Pelvic Floor Therapy for Endometriosis: What to Focus on Before and After Surgery.
The weeks before endometriosis surgery can feel overwhelming — filled with questions, fear, and a never-ending to-do list. Then, somewhere in the chaos, someone mentions your pelvic floor muscles. Wait… what are those? Are they causing some of my symptoms? Should I be doing something about them before surgery? These are very common and valid questions — and in this blog, we’ll gently explore the answers from the view point of a Pelvic Health Physiotherapist.
Pelvic Health Physiotherapy focuses on the assessment and treatment of the muscles, nerves, and tissues in and around the pelvis — while also considering how the whole body works together. It supports the function of pelvic organs like the bladder, uterus, and bowel, and often includes education around movement, posture, and lifestyle strategies. Physiotherapists in this field have completed additional training beyond their standard degree, with many choosing to specialise in areas such as pelvic pain, endometriosis, pregnancy, or postpartum care.
Understanding the connection between endometriosis and the pelvic floor muscles
The pelvic floor is a group of muscles that sit like a hammock at the base of your pelvis. These muscles support important organs like your bladder, uterus, and bowel, and they also help with functions like maintaining continence (bladder and bowel control), sexual activity, and supporting abdominal pressure.
In people with endometriosis, these muscles can become tight, overactive, or painful. This isn't because of direct endometriosis lesions on the pelvic floor itself, but more often due to how the body responds to persistent pain. For example, if you think about when a bird hurts it’s wing, it holds it close to protect it. For people who experience chronic pelvic pain, their muscles also guard, trying to protect the area.
When you're in pain- especially chronic pelvic pain- your body naturally starts to tense or guard. Over time, this guarding can become habitual, leading to a cycle of tension, pain, and dysfunction. To imagine how these muscles feel, hold your arm up above your head for a few minutes- does it feel tired? Maybe a little achey? Imagine your pelvic floor muscles holding on for a prolonged length of time, they also may feel the same.
Add in factors like:
Inflammation from endometriosis
Surgical trauma or scarring
Stress or anxiety (which also affect how we hold tension)
…and the pelvic floor can become part of the problem. This may be why you have heard people saying, some symptoms may be caused by the pelvic floor muscles, not all due to endometriosis.
Many people with endometriosis report symptoms like painful sex, general pelvic pain, difficulties emptying their bladder or bowels, and challenges when inserting or removing tampons. Lots of these symptoms can be due to the pelvic floor muscles.
That’s why pelvic health physiotherapy is often an important part of an endometriosis care plan — it helps retrain the muscles, and re-educate the brain, to let go of that chronic tension and support normal, comfortable function again.
What is Pelvic Floor Physiotherapy?
The pelvic floor is a muscle that people don’t often think about until there is a problem. When the muscles in this area become tight, or aren’t functioning as well as they could be, they can start to cause symptoms that many people with endometriosis experience.
Here are some common signs that might mean there is pelvic floor dysfunction:
Pain with penetrative sex or tampon use:
If you feel any sort of pain during intimacy or when inserting a tampon, it may not just be from endometriosis lesions — the pelvic floor muscles could be reacting too. In order to achieve penetration, these muscles need to relax, and if they don’t it can result in pain. This pain be sharp, dull, burning, or stinging in nature. It may also be vary in location, intensity, and duration.Pelvic aching:
An aching feeling in the lower belly or between your legs can be a sign that your muscles are fatigued or not coordinating properly.Trouble emptying your bladder or bowel:
Straining to wee, frequent urgency, constipation, or incomplete emptying may relate to how your pelvic floor muscles are contracting (or not relaxing) at the right time.Pain that lingers after surgery:
If you’ve had laparoscopic surgery and things haven’t settled — especially when it comes to pelvic pain — it may be muscular, not just inflammatory.Feeling “tight” or “tense” inside:
Some people describe it as a clenched fist deep in their pelvis or notice that they are always holding their tummy in or clenching their bottom cheeks.
These signs don’t mean you’re broken — they just mean your muscles might be overdoing their job. And just like any muscle in the body, the pelvic floor can learn to move better and relax, with the right education and guidance.
What Happens in a Pelvic Health Physiotherapy Session?
Understanding what to expect at your first pelvic floor physiotherapy session can go a long way in easing those “new appointment” nerves. Your physiotherapist will begin by warmly welcoming you and making sure you feel safe, comfortable, and heard.
The main goal of the first session is to learn about you — your symptoms, your goals, and how your pelvic health is affecting your life. You’ll be asked a range of questions, including:
Your experience with pain (including sex, bladder or bowel discomfort)
Bladder and bowel habits
Previous medical or surgical treatments you’ve tried
Your general health, stress levels, and any ongoing conditions
Social factors like work, relationships, sleep, hobbies, and movement
Your physio will summarise your story and reflect it back to you — to ensure everything important is captured — before offering tailored education. This might include:
How the pelvic floor muscles work
What we know about the nervous system and pain
Tips for improving sleep, movement, and daily comfort
The Physical Assessment
The physical component of the assessment is always discussed and agreed upon — and only happens if you’re ready and it’s clinically appropriate. It may be as simple as watching how you walk or move. Other times, your physio may use abdominal ultrasound to see how your bladder base moves, giving clues about how the pelvic floor is functioning.
In some cases, a digital vaginal examination may be offered (with full consent). This allows the physiotherapist to gently assess:
How the pelvic floor muscles contract and relax
Whether any areas feel tight, weak, or painful
How these muscles coordinate with the rest of your body
This type of assessment can be incredibly helpful, but it’s also invasive- and will only be done if you both agree it’s beneficial.
What Happens Next?
Based on what’s found, your physiotherapist may guide you through:
Gentle pelvic floor exercises or stretches
Breathwork to help relax and coordinate muscles
Advice on movement, posture, or pacing daily activities
Hands-on treatment to external or internal pelvic muscles
Education on strategies to optimise bladder and bowel function
This kind of pelvic floor physiotherapy for endometriosis is designed to empower you with knowledge, help reduce pain and tension, and support your body in preparation for or recovery from surgery.
How does Pelvic Floor Therapy Support Endometriosis Surgery Recovery?
Surgery can play an important role in managing endometriosis, but can continues after surgery. In fact, the weeks and months after surgery are a crucial window for healing, and this is one, of many places in an endometriosis journey, where pelvic floor physiotherapy for endometriosis can make a meaningful difference.
Before surgery, the pelvic floor may already be tense, overactive, or sensitive from time spent of guarding against pain. Surgery- while often necessary- can further irritate these muscles through inflammation, or changes in how you move and hold your body.
That’s why pelvic physio can be helpful both before and after surgery.
After surgery, Physiotherapy can:
Support muscle relaxation and coordination, especially if they’ve been in a protective state
Help you reconnect with your muscles and breath, which is important for healing
Improve scar mobility and reduce the risk of secondary pain from adhesions
Offer guidance on returning to movement, sex, and daily life with confidence
Address bladder or bowel issues that can sometimes emerge or worsen after surgery
Pelvic floor muscle training is not always about strengthening- it’s about restoring movement, comfort, and function in a part of the body that’s been through a lot.
FAQs About Pelvic Floor Therapy and Endometriosis
Does pelvic floor therapy help with endometriosis pain?
Yes — for many people, pelvic floor therapy can help reduce pain related to endometriosis. While it doesn’t treat the disease itself, it targets the muscle tension, sensitivity, and dysfunction that often develop as a result of chronic pelvic pain. This includes pain with sex, bladder or bowel issues, and ongoing discomfort after surgery. Pelvic Health Physiotherapy also looks at the whole body, including the nervous system, and optimises things such as sleep and movement, which help down regulate the nervous system. This can be useful in people with endometriosis or pelvic pain.
Is pelvic physio painful?
It shouldn’t be. A Pelvic Health Physio will always work gently and at your pace. Some discomfort can happen during assessment or treatment - especially if muscles are tight or sensitive- but it should never feel overwhelming. Everything is done with your consent, and you’re in control at all times.
Do I need a referral to see a pelvic health physio?
In most places, no referral is needed. You can book directly with a pelvic health physiotherapist. However, if you're going through the public system or claiming through a medicare chronic disease care plan, a referral might be required. It’s always worth checking with your GP.
How many sessions do I need?
It depends on your goals, symptoms, and how your body responds. Some people benefit from just a few sessions, while others may need ongoing support over several months. Your physio will work with you to create a plan that suits your needs, schedule, and finances.
Conclusion:
Pelvic floor therapy is one of the most gentle yet powerful tools in managing endometriosis-related pain. Whether you're navigating painful sex, bladder issues, or post-surgery tension, working with a pelvic health physio can help you feel more in control, connected, and comfortable in your body.