July 18. 2025
Lily Jilk, PT, DPT
Pelvic Floor Physical Therapist- trained through American
Physical Therapy Academy of Pelvic Health and Herman and Wallace
Pelvic Rehabilitation Institute
Doctorate in Physical Therapy- University of Minnesota
Bachelors in Psychology- Macalester College
Working and living in NYC
Nothing to disclose - no conflicts of interest
1. Introduce Pelvic Floor Physical Therapy (PFPT), pelvic anatomy, and physiology
2. Describe cancer treatment and possible impact on pelvic floor
3. Discuss PFPT evaluation and what to expect
4. Discuss PFPT treatment techniques
5. Case Studies (as time allows)
6. Questions
You will learn:
1. What the pelvic floor is, how it relates to daily function, and what to expect as a patient in pelvic physical therapy
2. How cancer and cancer treatment can impact the pelvic floor and lead to pelvic floor impairments
3. Key treatment concepts to improve cancer related pelvic floor impairments
Pelvic floor physical therapy is a specialized form of physical therapy focused on assessing and treating dysfunction in the muscles, ligaments, and connective tissues of the pelvic region.
Goals of Pelvic Floor PT:
● Improve muscle strength, coordination, and flexibility
● Reduce pain and improve function
● Restore bladder, bowel, and sexual health
● Support recovery after surgery, cancer treatment, etc.
Approach may include:
● Manual therapy
● Biofeedback and coordination training
● Exercise - stretching and strengthening
● Education and behavior strategies
The pelvic floor is a group of muscles, ligaments, and connective tissues that span the bottom of the pelvis like a hammock or sling. These structures support the pelvic organs and contribute to core stability and continence.
Key Functions:
● Supports the bladder, uterus (or prostate), and rectum
● Helps maintain urinary and fecal continence
● Plays a role in sexual function
● Stabilizes the pelvis and spine
● Assists in circulation and lymphatic flow
Anatomy Highlights:
● Made up of three layers of muscle
● Works in coordination with the abdominal and back muscles
● The muscles can contract (“kegel”), relax, and lengthen/bulge (“bearing down”)
● Urinary Stress Incontinence
● Urinary Urge Incontinence
● Urinary Urgency/Frequency
● Painful bladder syndrome
● SIJ Dysfunction, pelvic girdle pain
● Abdominal/perineal scars
● Low back pain
● Coccydynia
● Fecal incontinence
● Pelvic Organ Prolapse
● Levator ani syndrome
● Vaginismus
● Vulvar vestibulitis/vulvodynia
● Dyspareunia (painful intercourse)
● Pudendal neuralgia
● Piriformis syndrome
● Constipation
•Ischiocavernosus
•Bulbospongiosus
•Superficial transverse perineal
•External anal sphincter
•Deep transverse perineal
•Sphincter urethrovaginalis
•Compressor urethrae
•External urethral sphincter
•Levator ani
• Pubococcygeus (& puborectalis), iliococcygeus
•Coccygeus or Ischiococcygeus
•Pelvic Wall:
• Piriformis
• Obturator Internus
Female Anatomy
● Uterine
● Ovarian
● Cervical
● Kidney/Renal Pelvis
● Urinary/Bladder
● Colorectal
● Vaginal
● Vulvar
● Breast - hormone therapy, lymph changes
Male Anatomy
● Colorectal
● Prostate
● Urinary/Bladder
● Kidney/Renal Pelvis
Cancer diagnosis
Treatment: Surgery, radiation, chemotherapy, hormonal therapy, targeted therapy and immunotherapy
Tissue changes, nerve function, hormone changes, scars, etc.
Pelvic floor strength, coordination, muscle flexibility, sensitivity & tenderness can change
Pelvic pain, urinary frequency, leakage, constipation, urinary/bowel urgency, back pain
Physical Therapy
Treats pelvic floor, muscular, and neurological impairments
Rehabilitate and improve function and tolerance of activities
Increased participation in life!
Relevant Short Term Side Effects 1,2
● Pain
● Decreased Range of Motion
● Weakness
● Numbness, altered sensation
Relevant Long Term Side Effects 1,2
● Pain
● Decreased Range of Motion
● Weakness
● Numbness, altered sensation, nerve injury
● Lymphedema
● Scar Tissue
● Impaired Body mechanics/Posture- mastectomy
Relevant Short Term Side Effects 3,4
● Fatigue
Relevant Long Term Side Effects 3,4
● Fatigue
● Fibrosis
● Vaginal/Rectal Stenosis (and narrowing)
● Decreased range of motion
● Neuropathy
● Decreased strength
● Pulmonary and GI dysfunction
● Urinary dysfunction- dysuria, frequency, urgency
Relevant Short Term Side Effects5
● Chemotherapy Induced Peripheral Neuropathy (CIPN)
● Fatigue
● Weakness
● Constipation/Diarrhea
Relevant Long Term Side Effects 5
● Chemotherapy Induced Peripheral Neuropathy (CIPN)
● Fatigue
● Weakness
● Osteoporosis
● Sexual dysfunction
Relevant Short Term Side Effects 6,7,8
● Fatigue
● GI Symptoms
● Muscle pain
Relevant Long Term Side Effects 6,7,8
● Vaginal Dryness
● Genitourinary symptoms of menopause
● Osteopenia/osteoporosis
● Loss of muscle mass
● Joint and tendon pain
● Fatigue
A chronic, progressive condition due to estrogen deficiency, affecting genital, urinary, and pelvic floor health.
Genital Symptoms
● Vaginal dryness
● Burning or irritation
● Itching
● Decreased lubrication
● Pain with intercourse (dyspareunia)
● Thinning and loss of elasticity in vaginal tissues
Urinary Symptoms
● Increased frequency and urgency
● Painful urination (dysuria)
● Recurrent urinary tract infections
● Stress or urge urinary incontinence
● Nocturia (nighttime urination)
Pelvic Floor Impacts
● Reduced muscle tone and support
● Pelvic organ prolapse
● Pelvic discomfort or pressure
● Decreased sexual function and satisfaction
● Discussion of cancer diagnosis and treatments (e.g., surgery, chemotherapy, radiation, hormone therapy)
● Review of urinary, bowel, sexual, and pelvic pain symptoms
● Address fatigue, scar tissue, mobility, and quality of life concerns
● Consider emotional impacts and medical trauma
● Personalized intake on lifestyle, work, hobbies, and goals
● Breathing mechanics, core strength, hip mobility, and balance
● Focus on how cancer treatment may have affected strength, posture, or movement patterns
3. Pelvic Floor Muscle Assessment (with consent)
● Internal and/or external exam to assess:
○ Muscle strength, tone, coordination, and scar tissue
○ Pain or sensitivity
○ Pelvic organ support
● Adapted for post-surgical or radiation changes — always gentle and trauma-informed
● May be deferred if you're not ready
● Explanation of findings in plain, respectful language
● Personalized treatment goals:
○ Reduce pain, leakage, or urgency
○ Improve tissue mobility, comfort, and confidence
○ Restore bowel, bladder, and sexual function
● Home exercises (as appropriate)
● Collaborative planning of visit frequency, goals, and progress checkpoints
● Tissue quality
● Tissue color
● Scar healing
● Ability to contract
● Ability to relax
● Ability to bulge
● Strength of contraction
● How long can you hold contraction?
● Is it repeatable?
● Tenderness to touch
A gentle, hands-on technique used to help: 10
● Release tight muscles
● Reduce tenderness
● Improve tissue flexibility and comfort
Can be done:
● Externally (over clothing or on the skin)
● Internally (vaginal or rectal), only if you feel ready and give consent
Helps to improve: 11
● Muscle movement and coordination
● Comfort with stretch or touch in sensitive areas
● Often used to support healing after surgery, with pelvic pain, bladder urgency/frequency, pain with
intimacy
Your comfort and consent come first. You are always in control of what happens in each session!
Instructed in clinic and performed as home exercise program 3-5x per week
● Therapeutic tools in progressive sizes to improve tolerance of stretch and accommodation in the vaginal canal
● Commonly used with vaginal stenosis or tissue changes following radiation
● Start at smallest size that is comfortable and pain free, slowly progressing with guidance of PT
Agentle, hands-on approach to help:
● Release tightness or adhesions in the abdomen
● Improve movement and comfort of skin, muscles, and organs
● Support digestion, posture, and breathing
● Soft tissue techniques over the belly and lower rib area
● Scar mobilization: focused treatment around surgical scars (e.g. hysterectomy, oophorectomy)
● May include light pressure, stretching, or lifting of tissue
● Pulling, stiffness, or numbness near scars
● Digestive discomfort or bloating
● Restricted breathing or core muscle function
● Abdominal mobility and strength
● Posture and body awareness
● Overall comfort with touch in healing tissues
● Helps tight or painful muscles relax and lengthen
● Supports weak muscles by improving their ability to contract, especially during exhalation
● Improves awareness and coordination of the pelvic floor for better muscle control
The pelvic floor works closely with the respiratory diaphragm as a team
● During inhalation, the pelvic floor relaxes and lengthens (eccentric relaxation)
● During exhalation, it contracts and lifts (concentric contraction)
Problems with breathing due to postural issues or other underlying health issues can contribute to pelvic floor dysfunction
● Improve tissue stretch
● Improve relaxation
● Decrease pelvic pain
● Decrease abdominal pain
Strengthening exercises are designed to build and support pelvic floor muscles to improve:
● Bladder and bowel control
● Pelvic organ support
● Overall function and stability
● Functional weakness or fatigue
● Urinary or bowel leakage (incontinence)
● Post-surgical recovery
● Urinary urgency or frequency linked to weakness
● Low back or hip pain linked to core instability
Your plan will be customized to ensure strengthening supports your whole-body function, not just one muscle group.
May include isolated pelvic floor contractions (often called "Kegels")
● Sometimes with use of biofeedbackmanual or with a device
● Always tailored to your specific needs — based on your symptoms, medical history, and functional goals
● More than just “Kegels”— strengthening is more than just doing repetitive squeezes
Personalized strengthening to improve areas of weakness developed through periods of immobility, post surgical, or through treatment
Goals include:
● Improve lumbopelvic support
● Upper and lower extremity strengthening
● Improve functional activity tolerance
Profile: 61 year old female who underwent hysterectomy for uterine cancer 3 months ago, no other treatment at this time
Current concerns:
● Pain at lower abdominal incision site
● Abdominal weakness and core instability - notices herself not feeling strong while getting onto the city bus
● Urinary incontinence while coughing, sneezing, and walking quickly to cross the street
● She is avoiding leaving her house due to fear of leakage and fear of falling which is making her feel depressed as she misses babysitting her grandson
● Poor posture, leaning forward when walking
● Scar tissue and adhesions with pain upon palpation of lower abdomen
● Decreased lower abdominal strength on exam
● Inability to contract and coordinate a strong pelvic floor for contraction
● Reduce pain at incision site
● Improve core and pelvic floor strength
● Restore continence
● Return to functional activity with confidence
● Scar Mobilization: gentle techniques to reduce tension and pain
● Core Strengthening: breathwork, posture, abdominal activation
● Pelvic Floor Muscle Strengthening:
○ Coordinated contractions with exhale
○ Manual biofeedback for awareness - -always consent based
● Home Program: breathing, self scar massage, gentle core and pelvic
exercises
● 37 year old female diagnosed with cervical cancer months ago, treatment with external beam radiation and brachytherapy (completed 6 months ago), also underwent chemotherapy (cisplatin)
Current concerns:
● Intense pelvic and vaginal pain
● Pain and fear surrounding sexual activity (dyspareunia)
● Feeling of tightness and burning in pelvic region
● Avoidance of intimacy and significant emotional distress
● Anxious, guarded posture and tightly crossing arms/legs in exam room
● Becomes teary eyed upon history taking; following education requests to not perform pelvic exam today
● Pelvic exam deferred, only question taking done first day
● Patient consents to pelvic exam at second visit, revealing:
○ Vaginal stenosis and decreased tissue mobility
○ Hypersensitive vaginal tissues
○ Clenching of pelvic floor muscles
○ Inability to relax and bulge pelvic floor muscles
● Reduce pelvic and vaginal pain
● Improve tolerance to touch and intimacy
● Restore pelvic floor flexibility and coordination
● Support emotional well-being and body confidence
● Patient Education: Understanding effects of radiation on pelvic tissues and pain pathways
● Manual Therapy: Starting with external pelvic and abdominal work to reduce tension and pain -always consent based
● Dilator Therapy: gentle, guided reintroduction of internal tissue stretch tolerance vaginal dilators
● Pelvic Floor Relaxation: diaphragmatic breathing, mindfulness, and pelvic stretches
● Sexual Health Support: Positioning, lubrication, and communication strategies with partners
● Collaboration: Coordination with gynecologic oncology and mental health support as needed
1. Pelvic floor physical therapy is a treatment intervention involving the muscles, ligaments, bones, and nerves of the pelvis - and it can help improve urinary, bowel, and sexual function and reduce pelvic pain during or after cancer treatment.
2. Cancer and its treatments may affect the pelvic muscles, nerves, and tissues, leading to weakness or fatigue of the muscles, pain or sensitivity of nerve pathways, hormonal changes impacting the pelvic floor, and changes in bladder, bowel, or sexual function.
3. Your first visit includes a personalized evaluation of strength, mobility, scar tissue, and function that may or may not involve the pelvic floor. Treatment may include: manual therapy (pelvic, abdominal, scar), strengthening and coordination, home tools and self-care strategies with the goal of supporting your recovery and helping you feel strong, comfortable, and confident in your body.
1. Cai L, Wu Y, Xu X, Cao J, Li D. Pelvic floor dysfunction in gynecologic cancer survivors. Eur J Obstet Gynecol Reprod Biol. 2023;288:108-113. doi:10.1016/j.ejogrb.2023.07.010
2. Brennen R, Lin KY, Denehy L, et al. Natural history of pelvic floor disorders before and after hysterectomy for gynaecological cancer. BJOG. 2024;131(11):1545-1554. doi:10.1111/1471-0528.17870
3. National Cancer Institute. Radiation Therapy Side Effects. National Cancer Institute. Published January 11, 2022.
https://www.cancer.gov/about-cancer/treatment/types/radiation-therapy/side-effects
4. Varytė G, Bartkevičienė D. Pelvic Radiation Therapy Induced Vaginal Stenosis: A Review of Current Modalities and Recent Treatment Advances. Medicina (Kaunas). 2021;57(4):336. Published 2021 Apr 1. doi:10.3390/medicina57040336
5. American Cancer Society. Chemotherapy Side Effects | American Cancer Society. www.cancer.org. Published May 1, 2020.
https://www.cancer.org/cancer/managing-cancer/treatment-types/chemotherapy/chemotherapy-side-effects.html
6. National Cancer institute. (2019, September 24). Side Effects of Immunotherapy - National Cancer Institute. Www.cancer.gov.
https://www.cancer.gov/about-cancer/treatment/types/immunotherapy/side-effects
7. Hormone Therapy for Cancer. (2025, May 15). Cancer.gov.
https://www.cancer.gov/about-cancer/treatment/types/hormone-therapy#hormone-therapy-can-cause-side-effects
8. Targeted Therapy for Cancer - National Cancer Institute. (2014, August 15). Www.cancer.gov.
https://www.cancer.gov/about-cancer/treatment/types/targeted-therapies#what-are-the-side-effects-of-targeted-therap y
9. Kim HK, Kang SY, Chung YJ, Kim JH, Kim MR. The Recent Review of the Genitourinary Syndrome of Menopause. J Menopausal Med. 2015;21(2):65-71. doi:10.6118/jmm.2015.21.2.65
10. van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, Pelger RCM, Hagenaars-van Miert CHAC, Laan ETM. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev. 2022;10(2):209-230. doi:10.1016/j.sxmr.2021.03.002
11. Silva AP, Montenegro ML, Gurian MB, et al. Perineal Massage Improves the Dyspareunia Caused by Tenderness of the Pelvic Floor Muscles. Massagem perineal melhora a dispareunia causada por tensão dos músculos do assoalho pélvico. Rev Bras Ginecol Obstet. 2017;39(1):26-30. doi:10.1055/s-0036-1597651
12. Anderson R, Wise D, Sawyer T, Nathanson BH. Safety and effectiveness of an internal pelvic myofascial trigger point wand for urologic chronic pelvic pain syndrome. Clin J Pain. 2011;27(9):764-768. doi:10.1097/AJP.0b013e31821dbd76
13. Surles T. Pelvic Floor Therapy: What It Is & How It Can Help After Breast Cancer Treatment. Breastcancer.org. Published 2024. Accessed July 14, 2025. https://www.breastcancer.org/treatment-side-effects/pelvic-floor-therapy
14. Rutledge TL, Rogers R, Lee SJ, Muller CY. A pilot randomized control trial to evaluate pelvic floor muscle training for urinary incontinence among gynecologic cancer survivors. Gynecol Oncol. 2014;132(1):154-158. doi:10.1016/j.ygyno.2013.10.024.