Amanda Newman (00:00):
How can you strengthen your pelvic floor at home? What can you do about bladder leaks? Is pelvic floor physical therapy right for you? All that and more on this episode of The Healthiest You.
Amanda Newman (00:13):
That frequent urge to use the restroom or suffering from bladder leaks or pelvic pain are problems that can affect your everyday life. Twenty-four percent of women have at least one or more pelvic floor disorders. While it’s uncomfortable to talk about, sharing what’s going on with your doctor is that first step toward healing. Welcome back to another episode of The Healthiest You podcast, where we focus on women’s health and wellness. I’m your host, Amanda Newman. Whether you’re on your way to work or enjoying a cup of coffee, take this time to focus on your health.
Amanda Newman (00:50):
Here to talk about pelvic floor health, bladder health and pelvic floor physical therapy is urogynecologist Dr. Nabila Noor, and Karen Snowden, who has a doctorate in physical therapy and is a rehabilitation clinical specialist with Lehigh Valley Health Network, part of Jefferson Health. Dr. Noor and Karen, welcome to the show.
Karen Snowden, PT, DPT (01:12):
Thanks for having us.
Nabila Noor, MD (01:13):
Yeah, thank you for having us. Super excited and looking forward to our conversation.
Amanda Newman (01:17):
So let’s get started with what should women know about their pelvic floor? Why is it important?
Karen Snowden, PT, DPT (01:23):
The pelvic floor muscles are a group of muscles and tissue that work together to help provide support to the pelvic organs, and they help with all function regarding bladder, bowel and sexual function. So when we are thinking about muscle structures to provide support, any muscles in the body, there’s really two categories that we’re thinking of. There’s strength and there’s flexibility. So muscles can be strong or weak, and muscles can also be tight or flexible. Ideally, we want all the muscles in our body to be strong and flexible. So if the pelvic floor muscles are lacking any of that, maybe they’re not real strong and there’s some weakness – or maybe there’s tension instead of flexibility, that can cause issues. And when we have issues with our pelvic floor, we refer to that as pelvic floor dysfunction.
Nabila Noor, MD (02:19):
Yeah, I think I agree with everything Karen said. One of the things that I tell my patients also is think of the pelvic floor as kind of the floor for your torso. It’s kind of supporting all your pelvic organs, and there are lots of organs in that space, right? I mean, if you think about the uterus, which is the organ that holds babies or for when we menstruate, that’s where the blood comes out from. You have the bladder, which is the organ that’s storing our urine. You have the rectum and the intestines. So all these organs are supported by your pelvic floor. And, as Karen mentioned, the pelvic floor is important for all these bodily functions because all these organs need the support of the pelvic floor. So it needs to relax appropriately. It needs to tighten appropriately. Because we need that relaxation and that tightening to be able to empty our bladder, close our bladder, to be able to empty our bowels, close our bowels. And also, like Karen mentioned, during sexual function and even during childbirth, right? I mean the pelvic floor plays a very important role when we’re talking about the laboring process. And if you’re not engaging your pelvic floor correctly or taking care of it correctly afterward, there are lots of bad things that can happen. And I’m sure we’re going to be talking about a lot of them.
Amanda Newman (03:31):
I am sure. Well, that was a great explanation. So when do women typically experience the most changes to their pelvic floor?
Nabila Noor, MD (03:39):
Yes, so there are many reasons or many factors. Many risk factors as we talk about. But when we talk about timing in a woman’s life, so two life-changing events that happen. One of them, which we alluded to a little bit, is pregnancy. So pregnancy and childbirth, so what we call the postpartum period. And also as women go through menopause. So perimenopause, menopause, which is when women stop having their menses, there are a lot of hormonal changes that happen. And similarly in pregnancy too, there are a lot of hormonal changes that’s happening. There’s a lot of changes, because think about the whole process of laboring, the whole process of delivery. There’s a lot of stretching, there’s a lot of tear and wear. There are damages to muscles, to nerves. There’s a lot of things that can be affected, which over time as years pass, the cumulative effect of it can be affecting your pelvic floor muscles in the long run.
Amanda Newman (04:34):
So the two life-changing events would be pregnancy and childbirth or during menopause?
Nabila Noor, MD (04:40):
Yes, exactly.
Karen Snowden, PT, DPT (04:42):
And the great thing is with knowledge and information and getting the right people on your team, a lot of times you can prevent some of the trauma just by understanding how to use your body properly and different strategies – whether it’s in childbirth, different positioning, how to use your breath. And also in menopause, ways to help your pelvic floor be healthy. So we can be proactive to mitigate issues of pelvic floor dysfunction. Or if pelvic floor dysfunction occurs, which sometimes is out of our control, we have help for everyone.
Nabila Noor, MD (05:17):
Yeah, I think that’s a great point Karen makes. Because I think the last thing you want the audience to take from here is that, oh my God, two of the most important things in women’s lives are the ones that we should be terrified of most because we’re basically talking about damaging your pelvic floor. But to Karen’s point, that’s not the message that we want to give out. The message that we want to give out is that be aware of it, educate yourself, make yourself knowledgeable. I mean, we live in the Lehigh Valley where we have access to amazing physicians. We have access to amazing physical therapists and really experts in the field where together we can talk about these things as a preventative measure as opposed to just dealing with it as a matter of fact after, right? And so the whole point, in fact, to me, one of the greatest things that I hope comes out of these podcasts is that women kind of leave knowledgeable and excited that, look, I know what’s happening down there and I can be proactive about things and ways and lifestyle choices so that I don’t have to deal with the consequences as, say, my predecessors like my mother or my grandmothers did.
Amanda Newman (06:21):
I love that answer. I want them to know too that they’re not alone in this. And I think that’s one thing that we’re really shedding some light on today.
Karen Snowden, PT, DPT (06:29):
A lot of it is not rocket science. It’s just a matter of knowing, and we don’t know this stuff. We didn’t have this in health class.
Amanda Newman (06:34):
No, we did not.
Karen Snowden, PT, DPT (06:36):
Unless you’re in medicine, we wouldn’t expect someone to know this, but that’s what we’re here for. There’s a lot of people that we can get on the medical team, whoever’s appropriate for that particular person. So it’s always personalized care.
Amanda Newman (06:49):
How do you know if you have a pelvic floor disorder? What are the signs?
Nabila Noor, MD (06:55):
So I think when we talk about pelvic floor disorders, it’s a very broad term, right? Because there are multiple different things that can go under that umbrella. So specifically, there are few things that we often refer to. Number one being urinary leakage or what we call in our world urinary incontinence, where basically you’re not able to control urine. Now whether it’s because you’re laughing, coughing, sneezing and leaking urine, or for a lot of women it could be because when they have that urge to go, they really can’t control it. Similarly, you can have something called fecal incontinence where you’re not able to control your stool. For a lot of women, it could be gas; they just can’t control gas. There’s also something called pelvic organ prolapse where essentially your pelvic organs, all the things we talked about, whether it be the uterus, the bowels, the bladder, are essentially pushing through the vaginal canal.
Nabila Noor, MD (07:44):
And you can just imagine how debilitating and distraught it can be for patients. Some women have a lot of pain with intercourse. Which again, sometimes pain or intercourse can be uncomfortable, but if you’re in a pain perpetually, something is not right. So these are some of the common things that we hear about in our world when women come to us with pelvic floor dysfunction. In addition, there are other things like recurrent urinary tract infection, where some women are getting infections more than two in a matter of six months or more than three in a matter of year. There could be blood in the urine. They could have bladder pain, which is not an infection. So there’s a lot of other nuances as well. But the big categories, I would say, urinary leakage, bowel leakage and probably pelvic organ prolapse and pelvic pain. Would you say, Karen?
Karen Snowden, PT, DPT (08:34):
Yeah. I mean sometimes it’s really simple things that people actually don’t realize is abnormal, such as I always have to run to the bathroom. I don’t have much time. When I gotta go, I gotta go, I can’t wait. Or I’m always running to the bathroom, where I know where all the bathrooms are in town. … And a lot of people in this region, we go to New York City or to Broadway shows and we all know, wow, there are no bathrooms between here and getting to New York City, what am I supposed to do? So a lot of times that can really interfere with quality of life and people’s ability to go out and be social and to feel comfortable with that. And it is good to know what are the norms, and are there things I can do. And what people don’t realize, the body is very capable of being retrained. And so we can help with urgency, frequency or if somebody’s going frequently at night, we call that nocturia.
Karen Snowden, PT, DPT (09:29):
And that really interferes with quality of sleep. We all know one of the most important things for all of us to be healthy, we need to have sleep. We need rest and time to recuperate and get ready for the next day. And when we don’t, that next day is kind of miserable. We’re just too tired. But also just from a longevity standpoint, it really wears on our organs. So sleep is critical, and if somebody’s getting up three, four, five times a night, that person’s not getting quality sleep, and they’ll tell you, I am tired.
Karen Snowden, PT, DPT (09:58):
So we can help even with things that maybe don’t even seem as pronounced or drastic. You had mentioned about even passing gas. I had a woman one time that she couldn’t visit her grandchildren because she was just mortified. If I go travel there and I pass gas, I will not be able to deal with that. And so sometimes that can be a sign of muscle weakness. And we did some muscle strengthening, and she gained control and she’s off visiting her grandchildren now. So sometimes it’s really obvious where I have pain or I have tailbone pain, even things like that or burning or something doesn’t feel right down there. Sometimes it’s leakage, whether it’s bowel or bladder. But sometimes it’s literally I feel like I always have to go to the bathroom. And if I go to the theater and I’m in the middle of the row, that’s going to cause me a lot of anxiety.
Amanda Newman (10:55):
I literally make sure when my husband and I go to the movie theater that we get an end seat and that there’s a bathroom nearby. And I feel so paralyzed by it sometimes. And it’s frustrating.
Karen Snowden, PT, DPT (11:06):
Exactly. Or a plane – oh my gosh, I got the middle the seat or the window seat. How am I going to deal with this. And think of doing that for years and years and years. That could really interfere with quality of life. So one of the comments I hear a lot from patients coming in is, you’re kidding me. Why did someone not tell me this 25 years ago? Because literally what you just told me or what you told me last session, I’m seeing it’s working, and I’m not rushing to the bathroom now.
Nabila Noor, MD (11:36):
Yeah, that’s amazing. And I was just going to add something in a similar vein, is that a lot of these things, they don’t just happen all of a sudden. A lot of the symptoms maybe started, or a lot of the insults, started maybe when women were young in their 20s, 30s when they were pregnant or they were just recently postpartum. You leak a little bit of urine here and there, you go to your doctor or maybe your family members, they tell you it’s normal. A lot of women deliver and they have a little bit of leakage, so you don’t think much about it. And then fast forward 10 years, now you’re probably having two, three kids, and it’s gotten worse. And then you get busy because life gets in the way. Fast forward 10, 20 more years, now you’re in menopause and now you’re worsening in symptoms.
Nabila Noor, MD (12:18):
So by the time a patient will come see me in my office, they have probably been dealing with this for 20, 30 years thinking this is just a normal part of life, and we’ll tell you, there’s nothing normal about anything we’re talking about, right? Whether it’s leaking urine, leaking stool, pelvic organ prolapse, a lot of these things are common, especially like we talked about in the pregnancy or the postpartum period, in the menopause era of a woman’s life. But it’s never normal, and there are lots of help. There are lots of treatment options, and not every treatment option is surgery. I think when people come see me, because my title says I’m a surgeon, they automatically assume that I’m going to offer them surgery. A lot of the times, maybe their primary care doctor or their OB-GYN referred them to me and they don’t even make the appointment because in their mind they’re like, I don’t want surgery. And I think we’re here to tell you that there’s so many nonsurgical treatment options that can be equally effective for the right patient that I think we will be doing injustice to women if the message they get is the only way to treat any of these pelvic floor issues is through surgery. Surgeries are amazing, and we have some amazing surgeries for the right patient, but it’s not for everybody.
Amanda Newman (13:28):
I’m feeling so hopeful already because a lot of the things you’ve mentioned, I struggle with. Like waking up in the middle of the night to use the bathroom or always being on the search for a bathroom when we’re out and about. So I feel like I need to come see you.
Nabila Noor, MD (13:42):
Maybe you do. And you know to your point, a lot of the times that – I’m sure Karen sees it too – patients will come to see me, we talk about all the options, and I’ll tell them you don’t need anything. Just we’ll talk about how to mitigate some of the risk factors. How to make some simple lifestyle choices that can help some of their problems. How to do some behavioral modification, maybe refer them to pelvic floor PT. I mean, I love sending patients to my physical therapists. They’re amazing. I joke, I mean honestly, if every patient from my office should leave with a prescription to a pelvic floor physical therapist, not just any therapist, a pelvic floor physical therapist, because there’s a difference. And maybe vaginal estrogen for the right patient, like the menopausal patient. Because there’s so much that you can prevent with just two of these simple therapies that we don’t even have to go into the surgery phase necessarily.
Karen Snowden, PT, DPT (14:36):
And between, whether it’s physical therapy with a pelvic health physical therapist speaking with the physician, I think what a lot of people really appreciate when they come to see us is hearing the options. We’re not pushing an agenda.
Karen Snowden, PT, DPT (14:51):
There’s a lot of options. These are the options. I know that on both sides, sometimes I’ll see somebody and I may refer over and vice versa, whoever sees them first, there’s a lot of options. And what’s right for you is different for someone else. Somebody else, surgery is absolutely the correct option. Many, many people come and say, oh, I’m thinking about surgery. I really don’t want to have surgery. I’m not sure what to do. And I say, well, I think you’re in the right place because this is conservative. It’s easy. It’s pain free. It gives you time to consider. And in the meantime, we’re going to help get your muscles primed and healthy. So whether or not you choose to have surgery, you’re going to have a better result. So in other words, don’t feel rushed to make a decision. Let’s see where we go. You can keep talking with us. You’re not going to feel pressure from us. We’re going to give you the current evidence, this is what we know works best. But it’s your body and we want what’s best for you. You know your body, you know your lifestyle, you know what it is that you’re looking for.
Amanda Newman (15:54):
I love that we’re talking about both options because I feel like that was a really common question I got from a lot of listeners: Is what can I do about these issues without surgery?
Nabila Noor, MD (16:03):
One of the beauty of our field is we deal with a lot of quality-of-life issues. It’s not cancer, it’s not heart failure where you need to do a certain kind of treatment. And what I mean by that is the definition of quality of life is very different. Like Karen mentioned, what may be a good quality of life for me may not be your definition of quality of life. I have many patients who have leakage and they’re wearing pads, but they don’t want to go anywhere near the operating room. And then I have many young patients who are petrified that they even have to wear a little pantyliner because embarrassing to them, they’re embarrassed to be intimate with their partners. So again, a lot of my job, and same thing for Karen I’m sure, it’s to get to know the patient and really try to understand what is the best treatment option that can help this patient achieve whatever it is that they’re trying to achieve.
Nabila Noor, MD (16:54):
And that definition can be very different. I’ll tell you a funny story. I mean, as a surgeon, I get this question all the time. Patients will be like, well, if I was your mother, what treatment would you recommend to me? And it’s a fair question. But the difficulty of answering that question is, it’s such a subjective answer. My mom is petrified of surgery, so she may not be … the best surgical candidate because that gives her a lot of anxiety. On the other hand, if it was me, I have a busy job, and as much as I would love to be doing pelvic floor PT, I have to be realistic that, OK, what is the outcome that I’m hoping to get? And is this the fastest way for me to get to that outcome? And I think we have to be honest. And for us as their health care team for the patient is to guide you. Not necessarily make the decision for you, but we’ll give you all the tools so you can make the best decision for yourself.
Amanda Newman (17:45):
And as we’ve been talking about, many women suffer from that frequent urge to urinate and some experience bladder leaks. What exactly causes that urgency and loss of control? And are there ways to treat overactive bladder and urinary incontinence without surgery?
Nabila Noor, MD (18:03):
So when we talk about overactive bladder, right, so it’s a syndrome. So it’s a collection of multiple symptoms. One thing is urinary urgency, which is that sudden urge when you have to go, you can’t control it. Which means that if you don’t have a bathroom, you’re going to have an accident. Or at least that’s how patients describe it. There’s something called urinary frequency, which means they’re going more than often. So the question that comes up is, well, what is normal voiding and how do you know if I’m going more often or not? And there’s no standard answer, but I think on average going about seven times during the day, maybe once when you’re sleeping, is considered normal. So if you’re going more than that and … not because you’re drinking a lot of water or caffeine, then maybe something to think about.
Nabila Noor, MD (18:48):
And then also leakage associated with that, meaning when you have the urgency, you can’t control it. You have leakage. So that’s known as urgency, urinary incontinence and nocturia, which is the nighttime urination where literally patients will say that I’m waking up multiple times at night to go to the bathroom. So all these symptoms are a combination of any of these symptoms together. We call it overactive bladder. So then, well, why does it happen? There are many factors that cause overactive bladder. The first one, which is probably the most confusing one for a lot of patients, it’s called idiopathic. Meaning we just don’t know why a lot of women develop these symptoms. Age is a risk factor because we do see it in a lot of women who are in their 60s and 70s. Menopause because there are hormonal changes that happen in our body that can cause some of these urinary symptoms.
Nabila Noor, MD (19:38):
We actually use a term for that. It’s called genitourinary syndrome of menopause – where women going through menopause will start noticing that they have a lot of urinary urgency, frequency and some of these symptoms we’re talking about. Any kind of back problems because all the nerves that control our bladder are coming from our back. So anybody with any kind of neurological issues, whether it be spinal cord issues or any kind of injury or lesions in the brain, that can be a reason. Diabetes is a big one. So uncontrolled diabetes can also make women go a lot. There are certain medications that we prescribe, the common one being some of the heart medications. So diuretics like Lasix, the water pill, you may have heard about that. So that will make you go as well. So these are some of the common reasons that we hear about why women go a lot.
Amanda Newman (20:26):
Are there any sort of exercises that can help with overactive bladder?
Karen Snowden, PT, DPT (20:31):
Yes. So as a pelvic health physical therapist, we are considering where our piece of the pie, if you will, is to think about the muscles and how they are contributing or not to the problem. So people come in and we assess the muscles of the abdomen, of the pelvis, of the hips, of the back and see are things functioning the way they should? And, for instance, the bladder is covered by a muscle, so we can influence that muscle. And so there are little tricks that we can do to change some behaviors. The way we think we can use our mind to think differently and take charge of the bladder. The one thing we do know about the bladder is it oftentimes is very easily trained if you know what to do. And it’s a matter of using your mind and connecting it. Or activating different reflexes in the body with simple exercises, simple thoughts and simple ways to, instead of rushing to the bathroom as we all do, because we’re like, I don’t want to have an accident. That actually is tensing the muscle around the bladder. So what you want to do is turn it off by calming the body instead of rushing to the bathroom.
Karen Snowden, PT, DPT (21:39):
A lot of people tell us that that first morning-void when their bladder is most full, they have to rush and they can’t make it. Well, how about if you don’t rush. Calmly walk, but you absolutely have to distract your mind also, and get to the bathroom. So in physical therapy, we can help also with that overactive bladder and that we can help people to learn different strategies, behavioral modification, ways to think about how they can use their body to mitigate the problem or have them not having an issue of urgency and leakage. And it’s amazing because it can really build confidence to say, wow, I can control the bladder. My bladder’s not going to control me. There’s also other modalities we use, sometimes electrical stimulation, things we can stimulate nerves to just get them to work better.
Nabila Noor, MD (22:28):
One thing to add to that too, cutting down on certain things that irritate the bladder, right? Again, these are simple lifestyle choices that patients can make. And we of course talk to them about it. There are certain dietary things that irritate our bladder muscle. Things like caffeine. For some people it could be spicy food, citrusy food, alcohol, carbonated beverages, dark chocolate believe it or not.
Amanda Newman (22:50):
Oh no, don’t tell me that.
Nabila Noor, MD (22:53):
You know, not for everybody, but for some people it can be an irritant. And what I tell patients is don’t go crazy. You still have to live your life. You still have to enjoy all the things. But if you are really suffering, where it’s affecting your quality of life, or maybe you’re going out, know that these are some things that could potentially irritate the bladder. Maybe that’s not the day to be trying all these things, or at least bringing it down a little bit.
Nabila Noor, MD (23:17):
Again, just managing your lifestyle choices, managing your behavior so you don’t kind of have to go into something more invasive with regards to treatment. And for a lot of women, I’ll tell you, this is all they need, is just this. They don’t need to do anything invasive. Not for everybody. But the flip side is also if these simple measures are not helping you, don’t not talk about the next steps because you’re worried about it because then … you’re doing yourself a disservice. Because there are lots of amazing treatment options, which, yes, may be surgical, but it’s not really surgery in the traditional term. They’re really minor procedures.
Amanda Newman (23:56):
Would it be helpful if you stop drinking prior to bedtime at a certain time?
Karen Snowden, PT, DPT (24:01):
We recommend usually give yourself two hours.
Karen Snowden, PT, DPT (24:06):
I encourage people to be hydrated. Many people are dehydrated, particularly the person with bladder issues. They think that if they withhold putting in urine, it sounds logical, right? I don’t put as much in, I won’t be leaking. And in fact, that can often make the problem worse. So we need to get people to get hydration, and that hydration should primarily occur in the morning and in the afternoon, certainly by dinner. But depending on your lifestyle, your work, when you’re eating dinner, those types of things, I usually say kind of hold off, particularly with caffeine. You want to avoid caffeine in the evening. But all fluids, take your pills, brush your teeth. We’re talking about, oh, I haven’t drank all day. I think I’ll get hydrated at night. That’s not a good idea. Another really important thing that people don’t recognize is that the bowels and the bladder communicate. They’re right next to each other. So for many people, they’re leaking urine because they’re constipated.
Amanda Newman (25:08):
Oh, wow.
Karen Snowden, PT, DPT (25:08):
So when they come in, we always ask a lot of questions to try to put all the pieces together, recognizing they came in for their bladder. But we will ask other questions because it helps understand how things are functioning together in the pelvis. So if somebody says, yes, I do have constipation, if we solve the constipation, oftentimes the bladder issue is gone. So it’s amazing. People don’t realize that. I think that’s a really a good tip for people to recognize that we need to manage our bowels with good fluid intake, movement, exercise that keeps things moving.
Amanda Newman (25:44):
Move and groove.
Karen Snowden, PT, DPT (25:45):
And high fiber. Those are kind of some key points. Of course, people have some GI issues, and so you need more specialized care. But when people come in, we are putting those pieces together. Dr. Noor is saying there’s a lot of things that go into this. Maybe they’re diabetic, maybe they’re taking a heart medication. And so we’re able to look at the big picture for the person in front of us and put those pieces together and make sense of it. And now that person knows how to care for themselves.
Nabila Noor, MD (26:12):
And I think that’s why it’s so important too, when you feel like, OK, look, I’ve been really suffering with these conditions for a long time, to make sure you seek out the help from a specialist. It can get confusing. For example, like my title, it’s a urogynecologist. There’s so many people who may not even know what a urogynecologist is, but it’s a whole specialty that was built because we realized that it’s a relatively new field. We became a board certification in 2013. So prior to that, there was no urogynecology. So actually women who were suffering with pelvic floor issues, it was basically like if they were lucky, they went to a gynecologist or maybe a urologist who had experience with it. And if they happened to be in a place where there wasn’t anybody available who could help them, they’re pretty much on their own.
Nabila Noor, MD (26:57):
So we realized that there’s a huge need for a whole group of specialists to be trained, whether it’s physicians, whether it’s pelvic floor physical therapists. And even within physical therapists, sometimes patients will say that, oh, I’m already going to a physical therapist for my back. It’s not the same thing. Just like when you have a heart problem, you go to a cardiologist. When you have a pelvic floor issue, you want to come to a urogynecologist. And if you’re seeing a physical therapist, preferably you want to go to a pelvic floor physical therapist who has a lot of experience. Because otherwise what happens is you’re just getting the generic treatment. And a lot of the times you may not see the improvement that you’re hoping to get. And it’s frustrating because then you just feel like, well, I just wasted my time.
Nabila Noor, MD (27:41):
And we see that. I have many patients who will tell me, oh, Dr. Noor, I saw somebody many, many years ago and I tried PT, it didn’t work. And I’ll ask them, OK, how long did you try? What was it? OK, maybe I went to one session. One session is just not enough. It’s like working out in the gym. If you want a six-pack ab, you have to be consistent and you have to be dedicated. And it takes time. Now, I’ll tell patients, give it at least three months, especially if you feel that you know what, surgery is not for me. I really want to go the nonsurgical route. I really want to give pelvic floor PT a try. Know, it’s going to take time. So patience is very, very important. And also consistency and doing it the right way.
Nabila Noor, MD (28:21):
And I think that’s where working with a pelvic floor physical therapist can be really helpful because oftentimes patients will tell me that, well, I can just do it by myself. Sure, you can, but understand, if you’re not doing it correctly, you’re just wasting your time. And there’s really no way for a lot of patients to know, because a lot of the pelvic floor muscles that we are talking about, or the pelvic floor exercises that we’re talking about, these are muscles that we don’t see because it’s inside our body. It’s not like my biceps or my abs that I’m seeing if it’s working right or not. It’s internal. So unless you are very knowledgeable about, oh, OK, how to look for those signs, or you’re working with somebody who can guide you, it can be really difficult to understand whether you’re doing it correctly or not.
Amanda Newman (29:06):
So when you’re using the bathroom, are there things you may do that unknowingly weaken your pelvic floor, like blowing your nose, power peeing or peeing just in case?
Karen Snowden, PT, DPT (29:17):
Oh yes. That’s such a good question. So when we go to eliminate, whether it’s bowel or bladder, we should be relaxing the pelvic floor. So peeing and pooping are relatively passive. You should not be turning it into an athletic event. You should be relaxing. And women are notorious for this, because we’re always multitasking. We’re like, oh, I got five seconds, I’ll run in the bathroom. If you actually gave yourself an extra two or three seconds to let your muscles relax, things are going to come out on their own and you’re going to protect your pelvic floor. We’re doing a lot of protection strategies. If you are bearing down and straining to eliminate, whether it’s bowel or bladder, that can cause overpressure where the ligaments are getting weak, and over time it could set you up for pelvic organ prolapse. And that’s terrifying for women. Like, are my insides falling out? I mean, it’s terrifying. So yeah, we don’t want to hover. If we hover, and I understand, especially … we’re very germ-conscious now.
Karen Snowden, PT, DPT (30:28):
But if you’re hovering, remember they’re deep core muscles. Those pelvic floor muscles have to work hard to balance us and keep us steady so we don’t fall down. We’re tensing the muscles. And so it’s going to be a lot harder to empty the bladder and the bowels, and you might end up setting yourself up where you’re going more frequently because you peed, but you didn’t empty your bladder. Although we don’t empty a hundred percent, we empty mostly, and that’s what you want so you don’t have to return for several hours. You can be living life not based around the bathroom.
Amanda Newman (31:01):
Yeah, that would be nice.
Nabila Noor, MD (31:02):
I think one of the things to understand is that, and of course we don’t think about what happens to our body when you’re peeing, but maybe it’s helpful to take a step back and think about what’s happening. For us, as Karen mentioned, for females, men are different. So for females, all this urination – bowel movement maybe a little bit more so – but urination, definitely, it’s a passive process. It means we don’t have to create a lot of force to do it. So our bladder, remember we’re talking about the bladder, is like a balloon, so it can fill up slowly. So which means we can hold the urine for a long time. When it’s at its capacity, where the bladder muscle wall is really stretched out, that’s when it starts spasming. That’s what we call the detrusor muscle spasming, which sends signals to our brain being like, OK, your bladder is a little full, maybe time for you to go check out a bathroom.
Nabila Noor, MD (31:50):
If we’re close to a bathroom, that’s when we go to the bathroom. We have to relax our pelvic floor muscles, and then the bladder does its thing. It just squeezes, and the urethra opens up and the urine comes out. But that’s all because we are relaxing the pelvic floor muscles. All the things that you’re talking about, whether it’s hovering, whether it’s you’re going to the bathroom just in case: Your bladder is not full enough. You’re not allowing for a passive process to happen because when you’re hovering, you’re tightening those pelvic floor muscles. It’s not relaxing. I have many patients, maybe they’re sitting on the toilet, but they’re kind of tapping their toes. And I’ll tell patients, relax your foot on the floor. Take a deep breath and sit down on the commode. That is basically you relaxing your pelvic floor muscles, and then let the bladder just do its thing.
Nabila Noor, MD (32:38):
The bladder will generate the pressure and it will just happen. Now if it’s not happening like that, and you’re feeling that, oh my God, Dr. Noor, every time I go to the bathroom, I really have to strain to get the urine out, which I hear from a lot of patients. Then we have to worry about, well, why is that happening? Because that’s not normal. Is it happening because your bladder is not generating enough force? Is it happening because the outlet is blocked? Maybe you have something called pelvic organ prolapse, which is basically your pelvic organs pushing into the urethra and then blocking it. Or, God forbid, is there a tumor? Is there a mass? Is there cancer in that space? So that’s why when you come see me in the office and I’m taking the history, I’m putting all those things together because urination, I mean, it should be a normal process.
Nabila Noor, MD (33:25):
I mean, think about how kids do it. It’s not something that we have to consciously think about. Anytime that’s not happening, we have to think about why that’s the case. Maybe you had surgery done before. Because of the surgery, was there injury to the nerves? Was there some damage done? Was there a foreign material placed? Maybe you had some mesh surgery. So then those are some things that start coming up. And then we have to do some investigation. Don’t just assume that, oh, I’ve been doing this for many, many years and that’s just how I pee or how I urinate, because that’s not normal. And it may be that’s how you’ve done it, in which case we need to relearn how to properly void again. Because otherwise you can end up with voiding issues afterward.
Amanda Newman (34:07):
So for someone like myself … because I do pee very often, just in case. How can I stop breaking that habit? And I know I’m not the only woman out there that does this. … It’s like, OK, we’re going on a road trip. I don’t want to have to stop. Or we’re going to the movies, so I got to make sure that I use the bathroom just in case. How can I stop doing that?
Karen Snowden, PT, DPT (34:32):
We call that just-in-case voiding. That’s a no-no. And the reason being, I think of the bladder, almost like a gas tank. So the urine is filling, and if it’s hitting the side wall, the bladder here, it might send you a signal. Yeah, I could probably go. Or you know what? I don’t have to go, but because I’m walking by the bathroom right now, I think I’ll go just in case. Oh, next thing you know, half-hour later you’re heading out to the grocery store. I want to go. I don’t want to go in the public restroom. I’ll go again. Now you’re teaching the bladder to not do its job, which is just to store urine. And so it kind of, it’ll start signaling to you that when it’s only a quarter of the way full, it’ll now pick up the habit. So you’re actually training your bladder to go more frequently than it should.
Karen Snowden, PT, DPT (35:18):
So what you need to remind yourself is what is normal voiding frequency? It’s at least two hours, usually two to four, two to five hours. So if I am beyond two hours, I tell people, listen to your body. Your body’s going to send you the signals. If you need to pee, pee. If you need to poop, poop. If you don’t need to, don’t. Your body’s going to eliminate. Let the body. Sometimes we get very controlling. We try to control the situation. We’re controlling everything in our day. Let your body give you the signals when you need to empty. When you listen to the signals, that’s how you set up a healthy situation.
Karen Snowden, PT, DPT (35:54):
I wanted to comment. When I was listening to you, Dr. Noor, you were talking about relaxing the pelvic floor. It’s almost that sometimes we see people and help them in preparation for vaginal birth. And we say, hey, you don’t need to do the work with the pelvic floor muscles. What you need to do is not strain. You need to not fight the process of allowing the uterus to contract and deliver the baby. The baby is being delivered by uterine contractions. And if you’re scared or you’re tight or you’re trying to control things, you may be not helping that baby to come out and see the light.
Nabila Noor, MD (36:31):
That’s a great analogy. I didn’t actually think about that, but you’re absolutely right.
Karen Snowden, PT, DPT (36:35):
Yeah. When people come in and I try to help them prepare for a vaginal birth, I’ll say a couple of things. Number one, we want gravity to help you. So be upright as much as you can. Even if it means you’re in the bed, at least elevate the bed, the head of the bed. Any upright’s better than flat. Movement. Because when we’re moving, we’re helping the baby to find the way out. And so any movement helps. I don’t feel like moving. I feel like I just want to lay in this bed, or I want to sit in this chair. Fine, any movement. Movement. Doesn’t matter. Maybe you’re just swaying left and right or forward-backward. So all of those things help. Or maybe you’re laying on your side and you move 20 minutes later. But really what you’re doing is you’re allowing the muscles to relax. You’re trying to not get in the way of that. Let the body do what it knows to do, which is to deliver the baby. Or back to when we were talking about the bladder, same thing. And another really quick tip: You do not want to pee in the shower. And you know why? And it has nothing to do with cleanliness of the shower.
Karen Snowden, PT, DPT (37:43):
Because you will actually train your body: When I hear water, I should pee. And then you’ll be walking through the mall and the water fountain’s ahead, and all of a sudden you have to go to the bathroom. So you’re actually training yourself. Oh, water’s on. I think I’ll pee.
Amanda Newman (37:58):
All right, don’t pee in the shower.
Karen Snowden, PT, DPT (38:01):
Don’t pee in the shower.
Nabila Noor, MD (38:01):
What I will say, Amanda, to your point, there’s a whole terminology we use for what Karen is describing. We call that bladder retraining or bladder training. Which means you have been doing whatever you’ve been doing for years, whatever it may be. It can be unlearned, and you can relearn the right way of doing this. Don’t do it if you’re going for a road trip. Do it maybe on a day first when you’re at home. And then tell yourself if you’re already going every two hours, right? I tell my patients, start with that. See if you can push past when that urgency hits. See if you can just not give into that cue. Hold it for another half-an-hour. See what happens. Chances are nothing’s going to happen. And you have the urge and it will just subside. Distract yourself, get yourself busy, do something else. And usually the sensation goes away. Now, if you try it and you’re like, Dr. Noor, I tried it and I leaked. Different story, and there are other treatment options we can talk about. But for most people, that retraining, it’s just all us telling our brain, look, you can hold it. I mean, it sounds silly, but think about when we are potty training kids.
Nabila Noor, MD (39:03):
All of a sudden they’re like, oh, I can hold it. I don’t have to run to the bathroom. Whereas when you’re an infant, you’re like, as soon as the bladder senses there is some urine in there, it just comes right out. So in a very silly way, you’re almost relearning how to empty your bladder or how to hold your bladder again the correct way. And then slowly increase that time. And, like Karen said, if you can hold it for a good four hours without feeling that urgency, without feeling like if you don’t go right now, you’re going to leak. That’s pretty good. That’s pretty normal voiding.
Amanda Newman (39:35):
There’s so much more to talk about. So we’ll be continuing our conversation in Part Two of our podcast series. Thanks for joining us today, and stay tuned for Part Two coming soon.