So you’ve finally identified your particular symptoms as a pelvic floor issue and gone through the process of finding a therapist. What happens next? Whether you’re dreading your first pelvic floor physical therapy (PT) appointment or just ready for someone to finally, actually help you, it’s normal to have big feelings about this process. Is the therapist really going to put their hands in you and do a whole pelvic exam? Is it painful, embarrassing, or awkward? Fear not: Your therapist’s entire job is to make you feel comfortable.
When you get to your first PT appointment, which will last about an hour, you’re going to be answering a lot of questions. Your therapist will ask about what symptoms you’ve been experiencing, what interventions you’ve already tried, and what tends to make your symptoms better or worse. Think: Does drinking caffeine make your urinary incontinence worse? Does your pelvic pain flare up before your period starts? Hearing this from you, in person, will help your therapist immensely, and it might feel good for you, too, to tell someone who understands.
“My physical therapist was one of the first people to listen, to hear me,” says Jaime, 41, who has endometriosis. “We did a very thorough consultation. I don’t even know how much actual physical therapy took place that day because the consultation was so thorough. She reviewed all of my documentation that I filled out prior to the appointment, but she wanted to hear it from me. I did not feel rushed; I felt validated. I felt as though someone understood what I was going through and like I wasn’t crazy. Like, no, this is very real pain.”
After your therapist gets your full history, they might do a few different exams, like assessing your posture and gait. This is probably when they’ll recommend doing a pelvic exam. Since the pelvic floor can’t be seen, a manual exam is the best method therapists have to understand exactly what’s happening in your body. That said, they only perform an internal exam with your explicit consent before and throughout (and some therapists prefer to put it off until you’ve had a few more appointments together to build a relationship).
Exams usually happen on a treatment table (no stirrups), where you are dressed from the waist up and covered with a sheet from the waist down.
If you’re worried about pelvic floor therapy being embarrassing or painful, remember that therapy is meant to relieve your discomfort, never to make it worse.
“If you’re not ready for an internal exam or don’t feel comfortable with one, then we’re not going to do one,” says Andrea Freeman, a doctor of pelvic floor physical therapy at Sutter Health Alta Bates Summit Medical Center in Oakland, California. “Every therapist is aware that it may take one, three, even 10 sessions before the patient lets us put our hands on them, let alone inside them. Be up-front with what you feel. If you can just share that ‘It took me a while to get here,’ ‘I’m scared to be here,’ or ‘I’m embarrassed,’ I think that always helps because then we can be more sensitive.”
The first phase of the pelvic exam will be external, says Laura Meihofer, a board-certified doctor of physical therapy in Rochester, Minnesota. “I look at the vulva, perineum, and rectal area and I ask them to do different contractions and relaxations to see range of motion. I push gently (as if I’m pushing around your eye) on 10 different spots externally through the pelvic floor to see if the muscles are tight, tender, or inflexible. Then I will use a Q-tip to separate the labia and check for any skin sensitivity,” she says.
During the internal portion of the exam, using a gloved hand and lubricant, Meihofer places her finger in the vaginal opening to the first knuckle, pressing around gently to find any points of tension or discomfort. She repeats the process at the second and third knuckle, and with her finger fully inserted, walks the person through some pelvic contractions and relaxations. If there is any physical discomfort along the way, or the person being examined wishes to stop, the exam ends immediately.
If you’re worried about pelvic floor therapy being embarrassing or painful, remember that therapy is meant to relieve your discomfort, never to make it worse. “It should never, ever, ever be painful,” Meihofer says. She communicates with her patients throughout the session and says if their discomfort rises above a three out of 10, that tells her she needs to modify what she’s doing.
“PT is not even close to how uncomfortable a pap smear is, in my opinion,” says Bailie, 29, who also has endometriosis. “Most people seek pelvic floor PT because of pain and the anxiety around that pain, and these therapists know that, so they are very considerate. They talk to you before they do anything. She’ll say, ‘OK, you’re going to feel me touch your leg right here,’ so that you’re not startled.”
Every therapist we spoke to agreed that you will never be forced to undergo an internal exam, or do anything you’re uncomfortable with for that matter, while at pelvic floor PT. Each of them says they ask for verbal consent before doing exams and throughout, and you can revoke your consent at any time. They want to create a safe space for you so you can focus on healing your pelvic floor.
“In all my years of practice, 99% of the time people say, ‘Oh, my God, I was so scared to come here, and now I’m leaving this very first visit feeling so empowered, so energized.’ It's often very different for people than what they've experienced when they’ve gone to the physician,” says Meghan Markowski, a pelvic health physical therapist at Brigham and Women’s Hospital. “You want to feel like somebody understands you and not like ‘I’m the only person putting my finger in my anus to get the poop out.’ Actually, people have to do it all the time, we know that, and we’re going to see what we can do to get you to not have to do that.”
Andrea Freeman, PT, DPT, PRPC, pelvic floor physical therapist at Sutter Health Alta Bates Summit Medical Center in Oakland, California
Laura Meihofer, PT, DPT, pelvic health physical therapist in Rochester, Minnesota
Meghan Markowski, PT, DPT, WCS, BCB-PMD, pelvic health physical therapist at Brigham and Women’s Hospital in Boston, Massachusetts, board-certified in women’s health physical therapy and biofeedback for pelvic muscle dysfunction