Season 3, Episode 4: Pelvic Floor Function & Digestion

This episode features special guest Jeanice Mitchell a physical therapist with advanced training and certifications and women's health, biofeedback and pelvic health. Jeanice began specializing in this area of physical therapy after the birth of her son in 1999, and she has seen the profound impact of pelvic floor physical therapy on her own life, as well as countless patients over the years. She started mypfm.com, which is a non-profit 501(c)(3) in 2018 with the goal of improving global pelvic health awareness and access to resources. The mission of myPFM is pelvic health for everyone, everywhere, every language! You can find engaging pelvic health content and resources on her website, her Instagram and her YouTube channels.

This episode is going to dive into what the pelvic floor actually is and how pelvic floor muscles can impact digestion, as well as the role of the pelvic floor physical therapist for those who are dealing with digestive issues, and even digestive disorders like IBS. So sit back and enjoy this engaging and fun episode with Jeanice and then let us know what you think by leaving a review or coming over to the community where we can talk more about the episode!

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Erin Judge: Jeanice, thank you so much for being on! I want to dive right into just hearing a little bit about you, so can you share a little bit of your story and why you decided to become a pelvic floor physical therapist and specialize in that area?

Jeanice Mitchell: Yes, absolutely. Well, first of all, just thank you for the opportunity and thank you everybody that's listening! I know time is valuable, we really appreciate you being here. And I thank you for the opportunity, Erin!

So in 95, I graduated from PT school and in 99 I had my first baby. I was a young, healthy PT. In PT school, at that time, we didn't cover pelvic health, this was not something that we discussed or learned about. And so I had a baby and I had leaking, I had pain, I had heaviness and I was like, okay, what's happening? Nobody's talking about it. And, you know, kind of on a side note, I lived in a third floor apartment. So I'm walking up and down all these flights of stairs, with the diaper bag, with the baby, with the car seat, maybe even with the stroller on my back, I think maybe not that much. But you know, you really load yourself down, and I know this talk isn't specifically about that, but you know, just because you can in the immediate postpartum period doesn't mean that you should be doing that because the pelvic floor muscles undergoes so much during pregnancy, labor and delivery.

Alright, so I was doing all this stuff, I had these symptoms, I saw an ad for a course, small, little ad. And I'm like, okay, that looks good for me, so I went to the class. The first morning of the anatomy lecture literally was awe inspiring. I'm like, oh my word. And I had my master's right? And I grew up in a medical family, but I didn't know this, how the pelvic floor works and how it interacts with the bladder and the bowel and the vaginal canal and how everything is so interconnected, and that the pelvic floor muscles are at the core of the function of these organs. Right? And all the quality of life issues that could go along. So I'm like, okay, yes, this is what I want to do, and how can I know this information and not share it with others?

It was the beginning of my professional path too because I didn't want to look at the vaginas and anuses, that was never my plan for my professional career, but here we are! And so that was, again, my baby was born in 99, so I was in that class in 2000. And we're like 22 years into it, which is crazy. And I've had the opportunity to impact so many lives, and my myself like, it personally has made such a huge impact, and then professionally, being able to connect with people within my clinics, and then also now with social media, beyond.

Erin Judge: I love that, that's awesome! It is wild to think that in your training you did not learn about pelvic floor, and we're going to get into more of like, why that's so appalling, because it is. It's also interesting that you've been around then in this area and specialized in this area since kind of the beginning, right? Because if they weren't teaching that in school yet, then I'm assuming that you're learning about this right at the start of understanding the pelvic floor as a whole.

Jeanice Mitchell: I would say it was at the beginning, it was at the beginning of increase in awareness, but there's PTs out there now, you know, some have even passed away that were in their 70s, and 80s. So I feel like there have been a core group of people that were you know chugging away, but it just wasn't known. And so certainly, I would say in the early 2000s, it started becoming more well known, and then with social media, it's just exploded, and people are looking for conservative options. So what can I do without medication without surgery? What are some options? And here we are as physical therapists, that's exactly what we do!

Erin Judge: Amazing, I love that. And that's lines up a lot with digestion, as well, even nutrition for digestion, I didn't learn a lot in school, which is fascinating. So getting to why that's so appalling that you didn't learn about this, and I mean, being a human being who has a pelvic floor that we are interacting with every single day, in multiple ways, maybe in all the ways and not even understanding what that is, to me is mind blowing, like we should learn this in elementary school. But can you tell us a little bit on a more simple level, what is the pelvic floor? What does it do? Where is it and how are we interacting with it?

Jeanice Mitchell: You know, I love this topic. Okay, all right. So I have a model here and so this would be a female body, female pelvis. So we have the pubic bone to the front, and then we have the spine and that would be the tailbone. Okay, so we're going to look as if you were standing at this person's feet looking into the perineum from below. So this is where the glans clitoris would be, and, you know, anatomy is so important to the pelvic floor, and that's what we should be learning in elementary school too, because I didn't, I mean, yes, I guess I knew that I had three holes, one for pee and poop and sex, but did we really talk about it? No.

Okay, and certainly the clitoris, like that's a, you know, a taboo topic, but we don't want it to be. So clitoris, the glans clitoris there, and then it's very small, but the urethral outlet. So that's where pee comes out, this would be the vaginal opening and then that's the anus, so that's where poop and gas come out. All of these structures here are pelvic floor muscles. So depending on how you count, you have 19 pelvic floor muscles that do different things. And so that's when someone comes in and says, oh, I've tried kegels and they don't work. Well, there's so much more to pelvic floor muscle training than kegels. And even if you were contracting correctly, where are you contracting the right muscles correctly? Were you working on the relaxation?

So let's I'm jumping a little ahead. But let's say, so here's the anus, and you have a group of muscles here called the external anal sphincter muscles. So let's say that you're leaking poop or you're leaking gas, but when you're doing the pelvic floor muscle training, you're working on all these front muscles, and you're not really addressing the back part. Well, that's not going to make a huge impact in your symptoms, right? And then that's going to be like, oh, well, kegel didn't work. Well, no, no. Let's go back to the beginning. Let's assess the muscles and define which muscles are involved. What are they doing? And where do we want them to go?

So that's from the outside you and you have several layers too. So you have a superficial layer and deeper layers. And then this would kind of be a side view of the pelvis, so we're opening her up and this is the bladder, okay, so that's where urine would exit, here's the uterus, and the vaginal canal, and then the rectum and the anal canal. And let me just grab this, two things here. The pelvic floor muscles wrap around each of those canals, the bladder canal, the urethra, the vaginal canal, and the rectal canal. So if you imagine your bladder, kind of like a water balloon, and the pelvic floor muscles wrap around the outlet to control it, and the same concept applies with the rectal canal. So you have the pelvic floor muscles that wrap around it, so they need to stay active and have good strength, tone and coordination to prevent leaking. But then when it's time to poop, or when it's time to pee, you want them to relax and let go.

So that's some of the I mean, that's not everything the pelvic floor does, it also has a sexual function. And like the word says, pelvic floor muscles, it's literally the floor. So these organs, the bladder, uterus, and rectum are sitting on this floor, kind of like, I'm going to give you this little chicken here. So you have this floor, and the pelvic floor muscles are lifting those organs. And so if the pelvic floor muscles aren't doing a good job there, then you can have something called pelvic organ prolapse, and that can also affect digestion, you know, in terms of a rectocele where you have something dropping down. So that's a more advanced topic, but there's a lot of things that the pelvic floor does.

Erin Judge: That's amazing. And yes, there's so much to talk about with that, the connection to the core, the connection to all the openings, and we're gonna focus a lot more on digestion, but that's where I think getting more education and like you mentioned through social media is such a good way to see visuals and have those conversations to know what am I feeling? And what am I what am I connecting to and what's going on in my body because I even as a health professional myself, like, I didn't learn any of this. I took anatomy and physiology. You know, I learned about a lot of things. As a woman, I never learned about my vaginal canal, like, you know, I never learned about those things. And when you do learn about them, you learn about them, maybe from like a sexual point of view, or from just a peeing and pooping point of view. And it's always more symptomatic, it seems like or superficial versus like understanding actual function and what is health of muscle like all of that is something that is mind blowing when you start learning about it.

Before we kind of talk more about the specifics around digestion, I do want to maybe look at a few myths and things that I even kind of questioned and thought about and things I get asked about when I even mentioned pelvic floor and just get your viewpoint on those. And the first one is, are women the only ones with a pelvic floor?

Jeanice Mitchell: All people have a pelvic floor. So every person that's alive has a pelvic floor and pelvic floor muscles, children, male bodies, female bodies, people with penises, people with vaginas, everybody has a pelvic floor.

Erin Judge: So it just looks a little bit different from male and female anatomy, correct? Yeah. And some of the connection points are they also different or things customized a little bit?

Jeanice Mitchell: Yeah, so like the base of the penis, you have….but it's actually more similar than you would think. So with this model here, you can see how these two pelvic floor muscles actually go up and attach right there to the clitoris. And the males, or, you know, male bodies are very similar. So you have these muscles that wrap around the base of the penis. So there's a lot more crossover than you would think, but there are some variances as well.

Erin Judge: That's helpful. And it's helpful if anyone's listening that does have that anatomy, like you can kind of think about, you know, visualizing what that looks like for you too.

Jeanice Mitchell: Erectile dysfunction, premature ejaculation. Like those are two big ones and pain.

Erin Judge: Awesome. We're going to get into the symptoms in a little bit, because that is something that's so important to talk about is what are the warning signs? And are they normal? Are they not? On one thing about normal, is it actually normal to pee a little when you jump up and down?

Jeanice Mitchell: Not normal. It's so common and I think a lot of people have normalized it, but it's not how our bodies are designed to work. So remember going to that analogy of the bladder, and the muscles wrapping around the bladder. So we want those muscles to have the tone, the coordination, the strength and the support, because when you jump up, when you jump, there's extra stress being put on that bladder, right. And so the pelvic floor muscles have to be able to counteract that force, whatever the force is. And so if it's a baby jump, it's a little force. If it's a big jump, then it's a big force. And so the pelvic floor muscles may not have the tone, strength, coordination, support to counteract that force, and then you'll have leaking, but it's a warning sign. It's a warning sign, it's like, hey, something's going on. And too many times you see, okay, I leaked a little or I had a baby and I had a little leaking, but my mom had a weak bladder and and now you're 40 years old. And now you're having to wear, you know, a poise pad or depends. So you see liners turn into mini pads turn into maxi pads turned into, you know, more and more supportive undergarments and absorbent undergarments, and it doesn't have to be that way.

Erin Judge: That's awesome, like I hear that a lot of like, how normal is how much of a joke it is, what about this is not something actually prior to this, but what about like running, pooping while you're running? Because I know that's kind of a joke around like marathon runners and even athletes that I've met and worked with have like pooping on the run or pooping, you know, in your pants while you're running. And it's almost a funny, like, normal thing. Is that also normal or is that linked to pelvic floor?

Jeanice Mitchell: Yeah, it's the same concept that applies there from the bladder to the bowel. So those muscles, we want them to have the tone, the strength, the support, the coordination, to hold, to be continent, to not leak, to not leak poop, to not leak gas, to be able to hold it in so you can choose when and where you go. There's a whole lot of factors that go into that, but it's not a normal thing although it might be common.

Erin Judge: Yeah. And then when it comes to pelvic floor physical therapy, which we're going to talk more about what that actually means, but it's physical therapy for the pelvic floor. So we think about physical therapy as something's wrong so we're trying to fix that, right? We're trying to recover? Is that only for women, or for those who have had a baby?

Jeanice Mitchell: No. So we can see anyone, again, that has a pelvis, and that wants to get better and that has the cognitive function. So you know, there'll be maybe some seniors or somebody that or, you know, really any age range, if you don't have the cognitive function to be able to participate, then that's a challenge. And then in terms of children, generally, we'll say at least age five, and again, that's kind of from a participation standpoint, like you want them to be engaged and to be able to participate in the program.

Erin Judge: Yeah, that makes sense. And does that come down? I think something that would be helpful to understand is because when we think about digestion, specifically, or we think about even what you mentioned, like we should be able to pee when we need to pee and hold it in when we want to hold it in. It seems like that should be involuntary, right? Like it should be something that we don't even have to think about and that it should just happen naturally and normally. And when you're thinking about cognitive function, the first thing came to my mind is that difference between voluntary and involuntary, like action and muscles. So can you speak on that a little bit about why problems can happen when it should just happen naturally? Like, why did things go wrong with those muscles?

Jeanice Mitchell: Yes, so some key life events, although, like we said, even children can have pelvic floor dysfunction, but some key life events that really definitely put stress on the pelvic floor, are pregnancy, and so there's that myth that oh, I had a C section so I'm not going to have any pelvic floor issues. So that's not the case, it's a myth. So pregnancy, labor and delivery and during labor, during delivery, so you have this area in between the vaginal opening and the anus, this is called the perineal body. And so many people tear here, and there's different grades of tears, there's a grade one that's just a little bit to two or three, and then a four goes all the way into the rectal canal. So imagine, like a grade one doesn't actually tear the muscles, but a grade two, you're going into some of those muscle fibers and a grade three and four is going even deeper into those muscle fibers. So you can have, you know, tearing, and then also deeper pelvic floor issues, tearing and trauma called the levator ani avulsion during labor and delivery, and then another big life event is menopause. So, you know, we have, potentially, let's say you had a baby 20 years ago, or 30 years ago, and oh, wait, I didn't even tell you, I have to back up.

So the pelvic floor muscles, during a vaginal delivery, stretch up to four times their resting length. So if you imagine, let's take this piece of band here. And so let's say this is a muscle at rest, and then you took that muscle and you stretched it almost four times it's length, you know, the pelvic floor muscles are special, but they need recovery, they need time. And kind of like that analogy that I was giving you, where on the third floor of an apartment going up and down, carrying all this stuff. We need to be thinking and doing prevention, postpartum prevention, pregnancy, and even before pregnancy, getting your muscles in a good healthy condition to prepare them for what they're going to go through, because healthy muscles are going to be less likely to leak during pregnancy, and less likely to have issues postpartum than muscles that aren't healthy.

So then we have menopause. So lots of hormones affecting our muscles and affecting our tissues. And so you may have had some pre existing issues from that baby that you had 20 or 30 years ago that kind of reared their head during menopause. So some very common things happened during menopause, and then pelvic surgeries. So if you had any kind of pelvic surgery, or trauma, abuse, those kinds of things. So those are some of the big key life events that you'll see pelvic floor issues.

Erin Judge: Yeah. And when you're thinking about healthy muscles, so I think I always like the analogy of like, my bicep, I'm not going to be able to curl a heavyweight, if I don't actually, like curl some lighter weights, right? It's like if the muscle isn't strong, it's not going to do what it needs to do. And if it's not flexible, like I can't even reach my arm all the way like I need to. Is that something that, I know, we see that maybe later in life too. But is that something we see with kids even like if people just aren't connected in like training their muscles and like, just like with exercise, and you know, weight bearing activity, it's like, you probably can't climb a set of stairs, if those muscles that you use to climb stairs have never been worked before? Is that true of pelvic floor as well?

Jeanice Mitchell: You know, we need more information on like, healthy normal pelvic floor muscles. We know that the pelvic floor muscles are active, whether you tell them to be active or not. So in terms of what is an ideal, like training program, should people that have had no, you know, none of these things happen to them yet, should they be specifically training their pelvic floor or not? You know, there's a lot of different schools of thought and I think more research is needed out there. I'm of the belief in theory that it is important, especially if you know you, let's say you are about to be sexually active. Okay, so that's another life event that's about to happen. So preparing for that event, preparing for pregnancy, preparing for delivery. So doing these things in advance, but there's just not a lot of research out there to say, if you do X, Y, and Z in this time period, that it's going to reduce your you know, your issues. We infer it and there's a little research, but it's more we need more.

Erin Judge: Yeah, absolutely. And that would be interesting to see, it seems like it makes sense, right? It's like, well, if I have healthy muscles, like I can do things better and how do I know if I don't have healthy muscles? Like maybe I'm doing my movements wrong? You know, it's you don't know sometimes, so that would be interesting.

Jeanice Mitchell: If I could just jump in with one thing there. There was some guidelines released recently, well, last April, from the Royal Australia Obstetricians and Gynecologists, okay. And it's clinical care standards on how to prevent perineal tearing, so I just showed you about the perineal tearing. It's actually, one of the key recommendations there, is training the pelvic floor muscles, strengthening and releasing, not just releasing. So I think that there is this movement like, ah, stop strengthening, just work on relaxing. But a healthy muscle needs to do both, you know, you don't need to just have a muscle that's all the way stretched out and it's not able to do what we need it to do. So I think that's exciting that these clinical care standards are there, and that they're showing that they're helping to reduce third and fourth degrees tears. And we would love to see those across the world.

Erin Judge: Absolutely, absolutely. And I agree, I think with the awareness, you know, we've seen it with other conditions and with things before, where the more that people are aware, and they're asking, they're advocating, they're wanting it and the more that professionals are specialized and leading that charge, I think that's where we start to see that happen, because money can fund it. And also, you know, all of those things that go into it.

Jeanice Mitchell: Yes, in fact, I’m going to give you the link, I'm making notes, because too many times I'll say, oh, yes, I'll send you this, oh, I'll send you this and then I don't remember or, you know, so I'll send you that link so if you want to attach the wait for anybody that wants to read those kind of those clinical cares.

Erin Judge: Awesome! Okay, so now getting into the problems. So we know kind of what the pelvic floor does a little bit, and if you're listening to the podcast, and some of that isn't connecting, I do encourage you to go to the YouTube video because the video version of this will be really helpful, or go to Jeanice’s Instagram and go over there, to make sure that you feel like you're connected there. But let's get into digestion. So you mentioned that, you know, the muscles need to be able to contract and release properly. How are they involved specifically with digestion? And how could those muscles play a role in digestive disorders like IBS?

Jeanice Mitchell: Okay, so we didn't talk about this in the anatomy, we've got to include this. So pretend like this red tube is the rectal canal and pretend like this stretchy thing here are the pelvic floor muscles. So the pelvic floor muscles actually loop around the rectum and they create what is called the anorectal angle. So you have two key points of the pelvic floor muscles with controlling what comes out the anorectal angle. So when you poop, that angle needs to straighten out so that the poop goes out the rectal canal, right, because it's helping to close that off, which is good when we want it to, then we need it to release. And then the second point there is the sphincter there, so the external anal sphincters, kind of like this, right? So we need them to stay closed and active to prevent leaking, but then when it's time to poop, we want them to relax, to allow that opening to soften so that material comes out. So those are the two key points.

And then training, so with constipation, IBS-C, right, IBS constipation, your pelvic floor muscles may not be releasing, and so it's almost like you're pushing like against a brick wall, something is just not letting that food come out. And with that straining, you're actually doing bad things for your pelvic floor too. So here's my chicken again, so if you're straining, straining, straining, you know, that can even contribute to pelvic organ prolapse. And, you know, if you have it worsening of those symptoms, or if you don't have it potentially contributing, so that's IBS-C.

IBS-D, so the diarrhea portion, what are we most worried about with diarrhea? That you will poop your pants. So those muscles, we need that anorectal angle to stay nice and taut. And so the pelvic floor muscles are keeping the anorectal angle where it should be. And then the external anal sphincter part of the pelvic floor is keeping that closed. And then, you know, I think that the sampling reflex, if you haven't heard of it, it's a really cool reflex that is in your rectum, and it can tell if it's gas, if it's liquid poop or solid poop. And so I mean, I'm pretty sure most everyone has passed gas and it wasn't gas, right, like, so the sampling reflex didn't work so well in that scenario, but most of the time, you when you feel like you need to pass gas, you are, it's actually gas, and so the sampling reflex is able to control and be able to tell what type of substance it is. And so, then going into what we're putting into our bodies, and how all of that affects even the sampling reflex, you know, that can be a whole other, I'm sure you have so many resources on that, but what you put in definitely affects what comes out.

Erin Judge: Absolutely. Yeah, because I mean, if everything's liquid to start with, it's gonna be harder to figure that out too. Or if you have a lot of gas production, if you're putting pressure on it, you know, there's a lot that I think can happen there. But that's interesting. You mentioned straining can cause some damage. When someone's straining, I think the thought is, oh, well, I'm actually pushing things down and out, when someone is straining, are they doing that? Like, are they actually connecting to those pelvic floor muscles? Or what's the action that they're they're really doing?

Jeanice Mitchell: Well, there is an element of pressure that has to happen with a bowel movement, okay? What we want to avoid is like closed glottis straining, okay? So that's where you have no air exchange happening. This could be your face is getting red, your eyes are bulging, you're like, if you're listening only you couldn't get the whole effect. Okay, but so we want to avoid that kind of straining. The healthier kind would be, and there's so many tips that need to happen to like, are we are we going to talk about that? But your posture, so get on a Squatty Potty. So that's inherently, when you squat that helps to straighten out that anorectal angle. So, you know, who's putting standing up? Like, yeah, you know, I, I have a therapist that had a child, you know, that only poops stand up, but it's not a healthy, it's not a healthy posture. So we want to have those knees up to help straighten up the anorectal angle, and then you want air exchange. So you want to say move. And so there again, there is some intraabdominal pressure happening, but it's not that straining then most people associate with pooping.

Erin Judge: Yeah. So it's not as simple as saying strain or don't strain, push or don't push. It's making sure that what you're doing is effective and connecting to the right things and you're utilizing kind of the function of all the organs, which is so helpful. And that goes into what are some signs, you know, that someone would need support? So we've mentioned if you're leaking, that's not normal, so that's a big one. But let's say maybe you're not or maybe things aren't coming out, you're constipated. But what are some other signs that someone could maybe highlight like, maybe I need some help with my pelvic floor?

Jeanice Mitchell: Yeah. So I would say any pain, so if you're having pain with pooping, even if you are pooping, but it's painful, or pee, so if urination is painful, or if you have a stop start urine flow, incomplete emptying, so that would be either the bladder or the bowel, so you think you're done and you get up and you're not. Seeping that might happen. Also, we have any kind of pain with insertion, so especially like vaginal insertion, or deep thrusting, so any kind of pain, but then also difficulty with orgasm, that can actually be an issue with the pelvic floor. So if you're having a difficult time achieving orgasm, or if you're having pain with orgasm, or like what you know, I briefly mentioned with male bodies like premature ejaculation, erectile dysfunction, those are all signs and symptoms that potentially the pelvic floor muscles are involved. Bladder pain, interstitial cystitis, painful bladder, pelvic organ prolapse, feeling like there's a vaginal buldge. So do you feel like going back to our little chicken, you know, do you feel like you're sitting on a tennis ball or a golf ball? Do you feel like there's extra tissue down there? Do you feel extra heaviness or pressure at the end of the afternoon? That might be pelvic organ prolapse, and so getting that checked out, so that you can get on the right path for rehab and recovery.

Erin Judge: Yeah, that's so helpful. Could the muscles even on the external part or the internal pelvic floor muscles, those deeper layers, can they be cramping as well? I know we see cramping a lot with the intestinal muscles and that's something that people with IBS do deal with quite often. But sometimes there's that feeling of like, people have described it as like popping and bubbling and like cramping, almost like at the base, like, can that be pelvic floor? Or is that typically more intestinal?

Jeanice Mitchell: Yes because the pelvic floor, so we can have overactive pelvic floor muscles that are very, very tight and that they just aren't we aren't releasing well, and that would be more generally where we'd see like issues with constipation or difficulty pooping. But then the flip side would be, you know, underactive pelvic floor muscles and that can happen in any of the muscles, so it can happen around the external anal sphincter can happen in the deeper muscles like the puborectalis, it can happen at the front, so definitely you can have that cramping and overactive and sometimes it might feel burning, it might feel itchy, sometimes you can have numbness, all of that could be attributed to overactive pelvic floor muscles.

Erin Judge: That's so interesting. I'm sure a lot of people are thinking like, oh, that kind of that kind of sounds like me a little bit, especially people that are dealing with digestive issues. It's like, well, there's probably constipation or diarrhea or something going on and so it should be highlighted a little bit maybe you know, this could be a piece. If someone does think that, how can they advocate for a referral, maybe to a PT? And something I see a lot is does someone actually needed anorectal manometry exam first, or kind of what is the process actually look like to determine the function of the pelvic floor and the need for physical therapy?

Jeanice Mitchell: So you don't need anorectal manometry to see a PT, in fact, I would say that the majority don't have that test. Depending on where you are, many states are direct access, meaning you can go straight to the PT, you don't have to go to a referring provider. But with that, there's just many factors to take into. So if you have health insurance, and you're wanting the physical therapy to be covered by your health insurance, which it should be, because physical therapy should be a benefit, and this is part of physical therapy. Does that physical therapist accept health insurance? Are they cash pay only? So there's, you know, and then location? And do they treat, let's say, you're male, you know, you have a penis. Do they treat you? Do they treat children?

You know, so, I would say 99 out of 100 are going to see postpartum, pregnancy, you know, menopause, but some of these other specialty populations that physical therapy isn't necessarily mainstream for in terms of awareness, so making sure that they can see what you want to be seen for. And then if you, let's say, you, let's say you have health insurance, I would….let me just back up, I think it's important to be proactive, where you are. So understanding, if you want health insurance to cover it, do they require a referral from your primary care physician? If they do, then you need to then that, that's one step that you've got to go get a referral from the primary care. Is your state direct access? So let's say your health insurance doesn't require a referral, but your state is not direct access, so you can't go straight to the PT, then you need to go get a referral from you know, somebody that can that can send you there. And anyone like PA, nurse practitioners, MD, and all of those can send you to physical therapy.

So being proactive on mypfm.com, on our website, we have something called Find a PT and we have links to free searchable databases. So you can go in there, put in your zip code and where you live, and then you can see who pops up. And then I would be in it for patient, like call them, hey, I have XYZ going on, do I need a referral, you know, they're going to be very knowledgeable in what that state requires and so you know, making that connection with them. And if you live in a larger area, then you're going to have more options, if you live more rural, you're going to have less options, but that's a good place to start.

Erin Judge: That's great. That's really helpful. And, and I think it's also good to talk a little bit about what if you do need access, or maybe brought it up with your doctor that you trust and you know, you want to make sure that they're on board and they say, oh, you don't need that? Or like, yeah, let's do this manometry test first. And I say this, because this is what I've experienced a lot of my clients where they have to pay hundreds of dollars for the test, and you know, it might come up as positive for something or negative, and then they might get a referral then or, you know, doctors have said, you know, I don't think that that's needed, you know, what could someone do? Are there resources that they could share? Or is there kind of something you found that's been helpful for educating certain providers, especially like a gastroenterologist who's working on their care and could be a helpful collaboration?

Jeanice Mitchell: Whoo, I need to have a research article page that you could just go print off because that's what's gonna speak to them is the research, you know, you could send them to my Instagram, well, if they're not already on board with pelvic PT, the chances that they're going to be persuaded by you know, social media are pretty slim, they're going to want to see peer reviewed research from a reputable medical journal and there's a lot of research out there. So, you know, we have some professional resources at my pfm.com, we definitely have some, but they're not free. So yeah, that's not necessarily an easy question, but maybe we can develop a resource area together that we can send people to like hey, if you have this symptom or this is going on, here are some articles that you could print out, or, you know, some some information that you could print out to take to your doctor. I think that's a fabulous idea!

Erin Judge: Yeah, absolutely. I think anything that helps, you know, the patient advocate for what they need. And we see this a lot, even with dieticians, like sometimes doctors don't want to refer to a dietician. As the patient, you know, I think sometimes we forget that we have rights to health care, like we actually have the right to get the health care we want. And if you're dealing with leaking, and you believe that, you know, your pelvic floor needs to be evaluated by a professional, like, you have the right to keep pushing back and advocate for that. Sometimes it can feel so defeating and it can feel like you're getting shut down if someone says no, and you know, but then you also don't know what to do. And, you know, it's helped in the past with my patients to maybe even explain like specific symptoms they are having, something that you know, I talk about patients all the time is, well, do you have difficulty with insertion? Like, do you use tampons? Do you not? Like, why not? Or, you know, whenever you go get a pap smear, like, does that actually happen for you or is that painful? And sometimes that can help them get a referral, but even just constipation, or diarrhea or feeling like I don't know, if I'm using the right muscles, like someone's asking specifically because of that, versus just, should I go see a pelvic floor PT can be helpful. But I do agree a research, like research resource is always great to send on and say, you know, this might be beneficial for me. And we're at the point where we try to refer every single person

Jeanice Mitchell: Why wouldn't you have a pelvic PT on your team?

Erin Judge: Absolutely. Yeah and even just, I think I would love to see the research, like you mentioned, of what does a healthy pelvic floor look like? The more I learn about pelvic floor, the more I'm curious about, like, well is mine as healthy as it could be, you know, I want to know early like I want to know now before I have children, you know, I want to know now before I get older, like I want to know that I'm doing everything I can, just like preventing osteoporosis, you know, I want to prevent things. I want to be able to hike whenever I'm 80 years old, like if that's part of it, you know, I want to make sure I'm doing it! Outside of like anorectal manometry, which is a test that can be done, but how can you evaluate a pelvic floor? So it's part of pelvic floor PT, right? Like getting started is an evaluation? What does that actually look like and what do what the first steps usually look like?

Jeanice Mitchell: So getting that first appointment, the PT is going to hopefully build a very good connection with you and get a lot of history and get your goals and really listen to you too like, hey, what do you think is going on? What are you afraid of? What are your deepest concerns? So really diving into that because it's way more than just the physical aspects here, right? And listening to you. So generally, that first visit is going to involve taking off your pants and looking at the muscles externally, so feeling you know is are there tender points, do you have prolapse? How are the nerves, how's the sensation, and then doing an internal assessment too, either vaginally sometimes rectally, if needed. And then also looking at the whole body. Do you have a cesarean section scar? Do you have other pelvic scarring? What's happening with your tailbone? Looking at your posture, how you're walking, how you're sitting? The pelvis doesn't exist in isolation, right? All these other, you know, as part of the body, it works together. So looking at everything, but diving into the pelvic floor and doing the internal assessments, do an external assessment and then communicating with you, okay, so this is what I found and this is what I think will help, how does that sound to you? And so, you know, if it sounds bad to you, you want to have that relationship, like, hey, you know, I don't know if I'm really comfortable with that piece. Or maybe I can't afford that piece, is there an alternative? So being, hopefully being very open and honest, and then it's hard, though I know, especially as a patient provider, like, you know, it's sometimes hard to speak up, but speak up, we want you to speak up!

And then also understanding that not every pelvic PT is the same. So if you had pelvic PT in the past, and it didn't go so well, don't give up, it's kind of like other professions. So if you had your car serviced and it didn't go well, okay, does that mean you're never going to service your car again? You know, like, no, let's figure out and ideally, you know, working with that pelvic PT to say, hey, I feel like this is making a difference, but you know, I'm not getting here, what can we do? And again, hopefully they're being proactive each visit you come in, hey, what's going on? Okay, well, how's this going? Are we getting here? You know, we want to see progress every visit. It's not a magic pill so it's not going to be like, okay, I did one visit of PT, and now I'm cured, and I have no more issues. It takes time, it takes consistency.

There's a really good pelvic pt over in Europe, and she's done hundreds of research studies. And this protocol she uses has been duplicated in a lot of her research studies and others. And her protocol is a six month protocol. So I just want to plant that in your head, whoever is listening, like six months of consistent pelvic floor muscle training at least five days a week. So it's not just oh, I'll do five minutes on Monday and then I'll see the PT when I go every other week, you're not going to see the outcomes. Think about any other muscles that you're trying to train and build and improve their health and flexibility and coordination. Would that work for them? No. So you want to build up your bicep, what are you going to do? You're going to work on strengthening, you're going to work on a maximum voluntary contraction, you're going to work on endurance and coordination and lengthening, stretching, I mean, it's a whole approach to training your muscles and applying some of those same concepts to the pelvic floor.

Erin Judge: That's great. I think it's good to have those expectations, healthy expectations, of what does like time look like and, you know, being able to go in knowing what to expect, going in knowing that there's some trust that can be built, and that's okay. And I think what you mentioned earlier of like calling, making sure that things are covered like you want or making sure that people treat you like you want to be treated and you know, those who, maybe your anatomy doesn't match, like the gender, you know, that your your I don't know, the right words for that. Things don't match. Gender affirming, like, you know, just making sure that those things line up with what you need, because that could interfere with the progress that you're wanting to make, so I think that's really important. If someone's hearing that, and I know you mentioned a little bit about, you know, past traumas. And that's something that I've seen with clients like not wanting to get certain care because of past trauma that they've endured, and I'm sure you see that quite often. Is there kind of a first step, so if someone's listening, and maybe that type of assessment doesn't seem even doable, like that would not be something that they would be comfortable with, especially on a first appointment, is there a process that you like a pelvic floor PT would use? Or maybe like coordinate with, like their therapist? Is there a way to kind of go for that, so that they can eventually get to that point and be able to utilize that service?

Jeanice Mitchell: Absolutely. So there's a lot of things that we can do with externally, but then there's a lot of things we can do even with clothes on. So if you look at this, let's just use this as an example. Okay, so let's say that somebody had a grade three or grade four perineal tear and they're leaking poop, okay. And they have quite a bit of scar tissue and pain as well. So they come in to pelvic PT, but they aren't comfortable taking off their pants yet. That's fine. So number one, it's a red flag if your PT is like, you have to do this. Well, you don't have to, it's your choice. Okay. So there's a lot of things that we can do to help stretch this area, even with the clothes on. So think about, like, okay, so if you can see my model here, so we're working on trying to stretch this area, so or even, I'm going to just so even just some leg stretches, can you see me okay, here?

So basically, you know, this kind of stretch right here is going to help open up that area and there's, you know, multitude of variations on different exercises that can be done to help stretch. There's different ways that we can help to even mobilize the tissue, we can teach you how to palpate yourself. So we can kind of walk you through self assessments. And I think it's a great idea to collaborate if you have, like a mental health provider. I don't think we do that enough. But I would suggest that you suggest that to the PT, like, hey, I'm working with this really great counselor and I'd love it if you would communicate because I want to optimize our time together. And so I'm sure, I mean, I just sure that your pelvic PT will say yes, give me the number and let me connect. And if they say no, then again, that's another red flag, go find somebody else.

Erin Judge: Yeah, it’s good to like, pull out those red flags and like, ask the questions and, you know, speak up for what you need and what you want because I think that's a barrier, you know, especially, I don't know about everyone else, because I live in the US so that's kind of what I know, but it seems like that's a barrier to healthcare for a lot of people is that there's this belief that well, I need to do exactly what they say, and I see that with even dieticians, you know, with me, where maybe a client does something that I recommended, and they absolutely hate it. Like, why didn't you tell me that you hate it? You know, it's like going back to like, you don't have to do that if that doesn't align, if that doesn't work for you, you know, speak up and tell me, tell someone else. And the more that we communicate those things, I think the more you can get something out of it. I think that's helpful to hear that, you know, maybe if that is a barrier or concern, like it's okay to bring that up and then it might go slower, and that's okay.

Jeanice Mitchell: Yes, there's a wonderful way to phrase this that one of the pelvic PTs on Instagram, she did a webinar for us, her name is Krystyna Holland and how she phrased it was the menu of options. She talks to the client, here's a menu of options for how we can evaluate, here's the menu of options for intervention, so kind of giving the power back to the person and saying, okay, here are the options, here are different things that we can do. How does that sound to you? Where do you think you want to start? So I love that, I haven't always done that, but I think it's a great idea. And as a patient listening, you could actually say, hey, what are my menu of options?

Erin Judge: Yeah, I think we should ask that more, and with any provider, I think that's good. Like, what are all my options? And I think that would even open up when we talked about the role of pelvic floors. Like if maybe surgery is an option, or medication or, you know, whatever it may be, like, what are all the options? Like maybe there's not a lot, maybe there's different effectiveness of them or, you know, urgency to do certain things, but it would be helpful to know what your options are, and sometimes that question alone, can open up the door. And if they're not given any options, and, you know, it's okay to do research, and go back and say, well, you know, what about these, are these options for me, and I think we need to do that more often. And remember that our healthcare providers, they're working for us and on our behalf and, you know, there may not always and I always like to say, there may not always be a lot of great options out there, there may not be always the answers that we want, especially nutrition, but there might be some more and so it doesn't hurt to to explore it.

Jeanice Mitchell: Absolutely. Love it.

Erin Judge: Yeah, I love it too. And I love pelvic floor PT, it’s one of the health professions that I feel like do so much good. And it's all like diets, headaches, I think we're the goal is okay, you know, prevention, of course and like, we also want to work on sustainability, we also want to work on quality of life, and, you know, flexibility and personalization. And, you know, once you get into it, I think there could be some fear on the front end and a lot of my clients who've started pelvic floor PT, they're a little nervous, like the vulnerability of like, I don't know, if I want to, you know, do all of that, but they see so much benefit, because it is so personalized, and being able to have that vulnerability of like, getting the exam and like getting that care, like can get you so much further than if you didn't, and sometimes you don't know what's not normal. And I think that with digestion, like some people don't know they're constipated, because they've always been constipated. And you may not know and so it helps to get it checked out.

I don't think I need to ask this question, I had a question about, you know, is it just about doing kegals and pilates? And I think you answered that question. It's so much more than that. But what could someone start doing now? Like, what would be something that if someone's like, okay, you know, maybe I'm dealing with a little bit of constipation and diarrhea, I'm gonna bring it up and like, figure something out? But is there anything that someone could do now just to maybe start connecting more?

Jeanice Mitchell: I have a video on YouTube, it's about 40 minutes, I think, and it's called How to Poop When and Where You Choose. So I go over some tips for constipation, and also leaking there. I think that's a great place, and it's a great free place to start. Just kind of okay, trying some of these tips. Again, remember, none of this is medical advice, it doesn't replace evaluation by a qualified health care provider. But it's a place to start. So that's one place to start. You know, another option if you didn't want to actually see a pelvic PT in person, there's a lot of people do virtual sessions. And so if you would like to explore that, there's a lot of people out there that are doing virtual options. So those would be two of my big things would be the YouTube and there's tons of free resources on Instagram and so forth. I actually just launched a new platform called pelvicflix.com. And so on there we have a lot of educational videos, but then I'm also hosting live weekly pelvic floor workouts. And so if you wanted to come exercise with me on zoom, it's a really reasonable cost, because my PFM is a nonprofit as we're really trying to spread pelvic health awareness and make things very, very affordable for people. So that's another option to learn more, and then also to do some pelvic floor work at the same time.

Erin Judge: Amazing! I love that. I'll link all of that in the show notes. If you're interested in that, definitely do that. I think learning so much about where the pelvic floor muscles are located, what they're doing getting those visuals, it's a great place to begin, just to learn your body so that maybe when you do get into physical therapy, like you're kind of on the same page a bit more and you know, maybe able to like, connect faster and get that started. So I'll link all of that. How else can people connect to you?

Jeanice Mitchell: Instagram! I think the fastest way to connect with me is my email, so connect@mypfm.com. Direct messages on Instagram, I try to stay up with them, but you know, it's a challenge. And then if you don't answer it, and then you get 30 or 40 more in and then there's that unopened one that just you've never seen again, so email is the best way to connect with me.

Erin Judge: Awesome. Awesome. Well, thank you so much Jeanice, this was so informative and helpful. I always appreciate chatting with you. And I highly encourage everyone to go check out Instagram content because it's very informative and entertaining, which I think is the best combination. And so thank you for being with us. Is there anything else you want to share before we close down the show?

Jeanice Mitchell: Not at all, just thank you for the opportunity. And again, thanks, everybody for joining, I'm glad you made it this far and there's hope and help, so whatever is going on with you don't feel like you have to live with it. There's options!

Erin Judge: Absolutely.