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Welcome to a New Way of Treating Pelvic Floor Pain

Fiona McMahon PT, DPT, PRPC


Even though you may have just heard of it, pelvic floor physical therapy has been around for a long time. In fact, on a trip back home to Maine, I was rifling through an old baby box my grandmother had saved and found the pelvic floor exercises that my mom had been prescribed immediately after she gave birth to my twin sister and me in the Northern United Kingdom in the mid-’80s. I can not begin to tell you how much of a trip it was to see. Maybe I was destined to do this, or maybe it was just exceedingly good postpartum care and just a coincidence. Who honestly knows? Either way, I was delighted and tickled to see that pelvic floor physical therapy had been at least some small part of my life from the moment I ( and my sister) were born.


But what was on the paper? It was pretty basic but still a solid set of postpartum exercises. The British “physios” had given my mother gentle exercises to strengthen her core, back, glutes, and pelvic floor to ease her transition into the post-partum period and prepare her for the rigor and wiggles of negotiating two very large for their gestational-age baby girls.

That’s the thing, the basics are the basics for a reason. Much like many things we call basic, the Pumpkin Spice Latte and black leggings, are not just good, but great! I still find myself reaching for these tried and true exercises from time to time. They are effective, they are easy to do, and they are timeless. But, physical therapy and especially pelvic floor physical therapy has evolved and continues to evolve over time.


The first notable change is the training of physical therapists. Nowadays, physical therapists graduate and practice at the doctoral level, which is reflective of the extensive training we receive to diagnose and treat complex pelvic floor conditions. Though our favorite exercises from the 80s are still going strong, as they should, our practice has evolved to be more holistic, evidence-based, and most importantly patient-focused.


In my own journey developing my practice, I have sought out modalities and techniques that transcend “ye olde kegel”. To truly address my patients’ functional complaints. Thinking within but also beyond the pelvic floor is essential to allow patients to meet their own goals.

Before we dive into exactly why Ember Physical Therapy offers unique, comprehensive, and superlative pelvic floor rehabilitation care, let’s orient ourselves to the pelvic floor. The pelvic floor is a group of muscles that live between the pubic bone in front and the tailbone in the back. Think about the part of your body that makes contact with a bicycle seat. That’s the pelvic floor.


What does the pelvic floor do? It all comes down to the “S’s”. First, it was 3, then it was 4, and now we have 5 S’s to name the functions of the pelvic floor. Each one of these functions plays a huge role in your daily life, which is precisely why quality pelvic floor rehabilitation is so important.


Stabilizing - Stabilization may not be the first thing that comes to mind, but the pelvic floor works tirelessly to support the trunk and spine and is considered part of your core support. Poor pelvic floor function can contribute to pain in the pelvic girdle, the low back, hips, and pubic bone.


Sphincteric- This is what the pelvic floor is famous for. Regulating how we pee and poop! The pelvic floor provides the muscles that help keep waste in until it’s an appropriate time to trot to the loo. We can see weakness in the pelvic floor resulting in bowel and bladder accidents as well as over-tightened muscles making it really difficult, painful, or annoyingly frequent when it comes to the bathroom


Sexual- The muscles of the pelvic floor are integral to sexual function no matter your anatomy. The muscles of the pelvic floor work to allow blood flow to the clitoris or penis, as well as stretch to allow for penetration. We can sexual pain in both folks with female and male anatomy when the pelvic floor muscles are not functioning as they should.


Sump-Pump- For those of you lucky enough not to know what a sump-pump is, it’s a pump that clears the water from your basement ( cellar, for my New Englanders) and directs the water away from the foundation. In the body, the pelvic floor works to help return blood flow back to the trunk, to keep it oxygenated and circulating. Dysfunction in the pelvic floor can lead to a heavy draggy feeling in the pelvis.




Let’s think of a few case examples.

Postpartum Runner

You are a 36-year-old postpartum mother experiencing urinary leakage with coughing, laughing, and sneezing. This is annoying, but what is most distressing to you is the fact that you can’t run more than a mile without completely soaking your leggings. It sucks. You have identified as a runner from the time you were in high school and now suddenly you find yourself sidelined. The one outlet you have during the hectic postpartum period has been taken from you all because you’re tired of trashing your pants. It sucks.


Would kegels, and gentle squeezing of your glutes and abs on a physical therapy table, help you to return to running? It’s a good start, but probably not if that’s all you did. It’s just not specific enough to you, your body, and what you are asking your body to do. It’s a start but, you would need to progress to more specific exercises to get you back to your best.

This is where a more modern approach needs to be applied. First of all, kegels? The bane of my pelvic floor existence is doing Kegels, without knowing exactly what is going on in the pelvic floor. Sometimes it’s useful, sometimes it’s a waste of time, and sometimes it can actually set you back on your progress.


Firstly, pelvic floor muscles, just like any other muscles can get short and tight and thus, weak. You may not think this could happen after vaginal childbirth, but it absolutely does. This can also occur following a cesarean section. Whether it be through the pelvic floor overworking to support the trunk following prolonged stretch on the abdominals from your growing bundle of joy, conditions like diastasis, or pregnancy-associated pubalgia, from pain and discomfort from childbirth and postpartum, the pelvic floor can overwork to the point that it becomes so tight, that the only kegel it can muster is weak and ineffective.


Additionally, you may have a strong kegel, but only be a pro at activating the posterior or back part of the pelvic floor. Lovely, but to really support the bladder, we need the anterior or front part of the pelvic floor working effectively as well. Without a comprehensive internal pelvic floor exam, it is really hard to a.) know if Kegels are the right move for you or b.) if they are the right move for you, know whether or not you can perform them in a manner specific to your goals.


Let’s also think about exercise specificity. In the immediate postpartum period, gentle exercises are great. But if you have been lugging a growing baby all over creation, chances are you have developed at least some strength and it is likely time to throw you a little bit more of a challenge in terms of your postpartum exercise routine.


For running, we need to think as pelvic floor physical therapists but it also behooves us to think like sports physical therapists. When we run, our pelvic floor has to keep us continent against a ground reaction force that can be between 4 and 9 times our body weight. To lessen the burden on the pelvic floor, we need a strong core, a strong set of hips, strong ankles, and the coordination to use that strength to reduce the dynamic load on the pelvic floor. We need to start stepping up your exercise routine to a point where you can play with more advanced exercises that are more specific to the task of running. Lying on your back on a table contracting your core likely won’t get you all of the way towards your goals.


All this said, returning to high-caliber exercise postpartum can be really scary. Many of the postpartum mothers, I encounter express fear surrounding returning to fitness and especially making any symptoms such as prolapse or diastasis worse. I feel it is my duty as a physical therapist to guide you through these exercises in a safe but challenging way. It can be so much less intimidating when you have an expert at your side. Progressing at a pace that feels safe but is also aligned with your goals is key. Having an expert at your side is a surefire way to get you back on the trails.


Beyond exercises themselves, pelvic physical therapists are educated in the interplay of hormones and their effect on postpartum bodies. When approaching a patient and their goals I am always aware of how breastfeeding, lack of sleep, and increased cortisol production can affect our return to sport. In the case of returning to activity postpartum, awareness of hormonal effects on the body helps me tailor my recommendations to ensure that you get the absolute most out of your time with me.


Who else can be helped with pelvic floor physical therapy?

You may not have been surprised to see a postpartum mother in this blog. Most folks think of pregnancy and postpartum patients as the mainstay of pelvic floor rehab. But did you know we treat so much more than that? At Ember, we treat everyone with pelvic floor dysfunction, folks with male anatomy, folks with female anatomy who haven’t given birth, kiddos with potty issues, and adults with continence issues, and difficulty urinating or defecating. As this blog progresses, keep your eyes peeled for more. Or if you don’t want to wait, give us a call for a free 15-minute phone consultation. But let’s talk about a few more common cases, so you don’t have to wait too long.


The Guy with Pelvic Pain


Many folks overlook folks with male anatomy with pelvic pain. Recently, I tried to set up an out-of-town friend with a pelvic floor physical therapist who treats dudes. As I studied pelvic floor physical therapy practices in his area, I was accosted with pink website design and the phrase “women’s health” everywhere I looked. Don’t get me wrong, women’s health physical therapy is crucial. It is how I got started. But focusing primarily on female bodies leaves out a good percentage of the population who is suffering from pelvic floor dysfunction.

Although there are some obvious anatomical differences, a different pelvic shape, fused bulbospongiosus muscle, and most notably a penis and testicles, the male pelvic floor can fall victim to spasms, weakness, pain, and dysfunction.


When a person with male anatomy has pelvic pain, he may be diagnosed with prostatitis or chronic pelvic pain syndrome.


The diagnosis of prostatitis can be confusing. The “itis” bit of the name is suggestive of infection. There are actually 4 main types of prostatitis only 2 of which involve an infection. Both acute bacterial prostatitis and chronic bacterial prostatitis are infective in origin and are typically treated with antibiotics. Nonbacterial prostatitis occurs without infection but does involve inflammation of the prostate. Chronic pelvic pain syndrome (CPPS) is the most common form of prostatitis and commonly involves dysfunction of the pelvic floor.


Folks with CPPS/ prostatitis have a few very distinctive symptoms. The hallmark is the feeling of a golf ball being stuck in the anus. Not fun at all. To further the not fun of it all, folks with CPPS/ prostatitis may experience sexual pain and dysfunction, urinary issues like post-void dribbling, ( usually seen as a spot of pee on the trousers after peeing), difficulty starting the stream of urination, needing to pee frequently, or having pain with urination.


The thing about male pelvic pain is it is absolutely treatable. The other thing is, there are fewer pelvic floor physical therapists out there that treat patients with male anatomy than those who just treat women alone, and finding a qualified pelvic floor practitioner who can effectively treat male pelvic pain can sometimes prove very difficult.


At Ember treating male pelvic pain is part of the bread and butter of what we do.

Although every man with pelvic pain is different there are some very common throughlines that we see when we address male pelvic pain issues. Typical folks with male anatomy who are suffering pelvic pain will have very tight pelvic floor muscles. Tight pelvic floor muscles, contrary to popular belief, are not very strong. Furthermore, these muscles are so tight that they do not allow for good blood flow to the pelvic anatomy resulting in pain, post-urinary dribble, and sexual dysfunction.


These tight muscles can be treated through manual techniques to get the muscles to relax, strengthening the muscles around the pelvis to take further pressure off of the pelvic floor, and reducing the body’s response to stress.


We also feel we have to get specific and tailor our treatments to address any potential drivers of the dysfunction in the first place. Is there a particular posture you prefer that limits your ability to recruit your core and posture efficiently? Are you chronically holding tension in a way that causes your pelvic floor to get tight and grumpy? With this holistic eye on the prize, we can get you better and keep you better.


Kiddos with Pelvic Floor Dysfunction

My adult patients are always surprised when I say I treat kids with pelvic floor dysfunction. It often surprises them that young folks can suffer from pelvic floor dysfunction. These issues in kiddos often present in bowel dysfunction, constipation encopresis ( skid marks), urinary accidents, frequency, bedwetting, and unfortunately pain.


Kiddos are special people and childhood is such a special time, filled with pool parties, sleepovers, and maybe even summer camp! Potty issues can put a damper on the fun, if not scuttle it entirely.


By the time I see kiddos with potty issues, the whole family is often tired and frustrated. Unfortunately both the caregiver(s) and kiddo may have internalized a lot of shame about having pelvic floor issues. Despite the best efforts of the whole family, sticker charts have lost their shine, and requests for the kiddo to try and use the restroom are met with increasing resistance.


This is a normal but painful part of the experience, and my first goal when meeting you and your kiddo is to lift the shame and guilt. Muscles are muscles and they misbehave. That’s why PTs exist. We will work together to explain in an age-appropriate way why your child is having potty issues and develop a practical, non-invasive, and most importantly fun treatment plan to make potty issues a thing of the past!



For those of you with, or who know little kids, you know that if it isn’t fun, it isn’t happening. Getting core strength, practicing toileting postures, and learning about how our bodies function to allow us to pee and poop can all be tailored to keep your child interested and engaged in physical therapy.


The Ember Physical Therapy Difference

Ember offers expert bespoke care from me, Fiona McMahon PT, DPT, PRPC. I have spent nearly a decade working in one of the world’s best-known pelvic floor clinic in Manhattan, and I am beyond excited to take my expertise to you, in New Jersey.

I chose the name Ember, because I believe, much as the embers from a fire can grow into a powerful blaze, we kindle wellness and recovery with comprehensive, compassionate, and holistic care.

Are you curious if Ember is the right fit? Call for a free 15-minute consultation today!

Sources


Cohen D, Gonzalez J, Goldstein I. The Role of Pelvic Floor Muscles in Male Sexual Dysfunction and Pelvic Pain. Sex Med Rev. 2016 Jan;4(1):53-62. doi: 10.1016/j.sxmr.2015.10.001. Epub 2016 Jan 8. PMID: 27872005.


Thin RN. Prostatitis. Hosp Med. 1999 Oct;60(10):710-3. doi: 10.12968/hosp.1999.60.10.1213. PMID: 10656062.


van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, Pelger RCM, Hagenaars-van Miert CHAC, Laan ETM. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev. 2022 Apr;10(2):209-230. doi: 10.1016/j.sxmr.2021.03.002. Epub 2021 Jun 12. PMID: 34127429.



What are prostatitis and other related pelvic pain conditions. Urology Care Foundation. November 2021. https://www.urologyhealth.org/urology-a-z/p/prostatitis-(infection-of-the-prostate). [Accessed April 2023]


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