Pelvic floor physical therapists specialize in the muscles, nerves and connective tissues that live between your legs, also known as the pelvic floor. They gain their expertise through a series of post-graduate continuing education classes, certifications, and training. Their training allows them to perform both internal and external pelvic exams, and broadens their knowledge of conditions which affect the pelvic floor. Sometimes, people who specialize in modalities like biofeedback or dilator therapy, advertise themselves as pelvic floor therapists, but don’t have any hands on experience treating the sensitive and often reactive muscles of the pelvic floor. If you are seeking pelvic floor physical therapy, it is important to enquire about the experience and level of training your potential physical therapist has had in this specialty.
Pelvic floor dysfunction is an umbrella term for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. Although this condition predominantly affects females, up to 16% of males suffer as well. Symptoms include pelvic pain, pressure, pain during sex, incontinence, incomplete emptying of feces, and visible organ protrusion. Tissues surrounding the pelvic organs may have increased or decreased sensitivity or irritation resulting in pelvic pain. Underlying causes of pelvic pain are often difficult to determine. The condition affects up to 50% of women who have given birth.
A defecating proctogram is a test where you’re given an enema of a thick liquid that can be seen with an X-ray. Your provider will use a special video X-ray to record the movement of your muscles as you attempt to push the liquid out of the rectum. This will help to show how well you are able to pass a bowel movement or any other causes for pelvic floor dysfunction. This test is not painful.
When some or all of these structures of the pelvic floor are not functioning properly, they can cause a multitude of different symptoms. People who are suffering from bowel, bladder, and or sexual problems, as well as those who are suffering from pain in the pelvis, upper legs, abdomen or buttocks most likely have pelvic floor impairments contributing to their pain.
To assess the degree of dysfunction, three measurements must be taken into account. First, an anatomic landmark known as the pubococcygeal line must be determined, which is a straight line connecting the inferior margin of the pubic symphysis at the midline with the junction of the first and second coccygeal elements on a sagittal image. After this, the location of the puborectalis muscle sling is assessed, and a perpendicular line between the pubococcygeal line and muscle sling is drawn. This provides a measurement of pelvic floor descent, with descent greater than 2 cm being considered mild, and 6 cm being considered severe. Lastly, a line from the pubic symphysis to the puborectalis muscle sling is drawn, which is a measurement of the pelvic floor hiatus. Measurements of greater than 6 cm are considered mild, and greater than 10 cm severe. The degree of organ prolapse is assessed relative to the hiatus. The grading of organ prolapse relative to the hiatus is more strict, with any descent being considered abnormal, and greater than 4 cm being considered severe.
During the internal exam, your physical therapist will place a gloved finger into your vagina or rectum to assess the tone, strength, and irritability of your pelvic floor muscles and tissues. Internal exams and internal treatment are invaluable tools that are taught to pelvic floor physical therapists. It can tell us if there are trigger points (painful spots, with a referral pattern or local); muscle/tissue shortening; nerve irritation and/or bony malalignment that could be causing your pain directly or inhibiting the full function of your pelvic floor muscles. We can also determine if your pelvic floor has good coordination during the exam. A pelvic floor without good coordination, may not open and close appropriately for activities such as going to the bathroom, supporting our pelvis and trunk, sexual activity, and keeping us continent.