Pelvic Floor Physical Therapy

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end-to-end. Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, colorectal surgeon and president of Main Campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, I'm very pleased to have Erika Lydon, who's a pelvic floor physical therapist in the Rehab and Sports Therapy Neurological Institute here at the Cleveland Clinic. Erika, welcome to Butts and Guts.

Erika Lydon: Thank you so much for having me.

Dr. Scott Steele: We are so pleased to have you here. And just to start off, can you give us a little bit about your background, where you're from, how'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Erika Lydon: Sure. So I grew up in Cleveland. I grew up on the west side and I went to Duquesne University for my undergrad and grad program. I received two bachelor's degrees, one in biology, one in health sciences, and then completed their physical therapy doctorate program in 2014. I was lucky enough to do a clinical here at main campus. I thankfully got exposure to pelvic floor pretty early on. In my PT career, I had to do some shadowing hours to get into their program as a freshman, beginning an undergrad.

And a family friend of my parents happened to be one of the first pelvic floor therapists at the Clinic, so she was willing to have me come on and shadow her and get some hours done. She was like, "Sure, you can get your hours done and do a weird type of therapy, but come on in." And after seeing her treat for a day, I was hooked. And so it stuck with me and ended up getting a clinical and they hired me right out of school and I worked here for two years and I moved down to Youngstown, Ohio. I worked with the Mercy Health System down there, started a pelvic floor office within that hospital system since they did not provide those services at the time. I was down there for three years and then came back here in 2019. And so therapist for almost 10 years now.

Dr. Scott Steele: Well, we are glad to have you back. And as a colorectal surgeon, I must admit, I obviously have very much no pelvic floor physical therapy, but today we're going to talk about that and many people don't. So can you start and first explain what exactly is pelvic floor physical therapy?

Erika Lydon: So it's a very comprehensive view on the patient. A lot of patients are coming in with various diagnoses, which we'll cover in a minute, but a lot of it is just kind of zooming in and zooming out of the pelvic region itself. So very comprehensive. We're looking at head to toe at every one of these patients, but usually to hone in on the pelvis itself, we're asking a lot of questions. We take a very specific subjective with the patient looking at bowel habits, sexual function, urinary function, addressing their goals and what they're here for.

But pelvic floor in and of itself usually entails a pelvic exam of some sort depending on what the patient needs. But we're really honing in on the pelvis itself, all the muscles, tendons, nerves that come along with that and then the functions that it is a part of. Much like if you had a shoulder injury you'd go and see an orthopedic therapist, they hone in on the shoulder, but they're also looking at thoracic spine and they're looking at the neck, but we kind of go into the back, pelvis, et cetera. So we address those specific muscles along the way.

Dr. Scott Steele: So let's dig in a little bit there. What exactly are these pelvic floor muscles and what functions do they serve in the body? You mentioned a little bit of an overview for them, but give us a little bit more of an in-depth look.

Erika Lydon: So the pelvic floor itself functions multiple different ways. It's a support function, so it supports the pelvic organs in the viscera of the abdominal cavity. It helps with pressure system management, so every cough or sneeze, these muscles need to be working appropriately so that you're not having any leakage issues. They need to be able to relax completely for you to allow to have a complete bowel movement, empty your bladder, push a baby out if necessary, involved in breathing, involved in the lymphatic system, helping to pump the lymphatic system through the abdominal cavity as well. And it also is a huge support function, so it's part of the core system of the musculature. Oftentimes people think of the core as just your abdominals and your six-pack that we all strive to get and probably everyone get. But it's very much so deeply involved in the core musculature and it's often forgotten about when it comes to strengthening the core and making sure that everything's functioning well. Lots of things going on in the pelvis, which is why we kind of have people specifically addressing this area.

Dr. Scott Steele: So what are the more common conditions that pelvic floor physical therapy can help treat?

Erika Lydon: Oh, so many. The big ones are incontinence, so any sort of leakage and voluntary of urine or bowel, sexual dysfunction, pelvic pain, so anything happening down there in the groin, perineum, that fleshy patch between the legs. We see a lot of oncological conditions, so things like post-prostatectomy we see a lot of, any cancer radiation issues, constipation's a big one, whether it's at the outlet so right at the opening itself or motility issues. A lot of times orthopedic patients will come in and grab us if they have this funky hip pain that they can't seem to quite fix. And a lot of times there's a pelvic floor component to that. So multitude of things, abdominal issues, breathing issues. We see a lot of connected tissue disorders that have components of pelvic floor dysfunction like Ehlers-Danlos syndrome, even neurological concerns like MS and Parkinson's. So it spans a really big population.

Dr. Scott Steele: So I'm a patient out there and I was just referred for pelvic floor evaluation and then potentially physical therapy. Can you walk me through what a patient would expect during their visits to see you and what type of assessments or tests are typically performed during this evaluation?

Erika Lydon: So we have so much to cover. A lot of times we take a very comprehensive subjective. So like I said, we're asking so many questions. We get into the nitty-gritty, the vulnerable stuff of how are you going to the bathroom, how frequently, even if they're just coming in with just a urinary problem, we always touch on bowels, we always touch on sexual function. We make sure that we address the patient's goal specifically, "What do you want to get out of this visit” first and foremost because that's our goal as well. A lot of times our first visit we're just talking and educating the patient on what to expect for follow-ups, what is the pelvic floor, what exactly would we be doing in follow-up visits to address their issue? A lot of times people come in and say, "I don't really know why I pee so much." "Okay, what are you drinking?" "Two 2L of diet Mountain Dew."

It's like, okay, let's start there. So a lot of times it's just education like okay, what we're putting in our body is not necessarily helping us out in this aspect. A lot of subjective, a lot of education, and then as far as the exam portion goes, we always make sure the patient knows exactly what we're doing and why we're doing it. We'll show them pictures of the anatomy. And the pelvic assessment of the actual muscles themselves usually involves hands-on pelvic floor assessment externally and internally, whether it's vaginal or rectal, not every patient is this appropriate, but we will typically get a lot of information just on that assessment alone and then treat accordingly. But we're also looking at hip flexibility, spine mobility, what is their thoracic spine doing, what's their breathing like, everything, strength, you name it. So lots of things to look at. Typically, we can't get it all done in one visit, so usually it takes a couple for us to really get a good comprehensive view of the patient.

Dr. Scott Steele: So now that you've done that initial evaluation both the questions as well as some of the examination to it, what are some of the common treatment techniques that are used in pelvic floor physical therapy?

Erika Lydon: Sure. So a lot of times we get a lot of questions about Kegels. Everyone's like, "Yeah, my doctor told me to do Kegels. I do them all the time." Well, if they do truly have a strength issue, we'll incorporate the pelvic floor strengthening with that, but it's not just Kegels. Typically, it's abdominal strengthening, breathing, hip strengthening if they're weaker. So we'll kind of just piece together a treatment plan based on where they are currently at. So if they have really weak glutes and really, really weak hips, those are buddies with the pelvic floor, so if those guys are weak, pelvic floor is doing a little bit too much work, so those patients might need down training of the pelvic floor if it's overactive.

So it's all based on how they present. So to answer your question, typically if somebody comes in with weakness, we'll do pelvic floor strengthening, we'll do flexibility work, we do a lot of functional mobility, so we'll get them strengthening in specific exercises like let's say every time I stand up from a chair I'll leak. Okay, let's get you doing partial squats and we'll work up to that until that leakage is gone. We'll teach them how to breathe appropriately, how to use good body mechanics.

And if you have somebody who’s got more tightness and restriction in those muscles, we do a lot of hands-on therapy, so manual work, soft tissue massage, down training or retraining of the muscles to make sure can they get that full range of motion of the pelvic floor so that they're able lengthen in a case where somebody maybe has issues with outlet of the pelvic floor but they can't pass stool very well, their muscles are way too tight. So then for those patients, strengthening would not be appropriate. Typically, we'll work on the opposite and relaxing. So lots of manual stuff, lots of exercise, stretching, all the typical PT stuff but more specific to the pelvic floor on top of the lifestyle education and habit-forming.

Dr. Scott Steele: So truth or myth, pelvic floor physical therapy only helps women.

Erika Lydon: False, very false. We see all genders. So yes, men have pelvic floors too. All genders have pelvic floors. Everybody poops and pees last time I checked. So we definitely address everything and everybody has their own set of issues that they can run into. So a lot of males will see more erectile dysfunction specific to the prostate. Anything can go wrong for anybody down there and anybody could use a tune-up at some point. So yes, all genders. Absolutely.

Dr. Scott Steele: So Erika, you mentioned this briefly, but I think it's an important component of this type of thing, being a colorectal surgeon myself. How do you address any discomfort or embarrassment that patients might feel about either discussing some of these more sensitive issues or undergoing the actual therapy itself?

Erika Lydon: Oh yeah, patient comfort is hands down our top priority. We get consent every single time. We make sure that we are walking them through every step of our examination and our treatment. We always tell them, "This is why we're looking at this, this is the function of this treatment," and we always empower the patient. You have... any point in time if you're getting uncomfortable, you throw a hand up or let me know and we will dial back our treatment to level up with their comfort level. But I think a lot of it is just taking the time and meeting the patient where they're at. So somebody might walk into our office, say, "Whatever you got to do, I don't care. I just want to be fixed," and then some patients may be a little bit hesitant. They've been poked and prodded at a lot throughout their course of their medical journey.

So we really do take the time to meet them where they're at, educate them appropriately and say, "Hey, what reservations do you have for us? What would you like to get done today," and then that could change in every visit. So you might have a patient that was gung ho the first day, but then the next time they're a little bit like, "Okay, I think that was a little too much for me, let's dial it back." So we're constantly having that conversation to address their willingness and their comfort level, but ultimately making sure that they know everybody poops and pees. I think the last statistics I read was one in three women and one in five men will have some sort of issue down there at some point in their life. So very common but not normal and very fixable. And just giving them that reassurance that we're on their team and we are here to provide them a service. So our goals are their goals.

Dr. Scott Steele: So we've talked to many surgeons on this podcast in the past who have actually helped via surgery treat some of the more common pelvic floor disorder. So can you talk a little bit about the relationship between pelvic floor surgery and physical therapy?

Erika Lydon: Yeah, I think that that's something that we are really working towards having a hand-in-hand co-treatment with a lot of these surgeries like specifically what comes to mind is prolapse surgery. So a lot of women in particular will come in with rectal prolapse, uterine prolapse, bladder prolapse issues. Mechanically prolapse usually occurs from shifts in the connective tissue. So are they post-menopausal, have they had several pregnancies and deliveries? Are they operating with maybe suboptimal mechanics?

Like I said, the pelvic floor is a huge component of pressure management and core stability. So if they've been operating at a level where that pelvic floor isn't meeting them where they're at with every cough or sneeze or every bending over to lift a laundry basket, over time that can create a prolapse concern. So teaching them how to use their body pre-operatively and then post-operatively can be really beneficial for maintaining the integrity of that surgical intervention. And that goes for a lot of things. Anything related to prostatectomy, I would love to see more patients pre-op versus post. Bowel issues for sure. What are they eating and what are their habits and what can we change before they go into surgery, so they're set up for success post-operatively? So many things, it just depends on what the patient's coming from and what they're coming in with.

Dr. Scott Steele: So Erika, we talked a lot about your evaluation and treatment once things go wrong, if I'm a listener out there that says, "My pelvic floor is just fine, I don't have any issues," but are there things just like I want to go to the gym and work out my biceps or triceps? Can I work out my pelvic floor when it seems to be doing just fine on its own and I'm a listener out there?

Erika Lydon: Absolutely. I am biased to say that I think everybody should probably get checked out at some point in their life just for preventative measures. And we're getting a lot more of that lately where people are just coming in saying, "I think I'm going to get pregnant next year and I would love to just have a quick check of my muscles to set myself up for success." But as far as if you're just going out there and you want to start involving your pelvic floor, a lot of it is, let's say you go to a Pilates class and they say, "Engage your core," well, your core should include that pelvic floor. So if you're really tightening those abdominals, but you don't really feel anything happening down in those muscles between your legs like I always say, imagine stopping the flow of urine or trying to hold in gas, those are the muscles we want to activate along with our core.

That's a great way to start getting more body muscle awareness as to what you're doing with that bottom half of that core that oftentimes gets forgotten about. So let's say you're at the gym and you're about to do a squat. Okay, on an exhale, can you engage that core as you drop down into the squat and do you feel your pelvic floor active with that throughout the whole movement, things like that.

Dr. Scott Steele: So are there any advancements on the horizon when it comes to pelvic floor physical therapy?

Erika Lydon: Well, I think improving access and getting the right patients to come to see us is definitely coming along. And especially recently, a lot of people are educating them. Social media has been helpful for that. A lot of accounts out there are educating people on, "Hey, this is very common. This is not normal. If you have these issues, go and see somebody." So people are starting to come more to see us direct access just because they read something online, which I'm for.

I'm all about like, "Hey, let's just check you out. I'm glad that you're educating yourself." It comes to treatments on the horizon. We're using ultrasound, biofeedback, we're using a couple more modalities. We do use a biofeedback machine for appropriate patients, which is just an external sensor on the perineum to assess externally what is their pelvic floor muscles doing when they're breathing, are they activating? We do have stem. There are a couple places out in the US that are using laser treatments in their offices. We're not there yet at the Clinic, but at least as far as pelvic floor PTs. But really, I think it's just access is improving and getting the right patients in our offices and people being more proactive. And it comes a lot from the clinicians and getting the right referrals.

Dr. Scott Steele: That's fantastic. And so now it's time for a quick hitter is a chance to get to know you a little bit better. First of all, what is your favorite food?

Erika Lydon: Oh gosh. Depends on the day. I guess I can go with type of food. I'm always down for Asian food.

Dr. Scott Steele: What was your first car?

Erika Lydon: It was a Honda Passport with a steel bumper that I put a couple dings in over the years.

Dr. Scott Steele: Fantastic. What was your favorite trip?

Erika Lydon: Ooh, I did an awesome Euro trip. We flew into Rome and made our way up through Italy, France, and then ended in Spain for a wedding. We had a wedding in Barcelona, not mine, but a cousin of mine.

Dr. Scott Steele: Sounds amazing. And finally, who is or who was your favorite superhero?

Erika Lydon: Ooh, that's a hard one. Whatever one goes invisible or flies around. I don't know. That's always a hard one.

Dr. Scott Steele: The invisible fly-around superhero. I love it. So give us a final take-home message for our listeners.

Erika Lydon: Well, we're here and we're accessible. You do not need a physician's referral to come and see us. We are direct-access clinicians, so we are always available for questions. If somebody's like, "I'm not sure if I need this, do I need to come in? I want to chat this out a little bit," there's always one of us that has time to address any sort of issues or questions that a patient might have. So we're here, come and use us.

Dr. Scott Steele: That's fantastic. And I just want to echo that. So to learn more about pelvic floor physical therapy or to schedule an appointment here at the Cleveland Clinic call 216.444.6262. That's 216.444.6262. Erika, thanks so much for joining us on Butts and Guts.

Erika Lydon: Thank you so much for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.