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    Beyond Kegels: When do gynecologic problems call for physical therapy?

    Many gynecologic problems require multidisciplinary treatment. Physical therapy may play a significant treatment role in achieving successful outcomes and improving patients' quality of life.

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    Most gynecologic problems require multidisciplinary treatment. An often-overlooked modality is formalized physical therapy provided by individuals trained in the treatment of gynecologic problems.

    Although physical therapy for gynecologic ailments is not typically taught in medical school, physical therapists are able to offer new approaches to many gynecologic problems that are traditionally difficult to treat, including pelvic pain and disorders of the pelvic floor. This article reviews common gynecologic disorders for which referral for physical therapy should be considered and can make a difference.

    The role of physical therapy

    Physical therapy is commonly employed for rehabilitation after acute or chronic musculoskeletal injury. Pelvic muscles can require the same type of rehabilitation. The techniques employed by physical therapists for pelvic pain or dysfunction include treatment modalities similar to those for back pain or joint rehabilitation, including taking a detailed history, evaluating posture, stretching the muscles, applying manual massage, electrical stimulation, and exercises to increase control and strength of the pelvic floor, pelvic stability training, having patients keep diaries of pain or incontinence, and instructing the patient in behavior or voiding modifications. This list is not all-inclusive, but specialized physical therapy can contribute much toward improving the function and condition of a patient's pelvic floor.

    Gynecologic problems that can benefit from physical therapy can be divided into two broad categories: disorders of pelvic pain and disorders of pelvic function. Disorders of pelvic pain include chronic pelvic pain, dyspareunia, vestibulitis, and vulvodynia. Disorders of pelvic function include pelvic organ prolapse, overactive bladder, urinary urgency incontinence and overactive bladder, stress urinary incontinence, and fecal incontinence. Each of these problems and the evidence for the use of physical therapy is reviewed below.

    Disorders of pelvic pain

    Chronic pelvic pain (CPP)

    The treatment of CPP generally relies on symptom control rather than cure, and a multimodal approach usually is optimal. A study from a CPP specialty clinic observed that of 370 participants, the 181 who received medical treatment that included physical therapy reported pain improvement at 1 year similar to the 189 women who had surgical treatment.1

    Many women with CPP have some dysfunction relating to the musculoskeletal system, making physical therapy a viable treatment option.2,3 Physical therapists evaluated CPP patients in a masked, prospective, cross-sectional study.4 They found that compared with controls, the women with CPP had more abnormal musculoskeletal findings, higher median total pelvic floor tenderness scores, and poorer control of the pelvic floor.

    A systematic review of published literature from 1984 to 2006 examined the role of physical therapy in the management of CPP. The authors concluded that "the synchronized intervention by physicians and physiotherapists is becoming increasingly more necessary both in terms of a more refined diagnosis of the clinical situation and of the institution of effective, lasting treatment."2

    Dyspareunia/vestibulitis/vulvodynia

    Myriad factors contribute to dyspareunia. Attempts to identify a specific, modifiable source for the pain often fail; however, specific physical therapies directed at a number of discrete causes can produce improvement in symptoms. In women with known pelvic adhesions suspected as the cause of their dyspareunia, research has shown that manual physical therapy significantly reduces the pain associated with intercourse.5 When dyspareunia is caused by vestibulitis, physical therapy treat-ment produces significant patient-reported decreases in pelvic pain during intercourse and significant increases in intercourse frequency and levels of sexual desire and arousal.6 The participants in this study received an average of seven physical therapy sessions with a goal of rehabilitating the pelvic floor through patient education, manual techniques, biofeedback, electrical stimulation, and patient home exercises.

    Vulvodynia—sharp, burning pain limited to the vulvar vestibule—contributes to both dyspareunia and chronic pelvic pain. Treatment options recommended by the American College of Obstetricians and Gynecologists include physical therapy.7 In a survey of physical therapists' practices for pelvic pain, therapists reported assessing posture, tension in the pelvic floor, pelvic girdle, associated pelvic structures, and bowel/bladder function; testing digitally the pelvic floor; assessing hip, sacroiliac joints, and spine mobility; and strength testing abdominal and lower extremity musculature. Common treatment modalities reported in this study included exercise for the pelvic girdle and pelvic floor; soft tissue mobilization/myofascial release of the pelvic girdle, pelvic floor, and associated structures; and joint mobilization/manipulation. Many physical therapists also counsel patients regarding behavioral therapeutic interventions including bowel/bladder retraining, help with contact irritants, dietary changes, and sexual function. In this survey, physical therapists recommended that patients participate in 7 to 15 weekly 60-minute sessions.8

    In the pelvis, trigger points can develop from trauma, post-surgical healing, interstitial cystitis, and inflammation. Myofascial trigger points are taut bands or tender nodules that evoke twitch responses or reproduce the character and location of symptoms during palpation.9 Research has shown that these painful nodules improve with manual physical therapy in patients with painful bladder syndrome.10

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    Sara B. Cichowski, MD
    Dr Cichowski is a board-certified FPMRS Obstetrician and Gynecologist and assistant professor at the University of New Mexico and New ...
    Rebecca G. Rogers, MD
    Dr Rogers is Associate Chair for Clinical Integrations and Operations, Dell Medical School, The University of Texas at Austin.

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