By Stephanie Prendergast, PHRC Cofounder, Los Angeles
If you have been a long time follower of As the Pelvic Turns, then you might remember the Q&A we did years ago about Pelvic Floor Drops, Weak and Tight Muscles, Tilted Pelvis and More. As the years go by, new research, information and overall growth in the field occurs. With this, we reached out via our Instagram page, to find out what our patients/followers really want to know about their pelvic floor. Some of these questions might be ones you already had or didn’t know you had. Our illustrations prompted many of these questions, which we hope you find of value below.
Many people with pelvic floor dysfunction have hypertonic (really tight) muscles. When these muscles have too much tension, they will cause pelvic pain. Symptoms may include: painful sex, urgency/frequency/hesitancy/pain, painful BMs, constipation, penile, clitoral, perineal, anal pain, painful orgasm or anorgasmia, difficulty sitting, exercising, and wearing clothes. Treatments include: manual pelvic floor physical therapy, neuromuscular re-education, and home exercises (check our Youtube!). Medical management includes: pharmaceutical, and procedures (tpi and botox).
Q: Hi, I have pelvic floor dysfunction, my pelvic floor is too tight. My left side was affected. After orgasm or leg exercises I get spasms in the pelvic region and I experience urinary frequency, not fully emptying the bladder, slow and thin stream. When my therapist checked my muscles it was found that my piriformis muscles are too tight and pelvic is anteriorly tilted. Can posture and piriformis cause urinary problems along with tight pelvic?
A: Absolutely. Hypertonic adductors, hip external rotators, abdominal muscles, and pelvic floor muscles can all contribute to the symptoms you listed, collectively and on individually on their own.
Q: I have had these symptoms for three months but have also felt few prolapse symptoms for three weeks now. I went to physiotherapy, which found that I have weak muscles by an internal exam. Can I have loose muscles around vagina and tight elsewhere?
A: Historically the assumption was that women with pelvic organ prolapse also have pelvic floor weakness, the herniation of the pelvic organs into the vagina occurs because the integrity of the vaginal wall is not strong enough to support the organs. The vaginal wall is supported by connective tissue and pelvic floor muscles. As our knowledge of pelvic floor function improves, we now know that women can have prolapse and have tight pelvic floor muscles, which are functionally ‘weak’ because of a compromised length/tension relationship. Tight muscles are associated with myalgia. Women may also have true weakness and prolapse. It is important to have a thorough assessment and understand which impairments are causing pain and which impairments are leading to support issues for our organs. The impairments involve pelvic floor and girdle muscles, connective tissue, motor control deficiencies and strength and endurance deficiencies.
Q: What are the pharmaceuticals and procedures offered for hypertonicity?
A: Muscle relaxants are commonly prescribed to people with pelvic pain, especially vaginal and rectal valium. There are numerous misconceptions about benzodiazepines and how and where they work. First, these medications act on the central nervous system as a depressant. They do NOT act locally on the pelvic floor muscles because they are administered this way, using suppositories refers to ‘transdermal drug delivery’, meaning this is where the medication gets absorbed directly into the bloodstream to then act on the central nervous system. Studies have shown that vaginal valium does not reduce pelvic floor muscle pain, pelvic floor muscle hypertonus, or painful sex (Crisp et. al, 2013 & Larish et. al, 2019). However, some of our patients report feeling ‘better’ with muscle relaxants. It may be therapeutic for some people, it may not be for others. We suggest working closely with a physician if one is to try using these medications, they can be tricky to get on and off of. We do know that muscles relaxants reduce anxiety and CNS overactivity could explain why some people ‘feel’ better. As far as procedures, botox is commonly used as an effective way to reduce hypertonus and myalgia in muscles. Clinical trials and experience confirm this can be a therapeutic procedure for overactive muscles. Pharmaceuticals and procedures may not help as much as we want them to by themselves, a combination interdisciplinary approach that includes medical management and skilled physical therapy will work for most people. Finding the right medications is often a series of trial and error attempts, be patient and keep trying until you find what works for you.
Q: Hi, I got those pelvic floor issues after persistent urethritis which turned into epididymitis. Why do persistent infections cause these issues? I started physiotherapy which is helping but is this condition completely reversible? Thank you.
A: Infections and inflammation of visceral structures, such as the urethra and epididymitis can trigger a reflex called the visceral-somatic reflex. “Visceral” refers to organs, “somatic” refers to structures such as muscles. When a visceral structure is irritated it will have somatic consequences, such as muscle tightening, on muscles that share similar spinal nerves. A common example of the viscero-somatic reflex that people recognize is the situation when someone is having a heart attack, which is the visceral pain, and it refers to the left arm, which is the somatic component.
Q: I was diagnosed with tight pelvic floor muscles 4 months ago. I’ve been in physical therapy for 3 months and not seeing much change. I have always had an overactive bladder and the tight muscles make it so much worse. I feel like I will never get back to normal, any suggestions?
A: Everyone responds differently to pelvic health physical therapy and time frames vary. Things you can try are maybe discussing with your physical therapist your concerns that you are not seeing much change and maybe going through what’s working and what’s not, to be able to adjust your treatment plan together. You can also see if they are also incorporating soft tissue and connective tissue mobilization externally along the abdomen, inner thighs, and posterior hips since those areas can play a role in pelvic floor hypertension. Assessing your home exercise program, does it consist of dilator work, pelvic floor down-training stretches, foam rolling, etc.? If you would like to read in depth about what sessions should look like, including time frames, please check out our blog about what a good pelvic pain PT session is like.
Q: Is burning and itching a normal symptom of tight pelvic floor muscles?
A: Burning and itching are more tied to nerve dysfunction, vestibulodynia, and vulvar dermatoses such as lichen sclerosus. Tight muscles do not typically cause unprovoked burning and itching on their own, but muscle issues can cause nerve irritation which in turn can cause burning.
Q:How long should PT take? I’m still having awful symptoms even after 7 months of treatment once a week.
A: This depends on your pelvic health history, current symptoms and the goals curated during your initial evaluation. 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. If you would like to read in depth about what sessions should look like, including time frames, please check out our blog about what a good pelvic pain PT session is like.
References:
Crisp, C. C., Vaccaro, C. M., Estanol, M. V., Oakley, S. H., Kleeman, S. D., Fellner, A. N., & Pauls, R. N. (2013). Intra-vaginal diazepam for high-tone pelvic floor dysfunction: a randomized placebo-controlled trial. International Urogynecology Journal, 24(11), 1915–1923. doi: 10.1007/s00192-013-2108-9
Larish, A. M., Dickson, R. R., Kudgus, R. A., Mcgovern, R. M., Reid, J. M., Hooten, W. M., Green, I. C. (2019). Vaginal Diazepam for Nonrelaxing Pelvic Floor Dysfunction: The Pharmacokinetic Profile. The Journal of Sexual Medicine, 16(6), 763–766. doi: 10.1016/j.jsxm.2019.03.003
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Are you unable to come see us in person? We offer virtual physical therapy appointments too!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $85.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.