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When to Refer to a Pelvic Floor Physical Therapist

by Brianne Carroll, PT, DPT



The All – Important Subjective History

In conjunction with their evaluation, every patient should receive a systems screen, including the all-important subjective history. The subjective history gives patients the opportunity to voice their concerns, and guides the PT’s questions, assessment and treatment. A thorough systems review helps PTs make a differential diagnosis, refer patients to appropriate physicians or PTs and help get to the root of the problem.

In a systems review, patients might divulge a history of complaints of low back pain, frequent UTIs, IBS or constipation—all of these issues can be treated in Pelvic Floor Physical Therapy (PF PT). Consider the “red flag questions” for low back pain—most of the time patients don’t have saddle anesthesia, urinary retention and bowel and bladder incontinence that merits an emergency situation, but these questions can lead to a conversation about bowel and bladder function with these patients and reveal dysfunction. Some patients might report low back pain in conjunction with a sensation of bulging or dropping, with symptoms worse in standing—possibly indicating pelvic organ prolapse—also a PF PT diagnosis. Read on and consider if you have any patients that might benefit from a referral to PF PT.

Chronic pulmonary conditions 

Studies have also found that respiratory dysfunction is often associated with pelvic floor and lumbar spine dysfunction (Smith et. al 2006) and that breathing difficulties, urinary incontinence (UI) and allergies are more associated with LBP than inactivity and obesity. These studies are beginning to demonstrate the connections between respiration and pelvic floor function. 

  • In normal respiration, upon inhale, the diaphragm shoulder descends, the pelvic floor relaxes and on exhale, it ascends and the pelvic floor contracts. 
  • This is because the thoracic and abdominal cavities are a pressure system—described a soda can model by Mary Massery. The top is the glottis of the throat, the diaphragm, a pressure regulator, divides the thoracic and abdominal cavities and the base of this soda can is the pelvic floor.

Persistent coughing is repeatedly, increases in intra-abdominal pressure, and can weaken the pelvic floor. Often, UI is under-reported in these populations. Asking pulmonary patients if they have trouble controlling their urine while they cough, laugh or sneeze can determine the need for a PF PT referral.  This is why research has shown high instances of pelvic floor dysfunction in patients with chronic pulmonary diseases. When a patient has a past medical history of Cystic fibrosis or bronchiectasis, PTs should ask about PF function—pain, incontinence, control, bowel or bladder symptoms. Informing these (and all) patients that while“leaking” might be common, doesn’t mean it’s normal or that they’re stuck with it. Many PTs suggest a prophylactic referral to help prevent issues even if none are currently present.  

A history of abdominal surgery

Whether it was a caesarian section (c-section), a hysterectomy, oophorectomy, removal of the gall bladder, appendix or a colon resection, abdominal surgery can create scar tissue, reduce myofascial and visceral mobility and create complications for patients post-op.  Pelvic floor PTs assess scar mobility, visceral mobility and respiratory function. Abdominal scars can interfere with normal breathing patterns, and when breathing is affected, so is the pelvic floor. Issues with pelvic floor stability and control can create dysfunction in the lumbar spine, hips and lower extremities as well.

Painful Sitting

Coccydynia (a.k.a. painful sitting) is a fairly common patient complaint. It can be caused from a direct trauma like a fall, especially common with sports like snowboarding and horseback riding.  It can also be caused by prolonged sitting on a hard, narrow surface (think spin bikes), degenerative changes to the joint and vaginal child birth, and is implicated in chronic pelvic pain. 

Your patient may complain of difficulty sitting in general, or on a bicycle.  Painful transitions from sitting to standing are also common. Coccydynia typically involves dysfunction in the layer three muscles of the pelvic floor, including the levator ani and coccygeus. For these reasons you should consider a referral to PF PT. Pelvic floor PTs are trained on releasing muscle attached to and surrounding the pelvic floor, both internally and externally.

Sometimes pain with sitting is due to vulvodynia, or pain over the vulva, and can also be worse with sitting, tight fitting clothes and sexual intercourse. These patients are also candidates for PF PT. 

Hip Pain

PTs treat hip pain all the time, everything from osteoarthritis, labral tears to groin strains and more. However, sometimes symptoms don’t resolve despite your best efforts.  Hip muscles can refer pain to the pelvic floor, and down the leg. 

  • The obturator internus is one of these muscles. An OI spasm can present with ipsilateral posterior thigh pain, chronic hip pain or pelvic pain, as well as pain in the vagina or penis and the rectum. Bear in mind, many (if not most) patients will not volunteer this information, nor recognize the link between these symptoms. As PTs it is important that we are knowledgeable enough to investigate symptoms to make appropriate referrals.
  • Adductor trigger points can present with deep groin pain, antero-medial thigh pain and pain extending to the knee. Consider a patient with a diagnosis of mild hip osteoarthritis who is not improving with PT. Lingering complaints of groin pain, limitations in adductor mobility PF PT could point to an adductor restriction—a PF PT  referral could benefit your patient. PF PTs can release adductor spasms both internally and externally as well.  
  • Patients with pubic symphysis separation are also candidate for PFPT—the muscular and fascial connections between the pelvic floor and hip are elaborate.  Many times this occurs during pregnancy, or following a trauma. Patients often complain of pain with walking, stair negotiation, single leg stance and rolling over in bed—often unable to lie on one or both sides. Pain can be present in the low back, hip, perineum or midline over the pubic symphysis. 

Diastisis Recti Abdominus (DRA) 

The Rectus abdominus muscle bellies are jointed by the linea alba. A diastasis is a separation of these muscle bellies, however, whether or not it is the cause of dysfunction is under debate. However, most PTs feel the primary issue with a DRA is load transfer—does the separation create pain or dysfunction with bending, lifting, standing or transferring? DRA has been associated with pregnancy and many pelvic dysfunctions, but causation has not been determined.  The muscles of core stabilization and the pelvic floor are closely linked, and can improve core stabilization, its complications and help reduce the separation for functional and cosmetic purposes. 

Good clinicians know what they know, what they don’t and also who can help fill in the gaps. Building good relationships with coworkers and peers can improve outcomes for patients.   Find a trusted Pelvic Floor PT and consult with them if you think your patients could benefit from it.

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