Ep. 460 Pelvic Floor Health: Role, Dysfunction & Vital Conversations with Kim Vopni

I am delighted to connect with Kim Vopni today, who is passionate about sharing information on pelvic health. She is a self-professed pelvic health evangelist known as the Vagina Coach. She is also a certified fitness professional, a published author, and the founder of Pelvienne Wellness Inc., which offers pelvic health programs, products, and coaching.

In our discussion today, we dive into the role of the pelvic floor, looking at the core four and the challenge of addressing uncomfortable topics. We explain why the diaphragm is significant, and we look at the ABCs of posture. We also explore the impact of incontinence, constipation, overactive bladder, pelvic organ prolapse, and some common ideologies of pelvic floor dysfunction, including footwear, ankle positioning, and hypermobility issues.

This invaluable discussion with Kim Vopni is a complementary conversation to the recent episode with Dr. Rena Malik.

IN THIS EPISODE YOU WILL LEARN:

Why most women feel embarrassed or are secretive about having pelvic floor or genitourinary issues
The role of the pelvic floor in avoiding continence and supporting the internal organs and the sexual response
Why it is essential to address pelvic floor issues early
Kim explains her concept of the core four
Importance of proper posture and breathing for pelvic floor health
Constipation may lead to pelvic floor issues.
How statistics highlight the need for more awareness about the prevalence of incontinence in older women
Benefits of pelvic floor physical therapy and biofeedback devices for managing fecal incontinence
Symptoms of pelvic organ prolapse
Why individuals with connective tissue disorders have an increased risk of pelvic floor dysfunction

“If you are not hydrated, you are not going to poop well. That will also contribute to your urinary symptoms.”

-Kim Vopni

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Connect with Kim Vopni

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On all social media channels: @vaginacoach

Kim’s book, Your Pelvic Floor, is available on Amazon and most major bookstores.

Transcript:

Cynthia Thurlow: [00:00:01] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

[00:00:29] Today, I had the honor of connecting with Kim Vopni. Kim Vopni is a self-professed pelvic health evangelist and is known as the Vagina Coach. She is a certified fitness professional who is passionate about sharing information on pelvic health. She's also a published author and the founder of Pelvienne Wellness Inc., a company offering pelvic health programs, products and coaching.

[00:00:52] Today, we spoke about conversations relevant to the uncomfortable nature of discussing pelvic floor health, the role of the pelvic floor, including the core 4, the importance of our diaphragm, the ABCs of posture, the impact of incontinence, constipation, overactive bladder, pelvic organ prolapse, and common etiologies of pelvic floor dysfunction including footwear and ankle positioning as well as hypermobility issues. You will find this to be an invaluable and complimentary conversation to the recent podcast with Dr. Rema Malik.

[00:01:32] Kim, such a pleasure to connect with you. I was just sharing that your book was enjoyed by my puppy. He chewed up the first copy that you sent me so I had to buy a second. So welcome to the podcast.

Kim Vopni: [00:01:45] Thank you. Really honored to be here. I appreciate it. Thanks so much.

Cynthia Thurlow: [00:01:46] Yeah. So why is it that we're so uncomfortable talking about pelvic floor health? Anything related to the genitourinary system, is it a systemic wide issue? Why is there so much shame and secrecy around this?

Kim Vopni: Mm-hmm. Yeah, we can point to a lot of things. I do think it's a systemic thing for sure. I think we've just-- In our generation we witnessed our parents where our mothers, let's say in particular, who we don't talk about these things, that everything's very private. We knew nothing. Nothing was shared with us at all. And we now have-- We haven't necessarily grown up with social media, but we have-- It's been part of our life for a long time and a lot of messages, a lot of information is now being shared that is causing us to say “Well hold on a second, why didn't anybody tell me about that? And we look to our mothers, why didn't they?” And that was their generation.

[00:02:42] We're now a generation that is not putting up with it. I think there's also the millennial group of people who-- They have really been a force of not putting up with anything and really getting messages out there. So, we're kind of in this in between zone where we're starting to become comfortable talking about it, but we just grew up with, we had to hush the word vagina. And I'm all for giving some funny names to it, but we also have to step boldly into anatomy and call things what they are, but that's just not how were raised. It's not typically what we--

[00:03:17] It's also perpetuated with messages we see in the media. The ones that make me cringe are the incontinence pads and underwear that tell us that it's just part of being a woman. So that is just another way to silence us and say, “Well, I guess that's just what happens.” And if we were to ask. I hear from people every single day still. I've been doing this for 20 plus years every single day, I still hear from women who say, “My doctor said, ‘what do you expect as you age? What do you expect after you've had three children?’” And they're constantly dismissed. Then they're seeing the ads. They've never heard it from their parents. So, they're stuck in this place of acceptance of something that is so treatable and something that it's a part of the body that really deserves a whole and a lot more attention than it gets. I think it's the center of our universe. It's responsible for so many things in our life, and we don't think about it until there's a problem. And then it's one of the only things we think about because it influences our sexual health, our activity, our social outings, our elimination. It influences everything.

Cynthia Thurlow: [00:04:22] Yeah, it's so interesting. So, I was raised in a family of a lot of medical professionals. So, my grandmothers were all about using appropriate anatomical terminology. And I remember I was not allowed to call my vagina or my vulva by anything other than the appropriate terminology. But what's interesting is the anatomy piece was discussed, but nothing else. I think that I was probably 12 years old, and I think it was the summer that both my parents-- My parents were divorced. They both had conversations around periods and things like that. And that was probably a little bit more progressive. But beyond that, my mother never discussed with me what it was like going into menopause.

[00:05:03] In fact, I think there was so much shame and secrecy in that generation, even talking about their age or talking about end of their fertility or any of these things. And so, I agree with you that we are neatly sandwiched-- We truly are the sandwiched generation right now. Neatly sandwiched between differing generations of women, some of whom are more comfortable talking about what's going on with their bodies. In fact, I'm embarrassed to admit this, but it was on Facebook. There's a Dark Nurses Humor Facebook group, and it's exactly that, “Dark Nurses Humor.” And it's mostly nurses that are in there, but I'm in there because sometimes there's really funny memes. But they had brought in someone on TikTok who was explaining to women how to wash their vaginas.

[00:05:45] And the nurses underneath it and more of them were male were saying, “I think we have a generation where the whole discussion around personal hygiene has been missed.” And they were saying, “Because we are the healthcare professionals and we see this.” And so, it was just fascinating to me, social media in many ways can be helpful. And I think for some women, maybe they're not aware that there's a way to go about washing your genitals. But having said that, I thought it was fascinating. This might be one of those bridges of-- this is probably helpful information for people who need it, who may be their mother or their sister or their friends are not talking to them about some of these hygiene pieces.

[00:06:21] Having said that, one of the reasons why I wanted to bring you on the podcast was you do such a beautiful job of making information accessible for women and doing it in a way that is sometimes funny, but funny, we're not laughing at women. We're laughing at the experience that we're going through. And I'm chuckling with some of the things you have behind you, which people that are watching this episode on YouTube will be able to see up close and personal. Let's talk about the pelvic floor.

[00:06:47] I think most of us don't even think about our pelvic floor. We think about a Kegel because we were told we're supposed to be doing Kegel’s. I've come to find out most people are doing them wrong. And for those of us that have had pregnancies and have had childbirth, irrespective of whether or not you've had a C-section or a vaginal delivery, you very likely have some degree-- even if it's minor, some degree of pelvic floor dysfunction. But what I find is most patients, A, are unaware of this. B, it doesn't get diagnosed until it's significantly worsened and C, the beauty of it is a lot of what's going on with the pelvic floor can be fixed without surgical intervention, and there's certainly a place for that. Let me be clear. For me, the more I humbly understand about the pelvic floor, the more I'm just so appreciative and grateful for the synergy of muscles and nerves and tendons and blood vessels and ligaments that literally support our body.

Kim Vopni: [00:07:41] Yeah, yeah. And that was-- I grew up-- Similar to you, my mom was a nurse, and she was very open with proper anatomical terminology with my brother and I, [Cynthia laughs] and at the time, it's cringy right? when you're learning this with your brother. But I'm grateful for that experience. And she didn't necessarily openly share what she was going through, but if I ever asked questions, she would share. And her initial stories were about-- She always used to run. And when I asked her why she stopped running, it was because she was having bladder leaks, and she complained of back pain, and she complained of a tummy that wouldn't flatten no matter what she did from exercise. And her response was, “Oh, it's because of your brother and you.” And I remember that from an early age. And so that painted the picture of, “Okay, I’m not having babies.” And I also saw a childbirth video that was also confirming, “Nope, don't want to do that.”

Cynthia Thurlow: [00:08:28] [laughs] I think I'll pass on that.

Kim Vopni: [00:08:31] Yeah. So, growing up, I was pretty adamant that I was never going to have children because I had the image that it ruins your body, wrecks everything, and you're not going to be able to do anything afterwards. And so, anyway, fast forward, I get married, I did want to start a family, and my midwives had recommended a product to me that was a way to help prepare for childbirth. So being a personal trainer, you mentioned a group of muscles. We don't view the pelvic floor. I've never even heard the term pelvic floor when I was working on those muscles. But it is a group of muscles that can be trained just like the rest of the muscles in our body. And being a personal trainer of all of the muscles, I learned every other muscle in the body, but I didn't learn about the foundation of the core and yet we are teaching core exercise left, right, and center, so that needs to change, and I'm working on doing that.

[00:09:23] But this incredibly powerful, important group of muscles that is our base, is our foundation. It is the foundation of our core, and it is responsible for our continence. It is responsible for supporting our internal organs. It is responsible for pelvic and spinal control and stability. It's responsible for our sexual response. It works in synergy with our diaphragm to help move lymph and what have you around the body with our breath. These are really, really important jobs. And we have never been told anything about this. As you say, we might have heard the term Kegel. And then we think, “Yeah, we're supposed to do Kegel’s,” but no one has ever evaluated our pelvic floor. Nobody has ever evaluated our ability to perform what we think is a Kegel exercise.

[00:10:12] And so we have loads of evidence to show that Kegel’s are effective when they're done correctly, when they're done consistently. We also have evidence to show that the majority of women do them incorrectly, again because they've never been taught. And the expansion on the work of Dr. Arnold Kegel, who developed the exercise. It's a voluntary contract to lift and let go of the pelvic floor muscles. Expanding upon that, it's a limitation to think that-- There's no other muscle group that we just squeeze and release and squeeze and release. We take it through a range of motion. We go in various planes of movement. We experience load. We experience impact. So why are we not training the pelvic floor that same way?

[00:10:57] And if we had this information earlier in life, being females going through menstrual cycles, many of us becoming pregnant at some point, all of us, if we're reaching midlife, going through menopause, there's huge changes that happen to all the muscles in our body, but also to the pelvic floor. And when we had this information earlier, we are in a position of power to make choices about what we do along the way, as opposed to all of a sudden dealing with-- And pregnancy and childbirth are definitely major catalysts for this. To all of a sudden be dealing with a problem and thinking, maybe being told that surgery is the only option, maybe seeing the ads and thinking, “Well, I've had a baby. I guess I just leak now, and so I just have to wear pads.” Or experiencing pelvic organ prolapse, people thinking sometimes that they have a tumor inside of them because they have never heard the term. Prolapse is statistically more common than incontinence, yet we never hear about it, and nobody ever screens for it, and it's the one thing that halts people in their tracks more so than incontinence, so we have some work to do.

Cynthia Thurlow: [00:12:04] Yeah, absolutely. And it's interesting, my grandmother, who is deceased, but I'm sure as a nurse, would not mind me sharing the story. She was being hospitalized, and, gosh, this is probably 15 plus years ago, and I was helping her get from her bed to her bedside commode, which is like the bedside toilet for those that are less familiar with what that is. And I noticed my grandmother was putting her hand down in towards her genitals. I said, “You know, grandma, what are you doing?” And she was explaining. She said, “Oh, well, I've had five vaginal deliveries, and I have both a bladder prolapse and a rectal prolapse.” And so, she was explaining to me the mechanics of what she had to do to urinate. And I was stupefied. And she said, “Cynthia, in our generation, we didn't complain. We just dealt with it.” And she said, “We got accustomed to wearing pads, incontinence pads.” And she said, “It wasn't that I was incontinent. It was if I couldn't get to the-- if I got to go, got to go, got to go to the bathroom, I didn't want to have an accident.” And so, she was just explaining to me, as nurses do, her way of dealing with this issue. She said, “I never thought that I would be a surgical candidate.” And I said, “Why not?” And she said, “Well, no one ever talked to me about these things. I just figured it out on my own.”

[00:13:19] And all I could think of was, this is a very observant clinician noticing that she herself is dealing with not just one, but two prolapses. And I think there are hundreds of thousands of other women that, whether it's they urinate when they cough, they urinate when they do jumping jacks, they have an overactive bladder like all of these things we think of as just the shared experience of aging. And a lot of your messaging, and certainly my own is like letting people know there are ways to deal with these things. And again, it does not automatically go to surgical intervention. There could very well be things that you can do that can safely improve your pelvic floor that can lessen the likelihood of you ever developing these things.

[00:14:03] And so, I think when I'm thinking about the anatomy of the pelvic floor, I think a lot of people don't understand that our diaphragm and how we breathe or how well we don't breathe. I think a lot of people breathe very shallowly. How does the diaphragm impact the health of our pelvic floor? And do you find that most women that you're working with are shocked to understand that this is actually the roof of the pelvic floor? I think they think, “Oh, my lungs and everything. Oh, it's kind of nicely tucked away. There's no interrelationship between the diaphragm muscle and our--"

Kim Vopni: [00:14:39] I use a term called the core 4, which highlights the top of our canister being the diaphragm, the bottom of the canister being the pelvic floor, and the sides, front and back. Front would be the transversus abdominis, which is our-- People call it corset muscle. It's our deepest layer of abdominals, and then the multifidus along the spine. And so, these four players, this unit works synergistically for all of those jobs that I had listed earlier. And when one of them is not working optimally, it can throw the synergy off and could contribute to pain or incontinence or prolapse or poor digestion or poor breath.

[00:15:23] And so first thing we need to do is harness that relationship to improve-- to regain optimal function and then to promote it going forward. And there's many reasons why it can become disrupted. It can be from falls, from surgeries, from pregnancy, from childbirth, from posture, from the occupation you have, like so many things can disrupt this synergy. And with the right awareness, we can retrain and get that synergy back. So, every time we take a breath in, what should be happening is our ribs should expand laterally to allow the diaphragm to essentially flatten. Then what should happen underneath, reciprocally, is in that core 4 system we're talking about is the transversus, the belly should expand away from the spine, and the pelvic floor muscles should also expand and lengthen and that allows for oxygen to come into the body. It allows for some movement and massage of the internal organs, which people don't think movement of the organs is a good thing, but they are all moving, and we do need that to happen.

[00:16:33] And then the reciprocal exhalation is where the pelvic floor naturally contracts and lifts. The transversus naturally draws in towards the abdomen. The diaphragm comes back up to its arched position, and that should be happening all day long without us thinking about it. When we have a disruption again, there's many things, but one of the big things that I see is posture how we hold ourselves through the day. We as a society now, we spend a lot of time sitting, and often we're sitting in more of a posteriorly tilted pelvis. So, if you happen to be sitting right now, if you pull the flesh of your butt cheeks away, you should feel some bony points in your butt. Those are sits bones. We should be sitting on those. And then the third kind of point of our tripod would be our vulva would be on the surface of the chair, but many of us would be sitting--

[00:17:25] We might still see or feel our sit bones, but our vulva would be lifted and we'd be more on our tailbone. That in and of itself can really disrupt that synergy because when the pelvic floor is in that tucked position, it will become-- It'll adapt to a shorter, tighter position so that lengthening that we need doesn't happen. The abdomen also will be more-- We become quite grippy in our side abdominal muscles and our obliques. We can't get that nice descent of the diaphragm when we are in that collapsed state. So, we end up starting to breathe-- I see you shifting into your posture better. [laughter] We end up breathing more shallowly. Our digestion becomes impaired. We may start to deal with constipation. And that tightness in the pelvic floor--

[00:18:15] People interpret, tight is good, tight is strong. I want a tight vagina. The pelvic floor muscles, any tight muscle is not a strong muscle. A tight muscle has poor blood flow, poor circulation. It can't respond at the right time with the right amount of force. It can't develop as much power. So tight is not strong, tight is weak. And that tight pelvic floor that has adapted to that tucked position now cannot respond to the laughs, the coughs, the sneezes, the jumps, the whatever, and so it can't close the openings off to manage our continence. It doesn't support the organs. And we actually now even have created more downward pressure on those organs, so there's more likely to be prolapse.

[00:19:00] We're sitting on our tailbone. We're probably going to develop some tailbone pain, some SI joint pain, low back. It starts this cascade event with something as simple as posture. So, when I say ABC’s, we want to work on our alignment. Our alignment, it's like the byproduct of our posture. Then we want to work on the breath. So, we want to harness that relationship between the diaphragm and the pelvic floor where inhales lengthen and expand the pelvic floor, exhales, contract and lift. Then we want to coordinate into movement. I mentioned that my term, core breath, is basically a Kegel, but it's trying to highlight that the pelvic floor is the foundation of the core, and it works in synergy with the diaphragm and the breath is a really critical part of optimizing function.

[00:19:45] Then we coordinate-- The C is coordinate that into whole body movement, and that could be bridges, squats, lunges, pushups, all sorts of things. We can turn a lot of things into a core exercise by doing that. So, we always start with the ABCs. And then we also need to use visualization and cueing, because while we can see the external genitalia, we can't see the internal group of muscles. So, I can't go to the mirror and flex like I do my biceps or my legs and see that motion. And a lot of people are disconnected, maybe from scar tissue, maybe from trauma, maybe from nerve damage, like many different contributing reasons. Maybe we just have never thought about it. So, to access that group of muscles, we need potentially Biofeedback, some imagery, some cueing to help harness that relationship of the breath with the pelvic floor.

Cynthia Thurlow: [00:20:40] It's also very interesting, and one thing that you touched on, I just recently interviewed a urologist, and we talked a lot about why constipation is not benign.

Kim Vopni: [00:20:51] Mm-hmm.

Cynthia Thurlow: [00:20:52] And in your clinical experience working with your patients, how many women don't understand that interrelationship with pelvic floor dysfunction and chronic constipation? I'm not talking about-- most go on vacation and maybe because it's not your normal toilet, you don't go as regularly as you do when you're at home, but how many thousands of women think it is normal to poop twice a week?

Kim Vopni: [00:21:15] Mm-hmm. Sorry to interrupt you. Most people in my community are-- And again, hydration and constipation actually come even before the posture piece. If you're not hydrated, first of all, you're not going to poop well, and that's also going to contribute to urinary symptoms, but if you're not pooping well, and if you're straining to poop, constipation is going to make you feel like you need to pee more. And when you're straining to poop every day, you're literally not getting the shit out, you're recycling your toxins and your hormones, and you are straining. It's like a little mini childbirth whenever you do poop and that's damaging to your pelvic floor.

Cynthia Thurlow: [00:21:50] That just sounds unpleasant.

Kim Vopni: [00:21:51] Yeah.

Cynthia Thurlow: [00:21:52] I have a wonderful family member who will remain nameless that we jokingly refer to this individual as the non-public pooper. Meaning if this individual leaves their house, I'm not even sharing their gender, not anyone that lives in my house. If they leave their house, they cannot go. So, when they go on vacation, they're miserably constipated. They have to go on a business trip, they're miserably constipated. And I always say, like, “There has to be something you need to work on here because this is not the way that you want to adapt to the aging process.”

Kim Vopni: [00:22:19] Yeah.

Cynthia Thurlow: [00:22:20] Let's talk about incontinence. Again, if we look at-- If you're watching regular TV and you see these continence products. These essentially adult diapers and pads and things like that, we're normalizing what is not normal. And instead of encouraging women to go to their pelvic floor expert, their urologist, their GYN, we're normalizing something that is a sign that there's an imbalance in the body. I think the statistic in your book that really stood out to me is 38% to 55% of women greater than 60, up to 75% of women older than 65 years old report leakage. So, this is a very common shared concern and issue for women at this stage of life. And one in four women over 18, so younger women too, have episodes of leaking urine involuntarily.

Kim Vopni: [00:23:13] Mm-hmm. Yeah, and we think of it as just something that happens to older people.

Cynthia Thurlow: [00:23:17] No, it is not normal. So, let's talk about I think the most common version of incontinence is stress incontinence, let's talk about that. Especially for women that are experiencing this, again, they don't think it's a big deal, but it's over 15 million women in the United States alone. So, the ramifications of worldwide concerns around this, especially as 6,000 women a day go into menopause, I mean, that number is exponentially higher.

Kim Vopni: [00:23:44] Yeah, yeah. And that's exactly right. When you look at the statistics, they're alarming already. And you know that there are many people who are not reporting that. They are not being asked. They are not telling their care providers. They're not reporting. They're just suffering in silence. So, there is a lot of people struggling with the problem of incontinence. And there’s-- I mean, I want to separate out the different types. The one that we see when we're looking at the ads on TV is most commonly associated with stressed urinary incontinence. And this doesn't mean that you're stressed and you're going to leak. It just means where there's some sort of exertion that happens, some increase intraabdominal pressure.

[00:24:21] So, I talked about that core 4 system. Our intraabdominal pressure is what is contained in that core 4 and there are things that contribute to increasing and decreasing it all day long. Me standing up from my chair increases intraabdominal pressure. And for a while in the pelvic health world, it was sort of preached that we want to avoid anything that is going to increase intraabdominal pressure and that's just not accurate or real life. We need to build a pelvic floor that can manage intraabdominal pressure. And so, we have stress urinary incontinence being laughing, coughing, sneezing, picking up a grandchild, pushing a heavy door open, standing up from a chair.

Cynthia Thurlow: [00:25:03] Jumping jacks.

Kim Vopni: [00:25:04] Jumping jacks, yeah. [laughs] Jumping on trampoline. Those are very commonly associated with leaking a little bit of urine. And it's usually a little bit, like, drops, people will put a pad on. And often people that just accept it and they carry on. Then we have urge incontinence. And that is where maybe the person doesn't leak at all, but there's some sort of trigger that happens. Sound of running water, talking about a bathroom, seeing a toilet, putting the key in the front door when they get home, those are all, now they have become conditioned. The bladder has become conditioned with those behaviors to associate that with urination, and so it'll start to send signals that you have to go and it becomes frantic. Sometimes people will leak a little bit on the way to the bathroom. Sometimes people will have a complete release of their bladder. And you can imagine how life altering that would be. So, then people start to avoid social interactions, exercise, or they're always peeing just in case. If I pee before my exercise class or before I leave my home, I'm not going to need a bathroom. Then we create another problem of frequency where the bladder starts to think that it should void when it's a quarter full or half full as opposed to when it is truly actually full. So, it's a coping mechanism thinking we're doing the right thing by avoiding drinking or avoiding peeing just in case, but we end up now dehydrated. Then we're going to become constipated. Now we're also training the bladder to signal us more frequently and more urgently. Then you can have-- Somebody can have the two of them together, mixed incontinence. You could also have anal incontinence, gas or stool which is less common but definitely more life altering.

[00:26:51] Then we have the overactive bladder. There is a medical diagnosis of overactive bladder but there are also many people who have self-diagnosed themselves as having a small bladder or an overactive bladder because they feel like they go to the bathroom all the time or they're up multiple times a night to pee. And so often it is bladder irritant related, behavior related, dehydration related, constipation related, and low-estrogen related and tight-muscle related. So, these people that are afraid of not being able to find a bathroom or they're afraid of leaking are also now guarding the muscles that are responding to this fear and anxiety and maybe already have been in a short tight state and now they're even in a more short tight state. So, definitely not able to now respond to again the forces that we deal with all throughout our day, and so we just now are--

[00:27:47] We somehow think that, “Maybe it'll get better one day, maybe it'll get better post menopause, maybe it'll get better here,” without knowing this is so treatable, so preventable really. I also want to highlight that it is one of the number one reasons for admittance to nursing home facilities. It is the aspect of care that other family members aren't prepared or willing to manage somebody's continence. And that at that point is when the person would be going into a nursing home. That is established in the research as well. A lot of people are like “Are you sure about that?” “Yeah, I'm sure about that.”

Cynthia Thurlow: [00:28:29] Yeah. It's interesting. We just had Dr. Rema Malik on and I was asking her how do we define overactive bladder? Because I think some people just have anxiety thinking they have an overactive bladder. It's more than eight episodes of urination in 24 hours, so that's number one. Number two, I can't tell you how many women as I'm doing an intake on forms and they're telling me it's-- the term is called nocturia, but it's if you get up at night to pee. I'm not talking about once a week or twice a week. I'm talking about habitually two to three times a night. It's not common for men. It is not benign if men and women also get up at night to urinate. For men more often than not, it's related to hydration, bladder irritants, an enlarged prostate. For women, 99.9% of the time, it is related to low estrogen in the genitourinary system. And it translates as you just have more activity in the bladder. That loss of estrogen is profound, not just the urethra, but the bladder. It can be very irritating. I find for a lot of women, vaginal estrogen--

Kim Vopni: [00:29:35] Yes.

Cynthia Thurlow: [00:29:36] Vaginal estrogen can fix this. And it's interesting if you look at the research, yes, you see a lot of patients that are being admitted into nursing homes or assisted living facilities because they are no longer continent. The twofold issue is that generation of women in many instances because of the Women's Health Initiative, are not on vaginal estrogen. None of my mother's generation, my family members are. And I keep reminding them, “You can start vaginal estrogen with few contraindications truly.” You can start that in your 70s. You can start it in even older women, but it reduces the risk of developing urinary tract infections. And what we get most concerned about more often than not, a change in mental status. This was a number one reason I would be looking for, where's the source of the infection? We almost always, it was related to something called urosepsis. When you get a UTI, it gets into your bloodstream, you develop the systemic infection, and most older patients show up with a change in mental status, like, mom's no longer making sense, dad's no longer making sense, and it gets cleared up within a couple days with antibiotics. But the reason why I wanted to reinforce this overactive bladder does not have to be your destiny. Same thing with waking up at night to pee. Same thing with stress incontinence.

[00:30:55] And I think that, one of the things I've learned from so many different experts that have come on the podcast is that we will only allow what we accept. So, if it bothers you that you are getting up at night to urinate, if it bothers you that you've got a lot of urinary frequency and maybe you have that got to go, got to go feeling, which is totally frustrating. I had a male family member that had overactive bladder and he was stuck in his house. He felt like he couldn't leave the house because he felt this urge to urinate when he probably had 50 or 100 cc's of urine in his bladder, which is not a lot of urine. And it was because over time, his bladder just got conditioned to believe it's time to empty, as opposed to 400 to 700 mLs, which is where most people are feeling that sensation of needing to avoid.

[00:31:45] Talk to me. You mentioned fecal incontinence, and I know this is not a sexy topic, but it's important. I have several friends who had vaginal deliveries, what I would consider to be using their terminology, and from friends of mine who were GYN’s, traumatic deliveries, that they had significant tears into their rectum, like third- or fourth-degree tears. How many patients and clients have you worked with over the years that-- I mean, I would think if people are ashamed to talk about urinary incontinence, fecal incontinence is even like at another level. How many women come to you-- And this is what they're experiencing, but they're so ashamed and so uncomfortable, and that's why these conversations are so important. Let's talk a little bit about what this might look like for them.

Kim Vopni: [00:32:28] I often get asked by people, “Do you have any exercises or will this help for anal incontinence or fecal incontinence?” And the principles ultimately remain the same. There might be some different cueing or maybe a couple of different tweaks to some movement we may do, but the principles remain the same from a lifestyle, from an exercise, from a posture, breath, estrogen, and all of that type of thing. A big contributor to anal incontinence is, as you mentioned, pregnancy while childbirth, in particular. In a vaginal childbirth where there has been a third- or fourth-degree tear, and there's something called, the acronym is OASIs, “obstetric anal sphincter injuries.” And as it stands now, in many parts of Europe, there is automatic prescriptions to pelvic floor physical therapy for everybody who has given birth. And really this should be adopted worldwide. But at the very, very least it should be anybody who has had a third- or fourth-degree tear should automatically be referred on to get help because that greatly increases the risk of anal incontinence.

[00:33:42] And right now most of the people who come to me are in that population of women who have been suffering for years and have been dismissed, have been isolated, and they somehow randomly find me and they come in and they're feeling now hopeful for the first time in a long time that maybe something could help them. Many of them have probably also been dealing with constipation, which is another contributor. And so, we still start at the same place. We still go through the same diet, lifestyle, exercise, all of the things. And then we might tweak a little bit in terms of cueing or imaging. But really, at the end of the day, there is also help.

[00:34:27] And there's Biofeedback devices and also electrical stimulation that can be helpful for both urinary and anal incontinence as well. But I never jump right to a device. I always recommend pelvic floor physical therapy as your first line of defense. That should be your first stop. Not everybody has access to that. So, in that case, something like my program or something like the E-stim devices that are available could potentially be helpful, but you really want to work or create a team of people, and I emphasize the word team. I don't think that we benefit from just having one opinion or one person, so kind of having this diverse group of individuals who can offer their guidance so that we truly can make an informed decision about what options, like knowing all the options and then deciding which one is the best for us to pursue.

Cynthia Thurlow: [00:35:16] Well, and I like that emphasis on team, because there's no one provider who knows everything. And I think that patients and clients get the best care when you have a collaborative perspective where everyone's kind of lending their input on specific-- Because let's be clear, for every woman that goes through perimenopause and menopause, your experience is as unique as you are. And what works for these five patients may not work for these five patients. And so really working together with other healthcare professionals to kind of tailor your own treatment plan.

[00:35:53] Now, I think also kind of things that I commonly see, pelvic organ prolapse. We touched on that at the beginning. What I found interesting is, as I was reading your book, 50% of women older than 50 will experience vaginal prolapse. Now, I thought to myself, I had two C-sections because I had two breech kids. I didn't have one of those. I labored for 24 hours and then I ended up with a C-section. My kids were breech and they just weren't turning. How many women are you seeing with a combination of vaginal, uterine, rectal prolapse? Are they seeing more than one? I would imagine it has a lot to do with the risk factors that if someone's at a healthy weight, if they're not chronically constipated, did they have 15 children or 10 kids? I mean, sometimes when I look at these amazing women that have got 7, 8, 9, 10 kids, I think, I wonder if their uterus is still inside or does it completely prolapse into their vagina, but just curious, like your experience with some of these prolapsing organs and how much can be done. Obviously, I know we're speaking kind of high level, we're not speaking as a specific patient. How many of them can do quite a bit with pelvic floor therapy before they get to a point if something's particularly bothersome, where they need to be looking at surgeries?

Kim Vopni: [00:37:15] Yeah, pelvic organ prolapse is very, very common. And again, it's not screened for, not talked about. And early stage prolapse can often be very asymptomatic. We don't have any sensations. There are some people who have early stage prolapse who have a ton of symptoms and there are some people who have a very advanced prolapse who have no symptoms. So, symptoms don't necessarily indicate severity or that the-- We could nuance the type of symptoms as to what type of prolapse you may have. But generally speaking, it can be asymptomatic at an early stage, which is another reason why I always recommend everybody see a pelvic floor physical therapist once a year.

[00:37:56] Just like we see the dentist, go see your pelvic floor physical therapist even if you have no symptoms and get a checkup because when we catch it early, we are in a position of power to potentially improve, definitely prevent it from getting worse, maybe even reverse it. With regards to kind of-- I would say I don't know if it's people-- Like I get asked a lot about rectocele, so that's where the rectum bulges in the back wall of the vagina. Statistically, it's not the most common, but I get asked about it more so than the others, but I think it's because I had rectocele and I talk about it a lot. So, I think people just naturally have been following and many people are dealing with it, so maybe that's the bias that happens in my community.

[00:38:40] Bladder and uterine are probably the most, when you look statistically, the most common. Hysterectomy is a contributor to something called vaginal vault prolapse where the walls of the vagina-- So that would be a vaginal-- Like when people say vaginal prolapse, sometimes they mean a bladder, sometimes they mean a uterus or the rectus rectocele, but oftentimes the terminology they hear is vaginal prolapse, but there's something in the vaginal vault can happen after a hysterectomy. And hysterectomy increases the risk of other types of prolapse, and nobody is told that. So, there's a lot of people who get a hysterectomy because of prolapse, and that then increases the risk even more. If the reason they had the hysterectomy was because of uterine prolapse, the risk of other types of prolapse is now even greater than the already increased risk.

[00:39:29] So super common, symptoms don't matter, but when you catch it early, especially with bladder and uterine prolapse, you are in a position to, as I said, definitely prevent it from getting worse, maybe improve it and reverse it. Not everybody is going to reverse because it can be dependent on the ligaments, the fascia, and sometimes all the exercise in the world is not going to repair that and that will be a surgical need, and there's no shame in that. But even if that is the case, pelvic floor physical therapy, pelvic floor exercise, all of the lifestyle things are, I argue, even more essential and become your prehab. You've got to get your pelvic floor in the best state possible to your training for your surgery. You're then going to rehab after that surgery, as we should be after we've given birth, and then we are going to progressively load back to probably over four to six months, back to where we were.

[00:40:28] Unfortunately, right now with surgery, it's offered right away. So, if people finally-- it's usually about six and a half to seven years after suffering, they're finally asking for help, they get sent to a specialist, they're offered surgery, and that's the training that the specialist has. I don't want to take away from that. And we need it. And it sometimes is going to be the best option. However, if that person, if part of the reason they became-- They're dealing with prolapse is because of constipation or posture or poor lifting, chronic heavy lifting, and they go and then have that surgery and they get the clearance at six weeks to just, “Yeah, you can go back to whatever you were doing before,” and they still have those issues. Recurrence is really high after prolapse surgery. And I think a big part of it is because we are not training for surgery, because we are not rehabbing, because we are not told to do pelvic floor exercise and given like looking at the root causes so that we can take away some of what contributed to it in the first place.

[00:41:29] With rectoceles, those are really, really tricky. They don't respond as well to the classic other exercise methods that can help with bladder and uterine prolapse. So, rectoceles, I lived with one for nine years. I don't know anybody who has reversed a rectocele, or I've had a few people in my program who've improved symptoms. I was able, at certain points able to do that, and then once I was approaching my menopause with the low estrogen state, all of that was changing for me as well. So, my advice on surgery is there's many conservative options to try first. Pelvic floor physical therapy is your first line of defense. Posture, breathing, avoid constipation, stay hydrated, pessaries, they're like orthotics, so if you think of an orthotic for your shoes, this is like an orthotic for your pelvic floor.

[00:42:19] And there's really cool advances in the world of pessaries as well, but they can be life changing and they could be a reason why you may not need surgery. Maybe you still choose surgery and that's okay. But I want you to understand the root causes. Make the lifestyle changes, do the exercise first. If you are then still suffering, if it's interfering with the quality of your life, surgery is a really great option and you will be in a better position because of the work that you have done to have a more favorable outcome.

[00:42:49] And after surgery, many people are told, “Well, I’ve fixed the problem. You don't need to do pelvic floor exercise anymore.” I argue you need to do it even more because you've now had a change to the landscape. You now have scar tissue, and scar tissue is one of the things that can interfere with muscle function. So, we need to have a therapist help us keep that supple and moving. And we need to keep training that group of muscles as we do all the other muscles in our body.

Cynthia Thurlow: [00:43:13] Now, you alluded to the fact that you did have a rectocele. Did you ultimately require surgical intervention once you got closer to menopause transition?

Kim Vopni: [00:43:22] Yeah, it was a choice that I made. I wouldn't say I required it. I could have carried on managing, but I was just tired of managing. I was tired of always thinking about poop and always worried I had to eat a very specific way and I didn't ever commit to anything later in the day because if I was going to have a second bowel movement and it wasn't successful, then I would feel like crap. The image I always use was if you think of those baboons that have the big red bums, even though you could see nothing externally, that's what I felt like. I felt like a baby with a big full diaper. And it was uncomfortable and I didn't want to-- I would just sit down and want to be by myself. I didn't want to talk, do nothing. And I was like, “I'm not prepared to live like this for the rest of my life. And I know that this is an option. I feel very informed. I've done all the work. It's not helping. There are times where surgery is a good option.” So, yeah, I chose it. I didn't need it. I'm absolutely so happy that I did. It was just over four years ago now that I had the surgery and it was life changing. I pooped like a champ again. [laughs]

[00:44:33] I always-- that's a major thing with rectoceles. Constipation can contribute to it, but then because of that little pocket when the rectum is bulging in the vagina, you get poop stuck in there and it becomes really hard to poop and it's just like, it's so uncomfortable. And then when we think about menopause and getting rid of toxins and recycling hormones, the whole thing was my 40s were a struggle with perimenopause and the rectocele.

Cynthia Thurlow: [00:44:59] I can imagine. Well, and thank you for sharing a bit about your circumstances because I think for a lot of people listening, there probably are women that are experiencing exactly this. They don't necessarily know what's going on.

Kim Vopni: [00:45:09] Yeah.

Cynthia Thurlow: [00:45:10] This is where I think, you mentioned everyone should see their pelvic floor specialist every year. I think everyone needs a really good pelvic exam. And by someone that is savvy about what middle-aged bodies are supposed to be like, I'm very fortunate that I live in a fairly conservative part of the country, but I have a wonderful GYN who's very young. I mean, she's probably in her maybe early 30s, but she's like, “I love middle-aged women, you guys know what you want, you're very clear, you're not in most instances not dealing with contraceptives, you're not dealing with pregnancy issues postpartum, you guys are so clear, you know what you want.” And she's like, “It's easy to communicate, there's no nuance, you're very direct.” And so, getting a really good pelvic floor exam and/or referrals if you need them.

[00:46:00] In my area, we do have a great pelvic floor specialist. And I just share my personal experience because I think it's relevant. I've always had a tight right hip. I have something congenital that my hip socket, I have essentially a bone spur and it's very mild. What I have is very mild, thankfully, but I have family members who've had to have their hips replaced at young ages because of this, and that exacerbates this tight hip. And so, I find that both when I'm in the gym and when I'm working and doing PT, we laugh about this. And I'm like, all these years I thought it was because of this hip issue and that how tight that hip socket is. And I come to find out it's my pelvic floor that is contributing and exacerbating this tight hip. And so, it's always my mental check and if my hip is feeling particularly tight. I'm like, “Did I do my exercises? Do I need to go see my PT person more often?” Just that-- So it doesn't necessarily have to be overactive bladder, incontinence, or rectocele. It can be something as seemingly benign and innocuous that could be your hip. That's your body's way of articulating to you that you've got some pelvic floor work that you need to do.

Kim Vopni: [00:47:07] Yeah, a thousand percent. And on the hip replacement side of things, oftentimes as people are, excuse me, dealing with potentially osteoarthritis or issues with the hip as they lead up to the point where they would be considered candidates for surgery, often their incontinence symptoms will increase or maybe show up for the first time. And then dependent on the type of repair they have-- Sorry, replacement surgery they have, the posterior repairs will cut through the muscles. One particular muscle called the obturator internus, which is, you could argue a hip muscle or a pelvic floor, but it's part of that whole system, and so, some people will then have incontinence afterwards and that becomes another struggle that they now have to.

[00:47:58] So hip mobility, hip strength, balance is so, so important as we're aging. And being able to load our system, so load appropriately through our joints from a posture perspective and loading our bones. So also having the pelvic floor, the foundation that is able-- That allows us to do the impact and the heavy lifting. In the world of menopause right now, you hear so many messages about how women need to lift really heavy things and like lift heavy shit and they need to jump. And so many women dealing with pelvic floor dysfunction, they're thinking, “I can't jump because I leak. I can't jump because my prolapse bothers me.” So, either they have self-removed themselves from those activities or they have been told by a care provider, you can't lift anything over 10 pounds, you can't jump, you can't run because of your pelvic floor.

[00:48:55] One study looked at it was 46% of women avoid physical activity because of their pelvic floor dysfunction. And that is-- We think about the stats from a heart disease perspective and cognitive decline and osteoporosis, especially post menopause, we're now-- There's a whole group of women reaching that phase at even greater risk, so we have to do all we can to maintain our hips, to maintain our balance, to maintain our bones, but first we have to get that pelvic floor optimized so that we can do all those things and do them well.

Cynthia Thurlow: [00:49:28] Yeah, I think it goes without saying that loss of muscle begets frailty, frailty begets falls. And I think we talk a lot around these subjects, even the ones you just mentioned frequently on the podcast. But I tell everyone, unless you've worked in healthcare or in a field where you are working with older patients or older individuals, you go from being able bodied and being able to have good proprioception where your body is in time and space and you've got good flexibility to suddenly losing muscle. You become frail, you lose stability, you lose flexibility. It just gets worse. And many people just stop moving and that just exacerbates all of this. So, remaining active, however that looks for us throughout our lifetime, is so important.

[00:50:19] Now, when we talk about contributing reasons for pelvic floor dysfunction, there are some that you mentioned in the book that I hadn't even thought about. I'll be completely transparent, footwear, ankle positioning. How many of us have foots that kind of roll out? They don't roll in, they're not stable. Let's talk a little bit about how ankle positioning can play a role. This is fascinating to me. Ankle positioning can play a role in pelvic floor dysfunction. I think this is one that a lot of people probably do not realize. And I had to be reminded of it because there's someone, I follow on social media that talks all the time about this whole proprioception, being aware of where you are in time and space, but this footwear ankle position piece is worth mentioning.

Kim Vopni: [00:51:04] Mm-hmm. Yeah, our feet are connection to the ground and that's how we ambulate, that's how we move around. And we have been cast into certain foot positions based on the footwear that we have chosen. That for a long time, it was-- I remember I was a runner for many, many years. And it was so exciting to get the new magazine that would tell you all the new updates that have coming out in the shoes and the cushioning and then this and then that and stability control. And at the time I remember thinking, “Wow, this technology is amazing and it's going to help my foot so much.” All it was doing was weakening my foot and preventing my foot from experiencing different terrain, allowing it to navigate the earth basically. And so, it was like running or walking on marshmallows, you can't feel anything. And you think that's great that you have all this cushioning, but weakens our foot. It literally is taking away the ability of the muscles.

[00:52:01] We have so many muscles and joints in that foot and when we are in tight socks or shoes that have a narrow toe box and when we have positive heel, and positive heel is what is influencing that ankle position. And even if it's a neutral running shoe, the heel is always higher than the forefoot, so that is going to then put more pressure on the front part of the foot. And it also, what it does is when that heel is higher up the chain, the calf muscles, the hamstring muscles will adapt to that even very small elevation by shortening. And up the chain, the hamstrings attach up into the pelvis. So as they shorten because of this minute posture adjustment down below, that ultimately is pulling us into a posteriorly tilted pelvis, which we've already talked about as not being great for a pelvic floor.

[00:52:58] So, very subtle changes. It can be like half an inch. Anything greater than just completely flat is, you could argue, detrimental to our foot health and to our pelvic health. So, a big thing that I preach a lot is for people to transition to minimal footwear. And I also will emphasize the word transition because it's not something that you just, “Kim said to wear minimal shoes. I can go get a pair.” And then you wear those forever. Start for 24 hours a day kind of thing. No, you need to exercise, build up your tolerance to that, allow your body to adjust and to adapt to that new foot position. Your feet probably will ache a little bit. You're probably going to notice the back part of your body feeling a little-- You're going to notice change. So, you go into it slowly, I guess, is what I'm saying.

[00:53:53] But those small changes can make a huge difference in that posture, in that ability for us to be aligned. So, the diaphragm and the pelvic floor can work synergistically. Tight hamstrings and tight calves are so common because we have all been in these shoes with a positive heel and with that narrow toe box. So, a great-- there's a woman named Anya and she went through her own foot pain journey and now has a whole blog website all about minimal footwear. It's anyasreviews.com. I don't have any affiliation with her. I just think it's a really great resource for people wanting to know more.

[00:54:30] Also, one of my teachers, Katy Bowman, she's at Nutritious Movement. She has two books on footwear. One's called Whole Body Barefoot, the other one's The Guide to Foot Pain Relief. And it’s very much biomechanics and how we are aligned and how muscles work better or not, depending on the position of our feet. So, we want to be able to feel the ground. And when we think again, from this aging perspective, reducing fall risk, balance hip.

[00:54:59] If we are in shoes that have narrowed our base of support, then that is not contributing to us aging powerfully. We want a wide toe box. Ideally, we want to walk around barefoot so our feet can feel the ground and navigate that. A lot of people will-- We again, have worn shoes with cushioning because we don't want to feel things. But when you are walking, we should feel the roots. We should feel the cobblestones. We should feel that rock that we step because that gives us information to make micro adjustments. It goes up to the brain. It's a whole way of keeping us strong and have been able to, well, navigate, but also control from a fall reduction perspective, if we take out sensation, if we narrow that base of support, we are less able to prevent those imbalances and also then have the resilience in our body to catch us if we're falling, if that makes sense.

Cynthia Thurlow: [00:55:59] Yeah, it definitely does. And I think for how many of us in our 20s and 30s were wearing really high shoes like high heels, whether it was at special events or at work. And I cringe when I think about what I used to wear in clinic because I could get away with wearing higher heels because I wasn't wearing them in the hospital, but realizing it was just exacerbating any pelvic floor issues that I had. I just wanted to wrap up the conversation today because I get a lot of questions about connective tissue disorders. There's a lot of people that have Ehlers-Danlos or even Marfan, which is not as common. These for mobility impacts our range of motion. And so when you're working with these patients or you're working with clients that mention they've got a connective tissue disorder, how can you help them given the fact that they're going to be-- Their joints are going to have greater laxity, they're going to have more mobility concerns just by virtue of their bio individuality.

Kim Vopni: [00:56:53] Yeah. Evidence supports they are at greater risk of experiencing pelvic floor dysfunction, especially pelvic organ prolapse. And so, all of the things that we talk about are going to be steps that they're going to take. The interesting piece of information, when we think of a connective tissue disorder and we think of laxity, we think that person should never stretch because they're already lax. But many people with connective tissue disorders and hypermobility have a lot of tightness actually that their body is trying to compensate this additional movement that shouldn't necessarily be there for lack of a better way to describe it. So, they often have hypertonicity, hypertone tightness, tight pelvic floors, tight all muscles really.

[00:57:40] So, there's a balance between as I mentioned before, tight doesn't equal strong, tight is weak. So, they still need to, if and I would argue even more so, strengthen. But they also need to lengthen, not at the exact same moment, but there needs to be that balance as with anybody and how we navigate that is really going to be individualized on that person. So, anybody who comes in with tightness or with connective tissue disorder, I have a kind of a, I wouldn't say a protocol, but a recommendation onto you're going to proceed a little bit differently than the other people over here. And you're going to test the waters to see how your body will respond to this new posture, to this new voluntary activation relaxation. You're going to start with release work, see how you feel with that, but we don't want to just focus on releasing tension. We again have to strengthen the muscles there as well, arguably even more so. Again, the approaches are the same, they just might navigate that a little bit more zigzag than somebody who's on the straight and narrow path, so to speak.

Cynthia Thurlow: [00:58:46] Yeah. This has been such an interesting conversation. Please let listeners know how to connect with you on social media, how to work with you directly, and how to get access to your book.

Kim Vopni: [00:58:55] Mm-hmm. Thank you very much for having me. This is a really great conversation and I am so grateful for people who have a platform that can help get this information into the ears of more people. So, my website is vaginacoach.com. If you go to Google and put vagina coach in, you'll find me somewhere. @vaginacoach is my handle on social media. Typically, I hang out the most on Instagram. I do have a YouTube channel as well for some free content and my book is called Your Pelvic Floor. It's available on Amazon and most major bookstores.

Cynthia Thurlow: [00:59:23] Thank you again for your friendship and for the work that you do.

Kim Vopni: [00:59:27] You're welcome. Thanks, Cynthia.

Cynthia Thurlow: [00:59:30] If you love this podcast episode, please leave a rating and review. Subscribe and tell a friend.

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