symptom relief.
There are some patients who have very tight pelvic floor muscles, often since childhood. Known as “vaginismus,” they have never experienced pain free sex or comfortable gynecological examinations. It may be impossible to insert even a small finger into their vagina. In these cases, the physical therapist will always start with external muscle work, the goal of which is to slowly and steadily reduce muscle tension until you can tolerate internal work. With time, patience and determination, these patients do respond well to muscle therapy and achieve normal bladder and bowel function.
Are Kegel exercises recommended for IC/BPS or PFD?
Absolutely not. Kegel exercises NOT recommended for patients struggling with PFD because they tighten muscles. Rather, PFD patients must focus on relaxing, loosening and lengthening the muscles.
What if my muscles stay tight? Biomechanics Matter
If a patient is not responding to physical therapy over time, or if their muscles return to tension and trigger points recur, then both the physical therapist and patient must look beyond the muscles to the bones. Bony structures, such as the hips, SI joint, knees or feet can place long-term tension on muscles. Do you have scoliosis? SI dysfunction? Sciatica?
In his ground breaking book Breaking Through Chronic Pelvic Pain, Dr. Jerome Weiss wrote:
“Looking back, I can recollect many patients with pelvic pain complaints that were ultimately found to be biomechanically related, especially when their symptoms were present when engaging in certain activities. In particular, abnormalities of the sacrum and feet play a significant role in pelvic pain pathology that is generally overlooked by treating physicians.”(4)
Whether the patient has a broken tailbone that has healed out of position, scoliosis that has one hip raised above the other or a foot disorder, biomechanics abnormalities can result in long-term pelvic tension and pain. Dr. Weiss found that many of these patients were not walking correctly. They had a history of plantar fasciitis, Morton’s neuroma, Morton’s toe, were pigeon toed or duck footed. After a referral to podiatry and proper treatment, many patients finally found relief.
We strongly recommend that you purchase his book. It is a master class of in pelvic anatomy and explains how and why pelvic floor issues can cause bladder, vulvar, rectal, testicular pain. And, it’s filled with many success stories. You’ll find it in the ICN shop!
Watch our video
How to find a physical therapist to treat pelvic floor dysfunction?
What if I have no insurance or can’t afford pelvic floor physical therapy?
There are books and YouTube videos that