Why pelvic floor physical therapy for leakage, prolapse, and perimenopause looks very different in 2026 (and what that means for active women)
I love seeing repeat patients.
Not because something went wrong.
But because life happened.
Another pregnancy.
Kids are older and suddenly you have 45 minutes to yourself again.
You’re diving headfirst into perimenopause and wondering why your body feels… different.
Or maybe three years ago there was a lot to do and pelvic floor PT slid quietly off the priority wagon.
Recently, I was lucky enough to see a woman I’d treated three years ago. The goal was to get back to herself again, and one of my favorite parts of this job is helping women return to their recreational sport — soccer, ultimate, curling (yes, really), sword fighting (also really), a 5K fun run. That said, life got to life-ing and after a few visits, it wasn’t the right time to keep coming.
Getting back to the thing that makes you feel like yourself again? That’s not small.
That’s identity.
Not being able to be yourself? We shouldn’t have to give up on that, no matter how many grenades life throws at us.
The Pelvic Floor Isn’t a Block of Concrete
Here’s some fun stuff that happened in the meantime since I first saw that patient…
There’s A LOT we’ve misunderstood for a long time about the pelvic floor.
We’ve hyper-focused on the pelvic floor muscles — strength, kegels, squeeze harder, hold longer.
But structurally and functionally, your pelvic floor works with:
- Fascia
- Ligaments
- The vaginal wall
- Connective tissue support systems
Together, they create dynamic support to maintain continence and organ support.
It’s actually a simple pressure equation:
- If pressure below > pressure above → usually no symptoms
- If pressure above > pressure below → leakage or pelvic pressure
That’s it.
But here’s where it gets interesting.
In 2024, Marie-Ève Bérubé and colleagues published research showing that after a run:
- The levator hiatus (the opening) is larger
- The bladder neck sits lower
- The levator plate length is longer (aka the pelvic floor)
And this happened in runners with and without running-induced stress urinary incontinence.
Translation?
Your pelvic floor changes shape after running.
That’s normal.
It’s not supposed to function like a brick. It’s meant to be dynamic.
So when someone tells you to “just kegel before you jump,” it tells me they don’t understand how the pelvic floor actually works.
When you run or jump, your brain anticipates the impact and automatically activates your system. Mid-air, it decreases activation. On landing, it increases again.
You cannot consciously time that and you sure as hell can’t think that fast.
Anyone suggesting you can is asking your brain to override a anticipatory activation and reflex loop that fires faster than you can think.
Sometimes It’s Not About Strength. It’s About Support.
With this returning patient, we knew there were coordination and timing issues. Impact activities like hopping reliably caused leakage. We KNEW strength wasn’t the issue so kegels weren’t on the menu.
So we tried something that wasn’t even part of my skillset three years ago.
A pessary.
Think of it as an orthotic for your pelvis.
Before fitting, I had her hop in place.
Five or six hops in? Leak.
I assessed her pelvic floor, measured for a simple ring pessary, checked the fit, and had her try again.
She stopped at 30 hops…because she was tired…NO LEAKS!
We removed it to confirm.
Five hops.
Leak.
Sometimes clinical reasoning really is that clear. She didn’t have enough support or coordination. We added support, it was enough to address the symptoms.
Now the plan is straightforward:
- Order her personal pessary
- Ensure she can insert and remove it independently
- Add vaginal estrogen for tissue health support
- Shift focus to lingering hip/back discomfort
- Progress cardiovascular capacity and recreational sports to get back to feeling like herself again.
Because once your pelvic floor symptoms are no longer the barrier, everything else becomes possible.
What This Means for Perimenopause and “Vintage” Moms
I’m seeing more and more women my vintage (aka we have kids in middle school, high school or even college).
When we had babies, pelvic floor PT barely existed. If you went, it was often:
“You had a baby. You’re weak. Let’s get you stronger. Here are your kegels. Good luck.”
Maybe they worked.
Maybe they didn’t.
Maybe they partially helped and you quietly blamed yourself for not doing enough.
Now you’re in perimenopause and symptoms are back — or they never fully left.
Here’s the truth:
We’ve learned a lot.
Not just in 10 years.
In the last 3.
In the last 6 months.
Pelvic floor physical therapy for stress urinary incontinence, pelvic pressure, and return to running in perimenopause looks very different today than it did in 2019, even 2023.
Understanding normal pelvic floor morphology changes with impact allows us to choose better solutions because we understand the WHY more than ever.
Sometimes it’s strength (it’s usually not).
Sometimes it’s coordination.
Sometimes it’s tissue support.
Sometimes it’s external support like a pessary.
Often, it’s a combination.
But it’s almost never just “only do more kegels.”
If You Tried Pelvic Floor PT Before…
And it didn’t work…
Or it kind of worked…
Or you stopped going because life got loud…
Or you blamed yourself for not being consistent enough…
Enough of the guilt trips.
You’re not broken.
You might just be operating on outdated information.
I love when past clients come back because I get to look at them with new eyes and new tools. The science evolves. My skillset evolves. The options expand.
And sometimes it really is that simple.
Does this sound like you?
If you’re in the DC/Arlington area, I focus on complex and second-opinion pelvic floor cases for active women and perimenopausal athletes.
Not local? I offer virtual consults and collaborate with colleagues nationwide.
It might be worth another look.
Because returning to your sport — your run, your league, your fun — isn’t just about exercise.
It’s about getting yourself back.
Email me directly: carrie@carriepagliano.com
