Congratulations on beginning the next step of your journey! If you’ve found this blog (and have the intention of actually reading it) you will be well prepared to understand how to find the right provider. If you are already working with a pelvic floor physical therapist (PT), or have so in the past without success, PLEASE, keep reading. Regardless of whether you have or have not worked with a pelvic floor PT, you will benefit from the information in this blog. Let this be your guide to finding the right provider!
What to expect from your pelvic floor PT (...or should expect)
It all starts here, the exact details of your evaluation will depend on what your individual complaints and needs are. While there are some basic things that should be looked at, PT’s have a variety of tools in their toolbox to best evaluate you and come up with a comprehensive treatment plan. Prior to your evaluation, you will be asked to fill out some forms that give a general overview of why you are coming to see them (as a side note - the more detail provided is actually quite helpful) and likely some medical screening to help them get an overview of anything that may be relevant to your symptoms. Evaluations are typically an hour long, and some may want a family member, significant other, or friend to accompany them if that makes them feel more comfortable or even just a second set of ears. It is not uncommon for one to feel nervous about this appointment, especially if there has been a lot of gaslighting in the past. Pelvic floor issues can feel isolating or embarrassing to talk about, and it shouldn’t be this way. If you have a good provider (most are), you will not feel this way during your appointment and realize pelvic floor PT is not a scary place, despite your initial reservations.
This may be surprising to find nowadays in healthcare, but your PT will actually listen to your story. I know this sounds silly, but this part is extremely helpful in helping understand root causes, and what may be involved in your plan of care. They should ask details about the severity of your symptoms, strategies you’ve found that have helped, as well as any specific triggering factors you can pinpoint (this can be specific positions, activities, foods or beverages, medications, etc). In addition, knowing about any testing or imaging you have had (if any), other providers you may have seen, and most importantly, what your goals are.
For some, especially if your case is complex, the exam portion may take a few visits to fully complete. Before your exam, your PT will explain exactly what they will be doing (and why!) especially when it comes to the internal pelvic floor assessment. Yes, this involves an internal examination, which is different from an examination that your doctor may perform such as a PAP smear. There are no stirrups or speculums in this exam. The internal portion involves a visual exam (which will be explained) and a muscle assessment using a gloved finger and lube to palpate (touch) your muscles. Your PT is looking for muscle tenderness (myalgia), how well you can contract, relax, and bulge your muscles (this is your motor control) and how you react to the exam - are you clenching? They are looking at your breathing patterns to see if there is proper coordination of your breath with your pelvic floor muscles as well as observing anything else that may be a factor as to why you are having symptoms. They may also make additional comments on the quality of your muscle contraction and relaxation, identifying any abnormalities in contraction, relaxation, or bulging or coordination issues. All of this information is helpful in gaining a better understanding of how your pelvic floor muscles are contributing to your symptoms.
Now, some of you reading this may have just decided that there is NO WAY you are going to do pelvic floor PT if you have to do an internal exam. You may even feel triggered by hearing this if you’ve had trauma in the past. ‘Trauma’ in this case refers to any sort of trauma (big or small), including painful exams in the past. While this is a crucial part of pelvic floor PT, and should ideally be performed at the first visit (if not the first, within the first two to three visits), this is not the case for everyone and in some instances, it is not appropriate or can be delayed. A couple of examples would be if you’ve never had a pelvic exam performed by a medical doctor, you have a severe history of trauma and the risk to your mental or physical health is greater than the knowledge of the findings of the exam, or if you do not feel comfortable with the provider performing the exam. You are always the one in control and the one to make decisions about your body.
That being said, if an internal exam cannot be performed for any reason or you choose to delay or forgo this part, it may be hard to determine your specific cause and create an effective treatment plan. If you happen to be on your menstrual cycle and do not feel comfortable with an internal exam that is okay, but please know from a PT perspective that you absolutely can complete the exam on your menstrual cycle, there is nothing abnormal about this situation. You also do not have to apologize for not “grooming” down there before your appointment, there is absolutely nothing abnormal or “weird” about being in your natural state! We’ve seen it all, PTs perform internal examinations in all situations and are unphased as to the state your vulva is in.
Hopefully that provides some clarity if you were feeling nervous and you decided to keep reading and have not written off pelvic floor PT altogether!
Vulvar visual exam
This part of the examination is absolutely critical to help understand the cause of your symptoms, especially if pain is part of the picture. Your PT will examine your vulvar tissues - your labia, clitoris and clitoral hood, and vestibule. The vestibule is the tissue that is inside the labia minora (small lips) and surrounds the opening of the vagina and the urethra (where you pee). This tissue plays a very important role when it comes to pain. They will look at the size of the structures, any color changes like excessive redness (erythema) or pale tissue, atrophy (degeneration or shrinking) of the labia minora or clitoris as well as the structures surrounding the clitoris. They should also perform a Q-tip test, which can help to identify different types of vestibulodynia (a subtype of vulvodynia). The information gathered during this part of the exam is crucial, but is not commonly performed by providers unless they have had specific training in sexual health. It could be THE reason you are still suffering despite seeing numerous providers.
These findings can tell us about any present or past hormonal imbalances, such as the use and impact of hormonal birth control or other medications impacting hormones, inflammatory conditions, as well as the role the pelvic floor muscles play in contributing (or not contributing) to your symptoms. It will also be a crucial factor in determining the best course of action and where to start. For example, if your symptoms involve pain upon initial penetration or a diagnosis of “vaginismus,” and are currently taking, or have a history of taking, oral contraceptives and told to use dilators, or worse “just relax” and are not progressing, it may be that no one has identified irritation in the vestibule.
External evaluation: The pelvis does not work in isolation
While the majority of your symptoms may be primarily vulvar or pelvic floor muscle related, your PT should do a thorough evaluation of your connective tissue and pelvic girdle muscles (your inner thighs, hips, glutes, low back, and abdomen), nerve assessment specifically of the pudendal nerve, along with anything else they feel may be appropriate which may include a spinal exam and neural tension tests. This is a very general overview of what may be involved, but the important thing to remember is that the pelvis, and pelvic floor, affects the entire body. Your treatments should include more than just internal treatment.
Assessment: Putting the pieces together
An initial assessment is made once your PT has heard your story and confirmed their initial thoughts with the finding of their exam, putting the pieces together essentially. While they should have enough information to form an initial assessment, your response (or lack of response) to treatment will be important to determine your overall assessment. Based on this assessment and your goals, they will create a plan for therapy which will likely include various manual therapy techniques, appropriate exercises, a home program (which may not just be exercises), and goals, both short and long term. In addition to what your PT has in store for you, they may also make recommendations for other medical professionals that are necessary - this may be a medical doctor they work closely with that specializes in sexual medicine, pain management, and/or a therapist.
Treatment sessions: How long will I have to do pelvic floor PT?
This is extremely variable depending on the case. Postpartum and pregnancy treatment duration and frequency is often vastly different than pelvic pain conditions, and pelvic pain conditions are variable as well. As a general guideline, for conditions involving pelvic pain, you should expect to be seen weekly for at least 6-8 visits before your frequency changes and your appointments should be 45-60 min long. Whereas someone that needs more strengthening and less hands-on treatment may be just fine being seen every other or every few weeks and 30 min may be all they need.
In addition to in-person PT sessions, your PT may recommend various exercises as well as various tools or products to help you continue your healing without depending on someone else. Often, vaginal dilators or wands are recommended to allow you to continue your healing journey. NewFlora vaginal dilators and wands are designed with your comfort in mind and are easy to use. Talk to your PT and check out our blog here to find out if our dilators are right for you!
How to find the right provider
Not all pelvic floor PTs are the same, and this can sometimes be difficult to navigate as a consumer. For example, a pelvic floor PT who specializes in post-partum and pregnancy may not have the proper training when it comes to treating pelvic pain. Or, your PT may have the training, but may work in a facility that is very busy and your appointments may be too short, or too infrequent to see the benefits. Just know that if your experience was not what you were expecting or you plateaued in your progress, don’t give up, you may just need to try a different provider, it never hurts to have another opinion.
Below are some resources to find a provider: