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A spasm of the pelvic floor muscle can result in pelvic pain in both men and women, and patients are often referred to physical therapy (PT) for this issue. This case report describes the PT management of a patient who underwent sexual reassignment surgery (SRS) with resultant pelvic pain that hindered the vaginal dilation that is necessary to maintain the neovagina.This is a single-subject case study.A 59-year-old woman, who had SRS at 57 years of age, presented to PT with a diagnosis of levator ani muscle spasm and complaint of bleeding and pain with vaginal dilation. Physical therapy interventions included massage, electrical stimulation, relaxation techniques, vaginal dilation, home exercise programs, and multidisciplinary care. The physical therapist and gynecologist worked closely to identify pudendal nerve involvement and causes of vaginal bleeding with dilation.The patient attended 13 PT sessions over 3 months, resulting in reduced pain and no bleeding during vaginal dilation.Although the literature does describe treatment for pelvic pain in the female population, research is lacking in the treatment of pelvic pain in women who have undergone SRS. Careful examination of anatomy and functional limitations were used in this case to direct treatment. Further research regarding dysfunctions in the pelvic floor after SRS and their treatment is warranted to better serve this patient population.