In recent years, pelvic floor physical therapy (PFPT) has increased in popularity, much like endometriosis. More people have at least heard the term, and it has caught the attention of mainstream media recently in FX’s American Horror Story: Delicate. Though I will say the depiction of what we do was a bit horrific if you’ve watched the show, PFPT is a crucial part of one’s endometriosis journey. While there has been a large (and much needed) increase in practitioners and social media reels, there are some things you need to know to find the right physical therapist for you.
In earlier blogs, we’ve posted about the benefits of PFPT before excision surgery as well as the benefits after excision surgery which you can find in the links listed below.
Endometriosis and the Pelvic Floor
Endometriosis is most recognized for its 5 clinical manifestations: infertility, dysmenorrhea (painful periods), dyspareunia (painful intercourse), dyschezia (painful bowel movements), and dysuria (painful urination). It is important to note that many of these manifestations may have alternative causes aside from endometriosis, many of which can stem from pelvic floor dysfunction. When it comes to endometriosis, one of the most frustrating parts is getting a diagnosis, especially because it truly requires surgical intervention for definitive confirmation. Something that we emphasize is that when it comes to endometriosis, it is important to address all of the pain generators in addition to the lesions themselves in order to have the best outcome.
Endometriosis has a 7-10 year delay in diagnosis, providing ample opportunity for additional symptoms to develop either because of progression of the disease, ongoing chronic pain causing physical limitations, or even due to side effects of “treatments” for endometriosis such as hormonal suppression therapies like birth control and GnRH agonists/antagonists.
One of the key aspects of endometriosis that is often underestimated is its association with pelvic floor muscle dysfunction. The pelvic floor muscles (PFMs) play a crucial role in supporting the pelvic organs, providing core stability, controlling bowel and bladder functions, and contributing to sexual arousal and orgasm.
Women with endometriosis often experience PFM dysfunction due to the chronic pain and inflammation caused by the disease. This can lead to a variety of problems, including hypertonia (excessive muscle tone), trigger points (painful knots in the muscles), and myofascial pain (pain in the muscle and its surrounding fascia).
The Role of Pelvic Floor Physical Therapy
PFPT is a specialized form of physical therapy focusing on the pelvic floor’s muscles, ligaments, and connective tissues, addressing issues from the knees to the rib cage and beyond. Contrary to common misconceptions, PFPT goes beyond postpartum care, challenging the notion of a one-size-fits-all solution like Kegel exercises. Those with endometriosis typically fall into the category of “hypertonic” or “high-tone” pelvic floor dysfunction versus weakness or “low-tone” pelvic floor dysfunction, and this needs a vastly different approach than kegels.
Understanding that not all PFPTs are equal, training variations exist, with many PTs needing additional education beyond basic training. PFPTs treating pelvic pain often require a multidisciplinary approach, encompassing interventional pain management and sexual medicine, which is often not taught in the additional courses PFPTs are required to take beyond their basic education in PT school.
The bottom line here is that if your PT only has training in treating “low-tone” pelvic floor dysfunction and is recommending kegels, you may need to see what other options are available. There is also no standardization in what is considered to be adequate pelvic floor PT, though there are some key aspects those specialized in pelvic pain will utilize.
- Manual Therapy including myofascial release and visceral mobilization, involves the use of hands-on techniques to manipulate the body’s tissues. This can help alleviate hypertonia and trigger points in the PFMs, improve circulation, and give different inputs to the nervous system resulting in reduced symptoms.
- Exercises which typically do not involve kegels, at least initially, will focus on exercises that reduce tension in the pelvic floor muscles and will progress to include exercises that optimize your biomechanics and when appropriate, facilitate return to your previous level of function which may include weight lifting, running, yoga, etc.
- Modalities such as TENS unit or e-stim, ultrasound, or biofeedback. Biofeedback may be very helpful for those who are visual learners or may be the only option in your area, but ultimately, these should be adjunct therapies to complement the other techniques vs. the focus of your sessions.
- Education is probably one of the most important pieces of what we do. As the provider that likely spends the most time with patients, we can help answer questions, provide support, and essentially act as your liaison between providers to help streamline care.
- Differential Diagnosis. While PTs cannot make medical diagnoses, we can help in better identifying pain generators and communicating this to your team. For example, if your main complaint is painful sex (dyspareunia), we can help differentiate whether this is due to tight and painful pelvic floor muscles, vestibulodynia (a type of vulvodynia specific to the tissue surrounding the urethra and vagina) which is associated with superficial dyspareunia (or entrance pain) vs. deep dyspareunia which is more associated with endometriosis, or specific palpation techniques that point more towards endometriosis lesions.
Finding a PT that fits your needs may be difficult as this is a specialty that needs more practitioners. However, if you are suffering from pain and are not getting the results you expect, the frequency and length of appointments may be a factor. Typically patients with pelvic pain benefit most with at least weekly, sometimes twice per week, appointments for at least 6-8 weeks to begin to see changes. Ideally each appointment is 40-60 min and involves a combination of techniques, especially manual therapy. Because PFPTs are hard to find, sometimes busy schedules do not allow for this treatment frequency, so don’t write off PT altogether if your outcome was less than optimal. Additionally, there is a wide range of techniques we utilize which vary depending on individual training. Most important, not everyone is a good fit for each person and it is really important to find a provider you feel comfortable with.
The Impact of Pelvic Floor Physical Therapy on Endometriosis
Through a combination of these techniques, pelvic floor physical therapy can have a significant impact on the management of endometriosis. Studies have shown that this form of therapy can help reduce pelvic pain, improve PFM function, and enhance overall quality of life for women with endometriosis.
Moreover, pelvic floor physical therapy can also help address some of the underlying issues associated with endometriosis, such as muscular dysfunction and chronic inflammation. By improving the function of the PFMs and reducing inflammation, this form of therapy can help alleviate some of the pain generators present in those with endometriosis, leading to more effective and long-lasting relief and better outcomes along with surgery.
While PFPT is instrumental, it should be part of a broader treatment plan that includes medical treatments, complementary therapies, and lifestyle changes. Integrating PFPT ensures that endometriosis patients receive comprehensive and effective care for the best outcomes.
By integrating pelvic floor physical therapy into the broader treatment plan, healthcare providers can help ensure that endometriosis patients receive the most comprehensive and effective care possible.
Check out our iCareBetter vetted physical therapists here.
Additional reading: Managing Endometriosis: What You Need to Know.
- Wojcik, M., Szczepaniak, R., & Placek, K. (2022). Physiotherapy Management in Endometriosis. Int J Environ Res Public Health, 19(23). https://doi.org/10.3390/ijerph192316148
- Fraga, M. V., Oliveira Brito, L. G., Yela, D. A., de Mira, T. A., & Benetti-Pinto, C. L. (2021). Pelvic floor muscle dysfunctions in women with deep infiltrative endometriosis: An underestimated association. Int J Clin Pract, 75(8), e14350. https://doi.org/10.1111/ijcp.14350