Podcast Transcript: Pelvic Floor Physical Therapy

[Dr. Amy Park]
Well, can you explain what is pelvic floor PT? Like what exactly occurs, and how can we best explain it to patients so they actually go to PT?

[Ingrid Harm-Ernandes]
That's a great question because I think sometimes the fear of going to pelvic PT really stops. Even in our urogyne world where that's what we all work with, less than 50% of the patients referred to pelvic PT actually go, right? I think, again, the book has that knowledge in it, so io if someone picks it up, they know what happens in an assessment. They know what happens in a treatment. Basically, what I'll say is every pelvic PT will decide, after doing a long subjective assessment, what does this patient need? What I mean by that is, do they need an internal assessment? Do they need just external assessment?

Do they need a full out orthopedic assessment, which are wonderful skills that all PTs will use for joint motion and mobility and functional level? We will do that depending on the patient's needs and what they desire. Their goals are hugely important for us when we approach how we're going to form a treatment for them or a treatment plan for them. Once we have that assessment, if it's an internal, we look at muscle strength, muscle ability, muscle endurance, muscle quick response, trigger points, fascial restrictions. It's actually extremely extensive what we look for.

I will say that that relaxation component that we look for in the muscle is exceedingly important because we will not prescribe an exercise regimen until we know exactly what they and their pelvic floor can do. I know that sounds funny, but if I have someone with overactive bladder and their pelvic floor is upregulated, is hyperactive, there are many terms that we use for that, and I give them 100 pelvic floor exercises to do in a day, I can make their symptoms worse, so we need to prescribe the exercises based on what we find. Then that's kind of the tip of the iceberg, I'll say. From there, we'll do a comprehensive exercise program for their core, for their body.

I say knees to toes. I sometimes treat their neck or their feet if I need to in order to resolve the symptoms. Then we do behavioral therapies where it might be, how do we teach them to get their bladder to calm down so that they don't have urgency? How do we teach them to have a bowel movement so they can have a bowel movement without constipation? Because we all know that it's not just our organs, it's not just our colon, but it's our pelvic floor that hugely impacts how we're able to have a bowel movement. Teaching someone how to change their lifestyle, their life, their abilities, their functional level is huge while we're doing all these exercises.

You can see it's like, this is just like I said, the tip of the iceberg. It's extremely comprehensive that once you send someone to pelvic PT, that PT is going to figure out what's going on in their life. I may have two patients with the same diagnosis, but I might not do the same treatment because they're different people. One might be a retired person who has time on their hands. Not all retired people do. Then I might have someone who's pregnant, has three children, and a job. I'm not going to give them the same routine because they can't possibly do the same routine, so it's very, very individual.

[Dr. Amy Park]
There's a couple points that you just brought up that I wanted to just touch on because so many of my patients have underlying conditions like their back pain or hip pain, they're incredibly common. Pelvic pain conditions like endometriosis or interstitial cystitis or vulvodynia, and a lot of people just instead of holding all their tension in their neck and their shoulders, they're holding it in their pelvis. There's so many etiologies.

It's just, I think you nailed it when you talked about how it has to be a comprehensive assessment because if you just address the pelvic floor and you're not addressing some of the underlying issues like the back pain or the hip pain and strengthening their core, then you're just a little bit in a tailspin, I would imagine, so I really appreciate that about your specialty. Would you say that you're all women? Because especially if you're doing the internal work, I think it's very surprising for some patients.

[Ingrid Harm-Ernandes]
Yes. We're majority women, but there are men and it is increasing actually. Over time, we've had more men enter the field. Some of it is because we have, we treat men, so some of the misconception is that, oh, we just treat women and only women have pelvic floor issues. No, everybody's got a pelvis and everybody has a pelvic floor, so we really need to address all the issues across the spectrum. I think men are stepping in because sometimes it is uncomfortable.

I've had many men and they're so hesitant when they first come in and they're like, well, you're a woman's health. I'm like, no, just call me a pelvic health specialist. The poor, you know, post and pre and post-postectomy and prostatitis. Prostatitis kind of fits in this same unfortunate category of recurrent UTIs where everybody's busy blaming it on some infection when it's really not. Quite frequently, it's actually the pelvic floor mimicking the same symptoms. What we do with someone with a recurrent UTI or prostatitis is we actually have to get them off this cycle of antibiotics and antifungals and it just keeps going on and on.

When I started in the field, antibiotics were still given out very regularly and very easy. I had women who said I could just call my doctor, say I've got an infection, and please just give me antibiotics. I'd have to convince them to say, no, please go in for a culture, and if that culture is negative, we know we're looking at something else. They'd come back saying, I can't believe it, Ingrid. You were right. I don't have an infection, it feels like it. We would work on their pelvic floor and the infection-type symptoms would go away, and our men with prostatitis are in the same boat. I feel so bad that we really have to work on getting them away from this cycle of antibiotics, and once we do, they just do so, so much better.

[Dr. Amy Park]
You reminded me that I've heard some stories from pelvic floor PTs, how effective it is. A lot of them tell me it's even more effective for the men. They pick it up easier. It's like a classic story of, for the young men, especially, like soccer players and they have psoas pain or post whatever, you know, vasectomy or whatever pain, they actually respond very well and very quickly, and they're like, it's the most amazing, gratifying treatment. [chuckles]

[Ingrid Harm-Ernandes]
You're 100% right.

[Dr. Amy Park]
Yes, but anyway, I also wanted to just ask about what other indications can you think of to go to a pelvic floor PT.

[Ingrid Harm-Ernandes]
Yes, there are many, many different reasons to go. I would say one of the unfortunate things, once again, is that people, especially women here are taught it's okay to leak. It's normal to leak. It's normal and okay to have pain with sex. Just live with it. Put a pad on, and one of the reasons men get better quickly is pads are for women. They don't want to have pads. They want to get better yesterday, so it has a little to do with that.
It's this issue of, well, yes, you know, we giggle about it. We laugh about it. If I'm with my friends, I laugh and I pee on myself and we just kind of just say, well, no worries, but we have to dispel those myths that it's normal. I want the conversation to be normal about it, but not that the conditions are normal. Some of the most common things are any kind of leakage with coughing, sneezing, laughing, urgency where you can't make it to the bathroom on time, or even if you now make it to the bathroom, in a year or two years or five years, you might not make it to the bathroom. Solve that problem now before it becomes a leakage issue.

Fecal incontinence, my, that is a big one that people don't want to talk about. That is something that is kind of off-limits for people, but I want people to realize out there, if you've got patients coming in and they're hemming and hawing about things, go ahead and ask. Outright ask because these patients actually want you to ask so that they feel comfortable to say, yes, you know, by the way, every time I pull my underwear down, I have a stain on it. What's going on kind of thing?

Or constipation. No, it's not okay to live with constipation. The more you strain, the worse the problem gets, and sometimes it's such an easy fix working on the pelvic floor and proper toileting position can make a night and day difference with them, so constipation is another thing. Don't wait on that. Prolapse for women right after pregnancy and then later in life. It's been shown that operative deliveries are at a high risk for forming prolapse either immediately afterwards or years down the road when menopause shows up and the pelvic floor starts to change because of that. Any kind of bulging, any pressure that you commonly see in your practices can absolutely be treated by pelvic PT.

Pain with sex. That's another big one that people do not want to talk about, but that should be such a big checkoff right there that if they're having pain with sex, whether it's post, and I'll say fourth trimester, not postpartum because we have to stop thinking that the woman is better after six weeks. We may check off that they're okay, their bleeding has reduced or stopped, and now we say they're ready to go. A lot of times they're not. They're not ready to. They have back pain. They have incontinence. They have prolapse. They have fecal incontinence. These are the patients that absolutely need to go to PT. During menopause, pain with sex, again, increases. That's another time.

You mentioned before back pain and hip pain. This is a big one. If they have incontinence and they have back pain as well or hip pain, wow, that's a telltale sign to get them to pelvic PT. I can't tell you how many patients I've treated that come in and they say, well, I have incontinence and this is going on. I go through their history and they say, you know what, I've had a hip bursitis and I've been treated for it. Injections, whatever it may be. It doesn't get better. I treat their pelvic floor and their "hip bursitis" goes away because it was never hip bursitis, it was the obturator internus, a hip rotational muscle, so we need to look at that broad spectrum of multiple symptoms.

You mentioned before vulvodynia, IBS, interstitial cystitis. If they have this suite of problems, they have more than just a simple fix, I'll call it. They have an upregulated system. They have these comorbidities that are very, very typical. I'd say look for these comorbidities, migraines, asthma, all of that fits into this group of upregulated individuals that absolutely can benefit from pelvic PT.