About one quarter of women in the United States are affected by pelvic floor disorders. That’s according to the National Institutes of Health. Fifteen percent of men are affected too. Many people don't know about these disorders, or about treating or preventing them. But pelvic floor physical therapy can help. And as awareness grows, advocates point to health care disparities and the history of medicine ignoring female bodies.
Story
Rhea Muñoz expected childbirth to hurt and knew pregnancy would be uncomfortable.
“I was in bed crying, like I was in so much pain. And I just, I couldn't walk, I couldn't move, I couldn't sit, like everything was uncomfortable.”
But Rhea — who uses she and they pronouns — never expected how much pain they’d be in three months into their first pregnancy.
“I was on my baby moon with my husband, like trying to celebrate one last time before we had the baby. It felt like I was just on the verge of a breakdown,” she says.
The painful ache in their groin was so severe Rhea had trouble getting in the shower, going to bed, or walking. Her muscles felt stretched to their limits. Rhea’s midwife confirmed this was not normal and along with others in her midwife collective in Oakland, recommended pelvic floor physical therapy.
“And so they were the ones who were like, you need to look into pelvic floor physical therapy, which I had never heard of. And so I just started googling and searching and I was trying to find someone close.”
Rhea eventually found Dr. Anietie Ukpe-Wallace, PT, DPT, who goes by Tia. She’s a pelvic floor physical therapist in Emeryville.
“Cool so let’s take a look at that hip, I’m going to have you come onto the table. Let me have you bend your legs just a little bit, I’m going to come up on the table,” Tia says.
Pelvic floor physical therapy is a form of physical therapy that works on the muscles and structure of the pelvis. Tia explains.
“So the pelvis, I think if most people put their hands on what they would say are their hips, those are not their hips, that's their pelvis.”
The pelvis is the large bony structure at the bottom of the spine.
Tia describes the pelvic floor as a giant hammock of muscles and those muscles — more than 10!— support a bunch of organs. The muscles control things like your bladder, bowels, and reproductive organs. When they’re functioning and have the right amount of strength and tone, all the organs are well supported. Tia says to think about something like when you’re driving, and someone suddenly cuts you off.
“Think about where are some of the areas where you have a tendency to tighten up? I think most people are aware of definitely along their neck and their shoulders. But if you actually have awareness of your pelvic area, you'll actually notice you'll actually tense up around those pelvic muscles.”
But when those muscles don’t have the right amount of strength and tone, that leads to something called pelvic floor dysfunction. Pelvic floor physical therapy tries to fix the reasons the muscles aren’t working at their best. So Tia looks beyond just the pelvis.
“I'm not just going to be looking at their pelvis. I want to see how they move. So I always look at their posture and then I'll have them on the treatment table. I'll do a lot of the standard physical therapy stuff, just kind of take a look at their hips and their pelvis and do muscle testing.”
Physical therapists like Tia use different techniques like stretching, massage and breathing exercises. During one of Rhea’s visits, Tia kneels on the side of the table with Rhea lying face up. It looks like Tia is giving Rhea a massage: one hand is on the top of her hip and the other towards the side of her glute. Tia’s working to remedy some postpartum tingling and discomfort Rhea’s been experiencing in their hip. Tia’s checking out pelvis tightness and potential nerve irritation.
Initially, Rhea learned that years of jaw, hip, and pelvis clenching were key factors in the pain experienced during pregnancy. Now a year later, Rhea still sees Tia regularly for postpartum recovery work. The sessions focus on areas that are getting a lot of impact with having a new baby. Tia explains.
“I’m just palpating around her glute medius. So the muscle is on the lateral side and then a little bit of the glute max muscles. It feels like there is some tension that’s there.”
Pain during and after pregnancy is one reason people go to pelvic floor physical therapy. But pelvic floor dysfunction is not just experienced by people who have a uterus. Other reasonsare for things like constipation, frequent urination, pain during intercourse, or fecal incontinence. Tia says, she works on all kinds of people.
“Everyone has a pelvis. I also treat men as well too, and, you know, they have a pelvis and they also end up having lots of pelvic issues.
I found out about pelvic floor physical therapy last year as an almost 40-year-old. I had been experiencing years of pain from endometriosis — a disease in the uterine tissue. And, I had a growing cyst on my uterus. The debilitating pain was just getting worse and worse. But then, before cyst removal surgery, my surgeon referred me to pelvic floor physical therapy. And it worked. It had always felt like pain was just something I had to live with. So why had I never heard of this form of care? Tia says it’s because there’s a strong stigma — because pelvic health is seen as a women’s health issue.
“There's so much shame, there's so much stigma, no one wants to talk about it. We don't value what women do, I think, in a lot of ways. Whether it's during postpartum, or whether it's their perimenopause, or even to menopause, and they're having all these issues because it just isn't talked about. At any stage, it's not talked about.”
“Not only is it not standard care, a lot of women's health practitioners don't recommend it or know a lot about it,” says Jya Plavin. She is a pregnancy and postpartum coach. She also has a master's degree in public health and points tohistorical neglectas a reason why there is a lack of understanding about pelvic health.
“Because women's health has been underfunded, under recognized, under cared aboutsince the beginning of modern medicine,” Jya says.
Historically in the U.S., biological and medical research has largely studied bodies that are not female. That exclusion means much of our scientific foundations are tailored to bodies without uteri. Jya says this history determines a lot about our experience with health care and with our health outcomes.
“If there are pelvic floor physical therapists near you, if you have coverage for them, if you have any insurance at all, if you are a citizen, if you feel agency to advocate for your health in appointments, if you speak the language that health care providers speak and so many other things that determine the experience of this,” she says.
This context is part of the reason why Rhea chose a physical therapist who was also a person of color. But that wasn’t easy either. Insurance coverage proved to be a barrier.
“It's not lost on me that I had to go to the private sector to go and find someone like Tia. Everyone deserves this.”
Tia recognizes this, too. It’s why in addition to her private practice where she sees Rhea, she sees patients at Highland Hospital in Oakland. A new pelvic pain centeropened there two years ago that serves folks who would not be able to access pelvic floor physical therapy without support.
“So if you are someone who has MediCal or [is] low income, no insurance, you know, we see all of that. But the volume of people who need the help is so big, like my waitlist is at least two months long.”
Back in the physical therapy session, Rhea lays on her side for some more hip work.
“Like this would have killed me in pregnancy, laying on my side, I would have tapped out. So this is great to even do this work with you,” Rhea says to Tia.
Tia’s working where the glute attaches to the base of the spine. If there is tension there, it can pull the pelvis into an asymmetrical position.
Rhea says they continue to see Tia in postpartum “because honestly, she's really helped me see how everything is truly connected.”
Rhea’s also got a healthy six-month-old-now and, for the most part, is doing much better. They tell Tia during the session, “You fixed me! Do you hear me?” But they continue to see Tia for postpartum care regularly.
It’s hard to know how many people are getting treatment for pelvic floor physical therapy around the Bay Area or around the country.
Tia says often, her clients find out about her through word of mouth. But both she and Rhea hope for care that is more comprehensive and standardized.
“I think all of my friends deserve that. Whether they're going through pregnancy or not, I think all of my friends, anyone with a pelvis, really, deserves to be connected to their body and understand what's going on," Rhea says.
And the need is real and evident. Tia’s schedule is booked a few months out.