Understanding Pelvic Health with Kim Tonovitz, DPT

In this podcast join Jill and DPT Kimberly Tonovitz in our discussion of pelvic health and how we can age while still maintaining our continence and our quality of life. Kim is a DPT at Thompson Health in Canandaigua NY where she works with women and men to regain and retain their continence and sexual function. Fifty four percent of women ages 20 and up state they have had some kind of leakage in the past year. 

You will learn:

• The causes of incontinence and why it doesn't have to be a part of aging
• How does taking care of the musculature of the pelvic floor help to decrease kinds of incontinence and maintain sexual function as we age.
• What are some things you can do today to help yourself maintain your continence
• How to connect with someone who can help you get back to controlling your continence. 

If you want to connect with a Physical Therapist in your area, reach out to your provider and tell them what you're experiencing. Don't be shy or afraid that you are the only one who is having these concerns. This happens to lots of people, men and women, and there are ways to get better and strengthen or relax your pelvic floor. A specialized PT can tell you what your main issue is and prescribe you an exercise plan to get back where you want to be. 

Yoga is another way to relax and strengthen your pelvic floor with deep breathing and relaxation. 

Want to engage with me. Visit my website www.closedlotusyt.com or my you tube channel Yoga for Aging and Menopause. 

Transcript

0:31

I'm gathering up to some of the most knowledgeable ones I've had. If you like the podcast and want to know other things I'm doing, visit my website, CloselotusYT.com, and subscribe to my newsletter. Let's get into our episode. Welcome to this episode of Finding Balance and Menopause. My guest today is Kim Tennevitz. She is a doctor of physical therapy at URMC Thompson Health. She has a certificate in advanced um advanced practice in pelvic health and obstetrics. She's been working for 26 years as a physical therapist and has been 15 years now working specifically with pelvic health. She trains other physical therapists to work with this population and is also a mother of three. So thank you for joining me today, Kim. Thank you for having me. Yeah. The reason for my interest in pelvic health is obviously as a woman going through perimenopause, I really want to avoid having to use an incontinence product, um, you know, having other things happen. Um, personally, I have um I'm I have people in my family who have started to experience some side effects of aging with relates related to their um incontinence, um prolapse, and other issues. And that's really opened my eyes to wow, I do not want to be in that position when I get older. Um I also had worked a lot with people who are medically frail, um, who have a lot of contraindications like diabetes, heart disease, um, a whole host of different medical issues who also have to rely on incontinence products. Um, you know, it's so it's wasteful, it's um uncomfortable, you know, it's just really there's so many reasons that people should avoid getting to that stage. And it shouldn't be um like a natural part of healing, uh part of aging, I feel like. You know, it's not supposed to be that way. So um as we age, as you know, that we are more likely to have those issues. So that's why we're talking about it today. Um, so maybe you can start a little bit by telling us a little bit about you. And um, I know you also are in periomenopause. Maybe you can just tell us a little bit about um how you came to focus on pelvic health and then about your um how you're kind of, you know, that's showing up in your own life. Absolutely, yes. Well, first of all, I love that you mentioned that incontinence and these symptoms that many of us begin to experience are not normal because they're not. Uh I think too many people feel like, oh, well, I had, you know, a couple kids. And so of course I dribble when I cough or I sneeze or I laugh. But no, it's actually never considered normal or to be expected at any stage of life. So it's really great that we're now talking about this. Um, and you know, trying to be proactive if we're not having symptoms, trying to prevent them from occurring. Um, so yeah, my journey. So, yes, a mother of three. I have three amazing, I'd say kids, but actually two of mine now count as young adults. But uh I had three very different birth experiences with all three of my kids. I'd say my firstborn was the most challenging delivery I underwent, and that did leave me with some pelvic floor trauma. I had what they call a third to fourth degree tear during my vaginal delivery. It was a vacuum-assisted delivery, so they needed to assist the birth process. And I did, I tore pretty horribly. And at the time, I was a physical therapist, but I was not yet specialized. So the very beginning of my educational journey for this, I will admit, was a bit of a selfish pursuit. I was kind of trying to help myself heal and feel strong again and be able to go back to doing all the things I liked doing and leading up active, healthy lifestyle and not be suffering from incontinence. So, yeah, initially it was a bit of a pursuit to help myself. And then through that journey, I got hooked. I saw the need and uh the need in our community, especially where where we're located. There was not many therapists, if any, uh doing that around us. So that kind of got my journey going in that direction. And then, yes, as I've entered that lovely stage of what we're now calling perimenopause leading up to menopause, I have begun to see changes in my own body that I am not loving. And it's, you know, definitely a time to be aware and acknowledge what you're feeling and experiencing and knowing the best ways to care for yourself so you can prevent some of those common problems. So, yes, in myself, I've seen an uptick in my urinary urgency and frequency. I have to be more mindful of how many trips to the bathroom I find myself making in a day because that can be a slippery slope. Um, I'm a casual, I'll say runner. I do run on a regular basis, and I did start to notice that I was leaking a little bit, especially at certain stages of my run or with certain distances. And so I had to make sure I was getting on my own advice and managing my deep core and pelvic floor as I need to to help manage that. So yeah, yeah, there are definitely these common things that we experience in this stage. And there are things we can do to help and prevent, or if we are experiencing symptoms, make them better. Yeah, I think I think so many things come out of our own pursuits, right? I mean, um, I my own self as an example. I started yoga therapy because I wanted it for other people. Um, and or and then I and then it kind of I guess it was reverse. Like it, I started wanting to take help other people and ended up helping myself. But you know, in doing this podcast, it really helped to give myself information about these different parts of menopause and different ways to manage it. So that's definitely um, I think that's pretty common that people start off in those selfish ways and then end up sharing that. So I'm so glad that you did. Yes. I mean, it really helps if you're empathetic with those you're working with. It really makes a big difference. Yeah. So the women that you work with, what kinds of things do they how do they present with to you? Like what is it that their main complaints are? So if we're talking specifically kind of in this perimenopause and menopausal group, I see a lot of women that are struggling with what's commonly referred to as overactive bladder, which is an increase in urinary urgency and frequency. That's probably, I'd say, the most common symptom I see. And then as that evolves, sometimes we start to get incontinence. Now, incontinence can occur in a few different ways. There's what we call stress incontinence, which is leaking with things like coughing, sneezing, laughing, running, jumping, basically high pressure situations, creating pressure in your abdomen and then leaking urine as a result of that. Then there's also urge incontinence where you feel a strong urge to urinate and urine is escaping before it's time, before you've made it to the bathroom. Those are the two most common types we see. And then I also do see women struggling with prolapse. And prolapse is essentially when the organs in the pelvis or tissues in the pelvis move into locations they shouldn't be. So essentially falling south. And that can bring on a myriad of symptoms. That can lead to sensations of pressure or heaviness in your pelvis. It can lead to some of the urinary symptoms we just talked about, can also lead to bowel problems. Um, it can also make vaginal penetration difficult or uncomfortable. So, yeah, there are a lot of those symptoms, I'd say, are the base. Those are the main ones I see. Um, there's also pain symptoms. Some women just come to me because they've noticed that their tissue down there feels sore. Uh, they've had changes in their vulvar vaginal tissue, uh, can feel irritated, especially with intercourse, can feel like sharp. I hear razor blades and stinging and burning and those types of irritating symptoms that shouldn't shouldn't have to be there. Yeah, and so good that they feel like they were able to reach out to their gynecologist or to someone else to speak up about those issues that they were having. So that there is they can realize that there's hope for that, and that doesn't have to be like that. Yeah, absolutely. I am just so glad that we're talking about this and and also glad that providers are asking more questions. Um, you know, one of my most irritating stories is that after I had my son, who was my firstborn, and I was dealing with all of these challenges, I never once got asked by a medical provider in my postpartum care if I was struggling with any issues related to my pelvic floor. Never got asked if I was having continence concerns after having a very serious obstetric tear. And it just astounded me that if it hadn't been me bringing it up, it would have never been mentioned. And a lot of, unfortunately, a lot of people don't always bring this up to their providers. Um, so I'm glad too to see that providers are asking good questions. Yeah, I feel like when I was coming up in my 20s, it was all about the Kegel exercises. Um, so there was a sense of, yeah, there's something down there that's important that you're exercising, but and you should do these exercises, but there wasn't really like a sense for the network of your pelvic floor and all the myriad of muscles and the different intricate framework of the pelvis. Can you talk a little bit about the structures of women's bodies in that regard? Absolutely, yes. So, you know, kegels are a great place to start. That is contracting your pelvic floor muscles. And the pelvic floor is a lot more complicated than we give it credit for. So let's start there. Uh, the pelvic floor is a layering of muscles. There's actually three main layers of your pelvic floor muscles. There's muscles that are kind of uh superficial, that are sort of right around the vaginal opening in the anal sphincter. Uh, there, the ones around the vaginal opening are more involved in sexual arousal and sexual function. Then you have a layer a little deep to that. It's more the closure mechanism, I'll say, of the urethra. So more the muscles that are involved in continence control. And then you have your bigger inner muscles, the kind of main hammocking muscles of the pelvic floor that are the real support muscles. They're the ones that are kind of giving you that floor of support. Now, what is this the floor of? The pelvic floor is the floor of your core, and it is very important to view it as such. So, you know, Kegels help. They're a like I always say with my patients, they're a great start, they're a good place to begin. But if we're not working our pelvic floor as a um part of a hole, and that hole being your core, you're doing it a disservice. You're you're not gonna get all the benefits that you could get out of doing exercises. So, yeah, your pelvic floor is part of a system of muscles that support your midsection, so your core. Uh, the pelvic floor is the bottom across the front. The main muscle that you have that supports on the deep side is your transversus abdominis. And I think a lot of us when we think of abdominal strengthening, we think of things maybe like sit-ups or crunches. And that's only the superficial muscles. That is not doing a whole lot for your deep abdominal muscle layer that's the most important for physical support. That's your transversus abdominis, and it's the muscle that kind of draws you in, it kind of gives you that support from the front. It we often talk in the clinic about it pulling your belly button towards your spine, that muscle. And then in the back, you have posture muscles, the multifidae muscles that help keep your spine erect and help you maintain good posture through your spine. And then there's a ceiling to the core. So if we have a floor, we also have to have a ceiling. What is that ceiling? It is your breathing diaphragm. And the diaphragm is hugely important. And I feel a neglected muscle that's not thought of as often as it should be when it comes to core training. So when you walk into my treatment room on our back wall, I have just breathe because that is literally the foundation of almost every exercise we do. So, yes, my room, it's just breathe, and in my physical therapy assistant's room, it is inhale, exhale. But we have those reminders right up on the wall. It's the first thing you see when you walk into our clinic. And it's a specific kind of or way of breathing, too, if I'm not um if I'm correct. Because I I took a training about breathing properly, and I was amazed by some of the information she gave about how we were not breathing correctly. And one of the things that I've has carried over for me is that sense of like breathing kind of up and out, um, to kind of engage the diaphragm a little better, as opposed to that just thinking about the breath as going up through your center. I'm kind of thinking of that as like um up and out. I don't know if that is something that you work on people with. Absolutely. Yeah, we do. We do a lot of breath work. Um, yeah. I mean, for our purposes, when we're trying to have people work on these core muscles and get them working together, we work on diaphragmatic breathing. And diaphragmatic breathing means you're using your diaphragm to breathe. So, not necessarily what we call your accessory muscles, which are like your chest muscles. So we work on, you know, not seeing your chest rise and fall so much with every breath you take, but feeling an expansion through your abdomen in all directions. So kind of feeling the rib cage open, feeling your belly rise as you breathe. I do try to be careful, you know, there's it gets I don't like a much negative talk around breathing because the right versus wrong can feel overwhelming. If you're breathing, you're breathing right. You're alive, so you're doing pretty well. But can we maybe improve on it and make it better, especially when you're being physically active and when you're trying to get your core muscles to behave the way we want them to? Yeah, there are better ways to breathe. Um, but yeah, I know sometimes it this whole idea of I breathe wrong, the very essential function of life, I'm doing it wrong, can can feel really negative. Yeah. I think it's um somewhat like an awareness of your breath. Absolutely. Um more so than like we're obviously all breathing in order to be alive, but it's that intentional breathing or um an awareness of where you are or not or are not breathing. Absolutely. Yeah, yeah. And like I said, you know, when we're trying to be active and ask more of our body, we want to take as much air in as we can in the most productive way possible and get these muscles to behave the way we want them to. So there's definitely a better way to do that. So can you give an example of how you would choose someone to have more productive breathing or a breathing that's going to really target that area? Yeah, you know, we we usually start in a reclined position. Um, you know, I find that laying flat is a little tricky because you can't feel the abdominal movement as well as we'd like. Um, sitting upright for some is challenging just from a postural standpoint. So we usually start reclined. We find that works pretty well. And I often will do the put a hand on your chest and put a hand on your lower belly, and then in through the nose, out through the mouth. And what you're feeling for is quiet here. You know, make this hand that's on your chest maybe even a little bit heavy. And so you're telling yourself, quiet here, feel the breath lower through my abdomen, feel my rib cage expand. Think of an umbrella opening as you inhale. And then when we're trying to cue our pelvic floor into it, that's where things sometimes get a little overwhelming for people. We have to break this down in a step-by-step process. But our pelvic floor and breathing diaphragm are designed to work like an elevator. So when one goes up, the other goes up. When one goes down, the other goes down. This helps us keep our pressures managed in our midsection. So when we inhale, our breathing diaphragm is dropping. It's allowing that air into our lungs, which are up in our chest. So our breathing diaphragm has to drop. We like to see the abdomen expand, and then the pelvic floor should ease, relax a little bit. So inhale is actually relax for your pelvic floor, which seems counterintuitive to a lot of people. We have quite a few patients that really struggle with this in the beginning. And then as you exhale, as you blow your air out, your muscles are rebounding naturally. I won't say there's an um an active pelvic floor contraction that happens when you exhale, but they're kind of like we say bouncing back, but that's a good time to add in an active pelvic floor squeeze or a kegel squeeze. So yeah, we usually encourage the kegel or the pelvic floor activation on the exhale. And that often takes people a little while to get that rhythm, to get that harmony. So I often tell people your exhale is your power breath. You know, when you're exercising or doing any kind of strenuous activity, use your exhale through that activity, lifting something, pushing something, pulling something. Try to get yourself harmonizing your breath with what you're doing and use your exhale as your power breath. Yeah, I've heard it described as like a jellyfish. That a jellyfish um that it actually moves when it, it doesn't move when it's expanding and opening, it moves when it contracts down and in and kind of pushes itself through the water. So I feel like that's a great way of, and plus the jellyfish has that shape, right? Of kind of a um a diaphragmatic shape or whatever. Yeah, yeah, that's a good one. I might I might steal that. Yeah. Yes. There's um, I'm so glad that there's um, you know, there's so many benefits to deep breathing in terms of relaxation and um nervous system work, but also, you know, that I think bringing that into it is so important to know that there's, you know, just a million reasons why you should be taking some time to just pause and and breathe and tap into yourself then that way. Absolutely. Yeah, yep. Breathing is one of the best ways we can tap into our parasympathetic nervous system, our resp, digest, relax nervous system. Yeah. Yeah. It's a really powerful strategy for that. Yeah, absolutely. So, what are some other things that you do with people when they come in, aside from the breathing? What are some simple um exercises that people can do in terms of like physical therapy type exercises to help with these kinds of conditions? Yeah, that's it's kind of a tough one to answer because it very much depends on what the problem is. Um, you know, so it really depends on how their pelvic floor and core muscles are presenting in the clinic. Um, you know, I know two people leave our office with exactly the same exercise plan or exercise program. So it's it is tough. And, you know, if we do, I'll say the wrong things, um, sometimes it can make certain symptoms worse. So some people's pelvic floors are weak, they're struggling to contract, they're maybe hanging lower than we ideally want them to, they need toning and strengthening. You know, so those individuals would be given a lot of kegeling type exercises, keegling with other muscle groups activating exercises, doing those exercises in different planes of gravity. So whether that's lying down or sitting or standing, during functional movement patterns, you know, so that would be more like a strengthening protocol. However, now some people come to us and they have what we call pelvic floor muscle overactivity. So they have a pelvic floor that is essentially holding too much tension at the majority of the time. And so their struggle is relaxing their pelvic muscles. This can lead to symptoms like urgency and frequency sometimes of urinary function and lead to pain. Muscles that are tight are often tender. They're often sore. It can lead to pain with vaginal penetration. So in those instances, you know, we'd be giving more pelvic relaxation type exercises and work. So really teaching the opposite end of the spectrum with that and helping them learn how to ease that overactivity and that tension. And also maybe assisting with some manual techniques as well, kind of hands-on working with these tissues to try to help them lengthen. So yeah, it's it's I can't say there's like a here are some great pelvic floor exercises that are kind of cookie cutter for everybody because it's just not the case. It's just not that easy. But yeah, I mean, I would say for most people, just learning how to tap into your pelvic floor, feel that movement. You know, it is great to do with the breathing that we talked about, you know, trying to see how how high can I get that elevator to go, how low can I relax it down, you know, feeling that degree of movement, tapping into that, um, using that exhale, like we said, with exercises that can be with things you're already doing. That might be with things like squats or lunges or laying down floor type exercises, just remembering to include your pelvic floor in what you're doing. Yeah, engaging it. We always say in in our clinic, you know, engage during the hard part. So whatever the challenging part of your exercise that you're doing is, that's when your pelvic floor should be engaging and you should hopefully be using, like we said, the exhale stage of breathing during that part. So if you're lifting or, you know, doing some kind of a squat type exercise, you know, you're exhaling through the challenge, through the hard part. So it sounds like that's kind of the key to just general maintenance of that part of our bodies is um an awareness of the muscles there, um, exerting and um engaging that lower abdomen and the pelvic floor. Um, are there any other things that people can do to be preventive in this? One of the biggest things is managing your bladder and bowel health. We see this so often that it's not just a pelvic floor problem when you're having these types of symptoms that, you know, bring people in to see us. It's issues with general bladder and bowel health. And that is a great place to start. Um, you know, look at how your bowels are behaving because we know that things like constipation really seems to be a trigger for other pelvic-related symptoms, whether that be prolapse symptoms, whether that be urinary symptoms. What's going on with our bowels very much influences those areas. So for some, you know, it's it's a, yeah, well, I know I I'm I've been constipated for years. It's just part of my life. I just deal with this. And, you know, it's it's the getting people to realize this is a problem. You know, this is a real problem besides just the bowel issue itself. It's creating or at least contributing to these other symptoms that you're dealing with. So yeah, learning how to helpfully manage your bowels is really a big one. Um, you know, getting a good healthy amount of fibers in, that being soluble and insoluble fibers, managing your daily hydration, make sure you're getting enough water in. Um, and then, you know, maybe helping the bowels with something if needed to get you more regular. Not that that has to be every day, because every day isn't everybody's normal for their bowels, and that's okay. It's more important to us that when you're going, it's easy, it's comfortable. The stool is in that what we call soft but formed range. Um, I often tell people like overripe banana is where you want it. And so anything that you can do to kind of get it in that zone and keep it there is gonna be hugely helpful. And then bladder health. Yeah, you know, making sure that we're hydrating adequately, even if we're having urinary symptoms. I know some people restrict fluids when they're afraid of urinary urgency and frequency and incontinence. And that actually can have the opposite effect. When we restrict our fluids and we concentrate our urine, our own urine is an irritant to our urinary tract. So the more diluted our urine is, usually the happier our urinary tract is with fat fluid. So it's better to hydrate, um, even if in the beginning that means you have an increase in urinary frequency. It's likely going to be less urgent if you're well hydrated. So, yes, and then bladder irritants. Some people are sensitive to things they put in their body, and that can change as our bodies change. And we see this with perimenopause and menopause. People used to be able to drink as much of that diet soda as they wanted and have no concerns with it their whole life, and then all of a sudden, that coveted diet soda is now giving them a lot of issues. Um, and so that can be a hard, jagged pill, I know for many. Um, coffee, anything caffeinated energy drinks are art nemesis in my clinic. Uh, they're, you know, not good for our urinary tract for a lot of reasons. Um, yeah, things, anything carbonated often does bother this population as well. Artificial. Yeah, I notice I've noticed coffee. Um, when I would drink coffee, I would have to pee shortly after, and I could almost actually feel it like signaling my bladder is really funny how that how that worked. Yeah. So yeah, it definitely makes a difference. And you had mentioned something about going to the bathroom too often, too. Um, so I'm thinking about, I know for me, sometimes I'll be like, oh, I think I have to pee, and I'll go, and there'll just be a little bit of something there. And I'm like, oh, I didn't have to pee. Maybe I should have just waited. Um, so maybe you could talk a little bit about that. Yes. So yeah, along this stage of life, um, we do see changes in the genito-urinary system that can make our bladder feel full even when it's not. And so kind of giving in to that and doing that repetitively starts to create a sort of um the vicious cycle, I'll say. The more often you go, the less your bladder wants to hold, the more often you go. And so it becomes a bit of a spiral in that way. Um, so yeah, it's a really good thing to be open about with your providers, specifically your gynecologic providers. Um, they can help. There are definitely some things that can be done beyond the physical therapy that can help with those types of symptoms as well. But yes, you do want to be careful because I I always tell people it's a slippery slope. You know, when you're going a lot more often, you're gonna find yourself continuing to go a lot more often. So, you know, we've always been told that we should, you know, empty our bladder when it tells us to. And for the most part, that's true. You know, when the bladder is full, you want to empty it. You don't want to delay voids for hours and hours. But in some instances, going every time you feel the slightest inkling that you may want to go is isn't always good. So, yeah, we do tend to look at um a bladder diary for a lot of our patients. We'll encourage them to kind of chart or log their urinary frequency. Um, that way we can sort of look at it and say, okay, well, here's let's put a plan in place. You know, let's try to have you avoiding these clusters, and often it happens at certain times during the day when people find themselves going a lot more frequently. And we'll we'll give them a goal. We'll say, you know, okay, well, let's try to make sure it's been at least a half an hour. Let's try to make sure it's been at least 45 minutes, whatever that goal may be. And then they try to stick to that for a period of time. Now, this isn't a forever thing, this is just to kind of retrain the bladder to be more comfortable holding more urine again. Yeah. What impact do like those estrogen creams have that you might insert um that would help with like vaginal atrophy? Yeah. So I mean, we are finding really positive results with these estrogen therapies. Um, yeah, so you know, as our estrogen levels decline during the lovely perimenopause to menopause stage of life, we do see atrophy of the tissue down in it. Atrophy essentially means thinning. And as those tissues thin, they lose support. So now we are no longer fully supporting our urethra, the vaginal wall, the bladder in general. And with that can come the symptoms that we've talked about. Estrogen cream, for example, has been shown to help kind of re-fortify that tissue, allows it to kind of have more of its integrity back, and that can help a lot of these symptoms, um, uh urethro urogenital symptoms, including pain. So pain with penetration that we see around this time is often a result of that thinning tissue as well. And it can really help with that. So definitely a conversation worth having with your prescribing provider. Yeah. Um, I don't have any issues with um like bladder incontinence, but that's definitely the atrophy had been noted to me, and that cream has really been helpful for me. So um I could definitely say that it's worth considering if it's appropriate. Yeah. Absolutely. Yeah. Um, so some of the people I've had on the podcast so far have been functional doctors, um, functional medicine doctors. So they've, you know, talked a lot about nutrition and um like supplements and things like that. It sounds like um, you know, eating, drinking lots of water, getting, you know, fiber-rich foods, um, both soluble and insoluble, as you've already mentioned, are some things that can be done too, and giving up sodas and caffeinated things. Um, are there any other things related to diet that people could do that might benefit this part of their bodies? Um, so yeah, you know, I'm all about evidence-based. And, you know, I like to, if I'm gonna recommend something to my patients, I like to make sure there is some decent evidence behind it. Uh, one supplement that seems to be positively supported in the literature for urinary symptoms, um, things like recurrent urinary tract infections, urgency frequency is a supplement called DNANOS. Um, so that is one that I have, you know, recommended my patients look into and talk to their providers about. Um, but yeah, other than that, really what I promote in the clinic is like you said, healthy eating and drinking habits, you know, trying to keep the bowels and the urinary tract as healthy and happy as possible. I definitely see benefits to that. Yeah. Yeah. I mean, um the majority of people I think don't drink enough water and eat really bad foods for them. So um, and in this stage of life, it's harder to get away with that eating habit, I think, than it might have been before. Um, I wouldn't say I have a bad eating, eating. Um, I make most things from scratch, don't eat a lot of processed foods, try to get, you know, fruits and vegetables best you can. Um, but you know, even then, it's like, oh, I probably shouldn't have had that one thing that I'm now is now giving me a hot flash. Or if you decide like to have a decaf coffee or something, and then you know, a lot of those things that you could just kind of get away with before, you kind of pay for now with, you know, some other thing happening. Yes, that is, it's very true. And and sometimes, you know, we will have patients kind of uh diary or log their their food and beverage intake just so that we can critically look at that. And because everyone is different, you know, some people can get away with having things that would bother others, and then we find some who, you know, definitely discover they have some trigger foods or trigger beverages that really seem to bother their symptoms. So yeah, it's kind of on an individual basis with that. But yes, yeah, it is. I I'm always amazed at those that can get away with some of the things that I find bother me particularly. I know for me, one is uh fast food restaurant sodas. Doesn't matter, you know, what what type even I didn't we do a lot of traveling on the through way with my kids to go to different sporting events or back and forth to college. And you know, those throughway rest stops, you gotta stop and deal with whatever food is there. And often it's unfortunately fast food, which you try to make the healthiest choices you can, but it's not always easy. And then, you know, grab that quick soda from the soda fountain and take it in the car with you. Yeah, well, I might not make it to the next rest stop before I have to be. And I have definitely noticed that's a trigger for me. So I have to be really careful with that. Has anyone ever come back to you down the road and said, Oh my gosh, thank you so much for helping me with my pelvic floor. It's changed my life. We have. We've had some really great patients over the years that have come back and yeah, and told us in one way or another that they were very positively influenced by our services. And we also have patients that come back for what we call tune-ups, you know, where maybe they've they've fallen off uh the wagon a little and um all of a sudden symptoms have crept up again or changed. Um, that can happen too. New stage of life or new circumstances in life have led to a change in in their symptoms, and and they'll come back and they'll say, Well, this was really helpful before. I'm I'm hoping you can get me back on track again. And we always recommend a repeat client. It's uh never a problem for us. We're always happy to see people whenever they need to. But yeah, we have had patients that really have have shared with us their their success stories and it's touching. It's it's great to know that you're helping in a positive way. So um I know that in order to work with you or at your um with you or your PTA or anyone at your clinic who works with pelvic health, that there is a weight. Um, and yeah, I think you've given some good constructual things that people could do if they, you know, let's say they reach out to their doctor and they put a referral in, but it's gonna be several weeks or um, I don't know how long the wait tends to be. But um I think there's some good things that you've kind of set out that they could do in the meantime to maybe help a better identify what's going on in their bodies and maybe take some things to be proactive. Absolutely. Yeah, yeah. And you know, we're hoping that our wait list at my clinic in particular is gonna get a little shorter because now I'm on boarding a new physical therapist that's gonna be joining the pelvic health team, which is really exciting. So now there will be two PTs and my physical therapy assistant who is amazing. So yeah, we're we're hoping we're gonna turn that around and uh be able to get people in sooner. Um but yeah, in the meantime, I'd say, yeah, definitely just you know working on, like I said, getting in touch with your pelvic floor, finding your pelvic floor, getting comfortable with the contracting and relaxing, working on squeezing and holding. Um, that's always hard for people we find. The endurance piece of it is quite challenging for people. So that's a good one you can work on, um, you know, leading up to an appointment or an assessment. Um, so yeah, yeah, I think there's plenty things people can do to troubleshoot in the beginning. And then if you feel needed, you need to come in. Absolutely. We're happy to see you. Just get that referral from any prescribing provider, really. We're not fussy who it comes from, and uh give the office a call. And uh yeah, we'll get you on that list and get you in as soon as we can. Yeah, and I would all I meant to mention this earlier, but you know, there's also a part of that, um, like you had mentioned, the muscles and ligaments around the pelvic floor. It's also, you know, bowel control as well. Um, so that's just another thing I wanted to uh just throw out there because I know that sometimes will come up for people, either in addition to the um urinary incontinence or separately. So just that that is also kind of a part of that system there, if that's showing up. Absolutely. Yeah, yep, absolutely. Fecal incontinence is a is a concern of many and not just fecal, but what we call fleetal incontinence, which is incontinence of gas. I know I have had patients that have come in and said, Oh my gosh, I went to yoga and got into a certain pose and experienced an involuntary loss of gas, and it was so embarrassing, and it absolutely mortified me. So, yeah, I mean that is that is another component of it. Yeah. Well, I'm so I'm so grateful for the work that you do and the fact that as you pointed out, there aren't a lot of other people doing that. Um, if are there any other people doing that in your area? There there are some other clinics now that do have some providers that are that are doing public health. Yes. So yeah, there are other options around. I will say when I first started doing what I do, um there there weren't that many at all. So we are seeing a boom in in this area, which is is really great because the need is there. Yeah. And I think um, you know, we're less likely or less um willing to just deal with these things, I think. And we're at that our generation is in that place where we see our moms having struggled with this, or you know, as our moms are aging, like, oh, now they have this issue coming up. And I think it just um the result of more people doing this work is the result of more women saying, I'm not going to just accept this as a normal part of life, like we were talking about in the beginning, um, and really taking steps to improve, improve this for themselves so they have a better standard of living, a better quality of life. Yes, yes, definitely, definitely. Great. So if you if anyone is interested in working with Kim and wants to um, you know, engage with her, then you would want your doctor to talk to your doctor about your public floor concerns, whatever incontinence or other things are coming up for you. And then they would put a referral into you are at Thompson Health. Um, I appreciate so much your time and um just I'm grateful for everything that you're doing. Thank you so much. I I really enjoyed talking with you, and uh I I love sharing public health stories and helping people. Yeah, thank you. You're welcome. Thank you for joining me in this conversation with Kim Tonavis, a doctor of physical therapy specializing in public health. You learn ways to improve your public health, what anatomies apply in staying healthy, and above all, that there is health. You don't have to resign yourself to being a common or having painful sex. You can have good public health and continue to do all the things you enjoy now or enjoy before. As you pointed out, speak openly to your doctor about what's going on so you get the healthy deserve. You're not alone. Add that conversation with your doctor and get a referral. Until next time, stay open to your choice.