By Molly Bachmann PT, DPT, PHRC San Francisco
Urination is one of the most reliable body functions a person can have. You go about your daily routine, you receive a little message to your brain that says “Hey there! It’s me, your bladder. We’re pretty fully down here. Do you think you could empty me?” You listen to your body’s cues, find a toilet, eliminate, clean up, and continue about your day. It’s one of the most important ways your body can communicate with you that your organs, muscles, nerves, and microbiome are all working as they should. It’s a daily check on homeostasis.
But what happens when the balance shifts? What does it even mean to be within normal limits? How does one establish their individual baseline? How do I know when a change in statues is a true emergency that warrants in depth investigation? What could this change in status really mean?
And the tricky thing is, it could mean one thing or many things have changed. It all depends on the symptoms, the event that caused the change, and what else is happening around that time.
Based on years of research, medical professionals have a pretty good idea of what “normal” looks like. Take a look here:
- Normal urination frequency is six to eight times in a 24-hour period
- Leaking urine is never normal but has been normalized for postpartum people
- Bladder urge should not feel like a five-alarm fire, just a subtle feeling in the lower abdomen
- Normal voiding time is roughly 20 seconds
- Starting the urinary stream should be easy and quick
- Bladder urgency should go away after voiding
- Increasing our fluid intake should increase the amount we urinate, not the amount of times you have to urinate
- Normal bladder capacity is 300 – 600ml (1.5 to 2.5 cups)
- People under 60 years old may wake once per night to urinate, over 60 years old twice per night
- Pain before, during, or after urinating is never normal
When we fall outside of these normal ranges, it feels really distressing. It interferes with our sleep patterns, work productivity, enjoying time with family and friends, and distracts us from living in the moment. This distress usually leads to a series of doctors visits for multiple testing to rule in or out infection, changes to the bladder lining, organ prolapse, hormonal changes . . . you name it.
What we’re finding is that many people are misdiagnosed or the root cause of the issue is not identified. And within that population, seeing a doctor who understands the link between pelvic floor muscle control, mobility, strength, etc and urinary/bladder symptoms can be difficult to find. And many times, these muscles are involved on some level. Pelvic floor dysfunction that results in bladder symptoms can look like:
- Stress incontinence (leaking urine when coughing, laughing, sneezing, and/or during exercise)
- Urge incontinence (leaking on the way or before you get to the bathroom)
- Mixed Incontinence (both stress and urge incontinence)
- Pain or burning in the bladder and/or urethra before, during or after urinating
- Urinary urgency without a full bladder
- Urinary frequency without a full bladder
- Urinary hesitancy, slow or deviated urine stream
- Urinary urgency during sexual activity
- Urinary urgency/frequency after sexual activity or exercise
- Urethra or bladder pain
- Climacturia (leaking urine with orgasm)
Do any of these sound familiar? Do they sound like a UTI, bladder infection, STI, signs of dehydration, changes during pregnancy? Our pelvic floors have three layers of muscles, any one of which can mimic symptoms of the above mentioned diagnoses. Often we find that individuals diagnosed with Endometriosis, Vulvodynia, Painful Bladder Syndrome, chronic pelvic pain, Post-prostatectomy, Genitourinary syndrome of Menopause and postpartum changes can also experience pelvic floor dysfunction that presents with bladder or urinary changes.
How do I know if my pelvic floor muscles are involved? This requires a thorough examination from a pelvic floor physical therapist. No, it is not appropriate to “just do kegels” as some doctors or social media accounts recommend. As I mentioned before, your pelvic floor is THREE ROBUST LAYERS OF MUSCLE. Imagine presenting to your doctor for pain or weakness in your biceps, and your provider tells you to carry around a five pound weight in your hand all day to strengthen it and reduce pain. That would never happen! Why? Because that isn’t evidence based practice nor was that prescribed after an actual musculoskeletal evaluation. We should not be treating the pelvic floor any differently.
If you are experiencing any changes to your bladder/urinary function, pelvic floor physical therapy should always be on the table and included in part of the diagnostic process.
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Are you unable to come see us in person? We offer virtual physical therapy appointments too!
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
PHRC is also offering individualized movement sessions, hosted by Melissa Patrick, DPT. Melissa is a pelvic floor physical therapist at the Berkeley and San Francisco locations. Patients can expect a one hour 1-on-1 private session with Melissa Patrick, an experienced yoga instructor and pelvic floor physical therapist. Melissa will take a complete medical history, consider questions and concerns that the person may have, and discuss goals for the movement sessions. Melissa will provide the person with a tailored set of postures and mindfulness techniques to address the musculoskeletal needs of the individual. To schedule a 1-on-1 appointment visit us online.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.