Pelvic Floor Problems: What Physiotherapy Can Do and Who to See

The pelvic floor is a sling of muscle across the base of the pelvis. It supports the pelvic organs, contributes to bladder and bowel control, works with the deep abdominal muscles and the diaphragm during effort, and has a role in sexual function.

Dysfunction takes more than one form:

• Weakness or poor coordination, producing stress incontinence when coughing, laughing, lifting or running, or a sense of heaviness associated with prolapse.
• Overactivity, where the muscles hold too much tension and struggle to relax, producing pelvic pain, difficulty emptying, and pain with intercourse. Doing more pelvic floor squeezes makes this group worse, which is the strongest argument against self-treating from an internet video.
• Mixed patterns, which are common and need assessment to unpick.

Pregnancy and childbirth, prostate surgery, menopause, chronic constipation, persistent coughing and heavy lifting all feature in the histories, and it affects men as well as women.

NICE guideline NG210 on the prevention and non-surgical management of pelvic floor dysfunction is clear that pelvic floor muscle training programmes should be supervised by a physiotherapist or other healthcare professional with appropriate expertise in the area.

Supervision means specific things: assessing whether the person can actually contract and relax the muscles, tailoring the programme to that ability and to any discomfort, and supporting them to complete the course. Women should be offered a choice between group and individual sessions, and for mixed urinary incontinence supervised pelvic floor muscle training is a first-line treatment alongside bladder training.

The reason supervision is emphasised is that a substantial proportion of people perform the contraction incorrectly when working from written instructions, often bearing down instead of lifting. An assessment establishes what you are actually doing before you spend three months doing it.

Pelvic health is a post-registration specialism with additional training. A specialist assessment typically includes a detailed history covering bladder, bowel and sexual function, a bladder diary, and, with consent, an internal examination to assess muscle tone, strength, coordination and any prolapse.

Treatment may include individually prescribed pelvic floor training, downtraining and relaxation techniques for overactivity, bladder and bowel retraining, biofeedback, electrical stimulation, and pessary fitting in some services.

PhysioHub is a musculoskeletal clinic and does not provide specialist internal pelvic health assessment. Saying so plainly is more useful than stretching a general service to fit. What we do instead is get you to the right specialist quickly, which is the section below.

Pelvic health is a small enough field that the specialists know each other, and a big enough one that they differ in what they do most. Some hold most of their caseload in postnatal recovery and return to running. Some are the people you want for prolapse and pessary fitting. Some work largely with men after prostate surgery. Some specialise in persistent pelvic pain and overactive, non-relaxing muscle, which is close to the opposite clinical problem from weakness and needs a clinician who treats it regularly. A directory tells you who is qualified. It does not tell you which of them is right for the thing you have.

The professional network here is POGP, Pelvic, Obstetric and Gynaecological Physiotherapy, affiliated to the Chartered Society of Physiotherapy. Its members are the physiotherapists with post-registration training in this area, and it runs a public Find a Physiotherapist directory you can search yourself. Alex has worked alongside a good number of POGP physiotherapists across NHS departments and private practice over the years, in Sussex and beyond, and that is the useful part: a sense of who is strongest with what.

So if you come to us with pelvic floor symptoms, you will get a straight steer on which kind of specialist your case calls for and, where we know someone whose work fits it, a name rather than a list. The three routes open to you are a GP referral into NHS pelvic health physiotherapy, which is free and usually carries a wait, a private POGP-registered specialist, who will normally take a self-referral, or the directory above if you would rather choose for yourself. We have no financial arrangement with anyone we suggest, and we will say when the NHS route is the sensible one to sit on.

The pelvic floor works as part of a system, and several of the surrounding parts sit squarely in musculoskeletal territory:

• Low back, sacroiliac and hip pain, which frequently accompany pelvic floor symptoms and can drive them through altered muscle activity and guarding.
• Breathing mechanics, since the diaphragm and pelvic floor work together, and a held, shallow breathing pattern interferes with both.
• How you lift and brace, which determines how much pressure reaches the pelvic floor during daily tasks and in the gym. Technique changes here often reduce symptoms measurably.
• Returning to running and impact, particularly postnatally, where a graded loading plan matters as much as the pelvic floor work itself.
• General strength, especially glutes and legs, which supports the whole region.

Our article on back pain covers the musculoskeletal side that so often travels alongside.

If you have been assessed and told the muscles are weak, the standard programme is a mix of long holds and quick contractions, done daily over at least three months. Improvement is usually gradual and takes weeks to become obvious.

Alongside that, three things reliably help and are worth doing regardless:

• Manage constipation. Repeated straining is one of the most consistent aggravating factors, and fluid, fibre and toilet position all make a real difference.
• Stop pre-emptive toileting. Going "just in case" repeatedly trains the bladder towards smaller volumes over time.
• Adjust how you lift. Exhaling on effort rather than holding your breath reduces the pressure spike through the pelvic floor.

If symptoms include pelvic pain or difficulty relaxing, hold off on strengthening until you have been assessed, because that group needs the opposite approach.

The question that gets asked most often about this arrives sideways, usually at the end of an appointment about something else, and usually from someone building back towards Uckfield parkrun after having a baby. It is a version of "is it normal that I leak when I run?" Common is the honest answer, and normal is a different word that does not apply.

The clinical point is that the answer splits into two jobs. Assessing the pelvic floor itself, establishing whether the muscles are weak or overactive and prescribing accordingly, is specialist pelvic health work. Building the running back is musculoskeletal work: graded return to impact, calf and glute strength, and how you breathe and brace under load. At PhysioHub in Uckfield the second half is what gets done here, and for the first half you leave with a steer towards the POGP physiotherapist whose caseload actually matches your presentation, which for a postnatal runner is a different person from the one you would want for prolapse or for pelvic pain. Being clear about that division saves people from three months of a programme aimed at the wrong problem.

If you are unsure which route your symptoms need, a free discovery and triage call is the simplest way to find out.

Do I need a referral for pelvic health physiotherapy?
NHS services usually require a GP referral. Private specialist pelvic health physiotherapists generally accept self-referral.

Can PhysioHub point me to a pelvic health specialist?
Yes, and that is often the most useful thing we do with these symptoms. Tell us what you are experiencing and we will say which kind of specialist your case calls for and, where we know someone whose work fits it, give you a name. There is no financial arrangement behind any suggestion we make.

What does POGP mean?
Pelvic, Obstetric and Gynaecological Physiotherapy, the Chartered Society of Physiotherapy professional network for this specialism. A POGP-registered physiotherapist has post-registration training in pelvic health, and the network runs a public directory you can search yourself.

Are pelvic floor exercises always the answer?
No. Where the muscles are overactive, strengthening makes symptoms worse. That is why assessment comes before the programme.

How long until pelvic floor training works?
Programmes usually run for at least three months, with gradual change over that time rather than a quick shift.

Do men get pelvic floor problems?
Yes, particularly after prostate surgery and with chronic pelvic pain. Pelvic health physiotherapy treats men as well as women.

Is leaking after childbirth something I just live with?
No. It is common and it is treatable, and supervised pelvic floor muscle training is a first-line treatment with good evidence behind it.