Amber and Katie from Hulst Jepsen Physical Therapy talk with Alyssa again about women’s health pelvic floor rehab with a focus on urinary incontinence. You can listen to this complete podcast episode on iTunes or SoundCloud.
Welcome. You’re listening to Ask the Doulas, a podcast where we talk to experts from all over the country about topics related to pregnancy, birth, postpartum, and early parenting. Let’s chat!
Alyssa: Hello again, Amanda and Katie! How are you?
Amanda: Good, thank you. Excited to talk more about the pelvic floor.
Alyssa: Yes! So if any of our listeners listened to their last podcast, we talked about what is pelvic floor physical therapy, and Amanda and Katie are physical therapists who specialize in women’s health at Hulst Jepson Physical Therapy, and today, we’re going to kind of specifically talk about urinary incontinence. So let’s dive into it! What is it?
Katie: So there’s two major types of urinary incontinence. You can have stress incontinence or urge incontinence, or you can have a mixture of both of them. So stress incontinence is having leaking with coughing, sneezing, laughing, jumping, running, really any impact or force into the pelvic floor that causes a leak. Urge incontinence is leaking with a strong urge to go to the bathroom, like hearing running water or trying to make it to the bathroom but not quite making it because you have an urge that’s just so strong. And like I said, you can also have a combination of those things, too. It’s not one or the other.
Amanda: Yeah, and it’s fascinating. With stress and urge and mixed; there’s the and/or mix – why does this happen is often the biggest question people will have. Like, why am I leaking? What’s going on? I mean, you have this bowl, and at the bottom of the bowl, is this set of muscles. And there’s more than just one that consists of the pelvic floor muscles. And they span from the front of your body to the back of the body, so kind of the hard pubic bone in the front of your pelvis to your coccyx. So they kind of create this trampoline, I guess you could say. That’s really unique for a set of muscles to do. Typically, a muscle would maybe be in the front and then another muscle in the back, like your bicep and triceps, your quadricep, your hamstring. But the pelvic floor goes from the front and back. It’s all in one. Kind of like your diaphragm, where it splits you in half. And why I’m talking about this and we’re talking about incontinence is because these muscles and the diaphragm, this pressure system that’s going on, has to really work together. So this trampoline that’s holding everything up creates a pressure, and it also kind of squeezes around the openings, like your urethra, where urine comes out of. If those muscles don’t squeeze around that urethra, well, that is just a freeway for urine to go through at all times. So you have your bladder above your pelvic floor, and that bladder, when it gets full, it wants to activate. It wants to contract. Well, if you are at Target or out to dinner, let’s say, and you don’t want to go to the bathroom quite yet and your bladder wants to contract, well, the pelvic floor should do its job and squeeze around the urethra and create a pressure that’s greater than the pressure of your bladder, and you should be able to sit for a little bit longer. But sometimes those muscles don’t work very well, and they are weak or too tight, and that urine basically will escape. The bladder wins. So it’s all about this kind of pressure system that goes on. And the same with when you take a jump, right? You jump; pressure goes down. The pelvic floor has to say, we are going to beat that pressure coming down. We’re going to activate so urine doesn’t come out. Well, sometimes that pressure that the pelvic floor can create isn’t as great as it needs to be, and then you get that stress incontinence, we call it. And that’s where Alyssa talked about breathing. Why is that so important? And it seems pretty simple, right? Taking a break. Well, when taught correctly, breath plus thinking about your pelvic floor can be really helpful when you’re struggling with incontinence and other pelvic floor dysfunction. So when you take a breath in, the diaphragm goes down, and I had mentioned that the diaphragm and pelvic floor both cross the body, so if the diaphragm goes down, if the pelvic floor doesn’t move, that creates a lot of pressure within your body. So when you breathe in, the diaphragm goes down; the pelvic floor should go down, as well, and just kind of relax and soften. And then when you take a breath out, the diaphragm goes up, and your pelvic floor should lift a little bit. And this is something we love to teach patients. Basically, that pressure system, something happened where it’s no longer working in that way, and you just have to relearn it. It’s like riding a bike. Sometimes it’s a little harder; maybe rollerblading or something. But basically getting that ebb and flow of the diaphragm and pelvic floor, and some people, when they’re here, we teach them and they feel it; they’ve got it. Others, it takes them a week and they come back and see us and say, oh, it took me a couple days, but now I can start to feel that difference. And then we use that to basically help with the incontinence issues. Like, hey, when you take a jump, let’s have you breathe out. That will help lift that pelvic floor. And that’s what’s fun, training people, if you’re at the clinic, to basically use a breath; use a pelvic floor activation, or use the breath to actually relax that pelvic floor if it’s too tight.
Katie: Yeah, so the pressure system that Amanda just talked about is really important for the stress urinary incontinence, that jumping, any sort of impact like coughing, sneezing. Being able to relate that pelvic floor and diaphragm together. For urge incontinence, looking at how the brain and bladder connect is super important. So with urge incontinence, sometimes we feel the need to go to the bathroom when we really don’t need to. There may be a strong urge, and then when we get to the bathroom, there’s not much urine that comes out. When this happens, there’s often a disconnect between the brain and the bladder. The bladder is telling the brain that it’s full and emergency bells go off, and your brain says, we need to get to the bathroom right now. But really, the bladder may not be full. And so we can calm those signals to the brain and lessen that sense of emergency. And so one of the ways that we can figure out what’s going on and see if we need to kind of work on that brain-bladder connection is having a patient fill out a bladder diary. A bladder diary is just basically something you fill out for two or three days, and you just write down what you eat, what you drink, how many cups of fluid you’re drinking, and then when you go to the bathroom, you write down what time you go to the bathroom, and you just count how many seconds your urine stream is. And then you can bring that information back to us, and we can look at it and say, like, hey, does this look like normal activity, normal habits, or does it look like we maybe need to look at that brain-bladder connection and retrain things a little bit? We like to see people going to the bathroom every two to four hours, so if you are going to the bathroom every hour, then that’s something that we can work on telling your brain, your bladder, hey, things aren’t quite full yet. Let’s see what we can do to not go to the bathroom, even though we feel like we need to. And that bladder diary can also let us look at what you’re drinking, what you’re eating, and we can see if there’s anything that might just be irritating your bladder and making you feel like you need to go, too. For example, coffee, citrus juice, alcohol, spicy foods, and many others can be irritants to the bladder, and maybe even just cutting some of those out or reducing the amount of coffee you’re drinking might be enough to make your bladder happier and you not feel so much urgency and frequency and needing to get to the bathroom.
Amanda: Yeah. That’s a huge piece. I have a lot of women who go through and we say, hey, yeah, what kind of fluid are you taking in, and it might be like, oh, I have soda every day. Just cutting that back can help so much. Or even looking at the acidity in your coffee. I know that low acid coffee can be beneficial, definitely, for the bladder. Caffeine is one thing, but then you get the acidity of the coffee plus the caffeine, so even if it’s decaf coffee, I know it can still be an irritant. If you look at something that’s low acidity, it can definitely be helpful to not piss off the bladder so much. It’s hard to give up that coffee in the morning; even if it’s decaf, we have our habits, for sure. Another big habit people have is that just-in-case peeing. We grew up doing this all the time. “Go to the bathroom just in case!” When you’re an adult and you have control of when you do go to the bathroom, definitely you want to try to avoid those moments. Say you’re traveling to a friend’s house, and I know with COVID it’s a little bit tricky because, obviously, we try to stay away from public restrooms, probably, to an extent right now, but ideally, if you’re going somewhere, try not to go to the bathroom beforehand if you don’t really have to go. Let that bladder fill because if you’re always going just in case, that bladder is never going to full to its full extent, and like Katie said, the brain will start to learn that. It’s amazing. There’s a whole neurological loop, and it will just start to pick up on the fact, hey, I only have to fill to 100 milliliters and then I’m going to go. But you’re really got to get that to fill a bit more to just allow that bladder to expand.
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Amanda: Typically, I tell patients, too, when you urinate, you want to make sure you’re urinating more than eight seconds. Eight seconds or more is ideal. If you’re going one or two seconds, you didn’t have to go. You probably should have tried to hold it a little longer. If you feel that huge urge but you know you just went 30 minutes ago, try to distract yourself. Try some breathing. Go for a walk. Try to really kind of – it takes time. It might not happen over a week, but try to build a different routine for your bladder.
Alyssa: It’s interesting. I’ve never thought about going – I’m definitely a just-in-caser, but that’s only if I’m going somewhere, and I make my daughter do it too. But it’s good to know that we shouldn’t make that a habit. I’m assuming it’s okay – like, yeah, we’re going on a three-hour trip, a car ride. Let’s see if we can just go. But if you’re not doing it all the time…
Katie: Yeah. That’s perfectly fine. If you’re just going to Meijer and you’re only going to be gone from the house for an hour, and you just went to the bathroom relatively recently, then not a good time to go. Of course, any time – like, if you’re leaving the house and haven’t gone to the bathroom for two to four hours, please go. It’s more about that two to four hour window that we really like to hit so that you aren’t constantly spending your life in the bathroom.
Alyssa: My mother is 71, I think, and she – I don’t even know if she can make it an hour without using the restroom. Do you work with older women, too, and do you see – what kind of results do older women have?
Amanda: Definitely. I’ve treated multiple elderly females, and I would say the results take a little bit longer, just because there’s a lot of retraining. I find strengthening is a little bit more, in the elderly population, that pelvic floor has just kind of lost its integrity a bit. I can’t say that for everyone, but the females I’ve treated, it has been more about getting that contraction and strength. I think the biggest results I have seen, though, is the behavior piece really helps. So just saying, hey, see if you can distract yourself. Try some pelvic floor activations and breathing, and try to go 15 extra minutes – try to hold it 15 extra minutes. And I’ve also seen it really improve at nighttime. I know nocturia, urination in the night, like getting up to go – I’ve seen females really improve with that, as well, once they start to get control of the pelvic floor again, which is exciting, because that’s tough on the whole body and whole system if at night it keeps waking them up.
Alyssa: That’s actually the biggest area that I saw improvement was I would always have to wake up once in the night to pee, and I’m a sleep consultant, and sleep is my number one thing. I want a full night’s rest! And when I have to wake up to pee, sometimes my brain just turns on. Like, it is on, and it is so hard for me to fall back asleep, and then my whole next day is just off. So literally when I remember to do these exercises, I sleep all night. I don’t wake up at all, and I pee in the morning. So that is the number one. I really haven’t – because of COVID, I haven’t jumped a whole lot lately. I haven’t been to the Y. So I don’t know how good I am in that regard. But, yeah, just being able to sleep all night without getting up to pee is huge.
Katie: Definitely. And I think going back to talking about retraining and getting success at older ages, too, kind of touching more on what Amanda said, it is a lot about changing habits. Amanda was talking about doing some Kegels. We call it the freeze-squeeze-breathe technique to help control an urge. Like she said, we’re trying to maybe, if we have an urge, try to stop that urge for 10 more minutes. So that’s a way that we can work with changing those habits. We’ll have the person, the patient, freeze. It’s really hard to hold your bladder if you’re walking; it’s much easier to hold your urine if you’re sitting or standing. So we have someone freeze if they have an urge, and then squeeze, so do a little Kegel, and we’ll train them how to do a Kegel really well while sitting, and then breathe. Relax. Give yourself some positive self-talk. You can make it to the bathroom. You can control this urge. You can wait a couple minutes, if you’ve been to the bathroom fairly recently already. I find that working with this with all ages is helpful to help control an urge. And then you just work from, like, okay. Now we can wait for 10 minutes. Can we wait for 15? Can we wait for 20? Now eventually working up to, can we have at least 2 hours between every bathroom visit? That’s something that can work at any age.
Alyssa: That makes a lot of sense. What else about this didn’t we cover?
Amanda: I think the next point I was going to make is just talking about – Katie mentioned the Kegels. We talked a lot about, like, with the elderly, especially, can have some tightness in the pelvic floor at that age, too, but thinking about that strengthening, and we kind of term that an up-regulation of the pelvic floor. And if we find – everyone is different, but if we find that someone’s pelvic floor is weak, and we can do that through typically internal pelvic floor assessment. We can check not only tightness, but we check muscle strength, as well. So with your hip, we can check to see, hey, how strong is your hip, 0 to 5? We’ll grade you on your hip strength. Well, we can actually do that for the pelvic floor, as well. Typically, if someone has no pain and they’re having leakage with either urge or more so probably stress like with a jumping jack, let’s say, or a sneeze or a cough, we’ll test the strength of the pelvic floor activation. Which is cool, and a patient can kind of feel, oh, yeah, I can feel that muscle trying to fire, or, oh, man, yeah that muscle is firing up really well. We call that up-regulation when we try to get the muscles to fire up. And we train that in different ways, whether it’s just on the mat table laying down, no gravity, try to find the activation; seated forward, seated backwards a little bit, depending on where the weakness is. Let’s say you do CrossFit or you’re a runner. Well, we will definitely have to get you on your feet with a jump rope, with weight, and we’re going to test that pelvic floor. And that there is more after you really know where your pelvic floor is, because I would never take someone right at initial eval and say, okay, fire up your pelvic floor on a squat. Who knows what they’re doing at that point? So when I’m confident a patient knows how to fire up their pelvic floor, and then treating from there, which is fun when you can get to – let’s say postpartum, a mom who wants to get back to weightlifting, get back to running. When the body has healed and it’s ready to go, that transition is really fun to take them through. And then those who let’s say maybe do have pain with leakage and incontinence, and we do an internal assessment and we find there is tightness in that pelvic floor. That’s where some internal pelvic floor treatment, like manual releases – so you could think, hey, if you do a manual release on your upper trapezius because your neck is sore. Well, it’s gentle. It’s more sensitive tissue at the pelvic floor. But, yeah, we work through releases to try to get that pelvic floor to calm down. Or there are tools and stuff; I know we didn’t touch base about this in the first podcast, but other tools we do recommend for patients if they do have tightness: things like dilators to stretch that pelvic floor outside the clinic where they may see us once or twice a week. Well, there’s five or six other days that they can then at home work on stretching the pelvic floor or tools like the pelvic wand. It’s out there, like a trigger point release tool. So, yeah, there’s a lot of different tools out there that we’ll recommend to a patient. Or if they need strengthening, pelvic floor weights may be good for them to use for some feedback and for some strengthening of it.
Katie: And we’ll talk more about those treatment techniques, too. I think we’re going to cover a lot of those when we talk about pain with sex, as well. But you can see that everything kind of overlaps. So you might not just have one problem. You might have pain with sex and leaking and constipation, or you might just have some leaking. But because it’s all related to the pelvic floor, a lot of our treatment techniques definitely overlap. I think the last thing we just wanted to touch on was just Kegels and using them for years to come. You know, it’s great. You might not have to do as much of your home exercise program and as much of the intense exercise that you’re doing in physical therapy when you’ve graduated from physical therapy, but continuing to do Kegels, continuing to practice relaxation techniques, continuing to work on your good, healthy breathing techniques that we’ve taught you, even when you’re done with physical therapy, is helpful. Just as you would strengthen your arms and your legs and you would need to keep doing exercises throughout your lifetime to stay strong, you need to keep working on your pelvic floor exercises to keep your pelvic floor healthy. Just like exercising throughout life is good for us, paying attention to our pelvic floor and checking in and doing some strength exercises or doing some relaxation exercises is healthy throughout our lifetime, too.
Alyssa: Awesome! Thank you so much. Let everyone know how they can get ahold of you if they want to learn more or set up an appointment with you both.
Katie: Amanda and I work at Hulst Jepson Physical Therapy, the East Grand Rapids location, so we’re on Burton between Breton and Plymouth. Hulst Jepson also has several other locations. I believe they have five other locations with pelvic floor physical therapy. So you can check out the website and see which one’s most convenient for you.
Amanda: Yeah, and just give us a call. You can chat with Lexi up front here at EGR for an appointment, or just say, hey, Lexi, can I chat with one of the therapists there? Happy to take a call. Also, we do have free 15-minute consults. I forgot to mention that in the previous podcast. So if you have questions and aren’t quite ready maybe to commit to starting pelvic floor rehab but just want to chat with us about anything, we’re more than happy to sit down with you for 15 minutes or so and kind of discuss options, if PT would be right for you. We can definitely do that, as well.
Alyssa: Thanks so much. We will look forward to our next couple podcasts later, so everyone stay tuned for those. Thank you!