Leaking a secret: Sometimes it’s hard to be a woman
A few weeks ago, friends and I were sitting on my deck having cocktails, and the talk turned to bathroom woes, as can happen when you’re 40ish. One friend can’t sneeze without wetting her pants. Another feels permanently constipated. As for me, I’m up several times at night to pee, lulling myself back to sleep with vintage episodes of “Columbo.”
Fortunately, I’m getting help for my issues: I have pelvic floor dysfunction, which affects one-third of women — many of whom have given birth. People don’t love to talk about the symptoms: urinary or fecal urgency or incontinence; pelvic organ (bladder, rectal, uterine) prolapse; constipation; frequent urination; vaginal dryness; pelvic pain or heaviness. These problems also mimic other issues: I bounced from doctor to doctor, convinced that I had a UTI or fibroids, despite negative tests.
I finally found a urogynecologist — a doctor who specializes in female pelvic medicine, and a specialty that I had zero idea existed until I was over 40 — who suggested I try pelvic floor physical therapy because of tight muscles.
I felt like I’d stumbled upon a secret. Until then, I assumed PT was for athletes (not me). Now, when I talk about pelvic floor PT— because we need to normalize it! — many people haven’t even heard of it. Usually, I get: “What’s a pelvic floor?” Many of these women are also the very same people who swill MiraLAX or who plot their lives around rest stops.
“Pelvic floor therapy is a very underrated, unheralded modality that’s really just beginning to have a moment in the sun. There’s an emerging awareness of the importance of the musculoskeletal system as it relates to gynecological health,” says Cait Van Damm, who runs Ritual Pelvic Health in Jamaica Plain and who sees many women like me, who complain of what she calls “fake-out” UTIs.
Lately, she says, there’s been a democratization of pelvic health awareness on platforms like Instagram and TikTok (I’m a fan of Dr. Sonia Bahlani). Weirdly, COVID also helped: Increased sitting with remote work has caused more pelvic pain complaints. But too often, she says, it’s easy to see symptoms in isolation: urinary frequency must be a bladder issue; constipation or fecal incontinence is a GI problem.
“Pelvic floor therapists think about how all of these things work together.
A lot of us hold stress and tension in our pelvic floor that we’re not even aware of, and that tension can actually have an overflow effect, feeling like bladder spasms or rectal pain. It can feel very different than what’s actually driving the discomfort, which is very frequently the musculoskeletal system,” she says.
Think of the pelvic floor like a hammock or a bowl.
“Your pelvic floor is like any other muscle in the body, and it works just like any other muscle in the body. It’s located inside of your pelvis, attaching from the pubic bone at the front to the tailbone at the back, and then to either side, supporting all of your internal structures: your bladder, your uterus, your vagina, your rectum. And we need that pelvic floor to work for us,” explains Rachel Kim, a pelvic floor therapist at Emerson Health in Concord.
But sometimes it just doesn’t. A pelvic floor physical therapist can determine if those muscles are too tight, tender, or loose. An initial consultation looks at muscle function; abdominal, vaginal, or perineal scarring; and spine and hip function. Depending on patient comfort, there’s also an internal vaginal or rectal exam to palpate muscles — no stirrups, no speculum.
Kim says that while many women come to her thinking their muscles are too loose, often it’s the opposite. For me, and for many women, hypertonicity, or too-tight muscles, spur symptoms.
“Over time, if we have weakness in other areas of our body, our pelvic muscles tend to tighten up to try to protect us. Those muscles tense up. A tight muscle is a weak muscle. It’s not able to work through its full range of motion and elicit the power that we need,” she explains.
Pelvic floor therapy usually happens weekly as hourlong sessions. Kim says that many of her patients see improvement within eight to 10 weeks. My therapist uses a combination of trigger-point therapy (imagine someone pressing just hard enough on a muscle until it loosens) and stretching. Other therapists use biofeedback.
At first, it’s kind of awkward: It will never feel completely normal to have a gloved stranger chatting to me about weekend plans while internally manipulating my muscles. But you get over it. And the payoff can be huge — both in terms of symptom reduction and in terms of feeling like your discomfort is valid and conquerable.
That said: Demand is high. Some therapists don’t take insurance (Emerson Health does), and clients need to seek reimbursement on their own. I pay up front and then submit bills to my insurance company. It’s a difficult upfront cost, but it has also given me a modicum of sleep and sanity back. The American Physical Therapy Association (www.apta.org) is a good place to start your search, but don’t be afraid to bring it up at a PCP, gynecologist, or urogynecologist visit. Many providers maintain a list of recommended pelvic floor therapists. Ask and advocate for yourself.
“The bottom line is: If you feel like things just aren’t quite the way they used to be, seek support. I really like to lead with: You’re not doomed. There is support for this. And it’s OK to talk about,” says Van Damm.
“One of my favorite phrases is: There are a lot of symptoms that are common but not necessarily normal. I think a lot of people have decided: ‘This is part of being a woman; these are symptoms that I just have to live with.’ No one should have to live with these symptoms,” Kim says.