Pain during sex is NOT normal

I often get asked why I chose to become a pelvic PT. Many people postulate that I have my own pelvic health challenges (I do…but those came later after 2 c-sections). Others assume I’ve always been super into the pelvis. But neither is really the case. The answer is quite a long one… but, honestly, it all came down to the patients.

Sometimes you have a moment in time that ends up defining the trajectory of your life (if you know, you know). And for me, this moment happen during a rotation in Shreveport, LA, while I was working on my Doctor of Physical Therapy degree through Duke University. I had an amazing clinical instructor (Darla Cathcart, who I now teach with through Herman & Wallace), and we were working with a patient who had been experiencing painful sex for as long as she had ever tried to have sex. I remember her talking with us during her initial evaluation, telling us about the relationships that had ended because of this, and tearfully explaining how she wanted this to not be a factor for her current relationship.

Fast forward, several visits later, she came in for her session, sat down, and started crying. She looked up and said, “I had sex, and it didn’t hurt.” I still get goosebumps as I right this. I got goosebumps in that moment. And, it was then and there that I KNEW that I had to help more people like her. I felt such clarity in my path. And I have never looked back.

Painful sex is extremely common. In fact, some studies show that it impacts around 20% of women. Yes, my friend, that is 1 in 5. However, women aren’t the only ones dealing with pain during or after sex. All people can deal with it– regardless of gender or anatomy. And, it really tends to be one of those things that just isn’t talked about. Nearly every time I post about painful sex on social media, I end up with private messages from people who have been dealing with pain for years, and just thought it was normal. Common does not mean normal. A little louder (for the people in the back):

Just because pain during sex is common, does NOT mean it is normal. Not if you:

Have had a baby
Have never had sex before
Have had sex a lot
Have been told you are small
Think your partner may be large
Have had problems with bladder or other infections
Have sensitive skin
Anything else

While some of these factors may make someone more likely to have pain during sex (like if you had a baby and had a tear that took a while to heal), this still does not mean that pain is just something you have to deal with. Honestly, there are so many reasons why someone might have pain with sex. It could be related to:

Decreased lubrication
Hormones
Inflammation
Neural sensitivity
Dermatological conditions
Painful scar tissue
Orthopedic challenges (especially around the hip or low back)
Bowel dysfunction (hello constipation)
Conditions like endometriosis/adenomyosis, painful bladder syndrome/IC, or others.
Pelvic floor and abdominal muscle challenges

And many, many other things! And so so many different treatments to help! This can include finding the right moisturizers and lubricants for your body, additional medical interventions (medications, hormone creams, and more!) and working with a pelvic health specialist to help you optimize your pelvic floor muscles (through gentle manual therapy techniques, home exercises, lots of education, and a whole lot more!)

If you’ve been dealing with pain during sex, please know that you are not alone.

So so many other people deal with this too. And the great news is that enjoyable sex is possible for you. We can get there. There is treatment available. There are compassionate clinicians who care (if yours didn’t, pllleeeeasssseee go see a new one!). And we can work together to get you feeling better.

I have so much more to say about this!! But for now, I’m going to leave you with a few links for prior blogs with more information!

Vaginal Dilators for Painful Sex

How to Relax Your Pelvic Floor Muscles

Sex After Baby

Are you ready to get started?

We are offering 20% off through September 30th on our 90-min mini classes: Overcoming Painful Sex and Self-Treatment for Pelvic Floor Tension using the code, ENJOY20. These classes are full of awesome information, exercises, and resources for getting started!!

All my best,

Jessica

Pelvic Floor PT: Soooo IN right now!

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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:

Chronic pelvic pain effects at least 5-23% of women and 2-16% of men

Approximately 36% of female athletes leak urine

33% of individuals postpartum experience bladder leakage

Approximately 22% of older men experience bladder leakage

35% of people postpartum experience pain during sex

Vaginismus (painful vaginal insertion due to muscle spasm) occurs in 5-17%

20% of people experience constipation

Approximately 10% of people experience fecal incontinence

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:

Meet the Obturator Internus

FAQ: Isn’t Everyone’s Pelvic Floor A Little Bit Tender?

Head, Shoulders, Knees…And Pelvic Floor?

Yes, Men Can Have Pelvic Pain Too.

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!

Expert Interview with Dr. Yeni Abraham on Pelvic PT to Optimize Fertility

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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

5 Common myths about Pelvic Organ Prolapse

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“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!

~ Jessica

Meet the Obturator Internus

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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.

My finger here is inserted, curving toward the left to access the OI

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!

Cheers!

Jessica

Do you leak when you run? Try this!

August 11, 2020 ~ jesspreale ~ Leave a comment

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!

Have a great week!

~ Jessica

Re-thinking rehab for incontinence after prostate removal

June 16, 2020 ~ jesspreale ~ 2 Comments

This week is international men’s health week, so it seemed fitting to write on a topic related to pelvic health in men. Interestingly enough, men are actually an underserved population when it comes to pelvic health. I know, shocking, but it’s true. From a physical therapy standpoint there are way fewer clinicians who treat men than there are who specialize in women’s health or prenatal/postpartum populations. In fact, I can’t tell you the number of men I’ve seen in the clinic who tell me that they were turned away from multiple previous clinics or who saw another provider who clearly felt uncomfortable treating them.

For me, I knew when I started specializing in pelvic health over 10 years ago, that I wanted to treat ALL people. I never limited my training to vaginas, and I always tried to learn to serve everyone. When I opened Southern Pelvic Health last year, I wanted to build a clinic that could really serve ALL people. We treat anyone who comes in the door, and our clinicians and staff constantly strive to be educated to provide a safe and welcoming space for anyone we meet.

So, this brings us to Men’s Health week! Today, I want to talk a little bit about rehabilitation after prostate removal surgery– aka prostatectomy. Prostatectomies are most often performed when a person has prostate cancer, and involve removal of the prostate and the portion of the urethra that runs through the prostate. This is most often done robotically currently. Prostate removal surgeries can have some side effects, and one of the most annoying side effects is stress urinary incontinence. Sexual dysfunction is also a major side effect, and of note, these two side effects are ones that many express feeling unprepared for. These two can have a huge impact on quality of life of many individuals after surgery.

Why does incontinence happen after prostatectomy?

The prostate sits under the bladder, and thus, plays an important role in continence. There is an internal sphincter that is present at the level of the prostate right at the bladder neck, as well as an external urethral sphincter below the prostate, which is part of the pelvic floor muscles. When the prostate is removed, the support and sphincteric control at the bladder neck is impacted. Additionally, the external sphincter can be damaged with the surgery, and patients can also have damage to neurovascular structures, fascia and connective tissue and the urethra itself. This then leads to bladder leakage– most often termed as “stress incontinence” which is leakage occurring with an increase in intraabdominal pressure.

The majority of individuals will have some degree of bladder leakage immediately after the catheter is removed. When looking further down the line, numbers are actually hard to estimate as different authors and surgeons have different ways of defining and measuring leakage. One study found that at 3 months post-prostatectomy 35% had bladder leakage. Another study found that leakage lasting more than a year happened in 11-69% of individuals. Yes, those are vastly different numbers.

How can it be treated?

As I mentioned above, leakage after prostate surgery can be so impacting for patients! And many feel guilty for being bothered by it… it’s the whole, “At least I don’t have cancer anymore…” guilt. But, here’s the thing. Quality of life matters. Yes, not having cancer is HUGE, but YOU matter. Your life matters. And helping you live your best life? Well, that really matters a lot. So, if you’re reading this and feeling frustrated about your bladder problems after surgery (or any other problems for that matter!)– I see you. There’s hope and help available!

Retraining the external urethral sphincter an be helpful for some people after prostate removal, and that’s where we pelvic floor physical therapists come in. The key thing here is optimizing the muscle system, which involves retraining the pelvic floor muscles to help them be able to contract well, relax well, and coordinate. I remember working with a urologist previously who told all patients after prostatectomy to do 10 second pelvic floor contraction holds, 10 times, every hour of the day. And guess what? When I saw most of his patients, they had significant challenges with pelvic floor muscle overactivity, and some even had pelvic pain. Why? Because it was wayyyy more than THEIR pelvic floor muscles needed. The best treatment is the individualized treatment! So, if someone has pelvic floor muscle overactivity, the best treatment is the one focusing on relaxing/lengthening the pelvic floor muscles. If someone has underactivity, the goal should be in regaining strength, endurance and building control. And if a person struggles with coordination, the goal should be retraining timing and control of the pelvic floor muscles.

Research has always focused on strengthening the pelvic floor muscles, and honestly, I think this is one of the reasons we see mixed results in studies. It makes sense, and it really is what I tend to see in the clinic. I was so pleased to see this study come out a few months ago looking at an individualized pelvic floor rehab approach for patients after prostatectomy. In this study, they reviewed 136 patients who had leakage after prostatectomies, and they found that 98 of them actually had muscle overactivity with underactivity. Guess what? Only 13 had underactivity with no tension/overactivity. This is honestly what I tend to see the most clinically. In this study, they individualized treatment based on the examination findings, and they found that 89% of the patients had a reduction in their urinary leakage. 58% achieved what was deemed “optimal” improvements in their leakage. This is good news, and really highlights the benefit of having a comprehensive examination and treatment (not just going somewhere for “biofeedback training”)

When a person is ready for strengthening (generally, after overactivity has been improved), the way strengthening happens actually matters. In fact, it really, really matters. Paul Hodges has done amazing research to help us better understand the continence system in men. In short, the system is different, and requires a different approach to rehabilitation. When the prostate is removed and the loss of the internal sphincter occurs, compensation must take place, and involves the external urethral sphincter, and can also include other muscles (particularly puborectalis and bulbocavernosus). So, it is very important for a clinician to evaluate the entirety of the pelvic floor muscles and not simply focus on the muscles around the anal canal. Hodges has multiple recommendations for how to be as precise as possible with pelvic floor rehabilitation, and you can read more about what he recommends here. After the right coordination, and activation of the pelvic floor muscles happens, it is so important to integrate these muscles into function. A robust home program that integrates the pelvic floor muscles into movement is key to helping a person regain bladder control!

I hope you found this information useful. I have a lot more to say about all of this, but it’s late, and those thoughts will have to wait for another day! Let me know any questions you have in the comments!

~ Jessica

How to build a stellar bowel routine

May 13, 2020 ~ jesspreale ~ Leave a comment

Bowel problems are so frustrating. Let’s be real. Constipation remains the #1 GI complaint in the country and impacts millions of people (pun unintended, but I’ll take it!). I love writing about pooping, and we love treating poop problems at Southern Pelvic Health (both virtually & in-person!!). The cool thing about poop, is that often the smallest changes in our habits can make BIG differences. A lot of this is due to the physiology of the digestive tract. Our habits—what we do during the day—can hugely impact this physiology, and that’s what I want to talk with you about today.

How do you maximize the efficiency of your digestive system and build a stellar bowel routine so you can poop better?

To understand this, let’s look at the digestive system a little more closely.

When you eat food, digestion begins in the mouth. Chewing helps to break up the food, and your saliva begins to break down the nutrients. Chewing alone is an essential part of digestion. In fact, most of us don’t tend to chew enough. I’ve been there! Years of working as a physical therapist at busy practices, led to a habit of inhaling my food rather than eating slowly and actually enjoying the process. Did you know that in order to adequately digest an almond, you have to chew that almond over 20 times? I learned that a few years ago when I interviewed Jessica Drummond- an incredible clinical nutritionist who also happens to be a pelvic PT. You can see the whole interview here if you’re interested!

After we swallow our food, the food travels down the esophagus into the stomach. Here, the stomach churns the food, mixing it with acid and juices and continues the process of digestion. When food enters the stomach, this triggers an important reflex called the gastrocolic reflex, which pushes prior meals and snacks through the rest of the digestive tract. This reflex is SUPER important to know to help stimulate regular movement in the GI system.

The food then exits the stomach and enters the small intestines. Did you know that if you uncoiled your small intestines, they would be 20 feet long? The intestines are where the majority of digestion occurs. Juices from the pancreas and gall bladder are added in here to aid in processing our nutrients. Food moves throughout these coils, then enters into the large intestine via the ileocecal valve.

The large intestine, or colon, is the major water recycling plant in the body. The colon recycles about 70% of the fluid we take in to use throughout the body. It continuously removes fluid from our stool…. So, what do you think happens if you don’t drink enough fluid? Or what do you think happens if your colon moves a little too slowly? Yep, that’s right. You end up with hard and dehydrated stool. When stool enters into the last part of the colon, the rectum, the stretching of the walls of the rectum trigger another reflex. First, an incredible reflex called the “sampling response” takes place. In this reflex, a small amount of contents are allowed to enter the anal canal. Your nerves here sense what is present, and tell your brain if the contents are liquid, gas or solid. (Amazing, right?!) Now, this reflex can sometimes be dysfunctional. So, if you struggle with feeling a strong need to poop, and when you get to the bathroom, it’s only gas? That’s this reflex. OR, if you feel like you have some gas to release, and when you release it, it’s actually a little bit of stool? That’s a sampling problem as well. And guess what—we can actually do things to retrain and improve this reflex.

As the stool is filling the rectum, and stretch occurs, the brain will receive the message of what is in the rectum, and gets to decide what to do about it. If there is just gas, you may choose to release it or wait a bit to release it. If it is liquid, your brain knows you better get to the bathroom QUICK! Liquid stool is hard to hold back for too long—the muscles fatigue—THIS is why chronic diarrhea can lead so often to bowel accidents! And if the stool is solid, you can actually defer and postpone the urge, until an appropriate time to go. The challenge there is that postponing frequently can make it so the muscular walls of the colon help you less when it is actually time to go to the bathroom.

When it is an appropriate time to go, you then sit on the toilet, relax your pelvic floor muscles, and this stimulates a defecation reflex which will allow the rectum to empty via the anal canal. Sometimes, we need to generate some pressure to assist this process, and sometimes, the muscular walls of the colon take care of it themselves.

So, let’s get down to it.

How do you use the process of digestion to build your bowel routine?

Step 1: Eat at regular intervals during the day to regularly stimulate your gastrocolic reflex.

Remember, this pushes things through the system, so it needs to happen often. The colon LOVES consistency, and HATES change. So, skipping meals? Eating really large meals sometimes, then nothing the rest of the day? All of this can impact your bowel function.

Step 2: Slow down & chew your meals.

Remember, chewing begins digestion, so, stop what you’re doing and eat mindfully and peacefully. Also, digestion requires a lot of parasympathetic activity—this is your resting & relaxing nervous system—so, slowing down and making time to eat can help stimulate that too.

Step 3: If you need the bowels to move better, eat “bowel stimulating” foods/drinks around the time of day you normally go to the bathroom.

What stimulates the bowels? Warm drinks (especially coffee—because the caffeine is actually an irritant to the GI tract!) are a great place to start. Also, spicy foods can help stimulate the GI system to move.

Step 4: Sit on the toilet around the same time each day, preferably, after a meal.

Remember that gastrocolic reflex? That reflex is helping to move things through the system, so after a meal is a great time to spend a few minutes relaxing on the toilet.

Step 5: Exercise!

Yep, exercise also stimulates the peristalsis of the GI tract! So, aim to get in regular bouts of exercise. And, it doesn’t need to be too extreme? Even going on a 10 minute walk can help get things moving.

What does this actually look like in practice? Here’s a sample routine!

Jane wakes up in the morning and takes the dogs on a short 10 minute walk. She gets home and makes a cup of coffee and her breakfast. She eats breakfast slowly, taking time to chew her food. (Jane also makes sure that she is getting plenty of fiber and whole fruits/veggies in her diet—because this matters too for her stool consistency!). After breakfast, Jane goes and sits on the toilet. She sits in a nice comfortable position, relaxes, breathes, and thinks about her day—spending 5 minutes without trying to force anything to happen. After a few minutes, she starts to feel the need to have a bowel movement. She uses what she learned in the “How to Poop” article, and gently pushes with good mechanics to assist her rectum in emptying her bowels. Jane then goes about her day, eating small amounts every few hours to stimulate her GI system.

Now, it’s your turn my friend! How is your bowel routine? What can you change to actually use your physiology and poop better?

Want more on pooping? Check out these articles:

How to Poop

Dyssynergic Defecation or When the Poop Won’t Come Out

Sex, Drugs…& No Poop?

Have a great rest of your week!

~ Jessica

Virtual Pelvic Floor Physical Therapy

March 16, 2020August 31, 2020 ~ jesspreale ~ 2 Comments

We are in an unusual time. Like many of you, I have been reading way too many articles and watched way too many news stories. COVID-19 is sweeping the world, and all of us have this immense responsibility to act, where we are, to do what we can to prevent the spread of this virus. Everyone is impacted, and everyone (hopefully) is trying to make the best decisions for themselves, their families, and society at large.

Healthcare is also seeing a shift—away from in-person care and toward virtual platforms. Right now, this is essential for so many reasons. The interesting thing is that at Southern Pelvic Health, virtual sessions have always been a part of what we do. And now, more than ever, we are working to be sure this service is available for anyone who needs it. Because, the reality is, pelvic floor problems don’t stop during a pandemic. In fact, for many, they can be exacerbated. Social distancing also offers the opportunity to stop and care for yourself, your health (along with your family & the community by flattening that curve!).

So, what is virtual pelvic floor physical therapy and what can it do for you?

The initial visit starts the same as an in-person session. We spend time discussing what is bothering you, in likely more detail than you thought we’d be discussing. We talk about your history, what happened when all of this started, what changed along the way, what is happening now. We discuss any pain or orthopedic problems you are having, your bladder health, bowel movements and sexual function. And most importantly, we discuss your goals—what you want to achieve how you hope to feel.

Next, we provide an exam. Now, here’s the difference in the virtual session. The components of the exam during which your PT would palpate your muscles or feel you move—we can’t do that. So, the exam takes on a different flare. We still watch you move from head to toe to identify how your body is working for or against itself. We may ask you to do different self-tests, feel different areas and see if you have soreness/sensitivity. We will give you additional information to see if you can activate certain muscles. And, from here, we can actually glean quite a bit of information. You see, the pelvic floor does not work in isolation. So, watching a person move alone can give us so much information about your function. I’ve written about this before, and here are a few that address this:

Head, Shoulders, Knees and Pelvic Floor!

6 Reasons Why the Diaphragm May Be the Coolest Muscle in the Body

Pelvic Floor Problems in the Adult Athlete

Next, just like in-person sessions, we start you on a plan to address the problem areas we have identified. This likely includes specific exercises for you to get started on, and some educational pieces to start improving your habits. We will also make a plan for the future—which could include virtual sessions only, recommendations for in-person consultations, or perhaps a hybrid! At our practice, we already have much of our content and exercises in a digital format. Any exercises we recommend will be given to you via video instruction in your patient portal. Behavioral education and other pieces like that will be provided for you both in our virtual session, but also via handouts e-mailed to you after.

Already an established patient?

This is even better. We have already done a comprehensive exam (or perhaps, another PT has already done this exam!), so we will have a complete picture of your situation. We will be able to discuss your progress, modify and progress your exercises, continue providing specific education, and help you continue to move forward to improve your function.

Live out of state?

This one is a little tricky. Technically, we are not able to see patients for physical therapy services if they do not live in Georgia. BUT, that does not mean we are not able to help you. We regularly offer virtual consultations and coaching services for people all around the country. This has been an amazing service to provide to play a critical role in helping to guide people to the services they need to get better. Our virtual consultations offer a similar format as our initial telehealth sessions. The difference here is that we would not be able to examine you and progress you in a program. We can offer some general guidance based on your symptoms, and very importantly, we can help you connect with more local practitioners to be on your healing team. We do the legwork for you—we find you resources, skilled practitioners (yes, we help you decide who your best options are!), and coach you along the way.

Are you ready to take the virtual leap? E-mail us today to arrange your first session at Jessica@southernpelvichealth.com!

Stay healthy my friends! And please, wash your hands!

~Jessica

Video Interview with Dr. Ken Sinervo: Internationally- Recognized Endometriosis Expert

March 18, 2019March 15, 2019 ~ jesspreale ~ 4 Comments

Happy Endometriosis Awareness Month!

Did you know that Endometriosis affects more people that inflammatory bowel disease?

Did you know that 10-15% of women (and some men too!!) suffer with endometriosis?

Did you know that they often see 7+ physicians before being diagnosed with the condition?

Endometriosis is so common, and often can be a very life-impacting condition. As a pelvic PT, I often treat individuals with endometriosis, helping them with the musculoskeletal and neuromuscular sequelae of the condition. I have also helped many patients navigate the healthcare system to ultimately receive the appropriate care they so desperately have needed.

In honor of Endometriosis Awareness Month, I asked Dr. Ken Sinervo, the medical director for the Center for Endometriosis Care in Atlanta, GA to spend some time with me discussing this important diagnosis. Dr. Sinervo is an expert in treating endometriosis, and I can’t tell you how lucky I am that his office is about 20 minutes from mine! He is also a kind and humble person and a compassionate physician, and I was so excited to interview him for this post!

In the video below, we discuss:

What is endometriosis and where does it occur?
What are the current theories on the causes of endo?
How can it be treated?
Excision vs. Ablation surgery
How to find an Endo expert
For pelvic PTs: How do you identify patients who may have endo?
And, as an extra bonus, cherry on top, Dr. Sinervo describes the research he is involving in trying to identify potential markers to actually test for endometriosis!!

I hope you enjoy the video as much as I enjoyed interviewing him! I apologize in advance if our video cuts out a little bit, but I don’t think it impacts the incredible content (Our weather in Atlanta was a little struggly, so I think my internet had some difficulties!).

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