Physical therapy for endometriosis


Pelvic physical therapy: Another potential treatment option

This treatment approach may help provide relief for many women with chronic pelvic pain and urinary symptoms.

Published: June, 2018

The exact cause of pelvic pain for many women can be elusive, despite lots of tests and scans. In some cases, the symptoms are related to a problem that is often overlooked, says Dr. Eman Elkadry, an instructor in obstetrics, gynecology, and reproductive biology at Harvard Medical School. Pelvic pain may stem from a pelvic floor muscle problem that can be helped by a specialized form of physical therapy known as pelvic physical therapy.

“Although pelvic physical therapy may not work for everyone, it can be quite effective for certain individuals,” says Dr. Hye-Chun Hur, director of the Division of Minimally Invasive Gynecologic Surgery at Harvard-affiliated Beth Israel Deaconess Medical Center and associate faculty editor of Harvard Women’s Health Watch. She stresses that pelvic physical therapy is normally undertaken by a trained female practitioner.

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Pelvic floor physical therapy involves the pelvic floor muscle group, which is responsible for a variety of functions. These muscles support the pelvic organs, assist in bowel and bladder control, and contribute to sexual arousal and orgasm.

A person may be referred to pelvic floor physical therapy to treat incontinence, difficulty with urination or bowel movements, constipation, chronic pelvic pain, and painful intercourse.

Women may see a pelvic floor physical therapist for treatment of vaginismus or endometriosis. Male disorders, such as painful ejaculation and premature ejaculation, can also be treated this way.

Pelvic floor physical therapists might use several techniques:

  • Education. Patients may need to learn more about their pelvic anatomy and how different components work alone and together. They may also need to learn how habits or hygiene affect their symptoms.
  • Pelvic floor exercises. Patients are taught how to contract and relax pelvic floor muscles in relation to other muscles. They are also taught breathing and timing techniques to make the exercises more effective. Such exercises can stretch tight muscles, strengthen weak ones, and improve flexibility.
  • Manual therapy. A physical therapist may use hands-on massage or stretching to help with posture, blood circulation, and mobility.
  • Pelvic floor biofeedback. Biofeedback is a technique that can help patients “see” how the pelvic floor muscles are working. To do this, a probe is inserted into a woman’s vagina or a man’s anus and results are displayed on a computer screen.
  • Electrical stimulation. A low voltage electrical current may be used to teach patients how to coordinate their muscle contractions.
  • Vaginal dilators. These tube-shaped plastic devices can help women learn to relax their pelvic muscles to allow easier penetration. Women who have been treated for gynecological cancer may also find them helpful for vaginal rehabilitation after treatment.

Pelvic floor physical therapy may be part of a treatment plan involving primary care physicians, sex therapists, and mental health professionals.

What is Pelvic Floor Dysfunction (PFD)


The Initial Evaluation first involves a detailed history/discussion of all your symptoms related to the pelvic floor. Your DPT will listen to your main concerns. then will ask questions about specific complaints of lower back pain; hip pain; abdominal pain/bloating; surgeries that may have resulted in increased scar tissue/adhesions. Questions will be asked about bladder symptoms such as leaking, urgency, “key in lock”, hesitancy. Questions about bowel symptoms such as constipation, fecal incontinence manual disimpaction; if you spend more than 5 minutes straining on the toilet. Questions about sexual symptoms such as painful intercourse, erectile dysfunction, perineal pain, fear of penetration and difficulty with orgasm. It very common that patients may be referred to PT with one pelvic floor diagnosis, and during our history taking, we realize that there are some other pelvic floor symptoms. For example, a woman may have a diagnosis of “Stress Urinary Incontinence” and we discover there is a concurrent symptoms of constipation and dysparuenia.


After our detailed history taking and answering your questions, your DPT will educate you on anatomy of the pelvic bones and muscles using our anatomical model. This helps you visualize and understand the structures your DPT will be examining. We believe that education is empowering, so we spend time to review the anatomy, review the purpose and step by step of our pelvic floor physical examination. When you are ready to commence with the physical examination, we will ask for your permission. We understand the need for privacy, comfort, respect and patient’s involvement in their return to full pelvic floor health.


You will be comfortably positioned and draped before your DPT visually inspects the external pelvic region for skin color, tissue alignment while at rest. After the visual inspection, your DPT will ask you to perform some pelvic floor movements,. Such as asking you to contract or tighten your pelvic floor (sometimes known as “Kegel”). Then your DPT will ask you to relax the pelvic floor, observing the quality of the movement, then to “bear down” . Your DPT observes the excursion, hestitancy or inability to perform these movements. Many patients may not know how to do one or all of these movements and this is a common response especially when the pelvic floor muscles are in spasm, or weak or uncoordinated. Next, your DPT will palpate or feel the skin, connective tissues and muscles of the external hip, thigh, abdomen and pelvic floor regions to note for pain, mobility, restrictions, banding, referred pain to other regions.

With your permission, the internal exam follows. The internal exam is where the DPT inserts her gloved (non latex), lubricated (K-Y or astroglide gel) index finger intravaginally or intrarectally up to the level of the pelvic floor muscles, which is approximately 1 inch from the anal or vaginal opening. Your DPT will palpate or feel for tissue excursion, if one side is more flexible vs the other side, again noting pain, adhesions, trigger points and if her palpation over specific muscles reproduces your symptoms (a good sign).

Muscle strength testing of the pelvic floor follows with the DPT’s index finger remaining internally to feel for quality of muscle contraction. Your DPT will measure how strong your pelvic floor muscles are, how long can your muscle maintain that strong contraction up to 10 seconds and can this be repeated up to 10 repetitions.

Biofeedback testing may be next. “Bio” means body and “Feedback” means receiving information about a physiological activity. Biofeedback measures the electrical activity of the muscle and transmit that information to either a range of numbers and/or sounds. The patient sees the numbers and learns how to retrain their pelvic floor muscles with the guidance of the physical therapist. Your DPT will either insert either a vaginal sensor (width and length of a female index finger) intravaginally or use a rectal sensor (width and length of a female pinky finger) which is inserted intrarectally slowly, and with concious use of breath. The internal sensors have small metal strips to pick up the electrical activity of your pelvic floor muscles. For children/teenagers patients, we do not use internal sensor, rather small round surface electrodes are placed externally on the skin near the anus for most accurate reading of pelvic floor muscle activity. Your DPT will measure the electric voltage (microvolts) that your pelvic floor muscles elicits during rest, during slight contraction, during full contractios. We will measure if your muscle returns to full baseline rest following contractions, whether your muscles have good endurance etc. Biofeedback training is utilized during follow up physical therapy treatments to help you learn how to either relax or recruit your pelvic muscles and regain normal function.


DPT’s are specifically educated (7 -8 years in total education from college to a 3 year DPT program at accredited university) to examine all the musculoskeletal, neurological aspects relating to pain, movement patterns and we’ve learned wide range of therapies to correct these dysfunctions. We’ll discuss our finding and tests results with you and discuss our treatment plan for your optimum return to healthy pelvic floor/core. Treatment can include manual techniques such as myofascial release, visceral mobilization, connective tissue massage (skin rolling), trigger point massage. These techniques release intramuscular tension, mobilize the nerves, improve mobility of connective tissue, and improve the mobility of organs that lie beneath the skin and muscles. We will also teach you a tailored therapeutic exercise routine to improve flexibility, strength, balance and coordination.


You will be taught a specific posture, body awareness technique, self-massage, or given a stretch so you can immediately incorporate all that you have learned in the Initial Evaluation and start on your road to recovery.


Your DPT will guide you on the best frequency of treatment. After 17 years of healing thousands of patients, it is our experience that consistent weekly therapy treatments along with our patients performing their tailored home exercise program results in faster gains in their return to pain free normal function. Skin, connective tissue, muscles and joints that have been in faulty movement patterns for weeks, months and years (we see many patients with 10 to 20 years of pelvic floor symptoms) requires time to reduce spasm, adhesions, restrictions and require regular, gentle manual guidance by our trained hands to reverse these patterns. It is common for our patients to “clear their busy schedules” to attend PT 2=3 times a week consistently for the first month or so of care. With our regular scheduled re testing, we will guide you on when you can lower your frequency of care and be more independent.

Whether you’ve experienced symptoms for two months or 20 years, we can help you find relief, decrease pain, and return to normal function.

Conditions treated:


  • Painful intercourse (Dyspareunia)
  • Provoked/Unprovoked Vaginal/Vulvar Pain (Vulvodynia)
  • Vestibulodynia (Provoked/Unprovoked Pain at the Vestibule)
  • PGAD (Persistent Genital Arousal Disorder)
  • Urinary Urgency
  • Endometriosis
  • Interstitial Cystitis
  • Pelvic Organ Prolapse
  • Urinary/Fecal Incontinence
  • Diastasis Recti Abdominis, DRA (Pre/Postpartum)
  • Gastrointestinal pain
  • Abdominal Bloating
  • Low back pain
  • Hip pain
  • Chronic Pelvic Pain
  • Coccyx/Tailbone Pain
  • Osteitis Pubis (Pubic Bone Pain)
  • Constipation
  • Irritable Bowel Syndrome (IBS)
  • Pudendal Neuralgia
  • Sexual Dysfunction
  • Core Weakness
  • Post Cancer Surgery Recovery
  • Post Hysterectomy Recovery


  • Chronic Prostatitis
  • Post Prostatectomy Recovery
  • Erectile Dysfunction
  • Testicular Pain
  • Penile Pain
  • Incomplete Voiding (Bladder)
  • Constipation
  • Abdominal Bloating
  • Rectal and/or abdominal pain/pressure
  • Irritable Bowel Syndrome (IBS)
  • Chronic Pelvic Pain
  • Pudendal Neuralgia
  • Sexual Dysfunction
  • Rectum/Anal pain
  • Prolapse (Rectum)
  • Interstitial Cystitis
  • Urinary Urgency
  • Urinary/Fecal Incontinence
  • Post Cancer Recovery
  • Core weakness


  • Bedwetting
  • Constipation
  • Daytime Urinary/Fecal Accidents

Pelvic Floor Rehabilitation


As with any physical therapy examination, the evaluation will begin with talking to the physical therapist about your current problem/concern. Information your physical therapist will want to know include where you have pain, what causes your pain, information about previous pregnancies and deliveries, surgical history, and medication history. If you have had any previous bladder testing or imaging, this will be discussed as well. If you are not having pelvic pain, but instead are concerned about bladder retention or leakage, you and your physical therapist will discuss how frequently you are voiding (urinating), diet, activity level, and information regarding pads you have been using along with any surgical history, testing/imaging, and history of previous pregnancies/deliveries.

Orthopedic Assessment

The way your hips and back are aligned can often tell us a lot of information about your pelvic pain. We will begin by watching how you move and walk as well as checking alignment and typical muscle testing. We will also check for diastasis recti, or a separating of the abdominal wall that is common post-partum.

Pelvic Floor Muscle Exam

The pelvic floor muscle examination is very different from the typical pelvic exam you are used to having performed at a gynecologist’s office. The pelvic floor muscle examination will be completed in a private treatment room with your physical therapist. Another person may act as a chaperone to be present in the room if you request, otherwise it is a one-on-one treatment session. The pelvic floor muscle examination requires the patient to undress from the waist down but draping will performed for privacy. The physical therapist completes the exam using a gloved hand as the testing instrument. No speculums are utilized. For this examination, the physical therapist will examine the perineal area (vaginal area) externally to look for any asymmetries, scarring, or tissue abnormalities that help us identify areas of inflammation or irritation. Following this external examination, an internal examination will be performed with the patient’s permission. The internal examination utilizes a gloved hand as the physical therapists tool to assess the muscles of the pelvic floor. Through palpation of the vaginal wall, the physical therapist can assess muscle tightness, areas of tenderness or pain, and muscle strength. The pelvic floor muscles will be assessed for strength to better help understand areas of weakness and dysfunction.

Plan of Care

Through this examination, the physical therapist will find any muscle weakness, tightness, and areas of dysfunction. Combined with the history, this helps the physical therapist create a treatment plan for your pelvic pain or bladder dysfunction. Treatment often involves manual treatment both internally and externally, strengthening, relaxation training, and behavioral interventions that all work together to solve your problem!

Here’s Exactly What to Expect During Your First Pelvic Floor Physical Therapy Visit

Come to your first pelvic floor physical therapy appointment prepared, confident and ready to start your healing journey.

We understand the discomfort of the unknown. As you consider taking steps toward beginning your pelvic healing journey, you might start to ask yourself, “Wait…how does this actually work?” Many times, we get questions like:

  • “What do I wear?”

  • “What does a pelvic floor physical therapy appointment look like?”

  • “Do I have to do an internal exam?”

  • “How is pelvic floor therapy different from a typical visit to a doctor or orthopedic physical therapist?”

In efforts to answer these questions to the highest degree of convenience for our patients’ experiences, Dr. Julie Sarton, PT, DPT, WCS (Owner and Founder of Sarton Physical Therapy) sat down to answer those questions. We want you to walk through our doors with confidence that you are in the right place, taking the right steps toward a life not constrained by pelvic floor dysfunction. This video resource walks you through:

Step 1: Paperwork

Step 2: Pre-treatment Chat

Step 3: Pelvic Anatomy Education “Crash Course”

Step 4: Objective Exam

Step 5: Posture Assessment

Step 6: Fascial & Muscular Layers Assessments

Step 7: Internal Exam

Step 8: Change Clothes

Step 9: Plan of Action

Step 10: Begin Your Healing Journey/Next Steps

More information is available at If you still have questions, please contact us.

So your doctor has referred you to a Pelvic Physical Therapist… Now what?

You may be wondering how this will help with your concerns and symptoms. You may be wondering “how does this work”. What will happen during the first visit and follow up treatments. You may be feeling anxious or nervous. You may wonder if we treat women and men. You may feel like you have a hundred questions. Well, you are not alone! We hope this will help to ease some of your concerns and questions.

Pelvic Physical Therapy has been around for over 25 years. Don’t feel bad if you have never heard of it. Most people that we see have never heard of it. Pelvic Physical Therapists are specially training in the anatomy of the pelvis and surrounding area; muscles, joints, nerves, organs, connective tissue, and how this may be contributing to your symptoms.

What to expect on your first visit with a Pelvic Physical Therapist.

Please download and complete Patient History forms and Pelvic Patient forms (for Male or Female)

Please arrive as instructed 15 minutes before your appointment to have all the necessary paperwork completed.

Please bring:

  • Prescription
  • ID – Drivers License
  • Insurance card
  • Any tests and records that you think may be relevant to your concern
  • Form of payment

Arriving early to take care of paperwork will prevent cutting into valuable time with your Pelvic Physical Therapist.

  • Your Pelvic Physical Therapy will take a though history and discuss your symptoms. For example, if you are seeking treatment for urinary incontinence (aka urinary leaking) You will be asked questions such as how frequently does this occur, what causes you to leak urine, are you wearing pads, etc.
  • You will be educated on anatomy, muscle, joints, nerves, organs, connective tissue that may have a role in your symptoms.
  • Based on your history and symptoms an exam will be perform. This may include observation and palpation of back, pelvis, hips, abdomen and pelvic floor. Your therapist is looking for restrictions of mobility or movement, cause of pain or cause of pain that is referred to another location. For example, if you had a C-section, is there a restriction in the scar or connective tissue? This may be contributing urinary incontinence.
  • Next, your therapist would like to do an internal exam of your pelvic floor. Ladies, don’t panic! No speculum is involved, only a gloved finger. Gentlemen, same for you, one gloved finger.

We know that many of you don’t like being touched and especially “down there” this may feel like a deal breaker. Your Physical Therapist will absolutely respect your wishes and will not force this on you.

But let me explain why this is an important part of the exam. When symptoms such as burning, throbbing or aching are described as “deep inside.” Or feeling of heaviness on pelvic floor from pelvic organ prolapse (POP) Being able to palpate the muscle, connective tissue or nerve, will us give valuable information as the cause of your symptoms and how best to treat them.

For example, palpating the pelvic floor, your therapist may determine you have muscle trigger points causing ineffective muscle contraction or pain. Or tight connective tissue that may restrictive decreased blood flow and increase (hyper) sensitivity – pain

If this does not put your mind at ease, please, still come to the first visit and discuss your concerns with your therapist. It makes us feel sad that you have symptoms or concern and are willing to continue with your symptoms and not seek help from a Pelvic Physical Therapist because you don’t want a pelvic floor assessment.

  • After the assessment is complete, your Pelvic Physical Therapist will discuss her findings, explain what will be included in your treatment. Treatment may include manual techniques such as trigger point release, visceral mobilization, connective tissue release, scar tissue release, stretches, exercises, E-stim, or Biofeedback.
  • You will be given “homework”. I can already hear the sigh! You may only have treatment 1 or 2 x week. If you are not making changes in daily habits, exercising, stretching etc, your Physical Therapist will spend the hour undoing a weeks worth of something that is contributing to your symptoms. For example, if you are sitting all day in a slouched posture, it may be causing your pelvic floor muscle to be tight and ineffective to control urinary incontinence or cause your pain. Unfortunately, if you don’t do your “homework” then you will see minimal improvement in symptoms and not get the outcome you desire.

We hope this has answered your question and put you at ease. If you still have questions, please call your nearest office providing Pelvic Physical Therapy and ask to speak with the Pelvic PT. She will gladly answer your questions.

Current offices with Pelvic Physical Therapy are Orlando-downtown, Winter Park, Waterford and Sanford.


Original Editors – Rebecca Clark from Bellarmine University’s Pathophysiology of Complex Patient Problems project.

Top Contributors – Rebecca Clark, Kim Jackson, Elaine Lonnemann, Laura Ritchie and Wendy Walker


Endometriosis is a female reproductive disorder which affects the lining of the uterus, otherwise known as the endometrium. This estrogen-dependent disorder is defined by the presence of endometrial tissue outside of the uterus and becomes apparent after the start of menses.

In a typical monthly menstrual cycle, endometrial cells lining the uterine walls are stimulated through a release of hormones and multiply in order to provide an ideal environment for egg fertiliztion. If fertilization of the egg does not occur, the uterus sloughs off the lining of blood (endometrial tissue) and menstrual flow occurs for 3 to 5 days.

When affected by endometriosis, endometrial tissue is misplaced outside the uterus in various places. Despite the location of the tissue, the same monthly menstrual cycle occurs. The misplaced tissue engorges with blood, as it would in the uterine lining. Since this blood has no course to drain out of the vagina it remains where it is resulting in “chocolate cysts” wherever endometrial cells are located. In addition to cysts, trapped blood may lead to scar tissue, adhesions and irritation of the surrounding tissue which causes pelvic pain and fertility problems.

Blood deposits or ectopic implantation may occur anywhere in the body but most commonly affects the ovaries, fallopian tubes, broad ligaments, bladder, pelvic musculature, perineum, vulva, vagina, or intestines. It has been discovered that endometrial tissue has the ability to migrate through the body, and, in less common cases, has been found in the abdominal cavity, kidneys, small bowel, appendix, diaphragm, pleura, bone and even the brain.


The incidence of Endometriosis has been on the rise in Western countries for the last 40 to 50 years. Although there are statistics in the literature, the true prevalence of endometriosis is unknown because many women remain asymptomatic. It has been reported that endometriosis occurs in a wide range of 7%- 60% of all women. Further Reports in 2008 revealed that endometriosis occurs in 7%-10% of women in the general population, 2%-50% of women suffering from infertility, and 71%-87% of women with chronic menstrual pain. Unlike many common disorders, there have been no correlations between endometriosis and specific populations. Endometriosis has been shown to affect women of all race, cultures, ethnic origins, socioeconomic status, and geographic backgrounds.

Characteristics/Clinical Presentation

Generally, endometriosis becomes apparent soon after menses begins in early teen years, and symptoms continue until menopause. Although any woman of child-bearing age is at risk of developing Endometriosis, it is more common in those who have postponed pregnancy.

Endometriosis has been shown to vary in its degree of severity. In order to gauge the level of severity, the American Society of Reproductive Medicine has developed five stages of classification: I (minimal), II (mild), III (moderate), IV (severe), V (extensive). Despite these classifications, symptoms do not always correlate with disease severity. Many women with severe endometriosis have little pain or remain asymptomatic, while some with minimal or mild classification may experience intense symptoms affecting quality of life. It is likely that if gone untreated, symptoms will progress and worsen over time.

Common Sign and Symptoms

  • Abdominal pain, fatigue and mood change beginning 1-2 days before menstruation and continuing for the duration
  • Constant/intermittent, or cyclical pelvic and/or low back pain (unilateral or bilateral)
  • Infertility – often first diagnosed in women who are seeking treatment for infertility
  • History of ectopic pregnancy or miscarriage
  • Dysmenorrhea (painful menstruation) – commonly identified as the chief complaint if implants are located over the uterosacral ligaments
  • Dyspareunia (painful intercourse) – local adhesions may be irritated by penile penetration
  • Painful defecation – adhesions may be present over the large bowel. As faecal matter moves through the intestines these adhesions can be stretched causing local irritation.
  • Low-grade fever
  • Diarrhoea, constipation, rectal bleeding
  • Referred pain to the low back/sacral groin, posterior leg, upper abdomen, or lower abdominal.suprapubic areas
  • Menorrhagia/menometrorrhagia – excessive or occasional heavy periods may be experienced, along with bleeding between periods

Less Common Signs and Symptoms

  • Chest pain/hemoptysis – due to endometrial implants in the lungs
  • Headache/seizures – due to endometrial implants in the brain

Associated Co-morbidities

  • Several health problems have been shown to exist in combination with endometriosis.
  • A large percentage of women experience co-morbidities such as:
  • Fibromyalgia
  • Hypothyroidism
  • Chronic fatigue syndrome
  • Allergies
  • Asthma
  • Rheumatoid arthritis
  • Multiple sclerosis
  • Systemic lupus erythematosus
  • Auto-immune disorders


  1. Anti Inflammatories (NSAIDs)- Over the counter or prescribed NSAIDs work by decreasing the pain and amount of inflammation in the region of disease caused by displaced endometrial tissue or scaring. NSAIDs also decrease pain associated with menstrual bleeding by blocking the protein prostaglandin.
  2. Birth Control Hormones- creates hormone levels in the body similar to those during pregnancy. This may slow or cease the growth of endometrial implants, and stop the shedding and discharge of menstrual fluid which will lead to a decrease in pain. This treatment may be used in the form of a pill, patch or ring and has been shown to have the least amount of side effects.
  3. Gonadotropin Releasing Hormone Agonist (GnRH-a)- This form of hormone treatment lowers estrogen levels in the body producing a state which mimics menopause. Typically this form of treatment is utilized in more severe cases where the pain is not relieved by birth control hormones and NSAIDs. GnRH-a works by stopping the growth-shrinking implants which in turn reduces pain.
  4. Progestin (pill or shot) – This form of hormone therapy works to create levels of progestin in the body similar to pregnancy. By mimicking the hormonal characteristics of pregnancy ovulation ceases and estrogen levels lower which causes shrinkage of endometrial growths and reduced pain.
  5. Danazol – Increases androgen levels and decreases estrogen levels to create a menopause-like state. Similar to previous hormone therapy, this shrinks and stops the growth of endometrial implants which typically reduces pain. Treatment effects last approximately 6-12 weeks and may produce adverse signs/symptoms.
  6. Aromatase Inhibitors – May provide relief in women who have not had improvements with hormone therapy. Aromatase works by inhibiting the amount of estrogen the tissue can produce. Studies have shown that aromatase inhibitors are effective at reducing pain and preventing the return endometrial growths. This form of treatment is often used in conjunction with hormone therapy such as birth control pills or progestin.

Diagnostic Tests/Lab Tests/Lab Values

The following are common tests used to identify physical clues leading to the diagnosis of endometriosis:

  • Laparoscopy: Accurate diagnosis of endometriosis requires direct visualization of endometrial tissue through laparoscopic procedures. This is accomplished by distending the abdomen through the injection of carbon dioxide for adequate visualization of the reproductive organs. An instrument with a camera (laparoscope) is inserted through a tiny incision near the navel in order to determine if reproductive and abdominal organs possess endometrial implants. Laparoscopy is a valuable tool guiding the course of treatment for endometriosis by identifying the severity, size and location of foreign implants.
  • Pelvic Exam: Manual palpation of the pelvic region to identify abnormalities such as cysts or scar tissue surrounding reproductive organs. Although this exam may reproduce pain in large areas of implantation, it is often not possible to feel small areas, making this test less reliable at identifying the presence of endometriosis.
  • Ultrasound: Ultrasounds work by using sound waves from a transducer wand to create a video image of organs. Vaginal ultrasounds are performed by inserting a wand into the vagina to view images of the reproductive organs, while abdominal ultrasounds are done by moving a wand over the abdominal-pelvic region. Ultrasound is done in order to identify the presence of cysts associated with endometriosis, but it is important to note that this is not a definitive test used to diagnose endometriosis.
  • MRI: An MRI is used to view endometrial implants but proves to be more sensitive in comparison to the use of ultrasound.
  • Blood Labs: Cancer antigen 125 (CA 125) is a blood test that has been used to detect common proteins found in those with endometriosis. This is the same test that is used to tumour markers for various types of cancer. Although this blood test may identify proteins in advanced cases of endometriosis, it is not sensitive to the detection of mild or moderates disease. Due to the fact that this test is not sensitive to early disease detection, it is not recommended as a screening test for endometriosis.


The exact cause of endometriosis is unknown, yet several theories have been developed that explain the existence of displaced endometrial tissue.

  1. The most common theory suggests that menstrual blood containing endometrial cells flow into the pelvic cavity via the fallopian tubes through a process known as retrograde menstruation. This form of endometrial migration has been shown to occur in 90% of women affected by endometriosis.
  2. Another common theory strongly suggests that the presence of foreign endometrial tissue may be due to a faulty immune system. Dysregulation or dysfunction of the immune system allows endometrial cells to spread, and thrive in areas they do not belong.
  3. The spread of endometrial tissue via the lymphatics or vascular system. This form of aetiology could account for the presence of endometrial tissue in the lungs
  4. Meyer’s theory suggests that endometrial cells transform from one type of cell to another through metaplasia which explains the presence of displaced tissue in the joints
  5. Some believe in the existence of “pre” endometrial cells which were responsible for the formation of embryonic reproductive organs. Researchers theorize that genetic or environmental factors allow for the formation of foreign endometrial tissue later in life
  6. Speculation of intraoperative implantation of endometrial tissue due to a hysterectomy or episiotomy has been noted.

Associated Risk Factors

The following factors may place you at greater risk for developing endometriosis:

  • Early-onset of menstruation
  • Never giving birth or postponed pregnancy
  • Family history of endometriosis
  • Frequent menstrual cycles with a duration greater than eight days
  • Medical conditions which block the flow of menstruation (such as a closed hymen)
  • Low body mass index (BMI)
  • Sedentary lifestyle

Systemic Involvement

Endometrial implants can be deposited anywhere in the body. It was once thought that misplaced blood could only be found in the pelvic and abdominal regions, but evidence has proven that migration occurs throughout the body, even affecting bone, lungs and the brain.

Systemic involvement relies heavily on the location of endometrial implantation. Urogenital and Gastrointestinal systems may be affected causing urinary frequency, intermittent dysuria, bloody stools and/or urethral and bowel obstruction.

Medical Management

Endometriosis is a non-curable disease. The objectives of medical treatment focus on restoring normal pelvic anatomy, removal of endometriotic implants, and prevention of reoccurrence to decrease pain and increase fertility. In order to achieve these goals, the course of medical management depends heavily on the severity of symptoms, severity of disease, age and future child bearing plans. Generally, conservative treatment is recommended to control symptoms prior to surgical management.

Treatment Options

  • Medications to control pain – (refer to medication section)
  • Hormone Therapy – (refer to the medication section)
  • Surgical management – less common approach due to unchanged aetiology and rapid implant regrowth.
  • Non-traditional management – (refer to alternate/holistic management)

The main aspect of medical management is aimed at reducing or blocking ovarian function due to the fact that endometriosis is related to hormone function. Common medical treatments and their functions are listed in the medication section. In the instance that symptoms are severe and disabling, or conservative medical treatment fails, surgical procedures can be useful in removing/destroying implants and decreasing or ceasing symptoms. It is important to note that implant regrowth may occur following removal and may only be a temporary source of symptom relief.

Surgical Management

  • Pelvic Laparoscopy/Laparotomy – Identifies implants for the diagnose endometriosis. Once identified, endometrial implants and/or scar tissue is removed using a digital laparoscope device for viewing and surgical tools for excision. Removal has been correlated with the success of conception and is indicated for those trying to become pregnant.
  • Laparoscopic Cauterization – implants are destroyed using a cauterization probe. Indicated if endometriosis is mild with minimal adhesions.
  • Laparoscopic uterine nerve ablation (LUNA) – indicated for patients experiencing intractable pelvic pain. This procedure works by interrupting pain-conducting neural pathways by destroying the efferent uterine sensory fibres in the uterosacral ligament as well as their secondary ganglia exiting the uterus. Uterine prolapse and ureter injury are secondary risk factors that may occur following this procedure.
  • Total hysterectomy – removal of the uterus, both ovaries and fallopian tubes. Indicated for women 35 to 40 years of age who are disabled by pain, and do not wish to continue childbearing. Symptoms return in 1 out of 3 women who undergo partial hysterectomy’s. Total hysterectomy has been shown to be the best surgical procedure in the hopes of curing endometriosis.

Physical Therapy Management

Preferred Practice Patterns

  • 4C: Impaired Muscle Performance
  • 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction

Due to the fact that endometriosis is a common disease in women, physical therapists may encounter this as a primary diagnosis, co-morbidity, or possibly undiagnosed. It is important to be aware of the common signs and symptoms endometriosis presents with, especially those which mask as musculoskeletal.

The decision to treat patients diagnosed with endometriosis is based on the presentation of musculoskeletal and non-musculoskeletal symptoms. Patients with endometriosis may experience pain in the region of the pelvis, abdomen and low back. Secondary musculoskeletal impairments may occur in the region of endometrial implantation. For instance, endometrial implants on the psoas or lumbar musculature may reproduce musculoskeletal symptoms during the examination.

Secondary Musculoskeletal Impairments Caused by Endometriosis

  • Lumbar, sacroiliac, and pelvic floor pain
  • Muscle spasms
  • Trigger points (common in the pelvic floor and lumbar spine)
  • Connective tissue dysfunction
  • Urinary urgency
  • Scar tissue adhesion

Physical therapy may prove to be an integral treatment option for the patient with endometriosis presenting with musculoskeletal impairments. By addressing this disease using a multidisciplinary approach, decreased pain and increased functional capabilities may be provided, allowing for a greater quality of life.

Effective Physical Therapy Treatment Options

  • Modalities
  • Pelvic floor strengthening
  • Internal and external trigger point management
  • Myofascial manual therapy
  • Stretching and flexibility exercises
  • Spinal mobilizations
  • Nerve glides
  • Relaxation exercises

A study entitled Treating Fallopian Tube Occlusion with a Manual Pelvic Physical Therapy was performed in 2008 by Wurn, BF. et al. This study described the efficacy of a non-invasive soft tissue physical therapy treatment in opening bilateral occluded fallopian tubes in infertile women with a history of abdominal-pelvic adhesions. Through this study it was discovered that non-invasive therapy such as manual techniques may be useful as an adjunct therapy in treating tubal occlusion caused by adhesions.

Differential Diagnosis

The ability to differentiate between symptoms associated with pelvic disease remains an integral part of physical therapy examination and evaluation. It is important for physical therapists to complete a thorough examination to include standard screening procedures as well as auscultation for bowel and bruit sounds, palpation for masses, and percussion to assess the integrity of underlying abdominal structures. A number of primary musculoskeletal impairments can manifest as pelvic pain. Receiving a diagnosis of endometriosis may be a long process involving several different health care providers. Studies show that women typically see approximately nine different health care providers before receiving a definitive diagnosis of endometriosis. Below is a list of potential differential diagnoses to consider when evaluating a patient with abdominal, pelvic or low back pain.

  • Dysfunction of the hip, spine, and/or sacroiliac joints
  • Dysfunction of the anterior or posterior abdominal wall
  • Gastrointestinal dysfunction
  • Urinary tract dysfunction
  • Pelvic inflammatory disease
  • Ovarian cysts or tumours
  • Obstructive anomalies


  • The International Endometriosis Association (IEA): Established by Mary Lou Ballweg, RN, PhD. The IEA functions as an online support and advocacy outlet for women diagnosed with endometriosis.
  • Endometriosis Research Center: A lobbying organization working to support those with endometriosis through education.

Why Going to Pelvic Floor Therapy Transformed My Life

Health and wellness touch each of us differently. This is one person’s story.

Confession: I’ve never been able to successfully wear a tampon.

After getting my period at 13, I tried inserting one and it resulted in a sharp shooting, tear-inducing pain. My mom told me not to worry and to just try again later.

I tried many more times, but the pain was always so unbearable, so I just stuck to pads.

A couple of years later, my primary care doctor tried to do a pelvic exam on me. The moment she tried to use a speculum, I screamed in pain. How could this much pain be normal? Was there something wrong with me? She reassured me that it was okay and said we would try again in a couple of years.

I felt so broken. I wanted to at least have the option of sex — to have a relationship with physical intimacy.

Traumatized by the exam, I became jealous when friends could use tampons without problems. When sex entered their lives, I became even more envious.

I purposely avoided sex by any means possible. If I went on dates, I’d make sure they ended right after dinner. The worry of physical intimacy led me to breaking off potential relationships because I didn’t want to have to deal with that physical pain ever again.

I felt so broken. I wanted to at least have the option of sex — to have a relationship with physical intimacy. I tried a few more unsuccessful pelvic exams with OB-GYNS, but the intense sharp shooting pain would return each time.

Doctors told me there was nothing physically wrong, and the pain stemmed from anxiety. They suggested I drink or take an anti-anxiety medication before I tried to have intercourse.

Stephanie Prendergast, a pelvic floor physical therapist who is a co-founder and LA’s clinical director of the Pelvic Health & Rehabilitation Center, says that while information on pelvic floor issues isn’t always easily accessible, doctors can spend some time online looking at medical journals and learning about different disorders so they can better treat their patients.

Because ultimately, a lack of information can cause an incorrect diagnosis or treatment that does more harm than good.

“ things like it’s anxiety or drink wine, it’s not only offensive, but I also feel like it’s professionally harmful,” she says.

While I didn’t want to have to be drunk every time I had sex, I decided to take their advice. So in 2016, after a night of drinking, I tried to have intercourse for the first time.

Of course, it was unsuccessful and ended in lots of tears.

I told myself that a lot of people experience pain the first time they have sex — that maybe the pain wasn’t that bad and I was just being a baby. I just needed to suck it up and deal with it.

But I couldn’t bring myself to try again. I felt hopeless.

Christensen brought into the exam room a model of the pelvis and proceeded to show me where all of the muscles are and where things can go wrong.

A few months after, I started seeing a talk therapist for general anxiety. While we worked on reducing my intense anxiety, the part of me that wanted an intimate relationship still hit a dead end. As much as I talked about the physical pain, it didn’t seem to be getting any better.

About 8 months later, I met two other young women who struggled with pelvic pain. One of the women mentioned that she had started physical therapy for her pelvic pain. I had never heard of that, but I was willing to try anything.

Meeting others who understood what I was going through made me determined to start focusing on treating this issue.

Two months later, I was on my way to my first session

I had no idea what to expect. I was told to wear comfortable clothes and expect to be there for a little over an hour. Kristin Christensen, a physical therapist (PT) who specializes in pelvic floor disorders, then brought me back to the exam room.

We spent the first 20 minutes talking about my history. I told her that I wanted to have an intimate relationship and the option of sexual intercourse.

She asked if I’d ever had an orgasm and I replied by shaking my head in shame. I felt so embarrassed. I had disconnected myself so far away from that part of my body that it wasn’t a part of me anymore.

Christensen brought into the exam room a model of the pelvis and proceeded to show me where all of the muscles are and where things can go wrong. She reassured me that both pelvic pain and feeling disconnected from your vagina was a common problem among women, and I wasn’t alone.

“It is very common for women to feel disconnected from this part of the body. It is an extremely personal area, and pain or dysfunction in this region seems easier to ignore than to address,” says Christensen.

“Most women have never seen a model of the pelvic floor or the pelvis, and many don’t even know what organs we have or where they are. This is really a shame because the female body is amazing and I think in order to fully understand the problem, patients need to better understand their anatomy.”

Prendergast says that usually when people show up for physical therapy, they’re on many different medications prescribed by different doctors and aren’t even always sure why they’re on some of these meds.

Because a PT can spend more time with their patients than most doctors, they’re able to look at their past medical care and help pair them up with a medical provider who can effectively manage the medical aspect.

Sometimes, the muscular pelvic system isn’t actually causing the pain, Prendergast points out, but the muscles are almost always involved in some way. “Usually people with syndromes get relief with pelvic floor physical therapy because of that muscular skeletal involvement,” she says.

Our goal was for me to have a pelvic exam by my OB-GYN or be able to tolerate a larger-sized dilator with little to no pain.

In our first meeting, Christensen asked me if I would be okay attempting to do a pelvic exam. (Not all women do an exam on their first appointment. Christensen tells me that some women decide to wait until the second, or even third, or fourth visit, to do an exam — especially if they have a history of trauma or aren’t emotionally prepared for it.)

She promised to go slow and to stop if I felt too much discomfort. Nervously, I agreed. If I was going to face this thing head-on and start to treat it, I needed to do this.

With her finger inside me, Christensen mentioned that the three superficial pelvic floor muscles on each side were very tight and tensed when she touched them. I was too tight and in pain for her to check the deepest muscle (the obturator internus). Finally, she checked to see if I could do a Kegel or relax the muscles, and I was unable to do either.

I asked Christensen if this was common among patients.

“Since you had disconnected yourself from this area, it is really difficult to ‘find’ these muscles in order to do a Kegel. Some patients with pelvic pain will be able to do a Kegel because they’re actively contracting a lot of the time out of fear of pain, but many aren’t able to push,” she says.

The session ended with her suggesting we start with an 8-week treatment plan along with a recommendation that I buy a set of dilators online to continue working on things at home.

Our goal was for me to have a pelvic exam by my OB-GYN or be able to tolerate a larger-sized dilator with little to no pain. And of course, being able to have intercourse with little to no pain is the ultimate goal.

I felt so hopeful on my way home. After years of dealing with this pain, I was finally on a path toward recovery. Plus, I really trusted Christensen. After just one session, she made me feel so comfortable.

I couldn’t believe that there may soon come a time when I could wear a tampon.

Prendergast says it’s never a good idea to try and treat pelvic pain on your own since you can sometimes end up making things worse.

In my next talk therapy session, my therapist emphasized the fact that I had my first successful pelvic exam

I hadn’t really even thought about it until then. Suddenly, I was crying tears of happiness. I couldn’t believe it. I never thought a successful pelvic exam would be possible for me.

I was so happy to know that the pain wasn’t “all in my head.”

It was real. I wasn’t just being sensitive to pain. After years of being written off by doctors and resigning myself to the fact that I wouldn’t be able to have an intimate relationship I wanted, my pain was validated.

When the recommended dilator came in, I nearly fell over just by looking at the various sizes. The little one (about .6 inches wide) looked very doable, but the biggest size (about 1.5 inches wide) gave me so much anxiety. There was no way that thing was going in my vagina. Nope.

Another friend mentioned that she also freaked out when she saw her dilator set after deciding to try and pursue treatment on her own. She put the set on the highest shelf in her closet and refused to look at it again.

Prendergast says it’s never a good idea to try and treat pelvic pain on your own since you can sometimes end up making things worse. “Most women don’t know how to use , and they don’t know how long to use them for, and they really don’t have a lot of guidance,” she says.

There are very different causes for pelvic pain that result in very different treatment plans — plans that only a professional can help guide.

I’m about halfway through my treatment plan, and it’s been both a very unusual and very therapeutic experience. For 45 minutes, my PT has her fingers in my vagina while we discuss our recent vacations or upcoming plans for the weekend.

It’s such an intimate relationship, and it’s important to feel at ease with your PT since you’re in such a vulnerable position — both physically and mentally. I’ve learned to get over that initial discomfort and am grateful that Christensen has a unique ability to make me feel relaxed the moment I walk into the room.

She also does a great job of holding a conversation with me throughout the treatment. During our time, I become so engaged in the conversation that I forget where I am.

“I intentionally try and distract you during treatment, so that you don’t focus too much on the pain of the treatment. Furthermore, talking during our sessions continues to build rapport which is so important — it builds trust, makes you feel more comfortable, and also makes it more likely that you will return for your follow-up visits so that you will get better,” she says.

Christensen always ends our sessions by telling me how much progress I’m making. She encourages me to keep working on things at home, even if I need to take it really slow.

While the visits are always going to be a little awkward, I now look at it as a time of healing and a time to look toward the future.

Life is full of awkward moments, and this experience is reminding me that I just need to embrace them.

The emotional side effects are also very real

I’m now suddenly exploring this part of my body that I’ve blocked out for so long, and it feels like I’m discovering a part of me I never knew existed. It’s almost like experiencing a new sexual awakening, which I have to admit, is a pretty awesome feeling.

But at the same time, I’ve been hitting roadblocks as well.

After conquering the smallest size, I became overly confident. Christensen had warned me about the size difference between the first and second dilator. I felt like I could easily make that jump, but I was sorely mistaken.

I cried out in pain when I tried to insert the next size up and became defeated.

I now know that this pain won’t be fixed overnight, and it’s a slow process with many ups and downs. But I fully believe in Christensen, and I know that she will always be by my side on this road to recovery.

She will make sure I achieve my goals, even if I don’t believe it myself.

Both Christensen and Prendergast encourage women who are experiencing any type of pain during intercourse or pelvic pain in general to look into physical therapy as a treatment option.

A lot of women — including myself — find a PT on their own after years of searching for a diagnosis or treatment for their pain. And the search for a good PT can feel overwhelming.

For people who want help finding someone, Prendergast recommends checking out the American Physical Therapy Association and the International Pelvic Pain Society.

However, because there are only a few programs that teach pelvic floor physical therapy curricula, there’s a wide range in treatment techniques.

Pelvic floor therapy can help:

  • incontinence
  • difficulty with bladder or bowel movements
  • painful sex
  • constipation
  • pelvic pain
  • endometriosis
  • vaginismus
  • menopause symptoms
  • pregnancy and postpartum wellness

“I would recommend that people call the facility and maybe schedule the first appointment and see how you feel about it. I also think patient support groups tend to have closed Facebook groups and they can recommend people in certain geographical areas. I know people call a lot and we try and get them paired up with somebody we trust in their area,” Prendergast says.

She stresses that just because you have a bad experience with one PT, it doesn’t mean you should give up on the whole thing. Keep trying out different providers until you find the right fit.

Because honestly, pelvic floor physical therapy has already changed my life for the better.

I’ve started going on dates without fear of the possibility of physical intimacy in the future. For the first time ever, I can envision a future that includes tampons, pelvic exams, and intercourse. And it feels so freeing.

Allyson Byers is a freelance writer and editor based in Los Angeles who loves writing about anything health-related. You can see more of her work at and follow her on social media.

Preparing For Pelvic Floor Therapy

© 2014 Dr Sallie Sarrel. Cover image used with licensed permission.

The CEC often refers our post-excision patients to Pelvic Floor Therapy with highly qualified PTs who specialize in endometriosis and pelvic pain. It can be helpful to know what to expect, what the goals of your therapy are, how you can create a partnership with your PT and more. We’re very pleased to share some of Dr. Sallie Sarrel’s expertise to help you get prepared.

When treating endometriosis, your surgeon may choose to refer you to Pelvic Health Physical Therapy. Pelvic Health Physical Therapists are members of the team that treat the many causes of pain for the woman with endometriosis. Pelvic Pain is very complex, and in order to live the highest quality of life you can with endometriosis, you must treat all the causes of pain.

Preparing for a Pelvic Physical Therapy session can seem daunting, but here are just a few tips to make the situation seem less overwhelming:

Treat the First Session as a Fact-Finding Mission
During your first physical therapy session, the Pelvic Physical Therapist takes a medical history. Many send out questionnaires to be filled out before the session. Your therapist is exploring your case and you can explore your therapist as well. Ask your therapist how much experience they have with endometriosis, especially if your disease and surgical history are complicated. While Laparoscopic surgery may leave little scars externally, the work inside is complex. Treating women with endometriosis isn’t like treating most other populations, because the anatomy can become distorted from the disease. Find out how your therapist usually treats women with both pelvic floor dysfunction and endometriosis.

Many Pelvic Health Physical Therapists are primarily manual therapists. They believe in using skilled hands to elicit change in your body. To treat endometriosis, it is preferable for the pelvic Physical Therapist to be trained in techniques that address musculoskeletal causes and visceral relationships. Practitioners should have advanced training in visceral manipulation therapy and have significant training in pelvic floor work. Many Pelvic Health Physical Therapists also have training in Pilates, yoga, and nutrition to better facilitate lifestyle changes that will help your pain. Women with endometriosis often find the use of sensors or dilators internally rather uncomfortable. You should discuss your feelings on their use and your therapist’s beliefs on their use. Make sure you see eye to eye. Most of all, the first session is the time to decide if you and the Physical Therapist make a great team together. This is your health and physical therapy should be a partnership.

So, You May Have an Internal Exam…
Women with endometriosis may have issues with the muscles inside the pelvis. This is called pelvic floor dysfunction. Women with endometriosis can also have trigger points within the muscles of the pelvic floor. When a tiny fiber of a muscle or tissue stays contracted but the rest of the area does not, you can get an area of hypersensitivity called a trigger point. The trigger point can cause pain elsewhere from its location. Your trigger point may be inside your pelvis but it could cause lower abdominal or rib pain. You can have decreased mobility of scar tissue from childbirth and surgeries. During your first visit the physical therapist may want to evaluate your pelvic floor for some of these issues. Therapy will typically be in a private room. You will empty your bladder prior to the exam and then the Therapist will step out of the room so you can undress from the waist down and cover yourself with a sheet. Then the Therapist will conduct an exam much shallower than your regular GYN examination. It is a one- to two-knuckle deep exam. They will tell you step by step what is going on. Remember pelvic Physical Therapy is about that partnership – if you are not ready for the internal work, you need to speak up. This is your appointment and you need to be comfortable.

…Or, You May Not
You do not need to have the inside of your pelvis treated to make therapeutic gains. It certainly is one very useful tool in the Pelvic Health Physical Therapist’s toolkit but it is not the only tool. For non-sexually active women, especially teenagers with endometriosis, and women with issues like vulvodynia and vaginitis internal work, despite pelvic floor spasms, may not be advisable depending on the case. But, it is possible even without internal therapy to have improvements in your pelvic floor and pelvic pain. Additionally, you may have trigger points in your abdomen especially in the Psoas or hip flexor muscles. You may have spasming in the muscles around the umbilicus or other abdominal areas. The back and hip muscles may have length and strength issues. Your Therapist may chose to use that Visceral Manipulation technique to help work with the fascia, a saran wrap substance around everything in the body, to alleviate pain and dysfunction. For example, the fascia of the bladder ligaments is contiguous with the pelvic floor so visceral manipulation therapy may release issues driving your pelvic floor spasms. An internal exam is helpful, but it isn’t the only thing a Pelvic Physical Therapist can do to make you feel better. The treatment program should meet you where you are that day and that may or may not include internal work.

It isn’t all About the Pelvis – Even Though it is
Women with endometriosis tend to have central nervous systems that are highly reactive. You have experienced so many years of immense pain that the system is overwhelmed and the body may react to most stimuli as noxious. This is called upregulation. Because the brain has been so inundated for so many years with the painful stimuli, the brain may still recognize the pain even after the disease has been cut out. This is called central sensitization. Imagine being hit with a nail in your stomach for 8-10 years…as your natural computing system, your brain’s circuits would constantly be getting the message that the abdomen is being slammed with a pointy nail. When the nail finally stops, the brain may need a reset button to stop feeling the pain. That is one of the things Physical Therapy can do for centrally sensitized pain. Your Therapist may work on things like guided imagery, mindfulness meditation, breathing exercises, or use types of massage and myofascial release to help calm the body before even working on or in your pelvis. This is so when the pelvis is worked on directly, you don’t have reactive pain.

You Can Explore Options to Make Therapy more Comfortable
Sometimes – it is true – Physical Therapy may make you sore. You may have a reaction to the treatment and the soreness may be the movement patterns or fascia changing from therapy. Myofascial work can be very specific to adhesions and to the peritoneum as well. Patients are encouraged to drink plenty of water post-PT treatments to provide the cells and tissues with the hydration it needs as it experiences changes.

There are doctors who prescribe vaginal diazepam (Valium®) to help with pelvic floor pain. Vaginal Valium® is a small dose of either 5mg or 10mg that gets inserted into the vagina to relax pelvic floor spasms. It is available by prescription only. Many medical doctors prefer the first few times a patient uses the vaginal Valium® it is prior to Physical Therapy sessions in order to make therapy more comfortable. It is not something that is used instead of Physical Therapy. The intent of most doctors’ prescribing it is to serve as an adjunct to therapy. There is much debate in the pelvic health field about the use of vaginal Valium®. Some Physical Therapists feel it is better to treat the upregulation and centrally sensitized pain patterns than administer a drug. Some also feel that because it is given vaginally, it does not attend to the neuropathways in the brain that may be triggering the spasms. Others feel it is a valuable aide to Physical Therapy. Most patients try to experience Pelvic Physical Therapy and see how they react after a few sessions prior to exploring vaginal Valium® with their doctors.

So – now you are prepared to empower yourself over pelvic pain and embark on the journey of healing Pelvic Physical Therapy brings! Appointments in New York and New Jersey, contact Dr. Sarrel:

Dr Sallie Sarrel PT, ATC, DPT is a leading pelvic health Physical Therapist in New York and New Jersey. She has taken her own arduous battle with endometriosis to inspire women to empower themselves over pelvic pain. She frequently lectures nationally and internationally on the value of pelvic Physical Therapy and endometriosis. She has a fervent belief that you are not your pain, and is unique in her patient-centered approach to Physical Therapy and endometriosis.

Helpful links and resources:
Pain after Excision: Was my Surgery a Failure?
Endometriosis: Understanding a Complex Disease
American Physical Therapy Association



This study was designed as within subject design that compared one group of patients diagnosed with mild or moderate endometriosis before, after 4 weeks, and after 8 weeks performing an exercise program. The study design and sampling were carried out after obtaining approval from the hospital’s ethical committee to carry out the study at the Physical Therapy Department of Bab El-Sharia University Hospital and an informed consent form was signed by each patient before participating in the study. Ethical approval was obtained from the institutional review board at Faculty of Physical Therapy, Cairo University before study commencement (No: P.T.REC/012/001488). The study was followed the Guidelines of Declaration of Helsinki on the conduct of human research.

There were twenty patients suffering from severe premenstrual pelvic pain and diagnosed by laparoscope as having mild or moderate endometriosis13). Patients were selected randomly from the Gynecology Outpatient Clinic at Bab El-Sharia University Hospital and recruited according to the inclusion and exclusion criteria of the study. The main exclusion criterion was the presence of diabetes mellitus, gynecological hemorrhage, impaired sensation, tubo-ovarian abscess, chest diseases, scoliosis or previous trauma or fractures in the spine, pelvis, and lower limbs. All patients participated in a supervised exercise program for 8 weeks (24 sessions) and received the same regimen of hormonal treatment (Medroxyprogesterone Acetate 100 mg once/month for 6 months) without administering any analgesic drugs all through the exercise period (8 weeks). Their age ranged from 26 to 32 years and their body mass index (BMI) did not exceed 29 kg/m2. The duration of this study was 6 months from December 2015 till April 2016.

Further screening for inclusion and exclusion criterion and demographic details were recorded for each patient to confirm that the only cause of pelvic pain was endometriosis. All data and information of the patients were recorded in a recording data sheet. A detailed medical and gynecological history was taken for each patient before starting the study, according to the items of the recording data sheet. Diagnostic ultrasonography (Sonoace 3200) was used by the gynecologist before laparoscopy to locate endometriosis cysts and to exclude any pelvic pathology in each patient. Laparoscopic machine (Gemetex XL-300A) was used by the same gynecologist to confirm the diagnosis of endometriosis in patients. Before intervention, intensity of pain was measured by mean of the present pain intensity scale to help patients to determine the intensity of pain on a scale from 0 to 4 in which pain intensity was scored as follows: no pain=0, mild pain=1, moderate pain=2, severe pain=3, and unbearable pain=4. The Present Pain Intensity scale is reported to be a reliable outcome measure for pain evaluation14). Reevaluation for intensity of pain was repeated after 4 weeks (12 sessions) and 8 weeks (24 sessions) of performing the exercise program. Postural assessment revealed that patients suffered from postural kyphosis due to chronic pelvic pain and this diagnosis was confirmed by measuring the thoracic kyphosis angle by Formetric II instrument in the spinal shape analysis laboratory at the Faculty of Physical Therapy, Cairo University, before and after 4 and 8 weeks of performing the exercise program. Formetric II instrument was an optical 3D-spine, posture and measurement system, which was reliable, valid and safe to be used on patients15).

The exercise program parameters were based on the American College of Obstetricians and Gynecologists guidelines for exercise for sedentary women, according to the FITT principle (frequency, intensity, time, and type), which included frequency=minimum of three times/week, intensity=moderately hard perceived exertion, time=30–60 min/day, and type=low impact16). Class size was limited to five patients to ensure their close supervision. All classes were conducted by the same physiotherapist. Each patient was supervised carefully during the exercise program. The exercise program included posture correction exercises from crock lying, supine, and sitting and standing positions (each exercise was maintained for 5 s and then the woman relaxed for 10 s and repeated this 10 times), diaphragmatic and lateral costal breathing exercises (the woman took a deep breath for 5 s and relaxed for 10 s and repeated this five times), general relaxation and teaching muscle sense (for 10 min), Diversion drill training (for 3 min), positional education on cross-sitting and squatting positions (for 6 min), stretching exercises for lower back muscles, adductors muscles, hamstrings muscles and pelvic floor muscles each stretch was maintained for 45 s and repeated 3 times at the start and the end of each session. Each exercise session was terminated by walking on treadmill for 20 min. Patients attended exercise sessions 3 times/week, and for the rest of the week they were instructed to perform the same exercises regularly at home throughout the study period. Compliance with home-based exercise was monitored by a self-recorded diary. The total number of sessions that were conducted during 8 weeks was 24 sessions. Attendance of at least 20 out of 24 sessions was required to be defined as completion of the intervention.

Data analysis was performed using (SPSS, Inc. Chicago, IL, USA) program version 20 for Windows. The sample size (20 patients) was calculated to yield an 90% power and α=0.05. Prior to final analysis, data were screened for normality assumption and presence of extreme scores. This exploration was done as a pre-requisite for parametric calculation of the analysis of differences and of relationship measures. Normality test of data using Shapiro-Wilk test was used, this ensures that the data is normally distributed for kyphosis angle and not normally distributed for present pain intensity scale. Therefore, repeated measure ANOVA was used to compare the kyphosis angle at different measuring periods. Also, Friedman (nonparametric alternative to the repeated measure ANOVA) was used to compare the present pain intensity scale at different measuring periods and “Wilcoxon signed rank tests” was used as post hoc tests if Friedman test among three measuring periods is significant. As two statistical analysis tests (repeated measures ANOVA and Friedman tests) were performed on the examined sample, the alpha level was adjusted to 0.025 (0.05/2) for each of the two conducted statistical tests. Adjustment was performed to avoid alpha inflation and committing type I error.

What happens during pelvic floor physical therapy and how does it help?

Chronic pelvic pain can affect body posture, muscle tone and alignment. Muscles may become shorter, tighter and misaligned due to the perpetual responses of the body to pelvic pain. The role of the pelvic floor physical therapist is therefore to train the patient to relax her body and restore balance and alignment. While the pain emanates from the pelvis, the effects of chronic pain are far-reaching due to the role of the pelvic floor in core activities such as movement and coordination. Effective physiotherapy may need to involve muscle groups throughout the body.

Patient history

Pelvic physical therapy begins with a thorough patient history. In her own words, the patient tells her story about living with endometriosis, her pain and the treatments she has endured. She is also asked to recant any other incidents in her life history that might have jolted her pelvis, such as a previous skiing accident.

Biomechanical and musculoskeletal assessment

The next step is a biomechanical and musculoskeletal assessment; the therapist observes how the patient moves and walks, her posture and breathing, where her core areas of pain are, and takes note of the overall condition of her muscles (strength, coordination, alignment, and contraction).

Relaxation skills

Following this general assessment, the therapist focuses on relaxation skills. Massage is directed at loosening and relaxing muscles and relieving abdominal and pelvic pain. The patient is then directed in self-massage and relaxation exercises, which she can continue at home.

Physical examination

Next the therapist performs a thorough physical exam to test overall body flexibility and mobility, paying particular attention to the hips and possible joint malformations, the sites of abdominal scars and the motility of the internal pelvic organs. The physical exam comprises both an external and internal exam. During the internal exam, the different layers of the pelvic floor are assessed to check muscle spasm, tone and mobility, tissue rigidity and pain trigger points. While some patients may feel uncomfortable, internal work is essential in order to access the core muscles and tissues involved by PFD.

Retraining of muscles

Pelvic muscles that have been identified as tense and in spasm are then “down trained” by teaching the patient the difference between tensing and relaxing these muscles. This can be achieved with the help of biofeedback sensors placed on the muscles so that the patient can see her pelvic muscle activity fluctuate on the biofeedback monitor.

Home exercises

To improve flexibility and stretch tightened muscles, the patient will be instructed in stretching exercises, focused on opening the hips. The patient may also be instructed in vaginal dilation exercises to be performed digitally or with a home-dilation kit to further mobilize tissue within the pelvis. Further exercises will focus on core strength, and trunk and spine flexibility. Once pain and mobility improve, the patient will be retrained in basic movements such as walking and standing without tensing the pelvic floor and to improve pelvic-girdle coordination. The patient will be instructed in gentle exercises to restore coordination and mobility, such as basic yoga and Pilates, gradually building up over the course of 6 to 12 weeks.

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