What to expect at your first pelvic floor physical therapy appointment

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We recently caught up with Heather Fraebel, a physical therapist in Denver, Colorado who continues to grow in her specialization of women's health physical therapy. Heather is a Uqora customer, which is how we originally met her, but she’s also a wealth of knowledge.

Evidence has shown that pelvic floor physical therapy can help reduce recurrent UTIs. However, pelvic floor therapy has many other benefits including addressing urinary dysfunction, urinary incontinence, and painful intercourse or pain in the pelvic area.

The very first thing to make clear is that at pelvic floor physical therapy you are in control over any and all exam procedures and treatment options over the course of your care based on your comfort level. At pelvic floor physical therapy, you will never find stirrups or speculums (phew!) and you will get at least 45 minutes of undivided attention.

After bringing you back to a private exam room you’ll tell your story and history to your physical therapist, NOTHING is too taboo or embarrassing to mention.

After collecting subjective information, next comes the physical examination which has two options: external or internal. An external exam would be for those not comfortable with an internal exam (more on what this entails to come) or for those where an internal exam may be contraindicated due to reasons your physical therapist would discuss with you such as first trimester pregnancy etc.

The external exam would involve palpation of pelvic floor musculature to assess for ability to contract and relax as well as assessment of breathing and body mechanics. While still useful, really an internal exam is preferred to properly assess the many layers of muscles and structures within the pelvic floor. Have no fear, a physical therapy internal exam is much milder than your OB/GYN exams. Pelvic floor therapists are the only other trained medical professional aside from OB/GYNs who can perform internal examinations and are required to go through special training to do so.

Your physical therapist will have you undress from the waist down and perform the exam as follows: assess visually, palpate superficial (not within the vaginal canal yet) muscles to feel for tenderness, assess internally with one gloved and very lubed finger at three levels of the pelvic floor musculature to feel for tenderness or knots as well as grade strength of contraction and ability to relax/bulge pelvic floor and rule in or out other issues such as pelvic organ prolapse.

The whole exam should take about 15 minutes and you are in control of stopping any time you feel you need to. Based on what is found, your physical therapist will then discuss your individualized treatment plan from there and give you your first bits of ‘homework’.

• Manual work: if hypertonicity, tenderness, or nerve sensitivity is discovered upon exam then treatment will entail internal manual release. Just like when you have a knot worked out in your upper back, a physical therapist will work out and release your knots and tender spots within your pelvic floor. This is done internally by applying pressure to release and stretch these areas and tissues.
• Bladder retraining: through use of a bladder diary, your therapist will likely help you identify abnormalities in your bladder habits and discuss how to correct them. A bladder diary is just that — you logging your bladder movements, recording how many times you go to the bathroom, what you drink and how much, and so on. You’ll also be taught many techniques of how to optimize bladder and bowel voiding.
• Pelvic floor awareness/coordination training: to improve ability to contract and relax and thus better control your pelvic floor, your therapist will train you on techniques such as diaphragmatic breathing, Kegels and reverse Kegels (yes, REVERSE Kegels, which is a technique to relax the muscles vs. contracting them like a traditional Kegel does) coordinated with breath, etc.
• Exercise: specific stretches for the pelvic floor or other tight structure you may have, Kegels if needed, and core strengthening.
• Other tools: other tools may be used such as joint mobilizations, biofeedback training involving an electrode on your pelvic floor corresponding to a screen that visually shows you whether you are contracting or relaxing your pelvic floor or vaginal electrical stimulation (VES) which is a device to send gentle electrical pulses through the pelvic floor.
• Education: with a holistic mindset, your physical therapist may also address areas such as nutrition, fiber, bladder irritants, effects of hormones, other medical options, sex positions, best lubes on the market, supplements, etc. that could be beneficial for you.

Obviously, a physical exam performed by a physical therapist is not possible with Telehealth, however many pelvic floor physical therapists can still provide quality care over Telehealth just based on information you provide them or by teaching you how to even perform an exam on yourself!

My opinion is that while an in-person pelvic floor physical therapy exam and treatment (or at the very least exam with subsequent Telehealth treatment) reigns superior, Telehealth is a wonderful tool to provide quality pelvic floor physical therapy care to those that may not have access to it otherwise.

Many pelvic floor physical therapists out there accept insurance and depending on your insurance you may not even require a referral to set up an appointment.

Check out the Uqora Good Doc Club for a list of customer-nominated list of medical providers that have made Uqora community members feel seen and understood.