Wednesday, 24 April 2019

Kegels Are Medicine

Kegel are Medicine

As a healthcare provider I am always learning from leading physiotherapists in women’s health. I was watching a Facebook video by Isa Herrera, a physiotherapist form the United States and she was answering a question about Kegels and she something that really got me thinking, “Kegels are Medicine.”

Kegels are medicine. They work, when you do them as prescribed. Did you know there are over 20 different types of kegel exercises? Just doing one type of Kegel may not be right for you. It’s about finding the right Kegel and then prioritizing to do them.

Just like when the doctor prescribes you antibiotics for an infection and says to take it 3 times a day with food. Most people make it a priority to remember to take them as prescribed and they work.
Exercise is medicine, but perhaps we don’t view it that way because it’s not a pill that we take. We all live busy lives and it can be very challenging to change and re-prioritize ourselves. I have found that the client’s who get better are the ones that make a commitment to their health and well-being. You cannot expect to do a Kegel here and there and get better.

Exercise requires a connection of mind and body. The therapist is the guide, but you have to become the Master through practice. If you are just going through the motions to say, I did it. You may be missing out on some important information your body is trying to tell you and you can risk injuring yourself when you are not closely paying attention.

Practicing your Kegels is also about patience, you don’t just take one antibiotic and you’re done. You have to take many before it starts to work. Sometimes, an antibiotic that works for one person doesn’t work for the other and modifications need to be made to the exercise program. How will you know if it’s working, if you haven’t given the exercise a dedicated effort? There is no cookie cutter approach and the same is true for doctors. It’s an interaction between you, the therapist and tools/techniques.
In her latest book, Female Pelvic Alchemy, Isa the author actually has a page where you sign to make the commitment and she outlines the 10 factors that are needed for optimizing treatment.

A lot of what she lists is mindset. If we begin to view exercise as medicine and do it as prescribed, make it a priority, then massive positive benefits are possible. You can take back your life, take back control of your bladder, get back to activities you love, super-charge your sex life and love yourself more than you did before. Caring for your self is an act of self-love.

So my challenge to you is, if you have been prescribed Kegels by a trained professional, make the commitment and try to take your “medicine” and let’s see what type of magic can happen.

The Pelvic Health Lady

Wednesday, 20 February 2019

3 Exercises for Tailbone Pain

3 Exercises to help with Tailbone pain.

The tailbone, also known as the coccyx bone is a small triangular shaped bone that is attached to your sacrum, the bone between your pelvis and below your lower back.

People develop tailbone pain for a number of different reasons such as, falling on the tailbone, injuring the tailbone during birth, losing mobility in the tailbone or developing muscle tension that pulls on the tailbone.
Knowing what specifically is happening with your tailbone it is always advised to a tailored plan. So make sure to get an assessment with a trained professional, such as a pelvic floor physiotherapist.
Here are 3 exercises you may find helpful for relieving discomfort in your tailbone.

1.  Sacral Ligament stretch exercise

In this first exercise you will be laying down on your back. Legs straight out. Start with your right leg by pulling your knee inward towards your chest and lining up your knee with your right shoulder. Holding there for 30 seconds and taking nice long deep breaths into the stretch. Then you will bring your right knee over towards the left so that your knee lines up with the middle of your chest. Hold 30 seconds and breathe deeply into the stretch. Then finally bringing your right knee over to line up as closely as comfortable with your left shoulder. Holding 30 seconds and breathing deeply. Then straighten out your right leg and repeat with your left leg.

2.  Cat/Dog

In this second exercise you will be on your hands and knees, preferably on a yoga mat or something cushioned. You will move your spine into a hammock like position where you arch your back, stick your buttock out and look up with your head. This is the dog position. Then you will gently move into the cat position where you will round your back, look down with your head and tuck your buttock under. You will move back and forth gentle between these 2 positions, 3 sets of 10 repetitions. Once you are more familiar with the movement we can add breathing into the exercise, where you inhale going into the dog position and exhale going into the cat position.

3.  Child pose

Kneel down on a yoga mat and open the knees slightly to create a V shape. Place both your hands in front of your body and gently slide your hands forward so that your back begins to bend as your chest comes closer to the floor. Once in the child pose position I want you take a nice slow inhale through your nose and imagine you are pulling the air all the way down to the pelvic floor and relaxing the muscles around the tailbone. Then exhale slowly through the mouth as your try to stretch further into the position. Repeat for 10 breaths.

Video Link to these exercises: 

The Pelvic Health Lady

Monday, 28 January 2019

To belly band or not to belly band. That is the question

In the pregnancy and physiotherapy services it was believed that using a belly band in the first 8 weeks post partum would be helpful for “healing” a rectus diastasis. I am the first to admit that I too was recommending this for a period of time. I’ve learned some new information and ever since I have stopped recommending it proactively, but that is not say that in certain circumstances it is not helpful. So I want to share what I have learned.

Firstly using the word healing may be a bit deceiving in the case of a rectus diastasis. Yes we heal postpartum from tears or actual tissue trauma but when it comes to the ab muscles and fascia there is no inflammatory process happening that signals “healing,” like in the case of healing from a wound. Since there is no actual “healing” taking place, a band cannot heal a diastasis. The abdominal wall is actually recovering from a sustained stretch, which is why it is important to rest and allow the body to adjust to the new environment, I.e no baby inside.

One of the leading physiotherapists/educators Diane Lee suggests that using a band can actually prevent the abdominal wall tissues from tightening up. This is because the band puts the muscles/fascia on slack and tension is needed for collagen growth which is what helps muscles and fascia to develop.

We don’t really know why some moms get a smaller separation while others get a large separation. We also don’t really know why some moms regain function and tension in the abdominal wall faster while others don’t. What we do know is that the tissues need to be loaded to rebuild strength and tension.

As I mentioned above, there are some circumstances where using a belly band can be helpful, for example a mom who is experiencing back pain who has a newborn and/or additional kids and needs to get work done around the house or go out for groceries. If the band helps support her in those activities so she can get them done, this is an appropriate time to use it. However, as soon as that activity is done, the band should come off.

I have similar conversations when clients ask about back braces. Braces do the work that the muscles should be doing. There are going to be circumstances when they are needed to get through an activity but I never recommend for constant or permanent use. If the muscles don’t have to work they get weak, often times adding to the problem and creating a reliance on the brace.

Now its important to clarify that if using the band helps with the back pain in the postpartum period it is not because it’s changing the rectus diastasis, it is more because the band provides an increase in intra-abdominal pressure and a wall of support for activity. The same can be true for spanx. It can provide additional support to the back, pelvic and hips with activity but it won’t impact the connective tissue and muscles. So if you are using these to get through some activities by all means, momma’s gotta get work done, but make sure to take it off for most of the time.

Really the only way to address a rectus diastasis is through committed, consistent, hard work. If you read my previous blog on rectus diastasis I was mentioning that we don’t consider a separation a problem in the first 13 weeks post partum. After that if it persists, here are some timelines.

If the ab separation is due to a mechanical issue (meaning a muscle is not activating well or in coordination with other muscles) you can expect to see results from exercise in about 6-8 weeks. However if the fascia/connective tissues needs to re-build, meaning laying down new collagen it could take anywhere between 12-18 months with exercise.

One thing to consider in the time frame is that connective tissue will be impacted by breastfeeding so it can take 4 months after you stopped breastfeeding for the tissue to tighten, hence why it can take 12-18 months.

So the answer.. To band or not to band? Band if you have pain and it helps you get things done, spanx for an evening out but don’t be using this every day, all day as a solution. Make sure to see a physiotherapist.

Information for parts of the blog comes from a presentation done by Diane Lee PT from the Spring/Summer Birth Healing Summit 2018.

The Pelvic Health Lady

Monday, 31 December 2018

Pudendal Neuralgia

This blog is going to focus on pudendal neuralgia in men, what are the signs and symptoms, diagnostic criteria and treatment from a physiotherapy perspective.

Pudendal neuralgia, also known as pudendal nerve entrapment is mostly a clinical syndrome (1). What this means is that there is no clear “test” that says you have it. The doctor will look at a number of criteria and features and determine whether or not it is likely that you have it. 

This can be a frustrating experience for clients as they go from test to test to rule out more serious conditions to often times hearing that the “tests” come back normal. Which on one hand is great because you don’t have a serious illness/disease but not so great because it leaves you wondering, “what is going on with me.”

Another problem with diagnosis is that some doctors may default to this diagnosis whenever there is someone presenting with perineal, buttock or pelvic pain (1).

Let’s look more closely at the diagnostic criteria in the research.

There are 5 criteria that must all be present to conclude a diagnosis of pudendal neuralgia (1).

  1. Pain must be in the area of the pudendal nerve region, anus to base of penis. The scrotum may be involved but does not include the testes, epididymis or vas deferens. The pain may be at the surface or deeper in the anorectal region.
  2. Pain is predominantly with sitting. It is not a positional problem but a compression problem. What this means is that sitting on a toilet should decrease pain, while sitting on a regular chair should produce symptoms.
  3. Next criteria is that the pain should not wake the individual while sleeping. Someone with pudendal neuralgia may have pain at night that makes falling asleep challenging or may wake up needing to urinate but should not be woken up due to perineal pain.
  4. There should be no sensory deficits in the perineal area. Meaning you should feel and sense your perineal area when touched, if not then it may indicate a different problem.
  5. Lastly the pain is relieved by diagnostic pudendal nerve block. It’s really important that the nerve block is done in the right place and close to the deeper nerve root.

Here are some additional diagnostic symptoms that may or may not be present with pudendal neuralgia(1), such as,
  1. Burning, stabbing, numbing or shooting pain
  2. A painful response to pressure/touch that normally would not be painful such as tight clothing or underwear
  3. The feeling of something being present in the rectum. Some might describe this feeling as a ball inside or a lump or heaviness.
  4. Pain gets worse as the day progresses
  5. One sided pain
  6. Pain with bowel movements
Here are some symptoms that are not associated with pudendal neuralgia (1).

  1. Buttocks, pubic or tailbone pain
  2. Skin rashes
  3. Shooting pains down the legs
  4. Abnormalities seen on imaging
  5. Buttock pain with sitting
  6. Sciatic type pain
  7. Urinary frequency or pain with a full bladder
  8. Pain after ejaculation
  9. Pain during and after sex
  10. Erectile dysfunction

Physiotherapy treatment

Firstly you want to seek out a pelvic floor physiotherapist, as they have received additional training in pelvic floor anatomy, assessment and treatment.

The physiotherapist will start with a thorough assessment and treatment which may include but is not limited to pain education, breathing and relaxation techniques, sleep hygiene and lifestyle changes. Manual therapy to address muscle imbalances and restricted tissues, such as fascia (also known as connective tissue). You may receive postural correction exercises, range of motion exercises and stretches where appropriate (2). The home exercise program is very important for maintaining gains made in therapy and to ensure resolution of symptoms.

 The Pelvic Health Lady

  1.    Labat et al. 2007. Diagnostic Criteria for Pudendal Neuralgia by Pudendal Nerve Entrapemnt (Nates Criteria). Neurourology and Urodynamics.
  2.  Hibner et al. 2010. Pudendal Neuralgia. The Journal of Minimally Invasive Gynecology V 17: 148-153.

Wednesday, 14 November 2018

Rectus Diastasis Treatment Update

Rectus Diastasis Update
Research in physiotherapy is continuously on-going. What we once thought was true, can shift as new perspectives along with new information become available. This is true for the ab separation. There is an abundance of popular media, fitness news, as well as social media information on the internet that can make it very challenging for therapists, never mind clients to figure out what is true.
There is some exciting new research soon to be published on rectus diastasis. A panel of the top Canadian educators and clinicians in physiotherapy came together to try and reach some consensus on the assessment and treatment of ab separation. I want to high-light a few points that I learned, that may be helpful to you as a consumer. The information presented is a summary of points presented by Dr. Sinead Dufour at the 2018 Healing Birth Summit.
In my previous blogs about rectus diastasis, I mentioned that the size of the gap was less important in comparison to the function and the ability to tense through the connective tissue which holds the two rectus abdominal muscles. If you haven’t read my previous blogs, you can go back anytime to read them.
The panel of Canadian experts did reach consensus that the gap is not really helpful as it only tells you what the gap is, but not why. I always thought it was the rectus abdominis muscles that were the problem and that if you pull those muscles closer together and work them out, the problem would be solved. Clinicians are still treating rectus diastasis with an exercise that pulls those muscles together with a mini crunch. However, from the new research, it turns out this isn’t the best exercise and I’ll explain why.
The problem with rectus diastasis is not the muscles, but rather the fascia connecting them. We call the fascia between the two recti muscles the linea alba. The function and ability of the linea alba is to draw tension with the rest of the core and in response to activity, is what is the focus should be on.
The fibers of the linea alba are intertwined with the transverse abdominis (TA) muscle and the TA muscle co-contracts with the rest of the core muscles, which includes the pelvic floor, diaphragm and multifidus.

What we need to actually assess is not just the gap, but whether or not the linea alba tensions when you perform a voluntary pelvic floor or deep abdominal muscle contraction. How well can you contract your core individually and as a team? This will help us understand why, the abs remain separated. We also need to assess how your core responds to activity and exercise.
Treatment will be dependent on what is specifically needed and what part of the system is not working well for you.
I received this question a couple times from my pregnant soon-to-be moms:  “Is there anything I can do during pregnancy to avoid or reduce my risks of ab separation?” So firstly, by the third trimester all women will have a separation. Yup! This is normal and what our tissue is suppose to do to make room for baby. There are a few things you can do to reduce the amount of pressure on your tummy however. You can have your core assessed and the physiotherapist can teach you how to activate all the muscles of core individually and then together. A stronger core during pregnancy has the benefit of a better recovery postpartum.
The second thing you can do is avoid repetitive increases in abdominal pressure during pregnancy. Examples would include avoiding straining on the toilet or to avoid activities that make your abdomen bulge. There are several benefits to doing a pre-natal session with a trained pelvic floor physiotherapist. Seeing a physiotherapist has the benefits of them teaching you various strategies for reducing abdominal pressure and modifying activities.
So let’s talk about a few things postpartum. We were taught in our training to assess for an ab separation between 6-8 weeks postpartum. It turns out that it is normal to have a separation for the first 13 weeks postpartum. This is known as the fourth trimester and it is the healing trimester which includes the ab separation. Yes it can improve on its own and this is dependent on how well your core is healing and activating. A 6-8 week postpartum assessment certainly can help you with recovery by giving you the right types of exercise to promote your core healing.
If there is a separation present after 13 weeks, it can become problematic and we need to really investigate why that is. Every good treatment for rectus diastasis should have an offensive plan, which includes exercises to optimize the function of the core and defensive strategies such as education on reducing intra-abdominal pressure and how to perform activities that puts the least amount of stress on the tissues.
Another question I get asked a lot is about specific core exercises. Ladies will come in after researching on the internet what exercises are “good” and which ones to avoid. While it is true that certain exercises “tend” to be more challenging for the core, it is not true for everyone. For example, you may read that planks are “not good” for an ab separation. While that may be true for some, it may also be a fantastic strengthening exercise for another. It’s best to see a therapist who can assess what your core can handle. Rather than avoiding these activities, get tested and learn what to look for that might indicate a problem.
I found these points from the Healing Birth Summit very educational and helpful in giving me guidance on how to best serve clients. Hopefully this blog gives you some more information to ask questions or seek out help from a trained professional.

The Pelvic Health Lady

Friday, 2 November 2018

The reality of sexual experiences after a baby

I see many women post partum who express a variety of different feelings regarding sex after childbirth. Some women resume with no problems, while others experience pain, dissatisfaction or very low desire. For the women who experience issues with sex postpartum, they often feel they are the only ones. These women express frustration because they aren’t provided any clear guidelines as to what is common, why they have the problem or what they can do about it.

The World Health Organization describes sexual health as, “a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity” (1). The transition to parenthood comes with many changes that impacts sexuality and this blog will explore these changes and the impacts on sex.

Female sexual dysfunction affects approx 40% of women postpartum (2). Under the sexual dysfunction umbrella are sexual pain disorders, hypoactive sexual desire disorder and arousal and orgasmic disorders (1), which in layman’s terms means painful sex, lack of desire and difficulty becoming aroused or orgasming.

The most common reason for women to not return to intercourse at 6 weeks postpartum is pain. They may experience pain with penetration or an inability to penetrate due to muscle spasm. About 42% of women will experience pain immediately following delivery and will reduce to 22% at 8 weeks and 10% at 12 weeks. One study of 796 first time moms revealed that 62% experienced pain at 3 months, 31% at 6 months and 12% at 12 months.

Another study looked at the medical records of 626 first time moms and found that women with second degree tearing were 80% more likely to report painful intercourse than women with no or minimal tearing and that women with third or fourth degree tearing were 270% more likely to report pain at 3 months postpartum (1).

When it comes to tearing versus episiotomies, one study found women had more pain with episiotomies and assisted vaginal delivery versus tearing alone. FYI.. an assisted vaginal delivery may include forceps, suction, vacuum (2). Specifically, 30% of 438 women experienced pain at 8 weeks with assisted delivery versus 7% of women who gave birth naturally. Other studies have found similar results where women with assisted delivery report sexual pain at 8, 16 and 24 weeks post partum (1).

Low sexual desire is reported by about 53% of women at 3 months compared to 37% at 6 months post partum (1). Most studies find that desire improves over time and was mostly impacted by changes in body image, mother’s mental health and the status of the martial relationship (1). Many women report that the physical changes to their body following childbirth makes them feel less attractive (3) and that they were anxious about the looseness of their vagina (3).

Other factors reported by women are the changes in priorities. Whenever they get spare time, they just want to relax and read or sleep (3). The demands of the child often leave the mother fatigued and desiring alone, quiet time versus engaging in sex (3). When women were asked about their low desire, the most common reasons reported were, tiredness, breast-feeding, lack of time and concerns over vaginal damage from delivery (3).

Breast-feeding women versus non-breastfeeding women appear to return to sex much later. One study of 25 first time moms found decreases in the levels of testosterone and androstenedione, which are responsible for increased sex drive. This is supported by another study of 576 women who reported low or no arousal during the time of breastfeeding (1).

Another potential reason breast-feeding changes sexual activity is that the breasts are no longer viewed as a sexual or arousing area. Women find it difficult to associate breasts with sex when the focus now is on nourishing the child (3).

For those women who do engage in sex, many experience arousal and orgasmic changes. One study of 796 first time moms, 33% reported difficulty reaching orgasm at 3 months and 23% at 6 months postpartum. Orgasmic disorders were associated with perineal trauma, those who sustained more trauma had more difficulty with sex (1). Other factors impacting arousal and orgasm postpartum are the physical decrease in blood flow to the vaginal region, negative experiences such as pain with intercourse, distractions, sexual anxiety, tiredness and depression (1).

Some women admitted that they agreed to have sex with partners, while experiencing no desire to have sex. Some women would even pretend to be aroused and orgasm for the sake of their partner and relationship (3).

What I hope you gain from this blog is a better understanding of the factors that may be impacting your desire. I want you to know that you are not alone and that there is help if you are willing to talk about it and seek treatment. Pelvic floor physiotherapy is very helpful for addressing the pain aspect of intercourse, while a psychotherapist may help you work through all the thoughts and feelings you are having in this time of transition.

Your family doctor or a Naturopathic doctor may be able to provide you with other solutions centered on hormones, nutrition and getting rest. If you are reaching out to your healthcare provider and they don’t seem to be taking it seriously or offering solutions, then you need to find another healthcare provider for a second opinion.


The Pelvic Health Lady

1.       Abdool, Z et al. 2009. Postpartum female sexual function: A review. European Journal of Obstetrics & Gynecology and Reproductive Biology doi: 10.1016/j.ejogrb.2009.04.014.
2.       Yeniel, A. O and E Petri. 2014. Pregnancy, childbirth and sexual function: perceptions and facts. Int Urogynecol J 25: 5-14.
3.       Olsson, Ann et al. 2005. Women’s thoughts about sexual life after childbirth: focus group discussions with women after childbirth. Scand J Caring 19: 381-387.

Wednesday, 10 October 2018

I just don’t feel like having sex-Peri/Post Menopause

Recently, several women have been coming into my clinic and saying, “I just don’t feel like having sex” or “I have no sex drive.” A few women indicated that if they never had sex again, it would be fine with them. While the other half expressed deep concern over their decreased libido and what this means for their life and relationships moving forward.

This is an area I haven’t explored in depth and I wanted to better understand what might be some factors impacting women’s libido. For this blog I will focus on the perimenopausal to postmenopausal phase.

Is a lack of sexual drive and desire an age thing or a hormonal thing?

One study of four hundred and thirty eight Australian women between the ages 45-55 that were still menstruating sought to find an answer- is it age or hormones- what they found in the study is that it is both. As these women aged, sexual responsiveness decreased (1). Sexual frequency and libido was significantly less for postmenopausal women suggesting a hormonal role and how decreased hormones can impact pain with intercourse (1). Hot flashes did not impact sexual experience directly but had other impacts on health quality of life, which indirectly impacts sexual functioning (1).

Another study looked at healthy women and wanted to see if hormones were influenced and/or changed during sexual arousal. What they found was that following an erotic stimulation, estrogen levels actually increased and correlated with better orgasm and less pain (2). Estrogen’s role in arousal is vaginal lubrication and vaso-congestion, which means swelling of tissues, i.e blood flow (2). In the transition to menopause, estrogen levels drop and women more commonly complain about dryness, thinning of the vaginal walls and blood flow changes which can lead to pain with intercourse. When it hurts to have sex, our motivation to have sex is going to be impacted.

Testosterone, is another hormone that is believed to impact arousal. In the healthy women’s study, testosterone correlated with multiple orgasms and the women reported greater mental excitement, genital wetness and tingling after watching the erotic video (2).

In a book called, Hot Chixs, Hot Sex: How to survive menopause, the author talks about testosterone as playing a role in sex drive and libido. She mentioned that women who are stressed generally have lower amounts of hormones, including testosterone and that women who had a hysterectomy and their ovaries removed will have fifty percent less testosterone (3).

Another hormone of interest is cortisol, which is a hormone produced by the adrenal glands, along with DHEA, which is a main building block for estrogen and testosterone (2, 3). In the study of healthy women, cortisol levels dropped after erotic arousal and were correlated with higher levels of genital arousal (2). The study also suggested that higher levels of cortisol prior to arousal may actually inhibit sexual function (2).

Is it only age and hormones that affect sex?

No. There are a number of other considerations to take into account when sex drive is low. 

Menopause is a time of transition and change. Our bodies are changing and so are other psychosocial factors, for example, whether we have a partner, are single or been with someone for a long time (1). The age and health of our partner and their sexual functioning (1), how we feel towards our partners and the level of sexual activity previously. Other factors include, employment satisfaction, social class, level of education, access to health providers, personality, negative attitudes towards self or partner and actual physical and mental health (1).

I mentioned previously that sexual desire can be impacted by higher levels of stress because it produces cortisol. Another aspect we need to consider is our daily stressors. Are we getting any down time, are we constantly running around such that we don’t have the energy later?  Are we eating well to fuel our body?

If sex is something important to you, speak with your family doctor and work with a specialized compounding pharmacy to find the right hormonal treatment for you. If you prefer a more natural approach then perhaps a Naturopathic Doctor that works with bio-identical hormones may be appropriate for you. If you are having painful intercourse, make sure to find a Pelvic Health Physiotherapist to work on the tissues and find ways to make sex more physically enjoyable. Lastly, don’t forget about a psychotherapist. They will help you identify any psychosocial factors that may be impacting your sexual drive or the obstacles to living a healthier lifestyle.

The Pelvic Health Lady


  1.        Dennerstein, L et al. 2001. Are changes in sexual functioning during midlife due to aging or menopause? Fertility and Sterility 76(3): 456-460.
  2.          Van Anders, SM et al. 2009. Associations among physiological and subjective sexual response, sexual desire and salivary steroid hormones in healthy premenopausal women. J Sex Med 6:739-751.
  3.        Stronczak-Hogan, Irene. 2018. Hot Chixs, Hot Sex: How to Survive Menopause. Blackcard Books: