#521 Tales of the Pelvis

Summary

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

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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.

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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

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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!

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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.

Transcript

[Dr. Matthew Frank Watto]

It's 2026 and we're about to have our three year anniversary of our [e-mail] curbsiders. So to celebrate, we're offering the first

[Dr. Paul Nelson Williams]

1000 members who sign up free house

[Dr. Matthew Frank Watto]

officer privileges for one month. That lets you get access to 70 plus bonus episodes where Paul and I recap high yield pearls, answer listener questions

[Dr. Paul Nelson Williams]

and give our picks of the week. It's a lot of fun, so check

[Dr. Matthew Frank Watto]

us [e-mail] curbsiders or you can click

[Dr. Paul Nelson Williams]

the link in the episode description to sign up. Paul, you know how I knew my girlfriend thought that I was invading her privacy?

I'm scared to ask.

No, she wrote about it in her diary.

Did you look up diary jokes specifically

for the listeners? I was looking at a list of like 300 dad jokes and that was. I was really striking out tonight, but eventually, you know, I landed on that one. I don't know why. It has nothing to do with the episode, but.

All right, let me. I got one. Matt, are you ready for this? All right. What is the difference between PT and ot?

Okay, this seems relevant, but I don't know.

This is wholesome. PT will help you to walk. OT will make sure you do it with your pants on.

That's pretty good.

Yeah, that's cute.

Makes sense.

[Podcast Disclaimer/Announcer]

The Curbsiders podcast is for entertainment, education and information purposes only. And the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of the hosts and should not be interpreted to reflect official policy or position of any entity, aside from possibly cash, flag, moral, hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much. We aren't responsible if you screw up. You should always do your own homework and let us know when we're working.

[Dr. Paul Nelson Williams]

Welcome back to the curbsiders. I'm Dr. Matthew Frank Watto, here with my great friend and America's primary care physician, probably the primary care physician, Dr. Paul Nelson Williams. Hey, Paul.

Hey, Matt. How are you, Paul?

I'm doing well because we talked tonight about pelvic floor dysfunction, how it can affect, you know, just all sorts.

[Dr. Matthew Frank Watto]

How we can wreak all sorts of

[Dr. Paul Nelson Williams]

havoc and cause all sorts of symptoms

[Dr. Matthew Frank Watto]

that some of which I did not

[Dr. Paul Nelson Williams]

really connect to pelvic floor dysfunction.

[Dr. Matthew Frank Watto]

We had two great guests who you

[Dr. Paul Nelson Williams]

about in just a second.

[Dr. Matthew Frank Watto]

But Paul, first, what is it that

[Dr. Paul Nelson Williams]

we do on the Curbsiders? Why are we still doing this?

We're still doing it because, Matt, we have so much left to learn as we as this episode so plainly showed us, we are. For the listeners who are not familiar, we are the Internal Medicine podcast. We use expert interviews between your clinical pearls and practice changing knowledge. As you mentioned, we are joined by two special guests tonight. We are joined by Dr. Rachel Rosvold as well as Dr. Nicole Schaefer. But we are also joined tonight by our producer and the writer for this episode, Dr. E.L. burke. Dr. Burke, how are you?

[Dr. Elise Burke]

I'm fantastic. How are you, Paul?

[Dr. Paul Nelson Williams]

Thank you so much for asking. See, how hard is that, Matt?

[Dr. Matthew Frank Watto]

Well, she's a pro.

[Dr. Paul Nelson Williams]

I'm not. I've only been doing this for 10 years.

Paul, come on. Yeah, over a decade at this point. But at least we're thrilled to have you here. Would you tell us a little bit about who we talked to and what we talked about tonight?

[Dr. Elise Burke]

Absolutely. So we have Dr. Nicole Schaefer, who graduated from Temple University with a Bachelor of Science degree where she competed as a Division 1 gymnast. She went to earn her doctorate in physical therapy from Drexel university with over 15 years of experience as a physical therapist. Dr. Schaefer has a strong orthopedic background and holds a McKenzie certification. After having her own two children, she discovered pelvic floor physical therapy and quickly realized the profound impact it can have on women's health at every stage of life. She is now the co owner of Uplift Pelvic Floor Physical Therapy, where she is passionate about helping women stop leaking, build strength, and get back to the activities they love without fear, pain or embarrassment. Dr. Rachel Rosvold earned her doctorate in physical therapy from New York University in 2010 and received her pelvic floor specialty training through the Herman and Wallace Pelvic Rehabilitation Institute. A former Division 1 athlete at Syracuse University, Dr. Rosvold's foundation in movement and performance has only enhanced her career in physical therapy. She has worked in a wide range of settings, allowing her to develop a full body treatment philosophy before finding her true passion in pelvic floor pt. She is currently the co owner and founder of uplift pelvic floor PT in Horsham, Penns, outside of the clinic. Dr. Rosvold is an active mom of two who enjoys hiking, triathlons, baking, reading and cheering on her beloved Philly sports teams. In this episode, our guests teach us. They take us on a deep dive into pelvic floor function and anatomy and we learn what to expect and how a patient can benefit from the wonders of pelvic floor pt. So without further ado, let's get to it.

[Dr. Paul Nelson Williams]

A reminder that this and most episodes will be available for CME credit for all health professionals through VCU Health at curbsiders.vcuhealth.org Nicole, Rachel, welcome to the show. We've been troubleshooting some things offline and chatting for a while. I want bring the audience into this now and the first thing they're going to want to know is, Nicole, what's something that you're currently doing outside of medicine, a hobby or interest that you have?

[Dr. Nicole Schaefer]

Well, as the true PT I am, I love exercise and everything as far as movement based. But right now I'm really into snowboard season and getting onto the mountain as often as I can. I've taught my two little ones how to snowboard and they're five and seven and we're finally shredding the mountain all together as a family and it's awesome.

[Dr. Paul Nelson Williams]

So must be a great year for snowboarding because we've had two like monster storms. I don't know if you were actually able to get out.

[Dr. Nicole Schaefer]

Yeah, we went out yesterday and we tried. We made it back before the snow got pretty bad, but we went to Vermont already and actually Rachel and her family and our family are going to Gore Mountain this weekend in upstate New York. So we're really excited for all the snow that we just got dumped on. Hopefully they have pretty good conditions.

[Dr. Paul Nelson Williams]

That's going to be cool. Okay. And Rachel, how about you? Hobby or interest outside medicine?

[Dr. Rachel Rosvold]

Yeah, so recently kind of tailing onto what Nicole's saying, I have been very into Facebook marketplace trying to find skis to fit my 2 year old because no one will rent me skis for a two year old. So I have gotten very good at meeting strangers and I found some really cute boots and some really nice skis and we're all set for our weekend. So it should be fun. Last time he just wiped out a lot and ate a ton of snow. So we're, we're hoping for a little bit better than that. And then aside from that, I have had to stop just focusing on lifting and doing more training for my first triathlon that's coming up in June. So kind of the transition of training has been a little bit of a fun hobby to reprogram myself instead of doing it for other people. So it's been fun.

[Dr. Paul Nelson Williams]

Fantastic. Paul, any follow up questions?

I mean, I just, as a childless man who has not had to think about the stages of development in like a decade, I just, I'm not even I couldn't Even remember if 2 year olds are supposed to be walking yet, so the skis feels very advanced to me. But I, you know, I could be. My numbers could be off.

[Dr. Rachel Rosvold]

He's made of rubber. He just falls down and bounces right

[Dr. Paul Nelson Williams]

back up, just pushing down the mountain.

Well, they usually start walking around one and then you just.

This is none of my business. I don't need nothing.

Then you have a bad back because you chase them around half bent over, trying to prevent them from falling because they're top heavy.

[Dr. Rachel Rosvold]

Oh yeah.

[Dr. Paul Nelson Williams]

And that lasts for several years, it feels like.

Sounds great.

[Dr. Matthew Frank Watto]

All right, well, Paul, let's get to

[Dr. Paul Nelson Williams]

a case from Cash. Like. Cause I know you're more comfortable talking about that, so could you do the honors and read our first case?

Sure. Let's talk about Ms. Penelope Smith. So Ms. Smith, she's a 37 year old G1P1 cisgender female. She has status post a normal spontaneous vaginal delivery about six months ago. No significant past medical history and her postpartum course has been overall uncomplicated. However, she reports continued issues with urinary leakage. Whenever she coughs or sneezes. She knows that her delivery was largely uneventful, though she had to push for three hours. She is wondering if this is just her quote, new normal and if she will need to live with these symptoms forever. So before we get into how you might approach her case and sort of what all you do, I guess we'll start with Nicole. If you could. Well, or either of you really. If you could just kind of review the basic anatomy of the pelvic floor for us. For patients assigned female birth, I feel like this would be a helpful review to kind of start the conversation.

[Dr. Nicole Schaefer]

Yeah, of course. And this is something we review with every patient at every evaluation. We make sure they understand the functions of the pelvic floor and their basic anatomy. So the four functions of the pelvic floor, they're an attachment point to your hips, your spine and your deep core, including your transverse abdominis, which is a large muscle that wraps around your belly and starts into your back. So it's our inner back brace that helps support us. So this, all of these things provide structural support to your entire lumbopelvic region. Your lumbar spine also innervates the pelvic floor muscles. It acts as a sexual function of your pelvic floor. Most people do not realize that in order to have a full orgasm or ejaculation, your pelvic floor must fully contract and fully Relax. It acts as a sphincter, and it controls the bowel and bladder around the urethra and rectum. And then lastly, it acts as a pressure system, so it connects our breathing. So our diaphragm and our pelvic floor actually work together. So when we inhale, our diaphragm and our pelvic floor goes down and relaxes. And when we exhale, they lift together and contract. So that's just what's happening anatomically. And when there's something that goes awry, whether it's stress or stiffness of your thoracic spine or injury to your rib, that can absolutely influence what the pelvic floor is doing if our diaphragm isn't working properly. And then as far as the anatomy, there are many muscles within the pelvic floor, but if we kind of just think of it as the anterior and posterior part of the pelvic floor. So the anterior is the levator ani. So those. It's a big group of muscles. Their job is to lift and to elevate. And those muscles are the pubococcygeus, the puborectalis, the iliococcygeus. They help support the bladder and the urethra and control the urine flow. And then the posterior part of the pelvic floor, those muscles, the coccygeus, bulbocavernosus, obturator internus, and the piriformis. So think of them closer to the rectum, they assist with bowel control, and they stabilize our hips. So together, the pelvic floor muscles support your reproduction reproductive organs and then your bladder. And they all are working together.

[Dr. Paul Nelson Williams]

So, Rachel, what would be the normal timeline in terms of healing for a patient, like the one we presented, where she's postpartum and she's now starting to, like, wonder, is this going to be, like, the new normal for me?

[Dr. Rachel Rosvold]

That's a great question. I think it's one of the biggest ones that we get from patients, especially on their first visit. They kind of want to know exactly what to expect and how many times we have to see them or when they should start seeing improvements. So it's a little bit tricky to give everybody a timeline just because everybody is so incredibly different with not only their healing, but their whole birth process. So generally, when somebody comes in, we're gonna be asking them a whole million of different questions to try to figure out what exactly is going on, to then give them a better idea on this timeline. So I'm gonna wanna know exactly how long has this issue been happening? Was it happening when she was pregnant? Did it ever happen before? Maybe when she was working out, lifting something heavy? Did it start immediately after birth or did it start after some swelling went down? How often is it occurring? How much liquid are we actually losing? Is it a few droplets or is it a full gush? Is it happening on the way to the bathroom, or is it only happening with coughing, sneezing, laughing, lifting baby? We're also gonna ask her about that bowel function, too. A lot of people will come in with one complaint. And then using our kind of clinical reasoning, we can figure out if something else is going on. Generally with some incontinence of urine, you always wanna make sure it's not also happening with the bowels. So we'll ask. We'll whip out our little Bristol stool scale that I'm sure you guys are all big fans of, and we'll ask, what is your color? What is your consistency? How often are you going? Are you using any kind of supplements, vitamins, the whole shebang? What are you doing for voiding times? Are you peeing every hour and then also leaking on top of that? Or are you only urinating every couple hours? Are you able to get in enough water? Are you breastfeeding or not? What is this whole overall picture? We're then going to ask her about her whole sexual history. So if the patient's agreeable, of course, always the caveat is that we will ask questions. If they do not want to answer, that is 100% their call. They do not have to answer anything. And our bodies will still kind of tell us what's going on. So all of that will lead us into a better understanding of how long it's going to take her to heal. And we like to think about birth as a soft tissue injury in the pelvic floor world. We really don't believe that at six weeks, you're cleared for full activity. You're still healing. There's no way for any of us who have had the joy of pushing a baby out our vaginas, there's no way. You're back to yourself at six weeks. And so we never tell our patients to expect that. Is this her new normal? 100%? No. There is always improvements that we can make, and we always like to tell everyone that comes in our door, you should not be leaking anything you don't want to be leaking. So if that's happening, we will make sure it stops happening.

[Dr. Paul Nelson Williams]

And that's a ton of questions. And you had shared with us Like a questionnaire that was shorter. And I don't know if that's something you give to primary care docs just to sort of like screen and send your way. I can't remember the name. It was named after somebody, I think

[Dr. Rachel Rosvold]

the Cozene protocol, it's called. It's a pelvic floor therapist out in California who developed it. And it's a great tool to give to providers who maybe are unsure is this person right for pelvic therapy? And so they'll give them the screening and then from there, all the information is for the patient and sometimes even just seeing it written out and then, oh, yes, this is happening to me. It's kind of a light bulb moment for people to look at it.

[Dr. Paul Nelson Williams]

Oh, great. Okay. So we could. Is that like, proprietary? Are we able to include that with our show notes? And so our audience, she has it online.

[Dr. Rachel Rosvold]

It's. It's easy to find. Perfect.

[Dr. Paul Nelson Williams]

Okay, cool.

[Dr. Rachel Rosvold]

And a lot of physicians in the area will just have it like in a packet for like postpartum and just kind of give it to them.

[Dr. Elise Burke]

Perfect.

[Dr. Paul Nelson Williams]

Yeah. Because that's a ton of stuff to ask, but, I mean, a lot of it is intuitive, but just to try to think of all those things just from scratch every time is like, it seems like something where you should have like a little bit of a checklist or flow or even a questionnaire you give to them ahead of time.

[Dr. Matthew Frank Watto]

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[Dr. Rachel Rosvold]

So I think the biggest thing for providers is probably, are you peeing more than once every two hours? Are you leaking anything? Bowels, stool, or gas? Do you have any pain? And then the last one would probably be.

[Dr. Nicole Schaefer]

I mean, they're not clear to do it at that point, but, you know, I think if it's in their history, that would be something to ask. Or just at every. Every ob GYN visit would be, you know, always asking. Because that can be ever changing as we go through menopause and perimenopause. Is sex painful? It's easy enough to ask.

[Dr. Rachel Rosvold]

And I think everything we kind of talk about in pelvic therapy is very taboo almost. And so a lot of people are not comfortable telling their physicians about some of this without the direct ask, are you peeing all the time? Are you peeing your pants? Those with a penis and those without, I think, have the same struggle of bringing these issues up. And a lot of times people feel like there is no hope. Like, oh, I'm in menopause. I'm gonna be peeing myself all the time. Oh, I had a baby. Of course I have a prolapse and my organs are falling out. They feel like it's the price they pay for living, and they don't know that it doesn't have to be that way.

[Dr. Nicole Schaefer]

Yeah. And I think our society just normalizes leakage, like leaking with coughing or sneezing or laughing. Oh, I laughed so hard I peed my pants. Like, some people just think that that's the price of having a child or that's just, you know, what life is like, but it's not normal in any context. You shouldn't have to, you know, you shouldn't leak when you sneeze. You shouldn't avoid the trampoline park because you're gonna pee your pants. That's not just something, you know.

[Dr. Paul Nelson Williams]

There's much better reasons to avoid the trampoline park.

[Dr. Nicole Schaefer]

Yeah, I just went and I had a great time.

[Dr. Paul Nelson Williams]

No, well, I mean, you, I mean, you're snowboard with kids, you're, you're a non comparator. But no, I 100%. Like, I think, like, there's, there's often a lot of embarrassment around this. And by the time a patient's volunteering it to their primary care physician or clinician, it's, it must be really significant and impactful in disrupting their quality of life, like, hugely. So there's, there's probably been a whole sort of latent phase that we're missing out on just by not asking directly about those things.

[Dr. Rachel Rosvold]

And I think, too, looking ahead is a big one, because if this is happening to someone in their 20s, 30s, 40s, imagine what it's going to be like in their 50s, 60s, 70s, 80s, 90s. And as we know, like, often people are admitted to some assisted living facility or their family can't take care of them anymore. And a lot of times that's related to their incontinence and that's related to this issue that may have started and could have been nipped in the bud years ago. And instead it's kind of, it's reaching a bad point when they're older.

[Dr. Nicole Schaefer]

Right. And if you can work on the coordination and retraining of those pelvic floor muscles. Now, when we're cognitively intact and can learn how to control your body in your 20s, 30s, or 40s, because most people have no idea how to do a pelvic floor contraction or a Kegel. So once they know how to lift and to lower and to control their body, they usually stop leaking. But also it's going to just help them through their lifespan because they're not going to learn how to do a kegel when they're 89 with dementia. They're just not. But if we teach them now, it can really help them through their lifespan.

[Dr. Paul Nelson Williams]

So I feel like there's an increasing recognition of the value of pelvic pt, but also it's fairly mysterious to me. So what I'm hearing is that the initial visit patients love it. I'm thinking about referring more often. And they come back and they say it was wonderful. And it's still a little bit of a black box. So it sounds like the initial visit is extensive questions, which is great. What else could a patient expect when I refer them so that I don't just say it's a thing where you learn some stuff and then see them back and they feel better. So how can I do a little bit better coaching? What the first visit looks like in terms of, say, the physical examination?

[Dr. Nicole Schaefer]

So we ask all those questions. We ask about their bowel bladder, their reproductive history, all the things Rachel was saying. We ask a ton of questions. Like we get to know them very well, and then we take a look at their entire body. It's never just their vagina that is contributing to whatever symptoms they have. So we look at their spine, we look at their hips, we look at the range of motion, we look at the strength, we look at the way they breathe, what their diaphragm is doing. Are they getting a 360 breath or are they just breathing from their chest? If they're doing all these crazy compensations, breathing with their chest or their belly, there's a good chance that their pelvic floor is not doing what it's supposed to do. We check for every patient, if they have a diastasis recti, the separation of their abdominal muscles. That can happen with pregnancy, postpartum, and even with abdominal surgeries, hernias, you know, that can be a big part of that. Managing the pressure system of your intra abdominal pressure and what your pelvic floor is doing. So we look at your belly, we palpate everything. We, we check their ability to contract their deep core. So not their upper abs, all the, all the crossfitters in the world. They have like the strongest recta rectus abdominis in the world, but they have no ability to contract their lower muscles, the transverse abdominis, even their obliques, they're just compensating super well. So we look at all that coordination is a big part of what we do, that mind body connection of being able to do, you know, contract your lower core, do a pelvic floor contraction. So we, after we look at all the strength, we look at your hip strength, your rotators, as the hips are part of your pelvic floor and connect directly into your pelvic floor. So if your hips are tight, there's a good chance your pelvic floor is tight. So we look at all that stuff first. We look at balance, too. Balance and foot mobility play a big role in your pelvic floor as well. If your balance is terrible, then there's a really good chance that your pelvic floor is not strong at all. So after we do all that, then we do the internal exam, which is very much up to the patient. If they don't feel comfortable with it, we never have to do it. So, you know, we have them sign a consent form, we talked about them, what to expect. We step out of the room, let them change, and we do an external exam around their perennium, looking for any tenderness that they have, looking at some reflexes, how well they can contract and relax. And then we do just with one finger, there's no speculums. We do an internal exam. We palpate the three layers or levels of the pelvic floor, and we see what muscles, what specific muscles are tight, which ones are overactive, which ones are underactive. We check for any evulsions that can happen. We can see their scar from where they've torn during labor. We can look at the scar mobility, which that can cause issues. And then we test their strength. So everybody should be able to do a 10 second pelvic floor contraction, lifting up all the muscles of the pelvic floor. We should all be able to hold that 10 seconds and do that 10 times and then doing 10 quick contractions. So that's the perf. That's what we call like how to measure and test our pelvic floor strength. So all that information tells us what's going on with their body. If we're palpating the muscles and they're just like, they feel like a rock. They're just hard, they're not moving, moving. Patients are wincing. Like we don't go any further. But that's someone that we need to down train, meaning they need to stretch and they need to learn how to lower and they need to learn how to relax their pelvic floor. And that can be done in a very many number of ways. And then there's the patients who. Oh, and we look for a prolapse as well. So Rachel and I, not every pelvic pt, but it's kind of more. Coming to be more popular. We can both fit pessaries now, which are a medical device that are used to help support the tissue that can descend after having a child or from straining or there's many number of reasons for prolapse, but that's something we'll look at. We can't grade a prolapse. We can, you know, basically describe it pretty well and talk to the OB GYN to discuss our findings. But anyway, so after we find all those things, we make a plan and you know, the patients that have the tightness, we have to address the patients who are weak. Then we kind of work on the coordination and retraining. So there's a lot that goes into it. It's not just one thing. It's never just their vagina contributing to it. It's all the things. And we work on each one of those things to get them feeling better, get rid of their pain, and get them on a path to meeting their goals.

[Dr. Paul Nelson Williams]

Is there one thing on history or is it more of an exam thing to figure out if they're more hypertonic pelvic floor muscles or weaker pelvic floor muscles?

[Dr. Nicole Schaefer]

Yeah, no, that's a, that's a great question. And my high, our, our high anxiety patients, the ones that are clenching their glutes all day or grinding their jaw or, you know, are like talking a mile a minute. Those patients, I can put my money on it, they have a tight pelvic floor. So, so, you know, that's usually the, the scenario of just like how they're, they're acting or, you know, just their

[Dr. Rachel Rosvold]

history,

[Dr. Nicole Schaefer]

you know, the back and hip pain, that can be, it could be one way or another, but. And then I guess the ones that are probably, you know, needing more strengthening are, you know, just probably the ones that aren't as active, the ones that are a little more sedentary. And it really just depends, but I think are, I think on, on history, it's like the high anxiety, the ones clenching all day and, you know, just going a mile a minute, doesn't know how to stop, doesn't know how to slow down.

[Dr. Paul Nelson Williams]

I have to interrupt for a second because.

[Dr. Nicole Schaefer]

Is that everyone?

[Dr. Paul Nelson Williams]

Paul, are you a fan of Ferris Bueller's Day Off? I'm guessing not because you're a contrarian, but, you know, like he says about Cameron.

Yeah, Colt, a diamond line shirt.

Yes. Yeah, for the audience, some of which are too young to probably know the Ferris Bueller's Day Off. He comments that his friend is so high strung that if you stuck a lump of coal up his bottom that he would, he would have a diamond. So I guess that type of person

[Dr. Rachel Rosvold]

is, yeah, 100%, most likely, a little bit hyperactive.

[Dr. Paul Nelson Williams]

Yeah. Okay. Yeah.

[Dr. Nicole Schaefer]

Oh, the constipation, too. That's the. Another sign.

[Dr. Paul Nelson Williams]

And constipation.

[Dr. Nicole Schaefer]

Okay, constipation.

[Dr. Rachel Rosvold]

Yeah.

[Dr. Nicole Schaefer]

Tight pelvic floor.

[Dr. Paul Nelson Williams]

Interesting. All right. I'm learning a ton here and then. So I think that would be reassuring that you can get a lot of information without the internal exam and that it's not. Maybe on the first visit, if they don't feel comfortable, it's not something you're gonna be forced to undergo just by visiting a pelvic therapist.

[Dr. Rachel Rosvold]

Yeah, we have some patients who never undergo an internal assessment. They might be survivors. They might have some other issues happening. They might just not want to. And that's fine. We can get enough information from the surrounding tissue and from our external examination to figure out what's going on. And I don't even mean external examination of the pelvic floor, just how their body is moving and presenting. We can get a pretty good idea. Some pelvic therapists are not internally trained, and some are not internally trained for rectal and vaginal work. So it can depend, too, on the clinician. But across the board, the patient is. Is always in control. It's always their decision, and they never have to do internal if they don't want to. Most of the time, people are like, oh, that wasn't that bad. You know, you didn't. You didn't have stirrups, and I didn't have to put my butt off the table. Yeah, it's not. It's not terrible, and it can be super helpful.

[Dr. Paul Nelson Williams]

Okay, so the first visit sounding a lot less scary, Paul, and very useful, like, a lot of things we could learn from this. So. So what are we ready to go to next, Paul, you think we need to talk about how to coach people on exercises? Where do you want to go next?

Yeah, no, I think now is a good time to talk about actual specific exercises and maybe what initial coaching of the patient looks like.

[Dr. Nicole Schaefer]

Okay, so I guess we'll get into the hot topic of Kegels. So Kegels are the thing that most people think of when we hear pelvic floor pt. But when we do our internal assessment, like we just talked about, we can determine if Kegels are even appropriate. That patient with the hypertonicity doing Kegels are not appropriate. If we have a muscle that's already shortened, we don't want to shorten it anymore. Right. So we need to get that muscle to elongate fully, kind of like the bicep. We want it to be able to fully contract so that we cannot leak when we do the hard thing or when we jump, or we do double unders or whatnot. So we need to understand the length of their pelvic floor. If they have that tightness, then we don't want to do it in the beginning at all. We want to teach it how to relax, how to down train. We're doing a lot of stretching, a lot of diaphragmatic breathing, which is breathing 360 on all angles into your side of your. Your rib cage and into your back. We want to avoid using Kegel exercisers. I know there's, like, a lot of talk about that. They're not always the answer. Most people need to learn how to fully elongate. And then for those who have hypertonicity, the ones with stress incontinence, I see they are not the thing to do. We want to work on their full range of motion. If you. But we do also, eventually, once we get everyone's muscles to relax, we do want to teach them how to do it so they understand how to lift and how to lower. So with doing a contraction itself, if we can see someone clenching their glutes or, you know, using their shoulders to try to contract their pelvic floor, they're most likely not doing it properly. So the coordination and the motor control of doing that is something that we really work on. And it's surprising that, you know, some people just have no idea how to work those muscles at all. So we get to the root of figuring out what that looks like. But so I would say, as far as the exercise, breathing is a big part of it. Down training, stretching. We have them all do all sorts of stretching. Some of the muscles that insert into the first layer of our pelvic floor, we can stretch. Doing external stretches like straddle stretches or adductor stretches. You know, we can stretch the piriformis through other things. So we're guiding them exactly what to do in a certain time period, and then we're progressing them as their muscles start to listen to us. And as we go through the treatment

[Dr. Paul Nelson Williams]

for the deeper muscles of the pelvic floor, and you're trying to teach people how to isolate them, or is there certain ways you coach them or phrases you use to tell them, like, how to do this appropriately? Because it sounds like, well, if they're doing a Kegel exercise, how do you tell someone how to do that so that they know that they're isolating the right muscles?

[Dr. Nicole Schaefer]

So that's usually done best. Doing our manual treatment. So we do Our assessment, the first visit, as long as they're okay with it. And then if they're not doing. If they're not doing it properly, then each visit we do the manual work. And with a finger, we're literally talking them through of. Okay. Like, you know, we have all different cues. My. A couple of the girls there are all talking about it at the gym, but we talk about sucking in a thick milkshake through your vagina is one of our cues to contract your pelvic floor. Super weird, but it's one of the many ways that we can use visualization to help them contract the right muscles.

[Dr. Paul Nelson Williams]

This is the kind of pearls people come to the show for.

[Dr. Rachel Rosvold]

So that's. Yep.

[Dr. Nicole Schaefer]

The thick milkshake. So, yeah, so everyone's talking about the milkshake right now. But. But that's just how our brain gets to learn how to do something. And then once we get it, then it gets easier. It's really hard for people to do it if they don't know how to do it or to recruit those right muscles. So we're using our finger. We're giving them feedback on what muscles to relax. We don't want to see them clenching their glutes. We just want to use their pelvic floor muscles themselves. So the manual treatment is the best, but once they get it, we don't have to do it forever. Once they're getting stronger and once they understand what to do, then we take them to do that in other positions and other, you know, unloaded, like laying down or standing up or something functional, which, like, whether it's jumping or whatever else they're doing, and then we. We translate it into the functional activity. But we kind of start at the basics with just learning how to do it.

[Dr. Paul Nelson Williams]

I was reading about this, Paul, how they. They kind of progress where first people will practice this just supine, and then they might practice sitting or standing, and then they're like, practicing it during, like, functional movements. Like they're like doing a squat or something like that, which makes sense. But I just. Okay, people, this is what my thought of Kegel exercises was. Just like, oh, yeah, people just brag about you can just do them at any time so that, you know, there was never this. I didn't think about this progression of being able to do them over in increasingly more complicated situations.

[Dr. Rachel Rosvold]

It's also interesting if you look at the research and you just have people kind of, without cueing, do a Kegel. Like, 80 to 90% of people don't do it correctly. So most of the time, if a provider's telling a patient, oh, just go home and do Kegels, you'll feel better. Whether it's post abdominal surgery, prostatectomy, childbirth, chances are not only are you doing it incorrectly, but the coordination part is going to be missing. And I think that's the most valuable thing that our patients learn, is that it's not just that. Can these muscles turn on or off? When do these muscles need to turn on and off? What's the sequence of events? Is your posterior aspect coming faster than your anterior aspect? Is one side more tight? Is one side looser? Like, what really is going on? So we're not a huge fan of just saying, go home and do a million Kegels. And also, you'll fatigue out the muscle.

[Dr. Elise Burke]

Right?

[Dr. Rachel Rosvold]

So, like, if all you're doing is just Kegels all the time, you're not addressing the root cause. You're not getting the other surrounding tissues stronger. You're not helping support the rest of the body. And sometimes, why is your pelvic floor too tight? Like, okay, sure, you have anxiety, but what else? Well, it might be because your whole hip musculature is so weak that it's not doing the job to support the back, the hips, and the pelvis like it should. And so the pelvic floor is trying to overdo it and try to kick on and really do that. So some people may not ever do a pelvic floor contraction with us, but we might really beat up their booty. We might get their hips a heck of a lot stronger. We might really work on their coordination of their whole complex, but they really never need to do a Kegel. So it's not, like, a bad word in the pelvic floor realm, but we don't really throw it around that much.

[Dr. Paul Nelson Williams]

It's an oversimplification. Yeah. Everyone thinks that it's, like, the only thing that they need to do for this problem, but for some people, it's the absolute wrong answer, 100%. Somebody that has had too much caffeine and you're giving them more caffeine, Is

[Dr. Rachel Rosvold]

it You're just vibrating?

[Dr. Paul Nelson Williams]

Yeah, yeah, yeah. Okay, I got it. Well, so how is posture related to this as well?

[Dr. Nicole Schaefer]

Yeah, so posture plays a huge role in pelvic and spine health. Our society sits now more than ever. There is a bunch of articles about how sitting is the new smoking. All the pressure it puts on our discs, on our spine, the load that just sitting forward puts on everything is just terrible. The forward head position just puts, like, 60 pounds of force through your whole entire spine. So if we think about sitting in itself, it's flexion of the spine, which increases the pressure on the discs on the nerves. And our nerves of our spine innervate the whole our pelvis, the whole entire part of our legs into our toes. So, you know, back issues and pelvic floor symptoms are very much correlated. And we treat the back too, because it's not like sometimes that's what's bringing them in to see us is their back pain. That's not getting better with traditional pt. But if we think about the position of sitting, our pelvis is in a posterior tilt. That's contributing to a pelvic dysfunction because there's less blood flow there. There's a reason why we have that overactivity of the pelvic floor right there because everything is tucked in and tense. And that is another reason that can contribute to that hypertonicity or the constipation. So it's just, I mean, we should all be sitting less. We should be standing. We should be moving. You know, the. The more, the less sitting we do, the better it is just for our entire body, you know, and our pelvic floor. But they all go hand in hand. The back, the hips, the spine, for sure.

[Dr. Paul Nelson Williams]

Awesome.

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[Dr. Paul Nelson Williams]

Okay, Paul, what else do we have? I think we're coming towards the end. We've taught our patient here, what do we call her? Ms. Penelope. We've taught her a ton. But what else do we need to know before we move on to the next part of the case?

Yeah, I guess before we age her up. Is there any other behavioral counseling that you give in addition to the exercises? So things like time voiding or bladder diaries or that kind of stuff? Is there any other sort of coaching other than sort of the exercises and the actual physical training that you might recommend for someone in the case of Penelope here who's shortly postpartum?

[Dr. Rachel Rosvold]

Yeah, we love a good bladder diary. Our patients hate them because they're very annoying to complete, but they give us really, really good information. So a bladder diary would be exactly writing down when you're peeing, either by choice or by stress incontinence. In her case, if you are having stress incontinence, how much, you know, like full pad change, full underwear change, full outfit change, or couple drops, what time is that occurring? We're also going to want her to track on the bladder diary. What is she drinking, when is she drinking it and how much is it. Also her food intake, when is she eating, what is she eating and when is she having her bowel movement. If she's somebody who is also complaining of pain, anytime she feels the pain, what is she doing when she's feeling the pain? Writing that down. Sometimes it's not even Nicole and I that really find the most help out of these bladder diaries, but the patient themselves because having to write it down for three days. We like to say if you are at work, one day at work, one day at home, one day is dealer's choice. But if you're writing it down and you see this in black and white, some people have come in and said, oh my gosh, I did not know I was peeing every 35 minutes. But like clockwork throughout the day, I'm going. And then I'm also leaking on top of that. So we can see these really good, like light bulb moments for our patients. So we, we really love a good bladder diary. We counsel on how to have better toileting posture. Huge fan of squatty potties over here. It Helps put that. That pelvic floor, that nice, relaxed position. We counsel about not pushing for pee or poop. We really want to have that nice, even flow going. Always talking about, you know, we're not people who love to say you should never do X, Y, or Z. You know, if you're drinking only coffee and you're drinking five pots of coffee a day, we might have to talk about that. But if you're drinking a couple cups here or there, I'm not one to say, let's cut out your coffee. But maybe let's also add in some alternatives, like some water, dilute these bladder irritants a little bit. Same with counseling for like, okay, doc, I know I'm gonna go for a run. I know I'm gonna pee my pants. And it's just, I have to do it because I'm just. I'm going insane. The kids are driving me crazy, and I need to get out there. Okay, great. If you know you're gonna pee your pants and you're willing to accept that fate, go for it. And then let's also work on the back end of why is this happening? So a lot of people are scared that we're going to take away all the good things in life. Wine, alcohol. A lot of my guys are like, I'm not giving up my scotch at night. Okay, we don't have to give up your scotch, but maybe let's also water it down occasionally. So there's modifications we can make throughout the day that can lead to some beneficial changes in the pelvic floor. So we do all of that. We do a ton of education. There is a ton of resource out there between sometimes just that habitual peeing of, oh, I'm just going to go every hour, or, oh, I'm going to go to the store. I'm going to pee before I leave. Oh, I just got back from the store. Even though it's been 20 minutes. I'm going to pee again. Oh, I'm going to take a shower. I'm going to pee before I go to the shower. May or may not pee in the shower, and then I'm going to definitely pee after the shower. All of that's habitual. So we can talk them through that. We can do timed voids if needed. We can talk about how the nervous system is going to send that signal that you're going to explode your bladder if you really don't pee in that moment. And you can actually have these tools and tricks to ignore it and then pee when you actually Want to. So we have a big old toolbox, literally. And so we like to have our patients really use what's best for them.

[Dr. Paul Nelson Williams]

Looks like there's a bunch of bladder diary apps. I don't know if you all have a favorite or not, but that seems easier and more conducive to life than actually writing down a diary, which is what I was thinking of.

[Dr. Rachel Rosvold]

Yeah, no, there's some great apps out there. Some people love the ones that remind you, like, oh, hey, you haven't written in your app in two hours. What is it? Some people go for the one that's just more highly rated that day. There's some really great ones out there, I'm sure.

[Dr. Paul Nelson Williams]

Just a matter of time before the Apple watch finds some way to actually track that too.

[Dr. Rachel Rosvold]

So just, I mean, I wouldn't be surprised if it's already doing it.

[Dr. Paul Nelson Williams]

All right, so let's continue with the story of Penelope. So you work your magic. You do your comprehensive assessment. You teach her some things. Probably PT occurs and then she does great. So she has a significant improvement in her incontinence following the physical therapy course. Fifteen years later, we're all still practicing. Penelope is now 52 years old. She is a year out from her last normal menstrual period. She has noticed a recurrence of the stress incontinence while sneezing and now has also developed a sense of increased urgency when having to urinate. She notes that she has to go more often as well. She has visited her PCP who completed a urinalysis because an A1C, they were fine. She also remembers how helpful you were with her postpartum journey and is requesting a referral back to you all. So her PCP kindly provides the referral. She comes back to see you. So. So all of this is context to let you guys tell us about what changes to the pelvic floor do we typically see as part of menopause? Perimenopause. How does this change your approach, if at all?

[Dr. Nicole Schaefer]

Yeah, so we've been hearing some great results from our patients using the vaginal estrogen cream. When we go through perimenopause and menopause, our tissue gets thinner, less robust, and more painful. We typically see the complaint of. Of pain with sex and having more incontinence. And we also see the increased complaint of pelvic heaviness and the pressure as tissue can be prolapsing and is unable to sustain the support without estrogen. So us kind of reassessing everything, how it's functioning where the coordination is, and then them using the vaginal estrogen. Estrogen cream provided by the pcp. So often, sometimes they're coming to us and already using it. Or if we, you know, they come to us, haven't talked to their doctor really much about it, then we lightly suggest, why don't you contact your doctor? Like, they're having dryness with sex. You know, it feels like sandpaper. I mean, that's a common complaint in there. They do really awesome with the vaginal estrogen. Their body just sucks it in and they are like. It's like night and day and it's all very local. And then I guess the other things going as she's getting older is that the disuse of the pelvic floor muscle. So, you know, as we age, I mean, hopefully, you know, we all stay super active, but as we age, we typically are more sedentary and we have more issues, you know, the hip, the knee issues that can definitely contribute to the pelvic floor, too, if you're having, you know, all these hip problems. Well, the hip is part of the pelvic floor and connected, so that can be part of the puzzle. So we have to fix the hip to then help this issue as well.

[Dr. Paul Nelson Williams]

Yeah. I never thought of how much the hip is connected. It's come up so many times tonight. I have not thought about how much the hip is connected. And everyone's just sitting all the time. So we're just destroying our hip mobility and our spine is not happy. So it's all tied in together here. Okay, well, so vaginal estrogen therapy, we're a fan of that. It was curious to me that systemic estrogen therapy seems to maybe even worsen or even some people develop urinary incontinence. Incontinence on it, which I had not heard that before. But vaginal estrogen therapy certainly is something that I feel comfortable prescribing, and it seems like patients don't mind taking it for the most part. So for Ms. Penelope, she's gonna do some exercises. Is there any different approach to what you would give her exercise wise than somebody who's postpartum?

[Dr. Nicole Schaefer]

I think it really just depends on what her main complaints are. You know, if it's the. The hip or the back pain that's contributing to it, then we're definitely going to address that. But we're still addressing all the coordination issues. We're addressing the mobility. And, you know, it's really just her presentation at that time. It's probably. We're probably not as focused on healing that diastasis recti that most people have. Really, everyone has postpartum, so we're not really thinking about that because, well, we know that we were the ones who saw her, so we know we already fixed her with that. So we know that's working. So probably already, like, you know, any other things that come up the hip, the spine, you know, if there is tightness of the pelvic floor, you know, addressing that in itself, but.

[Dr. Rachel Rosvold]

And for some of our ladies, we also really encourage them to have these frank conversations with you guys. So please go back to your doctor, please explain to them what's going on. Please don't sugarcoat it. Don't be like, oh, yeah, you know, it's fine. Like the. It's not something that so many people have been told, oh, just have a glass of wine, it'll be fine. But really explain like, no, when I have sex, it feels like there is sandpaper in my vagina and I am unable to orgasm and really have these hard conversations because if you guys don't know what's going on, you can't provide the medical assistance that they may need. So hrt, we've seen some awesome results with people, if they're appropriate to be taking it often, like that combination of maybe patch and pill or that along with the vaginal estrogen is great. But we also start to talk about, think about what's going to happen in the next couple decades of your life. You know, let's talk about what's your bone density, like, what's going on with your strength? You know, we lose so much muscle mass each decade. We want to really make sure that you're not in that population. Are you doing any impact activity? Are you doing anything to really lift heavy and support these bones? And we promise we won't get you, you know, looking like Arnold in his prime. But we do want you to be strong enough to get through to your ninth decade of life or beyond. And so our treatment can be a little bit different at that stage. And we have some awesome trainers in the area that we can also progress them out of us and to another provider. And then there's also another thing we always encourage them to bring up to you guys is maybe they need a referral to some mental health counseling. It can be a huge change of life in menopause. A lot of things can change. Can correlate with maybe the empty nest syndrome or Perrymont, you know, having kids later in life, then perimenopause, the menopause and then, oh my God, I also have a teenager and like the world is crazy. So sometimes having we have a couple providers that we love for their mental health and also having that frank conversation with you guys about it can be so important because I think sometimes we just think we have to like grin and bear it and these things need to come up and sometimes they don't open up to us five, six times in, but eventually you can find out what's really going on. And I think it's so hard to be vulnerable and to admit what's going on. And so we like to just be open and aware and have some like, oh great, you're feeling that you're hearing this. Let's talk about here the resources. And then if it's anything red flaggish, then of course we'd alert their primary care or OB who's ever the referring provider.

[Dr. Paul Nelson Williams]

Yeah, we do have another case that's a male case. But before we get to that, I just have to ask, and I don't know if this is the place to do it, but I don't think men are using these pelvic wands. And I saw there's these tens like devices for incontinence. So what are your thoughts on pelvic wands? What are they used for? And then any of the tens devices, if you want to comment on those as well.

[Dr. Nicole Schaefer]

Okay, so a pelvic wand and a dilator. So those are the two kind of tools that we will often prescribe. You know, it's not for everyone. We go over it together, we teach them how to use it. But a wand is kind of like a curve shaped thing that we insert into our vagina. And it's its job is for our patients who have the hypertonicity to stretch the pelvic floor muscles. We can al. We actually also use them for our pregnant patients to help stretch the tissue so that they are less likely to tear during childbirth. So it's a great tool to have for our patients. So I guess we can talk about our hypertonic pelvic floor patient. But their the way the wand is with the hook, we can insert it into the first, the second, the third layer and we kind of hold it and stretch that muscle for 30 seconds to a minute until that muscle gives out. So it's a way that they can stretch their muscles on their own where we can't follow them around at home and stretch their pelvic floor muscles five days a week. So it can help them make progress to relax those muscles. The dilator is another option. So it's basically, it's a straight silicone based device and there's different levels. It goes from level like 1 to 9 depending on the brand. But level 1 is so skinny, it's like smaller than a finger. But with the patients that have severe vaginismus, the inability to put anything in there, those patients that you can't even do a pap test on, a vaginal ultrasound can't even do like, you know, an internal exam on those patients should definitely be coming to pelvic PT and usually the pelvic PT will guide them through it. But those devices are really helpful to have them do their homework at home to stretch those muscles. And always using lube. So we usually recommend a water based lube or a silicone based lube. And we try to pick the ones that have not a bunch of random ingredients trying to pick those clean products. So we have the certain ones we recommend. So that's kind of the wand, the dilator.

[Dr. Rachel Rosvold]

No. One other thing I wanted to mention about the dilators is that they can be very effective with anticipatory pain or trauma based response or any time that you have fear or difficulty with penetration or thrusting. And it can be really helpful for nervous system down training. So these tools can be used for a variety of patients. And there is actually a rectal wand. So don't worry, those with no vaginas are not left out. And there are dilators for the rectum as well. I'm just gonna. There's some weird stuff out there that patients have found on the Internet. So I'm always gonna say make sure anything rectal has a wide base. We recommend silicone based products, not glass, metal or wood.

[Dr. Paul Nelson Williams]

Yes. Okay, yes, nuff said. And that's a good transition to our next patient who does not have a vagina. So pa Paul, would you read our next case?

Sure. Let's talk about Mr. Bernie Johnson. So Mr. Johnson is a 43 year old cisgender male with a history of high blood pressure, high cholesterol and IBS C presenting for persistent pain in the perineum as well as dull pain with urination for about the past two months. About a month ago he went to a local urgent care where he reports he was diagnosed with acute bacterial prostatitis. He was treated with a four week course of ciprofloxacin which did not improve his symptoms. We do not have the records from that visit. Of course, today in our office he is afebrile, he's got stable vital Signs, he appears okay. Overall, he does not look acutely toxic. His prostate exam was done and it showed mild tenderness, palpation of the prostate, but no significant enlargement or nodules detected. His testicular exam did not reveal any masses or tenderness. Ear analysis, culture, STI testing were completed and were negative. His PSA was 0.7 nanograms per milliliter. Given his persistent pain, we did a CT without contrast to the abdomen and pelvis, and that did not show any potential etiologies of his pain. So really thorough worker for Mr. Johnson eventually referred to urology. Diagnosed with chronic prostatitis or chronic pelvic pain syndrome. Started on tamsulosin, 0.4 milligrams daily for six weeks and ibuprofen, 40 milligrams three times daily for one week, which kind of improved his symptoms, but not really. He was also trialed in Pregabalin, 75 milligrams twice daily, which was titrated and trialed with some reduction in discomfort. He is finally and ultimately referred to pelvic pore, pelvic floor physical therapy for additional assistance. So I'm not sure how substantially the answer will change here, but any anatomic considerations before we sort of delve into the case about how you might manage this and what you think is going on here?

[Dr. Rachel Rosvold]

Yeah, for sure. So I want to kind of break down the differences in what the muscles may be doing for especially erectile function and for those who have a penis. So when we're talking about the ischio cavernosis, it is responsible for maintaining and the rigidity of an erection because it compresses the crust of the penis. So this increases your intracaversal pressure during your erection. The bulbo spongiosis, we call it the bulbo. It compresses the bulb of the penis and assists in penile engorgement. It's also responsible for parts of ejaculation and expulsion of the the semen. And this can contribute to the venous occlusion during an erection. The pubococcygeus, or PC, part of that levator ANI that Nicole was mentioning earlier, does provide the pelvic support neuromuscular control, and with coordination of the IC and the bulbo, adds to that erectile stability. So it can also help with the organ positioning within the abdominal cavity. Then the pubococcygeus, which is part of the levator ani, provides that pelvic support, neuromuscular control, and then also helps with that urinary continence. So The Olivia ANI is still urinary focused for the continence. The iliococcygeus and puborectalis help maintain the pelvic floor tension stability, helps with bowels and supports vascular efficiency. I just want to remind everybody that S234 keeps the pee off the floor. And so those muscles are innervated by S234. So the vagus nerve is another big one in the area. And so all of these kind of things are running through your head as soon as someone walks in with pain and prostatitis.

[Dr. Paul Nelson Williams]

How common is it for somebody to have what is diagnosed as like a bacterial prostatitis and it ends up that it's actually just related to the pelvic floor.

[Dr. Rachel Rosvold]

This is huge. We're actually seeing it more and more too that younger men or younger people with a penis are experiencing this. So depending on what research you're reading, it can be anywhere from like 70 to 90% of these cases are not actually anything bacterial. They're pelvic floor dysfunction. Very similar to the IC population or the pelvic pain in women population that it can be mimicking like a UTI more in women and more like Bernie itchy. For the men it presents more as like a prostatitis. But in both populations it can often be a pelvic floor dysfunction.

[Dr. Paul Nelson Williams]

Do we know why? Like is this increased recognition or truly increased prevalence or some combination of those things?

[Dr. Rachel Rosvold]

I think it's a combination of both. So I've been seeing more and more providers, especially urologists, refer immediately to pelvic, pelvic floor when these guys are walking in the door. So I think it's a little bit biased in my mind because I'm seeing people a little bit earlier versus oh, I've been going through this thing for two years and no one can figure it out. And finally I'm just trying pelvic therapy because I don't know what I'll have to lose versus this is a first line defense now. So there is some really nice research that this especially pelvic pain or erectile dysfunction in a younger male population is increasing and I think awareness too. So there's an awesome article in like Forbes or the Times or something that actually brought this to light maybe two or three years ago with increased sitting, increased working from home, a lot more guys are having this pelvic pain and prostatitis and it's pelvic floor dysfunction. So I think it's kind of been a snowball effect of it. Might be happening more. And also we're seeing these populations earlier with pelvic pain.

[Dr. Paul Nelson Williams]

We did an episode on that in the past, and what we had talked about with the speaker was how you try to get a flavor from the patient. Like, do they have a lot of GI symptoms or are they more genitourinary symptoms? But, like, what do we think is the pathophysiology? Or, like, what are you doing to try to understand where this might be coming from when you're talking to a patient like this?

[Dr. Rachel Rosvold]

Yeah, it's a great question. So similar to people with a vagina, we ask the same questions about bowel and bladder habits, sexual function, and try to form an idea from that. We always like to ask the patients too, like, what's your level of activity? What do you do for work? What is your commute? How much are you sitting during the day? And also, honestly, what is your anxiety? Like, what is your sleep like? All of these big things that sometimes they don't want to really talk about can make a big difference. If someone is so caught up in work that they're sleeping three to four hours a night, it can be very different than the person who's able to relax and sleep for eight hours a night. So even something simple like that that you may not think correlates to your pelvic pain can certainly do that.

[Dr. Paul Nelson Williams]

Okay, so what would the approach be for treatment for a guy like this?

[Dr. Rachel Rosvold]

Yeah, so if he is agreeable, it would involve some internal work of the pelvic floor itself, similar to those of the vagina. We wanna see what muscles are firing, which ones are not, which ones are active, which ones are not. And it would be interrectally. So it's one finger inserted in your rectal canal. So based on that, we could see also what is his full range of the pelvic floor musculature, and where is he able to even expose your finger? So we can get a good amount of information from that after our full orthopedic evaluation. Same as the last patient. We really want to make sure we're getting that full picture. And honestly, it can be so hard to talk about the erectile dysfunction part of this. But typically those with pain are going to have some erectile dysfunction or some sexual pain. So it may not even be affecting the actual erection at this point, but post orgasmic pain, or pain that lingers for a few days even, can be a complaint that these guys come in with with. So we kind of have to dive deeper into what's going on. And so if you think about almost like a hose, to have a full erection, you have to have your blood flow go into the penis and then it has to be stopped to hold that flow there. So if a muscle is already contracted, it's almost like there's a kink in the hose. It can't fully contract off right. Till to restrict that blood flow and to hold that nice erection. But then also it can't fully relax to then have that full orgasm or ejaculation or you'll have that lingering penis tip pain afterwards. So all of these questions are hard to answer. And I so appreciate when people are able to be open and honest in the room because it will definitely lead our treatment plan.

[Dr. Paul Nelson Williams]

Yeah, I have had over the years a couple male patients who didn't have like the typical vascular risk factors and might even have been younger and were having issues. And I never really considered pelvic floor dysfunction might be part of it. I thought maybe it was like a partner issue or something like that. So probably have missed some cases there. Paul, any questions about this or any other, Any follow ups to this?

Sure. Well, I mean, this was. We made this a dense case intentionally, but this patient also has IBS C, so constipation is kind of part of their background. I'm wondering, can pelvic PT be helpful for the patient in that regard as well? And is that connected to some of the other symptoms that he's experiencing?

[Dr. Rachel Rosvold]

Yes, a million percent. We have people who come in just for their constipation alone. And also constipation can sometimes be this thing that they've been dealing with for 10 years. And there are Miralax for a bowel movement every day. And I don't understand why you're talking to me about this. This is just how I live my life. And that's a huge problem. So if you can't have your puborectalis fully relaxed to allow that colon to have a nice smooth release of bowels, you're going to be in trouble. When the pelvic floor is already contracted, it could be because it's trying to hold back that stool. Right. So when the stool is sitting in that last little chunk of the colon and it's getting harder and thicker and it's waiting days and days and days, then the pelvic floor muscles have to kick on even more to hold that weight up. And so sometimes it gets kind of past the point of no return where you don't know when to turn those muscles on or off. And then it can lead into almost like that dis. Synergistic defecation. And so even if we didn't have him report that he had constipation the first couple times, I would almost assume with pelvic pain and with hyperactive pelvic floor that he would be experiencing some kind of constipation. So he'd be doing all of our good toileting habits, making sure that he's not dehydrated. What is his fiber intake? What are his bowel habits in the morning, is he having anything warm to drink and then moving around and then eating something like what? What are we doing? And then a lot of the time, I'd say like 90% of these poor guys that walk in, we're going to be doing a lot of relaxation, a lot of down training, a lot of learning what it feels like when the muscle is on, but also what does it feel like when the muscle is off. And a lot of my people with a penis report that when the muscles are on, it feels almost like you're trying to move your penis or like you're pulling your balls to your belly. And when the muscle is off, it's almost like you're trying to spread your butt cheeks without moving any. So that's kind of what we work on. Like what is the coordination? What's going on? And then most of the time, again, because of either habitual or not, we're sitting all the time. And so can we get a little bit more movement in? We all know that movement helps the gut. We all know that movement can help that constipation alone. We can teach them, you know, mobilization techniques for constipation on their own. But a lot of it is down training and then retraining of these muscles to really have a nice full bowel movement. And I always get like really excited when my guys tell me, oh, I'm not taking Miralax anymore, or oh, I'm only taking it like maybe once a week. I'm like, yes, thank you. Because you know, we don't want you to have to take it every day. We want your body to be working a little bit better.

[Dr. Paul Nelson Williams]

I see just in my line of work, just tons of like opioid induced constipation. And I have to wonder now that sort of hearing you talk if part of this is not. Not it's not just the opioid themselves, but the sort of the self perpetuation and kind of dis synergy from the constipation in the first place. I'm wondering, is there any evidence to support like pelvic PT for constipation in that patient population or does that at least make mechanical sense? Because I. Yeah, I think it would

[Dr. Rachel Rosvold]

make a pretty good mechanical sense. I mean, obviously with the opioid you'd have to rethink that whole, you know, what is their nervous system pathway even doing at this point? But 100% we've had people have some really good success even having been on long term pain medications. And then a lot of them get into that constipation cycle where they're constipated for a few days, then they take a pretty intense drug, then they're diarrhea for a few days and they don't want to eat, then this whole thing. And so we kind of take the diarrhea and the days of constipation as it all being constipation. So. So it's definitely something we address frequently.

[Dr. Paul Nelson Williams]

Yeah, we've mentioned down training a couple times and I guess it paints a certain picture. But is that just more coaching people where through an internal exam, you're teaching them which parts to relax? But if someone doesn't want an internal exam, is there a way that you can still teach them down training?

[Dr. Rachel Rosvold]

Oh my gosh. Yeah. So the really nice thing is that we have that little paranese for everybody. So if we're able to get something proprioceptively against the perineum, say a big Swiss ball, sometimes we'll use pillows, sometimes we'll use a hand even. Yeah, you can actually feel a little bit of lift in the perineum. And then when you relax the muscle, you should be able to feel a little bit of relaxation of the perineum. And then sometimes with full elongation, you can feel that even elongate further past almost neutral. Some people do really well with a mirror, so not even in the office, but they'll go home, they'll get a hand mirror and they'll kind of take a look at what's happening when they're trying to do a contraction and a relaxation. So that can be really nice. There are machines like biofeedback that you can use for that. Those are external sensors or internal. You can use biofeedback for that. There's some great research based on that, but most people don't have a biofeedback unit in their house. So we always like to try to figure out how we can get this, you know, to work at home. And often it's that proprioceptive part. Sometimes it's Even kind of tricking the brain into doing different movement patterns or different lengthening of the muscles as they're working different muscle groups. Because the pelvic floor should be more of like an anticipatory muscle. It's not something that you should be thinking about all of the time. Ideally, you're not gonna go to your gym workout and be like, okay, I gotta clench all the time. It's gonna be on and off. Right. So you wanna be able to do the things that then turn your pelvic floor on and off, which could be a whole host of exercises from, you know, bridging to single leg balance stuff. I'm a big fan of like a single leg RDL to really get that nice length and strength going on. There's a hundred ways to kind of trick the brain into, to letting these muscles relax without forcing the brain to be thinking about it.

[Dr. Paul Nelson Williams]

So we talked about constipation, what about sort of the other direction, which is probably a crude way to refer to it. But what if this patient was experiencing fecal incontinence? We ruled out scary stuff as potential causes. How helpful is pelvic PT in that particular instance?

[Dr. Rachel Rosvold]

It's hugely helpful for those with and without a penis. We can again really work on that training of when these muscles should be on and when they're off. Anytime it is fecal incontinence. We know that already. This person has been through more than they ever should. Right. No one should be pooping their pants ever, let alone as often as these patients often are. So it's always. We talk a little bit about like their triggers, what do they find are causing this? Is it more movement based or is it that urge incontinence similar to urinary incontinence? We wanna see what's going on. Urge versus stress. Or is it a combination of both? And then treat it accordingly. Now, those with a vagina, they don't always have to undergo a rectal examination. That's another big question we get, especially with our fecal incontinence folks. And it's not necessary. Just like any examination is not always necessary when you're with pelvic therapy. So if this is happening, then they should be referred to pelvic PT for sure. Even if it's just like a every so often kind of thing. Again, looking 20, 30, 40 years from now, we don't want it to become an all day event. And so please send them in now.

[Dr. Nicole Schaefer]

Yeah, and there's a lot we can assess vaginally for those patients. Through the, when we do their internal work, we can palpate their puborectalis. They're all the same muscles that control our bowel and our bladder. It's a giant bowl and we can access most of them that we need to understand through the vaginal exam. If that's what's deterring some of them.

[Dr. Paul Nelson Williams]

Well, that's good news that we can, that we could provide support because that seems like one of the worst conditions and certainly like a big quality of life thing that, that I'm sure people would love help with if they have that issue. So let's, let's go to some take home points. This has been great. There's been so much, much learning. But maybe Nicole, if you want to give one or two take home points and then Rachel, you can give one or two take home points.

[Dr. Nicole Schaefer]

Yeah. So I think one of the things as far as when you write a script for pelvic pt, which hopefully a lot of you are now hearing this, that every woman postpartum should have Pelvic PT, but the ICD10 code for Dyspare is no longer an option and insurances stopped covering this about like five years ago. So instead of using the Dyspareunia, ICD10, you could use vaginismus vulvodynia or even decreased coordination or leakage, but just avoiding that ICD10 code.

[Dr. Paul Nelson Williams]

Okay.

[Dr. Matthew Frank Watto]

And Rachel, I think the biggest take

[Dr. Rachel Rosvold]

home is that common doesn't mean that it's normal. No one should be leaking anything at any time and no one should be in pain unless they're into that. So really we want to get as many people that need our help to get to us. We always like to say that there are not enough pelvic therapists to deal with all the pelvises that need our help. But the more that it becomes a little bit more normalized to talk about these hard topics and to ask like very, very pointed questions, I think the, the better our patient outcomes are going to be. Oh, and any PT that's in your area or ot, that's pelvic and you want to reach out to. Oh my gosh, we would be so excited. No one is going to want to not answer your questions or tell you more about their practice or whatever. We love our physician counterparts. We love working with you guys. We can't appreciate enough what you do and would be happy to answer any questions at any time.

[Dr. Paul Nelson Williams]

Anything you guys want to plug at all, Any resources or anything that's making you wealthy on the side?

No, we're pretty simple ladies go snowboarding and lower skiers ski.

[Dr. Elise Burke]

Go ski.

[Dr. Paul Nelson Williams]

Yeah, go ski and snowboarding.

[Dr. Nicole Schaefer]

Well yes, snowboard family over here.

[Dr. Paul Nelson Williams]

Okay,

This has been another episode of the Curbsiders bringing you a little knowledge food for your brain hole

[Dr. Matthew Frank Watto]

holes.

[Dr. Paul Nelson Williams]

Still hungry for more? Join our Patreon and get our episodes ad free twice monthly bonus [e-mail] curbsiders. You can find our show [e-mail] and sign up for our mailing list to get our weekly show notes in your inbox. This includes our Curbside Cider's Digest, which recaps the latest press, changing articles, guidelines and news in internal medicine.

And we're committed to high value practice changing knowledge and we want your feedback. So please email [e-mail] a reminder that this and most episodes are available for CME through VCU healthurbsiders.vcuhealth.org wanted to give a special thanks to our writer and producer for this episode, Dr. Elise Burke,

[Dr. Matthew Frank Watto]

and to our whole team.

[Dr. Paul Nelson Williams]

Our technical production is done by Pod Paste. Elizabeth Proto runs our social media, Jan Wotto runs our Patreon. Krista Chumanchu moderates our Discord. Stuart Brigham composed our theme music and with all that, until next time, I've been Dr. Matthew Frank Watto.

[Dr. Elise Burke]

I've been Dr. Elise Burke and as

[Dr. Paul Nelson Williams]

always, I remain Dr. Paul Nelson Williams. Thank you and goodbye.

With VRBoCare, help is always ready before,

[Dr. Nicole Schaefer]

during and after your stay. We've planned for the plot twists, so

[Dr. Rachel Rosvold]

support is always available because a great

[Dr. Nicole Schaefer]

trip starts with peace of mind.

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