In this episode, we speak with Dr. Lucinda Hayburn about the vagina, more specifically, the vaginal muscles and pelvic floor therapy. We talk about what pelvic floor therapy is, who would benefit from treatment, what a session looks like, how to find a PT who specializing in pelvic floor therapy, and the difference between pelvic floor therapy and Kegels.
For more information in Dr. Lucinda Hayburn, head to her website: https://lucindahayburnpt.com/
Women’s health locator: https://ptl.womenshealthapta.org/
TS: Today we will be talking about a topic that can be a little embarrassing for some women, the vagina, more specifically, the vaginal muscles and pelvic floor therapy. What is pelvic floor therapy?
LH: Pelvic floor therapy is a subset of physical therapy that focuses on the muscles, ligaments, joints and function of the pelvis. Because this part of the body is kind of a mysterious or veiled area with the general public, it’s often an area we don’t think about as being muscular. I think it’s really important to talk about what it actually does, and that it is hugely muscular and very treatable if something’s wrong. So in terms of pelvic floor, we’re thinking about all the muscles that attach onto the pelvic floor, including the abdominals, the back, the hips, the butt, the muscles around the vagina and the anus, and these muscles go to create four main systems. One is supportive, right? So, the muscles, go from the pubic bone to the tailbone and create a hammock for all your organs to sit on.
So, every time you’re standing, you get up from a chair, those muscles tighten up to bear the weight of those organs. They also have a core function. We usually think of our core as our abs or our butt, but our pelvic floor muscles are part of our core as well. So again, you’re running, you’re doing your squats, your pelvic floor is activating at the same time to help support the pelvis and move the body through space. They also have a sexual function. Your pelvic floor muscles create the tone in the vaginal canal. They create erection in both the penis, as well as the clitoris. They create orgasm. And lastly, they have a sphincteric function. So you have your sphincter that goes around your urethra, where the urine comes out and you have your sphincter that goes around the anus, and then you have your pelvic floor that wraps around these sphincters to provide extra support. If you want to urinate, they’re supposed to relax, and everything comes out. And when you don’t want to have an accident, the muscles should contract, ideally. So, nothing comes out. When we’re talking about pelvic therapy, we’re talking about any problem that could arise in any of these systems. It could be a sexual dysfunction, it could be incontinence, it could be pain with running or difficulty moving around after you’ve had a baby. It could be any of these things.
TS: I’m guessing if you’re peeing after you have a baby, you may need pelvic floor therapy.
LH: Exactly. Incontinence, constipation, fecal incontinence, pain, you know, sexual pain, pain, with intercourse. And again, you know, this, we often think about it more for women because we connect it to having babies, but men have a pelvic floor too, you know? So, this, this is not exclusive to women
TS: So how would we know that we have imbalance or some dysfunction in our pelvic floor? What are some symptoms that we would have?
LH: They could hit any one of those topics we talked about. The number one dysfunction that brings people in is stress urinary incontinence, which is when we have a little bit of urinary leakage with a heavy cough, sneeze or laughing, which is really common after childbirth. Because those muscles are a bit stretched and weakened, it can happen with anyone. We see it in runners and people who do weightlifting. We also see it in older people who have lost some strength in all muscles, but especially in the pelvic floor muscles. Urinary incontinence is one issue but, there’s also constipation, and pain with sex. People will say they used to be able to orgasm and now they can’t, or now orgasm is painful. Any problem from the knee to the belly button, pain or dysfunction in urinary bowel or bladder or with sex would fall under the umbrella of pelvic floor therapy.
TS: When you say constipation, what do you mean by that? How would I know that I’m not having constipation related to something that’s a bigger issue?
LH: That’s such an interesting question because, you know, as a physical therapist, I’m always thinking muscles like in terms of strength and treating the body from a very orthopedic standpoint. But within the pelvic floor, we really look at the person holistically. In terms of something like constipation, urinary or sexual function, we are also taking a broad look at their whole lifestyle. This includes things like diet and water intake. When someone comes to me and says they are constipated, that technically means they have three or less bowel movements a week, and/or that they have difficulty or pain with bowel movements. We assess the pelvic floor muscles from a physical standpoint to see how strong or not strong or how much control or lack of control you have over those muscles. We investigate diet at least in a superficial sense of, are you eating fiber? Do you drink water? What are your stress levels? Do you even know how to sit on a toilet to have a bowel movement? All these things that you think would be obvious are oftentimes not obvious to people.
TS: You mentioned that you are a physical therapist. When I think of a physical therapist, I’m thinking of, going to a gym with a lot of equipment and people. Because you’re a women’s health physical therapist, what does that look like when someone comes in and does pelvic floor therapy with you? It seems like something that would be so intimate. What does that environment look like?
LH: When someone comes into me to discuss their pelvic floor issues, as you mentioned, it can feel scary. It’s a private part of our body. Um, you know, it’s not a part of our body that we often want to share. If there’s a problem with it’s often associated with shame or vulnerability. A lot of association with trauma. I have a lot of trauma patients, so this can be an emotional type of physical therapy. The number one thing I can say is when you come in, you’re coming into a safe environment in a one-on-one private setting, in a room with someone who is there to listen to you and ask you a lot of questions. And we have a lot of time with our patients. I have 45 minutes of one on one time with my patients, and often it’s more like an hour or more. From the very first session, my goal is to really hear the story, to understand what’s been going on, you know, what have you tried? What have you not tried? What have you read? What have doctors told you and what tests have you had done? It’s really about understanding the picture because from that picture, I can learn so much. Without doing that physical assessment, just from hearing that story, I’ve learned so much. And usually patients tell me that it’s that first session where things really start to change for them. I provide education and a space where they can really get into the topics that they want to talk about. And so usually from very first session, they feel like things are going to change for them.
On the first session, we do a physical assessment, I’m looking to assess the joints and the muscles. This usually includes an assessment of the person’s lower back and hips and possibly other joints as well as a postural assessment where I am looking at the way the person moves through space. It also entails a pelvic floor exam, which is either going to be a vaginal or a rectal exam, depending on the sex of the person and the nature of their problem. Applying gentle pressure around their vaginal or rectal openings, and then an internal exam, similar that you might have at a gynecologist without the scary speculum, and then we would determine the treatment.
TS: Let’s go through the logistics of what it looks like when someone comes in. Would you lay down on a table or something like that? And then what would the treatments consists of? I’m guessing it would be different based on what you find, but what, how invasive would that be?
LH: Yeah. As you guessed, treatments are really varied between people and situations, and we use a variety of techniques that people are already familiar with. This includes things like stretching and core strengthening that you associate with physical therapy. We’re also going to be doing things like bladder and bowel re-training. I give people really horrible bladder diaries that they have to fill out. And, you know, I guarantee them that they’re going to be cursing my name for the next three days, as they can be horrible to fill out. We dive really deep into what their daily habits look like. We do a lot of talking about compromising. I’m not going to tell someone not to drink coffee, because I would never do that to anyone, but I might say, when you have a cup of coffee, can you also have a glass of water? Or can you throw in 10 pelvic floor contractions every time you’re standing, waiting at the bus or, you know, trying to make those lifestyle changes. There is usually some component of hands on work as well depending on what the issue is. If we’re talking about someone, for example, who has pain with intercourse that may be some internal or external work around the vagina or penis to help relax those muscles. The patient might also learn how to do some of those techniques themselves. One of our big goals in PT, in general, is making patients as independent from us as they can be so that when they’re done, they are confident that they have the skills to manage and prevent any further episodes. Pelvic therapy can be hands on work, strengthening, stretching, or talking about bowel and bladder habits. It has a lot of breathing techniques, stress management techniques, learning how to walk, sit, move, you know, wearing a better bra can be a big deal. You know, there’s, there’s a lot of very subtle things that go into the work.
TS: It’s so crazy. I feel like I hear that women in Europe have pelvic floor treatment after they have children. I never knew anything about this treatment until I actually had to go see a pelvic floor therapist.
LH: It’s really interesting because I was talking to a good friend of mine who lives in France and had her baby there and I had two children in the States. I was saying to her, you don’t know how lucky you are to live in France. She’s like, what are you talking about? No, we don’t have that. I was like, so wait after you had a baby, you didn’t automatically get pelvic floor therapy. And she was like, well of course we have that. I mean, of course we had six sessions of pelvic floor therapy, guaranteed for every woman, it was so obvious. Here, I have women who, have suffered for 30 years with their pelvic floor problems until they finally had a doctor who said, why don’t you try pelvic floor therapy? Or I have moms who’ve aggressively searched themselves and found it sooner but had to go through so many loopholes to get it.
- It’s so unfortunate that it’s hard to find that information. It’s horrible.
LH: A lot of it is education. Educating the medical field and the physicians to ask more questions. I know from having babies, and I love my OB GYN, but when I had my baby at the six- week mark, it was sort of like, okay, you’re good. It wasn’t. How are you feeling? How does sex feel? You know, all these questions that if you didn’t know better, you would just think, oh well, this is the way it is. I guess it’s always going to hurt to have sex now with my partner. I guess every time I sneeze, I’m going to pee on myself. And I’ve had women say that, Oh, I just thought that that was my new norm. Because how would you know, if your OB GYN, isn’t bringing it up to you, how do you know that it’s an issue? And I think that’s one place it is! We may need to be proactive and ask our OB GYN.
TS: For me, I asked my OB GYN maybe two years after I had my son. But again, I had to go through hoops. I had to ask my OB GYN and then she had to write me a prescription for treatment. It does sound like there was a little bit more complexity to getting treatment. I had a baby and I’m going to pee a little bit. I guess you would be able to tell me, is that my normal?
LH: No. I don’t want anyone peeing on themselves. Just blanket statement. I don’t care if you’re 85 or 25, you know what I mean? I really don’t feel like for the most part we should be peeing in our pants.
We’re relating this very much to pregnancy and postpartum issues, which is such an obvious topic but there’s so much more. And as, I was listening to your first podcast about your experience with your hip pain and having that hip fracture and, it reminded me as part of our advocacy that we do, especially within the OB GYN field, with our pregnant patients, you shouldn’t be walking around in extreme pain in pregnancy. If it’s a little bit harder to roll in bed and I get that it’s a little bit harder to get out of the chair and maybe you’re not running 10 miles a day or whatever, but you should feel for the most part able to distinguish what is quote unquote, normal pregnancy discomfort from carrying around a human in your belly versus my back really hurts. I’m not able to walk these couple of blocks. So yes, distinguishing what we should consider normal and acceptable versus when to seek help.
TS: And then like when someone starts therapy, they come to you, how long does therapy or treatment take? Is it a few weeks, a couple months? Is it like physical therapy with another muscle group where we just kind of have to keep doing it until we feel better, how does that work?
LH: So, most of my patients come in once a week for about 45 minutes to an hour. And that’s really for the initial period to create that treatment plan with the patient. And it’s really a plan that the patient creates with us because, as with all physical therapy, there’s no magic pill, we’re making you do the work. You have to be agreeable to the work we’re giving you to do. In those first four weeks, I generally like to see people once a week from there, if things are really moving forward. We might space those visits apart even more, maybe every two weeks, because a lot of what I’m offering, you know, is guidance through this journey. Sometimes we continue with that weekly session especially if there’s a lot of hands on work that needs to be done. I’m thinking particularly if maybe there’s scar tissue from a C-section or vaginal delivery or just postoperatively or maybe there’s a very long history of tightness or pain. That might facilitate wanting a more weekly basis therapy. If things are going well, four to six weeks of physical therapy. I would say more typically, however, it’s more like two to three months of weekly or every other week visits. If we’re talking about someone who’s had chronic pain, part of women’s health is working with issues like osteoporosis, fibromyalgia, chronic pain syndromes that could take longer, we’re talking maybe three to six months.
TS: How would I know if I needed to go see someone, how would I find someone that’s as specialized as you are? Is there a place where I would go and look for someone who specializes in pelvic floor therapy?
LH: I can provide that to you so that you can add to the show notes. But, there’s basically a women’s health locator. You type in your zip code or your city and whatever the problem is to find someone who’s really specialized in that area: https://ptl.womenshealthapta.org/
TS: One more thing before you go. Can you clarify that for us the difference between Kegels and Pelvic floor therapy?
LH: love that question because very often I think the idea is that, Oh, there’s something wrong with my vagina let me just do Kegels. And so, Kegels are just pelvic floor contraction. So, they’re the way that we contract our pelvic floor in. It’s also called the Kegel and they’re great for some people. But, for other people, they are the last thing you want to do. So, you know, it’s a tool in the toolbox that may or may not be appropriate to you. So if you have a real problem or something you consider a problem either with urinary leakage, constipation or sexual dysfunction, get the script, go to pelvic floor therapy, find out if pelvic floor contractions are right for you or not, because it may be actually the opposite of what you want to do. A lot of people, I ban Kegels from their vocabulary.