"Children are not small adults." Dawn Sandalcidi learned that lesson in the early 1990s, when a urologist asked her to help an eight-year-old girl who had failed two surgeries. There were no pediatric pelvic health courses at the time. Dawn went into the operating room, learned the anatomy, and built her approach one patient at a time.

More than 30 years later, her message to clinicians is clear. Children with bowel and bladder problems need skilled pelvic floor therapists, and there are not enough of them. Here is what she shared with host Allison Ariail in the first episode of Explore the Floor.

Why Is Constipation in Children So Easy to Miss?

Kids rarely report it, and their bowel habits often look normal on paper. In a 2019 study of Dutch schoolchildren, 46% of constipated children and 67% of children with fecal incontinence rated their bowel habits as good or very good. Most constipated children also had normal stool frequency (64%) and normal stool consistency (49%).¹

That means a child can poop three times a week, with a normal Bristol stool type, and still be constipated. Dawn says the question most clinicians skip is the most useful one: does the child strain? For parents, she keeps it simple. Do you ever hear your child grunt or hold their breath on the toilet?

How Does Constipation Cause Bladder Leaks in Kids?

A full bowel presses on the bladder. That pressure creates urgency and frequency, and over time it can thicken the bladder wall. This is why Dawn teaches every student the same rule:

When a child comes in with daytime wetting, bedwetting, or urinary urgency, Dawn looks at the bowel first. The International Children's Continence Society (ICCS) recommends treating constipation in children who have lower urinary tract symptoms, and Dawn stresses that it must be managed aggressively, not with a casual "try a little MiraLAX."²

She also sees what she calls the "constipation carousel." Families start a laxative, the dose is never adjusted, leaks get worse, and they stop. Nobody tracks it. Pelvic health therapists can help by watching the charts closely and working with the prescribing provider on titration.

Why Say "Leak" Instead of "Accident"?

Children already feel shame about leaking. Dawn watches kids drop their heads when parents list "accident, accident, accident" in the clinic. So she gives the responsibility to the organ, not the child. She asks, "Did your bladder have a leak today?" or "Did your bowel have a leak today?" It is a small change that fits trauma-informed care, and it keeps the child engaged in the session.

How Do You Teach a Child to Relax the Pelvic Floor?

Words like "relax" and "down train" mean nothing to a four-year-old. Dawn teaches "muscle on" and "muscle off" instead. Her favorite tools are simple:

• A skeletal pelvic model and a balloon "bladder," held tight in the child's cupped hands to show what the muscles do
• Surface EMG on the biceps first, so the child can see a muscle turn on and off
• Kid-friendly cues, such as how you stop a toot in class, with the child choosing their own word for the feeling
• A cocktail straw and a pinwheel in a toileting position, to build gentle pressure while the pelvic floor lets go

What Do Posture and Breathing Have to Do With Constipation?

A lot. Dawn often sees children with chronic constipation sitting in thoracic extension with a wide rib angle and flared ribs. The diaphragm loses its zone of apposition and is no longer parallel to the pelvic floor. Breathing moves forward into the belly instead of down. As Dawn puts it, "These kids live in the third trimester."

She also screens for hypermobility with a pediatric scale, checks developmental milestones such as crawling, and looks for signs of tethered cord. Restoring rib position and core function is part of the plan, not an extra.

How Do You Get Families to Follow Through?

Ask about barriers first. Dawn asks each family which one or two things are realistic this week. She gives the child a "bladder boss" or "bowel boss" chart and hands over the first set of stickers herself, so parents have one less errand. For kids eight and older, the child reports progress directly to the therapist. That way the parent does not have to nag, and the child owns the program.

Can Adult Pelvic Health Therapists Learn to Treat Kids?

Yes. Dawn's advice to PTs and OTs who treat adults is direct:

She calls pediatric bowel and bladder care "the easiest thing to treat." Most children respond to standard urotherapy, the first-line approach defined by the ICCS: regular bowel and bladder habits, education about how the body works, and support for the family.³ Connecting with kids is easier than most adult clinicians expect. Know the latest Disney movie, ask about their favorite games, and let them become "body detectives." When a child needs something outside your scope, refer to a developmental therapist and keep treating what you know.

What Is Kids Bowel & Bladder?

Kids Bowel & Bladder is the continuing education company Dawn founded to train therapists in pediatric pelvic health. It serves physical and occupational therapists who treat bowel and bladder problems in children. It also offers help for parents, including courses and free e-books on bedwetting and constipation. You can find her pediatric courses on Dawn's Herman & Wallace faculty page.

In April 2026, Kids Bowel & Bladder launched the Pediatric Pelvic Health Advanced Practitioner (PPHAP) certificate program, a structured path for clinicians who want to specialize. Kids Bowel & Bladder is now a Summit Professional Education company, alongside Herman & Wallace. For Dawn, the goal is simple: train more clinicians, so more children can find a provider who knows how to help them.

If you are exploring how to become a pediatric pelvic floor specialist, a good first step is Pediatrics Level 1, Treatment of Bowel and Bladder Disorders, developed by Dawn for Herman & Wallace. New to pelvic health overall? Start with this guide on how to become a pelvic floor therapist. When you are ready to go deeper, explore Dawn's pediatric courses on Herman & Wallace.

References

1. Timmerman MEW, Trzpis M, Broens PMA. The problem of defecation disorders in children is underestimated and easily goes unrecognized: a cross-sectional study. Eur J Pediatr. 2019;178(1):33–39. https://doi.org/10.1007/s00431-018-3243-6
2. Burgers RE, Mugie SM, Chase J, et al. Management of functional constipation in children with lower urinary tract symptoms: report from the Standardization Committee of the International Children's Continence Society. J Urol. 2013;190(1):29–36. https://pubmed.ncbi.nlm.nih.gov/23313210/
3. Nieuwhof-Leppink AJ, Hussong J, Chase J, et al. Definitions, indications and practice of urotherapy in children and adolescents: a standardization document of the International Children's Continence Society (ICCS). J Pediatr Urol. 2021;17(2):172–181. https://doi.org/10.1016/j.jpurol.2020.11.006

About Dawn

Dawn Sandalcidi, PT, RCMT, BCB-PMD, PPHAP, is a leading expert in pediatric pelvic floor disorders with more than 40 years of clinical experience. She graduated from SUNY Upstate Medical Center in 1982 and lectures nationally and internationally on pediatric bowel and bladder disorders. Dawn founded Kids Bowel & Bladder, a continuing education company for physical and occupational therapists who treat children. Kids Bowel & Bladder is now a Summit Professional Education company. In 2018, she received the Elizabeth Noble Award from the APTA Section on Women's Health. She is a faculty member of the Herman & Wallace Pelvic Rehabilitation Institute and developed Pediatrics Level 1, Treatment of Bowel and Bladder Disorders.

Pelvic health patients often present with more than a local pelvic floor problem. Stress, anxiety, pain, sleep disruption, urgency, constipation, pelvic floor guarding, and difficulty "letting go" frequently overlap in clinical practice. These symptoms do not exist in isolation. They are shaped by the nervous system, lived experience, emotional health, physical function, and the patient’s sense of safety in the body.

The World Health Organization identifies October 10 as World Mental Health Day, a day that reminds us that mental health is a global concern and that it affects every individual. The objective is raising awareness of mental health issues and mobilizing efforts in support of mental health. For 2026, the listed theme is "Lived experiences heard: real voices, real change."¹

This message matters deeply in pelvic rehabilitation. Patients with pelvic health conditions often carry stories of pain, embarrassment, fear, urgency, bowel and bladder distress, birth trauma, sexual pain, medical dismissal, chronic symptoms, or feeling disconnected from their body. Their lived experience should shape how we listen, assess, educate, and treat.

Neuro-regulation stands at the intersection of mental health and pelvic health. When the nervous system is in a heightened state of protection, the pelvic floor may guard, breathing may become shallow, pain may feel amplified, and bowel or bladder symptoms may become more difficult to manage. Acupressure offers pelvic rehabilitation clinicians a gentle, external, patient-friendly strategy that can be paired with breathwork, mindfulness, movement, and pelvic floor release.

Newer evidence supports self-applied acupressure as a promising adjunct for perceived stress, mood, sleep, pain, and anxiety-related symptoms, although the effects are generally modest and mechanisms are still being clarified. In Acupressure for Optimal Pelvic Health, clinicians learn how to apply acupressure safely and practically for pelvic health conditions, nervous system downtraining, stress reduction, and patient self-management.

Could stress be part of the pelvic symptoms you are treating?

As pelvic health rehabilitation professionals, we routinely assess muscle function, coordination, posture, breathing, pain, bowel and bladder habits, connective tissue mobility, and movement patterns. But many patients also arrive with a nervous system that feels braced.

They may present with braced shoulders, tensed jaws, shallow breathing, abdominal gripping, urgency, frequency, constipation, pelvic pain, dyspareunia, vulvar pain, rectal pain, bladder sensitivity, or a pelvic floor that does not fully let go. Many patients say:

These statements are not separate from mental health. They reflect upon how the nervous system, stress response, emotional state, pain processing, interoception, and pelvic floor function can interact.

Mental health is not only about diagnosis. It includes how a person feels, copes, connects, sleeps, moves, regulates stress, interprets body signals, and participates in daily life. For pelvic health clinicians, this does not mean treating anxiety, depression, trauma, or other mental health diagnoses as psychotherapists. It means recognizing that stress and nervous system dysregulation can influence function, pain, guarding, bowel and bladder symptoms, and the patient’s ability to engage in rehabilitation.

That is where downtraining becomes more than a cue. Patients often need a body-based strategy that helps them experience safety, quiet, and release.

Acupressure can become one of those tools.

Neuro-regulation: where Mental health and Pelvic health meet

Neuro-regulation, or nervous system regulation, refers to the body’s ability to move between states of activation and recovery. A healthy nervous system is not calm all the time. It is flexible. It can respond to stress, then return toward balance.

In pelvic rehabilitation, this flexibility matters.

When a patient feels safe, supported, and connected to their body, it may be easier to breathe deeply, relax the abdomen, lengthen the pelvic floor, coordinate bowel and bladder strategies, tolerate touch, move with less fear, and participate in treatment. When the nervous system is stuck in a protective state, the body may respond with muscle guarding, pain amplification, urgency, breath holding, digestive changes, sleep disruption, and heightened sensitivity to internal sensations.

This is why mental health and pelvic health cannot be completely separated. Stress, fear, anxiety, pain, and protective guarding are experienced through the body. The pelvic floor is often one of the places where that protection becomes visible.

Acupressure offers a practical way to bring neuro-regulation into the treatment room. It gives the patient something concrete to feel and do. The clinician can pair sustained pressure at selected acupoints with slow breathing, body awareness, grounding language, and pelvic floor release. This can help shift the session from "try to relax" to "let’s create the conditions where release is possible."

Consider the following questions:

1. Do your patients report that pelvic pain, urgency, constipation, or pelvic floor tension worsens during times of stress?
2. Do your patients understand the instruction to "relax," but struggle to actually feel pelvic floor release?
3. Do your patients need strategies to help them self-regulate outside the clinic, during symptom flares, travel, work stress, bowel urgency, or pain episodes?
4. Are you seeing patients whose pelvic symptoms are influenced by fear, hypervigilance, sleep disruption, emotional stress, or a sense of disconnection from the body?
5. Would your patients benefit from a simple, external, self-care tool that supports breathing, body awareness, and downtraining?
6. Are you confident explaining acupressure in an evidence-informed way without overpromising?
7. Could acupressure become part of your downtraining plan alongside breathing, mindfulness, movement, education, manual therapy, and pelvic floor coordination?

Acupressure as a practical downtraining and mental health-supportive tool

Acupressure is a noninvasive technique that uses sustained pressure at selected points on the body. In pelvic rehabilitation, it can be paired with slow breathing, body awareness, mindfulness, and pelvic floor release.

One of the most useful aspects of acupressure is that patients can learn to apply it themselves. It is a potent self-care technique and easy to integrate into a home program. For patients who feel overwhelmed, anxious, guarded, or disconnected from their body, acupressure may provide a tactile anchor:

This process is simple, but it is not superficial. It teaches the patient that self-regulation can be practiced through the body. It gives them an active role in their care. It can support confidence, self-efficacy, and a sense of calm.

That calm is central to whole-person rehabilitation. When patients feel that they have tools to help themselves, symptoms may feel less frightening and less uncontrollable. This does not mean acupressure replaces medical care, psychotherapy, medication, pelvic floor muscle training, manual therapy, or interdisciplinary collaboration. Rather, acupressure can be used as an adjunctive self-regulation strategy within a larger plan of care.

For pelvic health patients, this can be especially meaningful. A patient with urgency may use acupressure with breathing before rushing to the bathroom. A patient with pelvic pain may use acupressure as part of a flare-management plan. A patient with constipation may use acupressure as part of a bowel routine. A patient with pelvic floor guarding may use acupressure to help prepare the body for downtraining, stretching, or pelvic floor release.

What does the newer research show?

The emerging research is promising and supports that acupressure may help reduce perceived stress, pain, anxiety-related symptoms and sleep problems in some populations, with modest effects.

A 2026 randomized controlled trial of 250 adults with moderate depression compared self-administered acupressure training with mental health education of the same schedule and duration. The acupressure group showed a statistically greater reduction in PHQ-9 scores at 4, 8, and 12 weeks, with a week-12 mean difference of -1.46 points and a small effect size. The authors concluded that the program was potentially effective, while also noting clinically small effects and limitations in adverse-event collection.²

Stress research also supports a practical self-care message. In the Self-Acupressure for Stress trial, 159 health care providers were randomized to receive self-acupressure educational materials or waitlist control. The intervention group reduced perceived stress more than the control group at follow-up, and mental health-related quality of life improved more at the final time point.³

The anxiety literature is promising but heterogeneous. A 2022 systematic review and meta-analysis of 27 randomized controlled trials found that acupressure significantly reduced anxiety.⁴

Why this matters in pelvic health

Pelvic health is whole-person care. Symptoms are often influenced by the interaction of the pelvic floor, bowel and bladder habits, connective tissue, breathing mechanics, pain processing, stress physiology, sleep, movement, and lived experience.

This is why World Mental Health Day is relevant to pelvic rehabilitation. Mental health is not separate from physical health. The body expresses stress. The breath expresses stress. The pelvic floor can express stress. For some patients, pelvic symptoms become one of the ways the nervous system communicates protection, fear, overload, or loss of safety.

Stress and threat perception can contribute to protective guarding. Protective guarding can make it harder for patients to breathe deeply, relax the abdomen, lengthen the pelvic floor, or trust movement. While direct trials showing that acupressure reduces pelvic floor tone are limited, acupressure may help create a more supportive environment for downtraining by reducing perceived stress, anxiety-related arousal, pain, and body tension.

In a published case report by this author on conservative management of rectal prolapse, acupressure was integrated with pelvic floor muscle training, mindfulness, breathwork, manual therapy, and self-management. The patient reported marked improvements in pain, prolapse severity, function, and Pelvic Floor Distress Inventory-20 scores over the course of care. This does not prove that acupressure alone caused the improvement, but it does illustrate how acupressure can be incorporated into a multimodal, patient-centered pelvic rehabilitation plan.⁵

For many patients, healing begins when they feel heard and when they are given tools that help them reconnect with their body. Acupressure can support that process. It is hands-on, but it is also educational. It is calming, but it is also empowering. It allows the clinician to say, "Your symptoms are real, your nervous system matters, and there are practical tools we can use to help your body feel safer."

What Will You Gain from This Course?

Acupressure for Optimal Pelvic Health is designed to make acupressure practical and relevant for clinicians working in pelvic rehabilitation.

Participants will explore how acupressure can be integrated into care for patients with:

• Pelvic pain
• Bowel dysfunction
• Bladder dysfunction
• Constipation
• Digestive disturbances
• Dysmenorrhea
• Stress-related pelvic floor overactivity
• Anxiety-related body tension
• Difficulty with relaxation and downtraining
• Nervous system dysregulation
• Symptom flares related to stress, pain, or emotional overload

Clinicians will learn how to locate and map key acupressure points, apply appropriate pressure, pair points with breathing and body awareness, teach patients self-acupressure, and sequence acupressure with pelvic rehabilitation interventions.

The course also explores how acupressure can be used as part of a larger neuro-regulation framework. This includes acupoints for stress reduction, relaxation, breathing support, bowel and bladder symptoms, pelvic pain, and returning the body toward physiologic balance.

The goal is to give clinicians another safe, accessible, evidence-informed tool that can be used within their scope of practice as part of whole-person pelvic rehabilitation.

Join Dr. Rachna Mehta for Acupressure for Optimal Pelvic Health

If you want to expand your downtraining toolbox, improve your confidence teaching self-regulation strategies, and learn how to integrate acupressure into pelvic health care, this course offers a practical framework you can use with patients right away.

World Mental Health Day reminds us that mental health affects every individual. In pelvic rehabilitation, we see this every day. We see how stress can influence pain. We see how fear can influence guarding. We see how urgency, constipation, pelvic pain, dyspareunia, and prolapse symptoms can affect confidence, sleep, relationships, movement, and participation in daily life.

This course offers a practical way to bring that awareness into treatment.

Sometimes the next step is not another strengthening exercise. Sometimes the next step is helping the patient feel safe enough to soften, breathe, and let go.

References

1. World Health Organization. World Mental Health Day campaign page and 2026 event theme. https://www.who.int/campaigns/world-mental-health-day
2. Yeung, Wing Fai ; Yu, Branda Yee Man ; Ho, Fiona Yan Yee et al. / Self-administered acupressure training for depression in community-dwelling individuals : a randomized controlled trial and cost-effectiveness analysis. In: eClinicalMedicine. 2026 ; Vol. 96.
3. Abbott R, Hui EK, Kao L, et al. Randomized Controlled Trial of Acupressure for Perception of Stress and Health-Related Quality of Life Among Health Care Providers During the COVID-19 Pandemic: The Self-Acupressure for Stress (SAS) Trial. Am J Med Open. 2023;10:100056. doi:10.1016/j.ajmo.2023.100056. https://escholarship.org/content/qt9jz0q7mg/qt9jz0q7mg.pdf
4. Chen SR, Hou WH, Lai JN, Kwong JSW, Lin PC. Effects of Acupressure on Anxiety: A Systematic Review and Meta-Analysis. J Integr Complement Med. 2022;28(1):25-35. doi:10.1089/jicm.2020.0256 https://pubmed.ncbi.nlm.nih.gov/35085025/
5. Mehta R, Parr RE. Conservative Management of Rectal Prolapse in an Older Adult Using Acupressure and Integrative Physical Therapy: A Case Report. Journal of Women's & Pelvic Health Physical Therapy. 2026.

 

Menopause represents a transformative phase in a woman’s life, and as pelvic health practitioners, it’s an opportunity for us to make a significant impact. Rather than being the “beginning of the end,” menopause can usher in a new era of freedom and empowerment. Women spend a significant portion of their lives post-menopause, free from the limitations of periods, pain, and hormonal fluctuations, but only if we, as clinicians, provide the tools and education necessary to thrive during this transition.

Historically, women’s health during menopause has been overlooked. In the past century, limited life expectancy meant menopause healthcare and research were rarely prioritized. Combine that with the research gap in women’s health and well-documented medical misogyny, and one can see how generations of women’s health has been neglected. However, with advancements in healthcare and advocacy, that’s changing, and we need to lead the way in reframing menopause management, starting with conservative pelvic health approaches before defaulting to hormonal therapies.

The Overlooked Connection: Hormones, Voice, and Pelvic Floor Health

Among the myriad symptoms of menopause, the interplay between hormonal changes, the voice, and the pelvic floor often goes unnoticed. Hormonal shifts, especially decreasing estrogen levels, significantly impact voice quality, including reduced pitch range, vocal endurance, and an increase in vocal fatigue and dryness. These changes mirror similar phenomena in the pelvic floor, where decreased tissue elasticity, sarcopenia, and altered pressure management can result in incontinence, prolapse, or pain.

The voice is highly sensitive to endocrine changes throughout life. For example:

• Puberty: Testosterone lengthens and thickens the vocal folds, lowering pitch.
• Menstrual Cycle: Dysphonia premenstrualis, linked to inflammation and hormonal fluctuations, reduces vocal range and endurance.
• Pregnancy: Thickened vocal folds and decreased pitch are common due to hormonal and fluid changes.

Menopause, Hormone Therapy, and the Voice

Take puberty for example, when the presence of testosterone changes the dimensions of the male vocal tract. The vocal folds become thicker and longer and the larynx size increases, which changes the “fundamental frequency of the voice.” By contrast, premenstrual voice changes have also been noted, which is known as dysphonia premenstrualis and is characterized by a loss of ability to achieve high notes, as well as vocal fatigue and reduced vocal range. Some of these changes are driven by inflammation, mucosal dryness, and decreased mucosal secretions caused by progesterone. Other researchers have noted that cervical and laryngeal smears, taken during the premenstrual period phase consistent with progesterone peak, were indistinguishable.

Likewise, women going through pregnancy, and specific to the menopause discussion, experience unique voice changes as well. Vocal abnormalities noted in the literature include vocal fold thickening, lowered vocal pitch, vocal fatigue, reduced vocal range, and failure to reach higher notes. Though anecdotally I have also seen women struggle with mid-range notes rather than high-range notes in clinical practice, which underscores the importance of evaluating each patient case-by-case instead of making broad assumptions about voice and pelvic health during perimenopause and menopause.

Of additional concern is the change that HT can have on the vocal folds, which overall can be positive. HT can improve glandular secretions above and below the vocal folds, enhance mucosal viscosity, increase pitch range, capillary permeability, and overall better tissue oxygenation. Estrogen is also a well-known inflammatory mediator, which can help protect and prevent damage to the vocal folds. Additionally, sarcopenia is known to impact vocal fold shape, which could lead to vocal fold bowing, vocalis atrophy, and subsequent glottal fold closure impairment.

The Voice-Pelvic Floor Connection (V2PF)

The interconnectedness of the voice, respiratory diaphragm, and pelvic diaphragm provides a unique lens for menopause care. These three diaphragms share connective tissue and neuromuscular pathways, which influence pressure regulation essential for vocalization, continence, and core stability.

The V2PF Method offers a systems-based, trauma-informed approach to evaluating and addressing these connections. By focusing on:

• The orofacial/cervico-laryngeal diaphragm,
• The respiratory diaphragm, and
• The pelvic diaphragm,

Clinicians can help patients improve coordination, endurance, and strength across these systems. Techniques like musculoskeletal ultrasound imaging allow practitioners to assess and enhance pressure management strategies, leading to improved vocal and pelvic floor outcomes.

Empowering Women Through Education and Treatment

While hormone therapy (HT) can improve vocal function by increasing glandular secretions and reducing inflammation, among other benefits, it’s not a one-size-fits-all solution. Clinicians should consider HT as part of a comprehensive plan that includes conservative interventions such as manual therapy, exercise, and lifestyle modifications tailored to individual needs. Understanding the hormonal and structural changes of menopause empowers both practitioners and patients. With a holistic and interdisciplinary method like the V2PF approach, we can help women reclaim their voices, literally and metaphorically, during menopause.

References

1. Schneider B, van Trotsenburg M, Hanke G, Bigenzahn W, Huber J. Voice impairment and menopause. Menopause. 2004;11(2):151–158. https://doi.org/10.1097/01.GME.0000094192.24934.46

 

Menopause represents a transformative phase in a woman’s life, and as pelvic health practitioners, it’s an opportunity for us to make a significant impact. Rather than being the “beginning of the end,” menopause can usher in a new era of freedom and empowerment. Women spend a significant portion of their lives post-menopause, free from the limitations of periods, pain, and hormonal fluctuations, but only if we, as clinicians, provide the tools and education necessary to thrive during this transition.

Historically, women’s health during menopause has been overlooked. In the past century, limited life expectancy meant menopause healthcare and research were rarely prioritized. Combine that with the research gap in women’s health and well-documented medical misogyny, and one can see how generations of women’s health has been neglected. However, with advancements in healthcare and advocacy, that’s changing, and we need to lead the way in reframing menopause management, starting with conservative pelvic health approaches before defaulting to hormonal therapies.

The Overlooked Connection: Hormones, Voice, and Pelvic Floor Health

Among the myriad symptoms of menopause, the interplay between hormonal changes, the voice, and the pelvic floor often goes unnoticed. Hormonal shifts, especially decreasing estrogen levels, significantly impact voice quality, including reduced pitch range, vocal endurance, and an increase in vocal fatigue and dryness. These changes mirror similar phenomena in the pelvic floor, where decreased tissue elasticity, sarcopenia, and altered pressure management can result in incontinence, prolapse, or pain.

The voice is highly sensitive to endocrine changes throughout life. For example:

• Puberty: Testosterone lengthens and thickens the vocal folds, lowering pitch.
• Menstrual Cycle: Dysphonia premenstrualis, linked to inflammation and hormonal fluctuations, reduces vocal range and endurance.
• Pregnancy: Thickened vocal folds and decreased pitch are common due to hormonal and fluid changes.

Menopause, Hormone Therapy, and the Voice

Take puberty for example, when the presence of testosterone changes the dimensions of the male vocal tract. The vocal folds become thicker and longer and the larynx size increases, which changes the “fundamental frequency of the voice.” By contrast, premenstrual voice changes have also been noted, which is known as dysphonia premenstrualis and is characterized by a loss of ability to achieve high notes, as well as vocal fatigue and reduced vocal range. Some of these changes are driven by inflammation, mucosal dryness, and decreased mucosal secretions caused by progesterone. Other researchers have noted that cervical and laryngeal smears, taken during the premenstrual period phase consistent with progesterone peak, were indistinguishable.

Likewise, women going through pregnancy, and specific to the menopause discussion, experience unique voice changes as well. Vocal abnormalities noted in the literature include vocal fold thickening, lowered vocal pitch, vocal fatigue, reduced vocal range, and failure to reach higher notes. Though anecdotally I have also seen women struggle with mid-range notes rather than high-range notes in clinical practice, which underscores the importance of evaluating each patient case-by-case instead of making broad assumptions about voice and pelvic health during perimenopause and menopause.

Of additional concern is the change that HT can have on the vocal folds, which overall can be positive. HT can improve glandular secretions above and below the vocal folds, enhance mucosal viscosity, increase pitch range, capillary permeability, and overall better tissue oxygenation. Estrogen is also a well-known inflammatory mediator, which can help protect and prevent damage to the vocal folds. Additionally, sarcopenia is known to impact vocal fold shape, which could lead to vocal fold bowing, vocalis atrophy, and subsequent glottal fold closure impairment.

The Voice-Pelvic Floor Connection (V2PF)

The interconnectedness of the voice, respiratory diaphragm, and pelvic diaphragm provides a unique lens for menopause care. These three diaphragms share connective tissue and neuromuscular pathways, which influence pressure regulation essential for vocalization, continence, and core stability.

The V2PF Method offers a systems-based, trauma-informed approach to evaluating and addressing these connections. By focusing on:

• The orofacial/cervico-laryngeal diaphragm,
• The respiratory diaphragm, and
• The pelvic diaphragm,

Clinicians can help patients improve coordination, endurance, and strength across these systems. Techniques like musculoskeletal ultrasound imaging allow practitioners to assess and enhance pressure management strategies, leading to improved vocal and pelvic floor outcomes.

Empowering Women Through Education and Treatment

While hormone therapy (HT) can improve vocal function by increasing glandular secretions and reducing inflammation, among other benefits, it’s not a one-size-fits-all solution. Clinicians should consider HT as part of a comprehensive plan that includes conservative interventions such as manual therapy, exercise, and lifestyle modifications tailored to individual needs. Understanding the hormonal and structural changes of menopause empowers both practitioners and patients. With a holistic and interdisciplinary method like the V2PF approach, we can help women reclaim their voices, literally and metaphorically, during menopause.

References

1. Schneider B, van Trotsenburg M, Hanke G, Bigenzahn W, Huber J. Voice impairment and menopause. Menopause. 2004;11(2):151–158. https://doi.org/10.1097/01.GME.0000094192.24934.46

Erectile dysfunction (ED) affects an estimated 30 million men in the United States and becomes increasingly prevalent with age. Yet despite its frequency, treatment conversations often begin, and end, with a prescription.

While phosphodiesterase-5 (PDE5) inhibitors have transformed the management of erectile dysfunction, medication is only one piece of a much larger clinical puzzle. Successful treatment requires understanding the complex interaction between the vascular, neurologic, hormonal, musculoskeletal, and psychosocial systems that make healthy sexual function possible.

Commonly prescribed PDE5 inhibitors include sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®/Staxyn®), and avanafil (Stendra®). Importantly, these medications do not directly cause an erection. Instead, they enhance the nitric oxide (NO)-cyclic guanosine monophosphate (cGMP) pathway, improving blood flow to the penis in response to sexual stimulation. Sexual arousal is still required for these medications to be effective.

For rehabilitation professionals, understanding the neurovascular, musculoskeletal, hormonal, and psychosocial contributors to erectile dysfunction creates opportunities to improve outcomes beyond symptom management. Pelvic health physical therapists are uniquely positioned to contribute to the conservative management of erectile dysfunction through comprehensive evaluation, patient education, movement-based rehabilitation, and interdisciplinary collaboration.

The goal isn't simply to restore erections. It's to restore healthy sexual function by optimizing the systems that make erections possible.

Erections Are a Systems Problem

An erection requires coordinated function across multiple body systems. Successful erectile function depends on the coordinated interaction of multiple physiologic systems, including:

• Healthy arterial inflow
• Efficient venous occlusion
• Intact autonomic and somatic neural pathways
• Responsive pelvic floor musculature
• Hormonal balance
• Psychological safety
• Cardiovascular health

When one, or several, of these systems becomes impaired, erectile dysfunction can develop. This is why ED should rarely be viewed as an isolated diagnosis. Instead, it should prompt clinicians to ask: What system isn't functioning optimally?

Your ED Toolbox

1. Patient Education

Education remains one of the most underutilized interventions. Helping patients understand normal erectile physiology, age-related hormonal changes, cardiovascular influences, medication effects, and nervous system regulation are key components for clinical education.

Knowledge reduces threat, and reducing threat improves nervous system performance. Helping patients understand the "why" behind their symptoms often reduces fear, improves treatment adherence, and empowers them to actively participate in their rehabilitation.

2. Pelvic Floor Rehabilitation

The pelvic floor contributes directly to erectile rigidity, orgasm, and ejaculation. Muscles including the bulbospongiosus, ischiocavernosus, and superficial transverse perineal muscles help compress venous outflow and improve rigidity. Appropriately prescribed pelvic floor muscle coordination should be considered a first-line conservative intervention for many patients.

Beyond the pelvic floor muscles themselves, pelvic health clinicians should evaluate breathing mechanics, pressure management, scar mobility, hip mobility, lumbar spine function, abdominal wall coordination, bowel and bladder health, and movement patterns that influence pelvic floor performance. Successful rehabilitation often requires addressing the entire lumbopelvic system rather than focusing solely on isolated muscle activation or inhibition. Assessment should always guide intervention, recognizing that pelvic floor dysfunction may be a primary contributor in some patients and a secondary adaptation in others.

3. Nervous System Regulation

An erection is ultimately a parasympathetic event. Patients frequently associate erectile dysfunction with performance anxiety, but nervous system dysregulation extends far beyond psychological stress. Persistent pain, chronic inflammation, sleep deprivation, metabolic disease, and ongoing sympathetic activation can all influence erectile physiology.

Additionally, a person's experiences, beliefs, and learned messages about sexuality can shape their ability to experience arousal and intimacy. Individuals who were raised in sex-negative households, taught that sexuality was shameful, or influenced by cultural or religious beliefs that discouraged open conversations about sex may carry those messages into adulthood.

Relationship challenges, performance anxiety, previous sexual experiences, trauma, or fear of disappointing a partner can further contribute to a heightened threat response that interferes with normal sexual function. These factors do not suggest that erectile dysfunction is "all in someone's head." Rather, they highlight the powerful interaction between the brain, nervous system, emotions, and physiology.

Recognizing these influences allows clinicians to approach erectile dysfunction with greater empathy, curiosity, and clinical reasoning, ultimately leading to more individualized and effective care.

Helping patients regulate the autonomic nervous system through breathing strategies, exercise, pain management, stress reduction, improved sleep, and, when appropriate, referral to a mental health or sex therapy professional may improve erectile function while supporting overall health and well-being.

4. Dry Needling & Neuromodulation

Dry needling should never be viewed as a protocol. Rather, it is a neuromodulatory tool that may influence pelvic floor muscle tone, pudendal nerve sensitivity, lumbosacral neuromotor control, pain processing, and autonomic regulation.

Clinical decision-making should guide the selection of tissues to treat. A thorough subjective examination, comprehensive movement assessment, and skilled palpation are essential to identifying the structures contributing to a patient's symptoms. Rather than asking, "What muscles should I needle for erectile dysfunction?" clinicians should ask, "What impairments are contributing to this patient's presentation?"

Depending on the individual, dry needling may be directed toward the pelvic floor, abdominal wall, hip musculature, lumbopelvic stabilizers, or other tissues that influence movement, load transfer, and neuromuscular function. The goal is not simply to reduce tissue sensitivity or muscle tension, but to create an opportunity for improved movement quality, motor control, pain modulation, and functional performance.

Dry needling should also be viewed as a window of opportunity rather than a stand-alone intervention. Changes in tissue sensitivity or neuromuscular performance should be reinforced through movement, progressive loading, breathing strategies, and patient-specific exercise to promote lasting adaptation.

Like every intervention, dry needling works best when integrated into a comprehensive rehabilitation plan that includes patient education, exercise, behavioral strategies, and interdisciplinary collaboration when appropriate.

5. Medical Optimization

Successful management of erectile dysfunction often extends beyond the pelvic floor. Because erectile function relies on healthy vascular, neurologic, endocrine, and metabolic systems, optimizing overall health is an essential component of treatment. In many cases, erectile dysfunction may serve as an early clinical indicator of broader cardiometabolic or endocrine dysfunction, making timely referral and medical evaluation essential.

Clinicians should consider factors such as:

• testosterone deficiency and other hormonal disorders
• thyroid dysfunction
• hypertension
• diabetes and insulin resistance
• obesity
• smoking
• sedentary lifestyle
• poor sleep quality

Exercise remains one of the most effective interventions clinicians can recommend. Strength training, aerobic conditioning, nutrition, weight management, and sleep optimization all support endothelial function, nitric oxide production, cardiovascular health, and sexual function.

When indicated, medical management also plays an important role. Common treatment options include phosphodiesterase-5 (PDE5) inhibitors such as sildenafil, tadalafil, vardenafil, and avanafil, as well as vacuum erection devices, intracavernosal injections, penile prostheses, and hormone replacement therapy for appropriately selected patients.

Rehabilitation does not replace medical management. It complements it.

6. Interdisciplinary Collaboration

Erectile dysfunction is rarely the result of dysfunction within a single body system, and its management rarely falls within the expertise of a single healthcare provider. Optimal patient outcomes often require collaboration among:

• Primary care physicians
• Urologists
• Pelvic health physical therapists
• Endocrinologists
• Cardiologists
• Mental health professionals
• Sex therapists

Successful treatment is rooted in coordinated, patient-centered care rather than isolated interventions. No single provider has every tool, but together, the healthcare team can help patients achieve better outcomes.

The Best Toolbox Is Individualized

No two patients present with erectile dysfunction for the same reason. Clinical reasoning, not protocols, determines which tools belong in each patient's plan of care.

Beyond Erectile Dysfunction

Erectile dysfunction should never be dismissed as "just" a sexual health issue. It is often an early indicator of broader dysfunction involving vascular health, nervous system regulation, hormonal balance, movement quality, and psychosocial wellbeing. As rehabilitation professionals, we have an opportunity to contribute meaningful, evidence-informed care that extends well beyond symptom management.

The question isn't simply: 'How do we improve erections?' The better question is: 'How do we optimize the systems that make healthy sexual function possible?' Because when we optimize the systems that support sexual health, we often improve overall health in the process.

Continue Expanding Your Clinical Toolbox

Pelvic health professionals play an important role in the conservative management of erectile dysfunction, but successful care requires more than mastering individual techniques. It requires understanding the interaction between the nervous system, pelvic floor, hormones, vascular health, movement, and patient education.

At Professional Pelvic Health Consultants, we believe the most effective clinicians aren't defined by the number of techniques they know. They're defined by their clinical reasoning.

Our goal is to bridge current evidence with practical application, helping clinicians understand not only what interventions to use, but when, why, and for whom they are most appropriate.

Because the best toolbox isn't the one with the most tools. It's the one guided by thoughtful clinical decision-making. And that is exactly what transforms good clinicians into exceptional ones.

Writing on the Pelvic Rehab Report, Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC describes what happens when a patient sees inside their own body for the first time. In her experience there is something about visual biofeedback, and about watching what is actually happening during a contraction, that produces the moment a patient finally understands the task. They get excited about treatment, they become more motivated, and they start to see results they had not been getting before.

That is the argument for rehabilitative ultrasound imaging in a sentence. It is also why Allison built two courses around teaching it, so clinicians can enter the skill set at the depth that matches their practice.

What Rehabilitative Ultrasound Imaging Is

Ultrasound imaging is showing up in physical therapy clinics more and more, and therapists are using it in different ways. Some use it as a training tool to help a patient learn neuromuscular control. Others use it to guide needle placement during dry needling. As Allison has explained on the Pelvic Rehab Report, four distinct uses of ultrasound imaging have been reported by physical therapists. The first and most common is the evaluation of muscle structure and function to aid in neuromuscular control, where the images serve as a source of biofeedback. That use has been given its own name: rehabilitative ultrasound imaging, or RUSI.

The other three categories are diagnostic ultrasound imaging, meaning the diagnosis and monitoring of pathology; interventional ultrasound imaging, meaning the use of images to guide percutaneous procedures involving dry or wet needling; and ultrasound imaging paired with research. The first three are performed during clinical care and fall under the umbrella term point of care ultrasound. Both Herman & Wallace courses teach the first category, rehabilitative use.

Where RUSI Sits in Your Scope of Practice

This is the question that stops many clinicians before they start. Allison has addressed it directly on the Pelvic Rehab Report, reporting that rehabilitative ultrasound imaging sits almost entirely within the scope of the physical therapy profession. The obstacle has not been permission. It has been access to training.

Practice acts vary by state and by profession, so confirm the rules that govern your own license.

Which Patients Benefit

Allison has written that ultrasound can change your clinical practice, and the range of patients it touches is wide. Her Pelvic Rehab Report post lists:

• Back and sacroiliac joint patients
• Urinary and fecal incontinence patients
• Prolapse patients
• Post-prostatectomy patients
• Bowel patients
• Postpartum patients

And as she notes, the list goes on. Cost has also moved in the clinician's favor, with the prices of ultrasound units continuing to come down. Which of those patient groups fills your schedule is a useful way to decide between the two courses.

What the Evidence Behind the Tool Shows

Allison has covered the supporting research on the Pelvic Rehab Report as well. Reviewing a 2021 systematic review of rehabilitative ultrasound imaging as a feedback method during motor control exercise, she reported that the included studies assessed the abdominal wall muscles, pelvic floor, serratus anterior, and lumbar multifidus, and that rehabilitative ultrasound imaging proved more effective than tactile and verbal biofeedback for motor control exercise performance.¹

Imaging also answers questions that palpation cannot. In another Pelvic Rehab Report post, Allison examined a study of six different pelvic floor and abdominal contractions in nulliparous and postpartum women, with bladder positioning tracked by ultrasound imaging. There was significantly more lift of the bladder base when a submaximal contraction of the pelvic floor and transverse abdominis was performed with an elongation of the back, while a curl-up contraction produced significant descent.² That is the kind of finding that shapes how a clinician builds a postpartum return to fitness program, and imaging is how you confirm it in front of you.

Two Courses, One Skill Set

Both Herman & Wallace ultrasound courses share the same foundation. Both are intermediate level, both combine lecture with hands-on lab, and both let participants practice on machines provided by course sponsors. The difference is how far into pelvic health the imaging goes.

Rehabilitative Ultrasound Imaging: Orthopedic Topics, the two day course

This course covers the generation and interpretation of rehabilitative ultrasound images as they relate to the pelvic girdle and low back stabilization, so participants can immediately incorporate imaging into evaluation and treatment plans for patients with diagnoses including lumbo-pelvic pain and instability. Lectures and labs present both ideal and abnormal responses of real-time imaging of the transverse abdominals, rectus abdominis, deep multifidus, levator ani, bladder, and bladder neck. Imaging is transabdominal, and labs are external. Course objectives include:

• Listing current uses and limitations of ultrasound imaging in physical therapy practice
• Describing basic principles of physics that apply to ultrasound use
• Describing safety issues and the ALARA principle concerning rehabilitative ultrasound imaging in physical therapy practice
• Listing and appropriately using the components of an ultrasound machine
• Generating, recognizing, and interpreting ultrasound images of the bladder base, pelvic floor muscles, transverse abdominal muscles, deep multifidi muscles, and rectus abdominis before and after contraction using transabdominal viewing methods
• Using ultrasound imaging to take measurements of diastasis rectus separations
• Using ultrasound imaging to take measurements relating to the transverse abdominus and deep multifidi

Rehabilitative Ultrasound Imaging: Pelvic Health and Orthopedic Topics, the three day course

The extended course covers everything above and adds transperineal and translabial viewing methods alongside transabdominal viewing. Lectures and labs present ideal and abnormal real-time imaging of the transverse abdominals, rectus abdominis, deep multifidus, levator ani, bladder, bladder neck, urethra, and vagina during contraction and valsalva. That extra day widens the diagnostic reach to pelvic organ prolapse and urinary incontinence alongside lumbo-pelvic pain and instability, and adds the objective of generating, recognizing, and interpreting images of the levator ani muscles, detrusor muscle, bladder neck, and urethra using transperineal viewing methods. Prior experience with perineal and vaginal assessments is required to take this course.

Which one should you take

If your caseload is weighted toward low back, sacroiliac joint, and core stabilization work, and you want objective diastasis measurement, the two day Orthopedic Topics course covers it. If you are treating pelvic organ prolapse and urinary incontinence and already perform perineal and vaginal assessments, the three day Pelvic Health and Orthopedic Topics course gives you the transperineal and translabial skills those patients call for.

Ten to fourteen days before either course, participants receive an invitation to join Teachable, an online learning platform, where they will find video lectures, other pre-course learning materials, course manual files, the mandatory liability waiver, and URLs for any Zoom meetings. Teachable components must be completed in sequential order, and video lectures must be completed in full before proceeding to the next section. At the conclusion of the course, registrants access their post-test and course evaluation form and download their certificate of completion, all via Teachable.

These continuing education seminars are targeted to physical therapists, occupational therapists, physical therapist assistants, occupational therapist assistants, registered nurses, nurse midwives, and other rehabilitation professionals. Content is not intended for use outside the scope of the learner's license or regulation. One past participant wrote that Allison clearly has vast experience with ultrasound, that she was fantastic at teaching each group how to best use their machines even though everyone had different equipment, and that the still images and videos in her slides were a highlight.

References

1. Ariail A. Rehabilitative ultrasound imaging to assess motor control and muscle morphology. The Pelvic Rehab Report, Herman & Wallace Pelvic Rehabilitation Institute. https://hermanwallace.com/blog/rehabilitative-ultrasound-imaging
2. Ariail A. Ultrasound to help postpartum return to fitness. The Pelvic Rehab Report, Herman & Wallace Pelvic Rehabilitation Institute. https://hermanwallace.com/blog/ultrasound-to-help-postpartum-return-to-fitness-1

More From Allison on the Pelvic Rehab Report

• Ultrasound Imaging and Physical Therapy Practice
• Ultrasound Can Change Your Clinical Practice
• Rehabilitative Ultrasound Imaging to Assess Motor Control and Muscle Morphology
• Ultrasound to Help Postpartum Return to Fitness

Hello friends and colleagues! Dr. Amy and I are so excited about our September offering of Menstruation and Pelvic Health. This will be our 7th time giving it, and it just keeps getting better each time based on feedback we receive!

Our Class Favorites

We will do all the sessions you love, including:

• The Fifth Vital Sign
• Yoga and stretch movements you can use with your patients
• Demonstrations of menstrual volumes and absorptive/collection capacity of menstrual products: liners, pads, tampons, cups, discs, period underwear, period activewear
• Pros and cons of disposable and reusable menstrual products, help your patients navigate and enjoy the ever-increasing options
• Characterization of different kinds of vaginal discharge
• Menstrual Seasons, Menstrual Milestones, Menstrual Molimina
• Early morning flooding, gushing when exiting the pool
• ‘Go Bags’ and ‘Flow Management Plans’ to reduce stress
• ‘Cycle-Friendly Wardrobes’ to celebrate the variety of ways we show up
• Time to start treating male partners in BV!
• ‘Jane Austen’s Period Drama’, ‘Wearing White at Wimbledon’, ‘Irritable Male Syndrome’
• Cycle tracking and Cycle Syncing: What, Why, and How!!
• Menstrual cups, discs, IUDs, prolapse
• Positive aspects of the Menstrual Experience
• Preparing for tomorrow’s patient

New for September 2026

New additions to help make sense of your patients’ presenting symptoms and navigate common concerns:

• Genitourinary symptoms of hypo-estrogen states during menstrual pauses such as breastfeeding and perimenopause, and while using medications: hormonal contraceptives, tamoxifen, letrozole, Depo Provera
• Hormonal treatment options for hypo-estrogen states
• Cervical stenosis and dysmenorrhea
• Making sense out of irregular bleeding patterns on oral contraceptives and not on oral contraceptives
• Using Progesterone Challenges and Estrogen-Progesterone Challenges to understand underlying hormonal physiology
• Can I delay my period? Can I make it come sooner? Can I sterilize my menstrual cup in a kitchen pot?

Could a medication be the cause of the symptoms you are treating?

As pelvic health rehab professionals, we routinely evaluate range of motion, muscle function and strength, movement patterns, pain, and lifestyle factors. But there is more to the clinical picture that can be easy to overlook, medications!

Consider the following questions:

1. Do you routinely review patient medications and recognize when a medication may be relevant to their clinical presentation?
2. Could you confidently explain how commonly prescribed medications affect bladder, bowel and sexual health?
3. Would you recognize medication side effects that can mimic or contribute to pelvic dysfunction symptoms?
4. Are you comfortable discussing medications with your patients or other healthcare providers without stepping outside your scope of practice?

If you answered “no” to any of these questions, Pharmacologic Considerations for the Pelvic Health Provider is a course you should consider.

Medication Lists:

Medication review isn’t only for documentation purposes. It can be an important component of clinical reasoning and treatment planning. Let’s imagine a patient presents with constipation. Is pelvic floor overactivity the only consideration or, could a medication be contributing to altered gut motility? Or consider a patient that presents with urinary frequency. Is it a bladder problem, a fluid-management issue, a medication side effect, or could it be a combination of factors? A patient’s medication list may provide clues that change the questions you ask, the treatment approach, the goals you set, and when you decide to collaborate with other healthcare professional.

As pelvic health rehab professionals, we don’t prescribe, discontinue, or independently modify medications. However, understanding pharmacology can help us recognize potential medication-related contributors to a patient’s clinical presentation and communicate appropriately with the appropriate healthcare providers.

Pharmacology in Pelvic Health

Pelvic health rehab requires an understanding of multiple body systems. Our patients may be taking medications for cardiovascular disease, mental health conditions, pain, diabetes, gastrointestinal disorders, urologic conditions and/or hormonal conditions, all of which can potentially impact rehab.

Additionally, new medications are continually emerging, and established medications are used in novel ways. We may also find that our patients combine prescription medications with over-the-counter products and supplements. Polypharmacy becomes increasingly important as patients age.

What Will You Gain from This Course?

“Pharmacologic Considerations for the Pelvic Health Provider” is designed to make pharmacology practical and relevant to clinicians working in pelvic rehab.

You will explore medications commonly encountered for patients with:

• Pelvic Pain
• Urinary dysfunction
• Men’s health
• Menopause
• Breast cancer
• Gastrointestinal conditions
• Gender affirming care

You will also examine medication side effects, potential interactions with rehabilitation, and strategies for communicating effectively with patients and other healthcare professionals. The goal isn’t to turn rehabilitation professionals into prescribers but to make you a more informed clinician.

If you want to strengthen your pharmacology knowledge, improve your clinical reasoning, enhance interdisciplinary communication, and feel more confident when medications are part of the equation, this course can help you connect the dots.

Join Kristina Koch, PT, DPT, MS, CLT, PCES, on September 12, 2026 for Pharmacologic Considerations for the Pelvic Health Provider.

Whether you’re an experienced pelvic health clinician, newer to the specialty, or preparing for the PRPC or WCS examination, this course will give you a practical framework for understanding the medications that may intersect with pelvic health rehab. Sometime the next piece of the clinical puzzle isn’t another exercise, technique, or assessment, maybe its what’s on the medication list.

Picture a typical day on a pelvic health caseload. A patient with overactive bladder arrives on an anticholinergic. A patient with chronic pelvic pain is taking an antidepressant and an opioid. A postpartum patient mentions she just started a GLP-1 medication, and an older adult with urinary urgency hands you a medication list that fills an entire page. Every one of those prescriptions can influence bladder function, bowel motility, muscle performance, pain perception, or sexual health, which means every one of them can influence the outcome of pelvic rehabilitation.

Pharmacologic agents are often a first line treatment for pelvic floor dysfunction, and most patients who arrive in a pelvic rehab clinic are already taking one or more medications. The clinician who understands what those medications do, and what they can cause, is better equipped to interpret symptoms accurately, adjust the plan of care, and communicate with the rest of the medical team.

Why Pharmacology Belongs in Pelvic Rehab Practice

Medications can be the hidden variable in a patient's presentation. Conditions commonly seen in pelvic rehabilitation, including overactive bladder, painful bladder syndrome, chronic pelvic pain, and constipation, are frequently managed with medications that act on neuromuscular function, pain processing, hormonal balance, and urologic or gastrointestinal physiology. When a patient is not progressing as expected, the explanation may not be in the muscles at all. It may be in the medicine cabinet. Direct access has also raised the stakes. As more patients enter physical and occupational therapy without seeing a physician first, rehabilitation providers carry more responsibility for screening, safety, and recognizing when a symptom pattern points back to a drug effect rather than a musculoskeletal cause.

How Medications Affect Pelvic Floor Function

Medications influence pelvic health in more ways than most clinicians realize. Common examples include:

• Opioids that slow gut motility and drive constipation
• Antidepressants that can alter sexual function, arousal, and continence
• Anticholinergics prescribed for urinary symptoms that carry cognitive and systemic side effects, particularly in older adults
• Hormonal medications that influence tissue quality and pain sensitivity
• Newer agents, including GLP-1 receptor agonists, that change gastrointestinal transit in ways that show up directly in bowel and bladder symptoms

The same drug can be both treatment and culprit. A medication prescribed to calm an overactive bladder may dry the mouth and slow the bowel, and the resulting constipation can worsen the very urinary symptoms it was meant to treat. Recognizing these loops allows the pelvic health provider to tailor interventions, modify exercise and behavioral strategies around a patient's medication profile, and flag concerns to the prescribing provider.

What the Research Shows

Provider knowledge has not kept pace with prescribing. A 2017 study by Araklitis, Thiagamoorthy, Hunter, Rantell, Robinson, and Cardozo found limited knowledge among health care professionals regarding anticholinergic load, the cumulative burden of anticholinergic medications that can impact cognitive functioning in the elderly.¹

While managing medications is not within the scope of practice for rehabilitation therapists, reviewing them is a duty. That means reviewing patient medications at the initial evaluation and on an ongoing basis, watching for side effects that mimic or worsen pelvic floor dysfunction, assessing how medications may be affecting treatment response, and communicating clearly with referral sources and primary care providers when something does not add up.

Inside the Course

Kristina Koch, PT, DPT, CLT, PCES created Pharmacologic Considerations for the Pelvic Health Provider to close this gap. Taught by live instructor via Zoom, this one day remote course covers:

• Medications used for the treatment of pelvic floor and genitourinary conditions
• Common side effects of medications routinely used for pelvic floor dysfunction
• Medications for constipation and GI dysfunction
• Medications for pelvic pain conditions including vulvodynia, chronic prostatitis, and endometriosis
• Medications and side effects in gender-affirming care for patients who are transitioning
• Drug interactions and non-pharmacologic alternatives for pelvic and reproductive health
• Communicating effectively with referral sources and primary care providers about medications

Because the course is remote, registrants can attend solo from home or the clinic, with no partner or lab group required. The material is also a strong review for clinicians preparing for the Pelvic Rehabilitation Practitioner Certification (PRPC) exam, where pharmacology is one of the tested domains.

References

1. Araklitis G, Thiagamoorthy G, Hunter J, Rantell A, Robinson D, Cardozo L. Anticholinergic prescription: are healthcare professionals the real burden? Int Urogynecol J. 2017;28(8):1249–1256. https://doi.org/10.1007/s00192-016-3258-3

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How Widespread Is Pelvic Floor Dysfunction?

Pelvic floor dysfunction is one of the most common and least treated conditions in health care. In the landmark national prevalence study, 23.7 percent of United States women, nearly 1 in 4, had at least one symptomatic pelvic floor disorder, and prevalence climbed with age to roughly half of women 80 years and older.¹ The burden is growing: the number of American women with at least one pelvic floor disorder is projected to rise from 28.1 million in 2010 to 43.8 million by 2050.²

The need does not stop with adult women. Men experience pelvic pain, urinary and bowel dysfunction, and post-surgical pelvic floor issues, and research suggests as many as 1 in 7 school-aged children struggle with some form of pelvic floor dysfunction, including constipation, daytime and nighttime incontinence, and voiding dysfunction.³ The pelvic floor plays a vital role in supporting the bladder, bowel, and reproductive organs, and when these muscles do not function properly, symptoms such as urinary incontinence, pelvic pain, painful intercourse, and pelvic organ prolapse can significantly affect quality of life at any age.

Why Does Clinician Training Matter So Much?

Clinician training matters because the provider shortage is severe. According to the American Physical Therapy Association's Academy of Pelvic Health, fewer than 10,000 pelvic health providers exist nationwide to serve an estimated 40 million or more Americans affected by pelvic floor conditions.⁴ Patients routinely face months-long waits, incorrect referrals, or advice to simply live with their symptoms. Every clinician who adds pelvic health training to their practice directly expands access to care in their community.

Awareness campaigns work: when public understanding of pelvic floor dysfunction grows, more patients recognize their symptoms and seek help. That makes Awareness Month a double call to action for the profession, because a wave of newly aware patients needs somewhere to go.

What Can Clinicians Do During Awareness Month?

• Screen for pelvic floor symptoms in your existing caseload. Patients with low back, hip, or sacroiliac pain, postpartum patients, and older adults frequently have unreported pelvic floor involvement.
• Normalize the conversation. Patients often will not raise leakage, pelvic pain, or pain with intimacy unless a clinician asks directly and without judgment.
• Know your referral pathways to trained pelvic health providers in your area, and be the clinician who connects patients to care instead of another dead end.
• Consider becoming the resource yourself. Specialized pelvic health training is a defined, achievable pathway, and demand for trained providers far outstrips supply.

How Can Clinicians Start Building Pelvic Health Skills?

The entry point to pelvic rehabilitation practice is Pelvic Function Level 1 from the Herman & Wallace Pelvic Rehabilitation Institute, a foundational course in evaluating and treating the pelvic floor that requires no prior pelvic health experience. Upcoming Pelvic Function Level 1 courses include:

Pelvic Function Level 1 - Cape Cod, Massachusetts - September 19-20, 2026
Pelvic Function Level 1 - Coral Gables, Florida - September 19-20, 2026
Pelvic Function Level 1 - Chicago, Illinois - September 19-20, 2026
Pelvic Function Level 1 - San Luis Obispo, California - September 19-20, 2026
Pelvic Function Level 1 - Mission Hills, California - September 19-20, 2026

References

1. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008. https://pubmed.ncbi.nlm.nih.gov/18799443/

2. Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor disorders in U.S. women: 2010 to 2050. Obstet Gynecol. 2009. https://pubmed.ncbi.nlm.nih.gov/19935030/

3. Prevalence of urinary incontinence and lower urinary tract symptoms in school-age children. 2014. https://pubmed.ncbi.nlm.nih.gov/25015605/

4. Academy of Pelvic Health Physical Therapy, American Physical Therapy Association. https://www.aptapelvichealth.org

What Is Dry Needling in Pelvic Health?

Dry needling in pelvic health is the use of thin filiform needles by licensed rehabilitation clinicians to treat the pelvic floor musculature and its associated neuroanatomical structures, including the lumbosacral spine, abdomen, pelvis, and hip joint complex. Pelvic health specialists use dry needling to address lumbopelvic pain, urinary incontinence, voiding dysfunction, and sexual pain or dysfunction, reaching tissue at depths and with a specificity that manual techniques cannot always achieve.

Why Does Dry Needling Belong in Pelvic Practice?

Dry needling belongs in pelvic practice because pelvic floor dysfunction rarely lives in the pelvic floor alone. The lumbosacral spine, abdomen, hips, and trunk all participate in the patterns that produce pelvic pain, urgency, leakage, and pain with intimacy, and dry needling allows the skilled clinician to treat both the pelvic floor musculature itself and the surrounding structures that keep dysfunction in place.

For clinicians already practicing orthopedic dry needling, the pelvic application is a natural and career-differentiating extension. For pelvic specialists who have not yet added needling to their practice, the Herman & Wallace series provides the anatomy review, safety framework, and supervised lab time to build genuine competence rather than familiarity.

What Does Each Course in the Series Cover?

Dry Needling and Pelvic Health: Foundational Concepts and Techniques is the entry point to the series. This lab intensive course teaches the application of dry needling to the female pelvic floor musculature and the associated structures of the lumbosacral spine, abdomen, pelvis, and hip joint complex, framed around the presentations pelvic providers see daily: lumbopelvic pain, incontinence, voiding dysfunction, and sexual pain or dysfunction.

Dry Needling and Pelvic Health Level 2: Advanced Concepts and Neuromodulation builds on that foundation for clinicians with prior dry needling experience. Participants advance to needling male and female pelvic floor musculature and structures across the thoracolumbar spine, trunk, abdomen, pelvis, and hip, and integrate neuromodulation concepts and techniques into clinical reasoning. The course combines pre-recorded lecture with two days of live labs, with a strong emphasis on safety, precautions, and clinical integration.

Dry Needling and Pelvic Health: Pregnancy and Postpartum Considerations addresses the perinatal population specifically. The course covers the physiologic changes of pregnancy and the neuromusculoskeletal conditions common to the pregnancy and postpartum periods, giving providers who treat perinatal patients a safe, evidence-informed framework for needling in this population.

Upcoming Dry Needling Courses in 2026

Dry Needling and Pelvic Health Level 2 - Houston, Texas - August 29-30, 2026
Dry Needling and Pelvic Health - Lubbock, Texas - September 26-27, 2026
Dry Needling and Pelvic Health: Pregnancy - Omaha, Nebraska - October 17-18, 2026
Dry Needling and Pelvic Health - Washington, DC - December 5-6, 2026
Dry Needling and Pelvic Health Level 2 - Seattle, Washington - December 11-13, 2026

About the Instructors

Tina Anderson, MS, PT is a physical therapist and educator practicing in Aspen, Colorado. She received her Master of Science in Physical Therapy from Grand Valley State University and owns and operates a private physical therapy practice.

Kelly Sammis, PT, OCS, CLT, AFDN-S is a physical therapist, board certified in orthopedics, with additional certifications in lymphedema, Pilates, pregnancy and postpartum corrective exercise, and advanced dry needling. She practices in Parker, Colorado and serves as lead faculty developing and teaching dry needling and pelvic health courses nationwide. Together, Tina and Kelly co-instruct the Herman & Wallace Pelvic Rehabilitation Institute dry needling series.