Treatment Highlight: Internal Pelvic Floor Manual Therapy

Over the past week, and really the past year, the cases of sexual abuse and assault perpetrated by Larry Nassar, a medical doctor with MSU and USA gymnastics, have rocked the nation. The horrific abuse he inflicted on well over 150 young women, under the guise of “appropriate medical intervention” is deplorable, and I know many of us were glad to see him held accountable for his actions with both the verdict and sentencing last week.

In the pelvic PT world, this hit very close to home, and made all of us completely infuriated. For this person to take a completely valid, evidence-based and extremely beneficial treatment technique, and contort it into being an avenue for abuse was unfathomable to those of us who have dedicated our careers to helping men and women with pelvic floor problems. Several colleagues have spoken out about this. Particularly, Lori Mize, the incoming Vice President of the Section on Women’s Health, wrote an excellent post for the Huffington Post, that I would strongly encourage you to read.

Over the next year, I want to highlight a variety of treatment techniques used in pelvic floor physical therapy to help you better understand treatment options, and hopefully alleviate some fear that some of you may have about “the unknown.” In light of these current events, I thought it would be meaningful to start by discussing internal manual therapy techniques for the pelvic floor muscles.

What is it?

Internal manual therapy techniques are a treatment used for someone who has overactive, tender and/or shortened pelvic floor muscles. Before we get started, if you want to better understand the anatomy of the pelvic floor, check out this post by my friend and colleague Tracy Sher. Tender or overactive pelvic floor muscles can occur when someone is experiencing problems like pelvic pain, painful sexual intercourse, tailbone pain, as well as urinary or bowel dysfunction.

These techniques are performed either vaginally or rectally by a skilled medical practitioner who has undergone advanced training to learn to evaluate and treat the pelvic floor muscles. They are only performed once the patient has been thoroughly educated about the treatment techniques and consents to participating in the treatment.

What does treatment involve?

The goal of internal manual therapy is to improve the relaxation, lengthening and tenderness of the pelvic floor muscles. Generally, the patient is first positioned comfortably in either hooklying (on their back with knees bent, sometimes resting on a pillow– yep, no stirrups needed!), sidelying or sometimes on their stomach, depending on what position is preferable to the patient and allows the therapist access to the tissues being treated. The therapist then places one gloved finger within the vaginal or rectal canal and gently presses on the muscles of the pelvic floor to identify (with constant feedback from the patient) where the muscles are tender or uncomfortable. Manual therapy techniques then can be performed to help improve the tenderness of these muscles and promote relaxation and lengthening. These techniques can include:

  • Holding gentle pressure while the patient focused on relaxing and breathing
  • Holding gentle pressure while the patient performs a contact/relax of the muscles or a pelvic floor bulge.
  • Holding gentle pressure while simultaneously pressing with the opposite hand on a point around the pelvis to produce slack in the muscle (a modified strain counter strain technique.
  • Sweeping stretches over the muscle belly

Different therapists have different approaches, but they all are done in complete collaboration and communication with the patient and are modified based on the patient’s comfort and response to the treatment. Personally, I tend to prefer more gentle approaches while also focusing globally on improving awareness and calming the nervous system. This is not a “no pain no gain” situation– in fact, most often we see the best results when we are able to keep pain at a very minimal level.

What type of training should the therapist have?

It is very important that the person performing this treatment has had specialized training in this technique. At minimum, they should have attended an initial continuing education course that teaches a beginner level evaluation and treatment of the pelvic floor, generally weekend course including at least 24 hrs of instruction. Many training programs now include a 3 or 4 course series, and I strongly encourage clinicians to complete the coursework to learn how to comprehensively care for their patients. At Herman and Wallace Pelvic Rehabilitation Institute, the organization I am a faculty member of, we have a 4-course series which includes a level 1, 2A, 2B and Capstone. The Section on Women’s Health has a 3- course series and there are now several other companies offering varying training programs. Of course, I’m biased as a faculty member of H&W and if you’re reading this and work in healthcare in pelvic rehab, you should definitely come to one of my courses!

Who does this treatment help?

As I mentioned above, manual therapy to the pelvic floor is helpful when a person has overactive, tender and/or shortened pelvic floor muscles that are contributing to the problem they are experiencing. This can occur when a person has pain in and around the pelvis or if the person is experiencing urinary, bowel or sexual dysfunction.

We are producing more and more research about these techniques every day, but here are a few snippets:

  • In this study, 50% of the men treated to address chronic scrotal pain saw a significant reduction in their pain.
  • In this study, 93 people were treated with pelvic floor techniques to address coccyx pain (as well as pain after coccyx removal). Overall, they saw an average of 71% improvement.
  • This study compared comprehensive pelvic PT to cognitive behavioral therapy for women with provoked Vestibulodynia. They found that 80% of the women in the PT group had significant improvements compared to 70% in the CBT group.
  • This study evaluated the effects of pelvic floor physical therapy techniques on pain reduction in men who had chronic pelvic pain. Treatment included internal and external techniques and over 70% experienced moderate or robust improvements.
  • This study found that 62% of women experiencing urinary frequency, urgency and/or bladder pain who were treated with physical therapy interventions, including internal manual therapy techniques, reported feeling “much better” or “very much better” following the interventions.

I hope this was helpful and removed some of the fear from this technique! If you think this treatment may be a helpful one for you, talk with your health care provider! As always, I love to answer any questions you may have!


7 thoughts on “Treatment Highlight: Internal Pelvic Floor Manual Therapy

  1. I have been treated by Jessica and her team and can truly tell you first hand that pelvic floor therapy changed my outlook on painful intercourse after a bad hysterectomy and tons of adhesions in my pelvic area. I still have a tiny bit of pain with some positions but overall, so much better. Jessica I highly recommend you to anyone who needs this therapy . Thank you so much

  2. I live in central New Jersey. Is there anyone you could recommend in NY City area or New Jersey for me? My two diagnoses are pelvic floor dynfunction and pudendal nerve neuralgia. Thank you for any help you can offer. I’m desperate.

    1. I’m so sorry you’re hurting Hope! There are many incredible pelvic PTs in that area! I would start with Stacey Futterman or Amy Stein. Both fantastic clinicians! Best of luck in your recovery!

    2. Hey Hope, wanted to find out if you ever found a good OR to address your issues. I’ve never been on this site before today, because my insurance company is limiting my visits for P/T. for this and 3 other spinal issues. The insurance company have so badly that it existed into my lumbar spine. They claim this problem, alone, only gets 4-6 billable 15 minute sessions, which I don’t understand. Having had the problem for at least 10 years, how can they claim this? I’ve found a wonderful P/T facility in central .Jersey where I also live. if you are by some chance still looking, My name is Donna. And you can repost or email me. And I’ll get right back to you. Hope you are ok by now though!

  3. Thank you for your post. After a week of travel on rutted roads in a van with no shock absorbers, also without recycler porty stops, I developed a severe case of Pelvic floor dysfunction. Fortunately, my primary care physician knew what specialist I needed to see. Even more fortunately, the usual urogenital md (who favored surgery to the point of asking in his initial visit questionnaire if I would consider surgery) was on leave so I received initial diagnosis from a female md head of ug in her own hospital whose specialty was treating my disorder. She tested me and told me that in my case that I had three weeks in which to start treatment before it was irreversible by physical therapy. She also provided a list of every OT trained in the treatment in my entire state. I luckily found a PT in my own small town. 6 weeks later I was a new woman, pain free and with a new bathroom protocol to follow to stay healthy. I also formed the resolve to demand potty breaks even while on a tour. As my grandchildren get older I will be sure to discuss proper care of their pelvic floor.
    Thank you for making this info available to all!

    1. Hi Janet- Thank you so much for sharing your story!! I am so glad you were able to see a good pelvic PT who helped you so much!! Keep spreading the news!!! Happy Holidays! ~ Jessica

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