Part 1 of 2: What is a good pelvic PT session like?

Pelvic Health and Rehabilitation Center is proud to announce that we now have eight locations across the country. Our newest locations include Walnut Creek, CA, Bedford, NH and Westlake Village, CA. We pride ourselves on our constant commitment to give the best possible care for our patients. Patients suffering from long-standing pelvic conditions are often shuffled around from doctor to doctor with minimal relief of symptoms. Our aim is to help mold, shape, and challenge the standard of care for pelvic health.  

Considering that pelvic floor physical therapy is now included in the standard of care for conditions like vulvodynia, chronic prostatitis/chronic pelvic pain syndrome, interstitial cystitis and postpartum care, it is important for patients, clinicians, and physical therapists to understand what a “good” physical therapy session is like. Because there is currently no protocol for evaluation and treatment of high and low tone pelvic floor conditions, we want to provide our best answer to the question, “what is a typical pelvic floor PT session like?”

Evaluation Appointment

The evaluation appointment is typically one hour and the goal is to figure out what the main contributing factors are to the persons’ symptoms. We kind of act like investigators uncovering all of the potential reasons for why one might be experiencing pelvic pain, urinary urgency, painful sex, incontinence, etc.  If you are unsure if pelvic PT is right for you, check out our website for details here.

At the evaluation appointment, the first thing we do is interview the patient. We are looking to understand the full history and how they ended up in our office. Among the questions we ask are:

• When did your symptoms start?
• What exacerbates your symptoms?
• What alleviates your symptoms?
• How does it affect these three functions: Urination? Bowel movements? Sex?
• What activities do your symptoms limit?
• What kind of work do you do?
• What doctors/other PTs have you seen?
• Have you had any diagnostic procedures done?
• What past treatments have you had?
• What medications are you taking?
• How has this problem impacted your life?
• Have you stopped participating in things you enjoy because of this problem?

The interview portion helps us gather background data, helps us understand the impact the problem has had on the patient’s life and their understanding of pelvic floor dysfunction. The interview also allows us to gain the necessary information to know the most essential areas of the body to evaluate as it is impossible to examine the entire person on day 1. We have to prioritize about the areas that are likely most relevant for someone’s symptoms. Sometimes it can take a few appointments to evaluate all structures.   After the interview, the physical therapist leaves the room so the patient can change.

The examination consists of a visual exam looking at posture, alignment, and movement patterns followed by manual evaluation of the external structures. Typical areas of the body we palpate include the abdomen, inner thighs, bony pelvis (i.e. sit bones, pubic bones, hip bones, etc.), and buttocks. We are looking for myofascial trigger points, tight muscles, connective tissue restrictions, joint dysfunction, imbalances from side to side, and other impairments around the areas of pain/dysfunction. A key factor in understanding the contribution of that tight area to symptoms is if the area is painful, tender, or reproduces symptoms. Additionally, we are screening for every factor that may contribute to persistent pelvic pain and pelvic floor disorders. This includes screening for systemic, hormonal, dermatological, neurological, and psychological factors of these symptoms.

A key aspect that sets pelvic floor physical therapists apart from other physical therapists is our training in an internal pelvic floor muscle (PFM) exam. This exam is typically performed transvaginally in females and transrectally in males. If indicated, we may perform a transrectal exam in our female patients as well. During the internal PFM exam we are evaluating for muscle tone, trigger points, strength, and motor control. We examine for diastasis recti, pelvic organ prolapse, skin lesions, and dermatologic changes.  Additionally, we are screening for irritability in the peripheral nerves of the pelvis, and vaginal and anal tissue integrity.

At the end of the appointment and after the patient is once again dressed, we review what we found. It is important to us that our patients understand what we found, how we plan to help them with the problem areas, and how we are collaborating with their other providers. In addition, if we find that a key member is missing from their team or further evaluation is necessary that is out of our scope of practice, we will refer the patient to one of our trusted providers.

Assessment

The assessment is a critical part of the evaluation process. This is where we consider our patient’s history and how various factors could have led to the development of the impairments that we believe are primary sources of pain or dysfunction. This is an ongoing process that happens during each appointment as things improve. The assessment allows us to effectively develop short and long-term goals which help guide an efficient and effective treatment plan.

Short term and long term goals

When we are first evaluating the patient about their history we ask what their goals are for physical therapy. Everyone’s goals are different and it is our job to help them achieve them. Typically the duration of a  physical therapy treatment plan can last between a few weeks to several months, or longer, depending on the severity of the situation. We use short incremental goals to justify our treatments and collectively achieving the short term goals results in achieving the patient’s long term goals.

Let’s consider a 25 year old male who has perineal pain, post-ejaculatory pain, and the inability to sit greater than 30 minutes or lift weights because of his pain. Examples of short term goals could look like this:

1. Reduce pelvic floor hypertonus and perineal body tenderness to decrease perineal pain.
2. Decrease irritability of the dorsal nerve branch of the pudendal nerve to reduce post-ejaculatory pain.
3. Improve pelvic floor motor control so patient can maintain gains made in the clinic and reduce pelvic floor tightness.

Typically short-term goals can be achieved in 4 -6 weeks and then new short term goals are set if needed.

As the person improves, examples of long term goals for this patient would be:

1. Patient will be able to sit for 3 hours without a cushion without experiencing perineal pain.
2. Patient will not experience post-ejaculatory pain.
3. Patient will be able to lift weights 5-7 times per week without pelvic pain during or after.

Eliminating the impairments occurs over a series of visits and each week we have a specific plan in mind to tackle the impairments that are causing pain. We hope this helps people understand how the physical therapy evaluation works! To continue reading, Part 2 goes  into more detail about the treatment process.