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Limu. Emu and Doug Limu and I always tell you to customize your car insurance and save hundreds with Liberty Mutual. But now we want you to feel it. Cue the Emu music. Limu. Save yourself money today. Increase your wealth. Customize and save. We save. That may have been too much feeling. Only pay for what you need@libertymutual.com Liberty Liberty Liberty Liberty Savings vary underwritten by.
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Liberty Mutual Insurance Company and affiliates.
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Excludes Massachusetts.
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I'm at that point where I will cough or sneeze and like some like tinkles out. I just, I have to wear some of the kids diapers. Like it's really unenjoyable. Like I'm not gonna pee in the bed. It is a whole poem.
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What are you saying so much?
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Talking about my bladder. When you experience it, then you can talk about it. Thank you.
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All right, so all I asked my producer was, hey, find something medical. Find something about peripartum urinary incontinence and we'll go with it. You know, just as a little intro clip, this guy gives me something from like TLC on some, you know, dating slash fiance show. Oh my goodness. Tlc not a sponsor. But as a little cringe as that was, it's so real. So real. I did kind of chuckle a little bit when she said tinkle. A little tinkle comes out. Oh my goodness. But unfortunately, antepartum peripartum urinary issues don't get a lot of attention. Usually we think about things like urge incontinence or stress incontinence when guys come on postpartum, right? I mean, if you pass a mini watermelon through the vajayjay, obviously you're going to have some neuromuscular effect, some neuronal perineal nerve stretching. And obviously you would expect some form of UI urinary incontinence in the postpartum time frame. However, truth is, urinary issues don't start then they can start antepartum as early as the first trimester for both hormonal, functional and and anatomical reasons. And it's both. It is both overactive bladder, which may or may not include incontinence. Overactive bladder is just, you gotta go all the time. And some of that may or may not involve leakage. And of course stress incontinence, especially once the organ, once the uterus leaves the pelvis because of the physical pressure on the bladder dome and the trigone and or as the baby kicks on the bladder like woo hoo, look what I got. And makes the bladder a mini trampoline. Galene. It happens. You can have that inadvertent leakage. Okay, so yes, it is true. Urinary incontinence is not restricted to the postpartum timeframe. So I just received a wonderful message from one of our podcast family members, Laura, who had a great question. Hey, I'm seeing a lot of ads come up about antepartum pre delivery pelvic floor therapy. Is this a thing or do we have to or shouldn't we wait for this to be postpartum? And the answer is it's both. Obviously, if there are de novo symptoms, the earlier you start pelvic floor therapy or otherwise known as pfmt, pelvic floor muscle treatment or therapy. Yeah, it works. Now there is an advantage. Remember, the question that Laura had is, should we do this? And. And the answer is absolutely, but with a caveat. And the caveat is, is that it has to be in baseline continent women. If there's already a baseline of incontinence, it's unclear if doing exercises while pregnant is going to help. I mean, that kind of should have been taken care of before pregnancy, but it's just not that realistic. Nor do we have all that data that if you have a baseline incontinence that that starting Kegel pelvic floor muscle therapy, PFMT antepartum will help. It's unclear, but if you are baseline continent. So this is ideally, although it's for everybody, but ideally it is in the continent G1. All right, so first time pregnant, you can start this thing antepartum and do certain sets of therapies. We'll discuss in this episode to try to reduce postpartum incontinence episodes, both overactive and stress type. Now we're going to get into this because. And a lot of things have changed because the original thinking was that overactive bladder was all neuroendocrine. Right? It's over firing of the neurons. And so you got to block, you know, the receptors so that you have less stimulation of the muscles so that it contracts less. And that is true. However, we know that postpartum there's a special catch here for overactive bladder. And it has to do with the pelvic floor, just like it has to do with stress incontinence. So very quickly I'm gonna set the stage here. I'm gonna get out of the intro and then we're gonna get into antepartum PFMT pelvic floor muscle Therapy, otherwise known as Kegels. And we'll go over what seems to be the best strategy there. With or without weights. Yeah, your vagina can lift some weights. Okay. You don't want to overdo it, but, yep, you can do vaginal weightlifting. I thought we had an episode on that. I think we do. But at the same time, while there's truth to that, people misuse that and have wrong expectations for why they're doing it. Having vaginal weights or little cones that can help squeeze, so you can do kind of biofeedback so you can know how to hold onto the weights. Absolutely helpful for Kegels. Absolutely helpful in some patients for sexual response. But you got to know why you're doing it and set realistic expectations. So we're going to talk about this. Starting pelvic floor muscle therapy antepartum for both reduction of stress and urinary incontinence. Now, as we were saying, for obrect to bladder, that also has to do with the pelvic floor guys. It's not just over stimulation of the receptors for bladder dome and musculature detrusor contraction. That is fair. That is true. But we know postpartum. Guys, here's where I was going postpartum. Ooh, almost forgot where I was going there for a minute. Did you see that? Postpartum overactive bladder oab. With or without incontinence, it does have a basis with high pelvic tone of the pelvic floor. High pelvic tone. In other words, just as low pelvic tone. Postpartum has to do with stress incontinence because of leakage or weakening of the pubourethral ligament and a weakness of the pelvic floor, which can be temporary. Thankfully, it's not permanent. Usually it's temporary. Usually. And much more likely to be temporary if you include pelvic floor muscle therapy quickly. But just. Just as low pelvic floor tension has to do with stress incontinence, high pelvic floor tension can freak out the bladder and make you overactive. So, yes, overactive bladder can be overstimulation of the detrusor muscle. Absolutely no question. But it can also be a pelvic floor hypertonus issue, which is why in a patient who presents with overactive bladder, going, God, I just got to go all the time. You know, I don't really leak. I just. I feel like I got to go, and if I don't go, it's going to leak. And it's just. I don't feel like it's normal, you need to do an exam. Because if high pelvic tone is an issue, they also need pelvic floor muscle therapy. So intuitively, everybody considers pelvic floor muscle therapy to equal Kegel, right? Pfmt equal Kegel. And that's fair. That's good. I mean, pelvic floor muscle therapy. Kegels were typically done for stress incontinence. But as the data has now evolved. Here it is. Guys, we're in the intro. Okay, we're still in the intro. And I'm gonna give you a quick clinical pearl and I gotta get out. And then we get into the body of the episode. But the clinical pearl is that pelvic floor therapy and relaxation, not just tensing of the pelvic floor muscles, but relaxation, learning how to relax, those can also help pelvic floor high tension states, including vaginismus and overactive bladder in the postpartum interval. So yes, overactive bladder can be overstimulation of the jrusor muscle for which you need blockade. And it can also be high pelvic floor tension. So you need to do a physical exam, put your finger into the introitus with her permission on an exam and feel for levator hypertonus. See if there's a lot of component of vaginismus. Because that high tension state can actually contribute some to overactive bladder, as the bladder and the perurethral tissue gets thrown into spasm. Amazing. So pelvic floor muscle therapy, if you're asked on the oral board and you go straight to Kegel, that's fine, that's traditional. You're gonna be okay with that. Except that not all pelvic floor therapy is to make you Kegel. Let me say that again. Not all pelvic floor therapy is to make you Kegel. Some pelvic floor muscle therapy is to help you relax. Like with vaginismus and peripartum postpartum overactive bladder. So, Laura, great question. Yes, those ads, as long as they're not misleading patients that you're seeing pop up in your area. Yeah. There is something to antenatal pelvic floor therapy. If the patient is continent and you set normal expectation and know that they don't have to go to a clinic all the time to do this. They can do direct observation guided physical therapy, which I like. I send my patients to at least for one for an educational and instructional session. And then patients are allowed to do this at home with the results being almost the same with or without tools like the weighted cones. So pelvic floor muscle therapy can absolutely Antepartum help reduce urinary incontinence in the postpartum interval. We have plenty of meta analyses. There's also been some RCTs that show a significant, statistically significant and clinically significant reduction in the relative risk for pui. That is postpartum urinary intention as opposed to pur purr, which is postpartum urinary retention. Oh, my goodness. All right, so I think I've set it up enough. That's where we're going. In this episode, we will tackle the issue of peripartum postpartum urinary incontinence. And does exercising, does doing pelvic exercises antepartum, does it help with that issue? Laura, great question and. Oh, forgot one last thing. And we do have recent guidance. Guys, there's a systematic. I'm sorry, not a systematic. There's a narrative review that just came out. October of 2025, the month that we're recording this. There is a narrative review out of the Green Journal on this where we're going to pull some of this data. So there is a narrative review in the green journal on October 2025. We're going to be pulling data out of that to answer Laura's question. All right, I think I've set it up. We'll be right back. This is Dr. Chapa's OB GYN no Spin podcast. Morning. Can I take your order? Can I get a tall chai, A large black coffee?
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A what?
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Large black coffee. Do you mean aventi? No, I mean large. He means Aventi.
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Yeah, the biggest one you got.
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Aventi is large. No, venti is 20.
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Danny.
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Yeah, large is. Is large. In fact, tall is large. And grande is Spanish for large. Venti's the only one that doesn't mean large. He's also the only one that's Italian. So now you can skip all of the coffee shop etiquette or pseudo etiquette and make your great tasting coffee at home. We're thankful for our partnership with the Strong Coffee Company that is striving to reach our natural greatness, which is not your ordinary cup of coffee. It has adaptogens, collagen and nootropics to help you reach your maximum potential without the caffeine crash. So thank you to the strong coffee company for your partnership. 20% discount with the link only in our show notes. That is 20% off whatever you buy online so that you can make your own grande Venti large At home. Thank you for the strong coffee company for your partnership.
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When did making plans get this complicated? It's time to streamline with WhatsApp, the secure messaging app that brings the whole group together. Use polls to settle dinner plans, send event invites and pin messages so no one forgets mom 60th and never miss a meme or milestone. All protected with end to end encryption. It's time for WhatsApp message privately with everyone.
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Learn more@WhatsApp.com well, I do consider myself pretty much mainstream science. I don't consider myself one of the new age followers at all, although I do find it kind of interesting. But back in the day, there was a book named Think and Grow Rich. Not rich so much as in resources, although that was implied as well, but rich as in a rich life. Think, think and grow rich, meaning our thought life. Super important. It was a pivotal book in self help psychology circles and in philosophy by Napoleon Hill. Great book. Not a sponsor. But in that book he talks about putting things out into the ether, meaning out into the. Out into the universe, the harmony of vibrations. See, I told you. Kind of new agey, but the idea was that we're all kind of interconnected. And I'll tell you where I'm going with this because this has nothing to do with urinary incontinence by itself. However, I did see this narrative review in the green journal on October 1st, and I said, yeah, all right, interesting. Maybe we might could put on the list. We'll put on the list. And I told our producer like, hey, at some point we can talk about this. But nah, I don't know. Well, lo and behold, on October 14th, we had a message from one of our podcast family members asking literally something that is embedded deep right in the core of that narrative review. So I thought, oh my goodness. Either I put it out into the ether or she put it out into the ether. But proving again that we are somehow interconnected. What the hell is oh my goodness, Michael? All right, so let me tell you the background of this sound business. Oh my goodness. So Michael, turn that off. Turn that off for a minute. So Michael is goes, okay, let me just show you. Always whenever I bring this up, I'm like, hey man, I'm throwing something out into the ether. And he's like, oh my goodness, for being such a science guy. How can you say that? And he gets a kick out of it. So is that what you're doing? Sure enough. So basically he's making fun of me by saying we put things out into the ether. I kind of like this 1960s sci fi theme. That's what he told me. 19. Okay, great. I told him I was going to talk about putting things out into the ether. And this is what I get. I like this. I'm putting things out into the ether. Alright, you know what, Michael? You're fired. No, no, not fired. I need you go back. All right, you can keep doing that if you want to. We're done. So anyway, I may have put it out into the ether. I may not have. Nonetheless, that was stupid, Michael. Nonetheless, we're gonna talk about urinary incontinence. All to say, I did see this two weeks ago. Poof. It was out into the ether and it has materialized in this episode. I was going to talk about something else rather than this, but I'm like, I knocked out what I was going to talk about because that was kind of boring anyway. Well, it's not really boring, but this is better. Oh, my goodness. Let's get back to what we're talking about. What are we doing? Oh. So back to this narrative review. So in October 2025, there is in the Green Journal this narrative review, which isn't again, a single study. It isn't a systematic review. It's just an author's. The author's kind of review of the data, which is very good. And there are some things here that directly relate to Laura's question about antepartum, antenatal pelvic floor muscle training or muscle therapy. Okay, pfmt. So first we gotta remember that these things start during pregnancies. Both stress incontinence and overactive bladder oab. Those symptoms begin during pregnancy, and if they start in pregnancy, they're magically not gonna go away by themselves postpartum. So that's the catch. If we can get on top of this, especially if there's baseline continence and especially if the patient is a prima gravita. That's how we win. Based on who you read the overall prevalence of stress urinary incontinence during pregnancy, not just in the postpartum interval, but during pregnancy, is anywhere from 30 to 70. That's 7. 0. 70%. That's for stress urinary incontinence during pregnancy and then overactive bladder, with or without actual incontinence during pregnancy, about 60%. Some say about 65%. Y'. All. This is not postpartum. This is both overactive bladder. Like you got to get up all the time to go pee at night. That's pregnancy. One of the joys of the beautiful condition. And so is stress urinary incontinence. So these are not limited to postpartum. So I like that this called attention to these, that we got to ask patients about this. Maybe, you know, put a little sign up in the office, hey, if this is your first pregnancy, if you don't have any issues right now with urinary leakage or overactive bladder, let's talk about it, especially if it's your first pregnancy or ask me about bladder health, whatever. I think it's important that especially in like your little anola gravid teenage patients that for the first time they go, what the heck is happening when I cough and you know, urine comes out? This is a great time to educate them. And to start, even in the first trimester, you can start pelvic floor muscle therapy. The other nice thing that this review discusses is that not all pelvic floor therapy, as we said in the intro, is Kegels. Now historically, of course, Kegeling to stop the flow of urine in the toilet, that was the best way we instructed patients how to do it was for stress urinary incontinence. And that's fine. However, pelvic floor muscle therapy is not just Kegels. It also is for bladder relaxation. Pelvic floor relaxation, since that can lead to overactive bladder symptoms, as we talked about already, of course in the intro. Now, I found this super, super enlightening, and we've known this for about a decade now, that some forms of oab, especially in the peripartum interval, aren't just neurotransmitter related, but are of course in terms of hypertonus of the pelvic floor. Let me read this directly from this new narrative review and then we're do this very quickly, guys. The short answer is yes, absolutely. There is protective benefits to the pelvic floor if you start pelvic floor therapy early in the first trimester. And it helps reduce postpartum urinary incontinence of both types. Okay, stress and urge. All right, now some studies say, oh, it's better for urge postpartum, some studies say it's better for stress postpartum. The truth is it helps as a bucket overall. So whatever you're going to feel better overall based on who you read, it's going to be one or the other. So why not do it? It's fine. And I'm going to give you more or less one regimen that somebody published out of a Cochrane review. This was woodley so Woodley took a look at the Cochrane database, this was just in 2020 and said what can be the best, most intense kind of pelvic workout that you could do? And unfortunately, or fortunately, I don't know how I review it, that pelvic workout. I'm not talking about sex. All right? Although sex is a pelvic workout. But, but we're talking about pelvic health, pelvic floor muscle therapy. And we'll give you the Woodley answer here in just a minute. Now, you don't have to do that style. There's any kind of pelvic floor therapy, even closing and holding for a second and then relaxing, closing and tensing for a second and then relaxing for a second in alternating counts for about 10 to 15 of those. That works. Or you can hold and maintain that tension, which is significantly harder to do, which is where potentially the vaginal weights come in. Because you gotta cinch the pelvic floor and the paravaginal muscles around that to keep it in place. That seems to work better. Okay. Tonic contraction and then relaxation. And I'll give you that information in just a minute. But let me read this to you from this narrative review about hypertonus and, and overactive bladder and then we'll keep moving on. Quote, if the pelvic floor is weak, remember that's we're going to talk about weak first. The focus can be on strengthening and squeeze exercises, mainly for stress issues. It goes on to say quote on the other hand, if high tone pelvic floor dysfunction is detected, pelvic floor muscle exercises can emphasize coordinated relaxation, which can help alleviate postpartum overactive bladder symptoms. End quote. There you go. So pelvic floor, don't think it's all Kegel. You can actually do pelvic floor training to relax the pelvic muscles, especially with cases like vaginismus and or overactive bladder. Postpartum. If high pelvic tone is felt on pelvic exam. The protective benefits of pelvic floor muscle exercises do go into the postpartum interval. Not only is it protective during pregnancy itself, but, but this actually has sustained benefits. Based on who you read anywhere from 12 weeks postpartum, that's three months up to potentially a year postpartum especially. Here it is, guys. Especially if they are resumed in the otherwise quote, unquote, immediate postpartum interval. Now, immediate doesn't mean that you know that they have a vaginal delivery and eight hours later they have a vaginal cone in there to squeeze them muscles Let the body relax, relax. But immediate in general is defined by different people, different ways. But most people agree that that's within 72 hours to five days. So within the first week. So you gotta get in there and rebuild muscles after the initial pain and inflammation have somewhat resolved. Okay. And this can be either supervised and or physician or clinician guided or they can be at home. Either way, you're going to get some benefit here. But they do need to be somewhat standardized in what you're going to do. And I think that's where the value of going to a pelvic floor therapist is helpful, at least for the first time, so that they can have good instruction on what to do here. Okay. And that's with or without these pelvic floor devices, as we discussed.
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Now, pelvic floor training for everyone. Postpartum. Great. I have no problem with that. Also helps to some degree with sexual satisfaction. I think that's. That's an extra bonus thrown in there. No problem. But pelvic floor muscle therapy is especially an issue, not just for urinary incontinence, but to rebuild a periurethral, perianal strength and overall tone of the pelvic floor, especially with Oasis tears. All right, Oasis, Obstetrical anal sphincture injuries. In other words, third and fourth degrees. That's vital, as you got to make up for some potential for occult anal sphincter injuries that may occur that you may not even see. Okay, so I'm a big fan of pelvic floor muscle therapy, antepartum and postpartum, because, yes, absolutely, there is evidence that it helps. Now, patients also have to have expectations. You can tell a patient if you do this. And I'm going to tell you again, the proposed regimen here in just a minute by Woodley. You can't tell them that you're not gonna get incontinence. That's not what I'm saying. This is all about relative risk reduction, not elimination of risk, because we gotta put things in proper perspective. It definitely helps. But to say it's going to completely eliminate postpartum. Ui Urinary intention is probably just not fair to the patient. Cause you're saying an expectation that may not be realistic. All right. There is no one protocol that's better than the other. Woodley, the one that we talked about in the Cochrane review, recommends this regimen which is pretty darn intense. All right? He says, I want you to do eight contractions, with each contraction being an eight second hold. Okay? So this is called the eight, three three rule. 833 rule. 833 rule. Oh my gosh. Sorry. I was going to say something stupid. Do I? Yeah, I'm gonna do it anyway. Okay. Six, seven. Okay, My resident told me about this and so did my daughter. Six, seven. How stupid is that? If you don't know what I'm talking about, it means absolutely nothing. I'm not going to get into it. It is literally means nothing. Apparently started some social media thing where some kids said 6, 7 and people started cracking up. I don't get it. I don't know. I think it's stupid. Six, seven. All right, so Woodley et al recommends. Michael, are you gonna delete that? Just leave that in there. Six, seven, bro. Six, seven. Woodley et al recommends a regimen involving eight contractions, each one with an eight second hold, three times a day, three days a week for three months. All right? Eight, three three, eight, Three three eight contractions, slash eight second hold, three times a day, three times a week for at least three months. Man, that's the. That's a lot of work. Now I think that without some kind of feedback and sensation to tell you what you're doing, I think patients can get discouraged. Like, you want me to do what now? That's right. Do eight contractions. Each contraction is an eight second hold. I want you to do that three times a day, three days a week for three months. That's a long time. But if you give them the little weighted device and they can buy a variety of those online, not a sponsor, it can help like, well, now you can get some kind of biofeedback. I think that is helpful. Just make sure that they are good quality. Make sure that they are not porous so that you don't trap bacteria in there. I do have an episode on, on that vaginal stone or something like that is what I called it. Anyway. So yes, you can actually train the vagina, the perivaginal pelvic floor muscles. That's totally fine. But just have realistic expectations for what you're doing. So short answer is, is there evidence that antepartum pelvic floor muscle therapy works. Absolutely. Now, postpartum, if these things are just really severe, let's say this, we're going to wrap it up. If a patient has debilitating quality of life affecting urinary incontinence, stress incontinence may get better with time. So can oab. So don't get, you know, all, you know, guns a blazing in therapy here, at least for the first six to eight weeks, because with time it's going to get better. It's going to get better. But for the patient who says, look, you know, look, it's been six months and this is still driving me insane and it's not getting any better, you can place a midurethral sling for stress incontinence. Traditionally, I learned it and I'm very thankful. One of the past presidents of the Gynecological Surgery association, the GIN surgery group, Joe Schaefer, he was my attending physician when I was a resident at Southwestern. Joe Schaefer, who's urogynecologist, just phenomenal, trained Marlene Corden. Again, she was my resident above me. These are great pelvic floor physicians, but I remember, I mean, the traditional thought was like, oh, when we would present a traditional sling for sui, he'd say, are they done with childbearing? Because that was a traditional rule. Dr. Schaefer was right. Traditionally, we didn't put, we didn't want to mess. It's going to mess up if you have another delivery. Well, well, not necessarily the case. Even though the data hasn't been great and it's been mainly retrospective, there has been retrospective data that says that they maintain urethral slings if you allow proper healing. It basically forms a new pubo urethral ligament that's really not moving anywhere. It can maintain effectiveness after both subsequent vaginal and cesarean deliveries. However, no one's going to argue with you if you say we're not going to do that until you're done with childbearing. That's reasonable, but may not be the most evidence based, although we need more data to guide us. Same thing for oab. If it's been six months and it's just driving her insane, then you can consider medications. I mean, don't let her suffer with that. But of course, first line is behavioral. Go to the bathroom more frequently. Avoid bladder irritants, including, you know, wine or caffeine, some carbonated beverages. Just do what we can as behavioral. Second line is pelvic floor muscle therapy. Notice that's why we say pfmt, not Kegels, because it depends on what you're trying to do. And then if not better, after a reasonable amount of time postpartum, and most would agree that's basically about six months, then you can consider either medication or a sling, knowing of course that that's part of shared decision making. Quick word for OAB at six months after delivery. Traditionally things like botulinum toxin, which totally works, it was contraindicated. Especially if they're breastfeeding. That is still makes sense. Okay, so in general, we try to not use botulinum toxin based medications for OAB if they're breastfeeding. However. However, even though we need more data, the small case series of women who have received cosmetic botulinum toxin postpartum have found very low to no botulinum toxin levels expressed in breast milk. So that's reassuring. But nonetheless, in general, we try not to use botulinum based medications because it is a toxin if they're breastfeeding. Although we need more data to prove safe, it does seem to be okay. Although I don't recommend that as first line. All right, podcast family, so what have we done? We have covered a new narrative review from the Green Journal from October of 2025, and this is in response to Laura's question on peripartum urinary incontinence and does it make sense? Does it make sense for us to do pelvic floor muscle training antepartum? The answer is yes, because benefits not only in case reports, retrospective studies, but also in some meta analyses, including the Cochrane review, have found that benefits that extend not just during pregnancy, but extend into the postpartum time frame as well. All right, I think we are done now. I think we've done what we're supposed to do. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Now that we've done all that, I think we're ready to take it home. This has been Dr. Chapa Zobi, GYN no Spin podcast Podcast family. Thank you for yourself, support, thank you for listening and as always, we'll see you on another episode of the no Spin Podcast.