Exploring the Education and Practice Experiences of Pelvic Health Physiotherapists in Canada: A Qualitative Descriptive Study

Abstract

Purpose: Pelvic health physiotherapy involves sensitive practices including internal assessment and treatment of the pelvic floor. Pelvic health physiotherapy education is not standardized in Canada, which may lead to diverse experiences. The purpose of this study was to explore the education and practice experiences of pelvic health physiotherapists in Canada. Method: This descriptive qualitative study used semi-structured interviews with physiotherapists providing pelvic health services in Canada and a reflexive thematic analysis approach. Results: Based on interviews with 20 pelvic health physiotherapists (19 women and one man) from six provinces, we identified four themes: the right fit, managing vulnerability, the holistic nature of pelvic health physiotherapy, and entering pelvic health physiotherapy requires thoughtful consideration. Participants described pelvic health physiotherapy as the right fit for themselves personally and professionally. The clinical practice involved managing their patients’ and their own vulnerability and taking a holistic and biopsychosocial approach to treating patients with pelvic health conditions. Participants described the importance of mentorship and a supportive clinical environment when entering the field. Conclusions: This study provides an understanding of pelvic health physiotherapists’ experiences, which can help to guide the advancement of pelvic health physiotherapy education and practice supports in Canada.

Pelvic health conditions such as incontinence and pelvic pain affect people throughout their lifespan.^{1, 2, 3} Estimated to affect up to 45% of adult women and 34% of older adult men, pelvic health conditions can lead to reduced health-related quality of life, and place a significant financial burden on the health care system.^1,3 The prevalence of some conditions such as incontinence increase with age, thus, their negative personal and societal impacts are expected to magnify in the coming decades with the aging population.³

Pelvic health physiotherapy (PHPT) offers effective conservative care for people with pelvic health conditions through the use of targeted strategies such as education, behavioural techniques, exercise, and manual therapy.^4,5 A significant difference between PHPT and other physiotherapy fields is the use of internal (per vaginum or per rectum) pelvic floor assessment and treatment techniques. Given the intimate nature of the pelvic region and the knowledge and skills that extend beyond those required of new graduate physiotherapy generalists, PHPT is considered an advanced practice.⁶ As such, teaching internal pelvic floor techniques is not required for entry-to-practice physiotherapy programmes in Canada.⁷ Therefore, to practise PHPT, physiotherapists often seek post-graduate training.⁸ This training is typically delivered through courses that span one or more weekends and cover specific conditions or populations (e.g., pelvic pain, perinatal care, or urinary incontinence in females).^9,10 Since PHPT post-graduate education is not standardized in Canada, physiotherapists can access any number of these courses at different frequencies and stages of their careers. The potential variability in education experiences may result in diverse experiences and challenges associated with entering and practising in the field; however, few studies have explored these experiences.

Two qualitative studies conducted in Australia examined barriers and facilitators to delivering pelvic floor muscle training interventions for patients with urinary incontinence and men having a radical prostatectomy.^11,12 These studies highlight the various contextual factors and levels of support needed to facilitate PHPT practice, including practitioners’ own knowledge, skills, and clinical reasoning abilities, their access to education and mentorship, and administrative and practice supports from the clinical setting.^11,12 However, they do not provide insight into the holistic experiences of pelvic health physiotherapists since they focus on only one of many treatment options enacted by these practitioners.

One qualitative and one quantitative study of American physiotherapists who treat women with chronic pelvic pain¹³ and patients with sexual health concerns,¹⁴ respectively, provide evidence of the complexity and uniqueness associated with PHPT clinical practice due to its intimate nature,¹³ including challenges associated with discussing sensitive subjects with patients when entry-to-practice training does not develop this skill.¹⁴ These studies focussed on specific clinical populations, which still leaves a gap in our understanding of the experiences of physiotherapists who care for patients of different sexes or genders with a variety of pelvic health conditions, and whose experiences may differ because of these factors. Furthermore, it is unknown whether these findings are transferable to the Canadian context since physiotherapy practice and entry-to-practice education are regionally regulated.

To date, no studies have been conducted to explore the experiences of pelvic health physiotherapists in Canada. Understanding their experiences will help to identify education and practice supports needed to promote high-quality PHPT care in Canada, which is important to meet the growing needs of the population. Therefore, the aim of this study was to explore the education and practice experiences of physiotherapists providing pelvic health services in Canada.

Methods

Design

We adopted a descriptive qualitative approach since it is a flexible methodology that is well suited for understanding health care environments from the perspectives of those who experience them.¹⁵ Furthermore, this methodology was chosen because it can help us to understand people’s experiences by collecting and analyzing qualitative data in a way that stays “closer to the data”¹⁶ compared to other qualitative methodologies.¹⁵ This was desirable because we intended our findings to have pragmatic applications and because little was known from the perspective of the population of interest. Our study was situated in an interpretivist paradigm underpinned by a realist ontology (i.e., an objective world exists outside of consciousness) and constructionist epistemology (i.e., the meaning of the objective world is derived through consciousness).¹⁷ This paradigm was conducive to our aim of interpreting and constructing the meaning of subjective experiences at face value rather than further theorizing on those experiences, and was therefore appropriate for this descriptive study. The University of Toronto’s research ethics board approved the study protocol. The Consolidated Criteria for Reporting Qualitative Research guided our reporting.¹⁸

Sex and gender constructs

In this article, we use the following definitions for sex and gender constructs: sex refers to biological attributes (e.g., chromosomes, reproductive/sexual anatomy), and is often identified as “female” and “male” sexes, although it is not limited to binary categories.¹⁹ Gender is a social construct that relates to expected behaviours, roles, and expressions of identity associated with sex, and common terms for gender include “woman” and “man.”¹⁹ Cisgender refers to individuals whose gender identity aligns with their sex assigned at birth (e.g., an individual assigned female at birth who identifies as a woman) and transgender refers to individuals whose gender identity does not align with their sex assigned at birth.²⁰ However, gender identity and expression are not necessarily binary (e.g., identifying as gender diverse) nor static throughout the lifespan.¹⁹

Research team

The interviewer (SS) is a white cisgender woman PhD student with qualitative research training and experience. SS received post-graduate PHPT training in Canada and had 2 years of part-time PHPT clinical experience providing care for women and men in a private practice setting at the time of data collection. Participants were aware of the interviewer’s credentials and the purpose of the study prior to the interview. The research team also included academic researchers from entry-to-practice physiotherapy or occupational therapy programmes in Canada who did not have PHPT clinical or teaching experience.

Participants and recruitment

Physiotherapists registered to practise in Canada who had provided clinical PHPT services (including internal assessment/treatment of the pelvic floor) to at least five patients within the last year and spoke English were eligible to participate. Physiotherapists who completed their entry-to-practice education with the interviewer were excluded. This helped standardize the relationship between the interviewer and the participants without significantly limiting the pool of potential participants. Our recruitment strategy was designed to engage women and men pelvic health physiotherapists from geographically diverse areas. This strategy included sharing the recruitment notice through national and provincial professional organizations and a social media page. Snowball sampling was used to recruit men participants. Interested individuals were instructed to contact the interviewer by email, resulting in a convenience sample. Participants were provided with a $20 e-gift card honorarium.

Sample size

We aimed to recruit 15–20 participants. This range was selected because we anticipated that it would enable us to explore and generate a coherent and rich description of participants’ experiences,²¹ while being feasible for the interviewer and primary analyst (SS). Furthermore, selecting this range aligns with the perspective that data saturation may never be truly achieved within a qualitative paradigm, even with very large sample sizes.²²

Data collection

After obtaining informed consent, we collected data on participants sociodemographic and professional characteristics (e.g., years of clinical experience and practice settings) using an online questionnaire developed using REDCap.²³ The interviewer reviewed these data prior to the interview to help guide the discussions. The interviewer conducted semi-structured interviews that included the following topics: motivation for entering the PHPT field, experiences related to initial and ongoing PHPT practice, and education (see Appendix 1 for the interview guide). Two pilot interviews were completed prior to data collection to evaluate the comprehensibility of the guide and to help prepare the interviewer. This led to minor wording changes for clarity as well as expanding questions related to education to differentiate between initial and ongoing PHPT training (Appendix 1).

Interviews were conducted using Zoom (Zoom Video Communications, San Jose, CA, United States), audio-recorded, professionally transcribed verbatim, de-identified, and verified for accuracy. Participants could join by telephone or computer from work or home. The interviewer took field notes during and immediately after each interview.

Data analysis

Quantitative data were summarized using descriptive statistics in Excel (v16.0.5227.1000, Microsoft, Redmond, WA, United States). We used a reflexive thematic approach guided by Braun and Clarke’s six-phase process: (1) data familiarization and writing familiarization notes; (2) systematic data coding; (3) generating initial themes from coded and collated data; (4) developing and reviewing themes; (5) refining, defining, and naming themes; and (6) writing the report.²⁴ The primary analyst (SS) engaged in familiarization and note writing concurrently with data collection, and began by inductively coding the transcripts after all data had been collected using NVivo (version 12, QSR International, Doncaster, Victoria, Australia). Steps 2–5 were completed iteratively. Specifically, two distinct code management steps were undertaken, both of which involved reviewing and reducing and/or grouping codes, discussing the codes, and groupings with two co-authors (JR, NMS) to bring in multiple perspectives, and developing and refining tentative themes. This was followed by iterative coding, diagramming, and writing to produce initial themes that were presented to the research team alongside illustrative quotations for discussion. The themes were finalized based on discussions to address the cohesion, comprehensiveness, and clarity of the themes. Methodological rigour was enhanced by keeping reflexive notes, involving multiple researchers, maintaining a coding audit trail, and providing illustrative quotes.^{25, 26, 27}

Results

We conducted interviews with 20 pelvic health physiotherapists, including 19 cisgender women (95%) and 1 cisgender man participant (5%), with diverse levels of PHPT experience between August and October 2020. The interviews ranged from 40 to 83 minutes. Table 1 presents participant characteristics. We identified four themes: the right fit, managing vulnerability, the holistic nature of PHPT, and entering PHPT requires thoughtful consideration. Participant ID, gender (W = Woman, M = Man), and the number of years of PHPT experience are presented for quotations.

Table 1.

Participant Characteristics (N = 20)

Characteristics	No. (%) of participants
Age, y
21–30	4 (20)
31–40	7 (35)
41–50	5 (25)
51–60	4 (20)
Sex and gender identity
Female and woman	19 (95)
Male and man	1 (5)
Race/ethnicity identity
Asian (e.g., East Asian, South Asian, South East Asian)	2 (10)
Latin/Hispanic (e.g., Caribbean, North and Central American)	1 (5)
White/Caucasian (e.g, European, North American)	16 (80)
Other or prefer to self-describe	1 (5)
Province of physiotherapy practice
British Columbia	4 (20)
Alberta	8 (40)
Saskatchewan	1 (5)
Ontario	5 (25)
Quebec	1 (5)
Newfoundland and Labrador	1 (5)
Population size where practices physiotherapy*
Large urban population centre (population ≥ 100,000)	12 (60)
Medium population centre (population 30,000–99,999)	7 (35)
Small population centre (population 1,000–29,999)	4 (20)
Entry-level physiotherapy degree
Bachelor’s	8 (40)
Entry-level master’s	12 (60)
Highest degree obtained
Bachelor’s	6 (30)
Entry-level master’s	11 (55)
Research master’s	1 (5)
Other (e.g., master’s of clinical science in manipulative therapy, currently pursuing PhD)	2 (10)
Practising physiotherapy, y
1–3	3 (15)
4–5	2 (10)
6–10	3 (15)
> 10	12 (60)
Practising pelvic health physiotherapy, y
< 1	1 (5)
1–3	8 (40)
4–5	1 (5)
6–10	4 (20)
> 10	6 (30)
Current amount of time dedicated to PHPT practice
Sporadic (1–12 h/w)	3 (15)
Part-time (13–29 h/w)	8 (40)
Full-time (≥ 30 h/w)	9 (45)
Current PHPT practice setting(s)*
Physiotherapy clinic/practice	8 (40)
Multidisciplinary clinic/practice	12 (60)
Outpatient/ambulatory care clinic (publicly funded)	3 (15)
Current funding model(s) for PHPT practice*
Privately funded model	18 (90)
Publicly funded model/provincial health care plan	5 (25)
Motor vehicle insurance	3 (15)
Worker’s compensation	2 (10)

^*≥ 1 participants selected more than one response.

PHPT = pelvic health physiotherapy.

The right fit

Participants described PHPT as the right fit for themselves personally and professionally. On a personal level, several participants recounted how their own experiences with a pelvic health condition and receiving PHPT inspired them to work in this field and made them feel connected to it. Professionally, many participants were drawn to PHPT to fill a gap in the health care system because of the high prevalence of pelvic health conditions and the limited availability of PHPT services. One participant described how she felt about entering the PHPT field after practising in orthopedic and sports physiotherapy for 10 years: “[PHPT] felt like where I was always meant to fall” (PT14, W, > 10 years).

Participants described how their passion and fulfilment working in PHPT differed from working in other fields. They described that addressing pelvic health concerns such as incontinence could have uniquely life-changing benefits for patients but that some patients only came to PHPT as a last resort after being dismissed by the medical system or other health care professionals. As a result, participants could feel a special sense of satisfaction, as shared by PT2: “The gratitude that you get from patients is something that … you’ll only get it with pelvic [physiotherapy]” (W, 1–3 years).

Managing vulnerability

Participants described PHPT as more intimate than other areas of practice such as orthopedics, due to the private nature of the body part and the sensitive information shared by patients. This could make patients and providers feel vulnerable, and physiotherapists had a responsibility to manage this aspect of practice. To manage patients’ vulnerability, participants described the importance of building a strong therapeutic alliance by interacting with patients appropriately and creating a safe space. Physiotherapists recognized the importance of words and their meanings, and the need to navigate the task of asking important but sensitive questions (e.g., about bowel and bladder function, sex, trauma) that might make a patient feel uncomfortable or offended. Participants, therefore, worded their questions and comments carefully to communicate information in a clear, sensitive, and respectful way. Some physiotherapists expressed that finding the right language could be challenging, as shared by PT4: “It was delicate … I didn’t want to push on anyone because [asking about pelvic health] is a bit sensitive and there’s some vulnerability associated with that. And so, again, just finding the language was hard” (W, 6–10 years). Participants noted that this challenge could stem from a lack of training, confidence, or experience discussing sensitive topics with patients.

Additionally, physiotherapists worked to create a physically and emotionally safe space by giving the patient control through respecting their preferences stemming from religious, cultural, or personal beliefs, and establishing true informed consent. This could lead to abstaining from or ceasing an internal evaluation, as described by PT17:

Explaining that [the patient is] in control and at any point in time, they can say, ‘I’m done.’ And it’s also reading your patient. If your patient is squeezing their butt or their head’s pushing back on the pillow and their back is arching, as a therapist, you need to stop and check in with that patient. (W, > 10 years)

Participants also experienced personal vulnerability, with the majority of participants describing the early period of PHPT practice as “intimidating” or “scary.” Receiving an internal vaginal and/or rectal pelvic floor assessment during their introductory PHPT education and, for some, through their past experience receiving PHPT care was a valuable, albeit anxiety-provoking, experience that helped participants manage this intimate aspect of practice: “In retrospect, I appreciate that [internal examination] is a component of our training because we truly understand how patients feel when that happens” (PT19, W, 1–3 years).

While all participants cared for patients that identified as the same gender as themselves, not all participants provided care for patients of different genders in the context of PHPT since they could experience greater vulnerability associated with working with those populations. For example, some women therapists reported feeling out of their “comfort zone” providing care for men. This could be due to social dynamics or biological differences in the anatomy of the male pelvic floor. Indeed, the majority of women therapists reported that they had not practised internal pelvic floor techniques with a male during their initial training due to the paucity of males enrolled in those PHPT courses, which led to feeling a lack of competence related to those skills. Women therapists either overcame these barriers with education and experience, or it discouraged them from continuing to work with this population in this context. Women therapists also cited busy caseloads as a barrier to providing care to men, while the man participant’s primary reason for not providing care to women related to professional liability: “The real risk would be the misinterpretation of assessment or treatment in being misconstrued as being of a sexual nature” (PT15, M, 4–5 years). Conversely, some women therapists reported that providing PHPT care to men “wasn’t too big of an adjustment” (PT2, W, 1–3 years) and that experience working with men from an orthopedic perspective (e.g., treating groin injuries) facilitated this transition. Regardless, when deciding whether to treat patients of different genders from themselves, all participants considered the availability of services and the proximity of clinicians who care for those patients, as stated by PT15: “There’s lots of therapists out there treating women’s pelvic health. There’s not a need for me to be in that pool” (M, 4–5 years). While none of the participants had experience providing PHPT care for patients identifying as transgender, many brought up the need for increasing the availability of PHPT services for these patient populations.

The holistic nature of PHPT

Participants recognized that treating pelvic health conditions demands that you look at the whole person and warned against treating pelvic floor impairments in isolation from the rest of the body. They emphasized the need to consider broader influences of posture, breathing, and the nervous system on pelvic floor function to better address pelvic health conditions. Physiotherapists with many years of orthopedic experience prior to entering PHPT perceived their experience as an asset because it established relevant knowledge (e.g., nerve pain, neuropathy) and skills (e.g., analyzing movement, treating sacrum, and thorax issues), and provided a solid foundation for clinical decision-making.

Additionally, participants emphasized the importance of moving beyond physical impairments, often adopting a biopsychosocial approach to care for the whole person. Taking this holistic approach could be challenging in initial PHPT practice, even for some experienced physiotherapists, due to the cognitive demand associated with managing vulnerability, and applying new skills in pelvic floor examination learned on weekend courses. Over time, however, participants described expanding their use of psychosocial-related outcome measures and developing non-internal assessment and treatment skills such as exercise and behavioural techniques for pelvic health conditions. As a result, participants described their use of internal and hands-on techniques often decreased over time, as shared by PT20: “I tend to be a little bit more hands-off … Initially I was very much like everyone needs an internal exam because that was the only way that I knew how to assess” (W, 1–3 years). Furthermore, some participants recounted how their hands-off approach facilitated the transition of their PHPT practice to telehealth during the COVID-19 pandemic, which forced the temporary closure of clinics.

Participants described mentorship and continuing education as essential for providing high-quality holistic care. Participants reported that mentorship helped them improve their clinical effectiveness, communication skills, and confidence, especially in the early period of PHPT practice. Mentorship could come in several forms, for example, having formal on-site mentors that participants were able to observe or regularly discuss patient cases, or having informal mentors that participants sought out to consult with through other means (e.g., email, telephone). Formal mentorship appeared to be more common in publicly-funded settings than in private practice settings. Participants also described frequently consulting with colleagues, peer groups, and more recently, online networking groups to advance and share their knowledge and skills to care for patients more effectively, as shared by PT16:

As the pelvic health community has grown, it just creates more avenues for communication and support. So I’ve used [PHPT Facebook groups] quite a bit … I just look to more for, you know, new research articles or feedback and stuff like that. (W, 6–10 years)

Participants also took courses to increase their knowledge, skills, and confidence to treat a larger range of clientele, fill knowledge gaps, or pursue an interest in a niche area of pelvic health (e.g., high-impact fitness training, perimenopause).

Entering PHPT requires thoughtful consideration

Deciding when and how to enter the field, including how many courses to take and where to work, required participants to thoughtfully consider their needs and resources. Most participants reported their entry-to-practice programmes delivered little to no PHPT content, and all participants received their initial PHPT training through post-graduate courses. When deciding how many PHPT courses to take prior to practising, participants considered the availability and access to courses, personal preferences, and advice about required knowledge and skills prior to treating patients. For example, most participants who began practice after one course were those who trained over 10 years ago when only one course was available in Canada, and those who needed to travel to a different province to enrol in courses. These participants typically limited their initial practice to treating patients with urinary incontinence since that was the only condition covered in their first course. Participants who took multiple courses that covered content including urinary incontinence, ano-rectal dysfunction, and pelvic pain wanted to do so to have a larger base of knowledge prior to practising, as shared by PT8: “I’m not the kind of person that wants to figure it out as I go. I’d like to say, okay, I have a bit of knowledge to draw upon and then let’s sort of dive in” (W, 6–10 years) or because another pelvic health physiotherapist had recommended them.

Participants decided where to work by considering whether there was enough support to build or maintain a PHPT caseload and to develop clinical skills. The main factors in this decision were support within the clinical setting and access to mentorship. After their introductory training, some participants began PHPT practice in supportive settings that were already offering PHPT services (e.g., private practice clinics where pelvic health physiotherapists worked, multidisciplinary clinics, or hospital settings dedicated to perinatal health), while several other participants established PHPT services at the private practice clinics where they worked. A few participants faced barriers associated with establishing PHPT services. These barriers included physical layouts that were not ideal for creating a calm and private environment (e.g., treatment room next to a busy gym) or the lack of administrative support for building a PHPT caseload, as described by PT17: “The owners didn’t feel comfortable with asking the receptionist to ask questions of people that were calling in for pelvic floor” (W, > 10 years). Participants considered whether their setting offered sufficient support to develop their clinical skills, and if not, several participants changed where they worked. For example, when asked about their experience as the only pelvic health physiotherapist at their initial private practice, PT7 shared: “It probably added to the feelings of not really knowing if I was doing a great job … And so, this new position of having like a mentor in clinic has made a world of difference in my confidence” (W, 1–3 years).

Discussion

To our knowledge, this is the first qualitative study of education and practice experiences of pelvic health physiotherapists in Canada. Participants experienced personal satisfaction from filling a clinical need while navigating the vulnerable and complex nature of practice. Participants considered their access to continuing education, mentorship, and support within the clinical setting when deciding how to enter and advance in the PHPT field.

Our study contributes to a growing understanding that physiotherapists derive a distinct type of fulfillment from PHPT practice.¹³ This may be due to the personal connection and desire to fill a clinical need, which are known drivers for entering pelvic and women’s health physiotherapy.²⁸ However, most participants reported receiving little to no exposure to PHPT in their entry-to-practice programmes, which may be an untapped opportunity to foster interest among physiotherapy students and increase awareness of the clinical need. To date, we still do not have an in-depth understanding of the process for selecting which topics to teach in entry-to-practice programmes compared to post-graduate courses, which would help to advance the PHPT field.

The findings from our study reflect and expand on current PHPT competency and education frameworks.^6,29 For example, our findings support the notion that pelvic health conditions are complex and PHPT practice requires strong communication skills and clinical reasoning for building a trusting relationship with patients and treating an intimate body part.⁶ Additionally, our findings emphasize the importance that physiotherapists place on holistic care by considering how the pelvic floor functions in relation to the whole musculoskeletal system and the influence of psychological and social factors – hence, the participants’ focus on the biopsychosocial approach³⁰ in their practice. This highlights that PHPT practice involves skills beyond internal pelvic floor techniques or hands-on techniques in general, which is in line with research demonstrating promising outcomes of virtual care for patients with pelvic health conditions.^31,32 Our exploration of physiotherapists’ experiences treating an intimate body part also brings a more explicit focus on trauma-informed care³³ in PHPT practice because it emphasizes the need for safety, trust, and giving patients control. This is particularly important given the association between sexual abuse or trauma and pelvic health conditions.³⁴ Our results, therefore, point to future directions for expanding on current PHPT competencies by identifying competencies through orthopedic, biopsychosocial, and trauma-informed lenses.

The effects of receiving a pelvic floor examination as part of PHPT training have not been studied to our knowledge, but appears to be a valuable experience. While it is known that pelvic floor examinations can provoke anxiety in health care professional trainees learning to perform them on patients,³⁵ the findings from this study suggest that the peer-to-peer model of learning in post-graduate PHPT courses positively affects practice by fostering empathy in practitioners. Therefore, our findings highlight the benefits of continuing to use this learning model in post-graduate educational programmes, however, it is unknown whether these findings also apply to entry-to-practice PHPT education.

This is also the first study that we are aware of that has explored pelvic health physiotherapists’ decisions to treat patients of different sexes and genders in the PHPT context. Our results suggest that both sex and gender considerations may be at play in these decisions. Physiotherapists are required to practise “according to their own competence and limitations”³⁶ and must reflect on their abilities to treat certain populations. Some women participants recognized their lack of knowledge and education as a barrier for assessing biologically male pelvic floor structures, which is not unexpected given the lack of post-graduate education specific to men’s pelvic health reported among Canadian practitioners.⁸ Meanwhile, gender differences may have affected some physiotherapists’ comfort levels. Our findings support the hypothesis that therapists who are women may be more comfortable working with patients of the same gender, as proposed in a 2012 survey of women’s health physiotherapists practising in Canada.⁸ Our findings also suggest that physiotherapists who are men may consider other or additional concerns, although this warrants further examination given that this study only had one participant who was a man. Overall, our study invites a deeper exploration of the professional and ethical responsibilities and considerations associated with sex and gender in PHPT practice, particularly related to patients and providers who do not identify as cisgender since our study did not explore this.

Participants took different approaches to enter PHPT based on their circumstances. Although participants who entered PHPT after several years of practice could benefit from their established clinical experience, physiotherapists required education and support regardless of the amount of experience with which they entered the field. Sharing knowledge through mentorship and collaborative groups is considered an essential aspect of PHPT.^6,11 However, our findings suggest that not all practitioners have equal access to mentorship opportunities. This highlights the need to expand PHPT mentorship and broaden professional networking opportunities in Canada.

This study had several limitations. Firstly, we did not recruit participants from each province and participants were required to speak English, which may limit the transferability of results. However, the sample represented practitioners with variable amounts of PHPT experience working in diverse settings and geographical areas. Furthermore, while data saturation was not our goal, increasing our sample size could have provided insight into more variable experiences. Future research could explore to what degree our findings are transferable to larger or different groups of pelvic health physiotherapists to further our knowledge of the field. Similarly, we did not interview physiotherapists who had discontinued PHPT practice, thus the study findings may be influenced by the experiences of physiotherapists who find it fulfilling. Finally, all of the participants received their PHPT training through post-graduate courses, limiting the experiences to that type of learning environment. However, some participants received their training before or soon after graduation, thus contributing to our understanding of the experiences of new graduates who enter the field.

Conclusion

PHPT is a complex but rewarding area of practice that requires physiotherapists to manage vulnerable clinical encounters and consider factors beyond physical impairments of the pelvic floor. Physiotherapists must consider their access to education, mentorship, and support from their clinical setting when entering the field.

Key Messages

What is already known on this topic

PHPT is a sensitive area of practice that is growing, but the training is not standardized in Canada. Few studies have explored experiences of pelvic health physiotherapists, thus limiting our understanding of education and supports that facilitate PHPT practice.

What this study adds

Pelvic health physiotherapists found PHPT to be a fulfilling area of practice and highlighted important components of PHPT training such as receiving an internal pelvic examination, focusing on communicating sensitive topics, and broadening the lens of pelvic health through orthopedic, biopsychosocial, and trauma-informed approaches. Our findings suggest that pelvic health physiotherapists actively seek out supportive clinical environments and mentorship to advance their clinical practice, which emphasizes the need to expand mentorship opportunities in this growing field. More research is warranted to explore PHPT education in entry-to-practice programmes and ethical considerations for providing care to patients of different sexes and genders in the PHPT context.

Appendix 1: Interview Guide

Initial Practice

• 1.What motivated you to enter the field of pelvic health physiotherapy?
• 2.
  How did you feel when you first started working with patients with pelvic floor conditions?

  1. Probes re: setting, patient population, caseload
• 3.What aspects of practice do you think you did particularly well when you first started working in pelvic health and why?
• 4.What did you find most challenging when you were first starting out in pelvic health and why?
• 5.In this early period, where or to whom did you turn to for advice?

Ongoing Practice

• 6.
  Over time, how have your experiences working with patients with pelvic floor conditions changed?

  1. Probes re: setting, patient population, caseload, where or to whom do you turn to for advice now
• 7.What are some of the biggest lessons you have learned from practising in the field?

Education

• 8.What kind of pelvic health education did you receive in order to begin working in the field?
• 9.
  Can you tell me what it was like for you to learn the knowledge and skills required for practising in pelvic health?

  1. Probes: Were there any challenging or helpful aspects of the training?
• 10.Was there anything else you wish you had known or been taught before practising?
• 11.Were there any steps you had to take before starting to practise in pelvic health, for example with your regulatory college? If so, what was that process like for you?
• 12.What kind of educational courses or learning experiences have you sought out since working in the field and why?

Wrap up

• 13.What advice would you give to a physio interested in entering the pelvic health field?
• 14.Is there anything I have not asked that you thought I would, or think I should?