Pelvic Health with Dr. Rachel Parrotta, Physical Therapist

You're listening to the PT Profit podcast, episode number 93. Today I'm sitting down with physical therapist Rachel Porada, and we're talking about all things pelvic health. Are you ready? Let's get started. Hi, I'm Beverly Simpson, former fitness manager turned online personal training business owner. And this podcast is where smart fitness professionals, including trainers and clinicians, discover how to increase client performance in movement, package and position their products and services, and get out of their own way so that they can increase their revenue to live a life that they love without sleazy sales. Welcome to the PT Profit Podcast. Thanks so much for pushing play on another episode of the PT Profit Podcast. I'm your host, Beverly Simpson, and today, if this is your first day joining us, welcome. Thank you so much for pushing play on this episode. I am, well, really excited to get this one rolling. So I had the pleasure of working closely with Rachel in the PT Profit plus program, and she is absolutely brilliant, and I cannot wait to really dive into this episode and really share with you her brilliance. Because she has over a decade of practicing in New York City, she is now practicing in Long island, and she has had the pleasure and privilege of working with a wide array of clients, ranging from business executives, professional actors, to young athletes, and to college students. Now, the majority of her career, she has focused on pelvic health physical therapy, which we talk a lot about in this episode. And we talk about things that not a lot of people talk about. Now she's on a mission to empower her clients with the most effective tools and information to help them reach their goals. She believes that the power of healing lies in the hands of the client, and I could not agree with her more. So, without further ado, let's go ahead and roll that interview. What's up, Rachel? Thanks so much for hanging out with me today.

How are you? I'm good. Beverly, I'm so excited to meet with you. I love your podcast. I listen to it as well. So I'm so happy to be a guest with you.

Oh, that's so kind. I appreciate it. I'm really excited to dive in today. You have so much to offer, so I can't wait to dive in. So for those of you who have not heard of Rachel, I'd love for you to please just share a little bit about who you are, who you serve, and how you got there.

Sure. So my name is Rachel Porada. I'm a pelvic health physical therapist. So I serve clients in pregnancy and postpartum and also people across the lifespan for pelvic health, both men and women. And I particularly love the pregnant and postpartum folks who are really active and trying to stay active in the pregnancy, as well as help people return to their exercise and sports after they give birth. And how I got there. Do you want me to go into how I got there?

Love that. Go tell me.

So I started my career as an certified athletic trainer. So I was very into sports. I was in sports growing up. I was a gymnast. I was a diver. And then I also love watching sports on tv. So I loved when people would get injured. I didn't love it for them, but I was always curious about injuries and rehab, and I knew I want to go into something like that. So I started my career in sports as an athletic trainer. I worked with a couple teams in college, and then out of college, I worked with a minor league hockey team. I traveled a bunch. That was like my dream at the time.

So cool. Okay, keep going.

Yeah. So super fun. I did that for a year, but then I went back to PT school. And I always thought I would stay in orthopedics and sports, But I started when I was a pt, getting very interested in the birth world, just personally. So I was one of these people that was watching births on YouTube, just kind of like, really had this side interest in birth the same way I think a lot of people that become birth workers, doulas, and midwives do as well. So I knew I could do that as a physical therapist. And I decided to kind of change course, take my first continue education in pregnancy and postpartum. And I just loved it. And from there, I left my orthopedic job and I just really went into specialization in the pregnancy, postpartum, and pelvic health.

I love that. Now, you did say that you. And we will get to pregnancy postpartum.

We just.

We have to. Because, you know, I'm a mom. I always usually bring it back to that. But you did mention that you work with some males.

Okay, yes. Because men have pelvic floor muscles as well. So which people sometimes are surprised? They're like, oh, my husband doesn't have a pelvic floor. But everybody has muscles at the bottom of their pelvis. So male clients sometimes have different types of symptoms than female clients. But we would see male clients, I see them for sometimes issues of having too much tension in their pelvic floor. So from stress or from some kind of hip injury or sports injury, if they have what we call over recruitment overactivity in their pelvic floor, they can get some pelvic pain and some urinary dysfunction and sexual dysfunction. So that's part of what we do as well. Just a little bit less known in the pelvic world than the pregnancy and postpartum part.

And it also has to do with. There are different women, females. Let me reiterate, let me change. I'm learning, right. So females have three different holes, and so their pressure management is just a little bit different. But that doesn't mean that males don't have that or males don't have pelvic floor muscles.

Right. So we don't often see the same kind of pressure issues like the leaking urine or the prolapse. Right. That we're concerned about in women because our anatomy is different. But we do see the other side of it, which is like this over engagement pain side for men. And if men do happen to have some kind of prostate surgery, unfortunately, then we might see the more leaking of urine side for them as well.

Okay, got it. So now were you interested now? I follow you on Instagram. So this is. And we've worked together, so this is some context that you might not know if you're listening, but you're also a mom. So I'm curious, did you get into pelvic floor physical therapy before you became a mom?

I did. And I'd like to think I was a good clinician at the time. I think you do the best you can at the time with the information that you have. But I definitely going through those experiences as anyone that's been through an experience that they. Now coach knows that there is a different perspective on it. And I think that it helps to experience some of these things in your own body. It helps to. To understand the emotional side of things a bit more and the other life circumstance challenges that people go through. So I definitely became even more passionate about supporting people in the pregnancy and postpartum periods. Going through it myself, having my own struggles and being a mom. I think that right now those people, that's my jam. Those are my people that I really, really love to see.

Because you've been there. I know it's not true for all. Like, that doesn't mean. And I know some people get in their head. I've been in my head too, about like, I can't serve people unless I've gone through it. That's not true. But there is. Whether or not you've gone through it yourself or you have a story or a client that you connect with on a deep level, like we need to have that. Why? Otherwise how else are you going to get up in the morning if you don't love it? Right, Right. Okay. So I am curious just a little bit, you know, now you're. Are you doing prime your work primarily in, in person online? How are you facilitating your, your work?

Sure. So prior to Covid, I had always had on my to do list, start telehealth, you know, get into telehealth. I knew that it was something that could do and it seemed like a really great opportunity. Just had never been at the forefront of my to do list like the things I thought I should jump into immediately. But for me, during COVID that really pushed my hand into supporting people virtually. And it's interesting as a pelvic health pt, there is part of our work that we do lose in the virtual context, you know, this hands on assessment. But then there's so much I think that we've gained as clinicians where we have become better at watching movement patterns and doing exercise progression. Sometimes a lot of physical therapists rely very much on their hands on skills and there's a whole realm of treatment that we can provide and be valuable for clients that's not in that particular skill. So I really love virtual. I'd say right now my work is about 50, 50 virtual and in person. Even though I can see people in person, just the convenience of the virtual, especially for my clients that are pregnant or have young kids, like it's much easier to just hop on the computer. We can progress people's exercise programs. It's okay if there are kids running and out. Like the convenience of it can't be beat. So a lot of times I'm seeing folks in person and we'll even progress them to virtual for their follow ups if it's very exercise based.

I love that. Okay, great. Now one of the things that you did mention, and we will get to the postpartum side, but you did talk about how you actually help and support moms through their pregnancy. And I want to talk a little bit more about how you do that. What are some of the things that you're looking for? Because I had a really good friend who I had actually recommended to her, like go see a pelvic floor physical therapist during her pregnancy. And she got turned away. The pelvic floor PT was like, no, no, you see me, you don't see me during. And so I would love for you to just expand a little bit about that. Like what? You know, especially because we're working with other clinicians and trainers, like, what are some of the questions that they can ask and really navigate building the type of relationship that's going to support a mom through her pregnancy.

Sure. So it's interesting. I think different clinicians have had different comfort levels about treating people in pregnancy because our organizations that oversee physical therapists were not always very clear on if this was within our realm of practice or not. But they have come out more recently and say, yes, this is very appropriate with our skill set. You can see someone in pregnancy. We can assess the pelvic floor internally if there's no contraindications to do so. I love seeing people in pregnancy. I think it's an amazing opportunity. I see people in pregnancy, I think about two main categories of what I'm working on. One is exercise, scaling or modification. Keeping in mind pelvic floor and core concerns. That's a big chunk of what I like to do. If folks are really active, we want them to stay active, but they're starting to have some symptoms of pelvic pressure or leaking or noticing diastasis. We do want to educate them that they might want to choose to scale their workouts. Here are some ideas of how to do so. Just so that we're thinking not only about the pregnancy. Right. But what's their recovery going to be like and what their long term health is going to be like. And then specifically on the pelvic floor side, I think it's really neat to assess someone's pelvic floor in pregnancy and help them prepare for actual birth because we're learning that the pelvic floor muscles play a larger role in the actual birth, at least in a vaginal birth. Thank you. We may have thought in the past so we can dive that into that a little bit more.

But I was like, can we please expand upon that a little bit? I'd love for you to like, just share a little bit with that.

Sure. It's funny. Yep. Go ahead.

Because I feel like I see those memes that, like, you can't prepare for birth. And I'm doing quotation marks for those of you who can't see me. But I feel like I'm seeing, like, I see that message around the interweb. So I'd love for you to just dive in a little bit more about how a mom can do that.

Sure. So I think that it's good to acknowledge that there's many factors that will come into play about how a birth will happen and we don't have control over all of those factors. But if you're someone that's proactive and wants to, what we say, like, stack the cards in your favor, like, what can you do? I do think it is helpful to check in with the pelvic floor muscles, because I do think it's unfair in the birthing room if someone's having a vaginal birth that everyone's like, oh, push like this, push like that. No, you're doing it wrong. That's not good. I think it's unfair to have no tools for this scenario and to really not understand how the mechanics of that work for me. Over the years, I've become more and more passionate about this. What I do in pregnancy is I like to check the pelvic floor tension overall, because what we're learning is that the baby has to pass through the pelvic floor muscles as its last exit. And. And if the tension is very high, or if when someone is pushing, the muscles are contracting, closing instead of opening, we're now seeing in the research that this can really slow down the pushing phase. So that's stuff that we can check for in the pregnancy. I can check for tension and then help mom kind of decrease their pelvic floor tension in the next couple of weeks. And I can also have them give, like, a fake little push. And I'm doing a pelvic floor assessment internally. And I can see, do their muscles happen to close, which would make the pushing phase longer, or are they able to keep the muscles, what we would say, open or decrease tension? Again, the research is starting to show that that can shorten the pushing phase. That is what I notice in clinic, too. It's really fun, fascinating assessment to do. And then I can help guide the client into some strategies to prepare more for the birth if they find themselves in a scenario where a vaginal birth is going to happen.

So I can't. I, you know, I'm fully transparent. I'm an open book. And so my question is personal in the sense that for me, I did not know to see a physical therapist during my pregnancies or my first, at least 2015.

Right.

No idea.

So.

And I had kept hearing, you know, you need to do it after, not before.

Right.

So I had a failure to descend in my first birth. Right. So I had to have an emergency cesarean. So what I'm curious about, and I had a hyper. Hypertonic, so very tense pelvic floor. So for me, I'm curious if I had gone to a physical therapist potentially during pregnancy, and learned and discovered that about my pelvic Floor, floor. Could that have helped bring the baby into the birthing. The birthing canal?

So I think that if a baby is high because of their position, like babies can get into all of these non ideal positions. I'm not convinced that the pelvic floor would help the baby come down. There's some people that will take that a couple steps out and say, well, if the fascia is better balanced, of course you can go down this path of creating this certain environment. But I think a baby that is not all the way down, I'm not blaming the pelvic floor for that. If a baby is really right there on the pelvic floor, then I think this work can help. Interestingly, there were two research studies that looked at this question in the folks whose pelvic floor muscles were contracting or squeezing as the person was trying to push. It delayed the pushing stage, but it was not a risk factor for cesarean. So it wasn't like, oh, if your pelvic floor is not working well, that that's going to lead to C section. It seemed, at least in these studies, there are other reasons that the cesarean had to be done. So I like to, you know, tell that to my clients too. Right. It's not a failure that you didn't do it. Right. There was probably other things at play, but we do see sometimes midwives and doulas saying, like, I don't know, the baby was right there for so long and instead of, you know, like two hours, now it's like three or four hours. And then I see the client, it's like, oh, they do have a really hypertonic pelvic floor. Maybe this was kind of like prolonging that pushing stage.

Yeah. Okay, great. So can you share a little bit? Because I'm sharing my personal experiences. So just for some context, I'd love to hear a little bit like, what are some of the differences in a hypertonic pelvic floor? And you know, and to just dive into, you know, since you are a pelvic floor specialist, can you just dive a little bit into the anatomy of what we're talking about? Specifically when we're talking about this, you know, pelvic floor. Just give us a little bit of context. Context. And then what are some of the differences between and, you know, red flags you see between hypertonic and what's the other one?

So we would say it's not even that common actually, is to say maybe under recruited or weak pelvic floor. Okay, cool. Which is not the more common scenario actually, so.

Oh, that's something I'm surprised to hear because you. I feel like we only, we only ever talk about the under recruitment.

Correct. So I'll talk about the anatomy first if you want and we can talk about, you know, whether muscles are over recruited or weak or under recruited. So the pelvic floor muscles, they form a basket of muscle underneath the pelvis. There's three layers of muscle and depending how they're named, there's 16 to 18 muscles. So it's very cool. I like to bring that up because we don't really learn about this area in a muscular way. I think that's always like the afterthought. There's muscles there, so there's a lot of muscles there. They have three main functions. They support the pelvic organs, they're sphincteric, meaning they help you control urination and bowel movements. And also they have sexual function. They drive blood flow into the sexual organs and help with orgasm and being able to have sexual activity. So that is like an overview of the anatomy. What we find is that everyone's pelvic floor sits kind of at a different amount of engagement. Just kind of like some people, like their shoulders tend to go towards their ears or they may hold stress. In other areas we find that due to people's nervous systems or past injuries that oftentimes the muscles are what we are calling now over recruited. We try not to say tight, like maybe that has like a sexual connotation or maybe we think that's maybe more under someone's voluntary control. Like, oh, you're just like holding your muscles tight. That's why we've, we're switching maybe to this term over recruitment. Like the muscles are turned on maybe when they don't need to be. Like why are they jumping in when we're at rest? So there's a lot of folks in that category. Whether it is they have a nervous system that runs high, whether it's like a flight or flight or fight response, whether they are athletic and their pelvic floor is used to responding to athletic movements. We do see a lot of people in this over recruited category. What are some signs that people could be there? It's a little harder to know sometimes. Like sometimes people who urinate frequently, that could be a sign. People who might have pain with penetrative sexual activity or exams. Pelvic exams is like another kind of red flag that the pelvic floor might be tight. Trouble with tampons. If we're talking about people with female anatomy.

Yeah, I'm I'm only laughing because I've shared this on the podcast before, but oh my gosh, I did. We could not have, you know, intercourse for nine months after I gave birth and it was excruciating.

So that's something that I know I've heard you talk about before and I think we've chatted about online too, is that I think everyone assumes that after pregnancy and birth the pelvic floor is going to be kind of like out to lunch, right. Like overstretched and weak. And we find, I find, particularly after cesarean because maybe the muscles didn't go through this stretch in the birth, that they're 99.9% of the time in my clinical just experience, tight and over recruited and intercourse is painful. And I think a lot of that is the recovery from the scar, but also because the core is so elongated in pregnancy that I think it's a lot of the pelvic floor again is like over recruited compensating, I think for trying to. The body's trying to figure out everything else, including the core.

I think a lot of people don't realize that the core is. The pelvic floor is part of the core. When we're talking about the core, you got to remember the bottom part of the canister.

Yeah. I think, I mean it's like preach that because this is a little bit going to the side. But why do One third of NCAA Division 1 athletes have stress incontinence females? It's because the pelvic floor is left out of this core conversation. These athletes are undergoing so much strength and conditioning work, so much great, you know, education, but the pelvic floor is left out of the conversation.

Now I know we are going sideways, we'll come back. But just real quick, since you do bring up the athletes, like, do you find this to be true of your mom athletes or athletes in general?

Yeah, so we see it both. I think that in the athlete that has not had a baby, a lot of times the pelvic floor is showing signs of incontinence. Again, not because it's weak. Right. So I think like everyone assumes like leaking is weakness, but an Olympic level athlete, again, there's also like high levels of stress, incontinence and like Olympic gymnasts and other sports like that, their pelvic floor, I would, I haven't assessed any of these people. Right. But they're not weak and under engaged. A lot of times they're over recruited and then they can't dissipate force. It's like the pelvic floor has to be like a trampoline. Like if you are doing a front flip and you land really hard, your pelvic floor has to be able to like absorb that force. And if it's over recruited or too tight, you lose that elasticity. So there's kind of like their pelvic floor is not kind of weak and not working. It might be over recruited. So a lot of times incontinence is this over recruited side. Especially if someone hasn't had a baby.

And that's got to be counterintuitive and scary because if you are having this release of urine or release of waste, I'll say, and it's because you're too tight for me. My body does not want to be like let go, just release. Because then it's like, no, I. If I'm all. If I'm. If this is my baseline and I'm all and I'm leaking waste, then what's.

Going to happen if I release?

You know, so that's got to be counterintuitive and hard to teach.

Yeah, it's wild though and it's kind of fun to teach. So I'll give you a quick example. So let's say runners that are leaking urine, right. A lot of times they're like, well, I just try to Kegel the whole time or like I'm just trying to hold in my belly the whole time. But if you're talking about that core canister, what that does is if someone's like gripping their top of their abdominals when they're running, it's pushing all the urine down. So what's pretty wild is if you have someone that's leaking with running and then you try to get them to relax their core and relax their pelvic floor. Like you said, it feels scary to them. But a lot of times then that core canister can function better. It's not like frozen in this engagement and they stop leaking. Like that's the wild part, right? It's totally counterintuitive. But it's wild because then you don't even have to. It's not like the pelvic floor is in such bad shape. It's just kind of working on the mechanics of the whole canister.

I love that. Okay, so circling back and you actually just mentioned another one, right? So painful, you know, painful insertion. Whether it's female anatomy and we're dealing with tampons or intercourse. But also incontinence is a sign of having an over recruited.

It can be so incontinence is tricky. Incontinence can go either way, especially postpartum. So if someone has not had a baby and they have incontinence, I'm thinking more over recruitment. An issue with this core canister and like, their mechanics and their biomechanics. If someone's had a baby, then it gets a little trickier. Problem solving. Because if they had a vaginal birth, there may have been an overstretch, there may have been a tear and a repair. So there can be components of both. The pelvic floor can be weak. Sometimes it can be weak, but when you try to engage it, it gets a little stuck in the engagement. So that's kind of, again, as a pelv pt for me, it's the really fun part is this problem solving piece. Like, why exactly are you leaking? Is it weakness? Is it over recruitment? Is it scar tissue? Like, putting all of those pieces together is the fun part for me.

I love it. So, yeah, you know, well, before I ask that question, I just want to make sure we end this loop. Like, are there other signs and things that we should be paying attention to? As, you know, the first line of defense. A lot of coaches tend to be. People like a mom will oftentimes go to their personal trainer before they're going to go see their pelvic floor.

Physical.

Physical therapist. So what are some of the things that we can be paying attention to?

Absolutely. So I think that we see that oftentimes because the coaches have this close relationship. Right. So if someone's comfortable telling you these things, then you are the first line of defense. So leaking urine, like, 100%. It doesn't mean someone's pelvic floor is terrible, but it means that it could be better. And that's a very annoying symptom. Someone that has pain or pressure. So, like, if someone in the gym is like, oh, I can't do that movement, like a lot of moms, like, they won't. They'll step out of the jumping jacks or the jump rope or the box jumps. Like, if. If someone's opting out of an exercise, it's kind of worth a conversation if you're willing to have that conversation. Someone who feels pressure, like, ooh, something's kind of like, heavy in my pelvis, or I feel like there's like a stuck tampon. Those are signs of pelvic organ prolapse, which is actually more common than people want to talk about. So a postpartum woman who's being coached, that's something to look out for. I don't know if people would tell you like history of constipation or like running to the bathroom five times during your session. Those are also kind of just signs that there's something going on that maybe a pelvic floor therapist can help with.

At least provide some type of insight. It's worth having them look. Now there are some differences between pelvic floor physical therapists that do internal exams and don't do internal examples exams.

Right.

So what are some of the clarifying differences and when should we go to which one?

Yeah, it's a super good question because there are some really good pelvic health therapists who work with a lot of athletes who do not do the internal assessment. And what's cool is they get really great results because a lot of what we're dealing with is full body biomechanics. And I think that years ago when pelvic pts were trained, if it was very tunnel visioned, like just the kegel, like just the pelvic floor, this is still kind of an issue where again, sometimes it's not even. That's not the biggest piece of the puzzle. So the folks that don't do internal assessments, they oftentimes get really good results working on people's running mechanics or lifting mechanics. A lot of times if you work on the whole picture, the pelvic symptom will dissipate because you're just able to regulate pressure better, you're using better mechanics or you're just better trained in your strength and endurance overall. They will tend to refer a client if they're not getting the results that they need or if they're having really that like pressure prolapse symptom that a lot of times it's really good to have an internal assessment. So I'm a little biased because I do internal assessments. I think they are really eye opening. At least one visit. I often love to work with coaches and trainers where like I can do the one assessment and just give insight to what kind of cueing is best for that client. Or like just confirm yes, what you think was going on is going on. Or hey, like we were kind of surprised. We thought we would find this weak pelvic floor. But actually like there's a lot of over recruitment. So I do think the internal assessment, at least one session can then be translated into workouts, into coaching. And I like to be that bridge for coaches and trainers or like I don't have to see the client long term. I don't have that Performance piece. Like it's not as part of my work that I've been doing for these past 12 years. Like that's not my strong suit. I like that stuff. So like I'm happy to be the bridge. Like let me tell you what's going on. What you can't check internally, right? Most coaches, right, we're not checking internally. So let me just give everyone that piece of the puzzle and then it can be integrated.

Okay, I love that. Now I want to touch a little bit on that prolapse conversation because it can be very scary and I do think that it is under talked about and especially too like when it comes to, you know, female health or women's health, that it there. There's not enough research done about causation and correlation. And you often hear, oh no, no, that's for that to. For older generations or the older population, which just actually isn't true. So I'd love for you to talk a little bit about that.

Sure. And I would love to because I find that it's very under talked about and like you said, the research is not there, which is really frustrating as a clinician because I try to give a lot of information and I tell folks like, we don't. There's a lot we don't know about risk factors, about people's long term outcomes. But in general, prolapse refers to what I describe as the distension or elongation of the vaginal walls. We're starting to think that this occurs in the pregnancy. It can happen for other reasons too. People who are constipated and strain oftentimes, but that just as the belly distends in pregnancy, that there is pressure on the vaginal walls. And I think it can only handle so much load before it starts to distend. A lot of that's probably genetic. How your tissue handles this load. Research tells us that at eight weeks postpartum, up to 83% of women have a diagnosable prolapse of their anterior vaginal wall, which is the wall of the bladder. We call that cystocele. 83%. This is most people have what would on exam be diagnosable. It doesn't mean they're all symptomatic. So what I like to tell clients, I'm trying to get this message out that this is really common because what I find that happens is in the first two to six weeks after birth, the client feels something weird or they're looking internally and they see something weird because it will appear like a bulge and because this is nowhere in the conversation, they will have a total panic. And it's like an actual traumatic experience because it seems like, I don't know what this is. Something is in the wrong place. People will go to the er, they will call their doctor. It's a very traumatic experience. If there was just this education, like, hey, just as your belly descends, your vaginal walls will descend. This will be more pronounced early postpartum. And then it should start to get better. As the weeks go along, it also may not change completely. So I think that's the very realistic conversation. And I really wish there was more awareness to this because I just find I get these panicked phone calls and these experiences that people shouldn't be having. If it was more a part of the conversation.

Yeah, I love that. So now if 80, if most people have a diagnose, what happens? Like, what's the difference between people who need to have surgery and get mesh versus the people that it goes away? Is that even right to say, yeah.

It'S a good question. So what happens is it's diagnosable, meaning, like, if someone would see the change on exam, but it doesn't mean someone's telling folks they have it. Because I think these changes are so common that an OB GYN doesn't necessarily say at six weeks, like, oh, your anterior wall is a little bit weak. They say, oh, this is. If someone asks about it, they'll often say, oh, this is you just gave birth. Like, see what happened? I don't like the wait and see because I, as a pt, right, My bias is like, let's be proactive. So the difference is some people feel pressure, some people don't. We don't have all the answers to why. I feel that in the early postpartum period, when the core is not kicking on and the glutes and the whole body is just having trouble figuring out its motor patterns, a lot of pressure is just going straight down. If you're standing, trying to prepare a meal or hold your baby and you don't have any of the other support, there's a lot of downward pressure. And hopefully as you get everything else kicked on, I see a lot of improvement where people start really feeling better, symptom wise, if we can kind of get them strong early on. And like you said, a lot of it is, we don't know at six weeks, I don't know who's going to continue to have that symptom and who's not. And I think some of it maybe is we can change with exercise and get people active. And some of it might be genetic in terms of people's connective tissue. So people who wind up needing surgery are the folks who, after weaning their baby, if they're breastfeeding or pumping, after you give it a year or two of getting stronger and you have good levels of hormones circulating in your body, if people at that point still have symptoms that are disrupting their daily life that are bothersome to them, then those are folks that might choose to have a surgical repair.

Bothersome, you know? And when you say bother, do you mean like, just like a nuisance that it's there? Or are you also talking about pain? Like, are people like, in pain?

It's a great question. So oftentimes the symptom is more like pressure or like, I feel this thing. It's not often painful, but it can change the way someone has to urinate or have bowel movement. So like urinary and bowel function can be affected. So that definitely affects quality of life and other things. So those are the kinds of symptoms that, again, I use the word bothersome because it's not a medical emergency to have a repair. But if people are symptomatic and they're always feeling this, they feel limited in their exercise or it's affecting their bowel bladder function, they might choose surgery. But there's also non surgical options, such as pessaries, which are silicone inserts that can support the pelvic organs. So physio I met from Canada where physios can fit pessaries. She referred to it as a sports bra for your vagina. And I kind of love that because she was like, sometimes the organs need more support. So that is a non surgical option to manage symptoms.

Is it? Now with the pessary, do you like, what should that be? Something we're wearing all the time, or is that something that you're only wearing when you're moving or when you're experiencing symptoms? Like, how do you navigate your relationship with a pessary? And what if you, like, how many tries does it take to find a good fit?

Yeah, those are great questions. So pessaries, I think, are really underutilized. So I like to bring this up too, because we don't want people to stop being active. Right. That has negative effects on all these other aspects of our health. So if we have a client who wants to run or lift weights, but they feel too symptomatic, we don't want to tell that person, like, oh, don't do that, because of your pelvic floor. What about their cardiovascular health and their bone health and their mental health? I really think that pessaries are underutilized in young women. I think that the research is good for using them early postpartum. If someone's having these symptoms and they're able to use a pessary, then they can really be active without concern that we are putting pressure on these walls. So I think they're underutilized. Some people wind up using them, like you said, just if they're doing a certain level of activity or certain kind of activity that they find that they're symptomatic in. So if they go on a long hike or they know if they're going to be doing box jumps or just if there's something that brings on symptoms more than other times, then some people use them kind of in and out as needed. And finding a fit, like you said, that is one of the kind of negative sides of pessaries is finding a practitioner who is comfortable fitting them. And then there can be a lot of back and forth trying to find a good fit, which is not super convenient. You have to make this, you know, multiple appointments with the physician. You go in, they put it in, you walk home, you're like, oh, this doesn't feel good. I got to go back. So there is a bit of trial and error, which is why think like a place like Canada where the physios can fit them, it's a little bit more accessible. But that's not the model, at least here in the US So how do.

You get a pessary? You have to go to your doctor.

So the folks that are probably best at fitting them are urogynecologists. So they are board certified in either ob, GYN and urology and then they have another certification in urogynecology, which is this newer field of gynecology and urology. And they specialize in prolapse.

I see. Now do those people typically also perform the surgery if needed? If that is something that ends up happening?

Correct. Yeah, those are the people that perform the surgery. So I often recommend that people go beyond their GYN if they want to have an assessment of prolapse, because the urogynecologists are trained to do a really much more thorough assessment, even if it's just to get kind of like a baseline or to get some people, some people really like objective measures. Right. So that would be the person to see.

Now have these. I mean, forgive me, because this, this hasn't pertained to me specifically. So I don't know the answer to this, but is this a specialty that is new? And when I say new, like how new are we talking?

Yeah, it is a newer specialty. I'm not sure the exact number of years, but in terms of how medicine goes, it is one of the newer specialties. So in some places there are not that many urogynecologists. You know, there are definitely not as many as just obs and urologists. So some hospital systems might have like two or three. So it is a smaller specialty and hopefully a growing specialty.

Okay, love that. So now if you are a personal trainer and you're wanting to start to build relationships with a pelvic floor physical therapist, like, what are some of the ways that you recommend doing networking and collaborating so that you can start becoming a resource for your client? A complete resource for your client?

Yeah, I love that. I love working with fitness professionals. Like they're my favorite people to collaborate with. So I would say that most physical therapists are really open to someone reaching out to them, whether it's on social media or reaching out through the website. You know, for us, these relationships both help the client and help us as well. Because the fitness professionals have the active population that we would probably love to work with. And it works both ways. We're happy to refer back to fitness professionals and we should be, because whether we are cash based like myself and I try not to see people too many times, I just want them to get back doing what they like. Or even in the insurance based realm, clients are discharged way before they are really back where they're supposed to be. So having this relationship both ways, where we can refer back to the fitness professional and we can be there to help, I think is really, like you said, the best thing for the client. So I don't think many of us public pts are too formal. Like reach out, send us a message. If we have our own businesses, we're happy to like go for coffee or just have like a zoom chat. I really personally like to know who's in the community and we are thrilled when people have this interest and this specialization because as you probably find as well, there's a lot of people in the fitness industry that have taken some kind of certification for pre and postnatal that really don't have this kind of information. And the general public is like, oh, well, my trainer at this gym, you know, they're prenatal certified and they don't have this level of information that someone who's really interested in these topics would Have.

Okay, that's. That's really. That's really good. Love that. Okay, so the other thing, too, that I want to just touch on really quick. Like when we were talking about prolapse specifically, you talked about systole. I always forget how to say it, but the bladder prolapse, there are also two other kinds, right? We're also dealing with two other kinds, Correct.

Right. So there's uterine prolapse. Right. The uterus can get very low in the vaginal canal. I don't see that as common. Postpartum, then the posterior wall. So the back wall of the vagina, or if you were lying on your back, it would be the bottom wall. You can have what we call a rectocele, and that's when the bottom wall is weak. And the rectum, especially when it's full, if someone's constipated, the rectum can kind of press up into the vaginal canal. And that is pretty common. We see that. Pretty. I don't have a. I don't have a percentage on that like I did for the seal, but I see that pretty commonly as well. People that have history of constipation might have more of it, but it's also, again, can be a result of pressure in the pregnancy.

Oh, interesting. I didn't realize that. I thought it was. Honestly, I thought it was just mostly the bladder and uterine.

Yep, I would say. But again, these aren't always symptomatic. So sometimes we'll see these changes. It doesn't mean that someone really feels them in their body. They're not problematic for the clinical client.

So the fact that they're not symptomatic. I'm just curious, and I know, I'm just curious about your opinion on that, but the fact that they are not symptomatic, do you think that's why there's so much time that goes before we actually realize that this has happened and why that's correlated to older populations?

It can be. It can be. There's also a big shift after menopause. These tissues are very estrogen receptive. So after menopause, let's say you have kind of like a mild change in the tissue, mild prolapse that you haven't noticed. Then the big shift after menopause seems to kind of trigger this other time period in our lives where these symptoms can become much more to the forefront. So we see these symptoms after birth, and we see them postmenopausal.

Oh, can you talk a little bit more about that? So What? What do you. Okay, so when we're going through menopause, we're losing our estrogen. Estrogen, correct?

Correct. Right.

Okay. And so what do you mean? So it's an estrogen specific type of experience.

So the vaginal tissue is very estrogen receptive. So the tissue around the urethra is very estrogen receptive. The tissue that supports the pelvic organs is very estrogen receptive. So we see this both postpartum if someone is breastfeeding or pumping, and also as we go into perimenopause and menopause, that there can be less support in these tissues if there is less estrogen in the system.

Okay, I did not realize that. That's good to know. Okay, So I want to be very mindful of your time and respectful. So for any of the people that are listening to this podcast, where can I send them? What's the best place to send them.

To find a pelvic PT in their area? Yeah, okay. Yeah, sure. So there's a couple of directories. There is one called pelvicrehab.com and it will have a list of people that have taken courses from a certain organization that does continue education for PTS. There is one called pelvic guru.com and again, it's just a different organization that Tracy. Sure, yeah.

Okay. I've worked. I've seen a lot of her work. She does awesome stuff. So pelvic guru.com, okay, cool.

Right. So clinicians that are, like, more inclined to really do more education, right. Like, are on these directories because they've kind of gone beyond the basics. So those are the two directories that I recommend because they are international, I believe, as well. There's also the American Physical Therapy Association, Pelvic Academy. They have a directory as well. So people tend to be listed in one of those three places. But I always tell folks too, like, if you have someone in your community that works a lot with these populations, they are also usually a great resource. Like, if you have people that are pre, postnatal certified and they are in this community, like, they might have good recommendations as well.

So where would someone go? And you might not know the answer to this because I know this is, you know, a little bit different. But where would someone go to find, like a specialized urologist that we were talking about? Is that like doctor referral? Is that. Where would we go?

Sure. So people can ask their OB GYN. The OB GYNs usually know who these folks are because they are referring to them as well. But they'll usually be familiar with the ones in their own hospital system, you know, so just know that there's nothing wrong with that, but those are the people that they know. I honestly, for my clients will sometimes, like when I moved out to Long Island, I'm just kind of googling urogynecologist. And then at this hospital, just trying to learn. Usually these people are within hospital systems, I find not usually in private practice. So hospital systems will usually have a couple of these urogynecologists.

Okay, that's great. So now you had mentioned too, that you are working primarily you're doing in person and you're doing online. So the people that you're seeing online, are they local people or are you seeing people all over?

Yeah, it's a great question. So right now I'm seeing people really within the state of New York because as physical therapists, we have this tricky licensing. I don't call it an issue, but we are like within our state practice act, supposed to do telehealth within the state of New York if we are doing actual physical therapy. So I'm mostly seeing people in New York, sometimes over the border, like a few miles into New Jersey or Connecticut, but I'm thinking mostly in the state of New York. And then for some, most people, they're not super local to me, so they're people that I would not be seeing in person. They're in New York City, I'm out in the suburbs, and I'm serving folks in that capacity.

Okay, great. All right, so this has been amazing. Thank you so much for hanging out with me today. So for my people that are listening and they want to learn more from you and about you and connect with you. Where can I send them?

Sure. So I am on Instagram probably the Most, and that's RachelParotta. P A R R O T T A underscore DPT okay, amazing.

And we'll definitely link up all the incredible resources that you gave us in this episode and we'll put that in the show notes.

Awesome.

Cool. Thank you so much.

Thanks, Beverly. It was so fun. I'm so happy to see you and get to chat with you as well. Love it.

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