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�PELVIC HEALTH PHYSICAL THERAPY FOR THE AGING POPULATION

JENNIFER FERNANDEZ, PT, DPT, OCS

CAPP-OB, CAPP-PH

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OBJECTIVES

Understand the importance of pelvic health in older adults
Explore pelvic floor dysfunctions in the geriatric population
Identify the role and scope of pelvic physical therapy
Review assessment and treatment strategies
Discuss case examples and clinical outcomes

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CASE SCENARIO

75 year old female presents to her primary MD appointment for her annual physical. Patient notes she is doing well and has ”normal” urine leakage 1-2x per day, but she wears a pad so she is okay. She does say she goes to the restroom every 30 min because she doesn’t want to have an accident and gets up at least 3 times per night to go pee.

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WHAT IS PHYSICAL THERAPY?

Defined by the American Physical Therapy Association

“Physical therapists are movement experts who improve quality of life through prescribed exercise, hands-on care, and patient education. Physical therapists teach patients how to prevent or manage their condition so that they will achieve long-term health benefits.”

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WHAT IS�PELVIC HEALTH PHYSICAL THERAPY?

Physical therapy for many with “abdominal and pelvic concerns of women, men and children: incontinence, pelvic/vaginal pain, prenatal and postpartum musculoskeletal pain, osteoporosis, rehabilitation following breast surgery, lower back pain, lymphedema, conditions specific to the female athlete, fibromyalgia, chronic pain, wellness and exercise.” (Section on Pelvic Health, an Academy of the American Physical Therapy Association)

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PELVIC PHYSICAL THERAPY TRAINING

Bachelor’s Degree (kinesiology or another life science)
Doctor of Physical Therapy program (3 years)
Additional training for Pelvic Floor PT

Residency program 1 year
Optional board-certified specialty exam (Women’s health Certified Specialist, WCS)
Or training courses through the APTA or Herman and Wallace

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PELVIC ANATOMY

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FUNCTION OF THE PELVIC FLOOR

Maintain pelvic organs place in space within our bodies

Bowel and bladder control

Activate and relax

Sexual function

Have a role in stability and posture (Hodges 2007)

Coordinate with respiration (Talasz 2011)

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WHY PELVIC HEALTH MATTERS IN THE GERIATRIC POPULATION

“Incontinence is a predictor of functional limitations and is associated with an increase in falls, which may result in injuries and mobility impairment” (Gorina et al 2014)
Studies have shown a relation between incontinence and declining mental health. As well as an association with increase falls (Gorina et al 2014)

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PREVALENCE OF PELVIC FLOOR DISORDER (PFD)

24% of all women in the US are affected by one or more Pelvic Floor disorders (NIH).
28.3% of those 60 years and older suffer from Overactive Bladder (OAB) (Zhang 2025)
“Of noninstitutionalized persons aged 65 and over 50.9% reported a urinary and/or accidental bowel leakage…”(Gorina et al 2014)
“In women older than 60, approximately 9% to 39% reported urinary incontinence on a daily basis.” (Leslie et al 2024)
“Urinary incontinence is reported in 11 to 34% of older men,” (Leslie et al 2024)

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PELVIC FLOOR DISORDERS IN GERIATRIC POPULATION

Urinary incontinence (UI)

Fecal incontinence (FI)

Pelvic organ prolapse (POP)

Constipation

Chronic pelvic pain

Sexual dysfunction

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INCONTINENCE

“Incontinence refers to the involuntary loss of bladder or bowel control.” (Gorina et al 2014)
Urinary Incontinence is involuntary leakage of urine (Leslie et al 2024)
Types of Urinary Incontinence

Urgency Urinary Incontinence (UUI)
Stress Urinary Incontinence (SUI)
Mixed Urinary Incontinence (MUI)
Functional Urinary Incontinence (FUI)

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RISK FACTORS FOR URINARY INCONTINENCE FOR WOMEN�

Age
Race/ethnicity
Number of Childbirths
Previous hysterectomy
Obesity/High BMI
Arthritis

Diabetes
Cognitive impairment
Smoking/COPD
Thyroid disease
Menopause
Hormone replacement

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OVERACTIVE BLADDER (OAB)

The definition of OAB comes from The International Consultation on Incontinence Research Society (ICI-RS 2014): “Overactive bladder syndrome is characterized by urinary urgency, with or without urgency urinary incontinence, usually with increased daytime frequency and nocturia, if there is no proven infection or other obvious pathology.”

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URINARY FREQUENCY

Normal frequency of urination is 4-8 times/day (Carriere 2006)

Going to the restroom approximately every 2-5 hours

Nighttime frequency (According to the CAPP-Pelvic Committee 2014)

0 to 1 per night <65 years old

1 to 2 per night >65 years old

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RISK FACTORS FOR OAB

Advanced age

Gender

Obesity

GI disease

Ethnicity

UTIs

(Zhang 2025)

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PELVIC ORGAN PROLAPSE

“POP is characterized by the descent of pelvic organs, including the bladder, uterus, rectum, or vaginal apex, into or beyond the vaginal canal due to weakening of the supporting muscles, fascia, and ligaments. (Kuo et al 2025).”

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RISKS FACTORS FOR POPS (WORD 2009)

Females
Vaginal Childbirth
Increasing age
Increased intra-abdominal pressure
High BMI
Connective tissue disorders (Ehlers-Danlos Syndrome)
Combination of any of the above

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CASE SCENARIO

75 year old female presents to her primary MD appointment for her annual physical. Patient notes she is doing well and has ”normal” urine leakage 1-2x per day, but she wears a pad so she is okay. She does say she goes to the restroom every 30 min because she doesn’t want to have an accident and gets up at least 3 times per night to go pee.

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THE ROLE OF PELVIC PT

With conservative measures such as patient education and therapeutic exercise we can help address the musculoskeletal sources that may be playing a role in the bladder and/or bowel symptoms a patient may be experience
Tools:

Urge suppression education
Bowel or Bladder diaries
Breathing techniques
Mindfulness
Pelvic Floor Muscle training

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PELVIC FLOOR EVALUATION

Subjective questions
Outcome measures (Pelvic Floor Disability Index (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7)).
Objective testing

External observation of genitalia area and surrounding areas
Internal Pelvic or Rectal exam
PERFECT Scale

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SUBJECTIVE EXAM

Bladder questions:

Did your bladder symptoms start suddenly or was it over time?
How often do you go to the bathroom during the day? At night?
When you go to the restroom do you strain to start going or strain to fully empty your bladder? Do you have any pain with peeing?
Do you have any leakage? If so, how often? How much do you leak?
Do you use pads? How many do you go through in a day?
Do you feel like anything is falling out?

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OBJECTIVE EXAM

ALWAYS obtain written and verbal consent before starting.
Lumbar AROM
Hip AROM and or PROM
Flexibility: hamstrings, hip flexors, piriformis, hip adductors, hip IRs and ERs
Strength: lower abdominals, glute med and max
Palpate: lower abdominal quadrants, lumbar paraspinals, piriformis, iliopsoas
Posture and breathing mechanics
Movement analysis

Gait, transitions, load transfers

Pelvic alignment

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TREATMENT

Treatment of LUTS in the geriatric patient can generally be divided into four categories (Hartigan et al 2019)

Behavioral modification

Physiotherapy

Pharmacologic therapy

Surgical intervention

“Geriatric patients may present with a wide spectrum of mental and physical disabilities which may complicate any presentation of [Lower Urinary Tract System] LUTS.” (Hartigan et al 2019)

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TREATMENT OPTIONS

Manual Therapy treatments

STM, MFR, cupping, wand, “ILU” massage

Stretches and exercises

Happy baby, child’s pose, PFM activation with different positions and protocols, Hamstring stretch, pigeon stretch, Clams, bridges, squats, down regulation, etc

Education

Urge suppression
Breathing exercises
Mindfulness
Circadian rhythms
Health and hygiene
Diet, fluid intake
Toilet posture

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BEHAVIOR MODIFICATIONS

Urge Suppression techniques

Postponing voiding
Breathing
Heel raises

Diet/Nutrition

Types of foods and fluids they are consuming
Time of day the drink fluids

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INSTRUCTION ON DIAPHRAGMATIC BREATHING

Belly: “First and most”
Chest: “Last and Least”
Hand over chest and just below the belly button
Once a patient can coordinate their breathing correctly they you can incorporate the breathing with the exercise

Exhale on exertion

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BLADDER DIARY

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STOOL DIARY

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BENEFITS OF PELVIC PHYSICAL THERAPY

CONSERVATIVE TREATMENT

LONG TERM BENEFITS

NO HARMFUL SIDE EFFECTS

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CASE SCENARIO

75 year old female presents to her primary MD appointment for her annual physical. Patient notes she is doing well and has ”normal” urine leakage 1-2x per day, but she wears a pad so she is okay. She does say she goes to the restroom every 30 min because she doesn’t want to have an accident and gets up at least 3 times per night to go pee.

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RESOURCES

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QUESTIONS?

jfernandez@apu.edu

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REFERENCES

American Physical Therapy Association.
Carriere B, Markel Feldt C. Storage and Emptying Disorders of the bladder. In: The Pelvic Floor. Stuttgart Germany: Georg Thieme Verlag; 2006.
Gorina Y, Schappert S, Bercovitz A, Elgaddal N, Kramarow E. Prevalence of incontinence among older Americans. Vital Health Stat 3. 2014 Jun;(36):1-33. PMID: 24964267.
Hartigan SM, Reynolds WS, Smith PP. Dilemmas in Management of the Geriatric Bladder. Curr Bladder Dysfunct Rep. 2019 Dec;14(4):272-279. doi: 10.1007/s11884-019-00541-8. Epub 2019 Nov 13. PMID: 33312324; PMCID: PMC7731875.
Hodges PW, Sapsford R, Pengel LH. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362-71. doi: 10.1002/nau.20232. PMID: 17304528.
Kuo CH, Martingano DJ, Mikes BA. Pelvic Organ Prolapse. [Updated 2025 Sep 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563229/
Leslie SW, Tran LN, Puckett Y. Urinary Incontinence. [Updated 2024 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559095/
McAuley, J. Adrienne PT, DPT, MEd1; Mahoney, Amanda T. PT, DPT2; Austin, Mary M. PT, DPT3. Clinical Practice Guidelines: Rehabilitation Interventions for Urgency Urinary Incontinence, Urinary Urgency, and/or Urinary Frequency in Adult Women. Journal of Women's & Pelvic Health Physical Therapy ():10.1097/JWH.0000000000000286, August 21, 2023. | DOI: 10.1097/JWH.0000000000000286
Nüssler E, Granåsen G, Bixo M, Löfgren M. Long-term outcome after routine surgery for pelvic organ prolapse-A national register-based cohort study. Int Urogynecol J. 2022 Jul;33(7):1863-1873. doi: 10.1007/s00192-022-05156-y. Epub 2022 Mar 21. PMID: 35312802; PMCID: PMC9270303.

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REFERENCES

Pal M, Chowdhury RR, Bandyopadhyay S. Urge suppression and modified fluid consumption in the management of female overactive bladder symptoms. Urol Ann. 2021 Jul-Sep;13(3):263-267. doi: 10.4103/UA.UA_52_20. Epub 2021 Jul 14. PMID: 34421262; PMCID: PMC8343280
Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A. Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing-a dynamic MRI investigation in healthy females. Int Urogynecol J. 2011 Jan;22(1):61-8. doi: 10.1007/s00192-010-1240-z. Epub 2010 Aug 31. PMID: 20809211.
Word RA, Pathi S, Schaffer JI. Pathophysiology of pelvic organ prolapse. Obstet Gynecol Clin N Am. 2009; 36: 521-539.
Siracusa C, Mize L, Giglio S, Austin Mary M., Miracle E, Strauhal MJ, and Ziemba, M. Pelvic Health Physical Therapy Level 1: Lecture Manual. Academy of Pelvic Health of the American Physical Therapy Association, 2020.
Zhang, L., Cai, N., Mo, L. et al. Global Prevalence of Overactive Bladder: A Systematic Review and Meta-analysis. Int Urogynecol J 36, 1547–1566 (2025). https://doi.org/10.1007/s00192-024-06029-2

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