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Pelvic Health Physiotherapy in Oncology: An Essential Pillar of Cancer Care and Survivorship

  • Apr 14
  • 6 min read

Gráinne Walsh Clinical Specilist in Pelvic Health


Cancer survival rates are improving significantly. In Ireland alone, there are now almost 200,000 people living with and beyond a cancer diagnosis, and that number continues to grow each year.[1] While this is cause for celebration, it brings with it an important and often overlooked challenge: the long-term physical consequences of cancer treatment, particularly on pelvic health. As physiotherapists, we have a vital and evidence-based role to play in addressing these consequences, yet pelvic health services remain significantly underutilised in oncology care pathways.

This post explores who needs pelvic health physiotherapy, why cancer treatment causes pelvic floor dysfunction, and what the evidence tells us about the impact of specialist intervention.


What Is Pelvic Health Physiotherapy?

The pelvic floor is a group of muscles, ligaments, and connective tissues forming a hammock-like base to the pelvis.[2] These structures support the bladder, bowel, uterus, and rectum, and play a critical role in urinary and bowel control, sexual function, and core stability. When this system is disrupted, the consequences can be profound and wide-ranging.

Pelvic health physiotherapy is a specialist area of practice focused on the assessment and treatment of pelvic floor dysfunction. In the oncology setting, it spans prehabilitation (preparing the body for treatment), active treatment support, and long-term survivorship care.[3]


How Does Cancer Treatment Affect the Pelvic Floor?

Cancer treatments, including surgery, radiotherapy, chemotherapy, and hormonal therapies, can all negatively impact pelvic floor function through a variety of mechanisms.[4]


Surgery

Surgical procedures, particularly radical prostatectomy, hysterectomy, and colorectal resection, can directly damage pelvic floor muscles, nerves, and supporting structures. Post-prostatectomy urinary incontinence (UI) is one of the most commonly reported consequences, significantly impacting quality of life.[5]


Radiotherapy

Radiation therapy causes fibrosis and shortening of muscles and connective tissues, reducing flexibility and altering normal function.[4] Research demonstrates significant effects on bladder, bowel, and sexual function following radiotherapy for gynaecological cancers, with outcomes affecting quality of life both during and well after treatment ends.[6]

Chemotherapy and Hormonal Therapy

Chemotherapy can adversely affect the bladder and urinary system.[4] Endocrine therapy and chemotherapy are also associated with indirect changes in pelvic floor tissues through hormonal suppression, contributing to the onset or aggravation of urinary incontinence, vaginal dryness, and sexual dysfunction.[7]


The Broader Picture: Breast Cancer

Pelvic floor dysfunction is not limited to gynaecological or urological cancers. Research confirms that women with breast cancer experience significant pelvic floor problems, including urinary incontinence (prevalence of ~38%), faecal incontinence (~18%), and sexual dysfunction in up to 70% of cases, largely related to endocrine and chemotherapy treatments.[7][8]


The Consequences: Why This Matters for Survivorship

The impact of pelvic floor dysfunction on cancer survivors is far-reaching. Qualitative research confirms that survivors experience these issues as a "whole other layer of difficulty," with pelvic floor problems significantly affecting their quality of life, relationships, social participation, and psychological wellbeing.[9]

Common presentations seen in oncology pelvic health physiotherapy include:

  • Urinary incontinence (stress, urge, or mixed)

  • Bowel dysfunction (incontinence, constipation, urgency)

  • Pelvic pain and musculoskeletal dysfunction

  • Sexual dysfunction (dyspareunia, reduced arousal, vaginismus)

  • Vaginal dryness and stenosis (particularly post-radiotherapy)

  • Lymphoedema

  • Scar tissue and fascial restrictions

  • Fatigue and deconditioning[10]

Despite being common and significantly distressing, many patients suffer in silence, often unaware that effective, evidence-based treatment exists.[4]


What Does the Evidence Say?

The evidence base for pelvic health physiotherapy in oncology is growing rapidly and is compelling.


Urinary Incontinence

Pelvic Floor Muscle Training (PFMT) has demonstrated significant improvement in urinary incontinence in cancer survivors across multiple studies. A systematic review and meta-analysis found that PFMT can improve stress urinary incontinence after prostatectomy by up to 2.77 times compared to control groups.[11] Pre-operative PFMT in men prior to radical prostatectomy has also been shown to improve post-surgical pelvic floor muscle function and reduce incontinence compared to controls.[12] In gynaecological cancer survivors, physiotherapy-led interventions including PFMT and behavioural therapy resulted in 80% of treated patients reporting their urinary incontinence as "much better" or "very much better."[13]


Sexual Function and Quality of Life

Low-to-moderate quality evidence supports the effectiveness of PFMT and dilator therapy in improving sexual function and quality of life in cervical cancer survivors.[14] A structured 4-week pelvic floor rehabilitation programme for gynaecological cancer patients demonstrated significant improvements in pelvic floor strength and quality of life compared to controls, with mean pelvic floor strength differences reaching statistical significance.[15]


Radiation-Related Dysfunction

PFMT combined with dilator use is an important component of rehabilitation for pelvic floor dysfunction following radiotherapy for gynaecological cancers, addressing vaginal stenosis, pain, and sexual dysfunction.[6] Recent research also confirms that telerehabilitation-delivered pelvic health physiotherapy significantly reduced urinary incontinence, pelvic pain, and dyspareunia in women following treatment for gynaecological cancer.[16]


Pelvic Pain

Non-invasive pelvic floor rehabilitation is an effective tool for treating pelvic floor-related pain and its associated symptoms in cancer patients.[17]


The Role of Prehabilitation

One of the most exciting developments in oncology physiotherapy is the concept of prehabilitation: intervening before cancer treatment begins to prepare the body and minimise treatment-related dysfunction.

Evidence supports the use of pre-operative PFMT in men scheduled for radical prostatectomy, with research showing that pre-treatment pelvic floor exercise, combined with aerobic and resistance training, leads to better functional recovery and continence outcomes post-surgery.[18] For women undergoing radiotherapy for gynaecological cancers, pre-treatment PFMT has shown potential to maintain pelvic floor muscle strength and prevent incontinence during and after treatment.[19]

The International Continence Society (ICS) recognises prehabilitation as a key component of pelvic health physiotherapy in women affected by cancer.[10]


A Holistic Approach to Care

Pelvic health physiotherapy in oncology extends well beyond pelvic floor exercises. The ICS emphasises that comprehensive physiotherapy management in this population should include:

  • Pain education and neuroscience-informed approaches

  • Bladder and bowel retraining

  • Manual therapy to address pelvic floor over- or under-activity

  • Dilator therapy to manage vaginal stenosis

  • Lymphatic drainage and lymphoedema management

  • Nutritional guidance, sleep hygiene, and lifestyle modification

  • Guided relaxation, mindfulness, and psychological support strategies

  • Graded exercise and cardiovascular rehabilitation[10]

This holistic, whole-person approach is fundamental to effective oncology pelvic health care. As MD Anderson Cancer Center emphasises, pelvic floor physiotherapy is "best when it is holistic... taking into consideration partners and not working in silos, considering the whole mind-body machine."[4]


Who Should Be Referred?

Pelvic health physiotherapy is appropriate for patients across the oncology continuum, including those with:

  • Gynaecological cancers (ovarian, cervical, uterine, vaginal, vulvar)

  • Colorectal cancer

  • Prostate cancer

  • Bladder cancer

  • Breast cancer (due to hormonal and chemotherapy effects)

Referral should be considered at any stage: before treatment begins (prehabilitation), during active treatment, or at any point in survivorship.[3] In Ireland, the cancerrehabilitation.ie framework, developed with funding from the Irish Cancer Society and the National Cancer Control Programme, recognises pelvic floor rehabilitation as a core component of physiotherapy in cancer care.[1]


Addressing the Barriers: Breaking the Silence

A significant barrier to accessing pelvic health services is the stigma and shame many patients feel around discussing pelvic symptoms. As one specialist notes: "A lot of patients feel like they're suffering in silence or they're the only human on earth experiencing the problems they have, because we've put so much shame around our pelvises."[4]

As physiotherapists and allied health professionals, we have a responsibility to proactively ask about pelvic health symptoms in our oncology patients. The evidence is clear: these symptoms are common, they are treatable, and effective conservative management exists.[10]


Conclusion

Pelvic health physiotherapy is not a niche add-on to oncology care. It is an evidence-based, patient-centred, and clinically essential component of cancer rehabilitation and survivorship. With Ireland's cancer survivor population growing, now is the time to champion the integration of pelvic health services into every oncology care pathway.

If you are a cancer survivor experiencing bladder, bowel, or sexual health difficulties, or a clinician caring for people living with and beyond cancer, please reach out. Specialist pelvic health physiotherapy can make a profound difference to quality of life, dignity, and long-term wellbeing.


References

[1] Personalised Exercise Rehabilitation in Cancer Survivorship  https://cancerrehabilitation.ie/cancer-rehabilitation-and-survivorship/

[5] Construction of pelvic floor muscle rehabilitation training ...  https://tcr.amegroups.org/article/view/61050/html

[6] Rehabilitation of pelvic floor dysfunction after radiation therapy ...  https://pmc.ncbi.nlm.nih.gov/articles/PMC11550129/

[7] Effectiveness of Pelvic Floor Muscle and Education-based ...  https://link.springer.com/article/10.1007/s11912-024-01633-3

[8] Experiences of pelvic floor dysfunction and treatment in ... - PMC  https://pmc.ncbi.nlm.nih.gov/articles/PMC9255500/

[9] Patient and clinician experiences of pelvic floor dysfunction ...  https://www.ics.org/2021/abstract/509

[10] W16: Pelvic Health in Women Affected by Cancer  https://www.ics.org/Workshops/HandoutFiles/000683.pdf

[11] The therapeutic effect of pelvic floor muscle training on stress ...  https://pmc.ncbi.nlm.nih.gov/articles/PMC10406533/

[12] a randomized controlled trial of the impacts on pelvic floor ...  https://link.springer.com/article/10.1186/s12894-019-0546-5

[13] Physiotherapy interventions in the treatment of pelvic floor ...  https://www.sciencedirect.com/science/article/pii/S2468784723001551

[14] Effectiveness of Pelvic Floor Muscle and Education-Based ...  https://pmc.ncbi.nlm.nih.gov/articles/PMC11579103/

[15] Effect of a pelvic floor muscle training program on ...  https://www.gynecologiconcology-online.net/article/S0090-8258(12)00239-9/abstract

[16] Telerehabilitation reduced urinary incontinence, pelvic ...  https://www.sciencedirect.com/science/article/pii/S183695532500150X

[17] Non-Invasive Pelvic Floor Rehabilitation in Cancer Population  https://pmc.ncbi.nlm.nih.gov/articles/PMC11851868/

[18] Pelvic floor rehabilitation before radical prostatectomy - PMC  https://pmc.ncbi.nlm.nih.gov/articles/PMC12403351/

[19] The Impact of Pre-Treatment Nurse-Led Pelvic Floor ...  https://www.internationaljournalofcaringsciences.org/docs/43.lochana.pdf

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