Pelvic floor rehabilitation is a discipline that goes well beyond simple “exercises”. It is a multifactorial and multidisciplinary approach, aimed at restoring functional abilities to a vital anatomical area, responsible for essential functions and for sexual pleasure. We discuss it with Sabina Pelizzari, physical therapist specializing in abdominal-pelvic rehabilitation.

Dr. Pelizzari, many people associate the pelvic floor only with pregnancy or minor age-related problems. What is the reality?

“The pelvic floor is one of the most important compartments of our body. Suffice it to say that, without its proper functioning, basic activities such as urinating or defecating would be impossible. And it is a fundamental anatomical area at all ages: it can be a cause of very common symptoms, such as episodes of urinary incontinence or constipation, and even of idiopathic infertility, as well as of abacterial cystitis or the worsening of prolapse. Perineal well-being is also central in the postpartum period and in menopause, but it also plays a fundamental role in both female and male sexuality. Unfortunately, there is still no real knowledge about the pelvic floor: many patients live for years with pain or dysfunction, being told that ‘it’s normal’ or that the problem is psychological. It happened to me too, 24 years ago, after the birth of my first daughter. At the time, no one talked about it. Today, thanks to the work of many people, there is more awareness and, above all, there is scientific knowledge that has led to a specialist pathway guided by the expert physical therapist”.

Is rehabilitation “just” a matter of doing exercises?

“Absolutely not. Pelvic exercises are only a small part. Rehabilitating means first of all restoring an ability. The pathway begins with awareness-building: many people do not know where this musculature is or how to control it. We use visualization techniques, breath control and the management of intra-abdominal pressure. In addition to therapeutic exercise, we use physical therapies such as electrical stimulation, radiofrequency, electroporation and manual therapy to treat pain and stiffness. The ultimate goal is automation: the patient must learn to manage their own body in everyday life without having to think about it constantly”.

What are the most common everyday behaviors that can become risk factors?

“There are habits that seem trivial but are very harmful. For example, the ‘just-in-case pee’, that is, urinating without the urge before going out, gives wrong input to the bladder and to the control system. Or the way of hydrating: drinking a liter of water all in one go creates an overload without any real benefit. Posture in the bathroom is also crucial: pushing excessively or sitting on the toilet for a long time, perhaps looking at your phone, increases the risk of prolapse and pain. I often tell my patients that if being in the bathroom is a way to take some time for themselves and is an important moment, they should continue to do so, but sitting on the closed lid”.

Can the choice of footwear also directly influence pelvic floor health?

“This is a fundamental point that patients often overlook. The foot is our base of support: if we place the foot one way rather than another, the entire alignment of the pelvis changes and, consequently, the load on the pelvic floor changes. There is no absolute ‘good’ or ‘bad’, but each shoe produces a different effect. Those who habitually wear 10-cm heels, for example, shift their center of gravity forward, creating a very anteriorized perineal impact; over time, this alignment can predispose more to incontinence problems. On the contrary, those who always wear very low or flat shoes, such as classic ballet flats or slides, can develop tensions that are reflected in the back and in the posterior pelvic compartment, contributing to pain or constipation. Among men too the picture does not change: a worker’s rigid safety shoe or a professional’s loafer influence posture differently from a cushioned sneaker. In our clinical assessment, observing how a patient walks or how they get up from the couch is a priority”.

So does the physical therapist also have to “rehabilitate” the way people dress or stand?

“Above all, we need to make the patient aware. I would never tell a woman who loves heels not to wear them anymore, nor tell a worker to change shoes if they are mandatory for safety. The physical therapist’s task is to restore the ability to perform the sporting or work movement. If a warehouse worker who has had prostate surgery has to lift loads, we cannot tell him to change jobs; we have to teach him to manage the pressures inside the abdomen without negatively impacting his perineum”.

Before starting any treatment, how is the diagnosis made?

“The medical diagnosis is up to the specialist — gynecologist or urologist — but our physical therapy assessment is the pillar on which rehabilitation is based. We do not look only at the little piece: we analyze all habits, as mentioned, including sexual habits, the use of sex toys, lifestyle, sport. The assessment is thorough: we explain that we have two diaphragms, we start from the abdomen, we test the stiffness of the perineum and then move on to the internal and external examination of the musculature, probing sensitivity, reflexes and the presence of pain. We even observe how the patient enters the room and sits down: posture, foot placement and footwear, as we were saying, already tell us a great deal about the load the pelvic floor is subjected to. It is important to emphasize that the specialized physical therapist is the only professional legally qualified to perform pelvic rehabilitation, especially if we are talking about rehabilitation with the instrumental therapy we discussed earlier”.

Let’s talk about intimate longevity and sex education. We often consider it a topic for teenagers, but you argue that it is necessary at every age. Why?

“Because there is no real sex education, let alone for adults. Think of the postpartum period or menopause: no one explains to a woman that it is normal to have different lubrication or greater muscle laxity or stiffness. The same applies to men: premature ejaculation, for example, is often experienced as a resigned normality, but it profoundly undermines self-esteem and the couple’s relationship. For men, pelvic dysfunction undermines their deep identity. Many go as far as telling their partner to find another companion because they no longer feel like ‘men’. When we explain to them that with re-education they can regain control, everything changes: functional recovery becomes recovery of self-esteem. Male longevity requires awareness that intimate well-being does not end between 55 and 70. Educating means explaining that the body changes, that one cannot expect to have sex as at 20, and that new tools are needed: from proper communication between partners to knowing how the pelvic muscle influences pleasure. It makes no sense not to make the most of this compartment just because we do not know it. But this aspect is still experienced as a taboo”.

Within SoLongevity, there is the FemGevity project, a very in-depth pathway on women’s health. How does physical therapy fit into this vision of female longevity?

“As mentioned, in perimenopause and post-menopause physiological changes occur that can lead to pelvic pain. In these cases, various types of therapies can be used, such as radiofrequency or electroporation, which allows substances — such as hyaluronic acid or hormones — established with the physician to penetrate directly into the mucosa, for tissue hydration and regeneration. We then combine specific breathing exercises, muscle activation and relaxation exercises and postural control exercises, in addition to manipulation”.

In conclusion, what is the message for those who think that certain problems are simply part of aging?

“That ‘aging’ does not always mean ‘inevitable decline’. Whether it is a woman in menopause or a man who has had prostate surgery, pain during intercourse or small involuntary leaks, abdominal-pelvic rehabilitation can restore an optimal quality of life. Breaking down the taboo of pelvic health is the key to allowing men and women to age in the best possible way. We must stop being ashamed, start talking about it more freely and consider the pelvic floor as a precious ally for our health and our daily well-being”.