Amanda Newman (00:00):
Welcome back to The Healthiest You podcast. Here's Part Two of our latest episode.
(00:06):
What are your thoughts on those toilet stools that are very popular? Are they helpful?
Karen Snowden, PT, DPT (00:12):
Actually, they are. What we found is that when we're sitting straight. Well, before I talk about that, you were talking about having your feet supported. If your feet are not supported, you're not going to be able to relax. So there's that.
(00:30):
But then also the angle of the hips. If we're sitting and we're, say, at a right angle, we have 90-degree angle at our hips and our trunk, the pelvic floor muscles are like a loop, and they kink the colon so that we don't leak bowel. If we lean forward, those muscles release. So if you hinge forward where you're getting your knees higher than your hips and/or leaning forward, you're now releasing tension of the pelvic floor muscles to allow emptying. And guess what? That colon that's curved is a little bit more of a straighter shot. Ergonomically, it's going to work to your advantage. All the fun things we're learning today, right?
Amanda Newman (01:11):
I had to ask this because my husband and I gave that as a white-elephant gift at a party last year, at a holiday party.
Karen Snowden, PT, DPT (01:18):
And you wanted to keep it?
Amanda Newman (01:19):
No, we gave it.
Karen Snowden, PT, DPT (01:20):
But you wanted to keep the gift.
Amanda Newman (01:22):
I mean, maybe a little bit. It's pretty. I mean, it was like bamboo and stuff, so I mean it's very aesthetic. But I have yet to follow up with that relative to see how it's working for them.
Karen Snowden, PT, DPT (01:33):
Yeah, the ones they sell, there's an advantage in that there's a cutout, so you can put it the toilet and not trip over it. But the truth is, if you have a stool at home or a couple books, you can put your feet on top of a bunch of magazines. I mean, don't trip. But it's really about getting the knees higher than the hips is the key.
Amanda Newman (01:52):
It makes a difference. OK.
Nabila Noor, MD (01:54):
And I think what you'll learn, and same thing, I as a surgeon, there's so much of how our body, the body mechanics play a role in all the things we're talking about, right Whether it be for the functioning, whether it be when we're doing surgery, it's a lot of reconstruction. Again, you're trying to realign things the way they should be. And if you can learn that, and it's a process because it's not something that we learned in school. Even many people in health care may not know it. But start with if you're somebody who's suffering and you know that, OK, I want to start doing some nonsurgical things, like conservative treatment options. It's a lot of the times it's just changing lifestyle, changing how you live your life, how you move, how you do things. It's the simple things that can make a huge difference.
Karen Snowden, PT, DPT (02:40):
And sometimes, you know, a one-time appointment where you're getting that information.
Nabila Noor, MD (02:44):
Exactly. That's a great point.
Karen Snowden, PT, DPT (02:45):
Just is like, oh, I knew that, but I wasn't really thinking about that. A lot of people will come and say, thank you. I maybe didn't even touch them. They just want to talk. They don't want to feel that invasion of privacy. That's fine. You know what? It's all about you. And we want to meet that individual's needs. And if they have come in and have questions and they just want to talk, gathering good information from reliable sources goes a long way.
Nabila Noor, MD (03:12):
And I think one of my favorite things to do when I see patients in the office is showing them diagrams and even models. And I think that really is, you can see that "aha moment" in their faces because they're like, oh, that makes total sense. Now I can see it. Now I can understand it. Whereas before it was just very abstract to them, right? Even the fact when I'm explaining to them how does a person pee. What are some of the steps that's happening? And in their mind they're like, wow, there's all these things happening for me to just urinate. And same thing can happen when you're having a bowel movement. And so just being able to see it, understand it really helps them.
Amanda Newman (03:52):
Are there any supplements that you recommend for supporting your bladder?
Nabila Noor, MD (03:57):
Yeah, that's a good question. It does come up. So supplements are interesting. So there are some supplements that I sometimes will talk to my patients about, especially patients who are suffering with what we call recurrent urinary tract infections. So these are women who are getting urinary tract infections or UTIs, and they're getting it multiple times. So the definition that we use is two or more in a six-month period or three or more in a year's period. I mean, these women are miserable. They just cannot get rid of it. We see it a lot in our postmenopausal patients, and primarily their reason is because of all the hormonal changes that's happening to our body. And as a result, there are changes that happen to the pH of the vagina, to the microbiome that usually is helpful in protecting women from developing these infections. So talking about supplements, cranberry supplements, we do talk about that because what it does is it helps prevent the bacteria from sticking to the bladder wall.
(04:56):
So what I tell my patients [and] talk about cranberry supplements, there's a specific chemical that we tell them about, it's called PAC or proanthocyanidin. So they can get any supplement that they want. Sometimes they can get a little expensive. But the important thing to know is whether or not it has that chemical, that PACs. Specifically 36 milligrams of PACs, because that's what we are learning actually does the job of preventing the bacteria from sticking to the wall. So there is the cranberry supplement. Oftentimes people will also talk about d-mannose, which is a sugar supplement. The data with that is a little bit more, it's a little bit unclear because recently there was a large study that didn't really show a lot of difference. In general, my thing with supplements for patients is, of course the studies are not that great, but I have many patients who swear by it.
(05:50):
I have many patients who swear by taking probiotics. That helps them with the infections. There's the pumpkin seed extract for women who have a lot of urinary urgency, frequency. And of course, like I said, the data is not as clear cut. But having said that, if I have somebody who swears by it and it's not causing them any harm, hey, you weigh the pros and cons, right? I mean, what's the alternative? They have to be on antibiotics or be miserable. If they think it's helping them some and no harm done, go for it. But again, make sure you have been evaluated by a proper physician beforehand to make sure that we're not missing anything. And I think problems can happen where patients or women in general are just self-treating themselves with supplements and not getting the help that maybe they need.
Amanda Newman (06:38):
That was some great advice, especially for supplements because that market is very overwhelming. So I like that you listed a few options out. And also the fact that if it is working for you and you've talked about it with your physician, go for it, keep using it.
Nabila Noor, MD (06:50):
Absolutely. And it's funny because sometimes I'll be learning from patients. ... I have had patients who will come and tell me that, hey, Dr. Noor, I found out about this, whether it's from social media or maybe a friend. And then I'll go look [it] up and I'll be like, OK, maybe there is some literature on it. And so I'm learning as well. And I think from us being the physician, being the health care providers, we have to have an open mind but also understand it's a two-way street. It's that trust that happens from both sides.
Amanda Newman (07:16):
Now, another pelvic floor disorder that you mentioned earlier that affects women is pelvic organ prolapse. What are the symptoms of this condition and how is it diagnosed?
Nabila Noor, MD (07:27):
So what pelvic organ prolapse is, is essentially where because of the weakness of your pelvic floor, your pelvic organs – which could be the uterus, it could be the bladder, it could be the rectum or intestines – are essentially pushing through the vaginal wall. So what patients feel, or they complain about most often, is feeling a sense of pelvic pressure. They'll talk about heaviness, they talk about a bulge, or in worst-case scenario, they actually see something is coming out through the vagina. So as you can imagine for somebody who is not really aware of this, it can be pretty traumatic and scary, to be honest – because it almost feels like your insides are coming out, and should be told it is kind of that. But the part that's actually protruding out is your vaginal wall, or in some cases it could be the uterus.
(08:19):
So, how to diagnose it. A lot of the times when patients are feeling the symptoms, oftentimes my patients will say, I was in the shower and all of a sudden I was cleaning and I felt something was coming down from the vaginal opening. Or they actually felt a bulge or they actually saw something protruding out. Oftentimes they'll probably go to their OB-GYN or their primary care doctor, get a GYN evaluation, which is essentially a pelvic exam. And then they'll usually diagnose it and then refer them to me. For myself, when I'm assessing somebody for prolapse, I'm doing a very detailed pelvic exam. And we're actually doing measurements because you actually have to understand what area is prolapsing, how significant the prolapse is. Because we actually stage them, whether it's stage 0 versus stage 4, because all that information we take into consideration when we're talking about treatment options for patients.
Amanda Newman (09:11):
And this health condition, it can really disrupt your life, especially if it's left untreated. So what treatment options are there?
Nabila Noor, MD (09:20):
First of all, it can be really stressful for patients, like I said, especially if they're not aware what it is. The first thing I will say though, just to reassure all our viewers, is that pelvic organ prolapse is not life threatening. It actually looks a lot scarier than it is. Because I feel oftentimes patients are concerned, is it cancer? Is it my intestines coming out, or is it a body like an organ coming out? It's none of that. It doesn't become cancer. And it's also a slow progression, meaning if you just feel the ball right at the vaginal opening tomorrow, it's not going to just fall on the floor. It doesn't happen like that. Because those are some of the questions I hear from patients, and they're worried about that. But with regards to treatment, just like everything else we were talking about, there are conservative options, which is nonsurgical, and then of course there's surgery for the right patients, for patients maybe who want more definitive treatment options.
Karen Snowden, PT, DPT (10:12):
And from a pelvic health perspective and physical therapy, the people that do best with as far as their results would be those with a mild or moderate prolapse. So if it's significant ...
Amanda Newman (10:23):
OK, good to know.
Karen Snowden, PT, DPT (10:25):
Yeah. And there's a lot of things that we can do to help prevent it, as well. So when we see a woman that doesn't have a prolapse, we're always trying to give health strategies to help protect the pelvic floor to ward off, over time, the risk of pelvic organ prolapse such as avoiding straining, holding your breath, things like that.
Nabila Noor, MD (10:48):
Focusing on the risk factors, per se. I will say, though, not going into details about treatment, but especially for my young moms, because it can be really debilitating for a lot of young moms who may notice this prolapse immediately after childbirth. It's normal to feel things different down there. Don't beat yourself up. Give yourself the grace that you need. There's a lot that happens as pregnancy happens and childbirth happens – things meaning vaginally, things just don't feel the same. A lot of those symptoms, a lot of those anatomic changes, can revert back to how things were before as the hormonal changes get back to normal, maybe with some pelvic floor physical therapy. So I just want to give them some reassurance. Don't feel like, oh my God, what just happened and this is how I have to live with for the rest of my life.
Amanda Newman (11:37):
That's probably how you are feeling in those moments. But I love your advice of just give yourself grace and come see the two of you and you're going to feel better.
Karen Snowden, PT, DPT (11:46):
And in physical therapy, we have specialists also that specialize in obstetrics. So when you're pregnant postpartum, they do not get as detailed involved in the pelvic health care. But they are able to help restrengthen the pelvic floor muscles and the abdominals and how to use your breath and how to care for your child so that you're not creating problems and you can heal.
Amanda Newman (12:11):
So we've covered several pelvic floor disorders today, such as pelvic organ prolapse, overactive bladder and urinary incontinence. How can pelvic floor physical therapy benefit women with these health issues and other pelvic floor problems? What can you expect during your first appointment with a pelvic floor therapist?
Karen Snowden, PT, DPT (12:30):
So when somebody comes to pelvic health physical therapy, what they can expect, number one, is to guide the treatment. What are your needs? What are you looking for? Some people want a full-on give me the full assessment. Other people are saying, I just want to speak. Many times people come in and think, oh, let me just start with can we just talk. And by the end they're like, please, I do not miss a test. I want it all. And that's OK because it helps us to understand what are your needs, what's your lifestyle? So the first thing we do is take a very detailed inventory or history. What are the problems? What are you experiencing? What is your lifestyle? How do you use your body in a day? Are you exercising? Are you working? What are the issues for you? And then we also do a little screening of all the different areas of the pelvis because they do communicate and they interact and we understand how's the bladder, how's the bowel?
(13:29):
How's your sexual function? Do you have any pain? Pain is not normal. And so sometimes people will come in for one condition and they start to realize, oh, wait, I can talk to you about the fact that I've had pain with intercourse for a couple of years. Sure, it's all interrelated, and sometimes the muscles are part of the problem, sometimes not. And that's what we can help determine. I tell people we can figure that out today. It's very simple. And so we start with an external exam where we're looking at the larger muscles outside the body, anything that's kind of connecting to the pelvis. So the hip muscles, the abdominal muscles, the back muscles. We might be looking at the joints, the sacroiliac joint, the pubic synthesis that's in the front of the pubis. And so we're trying to understand the tailbone. Some people have some tailbone discomfort.
(14:20):
How is your back moving? Yes, I have spine problems, or not. And the nerves come out of the spine to the pelvis. So sometimes there's a relationship there. So we get the detailed history, we go into the external exam, and if somebody is interested in having their pelvic floor muscles assessed, we can do that very easily with an internal exam, whether it's vaginally or rectally. For women, a lot of times, because we have two ways of accessing the pelvic floor muscles, we'll often recommend a vaginal exam. However, sometimes people are like, I want more detailed information. Really my problem is at the backside with my bowels. And so we have all those skills and we're able to work with the patient to meet their needs and get the information, really. And again, we're trying to determine, do you have tightness? Do you have looseness? Do you have strength? Do you have flexibility? Are things functioning as they should be? I will say that our intention is to never induce pain. It would not be normal to have pain in any type of a pelvic health physical therapy session. And I say pelvic health, did you notice that?
Amanda Newman (15:28):
I did?
Karen Snowden, PT, DPT (15:28):
Because we're looking beyond the muscles of the floor. We're looking at the abdominals. And so it's kind of the health of the pelvis. So pelvic health physical therapy is often a term that's used to address the pelvic floor muscles and other things. And how are you using your breath? Are you holding your breath? How are you using your trunk? Because this is a pressure system. So we're helping with all of that. And a lot of times it could be that somebody has back pain and pelvic problems. So we might take that on and work with that where we may collaborate with other clinicians in physical therapy, where we team up with others that can address those needs.
Amanda Newman (16:07):
That was such a thorough explanation, and I think this is so helpful for our listeners because if they are interested in coming, I think they just have so much insight now, what to expect from beginning to end.
Karen Snowden, PT, DPT (16:18):
Yeah. I think also one thing that people might not be aware of is we help with conditions that you wouldn't expect a pelvic health physical therapist to help with – such as if somebody has a bladder process, interstitial cystitis or endometriosis, which is very common. In other words, I've had a lot of pain for years, the center around my period, things like that. What happens when we have pain? We go into protective mode. And so a lot of times our muscles are not doing their normal functions. And so while we're not treating the endometriosis or the process that's going on internally, we're working with our physicians to help calm the system, calm the muscles, getting the muscles to be strong as opposed to just tense. And it really helps people to feel better. It might not solve the problem, but it helps significantly and ultimately improves quality of life. So people can be functional, they can be social, they don't have to be afraid of, oh no, I can't go out tonight.
Nabila Noor, MD (17:20):
I think one thing to understand is that the pelvic floor and the whole pelvic floor musculature, the whole system, is more complex than we think. It's not just about doing kegel exercises. It's not just about tightening it and strengthening it. I think what Karen was referring to is sometimes when your muscles are too tight, patients can end up with problems, which is the pain component, right? And we do see it. We see it in a lot of young women, a lot of very young, fit, athletic women. Some of my pain patients or pelvic pain patients are people who, if you look at them externally, they're some of the fittest patients ever. They've been doing aerobics, they've been doing Pilates. A lot of them were gymnasts growing up since they were kids. And all those, when you hear their story, you realize all their life they've just been told to tighten the core and tighten the pelvic floor muscles. And they never quite learn how to relax those muscles.
(18:14):
I mean, the terminology I often use is that you want your pelvic floor muscles to be like a yoga muscle. You don't want it to be a bodybuilder muscle. You don't want it to be just buff and tough. You want it to be like a yogist muscle where it can stretch, it can relax, it can tense. It has that fluidity. And that's where working with a pelvic floor physical therapist or even seeing a urogynecologist, we can actually tell you. Because sometimes patients will come to me and they're convinced they have prolapse, and they're telling me that their main complaint is pain. Even before touching them, I know their problem is not prolapse because prolapse never causes pain. Anytime somebody tells me pain, it's probably because they have very tight pelvic floor muscles. And the treatment for that, as strange as it sounds, is learning how to relax those pelvic floor muscles.
(19:04):
And when you tell that to a person, they're looking at you like you have two horns. What are you talking about? Why are you referring me to PT when I'm telling you I have pain? Give me some medication, offer me some surgery. Because probably because they have seen multiple providers, and I am their, I don't know, third, fourth physician, and I'm telling them, I'm sending them to pelvic floor PT. And they're just like, OK. And then they trust you. They go do the PT, and six months later they're a completely different person. And it's actually really amazing to see that transformation.
Amanda Newman (19:34):
So once you learn how to really relax those muscles is when that alleviation of pain comes.
Karen Snowden, PT, DPT (19:41):
The other thing is you cannot strengthen muscles that are tight. I mean, you can, but it's very difficult. You're not going to be very effective.
Nabila Noor, MD (19:49):
Yeah, it's just a nonfunctional muscle that's just sore, pretty much.
Karen Snowden, PT, DPT (19:52):
So you need to actually get that flexibility first and then strength, and it's going to be very effective. And if you're doing things correctly, you really don't have to do a bazillion of them. But I would say too, the abdominal muscles. So your dancer, your yoga instructor or yoga people that are doing yoga, oftentimes they are that core tight.
Amanda Newman (20:13):
Yes. As a dancer, I started dancing when I was 2, and that was literally ringing true in my ...
Karen Snowden, PT, DPT (20:19):
Right.
Amanda Newman (20:20):
Yeah. You got to keep that core tight,
Karen Snowden, PT, DPT (20:21):
Right? You know how many women I have worked with who are dancers and they say, I don't understand what you mean. I should relax my abdominal muscles.
Amanda Newman (20:32):
We don't.
Karen Snowden, PT, DPT (20:32):
Right,
Amanda Newman (20:33):
Because you've been trained for so long, keep your core nice and tight for those arabesques and everything.
Karen Snowden, PT, DPT (20:40):
It's all about balance. We want balance.
Amanda Newman (20:42):
Yeah. So what are some of the exercises that are done during the pelvic floor physical therapy?
Karen Snowden, PT, DPT (20:48):
So again, it depends. Is there strength or is there a strength problem or a flexibility problem?
Amanda Newman (20:53):
Right.
Karen Snowden, PT, DPT (20:54):
If there's tension, we got to deal with that first. Because if we want to do any strength we're going to be more effective if we first address, let's get some mobility, the muscles. We can get some mobility just by having people breathing and doing breathing exercises. And the diaphragm and the pelvic floor muscles are connected neurologically. And so if we can get some deep breaths that helps to relax the pelvic floor. There's some stretches. We can have people stretching their groin and hips, and they're all helpful. They're the muscles that are next door, they're the neighbors. We need them to be flexible. But the truth is it's really hard to get a stretch of the pelvic floor muscle. Sometimes it requires manual therapy. Similar to if you had a back strain or pain or tightness of your neck muscle, you might get your partner to press on it, you might see a massage therapist.
(21:42):
We can do the same thing internally, and we're trained to do that. Of course, we use lubricant to make it comfortable and a glove, and we allow people to practice relaxing. And again, we're not inducing pain, we're just trying to relieve that tension. So a lot of times internal manual therapy is an option and highly effective. We can teach people how to do it at home, as well.
Amanda Newman (22:06):
Oh, wow.
Karen Snowden, PT, DPT (22:07):
Also, if you have a tense muscle, if you had a tense trapezius, you might also decide to exercise it. Maybe I'll stretch it, maybe I'll go to the gym and work it out. And a couple things can happen. You could leave the gym and think, wow, I feel more flexible. That was great. Or wow, I fatigued that muscle so much I feel like Jell-O. Or a third thing is you leave the gym and you say, dang, I made it worse. It's more tense now. So for somebody that maybe is exercising or doing Kegels or Kegels at home and trying to strengthen their muscles, if they're getting pain or they're noticing that things are not emptying as much, it could be that they're actually getting too much tension in their muscles.
Amanda Newman (22:50):
OK.
Karen Snowden, PT, DPT (22:50):
And that can cause problems. That might be why they go see the doctor and say, hey, when I sit on the toilet, my stream is very weak or it's interrupted, or I have to wait 30 seconds or a minute or five minutes before something starts to empty. Or I'm now constipated and I wasn't before. Or I notice with vaginal penetration, whether it's a GYN exam or intercourse, that's not comfortable and it used to be. Or are younger women coming in that are trying to put a tampon in? That could be a reason maybe there's tension. So to review that, we can use the breath, how people are using their body. We can talk about how do we reduce and manage stress. Maybe it also involves seeing a counselor because we're stressed out about something. Our society right now is quite stressful. So it's natural for us to understand that any muscle in our body could be tight, including the pelvic floor. So when you're thinking of pelvic floor muscles, it's like any muscles in the body.
Amanda Newman (23:51):
I think they just get forgotten about sometimes.
Karen Snowden, PT, DPT (23:55):
Well, the truth is we don't even know they're there. We don't need to know they're there if things are functioning fine. And then when they're not, such as, I just had a baby and there's weakness, or now it hurts to have sex. Is it because I had some trauma? Or is it actually because I'm breastfeeding? They talk about genitourinary syndrome of menopause. Postpartum when you're breastfeeding, you can have what's called genitourinary syndrome of lactation. And that means that because of your hormone levels, your body, its main focus is to feed the baby. You have less estrogen in the tissues. It can be uncomfortable. And so to know that that's temporary, you might need to use lubricant when you didn't need to do that before. So there's a lot of reasons why. We talked about the big stages of life, how we can have changes, and in menopause, there's the genitourinary syndrome of menopause. But there's also musculoskeletal syndrome of menopause where our muscles are impacted throughout our body because we have less estrogen. So these are the things that we can help with in physical therapy. Again, we're a piece of the pie. Our piece of the pie is to look at the muscles and the bones and are things working the way they should be.
Nabila Noor, MD (25:08):
Many patients, and in their mind, they simplify pelvic floor physical therapy to just Kegel exercises. And I think that's a false narrative. Yes, Kegel has its role, but that's not everything. And I think that's why, so, sometimes patients will come to me, I'm seeing them for the first visit and they're like, I've been doing Kegels all my life. And after I do an assessment, I realize they should be doing the opposite. They should be doing pelvic floor relaxation exercises, what we call myofascial release. And so it's very important that if you've been doing something for a long time and not noticing the improvement or things are not getting better, get yourself evaluated, get a good pelvic exam preferably by urogynecologist. And then make sure you're giving yourself the right treatment because you could be doing something for years when instead of helping you, it's actually hurting you more.
Amanda Newman (25:57):
And I think that's one of the most common things women think of when they think of pelvic floor physical therapy. That's like the go-to exercise that I've been hearing about that since I was younger.
Nabila Noor, MD (26:07):
Yeah, exactly. And yes, Kegel is good, but it's not the solution to all your pelvic health issues. I think that's the point that we both want to stress.
Karen Snowden, PT, DPT (26:15):
It's not for everyone depending on what's going on with your body.
Amanda Newman (26:20):
Could you also talk about how important it is to be proactive with your pelvic floor health? Are there ways that you can strengthen your pelvic floor at home?
Karen Snowden, PT, DPT (26:29):
Oh, yes. Well, the first thing to know is how do you even contract the muscles? There's a bunch of muscles. They all work together. They're helping to support the organs. And when we contract, just as if we were going to contract our biceps, you want to think of kind of this squeezing and lifting, because when the muscles contract, they kind of come together and lift inward. So your brain can think of a couple things. In the back at the anus, the backside, you can think of, I want to tighten as if I don't want to pass gas. And the research shows when women remember to tighten in the back, they're going to get stronger faster. And a lot of women don't even realize that's a piece of the pie when they're doing their Kegel or Kegel exercise. The other thing is you want to think in the front as if you want to stop the flow of urine. You would squeeze as if you were stopping the flow of urine.
(27:19):
And if you have a vagina, same thing, you're going to squeeze and lift inwards. So the point being the muscles are a sling. Front to back is like a hammock, starts at the pubic bone, goes underneath and slings back to the tailbone, and also kind of slings out to the side to our sitz bones. It's all muscles underneath. And what you want to do is bring all those muscles together, squeeze and lift. So it's like an inward-upward motion. The back, the front, the middle get everything to meet and lift inward. It's very subtle. Now, if you try really, really hard, you're going to get body movement. And that just means other muscles are trying to help out.
Amanda Newman (27:54):
I feel like I'm trying to do it right now while you're explaining it.
Karen Snowden, PT, DPT (27:56):
If you're lifting off your seat, you're using your buttock muscles.
Nabila Noor, MD (28:00):
You're not alone, because that's what a lot of people will do. And that's why I'll tell patients when you're starting, do it when you're laying down. Because that way if you're using your glutes and your hips too tighten, you'll actually feel that your hips are getting up. Because if your hips are getting up from the floor, that means you're using your hips and doing bridge. That's not necessarily working your pelvic floor muscles. Similarly, when your abs, because a lot of the times we'll use our ab muscles to tighten. So I'll tell patients, put a hand on your belly, and if you feel like that thing is rock hard, you're probably using your belly muscles and not necessarily your pelvic floor muscles. Once you get used to it, you could be doing, like you said, right now, nobody has to know. I mean, I tell my patients ...
Karen Snowden, PT, DPT (28:38):
I've been doing them for the last hour.
Nabila Noor, MD (28:39):
Yeah, I'll do it in the OR as I'm operating.
Amanda Newman (28:41):
Of course you have.
Nabila Noor, MD (28:42):
But that's the thing though, when you're starting, the idea is to make sure to get the form right. Think about when you're learning how to do any skill, when you're learning how to cook, when you're learning how to bicycle. Once you get the basics done, then you can start the repetition. Then you can start doing it anywhere and everywhere. But again, I will stress it. So important to make sure you're doing it right. And if you're not sure if you're doing it right, don't be shy to get the help that you need.
Karen Snowden, PT, DPT (29:09):
Yeah, we could check. That's what we do. We give feedback so that you can know. We can give feedback verbally. We can do it by palpation. We can do it with biofeedback where we put little electrodes on the outside of the body
(29:24):
And people can look at a screen on the wall and they can actually, when they contract their muscles, see the bar go up, or however we have it set up, that they're actually doing that, as well as the relaxation. Maybe the person that we're trying to permit relaxation with, we're saying, now relax. Think of the beach. Do your breathing, relax your body, drop your shoulder. And you can see how that influences the pelvic floor. So we can also use biofeedback. But the advantage to being able to do it correctly where you're isolating the pelvic floor muscles is that actually you don't have to work as hard. If you're not isolating those muscles, you're exercising, but it's just not going to help the problem because it's a lot of other muscles, the common muscles as you've mentioned, or the abdominals and the gluteals. Other ones are the hip abductors where you're squeezing your ... thighs together.
(30:18):
So you want to keep your body quiet. And the key point, that's why I said, hey, I've been doing them for an hour, is you should be able to do them anywhere, any place in any position. Your body's not moving, and unless you're moving your eyebrows up and down to help lift, nobody's going to know you're doing them. And then lastly, people want to know, how many do I do? How long do I hold it for? And the truth is we have different muscle fibers throughout our body, and some are for endurance, some are for speed, and we need to have endurance fiber. The pelvic floor muscles have both fibers as well, and we need to train both usually, depending on the condition. But if we want to do just a general exercise, if women are trying this at home, they could do some hold contractions where, how long can I hold it for? I think that's about seven seconds. OK, fine. Let's work with that. I'm going to try seven seconds and let me see if I can do 10 of them. But the key point is every time you contract, part of the repetition is to completely let go.
Nabila Noor, MD (31:21):
I'll tell patients on that repetition and just to make it easy, start with 15 sets, right? Maybe do 15 sets, two to three times. I prefer three times. Then it's a little bit more consistent.
(31:32):
So I'll tell them in the morning before getting out of bed, do a few 15. Then at night before you go to bed, do 15, and sometime during the day find a time and do it. The idea is to get yourself into a routine so you're doing it consistently. I think talking about prevention, I also want to say, what are some things that you can do to improve your pelvic floor function. In addition to doing Kegel exercises, also focus on avoiding risk factors, and I think sometimes we forget that because that's a very easy thing to do. Well, I guess easier said than done. But those are certain things that are under your control. So what do I mean by that? Things like constipation, chronic cough, losing weight, because obesity is a risk factor. Think about anything that puts a lot of pressure on your pelvic floor, over time weakens it.
(32:22):
So if you're somebody who's chronically constipated, work on your fibers: 30 to 35 grams of fibers is a must. And trust me, no matter how healthy your diet is, just fruits and vegetables sometimes don't cut it. So get your fiber supplements, get your hydration. If needed, go see a GI specialist so that they can come up with a regimen that works for you. If you're somebody who has chronic cough, whether it be because you have, you're a smoker or you have bronchitis, you have COPD, asthma, try to manage those symptoms. Because that chronic cough, we don't think about it, but over years and years, it puts a lot of pressure on your pelvic floor. Being overweight, again, here in the Lehigh Valley we have some amazing weight-loss specialists, and not everything has to be surgical. There are some amazing studies that show even if you lose at least 8 percent of your current body weight – which could just be with exercise and just conscious eating – that can improve your pelvic floor symptoms by 50 percent.
(33:20):
Things like urinary incontinence. So I'm not suggesting you go get a major bypass surgery if that's not what you want, but even just making healthy choices can help improve your symptoms. But for my menopausal patients or perimenopausal patients who are going through hormonal changes, talk to a specialist. Get yourself some vaginal estrogen cream. I mean, I cannot tell you how underused vaginal estrogen is. I mean, honestly, for all my patients that leave my office, unless there is a direct reason why I cannot give it to them – because maybe they have active cancer, God forbid – they're getting a prescription of vaginal estrogen. And it's not the same as taking hormone replacement therapy. They're two very different things. They're two very different. They do help women in that area or in that era of menopause, but they do very different things. So for your pelvic floor issues, vaginal estrogen is truly a non-negotiable and it's so easy. But those are some things that you can also do along with the exercises, along with all the things that we talk about, that can really help you take care of that pelvic floor
Amanda Newman (34:25):
So much fantastic information.
Karen Snowden, PT, DPT (34:27):
A lot of times it's the combination of things, too, that helps. So we're really trying to figure out, we have all these options. Oh, let's start here with these two or these three, because that combination, that helps. I do want to add one other thing. When you're doing pelvic floor exercises, because a lot of people, it's so hard to not do this. You do not want to hold your breath.
Amanda Newman (34:48):
OK. Don't hold your breath.
Karen Snowden, PT, DPT (34:49):
So if you're holding your breath, a good way to do is first inhale, and then as you contract your pelvic floor muscles or while you're contracting, you want to exhale. It's just like in the gym when you're contracting the muscles or doing the effort, letter E, exhale while performing the effort or the exertion.
Amanda Newman (35:07):
OK, that breath work's important.
Karen Snowden, PT, DPT (35:08):
You cannot hold your breath because if you're holding your breath, that's putting pressure downward, and what you're trying to do is squeeze and lift inward. You got a battle going on in there.
Amanda Newman (35:18):
Yeah. Well, to wrap up today's episode, which has been absolutely wonderful, what's the most important advice you'd like women to know about their pelvic floor and bladder health?
Karen Snowden, PT, DPT (35:32):
I would like to encourage every woman. I mean, you can see we're quite passionate about this.
Amanda Newman (35:38):
Yes, and I love it.
Karen Snowden, PT, DPT (35:39):
The information that we have, and this is the tip of the iceberg. We want other women to know, because it's so valuable, we could be preventing issues just by having this information. Or if we have issues, they're all treatable. It's all treatable. It's just knowing that there are a lot of options and you shouldn't feel uncomfortable with that. If somebody has pain of any type or if anyone has bleeding that is not related to menstruation, that's not normal. And so don't be like, ah, just kind of see what happens here. That's significant. It doesn't mean it's a serious thing. It could be, but it doesn't mean that. It just means that is completely not normal. There's nothing you should be doing, whether it's physical therapy or any kind of treatment that would cause bleeding or pain. So that would be my take-home point.
Nabila Noor, MD (36:29):
I think what I would say is that as women, we are probably just as guilty. We're always the caregiver and we always prioritize ourselves last, especially when it comes to pelvic floor issues, because, like I mentioned before, these are all quality of life. And so oftentimes in our mind we don't prioritize them. We often say, oh, it's not a big deal. It's not cancer, it's not heart problem. I'm not dying from it. But I think what I do see in my profession is yes, it's not causing them immediate harm, but over time women give up things that they used to love. It chips away at your life. Maybe you used to love taking your kids out to play and now you don't because you're worried if you're jumping on the trampoline, you're going to leak. Maybe you used to like hanging out with your friends and going on road trips, but now you don't because you're worried what if I don't find a bathroom and I'm going to have an accident? And you don't want to burden anybody. You don't want to be intimate with your partner anymore because you're worried that you're going to have an accident. It really chips away at that quality of life.
(37:27):
I see patients being miserable, and yet they have somehow convinced themselves that these are normal. This is a normal part of aging, and I'm OK. I'm OK. And when I tell them and when we have these discussions and when I bring it out to them like that, it's almost like you see the breakdown happening. They're like, I can't believe I suffered with this for 30 years. I mean, one of my favorite things is when I see my patients in the postop period or maybe they've gone through a treatment and they're just so happy and they're like, I can't believe I waited this long and I suffered all this time. I think I really want to emphasize for all our viewers that sometimes all the things we talked about, I mean we talk about it very easily, but these are embarrassing things.
(38:21):
And sometimes women are not comfortable talking about it. Definitely not to their loved ones, definitely not to their partners, sometimes not even to their primary care doctors because there's a whole list of things they have to talk about. You're talking about your diabetes. You're talking about your blood pressure. You're talking about so many things. Leaking urine or prolapse or a UTI or pain just doesn't seem that important. But if there's one thing I want to emphasize is that these are absolutely important. These are very treatable things, just like Karen mentioned. And there's really no reason that in 2025 in a place like the Lehigh Valley where we have access to so many amazing resources, that you should just live without treatment.
Amanda Newman (39:03):
This has been such an empowering and hopeful episode, and I just appreciate you both so much being here and just sharing all of this incredible information with our listeners. It's just been wonderful having you here today.
Karen Snowden, PT, DPT (39:15):
Thank you for having us.
Amanda Newman (39:17):
To learn more health tips, visit LVHN.org/healthyyou. Remember to leave us a review, subscribe or follow The Healthiest You wherever you get your podcasts, so you never miss an episode. And remember, be safe, be smart and be the healthiest you.
