(soft music) - Okay. Welcome my friends to
the Bob and Brad podcast, produced by Bob and Brad, the two most famous physical
therapists on the internet, in our opinion. I am Bob, I am one half
of the Bob and Brad team. And our guest today is a
physical therapist and co-owner of Entropy Physiotherapy and
Wellness in Chicago, Illinois. If you're in the area, stop by. Her area of interest is in
treating the spine and pelvis with a specialization in
women's and men's health. In 2008, she received her
doctorate of physical therapy and master of science
degree in women's health from Rosalind Franklin University and was awarded a board certification as a woman's health
clinical specialist in 2009. She's a busy lady. She has completed a certification in mechanical diagnosis therapy from the McKinsey Institute,
which is excellent, Brad and I have done that ourselves, And is a registered yoga
teacher, she is passionate about learning more about the human body in order to provide efficient
and compassionate care as she helps patients return
to optimal functioning. I want to introduce you to
our guest today, Sarah Haag. - Hello, thank you for having me. - Yeah, thanks for coming. Like I said, I've read your book. I'm gonna go ahead and
mention that right away. "Understanding and Treating Incontinence, What causes urinary incontinence and how to regain bladder control." So I read it actually a couple months ago and I've been doing it. I've been doing the Kegel exercise and, this is a little bit embarrassing, but, it's helped me with hemorrhoids. And it also, I was
getting up twice a night, now I'm down to one. - That's fantastic. - So it's really, I know that's
one of my questions actually is how long before they tend to help, but we'll get to that later. So can we just jump right in here? - Let's jump in. So if you wanna maybe
define urinary incontinence. - Sure. So the definition of urinary incontinence
is pretty straightforward. It's the, basically the unintentional loss of urine of any amount. So, a little drop it's still incontinence, perhaps a bit easily, more
easily ignored than other issues. But yeah, so it's basically just the
involuntary loss of urine. - Gotcha. So who are the typical patients you see for urinary incontinence? - Goodness. I think women
get most attention here. Women are more likely to be effected by urinary incontinence. Some of that is due to childbearing but then also just the
anatomy of our pelvic floors including the fact that we have
very short urethras compared to the male urethra. So there's a lot of reasons
why women are more likely but then within that,
within that population, of say women or people
of short urethras, it's, we'll see women actually elite athletes, elite female athletes who
have never had children, experience urinary incontinence. Women who have had children or who are currently
expecting children may be at risk for having it. But then also as we move into menopause and that post-menopausal phase of life, urinary incontinence is also very common but really never considered
to be like normal and something to just accept and ignore. - Yeah. My wife mentioned that she was at the one of the drug stores and she
saw a whole large section for incontinence products for males. So obviously it's still an issue. I don't know that I had this
as one of our questions, but can you speak to the, I mean, it really can be a devastating thing. My father-in-law who's
passed, but he had problems and it just socially isolated him. He was, it was really devastating. It kinda took away his social life. - Absolutely. There's a study that shows that urinary incontinence
can have a bigger impact, negative impact on quality of life, than I think it was cancer,
diabetes and arthritis combined. And while that might seem,
like it might seem silly but you hit it right on the
head, it can be very isolating. Very limiting for physical activity. A lot of people carry a
lot of shame because of it. So it can really impact in negative ways. And also you mentioned your father-in-law who, likely he'd be older than you, actually ends up determining where people end up
spending their later years. So if someone's in need
of extra assistance, if they're incontinent, females are twice as likely
then to end up in nursing homes. And for men it's like almost
four times as likely to end up in a nursing home, versus
being cared for at home because of incontinence - I imagine, just a simple thing as the risk of falls is higher. I mean, they end up
rushing to the bathroom and or even letting some spill out it's, they could trip over that. I mean, there's and also
mental health I'm sure. Just because of the social isolation which we've been all experiencing in the last couple of years
can have a larger effect. - Yeah. It definitely like,
'cause like you mentioned, the risk of fall goes up,
the risk of fracture goes up and then of course, if it's
limiting your physical activity, your risk for a lot of other
things goes up as well. So it can be devastating. And there are people who are like, ah, this is life and they
carry on and they manage. But I think we're missing a
large percentage of people who aren't doing well with incontinence. - Do you have some numbers as, you know, how common urinary
continence is, would you? - Yes. So, I mean, the numbers
are as high as 50%. Once we end up becoming senior citizens, the numbers like for
younger folk are varied. I mean, there's some, I'm trying to remember more exact numbers, but there's, you know, for elite athletes, the likelihood of experiencing
stress incontinence depending on the sport can
be as high as like 75 or 80%. So I would say it's so much more common than probably we acknowledge
in many age groups. - Sure. Some of these we've already talked about, maybe we'll, I don't wanna bore people and is this audience is the lay person but what are the normal
workings of the bladder? How often do people void,
how do you make sure that you're emptying
the bladder completely? I mean, all those questions. - Great questions. That's actually, part of a lecture I give because it's like before you can decide, that it's not normal. Like most of us don't really
understand what's normal for bladder and bowel function. So for the bladder, it's pretty normal to be
able to go at least two hours up to five hours between
trips to the bathroom. There are things and I always say that, like I love to have the
asterisk at the end of that because there's times where
if I have three coffees, I might be going more
than once every two hours but there's an understandable reason. So there's always caveats to that. But you should be able
to go two to five hours between trips to the bathroom. As far as emptying all the way, luckily, our bladder has a lot of
autonomic nervous system controls. So that means it's automatic. It's gonna do what it needs
to do to keep us alive. And with that, when we void, or when we go to the bathroom and urinate, it's normal to have between
five and 50 milliliters of urine leftover in the bladder. If it gets to be more
than that very frequently, we wanna figure out why. And there's a myriad of reasons
why that might be the case. But with that five to 50
milliliters that is normal. And some people get very caught up in it. 'Cause sometimes we'll
finish going to the bathroom but then feel like we still
need to go a little bit more and we'll be able to get
out a little bit more about post-void residual,
and then we'll start to think we're not emptying appropriately. I like to remind people that the bladder functioning normally, it's a reservoir to store the urine. So having a little bit leftover is okay, and isn't a sign of anything bad. - Sure - So like kind of in a more general sense when everything's working well,
the kidneys make the urine, the urine comes in and
it kind of like starts to fill up the bladder, and it'll eventually,
usually like 150 milliliters, start to stretch the wall of the bladder and that'll give us an early
urge to go to the bathroom. So it's those kinds of stretch
receptors that are like, hey, we might want to consider
heading to the bathroom when it's convenient. But a lot of times that
first urge can go away and we'll kind of forget we had to go but the bladder is still filling up. And eventually it'll kind of reach that more critical stretch of like so really we might need
to take care of this. Go to the bathroom,
relax the pelvic floor. The bladder kind of helps
squeeze everything out and that's when
everything's working normal. - I wonder how much genetics
play a role into this, 'cause, I always feel like
I had, "a small bladder", all my life, I felt like, other
people could hold it longer than me and so. - So I'd say the genetics might play into the actual size of our bladder but I've definitely had
friends who have also claimed the small bladder syndrome. And I wonder, 'cause people's
bladders are different sizes but also I would say, just my opinion, a greater impact would be like how we're potty-trained
and how bladder and bowel habits were
managed, kind of growing up what we kind of perceived as normal. 'Cause a lot of, when you're a kid, there's times where you
completely ignore the urges because you're having fun. So you can just ignore it
until your bladder is like, seriously, it's time to empty
and then an accident occurs. But then also I remember very vividly, luckily it only happened before car trips, but the just go try just go try one more time
before we get in the car. And again, there's times
where that can be okay depending on how long
that car is going to be. But if you're trained to empty every time you leave the house that could end up meaning you're
going to the bathroom a lot and create almost a need
to empty more frequently. - Well, I grew up with, believe it or not, 10 brothers and sisters. So we only had one bathroom for a while. So maybe that's how somehow it evolved. - Also place to be alone for
a second, in the bathroom. - Exactly. Exactly. So can you discuss some
of the different types of urinary incontinence? - Yes. I think if I wish for
everyone to know one thing, two things about incontinence. One is that it's not normal
and that there is help for it. But also is that there are
different types of incontinence which is why something like
Kegel doesn't work for everyone. So the most common type
of urinary incontinence is urge incontinence. So this is incontinence that's
preceded by like a strong and sudden urge where you're
like, I'm totally fine. And then all of a sudden, not fine. And you have a strong
urge to go and then leak. Then the second most common
type of urinary incontinence is stress incontinence. So this is maybe what we
hear a little bit more. I definitely see it in my gentlemen who have had prostatectomies but also postpartum moms
will notice this a lot. You laugh, you cough, you take
a jog and you notice this. So stress incontinence is
when you have an increase in intra-abdominal pressure and you lose a little bit of urine, but also you don't have
an urge to go necessarily. - Would that be the high end athletes, who are they, the female athletes? - Typically. - Sure. - Yeah. Yeah. There are some sports
where urgent incontinence is a bit more common, but yes. So like for our runners or dancers, trampoliners, not surprisingly
have a higher rate of the stress incontinence. And then we go into like a
third type, which is mixed and this is a type where
again, when people seek help or read a book and they're
like, well, I did this, I did the Kegels and it
helped but it didn't fix me. Then typically I'm like, okay
well let's really look at this and figure out what's going
on because it's possible, you got stronger and
figured some things out for the stress incontinence,
but maybe there's still an urge component that wouldn't
necessarily be addressed by a stronger pelvic floor. - Oh, I see. - Yeah. So those are like
the three most common. - Okay, well, we'll get into
Kegels in just a minute here but I guess it's part of this question, what are the common treatment approaches to urinary incontinence? - I'd say the best first
assessment to decide the treatment would be actually a voiding log
or a bowel and bladder diary where people actually
write down their symptoms, not their symptoms, but
how things are working. So from a voiding log we can determine how long are they able to go
between trips to the bathroom. When they do go, how much are they going and what was their urge to go? So sometimes people will have
a really strong urgent urge and they'll get to the bathroom and it'll be just a little tinkle. Well, obviously there's a mismatch there and that would not necessarily be Kegels we might be looking more at what we refer to as like
behavioral interventions. So like looking at time voiding or urge deferment techniques, or even looking at bladder irritants - Actually, urge to, what was that? - An urge deferment. - What does that mean? - So there are some times
where we get an urge and of course our limbic system or our little lazy brain is like, Ugh, we're grownups, don't pee at pants. So we will attend to that
urgent urge as a real indication of how badly we have to go
and then run to the bathroom. Some times, once we
establish that that urge is perhaps a little bit overly,
a little bit elevated, there are some things we
can do to start to give that person a little more
control over that urge. And then, so then we can
wait a little bit longer between trips to the bathroom. - I see. So with that voiding log
are you also keeping track of what you're drinking, I imagine? - Yes. Yeah. So keeping track of what you're drinking and how much of it. So I have had people where, they were drinking honestly,
close to two gallons of water a day but their output was
approximately two gallons. So I'm like, there's, like
I don't think you should try to hold this any more. I think we need to look at why are we drinking two
gallons of water a day? But some people really notice
with things like coffee or drinks with caffeine
in it, carbonated drinks, drinks with artificial sweetener,
alcohol, citrus drinks. These are all things that some people, not all people find are
irritating to their bladder or increase their urge to void. - That's interesting. So yeah, it would be very
important then to log that out. I can see. So, we got kind of a family joke, I don't know if I should
mention this or not, but my mother-in-law, she, we
would take her on a trip and while she's drinking, she'd be going, Oh, I need a bathroom, I
need a bathroom really bad and, stop drinking right now. Maybe that's the most important thing, so. - Yeah, it's all about balance. And if everything's working
well, we're producing urine and we will eventually have to empty but sometimes just figuring out or getting things back on
track to where it's not, it should be mostly a
subconscious part of our day. Like it shouldn't be like, I
shouldn't be thinking like, okay, we have another X number of minutes and then I can go to the bathroom again. As I like literally stand
here and feel my bladder fill. Really it should be almost
subconscious until it gets to a point where it gets your attention and you can go like, noted,
and carry on with your day but it really shouldn't be
the driving force in your day. - Awesome. Lets talk about Kegels. - Okay. So I actually usually refer them as like pelvic floor muscle exercises because the Kegels most
people will kind of know, ah, contracting down there. But not really, as far as
exactly what to contract or how long the contract, or
how many times to contract. I like to remind people or educate people that their pelvic floor muscles, are really just other skeletal muscle, just like your biceps,
just like your triceps. So we wanna work them out in that way but also like your biceps and triceps. We don't just biceps, triceps and then never use them together. We integrate it into
our everyday function. Same with the pelvic floor. So doing Kegels or pelvic
floor exercises is a great way to work on coordination
and strength and endurance of the pelvic floor, but
then sometimes exercises, other than Kegels are needed
to kind of incorporate it back into life and where you may
be experiencing incontinence. - So in that case, are
you talking about like, I've seen different approaches
to this where I met, I think in your book, you
mentioned focusing just on the pelvic floor, but then
I've seen other people talk about incorporating some
leg muscles along with it. Is that a later thing to do then? Or is something that
you'll not agree with? - I don't completely agree with it. So there are times where
we could apply this to any muscle where we have
difficulty doing something. So sometimes I'll say like practicing your pelvic
floor exercises a little bit like practicing an instrument. Like, I mean, I can flex
and extend my fingers, that does not make me a great pianist. I'd have to work on that. So sometimes when people are evaluated for their pelvic floor, like they're like, I don't know how to do that contraction. And I certainly did this
earlier in my career, is we would use accessory muscles to try to get the pelvic
floor to do something. And there may be times where there's a good benefit for that. In my opinion, my clinical
thinking now is like, I wanna know more why they can't do that. So how's sensation, how's
neurological status, all of those things to kind of work out, why can't they do it? Do we need to go that route or do we need to just be patient and focus on helping the pelvic floor
do what it's supposed to do? So I've kind of taken out
the let's do something to be doing something to like, let's just do one little
thing and focus on it because there's some
great research research by Kari Bo, who is like,
kind of like the godmother of pelvic floor research in incontinence. And she's like if you want to make your
pelvic floor stronger, you have to exercise your pelvic floor. Well, we're using our pelvic
floor when we're walking, when we're running, when we're doing yoga, when we're doing all the
things, but it's not the same as doing a focused pelvic floor exercise. - I'm glad you clarify that because, like I said I've
seen different approaches where they recommend,
it seems like right away from the get-go using
the accessory muscles and continue with it, I suppose. Well anyway. So a what should happen during
a pelvic floor contraction? And I think you have ways
of kind of doing feedback that you can do on your own. - Definitely. So I'd say one of the challenges with pelvic floor contraction is, again, if we go back to the arms, if we go to the gym to pump
some iron with their arms, we can look in the mirror, we can see it, we can see the muscle contract. It's very rewarding, we
can tell it's happening. With the pelvic floor, it
is a little bit trickier. And again, definitely early
in my career using a mirror to actually look would be one technique but it's really hard to be in
a decent position as a whole and still manage to
get a mirror down there and see anything. So I really prefer tactile cues and just kind of normal awareness. So of course, now I'm
doing a lot of tele-health, I'll just ask someone what's, what are you feeling when you do this? What do you feel move? And I can kind of get an idea of like, is that the muscle that's
supposed to be moving or not really? So, but I do like tactile cues.
It's not that hard to reach. And then there are also other things that you could perhaps sit on that would give a little
extra tactile cuing to that area that should be moving. - Well, maybe I'll jump
ahead to that then. Is that the PFProp? Would
that do that sort of thing? - Yeah. That is a commercial
option available from OTPT that I get no money if anyone buys it. So it's kind of just like a foam cylinder and it does have two
sides that you can sit on. So if you're sitting on a firm
chair and you put it kind of between your legs, like
a very skinny bike seat, you can actually feel the
contraction a little bit more because there is that
extra proprioceptive input. So that's a good way where
then your hands are free and you don't have to do any
slightly awkward reaching. - Sure. Do you still do feedback,
a biofeedback in the clinic or is that kind of, I just remember a hundred years
ago that they used to do it. - Yeah. Great question. So there's definitely, we
have a machine in the clinic. I would say I do it maybe
two to four times a year at this point. And there's a couple of reasons why. So the type of biofeedback
I have in my clinic is what they call EMG. And so we can use a
vaginal or a rectal sensor and it's recording the electrical activity in the pelvic floor. And I have seen it be
very helpful for people who have trouble feeling good
about what they're doing, like feeling confident
they're getting it right. But it's always with a big grain of salt 'cause actual numbers on as far as like how many microvolts you're
producing, vary a lot. And so there really isn't like, well, if you can hit a hundred,
you're strong enough. It doesn't really correlate
exactly to strength. So it's more activity. And then also, typically
people can't take it home. So there used to be, there's still are some various
pelvic floor feedback things that are out there in the world. But again, people find super helpful. If they can use it at home, I'm more than happy to help
them learn how to use it and understand and interpret what the feedback is telling them. But sometimes I would see
patients get way too focused on the numbers or how
high the graph was going and lose the internal awareness
as to what they were doing. 'Cause ultimately we wanna
finish with biofeedback and just be healthy and normal. - Obviously this year with Zoom or whatever you've been using,
you haven't had the option. So how has that turned out for you? I mean you still find
you've been pretty effective through Zoom. - Actually, yes. It's actually kind of amazing. It's really made me think more
and realize exactly how much of what I do is actually education and helping people understand themselves as opposed to me poking and prodding and telling them what to do. So it has been very helpful. There's actually been a couple of studies for pelvic floor issues like incontinence, pelvic organ collapse,
just out in the last year because of COVID that telehealth interventions
are actually quite helpful and quite effective for pelvic issues. - That's really advanced. The tele medicine world has an edge. So I know this was covered in your book. What should happen during
a pelvic floor contraction and what should not happen during the pelvic floor contraction? - I would say the way
I usually explain it is what should happen,
the muscles underneath, so basically the muscles
that would come in contact with the bike seat, you
should feel them kind of draw together and pull up and in. And then I always like to remind people, that when you stop contracting, you should feel them kind of
go back to where they started, keeping a muscle contracted
all the time isn't strong. It's not how muscles work. So you should be kind of like
feeling kind of dropping in and then go back to where
it started when you stop. A lot of instructions online will talk about abdominal muscles
when you're doing a Kegel or a pelvic floor contraction. And the transversus abdominis
muscle, which kind of wraps around our middle like
a corset is best friends with the pelvic floor. 'Cause the pelvic floor is actually like 70% endurance muscle. Because of it, it's part
of our posture system. So when we stand up straight, we shouldn't be clenching anything but there is more activity
now in those deeper abs but also our pelvic floor. So when you do a really good
pelvic floor contraction, you might feel your lower
abs pull in or tension. Totally fine. If it looks like someone just
punched you in the stomach 'cause you're working really hard and your voice changes, that's too much and that's another thing. So again, so tensioning,
lifting up and then down below and then maybe some lower
tensioning in your abdomen but then what shouldn't be happening is, I like to say your face shouldn't change and your voice shouldn't change. So face should stay
relaxed, no Kegel face. Your voice shouldn't change
while you're doing it. But also really looking
down at the lower leg. So like your inner thigh
muscles, your glute muscles, usually on tele-health, I'll tell people if I see you getting taller I know you're using extra muscles because you'll do like a glute set. You'll get higher and then down. So another cue I'll give people is that nobody should know
you're doing these. So if you're practicing them, so like I'm now doing right now
and you should have no idea And then when I stopped doing
it, you should have no idea. It's all very subtle
and not using anything. that would be very obvious. - Do you mind giving some
of your most effective cues? I know, might be a little graphic. The one you had for men
really worked for me. - Do you want to know what's funny. So this hasn't been looked at in research, but actually a lot of women
respond well to that one because we can use our imagination. - Really? - Yeah. So probably the most traditional,
two most traditional ones are contract like, you don't wanna, like you want to stop the flow of urine, or squeeze like you don't
want to pass gas in public. And even if you just do
those two things, you can, a lot of people can feel
like a slight difference. And in the accent of the pelvic floor, like where it's contracting. So sometimes I'll say that finding the right pelvic floor cue, it's a little bit like being
dropped into a foreign country and not knowing what
language people speak. So people are confident
about pelvic floors. When I am able to do like
say a vaginal or rectal exam, I'll start out with like,
well, can you feel my finger? And then can you squeeze it? Or can you imagine pulling it up and in. Another great cue in sitting is like, imagine picking up a precious
stone off of the chair without using your hands. So kind of getting that kind
of like gathering and lifting. Now the cue - Use of toilet paper,
right, and you could do that. You can also do that. I think, I wish I had
my pelvic floor model but if you Google an image
of the pelvic floor muscles, they go from the front to the back. So reaching back, most people, as long as they're physically
able, can reach backwards as if they were going to
wipe to clean themselves. So you can use just a
little bit of toilet tissue, when you find that anal sphincter, you are kind of picking that tissue up off of your finger, which is good. That is the posterior
part of the pelvic floor. But like I said, the pelvic
floor all works together. We can favor the front or the back. That might be favoring the back but that's a great place
to start for some people especially if they're not sure what to do. That's a great, it's
a fine place to start. - So am I right in saying, though, women should not stop their
flow of urine as a practice? - Yeah, so, I certainly
don't recommend that on a regular basis. It can be a fine functional test. Meaning if a woman feels like
she tries and she can't do it, if she tries again in two or three weeks after working on her
exercises if she tries and she can stop it. That's a definite
improvement that she can see. But doing it regularly
might create some confusion. So I mentioned earlier
like going to the bathroom like you're relaxed your pelvic floor and the bladder squeezes,
we mentioned urge deferment. So some times you can
squeezer the pelvic floor and have the bladder relax. But if I go to the bathroom
and I relax my pelvic floor and the bladder starts to
go, and then I say, nope, and then you start to go, nope, it can be a little bit confusing. There isn't evidence that it creates any huge
physiological issues, that would be really bad, but it may impact bladder function. And there's just other ways to do it. - That are more effective. - That are more convenient
and more effective, yeah. Should we go back to the
cue that worked for you? - Yeah, sure. Maybe you are gonna avoid that one. - Oh no, oh no, I love this
one so much because even, so if there's any ladies watching
at any time give this a shot Is that really, the cue is
to like draw in the penis. And it's like a very, I
like to have people feel how the contractions feel
different depending on their cue But like that draw in the penis and get way more like
anterior pelvic floor which is where urinary
incontinence happens. And a little bit, I get a nice
little lower belly tensioning when I do that even though
I don't have a penis. So it's a good one, try it. - Yeah. Well, they all
worked for me to be honest but that seemed to be the
one that resonated most and was effective. So this kind of alludes to what we were talking about earlier or how long before you would
expect to see some results, or how long before you think,
oh, this just isn't working? - Great question. So again, just kind of
my clinical observation that there tends to be a much bigger issue with like pelvic floor
coordination and awareness as opposed to like true
pelvic floor weakness. So if I do a test and you're not very good at
contracting your pelvic floor, it probably won't test super strong. But the good news is with
that is that coordination and awareness can improve
a lot faster than shrink. - Right. - So to really get those
true strength grains, like we go back to
strength and conditioning, we're looking at like,
what like eight to 12 weeks of regular strength training
to like hypertrophy muscle and all of that. I do see changes much
more quickly than that. So I think again, most of the time that's a matter of
awareness and coordination than anything else magical happening. So, it can happen. I mean, I've had people
come in for two visits and say like, weirdly enough, I'm okay. Other people it does take the time to kind of build up that stronger base. - So what are some of the other options beyond Kegels for, let's
say urinary incontinence. I mean, let's say the
normal urge incontinence? - So urgent incontinence, one of the first things I wanna make sure if possible is that the
pelvic floor is relaxing. So sometimes again, if we
kind of go back to that how it's kind of supposed
to be a conversation between the pelvic floor and the bladder, but if the pelvic floor is
kind of always kind of tense that the bladder, sometimes I'll say it's
like an old married couple where it's like the pelvic
floor is not being quiet and the bladder it's
just slowly going, like, I'll talk louder, if you want me to. And that bladder kind of
becomes a little overactive or giving you, kind of
elevated urgency messages. So making sure pelvic floor
function is still good is important, but strength
usually isn't the issue. It's more that they need to relax. Oddly enough I might still give them
what seems to be Kegels but more for that awareness and proprioception aspect
as opposed to strengthening. So if I just tell you to relax a muscle that you weren't contracting on purpose, it can be really frustrating but also for a muscle, you can't see. So like I could take
your shoulders and go, let's bring them down a little. The pelvic floor is a little harder. So sometimes I'll use a
little contract, relax with the focus on feeling like, so can you feel the contract, yes. Do you feel, do you feel the let go? Eeh, not so good. Okay, let's just take a little break take a couple of breaths. Let's try it again. And kind of focusing
on finding that let go and having that be the first
thing to make sure again, the pelvic floor is doing its job. But then with other urgent incontinence or urgency and frequency
where you're not leaking but it's frequently a
close call is, I mentioned like behavioral interventions. So sometimes it's doing that voiding log and going like, okay, so during the day, like here you are sleeping
through the night fine but you're going to the
bathroom every 45 minutes during the day. What do you think would be
a reasonable goal to stay out of the bathroom? Like how long do you think you could go? And, you know, sometimes I
had one person where honestly, we were going in one minute
increments because more than that kind of excited
their nervous system too much. But you know, some people are like, well I could wait longer. I just don't. Okay. Let's try that and then slowly
what'll happen is it's almost like a recalibration of
the signals where now where you maybe used to
get high alert half full. Now you're not getting high alert until you're three
quarters of the way full. So just by stretching the time
out slowly, but also looking at those, what might be
irritating your bladder. And also looking at those bladder habits. Are you going just in
case before you leave and when you get to
every place you go, okay. We need to start skipping
at least one of those 'cause you only leave
10 minutes from work. So you don't have to pee before and after looking at it from that way - This could go back to the like maybe a
carbonated drink or coffee or it could be a possible irritant that if you don't get rid of that you're still going to
have to have trouble. - Absolutely. Well, and I think
sometimes people think it's like an all or nothing perspective. One of my very first
patients was actually, she did home health. So she's in her car all day,
but she would drink like, what is it like 16 ounce iced
tea, which has caffeine in it between each patient. And really, I mean, it's a lot, as I was like five to
seven of those a day. But then, so what we did is
we're like, well let's just try, what if you alternated? You can still drink the same amount. What if you alternated tea and water? And so just by limiting, by
taking out, ended up being like half of her caffeine, she
was drinking the same amount but she was able to not
have those accidents. So those urgencies. - That's interesting. You know one thing we had
mentioned with Kegels, how long do you hold a contraction? I heard you mentioned different
lengths depending on, well, I guess you mentioned different
lengths of time, I believe. - Yeah. So I usually don't have
people have a goal more than 10 seconds. Mostly because it is an
endurance muscle anyway, we can use it in other ways. And also to be perfectly frank, we start to get really bored holding it for longer than that. And I've actually started using
breaths instead of seconds. So if we think about how long
it takes us to just do a nice (breathing in and out) it's about five seconds and a
common error that people make with Kegels is they, they hold everything for five,
six, seven, eight, nine, 10. And I'm done. While if I'm like, instead,
can you just contract, breathe in and breathe
out twice and then relax. Now we've tricked them into actually contracting
their muscles, breath in which is good for everything. And also not rushing through
a count of 10 seconds. - Right. Cause people start going one, two, three four, five, six, seven, eight, nine, 10. So that's a very good cue. So how would someone
find someone like you? I mean, let's say, we're in Minnesota, how do I find a therapist who's trained, has additional training? - Great question. So the Academy of Pelvic
Health, which is a section of the American Physical
Therapy Association as well as the American Physical
Therapy Association itself, both have find a therapist searches and you can pick the specialty. So you can find a
women's health therapist. And I believe they're still putting it under women's health when
really it has been expanded to pelvic. So for, if someone doesn't
identify as a woman, there are people out there
who are happy to help. And very often in the profiles
on those two websites, it'll say kind of more
specialty, like some therapists on that site will just
be more like pregnancy and postpartum without
necessarily addressing any sort of internal pelvic floor or
incontinence specifically. So you can find out a little bit more. If you're not sure, two
things I do as well, and you can find me on Twitter and you can tag me on
Twitter and I'm happy to kind of take a pick in my
network and see who's around. But also I think finding
a physical therapist for an issue like this or
anything else is a little bit like finding a hairstylist
you love or a massage, like it really is kind of a relationship and we all have different
approaches and different styles. And I might not be your cup of tea but someone else would be. So I like to come up with kind of a, I can describe a short list of questions you might wanna
ask or kind of what type of therapies would be in line
with best current practice and current evidence. So you can ask, if you're
just going to do biofeedback and e-stim, I'd argue that's not a fully
comprehensive pelvic floor plan for incontinence. And also remind people that
they should be getting better. You asked how long, how
soon might we see change. We could see it right
away, it could take longer, but if you've been at it
really diligently for 12 weeks and you haven't seen a little change, something else needs to change,
you're doing a great job and it's just not the thing
that's going to fix you. - So I think we're gonna cut off here. I wanna again mention your book for Urinary Incontinence, understanding and treating incontinence what causes urinary incontinence and how to gain bladder control. Also want to mention, they can find you on Twitter @SarahHaag
S-A-R-A-H-H-A-A-G-P-T. And then she has a website
for your clinic, correct? - For the clinic - Entropy, I keep saying
this wrong entropy.physio.com No. - No, just .physio. - E-N-T-R-O-P-Y-.-P-H-Y-S-I-O Probably I can, just a little
bit, anything else, Sarah? You're in Chicago. If people want to look you up and they certainly can on Twitter. - Absolutely. I mean, Twitter I'm there quite frankly, frequently. I'm in Chicago. I live there. I'm coming to summer when it's nicer and everyone can be outside
and safely distanced. - That sounds great. Well, thank again. Thank you again for taking
the time to be on our show and I hope we can have you in the future and talk about
some men's health, then - That would be great. I feel like men are super
underrepresented in pelvic health so I'd love to have that opportunity. - Awesome.
