Understanding Pelvic Health: Interview with Pelvic Floor Therapists

 

Tiffany Baker, PhD (eligible), PT, DPT, CFMT, C.Ac., CPT (NASM-PES)
Baker Physical Therapy,
Greenwich, CT

 

Kelly Shroeder, PT, DPT, CLT, MBA
TheLippyPT

 

In this insightful interview, pelvic health experts Tiffany Baker, PhD (eligible), PT, DPT, CFMT, C.Ac., CPT (NASM-PES), and Kelly Schroeder, PT, DPT, CLT, MBA, discuss the intricacies of the pelvic floor, the importance of pelvic health for women, particularly those with Lipedema, and what to expect from pelvic floor therapy. Their combined expertise offers valuable information for anyone seeking to understand and improve their pelvic health. 


What is the pelvic floor? 

Kelly Schroeder (KS): The pelvic floor is a group of muscles and connective tissue that sits on the inside of your pelvis. These muscles span from sit bone to sit bone, and from the pubic bone to the tailbone [See more about pelvic floor anatomy in the “Anatomy” section here]. The pelvic floor supports and holds your bowels and bladder in place, and in females, the uterus and vaginal canal. It assists with urination, bowel movements, and sex. The pelvic floor also makes up the bottom of our core. Our core is a “canister” of muscles that help support our back and pelvis. Other muscles in the core include the diaphragm, abdominals (particularly the transverse abdominis), and muscles in the back. It is important that your pelvic floor works in coordination with all the other muscles in your core to provide stability. 

Tiffany Baker (TB): There are three layers of the pelvic floor, each responsible for different functions and movements. The pelvic floor region also contains a number of lymphatic vessels and nodes, which are part of the body’s immune system and help fight off disease and infection. Additionally, arteries and veins are found alongside these lymphatic vessels. The pelvic floor helps pump lymph between the pelvis and the abdominal organs, supporting the movement of lymph throughout these regions.  

Why is pelvic health particularly important for Lipedema patients? 

TB: Sexual dysfunction impacts roughly 45% of women in the US population [1], and 28.1 million American women have at least one pelvic floor disorder and this number is expected to jump to 43.8 million in 2025. 9.2 million women will experience pelvic floor prolapse [2], and 30 million women in the United States have irritable bowel syndrome [3]. Research shows that women with increased body weight and subcutaneous fat have a statistically significant decrease in sexual interest [4]. Current research demonstrates that about 11-42% of women with Lipedema are overweight, and 8-76% are obese class 1 [5, 6, 7, 8, 9, 10]. A systematic review concluded that being overweight and obese impacts overall sexual health and life satisfaction [11]. 

Sexual dysfunction and lower urinary tract disorders are linked in multiple studies [1, 5, 12, 13, 14]. I will be gathering data later this year to support standardized tests and measures that will help inform insurance coverage and care for patients with Lipedema.  

Increased weight demands from tissue, fluid, and force can cause increased tension and strain on the muscles and bones. Clinically, we have seen patients with trauma, pain, and bone changes to the coccyx and other pelvic girdle tissues due to postural changes and added weight, requiring treatment. 

KS:  Many people with Lipedema have hypermobility or hEDS, which increases the risk for prolapse and pelvic floor pain [it is estimated in the Standard of Care for Lipedema in the United States that 50% of women with Lipedema have hypermobile joints]. The pelvic floor may become too tight to compensate for laxity in other parts of the body or too loose to support pelvic organs. The research supports an increase in pelvic floor prolapse in persons with joint hypermobility. For those with hypermobility, it is important to alert your obstetrician and care team, as increased attention and care during pregnancy may be required. 

TB: Grade 1 and 2 prolapse [find more information about Pelvic Organ Prolapse here] can be successfully treated by physical therapists, and if surgery is required, it is highly recommended to see a physical therapist before and after. Women with Lipedema struggle with pain that may make movement difficult, leading to fluid buildup in the pelvis and abdomen, muscle atrophy, and histological changes in tissue. 

KS: A recent study found that about 33% of women with Lipedema have gastrointestinal problems. IBS and chronic constipation can cause stress on the pelvic floor, increasing the risk of pelvic floor pain [15]. Straining to go to the bathroom increases the risk of prolapse, diastasis, and hernias. This study also found that about 26% of women with Lipedema have urinary incontinence, which increases with stage and upper extremity involvement [15]. 

Postural changes increase the risk for pelvic floor problems. With Lipedema, extra tissue can cause postural changes that stress the pelvic floor. We often see changes in foot and knee alignment, and over time, pelvic floor muscles may compensate for flat feet or turned-in knees, causing them to become too tight or weak. 

Inflammation and a buildup of proteins in the extracellular space can prevent muscles from firing correctly and negatively impact the pelvic floor and core muscles. Research shows that movement and exercise can help reverse this imbalance, and physical therapists can guide safe, progressive movements to restore balance. 

If swelling isn’t managed well during the day, fluid can influx back to the kidneys at night, potentially irritating the pelvic floor and bladder, causing pain, tension, or problems going to the bathroom. Hormones can also affect the pelvic floor and connective tissue, increasing the risk of prolapse or vaginal dryness. 

Are women who have given birth and also have Lipedema more likely to require pelvic health support? 

KS: I believe all women deserve pelvic health therapy before and after birth. This is standard care in other countries but unfortunately not in the US. In addition to managing Lipedema itself, we need to account for associated conditions like hypermobility, swelling, varicose veins, mental health, vitamin deficits, POTS, and MCAS. Although there is no research to show if Lipedema increases a woman’s risk for postpartum issues, some risk factors for pelvic floor problems postpartum are often seen with Lipedema. Proper nutrition and exercise are important for postpartum healing and breastfeeding. A pelvic floor therapist can help with safe exercise, birth prep and positioning, breathing, relaxation, and pain management strategies. 

TB: I agree that pelvic health should be standard care. Annual visits with physical therapists should be considered as part of musculoskeletal health and wellness. Many physical therapists have direct access, meaning you do not need a script to see us. Clinically, I have seen an improvement in symptoms and comorbidities during pregnancy, possibly due to the dampening of the immune system. It is important to understand the vulnerability of a Lipedema patient during this time. 

If you have a family history of Lipedema, about 53% of women believe the onset occurred during or after pregnancy [15]. There can be a worsening of symptoms immediately following delivery due to changes in the immune system and the return of immune-related issues. A pelvic floor therapist can help with managing the fatigue of motherhood on top of chronic fatigue from Lipedema. 

How does someone know if they should pursue pelvic floor therapy? 

KS: You should seek out a pelvic floor therapist if any of the following apply: going to the bathroom or having sex is painful; you have leaking or incontinence of urine or stool; you feel excessive pressure or heaviness in your pelvic floor; you feel like you can’t empty your bowel or bladder completely; you have a hard time starting or stopping urination or a bowel movement; you use the bathroom more frequently than every two hours during the day or get up two or more times at night; or you have pain in your hips, groin, low back, or tailbone that won’t resolve. Additionally, sitting for prolonged periods increases symptoms. In my opinion, all women should have access to pelvic floor therapy pre- and post-pregnancy.

TB: You should pursue pelvic floor therapy after delivery of a child if you have an increased push phase longer than one hour, if you have tears or require an episiotomy during delivery, if you have diastasis recti, or if you’ve had a cesarean section. Any pain in the pelvic floor or abdominal region greater than a 2-3 on the visual analog scale [a pain measurement scale with a rating from 1-10], any continence issues, or changes that last longer than a few days should be addressed. Pelvic floor PT is also recommended for pain in the pelvic floor region, pain with sex, standing, sitting, during exercise, constipation, and urinary incontinence issues. One validated screening tool that is used both in the clinical and research fields is the Urogenital Distress Inventory, short form (UDI-6). This tool identifies whether women have urinary incontinence specific to lower urinary tract dysfunction and genital prolapse, and examines quality of life and ability to participate in activities of daily living. The higher the score, the greater the severity of urinary incontinence [16, 17]. 

What should someone expect at their pelvic floor therapy evaluation? 

KS: We will start by getting a history and asking questions about your symptoms and concerns. We may ask you to do certain movements to assess your strength, posture, coordination, and mobility. We may look at how you breathe, how your core muscles work together, and observe your pelvic floor externally. In some cases, we may suggest an internal exam of your pelvic floor muscles, which means inserting a gloved finger into your rectum or vagina. We only do internal exams if the patient is comfortable with it. 

TB: We will conduct special tests to try to recreate your pain or discomfort, determine contributing factors, and rule in or out issues such as nerve entrapment, hip impingement, sacroiliac joint issues, muscle tightness, weakness, and motor control. If necessary, we will do an internal examination of muscles and muscle function. If you are not comfortable with this, we will do everything we can to treat you without the internal piece, and I have always experienced improvements in symptoms for my patients. 

What does pelvic floor therapy treatment include? 

KS: Treatment should focus on your goals and what is important to you. Pelvic floor therapy is not just Kegels. The pelvic floor can get tight and may need to be stretched before it can be strengthened. Exercises focus on stretching and relaxing tight muscles, strengthening weak muscles, and ensuring the correct muscles are firing at the right time. Breathing is also a huge part of pelvic floor therapy. We may do soft tissue work externally or internally to help tissues move as they should and free up restrictions. We will help with scar tissue mobilization and movement of tissue to encourage proper healing. We can also train the brain to recognize safety and rewire pathways that send inaccurate messages to the pelvic floor. 

TB: We provide a lot of education and may suggest modifying certain activities. Topics may include diet and fluid intake, different positions for using the bathroom, sex, birth, bladder retraining, and sleep. We may use modalities like dry needling, taping, electrical stimulation, biofeedback, ultrasound, or cupping. Education is key, and we provide expert advice on diet, nutrition, exercise progression, pelvic health, and the mind-body connection. We will also suggest when to see another provider or add another provider to your care team. 

What’s the best way for a patient to find a provider who specializes in pelvic health? 

KS: Websites like pelvicrehab.com and choosept.com can be helpful. I recommend starting with the Lipedema Foundation’s Provider Directory to find a therapist familiar with Lipedema. If they can’t treat your pelvic floor conditions, they can likely refer you to another clinician who can. 

TB: Local or moms' Facebook groups can also be a resource, especially if you are in an area without a listed provider. It’s important to verify the accuracy and integrity of online resources.

What online resources are available to patients? 

KS: The Lipedema Foundation website is invaluable for information on Lipedema. The FDRS videos on YouTube are also helpful. 

TB: As a researcher and clinician, I find that most online resources are not accurate and some can be harmful. The most reliable sources are the Lipedema Foundation, hospital or university posts, the American Physical Therapy Association, and evidence-cited content from clinicians like Kelly and me. Always be curious, informed, and cautious when consuming online information.  

Pelvic health is a crucial aspect of overall well-being, especially for Lipedema patients, and understanding it can significantly impact one's health and treatment journey. We hope this interview with these experts provides valuable insights and encourages you to explore pelvic floor therapy if needed. Remember, seeking professional help and gaining knowledge is the first step toward better health and well-being. 

 

To learn more, visit Lipedema.org or contact us today. 

References 

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