Unlike Dr. Nassar, practitioners of pelvic floor physical therapy always wear gloves, which prevent infections but also make patients more comfortable. They manipulate muscles to release and elongate those that are tense and shortened or to strengthen weakened muscles. They often assign patients exercises to do at home.
“There is nothing sexual about it,” said Rhonda Kotarinos, a physical therapist in Chicago who specializes in the pelvic floor and is an author of several studies on the therapy.
She, like many other practitioners, now worries that women with pelvic problems who could benefit from the treatment will be reluctant to seek help for fear of being abused.
“There could be a backlash from this,” Dr. Kotarinos said. “But if people decide physical therapists should not do this work, a lot of women will suffer with pain and a markedly compromised quality of life.” (Men also develop chronic pelvic pain that can benefit from the treatment, but in that case massage is typically performed through the anus.)
Many cases of muscle-based pelvic pain remain undiagnosed or under-treated, experts say, and patients often turn to medication or surgery instead of first trying more conservative approaches like physical therapy.
“Much of the general public doesn’t realize what we as physical therapists have to offer them,” said Lori Mize, director of education for the section on women’s health of the American Physical Therapy Association and an assistant professor of physical therapy at Lynchburg College in Virginia.
Some patients who come to a physical therapist will say they aren’t comfortable with transvaginal manipulation, and therapists say they utilize it only if the patient both understands what’s involved and freely consents. Furthermore, they generally offer it only after other interventions have failed.
Karen Connor, a physical therapist also with University Hospitals in Cleveland, said she uses three-dimensional anatomical models of the pelvis to explain to patients what’s entailed.
“I’ve had patients who say, ‘I’m just not ready for it yet,’” Dr. Connor said. “I say ‘that’s fine, we can work on hip weakness and tightness in the back, and that can impact the pelvic floor.’ The patient is always in control.”
Dr. Kotarinos helped design the protocol for trials comparing pelvic floor physical therapy to other treatments. She is one of the authors of a 2013 study, published in the Journal of Urology, that randomly assigned 81 women with pelvic floor tenderness and painful bladder syndrome to either 10 sessions of pelvic floor physical therapy involving targeted internal and external muscle manipulation or 10 sessions of full body massage.
Women who received the targeted pelvic floor therapy were more likely to respond to therapy, with 59 percent experiencing improvement in symptoms compared with 26 percent in the full body massage group, though both groups saw easing of pain and urinary problems. (A limitation of these studies is that patients cannot be “blinded” to their form of treatment, which can influence results.)
Another small study by Dr. Mahajan that examined patient charts from her clinical center found pain scores improved after patients started getting pelvic floor physical therapy and improvement increased in direct proportion to the number of sessions patients had. Of the 75 patients whose cases were examined, 63 percent reported significant pain improvement.
Though many women develop pelvic problems after childbirth or later in life, Dr. Mahajan said gymnasts are prone to pelvic floor problems because they land hard and slam on to the floor repeatedly. She said it was “not inconceivable” the therapy might be appropriate for them under certain circumstances.
But several physical therapists said they would suggest the therapy to girls under 18 only as a “last resort” in extreme cases of severe injury, and once other treatments had failed. And it should always be done with safeguards in place.
“I use this every day in my own practice,” Dr. Mahajan said, “but it’s always with gloves, by a female therapist, with consent, and supervised. When they’re in my office, we have a chaperone. These safeguards must be in place.”
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