Pelvic Physical Therapy: The Reality Behind the Curtain


By Carrie Pagliano, PT, DPT, OCS, WCS

There can be a sense of mystery behind pelvic physical therapy, not only from the point of view of the patient, but from professional colleagues in the medical community.  Perhaps this has to do with the fact that pelvic Physical Therapists (PT) are often tucked away in physical therapy clinics behind a closed door. But let’s be honest; most of the mystery comes down to the internal (vaginal or rectal) muscle examination as a potential component of examination and treatment. That said, simplifying pelvic physical therapy down to an internal assessment or a vagina therapist is akin to saying the late Stephen Hawkings studied donut holes.  There is so much more to pelvic PT and the conditions we treat.

The beauty of practicing in pelvic physical therapy lies in the culmination of so many areas of expertise.  It requires an integrative understanding of the human body, finding the right clinical hypothesis and treatment direction in an area of practice where research is still evolving.  Pelvic physical therapy has the unique privilege of being truly wholistic.  Our patients have issues ranging from pelvic organ prolapse, chronic pelvic pain, pain from oncologic or dermatologic issues, urinary and fecal incontinence, issues related to pregnancy or surgery, pain or difficulty with orgasm or intercourse, and the list goes on.  Our patients are female, male, intersex, and transgender.  Our patients are adults and children.  Our patients are referred to physical therapy from ObGyn, Urology, Colorectal, Neurology, Orthopaedics, Pediatrics, Psychology and Dermatology.  Our patient’s problems range from simple to complex.  Our examination includes the entire person, from a comprehensive subjective examination, where the patient can share their story, to a thorough objective assessment which includes the spine, pelvis, hips, etc.  The smallest part of the exam focuses on the internal assessment; either vaginal, rectal, both, or not at all.  For many patients, this portion of the examination is the first time which a medical provider identifies their pain or problem after seeking advice from multiple practitioners.  Pelvic PT’s are often the first provider who has listened to their story for more than a few moments and acknowledged that as a patient, they are not broken, and there is hope.

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Physical Therapy Keeps Hips Healthy for Post-Retirement Activities

Pain, soreness and weakness in the hips can interfere with desired activity levels, particularly for men and women 65 years old and older. For active Americans trying to enjoy their retirement years, poor hip health simply isn’t part of the plan—but that doesn’t mean they’re destined to miss out on life’s many pursuits. The good news is that physical therapy can help seniors remain physically active by addressing small issues before they grow. Many are surprised to learn that when it comes to hip pain, the answer is closer than they think. According to Harvard Medical School, strengthening the surrounding muscles—including the quadriceps, glutes and hamstrings—can take some of the stress off of the hips. Learning to take care of our hips as we age means recognizing when a new pain or limitation arises, and making

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Ladies: Dos and Don’ts for Vaginal and Pelvic Health

Women are taking their pelvic health seriously today, and that’s a great thing. Especially considering that most will experience at least one issue with their lady parts at some point. It could be bladder leakage, recurrent yeast infections, uterine fibroids, heavy periods, or something else.

But, while some pelvic health trends are making the taboo topic of your vagina mainstream, others are at best useless and at worst harmful. Read on to see our dos and don’ts for vaginal and pelvic health.

Click below for full article

5 Ways to Manage Your Child's Constipation and Bedwetting Treatment on Vacation

By Steve Hodges, MD

For children prone to constipation, travel almost inevitably leads to clogged pipes. And if your child is on the Modified O’Regan Protocol (M.O.P.) for bedwetting and accidents — well, a spring break visit to Grandma’s or a summer camping trip poses a whole range of challenges and concerns.

As one mom in our private Facebook support group posted: “If we skip enemas for a week but continue laxatives, will that set us back to square one?”

Another mom, whose daughter is on M.O.P.+ (large-volume enemas) for bedwetting, wrote: “The thought of trying to do this discreetly is freaking me out. I think my extremely old-fashioned mother-in-law would claim child abuse if she heard we were giving our daughter enemas.”

A dad whose 7-year-old is on M.O.P.+ for encopresis asked: “Is there a simpler method we could substitute for a few nights? She’s had 5 or 6 accident-free days and we don’t want her set back while we’re away from home base.”

There’s no easy answer to these questions. Some families, despite tremendous vigilance on the road, do experience big setbacks.

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Can a healthy diet fix constipation?

Steve Hodges, M.D.

Associate Professor of Pediatric Urology, Wake Forest University School of Medicine

The other day a patient’s mom asked me, “Why is my daughter so constipated? She’s been on a ‘real food’ diet since birth. She’s gluten free and does karate or ballet every day.”
Most folks assume that when a child’s pipes are clogged, the culprit is highly processed, low-fiber diet.

But that’s not always true, and trying to fix constipation with “clean” diets may only frustrate families without actually solving the problem.

Always treat constipation aggressively!

Most folks assume that when a child’s insides are clogged, the culprit is highly processed, low-fiber diet.

But that’s not always true, and trying to fix constipation with “clean” diets, prune juice, or fiber supplements may only frustrate families without actually solving the problem.

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How Physical Therapy Helps Retirees Keep Dreams Alive During the Golden Years

Private Practice Section, APTA

Are you among the millions of Americans who have high aspirations for how you’ll spend the extra time during your post-retirement years? Whether you plan to travel the world, pick up fly fishing, spend more time woodworking or sign up for a golf league, your physical fitness level will be a factor.

A 2010 study suggests that the fitness declines we typically attribute to advancing age are largely caused by living sedentary lifestyles—which are on the rise due to the prominence of desk jobs in the workplace and activity-limiting personal technologies including smart phones and voice-activated remote controls in the home. Still, this runs contrary to the widely held belief that any declines in our physical abilities are caused solely by biological aging. Do we really have control over how active we’ll be in our “golden years”?

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Want to Fix Your Child’s Bedwetting? Avoid These 5 Mistakes

By Steve Hodges, M.D.

Shoulda, woulda, coulda. If I had known 10 years ago what I know today about treating bedwetting and accidents, I could have saved countless families from anxiety, frustration, and embarrassment, not to mention tons of laundry.

But you can’t dwell on your mistakes. You can only learn from them, adjust accordingly, and pass on your knowledge.

That’s what I remind parents who beat themselves up over their children’s bedwetting struggles. Plenty of parents have told me: “I can’t believe all the useless treatments I wasted time on. My daughter could have been dry a long time ago.”

As one mom of a bedwetting teen emailed me, “I am beside myself with guilt, as this has been going on for years. I knew something was wrong, but didn’t do anything."

To parents like these I point out: At least now you know what to do! That alone puts these families way ahead of most, given how poorly the medical community serves kids with enuresis (wetting) and encopresis (poop accidents).

In this post I will share a list of mistakes commonly made in the treatment of bedwetting and accidents. Some are mistakes I, myself, have made; other items on the list come from parents of my patients or parents in our private Facebook support group.

I take the term “medical practice” seriously. The way I approach accidents today is radically different from — and more effective than — the approach I advocated 10 years ago. It’s even different, in more subtle ways, from how I treated the condition a year or two ago.

You can’t resolve a child’s bedwetting and accidents overnight, but by avoiding these mistakes, you can save your family months, even years, of distress.

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Fascia—What You Should Know

by Cinthia P. Cable, L.M.T.

What is fascia?

Fascia is a body-wide, protective, supportive, flexible, soft tissue network. It has been found to be the most abundant tissue in the body. It looks much like a three-dimensional spider web that surrounds and separates muscles, nerves, arteries, veins, and organs. It attaches one body element to another and stabilizes and supports structural components with its connective ability.

Fascia exists just below the surface of the skin but also penetrates deep within the body, surrounding the organs and filling the space between the organs and other components. Scientists have identified three types of fascia. The first is superficial fascia, which lies just below the skin and gives the body its shape. The second is visceral fascia, which surrounds and suspends the organs. The third is deep fascia, which surrounds muscles, bones, nerves, and blood vessels.

The web-like fascia fibrils are composed mostly of collagen, which makes them strong, and elastin, which makes them flexible. But there is another component within the fascia—slippery proteins—which makes the collagen fibers moist and slippery. This moisture gives the fibrils a dewy sheen and facilitates movements between the various bodily components.

Fascia is one continuous network that extends from the top of your head to the soles of your feet. The word for this quality is continuity. Fascia has the quality of plasticity as well, which means it has the ability to soften, lengthen, and separate—to become more pliable. And finally, fascia has the quality of sensitivity due to the many nerve endings and mechanoreceptors contained within it. This sensitivity gives us the ability to be physically aware enough to control and coordinate our movements. Perceived sensations within the body are felt via the fascia, starting just under the skin.


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Comparing Treatment Options for Bladder Leaks: Pads vs. PeriCoach

You’re already running late for work when, halfway into your commute, you realize you didn’t restock your purse with bladder pads. “Great—and no time to stop by the pharmacy,” you think. You resign yourself to creating makeshift “pads” out of toilet paper or awkwardly asking any sympathetic female coworker you can find to spare a couple of pads to get you through the day.

This is an all-too-common scenario for women living with bladder leakage, known as urinary incontinence (UI). In a previous post, we compared how prescription drugs stack up against the PeriCoach Kegel exerciser for addressing the symptoms of bladder leakage. In this post, we’ll compare bladder pads with PeriCoach. Before we do, let’s revisit just how common bladder leakage is among women.

Bladder Leakage: A Problem for Millions of Women

The numbers are striking: Nearly one in three women will experience some form of UI in her life. Stress incontinence—leaking a few drops or a stream of urine when you laugh, cough, sneeze, or physically exert yourself—is the most common type.

UI does not discriminate by region, race, age, or fitness level—women in every corner of the world experience bladder leakage. While it’s more common in menopausal women and those who have been pregnant and given birth, it can also affect younger women who haven’t had children.

Many women turn to pads to deal with their bladder leakage. Yet, at best, this is a temporary solution. Pads don’t address the root of the problem, which, in many cases, is weakened pelvic floor muscles—more on that later.

First, let’s look at the cost of bladder pads and their impact on women’s daily lives.

Pediatric Incontinence and Pelvic Floor Dysfunction

“What's wrong with children?”

By Dawn Sandalcidi, PT, RCMT, BCB-PMD

As pelvic health physiotherapists it would be safe to say most of you are treating adults with bladder and bowel dysfunction and pelvic pain. I was in the same place when I was approached over 30 years ago from an urologist to take care of his pediatric patients. My reply: “What’s wrong with children?” I will never forget the whirlwind of learning since that day.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, by 5 years of age, over 90% of children have daytime bladder control (NIDDK, 2013) What is life like for the other 10% who experience urinary leakage during the day?

Bed-wetting is another pediatric issue with significant negative quality of life impact for children and their caregivers, with as much as 30% of 4 year-olds experiencing urinary leakage at night (Neveus, 2010). Children who experience anxiety-causing events may have a higher risk of developing urinary incontinence, and in turn, having incontinence causes significant stress and anxiety for children (Austin, 2014; Neveus, 2010).

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Nope, Deep Sleep Doesn't Cause Bedwetting

Steve Hodges, MD

 At my pediatric urology clinic, just about every parent of a bedwetting child is convinced that “deep sleep” explains the wet sheets.

Parents tell me, “She’s such a deep sleeper that you could blast Motorhead in her room and she wouldn’t budge.”

Or, “When he’s out, he’s out — there’s no chance of waking him up.”

In many cases, the child’s pediatrician has confirmed this theory or suggested it in the first place. And when families search online, they find additional support for the idea that deep sleep causes bedwetting.

For example, under the heading “Causes of Bedwetting,” the American Academy of Pediatrics (AAP) states: “Your child is a deep sleeper and does not awaken to the signal of a full bladder.” This statement tops a list of 8 bedwetting “causes.” And in an article titled "Nocturnal Enuresis in Teens," the AAP lists among the “contributing” factors to teenage bedwetting: “a deep sleep pattern that can be part of normal adolescent development, inconsistent sleep schedule and limited hours sleeping.”

On its website, the Enuresis Treatment Center calls bedwetting “a treatable sleep disorder” and claims that “targeting treatment to changing the sleep pattern will not only end the bedwetting, it will allow the bedwetter to experience better night’s sleep.”

There are two problems with the deep-sleep theory: 1.) it makes no sense, and 2.) no evidence supports it.


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Exercising During Your Second and Third Trimester

Dr. Kristin Anderson ,PT, DPT, OCS, CLT

As your baby continues to grow, you are going to be experiencing more wonderful changes in your body. Your abdomen is growing, meaning that the abdominal muscles are no longer in a prime position to work or help support you. Hormones are creating increased laxity of your joints to prepare to make room for the growing baby in your pelvis. Your diaphragm (breathing muscle) is rising, meaning there is less room for you to expand your lungs. You may notice that it is easier to get out of breath, even just walking up the stairs! To top it off, your heart is having to work harder because it is working to circulate 50% more blood volume then it normally does!

Our bodies are amazing and we need to appreciate the changes that our bodies are going through. Here are some guidelines for exercise in your second and third trimester. Please refer back to our article on exercise in the first trimester in our blogs!

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Comfortable Sex Positions for Women with Pelvic Floor Disorders

Life can take its toll on your lady parts. Pregnancy, childbirth, menopause, and even chronic constipation and obesity can weaken your pelvic floor muscles. These important muscles act as a hammock, stretching across your pelvis and holding your organs (bladder, bowel, uterus, vagina) firmly in place.

When the pelvic floor muscles are weakened or the connective tissues of the pelvic area are damaged—whether from a rambunctious baby doing somersaults in your belly, or hormonal changes during menopause—you can develop a pelvic floor disorder (PFD).

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Has Your Constipated Child Achieved the "Spontaneous Poop"?

Steve Hodges, MD

Has your child achieved the vaunted “spontaneous poop”?

That’s a hot topic in our private Facebook support group! “Spontaneous poop” is a term I mention in The M.O.P. Book but don’t explain in detail. It’s worth further discussion.

By “spontaneous poop” I mean a bowel movement that is not preceded by an enema — one that the child feels coming on and “just happens.”

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Sleep Health

By Dawn Sandalcidi, PT, RCMT, BCB-PMD

One third of the US population suffers from sleep disorders. Sleep disruptions occur across a person’s lifespan, for example:  erratic sleep patterns during teen years, new babies, work or kid stresses, hormones and pain are all big culprits when it comes to having difficulty falling asleep, staying asleep or getting sufficient sleep. 

Getting good sleep is necessary for optimal health and poor sleep impairs function. 

Quality sleep is imperative for the function of your body systems including:  immune system function, healing, pain management, cognitive function, learning, memory and cardiovascular function.

Sleep is a basic human need. Without adequate sleep, people can experience:

·         Increased pain perception 

·         Loss of function

·         Decreased quality of life

·         Increased depression and/or anxiety

·         Attention deficits

·         Disruption in ability to process information

·         Memory impairment

·         Decreased ability to learn new motor skills or exercise putting people at risk for balance issues and falls 

·         Decreased functioning in work related and recreational activities, as well as self-care


The cost of insomnia is over $100 billion per year! 

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PARENTS: Advocate for Your Child to Use the Bathroom at School!

By Dawn Sandalicidi, PT, RCMT, BCB-PMD

I have been working with children who experience bowel and bladder issues for over 30 years. One of my primary concerns is that children are not allowed to use the bathroom during the school day except for scheduled times. This leads to holding patterns and decreased fluid intake throughout the day, which can lead to constipation and bladder and bowel problems!

This is a crazy cycle that needs to stop!  Parents need to educate themselves on normal bowel and bladder health.

I can certainly understand the concern teachers have with children taking advantage of bathroom privileges. However, in the elementary school population, children always want to please their teacher and feel ashamed if they need to ask to use the bathroom too often.  Middle school students lose homework passes and classroom privileges for using the restroom and are given rewards for NOT listening to their bodies.

Shana Peeples, 2015 National Teacher of the Year, had a unique approach.  She allows her students to use the bathroom whenever they feel the need as long as they're respectful when they get up to leave the room and return without disruption.  Her approach was not always well received with administration however it has worked!  In her article (linked below), she discusses trusting the students with their own bodily functions.

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How to Avoid a Bedwetting Relapse!

By Steve Hodges, MD

When bedwetting stops, it's easy to move on with life — that's when constipation creeps back.

To avoid relapse, it's critical to complete the entire M.O.P. regimen. You may even want to maintain daily enemas after your child has 7 days of dryness — perhaps an extra week or two. Then, stick with enemas every other day for more than the recommended 30 days.

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Taking Control of Your Pain: Part 1

By Mara Towne, PT, DPT

Pain. Even reading the word evokes a negative feeling for most people.  This can be especially true when a person has been dealing with pain for several months or years!  Pain is a protective mechanism.  Without pain we would not be able to live. However, when pain becomes chronic, it no longer protects us and often hinders our day to day activities. Chronic pain consumes people’s lives.  Often people have numerous tests and appointments with different specialists trying to find the source of their pain. With all this back and forth, you can lose your sense of self in the process. It is very challenging to know what you can do to manage your pain on your own. Where can you begin?

This blog is part 1 of a series in which we will unravel what people can do to manage their pain at home with help and support from their physical therapist. The materials and information in this blog are from an excellent continuing education course called, Transforming Your Clinical Practice: Integrating Cognitive, Behavioral and Motivational Skills into Physical Therapy presented by Kristin R. Archer PhD, DPT and Stephen T. Wegener PhD, ABPP of Vanderbilt University. The handouts attached are reproduced and distributed with their expressed permission.

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By Kristin Anderson, PT, DPT, OCS, CLT

Have you noticed the “Me Too” campaign occurring on Facebook? The campaign is designed for women to post “Me Too” if they have experienced any form of sexual trauma in their lives.

If you have seen the campaign, what where your initial thoughts?  Did the number of women who posted surprise you?  Did you yourself post or did you privately know you had experienced sexual trauma as well?  Regardless of your response, did you know that 1 in 3 women experience sexual assault in their lifetime?

In addition to emotional distress, physical changes and pain can also occur from sexual trauma. If you or a loved one has experienced sexual trauma and now have pain with penetration (from a tampon, women’s wellness exam or intercourse), this could be due to the trauma you’ve experienced.  Why does this occur?

After we have experienced trauma, our bodies want to protect ourselves. To protect our bodies, our autonomic nervous system (which is the part of the nervous system responsible for our fight or flight response) can cause an involuntary response to increase the muscle tension of the pelvic floor.  Even though you may be in a safe situation, for example: getting a speculum exam from a trusted doctor, you may still experience pain. What can you do about this?

Physical therapy may be the answer!  Physical therapists are trained to help restore normal muscle tension and utilize strategies to help the body understand how to adapt to healthy situations. It is also important that you form a team around you to support yourself after a trauma has occurred. This team can include a psychologist and a physician, as well as, a physical therapist. 

There is help to heal both physically and emotionally! Contact us today.  Our experienced, compassionate and caring staff wants to help!

Physical Therapy’s Scope of Practice Extends Beyond Aches and Pains

Physical therapy is an obvious choice when you’ve sprained an ankle or developed tennis elbow, but what about when you need to boost your mood? Though highly skilled in methods that improve mobility and reduce pain following an injury, physical therapists can also play a key role in improving a patient’s mental health.

Exercise, a core component of any physical therapy regimen, is known to benefit patients with mild to moderate mood disorders such as depression. Depression is an underlying condition often associated with chronic illnesses and orthopedic injuries that limit mobility and participation in daily activities. With depression affecting one in 10 Americans at some point in their lives, physical therapy is another avenue to diagnose and treat the associated symptoms.

Physical activity reduces feelings of anxiety, depression and stress by improving the patient’s cognitive function and self-esteem. Moreover, studies have shown that aerobic exercise decreases overall tension levels, elevates and stabilizes mood and improves sleep. Because exercise’s mind-altering effects are temporary, however, patients should work with a physical therapist to develop a regular exercise routine to ensure continued benefits.

Patients can expect to work closely with a physical therapist to develop a custom treatment plan based on a thorough assessment and detailed patient history. PTs are trained to recognize the signs and symptoms of depression and identify the ways in which mental health disorders interfere with a person’s ability to enjoy life. Each individual care plan includes some combination of flexibility, strength, coordination and balance exercises designed to achieve optimal physical function.

Physical therapists may be trained to identify and treat a wide range of movement disorders including sprains and strains but they’re also adept at identifying and reducing symptoms of depression. Developing behaviors that maintain good mental health is an important part of overall health and wellness, and it’s never too late to get started.