“How did I not know this was a pelvic floor issue? Why didn’t my doctor send me here sooner? Do you have other patients with problems like mine?”

As a physiotherapist, I hear these questions again and again, from people of all ages and genders, who are struggling with issues related to the urinary system, sexual function and the lower digestive tract.

Adrian is one example. A 35 year-old active cyclist and successful professional, he has a nagging pain in the private parts that just won’t go away. It is interfering with his sporting activities and ruining his sex life. Pressure from the bicycle seat, the ambitious effort to cycle 100 kilometres in record time, and the stress from a crazy week at work have all resulted in pelvic floor muscle tension and chronic pelvic pain.

Then there’s Lisa, a 63 year-old woman who is ready to become involved in a new relationship. In her search for a companion, she explores online dating and begins to realize that sex may be involved sooner than later. She worries that she may not be ready, physically, not having had sex for quite a few years, and wonders what she could do to improve her vaginal comfort and physical confidence.

These patients, and many others, did not know that a physiotherapist could help them. In my role as a clinician and as course co-ordinator for pelvic floor rehabilitation at McGill University’s School of Physical and Occupational Therapy, I see a huge lack of awareness of the impact that physiotherapy can have on the lives of people suffering these very personal conditions.

From pain during sexual intercourse to urinary incontinence after surgery for prostate cancer, to anal incontinence after pregnancy, physiotherapy can help.

Pain during sexual intercourse

Up to 20 per cent of women have pain during sexual intercourse. This is a surprising statistic, especially when it predominantly includes active women in their twenties and thirties, who may believe that there is something psychologically wrong with them when all of the gynaecological tests come up negative.

Vestibulodynia, an invisible hypersensitivity at the entrance to the vagina, is considered themost common cause of sexual pain in pre-menopausal women. It can be treated in physiotherapy.

The pelvic floor muscles span the private area under the pelvis. They are responsible not only for helping to control the passage of urine, stool and gas, but also for allowing comfort and pleasure during sex.

These muscles also support the pelvic organs and help with balance and stability. It is important to be able to contract and to relax these muscles. Pelvic floor exercises train the muscles for the desired result, and are sometimes referred to as “targeted” Kegels.

In pelvic floor physiotherapy, patients learn exercises, and they may receive manual treatments, biofeedback and/or electrical stimulation. Biofeedback displays pelvic floor activity on a computer screen, making it easier to contract and relax muscles that are usually hidden from view. Electrical stimulation causes a pain-free muscle contraction, with the goal of improving the ability to contract and relax naturally.

Research supports the use of physiotherapy in the treatment of a variety of pelvic disorders. A team approach is ideal, and, depending upon the condition, may involve collaboration with general practitioners, urologists, gynaecologists, sex therapists and others.

Prostate, pregnancy and potty

After surgery for prostate cancer, up to 40 per cent of men experience problems with urinary incontinence. Pelvic floor physiotherapy teaches men different strategies to control leakage. Men can even consult prior to surgery, in order to prepare.

Women experience an array of pelvic floor issues during and after pregnancy. It is important to mention that many women who have had a third or fourth degree tear during delivery will experience issues with anal incontinence later in life.

Some countries systematically refer these patients for preventative physiotherapy and some centres in Canada are now beginning to follow suit.

More than 40 per cent of women also have issues with bladder control. Patients with stress urinary incontinence and those with an overactive bladder can experience significant improvement in physiotherapy.

Physiotherapy is considered first-line intervention for both types of incontinence by the International Continence Society, the Canadian Urological Association and the European Association of Urology.

Constipation is another issue that may be caused by the inability to relax the muscles of the pelvic floor and anal sphincter at the appropriate time. Physiotherapists can work to improve “defecation dynamics” and provide suggestions for lifestyle changes.

In children, constipation may lead to soiling or overflow incontinence. Children may also be seen for urinary disorders.

A co-ordinated physiotherapy plan

The internet has been instrumental in enabling patients to learn about embarrassing or taboo subjects in the privacy of their own homes, and has led many to seek out physiotherapy as a viable treatment option for pelvic conditions.

Patients consulting for pelvic floor issues learn how the bladder functions, how the pelvic floor muscles can be involved in constipation, what causes the muscles to be such culprits in pelvic pain and how new brain research supports a bio-psycho-social approach for the management of their problems. They find an ally in the physiotherapist, who supports them and directs them towards the improvement of their condition.

A step-by-step coordinated physiotherapy plan is a key element in the interdisciplinary management of patients with disorders related to the pelvic floor.

Author:Claudia Brown Assistant Professor, School of Physical and Occupational Therapy, McGill University

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