Physiotherapy for urogynaecological conditions

Some of the people we talked to had seen a physiotherapist for treatment for prolapse, urinary incontinence, bladder pain, repeated UTI infections, or chronic pain after surgery. Some physiotherapists specialised in pelvic floor health and may be referred to as women’s health physiotherapists.

This section covers:

  • Accessing physiotherapy
  • Experiences of seeing physiotherapists
  • Exercising the pelvic floor muscles
  • Other physiotherapy approaches and types of support

In this section we use the terms:
Pelvic organ prolapse (prolapse) is a condition in which pelvic organs, like the bladder and uterus (sometimes called the womb), move down or slip out of place and may bulge into the vagina.

Urinary incontinence is the unintentional loss of wee/urine. There are other bladder symptoms that do not involve incontinence, such as needing to urinate a lot, getting up at night a lot for a wee, or difficulties emptying the bladder.

UTIs (Urinary Tract Infections) are when bacteria infect the system that stores urine (such as the bladder). There are other types of conditions that can involve bladder irritation and pain, such as interstitial cystitis (also called bladder pain syndrome).

Accessing physiotherapy

Physiotherapy for urogynaecological conditions can be accessed through referral from the GP. Chloe and Sue Y lived in an area where they could self-refer to see an NHS physiotherapist. However, accessing physiotherapy wasn’t always an easy process for people we talked to. María had chosen not to see a physiotherapist.

Kerry would like for it to be an option to self-refer to physiotherapy for prolapse and for there to be more emphasis on non-surgical treatments.

I think some sort of self-referral to physio. I don’t need to see a surgeon at this point. I’m happy to wait for surgery. I don’t even know if I want surgery but self-referral to a specialist women’s physio who’s got the expertise to help me with the pessaries, to tell me whether or not I need the oestrogen cream, you know, just – and they’re such low level things. Surgery’s a huge expensive thing. I don’t understand why the NHS isn’t prioritising first level care really, I really can’t get my head round it and I think I should have had access to that within six weeks really as a minimum and it shouldn’t be, I can self-refer if I have a knee for a foot problem, for a wrist problem, for a hand problem, I can go and I can be seen within two weeks. Why can’t I self-refer for a prolapse? It just doesn’t make sense to me, but they won’t take the referral.

 

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Once referred by a GP, some people faced long wait times, particularly during the Covid-19 pandemic. Vickie, Elly, Kezia, and Alaina waited several months to get an NHS appointment to see a physiotherapist. Vickie said the wait had involved “some dark times and felt very lengthy for me”.

Vickie and Elly were concerned that their prolapses were becoming more severe whilst waiting for a physiotherapy appointment. Kerry, Kezia, Janet, and Iris felt that being able to refer themselves for physiotherapy would have been helpful, but this is not an available option everywhere.

Elly thinks that there should be an automatic referral for physiotherapy for those showing signs of prolapse after giving birth.

I personally think that, if a woman at her six-week check shows signs of having a prolapse, there should be an automatic referral to physiotherapy and you should be seen by a physiotherapist within a timescale and you should be given an intensive course of physiotherapy, which is probably a lot to ask. I know things cost a lot of money but I do feel like, if you’re going to correct prolapses through physiotherapy, the only way you can do that is when they’re at very early stages and by having intensive physiotherapy very quickly so a twelve week programme of weekly visits to the physio. Very early on would probably actually help things get corrected instead of saying, “Come back in six months’ time. Come back in six months’ time.” And by that time, you know, you’re stage three prolapsed.

 

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Some were able to look for options outside of the NHS after a long wait or a negative experience with physiotherapists. Kerry, Holly, Kezia and others said they had “lost patience” and “decided to go privately” to see a physiotherapist sooner. Beth, who was concerned that she had torn a muscle during childbirth, felt that she had to “fight” for care, and she eventually sought out a private physiotherapist. Sharon and Phoebe highlighted that private treatment could be very expensive and may not be an option for everyone.

Sharon and Beth had accessed physiotherapy classes and videos online, which they had found helpful. Until they were experiencing problems, Vickie and Catherine said they had not known that women’s health physiotherapy existed. If she had not been able to refer herself for physiotherapy, Chloe felt that she would have just “fallen through the net”.

Sharon felt unsupported by NHS physiotherapy services, so she paid for an online physiotherapy programme.

And because I wasn’t getting any support through the NHS, I finally found some wonderful online programmes run by pelvic health physios that had a very holistic approach that most of them do say, yes Kegels but it’s not just about Kegels and, and you can overdo it with Kegels. I’m lucky I don’t have pelvic pain or tension and they work for me but the thing that has improved was actually doing these programmes and strengthening all of the muscles that surround and support the pelvic floor and stepping away from that fear of movement. Because I remember during Covid getting, finally getting through to my old NHS physio and I’ve said, “I had it, I think I have a uterus prolapse now too,” and she said, “Well let’s talk you through a Kegel, how to do a Kegel over the phone,” and we did that and I already know how to do that and she said, “Well now you should do yoga,” and I just didn’t quite get that like before when I just had a bladder prolapse you said don’t do yoga, now things have got worse, you’re telling me to do yoga and explaining all these poses over the phone. It was just rubbish.
 
So there are some really good courses online and I think at the moment with what NHS women’s health being what it is, you really have to, to go online and invest in one of those programmes or find these physios on Instagram, they do a lot of free videos as well and, and kind of supplement the advice you’re getting yourself from, from the NHS.

 

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Hope, Sue X, and Mehar had not thought about seeing a physiotherapist to help with their urogynaecological condition, nor had it been suggested to them.

Experiences of seeing physiotherapists

Typically, a women’s health physiotherapist will discuss the nature and impact of symptoms and talk through exercises that might help. They may also suggest an examination to better understand what is happening with the pelvic muscles and organs.

Jo, a physiotherapist, discusses the importance of pelvic floor physiotherapy and what an appointment with a physiotherapist may involve.

As pelvic floor physios, we’re talking a lot about pelvic floor, and so firstly if our goal was to strengthen the pelvic floor and we know that with, with conditions like stress incontinence and prolapse, supervised pelvic floor strengthening, or pelvic floor training with a pelvic floor physiotherapist so a programme of pelvic floor strengthening, for around 50% of women will sufficiently improve their symptoms that they’re no longer sort of bothered by their symptoms. So we know that pelvic floor strengthening does work, you know, particularly in those conditions, and so a pelvic floor squeeze is when you’re tightening and pulling in around the vagina and back passage. So it might be like, it might, you might sort of imagine that you’re pulling in around the back passage, like you’re holding wind, and pulling up towards the so the pubic bone at the front, like you’re trying to stop yourself passing urine. And, and then relaxing and letting go. So it’s a squeeze and pull in around the vagina and back, back passage, and then a relax and let go. We do want to make sure that we’re isolating the pelvic floor muscles and not bringing in other muscle groups, so for example we don’t want to be squeezing our legs together. We don’t want to be clenching our buttock muscles, we want to be able to keep breathing nicely throughout and we don’t want to be overusing our abdominal muscles. So a little bit of gentle sort of core abdominal involvement is okay but not a lot of sort of abdominal work. So we’re trying to isolate those muscles without bringing in other muscle groups and we would then normally develop a programme of two different types of exercises. So want to do some quick squeezes, so an exercise would be just a nice strong squeeze and pull up of pelvic floor and then relax and let go. And we’d build up and ideally sort of build up, you know, to be able to do maybe ten of those in a row. And they’re really important for things like stress incontinence. If you cough or sneeze and, and leak, we want to be able to recruit those muscles quickly, so that if you felt a cough or squeeze, cough or sneeze coming on you could do a quick pelvic floor squeeze. We also want endurance in the pelvic floor muscles. We want them to be able to squeeze and hold and provide sort of, you know ongoing support. So we’d also develop an exercise programme where they’re tightening and pulling up the pelvic floor and holding, keeping breathing, really importantly. And so part of our examination we want to get an idea of how long someone can hold a pelvic floor squeeze for, again up to about 10 seconds. I think a lot of the time people think they are holding the pelvic floor and then we assess them actually find that the muscles fatigue quicker than they think. So with an endurance hold you want to be able to feel the pelvic floor squeeze and pull up, and then at the end of your hold you want to be able to feel it letting go as well, so that knowing that you’ve released that muscle and it’s not fatigued before then. So yeah, it would be a combination of quick squeezes, so squeezing and pulling up, relaxing and letting go plus some endurance holds where you’re squeezing and holding and breathing and then relaxing and letting go. And again, we might aim to do up to a ten second hold and up to ten of those in a row. And there’s good evidence to show that an exercise programme of three sets per day is, is, is what, you know can be quite sort of effective in improving those symptoms of sort of stress incontinence and prolapse, particularly.

I think a lot of people know about pelvic floor strengthening exercises, but that’s not necessarily the right thing for everyone. If you have, for example, pain, or painful intercourse or for some people it might be that their pelvic muscle, pelvic floor muscles they’re holding them tight. So the pelvic floor muscles are slightly high tone. Slightly tight. And actually might need to learn to relax the pelvic floor muscles.

So part of what we do is firstly assessing well, you know do you know how to do a pelvic floor squeeze. But also how well the muscles are functioning at the moment, how strong the muscles are, can someone squeeze and hold the muscles, can they actually relax and let the muscles go as well. And the best way to assess that is to do a vaginal examination. So that does involve sort of undressing from the bottom half, having a lie on a bed, we’d, you know we’d always give someone something to pop over them for, you know, for sort of dignity. And we’re having a look around the opening of the vagina, we’d like to check sensation, so check that the skin sensation is normal. We would ask someone to do a pelvic floor squeeze and see how well they can activate the muscles. What their technique is like. How well they relax the muscles. We might get them to cough or bear down to look for any signs of prolapse. And then we would again with their consent, insert a finger into the vagina, and that’s, we can then get an assessment of the tone of the muscles, again we can assess for any prolapse, and then we would go through more pelvic floor squeezes so really trying to get a good idea of how well they can squeeze and hold by being able to palpate the muscle, by sort of via the vaginal examination we can really assess how strong the muscle is, how well it squeezes, how well it holds, how well they let go.

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Some women we talked to, like Iris, Alaina and Kerry, told us how important it had been for them to find a physiotherapist who they found supportive. Vickie said that her physiotherapist was so good at listening that she should get a “pay rise”. Without any “blame or shaming”, Iris’s physiotherapist helped her to get back to running despite incontinence. She had an internal massage to treat her hypertonic pelvic floor, so it was very important to her that she trusted her physiotherapist as she found the treatment embarrassing.

Jeannie felt that her NHS physiotherapist listened well and took the time to understand her needs.

I think the best time was when I went to see the physiotherapist. Because I felt like she really understood me, that she listened to what I was saying. And she asked me lots of questions, you know relevant questions, and she gave me lots of information and she answered all my questions. And she, I felt like she, she was sort of on the same wavelength in that she didn’t want to talk about the sort of drastic, you know like she wasn’t talking about starting with operations, she was sort of about the, the, starting with pelvic floor exercises and then you know going on from there, starting with just me being able to help myself but then if that doesn’t work then there’s this we can try and that we can try, you know. And being operated on was a very last resort which was exactly how I was feeling as well.
 
So that was really good, I just felt she had a really good understanding of my difficulties, and she was very positive about what could be done, and she also, it wasn’t just a one-off appointment, she said, you know, come back and if you’ve got more questions, ‘cos the first time you, you know when you ask loads of questions and then you go away and then quite often you think, ‘Oh why didn’t I ask this or that?,’ you know. So it’s always good to go back and, and also she gave me loads of exercises to do and it’s good to go back and know that you’re doing them properly and that, see if there’s been any improvement or not, and just to have, that just felt like proper care, it felt like you know it was, it felt hopeful and encouraging and it felt like it was more of a two-way conversation than just me being told what I should do, or what’s gonna happen or something like that.

 

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Chloe self-referred to an NHS physiotherapist who was empathetic and gave her practical steps to improve her pelvic floor symptoms.

Yes, yeah so they came in, they were really responsive when I emailed them for a self-referral, they got back to me straight away and then someone gave me a phone consultation really early on and that was critical because I needed someone to talk to me early on to say, “This is going to be, like things are going to get better,” because all the other support was like 6, 8, 12 16 weeks away and I would have been in the dark and in a stressed and worried atmosphere for eight weeks, you know, if they hadn’t got in touch so early but yeah they were just really full of really evidence-based suggestions really empathetic around me, like I said to them, “I haven’t looked at the scar, I really don’t want to. I’m really scared of looking at it.” and they were like, “That’s fine, that’s normal, that’s completely understandable,” and no-one said like, ‘Oh come on, stop being stupid, like go and have a look’ [laughs].
 
So yeah they were, they were just very practical, knew all the, all the things I was gonna ask him about, they kind of already knew to tell me because they’d obviously had so much experience with people in the same boat as me and then, yeah the lady that I’ve, I’ve seen a couple of times in person just let me tell my story and let me get all these worries off my chest and then was just really practical in the examination and was just, you know, checked how I was doing my exercises properly and just really reassured me that I was doing them okay and even when I’ve said like, “I don’t think certain aspects are getting better,” she’s always got a solution or a suggestion and it’s always very much if you want to do this you can but you don’t have to and, yeah, I think I think it’s a really well run service in our local area but I know that not everyone has access to that and I know that a lot of people from when I from a Facebook group I’m part of, a lot of people have to end up taking that care privately and I think that’s really sad. I think if everybody had access to what we have access to here you know, that would be game changing, I think.

 

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There were some people who told us about negative experiences, where physiotherapists had not been very knowledgeable or lacked a good bedside manner. Elly had been upset by a physiotherapist who told her that her prolapse “doesn’t look that bad” when she had been struggling for two years.

Some women like Leah, Phoebe, and Catherine had seen more than one physio and said they had very different experiences of care. Leah had issues with one of her physiotherapists giving “out of context” advice as they didn’t have as much “specialist knowledge” on treating people with UTIs. She prefers the care that she has had through a specialist UTI clinic, where the exercises are more focussed on internal massage and relaxing her pelvic floor. Eve found one of her physiotherapists “condescending” and was relieved to find another who “gets it”.

Catherine tells us about two very different experiences of physiotherapy and why the clinical relationship is so important.

My first physio was a nightmare if I’m honest and it, as a result I did actually end up going to counselling so she just showed no empathy or kindness, she was very factual. I know you have to be factual, but she was, this was very much how she kind of said things so the first-, there were a few things that kind of really stand out about it. One of which obviously I was saying there, she was asking about sex, not having sex and I just didn’t feel like I wanted it and she’s like, “Oh it’s okay, you just have to get back on it,” and I was like, “What does that mean, you know, I don’t, how do you do that?’ I don’t, I’m so lost now,’ I didn’t, I don’t, I think I lost myself as well within the whole process as well and so she said about coming off contraception which I because I was on the pill and I did because she said, “Oh yeah then it will just kind of come back,” and it’s like ‘Oh right, okay,’ so I just did that and her bedside manner was not very kind I suppose or it wasn’t, it wasn’t unkind, I think it was more empathy towards it because obviously you’re going in there, it’s quite, it’s quite daunting, it’s quite embarrassing. I wasn’t really expecting the physio that I had. I mean, I’ve had physio before from sport injuries and I just assumed, whether I didn’t read the letter properly I don’t know, but obviously it was internal physio and I found it quite intrusive.
 
The second physio, it wasn’t patronising or anything like that but she just, she just made me feel comfortable. I don’t know how she done it, she just made me feel comfortable. She didn’t do anything physically different to what the first physio done, she was still examining, examining me internally, it was just her way she did it and explained it, I think. Where the first physio was very direct and very blunt and this is it, it’s like black and white. Whereas sometimes you need that pink and fluffy because it’s quite undignified, when you have, when you know you’re pregnant, it does become undignified because everyone has to look up there, you know, everyone you kind of that bit kind of goes out the window.
 

 

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Exercising the pelvic floor muscles

Elly “passionately” feels that women need to know more about pelvic floor exercises. Chloe, Sabrina, Catherine, and others told us that learning how to do pelvic floor exercises (also known as Kegels) was really important and should be part of a daily routine. Eve found that learning how to do pelvic floor exercises with a physiotherapist has helped her to now feel ready to have another baby. Rosie, who has urinary incontinence, said she had to be quite consistent with these exercises but found “it makes a difference quite quickly”.

Others, like Phyllis, Jackie, Elisabeth, and Sarah, had been doing pelvic floor exercises but felt it had not made a noticeable difference which made it difficult to stay motivated to do them. Sue Y saw two physiotherapists on the NHS, but ultimately found that pelvic floor exercises didn’t help her symptoms as much as she would have liked.

Chloe explains how she does her pelvic floor exercises.

So, the description that I like is a zipping up the pelvic floor and someone also said, “Trying to suck up a piece of spaghetti.” I’m not quite sure how that works but I can kind of imagine it as like a tightening throughout the whole of pelvic floor as though you were stopping yourself having a wee and I kind of try and centre it on the vagina and just bringing things upwards, holding them there and then releasing and making sure that I can feel I’ve released everything and relaxing fully until everything, yeah, feels like it’s completely let go. But yeah, I can definitely identify with that sense of it being a very nebulous entity. Up until now, I’ve always kind of done pelvic floor exercises but not with any regularity or, you know, sort of routine but this has kicked me into doing them thoroughly definitely.
 
Yes so, I have this Squeezy App on my phone which I think is fantastic so three times a day generally 9 o’clock, 3 o’clock and 9 o’clock in the evening I will do 10 sets of holding for 10 seconds each time I try and do one, one set lying, one set sitting, one set standing because the standing ones I find hardest and I know I need practice on. I do that three times a day and then do a quick fire one so like a second holding and a relaxing and a holding, relaxing, you know, quickly and then throughout the day like if I find I’m standing in a queue or something, I’ll just do a few more and then I do a couple of Pilates classes each week so obviously that part, the pelvic floor is engaged in some of that as well and I have a little post-natal Pilates routine that I try and do two or three times a week as well but that’s less good. But yeah, I have to say I do them religiously, I don’t miss any days because I get symptomatic if I don’t and I don’t like that, so I have a big motivation to do them three times a day every day.

 

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Liz, Amy, Jeannie, and others said that it can be hard to know if you are were doing pelvic floor exercises “properly” unless a knowledgeable health professional was checking. Kerry, Elly, and Catherine felt like they had been sent away without really knowing what to do.

Although some women, like Phyllis, Holly, and Megan, found it “embarrassing” to have an internal examination, several others, like Beth and Jeannie, found it reassuring for the physiotherapist to check that they were doing the exercises the “right” way. You can also read more about experiences of pelvic examinations here.

Elly feels like she was sent off on her own to do pelvic floor exercises after her post-natal check. She thinks her prolapse worsened in part because she didn’t know how to do the exercises correctly.

And it, I was also told, from six weeks, to go away, do pelvic floor exercises, that will sort you out, you’ll be fine only to find in my first physio appointment that I actually cannot do a pelvic floor exercise correctly, which is probably not helped the fact that things have got worse with my prolapses because I’ve been working for two years on them but not been working correctly so I feel like if I’d been offered the help maybe sooner. I would have discovered that I wasn’t doing them correctly and I may not have got to the point that I’ve got to with my prolapses, so yeah.
 

 

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Elly and Mary X had been given equipment by their physiotherapist to use at home to help with their pelvic floor exercises. Jenni and Jackie bought pelvic floor machines to help them. Jackie had used egg-shaped weights and an electrical stimulator, but she didn’t think it had made much difference.

Many women, like Eve, Jasmine, and Sabrina, told us that it was difficult to keep doing exercises regularly in the long term. Hope said if she knew that she was doing them correctly then she would be more motivated. For Jessy, Jasmine and others, the demands of busy lives meant that their pelvic floor health was not always at the top of the list. This could be especially difficult after having a baby, or while caring for children. A few, like Vickie, Sharon, Liz, and Beth, had found mobile phone apps helped them with their pelvic floor exercises.

Pelvic floor exercises were the last thing on Sabrina’s mind with the demands of having a baby.

So he, yeah, he keeps going on about my Kegel exercises, which is all very good for him, when he’s just sat on his computer and just playing games at the end of the day. But it’s just the fact that you forget to do it. Like when, and as soon as you have a baby and they tell you, “It’s so important to do it, do it at times that you know, it’s really important to do it when you brush your teeth, or when you do something every day,” and I don’t know about them but when you’ve got a newborn baby, the last thing you, you’re thinking about when you’re brushing your teeth is, ‘Oh let me just squeeze for ten seconds and see if I can hold it.’ Like it just doesn’t even cross your mind, you’re kind of thinking like have they been fed, are they quiet, can you hear them? Like can I get some sleep? Then you’ve got your partner, and you’ve got animals, and just everything else, like squeezing down there is the last thing that comes to your mind when you’re brushing your teeth when you’ve had a baby. And even now when he’s old enough to, to, to sort of be his own person and stuff, I think once you have kids you just, you just don’t think about yourself anymore. You are the last thought for anything, and yeah. Like even when days, where it’s happened an hour later it’s, it’s gone, like the fact that I really should be doing exercises just isn’t, isn’t the thought anymore. It’s got to get the dinner on, or snack time, or has he had a poo, I’ll do his nappy. It’s like, everything else just is at the forefront of your mind, and your body just, you just whack a big pair of pants on and you whack some clothes on, and as long as it hasn’t got anything on it, then you’re good to go. Like you’re lucky if you get a shower of a day and let alone get to do some exercises.

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Several, like Alaina, Iris, and Leah, and others had been told that their pelvic floor was overworking, hypertonic or ‘tight’, which this could make bladder symptoms worse. Physiotherapists had suggested yoga, Pilates, relaxation, stretching, and massage. Amy, Beth, Sharon, and others had tried a different type of exercises called ‘hypopressives’ which aim to lift the pelvic floor through breathing and exercise techniques.

Holly’s pelvic discomfort has improved after her physiotherapy treatment for overactive pelvic floor.

And so I’ve had a hypertonic pelvic floor can cause issues with urinary retention, so I went along, I had a lot of pelvic pain, and so I went along to a women’s health physio, which was something else that I had to finance privately, and she’s been working on trying to release the tissues with internal massage basically, it’s fairly, fairly invasive, it’s not particularly pleasant either. So, she’s been doing some internal massage with me and some, I’ve had some acupuncture with her, and also, I’ve had she recommended I buy a therapy wand, so I can do a little bit of some massage myself in between sessions, just to try and free up the tissues, and soften them so that my bladder sits in a better position. And it isn’t, you know it isn’t quite so, the flow is better, my urethral flow is better.
 
You said that’s a little bit uncomfortable?
 
Yes, it’s uncomfortable because, and also, it’s, you have to have trust in the therapist because obviously they’re working internally, they’re massaging internally, so it’s, it can be a bit painful, and also it’s embarrassing I suppose.

 

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Other physiotherapy approaches and types of support

Amy said that physiotherapy should not be “just about your pelvic floor”, and we heard about some other physiotherapy approaches and types of support received. Phoebe, Janet, and others had talked to their physiotherapists about bowel management, diet, and the importance of avoiding constipation. Rosie’s physiotherapist had used massage to reduce pain from her episiotomy scar. Fran and Jackie had attended chronic pain management sessions following complications of surgery. Megan found that acupuncture from an NHS physiotherapist had reduced her bladder pain.

Janet is pleased that she was treated in a “holistic” way which included physiotherapy and pelvic floor exercises amongst other things.

I mean you go in and it’s not about them telling you what to do. They take a full history, they explain all how it all works, they were we did diary exercises about bladder and bowel and all that kind of stuff and then had a proper discussion about what the various options might be. It was much more of a holistic approach, so it wasn’t just pelvic floor exercises, it was diet, it was exercise, it was the pelvic floor stuff and I felt that I was being listened to. I felt that my views were valued and that we were working together to try and seek the best solution we could so that that for me works really well. I don’t want to be just told what to do. I want somebody who’ll talk me through what the options are and what the implications are of the various things that, that we might try so that for me works really well.

 

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