The Gut Health Podcast
The Gut Health Podcast explores the scientific connection between the gut, food, mood, microbes and well-being. Kate Scarlata is a world-renowned GI dietitian and Dr. Megan Riehl is a prominent GI psychologist at the University of Michigan and both are the co-authors of Mind Your Gut: The Science-based, Whole-body Guide to Living Well with IBS. Their unique lens with which they approach holistic conversations with leading experts in the field of gastroenterology will appeal to the millions of individuals impacted by gut health.
As leaders in their field, Kate and Megan dynamically plow through the common myths surrounding gut health and share evidence-backed information on navigating medical management, nutrition, behavioral interventions and more for those living with or without a GI condition.
The Gut Health Podcast is where science, expertise, and two enthusiastic advocates for wellness come together to help you live your best life.
Learn more about Kate and Megan at www.katescarlata.com and www.drriehl.com
Instagram: @Theguthealthpodcast
The Gut Health Podcast
Pelvic Floor PT Explained: Who Needs It and Why?
Pelvic floor physical therapy (PFPT) is a crucial yet often overlooked component of gut health that can dramatically improve quality of life for people suffering from bowel issues, bladder problems, or pelvic pain. Dr. Alicia Jeffrey-Thomas joins us to demystify and normalize this specialized therapy and explain how proper pelvic floor function impacts everything from constipation to sexual health.
• Understand that daily bowel movements don't necessarily mean you're not constipated
• What happens during a PFPT session and how therapists create a safe + comfortable environment
• The importance of proper pooping position
• Why breathing techniques and sounds (like mooing!) can help relax your pelvic floor during bowel movements
• Demystifying tools like pelvic wands and dilators for at-home maintenance
• How dyssynergic defecation affects approximately 50% of people with constipation and how pelvic floor PT can help
• Why all women can benefit from pelvic floor PT after childbirth (and even during pregnancy)
• Men face pelvic health issues too, like post-prostate surgery incontinence
• The downside of "peeing just in case" and how it trains your bladder to signal fullness prematurely
If you've experienced pelvic floor issues, don't accept them as normal - seek help from a pelvic floor physical therapist who can address these problems and improve your overall quality of life.
References and Resources:
Where to find a pelvic floor PT:
Alicia Jeffrey-Thomas' book, Power to the Pelvis.
Got constipation? Check out Kate's constipation guide.
Learn more about Kate and Dr. Riehl:
Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast
Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.
The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.
This episode has been sponsored by Ardelyx. Maintaining a healthy gut is key for overall physical and mental wellbeing. Whether you're a health conscious advocate an individual navigating the complexities of living with GI issues or a health care provider you are in the right place. The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food and the gut. Come join us. We welcome you.
Kate Scarlata, MPH, RD:Hello friends, and welcome to The Gut Health Podcast . where we talk about all things related to your gut and well-being. We are your Jeffrey
Kate Scarlata, MPH, RD:Kate Scarlata, a GI dietitian.
Dr. Megan Riehl:And I'm Dr Megan Riehl, a GI psychologist.
Kate Scarlata, MPH, RD:You know, when we think about the dream team for achieving your best gut health, there's a crucial piece we're spotlighting today, and that's pelvic floor physical therapy. We are joined by Dr Alicia Jeffrey-Thomas, a pelvic floor physical therapist. If you've ever struggled with bowel or bladder issues yes, I'm talking to you, friends. If you are afraid to sneeze and pee or dread those jumping jacks in exercise class, maybe you've had a baby or experienced pain with sex or dealt with any condition affecting the pelvic floor, this episode is for you. And men don't skip this episode too, because constipation and prostate issues can benefit from pelvic floor physical therapy too. We're going to enlighten you today on how pelvic floor physical therapy might be just the missing link in your health journey.
Dr. Megan Riehl:So welcome Dr Jeffrey- Thomas.
Dr. Alicia Jeffrey-Thomas:Hi, thank you so much for having me.
Dr. Megan Riehl:Let me share a little bit more about you. You have a really impressive history and we are just so thrilled to have you today. You have been a pelvic floor physical therapist since 2016 and treat people of all genders in the greater Boston area, and you aren't one to shy away from the taboo topics, so from bladder problems to bowel movements to sex, Alicia is always game to talk through the dirty details of helping her patients figure out what is going on, quote unquote, down there.
Dr. Megan Riehl:You're also the creator behind @AtT he Pelvic Dance Floor, a social media presence with over a million followers across Instagram and TikTok, and I've been watching. You use a lot of humor and share evidence-based pelvic health information in a very relatable way, and also you just published your first book, Power to the Pelvis, which aims to further the mission and empower people to take charge of their pelvic floor health. We are so, so excited to talk with you today.
Dr. Alicia Jeffrey-Thomas:Thank you.
Dr. Megan Riehl:Also, we like to kick off every episode with a myth buster.
Dr. Megan Riehl:So what in the kind of the pelvic floor health space or overall health and well-being? What myth would you like to bust for us today?
Dr. Alicia Jeffrey-Thomas:So if we're trying to kind of combine gut health and pelvic floor health, I think the thing that I hear most commonly from people is well, I poop every day. There's no way that I can be constipated. And that's just really not true, right? Because if we have kind of that incomplete evacuation, where your pelvic floor muscles maybe aren't getting out of the way to allow for that full emptying, you can kind of have this buildup and backup of stool so that you're still constipated, even if just a little bit's coming out every day.
Dr. Megan Riehl:The constipation I mean we've had this conversation so many times that like at the root for so many people, especially those that are having diarrhea, we're always like we got to check. We got to check to see if actually constipation is really at the root of things. So that is a perfect myth to kind of kick us off. Thank you for sharing that.
Kate Scarlata, MPH, RD:Yeah, absolutely. I would say too, in my practice that has been a huge problem and I always recommend a pelvic floor evaluation and a referral. And I would say, you know, I've been seeing thousands and thousands of patients over the last 30 years and pelvic floor physical therapy has been probably one of the most top-tier treatments that have really altered my patient's quality of life. And it's just to that point they weren't eliminating that stool and you have that extra stool in your colon that's really slugs down your small intestine motility, so that bloating and that distension can really be a problem and patients hate that. So when you work with patients, is there more common conditions that you see in your practice? Can you please just talk about what a pelvic floor physical therapist does on a day-to-day operation and then what you see more commonly in your practice?
Dr. Alicia Jeffrey-Thomas:So, as a pelvic floor therapist, I tend to kind of lump my categories of things that I treat into three. So you have your urinary issues, which most commonly people will think of stress incontinence so leaking urine when you cough or laugh or sneeze or jump or run or urgency related issues so not making it to the bathroom in time or feeling like you constantly have to go. And then you can also kind of get into the bowel side of things, where the most common thing that I treat within that category is going to be constipation, whether that's working on motility through the system or that sphincteric piece of making sure that the doors are able to open and everything is able to make its way out. And then there's also fecal incontinence. That falls under that umbrella as well.
Dr. Alicia Jeffrey-Thomas:And then your third umbrella is going to be pelvic pain, and that could be anything related to pain related to either urinary or bowel function. It could be pain related to things like endometriosis or interstitial cystitis. It could be pain with sex. It could be this kind of tension in the pelvic floor that's maybe contributing to hip pain or back pain. So it's all-encompassing. It's not just that hammock of muscles at the bottom, it's how it affects everything around it as well.
Kate Scarlata, MPH, RD:Can you just talk a little bit about tension in the pelvic floor? And I think when people think of tense they think like their muscles are tight, obviously, but are they also weak sometimes, Like is tension sometimes present with weak muscles or is tension typically with they're strong? What are you working against, say, in someone with constipation typically?
Dr. Alicia Jeffrey-Thomas:It can go either way. You can have tension in the pelvic floor, where the muscles just don't have the room to move, and so that could mean that the muscles are weak. And once we get the pelvic floor to relax it's like oh, this muscle doesn't know how to coordinate at all, it can't contract on its own because it's been stuck in this tense, contracted state for so long. Or you can have people where their pelvic floor is tense but they do have that ability to kind of tension further. That tends to happen a little bit less often. I generally tend to find that there's this dis-synergy, this discoordination, where the muscles have been stuck in one position for so long that they kind of lose the plot and don't know how to do their jobs appropriately once we get that range of motion back.
Dr. Megan Riehl:Awesome. And one of the things I want to just kind of think about here is, a lot of times, our patients that we're seeing from a gut health perspective or just in general, I say comfortable being uncomfortable. So this idea that, like, I gave up running because I pee a little bit every time I run, like and that's just the way it's supposed to be because I've had three babies, and that's not the right mindset, right Like, and women that are in their seventies or eighties that they get up to pee or something just dribbles out, these are not common things, that or I guess they are common things but they're not things that we have to live with. Is that right?
Dr. Alicia Jeffrey-Thomas:thinking that's totally correct. I mean, I think that pelvic floor dysfunction tends to slowly rob you of these little joys and you make these adaptations in your life to where you're not exercising the way that you want to because you're afraid to run or to jump on a trampoline because you don't want to pee and be embarrassed by that, or you stop having sex because it's painful and you're like oh well, maybe this is just how it is as I get older and so over time we're kind of missing out on these integral pieces of life. And then also, I mean, there's just the ways that it just affects you on a day-to-day. I mean, if you have a lot of urinary urgency, you may not want to travel because you're afraid of not being able to find a bathroom in time. So there's just little ways that it starts to impact you.
Dr. Megan Riehl:Yeah, so walk us through that introductory consultation with a patient, because I think people are just very curious and anxious about what that might look like to work in kind of the pelvic floor area. So what is a typical consultation for constipation or diarrhea or even some of those urinary issues?
Dr. Alicia Jeffrey-Thomas:So I'm looking at all of these things simultaneously. If somebody comes in saying that they have a constipation issue, I'm already thinking, hmm, I need to make sure I ask about pain. I need to make sure I ask about bladder issues, because I kind of call it the theory of stuff. There's only so much room for everything to coexist within the pelvis. And so I'm going to start out asking a bunch of personal questions, depending on what you're comfortable with from an exam standpoint. That doesn't happen until way later. I want to get a good idea of what's going on. So I'm taking a really thorough history. I'm asking about all of those different kind of umbrella areas and then, depending on what you're telling me, I'm also asking about back pain. I'm also asking about whether you've had other abdominal surgeries before, things that might be impacting what's going on, and then my exam tends to flow from that into looking like a more orthopedic exam first. So if you've ever been to physical therapy for your back or for your shoulder, we're looking at range of motion in your hips and in your back and we're making sure that there aren't any limitations there that might be telling me that something else is going on. We're looking at strength. We're looking at all of these other different pieces that when we get to the pelvic floor, that's going to tell me, oh okay, we tend to have a little bit more weakness on the left side. How does that then translate to what's happening at the pelvic floor?
Dr. Alicia Jeffrey-Thomas:And the pelvic floor exam is never mandatory, right? I'm never going to force anybody to do anything. It's another piece of the information that we're trying to gather to figure out what's going on with you. So that doesn't have to happen at the first visit, it doesn't have to happen at the second visit, it doesn't have to happen at all if you're really never comfortable with it. I've had people where I've walked them through how to do this assessment on their own if they're more comfortable with doing that and giving me some information. It's just we're more limited in how we can interpret that information when it's not me doing the exam. So that exam for somebody with a vagina is going to be a single-digit vaginal exam or a single-digit rectal exam, depending on what's going on.
Dr. Alicia Jeffrey-Thomas:And what we're doing there is. We're assessing what's happening with the muscles, so the range of motion, the same way we would assess in the hips or the back the strength, so whether that muscle is able to contract and relax fully. We look at whether you're able to bear down appropriately what's happening with the muscles when that's occurring, so we're able to put all of those pieces together. Is there pain, is there something else going on, so that we can form this full picture and say, okay. I think that the reason that you're having constipation isn't because you're not moving things through the system appropriately. It's that that exit is blocked and it's not wanting to relax and get out of the way, and maybe that's also driving why you're having some urinary urgency, because there's just more pressure built up in that system and it's maybe putting a little bit of pressure onto the bladder and causing some of the bladder spasms there.
Dr. Megan Riehl:So I always say that therapist is incorporated in your name because this is a very sensitive type of collaborative working relationship right working relationship right and so people that have a history of trauma. It's important to advocate, as well as I'm sure on your consultative side you're asking about that. And again, like you're saying, a digital exam doesn't have to be incorporated into the treatment plan right away or ever so your comfortability. We know there is a high prevalence of individuals with pelvic issues that may have a history of trauma and we don't want to avoid this aspect of the treatment plan because of that, and we can help you to feel very safe and comfortable.
Dr. Alicia Jeffrey-Thomas:Exactly, and I honestly I tend to assume, based on the statistics right, I tend to assume that there is something there in most people that come into my office and I'd much rather approach it from that really trauma-informed lens of what are you not telling me, because you're already coming into this office really anxious about just talking about the bowel and bladder issues that you may not even think to bring this up, and that's honestly what will happen a lot of times is somebody will disclose a previous assault or abuse history on that second visit once they're starting to get more comfortable with me, and so I always want to make sure that I'm leaving space for that and making somebody feel comfortable with disclosing that to me so that we can form a better therapeutic relationship and make sure that I'm not doing anything that's going to trigger them in session.
Kate Scarlata, MPH, RD:Yeah, that rapport is so huge. I think in my practice as well, you know when patients will say I'm so sorry, I'm talking about my poop and it's like that's my business. Yep, exactly that's why you're here. That's why you're here, we're good with that. So I'm going to shift things here a little bit. You know, I see a lot. I've heard a lot about pelvic wands Very intriguing. Do you have one? Of course I do. Of course you do. Look at that. I mean, I don't know if it's like intriguing or scary or, you know, just provocative. But let's talk about pelvic wands and when you might use them in your field.
Dr. Alicia Jeffrey-Thomas:So yeah, so a pelvic wand is another tool in the toolbox. Again, it's not something that everybody's going to have to use. I usually use it related more to pelvic floor tension and it's a way that you can recreate some of the manual therapy techniques that I would do in the clinic on your own at home. So it can be really good for managing in-between visits or even long-term once you've graduated from physical therapy. Now, just looking at this wand right, there's this big long thing here and everybody gets really intimidated by this. The amount that's going in. It's trying to mimic what's happening when my finger is inside, so that much at most is going inside Finger length If you're looking at.
Dr. Alicia Jeffrey-Thomas:So this is the Intimate Rose brand one. There's actually a little flower right there and that's usually where I tell people. That's the limit of where you want to try to go usually and it has this curve to it because it's trying to be able to kind of get down onto the bowl of the muscles in the pelvic floor. It's not just a straight canal. You want to kind of be able to like gently angle down onto the muscles. It's really similar to like a Theracane that you would use to get knots out of your shoulder, so it kind of has to have that little bit of an arc to it to be able to kind of get into that muscle to do a gentle self-release. And then the other end of it is typically designed if you're using it in the back passage. So if you're using it inorectally, then you're able to better get onto the muscles there. It's a little bit more of a tapered end and so people are a little less intimidated by that.
Dr. Megan Riehl:Wowza, I love it.
Dr. Megan Riehl:So you would be teaching somebody how to use something like this in your sessions and again their comfortability level, like going home and trying this on your own might take some time and practice and you might engage in the exercise for 60 seconds and call it good. I've worked with a lot of patients where sometimes they feel overwhelmed at the exercises that they're supposed to do in between their sessions and then they just don't do them. And so on the GI psychology side, I kind of talk about well, number one, talk about this with your pelvic floor physical therapist and then also have some flexibility with yourself and also you probably need to be pretty relaxed to be doing this type of homework and normalizing that.
Dr. Alicia Jeffrey-Thomas:Yeah, absolutely. I mean, you don't want to have your nervous system be super upregulated at the thought of using the pelvic wand, because then we're just kind of fighting this uphill battle and nothing's really going to relax, right. And so I want to make sure that you're comfortable at least attempting to use the wand and again, even if it's like I'm just going to, like, place it here at the entrance and see how that feels and come back to it later, that's good, right. Like we're resolving some of that fear, that nervous system upregulation, before we get into doing, you know, maybe more of like a full session of muscle releases, and I'm guiding people in the clinic. They're going home trying something, they're coming back, we're doing something in the clinic and it's that back and forth of making sure that they're getting the right feedback there. That's right.
Kate Scarlata, MPH, RD:So just with these wands, you're really is it almost like identifying a knot. Is that what we're like? Targeting to help relax, like you would have a massage break up a knot in your back.
Dr. Alicia Jeffrey-Thomas:Is it similar? Similar, yeah, and everybody's going to be a little bit different in terms of what we're specifically targeting. There are also versions of these wands that have vibratory functions or have temperature functions, and so if somebody is not really thinking that they want to be applying a lot of pressure to that muscle which I don't really recommend anyway but with, like, the vibrating ones, you can apply even gentler pressure and use that low level vibration to help to facilitate that relaxation as well. So it's maybe more of a generalized relaxation as opposed to specifically finding a spot in those cases, excellent.
Dr. Megan Riehl:All right. So something that definitely applies to all of us is proper pooping. Can you explain to us how you describe proper pooping position and do you have any personal tips and tricks that help your patients poop like a champion?
Dr. Alicia Jeffrey-Thomas:Oh, of course. So my number one recommendation is to get some kind of toilet step stool. We'll call it I'm not going to necessarily call out a specific brand but you want to have your knees in a position where they're a little bit higher than your hips, because that's going to help to facilitate more relaxation of the pelvic floor. Typically, when your feet are just flat on the floor, your pelvic floor is kind of kinking around your large intestine, so everything has to make an extra turn before it comes out. If you get your knees higher than your hips, that relaxes that pelvic floor muscle, so your colon straightens out and then everything has an easier path to the exit.
Dr. Alicia Jeffrey-Thomas:Now where I see this getting messed up for people sometimes is when there's a flexibility deficit.
Dr. Alicia Jeffrey-Thomas:So they get their knees up, but then they're kind of hunched over because they don't have the ability to kind of hold themselves upright in that position.
Dr. Alicia Jeffrey-Thomas:So I'll tell people, okay, like maybe we bring the height of the step stool down a little bit and you work on trying to get that like upright posture as well, so that you know your tailbone isn't then getting in the way of everything making its way to the exit. And then in terms of actually making things happen right, further relaxing the sphincteric muscles and allowing things to empty. I like to incorporate a lot of breath work and a lot of sound use, so I'll teach people how to do diaphragmatic breathing, specific types of exhales, so pretending like you're blowing on a pinwheel or blowing bubbles through a bubble wand. That kind of slow, pursed lip exhale helps to kind of keep the pelvic floor muscles in a relaxed position so you're not straining, you're not holding your breath. If somebody needs a little bit more help and a little bit more oomph, sometimes I'll teach them to do like a shh as they're doing that exhale, or even making low pitch sounds like a moo or a humming sound to try to facilitate that as well.
Dr. Megan Riehl:I was going to say can you give us some sound examples? So a moo is one of them and you can feel that lower in the pelvic floor, in the belly, when you make those lower sounds. So it's a really good tip and very helpful.
Dr. Alicia Jeffrey-Thomas:And it's definitely one that you want to practice in the comfort of your own home. That might not be a public bathroom, first attempt.
Kate Scarlata, MPH, RD:I was just thinking that too.
Dr. Megan Riehl:But you know what, once you do get good at this, listen, go for it If that's going to help. You have a more complete bowel movement and you're traveling or you're out and about. I've heard the tip of like throw in some headphones, go into the public bathroom. That way you're not worried about what everybody else is doing, but you're able to do what you need to do and you know before you're done or I guess before you know it you're done and onward with the rest of your day, exactly.
Kate Scarlata, MPH, RD:You broached this topic before, but I'd like to really do a little more of a deep dive into dysnergic defecation. It's about 50% of people with constipation have dysnergia and I'd like to really break this down for our listeners because I think it's probably could be part of their picture.
Dr. Alicia Jeffrey-Thomas:Yeah, so basically dyssynergic defecation is that discoordination or so that misalignment between what's happening in the rectum and what's happening at the pelvic floor and the anal sphincter.
Dr. Alicia Jeffrey-Thomas:So a lot of times when I'm doing just a visual exam of the pelvic floor, I'll see this.
Dr. Alicia Jeffrey-Thomas:I'll say, okay, try to bear down like you're pooping, and they'll start to have a little bit of movement downward with their pelvic floor, but then the sphincter will just clench up and close up and pull inward instead of that kind of like dropping and lengthening.
Dr. Alicia Jeffrey-Thomas:And so if that's happening every time you go to try to poop, then a lot of times people will describe having very skinny bowel movements or feeling like there's a blockage, that something won't come out, and so then we're really focused on okay, how do we link things back up? And maybe that's working with some of the breath and sound strategies that I was just talking about. Maybe that's doing some manual release work to the pelvic floor muscles to kind of get that range of motion back so that it's accessible. When you are trying those other strategies. I'll teach different stretches and breath work in different positions to again kind of access that range of motion and be able to tap into it when the time comes, and sometimes we're even doing work with rectal dilators where they can almost kind of have that pooping practice outside of the stressful situation of trying to make a bowel movement happen.
Kate Scarlata, MPH, RD:Perfect.
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Dr. Megan Riehl:So the next topic again, I think, is one that some people may just be living with and or avoiding, and that's painful sex, and so how common is it? And let's normalize this for people and what might pelvic floor PT kind of look like in order to address that issue?
Dr. Alicia Jeffrey-Thomas:Yeah, I mean, the vast majority of people will have a painful sexual experience at some point in their lives. It's whether it becomes something that is more chronic and continuous, and that's where we want to make sure that we're diving in and figuring out why that's happening. So, because that could happen for muscular reasons, it could be because the muscles are too tense and so we're kind of having that painful response as something tries to kind of go past them. It could be a hormonal issue, so there could be dryness, there could be a decrease in estrogen. That could be driving some of that. There could be kind of that nervous system upregulation where we're anticipating that something is going to hurt and so we're involuntarily kind of clenching those muscles.
Dr. Alicia Jeffrey-Thomas:So pelvic floor physical therapy in that instance is really trying to find the driver. Is this a hormonal issue? Is this a muscular issue? Is there something else happening further up and down the chain? And then maybe we're doing manual release work, we're practicing breath work to be able to relax the pelvic floor in that moment. Sometimes we're working with vaginal dilators, which are progressively sized cylindrical devices Hold on, I have one right here so they're progressively-.
Kate Scarlata, MPH, RD:Of course you do.
Dr. Alicia Jeffrey-Thomas:Of course I do. I tried to set aside a bunch of things. I'm like maybe I can reach for this.
Dr. Megan Riehl:I love this. We're going to include some pictures with this episode today, so you'll have to check out the Instagram page for us, because we will help you understand what we're talking about.
Dr. Alicia Jeffrey-Thomas:Perfect and so progressively sized cylindrical devices. They start as small as your pinky, if not smaller in some brands, and it progresses all the way up through the size of most partners, and so you're able to kind of work through being able to relax the pelvic floor around these devices so that you're not anticipating pain and you're able to maybe even stretch into certain directions where, if you say, oh I tend to have more tightness on the left, let me pull down and stretch. That way it becomes a way that you can be doing things on your own in addition to just coming into therapy.
Dr. Megan Riehl:Some of these topics that are taboo. They don't need to be. They don't need to be stigmatized. We want to have conversations about this. We want women and men to be able to communicate to each other what they're experiencing, and it also makes me think about women that have had vaginal deliveries. Do you think that most women that have had a baby would benefit from a consult with a pelvic floor physical therapist?
Dr. Alicia Jeffrey-Thomas:I honestly think that, regardless of how you delivered, you should have a consult with a pelvic floor therapist afterwards, because even if you have a C-section, that's still a major abdominal surgery that is affecting how your abdominal muscles are able to function. And also, you just went through a pregnancy where for nine months, there was pressure sitting on top of your pelvic floor. So I would love it, in the ideal world, if everybody at least came in and had things screened, because I'm also maybe going to be the only person that's going to ask you these more in-depth questions. Your six-week follow-up with your gynecologist or your OB isn't going to necessarily get into the dirty details of are you having fecal incontinence? Are you having urinary incontinence? Does it hurt when you have sex? That would lead us to maybe needing to do some therapy to help to alleviate that.
Dr. Megan Riehl:And is there any timeframe? So if you are somebody that has a three-year-old and you're like, well, I didn't go do that, should I maybe go back? What are your thoughts on the timeline there?
Dr. Alicia Jeffrey-Thomas:Absolutely. It's never too late to see a pelvic floor therapist. I have people that come six weeks right after they deliver and we start working right away. But I have people that come 20 years afterwards and they're saying, oh, I've kind of been sitting on this because I was raising children and busy and nobody told me that this was a thing. And suddenly, you know, they had a friend that mentioned it and now they're taking time for themselves and coming in and we still see them getting better. We still see them having improvements. So, yes, earlier is going to be ideal because then you're not going to have those years lost where you're peeing your pants or having all of this pain. But it's never too late. If you want to come in, if you're having issues, please seek care from a pelvic floor therapist.
Kate Scarlata, MPH, RD:I'm glad it's getting its day. I know you probably feel like you're seeing it and you're making a big difference by being out there and letting people know about pelvic floor physical therapy, because it's sad to me that people are peeing their pants and thinking it's okay or normal after having a baby or having fecal incontinence and being embarrassed and not thinking that there's help out there.
Dr. Alicia Jeffrey-Thomas:It's super valid because there's the embarrassment factor where you say, ooh, am I the only person dealing with this? Or if you do start to bring it up, a lot of times, that conversation gets shut down with oh, that's just normal, that's just how it is. And because of that embarrassment factor you never ask a second time, and whereas maybe asking a second provider, you would get a completely different answer. So it's really good to see that more people are realizing that they can seek care for this. I mean, in the nine years that I've been doing this, it used to be that when people came in, their doctors referred them. They had no idea why they were showing up to pelvic floor therapy, and so it was a lot more education on my end to try to get them on board with what was happening. And now I'm seeing people that are self-referring, that recognize that they're having these issues and don't want to just have this be their normal.
Dr. Megan Riehl:And I think maybe to your point, Kate, that, like people are suffering unnecessarily and maybe some of it is an access issue, that you just haven't heard about it or you don't know where to turn, and that was part of the reason we wrote our book was to increase access, and I'm sure part of your motivation too to write yours that you know we've got to put this out there and let people know of the variety of different ways in which we can address these health issues, absolutely.
Kate Scarlata, MPH, RD:So can we talk a little bit more about fecal incontinence? Because certainly I've worked with a number of patients and interestingly, you know, early in my practice it wasn't a question I really asked and then I developed an online questionnaire that patients did prior to their visit and I added it and I was really surprised to see the numbers of patients coming back where it was a problem, especially the older woman that came to see me. So what are some of the tools and tricks that you do for this condition?
Dr. Alicia Jeffrey-Thomas:Yeah, and fecal incontinence for sure is one of those hidden ones. People don't think to bring it up, but I saw a statistic somewhere that said it's as common as asthma. So we really want to make sure that we're screening for this, because this is something that is really going to keep people home if they're thinking that they're going to have an accident in public or something like that. So, similar to anything else, I want to figure out why this fecal incontinence is happening. Is what's happening more solid stool, more liquid stool? Is there an underlying constipation within kind of an overflow that's happening? So it maybe isn't necessarily.
Dr. Alicia Jeffrey-Thomas:Oh, I need to be doing a bunch of Kegel strengthening exercises. Yes, that does come into play for a lot of people with fecal incontinence, but sometimes we are defaulting back to oh, it's actually because you're not emptying, and so we want to make sure that we're having this full, comprehensive thing going on. And even if we're getting into the strengthening of the pelvic floor, it's not just going to be that in isolation. If we're looking at fecal urgency, I'll teach them different strategies and techniques to manage that urge when it happens, so that they can be able to comfortably make their way to the bathroom without having an accident before they get there, and we really just wanna make sure that we're looking at this comprehensively and not cutting any corners and making assumptions when it comes to fecal incontinence.
Dr. Megan Riehl:Do you
Dr. Megan Riehl:have a tip or trick on how to get there, how to hold it. That might be a very general kind of tip for urgency.
Dr. Alicia Jeffrey-Thomas:So I base it off of the technique that I use for urinary urgency. So I usually give people a few different strategies of like, okay, don't try to do this as you're running to the bathroom, right, you want to freeze in place, you want to try to take a few deep breaths to regulate the nervous system. But where I would cue somebody to do quicker pelvic floor contractions when it's urinary urgency, I'll get them to do a longer pelvic floor contraction if it's for bowel urgency, because we're trying to kind of reset that rectoanal inhibitory reflex where basically it's like if we're able to kind of like pull things up and hold things up out of that chamber for long enough, it hits a little bit of a reset button to allow people to get where they're going.
Kate Scarlata, MPH, RD:Got it. Interesting. So I know diaphragmatic breathing can really get that kind of high anxiety down. Is that kind of what you're talking about, those deep belly breathing?
Dr. Alicia Jeffrey-Thomas:Exactly, Exactly.
Dr. Megan Riehl:So I forgot to ask, and I'm also thinking that this might be beneficial what about seeing you while you're pregnant? I'm thinking that, of course, after you have a baby and you're saying, pretty much every woman that has ever had a baby could benefit from this but what about during your pregnancy?
Dr. Alicia Jeffrey-Thomas:Absolutely so. During pregnancy is usually the first time that a lot of people start to see pelvic floor issues manifesting. So maybe that's an increase in frequency of urination, or maybe that's they're starting to notice some urinary incontinence because of that growing pressure and heaviness. You don't have to wait until you deliver to start addressing that. So I'll see people during pregnancy to work on strengthening not only their pelvic floor but their deep core and everything that's helping to support that whole system. But then I'll also help people to manage any pelvic pain. So if they're having pubic symphysis pain, back pain, hip pain during pregnancy, you don't just have to exist with that. Nine months is a long time to be in pain and I don't want people to think that that's just how it is.
Dr. Alicia Jeffrey-Thomas:There's a lot of things that we can do from a muscular standpoint. We can talk about different supports, that you can be wearing a whole bunch of different things there, and then, as we get into that third trimester, we're also talking about birth prep. So, instead of then focusing more on strengthening, how do we get the pelvic floor to be able to get out of the way so that the uterus can push the baby out. So we're talking about pelvic floor relaxation. We're also talking about optimal labor positioning, ways that you can kind of open up some hip mobility to allow for that positioning to be possible in the moment. So there's a lot, a lot that we can do there. And then also you've established care with a pelvic floor therapist so that you can get right back in after you hit that six-week clearance with your OB.
Dr. Megan Riehl:Exactly. It can be so hard to think about taking care of yourself when, all of a sudden, you have this new baby that is 100% reliant on you, and so this may be. People are always saying, like what could I get the mom? Partners, spouses, best friends, girlfriends remind your pregnant friends or loved ones that this could be a beautiful gift, a good referral, and pair you with a good postpartum massage or a prenatal massage, and that sounds like a picture-perfect day for me.
Dr. Alicia Jeffrey-Thomas:Exactly.
Kate Scarlata, MPH, RD:Lots of self-care. I like it. So, while we're talking about pregnancy a little bit, I hope I don't butcher this term diastasis recti yeah, is that right, you did it. So it's a separation of the abdominal muscles and it can be seen in postpartum women. Can you talk about how pelvic floor physical therapy might help with this?
Dr. Alicia Jeffrey-Thomas:Now just to clarify the term itself. It's not a separation of the muscles themselves. It's a separation of the fascia between the two sides of your six-pack muscles.
Dr. Alicia Jeffrey-Thomas:So, the muscle itself isn't tearing, it's basically a thinning and a stretching of that line in the middle. And so we start to notice maybe that widening which can result in coning or doming when you're doing different abdominal exercises or even when you just go to sit up in bed, and that can contribute potentially to an inability of that whole core system that exists between your pelvic floor, your core, your diaphragm, to be able to manage pressure. So that could mean that you're dealing with back pain or abdominal pain or even contributing to some of those pelvic floor symptoms In pregnancy. It's pretty common, it's going to happen to most people. So it's no failure of your own activity levels or something that you did that you end up with a diastasis.
Dr. Alicia Jeffrey-Thomas:There are certainly things that you can be doing in terms of strengthening the deeper core muscles. You can be more mindful of breathing out when you're doing exertional movements. That can keep it from maybe progressing or getting worse. But there's definitely going to be some amount of separation in most people. And then postpartum, we're thinking about re-engaging that whole system, so the deep core, the pelvic floor, your breath, and being able to create support through the spinal column so that we're not ending up with back pain and more pelvic floor issues.
Dr. Alicia Jeffrey-Thomas:I'm not so concerned with closing the width of the gap. A lot of that is going to happen kind of on its own, but I'm really also thinking about being able to generate tension and support across that separation. So the muscle that's below that or deeper to that is called the transverse abdominus. I wanna make sure that that is able to be doing its job, because it's acting more as kind of like a corset to help to support everything, and so that's going to be the more functional piece versus focusing on the aesthetics of closing the width of the gap?
Dr. Megan Riehl:Stress which symptoms might drive somebody to this.
Dr. Alicia Jeffrey-Thomas:Definitely.
Dr. Alicia Jeffrey-Thomas:Back pain, urinary incontinence, abdominal pain those are going to be the main things that you're going to see with a diastasis.
Dr. Megan Riehl:Okay, what, on average, might somebody expect in terms of like how long they're working with somebody like you? Just to kind of set the stage of expectation.
Dr. Alicia Jeffrey-Thomas:So I'm going to use a really common physical therapy phrase and say it depends. Okay, that's fair. Everybody is going to be a little bit different. Everybody's level of body awareness is completely different. There are some people that come in and they get what I'm trying to tell them immediately and we can kind of move through a progression at a much faster pace. And so those people, maybe I'm seeing them for I don't know, six visits or so.
Dr. Alicia Jeffrey-Thomas:But then I certainly have people who have more complex things going on. Maybe they have chronic pelvic pain or they've had constipation for 10, 20 years before they've thought to come and get it addressed, and so we're unwinding more and more pieces, and so those are people that I'll see much longer term. I mean, I have people that I've seen for over a year at this point and they're certainly doing so much better than where we started from. But we're trying to really get back to that optimal function than where we started from. But we're trying to, like, really get back to that optimal function. And you're not necessarily going to have this straight, linear path of everything is getting better all the time. You're going to have dips, you're going to have regressions, and so you want to kind of be gentle with yourself and know that your body is moving at the pace that it's meant to move at, based on a lot of different factors.
Kate Scarlata, MPH, RD:I often think and see in my patients, you know, a refresher, like nutrition, like a psychology refresher. I send patients back after they haven't been for a couple of years. It's like you know what, maybe you just need a little refresher here, a little tune up, exactly, exactly. So I'm constantly re-referring after a few years and it definitely makes a difference. So you know, we all need refreshers.
Dr. Alicia Jeffrey-Thomas:No, exactly. I think I heard somebody use the example of you go to the dentist twice a year but you still brush your teeth in between, and so you know we're still doing all this maintenance stuff, but you do still need to see the dentist.
Dr. Megan Riehl:So thank you to all the men that are still listening. We have a very important question for you now, because pelvic floor PT is not just for the ladies, so can you talk to us a little bit about how this PT could be helpful after a prostate surgery or when men are dribbling and having urinary leaks, or even for erectile dysfunction? Tell us a little bit about what they could expect in terms of treatment.
Dr. Alicia Jeffrey-Thomas:Yeah, absolutely. I mean, you start to see it even in much younger men who have had a diagnosis of prostatitis, which is an inflammation or an infection of the prostate, and they're given antibiotics and they're thinking that this is going to make them better and it doesn't quite resolve all of their symptoms in a lot of cases and that's because it's actually more of a pelvic floor issue in this case. So if you look at kind of a cross-section side view of a male pelvis, you can see that the prostate sits right next to the pelvic floor muscles and so oftentimes people will think, oh, there's pain in my prostate area, but it's really that those pelvic floor muscles are in spasm and so that can be contributing to pelvic pain symptoms. That can be genital pain, that can be pain through the perineum, pain in the groin, it can also have urinary and bowel implications, so they may not feel like they're emptying completely pelvic floor, keeping that tension from building back up. And then kind of, as you progress through things, let's say that you have to have surgery for prostate cancer.
Dr. Alicia Jeffrey-Thomas:The prostate is a space-occupying thing and so it helps to support the neck of the bladder and when you take that out a lot of times that instability can result in urinary incontinence, and so we're training the pelvic floor to essentially make up for that lost function, so that people don't leak when they're doing activity and then you can also have dribbling after you go to the bathroom. That could be a weakness issue, but it could also be a tension issue. So we're kind of thinking about why is that happening? Do we need to make sure that you're not power peeing and trying to force every last drop out? We're actually focusing on okay, let's relax the pelvic floor, and a lot of times guys don't even realize that they have a pelvic floor. So there's this whole rebuilding of bodily awareness that's going on.
Kate Scarlata, MPH, RD:Can you talk about power peeing in women too? Because I think some people are pushing it out real quick and trying to move on with their day. But that's probably not a good idea?
Dr. Alicia Jeffrey-Thomas:It's really not a good idea. When we're pushing. It's putting a lot of pressure down onto the pelvic floor, which can weaken it over time. So even if there is a kid screaming in another room or you're trying to get onto a meeting in the next five minutes, you really want to give yourself that time to relax, take a deep breath while you're going so that we're not messing with our pelvic floor muscle function over time. It should not sound like you're frying chicken in the toilet bowl. I know there's people that want to have a strong stream, but that's a little too far.
Kate Scarlata, MPH, RD:Yes, that's so funny. One more question. Peeing, just in case? I have to hop on a call. I'm running out to the grocery store. There's some negative effects to that? Or tell us about peeing, just in case. Totally.
Dr. Alicia Jeffrey-Thomas:In most cases you shouldn't be peeing just in case. Your bladder needs to be able to fill up appropriately in order to be able to contract empty appropriately. And so if we're repeatedly going in and kind of cutting it short, we're losing some of that contractility of the bladder and it's also going to affect when your bladder senses that it's full. If it's only filling up to 50%, most of the time it's going to start to tell you oh hey, you need to be going to the bathroom when you're only about 50% full, even if the capacity of the bladder is much larger. And so then that can result in more urgency and more kind of compounded frequency, because then you're trying to jump the line and get in front of when you're going to get that signal.
Dr. Alicia Jeffrey-Thomas:So normal time between trips to the bathroom is anywhere between two to four hours. So I usually use the examples of. You know, if you're just making a quick trip to CVS and it's only been an hour since you last went to the bathroom, like don't go, just in case before you do that, like you can get in, get out, get home, it's going to take maybe more time to work up to doing a Costco run without doing a just in case pee. But you can get there. You absolutely can get there. It takes a little bit of that bladder retraining knowing what your limits are, knowing what's happening with your pelvic floor and how to manage an urgency situation when it occurs.
Kate Scarlata, MPH, RD:That's good advice yes, so this has been incredible and just so much valuable information for all of our listeners, all sexes, all ages, all stage of life. So, as we wrap up, we'd love to hear what you do for your own gut health and well-being.
Dr. Alicia Jeffrey-Thomas:So I was a really constipated kid and so I have my routines that I've kind of fallen into right. So I make sure that I have my smoothie every morning. I use my coffee to get things going. Obviously I make sure that there's a squatty potty pretty much wherever I go, so we put them in the office at work I have them in all of our bathrooms. At home I have a travel squatty potty that I take with me. I never want to be caught in a position where I'm trying to be up on my tiptoes or making something up to try to get by there and then also just staying on routines in terms of physical exercise and movement, also just staying on routines in terms of physical exercise and movement. If you're active, you know movement is good for bowel movements, and that is one of the things that I like to impart the most to my patients.
Dr. Alicia Jeffrey-Thomas:And I try to be that example for them as well.
Kate Scarlata, MPH, RD:I love that.
Dr. Megan Riehl:Yeah, you know. I hope that everyone will pick up power to the pelvis because, as we've learned, we all can benefit from it, and you'll have some fun following you on social media at the pelvic dance floor. So, Dr. Jeffrey- Thomas, thank you so very much for joining us today and, to all of our listeners, we hope that you will subscribe, follow and like The Gut Health Podcast. Your support means the world to us, our friends.
Dr. Megan Riehl:Thank you for joining us as we grow this gut health community. We hope you enjoyed this episode and don't forget to subscribe, rate and leave us a comment. You can also follow us on social media at The Gut Health Podcast, where we'd love for you to share your thoughts, questions and experiences. Thanks for tuning in, friends.
