Y’all, I am so excited to be rolling out our Fall Small Group Mentoring Program! If you follow my blog for my clinical info– I’m sorry to interrupt your content with this post for other clinicians– but I promise I’ll be back to clinical stuff next week :).

I started mentoring other clinicians many years ago, but as time moved on, and I moved into other teaching positions, I became aware of just how much need there was for support as clinicians are moving into pelvic floor rehab. Each time I teach coursework, people often approach me asking how they can keep learning and growing, especially with complex patient cases, when they return to the clinic. And that my friends, is why the Small Group Mentoring Program started!

This is our second round of the program, and we have several excited things to roll out!

The program includes:

• Biweekly small group mentoring (via zoom) over 12 weeks with a group of 6-9 practitioners, and an expert mentor
• Learning modules each month to explore how to optimize your examination approach, get started with treatment more effectively, and progress through treatment, discharge and beyond.
• Growing library of sample videos discussing patient cases, demonstrating examination and treatment techniques, exercise progressions and more!
• Private Facebook community to discuss patient cases, practice patterns and more!
• Bonus mentoring sessions with Jessica!

If you are a pelvic PT or OT, and looking to grow in your expertise to better serve your patients, we hope you’ll join us in this program!! Click here to register today!! Slots are limited, so don’t delay!

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!

Building a Stellar Bowel Routine

5 Ways to Help IBS

How to Poop

Dyssynergic Defecation (or When the Poop Won’t Come Out)

Happy Pooping!

~ Dr. Jessica

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.

Stress:

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.

Dietary Changes:

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.

Routine Changes:

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!

~ Jessica

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! 

Register here! 

Hope to see you there! 

~ Jessica

Good morning everyone!

This past week, I was so fortunate to sit down with Dr. Swetha Ramakrishnan to discuss fecal incontinence. Fecal incontinence is a MAJOR problem, impacting 7-15% of people. It is the #2 most common reason people are admitted to nursing facilities (guess what? #1 is urinary incontinence!) and it can happen in young and old alike. In fact, anal sphincter injuries are a common occurrence during vaginal birth (occurring in around 10% of vaginal births worldwide) and 9-24% of those people go on to develop anal incontinence.

At SPH, we use a multi-faceted approach to help people with bowel leakage which includes helping to optimize their stool consistency, facilitating a strong bowel routine, retraining digestive reflexes and encouraging functional pelvic floor muscle function (which does include that anal spinchters).

I’ve been treating colorectal conditions for over 10 years, and Dr. Rama and I have worked together for the past 5 years. She is an incredibly skilled, intelligent and kind provider with ATL Colorectal in the metro Atlanta area. I hope you enjoy our discussion on bowel leakage– what it is, why it happens, and the very important, what you can do about it!

If you have any questions, drop them in the comments below!

~Jessica

At Southern Pelvic Health, we offer free 15-minute phone consultations for people to determine if pelvic floor physical therapy is the best next step in their health journeys. These consultations are awesome– they give us a chance to get to know the patient, give the patient a chance to ask any questions, and help us start building a partnership if physical therapy care ends up being their next step. For some, it is. And for others, it’s not. Sometimes we refer patients to their physicians or other specialists. Sometimes, we encourage them to wait before coming in for a procedure, surgery, or something else.

Recently, I spoke with a new mom experiencing some difficulties that happened after birth. As we were talking, I asked her if she was having any bladder leakage, or other bladder challenges. She said, “During pregnancy, I had the normal incontinence, and I do leak some now, but nothing unusual.” Let that sink in. Why is bladder leakage, ever, looked at as a normal thing? Spoiler alert: It’s actually not normal. And guess what? There is something you can do to help it. Even during pregnancy.

So, this inspired me to write a post on some of the common pelvic health myths around having babies.

Myth #1: Bladder leakage is normal during pregnancy or after you’ve had a baby.

I already spoiled this one. It’s actually not. Common, yes. But not normal. During pregnancy, people can be more susceptible to leakage at certain times as the growing uterus changes the angle of the urethra, but the body should still be able to compensate, support the urethra, and avoid leakage. After having a baby, it can be normal to have some leakage in the first few weeks (depending on your birth), but then, it should improve. Continuing to leak after that initial healing period is actually not normal, and there is so much that can be done to improve this!

Myth #2: If someone is experiencing prolapse after having a baby they will eventually need surgery.

I hear this one a lot. Comments from well-meaning providers saying things like, “we’ll need to fix that when you’re done having kids.” So, let’s dispell a few myths. First, prolapse is SO common. Some studies have shown that up to 90% of people have some level of prolapse after birth (when checked on examination). This, of course, is going to be a much lower number when you look at people also having symptoms of prolapse. Prolapse is a pressure management problem impacting organ and tissue support. Organs and tissues are supported in the pelvis by fascia, ligaments, connective tissue and muscle. While we can’t necessarily change prior tissue damage via rehabilitation efforts, we can optimize muscles to improve the pressure system. And there is evidence that this reduces the stage of prolapse and improves the symptoms too! Additionally, there are other conservative options to help manage prolapse as well. Pessaries are wonderful support devices that can be used, and most people found them to be very helpful when we look at the research.

Myth #3: After having a baby, it’s normal for sex to be a little uncomfortable.

Pain is the body’s alarm system, produced by the brain to protect us. Pain is meant to evoke action on our part– to get us to protect the body, do something, to stop the “threat” from occurring. Sexual intimacy is meant to be pleasurable–before and after having a baby. Upon first returning to sex after birth, it can be normal to have a little bit of discomfort, HOWEVER, this should very quickly go away. If it persists, that’s a problem, and (you guessed it!), there is SO much we can do to make this better! Why does pain happen after birth? It can be a lot of reasons: scar tissue inhibiting the movement around the vaginal opening, decreased lubrication due to hormonal changes, musculoskeletal restrictions due to injury or dysfunction, and others! Read more on sex after baby here!

Myth #4: Low back or pelvic pain during pregnancy is just part of it.

Let me say it a bit louder for the people in the back: COMMON DOES NOT EQUAL NORMAL. Low back and pelvic girdle pain are indeed common during pregnancy, impacting anywhere from 4-84% (don’t you love those huge ranges we get in research) of pregnant individuals. While many cases resolve after birth, some people will continue to experience problems. Also, who wants to struggle with back and pelvic pain for months on end while they are pregnant? Not me, and I’m guessing not you. So, there is a lot that can be done to help this during pregnancy. Not surprising, research is mixed on the effectiveness of various techniques, and honestly, I think that is because treatment really needs to be individualized. Some tout “stabilization exercises” however, some studies have shown that most people with pelvic girdle pain actually have pelvic floor muscle overactivity— so of course, transverse abdominis and pelvic floor strengthening is going to make them feel worse! Key concept here- if you are pregnant and experiencing back or pelvic pain, go see someone who has specialized training in perinatal and pelvic floor care who can assess YOU (individually– not making assumptions!) and help make a plan to get you feeling better.

Myth #5: There’s nothing you can do about constipation during pregnancy.

Constipation during pregnancy is the worst! We can thank hormonal changes for that. While there’s not much we can do to change the hormones (nor would we want to!), we can do everything else to optimize our bowel habits and promote better bowel health. This includes learning the best way to sit on the toilet, proper mechanics for defecation, how to build a stellar bowel routine, and making dietary changes to promote better bowel function.

Myth #6: Do your Kegels, mama!

Surprisingly, this is actually false. While all pregnant individuals were told in the past to do kegel exercises to protect their pelvic floor muscles and optimize their births, we know now that not everyone actually needs pelvic floor strengthening. Remember, a large percentage of people actually struggle with pelvic floor tenderness and overactivity— especially if they are experiencing back/pelvic pain, or have pre-exisiting pelvic floor disorders. So, the best way to optimize pelvic floor function during pregnancy? Go get an exam, and have a skilled, specialist trained clinician help you get an individualized program for your pelvic floor.

Myth #7: There’s nothing you can do to really prepare your body for birth or prevent problems after.

Actually, there is emerging evidence that suggests we can do something to prevent problems like urinary incontinence, and other pelvic floor disorders. A recent Cochrane review (this is basically, the highest level of evidence we have) indicated that a targeted pelvic floor training program early in pregnancy actually decreased the risk of urinary incontinence during and after pregnancy. Exercise during pregnancy has also been shown to be safe and beneficial for the baby. Perineal massage has also been shown to be helpful in improving pelvic floor mobility and reducing perineal trauma during birth (particularly, during the first vaginal birth!). Want more info on preparing for birth? Check out our class on the topic! 

Myth #8: The only way to change your belly problems after having a baby is with surgery.

If you’ve been following this blog, you’ve probably read our recent 2-part series on diastasis rectus after birth (If not, check out part 1 & part 2!) Many people experience diastasis rectus during pregnancy and after birth, or may just feel laxity and a loss of support at their belly. Rehabilitation of the abdominal wall can be so hugely beneficial for these people (myself included– hello cesarean birth x 2!). Surgery can sometimes be an option, but really, this should be used after a person has exhausted conservative options. So, if you’re struggling with belly problems after birth, give us a call! Check out our DRA class in the meantime also!

Myth #9: You can jump right back in to whatever exercise you want after having a baby.

I guess technically this one is true. You can do anything you want. But, that doesn’t mean it’s a good idea. Having a baby can be very impacting to the abdomen and the pelvic floor muscles, and it’s best to build back up to desired exercises slowly and methodically. I always say I would much rather someone wait and slowly get back to exercise than to jump into strenuous exercise too quickly. I can’t tell you the number of patients I have seen who have had problems like pelvic organ prolapse, or other pelvic floor conditions after resuming really high intensity exercise without adequately preparing their bodies. I don’t tell you this to scare you– believe me, I want you to get back to EVERYTHING. I want you to be a strong mama who can rock exercise EVEN BETTER than you did before your birth. BUT, I think we need to be smart about it, ease into it, and learn how to self-asses our bodies to make sure we do the exercises that are most appropriate for us at the time.

Myth #10: Moms don’t need to see a pelvic PT if they don’t have problems after birth.

Did you all know the pelvic floor physiotherapy is actually the norm after birth in some European countries? And why shouldn’t it be? Birth is transformative and hugely impacting to the body! Why is rehab after an orthopedic surgery nearly required, yet moms are not even offered rehab after cesarean births or operative vaginal births? In my perfect world, I would love to see all parents given the opportunity to seek pelvic health care after birthing a baby. In fact, wanna know a little secret? I’m actually seeing my colleague (Dr. Kate Schenk, who is a rockstar!) for pelvic floor and abdominal wall rehab this week! You may be thinking, didn’t you have your baby a year ago, Jessica? Good point my friend. But, like many other moms, I decided to put myself on the back burner for a while…and a while turned into a few months…which then turned into a year. When we celebrated my little Mary Lynn a few weeks ago, I had a moment of, “what am I doing?!” and quickly contacted Kate to make my first appointment! I’ll write on my journey later, you can be assured of that. But, don’t be me. Put yourself first. I know it’s hard (believe me!) but self-care is actually not selfish, it’s self-less! (And reading my post on self-care from 3 years ago, I realize that this has clearly always been a struggle for me!) Recently, we actually took a close look at the ways we are caring for our pregnant and postpartum patients, and realized, we can do better! So, we started offering in-home prenatal and postpartum care! I am SO excited about this– to be able to reach people where they are, reduce their (and their baby’s) exposure to…ummm… “germs” in the community, and take away some of the stress of getting childcare to get out of the house!

What else have you heard is “normal” for people during pregnancy and after birth? I know I didn’t hit all of the common myths out there! Let me know in the comments, and let’s keep the conversation going!

Happy Monday!

~ Jessica