From Anxiety to Empowerment: The Truth About Pelvic Floor Therapy

Pelvic floor physical therapy can feel intimidating, especially when you don’t know what to expect. In this episode, I sit down with MJ Strauhal, one of Portland’s most experienced pelvic floor PTs, to walk through what really happens at that first appointment. 

You’ll hear: 

- Why pelvic floor PT isn’t like any other therapy you’ve had 

- What the intake process looks like (yes, we ask about pooping, peeing, AND sex!) 

- Why comfort, privacy, and patient choice are central to PT 

- How PT can help with leaking, prolapse, pain, and more 

If pelvic floor PT has ever made you nervous, this conversation will give you the clarity and reassurance you need. 

Additional information: 

PT finder https://www.aptapelvichealth.org/ptlocator

https://www.voicesforpfd.org/find-a-health-care-professional/

Timeline:

00:30 Introduction to Pelvic Floor Physical Therapy

01:54 Understanding the First PT Appointment

02:81 Scheduling and Preparing for Your Visit

03:45 The Importance of the Intake Form

05:33 Patient Comfort and Initial Assessments

07:37 The Role of Anatomy and Education

08:56 Exploring Treatment Options and Techniques

15:25 Virtual Visits and Online Classes

17:39 Addressing Common Concerns and Misconceptions

23:16 Conclusion and Final Thoughts

Transcript

Hi there. As a urogynecologist, I work very closely with pelvic floor or physical therapist. Most of my patients benefit from pelvic floor pt, whether it is muscle strengthening, learning how to relax those overstimulated muscles, learning how to optimize your ergonomics at work. Or just plain protecting your surgery.

And while I love physical therapy and think there are so many potential benefits that come from it, it is a huge source of anxiety for a lot of my patients. So many women are nervous about what will happen, what the exam is like, what the space is like, will there be a cute guy next to me who's rehabbing his knee?

All of this creates a lot of uncertainty and fear about physical therapy. A few years ago, I sat down with a good friend of mine, MJ Stro Hall, and we talked about the PT experience and what you could expect, and a lot of my patients have found this to be really helpful so that they have a good understanding of what will happen during that exam.

Things have changed a little bit since this conversation. MJ has retired, but the essence of the PET PT experience is the same. Listen and learn. Hi there. I'm here today with MJ Stro Hall, who is a longtime friend of mine and one of the queens of pelvic floor physical therapy here in in Portland. So MJ works for Providence and she is the Clinical Advancement Program lead for pelvic health.

So she has been a pelvic health physical therapist for a long time. She's helped me with a lot of my really complicated patients. I think the. You know, one of the best things about you, MJ, is that you really love what you do, and it, it always comes through for the patients as you're helping them, you know, through some of their struggles or things that they've been struggling through for a long time.

And I just wanted to talk to you today about that first appointment and what that, what that's like for women. You know, I think there's a lot of fear about that first appointment. You know, when they're in my office, I put in the referral and then, and then what, what happens? What's the next step? So you're right, that first appointment can be kind of scary.

Um, but when you put the referral in, usually our schedulers will call the patient and schedule a time that is convenient for them. But also we have several locations within the Providence system, and it's not just for Providence Care Plan insurance folks. For, for others as well. But there are like 18 satellite locations.

We've got the major hospitals in the Portland Metro area covered with pelvic health trained pt, so our schedulers are gonna work hard on getting a patient to a location that's convenient for them. It's also based on their diagnosis. As you mentioned, I see a lot more of the complex patients. We've got therapists that are at different levels of their training, but do a great job with kind of simple urinary incontinence or pelvic organ prolapse, so, so that's how they get into C Us and.

That first visit. Yeah, it can be scary, especially if you've had PT before, but it's been like for your knee, and so what is it gonna look like for my pelvic floor that I, I really wanna reassure patients that that first visit, we do a lot of talking before they come to us. We ask them to either complete online an eight page questionnaire.

It's really lengthy, and if they can't do it online, we ask them to come in at least 15 minutes early to do that. The length of the intake form is important because we talk about pooping, peeing, and sex basically. Um, the pelvic floor com, it, it combines all of those. And even if you only have a urinary incontinence problem, it's important that we know if that's affecting your bowel health or your sexual function.

And so the questionnaire. Ask a lot of questions. Many of them you can skip over if it doesn't apply to you, but it's important that we help patients make that link for what's in the pelvis, right? Yeah. You have the, the bladder, you have the vagina and the uterus, and you have the rectum in there. They have to be good neighbors.

I like to tell my patients they have to play well in the sandbox together. Right. Um, so, so that's the first part. And that's always a little overwhelming for our patients. Wow. This questionnaire, it's like, my goodness. But it's helpful. It's interesting, right? Because a lot of times patients feel like. Oh my gosh, this could be so much worse.

And there are so many things here that don't apply to me. Yeah. Or sometimes they're so reassured because they see how all of these things kind of fit together. Yes. So I'm laughing at you as you're speaking 'cause I always tell my patients that I'm kind of the doctor of TMI, I mean, I ask you all the questions that you don't really wanna talk about, but I forgot you too Are, um, well versed in TMI of.

Yeah. Pelvic floor health. Oh, so I, I just wanna clarify one thing that you said. So you have different physical therapists who are at different levels of training, and so based on the complexity of that patient, that patient pretty much gets assigned to someone who meets their complexity, right? Exactly.

So someone who has more pain issues or you know, maybe has. A more complicated medical history, contributing factors mm-hmm. Gets sent to someone who's more experienced and you have that whole triaging system. We do bleed out. Yep. Yep. And what's really nice about our team is that we also inter refer. So if somebody really feels like they want another set of eyes, um, on, on the case, we'll inter refer if the patient feels comfortable for that.

One of my biggest concerns is that patients build a therapeutic relationship. Yeah. With their, the physical therapist that they're gonna see because, um, let's face it, talking about these private, um, really sometimes very embarrassing, um, symptoms. You wanna only do that with one person if possible, right?

Mm-hmm. Um, and so, yeah. Um, one of the things that I always tell patients when I'm referring them is I always say, you know, this is a really intimate relationship and you may love your physical therapist. You may not, and if you don't, you should tell me and we'll find someone else for you. And I always interpret that as.

It's not a good match. Mm-hmm. For whatever reason. But it has nothing to do with that physical therapist's ability. Right, right. I mean, sometimes, you know, for whatever reason you're just not jiving with that person. You know, I mean, I've had patients, you know, come in, come back and say, you know, that person was too young for me.

I mean, sometimes it's something super subjective, but when you're, you know, revealing some intimacies, uh, it has to, it has to feel okay. It does. It does. And that's really important, and that's what we want for the patient as well. So again, back to that first visit, um, a little overwhelming at first with that intake form and that's why we like 'em to fill it out at home if possible, so they don't feel rushed.

And then that first visit, it's a lot of talking. We go over the questionnaire and so we make sure that we're paying attention to their responses. If they took the time to fill it out, I sure wanna take the time to talk about it. We do a lot of. Patient education. So anatomy. So why did we ask questions about pooping when my problem is about peeing?

Right? Um, and so the anatomy is very, very helpful. And then we talk about the structures. And one of the things, the term I use is that we go global. Before we go local. So if a patient's had other injuries or a history of back pain or hip pain, or maybe they've had a total hip surgery, or maybe they had pelvic girdle pain during their pregnancy, we wanna know if that's impacted the health of their pelvic floor.

So we'll look at the structural support system, we'll look at their posture, we'll talk about the impact of those other muscles, and we may do some assessment of that, which is very similar to going to an orthopedically trained. Physical therapist, so. We start there, um, we do talk about the, the anatomy of the pelvic floor and what our assessment might look like.

Very rarely do we do an exam of the pelvic floor, whether it's vaginally or rectally. Internally, that first visit, and we talk about how comfortable are you, um, with doing that kind of exam. Would you prefer a different kind of exam? More external? We have. Biofeedback available to us. Some of our clinics have ultrasound imaging available to us.

So, um, if a person isn't ready to have an internal pelvic exam, which by the way, is very different than a GYN exam, we don't, we don't use stirrups. Um, but we start, uh, very slowly externally to look at the genitalia before we go into the musculature. So one of the things I like my patients to do is be familiar with their anatomy.

We may just use a mirror or I'll ask a patient to use a mirror at home. To look at their genitalia and maybe to do a contraction and relaxation of the pelvic floor, AKA, A Kegel, and see if they see movement there. So that's very important for them to become familiar with their arm anatomy, maybe even self palpation if they feel comfortable with that.

Interesting. Right. Because those are things that a lot of women haven't done or haven't done, they have done, but perhaps not in an educated fashion. Right. They're not really sure what they're looking at. When you're having these conversations with women, where are they? Can you talk about the space, what that feels like?

Is it private? Are you know? Is there a cute guy working on his knee next door? Yeah. Yeah. Thanks. That's really 'cause I. Almost take that for granted because all of our, um, rooms, well, it's your space, right? You're used to it. Yeah. Yeah. Um, all of our rooms, um, have solid doors on 'em. We never are out in the gym with other patients.

It's very private. As a matter of fact, in my office, which is right downstairs from yours, um, we have a, a, a whole separate section for kind of specialty practices, things more private versus our big open orthopedic gym. And so private room, private door. We have a bathroom right next door. My, um, assessment room has a sink in it.

Um, so it's very private. It does feel a little bit more. Medicalized. If I had my way, my room would look very different. I'd have kind of like a lounge chair and, you know, pretty flowers and maybe some aroma therapy just to make it a little bit more calming and peaceful. But it's still a medical office building, so, um, I don't have that ability.

But we try to make people feel very comfortable. And during this whole process in education, they are not laying down on a bed. They are sitting in a chair facing me with their pants on. With their clothes on. Yes, exactly. No clothes come off and usually not until maybe the second or third visit, if ever.

Right. We can still help people without doing. That whole take off all your clothes thing, right? So again, education, we do a lot of talking about how the bladder and bowel work and um, we ask them to complete diaries and that can be really helpful in telling about their symptoms. Um, so. That's usually what the first visit looks like.

Anatomy, patient education, discussion of um, how we're gonna assess, um, their symptoms. And then completion of, um, maybe bladder and bowel diaries together. That takes up 45 minutes. Our appointment times are not real long. Um, 45 minutes seems long compared to probably your visits, but it goes fast. And so we ask patients to come back usually.

One time a week to every other week. So if they've had physical therapy, say for a shoulder where they come, you know, three times a week for three weeks and they're done. That's not how pelvic health looks. We spread these visits out. I might be seeing patients. Six months from now. But some people respond very, very quickly.

Maybe it only takes three visits. So I, I mean, I think the most important things that I've heard you say is you know that that first visit is really all about education and it's really patient led where Yeah, very much that patient gets to dictate the tempo and kind of the next steps. Right. And, and if a pelvic exam is not desired or not comfortable, then that's.

Reasonable. Right? Yeah. They're, they're not kind of pushed in that direction. And, and I think it's important to know that, you know, there are some limitations, right? We do get more information when we do a, a pelvic exam. Yeah. But that doesn't mean that we have to do that. That's correct. Right. And it's important to meet people.

They're where they're at, they're at. And then you're also assessing for previous injuries, which I think, you know, is so invaluable, right? Because it's not uncommon that we see people who have an injury that, you know, stems from a labrum tear or an old sports injury or maybe a, a knee injury. Are you also assessing for workplace ergonomics?

How much do you talk about that? So we're all PTs, so of course we're looking at at, at posture. Um, we wanna know what their workplace setting is like, even home, you know, how often do they sit down at a computer and that kind of thing. But, um, yes, we can do that. It depends on how important it is for patients.

Symptoms. So if someone's coming to me with pelvic pain, their work ergonomics play a much bigger role than someone that has maybe just straight stress urinary incontinence. Um, so it really depends on their diagnosis. But again, we all are PTs and calm with essential tools like that to, to make sure we're not missing anything.

Yeah. We also talk a lot about their exercise habits. Do they walk, do they run, do they bike? Do they do CrossFit? Are they really into Pilates? We wanna know how they manage. Pressure. So for someone with pelvic organ prolapse, that's really important as well. So their breathing and things like that are very, and depending on the time that we, we certainly talk about breath work first and second visit as well.

And then all through their therapy. So I think, you know, the PT journey is frequently such an education for women, right? Because there are so many things about your body that you don't realize, right? You don't realize how you're holding yourself, how you're transmitting pressure, your breathing, your asymmetries.

I mean, all of those things. You know, sometimes it's a little bit humbling to realize that you've been breathing incorrectly for years and years and years, but that can definitely be part of the problem. Right. So how important do you think coming to the office is versus the homework that you give women?

Well, I think they're both important. We do have a therapist, um, and not all of us have the capacity just because of our workspace in place to do virtual visits. So we have a couple of different therapists that do virtual visits with patients. They may translate into office visits, but if someone really feels more comfortable doing a virtual visit, we have that.

Availability, and they do much of the same thing on that first visit. Um, and then kind of direct the therapy based on the, the responses as well as the patient education and whether they should come back for their second visit as a virtual visit, or whether that therapist, especially if it's a pain patient.

Or if it's someone that really has never felt comfortable doing Kegels or doesn't have good sensory awareness of where the pelvic floor muscles are, or, or a sensory perception of the ability to feel a contraction and a relaxation, that person is gonna do better in a clinic setting, even if all we do is maybe do some palpation or visualization externally.

Um. It does depend on patient's sensory awareness as well as their diagnosis, but we do have that available, especially for people that may have difficulty with transportation or location or just comfortability of seeing someone, you know, face-to-face. I think one of the benefits that PT offers as well is, you know, there's definitely a counseling aspect, right?

There really is, yeah. You know, telling women how common this is and you know, just providing a lot of reassurance. I, I think, is. You know, such an important part of it. And, and you know, I think that's something that women get a lot of value from as well. Yeah. And in this age of Zoom, right? Yeah. Um, it's, it's really hard to, um, establish a more personal connection.

And I think you're right that that can be very helpful in any setting, whether it's a physical therapy setting, whether it's a physician setting. That it helps because we're human beings and this, that human interaction can be really valuable. Well, and I think, you know, prolapse and incontinence can be so isolating, right?

So many women think that they're the only person that have this issue, just because we don't really talk about it and, and realizing that there are whole clinics set up. To handle this and that we talk about these issues all the time, and it's so very, very normal and not shameful or embarrassing. I think that provides a lot of solace to many women, and I think you're right in that our culture has gotten a little bit more comfortable talking about urinary incontinence.

We see advertisements. On the television all the time, um, you know, it's gotten more press. The things that haven't gotten as much press are things like chronic pelvic pain, accidental bowel leakage. Yeah. Um, so that can really be a, a. A problem as well. So bowel leakage is I, I mean this is definitely an understatement, but it's the worst.

Right? Because it is the hardest to hide. Exactly. It feels there's a lot of shame associated with that. And you know, there are so many things that can cause it, right From childbirth injury to neurologic injury, and. I feel like those are, you know, everyone feels like their sphincter should work without thought, and when they don't, it must be something we're doing incorrectly.

And a lot of times it's just a failure of your system through no fault of your own. So you offer in-person pt, you offer, um, virtual pt, but there's also an online class that I wanted to ask you about. So who can go to that class? How does that work? Okay, so right now under the Providence system, anybody that has a Providence Healthcare Plan, um, can access that virtual class.

We do it once a month. Right now I'm the one that instructs it, but we have a couple other people that do it, um, when I'm not around. Um, but it's an. 90 minute class and it goes through a lot of information that we do on that first visit. And so sometimes it really helps prepare people to come to an in-person visit because we talk about the anatomy and function of the, um, pelvic girl on the pelvic floor.

We talk about how the bladder and bowel work, and then we do. I have an introduction, at least to pelvic floor muscle training, also known as Kegels, so that if somebody's not familiar with that, um, that they have a, a better idea. So it's a 90 minute class. It is a Zoom class, so it's live. So lots of good interaction q and a for, for patients.

Um, and they can access that class if they have Providence Healthcare insurance. Through their primary care doctor or through someone like you, a specialist. Right now it's only for Providence Healthcare Plan patients, but we are working with, uh, some of the other healthcare plans to, um, get coverage for that so that patients can access that, that may be the only thing they need initially.

And we certainly talk about how to access one-on-one physical therapy after that if there's symptoms. Um, don't. Um, get better with some of the tools that we teach them. How big are those classes usually? So we limit it to 15. And so it varies from two to three to a full on 15. Um, but they're small and so a little bit more personal.

And if people feel, uh, comfortable having their camera on and asking questions when we do q and a, that's great, but they don't have to. We also have an admin person that monitors the chat, and so if you wanna ask questions without feeling embarrassment, those, those questions can be asked in the chat and then we discuss 'em.

So, so, I'm so curious about that. Do, do women interact? I mean, do people keep their camera on? You know, I'm, I'm thinking, you know, when my kids were doing virtual school and, and we had my son's first parent teacher conference, the teacher said, oh my gosh, it's so nice to see what you look like. 'cause he would never turn his camera on, even though we had been telling him to.

Right. Well, we do have PowerPoint. So during that time we ask people to keep their cameras off just for bandwidth. Um, so all they're seeing on their screen is the PowerPoint, but then at the end we take the PowerPoint off and the screen looks like what it looks like for you and me right now. Whoever wants to have their camera on can have it on.

Um, but they can unmute their microphones and just ask questions in real time. So it's nice. I mean, how many people do that? Um, it, it depends, you know, we've been doing this now for a couple of years. Yeah. Uh, and it, and it really depends. I think people are getting more comfortable now that everybody's pretty much done a Zoom meeting.

Um, yeah. We still have a few folks that are like, I don't know how to do that. Where do I find my camera, et cetera. Right. But for the most part, you know, we have a wide variation in age. We have a lot of younger folks who are like, yeah. I got no problem with this and cameras are on, um, microphones are on and, um, and, and it's pretty interactive, so it, yeah, makes it for a good learning environment.

Yeah. I, I think it's such a great option, especially for women who are really busy. I mean, I'm thinking about postpartum moms, right? Women with new babies. Yep. I mean, it's great to be able to get this information and, and not have to leave your home, which might be really difficult for you at that point.

And I do think that information does help make for a more educated interaction with their, their healthcare provider. Mm-hmm. Now, now they know the right questions to ask. Yeah. Yeah, absolutely. And it's hard to get good information sometimes, right? I mean, there's definitely a lot of rabbit holes on the internet.

Um, and having said that too, I do wanna mention, because I think this is something that, um, every healthcare system is having difficulty with. Um. All of us as pelvic health PTs have long wait lists. Yeah. Um, and so when they get scheduled, their first appointment might be two months out. Um, one of the good things about our system is that we have what we call FastPass.

So they may have an appointment scheduled out in July, but if they are in FastPass, we can send them a notice. Anytime I get a cancellation. And um, and they can click on it and say, yes, I'll take that one and sometimes get in a lot earlier. Um, but I do wanna warn patients that sometimes there's a long wait.

And that's just the nature of healthcare system right now. I didn't realize you had fast passed. It's like Disneyland. It's really great. Who knew? I know, right? Um, it, it's hard. I mean, I think it's really hard for patients, but that's where I think, you know, having more virtual opportunities and group classes Yeah.

Can just help you get started. Even if that isn't the full answer. And if it is, then, you know, then great. The other thing I wanted to speak to is you help train all of your physical therapists and so you're super comfortable with this. System and the level of care that the Providence PTs provide. I would say, I mean, I, you know, I see that too.

I mean, a lot of times, you know, patients will come to me and they'll say, you know, tell me who I should see. And you know, if it is somebody super, super complicated, I do send them to you. But for the most part I say, you know, this is a really great system and they've really figured out how to triage you to the right therapist, and, and so I would let the system handle it.

I don't know what the wait times are for any individual therapist. Right. And so I think it just makes things work a little bit better. And we do a lot of interaction as a team. So we are constantly interacting with each other because we're all connected by way of the healthcare system. And so if we have a difficult case and I need to just troubleshoot with, with another therapist, I have that, um, availability within our system, which makes it really nice too.

No, I, I mean, I agree with that, right? I mean, I think relying on your resources is so important, right? Because no one person has all the answers and sometimes. You know, even just talking out a case, I mean, there have been lots of cases that, you know, we've discussed over time or, you know, brought in a colorectal surgeon or urologist just to say, okay, I'm thinking about it this way.

What do you think? What's the best approach? And that collaboration becomes so important for, for many women, and the program has to be very individualized. Not every patient that presents with similar symptoms actually. Is gonna be treated exactly the same. Right. So, um, we definitely individualize the programs and, and that takes collaboration, so, yeah.

Well, and I think that's what makes it so strong too, right? Because you're not, it's not a cookie cutter approach, right. Exactly. Saying, oh, you have urinary incontinence, you will do this. Right? You're looking at that whole person and developing an approach for them. Thank you so much for your time. Do you have any.

Parting words of wisdom for all of those women with bladder leaking out there. The one thing I would emphasize is that this is not a quick fix, right? And so, um, it's not about kaling until the cows come home. It's about learning and understanding your body, how you need to address your symptoms with your body and your symptoms.

And that it may take a while. It's, it's not going to be something that. You do some Kegels, maybe you've never done them for the first time, or, um, you know, there's not a silver bullet. And I think that may be the hardest pill to swallow, if, if I can put it that way, because most of us that have symptoms that have to do with pooping, peeing or sex really want it fixed.

We wanna fix now, but it is a journey, not necessarily a destination. And that's why when I mentioned that we might see patients even down to once a month for a few months, so that we can not only, um, be your coach, but also your cheerleader. Yeah. Again, I want patients to understand that, that it's a journey and it may take a while, and that's okay.

Yeah. I mean, I think that's really true, right? Where you are, the therapist, the coach, and the cheerleader, and that's what makes. Physical therapy, so very, very strong as a therapeutic intervention. Well, thank you so much. I appreciate all of your brilliance and your time and everything that you do for all of our patients here in Portland.

Well, thank you for having me. It's been a privilege to be able to talk with you today. Thanks so much. I hope this discussion makes you feel more comfortable with the idea of physical therapy and what it all entails and what you can expect to experience. If you need help finding a pelvic floor physical therapist, I've included a PT finder in the show notes, so look for it there.