Pelvic Floor Therapy – The Therapy You Didn’t Know You Needed

Susan Winograd is a Jewish woman living in South Florida and has been a physical therapist for 26 years— she owns her own business (Pelvicore Rehab). They specialize in pelvic health and wellness, along with bowel, bladder, sexual, and GI dysfunction. She earned her master’s degree, began as a general physical therapist, and then moved on to the specialty of pelvic floor when she realized that there were men and women who were experiencing issues in their daily lives caused by the muscle and fascia of the pelvic area. 

I asked Susan how someone can determine who needs pelvic floor therapy. She’s a big fan of using a non-clinical acronym: the 4 Ps (Peeing, Pain, Pressure, and Poop). If you have any kind of urine leakage, disrupted stream, urgency, frequency, retention, or hesitancy. If you have pain in your pelvis, groin, low back, bra-line area, pain during sex, or in your hips, it can all be an indicator that your body has a pelvic floor issue. Pressure in the perineum, like something is falling out, the feeling of a golf ball in the rectum, or pressure in the rectum. The last one is poop. Susan believes that pelvic floor therapy should be the first line of treatment for constipation and incomplete evacuation. Fecal urgency, frequency, or fecal incontinence along with the inability to hold back gas are indications that there is a problem. These are the foundational components of what a physical therapist should be sought out for. 

I asked her something that I’ve been led to believe all my life: “Isn’t peeing yourself just a part of being a mom and an aging woman?” I had been told over and over by adult women that this was just what happens and we just deal with it by no longer jumping, by crossing your legs when you sneeze, or wearing a pad daily. Susan responded by saying that although leaking is common, it is absolutely not normal. She gave me the example of an 82-year-old lady who was a housekeeper and had bladder leakage. Her doctor told her that she shouldn’t be cleaning houses at her age, and that there was no cure for her leaking. She found Susan through Google and after two sessions, her urine pressure management issue was gone. The leaking totally stopped. The lesson here is that leaking should never be considered normal and that regardless of your age, there’s always hope! 

This led our conversation towards Kegel exercises. The million-dollar question is always “to Kegel or not to Kegel” and the answer is that Kegels can actually sometimes make pelvic floor dysfunctions worse. Some pelvic floors are actually too tight and Kegels cause more tension in the muscles… especially because many women don’t actually know how to do Kegels properly. During a visit with your PT, they should be doing an internal examination to see whether you are using the correct muscles or not. Susan

mentioned a study where 80% of women were doing them incorrectly. This is also why it’s important to have an individualized plan created for you by your PT, rather than following a generic program. 

We talked about exercise during pregnancy and how it can affect the pelvic floor. There’s an outdated thought that women need to stop working out during pregnancy or that they can only do gentle exercises like yoga and walking. This is so far from the truth. Susan has worked with pregnant women who lift weights, are equestrians, and do many more high-intensity exercises throughout their pregnancy. There should, however, be some guidance to help women learn how to support their pelvic floor and abdominal walls so that their pregnancies and recoveries can be much easier. She said many of us do not create our strength from the inside out— we instead do it from the outside in and that causes a lot of muscular dysfunctions. After pregnancy, she recommends that every single mother sees a pelvic floor therapist to make sure they are reconnecting with their deep core system and are generating support in the right way before they get back to any exercise. When we learn our anatomy, we are able to monitor and modify exercises to make sure they are helping us rather than hurting us. There is no such thing as a “bad exercise” however, there is only a “bad way to do exercise.”

The conversation moved on to methods of delivery. Any woman who has given birth, whether it’s via cesarean or vaginally, has experienced 40 weeks of stretching and pulling of the pelvic floor. Their pelvic floor muscles need to be rehabilitated. If they had a vaginal birth, it’s common that we’ll see issues like leakage, scar tissue tightness in the perineum if there was a tear, or sometimes a prolapse of the bladder or uterus. For cesareans, common issues Susan sees are scar tissue adhering to the bladder or other organs and pain with sex. Releasing the scar tissue is of utmost importance for anyone looking to have a VBAC. For both types of deliveries, she evaluates the rib cage, diaphragm, linea alba (for diastasis recti), bones, pelvic floor, and any scar tissue that needs to be released. 

I asked Susan if she could talk to me about a “squatty potty” because I know pelvic floor physical therapists love them! It is a stool that elevates your knees to be higher than your hips while you are moving your bowels. Historically, this is how humans were made to use the toilet so that the anal-rectal angle can open up, the puborectales muscle can release tension, and stool can easily move through and out through your lower digestive system. Engaging any of the lower abdominal or pelvic floor muscles while using the toilet, even if to pee, feeds the dysfunctions. Hovering over the toilet (maybe