The Problem With Treating Pelvic Floor Diagnoses Like Protocols
This question I saw recently in a pelvic floor therapy group chat wasn't wrong, but it represents something I think healthcare gets wrong all the time… Someone had essentially asked:
“I've had an influx of patients with prolapse recently. What is everyone's protocol to get these patients better?”
And it got me thinking. Not because the person asking the question did anything wrong. They may be newer to pelvic floor physical therapy or are a student just beginning their knowledge on this area as we don’t get much if it in PT school (crazy, I KNOW). They may work in a healthcare system where appointments are short, productivity matters, and clinicians are expected to move quickly from diagnosis to treatment. Or maybe this is simply how they were taught to think about physical therapy.
But the question represents a bigger issue that I think is worth talking about:
PT can become so focused on the diagnosis that people start looking for the corresponding protocol.
And somewhere along the way, we can forget that there is an actual human being attached to that diagnosis.
A diagnosis is a starting point - not a treatment plan.
This is not me saying that protocols, clinical guidelines, or standardized approaches are inherently bad. They aren't.
There are plenty of situations in healthcare where having a defined protocol makes sense. A standardized rehabilitation progression after certain orthopedic surgeries, like a total knee or hip replacement, can provide useful structure and consistency. And pelvic floor physical therapy absolutely should be evidence-informed.
But there is a difference between using evidence to guide clinical reasoning and using a diagnosis to skip clinical reasoning altogether. Because two people can have the exact same diagnosis and need completely different things.
So if we use prolapse as the example here since that was the original person’s post…
One person may have recently had her first baby, notice pressure or heaviness, and be terrified that lifting weights or returning to CrossFit will make things worse.
Another person may have a similar diagnosis but couldn't care less about CrossFit. Her biggest concern might be being able to pick up her toddler without feeling downward pressure. She may also be struggling with constipation and straining.
Another person may have prolapse identified on an examination but little to no symptoms. Her primary concern might be understanding how this could affect a future pregnancy and what she can do to support her recovery and function moving forward.
Same diagnosis. Different person. Different goals. Different symptoms. Different priorities. Why would we assume they need the exact same treatment plan? Even clinical guidance for pelvic organ prolapse recognizes that management should take into account the individual's symptoms, preferences, lifestyle, goals, and other personal circumstances. Pelvic floor muscle training is an evidence-supported treatment for appropriate patients with symptomatic prolapse - but that does not mean every person with prolapse needs an identical exercise prescription.
And honestly, this applies to almost everything we do in pelvic floor physical therapy.
The same exercise can be part of completely different treatments.
This is something I think gets lost when we talk about individualized physical therapy. Individualized care does not always mean that every patient gets a completely different set of exercises. Two people may absolutely do the same squat-type exercise, but the difference is why they're doing it.
One person may be learning to tolerate loading again because she's become afraid of movement after developing pelvic symptoms.
Another may be rebuilding strength so she can return to lifting heavier weights.
Another may be working on coordinating her the ankle/foot and the hip/pelvic floor during a task that previously triggered symptoms.
Same squat. Different goal. Different focus. Different clinical reasoning.
The exercise itself is only one piece of the treatment. The why matters. The cueing matters. The dosage matters. The starting point matters. How we progress it matters. And perhaps most importantly, what the person actually wants to get back to doing matters. That's why I don't confuse an exercise with a treatment plan.
Your pelvic floor doesn't exist in isolation.
Another reason I don't believe in diagnosis-specific formulas is that the body doesn't operate in neat little diagnostic boxes. If someone comes to see me for prolapse, I'm obviously interested in what's happening with their pelvic floor. But I'm also very much interested in the bigger picture!
Depending on the person, that might include:
How they breathe and manage pressure during movement
How their abdominal wall and pelvic floor coordinate
What is happening around their ribs and trunk
How their hips and ankles/feet are contributing to movement and force absorption
How they tolerate and transfer load
Their bowel habits and whether straining or constipation is part of the picture
Their birth, surgical, or injury history
What symptoms they actually experience and when
Their current physical capacity and habits or patterns of movement
What activities they have stopped doing because of fear or symptoms
Their stress, recovery, and overall nervous system state
And, perhaps most importantly, what they want their body to be able to do
That doesn't mean every single one of these factors is causing someone's pelvic floor symptoms. And it certainly doesn't mean that every problem can be solved by “fixing” the rib cage, the hips, the feet, or the pelvic floor.
It means I don't want to assume I know what matters before I've actually assessed the person in front of me.
That's the difference.
Evidence should inform treatment - not replace clinical reasoning.
This is where I think the conversation around “protocols” gets particularly important, because I'm not anti-evidence. Quite the opposite actually! I care deeply about using research to inform how I practice. Pelvic floor muscle training has strong evidence behind it for conditions including urinary incontinence and can be an effective conservative treatment for folks with pelvic organ prolapse. But research tells us what tends to work across groups of people.
It doesn't eliminate the need to determine how that evidence applies to the individual sitting in front of you. Even when research supports a particular intervention, there can be meaningful differences in how that intervention is performed, progressed, cued, and combined with other strategies. And sometimes the evidence simply doesn't give us a neat answer, and that is just life. Clinical practice is not a multiple-choice test where every diagnosis has one correct treatment. Evidence gives us a map. Clinical reasoning helps us decide how to use it.
This is why I created Sonder.
This philosophy is a huge part of why I created Sonder Pelvic Therapy & Wellness. I wanted to create a practice where physical therapy could be more than a diagnosis, a handout, and a list of exercises. Where I could take the time to understand what someone is actually experiencing.
Where the question isn't just: “What's wrong?” but more so: “What do you want to be able to do?”
Because I don't have a “prolapse protocol” waiting for you before I meet you. I have evidence. I have clinical experience. I have a framework for assessing movement and function. And I have a lot of questions!
Then we figure out what actually makes sense for you. Because you are not an average research participant. You are not a diagnosis. And you shouldn't have to fit yourself into a protocol just because you happen to share a diagnosis with someone else. Good physical therapy isn't about finding the perfect protocol.
It's about knowing when to use a framework, when to adapt it, when to ask more questions, and when to recognize that the person in front of you needs something different. That's the kind of physical therapy I believe in. And that's the kind of care I built Sonder to provide.
Ready for a different kind of physical therapy?
If you're dealing with pelvic floor symptoms, navigating postpartum recovery, returning to exercise, or simply feel like you've been given a generic list of exercises without understanding why you're doing them, I'd love to help you figure out what actually makes sense for your body and your goals.
Want to better understand your core?
If your biggest goal is learning more about your core, pressure management, and how to build more intentional control and strength, The Midline Project was created to give you that deeper foundation.
It's not a replacement for individualized physical therapy, but it can help you move beyond random core exercises and understand the why behind what you're doing.
