From constipation and incontinence to painful sex and vaginal prolapse, women's health physiotherapy can help to relieve symptoms that affect the pelvic floor. We look at the potential benefits of treatment and what to expect from an appointment.
Historically, women's health physiotherapy covered obstetrics only, treating women for back pain and pelvic pain during pregnancy. However, this growing area of specialty now encompasses a range of conditions relating to the pelvic floor that affect the bladder, vagina and bowel. Pregnancy and postnatal issues are still a focus, but so are painful bladder syndrome, vaginismus and vulvodynia which can be a cause of painful sex.
Underactive and overactive muscles
Lucia Berry is a clinical lead pelvic health physiotherapist, a lecturer in physiotherapy and a trustee of UK-based professional network, Pelvic, Obstetric and Gynaecological Physiotherapy (POGP). Women's health physiotherapy, she says, is all about 'muscle coordination' and treating pelvic floor muscles that have become either underactive (hypotonic) or overactive (hypertonic).
"An underactive muscle is one that is weak and lengthened - it might have been stretched significantly after giving birth, which can cause urinary incontinence or vaginal prolapse, whereas an overactive muscle is shortened and has little stretch to it," she explains.
"Muscles become overactive because the brain is constantly sending messages to those muscles to contract - for example, if you have frequent symptoms of bladder urgency or sex is painful the muscles will be used more and become shorter. This can make the vagina or back passage tighten up which can increase pain."
What to expect from a first appointment
A physiotherapist will begin by asking specific questions to try to establish what is causing your symptoms.
"If the symptom is pain, it is our job is to work out where and why, and what can we do about it," explains Berry. "I'm also interested in what you want to achieve from the appointment. Physiotherapists will set goals and expectations early on so treatment is specific to the problem."
Some women are anxious about having a vaginal examination as part of their assessment, but Berry is keen to offer reassurance.
"We will talk you through the whole examination beforehand and they'll be a lot of reassurance along the way," she says. "It may just involve observation of the area or the insertion of a gloved finger to apply light pressure to find out specifically what's is causing the symptoms."
Berry also uses ultrasound to scan the pelvic muscles of some patients, a form of biofeedback.
"Then the patient and I can both see on the screen whether the muscles are moving in the right way and I quickly help them change that movement if need be," she adds. "Visual feedback shows people just how gentle these exercises are. You don't have to squeeze or push hard, yet gently changing how these muscles work can have a huge impact on symptoms."
Relief from painful sex and vulval pain
Sometimes overactivity of the pelvic floor muscles can occur as a result of a trigger such as emotional or physical trauma, a vaginal or urinary tract infection, or an underlying skin condition which has caused discomfort in the area. The muscles may go into an involuntary protective response, staying tense and tight, and compressing the vaginal entrance.
Women with vaginismus and vulvodynia, which can cause painful sex, may benefit from women's health physiotherapy to release these muscles and reduce symptoms.
"Manual therapy and trigger point release can definitely help," says Berry. "Finding sore points on muscles within the vagina and teaching the woman how to very gently release these muscles at home is effective."
Treating bladder and bowel issues
Berry sees patients with faecal incontinence and those who have difficulty emptying the bowels.
"Many people are diagnosed with constipation when actually it's a difficulty relaxing the pelvic floor to get the faeces out," she explains. "Patients may be contracting instead of relaxing without even realising it. I can teach them the right way to poo."
Bladder pain syndrome, also known as interstitial cystitis (IC), is another condition that Berry has treated successfully.
"With IC you often get referred pain into the vaginal muscles of the pelvic floor and the abdomen," she adds. "The pelvic floor muscles might have become quite short and tight and this can affect how well you wee. If you don't fully empty the bladder, you might retain urine and that could irritate the bladder further, so we focus on how to relax the muscles and void well."
Support during pregnancy and with postnatal complications
"We may treat women with back pain in a group setting first and ask questions to ascertain what might be causing the pain for each person," says Berry. "There's a particular test we do to find out whether a belt might be helpful and we also prescribe exercises. Commonly the gluteal muscles of the buttocks are weakened in pregnancy due to changes in posture so we might suggest wall squats or bottom-clenching exercises. Some gentle tummy strengthening and pelvic floor exercises can also be useful; this is why yoga and Pilates can be so beneficial in pregnancy and postnatally."
Incontinence is another common symptom during pregnancy and Berry advises treating this early on.
"It's important as otherwise it can get worse after giving birth," she cautions. "I work to help postnatal wound healing after women have given birth, as well as prescribing pelvic floor exercises to strengthen the weakened muscles which helps with urinary incontinence."
Sarah* was initially referred to a women's health physiotherapist to treat urinary incontinence following the birth of her second baby.
"At the first appointment my physio talked me through the correct way to do pelvic floor exercises. She was very reassuring and put me at ease and at the second session I had a vaginal examination. It was painless and meant we could make sure my treatment was really individualised. She established how strong my pelvic floor was and we agreed on how many seconds I should be trying to hold my contractions for to get the best result. By the third session I had eliminated any leaking."
Four months after giving birth Sarah also developed vaginal symptoms that needed treatment.
"I pushed myself to do some exercise and following that I had a strange sensation in my vagina. At my appointment the physio did an internal vaginal check and found an over tight part of my pelvic floor which she thought might be causing it. She helped release the muscle and since then I'm relieved to say the feeling has gone away. I had times where I thought I would never recover properly from birth and now I feel hopeful that I am going to get back to normal."
How to seek help
*Name changed at participant’s request