How Pelvic Floor Dysfunction Can Impact Your Health

Episode Intro:

Welcome to Dr. Ruscio Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now, let’s head to the show.

DrMichaelRuscio:

Hey, everyone. This is Dr. Ruscio. On the podcast today, I have a pelvic floor specialist – Jandra Mueller. I have to say – this was one of the more insightful episodes that I’ve had. If you’re experiencing distension, bloating, abdominal pain, constipation, vaginal dryness, pain upon intercourse, or as a male – erectile dysfunction, it’s possible that a pelvic floor disorder is present. However, some of these pelvic floor disorders can be somewhat misrepresented online and offered up with a simple solution of Kegel exercises as one example that she helped me to understand. This can actually be the opposite of what some people need. So, not only does she have a very strong knowledge base in pelvic floor, but also a good overlapping into SIBO and much of what we discuss on the podcast. I’m looking at issues in the pelvic floor as one of an array of things that are positioned at the end of the gut algorithm. Once you’ve worked someone through, if there’s a degree of symptoms still present, this is one area to consider.

DrMR:

She really helped me firm up how I’m thinking through early indicators – to see if those early indicators are there for more ruled in via the process of working through the algorithm and still seeing some symptoms that have been recalcitrant or non-responsive. So, very appreciative of her conversation. For our audience, I just want to flag this as something that I don’t feel gets quite enough discussion. I think this conversation really brought a lot of it home. As a reminder, every one of these interviews really does lead me to go back and try to better conform our clinical model. This is to make sure that for the patients we work with, this is not something that’s missed and it goes into our problems list. We will either integrate some of these therapies into our clinic and vector them ourselves – or we will establish when is the right place/right time for the referral. All of these conversations enhance the care that our patients get at the clinic. We will now go to the interview with Jandra.

DrMR:

Hey, everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio here with Jandra Mueller. We are going to be talking about pelvic floor dysfunction. We touched on this before, but it is something I’d like to explore more deeply. When you have constipation, IBS, diarrhea, hemorrhoids, abdominal pain (especially lower abdominal pain), there can be this other layer that is more muscular/structural. This is where I want to try to pick Jandra’s brain as much as we can so people will know when they should pivot to go beyond the core gut care that we talk about a lot in the podcast and know when they may want to bring pelvic floor support into their care plan.

DrMR:

I also want to refer you back to the conversation we recently had with Dr. Anna Cabeca. She had remarked that her anti-aging cream that’s often used on the vulva – it’s a DHEA based cream – is helpful for strengthening the pelvic floor with incontinence, vaginal dryness (its main purpose) and some of these other conditions that seem to map onto and relate more to the pelvic floor. So, there’s a lot going on down in the perineal area. Jandra – I’m happy to have you here to help us work our way through how to understand symptoms and flags that someone should consider when working with a pelvic floor therapist.

JandraMueller:

Yeah. I’m very excited to be on the podcast and talking more about it. Actually, her cream is something that I have often recommended to our patients. Different times of life can really utilize it. It’s not just for aging women. There are indications for younger women too, which I can get into a little bit as it relates to the gut. I recommend it and it’s a great cream.

DrMR:

That’s great to know.

JM:

There are lots of connections from the gut to the pelvic floor. Actually, that is how I got into all of this. In my own personal story and my own GI issues – I was already a pelvic floor PT – a lot of what I was dealing with was really hard to figure out . I went through multiple doctors, even being in the field. When I started getting things figured out and working with functional medicine doctors, is actually where I really found the most benefit. I started seeing a lot of similarities in a lot of the patients that I treat. It really got me curious to dig in deeper. I went back to school and got my Master’s degree in Integrative Health and Nutrition from Maryland University of Integrative Health. The more and more I see it, the more and more I learn. Now that I see it, I can’t really unsee it. So, it’s pretty amazing how inter-connected they are.

DrMR:

What would be the high level, simple heuristic that you would paint for someone in terms of gut problems – let’s say IBS, SIBO, maybe a bit of irritable bowel? How does this increase the risk of something going on with the pelvic floor? Perhaps you’d skew that a little bit differently, but what’s the high level? Here’s where you start to wrap your head around this so people can orient as we engage further into this conversation.

The Pelvic Floor

JM:

Let’s first talk about what the pelvic floor is because it will make a lot more sense. The pelvic floor is a group of muscles that every person has. You cannot not have a pelvic floor. It’s a group of muscles that really do a lot of things for us. They’re part of our core muscles. They work with the abdominal muscles, the glutes and the inner thighs synergistically. So, that means when you engage your abs, you engage your pelvic floor and they hold our organs into place. They control bowel and bladder. They participate in sexual functioning, urination and core support. They do not work alone and they work with other muscles like our abs.

JM:

When we start to get into gut issues, one of the things I see a lot is people have bloating. This can be all genders. It’s not just females. What do you do when you’re specifically a female, but also many of my male clients, and you don’t want to have this pooch belly? You hold it in. When you hold it in, you engage your abs. When you engage your abs, your pelvic floor engages. There’s this whole connection – even aside from just IBS, constipation or diarrhea – that is connected in this whole system per se. So, that’s one connection. I think there are connections – specifically a causation, but there’s a lot of correlation. Sometimes we don’t really know what comes first or what’s following. Many people have this for years. The Mayo Clinic has a stat where they believe that greater than 50% of those suffering from constipation have pelvic floor dysfunction, which is a lot of people. So, you might want to get your pelvic floor checked out to see if that’s contributing.

DrMR:

And that was with constipation? Was that the population?

JM:

Yep. Those with constipation. Now, when you see somebody with diarrhea, the thing that you think about is – 1. How urgent is it? 2- Are they leaking? The anal sphincter is a very sensitive structure. It has to determine what is solid, what is liquid, what is gas and it’s very sensitive to those things. Most of the time, we know when there’s a bowel movement coming or when it’s gas and you can pass it. Some people get to a point where they’ve had these issues so long that they don’t know – especially postpartum, when they may have had tearing occur and their muscles literally can’t work structurally because there’s some scar tissue and it’s still healing. Now they have not only urinary leakage, but fecal incontinence. Additionally, this applies for some of the aging population – especially for females that lose some of those hormones that are the nutrition for the vulvar tissues. They atrophy a bit and they do get a little bit weaker, hence the use of the Julva cream. They may not be able to control that as well if they do have something like IBS and it’s not a one time thing. This is what they’re constantly going through. So, there are a lot of indications there between both constipation and diarrhea.

DrMR:

To parse one detail here, is it correct to say that if someone has urgency, that’s not necessarily indicative of a pelvic floor problem? However, if they – sorry to be graphic here – have a little bit that sneaks out or some urinary incontinence, that’s more demonstrative of there being a pelvic floor problem?

JM:

Yes, absolutely. So, urgency should happen. I mean, urinary urgency can be a lot more complex than that because you bring in the central nervous system. Is it a real urge? Is it behavioral? Is it because their bladder is sensitive to something? You know, SIBO is very indicated. We can talk a little bit about that when it comes to the diagnosis of interstitial cystitis, which is classically bladder pain or urgency/frequency/nighttime urination. However, with fecal urgency, sometimes we feel a bowel movement. If you have pretty normal bowels, you can probably delay that until a time that’s appropriate to go to the bathroom. You might be able to hold it for quite a long time, but if there’s more bowel irritation, IBS, more of that diarrhea, you may have to run to the bathroom right away. Some of those urges can be a little bit normal, but if you’re leaking, you absolutely need to see a pelvic floor therapist. No ifs, ands or buts.

JM:

They can do a thorough evaluation to see if it’s a muscular thing and what else is going on. They can help work through some of the root causes. The urgency regarding bowel movements may be normal. The bladder stuff can be a lot more complex than that. Some can be normal. Most of the time, I would say it’s much more frequent than it should be. We also normalize things in our society. We don’t talk about bowel and bladder issues. Many times people think, “I have a small bladder.” Nobody has a small bladder. It’s the way that it’s functioning that’s different, or there might be something functionally going on that makes you feel that way. In general, adults pretty much have the same size bladder across the board. They don’t realize that going to the bathroom every 1 to 2 hours … or being on a two hour car ride and having to stop multiple times… is not necessarily normal, but it’s very common.

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Pelvic Pain

DrMR:

Now, what about pain and Pelvic Pain Syndrome, which has overlapped to pelvic floor disorders? I’m wondering if there’s this mixed description of what could potentially be pelvic floor dysfunction/pelvic pain, but people are interpreting this lower abdominal, subtle ache as distension, bloating or gas pain. Is there a murkiness in terms of what people feel, how they describe it and how clinicians are cued in to interpret what patients are saying?

JM:

Yeah. A lot of people actually don’t catch onto that, which is great that you’re bringing this up. As a pelvic floor therapist, it’s the core of the body. You can’t ignore the rest of the body. So, we see a lot of people with abdominal dysfunction as well. Bloating is a sensation. Distension is an objective sign. So, people can feel bloated, but they don’t necessarily look distended. Again, that plays into the central nervous system a little bit. Maybe they have a history of longstanding bloating… maybe they’ve been pregnant… maybe there are some dysfunctions going in and they’re holding in their abdomen all the time. So, when they don’t and they can finally let go, they sense this as bloating. Absolutely. That can be a pelvic floor dysfunction.

JM:

They have core weakness. They might be compensating by holding those muscles in all the time really tight. So, when they don’t, they can sense this. Sometimes there can be – with the central nervous system – this feeling almost like a phantom limb pain, but it’s in relation to bloating. It’s hard without a thorough evaluation. Sometimes, you don’t have an answer right away. You have to go through the checklist of looking at the gut. What’s your diet like? What are the trigger foods? Do you associate this feeling with specific foods? For example, if they’re eating all these high FODMAP foods and you tell them to do a low FODMAP diet as a trial for two or three days, and they have significant improvement, you’re probably going down the GI route at that point.

JM:

If you’ve gone through your checklist, you’ve looked at different high histamine foods, (which mast cells are really prevalent in the GI system) you’ve ruled out pelvic floor dysfunction/timing issues, and you’re not really making these connections, then you might start to think about this central nervous system feeling. It really comes down to your thorough evaluation. Sometimes you just don’t know what you don’t know. Somebody might not ask the right questions if they’re not very aware of the GI portion of it. Vice versa – If a GI doctor is not very aware of the pelvic floor piece, you may be missing a whole reason why this person is experiencing these feelings.

DrMR:

I’ll try to recapitulate this and let me know if you’d modify this at all, especially for the clinicians who are listening to this or reading this. The further someone has gone through the GI hierarchy or algorithm – meaning you’ve made a few dietary modifications and there’s been minimal responsiveness… probiotics, elemental dieting, immunoglobulin therapy, anti-microbials, and you’re really seeing a lack of responsiveness. The further you go with less of a response, the more likely one of these pelvic floor issues is present. I’m assuming that’s a fairly safe assumption to make, but would you modify that at all?

JM:

No. Absolutely. Depending on their history, maybe some of those things have been treated. Objectively, the distension is improved, but the bloating is still there. Maybe the nerve is sensitive so they’re still feeling the sensation. That’s a whole other line of behavioral therapies – maybe desensitization, education around what’s normal/what’s not, etc. You’re really targeting the nervous system at that point, but you summed that up very well.

DrMR:

I’m assuming that surgery is a risk factor, but I also try to be careful and not just conflate every surgery as being equally problematic. There could be a hysterectomy, partial hysterectomy, C-section… Are certain surgeries more indicative of posing a risk here as opposed to others and if so, which ones should providers and patients be on the lookout for?

Pelvic Floor PT & Surgeries

JM:

Yes, absolutely. From a pelvic floor dysfunction standpoint, many people don’t realize that C-sections need pelvic floor PT. Though they haven’t had a vaginal delivery, which is the number one risk factor for prolapse, that person just carried a baby for nine months and had all these changes happen. Their pelvic floor has to support everything going on. Maybe they had constipation, pushing and straining. Hemorrhoids are super common in pregnancy, usually due to the hormonal shifts that are causing constipation. I can’t tell you how many doctors never talk to their patients – vaginal delivery or C-section – about pelvic floor therapy. A few years ago, ACOG actually put out a position statement that this needs to be addressed in their six week checkup. I still haven’t really seen that develop into actual practical recommendations. Patients often find us on their own because they’re having problems.

JM:

So, C-section – absolutely. There can be scar tissue that affects how the abdominal muscles are working. There’s usually sensory changes that occur in that scar at that time. They don’t necessarily feel that they’re doing something correctly because they’re not having that feedback from their body. We just talked about how the abdominal muscles are intimately related to the pelvic floor. So, they should absolutely see a pelvic floor PT – even if they’re not having pain – just as a checkup… for education on here’s what’s normal/here’s what’s not. Many people get advice from their friends or their family who have had babies and again, we come back to the debate of common vs. normal. Anybody that has been pregnant or has had a baby should be (at least one time) checked out by a pelvic floor PT.

JM:

With other surgeries – laparoscopic surgeries for endometriosis, hernia repairs, hysterectomies (there are many ways you can do hysterectomies), all of that – as pelvic floor PT’s, we look at the whole system and not just the pelvic floor. We know that it addresses many aspects of somebody’s life. Do they have scar tissue? Is that scar hyper-sensitive? Is that affecting the fascia underneath and affecting how they’re going back to exercise or their movement patterns in general? Did it hit a sensory nerve that affects the innervation around the genitals?

JM:

You have three nerves that are in the lower abdomen – they’re sensory nerves – your genitofemoral, ilioinguinal, iliohypogastric nerves. These provide sensation to the lower abdomen, the pubic area, the labia and the scrotum in people. Hernia surgeries are the number one cause of nerve dysfunction of those nerves. If somebody comes in with labial numbness/tingling or scrotal pain and they recently (within that year) had a hernia surgery, or they had mesh placed that can entrap nerves and cause dysfunction, these people do not get referred to PT like somebody would that has a meniscus repair or an ACL. This is not routinely discussed to patients for pelvic floor issues. I think little is known about it and people have little awareness. It is something that, as a society, we’re often ashamed to talk about, it’s embarrassing and this gets missed all the time.

Bloating & Distension

DrMR:

Right. I’m glad we’re having this conversation. To clarify for our audience, bloating would be the sensation of discomfort, pressure and pain; distension would be when you look down at your abdomen and it actually looks like it’s protruded. Let me contextualize. In someone who you’re not suspecting a super high FODMAP diet or raging SIBO and some of these causes of excessive gas are not likely present and you’re seeing distension, are you thinking that there is weakness? Is it potentially a neuromuscular inhibition where the muscles have strength, but they’re just not being turned on? How do you think about distension? I know there is definitely a subset of patients where distension is one of their primary concerns. I’m sure they’re very keen to hear how you unravel this.

JM:

Surprisingly, I oftentimes don’t necessarily think of weakness as my first thought. I actually think of hypertonicity – so, too tight. That causes dysfunction in the ability of the muscle to contract, relax and work together with the other muscles. Backtracking a little bit. There are low tone disorders. So, muscles are weak. They don’t have a lot of strength/control. You think of the fecal incontinence, the urinary incontinence (most of the time) and prolapse. Then, there’s the hypertonic side. That’s where chronic pelvic pain (as a general statement) comes into play, pain in general and usually constipation. Everything is too tight. They maybe have some dietary factors, but their muscles aren’t really relaxing and they can’t let gas out… or is gas is such a problem that they’re embarrassed in public and they constantly clench and hold so gas doesn’t come out?

JM:

Over time, that adds up and that creates a lot of tension. That can then lead to nerve pain on the pudendal nerve, which is the primary nerve that innervates all of the pelvic floor. It’s a specialized nerve. It’s involved in autonomic functions like controlling bowel, bladder and sexual function. It provides sensation to the majority of our genitals and pelvic floor and the muscle control for the muscles. So, does the pelvic floor dysfunction cause the gas? Maybe, but is it going to lead to pelvic floor dysfunction if they have gas? Probably – more often than not, yes. So, there are a few people that this really affects. One, being those with endometriosis. Endometrium is the lining of the uterus that gets shed every month during a menstrual cycle. These cells are similar to, but different, that come and implant themselves outside of the uterus. They can basically create their own estrogen. They aromatase testosterone into estrogen. They create their own blood supply and their own nerve supply. They can cause a lot of dysfunction. In this population, about 90% of them have IBS. It’s mostly constipation, but ‘endo belly’ is a term that is very common among this population. It describes this immense distension that comes about cyclically – not all times of the month, although some women do experience it the majority of the month – but, specifically during certain times of the menstrual cycle. That can be because of inflammation, but usually SIBO is involved and that almost always has to be ruled out or treated in this population. The other thing with this is that one of the theories that has finally come out about this disease is the bacterial contamination theory, in that the gut actually may be a huge driver.

JM:

This disease is multi-factorial in how it comes about, but the gut is now being actually described as a major player because of dysbiosis and high gram negative profiles in the gut, which create a lot of lipopolysaccharide and endotoxin that can get out of the gut, promote more inflammation and this whole cycle continues. That’s a population that you always want to assess the gut and pelvic floor dysfunction. About 90% also have pelvic floor dysfunction in that population. So, major connections.

JM:

Urinary symptoms – going back a little bit to those that are diagnosed with interstitial cystitis. This is one that really bugs me in my practice. The name has now changed to Painful Bladder Syndrome because we know that there are different sub-types. There’s a true bladder issue, where the lining is dysfunctional, but there are also those that have hormonal deficiencies, central nervous system issues or pelvic floor dysfunction. This name is now given to those that have bladder frequency, urgency, bladder pain, where sometimes the bladder is actually the victim. I bring this up because we are talking about bloating and urgency. If I get somebody that comes in with these symptoms or this diagnosis, and I start to talk to them – “Do you have GI issues?” And they’re like, “Yeah, it’s really hard to go to the bathroom. And I get a lot of bloating and I have gas. I’m thinking SIBO.” There was a small study that looked at about 21 patients who had a diagnosis of IC – Painful Bladder Syndrome. They had a positive lactulose breath test. They were given the treatment of Xifaxan and the majority of them had a statistically significant improvement or elimination of their IC symptoms. In my practice, once I started getting into this, I see that all the time. When they have a sense of bloating, sometimes the brain reads it as ‘I’m having urgency and I’m having bladder pain,’ but it really is the bloating or distension that’s the trigger.

DrMR:

To try to help me wrap my head around this, when someone has distension and they have this hypertonicity, are you thinking the pelvic floor is hyper-contracted so the abdominal contents don’t have as much area to disperse? Instead of going down, stuff pushes forward? Is that where the distension comes from? Or is it a different mechanism?

JM:

I think there are multiple mechanisms going on. In the majority of my clients, they don’t want to let out a fart in public or at their workplace. So, they do hold it in and I think it can’t get released. If there’s something else like SIBO going on, something that’s producing the gas or even just dysbiosis in the large intestine that can produce a lot of gas, they don’t have to have a tight pelvic floor. I think there’s a correlation. For example, if I have a patient coming in for pelvic floor dysfunction and they may have these GI symptoms going on, I don’t think everybody that has gas necessarily has pelvic floor dysfunction, but I question that with other things that are involved. If that’s happening, I would say the majority have tight pelvic floor muscles.

DrMR:

Okay. It sounds like hypertonicity and constipation track together fairly well and hypotenicity and leakage track together pretty well. Again, in the context of people having had laid this gut-first foundation, and we’re not suspecting flagrant SIBO or anything like that. Would you say those are accurate benchmarks for people to paint in their heads?

JM:

Absolutely. That is perfect.

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Constipation

DrMR:

With the constipation, is this a cause or an effect? Recently, in our research review, we came across a study that found subjects with prior physical or emotional abuse were more prone to have constipative-type IBS. This cues into what you were mentioning earlier regarding the nervous system, and this makes sense. There could potentially be this hypertonicity, which would indicate that the constipation could be a secondary cause of the hypertonicity. Perhaps in other people, the constipation is not secondary – it’s primary. So, how do you suss out if the constipation is cause or effect?

JM:

This is a great question because there are different types of constipation. The diagnosis that’s related specifically to pelvic floor is outlet dysfunction. So, typically how the pelvic floor and pooping works is you have your peristalsis – or the contractions in your GI system – that move the stool through the intestines. At the end, you have your sigmoid colon, and then it drops down into the rectum. I was actually talking to a male patient today about this because to do pelvic floor work, we have to go through the rectum (and occasionally for females, too depending on what’s going on.) They’re really nervous about getting a pelvic floor exam or doing work on the pelvic floor, whether they have constipation, gut issues or not. They’re just worried – “What about the time of day?”… “What if I haven’t gone?”

JM:

Poop does not stay in the rectum unless there’s an issue – or maybe you just caught it at the right time, you’re holding it in and you haven’t gone to the bathroom. Generally, once stool moves through the sigmoid and goes into the rectum, it creates a distension. That signals the brain – “Oh, that’s an urge. I have to go and have a bowel movement.” You go to the bathroom, you let it all out and now there’s no more stool in the rectum assuming everything gets out. That’s normal. Now, when you have a tight pelvic floor – with or without any GI issues – and you go to sit down in the bathroom, everything’s super tight and you’re pushing and straining, you might get a little bit out. You think, “Okay, that was a good bowel movement.” However, you actually may still have stool stuck in the rectum.

JM:

Eventually, in certain more severe conditions, that stool can actually start to create more distension in the rectum, and you start to lose that sensation of that urgency. So, that’s where the megacolon gets brought up – it’s just stretching, stretching and stretching. You desensitize the nervous system to sense that amount of stretch and now you have even more of a problem. You’re not getting urges to go to the bathroom. That could eventually – in more severe cases – lead to some leakage too because you’re over distending. So that’s one instance. Secondly – and going back to your question about how you would distinguish – is our exam. We use a gloved finger and you look at somebody’s motor control. So, when they’re in your office, the first thing you do on the first day is assess the tone of the muscles. Are they hypertonic? Are they relaxed? Are they just nervous? Can they relax their glutes and legs and everything relaxes?

JM:

We look at diaphragmatic breathing. So, as you breathe and you’re doing a diaphragmatic breath, there’s a coordination with the pelvic floor. As you’re inhaling and the diaphragm is flattening, your pelvic floor should relax and open up. As you go back to that resting tone, everything comes back to center. So, is that happening? A lot of times, it’s not happening and they’re just stuck in this guarded state. Can they squeeze? Can they produce a contraction? For a lot of my patients who have tight pelvic floor muscles, they are actually weak because muscles work on a tension relationship. So, you want muscles to be at the mid-range to produce the best contraction. When they’re too short – like in hypotonic disorders where there’s low tone – they don’t produce an adequate contraction. If they’re too tight, they also can’t produce an adequate contraction. You have them relax – or what we call a drop – and just let go of that tension. Is that working? Can they bear down? You have to bear down to have bowel movements and babies. A lot of times, the motor coordination is also very disrupted in these individuals. So, we work a lot on motor control and training, and there’s some fun tools. Pelvic floor therapy for kids – A lot of it is focused around constipation. They can blow on the little windmills and that actually can generate some normal motor control. You can do some fun things with kids. I do it with adults, too. So, you retrain. You retrain, things get better… great.

DrMR:

This is like biofeedback. I’m not sure if you caught some of Satish Rao’s work with this. I’m sure there are other protocols, but essentially re-establishing that coordination. Rao describes it as – you need to get toothpaste out of the tube, you need the cap to come off or relax and then the muscles or your hand to squeeze the tube. It’s re-initiating that coordination.

JM:

Exactly. Again, you can’t leave out the abdominals… you can’t leave out the diaphragm. It’s all connected in how everything functions together. There’s absolutely biofeedback that can be helpful for that. There are balloons that you can do in clinic to help them expel the balloon and then there are tests. Going back to diagnosing what’s what – there are various tests that people often have to do. One of the worst ones – the most embarrassing test where people come in and say, “I hated this” – is where they actually undergo a defecography where they’re pooping in an MRI.

DrMR:

That sounds like a blast.

Testing Issues

JM:

My patients come in – sort of tail between their legs – like, “I can’t believe I had to do that.” It can give some information about non-relaxing pelvic floor muscles, but it’s not quite functional. You’re not quite in the same position you would be in a toilet, but it can give some indication. Actually, one of our PT’s just did a review. What we kind of gained from all the different testing is a lot of this we can get from our evaluation without having to undergo all of these various tests that can be expensive, time consuming and embarrassing.

DrMR:

Thank you for saying that. Let’s say someone is listening to this and they’ve been dealing with constipation for five or eight years. They may come to the mistaken conclusion that they need to go do that MRI test because it’s going to tell them what’s wrong. It can’t be said enough because it’s so alluring that fancy tests will tell you what’s wrong with you. There are some fancy tests that are helpful. I would argue that more often than not, the fancy tests only lead you right back to the clinical algorithm that we’re going to go through anyway. They’re not demonstrably helpful for how you help that person.

JM:

Exactly. Usually, we get them after the test. We don’t see them before or else they probably wouldn’t have the test, but I just feel so bad every time. Most people say to me – “That was the worst thing I’ve ever had to do.”

DrMR:

Yeah. Thank you for saying that. The more people who are experts in their own niches can verify that testing has a time and a place, but it’s more limited than I think patients portray it as. I think it will help patients not fall victim to – “Well, we’re not sure why you’re constipated. Go do this fancy test.”

JM:

Exactly. I mean, everything has a purpose, but it’s limited.

Sexual Function

DrMR:

Coming to sexual function, there are many claims around sexual dysfunction and pelvic floor disorders. One of the things I have come across – I’m not sure how accurate this is – but you go on YouTube and the stuff people want to be true gets the most watch throughs and climbs the highest in the results. This comes up for women. It comes up for men. It comes up for erectile dysfunction and this theory that if you don’t have enough tone, you don’t hold blood in the penis and therefore, you don’t have a good erection. That seems plausible, but I also wonder how common that is. Regarding sexual issues for women – I’m assuming there are probably some challenges with orgasm. I doubt vaginal dryness would be caused by a pelvic floor problem, but you might see vaginal dryness and pelvic floor dysfunctions go together as there is a lack of adequate hormone. What’s going on here with the pelvic floor?

JM:

This is my favorite topic to talk about. So, let’s start with females first – or those that have vulvas. They may not identify as female, but have vulvas. One of the major things I see is called vestibulodynia. It is a sub-type of vulvodynia. People may know vulvodynia from ‘Sex and the City’ where they bring up Charlotte and her depressed vagina. Well, this is a sub-type that affects many women. There are many causes, but one of them is actually the birth control pill. Tying back to the gut, birth control can have nutritional deficiencies and gut irritation. Some people have a genetic pre-disposition to this and systemic birth control can have an impact. So, this is not the Mirena because it’s more local. It almost makes younger women’s vulvas very similar to somebody who has gone through menopause.

JM:

It depletes both estrogen and testosterone – and that’s a key one – in the tissue and the vestibule, which is the tissue right at the opening of the introitus or the vagina, and around the urethra. This tissue becomes very sensitive. So, females will have a lot of pain with sex. This could range from discomfort, dryness, lack of sex drive and then entrance pain happens. Then they say “Well, once it gets past, it’s fine.” Now, there’s a degree that can be more severe than that. That’s because birth control (even after you’ve come off of it) elevates something in your liver called sex hormone binding globulin (SHBG), and that can stay elevated even years after coming off of birth control. There can be other triggers like breastfeeding where your hormones go down, too. This can trigger that same sort of feeling. This gets missed a ton. I’ve had numerous patients under 21 that have been told by their MD’s – “Just have a glass of wine… relax.”

JM:

This is a true story and it’s not a one time thing. So, there’s a hormonal component so that also atrophies the tissue. It makes it dry. There are objective signs that you can look for to see this, but that comes often with diminished orgasm and lack of sex drive. Why? It is because we have lower testosterone. Also, in our society, it’s not well accepted that women need testosterone. This is silly because males and females need all the hormones – just at different levels. So, this is a big one that I see for females. Now, there can also be pudendal nerve issues that cause pain in similar areas. They can also cause clitoral sensitivity. Just general pelvic floor tension can prevent entrance of a penis into the vagina. Even if they have same-sex partners, it limits them from doing various things because they have sensitivity in the tissues. It can range from a number of things. So, that’s one of the main things I see for females.

JM:

Now, for males, this gets really interesting. You said something really important – we think that with erections, we just have weak muscles and so blood is not getting into the penis and being held there. So, what do males do? They go online – to Reddit oftentimes – and they find these protocols that say, “Well, my sexual function isn’t what I want.” Maybe they have premature ejaculation… maybe they’re not experiencing the sensation of orgasm as they feel like they should… maybe they’re not getting as full erections… so they decide to do these different protocols. A lot of it involves Kegels. A Kegel is a tightening contraction of the pelvic floor muscles. Well, this population almost always has too tight of muscles causing muscle dysfunction, thus maybe causing decreases in blood flow into the penis.

JM:

I wrote a blog a few years ago about the implications of pelvic floor on erectile dysfunction for men. It’s something where tests need to be ruled out – blood flow, hormone levels, both testosterone and estrogen. Of course, those things need to be checked, but a lot of times they’re normal. You talk to them and they’re like, “Yeah, I feel like I need better orgasms. So, I’ve been doing delayed ejaculation or these jelqing protocols.” I’ve also seen men where their decreased sensation in sex has come from being circumcised. So, there are protocols online that talk about re-growing your foreskin by basically placing tourniquets and doing this gradual stretching, which causes nerve stretching, and sometimes permanent nerve damage – thus, erectile dysfunction. So, there are various reasons why.

JM:

This also comes into our society with the implication of pornography, porn addiction and what is reality vs. something on TV. There are a lot of misperceptions there. That is where sex therapists come in and are really helpful, too. It goes through the same system. Let’s look at your motor control. Let’s look at your impairments. Do you have a lot of fascial restrictions, especially in the abdominal region? There are a lot of connections into the penis there that control erections. So, men that might do tons of ab work might notice this, and it’s because of the restrictions and the fascia that come from the abdomen. That is a big area of a population that we often see, especially young males that have sexual dysfunction or erectile issues.

DrMR:

So, it’s a hypertonicity more often than it is a hypotonicity?

JM:

Yes.

DrMR:

This is interesting. I’ve had a few men in the clinic – and one in particular – who posed the question to me that made a lot of sense. I just don’t have the background here to be able to know if this speculation holds any merit or not. He said, “I feel like my testicles don’t hang as low as they used to. I think it’s because I’m exercising so much.” He was wondering if that was correlating to his dysfunction. I was actually thinking, “Well, maybe the lack of hang is some sort of compensatory issue because of weakness.” This is because that’s most of what I had seen when I had done some probing around. Of course, there’s this surgical release maneuver, but that seemed like overkill for a healthy individual.

DrMR:

I didn’t really have a good answer for him, but that question always stuck with me as an interesting one. It kind of fit this picture of, “Well, he just does the pelvic floor exercises and he’s experiencing this kind of tightness of those muscles, but it’s actually due to weakness.” It sounds like in this case, I’m assuming he’s more likely to see lack of ‘normal hang,’ if you will – I’m not sure what the technical term is. That’s more likely going to accompany hypertonicity than it is hypotonicity?

JM:

Yep. What I explain to patients is – You can still have a dysfunctional muscle contraction. It can still present as weakness. It’s like a functional weakness. The example I give is – You’re going to the gym and you know it’s arm day, but all day long you’ve been lifting a barbell up and down, up and down, up and down. When you get to the gym, you’re going to be tired, and your output of that exercise is going to be limited. It’s not going to be like how you would be if you just had a normal day and you go to the gym. You’re ready to work your arms. Those muscles are going to be fatigued because they’ve been turned on all day long. With the heightened testicles, I always match what I find on my evaluation to their symptoms and go from there.

JM:

If you stroke the inner thighs (the adductors) – this is a synergistic muscle with the pelvic floor – you have the cremasteric reflex, which pulls the testicle up on that same side. We look at fascial restrictions in the inner thighs – muscle trigger points, fascia, just dysfunction there – and then again in the abdomen, especially if he works out all the time and is doing tons of leg lifts. That’s going to challenge that area. Core in general is going to activate the pelvic floor. If they don’t know how to relax, especially between contractions, that muscle is tight, tight, tight, tight, tight. Now, other things throughout the day can also contribute to that tightness. Stress, TMJ, tightness in the shoulders/neck and pelvic floor dysfunction have been correlated so many times. People just have so little awareness of these muscles – how to sense them – because we don’t talk about them. You can’t see them. Am I relaxed? Am I tight? It’s hard to know until you start to have signals coming from your body that are saying, “Hey, something’s going on. Something’s not working right.”

DrMR:

That’s really good for me to know. I had referred a few men to do the Kegel exercises. Not that this is very common in men, but every once in awhile, you have younger, fairly fit males who also complain of erectile dysfunction. The last thing I’d want to do is, as I was saying before, feed the YouTube algorithm that’s just rewarding what might be a specious argument, but nonetheless it’s incorrect and not helpful. For perhaps the majority of people, I’m sure there’s a time and a place when maybe the exercises are warranted. That’s really good to know.

JM:

One more thing on that note, too… It’s really good to have this conversation. I feel bad for all my patients, but women have – not that they’re always listened to – multiple outlets. They have their OB-GYN, they have multiple people they can go to and they talk about it more among their friends. You are exactly right. Oftentimes, my patients are 20’s… 30’s… 40’s. I get the outside too of older males, but these issues are predominantly in young males. So, why would they have weakness? That’s what I come back to. They’re embarrassed to talk about it. They don’t think it’s normal, so they often get their information from online forums. Reddit is a huge one. You have urologists that would make sense and men do go there, but you don’t think as a 20 year old that you need to go to a urologist. Right?

DrMR:

Right. Yeah. It makes complete sense. Hopefully, this will help a few young men out there who might be in need of competent advice, but don’t want to go to a doctor’s office.

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Topical Cream Application

DrMR:

So with the cream you mentioned earlier – I’m curious if there are any key applications that you’re finding for the cream? I’ve given samples out to a few patients at the clinic now, and I’m trying to figure out the best time to position that in our care. I’m very curious to pick your brain on this cream.

JM:

I will recommend that for people that want a more natural approach. I work with a lot of specialists that do specifically make compounded topical creams – estradiol and testosterone – to apply to the vulva. People get this cream – whether it’s Julva (which is DHEA) – or it’s a combined hormonal topical given by a specialist. There are a few key things where people don’t apply it correctly, they’ve been using it for months and they’re like, “I’m not really seeing improvement.” One thing you want to do is – if you don’t know your anatomy, look at your anatomy. We have a YouTube video on our website that actually goes through your vulvar anatomy to look and how to do it. I actually think we have a video about applying the cream.

JM:

It is recommended to look at your tissues so you can see where you’re putting it. You want to spend time. One of our doctors recommends 30 seconds, which might be a long time, but you don’t want to just slap it on. You want to make sure you’re getting it into the right spot, and it’s actually absorbing. Now, some people will use it a little bit into the vagina, as well. The periurethral tissue is oftentimes atrophied, too and that needs hormone. A lot of urinary issues or after sex – that friction kind of irritates it. You want to get it up there a little bit, too. These are creams that are used topically. They’re not used to be intra-vaginal systemic hormones. They are meant to help soothe the tissues externally. The application process is very important to put it in the right spot and actually rub it in so it’s absorbing.

DrMR:

Let’s say someone has some rectal pain – perhaps from having labor defecation, or they’re more skewed to the diarrheal end of things, or perhaps they have hemorrhoids. Are you ever using it with a rectal application?

JM:

I haven’t used the hormone or the Julva cream necessarily for that. I know with the Julva cream, it’s been described as ‘all the way around,’ which would be fine. I do recommend various topicals. There are certain hemorrhoid creams or fissure creams that can be helpful for those issues. If it’s postpartum, is there scar tissue? I will have them work on that tissue with some sort of topical cream that’s appropriate. Those things can be very helpful, especially as you’re working with calming down the diarrhea with whatever interventions you’re doing – whether it’s referring out to a GI or working with them on diet – and controlling and getting that solidified. Sitz baths can be very helpful. You want to soothe that tissue because it is irritated from constantly having to work; from being inflamed from whatever is going on. I talk to my patients about whatever cream is appropriate, if that is how to do it and what to do. They are very helpful in addition to the other interventions you’re doing.

Episode Wrap-Up

DrMR:

Jandra – This has just been a phenomenal conversation. I’ve learned a lot. This is an area I’ve been probing into, but you’ve certainly opened me up to the wealth of resources for patients. From my perspective, these patients have gone through a lot of the gut algorithm and perhaps are hitting a roadblock. Now, I can expand some of my thinking into other therapeutics we can integrate into the clinic and/or when to refer to a specialist. So, I really want to thank you for that. You seem to really not only understand your field, but also as it touches onto more functional GI care – SIBO, mast cells, histamine. I’m just really impressed with your breadth of knowledge. I’m sure the audience is also. Do you have any closing thoughts that you want to leave people with? Would you also let us know where we can learn more from you? And where can we find your website or wherever you’d refer people to online?

JM:

Well, thank you so much for asking me. I was very excited to come onto the show. I think people really want this information and they don’t know where to find it, and they don’t know good information from bad. So, I think it’s great that you are bringing this to the forefront. I know a lot of people listen to your podcasts. I mean, I listened to your podcast well before talking with you. I think it’s great information. You always have great information on it. So, thank you for bringing the pelvic floor piece into it. I would say my advice for people is – you know your body the best and many times, and more often than not, you will get shut down by doctors. You will be told that nothing’s wrong. You will be told that things are in your head.

JM:

I would just really recommend to keep seeking out answers because you are probably correct in your intuition that something is wrong. There are a few websites for sexual health: www.isswsh.org is one really for both females and males. Although it’s the study for women’s sexual health, there’s a lot of good specialists that also do male pelvic pain. I would find a therapist in your area. Some recommendations, especially if you’re dealing with hypertonic – or you don’t know, but you suspect that because you’ve listened to this podcast – is finding a clinic that treats both males and females. You’ll probably have somebody that has a bit more experience in treating pelvic pain and hypertonic disorders. You never know, but that’s a good start. To find us, we also do digital health consultations. We have offices mostly in California and a couple on the east coast, but we are available via tele-health to answer questions, help direct people and find specialists in their area.

JM:

Our website is www.pelvicpainrehab.com and everything on there is available for booking. A lot of our therapists do tele-health so you can be in another state and we’re happy to talk with you, help you out and find somewhere for you to go. We also do a blog every Thursday, and it’s all things pelvic health. We bring in specialists. We write on topics. We do our research for that, and really try to get good comprehensive info out there.

JM:

We are on Instagram, TikTok and YouTube with good information on various topics about pelvic health. @pelvichealth is our Instagram. @pelvicpainrehab is our TikTok. The Pelvic Health and Rehabilitation Center is where you can find us on YouTube. Again, thank you so much for asking me to join you on your podcast.

DrMR:

It’s been a pleasure, and thank you again.

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