A Comprehensive Guide to Pelvic Floor Physiotherapy
I am SUCH a freakin’ advocate of Pelvic Health and Wellness that this is the second Pelvic Floor 101 Guide I’ve written. I’ve linked the original here, it can be used as a Coles Notes version but if you want to really understand your pelvic floor and the AWESOME relationship you can build with it, keep reading below!
Table of Contents
What is Your Pelvic Floor?
Tasks of the Pelvic Floor
The Dream Team of the Core
Common Pelvic Floor Dysfunction That We Treat
How is a Pelvic Floor Physiotherapist Certified?
What Is Your Pelvic Floor?
Your pelvic floor is a series of muscles housed within your pelvis. Your pelvis is made up of bony scaffolding including your right and left pelvic bones (put your hands on your hips - you’re on ‘em!) and your sacrum (the flat triangle-shaped base of your spine) and tailbone. It is divided into the pelvic inlet and pelvic outlet.
Your hips bones connect in the front at your pubic symphysis joint (or pubic bone) and connect in the back to each side of your sacrum (your sacroiliac or SI joints, you have two of them).
There are three layers of pelvic floor muscles that attach to the pubic bone in the front, the tailbone in the back and our ischial tuberosities (Sitz bones) on either side. They also attach much deeper internally, acting as a ‘bowl of muscles’ within our pelvis.
The perineal body is where the pelvic floor muscles intersect with the perineum at the space between our vagina and our rectum. This is ‘Grand Central Station’ for tissue stretching and accommodation during vaginal birth and a common area of pelvic pain and heaviness because so many structures pass through this area.
Tasks of Pelvic Floor
Pelvic floor muscles have five major functions; they provide:
Support or act as a “ floor” for our organs
Sphincteric control (open and close) of the urethral, rectum and vaginal holes
Stability of the hips, low back, trunk and pelvic girdle
Sump-Pump function of keeping our blood and lymph fluid circulating throughout our body, and on a related note…
Sexual Function: bringing blood in for arousal and preparing our tissues for intimacy.
To summarize, the pelvic floor muscles:
Keep all of our organs on the inside and not the outside, everyone stays in their designated zones
Keeps our pee and poop off of the floor
Keeps our low back, trunk, hips, and pelvic joints healthy, happy, and strong
Keeps our blood and lymph fluid moving and grooving
Helps with pain free sex and improves orgasms and arousal
The pelvic floor works as one piece of an even bigger puzzle which is our entire Core System. Your Core System is like a canister and includes three important muscle groups. These muscles are your Diaphragm, Transverse Abdominis (TvA), Multifidus and Pelvic Floor Muscles. This Core System Canister spans from your ribcage to between your legs and encircles your entire body. The pelvic floor muscles are at the bottom of this can. With only the base of the canister, we can’t do much to feel strong and stable during pregnancy…we need the entire dream team.
The Dream Team of the Core Canister
Diaphragm
The beloved diaphragm is the lid of the canister. The diaphragm is a muscle we use for breathing, with each inhale and moves downwards towards our toes and allows our lungs to fill with air. With each exhale, it moves upwards towards our head and helps ‘push’ the air back out. Get ready to be mind blown because the diaphragm and pelvic floor muscles move in unison with each other! They are best friends that travel up and down together in your body with each breath.
Transverse Abdominis
Transverse Abdominis (TvA) make up the walls of your canister. When we inhale, our diaphragm muscle pulls air into our lungs. Our pelvic floor and TvA muscles should respond to the pressure of every inhale by relaxing. On exhale, your pelvic floor and TvA muscles should gently contract to assist in pushing air back out of the abdomen.
Think of this in action as the softening/expanding of your belly and lowering/relaxing of your pelvic floor on inhale, and the contracting/inward movement of your belly and contracting/rising movement of your pelvic floor on exhale.
Inhale → Belly (TvA) and Pelvic Floor relax and move out
Exhale → Belly (TvA) and Pelvic Floor contract and move in
The diaphragm muscle never stops contracting and relaxing, and neither should the TvA or pelvic floor muscles.
Multifidus
Think of the multifidus muscle as the guide wires that they use on super tall skyscrapers. There are many multifidii and they all attach to the spine to add segmental stability. Just like a guide wire could help support a skyscraper in a slight breeze, they can help our spine feel stable and balanced for tiny movements or still standing. But if Godzilla is climbing up that tower, the guide wires are too small to create any real support. Similarly, the multifidii aren’t designed to do major stabilization, that’s why they work with TvA (who is down for that job).
It’s this team of muscles working together in a coordinated way that keeps our core and pelvic floor canister system strong, stable, and functional. A functional system supports continence (not peeing or pooping ourselves), your abdominal and pelvic organs (keeping them up inside of us), and breathing.
When this canister system stops working, for example the activation of these muscles are absent, delayed, too much or not enough and we see poor coordination between muscle groups. This can be caused by pain, pregnancy, trauma, surgery, childbirth, lifestyle changes, chronic illnesses, etc.
Common Pelvic Floor Dysfunctions That We Treat
Urgency Incontinence
Mixed Incontinence
Fecal Incontinence
Constipation
Pelvic Pain
Vaginismus
Vulvodynia
Vestibulodynia
Overactive Bladder
Interstitial Cystisis
Bladder Pain Syndrome
Endometriosis
Adenomyosis
Dyspareunia (Painful Penetration)
Dysmenorrhea (Painful Periods)
Pelvic Girdle Pain
Persistent Genital Arousal Disorder (PGAD)
Post -Pelvic Cancer Rehab
Prenatal Fitness Programming
Postnatal Fitness Programming
Prenatal Pelvic Floor Care and Birth Preparation
Chronic low back pain and hip pain and tension
Pudendal Neuralgia
How is a Pelvic Floor Physiotherapist Certified?
Pelvic floor physiotherapists are Registered Physiotherapists who have undergone extensive training after their 4 years of university undergraduate program and their 2 years Masters program. There are several governing bodies that train Physiotherapists, as well as Chiropractors, Naturopaths and Medical Doctors in pelvic floor therapy. The biggest difference between a Physiotherapist and a Pelvic Floor Physiotherapist, is that a Pelvic Floor Physio is trained in internal examination of the pelvic floor muscles and structures and organs.
The training involves classroom learning and hands-on practical labs (yes, we practice on each other before ever working with a patient!) After completing the certification, we roster with our professional regulatory body (for me, this was the College of Physiotherapy of Ontario and the Canadian Physiotherapy Association). Rostering is essential for ‘controlled acts’ such as Pelvic Floor Physiotherapy, Acupuncture and anything else that requires additional training.
I trained through Pelvic Health Solutions, which is an Ontario based organization that hosts courses for professionals in the pelvic health field. I also have a special interest in women’s fitness and the connection between exercise and movement and pelvic floor therapy. I then went on to complete several courses that tie together pelvic floor therapy and movement/exercise including:
Brianna Battles: Pregnancy and Postpartum Athleticism Coaching
Julie Wiebe: Women’s Sports Medicine and Fitness, Treating and Training the Female Runner
How to Find a Pelvic Floor Physiotherapist
If you’re looking for a pelvic floor pt and not local to Durham or Clarington, Ontario then I suggest using one of these directories to find a pelvic floor pt near you:
Pelvic Health Solutions Practitioner Database: https://pelvichealthsolutions.ca/find-a-health-care-professional
Pelvic Guru and the Global Pelvic Health Alliance: https://pelvicguru.com/directory/
Institute of Clinical Excellence Find a Clinician: https://ptonice.com/find-a-clinician/
(US Patients) APTA Pelvic Provider Directory: https://aptapelvichealth.org/ptlocator/
Who Needs Pelvic Floor Physiotherapy?
At Flow Physio + Wellness, we treat all women with pelvic floor dysfunction. Women health therapy encompasses care all along a lifespan - from childhood bedwetting and constipation, to painful periods, to pregnancy and postpartum to menopause and beyond!
There are many pelvic floor conditions as well as common (but not normal to just ‘live with!) signs & symptoms that women may experience during the seasons of their lives and we are here every step of the way to help you navigate them - nothing is TMI with us!
Have you ever said any of the following?
“I just laughed/sneezed/jumped/coughed and I peed my pants!”
“I have no idea how to exercise safely while pregnant!”
“My bladder is the size of a walnut!”
“I have to go pee before my workout!”
“Sex has just been painful/not great ever since having a baby”
“I have a weak core”
“I can’t leave the house without wearing a panty liner now”
“I have to avoid a lot of movements in the gym like jumping, running, skipping because of leaking and/or pelvic heaviness”
“It feels like something is falling out of my vagina!”
“I have to pee every time I go somewhere in the car!”
“I want to prepare my body and my mind to have the most positive birth experience possible”
“I want to do everything I can during pregnancy to optimize my healing postpartum!”
“I go poop every 2+ days”
“My posture has never felt the same since having kids”
“I feel so much heaviness between my legs after prolonged standing, walking, sitting all day”
What Can Pelvic Floor Physio Help You With?
Here is a list of feelings, emotions and situations that I can help improve in women’s lives:
Feeling empowered in her body and how she uses it
Feeling confident in trusting her core and pelvic floor
Feeling in-tune with her breathing and how it affects her nervous system, resting state and pelvic floor
Feeling coordinated when using her core and pelvic floor with movement and exercise
Having enjoyable sex and intimacy with herself and her partner
Having a positive birthing experience
Having a seamless postpartum recovery and healing process
A visible improvement in diastasis rectus abdominis (DRA) symptoms
Leak-free exercise and staying dry with coughing, sneezing, jumping, laughing, running
Feeling confident in doing any physical activity that she wants
Wearing only 1 pair of underwear and no liners every day
Having comfortable periods with minimal PMS symptoms
Managing chronic pelvic pain at home using mindfulness and movement
What To Expect During Your Pelvic Floor Physiotherapy Appointment
A pelvic floor therapy initial assessment is an hour long. During an initial assessment, we will discuss any past medical history, past injuries/traumas/surgeries, current issues or pelvic floor dysfunction.
We will review relevant pelvic anatomy and education on “why you’re feeling what you’re feeling”.
The pelvic health assessment can include the following:
A full body postural assessment
A breathing assessment to check mobility of the diaphragm
A functional assessment of the core and determining integrity of the midline (linea alba)
Assessing stability of the pelvic bones
Assessing mobility and function of the hips
Assessing lumbar spine mobility and joints
An external pelvic floor assessment (observation looking for the presence of pelvic organ prolapse and pelvic floor muscle coordination)
Checking sensation around abdomen and pelvis (if applicable)
Checking integrity of scar tissue and adhesions in abdominal wall and/or pelvic floor (if applicable)
Visceral mobilization (checking movement of the uterus, bladder, ovaries, large intestine)
Internal pelvic floor assessment to check pelvic floor muscle tone, tension, pain, muscle activation and relaxation (if consented to)
Internal pelvic floor assessment to check position of pelvic organs (if consented to)
Lifestyle strategies to implement at home to manage pelvic symptoms
Home exercise programming including a synopsis email and videos sent to you after your appointment to summarize our discussion
A treatment plan including personalized goals and a short term and long term plan
How Many Pelvic Floor Physio Visits Does Someone Need?
This depends so greatly on each woman’s pelvic history, trauma, lived experience and consistency with implementing the ‘homework’ and new strategies on her own at home.
On average, I see women for an Initial Assessment and 4-8 follow up visits. I personally like to space visits out (every 2-3 weeks) to allow lots of time to internalize the learning and practice the homework I give women to work on.
My goal is to create self-efficacy and independence with managing your own pelvic floor symptoms for the long term. I equate it to “I give you the tools for your toolbox and teach you to become the carpenter”.
What Is the Cost of Pelvic Floor Physio?
Pelvic floor physiotherapy is covered under extended health benefits if you are a Canadian resident with a benefits plan through your employer or purchased privately. You can submit your visits with us through ‘Physiotherapy’.
Some insurance companies require a referral from your family doctor, OB, midwife, gynaecologist, urologist, gastroenterologist - the best thing to do is call your insurance provider and ask:
How much physiotherapy coverage you have
If a referral is required to access your physiotherapy coverage
Pelvic floor physiotherapist is slightly more costly than traditional physiotherapy because pelvic floor physiotherapists have invested in further education, training, courses, equipment, insurance associated with this specialized field of care.
Flow Physio + Wellness Pelvic Floor Physiotherapy Fee Schedule March 2023
Initial Assessment (60 min) $170
Pelvic Floor Follow Up (30 min) $115
Birth Prep with Birth Support Person + Pregnant Person (60 min) $160
My Approach to Pelvic Health & Personal Values
When I first began my career as a physiotherapist, I realized there was a huge population of people I could not help. I did not have the understanding, skills, or language to treat women with pelvic floor dysfunction OR women during pregnancy or postpartum. I felt like I was doing women a complete disservice and wanted to make sure I could support these women in a world amidst lots of contradicting information and dangerous myths out there on the Internet.
My values as a physiotherapist are: Empowerment, Education, Movement and Fun! I strive to incorporate each of these while working alongside women to manage their pelvic symptoms and take control over their own pelvic health.
Feeling empowered and confident can have a major positive impact on pain, on symptom management and are associated with better maternal birth outcomes even!
Movement and having fun with movement can also be empowering - feeling like you have control over your body and how it’s feeling and responding helps manage pelvic floor symptoms.
I like to approach pelvic floor physio holistically, through my training we always circle back to how multifaceted pelvic floor symptoms can be. I take a biopsychosocial approach to treatment, meaning that we consider social situations, family support, friend network, physical environment and stressors, workplace demands, coping skills, beliefs around women’s health, beliefs around pain, physiological factors with treatment.
Movement as Pelvic Floor Therapy
As a past strength & conditioning coach, and current perinatal fitness coach and Pilates instructor, I appreciate the importance of movement in treating pelvic floor dysfunction. It can help us manage pain, re-regulate our central nervous system, find confidence in what our body can do, re-train our tissues, mobilize our joints and organs and feels GOOD!
Movement during pregnancy and postpartum has been shown to:
Improve maternal and fetal outcomes
Decrease risk of gestational diabetes
Decrease risk of macrosomia (baby born > 9lb)
Improve pelvic floor and core coordination
Create a positive perception of pregnancy and birth
Reduce risk of PPA and PPD (postpartum anxiety and depression)
I Want To See a Pelvic Floor Physiotherapist - What Are My Next Steps!?
If you’d like to see us at Flow Physio + Wellness, you can make an appointment for a Pelvic Floor Initial Assessment using the link below:
If you’re not local to us, but would still like to chat we do offer Virtual Pelvic Floor Initial Assessments, you can book that using the link here!
If you have further questions, you can reach out directly to me at danielle@flow-wellness.ca.
Certifications and Training
Danielle Ufniak MSc PT
Registered Physiotherapist
Registered Pelvic Floor Physiotherapist
Certified Reformer and Mat Pilates Instructor
Pregnancy and Postpartum Athleticism Coach
Certified in Contemporary Medical Acupuncture
Author of ‘Empowered Mama: A 52-Week Pregnancy Guide and Reflection Journal to Prepare Your Mind and Body For Your Bump, Birth, Postpartum + Beyond’
Owner of Flow Physio + Wellness
Pelvic Health Solutions Level I: Introduction to Internal Treatment of the Pelvic Floor October 2016
Pelvic Health Solutions Level II: The Role of Physiotherapy in the Treatment of Anyone Through a Trauma-Informed Lens November 2016
Pelvic Health Solutions Level III: Management of Chronic Pelvic Pain November 2016
Julie Wiebe: Women’s Sports Medicine and Fitness November 2016
Julie Wiebe: Treating and Training the Female Runner November 2016
Pregnancy, Pelvic Girdle Pain, and the Pelvic Floor July 2022
Caesarian Birth & Rehabilitation March 2023
Labour & Delivery: Maternal Support Through Comfort Measures and Pelvic Biomechanics September 2022
The Evil Triplets of Pelvic Pain: Endometriosis, Dysmenorrhea, Irritable Bladder Syndrome August 2022
Antony Lo: The Female Athlete May 2019
Brianna Battles: Pregnancy and Postpartum Athleticism Coaching April 2020
Practicing physiotherapy since 2014
Practicing pelvic floor physiotherapy since 2016