Emily Oster

21 minute read Emily Oster

Emily Oster

It’s Never Too Late for Pelvic Floor Therapy

And why it’s about more than Kegels

Emily Oster

21 minute read

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? 

Dr. Sara Reardon:

A Squatty Potty is the designer name for these poop stools. And it’s really just a stool you put onto your feet. You can use a toddler stool, you can use yoga blocks, you can use an old Amazon box. I don’t care what you use. But the goal is to get your knees above your hip level. So, when you’re sitting on a regular toilet, your knees are kind of in line with your hips. If you elevate your feet, then your knees go up, and it helps your pelvic floor muscles relax.

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.

Emily Oster:

Is it a good idea to pee with a Squatty Potty, or is that not as important?

Dr. Sara Reardon:

It’s not a bad idea, but it’s not a must. So, it’s really just the butthole muscles that relax best with squatting. You can use a Squatty Potty when you pee, but you can also just sit with your feet flat.

What are Kegels, and should you be doing them?

Dr. Sara Reardon:

[A Kegel is] a pelvic floor contraction. It’s a closing of the sphincter, it’s a lifting of those pelvic organs. It’s like a bicep curl. It’s like a crunch. It’s like one exercise you can do for a group of muscles.

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?

Dr. Sara Reardon:

If they go unaddressed? Yes. So, the research is clear that the majority of dysfunction can happen typically with a first birth. But this is why it’s so important to make sure that you are rehabbing your body afterwards. You have just gone through a huge transformation. So, that postpartum period in the first year, again when we’re exhausted and sleep-deprived and physically just drained, that’s the time to do the pelvic floor PT.

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.

Emily Oster:

Sara, thank you so much for joining me.

Dr. Sara Reardon:

Hey, Emily, great to be here.

Emily Oster:

So, we’re going to talk all about the pelvic floor today. And I would encourage people to stick around till the end where we’re going to talk about why I think about you every time I pee. I don’t want to spoil that for people, but it will come up.

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?

Dr. Sara Reardon:

Absolutely. So, I’m Dr. Sara Reardon. I’m a board-certified pelvic floor physical therapist. I live in New Orleans and I’ve been practicing as a pelvic health PT for 17 years. I have a social media presence as the Vagina Whisperer where you’ll occasionally see me, again, showing folks how to pee and educating you while I’m in a vulva costume. And I’m the recent author of a new book, Floored: A Woman’s Guide to Pelvic Floor Health at Every Age and Stage.

Emily Oster:

Which is fantastic. Okay. So, I want to start with why you love the pelvic floor so much and why you chose this part of the body. Where does your passion for the vulva and pelvic floor come from?

Dr. Sara Reardon:

So, I started in this field immediately after grad school. In 2007, I went through regular pelvic floor physical therapy school and thought I was going to be a trainer for the New Orleans Saints football team and just was really into sports and activity.

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.

Emily Oster:

It seems like one of the things I get out of your book is this feeling of some of the time when you tell people things, it seems like magic. They didn’t know a whole area was unknown and then you can explain something which somebody was struggling with or was painful or just you illuminate in a way that I’m not sure we get with dentistry or something since we all know we have teeth and things like that.

Dr. Sara Reardon:

Well, I think that’s one of it. You can’t see the pelvic floor, so it’s hard to even see or imagine what is it, what is it doing? It feels very mystical, yet it’s super important. Again, it plays this role in peeing, pooping, sexual health, reproductive health, pregnancy, birth, menopause.

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?”

Emily Oster:

So, for those people who are listening now and thinking, “Wait, I also don’t know where my pelvic floor is,” let’s do a very quick one-on-one. When you talk about the pelvic floor, what is the muscle group you’re talking about and how would I know that I had one?

Dr. Sara Reardon:

Well, everybody has one. So, we’ll start there.

Emily Oster:

Check. You have one. Okay.

Dr. Sara Reardon:

Yeah, you have one. So, I would say if you’re sitting right now or standing, I want you to put your hands on your hips. And you can feel those little hip bones that we often feel and we’re used to seeing in a pair of-

Emily Oster:

I want the listeners to know that both Tamar and I are doing this right now. Okay. Go ahead.

Dr. Sara Reardon:

And you’re used to seeing on your skeleton jammies for your kiddos. And that’s your pelvis. So, your pelvis is a ring of bones that attaches in the front at the pubic bone, the back at the sacrum tailbone. At the very bottom of that, imagine this hammock of muscles.

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.

Emily Oster:

So, let’s talk about a little bit of that day-to-day stuff before we get into the seasons of life. So, the pelvic floor when one is peeing, what is it doing?

Dr. Sara Reardon:

It’s holding pee in your bladder so that you don’t leak, ideally. And then when you sit down to pee … Again, I encourage sitting, not hovering over a toilet unless it’s super gross. But when you sit down to pee, it relaxes. So, the muscle relaxes and then your bladder pushes the pee out for you. So, it’s helping you say what we call continent which is the ability to hold in urine.

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.

Emily Oster:

Okay. So, let’s talk about pooping. You are online, you show us the use of a Squatty Potty very frequently. I have a Squatty Potty.

Dr. Sara Reardon:

Love that.

Emily Oster:

Can you explain what that is and why people should have one?

Dr. Sara Reardon:

So, a Squatty Potty is the designer name for these poop stools. And it’s really just a stool you put onto your feet. You can use a toddler stool, you can use yoga blocks, you can use an old Amazon box. I don’t care what you use. But the goal is to get your knees above your hip level. So, when you’re sitting on a regular toilet, your knees are kind of in line with your hips. If you elevate your feet, then your knees go up and it helps your pelvic floor muscles relax.

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.

Emily Oster:

Is it a good idea to pee with a Squatty Potty or is that not as important?

Dr. Sara Reardon:

It’s not a bad idea, but it’s not a must. So, it’s really just the butthole muscles that relax best with squatting. You can use a squatty potty when you pee, but you can also just sit with your feet flat. That’s a great question.

Emily Oster:

I think we should get into a little more about peeing also because I feel like this is the segment of the podcast where people should get a lot of takeaways. So, every time I sit down to pee now, I think to myself, “Don’t push the pee out,” because this is a big thing in your book. Can you please tell people why they should not be … First of all, what does that mean and why should they not be doing that?

Dr. Sara Reardon:

This is music to my ears because that’s a big takeaway from the book. Don’t push when you pee. I call it power peeing. And as busy women, as moms, as parents, as working women, we are notorious for power peeing. And then we-

Emily Oster:

Totally.

Dr. Sara Reardon:

Right?

Emily Oster:

We’re like you can skid so fast. Okay. Anyway, go ahead.

Dr. Sara Reardon:

It’s true, right? We are trying to rush through everything including peeing. So, when you pee, you really just need to sit and chill because your bladder is the muscle that’s pushing the pee out. If you push and power pee, you are putting extra strain on your pelvic floor muscles which can weaken them over time. And this can lead to urinary leakage or pelvic organ prolapse which is a scary thing when it’s like your organs are falling into your vagina. So, it can weaken your muscles over time and lead to other pelvic floor conditions which we want to try to prevent.

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.

Emily Oster:

What if I’m in a hurry though? Is there a situation in which I should be power peeing?

Dr. Sara Reardon:

Never.

Emily Oster:

Okay.

Dr. Sara Reardon:

I don’t care if there’s little … No, never, never. Just sit and chill and breathe. And it will actually come out faster and better and you’ll empty better. If you push, you actually don’t even empty your bladder as well. And so then, you’re going to have to go back 30 minutes, 60 minutes later and pee again. So, just really from an efficiency standpoint, Emily, I just recommend chilling.

Emily Oster:

Is it okay to pee in the shower?

Dr. Sara Reardon:

100%. Totally fine. And quite good for the environment.

Emily Oster:

Great. All right, so I think it’s a good place to start because peeing and pooping are things that happen for everybody. And it is important to note that the pelvic floor therefore is important at all ages. The time people most frequently hear about the pelvic floor is during pregnancy. Is there a time before pregnancy where you would say, “Here’s another time of life that you really should be thinking about your pelvic floor a little more,” where it’s doing other things for you other than peeing and pooping?

Dr. Sara Reardon:

Yeah. So, it’s interesting because I think as parents, we think about what do I need to do for my pelvic floor? But I even think we need to have these tips and tools to educate our kids, right? We’re potty training them. We’re teaching them how to poop in toilets or kids struggle with constipation. So, if you’re a parent, some of the things that you’re going to learn and forth, you need to be implementing and teaching for your kids because again, if they don’t learn it young, when are they going to learn it?

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.

Emily Oster:

Going back quickly to puberty, I think one of the pieces that’s very helpful for me in thinking about the book is this is a scientific way to approach a topic that with an adolescent is often very uncomfortable to just be like, “Hey, there are muscles in the pelvic floor. Let’s talk about inserting a tampon.” But rather than talking about it in an uncomfortable way, at least there’s a little bit of a way to come into it with like, “Here’s some interesting cool facts about muscles and the muscles you have and all the cool stuff they can do. And by the way also, this is where your vagina is in case you want to use a tampon.”

Dr. Sara Reardon:

Right. And it’s so much more. It’s kind of like we … And that’s in a very practical sense of how do we approach pelvic floor health. But I think it has even greater implications about how do we feel comfortable talking about our bodies as women in the greater scheme. Where do we start going to for help? Where do we get education about our bodies?

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.

Emily Oster:

So, let’s talk about sex, either becoming sexually active or just in general problems with sex. Give me a little bit of a sense of what is the pelvic floor doing during sex that it might fail at?

Dr. Sara Reardon:

Let’s talk about potential failures, but also achievements.

Emily Oster:

Achievements, okay.

Dr. Sara Reardon:

I would say, so the vaginal opening is through the pelvic floor muscles. So, in order to have anything insert into the vagina, whether it’s a penis, a dildo, a finger, ultimately a speculum for pelvic exams or, again, we mentioned tampons, the pelvic floor muscles have to relax for anything to enter into the vagina.

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.

Emily Oster:

And then if the sex is successful in a different way than an orgasm and you get pregnant, this is the time I think people almost always hear about or at least, well, this is the time people should always hear about the pelvic floor, whether they do or not.

So, during pregnancy, your pelvic floor is doing a tremendous amount of additional work, correct?

Dr. Sara Reardon:

Right.

Emily Oster:

Because it is holding up, I’m going to see if I get it right having done my little, now that you’ve taught me about the smoothie thing, the pelvic floor muscles are holding up the baby which is getting larger and larger and larger and there’s a lot of water in there also and it’s a lot of work. Am I roughly correct?

Dr. Sara Reardon:

Right. You were spot on, Emily.

Emily Oster:

Spot on.

Dr. Sara Reardon:

And so, we’re so used to getting these text messages or emails about the size of the baby. It’s the size of a blueberry, then it’s the size of an avocado and then it’s the size of a watermelon. Well, your pelvic floor muscles are ultimately the hammock that’s holding up that blueberry, avocado or watermelon.

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.

Emily Oster:

I want to talk about what that looks like but first, I want to tell you the most embarrassing story that I have from either of my pregnancies which is during my second pregnancy, I was in New York and I wanted to get home and I was a little bit late for the train and there was a lot of traffic.

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.

Dr. Sara Reardon:

Yeah. And if you think about-

Emily Oster:

My pelvic floor failed me.

Dr. Sara Reardon:

You’re not alone. Well, you were pregnant and that’s a lot of pressure and running is extra pressure on your pelvic floor. So again, it’s one of these things where I’m like, “We have to train these muscles like we do any other muscles in our body.” If we’re going to ask it to support a five-month-old baby, running through the streets of New York, we have to train it for that.

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.

Emily Oster:

So, in your ideal incorporation of this into prenatal care, when would it start and what happens beyond, I think Kegels are the thing people have most frequently heard of, but the scope of this is much larger than that. So, if I’m telling someone who has just found out they’re pregnant or before, what is the advice about how long and what would that even look like for them?

Dr. Sara Reardon:

I mean, I would start week one. I mean, if you’re pregnant week four, start getting some education about, of course, I have all these videos about this, but your pelvic floor is going to go through changes even in that first trimester. You’re going to have constipation from surging progesterone. You’re going to have urinary frequency. You may have some … Leakage even start right away.

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.

Emily Oster:

What is a Kegel?

Dr. Sara Reardon:

It’s a pelvic floor contraction. Well, first of all, it’s an exercise named after a man which I’m going to start a revolution to rename it. I mean, we don’t need any more body parts or anything to do with the female genitalia named after a dude. Second, it’s a pelvic floor contraction. So that sipping up the smoothie that we all practiced earlier, that’s a Kegel contraction. So, it’s a closing of the sphincters, it’s a lifting of those pelvic organs. And again, it’s like a bicep curl. It’s like a crunch. It’s like one exercise you can do for a group of muscles.

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.

Emily Oster:

I think there’s a core insight in the book which I found very illuminating which was I’ve gone to physical therapy for other things. And generally, when you go to physical therapy, they look at what the issues are that you are personally struggling with and they give you a set of exercises to deal with those issues. And this is the same thing, it’s just not a muscle that you see.

Dr. Sara Reardon:

Correct.

Emily Oster:

And therefore, the same logic applies. You figure out what’s going on and you develop a set of exercises that are going to train that problem away, which may involve Kegels just like-

Dr. Sara Reardon:

Which may-

Emily Oster:

… sometimes there are squats or bicep curls or crunches in your regular physical therapy.

Dr. Sara Reardon:

Correct. I think we want to think about that. And I think that one, I mean, we are kind of illuminating so much more about the pelvic floor now that, hey, it doesn’t need to just tighten, it also needs to relax. But I also think that there is no one-size-fits-all protocol. I always say it’s like if you have back pain and your therapist is like, “Hey, just go do a bunch of crunches,” or that’s what your physician tells you, you’re like, “Well, that doesn’t sound like the right prescription.” We need to look at how you move and breathe and what’s tight and what’s weak.

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.

Emily Oster:

I want to talk about a third part of life which is the kind of perimenopause, menopause piece because this is another time in which even people who have not had problems prior with their pelvic floor can develop almost unexpectedly. So, things like prolapse can come up in perimenopause or menopause even if it didn’t come up before.

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?

Dr. Sara Reardon:

I know.

Emily Oster:

Please.

Dr. Sara Reardon:

And so, I was thinking about that. It’s always about protein. So yeah, I mean, yes and no. So, muscles weaken over time. They atrophy over time when we don’t address them. And when you go through transitions like pregnancy and postpartum where those are risk factors for developing pelvic floor dysfunction because again, you are going through physical changes, hormonal changes, lifestyle changes.

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.

Emily Oster:

Wait. Sorry, what? Can we back up? What? Can you say more about the … Please say more.

Dr. Sara Reardon:

So, there are moisturizers that you can use for your vulva and vagina. And some people use these postpartum when they are lactating and have low estrogen levels, but then also in perimenopause and menopause. And so, there’s a brand called Medicine Mama that has a vulva balm. It’s olive oil-based. It’s organic ingredients.

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.

Emily Oster:

So much to look forward to.

Dr. Sara Reardon:

So much more to add to our daily routine.

Emily Oster:

Yes, I’m barely making it as it is with just putting a small amount of moisturizer and washing my face. So, PBD on that. Do men have a pelvic floor and what is it important for? I feel we’ve left them out, so I’d like to have just-

Dr. Sara Reardon:

We’ve left them out.

Emily Oster:

… brief discussion of men.

Dr. Sara Reardon:

Pull them in. So, men absolutely have a pelvic floor. The differences are they have two openings. So, when female pelvic floors, we have an opening for urine, the urethra, we have an opening for the vagina, and then we have an opening for the anus where poop and gas exit. Male bodies have two openings, one for the urethra which goes through the penis and exits through the opening of the penis and then one for the anus. So, they have two openings.

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.

Emily Oster:

Do they also have urinary leakage problems? Is that an issue for men?

Dr. Sara Reardon:

It can, especially if they have a prostate procedure because the prostate kind of surrounds the urethra. So, if they have a procedure to the prostate or a surgery to remove it because of prostate cancer, then it affects the urethra and they can leak urine, they can have erectile dysfunction because the nerves are impaired, they can have pain. So, it is a common issue.

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.

Emily Oster:

They definitely need more attention in general. So, I want to end with a few rapid-fire questions.

Dr. Sara Reardon:

My favorites.

Emily Oster:

Okay. What is your favorite of the pelvic floor muscles?

Dr. Sara Reardon:

The puborectalis which relaxes for pooping.

Emily Oster:

What should I do if the porta potty is really dirty?

Dr. Sara Reardon:

Hover, lean forward, rest your elbows on your knees and take some big deep breaths to empty.

Emily Oster:

Is it bad if I hold in my poop for a long time while I’m running? Asking for a friend, hashtag.

Dr. Sara Reardon:

It’s not ideal. If you’re running, you have two options, you hold it or you squat on the side of the road. If you are ambitious and courageous enough to squat, go for it. If not, hold it. But when I get back from running, I would drink some hot water, I would maybe eat a little something and that can stimulate the urge for the poop to go. But it’s not ideal to hold it unless you have to.

Emily Oster:

Is it important to pee after sex to prevent UTIs?

Dr. Sara Reardon:

Yes, it is important to pee after sex. I’m not a fan of what I call just in case peeing, which is like every time you get to Target and then you get home from Target and then you go pick the kids up from school and every time you pass a bathroom. However, times that are okay to pee just in case are before sex, after sex, before pelvic floor therapy, after pelvic floor therapy. Or if you’re not going to have access to a bathroom for many, many hours, typically you want to pee every two to four hours, but after sex is an important time to go.

Emily Oster:

I have one more which is kind of specific. An issue that many people have raised to me is as they’re getting ready for bed, they feel they need to pee many times. And sometimes it’s just in case peeing or it’s just this feeling of like, “Maybe I have to, a little bit, a little bit.” Why is that happening and should I give into it?

Dr. Sara Reardon:

So, no. It’s a miscommunication between your bladder and your pelvic floor. So, typically, you are supposed to every two to four hours if you have a drink. So, if you have wine or a cocktail or spicy food that could irritate your bladder, that might make you more susceptible to pee more often.

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.

Emily Oster:

So, when we think about kids, is bedwetting something that’s associated with the pelvic floor or is this a totally different issue?

Dr. Sara Reardon:

It can be, but I would say bedwetting in kids is typically multifactorial. It’s not just like they’re holding it too long and then they have to pee at night. There’s typically some neurodivergence that can be involved, some behavioral issues.

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.

Emily Oster:

And I should say that until the age of about seven, it is actually pretty typical for kids to just not wake up to pee and to need a pull-up. So, when we talk about sort of bedwetting you would want to see somebody about, it’s really if they are still not dry at night after 6 or 7.

Dr. Sara Reardon:

My son, he’ll probably not let me share this, was five or six and he was still in nighttime, but completely continent during the day. He just was lazy and he didn’t want to pee all day so he’d hold it till the nighttime. And I’m like, “Dude, I get that. I mean, how many times are we cold in bed and don’t want to get up and pee?” But then he just grew out of it and I was like, “Okay, if he’s nine or 10 and we have this issue, we’ll get some help.” But otherwise, they typically do grow out of it.

Emily Oster:

So, can you say a little bit more about when you do physical therapy, what does it involve? Somebody mentioned some kind of zapping of the vagina and I’m just curious if that’s a core element or just a sometimes extra?

Dr. Sara Reardon:

Vaginal zapping is not standard in pelvic floor therapy. So, think of traditional physical therapy where you get an assessment. However, the assessment is an internal examination of the pelvic floor which is either through the vagina or through the anus. And this is obviously with consent.

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.

Emily Oster:

But I think it is good for people to know that you go for pelvic floor physical therapy, there is a physical component of this, an internal exam physical component of this.

Dr. Sara Reardon:

Yeah, there should be. And the only time we don’t do it is maybe during the first trimester with a higher risk pregnancy or in the first six weeks postpartum, or if somebody does not want it, obviously. But yeah, the way that we assess the pelvic floor is through the vagina or anus.

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.”

Emily Oster:

You don’t need Lululemon for that. Okay. Now, we’re back to our lightning round. Do pelvic floor problems get worse with each pregnancy if I have multiple pregnancies?

Dr. Sara Reardon:

If they go unaddressed? Yes. So, the research is clear that the majority of dysfunction can happen typically with a first birth. But this is why it’s so important to make sure that you are rehabbing your body afterwards. You have just gone through a huge transformation. So, that postpartum period in the first year, again when we’re exhausted and sleep-deprived and physically just drained, that’s the time to do the pelvic floor PT.

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.

Emily Oster:

Sara, I really think the work you’re doing is incredibly important and I am very grateful for you being here, but I’m very grateful for the book and I think you are going to change the lives of a lot of people and that’s a really special thing. So, thank you for sharing with us today and for changing how we pee and it’s wonderful.

Dr. Sara Reardon:

Thanks, Emily. Thanks for having me. I’m super grateful for your support. But also, I also hope that this changes the lives and vaginas of many, many people because we need it and we deserve it. So, I hope that that is what happens as well.

Emily Oster:

No power peeing. Thank you for listening.


Emily Oster:

ParentData is produced by Tamar Avishai with support from the ParentData team and PRX. If you have thoughts on this episode, please join the conversation on my Instagram @profemilyoster. And if you want to support the show, become a subscriber to the ParentData Newsletter at parentdata.org, where I write weekly posts on everything to do with parents and data to help you make better, more informed parenting decisions. 

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?

Penelope:

Right, mom.

Emily Oster:

We’ll see you next time.

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