Stop Avoiding the Pelvic Floor: Essential 101 for Physios

For many of us as non-specialist physiotherapists, the pelvic floor can feel like an intimidating topic—one we often sidestep with the justification, “that’s not my specialty.” But why does the pelvic floor seem so different from other areas of the body? We don’t hesitate to treat knees, feet, or shoulders, even if they aren’t our primary focus. So why are pelvic floor issues often dismissed or, in many cases, avoided entirely? Expert pelvic health physiotherapist Gráinne Donnelly challenges this mindset, arguing that the pelvic floor deserves just as much attention as any other part of the body—especially in the realm of sports medicine.

Fellow physios, consider this your call to action; it’s time to stop overlooking the pelvic floor and start incorporating it into your screenings. Thankfully, Gráinne’s exceptional Masterclass offers a clear and practical guide to integrating pelvic floor assessments into our practice. In this blog, I’ll share some key takeaways to help you get started. Let’s break the cycle of under-reporting, under-assessing and under-treating, and give the pelvic floor the attention it deserves!

If you want an in-depth insight on pelvic floor assessment and management, watch Gráinne Donnelly’s full Masterclass HERE.

Background

Did you know there’s Level 1, Grade A evidence supporting the role of Pelvic Floor Muscle Training (PFMT) in preventing and managing pelvic floor dysfunction? (1-3). That’s stronger evidence than many treatments we commonly use for other areas of the body. So, why aren’t we integrating it more? There are several reasons why many physios might not prioritise pelvic floor screening or management – limited education on the topic during training, minimal emphasis in clinical guidelines and consensus statements, or even the fear of making patients uncomfortable – these can all contribute to putting pelvic floor issues in the “too hard” basket. This often leads to either referring patients to pelvic health specialists, or avoiding the topic entirely, choosing to focus on contributing factors we’re more comfortable with.

But here’s the reality: Pelvic Floor Dysfunction (PFD) is incredibly common and has a significant impact, especially on women in sport. Around 49% of adolescent athletes experience urinary incontinence (4), though the true numbers are likely higher due to under-reporting. Even more concerning, PFD often stops women from exercising altogether (5). Watch Gráinne discuss the prevalence and risk factors for PFD in sport in this short clip from her Masterclass:

This is unacceptable. Women shouldn’t have to see a specialist physiotherapist just to receive some help. It’s time for us to step up and integrate pelvic floor screening and education into general practice. This essential aspect of care needs to become a standard part of what we do. So here’s how..

Screening

For starters, it’s important to be on the lookout for some key signs and symptoms of PFD. They can include:

• incontinence (bladder and/or bowel)
• sudden urge to void or defecate
• nocturia (>8 times during day, >1 per night)
• feeling of incomplete emptying
• feeling of heaviness, pressure bulge in vagina
• recurrent urinary tract infections
• haemorrhoids
• straining to empty
• dyspareunia (pain with intercourse) or pain with inserting tampons
• pain in saddle region/vagina/back passage

To make things simple, Gráinne recommends a screening tool called the PFD SENTINEL to screen all female athletes for PFD. She explains this in the below video taken from her Masterclass:

Treatment

One of the biggest barriers to screening for general physiotherapists is the fear of identifying an issue and not knowing how to address it. It’s time to stop letting this hold us back and return to the basics, just as we would with any other part of the body. We should also be educating athletes early, not just at childbearing age! Here are some simple, yet valuable, pieces of advice to get started:

• Using a foot stool during defecation
• Diaphragmatic breathing can help manage symptoms, especially for patients with a non-relaxing pelvic floor
• “Tightly Wound” is an educational short film for patients experiencing vaginismus, pain during sex, or difficulty inserting tampons
• Using splints (e.g., “Femmeze”) can assist patients who have difficulty with defecation

To effectively train the pelvic floor, Gráinne emphasises the importance of applying strength and conditioning principles: specificity, overload, and progression. This means using 3 sets of 8-12 reps and selecting the cue that resonates best with the individual. Here are some helpful cues to get started:

• “close/squeeze the ring of muscle at your back passage”
• “close a zip from your back passage to the front”
• “close the anus”
• “stop the flow of urine mid flow”
• “lift a blueberry with your back passage”

As with other injuries we also need to consider cumulative load (think occupation, caring responsibilities etc.) AND we need to help patients return to running or sport, just as we would someone recovering from a knee injury. Watch Gráinne explain a great testing battery for return to running in PFD in the below snippet from her Masterclass:

Wrapping up

It’s time for physiotherapists to stop avoiding the pelvic floor. We already have the foundational knowledge and principles to help patients on their journey, and it’s time to apply them to this area of the body. Of course, it’s essential to understand our scope of practice and refer to a pelvic health physiotherapist when needed. However, learning how to screen, provide basic education, and know when to refer for PFD should be fundamental skills for all physiotherapists. By doing so, we can start addressing the impact of PFD on women’s participation in sport.

Gain an in-depth understanding of how physios can prevent and manage PFD – watch Gráinne Donnelly’s full Masterclass HERE.