Expert Q&A: Making Pelvic Exams Less Painful

At Origin, we love to learn from legendary pelvic floor physical therapists and Ingrid Harm-Ernandes, PT, WCS, author of The Musculoskeletal Mystery: How To Solve Your Pelvic Floor Symptoms, falls squarely into that category.

Ingrid has been a pelvic floor physical therapist for 27 years. Much of her impressive career has been spent at Duke, where she helped start the first women's health physical therapy residency program in the United States. She now not only trains pelvic floor physical therapists and writes research papers, she also instructs providers who want to learn more about the pelvic floor and learn how they can support women’s pelvic health.

We were delighted to interview Ingid on critical topics including what to do if you find pelvic exams uncomfortable or painful, why it’s so easy to talk to pelvic floor PTs about the most intimate symptoms, and how you can help others by advocating for yourself. Check out a video excerpt or read the entire interview below.

Making pelvic exams more comfortable is a topic that’s close to your heart, isn’t it?

Yes, it is! I teach nurses and PAs and doctors how to do comfortable pelvic exams, and I counsel my patients on how to advocate for themselves during a pelvic exam. For years, I’ve heard so many patients say, "I don't want to go for a pelvic exam. It is so painful. I don't want anything to do with it."

Often, the provider is very focused on getting to the cervix. And when it comes to the vulva and vagina, it's like, well, we just have to get the speculum in there and move those things out of the way. Well, that, to me, is such an injustice to people who have to have vaginal exams, because those muscles — the pelvic floor muscles — play a major role in terms of what we can tolerate in order to have an exam.

For many people, just the anticipation of a pelvic exam can be anxiety producing.

When a person knows they have an exam coming up and they’re worried about pain, their pelvic floor muscles tighten further, making the exam even more uncomfortable, this causes more pain and more tightness creating a snowball effect. The anxiety will actually cause the muscles to get tighter.

And if they speak up about their pain and a provider just pats them on the shoulder and says, "You'll be okay, honey," it makes it even worse — because now it's like, "Well, you just think I'm making this up."

What can we do to make pelvic exams more comfortable?

There are lots of things we can do. I counsel patients on everything from relaxation and breathing techniques and muscle stretching. Then, when they’re ready to have an exam, I say "Okay, now here's another job for you: You need to talk to your practitioner first. You can blame it on me and say, 'My physical therapist told me that I need to breathe first, that you need to breathe first. We need to take it slow and I need, as the patient, to be able to guide the speed of the exam and the degree of the exam.”

I know it can be hard to advocate for yourself, but you have to do it. And it’s not just going to benefit you — it’s going to help the next person walking in the door.

Why is it that, when you talk to even the most health-focused people, so many still don't know that they have a pelvic floor?

For years, the conversation around women's health has been so limited. It was okay to talk about breast health. It was okay to talk about pregnancy. But it wasn't okay to talk about ‘down there.’ People aren't willing to say vagina or vulva. Healthcare providers themselves might not be comfortable bringing the subject up. So if the patient's not comfortable with bringing it up, they don't talk about it.

We really need to normalize the conversation — not just the problems, but the conversation. If we normalize the conversation, then everybody benefits from it. And pelvic floor PTs are perfectly poised to do that because we talk about this area of the body all day long.

It would be so helpful if we all checked in with a pelvic floor PT every year.

I have always said, from the moment I started being a pelvic PT, I wish I had every 18 year old come into the clinic so we could do an assessment. So I’d have a chance to say "this is what's going on for you, this is what you need to do — or you're good to go." And the same goes for pregnancy, postpartum, and menopause.

I think that’s where we need to head with pelvic floor PT — toward this open relationship throughout a person’s lifespan. So patients know what they need to do at every stage to prevent problems later on. If we can do a good job working with our patients throughout their life, I think we can really help people minimize risk.

Unfortunately, getting people to engage in preventative care can be a challenge.

Yes, so educating providers is critical. By training providers to do a musculoskeletal exam and look for symptoms, it gives them the opportunity to say "You should go to pelvic PT."

So, there's balance — the patient does need to be an advocate for their pelvic health, but we also need to grow the knowledge base of all these practitioners, including family medicine, OBGYN, urogynecology, urology… I even talk to mental health experts to have them recognize pelvic floor issues. I'm going to talk at a dental office to show them that things like teeth fracture, bruxating, clenching your teeth often has a strong relationship with pelvic floor problems.

What else do you wish all patients and providers knew about the pelvic floor?

I wish everyone knew that things like abdominal pain, back pain, hip pain can all be connected to the pelvic floor. People with these types of pain are at such high risk for pelvic floor problems. I teach providers that they can co-treat their patients with a pelvic floor physical therapist.

And I wish that every patient knew that they can ask their pelvic floor PT about any health issue. Even if it's something we can't treat, we can guide you to a medical practitioner who can help.

That’s another little-known role that a pelvic floor PT can play — they can help connect you to other providers.

I used to think that the physician was the hub of the wheel, and I was just out here as a spoke. And it was interesting that over time I was like, no, I'm here in the middle. After evaluating them as a whole-person and considering their whole body, I'm getting patients to dermatology, urogynecology, mental health, whatever they need.

Tell me more about the book you’ve written to help people take control of their pelvic health.

The Musculoskeletal Mystery: How To Solve Your Pelvic Floor Symptoms is written so that people understand when to get help with pelvic conditions, why their musculoskeletal system is involved, and what's going to happen in a pelvic PT session. The last chapter is devoted to self help tools to get them started.

I want to get people to the point where they feel, "I understand this, and when I go talk to my pelvic PT or I go talk to my other providers, I’ll feel comfortable." I want them to understand that there are tools to help them and we don’t have to be afraid to talk about it anymore. That's my dream.

Who should be reading your book?

If you have any pelvic symptoms — urinary incontinence, fecal incontinence, constipation, pelvic pain, hip pain, back pain, pain with sex, IBS, interstitial cystitis — I could go on. Also, if you've been diagnosed with pelvic floor dysfunction, but what you’ve tried so far isn’t helping, you’re not getting better, or it’s really slow going.

If you sense any of those symptoms, this book is for you because you are going to be able to read about all of this and feel very comfortable discussing it with your healthcare providers.

You might also read this book if someone you care about has symptoms or if you’re a provider who is interested in learning more about the pelvic floor. Lastly, it is also written for all practitioners so that everyone is speaking the same language and they can help patients get to care sooner.