Overview and Introduction to Women's Pelvic Health

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

Introduction

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”.

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

• Breast rehabilitation
• Lymphoedema
• Osteoporosis
• Fibromyalgia
• Eating disorders

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.

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?

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

• 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.

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
• 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”
  • Frequency is defined as: “Abnormally frequent urination”
• 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”
• 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)

• Chronic pelvic, vulvar or vaginal conditions in women, which include:
  • 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
  • Dysmenorrhea / period pain
    • Affects around 75 percent of women during their reproductive life
    • It is particularly common during teenage years and early adult life
  • 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
  • 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
  • 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
  • Vulvodynia
    • Vulva pain that occurs during sexual and non-sexual activities
    • Affects 8 to 10 percent of all women
  • 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

• Female sexual health concerns, which include:
  • 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
  • Primary or secondary vaginismus: Vaginal spasms prevent penetration during sexual intercourse
  • Anorgasmia
  • Diminished or painful orgasm
  • Sexual trauma
• Women of childbearing age may present with:
  • 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
      • They are linked to venous thromboembolic events, superficial dyspareunia, and vulvodynia, as well as psycho-emotional and social issues
    • 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:
  • 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)
• Pre-and post-surgery:
  • 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?

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.

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

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

These conditions can affect a women's:

• 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?

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. 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