What is Pelvic Floor Therapy?


By Erika N. Johnson and Carolyn Seale, Physical Therapy at UNC REX Outpatient Rehabilitation, Erika.Johnson2@unchealth.unc.edu, 919-784-4696

Who (would benefit):  YOU!

Who (is the provider):  Physical and Occupational Therapists

What:  Pelvic floor therapists are specialists in assessing and treating pelvic floor dysfunction, which includes a wide range of impairments that often involve either weakness or tightness of the pelvic floor muscles. Pelvic floor therapists have the same initial training as “regular” PTs or OTs, with additional specialized training in the anatomy and physiology of the pelvic region, as well as in bowel and bladder function. Your initial evaluation would take place in a private setting and may involve a pelvic exam to assess your pelvic floor muscles. Each rehab program is individualized to meet your needs and may include patient education, exercise training, biofeedback, manual therapy, postural retraining, and more.  The number of therapy visits needed varies from person to person and can range anywhere from two times per week to every other week.

When: You may be a candidate for pelvic floor rehabilitation if you are experiencing bladder or bowel symptoms such as accidental leakage, incomplete emptying, increased urgency, increased frequency, or pain with elimination. Pelvic floor rehabilitation may also help women with pelvic organ prolapse, and women who experience pain with vaginal intercourse, vaginal exams, or the insertion/removal of tampons. Pelvic floor rehabilitation can also help women before and after they give birth, with any of the before mentioned symptoms, and with diastasis recti (DRA).

Where: These services are available in outpatient rehabilitation settings but may also be offered in inpatient and skilled nursing facilities. UNC and UNC REX both offer Pelvic Floor Rehab at multiple outpatient locations in Wake and Orange counties.

How: Your insurance may require a referral to Pelvic PT or OT. If not, you can refer yourself but we recommend that you have had a pelvic exam within the past year and/or have discussed your concerns with your medical provider.


Where Is the Research At?


By Jennifer Wu, Associate Professor, Urogynecology and Reconstructive Pelvic Surgery

Pelvic floor disorders (PFDs) include problems such as incontinence, which is the accidental leakage of urine or stool, and pelvic organ prolapse, which is the dropping of the pelvic organs into the vagina. These conditions are incredibly common, affecting at least 1 out of every 4 women, with older women having an even greater risk. Also, 1 out of every 5 women will have surgery for one of these conditions over her lifetime. Unfortunately, even after surgery, symptoms may return.

Currently, we do not have a complete understanding of why these conditions occur. We also do not know which women are at highest risk and what the best treatment options are. We need to study these important questions in order to provide better care for women, and to eventually prevent these conditions from occurring in the first place.

Recently there has been more of a focus on PFD research, and we hope to see this trend continue in the future. Women’s health IS important! We are just now beginning to get a sense of how common these conditions are and what some of the risk factors are, such as age, childbirth and obesity. However, more research needs to be done to address these unanswered questions so that we can improve the lives of women suffering from these disorders.

How does diet affect bladder health?


By Katherine Husk, Fellow, UNC Urogynecology and Reconstructive Pelvic Surgery

Overactive bladder (OAB) affects more than 40% of women in the US, but the actual percentage is likely much higher. Unfortunately, many women do not seek treatment for OAB due to embarrassment or because they think it’s just a part of being a woman or of getting older. OAB symptoms include urinary urgency (feeling a sudden urge to go), urinary frequency (going to the bathroom more than 8 times in 24 hours), and having to wake up to go to the bathroom in the middle of the night. These symptoms can be experienced with or without urinary leakage/incontinence. While OAB is a common issue experienced by women, we do not know exactly what causes it. However, we do have an idea of what can help with these symptoms – starting with changing what you eat and drink!

Making dietary changes such as eliminating (or cutting down on) certain items can help symptoms of OAB. However, what works for one person may not work for another. Some women may be impacted more by a certain type of food or drink, and still others may find that even with making these changes, there is little change in their symptoms. The good news is that making these dietary changes is certainly not harmful and it’s something you can do at any time!

What foods or drinks should I avoid?

Bladder irritants are foods and drinks that increase your OAB symptoms. Try experimenting with decreasing or eliminating certain items on the list and keeping track of your symptoms so that you can see what works best for you.

Common bladder irritants:

  • Caffeinated beverages such as coffee, tea, and soda
  • Carbonated beverages
  • Food and drinks with artificial sweeteners (i.e. aspartame, saccharine)
  • Alcoholic beverages
  • Acidic items – particularly fruits and fruit juices (i.e. apples, apricots, citrus, cranberry, grapes, plums, nectarines, peaches, rhubarb, pineapple, strawberries, pomegranates, bananas, cantaloupe, avocado, tomatoes)
  • Spicy foods
  • Aged, canned, cured, processed or smoked meats and fish
  • Certain milk and dairy products such as aged cheeses, sour cream, yogurt, and chocolate
  • Other condiments/seasonings such as mayonnaise, soy sauce, salad dressing, vinegar
  • Excessive fluid intake: While some sources recommend six 8 oz glasses of water per day this may be way too much. We recommend a moderate intake (drink when you are thirsty), drinking small sips throughout the day, and avoiding drinking later in the evening/before bedtime.




Why do women get more UTIs than men?


By Taylor Brueseke, Fellow, Urogynecology and Reconstructive Pelvic Surgery

The urethra is the tube which passes urine from the bladder to the outside world. In women, the urethra is only about 3 to 4 cm (1.2 to 1.5 in) in length. So for any bacteria that may be present in the outside world to enter the bladder, that bacteria only needs to travel a short distance. And unfortunately, the bladder is a dark warm place that certain bacteria grow very well in. While there is no way to make the urethra longer, there are things you can do to try and keep bacteria from traveling through it.

Like the rest of the vagina, the urethra is sensitive to hormones – the most of important of which is estrogen. After women pass through menopause, the amount of estrogen in the body decreases. This causes the strength of the vaginal (and urethral) walls to decrease which can result in vaginal dryness and pain with intercourse. As the strength of the urethra decreases, bacteria are more easily able to pass through the urethra and enter the bladder which results in a UTI. This is the reason why doctors often prescribe estrogen supplementation for women with frequent UTIs who have passed through menopause. The lowest dose of this estrogen can be used in the form of a cream which is placed inside the vagina several times per week.

Another reason why bacteria can more easily enter the bladder of women is simply anatomy – the opening of the urethra is right next to the vaginal opening. The fact that the urethra is so close to the vagina, which is also so close to the anus, means that there are naturally a lot of bacteria near the urethra. Unfortunately, it’s not possible to get rid of all the bacteria in ANY part of the body. But practicing good hygiene, including remembering to wipe from front to back, can help keep bacteria from being dragged towards the urethra.


Should I Wait or Should I Go?


By Mary H. Palmer, Helen W. & Thomas L. Umphlet Distinguished Professor in Aging, UNC School of Nursing

Habits, as we all know, are the particular acts or ways of acting that we tend to do regularly. Our habits at work are often different than our habits when we are alone at home. We have habits related to many types of activities, such as working, eating, exercising, and even toileting.

Yes, we all have toileting habits, but like many of our other habits, we often don’t give them much thought. However, just as with our exercising and eating habits, our toileting habits can have health consequences over time.

What about you? Do you habitually wait so long to empty your bladder that you think you won’t make it to the bathroom in time? Do you sit on or hover over the toilet to urinate? Some women say, “It depends on where I am.” In a recent survey, most women said that they sit on the toilet to urinate when they are at home but that they’ll hover or crouch over the toilet when using a public restroom.

Which toileting habits are best for bladder health? The unfortunate answer is, we don’t know yet. However, recent studies have shown a link between waiting too long to urinate and lower urinary tract symptoms, like bladder leakage. Other factors may be involved too, like obesity, but there is growing evidence that our toileting behaviors can affect our bladder health.

When we were young children and just learning how to control our bladders, we were taught to pay attention to the urge to go. Yet as adults, many of us will ignore the urge to go because we don’t want to – or can’t stop what we’re doing – to use the toilet. When you don’t respond to your bladder’s increasing demand to urinate, several things happen. The pressure in your bladder increases and it can start to contract in response to the stretching of the bladder wall. Your bladder sphincter and pelvic floor contract more forcefully in an attempt to hold urine in the bladder, and if you avoid urination for too long, your bladder will ultimately “win” and leakage will occur.

Even if you don’t immediately leak, habitually delaying going to the bathroom can lead to over stretching which damages your bladder wall muscle. This in turn can lead to to the inability of your bladder to contract sufficiently so that you empty completely, as well as the development of kidney damage from “backed up” pressure from the bladder.

So, until we have more evidence about the effects of toileting behaviors let’s try to do the following. Go to the bathroom when you know you need to, don’t delay! Sit on the toilet seat so that you can relax and let your bladder empty completely. Paying attention to your bladder can help it and you, stay healthy!

Let’s talk about sex!


By Maggie F. Wilkins, MSN, Nurse Practitioner, UNC Department of Obstetrics and Gynecology

Sexual health is an important part of adult life and yet it is not often discussed in mainstream society or health care (unless you are a man, in which case there is no shortage of Viagra and Cialis commercials encouraging you to rise to the occasion). In fact, very little is known about the relationship between female sexuality and chronic health conditions such as pelvic floor disorders (PFDs), which includes urinary leakage, pelvic organ prolapse, and accidental bowel leakage. What we do know is that many women don’t seek treatment for PFDs – usually because of a combination of embarrassment and not knowing that there are available treatment options. The additional layer of embarrassment in talking about sex in general keeps even more women from seeking treatment for sexual dysfunction. Studies have shown that patients see an average of 7 providers before their issues are adequately addressed.

Even in our field of Urogynecology, which arguably has a higher focus on women’s quality of life than most specialties in medicine, improvements still need to be made in addressing women’s sexual health. We can do better and this is something I am hoping to change!

People often ask me how I ended up in this field of health care, and their undertones seem to assume it must have been by chance or bad luck. However, the truth is this area of healthcare is very purposeful for me – and it is for most other providers in Urogynecology. I was drawn to our field because it focuses on women’s quality of life – and undoubtedly, a fulfilling intimate relationship with another person is part of the ideal picture.

Whether or not we want to acknowledge it, we are hard-wired for human connection. In infancy, when children don’t bond with their parents or there are problems in the parent-child caregiver relationship, this can lead to a serious medical condition known as failure to thrive; these children do not grow and develop normally compared to other children of the same age, and these complications can be permanent. I point this out to highlight that we NEED human connection and a sense of love and belonging to thrive – even as adults. Sex is important and arguably can be seen as the foundation of human connection.

Women are complicated, we know that. On average, it takes a woman 12-14 minutes to achieve an orgasm, even when she is doing it herself and knows the fastest and best route, and this is in the absence of complicating PFDs. And when you add in the additional interplaying pieces of emotional intimacy, desire, physical arousal and lubrication, satisfaction, pain, etc., it becomes even more complicated. But this doesn’t mean it is any less important. There are treatment options, and they can be very effective in addressing sexual health issues. The first step is to rule out and treat underlying causes, which includes PFDs such as urinary incontinence, pelvic organ prolapse, accidental bowel leakage, and vulvovaginal atrophy. This alone may or may not fix the problem, but it is the first step! After that, other options include physical therapy, bibliotherapy, sensate focus exercises (planned loveplay), therapy or relationship counseling, and herbal or prescription medications.

Thank you for your interest in bladder health week and this blog on sexual health. I hope you will join us in person Wednesday at the Arts Center. I welcome any questions that evening or if preferred, I look forward to seeing you in my clinic.

What do you know about your pelvic floor? Take our quiz!


By Erika Johnson and Carolyn Seale, Physical Therapy at UNC REX Outpatient Rehabilitation, Erika.Johnson2@unchealth.unc.edu, 919-784-4696

  1. True or false? The pelvic floor is made up of muscles.

True– The pelvic floor is made up of a group of muscles that rest at the bottom of your pelvis in a hammock shape. These muscles help control your bowel and bladder, aid in sexual functioning, support your pelvic organs, and aid in the stability to your pelvis and lower back. 

  1. True or false? The best way to do Kegel exercises is when you are peeing, by stopping your flow of urine mid-stream.

False- Stopping your flow of urine mid-stream is a good way to identify the correct muscles to use during Kegel exercises, but doing this regularly interrupts your flow of urine and may prevent you from completely emptying your bladder.

  1. True or false? The best way to strengthen your pelvic floor muscles is to squeeze them as often and as hard as possible.

False- The most effective way to strengthen your pelvic floor muscles is to perform muscle contractions at about 30-50% effort, with full relaxation following each contraction. When you are ready to advance your training exercises, slowly increase the number of repetitions and/or the length of each contraction. Be careful not to overwork your muscles, it is possible to overdo it!

  1. True or false? Pelvic floor exercises can help me with my bladder leakage.

True- Pelvic floor exercises can help you improve control over your bladder and bowels. They also contribute to core trunk stability, postural control, and spinal health.

  1. True or false? Pelvic floor exercises are only helpful for women who are older.

FALSE- It is important at any age for you to get in the habit of routinely performing pelvic floor exercises. Long term strength maintenance is key. If you don’t engage your pelvic floor muscles, they will lose strength over time. Starting pelvic floor exercises now may even prevent you from having problems when you are older. Prevention is key!

  1. True or false? Learning how to properly do Kegel exercises is easy.

False- Studies have shown that many people who think they are doing Kegels correctly are in fact using the wrong muscles or straining their pelvic floor. If you are unsure of how to do these exercises or are experiencing pain when completing them, it may be helpful to be evaluated by a pelvic health therapist to ensure that you are using the correct technique.

  1. True or false? Pelvic floor strength is good for your sex life.

True- Pelvic floor strength increases the flow of blood to your genitalia, helps with lubrication, strengthens vaginal wall tone, and increases clitoral erection and orgasm.

  1. True or False? Kegels are for everyone.

False- Some women have tight pelvic floor muscles, and strengthening them can actually worsen their symptoms. If you are unsure if this is you, it may be beneficial to be evaluated by a pelvic health therapist. 

Bladder Health & Pregnancy


By Alexis Dieter, Assistant Professor, Urogynecology and Reconstructive Pelvic Surgery

Pregnancy is a time of a lot of physical change for your body, including changes in your bladder health. One of the most frequent symptoms during pregnancy is an increase in the number of trips to the bathroom, which unfortunately, can occur in any trimester. I can speak to this personally as I am 39 weeks pregnant!

So why do I have to go more when I’m pregnant? One reason is because the blood flow to your kidneys is increasing. This ensures a sufficient blood supply is reaching your uterus and helps to prepare your body for potential blood loss when you deliver. Another reason is because as your uterus grows, it places more and more pressure on your bladder, thus making it harder to hold these larger volumes comfortably. Despite the increase in bathroom trips, it is important to stay hydrated, so going frequently is a good way to avoid having to rush suddenly to the bathroom.

What if I get a UTI? When you are pregnant, you are at an increased risk of a UTI spreading to your kidneys, although this is a rare occurrence thank goodness. Both the increased pressure from the growing uterus and progesterone’s effect of decreasing tone in the ureters (kidney tubes) that bring urine from your kidneys down to your bladder increase the chance of bacteria spreading from the bladder to your kidneys. Your OB/GYN provider will check your urine for infection several times during your routine prenatal visits, but if you think you have a UTI (burning with urination, urgency to urinate, etc.) you should call your OB-GYN to get tested and possibly treated.

Why am I leaking when I laugh or cough? It is very common for women to experience urinary leakage at some point during pregnancy. You could be coughing, laughing, sneezing, or just bending over to pick something up. This is especially common in the second and third trimesters when the uterus is larger and there is more pressure on your bladder. It is also common after you deliver as your pelvic floor takes time to heal after childbirth.

What can I do to help prevent bladder leakage? Usually, urinary leakage improves after recovering from giving birth. But to help prevent leakage, go to the bathroom regularly to avoid having a very full bladder. You can also practice Kegel exercises to help strengthen your pelvic floor muscles (this can also help with delivery!). In order to correctly identify which muscles are your Kegel muscles, try to stop your urine flow mid-stream when you are using the bathroom. However, do not do this routinely, just once or twice to get to know what muscles you need to contract when doing a Kegel. Try doing 3 sets of up to 10 contractions throughout the day, while holding each contraction 5-10 seconds. Make sure to also work on relaxing your muscles in between contractions, as well as breathing normally. If you are having trouble you can also ask your OB-GYN provider for help identifying the correct muscles and for handouts on exercises.


What are PFDs & why should we care?


By Samantha Pulliam, Assistant Professor and Director, UNC Urogynecology and Reconstructive Pelvic Surgery

When you’re a Urogynecologist, you somehow end up knowing a lot about the personal lives of your friends! Imagine having your OB-GYN on speed dial – for any question that you think of, not just the ones troubling enough to make you go to the doctor. Over the past few months, I have received panicked calls from THREE of my closest friends from high school, each one detailing symptoms of a pelvic floor disorder. For awhile I wondered what was going on to generate this flood of calls. After all, I (and all of my friends) are still in in our forties – still young! But the truth is, what we know about pelvic floor disorders makes these calls not so surprising after all.

Pelvic floor disorders (PFDs) are very common. We know that at least 1/3 of women in the US have PFDs, including problems like urinary incontinence, accidental bowel leakage, and prolapse of the pelvic organs. This is not just a problem experienced by older women. One in four women in their forties have at least one of these problems too, so no wonder so many of my friends are calling me!

Urinary incontinence can be a real bummer.  Some women leak with exercise like running or jumping, or when they cough, sneeze, or laugh. Others leak urine suddenly, when they feel the need to urinate they can’t get their pants down fast enough! It can also be an expensive problem – some women spend up to $900 a year on things like incontinence pads and diapers.

Bowel control problems can be devastating as well. Some women who experience these problems are afraid to leave their house for fear of having an accidental in a public place, or carry a change of underwear with them “just in case.”

Pelvic organ prolapse is the descent of the vaginal walls or the uterus out through the opening of the vagina, and can feel like a tampon that isn’t in far enough. It is often discovered in the shower or after a long, active day when the prolapse has come down a little further, and a bulge of tissue can be seen at the vaginal opening.

Too many women have suffered too long in silence with these disorders. The truth is, it’s important to talk about these issues – even if it feels a little awkward. Most likely, you will find out that more and more of your friends are going through the exact same thing!

There are so many things that women can do to help with PFD’s, and the first step is talking about it. There are some amazing treatment options out there, and although surgery is sometimes a solution, it is certainly not the only one. There are lifestyle and behavioral changes that can dramatically improve symptoms, as well as medications, exercises, and physical therapy that can make the pelvic floor function more effectively. There are also vaginal devices that can be used to help control symptoms of urinary incontinence, accidental bowel leakage and pelvic organ prolapse.

So even if YOUR best friend isn’t a OB-GYN, make a plan to talk about PFD’s with the lovely ladies in your life – you will find you are not alone! AND make a plan to talk about it with your healthcare provider. Working with the right people, including urogynecologists, nurse practitioners and pelvic floor physical therapists, can be a step toward a healthier and happier you.



This is our very first post! We’re starting this page to share a series of blogs written in honor of National Bladder Health Week, November 6th – 12th. Each day during Bladder Health Week we will post stories and links that highlight what every woman should know about pelvic floor disorders and what can be done to prevent and treat them. Too long have women suffered in silence. It’s time to speak up and speak out!

We are also hosting a Break Free From PFDs community event during Bladder Health Week on Wednesday, November 9th, from 6-8pm at The Arts Center in Carrboro.  Please join us for food from Med Deli, drinks, and conversation with our providers and other community members about PFDs. We hope to see you there!

You can register for this event at: https://goo.gl/O0BQNi