Pelvic Floor Physical Therapy Experiences (Men and Women)

@DocH2O asked for more details about my experiences with pelvic floor physical therapy (PFPT) in the Flomax thread, but I thought that it should really be in it's own thread. Maybe other people can share their own experiences with PFPT.

For those who don't know, PFPT is done by licensed physical therapists (usually with doctoral degrees) who concentrate on the muscles of the pelvic floor. When those muscles are too week (hypotensive) or too tense (hypertensive), this can cause or worsen a whole lot of different problems: bladder issues (leakage, not getting fully empty, frequency, etc.), bowel issues, chronic pain, erectile dysfunctions, etc. And a lot of these issues feed into one another.

This was originally developed to help women deal with the damage that childbirth causes, but it has expanded to other issues that women have and issues that men have as well.

I am going at this from male perspective, but this applies to women as well. (Although some of the things done rectally in men might be done rectally or vaginally in women.)

I have nerve damage which leads to incomplete bladder emptying which leads to frequency and urgency issues. I've used a variety of things to manage this over the years but wasn't having the best results so I pushed my urologist for tools that might help.

One of the options that she gave me was the pelvic floor physical therapy.

It took me quite a while to get on the schedule and there was a gap between getting the initial evaluation and starting therapy proper. There are no where near enough therapists out there, so expect to wait and you might be handed off to a different therapist for part of your course of treatment.

Your therapist will most likely be a woman. There are a few men in the field, but it is mostly women. If you aren't comfortable with that, you will have a harder time finding a therapist.

The general order of things is that you will meet with your PT and she will take a history and do some exams. Usually she will do a general PT exam (posture, core strength, etc) first and then do the pelvic floor exam. For me this was reversed.

If she finds an issue with one or more of your pelvic floor muscles that she can address, then she will talk about your goals and the different modes of therapy to use. This may include some of the modes below.

- Exercises: Expect to have a bunch of exercises to do a home and in the session. Streches, core building exercises, kegels, etc.

- diet changes

- advice on how you are urinating (or pooping or whatever)

- use of TENS

- manual therapy: basically her pushing on the muscles externally or via a finger in the rectum or vagina. Kind of like trigger point massage.

- use of a pelvic wand: like manual therapy, but you are doing it at home

- dry needling: putting needles in hypertensive muscles to break them out of their spasms. This may or may not include applying tapping or electricity to the needles after they are inserted.

So in my case, I met my therapist after waiting a few months. She took me to a private room off the gym area with sort of mat/exam table that went up and down. We went over my history, I filled out some questionnaires, and talked about I was trying to accomplish. It was surprisingly easier to talk to her about embarrassing things, like having trouble peeing and how well I pooped. I think that still being in the masking phase of covid helped. :-)

For scheduling reasons, she asked if we could do the pelvic exam at that session instead of at the second one. I agreed and she explained three options that I had.

1. She could do an external exam over my cloths. This provided the least information, but if you were really embarrassed....

2. She could have me undress and she could do an external exam feeling around my perineum etc with out doing the rectal exam.

3. She could have me undress and she could exam the muscles externally and then check them rectally.

She said that the third option would give her the most information, but that it was total up to me. I chose the third option. She instructed me to undress below the waist and get under a sheet and left the room to let me undress.

When she returned, she had turn on my side and pull up my knees. She uncovered my butt, spread my cheeks and spend a couple of minutes pushing different spots around my anus and in my perineum. She then changed gloves and lubricated one finger and inserted it just inside into my rectum. She felt each of the muscles going in a circle and then inserted her finger further and repeat. I think that she did this at three levels. Finally she went through a series of squeeze and release, try to expel my finger, etc. type tests.

It was the longest rectal exam that I had ever had and one that required the most participation on my part.

Then she left me so I could get cleaned up and dressed. When she returned, we went over the results. We went over some treatment options and she gave me some exercises to do at home until our next meeting.

At the second meeting, she completed the rest of the evaluation and we went over goals, how to measure progress, adjusted the exercise program, etc..

At each of the weekly sessions, we would go over my progress, adjust my excises, give me advice on altering my "urination technique", etc. At one of the early sessions, she had me bring in a TENS machine and showed me how she wanted me to use it. At another, she gave instructions on using a pelvic wand.

About half way through, she did another pelvic floor exam to measure my progress. That one lasted a little longer as I could do "better" on some of the tests.

At that point, we shifted to dry needling sessions for 5 or 6 weeks.

For the dry needling, the PT used thin needles about 2 inches or so long. She had me get undress below the waist and get under a sheet on my side. She would then fold back the sheet spread my buttocks, clean the area with alcohol, and then stick in 4 to 8 needles targeting different muscles, leave them in for a short while and then remove them. Sometimes I could feel it trigger a muscle spasm. It wasn't anymore painful that the stick from a flu shot.

After that, I had one or two more regular sessions, including a final internal pelvic floor exam. They had taken me about as far as I could go. I was given a maintenance exercise program, and told to come back sometime in the future if things reverted back or changed in some other way.

Over the 3 or 4 months that I was in PFPT, I got improvements to my symptoms. I have also continued to get improvements in the months following. In fact, I probably got half of the improvements in the months that followed.

It didn’t fix my problems out right, but it has been the thing that brought be the most improvement for the least side effects. (Unless you count having to exercise as a side effect.)

It was all focused on evaluation, education, and exercise. The PTs were all professional, kind, and matter of fact.

If you have any problems that might be helped by PFPT, I would urge you to talk to your doctor about getting referred. Just remember, you are going to have to do most of the work. The PTs are really just there to guide you. And results may come slower than you expect.

Well, I've got an appointment for PFPT in a week and a half. It's at the local University PT program, with a female, for an Internal evaluation. I'm hoping she has several students who are interested, as we need more of Providers doing this kind of treatment. We will see if they can help me with several problems I think are related to my Pelvic Floor. Urge urinary incontinence is definitely getting better with Kegels, but inability to stop liquid stool from leaking when pushed by gas is not. In addition, intermittent constipation, and pain in the low back, hip, thigh area hopefully can be addressed. I don't hold out a lot of hope for improvement in my longstanding ED.

Thank you @RTmemories for a very good report of your experiences! I'll report back on mine, as they occur.

@RTmemories Let me know if I've got this right, the only times she did anything internally was during your 3 exams/ evaluations? The only other times you were undressed were during the dry needling that didn't start until about half way through? Were most appointments fully dressed and you doing exercises? Did she ever do any abdominal exams, evaluations, or manipulations? I just assumed that you would be half naked and get the finger almost every appointment. I also assumed there would be more work on your lower abs and upper pelvis. Can you tell us more about the pelvic wand? Very interesting, thank you for this post.

@BenDover It is all very dependent on the problems that your are trying to address, what is wrong with your body, and how you and the PT decide to address it.

There are really three or four components: evaluation, direct therapy (like dry needling and manual therapy), exercise, and education (teaching you things to help make your problems better). (I say three or four, because the last two are kind of the same thing, giving you the tools to make yourself better.)

I was looking to get help with managing a long term, chronic problem that is never really going to be fixed, so I let her know that my emphasis was on evaluation and getting tools that I could use after I finished seeing her, so that is where her emphasis was.

To answer your questions though, I didn’t do any manual therapy. Instead the dry needling was the “direct treatment mode” in my case, so I was only undressed on the visits where she did the pelvic floor exams (rectally) and on the visits where she did the dry needling (through the perineum and the area around the anus). And a little bit where she was showing me how to use the TENS. So I only had to get undressed at little more half of the sessions.

Now if you were doing manual therapy as the primary mode, then you would be undressed more and getting a finger inserted rectally or vaginally more often. Or if kiegals and exercise would be the primary mode, you wouldn’t have to get undressed at all except maybe for the evaluation.

As to the upper abdomen, that was not really where my problems were, so there wasn’t much attention paid to it. I think she did feel my abdomen as part of the initial evaluation along with other things like posture, core strength, gait, etc., but other than the initial eval and checking me out on some exercises, my care was focused on the pelvic floor.

On my visits where we weren’t doing a pelvic floor exam or dry needling, we would start by going over my symptoms for the previous week (I had some objective numbers on bladder emptying so that was helpful) to see if things were helping, to see if I was getting closer to my goals. She would answer questions that I had and provide some education (bladder emptying technique, wand use, etc.), and adjust my home exercise program. Then I would do some exercises with her guiding and correcting me. On these days, I was just in some workout clothes.

As for the pelvic wand, I don’t have a lot to say, because I have never been really skilled at using in. The PT pointed me at the model she suggested for me and gave me instructions on how to use it. It is an s shaped piece of medical grade silicone that is kind of used for a self care version of manual therapy. Some of them are inert, some can vibrate, and some are designed to be heated or cooled. If you search for intimate rose, you can find a variety of models designed by a PFPT. The idea being that you insert them rectally or vaginally and use them to press on a muscle that is in spasm or is hypertonic. You can also use it to gauge your rectal tone by trying to expel it.

I hope this was helpful. Again, every course of treatment will vary based on your exact problems and goals.

@DocH2O

Good luck with your treatment.

And as a couple of words of encouragement:

One, remember that your problems don’t necessarily have a single cause. They might have 5 causes and this might only address 2 of them, but that may still get you improvement. You can’t always get fixed, but sometimes you can get better.

Two, the improvement might not all come at once. I got a lot of improvements during therapy, but at least half of my improvements came in the months after they cut me loose with a maintenance program. Sometimes after removing a problem source, it takes a while for your body to finish responding and recovering.

Three, this is definitely one of those things where what you get out of it is really, really, really dependent on what you put into it. Be honest and frank with your therapist and follow the program the best that you can.

Good Luck!

Well, I had my PFPT evaluation yesterday, and have been thinking through it all to determine how best to report on it. I had my evaluation done at the local University PT program, and had made it clear that I was going there so that they could use me to teach students. Interestingly, although most PFPT's are female, the two students they had were both male. The DPT in charge of the eval was female. She did the exams, but allowed the students to help with treatment options.

They had read the intake forms I filled out online, but still had a lot of questions about bladder and bowel habits, back and pelvic pain, sexual functioning, and what I was doing to try to treat the bladder and bowel incontinence I made the appointment for. I have been doing Kegel exercises, but not much more. That was helping with urinary urge incontinence, but still was leaking stool if it was soft and I had gas.

After a significant amount of time spent on history, it was time for examination. I took off pants and underwear, and layed on the exam table, with a sheet over me. The exam started in the Lithotomy position with feet on the table close to my butt, with a careful skin exam of the waist and pelvic area. Then it progressed to external pressure on the pelvic floor muscles that are palpable from the outside. The external exam took about 15 minutes.

Then it was time for the internal exam. I was turned to my left side, and had my knees pulled up (Simm's position.) She carefully inserted her middle finger, after lubing with KY and asking me to bear down. First she checked as I did a Kegel as I had been doing them. Then she had me change to doing Kegels with exhalation rather than inhalation, which is counterintuitive, but allows stronger contraction. Next she timed how long I could maintain a Kegel - about 18 seconds before I start losing strength. Finally pressure point palpation of each of the internal pelvic floor muscles. The entire internal exam took about 20 minutes, with her finger in place the whole time - no in and out.

So, I've got a treatment plan to start doing at home for the next 4 weeks, including...

1. Continue doing Kegels for 1 second on/off, and 6 seconds on/off, but do them in exhalation. Slowly work on longer Kegels with 30 second goal.

2. Work on "bearing down" without using my abdominal muscles.

3. Strengthening my upper quads and attached pelvic floor with seated "step exercises."

4. Strengthen my lower back and tranversus abdominus mucles with seated twisting exercises.

5. Work on not rushing off to urinate every time I feel a slight urge, but control the urge with Kegels.

Then I get to head back to evaluate my progress. I am hopeful that we'll have some significant improvement in that time.

@RTmemories, do you mind sharing more about your nerve damage/incomplete bladder emptying? Is this related to spinal stenosis or disc problems?

@Neil517 There is not a lot interesting to share. I had some nerve damage to my spine as a young child. (Some combination of an initial problem and the side damage from the surgeries to fix it.)

The biggest side effect was some damage to the nerves to my bladder. My bladder sort of works, but getting it to empty is difficult because the normal signaling doesn’t always work. All this leads to incomplete emptying and a stretched out bladder. Which makes the problem woase and leads to frequent small pees, urgency, etc.

It is all a big self re-enforcing cycle.

This came to a head in my 30s with a big flare up in symptoms and I have been trying a whole variety of things to manage it since including various drugs and some self cathing.

The PFPT therapy was the latest thing. It can’t deal with the root cause, but it it helped me eliminate some things that made it harder to empty my bladder and gave me some better tools for “tricking” my bladder into starting.

RTmemories Thanks for the additional info. I haven't spent a lot of time with this group but I am looking for PFT relative to bladder control/pelvic floor due to stenosis around L5 to S1. Good luck

Well, I had my PFPT evaluation yesterday, and have been thinking through it all to determine how best to report on it.

…………

So, I've got a treatment plan to start doing at home for the next 4 weeks, including...

1. Continue doing Kegels for 1 second on/off, and 6 seconds on/off, but do them in exhalation. Slowly work on longer Kegels with 30 second goal.

2. Work on "bearing down" without using my abdominal muscles.

3. Strengthening my upper quads and attached pelvic floor with seated "step exercises."

4. Strengthen my lower back and tranversus abdominus mucles with seated twisting exercises.

5. Work on not rushing off to urinate every time I feel a slight urge, but control the urge with Kegels.

Then I get to head back to evaluate my progress. I am hopeful that we'll have some significant improvement in that time.

@DocH2O items 3 and 4 along with some other core strengthening exercises are what my PT therapist gave me for some back problemsi had a few years back. I recently bought a book on PFPT home exercises (PELVIC FLOOR EXERCISES FOR SENIORS) and there were several other core strengthening exercises similar to my back therapy in the book. My doc had recommended PFPT but the PT clinic is swamped and not taking new patients, plus it’s a sizable time investment difficult for me to sign up for. I don’t have a serious urinary problem, so I’m going it on my own.

https://www.amazon.com/dp/B0D4KG73NZ?ref=ppx_yo2ov_dt_b_fed_asin_title

@Rigel - Very popular topic, as Amazon has 5 books with the same basic title available. I may get that book, to help out. I wish you the best in your quest to work this into your life, time-wise, and availability of PFPT doctorate wise. The lack of Therapists is why I insist that they have students around to teach this to when I'm there. They offered to give me a list of up to 10 exercises to do, but as the complexity of a workout goes up, the liklihood of me sticking with it goes down dramatically. I asked that they give me a simplified program I can stick with.

If you have a TENS unit, I'd highly recommend getting a rectal probe to help out with the Kegel exercises. I find that it helps me with timing and strength of contractions, but is not a "miracle device." You still need to work at contractions.

Years ago after delivery of my daughter, to prevent urine loss due to weaken musles, they gave me a set of kegel balls.

Now i have my own set 😉

The other things my doc and the Pelvic Floor Physical Terroists will tell you is to avoid certain foods that irritate the bladder. Coffee is the big one for me (my nemisis), anything tomato based or carbonated or acidic, among others. In other words, don’t enjoy eating anymore!

At my stage in life, I'll live with it as I have given up too many vices and treasure the few I have left!!

@Rigel - I hear and feel your comments on vices. I too enjoy my coffee and Sodastream, and eat too much. Trying to moderate intake of such things, but giving them up isn't going to work.

@MilfEva - I used to give the Kegel Balls out to my pregnant patients and teach them how to use them. I never really got much feedback on how much they got used or if patients found them helpful. I can say that, with the improvements in PFPT in the past 5 years, I would be trying to get all my pregnant patients into PFPT at this time to help with both during and after the delivery.