I don’t know if you’ve realized it– but the pelvic floor has become crazy popular! This article by The Guardian was published 2 months ago. 3 different patients and a few friends forwarded it to me, as it highlights just how popular pelvic floor rehabilitation has become. And I’m not surprised. When I first started treating pelvic floor disorders, nearly every patient who came in the door had never heard of the pelvic floor, let alone, a physical therapist who treated the pelvic floor. They would look at me with a perplexed and nervous gaze as I would do my best to explain the anatomy and why there really was a GREAT reason that their doctor had recommended them to come see me. This situation repeated itself again, and again, and again.
But now, it’s actually a much more foreign experience. For the most part, my patients have some level of knowledge about the pelvic floor muscles. The internet and social media has allowed people more access to knowledge– including experts who make informative Tik-tok videos, infographics and blog posts 🙂 on their diagnoses and treatment options. This has created more informed consumers who are learning more about their health, care about their wellness, and are seeking to find the best answers for their care.
In fact, it now very rare for for someone to come in and tell me they’ve never heard of pelvic floor rehabilitation. And that is AMAZING my friend.
When I first moved to Atlanta in 2014, I could count the number of pelvic PTs in the area on one hand. Now?? The last time I counted, there were more than 30 of us. I’m sure that number is closer 50 or even more (I know this because nearly every level 1 pelvic floor course I teach has at least a few Atlanta based people in it!!). And while, again, this is amazing– it’s only barely scratching the surface of what is actually needed!
The reality is that pelvic floor problems are super common, and people dealing with pelvic floor problems are often struggling to find care! Look at some of these numbers:
So… while we are serving so so many more people than we used to, we are just scratching the surface! If you are new to this blog, and want to read a little bit more to start learning about the pelvic floor, check out some of these posts:
Also, if this is resonating with you, and you’re feeling like you may need some help, reach out and let us know!! You don’t need to be one of those statistics– you can get relief, you can feel better! And if you’re not ready to see someone in person, check out some of our mini-courses online on pelvic floor topics!
Every time I meet a new patient, I ask them about their pooping. Sometimes this throws people off, and they’ll say “…but…I’m here for my shoulder” LOL jk, jk– I don’t treat people who have primary shoulder problems. Remember, pelvic floor problems are my jam! BUT, even when people have a “pelvic” problem (and I put it in quotes, because while I saw I specialize in the pelvis, the reality is that the pelvis is in the body so the whole body can impact the pelvis), they can struggle to see the connection between their bowel movements and their bladder leaks, painful sex, low back pain, prolapse– and more! The reality, however, is that what is happening with your bowel movements is ABSOLUTELY important for any pelvic problem we see. And, this is especially the case if someone struggles with constipation.
Why does constipation matter for pelvic health?
The reality is that the pelvis is not as big as you’d think. A full rectum that isn’t emptying well can press on the other structures around it (including the bladder and vagina, pelvic floor muscles and nerves around the pelvis) and can also stretch to an uncomfortable level and refer to the low back. Hard, dehydrated stool is also more difficult to empty, and can require more effort, placing increased pressure on the organs in the pelvis and the pelvic floor muscles themselves.
6 Tricky Things that Can Actually Be Caused or Worsened By Constipation
This is where things get interesting. Because of how close everything is, and how intricately the muscles are connected to defecation, people are often shocked at the things their bowel movements can be involved with. Let’s look at a few:
#1 Pelvic or Tailbone Pain
That’s right! Constipation can lead to worsening pelvic pain, or even be a primary cause to begin with. There are several reasons for this. First, when stool is in the rectum, it will put pressure on the puborectalis muscle, whose job it is to maintain the angle between the rectum and the anal canal, preventing leakage, and opening to allow for defecation. Typically, if the rectum fills, this will trigger a sampling response where literally your rectum allows a small amount of contents into the anal canal to determine– solid, liquid or gas? Then, it will trigger a reflex to facilitate defecation. If someone has harder stool with less forming together, they may not empty their bowels well, leading to stretching of the rectum. This will put pressure on the puborectalis muscle, which then can lead to increased muscle activation (hey, there’s more stool to hold back!), and ultimately, muscle irritation and overactivity. Pelvic floor muscle overactivity can lead to pain around the pelvis and into the tailbone and sacrum. And it’s a tricky cycle, because overactive muscles don’t stretch as well, making it harder to have a bowel movement, and the harder it is, the more the muscles become irritated.
#2 Pelvic Organ Prolapse
Prolapse occurs when there is a loss of support around the walls of the vagina and an organ (the bladder, rectum, small intestines or uterus) protrudes into the vagina. It can be very annoying and uncomfortable, and can lead to a feeling of a bulge in the vagina, heaviness in the pelvis, or pressure into the perineum or pelvis. Pregnancy and childbirth can be a big factor with prolapse due to a loss of connective tissue or fascial support, however, increased pressures on the pelvic floor over time can also play a role. I’ve seen this happen for people who worked in jobs that required extensive heavy lifting, when people are doing exercises that their bodies cannot really do well, and, yep– in cases of long-term constipation. Constipation leads to increased pressure on the pelvic floor and more effort required for emptying. So, when a person is constipated and has to strain more to empty, this can weaken the support around the vagina, and can ultimately be a big factor for people with prolapse. And the great thing– when we help this to improve, usually we’ll see the prolapse symptoms get better too!
#3 Painful Sex
Similarly to pelvic pain, overactivity in the pelvic floor muscles can be very involved when a person is dealing with pain during sex. Additionally, if their rectum is staying full with stool, this will put pressure on the vagina and decrease the space allowed for the vagina to stretch with insertion. So, you guessed it, optimizing constipation can make a difference for people having pain with sex.
#4 Low Back Pain
This one is very interesting! We already talked about how the pelvic floor muscles can become overactive if someone is dealing with constipation, and of course, this can be a factor with low back pain. However, the colon itself can also become very stretched when stool is backed up, and this will refer into the low back. This is surprisingly more common than you would think! I’ve seen many people dealing with long-term back pain that noticed a significant change (if not a cure!) by optimizing their bowel health. And this makes sense when we think about how organs can often refer to somatic structures around the body (Remember how a heart attack can present as shoulder pain? Kidney stones as low back pain?).
#5 Pudendal Neuralgia
I had to include PN in this group! The pudendal nerve runs through the pelvis so sits in very close proximity to the rectum. When a person strains and has difficulty emptying the bowels, this nerve can be stretched and irritated. Long term constipation can cause a person to develop pudendal nerve irritation, and if a person has pudendal nerve problems already (from an injury during surgery, cycling irritation, childbirth, or other), constipation will absolutely worsen their pain levels.
#6 Bladder Leakage
This one is always harder for people to grasp. Yes, constipation could be the reason you are leaking or it could be making your leakage much worse! This can happen for a few reasons. First, the pelvis is not that big. So, a full rectum could be pressing on the bladder putting it into a position where it is more likely to leak. Additionally, remember how the muscles get involved with constipation? Well, they’re important for the bladder as well! Overactive and irritated muscles do not work as well for the bladder so can often struggle with holding back urine.
So, what can you do if you’re struggling with constipation?
First, realize that you’re not alone. Constipation is the #1 GI complaint in the US for a reason, and there is SO much that can be done to improve this! So, don’t just deal with it. Don’t write it off as something “you’ve always dealt with” or something “that runs in my family” or anything else. Take steps today to help your body poop better, and I promise you– your world will be a happier place.
If you’re able, I would STRONGLY recommend my mini-course on overcoming constipation. In this class, Dr. Sara Reardon and I give you all of our big tips to help you poop better, and for $39 you can’t beat the value you’ll get in this class!
Check out these other articles I’ve written on pooping (yep, I write about poop a lot!) and hopefully this helps you get started!
This past year, I was so fortunate to meet Dr. Yeni Abraham, an amazing pelvic health physical therapist and educator. Dr. Yeni is incredibly knowledgeable and owns a private practice, Triggered PT, in Arlington, TX. A few months ago, I saw Yeni post about traveling to pursue a specific training utilizing manual therapy to optimize fertility health, and I knew, I just had to talk with her!
I’ve been working with people struggling with conception for many years. I initially started helping this population around 10 years ago when I lived in Greenville, SC. I had connected with a few fertility specialists in the area, and they started referring patients to me who were trying to conceive, but had struggles related to pelvic pain and pain with sex. It was incredibly rewarding to work with these people, helping them feel better and have pain-free sex. And, that follow-up e-mail of, “Guess what? I’m PREGNANT!” was literally the absolute best!! So, I’ve known for a while that there is power in touch, helping a person connect with and optimize their bodies. And, through witnessing many of my friends, patients, and colleagues struggle with fertility challenges, I’ve learned that fertility challenges are complicated, multifactorial, and often require a team-based approach.
So, enter Dr. Yeni. This amazing, passionate person, who truly cares so much about helping people! Her journey toward helping this population was inspiring, and I’m amazed at what can be done to make a difference for people. I hope you’ll enjoy listening to her interview as much as I loved recording it!! Please know that Yeni sees patients in her office in Arlington, TX, and some patients additionally travel to see her. So, contact her if you want to learn more!! Thanks again Yeni!! <3
A few weeks ago, I connected with Noa Fleischaker, the founder of Tight Lipped. This organization started as a podcast in 2019, and has grown to reach over 3000 people from 58 countries around the world. Tight Lipped is all about supporting people who have been struggling with vulvovaginal pain conditions– problems like vulvodynia, vestibulodynia, pelvic pain, painful sex, and more. They share stories to build community, normalize often very private problems, and advocate for better care. They recently published their first Zine, “Opening Up,” and it is a beautiful compilation of art and stories from people who have dealt with vulvovaginal pain conditions. I received my copy last week, and it is in our waiting room as I type this!
I hope you enjoy this interview and connect with Noa’s message! If you would like to support the work of Tight Lipped, please visit their website! They also have events, meet-ups (with one coming up this week!!), workshops, and book clubs! So check it out and connect with this amazing group!
Last week, my husband and I toted our 2 daughters to the clinic, and put up a Christmas tree, lights, a menora and a beautiful locally made wreath. We did the same to our house the week before, plus added the lights outside, stockings by the chimney, as well as the santa and snowmen collections (We’re BIG Christmas people– totally unabashedly Christmas obsessed!). Last night, we put those same little girls in the car with travel mugs of hot cocoa, and drove to a local lights show. And really, this is just the beginning of our holiday festivities.
Again, I love Christmas. But as you just saw above, holidays (like Thanksgiving, Chanukah, Christmas, or whatever you celebrate!) can lead to big changes in our day-to-day routine. These changes can bring us joy (or stress!), but can create major difficulties for people dealing with pelvic floor problems, like pain and constipation.
Why do holiday flares happen?
There are lots of reasons why the holidays can create unique challenges for people.
I don’t have to tell you that for many people, the holidays are extremely stressful! Changes in routine, combined with added pressures (often placed by ourselves!), events, and financial difficulties can lead to lots of overwhelming feelings. This paired with spending time with family you may not see often (but hey, it’s a pandemic year, so we really shouldn’t be doing that– right?), can lead to people feeling incredibly stressed and overwhelmed. The pelvic floor muscles are known to be threat responders, so this can lead them to overactivate to guard and protect you against all of the stress. The challenge here is that protective pelvic floor muscles can often worsen symptoms like constipation, pelvic and lumbar pain, and incontinence.
Turkey? Stuffing? Mashed Potatoes? Christmas Cookies? Pies? All the wine? I don’t know about you, but my holiday eating and my normal eating are quite different. This leads to us often getting less fresh fruits, veggies and natural fiber in our diets, and often getting way less fluid too. These dietary changes can make us more likely to develop constipation, and if you’ve worked with me, you know that constipation makes alllllll pelvic problems worse! Our habits can also lead to dehydration, as we exchange water for holiday drinks, and scurry around forgetting to get our fluid in.
For many of my patients, they’ve made progress by building habits that support healthy pelvic function. So, this may be an exercise routine they do in the mornings or at the end of the day. It could be taking a warm bath a few times per week with self-treatment. Perhaps it is doing a guided meditation before bed to relax their body. Perhaps it is something else entirely. But regardless, it can be really hard to keep these routines up over the holidays. This leads us to removing some of our self-care from our schedule, and without it, some of our symptoms can start to creep back up.
So, how can you make it through the holidays without worsening pelvic health problems? Well, I’ve got you my friend! Try these 5 tips!
Tip #1: Simplify your holidays
I get it, remember– BIG Christmas person! I’m not telling you to remove your traditions, and stop the things you love. But, I am encouraging you to prioritize what is important to you, and to remove pressures for what you think “should” be happening. Look at your schedule, your calendar, your family, and determine what naturally fits in. And if something doesn’t, gently let it go this year. Prioritize joy, family, and quality-time, and remove any pressures and obligations that you have placed on yourself.
Tip #2: Plan for healthy eating & hydration
I’m never going to tell you not to enjoy those delicious holiday meals, all the yummy pies and cookies, or the celebratory drinks. But, what I’m going to encourage you to do is to plan your day to make sure you’re also eating fresh fruits and veggies, getting adequate fiber, and getting adequate fluid. For many people, this means keeping one or two meals consistent during the day. So, for example, you might choose to have a salad for lunch, and keep yourself hydrated prior to having that turkey dinner that night. You may start your day with oatmeal and fresh berries, knowing that you have a big family lunch coming a little later. For bowel problems, this is especially helpful, as your colon LOVES consistency!
Tip #3: Create a daily stress-reducing routine
Stress can be one of the reasons symptoms tend to flare over the holidays, so I encourage people to be proactive in managing this! Some of my favorite stress-reducing routines include: warm baths with scented candles, guided meditations/relaxation, alone time with a cup of warm tea and journaling, yoga or tai chi, listening to binaural beats while you practice breathing exercises, and gratitude journals. Take some time to think about what feels relaxing and stress-reducing to you, then try to build that in to your day.
Tip #4: Prioritize your self-care
This one is hard as schedules get busy. But, as you plan your days and weeks leading up to the holidays, keep yourself in the equation. Think about the key pieces that are helping you right now, and make sure these stay in your schedule. This can mean keeping up with your exercise routine from your pelvic PT (ahem ;-)), making time to go outside for a walk or a job, waking up a little early to hop on your bike, or whatever it means for you. It’s really easy to let self-care go (believe me… I know), but when we do this, it hurts us and everyone around us. Being our best self means caring for ourselves. See this post on “Prioritizing Self-Care”
Tip #5: Treat flares with compassion
Despite trying these things (or not trying them), you may have a flare. Your symptoms may worsen. You may have increased pain or feel like you can’t poop. And I know it’s easy to go down the rabbit hole of despair. It’s easy to catastrophize, thinking things like, “I’m never going to get better!” “My body can’t even handle Christmas, I’m going to deal with this for the rest of my life.” “I’m headed for surgery…it’s just inevitable!” You get it. Maybe your brain has told you these stories. But, hear me when I say that while flares can feel incredibly overwhelming, they are just flares. So, take a slow, long breath, and let it go. See your flare for what it is– a flare. Recognize what likely caused it (oh yes, I haven’t been doing my exercises, and Aunt Betty was super stressful this year, and I don’t think I drank water for 3-days straight!), then gently make a plan to move forward. It may mean calling your pelvic PT to get an appointment, then jumping on your self-care plan, making some time for breathing and quietting your system, and taking some time for yourself away from Aunt Betty. Build your plan, and start taking steps in the right direction. You will get through this!
While the holidays can create challenges, there is so much beauty to our celebrations! I hope you and your family have a lovely, peaceful and joy-filled holiday season!
Yesterday afternoon, I met my team of pelvic PTs at at the office for some photo and video time. Our model? Dr. Kellie, who is about to have her last week with us in the clinic before leaving on maternity leave for her second daughter. You see, working at a pelvic PT practice, we have to take advantage of one of our own being pregnant! How could we miss an opportunity to record videos and take pictures to expand our library! 🙂
Movement during pregnancy is incredibly useful. First, it can help with many of the aches and pains that commonly develop. It helps to keep your muscles active, and ultimately, can help prepare you for the process of labor and birth. We wrote a while back on healthy exercise during pregnancy, so start there if you want to know where you should get started for movement.
Today, I wanted to focus on movement to help you feel better. These exercises promote gentle movement around your spine and pelvis and activation of the muscles around your deep core.
Goal: Improve mobility around your spine and pelvis. Coordinate movement with breathing.
Inhale slowly, and as you do, gently let your tailbone out, and lift your head
Try not to allow your back to dip super far down but stay within a comfortable range.
2. Exhale and gently tuck your head, lifting your belly up and rounding your spine, allowing your tailbone to tuck.
3. Repeat this flowing gently with your breath as you inhale and exhale
Aim to do this 10-15 times in a row, alternating with the modified child’s pose that is described below.
Modified Child’s Pose
Goal: Lengthen lower back, gluteal muscles, pelvic floor, and inner thighs. Encourages relaxation and opening around the pelvis.
This exercise works really nice to alternate between sets of the Cat-Cow.
First, place pillows in front of you, leaving a gap for your belly. You can use 1-3 pillows, depending on your belly size.
Sit back on your heels, and open your knees to a comfortable width.
Lean over the pillow, allowing your body to relax and reaching your arms forward. Let your head rest to one side or the other.
Relax in this position for 1-2 minutes.
Ball Pelvic Mobility
Goal: Improve the movement around your pelvis and spine
Sit comfortably on an exercise ball with your feet supported on the floor
Inhale, letting your pelvis out, allowing a small arch in your back
Exhale, tucking your pelvis under gently pulling your belly in.
Repeat this to warm-up x 10
Then, add a rotation, inhaling and rotating clockwise with your pelvis until you reach the arched back position. Then exhale, continuing to rotate clockwise until you reach the tucked position.
Repeat this x 5-10 repetitions, then switch to counter-clockwise.
Goal: Activate your deep abdominals and pelvic floor muscles paired with your breath.
Begin in a hands and knees position with your spine in a neutral position (not flexed or arched)
Inhale to prepare, exhale and gently engage your pelvic floor muscles while gently drawing in your belly. Aim for a slight contraction (not hard!).
While you do this, extend one arm in front of you.
Exhale, lowering your arm and relaxing your muscles.
Repeat, alternating lifting with your opposite arm. Be sure to keep your spine in a comfortable position while you are doing this exercise. Repeat this movement for 10-15 repetitions.
To progress this exercise, you can also perform with an alternating leg movement, aiming to keep your spine in a neutral position.
Goal: Coordinate movement with breath, activate pelvic floor with gluteal muscles
Place a ball behind your back and lean against a wall. Keep your feet placed out in front of you, flat on the floor.
Inhale while you bend your knees and lower.
Exhale, engage your pelvic floor muscles slightly, and lift up to standing.
Repeat this exercise for 10-15 repetitions, performing 2-3 sets.
Note: While doing this, keep your feet far enough in front of you that your knees don’t cross your feet.
I hope you’ve enjoyed these exercises! What exercises do you like to do to move well during pregnancy? Any favorites we need to add?
Look for more coming from us on all of this in the future!
“I was just showering and reached down and suddenly noticed a bulge”
“I had no idea something was wrong until my doctor examined me and told me I have a stage 2 cystocele”
“I started feeling heaviness in my pelvis, then was wiping after I went to the bathroom, and noticed something was there!”
Pelvic organ prolapse impacts a lot of people. Some studies show that between 50-89% of people experience prolapse after vaginal birth (if they’re examined and someone is looking for it!), however, people can experience prolapse when they have never been through pregnancy or childbirth. Prolapse is one of the “scary diagnoses” as I tend to call them– not because I think it’s actually scary– I don’t– but because there is so much AWFUL information about prolapse out there. And when people suddenly learn about this, they dive deep into a rabbit hole of research, and often end up scared about what the future holds for them. BUT– I’m here today to tell you that: 1) Prolapse is actually very common and 2) there is so much you can do to help this problem!
To digress slightly– Working with people dealing with prolapse is a passion of mine, and I’m super excited to be teaching a LIVE class on managing pelvic organ prolapse with my friends and colleagues, Sara Reardon & Sarah Duvall. It’s going to be happening this Sunday at 4pm EST, and registration is limited! I hope you’ll join us for this awesome class! (Note: If you’re reading this after the event, and missed it– no worries! The recording will be available– just click the link above!)
What is Pelvic Organ Prolapse?
Before we jump into the myths surrounding prolapse, let’s talk about what it actually is. Pelvic organ prolapse refers to a loss of support around the bladder, uterus or rectum, and this causes descent one or more of these organs into the walls of the vagina. The organs themselves are supported by fascia, ligaments, connective tissues and… you guessed it! Muscles! So, how can loss of support occurs? Well, it could be due to straining of these tissues like would happen during pregnancy and childbirth, particularly if people have injuries during birth like stretch injuries to the nerves of the pelvis, tears in the connective tissue and fascia, or tears in the pelvic floor muscles themselves. This can also be due to chronic straining of the tissues that might occur with age, chronic lifting (with poor mechanics) or chronic coughing problems. Other factors like hormones, body size and joint hypermobility can also be involved.
What does prolapse feel like?
Maybe you’ve been diagnosed with prolapse, maybe you just think this is a problem you have, or maybe you know that you have this problem. Regardless, let’s chat about what prolapse can feel like. These are some of the things people who have prolapse can feel:
A bulge coming out of the vagina
Pressure in the pelvis or perineum
Lower back ache
Difficulty emptying the bladder
Difficulty emptying the bowels
Heaviness or a dragging feeling in the pelvis
Symptoms are often better first thing in the morning, then worsen as the day goes on (thanks so much gravity!). Symptoms vary person to person based on where they have prolapse and the severity of their prolapse.
So, now that we know what it is and what it can feel like, let’s jump into prolapse myths.
Common Myths Surrounding Pelvic Organ Prolapse
Myth #1: “You’ll likely need surgery at some point.”
I hear this one all the time. A well-intending physician tells their patient that they have prolapse, then follows it with, “we can fix that whenever you’re done having children” or something along those lines. While some people do end up needing surgery– particularly with more severe prolapse or if their prolapse is significantly impacting their function, many people are able to manage well conservatively with specific exercises or pessaries.
Myth #2: Prolapse is probably the cause of your pelvic pain, pain during sex, or genital pain.
So, you’ll see that I listed low back pain in the symptoms, but I didn’t list other types of pelvic pain. While I get that prolapse can look like it would be painful, it typically is not a painful condition. It’s an annoying condition, and can lead to behaviors that may cause pain (like constantly trying to grip your pelvic floor muscles to prevent things from falling down!). Prolapse can cause a back ache that worsens as the day goes on, and this is due to the ligaments around the organs stretching as the descent occurs. Additionally, the pressure/bulge can be uncomfortable, and people may feel like something is being pushed on during sex. That being said, we very often find that people have prolapse and something else going on when they are dealing with significant pain.
Myth #3: Because prolapse is structural, physical therapists likely won’t be able to help.
So first, support of the organs requires coordination of forces– ligaments and fascia are involved for sure, but muscles are also involved. All that aside, prolapse is a problem related to pressure management– so it matters what is happening at the pelvis, but also, what is happening outside of the pelvis that is impacting the pressure system.
Pressures within the intrathoracic and intraabdominal cavities can impact what is happening in the pelvis. Several muscles are involved in this pressure system, including the glottal folds at the top, the intercostal muscles, the respiratory diaphragm, the transverse abdominis muscle, the multifidus, and the pelvic floor muscles. These muscles work together in a coordinated way to help manage pressure and spread the load (so it is not funneled down to the pelvic floor).
Physical therapists help people with pelvic organ prolapse by helping them manage their pressure system as optimally as they can. This means looking at posture, spinal mobility, movement patterns, hip function, breathing habits, and so much more! It also means optimizing the function of the pelvic floor muscles. With this approach, we see good improvements. A Cochrane review of 13 studies in 2016 found that most people saw good improvements in their prolapse symptoms and their severity of prolapse on exam. A multicenter trial published in 2014 found that individualized pelvic floor training led to good improvement in symptoms and severity of prolapse.
Myth #4: Pessaries are for “old people”
Not true. Pessaries are amazing medical devices that help to support the walls of the vagina and can be very useful for reducing symptoms of prolapse. There are lots of different types of pessaries, and generally, people who wear them really find them to be helpful! In fact, this study found that 96% of the people who were appropriately fit with a pessary were satisfied and thought it helped with the severity of their symptoms.
Myth #5: If you have prolapse, you should never do certain exercises and movements so your problem doesn’t get worse.
I’ve said this before, and I’ll say it again– there are no bad exercises– BUT there may be times when certain exercises may not be optimal for you. Ultimately, the best thing to do is to work with a professional who can watch you move, watch you exercise, and see how you modulate pressure during these movements. Then, they will be able to make recommendations specifically for you– help you modify where you need to modify, observe your form during movement, and then strategize with you to make a plan to get back to whatever movements you would like to get back to!
If you’re experiencing prolapse, or you think this might be you– there is hope available! I’m very excited to be working with Sara Reardon and our special guest, Sarah Duvall to jump further into this topic in our upcoming class this Sunday 10/25 at 4pmEST on Managing Pelvic Organ Prolapse. Come join us LIVE and get all of your questions answered! If you can’t make the live, no worries!! A recording will be available.
What prolapse questions do you have? Let me know in the comments!
You all know by now that I’m fairly nerdy. I love reading research articles, trying to understand complex topics, and everything about learning. Honestly, I think that is why I love pelvic health so much! The pelvis is so complicated! There’s so much to know, and the more I learn, the more I truly realize how much more there is to know! As an anatomy nerd, you know I have favorite muscles. I’ve written about the respiratory diaphragm, who is one of my most favorites, but I haven’t spent much time introducing you to my other love~ the obturator internus!
Meet the Obturator Internus
The Obturator Internus (Or OI, as they are known by friends) is a muscle that lives inside your pelvis in the obturator foramen and attaches to the hip via the greater trochanter. You can see it here:
The OI has several major functions for the body. First, it is a deep hip external rotator, and has shown to be active during the movements of hip extension, external rotation and abduction. In fact, this research showed that it was the first muscle to turn on in these motions (which I theorize could be part of it’s connection to the pelvic floor muscles and the anticipatory role the pelvic floor has in movement, pressure management and postural stability). My theory on this makes sense when we look at some of the research on the involvement of the OI in hip stability. This excellent article identifies the obturator internus & externus, quadratus femoris, and gemelli as important synergistic muscles that work together to modulate the position of the femoral head in the acetabulum during movement. This is particularly cool because in many ways, this function is very similar to the pelvic floor muscles! The authors suggest a dynamic stabilizing role for these muscles, making subtle alterations in force to control the femoral head position.
This study also recognizes the stabilizing role the OI can play, particularly when it works as a team with the other deep hip rotators. The authors here highlight that the obturator internus, obturator externus, superior & inferior gemelli (who I affectionately call the gemelli brothers) are essentially fused. And this fusion, actually leads to a decent cross-sectional area and ability for force generation. The orientation of the fibers adds further credence to the view that these muscles are crucial to hip stability.
The OI shares fascial connections and attachments with the pelvic floor muscles, which makes it an even more unique muscle. The iliococcygeus attaches to the arcus tendoneus linea alba, a fascial line that is also an attachment of the obturator internus. Additionally, the pubococcygeus and OI are fascially connected around the pubic bone, and the fascia around the bladder and urethra also is connected to the OI. What does this mean? It means that the OI can be impacted by what happens at the pelvic floor and can impact what happens at the pelvic floor. And research tends to show this. This study showed that the vast majority of people with pelvic girdle pain have obturator internus tenderness. This study found that most people with chronic pelvic pain have obturator internus tenderness with palpation. And here’s another study that found that 45% of people with pelvic pain had tenderness at the obturator internus. Another study found that in people with lumbopelvic pain, experiencing urinary urgency, and central sensitization made them 2x more likely to have concurrent pelvic floor and OI involvement.
Finding the Obturator Internus
One of the cool things about the OI is that it is a muscle that can be palpated both internally via the vagina or rectum, and also externally. The OI is palpated internally with an examining finger angling out toward the hip. You can see the palpation here on my lovely pelvic model.
The OI can also be palpated by examining medial to the ischial tuberosity, then angling in toward the obturator foramen. You can see where palpation would be happening here.
Treating the Obturator Internus
If you think your Obturator Internus is involved in the pain or pelvic floor problems you’re experiencing, the first step is to have it examined. Your PT can palpate these muscles as described above. The muscles should be soft and move well, so they should not be sensitive or painful to touch. If they are, they could potentially be involved in the pelvic problems you are experiencing.
From a treatment standpoint, we can address the OI by first improving the mobility via gentle manual therapy, and then improving the overall hip stability (retraining the anticipatory function through the relationship between the pelvic floor & OI). It usually isn’t the “sole” problem happening. But including it within your treatment can be key to helping you get better!
Did you know that 1 in 5 people struggle with constipation?
Constipation is the #1 reason people seek a GI specialist. I write about pooping problems a lot. And for good reason– the bowels are something people often take for granted, until things aren’t working optimally.
The great news is that there is SO much you can do to help your bowel function! This Monday 8/31, Sara Reardon and I are teaching a LIVE 90-minute class on Easing Constipation!
In this class you’ll learn:
✅ What defines constipation and common contributing factors
✅ Pelvic floor muscle anatomy and how to use your muscles to help with defecation
✅ Dietary recommendations to help keep bowel movements soft
✅ Tips on managing constipation with prolapse (rectocele)
✅ Self-treatment techniques including building a bowel routine, optimal toileting posture, and breathing and relaxation exercises
✅ BONUS Handouts on abdominal massage for constipation, proper toileting mechanics to facilitate emptying and more!!
You won’t want to miss this class! Registration for the LIVE class is limited, and we think this class will fill quickly! So be sure to secure your spot soon, and get your questions answered! If you can’t make the LIVE class, register now and receive access to the recording & all bonus content within 24 hours after the event!
I love running. To be honest, I’ve been out of a good running routine since Mary was born. She’s one now. I would like to change that. I’m scheduled (yes, my husband and I literally have to schedule everything with our crazy work weeks!) for a run this week and I’m thrilled.
As a pelvic physical therapist, my goal is always to help my support my patients in whatever exercise or fitness routine they enjoy. Sometimes, pelvic floor problems get in the way. I can’t tell you how many times I’ve heard things like: “I used to run all the time, but ever since I had a baby, I just can’t” or “I tried just wearing a pad while I was running, but I can’t get over the feeling that I’m making everything worse” or “I can run if I go first thing in the morning, empty my bladder before I leave, and then stop at the park on the way to go again.” Bladder leakage during running is ANNOYING. It can be so impacting to people, and for many, it can lead them to stop a movement or activity they enjoy, for the long-term.
5 years ago (has it really been that long!?!) I wrote on the topic, “Is running bad for the pelvic floor?” after receiving that question several times. Spoiler alert: There are times when it may be appropriate for someone to stop running for a period of time to retrain their body and regain their pressure modulating system optimization– however, running can be an excellent way for someone to exercise and move! There are no “Bad” exercises, just bodies that sometimes aren’t quite ready for them.
So, if you’re struggling with leaking every time you hit the pavement, what can you do?
Let’s consider what happens during running, from a pelvic floor standpoint. Several studies in the past few years have demonstrated that the pelvic floor muscles are active during running. This study from 2017 used EMG electrodes at the pelvic floor muscles, and found that there was increased activation of the pelvic floor prior to heel strike and reflexive activation after heel strike during running. This is in line with what we know about the pelvic floor muscles. They play a crucial role in anticipating movement, preactivating, then have modulating force during movement based on the task at hand. And, this is protective. We would want the muscles to have varying levels of activation so that we can support ourselves during movement, support around the urethra, not leak.
What happens then when someone is leaking with running? We of course, want to say that this reflexive thing is not happening. This review did show some alterations in the way that those who leak contract vs. those who do not leak. However, this study found that the reflexive action was the same in those who leaked and those who didn’t. This one also found that patterns of engagement were the same. So, it is likely that there are sometimes differences, but sometimes not. And this seems in line with what we know about leaking. Leaking during running is a pressure system problem. So, to help it improve, we have to address the whole system– which includes the pelvic floor muscles, but not only the pelvic floor muscles. It makes sense that sometimes the issue is stemming from these muscles not activating at the right time, with the right force–but sometimes, the pressure problem is from something else.
How can we address the pressure modulation system?
First, we need to evaluate the system to see how the structures are functioning, and this includes looking at you– the full person– to see how you control pressure through your pelvis. So, we need to look at how you move from head to toe, then evaluate your running mechanics, then look more closely at your breathing pattern, your abdominal wall, and your pelvic floor muscles. Once we do this, we often have a clear idea of what is happening and can make a strategy to get this better.
So, my big Tip #1– Go see a pelvic floor PT–but make sure it’s someone who is trained at looking at the whole person and can really evaluate you well.
If you’re nervous about doing this, I feel you. It can be hard to talk to someone about very private things. And I totally understand that the idea of having an internal examination can be a barrier for some people. BUT, know that those of us living in the pelvic floor world talk about this stuff ALL THE TIME. You won’t surprise us. Seriously, we hear this stuff all day. And, if you don’t think you’re ready for an internal exam, that’s cool. Honestly, we don’t mind. There is SO much that can be done to help the pelvic floor and bladder leaks that can be done without an internal exam! If you want to learn more, give us a call. One of our doctors of physical therapy will be happy to do a virtual consult with you and get you started!
Ok, off my soap box… What else can you do to impact the pressure modulation system and decrease leakage?
Tip #2: Breathe!
This seems so simple. I know, you’re thinking, “Of course I’m breathing!” But, are you? Or are you going through a series of breath holds? Next time you run, pay attention, and keep your breath flowing in and out as you run. The diaphragm is the major pressure regulator of the body. So, we need to keep your breath moving so pressure is spread out!
Tip #3: Let your ribcage move!
Many people tend to run with stiffness, locking down their ribcage. This can funnel pressure downward toward the pelvic floor muscles leading to increased load, and potential leaking. Instead, relax your ribcage, let your arms swing and allow your trunk to rotate. This will actually turn on more of the muscles around your core improving the synergistic activation of your pressure modulating system.
Tip #4: Lean into the hills!
When going up or down hills, it is easy to lean back to try to control the movement. This can alter the position of your ribcage over your pelvis which will impact your pressure control. Instead of doing this, lean into the hill as if you have a strong wind blowing against you (I love this visual I got from my friend & colleague, Julie Wiebe!). When going downhill, lean into the downhill and let yourself pick up a little speed instead of leaning back to slow down. Relax into the hill. Many of my patients find that doing this actually reduces the pressure they feel and can decrease leakage.
Tip #5: Get a running evaluation!
Running form matters, it really does! So, go see someone and have them take a look at your running form to offer you guidance on how you can optimize it! Be sure you’re using the best type of shoes for your foot as well! This can make a big difference! Awesome running stores in your area should be able to help you with this!
I hope this is helpful! What questions do you have about running and the pelvic floor? Ask away! We are here to help!