The Truth about Biofeedback and E-Stim

In Female Pelvic Pain, Low-Tone Pelvic Floor Dysfunction, Male Pelvic Pain by Elizabeth Akincilar87 Comments

Many PTs use either biofeedback or e-stim as part of their protocol for treating pelvic pain. Indeed, a google search of either term will bring up a slew of pelvic floor PT websites boasting the benefits of both treatments. Meanwhile, based on feedback we’ve received from our patients and the PTs taking our class, I believe there’s a good deal of confusion surrounding these two treatment methods, and that some PTs are misusing them.

It seems that biofeedback, e-stim or both are in some instances being used as part of cookie-cutter treatment plans with little thought given to whether they’re appropriate. The major concern with this is that in certain circumstances, misusing biofeedback and or e-stim may not only be ineffective, it can actually cause a patient’s condition to worsen.

So what’s the deal with biofeedback and e-stim? When are they appropriate for pelvic floor PT and when are they not?

In this post, I will answer those questions, and hopefully clear up the confusion surrounding these treatment methods once and for all. Let’s begin with biofeedback.


First a look at how biofeedback works: When administering biofeedback, a probe is inserted either vaginally or rectally or electrodes are stuck to the perineum and or peri-anal areas of the patient. The probe or electrodes are used to measure the electrical activity of pelvic floor muscles at rest and when contracted.

The feedback for the muscle activity is shown to a patient  in a variety of ways depending on the machine used. The patient might view them as graphs on a computer screen or as a light that lights up indicating muscle activity.

Whatever the means of giving the patient feedback, the idea is to show them the activity of their pelvic floor muscles. The thinking behind this is that patients can see for themselves when their muscles are too weak or too tight, and from there, using the visual feedback as a guide, they can work to either relax or contract them. In other words, biofeedback has the capacity to either assist a patient with muscle strengthening or to help a patient learn how to relax their pelvic floor.

Now that you know what biofeedback is and how it works, let’s get to how and where it fits into pelvic floor PT.

There are two appropriate uses for biofeedback in pelvic floor PT. One, is to “up train” or strengthen the pelvic floor if it’s truly weak or overstretched. The patient who might need biofeedback for this purpose likely has either incontinence or organ prolapse, not pain.

The other reason to use biofeedback is to help someone who has a tight pelvic floor learn how to relax their pelvic floor muscles. This person might have pain. With these patients, a PT would insert the sensor and instruct the patients on how to drop or relax their pelvic floor. Because they are getting visual feedback on their muscle activity, the patients can see for themselves when they are dropping their muscles. This visual feedback allows them to mentally note what it feels like when their muscles are dropped or relaxed or when they are too tight. The hope is that going forward the patients will be able to identify these feelings on their own without the sensor, and can relax their muscles when they are too tight.

While it’s okay to use the relaxation component of biofeedback on pelvic pain patients, it is not appropriate to use the strengthening/uptraining component on them. Here’s why: typically, if there is pelvic pain there are tight muscles and trigger points. Administering muscle strengthening/uptraining biofeedback under these circumstances will cause pelvic floor muscles that are already overly tight to further tighten thus causing further pain. Also, trigger points can be activated when tight or hypertonic muscles are made to tighten further. So in effect, the strengthening/uptraining biofeedback administered to the pelvic pain patient will simply serve to keep their cycle of pain spinning. Using biofeedback this way is tantamount to doing kegels if you have tight muscles and trigger points–a big no no!

All that said, while there are appropriate reasons to use biofeedback in pelvic floor PT, neither Steph nor I opt to use it. We believe our time is better spent with our patients with our hands on them. In the time it takes to hook someone up to a machine and have them go through the exercises, we could be administering manual therapy that is much more beneficial. To be sure, there are a variety of manual techniques that can cue muscles to either contract or relax. Plus, when it comes to relaxing tight muscles, we teach patients to get into a position called “the drop position.” See an illustration of the drop position below.


Now let’s get to the bottom of e-stim. As with biofeedback, e-stim, short for electrical stimulation, is administered with a probe that’s placed either in the vagina or the rectum. The probe contains sensors that deliver a weak electrical current designed to contract the muscles of the pelvic floor. The thinking is that this facilitates a pelvic floor muscle contraction.

When is e-stim not appropriate?  E-stim is not appropriate for pelvic pain PT, ever. The reason is the same as the reason it’s not appropriate to administer strengthening/uptraining biofeedback to pelvic pain patients. But, it’s worth repeating, so here goes: the last thing you want to do is cause already too-tight, hypertonic muscles to tighten further and or irritate trigger points.

When is e-stim appropriate?

E-stim is appropriate when there’s pelvic floor weakness, for example, often with incontinence or prolapse. In these situations,  PTs can use it  to try to retrain the muscles to contract and strengthen.

To sum up, check out the crib notes I’ve provided below:


  • appropriate: uptrain/strengthen weak muscles
  • appropriate: to help relax tight or hypertonic muscles
  • not appropriate: uptrain/stengthen tight, hypertonic muscles or muscles with trigger points



  • appropriate: uptrain/strengthen weak muscles
  • not appropriate: uptrain/strengthen tight, hypertonic muscles or muscles with trigger points

I fully expect there to be pushback as a result of this post. In the class we teach for PTs, and when we lecture, we constantly come across PTs who defend both uptraining/ strengthening biofeedback and e-stim for use with pelvic pain patients who have tight or hypertonic pelvic floor muscles. Their argument is always that muscle contraction or kegels will cause what is known as “reflexive relaxation” after the contraction/kegel. The theory is that after the round of contractions/kegels, the muscles tire and thus relax.

This line of thinking is incorrect, however.

While reflexive relaxation can occur with other muscles in the body—triceps or biceps for instance–it will not happen with pelvic floor muscles. The reason is that pelvic floor muscles are different from the other muscles in the body in that they are NEVER at a fully relaxed state. That’s because they have to hold up organs and keep us continent or able to control urination or defecation. Therefore, the theory that if you tighten the muscles, they will tire and relax, doesn’t fly with the pelvic floor. If this were the case every time you tensed your pelvic floor, like with orgasm or even just when it’s cold outside, you’d be in danger of becoming incontinent.

PTs who misuse biofeedback and or e-stim are more often than not just doing what they were taught to do. Often we’ll ask the PTs who take our class if these methods work for them, and that is enough to get them to think critically about their use.

I hope this post has cleared up any confusion you might have had about biofeedback and or e-stim. But, please ask any questions you may have in the comment box or email me at [email protected].

Also, I’m really interested to know what your experiences have been with biofeedback and or e-stim?

Please let us know in the comment section. If you’d like to leave an anonymous comment, just do not fill in your name or email address, and the comment will show up as “anonymous.”

Be well,


  1. Hi Liz,

    Thank you for the blog post. My question is: I get e-stim done, but I have both prolapse and trigger points/pain. What is the protocol in this case?

    1. Dear Reader,

      Thank-you for your appropriate question. In certain cases, patients may present with what we endearing call a ‘hybrid pelvic floor’. This means that they may be hypertonic, with or without trigger points, in certain muscles, and truly weak or over-lengthened in other muscles. Prolapse is caused by a combination of factors – ‘loose connective tissue’ and/or weak/overstretched pelvic floor muscles. Pain is usually caused by tight muscles and trigger points.

      A patient that is experiencing both prolapse and trigger points/pain is a great example of why treatment plans need to be individualized to be effective. As mentioned in the blog post, electrical stimulation may be used to help ‘up-train’ the muscles or be used to facilitate improved motor control, which can lead to less symptoms and better function. As also mentioned, e-stim may also exacerbate pain by contributing to further hypertonus and/or trigger point irritation. Therefore, focusing on the patient’s impairments and responses to treatment should be used to design the treatment plan.

      First, not all patients with prolapse have muscle weakness and excess length. e-stim should only be considered if, in fact, this is the case. The second consideration is which symptom is causing the patient the most distress. If the patients expresses that pain is worse than the symptoms of prolapse (typically pressure and/or incontinence) the treatment may want to focus on WHAT the PT thinks the causes of pain are first. Treatments may involve down-training and manual therapy. As the pain improves the patient and PT can change their goals to address the impairments associated with the prolapse. This may be accomplished through e-stim, manual therapy, etc. Through communication the PT and patient can figure out how to achieve maximum improvement for both situations with managed flare-ups.

      Be well,

      1. Hi Liz,
        I have even had urologists tell me that kegels are ok but over all my urogyno and PT both said it was an absolute NO on kegels. I have an actual inter- stim that helped with my bladder retention which lead me to have alot less pelvic pain. Since the interstim hasnt been working correctly they have tried a number of different things,the last was botox for my hypo pelvic floor dysfunction. I maybe that hybrid you were speaking of as my issues seem to have gotten much worse.I think Im having symtoms of a prolapse and am trying to get in with someone ASAP. Have you ever heard of such a thing?

        1. Dear Tera,

          I’m sorry, from your explanation I am not clear as to what your question is, so I can not answer it. Can you please be a bit more clear? Best, Liz

  2. What about vaginal TENS set at a different frequency that is more appropriate for pain conditions (not 12.5 Hz or 50 Hz as the vaginal e-stim units are set at)?

    1. Dear Reader,

      This is a great question. Recent literature from Italy demonstrates a protocol that may be effective in helping vulvar pain. As soon as we locate this study, we will post a link to it on the blog. More research is needed, however, the initial findings may be promising for certain patients. As we have discussed, eradicating the impairments that causes the pain are the key to successful treatment plans. Pain modulation strategies, such as the application of TENS unites, therefore, may be helpful to help manage pain as part of a comprehensive treatment program.

      Be well,

  3. Great blog Liz. Completely describes my experience with both. I told the doctor that neither therapy were helpful. I told him that kegels actually intensify the pain & on release does not relax, thus the pain continues. I now see a urogynocologist that does not promote this therapy. After a botox injection to the pelvic muscles, the PT does manual therapy to stretch them. I have had three episodes of pelvic pain in six years and this method rids me of pain, generally after the 3rd or 4th PT therapy. Keep up the good work.

  4. Thanks Liz for another great article. I have been going to PT for about 6-7 weeks now. My problems started 2 years ago with the birth of my daughter and presented as urinary frequency but, mostly inability to empty my bladder, occassional vaginal irritation but, no pain really. Then beginning this year the pelvic pain kicked in and I got really scared. At my PT appts we do manual therapy but, they also do about 10 minutes of e-stim. on a “pain” mode. It has not seemed to bother me too bad. But, my question is this-I have a grade 2 cystocele and rectocele so would e-stim be appropriate for those? When is it safe to begin to strengthen the floor again so I do not have problems from prolapse as well??? Thanks so much-

    1. Dear Reader,

      Thank you for your comment. To answer your question, it’s important to keep in mind that e-stim is rarely absolutely necessary to strengthen the pelvic floor. I like to utilize it only if my patient has very little or no ability to contract her pelvic floor musculature. Otherwise, you can strengthen the pelvic floor with manual cues and a home exercise program specific to her needs. So, to answer your question, if you can recruit or activate your pelvic floor muscles fairly well, then I would say that e-stim isn’t necessary, but may be appropriate. However, if your pelvic floor muscles are tight and weak, then e-stim is not appropriate. You must wait until your pelvic floor muscles have normal tone (not tight) to begin strengthening. If you have a tight pelvic floor and prolapse, waiting until your pelvic floor muscles are no longer tight will not worsen your prolapse because normalizing your tone will likely improve your strength too.

      Be well,

  5. This is a great article that really elucidates the idea that we should not be doing “cookie cutter” modalities. I totally agree about what you wrote about biofeedback and estim. The only clarification that should be made is that this is relating to pelvic floor muscles. Many patients who are dealing with pelvic pain have several things going on- for example – tight/overactive pelvic floor muscles and painful intercourse AND bladder pain AND endometriosis or dysmennorhea (painful periods) . Electrical stimulation applied to the abdominal area (with certain protocols) can be very helpful in dealing with the pelvic pain associated with painful periods/endometriosis/bladder pain. However, this should not be used for the pelvic floor. Thanks!!

    1. I was wondering if you could please elaborate on the protocols that you mentioned for pelvic pain as I have endometriosis and a home TENS unit.
      Thank you!

  6. I am wondering if you could comment on labral tears and PN. I have just been diagnosed w/ labral tears on both sides and my worst PN pain is clitoral. A surgeon won’t do labral surgery b/c of my PN fearing to make it worse and he said the hip surgery won’t help the clitoral symptoms. I really would like to get my hips fixed and confused as what to do. I appreciate any help. Thanks

    1. Hi Steph,

      We are actually working on an entire blog post about labral tears. Please give it a read in the coming weeks, and if it doesn’t answer all of your questions, definitely leave a question or comment on the post.

      All the best!

      1. Hi, i haven’t seen anything about labral tears yet. wondering if i missed it or if it’s still coming up? thanks!

        1. Hi there, No, you haven’t missed the post. It’s one we’re working on to run at the beginning of next year! Thank you so much for letting us know what topics you’re interested in reading about! It’s super-helpful for us!

  7. Thanks for posting this. I have PN and strengthening in any fashion has flared things up for me. I wish more PT’s were competent like you ladies are.

  8. I have had Levator Spasms for over 20 year. As you probably know, Leavtor Spasms are spasms of the rectal muscles.This is a very uncomfortabe condition. I have been told that pudendal nerve entrapment can cause these spasms.I have these spasms 24/7. I have heard there a two doctors who treat this condition. One doctor is in Phoenix and the other doctor is in Houston, Texas. I really don’t want to have surgery. I have heard that some get better and some don’t.Some people who had surgery are bedridden.I have tried PT but the therapist did not specialize. Do you think you could help me? Any help will be appreciated. Thanks, Ray.

    1. Hi Ray, thank you for your question.

      I’m sorry that you’ve been suffering for so long. Your question is complicated and to be fair, without evaluating you I am unable to give you a good answer. However, I’ll try to shed a little light on your situation.

      The levator ani muscle group is the primary group of muscles in your pelvic floor. They are, in part, responsible for urinary, bowel, and sexual functioning as well as supporting your pelvic organs. When these muscles become too tight or ‘spasm’ they can cause pain in any part of the pelvis (genitals, anus, rectum, perineum, urethra) or urinary, bowel and/or sexual dysfunction. Many different things can cause these muscles to become too tight. Examples are: injury, surgery, infection, trauma, behavior, or compensatory muscle reaction to another muscle group.

      Pudendal nerve entrapment will cause these muscles to become tight, but that doesn’t mean that you have pudendal nerve entrapment. Pudendal nerve entrapment is characterized as burning, shooting, stabbing pain in one or more of the following areas: penis, testicles, perineum, anus, peri-anus, rectum, and urethra. If you don’t have these symptoms, you definitely don’t have pudendal nerve entrapment. However, if you do have these symptoms, that doesn’t necessarily mean you have pudendal nerve entrapment either. These symptoms can be caused by tight muscles alone.

      In order to get a more definitive diagnosis, you really need to see a specialist, preferably a physical therapist. She or he can help you figure this all out. As far as MDs who specialize in pudendal nerve entrapment, there are only a few in the country, that is correct. However, it is much too early to seek their consult. Plus, I do not recommend the surgery, ever.

      First you need to see a specialized physical therapist who can give you a more accurate diagnosis and begin treatment. If you would like to speak to one of our physical therapists more about your specific situation feel free to call our office and schedule a free 15 minute phone consultation. At the very least, we’ll likely be able to refer you to someone who can help.

      I wish you the best of luck in your recovery.

  9. Liz, Do you know of a PT in the Fort Worth-Dallas area that specializes in treating levator spasms?

    1. Dear Ray,

      Sara Reardon, PT, DPT, WCS is a pelvic floor PT in the Fortworth-Dallas area. As of today she is starting to practice at UTSW Medical Center in Dallas. She is joining an existing pelvic floor rehab program comprised of 4 pelvic floor therapists and a physician who will oversee the program, Dr Kelly Scott. She will be physically located at Zale Lipshy Hospital in the Charles Sprague Building.

      To make an apt with her contact Sandy Hall at 214-645-2084 or email her directly at either [email protected] or [email protected].

      Wishing you all the best,

  10. Slowly over the past few years I’ve noticed problem with having to go more and more. Recently I had an accident and hurt my leg at which time I must have been in shock or just scared because of the injury. Well wet on myself and after the hospital visit and getting my leg treated I started thinking about incontinence. I had also started staying at home more and more because I always needed to be near a toilet. I recognized I had a problem went to the dr. He suggested pills but I am already on a few pills from having breast cancer and did not want to take any more if I could help it. So he suggested therapy. I was unsure about therapy but I thought well if it stops me from having to take a pill thats all good. Long story short I have been going to therapy now in my 5th week. My treatment consists of biofeedback which I think is a good thing for me because finding the pelvic floor muscles was really hard for me. Then I am getting about 10 minutes of estim on a few seconds on and few seconds off. I call this gadget the bladder zapper. After my treatments my bladder quiets down for about 2 1/2 days. Oh I also get up during the night 3 to 5 times. All this is getting much better from treatment. I am now setting my little timer to go every 1 1/2 hr and this is pushing it. Next week I work on longer time and go by the clock. This has been helping me tremendously because its helping me to understand and hear what my body is saying and doing. But, my insurance runs out soon and I do not know what I am going to do. I want a estim unit so I can have it and use it twice a week and continue the program at home. Its the only way I see I can continue the program and getting relief from this spastic bladder. I had a hysterectomy 20 yrs ago and my therapist thinks scar tissue could be interferring. I dont know what to do. I feel I am getting help but do not understand exactly how long because of financial considerations. I asked about getting an estim via insurance paying for it and was told my insurance does not. Is there a thing if the insurance pays for the estim the patient cant continue getting the treatment and biofeedback in the clinic? I am at loss on what is and could be available if anything else.

    Im still having leaking and slippage but feel its getting better some days and others it like 2 steps back.

    Any suggestions?? Thank you

    1. Dear Reader,

      I’m so sorry for all that you’ve gone through.

      Every insurance company has a different policy regarding reimbursement for biofeedback and estim. It is my understanding that it’s very uncommon for an insurance company to pay for a home biofeedback/estim unit. The best idea for you may be to buy the units yourself if your insurance is going to discontinue your physical therapy. Very basic biofeedback units can be purchased for under $100. Your PT should be able to recommended which basic model would work for you at home. Estim units are much more expensive though, usually several hundred dollars. Again, you should talk to your PT to see if that’s appropriate and if it is, he or she can recommended which unit to buy for home use.

      I hope this helps!

      All my best,

  11. My Physical Therapist who is fantastic, never puts the elctrodes internally. She places them on my lower back, pelvic region and or behind my ankle. The e-stem helps with my pelvic pressure and with frequent urination. I recently purchased my own unit from Amazon for $32. It was a life safer when I had to travel for several long hours on a plane and my pelvic muscles tightened greatly. Once I got to the hotel I used the Tens Unit and the pressure was gone. I use it whenever the pressure gets bad and change the postions of the electrodes.

    1. Thank you so much for your input Lisa! So glad you are finding relief for your symptoms!

  12. Liz-

    This is a great article. I think it’s a shame that there are still so many PTs out there who have patients with pelvic pain and shortened pelvic floors do Kegels! Also, ES and biofeedback are often so over-utilized when the patient really needs good manual therapy and relaxation training. Hopefully we can continue to change this in the future so more patients will receive the quality care they deserve.

  13. After reading this, I am really scared. I have been suffering with frequent urination for 6 years now. I do not have pain or incontinence. I feel like I need to urinate 24/7. I had my first appointment with a PT the yesterday. She did the biofeedback. She had me do Kegels to measure my “work” phase and “rest” phase. My work phase was a 21. The rest phase was a 13. She said that the rest phase should be between a 3 and 5. I guess I also had the E-stim treatment because I laid there for 15 mins with a wand stimulating me internally. After that, she measure my “rest” phase and it had lowered to a 6. She told me to do Kegels at home 2-3 times a day…10 reps of 10 second squeeze and 20 second relax. I felt fine until about midday today. Now I am sore and I feel the need to urinate even more. This has happened before when I have done Kegels in the past, but thought that since she suggested it that I must not have been doing it right the other times. I see a pelvic floor PT. I already have to travel an hour to go see her. There are no other ones close to me at all. I go back next week. I think I’m going to stop the Kegels for now and talk to her about it. I hope she will have other suggestions . I was feeling great yesterday after I left. Now, I’m just discouraged.

    1. Hi Paula,

      I am sorry to hear of your trouble and do not be discouraged. The most important thing to do in this case is communicate with your physical therapist. If the current plan is ineffective or exacerbating she should be able to come up with more effective alternatives for you.

      All my best,

  14. I have suffered with edometriosis and levator ani spasm since I first had a period – at 12 yrs old. My periods were horrible and I always had pelvic, vaginal, and rectal sharp pains during period, during and after gynecological internal exams, masturbation, out of the blue, etc. I seeked treatment at the age of 17 yrs old with birth control pills, then pain killers, then laproscopy surgery, then at 24 yrs old – anti-inflammatory, muscle relaxer, and lidocaine. I used this for a year and it helped but did not cure all my pain. So my GYN gave me a prescription to a physical therapist to treat levator ani spasm. I know the invasive internal treatments are useful for some women – but, I personally don’t feel comfortable with the treatments especially not being a sexually active person. Plus, I feel that my GYNs are pressuring me to be sexually active and use the “treatments” as well. I don’t know what other options I have so it’s a continuation of embarrassment and pain!

    1. Please give your body the love and honor it deserves by being treated for levator ani spasm. It’s not embarrassing and has nothing to do with being sexually active. It is a spasming muscle and thank god their are professionals who specialize in these muscles. I’ve had this physical therapy and I definitely would not call it “invasive.” I would call it a gift, and I feel so lucky that compassionate, knowledgable female physical therapists have dedicated their lives to learning this modality. Surgery is invasive …. And you may be headed in that direction if you don’t open up to gentle physical therapy. It’s really a mental battle your having, the actual therapy is wonderful. Good luck, hope you feel better.

  15. Great article in terms I can understand! Please help me a little more by explaining because I am ready to get a second opinion.

    I am 40, have had 3 babies, all delivered vaginally after long induced labors-all three were over 9lb delivered. I had bad episiotomies on the 1st two but did not need one on 3rd. 5 years ago I had a suburethral sling procedure because of bad stress incontinence. I have done kegels religiously for years and while I feel they improved some tone, they have never been able to fix everything.

    I have ha recurrent UTI’s for the last year and problems with urinary retention and constipation. I finally saw my gynecologist for help. She diagnosed me with cystocele, rectocele and uterine prolapse of moderate degree. She recommended surgical repair and hysterectomy. She did a pelvic ultrasound to rule out any masses and then referred me to urogynecology because of my bladder sling.

    I have to sometimes press on perineal area or back of vaginal wall to finish having a bowel movement-it gets stuck, in addition to constipation. I’m under a bowel regimine with a GI dr now for the motility problems. The urogyn looked inside my bladder and assessed the prolapse and discovered I still had too much residual urine after voiding. The only pain I have during sex is with deep thrusting, and I always have slight spotting after sex. More concerning to me is the vaginal laxity-where there is a feeling of loose muscles and no friction.

    The urogyn taught me self cath to avoid trips to the ER for retention problems and said I needed to do ther pelvic floor therapy w/biofeedback and estim because the muscles were too tight and causing the retention problems. I explained I felt the muscles were actually too loose. I felt discouraged that he was sticking me into a therapy specific for one problem when I might have both. He did a manual exam and asked me to contract with kegel and release, to which he was surprised by my muscle strength and acted like he was shocked I told the truth about using kegels daily. He said the PT won’t help prolapse but may help urinary symptoms from retention. I was told I must complete 4-6 sessions before they determine it was not effective-every othe week so a minimum of 2-3 months.

    I worry he is misdiagnosing/treating with wrong therapy. Is there any reason the biofeedback and estim will help my laxity, retention, urinary frequency and constipation? He kept saying I probably had leaking and I told him I did not because of the urethral sling.

    1. Dear Reader,

      Your symptoms are likely a result of a combination of muscle impairments as well as pelvic organ prolapse. I think the correct thing to do is to get an evaluation by a physical therapist who specializes in the pelvic floor and then follow his or her recommendation. If you have pelvic organ prolapse, which is sounds like you do, you likely have some motor impairments in your pelvic floor muscles, but the retention and urinary frequency are likely secondary to muscle hypertonus or tightness. That is best evaluated by a pelvic floor physical therapist. The physical therapist should make the final decision on what type of treatment is best for you given his or her objective findings upon evaluation even if the MD prescribed biofeedback and estim.

      All my best,

  16. Thank you so much for this. I have lifelong (primary) vaginismus, and it is so bad that I literally am not able to insert anything in my vagina at all. It is like a wall. No tampons, never had an exam, definitely can’t have sex (though I’ve tried). I went to a counselor who has read up on vaginismus out of desperation and she highly recommended biofeedback, emphasizing the great results people saw.

    At first I was excited, but as I read about the treatment I became very skeptical. It didn’t make sense because apparently they insert a probe in your vagina (just as you said) in order to do it. Which is all fine and dandy, except I can’t fit anything at all into my vagina, not even a q-tip. How in the world could I receive this treatment? And then I thought “my muscles are already going into overdrive, and they want to stimulate them more?” So I googled my question and this came up.

    I really hate that people don’t understand what is going on in my body, even when I explain it to them. Would you recommend any other form of treatment for someone who has never been able to insert anything into her vagina? I am at my wit’s end.

    1. Dear Tessa,

      Have you tried manual pelvic floor physical therapy? I’ve had many patients with your exact symptoms and have had success with manual techniques. Have you been evaluated by your gyn MD for an imperforate hymen? That’s when your hymen is still partially intact. Some women have a thicker hymen that doesn’t completely break on it’s own. This can be surgically removed.

      All my best,

      1. Not yet, though I’m looking into it. How does manual therapy work if literally nothing can be inserted? The pain is excruciating. My ob-gyn said that from what she could see, it did not appear that my hymen was the problem (although she couldn’t really get anything inside, so who knows?)

        I suppose my question is, how in the world do I get treatment when all of the treatment options require insertion? I can’t seem to even get to that point, unless I was put under anesthesia or something of that sort. Is it a gradual thing?

        1. Dear Tessa,

          Manual physical therapy is just not internal work. We would start with external work to the surrounding muscles and tissues in the pelvic girdle. Doing external work first facilitates relaxation of the pelvic floor muscles. This allows us to be able to insert a finger or small dilator vaginally, eventually. I have never, in my 10 yrs of practice, not been able to achieve vaginal digital (finger) insertion with a patient with vaginismus unless she had an imperforate hymen. What I would suggest is you start PT, see what you and the therapist can achieve in 4-6 visits, and if you still can’t tolerate digital insertion, ask your gyn to evaluate you for an imperforate hymen under anesthesia.

          Where are you located, perhaps we could refer to a PT in your area.

          Please feel free to ask any additional questions you may have and keep us posted on your progress!

          All my best,

  17. Hi Liz,

    I have posted on her before. I have PFD that just causes the constant feeling of needing to urinate. i do not have pain. I have been doing stretching and my husband has been doing internal trigger point therapy shown by a PT. I was not entirely satisfied with my PT because she had me doing kegels & E-stim. I’ve read “A Headache in the Pelvis” & I’m thinking about going to Dr. Wise’s clinic in CA. Any thoughts on that? Also, I purchased a TENS unit & thought I could use it on my pelvic region near the pubic bone. I’m hoping it willl help relax the muscles and nerves in that area. Is this the correct way of thinking or will the TENS contract my muscles & make them tighter/worse? Please help!

    1. Dear Paula,

      Dr. Wise’s clinic primarily focuses on learning his paradoxical relaxation technique for pain, specifically. I’m not sure if that makes the most sense for your situation. I would agree with you that kegels and e-stim may not be the best choice for you. TENS, on the other hand, is pretty benign. The stimulation is not strong enough to actually cause a tightening of your pelvic floor muscles. If you feel like it helps your symptoms, go ahead and use it. I doubt it’ll help all that much, however, but I’m pretty confident that it won’t hurt you either.

      All my best,

      1. Thanks for the reply, Liz. I am trying to rid myself of this uncomfortable, life consuming condition. I’m willing to try anything. However, I will probably opt-out for Dr. Wise’s clinic because I believe I am doing everything that his book suggests anyways. I am always doing belly breathing and constantly dropping my pelvic floor which feels like pressing down a little bit. I have noticed that as the day wears on, I feel pretty irritated around my vaginal opening. I don’t know if it is my underwear rubbing against it all day or somehow the muscles being pushed down are getting rubbed together and becoming irritated. Have you ever heard of anyone complain about this?

        1. I also meant to say that I do believe my PFD is from anxiety. That is one of the reasons I was thinking about going to Dr. Wise’s clinic. I do have his Paradoxical Relaxation book and I have been practicing the techniques he mentions in it.

        2. Dear Paula,

          It’s pretty common for those dealing with pelvic floor symptoms to report that the worsen through the course of the day. The pelvic floor is simply in use more and also if you have certain aggravators, like sitting, wearing underwear than it stands to reason that the cumulation of those triggers will cause an increase in symptom intensity. It’s important to figure out what your triggers are and avoid them until you are better. Many women with pelvic pain do not wear underwear or even go without wearing pants/jeans until their symptoms clear opting instead to wear skirts/dresses or baggy pants/shorts if they do wear them.


  18. Thanks again for a wonderful and informative post. I am wondering if e-stim would be comparable to the sacral neuromodulation (stimulator) that I am currently trying? No surgery yet, but after reading your post, it sounds like an internal version of e-stim, and I have pelvic floor dysfunction, pudendal neuralgia, have been in pt for two years. This is being proposed as a way to relax my pelvic floor muscles, giving me pain relief. I haven’t heard of anyone else using sacral neuromodulation. Wondering if you have any thoughts. Thanks in advance. I always look forward to reading your posts. You are the best!!!


    1. Dear Kara,

      No, estim is completely different from sacral neuromodulation. Estim is meant to facilitate a contraction of the pelvic floor muscles. Sacral neuromodulation is meant to decrease neuropathic (nerve) pain by stimulating specific sacral nerves in specific patterns.

      All my best,

  19. I’m sorry to post same one but the above one is default.

    Hello i was wondering about outcome of e-stim

    i had done 3 times of e-stim at hospital for “functional constipation with impaired rectal sensation”.

    i didn’t feel urge to defecate fo almost 2 years.

    After 3 times of e-stim i can now feel more urge to go but the problem is I feel like my anus is getting so tight

    On your blog you talked about strenghten muscle is the outcome of e-stim

    should i stop getting e-stim? After having each of e-stim done i feel like anus is getting more and more tightened

    I am afraid if it gets too tightened so i can’t defecate

    1. Dear Keun,

      Electrical stimulation can be useful to help certain impairments – such as pelvic floor weakness and motor cotrol deficiencies, but it can also create muscle hypertonus and contractions which may cause pain or nerve irritation. If the estim is necessary to help one impairment you may need a second intervention to deal with the unintended side effects. for example, doing self-stretching or pelvic floor drops after you use the estim. Your PT should be able to help you figure out a reasonable plan.

      All my best,

  20. Hi Liz,

    I was wondering if you could recommend an affordable at home biofeedback unit for pelvic pain. I’m going to the pt next week and having it done for the first time there, but can only afford a couple of visits. Thanks.

    1. Dear Jacob,

      Please re-read this blog post. Biofeedback is NOT appropriate for pelvic pain.


      1. I’m a little confused by your response. The part of the blog post I was talking about is this:

        The other reason to use biofeedback is to help someone who has a tight pelvic floor learn how to relax their pelvic floor muscles. This person might have pain. With these patients, a PT would insert the sensor and instruct the patients on how to drop or relax their pelvic floor. Because they are getting visual feedback on their muscle activity, the patients can see for themselves when they are dropping their muscles. This visual feedback allows them to mentally note what it feels like when their muscles are dropped or relaxed or when they are too tight. The hope is that going forward the patients will be able to identify these feelings on their own without the sensor, and can relax their muscles when they are too tight.

        That’s what I’m going in for Monday to have done. That’s why I was asking if you know if there is an affordable biofeedback device you can use at home to also get feedback to help you relax the pelvic floor.

  21. Hi,
    I am trying to be proactive about my sexual health. I am a 34 year old woman who is currently using an E-stim unit for both sexual stimulation as well as kegel strengthening. I use both a small vaginal plug and a large anal one, oftentimes simultaneously. I also use TENS pads occasionally.
    My question to you is this: What is the best way to gain PC strengthening benefits both while using it to achieve orgasm (which I often find difficult to reach using traditional methods!), as well as setting the unit for therapeutic benefits? Also, what is the recommended length of time/ intensity setting, and is it best to do the slow, medium, or fast pulsation (or the “steady”) settings?
    Thanks for taking my questions seriously, and you deserve commendation for helping all these folks here on your board! :^)



    1. Hi Jane,

      I apologize, but we do not have any recommendations on how to acheive an orgasm while strengthening your pelvic floor. We suggest you speak with your gynecologist regarding the use of an e-stim unit intra-urethally, but there is a general concern about the electrical current passing through vital organs such as heart, thus most units advise against using e-stim while pregnant.




      1. Hi,

        Thanks for your response! Just to elaborate: Would you have any general suggestion for therapeutic settings for just kegel strengthening? For instance, what intensity, how fast to set the pulse, and how long should a session last? I haven’t been able to get a straight answer just looking on the internet!



  22. P.S.- What is your professional opinion on use during pregnancy ( from 20 weeks onwards), and do you feel it is safe to do e-stim intra-urethrally (aka: sounding)?

    Thanks again!

  23. Hi Liz,

    I had a Pudental nerve block 9 days ago (some relief) and as part of treatment the PT is performing both Biofeedback and E-Stim. I need to go to 10 sessions ( 2 done). E-stim gives me relief after the sessions.. Should I stop.?. My insurance covers the treatment

    I have had PN since Feb 25th due to cyling and prolonged siting. I have also done a electrodiagnostic test that among others, showed a motor latency test of the left pudental nerve at 6.6 Ms and 3.1 Ms for the right pudental nerve. All other test are norma ( lyrica 75mg in the morning and 150mg at night).. I can sit for 1-1.5 hours before disconfort starts.

    Forgot to mention that I am thinking of visiting you for the outpatient program if the local treatment doesnt work. I have only been dealing with this for 2.5 months but it has changed my way of life.. no libido, I cant excercise (only swimming), etc. and thinking everyday about when this situation will go away…

    thanks for your feedback

  24. I would like to buy a cheap under 100$ biofeedback device for home use for bladder incontinence. My therapist uses, it and now its getting expensive to see her.

  25. Can you recommend a Pelvic Floor PT in the Venice, Fl. area?
    I have severe levator ani spasms and pain following surgery for endometriosis that triggers debilitating sciatic nerve pain in my left leg.
    I just moved after my first PT appt. in Oregon and would really like to get started again and get better.

    Thank you!

    1. Hello Carrie,

      We do not have a recommendation for Venice, FL but I can recommend a few therapists nearby. Their information is below:

      Ashley Arango, PT and Katherine Marsh, PT
      Florida Hospital Pelvic Health Rehab
      Orlando FL
      (407) 303-8280

      Tracy Sher, PT
      Florida Hospital
      Altamonte Springs

      Pamela Downey, PT
      Miami FL
      (305) 666-3232



  26. I saw in a comment by Stephanie above (2012), that you would bolg about labral tears. I cannot find anything here on this….did you write one? Thanks!

    1. Hi Jamie,

      We have not yet posted a blog on labral tears. We do however have many blogs and pregnancy and postpartum.


  27. Hi, can you tell me if it’s safe to use a TENS unit to relieve sharp pain around the anorectal area? I’m considering buying one with electrodes.

    Here’s some history: I had colon cancer as a teenager & had a colostomy surgery, chemo, & pelvic radiation. Then a few yrs later a vaginoplasty to remove scar tissue. I’ve always had to use dialators if not being sexually active. About 6 months ago I saw a PT for a few weeks for bladder weakness. We did biofeedback relaxation techniques, exercise & stretches, then finally started kegels. I just couldn’t afford to keep going but have religiously been doing what I was told. However, lately I have been getting a strong pain in the anorectal area mostly around the time of my period but random other times. It is so bad and wakes me up at night. I wouldn’t want to take pain pills on an empty stomach and lay back down at night so figured the TENS would help. What do you think? I would greatly appreciate your help.

    1. Author Liz Akincilar says:

      “TENS has not been shown to be particularly helpful in treating pain. However, a TENS unit is an inexpensive pain management option. That being said, I would not recommend a TENS unit for neuropathic pain, which, given that your pain is sharp in nature, you may have. I would recommend that you try to figure out where this pain is coming from first, with your physician and physical therapist, before buying a TENS unit. If your medical team conclude that it is not neuropathic pain, you could consider a TENS unit.”

  28. Hi,
    I am a 70 year old male receiving E-Stim for paradoxical (non-relaxing) puborectalis. The muscles tighten when they should be relaxing to pass the stool. My understanding is that the E-Stim is constant to wear down or weaken the muscles as opposed to alternating E-Stim to strengthen the muscles is cases of incontinence which is not my problem. After 4 sessions I have had much less outlet constipation.
    I also suffer from an internal rectal prolapse, an enterocele/peritoneocele and a rectocele. These issues are not be addressed at this time. I am hopping to avoid surgery.

    Any feedback will be great.


    steve frantz

    1. Author Liz Akincilar says:

      That’s great that e-stim has helped your constipation. Regarding the prolapse/rectocele/enterocele, it really depends on the severity of it on whether surgery can be avoided. If it is fairly severe, surgery may be a necessary treatment. This is something to discuss with your physician. If you have pelvic floor muscle weakness that is contributing to the prolapse, then physical therapy will likely help. Whether it will allow you avoid surgery, I do not know.

  29. I have been suffering from bilateral pudendal neuralgia for 6 years. For me surgery is not a solution, I have been reading a lot of cases, this way many patients had problems and got even worse.. I read about PT is a great alternative to find a solution. I am an educator in Houston, so I am wondering if you have any PT in Houston expert on pudendal for analyzing my case. I already tried chiropractors, orthopedists, PRP, Plorotherapy, block injections, acupunture, MRI says I have obturator bursitis and Neurography said I have no neuropathy. Horrible EMG shows reading shows 5.5 left and 5.1 on right nerve

  30. I am currently suffering from pelvic floor pain caused by having a tight pelvic floor. My current PT is using both manual and E-Stim. I was wondering if this is the best and proper path to try and cure my CPPS. I also do a stretching regiment twice a day to help and try and relieve pain. Any suggestions?

    1. Author Liz Akincilar says:

      “Hi Dan,

      It is very difficult for me to say whether that’s the best treatment strategy for you since I have not evaluated you myself. If you indeed have a tight pelvic floor, then the manual treatment is most likely indicated. I do not utilize estim for a tight pelvic floor, as I do not think it is usually indicated. With regards to stretching, some stretches can actually be aggravating if you’re stretching muscles that have active trigger points. You would have to ask your PT if that’s the case with the muscles that your stretching. If there are trigger points in those muscles, it’s best if you use a foam roller or some other device to mobilize those muscles. Hope this helps!”

  31. Hi there,
    I just found this article while researching estim. I had a baby via c section almost 6 months ago. Sex is still painful and my ob-gyn said my muscles are constantly spasming/too tight. My PT has been doing biofeedback and estim, which according to this is the wrong thing to do! What should be done in my case?? I don’t have pain except during intercourse and I don’t have any continence issues.

    1. Author Liz Akincilar says:

      “Hi Laura,

      It is very difficult to determine what treatment is appropriate for you since I haven’t evaluated you. However, if you’re having pain and your pelvic floor muscles are indeed tight, I would not recommend biofeedback and estim. I would recommend manual therapy and home exercises to decrease the muscle tightness. I hope this helps!”

  32. Background: chronic low back pain, prominent left sided SI pain, endometriosis, history of episiotomy at age 15 with single birth. I’m late 30s now and a nurse. I have been abstinent (not married)for 15 years but sex used to be painful. I have a history of fluctuating but usually mild stress incontinece and urge/ behavioral incontinence, as well as vaginal spasms that sometimes occur (almost always at night and wake me from sleep, more often if I don’t have a completely empty bladder before laying down) I’m currently receiving pelvic floor PT using biofeedback and manual massage (typically anally) for coccygeal pain. Seems to focus on a tight left piriformis often, among other trigger points. Biofeedback has been the main method of treatment. Back to the coccyx pain- it began 9 months ago following a week of lots of walking. NSAIDs helped a bit. I had to convince my primary and gyn to let me go to pelvic pt as I’d been in the past due to stress incontinence (biofeedback therapy, external sensors while I peed, worked on relaxation mostly as I was not relaxing well. no kegels, went once a month for several months). My current biofeedback shows an incredibly week pelvic floor (I don’t know how weak or strong it was years ago in PT but can’t imagine it was much better then- but I didn’t finish out he full course of therapy then). From what I can tell, my relaxation phase looks ok but my contraction ranges from 9-12. I have poor holding power. After ten sessions, she suggested the tens Unit yesterday. I tried it in office and was able to get to a level of 16 (out of 99). So far I have not had increased pain or irritability with it. This therapy center is different from the one I went to before. ISO you have any suggestions?

    1. Author Liz Akincilar says:

      Hi Cat,

      It’s impossible for me to tell you why you are experiencing these symptoms without evaluating you. It sounds like you may have some pelvic floor hypertonus because you do have some pain, so maybe the weakness is due to hypertonus? Or, maybe you’re also weak? I’m not sure. The way to treat it though is to first normalize the tone, then retest the strength. If you’re still presenting weak, then introduce a strengthening program. Good luck!



  33. I am a 75yr. old female who is obese. I am single, never had children,and a short term gay relationship when I was young. For the past 3-4 years I have had some leakage but inthe last year t has become worse. I have seen my urologist and have tried several medicines such as oxybutynin, and toviaz. Neither of them have not been effective. I now have heavy leakage and don’t know it until I feel the wet pad. I never have any pain. At present my recommending diet and Kegal exercises. Sounded like a good idea until I read that many woman do not do Kegel exercises properly. Is there any biofeedback device that you could recommend so I don/t waste time doing them incorrectly?
    I thought of seeing a PT but would prefer not to. Presently I am have PT for an arm injury and will use up my allotted time from Medicare. I would see a PT if it was for just a few sessions and pay for it but all I read it looks more long term.
    Any suggestions will be helpful

    1. Author Liz Akincilar says:

      Hi Kim,

      I have a few recommendations. Has your MD recommended using a topical estrogen cream around your urethra and vagina? Since you’re post menopausal, the lack of estrogen will contribute to urine leakage. This is an easy and safe treatment. Next, I think you should see a pelvic floor PT. It sounds like you need pelvic floor strengthening. A PT can teach you this in a few sessions. I think it’s worth it to see one. Lastly, if you lose weight, that will also lessen the leakage. Your pelvic floor muscles are being too taxed by the extra weight, therefore, they can’t do their job sufficiently, which contributes to the leakage. Good luck!



  34. I just found your blog and subscribed. I have been dealing with this for so long, I do not think I could put it all in a question. I have been through it all in the last 25 years. At this point I am ready to try pelvic floor therapy again. I have bowel movements that start and stop and over all take hours to complete. I am convinced it is really not pelvic floor dysfunction, but some type of internal prolapse of the bowel. It has been shown on some tests and then not on others. The doctors tell me that it is not my problem, and that it is that the pelvic muscles do not work properly. They also tell me if they can not detect it in testing, MRI or defecography then it is not the problem and they can do nothing for me. When they do detect it they say I cause it and send me to pelvic floor therapy. Often depending on the therapist they try different things and at some point tell me the pelvic floor is slightly tight, but bio feed back and hands on work show that it should not cause my problem and there is nothing more they can do for me. Have you heard of this before?

    1. Author Liz Akincilar says:

      Hi Josette,

      I’m sorry you’ve been struggling for so long with these symptoms. Yes, I have seen patients with similar symptoms. It is impossible for me to know exactly why you are experiencing these symptoms without evaluating you, but I’ll give you some ideas of things that I would want to look at and possibly treat. Although this is not something that I could diagnose as a physical therapist, I would want to work with a good gastroenterologist and urogynecologist to definitively determine whether or not you have some sort of rectal prolapse or rectocele. Your symptoms do sound suspicious of one or both. From the PT perspective, I would want to make sure the tone of your pelvic floor muscles was normalized, the motor control of your pelvic floor muscles was normalized, your stool was the correct consistency, your positioning during a bowel movement was correct, and lastly, being sure you were not bearing down to have a BM. To briefly explain how I would do these things, I would use manual therapy techniques to ensure the tone of the muscles were normal. I would not use biofeedback. I would also use manual techniques to ensure you have normal motor control of those muscles as well. Again, I would not use biofeedback. To normalize your stool, I would recommend dietary changes, exercise, water, and maybe over the counter medications. Lastly, you should be using a stool under your feet with your knees spread apart and your feet together when trying to have a BM and under no circumstances bear down to push stool out. If you feel the need to push, blow out with pursed lips, like your blowing a pinwheel. These are the basic treatment interventions I would start with. I hope you find some relief!



  35. I’d love to see a reference page for this post. I think most PTs worked off flawed assumptions include even the presence of trigger points, which has not been validated in the literature. Link below.

    I’m also hard pressed to find large research studies where manual therapy is better than other forms of treatment. It seems mostly anecdotal in this post. For me, I’d much rather teach the patient body awareness (sometimes using biofeedback as a took, sometimes not), than make them overly reliant on manual therapy. Yes this will keep them coming back, perhaps make them feel good in the moment, but does little for their sense of resilience and control over their symptoms–instead the PT controls the symptoms. Good for our wallets, but not the route I usually take to give the efficient care possible.

    Just some thoughts,



    1. Author Liz Akincilar says:

      Hi Christin,

      Thank you for your comment. There are several studies examining the presence of trigger points as well as the validity of clinical exam and diagnosis. I’ve included a couple recent articles, one being a review article, but there are many other relevant articles available on pubmed.

      You are correct, there is a lack of research in physical therapy, particularly when it comes to manual therapy. To clarify, manual therapy is only one aspect of treatment. Neuromuscular re-education and development of a home exercise program is just as important as manual therapy. The goal of treatment is always to reduce pain, improve function and foster independence, in that order. We like our patients, but we love discharging them as soon as possible as that indicates their goals have been met!



  36. Can doing Kegels reverse a cystocele? Is there any research on how helpful biofeedback is to completing a kegel correctly.

    1. Author Liz Akincilar says:

      Hi Mary,

      Improving your pelvic floor motor control may be able to reduce a mild cystocele. Yes, there is some research on kegels and biofeedback. I would recommend doing a search on for a list of articles.



  37. Hi Liz
    I have recently had my 3rd child I have no pelvic pain as such I’ can jog comfortably but I’m very far off my pelvic strength pre children. When I run fast or downhill I suffer incontinence . Is e stimulation suitable for me?

    1. Author Elizabeth Akincilar says:

      Hi Deborah,

      Thank you for your question. Without evaluating you it is impossible for me to be certain, but given your description, it doesn’t sound like you would require e-stimulation. It sounds like you could benefit from some pelvic floor strengthening. If you haven’t seen a pelvic floor physical therapist I would recommend seeing one. He/she will be able to tell if you need to strengthen your pelvic floor muscles and if you do, they will be able to prescribe exercises to do so.

      Good luck!


Leave a Comment