Desensitizing the Pelvic Floor: One poop, pee and orgasm at a time!

I’m a pelvic floor physical therapist which means I casually talk about the things that most likely make you uncomfortable: pooping, peeing, sex, orgasm, pain in your vagina and penis…..yes, I just said vagina and penis and sex all in one sentence. These words have become normal, everyday things that I talk about. I no longer wince and I can openly have a conversation among friends describing what I do for a living. Although, sometimes I do wait until after dinner is finished to really get into the nitty gritty! 

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It is (one of) my mission(s) to de-stigmatize and encourage more open, matter-of-fact conversations about the pelvic floor and ultimately what the main point of having a well-functioning pelvic floor is; to painlessly excrete waste (urine and feces), support our pelvic organs, and provide enhanced sexual experiences. There are a couple other functions of the pelvic floor but those three are the most exciting ;) 

So, since we all poop and pee daily (well, hopefully daily...if not, maybe you should call me) and we all want our organs to stay in place and a majority of us crave some form of sexual pleasure (it is 100% okay if you don’t), why can’t we talk about it? I’m not saying we need to discuss every time we have a bowel movement and what it looked like. BUT, if these topics weren’t so taboo in our society, then when something wasn’t feeling quite right, we might be more apt to bring it up with a friend, family member or healthcare practitioner and get the help we need sooner rather than later. 

Pelvic floor physical therapy is much more than teaching how to perform kegels. As a physical therapist who specializes in pelvic floor, I teach how to integrate your entire core (pelvic floor, diaphragm, deep back muscles, and the deep abdominal muscles) into your every day routine. I educate on how breathing can make a significant impact on chronic pain, indigestion, and how breath can help you learn how to activate muscles. I talk about proper positioning for having a bowel movement and how many seconds you should pee for to know that you are in control of your bladder and not the other way around. I focus on bringing the “black box” of the body out into the light, educating on it, and help to make talking about it less stigmatized. The more we feel comfortable talking about these things, more people will know about conservative measures for their pain and dysfunction; less unnecessary surgeries will be performed and less people will suffer thinking they are alone in their pain.

Want to talk about all things related to pelvic floor, learn about your entire core and how to use in to improve function and strength, or know you need to see a pelvic floor PT and just haven’t made it happen? Contact me today and let’s get the conversation started!

Can You Prevent Perineal Tear During Labor? What the research says!

Have you ever wondered if there was a way to reduce your risk of experiencing a perineal tear during vaginal delivery? Well, there are things you can do proactively to try to prevent tearing but the jury is still out on whether it actually helps. Just like how the jury is still out on whether the type of stretching (active vs. static) and stretching pre- or post-activity will actually help prevent injury in sports, the research is limited and somewhat inconclusive as to what you can do to help prevent perineal tears during vaginal delivery.  So let’s talk about it!

First off, let me explain some basics:

Spontaneous tears during vaginal delivery happen in 44-79% of women (Soong and Barnes 2005; Dahlen, Homer et. al. 2007) and the tears can range from a 1st degree tear (tearing only of the perineal skin) to a 4th degree tear (perineal skin, muscles, anal sphincter and surrounding tissues). 4th degree tears happen in in 0.25%-2.5% of spontaneous vaginal births (Byrd, Hobbiss et. al.2005; Groutz, Hasson et. al. 2011).

What does the research say?

In 2006 Beckmann and Garret combined the results from four high quality research studies done on perineal massage and its effectiveness. They found that women who were assigned to do perineal massage had a 10% decrease in their relative risk for perineal tears (relative risk - the number that tells you how much doing something you do, such as maintaining a healthy weight, can change your risk compared to your risk if you’re very overweight).  So, if your absolute risk for experiencing a spontaneous perineal tear during vaginal delivery is 35% and you do a perineal massage as prescribed to decrease your relative risk by 10% then you will have decreased your absolute risk for experiencing a spontaneous perineal tear from 35% to 31.5% (0.35x0.1=0.0315). These findings are for first-time moms only.

Other findings:

  • Second-time moms who had delivered their first child vaginally did not have a decrease in perineal trauma (any tearing that requires stitches) whether they followed a perineal massage protocol during pregnancy or not.

  • Second-time moms who followed a perineal massage protocol did report a 32% decrease in the risk of ongoing perineal pain at three months postpartum.

  • Perineal massage during pregnancy decreased the overall risk of perineal trauma (any tearing that requires stitches so this includes non-spontaneous tears such as an episiotomy) but the research is too weak to see if there are any differences in outcomes of types of tears (1st-4th degrees)

To massage or not massage?

As long as you are not massaging and stretching into pain then I say go for it! As a pelvic floor specialized physical therapist with a background in sports and orthopedics, I tell patients who ask about stretching before running or other athletic events that the research is inconclusive so as long as it feels good to you and you are not stretching/massaging into pain then they should do it. I take the same approach with my pregnant mommas. If you feel comfortable doing it and you are not causing pain then go ahead. Will you not experience a perineal tear during vaginal delivery if you do perineal massage? The research says that it does not make much of a difference. However, it can’t hurt (as long as you are listening to your body and not pushing into pain) so why not right?

My biggest piece of advice I give to expecting mommas who want to be proactive with their musculoskeletal health is to pay a visit to a pelvic floor physical therapist in the 2nd trimester. You will learn how to correctly contract and relax your pelvic floor muscles, how to do a self perineal massage, and other stretches and exercises that will set you up for a speedier and healthier recovery postpartum. The research DOES show that pelvic floor physical therapy during pregnancy improves women’s outcomes postpartum!

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Have questions? Don’t hesitate to contact me! I love helping women navigate the beautiful waters of pregnancy and postpartum life! There are resources out there (me!) for expecting and postpartum mommas so why not use them?!

carolyn@verityptw.com

615.604.5367

STOP PEEING AT NIGHT: How proper sleep habits will decrease the need for nocturnal urination

What do your pre-bed/sleep habits have to do with the pelvic floor? Well, not a TON but, I promise to make the connection. As a pelvic floor physical therapist, I teach that it is not a healthy sign if you have to get up to pee in the middle of the night. When a patient reports that they do get up once, twice, three times per night to go pee I will discuss things like bladder irritants, hydration intake before bed and teach habits to “retrain” the bladder. These things are all very important to continue working on but there’s another aspect to why we shouldn’t be getting up in the middle of the night to pee; it’s a sign that we are not reaching the very important REM (rapid eye movement) cycle! 

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A lot of great things happen in our body during REM. It is a very important stage of sleep that influences learning, memory and mood. It is also one of the times when antidiuretic hormone (ADH) is released. ADH’s most important role is to conserve the fluid volume of your body by reducing the amount of water that is passed out through the urine. When fluid needs to be conserved and not expelled, ADH secretion increases and we urinate less. When we are properly hydrated, ADH secretion decreases and we urinate at the normal amount (every 2-3 hours and the flow should be strong for 8-12 seconds). 

ADH plays an important role in hydration but it also plays a huge role in our ability to sleep through the night! A well-hydrated adult should need to urinate every 2-3 hours. So, how are we supposed to be able to sleep 8+ hours straight without urinating? ADH! When we fall into REM sleep, ADH release is increased which decreases the amount of urine that is produced, we do not have to pee as much and, voila! We are able to sleep without peeing! 

The takeaway:

If you rarely fall into your REM sleep cycle, your ADH secretion will not increase, you will continue producing urine at the “daytime” rate and you will inevitably have to pee during the night. 

What to do about it:

Practice good sleep habits so you can fall into your REM cycle, increase your ADH production and NOT have to get up in the middle of the night to pee! If you chug a 32 ounces of water an hour before bed then inevitably you may have to get up to pee. Also, alcohol prevents ADH release which will cause an increase in urine production and dehydration. So, if you had a glass of wine before bed, this most likely will cause you to have to pee during the night. 

Healthy Sleep Habit suggestions: 

  1. Set a consistent sleep schedule - go to bed at roughly the same time each night. 

  2. Have regular bedtime rituals - take a bath, listen to music, meditate. These should be relaxing activities and so that you cue your body that it is time to go to sleep. 

  3. Get regular exercise but make sure it is at least 2 hours before bedtime. 

  4. Limit caffeine and avoid nicotine - these are stimulants and will interfere with your sleep. Try to stop caffeine intake after 12. Withdrawal from nicotine will initially interfere with sleep. However, once you are past the withdrawal phase, you should be able to sleep better (studies show).

  5. Don’t eat a meal right before bed. Try to eat dinner at least 2 hours before bedtime. A light snack before bed has been shown to promote sleep however. 

  6. Avoid alcohol - although alcohol is a sedative and initially promotes sleep, it will interfere with the quality of sleep; you will wake more often and might have increased nightmares.

  7. Keep naps short to increase your “sleep debt” during the day to help you fall asleep easier. 

  8. Use your bedroom for sleep (and sexual interactions) only! Try not to eat, watch TV or use other electronics in bed. You want to associate your bedroom with sleep and not other things that might trigger stress. 

  9. Stop screen time 2 hours before bed - using screens (TV, cell phones, tablets, laptops) can damage our biological clock. The light emitted “confuses” our brain and makes us think its daytime.

  10. Make sure your bedroom is cool, quiet and comfortable!

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COMMON ≠ NORMAL

All too often I hear things like, “oh ya, I pee my pants when I run but I’ve had kids so it’s totally normal and that’s life.” Or, “I can’t jump on the trampoline with my kids because I pee my pants and I just live with it.” I hear this one less often than the “pee my pants” one but, in my opinion, hearing it once is one too many times, “sex is uncomfortable and less enjoyable after having kids.”

My newest schtick is educating on the saying “common does not mean normal.” Yes, leaking urine after having children is common. Muscles, fascia, ligaments all get stretched out during pregnancy and childbirth. This can cause changes in strength and alter the ability of the muscles of the pelvic floor, core and glutes to function correctly and in unison. These changes will affect your ability to create pressure enough to close off the urethra (where our pee comes out) and possibly your rectum and can lead to unwanted leakage. However, just because these changes and stretching happens during pregnancy and with childbirth, does not mean long standing effects from these are normal and should be lived with.

Along with urinary incontinence, I also hear women stating that their experience sexually is uncomfortable and marginally (sometimes extremely) painful ever since having children but they live with it because “that’s just what happens after experiencing childbirth.” Again, things do get stretched, pulled, irritated, torn, changed, during pregnancy and childbirth and some women experience these more than others. However, living with less-than-satisfactory sexual interactions that are considered to be due to the physical act of childbirth should not be considered normal and do not have to be “lived with”. Pelvic floor physical therapy can conservatively and effectively help to decrease incontinence and dyspareunia linked to childbirth. Whether you are 6 weeks postpartum or 6+ years, pelvic floor PT can help make a difference and improve your quality of life.

Here are a few reasons why you may be having incontinence or dyspareunia:

  • You had tearing during childbirth that was stitched. Everything is back together and that is great. However, you may have scar tissue from the tearing. Scar tissue can grow like a spiderweb below the scar and adhere onto other structures. This adhesion pattern will affect the muscles ability to contract and relax appropriately thus decreasing strength. Adhesions can also cause pain. Similar to when you pull a bandaid off of your skin, scar tissue that has adhered down can pull on structures and cause pain.

  • You think you are performing kegels correctly but you’ve never been formally taught or checked. I have treated many women who say they are doing their kegels religiously but still leak. When I do an internal examination I find that they are squeezing their glutes and abdominal muscles but have very little activation in the muscles of the pelvic floor; the ones that ultimately keep us from peeing our pants!

  • Tightness! Muscles cannot be strong if they are too tight. Imagine that you can only straighten your elbow 50% of the way. Your bicep muscle (the one that bends your elbow) can only be 50% strong. For it to have 100% strength, it must be able to stretch out fully. This concept is the same for the pelvic floor muscles and is actually heightened due to the size of the muscles “down there”. The pelvic floor muscles are small and do not have much excursion (amount of distance a muscle can stretch and then contract) to begin with. Therefore, if they are at all tight, the strength is going to be severely affected.

How can we help these things?

  1. Learn how to correctly contract and relax your pelvic floor muscles (also known as doing kegels). The best way to do this? Go see a pelvic floor PT who does internal work!

  2. Assess for tightness around the hips, groin and pelvic floor muscles. Again, a pelvic floor PT who does internal work will best be able to assess this for you.

  3. Work to decrease scar tissue adhesions through manual internal release.

Remember, common does not have to mean it is your new normal! You can do something about your pelvic floor symptoms and improve your quality of life!

Contact Verity Physical Therapy & Wellness today to schedule your assessment!

INJURY SPOTLIGHT: The Role the Obturator Internus Plays in Hamstring and Hip pain

Do you have hip pain? Do you have hamstring pain? Have you been told that you have hamstring syndrome? When asked to describe where your pain is, do you feel like you need to point “up there” to really pinpoint the location of pain? If you answered yes to any of these questions, your obturator internus muscle could be contributing to the pain and dysfunction that you are experiencing.

The obturator internus (OI) is a hip muscle that originates deep within the pelvis, wraps out and inserts on the posterior aspect of the femur head (the top of the thigh bone when it combines to form the hip joint). The main movement function of the OI is to rotate the leg externally. In addition to external rotation, the OI plays a major role in stabilizing the hip joint and is an important pelvic floor muscle.

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The picture on the right is depicting the OI in green and is being viewed from behind.

Muscle Dysfunction and Trigger Points

Just like any other muscle in the body, the OI can become dysfunctional and trigger points (TrP) can arise for various reasons. In general, TrPs are an involuntarily contracted group of muscle fibers within a whole muscle. Because the TrP is involuntarily contracted and we cannot consciously relax the muscle fibers, blood flow is restricted to that area of the muscle as well as surrounding nerves and other tissues. This decreased blood flow can then result in hypersensitivity directly at the site of the TrP as well as aching pain in and around the area.

TrPs can be latent or active. A latent TrP is one that does not cause pain unless provoked, like with direct pressure during a massage or foam rolling. An active TrP is one that is painful without provocation. A latent TrP has the ability to become active and therefore start causing unprovoked pain. Both latent and active TrPs have the ability to refer pain to other areas of the body based on the referral patterns of the muscle that the TrP is in. OI trigger points can refer throughout the hip and leg on the side that it is originating from and often refers pain into the posterior hip (glute region) and hamstring. This common referral pattern is a large reason why many patients do not have resolution of pain after treatment of a hamstring or glute syndrone diagnosis; their pain is manifesting in the posterior hip and/or hamstring but the origin of the pain and dysfunction is from the OI muscle.

Is it the OI?

Having had personal experience with OI Dysfunction and treating patients with the issue, I have found that there are a few initial cues that help to tease out whether a patient is suffering from OI dysfunction versus hamstring, piriformis and/or gluteus medius syndromes. The first major sign is that the patient has difficulty pinpointing one location of pain. This is because of the many different referral patterns that the OI muscle has. Patients might say one day that they have pain on the outside of their hip or the pain is in the buttock region. Then, on another day they might describe a burning-type of pain at the insertion of the hamstring muscle at the “sit bone”; or maybe all three at once. Upon further investigation of these muscles with deep palpation, the patients might report that there is soreness in the area but that is not their “familiar pain”.

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The next appropriate question focuses on locating where the exact familiar pain is as best as possible. This can be achieved by ruling out other muscles first. When asking a patient to pinpoint the exact location of the majority of their pain I ask it three ways. First, I ask by pointing to a spot directly over the piriformis muscle. Second, I point to the origin of the hamstring muscle at the “sit bone” (red arrow). And thirdly, I ask is it “up there” (green arrow)? If with deep palpation just medially to the “sit bone” and above the bottom of the butt cheek, familiar pain is reproduced you could be suffering from OI Dysfunction.  

OI Dysfunction Symptoms

The pudendal nerve runs in close proximity to the OI muscle. If there are latent or active TrPs in the OI, the pudendal nerve can get irritated and cause nerve symptoms such burning, pins and needles, shooting pain into the pelvic floor area or weakness of the pelvic floor muscles. The pudendal nerve is highly involved with pelvic floor functions such as helping to maintain urinary and fecal continence through innervating many of the pelvic floor muscles as well as providing sensation to the genitalia. Entrapment of the pudendal nerve is very rare and mostly seen in professional cyclists, however, irritation of the pudendal nerve can cause pelvic floor dysfunctions and the OI muscle could be playing a part in that irritation. Alleviating the irritation through manual work to the OI muscle, stretches and tailored exercises can significantly reduce symptoms and help prevent more permanent injuries that may occur with prolonged nerve irritation.

Many patients seek physical therapy to alleviate their hip and leg pain that they experience with running and biking but do not have full resolution. Evaluation and treatment of the pelvic floor, specifically the OI muscle, can significantly improve symptoms and help patients return to their sport pain and dysfunction free!

Carolyn Yates, PT, DPT is an athlete herself and is skilled in treating all musculoskeletal pains and disorders. She has taken extensive continuing education courses on how the function and mobility of the pelvic floor can effect your athletic abilities.

Verity Physical Therapy & Wellness can help you through any musculoskeletal pains or dysfunctions you may be experiencing. Contact Verity today to schedule an appointment.