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20: Pelvic Floor In-Depth with Stephanie Prendergast, MPT
547 Plays2 years ago
Welcome to Episode 20 of the Movement Logic Podcast! In this episode, Sarah interviews Pelvic Floor Physical Therapist Stephanie Predergast, co-founder of the Pelvic Health and Rehabilitation Center, about everything and anything pelvic floor related. Stephanie also answers your questions from Instagram! Here’s what we cover:
- Understanding the mechanics and function of the pelvic floor and how it’s different than other muscles in the body
- Why strengthening your pelvic floor is not always the goal and how it might make your incontinence symptoms worse
- The difference between stress incontinence and urge incontinence
- Why dyspurnia (painful sex) and vulvodynia (vulvar pain) are treatable but might get misdiagnosed as an ‘incurable disease’
- When pelvic floor muscular dysfunction gets misdiagnosed as a UTI, depending on which kind of practitioner you see
- The efficacy and safety of hormone therapy for menopause symptoms according to NAMS (North American Menopause Society)
- What is GSM (Genitourinary Symptoms of Menopause) and how is it treatable
- Pelvic floor concerns for people with male genitalia, a chronically underserved population
- Why people with low back or hip pain very often have an underlying pelvic floor issue
- What are some signs that a movement teacher can look out for with their clients to indicate they may need to see a pelvic floor specialist (and a screening questionnaire included below)
- What is the female pelvic triad and how teenage athletes may need help
Reference links:
As the Pelvis Turns Newsletter
NAMS position paper on hormone therapy
Pique Health for online care for pelvic floor and sexual health
Poise Impressa for incontinence support
Speax by Thinx for incontinence support
Quick Screen for pelvic floor PT
Pelvic Health and Rehabilitation Center (they’re hiring PTs!)
Watch the video of this conversation at: www.movementlogictutorials.com/podcast
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Thanks for listening!
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Transcript
Introduction to Movement Concepts Podcast
00:00:02
Speaker
Welcome to the Movement Logic podcast with yoga teacher and strength coach Laurel Beaversdorf and physical therapist, Dr. Sarah Court. With over 30 years combined experience in the yoga, movement and physical therapy worlds, we believe in strong opinions loosely held, which means we're not hyping outdated movement concepts. Instead, we're here with up to date and cutting edge tools, evidence and ideas to help you as a mover and a teacher.
Guest Introduction: Dr. Stephanie Prendergast
00:00:37
Speaker
Welcome to episode 20 of the Movement Logic podcast. I'm Dr. Sarah Kaur, physical therapist, and I'm here with my guest, Dr. Stephanie Prendergast. Stephanie is a pelvic floor physical therapist and co-founder of the Pelvic Health and Rehabilitation Center, which now has
00:00:52
Speaker
10, I believe, locations across the US, including Northern and Southern California, Massachusetts, and New Hampshire. PHRC puts out a newsletter called As the Pelvis Turns, which is not only funny, but hugely informative and educational, covering an encyclopedic number of pelvic floor concerns. So if you get nothing else from this conversation, you want to subscribe to that newsletter for sure, and I will link to it in the show notes.
00:01:20
Speaker
Fortunately for me, Stephanie lives here in Los Angeles, although you may have gathered from this introduction, she's an extremely busy person, and I am grateful that she's given us this time to chat on our podcast.
00:01:31
Speaker
Stephanie's passionate about educating professionals and regular humans alike around pelvic floor issues. And I can honestly say that I have lost count of the number of times she's told me something that just totally blew my mind. Today, we're talking about all things pelvic floor. And some of the focus is going to be on hormonal changes, but a lot of it's just sort of like things that people maybe misunderstand or symptoms or pain or problems, frustrations that people put up with if they don't have to.
00:02:01
Speaker
So I'm excited. I'm very excited. Stephanie, thank you so much for coming on the podcast. Lynn, thank you for having me. I'm really happy to be here.
Understanding Pelvic Floor Misconceptions
00:02:10
Speaker
So pelvic floor has been, it probably will continue to be kind of a hot topic for movement teachers of all kinds, yoga teachers, Pilates instructors. But where I see a big disconnect is that a lot of the time it's just considered an area that people are supposed to strengthen. Like there was that t-shirt at one point that I said like,
00:02:31
Speaker
said something like, you know, may your coffee and your pelvic floor be strong or something like that. How and why is that idea of like, we just need to strengthen? How and why is that inaccurate?
00:02:44
Speaker
And that's a great question. And I am glad pelvic floor is becoming a hot topic. I mean, five years ago, people weren't talking about it. And so, of course, there's going to be a learning curve. But breaking it down simply, the pelvic floor is unlike any other muscle in our body. And I think it benefits all of us to have strength in our bodies. But the pelvic floor never turns off.
00:03:07
Speaker
What's different about it is it has sensory and motor fibers just like other muscles, but it has an autonomic component, which means similar to our breath is the best way to relate. We can breathe without thinking about it, but we also have the ability to control our breath. With the pelvic floor is the same. It's always going to be active. A good example of some of the reflexive activity is as urine fills our bladder, our pelvic floor muscles get tighter and tighter.
00:03:35
Speaker
to keep us continent until we're in a socially acceptable place to release it. And so that's a good example of we're not thinking about it, and then we are. And so I think in people's minds, they think stronger is better.
00:03:48
Speaker
But because these muscles never relax, sometimes we actually do not need to strengthen them if they're working in conjunction properly with our core. Now in certain cases, there becomes motor control issues just like we can have neuromuscular impairments in other parts of the body. And the pelvic floor may not be responding either reflexively or voluntarily as it should. But in certain demographics, it's usually the muscles getting too tight and overworked. So they actually need to be lengthened
00:04:16
Speaker
And then depending on what's going on with this person, they may or may not need to strengthen because again, the pelvic floor should be working all the time anyway.
00:04:27
Speaker
Yeah, it sort of sounds like when people have what we would consider like weak but tight other musculoskeletal muscles where it's like, well, yes, it's not strong particularly right now, but I can't strengthen it until I'm actually able to access the full range of motion of that muscle.
00:04:47
Speaker
And so even though it doesn't cross a joint, there is a range of motion with our pelvic floor. So that's an excellent
Pelvic Floor and Health Conditions
00:04:53
Speaker
point. I mean, what we're both talking about is the length tension curve. And the muscles can't contract if basically they do this. And this is what can happen in some people's pelvic floor muscles. They just get so tight that normal function is impaired. Yeah. What do you
00:05:12
Speaker
recommend? Well, you know what, I'm going to get to that later because I think that's an interesting question to sort of be like, okay, well, then what do I do for that person? But the same way that I think movement teachers understand or have an idea that there's strengthening that needs to happen, and it's not to say that there isn't, but it may not be the first appropriate thing to do for someone. I think they also understand the relationship between the public floor and urinary continents.
00:05:44
Speaker
But, you know, and I hesitate to speak for everyone, but I'm going to do it anyway. But I think I think that's like the number one thing that kind of comes up for people as far as like, oh, you know, I'm lifting weight and I'm peeing or something like that.
00:06:00
Speaker
So, continents is a pelvic floor issue, but there's a lot of other potential pelvic floor issues or pelvic floor health sequelae. And for people who don't know what that means, it means like if something's going wrong with the pelvic floor, there's a sequence of other things that get affected by it. Some that might seem obvious, like
00:06:20
Speaker
incontinence or continents and some that may not. Can you speak to the connection of the pelvic floor health and then other conditions like Volodynia or other things that are common for women? Yes, absolutely. So women, our bodies, especially in the pelvic reason, have a very interesting intersection because of all that that does. I mean babies, our menstrual cycle,
00:06:45
Speaker
And then all the things that you mentioned urinary balance sexual function. And so there is a range of impairments that people may be experiencing. We can start with the urinary component because you just mentioned, so there can be incontinence stress incontinence is what it's called when people
00:07:00
Speaker
involuntarily leak urine during physical activity, but there can be urgent contents too, which is basically when they have the urge to go, all of a sudden it's so strong, they leak. On the other end of the spectrum, you mentioned some of the pelvic pain conditions. Usually incontinence is associated with weaker pelvic floors, except in athletes and teenagers. That's part of the female athlete triad. They actually may be too tight to actually have a proper closure around their urethra, so they also may leak.
00:07:30
Speaker
that's a different situation than a postpartum or a perimenopausal woman who is leaking. So we got to look at the individual. But when the muscles also become too tight, there can be the main symptom of dyspareunia, which basically means painful sex. This affects one in four women under the age of 40. So this is not
00:07:51
Speaker
menopausal painful sex, this is dyspareunia that's related to pelvic floor myalgia. That can also cause what's called vulvodynia, which just means pain in the vulva. And that can exist in a provoked or unprovoked situation. So as it progresses, if it's not treated, it may go from having pain with tampon, gynecologic or sexual contact to I can't wear underwear, I can't wear pants, I can't sit down, I feel it all the time.
00:08:17
Speaker
It's and I can't emphasize enough, it is a treatable condition with nine known causes and eight associated but many doctors are still telling women. Oh, it's just an incurable disease. It's not a disease. It's a syndrome.
00:08:32
Speaker
I get very worked up about it because I've been part of some of the nomenclature studies that have really identified and went through the evidence for these causes. So if somebody's dealing with this, just know if there's an answer. If somebody tells you there isn't, you've got the wrong provider. The other thing that can happen with some of the pain conditions is the irritated bladder symptoms that can come with something called interstitial cystitis. I also think that that's a misnomer because it's pointing to a problem in the lining of the bladder.
00:08:59
Speaker
But your pelvic floor muscles can make you feel like you have to urinate all the time and they can make you have pain when you do. So that's also a very bothersome symptom for people that gets misdiagnosed as UTIs and and a bladder. I was going to say, that sounds like a UTI. Like, I feel like it feels like and then it hurts. But you're saying potentially that's an issue with the pelvic floor and not an infection issue at all. And to put the two of these things together,
00:09:28
Speaker
Depending on if you see a gynecologist or a urologist, most people with this have both symptoms because it's coming from the pelvic floor. But if you go to a urologist, you may be diagnosed with IC. If you go to a gynecologist, if you're lucky, you're told you have vulvodynia and at least you have the word that you can look it up.
00:09:43
Speaker
It's both the bladder, pelvic floor, and the opening of the vestibule are derived from the urogenital sinus. And so it's very common for people to have symptoms in all these areas when the muscles start to function improperly.
00:10:00
Speaker
There's also constipation and bowel issues that are related to pelvic floor. And one of the things that can lead into pelvic floor dysfunction in adults is childhood constipation. So pelvic floor PTs also work with pediatrics. And if a child isn't able to properly evacuate, it leads to faulty bowel mechanics where they're straining and we have bowel movements every day. So that can lead to a lengthening issue that then could cause a pelvic floor injury.
00:10:29
Speaker
as adults. There's a few other diseases that affect women such as endometriosis, which is basically when the lining of the uterus has endometrial like cells implanting in our peritoneal cavity, very painful periods also known as dysmenorrhea.
Hormonal Impacts on Pelvic Health
00:10:45
Speaker
And there's a viscerosomatic connection. So when there's visceral disease such as endometriosis, SIBO, Crohn's disease, there's going to be somatic consequences to the pelvic floor.
00:10:57
Speaker
because they share spinal segments of innervation. And so many people with these diseases also have pelvic floor dysfunction that can create pain, irritated bladder symptoms, bowel issues, sexual pain. Sorry, that was a little long way to do that. No, no, no. I'm always just sitting here going, wow, wow, wow, wow. It is interesting, I think for
00:11:25
Speaker
those of us that work with movement, it is interesting to think about a muscle, or a series of muscles, I should say, having not just, it's a skeletal muscle, but it's involved with so many other systems in the body.
00:11:45
Speaker
I think it speaks to this sort of disconnect, like you were saying, between if you see a urologist or you see a gynecologist, maybe they're not putting all the clues together. But also, the thing that I see the most or that I have experienced as well the most, I'm just going to backtrack for a second. Some of you listening to this will know and some of you won't know. I was diagnosed with breast cancer last year. I went through surgery and I went through chemotherapy. And once I was done with chemotherapy, I was like,
00:12:15
Speaker
uh not to not to be you know too graphic but chemo involves a lot of GI distress in every i'm not going to name them but if you can think of a way that your intestines can be distressed and the resulting actions in your body you have i went through all of them right and often like the every both ends of the spectrum one day to the next so
00:12:37
Speaker
at the end of that I went to see Stephanie because I was like everything down here is just so confused by what just went on and feel like things are not functioning properly. And you know I went in sort of expecting like well she's a pelvic floor physical therapist so she's going to give me some like
00:12:53
Speaker
pelvic floor homework and maybe I have to foam roll on something and da da da. But the conversation that we had that just blew my mind was about the health of the tissue and what was happening because of the other spoiler, not a spoiler, this is not a movie, I am going through medical menopause right now as part of my treatment. So all of the
00:13:15
Speaker
hormonal related changes to the tissue are also impacting the pelvic floor health. And I hadn't sort of put that together in my head that that and I had a very, you know, eye opening session with Stephanie where she basically showed me a bunch of things. There's like, this is impacting this and this is impacting this. Can you can you speak to
00:13:41
Speaker
because I think a lot of our listeners are people who have been teachers for a while. They're maybe sort of close to my age or maybe a bit younger, a bit older, but certainly there's a chunk of our listeners who are either perimenopausal or, you know, completely in menopause and are having some of these things that are, you know, unfortunately just considered, well,
00:14:04
Speaker
you have to put up with a drug emoji like dryness, burning, pain, all of that kind of stuff. Can you speak to how, you know, getting pelvic floor therapy and also any sort of adjunct therapy that you think is appropriate for women?
00:14:20
Speaker
And you know, it's not your fault you didn't put two and two together, but it blew my mind when we spoke. You are an educated person in the medical field. Nobody told you. And so I'm going to bring the rage because you have survived cancer and nobody told you that you're going to have painful sex, irritated bladder symptoms. And there's actually something you can do about it. And I just, that is what upsets me the most. I've had several friends diagnosed with cancer in our age bracket and they didn't know either. And then I'm like, whoa, whoa, whoa,
00:14:49
Speaker
So you mentioned a few very important things. There can be medical menopause, which happens with cancer survivors. There is perimenopause, which people don't realize starts as early as 35 menopause. And then the birth control pill are all going to put our vagina and pelvic floor into a hypoestrogenized state. And that can you explain what that phrase means, please? Yes. And so that basically means we need hormones in our bodies.
00:15:16
Speaker
And these four situations are in an estrogen deprived situation. Our pelvic floor muscles, our vestibule, which I can talk about, the bulba, the bladder, the urethra, all have estrogen receptors on them. And if we are in a diminished state of estrogen, we're going to have somatic consequences even outside of what happens to the tissues that need the estrogen, which are,
00:15:43
Speaker
the lining of the bladder, you know, that even independent of the pelvic floor influence, it will have some vulnerability to making people feel like they have a UTI. The vestibule is, as one of my patients in dealing calls it, the welcome mat. The vestibule is when you switch from the bulb into the vagina. And that has a time out. I love that. That's great.
00:16:09
Speaker
The things that go on in our offices, right? We have to because it's ridiculous and it is a war on women and I do bring the rage but we also have to protect humor as we fix it. But that has estrogen and testosterone receptors on it and that's one of the things that you and I talked about and so
00:16:28
Speaker
Also, it's not just the estrogen with the external genitalia. Women don't even realize that we need testosterone too. That starts to decrease it when we're 35. It is completely taken away when you're on the birth control pill and it's gone by the time you're in menopause, medical, or age-related. That is going to cause a significant amount of pain at the opening and the welcome mat becomes the unwelcome mat because it just hurts. It also surrounds your urethra.
00:16:58
Speaker
So then it's going to make it burn when you urinate and both of those things are considered an organ. Which then have that visceral somatic consequence to the pelvic floor so your pelvic floor is getting weaker because you don't have hormones. And then it's also getting cranky because you've got a negative pain stimuli and this creates a whole series of.
00:17:17
Speaker
of symptoms that are so treatable, but they're not understood. And so I really work closely with medical providers and I do have a solution for listeners because some tech companies are going around the medical system because it's been such a nightmare for women. I want to touch on the fact that this is also the 20 year anniversary of the women's health initiative. Actually yesterday was the 20 year
00:17:44
Speaker
anniversary of the first longitudinal study that launched in the 90s to study the effects of hormone therapy on menopausal women, and the study had significant flaws in it. The media got ahold of the fact that there were a few instances of cardiovascular distress and breast cancer, and the whole world went crazy.
00:18:04
Speaker
on July 7th, there was a media frenzy everywhere associated with with what they were saying hormone therapy causes cancer and cardiovascular disease. This is not true. And the authors have since repudiated their own information. But because the media got ahold of it at that point in time, 60% of women, 60 to 90% of women were on hormone therapy and menopause. And because of that study overnight, insurance companies, doctors,
00:18:31
Speaker
friends talking to friends, said, throw away the hormones. Everybody cold turkey went off. Do you want to know how what the percentage of women are on hormone therapy now? Sorry, I'm just holding my head in sadness and horror. Not enough probably. 7%. 7% of what? Menopausal women? Yes. And so women are suffering because everybody thinks it's going to cause cancer and this is not true.
00:18:56
Speaker
And I can't say this enough, I have two separate lectures on this that I can share with you and the North American menopause society just Monday released their position paper. Again, saying the safety of this because the average age of menopause is 52 and women are living into their 80s.
00:19:11
Speaker
which means one-third of their life they can be suffering from all these things that they should not be suffering from because of misinformation and a media frenzy. And it's concerning to me because again, you weren't told that this is happening. Doctors didn't offer this for you. And most women, if they go to the doctor who delivered their babies and they're saying, oh, I'm afraid of hormones, that doctor has five minutes with you, they're not going to tell you otherwise. Or in fact, they're going to tell you the wrong thing, which is like, oh,
00:19:39
Speaker
you're going to get a blood clot and have a stroke maybe. So no, it's bad. This is not true. The reason I'm so angry about it is because it directly affects the work I'm doing with my patients with their pelvic floor therapy, because I have no chance of helping with these symptoms if we don't have the proper medical management too. Yeah.
00:19:57
Speaker
Yeah, I'm going to give you a moment to breathe, because I do want to hear also about what the solution is for our listeners. But I also wanted to just really emphasize and reiterate. And I think, hopefully, I know that this has come up on a previous episode. And I just want to make sure everyone's very clear. Hormone therapy is not dangerous for menopausal women. It's not going to give you cancer. And in fact, it's really vital to just
00:20:26
Speaker
to your point about the last third of your life, how about you're not suffering, right? How about we do something about it? And I'll say this as well, and this is just going back to my specific story. I know a lot more about cancer than I did before I had cancer, but one of the things that I now know more about is something called estrogen and progesterone
00:20:49
Speaker
receptive tumors and I have a, so they call it ERPR positive. And my kind of tumor was ERPR positive, which means that's why I'm being put through menopause, which is trying to take the estrogen out of my body so that it's a unwelcome, it is a, my whole body is an unwelcome mat for a future tumor. However,
00:21:08
Speaker
Even within that, I have been permitted, and I currently am using both estrogen precursor and also testosterone, topical help, for want of a better word, for my pelvic floor and all of the associated tissues. And I'm someone who's had cancer, right? And so nobody's being like, oh, no.
00:21:30
Speaker
And, you know, let me let me also say everyone's tumors are different. Everyone's sequelae is different. It's not. I'm not saying everybody with this could have done it. But I'm an example of somebody where where, you know, we are still actively trying to keep estrogen out of my body. And even so, I'm allowed to take care of my pelvic floor. And so that's a good point, because you're talking about the genital urinary syndrome of menopause, which is very different than hot flashes, the vasomotor symptoms, the things that people think about.
00:21:58
Speaker
the Geneno urinary syndrome of menopause has only been a term since 2014 and it is encompassing all the things that can happen. And it is safe to use local therapies like you're doing in this area that are not going to affect tumors in other parts of your body. And I think that that's also something that people don't really realize if it only became a term in 2014, because it just everything was called bovovaginal atrophy and it didn't encompass all the bladder symptoms.
00:22:27
Speaker
And so it's more expansive and I really am encouraged by a number of young female urologists who are out there screaming from the rooftops about this because it needs to be different than it has been. And who knew people are gonna get the right medical information on Instagram. Thank you to these people.
00:22:48
Speaker
And with that said, I had to go chasing after this care.
Navigating Menopausal Treatments
00:22:52
Speaker
I had to go to my oncologist and say, hey, here's the doctors I've spoken to and here's what they want to do. And can I get a clearance to do this? This was not being offered to me in any way. Nothing was being offered to me in terms of managing menopausal symptoms, not just genital urinary, but also the hot flashes that I have, the irritability, all of that stuff.
00:23:15
Speaker
It is so boring, the number of things I have to do every day to just keep everything kind of like not exploding like a volcano. But I'm willing to do it because it works, you know? And so you spoke earlier about some solutions or something for our listeners.
Introduction to Peak Health Services
00:23:32
Speaker
Are you speaking specifically about going through menopausal symptoms or just or any sort of like vaginal distress or pain or things like that?
00:23:39
Speaker
I guess I'm talking about sexual health and hormonal consequences that have been difficult for people to manage themselves, not just in terms of their own fear, which is a barrier, a lack of informed healthcare providers, but the cost, the cost of these medications is significant. And so there is a company that we have recently partnered with called Peak Health, and I can send their information in the show notes.
00:24:07
Speaker
What they're basically doing is offering affordable sex therapy online, as well as consultation with a leading expert, the CMO of the company is Dr. Ashley Witter. She's one of the urologists that I mentioned with a female sexual health fellowship. And what they're basically doing is reducing the cost by using cloud pharmacies. And so women can
00:24:32
Speaker
women can contact PEAK, they will get a call back from their expert staff, set up with an appointment with a physician or a nurse practitioner for their hormone health and concerns. The second aspect of that is they have a sex certified sex therapists that are offering counseling for women at a very low rate compared to standard of care.
00:24:55
Speaker
So our patients need sex therapy and average cost of these visits in LA is somewhere between 250 and $400 a session. They are offering it at 125, which is something that is more affordable. And because of the cloud pharmacy and the number of providers they're going to have across the country, they're actually going to be able to reduce the costs of things that can be as much as $500 a month.
00:25:20
Speaker
down to under 50. And you may be aware that Mark Cuban also did something similar with his who can you imagine Mark Cuban is getting involved in menopausal health, but it's amazing. And so this is a similar concept. And so it's they just launched my whole company is working with them right now. And it has been
00:25:40
Speaker
such a great service to be able to offer, especially in some of our locations. We don't have access to the providers that you saw here or that I work with. Some of our offices were really struggling. I'm teaching my staff one thing and they can't get it. So this has been a very welcomed solution when people are really struggling. And I think about the people who couldn't afford the cost of these meds and it's just not okay.
00:26:07
Speaker
No, that's fantastic. And we'll definitely link to that in the show notes so our listeners can look into it.
00:26:15
Speaker
Hey guys, it's Sarah. Laurel and I really hope you're enjoying the new Movement Logic podcast. We are having such a good time. We both really love sharing ideas with each other and getting sparked by things that the other person has learned. Our goal for the show was to help you feel the same way so that you can feel excited and inspired by what you're learning and even maybe take some of these ideas into your teaching. That would be amazing if that's what happened, I'd be so happy. Because I know, oh my God, we both know
00:26:44
Speaker
what it feels like to be uninspired, to be stuck in a rut, desperately trying to come up with new ideas so you take another training and it just ends up you fall back into your old
00:26:55
Speaker
habits and things you already know how to do because it's too hard to change who you are as a teacher. We've all been there. The whole reason why we created the movement logic tutorials was so that you can enhance what you're already good at instead of trying to be some other different kind of a teacher. Every movement logic tutorial contains so much to help you do that, hours and hours of.
00:27:17
Speaker
anatomy, kinesiology, myth busting. Myth busting is maybe my favorite part of the whole thing, but most importantly, dozens of exercises that help you with strength or flexibility or functional movement, whatever you and your clients want to do in their life. Because we're so grateful that you are listening to our podcast, we have a podcast exclusive
00:27:39
Speaker
discount. To say thank you for supporting our efforts with your years, what you can do is you enter the coupon code podcast at checkout to receive 10% off of your entire purchase. You heard that right. You go to movementlogictutorials.com, take a little scroll through all of our different tutorials, stick some of them in your cart, the ones that you're like,
00:28:00
Speaker
pelvic floor, ooh, shoulders, and then enter the code podcast at checkout and you'll receive 10% off your entire purchase because we appreciate you. So thank you and go forth and save.
00:28:19
Speaker
So I'm going to take a little bit of a left turn or a different
Pelvic Floor Issues in Men
00:28:23
Speaker
direction here. We've been speaking specifically about issues that affect people who have female genitalia. I would like to speak also about people who have male genitalia because there is also a pelvic floor there.
00:28:35
Speaker
And as much as pelvic floor has become something that people are more comfortable discussing, I feel like the part that maybe is still a little bit in the shadow is for people with male genitalia. Either there's not an understanding that they also have a pelvic floor or because so much of the focus has been on female genitalia, pelvic floor issues.
00:29:00
Speaker
Can you talk about what are some common things that you see in the clinic and how do you work with those conditions?
00:29:09
Speaker
So first, I think it's important to note that half of our patients are met. So while we're speaking and women have certain things that go on that render them needing pelvic floor PT, our male patients are very underserved. They are always told they have chronic prostatitis or a prostate infection, and they almost never do. And so the symptoms that they present with, similar,
00:29:37
Speaker
urinary urgency, frequency, pain at the tip of the urethra, erectile changes, post ejaculatory pain is one of the biggest symptoms that they see, that we see, perineal pain,
00:29:49
Speaker
They can also have the anal issues and constipation. But it is very, it's difficult to test a man for a UTI compared to a woman. So I think we should start there and why this is always being, they're being prescribed antibiotics without even testing them. For us, we give a urine sample, we take antibiotics for a week, we're done. It's not the same situation with men.
00:30:12
Speaker
in order to get an accurate catch because of the length of their urethra, they actually have to urinate, milk the prostate, it's called a four glass test, ejaculate, then urinate again, the whole thing is very painful, it takes 15 minutes, nobody does it, they just empirically diagnose everybody with these symptoms once STIs are ruled out as having a prostate infection. And when men get a prostate infection, true,
00:30:38
Speaker
It actually takes like three months of antibiotics, so it is a little porous, annoying creature when there is actually an infection. The prostate? Yes. It's the one area on their bodies where I'm like, that's worse than women.
00:30:57
Speaker
But because they don't have the vestibule, they don't have all the horrible things as much. But most of the men that we see have some sort of movement-based, neurologic, neuromuscular deviant that whatever they're doing during their day, whether it's 18 hours at a desk, whether it's a two-hour commute, or whether it's something like CrossFit or however they want to exercise, likes.
00:31:20
Speaker
some anatomic change has occurred and it's not just the pelvic floor, it's almost always involving the entire lumbopelvic lower extremity chain that makes a pelvic floor not able to handle the load. And then they start to get all the symptoms that I just mentioned. And so it's a little less complicated because it doesn't have the hormone intersection. But it's also not right because they are
00:31:46
Speaker
not treated properly. And men, unlike women, women may go to five doctors, men are going to go to their one doctor. And even if those antibiotics aren't working, they may keep taking them. And it's important to note that some of the broad-spectrum antibiotics like cipbro and bactrum that are prescribed have the analgesics in them. So they erroneously give men the impression that they have an infection because they feel better when they're taking it and then they stop and it comes back. That's because of the analgesic.
00:32:14
Speaker
So then they think they have an infection again, and they go back to the urologist and get another round. This is problematic because it causes extreme gastrointestinal distress. And as we know, Cipro causes muscle tearing in parts of the body. And so if they're on Cipro for a year and trying to work out, now we've got an Achilles tendon rupture. Now we've got a hip flexor tear. Now there's an adductor tendonopathy, and this is not okay.
00:32:39
Speaker
And 97% of the men that's a statistic that came out recently in a urology office under the age of 40 actually have pelvic floor dysfunction, not a prostate infection. Wow.
00:32:52
Speaker
Yeah. Wow. And a lot of public floor PTs are women. In fact, almost all of us, I think over 90% of us are, and they may not be trained the way we were to treat men. And so a lot of our practices have more men than women sometimes because the surrounding practices only treat women. And I think it's very unfortunate. And I'm concerned about that.
00:33:13
Speaker
My background was working with a urologist when I started. And so from day one, we saw men and women with pelvic pain. And I was taught on patients, if you go to a Con Ed course, and there's only women in it, I can understand why they may not feel comfortable navigating their genitalia and feeling comfortable in a room doing these types of these types of treatments. But we really need to change that. Yeah. Um,
00:33:41
Speaker
Do you think there's any reluctance on the part of a lot of the male population to see a pelvic floor therapist because they
00:33:53
Speaker
for any reason that they feel like it's not for them or if maybe they're concerned to see a woman who's then gonna be like doing stuff to them that maybe they feel nervous about. I mean, do you think that's part of why they're not getting care or do you think it's really mostly about just uninformed patient care where they're just being given antibiotics for a year or something like that? I think it's both. And so we really work hard to make them feel comfortable.
00:34:22
Speaker
If you take a look at our YouTube page, the videos that we have posted about male pelvic health have hundreds of thousands of views and men in the comments section actually interacting with each other, which just blows my mind, helping each other. And so by trying to put out educational content to make them feel more comfortable and case studies and success stories where they're reading on our blog, somebody who had the exact same symptoms, they realize they're not alone.
00:34:50
Speaker
and this is probably what they need to do because the antibiotics aren't working.
00:34:54
Speaker
And so we do our best to make them feel comfortable. And I've heard both sides from my patients, I've asked them, would you want to see a man or a woman and some heterosexual men are like, Oh, no, you, I don't want to see a man because we're doing trans anal work. I am addressing tissues underneath of their testicles. You know, so I think it's both, but they feel badly enough. And it's obviously their vitality as well that they eventually make their way in. Yeah.
00:35:22
Speaker
And I've certainly had male patients where they came to me for a outpatient orthopedic musculoskeletal issue, usually either low back or pelvis related or something around the lumbar pelvic area.
00:35:39
Speaker
And based on, you know, I might have a couple of sessions with them or even just the evaluation where I sort of said, you know what, we need to back up. You need to go to a pelvic floor PT first. And they need to do some, you know, there's an underlying issues that are getting in the way of me helping you with what you came to see me for. And I think that's another, I mean,
00:36:02
Speaker
I do feel like that's a little bit of a net where we catch people sometimes who do need pelvic floor therapy. But those are only the people that are having musculoskeletal symptoms. If they're told it's an infection and they just think it's an infection that's coming back and back, they may not be associating their low back pain with, oh, there's actually a musculoskeletal disorder going on here that I need to address.
00:36:27
Speaker
So you're exactly right with that. And to touch on that more, and you and I have talked about this, I had no idea how pelvic and orthopedic got so separate. It should not be because it's all tied together. We're not talking about any of these things in isolation. But there is a very excellent paper that came out from our friends in Canada that showed that people who have low back pain or hip pathology, 90% of them had pelvic floor dysfunction too. And it's not being screened in ortho clinics. And maybe that's why some patients don't get better.
00:36:57
Speaker
And so we can also drop in the show notes. If you answer yes to some of these certain questions, it's a highly correlated with having a pelvic floor issue that should be evaluated. And so people may not, again, put some of the symptoms together or think it's separate. It's not.
00:37:16
Speaker
Yeah, I mean, people have a hard enough time when they come in and they've got pain in their back. And I'm like, oh, well, it's actually related to your shoulder. And they're sort of like, well, that's a totally different part of my body. And I'm like, well, it's pretty, it's pretty close. It's not that far away, you know, we got the switchers. Yeah, it's not that far away. And it's not things attached to other things. But I think, um,
00:37:35
Speaker
having any real understanding and I think it speaks to just sort of our historic lack of education and also there's a certain tabooness around this part of the body and depending on your culture or your community or your religious group that you're a part of or any of those things, you may or may not be able to consider it sort of freely and openly and go and seek help for it, right? It might be really difficult.
00:38:04
Speaker
Um, okay. Oh God. I could just, I like, there's so many things I want to talk to. We need a 24 hour session. I know. I know. Um, okay. So.
00:38:19
Speaker
Let's say, because I want to give our listeners some concrete things as
Role of Movement Teachers in Pelvic Health
00:38:26
Speaker
movement teachers. Let's say I'm a yoga teacher. I've got a private client that I'm working with. They came to see me because they're having low back pain, for example.
00:38:35
Speaker
And maybe I'm having a hard time figuring out like, oh, these kind of movements feel better or these things are helping or stuff like that. So what are some things that people can keep an eye out for that might indicate that actually this person needs to see somebody for their pelvic floor? Are there sort of tips that you can give us?
00:38:56
Speaker
Yes, so it starts out as something that may be a little bothersome, but not alarmist. And so one of the first things that can show up for people is after exercise, after a yoga session, they feel like they need to urinate like every 30 minutes, they have a little bit of urinary frequency, it doesn't hurt.
00:39:13
Speaker
But it's there. And I mean, I know for my own self, I'm somebody who if I do the elliptical, I have some pelvic obliquity. This is me, you know, I'm urinating for every 30 minutes and then you know, time gets away from the time I was doing the exercise and then it's fine again.
00:39:29
Speaker
I need to work on my pelvic floor myself. We're the worst. We don't do anything helpful for ourselves. So I've hurt my neck the other day and I was like, well, I'll just wait. It'll get better. I'm like, I'm still going to do it. And I probably need to see one of my staff, but we don't have time for that. So I mean, it does start out as like, you know, not bothersome. But again, if there's back pain or hip pain, I think people jump to strengthening before lengthening sometimes.
00:39:58
Speaker
And so listen to your body and see how you feel. And now that we're actually talking about these things, people may notice, oh, I have a little bit of pain with intercourse. Or, you know what? It's a little hard to evacuate my stool. It takes me 10 seconds to start my urinary stream. Again, nobody's going to really do anything about that. But those are like precursors to some of the
00:40:20
Speaker
provoked or the unprovoked symptoms that we've been talking about. But I think everybody should look at the little thing that we can drop. It's a screening questionnaire. If you answer yes to any of the questions in these four categories, you might have some pelvic floor issues that are going on.
00:40:35
Speaker
Great, I think that's gonna be a great tool for our listeners too, for themselves and for their clients. And I think as well, I mean, certainly when I went to PN, and you have to use this language far more often than I do, but I had to get over my own inner 12 year old boy to ask my patients questions like, any issues with incontinence? Any issue with fecal incontinence? Any, you know,
00:41:02
Speaker
is, you know, because I'm just extremely immature. And I think, you know, that having the screening questions, if there is anyone who feels like, oh, maybe even even if it's like, I don't feel like it's in my scope of practice as a movement teacher to ask somebody how long it takes them to start urinating. But if there is a sort of checklist of things that you can just hand to somebody and say, hey, you know, look through these, and if any of these are coming up, then probably we should also find a public floor person for you or something like that. I think that's that sounds like a great
00:41:33
Speaker
So thank you. Thank you. And they will be very grateful. It is within the scope of movement teachers to ask these questions. People come to us all different ways. And the one thing that we hear all the time is, why didn't somebody tell me? And because the physicians may not tell them, you have more time with your clients. You're with them more. And it is absolutely okay to ask. Yeah.
00:41:57
Speaker
and then warn them when I get here, I'm going to be like, how long did it take the Tarsus dream? How many seconds do you pick? Did it hurt? Do you sit down on the toilet seat? How much toilet paper do you need to use after a bowel movement? It's going to get way worse in here. All of a sudden though, they're like, oh, and they realize that we do know what we're talking about with these questions, but it gets really, we're getting them back. Yeah. Yes.
00:42:25
Speaker
All right, so we also have some questions that were submitted over Instagram and some great questions. So these are directly from people who listen to the podcast or who follow movement logic and have some questions of their own. So two of them are actually related. So the first one is, what are exercises you can do for stress, urinary incontinence? The second question that's related to this is, when I do box jumps or hopovers at the gym, I pee a little, how can I fix this?
00:42:54
Speaker
And you also spoke about the female athlete triad. Can you touch on that? Like what that is? And then I think these two people are sort of asking similar questions. Maybe the source of the stress incontinence is not, you know, box jumps, but it may be, you know, running for the bus or something. It's so fascinating too that you and I just did. I don't know how many minutes before we said the word Kegel. And not talk about that because it is so
00:43:24
Speaker
Our bladder function is actually more complicated, I think, than people realize. It's not just a weakness issue. There can also be what's called pelvic organ prolapse, which is a descent of either the urethra or the bladder into the vagina. And that can happen in different stages from just a little bit through the vagina, maybe, you know, the bladder may be coming out of the opening of the vagina, which is always alarming for people when that happens.
00:43:49
Speaker
But stress incontinence is a symptom where your neuromuscular self is not working as best as it can. And outside of prolapse, what can we do about that? So the first thing we can also talk about is having people listen, can they move their pelvic floor? Like as we sit here right now, can you squeeze? Can you push? Everyone starts to make faces, but because we, again, it works on its own, but we also have the ability to work with it. And in a normal situation,
00:44:19
Speaker
When we increase our intraabdominal pressure, the pelvic floor should contract with it. When people start to leak, they may be impairments, postpartum, perimenopause, things are just not coordinated as well as they should be. So it's not just about doing cables. It's about getting your pelvic floor to work again as part of your core. And for some people, they may need to lengthen before strengthen.
00:44:43
Speaker
And then a lot of people may need to do Kegels. And as part of core work, though, we usually integrate it with the breath and the transverse abdominis and learning how to control it actually when you're doing these higher impact activities. So it's going to be a range of things that can be provoking for people. Obviously, impact is going to be more difficult than static.
00:45:05
Speaker
or non-impact activities. And so you also kind of need to meet your body where it's at until you can get to what you want to do. And if box jumps are causing incontinence, I think the exercises need to be backed up. You need to figure out how to get the pelvic floor working as part of the core and then try that again. If there is pelvic organ prolapse, certain things like impact and squats past 90 degrees actually can make it worse.
Pelvic Health in Athletes and Pregnancy
00:45:31
Speaker
And so we also have to then maybe modify the activity because we're talking about what could potentially be a surgical situation. And it's hard for people because sometimes I am telling them I don't want you to do that right now and this is why. Let's keep it a short term temporary lifestyle modification and see how far we can get you. Right.
00:45:53
Speaker
And does that answer? Yes. Okay. The other part of the question was what is the female athlete triad? So that's an opposite end of the spectrum. So we see a lot of younger women who are gymnasts, ice skaters, equestrians, and their pelvic floor muscles are actually very tight in their teenage years. And as a result of that, they also leak during jumps and impact and sometimes urgent continents too. And that's because everything is actually tighter than it should be.
00:46:23
Speaker
They can't effectively close the muscles because they're too tight to keep themselves confident. They also may be in a hormonally deficient state. I mean, I know myself, I was a hurdler. I didn't get my period from January till March every spring when I was in high school. I had stress fractures. My career ended my senior year because of the stress fractures. I was in menopause.
00:46:44
Speaker
I wasn't menstruating as a teenager. That should not be the case. And so I also think that they need to consider that and look at it as a symptom that needs to be addressed. We have to work on making sure they have enough body fat for the exercises that they're doing and their hormones are okay. And then their pelvic floor can be too, but that crowd does not need to strengthen that crowd needs to be lengthened. And so it's a completely different treatment plan. Yeah. Yeah.
00:47:11
Speaker
Awesome, thank you, thank you. One of the other questions was, what is the effect of having a caesarean section on the pelvic floor? What's the effect of using, well, I guess this is three questions in one, effective using tampons, diva cup, et cetera. I would imagine the C-section has an effect.
00:47:28
Speaker
It does. And it's important to know that pregnancy has an effect. So regardless of the method of delivery, pregnancy by itself causes pelvic floor dysfunction. As our pelvic girdle has to relax to accommodate baby, pelvic floor muscles have to get tighter to keep things in order. And there's just a
00:47:46
Speaker
a laxity situation that goes on, especially during the third trimester with pelvic floor and girl consequences. So regardless of C-section or vaginal delivery, every woman should have postpartum physical therapy. And this happens in other countries with socialized medicine. It does not happen here. And if we do have that, all this prolapse and other stress incontinence would not happen because you need, why wouldn't you need rehab after pregnancy?
00:48:14
Speaker
So then the C-sections. I know, it's the same way. It's like, you know, you would get your ACL repaired and you're like, well, yeah, of course I need physical therapy. You just had an extreme, you know, dramatic, traumatic for a lot of your tissues. Event happened. Why would you not need assistance getting it back together? And I think a lot of women probably have that sense, but it doesn't seem to have made its way into the medical field. And it's certainly not automatic or probably not covered by inch. A lot of...
00:48:42
Speaker
Well, actually, the American Physical Therapy just put out something last week and the American College of Obstetrics and Gynecology is acknowledging this fourth trimester. But a lot of it's still it's the insurance problem. Insurance companies don't want to pay for it. And so postpartum is not a diagnosis.
00:49:04
Speaker
It's not right. So we've got to, we've got to call it something else. Stress incontinence back myalgia. They don't want to pay for that either, but all women should have it. And so with the C section, there's a special set of circumstances that can occur with the C section scar. Obviously it cuts through all of the abdominal muscles. So we are going to need safe rehab for the abdominal area.
00:49:26
Speaker
But because of where the scars are, there can also be ileo inguinal and genitofemoral morale that develop, which cause sensory changes in the labia, the clitoris, some of the super pubic area. And those nerves also go to the urethra. And so there can be urinary urgency and pain that can be associated with the C-section scar and the scar itself can hurt.
00:49:50
Speaker
And again, with manual therapy and proper therapeutic exercises can all be rehabbed, but women don't even know that they need it. And they've got a newborn they have to care for. So when it's baby number one, they're overwhelmed. And then add in baby number two, where they never rehab themselves from baby number one. And now they're really in a predicament and they have even less time. So it's, it's, I think it's tough for women and we just need to be set up better to care for people.
00:50:18
Speaker
And then what about tampons or diva cups or things that you're inserting, any issues for the pelvic floor that you see related to that? I don't. I think that however people want to control their menstrual cycle is fine. As women start to, if there is some vestibulodynia or some pelvic floor pain,
00:50:37
Speaker
the tampons may be uncomfortable going in and going out. That can also be an indicator they shouldn't hurt and you shouldn't be able to feel it. So if you feel either of these devices that you're trying to use, there may be something wrong. Yeah, okay. Slightly unrelated, but related to tampons. One of the things that I was told in terms of having stress urinary incontinence is if you wanted to sort of temporarily
00:51:05
Speaker
Not that this negates the need for therapy, but let's say you're going to a party and there's going to be dancing and you don't want to be worried about, am I going to go to the bathroom? One of the things I was told is that you can insert a tampon as a way of, I'm not even exactly sure what it does. I guess it just increases the pressure.
00:51:23
Speaker
or something and that would be a way for the duration of that evening where you want to have a good time and not be worried about, am I about to be leak here on the dance floor, that that's a good temporary solution. Do you agree with that? Yes. In fact, there's an even better solution that's commercially available, same concept. It's called the Poise Impressa and they come in sizes one through five and they're basically like big tampons that go like this inside.
00:51:52
Speaker
mostly help if people especially have incontinence because they have prolapse, it's going to help provide some support that they may not be getting from the connective tissue or their pelvic floor muscles. So I do advise people using them and they actually make people feel more comfortable, which I think is great. Also, I really like the thanks products. And they are basically underwear that are pads.
00:52:17
Speaker
And so you can use them either for your menstrual cycle or they have versions for incontinence. So if you know you're going to an event where this may be an issue, the combination of those two things is like a secret weapon for women. Nice. Okay. We'll definitely link to all of that. So we got a, this would be a long show notes, but I'm glad because I feel like the resources really aren't out there.
Solutions for Bowel and Bladder Control
00:52:36
Speaker
And, or if, if you're trying to find the resources, you have to go on some sort of expedition to get, to get anything. And, and it just needs to be more.
00:52:43
Speaker
more publicly known. Okay, the last question that we got from Instagram, is there any hope if you are 77 and have already lost control of bowel function?
00:52:56
Speaker
There's always hope. We need to know why you've lost control of bowel function. And a lot of times that is related to hormone deficiency pelvic floor changes. There can be, there's injectables that can be done now to help restore confidence to the sphincter. And again, a lot of women may go down the fecal incontinence route because they had an obstetric injury 50 years ago, maybe that they were able to
00:53:21
Speaker
sustain over time, but as we age, maybe not so much. So there are treatments that are available both on the medical side. And I asked, sorry, what is an obstetrics injury? Like pregnant childbirth injury. Got it. So sometimes people tear all the way from their vagina to the external anal sphincter. And they may struggle a little bit in the postpartum period, but they've got age on their side. And so with
00:53:48
Speaker
you know, some intervention, right, PT, they may be okay again until they start to get into the later decades of life. And I always think that there's a solution or probably more to be done. You just need to know how to find the people that can help. And a lot of times they're going to be dismissed, but there are experts out there that can help with that too.
00:54:08
Speaker
Okay. Would you recommend for someone in this situation going to a physical therapist route or going to just finding a different, your genital provider or something like that?
Collaboration in Pelvic Health Care
00:54:18
Speaker
I think pelvic floor PTs, we have to make our village of medical providers. So if the medical side isn't going the right way for somebody, go to a pelvic floor PT and they may be able to refer you to somebody that they work with that's more involved in the specific symptom that somebody has.
00:54:36
Speaker
That's how we work. A lot of our patients went to five, 10 doctors before finding us on their own, and then, oh, I'm going to send you to these two, and now we've got a completely different experience happening. Yeah. Okay. Awesome. Thank you. Was there anything you wanted to talk about that I didn't ask you or anything you want to plug or let people know about?
00:54:58
Speaker
We do listen to this as well. So if, if you're hiring, we are hiring and we have an excellent resident quality training program. Um, you know, experience is not required as we know pelvic floor physical therapy is not taught in schools yet.
00:55:16
Speaker
And so people may have interest in this field and they don't know how to get into it. So one of the missions of our company is to actually help with that. And we understand and we get it. Our experience was so unique and different. The more I look at it and the more I see what other people do to try to work in this field.
00:55:32
Speaker
You know, we were lucky. I had a great mentors and immediate learning curve with the amount of patients I saw that only had this issue. So yes, I want to encourage people if they are interested in this field to reach out to us. We have people come to our staff meetings. If people are interested at all, we try to create shadow experiences, student internships, that type of thing.
00:55:53
Speaker
I think the one diagnosis we didn't talk about was pudendal neuralgia, which I call carpal tunnel of the butt. Because people basically can feel carpal tunnel syndromes in men and women, urinary bowel, urinary bowel symptoms, and then they may have unprovoked pain in the clitoris, the penis, the perineum, the rectum. So that's also something that people can read more about if they're starting to experience that on our social media.
00:56:22
Speaker
And I just thank you for doing this podcast. I always love talking to you. I always love talking to you and I always learn so much. I want to thank you so much for taking this time out of your ridiculously... Stephanie and I have been trying to get together socially, I want to say, since January. Okay, we're going to do it this month. You're busy too.
00:56:44
Speaker
But thank you so much for coming on and for such an educational and informative conversation. I know that our listeners are really going to appreciate it. A note to you listeners, you can check out our show notes for links to all the references we mentioned in this podcast. And you can also visit the MovementLogic website where you can get on our mailing list to be in the know about sales on our tutorials.
00:57:05
Speaker
You can also watch the video version of this episode if you want to see what our faces look like while we think out loud and talk to each other and what my, quote unquote, recording studio looks like. I mean, let's be real, it's a closet. And that's at movementlogictutorials.com forward slash podcast.
00:57:25
Speaker
And thank you so much for listening and joining us today. It helps us out tremendously. If you liked this episode to subscribe and rate and review on Apple Podcasts or wherever you listen, wherever you're listening right now, it would be super, super appreciative if you did that. Please join us again next week for more movement logic, strong ideas loosely held.