by Heidi Giroux, P.T.
My interest in Pelvic Floor Physical Therapy came shortly after the birth of my first son. I had third-degree tears and significant swelling; recovery was slow. Although the birth of this baby was surrounded by excitement, the aftermath induced a bit of fear.
I remember being in the parking lot approximately five weeks postpartum and carrying my son in the car seat. I had a full bladder, and the car seat pressed against my abdomen. I lost complete control of my bladder and had a full episode of incontinence in the parking lot. I remember crying and wondering what just happened. I had been a practicing physical therapist before the birth of my son, and I remembered reading information about how this problem can be helped.
This kind of treatment was relatively unknown 25 years ago, but there were therapists assisting patients with these issues. I decided to order the level one home study course to learn techniques and exercises to help my condition. Thankfully, the incontinence resolved itself through exercises and techniques (which are much more than Kegels).
However, after the birth of my fourth and fifth children, I again noticed leaking when I coughed or sneezed. The problem also happened when running after my children.
It was interesting to notice that it was most pronounced during the luteal phase of my cycle. This discovery piqued my interest in how hormones affect the pelvic floor muscles, reproductive organs, and supporting structures.
As I continued to study, and as I learned and understood the reproductive cycle taught in the Billings Method™, I was able to assist many patients and Billings clients with practical advice in the physical rehabilitation of the pelvic floor.
What is Pelvic Floor Physical Therapy?
Pelvic Floor Physical Therapy is a specialized area of physical therapy that involves evaluating and treating musculoskeletal and neuromuscular dysfunction related to the pelvis.
The pelvic floor is made up of muscles and other tissues that form a sling from the pubic bone to the tailbone. They assist in maintaining an upright posture, supporting abdominal and pelvic organs, and help to control the bladder, bowel, and sexual activity.
Pelvic floor dysfunction refers to a wide range of problems that occur when the muscles of the pelvic floor are not functioning normally and are often too tight or weak. Typically, there are related impairments of the abdomen, sacroiliac joint, low back, coccyx, and/or hip joint that accompany this condition, and can contribute to pain and loss of function.
Pelvic floor issues are rarely isolated. It is common for symptoms to emerge together or for one problem to cause a cascading effect and should be treated comprehensively to resolve the symptoms.
In my physical therapy practice, I schedule each patient for a one-hour session. I work to treat a wide variety of conditions but predominately urinary incontinence and pelvic pain.
On average, for urinary incontinence, patients require 6 – 8 sessions. However, many times there are other orthopedic issues. Sometimes these are combined with pelvic pain, so, for those patients, they average more like 10 – 12 sessions.
How many types of urinary continence are there?
There are three categories of urinary incontinence: urge incontinence, stress incontinence, or a combination of both. Urge incontinence, in particular, can be triggered by such seemingly innocuous things as cold, running water, or putting a key in the door.
All three types are treatable with physical therapy that includes behavioral techniques and lifestyle changes, and physical retraining.
When treating Urge Incontinence, we apply these seven steps:
Step 1: The patient keeps a diary over a 72-hour period that includes the number of voids, the volume voided, incidents of leakage, potential food irritants, and fluid intake.
Step 2: Bladder retraining is achieved by increasing the amount of time between bathroom visits. The optimal is to void every two to five hours. However, a patient with urge incontinence voids every hour or more often. I will ask the patient to increase that by minutes or hours. When the patient has increased time between voids with ease, and there are no accidents, we consider this success.
Step 3: The patient focuses on healthy fluid intake. That means slowly sipping throughout the day, 40-50% of body weight. She also will be encouraged to avoid bladder irritants, which are found in fluids that are more acidic such as coffee and sodas.
Step 4: We initiate the goal of completely emptying the bladder during each void. Often during this step, breathing techniques or double voiding are discussed and practiced.
Step 5: Now we are at the point where we incorporate urge control techniques:
Step 6: We discuss optimal voiding postures, such as avoiding a hunched over position.
Step 7: Avoid “just in case peeing” because when voiding for no reason, only “just in case,” the brain becomes trained to go all the time.
These steps can be taught at any age, even during the later years. We have found that staff in nursing homes can help patients with cognitive impairment by getting them to void at intervals, such as every two to three hours. It often improves urge incontinence.
Stress Incontinence can happen during physical activity such as coughing, laughing, sneezing, running, or lifting something heavy, which puts pressure on the bladder causing urine to leak.
When treating stress incontinence, we apply these four phases.
Phase 1: We start therapy by discussing breathing techniques. When we inhale, the pelvic floor drops. When we exhale, the pelvic floor should lift and the deep abdominal muscle contracts. Effective breathing is extremely important for continence because it gives proper pressure control.
Phase 2: The second phase has the patient working on pelvic floor muscle and abdominal contractions coordinated with breathing. The goal would be for a patient to contract the pelvic floor with the abdominal muscles for 10 seconds 30 times per day. Caution is advised for post c-section or those athletes who tend to have very tight abdominal muscles.
Phase 3: The patient is then taught about getting the pelvic floor muscles to work synergistically with the hip, gluteal and abdominal muscles with proper breathing patterns.
Phase 4: During this final phase, we work on functional movement combined with proper pelvic contraction coordinated with effective breathing. Movement practices are going from lying to sitting; sitting to standing; bracing with coughing/sneezing, reaching, squatting, climbing stairs, lifting, walking, jogging, and other impact exercising.
Whether my patients are postpartum or menopausal, I take them through these phases. They help women throughout their reproductive life as well as post-reproductive life.
Some conditions treated by pelvic rehabilitation physical therapists include:
Pelvic Organ Prolapse
Painful Bladder Syndrome/Interstitial Cystitis
Chronic Pelvic Pain
Chronic Abdominal Pain
Levator Ani Syndrome
Pregnancy related issues
Chronic Prostatitis (non-bacterial)
Post-Prostatectomy Urinary/Bowel Dysfunction
Chronic Pelvic Pain
Physical Therapy Treatment:
Postural education and functional training
Education on dietary irritants and bowel/bladder diaries
Manual Therapy: soft tissue mobilization, trigger point therapy, connective tissue manipulation, dry needling, myofascial release
Movement and Exercise Training
Relaxation Techniques, breathing, down training, chronic pain education
Modalities: biofeedback and electrical stimulation
BOMA-USA provides education and training for The Billings Ovulation Method® which is a natural method of fertility management that teaches you to recognize the body's natural signs of fertility.