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So you have been referred to pelvic floor physical therapy. You don’t have a clue what to expect. Trepidation and anxiety are standard responses, and keep many people from following through with this referral and from getting help they need.
Allow me to walk you through what you can expect during a pelvic floor initial assessment, address often asked questions and to take away the mystery! Let’s go behind the veil, shall we?
A lot of talking.
A thorough subjective part of the exam is how any pelvic floor physical therapy (PFPT) evaluation should start. What we will ask will include:
Your current symptoms, essentially what is bringing you to PFPT. Pain, leaking, symptoms of GSM, vaginal pressure or heaviness, known issues diagnosed by your OBGYN, pain with sex, a desire to return to sex, a recent birth, your are pregnant, etc,
Your medical history: this is critical. Your PF muscles work as part of your WHOLE BODY. Do not under report birth history, orthopedic issues, prior surgeries, auto-immune issues or other chronic medical conditions such as diabetes, smoking, blood pressure issues, known fibroids, endometriosis…the list goes on. You cannot over report. Even if if feels unimportant or unrelated, it may help us solve your problem. TMJ, foot pain, neck pain - report it all!
Current medications, over the counter, presciption, supplements
Bowel and bladder habits - incontinence, pooping, peeing.
Sex - partnered or unpartnered. What is happening - or not happening - in that area of your life.
Trauma. I know this is hard. And you may not be ready to discuss this in visit one. But this is important and we are here to listen and figure out if this is part of your physical symptom profile.
Your work life, recreational pursuits, and lifestyle. What is impacted.
Your goals with coming in for PFPT. We are part of your team. Making PFPT specific to you is what we are here for! You are not a protocol. Your PFPT should be tailored to your end-goals.
The exam.
Let me be clear. We do internal vaginal exams.
And sometimes rectal exams if that is appropriate for your situation. We use one gloved finger. HOWEVER! If you are not comfortable with this, we can wait and do this part of the exam at another future visit when you are more comfortable or never. It gives us really important information about what is happening with your body. I often liken it to an exam if you came to me with neck pain, as the pelvic floor (PF) muscles (in your vaginal and rectal canals) are skeletal muscle just like your neck. I am assessing for pain, muscle tightness, muscle knots (or spasm), and your ability to contract and relax those muscles on command.
Whether or not you choose to do an internal exam, your initial assessment/exam may include any other combination of the following:
External biofeedback to assess your ability to properly use your PF muscles. This involves sticky electrodes that you self-place and are used with a computer program to look at graphs of your ability to contract and relax your PF muscles versus say, your abs, your glutes, or your inner thigh muscles.
Breathing assessment.
Postural assessment: Standing and sitting.
Orthopedic Examinations: how you can move, pain elsewhere in the body.
Examination of diastatis recti (DRA).
Education.
Education starts PRIOR to the examination. You should understand and be clear on what is happening during an examination and the goals of that exam.
Exam findings.
This will include anatomy education, education on other exam findings, and your proposed plan of care. It is important that you participate in the development of your care plan. Your plan will only work if it is something you are willing to participate in. You’ve heard the adage: “You can lead a horse to water, but you can’t make it drink”? Keep that in mind. I would much rather a patient be honest with me about their level of commitment and time per day - of even per week - that they can commit to their care plan. Meeting a patient where they are at versus giving them a plan that will never work, is essential.
Setting expectations.
PFPT, in general, does not magic symptoms away. The patients who feel like their plan “failed” often have just given up too quickly. As a generization, it takes 4-6 weeks of committed PFPT (in person treatments, completion of prescribed self care, and lifestyle changes) for a patient to really notice change. Decreased commitment extends this time frame. For committed patients, it takes 6-9 months for symptoms to fully resolve and for them to hit a “maintainence” level. This is a mass generalization and is based on studied time frames for neuromuscular change (4-6 weeks) and muscle growth (6-9 months). And this does not mean that all patients are actively attending PT for 9 months. Frequency and duration of PFPT sessions are mostly based on a patient’s starting level of severity as well as their participation and commitment to their care plan.
Tools and self care aids.
If I feel that different PFPT tools may help a patient with their self-care (home exercise) program, I will spend a lot of time educating them on options that may be right for them and giving resources of how to acquire those tools. My general recommendation is for a patient to gather their tools and, should they decide to add x,y,z to their routine, to bring them to a future session for education in their use. I find that this lowers the barrier to entry, allowing for greater patient success.
Additional team members.
As PFPTs, we cannot address everything. But we can help to surround your with a healthcare team and we may make suggestions for other health professions that you may need to involve in your care. And we can help connect you with these team members. In my own practice this often includes a referral to a phsycologist for emotional support, sex therapists for partner communication, urogenecologists for additional testing that I cannot do or things like a pessary fitting, as well as referrals to doulas for my birth and post partum PFPT populations.
Goal Setting.
I set goals with my patients and hope (expect) that other PFPTs do the same. Your PFPT plan of care should move your towards these goals. If other health or medical professions are involved in a patient’s life, I ask to connect with these other providers to make sure we are all working as a collective team around the patient to move them towards these goals and have clarity in care with all team members, patient included.
Leaving with a purpose.
As you can imagine, this is a lot to accomplish within a 45-60 minute exam, depending on the clinic and provider you are seeing. I always try to end an exam with a goal for the patient to work on prior to the next session. This may be as simple as gathering tools, postural cuing, or some breath work. But an objective to bridge between the first and second visit so that there is a sense of purpose and forward movement towards our set goals.
A few more thoughts. First, come as you are. We aren’t judging body hair, body odor, if you are bleeding or spotting, or anything else. Trust me, we have seen it all. We assess bodies - that is our job. We are not here to judge, only to educate and empower. Second, you should feel seen and heard. Third, you should leave a session feeling empowered in your health and knowing more about your body than when you walked in our door.
My hope that this information takes some of the mystery out an initial PFPT visit and allows you to walk in our door if you have been previously nervous to do so. Whether you are located in Los Angeles, or haven’t found a therapist that you have connected to in your area, I am always happy to help with in-person or virtual PFPT. You would be amazed at how well we can can accomplish PFPT over the computer. Definitely was skill we mastered back in 2020!
Lastly, let me provide you with resources to find a trained PFPT specialist in your area. This is a specialty requiring additional training a certifications beyond our PT Schoold training - even those of us that are Doctors of Physical Therapy (DPTs).
Herman and Wallace Trained PFPT providers:
APTA Trained PFPT providers:
https://www.aptapelvichealth.org/ptlocator
Maven Clinic - virtual PFPT:
Bloom Health - virtual PFPT:
https://swordhealth.com/solutions/bloom
Me! - in person, Los Angeles based in person PFPT or world-wide virtual PFPT:
With Pelvic Love,
xx
Dr. Heidi
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