Same Pelvis, Different Lens: What PTs and OTs Can Learn From Each Other in Pediatric Pelvic Health

Walk into a pelvic health conference today, and you’ll see something that wasn’t true fifteen years ago: roughly a third of the room has OTR/L after their name. Occupational therapy’s move into pelvic health is no longer emerging. It’s here, it’s growing fast, and it’s changing the conversation.

That growth has produced a fair amount of turf anxiety on both sides. I’d like to suggest a more useful question. Not who owns the pelvic floor, but what does each profession see that the other one misses? Because after 38 years of treating kids with bowel and bladder dysfunction, I can tell you: nobody sees the whole picture alone.

The two professions may approach the same child from different starting points, but the goal is the same: helping that child feel more comfortable, become more independent, and ultimately improve their quality of life.

Neither lens is inherently more complete. In fact, pediatric pelvic health is an area where we can learn a lot from looking through both.

The difference between PT and OT in pelvic health is not necessarily about what we do. It is often about where our clinical reasoning begins.

Physical therapy begins with the movement system. Our training orients us toward impairment: what is the tissue doing, what is the motor control pattern, how are forces being managed, where is the load going? We’re taught to identify the physiological problem and then trace it outward to the functional consequence. Weak or poorly coordinated pelvic floor → pressure management failure → leakage with running.

A PT may ask:

“What physical or movement-related factors are contributing to this child’s symptoms?”

Occupational therapy begins with the occupation. The Occupational Therapy practice framework names toileting and sexual activity explicitly as activities of daily living, which is the formal basis for OT’s presence in this space. But the deeper point is the direction of the reasoning: OT starts with the daily task the person can’t perform, analyzes that task and the environment it happens in, and traces inward to the barriers. The child can’t manage the school bathroom → why not → is it the stall door, the noise, the routine, the clothing fasteners, the fact that they don’t recognize the urge until it’s urgent?

An OT may ask:

“What is making this daily activity difficult, and what does this child need to participate more successfully?”

Same child. Same pelvis. Opposite direction of travel through the problem.

A pediatric pelvic health PT may examine how the musculoskeletal and movement systems contribute to bowel and bladder function.

This evaluation tends to prioritize:

• Postural and breathing mechanics; diaphragm–pelvic floor coordination
• Lumbopelvic, hip, and abdominal wall assessment
• Pelvic floor muscle assessment: strength, endurance, coordination, tone, ability to relax
• Motor learning capacity and exercise tolerance
• Biofeedback (surface EMG, real-time ultrasound) for muscle recruitment
• Palpation and manual assessment of tissue restriction

For example, a child who struggles to have a bowel movement needs more than a conversation about constipation. Their ability to sit in an effective position, relax their pelvic floor, coordinate their breathing, and generate appropriate abdominal pressure may all be relevant.

The PT lens asks us to understand how the body is contributing to the problem.

An OT may look at that same child and start somewhere different.

This evaluation tends to prioritize:

• The occupational profile: roles, routines, habits, what the person actually needs to do in a day
• Task analysis of toileting from start to finish, including clothing management and hygiene
• Sensory processing, including interoception: the capacity to perceive and interpret internal signals
• Cognitive and executive function demands of the routine
• The physical and social environment: bathroom setup, school, workplace, caregiver system
• Adaptive equipment and energy conservation needs

A child who appears to be “refusing” the toilet may not simply be refusing. They may be overwhelmed by the environment, unable to interpret their body signals, fearful because of previous painful bowel movements, or struggling with the many steps required to complete the routine.

The OT lens asks us to understand what is making participation difficult.

Imagine a child with constipation, stool withholding, and toileting refusal.

A PT might explore:

• Is the child sitting with adequate foot support?
• Can they coordinate breathing and pelvic floor relaxation?
• Is there abdominal, hip, or trunk stiffness affecting positioning?
• Is having a bowel movement painful?
• Can they appropriately coordinate the muscles needed for defecation?

An OT might explore:

• Is the bathroom sensory environment overwhelming?
• Does the child recognize rectal fullness?
• Is there fear or anxiety associated with toileting?
• Can they complete each step of the toileting routine?
• Can they manage their clothing independently?
• What happens during transitions to the bathroom?
• How are caregivers responding to refusal or leakage?

Notice how much overlap exists.

This is not about saying, “PTs do this and OTs do that.” Individual clinicians have different training, experience, and areas of expertise. Rather, these are two different ways of looking at the same child, and both can reveal information the other clinician might miss.

There is actually a lot of shared territory in pediatric pelvic health.

Both PTs and OTs may address:

• Toileting routines and positioning
• Body awareness and interoception
• Breathing and regulation
• Caregiver education
• Habit formation and behavior change
• Environmental modifications
• Trauma-informed, child-centered care
• Participation at home, school, and in the community

Additionally, both PTs and OTs may perform an internal pelvic floor examination where training and state practice acts permit. And I want to be precise here, because this is where most of the confusion lives. Pelvic health falls within scope for both professions, but the specific authority for internal assessment and treatment is governed at the state licensure level and varies. The Occupational Therapy Association of California’s 2024 pelvic health position statement was a significant step in clarifying this for OTs. Check your own practice act rather than assuming your neighbor state’s answer applies.

So the question is not whether one profession can address something.

The more useful question is: What perspective does this particular child need?

I’ll go first, because I think we (as PTs) have more to gain than we like to admit.

Occupation is the outcome, not the muscle. We are trained to measure success in degrees, grades, and repetitions. A child can hold a 10-second pelvic floor contraction and still not use the toilet at school. OT never loses sight of the fact that the muscle only matters because of what it lets the person do.

Task analysis is a real skill, and most of us don’t have it. Breaking toileting into its actual component steps reveals failure points that a muscle exam will never surface:

1. Noticing the signal
2. Interrupting the current activity
3. Navigating to the bathroom
4. Managing the clothing
5. Positioning
6. Relaxing
7. Wiping
8. Redressing
9. Handwashing

I’ve watched children who could contract and relax beautifully fail at step two.

Interoception belongs in our vocabulary. A significant number of the kids on our caseloads, particularly autistic children and those with sensory processing differences, don’t reliably perceive bladder fullness or rectal distension until the signal is overwhelming. Literature is now emerging on sensory integration and interoceptive training for functional urinary incontinence in children. We have been coaching these kids on urge suppression techniques when the actual problem was that they never felt the urge in the first place.

The environment is a treatment target. Bathroom lighting, hand dryer noise, stall privacy, seat texture, clothing fasteners, and footstool availability. OTs modify these as a matter of course. PTs tend to treat them as background conditions.

Habit and routine formation is a discipline. We hand out home programs. OTs think systematically about how a behavior gets embedded into an existing daily structure, which is exactly what a timed voiding schedule or a post-meal sit program actually requires to succeed.

PTs also offer an important lens when physical contributors are getting overlooked.

Musculoskeletal reasoning has depth that’s easy to underestimate. Differential assessment of hip, lumbar spine, sacroiliac, and abdominal wall contributions to pelvic pain and dysfunction is a substantial body of knowledge. So is recognizing when pelvic symptoms are downstream of something orthopedic entirely.

Pressure management and breathing mechanics. The relationship between the diaphragm, abdominal wall, and pelvic floor as a pressure system is core PT territory and enormously useful. Breath-holding, bracing, and posture drive symptoms is key as well.

Dosage is not a detail. Motor learning principles, load progression, and exercise prescription determine whether a home program produces adaptation or frustration. Sets, reps, frequency, and progression criteria all have an evidence base behind them.

Tissue-level assessment and manual skill. Assessment of muscle tone, trigger points, connective tissue restriction, and scar mobility. PTs are skilled in the manual techniques that address them.

Return-to-load reasoning requires a graded exposure framework that PT training supplies directly.

Sometimes the best next step is not adding another intervention but rather adding another perspective. Consider collaborating with or referring to another discipline when:

• Progress has stalled despite consistent treatment.
• Physical symptoms and participation barriers are both significant.
• Sensory, emotional, motor, and toileting concerns are interacting.
• A child can perform a skill in therapy but cannot carry it over at home or school.
• You identify needs outside your training or scope of practice.
• The family is overwhelmed by a plan that does not fit naturally into their daily life.

Collaboration does not mean duplicate treatment. Sometimes it simply means communicating with another clinician and asking, “What are you seeing that I might be missing?”

Consider looping in an OT when:

• The child can perform the muscle task in clinic but not the daily task at home, school, or work
• There’s a suspected or confirmed sensory processing difference, autism diagnosis, or ADHD
• Interoceptive awareness seems absent or unreliable
• Executive function, sequencing, or initiation is breaking down the routine
• Environmental or equipment barriers dominate the picture
• Clothing management, hygiene independence, or caregiver training is the rate limiter

Consider looping in a PT when:

• Musculoskeletal pain is driving or accompanying the pelvic symptoms
• There’s a pressure management or breathing mechanics component
• The child needs graded exercise progression or return to sport
• Postural, gait, or lower extremity contributions are suspected
• Tissue mobility or manual intervention is indicated

So rather than asking which profession “owns” pediatric pelvic health, I think we should ask a better question:

“What does this child need?”

Two professions arriving at that same pelvis from opposite directions isn’t a redundancy problem. It’s a coverage advantage — but only if we’re willing to learn each other’s reasoning instead of defending our own. Read the other profession’s literature. Take the co-treatment. Ask the OT down the hall what they see when they watch your patient’s toileting routine, and be prepared to be surprised.

My online course, Pediatrics Level 1– Treatment of Bowel and Bladder Disorders, is designed to train both PTs AND OTs about pediatric pelvic floor dysfunction. Come join amazing practitioners in this growing speciality!

Selected References and Further Reading

• American Occupational Therapy Association. (2020). Occupational Therapy Practice Framework: Domain and Process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2).
• American Occupational Therapy Association. (2021). Occupational therapy scope of practice. American Journal of Occupational Therapy, 75(Suppl. 3).
• Occupational Therapy Association of California. (2024). Pelvic health position statement.
• Akselrud, R., & Vestal, L. (2021). The role of occupational therapists in pelvic health. SIS Quarterly Practice Connections, 6(3), 12–14.
• Fyhrie, J. H., Le Fevre, E., Fruhauf, C. A., Weaver, J. A., & Schmid, A. A. (2025). Identifying occupational therapists’ perspectives on their unique role in pelvic health care.
• Sensory integration combined with interoceptive interventions for functional urinary incontinence in children: a case report. (2025). PMC12279691.
• Mahler, K. Interoception and toileting resources. kelly-mahler.com