Pelvic floor therapy

The pelvic floor supports the pelvic organs and controls continence. Like any muscle group it can be weak, overactive, poorly coordinated, or painful — and those four problems need different treatment, which is why the assessment matters more than the exercises.

This is the key point: pelvic floor symptoms are not always caused by weakness. An overactive, tense pelvic floor produces urgency, pain and incomplete emptying, and prescribing strengthening exercises for it makes the symptoms worse.

Stress and urge incontinence, pelvic organ prolapse, pelvic pain, painful intercourse, postnatal recovery including abdominal separation, bowel symptoms, and pelvic floor dysfunction after prostate surgery in men.

It is also part of rehabilitation after gynaecological and colorectal cancer treatment, and in neurological conditions affecting continence.

Assessment first, including internal examination where appropriate and consented to, because that is how coordination and tone are determined. Then a programme combining specific muscle training, biofeedback so the patient can see whether the right muscle is activating, electrical stimulation where activation is very poor, manual therapy where tone is high, and bladder and bowel retraining.

About a quarter of people contract the wrong muscles when told to do a pelvic floor exercise, and many push down instead of lifting 1. This is why a leaflet does not work and biofeedback does.

Supervised pelvic floor training resolves or substantially improves stress incontinence in most women: in a Cochrane review, 74% of women with stress incontinence who trained reported that their symptoms had resolved or improved, compared with 11% in control groups 3. It is recommended as first-line treatment before surgery is considered. Results take three months of consistent practice; there is no quick version 2.

Sessions are private, chaperoned if you wish, and nothing is done without explanation and consent.

Assessment may include internal examination, which is explained fully beforehand and is entirely optional. Treatment can proceed without it where a person prefers, using external assessment and feedback methods.

Nothing is done without explicit consent, and a chaperone is available. Being told this in advance is part of why people who need this treatment actually attend.

Incontinence, prolapse symptoms and sexual difficulty are common after childbirth, after prostate surgery and in neurological conditions, and they are among the least reported problems in medicine.

We ask directly rather than waiting, because untreated these affect activity, sleep and social life more than most of the conditions people do mention.

About one-third of women have urinary incontinence after childbirth 4. For women who are continent when they start, structured pelvic floor training in pregnancy probably helps: in a Cochrane review, it lowered the risk of reporting incontinence by 62% in late pregnancy and by 29% between three and six months after birth, on moderate- and high-quality evidence respectively 4.

For women who already have incontinence during pregnancy or after birth, the same review found the effect of training uncertain, in contrast with its more established effect in women in mid-life 4. It also found little evidence about effects beyond 12 months after birth 4.