 Aloha and welcome back to physical therapy for a better life. I'm your host Christine Lenders, physical therapist and board certified orthopedic clinical specialist. Today, let's get to know our pelvic floor ladies. Whether you're a young athlete, a new mom who has just given birth or a woman of retirement age, you want to learn right now how to keep your pelvic floor muscles functioning well or tune them up to prevent leakage, pain, prolapse and more. I'd like to welcome back Dr. Pauline Lucas who is a physical therapist and board certified in women's health to teach us how. Aloha and welcome back Pauline. Hey Christine, I'm so glad to be here with you again. I am so, so, so grateful. You have so many different talents from mindfulness, health coaching, women's health, amazing. I'm so inspired. I can't wait for the show so I'm going to drop a big question so everyone knows what we're going to talk about and that is what is the pelvic floor? How can we use it or how does it relate to leakage and should we be kegling or not? That's the question, right? And wow, well again, thank you for having me on your show. It's really fun and I love teaching women about their pelvic floor, men too, but I'm only treating women with pelvic floor issues and it is so important and it is not talked about although I have seen so I've been doing this for 20-something years now and I have seen a change and that is because of social media and I would say especially over the last two years or so my patients come in and they tell me that they've requested to come go to a physical therapist to help them with their pelvic floor because of something they saw on YouTube or TikTok or red on Facebook or Instagram and so the word is getting out a little more which I think is incredible because pelvic floor problems are going to are affecting a third or like even like 25% or 30-something percent of women during their lifetime so we better talk about it, right? Yeah and so the issues I'm going to give a little anatomy lesson in a little bit. I brought my model so I can actually show what the pelvic floor is but pelvic floor dysfunction can result in things like bladder incontinence or even having a difficult time urinating like you know not having a good urine stream. It could be constipation, it can be pain, it can be sexual pain so there's a lot of different things that can actually be related a lot of dysfunction that can be related to pelvic floor problems so let's start at the beginning what is the pelvic floor and I have to tell you when I went to physical therapy school in the Netherlands we talked in detail about the abdominal wall every bit I knew it all and then there was a mention about this pelvic floor and then we went right on to the hips so I pretty much didn't know anything about it until I was pregnant and I started having problems with my pelvis pelvic pain and so that's when I started really learning about this pelvic floor this this secret pelvic floor and since then it has been my mission to educate as many women as possible about their pelvic floor and men have a pelvic floor too let's let's you know make sure that we address that but I'm going to focus on female pelvic floor disorders there is some overlap so if men are listening you can absolutely keep listening because you'll learn something too but here's a pelvic a pelvis a female pelvis so we do not have these screws just thought I pointed out so so this is a female pelvis like the way I'm sitting right now and this here this bone right here if you put your hand on your hip then you feel that bone on the top right if you have your hands on your hips so this is called your iliac crest and you have them on each side this here is the pubic bone and the pubic bone is really if you're having your fingers on your belly and when I'm with patients this is what we do we have an anatomy lesson and I have them push into their belly and it's soft soft soft and then they go down until they hit that bone okay now I'm going to tilt this pelvis so you can actually see the pelvic floor in more detail so here is the sit or the sit bones and what I tell my patients to do is lift one of your cheeks and put your hand underneath and sit on your hand and you feel big bone sitting right in in your hand and when you put your fingertips around there your fingertips are on your pelvic floor so the pelvic floor starts here at that pubic area and then goes all the way to the sit bones and then all the way back to the tailbone so now this person will be doing a headstand it is the backside but here's the tailbone so I can also show it to you this way like that so this is the backside and so here's the tailbone and the pelvic floor also attaches to that tailbone so really it's the whole bottom of the pelvis that is covered with the pelvic floor now the pelvic floor is a collection of muscles and connective tissue and they form the foundation the base of of the pelvis now you may have seen when you're looking here that there's three openings so that's where of course the anatomy differs from the males and so the urethra is on the front here right behind that pubic bone vagina is right there and then the anus is right here and we see that there's a superficial layer of muscles and connective tissue right here and then a deeper layer this deeper layer in the medical terminology we call it the levator ani which kind of means lifting of the anus the lifter of the anus and in the more popular terminology it's often referred to as the pc muscle which is really only one part of the levator ani but that's often what I see on the popular media and now if you look at it from the top into it you can see it here so this whole like sling of muscles almost right so these muscles I'm going to continue the anatomy lesson if that's okay yes please okay so these muscles have a couple of very important jobs number one to keep your female organs on the inside very important right and number two to keep this continent so that's going to be leading into your next question right yes and so and then the other thing is it plays a role with our sexual function and and this is really important for the athletes too it also plays a role with our core stability so you know a lot of people talk about strengthening their core and then they talk about their abdominal muscles mostly but the core is also the back muscles the anus pelvic floor yeah the core is quite extensive and it's funny you mentioned how the functions of the pelvic floor are to keep our organs inside right they aid in sexual function and also a part of stability and I remember that I was in Connecticut at a sports clinic and I was teaching people pelvic floor exercises for various things and I remember when I was having an issue in my I think it was my early 30s it was sports incontinence I would if I had to if I had to urinate and I was playing volleyball and I jumped from a landing I would leak and I'm like my gosh what's happening especially if I was menstruating at the time that's usually when it would happen I felt like everything was maybe weak at that one time a month and I would leak and I I didn't know I had a tailbone injury and snowboarding and I kind of connected to that but I like you didn't learn about the pelvic floor in PT school so I went to my OBGYN and she was asking if you had any other questions and I said actually yeah I'm having having this problem and you know I don't know and ask anybody else but she checked me and said oh yours is strong but maybe you don't have the endurance during that time of month and she said just do 20 kegels a day so 20 years later I kind of coined the phrase with my patients 20 kegels a day takes all your problems away sexual function helps with incontinence keeps your organs inside and works it with your core to give you stability so I just remembered that when you were throwing out all those amazing functions of the pelvic floor yeah so what a great physician to give you that information right amazing I'll never forget her I'll never forget her that was my first interest in doing pelvic floor exercises and then you know I'm craving so much more knowledge so thank you yeah absolutely yeah so um so it's interesting right with athletes because often athletes are very strong but then they have incontinence and I mean sometimes when you go on YouTube you can see crossfitters or you know people that lift extremely heavy and they're losing urine and um or in gymnastics and it's and you know these are strong women what can happen is really that the abdominal wall can be very strong and tight and actually putting excessive pressures on the pelvic floor that can be one thing and the other thing can be that there's just an imbalance between the abdominal wall and the and the bladder or the pelvic floor and yeah pelvic floor strength training is part of it but what is actually really interesting too is that sometimes those muscles are too tight so the pelvic floor muscles can be too weak but they can also be too tight and when they're really tight it can also result in weakness so a lot of times I have to actually first work with my patients on relaxing the pelvic muscles and lengthening the pelvic muscles and then we work with strength training that's amazing and often other symptoms that go hand in hand with the pelvic floor that's too tight is painful you know pain conditions like pain in the in the vaginal area sometimes constipation because those muscles if they don't relax well it's hard to have a bowel movement sometimes it's your you know urination that you're on stream that's hard to initiate sometimes urgency like the bladder is all of a sudden it's like oh I just have to go and and you know we have to run to the bathroom to try and make it and then sometimes painful intercourse can be related to that as well and yeah yeah so that's where you when you said do we do cables or not what kind of depends right it does and how can you like I know you can tell in the clinic if you're seeing someone but how could you tell whether someone's let's say a leakage for example or urgency they can't make it and they're just like I have to go and they can't make it to the bathroom like how can you tell if that pelvic floor is something that's too too tight and that's why it's giving them that problem or it needs to be tightened because that's a big differentiation and the only way that you can truly figure that out is by having somebody examine you you know and really I would say typically physical therapists are the ones to go to a pelvic floor physical therapist because not every physical therapist will do internal examinations you know we have to do training to do this yeah like in a case like yours for example I would actually guess you know with being an athlete and working out a lot I would probably have expected that there may have been some tension there it kind of depends on how much attention and how much of a problem that is sometimes doing cables and if you do them correctly which is also an issue not a lot a lot of my patients have done cables and they actually didn't do them correct but sometimes if there is some tightness and weakness sometimes doing cable exercises can actually be beneficial and takes care of both but sometimes you can really create a pain condition if you're just doing too much of these strengthening exercises when it's already tight so if you want to know hundred percent sure I'd say go see a physical therapist if you're like kind of like you and you're like hey I'm going to just try this out hey if it helps your symptoms you did the right thing if you're getting more if you had pain already probably if you had pain already I would go see somebody first but let's say you're doing these exercises but your problem is only getting worse yeah probably also time to go see somebody but if you're like yeah I'm having a little bit of leaking I'm going to try some of these exercises and really read the instructions and you feel like you can do it do it maybe for a month or two months and if you feel it's improving hey that's it that was your solution and if not I would go see somebody yeah that's like that's a great recommendation so now the burning question is how do you do them correctly yeah and this is actually it is a bit of a trick right so when I teach it to somebody I always check so for me to just tell you how to do them is actually kind of hard but I'm going to do my best so sometimes I suggest go to the bathroom you know urinate can you stop the flow of urine that could be one trick and if you're like yep I can do it then I say well what did it take what did you have to do in order to make that happen and most likely you were doing a bit of a pelvic muscle contraction at that point right yeah the other thing I sometimes say is pretend you're about to pass gas and it's not a good up good moment what do you do sometimes it works to tell people that but sometimes they just start squeezing their glutes together and if you do that in sitting your body goes up and down so if you if I say yes exactly what you're doing here so that means you're doing glutes right we go up and down so can you tighten more around the anus sometimes I just tell people tighten the muscles around the anus and around the vagina without tensing everything else around it so not the hip muscles you know not your inner thighs the abdomen will engage a little bit and you know see if you can hold that sometimes they say pretend this is kind of a weird one but pretend that you're picking something up from the floor with your vagina muscles oh yeah when you're standing you know so there's different ways like that if you're very comfortable with your own body you can insert your finger vaginally yeah and can you feel a squeeze around your finger when you're when you're contracting yeah so those are some things or if you know ideally when you have your peps mirror and when you have your annual exams the doctor checks it but unfortunately that's not typically the case ideally in my ideal world the gynecologist would check you know or your primary care physician who does your exam like minded that day when I told her I was having that problem she goes oh we were just done and uh she said oh let me let me check she put the glove back in and she goes squeeze and she's like oh squeeze again squeeze and hold she's like well you're strong uh you just might not have the endurance or whatever I mean this was so long ago I can't I just remember her checking and saying it worked and then telling me you can do these exercises to help with with the endurance which um which I know this might jump the endurance made me think of jumping to a little offshoot I've had some patients who will go to the bathroom and they wake up in the morning they go to the bathroom and then they have to walk down the hall to go to the kitchen to take care of their pet or make their breakfast and when they get there they're leaking they're like peeing and so I'm not sure what kind of instance that is or like maybe discussing a little bit about the normal bladder function and what that kind of means with pelvic floor and bladder uh if you could explain anything about that it just popped in my head right now yeah yeah no that's a great question uh because we didn't really explain the whole idea of incontinence like what actually happens okay so I'm going to talk a little bit about the bladder and I'm gonna you just use my hand because I didn't have an anatomy teacher but let's say this is my bladder and the bladder what you need to know about the bladder is that it's it's like a balloon like a little like a hollow muscle almost right and so the bladder when it's when it's empty is small they're constantly gradual drip from the kidneys like I compared with an IV drip so you know the kidney is constantly producing urine and very gradually the bladder fills so it is a little balloon that sits right behind that pubic bone right behind it above most people will know where their bladder is because you can feel it when it's full yeah and so that bladder gradually expands as it's filling at some point when it's filling the little sensors on the inside there were little receptors on the inside of the bladder will give a signal to the brain saying hey it's time to go find a bathroom you know and then typically we get some advanced notice right like maybe 30 minutes or so maybe a little longer and as it fills more the pelvic floor gets a little tighter to make sure that everything stays closed right um and so for some people that mechanism doesn't work quite right and so they feel a little bit of expansion and immediately they feel an urge to go and they need to run to the bathroom and as they run they actually leak so that's one and that would be called urge urinary incontinence okay okay so the one that you're talking about let's say you wake up you have a very full bladder you know to really expand the pelvic floor is just having to you know keep everything closed and there's also some muscles some muscles right around the urethra the pipe that goes from the bladder down out you know to to urinate so let's say that person doesn't actually go even though she feels a really strong urge and now gets up and imagine now the pelvic goes to work harder than when you were lying down so if you now walk through the kitchen with that really full bladder the pelvic floor better really worked very hard and so there's a good chance otherwise that you will leak urine my advice for her would be take care of yourself first empty your bladder before you take care of your animals yeah like take some time and like breathe and relax and just really empty your bladder and sit there and let it go that's yeah that's a good a good strategy yes yeah and some women i mean i could talk about this for hours so stop me when it's too much but some women need to double void so let's say you've had a prolapse or something which means that the organ sit a little lower in the pelvis which can happen after childbirth or with aging sometimes they feel like they urinate and they're like hey i get up and it's like i'm leaking a little afterwards or i need to go sit down again i have to pee some more and what we what we tell them is okay empty your bladder without pushing it actually needs to happen quite naturally by just relaxing those pelvic floor muscles that have kept everything closed and then the bladder squeezes the urine out that's how that works okay so the pelvic floor relaxes the bladder squeezes the urine out so we don't have to sit and push the urine out because that's dysfunctional voiding and can create problems so anyway so let's say they empty their bladder then i suggest okay move a little bit side to side or forward and backward and then often they can they feel they can easily release a little more urine without pushing that's a great strategy you know i i didn't even think about that i gave this woman um the strategy of like why don't you know sometimes i think i told you in the mindfulness sometimes in between patients when i go to urinate um i will just do my mindfulness breathing and sometimes i just bend forward and let my stomach rest on my thighs and i breathe because i'm just trying to like calm myself and do the same thing while i'm urinating and i just told her well maybe hug yourself and lean forward or something just to and take some deep breaths which probably was the wrong thing it did work but it might have been the wrong thing uh i was just trying to have her relax and breathe and be in a different position to try to help her fully void before she i like the movement better yeah yeah so it's both i mean i like your idea too it's actually really important but you said to actually relax and take a moment we're so rushed you know and so now we're trying to squeeze as you run out in 30 seconds so we can go on do all the things that are important but this is an important thing so yes and i see all the people all the women that have problems with this so you know be grateful that you can urinate first of all take your time to actually be complete and make that a moment of mindfulness to tie it back to mindfulness which we talked about the last time uh but make this a moment you're taking care of your body and because if you do if you do all these things too fast and you just kind of rush through it you can end up with problems so take your time to empty the bladder and but here's another thing that came to mind some women especially in public restrooms don't want to sit down yes and then well think about how i was showing you know the pelvic floor relaxes while the bladder squeezes well when you're in a squat pelvic floor isn't gonna fully relax you know so if that happens occasionally because you happen to encounter a really dirty toilet i get it but don't make it a habit especially if you have to frequently be on on a public restroom i'd say bring your disinfecting spray use the seat covers do whatever you need to do so you can actually sit in that that way empty your bladder that's uh that's really important i'm glad you mentioned that because i hear it from my friends more and more and more about the the hovering and i have a very hard time hovering because i feel like i can't pee all the way and and it and i also remember um and this was just a small women's health section meeting that i went to years ago and they were saying how they were doing studies of this is old like probably from 2003 or five or eight or something they were doing studies with women of different countries and pelvic floor weakness and they were saying women in asian countries that sat in the deep squat had almost no trouble with pelvic floor and one of the exercise i used to give people is to put their legs wide squat down squeeze kegel pull the tummy in and then stand up squat down squeeze pull the tummy in and stand up and exercise it that way so here we are in a in a squat that's great to exercise and already make the pelvic floor engage and then we're trying to relax it at the same time i remember that yeah exactly yeah yeah so that's a good exercise unless people have a prolapse then i wouldn't do that deepest squat but yeah so that's a good one and you're right you know like we're doing some really strange things if you think about it because if you consider like your cat or your dog that's honestly you know that's how we should kind of go about it too so until you know somebody invented this little porcelain party we were squatting and that is really a much healthier way to urinate to have a bowel movement and of course to have babies too really that's that's how nature works but we're sitting on this toilet and some people even these elevated toilets and we we don't do our pelvic floor a favor honestly yeah you can even go as far as getting like a squatty potty you know i mean some of my patients just get a regular step stool which works too but then i'm afraid as a physical therapist about tripping hazards so but a squatty potty you know you place your hips in a better angle and it's easier to allow your pelvic floor to relax so that's another option that's a great option so we've learned so much and and now the the next big question is what about childbirth and how that affects the pelvic floor i hear this from so many of my friends my mom everybody about different issues or complications that can happen during or after childbirth and what can we do yeah yeah so that's you know childbirth is a major concern it means awesome of course but you know if you think about i just showed you this this model yes and so you know head of a baby coming through this little area i mean that there's something about that design that that is a bit challenging right now here's the good news when we're pregnant there's increased flexibility so it helps you know the body gets prepared for this childbirth process but still especially if it's a longer labor if the baby's head is larger and especially if its instrumentation is being used like vacuum or forceps or something like that i mean tearing can happen and of course a physiology is better than just tearing because it goes its angled sideways so it doesn't go straight to the anal area but it's still it's damaged to a muscle and sometimes there can be a bit of a nerve attraction injury as well and so it's you know very common to have some urinary leaking right after but what i want to emphasize to all the women that are listening is that it's not normal to then from then on have urinary leaking and a lot of my patients think that they tell me like well you know i figured i'm a mom so that comes with urinary leaking you know what every doesn't every woman have this when they're laughing or coughing or sneezing and i really don't have to jump on the trampoline anymore is what they would say and i say well why not try and see what we can change here right and so that is really where a good physical therapist can can come in and help with just strengthening exercises and addressing any scar tissue that might be there even abdominal strengthening in the right way you know drawing in like the abdominal bracing i'm sure you've talked about that at some point really important so please do not just think that because you had a baby it's normal to leak because really it's not it's common but there's something that can be done so you know that's a really good news i would say that's such a big message right there and you stated what i heard in that first women's health section meeting at a at the CSM conference which in San Diego a long time ago which was urinary incontinence or leakage is not like a sentence that all women are just destined to get it's not it's not normal but we've all said like oh you hear about it you giggle about it that's a girl thing they're leaking oops gotta pee oops i laugh when i sometimes when i laugh i pee and it's not normal for that to happen it's common like you said 25 to 33 percent of women i've read those studies in in 25 years and up are having incontinence issues during some form of sports uh childbirth all day it's so common and i talk about it and you talk about it but in the common circle non-social media no one's really talking about it and it's such a it's so um enlightening and freeing to know that there's something you can do there's someone you can go to for help like you're saying uh people are saying social media and saying oh my gosh wait i i can get help with this i love that the word is getting out there i love that this show is gonna it touched so many people yeah yeah so yeah and it's not only about doing kagels it has to do with also training the hip muscles and the abdominal muscles and you're you know learning to breathe correctly there there's a lot to it but just starting super simple with just some basic core strengthening including these pelvic floor muscles and if any doubt really ask your doctor to refer you to a physical therapist um if you know some insurance is allowed to just go straight to the to the physical therapist without a referral but otherwise your ob gyn or your primary care doctor ever refer you to a physical therapist and do an evaluation that's great that's right so i think that we're kind of almost out of time and i just want to know uh this has been so amazing the education of the pelvic floor and showing the pelvis and showing us all the intricacy and of the pelvic floor and all the jobs it's like a pandora's box right we could talk for for five weeks about this subject in and out but is there any last words you want to share with everybody before we close um my last words are your pelvic floor is really important and if it's not functioning right if you have painful sex if you are leaking urine you know with all these things there's help available so don't just take it for granted don't just accept it but get help that's very nice there's so many improvements in my patients and i wish that for everybody and i know that people can get in touch with you um to talk to you about it through your website is that right yeah actually you know i work for Mayo Clinic in Arizona and so for for the pelvic health they can just reach out to Mayo Clinic in Arizona excellent yeah that is excellent so thank you so much dr pauline lucas for coming on and teaching us a wealth of information opening pandora's box um i am so grateful to you thank you very much thank you for having me again that was awesome excellent life is better when you listen to your physical therapist thanks thank the thing tech hawaii aloha everyone thank you so much for watching think tech hawaii if you like what we do please like us and click the subscribe button on youtube and the follow button on vimeo you can also follow us on facebook instagram twitter and linked in and donate to us at think tech hawaii dot com mahalo