Urinary Incontinence Treatment, Pelvic Pain & the Problem with Just Doing Kegels | Dr. Diana Mendez

Dr. Brighten: [00:00:00] Welcome back to the Dr. Brighton Show. I'm your host, Dr. Jolene Brighton. I'm board certified in naturopathic endocrinology, a nutrition scientist, a certified sex counselor, and a certified menopause specialist. As always, I'm bringing you the latest, most UpToDate information to help you take charge of your health and take back your hormones.

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Don't forget to subscribe, leave a comment, or share this with a friend because it helps this podcast Get out to everyone who needs it. Alright, let's dive in. Dr. Diana Mendez, welcome to the show. Thank 

Diana: you very much. It's a pleasure to be here. Thank you for the invitation. 

Dr. Brighten: Oh, I'm super excited today. So for everybody listening, you're gonna get a lot out of this episode.

However, you're probably gonna wanna take a trip to YouTube and see the video because we're going over the pelvic floor. You urinary incontinence, and you brought a model today, and so you brought a model today. I'm so excited about that, so that we can really help people visualize it, right? Because there's a lot of tissue in the way down there, so you can't really just see your muscles or visualize what's going on very easily.

Totally, totally. Yeah. So I wanna open this by asking you what's the one thing that women are doing on a daily basis that's like wrecking their pelvic floor? 

Diana: Okay. I would definitely say, um, pushing, like bearing [00:02:00] down. Okay. This is like. We're human beings and we're all the time, like bearing down, like we stand up from a chair or do we do something that's making us like, make an effort.

Mm-hmm. And then we just like bear down. Like we, we just stand up and burn down. Okay. We just exercise and bear down. Mm-hmm. And everything we do, we do it like bearing down. Like we go to the bathroom like pee and some people burn down. We also go to the bathroom and poop. 

Dr. Brighten: It's true. 'cause you know, as we know, a lot of people suffer from constipation.

Not drinking enough water, not exercising enough, not getting enough fiber. Those are three key things that are usually missing. That's like a starting place with constipation. We'll talk about pelvic floor and constipation, but you're right with the, the bearing down is that some people like, you know, they get told too, you don't wanna sit there for like 15 minutes just scrolling, TikTok, uh, you wanna, you wanna, you know, get your business done.

And so people will push. And so what I'm hearing from you is pushing down. Is a really big problem. What's it doing when people bear down? 

Diana: When you bear down? So you're basically like pushing [00:03:00] your organs down, like everything. Okay. Like you're closing your throat and just like sending all that pressure mm-hmm.

Down to your pelvic floor. Like nothing is supporting that pressure. Nothing is like taking that pressure away and you're just putting it directly into your pelvic floor and to your organs that are supported by your pelvic floor. So that's like basically one of the main causes of pelvic floor dysfunction.

Dr. Brighten: Okay. So people bearing down, they're pushing down, they're pushing their organs down. You said this leads to pelvic floor dysfunction. How does that play out? How can someone identify? They have pelvic floor dysfunction, 

Diana: so pelvic floor dysfunction like might look different because there are like a lot of pelvic floor dysfunctions.

But basically like, like the, one of the most common dysfunctions is like urine incontinence. Um, I think this is one of the main ones. And this is definitely caused or can be caused by bearing down, for example, um, prolapse too. The, that can also be caused by bearing down what's a prolapse for 

Dr. Brighten: people who don't 

Diana: know.

Oh, okay. So a prolapse is when [00:04:00] one of the pelvic organs like go, like descents. Mm-hmm. And goes, I mean, there are grades of prolapse, like you can have like a little descent of one of the organs, like bladder, uterus, rectum. But you can also have like. Mm. Advanced degrees of prolapse where the bladder, or like the uterus or like the rectum are like pushing the vaginal walls down.

Mm-hmm. So it's coming out of the vagina. 

Dr. Brighten: Yeah. So sometimes you can visualize it, you can actually see this yourself. You can get a mirror squat down and you'll see the vaginal wall coming down, but sometimes you're feeling pressure as well. So the cysto seal, that being the anterior vaginal wall, I feel like we're gonna have to get a model out soon already.

Yeah. Um, where the, the bladder is prolapsing. Maybe someone isn't super aware, they're not filling that, that bulge in the vagina. So what kind of symptoms, you said there's urinary incontinence. Is there anything else happening in the urinary tract? 

Diana: Yes. They can also get infections. Okay. [00:05:00] And they, because I mean, if the organ is like.

More exposed. Mm-hmm. It's usual to get frequent urinary tract infections, like this feeling of heaviness down the vagina. But I mean, it, it's not like something that's every time, like for example, there are people having like grade three that's an advanced degree of prolapse. Mm-hmm. And not having any symptom or, or just like being, like when I go to the bathroom, I just feel like something's coming out.

Like I feel something like bulgy. Mm-hmm. Um, but not feeling, not having urinary incontinence or not having like any heaviness or pressured on the vagina. And there are some people that have like. Prolapse grade one. Mm-hmm. And they're having urinary incontinence and they're feeling heaviness and they're feeling like, I mean, the grade doesn't depend on, like the symptoms don't depend on the, the grade of the prolapse.

Dr. Brighten: Yeah. This, I think for anybody with like endometriosis and some of these other conditions that we grade, they really resonate with that because sometimes it's like. How do you not have pain? How do you not have symptoms? 'cause this is like worse, [00:06:00] like, you know, version of this, you know, presentation. We could see, and it's that every body is different and how it presents totally when the bulge is happening in the posterior wall.

So the rectus seal, uh, we're talking about issues with defecation, we're pooping for the lay person. What does that look like for somebody? 

Diana: Um, for example, there are people that whenever they have like rectus seal or posterior vaginal wall descent, they're having like a lot of trouble pooping, for example.

They have, sometimes they have to even like, stick like some fingers into the vagina to do like pressure. Mm-hmm. So they can finish like emptying their bowels. 

Dr. Brighten: Yeah. So, yeah. So for people that are listening, you're talking about. Inserting. Usually it's a finger or two into the vagina and then they push back towards their tailbone.

And so that's to act, that's basically to give the support Exactly. That your pelvic floor should have been giving. 

Diana: Exactly. 

Dr. Brighten: Totally. Yeah. And so can this also present with constipation that can also 

Diana: present with constipation? Yeah, there are like difficulty emptying the bowel. Yeah. And also [00:07:00] like, um, having to push a lot.

Dr. Brighten: Yeah. 

Diana: Okay. That makes pelvic floor dysfunction too, so, 

Dr. Brighten: yeah. Well, it's important for people who are like, I am moving my body. I am drinking water, I am eating fiber, and I still am having these issues. I think the first thing that comes to mind are people who are like, well, that only happens to women who have babies.

Is that true? 

Diana: No, definitely not true. Okay. Because it can also happen to, for example, people that, that have, um, that make a lot, a lot of exercise of, or like athletes Yeah. That are, that they don't know how to be, like, exercising correctly. Or like, one of the main, uh, problems we have is like that nobody teaches you how to really, um, like activate your core.

Yeah. Like, properly. So as no one teaches you how to do that, then you keep, like, you start your whole like, uh, sporty life, like just exercising and not knowing that you're giving a lot of, or putting a lot of pressure down to your pelvic floor. Mm-hmm. And you're predisposing [00:08:00] yourself like to have a dysfunction or a prolapse.

And for example, there are like, uh, adolescents, I've had people with 18 years old having prolapses because Oh gosh, they're too constipated. Or they just like. CrossFit and bare down a lot. And nobody ever taught them how to activate pelvic floor, how to, uh, like activate their, their deep abdominal muscles.

So I think this is like a very important thing that we have to, to keep in mind, that we have to be assessing, like how to really activate our deep core, because we usually are told by coaches or by, by people, by trainers, like, um, contract your abdomen. Mm-hmm. And you're contracting, but if you're not contracting the proper muscles, then you can be bearing down.

You can be pushing. Because if you contract your abdomen, like in general and then you add to that an effort, then you probably will be just like pushing. 

Dr. Brighten: Yeah. Okay. I think it's time we teach people how to do that. How does that sound? [00:09:00] Perfect. Okay, so let's go first. What is the core? Because you just said engage your core and I think people always think suck your belly button in and hold your breath.

Yeah, I grew up a dancer and oh my god, it was beaten into us where they're like, when they would say, pull up, that's I, oh my God, I just like, can try, I just did a Kegel. Um, this is how ingrained it is to me. As soon as they say pull up, I'm like, lift your pelvic floor. Like, you know, but, um, it would be, they would like drill this into us, ask us all the time, and if you ever said like, you know, suck in or like, pull your belly button, any of that stuff, they're like, no wrong.

Like, um, they weren't like the most militant. Ballet instructors, but you know how ballet instructors can be. Yeah, definitely. So, um, let's talk about what is the core, and then let's take people through how to engage their core. 

Diana: Okay. So the core, basically, like, it's usually thought that the core is, uh, the abdomen or just like, well, I usually get like it's the abdomen and I'm like, mm, or your belly, right?

Or your belly, yeah. Yeah. [00:10:00] Like, activate your belly and that's the core, right? And I'm like, oh, no. Like, there's way more to the core than that. So the core is basically formed by the diaphragm that it's. Are like our main breathing muscle by the transverse abdominal muscle that it's like the deepest layer of our abdominal muscles.

We have like our rectus abdominals, our o external obliques, our internal obliques, and then deep to that we have the transverse. And most people don't know this muscle because this is what we're not usually, uh, taught. Um, and it doesn't give 

Dr. Brighten: way to six pack ab. So 

Diana: no, I know 

Dr. Brighten: some people don't care. 

Diana: Exactly.

But the thing is that when you go and just activate your, your rectus abdominis or your obliques and you're not activating your transverse, then you're basically just like bearing down. Those are the main muscles that activate when you bear down. Mm-hmm. So it's very important that. Apart from that, I mean, those muscles have like a function, but they can't activate if the transverse [00:11:00] isn't activating first.

Mm-hmm. Because if the transverse isn't activating first, then the lumbar spine, like the center, the core is just like unstable. Like it doesn't have stability. So the transverse its main function is to give like stability, support to our abdominal organs and stability, like to the whole center of our body.

Mm-hmm. And this is why it's important and why it's called like the core, because it just like, it's just like the tissue that surrounds our whole center, like the center where our center of gravity goes through. Yeah. So this is very important. And also this transverse abdominis comes right to the pubis where our pelvic floor starts.

And these are also like other muscles of the core, the pelvic floor, which are our muscles like. That are super important for our, uh, function, our basic functions like urinary continence, fecal continence, sexual function, like this is important. And we also have, as a part of the core, the mitus muscles mm-hmm.

That are like little [00:12:00] muscles in between like the vertebrae that just like give stability and support. And these, all of these muscles are just like very connected through a thin layer of tissue that we called fascia. Mm-hmm. And this layer of tissue makes, uh, what it does is that it connects this whole like, complex of muscle, which is why 

Dr. Brighten: it's also called connective tissue.

Exactly. 

Diana: Exactly. So as this is all connected, um, if one of them gets like. Weakness or tightness, then that affects the other muscles of the core. Mm-hmm. And so we might have like, uh, tightness in our pelvic floor, but then we also might have tightness in our, in our abdominal like muscles. And then we also have like weakness because tightness also like leads to weakness because there are muscles that aren't working properly.

Mm-hmm. That can't be relaxing. And as they can't relax, then they can't also contract properly. 

Dr. Brighten: Mm-hmm. So 

Diana: this is important, 

Dr. Brighten: I would imagine, if you don't know how to engage your transverse abdominus. That could lend [00:13:00] itself to back pain and chronic back pain? Definitely, definitely. 

Diana: Actually, there are studies that tell us that the main muscle that we have to be like activating after, uh, surgery, like lumbar surgery or back pain, uh, uh, rehab, we have to be activating this muscle.

And no one teaches you how to, like, only when, when you, um, go to a pelvic pt, then they tell you like, this muscle exists and we have to activate it this way. But it's not like very easy to activate it. Yeah. Because sometimes people, especially like after birth, after giving birth, or people that already have kids, they're not very connected to this muscle because as the, the belly like just grew and grew and grew and grew then.

Mm-hmm. This whole, like this whole, um, abdominal layers just stretched. Yeah. And if they never like. Like activated them, then they're just like very weak. Mm-hmm. So the whole abdominal like [00:14:00] function just goes like uncoordinated, like it just goes out of balance. So we have to reeducate this abdominal function, these transverse abdominals, so it's activating properly.

How do we activate it? So basically, I mean, there are like different commands we can give to, to people so they can start filling it. But basically, like some of them are, like, for example, this transverse is a muscle that helps with exhalation. Mm-hmm. So whenever we, for example, uh, talk, we are getting air out.

Yeah. Whenever we cough, we're getting air out. So this muscle has to be activating, uh, whenever we cough, whenever we sneeze. And this is what makes, uh, the pressure we're doing whenever we're coughing or sneezing or breathing or, um. Uh, laughing. Yeah. This just, this muscle just like, uh, helps decrease the pressure going down to the pelvic floor.

Mm-hmm. So they activate together, basically they're just [00:15:00] like, transverse is going in, supporting like the abdominal organs and pelvic floor is going into. If we have this coordination, like proper coordination, then we, uh, tend to not have pelvic floor dysfunction. We tend to be like having a pelvic health we can say and how we activate it.

Like there are different forms of activating it, but basically as it's a, a, a muscle that helps with exhalation, we usually teach it. Like whenever we inhale, we just feel like, well first we have to check the, the breathing pattern because there are people that breathe and just breathe and put the belly in.

And there are people who breathe, uh, out and put the belly out. Yeah. So first, what do we have to check Is that, um, the person is breathing properly. So what does it look like to breathe properly? What should our belly do? Sh our belly. Should we have, we, we should have like a 360 degree breathing. I like to call it like that.

Mm-hmm. Our, our wrists should be moving. This should be moving too, but not only moving like this, so [00:16:00] your wrist, your chest, and your belly. And your belly. Okay. Like everything, just like. Expanding. Mm-hmm. And then whenever you, you, 

Dr. Brighten: uh, exhale, everything just goes. And as we're doing this, our diaphragm, which is part of the core that you talked about, is also moving.

So as we're inhaling, diaphragm goes down. Exhale diaphragm goes up. Goes up. Exactly. 

Diana: Okay. And that's why we say diaphragm. It's, it's, it's also like very important to the pelvic floor because mm-hmm. I usually see, for example, people having like very, um, a very diff having difficulty, for example, breathing or like moving their ribs and just mm-hmm.

The diaphragm is just like. Static, it's not moving. Yeah. And as a diaphragm it is parallel to the pelvic floor. Then if the diaphragm is just like still, then the pelvic floor is still too, and they're not moving. Okay. When they should be doing this. 

Dr. Brighten: Like, and so the pelvic floor, you're saying, should be moving the same way the diaphragm is Inhale it goes down.

Exhale, it comes up. Exactly. Which is why when you're lifting weights, if you are [00:17:00] inhaling and straining, they're, that's bearing down. Exactly. Okay. Making connections. Making connections. Yeah. So, um, I really wanna give people like something tangible that if they're listening right now, let's, so let's say like they're sitting at their desk, they're at home, they can stop.

What exercise would you have them do to engage their transverse abdominis to identify that set of muscles? Okay. So 

Diana: I would just have them like putting their hands here, like in, in the, up in the lower part of the abdomen. Okay. And just like 

Dr. Brighten: touching, so I wanna just explain this 'cause some people are just listening.

You're making a v, so fingertips go down, palms of your hands. So the two little bumps on the front of your pelvis. Mm-hmm. So if anyone's felt that on their hips, that's where you have the heel of your hands and then you're pointing down towards the pubic bone with your fingertips. The pub. Okay. 

Diana: Exactly.

So whenever you breathe in, you have to feel like your belly, not exaggerating, like the going out, just like feeling it moving like. Out and whenever you exhale, it's better if you exhale through your mouth. Okay. Like if you're blowing [00:18:00] something but not blowing, like with your mouth, like really closed.

Yeah. Because if you close it a lot, then you might be like pushing. So is it more like, more like, okay, Uhhuh. Exactly. And so you're, you're inhaling and you feel your belly like naturally going out. Yeah. Yeah. And then when you exhale, you can be just like, ah, and your belly has to be like going in. Yeah. But you have to feel only the movement, like in this lower part, this is how you identify the muscle.

So just the 

Dr. Brighten: lower part, what if I feel my ribs coming in or, 

Diana: so if you feel you might be activating like your external obliques and another muscles, I mean, it's not bad that you're doing that, but whenever you're activating those first before than the, than the transverse, then you might be like, uh, it's, it's more difficult to activate the transverse after you already activated the superficial layers of the abdominal wall.

Dr. Brighten: So what I hear you saying, and correct me if I'm wrong, is doing this exercise and filling just that lower [00:19:00] part of your abdomen going in. That's how we know we're engaging the transverse abdominus. And then once you do that, once that's coming in, then the rib cage coming in, the obliques and everything else engaging, that's fine.

We wanna be doing that as well so that we get the full core engagement. 

Diana: Exactly. Okay. And you wanna be like, knowing how, how to activate this also during exercise, for example, doing, uh, sit ups. Mm-hmm. And not activating the transverse might make, uh, and this is something I really want to give, like people to take, uh, and to really analyze whenever they're exercising.

Yeah. Like whenever you're making or you're doing an exercise and you feel your belly. Coming out or you're sink. Okay. So if you're like 

Dr. Brighten: sitting up or you're squatting or whatever, or anything and your belly's coming out, that's what you're talking about? Yeah. Okay. Okay. 

Diana: Or for example, this, this typical exercise when, when you're like laying down and you lift both of your legs.

Yeah. Like an up, uh, like a lower ab, uh, exercise. Yeah. If you are doing [00:20:00] this, uh, usually like. The, the muscles or the abdominal muscles aren't ready for this. Mm-hmm. And if you're doing this and you're seeing your belly coming out, then this is not working for you. This is not a functional exercise for you.

So are you causing harm because you're causing harm? You are. Okay. And you're probably just like, uh, as it's being like very hard exercise, you're probably just like keeping the air in, like mm-hmm. Not breathing it out. And as you're keeping the air in and making an effort, you might be pushing and bearing down.

And so this helps, or these, these, um, increments, the possibilities of having like pelvic floor dysfunction. Mm-hmm. Like sometimes we're doing things that we're not noticing that are harming us, for example, in men that we are usually see also, like men. Men, men are usually like, we don't, we never get urinary incontinence.

Yeah. And they're, they think they're like. Fine with that. But the thing is, men usually have diastasis recite. 

Dr. Brighten: Okay. Men [00:21:00] usually have the, wait, wait, what is diastasis recti? 'cause not everyone knows that term. Yeah. 

Diana: So diastasis recite is when the rectus abdo muscle, the typical like abs, like the square abs, like we, we wanna have, everyone wants to have like the, the abs in the, like the muscle super strong.

So whenever, uh. These muscles are having a lot of pressure coming out because you're doing these exercises that are like forcing them out. Yeah. Then they might start having like this separation in between the, the, the muscles. Mm-hmm. Like the muscles are like a like, kind of like a chocolate, uh, tab. Oh 

Dr. Brighten: look, 

Diana: a chocolate bar.

It's just like 

Dr. Brighten: a chocolate bar. It's a such a great c analogy. Like a bar. Yeah. It's like, yeah. So you've got that line down the center. Exactly. Exactly. And so that's what you're talking about, the separation. 

Diana: Yeah. Yeah. And 

Dr. Brighten: we all want those chunky squares in the front. Well, I don't know. Not all of us, but some, some people I feel like, you know, my 20 something self is like, yeah, I need ripped dabs.

And then my 40 something self is like, I need a strong core. 

Diana: [00:22:00] Exactly. Exactly. That's it. Because usually, or you can see like very strong people like having like their apps like very toned and, and everything just looking like very perfect. They have a lot of. Low back pain. Mm-hmm. And why is this? Because they might be activating the superficial layers of the abdomen, but they're not activating the deep core that is the one making them stable, like have stability.

Dr. Brighten: So the diastat recti, the separation of the abs, you said this is actually common in men. I think a lot of women, um, that have been pregnant or familiar with this, 'cause this gets checked post well, should get checked postpartum. Definitely. What is the problem if this happens? So your ab, your abs are separating the fascia that's between them has weakened What?

Happens. So this 

Diana: is usually something that, uh, women after pregnancy have, because as I was saying, like everything has to grow and just adapt to the, to the growing of the baby. So, uh, muscles have to adapt and they just stretch. But, [00:23:00] um, this, usually this has to be functional. Like the diastasis has to be functional, meaning that if you have diastasis and these muscles are separated mm-hmm.

But your transverse is activating and giving proper, like support to your abdominal organs, then your diastasis might be functional and that doesn't give you any trouble. But whenever you have diastasis and you're not activating your transverse properly and you're not having like that stability, then this is pressure coming out of your, of your abdominal wall.

And this pressure coming out of your abdominal wall is also like going down. So people with diastasis recite might have urinary incontinence. Okay. Might have a low back pain because. It's like, it's not like activating or bracing properly. So these, these are like the most common problems with diastasis recite and going back like to the men, to the main, main things that I was saying that men don't usually have urinary incontinence, but they have a lot of hernias and [00:24:00] a lot of diastasis recite.

And I like to say that in men hernias are like the equivalent to the urinary incontinence in women. Yeah. Because that pressure, that all of that pressure that they're doing, like whenever they're doing like ab exercises or this, they're giving like that, all of that pressure doesn't go down, like it goes down to the public floor.

But, but as they don't have like this, uh, extra, uh, hole that is the, the vagina. Yeah. They just have the urethra and the anus and they, and we have urethra, anus, and vagina. Mm-hmm. And so we have an extra, uh, part where pressure is coming up and the extra escape patch, if you will, an extra escape patch. So we get ary incontinence as women.

Yeah. But men don't have that. So all of that pressure going on out to the pelvic floor and going out to the abdominal wall has to exit somewhere. And that's why they have hernia hernias. Mm-hmm. And that's why doctors usually say that, uh, [00:25:00] they can have surgery, they can operate the hernias, but they. Have like a high risk of having a hernias.

Hernias again. Yeah. So, uh, this is because they never reeducate those muscles. Mm-hmm. They never teach people, we never teach people how to really like, properly, uh, stop giving pressure out or stop putting pressure down. Yeah. And so this is a way to stop this, to stop having hernias, to stop, like having pelvic floor dysfunctions.

Like we have to know how to properly activate our deep core muscles. 

Dr. Brighten: Okay. We've talked about the deep core muscles. I wanna talk about what the pelvic floor is though, because we've been talking about it, but I don't, I think it's not this thing, like you said, we're, we're not taught about it, but I think it's very intangible.

Unless you've actually looked at a model, unless you've actually looked at what's going on. Can you use your model and explain, explain to us like what the pelvic floor is? Sure, sure. I'll show you the model. And it's [00:26:00] such a beautiful model, I 

Diana: must say. Thank you. I love it so much. Okay, so this is a pelvis.

This is a, the pelvis as we are sitting down like right now. And we can see here we have the pubis and here we have our coys. This is, uh, which is the coccyx is the tailbone. It's a tailbone. It's a tailbone. So this is, uh, um, a female model of pelvic floor. And so we have muscles. That go like from our pubis to our tailbone and to the bones that we usually feel when we're sitting down.

And so this is like a whole complex of muscles that have like different functions. For example, they are in charge of our urinary continence or fecal continence because we have like here. Sphincters that surround our urethra. This is from where like P comes out. This is the vaginal opening and this is the anus.

And if you can see, we have all of these muscles, like just surrounding these, these three, uh, parts. So [00:27:00] these muscles are in charge of contracting, like, or, or having like a tone or like a resting tone so that we can just like, uh, walk and not have like urinary leakage. Mm-hmm. Or fecal leakage. And then they're also in charge of the sexual function, specifically this ones that are here.

As you can see, they go right through the clitoris. Mm-hmm. So they improve like blood flow to the clitoris and they also contract during orgasms. Mm-hmm. So this is like very, 

Dr. Brighten: very important to know. So the health of your pelvic floor is directly connected to the health of your orgasms. It's, 

Diana: yeah. I mean, orgasms like have like this physical part and, and the pelvic floor is part of that physical part.

Yeah. Because it's also has like, have like this emotional part. 

Dr. Brighten: Mm-hmm. 

Diana: And it's like a very complex, uh, 

Dr. Brighten: yeah. And there's the nervous system component that, and it's a nervous system. I think we're gonna have to talk about orgasms and, um, the pelvic floor, but I'll let you keep going. 

Diana: Okay. So these muscles are also responsible for that.

For [00:28:00] example, I usually have people specifically, like with endo telling me like, I have pain, um, after an orgasm. Yeah. Or I have pain during orgasms. Mm-hmm. And I just know I just have to go and check this muscles because they might have like. Tightness or some tender points that are bothering them and that are reproducing these symptoms.

Yeah, so this is also important for that. And we have mu, these muscles have like a superficial layer that are, that is this layer. But we also have like a deep layer where we can see, like inside we have our bladder, uterus and rectum. And if we take these organs out, we can see like a whole lot of. Uh, deep pelvic floor muscles.

So this is also like very, very, very important because when we evaluate this, we usually have to, or, I mean, it's not necessary, but it gives us a lot of information if we can check like the inside, like we usually touch, like do a, a vaginal exam so we can get [00:29:00] to feel these, uh, deep muscles. Mm-hmm. Because they might be weak.

And this is what usually people think about urinary incontinence. Like for example, I have urinary incontinence because, uh, my pelvic floor is weak. Yeah. This is usually thought, but it's not that, uh, every time it's, it's, it has to be weak. Like sometimes it's just tight and as it's tight, it's just not working properly.

Mm-hmm. And so you can have urinary incontinence because of tightness too. So this is important. 

Dr. Brighten: And what about trigger points? What, what are trigger points and how do those contribute to urinary incontinence? 

Diana: Okay, so trigger points are basically tender points in the muscles that are like, uh, for example, muscles have like little fibers that can like just, uh, have a dysfunction and just be like tight and, and make it a tender point.

Mm-hmm. A trigger point is this area in the muscle that just, uh, it's called trigger point because you press it and it triggers pain Yeah. To other areas of the body. For example, specifically in [00:30:00] the pelvic floor, we can have trigger points just going to your abdomen or just going to your back or to your hips.

Mm-hmm. Like these patterns of eradiation. Um, for example, people having people with endo, for example, having, um. Uh, menstrual cramps. Yeah. Like pelvic floor can be, uh, contributing to those menstrual cramps. Mm-hmm. Because you can have tightness or tender points, or trigger points in your pelvic floor, and those are contributing to that pain you're feeling to that pelvic pain, they usually contribute more to pelvic pain and tightness, like just having like a pelvic floor that isn't able to relax.

That contributes to urinary incontinence because if your pelvic floor can't relax and then it can't also contract properly. Mm-hmm. Because you need whenever, and this is for like. Every muscle in the body, if you want function, the muscle has to be able to relax properly and to fully contract because people usually tell me like, I want, uh, tight [00:31:00] muscles.

Like, I want to feel them hard. 

Dr. Brighten: Okay, here's the, here's where I think this comes from, um, is that society has this myth that's perpetuated that a tight vagina is the ideal vagina, right? So, um, I'm just gonna call out Sarah J Mass, uh, because I read her books. I've read all of her books, and, uh, she's a female author and the number of times she has, um, a sex scene and the male comments on, oh, she's so tight and I just grip my teeth, and I'm like, A tight vagina is an unhappy vagina.

Like a tight vagina is not an aroused vagina. Like you haven't done your job in getting that woman excited for what's to come next if the vagina is tight. But I think that's where it comes from is a lot of. Uh, stigma and shame about this idea of like, oh, you have a loose vagina. Oh, you've had a baby, you have a loose vagina.

And in reality, let's, I want you to tell people what is the problem with having hypertonic tight [00:32:00] pelvic floor muscles? Because the tight vagina is not what we're after. 

Diana: Tight vagina is not what we're after. Definitely A tight vagina is usually, uh, a vagina that has, or, or a person that has pain with sex.

Mm-hmm. With, with penetration. Yeah. Because a tight vagina is that it's, it consists of muscles, of pelvic floor muscles because we have muscles also like surrounding these vaginal opening. Mm-hmm. And so when these muscles are tight. Which is a tight vagina. Yeah. Then, uh, people usually have pain. Women usually have pain and, and then, and sex is not enjoyable and sex is not enjoyable.

But for many people, they just like, or, or for many women there, it's just something like to be ashamed of. Mm-hmm. And then they don't talk about it. Yeah. And this, then these kind of dysfunctions get like really lonely. Mm-hmm. Because, because nobody talks about that because of the stigma. And sometimes they even cry like during sex because it's hurting a lot, but they don't know [00:33:00] like what to do about it.

And here we also have like this problem of, uh, gynecologists. Not referring to pelvic pt. Yes. And this is like a big thing because, uh, we can do so much about that. We can do like a lot about that. And we see people telling us, or we see women tell, telling us, like, uh, my, my gynecologist told me to just like, drink wine and get drunk before, before having sex.

Dr. Brighten: I wrote about that in my book. Is this normal? Because it is so common the number of times patients have said, oh, my gynecologist told me, just have a glass of wine. So you relax and just lay there and you, and you'll be fine. I actually, um, I struggled with vaginismus and chronic pelvic pain and pain with sex.

When I was in my twenties, I was on the birth control pill and I, it led it to, uh, chronic yeast vaginitis, right? So like, if you have a very irritated, unhappy vagina and, and it's gonna get, you know, the nervous system's gonna get scared. The, [00:34:00] the tissues are gonna get tight, so. And all these problems. I had a female gynecologist, and this is, I say female because this is just how appalling it is.

She told me to cut my pudendal nerve. She told me that I should have a procedure to cut my pudendal nerve so that I could just have sex. And I was like, but what about my own pleasure and what about my function and what does this do? And she was like, you really owe this to your male partner to be able to accommodate a penis.

Like that was basically the conversation. And here I am, I'm like 23, and I'm like, you want me to undergo a major surgery? Now I wanna say she was covering for my male gynecologist who was out. He comes back from vacation. I tell him the story of what happens. He was furious. He was like, absolutely not.

Should you have that surgery? What? Well, I love that about him. I'm so sad that he never said, and you should go to a pelvic floor physical therapist for this. 

Diana: This is something that we see [00:35:00] like every day. I can, I can tell you like. Every day we see people telling us like, I, I wasn't referred, how did I not know that this existed?

Yeah. Like, I've been in so many years, I have people, women in their sixties, like coming and not have, not being able to have like penetration, like for their, their whole lives. Yeah. Like never, or even touching themselves because they're afraid that something might hurt. Mm-hmm. Because they had like a very, um, very painful experience sometime, and they, then they didn't experience it again.

And then they come in and they're like, how did I not notice before? How did I not hear of this before? How did anyone tell me about this? 

Dr. Brighten: Yeah. 

Diana: And it's, that's a big thing because it changes people's lives. 

Dr. Brighten: Absolutely. And, and it can disrupt relationships. It can, it can be a lot of internalized shame, as you said.

It can be really lonely. I just said vaginismus. Not everyone knows what that is. Can you define vaginismus and I wanna talk a little bit about how do we approach pain with sex? 

Diana: Yeah. So Vaginismus is basically like, [00:36:00] uh, the. Inability to have like penetration of any kind. Mm-hmm. Like there are people with vaginismus or women with vaginismus, like telling, I can't even get like a, like, um, a swab in like for an exam.

Yeah. So they can't 

Dr. Brighten: have a gynecological exam. No. Speculum not, I mean, sometimes not even like a, a finger for palpation. Nothing. Yeah. Like 

Diana: nothing. So vaginismus is this. And so, um, this tightness or this, this increase of the, of the activity of the pelvic floor, of the, of the tone of the pelvic floor makes it impossible because it's super painful.

Likes really painful for women, uh, with vaginismus to try and just put anything in. Yeah, anything being like a novel. A novel or, or, or like a tampon. Like a tampon, like. Anything being, even if it's small, like it just like burns. Mm-hmm. They describe this pain like it's burning. Exactly. That's exactly what it's like.

Dr. Brighten: Yeah. What do you do about it though? Because, um, [00:37:00] women with vaginismus, so they're often told just have a glass of wine, relax. Um, I now that cannabis is legal and a lot of places, doctors will now be re recommending that. I think you, I don't think alcohol is never a great. Anything. It does not a treatment for anything Cannabis Navy can help with, you know, nervous system dysfunction, things that are going on, but this is like chasing symptoms.

It's not getting to the root of what's going on. How do we address Vaginismus to actually get women to a place where their pelvic floor is functional? 

Diana: Okay. So we usually work also with sex therapists. Mm-hmm. Uh, sometimes women with vaginismus also have a history of sexual trauma or sexual abuse. Yeah.

And so all the body, like whenever there's trauma or there's pain or there's abuse, like the body just protects Yes. And it, and it learns how to be protected the whole time. Mm-hmm. And if it's always protecting, then the muscles are always tight. And this doesn't help in any like way to this tightness of the pelvic floor and to [00:38:00] this, to this problem.

So we usually work with sex therapists that work with this like, emotional, uh, response. And we work with the physical part of, of relaxing the pelvic floor, of relaxing the tissue, of making, uh, the, the patient like just trust and see that not. Everything that goes in has to be hurting. Mm-hmm. So we start working, like, for example, I, I, I personally like to, to address vaginismus, like working it, uh, by the patient tolerance.

Yeah. Like, for example, their pelvic PTs, I've known of that, that just work. And they're like, it's gonna hurt. It's just gonna hurt and, and just go with that. But I feel like giving them this response of, or, or this feedback of I'm doing this and it's hurting a lot, it's just like, um, uh, making you reinforce this idea that everything hurts.

Yeah. And so working it, working with that and just releasing it and just teaching you how to not be [00:39:00] protecting your whole body the whole time. Mm-hmm. Like in your day-to-day lives. Because we, we also have like, um. People that are so in, well, everyone we're, everyone is like so into our like activities and our day-to-day lives, and we're not noticing how our body is reacting to that.

Yeah. And so sometimes, like there's a lot of people that have a pelvic floor overactivity or, or, or tightness because we're not being conscious about our bodies. Mm-hmm. And so whenever we're just like working in the computer or just like, um, I don't know, uh, doing our day-to-day lives or just like washing the dishes or whatever, we're not noticing that we're tightening our glutes and that we're tightening our legs and that we're tightening our, our apps and the, all of these muscles as I was, as I, as I said before, they're connected through fascia to the pelvic floor.

Mm-hmm. So we, we can be tightening the muscles all the time and no muscle is made to be tight or to be contracted all the time because then [00:40:00] they create. Tightness. Yeah. And then they, they stay like shortened. And this creates like also pelvic floor dysfunction. So we have, so we basically have pelvic floor dysfunctions, like being of, uh, weakness and pelvic floor dysfunctions being of overactivity.

Yeah. And so we can, uh, like, um, make them, uh, divided in, into those two parts. And also like people with vaginismus have, um, they don't have like a lot of consciousness about their bodies. So we in pelvic pt give them like a lot of, uh, awareness mm-hmm. Of, of how to, we, we like to give them tools. Like it's important to have tools because for example, there are people going to pelvic PT and after a while of living it, they go back to being tight.

Yeah. And why is that? It's because you don't have like the tools to apply into your day-to-day life to, um, not be. Protecting your body the whole time. So I think this is important to give people tools to, to, to not [00:41:00] be like protecting the body. And that's why therapy also helps and pelvic BT helps because we work with the tissue.

Dr. Brighten: Mm-hmm. I wanna highlight something I think you said is really important, is to basically put the patient in the driver's seat. They are in charge, they are giving feedback and that you're not just plowing through and, and pushing ahead because the, one of the big reasons I got into women's medicine. It's just having the epiphany that it is.

Medicine is always done to women. It's not with women. It is lay there, be a good girl. This is going to happen. It's not. Can I insert the speculum now? It is. I am going to insert the speculum now. And I really appreciate how you're taking a different approach to not just power through, not push through, not just tell the patient, lay there, it's gonna hurt, but to let them be in control and let them really guide the treatment and their healing.

I think that's so empowering. Especially if you come from a place where the triggering event was sexual assault, when you were disempowered, when you weren't in [00:42:00] control. I think that is such a important part of healing. You mentioned giving people tools. What kind of tools do you give patients with vaginismus so that they do have a road of long-term recovery?

Diana: So, for example, this, uh, that I said before about the awareness of their, of their bodies. Mm-hmm. For example, uh, meditation techniques like, I like, uh, to give them like body scan meditations that are these meditations that make you go through like how your body is feeling. And I like to give them this so they can stay connected to knowing like.

And connecting to how their body feels. Mm-hmm. When it's completely relaxed. Yeah. Because they're usually not noticing that they're always like tightening like their legs. Mm-hmm. Or their ab or their glutes. And so this predisposes their pelvic floor to be tight all the time. So making them connect with their body in a full different, uh, way that is like being relaxed.

Yeah. So asking them like to [00:43:00] meditate this body scan meditation. Um, what, what's a 

Dr. Brighten: body scan? Meditation. Maybe people aren't familiar with that. 

Diana: Okay. So a body scan meditation is a meditation that takes you through scanning from your. Toes to your head, like seeing, and like, really it takes you through the meditation that is like the breathing and everything, like guided, but also like really, uh, being mindful and connecting with each part of your body.

Mm-hmm. And just going through like, how are your toes feeling? Your feet, are they like completely relaxed or are you, or are you tensing or tightening something? Yeah. And then you can be just like, oh, okay. I was tightening my, my, my toes were like this, like tight or, yeah. My, my left leg was just, I was just like, uh, tightening it.

And so this makes you more conscious and more aware mm-hmm. Of how your body's reacting or what it, it makes you learn a lot about yourself. Yeah. Because sometimes you're like, um, you're not, you, you don't know you're tightening things or you're [00:44:00] protecting yourself. And then. Uh, when you start like being conscious about it and really like noticing it, you, you see, and you realize that you're tensing like the whole time.

Like you're washing the dishes, like you're working in the computer, like you're, whatever you're doing, you're tightening or even your posture. The posture also has like an influence here because if your pelvis isn't like in a neutral position, if it's like, just like forward or backwards. Yeah. It's making an, um, a muscle on balance there that can be, uh, leading you to tightness somewhere.

So that's also important. 

Dr. Brighten: People have to comment right now. How many of you just checked in your body and found there was something tight? Because as you were talking, I was like. My jaw is so tight right now. I need to relax my jaw. Um, my, my jaw is like kind of my stress place. Uh, and so I will like clench my jaw.

Um, I would just love to hear from people though, if they could leave a comment of like, yes, it was my toes. Yes, it was actually [00:45:00] my shoulders. When, uh, do you recommend people do this body scan and how often are they doing it in a day? 

Diana: So, um, basically I always tell them that like, being aware of this is something we have to learn.

Mm-hmm. Because you've been, I mean, some people have been like, their whole lives with like childhood abuse or things that make them like be protected all the time, like be tied all the time and then they have to learn something that they haven't been doing for a long time. And so, uh. At first, like it's going to have to be like very conscious, like you're, have you, you will have to dedicate energy.

Mm-hmm. And, and giving it a thought, like how, how your body is reacting to your day-to-day activities. For example, I'm, I am having a meeting with my boss, how is my body reacting to that? Ah, or I am, I'm having a conversation with a person. I think, like, I like this person, but how is my body feeling about it?

Like being, like listening, really listening to our bodies. 

Dr. Brighten: This is like [00:46:00] the dating, like the, the dating tool. I think right here you should be leveraging. So if you're dating and you, and you go on a date, and you should definitely scan your body and be like, how does my body feel when I'm around this person?

Exactly. Yeah. We always talk about like, get out of toxic relationships, like people who don't, I, I always say if they don't make you feel like glitter, like don't, you don't wanna be in that situation, but. This body scan can be so powerful for how you're interacting with coworkers, the friends that you're keeping, the relationships that you're in.

Um, it's got a lot more utility than just like your, your musculoskeletal help for 

Diana: real. Because sometimes you're, you're not noticing that you, you're like, I'm with my friend that I love. And then you're seeing your body's just like protecting. Yeah. And why is it protecting then listening to our bodies is like a really powerful tool.

Mm-hmm. And it's something like, I can say my patients appreciate a lot, like being able to connect to their bodies and being like, Hey, I didn't, I wasn't aware of this going on. And of course, I'm super tight because I'm all, all the time I'm like, just tensing. And I hadn't [00:47:00] noticed that. Yeah. And so it's, it's important to do these kind of exercises so we can like.

Yeah, really like listen to our bodies and improve our pelvic health because pelvic health has everything to do with your emotions, with stress. Mm-hmm. And with how we are feeling in the, in the moment. So at first I always tell them like, uh, this is going to be like very, very conscious. You're really gonna have to think about it.

For example, like, it's like learning 

Dr. Brighten: something new, maybe setting an alarm like every hour on your phone or something. Exactly. Okay. Exactly. 

Diana: That's just what, what what we have do we have them doing. Because, um, at first you're not gonna notice, like you're gonna be so immersed in your activities that you're not gonna see that you're tightening.

Mm-hmm. What do we have to do? Well, maybe set an alarm. Something that sounds like nice, that doesn't like alter you. 

Dr. Brighten: Oh man. I know exactly what you're talking about. Something that's like a. Strumming instead of the like. Exactly, exactly. 

Diana: Because if, if you, if you have this alarm set [00:48:00] and then you're, you're gonna catch yourself like, just like, what's going on?

And so it's important to have like a nice alarm, maybe a vibration in your clock or something that just reminds you of like, Hey, can yourself. Yeah. And you, just as you've been doing your meditation, your body scan meditation, then you can like really connect to your body faster and just say like, okay, I'm working in the computer, but oh, my alarm's going on.

Okay. How am I like, just like really analyze, like, how are my glutes, how are my feet, how are my legs? Oh, I was tightening my legs. Okay. I, I re accommodate. I'm just like, re I'm gonna sit down and just like, uh. Try to relax and go back to that moment or what I feel when I'm meditating. Yeah. Doing that body scan meditation, when I'm fully relaxed, I'm gonna remember that and just try to go back to that point.

And then every time you're catching yourself, like tightening something, you're just gonna have to go back to that point. Mm-hmm. And then at first you're, when you're learning this, I, I always say it's like learning how to [00:49:00] drive, but at first you have to be like very conscious of what you're doing, and then you're just like doing it automatically.

Yeah. And then this, this happens with everything that you learn at first when you're relearning something, you have to be like paying a lot of attention to that. But whenever you're more conscious about that. You're gonna be like automatic, like for example, you're gonna be able to just like, um, look at yourself and, and not pay full attention to that, but your body's just gonna feel off the relaxation and it's just gonna go back to that point.

Mm-hmm. And so that's, that's important one, that's one of the biggest tools we can have to, to keep like pelvic health, not like, not be tight. Yeah. This is one of the, of that main, those main tools. 

Dr. Brighten: I love that you mentioned radiation of menstrual pain, so that's very common in endometriosis, but it can happen even if you don't have endo.

Yeah. When you see radiation of pelvic pain, where is it commonly [00:50:00] going and where is it coming from? 

Diana: Okay, so as we have a lot of pelvic floor muscles, well, for example, menstrual or or pelvic pain, specific pelvic pain, it can come from like any part, any muscle in the core, for example. Okay. Like you can have trigger points in your back going to your, to the, to the abdomen, or you can have trigger points in your pelvic floor going up to your abdomen or going up to your back.

Or you can have trigger points in your hips going up to your, to your pelvic floor. For example, I sometimes have people, um, palpate, I have them like, uh, palpating their, their abdomen and they're telling me like that where you're touching is giving me tingling in the vulva. Mm-hmm. Or, or this, that, or I'm touching the leg, the inner part of the leg.

And that where you're touching is giving me cramps in the vulva. Mm-hmm. Or that is giving me pain through the, through, through my, like SOAs. Because sometimes people think like they have dysfunction with their SOAs, and [00:51:00] it's more like the inner part of the, of the leg. So as we look at, um, ira, like trigger points and pain, like eradiated pain, we sometimes see people having pain and focusing or treating that pain like locally.

When most times or, or sometimes it's not local, it's mm-hmm. Like the origin is somewhere else and that's why we have to seek for the first specialists that can check that and evaluate that so that can, it can be properly treated. 

Dr. Brighten: Yeah. You brought up the pain going down the legs. That's a very common one with endometriosis.

Yes, definitely. 

Diana: That's also like, because nerves can be like affected, but muscles can be like not contributing to those affected nerves or to that pain. So that's also like very common in endo. 

Dr. Brighten: Yeah. Mm-hmm. Are there exercises or stretches people can do if they're having menstrual cramps and it's low radiating to their low back?

That's a super common one. 

Diana: Yes. Actually we have a lot of [00:52:00] exercises that can improve. For example, menstrual cramps, low back pain, hip pain, pelvic floor tightness, like, uh, specific, um, stretches that target the back, that target the hips or the target like the abdomen can help and can improve the fascial movement so that, um, pain decreases.

So, yeah, we have a lot of stretches that we can 

Dr. Brighten: you say you have a lot, can you give us like three? Like maybe describe like, I don't know, maybe even just one. 

Diana: Yeah. For example, um, for, for menstrual cramps and for low back pain, we have these, uh, back stretches that can help. Like, for example, laying down flat and just like putting one knee up and then the other one and just like hugging them, that, that's helpful.

Or also like this figure for exercise that mm-hmm. That is very, uh, famous. This is a hip rotator, uh, stretching and as hip rotators. Like, for example, I'm gonna show the model again. Hip [00:53:00] rotators. We, we have this, this muscle, we can see here, it's a piriformis, and this is the muscle that usually traps the sciatic nerve.

Mm-hmm. And as we can see, piriformis is very, very close to the pelvic floor. So the hips and the, the activity, and this is the 

Dr. Brighten: backside. Just so 

Diana: Don orient this, everyone 

Dr. Brighten: that's, that's the tailbone back there. 

Diana: This is a tailbone. This is a sa, the sacrum, and this is like the back part of the, of the pelvis.

And so we have here this rotator exercise, this rotator muscle. And so this, as we can see, is very, very, very close to the pelvic floor. So whatever we do to our hips. Also affects her pelvic floor. Okay. Like negatively or positively. Like if we stretch our hips properly, then that can help like decrease tightness and uh, address also like pelvic floor trigger points or overactivity.

And this also helps like with, uh, pain in the low back or menstrual cramps. [00:54:00] Like everything, uh, stretches that can make us like move or for example, the happy baby pose, like this famous yoga pose where you're like doing or imitating this position of the, of a baby, like just, uh, holding their feet like, like apart.

Dr. Brighten: So that's when you're laying on your back and you bend your knees, you pull 'em to the side. Of your body. They're not coming into your chest like the last one. And then you grab the outside of your feet and you, you, and you can just rock around and play baby a baby. You can just, 

Diana: yeah. Yeah. That's also helping a lot.

Dr. Brighten: And the figure four, that's actually how I am right now. Right? It's ankle over knee. Correct. And you have your knee over and you can lay on your back and you can reach through and pull it in. Or even if you're sitting at a chair, you can just bend forward. And so there's the knees to chest. On your back.

Mm-hmm. The figure four and then the Happy baby, those are three that you recommend for menstrual cramps. 

Diana: Yeah. Also, I don't know how this exercise is called in English Act actually, but like this, uh, it's also a yoga, I think it's the child's pose. Oh, child's pose? Yeah, the child's pose. Yeah. Uh, [00:55:00] that also helps a lot.

Yeah. Because, um, these menstrual cramps also have like this connection with the back part of the sacrum and like everything here. And so, uh, whenever you're stretching also like the, the, the back part of, of your, of your back, then it helps also like to move everything around. Like basically everything you do with your, like stretching around like your hips.

Mm-hmm. Or your abs or your, um, abdomen will help a lot with, uh, with these symptoms. Yeah. With low back or with menstrual cramps, for example. 

Dr. Brighten: I love child's pose. I'll actually have my husband put the heel of his hands on my, um, pelvis and stretch it down a little bit more. And yes, whenever I am having menstrual cramps that radiates my back.

I'm like, that's the one. It helps so much. Yeah. That's very helpful. Yeah. So I wanna sh I wanna shift the conversation e bit to talking about urinary incontinence. 

Diana: Mm-hmm. 

Dr. Brighten: There is a common myth that peeing your pants after having a baby is [00:56:00] normal. What do you say to that? It's 

Diana: no, uh, involuntary, uh, leakage is normal.

It's never normal. Even if you're 80 years old, even if you had six babies like vaginally, it's never normal. Okay. And you can do something about that. Every time. 

Dr. Brighten: Okay. What happens when you have a baby that makes it more likely you're going to have urinary incontinence? And is there anything we can do to prevent it?

Sure. 

Diana: So whenever you're, you're pregnant, for example. Uh. All of your abdominal muscles, as we talked about the transverse ados, uh, this muscle helps a lot like with, uh, uh, the pressure going down to the pelvic floor. And so this is one of the main muscles we have to be activating and preparing during pregnancy so that whenever you go to your postpartum, you're not as weak as you would have been if you hadn't, uh, exercised this muscle.

Mm-hmm. So that's a way to prevent it. But [00:57:00] what happens is that whenever, like usually pelvic floor muscles are not targeted. Like no one exercises those muscles and their muscles as any other muscle in the body. And as these muscles are like, I'm gonna show this again, or this, as these muscles are in the low part of our pelvis, like they're always charging like, or, or, or supporting gravity or organs or body weight.

And so these muscles, if we don't exercise them, then they will start like, uh, getting weak. Mm-hmm. And then whenever. Uh, you're pregnant. Like, uh, you inc these muscles are adapted or are, are capable of supporting your, your weight. But whenever you add more weight, like a baby weight, then these muscles are like, okay, but I can support your weight with you not training me.

Yeah. But now that you're adding extra weight that is a baby, then I will not support you. And that's why there's so much urinary incontinence in pregnancy. 

Dr. Brighten: What's the problem with [00:58:00] telling women just to do Kegels? 

Diana: Okay, so this is a great question because, um, doc, even doctors usually tell them, tell people to do them, but.

We pelvic PTs are so against that because it can make it, like, it can make it worse. Okay. It can always make it worse. But because sometimes like if Kegels or like pelvic floor muscle training, we, we actually like to, to call them pelvic floor muscle training. Mm-hmm. Because Kegels, what, when we think about Kegels, they're like pelvic floor contractions.

But as I was saying like before, these muscles are like any other muscle in the body. And so these muscles also have to have those to have dosed exercise, like prescribed individually, like according to your needs exercise. And so, uh, what you're doing with gigs, first of all, when you say to a person, like you have to do your gigs, um.

You don't know [00:59:00] if that person is like, correctly or properly activating those pelvic floors, the, those pelvic floor muscles or the, or the, if they are like bearing down, because some people are like, I'm, I do kegel all the time. And when you check that they're just bearing down. Mm-hmm. And it's making everything worse.

And, and also like sometimes, uh, doing Kegels when you have a tight pelvic floor, like when you're not conscious about being able to relax. And also like contract. If you're not being able to do that because your muscles are tied because you don't, you're not very connected to your pelvic floor muscles, then you might be doing them wrong and then you might be like just contracting and you stay there and you never relax and that makes you be like more vulnerable of having, uh, pelvic floor tightness.

Mm-hmm. And then we shouldn't prescribe kegels or pelvic floor muscle training unless it's via pelvic pt because we, what we do is like check and assess if that's where the [01:00:00] muscles are. Like if, if the muscles need exercise now or if first we need to be, relax those muscles or relax those, that tissue so that it can properly activate and make the exercises.

Mm-hmm. That's the main problem with public with, with giggles because they usually send them to anyone and it's, it shouldn't be like that. 

Dr. Brighten: Yeah. Mm-hmm. Is it normal to have a little bit of urine leakage if you cough, laugh, or sneeze? 

Diana: No, that's also never normal because that means you're giving your pelvic floor some kind of pressure down.

Okay? And it can be because your pelvic floor is weak, but it can also be because your transverse is weak and it's not like, uh, supporting that pressure for, from not going directly down. So, uh, it's not normal. It's never normal, and we have to properly know how to cough. And I, I actually would like to show something.

Dr. Brighten: Do it. Yes. 

Diana: So a quick test that everyone at home can do. I, I love 

Dr. Brighten: how the, like the uterus just comes out, goes [01:01:00] back in like, so easy. Life's so easy. 

Diana: So a quick test we can do like at home is just like put our hands, uh, above our pubis 

Dr. Brighten: Okay. 

Diana: And feel what's going on when we cough, so we can just like assess, for example, like a quick assessment whenever you cough.

Uh. Your belly, you should feel your hands going in. Okay. And this is usually opposite to what happens with people after having, uh, kids, because the whole abdominal wall is so weak that it doesn't know like what's 

Dr. Brighten: well also out, out was the thing to do, right? Like what you're pregnant, like going out is like what the, the entire like nine month experience is about.

Diana: Exactly. And as everything is like going out, then, uh, you're, you're, it's like, I, I like to think about like the transverse being asleep. Yeah. Whenever, like during pregnancy, if you don't like activate your transverse during pregnancy, then you go to [01:02:00] postpartum. And that transverse is like vacationing, like just having a, a red cas done, like rest done.

Yeah, exactly. And so whenever you're trying to, to get it back, it's more complicated. Mm-hmm. So I would really, really recommend, um. People or women I would really like, um, tell them to prepare for their pregnancy. Like this is a thing, like we get people or women coming like, I want to get pregnant. How can I prepare?

And we can prepare for that. We can prepare for pregnancy and also like being pregnant and coming and what can I do? Like what do I have to do? And the main things we do is like teach them how to properly activate that, that uh, deep abdominal layer. Because as everything is stretching, then it should be stretching.

Yeah. Because that's natural, but it also has to be activating so it isn't weak. And so going back to the, to the exercise we were doing, I want you to, to try and just like put your hands like [01:03:00] here uhhuh so 

Dr. Brighten: everyone can do this right now. Yeah. Everyone can 

Diana: do this right now. Yeah. 

Dr. Brighten: And for people who are listening who can't see this heel of the hands on those little bumps on the front and then the fingertips are pointing down, we're just making that V again on the pelvis.

Diana: Exactly. And so what we're gonna do is we're gonna cough. And we're gonna see what happened to our belly. And if you have to do it again, like do it again. Yeah. Or laugh, laugh. Ha.

And we have to see what happens with that, with, with those hands. Are they going in? Yeah. Or are they going out? If they're going in, then that transverse is holding the pressure we're doing with your, with our lap or with our cough. The transverse is getting in to hold it. And the, as the pelvic floor also contracts with the transverse and they're both getting in.

And then you're not in risk of having urinary encount. So in is what we want in is what we want. Mine just 

Dr. Brighten: fluttered. I was like trying to go in, but then it wanted to go out. What's going on with that? And I was [01:04:00] like in, and it's like, we don't know what we we're doing. What should we do? 

Diana: We're confused.

Yeah. And if you felt that and you felt your belly going out Okay, then that transverse is inactivating. Mm-hmm. And that all that pressure that you're doing when you're. Coughing, sneezing, laughing is going out. Mm-hmm. And directly down. And as the transverse didn't activate, then the pelvic floor didn't activate either.

Okay. And everything went down and maybe urinary leakage. 

Dr. Brighten: And so we want people to go see a, a pt because there can be a lot more going on that by doing that exercise alone and training that transverse abdo, they can start to improve urinary incontinence. 

Diana: Yeah. And also like being aware of the pelvic floor.

Like there's something we like to give people as a tool. And this has made like a big, big difference. This is called the neck. And this is, um, uh, something we pelvic PTs give to patients as, um, like. [01:05:00] To make them prepare for the effort they're gonna do. So for example, if you're gonna cough, like if you're having urinary leakage, then for example, um, you can prepare for that.

And at, uh, the same thing I said with the, with the being conscious about your body and at first being like really having to focus on that. Uh, we're also relearning something here because we want to really focus on preparing our pelvic floor. Mm-hmm. Whenever you activate pelvic floor, transverse is gonna synergistically or like co activate with the pelvic floor.

They both are activating together because the transverse is coming all the way here to the pubis and then connect with the pelvic floor. So whenever transverse is activating, pelvic floor is activating too. Okay. This is what should be happening. So better than a Kegel. So better than a kele. So whenever we want to prepare, because we know I'm feeling that I'm gonna cough, and then if I know that I have urinary leakage every time I cough, then what I really wanna do is try and like close my [01:06:00] pelvic floor.

Mm-hmm. Like activate, there're like different, um, uh, things we say that can make you like more conscious about that. Like, for example, trying to hold gas or trying to, uh, hold p mm-hmm. Or trying to close. I like to give this example of the smoothie that I've told before, that, um, you have to imagine like you're gonna like drink a smoothie with your vagina.

Okay. Yeah. And then you want to close around the straw and then like put up, yeah. This is what you want to be doing with your pelvic floor. You have to be feeling like. Going up, like closing and up. Mm-hmm. This is what you wanna be feeling. And so whenever you're gonna cough, sneeze, or laugh, what you can try and do is just like, call, like, close that pelvic floor, like contract that pelvic floor and hold it while you cough.

Mm-hmm. And hold it while you laugh. Mm-hmm. And then after you finish laughing, after you [01:07:00] finish coughing, you can let it go. And make sure you let go. Because if you stay like this, then that can predispose you to like too, too tight and have tightness. But if you're conscious about this, you can prepare for a cough for, for a sneeze, for a laugh, for lifting a heavy box, for example.

Yeah. These are all efforts, like efforts that if are not properly done, you're gonna be bearing them down. 

Dr. Brighten: I remember you said, uh, we had a conversation previously, you said there's a saying in Spanish about the preparing. Mm-hmm. Like being ready. What is that again? 

Diana: Oh, so in Spanish we call it pre contraction.

Okay. In English we call it the N. Yeah, it's like the same thing. The nac, it's not as pretty though. No, it's not as pretty. It sounds better if I say pre contraction. Yeah, yeah. Like, but, but it's mainly that like pre-contract to the effort. Mm-hmm. Like you're gonna cough. Okay. Then close and then you let go.

Mm-hmm. You're gonna laugh. Okay. I'm feeling like this guy is very funny. I'm just [01:08:00] gonna laugh. So you prepare and ha ha ha, ha ha. And then you let go. So this is why pelvic floor, this is why Kegels like going back to Kes, this is why Kes aren't like the main thing to do. Because Kegels, you're doing just like contraction.

But whenever you're doing like pelvic floor muscle training, you have to be. Doing like, um, uh, contractions, but like with power, but you also have to have resistance. Mm-hmm. For example, being able to hold that for a few seconds. We, we usually say it's ideal if you, for example, can hold a pelvic floor contraction, like eight seconds standing up.

Okay. 'cause also position is important for the pelvic floor. For example, um, laying down flat, pelvic floor is activating like in, and gravity is going like down, but it's, it isn't affecting pelvic floor. So it's easier if you try and activate pelvic floor lying, like laying down. Because if you try and activate pelvic floor, [01:09:00] like standing up, then there's gravity coming down, there's your body weight coming down, then you, your organs coming, like everything is like more like heavier.

Mm-hmm. And then it, it has to be stronger to be able to contract against. All that weight. 

Dr. Brighten: Yeah. 

Diana: So, yeah. 

Dr. Brighten: Okay. I really love these, you know, tangible exercises that you're giving people. I think it's super helpful, especially, you know, as you knowing that you can prepare to prevent urinary incontinence from happening.

Is it the same for people who are having fecal incontinence? 

Diana: Yeah. But we also want to focus like, on, on that, on that sphincter activity because Yeah, I mean, the pelvic floor is a muscle complex. It's like a whole complex. You can say like, I want to activate only this one, or only that one, or only, no, like, they all activate together.

But you like, whenever you're more conscious about that, like more advanced in, into your pelvic floor muscle training, then you can [01:10:00] dissociate a little bit, uh, your muscles like from like your superficial muscles. From your deeper muscles. Mm-hmm. But yeah, mainly it's what you have to do too, like. Really strengthen that pelvic floor, improve that muscle tone.

Dr. Brighten: Yeah. People who hover when they pee, so they go to a public restroom, they won't sit on the toilet. Are there problems with that? There are a lot of problems with that. No. Break it down. 

Diana: So there are basically five things that we shouldn't be doing when peeing. Okay. So one of them is like hovering. Mm-hmm.

Because whenever we hover to pee, as I said before, like the, the, the leg, the muscles in the legs, in the muscles in the glutes, the muscles in the abs, they all contract with the pelvic floor. And what you want to be doing whenever you're going to the bathroom is relaxing your pelvic floor because this is what makes the bladder able or the rectum able to like, um, uh, get everything out.

Relax, relax, relax. Uhhuh, well not relax, but contract like whenever, [01:11:00] um. We, we are peeing. Mm-hmm. Our bladder is contracting. Oh, okay. I was thinking the sphincter, sorry. 

Dr. Brighten: Yeah, yeah. I was sphincter relax. 

Diana: Yeah. Like the bladder contracts and the sphincter has to relax. Yeah. And so if thi this, this happens like with the rectum and with the bladder, but whenever we're hovering to pee, like we're tightening because we have to keep this position of like squat.

Mm-hmm. And so the, the knees have to be like, uh, activated. The core has to be activated. Like everything has to be activated. And so our pelvic floor will, might relax, but it will not relax fully. And if it doesn't relax fully, then the bladder can't. Empty fully. Mm-hmm. So this might give you like, uh, incomplete, um, voiding.

Yeah. Be, and, and that can make you like more vulnerable of having infections. I always tell people like, it's, you're more, um, it, you might get an infection like [01:12:00] more, uh, frequently if you hover mm-hmm. Than if you sit down. Okay. 

Dr. Brighten: So, yeah. So the, you said there's five things we should never do when we pee.

Can you list those five things for us? Sure. And then we can go into 'em deeper. 

Diana: Sure. So hovering to pee, because we're not fully relaxing pelvic floor and bladder is not fully emptying. So other one is like kegels while we pee that sometimes we, we also hear this like, uh, make your pelvic floor exercises when you're pee.

No, no. This is confusing your bladder. Yeah. And this is not good. Also, uh, like bearing down to pee. This is the third thing we can't be doing. Um, also like holding pee for long periods of time. Mm-hmm. Because we have normalities, we have like normal parameters of like peeing. Like for example, it should be like, for a person that drinks two liters of water, it should be like six to eight times to go to pee.

Mm-hmm. Every two to four hours. But not, uh, very frequently [01:13:00] because we also have overactive bladders that want to Yeah. Empty like all the time. And one of the, the fourth habit that is leading us to this dysfunction of overactive bladder is like preventive being 

Dr. Brighten: mm-hmm. That I think nurses everywhere right now are like, what?

You know, because there's certain occupations and jobs where it's like you're drinking water, but you can't just go to the bath. It's not that easy for you. Yeah. And I 

Diana: think this is also something like very social like. Moms teach us to do this. Mm-hmm. Moms teach us how to like, not Well, they teach us to hover and they teach us to you we're gonna go out, so go to the bathroom, but I don't want to go go to the bathroom because I don't want you to be like, yeah.

Needing to pee. And this is me 

Dr. Brighten: right now in the phase I'm in though with a 3-year-old is that I'm like, we have, we have to go to the potty like we have to try before we go out because if we go out, then we end up with a potty accident. But what I'm hearing from you is I should not be doing this. Look at your face.

You're like, no, this [01:14:00] is good though. This is good. You know, because it is, I mean, I do this with myself too. I'm like, oh, I'm leaving the house. I should try to go before I leave. Yeah. Oh man. And so now I'm hearing that it's. My whole life has been wrong. 

Diana: Yeah, definitely. It's like some, a reaction that everyone has.

Like I've been doing this for my whole life and Yeah. Like this is something we're taught. Mm-hmm. Like, but I mean, it's not that you should never do it. Yeah. Because sometimes like you have to do it because you're going to take a road trip. Mm-hmm. Or you're going to like a concert. Yeah. Like you, you have to maybe prevent like that.

Right? 

Dr. Brighten: Yeah. Or you'll be at passport control for like three hours. Right. 

Diana: You have to prevent from those kinds of things. Yeah. But it shouldn't be part of your normal. Okay. Like this, these things that I've listed, uh, I mean, we can do them, but this is not a good thing to do. Yeah. Like they, they don't have to be our usual because if then, if they are our usual, then we're gonna have dysfunction.

Okay. [01:15:00] And is there a fifth? Did we get through five? So it's like not bearing down, not holding pee for a long time. Mm-hmm. Uh, not giggling while peeing, not hovering and not, uh, preventive peeing. So not like forcing yourself to go 

Dr. Brighten: all the time. Yeah. Okay. Mm-hmm. Those are definitely helpful things, um, to hear.

And I think, uh, you know, as much as I'm like, oh gosh, like, yeah, I'm surprised. Like I, I've been doing this thing wrong. I think a lot of people are going to be like, okay, like we need to, to re reassess the way we're doing things. I also think it. As I listen to this, I'm like, we need to normalize, like in the society having more access to public restrooms and things being available so that we don't have to have those habits of holding it too long or, um, you know, having to preventively pee and, and go before then.

And also clean bathrooms I think, so that we don't feel like we have to. There are definitely, I just want everybody to listen. You have my permission. You're in a porta potty, like the, uh, I don't know what they're called here, but at concerts we have those bathrooms. Yeah, the portable ones. [01:16:00] You gotta hover some, you gonna hover most of the time, like I think that, would you say that it's okay that sometimes you're in a time and a place where it's like, yeah, you just have to hover.

Diana: Yeah. I mean, there are some places that you're like, I am definitely not gonna sit down here. And for example, airports or airplanes or things like that, or concerts, like those blue public, public, like bathrooms. Yeah. But what you should be like really focusing is if you are gonna, if you have to hover, if you have to then just be very, very mindful of, uh.

Putting like a tip I would, or a recommendation I would give to everyone is, like, for example, in airplanes, we have like these bars, like, I was gonna 

Dr. Brighten: ask you that. 'cause if there's ever a bar or even the door handle, because sometimes nobody designs a bathroom, so you can actually get in and out easily.

Right. And the door handle's too close. I'll hold on it. If I have to hover, I'll hold and try to like disengage a little bit. So is that what you're [01:17:00] saying? 'cause I'm hopeful for it. That's what I'm saying. Definitely. You're 

Diana: doing that, right? Yeah. Because if you, if you're gonna hover because you have to, because you're in a place that you want to sit there.

Mm-hmm. Then what you should be doing is like trying to make the, the mo like the, the effort should be in the upper part. Yeah. Not in the lower part. Like try and relax as much as you can. The legs, the abdomen, and the pelvic floor. Mm-hmm. And just like hold with your arms so you don't have to be like.

Tightness here and you can empty better. Yeah. 

Dr. Brighten: Do you have any tips just overall with pelvic floor musculoskeletal health? Um, people who have connective tissue disorders where they have laxity to their connective tissue, um, do you have any tips for them because they can end up with pelvic pain because there's so much instability with the connective tissue.

Diana: Yeah. Strengthening, like pelvic floor, muscle strengthening, uh, abdominal strengthening, like really? Uh, do you mean like specifically in the pelvic area or like [01:18:00] general? 

Dr. Brighten: Well, in general because like, uh, aler Danlos, that's one that you know, is very common among people who are neurodivergent. There's kind of the double-edged sword of being neurodivergent is that like, you've got this, you can have this ligament laxity, um, this connective tissue issue.

You then have pain, but some neurodivergent people disassociate from pain, they don't even realize that they're having pain and then they start having dysfunction. And so I feel like this is a whole huge conversation and yet I'm just curious like, you know, what can they be doing to supporting, to support their pelvic floor?

Because if they're not having urinary incontinence now we know that it's something that's usually in their future. 

Diana: So mainly like the main recommendation I would give is to, to have an assessment like prevent, because this is, this is a very important thing to, to say. Uh. Uh, we shouldn't be, uh, going to specialists or to doctors or to PTs or to anyone.

When we have a dysfunction only, we can't [01:19:00] prevent things. Ah, yeah. So it's very important to, like, if, if you're, if you're suspecting or only if you want to check like how you are, you should, you definitely, like, you don't have to wait to have till you have a dysfunction or, or a condition or anything to really assess your body.

Mm-hmm. So you can just like, oh, I'm interested in, in seeing how, how I am or how I can be better or how I can exercise better. Mm-hmm. Then that's important and you, that can be assessed to see like, what's, what's better for each person. We can individualize like what we do and so people with Zalo or for example, um, uh, conditions that make.

Tissue more, more elastic or, or that also, uh, can affect, uh, joint stability. Yeah. And as it can affect joint stability, then we need the structures around to be like strong. Mm-hmm. And to be like, really, uh, making the, their function. So. What I would recommend [01:20:00] definitely would be like addressing or assessing, like going somewhere to, to be, to have an assessment and also like to strengthen, like do mm-hmm.

Like really do like, um, strength training in general. Yeah. Like in, in general, but also like in the pelvic floor area. That's important because those are muscles that are carrying us all the time against gravity. Mm-hmm. Those are, I think they're one of the main muscle complex that, that, uh, are doing this against gravity.

Like all other muscles like move against gravity, but these are like all the time. Mm-hmm. Like carrying us against gravity, so they're very important. 

Dr. Brighten: You said that it would be best if we're having preventative pt. I think it's really interesting. If you look at some countries, like France for example, you have a baby, you are going to pt, like pelvic PT is just part of their structure.

I wish. I think that, and I would, I wonder if you would agree. Pelvic PT [01:21:00] assessments should be as frequent as annual gynecological assessments. I would agree. Definitely. Yeah. And so when you say like, looking at like preventative, like I can imagine someone right now is a mom and she's got a 12-year-old daughter.

She's like, should I be taking my 12-year-old daughter to get assessed? Like, at what points in our life are like, you know, could you, could you give, like at these life events or these stages in your life, you should definitely consider getting assessed by a pelvic pt. 

Diana: Um, especially like whenever you want to get pregnant, like everyone can be assessed.

Mm-hmm. Even like, for example, kids, maybe not like the. The normal assessment you would do to, to an adult. 

Dr. Brighten: So like, not an internal, like vaginal? No, nothing. Nothing. Yeah. 

Diana: But, uh, in kids we can teach them, like from kids, like give them all the educational part of what to do, what to not do about like pee, like all these five things I said.

And also like teaching them how to properly exercise, how to [01:22:00] properly make their efforts. I think this would save us a lot of pelvic floor dysfunctions in the long term. Yeah. And but like main moments, uh, specifically like before pregnancy, during pregnancy, after, uh, having babies, uh, whenever you have like.

A condition or, or a disease or something, for example, endometriosis. Um, if you have, for example, if you're in menopause, like these are like moments that you should, or that you wanna target, even if you don't have a dysfunction that you wanna check that everything's going okay. Because, for example, also in menopause, like tissues, uh, loose elasticity.

Yeah. And then that also, uh, can affect, for example, um, scars, like epitomy scars, like the scars they, or, or the, or the surgeries they do whenever you're, you're giving birth. Um, those might not give you any trouble in the moment, but sometimes they give you trouble in menopause. 

Dr. Brighten: Interesting. So [01:23:00] just for everybody, for, for clarity's sake, you could have a vaginal tear or an app episiotomy.

You heal from that, you have no issues. You enter into menopause. The loss of the estrogen now is changing the tissue, and now you start having pain in those areas. Yeah, because 

Diana: Okay. You also lose like elasticity in your pelvic floor muscles. Yeah. In the tissue around that. And that can start like making that scar that it, that might have not been bothering you before, uh, start bothering you.

Yeah. Like start, like being pulled and being able to reopen or like mm-hmm. Re like bother you. 

Dr. Brighten: Yeah. Yeah. This is why we need to start vaginal estrogen or you know, in some cases DHEA before we have symptoms and I move big advocate of like, when you're in late stage perimenopause, you're counting down those 12 months to where you're gonna be diagnosed as menopause.

We should be starting vaginal estrogen because if we can prevent UTIs, which do kill women, and this is something that it's like, oh, you pee your pants a little bit and oh, you get some new urinary tract infections, like. [01:24:00] We see so much antibiotic resistance to UTI, you know, specific organisms because we're treating it over and over and we're not addressing what's really going on, which can be pelvic floor dysfunction, but also can be the estrogen component.

But I really want everyone to listen because I think now that hormone replacement therapy is like having its moment and everybody, you know that you're seeing a lot more doctors jump on board. They're still not making the referral to pelvic floor physical therapy, and you are not going to out estrogen pelvic floor dysfunction.

Even if estrogen was kind of the catalyst, the loss of that was the catalyst to the pelvic floor dysfunction. You're not going to give estrogen and walk it back. It's going to take rehab. You have to rehabilitate the tissues and the muscles. 

Diana: Exactly. This is very, very important because yeah, most people wait till they have like a dysfunction.

Mm-hmm. To go and, and see and check what's going on. 

Dr. Brighten: Well, and it's how we're trained. I mean, to be fair for the individual, we're trained that, uh, you know, as, as patients, uh, so I'm saying it from that [01:25:00] perspective that wait until you have enough symptoms that get you the diagnosis, that then have the medication for it.

Like it's very much the paradigm that people have been trained in. Totally. And you know, what you're saying I think is so powerful of like, why even wait, I'm the fan of like, let's never get to where we can diagnose it. Is it vague? We've got a little bit of symptoms, let's intervene the best way we can so that you never reach diagnosis.

So that it's like, yeah, it could have been, it could have been, you know, developed into that. But we walked it back before it got to that point because we were early in that intervention. I think it's really unfortunate that like. Pelvic floor physical therapy isn't seen as a necessary preventative medicine.

And really we have a myopic, uh, perspective where much of conventional medicine says like. Vaccines are preventative medicine. And then that's where they stop and it's like, well, that's getting sick. That's one branch of, of, um, health. But like we've got this whole other aspect. And when we look at pelvic floor physical [01:26:00] therapy, it gives people their quality of life.

And I think that is one of the most important metrics. It's not just like, do you have a disease or do you not? The absence of disease, as we all know, isn't health. It's just you haven't have a diagnosis yet. We want people to have that quality of life. 

Diana: Totally. I couldn't agree more. It's important to know that.

Dr. Brighten: I'm gonna go back to the orgasm piece though, because I said I was gonna do, I was gonna ask you questions about it, and I know somebody's gonna be like, whoa, wait. So pelvic floor health, what can we be doing to improve our orgasms? Everybody wants better sex. We talked about the vaginismus piece, but you showed on your beautiful pelvis how those muscles are, are running through the clitoris.

Blood flow and circulation is super important. So for everybody listening. If you read, is this normal? You already know this. The clitoris and the penis are the exact same tissue. We've got oodles and oodles of research on the penis, and it is one of the times we can take research on men and actually apply it to women.

A lot of times, medicine's [01:27:00] doing it, it doesn't work. But in this instance, we can, where we know that if we have blood pressure issues, if we have insulin dysregulation, diabetes, we have issues with erectile dysfunction, we also have the, the clitoris gets an erection as well. Sure. So as you said, these muscles.

They help with blood flow, but they could also impede it. Yes. 

Diana: Yes. Okay. So talk to us 

Dr. Brighten: about it. 

Diana: If, for example, we think about, uh, a tight muscle mm-hmm. Then we know that it has like some part that isn't getting blood flow correctly. Okay. And as it isn't getting blood flow correctly, then it's not like conducing blood flow properly to either like, to the, to the clitoris.

So what we want to see here is that these muscles, specifically the, the, the superficial layer of, of these muscles, we want them to be like relaxed. Mm-hmm. And, and flexible, but also like. Powerful. Like strong. Yeah. We want them strong because for example, there are people that [01:28:00] after giving birth, they have their, they're like, my orgasms changed so much.

Mm-hmm. But that's because if they never trained like their pelvic floor, then their pelvic floor, after all that weight, it went like week, week, week. 

Dr. Brighten: I will say, I've heard from a lot of women who say, sex got better after they had a baby, and their orgasms were much better. What's going on there? 

Diana: Yeah. I, I mean that's, that's like a whole, that's a yay.

Right? We love this. That's a yay. That's like a whole different scenario. 

Dr. Brighten: Yeah. 

Diana: Like. It depends. We have, like, it depends because, I mean, I don't know if the, if, if those women like trained those muscles or if they exercise a lot, because sometimes this is also like we're, we don't know we're activating the pelvic floor, but as.

There are people as there are people that don't activate properly like the core, there are people that don't even know they're activating it properly. Yeah. And then they are like doing Pilates or doing like yoga and they're properly activating everything and they don't even know they're [01:29:00] training their pelvic floor.

Mm-hmm. And they are. And then I think. That depends, or those might be like those women that feel it, like better if they're active during pregnancy, if they exercise, if they like kept, um, their body moving, I think that makes a big difference. Mm-hmm. Yeah. 

Dr. Brighten: But to go back, 'cause I, I realized that, I'm like, I went for the yay.

And then there's like, people gonna be like, well, wait a minute, what about those that we had a baby and now our orgasms are weaker, less satisfying? Or there's even the phenomenon where it feels like you have the entire buildup to climax and then it's like me, nothing happens. It's just like where it just went away.

So in those situations where women have had a baby and now their orgasms have changed and it's not for the better, what's going on there? What can they be doing? 

Diana: Well, talking about like the, not the physical part, like the women have in postpartum are usually like with low, uh, sexual drive. Mm-hmm. Um, because of also about like the [01:30:00] hormones and everything going on in 

Dr. Brighten: there for people who don't know, when you lose the placenta, you birth the placenta and now you are in basically the same state as a menopausal woman.

Your hormones completely drop. Um, and menopause is this gradual transition. We never talk about how postpartum is just like. Snap, you're done. Like, you just, you just flipped the hormones, so there's that. There's not sleeping. There's the stress of a newborn baby. There's the stress of your identity.

There's body image, right? There's like, it's very complicated. Not just the pelvic floor is what I'm hearing from you. 

Diana: Yeah. Not just the pelvic floor, but from the physical part. Like from the pelvic floor part. Yeah, like if muscles during the pregnancy or if, if, if the, A woman ha hasn't trained these muscles like.

During, like her whole life or during pregnancy, then these muscles come to, to postpartum. And we have also to talk about like the relaxing mm-hmm. This hormone that makes everything like more like, um, flexible or more lax. 

Dr. Brighten: Yeah. 

Diana: And then, uh, muscles [01:31:00] are like in a natural state of like, weakness in an unnatural state of weakness.

And as they're weak, we need these muscles, like these superficial muscles that participate in our orgasms. We need them to be properly activating. So if we want like strong orgasms, we have to have strong muscles. Mm-hmm. So that's what, that's what I, that's where I wanna go. Like if we want like good function overall, like in the pelvic floor, we also want like to prepare these muscles for giving us like.

Normal or, uh, satisfactory like function. Mm-hmm. So we have to train them 

Dr. Brighten: and that's everything that we've talked about in this episode so far. Exactly. Perfect. Have you heard of the husband stitch? Yes. Tell us why. The husband stitch is one of the worst things a doctor can do to a woman 

Diana: that's, that's obstetric violence.

And, uh, the husband stitch is a stitch like some doctors do to, uh, [01:32:00] make the vaginal opening less. Like open, or, or, or like tighter. 

Dr. Brighten: Mm-hmm. Smaller. Yeah. 

Diana: Smaller. So that the husband, whenever they're having like, uh, sexual relationships or penetration specifically, uh, gets more pleasure. Mm-hmm. And so, uh, some women are not even told about this.

Like, they're, well, most women are not even told about this. Yeah. And the doctor's just like, ah, with the husband, like, Hey, I will do this. Yeah. Or, or they don't even tell them. And they, they're like, Hey, I, I, I made you a favor. And, and then like, they're stitching whenever they're like, there was a tear, a vaginal tear when giving birth.

Or they do an epitomy, they just like, should, they should like su like suture, like some part, but they suture like an extra point. Yeah. So that it's smaller and it, that's, that's. 

Dr. Brighten: Well, okay, so firstly I wanna say it does no favors to the husband. And also, how are you [01:33:00] even a gynecologist doing that? And you don't understand how the vagina works because when you make it smaller and then she can't have penetrative sex, then it's not good for anybody in this situation.

But what can it lead to in terms of like the physical, the pelvic floor? 

Diana: Well, pain. Pain. Mm-hmm. A lot of pain. Pain with like, with penetration, it can lead to pelvic floor dysfunction. Like for example, uh, the tissues. Whenever we have a scar, and this is also something important to say and that, that, that we should talk about.

Nobody ever tells us to treat our scars. 

Dr. Brighten: No. 

Diana: Yeah. Like for example, you have surgery and okay, your surgery is done, but beneath those scars that you can see like fully recovered, there are things going on. Mm-hmm. And they're, those scars whenever they're like in their process of being a scar, they can, um, start like for example, in the abdominal wall after a C-section for example, that scar like to, to, to do that, uh, [01:34:00] procedure, they have to cut through different layers of Yeah.

Tissue. So whenever, uh, a woman ha a woman has a c-section, um, they have to cut through different layers of tissue, of different kinds of tissue. And so the, all of these layers, like you see your, your maybe like a c-section scar, like very pretty, like in the outer part you see it like perfect. Mm-hmm. But sometimes they are painful or they're giving dysfunction or they are making your muscles not to be able like to, to glide between them and to move.

And so you're having back pain also because you're c-section and you're also having bladder pain because beneath that, that, uh, scar, there are tissue that are, that, that's above like your bladder. And you can also have bladder pain, or that's also like something common after surgery is like in the abdominal wall bladder pain, like, um, um, low back pain or things like that.

Because every time like a muscle is [01:35:00] cut. It protects, like it goes like, oh, they're cutting me in. Oh, yeah. So it gets tight and tightness decreases, uh, optimal function. Mm-hmm. And so, uh, scars should be addressed because, uh, they can be better. I mean, also like pelvic floor PT or, or like PT in general, we have technology like, for example, uh, laser or, uh, radio frequency or things that can help or can improve, like scars and make them like not be, um, pasting or adhering to the deeper tissues.

Mm-hmm. So we have to, to know that. And so in the case of the husband stitch like. When you have like more scar than you should, then it's tightening more tissue than it should. Mm-hmm. Like normally we work with those scars and make tissue like flexible so that, uh, the scar doesn't give like any problem or doesn't like, um, [01:36:00] make the, the women ha have like, pain with sex, for example.

That is like the most common thing. But whenever we have more scar than we should, then that retracts more tissue than it should. Yeah. So that's not good. 

Dr. Brighten: What can you do if you've had the husband stitch? They have to go recut it? 

Diana: No, no, no, no. Because it's already like a scar. Mm-hmm. A stitch. But, uh, we, we have to work with that.

Mm-hmm. Like, you have to make sure the tissue is working properly. I mean, when I, I think one of the, the main things that we have to see is that. Well, for example, I've had a lot of patients coming and telling me I don't want to look at myself. Mm-hmm. And so sometimes because, because I don't recognize myself and my Volvo isn't the same anymore and they don't want to look at themselves.

Yeah. And so like if they are having like this husband stitch and you notice it immediately, then you can do something about it. Definitely. But if you have the husband stitch and it's been like a long time and then you start suspecting, [01:37:00] then, I mean, you also have to address that. Mm-hmm. Like see what you can do about that.

Consult with someone that you're like, that you trust. Yeah. Because yeah, that's a big thing. 

Dr. Brighten: And you're saying there is something that can be done about it after the fact? Yeah. Yeah, definitely. Okay. And what is that? What can you do? Well, for 

Diana: example, like. Specifically, uh, I mean it depends on how, how the person is, but if talking about like an old scar mm-hmm.

Like a, an old, uh, like a person caught and suspects that their gynecologist like maybe a long time did that then work with the tissue. Mm-hmm. Work with the tissue like around to make it like flexible and make it like able to have a sexual activity or to so can stretch again. So it can properly, 

Dr. Brighten: because the scars are much harder to stretch.

Diana: The scars are harder to stretch mm-hmm. Because they retract tissue around. Mm-hmm. So, yeah. But I mean, it would be wonderful if. That didn't happen in the first place, but also if [01:38:00] that, if it happened, that it can, that it's caught like, um, as soon as 

Dr. Brighten: possible, it's incredibly frustrating. Maybe not the best note to end this conversation on, but I think it is giving a lot of hope that something can be done.

If this was done to you, and as you've really highlighted through this entire conversation, no matter where you're at in your journey and what you're experiencing, there is hope. There is something that can be done. Definitely. Sometimes, 

Diana: um, I I get asked like, when's the best time to like, or, or no. For example, people telling me like, I should have done this before.

If only I had, if only I had known. If only I had come when I was pregnant. If only I had come when I was 20 years old. If only I had like, and it's not. Like when you come, it's like you're, you're, you're coming and you're doing something about it. Mm-hmm. And anytime is a good time. Like it's best to start treatment, like, [01:39:00] uh, anytime that not, not having treatment.

Mm-hmm. So it doesn't matter, like there's always some things we can work on and things we can do about, uh, your health. 

Dr. Brighten: Well, thank you so much for sharing your time and your expertise with us. This has been a fantastic conversation. I'm gonna link to you all over the place so people can find you, learn more from you because you are such a fantastic educator.

Diana: Thank you. Thank you very much for the invitation. I'm really happy I got to share this with you today and with and with all the audience, and thank you for having me 

 

Dr. Brighten: here. I hope you enjoyed this episode. If this is the kind of content you're into, then I highly recommend checking out this.