I have a very special post for you this month! For the first time ever, I’m welcoming some guests to the blog! Ever since I went to the Pelvic, Obstetric and Gynaecological Physiotherapy conference in Cardiff, I have found myself recommending pelvic physiotherapy to more people. I didn’t know much about it before that event, but being there and speaking with so many specialists made me realise what a valuable resource it can be for people with pelvic pain disorders. I’ve never actually had pelvic physiotherapy myself – until I read ‘The Interstitial Cystitis Solution’ by Nicole and Jesse Cozean, I was actually quite sceptical about it – but the things I’ve read and heard over the last few years have completely changed my opinion of it. It was thanks to that book and to the aforementioned conference that I plucked up courage to try the EZMagic wand for my own Persistent Genital Arousal Disorder.

Rather than write a post about pelvic physiotherapy myself, my plan was to call some of the people who were at the conference and see if any of them wanted to write a guest blog for me. However, I recently woke to an email from a two pelvic physiotherapists who were interested in some Desert Harvest practitioner samples and I seized the opportunity to ask them to do it instead! It is thus my great pleasure to introduce you to Laura Maleh and Farhana Sonday, our first ever guest bloggers, who have kindly answered all the questions I asked on your behalf! (In the interest of professional pride, I want to point out that of course I already knew the answers to some of them!)

What sort of conditions might a pelvic physiotherapist treat?

Pelvic health physiotherapists are specially trained to assess and treat conditions such as incontinence of the bladder or bowel, pelvic pain and sexual dysfunction, as well as pregnancy-related musculoskeletal and postnatal conditions. These can include:

• Bladder dysfunction in women and men - urinary incontinence, overactive bladder and voiding dysfunction (difficulty emptying bladder)
• Prolapse - pelvic organ prolapse in women and rectal prolapse in men
• Bowel dysfunction in women and men - bowel incontinence and bowel evacuation disorders such as constipation
• Sexual dysfunction in women and men - pain with sexual intercourse and erectile dysfunction
• Prostate cancer - pre and post prostatectomy
• Chronic pelvic pain - bladder pain syndrome, vaginal and/or vulval pain, groin pain
• Prenatal and postnatal musculoskeletal disorders, including lower back and pelvic girdle pain, diastasis of rectus abdominis (tummy separation), as well as carpal tunnel syndrome

I know a lot of readers are going to be particularly interested in the role of physiotherapy in addressing interstitial cystitis. Can you talk a bit more about that? And will treatment aggravate interstitial cystitis at all – should people expect a flare after a session, or should they expect to get worse before they get better?

Many people suffering from interstitial cystitis have pelvic floor dysfunction. Physiotherapy can help in several ways. Manual therapy might be administered to the tight muscles, which might include both internal and external soft tissue and myofascial release. The practitioner might recommend that you also use a therapeutic wand such as the EZMagic pelvic wand to do daily self-massage at home. Electrical stimulation and/or biofeedback might be used and pelvic floor exercises might be recommended. These can be either relaxation exercises or strengthening exercises, depending on your needs. Physiotherapists might also teach breathing techniques and techniques to ensure that you empty your bladder properly, along with bladder retraining to decrease urinary frequency. Finally, they might give dietary advice to help avoid bladder irritation and constipation.

Manual therapy can be a bit painful; however, you are always in control of the session and the physiotherapist can adjust their pressure to make it more comfortable for you. As with all manual therapy techniques you may feel a bit tender after a session, but this usually eases quite quickly.

Can you also talk a bit about the role of pelvic physiotherapy in vulvodynia and similar conditions?

Vulvodynia is chronic or recurrent, unexplained pain in the vulva, including the skin surrounding the opening of the vagina. The pain can occur spontaneously or when the vulva is touched. The ongoing pain can cause significant distress and anxiety and can affect sexual relationships. Vulvodynia patients usually have overactive pelvic floor muscles. Some women also have problems such as vaginismus, interstitial cystitis, painful periods and irritable bowel syndrome (IBS).

• Physiotherapy may include:
• Education about your anatomy and understanding your pain
• Advice regarding pain-relieving and moisturising lubricants, for example Desert Harvest Releveum or Desert Harvest Aloe Glide
• Breathing techniques
• Pelvic floor relaxation (like reverse Kegels)
• Internal and external manual therapy (including myofascial and soft tissue release, trigger-point pressures)
• Manual therapy to surrounding joints and muscles such as the lumbar spine, SIJ and pelvis
• Possible use of biofeedback
• Stretches
• Home program including the use of progressive vaginal dilators, a therapeutic wand like the EZMagic or EZFit, manual stretching of the vaginal tissue and lower body/ hip stretches and exercises
• Recommendations to try CBT, mindfulness or other talking therapies

I believe pelvic physio is something that could be useful in persistent genital arousal disorder. However, because this is such an unusual condition, many practitioners have never encountered it in real life before. Sometimes they prescribe Kegel exercises, which can be very aggravating for PGAD patients. If a PGAD patient has a physio who prescribes Kegel exercises, what should they do?

You’re absolutely right, the condition is not very common and very little is understood about it. In some cases, it seems that the PGAD is due to over-firing of the pudendal nerve (a nerve which supplies the pelvic floor muscles), leading to pelvic floor over-activity. If Kegel or pelvic floor strengthening exercises are prescribed, this will likely exacerbate the situation. Instead, pelvic floor relaxation exercises should be done, as well as manual therapy techniques for the pudendal nerve.

If your physio prescribes strengthening exercises for this condition, it would be worth discussing this with them and asking them if they have sufficient experience in treating the condition or have sufficient knowledge thereof. It is important that you feel confident in your therapist!

As with vulvodynia, treatment for PGAD also involves manual therapy, self-massage, breathing and relaxation techniques and lifestyle advice. Often treatment may include medicine or nerve blocks prescribed by a doctor, as well as talking therapies.

If a woman comes to you with a genitourinary pelvic pain disorder, what should she expect at her first session? How long does the appointment take and what actually happens? (I think the thing we want to know, but are worried to ask is: do you actually perform any internal physio? A lot of people are confused about whether the practitioner actually does it, or whether they give the patient instructions to carry out on themselves at home!)

The first session will be an assessment which lasts 45-60 minutes. We’ll ask you many questions, including any symptoms regarding your sexual, bladder and bowel function and pain. Yes, we do actually perform internal physiotherapy! With your consent, part of our assessment will involve an internal vaginal examination. You can withdraw your consent at any time – if anything is too painful or uncomfortable, or if for whatever reason you want us to stop, this is not a problem at all. We can also adjust the pressure we are using to make you feel more comfortable.

With manual therapy to the pelvic floor muscles, part of your treatment may involve the physiotherapist using their finger or a therapeutic wand internally to release tension in the pelvic floor muscles and showing you how to do this at home. It is important that you actually do the home treatment, as physiotherapy alone won’t resolve your symptoms!

We may also do external manual therapy where needed. This could be joint and muscle mobilisations around the lumbar spine, pelvis, hips and SIJ.

Obviously things are going to be a bit different for male patients – can you talk a bit about what a man can expect at his appointment?

As with women, most pelvic health conditions in men involve pelvic floor dysfunction (either weakness or over-activity). Whereas with women we would assess the pelvic floor muscles vaginally, with men we do this rectally. In some cases, if a man is too uncomfortable for a rectal examination, we can use real-time ultrasound on the abdomen which allows us to view the bladder and assess pelvic floor function. It is also a great tool to provide biofeedback.

Treatment is fairly similar. We will do certain techniques on men and then show them how to do this at home. Treatment may include:

• Education and advice
• Breathing techniques
• Pelvic floor relaxation or strengthening
• Internal and external manual therapy (including myofascial and soft tissue release, trigger-point pressures)
• Possible use of biofeedback and/or electrical stimulation
• Teaching men how to use a therapeutic vacuum pump for erectile dysfunction
• Home program and exercise

Am I allowed to bring a chaperone to my appointments?

Pre-COVID, yes you were allowed to bring a chaperone such as a family member with you to an appointment. Unfortunately, this is not possible at present due to health and safety. However, when we conduct an internal examination, we will always ask you if you would like a chaperone present. If this is something that you would like, we can arrange for another healthcare professional to be present for this.

I know a lot of people are going to be worried that they might pass some urine or wind during their appointment. Can you say something about that?

We are aware this can happen during an examination and know this is a big concern and fear for many people. Please be assured, we are there to not pass any judgements, and most of all we are there to help and support you!

How many sessions should a person expect to have before they start to see results? And how often should they see their physiotherapist?

This varies greatly between NHS and private practice. It also depends on your condition and your goals. This, along with your expectations, can be discussed at your initial consultation with your physiotherapist.

Do patients reach a stage where they no longer need physiotherapy, or do they have to come back for ‘top up’ sessions every so often?

Again, this is dependent on your condition. Generally, once you reach a stage of self-management and a reduction in your symptoms, your physiotherapist will discharge you from their care. Sometimes, you can be placed on an open appointment, which means you can contact your physiotherapist for a follow-up appointment for a certain amount of time after you have been discharged.

How can I access a pelvic physiotherapist? Do I get referred by my GP, or is it something I organise myself?

There are many ways to access a pelvic health physiotherapist. You can visit your GP and be referred to your local NHS Hospital. If you are pregnant, your midwife or your consultant can refer you to the team as well.

For appointments in a private clinic, a GP or Consultant referral is not required. You can self-refer. However, if claiming through insurance, you need to clear this with your provider.

If you have access to the internet, you can find private and some NHS physiotherapists online using the multi-award winning Squeezy app or via the POGP website. These are really useful directories that you can search via location/postcode.

How much does it cost?

NHS treatment is free. Private pelvic health costs vary from clinician to clinician and from private clinic to private hospital.

What training do pelvic physiotherapists have? Are they qualified in ordinary physiotherapy as well, or do they do different training from the start?

Pelvic health physiotherapists do a degree in physiotherapy. To specialise as a pelvic health physiotherapist, they will go on external specialist courses to further their knowledge on bladder, bowel and sexual dysfunctions, for example.

That’s lovely, thank you! And suppose readers would like an appointment with one of you in particular – how can they find you?

We work together at the private Hospital of St. John and St. Elizabeth in London – you can find the physiotherapy department here, or you can email physiotherapy@hje.org.uk or telephone 0207 806 4010. Laura also works in the NHS at The Royal London Hospital. Farhana has a private clinic called PhysioReform in Marylebone and Fulham which you can find here. Laura has pages on Instagram and Facebook called pelvic_physio_laura. You’ll only be able to look at those if you have Instagram or Facebook yourself. We’d be happy to see any of your readers who happen to live in the London area – do tell us if you came to us after reading this guest blog!

Big thank you to Laura and Farhana for their time in answering those questions so thoroughly. I hope I asked the sorts of things you wanted to know and I hope you found having guests on the blog nice for a change! I know I did – it was nice to sit back and let someone else do most of the writing! 

Until next time,

Tiny x

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