SEASON 2 EPISODE 2
Get Floored [Podcast]
Everything You Need to Know About Pelvic Floor Dysfunction and Physical Therapy
Published March 2023
About this Episode
Each year, pelvic floor disorders affect millions of people, and those people seek help for issues like bowel and bladder changes or pain during sex. But there are ways to treat these disorders. Northwestern Medicine physical therapist, Lesli Lo, PT, DPT, joins the podcast to break down pelvic floor therapy and what it can do for you.
In this episode, we discuss:
- What the pelvic floor does
- What to expect in pelvic floor therapy
Featured Guest Expert
Lesli Lo, PT, DPT
About the Get Better PodcastLiving a healthier life is a journey with no final destination: You can always get better.
Susan Russell, MD, Khalilah Gates, MD, and Michelle Prickett, MD, are three pulmonologists at Northwestern Medicine who help people get better from critical illnesses. They are also lifelong friends and lifelong learners who want to get better from head to toe.
These three physicians will learn alongside you as they interview other Northwestern Medicine experts about health and medicine topics meant to help you achieve better health.
Russell [00:00:02] Let's get stronger.
Gates [00:00:03] Healthier.
Prickett [00:00:04] Calmer.
Russell [00:00:05] Smarter.
Gates [00:00:06] Better.
Russell [00:00:07] Living a healthier life is a journey, not a destination.
Gates [00:00:10] You can always get better.
Prickett [00:00:12] Let's get better together.
Prickett [00:00:20] All right. Welcome back, everyone. We are talking about pelvic floors to day. More than 25 million adults in the U.S. experience urinary incontinence. It's most common in women over the age of 50. So, chances are we've all experienced urine leakage at some point in our lives. When we sneeze too hard, laugh too loud or cough too much. But most of us don't talk about it, which means we're more likely not to get help for it. So today, we're hoping to change all that and break the stigma around incontinence and work towards healing. So, we are chatting with a wonderful guest today. We have Lesli Lo. She is a Northwestern Medicine pelvic floor physical therapist. We have Dr. Susan Russell and Dr. Khalilah Gates to join in on this discussion.
Gates [00:01:04] I'm excited about this conversation. It's a conversation that so many of us are perhaps a little bit ashamed to talk about, but so, so needed, so that we normalize the changes that occur with our bodies after childbirth.
Russell [00:01:18] When I was a resident, I did a women's health rotation, and as part of that, I did shadow in a pelvic floor clinic, and I was just amazed at the expertise and specificity of watching one of these exams performed. Even just describing what this is is going to be helpful to people.
Prickett [00:01:36] Again, I think this is one of those topics. Everyone's like, "Oh, I just, you know, I have issues that I just have to deal with it." So, I am very excited to learn and share what the options are, what's available, what's out there and how we can make people better.
Russell [00:01:48] All right. Let's get to it.
Prickett [00:02:01] We are going to cover a lot of ground today, including the types of incontinence, bust some myths about Kegels, and most importantly, talk about treatment options that are available to everyone. Welcome, Lesli Lo today, who is a Northwestern Medicine physical therapist specializing in pelvic floor disorders.
Lo [00:02:19] Thank you so much. I'm so glad to be here.
Prickett [00:02:22] Lesli, before we get into today, do you mind just introducing yourself?
Lo [00:02:24] I specialize in the pelvic floor, which is situated at the bottom of our pelvis. We all have a pelvic floor. Everybody shares that common ground. I have been doing pelvic floor physical therapy specifically for 22 years now.
Gates [00:02:38] Let's just talk about what the pelvic floor does. We all have one. But what does it do?
Lo [00:02:43] So the pelvic floor muscles have four main functions. They help to stabilize our pelvis and spine. So, they work with our diaphragm, our main breathing muscle that sits underneath a rib cage at the top. The public four muscles, again, are at the bottom of our pelvis. They work with our deep abdominal muscles in the front and the deep multifidus muscles in the back. So, those four muscle groups create a cylinder of support for our pelvis and for our spine. So, that's the first function. Their second function is that they aid in urination and defecation processes. So, the pelvic floor muscles communicate with our bladder and they communicate with our bowel to allow us to be continent and to void when we're ready to void. The third function of our pelvic floor muscles is to assist with sexual function. So, the public four muscles contract and relax. And when they contract and relax, they bring blood flow to the area that helps with lubrication, that helps with arousal, that ultimately helps with us achieving orgasm. So, they play a very important role in sexual function. And the last function of the pelvic floor muscles is to support our pelvic organs. So, we have three main pelvic organs. We have our bladder that sits right in the front, near our pubic bone. Our uterus is right behind our bladder or, in males, they have a prostate. And then we have our rectum. And those three pelvic organs are supported, connected to one another and supported by the side walls of our pelvis, and our pelvic floor muscles are just underneath them and help to support from below.
Gates [00:04:04] Wow. Lesli, in the last three minutes, you've managed to blow my mind and teach me something new. So, thank you.
Russell [00:04:12] You mentioned incontinence, but can you speak a little more about what it is and what could cause people to develop it?
Lo [00:04:19] So, incontinence is any involuntary loss of urine. Most people, when asked about incontinence, they will say they don't have it. And then when they're meeting with us and we're talking, they'll say, well, "I leak urine with coughing, and I leak urine with laughing, but I don't have incontinence." However, that's the definition of incontinence. We don't want to be leaking when we cough, sneeze, laugh. Any loss of urine is — even if it's the littlest bit to a full bladder loss — is considered incontinence. There are several types of incontinence. The main ones that we'll probably talk about and touch on today are stress urinary incontinence, and that's incontinence that is brought on with increased intra-abdominal pressure from coughing, laughing, jumping, running, sneezing. That puts more pressure down on the pelvic floor muscles in our pelvic organs and might result in a leak if our pelvic floor muscles aren't strong enough to resist that. There's also urge incontinence; that incontinence is when we had that strong urge to have to go. We have the key and the door and we know we're almost to the restroom, but then our body just says, "Hey, it's time to go" and we lose urine. In that way, the majority of women, especially over the age of 50, have a mixed incontinence, and that's both stress incontinence and urge incontinence. And that's what most people will end up having over time.
Russell [00:05:38] Do you have a kind of rough estimate of what proportion or percent of women over 50 have some form of incontinence?
Lo [00:05:44] Research tells us that probably about 72% of women over the age of 50 have experienced incontinence at some point in their life.
Russell [00:05:53] Wow. Yes. For something that's so common that you almost never hear talked about among friends.
Prickett [00:06:01] There's four of us here today on this podcast. And so statistically, I would say over the age of 50, three of us are going to be needing pelvic floor physical therapy. So, Lesli, can you tell us now that we've identified the problem, what are the treatment options?
Lo [00:06:15] So if you need pelvic floor physical therapy, you'll get a referral from your provider and they'll send you our way as a pelvic floor physical therapist. We're going to look at your pelvic floor muscles to see how they're contributing to the incontinence and where that miscommunication is happening between the bladder in the pelvic floor muscles that's leading to that leaking of urine. We address the pelvic floor by assessing the pelvic floor, which means more than likely you're going to need an internal pelvic exam. And I know that that sounds extremely scary. And that's mostly why women don't want to come in to see us or men don't want to come in to see us. However, that exam gives us the information that we need that's going to help you the most. So, when you walk in the doors, we do our best to make you feel as comfortable as you can because we know that you're walking into something that is not comfortable. We want to understand why you're coming in. We have the notes from your provider that say that, "Yes, you have incontinence," but we want to hear from you in your own words. How is this incontinence affecting you? So, we sit down, we take your history. After we take your history, we educate you about the pelvic floor muscles, their functions, why you might be experiencing incontinence or whatever pelvic floor disorder that you're coming in to see us with. We go through the detailed anatomy so that you have a better understanding before we even get to the pelvic assessment. As pelvic floor physical therapists, we're also regular physical therapists, so we do address the musculoskeletal components. So, we look at the spine, we look at the pelvis. But then after we do that, those range of motion activities, we check to make sure the alignment looks good. Then we're going to perform an internal exam, and when we do that, we give you the privacy, we step out, we let you change, you're covered up and draped with a sheet. And when you're ready, we come in. The pelvic exam takes maybe two minutes, if that, and it's a different pelvic exam than what your gynecologist is going to be performing. We don't use a speculum, so that's usually a big thumbs-up for patients. But we do use a finger and we do look at the area. We observe the perineum and the vulva region because we want to make sure that everything is looking healthy and normal. We also, after that, will be pressing on the pelvic floor muscles that are in that area on the outside. But then we'll get to that internal assessment. We use a glove with lubricant, one finger, we enter as we're talking through with you what each step is going to entail. And then we get to the pelvic floor muscles on the inside. When we're working on those muscles on the inside, we are going to the pelvic floor muscles. There are two main layers that we're looking at, a superficial and a deep layer. And that deep layer we can access through the internal vaginal assessment we're assessing for tenderness, increased tension or restriction in the muscles. And then I'm going to go back to the center, and we're going to talk you through a pelvic floor muscle contraction or Kegel — "kay-gal" — as everyone calls it, to see how your muscles are functioning. Are they able to contract all the way up? And we get a nice squeeze at the top and the return all the way back down to resting, because that's what we want the pelvic floor muscles to do. Or are they stuck in that tightened state, and we're asking them to recruit. Nothing happens. We don't feel that squeeze. We don't feel any movement. We do see some tightness in the abdominal area or lifting of the bottom off the table to try to help. But we talk you through how to isolate the pelvic floor. And in most cases, someone isn't able to isolate the pelvic floor because the pelvic floor muscles have dysfunction. They're not able to do the normal things. And that's why someone is coming to see us, and they're coming to see us because they're leaking urine or they're having other pelvic floor disorders.
Gates [00:09:47] So, you mentioned Kegels or "kay-gals," or however we say that.
Lo [00:09:52] Yes.
Gates [00:09:52] And I want to myth bust. Everybody says if you have incontinence, that's what you need to do. Is that true? Yes or no? And how do you decide that?
Lo [00:10:01] So I will say, no, that's not true. And how we decide that is that pelvic floor exam, performing that assessment. When women, specifically, were asked to perform a "kay-gal"/Kegel pelvic floor muscle contraction, only 32% were able to do it. So only a third of women are able to correctly perform a pelvic floor muscle contraction. That means there's a bunch of us out there that don't know what they're doing or how to do it or can't do it because there's dysfunction in the pelvic floor muscles. So, when a provider tells someone who's coming to them with incontinence, "Oh, just do Kegels and you'll get better." Well, for about two thirds of the population, they're not doing it correctly or they don't know how to do it or they can't do it. So doing what they think is a Kegel was never going to help them. Someone can do Kegels till the cows come home, but it's not going to make a difference when dysfunction is present.
Russell [00:10:55] Are there any resources out there for people who maybe just want to learn more about it, or at least get a feel for what that type of exercise is before seeing somebody like you in person?
Lo [00:11:07] So at Northwestern Medicine, we have information on our website that talks about the pelvic floor muscles, what dysfunction is and how to find your pelvic floor muscles. So, you could go to nm.org and look up pelvic floor physical therapy and find that information.
Russell [00:11:24] Are there other groups where pelvic floor dysfunction occurs in and what other kind of people out there should be thinking about coming to see somebody like yourself?
Lo [00:11:33] Yeah, we see pediatrics. We've seen patients from the age of 12 all the way up to 99. Men and women, transgender patients. We see a little bit of everybody because again, everybody has a pelvic floor. We see them for many different dysfunctions or many different reasons. Pain during intercourse is a big one, whether that's pain with penetration, pain right at the opening from either vulvodynia or vestibulitis diagnosis, or just pain with penetration because of scar tissue that's formed from a tear with delivery. We see patients during pregnancy and delivery for musculoskeletal issues like pelvic girdle pain, low back pain, but also pelvic floor dysfunction and incontinence during pregnancy. Postpartum, our body has just gone through this wonderful event, but traumatic event, of being pregnant and then delivery. So, our pelvic floor muscles have had to work extra hard to hold up the lovely growing fetus. But then it has to be able to relax and stretch to its maximum 3.2 times its actual length to be able to deliver that baby vaginally. But we also don't want to forget about the C-section patients, because oftentimes our C-section patients get like, "Oh, well, you didn't deliver that baby vaginally, so your pelvic floor should be fine." But again, they still went through pregnancy and a C-section as a major abdominal surgery. So, we're cutting through the abdominals that in the beginning when I talked about the functions of the pelvic floor, the public floor muscles work intimately with the abdominals to help stabilize our pelvis and spine. So, if now our abdominals are weakened because they're stretched and cut through, then our pelvic floor muscles take over and tend to have too much tone or tightness in them. We also see patients with pubic organ prolapse. So, whether it's a cystocele or rectocele, enterocele where the pelvic organs can fall into the vaginal canal. We assist with fecal incontinence and constipation, patients with chronic pelvic pain. So, patients are coming in with a history of fibroids or endometriosis. Those are patients we can also help with. The male patients that come in with benign prostatitis or have had prostate cancer and a prostatectomy. We can help all of — really almost any population — because again, we all have the pelvic floor so we can treat it.
Prickett [00:13:52] So that was a lot of great information. And it sounds like there are a lot of reasons that people would benefit from a pelvic floor evaluation and seeing a pelvic floor specialist. Can you give us a sense of, what's the success rate for this and how long does it take to see success?
Lo [00:14:07] Our goal is to hopefully get you better within 12 sessions. We see a patient for an hour-long session 12 times, and we're hoping by that time — with the education that we provide, with the manual therapy that we provide, the exercises strengthening and the home exercise program. So, with the patient really buying in and doing what they need to be doing to get themselves better, we're hoping that we can get you treated within 12 sessions. Sometimes it only takes four, sometimes it might take 24. It really depends. It's unique to each individual. And I would say there are times — we have tuneups, if you will — like I have seen a patient 12 years ago and then she called me and said, "Hey, do you have time to see me again? Because I'm starting to notice the leaking. I'll be honest, I haven't been doing my home exercise program for years, but can I come back in to see you?" So, there are times where we might — we call them tuneups — but for the most part, we want you to be one and done. We want you to come in and see us get better, have the knowledge and information to maintain that improvement, and then move on with your lives and be happy.
Gates [00:15:02] Lesli, I want to clarify something. It's kind of going back to earlier. We talked about most of the problems happening with women or people 50 years and older, but there are a large group of us, I suspect, that haven't quite hit 50, but have had one or more children and are still experiencing some of these. And so, I just wanted to touch a little bit about that group. Can I de-stigmatize for that group? And we don't have to wait until we're 50 to think about these things.
Lo [00:15:29] Absolutely. The sooner the better. Over time, as we age, it's the normal aging process for our connective tissue in our muscles to get thinner and a little tighter and not as strong. So, the sooner that we can start working with the pelvic floor muscles, the better. In my specific office, I work out of an OB-GYN office. So, we see patients really from age 18 to 42-ish, and we like to see patients as soon as we possibly can, because the sooner we can see them after their symptoms develop, the better the outcome will be. So, waiting until you're 50 is not a good idea. If you have pelvic floor dysfunction, you want to seek out a pelvic floor physical therapist sooner rather than later. And it affects, again, people of all ages with various backgrounds for various reasons. There are so many reasons that someone may have pelvic floor dysfunction. And as a pelvic floor therapist, We're here to help you figure out what those reasons are and then treat the pelvic floor and help you to get better.
Gates [00:16:28] Lesli, I'm going to come out the box. I'm going to ask you about Squatty Potty. Go.
Lo [00:16:34] Yes. So, Squatty Potty, I love Squatty Potty. I wish I would have come up a Squatty Potty, but I didn't. The Squatty Potty is amazing. The reason it's so important — and this is for whether you are going number one or number two. So, you need to use the Squatty Potty or a stool of some kind with your feet a little bit elevated. The ideal voiding posture is where our knees are higher than our hips. We can lean forward and rest our elbows on our knees. We can relax our abdominals because voiding, whether it's urination or defecation, is a relaxation process. So, we need to be relaxed in order for urine to pass out, in order for feces to pass out. So, we want to get into this position with our feet higher so that our knees are higher than our hips. We can get down and we can rest our arms on our legs. We can rest our belly and let it relax so that then, in return, our public form muscle relaxes so that urine passes out and then the pelvic floor resumes its normal tone to tell the bladder, "Hey, you can stop contracting now you've emptied and now we can get up and go on our way." So, I'm a big fan of Squatty Potty.
Gates [00:17:41] I am a proud owner of the Squatty Potty.
Lo [00:17:43] Awesome.
Gates [00:17:44] So, Lesli, you talked about the assessment part where there is an internal assessment and trying to figure out the problem. You also talked about home exercises. Can you give us a sense of in that hour, what are you doing in the clinic? But also, what are you, what exercises are you giving us to do at home to help?
Lo [00:18:02] So oftentimes we're starting off with relaxation exercises. Most people think they need to come in and strengthen. But we really first need to relax the pelvic floor. We need the pelvic floor muscles to understand that they need to be able to let go because that's a huge part of their strength. They need to be able to contract up and relax down. So, a lot of those stretches that we're doing will be inner thigh stretches or hamstring stretches, hip flexor stretches, hip external rotators, glute stretches so that we are stretching and relaxing all of the muscles around the pelvic floor. So then, in return, the pelvic floor muscles can relax. So we also do diaphragmatic breathing back to the diaphragm. That main muscle that's underneath our rib cage, that is our main breathing muscle, that is the top of the cylinder, the pelvic floor muscles being the bottom of the cylinder. So, if we really use our diaphragm as we're breathing, it's a relaxed type of breathing that will also help our pelvic floor muscles to relax. We might have you do some strengthening exercises. The hip muscles need to be strengthened so that they can help to support so the pelvic floor muscles don't feel like they have to do it all. Our abdominals may need strengthening as well, so a lot of the exercises initially are going to be related to more relaxation, making sure that the pelvic floor muscles can return to their normal resting state. And then we'll add some more strengthening exercises to the mix. But a lot of it is education. And with that education, it's talking about voiding posture. It's talking about what is going on with the bladder and the pelvic floor muscles, how do they communicate. We might be talking about timed voiding; we might be talking about urge suppression. So, when you get that strong urge, rather than tightening everything up to try to prevent leaking, we really talk that relaxation is the better option. So, we do a lot of different education for the individual so that when they get home, they know what to do. That's going to help their specific needs.
Russell [00:19:57] The entire abdominal compartment is involved with this process. That's really fascinating to me and not surprising that this is bringing it all back to those core muscles and muscles that as we kind of become couch potatoes with age, we don't really think about as much as we did in our younger years.
Prickett [00:20:18] This was a really great recap. We have so much information and pelvic floor therapy is really for everyone and but it needs to happen early. So, Lesli, can you tell us, if we've identified that this is something that we may benefit from, what are the expectations?
Lo [00:20:34] I would say talk to your physician, talk to your PN, your midwife. Let them know that you're experiencing incontinence, that you're experiencing pelvic pain. Sometimes they won't know unless you tell them. As soon as you tell them, they can get a referral to you for pelvic floor physical therapy. While there are quite a few pelvic floor physical therapists out there, many of us have a long wait in order to get in simply because the demand is much higher than we are able to help because there's so many people with pelvic floor dysfunction out there. We want to be able to help everybody. But just know if you've been living with incontinence for 11 years now, you might not get in in two weeks. It may be a few months before you're able to be seen by pelvic floor physical therapist.
Gates [00:21:17] Leslie, this has been absolutely fantastic. I learned something new today and some take-home points as well. So, final thoughts that you want our listeners to know here before we end up our session.
Lo [00:21:30] Don't live with pelvic floor dysfunction. If you are experiencing pain with intercourse, that is not normal. If you are leaking urine or leaking feces, that is not normal. And there's something that can be done about it, something conservatively that can be done about it. And the sooner that you can have the situation addressed, the more likely you are to get better faster.
Russell [00:21:52] So we really appreciate you spending time with us today to educate us more about the pelvic floor.
Lo [00:21:58] Thank you so much for having me. This has been great.
Russell [00:22:04] Thanks for listening to Get Better.
Gates [00:22:06] We hope you'll leave this podcast better than when you started.
Prickett [00:22:09] For more information, visit nm.org/healthbeat.