Joey Wahler (Host): It's a common condition. So, we're discussing pelvic pain. Our guests are Beth Werner, she's a physical therapist, and Jastine Sahota, an occupational therapist. This is Silver Cross Hospital's iMatter Health podcast, where medical experts bring you the latest information on health topics that matter most to you and your family. Thanks so much for joining us. I'm Joey Wahler. Hi, ladies. Welcome.

Beth Leonard, PT: Thank you.

Jastine Sahota, OTR/L, PCES: Hi. Thank you, Joey.

Host: Hi there. Great to have you both aboard. So first, Jastine, for you, in a nutshell, what do we mean by pelvic health, and why is good pelvic health so important for people really of all ages and body types, right?

Jastine Sahota, OTR/L, PCES: Certainly. So as you said, any person with a pelvis, so that's sex of both female, male; and anyone with reproductive organs, uterus, bladder, rectum, that all sit in the pelvis, need those things functioning well for activities of daily living like toileting, sexual health, and even stabilizing the body. And so, maintaining pelvic health regardless of what age you're at really matters in terms of your quality of life. So, it helps us move well, helps us empty our bowels well, and it also helps us feel fulfilled when we have a healthy working pelvic floor.

Host: So, that being said, Beth, what are the most common pelvic health issues you and yours see, and what surprises patients most when they come in for care? Is there a common misconception about this part of the body on the part of most people?

Beth Leonard, PT: I would say the most common referrals we see are for people with urinary incontinence, urinary urgency, pelvic pain, constipation, and then a lot of women after postpartum, either they have problems during pregnancy or after pregnancy, or they just want to get ahead of not having problems in the future.

And then, I would say people mostly are surprised that pelvic health is not just Kegels. Most people think, "Oh my gosh, pelvic health, Kegels, Kegels, Kegels." But no, it's not just Kegels. There's a lot more to it than just that.

Host: And speaking of Kegels, good point. For those unfamiliar, tell us what you mean by that, please.

Beth Leonard, PT: So, Kegels are just a pelvic floor contraction. It's an exercise, just tightening the pelvic floor. They were named after a doctor named Dr. Kegel. And that's just the big buzz online, but it's really not appropriate for everybody to be doing Kegels.

Host: And Beth, who's typically most at risk for pelvic issues?

Beth Leonard, PT: Really everyone. So, anybody who has a pelvis is going to be at risk for pelvic health issues.

Host: All right. So, everyone needs to take heed of the conversation that is underway right here then. So, how about a pelvic health therapy session? Jastine, what does that look like, and how do you and yours help patients to feel comfortable and really empowered during that process?

Jastine Sahota, OTR/L, PCES: I love that you use the word empowered, because there should be a lot of collaboration between the therapist and the patient to really build a sense of trust, being that this is one of the most intimate part of our bodies that we are assessing. So, most people think pelvic floor evaluations and treatment will only silo the pelvis. But in fact, there's a full-body approach to it. We look at posture, we look at muscle coordination, breath coordination; even lifestyle habits, like are you drinking enough water? Do you have a lot of anxiety or stress that could be contributing to your pain?

And then, alongside with that, we do—with consent—a manual assessment of the pelvic floor structures of the muscles and see if they are tight, hypertonic, if they are weak, hypotonic, if there's any tender spots, and also checking for coordination along the way.

Host: And so, Jastine, what are some of the typical causes of pain in this part of the body?

Jastine Sahota, OTR/L, PCES: Typical causes. So, we can have a lot of musculoskeletal compensation. So very straightforward, certain muscles of the body are overdominant. And then, we have overcompensations. And sometimes the pelvic floor can be one of those overcompensating areas where, like, "We're going to be the lead of the group project," and then that can create a lot of high tone and pain for the patient.

Other possible contributors would be people with postpartum, post-abdominal pelvic surgeries, anybody who has a pelvic organ prolapse, that can be with or without history of pregnancies and childbirth. And another common one I'm seeing a lot more of lately is vascular contributions.

Host: So, Beth, the pelvic floor really supports everyday functions, sitting, lifting, exercise, work, even sleeping. And I would imagine many joining us right now don't know that necessarily. Give us a little bit of an idea of just how important that all is.

Beth Leonard, PT: So, the pelvic floor really works with everything throughout the day. And it has both voluntary and involuntary muscles, and they help with elimination, so both bowel and bladder elimination. But it also is part of our core. So, we've heard of our abdominals as being part of our core, but actually there's more to it than that. There's abdominals, there's our diaphragm, there's our back muscles. And then, also at the bottom of what we call a core canister is the pelvic floor. So, it interacts with everything we do, whether we're walking, lifting, pushing, pulling. Everything we're doing throughout the day, it has to support our pelvic organs. So, that's part of our core, and it's very important throughout the day.

Host: Absolutely. And Jastine, how about life events that tend to impact pelvic health the most? What are the ones that most typically could cause an issue here?

Jastine Sahota, OTR/L, PCES: Life events like surgical procedures; abdominal pelvic surgical procedures, because we can build scar tissue along the way; pregnancy, childbirth, regardless of the mode. So, vaginal and C-section can be a high risk factor for needing pelvic health support.

Host: How about as we age? How much of a factor is that?

Jastine Sahota, OTR/L, PCES: Certainly. We do get this question a lot like, "Do I have to do these exercises the rest of my life?" Everybody has to move their body in some way for the rest of their life. We put more maintenance effort into our cars sometimes. So, being able to put that effort into your body and moving your body.

Aging is definitely a factor. Muscles need strength. And the strength will support us along with the pelvic floor, because it's a group of muscles. So, we got to work at it.

Host: Speaking of exercise, Jastine, high-impact exercise can also cause pelvic pain, right? Especially if you overdo it or pull a muscle, right?

Jastine Sahota, OTR/L, PCES: Certainly. Yeah, especially breath coordination. A lot of people don't think about breath being a big aspect in pelvic care. But if breath coordination isn't on your radar and you're training for heavy load or a lot of jarring movements like plyometrics, then you can put a lot of demand on the pelvic floor and request a lot of demand on just a small group of muscles. And pelvic health can really help you integrate a full body coordination, full breath coordination to keep it healthy.

Host: So Beth, maybe pick up on that for us, please. When we talk about breath coordination, that's a new one on me. What do we mean by that?

Beth Leonard, PT: So when we move, we have to coordinate our breath. So, I would say the majority of time I see with people is we hold our breath when we're doing things. So whether you're lifting, pushing, pulling, we tend to hold our breath. And when we hold our breath, we increase what's called the intra-abdominal pressure, and that pressure can put pelvic pressure on our pelvic floor. And that can cause the pelvic floor to weaken. It can cause, you know, people to leak, cause prolapse, things like that. So, breathwork is super important when it comes to the pelvic floor.

Host: Yeah. I think, for instance, if you're lifting weights or doing any kind of physical movement, during exercise, you'll find that if you can get into a good, strong, consistent breathe in, breathe out routine, you'll be amazed at how much more you can do, right? Because otherwise you're holding yourself back, correct?

Beth Leonard, PT: Correct. And also, I'd like to point out that even when people are doing what we call functional activity, so even a lot of my older people are coming to stand up and they're holding their breath when they stand up, or when they're laying down and coming to sit up and they're holding their breath when they're coming up. So, that recreates that intra-abdominal pressure, puts pressure on our pelvic floor

Host: Now, Jastine, there's such a thing called pelvic floor exercises. So, how do people know whether they actually need to strengthen or relax or simply become more aware of their pelvic floor?

Jastine Sahota, OTR/L, PCES: This is where the internet is great for many things, and Dr. Google can sometimes lead us down a certain path. And without a therapist or at least a guided understanding of what's going on with muscle tone of the pelvic floor, you could possibly be doing something that might not be beneficial for you. So, understanding your pelvic floor strength or weakness or combination of both is typically very beneficial to tease out with an educated provider.

So, some people will get a hint of that need through a urogynecologist or a gynecologist, where perhaps they're going through a medical exam and they're like, "You know what? This was actually a bit tender. This was a bit painful or uncomfortable." So, that's a stepping stone that most of our patients will experience. And then, they'll get the referral over to pelvic health, and then we can really tease out what is going on with your strength or weakness or combo, and how can we fix that.

Host: Gotcha. So Beth, how is pelvic health connected to pain in other parts of the body? Lower back, hip discomfort, it's all connected, right?

Beth Leonard, PT: It's all connected, yeah. Like I tell everyone, hip bone's connected to the, you know, leg bone. So, the back, whenever we see people, we always tend to look at, like, their posture. We'll look at their back, their hips, their legs. Because whenever there's weakness or tightness, a dysfunction in one area of the body, then the pelvic floor can also take the brunt.

So, like the pelvic floor, for instance, if the hips are weak, the pelvic floor can take over to try to stabilize for the hips. So, that's where looking at everything in the body is important. So, not just looking at Google and saying, "Oh, I need to do these exercises," but having a therapist look and see, "Oh, what areas are my areas of concern? Where do I need to strengthen? Where do I need to stretch so that I can safely work my pelvic floor?"

Host: Jastine, how about good posture, something that many people overlook, take for granted? How important is that here?

Jastine Sahota, OTR/L, PCES: We mentioned a bit earlier about the concept of intra-abdominal pressure. So if we consider our torso just from like your collarbone, your rib cage, all the way down to your pelvic floor, the base of your spine, we look at this as a canister of pressure. Ideally, when we're breathing, we've got a piston-like motion of your diaphragm and your pelvic floor muscles moving as your breath comes in and out.

But if we are collapsed, rounded, flexed, hyperextended, favoring one side, that ideal canister of pressure then has a bit of imbalance. And so, that can change the amount of pressure that's put down on your organs. That changes the amount of pelvic floor expansion and contraction that you can get. And it really can also contribute to symptoms like stress incontinence or even just functional incontinence when you're moving around because too much pressure is put onto certain areas since we're kind of kinked up above.

Host: A couple of other things for you two. First, Beth, walk us through a little bit more please of what a typical session with one of you would look like. What are some of the basic kinds of things that you do to help these people out that are experiencing such difficulties?

Beth Leonard, PT: For like the evaluation, what we would do is do an intake, look at their history. And then, we do usually look at their posture, back, hips. And then, sometimes we'll do an internal exam, and some people get nervous about that. And the internal exam, some people, usually, for myself, I will not do an internal exam on the first visit because usually people are nervous about it. So, I'll explain it to them, go over anatomy, and then say, "Okay, we'll do the exam at the next visit if you're okay with it." But some people are not comfortable with that. So, there are times that I won't do an internal exam, and we'll just work externally, what we call externally.

So, from there, when we do the evaluation, when they come in, we will also then work on exercise. There'll be a lot of education. So usually, for pelvic floor therapy, there's a lot of education. People need to know how to do things throughout their daily life, like, learning about bladder health, learning about toilet posture. Just our activities, what we do throughout the day and what we do in the bathroom really affects our pelvic floor. So, I'm really passionate about educating the patients about how to really utilize their pelvic floor.

Host: Now, there's another term I'm unfamiliar with. So, clear up for us, Beth, what do we mean by good toilet posture? I'm guessing means just what it sounds like. Don't scrunch over and—

Beth Leonard, PT: Yes, don't scrunch over. And if you've heard of the Squatty Potty, that is something that we recommend here. So, a Squatty Potty or a stool under the feet. So, it helps to put your hips and your pelvis at a better position to eliminate better.

Host: Kind of similar to what a kid would use when going through potty training, right? Where there's that step ladder and it's got a little base on it, right?

Beth Leonard, PT: For sure, yes—which brings me to another point is that in this day and age with people on cell phones, that they should not be sitting on the toilet for long periods of time, more than five to 10 minutes.

Host: I suspect, Beth, that that is a conversation for a whole other episode, yes?

Beth Leonard, PT: Yeah, right.

Host: We can put that on the agenda. Jastine, how about the fact that I would imagine most people joining us and beyond probably normally consider pelvic health to be just a women's issue, maybe even only applying mainly to women of childbearing age. But again, talk to us about the fact that it can affect anyone.

Jastine Sahota, OTR/L, PCES: Yes, absolutely. We see a very good range of patient's age and gender here. And you can also get pelvic health conditions regardless of your female or male anatomy, meaning uterus owners or penis owners anatomy. So, your pelvic floor muscles are very similar regardless of what sex you are. When we stabilize our hip bones, everybody has those muscles.

So, people who are weightlifting, I see a lot of weightlifters, and you mentioned that before about having a lot of pressure put down on the pelvic floor. So, I get a lot of male patients who have pelvic floor pain from heavy lifting, or perhaps their posture is really bad and they really sit a lot hunched over. And you can irritate the nerves on the lumbar or sacral area. So, your lumbar and sacral plexus can be irritated as well. And whoever has a lumbar or sacrum has those nerves, and those nerves are innervating the pelvic floor. So regardless of your sex, it can be a concern. And so, I also see a lot of people with urinary incontinence and stress incontinence due to enlargement of prostate, whether it's benign or otherwise. But a prostate enlargement can be an issue too.

Host: And in summary here, Beth, you've both done such a great job breaking down some of the details here. To put a bow on this, if those joining us want to do just one or two things, job one, job two, simple things that anyone can do to take a step toward better pelvic health long-term, what would it be?

Beth Leonard, PT: Like I mentioned before, like the Squatty Potty or a stool underneath your feet when you're toileting. Don't sit on the toilet for more than five to ten minutes. And then, probably also avoid what we call just-in-case toileting. So, "I'm going out to the store. I'm just going to go just in case. I don't really have to go, but I'm going to go just in case." So, we can create bad habits when we do that.

Jastine Sahota, OTR/L, PCES: I just want to say drink water. Drink water. Eat fiber.

Host: So, to recap, folks, more drinking, less time on the toilet if possible, especially with your phone. And good posture when you're on the throne as they say, right? Folks, we trust you're now more familiar with great pelvic health. Beth, Jastine, as we've emphasized, information that anyone can use. Thanks so much again.

Beth Leonard, PT: Thank you.

Jastine Sahota, OTR/L, PCES: Thank you.

Host: And for more information, please do visit silvercross.org/pelvichealth. Now, if you found this podcast helpful, please do share it on your social media Thanks so much again for being part of Silver Cross Hospital's iMatter Health Podcast.