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Everything You Need to Know About Pelvic Floor Physical Therapy (PFPT) for Endometriosis

Everything You Need to Know About Pelvic Floor Physical Therapy (PFPT) for Endometriosis

If you’ve ever heard of pelvic floor physical therapy, chances are that kegels and postpartum come to mind. Most of us have heard the stories of how a sneeze or a laugh can induce leaking, or urinary incontinence, postpartum. And some of us may have experienced this ourselves. 

But did anyone ever tell you that pelvic floor physical therapy isn’t just for postpartum women? And that it’s more than kegels?

Believe it or not, an estimated 47% of women have a pelvic floor disorder, including chronic pelvic pain And a whopping 80% of women with chronic pelvic pain have endometriosis. It is no surprise to those living with endometriosis that chronic pelvic pain is a symptom and frequent occurrence. What may be surprising is that the location of your pain vs. the location of a lesion are not always similar. This means that there are other sources of pain, or referred pain, creating those painful sensations. Endometriosis and pelvic floor dysfunction, it turns out, often go hand in hand. 

In this interview with Caroline Pillsbury, PT, DPT, an experienced pelvic floor physical therapist, we discuss all things pelvic floor physical therapy and why you should think about it if you have endometriosis. 

Pelvic Floor Physical Therapy (PFPT) Defined

If you’re unfamiliar with physical therapy, it is a type of care that aims to support and restore the musculoskeletal system. It focuses on improving movement and mobility to restore bodily function.

A physical therapist is a licensed healthcare professional trained in physical therapy. They are often called “PTs” or physiotherapists. Now with that in mind, let’s jump into everything you need to know about pelvic floor physical therapy.

Morganne Skinner (interviewer): What is pelvic floor physical therapy?

Caroline Pillsbury: Pelvic floor physical therapy is a specialty within physical therapy that focuses on pelvic floor muscles and abdominals. We help people with bowel and bladder incontinence, constipation, urinary urgency/frequency, pelvic/abdominal pain, pain with sexual activity, prolapse, pain during pregnancy/postpartum, and abdominal muscle separation. 

The pelvic floor muscles span the bottom of the pelvis and support the bladder, bowel, and vagina/uterus and therefore help with bowel, bladder, sexual function, and stability of the pelvis as a whole. We use different stretches, strengthening exercises, manual techniques, and lifestyle tips and tricks to optimize the function of the pelvic floor muscles and abdominals.

PFPT and Endometriosis

MS: Why is pelvic floor physical therapy beneficial for endometriosis pain?

CP: Pelvic floor physical therapy can be helpful for people who experience pain from endometriosis. Uterine pain or pain from endometriosis adhesions [and lesions] can cause the surrounding muscles to protectively contract to guard the area of pain. When this occurs repeatedly over time, it can create areas of muscle tightness and pain about the pelvis, pelvic floor/vagina, abdomen, and back. Physical therapy addresses the musculoskeletal system and soft tissue dysfunction contributing to this pain. 

Adhesions are tissues that form during the healing process in response to injury, binding two structures together. Adhesions can be a result of endometriosis itself, surgery, or an injury. Whether one has surgery or not, untreated endometriosis can be accompanied by adhesions. In one study of 109 women with endometriosis, 37.6% were found to have adhesions upon laparoscopy, though a few studies report up to 82% of women with endometriosis have adhesions. These adhesions can cause pain, which pelvic floor physical therapy can address.

MS: When should someone with endometriosis go to pelvic floor physical therapy?

CP: Someone with endometriosis should come to pelvic floor physical therapy if they experience pelvic, abdominal, or back pain in general but specifically if it is interfering with completing activities throughout the day, exercises, recreation, sexual activity, and work. We can determine if the pelvic floor muscles or abdominals are contributing to your symptoms and provide treatment if needed.

MS: What can someone expect from their first session with a pelvic floor physical therapist? 

CP: The first session will most likely be having conversations about what brings you to physical therapy: your medical history, what has worked and not worked for your symptoms, your work/recreational activities, and your goals. It is very important to establish your goals and understand your experience so we can best tailor therapy to your needs. 

We will discuss the anatomy of the pelvic floor/abdomen and how these areas are related to endometriosis, and the symptoms you have. You will also be given some stretches and possibly breathing techniques or other tips and tricks to start at home. If there is enough time during the first session, we will also complete more of a physical assessment. 

MS: And from the following sessions? 

CP: At subsequent sessions, we will assess the strength and mobility/flexibility of the back, pelvis, hips, and abdomen, as well as posture. We will also complete a pelvic floor muscle assessment. This is similar to a pelvic exam like you get for a pap, but we don’t use a speculum or stirrups. Instead, it’s just gloves and one finger intra-vaginally to assess your strength and determine which muscles could be contributing to your symptoms.

However, if you are not comfortable with a vaginal pelvic exam, we can always complete the assessment at a future visit or modify the exam to not assess internally at all. All options are valid and what you are comfortable with is the most important. Once we have completed these assessments we can tailor physical treatment to your needs. Subsequent sessions will include stretches, breathing techniques, strengthening/coordination exercises, and manual techniques in the clinic and at home to improve your symptoms. 

The length and frequency of therapy sessions will vary greatly from person to person. Certain things like insurance, availability, location, conditions, and symptom severity will dictate your prescribed treatment regimen. One study found that 63% of patients with endometriosis experienced an improvement in pain after six sessions. There is no universal or gold standard treatment frequency, so be sure to ask your therapist what to expect for your case.

Misconceptions of PFPT

MS: What misconceptions have you heard about pelvic floor physical therapy?

CP: That all we do is kegels! Strengthening the pelvic floor can be important but it is definitely not the whole picture. In fact, for most people who come in with pelvic or abdominal pain, we focus on mobility and coordination of the pelvic floor, not strengthening.  

Another one is that it is really painful. When an area of the body has been feeling pain for a while, it can be uncomfortable to assess the area and start treatment on it because we don't do that often and areas of discomfort are really good at feeling discomfort. 

Everything we do for treatment will stay within your comfort level and your feedback; those boundaries dictate what we do.

There are many ways of assessing pelvic floor muscles, so if one method causes you pain, always speak up and communicate that with your therapist. They can assess your pelvic floor muscles through visualizing your movements, observing functions, and by an external observation in addition to an internal exam. Your therapist can continually modify their assessment and treatment plan based on what you feel comfortable with at that time.

MS: How do pelvic floor muscles contribute to pelvic pain and does physical therapy mitigate this? 

CP: Uterine pain or pain from endometriosis adhesions [and lesions] can cause the surrounding muscles to protectively contract to guard the area of pain. When this occurs repeatedly, over time, it can create areas of muscle tightness and pain about the pelvis, abdomen, and back. 

Sometimes we can feel pain in an area where there is no tissue dysfunction when pushing on a tight/painful muscle—this is called referred pain. It explains why you can feel pain in the back or abdomen when it is actually coming from the pelvic floor muscles. 

Physical therapy helps to improve muscle flexibility, sensitivity, strength, and coordination to improve how the muscles are functioning, therefore mitigating symptoms stemming from the pelvic floor muscles.

Pelvic floor physical therapy will not cure your endometriosis. It may, however, provide some much-needed pain relief. Managing endometriosis usually requires multiple strategies, as there are often multiple sources of pain. This is why some people continue to have pain, even after successful excision surgery. Removing endometriosis lesions does not automatically resolve pelvic floor dysfunction any more than removing a uterus resolves existing endometriosis lesions. 

MS: If you could share one thing with women living with endometriosis, what would it be?

CP: Keep being an advocate for yourself. I wish we lived in a system where this was not necessary. If you have not found answers yet, that does not mean they aren't out there. With that being said, it can be exhausting advocating for yourself and seeking different treatments and it’s okay and sometimes very beneficial to take a break from it all. 

MS: Is there anything else you’d like to share?

CP: I am so glad you’re reading more about pelvic floor physical therapy. Pursuing pelvic floor physical therapy can be so helpful for people who have endometriosis, but unfortunately, it can be hard to find a therapist depending on where you live, and it’s not super well known. The unknown of it all can be scary and let's be honest, potentially getting a pelvic exam is not anyone's favorite afternoon activity!

How do I find a pelvic floor therapist?

A great place to get started is to check with your doctor, who can recommend a PFPT or provide a referral for you if insurance requires it. If you are not currently under the care of a doctor or are just needing some help finding a therapist, there are some great online resources.

You can check out a few that Caroline shared here: 

Remember, pelvic floor therapy is not just for postpartum women! And you don’t have to have a diagnosis to be seen. Simply experiencing pain and/or dysfunction is enough of a reason to seek pelvic floor therapy. While pelvic floor therapy will not cure your endometriosis or take away all of your pain, it can be a great tool to ease some of your symptoms.