Pelvic Floor Therapy — what happens during an appointment

Transcript: What Happens in a Pelvic Floor Therapy Appointment?

Nina:  Hello and welcome to Women Living Better’s Interviews with Expert Series. Today we’ll be talking about pelvic floor therapy, specifically what happens in a pelvic floor therapy appointment.

I think most people know what physical therapy is but might be wary of or at least curious about pelvic floor physical therapy. Luckily, today we have expert Kathy Kates to walk us through an appointment.

Kathy is a nurse practitioner, a pelvic floor therapist and founder of the Institute for Pelvic Health, an organization that educates healthcare providers about the pelvic floor.

Full disclosure, I have been a patient/client of Kathy’s, and we knew each other before I was, so it had the potential to be awkward. I assure you it wasn’t.

On the Women Living Better site, we explain the different types of pelvic floor dysfunction that pelvic floor therapy can address, so we won’t talk about that today. We’re really going to focus on an appointment.

So, Hi Kathy, Welcome. Thank you so much for discussing this with me. I think there’s more and more awareness that our pelvic floors might need attention in midlife, and I think there’s a lot of curiosity, so I’m thrilled to have you here. Can you just start us off by talking about the first appointment? What are you assessing and what actually happens?

Kathy Kates: Absolutely. Thank you so much for having me, Nina, and thank you for the incredible work that you do for Women Living Better. I recommend it to my patients all the time, and I’m so glad to have an evidence-based, thoughtful resource. So a huge thank you to you for all of the work that you put into this.

So what happens in your initial pelvic floor therapy appointment? So first, we have to assess for trauma and make sure that someone would be comfortable with an internal exam. That’s number one. Number two, usually the first session, if someone is comfortable with an internal exam, we’re going to start very locally. So we’re going to start by looking. We’re going to ask you to get undressed and hop under the sheet, and then we’re going to take a very good look at the external part of the pelvis, the pelvic floor muscles.

Kathy Kates: We’re going to do a very detailed look at all of this genital anatomy because we’re looking for signs of dryness, we’re looking for changes in tissue and all of that. We’re also, if you’re comfortable, we’re going to palpate or touch all of this right where my fingers are all on the outside and then in between, these are your labia minora. We’re going to palpate or touch all in there. We’re going to look at the mobility of your clitoral hood or the hood of that erectile tissue to make sure that it moves appropriately. Then we’re going to take a glove lubricated finger, and we’re going to put it, we’re going to go through the genital or vaginal opening, and we’re going to go in to the muscles of the pelvic floor.

And so there are three layers of pelvic floor muscle, and as the therapist, we assess based on how far in our finger is. So, the finger is gloved and lubricated.

If we go in this far to the first joint on your finger, that’s that superficial or first layer of pelvic floor muscle. When we go into the middle of our finger or your second joint on your index finger, that’s the second layer. And then we’ll go in, if it’s comfortable for someone, all the way to that last joint, and that’ll put us deeper into the pelvic floor.

And we go around, and we assess for the muscle tone, meaning does the muscle feel tight? Does it have the appropriate ability to sink into it and release it? Or does it feel very, very, almost floppy, like there’s no tone. Like you’re sinking your hand and finger into a piece of jello. So a tight muscle is putting your finger on a piece of well-done steak. It has almost no give. An appropriate tone of muscle would be probably like a medium, medium rare piece of steak.

And jello would be like when there’s low tone or very, very weak tone, and you might hear the words high tone or hypertonic pelvic floor. It just means there’s a lot of elevated tone. Or you might hear low tone or hypotonic pelvic floor. So we assess the muscle tone. We’re looking for that. We’re looking, do you have any trigger points or knots? Just like you can get a knot in your neck if you sleep on it the wrong way, you can get knots within the muscle fibers of your pelvic floor.

Then we’re going to ask you to, so if this is my finger or the therapist’s finger, and these are your pelvic floor muscles, we’re going to ask you to contract or squeeze around the finger and release. And what the therapist is doing when we do that is we’re assessing can your pelvic floor muscles contract and release. Meaning can they squeeze and then can they relax? So those are the big things that we’re looking for, the pelvic floor muscle tone, and then the pelvic floor motor control, which is the ability to contract and release.

Nina: Excellent. Now, I will take you back, so for my very first appointment, first before I undressed, you were looking at my posture, and maybe that’s not something you do with everyone. Maybe you just immediately saw that I had some interesting tipping in my pelvic floor, but I thought that was a surprise to me. So is that not something that happens all the time, or is it?

Kathy Kates:  So it depends on the order of things. So it’s very much depends on the individual therapist. And ideally we want to do everything in the first visit, but we often can’t. So sometimes after you’ve taken a good history and you might go directly, and your patient is comfortable, you might go directly to an internal exam at the first visit. Or you might do the external exam, meaning the outside, all of the other things except for the pelvic floor on your first visit like you and I did when you came to see me.

And so in an ideal world, all of that has to happen. It might take two or three sessions if your therapist is very thorough to really look at all of those things. And so the big thing when we’re looking externally at someone, we want to see, we’re looking for the balance of their pelvis.

So pelvis means basin in Latin. And so you need a balanced pelvis for the muscles, the pelvic floor muscles to function optimally. So here is a balanced pelvis if you go and sit on your hands. But if I sit on my hands and I feel the bone, those are my sitting bones. So when you can feel your hands and you’re sitting on them, that means that you stand the best chance that your pelvis is balanced, meaning a balanced pelvis. If you think about it means basin and you have a level of water. There’s no water spilling out either over the front, over the back, or on the side. A level or an even water level equals optimal pelvic floor functioning in a pelvic floor therapist world.

So, for example, if you’re sitting down and you can’t, let’s say you’re sitting on both of your sitting bones, all of a sudden if you start to lean back and your sitting bones slide in front of you, all of a sudden, your pelvis is no longer neutral. The basin is no longer neutral, it’s tipped forward. That makes all of your pelvic floor muscles contract, right? Muscles that are always contracting can’t function optimally because they’re constantly being contracted, contracted, contracted. So then if you come back into neutral and then you all of a sudden perhaps really lean forward, now your sitting bones are behind you, that creates an entirely different kind of pelvic floor dysfunction. So that’s why it’s so important to think about sitting on your sitting bones whenever you can because that’s going to promote the optimal balance within the pelvic container.

Nina:  Gotcha. Okay. Are follow-up visits, how are they different? Once you’ve assessed and have the lay of the land? Are follow-up visits usually similar, the internal and sort of releasing certain places? Or how would you describe the follow-on visits?

Kathy Kates:  Yeah, so I think it probably will take two to three visits to get a really good history from your patient to look globally, head to toe, and then to do a very thorough look at the tissue and then to assess the pelvic floor muscles.

So once you do that, you or your therapist will make the appropriate treatment plan. So it depends. It might be that you spend 15 or 20 minutes doing certain techniques that will help to release any muscle tension that will help to restore balance to the pelvis that might entail work on your abdomen. It might entail work on your quads or your hamstrings. A lot of times on your inner thigh muscles, because those attach right up at the pubic bone. They attach right into the pelvic floor. So it really depends, but typically you’ll probably be doing, if it’s a 55 minute session, probably 20 to 30 minutes of external balancing and 20 to maybe 15 or 20 minutes of internal release work. And when we say release work, we mean we’re looking for tight muscles or trigger points or knots, and we’re using different techniques to release those knots or that tension.

Nina:  Gotcha. And so after the initial three, is there an average number of sessions usually required? I’m sure that’s a difficult question and it depends.

Kathy Kates: It’s a very difficult question and it depends. I would say the shortest you could expect would probably be about 8 to 12 sessions. And then I think from there, I think it’s very hard to know because everyone has their unique symptoms. Everyone has their unique patterns of the way that they sit and they stand. And then you have certain levels of how much are people going to do in between sessions because many people have very busy lives, and pelvic floor therapy is not high on their list. So it depends on a lot of factors.

Nina: That was going to be one of my next questions, which is are there things, is there homework? Are there things that one can do to speed, the healing, the righting the basin along?

Kathy Kates: Balancing the pelvis? For sure. Yeah. I mean, there’s so many things and it’s unique to that person, but your pelvic floor therapist will give you and guide you through specific exercises and stretches. So for stretches, it’s going to be to balance the pelvis. Number one, they’re all going to do that. We’re going to give you prescribed exercises to help you connect to your diaphragm so that you can use diaphragmatic breathing. From there, those we give to everybody. And then I think depending on what the issue is, there’s a whole host of other things that your therapist might prescribe for you.

Nina:  I’ll share my experience in working with Kathy, which is I did have homework and there were certain things that I think you asked me to do 10 of them if I could twice a day. And it involved breath, certain releases, just a lot of awareness of muscles and parts of my pelvis that I really had never thought of. And so it was quite interesting. How would you suggest somebody find a pelvic floor therapist?

Kathy Kates: Great question. So there are a lot of resources, and databases to find them.

Nina: And I have two listed on the site.

Kathy Kates: Okay. Yeah, so I think the first thing is you ask whoever you’re most likely you’re seeing a gynecologist or a family practitioner or maybe an internist, and so that’s always a good place to ask because they may have people within their network they refer to. I think those databases that I shared, and I’m happy to share, I think there may be two more are also good places.

[You can find locators for pelvic floor therapists on our pelvic floor changes page]

Nina: And then what are the range of people who are qualified to do pelvic floor therapy?

Kathy Kates:  Yeah, it’s a great question. So physical therapists, those are called pelvic floor physical therapists. Occupational therapists, they do additional training. So both physical therapists and occupational therapists do extensive training because in their training to become a PT or an OT, that’s an occupational therapist, that doesn’t involve pelvic exams or internal exams. So that’s a specific skillset that they have to learn on top of being a PT or an OT.

For someone like me who’s a nurse practitioner, nurse practitioners, doctors, physicians assistants, nurse midwives, anyone, any medical professional who’s licensed to do an internal pelvic exam can take additional coursework to become a pelvic floor therapist.

Nina:   Okay. Makes a lot of sense. All right. And anything else on this topic? Kathy and I are going to record another video that I encourage you to watch. It’ll be further down the page about diaphragmatic breathing. Put a little plug in. Anything else just related to the appointment that you think it would be helpful for people to know? I think we’ve covered.

Kathy Kates:  I think we’ve covered a lot. I think you’re very brave if you call. And it’s something that every single person with a vulva and a vagina should do, because there’s so much to learn, and because I come from primary care, I love prevention, so everyone should go so that even if you think everything is fine, amazing, let’s keep it fine!

Nina:  Mean I went for a reason, but there was so much learning. And there was just that awareness that came with the appointment too. So I echo that. All right. Thank you so much, Kathy.

Kathy Kates:  You’re so welcome, Nina. Hugely helpful.