As a new pelvic health physical therapist, you’re quickly discovering how interconnected the body’s systems truly are. Pain, bowel and bladder function, sexual health, and emotional well-being are all influenced by factors that extend beyond the musculoskeletal system. One emerging area that deserves attention is nutrition - a key player in inflammation, gut health, and even pelvic floor muscle function.

Integrating nutrition awareness into your practice doesn’t mean stepping outside your professional scope. It means understanding how diet affects the systems you already treat and collaborating effectively with nutrition professionals to optimize patient outcomes.

Why Nutrition Belongs in Pelvic Rehab
The gut and pelvic organs share complex neural and biochemical communication pathways. When the gut is inflamed or imbalanced, this “viscerosomatic crosstalk” can alter pelvic floor tone, coordination, and reflex activity, potentially amplifying pain via musculoskeletal pathways (1). Gut microbiota also influences the production of short-chain fatty acids and other byproducts that affect intestinal permeability, immune signaling, and systemic inflammation, which are key mechanisms in central sensitization and pelvic pain (2).

Certain foods may act as direct irritants to sensitive pelvic tissues, like the bladder or vulvar mucosa, triggering burning, urgency, or pain flares. In addition, food sensitivities or intolerances (especially non-IgE–mediated types) can increase inflammation or disrupt digestion in ways that influence pelvic symptoms (3). Understanding these connections helps you appreciate why some patients experience symptom changes after dietary shifts, even if formal nutrition counseling is provided by a functional nutrition provider or other nutrition professional.

While research is still developing, clinical studies are strengthening the nutrition–pelvic pain link. A 2023 study found that individuals with both IBS and endometriosis who followed a low-FODMAP diet experienced significant reductions in pain and improvements in quality of life (4). These results support what many clinicians observe in practice: thoughtful dietary modification can complement pelvic floor therapy and reduce symptom burden.

Practical Ways to Integrate Nutrition Awareness
As a new clinician, you don’t need to “prescribe” diets, but you can begin building awareness, gathering relevant information, and partnering with nutrition professionals.

1. Ask About Diet and GI Symptoms
   Include food-related questions in your intake:

• “Have you noticed any foods that make your symptoms better or worse?”
• “Do you experience bloating, urgency, or pain after meals?”
• “Have you ever tried dietary changes to help with your symptoms?”

Even these simple questions open the door for meaningful discussion and collaborative problem-solving.

2. Recognize Patterns and Refer Appropriately
   If a patient reports consistent food-related flares, unexplained weight loss, GI bleeding, or restrictive eating behaviors, refer to a physician or nutrition professional specializing in gastrointestinal or pelvic health. Working as a team ensures patients get safe, targeted guidance.

3. Use Low-Risk Dietary Experiments
   Under supervision or as part of a multidisciplinary plan, patients can trial small, low-risk adjustments such as reducing bladder irritants (caffeine, alcohol, acidic foods) or following a structured elimination/reintroduction process guided by a dietitian or functional nutritionist. The key is tracking outcomes systematically using food/symptom diaries.

4. Reinforce Foundational Nutrition Principles
   Encourage balanced, anti-inflammatory dietary patterns: vegetables, fruits, lean proteins, fiber (if tolerated), and healthy fats. These broad principles align with general wellness recommendations and support tissue healing, hormonal regulation, and immune balance.

Building Your Competence as a New PT
Early-career clinicians often feel pressure to “know everything.” When it comes to nutrition, your role is not to diagnose or prescribe, but to:

• Recognize when food may be contributing to symptoms.
• Collaborate with nutrition professionals and physicians to ensure comprehensive care.
• Educate patients on body awareness, symptom tracking, and realistic expectations.

Courses like Nutrition Perspectives for Pelvic Rehab, scheduled next on December 6-7, 2025, by Megan Pribyl, PT, CMPT, offer an excellent foundation. This course introduces the science of nutrition’s impact on pelvic health and provides practical frameworks for integrating it into clinical reasoning without overstepping scope of practice.

For new pelvic rehab therapists, integrating nutrition awareness offers a powerful way to enhance patient care. Understanding the links between diet, gut health, inflammation, and pelvic pain helps you view each patient through a truly whole-body lens.

By asking informed questions, observing patterns, and collaborating across disciplines, you can empower patients to take an active role in their healing. When nutrition meets pelvic rehab, we move closer to comprehensive, compassionate, and evidence-informed pelvic health care.

References:

1. Zhou Q, Verne GN. Molecular Mechanisms and Pathways in Visceral Pain. Cells. 2025 Jul 25;14(15):1146. doi: 10.3390/cells14151146. PMID: 40801578; PMCID: PMC12345894.
2. Palma, G. D., Reed, D. E., & Bercik, P. (2023). Diet–microbial cross–talk underlying increased visceral perception. Gut Microbes, 15(1), 2166780. https://doi.org/10.1080/19490976.2023.2166780
3. Ren, H., Cao, B., Xu, Q., Zhao, R., Li, H., & Wei, B. (2025). Role of microbiota in pain: From bench to bedside. IMetaOmics, 2(1), e58. https://doi.org/10.1002/imo2.58
4. Varney JE, So D, Gibson PR, Rhys-Jones D, Lee YSJ, Fisher J, Moore JS, Ratner R, Morrison M, Burgell RE, Muir JG. Clinical Trial: Effect of a 28-Day Low FODMAP Diet on Gastrointestinal Symptoms Associated With Endometriosis (EndoFOD)-A Randomised, Controlled Crossover Feeding Study. Aliment Pharmacol Ther. 2025 Jun;61(12):1889-1903. doi: 10.1111/apt.70161. Epub 2025 May 4. PMID: 40319391; PMCID: PMC12107219.

Chronic pelvic pain often involves multiple intersecting systems - gynecologic, urologic, gastrointestinal, musculoskeletal, and neurological. An increasing body of research suggests diet may be an important, modifiable factor in many of these conditions.

Self-reported food sensitivities and dietary patterns are being explored in relation to symptoms like bladder pain, pelvic floor-related pain, vulvar pain, and bowel-related pelvic pain.

What the Research Shows
Recent studies and reviews are beginning to clarify how diet and food sensitivities relate to chronic pelvic pain. An umbrella review in 202 by Neri et al 5 found that a higher intake of vegetables and dairy products might reduce the risk and symptom severity of endometriosis.

Research on chronic primary pelvic pain syndromes (CPPPS), which includes interstitial cystitis/bladder pain syndrome (IC/BPS) and vulvodynia among others, emphasizes the multifactorial nature of these syndromes and suggests that diet may play a role, but the data are still inconclusive in many areas.

For IC/BPS, there are surveys and qualitative studies in which many patients report that certain foods or beverages (such as caffeine, acidic foods, alcohol, spicy foods) act as triggers. However, rigorous intervention trials (e.g., randomized controlled dietary interventions) are limited. The American Urological Association’s 2022 Guidelines do acknowledge dietary triggers in patient reports but do not prescribe specific elimination diets due to limited high-quality evidence.

In endometriosis, the umbrella review and some cohort studies suggest anti-inflammatory dietary patterns, increased fruit and vegetable intake, and possibly dairy consumption may correlate with lower pain or symptom burden. Yet the causal evidence (especially from randomized trials) remains sparse.

Regarding vulvodynia and vulvar pain, the research and literature is less developed. There are observational reports and case series that suggest some patients may benefit from dietary modifications, but strong clinical trials are nearly absent. Proteomics and biomarker studies in vulvar pain disorders are uncovering potential mechanisms, but do not yet conclusively link specific dietary interventions to symptom improvement.

Overlap with gastrointestinal disorders like IBS is well-documented among pelvic pain populations. When GI symptoms are prominent, interventions such as low-FODMAP diets have been shown in some studies (mostly observational or small trials) to reduce GI symptoms, which in turn may reduce pelvic floor complaints or pelvic pain by reducing visceral hypersensitivity or bowel dysfunction. However, even in this area, high-powered randomized controlled trials with pelvic pain outcomes as primary endpoints are limited.

From what is currently known, patient-reported dietary triggers are common across pelvic pain conditions, and many individuals report subjective improvement with dietary adjustments. The existing studies lend support to low-risk modifications, like avoiding known bladder irritants and adjusting diet when GI symptoms coexist. However, limitations include a lack of large randomized controlled trials with robust design comparing specific diets head-to-head for pelvic pain and heterogeneity in how pelvic pain conditions are defined & diagnosed. Some studies mix patients with different etiologies (bladder, bowel, muscular, nerve). Other issues are that comorbid conditions (IBS, fibromyalgia, psychological stress) are frequent and often not controlled for, and mechanistic data (microbiome changes, immune signaling, visceral cross-sensitization) are promising but mostly preliminary.

Mechanisms by Which Diet May Be Relevant
Several plausible biological and physiological pathways support the link between diet and chronic pelvic pain. Certain foods or substances may act as direct irritants to sensitive tissues like the bladder mucosa or vulvar skin/mucosa, which can cause burning, urgency, or pain flares.

Diet can influence the gut microbiota and the substances they produce, such as short-chain fatty acids and gases. These byproducts can affect intestinal permeability and alter systemic inflammatory or immune signaling, which in turn may modulate pain perception and contribute to sensitization. In some patients, non-IgE–mediated food intolerances or delayed hypersensitivity reactions to fermentable carbohydrates, additives, or specific food components may further drive these processes.

In addition, Viscerosomatic crosstalk provides another lens to understand diet’s impact on the pelvic floor. Dysfunction in organs such as the gut or bladder can send altered sensory signals to the nervous system, which in turn influences pelvic floor muscle tone, coordination, and reflex activity. This interplay means that gastrointestinal irritation from certain foods may not only trigger digestive discomfort but can also lead to changes in pelvic floor function. Over time, these altered neuromuscular responses may amplify pain through musculoskeletal pathways, creating a feedback loop that perpetuates both visceral and pelvic floor symptoms.

Practical Clinical Approach
Dietary sensitivity likely plays a role for many individuals with chronic pelvic pain, but the pattern is highly individual. As pelvic rehab providers, pelvic rehabilitation practitioners can support patients by validating concerns, initiating low-risk dietary trials, monitoring outcomes, and collaborating with dietitians for those cases that are more complex. When combined with pelvic floor rehabilitation and multimodal care, dietary approaches offer a promising route toward reducing pain and improving quality of life.

Given the current evidence, practitioners can use a patient-centered, low-risk approach to exploring diet’s role in pelvic pain.

1. Screen systematically. Collect detailed histories: what foods seem to trigger symptoms, timing (after meals, specific foods), associated GI symptoms, and any prior dietary experiments. Use food diaries or symptom trackers.
2. Identify red flags. Be alert for signs of serious pathology (e.g., GI bleeding, weight loss, malabsorption, celiac disease, severe allergies) and refer appropriately for medical evaluation or nutritional consultation.
3. Begin with simple diet trials. For example, remove or reduce common irritants (caffeine, alcohol, acidic or spicy foods), track symptoms over 2-6 weeks. If GI symptoms are present, consider a trial of low-FODMAP style elimination (with reintroduction phases) under dietitian supervision.
4. Elimination/rechallenge when indicated. If a patient reports a specific suspect (gluten, dairy, additive), a structured elimination followed by reintroduction can help confirm or rule out the trigger while minimizing unnecessary dietary restriction.
5. Promote anti-inflammatory whole-diet patterns. Emphasize vegetables, fruits, fiber (if tolerated), lean proteins, healthy fats, and minimally processed foods. Dietary patterns rather than single nutrients may be more achievable and sustainable.
6. Integrate other contributors. Diet doesn’t act in isolation. Combine dietary strategies with pelvic floor therapy, behavioral/pain education, sleep hygiene, psychological supports, and addressing comorbid conditions like IBS or mood disorders.

Exploring diet in the context of pelvic pain is not about chasing a single “trigger food,” but about understanding patterns, empowering patients, and integrating nutrition into a whole-person approach. By combining careful screening, individualized trials, and collaboration with nutrition professionals, pelvic rehab practitioners can help patients discover meaningful connections between food and symptoms—ultimately enhancing both symptom control and quality of life.

Learn More in Our Upcoming Course
If you'd like to deepen your understanding of nutrition’s role in pelvic pain and gain clinically actionable strategies, then register for Nutrition Perspectives for the Pelvic Rehab Therapist on either October 11–12, 2025, or December 5-6, 2025. This course is instructed by Megan Pribyl, PT, CMPT, CMTPT/DN, PCES, and covers the latest research, digestion basics, nutritional interventions for bowel/bladder dysfunction, pain, and healing, and includes immersive labs to help you apply what you learn in real clinical settings.

Additional dates in 2026 are available on the website.

References:

1. Neri LCL, Quintiero F, Fiorini S, Guglielmetti M, Ferraro OE, Tagliabue A, Gardella B, Ferraris C. Diet and Endometriosis: An Umbrella Review. 2025 Jun 13;14(12):2087. doi: 10.3390/foods14122087. PMID: 40565701; PMCID: PMC12192176
2. Pinto L, Soutinho M, Coutinho Fernandes M, et al. (December 01, 2024) Chronic Primary Pelvic Pain Syndromes in Women: A Comprehensive Review. Cureus 16(12): e74918. doi:10.7759/cureus.74918
3. Varney, J. E., So, D., Gibson, P. R., Rhys-Jones, D., Lee, Y. S. J., Fisher, J., Moore, J. S., Ratner, R., Morrison, M., & Burgell, R. E. (2025). Effect of a 28-day low FODMAP diet on gastrointestinal symptoms associated with endometriosis (EndoFOD): A randomised, controlled crossover feeding study. Alimentary Pharmacology & Therapeutics, 61(12), 1889-1903. https://doi.org/10.1111/apt.70161
4. Fehring, R. J., Schneider, M., Raviele, K. M., & Isaa, M. (2025). Dietary interventions in endometriosis: prospective study comparing low FODMAP diet and an “endometriosis diet.” [Details from the study]. Journal name, volume(issue), pages. (Note: This is “The effect of dietary interventions on pain and quality of life in women diagnosed with endometriosis: a prospective study with control group.”)
5. Jankovich, E., & Watkins, S. (2017). The low FODMAP diet reduced symptoms in a patient with endometriosis and IBS. South African Journal of Clinical Nutrition, 30(4), 32-36.
6. Drummond J, Ford D, Daniel S, Meyerink T. Vulvodynia and Irritable Bowel Syndrome Treated With an Elimination Diet: A Case Report. Integr Med (Encinitas). 2016 Aug;15(4):42-7. PMID: 27574494; PMCID: PMC4991650.

Rebuilding the Urge: Where to Start
Restoring bowel urgency is one of the most important portions of a bowel retraining program. When a patient no longer has a normal bowel movement urge due to prior postponing, the slowness of their system, chronic use of enemas, or idiopathic causation, helping the patient retore the natural bowel movement urge may be the immediate focus of the treatment.

Restoring defecatory urge is one of the first steps in the treatment process. Reviewing and understanding colon physiology and determining where the focus of treatment should start, especially in complex patients, is key. Synthesizing new treatment ideas and use of modalities to assist with colonic motility can be one of the first steps to help the patient improve their defecatory urge.

For complex cases, this can involve mapping out where motility is most compromised. Is it a problem of peristalsis? A nervous system misfire? Inflammation in the gut interfering with communication pathways? Or is it something else?

Here’s where innovative thinking and a comprehensive approach come into play.

Treatment Tools and Modalities to Restore Motility
There are many ways to support and enhance colonic motility and restore bowel urgency. These can include:

• Neuromuscular stimulation and biofeedback therapy: These help retrain the pelvic floor muscles and encourage a coordinated bowel response.
• Rectal balloon training: Assists in retraining muscle function and can also enhance patient confidence during bowel movements.
• Behavioral techniques and bowel habit training: Regular scheduling, posture optimization during defecation (hello, squatty potty!), and mindfulness around urges.
• Manual therapy and visceral mobilization: Often used by pelvic floor therapists to reduce adhesions or fascial restrictions.
• Abdominal massage and diaphragmatic breathing: Gentle but effective ways to stimulate internal movement and improve gut tone.

Gut Microbiota: The Missing Piece of the Puzzle
A healthy gut flora is essential to regular and urgent bowel movements. The microbiota helps regulate everything from stool consistency to inflammatory responses in the colon. A disrupted microbiome, such as one lacking microbial diversity or populated by too many pathogenic strains, can slow transit and dull natural urges.

Dietary diversity is key to nurturing a thriving gut ecosystem. Encouraging patients to consume the following foods can make a significant difference in restoring microbial balance and improving colon motility:

• Fiber-rich vegetables and fruits
• Fermented foods (like kefir, kimchi, sauerkraut)
• Resistant starches (like cooled potatoes or green bananas)
• Prebiotic foods (such as garlic, leeks, and onions)

Hormones and the Colon: An Overlooked Connection
Sex hormones, particularly estrogen and progesterone, have a notable impact on gut function. Many individuals report changes in bowel patterns during their menstrual cycle, and hormonal shifts during menopause or andropause can contribute to constipation or erratic bowel habits. Understanding this connection is essential when working with patients whose symptoms appear to cycle with their hormonal changes.

Hormonal imbalances or deficiencies may require a referral for endocrinological evaluation or functional medicine support, especially if gut symptoms persist despite other interventions.

What You'll Learn in the Bowel Pathology and Function Course
Bowel Pathology and Function is a remote course designed for healthcare providers looking to sharpen their skills and deepen their understanding of bowel function restoration. Through a mix of physiology review, clinical tools, and real-world strategies, participants will walk away with a clear plan for helping patients recover their natural urge to defecate.

This bowel course will help you identify where the focus of the patient’s treatment needs to be addressed. Getting to decide where their efforts should be focused and what part of the system seems to be slow or inefficient and helps the healthcare provider narrowing the treatment focus.

Session learning objectives include:

1. In-depth review of colon physiology – Understand the mechanics of motility, nervous system input, and the role of pressure gradients.
2. Use of supportive modalities – Learn how to employ tools like electrical stimulation, manual therapy, and breathwork to enhance gut movement.
3. Microbiota and diet strategies – Dive into microbial diversity and how to coach patients on food choices that support a healthy microbiome.
4. Sex steroids and gut health – Examine the influence of estrogen, progesterone, and testosterone on gut motility and bowel pattern changes.

Restoring bowel urgency isn’t just a digestive issue - it’s a quality-of-life issue. Whether you’re a clinician or a curious patient, understanding the full picture—from gut mechanics to hormones to microbes—can unlock powerful healing. And sometimes, it’s the “down and dirty” details that lead to the biggest breakthroughs. Join me June 7-8^th for Bowel Pathology and Function.

References:

Banibakhsh A, Sidhu D, Khan S, Haime H, Foster PA. Sex steroid metabolism and action in colon health and disease. J Steroid Biochem Mol Biol. 2023 Oct;233:106371. doi: 10.1016/j.jsbmb.2023.106371. Epub 2023 Jul 28. PMID: 37516405.

Barbara G, Barbaro MR, Marasco G, Cremon C. Chronic constipation: from pathophysiology to management. Minerva Gastroenterol (Torino). 2023 Jun;69(2):277-290. doi: 10.23736/S2724-5985.22.03335-6. Epub 2023 Feb 2. PMID: 36727654.

Seo M, Bae JH. [Nonpharmacologic Treatment of Chronic Constipation]. Korean J Gastroenterol. 2024 May 25;83(5):191-196. Korean. doi: 10.4166/kjg.2024.044. PMID: 38783620.

Scott SM, Simrén M, Farmer AD, Dinning PG, Carrington EV, Benninga MA, Burgell RE, Dimidi E, Fikree A, Ford AC, Fox M, Hoad CL, Knowles CH, Krogh K, Nugent K, Remes-Troche JM, Whelan K, Corsetti M. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Neurogastroenterol Motil. 2021 Jun;33(6):e14050. doi: 10.1111/nmo.14050. Epub 2020 Dec 2. PMID: 33263938.

Yang C, Hong Q, Wu T, Fan Y, Shen X, Dong X. Association between Dietary Intake of Live Microbes and Chronic Constipation in Adults. J Nutr. 2024 Feb;154(2):526-534. doi: 10.1016/j.tjnut.2023.11.032. Epub 2023 Dec 9. PMID: 38072155.

AUTHOR BIO
Lila Bartkowski-Abbate, PT, DPT, MS, OCS, WCS, PRPC

Lila Abbate, PT, DPT, MS, OCS, WCS, PRPC (she/her) is the Director/Owner of New Dimensions Physical Therapy with locations Roslyn, Long Island, and the Noho Section of New York City. Dr. Abbate graduated from Touro College in Dix Hills, NY with a Bachelor’s of Science (BS) in Health Sciences and a Masters of Arts (MA) in Physical Therapy in 1997. She completed her Advanced Masters in Manual Orthopedic Physical Therapy (MS) at Touro College, Bayshore, NY in 2003 and continued to pursue her Doctor of Physical Therapy (DPT) at Touro in 2005. Dr. Abbate is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She has obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) from Herman & Wallace Institute, 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012.

Dr. Abbate has been an educator for most of her physical therapy career. She has full-time faculty experience at Touro College, Manhattan Campus from 2002 to 2006 teaching the biomechanical approach to orthopedic dysfunction and therapeutic exercise as well as massage/soft tissue work that highlighted trigger point work, scar management, and myofascial release.

She is currently on faculty as a Lecturer at Columbia University teaching the private practice section Business & Management course (since 2016) along with the Pelvic Health elective (since 2012). She teaches nationally and internationally with the Herman & Wallace Pelvic Rehabilitation Institute teaching advanced courses of her own intellectual property: Orthopedic Assessment for the Pelvic Health Therapist, Bowel Pathology Function, Dysfunction and the Pelvic Floor, Coccydynia & Painful Sitting: Orthopedic Implications. She was a co-writer for the Pudendal Neuralgia course and teaches the Pelvic Floor Series of Pelvic Floor 1, 2A and 2B and Pregnancy, Postpartum. She has written two book chapters in 2016: Pelvic Pain Management by Valvoska and Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies by Chughtai.

She is a member of the American Physical Therapy Association, the National Vulvodynia Association, the American Urogynecology Association, and the International Pelvic Pain Society. Dr. Abbate is also a Senior Physical Therapy consultant for SI Bone, a sacroiliac joint instrumentation company.