Ask the Expert - Pelvic Floor Health with Melia Perrizo, DPT
Elaine: Welcome. I am really excited to have a special guest today, Melia Perrizo. She is a pelvic floor physical therapist
Elaine: I just want to say a big welcome to Melia Perrizo. She is a physical therapist. She has her doctorate in physical therapy. She also has an orthopedic specialty. She works with athletes. And she works in women's health treating pelvic floor dysfunction, including low back pain, diastasis recti. She's a Pilates instructor. She does cranial sacral therapy and she does visceral manipulation. So welcome. Thank you for being here.
Melia: Thank you. I'm excited to be here.
Elaine: Tell us where are you based? Where's your practice?
Melia: I'm in South Orange County. So my practice is in San Juan Capistrano.
Pelvic Floor Symptoms
Elaine: Can you tell us what are some of the symptoms of pelvic floor dysfunction? How would we even know if we have an issue with our pelvic floor?
Melia: It's a great question. A lot of women who come in and once we start talking they go, "Oh, I didn't know when I was filling out your forms that all those things are connected to my pelvic floor." So certain things that we look for in pelvic floor dysfunction are things that come up are things like leaking, so leaking urine with coughing, sneezing, laughing, jumping. You can also have fecal leaking or fecal incontinence as well. So some women will say they'll have staining on their underwear as well. They'll notice that I felt like I wiped but it's still there. They'll also notice pain and pain could be with intercourse, tampon use, pelvic exams when you go to OB-GYN appointments, pubic bone pain, sitting pain, even sometimes low back pain can show up as that as well. And I think those are some of the major ones.
What exactly is the pelvic floor?
Elaine: And what is the pelvic floor? Can you tell us where are the muscles? Where is this pelvic floor?
Melia: That's another one, especially some of my guys, too, who are like, "Wait, where's the pelvic floor? I have a pelvic floor?" Yes, everyone has a pelvic floor. So I actually have my little model too. So this is the pelvis. I'm going to kind of orient you here. I'm gonna take the pelvic organs out. But this is the front of the pelvis. This is this spine. Pelvic bone is here. So the hips would be here and deep down inside and all of that is pelvic floor. So that pelvic floor sits at that base of that pelvis to help support everything. So all of that is soft tissue. The only bony portions of that really are the sit bones that you sit on the outside. But all of that middle portion is all soft tissue. So that soft tissue has to be really dynamic in order to hold everything up and in and support. But then it also has to be dynamic and release and allow pelvic floor to relax, allow urine to pass, feces to pass, parts of sexual function. So it has to be really dynamic in that on and off mobility.
Elaine: Right. So we want it strong but we also want it flexible. Is that right?
Kegels might not be the answer to your pelvic floor issues
Melia: That's very correct. Which is kind of...I mean, even way back when it was...Kegels was kind of the answer to everything. So tighten, tighten, tighten was kind of that answer to do. We need to help support, and support, support. It must be weak. But we also actually need to relax that muscle to allow all of those bowel and bladder functions to correctly happen.
Elaine: Right. So for anyone who's listening who might not know what a Kegel is, what exactly is that?
Melia: Yeah. So a Kegel is that pelvic floor actually turning on and going into a contraction to help support those muscles. So if you were to actually insert one or two fingers vaginally or for guys rectally and you try and squeeze around those fingers, that's that pelvic floor contraction. And so that support system, you can feel turning on when you actually do that Kegel and squeeze.
Elaine: Right. Can we overdo those? Can we do them too much?
Melia: For sure. So most of the women that come in with pelvic floor dysfunction into my practice usually have a high and tight pelvic floor. So they're actually in more tone than they should have. And so most of the time I'm actually down training them. So I've had patients come in who said, "Oh, well, my OB-GYN said just do 100 Kegels a day." And they've really done really well with those 100 Kegels a day. And they're so high and tight that that muscle tissue needs again to relax to truly turn that pelvic floor off...or not off but it needs to be able to relax in order to let urine pass nicely, feces pass nicely, and again, parts of that sexual function. So yes, you can overdo Kegels. And, most of the time, I'm actually down training those ladies so that they're starting to have some normal tone in that muscle tissue.
Elaine: Interesting, because I grew up reading "Cosmopolitan" magazine and all these magazines it was Kegels, Kegels, Kegels. And you're saying maybe we've all been Kegeling too much.
Melia: Yes, exactly. And definitely, my training is now down training the pelvic floor for sure. And most of the time, women have a great Kegel. It's strong. It's very strong, but it's almost too strong...or not too strong but too high and tight. And so it's really getting that opposite of can we get that full relaxation. And sometimes I'll talk about it like the range of motion can be so much better if you fully relax it. So I'll say like it's like my bicep, you should have this full range of motion of that, right? So if I'm fully contracted and I fully relaxed, I have this nice big length of range of motion. If I'm sitting in this high and tight position, this is all I'm getting out of that Kegel. This is it. And so if we truly relax then I can get more strength out of it.
Elaine: Interesting. So what are some of the exercises or what would you say to a woman whose pelvic floor is too tight? Where would you start to down train that?
The pelvic floor is part of our respiratory system
Melia: I always start with breath work because the pelvic floor is also part of our respiratory system. So that pelvic floor sits as our deep core. So pelvic floor sits at the bottom, diaphragm up top, transverse abdominis comes around, that kind of personal corset muscle that we use a lot in Pilates, right, and then multifidi along the spine, those four muscles make up our deep core. And so knowing with respiration, when we breathe, that diaphragm on the top needs to contract and come down, pelvic floor on the bottom needs to relax in order to let the lungs fill. And so inhale is this way. Exhale, pelvic floor contracts, diaphragm relaxes. And so if I know respiration should be happening like this all day long, that's what I tune into first with my patients is let's tune in to what's happening there and see if we can get some of that normal mobility.
Post-pregnancy, that diaphragm starts to sit up a little higher, right? Baby is in there. So sometimes that diaphragm is sitting a little high and tight. So can we get that diaphragm to start doing some normal mobility postpartum. Or my high stress ladies, they sit a little high and tight, right, so that diaphragm sits a little higher and tighter, that pelvic floor sits higher and tighter. So starting with breath work is always that first key to getting pelvic floor to start to relax into that.
Too much sitting can cause pelvic floor tightness
Elaine: Wow, I love that. Do you notice the tightness? Do you think any of that is coming from the fact that we sit so much? Especially I know moms in Southern California, they're sitting in the car driving kids everywhere all day long. We're sitting at desks on computers. Is that contributing to it?
Melia: It can certainly contribute to not having optimal alignment for pelvic floor. Especially if sitting, we'll tend to...you know, the glutes are a big stability muscle for us. And if those guys start to be not as strong from all that sitting, then the pelvic floor tends to have to take over for stability in the pelvis. So there's definitely a correlation of prolonged sitting and just not optimal postures.
Low back pain can stem from pelvic floor weakness
Elaine: And then you and I were talking, before we jumped on here, we were talking about also the connection between pelvic floor and low back pain, which I wasn't aware of. So tell us about that.
Melia: Yeah, that's kind of the original way I got into pelvic floor because I started out in just orthopedics. You know, I think even Nazly will remember this back in PT school when I was doing residency with her is I was like, "Pelvic floor, no, I'm not going there. I know what they do in pelvic floor. I'm just doing orthopedics." So as I was noticing though, all of my low back patients who were coming in to me were also saying, "I have leaking when I jump, when I sneeze, when I cough. I have pain with intercourse." And it's like, "Wait, there's got to be a correlation here." And so as I started treating more of the pelvic floor, the low back pain was going away. And so really, it's because the pelvic floor is a part of our deep core system. And so that deep core, if you can get it to truly turn on correctly and be utilized as it's meant to be, the low back compensations then start to shift.
Elaine: Oh, interesting.
The connection between pregnancy and abdominal separation
Elaine: Okay. What about in pregnancy? I see this as a Pilates instructor, women developing diastasis recti. I hope I'm saying that correctly. Correct me if I'm wrong. But can you tell us a little bit about that as well?
Melia: Surely. And yes, it's kind of like where you are in the country or what country you're in, diastasis recti, diastasis recti, or just easier DR. So diastasis is really the separation of those six pack abdominals, that rectus abdominal in the front of the core system. And as we have baby in belly, it's meant to separate to allow for baby to grow inside. And then postpartum, what we look for is how well does that come back together. And really, the thought processes with that separation as it starts to stretch out, the fascia between the right and left side starts to thin. And if you think about a muscle thinning, you can't generate as much force or tension to create force or tension outside. So if I go to, you know, push a door open that's heavy, I want to generate force within my core system to do that. And if I don't have as much force tension build up inside of my core, then it's harder to do something else.
And so what we look at returning is that same production of force in the core system. And, you know, a lot of what we hear is how much of that diastasis contributes to maybe some of the low back pain, maybe some of the pelvic floor dysfunction, because you can't generate as much force when some of that tissue is thinner. And so getting some of the force production back and that tension back is really important.
And again, I start with breath work with a lot of that as well just to really reeducate how to turn that core on properly, so that when you go to pick your head up, or lift baby, or pick up a 50 pound grocery bag or something, that you can do it correctly, and that the force isn't constantly going against that thinning wall. So if we open our glottis, our airway and exhale that airway or that pressure out, it helps us to pressurize so it doesn't keep coming against that thinning of the wall.
Allow your body to heal after pregnancy before diving into exercise
Elaine: Okay, got it. What do you think about...you know, we see a lot of these celebrities who have a baby and then they talk about going to the gym and they do all these crunches and sit-ups and this and that, what do you think of that postpartum?
Melia: So it's really dependent on body, too, but ideally that first, you know, three to six months is truly our time to heal our body. And it takes 9 to 10 months to grow a baby so 6 weeks later, you're not ready to go back to exactly the way you were doing things before. That pressure system changes so drastically with vaginal birth, C-section, any kind of birth. There's so much change in that pressure system. And especially then if you're then nursing or had trauma during birth, you just...you need that time to heal and it takes time. So that six-week mark when the OB says you're good to go, that good to go means your uterus isn't rupturing. It doesn't mean you can go back and do a 10K, 6 miles tomorrow.
Elaine: Can you speak a little bit to exercise postpartum? Like what do you recommend? What would you say should be checked out by...would you say a physical therapist should evaluate for diastasis recti and pelvic floor issues? Because I've found a lot of OB-GYNs don't even understand the muscles. What do you have to say?
Your OB/GYN isn't evaluating your pelvic floor after child birth
Melia: Yeah, and that's very true. Like that six-week checkup that they're doing, they are looking very specifically at things like, you know, too much bleeding, rupturing. Their assessment is very different from a pelvic floor physical therapist. The pelvic floor physical therapist is going to look more specifically at function of the pelvic floor muscles. And so when I do an assessment, it really is looking at how well can you turn on that pelvic floor. Sometimes just with the way that the baby's head comes out, one side might be weaker than the other. So right side might be a little weaker than the left side. And so I'm assessing can you turn on a uniform contraction because that right side might need a little more feedback. And so giving you that assessment where an OB is not going to look specifically at that muscle tissue. And then getting diastasis checked as well. How much do you need to pay attention to this when you go back to exercise? Yeah, so definitely seeing a pelvic floor PT. And then exercise-wise, really, I think a lot of us will start you with some breath work to kind of coordinate with that. And then Pilates is a great kind of return so that you can start to get some of that deep core activated. And I typically will say that three to six months is where I'm looking for more of those dynamic movements, such as running, jumping, that type of stuff.
Pelvic floor and aging
Elaine: We've talked about pregnancy and postpartum. Talk a bit about as women age. I had a question come in. Someone said, "My mom is 99 years old, and she is incontinent. Is this an inevitable part of aging?" So talk about that.
Melia: Yeah. So inevitable part of aging, yes, in the sense that we do lose muscle as we age, right? But at 99, that's a tough one. But really, the more you utilize your muscles system, the greater you can maintain it. And so if you can maintain muscle mass with movement and with pelvic floor, knowing that you can utilize it with breath work, you should be able to still maintain quite a bit of a healthy pelvic floor as you age. And so it's not inevitable to have incontinence as you get older.
Elaine: I know it is a big issue. I think, I don't know the statistic, but a lot of women especially seem to end up in skilled nursing at the end of their lives because they are incontinent.
Melia: Right. Which is a tough one. And then usually it's a medication that they're given. It's not very likely that they're going to get pelvic floor PT at that point. But I think if we were able to give that to them before, that would have been really helpful for them because that would be something that they could have...if cognition also starts to go, if we could have given that to them before, that would have been helpful.
Pelvic floor in perimenopause and menopause
Elaine: We've talked about pregnancy. We've talked about aging. Let's talk about the middle. In perimenopause and menopause, what are the changes that you see in pelvic floor and what can we do to keep it strong yet flexible? Which is what we've been talking about, right?
Melia: Yes. So kind of similar hormonal changes happen, my postpartum ladies and my perimenopausal ladies, where our estrogen levels actually start to deplete. And with that comes vaginal dryness, vaginal atrophy, meaning the tissues around the vaginal opening starts to thin as well, the elasticity of those tissues also starts to be less. And so some of the pelvic organs, our uterus, our colon, and our bladder are held up by some ligamentous support. And so as that estrogen starts to deplete, we'll start to see a little less support. And so the idea is can we keep a healthy pelvic floor in order to maintain that support system. So pelvic floor again, if you can get that muscular system to be dynamic, that on, off can be helpful to the pelvic organs. And then sometimes with vaginal dryness and with the estrogen depletion, lubrication is really big, so postpartum and that perimenopausal age is really using a good quality lubrication. So it's something that doesn't have parabens in it, that doesn't have phthalates in it, all of that stuff, right? But using a quality lubrication can help with a lot of that as well.
Elaine: Awesome. If anyone listening in has any questions, be sure to drop them in the chat because Melia definitely wants to answer anything you have. I think that is all the questions. I know you and I talked also about you do cranial sacral therapy, you do visceral mobilization. Tell us just a little bit about those and how those can be really beneficial for overall health.
Organ mobilization can help you to breath better
Melia: So some of the kind of supplements of this pelvic floor, I think, Elaine, you and I were talking a little bit about how the pelvic floor and diaphragm kind of sit...or are so interrelated. And so some of the things that I see with that is when that diaphragm sits a little higher and tight. Right underneath the diaphragm is the liver on the right side and the stomach and the spleen and pancreas on the left. And so the mobility of those starts to decrease as well when that diaphragm isn't going into its full range. And so visceral mobilization really just means organ mobilization. So I can go in and help some of those organs start to move a little bit better so that you have better mobility of those, the organ system, as well as that diaphragm allowing it to come back down. And it's been so helpful.
I think I share a story all the time about visceral mobilization in my orthopedic practice where I had a 14-year-old golfer who was trying out for the high school team, and he was showing up with this left rib cage pain all the time. And I would mobilize him and do all my normal orthopedic, PT stuff and soft tissue work. He'd be fine at the end of the session, but then he'd come back and he's like, "It's back. I have this left pain every time I rotate." So by the third visit, I said, "Okay, tell me what else is going on?" And he said, "Well, I also have Crohn's disease," which is an inflammatory bowel. And so I said, "Well, let's take a peek." And so I went into his descending colon on the left side and his kidney and mobilized those, and he got off the table and had full left trunk rotation. And it was like, "Oh, there's other things that attach to the bony system, not just muscles and joints," right?
And so the organs have so much play in what we are looking at as well. So the visceral mobilization is so key in my pelvic floor ladies as well because of where they sit against that pelvic floor and how they attach to the pelvic bones. So the uterus again and the bladder and the colon all sit in that pelvic bone but they have to be supported by that ligamentous system. And so if there's a shift or a rotation in them, they start to pull on that system, on that bony structure as well.
Elaine: I've had visceral manipulation. I get it about once a month. I love it. I swear by it. It's amazing. Absolutely amazing.
Melia: It is.
Elaine: I highly, highly recommend it to anybody, whether you're postpartum or not. It's just great. And then tell us a little bit about cranial sacral therapy. How can that be helpful for people?
Cranial sacral therapy allows mobility through the whole diaphragm system
Melia: Yeah, so the other part of cranial sacral that I use a lot with my pelvic floor ladies is there is such a fascial connection in through the head as well. So we talk about certain diaphragms, pelvic floor has a diaphragm, respiratory diaphragm, epiglottis. And then in through the sinus cavity, the tentorium is another diaphragm. And so using some of the cranial sacral stuff allows you to get some mobility through that whole diaphragm system. Usually, if there's a dysfunction in one, there's a dysfunction on the other. And so the cranial sacral stuff I utilize to get some fascial movement starting to happen in the head that can affect some of the other lower systems. And cranial sacral is great. It's very light touch. It's very calming to the nervous system. Yeah, it's also a wonderful adjunct.
Elaine: I always say to people when teaching Pilates that the whole body is connected. When you come in and just tell me one thing is hurting, I try to figure out, like connect the dots.
Elaine: Nothing in the body acts in isolation.
Melia: So true. So true. Yes. And that's kind of that whole perspective, if you can get a practitioner who kind of looks at that whole body, it's so helpful instead of like, "Okay, you came in for this one problem and I'm just gonna deal with this one problem." If you can get somebody who deals with that whole body picture, it's so helpful.
Elaine: Right. So it sounds like pelvic floor physical therapy can really be appropriate at any age or stage in life. It's not just for pregnant ladies and postpartum.
Men having a tight pelvic floor can be the root cause of heartburn and acid reflux
Elaine: And do you want to touch a little bit on men, men and pelvic floor? We could wade into that topic.
Melia: Yes, so definitely men have a pelvic floor and that as well for them can come up as anywhere from erectile dysfunction to bladder urgency, frequency, pain with intercourse as well, testicular pain. So definitely, those things can be affected again more likely by a high and tight pelvic floor, and getting them to find that release as well. Sometimes I'll even notice as that pelvic floor sits high and tight, again, that diaphragm sits high and tight, and you'll see some of them also complain of acid reflux, heartburn because that diaphragm isn't coming down and giving that stomach as much mobility as it should have as well. And everything just sits a little higher and tighter. So that can be a very common complaint too.
Elaine: Wow. And then I feel like I see more in men hernias. Are hernias in men anywhere tied into pelvic floor issues?
Melia: So with men, because they only have one really opening at the base of that pelvic floor, which is the rectum...for us, we have that larger opening, that vaginal opening, so for us, women tend to see prolapse, which is those pelvic organs falling through the vaginal space, but the rectum is a little bit of a tighter sphincter, so when they pressurize their system, that pressure is going to go to its weakest link. And for men, it doesn't tend to be at the base of the pelvic floor. It'll be through that abdomen or inguinal hernias, that type of thing. So you'll see those hernias pop up in their weakest link.
Elaine: So interesting. I'm learning so much here. So I'm assuming you also work with men.
Melia: I do. Typically, we'll refer out for some of the internal portion. So if they need that, I have lots of colleagues who do men's pelvic floor health as well. And so a lot of times I do end up referring out for the internal portions of that.
Elaine: Wow. Wow. Well, Melia, this has been amazing. Thank you so, so much.
Melia: You're so welcome.
Elaine: So tell us where can we find you? How can we get in touch with you? And also tell us what do you offer? If people are not in the Orange County area, how can they work with you?
Melia: You can get in touch with me definitely by Instagram. My handle is up there as well. My website, we can probably put on this as well. And then I am local here in South Orange County, but I do virtual consults as well. So if you're anywhere far or even through the pandemic, I had some people who just didn't feel comfortable coming in so I did follow-up visits with them virtually and I'm happy to do that and walk you through kind of your care and get you going that way as well.
Elaine: Awesome. Awesome. Well, thank you so much for your time. Thank you for sharing your knowledge. I hope we'll do this again.
Melia: For sure.
Elaine: If anybody has any questions, feel free to message either one of us and we would love to connect with you. So, thank you, and I hope everyone has a great rest of their day.
Melia: Thanks, Elaine for having me on.
Elaine: Yeah, it's great. Thank you so much.
Melia: All right. Take care.
Elaine: You too. Bye now
The content of this conversation between Elaine Morrison and Melia Perrizo is not meant to be construed as medical advice.
Always seek the guidance of your doctor or other qualified health professional with any questions you may have regarding your health or a medical condition. Never disregard the advice of a medical professional, or delay in seeking it because of something you have read on this website or heard or read in this conversation.