5 Signs You Have Pelvic Floor Dysfunction & Could Benefit From Physical Therapy

If you’re a person — of any age and any gender — you have a pelvic floor. And studies show that 1 in 3 women, 1 in 2 women who have given birth, and 16% of men will experience a pelvic floor disorder (PFD) in their lifetime. So while pelvic floor dysfunction might not be your favorite thing to talk about at family dinner, or even over drinks with friends — in fact, it may not even come up at your annual OB-GYN appointment — it’s a conversation worth starting. And one that birthing parents, and the people who love them, urgently need to have.

“We know that your pelvic floor is transformed during pregnancy. Whether you have a vaginal birth or cesarean birth, you start having pelvic floor issues during pregnancy. We know that postpartum people are having issues,” says Sara Reardon, a pelvic floor physical therapist in New Orleans. While slapping on a pantyliner and waiting it out seems like the simple solution, pelvic floor conditions often don’t improve with time alone. They also take a grave toll on women’s mental health. Studies have linked urinary incontinence (UI) to more than double the rate of depression and anxiety compared to the general population.

There are medications and surgeries to treat the most common PFDs — fecal and urinary incontinence, and pelvic organ prolapse — and depending on your symptoms, your doctor can prescribe you medications, topical creams, or implantable devices to help. Because pelvic floor physical therapy is (relatively) noninvasive, and a source of significant relief for people with pelvic floor symptoms, therapists say it’s where you should start.

Pelvic floor PT can be especially helpful to those who’ve just given birth. “Everyone is hoping for a vaginal delivery, but no one talks about what can happen after. At your six-week checkup, if you’re not having any complaints, the recommendation is to see your doctor a year later,” says Dr. Tirsit Asfaw, M.D., a urogynecologist at Weill Cornell in New York City. “There’s no official screening for prolapsed organs after childbirth; it’s almost as if it’s a luxury to maintain bodily function. Unfortunately, that’s what society has done to women.”

And in a nation where Black women are three times more likely than white women to die from pregnancy-related complications, it’s reasonable to guess that their pelvic floor dysfunction is likely dismissed at higher rates than that of white women. “If people have been gaslit … it makes it really hard for that patient to trust their body. With a lot of the Black maternal health crisis, I feel like that’s a huge piece,” says Anietie Ukpe-Wallace, a pelvic floor physical therapist in Oakland, California.

“Why aren’t we proactively helping women?” asks Reardon. “I hope I see that needle move where physicians are referring more proactively, that it just becomes integrated into our health care system, that every pregnant person, every postpartum person, every menopausal person sees a pelvic PT, that there’s less stigma and more awareness and access.”

Romper spoke to numerous women with pelvic floor conditions, and the vast majority found their OB-GYNs — the providers they trust with their reproductive care — either didn’t know how to help them or dismissed their concerns outright. Reardon added that historically, OB-GYNs haven’t had a good understanding of what pelvic floor therapists can do to help patients, and the public didn’t know enough to ask for a referral themselves. “I think that’s changing, but I don’t think it’s anywhere near where it needs to be. I read a study recently about the reasons OB-GYNs didn’t [counsel on pelvic floor dysfunction risk], and one of the reasons was because they didn’t even know how to assess for pelvic floor issues and then they didn’t know where to refer. Those aren’t reasonable excuses to me anymore,” she says. “The medical community needs to step up and say, ‘Hey, we need to integrate this into our gynecological care and obstetric care. How are we going to do that?’”

“How’s a woman with a newborn baby supposed to come in to get a postpartum check if her husband’s already back at work because he doesn’t have postpartum care and she can barely leave the house because she’s in so much pain? A lot of the women I see, they can come in for one visit and then they just disappear because there aren’t those social safety nets in place to allow women to get the care that they need,” says Ryan Simmons, DPT, a pelvic floor physical therapist practicing in Seattle and Mexico.

How to tell if you need pelvic floor PT.

If you answer yes to any of these five questions, you would likely benefit from pelvic floor PT, says Laura Meihofer, a board-certified doctor of physical therapy based in Rochester, Minnesota.

1. Do you have any difficulties urinating? Maybe you have a hard time emptying your bladder completely, you have leaks, or you feel the urge to pee more often than you think is normal.
2. Do you have any difficulties with bowel movements? Incontinence or being unable to relax enough to poop are red flags.
3. Do you experience pressure, heaviness, or a feeling like something is falling out? This could be a sign of pelvic organ prolapse, when your organs drop and bulge into the vagina or rectum.
4. Do you have ongoing back, hip, or abdominal pain? The pelvic floor muscles provide support to everything in the trunk of your body. If you’re having aches and pains without another explanation, checking in with a pelvic floor PT might be the solution.
5. Do you have a hard time enjoying sex? If you’re unable to orgasm or sex is painful, PT could help.

How to find a pelvic floor physical therapist.

It can be tricky to access pelvic floor PT because, in many cases, you need a referral from a physician. A good first step is to call your OB-GYN, midwife, or primary care doctor (if you have one) to find out whether you need a referral. Annoyingly, this varies by state, insurance provider, and health care facility, so you will need to call and ask.

However, in every state in the United States, you are entitled by law to see a pelvic floor therapist, or any physical therapist, for at least an evaluation. After that, the act varies by state. In the state of Texas, you have to have a physician’s referral to continue therapy after the initial evaluation.

In Louisiana, where Reardon practices, you can continue to see a patient as long as they’re progressing with therapy. Louisiana requires the physical therapist to make a referral to an appropriate provider if the patient is not progressing after 30 days of treatment. Reardon, who is a board-certified pelvic floor physical therapist and owner of NOLA Pelvic Health, says that, depending on what state you live in, these laws can create a barrier to access. If you’re not sure where to start, call your primary care provider or OB-GYN’s office and ask if they know more about your state’s requirements.

If you have specific concerns about finding a physical therapist — like looking for someone who is trauma-informed, say, or who specializes in postpartum rehabilitation — read reviews online, and don’t hesitate to ask your friends, doctors, and other women in your area for recommendations. Jane, 28, had a hard time feeling safe during pelvic exams, but after making a plan with her therapist, she benefited greatly from treatment. She suggests discussing your needs up front. “It may be uncomfortable, but if you have that history of violation, or you need to feel safe, you need the lights dim, you want to meditate before, ask for that.”

Will my health insurance cover pelvic floor physical therapy?

Next step: Decide whether you need a PT who takes your insurance or accepts self-pay patients. PTs on staff at hospitals or clinics are more likely to accept insurance, though this can mean their waitlists are longer. Therapists in private practice are usually easier to get in with, but you’ll see them on a self-pay basis.

All insurance plans sold through the federal marketplace or the state exchanges cover physical therapy in some capacity, and so do most health insurances from an employer. Pelvic floor physical therapy will be billed the same way as other PT services. Assessing your coverage for PT services will tell you what your copays and coverage would be for your pelvic floor PT as well. PTs we spoke to said copays tend to range from $0 to $10, but up to $60 per visit.

If you see a physical therapist who is not in your insurance network, ask them to provide you with a superbill to send to your insurance provider for reimbursement. You may also be able to use FSA or HSA funds toward your PT costs. Medicaid and Medicare will cover pelvic floor PT too, though sources say finding clinics or providers who accept them can be a challenge. (The American Physical Therapy Association is also working with lawmakers on a bill to expand Medicaid’s coverage of PT for postpartum people.)

If you choose a cash-based PT, they’ll charge you a flat rate per session. The price can vary widely depending on the provider’s education level and your geographic location, ranging anywhere from $150 to $450. The first appointment may also be slightly more expensive, since it tends to take longer.

Whether you want to find a pelvic floor PT who works at a clinic or hospital or someone who is in private practice, experts recommend you start by searching your area using these resources:

• The American Physical Therapy Association (APTA) Pelvic Health PT Locator
• The Women of Color Pelvic Floor Physical Therapist Directory
• Herman & Wallace Pelvic Rehabilitation Institute’s practitioner directory
• Pelvic Guru’s PT locator

While finding a pelvic floor physical therapist often feels overwhelming, especially for women who are caring for a newborn and recovering from birth, it is absolutely worth it. “If someone feels like they don’t have time or energy to pay attention to this because they’re also not sleeping, caring for a newborn, and trying to go back to work, I just want to say it is possible for you to get all of your function back, even if it feels really, really impossible,” says Danielle Robinson, 43, a mom of two in Portland, Oregon, who experienced fecal incontinence and pelvic pain after a birth injury. “It was really hard for me to believe when I was going through it that I would get all of my function back and I wouldn’t be somehow faulty or carry this with me for the rest of my life.”

“It was worth it times a million,” says Helen Bost Karel, 31, who dealt with pelvic organ prolapse after birth. “It literally changed my life.”

What other treatments are available?

Of course, the remedies for your pelvic floor dysfunction depend on your specific condition and there are options beyond therapy. For urinary incontinence, the most common of all PFDs, you can take medications that decrease that “gotta-go” feeling so you’re running to the bathroom less frequently. Your doctor might recommend a catheter or pessary, a small plastic device you insert into the vagina to put pressure on the urethra and hold in urine. There are surgical options too: bladder augmentation or enlargement, if your UI is the product of nerve damage, or sling surgery, in which a surgeon implants a synthetic mesh to better support your organs and relieve incontinence. For both urinary and fecal incontinence, doctors can stimulate nerves in the area electrically to help retrain them to work normally. As for devices, there are several designed to narrow the tissue around the anus. A conversation with your doctor is the best place to start if you want to explore these.

Studies cited:

McCool-Myers, M., Theurich, M., Zuelke, A., Knuettel, H., & Apfelbacher, C. (2018). Predictors of female sexual dysfunction: A systematic review and qualitative analysis through gender inequality paradigms. BMC Women’s Health, 18(1). https://doi.org/10.1186/s12905-018-0602-4

Hagen, S., & Stark, D. (2011). Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd003882.pub4

Smith, C. (2016). Male chronic pelvic pain: An update. Indian Journal of Urology, 32(1), 34. https://doi.org/10.4103/0970-1591.173105

Jelovsek, J. E., Barber, M. D., Brubaker, L., Norton, P., Gantz, M., Richter, H. E., Weidner, A., Menefee, S., Schaffer, J., Pugh, N., & Meikle, S. (2018). Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy for pelvic organ vaginal prolapse on surgical outcomes and prolapse symptoms at 5 years in the optimal randomized clinical trial. JAMA, 319(15), 1554. https://doi.org/10.1001/jama.2018.2827

Experts:

Dr. Tirsit Asfaw, M.D., a urogynecologist at Weill Cornell in New York City

Laura Meihofer, PT, DPT, pelvic health physical therapist in Rochester, Minnesota

Sara Reardon, PT, DPT, WCS, BCB-PMD, board-certified pelvic floor physical therapist and owner of NOLA Pelvic Health in New Orleans, Louisiana

Ryan Simmons, DPT, a pelvic floor physical therapist practicing in Seattle and Mexico

Anietie Ukpe-Wallace, PT, DPT, a pelvic floor physical therapist in Oakland, California