When you hear hoof beats, think horses not zebras.
 
This is a saying I picked up along the way at some point during my physical therapist education.  The idea is, when you pick up on a sign or symptom, to first hypothesize it’s cause has a more common origin (a horse)…rather than immediately jumping to some kind of rare condition (a zebra).  
 
The thing is, EVERY DAY horses walk into my clinic.  Or at least they’re what I would consider horses…but they’re things that are flying under the radar in the medical system in general to the point that they seem like zebras to the patients bringing them in, or the medical providers they’ve seen before me.  At first, patients are surprised that nobody had recognized their hoof beats as horses before, despite their intuition that they’re not alone in their suffering.  The worst part is, often because those hoof beats and the patients reporting them have been ignored or dismissed, or ineffectively treated, the hoof beats persist….way longer than they should before patients get the help they need.

It shouldn’t be a zebra or a surprise that…

• frequent urination often precedes or accompanies other issues worth investigating.
• continence matters for back pain (and vice versa).
• prolapse and diastasis matter with respect to function.
• pelvic floor health involves SO MUCH MORE than kegels.
• your pelvic floor could use some professional TLC after birth.
• you can and deserve to have enjoyable pain-free sex.
• how you breathe matters for all of the above and more.
• the hip matters with respect to the pelvic floor.
• movement, nourishment, hormones, gut health, sleep, stress, and mind-body-spirit factors matter with respect to healing.

 The more we can share our stories, encourage friends to go to PT/physio (or try a different one if the first one didn’t work out), ask questions of our medical providers, give feedback as to what’s working and what’s not….the closer we will become to these hoof beats being recognized for the common everyday horses they are and make getting the right help quicker and easier. 
           
You should never be made to feel like what you are going through is not a big deal, or there’s nothing that can be done.  You should also not have to walk away from an encounter with a medical provider feeling MORE worried or afraid than when you walked in.

            You matter.
            Your hoof beats matter – horses, zebras….or neither.
            Thank you for sharing.
​            I’m sorry for your suffering.
            I love you.
            You can do this.
            I can help.

​

A few examples:

• If you are outside the bladder “norms” mentioned here. (ex: voiding more frequently than every 3 hours, voiding more than 7 times a day, voiding at night if you are not pregnant or elderly)
• If, even occasionally, you leak any amount of urine, feces or gas when you cough, sneeze, laugh, blow your nose, jump, run, lift something heavy, etc.
• If you have sensations of severe urgency or incomplete voiding, with or without a loss of urine
• If you have urinary hesitancy, difficulty initiating stream, or your stream sounds like morse code
• If you “gotta go right now” or don’t make it to the toilet in time
• If you dribble after you stand up from voiding or are having to "splint" to void completely
• If you feel pressure, discomfort,  a “bulge”, heaviness, dragging, dropping in the vagina
• If you have bowel incontinence (including inability to hold back gas)
• If you poop less than once per day or strain/push to get it out
• If you have pain in the genitalia (vulva, vagina, rectum, penis, testicles), pelvis, thoracic cage, abdomen or lower back, hips, legs even feet (especially if you also have any of the above mentioned bladder/bowel symptoms)
• If you have pain with intercourse, tampon use, or gynecological exams
• If you have sexual health and function concerns such as anorgasmia, erectile dysfunction or ejaculatory pain as these are sometimes indicative of pelvic floor muscle dysfunction
• If you have diastasis recti - the mid-belly split often associated with post-partum, but occurs in men and nulliparous women too.  This is a sign of a "fault" in the system and can be helped!
• If you’ve tried Kegels and they’re not working for you – even Dr. Kegel noted in the 1940s/50s that verbal instruction alone was not enough to teach women how to correctly perform a proper pelvic floor contraction.  This is where a pelvic health PT comes in!

Did you know that you can ask for physical therapy?  Even in areas where the law and/or insurance/payers require a physician’s referral, you can request your physician to refer you to a pelvic health PT before medication or surgery.  In most cases, if your situation is not an emergency, they will agree to at least a trial.  You also (at least in Texas) have the legal right to go to the physical therapist of your choosing.

How do I find a pelvic health PT?  If you’re in the Houston or Austin area, contact me!  If I’m not the right person to help you, I can refer you to a colleague.  If you’re not in the Houston or Austin area, try conducting a search on one of these websites below to find a provider near you.  If you have not yet seen your physician to be medically screened and referred to PT, you may want to print a list from one or both of these sites and take it with you to your doctor’s appointment so the doctor knows you’re going to a specialist, not just any PT.

• https://www.hermanwallace.com/list-of-certified-pelvic-rehabilitation-practitioners
• http://pt.womenshealthapta.org

A colleague put together another wonderful post on this with links to a few more.  Check it out!

What can you do right now to help reverse or prevent urinary incontinence?  Building better bladder habits is a big one, and of course seeing a pelvic health PT can help guide you through the entire spectrum of treatment options. 

The bladder LOVES habits.  Unfortunately many of us have trained it with bad habits.  Here are some steps you can take toward creating better bladder habits:

• What is "normal" voiding (urination)? Approximately every 3-4 hours, or 5-7 times in a 24 hour period with no voiding in the middle of the night unless you are pregnant, breastfeeding or elderly.
• Don’t dehydrate yourself.  Dehydration causes a host of problems, including concentrated urine which is more irritating to your bladder (leading to increased feelings of urgency even when your bladder is not full).
• Aim for at least 2/3 of your daily fluid intake from water (about a half ounce per pound of body weight is a good rule of thumb for many, increasing if you're pregnant, breastfeeding, or sweating)
• Eliminate “just-in-case” voiding.  You may think it’s a good idea to “never pass up an opportunity to pee” but what this does is train your bladder to want to void at less than full and/or create triggers to needing to void such as every time I get to X place or X time
• Don't hover – semi-squatting over the toilet to avoid touching the seat does not allow your pelvic floor muscles to fully relax the way they are intended to while voiding.  If you're in a public toilet and worried about germs, just take the extra few seconds to put down one of those covers or a couple strips of TP.  Full squatting can actually be great, but our western toilets weren't designed for that - so leaning forward or elevating the feet can help some folks.
• Don’t rush it.  Sit on the toilet for at least 8 full seconds (ideally closer to 15) and don’t strain or push to empty faster.  
• Peeing in the shower is not the best idea.  It can create a habit/trigger for your bladder for you to feel a sense of urgency every time you see or hear water.
• Blowing your nose while sitting on the toilet is also not the best idea – it trains your pelvic floor to relax while creating the pressure to blow out the nose/mouth (same reflex as for coughing and sneezing) In fact, creating the opposite habit is helpful: train yourself to pre-engage your pelvic floor muscles before blowing your nose, coughing, sneezing, lifting, etc. 
• Avoid or reduce potential bladder irritants.  These can be highly individual, but some common offenders include:

• If incontinence during sex is an issue, void before
• Prevent urinary tract infections (which can be a major underlying factor in urinary urgency, frequency and urge UI) Here are a few basic suggestions:

• Rule out chronic or recurring yeast infections or bacterial vaginosis as a possible trigger as well.  There are some complex functional gut health and nutrition considerations, but you can try simply eating less sugar and move live probiotic foods to see if that helps.  Also, the vagina is self-cleaning - it does not need anything more than water.  Oh the French had it right with their bidets!  Often over-washing (or using products containing irritants) is leading to irritation or recurrent infections due to wiping out your body's natural defense mechanisms.
• Take care of constipation to make room for your bladder, remove pressure from the pelvic floor, and reduce straining or bearing down on the pelvic floor.  The functional nutrition considerations are complex and best ironed out with help.  An easy thing to try is to elevate your feet to get into more of a squatting position as long as you don't have hip problems with that position.  Have you ever tried a "Squatty Potty"?  You can also just rest your feet on a footstool or yoga blocks by the toilet to put your pelvic floor muscles in a more poop friendly position.
• Orgasm – yes ladies, our new mantra is “an orgasm a day keeps the incontinence away"
• Learn proper posture, abdominal and pelvic floor engagement and timing – best with the help of a pelvic health PT

Not sure what your current bladder habits are like?  There's an app for that.  The Share May Flowers blog highlights a free app called BladderTrakHer which helps you get started on your bladder diary and retraining program.  Track your habits for a few days and export them for your visit with your pelvic health PT!