For clinicians

Pelvic health physiotherapy

pelvic floor physiotherapy, pelvic health PT

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Bottom linePelvic health physiotherapy addresses pelvic floor muscle function, pelvic girdle pain, abdominal wall recovery, birth preparation, and postpartum rehabilitation. Antenatal and postnatal pelvic floor muscle training has trial evidence for reducing urinary incontinence. Layer with rheumatic-disease-specific joint protection and fatigue pacing.

In practice

What pelvic health physiotherapy is ●●●○moderate evidenceconditional

Assessment and individualised training of the pelvic floor and related musculature, delivered antenatally and postnatally, with education and graded exercise.^[1]

Bladder control (leaking urine) ●●●●high evidenceconditional

Woodley 2020 Cochrane review (46 trials, 10,832 women, verified primary text): in continent women, antenatal PFMT probably lowers the risk of urinary incontinence in late pregnancy (RR 0.38, 95% CI 0.20-0.72; 6 trials; moderate-quality) and reduces it at 3-6 months postpartum (RR 0.71, 95% CI 0.54-0.95; 5 trials; high-quality, the review's strongest result). A mixed prevention-and-treatment population shows a smaller late-pregnancy effect (RR 0.78, 95% CI 0.64-0.94). Evidence for PFMT as TREATMENT of established antenatal or postnatal incontinence is uncertain, contrasting with its well-established effectiveness in mid-life women. No meaningful adverse effects were reported. The 2019 Canadian physical-activity-in-pregnancy guideline independently recommends PFMT (e.g. Kegel) daily to reduce urinary incontinence, citing a 50% reduction in prenatal and 35% reduction in postnatal urinary incontinence with proper-technique instruction (Weak recommendation, low-quality).^{[1, 2]}

Pelvic girdle pain ●●○○low evidenceconditional

Pregnancy-related and postpartum pelvic girdle pain presents at the sacroiliac joints, pubic symphysis, or gluteal region, provoked by single-limb loading, transfers, and prolonged walking. The APTA Academy of Pelvic Health clinical practice guideline (2022) grades exercise at aggregate evidence level I, grade of recommendation A: there is strong evidence that exercise improves performance of the pelvic floor, back flexors, back extensors, and hip extensors, and physiotherapists should prescribe exercise to address those muscle performance impairments. The same guideline states plainly that the influence on pain and disability in postpartum pelvic girdle pain is not well understood, that painful exercise should be modified, and that cointerventions (education, a pelvic belt, an assistive device for gait, functional training, manual therapy) may be considered until exercise tolerance improves.^{[2, 3]}

Tummy-muscle separation (diastasis recti) ●○○○very low evidenceconditional

Abdominal and transversus training may support diastasis recti recovery; the evidence base is limited and of low quality, so advise honestly.^[1]

Getting ready for birth and recovering after ●●○○low evidenceconditional

Birth preparation and structured postpartum rehabilitation, including pelvic floor recovery and graded return to activity.^{[1, 2]}

If you have a rheumatic disease ●●○○low evidenceconditional

Scale the programme to disease activity, fatigue, and joint involvement. Note the differential: the APTA Academy of Pelvic Health clinical practice guideline (2022) lists inflammatory arthritis (ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, lupus, reactive arthritis) and compression or stress fracture among musculoskeletal-origin causes of pain in the pelvic girdle region, alongside lumbar disc disease, hip labral tear, and snapping hip. It also flags that hip pain warranting medical referral includes systemic causes (infection; Paget disease; rheumatoid, psoriatic and septic arthritis; haematoma, all reported postpartum), and that the clinical presentation of systemic-origin hip pain resembles that of musculoskeletal origin. In a pregnant patient with known axSpA, distinguishing inflammatory back pain from mechanical pelvic girdle pain changes management; see the axial spondyloarthritis guide for the inflammatory back pain features. Sacral or pubic stress fracture is also on the differential, including postpartum osteoporosis, which is relevant after glucocorticoid exposure.^[2]

Key points

Point	Evidence
Offer antenatal pelvic floor muscle training to reduce incontinence risk (Woodley et al. 2020).^[1]	●●●○moderate evidencestrong
Flare-aware modification maintains activity through disease fluctuation rather than full cessation.^[2]	●●○○low evidenceconditional

Key numbers

Woodley 2020: antenatal PFMT in continent women, UI in late pregnancy RR 0.38 (95% CI 0.20-0.72; moderate-quality).^[1]
Woodley 2020: UI at 3-6 months postpartum RR 0.71 (95% CI 0.54-0.95; high-quality evidence).^[1]

References

Woodley SJ, Lawrenson P, Boyle R, Cody JD, Morkved S, Kernohan A, Hay-Smith EJC. Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2020;(5):CD007471. https://doi.org/10.1002/14651858.CD007471.pub4
Mottola MF, Davenport MH, et al. 2019 Canadian Guideline for Physical Activity throughout Pregnancy (SOGC/CSEP). J Obstet Gynaecol Can / Br J Sports Med. 2018;52:1339-1346. https://www.jogc.com/article/S1701-2163(18)30567-X/abstract
Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev. 2015;(9):CD001139. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001139.pub4
Clinical Practice Guidelines for Pelvic Girdle Pain in the Postpartum Population. Academy of Pelvic Health Physical Therapy, APTA. J Womens Health Phys Therap. 2022. https://journals.lww.com/jwhpt