My first exposure to the Kegel exercise, like many women of my age, was in Cosmopolitan magazine, where I was promised that doing Kegels religiously was the key to great sex. At the time, I was a decidedly not-sex-having high school student, so I promptly forgot about them. Kegels then came roaring back during pregnancy, when they were promised to preserve my pelvic floor for great sex later, along with improving my birth experience.
Interestingly, throughout this discussion of the exercise, no one ever told me what these exercises were doing or connected them to my pelvic floor. I’m not sure I was entirely clear on what a pelvic floor even was, which is why I am delighted that Instagram introduced me to a woman dancing in a vulva costume, the Vagina Whisperer, Dr. Sara Reardon. Sara is an expert on the pelvic floor, and it’s safe to say her knowledge goes way beyond Kegels.
The pelvic floor turns out to have a hand in many things, including peeing, pooping, sex, pregnancy, labor, birth, postpartum, and menopause. Sara explains all of this online and now in her new book, Floored: A Woman’s Guide to Pelvic Floor Health at Every Age and Stage, which will be released in June.
Today, we talk about the book and about the seasons of life with a pelvic floor, from puberty to menopause. We spend quite a lot of time on the optimal ways to pee and poop and discuss what actually happens when you go to pelvic floor therapy. We discuss Kegels and why they are often good but also not a panacea. For me, Sara is special because she does an amazing job of shining a light on something that affects everyone and that we ignore because we just don’t see it.
Here are three highlights from the conversation:
Do you need a Squatty Potty?
Squatting is the best position to relax your pelvic floor muscles for pooping. So, think about if you’re in the woods or if you’re on a run way out in the forest or you’re camping, you squat over the ground; or in other, Eastern countries, you squat over the ground to poop. It’s the physiological way to have a bowel movement that’s best.
What’s happened in the Western world is we have these porcelain thrones that are indoors and they’re comfortable and we’ve got heated bathrooms, and so we’ve kind of moved away from the physiological way to poop. And now we have to re-create that with a pooping stool under your feet.
What are Kegels, and should you be doing them?
It’s the most popular one that we hear about. It’s kind of the foundation of pelvic floor training for strengthening. However, you can’t just sit in the carpool line and do Kegels. You need to do quicker contractions. You need to do longer-hold, 10-second contractions. You need to work this muscle in standing. If you’re a runner, Kegels in the carpool lane, it’s not going to help you out. You need to do squats and lunges and kind of higher-impact stuff while training your pelvic floor.
The flip side of this, I’ll say, is a lot of people actually have tight pelvic floors, and we think, like, “Oh, tight vagina, that sounds awesome.” But tension can also impair function, [meaning that] you can’t relax your muscles to pee, poop, [or] have sex. So I caution people to just start doing all their Kegels because a lot of people have tension, which is normal in today’s world. You want to address that first, before doing strengthening.
If you have multiple pregnancies, do pelvic floor problems get worse with each pregnancy?
But yes, it can obviously get worse. Three or more births, three or more vaginal births are definitely a higher risk factor for pelvic floor dysfunction, which is why you want to be proactive about that pelvic floor care. But even if you haven’t started it, it is never too late ever, ever, ever, ever. You could be in your third trimester. You could be in your 50s, 60s, 70s. It’s never too late to start pelvic floor rehab.
Full transcript
This transcript was automatically generated and may contain small errors.
But before we get into any of that, could you start by just telling us who you are, where you’re coming from, a little bit what you do?
And during my grad school education, we had a professor who taught us about the pelvic floor. It’s like a two-week stint and I was like, “Huh, this is really interesting to learn about this part of my body that I never knew that I had, that everyone has, all genders, males, females, everyone.” And it’s super important, like every time you pee, your pelvic floor is activating. Every time you have to pass gas, it’s relaxing. When you birth, when you run.
And I really just loved learning about my own body as a woman and thought, “Everybody needs to know this information. It seems pretty important.” And right when I started my career, I jumped right into it in my first job in Austin, Texas. And since then, I’ve worked with tens of thousands of patients, I would say. And it’s just an incredibly rewarding feel to educate folks about their body and help them prevent issues which are super common yet so rarely talked about.
So, there are so many seasons and stages of life where this group of muscles is very much impacted, sometimes transformed. And one in two women will have a pelvic floor dysfunction later in the later years of life. I’m like, “Why aren’t we talking about this more and giving people tips to prevent these issues down the line?”
So, I want you to think about what you would do if you had to stop your urine stream. You tighten a little muscle down there. You’re trying to kink off your urine stream. Or if you have to pass gas and you’re in an elevator and you’re like, “Oh, squeeze it.”
Also, my favorite way to cue people to do this is to take a big deep breath and then on the exhale, think about sipping up a smoothie with your vagina. So, I’m like, “Who does that?” Every patient of mine imagines it. But when you think about that sipping up maneuver, it activates those pelvic floor muscles. And again, Emily and Tamar are both doing this as we’re talking. And you get that like, “Oh, there’s something happening down there.” And that’s your pelvic floor muscles.
So, it’s a way to kind of just start connecting with them. But everybody has them. And again, there are different seasons of life they’re affected and there’s just day-to-day stuff that they do to help us function.
And the same thing for pooping. It holds in poop as your rectum fills and your colon fills with waste. And then when you sit down, ultimately, ideally with a Squatty Potty or a little poop stool under your feet, you can relax your pelvic floor muscles, aka your butthole, and then you can empty the tank.
So, squatting is the best position to relax your pelvic floor muscles for pooping. So, think about if you’re in the woods or if you’re on a run way out in the forest or you’re camping, you squat over the ground or in other eastern countries, you squat over the ground to poop. It’s the physiological way to have a bowel movement that’s best.
What’s happened in the western world is we have these porcelain thrones that are indoors and they’re comfortable and we’ve got heated bathrooms and so we’ve kind of moved away from the physiological way to poop. And now, we have to recreate that with a pooping stool under your feet.
So, don’t push when you pee. You just need to sit and chill and breathe and your bladder actually pushes the pee out for you.
I think the other incremental time when we’re thinking about how early is it appropriate to start really learning about this, it’s really puberty. When you have a young woman who is going through menstruation, their body is going through significant hormonal changes and hormones affect our pelvic floor function and our vagina and vulva.
But also, this is their first exploration into their genitalia, into their body. And if we don’t talk about it, it can often feel embarrassing or shrouded in shame, but it’s also they’re learning how to use menstrual hygiene products. They’re learning how to find their vaginal opening perhaps to insert a tampon or a menstrual disc or cup. They’re learning about what is the significance of a painful period. Does that mean something else could be going on like an endometriosis or something?
So, really teaching them about their bodies young is where it needs to start because it opens the doors for greater and bigger conversations and curiosity later versus not talking about it at all. So, that’s just another major time. And I would say after that, it’s also when someone becomes sexually active. So, the vagina is part of the pelvic floor and one in four women will experience pelvic pain and painful sex at some point in their life and they don’t even think of the pelvic floor muscles as a source of that pain.
And then when we become sexually active or we struggle with infertility or we’re pregnant and postpartum, we kind of start keeping all of these things in because we’ve never talked about them. So, I think there’s so much more we can achieve by having these conversations early that the ripples of that go really way far into the later stages of being a woman.
So, if those muscles are tight or tense, it can often obstruct insertion. And this is when people complain of something like, “Oh, it feels like my partner’s hitting a wall,” or, “When I put the tampon on, it just feels like I can’t go any further.” That can often literally just be muscle spasm.
And so, we really need those muscles to be able to relax at the opening and then even at the deeper level. If someone experiences pain with deeper insertion or certain positions or it feels like their partner’s poking them or there’s a bruise, that can literally just be muscle tension.
So, as physical therapists, we work with muscles to help relax them, teach you how to breathe, different positions and stretches to relieve tension and pain. Also, the outer layer of the pelvic floor muscles, there’s two layers. The outer layers are the ones that contract and relax during an orgasm.
So, we go through stages of arousal which hopefully ultimately lead in the climax which is an orgasm. And those muscle contractions are what’s happening during an orgasm. So, if you have pain with orgasms or difficulty having an orgasm or leakage with orgasms, your pelvic floor muscles are also involved.
So, during pregnancy, your pelvic floor is doing a tremendous amount of additional work, correct?
And so, if you can imagine a hammock holding an avocado, it’s not going to sink down or stretch that much. But if it’s holding a watermelon, it’s going to sink lower, it’s going to be really stretched out. It’s not going to be able to support you as well.
So, regardless of what type of birth you have because it’s a misconception that only vaginal birth moms need pelvic floor PT, your pelvic floor changes just through pregnancy itself. And this is when we start to see things like urinary leakage, hemorrhoids, prolapse, all this vagina stuff starts to pop up that we’re like, “Oh, this is just pregnancy.”
However, there is research to support that getting pelvic therapy interventions sooner during pregnancy give you better postpartum outcomes. So, yeah, your vagina’s changing, your pelvic floor’s changing. You got to get pelvic floor therapy during pregnancy.
So, I decided to run and I did have to pee a bit. And so, I ran a lot of blocks and I was maybe five months pregnant and I just the entire time was peeing on myself as I was running through the streets of New York. And thank God I had another pair of pants with me when I got on the train which I totally made. But it is a very salient memory of the pelvic floor.
Just like you would run a marathon, you Emily, and you trained for months and months and months, pregnancy is no different. The demands on our body are different, so we need to train our pelvic floor to meet those demands, and yet we just haven’t incorporated this into prenatal care.
But I would say at the latest, you need to really be checking in with a pelvic floor therapist or starting some pelvic floor training at the very beginning of your second trimester, because this is when our body starts to really transform with respect to ligaments get more soft and lax and we get some instability in our pelvis. We start getting more stretching of the core muscles, the abdomen and pelvic floor. We are trying to stay active but not sure how to modify what workouts we’re doing. And aches and pains start to pop up, hip pain, back pain, things like that.
So, all of those things can be addressed proactively. And if you get pelvic floor muscle training and address issues during pregnancy, it’s going to one, optimize your birth. You can get a lot of education on how to prep for birth, pushing cesarean birth preparation and then postpartum recovery.
So, I would say as early as your second trimester, check in with a pelvic floor therapist in person or start doing some training to really get your body ready for that long marathon of the next several months.
However, it’s the most popular one that we hear about. It’s kind of the foundation of pelvic floor training for strengthening. However, you can’t just sit in the carpool line and do Kegels. You need to do quicker contractions. You need to do longer hold, 10-second contractions. You need to work this muscle in standing. If you’re a runner, Kegels in the carpool lane, it’s not going to help you out. You need to do squats and lunges and kind of higher impact stuff while training your pelvic floor.
The flip side of this I’ll say is a lot of people actually have tight pelvic floors and we think like, “Oh, tight vagina, that sounds awesome.” But tension can also impair function, so you can’t relax your muscles well to pee, poop, have sex or even contract. So, I caution people to just start doing all their Kegels because a lot of people have tension which is normal in today’s world. We have tension in our bodies and you want to address that first before doing strengthening.
And I go through in the book kind of a checklist of if you’re doing this at home and not seeing a pelvic floor therapist in person, which kind of pathway do you fall in? How do you know if you have tension? How do you know if you have weakness and need Kegels or tension and need relaxation? And I even give you tips on how to explore your pelvic floor, like how do I know if I’m doing a Kegel properly? And to give people really to demystify this a little bit and to also just give them some simple practical tools at home to start addressing these issues.
So, can you give us a sense of, is this just my pelvic floor is aging and starting to droop like all my other muscles? Is that basically what’s happening as I turn to ash? Did I not get enough protein? Is it something about protein?
And if those don’t get addressed at those early stages, then when you hit perimenopause and you don’t have your hormonal system to prop you up anymore, things start to take a nose dive. So, during perimenopause, you start having less estrogen in your body and estrogen is the hormone that really plumps up the vagina. It keeps you well lubricated in the vulva and vagina and it gives you more tone and thickness to your pelvic floor muscles.
You also lose testosterone during perimenopause, so you have less muscle strength, different things like that, more visceral fat, and then you lose collagen. So, I put collagen in my coffee and I rub it all over my face. I’m like our vaginas and vulvas are also losing collagen.
So, all of those things do lead to more pelvic floor weakness, less tone in the muscles which can lead to prolapse and leakage and vaginal dryness. So, one of the biggest things people experience is more vaginal dryness and painful sex in perimenopause and definitely into menopause because you don’t have the natural lubrication of estrogen to help provide moisture down there.
So, I’m a huge fan of obviously doing exercise and proactively strengthening your pelvic floor looking at perimenopause like a runway like, “Hey, there’s a red flag down there.” And you need to start working to get yourself ready to address that. We have this runway where it feels like things are going bananas, but it’s also a warning sign of your body’s changing and you need to make it kind of stay healthy so that when you get there, you’re in your tiptop pelvic floor shape.
The other thing is I do encourage folks to have a vulva care routine just like we have a skincare routine and not using harsh products, but also thinking about using an all-natural moisturizer for their vulva and vagina using good lubricants for sex.
Some people just use coconut oil. There’s another brand called Kindra. So, there’s a bunch of these balms or lotions that are specifically made for the vulva and vagina that aren’t going to alter your pH and put you at risk for infection, but they’re going to keep it lubricated.
So, it’s just like we do for our face. And you’ll notice, going through perimenopause and definitely menopause, it’s dry down there, it’s itchy, it’s uncomfortable, it can even close up. So, I’m a big fan of that. And then some people do use a topical estrogen cream as well to help plump up the tissues.
They obviously don’t have a vagina, but the pelvic floor also closes the sphincters. It maintains an erect penis, so blood stays in the penis when those muscles are tight or tense. And they also contract and relax during climax and orgasm. They support your pelvic organs. They assist with breathing just like they do in the female body.
More often though, men have tension versus weakness. So many more women experience weakness because of the hormonal fluctuations and because of events like pregnancy and birth and menopause. But male bodies typically, what I see is much more tension in the area and that needs to focus more on relaxation unless they have a prostate surgery which could lead to weakness issues as well. So, they have problems just like female bodies do.
It’s interesting because as little as we talk about the female pelvic floor, we talk about the male pelvic floor actually a lot less. And I’ve seen men in my practice my entire career, we have wives coming in like, “I think my husband needs this too.” And so, we do see a lot of males as well and it’s an up-and-coming sector of pelvic floor therapy.
If you don’t frontload your fluids and you drink everything in the evening after getting home, that can make you have to pee more often. Or you have a little bit of overactive bladder. An overactive bladder is like your bladder saying, “I got to go, I got to go,” when it’s not really that full.
So, there’s two things that I tell people to do is frontload your fluids earlier in the day. Cut off your fluids two hours before you go to bed. Pee. And then if you go to the bathroom and pee and you still have the urge, I want you to take five big deep breaths and then five Kegel contractions.
Suck up that smoothie five times because tightening your pelvic floor tells your bladder to chill out. And so, if you do that on repeat and you can buy yourself 15 minutes, 30 minutes and then you’re like, “Shit, I got to go again,” go again, that’s fine. But eventually, you’ll push that urge off enough where you don’t have to go every five minutes and keep going. Because it’s a false urge, there’s nothing in there when you have to go again.
I will tell you one of the biggest contributing factors to nighttime bedwetting is constipation, which is the most common GI complaint in kids. So, if you’re constipated, and this kind of goes for adults too, think of that basket of muscles holding. It only has so much space in it. And if it’s full of poop, that’s going to push on your bladder.
So, some people find like they have more urgency to pee when they’re constipated and that’s true. The same thing for kids, when they’re bedwetting, one of the first things I do is I actually talk to their parents about curing their constipation and then getting them on a voiding schedule of going every couple hours during the day and then setting alarms at night.
But there’s also some kind of behavioral things and neurological things that need to be addressed as well that’s outside of pelvic floor therapy. But some of these tips do help when it comes to addressing pooping and peeing habits.
And once we evaluate those muscles, if they’re tense, we may work on strengthening exercises which again can include pelvic floor contractions or Kegels. We do use some machines which are called biofeedback which kind of are like an EKG for the heart, but it goes around your butthole or in your vagina and it shows you on a screen how your muscles are performing. But then we do squats and lunges and hip strengthening and all kinds of stuff.
If it’s a weakness issue, I mean if it’s a tension issue, we may do more relaxation like internal vaginal massage to the pelvic floor using trigger point wands or dilators to relax the muscles. There is something called electrical stimulation which can activate the muscles kind of like, I don’t know if you remember the old Bruce Lee days, he used to put this thing on his stomach and it would fire up his six-pack. It’s that for your vagina. However, the research is really mixed in how effective that is long-term. Ultimately, we want you doing these exercises on your own and with different activities during the day.
So, these vibrating chairs and vagina zappers and lasers are very minimally effective and can be quite expensive. And ultimately, you still have to just keep up with these home exercises to give yourself long-term relief.
And it’s funny. I mean, I’ve had people show up in their workout clothes and they’re like, “I’m ready.” And I’m like, “You can take those off. It’s fine. You’re going to be laying on a bed and we’re doing an exam. Don’t even worry about what you’re wearing.”
But yes, it can obviously get worse. Three or more births, three or more vaginal births are definitely a higher risk factor for pelvic floor dysfunction, which is why you want to be proactive about that pelvic floor care. But even if you haven’t started it, it is never too late ever, ever, ever, ever. You could be in your third trimester. You could be in your 50s, 60s, 70s. It’s never too late to start pelvic floor rehab.
There are a lot of ways you can help people find out about us. Leave a rating or a review on Apple Podcasts. Text your friend about something you learned from this episode. Debate your mother-in-law about the merits of something parents do now that is totally different from what she did. Post a story to your Instagram, debunking a panic headline of your own. Just remember to mention the podcast too. Right, Penelope?
Community Guidelines
Log in