Pelvic Floor Rehabilitation: My Opinion as a Physical Therapist

What is meant by pelvic floor rehabilitation?

Pelvic floor rehabilitation refers to all behaviors, actions, methods, and devices that seek to have an effect on the pelvic floor and the surrounding tissues and muscles.

The goal? Most often, it is to prevent or treat urinary leakage (urinary incontinence).

Other effects may also be targeted: avoiding or treating fecal incontinence, reducing pain in this area, or even avoiding the risk of perineal tear or episiotomy during childbirth.

The pelvic floor is a set of muscles, ligaments, and other tissues. The perineum is the most well-known muscle included in it.

That’s why we often refer interchangeably to:

• Pelvic floor rehabilitation
• Perineal rehabilitation
• Pelvic rehabilitation
• Sphincter rehabilitation
• Perineal physiotherapy or physical therapy
• Pelvic-perineal physiotherapy or physical therapy
• Urinary incontinence rehabilitation
• Uro-gynecological rehabilitation

All these terms refer to the same set of techniques and expected effects, although it can indeed be confusing with all these denominations!

Pelvic floor rehabilitation can concern women as well as men, children as well as adults, and the elderly. It’s often pelvic floor rehabilitation in women after childbirth that is the most well-known.

Why does it seem logical to strengthen the pelvic floor to prevent or treat urinary leakage?

Simply because it controls the sphincters that allow urine to flow.

A well-muscled pelvic floor, especially one that can be controlled by contracting it, would thus prevent urinary leakage by closing the sphincters.

Pelvic floor rehabilitation most often involves performing exercises with or without equipment to prevent or reduce the frequency of urinary leakage.

Pelvic floor rehabilitation in women before and after childbirth

First, it’s important to distinguish between two different situations:

1. The case where the woman does not have declared urinary incontinence, either before or after childbirth (which is most often the case).
2. The case where the woman has urinary incontinence (a less frequent situation but one that has been studied more).

Let’s first look at the situation where the woman does not have urinary incontinence.

Pelvic floor rehabilitation then aims to prevent the onset of incontinence and potential other problems such as pelvic pain.

Rehabilitation during and after childbirth to prevent urinary leakage

More than a third of women experience uncontrollable urinary leakage during the second and third trimesters of pregnancy. These urinary leaks are also present in about one-third of women after childbirth.

Because urinary leaks are relatively common before and after childbirth, preventive management of these disorders is often recommended for women.

Its effectiveness has been tested in clinical studies involving more than 9,000 women in 20 different countries. What are the results of these studies?

Among pregnant women without urinary leakage who undergo preventive pelvic floor rehabilitation, urinary leakage is less frequent:

• At the end of pregnancy
• 3 and 6 months after childbirth
• It’s unknown if they are still less frequent one year after the baby’s birth compared to women who did not receive preventive rehabilitation.

What do the sessions offered to women in these studies consist of? They involve exercises to strengthen the pelvic floor muscles.

The central principle of these exercises is to contract the pelvic floor by “squeezing the buttocks,” as if one were holding back urine.

All types of rehabilitation variants (with or without pelvic rehabilitation probe, with or without electrostimulation, with or without biofeedback, with or without abdominal contractions/transverse muscle, etc.) were considered without seeking to determine if any stood out.

There are no studies on the cost-benefit ratio of this rehabilitation in this context. (Woodley et al., 2017)

Pelvic floor rehabilitation before and after childbirth prevents the risk of urinary leakage in the 6 months following childbirth.

Perineal Rehabilitation during and after childbirth to treat urinary leaks

It has been observed that perineal rehabilitation helps prevent the onset of urinary leaks during and after pregnancy, at least for a few months. But does it also decrease or eliminate urinary leaks in women who experience them before or after pregnancy? This is not certain. Studies do not provide conclusive evidence on this matter. However, no side effects have been noted. (Woodley et al., 2017) It is uncertain whether perineal rehabilitation reduces the frequency of urinary leaks after childbirth in women who already experience them.

Perineal Rehabilitation during and after childbirth to prevent and treat fecal incontinence

There are fewer studies on this subject. Existing studies do not indicate whether perineal rehabilitation, before or after childbirth, is effective in preventing or treating fecal incontinence in pregnant women and new mothers. (Woodley et al., 2017)

It is not certain whether perineal rehabilitation reduces the frequency of fecal incontinence after childbirth.

Perineal Rehabilitation in women after cesarean section

Regardless of whether a woman has had a cesarean section or not, perineal rehabilitation is often recommended. Indeed, weight gain during pregnancy may have weakened the perineum and the surrounding tissues, as the baby’s weight pressed on it.

Additionally, hormonal changes during pregnancy may have also weakened the perineum.

Even with a cesarean delivery, perineal rehabilitation may be relevant. Perineal rehabilitation should also be offered to women who have had a cesarean section.

Rehabilitation in case of urinary leaks after perineal rehabilitation

Despite diligently attending perineal rehabilitation sessions (either alone using applications or with healthcare professionals), some women may still experience urinary leaks after childbirth.

For these women, remote perineal rehabilitation sessions conducted after childbirth may be relevant. It may be beneficial to vary the type of exercises practiced.

For example, if the person had performed exercises with a perineal rehabilitation probe and electrostimulation, it may be pertinent to propose exercises based on the contraction of the transverse muscle (one of the abdominal muscles) and the associated co-contraction of the perineum.

Is perineal rehabilitation mandatory?

Because time is often limited after childbirth, many women wonder if perineal rehabilitation is truly mandatory after pregnancy.

Obviously, the answer to this question is no: everyone is free to undertake or not undertake rehabilitation sessions or exercises autonomously, just as they are free to do nothing. It is important to bear in mind, however, that not undergoing perineal rehabilitation increases the risk of experiencing urinary leaks within 6 months after childbirth.

Perineal rehabilitation is not mandatory! It simply increases the chances of not having urinary leaks within 6 months after childbirth.

Perineal rehabilitation in women in general

Both women who have had a child and those who have not may experience urinary leaks. These leaks can occur during sports, coughing or laughing, at night, or even without any specific activity.

Is rehabilitation effective in reducing or eliminating these leaks?

The answer to this question is YES. But here are more details. (Dumoulin et al., 2018)

Women with stress urinary incontinence are 8 times more likely to report being cured when they have had perineal rehabilitation.

• Women with urinary incontinence (regardless of type) are 5 times more likely to report being cured when they have had perineal rehabilitation.
• Women with urinary incontinence have, on average after rehabilitation, one less episode of leaks per 24 hours compared to those who have not had rehabilitation. The quality of life of women who have undergone rehabilitation is improved.
• Women who have undergone perineal rehabilitation are more satisfied with the treatment.
• Those who have undergone a different treatment or no treatment are more likely to seek further treatment.
• The side effects of perineal rehabilitation are rare and minor (transient pelvic pain).
• The cost-benefit ratio of perineal rehabilitation for treating urinary incontinence in women seems promising (based on a single study).

Is there a more effective type of perineal rehabilitation than another? The answer to this question is no.

For now, no particular type of rehabilitation stands out in studies conducted. The only thing we are reasonably sure of is that women who receive regular supervision during the perineal rehabilitation period report better improvement in their incontinence than those who have little or no supervision from a healthcare professional.

The relevant frequency of supervision appears to be once a week. (Hay-Smith et al., 2011)

Perineal rehabilitation can eliminate urinary leaks in women who have them or reduce their frequency, and no specific rehabilitation method appears to be more effective than another.

Perineal rehabilitation probe and electrostimulation: Essential?

Whether alone or with a healthcare professional (midwife or physiotherapist), it is possible to undergo perineal rehabilitation using a perineal rehabilitation probe and electrostimulation.

The probe is inserted into the vagina, and active exercises involving contraction of the perineum are performed. Electrodes also help to stimulate perineal contraction.

Does using this equipment result in fewer urinary leaks or better reduction of their frequency?

Several studies have investigated this issue. It does not seem that using a perineal rehabilitation probe and electrostimulation is more effective than simple exercises for strengthening and engaging the perineum without equipment.

(Stewart, 2017)

Perineal rehabilitation probes and electrostimulation are not more effective for perineal rehabilitation than performing exercises without equipment.

Perineal Rehabilitation with Probe: Side Effects?

There are some theoretical possible side effects when using a probe:

• Discomfort, unpleasant sensation, or even pain in the vagina during or after the session.
• Risk of infection.

These side effects can also be present with perineal rehabilitation where therapists’ fingers are inserted into the vagina.

However, this remains relatively rare: studies do not report any serious or even significant side effects between groups with or without probe rehabilitation.

Manual Perineal Rehabilitation

There are increasingly more devices for practicing perineal rehabilitation using equipment: perineal probes, electrodes, devices or electrostimulation probes, etc.

This equipment can be purchased and used by physiotherapists or midwives.

Furthermore, more and more devices are directly targeting patients and offer the possibility of doing perineal rehabilitation at home simply using a smartphone application, which can be connected, for example, to a perineal probe.

Is there a real benefit to using this perineal probe? No: manual rehabilitation or even performing simple pelvic floor muscle strengthening exercises is just as effective.

Manual perineal rehabilitation is just as effective as rehabilitation with a perineal probe, muscle strengthening, or electrostimulation.

(Stewart, 2017)

Perineal Rehabilitation through Visualization (Biofeedback)

As we have seen, perineal rehabilitation is effective in women to reduce or even eliminate urinary leaks. However, no particular method of rehabilitation seems to stand out.

Rehabilitations with visualization (feedback or biofeedback) therefore do not appear to be inherently more effective than perineal rehabilitations without visualization.

This applies whether the feedback comes from a person, a smartphone application, or computer software.

In fact, what seems to be more effective for perineal rehabilitation is regular contact with a healthcare professional – whether they provide feedback or not.

The estimated relevant frequency of contact is a meeting once a week with a healthcare professional.

(Herderschee et al., 2011)

Perineal rehabilitation with biofeedback is not more effective than other forms of rehabilitation. What matters is the weekly supervision of a healthcare professional.

Perineal Rehabilitation: Exercises

There are numerous exercises for perineal rehabilitation. These exercises are the same whether it’s postpartum rehabilitation or perineal rehabilitation for urinary leakage issues.

Is it useful to know and practice a large number of them? No, the only potential benefit of regularly changing exercises is to stay motivated.

All perineal rehabilitation exercises are based on the same principle: combining a contraction of the perineum and the transverse muscle, regardless of the position adopted.

How to contract the perineum?

By squeezing the anus and the vagina and trying to maintain the contraction for as long as possible, or by releasing and then contracting as many times as possible. Once you can do this, you can combine the perineal contraction with the contraction of the transverse muscle.

To contract the transverse muscle, simply pull in your stomach as much as possible, remembering to engage the perineum. I explain in detail here how to do transverse muscle exercises, also known as stomach vacuum exercises.

These perineal and transverse muscle contraction exercises can be done in various positions:

• lying on your back, with your legs bent (often the easiest position) or straight;
• sitting down, in front of the TV, computer, while driving, or even on the bus;
• standing, while doing dishes or carrying a baby to help them fall asleep;
• while walking;
• while going downstairs;
• etc.

Perineal rehabilitation, when performed with a healthcare professional, involves finding exercises that suit each individual based on their specific difficulties or ease, as well as their motivation.

It is entirely possible to rehabilitate the perineum alone at home without the intervention of a third party. For this, simple exercises can be practiced without equipment.

Perineal rehabilitation with a perineal probe or using an app is not more effective than simply doing exercises without equipment.

However, being in contact once a week with a healthcare professional who can supervise the rehabilitation increases the chances of perineal rehabilitation being effective.

Home perineal rehabilitation

After childbirth, it is often difficult to find time to visit a midwife or physiotherapist. It is possible to do perineal rehabilitation alone at home.

There is no need to invest in expensive devices such as perineal probes and biofeedback apps.

As we have seen, their use does not improve the effectiveness of perineal rehabilitation based on simple perineal and transverse muscle contraction exercises.

In France, the Connaissance et Maîtrise du Périnée (CMP) is a method that has been developed to encourage self-perineal rehabilitation. It is aimed directly at individuals who want to self-rehabilitate, as well as healthcare professionals.

This method has not been the subject of clinical studies; it is entirely possible to perform perineal rehabilitation autonomously without following a formalized method.

However, it seems important to keep in mind these few points before starting perineal rehabilitation, whether alone or with a physiotherapist or midwife:

• Perineal rehabilitation prevents the risk of urinary leaks within 6 months following childbirth, but it is not certain whether it has a long-term effect.
• Women with urinary incontinence are 5 times more likely to report being cured when they undergo perineal rehabilitation.
• Using a perineal probe, electrostimulation, or biofeedback, as well as having manual perineal rehabilitation, is not more effective than performing simple exercises without specific equipment.
• Being followed once a week by a healthcare professional improves the effectiveness of perineal rehabilitation.