By  Melinda Fontaine, DPT

Having a baby is like running a marathon with your pelvic floor and pelvic girdle muscles. Did you know that:

• 65% of women who had low back or pelvic girdle pain during pregnancy reported persitent symptoms 14 months after delivery¹

• 20 -70 % of new moms experience stress urinary incontinence ²

• 24% of women still experience pain with sex 18 months postpartum³

• Diastastis Recti exists in 39% of postpartum women 6 months after delivery ⁴

Leaking urine, low back and pelvic girdle pain, pain with sex, and compromised abdominal wall integrity are common issues that many mom’s encounter after childbirth. The good news is that these complications don’t have to be permanent!  Pelvic Floor Physical and Occupational Therapy,  home exercises, and lifestyle modifications can help tremendously. In this week’s blog, pelvic floor physical and occupational therapists, and new mom, Melinda Fontaine breaks down how new mom’s can care for their newborns while still conserving their health.

Recently, I had the opportunity to be a guest speaker for the MuirMommies group at John Muir Health in Walnut Creek.  As an alumnus of the group I was elated to be back, and to meet with the attentive parents who gathered to discuss a myriad of questions. Most were interested in learning how to better care for their children. However, on that day I wanted to turn the tables, and talk about how parents can take care of themselves. Predominately, I wanted to equip parents with tools to prevent common injuries that are often associated with the daily activities of caring for a baby.

It is estimated that 67% of women experience back pain postpartum, and the most associated factor with back pain is heavy work. It’s important to note that  “heavy work”  can also include repetitive tasks such as lifting a baby, breastfeeding, or bottle feeding as well as heavy lifting. When a newborn comes home, he or she spends the majority of their day eating, sleeping, and dirtying diapers. So let’s focus on how to take care of Baby’s needs without compromising your own well being. Whether breastfeeding or bottle feeding, caregivers should always be aware of their posture,bringing Baby close to their body and finding a position that allows them to sit (or stand or lie) with a straight spine and relaxed arms.  Be wary of really plush seats that mold you into a forward bent position.  I highly recommend propping Baby on a pillow for feeding. Additionally, some pillows have belts to keep them close to you, and I find this very helpful to keep Baby from sinking into a gap between you and the pillow. If using a bottle, try to keep your wrist as straight as possible to avoid carpal tunnel syndrome. It is natural to look down at your baby during feeding and marvel at the wonder that is this tiny little human in your arms.  My suggestion for when you do so is to avoid sticking your head way out in front of you.  Keep your head towards the back of your chair.  Yes, this means you will have a double chin, but Baby won’t mind, and it will help prevent your neck from getting sore (All these same rules apply if you are pumping).

 

It is also beneficial to be cognizant of how you lean over a crib to pick up your newborn. Unfortunately, most cribs have a railing that prevents you from being close enough to the mattress to use proper body mechanics when lifting your baby. Because of this, it is extremely important to do all that you can to help save your back. There are a few cribs on the market that have sides which open like doors (ie. Gertie) or fold down a little at the top (ie. Foundations). When lifting Baby into or out of the crib, be sure to get yourself as close to the crib as possible.  Hold Baby as close to your body as possible and bend at your hips while keeping your back straight. Activating your abdominal muscles can also help support your back. To protect your thumbs, keep them glued to the rest of your hand. I prefer to lift baby with one hand under the head and neck and one under the buttocks. You can also lift Baby by grasping around the torso (once your baby has decent head control).  Furthermore, as long as it is safe for Baby, and he or she can’t climb out  of the crib, keep the crib mattress high. A higher mattress means less bending and leaning!  The same principle applies to changing diapers and using a higher changing surface will be  better for your back.

OK, Baby is now fed, rested, changed, and you’re ready to hit the town! I know there is probably a crying fit, some baby vomit, and another diaper change first, but bear with me here.  When getting  Baby into the car seat, it’s important to be sure to do so without bending or twisting your spine too much.  As always, brace with your abdominal muscles and keep Baby close; avoid holding Baby at an arm’s length away from you.  Get as close to the car seat as possible when putting Baby into the car seat. If your car seat is in a middle seat, sit in the car facing the door with Baby on your lap, turn your whole body to face forward, and then put Baby in the seat next to you.  (Orbit Baby even makes a car seat the swivels.)  After securing Baby’s racing harness, hop in the driver’s seat and take off.  Your seat will try to make you slouch, but you can fight this by sitting up straight, sticking your butt and lower back as far towards the seat as you can get it, adding a lumbar pillow if needed, and pulling your head back all the way to the headrest.  When you have reached your destination, reverse the directions above to get Baby out of the car.  At this point, it becomes a choose-your own-adventure endeavor. Option A means you’ve opted to use expert body mechanics to load Baby into a stroller by keeping Baby close to your body, bracing with your abdominal muscles, and getting low and close to the stroller. You’ll then push Baby around to your heart’s content while holding your head up high and your wrists straight to avoid carpal tunnel syndrome. Option B is strapping Baby to yourself using a carrier.  I recommend carriers that go over both shoulders and around the waist to evenly distribute the weight.  Many people are concerned about the carriers that hold Baby facing you with their legs spread wide.  Fear not, This is actually a good position for Baby’s legs.  Babies’ hip joints are still developing and this frog-legged position provides the most congruency between the bones, which is actually good for developing hips.  You may notice that neither of these options included balancing Baby on one of your hips as we often find ourselves doing.  This balancing act should not be an option because it stresses your body unevenly and can lead to hip, back, neck, shoulder and other pains.

After a successful outing, you make it safely back home with Baby and a huge sense of accomplishment.  Now you are just one bath (and a few feedings and at least one change of clothes) away from bedtime! The best place to bathe Baby is the kitchen sink.  I like the kitchen sink  because the kitchen faucet is typically the highest faucet in your home, so you don’t have to bend over to wash Baby.  Don’t worry about the kitchen sink being uncomfortable for baby, there are a number of bathtubs or padded contraptions that you can use in your sink to make it nicer if you desire. If your sink is not amenable to bathing, or when Baby gets too big, you will have to move to the adult tub.  To avoid having to bend over the side of the tub to scrub behind your little one’s ears, go ahead and get in the tub if possible.  This allows you to get really close to have good body mechanics, plus you’ll have a good time to bond  while splashing in the water.  If you cannot get into the bathtub, then get as close as you can to the tub and kneel on a padded mat or sit on a stool.

After bathtime, proceed with your bedtime routine.  Maybe you give Baby a little massage with some lotion or sing “Head, shoulders, knees and toes” or recite Goodnight Moon for the upteenth time today, and then  get Baby down to sleep.  Before you collapse into bed, for a few hours of much needed rest, I have one more set of instructions.  Gently, put yourself to bed.  You deserve it!  Brush your teeth and put on your pajamas.  Sit on the side of your bed. As you lift your legs up onto the bed, use your arms to guide your upper body to the bed so that you are lying on your side.  Roll onto your back or your other side keeping your body as straight as a log.  Remember logs don’t twist, so your hips and shoulders should be in alignment at all times.  Try placing a pillow under your knees if you are a back sleeper or between your knees if you are a side sleeper to keep your spine in alignment through the night.  When it is time to get out of bed in the morning, or in the middle of the night, reverse these instructions.  This way of getting in and out of bed, known as the log roll, protects your hard working back so that you can wake up feeling refreshed and ready to start again.

I hope you are able to try some of these tips to keep yourself in good health while raising healthy children!

Readers we want to hear from you! What parenting, baby, or childbirth questions do you have? And if you haven’t already, SUBSCRIBE to this blog (up top, to the right, under Stephanie’s photo!), so you can get weekly updates in your inbox, and follow us on Facebook and Twitter where the conversation on pelvic health is ongoing!

Regards,

Melinda Fontaine, DPT

 

Melinda is a native of Concord, California and is part of our Berkeley team. Melinda earned her bachelor’s degree in exercise biology from UC Davis and her doctorate in physical and occupational therapy from Simmons College in Boston. When she’s not at PHRC, you’ll find her either dashing around in her running shoes or cooking up delectable meals in her kitchen. She’s famous for her killer baked chimichangas and her inability to stick to a recipe.

 

 

 

---

1 Bergström C, Persson M, Mogren I. Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy – pain status, self-rated health and family situation.Umeå, Sweden: BMC Pregnancy Childbirth.; 2014.
2 Sangsawang B, Sangsawang N.Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. Bangkok: Srinakharinwirot University; 2013.
3 McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study.Melbourne: Murdoch Childrens Research Institute; 2015.
4 Fernandes da Mota PG, et al. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Lisboa: Univ Lisboa, Fac Motricidade Humana;2015.
5 Irion JM, Irion GL. Women’s Health in Physical and Occupational Therapy. Philadelphia: Lippincott Williams & Wilkins; 2010.

 

 

By Stephanie Prendergast, PHRC Cofounder

Most people dealing with the symptoms of Pudendal Neuralgia (PN) will tell you reading about PN, mostly online, can be traumatizing. “Chronic” conditions often translate to gloomy situations for both patients and providers.

In recent years, the knowledge of pain science and PN has advanced tremendously. In the medical community there is overwhelming evidence to support that educating people who are experiencing persistent/chronic pain on the physiology behind these symptoms elicits far better outcomes (less pain). Information about an individual’s symptoms and diagnosis matters, and it influences the way we are able to process what we are feeling in our bodies.

Let’s consider a typical situation of PN:  An otherwise healthy person develops severe perineal burning when sitting. What often happens: people are bounced between physicians and are often told things from ‘it’s all in your head’ to ‘‘you have a chronic condition that no one can treat’. Conversely, let’s now imagine that the same person is told they have a treatable pelvic pain condition by the first provider they see.This person goes home with medication and a referral to a pelvic floor physical and occupational therapists.  While their symptoms are uncomfortable, they were told they can and will be treated. The truth is, the impact of these initial encounters will often dictate how a person feels and reacts to navigating this complex terrain.

On May 7th, 2015, US News and World Report published this article on Pudendal Neuralgia. The  information in this article is conveyed in a manner  that may be necessary for media attention however, as a provider, I have a different take on it.  I view this article as  deleterious to people who have yet to be diagnosed, who are on the road to recovery, or who are stuck in their current treatment plan and may need better management. I am here to tell you PN is a treatable condition.

The article begins by describing how a young woman developed PN. As we approach the end of her case study, the article states,

“According to doctors, pudendal neuralgia occurs in both female and male patients, and can stem from multiple causes. However, it’s often mistaken for other conditions, or overlooked due to embarrassment or a lack of awareness. And the worst part? Sometimes it comes and goes in patients, but often lasts for years – or even decades. Receiving an early – and correct – diagnosis and treatment, experts say, is key to finding relief.”

If I recently developed symptoms of PN, and read this paragraph, my brain would lead me right to  crazy town and I would think my life is over. If you are a person feeling symptoms of  PN and you read this, you might think you are doomed to a life with a disorder that is not treatable. Chances are you have already seen a handful of doctors who did not know what was wrong with you, causing further hopelessness and fear. Far too many people have suffered for too long but thankfully, the landscape has changed! When I started in the field 15 years ago, most of the people I treated had lived with symptoms for over five years. Yet in the last year, and within our 5 practices, it is rare to see a person that went undiagnosed for more than a year. Symptoms of PN do not have to last years, and certainly not decades!

The article then goes on to say:

“Although doctors don’t know how often pudendal neuralgia occurs in the greater population, they say it affects women and men with almost equal frequency. It’s also “much more common than people realize,” says Dr. Jerome Weiss, a San Francisco-based urologist and founder of the Pacific Center for Pelvic Pain and Dysfunction. “It’s unrecognized in a large portion of patients. I see it frequently; I probably have 1,000 patients [with the condition]. There are people who are suffering because they have no diagnosis made.” This, he says, is because many doctors aren’t trained on how to diagnose and treat the disorder, or they’re so rushed during appointments, they don’t have time for a thorough screening. Instead, he says, “they blame it on something else – the prostate or the bladder. They don’t think about  the nerve.”

Currently, we know for certain between 1 in 3 to 4 women suffer from pelvic pain at some point in their lives and that it can affect 8 -10 % of men. Pudendal Neuralgia is a pelvic pain symptom and we do not have data on the prevalence for this particular diagnosis. One of the reasons why we do not have information is because we do not have diagnostic tests to confirm the diagnosis (you can read more about this here). This diagnosis overlaps with other pelvic pain conditions, which are also symptoms. Furthermore, despite our best efforts medical providers will have a professional bias and as a result, patients are often confusingly and frustratingly given multiple diagnoses.

For example, take the case of a woman with burning vulvar pain and urgency and frequency symptoms.  If this woman travels to see a ‘PN specialist’, more often than not they will be diagnosed with PN. This same person may see a urologist and get diagnosed with Interstitial Cystitis, and may see a vulvar specialist and get diagnosed with Vulvodynia. As a physical and occupational therapists, I will likely find a high-tone pelvic floor pain syndrome. All of these diagnoses may be technically accurate for this woman, but each diagnosis on its own is like a puzzle piece, only giving part of the picture and accordingly, part of the treatment picture. Because most pelvic pain diagnoses are symptom descriptors, they open the door to many different types of treatments depending on where and by whom the person is evaluated. Secondary factors include how conservative or invasive people are willing to be with treatment.

Where things go south is with a definition of chronic symptoms, multiple diagnoses, and a confused patient with pain but without medical guidance to establish a plan. This problem can be easily corrected by working with one medical professional who can act as a ‘case manager’. Primary care physicians, pain management MDs, gynecologists, physical and occupational therapistss, and urologists are well positioned to use their medical knowledge to help an individual suffering with PN make informed decisions about what is right for their particular case.

The article then claims:

“The most reliable sign that someone has pudendal neuralgia, experts say, is if he or she feels pain while sitting. That person will find relief, however, if he or she stands up, lies down or sits on a toilet seat.”

For the record, people with symptoms of PN do not always get relief with standing or on a toilet seat. Additionally, numerous musculoskeletal and central nervous system impairments other than the PN can cause pain with sitting. In order for it to be PN, the pain must be in the territory of the nerve and the nature of the pain needs to be neuropathic. Many people feel pelvic pain with sitting outside of this territory and it may be achy or sore instead of burning or numb. This is not PN. The Posterior Femoral Cutaneous Nerve is often overlooked, as pointed out here, trigger points in the Obturator Internus muscle can cause sitting pain at the ischial tuberosity, so can vulvar and anal fissures, to name just a few. Successful treatment involves identifying all of the impairments that are collectively causing the symptoms.

The article describes different factors that can contribute to development of PN. This IS important for treatment because there are many different causes and will clue us in to the differential diagnosis, leading to the initiation of an effective treatment plan. Each person with PN symptoms has different contributing factors and different symptom-causing impairments, which is why a ‘one-size-fits-all’ protocol fails. In the past, patients were prescribed  three pudendal nerve blocks and then surgery if the pain persisted. This approach was not successful because multiple impairments coexisting with nerve dysfunction were often left untreated. If you have had a pudendal nerve decompression surgery and still have persisting pain it can be treated, regardless of when the ‘failed treatment’ occurred.

The article then continues with:

“Those who do receive the correct diagnosis have often suffered for about four years and have seen 10 professionals without any diagnosis,” says Dr. Jacques Beco, a Belgium-based obstetrician and gynecologist who treats patients with pudendal neuralgia. “Neurologists and neurosurgeons never make a gynecological examination or a rectal examination,” he says. “And gynecologists, urologists and proctologists treat the organs, but have little knowledge about the nerves and muscles of the area.” Because of this, a correct diagnosis of pudendal neuralgia sometimes requires a task force of urologists, gynecologists, neurologists and pain-management physicians.

The key to making a diagnosis, Beco says, is to take a full medical history, assess the patient’s symptoms and conduct a thorough external and internal physical examination.”

It is true that many medical professionals are unfamiliar with PN. However, The APTA and IPPS have links on their websites to help people find qualified medical  professionals who are familiar with PN and have treated PN patients. Hundreds of skilled professionals are on these lists. In addition to providers with a particular interest in pelvic pain, pain management physicians specialize in pain and therefore can be of great help. Through conversations with my patients I have heard their disappointment regarding appointments with pain management doctors. Their expectations were to go in, see a doctor, and come out with a ‘cure’. Understanding that pain management doctors can only prescribe and manage medications while the underlying causes are getting addressed is key. It is important to remember that pain management specialists are experts at managing pain, regardless of how much they do or do not know about PN.

and then later in the article:

Many patients who experience this type of chronic pain suffer from mental health problems, experts say. “I have worked on the pudendal nerve since 1995,” Beco says. “Since then, three of my patients have killed themselves because of the pain. It’s a very, very bad disease, and many patients are depressed because of it.”

Many people experience emotional consequences of persisting pain. The situation of suicide is extremely sad and unfortunate. Many more patients have survived PN distress and treatment, than have perished due to their emotional and physical distress. PN is no longer a medical mystery. Every day my patients describe the fear, anxiety, and hopelessness that they felt when they first read about their symptoms and connected with other suffering people online, and their statements are the genesis of this blog post. Behavioral health professionals are great resources to help with the emotional consequences of pelvic pain, and have . It is useful to find a provider that specializes in strategies that can help individuals manage their emotions around their symptoms and think about their pain in a way that results in less suffering. In LA, we work with the Pain Psychology Center. Examples of their therapeutic process can be found in the How It Works section of their website.

The article then states:

Pudendal neuralgia is painful, but treatable. After identifying physical problems that might’ve contributed to the nerve damage – say, abnormal body mechanics – and possibly treating them with physical and occupational therapy, doctors can try treatments such as muscle relaxers and neuromodulator drugs, as well as manual therapy.

Here is what I felt this statement failed to inform readers:

1. Physical therapists are neuromuscular experts and therefore well-positioned to treat pelvic pain syndromes after undergoing specialized training.
2. Most physicians are not trained to treat the pelvic floor muscles with manual therapy.
3. Physical therapy is considered a first-line, effective treatment for pelvic pain syndromes.
4. A physical and occupational therapists’s opinion. Here is what what PT’s  think about PN management.

As I read this article I imagined a wrecking ball demolishing the progress physical and occupational therapistss are trying to making in this field. Exacerbated I emailed the article to neuroscientist Lorimer Moseley, co-author of Explain Pain and other great resources on pain physiology. This is what he had to say:

“Hi Stephanie –

There are some disturbing things in there for sure. I agree that it is great to see PN getting some attention, but it is a reminder that what we say and how we say it will affect any pain condition. The reality of any pain condition is that pain, and anxiety, fear and expectations, is dependent on more than just information coming from the body. Therefore, we need to be very careful to give people accurate information that does not needlessly ramp up these protective responses.  we need to take care in ordering tests – are the tests sensitive AND specific? that is, how common is it to have positive tests in healthy participants. if it is common, then tests and the medical terms we give to describe them, can do more harm than good, a point captured in the Choosing Wisely campaigns in US, Canada and Australia.”

I completely agree. To the individuals who are suffering with pelvic pain, please take the time to learn about pain physiology, stay strong, and remember you can and WILL get better.

All my best,

Stephanie Prendergast, MPT

Stephanie grew up in South Jersey, and currently sees patients in our Los Angeles office. She received her bachelor’s degree in exercise physiology from Rutgers University, and her master’s in physical and occupational therapy at the Medical College of Pennsylvania and Hahnemann University in Philadelphia. For balance, Steph turns to yoga, music, and her calm and loving King Charles Cavalier Spaniel, Abbie (Abbie is a daily fixture at PHRC Los Angeles). For adventure, she gets her fix from scuba diving and global travel.

Urinary tract infections (UTI) are considered to be the most common bacterial infection in humans, costing the US health care system about $1.6 billion dollars per year.  These infections plague millions of people at some point or another throughout the lifetime. In fact, some research suggests that a female’s lifetime risk of getting one is as high as 1 in 2. And merely having one UTI means that we are more prone to getting another one! According to a 2008 article by Hooton and Gupta: about 20 percent of women who become diagnosed with an initial urinary tract infection will experience a recurrence. And 30 percent of those people will get diagnosed with a third. AND, 80 percent of those who have had three UTIs will get a fourth, et cetera.

But I am getting ahead of myself, let me first explain the basics. A urinary tract infection (UTI) is a bacterial infection that is found anywhere in the urinary system: kidneys, ureters, bladder, urethra. The majority of infections involve the lower urinary tract, the bladder and the urethra, and are treated with antibiotics. Bacteria, e.g. E. coli, that is found in fecal matter can migrate toward the urethra and then bladder, and if the infection isn’t treated, it can continue up the urinary tract to infect the kidneys.

Common symptoms of a UTI include:

• burning/pain with urination
• urinary urgency/frequency
• low back or abdominal pain
• cloudy, dark, bloody, or strong smelling urine
• feeling tired or shaky
• fever or chills (a more serious sign that the infection may have reached your kidneys)
• voiding frequent, small amounts of urine

Why do UTIs happen? Let’s think about the anatomy: the urethra is located really close to the anus. Both men and women can get UTIs, however women are especially prone to getting UTIs due to having shorter urethras, which allow bacteria easier access to the bladder. (Ladies, see Rachel’s blog on vulvar anatomy if you need a refresher about what is going on down there).

If you suspect you have a urinary tract infection, get in to see your doctor right away. You will need to give a urine sample, which will be tested for the presence of UTI-causing bacteria. The first line of treatment: antibiotics. *Antibiotics can be a extremely effective treatment for bacterial infections, however they can also wreak havoc on the gut and vaginal flora (aka good bacteria). I always recommend talking to the prescribing physician about ways to best maintain the health of our good bacteria while taking a course of antibiotics.*

Men, I haven’t forgotten about you. Men can experience these same symptoms however it is often diagnosed as prostatitis. For more information on this issue, read Malinda’s most recent post.

Some women will experience recurrent UTIs for a variety of reasons: genetic predisposition, anatomical issues, new sexual partner, diabetes, pregnancy, multiple sclerosis, and anything that affects urine flow, such as kidney stones, stroke, self-catheterization, and spinal cord injury.

As I mentioned above, if you are experiencing any of the listed symptoms consistent with a UTI, make an appointment to see a physician immediately. UTIs, when left untreated, can lead to serious medical complications.

So what happens if you take the prescribed antibiotics and the symptoms persist? You go back to your physician, leave ANOTHER urine sample, which is cultured and the results are negative for infection. Often the physician may prescribe another course of antibiotics. More antibiotics can lead to a further decrease in our good bacteria which can sometimes lead to bowel irritation and vaginal yeast infections.

In a different scenario-you are experiencing the maddening symptoms associated with a UTI, but you go to the doctor and they find nothing. In this case, they will often write you a prescription for antibiotics anyway, as a precaution. You take the antibiotics, nothing happens, and you are left wondering where to go from here.

If this sounds like you and you are consistently getting negative urine cultures when tested, it is time to think about trying pelvic floor physical and occupational therapy. These are extremely common presentations that the therapists at PHRC help their patients deal with on a daily basis.

As I mentioned above, UTIs are a bacterial infection occurring anywhere along the urinary tract (urethra, bladder, ureters, kidneys). Infections are considered a serious threat by our immune system, so not only will we get an influx of immune system inflammatory cells to the area, but we will also often see muscle guarding of the pelvic floor (specifically the urogenital diaphragm which has attachments to the urethral sphincter).

So even though we may be infection free, the muscles are still in protection mode. And because we have muscles in the urogenital diaphragm which can have small attachments to the urethral sphincter, they can actually mimic all of the UTI symptoms. Hence, what may have started as a real infection is now an overactive muscle dysfunction causing the same symptoms.

Does any of this sound familiar? Last month I blogged about recurrent yeast infections which can result in pelvic pain/dysfunction by an almost identical mechanism. And as we’ve blogged about before: tight muscles can lead to myofascial trigger points, pudendal nerve irritation, connective tissue restriction, and decreased blood flow to the involved tissues. This leads to a further influx of inflammatory chemicals, causing even more pain and muscle dysfunction. As a result, the self perpetuating cycle of pelvic floor muscle dysfunction caused by a UTI is in motion.

The bottom line is that if you are experiencing some or all of the symptoms that I have listed in this blog post, and you have been through all of the first line steps but are STILL having issues, get evaluated by a physical and occupational therapists that specializes in pelvic floor dysfunction. Your symptoms may not actually be a UTI but may be the pelvic floor muscles masquerading as such. Here is a link with some tips to find a pelvic floor physical and occupational therapists in your area.

*Fact: It is due to the risk of getting a UTI that women are often taught to wipe from front to back.

Readers we want to hear from you!  Have you experienced any complications after a UTI? Please share in the comments section below!

And if you haven’t already, SUBSCRIBE to this blog (up top, to the right, under Stephanie’s photo!), so you can get weekly updates in your inbox, and follow us on Facebook and Twitter where the conversation on pelvic health is ongoing!