There is growing awareness among health care professionals and the public more generally that pelvic floor physical therapy can help people with pelvic pain, sexual function problems, and bowel and urinary or bladder problems. The challenge is to find the right pelvic floor physical therapist for you. Your doctor or nurse practitioner might refer you to the American Physical Therapy Association website or give you a list of pelvic floor therapists in your area, but then what? Here are some questions to ask a physical therapist to determine if they are the right therapist for you.
Note: everyone should know that a visit to a pelvic floor physical therapist should not be a sexual experience. There is no role for sexual stimulation or activity during a physical therapy appointment. Sexual activity between a therapist and a patient is unethical and prohibited.
1. Do you have any special training to treat pelvic floor problems?
Most physical therapy clinics or practices require that a physical therapist who performs pelvic floor therapy to have specialized training and certification to treat pelvic floor disorders. Two well-established certification programs include the Certificate of Achievement in Pelvic Physical Therapy (CAPP) provided by the American Physical Therapy Association (APTA) and the Herman and Wallace Pelvic Rehabilitation Institute. A physical therapist chooses which certification to pursue, usually influenced by location and cost of the training. Physical therapists may also pursue board certification in Women’s Health Physical Therapy, granted by the American Board of Physical Therapy Specialists. For board certification, a PT must demonstrate proficiency through a combination of clinical care in women’s health/pelvic health, a written board exam, and submission of a case report. These therapists have the designation of Women’s Health Clinical Specialist, or WCS. All physical therapists are also required to participate in a required number of continuing education hours annually to maintain a license. Continuing education keeps the pelvic physical therapist up to date with new treatment techniques and discoveries in the field.
2. What professional meetings do you regularly attend?
People with expertise in pelvic floor physical therapy to treat female sexual function problems should participate in both continuing education activities with other professionals in the pelvic floor physical therapy field and in lifelong learning in the field of female sexual function. The following organizations are a range of examples of some organizations that provide continuing education appropriate for physical therapists working in the field:
- The Scientific Network on Female Sexual Function
- The North American Menopause Society
- The International Society for the Study of Women’s Sexual Health
- The American Society of Reproductive Medicine
- The International Pelvic Pain Society
- The International Society for the Study of Vulvovaginal Disorders
- The Chicagoland Pelvic Floor Research Consortium
- The American Urogynecologic Society
3. Do you treat pelvic floor problems that cause dyspareunia or pain with sexual activity or penetration?
Some pelvic floor physical therapists are exclusively focused on treating pelvic pain and problems like urinary and stool incontinence or constipation. Just like gynecologists and psychologists, for example, not all pelvic floor physical therapists are trained and willing to help women whose primary concern is a sexual function problem.
4. Do you have experience using internal (transvaginal or transanal) pelvic floor physical therapy techniques to help women with vaginismus?
Some pelvic floor physical therapists only perform external treatment and do not have training or skills to perform internal vaginal or transanal pelvic floor physical therapy. Transvaginal and transanal physical therapy skills are important for effective pelvic floor physical therapy for treatment female sexual function problems.
5. Are you comfortable treating women with pelvic floor problems who also are experiencing decreased sensation in the genital area and difficulty with sexual arousal and orgasm?
Some pelvic floor muscle problems cause decreased sensation in the genital area. Decreased sensation may be due to nerve damage from trauma or injury due to labor or vaginal birth, other kinds of groin or back or hip injury, or pelvic floor muscle tightness. Permanent nerve damage is an uncommon cause of difficulty with sexual arousal and orgasm. To make sure you don’t have nerve damage, your physical therapist should be experienced in a thorough evaluation and understanding of the nerves going to the genital area and specialized, personalized treatment of the nerve or nerves involved. Pelvic floor physical therapists are trained to evaluate women for nerve and muscle problems.
6. Do you use any biofeedback tools or techniques? If so, what kind and do you always use them or is the decision personalized to the patient?
The word biofeedback means a way of learning to control your own body functions by seeing or monitoring how your body is working – for example, using a hand mirror to see a bulging out of your vulva when you bear down is a form of biofeedback (see this blog about how an important pelvic muscle works). This method is very useful for muscle retraining to gain strength and to learn relaxation. There are different types of biofeedback that pelvic floor physical therapists use. The type of biofeedback a therapist uses is a decision personalized to each patient.
7. Do you have experience helping women with vaginal dilators?
Vaginal dilators are used in some cases to treat difficulty or pain with vaginal penetration for conditions like vaginismus and vaginal narrowing or scarring after radiation treatments for cancer. A pelvic floor physical therapist is skilled in treating female sexual function problems and is knowledgeable about how and when to use vaginal dilators or make adjustments if they’re not working.
8. Do you have experience treating difficulty with urination, bladder problems and constipation in women with tight pelvic floor muscles?
These other problems commonly occur along with sexual function difficulties in women who are referred for pelvic floor physical therapy. Women can have a weak pelvic floor if the muscles are lax (or stretched out), but also if the muscles are very tight. A pelvic floor physical therapist who treats female sexual function problems should also be capable of evaluating and treating for urinary, bladder and constipation or stool incontinence problems.
9. Do you work with a gynecologist or another medical doctor with expertise in female sexual function?
Physical therapists working in the field of female sexual function typically do have an ongoing working relationship with a gynecologist, physiatrist, family physician or other physician with gynecologic expertise.
10. What should I expect for the evaluation and what is a typical treatment period for a woman with problems related to a tight pelvic floor and vaginismus?
Women seeing a physical therapist for sexual function problems should expect to be asked a detailed history, including sexual and partner history, history of trauma or abuse, history about injury and other health history. Also expect an exam that includes inspection of the vulvar area and an internal vaginal and possibly a trans-anal exam if relevant to your concerns. A thorough examination will also include screening for any problems in the back, hips and pelvis, all of which can contribute to sexual pain.
11. Are there any women you do not treat?
Physical therapy may not be indicated, or may be put on hold, if there are other medical conditions that warrant further assessment or medical treatment prior to participation in physical therapy. For example, a woman with an active infection in the pelvis may need medical treatment prior to initiating physical therapy.
Women who do not have the ability to pay a co-pay or who are uninsured may have limited access to pelvic floor physical therapists. Some therapists offer a limited number of free services or sliding scale services to low-income women. We recommend avoiding therapists (and health care professionals more generally) who have a policy of excluding patients on the basis of their sexual or gender identity or other protected statuses.
12. Are you comfortable treating women with a same-sex partner or no current partner?
The answer should be yes. If it’s not, then find another therapist.
13. How to check if a physical therapist is certified in pelvic floor physical therapy:
To our knowledge, there is no single website or other public resource that provides this information. Usually the best way to learn about a qualified pelvic floor physical therapist is to ask a gynecologist or another physician who commonly refers to these therapists. You can also look at the website where the physical therapist practices. Look for a description of the therapist to learn how many years of experience, areas of special focus or interest and special certifications they have. If this information is not available, it is important to call and ask before you schedule an appointment. In Illinois, where we practice, every physical therapist must be licensed through the Illinois Department of Professional Regulation. It is possible to check on the site to make sure that the physical therapist is currently licensed. Every state has its own licensing board.
If your health care practitioner is not aware of this type of physical therapy, refer to The American Physical Therapy Association Section on Women’s Health to search for a women’s health physical therapist in your area.
For a printable version of these questions, click here.
Thank you to Judy Florendo, PT, Suzanne Badillo, PT, Sarahann Callaway, PT, DPT, and Sarah Macrowski Macaraeg, DPT, for their edits and contributions to this piece.