The Curbsiders Internal Medicine Podcast Episode #521: Tales of the Pelvis Released: April 13, 2026

Episode Overview

This episode takes a deep dive into pelvic floor dysfunction—what it is, why it matters, and how pelvic floor physical therapy (PT) can dramatically improve patients’ quality of life. Hosts Drs. Matthew Watto and Paul Nelson Williams are joined by special guests Dr. Nicole Schaefer and Dr. Rachel Rosvold, both expert pelvic floor physical therapists and co-owners of Uplift Pelvic Floor Physical Therapy. Producer and episode writer Dr. Elise Burke also joins the discussion, contributing to a wide-ranging conversation on pelvic floor function, assessment, therapy, and both female and male patient perspectives.

Main Theme:
Stop normalizing pelvic floor issues—urinary incontinence, pelvic pain, and more are never just the inevitable price of living, aging, or childbirth! The team highlights how pelvic PT is more than just "doing Kegels," and why it's essential for providers to screen for dysfunction, ask the right questions, and refer patients early.

Meet the Guests (05:17)

• Dr. Nicole Schaefer

  • DPT from Drexel, former D1 gymnast, McKenzie-certified PT, discovered pelvic floor therapy after her own pregnancies.
  • “I’m passionate about helping women stop leaking, build strength, and get back to the activities they love without fear, pain, or embarrassment.” (03:17)

• Dr. Rachel Rosvold

  • DPT from NYU, former D1 athlete, trained via Herman & Wallace Institute, brings full-body, movement-focused approach.
  • “My foundation in movement and performance has only enhanced my career in physical therapy… I found my true passion in pelvic floor PT.” (03:17)

Key Discussion Points & Clinical Insights

1. Basics: Pelvic Floor Function & Anatomy

with Dr. Schaefer & Dr. Rosvold (08:46 - 11:09)

• The pelvic floor has four main functions:
  1. Structural support: Attaches to hips, spine, deep core (transverse abdominis), "acting as your inner back brace."
  2. Sexual function: Needed for orgasm/ejaculation—requires full contraction and relaxation.
  3. Sphincteric control: Manages bowel and bladder continence.
  4. Pressure regulation: Coordinates with the diaphragm and breathing.
• Anatomy: Divided into anterior (levator ani: pubococcygeus, puborectalis, iliococcygeus for bladder/urethra) and posterior muscles (coccygeus, bulbocavernosus, obturator internus, piriformis for bowel/hip stabilization).

Quote:
"When there's something that goes awry—stress, thoracic spine stiffness, rib injury—it can absolutely influence the pelvic floor." —Dr. Schaefer (09:45)

2. Timeline of Postpartum Recovery

(11:09 - 14:23)

• There is no one-size-fits-all postpartum "healing time." Every case is different.
• Think of childbirth as a soft tissue injury—“At six weeks, you're NOT back to yourself."
• Symptom normalization is a problem: Leakage after childbirth is common but not normal, and it's never too late to improve.

Quote:
"Is this her new normal? 100% no." —Dr. Rosvold (12:30)

3. Screening & Patient Intake

(14:23 - 18:10)

• Use structured tools like the Cozene protocol for screening.
• Ask directly about frequency of peeing, incontinence (urine/stool/gas), pain, sexual dysfunction.
• Many patients won't volunteer symptoms—normalize asking!
• Society normalizes leakage and “suffering through” these symptoms—don’t let it slide!

Quote:
"Some people just think that's the price of having a child… but it's not normal in any context." —Dr. Schaefer (19:26)

4. What Happens in Pelvic PT? Demystifying the First Visit

(21:38 - 30:15)

• Holistic assessment: examines spine, hips, breathing mechanics, abdominals, hip rotators, balance, and more.
• Internal assessment ("one finger, no speculums"): offered with full consent, never required.
• Strength testing: Should be able to hold a 10-second contraction ×10.
• Assess for prolapse, scarring, evulsions.
• Always tailored—never "just about the vagina."
• Patient autonomy: Many benefit even without an internal exam.

Quote:
"It's never just their vagina… and we work on each one of those things to get them on a path to meeting their goals." —Dr. Schaefer (26:45)

5. Understanding Hypertonic vs. Hypotonic Pelvic Floor

(27:04 - 28:57)

• Clues to hypertonicity: High anxiety, glute clenching, constipation.
• Sedentary or less active patients may have more weakness.
• Hypertonic (overactive) pelvic floors require down training (relaxation), not Kegels.

Memorable Moment:
"If you stuck a lump of coal up his bottom… you'd have a diamond." Ferris Bueller ref on high-strung (hypertonic) patients (28:24)

6. Coaching Kegels & Why “Just Do Kegels” is Oversimplified

(30:30 - 37:48)

• Kegels are not for everyone, especially those with tight/hypertonic muscles.
• Focus on teaching how to relax and coordinate the pelvic floor first.
• Cues: “Suck in a thick milkshake through your vagina.” (34:13)
• Progression: First supine, then sitting, standing, then during functional movements.
• Most people, without guidance, do Kegels wrong (~80-90%).

Quotes:

• “If a provider's telling a patient, ‘just go home and do Kegels,’ chances are not only are you doing it incorrectly, but the coordination part is going to be missing.” —Dr. Rosvold (36:02)

7. The Bigger Picture: Posture, Habit, and Behavior in Pelvic Health

(38:15 - 39:55)

• Prolonged sitting is "the new smoking"—destroys hip mobility and pelvic function.
• Proper posture, varied movement throughout the day, and hip/spine strength are all crucial.

Quote:
"…All the pressure sitting puts on our discs, our spine… Our nerves innervate the pelvis, legs, toes. Back issues and pelvic floor symptoms are very much correlated." —Dr. Schaefer (38:15)

8. Additional Counseling: Diaries, Voiding, and Lifestyle Modifications

(41:51 - 46:33)

• Bladder diaries (or apps): Help patients and clinicians ID patterns, triggers.
• Habitual voiding vs. physiological need—time voiding, nervous system cues discussed.
• Optimize toileting posture (squatty potties!), avoid pushing.

Quote:
"When you see it in black and white, some people say, 'I did not know I was peeing every 35 minutes.'" —Dr. Rosvold (42:30)

9. Menopause & Changing Pelvic Floor Needs

(47:36 - 51:12)

• Tissue thins and loses support with estrogen loss; incontinence and pelvic heaviness/prolapse become more common.
• Vaginal estrogen (not systemic) is extremely helpful—reduces pain, dryness, atrophy.
• Functionally, all the same assessment principles apply; may emphasize bone density, strength, and mental health as women age.

Quotes:
"It feels like sandpaper… [but with] vaginal estrogen, it's like night and day." —Dr. Schaefer (48:20)

"…No one should be leaking anything at any time and no one should be in pain unless they're into that." —Dr. Rosvold (77:01)

10. Tools in Pelvic PT: Wands & Dilators

(54:15 - 57:53)

• Pelvic wands/dilators: Used for stretching tight muscles (hypertonicity, vaginismus), trauma, anticipatory pain, or to prepare tissues pre-childbirth.
• Always use lube, stick to safe materials (silicone only).
• Rectal versions exist for patients w/o vaginas.
• "Make sure anything rectal has a wide base. We recommend silicone-based products, not glass, metal, or wood."—Dr. Rosvold (57:46)

Male Perspective and Chronic Pelvic Pain Syndrome (CPPS)

(58:04 - 75:25)

• Many "prostatitis" diagnoses are actually pelvic floor dysfunction (70-90% non-bacterial).
• Anatomy: Ischiocavernosus (erectile rigidity), bulbospongiosus (engorgement, ejaculation), pubococcygeus (support, continence).
• Younger men presenting with pain, “prostatitis,” and even erectile dysfunction: pelvic floor dysfunction is a key consideration.
• Chronic constipation and pelvic pain (including post-UTI, after antibiotics fail) respond well to PT: Relaxation, retraining, movement, toileting habits, fiber/hydration guidance.
• Fecal incontinence: Also very treatable by pelvic PT.

Quotes:

• "Depending on what research… 70-90% of these cases are not bacterial. They're pelvic floor dysfunction." —Dr. Rosvold (61:40)
• “If a muscle is already contracted, it's almost like there's a kink in the hose… all of these questions are hard to answer, but they will definitely lead our treatment plan.” —Dr. Rosvold (65:00)

Take-Home Points

(76:19 - 78:03)

• ICD-10 Coding tip: Don’t use Dyspareunia for pelvic PT scripts (insurance won’t cover); use vaginismus, vulvodynia, decreased coordination, or leakage.
• Common isn’t normal: Leakage or pain warrants evaluation—everyone deserves help.
• Normalize, screen, and refer early—pelvic health = lifelong health for all bodies.
• Huge value in collaborating with pelvic PTs; reach out and build partnerships.

Quotes:

• “Every woman postpartum should have Pelvic PT.” —Dr. Schaefer (76:19)
• “There are not enough pelvic therapists to deal with all the pelvises that need our help… We love our physician counterparts!” —Dr. Rosvold (77:30)

Memorable Moments & Quotes

• “[PT] will help you walk. OT will make sure you do it with your pants on.” – Dr. Williams (01:15)
• “If you stuck a lump of coal up his bottom, you'd have a diamond.” – Dr. Williams, referencing hypertonic, high-anxiety patients (28:24)
• “Suck in a thick milkshake through your vagina.” – Dr. Schaefer (34:13)
• “No one should be leaking anything at any time and no one should be in pain unless they're into that.” – Dr. Rosvold (77:01)

Notable Timestamps

• Anatomy overview: 08:46–11:09
• Postpartum healing: 11:09–14:23
• Screening and tools: 14:23–18:10
• Internal/external exams: 21:38–30:15
• Kegels explained: 30:30–38:15
• Behavioral counseling: 41:51–46:33
• Menopause care: 47:36–51:12
• Pelvic wands/dilators: 54:15–57:53
• Male pelvic pain syndrome: 58:04–67:36
• Constipation and PT: 67:36–71:28
• Fecal incontinence: 73:50–75:25
• Take home points: 76:19–78:03

Resources & Pearls

• Cozene Protocol: Pelvic PT screening tool, available online.
• Bladder diary apps: Helpful for both clinicians & patients.
• Vaginal estrogen is highly effective and safe for atrophic symptoms.
• All genders benefit from pelvic PT—and it’s more than just Kegels!

Final Thought

Pelvic floor dysfunction is not inevitable—help is available, effective, and life-changing. Screen for it, ask about it, and refer for pelvic PT. Normalize the conversation so patients can thrive at every stage of life.