June 21, 2017
STOP! Don’t Do Kegels!
This week, Jess is joined by Rachel Gelman, a pelvic floor physical therapist from San Francisco. Rachel shares her unique insight on pelvic floor health, sexual pain and the fact that Kegels are overprescribed. Tune in to find out if you should be doing Kegels.
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This is a computer-generated rough transcript, so please excuse any typos. This podcast is an informational conversation and is not a substitute for medical, health or other professional advice, diagnosis or treatment. Always seek the services of an appropriate professional should you have individual questions or concerns.
STOP! Don’t Do Kegels!
Hello, my friends. This is Sexologist Jess O’Reilly. Of course, your friendly neighborhood sexpert. And every neighborhood should have a sex birth. That’s what I think. And today, as usual, in the next 20 minutes or so, we’re going to be covering some sex science and advice you can use tonight. Now, today I am joined by Rachel Gellman, the director of San Francisco’s Pelvic Health and Rehabilitation Center. She has a doctorate in physical therapy, and her work specializes in pelvic floor health. Now, if you don’t know what a pelvic floor physiotherapist does, you’re going to learn today. I have learned in person already, and it was quite an experience. So for a long time, I’ve been wanting to ask more and more questions of somebody in this field, and I came across Rachel, actually via Instagram. So you’ll make sure you follow her. She’ll give you all the info. Happy to have Rachel here. Hi there. How are you? Hello. Thank you so much for having me. My pleasure. So most people have not heard of pelvic floor physiotherapy. Is that correct? That is very correct. Most people who I meet out in the world and patients obviously are a little confused by what I do and have a lot of questions and always makes for fun dinner conversations. Most people don’t know what I do, but I’m always happy to tell everyone what I do. Okay, so let’s start here if you go see if we come to your office and I’m a person with a vagina because it’s going to be different, I suppose, whether I have a vagina or a penis. Yes. I mean, obviously, yeah, there is going to be some difference. But I’d say for the examination and everything we do, 75% of it is the same for if you’re a man or a woman. So usually the first visit is a lot of talking. I want to get to know you. I want to hear your story, depending on what you’re coming in for. I’m going to ask a lot of questions about your symptoms. And then I’m always going to ask questions about bowel bladder and sexual function, regardless of why you’re coming in. I’m always going to ask questions about that. And then I’m always going to be looking externally first because I am a physical therapist. So I’m going to look at your posture, how things are moving. And then I’m going to be looking at all the muscles and connective tissue, all the soft tissue externally, basically from the ribcage to the knees, is usually how I describe it. So I’m going to look at your abdomen and look at your legs and look at your back, your glutes, your hips. And then I will do an internal examination. And that’s where it is a little bit different for men and women, because obviously, men, there’s only one way for me to access the pelvic floor and that’s through the rectum. And then for women, I typically do the examination vaginally. But for some women, I may do it rectally depending on what their symptoms are. Really, it sometimes can be the same for both men and women. The only difference is, obviously that men have a penis, women have a Volvo and a vagina. So there’s not too much of a difference in reality other than how I’m going to actually access the pelvic floor. Okay. Because on my first visit and it was a little while ago, it was a few years ago. I went all I remember is fingers in the vagina.
Probably. I could see why that would be, like the big takeaway in the vagina. You would remember because I always have to remind myself, like, what I do. I do that all day, every day. And that’s probably not everyone’s normal everyday activity. No, that’s like a once a year thing for me. Yeah. And for most people, I see maybe once every three years. And for male patients, maybe they’ve never had their prostate examined. So usually it is like a bigger event for them event. I like the way you put that. Are you ready for your event? Yeah. Sometimes I try to say I tried to make it fun. I’m like, oh, we’re going to do internal party time, but most people didn’t like that. They don’t find it to be fun. So I got rid of that. Yeah. No, I don’t think you can trick them into party time. Yeah, I understand it’s not everyone’s favorite thing, but it does help. I wouldn’t do it if I didn’t think it was beneficial. Of course. Well, yeah, of course. Okay. So you’re examining and what are you looking for? Yeah. Great question. I mean, externally and internally, I’m going to be looking at kind of the quality of the muscles and the soft tissue. Is there any restrictions? Are there any trigger points? What it feels like? Is there anything going on that I think is restricting blood flow to these areas? And that’s the same for when I’m doing an internal examination, I’m wanting to feel the quality of the muscle. Does it feel like it’s restricted anywhere? Are there any tight bands or knots in the pelvic floor muscles? And then in the internal examination, I’m also going to be looking at motor control. So just like any other muscle of your body, your pelvic floor should have a certain range of motion. So these muscles should be able to contract, relax and lengthen. So I want to see, are you able to do that? Are you able to activate these muscles and are you able to activate them correctly and how much range of motion you have some people I ask them to do a contraction or a Kegel and nothing happens or they squeeze their butt. Yeah. I have difficulty, like separating the muscles. Sometimes you squeeze those finger muscles at the same time. Yeah. And sometimes I have patients who they can contract, but then there’s no relax. There’s no let go. And that’s what kind of I feel like I’m always getting in my little soapbox. That’s the big thing I always talk to people about, because there is this obsession with key goals and strengthening the pelvic floor, which is a great concept. However, people always seem to forget that there needs to be a let go. That’s actually my problem. I was doing Kegels. Yeah. I should take it back a step because I was really excited to speak to you, and I think I didn’t talk about why we’re talking about this, but ultimately, your pelvic floor tone impacts your sexual function. Correct. Correct. It can impact sexual function, urinary function, bowel function. And just overall, most of the patients that I see in our San Francisco office, we do have offices in other locations in the Bay Area as well as Los Angeles and Boston. But in San Francisco, most of my patients tend to be coming in because they’re having pelvic pain. And that can be anything from pain with sitting, abdominal pain, groin pain, basically, any pain between the rib cage and the knees, so that could obviously cause a lot of issues with quality of life, ability to exercise. So it can be a lot broader than just sexual dysfunction, although that is obviously a big thing that I see as well. Okay. Now you mentioned the Kegels are all the rage, but it’s not as simple as just do Kegels. And I mentioned that I was banned from doing Kegels. I was diagnosed, as I think they call it hypertonic. Yes. Okay. So can you explain to people what that is? Because not all of us should just be doing our kegos at every stop line. Yes. Correct. I’m glad you’re saying that, because I say that to probably like, majority of my patients, a lot of my patients get banned. So you’re not the only one who’s been banned from giggles. So a hypertonic pelvic floor, all our muscles have tone. So that’s where that tonic comes from. So all muscles have tone. If we didn’t have tone, we’d basically be jellyfish, kind of like floating around the universe. So we all have tone. And then if you’re hypertonic, that usually means you have too much. So those muscles are restricted. Or I don’t like using the term tight, but they’re basically too tight. And then you could have hypo, which is less. So patients might feel like there’s too much laxity in the tissue or those muscles. So that’s what hypertonic means. And the reason someone with a hypertonic pelvic floor might get banned from doing Kegels is because imagine if your bicep, like, the muscle in your arm was contracted or too tight, and then you decided, well, in order to treat this, I should start doing bicep curls. I should just keep lifting all day long. That’s probably not going to help make that muscle relax. It’s actually going to make it tighter so if your pelvic floor is already resting in this, like, high tone state, it’s just contracted too much. And then you start doing more contractions. You’re just adding fuel to the fire, and it’s going to make those muscles even tighter, even tighter. And again, your muscles should have a certain range of motion. So if you’re just kind of getting it hanging out in this tightened state, that’s not very good for those muscles. And it’s not good for all the organs that those muscles support, such as your bladder uterus. If you’re a woman prostate, if you’re a man and colon, you know what? I have trouble. So I don’t often share a lot of information about myself. So maybe this is TMI for people out there, but sometimes I have trouble starting to pee. Does that make sense? Yes. It definitely makes sense, because in order to urinate your muscle, your pelvic floor muscle should relax in order to void it’s really stressful. Yeah. And again, you’re not alone. I see people with the same symptoms and presentation, and it is very stressful. And then you get stressed about it or anxious. And then that’s just going to make your nervous system overreact, which causes your muscles to contract more. And it just becomes this vicious cycle that hopefully one of the things I tried to do is basically break that cycle and get your nervous system to calm down, get these muscles to relax. So that way, you no longer have difficulty urinating or pain with sex or whatever else your symptoms are. Well, I want to go back to the fingers and the vagina. What I recall from my exam is they put the fingers in, and of course, you tell us to contract and you tell us to release, and then they’re like, no release. Jessica release. Yeah. And then she was kind of poking around. I’m sure that’s not the technical term, but that’s how it felt. And she would say, Is this hurt? Does that hurt? Does this hurt? Does that make sense? Yes. That definitely makes sense. So yeah, we would say palpate, but it probably does feel like poking. And sometimes I say that to patients, I’m like, you might feel like I’m poking you. I’m just going to be palpating these muscles. And then at the end of the exam is typically when I’m like, I want you to contract around my finger. Now I want you to relax. And then typically I say, now try to push my finger out. Or bulge is another term that you might hear. But you’re trying to again lengthen those muscles. You’re trying to go through bulge. Oh, bulge. Yeah. Bulge my finger. Okay. This is really interesting. And then if you don’t have a vagina, you’re putting your fingers in the rectum. Yes. Again, I sometimes do the internal examination via the rectum for female clients. I didn’t win that price. Yeah. Not everyone gets lucky, but some people do. And I definitely have some patients who female patients who, for whatever reason, request the examination rectally everyone’s different. I always give that as an option. But yeah, most people, if they have a choice between a vaginal exam or a rectal exam, they typically select the vaginal examination. But Unfortunately, I always tell male patients. Unfortunately, there’s no other option. This is your prize. But then I also always tell them like, I have very small hands and very small ears. So I’m like my finger is definitely smaller than any stool you’re passing. So if you’re able to have a bowel movement, you can probably handle having me put my finger in your rectum for, like, a couple of minutes. And that usually maybe doesn’t make them feel as comfortable. But they’re a little more relieved because most male patients have seen typically a male urologist. And male doctors tend to have very large fingers. So I’m always like my fingers definitely smaller than doctor. So. And so that always makes them feel a little bit better, I think.
But it’s definitely not everyone’s favorite part of their day. No, not their cup of tea. But very important when you think about doing these types of exams, as opposed to just asking people about their symptoms, which is what people, for instance, in therapist office and traditional can do. You’re really taking it to the next level because you’re able to pinpoint where we are, as you said, like week or where we are tense or where we have some sort of issues with our muscles and prescribe us with very specific exercises to meet our specific case. Right. I think for many years, people in my field were saying, you got to do your Kegels. You’ve got to do this because this is a relatively new field, and it seems that not many doctors, medical professionals and sexuality professionals are aware of the work and the research you’re doing. Yeah. No, that’s definitely true. And I mean, key goals are definitely over prescribed and kind of told you, pick up any women’s health magazine. That’s one of the things that’s everywhere. It’s like you should be doing Kegels. You can do Kegels over here. You can do Kegels in your shower. You can do Kegels upside down, like your pelvic floor. And it’s like I get why it’s become a fad. But yeah, they’re definitely over prescribed. And our profession as pelvic health physical therapist is definitely still, like you said, a new field. So hopefully that trend continues to change. And more people are hearing about us and recognizing that Kegels are not the answer to everything. It’s not just like panacea for all your problems, because we all know coconut oil is the answer to that BBC article that came out this week about coconut oil. I think so. Is it the one that said that it’s not healthy for you, right? It’s not the one that’s going to save the world. Yeah, I know. I like to pretend it will. But I just think I think that goes for anything. There isn’t one thing that’s going to fix all your problems. Absolutely. And that’s why I feel like if someone’s telling you that you should be a little wary of what the advice is, right. One of the challenges in my field, and I think also in the digital age is the clickbait of one way guaranteed to make your marriage last or three ways to divorce, proof your relationship. And I’m always trying to convince reporters that okay. So these are good ideas, and they may work often times, but there is no one size fits all approach to relationships, to sex, to love. Now, I know without seeing someone, some of these questions might be difficult to answer, but I wanted to ask you who should do Kegels and who shouldn’t. Are there any signs without seeing you that keecoles are contraindicated or indicated? Yeah. I mean, it’s definitely like you said, it’s a difficult question to answer without seeing someone. I would say kind of in general, if you’re having pain pelvic pain, if you have constipation, like difficulty with bowel movements, if you are having difficulty starting your stream or when you urinate anything like that, I would advise against just doing Kegels all the time or doing them in general until you ideally get to see someone I know not everyone has that luxury or that ability to see someone, but right off the bat, if you’re having any form of pelvic pain, you probably don’t need to be doing Kegels. I’d say, for the most part, if you’re postpartum you’ve had a baby and delivered, even if you delivered via C section or vaginally, you probably could do key goals after your delivery. That’s usually kind of a safe bet. But again, I don’t want it to sound like everyone’s different, but I’d say that’s usually someone that I’m like. Yeah, that makes sense. You just had a baby. Those muscles just were carrying a ton of weight. And if you delivered vaginally or you were pushing for a long period of time, those muscles did get sometimes got a lot of a big workout is how I like to describe it. Now they’re probably a little sleepy. They need to be woken up. So doing some Kegels is a good idea. But I usually recommend if someone’s comfortable inserting a finger vaginally or rectally, wash your hands, put on gloves and insert a finger. And if you’re able to contract around your finger and relax and you can feel that happening, you can feel something squeezing your finger and then you can feel, let go. Then you probably are okay to do Kegels. I guess my question is always why do you feel the need to do them? Because really, these muscles, your pelvic floor muscles are always working. So I guess that’s like the question I should have asked first is what is the intent behind doing them? Well, I think for many people, we think we need to do key goals because it will make us tighter. Again. I don’t love that word either. You can be tight, but not strong, right. Like, for instance, my muscles are weak, even though I’m hypertonic. Correct. I think people want to do Kegels because they think it will give them stronger orgasms. I mean, that’s something that we have taught in the sexuality field. So perhaps there’s some misinformation there. We need you to debunk. Yeah. And I mean, it’s funny because I try to find I’m always wanting to find research that supports these claims. And women’s health and sexual health is not the most researched field. So it’s kind of hard to find good quality research, but that’s a whole nother topic that we could talk about at a later time because that’s a whole other subject. But there is some research that supports Kegels promoting better orgasms. There’s some research that says it’s inconclusive. So I mean, I guess I could see how if you had more again, range of motion, not necessarily strength, because what happens when you orgasm is your pelvic floor muscles are going to contract and relax, contract and relax rapidly. So if you had a big excursion, so, like, more relaxation and a bigger contraction and it moved through that range of motion, then you could potentially have a stronger orgasm. But it’s not all about strength. So I think that’s where the confusion comes in, and most people don’t need to be doing Kegels. That’s why I’m like that would be. My first question is like, why someone feels the need to do Kegels. What about awareness? I think sometimes when people learn to do Kegels because it’s an area of our body that we aren’t particularly in touch with. Correct. Do you think that the awareness of that of the region of the muscles can help with orgasm? Yeah. Most definitely. I think it’s all about knowing your body. So if you have increased awareness of that area, that’s obviously going to help increase your heightened arousal, sexual pleasure, orgasm things like that. So doing Kegels is one way to do that. I think for all women, particularly looking at your vulva is another good step, because people are just so detached from that area. Like you said, people kind of shy away from it. They don’t think about it. So I’d say just looking at your body and becoming comfortable with looking at it and doing self exploration. If that includes Kegels, I think that’s one way of going about it. I think it definitely helps build awareness. But again, I think people tend to get a little hyper vigilant. Right. And so there’s that Gray area. We need to find words, having awareness and understanding your body without getting too extreme. Okay. That makes sense to me. Now, should everybody see a pelvic floor physical therapist? I mean, not everyone, if you’re able to go about your day and you’re not having any urinary dysfunction. You’re having normal bowel movements. You’re able to have sex or sexual activity without difficulty or not having any pain. You probably don’t need to come and see someone like me. What about lower back pain? Because you can help to resolve lower back pain that a traditional physical therapist cannot. Yeah. So I definitely see people who maybe have gone the traditional route with like orthopedic physical therapy and they’ve been having low back pain or hip pain. I see people with abdominal pain, inner thigh pain, sometimes, groin injuries. Tailbone pain is a big one. We have that. I need an appointment. Yeah. Come see me. Yeah. Tailbone pain is a big one. I’m trying to think of other ones that are I have some patients who come in if they’ve done traditional orthopedic PT, and nothing is changing. Sometimes there are some deep hip rotator muscles that I can access via the pelvis that can sometimes refer to areas that you wouldn’t expect, such as the hip or the back. And sometimes they might benefit from seeing me if they have failed other types of PT for more. What is thought of as a more orthopedic issue? I can see people like that. So I wouldn’t say every single person needs to come see a pelvic floor PT. Okay. But definitely anyone experiencing urinary dysfunction, bowel dysfunction, sexual dysfunction, pelvic pain or low back pain, SIJ or sacral iliac, joint dysfunction, pubic synthesis pain or pain, like in the pubic bone in the front of your body. Any pain between the knees and the ribcage? Yes, exactly. I was just going to say if you pain between the ribs and the knees and you haven’t been able to resolve it through traditional means, you might benefit from a consult at least, and we don’t have time to go over vaginaismus. But I know that I have some clients with vaginasmith who have had really great success working with a pelvic floor physical therapist. When traditional kind of talk and counseling and education doesn’t work for people who can’t come see you or go to one of your clinics and we’ll get all your contact info up on our post as well. Is there anything they can do at home? Especially because obviously, I’m focusing on sex and relationships if they have any sort of pain with penetration. Do you offer any general guidance? Yeah.
First of all, there’s a lot of good resources. I mean, obviously, you have an amazing website. We have a website, so there’s a lot of different resources out there that can give you information. There’s a lot of good books, so that way you could be able to access that at home. Being mindful of your breathing. I think people forget that. Or I shouldn’t say forget aren’t even aware that your diaphragm, which is your big breathing muscle under your rib cage, creates kind of the top of this canister in your trunk. So you have your diaphragm under your ribs, which is the top of the canister. Your pelvic floor is the bottom. So those two muscles really work together. So the more you’re able to really breathe deeply into your abdomen and allow your diaphragm to fully relax. Your pelvic floor will relax as well. I think people don’t really realize the power of breathing and how that can really help not only calm your nervous system, but relax your pelvic floor. Okay. Something I definitely recommend for anyone. And that’s pretty safe. It’s pretty passive. So doing some, almost like guided meditation, guided imagery while doing some deep belly breathing is a good idea. And something that someone with vaginism or pain with sex or any pelvic pain would benefit from. That makes sense because our breast patterns are tied to our ability to have orgasms. Right. We have difficulty reaching orgasm. So it’s physiological as well as psychological. Yes. Exactly. So that’s something I recommend to pretty much all my patients. So that’s something without seeing someone. I could definitely recommend belly breathing that was actually prescribed to me as well. Yeah. Diaphragmatic breathing is what you could look up if you’re wanting to get more information. And what is your website you mentioned you have a website? Yes, it’s pelvicpainrehab. Com. Okay. And we’ll make sure we post that on our site because we have run out of time. I have lots of questions. I actually was doing my research on you and saw this article you wrote on. I can’t even say it on Poop. I hate Poop, and I thought, I hope we don’t have time to get to that. So we don’t. Oh, no. Another time we’ll but I’m going to have to do some CBT first in order to participate in that interview. Okay. That’s not torture people for my Cank listeners. No therapy. Okay. Every time I say CBT, some of my people say, oh, cockenball torture. No. Cool. So tell us where we can find you on Twitter. Instagram, Facebook, anywhere else we should find you personally. Yes. So personally, I’m only on Instagram, and my Instagram is Pelvic Health SF, and then our company. We’re on Facebook as Pelvic Health and Rehabilitation Center. And then our Twitter and Instagram is just at Pelvic Health. And so you can find us on there. We’re also on Pinterest. All of our blogs are on Pinterest. So if you look for the Pelvic Health and Rehabilitation Center on there, there’s a lot of good information and our website. You can also access our blog through that and all of our other social media channels through the website Pelvic Painting rehab. Com. Okay. Awesome. Thank you so much for speaking with me today. I really appreciate it. Yeah, of course. Anytime. Thank you. Yeah. All right, folks. So I did some learning there. Perhaps I shared just a little bit too much information, but that’s okay. I’m always learning. And hopefully you are, too. I like the advice about the deep breathing and a breathing exercise that I practice. I can’t offer the physiological advice, of course, that Rachel can, but the visualization technique I use is of an ocean. So as I inhale, I picture the waves very slowly rolling onto the beach. And as I exhale, I picture the waves rolling away. And as someone who has a good amount of difficulty relaxing and breathing deeply related to sex but also unrelated to sex, just helping myself to calm my mind and clear my head. That’s an exercise that works really well for me. So the waves rolling in, the waves rolling out, and I encourage you before you move on to the next thing today to take some big deep breaths, maybe three, four, or five, and make sure you are taking care of your pelvic health. I think often we think that sex is just a physical activity that we engage in for emotional connection and intimate bonding. But of course, there are health aspects with which it intersects. So I encourage you to follow along, follow Rachel Galman on Instagram, and we’ll be posting the links to the Pelvic Health and Rehabilitation Center’s website as well. Thank you so much as always, and thank you to Desire Resorts for making this podcast possible. Desire Resorts, of course, is a clothing optional adults only paradise and playground down in Mexico with several locations, and I’ll be setting sail with them out of Venice in September. I hope to see you on board. The ship looks beautiful, and we’ll be heading along the coast of Italy and Croatia. So please also look up Desire Resorts. Thanks so much, folks, and I will look for your comments, your questions, and try and get you all of them on Twitter, Instagram and Facebook at Sex with Dr. Jess.