© 2014 Dr Sallie Sarrel. Cover image used with licensed permission.

The CEC often refers our post-excision patients to Pelvic Floor Therapy with highly qualified PTs who specialize in endometriosis and pelvic pain. It can be helpful to know what to expect, what the goals of your therapy are, how you can create a partnership with your PT and more. We’re very pleased to share some of Dr. Sallie Sarrel’s expertise to help you get prepared.

When treating endometriosis, your surgeon may choose to refer you to Pelvic Health Physical Therapy. Pelvic Health Physical Therapists are members of the team that treat the many causes of pain for the woman with endometriosis. Pelvic Pain is very complex, and in order to live the highest quality of life you can with endometriosis, you must treat all the causes of pain.

Preparing for a Pelvic Physical Therapy session can seem daunting, but here are just a few tips to make the situation seem less overwhelming:

Treat the First Session as a Fact-Finding Mission
During your first physical therapy session, the Pelvic Physical Therapist takes a medical history. Many send out questionnaires to be filled out before the session. Your therapist is exploring your case and you can explore your therapist as well. Ask your therapist how much experience they have with endometriosis, especially if your disease and surgical history are complicated. While Laparoscopic surgery may leave little scars externally, the work inside is complex. Treating women with endometriosis isn’t like treating most other populations, because the anatomy can become distorted from the disease. Find out how your therapist usually treats women with both pelvic floor dysfunction and endometriosis.

Many Pelvic Health Physical Therapists are primarily manual therapists. They believe in using skilled hands to elicit change in your body. To treat endometriosis, it is preferable for the pelvic Physical Therapist to be trained in techniques that address musculoskeletal causes and visceral relationships. Practitioners should have advanced training in visceral manipulation therapy and have significant training in pelvic floor work. Many Pelvic Health Physical Therapists also have training in Pilates, yoga, and nutrition to better facilitate lifestyle changes that will help your pain. Women with endometriosis often find the use of sensors or dilators internally rather uncomfortable. You should discuss your feelings on their use and your therapist’s beliefs on their use. Make sure you see eye to eye. Most of all, the first session is the time to decide if you and the Physical Therapist make a great team together. This is your health and physical therapy should be a partnership.

So, You May Have an Internal Exam…
Women with endometriosis may have issues with the muscles inside the pelvis. This is called pelvic floor dysfunction. Women with endometriosis can also have trigger points within the muscles of the pelvic floor. When a tiny fiber of a muscle or tissue stays contracted but the rest of the area does not, you can get an area of hypersensitivity called a trigger point. The trigger point can cause pain elsewhere from its location. Your trigger point may be inside your pelvis but it could cause lower abdominal or rib pain. You can have decreased mobility of scar tissue from childbirth and surgeries. During your first visit the physical therapist may want to evaluate your pelvic floor for some of these issues. Therapy will typically be in a private room. You will empty your bladder prior to the exam and then the Therapist will step out of the room so you can undress from the waist down and cover yourself with a sheet. Then the Therapist will conduct an exam much shallower than your regular GYN examination. It is a one- to two-knuckle deep exam. They will tell you step by step what is going on. Remember pelvic Physical Therapy is about that partnership – if you are not ready for the internal work, you need to speak up. This is your appointment and you need to be comfortable.

…Or, You May Not
You do not need to have the inside of your pelvis treated to make therapeutic gains. It certainly is one very useful tool in the Pelvic Health Physical Therapist’s toolkit but it is not the only tool. For non-sexually active women, especially teenagers with endometriosis, and women with issues like vulvodynia and vaginitis internal work, despite pelvic floor spasms, may not be advisable depending on the case. But, it is possible even without internal therapy to have improvements in your pelvic floor and pelvic pain. Additionally, you may have trigger points in your abdomen especially in the Psoas or hip flexor muscles. You may have spasming in the muscles around the umbilicus or other abdominal areas. The back and hip muscles may have length and strength issues. Your Therapist may chose to use that Visceral Manipulation technique to help work with the fascia, a saran wrap substance around everything in the body, to alleviate pain and dysfunction. For example, the fascia of the bladder ligaments is contiguous with the pelvic floor so visceral manipulation therapy may release issues driving your pelvic floor spasms. An internal exam is helpful, but it isn’t the only thing a Pelvic Physical Therapist can do to make you feel better. The treatment program should meet you where you are that day and that may or may not include internal work.

It isn’t all About the Pelvis – Even Though it is
Women with endometriosis tend to have central nervous systems that are highly reactive. You have experienced so many years of immense pain that the system is overwhelmed and the body may react to most stimuli as noxious. This is called upregulation. Because the brain has been so inundated for so many years with the painful stimuli, the brain may still recognize the pain even after the disease has been cut out. This is called central sensitization. Imagine being hit with a nail in your stomach for 8-10 years…as your natural computing system, your brain’s circuits would constantly be getting the message that the abdomen is being slammed with a pointy nail. When the nail finally stops, the brain may need a reset button to stop feeling the pain. That is one of the things Physical Therapy can do for centrally sensitized pain. Your Therapist may work on things like guided imagery, mindfulness meditation, breathing exercises, or use types of massage and myofascial release to help calm the body before even working on or in your pelvis. This is so when the pelvis is worked on directly, you don’t have reactive pain.

You Can Explore Options to Make Therapy more Comfortable
Sometimes – it is true – Physical Therapy may make you sore. You may have a reaction to the treatment and the soreness may be the movement patterns or fascia changing from therapy. Myofascial work can be very specific to adhesions and to the peritoneum as well. Patients are encouraged to drink plenty of water post-PT treatments to provide the cells and tissues with the hydration it needs as it experiences changes.

There are doctors who prescribe vaginal diazepam (Valium®) to help with pelvic floor pain. Vaginal Valium® is a small dose of either 5mg or 10mg that gets inserted into the vagina to relax pelvic floor spasms. It is available by prescription only. Many medical doctors prefer the first few times a patient uses the vaginal Valium® it is prior to Physical Therapy sessions in order to make therapy more comfortable. It is not something that is used instead of Physical Therapy. The intent of most doctors’ prescribing it is to serve as an adjunct to therapy. There is much debate in the pelvic health field about the use of vaginal Valium®. Some Physical Therapists feel it is better to treat the upregulation and centrally sensitized pain patterns than administer a drug. Some also feel that because it is given vaginally, it does not attend to the neuropathways in the brain that may be triggering the spasms. Others feel it is a valuable aide to Physical Therapy. Most patients try to experience Pelvic Physical Therapy and see how they react after a few sessions prior to exploring vaginal Valium® with their doctors.

So – now you are prepared to empower yourself over pelvic pain and embark on the journey of healing Pelvic Physical Therapy brings! Appointments in New York and New Jersey, contact Dr. Sarrel:



Dr Sallie Sarrel PT, ATC, DPT is a leading pelvic health Physical Therapist in New York and New Jersey. She has taken her own arduous battle with endometriosis to inspire women to empower themselves over pelvic pain. She frequently lectures nationally and internationally on the value of pelvic Physical Therapy and endometriosis. She has a fervent belief that you are not your pain, and is unique in her patient-centered approach to Physical Therapy and endometriosis.

Helpful links and resources:
Pain after Excision: Was my Surgery a Failure?
Endometriosis: Understanding a Complex Disease
American Physical Therapy Association