The Growing Concern and Knowledge Gaps in Pelvic Floor Dysfunction in Women

Many women will experience pelvic floor dysfunction in their lifetime, but awareness and treatment access are lagging.

By Harleigh Markowitz

In March 2024, influencer, entrepreneur, and former professional athlete Brittany Mahomes shared an important message about women’s health to her two million Instagram followers. “Just a daily reminder: Once you have kids, please take care of your pelvic floor,” Mahomes wrote on her Instagram story. This post prompted renewed conversations about women’s health and pelvic floor dysfunction, shining a light on a problem that affects millions of women around the world. 

The pelvic floor refers to a group of muscles, nerves, and connective tissue located at the base of the pelvis. The pelvic floor spans from the pubic bone to the tailbone in a hammock-like shape and supports the bladder, large intestine, rectum, and reproductive organs. The pelvic floor functions differently depending on an individual’s sex, but the general functions of the pelvic floor remain the same: controlling bowel and bladder function, supporting the pelvic organs, and promoting sexual function.

Pelvic floor dysfunction (PFD) is an umbrella term that refers to a broad range of symptoms and conditions associated with the pelvic floor. The most common types of pelvic floor disorders include urinary incontinence, or the loss of bladder control; fecal incontinence, or the loss of control over bowel movements; pelvic floor prolapse, or the descent of pelvic floor organs from their normal position; and chronic pelvic pain. Pelvic floor dysfunction is caused by injury or weakening of the pelvic floor muscles due to pregnancy and childbirth, aging, obesity, menopause, sexual trauma, surgery, and connective tissue disorders. Pelvic floor dysfunction is more common among women, although both men and women can experience weakening or injury to the pelvic floor. 

Pelvic floor dysfunction and the associated symptoms have been found to greatly diminish an individual’s quality of life. A 2023 study published in Frontiers in Public Health found that women with pelvic floor disorders report a worse perceived quality of life in regards to their physical, psychological, social, and emotional well-being. Despite its relatively high prevalence and capacity to significantly impact women’s quality of life, pelvic floor dysfunction remains underdiagnosed, poorly understood and stigmatized, despite its high prevalence and capacity to significantly impact women’s quality of life. Limited access to treatment, particularly among historically marginalized communities, suggests pelvic floor dysfunction is not just a gender-based health disparity — it’s a public health concern. 

Pelvic floor dysfunction is a common condition among women, despite the general lack of awareness and understanding of the condition. In fact, approximately one-third of adult women experience symptoms related to the weakening of the pelvic floor, according to a 2022 study published in Nature. Still, it is estimated that less than 50% of women seek medical care for issues related to the pelvic floor. This is likely due to a lack of understanding of the condition by both patients and clinicians, patients’ perceived stigma or embarrassment, or mistaken beliefs that their symptoms are a normal part of aging.

“Pelvic floor dysfunction is poorly recognized, poorly understood, and poorly diagnosed by many physicians,” says Dr. Jennifer Sobol, a urologist at Michigan Institute of Urology and Medical Director of REDEEM Sexual Wellness & Aesthetics Center in Birmingham, Michigan. 

Symptoms of pelvic floor dysfunction such as pelvic pain and incontinence are often misdiagnosed when healthcare providers are unaware or unfamiliar with pelvic floor disorders. They may mislabel them as gastrointestinal or other urological conditions with overlapping symptoms, such as irritable bowel syndrome (IBS), urinary tract infections (UTI), interstitial cystitis, and endometriosis. These misdiagnoses ultimately lead to unnecessary suffering, prolonged discomfort, and delayed treatment.

“It’s amazing how many people come to see me for a wide range of issues and it turns out it’s their pelvic floor that’s causing the problem,” says Dr. Sobol. “I’m always shocked when I see patients who have been struggling for years, and as soon as I examine them, I see that the issue is with their pelvic floor and send them to physical therapy.”

Pelvic floor physical therapy (PFPT) is generally the first line of treatment for pelvic floor dysfunction. Pelvic floor physical therapy is a specialized type of physical therapy that aims to reduce pelvic pain, strengthen and support the pelvic floor muscles, and improve bowel, bladder, and sexual function. PFPT can involve exercises to strengthen the core and pelvic floor muscles, biofeedback to understand individual patient’s pelvic floor muscle activity, manual therapies such as trigger point therapy and myofascial release, and patient education on pelvic floor anatomy and physiology. Surgical treatments are also an option for individuals with more severe pelvic floor disorders, in addition to non-surgical treatments for pelvic floor dysfunction, such as pelvic floor physical therapy, medications like muscle relaxants, and certain lifestyle modifications. These procedures include incontinence surgeries to improve bowel and bladder control and surgical repairs of pelvic prolapse.

Pelvic floor physical therapy has been found to be highly effective in strengthening the pelvic floor muscles and improving patients’ quality of life, according to an article published in Clinical Interventions in Aging. However, many patients face significant barriers to acquiring this type of treatment such as availability of providers and gaps in insurance coverage.

“There’s more demand than there is availability for pelvic floor physical therapy,” says Dr. Rebecca Jacobson, an obstetrician-gynecologist at Endeavor Health in Chicago. “Most women that I refer to pelvic floor physical therapy report that it takes them a good three or four weeks to even get in to see a pelvic floor therapist because there’s a pretty high demand and not enough providers.”

For many women, geographic proximity to pelvic floor providers is a substantial barrier to treatment. In 2024, a group of researchers at Oregon Health & Science University analyzed 31,754 zip codes in the continental United States to estimate the geographic availability of urogynecologic services and providers, including pelvic floor physical therapists. The results, published in the journal Urogynecology, showed that only 2.47% of zip codes had at least one pelvic floor physical therapist. Another study published in the journal Physical Therapy found that half of the its participants had to drive at least twenty miles for pelvic floor physical therapy visits.

The shift to telehealth appointments during the COVID-19 pandemic offers a potential solution to geographic barriers to pelvic floor physical therapy. Sessions involving patient education sessions and pelvic floor exercises can be conducted over telehealth platforms, though some treatment models, such as those involving manual therapies and biofeedback, require in-person visits. In fact, patients attending telehealth pelvic floor physical therapy appointments in the years 2019 and 2020 had a significantly higher attendance rate compared to in-person appointments, according to a studyconducted at the University of California, Irvine, and the University of Illinois at Chicago. An increase in the availability of telehealth pelvic floor physical therapy offerings may allow for increased access to care for individuals who face geographic barriers to attending appointments. 

Insurance coverage and affordability, however, remain a significant obstacle to receiving pelvic floor physical therapy and similar treatments for pelvic floor dysfunction. A survey administered to over 150 adult women diagnosed with pelvic floor dysfunction revealed that financial constraints and affordability were the primary barriers to treatment for over half of respondents. Similarly, a study published in the American Journal of Gynecology and Obstetrics found that women who were enrolled in Medicaid or were uninsured were less likely to participate in pelvic floor physical therapy than those with Medicare or private insurance.

Despite barriers to treatment, pelvic floor dysfunction is emerging as a growing area of concern due to advancements in research, media coverage, and increased public discourse. Public figures, such as Mahomes, actress and comedian Ilana Glazer, and social media influencer Sara Reardon, are discussing their own experiences with pelvic floor dysfunction, normalizing the condition amongst women of all ages. More women may feel empowered to seek care and regain control of their pelvic floor health with continued dialogue and innovative ways to improve access to treatment.