Episode Transcript
Lindsey Sandbeck:
In physical therapy, we’ve seen just a huge growth in women’s health, pelvic floor physical therapy. And partially I think it’s because social media – people are starting to see some of these things online and they’re realizing like, this isn’t normal for me to experience, or there are things that I can do now to help prevent some of these things in the future.
Courtney Collen (Host):
Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. We want to start new conversations about age-old topics from fertility and pregnancy to postpartum, managing stress, healthy living, and so much more. “Her Kind of Healthy” is here to bring you honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.
This episode is all about pelvic floor dysfunction, specifically what that is and when you should seek care. I have Lindsey Sandbeck, PT, and Melissa Pytlik Monson, PA-C, joining me for this conversation from Fargo, North Dakota. Lindsey is a physical therapist specializing in both orthopedics and women’s health, and Melissa is a physician assistant specializing in women’s health as well. Both of these providers work with patients at the Sanford Pelvic Floor Clinic in Fargo.
Thank you both, Lindsey and Melissa, for being here.
Both:
Hi. Thank you. Thanks for having us.
Courtney Collen:
To start, let’s talk about defining the pelvic floor. And I know I’m not alone here. I’m actually almost nine months postpartum as we record this. And before I was pregnant, I didn’t know what exactly this was or what it meant to have a healthy pelvic floor.
Lindsey Sandbeck:
Everybody has a pelvic floor, right? But we primarily focus on care for female patients. So the pelvic floor and two, I went through physical therapy school. I felt like I was really well versed in the muscle skeletal system and all the muscles. But even in PT school, we don’t get much education in the area of our pelvic floor. We get basically a lecture or two of, “Hey, this exists, but if you want to treat it, you need to get some more education outside of your graduate program.”
And so it took actually for me, going through my first pregnancy to dive into those muscles. So I was treating everything around the pelvic floor at the time, but it really took my pregnancy to learn more about those actual specific muscles that we consider the pelvic floor. And it was shocking. How did I not know this after I’d been practicing for a period of time?
So when we think about the pelvic floor muscles, the muscles themselves run from the front of our pelvis, so from our pubic bone all the way back to our tailbone. And then kind of from one side to the other, from like those sits bones, so where we sit. And so it forms this hammock. You’ll hear it called a hammock. You’ll hear it called a bowl. But basically it’s a group of muscles that sit in the bottom of our pelvis, but they have to work with a lot of other muscle groups to function well.
And so we can get into some of the different dysfunctions of when those pelvic floor muscles don’t work well. Sometimes it’s because they themselves are not working well. Maybe they’re too tight. Maybe there’s some weakness going on there, but maybe there’s an issue with some of the other surrounding things like the core muscles, the back muscles, how we’re breathing, our rib cage. And so yeah, it’s definitely a group of muscles that is not very well understood until we start to have some sort of dysfunction there.
And it’s always fun to bring out my models for patients and go, OK, so these are the muscles we’re going to be looking at today. And they, you know, they’re always shocked. I have that many muscles down there? I didn’t even know they existed.
Courtney Collen:
It is amazing to learn more about your own body. So it would probably be safe to assume that pelvic floor dysfunction is when things are not working properly.
Melissa Pytlik Monson:
Yeah. So I feel like a lot of times you know, the pelvic floor, again, we’re talking about those muscles and those supportive structures, but oftentimes people will notice symptoms related to a different organ system. And that’s oftentimes what kind of prompts us because that hammock, that basket is supporting reproductive organs. It’s supporting urinary organs and it’s supporting bowel. And so most oftentimes when we really start to think about the pelvic floor is when there’s something wrong.
When you’re noticing urinary urgency, urinary frequency, you’re noticing leaking from your bladder, you’re noticing pain with urination or if you’re noticing constipation or you’re noticing trouble controlling your bowels, people will also notice it when they’re having trouble healing after a delivery or if they’re noticing that the vagina doesn’t feel normal like it used to, or they’re having pain.
And so I feel like oftentimes from kind of the health care provider aspect of it, most people aren’t going to notice anything going on with their muscles. They don’t even realize really that those muscles are there and supposed to be providing support and functionality. Most oftentimes it’s a problem with their sex life or problems with going to the bathroom. And, I feel like because those tend to be a little bit more uncomfortable things for people to talk about or there tends to be some stigma about things, then I feel like oftentimes it’s a conversation that doesn’t happen as early on as it should.
Courtney Collen:
Well, that’s why this conversation is so valuable for women of all ages. Have you seen an increase in questions, curiosity or concerns from women surrounding pelvic floor health in your practice?
Lindsey Sandbeck:
In physical therapy? We’ve seen just a huge growth in women’s health, pelvic floor, physical therapy. And partially I think it’s because social media – people are starting to see some of these things online and they’re realizing like, this isn’t normal for me to experience, or there are things that I can do now to help prevent some of these things in the future.
And so it’s fun to see people coming in that are asking for some of these services or being proactive about these things and taking that control back in terms of their own bodies. And so I work with a lot of pregnant patients that are coming in and they may be coming just for some like low back pain or some hip pain. And so we start having the conversation about some of these other symptoms and then, oh, I can address this now even while I’m pregnant. It’s like, yes, there’s so many things we can do now to help prevent some of these things in the future.
And then things that they can just be aware of that hey, after baby, if you start experiencing some of these things, ask your provider to come on back and see me, and we can work through these things as you can kind of get ahead of it too.
Courtney Collen:
Melissa, you mentioned could be problems with sex life or when using the bathroom. Can we expand on what might be the cause of pelvic floor dysfunction and are there specific age groups where it’s more common?
Melissa Pytlik Monson:
Yeah, absolutely. So really it can be any age that you start to have problems. I would say some of the issues tend to be more common with increasing age, so definitely problems with bladder control or symptoms of pressure. Those tend to be seen more often the older that we get just because aging and gravity definitely work against us.
But things like pain, things like chronic constipation, those things can present from early on that can present from childhood. Sometimes, it is not really addressed until people are older. But yes, definitely can affect all ages. Definitely things that we see more commonly after surgeries, after pregnancies or after deliveries. And you know, it may be that it’s easier to have that conversation once you have had a major event happen and we’re acknowledging that your body has changed. So we’re asking those questions or people are noticing things that are different than they used to be.
Lindsey Sandbeck:
A lot of times too, when people are coming in, one of the first things that we look at are just some of what are our habits around some of our bladder and bowel things. And so being able to start addressing some of those things and kind of figuring out too, like what is normal or typical for somebody to expect? So how often should I be going to the bathroom during the day? Should I be getting up at night?
And so we start by addressing some of those things along with bladder irritants. And those things can make a big difference in terms of somebody’s ability to get more control just from that. So when we think about what’s normal, you know, going to the bathroom every two to four hours during the day is considered normal and then getting up zero to one time at night. And so that oftentimes is something where people can go, “Oh, OK, maybe I do need to change some of those things.”
You know, we grow up with that, like, “oh, we’re leaving the house, you better go just in case.” And then we start to kind of take some of those patterns as we go into the rest of our lives. And so we might be going a lot just in case we might be trying to sit down and we’re busy, we’re in a hurry, and so we might try to rush going to the bathroom and not really give our pelvic floor the time. And so being able to realize like, “Oh, I should just be able to relax these pelvic floor muscles to be able to urinate or have a bowel movement. I shouldn’t have to push either one of those out.”
So we talk a lot about how do you position yourself when you’re using the toilet. And so some of those things can help people that, you know, before they even have some of these dysfunctions, set themselves up for good bladder habits, avoiding some of the irritants.
So, you know, people talk about coffee and carbonation and alcoholic beverages. Some of those things are just more irritating to our bladder. And so realizing that, and that might be contributing to some of the symptoms we’re experiencing.
Courtney Collen:
Yeah. So important. How can we support our pelvic floor or be proactive about our health in this region?
Melissa Pytlik Monson:
Yeah, I think that’s a big part and I think again, it’s just kind of a lack of nobody told you so why would you know?
But I think one of the things that we see, especially over time is I think there’s a lot of what has been normalized as far as constipation, as far as bladder leaking. And so people don’t realize that they could be doing things differently. So I think one thing is just kind of being aware of your body and noticing like, “oh, I guess do I push when I have to go pee? Am I able to have bowel movement without sitting and pushing?”
And so I think a lot of it has to do with paying attention to your body. So if you are not having regular bowel movements or if you feel like you tend toward constipation, looking at almost nobody gets enough fiber in their diet. And so you know, having a goal of getting 25 to 30 grams of fiber in your day, making sure that you are getting adequate hydration.
But there’s also such a thing as too much hydration. So one of the things that I see commonly out on social media is you know, you need to drink half of your body weight, you need to have a gallon a day. And that’s not true for the vast majority of people. You know, you need to listen to your body and drink when you’re thirsty. Ideally your urine should be a pale yellow color. But kind of generally, if you’re getting about a glass with each meal and one to two in between, that’s typically adequate hydration.
And so getting enough that you’re staying hydrated, but not that you’re stressing your bladder out all the time by processing that much. So I think that’s a lot of what we talk about is making sure we’re getting adequate hydration. Of course, we want people to live and enjoy their life, so we’re not going to take away your coffee. We’re not going to say you can never have a beer. But it’s about finding that balance.
And each person will find too what really bothers their body and what doesn’t. And so you know, if you look at your day and you say, “Well, I drink about a pot of coffee and I have maybe a glass of water,” but your bladder’s probably not going to love that. And so of course we don’t want to take your coffee away, but we want to work toward a better balance. And so I think that’s a big part of it.
Like I said, fiber again – almost nobody gets enough fiber. And so getting fiber, getting your fruits and your vegetables you know, getting whole grains, paying attention to foods that bother your body. So common offenders would be things like dairy products. People can have a sensitivity to gluten, artificial sweeteners can be bothersome, red meats can be bothersome. And so kind of trying to pay attention to what you’re taking in as far as what are you eating and what are you drinking.
Another one is activity: Are you moving? So for your bowels to be moving regularly, it helps for your body to be moving regularly. And so not that you need to be running marathons or be a CrossFitter but getting some of that movement in every day.
Courtney Collen:
Yeah. So important.
OK, I have to clarify. So when you’re urinating, you should not be pushing, is that correct? That’s a dysfunctional pelvic floor?
Melissa Pytlik Monson:
Yeah. So I would say kind of like the idea of power peeing or you know, needing to push to start your urine stream or to feel like you fully emptied your bladder is not normal. Yeah.
Lindsey Sandbeck:
So we oftentimes see there’s actually a lot of people that have almost too tight of a pelvic floor and have trouble relaxing their pelvic floor. So oftentimes, especially when it comes to physical therapy, people think, “Well, all I need to do is some Kegels, like, why would I go see a physical therapist? I’ll just do my Kegel at home.” But they are definitely not always the answer and they can definitely make some things worse.
And so one of the areas that we see this in is when people feel like they’re needing to push their urine out and they’ve gotten so used to just doing it, whether they’re just in a hurry, but it’s a sign that those pelvic floor muscles might be a little bit on the tighter side, they’re having trouble relaxing. So when we urinate, our pelvic floor muscles need to just relax to allow that urine stream or that bowel movement to come out. And so we use things to position, you know, if people have heard of the Squatty Potty, any sort of stool that gets those knees kind of up a little bit past their hips to relax those pelvic floor muscles so that they can just sit down and go and not push that urine out.
Courtney Collen:
One vote for the Squatty Potty, by the way. It is amazing.
Lindsey Sandbeck:
Yes, yes. Yeah. Yeah. And I’ll say it like, before I learned about a lot of this stuff, when I saw a Squatty Potty, I thought that was like a white elephant gift. I thought, “Oh my God, that’s so funny.” And now it’s a, you know, important part of my life. And it’s something that I talk about way more than I ever knew I would for sure.
Courtney Collen:
Lindsay, you mentioned Kegels. I have to ask, what is a Kegel and then when is it appropriate to do them?
Lindsey Sandbeck:
So a Kegel is a pelvic floor contraction. And so just like any other muscle in our body, the pelvic floor needs to be able to fully relax and then be able to fully contract. So we want it to relax when we need it to, but then we also need it to contract if we are trying to hold on to get to the bathroom. And we don’t want anything leaving our body before it’s time.
And so a Kegel is actually just working on that strengthening. A lot of times though, there are some different components of that pelvic floor that are going on where we need to learn if it is appropriate. So if somebody does have weakness of their pelvic floor muscles where it’s appropriate to do a Kegel, we need to make sure that we’re doing it correctly. Most of the time in the office when I am doing my assessment, I’ll have people try a Kegel and they’ll say, yep, I’ve been doing my Kegels, I just don’t really feel like they’ve changed anything. And then they go to do their Kegel and they might be bearing down instead of lifting up. And so that makes a difference.
There’s also different types of muscle fibers, and so doing our Kegels a certain way, if we just do ’em one way all the time, we’re working certain ones but not the other ones. So we need those muscles to be able to move through the full range of motion or what we call mobility. And then we also need them to contract quickly. If all of a sudden you need to sneeze or cough and you want those muscles to contract quickly, they need to be able to do that.
And then we need them to have some endurance to be able to hold on when all of a sudden we need to go, but we’re not really close to a bathroom. So being able to use that Kegel. So finding those muscles, being able to isolate those muscles is important of just like, oh, those are those muscles of the pelvic floor.
But then we’re really finding through more research now that it’s great if that is appropriate for someone to do a Kegel, but then doing some of the other surrounding muscles. So really working on a lot of pressure management, working on their core, their diaphragm, their low back, their hip muscles. Those are all fantastic and they all need to work together for that to work in terms of some of the strengthening.
And then they’re not appropriate oftentimes for those patients that are having pelvic floor tension, their pelvic floor is already stuck up a little ways. And so if they start doing Kegels, they’re just playing into that tightness and that’s going to make their symptoms much worse. So with those patients, we don’t do Kegels, we’re working on relaxation exercises. So being able to find that full range of motion so that eventually we can lengthen them to then eventually strengthen them. But sure, we need that full range of motion, just like we wouldn’t work our bicep mid-range, we’re going to work through that full range of motion. Same thing applies to that pelvic floor.
Courtney Collen:
Appreciate you for expanding on that.
Melissa Pytlik Monson:
Yeah. Well, and I think it’s one of those things too you know, understanding pelvis versus buttocks. And so oftentimes what I will see is when I ask a patient to do a Kegel for me to assess some of that, oftentimes I’ll see them contract those butt muscles. And that’s great. Those are, I’m glad that you’ve got some strength there. You can contract those, but it’s not the same. And so sometimes what I’ll see is when patients will tell me, I’ve been doing Kegels, I’ve done them for years, it really hasn’t made any difference. But then when you evaluate and then you can’t fault them. Nobody’s taught you.
And so I think that’s a big part of it, too, is learning what is actually going on, what is involved and how to coordinate all of it. And again, nobody teaches you. So again, I think it’s one of those things where there tends to be a lot of shame or a lot of embarrassment or you know, I don’t know how my own body works. But that’s super common. And so that’s why it’s important that you have people that you can go to, to help you understand.
Courtney Collen:
Yeah. And I think speaking more broadly about this helps to educate because the more you know, the more you know.
Both:
Right. For sure.
Courtney Collen:
When a patient comes in with pelvic floor dysfunction, talk about the care journey briefly.
Lindsey Sandbeck:
We’ll talk through some of those habit type things and just kind of educate them on what is considered more normal in terms of frequency of going to the bathroom and some of the different bladder irritants, their labor and delivery history in terms of did you have an episiotomy? Did you have any tearing? How was your healing after that? And so we’ll talk through their symptoms.
And then I spend quite a bit of time talking to them about their pelvic floor. I have some different models that I use and explain like, these are your pelvic floor muscles. There’s different layers to your pelvic floor muscles. These are these different layers. These are what they do. And then that way they have a better understanding of why do I need to do this exam to find out some of this different information. And so I think that helps in terms of making them more comfortable for that other piece.
Because I hear that’s oftentimes from people, they’re like, “Well, I wanted to do this, but I was a little nervous about having the actual assessment piece done or the evaluation piece done.” But by the time we’re done talking about some of those things, we’re like, “OK, yes, I want to find out what’s happening at those muscles.”
And so I’ll go through a bit of an orthopedic screen in our pelvic floor clinic. It’s a little bit more limited down there compared to what I can do in my regular evaluation. But we’ll go through what is low back, hips, abdomen, what do those things look like, how are they breathing?
One of the first things that I’ll go through with most people is called diaphragmatic breathing. A lot of times people think that they’ve done it before and they’re like, how is it this hard to breathe properly? But the pelvic floor and the diaphragm have a very good relationship when they’re working well. So if we inhale our pelvic floor moves down. As we exhale, our pelvic floor will elevate. So that can really help patients in finding some of that range of motion just by breathing. And so we, we spend some time going through that because that’s oftentimes a little tricky.
And then we’ll go through more of that internal exam if the patient’s comfortable with it. Start by just looking on the outside similar to what Melissa’s doing in terms of just looking at those tissues, which then, especially if I’m seeing them, I can say, “Hey Melissa, what do you think of this?”
And then we’ll do that internal exam. I just use one gloved finger with a little bit of lubrication and I’m just working my way through those different layers of the pelvic floor looking for any areas of tenderness, any areas of tightness. And then we’ll do more of that strength assessment. Can you do that Kegel? Or can you do that pelvic floor contraction? Can you bear down and relax? Can you hold it for any period of time? Can you do some quick ones and have some of that coordination of the pelvic floor?
And then based on that information, then we can go into what’s going to be most appropriate in terms of a home exercise program. So do they need to start more with some relaxation type things first? Are they ready to start some strengthening? And that may include some, you know, I call mobility. Kegels, really moving through that full range of motion and practicing that breathing so that we can then get them up and start working on some of those other exercises so that if they’re in the gym, they’re able to support while they’re doing some of their other exercises.
So how do you get your rib cage over your pelvis so that your pelvic floor can work well for you and not leak while you’re exercising? Because oftentimes people stop exercising because they’re leaking. It’s embarrassing. And they’re like, “I just don’t want to deal with it.” So they just stop exercising.
So that’s one of the things we work towards is finding some exercises they feel comfortable doing, and then how can we progress them so they can get back to picking up their grandkids and, you know, groceries and all those things we have to do throughout the day.
Courtney Collen:
Yeah. Well, quality of life too.
Both:
Absolutely.
Courtney Collen:
That’s what it’s all about.
Lindsey Sandbeck:
Yes. I think that’s the biggest thing with this is I think sometimes it does become so normalized that people just start to think it’s normal. Right? It’s common, but it’s not normal. And so if you’re experiencing any of those symptoms that it’s time to have them checked out because you shouldn’t have to live with any of that at all. So there’s lots of different things that can be done to help those things and get you back to doing the things that you enjoy doing.
Courtney Collen:
Thank you so much.
Melissa Pytlik Monson:
And I think one thing that is important, you know, both of us having graduate level of education, having training, we have actively sought out additional training for these areas. And so I would say don’t be disheartened, don’t be felt brushed aside if/when you first bring something up maybe somebody in family medicine or internal medicine, primary care, this may not be something that is their niche that they have a lot of information about. But never be afraid to ask for the referral to say, I think something’s going on. And if you aren’t able to give me recommendations, there’s somebody who can.
And so you know, I think that happens commonly. That I’ll talk to patients, (and) they’re like, “Oh, I mentioned leaking when I saw somebody a couple years ago, but they didn’t really do anything about it” or, you know, “I guess there’s like medication, but I don’t really want to take a medication.” So just knowing that there are resources out there, and it might not be your primary because they have to know a little bit about everything. But they may be able to get you to a provider who can. And we have the really unique ability to have a collaborative approach from both a medical and a therapy perspective.
But usually no matter where you are, you can find somebody to be your starting point. And oftentimes, before I had the opportunity to be in a pelvic floor clinic in a prior practice I still knew who my PT resources were. So if it was stuff that I felt like I could start with, but you need that PT component. We can refer to PT or patients that have been referred to PT and they think, you know, I think there’s more of a medical perspective that we need on this. So just don’t hesitate to ask for the help and advocate for getting to where you need to be.
Courtney Collen:
Melissa, Lindsay, thank you both so much for your insight, expertise, and all that you do here at Sanford Health. I appreciate you.
Lindsey Sandbeck:
Awesome. Thank you so much for the opportunity. Thank you.
Courtney Collen:
I sure hope you learned as much as I did from our conversation today. For more information or to schedule an appointment and find solutions to improve your pelvic floor health, visit sanfordhealth.org. This was another episode of the “Her Kind of Healthy” podcast series, brought to you by Sanford Health. For Sanford Health News, I’m Courtney Collen. Thanks for being here.
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Posted In Family Medicine, Fargo, Gynecology, Menopause Care, Pregnancy, Specialty Care, Women's
