What Is a Pelvic Floor OT? Scope, ADLs, and the OT Approach
OTs in Pelvic Health Podcast · 22 min listen
Most people have heard of a pelvic floor PT. Far fewer have heard of a pelvic floor OT, which leads to the question I get asked more than any other: can OTs even do this work?
"It all comes down to your approach, not your credentials."
Yes. And the answer isn't about carving out territory from physical therapy. There is no skill PTs have that OTs can't acquire, and none OTs have that PTs can't. It's skill acquisition and desire.
What makes an OT's approach distinct is the lens: the whole person, in their actual life, doing the things that matter to them. And pelvic health happens to sit squarely inside what OTs already do, because toileting and intimacy are activities of daily living.
In this episode:
- What a pelvic floor OT actually does, and why the role is defined by approach rather than credentials
- The three jobs of the pelvic floor, and why two of them happen behind closed doors
- The ADLs of pelvic health, and how habits, roles and routines show up in symptoms
- A client story: 30 years of holding it, and what changed in four weeks
- The objection some PTs raise about OTs in this field, and how to answer it
What is a pelvic floor OT?
Definition
A pelvic floor OT is an occupational therapist who treats pelvic floor dysfunction as a problem of daily living rather than only a problem of muscle function. Because toileting and sexual activity are named as activities of daily living in the OT Practice Framework, pelvic health sits within OT scope of practice. The work looks at the whole person — physical, emotional, mental and spiritual — along with their habits, roles, routines, relationships and environment, and how all of those shape the symptom.
There is no single road to becoming one. Specialized learning mostly happens after graduation, for all of us, and both OTs and PTs arrive in pelvic health from wildly varied backgrounds. That's part of what makes the care rich and individualized. It's also part of why nobody can agree on what a pelvic health session looks like — it can involve internal work or external work, and there isn't even a settled definition of that.
What becoming one should not look like is an OT walking around in a PT's clothing. Or, for that matter, a PT walking around in an OT's.
The three jobs of the pelvic floor
1
Elimination
Keeping it in when it isn't time to go, and letting it out completely when it is.
2
Intimacy
Participating in whatever intimate act you choose, having it be pleasurable, and being able to experience orgasm.
3
Support
Holding up the organs in the pelvis, and everything above them. Thanks to gravity, the pelvic floor supports the viscera in the abdomen, the heart and lungs, and a ten-pound skull. That's a big job.
Two of those three happen behind closed doors. And when an activity happens in secrecy, we never get the chance to learn what normal looks like.
Think about it. Have you ever asked a friend whether they push a little to get their urine stream started? Or mentioned that it hurts when you and your partner start fooling around, and asked whether that happens to them?
No. Not even with our closest friends.
The myths that silence creates
So people never find out some basic things.
MythIt's normal to push to start or stop your urine stream.
ActuallyIt isn't optimal to use effort either way.
MythGo whenever you get the chance.
ActuallyRoughly once every two to four hours is the target. "Just in case" peeing disrupts the communication between bladder and brain.
MythSome discomfort during intimacy is part of it.
ActuallyIntimacy of every kind should never hurt.
These are the kinds of myths we'll keep busting on this podcast.
Learn with me for free
Start where every pelvic health OT starts, with a free AOTA-approved CEU class. Take either one, or both.
New to pelvic health?
The OT Practitioner's Role in Pelvic Health
Where pelvic health sits in OT scope of practice, plus simple interventions you can use with clients tomorrow.
Free · 1 hour · 0.1 AOTA CEU
Sign up for freeWondering where it fits in your setting?
The OT's Guide to Pelvic Health Practice Settings
Nine settings where OTs are already doing this work, from hospitals and SNFs to living rooms and L&D units. No private practice required.
Free · 1 hour · 0.1 AOTA CEU
Sign up for freeThe ADLs of pelvic health
So what are we actually looking at in a session?
The most obvious one is toileting. How someone urinates, how they have a bowel movement, and what that experience is like for them. Elimination is one of the pelvic floor's main jobs, so how they do it matters — whether they can't get it out completely, or it comes out before they're ready. It's a hugely under-discussed part of ADLs, and it falls squarely within a pelvic floor OT's purview.
From there we look at:
- Habits, roles and routines as they relate to toileting and sexual function
- The psychosocial picture: relationships, jobs, environments, and how all of those interact
- The physical: OTs are trained in manual muscle testing and rehabilitation too
And crucially, we're trained to notice when focusing on the physiological dysfunction is itself creating more stress and anxiety. OTs bring a strong background in sensory approaches and in working with trauma, and in pelvic health that matters enormously.
Thirty years of holding it
We would be doing our clients a disservice if we didn't look at habits, roles and routines. In my practice it's often a huge part of what's driving someone's incontinence. There may well be a muscular component — hypertonicity, hypotonicity, something that needs addressing. But sometimes it really is as simple as what someone has been doing every day for decades.
From the clinic
I had a client with urge incontinence. She was a teacher, and before that she'd been a nurse. In both careers, her time was never her own — she couldn't just pop into the bathroom when she wanted to. Over an eight-hour shift she was lucky to go once, occasionally twice.
The recommendation is once every two to four hours. When someone goes far longer than that, the stretch receptors in the bladder get stretched out. They become less sensitive to the perception of filling, so the reflex that travels up the spinal cord to say time to find a bathroom stops firing when it should.
After years of this, she'd arrived at a vicious cycle. She wasn't getting an urge until around the six-hour mark, and when it came it was intense. It was compounded by the fact that she wasn't drinking during the day either — which makes sense, if you know you don't have reliable bathroom access. But withholding fluid concentrates the urine, making it more acidic and more irritating to the delicate lining of the bladder wall. So the urges got more intense still.
We put her on a bladder schedule. At first she had to go once every four hours, which felt extreme and unnecessary to her, and over a few weeks we brought it down closer to three. What that gave her body was a chance to rebuild its perception of what needing to go actually feels like. It normalized the communication between brain and bladder.
After about four weeks, her urge incontinence was gone entirely. For someone with a thirty-year career of doing the opposite, I'd call that pretty amazing.
That's what looking at habits, roles and routines means in practice.
"Should OTs really be doing this?"
It's no secret that some PTs think OTs don't belong in this area. I've talked with them to understand why, and the objection I hear most often is a specific one: concerns about our ability to conduct an orthopedic lumbopelvic assessment and differential diagnosis across the hip, thorax, lumbar spine and SIJ.
It's a fair thing to raise. Plenty of OTs don't feel comfortable with those assessments, because many OT programs don't cover them in depth.
I have two answers.
First, most of us learn our skills outside of school anyway. If that's a skill set an OT wants, there are any number of courses available.
Second, we can refer out for anything we don't feel confident assessing. Many of us are glad to work collaboratively with chiropractors, PTs, osteopaths, and whoever else we've built a referral relationship with.
"It takes a village to help our clients."
Get to know the other pelvic floor professionals and bodyworkers in your area, whether or not they look like direct competition. Cross-referring keeps the client's interest at the center, and isn't that why we became rehab professionals? Sometimes it isn't even about skill set — it's about personality fit, and I refer out to competent colleagues for that reason too.
There are more clients who need this kind of rehab than there are of us. There is room for everyone. OTs and PTs work side by side in every other area of rehab, and the need for us to collaborate here is just as great — maybe greater, given how sensitive and taboo this area still is.
The general public's understanding of pelvic floor function, and of how profoundly it's shaped by the whole body and the whole person, is still poor. The more of us spreading that message, the better.
