Release Pelvic Pain in 2-3 months with Pelvic Floor Physical Therapy

Many evidence based studies prove that pelvic floor physical therapy is an effective treatment approach for men and women suffering from pelvic pain caused by tight muscles and restricted tissues.  The pelvic floor muscles, namely the levator ani, coccygeus and obturator internus can develop adhesions, tension or trigger points which restrict movement and cause pain.  Trigger points are palpable spasms/knots within muscle tissue and can occur in pelvic floor muscles.  Trigger points can lead to adhesions of fascia/connective tissue of the abdomen, groin, pelvic floor and even restrict the viscera (colon, uterus, bladder, prostate gland) within the pelvic bowl.

The pudendal nerves and its branches, traveling from the sacrum (back of the pelvis) and running all through the pelvic floor region innervates the vaginal/penile and rectal areas. The nerves can become squeezed as it travels through tight muscles and fascia, which then decreases optimum pelvic floor function and increases pain.

The pelvic floor muscles are located INSIDE our bodies, in women the muscles are approximately 1-2 inches up from the vaginal/rectal region and in men, the muscles are approximately 1-2 inches up from the base of the penis/rectal region.

The pelvic floor muscles are key for four functions of the body:

1) lower back/core stabilization; 2)  normal urinary function; 3) good bowel function; 4) satisfying sexual function.

As a core stabilizer, the pelvic floor works with 3 other core muscles, the Transversus Abdominus (deepest stomach muscle), Multifidus- (deep low back extensor muscle), and deep fibers of the Iliopsoas (hip flexor muscle). These 4 muscles work together to keep our core strong, flexible and prevents lower back pain. If one of the 4 core stabilizer muscles becomes weak or injured, then the other 3 muscles have to work harder to compensate. Over time this puts great strain on the whole core, which leads to back pain/stiffness/weakness.

The pelvic floor muscles are directly involved with three bodily functions, urinary, bowel and sexual.

For functional urination, the pelvic floor muscles surround the urethral opening and should relax when you are voiding and maintain closure or tension when you are not voiding.   If the muscles are in spasm, urinary symptoms such as leaking,  or feeling a strong urge to void, or having to go to the bathroom multiple times a day (called urinary frequency) and/or being awoken at night to void more than once (called nocturia), can occur.   Women using public restrooms should not “hover” over the toilet, as this sustained half squat creates tension in the pelvis and does not allow full relaxation of the sphincters around the urethra to allow full urination. Best to use the protective toilet seat covers and sit comfortably.

For normal bowel movements, the pelvic floor muscles should be able to open and widen to allow the full passage of stool. When not having a BM, the pelvic floor maintains tension at the rectal opening to prevent leakage.  If the pelvic floor is weak, leakage can occur.  If the pelvic floor is tight, constipation resulting in sitting too long at the toilet, straining to defecate can occur. Toileting should take no longer than 5 minutes following the urge to void.  Even though you may not feel completely empty, it’s better to stand and leave the bathroom  versus continue to sit and strain. Constant straining can result in hemorrhoids and/or the development of a rectocele, which further impedes good function.

For satisfying sexual function, the toned and flexible pelvic floor allows for more intense orgasms in men and women.  A fully relaxed pelvic floor helps women experience pain free intercourse with their male partners.  Many patients who are experiencing sexual pain may experience difficulty with partner relationships or even avoid them due feeling of shame or inadequacy.

Pelvic pain due to restricted muscles can be released and return to normal function, no matter how long a person has been experiencing symptoms.

Physical therapists trained and mentored in pelvic floor work can:

  • apply targeted manual therapies to rid muscles of trigger points
  • utilize biofeedback therapy to help patients learn how to either downtrain (relax) their pelvic floor or to uptrain (strengthen) the pelvic floor
  • perform visceral mobilization to improve the mobility of organs lying within the pelvic bowl
  • mobilize and teach a patient self-connective tissue (skin rolling) techniques to abolish tight skin and fascia of the inner thighs and abdomen
  • teach patients gentle stretching techniques with foam rollers, tennis balls, knobbles, Theracane,  S –wands and dilators
  • educate in exercises for a strong core
  • teach diaphragmatic breathing and visualization to help lower tension of the pelvis and to increase oxygenation to the body and decreased stress
  • guidance in cardiovascular exercise to pump more oxygen and nutrients to the tissues
  • teach proper bladder and bowel techniques and habits

Most people start to feel better after 2 months of consistent, twice a week therapy which incorporates many of the above techniques. Some reach goals sooner; others may take up to 3 months.  By attending regular pelvic floor physical therapy and performing all the home exercises, faulty pattern are reversed and many people are pain free within 2-3 months.


A prostatectomy is the surgical removal of all or part of the prostate gland. The prostate gland is located just under the bladder and has the urethra traveling thru it.  The urethra is a tube like structure that carries urine from the bladder to the penile opening.  When the prostate gland becomes enlarged, there is increased “squeeze” pressure around the urethra which restricts the normal flow of urine, causing discomfort and difficulty voiding.

There are three types of prostatectomy’s:  1) transurethral resection of the prostate (TURP), primarily performed to treat benign prostatic hyperplasia (BPH); 2) open prostatectomy which allows manual manipulation and open visualization through the incision; and 3) radical prostatectomy, the removal of the entire prostate gland along with some surrounding tissue in order to remove the entire cancer.

Robotic prostatectomy is a state-of-the-art procedure that has recently become the most common form of prostate removal.  With the latest technology, greater accuracy is gained, smaller incisions are made, shorter recovery period occurs and post surgical pain is lessened.

A prostatectomy, like any surgery, has possible complications and side effects. Due to the prostate’s location and anatomical components, incontinence and erectile dysfunction are possible side effects.  While it is common for men to experience some leaking for a few weeks post surgery while tissues heal, some men can experience symptoms for many months post op.

When the prostate is surgically excised damage to the cells/tissues that provide continence may occur.  The pelvic floor muscles must take the lead to maintain continence.  The pelvic floor muscles (PFM) are a group of muscles located the base of the pelvis that help control sexual, urinary and bowel function.  The PFM could present as either very weak, too tight or be uncoordinated, resulting in pelvic floor dysfunction.  If the PFM are weak, they cannot squeeze tightly, or contract fast enough around the urethra during a sudden sneeze, resulting in leaking. Some men may experience leaking only with coughing, laughing or lifting weight. Other men may experience constant dribbling throughout the day with increased leakage during physical activity.   If the PFM are too tense or restricted, both leaking and erectile dysfunction can occur as well.

A successful treatment option for men experiencing pelvic floor dysfunction following prostatectomy is physical therapy. The PT, who is specially trained in the pelvic floor, first evaluates the function of the PFM.  Flexibility, mobility and strength are measured via manual intrarectal exam (PFM are located approx one inch intrarectally).  Biofeedback assessment of resting tone, strength and endurance of the PFM are performed.   A study published from the World Journal of Urology titled “Evaluation of early pelvic floor physiotherapy on the duration and degree of urinary incontinence after radical retropubic prostatectomy in a non-teaching hospital” reviewed the effects that early pelvic floor re-education had on the degree and duration of incontinence. This study concluded that the time period towards continence after a prostatectomy procedure can be shortened significantly if pelvic floor re-education is started early in recovery.

Physical therapy treatment for incontinence and erectile dysfunction consists of manual therapy, neuromuscular re education (biofeedback), strengthening and coordination training.  Manual therapy improves extensibility of the PFM, enhancing endorphin production and blood flow.   Soft tissue work is a key component for many patients post prostatectomy. Men may subconsciously tighten their PFM all day, thinking this prevents leaking. However, constant tension causes the PFM to become tight and restricted resulting in further weakness/dysfunction.

Once the PFM are free of tension, manual quick stretch techniques are performed to promote strength, recruiting muscle fibers that may be inactive.  Biofeedback, which is first used to assess the PFM can also be incorporated into the treatment process.  The biofeedback hand held units read the electrical activity of the PFM, giving both the physical therapist and the patient quantitative information about the state of the muscles. Are the muscles too weak, too tight, have poor endurance?  Biofeedback training educates patient how to locate their PFM, lower the muscle tension and strengthen weakened  muscles.  A tailored home exercise program is taught to help men improve their PFM awareness during home/work/sport and empowers men to improve PFM function.

While working with one of the staff DPT (Doctor of Physical Therapy)  at EMH Physical Therapy and under the  guidance of Evelyn Hecht, PT, ATC  the first to offer pelvic floor rehabilitation in NYC 16 years ago,  most men with symptoms of incontinence  post prostatectomy can regain full continence in 2 to 3 months.


Cornel, E. B., de Wit, R., & Witjes, J. A. (2005). Evaluation of early pelvic floor physiotherapy on the duration and degree of urinary incontinence after radical retropubic prostatectomy in a non-teaching hospital . World Journal of Urology , 23(5), 353-355.



Everyone keeps talking about your core: ‘keep your core strong,’ ‘activate your core,’ ‘stabilize your core’ etc.  But what does that really mean?  What IS your core?  How do you REALLY activate it?

Your core primarily consists of your transversus abdominus, multifidus, and pelvic floor.  More secondary components of the core muscles include your  rectus abdominus, obliques, gluteal muscles, hip rotators, hamstrings, quadriceps, and latissimus dorsi.  The core’s primary role is to stabilize your spine and pelvis during dynamic movement, for example running, twisting, or walking. These muscles help lock everything in place and also help transfer forces so your bones don’t jar against each other.

The scientific article: The Relation Between the Transversus Abdominis Muscles, Sacroiliac Joint Mechanics, and Low Back Pain by Richardson, CA et al, is a study of the core muscles before walking or lifting.  It demonstrated the activation of core muscles milliseconds BEFORE walking or lifting or moving from sit to stand is performed. By placing external electrodes over these muscles, an analysis of each muscle’s activation, force, and timing was recorded.  It also compared the activation sequence in people with healthy lower back versus people with painful non-healthy lower back.

To summarize, this article found that when transferring weight from one foot to the other, picking up an object, taking a step,  the transversus abdominus and pelvic floor were activated milliseconds before the rest of the secondary core muscles were activated.

The study noted that people with lower back, hip/pelvic pain, the transversus abdominus and pelvic floor muscles were activated either simultaneously or after the other core muscles, not before, as demonstrated in people without pain.  In some cases the core muscles did not become activeated at all.

So how do you activate the transversus abdominus and pelvic floor? Correctly? And keep it active? A licensed physical therapist at EMH Physical Therapy teaches you how to locate and palpate the transversus abdominus, how to recruit the pelvic floor muscles and develop awareness for both muscle groups.  We then teach you how to strengthen these muscles and incorporate them during movement patterns.

What are the benefits?  By having a stronger core you can expect to move freely- no more catching or sharp pains.  Patients have told us they can walk and run faster, have better endurance, can bend down and lift easier and our youth athletes are able to return playing sport pain free.

The core muscles are the powerhouse of your body.  If you have back pain, becoming aware of your core muscles through guided physical therapy will be the key to resuming a pain free lifestyle.


Constipation is a common disorder primary care physicians and gastroenterologists diagnose on a regular basis.   There are many causes, but when constipation is due to “pelvic floor dyssynergia”, which are restricted pelvic floor muscles around the anal region that contract instead of relax during attempted bowel movements, a licensed physical therapist, trained in pelvic floor dysfunction can reverse constipation and help you resume normal bowel function.

The pelvic floor is a group of muscles at the base of the pelvis that help control sexual, urinary and bowel function. These muscles, namely the puborectalis, levator ani and coccyxgeus must relax and contract properly to maintain urinary and fecal continence, sexual function and proper voiding habits. When the pelvic floor muscles fail to relax and contract properly, this can be referred to as “pelvic floor dyssynergia”.  The inability to relax and contract the pelvic floor muscles correctly can lead to symptoms of constipation, straining with bowel movements, and feelings of incomplete evacuation.

Some of the physical therapy treatments for constipation include external and internal rectal myofascial release techniques, trigger point release techniques, biofeedback therapy to help down train tight muscles and/or up train weak muscles, instruction to correct bowel techniques to prevent straining, instruction in home exercise program to stretch and strengthen pelvic floor, hip and gluteal muscles.

Manual therapy is needed to reduce the tension, adhesions, and knots in muscles that cause them to become dysfunctional.  This treatment is always with a patient’s permission, may be uncomfortable, but overall a very successful approach to rehabilitate faulty pelvic muscles patterns that resulted in constipation.

Biofeedback therapy helps retrains your pelvic floor muscle’s ability to contract and relax within their full range of motion. It is a treatment which requires insertion of a rectal sensor (sensor is the size and length of a pinky) to measure pelvic floor muscle tension through electromyography (EMG). The EMG activity is visually displayed on the biofeedback unit so you can see what your muscles are doing and learn to better control these muscles with verbal and tactile cueing from the physical therapist.  Identifying the internal sensations associated with the relaxation and how to maintain the ability for your pelvic floor muscles to be at a relaxed state throughout the day is taught as well.

Specific stretching and strengthening exercises are taught for the pelvic floor; the abdomen and pelvic girdle (the gluteal, hamstring and adductor musculature).  Manual therapy such as soft tissue mobilization and trigger point release are administered to tight and restricted tissue both to the lower abdominal region and pelvic floor musculature to help increase blood flow, decrease restrictions and promote healing.  Education regarding normal bowel function and identification of problematic toileting habits is also an important step to recovery.

By complying with a pelvic floor physical therapist’s recommendations, you can be well on your way to pain free and stress free bowel function – no more constipation!