Pelvic Floor Health: An Investment in Your Future

I am not shy about my history with pelvic floor physical therapy, and the urinary incontinence that sent me to pelvic PT years before ever getting pregnant. Talking about your pelvic floor muscles in mixed company may seem taboo, but that is exactly the problem. 

It wasn’t until my early 30’s that I even realized that having a hard time holding your pee while doing jumping jacks wasn’t normal. I had never even heard of pelvic floor physical therapy.

I was a female-bodied person – in the middle of writing a dissertation about pregnancy – and I was pelvic-illiterate. 

And here’s the thing, pelvic physical therapy is dope! My first round of pelvic physical therapy may be the best thing I have done for my health. It changed the way I exercise, developed my body and postural-awareness, and gave me back a lot of control over my own body.

You move through the world more freely and lightly when you’re not worried about peeing all over yourself. We should be shouting on the rooftops about women’s health issues and awesome, non-surgical treatments like pelvic floor physical therapy available to us. As soon as humanly possible after having my baby, I was back in my pelvic physical therapist’s office.

My goal with this post is to encourage you to not neglect your pelvic floor, especially postpartum and during pregnancy. I also address concerns I had prior to starting pelvic PT, including:

• What would pelvic floor physical therapy be like?
• Is pelvic physical therapy weird or uncomfortable?
• How much does it cost to maintain your pelvic floor health (with therapy and its accoutrements)? 

Reading this may make pelvic floor rehabilitation and maintenance seem like too much effort or costly. From my experience, it is 100% worthwhile. Pelvic issues often get progressively worse as we age so being proactive now can mitigate troubles down the road. I think it is worth it because it is still cheaper, easier, and less invasive than other treatment options like surgery.

Still, I discuss the time and cost commitments of pelvic floor muscle work to help those on the fence because they worry about the experience or cost, and to highlight another example of unseen work and health issues women face postpartum.

Before we dive in, a reminder that I’m sharing my pelvic rehab and physical therapy experience, in hopes of demystifying it for others. Clearly, I’m not your doctor or your physical therapist. They should be your first stop to discuss your pelvic floor muscles, urinary incontinence, painful sex, bowel movement troubles, etc. I also have no idea what your health insurance is, call them for the 411 on your pelvic therapy benefits. 

What are your pelvic floor muscles & why do they matter?

Your pelvic floor refers to muscles that hammock the organs in your lower body. They run from the pubis in the front of the body to the coccyx in the back of the body. Both men and women have pelvic floors.

In women, pelvic floors supports the bladder, intestines and the uterus. There are openings in the pelvic muscles for the urethra, vagina and anus.

Often women are told they need to strengthen their pelvic floors and exercise them as they would other muscles in the body. When the pelvic floor muscles are strong, they better support and stabilize the organs. Pelvic floor muscles exercises are often referred to as kegels.

People are often told to do a kegel by emulating the feeling of stopping a stream of urine. However, this description is often incomplete for most people to achieve full muscle engagement. My initial pelvic floor physical therapy work involved learning to properly exercise my pelvic muscles.

The way my therapist described it to me, you can engage your pelvic floor muscles by emulating these feelings:

• Tensing your anus as you would when holding in a fart
• “Pulling” down your clitoris towards the back of the body
• “Zipping up” your vaginal opening to give a ‘lifting up’ feeling in the vagina

However, it is also possible to have your pelvic floor muscles be too tight and unable to relax. In these cases, the emphasis is not on exercising your muscles, but instead working to relax them.

As we age, we are more likely to encounter pelvic floor disorders. Even if you don’t think you actively have problems with your pelvic floor now, your current habits and behaviors, like proper pelvic strengthening, impact your pelvic health down the road.

Many people are unaware of the many activities we do on a daily basis also require pelvic floor engagement. Doing things like improperly lifting objects without core and pelvic engagement or straining to have a bowel movement can have negative repercussions on your pelvic health as you age. Caring for your pelvic muscles now is important to help mitigate future problems.

Learning to properly strengthen or relax your pelvic area is an investment in your future, and likely is cheaper than future, more elaborate interventions will be.

What is pelvic floor physical therapy like?

So what is it like to go to pelvic floor physical therapy? First, it bears repeating that much like pelvises themselves, everyone’s pelvic PT is going to look a little different. I’m giving you a run down of mine as a case study.

I needed pelvic physical therapy to strengthen my pelvic floor muscles, mitigate a sampler platter of pelvic prolapse (bladder prolapse, uterine prolapse, the works!) and recover from months of pregnancy-related bed rest. I have a connective tissue disorder called Ehlers-Danlos, and essentially my pelvic area is “too stretchy.” I proactively manage it with pelvic floor exercise.

Related posts: My Hyperemesis Story

My pelvic physical therapy appointments were divided in work done in a private room one-on-one with a therapist and core-focused work done in the open gym part of the clinic.

The exercises done in the gym worked on controlled core muscle engagement. This part of the appointment is similar to what you’d find in a regular physical therapy appointment or even in a fitness class. My therapist developed a list of exercises for me that I worked through each visit. We adapted my list was my treatments progressed.

Some of my example floor exercises included:

• pulling my belly button towards my spine in 5-second intervals in various positions
• a variety of crunch-like exercises
• bridges
• elastic band work 

In a private room, I worked one-on-one with my therapist on pelvic floor exercises. In my first in-take appointment, this did involve the therapist doing a vaginal exam on me.

She checked for areas of tenderness or tightness, evaluated my vaginal birth and episiotomy recovery and scarring, and worked with me on kegeling. The kegel work allowed her to assess my pelvic strength and develop our therapy plan.

At my first appointment, I had the choice of purchasing a vaginal sensor to be used in future appointments. The sensor was an electromyography probe that you insert in your vagina and looks like this. Alternatively, the therapist could put stickers on the outside of my body (around my butt and upper thigh) to monitor my pelvic floor muscle activity.

I elected to buy the vaginal probe so for my other appointments, I would insert the probe while I was alone in the private room and would be covered once my therapist came in. She then able to see my kegel pelvic floor muscle activation on a computer screen. My office referred to this as pelvic floor biofeedback.

Most appointments, my therapist did not see my disrobed and did not do any manual work or vaginal exams on me. I had one appointment where she worked on tightness which involved a manual examination and at set intervals, we’d redo in-take examination to evaluate my progress and adjust my treatment plan.

Since I bought the probe, I also had vaginal electrical stimulation during some of my appointments. It is similar TENS unit treatment and basically gives a small electrical signal to tense your muscles for you. It felt like a little non-painful shock and you can control the strength of the signal. I would it as weird but not painful.

The costs of pelvic floor muscle recovery

A note as I breakdown costs: I hit my maximum out-of-pocket limit before any of my postpartum appointments because I was hospitalized a few times during pregnancy. I paid nothing for all my appointments between my delivery and the end of that calendar year. 

In addition to pelvic floor physical therapy, my pelvic rehab has included doctors visits, equipment purchases, and some medications. I break down the cost for each of these in the following sections.

When applicable, I break down estimated costs for the following situations:

• Having insurance where you pay a co-payment
• Having insurance where you pay an out-of-pocket cost until you hit a deductible, such as a high-deductible health plan
• Not having insurance
• What I actually paid

Insurance coverage for pelvic treatments, infuriatingly, varies a lot by company. Even if your medical team believes a treatment is medically necessary for you, you may still have trouble getting it covered. For example, I was unable to get vaginal electrical stimulation covered. Double check your benefits prior to your first appointment. 

Lastly, this cost breakdown also includes time and transportation costs for pelvic physical therapy appointments. I felt as though I spent a large chunk of my initial maternity leave working on my pelvic floor muscles. There is an opportunity cost to the time spent in therapy that should be acknowledged.

Related Doctors Appointments

I have had two doctors appointments postpartum related to my pelvic floor. The first was my 6-week postpartum check-up and the second was with a urogynecologist. 

6-week postpartum appointment

Per U.S. norms, I only had one follow-up appointment with my high-risk ob at 6-week postpartum. My doctor said everything looked fine and suggested I work on kegels independently before enlisting a pelvic PT. Luckily, I knew how valuable pelvic physical therapy was based on my past experience so I wasn’t deterred.

Honestly, the exam part of my 6-week follow-up felt cursory, and I left the appointment being told I didn’t have any prolapse worries (I did), knew nothing of my episiotomy healing, and wasn’t scanned for postpartum depression. Thankfully, my pelvic therapist was incredibly thorough in evaluating and discussing my postpartum healing.

• Estimated cost for out-of-pocket (insurance negotiated rate): $130 – this is an estimate based on my first maternity-related appointment as I was not charged for this appointment based on my insurance
• What I actually paid: $0 – max out of pocket limit hit and maternity visit. 

Urogynecologist 

Many people will not enlist a urogynecologist for their initial postpartum pelvic recovery. I am including it here since it was a good experience for me and it was a subspecialty I was not aware of until very recently (even though all my medical issues should have gotten me a referral there years ago).

Part of my motivation in going to a urogyn early was to stay ahead of age-related pelvic floor deterioration. Urogyn may be a good stop for those who feel their linger postpartum issues like urinary incontinence, bulging feelings, etc. aren’t being adequately addressed during routine appointments. 

The urogynocologist did a much more thorough exam of my pelvic area and prolapse than I had with either my O.B. or my previous urologist. She took measurements of my pelvic area which I had never had done before, even with my extensive pelvic-related medical history. 

Pelvic issues like prolapse are one thing that can get worse the farther removed you are from delivery so I’ll go back to be reevaluated soon. The urogynecologist already told me that I will be working on my pelvic floor muscles for the rest of my life.

• Estimated cost with a co-pay: $40
• Estimated cost for out-of-pocket (insurance negotiated rate): $240
• What I actually paid: $0 – max out-of-pocket limit hit

Pelvic Floor Physical Therapy Costs

First, let me again stress that I don’t want these pelvic physical therapy costs to discourage people from going to pelvic physical therapy. My treatment plan could have easily been tailored to less visits, and we did in fact wrap up my therapy quickly once I had to start paying out-of-pocket.

You can learn the skills you need to do a lot of the exercises at home very quickly. Even a couple appointments to get a treatment plan for your particular issues and learn proper technique for exercises could be very beneficial and more manageable from a budget- and time-perspective. In the next section, I detail what equipment I bought to be able to do nearly all of my pelvic physical therapy work at home now that I know how to do the exercises.

My PT office offered a set rate for those not using insurance, so an estimate for those not using insurance is included in this section.

PT in-take appointment

As explained above, the first appointment was a longer evaluation appointment to assess baseline pelvic condition and establish a treatment plan. This first appointment is a long time one-on-one with the therapist (over an hour and a half in my case) and is therefore more expensive than the subsequent appointments. 

At my in-take appointment, I opted to pay $50 for the vaginal sensor probe that would be used vaginally in the subsequent appointment. Had I gone for the alternative external stickers, they would have been included in the cost of the appointment.

The estimated cost of the initial intake appointment is as follows:

• Estimated cost with a co-pay: $40
• Estimated cost for out-of-pocket (insurance negotiated rate): $140
• Non-insurance rate: $100
• What I actually paid: $0 for the visit, max out-of-pocket limit hit. I had previously purchased the $50 probe.

Regular PT appointments

The rest of my pelvic physical therapy appointments were at the lower, regular appointment rate. The estimated cost for regular pelvic physical therapy appointments is as follows:

• Estimated cost with a co-pay: $40 per visit, $560 for 14-sessions 
• Estimated cost for out-of-pocket (insurance negotiated rate): $115, $1610 for 14-sessions
• Non-insurance rate: $75 per visit, $1050 for 14-sessions
• What I actually paid: $115, I had one appointment in the new calendar year when my annual max out-of-pocket reset.

As I detail more below, my insurance ultimately refused to cover the vaginal electrical stimulation treatment my therapist recommended. I even had a proven history of it being a successful treatment for me and was not able to get it covered.

I skipped this treatment because of the insurance issue. Had I done it, it would have been an additional $40 per appointment for that treatment, for a total of an extra $560 for my 14-sessions. 

At-home Pelvic Floor Exercise equipment

I have bought two pelvic floor exercise machines to support strengthening at home. These devices are not necessities but they have been a worthwhile investment for me.

I bought the:

• K-Fit: an pelvic floor electrical stimulation device
• Elvie: a kegel trainer with real-time through a phone app.

The combination of the real-time feedback and the electrical stimulation is very similar to the work I did in my therapist’s office each week. 

Note that both require privacy and insertion of medical devices in your vagina, which isn’t always #1 on the to-do list. However, these tools allow me to do an at-home pelvic muscle tune-ups without more therapy sessions, so ultimately they pay for themselves in saved therapy costs.  

K-Fit Kegel Toner: pelvic floor muscle electrical stimulation device

My physical therapist recommended the K-Fit machine, which is FDA approved for urinary incontinence and is comparable to the machine used at the therapist’s office.

The K-Fit has pre-set programs so it is ready to go out of the box. My therapist programmed my machine with an exercise program tailored to the work we were doing together and taught me how to use it. Since each 10-minute vaginal electrical stimulation treatment would have cost $40 at my PT’s office, it made more sense for me to buy the machine.

I really like my K-fit and definitely recommend it. It helps me maintain the progress I made with pelvic physical therapy. Having it made me feel able to ‘graduate’ pelvic physical therapy sooner since I could keep up my program easily at home. In that regard, the K-Fit also paid for itself since it reduced the number of physical therapy sessions I needed. 

That said, using electrical stimulation for the first time is a weird feeling! It does not hurt and you have complete control over the intensity. If I get the intensity too high, it feels like a little pinch or shock but not ‘ouch!’ painful. The way it feels also varies day to day based on how it is inserted.

For me, sometimes I’ll feel it more at my episiotomy scar and need to readjusted the probe. Each time you use it, slowly move up the intensity and you should be able to find the right level for you. 

The one thing I don’t like about the K-fit compared to the device I used in the PT’s office is there isn’t much of a stopper on the probe so it can go further past the vaginal opening. If you have this issue, I find that bearing down when you go to remove it, like you would a menstrual cup, brings it down so you don’t have to tug on the cord to pull it out. 

Elvie: pelvic floor muscle kegel trainer

I bought an Elvie, a kegel exercise biofeedback trainer, before I started pelvic physical therapy the first time. When I got it, it was relatively new on the market and my therapist was glad to have someone trying it.

The Elvie connects to your phone and visualizes your kegels in real time. Basically, as you squeeze a kegel, a ball moves up and down on your phone screen depending on the intensity. This is essentially the same thing that is done with your pelvic physical therapist during biofeedback work. The design of the Elvie is great, and the product and company feel in-tune with women’s bodies and experiences. 

Time and transportation to pelvic floor physical therapy

In most areas, the supply of pelvic physical therapists does not meet demand. Pelvic physical therapy takes specialized training. Additionally, it can be a more expensive treatment for clinics to run because it requires private rooms, specific equipment, and additional hygiene products. Waits can be long and distance between providers can be far. 

Time cost of pelvic floor physical therapy appointments

Going to pelvic physical therapy is a time commitment. My appointments ranged from an hour to an hour and forty-five minutes. There was not a pelvic physical therapist in my neighborhood so I drove 30-45 minutes each way for an appointment. The approximate amount of time I spent on pelvic PT breaks down to:

• Transport to appointments = 15 hours (15 appointments * 1 hour round-trip commute)
• Time in appointments = 18 hours (15 appointments * 1.2 hour average appointment length)

According to census date, the average salary for a women aged 25-34 years old is about $18/hour. Estimating off this average salary, undergoing pelvic physical therapy would cost an estimated $594 in lost wages if all appointments were done during work hours. 

Mileage costs to pelvic floor physical therapy appointments

Now let’s calculate the cost of commuting to appointments. The IRS rate for mileage reimbursement is 57.5 cents per mile. My therapist was about 15 miles away, one-way. 

Estimate cost of commuting to appointments = 15 appointments * 30 miles round-trip * 0.575 $/mile =  $258.75 in transport costs

Miscellaneous Pelvic Health Costs

Pelvic physical therapists can also work to improve postpartum bowel and rectal problems. I was on Zofran, an antiemetic, for the majority of my pregnancy, which is a highly constipating medicine. I developed an anal fissure and a small hemorrhoid prior to even giving birth.

Related post: 7 Things I’d Do Differently with Hyperemesis Gravidarum

Some women develop rectocele postpartum, where the supportive tissue in their pelvis weakens and stretches allowing part of the large intestine to bulge into the vaginal wall. 

Bowel issues are often improved with the pelvic strengthening work done at PT. My physical therapist also worked with me on strategies to avoid straining with bowel movements, which can exacerbate fissures and prolapse over time. She recommended the following:

Squatty potty

I already had a squatty potty and love it. A squatty potty is a ‘defecation postural modification device (DPMD)’ that better aligns your body in a squatting position when using a western toilet. Squatting and DPMD’s have been found to reduce straining when having a bowel movement and allow more complete emptying of the bowels.

Medication

My physical therapist recommended preventatively taking a half a dose of Miralax every other night or so to reduce risk of straining and constipation while I was healing postpartum.

My gyn recommended using Bourdreaux’s Butt Paste while the anal fissures and hemorrhoid healed

Key Takeaways

Summing it all up, I spent $531 on my postpartum pelvic floor recovery. Had I not hit my maximum out of pocket limit for the year, my pelvic physical therapy appointments would have totaled:

• Paying a co-paying: $600
• Paying out-of-pocket (insurance negotiated rate): $1750
• Paying the non-insurance rate: $1150

The majority of my postpartum pelvic costs came from buying home pelvic floor exercise equipment – to the tune of $359.

Looking at the opportunity cost of attending pelvic PT appointments, an average woman would face estimated $853 in lost wages and transportation costs (based on my therapy time and the census average U.S. salary). This number is high partly given the limited number of pelvic physical therapists, requiring longer commutes to offices.

I highlight these time and cost commitments not to dissuade people. Pelvic rehab and physical therapy was one of the most empowering and important things I’ve done for my health and recommend it to everyone I know.

Rehabilitating and maintaining your pelvic muscles are worth your efforts. It is an investment that helps mitigate future problems like incontinence and prolapse which can negatively impact your life, and can keep at bay more invasive treatments like surgery.

I discuss the work that maintaining your pelvic floor muscles entails to drive home three key takeaways about pelvic floor health and women’s health in general:

• Women’s health issues like pelvic floor health need to be openly discussed and demystified. No one should deal with life-altering conditions like urinary incontinence because they didn’t know about treatment options or were worried about their cost.
• Women need access to health care, insurance, and sick time that make pelvic rehabilitation and maintenance affordable. Pelvic floor physical therapy is so much easier and cheaper than more invasive options like surgery to correct an issue like prolapse.
• Pelvic rehabilitation is another form of unseen work that women undertake. Especially after a pregnancy, women have the additional work of rehabilitating their pelvic floor postpartum.

Have you done pelvic physical therapy? Have other suggestions for maintaining pelvic muscle health? I’ve love to hear from you in the comments.

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