Pelvic Floor Physical Therapy

An informational word-sketch on pelvic floor physical therapy -- the benefits and what to expect.

A few months ago my therapist recommended I go into my OBGYN to talk about the issues I had been experiencing "down there". I had pain and cramping in my lower abdomen, rectal pressure and pain, and vaginal discomfort. She thought I might need to go see a pelvic floor physical therapist.

The OBGYN did recommended I go see a pelvic floor PT. As soon as the recommendation was put in, I started to get really nervous. I had no idea what to expect, I mean, what does a pelvic floor PT even do? Searching the internet wasn't super helpful and actually kind of made me more nervous (as searching the web about medical stuff usually does -- why do I do that?!)

So, I decided to use it as an opportunity to practice remaining calm during stress and to take each moment as it comes, instead of anticipating the worst. (key word here = practice)

I wanted to share my experience just in case it could help someone else know what to expect and hopefully calm any nervousness.

Session One

Last week I attended my first session of pelvic floor PT and it actually went really well. She started by going over my personal history and the symptoms I had been experiencing. [note: this is where you want to disclose any past trauma].

This was followed by a detailed explanation of the anatomy of the pelvic floor (which is way more complex than I thought). Then she explained what the internal exam would be like -- the part I was most nervous for. After her explanation I felt a lot better about it.

She ended the session with an external exam that consisted of:

• Watching me walk

• Having me stand on one leg and then the other to assess my balance and muscle strength

• Assessing muscle strength in my abdomen, glutes, and legs (She had me lay on my back and put one leg in the air. Then she applied pressure against my leg from different directions and I had to try to keep my leg in place)

• Abdomen palpations (palpation = to examine by touch). Basically, she lightly pressed on different parts of my abdomen to see if there were any areas that were tender -- which for me was basically all of it -- and if anything felt out of place.

Based on session one, she hypothesized that my main problem was pelvic floor muscles that were too tight or short, and that had difficulty relaxing or elongating.

She gave me two exercises to do throughout the week:

1. Deep, Diaphragmatic Breathing 5 minutes, 1-2 times a day
   

2. Modified Happy Baby Stretch hold for 60 seconds, 2-3 times a day

   1. Lay on my back, legs bent

   2. Hold my legs behind my knees

   3. bring knees up and out so I felt a stretch between my sits bones or in my inner thighs

   4. slow, deep breaths throughout the stretch

She also sent me home with 3 days worth of a bladder diary to track:

• When I ate and what

• When I drank fluids, what and how much

• When I went to the bathroom, the amount (small, medium, large) and amount of urgency felt (none, mild, medium, urgent)

• Any time I experienced leakage or incontinence

I left still feeling a bit nervous about the internal exam, but a lot more comfortable than before we started.

Session Two

We started by reviewing my bladder diary to see if anything stood out. She said it looked good and we didn't need to make any changes to my diet right now. She asked me how the exercises went and if there was anything of note that happened throughout the week. Then she had me show her how I was doing the exercises at home just to make sure I was still doing them correctly.

She asked if I wanted her to explain the internal examination again (which I did) and if I was still okay with the exam. She used her plastic model of a pelvis to explain the exam and again asked if that sounded like something I was okay with. I then signed a form consenting to the exam. She offered to have another person present during the exam, but I actually preferred it being just us, which was also fine.

She started by just observing what happened down there during a pelvic floor contraction (kegel) and a cough. She asked permission to do each step of the exam, which is one of the many benefits of disclosing past abuse. (They can't know what they don't know). She then lightly pressed on different parts of the labia majora to identify any tenderness or pain.

The internal exam consisted of applying light pressure in a clockwise motion at 3 different depths of the vaginal cavity -- just barely inside, a bit deeper, and deeper still. At each point she felt for abnormalities and asked if there was any pain or discomfort. If there was she had me rate the discomfort/pain.

At one point, the pain shot up into my lower abdomen and felt exactly like my IBS pain. She said there's a very good chance that my IBS symptoms are actually related to pelvic floor issues. (Which makes sense seeing as IBS is really just a diagnosis of "we don't really know what's wrong with you").

Her suspicions were correct that the muscles in my pelvis are incredibly tense and have a hard time relaxing. In fact, they can't actually fully relax. She explained that this is a common response of the brain to trauma -- it tenses up in attempts to protect that part of the body from further trauma. Over time, the body and brain become attenuated to that level of tenseness and needs to be retrained to relax.

She likened it to when someone breaks their arm and needs to be in an elbow cast (with the elbow set at a 90° angle). When the cast comes off, you're told to straighten your arm out, but your arm will only straighten to about 20°. Your brain thinks your arm is fully straightened because it's become attenuated to the 90° angle being the baseline. Exercises need to be completed to retrain your brain to fully extend your arm without thinking it's being hyper-extended.

The same is true of the pelvic floor muscles.

So, with my permission, we then worked through exercises where she would apply light pressure in a tight spot within the vaginal cavity, and I would breath deeply into the area. After a while, the spot would relax and I wouldn't feel any discomfort in the area anymore. We did this about 8 different times. She then had me do a pelvic floor contraction again and try to fully relax. This time I was able to actually fully relax the muscles.

It's important to note that I was in complete control of the session the entire time.

If at any point I felt overwhelmed, afraid, or triggered, she wanted me to tell her to stop immediately. She said, "We're not just training your body to relax, we're training your brain that it's okay to relax. This needs to be a completely safe space for you. If we push through while you're triggered, it will be counter-productive. Your brain needs to feel safe to connect to each area in your pelvic floor and to allow the muscles to relax." She also had me end the session by saying, "stop" firmly. She said this can affirm to my brain that this is a safe space and what I say goes.

She added one more exercise to do at home this week:

1. Deep Diaphragmatic Breathing

2. Modified Happy Baby Pose

3. Light Kegel with focus on relaxation

   1. If you imagine your pelvic floor is a bowl holding an elevator, I'm supposed to bring the elevator to floor 2 or 3 and then back down to the main level. The focus is helping my brain connect with my pelvic muscles and to start practicing relaxation.

My thoughts

The whole experience was actually incredibly empowering and encouraging. She explained how our brain and body process and react to pain in a way I had never heard before. I'm an information gatherer -- I love to learn and find comfort and power in knowledge. She shared so many insights into the tailbone, rectum, vagina and abdomen -- how they're all interconnected and why my brain and body is likely as tense as it is.

She just made me feel like my body isn't fundamentally flawed or broken. It simply did what bodies do when trauma is experienced. My body was injured and my brain reacted accordingly. Now, we just need to let my body and brain know, "Hey, you did it. It's okay to relax now. You've been protecting us for a long time so, let me remind you how to let go."

She said based on how long my body has likely been in this protection mode, PT will definitely be a marathon, not a sprint, with ups and downs. After almost 3 years of trauma therapy, I'm well acquainted with the healing process -- the time it takes, and the highs and lows.

Trauma Therapy First, Physical Therapy Second

I would recommend that anybody who has experienced sexual trauma work with a trauma therapist before trying pelvic floor PT. The brain is integral to healing the pelvic floor, as I've recently learned, and the trauma needs to be processed first. My PT actually recommends that women who've experienced sexual trauma work with a trauma therapist while working with her because it can sometimes bring up memories, emotions, and such that were being stored in the body.

I definitely don't think I could have done this without the many hours of trauma therapy first. Instead of the experience being triggering, overwhelming, or scary, it was empowering, encouraging, and healing.

I'm excited to continue working with her and to have another method of healing my body and my brain.