Anyone working in pelvic health knows all too well that the symptoms of female pelvic floor dysfunction (PFD)  — from bladder leaks and pain with vaginal penetration to anal pain and fecal incontinence —  are vastly underreported. Most providers do not screen for pelvic health symptoms and patients are either reluctant to bring them up or assume that they’re ‘just the way it is’ if you own a uterus (and especially if you’ve had kids).

Just how underreported are pelvic health symptoms? That’s one of the questions that the 2024 Origin Pelvic Health Study sought to answer. The consumer-facing study consisted of a 10-minute, double-blinded, online, quantitative survey conducted by the market research firm Ipsos, with a base sample of 612 U.S. women, ages 18-59.

Study participants were asked whether they had experienced bladder, bowel, and sexual symptoms in the past year, how those symptoms had impacted their lives, and whether they had gotten care for their symptoms. Additional questions were asked of those who had given birth within the past five years or who were in peri/menopause to both explore how these major life events impact pelvic health symptoms and reveal gaps in related care and education.

As a clinical reviewer of the study and an APTA Pelvic Health grant recipient working on my own research, I’m excited that companies like Origin are collecting this valuable data, which not only garners media attention that can be hard for pelvic health researchers to attain (the Origin study was written up in Vogue), it can help inspire and steer our research in important new directions.

The study includes too many eye-opening statistics to list here, but below are 3 high-level takeaways:

1. The majority of U.S. women ages 18-59 are dealing with multiple pelvic health symptoms.

PFD has most recently been found to impact 1 in 3 women, based on a 2022 study that examined the medical records of 25,425 women seeking primary care. ICD-10 codes were used to determine presence of PFD, including urinary incontinence, pelvic organ prolapse, bowel, dysfunction, and difficult defecation. Other pelvic floor-related conditions like vulvovaginal pain or orgasm difficulty were not included.

In contrast, the Origin study included a long list of pelvic health symptoms described in terms women often use themselves, with the goal to expose just how common these symptoms really are. What they found was that most women had one or more symptoms, and only a tiny minority had received care for them.

75% of U.S. women between the ages of 19 and 58 have dealt with two or more pelvic health symptoms within the past year. The average number of pelvic symptoms reported was 5.

Some of the symptoms experienced most often in the past year by U.S. women ages 18-59:

Bladder sypmtoms:

• 48% report bladder leaks when they cough, sneeze or exercise
• 38% report peeing more than once every 2 hours
• 37% report feeling like they had to pee again right after going
• 33% report feeling like they could barely hold their pee
• 27% report feeling like they couldn’t fully empty their bladder

Bowel symptoms:

• 52% report straining to have a bowel movement
• 48% report feeling like they can’t fully empty their bowels
• 29% report pain with having a bowel movement 
• 21% resort leaking gas or poop

Sexual symptoms:

• 33% report inability to orgasm
• 25% report unsatisfying orgasm
• 22% report pain with sex
• 18% report delayed orgasm

Interestingly, the study also found that Millennial women were more likely to report a host of symptoms in the past year, compared to Gen X.

2. Pregnant and postpartum patients are left in the dark when it comes to preparing for and recovering from the immense physical strain of childbirth.

As major health organizations seek to improve the current dire state of postpartum care, mentions of pelvic health and pelvic floor physical therapy are often limited to recommendations that postpartum patients be evaluated for urinary and fecal incontinence and referred to pelvic floor PT as needed.

Those of you who are women’s health specialists who focus on prenatal and postpartum PT, know that we have so much more to offer. The Origin Study highlighted the need for the exact guidance and expertise that pelvic floor PTs can provide.

Among women who had given birth with in the past 5 years:

• 85% report receiving no guidance on reducing their risk of tearing during childbirth.
• 65% report receiving no guidance on how to effectively push out a baby.
• 50% report receiving no guidance on how to manage pregnancy pain.
• 86% report receiving no guidance on how to heal their pelvic floor after childbirth.
• 83% report receiving no guidance on how to heal their abdominals after pregnancy and childbirth.
• 71% said they received no guidance on how to exercise safely before or after childbirth.

In addition, 44% of women who had a baby in the past 5 years say providers did not help them understand what is or isn’t normal in terms of their pelvic health systems. And 23% said they felt “not at all supported” by their medical providers during their postpartum recovery.

3. Pelvic floor PT continues to be underutilized, resulting in unnecessary pain and suffering for women of all ages.

It’s unlikely to surprise you that, of the Origin study participants who reported pelvic health symptoms within the past year, 96% had not received medical care for their symptoms. Of study respondents who had given birth within the past 5 years, 92% said they had not seen a pelvic floor PT to support their recovery after their most recent delivery.

Without proper screening by providers and referrals to pelvic floor PT, women will continue to suffer in silence, confused about what is and isn’t normal when it comes to their pelvic health.

The Origin study reiterates what pelvic health specialists and their patients already know — pelvic health symptoms significantly disrupt women’s lives. 64% of study respondents who report pelvic health symptoms in the past year say that these symptoms negatively impact their lives. And that number is even higher among women who have given birth within the past 5 years, at 79%.

Despite how discouraging it can be to read through these statistics, it’s important to get loud about them and continue to demand better. I’m grateful to my colleagues at Origin for making research part of their mission and am excited to see this data is used to fuel more research, draw more attention to pelvic health, and drive positive change in our healthcare system.

AUTHOR BIO:

Jessica Swartz, PT, DPT, CCI

Jessica Swartz, PT, DPT, CCI, is a physical therapist at Origin, a leading provider of pelvic floor and whole-body physical therapy with a special focus on pregnancy and postpartum. She is also working on her PhD in Public Health with an emphasis on Health Behavior in the Joint Doctoral Program of Public Health at UC San Diego/San Diego State University, where the focus of her research is developing ways to use physical therapy as a tool to improve women’s and maternal health outcomes and address health disparities.

Sarah Clampett, PT, DPT, is Head of Clinical Operations at Origin, a leading provider of pelvic floor and whole-body physical therapy with a special focus on pregnancy and postpartum. After studying Kinesiology and Psychology at the University of California, Sarah stayed on to earn her Doctorate of Physical Therapy. As a clinical leader at Origin, she’s as passionate about helping PTs love the work they do as she is helping patients feel good in their bodies.

Shortly after I started physical therapy school, I realized that being a physical therapist is a fantastic conversation starter. People’s eyes tend to light up when they hear I’m a PT because almost everyone has had an experience with physical therapy — and even if they haven’t, they’ve had an injury. They want to tell me about the physical therapy they did in high school for their scoliosis or that time they tore their ACL skiing. They even seek advice for that pesky low back pain that hasn’t fully resolved since throwing their back out six months ago. 

I love to hear people’s stories and genuinely enjoy engaging in casual conversations about injuries. When I’m done explaining that core strength is important when dealing with back pain, I go on to say that while I started my career in ortho, I’m now a pelvic floor PT. That’s when one of two things happens: 1) They stare at me blankly, then quickly change the subject, or 2) Their eyes light up even brighter and they start asking questions. That’s when the conversation gets really fun. “What exactly do you do?” “What do you treat?” and “How did you get into that?”

Where My Passion for Ortho Started
I decided to go to PT school for a couple of reasons. I’ve always loved sports and consider sports a large part of my upbringing. (Fun fact: I only listened to AM sports radio until I was about 13). And, like many PTs, I discovered physical therapy as a patient. In my case, it was after injuring myself in high school playing volleyball.

I loved going to PT, not only because I was getting better — I loved seeing all the other patients getting better around me. It was a very sports-oriented PT clinic and my first and only experience with PT, so when I declared Kinesiology as my major and started my pre-PT coursework in college, I had my heart set on being a sports/ortho PT. It felt like the perfect fit at the time. I was a student athletic trainer for 2.5 years in college to learn as much as I could about the sports rehab world before heading into PT school.

Fast forward to my final semester and clinical rotation at PT school: I was at an ortho clinic with a large population of athletes. I loved it. After I graduated, I was hired as a PT at that same clinic and started my career as a working PT. I began working a few days a week to build my caseload with the plan to transition to full-time as my schedule filled. That clinic happened to also own a women’s health clinic that treated primarily prenatal and postpartum patients. A few weeks after starting, I was asked if I wanted to work additional days by filling in at the women’s health clinic. As a new grad who needed to pay rent, I said yes because more days meant more money. It was supposed to be temporary.

My Journey to Becoming a Pelvic Floor PT
As soon as I walked into the women’s health clinic, something clicked. I fell in love with the patient population and helping them feel better. I remember early on, a patient with such severe pelvic pain that they could barely walk to the bathroom. At their next visit, they said they could walk without pain again. The ability to help people going through pregnancy and postpartum felt especially meaningful. I spent a year and a half working in both clinics and then transitioned to treating women’s health full time.

After working in women’s health for a couple of years, I eventually got tired of referring my patients with pelvic floor conditions to colleagues who treated pelvic floor and decided it was time to start treating it myself. To be honest, I was hesitant at first and definitely nervous about taking my first course. But as soon as I started treating the pelvic floor, something clicked again.

Even more so than in the past, I connected deeply with my patients and their goals. Giving someone the confidence to leave the house without wearing a maxi-pad or carrying extra underwear because they’re no longer worried about leaking was amazing. So many people suffer in silence from pelvic floor disorders and are resolved to just live with them. I’m lucky enough to provide a safe space to talk about it and assure them that it can get better. How cool is that?  

Advice for an Ortho PT Curious About Pelvic floor
Take a course! Just because you take the course does not mean you are committing to a career change. Even if you decide it’s not the right time to switch or you didn’t enjoy it as much as you thought you would, you’ll still learn valuable information that you can immediately incorporate into your practice. That overworked, stressed patient with lingering hip pain might need pelvic floor lengthening to get that last bit of pain to resolve.

Most ortho PTs who make the shift are nervous they won’t be able to use their ortho skills when treating the pelvic floor, and that simply isn’t true. My time in ortho has definitely shaped the pelvic floor PT I am today.

In ortho, you treat the whole body. If your foot hurts, you look at the knee, the hip, the low back, and how everything works together to figure out what’s causing the foot pain. Pelvic floor PT is no different. You must look at the whole body and figure out how all the parts are working together to get the results you need. I continue to use many of the same exercises now that I used back when I was working as an ortho PT.

Lastly, the pelvic floor is a group of muscles. If it’s weak, it needs to strengthen. If it’s overactive, it needs to lengthen. If it’s uncoordinated, it needs to be retrained. Yes, treating pelvic floor dysfunction requires special training, but at the end of the day, muscles are muscles.

Bre Stuhlmuller is an LA-based doctor of physical therapy (DPT) who practices at Origin, a leading provider of virtual and in-person physical therapy for women and individuals with vaginal anatomy. Dr. Stuhlmuller is especially interested in helping women through their pregnancy/postpartum journey and strives to help her patients understand the purpose behind the therapy they are receiving so they can begin to relate to their bodies differently and take an active role in their rehabilitation process.

When Covid ramped up in 2020 and Origin began to focus more fully on virtual care, many PTs were excited about this new way to reach patients. Although the prospect of working from home piqued my interest, I was still skeptical. I dabbled in virtual care at the beginning of my time at Origin, with the occasional appointment here and there. Even still, the concept of it was hard for me to fully grasp and I couldn’t say that I loved it. It felt unknown and even intimidating. I love to connect with my patients — establishing a good rapport is one of my strong suits — and I was worried that what I did in person wouldn’t translate the same way through a screen.

Looking back, I realize my attitude was very much informed by what I’d learned in training. I had a mentor during one of my rotations who emphasized the importance of human touch, how it was integral to the healing process. What would assessment and healing look like if I couldn’t use my hands?

To be fully transparent, manual therapy had also become a fallback for me while caring for my patients. If a patient was struggling to understand a concept, I could use my hands to show them. If I found myself at a loss of what to do next, I could provide manual therapy — it was always welcomed, felt productive, and gave me time to plan. With virtual, I knew I would have to rethink how I approached my assessment and treatment strategy, and I had no idea what that might be. 

New Fuel for Creativity & Connection

When it was clear I didn’t really have a choice, I gave virtual PT a try for more than just those occasional appointments. At first, as I was building up my caseload, it lived up to my not-so-positive expectations. It just wasn’t the same and I felt completely out of my element. It wasn’t until I began filling my caseload entirely with virtual visits that it began to surprise me. 

As I engaged more consistently with patients on Zoom, my creativity kicked in. Without my hands to fill in the gaps, I really had to think about the cues that I was giving and how I was explaining things. Suddenly, my mind was lighting up with new ideas and ways of getting my point across. Where should the patient be focusing their attention? What should they be noticing or feeling?

I began helping patients tune into their bodies, instead of solely looking to me to give them information. Often, when I first ask “What do you feel when you do X?” a patient’s first response is vague and unsure. Then I’ll try again, talking through the concepts and movement in more detail. I’ll describe the outcome I am after and provide analogies and examples. If that doesn’t work, I’ll have them try a different position, or experiment with a new analogy that relates to their life and specific situation.

What happens next has been so encouraging — I see them have a pretty powerful ah-ha moment. (And because they’re not wearing a mask, it’s great to be able to see the understanding on their face!) They’re connecting with and learning from their body directly, which gives them so much empowerment. They tap into their own abilities instead of only relying on mine, which is exactly what we hope to give to our patients. On my side, I continue to gain clarity and hone my communication skills. I’m excited to share that despite doing all of this through a screen, my connection with patients feels as strong as ever.

That’s not to say that patients aren’t missing manual therapy! If you’re a PT who sees patients in person, you know how much they like (and often expect) it. I think they can tend to rely on it too much — and a decent number of people really want to come in and just get something like a massage. That can be a struggle. We are not massage therapists. And unfortunately, some patients think they need it in order to get better. I think that will be an ongoing struggle when it comes to getting patients to try virtual physical therapy. But, in my experience, once they do try virtual, they are quickly won over.

The Habit Building Power of Home

Another unexpected benefit of virtual physical therapy is the level of follow-through. For starters, patients cancel much less, which makes sense — it’s a lot easier to hop on a Zoom call at the last minute than it is to get in the car (and find parking). And if childcare isn’t available, they can keep an eye on their kids while we do our visit. We may not always get quite as much done, but at least we are able to do something, which I’m constantly reminding my patients is always better than nothing. 

Along the same lines, in the few months since I’ve switched to solely treating virtually, I’ve been surprised to discover that patients seem more consistent with their exercises, not less. We’ll be collecting more data on this at Origin, but my guess is that being introduced to an exercise in the same environment where they’ll be doing it on their own makes a difference. When they do their exercises with me during a virtual visit, they’re creating a foundation of a habit. Later on, when it’s time to continue on their own, they can pick up right where they left off.

As much as I absolutely love our clinics at Origin  — having all the equipment on hand, the music playing, and the other patients and PTs around — it is a very different experience for patients compared to being at home. At home, patients have to self-motivate and are limited to the equipment they happen to have or are willing to buy. Starting from scratch in their own space can often be a major barrier.

When we’re in a virtual visit, I can help a patient set up the space where they’ll do their exercises, and we can improvise. They may need to use a thick pillow instead of a pilates ball, or a rolled-up towel instead of a yoga block. This eliminates all those excuses along the lines of, 'I couldn't do my exercises because I didn’t have X.’ It not only helps me stretch and refine my skills as a PT, it helps patients gain more agency— it encourages patients to get into the mindset of “let’s see how I can make this work with the resources I have.”

Just as invaluable is being able to coach a patient through functional movements. I can watch a new mom lift their baby out of their crib or get up from their couch, then give tips and recommendations that are specific to their setup. Then I watch them immediately apply those tips and feel the difference. And boom, I know they’ve got it.

Tips for PTs Interested in Going Virtual

As a PT, having a separate, designated space to work is critical. At first, I was doing it in the corner of my bedroom, next to my bed, with limited lighting. Although I made it work, it was awkward to not have room to move and didn’t serve my patients the way I wanted. I have now made a space in our garage with bright lighting and a white backdrop behind me. You don’t necessarily need a whole setup, but you want to ensure that your patient can see your entire body when demonstrating movements or exercises. And of course, you need strong, reliable wifi!

One challenge that comes up is that virtual patients can be distracted at the start of or even throughout a visit. Because they’re at home and may have just stepped away from kids or work, they may need time to refocus. This is very different from being at the clinic, where the few minutes it takes to check-in and get settled helps them be more present. So I’ve learned to expect this, give them some grace, and will spend a few minutes bringing their attention back to their goals.

I also want to say that I do miss being in the same space with other Origin PTs. I miss the time in between patients when you can have those quick, but incredibly helpful conversations like “oh have you had a patient who presents like this,” or “let’s go into a room and I’ll show you how I do this.” It’s hard to recreate that kind of spontaneous interaction online. We have a shared Slack channel where PTs can chat throughout the day about our cases and although it helps to fill in that missing gap, it can also be nothing but crickets and still lacks that same feeling you get physically being in the office with your colleagues. 

One major perk, however, is being able to spend more time between patients with my 2-year-old daughter. It makes being a working mama feel a little less of a sacrifice. But don’t get me wrong, it also comes with its challenges. I don’t have that same downtime driving to/from work to decompress and switch between mom mode and work mode. And it can be easy to get distracted between appointments and do chores or play with my daughter instead of cranking out my notes. At some point, I imagine I will want to split my time between the clinic and working from home. But for now, I am honestly more than content working virtually.

Origin is already working on new ways to integrate virtual and in-person therapy — thinking beyond either/or, toward a model where we can choose what works best from patient to patient and visit to visit. In the meantime, I’m excited to continue with virtual care and our patients are loving this option. My schedule has been more full in the past 4 months than it was before I went virtual, and I’m seeing more people get better under my care. It’s truly amazing to see them making so much progress, right at home. 

Ashley Rawlins is a Dallas-based doctor of physical therapy (DPT) with advanced certification in pelvic health and obstetric health. She practices at Origin, leading provider of virtual and in-person physical therapy for women. Dr. Rawlins's areas of specialization include pelvic pain, sexual dysfunction, pregnancy-related pain, postpartum recovery, and bowel and bladder dysfunction. She is a passionate author and educator and enjoys creating educational materials and teaching classes for patients, students, and fellow physical therapists.

I may be biased, but pelvic health is arguably one of the most important specialties in physical therapy. It's well known that pelvic floor muscle dysfunction affects individuals across every age group, life stage, sex, and gender, and can contribute to pain and dysfunction in many other areas of the body. According to research, 23.7% of women have at least one pelvic floor disorder and this percentage only increases with age. (1) So, why aren’t more physical therapists specializing in pelvic health?

A cross-sectional survey completed in 2018 found that the biggest barriers to entering this specialty are “lack of awareness, mentorship, and continued education.” (2) An alarming 59% of physical therapists have received little to no information on pelvic health physical therapy when graduating from their entry-level program. (2)

If you’re a physical therapist reading this, you’ve probably received a peppering of instruction on topics including lymphedema, osteoporosis, pregnancy, and maybe urogenital dysfunction. When I was a student, I only had two lectures covering topics related to pelvic health, plus one afternoon dedicated to observation of the prosected female sex anatomy. Luckily, those lectures and that one afternoon were so fabulous, they got me hooked on this specialty, but it was hardly enough education, given the prevalence of pelvic floor dysfunction.

More awareness of and education on pelvic health is needed so that physical therapists can better care for their patients. At Origin, we’re helping to fill this need by supporting physical therapy students who are interested in pursuing a career in pelvic health, but who may not be able to get the required experience.

Pathways to Pelvic Physical Therapy

There isn’t one specific path to becoming a pelvic physical therapist. Some students will complete a post-professional residency in pelvic health. Some will independently take continuing education courses and pursue certifications or board certifications in pelvic health. Whichever path you take in getting the knowledge and hands-on skills that are critical for safely diagnosing and treating this patient population, one thing is true: It can be both expensive and nerve-wracking!

If you are lucky enough to get a pelvic health clinical rotation, you’ll likely need to complete an advanced training course on pelvic health first. This is so you’re familiar with examination and treatment frameworks. These courses are costly for students in physical therapy school and can make these opportunities an impossibility for those with fewer economic resources.

In addition to being expensive to prepare for, clinical rotations for pelvic health in physical therapy school are intimidating. Yes, it’s exciting to finally be out in the “real world” after being stuck in a classroom for months. But even if you’re didactically prepared, walking through the doors of a new clinic with little more than the name of your clinical instructor (CI) can be terrifying. My clinical rotations felt more like boot camp, at times — I was dropped into the waters of patient care and made to sink or swim, based on my CI’s rules. Looking back, I know this was really more of how it felt versus the reality, but I longed for a rotation that was collaborative and curated to improve my clinical competence.

Educating & Mentoring Students in the Clinical Setting

At Origin, we don’t want finances to be a barrier for those pursuing a career in pelvic health, nor do we want students to feel underprepared or unsupported. We value creating opportunities, providing education, and mentoring those wanting to enter this area of specialty. Much like the patient care standards at Origin, we have worked to create an elevated student clinical experience. Below are some of the ways that we are providing this education and experience in our pelvic health clinics.

Onboarding: We start each clinical rotation with thorough onboarding so every student feels prepared. Prior to the first day in the clinic, students get a Student Handbook which details everything they need to feel prepared in their clinical rotation, from what to wear, to information on our company’s values, mission, and policies. We also take the time to train students on our EMR system, billing practices, telehealth services, and our model of care.

Learning Modules Depending on the length of the clinical rotation, we have developed various training modules for each of the students to complete with their CI. Important topics related to orthopedic and pelvic health physical therapy include infection control, informed consent, internal and external pelvic floor muscle examination, as well as a thorough training on some of the more common conditions that we treat in our clinics—weekly student “check-ins” help to inform the curriculum organization and tailor each student’s experience.

Simulation Experiences: Taking a course in pelvic health in advance of the clinical will set students up for a more in-depth rotation in pelvic health, but if getting this training is a barrier to starting in pelvic health, we’ve developed simulation experiences for the student. Once the students have completed the appropriate learning modules, we pair students to practice on each other, or help in getting volunteer pelvic models. Additionally, skills labs, team Learning and Development meetings, and student in-service assignments help to reinforce concepts learned throughout the clinical rotation.

At Origin, part of our mission to expand access to healthcare includes expanding the community of knowledgeable and expert pelvic health physical therapists. We feel that by improving the student experience and initiating the path to specialization in pelvic health, we can proactively change the status quo of pelvic floor care.

References:

1. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311–1316. doi:10.1001/jama.300.11.1311.

2. Dockter M, Benson S, Zhang Y, Anderson C, Le D. Factors influencing physical therapists to enter into women's health specialty practice. Journal of Women's Health Physical Therapy. 2018; 42(3): 154-164. doi: 10.1097/JWH.0000000000000107.