Journal of Midwifery & Women’s Health www.jmwh.

org
Review

Pelvic Floor Physical Therapy and Women’s Health Promotion

Samantha Lawson, CNM, WHNP-BC , Ashley Sacks, PT, DPT

Pelvic floor dysfunction is defined as abnormal function of the pelvic floor and includes conditions that can have significant adverse impacts on
a woman’s quality of life, including urinary incontinence (stress, urge, and mixed), fecal incontinence, pelvic organ prolapse, sexual dysfunction,
diastasis recti abdominis, pelvic girdle pain, and chronic pain syndromes. Women’s health care providers can screen for, identify, and treat pelvic
floor dysfunction. This article examines the case of a woman with multiple pelvic-floor-related problems and presents the evidence for the use of
pelvic floor physical therapy (PFPT) for pregnancy-related pelvic floor dysfunction. PFPT is an evidence-based, low-risk, and minimally invasive
intervention, and women’s health care providers can counsel women about the role that PFPT may play in the prevention, treatment, and/or
management of pelvic floor dysfunction.
J Midwifery Womens Health 2018;00:1–8  c 2018 by the American College of Nurse-Midwives.

Keywords: gynecology, postpartum care, preventive health care, primary care, midwifery education

CASE SUMMARY concerns but wishes to avoid medication and delay surgery
A.B., a 32-year-old woman, gravida 2, para 2, presents for until she is certain she is done having children.
an annual gynecologic examination. She was last seen for A.B. is diagnosed with midline grade II cystocele and
her 6-week postpartum visit 18 months ago, after her sec- rectocele, stress urinary incontinence, and diastasis recti
ond normal spontaneous vaginal birth. She jokes that she abdominis. The midwife discusses lifestyle changes that
has been “falling apart” since her last birth and reports she may alleviate her symptoms and reviews her treatment op-
is “quite a bit bothered” by the sensation of “something tions. She is referred to a pelvic floor physical therapist for
falling out” that has worsened during the last couple of pelvic floor muscle training.
months. A.B. tells her midwife that she saw a gynecologist
this past year, per her mother’s recommendation. She states INTRODUCTION
that she was diagnosed with “some kind of prolapse,” and
Well-woman, preconception, and antepartum visits are all op-
she also mentions some persistent pelvic, perineal, and low
portunities for women’s health care providers to identify risk
back pain. She declined surgical intervention, and she was
factors for adverse health and initiate measures to promote
told that a pessary would likely not be effective. She expe-
health and prevent disease across the life span. These interac-
riences urinary incontinence with exercise, and she denies
tions are ideal times for identifying pregnancy-related pelvic
strong urinary urges, fecal incontinence, or constipation.
floor disorders, but this opportunity for prevention and early
She does report dyspareunia, specifically pain with initial
intervention is often missed.1
and deep penetration.
Pelvic floor dysfunction is defined as the abnormal
A.B. does not smoke, drink, or use recreational drugs,
function of the pelvic floor, and it may be caused by structural
and her body mass index (BMI) is 19.5 kg/m 2 . She does
abnormalities, underlying disease, or physical trauma. Health
not have any other significant medical or surgical prob-
care providers may recognize pelvic floor dysfunction as a
lems, and she reports her mother had a complete hysterec-
condition, such as urinary and fecal incontinence, pelvic
tomy for “these same kinds of problems.” Her maternal
organ prolapse, sexual dysfunction, diastasis recti abdominis,
health history is significant for a third-degree laceration
pelvic girdle pain, and chronic pelvic pain.2 Risk factors for
that was repaired after her vaginal birth 4 years ago but was
prepregnancy pelvic floor dysfunction are primarily modi-
otherwise uncomplicated. She had no perineal laceration
fiable and include smoking, frequent vigorous exercise, high
during the birth of her second child, and she is no longer
BMI, and high hip circumference.2 The greatest risk factor for
breastfeeding.
postpartum pelvic floor dysfunction is prepregnancy pelvic
Her physical examination reveals a midline cystocele
floor dysfunction, although birth by forceps and third-degree
and rectocele that both extend one cm past the hymenal
perineal lacerations are clinically significant risk factors.2
ring, and a 5-cm wide diastasis at her umbilicus. Umbili-
Pelvic floor dysfunction adversely affects a woman’s quality
cal hernia is absent. She reports pain that is 5 of a maxi-
of life and overall well-being. Medical and surgical treatment
mum of 10 with speculum placement and bimanual exam-
methods are not without risk, and these options may be
ination, she has minimal strength when asked to perform a
further limited during pregnancy and breastfeeding.
Kegel contraction, and she leaks urine when asked to cough.
Pelvic floor physical therapy (PFPT) is evidence based
She verbalizes interest in treatment for her pelvic floor
and minimally invasive, can be used during pregnancy and
breastfeeding, and may be offered as a first-line treatment
choice to women experiencing pelvic floor dysfunction. This
Address correspondence to Samantha Lawson, CNM, WHNP-BC. Email: article reviews the evidence that supports PFPT for treating
SamanthaALawson@gmail.com pregnancy-related pelvic floor dysfunction.

1526-9523/09/$36.00 doi:10.1111/jmwh.12736 
c 2018 by the American College of Nurse-Midwives 1
PELVIC FLOOR ANATOMY
Understanding the structure and function of the pelvic floor
aids the provider in the assessment, diagnosis, and manage-
ment of pelvic floor dysfunction.3 The pelvic floor is made
up of a sling of muscles, ligaments, and fascia that support
the bladder, rectum, and reproductive organs. The bony pelvic
girdle includes the 2 innominate bones and the sacrum, and
these structures form the bony framework that surrounds and
anchors the pelvic floor.3 The innominate bones are made of
the ilium, ischium, and pubis. The innominate bones articu-
late with each other anteriorly at the pubic symphysis and with
the sacrum posteriorly at the sacroiliac joints. The coccyx ex-
tends from the sacrum and serves as an attachment for various
ligaments and tendons. The bilateral sacroiliac joints are sta-
bilized by multiple ligaments anteriorly and posteriorly; how-
ever, musculoskeletal changes during pregnancy may stretch
and stress these ligaments, causing posterior sacroiliac joint
pain. The pubic symphysis is reinforced by ligaments on all
sides as well; however, this cartilaginous joint can be a source
of pain or discomfort as it is subjected to much mechanical
stress as it relaxes and widens during pregnancy.3
The musculature of the pelvic floor contains 2 basic layers.
The bulbospongiosus, ischiocavernosus, internal and external
urethral and anal sphincters, and superficial and deep trans-
verse perineal muscles constitute the most superficial layer of
the pelvic floor. These muscles help control bladder, bowel,
and sexual function and can frequently be injured during
childbirth. The deep layer of pelvic floor muscles—containing
the levator ani, coccygeus, and surrounding fascia—make up
what is known as the pelvic diaphragm. The levator ani in-
cludes the pubococcygeus, puborectalis, and iliococcygeus
muscles, which are innervated by sacral nerve roots S3-S5.
The pubococcygeus, the most anterior component of the le-
vator ani, functions primarily to maintain pelvic floor tone
and support pelvic viscera. The iliococcygeus is located most
posteriorly and contributes the voluntary control of urination.
The puborectalis sits below the pubococcygeus and forms a
U-shaped sling around the rectum, and its fibers interdigitate
with the external anal sphincter.3,4 The coccygeus is a triangle-
shaped muscle that attaches at the ischial spines and inserts on
the lower sacrum and upper coccygeal bones. It functions to
support pelvic viscera and stabilize the sacroiliac joint.3 The
perineal body is a dense mass of connective tissue between
the vagina and anus, where multiple muscles, tendons, and
sphincters come together to support the pelvic floor. Injury to
the perineal body during childbirth may contribute to pelvic
organ prolapse.4 Muscles of the pelvic walls include the obtu-
rator internus and piriformis, both of which function to later-
ally rotate the extended hip and abduct the flexed hip.3
The pelvic floor supports the reproductive organs against
changes in intraabdominal pressure by maintaining a constant
state of tone.4 The levators may be voluntarily contracted (as
occurs during Kegel exercises), but dysfunction may occur if
these muscles are hypertonic or hypotonic. The levator ani
muscles relax briefly and intermittently during voiding, defe-
cating, and birth.4 The pudendal nerve, emerging from the
sacral plexus at S2-S4, innervates the clitoris, superficial pelvic
floor muscles, the urethral sphincter, the anus and external
anal sphincter, and the perineum.3 It plays a critical role in
2 Volume 00, No. 0, xxxx 2018
genital sensation, continence, and orgasm, and the disruption
of its function may significantly impact quality of life. Mic-
turition, defecation, and normal sexual function, which are
the result of coordination between the pelvic floor and the
autonomic nervous system, may be disrupted when the mus-
culoskeletal structures of the pelvic floor are injured or not
functioning normally.
PELVIC FLOOR PHYSICAL THERAPY
Dysfunction of the pelvic floor sling subsequently results in
the dysfunction of the structures that depend on its support.
PFPT targets the muscles, nerves, ligaments, connective tis-
sue, lymphatic system, and joints inside and around the pelvic
girdle and focuses on addressing mobility and function.5
Pelvic floor physical therapists use internal or external manual
therapies such as myofascial release, connective tissue manip-
ulation, and joint and scar tissue mobilization. Manual ther-
apy uses palpation to loosen spastic muscles and lengthen
tightened tissue to provide relief from pain. Therapies such
as neuromuscular electrical stimulation and biofeedback use
technology to help women gain functional awareness of the
pelvic floor, better coordinate muscle contractions, and im-
prove endurance to promote maximal functioning. Physical
therapists are experts in the treatment of musculoskeletal dis-
orders, and they combine neuromuscular reeducation and pa-
tient education to optimize outcomes and improve quality of
life.5 These therapies do involve intravaginal and intrarectal
assessment, examination, and treatment, so a woman may ap-
preciate this anticipatory guidance prior to accepting a referral
to PFPT.
Education and Certification
Additional education and training are not required for phys-
ical therapists to provide PFPT. Although pelvic floor and
women’s health topics are a required component of graduate-
level physical therapy education, curricula vary by institution,
and many physical therapists practicing PFPT seek out ad-
ditional training. The 2 institutions in the United States that
offer additional education and certification opportunities for
physical therapists and health care professionals are listed in
the table of resources at the end of this article (Appendix 1).
Both organizations maintain a directory of certified pelvic
floor therapy providers and offer continuing education op-
portunities and/or online and traditional classroom courses
for physical therapists and other licensed health care prac-
titioners, including physicians, nurses, nurse practitioners,
nurse-midwives, physician assistants, chiropractors, and oc-
cupational therapists. Practitioners must know if pelvic floor
rehabilitation falls within their state-specific scope of prac-
tice. Certification requires obtaining additional education,
meeting requirements for direct patient care, and passing a
certification examination.
STRESS URINARY INCONTINENCE
Urinary incontinence is categorized as stress, urge, or mixed
incontinence based upon symptoms (Table 1). Stress urinary
incontinence is defined as urine leakage that occurs with
physical stress on the bladder such as laughing, coughing,
 Table 1. Definitions of Pelvic Floor Dysfunction Disorders
Disorder
Stress urinary incontinence
Urge urinary incontinence
Mixed urinary incontinence
Pelvic organ prolapse
Uterine or cervical prolapse
Vaginal vault (cuff scar) prolapse
Anterior vaginal wall prolapse
Posterior vaginal wall prolapse
Definition
Involuntary loss of urine on effort or physical exertion or on sneezing or coughing
Involuntary loss of urine associated with urgency
Involuntary loss of urine associated with urgency and also with effort or physical exertion or on
sneezing or coughing
The descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or
the apex of the vagina (vaginal vault or cuff scar after hysterectomy)
Observation of descent of the uterus or uterine cervix
Observation of descent of the vaginal vault or cuff scar after hysterectomy
Observation of descent of the anterior vaginal wall, most commonly because of bladder prolapse
(cystocele) or prolapse of the urethra (urethrocele)
Observation of descent of the posterior vaginal wall, most commonly because of rectal protrusion into
the vagina (rectocele)

Source: Haylen et al.24

sneezing, or lifting.6 Weak pelvic floor musculature may con-
tribute to hypermobility of the bladder, or there may be intrin-
sic weakness of the urethral sphincter, and either may cause
involuntary loss of urine with physical exertion and increased
intraabdominal pressure. Assessment of stress urinary incon-
tinence may also include asking how often a woman leaks
urine and whether the leak is a small or large volume.
The prevalence of stress urinary incontinence in the
general population ranges from 30% to 60% in middle-
aged women and increases with age.7 During pregnancy,
as many as 60% of parous women may report stress uri-
nary incontinence, and the prevalence and severity increase
throughout the course of the pregnancy.8 The prevalence
of postpartum stress urinary incontinence ranges from 9%
to 45%,9 and although symptoms frequently improve dur-
ing the first year after childbirth, women with incontinence
during pregnancy are at an increased risk for postpartum
urinary incontinence as well as incontinence that persists
beyond the postpartum period.8 Women with stress uri-
nary incontinence are also at an increased risk for anxiety
and depression as well as decreased sexual satisfaction, de-
creased participation in physical activities, and poor self-rated
health.10,11
Initial treatment for stress urinary incontinence includes
lifestyle modifications, among them weight loss, reduc-
ing consumption of bladder irritants (alcoholic, caffeinated,
and carbonated beverages), preventing constipation, quitting
smoking, normalizing fluid intake, and eliminating fluid in-
take in the hours before bedtime.12,13 Women may be in-
structed to maintain a voiding diary and implement blad-
der training strategies, such as scheduling voids. Although
there are no medications approved by the US Food and
Drug Administration for treating stress urinary incontinence,
duloxetine (Cymbalta) is used in Europe. Two systematic
reviews found that duloxetine, a serotonin-norepinephrine
reuptake inhibitor, reduced incontinence episodes and in-
creased quality of life; however, one in 3 women reported ad-
verse effects.14,15 Alpha-adrenergic agonists are no longer rec-
ommended for the treatment of stress urinary incontinence
as they, too, have a high rate of adverse effects and are not
very effective.16 Antimuscarinic drugs are recommended for
women with urge incontinence.
Surgery is acceptable to treat stress urinary incontinence,
but continence rates may decrease over time after surgery.6
Risk factors associated with lower long-term success include
age, menopausal status, and prior continence surgery.17
Management
PFPT is effective for prevention and treatment of stress uri-
nary incontinence in pregnancy and the postpartum period
and is recommended by the International Consultation on
Incontinence as the first-line treatment for women across
the life span experiencing stress, urge, or mixed urinary
incontinence.18,19 PFPT helps women manage incontinence
because effective contraction of the pelvic floor musculature
(prior to and during exertion) raises the pelvic diaphragm in
a forward and upward direction, compresses the urethra, and
increases urethral pressure, thus preventing urinary leakage
with urge or stress.11 Although PFPT is effective for preven-
tion of stress urinary incontinence, it is most successful when
supervised training is conducted, high adherence to the exer-
cise protocol is maintained, and close follow-up is provided.20
This need for adherence to a training program is challeng-
ing, as studies have shown that few antepartum and post-
partum women exercise regularly as recommended without
supervision.21,22 Patient counseling may include the recom-
mendation that the pelvic floor be exercised effectively and
regularly to increase strength, as is the case for any muscle
group; improve motor control; and, subsequently, reduce uri-
nary leakage. The effect of any training program will fade over
time if it is not maintained.20
Women who can perform strong pelvic floor contrac-
tions and are highly motivated to follow recommendations
are more likely to benefit from unsupervised PFPT; nonethe-
less, the current practice of recommending suboptimal PFPT
(low-dosage or unsupervised training, ie, advising a woman
to do more Kegels at her 6-week postpartum visit) may lead
some women to believe they have attempted PFPT without
success.20 These women may feel less inclined to reattempt

Journal of Midwifery & Women’s Health r www.jmwh.org 3

PFPT with more optimal dosage and supervised training and
opt for more invasive treatment methods instead. It is impor-
tant to teach women how to make the Kegel more purpose-
ful, specifically by using it during functional activities during
which they experience leakage. The success of PFPT depends
on several factors, and seeing a pelvic floor physical therapist
likely yields better results than individual use of Kegels only.
A systematic review of 18 trials involving 1281 women
found that women who underwent PFPT reported improved
quality of life because of improved incontinence and satis-
faction with PFPT treatment. They also leaked urine less of-
ten, lost smaller amounts of urine, emptied their bladders
less often, and reported improved sexual outcomes.11 Four
trials within this systematic review examined the relation-
ship between PFPT and stress urinary incontinence. Women
with stress urinary incontinence who underwent PFPT were
8 times more likely to report cure than women in the control
group (46/82 [56.1%] vs 5/83 [6.0%], respectively; risk ratio
[RR], 8.38; 95% CI, 3.68-19.07) and 17 times more likely to
report cure or improvement (32/58 [55%] vs 2/63 [3.2%], re-
spectively; RR, 17.33; 95% CI, 4.31-69.64).13
It is not known how long benefit from participating in
PFPT lasts, but adherence to treatment is believed to improve
both symptoms of stress urinary incontinence and the dura-
tion of the benefits.11,20 There is insufficient evidence to sug-
gest that adding PFPT to other active therapies (vaginal cones
or pessaries, behavioral therapies, pharmacologic therapies)
is beneficial7 ; however, it is appropriate to try PFPT as a first-
line conservative treatment for stress urinary incontinence, as
it may cure or improve symptoms and quality of life so that
more invasive treatment options may be delayed or avoided
altogether.
PFPT may also be used in the antenatal and postnatal pe-
riods to prevent stress urinary incontinence. A systematic re-
view of 22 trials found that pregnant women without prior
stress urinary incontinence who were randomized to super-
vised PFPT were less likely than women randomized to no
PFPT (or usual antenatal care) to report stress urinary in-
continence up to 6 months after birth (RR, 0.71; 95%, CI
0.54-0.95).18 Providers may consider recommending PFPT to
prevent the onset of stress urinary incontinence during preg-
nancy and in the postpartum period. When used optimally,
PFPT is also effective for improving symptoms of urge and
mixed urinary incontinence.11
PELVIC ORGAN PROLAPSE
The International Urogynecologic Association and the Inter-
national Continence Society define pelvic organ prolapse as
“the descent of one or more of the anterior vaginal wall, pos-
terior vaginal wall, the uterus (cervix) or the apex of the vagina
(vaginal vault or cuff scar after hysterectomy).”23 A prolapse
may involve the anterior vaginal wall (cystocele or urethro-
cele), the posterior compartment (rectocele or enterocele), or
the apical compartment (uterine or vaginal vault prolapse).6
Prolapse may be assessed and graded using the International
Continence Society Pelvic Organ Prolapse Quantification
system (Table 2).24
The etiology of pelvic organ prolapse is multifactorial
and likely a result of pelvic floor or pelvic connective tissue
4 Volume 00, No. 0, xxxx 2018
Table 2. Assessment of Pelvic Organ Prolapse
Pelvic Organ Prolapse Quantification System
Stage Description
0 No prolapse
I ⬎1 cm above the hymen
II ࣘ1 cm proximal or distal to the plane of the hymen
III ⬎1 cm below the hymen, but protrudes no farther
than 2 cm less than the vaginal length
IV Complete eversion of the lower genital tract
Source: Haylen et al.24
injury and/or dysfunction as well as genetic predisposition.4
PFPT may help women strengthen and better control the le-
vator ani muscles that function to support the weight of ab-
dominal and pelvic contents against increased intraabdomi-
nal pressure.4 Pelvic organ prolapse affects between 5% and
10% of women and is strongly associated with parity, obesity,
and hysterectomy. It is a common condition as women age,
as uterine prolapse occurs in 40% of women aged older than
50 years.25 Women often report bulge or pressure symptoms,
constipation, incomplete emptying of bowels, urinary incon-
tinence, overactive bladder symptoms, or difficulty voiding;
however, the severity of symptoms does not correlate with the
stage of prolapse, and some women may be asymptomatic.26
Prolapse symptoms may interfere with daily activities, in-
cluding negatively affecting exercise, sexual functioning, and
body image.27 Treatment is indicated for symptomatic women
and may be individualized based on symptoms and patient
preferences.
Treatment methods for pelvic organ prolapse include ex-
pectant management and the use of pessary, surgery, and
pelvic floor muscle training. Expectant management is a rea-
sonable option for women who are able to tolerate their symp-
toms and wish to avoid treatment. Pessaries are intravaginal
devices that attempt to alleviate symptoms by restoring the
pelvic organs to their normal position.23 They are also a con-
servative treatment option; however, success rates with pes-
sary use range from 41% to 86%, and younger women may be
less satisfied with using a pessary.28 Factors associated with
unsuccessful pessary fitting include higher BMI and inactive
or underactive pelvic floor muscles.28
Surgery may be indicated for women experiencing symp-
tomatic prolapse who have failed or opted out of conservative
therapies. There is an 11% to 19% lifetime risk for women un-
dergoing surgery for pelvic organ prolapse, and there is a re-
operation rate of up to 30% after the initial surgery.29–31
PFPT Management of Pelvic Floor Prolapse
Unlike the evidence supporting the use of PFPT for stress
urinary incontinence, the evidence about the effect of PFPT
on pelvic organ prolapse symptoms is somewhat less clear.
By strengthening the pelvic floor muscles, PFPT improves
support for pelvic organs in response to changes in intraab-
dominal pressure.32 Should surgical repair be necessary, this
presurgical physical therapy may prevent the need for surgi-
cal revision. PFPT may also teach women proper techniques
for bearing down with constipation, as well as optimal body
mechanics to reduce the amount of stress on the pelvic floor.
Randomized trials that have evaluated use of PFPT for
treating women with pelvic floor prolapse have demonstrated
a small but clinically relevant improvement in both pelvic or-
gan prolapse and bowel symptoms when women adhere to
PFPT treatment.33,34 A meta-analysis of 13 trials concluded
that pelvic floor muscle training was associated with a greater
improvement in prolapse symptom scores; therefore, a trial of
PFPT is likely appropriate as it may improve symptoms and
presents very little risk for harm.35 Prolapse symptom scores
were used to assess subjective changes in prolapse symptoms,
and pelvic floor prolapse stages were used to assess changes
in severity of the disorder. The study authors found that
women who underwent PFPT reported a greater improve-
ment than women in the control group in prolapse symptom
scores (mean difference −3.07; 95% CI, −3.91 to −2.23) and
demonstrated an objective improvement in pelvic floor pro-
lapse severity (RR 1.70; 95% CI, 1.19-2.44).35
The randomized trial by Panman et al found that PFPT
was superior to expectant management in that women who
underwent PFPT had a 12.2-point increase (95% CI, 7.2-17.2;
P ⬍ .001) in the score on the validated Pelvic Floor Dis-
tress Inventory.36 In one randomized controlled trial, 39% of
women with pelvic organ prolapse receiving PFPT reported
improved sexual function compared with 5% of women in the
control group (P ⬍ .01). Specifically, some women reported
increased control, better strength and awareness of their pelvic
floor, improved self-confidence, and resolution of pain with
intercourse.37 Improvement in sexual function was noted in
the women who demonstrated the greatest increase in mus-
cle strength (r = 0.43, P ⬍ .01) and endurance (r = 0.27,
P = .01).37
A subsequent Cochrane systematic review concluded that
PFPT is effective for improving pelvic floor prolapse symp-
toms and severity.38 PFPT may be effective for women with
only mild prolapse and may also improve sexual function in
some women with pelvic organ prolapse.38 These small im-
provements in prolapse symptoms may be of great signifi-
cance to women and could be an impetus to delay or forgo
surgery.33 After PFPT, women may choose to proceed with
more invasive measures with the confidence that conserva-
tive therapy was insufficient and that surgery is the appro-
priate choice. It appears that there are subgroups of respon-
ders and nonresponders, and identifying the characteristics of
who may respond to PFPT is beyond the scope of the current
research.38
Based on this body of research, PFPT is recommended
as the first-line treatment for women with pelvic organ pro-
lapse (Grade A Recommendation)32 ; however, more research
is needed to understand what PFPT regimens are most effec-
tive in managing pelvic organ prolapse, the cost-effectiveness
of PFPT in the treatment of pelvic organ prolapse, and how
long benefits persist after treatment.39 For women undergo-
ing surgery for the treatment of prolapse, it is unclear whether
adding perioperative PFPT to surgery is superior to surgery
alone.40
Health care providers may inform women that it is diffi-
cult to predict how well they may respond to PFPT. This ther-
apy increases muscle strength and endurance and results in
Journal of Midwifery & Women’s Health r www.jmwh.org
objective and subjective improvements in prolapse symptoms,
but it does not predict or always prevent the need for further
treatment.35 Women with more severe prolapse or more both-
ersome symptoms are more likely to seek further treatment
after PFPT.34 Counseling may include informing women that
PFPT is a reasonable treatment option and that a pelvic floor
physical therapist may assist in setting treatment goals to ad-
dress the bothersome prolapse symptoms, despite not being
able to completely resolve the prolapse.
DIASTASIS RECTI ABDOMINIS
Diastasis recti abdominis is a condition in which the 2 rectus
muscles are separated by an abnormally wide distance; how-
ever, although the distance that is considered to be abnormal
is undetermined, an inter-rectus width of greater than 2 cm
(at the umbilicus or 4.5 cm above or below the umbilicus) is
recognized as a widened diastasis.41,42 Diastasis recti abdomi-
nis occurs when there is a weakening of the linea alba fas-
cia and is not an abdominal wall hernia. It may be diagnosed
during a physical examination when the woman raises her
head and abdominal contents protrude into a weakened linea
alba as a result of increased intraabdominal pressure. Diasta-
sis recti abdominis persists in approximately 33% of women
at 12 months postpartum.43
The physiologic changes of pregnancy, specifically in-
creasing pressure applied by an enlarging uterus and the
displacement of abdominal organs, can have a nonoptimal
impact on the structure and function of the abdominal can-
ister. Dysfunction of the rectus abdominis may contribute
to lumbopelvic instability and postural changes, resulting
in discomfort with movement, low back pain, sacroiliac or
pubic symphysis pain, or exacerbation of existing pelvic
floor dysfunction.42 Research does not indicate, however,
that women with diastasis recti abdominis experience more
lumbopelvic pain, pelvic organ prolapse, or urinary incon-
tinence than women without diastasis recti abdominis.43,44
Some women may express concern about the cosmetic ap-
pearance of the diastasis, whereas others may inquire about
how soon they can resume an exercise regimen or whether
abdominal exercises will reduce the inter-rectus space. Dias-
tasis recti abdominis may also be corrected surgically through
abdominoplasty or laparoscopy.41
Management of Diastasis Recti Abdominis
Exercise appears to be beneficial for diastasis recti abdomi-
nis. A systematic review found that exercise during the ante-
natal period reduced the presence of diastasis recti abdominis
by 35% and suggested that diastasis recti abdominis may be
reduced by exercising during the ante- and postnatal periods
(RR, 0.65; 95% CI, 0.46-0.92).42 The implications of this re-
view are limited, as there is little high-quality literature on the
subject of exercise and diastasis recti abdominis, and more re-
search is needed to determine what exercise regimens are best
for reducing diastasis recti abdominis.42 Physical therapy may
address diastasis recti abdominis by improving postural con-
trol and core stabilization through the training and use of the
transverse abdominis and pelvic floor musculature, thus pre-
venting overuse of the rectus abdominis.
5
 Dysfunction of the abdominal canister and related com-
pensatory measures also contribute to pelvic girdle and low
back pain. For women experiencing diastasis recti abdomi-
nis, pelvic girdle pain, or low back pain, pelvic floor physical
therapists can assess the myofascial integrity and function of
the structures of the abdominal canister, as well as how other
joints may be interrupted as a result of this dysfunction.45
Physical therapists can teach women with these conditions op-
timal strategies for restoring function by correcting misalign-
ment of the pelvis, teaching proper patterning of the transver-
sus abdominis and pelvic floor muscles, and providing
postural and movement retraining for activities such as stand-
ing, bending, single-leg loading, and squatting.45
It is important that women understand that physical ther-
apy will not completely reverse or close a diastasis recti ab-
dominis; however, education may highlight the benefits that
accompany evaluating and restoring the function of the ab-
dominal canister.
IMPLICATIONS FOR PRACTICE
Based on the literature supporting PFPT for the prevention
and treatment of urinary incontinency and pelvic floor dys-
function, women may be advised to perform PFPT during
pregnancy and the early postpartum period, provided that
they are able to correctly isolate and adequately contract their
pelvic floor muscles.46 Providers can include screening for
prepregnancy and antenatal pelvic floor dysfunction at the
initial prenatal visit and again at the 6-week postpartum visit.1
Women’s health care providers should routinely ask women
about the onset or exacerbation of pelvic floor dysfunction be-
cause women may not volunteer this information, and they
can then provide education about the signs and symptoms
to report as well as the modifiable risk factors that women
can address to decrease their risk of developing or worsen-
ing pelvic floor dysfunction. Empowering women to address
modifiable risk factors (avoiding smoking and constipation,
maintaining a healthy BMI, adhering to PFPT) and make in-
formed decisions about their treatment for pelvic floor dys-
function is in line with the philosophy of care that women
have a right to self-determination and active participation
in their health care.1 Education may include the risks and
benefits of, as well as the alternatives to, medical and surgi-
cal interventions, and low-risk treatment modalities such as
PFPT should be included. Extensive education and instruc-
tion about PFPT cannot reasonably be completed in a 10 to
20 minute office visit; therefore, individuals with these dis-
orders or symptoms may benefit from referral to a pelvic
floor physical therapist so that intensive regimens, sufficient
education, and support may be provided to ensure optimal
outcomes.20,47
Barriers to Use
Despite the evidence supporting the effectiveness of PFPT,
it is not commonly used as a first-line treatment for pelvic
floor dysfunction in the United States.19,48 There are several
potential reasons for this: more research is needed to better
understand the long-term benefits of PFPT, the most effec-
tive training regimens, and barriers to patient adherence; ed-
ucation about conservative pelvic floor dysfunction may be
6 Volume 00, No. 0, xxxx 2018
lacking in the graduate education curricula of nurse-midwives
and midwives, advanced practice nurse practitioners, and
physician assistants; and reimbursement may be challenging
to navigate, insurance companies may not cover all treatment
modalities, and co-pays may be a barrier to patient access. In
addition, there is a lack of resources to appropriately teach
patients, no standardized treatment protocol to guide clinical
practice, and no standard for long-term follow-up care.48 The
first step in addressing these barriers must include address-
ing health care provider knowledge deficits about the benefits
of PFPT.
CONCLUSION
Increased health care provider knowledge about the benefits
of PFPT may benefit women and their families. As health pro-
motion and disease prevention are a priority in the health
care field, it is in a health care provider’s best interest to
use a treatment method that maximizes patient outcomes
and minimizes risk. Health care providers may do this by
screening for disorders that would benefit from PFPT, refer-
ring women to PFPT in a timely manner, and educating pa-
tients about PFPT in a way that cultivates hope and reduces
anxiety.
A.B.’s case represents a sequence of events and inter-
actions with health care providers that is shared by many
women. After her referral to PFPT, A.B. was seen by a pelvic
floor physical therapist for 3 visits, and she reported im-
provements in her symptoms of stress urinary incontinence,
pelvic organ prolapse, and dyspareunia. Ultimately, A.B.’s in-
surance provider changed and PFPT was no longer an af-
fordable option for her, but she hoped that adhering to her
at-home physical therapy regimen would continue to yield
results.
Pelvic floor dysfunction is not an acceptable normal result
of pregnancy and birth, and medication or surgery does not
need to be presented as a first-line treatment when a safer, less
invasive option is available. Although A.B.’s history suggests
there were several missed opportunities for PFPT interven-
tion over time, her case also represents an opportunity for the
provider to provide education and counseling about PFPT as a
conservative, evidence-based treatment option for her pelvic
floor dysfunction.
AUTHORS
Samantha Lawson, CNM, WHNP-BC, is a recent graduate
from the University of Utah’s Nurse-Midwifery & Women’s
Health Nurse Practitioner program. She will be practicing
full-scope midwifery in the US Air Force.
Ashley Sacks, PT, DPT, is a physical therapist at the University
of Utah and is certified through the Herman & Wallace Pelvic
Institute to treat pelvic floor dysfunction, including rehabili-
tation for pregnant and postpartum women. She also serves as
the Utah State Representative for the American Physical Ther-
apy Association Section on Women’s Health.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
ACKNOWLEDGMENTS
The authors would like to thank Emily Hart Hayes, CNM,
WHNP, and Scott Christensen, MBA, APRN, ACNP-BC, for
their guidance and support in the writing of this manuscript.
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Appendix 1: Resources for Providers

Herman & Wallace Pelvic Rehabilitation Institute

Provides continuing education courses, as well as a practitioner directory.
https://hermanwallace.com/practitioner-directory
American Physical Therapy Association (Section on Women’s Health)
Offers a Physical Therapist Locator, resource directory, continuing education courses, educational materials for patients, and the
Journal of Women’s Health Physical Therapy.
http://www.womenshealthapta.org
The International Continence Society
An international, multidisciplinary professional organization that prioritizes education, research, and advocacy as they pertain to
pelvic floor health. Of note, the International Continence Society publishes joint reports with the International Urogynecologic
Association that standardize the terminology used to describe pelvic floor dysfunction.
https://www.ics.org/
The Pelvic Guru
Includes several resources for professionals, including courses, mentoring, and a free pelvic floor anatomy review guide. This
website offers educational materials for patients, access to a blog featuring articles about PFPT, and private support groups on
social media for new mothers and women experiencing pelvic pain.
http://pelvicguru.com/

8 Volume 00, No. 0, xxxx 2018