Have you heard of “internal work” when hearing about pelvic floor physical therapy? Maybe you feel like that is something you need, or something you don’t want, or you have no idea what that even is. These are all legitimate initial thoughts! Let’s explore what “internal work” is, and how it may or may not be used during evaluation and treatment, and why it is crucial to successful pelvic floor physical therapy! 

• What is internal work? Internal work refers to the assessment and/or treatment of the pelvic floor muscles through either the vaginal or rectal canal. Internal work is done with one finger only. For women, this assessment is typically done vaginally as that is more comfortable. For men it would have to be completed rectally. 

• Evaluation/assessment: Internally, we are assessing multiple things. The first thing is muscle strength. When the therapist is directly on the pelvic floor muscles, the patient can contract the muscles (aka doing a kegel). This way, the therapist can feel exactly what is happening with the muscles and how strong the contraction is and provide immediate feedback to the patient. The second thing to assess is muscle tone. Are the muscles flaccid or are they super tight? This is very important to know as it will completely determine the treatment strategy that will actually solve your pelvic floor dysfunction. The third thing we can assess (in people with vaginal canals only) is prolapsing. This is a visual inspection to see if the bladder, rectum, and/or uterus are prolapsing. 

• During treatment: Depending on the evaluation findings, internal work is often indicated for treatment. This can include continuing to work on the strength of the pelvic floor (kegel). Say someone had poor strength in their pelvic floor muscles and poor technique with their kegel. This is something we will want to have the patient practice then definitely check back up on! We need to make sure they are progressing well. Internal treatment can also include relaxing the pelvic floor muscles. Say someone had a lot of tightness in their pelvic floor, we can spend time on each muscle that is tight and get it to relax down just like working on a trigger point in your upper trap. Sometimes people do not have internal issues and need to focus on external physical therapy including core strength, hip strength and mobility, etc. Often treatment is a combination of internal and external physical therapy.  Below are a few examples of activating your pelvic floor and how to work on some of the muscles around the pelvic floor.

Internal evaluation and usually treatment is crucial to successful pelvic floor physical therapy. If we do not assess internally, we will be missing essential pieces of the puzzle. This can cause us to choose the wrong treatment option wasting time, effort, money, and potentially even making the problem worse. Internal treatment is usually indicated for most patients and will facilitate progress made in therapy exponentially compared to not completely internal assessment and treatment. All pelvic floor therapists should conduct an internal examination for their work to truly be considered pelvic floor physical therapy (this is my personal opinion). Of course, if the patient is not comfortable with an internal exam this would never be forced upon them, but it is indicated due to the vast benefits. If you have been struggling with pelvic floor dysfunction and think you may need internal examination and treatment, our pelvic floor experts at Alpha Project Phyzio will be able to help you!

Make sure to look at our Pelvic Floor Physical Therapy and Women’s Health page to learn more about pelvic floor physical therapy and if it is right for you.