Bob Underwood (Host): Understanding bladder and bowel control can be difficult, especially when problems with continence can have many different causes. So, let's explore continence and the important role that the core and pelvic floor muscles play in controlling the bladder and bowels. This is Southwest General Health Talk.

I'm Dr. Bob Underwood. I'm here to discuss this important topic is Doctor of Physical Therapy at Southwest General Health Center, Trish Strazar. Dr. Strazar, thank you for being here with us today.

Trish Strazar, DPT: Yes. Thank you for having me.

Host: Sure. Now, when we talk about continence, what does that really mean? And what symptoms might indicate that there's actually a problem?

Trish Strazar, DPT: So basically, continence is your ability to control your bowel and your bladder function. So, a lack of control would be considered incontinence. And that's what we treat, is the incontinence. And that's the accidental leakage of urine, stool, gas that people start having a lack of control in. So, that would be considered incontinence. So if you find yourself accidentally leaking urine or passing gas in situations that you should not be doing so, we would consider that incontinence.

Host: Sure. Now, we talk a little bit about the pelvic floor and the core. And we might have friends that go to the gym say, "Yeah, I'm working on my core." So, what does that really mean? What muscles make up the core? And what role do those play in everyday movement and body function?

Trish Strazar, DPT: So when people talk about the core, they're actually talking about the muscles in the front of your torso, all of your abdominal muscles. Now, there are several abdominal muscles. You have your rectus femoris, which is your six-pack muscles. Everyone wants to have a nice six-pack. Then, you have the muscles on the side. I call them the side guys. They're your obliques. You have external and internal obliques, which also help to hold your abdominal contents in. And then, you have your transverse abdominis, and some people actually have a pyramidalis. And what these muscles all do is they hold all your organs in to keep your organs in the best alignment.

So when people are talking about core, that's what they're working on. And what I tell my patients is the core is the center of your universe. If you don't have good core control, nothing else that moves off the core will be working as effectively and as efficiently as it can, such as your hips and your shoulders, your knees and your elbows.

Everything works best when it's moving off of a strong and stable core, and that's why strengthening the abdominal wall is so important. One of the things I call the core is your corset. We all know about the corset that everyone used to wear around their belly to keep things pulled in. And by strengthening your abdominal wall, that becomes your natural corset. People ask me, "Well, could I wear a back brace or a lumbar brace?" And you can, but you're best served to strengthen the muscles that you're born with, and those are your core muscles.

Host: Absolutely. And that was a great visual to try to understand where those muscles really are. Now, the next part of it, of course, is the pelvic floor. So, how does the pelvic floor work with the core?

Trish Strazar, DPT: Well, first of all, understanding what your pelvic floor muscles are. Your pelvic floor muscles sit at the bottom of your trunk. They're the muscles that surround the vagina, urethra, rectum, and they act a sling or a hammock. So, think of this hammock that surrounds these openings. And when the hammock tightens, it lifts the organs and closes up the holes. And when the hammock relaxes, that's when we go to the bathroom voluntarily. We relax those muscles, and it allows us to have normal evacuation abilities. So, understanding the pelvic floor's function is really important. The pelvic floor is unique because, again, it has to relax to go to the bathroom, but also has to tighten at times.

So, say, when we cough or sneeze or lift something heavy, the core and the pelvic floor have to be able to tighten and support our organs so everything's just not going all over the place. And so the pelvic floor works very intimately with the core. They've got to work as a team.

One of the analogies I was going to use is like a paper bag and you fill your paper bag with groceries. And if the side wall of the paper bag is weak, like your abdominals, your groceries will spill out the front. But if the bottom of the paper bag is soggy or wet and you go to lift that bag up, all the groceries fall out the bottom, right? And that's the job of the pelvic floor is to keep everything up and in and supported.

Host: Oh, that's a wonderful analogy too. So, how do the core and pelvic floor help control the bladder and the bowels? I mean, I understand the support part, but how does it help control the bladder and bowels?

Trish Strazar, DPT: So again, the two work together as a team, and we don't really appreciate how smart our body and our muscles really are. And again, when you have that involuntary cough or sneeze that sneaks up on you, your core should automatically tighten, as should your pelvic floor to tighten to lift your organs up and away so that you don't have involuntary leakage.

So,, it's really a wonderful mechanism, and I just really appreciate that. And it's important for patients to learn how to engage those muscles voluntarily because sometimes, for a variety of reasons, that action of the core and the pelvic floor working together just no longer happens automatically.

Host: Understand. So, what can weaken or disrupt these muscles and lead to problems with continence?

Trish Strazar, DPT: So, the number one reason that a lot of people have weakness in their pelvic floor and difficulty afterwards is the most obvious one, and it's pregnancy. And when a woman is pregnant and they're growing a human being inside of them, this baby is taking up space, pressing on organs, and it'll press wherever it can. And it'll press on that bladder, press on the bowels. That's part of the problem, is actually growing the human. And then, the second problem comes in when you actually have to birth this baby. If they have a vaginal delivery, the trauma to those pelvic floor muscles really causes issues down the road with that pelvic floor being able to support and sustain contractions when it needs to.

If you end up delivering with a cesarean section, there is a cut that goes through your abdominal wall, and that's that relationship again. If the abdominal wall is not supporting those lower organs, you may start having problems with incontinence as well. So childbirth, number one.

Number two, in men, and I do see a fair amount of men, men who have prostate issues like prostate hypertrophy, where they end up having to have a prostatectomy where the prostate is removed, all of a sudden they lose that little faucet gauge, that little spigot, and men who are not used to having to engage their pelvic floor now have to. And so, prostate issues in men is a big reason why we have issues with incontinence.

And then, there's just people who have trauma. You know, they lifted something heavy, they're runners, there could be several other reasons why the pelvic floor stops functioning as well as it should. But certainly, childbirth, prostate issues. Another one is menopause in women. As women's hormone levels change, they lose that integrity in their muscles or the ability to keep things firm. And we know that happens in the normal aging process. Things are not as firm as they used to be. So, that can also lead to incontinence issues.

Host: Sure. And I think that really led to the next question, which is continence issues are associated with pregnancy, aging. What about other stages in life? And I think you covered a lot of those, but are there other medical issues like, say, neuromuscular diseases like multiple sclerosis, for example.

Trish Strazar, DPT: Sure. So, anytime there is a neuromuscular issue as in demylenating diseases like multiple sclerosis or ALS, when you lose the normal ability to get your muscles to function on command, that certainly leads to continence issues. And a lot of it depends on whether the patient has too much tone or not enough tone, and that's where having a good examination and understanding the disease process really comes in.

But again, I know I spoke briefly on it. A lot of runners have incontinence issues because with running and no matter what age, they find that they just lose the ability to control when they have to have a bowel or bladder issue. So, runners have a problem and then, you know, everyone's into weightlifting, and I get a lot of young athletes, especially your young football players, wrestlers, they want to see who could bench press the most amount or squat the most. And if they don't have control over their lower abdominals and their pelvic floor, all of a sudden, they're wondering why they're having accidents. So certainly, the incontinence can affect people with neuromuscular issues, other disease processes, and the young athletes.

Host: So to your specialty, how does physical therapy help someone improve bladder or bowel control?

Trish Strazar, DPT: So, one thing a lot of people don't understand now is that the profession of physical therapy has elevated, even in my career time, to the doctoral level. So, we are all doctors of physical therapy, and we go through a little bit more extensive training to be able to diagnose and treat different issues, different neuromusculoskeletal issues.

So, physical therapists are uniquely trained to address the nerves, the muscles, the joints, in particular with dealing with incontinence. A physical therapist would evaluate to see what is the specific problem that is causing the incontinence. You can't just go in and give a blanket exercise for everybody. There's a specific program for each person depending on their need.

Host: Sure. So, what might a patient expect? I'm guessing there would be some way to diagnose or to help figure out what that need is during pelvic floor physical therapy, or at least at the beginning of it. And then, what might they expect?

Trish Strazar, DPT: Right. So whenever patients are referred, they're always a little bit frightened by what to expect because, you know, the pelvic floor is a sensitive area, unlike coming in with a rotator cuff tear. But I know in my practice, the first evaluation is coming in and having an extended conversation. Find out what's been going on in their life that may have caused the incontinence issue.

Then, what I do is I always look at the surrounding joints. You know, I'm looking at how their spine is moving, how their hips are moving. I'm going to look at a flexibility of the back and the hips, range of motion, strength of the back and hips. And then, usually, in that first day, I personally don't dive into doing an external or internal pelvic evaluation that day because many times the issue they're having is more related to a spinal or hip issue. So, there are plenty of things I can give patients to do after their first day.

If they do need an internal evaluation, that usually won't happen till the second day. And the, way I explain this is this: if you have a biceps issue, I want to be able to touch your biceps and test it to see if it's working. Well, if one of the muscles of your pelvic floor are not working, I need to be able to touch and test it to see which muscle it is. So, it's a muscle just like any other joint of the body. It just happens to be in an area that for many people is a private area. But again, you're dealing with medical professionals that are used to, you know, treating, evaluating musculotendinous things.

So, sometimes our evaluation and treatment involves internal work. One of the things I use in my practice is biofeedback, where we can use electrodes to determine how the muscles are functioning. And it's actually a very effective way to, to treat muscle dysfunction because the patients can see what their muscles are doing when we use an electrode to create a graph on the computer, and they can see if their muscles are tightening, relaxing. And I found it to be a highly effective way to rehabilitate pelvic floor dysfunction

Host: Yeah, and that's phenomenal. And then, from there, they can have rehabilitation exercises just depending on what you find during that initial evaluation.

Trish Strazar, DPT: Absolutely. So, we definitely tailor our treatment program based on what your issues are. So, you know, what your friend's issues are might be different than your issues, just because everyone has pelvic floor. Sometimes, believe it or not, it's a relaxation issue. The pelvic floor is so tight that when it comes time to prevent an involuntary leakage of urine, that the muscle can't tighten anymore because it's already tight. So, you can't get tighter from tight. So, sometimes it's working on relaxation and breathing and just being more in tune to what your pelvic floor is doing. So, that's why it is really important to get an evaluation from a therapist that's specifically trained in pelvic floor. Just like in medicine you have specialties, we have the same in physical therapy. Some people might specialize in orthopedics, geriatrics, neurology, shoulder, hip, knee, ankle. Pelvic floor physical therapists are specifically trained to be able to recognize issues with the pelvic floor and how to treat them appropriately.

Host: That's awesome. Anything you'd like to add as we finish today?

Trish Strazar, DPT: No, I think the biggest thing is everyone thinks that having incontinence is a normal part of aging. And granted, we all get older and our muscles don't work like they used to, but it really isn't a normal part of aging. It is very treatable. And if it was up to me, everyone would get pelvic floor rehab because it impacts all stages of our life.

And the thing that I tell my patients is, as we age, the number one reason our elderly become institutionalized is because they're incontinent. And family members, friends, people don't want to have to take care of incontinence in the elderly. So if we know that going into our older years, it behooves us to try to keep our pelvic floor as strong as possible so that we don't have to deal with that end-of-life issue.

Host: Yeah, absolutely. Thank you so much for all today. It's been really wonderful.

Trish Strazar, DPT: Well, I hope it was informative. Thank you so much.

Host: That was Trish Strazar, Doctor of Physical Therapy with Southwest General Health Center. To request an appointment or learn more, you can visit swgeneral.com. If you found this episode to be helpful, consider sharing us on your social channels and check out our full podcast library for topics of interest to you. I'm your host, Dr. Bob Underwood, and this has been another episode of Southwest General Health Talk. Thank you so much.