Valsalva and the Vaginal Vacuum

Terminology and Technique for Pelvic Floor Rehabilitation

The time has arrived to correctly describe and effectively use the Valsalva maneuver–and the all-important Vaginal Vacuum that can accompany the maneuver–in pelvic floor rehabilitation. How one performs the Valsalva breath holding technique is an important consideration in pelvic floor health and rehabilitation. The Valsalva maneuver was introduced as a medical procedure in 1704 by an Italian physician to expel pus from the middle ear. Over the years, the Valsalva maneuver has been used in medicine for everything from changing cardiac rhythms to testing for disc herniation.

Valsalva vs. Strain Maneuvers and the Pelvic Floor (PF)

First, we need to define Valsalva versus Strain from a pelvic health and rehabilitation perspective. Clarifying these definitions is a beginning, improving the understanding of the effect of managing Intra-Abdominal Pressure (IAP) in pelvic floor dysfunction (PFD).

The Valsalva maneuver is a moderately forceful attempted exhalation against a closed airway. The 2017 International Urogynecologic and Continence Societies (IUGA/ICS) joint Terminology Report for the conservative and non-pharmacological management of female pelvic floor dysfunction defines the Valsalva maneuver as “the action of attempting to exhale with the nostrils and mouth, or glottis closed. Valsalva is usually performed with digital closure of the nose, as when trying to equalize pressure in an airplane.” Properly used, the term “Valsalva maneuver” does not address the pelvic floor.

In contrast to the Valsalva maneuver, the strain maneuver is a forceful bearing down which can cause excessive perineal descent. We use a strain maneuver to test for pelvic organ prolapse, but it is otherwise discouraged in most of our patients with prolapse or incontinence. Straining/bearing down as defined in the above IUGA/ICS terminology report “may have a similar meaning to Valsalva; however, in practice, straining/bearing down may be interpreted as meaning pushing downward and trying to relax the pelvic floor, as when defecating.” A strain maneuver therefore does address the pelvic floor.

In reality, the Valsalva maneuver does affect the pelvic floor. During the Valsalva maneuver the pelvic floor elevates. I term this elevation the Vaginal Vacuum. For more information on pelvic floor elevation during the Valsalva maneuver, see Talasz et al., 2012 which states that “the Valsalva maneuver reflects an expiratory pattern with diaphragm and pelvic floor elevation, whereas during straining the pelvic floor descends.” Also see Baessler et al., 2017, who demonstrated that Valsalva maneuver is associated with better bladder neck support and a stiffer pelvic floor.

Vaginal Vacuum Technique (VVT)

I consider using the Vaginal Vacuum breath holding technique when the primary presenting pelvic floor muscle diagnosis (Spitznagle et al., 2017) includes a force production deficit with or without movement pattern coordination or IAP impairments. In my practice, patients with some pelvic floor muscle awareness and without pelvic floor muscle overactivity respond the best to the VVT.

Most pelvic rehabilitation practitioners are familiar with coaching a pre-contraction of the pelvic floor (termed the “Knack”) prior to a symptom-provoking cough. The Vaginal Vacuum Technique is designed to be a symptom reduction breathing technique.  It is a short duration Valsalva breath hold used with a symptom-provoking activity like a lift or a push. The VVT can be accompanied by pelvic floor activation either reflexively or with coaching pelvic floor cues.

To identify if the patient has a reflexive Vaginal Vacuum effect, instruct the patient in a brief, sub-maximal breath hold on exhalation to be directed upward against a closed throat and mouth, (clearing your ears on the airplane– Valsalva maneuver) and observe for the response of stiffening or lifting of the pelvic floor.

Non-responders may need coaching. I suggest adding a contraction cue for the pelvic floor or providing more training in the coordination of this technique. Patients with significant PFD may need to use both the Knack and the VVT to manage IAP. For some, this Valsalva breathing technique may never produce an elevation of the pelvic floor.

Management of IAP with the Vaginal Vacuum Technique

Management of IAP is an important treatment consideration in patients with PFD.  Breath holding, often unavoidable when pushing or lifting heavy loads, can be performed with different pelvic floor responses.  The Valsalva maneuver can be of value in pelvic floor rehabilitation. Terminology is important, and I encourage you to reverse the trend of using Valsalva as a term to describe a straining/bearing down maneuver in clinical practice. I also encourage you to perform terminology fact checks: look closely at research publications for their specific descriptions of the Valsalva maneuver.

Finally, try the VVT during your initial patient assessments and use it as an additional self-care behavioral strategy to manage IAP.  Clinically, many patients have reported improved quality of life–an ability to lift or push with fewer symptoms. I hope your patients do too.”

To learn more about advanced pelvic floor examination and the importance of managing IAP visit my  professional continuing education teaching  page.



Want to learn more about pelvic floor dysfunction and pelvic organ prolapse while earning PT CEU’s? Register for our upcoming course!

A Boost Camp Seminar to Advance Your Clinical Practice Skills Pelvic Organ Prolapse (POP) Exam and Rx (5)



Kathe-WallaceAbout Kathe Wallace

Kathe Wallace has practiced physical therapy since 1976, focusing on pelvic floor rehabilitation since 1988. As a nationally recognized leader in the pelvic floor specialty of physical therapy, she evaluates and treats many types of conditions referred to her by medical specialists in orthopedics, physical medicine and rehabilitation, urology, gynecology, gastroenterology and colorectal surgery. Full Bio.. →

Every”body” is Unique!

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Healing and re-training your muscles can be a slow process. 🐌

Every”body” responds differently to therapy and treatments. Our therapists take into consideration your particular goals and how your body is responding to exercises, manual therapies and modalities.


Pain and musculoskeletal dysfunctions often contain many layers and may require a multi disciplinary approach. We assess you as an individual, not just your diagnosis or symptoms. For example, if you come in with back pain . . . we will not only assess your lumbar musculoskeletal function, but also other coordinating muscle groups, such as your pelvic floor muscles and deep trunk muscles.


How long will I have to come to therapy?


Some patients require just a couple of visits while others require much more. Generally, twice a week for four to six weeks is the time it takes for muscles to gain strength, endurance and coordination. The time needed for therapy will also depend on the complexity of your issue, how your body responds and if you are doing your homework (home exercise program).

Trust the process and be patient with your body!

Postpartum Strong® Workshop!


Are you pregnant, postpartum or planning to have kids? 👶🏼🧒🏾👶🏿👶🏻
Don’t miss out on our first Postpartum Strong® workshop of 2019!
Our workshops are a great way to get connected with other moms, learn about your amazing body and have an engaging Q & A time! (All those things you wanted to know about bladder leakage, uncomfortable sex, weak abs, back pain, etc!)
In this workshop you’ll:
🤰🏻🤱🏽 Learn about common concerns & issues faced by women during pregnancy and postpartum.
💪🏾 Learn how you can regain strength & reduce pain!
🧘‍♀️ Walkaway with expert tips + exercises!
✅ Receive a belly, posture & body mechanics check ($45 value)
Kids are welcome!
Easy parking!
Tickets available via Eventbrite 

January is Cervical Health Month

Cervical Health Month (1)

As you may have figured out . . . we are pretty passionate about the pelvic floor. Yes, January is Cervical Health Awareness Month, but how does it relate to the pelvic floor?
We know that any condition that causes pain in the pelvic organs (bladder, urethra, uterus, cervix, vagina, rectum) can cause pelvic floor dysfunction, and tense/painful muscles.
As pelvic floor physical therapists, we are strong advocates for knowledge! The more we know about our own bodies, the better able we are to identify when something is not quite right. 🌸
Some procedures such as hysterectomy and radiation, can lead to symptoms including pelvic pain, loss of bladder control, overactive bladder, constipation, fecal incontinence, painful intercourse, lymphedema and others. Scar tissue from surgery and tissue changes from radiation affect the ability of the pelvic floor to function normally, and can also lead to chronic pelvic pain. These symptoms can have a huge impact on patient’s quality of life and participation in daily activities.
Pelvic floor physical therapists are specially trained to work with you and assist you in decreasing and even eliminating these symptoms!

Heal your body, from the inside out!

May allwho enter,leave inspired.

Do you notice changes in your body? Are you experiencing aches, pains or weakness that wasn’t there before?
You may feel like this is just your new normal or that there’s so much you can’t control.
Whether you’ve just given birth, are dealing with a sports injury or just want to be stronger … there’s a lot you can do to strengthen your body from the inside out!
We are huge advocates for empowering our patients with knowledge about their bodies and how they work. We are passionate about creating an environment that is both comfortable and a place to strengthen and help you reach your individual goals.
The more you know about your body, the better you can take care of it and see changes that occur. You’ll feel great — and your body will thank you too!

The limited role opioids play in treating chronic pain

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Potentially addictive opioid💊 painkillers are often prescribed for chronic pain, but they actually work only slightly better than placebo pills, a new review shows.
The analysis, of 96 clinical trials, found that on average, opioids made only a small difference for people with conditions like osteoarthritis, fibromyalgia and sciatica.

“Opioids should not be a first-line therapy for chronic, non-cancer pain,” said lead researcher Jason Busse, of the Institute for Pain Research and Care at McMaster University, in Canada.

Dr. Michael Ashburn, a pain medicine specialist at the University of Pennsylvania, in Philadelphia, agreed.

“This is confirmation of the limited role opioids play in treating chronic, non-cancer pain,” Ashburn said.

So what are the alternatives?

Dr. Casey with patient room 1
Overall, his team found, opioids were no better than non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen.

But, he stressed, there are also non-drug options — including physical therapy🧘, exercise, acupuncture and cognitive behavioral therapy.

Happy 17th Birthday To Us!


17 years

It has been a pleasure serving the RVA community for 17 years! Thank you for your support!




First private physical therapy practice focusing solely on pelvic health & women’s health conditions




Established the second APTA credentialed Women’s Health Residency




Ongoing mentoring programs for students from many top Universities




Developed and patented the FEMME, an orthotic to support those with prolapse, incontinence, or challenging exercise





Co-author of Mommy and Me Pilates exercise guide






black mom exercising


Developed the Postpartum Strong® Program for women during the maternal year.





Presenter of research and lectures at American College of Obstetrics and College, International Pelvic Pain Society, Nurse Practitioners Women’s Health Annual Meeting, American Pain Society, International Society for the study of Female Sexual Health


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Interviewed by Richmond Times Dispatch, Virginia Morning Show & CBS to name a few!




Tupler Technique® program offered for women who have diastasis recti

Having a Baby is Like an Athletic Event.

Having a baby is like an athletic event. Women across the world routinely see a musculoskeletal specialist, a physical therapist, to decrease pain and increase function. Most insurance companies will pay for (1).png

Women across the world 🌎 routinely see a musculoskeletal specialist, a physical therapist, not just for sports injury and ortho rehab… but to decrease pain and increase function, after having a baby! 👶
This is why we created Postpartum Strong . . . a specialized and individualized program for women during their last trimester of pregnancy🤰, and during the postpartum period🤱 (which could be 2 days or 20 years!), to strengthen their bodies from the inside out!
No matter what your goal is after having a baby …. a triathlon🚴 or picking your baby up without pain💪 …. we are here to support you!
. (Psst …Most insurance companies will pay for postpartum physical therapy!)

“How Can I Have Faster Recovery Post-Baby?”

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Sit-ups, planks, burpees, tons of cardio, barre, Pilates, CrossFit and/or HIIT routines…? 💦
Actually, (and according to research-based studies) your body recovers faster when you -first- strengthen from the inside out.
This may mean doing exercises that feel so gentle, you may not feel like you are exercising at all. 🧘
After having a baby👶, focusing on regaining strength, endurance and coordination of your pelvic floor muscles, in combination with your deep trunk muscles, is a MUST.
Being able to properly engage your pelvic floor muscles means you will reduce your risk for so many issues down the road (or current ones), like abdominal muscle separation (#diastasis), bladder leakage when exercising, coughing, laughing and sneezing, prolapse and painful or unsatisfying intercourse.
Wow! Who knew that not sweating profusely 💦 could have such a huge impact on post-baby recovery!!💃
If you are planning on starting an exercise program or gym routine – PLEASE – get a pelvic floor exam first and coordinate care with a pelvic floor physical therapist. 🌺

The Role of Physical Therapy After Surgery and During Cancer Treatment

U.S. Breast Cancer Statistics. About 1 in 8 U.S. women (about 12.4%) will develop invasive breast cancer over the course of her lifetime. ... About 2,550 new cases of invasive breast cancer are expected to be di.png

The goal of physical therapy after surgery and during cancer treatment (radiation, chemotherapy) is to minimize side effects and to optimize function.
Physical Therapy interventions include:
Manual Therapy: Manual Therapy is defined as skilled hands on treatment to the joints, muscles, fascia and scar. This can help with restricted range of motion, pain and swelling.
Lymphedema Treatment: This treatment includes manual lymphatic drainage, compression bandaging, evaluation for garments, and instruction in exercise and self-care.
Postural Training: Physical therapy will address the postural changes after surgery with postural specific exercises and ergonomic assessments.
Exercise: Exercise through all the phases (prior, during and after) is of vital importance and has been proven to minimize, or eliminate the side effects of treatment.
Physical therapy will provide an individualized programs with specific goals.
Bearskens CH et al: The effeicacy of physiotherapy upon shoulder function following axillary dissection in breast cancer, a randomized controlled study. August 2007 volume 7: 166
Courneya KS, Mackey JR, Jones LW. Coping with Cancer: Can Exercise Help? The Physician and Sportsmedicine (28)5, 2000