Maggie McKay (Host): Welcome to Conversations like No Other, presented by Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. Thanks for listening. I'm your host, Maggie McKay.

Today, we have with us physical therapist, Dr. Allison Heschle, to discuss pelvic health. Thank you so much for being here today.

Dr. Allison Heschle: Hi, great to be here.

Host: What exactly is pelvic floor therapy and who could benefit from it?

Dr. Allison Heschle: So, pelvic floor physical therapy is a specialized kind of physical therapy that mainly focuses on improving the function of the pelvic floor muscles. So many people are familiar with physical therapy, like if they've broken a bone or had a knee replacement or hurt their back. You go to the physical therapist, they do some exercises with you. They have a look at your overall musculoskeletal system, and then get you on your way. So, what we do though is we focus more specifically on the pelvic floor muscles, which they live kind of at the bottom of your torso, so in between your sit bones and then in between the pubic bone and the tailbone.

And so, what we want those muscles to do ideally is fully relax, fully contract, and have the ability to perform endurance holds or fast twitch holds just really like any other muscles. So we approach it really just like we would approach any other kinds of muscles. And the kind of patients that could benefit from this kind of therapy really are anyone with a pelvic floor, which is everybody.

 Some people are surprised to find out that everyone does have a pelvic floor. And our patient demographic at Valley is highly varied and super inclusive of any and all pelvic floor conditions. So, that includes, but not limited to, urinary incontinence. We serve all kinds, genders, ages. We serve the pregnant and postpartum population with all kinds of conditions related to that. We serve a lot of constipation and functional GI disorder patients. We also see patients with prolapse, different kinds of pelvic pain or pain with sex. We also see a lot of patients with the secondary effects of like pelvic-related cancers. And like I said before, we see like all ages, all genders, male, female, the whole gamut.

Host: What's the most common misconception about pelvic floor therapy?

Dr. Allison Heschle: I would say that the most common misconception about pelvic floor therapy is that pelvic floor PT is only for women and especially for women postpartum. Many women are surprised when they come in, maybe after they've had a baby, that they could have come while they were pregnant, or many people don't realize that they could have come later in life too.

Host: Would you please explain what happens at a pelvic floor physical therapy appointment? Because until you've been to one, I guess, we would have no idea.

Dr. Allison Heschle: So, sometimes it is a little scary and intimidating to think about, but I promise it is not that scary. So, as I alluded to kind of the first question there, it really is kind of the same process you would follow if you were coming for your back, your knee, your hip, like really anything else.

So, we would start off with a detailed subjective evaluation where you and your therapist would then discuss your symptoms, medical history. Feel free to bring up any questions you might have there too. You just bring them up right away. A lot of those questions are going to involve your bowel functioning, your bladder functioning, and your sexual functioning.

We would then move into more of that objective or hands-on kind of portion of the exam. So, that's where it would look like a regular PT evaluation. So, we would look at your posture, your range of motion, your strength, your coordination, all that kind of stuff. We look at this primarily in the core and the hip muscles. By those core muscles, we mean your breathing diaphragm, your abdominals, all the layers of your abdominals, your back muscles, and your pelvic floor. We look specifically then at your abdominal wall mobility and your breathing patterns as well. And we look a lot at those hip muscles because they share a lot of the same functions at the pelvic floor does and vice versa.

After that, then we would do a more specific pelvic floor examination, and that can be done internally or externally, depending on whatever the patient is comfortable with. All of our pelvic floor PTs at Valley and any pelvic floor PT, anybody goes to ever should have extensive continuing education and training that would qualify them to perform then that internal pelvic floor muscle examination.

And then, for that internal exam, our focus is primarily on the comfort of the patient. And our goal is to keep it a pain-free and positive experience. So, it's not like when you would go to the OB-GYN, there's just different goals involved. We don't use a speculum or anything like that. We just use like one gloved, lubricated finger that's inserted either vaginally or rectally. And then, we can assess the tone, the strength, the length of the pelvic floor muscles. And then, by doing an internal exam, it also allows us to screen for other issues that might pop up such as prolapse or other pelvic floor disorders.

 But if that's something that a patient is just not comfortable with on that first day, we certainly can take a step back. We could just do an external view of the pelvic floor muscles and things like that, just to make sure that patients are comfortable.

Host: So when a patient comes to you and says, "Is peeing when I sneeze or cough my new normal?" what do you answer?

Dr. Allison Heschle: No. With so many exclamation points, "No, no, no, no, no." So, super common maybe, i mean, if you walk down the aisle of any, like, retail story, you'll just see like so many like different products to address that. But certainly, it should not be considered normal. What happens with that is when we have any changes in our abdominal pressure with either like a cough, a sneeze, a laugh or lift, our pelvic floor and our abdomen should be working together to contract and make sure that no leakage is occurring. It kind of seals everything off there.

If you are having leakage from any of those tasks, what that tells me is that there's something going on in that pressure system. Either your abdominals are doing something wrong or your pelvic floor is doing something wrong. And then, we can certainly address that with some PT. So, a lot of times I have patients that have that issue and it's simply just a timing. We just teach them when to contract their pelvic floor muscles and that kind of fixes the issue. So, no, not normal. And definitely, if it's happening, tell your OB and get a referral for pelvic floor PT.

Host: Are Kegels always the answer? And what are some exercises women should do?

Dr. Allison Heschle: Yes. So, thank you so much for this question. Kegels or pelvic floor muscle contractions are catching a lot of heat lately on social media. And like many things on social media that we see, there's a bit of nuance here.

So, first and foremost, this is just my personal view, but I always make sure that my patients know how to both properly engage and relax their pelvic floor muscles regardless of their diagnosis. Not everyone needs to work a ton on strengthening. Not everyone needs to work a ton on lengthening, but it's important just like with any other muscle in the body that you know how to use it.

However, though most patients do not need to just be doing Kegels all day. You're unlikely going to see progress from just Kegels alone. And for some people, like maybe those people that are having some of that pelvic pain, pain with sex, things like that, if you're just doing Kegels, you might be making your issue worse. But what Kegels are helpful for and pelvic floor muscle contractions are helpful for is learning how to use your pelvic floor as you would incorporate it into whole body strengthening. It's also helpful too to sometimes learn how to relax your muscles. So sometimes if you just tell somebody, "Okay, just relax this muscle," it's very hard to find. But if you squeeze first and then you relax, it can be easier.

So, like with many things, you know, it depends. But a good example of then an exercise that you would do that maybe wouldn't be a strict Kegel would be like a squat or any other kind of functional mobility kind of activity that way. So, if you were squatting, what we would do is we would teach you when would be the best way to kind of activate your core and your pelvic floor to maintain continence. If say you were incontinent or if you're having prolapse or any of those other issues, we would teach you then how to kind of incorporate those pelvic floor muscles there.

But as far as like any other specific exercises, that should really just depend on the individual. So if you love running, great, do that. If you can't stand running, awesome. Let's just have you walk or bike or whatever. The best kinds of exercises are going to be the ones you're going to do. And what I recommend women doing is definitely prioritizing strength training. So, about two to three days of strength training within 150 minutes of exercise weekly, so with two of those days being strength training-focused.

Host: What about C-section moms? Can they benefit from pelvic floor physical therapy?

Dr. Allison Heschle: Absolutely. So, women who have had C-sections can also have many of the same impairments as women that have delivered vaginally, and they can also then reap many of the same benefits. Would they also have some more like specialized interventions that we can employ to kind of help them work with maybe dealing with some of that residual pain or sensation issues from the C-section scar, as well as some more of like the abdominal weakness that might be present like after a C-section scar?

Host: So after you have your baby, is it normal for sex to hurt after?

Dr. Allison Heschle: So again, no. One of those things that's super common. But again, no. That's not to say that if you know you're having some discomfort the first-time that you have intercourse after you deliver, that's automatically a red flag. But it shouldn't be painful. Your body just underwent a massive change. So, you know, some of that discomfort can be within normal, but it shouldn't be then just accepted that that's how it's going to be and that's just your new normal, everything's going to hurt now. If that's something that you're experiencing, you should definitely then speak to your OB about it, and then try to get in with the pelvic floor PT to see if you have any potential scar tissue, muscle tightness.

Many people think like, "Oh, after you have a baby, everything is just so weak." But actually sometimes what happens is those muscles actually tense up even more, following an injury. If you think about it, like if you stub your toe, you tense, you know? So, those muscles tense reflexively, and people do end up with pain with sex really just because they have a lot more pelvic floor tension, surprisingly.

Host: Dr. Heschle, do healthy bowel movements imply a healthy pelvic floor?

Dr. Allison Heschle: So, yes and no kind of thing. So, it's certain that if you have healthy bowel movements, it doesn't necessarily mean that your pelvic floor is perfect, but your pelvic floor certainly does have a huge role to play in your bowel health. So if we lack strength at our pelvic floor, we can experience some loss of gas or stool. And if our pelvic floor muscles are too tight or we don't know necessarily how to properly relax them, you can end up with constipation and all the things associated with constipation. So, straining for bowel movements, pain with bowel movements, hemorrhoids, fissures, like any of that kinds of stuff. And also too, if you are experiencing any sudden changes in bowel habits, it's always good to let your doctor know. But if you've had like lifelong constipation and you just feel like you're straining all the time, nothing else has really worked. It could be your pelvic floor.

Host: You mentioned prolapse. What is that and what does it feel like?

Dr. Allison Heschle: Pelvic organ prolapse is when one or more of the pelvic organs drop from the pelvic cavity more than into the vagina. So, it then causes a bulge in the vagina. So, that would be some people would describe, they feel like there's a ball in their vagina. They feel like there's a bulge in their vagina, or they see a bulge coming out. That could either be their vagina, the bladder, the uterus, the urethra, and the rectum. So depending on where you're having some of that weakness, that would dictate then what organ is then prolapsing.

It can happen though when the muscles or tissues of the pelvic floor weaken due to pregnancy, childbirth, menopause, and can also happen to people who have never given birth or never been pregnant; if they have some kind of connective tissue disorder too, like Ehlers-Danlos syndrome, it could definitely be treated. So, we treat that in PT. And it could also have other more non-surgical options, like a pessary as well. But sometimes they do need surgery. But it is always good to go to a physical therapist or pelvic floor PT prior to any kind of pelvic and organ prolapse surgery. That way, you can learn like the proper patterns, avoid that straining that varying down, putting that pressure on your pelvic floor for optimal outcomes.

Host: Is it too late for someone to get pelvic floor therapy if their kids are older?

Dr. Allison Heschle: Definitely not. So, pelvic floor PT is effective for all age ranges and not just for those who are pregnant or recently given birth. Due to, you know, various life circumstances, sometimes people just can't get to it like right away kind of thing. But me and all my colleagues know, like we've had people as old as like 95, get relief from like some of their symptoms and older, even really. So, it is not too late.

Host: Is pelvic floor therapy ongoing? And how long should someone go to therapy?

Dr. Allison Heschle: So, this all depends on the patient. I will say that the most common length for plan of care is about eight to 12 weekly sessions. Give or take some people need less, some people need more. And this varies on just so many things. So, sometimes I have new moms especially, or maybe they have like multiple children who are also working and they want to prioritize this, but they just cannot do a weekly session.

So, we make sure that they have a good home exercise program at home. And then, maybe I see them once a month or something like that. That way, we would adjust expectations and timelines and say, "Okay, maybe instead of getting better in six weeks, it's going to take a couple months." But we always can work with people like in different kinds of life stages and with different kinds of availability too.

Host: In closing, is there anything else you'd like to add that you think people need to know?

Dr. Allison Heschle: So, I feel like pelvic floor PT and pelvic floor health really is just like the world's best kept secret, and I don't really know why. So, I hope that those that listen either try to seek out a little bit more information on their own or are encouraged to then seek out help from a pelvic floor PT, because it really helps people with so, so, so, so many different things. And I really can't speak enough to how powerful and transformative like some of the treatment options can be for people.

Host: That's so good to know. Thank you so much for sharing your expertise and making the time to talk with us today.

Dr. Allison Heschle: Yeah. You're welcome. Thank you for having me. This was great.

Host: Absolutely. Again, that's Dr. Allison Heschle. To learn more about pelvic floor therapy at Valley, please visit valleyhealth.com/pt. Thanks for listening to conversations Like No Other, presented by Valley Health System in Paramus, New Jersey. For more information on today's topic or to be connected with today's guest, please call 201-389-0099 or email valleypodcast@valleyhealth.com.