Don't Pee in the Shower (And Other Things Nobody Told Us) w/ Pelvic PT Cindy Furey

In this episode, Jenn, Karen, and Aliza sit down with pelvic floor physical therapist Cindy Furey for the conversation we all wish we had decades ago. Cindy has a gift for making the complicated feel completely approachable, and yes, she will absolutely tell you to stop peeing in the shower and to quit going just in case!

In this episode we cover:

• What the pelvic floor (bowl) actually is and why it does so much more than you think.
• The important role the pelvic bowl health plays in organ function, abdominal health, and joint stability, especially in hip and lower back comfort.  
• Why normal urinary frequency is every two to five hours (yes, really).
• Tips on how to train your bladder to reach maximum capacity for optimal bladder health and uninterrupted sleep.
• How prompting little girls and boys to pee "just in case" may be accidentally teaching them to stop trusting their own bodies, and what that costs them in body awareness and agency as they grow up.
• The effects of carbonation and caffeine on bladder health and urinary frequency.
• The connection between your nervous system, fight or flight and your bladder.
• The link between TMJ clenching and pelvic floor tension.
• How chronic tension and the freeze stress response can shut down glandular function, leading to dryness, pain with insertion, and why it is not just a hormone problem.
• The 12 second rule: how long you should actually be peeing and what it means if you are done in five.
• Why hovering over the toilet is working against you.
• How de-estrogenization during perimenopause impacts pelvic organ function and floor health.
• Why letting go is sometimes how you gain control.
• The case for vaginal estradiol and personalized pelvic PT.

The bottom line: Your pelvic floor is not broken. It just needs some attention, some education, and maybe a squatty potty.

This is Part 1 of 4 with Cindy. Trust us, you will want to come back for the rest.

Chapters

00:00 Introduction to Pelvic Health Awareness
01:43 Understanding the Pelvic Floor
06:35 Bladder Health and Frequency
11:57 The Impact of Habits on Bladder Control
14:14 Peeing in the Shower: Myths and Facts
19:23 The Connection Between Pelvic Floor and Nervous System
20:19 Understanding the Pelvic Floor and Nervous System Connection
33:01 Exploring Bladder Health and Incontinence
45:22 Conclusion and Future Topics on Women's Health

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Transcript

SPEAKER_01 0:01

Real women.

SPEAKER_04 0:02

Real talk. Real messy. This is Messy Midlife. Hi, everybody, and welcome back to Messy Midlife. Hi, ladies.

SPEAKER_01 0:15

Morning.

SPEAKER_04 0:17

You guys might recognize anybody who's actually happening to watch the video. You might recognize somebody that you've not seen before, a new person to the podcast. So welcome, Cindy. We're very excited to have you joining us today.

SPEAKER_00 0:31

Thanks for having me.

SPEAKER_04 0:33

So I'm going to give you guys just a quick introduction. Aliza, you already know Cindy. You actually have known Cindy longer than I have, even though I was the one who talked her into coming to join us today. So you knew Cindy, who is a physical therapist. You knew her through a friend of yours and also through like professional networking and referrals, right? Send tons of patients to her. Yeah. Uh Karen, you have never met Cindy, but you have heard of Cindy, and I have said something to you at least once that made your brain explode and said, I need to talk to this woman and find out why she is telling you, don't pee as often as you think you need to pee. It's going to be that kind of episode. We're going to talk to Cindy about all of the things that she tells me in physical therapy, including pelvic floor physical therapy, which is how I ended up meeting Cindy in the first place. And so we're going to talk about all of the things that she tells me, all of the things that we need to know as women who are in that certain age in life where you need to start being aware of your pelvic floor. Cause if you're not paying attention to it, it is going to make sure you are aware that it exists and that it needs some help. So welcome, Cindy. I'm so thrilled to have you here and to share all my dirty secrets that we talk about in our weekly sessions.

SPEAKER_00 1:53

Well, thanks for having me. And truth be told, we probably should have learned all this when we were like, I don't know, 16, 20. Because no one appreciates their pelvic floor until it's not working. But that can happen at any age. Yes. There is, there are a lot of changes that happen during menopause. So we'll focus there.

SPEAKER_04 2:16

Yeah. I think that maybe the best place to start, and we're just gonna hammer you with questions as things come up and share our own personal anecdotes of stuff. I think maybe the best place to start is to just set the level, like a level setting of what the pelvic floor actually is. Because I gotta tell you guys, you know, as you guys all know that I just at the end of the day, all I can do is watch Bravo TV shows, right? Like that's I don't watch TV shows. Like all three of you have asked me about have you seen this documentary? And I'm like, who do you think I am? Yes, I have watched the documentary of the real housewives of Beverly Hills, if that's the documentary you're talking about. But have I watched the documentary on what was it, Cindy? The big M or something like that that you you keep telling me about? The M Factor. The M factor. Um, yeah, who do you think I am? You should all watch it.

SPEAKER_00 3:00

If you have not watched it, you really should. Have you watched it yet?

SPEAKER_04 3:04

No, I no, because I watched the documentary of what happens on on super yachts when people charter them for a couple of days and you know get into shenanigans. That's the that's the documentaries I watch. So I because I watch this type of documentary, I have learned that there are plenty of adult women who don't even know what their uterus looks like and probably therefore have no idea what the pelvic floor is. So tell us what the pelvic floor is and why it matters.

SPEAKER_00 3:35

All right. So the pelvic floor is a group of different layers of muscles and connective tissue. And I would argue that it's more of a bowl than a floor. So it's not flat, it's actually a bowl. Goes from your pubic bone in front all the way to your tailbone and back and out to your hips. So it is shaped a little bit more like a bowl. There are different layers. So the urogenital triangle is very superficial. The vaginal opening, urethral opening, and the anus are all considered the anus is the back part of that, but the triangle in front is really urethra, a vaginal opening. Lots of glands there as well. The deepest layer, the levator ani muscles, go all the way front to back. And they make loops around the organs, and they have different functions. I mean, the pelvic floor or pelvic floor musculature does a lot. So it basically has five functions: sphincteric control. So you have control when you laugh, cough, sneeze, when you don't trust a fart. So sphincteric control, sexual function, like I said, that urogenital triangle is glandular, or there are glands in that first layer. Uh, so that's really important. Um, it actually acts as a sump pump. It's very vascular. So it works to improve the circulation of the abdomen, pelvis, and lower extremities. And then it's stabilizing. So it stabilizes our sacroiliac joints and our uh hip joints, and it supports our organs. So it keeps them from falling out to a certain extent. Although our organs are supported by other connective tissue and ligaments. We don't really think about ligaments when it comes to organ function, but it's a huge role. So people think of ligaments when they sprain their ankle, they blow out their ACL, but your uterus, bladder, rectum, all held in place, our little ovaries held in place by our ovarian suspensory ligaments. So there's ligamentous structures in the pelvis itself. So the burden of organ support isn't necessarily entirely on the pelvic floor, but it does play a role in organ position and support.

SPEAKER_04 6:02

So basically everything. We need it for all of the things.

SPEAKER_00 6:05

It's the base, it's kind of our root, right? So we need a strong pelvis. So our legs work well, so our back works well, but so our, you know, our end functions for bladder and bowels work well too. Yeah. And they and the pelvis itself comes in different shapes and sizes, as does the muscular control, flexibility, strength, stiffness. So uh pelvic PTs take into account every person's anatomy. And it's it can vary a lot.

SPEAKER_04 6:42

So let's answer the question that that Karen had initially, which was what why should I not pee very often? And what if I drink a whole lot of water?

SPEAKER_00 6:52

Okay, so let's talk specifically about bladder. Normal bladder frequency or urinary frequency is every two to five hours for women. Two to five hours.

SPEAKER_04 7:05

Karen, I can't believe you didn't like lose your like mind with that when Cindy told me that the other day, because I asked her because I was like, okay, we're gonna have to ask you this because Karen about fell out of the chair when I said, My physical therapist would say don't go pee right now. And and I said, How often should you be peeing? And then when she said this, I nearly fell off the table while she was stretching my leg in some crazy position. And and I was like, Are you kidding me? Really? And and I said, How long is it like, how long do you go? And she told me I was seeing her at like 12 30. And she's like, Yeah, I last peed at like eight o'clock. What? Yeah. And I'm like, Are you super dehydrated? She's like, Oh, I mean, I'm probably a bit bit dehydrated at this point.

SPEAKER_00 7:44

Let's get back to like why it's important not to pee all the time. So the bladder and pelvic floor work on an opposition, an opposition reflex. So the bladder relaxes and fills as the pelvic floor contracts. Okay. So it fills, it fills, it fills. As the bladder gets about halfway full, and the bladder usually can hold four to six hundred cc's of fluid. When it gets halfway full, it says, hey, gives us a little signal, we need to go. And I'm in the middle of a podcast right now, so I can't go. So my pelvic floor contracts a little bit more and squashes that reflex. For the next two hours or is however long, an hour, it relaxes and fills, relaxes and fills, relaxes and fills. It's like a muscular balloon. Then when we sit down and go to the bathroom to pee, we let go of those pelvic floor muscles because we're sitting down all the way and really relaxing and giving ourselves time to go to the bathroom, then the muscle, the trucer muscle, the bladder will contract all the way so that we can pee. Right. But if you go more often, we call it a jick, adjusting case pee, and you go every time you have the first urge, then your bladder never gets to that four to six hundred cc's. Remember, the first message is about halfway. So if you go at first call, then your bladder's gonna shrink in size and it's gonna be a 300cc bladder. And half of that is 150, and half of that is 75. So I'm sure you guys have had clients, they're like, oh, I had a small bladder. I was just born with a small bladder, but were they, or were they trained? And so their bladder as a muscle never stretched. It is a muscle. Just like you can stretch your hamstrings or your calf, you can stretch it out. So I never want people to get in the habit of going every hour because every hour all of a sudden turns into every half hour, turns into every 15 minutes. And that is life disruptive, right? They can't sit through a meeting. They can't go, they can't travel, they can't, they can't go in a car or in a plane. They're like freaked out. And then they get anxious about it and it gets even worse. Um, or worse than that, I think, is they can't sleep at night. But interestingly enough, people that have the habit during the day don't always have that habit at night. It's one of the things in pelvic piti. I'm like, okay, so you're paying 16 to 20 times a day, which is way over. We should be peeing five to seven times a day. But what some of my patients will come in and they'll show me their bladder diary and they'll pee 15 to 20 times a day. But then at night, they sleep eight hours. Like, what are you doing? You're going just in case, and you've kind of trained yourself, but your bladder has an eight-hour capacity. That's crazy, that's amazing. So talking to people about that kind of helps them understand what their normal bladder function is. But you shouldn't go just in case. But we train little girls this way, right? So when little girls and little boys are potty trained, totally different. Totally. So, boys, you know, you take a little potty toddler to a park and dad'll take the kid behind a tree and pee, right? But girls, it's like, oh, we got to go to the bathroom before we go to the park. Oh, we got to go to the bathroom before the game. We got to go before the movie. We got to go right after the movie. We prompt little girls a lot more than we prompt little boys. And I think that's like that's an early habit. Things have changed, things have improved because now super moms will just bring a little potty in the back of their car, but we still I feel like we shouldn't be prompting little girls as much. And we shouldn't prompt ourselves as much and just really really kind of keep an eye on the clock, you know. Has it been two hours? Has it been three hours? But we should wait two to five hours is normal.

SPEAKER_01 12:10

Now if you drink caffeine, that's a little different too.

SPEAKER_04 12:14

Yeah.

SPEAKER_00 12:15

Or alcohol.

SPEAKER_04 12:17

I've been more conscientious of it, and I've actually been paying attention since we had that conversation with where you gave me like the window to see how often I'm going. And and I have been challenging myself sometimes when I'm like, okay, you could go, but do you really need to? Like, do you really need to? And I'm glad you brought up the little girls because I'm totally guilty of every time we leave the house, if we're gonna go on any sort of car ride, you gotta go. And we're all gonna go. And I've been trying to be less like vehement about that in the last couple of weeks with my daughter. If she says I don't have to go, I've been trying to do a better job of listening to her.

SPEAKER_00 12:54

Yeah, it's just it's we want her bladder to be able to expand. We also want them, little girls, little boys too. We want to get them in the habit of learning what their body feels like. If we're preemptively going to the bathroom to pee, then we don't know what it feels like to be full.

SPEAKER_04 13:14

Is this any is this in any way uh connected to like the us not knowing our whether we're hungry or not? And like the feelings of fullness too? Like, is this just another extension of that?

SPEAKER_00 13:26

I sorry, could be.

SPEAKER_04 13:29

My head was blown because there's so many ways that we are disembodied and disconnected from ourselves. And I'm just are we inadvertently training our little girls to not understand their normal cues of other things in their body just because we're trying to potty train them and not have to stop at a gas station.

SPEAKER_03 13:47

This is be a whole other podcast in and of itself, but we are trained definitely to ignore our body signals, right? Are we hungry? Are we not? Well, we're not supposed to eat, right? It's better to be hungry and not eat because you'll stay slim, right? Is part of our body hurting? Well, it's fine, you just push through it. Like you push through the pain, you don't worry about it, right? On every level, we're taught that we just push through and we just do what we're supposed to do. And so I do think there is a connection there. Cindy, I have a question for you that from what Jen told us one time, that we're not supposed to pee in the shower.

SPEAKER_00 14:23

Definitely not pee in the shower.

SPEAKER_03 14:25

Tell me about that. Sometimes I'll be like, I'm not gonna go because I can't wait to get into the shower to pee.

SPEAKER_00 14:31

I would rather have you go to the bathroom and pee before you get in the shower. There are four loops of bladder control. There are four loops called Bradley's loops of control. One is the important one: mind over matter. So we have cortical control. We have brainstem control, no control. I mean, we don't have volitional control. That's a reflex. The sphincters should just hopefully work. We have sympathetic, fight or flight, the nervous pee, the nervous poop, the running water. I actually don't know if the running water is in brainstem or sympathetic, but then we have our pelvic floor muscles. So we have the spinal control. So our pelvic floor can contract and our bladder relaxes. So if you have to pee just a little bit and you hold and hold and hold that pelvic floor and prevent yourself from peeing in the shower, yay, you just did an exercise. But if you jump in the shower and you get the urge to pee and you just let it happen, then it's gonna happen more often. And when you wash your hands, it might happen. Or when you're in the grocery store in the veggies section and the water spritzes on the vegetables, it's cold water. And if your hands are in it, oh my gosh, you're gonna have to pee in the middle of Trader Joe's. So I prefer people not to pee in the shower. And I know that there are practitioners out there, and my patients have told me, oh, my doctor says it was fine. I'm like, no, it's not fine. It's like Seinfeld. Remember, George, he's not supposed to pee in the shower. You're not supposed to do that. But it's it's really because it's habit forming. So I don't want people to, you know, they're doing dishes, then they turn the water on, and all of a sudden they get a huge bladder urge. Or and again, the grocery store thing, that's real. I have definitely had people say, look, I can't go to the grocery store. So what they do is they do a just in case pee before they leave the house. But now they've spun up their nervous system. And again, that sympathetic fight or flight, I'm nervous. Oh my God, am I gonna be anxious? And what if there's a line at the Trader Joe's bathroom? You know, they get, or what if it's gross? You know, they they get all nervous. And then that spite spins up the anxiety. It makes the urge worse. So don't be in the shower. Make your muscles work harder to suppress the urge. Or if you know that, look, it's been two hours, I've had a cup of tea, I really do need to go, just go before you get in the shower so that we're not exciting that reflex. It's this weird rudimentary reflex. I don't know why we have it, but but we have it. I mean, some teenagers used it from sleepovers. Did you ever do that? Sleepovers, you'd put your hand's friend, put your friend's hand in some water, and you see if they would pee while they were sleeping. Terrible things we did to each other. We tortured each other as teenage girls. We really did. But that's another story. But I don't know why we have the reflex, but it's still there. But I don't want to spin it up because it's a slippery slope. And bladder urgency frequency, oof, it's a doozy. It is a doozy. And it happens to both men and women. And there are other reasons for that, like all the caffeine. The caffeine, alcohol, other bladder irritants can really spin up the urge as well. So it's important. High sugar, artificial sweeteners, there's all these things that irritate the bladder. People think they're being healthy, and it's like, well, you had a diet, whatever, and that's an irritant too. Bubbles, that's another thing. So it's important to be aware of what we're consuming and our reflexes, but really don't shower.

SPEAKER_04 18:24

Bubbles are an irritant to the bladder.

SPEAKER_00 18:26

Bubbles can be, and plus, they're just not good for us. I mean, carbonated drinks also have high phosphate levels. It's bad for your bones. Leech is the calcium. I mean, it's not great. Not great. Plain water is better. You know, naturally occurring bubbles from France are probably better than water actually does taste better in France, just so you know. But everything tastes better. Yeah, everything tastes better in France, right? But anyway, I'm not a fan of bubbles. Not bubbles all the time. Bubbles once a day, fine. But people that are drinking carbonated, the fancy water. Topo Chico, bubbles aren't the greatest for us. I'd rather have us just drink water.

SPEAKER_01 19:11

So, Cindy, you mentioned the uh fight or flight, and I am really excited to talk to you about how the nervous system shows up for us in our pelvic floor. I learned a while back, I think I think I learned it from a reputable source, but I would love to hear what you have to say about this, that TMJ uh grinding and and jaw tension can be linked to the pelvic floor as well.

SPEAKER_00 19:36

So there's a lot of overlap. Um, I'm a clincher, so I know this well. Live, I live it, I clench for world peace. And if you haven't noticed, we're going to hell in a handbasket. So my jaw is actually killing me. I have tried all the appliances. I've tried hypnosis, and man, I am just a clencher. But there is a very high, high correlation between pelvic floor clenching and TMJ clenching. But back to your first part to that question was the nervous system. So I mentioned fight or flight, but there's also freeze. So we added that third one in a few years ago. So we're either running for our life, right? We're fleeing, we're fighting really hard. Our body can turn on itself and we're literally fighting. I mean, think autoimmune type things, or we might freeze. Uh, we might disassociate, uh, we might get locked down. Uh, but in the pelvic floor, you're either it could lead to bladder urgency, that fight or flight. Oh my God, I gotta, I'm so nervous, I gotta go. So calming the nervous system, taking deep breaths is super important. Learning um how to put things in perspective. Do I really get nerve have to be that nervous before I'm doing a podcast with three other super cool women? You know, I gotta chill myself out. But freezing is also an issue. So that can lead to actually urinary retention or constipation or both. Freezing is not great for us either. We can get stuck, our systems get stuck. We need things to move through us, you know, all the things that we're drinking and eating, all that needs to go through us. We need to, you know, digest and rest and absorb. And if we're not doing those things, we're gonna be malnourished in certain ways, but it can lead to a host of all other kinds of issues. Constipation's a big one too, huge problems, which can eventually lead to prolapse, hemorrhoids, fissures, all kinds of issues. But the stress levels. I talk to my patients a lot about stress. Why are we stressed? Is it self perceived stress? Are we doing this to ourselves? Are we watching the news? Are we doom scrolling? What is the stress? Is it old stress? Is it PTSD? Is it past trauma? All that plays a role in our health. Um, and it can lead to pain as well, dysperonia. We treat that a lot, uh, just pelvic pain in general. Dysparunia is technically pain with insertion of anything. So fingers, tampons, speculums, the occasional penis. But it could be super painful if we're holding, right? And those holding patterns can also lead to decreased glandular function. And then we will go through the whole dryness and and tearing, and then our our tissue changes, and there's so much. But as far as the nervous system goes, we focus a lot on how to calm things down. First, I think it's important to evaluate why, why we're so stressed or nervous, and then help my patients kind of work through what they can do to balance that stress or anxiety. Um, and certainly I recommend a ton of resources when it comes to um other practitioners who can help in that department. From good dentists and TMJ, hypnotherapists, you know, psychotherapists, LMFTs, there's so so much bio other biofeedback therapists that might be able to work on heart rate, down regulation, breathing rate. We do some biofeedback too, but um, there are other forms. So yeah.

SPEAKER_04 23:35

Does it go both ways though? Like, is it is it always your nervous system affects your pelvic floor, or can your pelvic floor affect your nervous system?

SPEAKER_00 23:45

It's a loop. So they just go round and round and round and they spin each other up. Back to should I pee in the shower? But if every time you now walk into Trader Joe's, if you have one bad experience with bladder urgency, most folks don't want to repeat that experience. So then they're nervous about walking into the grocery store. They're nervous about going out in the rain, they're nervous about long lines at at the stadium because are they going to be able to hold in time? So that spins up the anxiety, but then you have more anxiety and stress, and then it amps up your nervous system and that that pelvic floor scenario kicks in again, and then bladder tends to have a mind of its own. Sometimes the bladder can be a bully, it gets spun up in that sympathetic system. And I've had a I had a patient years and years ago, and she said, My God, my bladder is a bully. It's totally a bully. Tells me what to do all the time. So a lot of it's about taking back control over the bully and making sure that, you know, we have control. We have control over our pelvic floor so we can control our bladder. We have control mind over matter. We have to tell ourselves, I am calm, I am strong, I will stay dry. We have to give ourselves some mantras, um, you know, and then we have to calm our breathing to calm our fight or flight, right? So we have volitional control over three of the loops. It's just that fourth loop we don't have control over. So we do our best to control the other ones. And luckily we have these loops, right? If it was all in one, man, we'd be screwed. We have backups. So if the pelvic floor is weak, that's another reason we can get bladder urgency and frequency. If the muscles themselves are weak, that's being a little bit more.

SPEAKER_04 25:40

We're gonna ask you all about cagles in a minute. I feel like, yeah, we got there's so much to talk about with cagles.

SPEAKER_00 25:45

There's so much to talk about, right? But if your pelvic floor muscles are actually weak, your bladder might be perceiving that as a, oh, she's already relaxing. You have to be strong enough to hold those muscles up to squash that reflex of the bladder so it can relax and fill more.

SPEAKER_01 26:02

Thinking about you mentioned the urinary retention. Could incomplete evacuation also lead to frequent urge to urinate?

SPEAKER_00 26:12

Like absolutely.

SPEAKER_01 26:14

Yeah.

SPEAKER_00 26:15

Yeah.

SPEAKER_01 26:16

That makes sense.

SPEAKER_00 26:16

Tons of people. So again, our back to the bladder urge and and that pelvic floor, right? So a very basic model, right? Our pelvic floor contracts, our bladder relaxes and fills. Okay. If we go at the halfway mark, is our bladder on full stretch? Nope. What if we're in a rush because we just went and our kids are in the room next door? Now we're bearing down and we should never bear down to pee. Ever, ever, ever. Ever, ever, ever. Don't push when you pee. The only time we push, we're pushing babies out, and we might have to push to initiate a bowel movement, but only initiation. So we never ever push. But if we get stuck and and we're we're going when it's only halfway, and then we're bearing down, you can push your organs out of position because you're forcing the emptying. And then things can get kinked. And then you didn't really empty, and you know you didn't empty. So then you're nervous about the fact that you didn't empty. And again, it's another one of these horrible loops. So then you're gonna sit back down and work a little bit, and then you're gonna be like, okay, now I'm gonna try again. Oh, I want people not to try too often, you know? And again, back to listening to our bodies and our signals. Do you know, do you really have to go? Or are you just going just in case? Now, some people do wait too long, our teachers and our nurses, because you know, you can't leave kids in the classroom by themselves. So those poor teachers, sometimes they don't go all day. And that can lead to a whole other thing, which thankfully is much more rare. But the bladder can actually get overstretched and then it loses the sense, the stretch sensation. So then they never feel the need to urge, they never feel the need to urinate. They never get the urge. So then they haven't peed for eight to ten hours. It's not great. Because that's much, that's actually much harder to treat. Because those gals sometimes have to catheterize and it's a whole, again, a whole other Oprah. But yeah, we we definitely wanna make sure we're on the two to five hour interval. And I like people to pee for at least 12, 15 seconds, up to 30 seconds. If you go to the bathroom and pee and it's only five seconds, you did not need to go. You did not. That was adjusting case. That was a nervous system thing. So count seconds when you pee.

SPEAKER_01 28:58

Okay, okay, okay. 12 seconds. Okay, so this means that this means I'm okay. Cause my I am definitely over the 30-second mark each time. I mean, sometimes I add to this is kind of a funny story. Was at my son's soccer game this weekend and had to use a porta potty. So it was a squatty potty situation. And I counted because I'm like, this is miserable. And it was almost two minutes. So, all right.

SPEAKER_00 29:24

So that's a problem too, though.

SPEAKER_01 29:27

Well, sorry, Karen. That was I was trying not to have to use the the porta potty is the issue. I was like, I can make it, I can make it. And I was like, nope.

SPEAKER_00 29:34

Okay. So there's a big difference between squat and hover. You were hovering over the porta potty, right? In many rural cultures, they squat. I went to China a few years ago and they had squat pots. You squat all the way down. In a squat position, your pelvic floor reflexively relaxes. That's why we birth babies in those positions. That's why we, it's an easier defecation. We want to squat. That is way different than a hover because a hover, your muscle, your pelvic floor muscles are holding you up. Remember, I said it was like strength and stability of your pelvic floor and your hips. So they're holding you up. So you're not getting the full relaxation. So your bladder isn't getting a good contraction. You just slow down the reflex. I will say portapodties are my only exception to sit your butt down because they're gross.

SPEAKER_04 30:35

You need to do it, what it says not to do on all of the like harbor cruises here in San Diego, where they've got the pictures of people actually standing on the toilet to squat. Apparently, that's what I'm saying.

SPEAKER_00 30:45

Standing on the toilet, yes. Yes. And a lot of when I travel in airplanes too, they will have those pictures of people squatting on the toilet. But it's it's mechanically, that's how we're designed. So it is actually functionally better for us to squat, not to hover. Hovering is bad. And it's it's a bad habit. I'll tell you one time there was a I was giving a talk at UCSD. It was grand rounds, and I was talking about these things. And my colleagues who I know really well, all these physicians, Eurogynes, urologists, OBGYNs, they're all in the audience going, and I afterward, I was like, ladies, what the heck? What were you talking about? They're like, we all pee every hour. They're so super caffeinated, these poor physicians, and they never let their butts hit the toilet because they're going so often. So they're hovering, they're going too often, they're drinking too much caffeine. It was eye-opening to me, just like that world of fast medicine, right? They don't, they don't have time for self-care, right? They're they're working long shifts, they're just drinking caffeine all day long. So they're continually dehydrated. Anyway, even even the the higher up professionals have issues. But yeah, so Karen, be careful because you shouldn't be peeing for two minutes. Should really be 30 to 40, maybe 45 seconds. But I'm proud of you for counting, though.

SPEAKER_01 32:21

It was it was a a tool, I think, to not give up.

SPEAKER_00 32:26

So the other thing to do, take deep breaths and see if you can let go more. Right. But when people have issues when they're peeing too long, like can't make it happen, anxiety that's that freeze. They get they get stuck. So you gotta take those deep breaths, try to relax. I'm a huge fan of the squatty potty, by the way. Huge. I wish I would have invented it. I've probably sold a million of them. Recommend it all the time. All the time.

SPEAKER_04 33:12

I've got just a, I think a couple more questions and Lisa and Karen, if you guys have any more about the urinary stuff, since we've managed to stay on topic. And then I think we'll wrap up and have you um join us again for another episode on one of those other two topics. So I'm hearing a lot of things that are explaining why women, regardless of whether they've given birth, because we always just think, oh, you give birth, you're gonna pee yourself for the rest of your life. Which I know, like Cindy, you're like, no, you don't have to. Come on, you can fix this. There's things that you can do. So it's not a guarantee. You can give birth and not pee yourself. I gotta tell you guys, I went to this is a little bit of an aside, but totally relevant to what we're talking about. I went to one of those early bird dance parties for like old women where it starts at six and it's in you're done by 10. Women who are dancing around to music from the 80s, 90s, and early 2000s and were jumping and jumping and everything. And all I could think was how many people are peeing themselves right now. And I had told Cindy that like the next day, because I saw her the next day. And I was so proud of myself because I didn't. And I was like, oh, this is amazing. There was no like issues that came up. So it doesn't happen. And the trampoline parks in other places. Right. Yes. Um, it's not just women who've given birth who have issues. I've got plenty of friends who've never given birth or who've had C-sections. So it's not just about whether a baby tears through your pelvic floor that can lead to pelvic floor dysfunction and perimenopause. You've shared a lot of the habits, like the lifestyle things that can contribute to weakening our pelvic floor or changing the way that the nervous system is connecting and signaling different things that can shift how our continence is. We can also end up with bladder prolapse, which, you know, full disclosure, I've got a small bladder prolapse that Cindy has been working with me on and helping me with as well. And one thing that you did say, don't push, but you can tilt if you need to. So tilting is okay.

unknown 35:05

Yes.

SPEAKER_04 35:06

Pushing is not.

SPEAKER_00 35:07

Pushing is not.

SPEAKER_04 35:09

So just somebody needed to hear that. You can tilt, but you don't push. Are there other things that contribute with in the perimetopause place to pelvic floor instability that contributes to urinary incontinence?

SPEAKER_00 35:20

Yeah, so we talked about weakness, but there are women who are high toned. So clenchers, clenchers. We can have a high-toned pelvic floor, but remember, remember, I said that the there's that opposition reflex. If your pelvic floor is on all day long, and then your bladder relaxes and fills, relaxes it fills, it gives you the urge. But then you have to contract more to squash the urge. But if you're lifted all the way, there's no differential. So you won't get a clear signal to the bladder. So some of the some of my clients, I have to teach them to let go to gain control. It's this crazy concept because once you've had an issue with your bladder when it comes to control, no one wants to let go. It's very hard to get comfortable letting the concept of letting go to gain control. But we need a differential. Our pelvic floor, as we sit here, should be working 10 to 20% of max. As we go on, and Karen drinks more water and Jen sips more tea, and I sip more tea, and Elisa, and I'm not sure what you're sipping on. But as our bladders fill, then our pelvic floor should come up. But if it is up all the time, then there's no nowhere for it to go. So that can also lead to urgency and frequency. Um, positional faults. So you touched on prolapse. That's a, again, that's a whole other topic, but our organs are held in position. So if organs get out of whack, um, it can lead to higher frequency or issues with urinary retention. Sometimes some of my gals come in post-bladder sling, but now they have urgency because all those years, their bladder, instead of this is the front here, our bladder is kind of up and forward. But at some point, with age, with birthing babies, with lots of exercise, with chronic constipation, if our bladder goes this way, it's kinked. So the internal urethra sphincter and maybe part of the urethra itself is kinked. And so the physician does this fantastic surgery, putting everything back in position. But now the bladder's like, what the heck? I haven't been here in so long. So then we have to retrain that. But thankfully, those patients actually do really well, but it's getting used to how to what it feels like again because they just haven't had that feeling of fullness in so long with their organs being back in.

SPEAKER_04 38:15

Yeah, there's changes in our hormones that impact our tendons and how the strength of the tendons that can change things too, right?

SPEAKER_00 38:21

Remember, menopause is not just de-estrogenization, but also we lose our testosterone. So here we are talking about muscle control and building muscle and strength. But we ain't got no testosterone anymore. So it's harder. So we really do need to focus. And it's not just the strength of the pelvic floor muscles, it's the strength of our hips, the strength of our abdomen, and it's how we use them, not just how strong they are, but but how we are actually functionally using them. But with deastrogenization, um, there's the urethra sphincter. It's this plump little, little, little teeny tiny pinpoint sphincter. And when we have all of our estrogen, ooh, it's juicy and full and and seals nice and tight. But as we deestrogenize, our tissue dries, it atrophies. Without the testosterone, it gets weaker. And ladies, it is definitely use it or lose it. But at the urethra sphincter, all of a sudden, it starts to open more because it's not as plump and juicy as it used to be. So that's perceived as relaxation by the bladder, and then you're going to get more urgency or leakage or lose it when you laugh, cough, sneeze, more of the stress incontinence. So if we can plump up that external urethra sphincter with a little topical estradiol, it goes a long way, a long way. I'm a huge fan of vaginal estradiol. And then doing the right exercises to strengthen what we can. So we can strengthen our pelvic floor and use our muscles correctly. But everyone's different. So that's why I, you know, when people come in, I really do a thorough exam because all of our anatomy is different. And you can say you're doing kagels. We don't really call them kaggles anymore, but pelvic floor muscle exercises. But uh, you might not be doing them right. There's quick ones, there's slow ones, there's eccentric loading, there's timing.

SPEAKER_04 40:27

You might be doing them too much when you need to be focusing more on the relaxing, too, and you just don't know.

SPEAKER_00 40:33

Yeah, you gotta have the differential. But you don't know that until you get an exam. So typically some exercise is better than none. And I know, I mean, thankfully, there are a lot more resources out there. There are podcasts, there's there's Instagram, there's TikTok, there's all this stuff on chat. When I first started doing it, we didn't have computers. That's how old I am. So we didn't have the resources. Now we do have resources, but some of those resources might be giving you things that might not be designed particularly for your specific needs.

SPEAKER_01 41:09

Hallelujah.

SPEAKER_00 41:10

Like the two and a half minute pee that Karen had.

SPEAKER_01 41:14

Hallelujah, Cindy. I love that you're talking about that. There's so much great information out there, and the personalization of medicine is so important. And that your assessment is going to help identify: is it two-toned? Is it not toned enough? Do you have a weird kink going on because of maybe a tilted uterus or I don't know, whatever might be happening? So that's so important.

SPEAKER_00 41:39

And a lot of what I do is it's a lot of education. I mean, I do a super thorough exam. I mean, standing up, posture, range of motion of everything, flexibility, core strength. And I have the luxury of seeing my patients for 30 to 40 minutes. My patients could be in the clinic an hour, hour and a half, depending on if they're doing exercise afterward. But physicians are on a time crunch. The lucky ones get 15, 20 minutes. So I take what the physician has told the client, and I definitely get calls from my colleagues. Can you please explain why she would benefit from blah, blah, blah? And I have the luxury of hitting it again and again and again because I see my patients weekly. So I get to talk to them about why estradiol is safe vaginally. Even as a breast cancer survivor, you know, I can still use vaginal estrogen. But other people, you know, people have to be comfortable with the prescriptions that their physicians offer. But I can explain it in a way where they might just understand it better and therefore take whatever advice it is. A pessary, you know, more exercise, changing medication, you know, more fiber in their diet. You know, the physician told them that they need to improve their bowel regularity, regularity, but they may not have had the time to explain how we get there, right? Or why you shouldn't pee in the shower, or why you shouldn't hover, you know. So I do have the luxury of seeing my patients, you know, time and time again. So after a few sessions, I've hit on all the points that they need.

SPEAKER_02 43:26

Yeah.

SPEAKER_04 43:27

All right, ladies, we're we're reaching the end of attention spans for a lot of people on this particular topic. But do either Karen or Elisa, do either of you have any other questions?

SPEAKER_03 43:36

I mean, I have one silly question, which is um, is there any reason women shouldn't use like the funnels to pee when you're standing up?

SPEAKER_01 43:45

Oh like the Shiwi. Yeah, like the camping Shiwi.

SPEAKER_00 43:50

So I'm not a fan of the position. That's the only thing. You know, I want if you're camping, can you just go squat and do it and not stand and do it?

SPEAKER_04 44:00

But other than that, I I'm Well, if you have to choose between squatting, if you have to choose between a siwi and a hover, would you choose you would choose a siwe? Shiwi.

SPEAKER_00 44:10

I guess, but I just wouldn't want it to be a habit, right? If you could again, if you could squat versus stand, that's what I would do. Squat with the Shiwi versus stand with the Shiwi. Because I don't want anyone in the habit of standing to pee. Guys can do that, but they're designed differently. We are not designed to do that. And if you if you do that once or twice, will your body get in the habit of going, oh, she did that before. She brought that little thing out. But what if you don't have the thing? What if you don't have the Shiwi and your body's going, but we're standing, but you're almost at the bathroom, but you didn't quite get there, then you can again spin up some of these bad habits. So when you're camping a couple times a year, just see if you can squat when you do it versus stand. That would be my take. But it is better than hovering. But if you're out in the woods, I think you can pee behind a train anyway. Yeah. But squat all the way down. Don't hover. Squat, squat, squat.

SPEAKER_04 45:12

All right. Well, I think we'll wrap for this episode on the urinary health implications of getting older and perimenopause and all the things that we've already talked about. So, Cindy, let's have you backed so we can talk about bowel health and sexual health too in the next couple of episodes. Sound good, everybody? Sounds great.

unknown 45:32

All right.

SPEAKER_04 45:33

Thanks for having me. Take care, everybody.

SPEAKER_01 45:34

Thanks so much, Cindy. Bye. Bye, guys. Love you guys. Love you. Bye. If our messy is your kind of messy, we'd love for you to rate, review, and follow or subscribe wherever you get your podcasts.

SPEAKER_02 45:49

We'd also love to know what's on your mind. If you were to join us, what would we be talking about? Email us at messy midlifepodcast at gmail.com or message us on Instagram or TikTok.