Overview and Introduction to Women's Pelvic Health

Original Editor - Jess Bell based on the course by Ibukun Afolabi
Top Contributors - Jess Bell, Wanda van Niekerk and Kim Jackson

Introduction[edit | edit source]

When introducing women's pelvic health physiotherapy, it is important to understand the distinction between a “women’s health physiotherapist” and a “pelvic health physiotherapist”.[1]

Women’s health physiotherapists typically treat female issues such as:[1]

They may or may not treat pelvic health conditions.

Pelvic health physiotherapists may take a whole-body approach, but they also work directly over the pelvic floor structures.  They may treat men, women, children, and diverse genders.[1]

This page focuses on introducing women’s pelvic health physiotherapy. In particular, it explores:

  • Who do women’s pelvic health physiotherapists work with?
  • Why do they do what they do?
  • How do they best serve women who present with pelvic health concerns and conditions?

Who Do Women’s Pelvic Health Physiotherapists Work With?[edit | edit source]

Women’s pelvic health physiotherapists treat a range of clinical conditions that are classically categorised as:[1]

  • Urological
  • Gynaecological
  • Gastroenterological
  • Oncological
  • Geriatric
  • Surgical
  • Orthopaedic
  • Obstetric
  • Chronic (i.e. persistent pain conditions)

However, these categories are somewhat arbitrary as women might present with conditions that fall into a number of different areas. For instance, a pregnant woman who has vaginismus and pelvic girdle pain would fall into the orthopaedic, obstetric, chronic pain, and gynaecological categories. Pelvic health physiotherapists must, therefore, consider the woman as a whole.[1]

Women might seek pelvic health physiotherapy for a number of reasons, some of which are discussed below.

  • Urinary incontinence
    • An involuntary loss of urine, which affects millions of people around the world[2]
  • Faecal incontinence
    • An involuntary loss of stool (either liquid or solid)
  • Constipation
  • Bladder urgency and frequency
    • Urgency is defined as: "An abrupt, strong, often overwhelming, need to urinate”[3]
    • Frequency is defined as: “Abnormally frequent urination”[3]
  • Bladder  hesitancy / underactive bladder
    • Patients with bladder hesitancy experience “a slow urinary stream, hesitancy and straining to void, with or without a feeling of incomplete bladder emptying and dribbling, often with storage symptoms”[4]
  • Bladder pain
  • Pelvic organ prolapse (POP)
    • Occurs when there is descent of one or more parts of the vagina and uterus, which enables other organs to herniate into the vaginal space (cystocele, rectocele, or enterocele)[5]
  • Chronic pelvic, vulvar or vaginal conditions in women, which include:[1]
    • Polycystic ovarian syndrome (PCOS)
      • PCOS is considered the  most common hormonal disorder in women of reproductive age
      • Individuals experience at least two of the following: irregular periods, hyperandrogenism (i.e. high levels of androgens), and polycystic ovaries[8]
    • Dysmenorrhea / period pain
      • Affects around 75 percent of women during their reproductive life
      • It is particularly common during teenage years and early adult life[9]
    • Interstitial cystitis or painful bladder syndrome
      • A chronic condition that causes pelvic pain, pressure or discomfort that the patient perceives is associated with the bladder
      • Other urinary symptoms associated with interstitial cystitis include a persistent urge to void / urinary frequency without any other cause/condition being present[10]
    • Endometriosis
      • The most common cause of chronic pelvic pain in women
      • It is a complex condition associated with an "estrogen-dependent chronic inflammatory process", which largely affects the ovaries and other pelvic structures
      • Associated with infertility[11]
    • Coccydynia / coccyx pain
      • Has many traumatic and non-traumatic causes
      • Middle-aged women are most often affected, but it can occur in anyone at any age[12]
    • Vulvodynia
      • Vulva pain that occurs during sexual and non-sexual activities
      • Affects 8 to 10 percent of all women[13]
    • Provoked vestibulodynia
      • Vulva pain, localised to the vestibule, which has been present for three or more months
      • There is no clear cause, but pain is provoked by touch and sexual activity[14]
  • Female sexual health concerns, which include:[1]
    • Dyspareunia
      • Dyspareunia is recurrent/persistent genital pain, which is associated with sexual intercourse - both men and women can have dyspareunia, but it is more common in women[17]
    • Primary or secondary vaginismus
      • Vaginal spasms prevent penetration during sexual intercourse[18]
    • Anorgasmia
    • Diminished or painful orgasm
    • Sexual trauma[19][20]
  • Women of childbearing age may present with:[1]
    • Prenatal or pregnancy concerns such as:
      • Low back pain
      • Pubic symphysis or pelvic girdle pain (PGP)
      • Vulvar varicosities
        • Varicose veins of the vulva are dilated veins in the labia majora and labia minora
        • They occur in between 22 and 34 percent of women who have varicose veins of the pelvis and in 18 to 22 percent of women who are pregnant[21]
        • They are linked to venous thromboembolic events, superficial dyspareunia, and vulvodynia, as well as psycho-emotional and social issues[21]
      • Sciatic pain
      • Postural concerns
      • Other orthopaedic conditions
      • Intrapartum care - i.e. during the actual labour and delivery
      • Postnatal care including breastfeeding-related assistance
      • Abdominal rehabilitation
      • Caesarean rehabilitation
      • Fertility challenges
      • Return to sports, athletics and exercise
  • Women approaching or at menopause
  • Women facing cancer rehabilitation, particularly breast and pelvic cancers, may come for:[1]
    • Pain issues
    • Sexual dysfunction
    • Movement therapies
    • Lymphoedema etc
  • Female athletes of all ages who participate in all kinds of sports, but particularly those associated with high load or impact (e.g. running, weightlifting, CrossFit etc)[1]
  • Pre-and post-surgery:[1]
    • Caesarean section
    • Hysterectomy
    • Procedures for prolapse or incontinence
    • Fistula repair
    • Myofascial dysfunction
    • Scarring and adhesions
    • Pain
    • Mobilisation
    • Strengthening etc

Why Do Women's Pelvic Health Physiotherapists Do What They Do?[edit | edit source]

Women around the world experience bias and barriers to healthcare by providers, institutions and systems. They are more likely to be dismissed, have their concerns minimised, or experience delays in getting an accurate diagnosis.[1]

The need for women’s pelvic health care is significant:[1]

  • 1 in 3 women live with urinary incontinence[22]
  • 1 in 8 women experience faecal incontinence[1]
  • At least 50 percent of women aged over 50 years have some degree of POP[23]
  • 30 to 50 percent of surgeries for POP are reported to fail within 5 years[1]
  • 25 to 35 percent of women report that childbirth was traumatic[24][25]
  • 1 in 5 women have pain with sex[1]
  • 64 percent of women report sexual dysfunction in the first year postpartum[26]
  • 10 to 15 percent of women live with chronic pelvic pain[1]

These conditions can affect a women's:[1]

  • Confidence
  • Self-image
  • Mobility and strength
  • Mental, emotional and physical health
  • Participation in activities of daily living, work, hobbies, and social activities
  • Sexual health and freedom
  • Relationships

How Do Women's Pelvic Health Physiotherapists Best Serve Women Who Present With Pelvic Health Concerns?[edit | edit source]

There are many different approaches to clinical care for physiotherapists and other health professionals. Ibukun Afolabi shares ten approaches that she uses in her pelvic health practice:[1]

  1. Biopsychosocialspiritual framework (i.e. a holistic and integrative approach)
  2. A trauma-informed lens
  3. Evidence-based practice
  4. Client-centred care - compassionate, client-directed care using motivational interviewing
  5. Preventative and proactive perspective - particularly during childbirth
  6. Collaborative treatment (i.e. working with the multi-disciplinary team)
  7. Educational approach, including the education of clients, the community, other health professionals and the therapist
  8. Advocacy (for women, health, access, care, etc and teaching clients to advocate for themselves)
  9. Adopting a creative clinician lens
  10. Humility

References[edit | edit source]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 Afolabi I. Overview and Introduction to Women's Pelvic Health Course. Physioplus, 2021.
  2. Pizzol D, Demurtas J, Celotto S, Maggi S, Smith L, Angiolelli G et al. Urinary incontinence and quality of life: a systematic review and meta-analysis. Aging Clin Exp Res. 2021;33(1):25-35.
  3. 3.0 3.1 Wrenn K. Dysuria, Frequency, and Urgency. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 181. Available from: https://www.ncbi.nlm.nih.gov/books/NBK291/
  4. Uren AD, Drake MJ. Definition and symptoms of underactive bladder. Investig Clin Urol. 2017;58(Suppl 2):S61-S67.
  5. The American College of Obstetricians and Gynecologists and the American Urogynecologic Society INTERIM UPDATE: This Practice Bulletin is updated as highlighted to reflect the US Food and Drug Administration order to stop the sale of transvaginal synthetic mesh products for the repair of pelvic organ prolapse. Pelvic Organ Prolapse. Female Pelvic Medicine & Reconstructive Surgery. 2019;25(6):397-408.
  6. Osmosis. Urinary incontinence - causes, symptoms, diagnosis, treatment, pathology. Available from: https://www.youtube.com/watch?v=vsLBApSlPMo [last accessed 25/11/2021]
  7. Medical Centric. Urinary Frequency, Causes, Signs and Symptoms, Diagnosis and Treatment. Available from: https://www.youtube.com/watch?v=j3d4gWHRhZU [last accessed 25/11/2021]
  8. Rasquin Leon LI, Anastasopoulou C, Mayrin JV. Polycystic Ovarian Disease. [Updated 2021 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459251/
  9. Armour M, Parry K, Manohar N, Holmes K, Ferfolja T, Curry C et al. The prevalence and academic impact of dysmenorrhea in 21,573 young women: a systematic review and meta-analysis. J Womens Health (Larchmt). 2019;28(8):1161-71.
  10. Homma Y, Akiyama Y, Tomoe H, Furuta A, Ueda T, Maeda D et al. Clinical guidelines for interstitial cystitis/bladder pain syndrome. Int J Urol. 2020;27(7):578-89.
  11. Bulun SE, Yilmaz BD, Sison C, Miyazaki K, Bernardi L, Liu S, Kohlmeier A et al. Endometriosis. Endocr Rev. 2019;40(4):1048-1079.
  12. White WD, Avery M, Jonely H, Mansfield JT, Sayal PK, Desai MJ. The interdisciplinary management of coccydynia: A narrative review. PM&R: The Journal of Injury, Function and Rehabilitation. 2021; 1- 12.
  13. Bergeron S, Reed BD, Wesselmann U, Bohm-Starke N. Vulvodynia. Nat Rev Dis Primers. 2020;6(1):36.
  14. Henzell H, Berzins K, Langford JP. Provoked vestibulodynia: current perspectives. Int J Womens Health. 2017;9:631-42.
  15. Demystifying Medicine. Pathophysiology of polycystic ovarian syndrome. Available from: https://www.youtube.com/watch?v=BgNpATWfR5Y [last accessed 25/11/2021]
  16. PhysioPathoPharmaco. Painful Bladder Syndrome (PBS) / Interstitial Cystitis (IC). Available from: https://www.youtube.com/watch?v=CWSLWspNg20 [last accessed 25/11/2021]
  17. Arora V, Mukhopadhyay S, Morris E. Painful sex (dyspareunia): a difficult symptom in gynecological practice. Obstetrics, Gynaecology & Reproductive Medicine. 2020;30(9):269-75.
  18. Achour R, Koch M, Zgueb Y, Ouali U, Ben Hmid R. Vaginismus and pregnancy: epidemiological profile and management difficulties. Psychol Res Behav Manag. 2019;12:137-43.
  19. DiMauro J, Renshaw KD, Blais RK. Sexual vs. non-sexual trauma, sexual satisfaction and function, and mental health in female veterans. J Trauma Dissociation. 2018;19(4):403-16.
  20. Sobel L, O'Rourke-Suchoff D, Holland E, Remis K, Resnick K, Perkins R et al. Pregnancy and childbirth after sexual trauma: patient perspectives and care preferences. Obstet Gynecol. 2018;132(6):1461-8.
  21. 21.0 21.1 Gavrilov SG. Vulvar varicosities: diagnosis, treatment, and prevention. Int J Womens Health. 2017;9:463-75.
  22. NHS England. Excellence in continence care: Practical guidance for commissioners, and leaders in health and social care. Leeds: NHS England, 2018.
  23. Yoon I, Gupta N. Pelvic Prolapse Imaging. [Updated 2021 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551513/
  24. Simkin P. Birth trauma: definition and statistics [Internet]. PATTCh. 2020 [cited 25 November 2021]. Available from: http://pattch.org/resource-guide/traumatic-births-and-ptsd-definition-and-statistics/
  25. Soet JE, Brack GA, DiIorio C. Prevalence and predictors of women's experience of psychological trauma during childbirth. Birth. 2003;30(1):36-46.
  26. Khajehei M, Doherty M, Tilley PJ, Sauer K. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med. 2015;12(6):1415-26.