While most of us are familiar with the use of physical therapy to reduce muscle pain and improve or restore mobility after surgery, it’s probably not as commonly thought of as a treatment for women’s health issues.

However, one Spokane-based therapist, Julia Salazar, says she’s hoping to change that by increasing education on how physical therapy can be used to help women who are experiencing pelvic floor dysfunction.

Salazar is a physical therapist and board-certified specialist in women’s health physical therapy at Apex Physical Therapy, in Airway Heights, who specializes in identification and treatment of pelvic floor dysfunctions.

“While I do treat women, men, and children with these issues, the bulk of my patients are definitely women,” she says.

Salazar describes the pelvic floor as the grouping of muscles at the base of the pelvis which act like a sling to support the certain organs, including the bladder, rectum, and uterus.

Contracting and relaxing these muscles allows you to control your bowel movements, urination, and for women particularly, sexual intercourse. These muscles can suffer physical damage or become stressed through mental or emotional trauma, leading to a lack of control called pelvic dysfunction.

A study conducted in 2008 by Oakland, Calif.-based health cooperative Kaiser Permanente found that a third of women suffer from one or more pelvic floor disorders, which include symptoms such as the frequent urge to urinate, dropped pelvic organs, and incontinence.

“The knowledge of pelvic floor therapy is growing, but my goal is always to keep expanding that awareness,” Salazar says. “I give a lot of talks both at Apex and out in the community on how to identify pelvic floor issues, as well as how these muscles are affected by different exercise routines and habits.”

Salazar says she was awarded her certification in women’s health physical therapy last July by the American Board of Physical Therapy Specialties of the American Physical Therapy Association and is one of only 433 women’s certified specialist providers nationally, 22 of whom are active in Washington state.

Jennifer Pence, a physical therapist with MultiCare Health System, also specializes in pelvic floor therapy.

“I’d says 95 percent of my patients come to me for some form of pelvic floor therapy, and most of them are women,” she says. “At MultiCare, we do have other physical therapists who can perform some external therapy for pelvic floor, but I’m the only one who’s able to perform internal muscle assessment and treatment.” 

Although there’s still a lot of work to be done to raise awareness about pelvic floor issues, Pence says she’s noticed an increased awareness among her patients here in recent years.

“I do feel there are more women and men coming in for treatment of problems they may have previously thought they’d simply have to deal with,” she says. “There’s more knowledge out there in our community from family, friends, support groups, and doctors who are able to suggest physical therapy as a treatment that may help.”

Since obtaining her women’s health physical therapy certification, she has been receiving more patient referrals from Spokane-area physicians, Salazar says.

“To me, that says my message is finally getting out,” she says. “It makes me happy to know that more patients will be trying physical therapy for pelvic floor issues first, because there are a lot of things it can help with.”

Salazar says often times pelvic floor muscles are either painful and tight, or weak, so she starts initial patient visits by performing an internal examination to test muscle function. 

“I ask a lot of questions as we go, and also watch for how nearby muscles are functioning because sometimes the body has begun using other muscles to compensate for pelvic dysfunction,” she says. 

By the end of the visit, patients understand how to do basic internal clench-and-release exercises called Kegels, that are designed to strengthen the pelvic floor, Salazar says.

“I also teach them some breathing exercises and get started on retraining bad habits they may not even be aware of,” she says.

Unlike most physical therapy, exercises for the pelvic floor are all internal, which Salazar says can make them more difficult.

“Part of what makes it harder is that these are underused or not used muscles so it can be frustrating to find them and learn how to use them,” she says. 

After the first initial visit, Salazar says she sees patients once a week for up to six weeks, with a follow-up appointment one month later.

“A lot of patients are a bit standoffish when they first come in, because these are sensitive and sometimes embarrassing topics to talk about. It can get pretty emotional, but once we get through it, they’re really appreciative of what they’re able to regain as a result of the work we’ve done.”

Salazar asserts the biggest part of her job is education and awareness, as many women mistakenly assume that pelvic floor issues are an inevitable part of pregnancy or aging.

“One of my most-used sayings with patients is “This may be common, but it’s not normal,”” she says. 

Salazar says some of the more common pelvic floor issues she sees in women include painful intercourse, pain in the pelvic area, incontinence, and endometriosis.

“It’s not unusual for women to have already seen up to nine different providers before coming to me,” she says. “Part of the problem is that there are often layers of issues occurring, and it takes a while to check each muscle and determine the root cause of whatever pain or dysfunction they have.”

Some of the symptoms Salazar says women should watch for that could indicate pelvic floor dysfunction include bladder leakage when coughing, sneezing, or jumping; painful intercourse; a heavy or fall-out sensation when standing; and excessive cramping or heavy bleeding during menstruation.

Like Salazar, Pence also says that education is the biggest part of her job.

“We consider how patients carry themselves and use their muscles throughout the day, as well as possible food triggers that can irritate symptoms,” she says. “If you don’t know what’s causing or contributing to the problem, the pain can seem random and out of control, but having that knowledge helps give them back some of that power.”

She adds, “As the mother of twins, I’ve experienced pelvic floor therapy myself, which also helps me relate well to patients.”

Pence says she advises women to ask their doctors about any changes or pain in their pelvic floor as soon as possible.

“Most of us know when something’s changed or doesn’t seem right,” she says. “Any sense of pain or pressure in the lower abdomen or groin region is something you discuss with your doctor, and they can help you rule out possible causes and refer you to a physical therapist, if needed.”

When it comes to pelvic floor therapy as a specialty, Pence agrees with Salazar that it may not be for everyone.

“You have to have the desire to go into this kind of subspecialty and it’s difficult to find enough therapists to pursue it,” she says. “But the patient population is definitively there, so it’s a field that’s just waiting to grow.”

Because pelvic floor dysfunction can be complex, certain patients may find they need surgery to correct some issues.

Dr. Derrick Havin is an obstetrics gynecology specialist, and medical director for Providence Health’s gynecology department here in Spokane.

Havin’s practice at Providence’s Surgical & Medical Gynecology Clinic focuses on complex surgeries as well as women’s health issues, and he says pelvic floor issues make up about one-third of the cases he sees on a regular basis.

“The main thing we offer is aggressive surgery to correct advanced pelvic floor issues,” he says. “The majority of my patients have already visited with pelvic floor rehabilitation specialists or physical therapists or had surgeries without success.”

Havin says pelvic floor surgery is complex and has high recurrence rates.

“A lot of pelvic floor surgeries have high recurrence rates because of movement and the forces at work in that area,” he says. “Over the years some techniques have come into play to try to reduce those recurrence rates, but they’re still a long way from being perfected.”

Although he specializes in pelvic floor surgeries, Havin says physical therapy often plays a significant role in treatment of pelvic floor issues, either before or after surgery.

“I’d say nearly all of my patients have tried some form of physical therapy to try to correct an issue before they pursue surgery,” he says. “After surgery you also have to retrain yourself a bit in how to perform certain functions, so it’s also not unusual to have physical therapy to help with that.”

Havin says he also can recommend nonsurgical options for patients that may enable them to avoid surgery or make better progress in physical therapy exercises.

When it comes to pelvic floor issues, Havin says his advice to patients is similar to that of Pence and Salazar: Be honest.

“Many people tend to ignore these kinds of issues because they’re embarrassed, or they think it’s something they just have to live with as a part of getting older or having had babies,” he says. “But there are both surgical and nonsurgical options that can help you to see substantial improvements, so I urge all my patients to be as upfront as they can.”