Pelvic Floor Physical Therapy for Sexual Health

By Elizabeth Boskey, PhD

Pelvic floor physical therapy (PT) can be used to treat or help treat a number of sexual health problems. It is also commonly used to treat problems such as urinary or fecal incontinence, particularly when that incontinence occurs after childbirth or prostate surgery. Conditions for which pelvic floor PT can be helpful include:

All of these conditions have one thing in common—they are affected by the function of the pelvic floor.

What Is the Pelvic Floor?

The pelvic floor has several different functions. First, it supports the abdominal organs, such as the bladder, the intestines, and the internal genital organs (i.e. the uterus) inside the pelvis. Second, it resists against the pressure that builds up in the pelvis and abdomen during activities like coughing or lifting. Finally, it is the action of the pelvic floor that allows people to hold their urine and feces until they are ready to use the bathroom. The urethra and rectum pass through holes in the pelvic floor. It is relaxing the muscles of the pelvic floor that allows for urination and defecation. The normal tension in the muscles of the pelvic floor serve as a sphincter to otherwise hold these substances in.

The pelvic floor lies at the base of your pelvis. Often described as being shaped like a funnel or a bowl, it is made up of two muscle groups – the levator ani muscles and the coccygeus, The levatyor ani muscles are the pubococcygeus, the puborectalis, and the iliococcygeus. Each muscle that makes up the pelvic floor contributes to its function. Pelvic floor PT can be helpful if there are problems with one or more of these muscles, something called pelvic floor dysfunction.

Pelvic Floor Dysfunction

Pelvic floor dysfunction simply means that one or more of the muscles of the pelvic floor is not working correctly. This could mean that they are too tense, too loose, or that a person has trouble contracting and releasing them appropriately. It is also possible for the pelvic floor muscles to be damaged by childbirth, medical treatments, or certain types of surgery, such as as prostatectomy.

Pelvic floor dysfunction can be diagnosed through a combination of history taking, physical examination, MRI, and/or ultrasound. It is thought to affect up to a quarter of women in the United States1 . There is less data on prevalence in men. Pelvic floor dysfunction can be treated through a number of means including medication, surgery, and pelvic floor physical therapy. Pelvic floor PT is often a good first-line option, as it has far fewer risks and side effects than other options. That is particularly true for surgical options for pelvic floor repair, which have the potential to have significant sexual and other side effects.2

Pelvic Floor Dysfunction and Sexual Health

Pelvic floor dysfunction can affect a number of areas of sexual health. These effects can be both direct and indirect. For example, a direct effect of pelvic floor dysfunction could be pain during intercourse. The potential direct sexual effects of pelvic floor dysfunction are numerous, as the pelvic floor muscles affect numerous aspects of sexual function. Muscle contraction plays a role in sexual arousal and orgasm, as well as in penile rigidity

An indirect effect could be stress urinary incontinence leading to a fear of sexual intimacy. Types of sexual health problems associated with pelvic floor dysfunction can also be categorized as either being caused by overactive or under-active muscles. In general, direct effects tend to be caused by too much muscle contraction in the pelvic floor, while indirect effects tend to be caused by too little.

Overactive Muscles

Overactive pelvic floor muscles can cause pelvic pain and pain with sexual activity. In men, this pain may be anywhere from the testicles, to the tip of the penis or the abdomen. In men, overactive pelvic floor muscles can also contribute to:

erectile problems
premature ejaculation
pain after ejaculation

In women, overactive muscles can contribute to:

itching or burning of the vulva (the outer portion of the genitalia)
pain in the clitoris
pain in the vagina

In all individuals, sexual dysfunction caused by overactive pelvic floor muscles may or may not be accompanied by pain.

Under-active Muscles

Under-active pelvic floor muscles increase the risk of conditions such as pelvic organ prolapse and urinary incontinence. Both urinary incontinence and pelvic organ prolapse have been shown to have negative effects on individual’s sex lives. 3 Each condition can affect a person’s self image, and there may also be concerns about pain during sex (with prolapse) or odor (with urinary incontinence.)

It’s worth noting that some people have pelvic floor muscles that are simultaneously over- and under-active. This is a component of some types of pelvic pain syndrome.

Pelvic Floor Physical Therapy

Going for an initial consultation for pelvic floor PT can be an intimidating experience, particularly if you do not know what to expect. The specific experience of working with a pelvic floor physical therapist will depend on why you are seeking help. However, there are several experiences that will be common to most consultations with a pelvic floor PT.

History. You will be asked to talk about what brings you to pelvic floor physical therapy. If you come for a particular symptom, you may be asked about potentially related symptoms. As talking about pelvic floor symptoms involves talking about sexuality, urinating, and pooping, this can be very difficult for some people. It may help to write down a list of your concerns in advance. You may also be asked to fill out a questionnaire about pelvic floor symptoms and function. There are several assessment tools that providers use to assess the pelvic floor.
Exam. There may be both an external and an internal exam. The external exam may involve having the pelvic floor physical therapist press against different muscles or having you perform actions that might activate those muscles (like coughing.) It may also involve looking at range of motion in surrounding areas. An internal exam may involve the provider putting their fingers in your vagina and/or rectum in order to check the tension in the muscles that surround and support those tissues.
Intervention. Physical therapists use a number of different techniques when working on the pelvic floor.

Some common types of pelvic floor PT interventions include:

Education about relevant aspects of pelvic anatomy, function, and hygiene
exercises designed to teach patients how to contract and relax the muscles of the pelvic floor. “Kegels” are a form of pelvic floor exercise.
Breathing exercises to help people relax and improve the efficiency of other exercises
Manual therapy, which could include hands-on massage or stretching. For some conditions, manual therapy may involve a provider having fingers inside the vagina or rectum in order to access affected muscles.
Biofeedback, which often uses technology to show patients how they are activating their pelvic floor muscles. This could include the use of a probe that is placed in the vagina or muscles and connected to a computer. Images on the computer show the person how their movements are affecting their muscles. They can then use this to learn how to relax and contract specific muscles. Biofeedback can also be performed by a therapist giving verbal feedback about muscle contraction.
Electrical stimulation of muscle groups to teach people how to coordinate the movement of those muscles. Percutaneous tibial nerve stimulation is another electrical stimulation technique that uses an electrode placed near the ankle to stimulate the nerves of the bladder. There is also some evidence that it can improve sexual function.4
Use of vaginal dilators to help patients learn to relax the muscles of the pelvis. Vaginal dilators may also be used in other circumstances, such as after vaginoplasty or for the treatment of vaginal agenesis.

One of the most important things about any physical therapy is that for it to work, patients need to do the work. That’s why in person physical therapy can sometimes be a better option for patients than being given instructions and asked to do exercises at home. If a doctor or other provider asks you to do pelvic floor exercises, and you think you’re not going to manage on your own, you might benefit from a referral to see a physical therapist.

Does Pelvic Floor PT Work for Sexual Health?

In spring of 2020, the American College of Obstetricians and Gynecologist released a practice bulletin on pelvic pain, in which they discussed that a combination of pelvic floor physical therapy and sex therapy can be important for individuals experiencing pain during sex.5 This is because, for many people, pain during sex is a reflection of a combination of both neuromuscular and psychosocial factors. The sex therapy helps with the psychosocial factors. The pelvic floor PT helps with the neuromuscular ones.

Special Training for Pelvic Floor Physical Therapists

Pelvic floor PTs are doctoral-level providers. They then must undergo additional, more specialized training to learn how to work with pelvic floor conditions, particularly those that require internal exams or procedures. Some pelvic floor therapists go even further and pursue certification as a Pelvic Rehabilitation Practitioner (PRPC) or a Women’s Health Clinical Specialist (WCS) or to seek a Certificate of Achievement in Pelvic Physical Therapy (CAPP).

It may be helpful to seek out therapists who are either board certified in a pelvic specialty or who are currently pursuing such certification under supervision. Physical therapists and other professionals who are particularly interested in sexual health may also seek training or certification from a specialized organization like the American Association of Sexuality Educators, Counselors, and Therapists (AASECT).

Can People of All Sexes Benefit From Pelvic Floor PT?

Everyone has a pelvic floor. Thus anyone has the possibility of developing pelvic floor dysfunction. This is true no matter what your sex or gender. Depending on the particular pelvic floor PT clinic, therapists may see more individuals of one sex or another. However, issues like stress urinary incontinence are independent of sex. That said, specific risk factors are often sex-related. For example, two relatively common causes of incontinence are trauma from childbirth and prostate cancer surgery and radiation.

Transgender individuals can also benefit from pelvic floor physical therapy. Pelvic floor PT is often recommended for individuals considering a vaginoplasty, both before and after the procedure. Pelvic floor PT prior to surgery can identify and help with concerns related to pelvic floor dysfunction. After surgery, pelvic floor PT can help maintain pelvic floor health. It can also help women who have difficulty with the vaginal dilation that is required after vaginoplasty.6

A Word from Verywell

If you are experiencing sexual or other problems that could be related to pelvic floor dysfunction, talk to your doctor about whether it might make sense for you to explore pelvic floor PT. Pelvic floor PT can be a game-changer for some individuals who experience sexual difficulties such as pain or difficulty with penetration. It can also be a big help for those dealing with issues that can affect their sexual self image, like incontinence.

If you are trying to find a pelvic floor PT, it may take a little calling around. Check with your insurance to see what physical therapy providers are in-network, and then pick up the phone. You will want to ask not just whether or not the office provides pelvic floor PT but also things such as:

If any of their therapists are board-certified in pelvic floor PT
What, if any, specialized training providers have undergone
Whether they have experience treating your specific condition
Whether they have experience treating people of your gender

Because of the intimacy of the physical touch involved in pelvic floor PT, it is also reasonable to ask about the gender of potential providers—if that is important to you. Pelvic floor PT doesn’t involve sexual touch. However, for some individuals, clinical touch of sexualized areas of the body may be easier with either a same-gender or different-gender provider.

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