Pelvic health is an important but often overlooked component of a person’s overall well-being. And in the case of the trans community in particular, pelvic health is also easily misunderstood or misrepresented—including by care providers who fail to realize the different needs and concerns that different trans people may have.
To get a better understanding of pelvic health, particularly as it pertains to transgender people, Terri Wilder spoke with Patrick Wenning, M.P.T., CIMT, a physical therapist in the Washington, D.C. metro area. Wenning gave a presentation entitled, “Pelvic Health for Trans Health” at the recent SYNChronicity 2020 conference, in which he discussed the basics of pelvic floor awareness, anatomy, and education for the transgender population.
Wenning ran his own private practice in Manhattan for over a decade. In addition to his general orthopedic practice, he worked with dancers and actors of all levels, from amateur up to Broadway. Wenning joined Restore Motion, a physical therapy practice in Rockville, Maryland, and Washington, D.C., in 2016. There, he treats patients with spine, foot and ankle, and pelvic issues—including pelvic floor difficulties—and specializes in men’s pelvic floor issues, fine arts rehabilitation, and foot orthotic casting.
The Basics: Pelvic Health and the Pelvic Floor
Terri Wilder: Patrick, thanks so much for talking with me today. Let’s start out with the basics. What exactly is pelvic health?
Patrick Wenning: With pelvic health, of course, you’re dealing with the pelvic area of the body: the abdominal and gluteal regions, in both adult care and pediatrics. It encompasses health concerns of the gastrointestinal tract, bowel, and bladder function—so, incontinence or constipation, sexual and reproductive functions, and pregnancy and postpartum. Pelvic health is also a consideration in cancer diagnosis; for instance, in the case of breast, prostate, and rectal cancers.
Wilder: I’m wondering if you wouldn’t mind explaining some of the relevant anatomy terminology, starting with the pelvic floor and its purpose?
Wenning: Right. The pelvic floor is a group of muscles at the bottom of the pelvis, the big, bony structure at the bottom of the spine. The pelvis has three different muscles that form a sort of bowl-shaped group of muscles, and the pelvic floor are the muscles at the bottom. They’re shaped like a sling or a hammock and extend from the coccyx—which is the end or the tip of the spine—forward to your pubic arch, that bony arch that protrudes to the front, and side to side from your two sit bones, those two pointed bones that we can feel when we’re sitting upright on a surface.
Wilder: During your presentation, you mentioned the five functions of the pelvic floor. Can you elaborate on those?
Wenning: Yes, we call them the five “S” functions of the pelvic floor. That’s our mnemonic, just to remember everything when we’re in school, of course.
The first function is support. I just talked about how the pelvic floor is shaped like a hammock or a sling, and it’s right there at the bottom of the pelvis. That sling of muscle, fascia, and ligaments in the pelvic floor support all of the organs inside the pelvis—the sexual organs, the bladder, the intestine, the ovaries, and the uterus—moving up into the abdominal cavity. That’s going to support all of that weight that we have inside the abdominal cavity.
The second “S” would be sphincter. We think of our sphincters when we think of the anal sphincter, and we think of the urethral sphincter. The pelvic floor is a muscle, and a sphincter is a round muscular band. So, the contraction and relaxation of the sphincter is going to control how we urinate and how we have a bowel movement, both holding it in and releasing it.
The third “S” would be about sex. We’re talking about a few of those pelvic floor muscles that create the openings and part of the sexual anatomy. These muscles help us with that function of sex. With my patients, I talk about the arousal that you feel during an orgasm. There’s that little spasm of the muscle that’s part of those superficial muscles of the pelvic floor, along with your nerve endings, spasming for that orgasm.
The fourth function is one that everybody kind of forgets about—sump pump. So, you’ve got all of these muscles in the pelvic floor, contracting and relaxing. But our lymph system in our body moves lymph around—along with the circulatory system—and moves white blood cells and all the disease-fighting mechanisms. We’ve got a lot of those lymph nodes in the hips and the groin and in the abdominal cavity; so that muscle action is that nice sump pump right at the base of our trunk, helping push and move the lymph system back up into our body towards the heart and pushing it around for the rest of the body.
The fifth “S” is stability. The pelvic floor is a group of muscles—it acts like a group even though it’s made up of a bunch of individual muscles, what we call the core muscles. I’ve heard all sorts of different ways of describing core muscles, but there’s only four core muscles, and they’re very deep and wrap around the trunk. They provide the stability of the pelvis, trunk, and spine so that we can perform all of these other muscular functions.
When trainers work with you to strengthen your core, that core is going to support your body so that your arms and legs can do all those wonderful functional activities that we all love to do.
Wilder: Going back to a question you were asked during your presentation: Are there particular areas of pelvic health of particular consideration for or unique to the transgender community?
Wenning: Well, when you’re talking specifically about the transgender community, anytime someone is transitioning, there are changes that they’re making directly in terms of either the sexual or the reproductive organs—and that’s going to have some effect on the pelvic floor and pelvic health, in general.
To be more specific, it can be as simple as how aggressively a person may tuck their reproductive organs in order to smooth out the groin area or how aggressively they may bind other organs that would, say, flatten their chest. Anytime you’re physically maneuvering organs, there’s a disturbance in blood flow and a change in the muscle activity. There can also be breathing issues—for example, skin breakdown, because you’re wrapping body parts and keeping air out. And infections can arise from this activity. So, all of those factors can and need to be addressed, if they come up.
There can also be a risk of more complex issues with someone if they start taking hormone treatments or begin having surgeries to alter their sexual organs. When someone gets to that stage of transitioning, physical therapy needs to be part of their overall health care.
My concern, with patients who are transitioning, would be basic good health and healthy tissue. You want everything to be working well with all of the basics of bowel and bladder function. If you’re going to be implementing changes, starting from a good, healthy base is going to give you a much better, healthier outcome.
How Pelvic Health Affects Your Overall Health
Wilder: During the conference, you spoke about pelvic floor dysfunction, and one of the more common of those being back pain. How are back pain and pelvic floor dysfunction connected?
Wenning: For back pain, you want to think back to that stability as being one of the functions of the pelvic floor, and your pelvic floor is part of your overall core. You’ve got your pelvic floor on the bottom, then you’ve got your diaphragm, which is the muscle at the bottom of the rib cage that separates your thoracic cavity—where your lungs are located—from your abdominal cavity. Wrapped around that is the very deepest abdominal muscle, called the transverse abdominal muscle. The core works as a unit—it’s always engaged and stabilizing us.
If the pelvic floor is weak, or if there’s a dysfunction or a disruption in the pelvic floor, it can’t operate along with that other part of the core. That means some other part of the core or something else within the body has to work harder—say, back muscles that aren’t designed necessarily for stability, they’re designed for movement—they’ve got to work harder. That overworking can develop into painful muscles or joints.
Wilder: That overworking results in back pain?
Wenning: Yes. The analogy that I always give that is the lazy worker analogy. If you have two workers, and one’s doing all the work, and one’s not doing anything, who’s going to get sick first? It’s the one who’s being overworked. The solution is to make that person not work so much and for the lazy worker to work a little bit more.
So if that pelvic floor isn’t working, other things are going to have to compensate for it. And you’re going to most likely end up with back pain.
Wilder: You also discussed constipation, overactive bladder, and pelvic pain with sex. Can you touch on each of those as they relate to the pelvic floor and pelvic floor dysfunction?
Wenning: For constipation, the pelvic floor assists with the mechanics of pushing out waste. Think back to sphincter function I discussed earlier. If you cannot move things around and move out waste, there will be a buildup in the waste system, and that can result in constipation.
Overactive bladder is a little bit more complicated. So, first, there’s a reciprocal relationship between your pelvic floor and your bladder; they work together all the time. The bladder is made up of a special muscle that squeezes to push urine out. In order for it to be able to squeeze, that pelvic floor—which is supporting the bladder—has to be able to relax. If the pelvic floor is too tight, it’s going to have a hard time relaxing.
So, you’ve got that reciprocal relationship between the bladder contracting and the pelvic floor relaxing, and then the pelvic floor being strong so that that bladder can fill up with urine. If your pelvic floor is weak, it’s not going to be able to support the weight of the bladder filling up. Instead, it’s going to send a signal to your brain that says, “Oh; everything’s too heavy. I need to go to the bathroom.” And you’re going to go continuously. That’s the connection with overactive bladder—you’re getting the signal that the bladder is full because the pelvic floor isn’t supporting it.
With sex, well, in large part sex involves using the pelvic floor. It’s one of those main components. And if any muscles are weak or tight or deconditioned, they can become painful if they’re used beyond their capabilities. So, sometimes that capability is so low that even small amounts of activity or stress can be painful.
A lot of times, weakness in the pelvic floor or tightness in the muscles that are trying to be stretched can result in painful sex.
Pelvic Floor Problems: Common, but Commonly Ignored
Wilder: I read somewhere that pelvic floor dysfunction is a common health issue that isn’t commonly discussed. Why do you think that is—and just how common is it?
Wenning: Well, there have been lots of studies over the years showing that it is actually more common than most people might think. What tends to happen most of the time, or what’s been happening, I should say, in recent years is that people just don’t talk about it. It’s embarrassing. It’s a health issue that we just don’t talk about, not even with our primary care doctors or our spouses.
One study from NIH found that 25% of [cisgender] women will have at least one, if not more, pelvic floor disorders within their lifetime. So, specifically, urinary incontinence is one of those issues that tends to be pretty prevalent—with women, it’s at about 35%.
There have also been studies showing that pelvic pain complaints can range anywhere from 2% to 16% in [cisgender] men, and most commonly, urological conditions [are] especially prevalent in men over 50. Another very interesting issue is chronic pain after surgery. So, any type of pelvic surgery or even a pregnancy—research shows that 10% to 40% of individuals will have some chronic pelvic pain after.
The other interesting fact is that 50% of men over 50 are going to suffer with some sort of prostate symptoms—and primarily urinary symptoms. These issues are not necessarily prostate cancer; they may be an enlarging of the prostate, which is a normal phenomenon. But it can cause other urinary problems.
Wilder: The information you’re providing is primarily based on data in cisgender people. I would imagine, for transgender people, there’s very little data.
Wenning: You’re right—there’s very little data. I think you have to think about—just like when we’re talking about transgender people, you’re trying not to say “male” or “female,” right? We’re also trying to be very gender-neutral and careful about labeling sexual organs.
As far as an increased occurrence of pelvic floor or organ dysfunction within transgender people, I haven’t found that to be the case, and I have never seen studies suggesting that.
Wilder: Given that it’s a condition that many people ignore or may be reluctant to discuss, I’m wondering, what would be consequences of not seeking treatment for pelvic floor dysfunction?
Wenning: With any untreated condition, you’re going to have the chance that the condition is going to get worse. So, that’s true with any kind of system that you have in your body, whether it’s musculoskeletal or internal. So there’s a risk of loss of function and an increase in pain.
So, anytime you ignore a condition like this, it’s probably not going to resolve itself—or your body is going to have to resolve it by doing a substitution motion. And somewhere down the line, you’re probably going to start to feel its effects.
Wilder: In terms of causes and triggers for pelvic floor dysfunction, are there certain age groups that are more vulnerable? Can it be triggered by another disease or illness? What typically causes the onset of pelvic issues?
Wenning: Pelvic floor issues can arise at any time in your life. I think many people think that pelvic health issues are part of the aging process. But I want to stress that urination problems—leaking urine when you cough, laugh, or lift a heavy object—are not a normal part of aging. Getting up more than one time during the night to urinate is also not a normal sign of aging. These are more than likely indications that there’s a pelvic floor problem.
Now, when we age, we do become less resilient. [Cisgender] women, when they’re going through menopause, experience hormonal changes, and there can also be indications of pelvic floor dysfunctions. [Cisgender] men over 50 may have an increase in their prostate size, and that can affect urinary flow, which can be painful.
Neurologic conditions can also trigger bowel or bladder problems, as can pregnancy, depending on the circumstances.
How to Improve Your Pelvic Health
Wilder: Are there broad exercises or treatments that can help people dealing with various types of pelvic floor dysfunction?
Wenning: When we talk about treatments, they really need to be specific to the problem. First, you need a very detailed evaluation to determine what the symptoms are and what’s going on.
One big myth is that pelvic floor physical therapy is just about Kegels. In the last decade, research is pointing us to a combination of a flexible pelvic floor that can relax and a strong pelvic floor that can support—and you really need a good balance between the two. In fact, overdoing strengthening can actually cause an overworking and an over-tightening of the pelvic floor, and that can actually lead to more dysfunction.
So, in general, the way we relax the pelvic floor is we use diaphragmatic breathing. When you inhale, everything sort of expands—your belly, abdominal muscles, and chest—and then as you exhale everything contracts. So that breathing action will move the pelvic floor and keep those fibers elastic and mobile. You can add different positions, like yoga positions, where you stretch your leg, glute, hip, and abdominal muscles, so that they are all mobile and relaxed.
Wilder: Then, are Kegel exercises still considered useful?
Wenning: The Kegel is still the go-to for the strengthening. And a Kegel, the research has been showing, when you’re strengthening for overall pelvic health continence and control issues, you’re strengthening at a very submaximal level. So you’re strengthening only at about a 25% contraction. A Kegel is that feeling of lifting up into your pelvic floor, into your abdominal cavity—which can be confusing, because we don’t always know what’s going in there or how to isolate it. That’s where you may need extra help.
Wilder: Are there medications that are helpful for treating pelvic floor dysfunction, in addition to physical therapy?
Wenning: As a physical therapist, I cannot recommend medications, but I can, of course, discuss them. There are medications that are targeted for the bladder and for how the bladder muscle specifically works that can help with urine flow and retention. And since we’re talking about muscles within the pelvic floor, muscular medications such as muscle relaxants might be recommended.
There are, of course, medications for erectile dysfunction and antibiotics for urinary tract and other infections. Then, hormone treatments can help with regulating the reproduction system. It’s so complicated, because with pelvic health issues, there’s often not just one thing that’s going on.
Wilder: If people are interested in learning more about pelvic health, are there websites or other resources you would recommend?
Wenning: I always point people—I mean, you’re talking to a physical therapist—to the American Physical Therapy Association pelvic health website. There’s a patient education section on the website that focuses on pelvic health. The Prostate Cancer [Research] Institute and the Breast Cancer Institute are also very good resources.
While gathering general information online—for example, on blogs—can be a good place to start, I recommend not trusting Dr. Google with your pelvic health. You really should discuss any concerns with your primary doctor.
Wilder: To close, are there specific issues that you think the LGBTQ community should be aware of regarding pelvic floor health?
Wenning: I’ve been thinking about this for a while. I’ll say that when we’re thinking about the LGBTQ community, we are, in fact, talking about all people that may experience pelvic floor issues. I hesitate to categorize any sexual practices that might be unique, specifically, to LGBTQ communities, because just about anyone can perform just about any sexual practice; and they often do.
I haven’t come across any studies that suggest LGBTQ people are at a greater risk for pelvic floor dysfunction, so I don’t think there’s anything specific to share. If we’re talking about the transgender community or transitioning, then we’d need to get very specific.