Addressing Pelvic Floor Dysfunction: 5 Steps for Getting Started

I receive emails on a regular basis from occupational therapists who would love to start treating incontinence in various settings. I am often asked what exercises to do or how many Kegels to prescribe.

While I am always excited to hear from therapists interested in pelvic muscle programming, I don’t jump in to talk about exercises. Instead, I always point these eager professionals back to the basics of pelvic floor anatomy and types of incontinence. Therapists need to understand the mechanics of urination and defecation before they start treating the dysfunction they identify in their patients.

The five points listed here can help practitioners add to their knowledge regarding pelvic health as well as support strong clinical awareness and recommendations. Practitioners can also use these points to explain anatomy and physiology to patients, empowering them through a stronger mind-body connection and awareness.

1. Orientation

The pelvis is the easiest place to orient yourself—and your patients— because it’s easy to locate, which is very much not the case for the three layers of muscles that make up the pelvic floor.

The skeletal muscles, ligaments, and fascia of the pelvic floor support the organs in the pelvis and can be found in the bottom of the pelvis. Think about a breadbasket lined with three layers of napkins. This simple analogy of the pelvic floor within the pelvis can help patients begin understanding where their own pelvic floor lies.

Therapists wanting to know more details about these muscles (and I encourage this!) should initially focus on the coccygeus and levator ani muscles, such as the iliococcugeus, puborectalis, and pubococcygeus.

2. Openings

The urethra, rectum, and vagina create openings that pass through the muscles of the pelvic floor. Depending on whether a patient is experiencing incontinence (urine or fecal), pelvic organ prolapse, retention, or pelvic pain, there is often a direct connection to dysfunction in the pelvic floor. For example, if a patient experiences a weak pelvic floor and can’t contract the muscles completely, then the urethra isn’t closed off and urine leaks or flows out. Alternatively, a patient may experience hypertonicity of the pelvic floor and struggle to get urine or feces out.

Therapists need to assess each patient’s needs in detail to determine the problem. If a therapist skips this important step and jumps into a pelvic floor exercise program, the treatment can actually make the issues worse. I encourage therapists to integrate teaching videos that demonstrate how the pelvic floor muscles work to support patient understanding as well.

3. Keeping a Diary

After a practitioner and patient discuss the anatomical function of the pelvic floor, the next step is taking a detailed look at the patient’s voiding patterns. While you can set the stage by discussing patterns with a patient, both the patient and therapist will have more objective data to review if the patient fills out a voiding diary for three to five consecutive days. Therapists may provide blank sheets to help patients track patterns, or patients can simply keep a log.

Therapists should look to gather information over the course of at least 72 hours. The information gathered should include the following:

• Time of day when the patient uses the toilet
• Time of day when the patient experiences urine or fecal incontinence
• Everything the patient eats and drinks, and when
• What the patient was doing when they experienced leakage

4. Reviewing the Diary

Once the patient and therapist review the voiding diary together, the therapist can start to identify what may be the root cause of the problem. A therapist can use the information from the log, along with their base knowledge of the pelvic floor, to determine if a patient is experiencing one or a combination of the issues listed here.

• Urinary stress incontinence
• Urinary urge incontinence
• Mixed incontinence
• Fecal incontinence
• Constipation
• Overflow incontinence

I recommend therapists complete education to understand these issues in more detail before starting a treatment program.

5. Beginning Treatment

Once a therapist can accurately discern what a patient is experiencing, the treatment plan can begin. Areas to review with patients may or may not include pelvic floor exercises. The MedBridge Home Exercise Library includes nearly 100 pelvic floor exercises you can use to create a customized home exercise program, including the one shown below, the Supine Pelvic Floor Stretch.

In addition to exercises, therapists should incorporate other strategies into pelvic floor rehabilitation. These may include dietary modifications, behavioral modifications to improve voiding at an appropriate frequency, and integrating strategies like the pelvic brace when moving from sitting to stand or the urge-suppression technique.

Hopefully, you can see the complexity of addressing pelvic health—and that Kegels are not the only pelvic floor tool to include in your pelvic rehab toolbox! I encourage all OTs to lean into learning about pelvic health because it affects people of all ages, genders, and backgrounds. Comfort in discussing pelvic health, awareness of healthy versus non-healthy pelvic functions, and confidence in treatment planning—which includes knowing when to reach out to a specialist—are skills every OT should cultivate.