How a Stigma was Born
Interestingly, the lack of awareness on the pelvic floor seems to be much more of a Western cultural phenomenon. When you look to the East, and within many Indian cultures, conversations around Kamasutra, Tantra, Ben Wa Balls, and the pelvic floor have been going on for thousands of years.
I think a lot of it has to do with that patriarchal, Christian upbringing, and religion that has historically been at the core of Western culture. This view is centered around sex being specific to reproduction versus pleasure and not focused on or comfortable with conversations around our body - this has created a real stigma, not just regarding the pelvic floor, but our body parts in general.
“This is Normal”
"Another huge misconception, specifically for women, is that issues related to the pelvic floor, such as bladder leakage, urgency, and many other types of incontinence
are normal, especially after childbirth or as we age. I always tell my patients, 'this may be a common occurrence, but it's not normal, there are solutions."
Many women just assume this is a part of life and that nothing can be done to correct these issues, but that’s just not the case.
The Pelvic Floor in Men
We’ve had little research done on men’s pelvic health, and therefore little information is available. I find that almost everything out there is focused on the prostate, and I honestly don’t know why we’ve gotten stuck on this path of everything being related to the prostate for men.
I recently had a patient who has been experiencing urgency and frequency for quite some time and has been to three separate urologists and myself, looking for answers. Two out of the three urologists told him, "it’s your prostate that is causing these issues", and both were resistant to any additional urodynamic testing. Urodynamic testing can separate whether an issue is related to the bladder muscles, to the prostate, or is correlated to the pelvic floor. This is one of my favorite things to perform on a patient because it gives so many answers.
So when this patient came to me and found out that he hadn’t had this test, I was shocked. I’m not sure if it’s my background or my training, but to me, the most crucial aspect of treating my patients is figuring out exactly what's going on and treating the issue in the best way possible. Immediately, this patient is set up for urodynamic testing, and come to find out; it’s his pelvic floor! He doesn’t have a prostate issue. And it’s crazy to me that this patient, who was on the path to surgery for his prostate, after only a few sessions with a pelvic floor therapist to loosen his pelvic floor, had his frequency and urgency stopped!
The Core Issue
On top of the stigmas associated with discussing the pelvic floor and the idea that these issues are normal, in my opinion, a large part of the lack of awareness of the pelvic floor lies within what we are taught in medical school.
Urologists are so focused on prostate, prostate, prostate. And this is the main focus in medical school; the pelvic floor is hardly touched on. So when a patient comes to you experiencing issues such as the above, your mind immediately goes to the prostate, and the pelvic floor doesn't even cross the doctors' mind.
Urologists are so focused on prostate, prostate, prostate. And this is the main focus in medical school; the pelvic floor is hardly touched on.
I noticed this lack of education and awareness on the pelvic floor and took it upon myself to get additional training.
An issue also lies within the structure of referrals. The patient mentioned above who was helped by a pelvic floor PT avoided referrals, avoided surgery - probably multiple surgeries - and decreased profitability.
Advocating for Yourself
There are so many resources available around the pelvic floor. It’s just about knowing where to find them. We have a long way to go in normalizing conversations and expanding education on the pelvic floor, and honestly on physical therapy, potentially over surgery, and in general.
One great approach is to educate yourself and, in turn, educate your healthcare provider. Make sure that you are always questioning your provider. I never ever get offended when my patient says, ‘I was reading on the internet’ or ‘I saw this’. I love talking them through questions or ideas that they have.
And also, don’t hesitate to get a second opinion. The patient I mentioned earlier spoke to three providers before getting an answer that resonated and made sense to him. A lot of patients say, ‘I don’t want to hurt my doctor’s feelings’. But we are professionals and adults, and it’s okay - we want you to advocate for yourself.
A resource that I love is the American Physical Therapy Association
(APTA) website. This site has a tool to search based on the issues you are experiencing and find a pelvic floor PT in your area. I personally think that a great plan would to start with a pelvic floor therapist and work with them to formulate a holistic approach to dealing with health issues. Often, on top of PT, a person could need guidance from a mental health provider or a sex therapist. For me, utilizing that full team to help the patient is essential.
Future Outlook for Pelvic Floor Awareness
As mentioned, a massive component of the lack of awareness on the pelvic floor stems from stigma. I think we are making strides in this area, for women, mainly due to women visiting their providers more frequently. The biggest issue here is that pelvic floor issues are still thought of as common.
With males, they can be more prideful and oftentimes want a quick fix. It’s hard for men to talk about bladder leakage and issues, and once you have the conversation, telling them they need to go to PT once or twice a week for a few months, they would rather have a pill or surgery to fix it.
The struggle of a quick fix can happen across the board and is something I run into with both male and female patients.
They all ‘have jobs, need to get home, need to help with the kids, etc.’ and aren’t as focused on long-term solutions that will take time away from their already hectic schedule.
All of this to say that I absolutely see conversations around the pelvic floor increasing; however, this educational campaign lies on our medical community's shoulders and making sure that we are educating ourselves on new topics. We often focus on broad issues such as diabetes and high blood pressure - this is what is at the core of the curriculum in med school - and we leave behind information on the pelvic floor and other important topics because ‘there isn’t time’. But this is such an important area that deserves attention and recognition.