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The Pelvic Floor Problems We’re Not Talking About with Laura Bunso, PT, MTC · NHA Today Podcast

• Stephan Esser MD: Hello and welcome to another edition of the NHA Today podcast. Today I'm excited to be joined by Laura Bunso, who holds a master's in physical therapy and specializes in women's health and pelvic health. completed her training at the University of St. Augustine in Florida and went on to care for patients at the world-renowned Mayo Clinic. After that, she started her own program with the a company called Smart Body Physical Therapy, now runs one of the largest practices in the country focused on pelvic health and wellness. In addition, her own personal being the mother of three children. So Laura, welcome to the podcast today. Laura Bunso, PT, MTC: Thank you for having me, Dr. Esther, and thank you for that very generous intro. Happy to be here. Okay. Stephan Esser MD: You know, I'm gonna ch I'm gonna jump right in. You know, urinary incontinence, painful sex, pelvic pain, weakness, they're all such crucial areas that are often kind of overlooked in the medical setting. Why did you decide to tackle these areas? Laura Bunso, PT, MTC: Well, these are all burning questions for people who are actually suffering with them. How I got into doing this 100% is really a kind of a slow evolution of migration into it. originally my love for it actually started. I was a nanny for a family in college. ⁓ the mom of the family, who's one of my dearest longtime family friends still was labor and delivery nurse. And so the miracle of life, and on top of God's miraculous design for us to heal. Stephan Esser MD: ⁓ huh. Laura Bunso, PT, MTC: Just inspired me. It's captured my attention from the time that I was a small child, the anatomy of the fish was ⁓ more important me on the boat than just about anything It's always intrigued me. And then in this ⁓ actual space, the mystery the difficulty of the problem solving of these things that are challenging for people to to talk about. Number to even bring it to someone's attention or to even to their own attention. Sometimes you're not even aware that you're experiencing something until it really gets out of control. There's this interesting, I think just to dive right in, ⁓ for example, difficulty with controlling your bowels or fecal incontinence where you leak stool. People end up Stephan Esser MD: Yeah. Laura Bunso, PT, MTC: accident accidentally. They they no one wants their life to revolve around their bowels, but nothing will keep you home, like not having control of your bowels. ⁓ Stephan Esser MD: Right. Laura Bunso, PT, MTC: People end up their their lives really shrink. end up managing entire lives around their bowels. Same thing happens with chronic constipation. and they just really shrink down so that they don't get embarrassed and that they can actually try to manage all these things. But it it's like slip sliding into a smaller life. Same thing happens with ⁓ urinary leakage, painful At first it's just like, okay, let you know. Stephan Esser MD: Right. Laura Bunso, PT, MTC: Maybe everything just has to be perfect. Now then we go all the way to the other end where we're like, well, now we just have to avoid it because it hurts. And of the things that are associated with that, whether you're in a in a relationship not, but ⁓ all just so much that's taboo about it. People are not comfortable talking to their provider about it. Stephan Esser MD: Right. Right. Laura Bunso, PT, MTC: and ⁓ not even comfortable talking to a family member or a best friend because they feel like something's wrong with them, like inherently wrong with them. I had a patient yesterday who was young her 30s and coming some bladder issues that in my mind are quite ⁓ simple to address, easy. You there's some work to it, but definitely pelviclore rehab will Stephan Esser MD: Right. Laura Bunso, PT, MTC: change her life and she is really not functioning and not having any life at all. It's revolving around these flatter symptoms. And it's heart-wrenching. And one of her questions to me was I feel like I did this to myself because I waited too long to come and and I just ⁓ it gives me chills just to ⁓ know just to it's these are just life changing for people. ⁓ and I say as long as your as long as your brain and your Stephan Esser MD: Hm. Mm. Right, right. Laura Bunso, PT, MTC: dysfunctioning, your heart is pumping. What's more important than peeing, pooping, and having sex? I mean there's you know, there's that's you know, really really important life stuff. Stephan Esser MD: Yeah. Right. Well, it's I was gonna say such a personal area, and certainly I've seen that in clinic as well. Just like you said, that these people think it's normal initially and then little by little are modifying their life so much the point that when they finally bring it out into the open, people go, That's not how it should be. You know. And I think ⁓ many people got sex ed in school and that's all about the they know about the pelvis and the pelvic floor. So I was hoping you as an expert could teach us a little bit about the anatomy of the pelvic floor. ⁓ And introduce our viewers. What it what is that even? Laura Bunso, PT, MTC: yes. I actually, there's my little thing. ⁓ I should have brought my little ⁓ that's it's in a different room. ⁓ My can can we hit pause? Okay. ⁓ Okay, think I know right where it is, hopefully. One side. ⁓ Stephan Esser MD: You You can go grab it if you want and come back. Yeah, 'cause they'll well they'll edit this out, so just go ahead. Good. You're good. Laura Bunso, PT, MTC: quite sure where I set my big pretty one but this is at least a little bit of something here. And I'll stand up if that's okay. Just show you. Okay. Stephan Esser MD: Sure. Yeah, I'll jump right back. I'll start that question again and then she can edit it in. So you tell me when you're ready. All right, here we go. So many people, right, the the most they learned about the pelvic floor was really just sex ed in school. So, you know, can you teach us more about the anatomy of the pelvic floor? Laura Bunso, PT, MTC: Yeah. Absolutely. So really interesting about the pelvic floor is people really it because you can't see them, right? We really like to see things to to prove that it's real or to know that it exists. Like you if I'm gonna work my biceps, I can look in the mirror and I can see that I'm doing that, I or even my jaw. Something like this, right? You can clench it and see it's moving, or you can relax it. pelvic floor muscles are tucked up inside of your pelvis, like they're almost inside of a cave, but they're musculoskeletal, they're part of the musculoskeletal system. They're striated just like your biceps, just like your deltoid. ⁓ That means can be made stronger, they can be weak. You can pull them just like you could pull a hamstring. You could strain your pelvic floor. You know, I've had so many. Stephan Esser MD: ⁓ huh. Laura Bunso, PT, MTC: Male patients that had multiple ER visits because they thought they had chronic prostatitis, went on antibiotics. Of course, it helped because there's an anti-inflammatory component, but it they would have had more help just taking some ibuprofen or ⁓ a leave probably from it. ⁓ but they pulled the muscle, helping someone move furniture. That's usually one of my first questions. Like, when did it start after you moved to the third floor of your apartment? But those muscles let me see if I can tilt this down just a little bit. Stephan Esser MD: Right. Interesting. Yeah, yeah. Laura Bunso, PT, MTC: So they run from one hip to the other. So if I were to take my hand and just place it underneath and flat against the perineum, all that is pelvic floor. And it's about like this. So ⁓ I people it's a little bit like trampoline. So you've got the bony rim ⁓ of pelvis. Stephan Esser MD: Wow, kim. Laura Bunso, PT, MTC: And then the pelvic floral muscles go from the front, from the pubic bone, they wrap around underneath and attach to the tailbone and the front side of your sacrum. So it's the bottom of your spine. So they attach the front of your pelvis to your back, basically, and then they go from the inside of one hip all the way to the inside of another hip. So on exam, whether it's vaginal or rectal. Stephan Esser MD: Wow. Laura Bunso, PT, MTC: I can actually feel the inside of the hip. That's why we work really closely. Our most recent location is inside of. Stephan Esser MD: ⁓ yeah. Laura Bunso, PT, MTC: Of a local orthopedic practice here, those hip surgeons called us and said, Hey, we're missing something here. What can you know, can we incorporate pelvic floor? It's essentially the inside of the hip, also. And then, in addition to that, on top of the pelvic floor, have all of your organs sitting there. So, bladder, if you're a female uterus, if you're a male prostate, and you've got the rectum. Stephan Esser MD: Right. Right. Well Right. Laura Bunso, PT, MTC: and you know all those things are coming down on top of the public floor they those muscles are ⁓ controlling anything that is allowed in or allowed out it's the gatekeeper it's the door Of this pelvic cavity. So is a little bit of an idea. It's a perfect, perfectly ⁓ correct thing, but you can see all of this red. So this the pubic bone at the front, tailbone at the back. This is your sit bone, people call it. If you have a ⁓ bony tush you set it on a concrete bench, it would be right here. So they go from right to left, front to back. And the action of those muscles, lot of people describe it like an elevator going up and down in a in a in a in a building, but I I a really old school example that I I like to use for for a metaphor. I try to be careful with metaphors for all of this because it's difficult to learn the movement, but the movement of those muscles the way that I describe it, whether it's vaginal or rectal. You know remember the stuffed animal claw game at the bowling alley you stick the quarter into? They still have ⁓ Now you swipe your card on it, but Stephan Esser MD: Right, right. Laura Bunso, PT, MTC: The that claw closes and lifts then lowers and opens. And not, it's it's not it, that's about how much force. You know, those animals don't get crushed, right? They they're barely hanging on, right? And it sometimes they fall out, right? But so you close and lift and then lower and open. And that movement, if you're exercising or doing that range of motion, the the close and lift, a lot of people read about that or hear about that online. Stephan Esser MD: Right, right. Laura Bunso, PT, MTC: or watch a video and you're doing kagles, right? I I mean I don't even know what people mean for that to be. But patients will come in and like, I've been doing kaggles for 20 years. And I'll do an exam and they'll have a zero out of five strength. I'm like, well I don't know what you've been doing, but you haven't been working your pelvic floor. So whatever you want to call it. Stephan Esser MD: Right. Right. Laura Bunso, PT, MTC: So that is the motion. So I'll have my finger there and have them try to close and lift, then lower and open. But the lower and open part is what allows you to empty, not pushing, not straining, lower and open, because you have sphincters, like little rubber bands around the urethra, which is the outlet for the bladder. Stephan Esser MD: ⁓ yeah, yeah. Laura Bunso, PT, MTC: And around the your bottom, your at the anus, the sphincter, those little rubber bands, over time, just like a regular rubber band, might lose their elasticity a little bit. And then these muscles are the backup system. Our body is woven together a basket, weaved together. So I it's we're just so incredibly designed. So you could have a component knocked out, right? Whether you have a nerve entrapment or you had a tear during giving birth, or you had a prospect. Stephan Esser MD: ⁓ okay. Laura Bunso, PT, MTC: Surgery, and you had a little insult to things and it's swollen or whatever. But this this basket that's woven together, you could, if it was, if you think about a basket holding eggs, you could pull a reed of that basket out, like an actual, I'm talking about a real old school basket. You could have a reed or two of it pulled out, and it would still hold the eggs. At some point, the eggs start to fall out of the basket. Literally, for women, sometimes that's an organ prolapse. And so the strengthening of that pelvic floor is the backup system. So if you go if you're going through menopause or you've had a grade four perineal tear from giving birth, or you know, whatever the things are. Stephan Esser MD: Yeah. Laura Bunso, PT, MTC: you've lost some of that bulk of the muscle, just like if if you don't exercise, you'll lose the bulk of the muscle. When you start working out correctly, you do have to do the right muscle, it bulks up the muscle and gives that support. But the hardest part of the pelvic floor strengthening is that when people come in, move down so you can, I think the arm is a good example. When ⁓ can't give them a workout to strengthen their pelvic floor. Stephan Esser MD: Right. Laura Bunso, PT, MTC: if am to say, okay, contract your public floor, do that close and lift, then they go like this. So to give someone 50 kagles is to put a 10-pound weight in my hand when I can't even I can't even do this. ⁓ I even raise my arm. Why would I put why would I do 50 arm raises? I can't raise one time. ⁓ Stephan Esser MD: Right, you don't even know what to do with it. Right. Right. Right, right. Laura Bunso, PT, MTC: So that's where the true rehab part comes in. And then once you can do it, then we can give you a workout. You can go do stuff at home. Stephan Esser MD: You know, interesting. So I'm hearing from you that the pelvic floor, all these interwoven muscles, have like this basket on the bottom, but they're voluntary muscles, which means, right, that there's something we can do about it. And I'm also registering from you here that, you know, I'm thinking in my head of the older ladies, let's say that I see and gentlemen who are sarcopenic. They're just losing muscle everywhere. Andor people, like you said, that perimenopausal menopausal state where collagen is beginning to fall apart a little bit. Well, it's probably falling apart in the pelvic floor too, right? Laura Bunso, PT, MTC: Absolutely the same thing that's happening that it's up, we're, you know, we just wake up battling gravity every day, basically. So of us are better at it than others, ⁓ you know, it's it is literally a a fight, right, to keep your strength. And we're losing half a pound of muscle a year as we age, right? So you you what you did last year will not even maintain what you had last year. You have to do a little a smidge more each year just to keep it. And Stephan Esser MD: Yeah. Yeah, yeah. A little bit more. Laura Bunso, PT, MTC: And the same thing is true for your vaginal fitness or your rectal fitness. And then if you add an insult to it, radiation, a can't, you know, some sort of cancer, whatever, whatever going on, you long list of things that start to happen as we as we age. Stephan Esser MD: Yes. Yeah. Laura Bunso, PT, MTC: then you really have to work and be intentional about regaining that strength and sometimes just strength, sometimes it's coordination also. And that's usually one of the most crucial components of this, especially in the younger population of people. Stephan Esser MD: Yeah. That makes sense. So so now that we know a little bit more about the anatomy, I have a question. Is it normal for women over the age of forty to have urinary incontinence? Like when they laugh or sneeze. Is that normal? Laura Bunso, PT, MTC: It is not normal. It's very common. And that's one of the things that we say is that just because it's common doesn't mean it's normal, right? There are a lot of things in our lives that we tolerate because it's common, but it's really not good for us. And it's also not normal. But even in teenagers or young adult females that are lifting, you know, there's jokes about it all the time. People tag me all the time ⁓ on ⁓ look at, you know, da da da. I'm like, well, I mean, okay, that's cute. I guess if you're okay pee in your pants whenever you're 23. I'm not. Stephan Esser MD: Right. Right. Right. Laura Bunso, PT, MTC: but because it is so prevalent and so common and these are in noliperous women, these are in women who haven't had a baby that are leaking. ⁓ Stephan Esser MD: Right. So so all right, so hit me with this. So let's say you're otherwise healthy, you've had no you know, you have you don't have any neurologic injuries, you don't have any, you know, problems nerve wise. ⁓ And and you've got a little bit of vaginal leaking when you laugh, cough, or sneeze. What the likelihood that with pelvic floor PT you can get rid of that? With good pelvic floor PT, and how long do you think it would take? Yes, yes. Laura Bunso, PT, MTC: Yeah, you're generally healthy. No no issues here. With the right pelvic floor PT. ⁓ yes. is as long as you don't have any other like detruser, you ish there's no other ⁓ more sinister thing going on, you should absolutely be able to regain control. No problem. ⁓ I don't know. I don't Stephan Esser MD: Yeah. Ninety percent of women, eighty five, a hundred percent w ⁓ Laura Bunso, PT, MTC: if you do the things, you you you should be better, you know. If you're if you if you the the key is you have to strengthen to the of the load you're placing on your body. So that's the key. So for example, I have someone, you know, if I have a collegiate runner in mind. Collegiate runner actually had a strong pelvic floor. Stephan Esser MD: Okay. Okay. Okay. Laura Bunso, PT, MTC: Like went on assessment. Now, when I say strong, I mean like physical therapy clinic strong. Five out of five. But she was leaking. Yeah. Stephan Esser MD: Right. And just for our just for our viewers, real quick, you evaluate pelvic floor strength not only with like a digital exam where they're squeezed, but also use some high tech equipment, right? Where they can squeeze devices and show how much actual pounds per square inch can be produced, correct? Laura Bunso, PT, MTC: Yes, yes. Well we do, we actually use, we don't use a pressure device because it's very easy to fake. ⁓ you can bear down ⁓ the organs pressing can give pressure and you get a false ⁓ you actually can make them worse with that. ⁓ Stephan Esser MD: Okay. ⁓ okay, okay. Yeah, yeah, yeah. Laura Bunso, PT, MTC: ⁓ so you do need to be careful about the there are some really great devices and if they're used properly, which you you might accidentally use it correctly if you just bought it online, but you also might accidentally use it incorrectly. I think you got a 50-50 shot on that. ⁓ we use Surface EMG. Stephan Esser MD: Right. ⁓ wow, okay. Laura Bunso, PT, MTC: So you can also fake that, but a little bit easier for us to you surface EMG, which is called ⁓ and in this specific space, perineal biofeedback, which Medicare covers, strike care cover, you know, a lot of these insurances do cover if you have it, you know, you gotta do it all correctly, all the work all the ⁓ magic and all that, but Stephan Esser MD: Right, right, right. Laura Bunso, PT, MTC: But the surface EMG can show you of the really crucial pieces, which is how well you're relaxing the muscles. And also the ramp up and how well you're contracting and if you're maintaining it. So endurance is a huge component of this. Two-thirds of the fibers of your pelvic floor are Stephan Esser MD: ⁓ okay. Right. Laura Bunso, PT, MTC: Marathonners, long distance runners. So it's really important to not just squeeze. You know, you you have to actually contract and hold. Normal endurance of the pelvic floor is a 10 second hold for 10 repetitions. And that Stephan Esser MD: Right, right. Okay, that's a lot. Yeah. Laura Bunso, PT, MTC: That's that's a lot. and I'll ⁓ you know, every now and then I'll get so I had someone yesterday who was actually able to hold it for ten seconds the first time, which was great. She couldn't do it a second time. That was it. She was gassed. It's it's it's it's the equivalent of like, ⁓ I can run a mile and then I'm like, okay, now run more, run more. And they're like, God, I'm cooked. That's it. Now. Stephan Esser MD: Yeah. And I think what I've heard from, you know, you in the past too about this, and some of my patients have come back reporting kind of updates on their pelvic floor PT is that so many people are misfiring that area, like you almost just suggested. They're they're misfiring certain muscles, pulling abnormally, instead of having that billy just kind of relax that claw like you described, and then kind of gently all the fibers coming together, right? And and kind of working in unison to create that safe, robust, strong, stable place. Laura Bunso, PT, MTC: Yes. Stephan Esser MD: ⁓ you know, in in the pelvis. Yeah. Laura Bunso, PT, MTC: Well, what what what is ⁓ probably don't know what the age range is on of your audience, but in the younger, ⁓ say younger female population that's having urinary incontinence, stress specifically, oftentimes one of the biggest components for them. Is that we need to teach them how to relax the public floor because they're walking around with this low-grade clinch because they're scared. When two when you're fearful of leaking, we get we start doing all these really strange things when we're fearful. We do the same thing in any other area of life when fear is driving whatever the decision is. Stephan Esser MD: Right. Yeah. Right, right. Laura Bunso, PT, MTC: With leakage or organ prolapse is another really common one. So it'll start with a little bit of leakage then you develop this low-grade clench because you think you want to squeeze all the time the whole time that you're lifting. Well, when you're there's all kinds of studies. You you guys could search the stuff on ⁓ you know, use or WebPT or I'm not web ⁓ WebMD or whatever. But when you're exercising, when you walk, when you're running, you're lifting weights, any those things that you're doing, when you're doing those, your pelvic floor naturally is activated and should be working to help hold you up. It's part of the load transfer. So you step down on one leg, load, can't, you know, the this all of the mechanics, the physics of this is that that energy comes up the leg, comes around down, you know, it's gotta go somewhere. So the pelvic floor is Helping to support and accept this load transfer. And so when you start this low grid clench, if you think about if I went to lift weights and I just did this the whole time, and then I tried to push up while I can't while I kept it. I can't, I mean, I don't even think I I can't even move my arms up, just let alone put a you know 50-pound bar in my hands, right? So When you start to clinch do this low grade tension, you just build tension and you just make it hurt. Just like if I did that with my shoulders all day or my jaw, I'd have a raging headache by about five o'clock. And so we're working with those people oftentimes to let have them let go. ⁓ of like they're walking around, they're wanting to get stronger at grip, but just walking around with a hand halfway closed. So you got to open it before you can work ⁓ on. Stephan Esser MD: Right. Yeah. Right. Right. Work it. Laura Bunso, PT, MTC: Closing it. And then as far as the load goes, for those ladies that let's say organ prolapse or stress incontinence and someone in their 20s or 30s that's lifting weights, CrossFit, running, whatever the things are, you can have normal strength on a test, five out of five, where you are able to squeeze, and five out of five is like a baby sucking on a bottle. It's a clamp down, it's a good strong pelvic floor, but that might not be enough. For someone who is running at the collegiate level or and competing at a high level for something, you know, like a you know heavier weights. So you have to actually increase the strength and the load on those muscles, just like you would increase the load on your hips or your shoulders for any of the other things that you're doing. And I I can't tell you how many times I've had someone come in super fit, I mean ripped, shredded, and had a zero out of five public floor. Nothing. Not not because anything was broken, but just because it just shut it off and it just, you know, not activated. Stephan Esser MD: Right, right, yeah. Right. N not working those muscles, not activating. Yeah. Interesting. You know, so I'm gonna turn our attention for a minute to kind of women who are postpartum. A lot of women struggle with pelvic pain after their postpartum state. You know, kind of based on the literature and the and the therapeutics, you know, studies, long is it normal for a woman postpartum who otherwise had a healthy pregnancy ⁓ kind of continue to have some pelvic floor discomfort or pain? You know, how how how long on average? Okay. And so if she if this woman's out at Laura Bunso, PT, MTC: Three weeks. If you're experiencing symptoms after three weeks still, after the initial tear or incision or cut is healed, if you still are hurting, you you should see a pelvic core therapist. I think you should see a pelvic floor therapist wherever you are three weeks ⁓ three weeks anyway. Three to six weeks ACOG guidelines is that you should have a post pelv ⁓ postpartum assessment of your pelvic floor in that three to six week window, which is perfect. ⁓ you're working, it's before you go back to work. If you're not working, it's probably when you have the most help. Go go to your appointment, get someone to watch your baby. You know, if you time it right for nursing, hopefully, you know, or whatever if you're nursing, see if you can go without the baby so that you can give your undivided attention and actually work on it. Stephan Esser MD: Yeah. Right. Right. Nice, nice. And so then back progressively over time, right? Kind of over the next 'cause on how many weeks would we expect? Is it the same like in PT, let's say for the shoulder? We might expect four to eight weeks to see meaningful benefit. What is it in the pelvic floor? How long do they need do P T before they're seeing some good benefit? Okay. Laura Bunso, PT, MTC: It's striated muscle. It's the same tissue healing time. Once you start working on it, right? So you You know, people will say, ⁓ it's been, you know, it's been six months since I have my baby. I'm still not better. but the same thing with your shoulder, like it's it's, you know, if you if you strained a rotator cuff and still not better six months later, but you haven't, you have you're not actually working on it yet. It's ⁓ so I usually tell people to give yourself about six to eight weeks. there the the other things that make the pelvic floor a little bit more complicated. It is tissue healing, just like tissue healing in the body. Stephan Esser MD: Right, right. Laura Bunso, PT, MTC: gaining strength just like gaining strength in the body. The the you have to make sure that you know how to do it first. Sometimes it takes three weeks to learn how to do it so you can start to strengthen. Now now we're in that six week window when we're finally doing the exercises correctly at home. And then in addition to that you have other things that Stephan Esser MD: Right. Right. Yeah. Yeah. Laura Bunso, PT, MTC: that will have a deep impact on the function, which are your your bowel and bladder function. So Stephan Esser MD: Yeah, I was I was gonna say about that bladder piece, you know, a lot of people struggle with chronic constipation in America today, right? I mean, poor hydration, adequate activity, ⁓ lack less than ideal fiber intake, you obviously play a part for a lot of people, in your experience, how much is that pelvic floor playing a big part in this sort of constipation sort of paradigm as well? Laura Bunso, PT, MTC: Well, all of my patients who come to me for constipation, it's because of their public floor. So in my experience, it's a hundred percent. So I ⁓ you know, I wish I had a statistic on that. I think that that is something as a stone that's not been turned over. I'm actually working very hard. Stephan Esser MD: Yeah. Right. Laura Bunso, PT, MTC: in our ⁓ medical communities to turn that over because the number of people are taking Motegrity, Lenses, True regular laxatives, are on you metamusle, Muralax, ⁓ all of those I I had someone was taking fifteen laxatives a day, like laxative that's that Stephan Esser MD: Rem. Right, right. It's insane. Right. Right. Laura Bunso, PT, MTC: That's don't know how much they are right now, but that's at least a dollar a pill. That's $15 a day to go to the bathroom, and it was her pelvic floor. ⁓ and you can get really, really sick. I ⁓ like see the standard of care that if you're going to your primary care and you're saying Stephan Esser MD: Ray. Yeah. Laura Bunso, PT, MTC: I am struggling with constipation that you have a consult with a pelvic floorist that is trained in this area. They're not all trained in the area of bowel management or constipation. In fact, most of them, a lot of them don't do it. So just call ahead and if they don't do it, they probably can refer you to someone who can, because you can even do something like this virtually as far as the conversation goes. We can usually tell by about a 15-minute conversation if your pelvic floor is component of all of this. But I can't tell you how many times people get what I call the million dollar medical workup, where had all the, you know, anal defec anal defecography, anal anal manometry, colonoscopy, endoscopy, all ⁓ all of the ⁓ which is great when they come to me and we've ruled out any sinister because it basically turned inside out. We we know there's not a tumor blocking it, so that's good. but Stephan Esser MD: Right, right. Right, of course. Right. Laura Bunso, PT, MTC: Some of this have most of it could have been addressed with just an initial consult with a pelvic floor therapist to assess the pelvic floor. but we're very resistant to having an exam like that, to having it. It takes two seconds to check someone rectally to see if their pulp floor is functionaling. it's it's really no cold metal objects, no speculum used during the exam. a quick assessment to see if it's functioning and to do some retraining on it. it's very inexpensive as far as medical costs go. But my one of my goals is that the standard of care, the gold standard in healthcare, is that before you have all of these incredibly expensive tests or even start on one of these sometimes life-changing medications, if you're on one of those medications that I just listed and you take it in the morning, you probably can't leave your house for two hours. Your whole life revolves around your bowels. And we can teach you the things are. We know all the tricks to get your bowels moving. So in the absence of anything sinister, you can certainly manage your bowels. We can do, we can, we teach people how to do there's a really specific massage to help with your intestines. We have, I call it the Fantastic Five, a little series of exercises that I designed to help get things pumping and moving. But movement is medicine for everything, including your intestines. But just like when we start to hurt at our back or our hip or anything else, our life really shrinks down, we quit moving, it makes it worse, snowballs, and then we go and we get a study done and we do the thing, you know, where you swallow the thing and they do the study and they say, ⁓ got slow motility. I'm like, well, I guess so. Just like if I had the door closed of this room, I'd be very slow to getting the furniture out. If I open the door, we'll just take right on out. Stephan Esser MD: Right. Right, right. Laura Bunso, PT, MTC: It just, you know, you've got to be able to open the door to get the things out. And going on a medication like that, yeah, I was just gonna say going on a medication like that, I I describe it like this to my patients because they don't want to come off of it. It's not working. They're still coming to me, even though they're on these medications. It's not working, but they're scared to go off of it because they might end up with another emergency room visit. Or some of these people are really sick, like vomiting stool, they get so backed up. Stephan Esser MD: Right. No, I have a question for you. Right. Laura Bunso, PT, MTC: Or I've had people with an ostomy placement because of it. And then we work to get a re-anastomosis. Like you can get sick from it. And the way that I describe it is, you know, opening the door and getting the furniture out. It's the normal way, right? But when your pelvic floor doesn't function well, it's like it the door is not just shut, but then if you strain, you're like pushing it shut. Stephan Esser MD: Right. Laura Bunso, PT, MTC: Now you're never getting the furniture out. But I'm like, if you're if you're life-dependent on it, we splinter this furniture into a thousand pieces and get it slided under the door. That's what you're doing with those medications. You're liquefying your stool so that it can come out of this tiny opening because you don't have the ability to just do this let the stool pass. Stephan Esser MD: Well it's interesting as you're talking because I've dealt with so many patients as well with this horrible conditions like that chronic constipation, et cetera, the level of anxiety that it creates, of fear, of just being overwhelmed. And it's just it's a vicious cycle, isn't it? Because in order to have a good bowel moment, you need to be able to relax, right? And kind of just the door be open, like you said, versus kind of this fear and this angst ⁓ it will it work, will it not? What will I get out? How much do I have to push? Laura Bunso, PT, MTC: ⁓ yes. Stephan Esser MD: You know, you know, the whole autonomic nervous system, you know, kind of kicks in that fight or flight response. And we're not meant to poop when we're scared, you know. I just I'm hearing so much there. It's it's interesting. I'm I'm hearing about, you know, there are a lot of different people that I feel like should be coming to see you, right? And having good pelvic floor PT. I'm hearing about maybe even the the expectant mothers who haven't even had babies yet, right? Who wanna start focusing on their pelvic floor and be proactive. ⁓ the women who the women who have had babies. ⁓ Laura Bunso, PT, MTC: Yeah, yeah. Stephan Esser MD: The women who are perimenopausal, menopausal, right, who are struggling with a little bit of urinary incontinence, et cetera. The individuals, male or female with some constipation issues, right, or a history thereof, people who have had some sort of pelvic surgeries or hip surgeries, even down in that area, that might benefit from an evaluation just to see how much of their dysfunction is related to that. You know, there's a whole host of people that I believe, you know, kind of, and this is why I wanted to have you on today to talk about this, because this is such an undercon, you know, talked about topic. And yet it is so human. Laura Bunso, PT, MTC: Yeah. Stephan Esser MD: Right. So my viewers, you know, all the viewers out there, you know? Yeah. Laura Bunso, PT, MTC: It and it's so prevalent. Yeah. And then, you know, pain, out of the add the whole pain component into it, you know, pain with intercourse, hip pain, tailbone pain, all of those things. yeah, it is, and it is I don't know, it just gets me. I it just it's a dagger in my heart when I see someone suffering from this, but you really do when you don't understand and we if you once you learn about it and you learn the mechanics of it. Stephan Esser MD: Right. Right. Laura Bunso, PT, MTC: you know, I don't know if you've ever I mean, you're in medicine, so obviously you've had mysteries revealed to you of the body, right? And once you understand them. They're less scary, you know, like ⁓ you know, I I think, you know, I I broke my foot. make mixed moshurists is my sport. I broke my foot fighting one time. And for for some people, that's like a it's really scary for them. Like, it's a broken bone, it'll heal in eight weeks, I'll get my cast off, I'll start working on it, I'll gain my strength back. It's, you know, it's a little demoralizing, it's frustrating. I don't don't get to work out. Stephan Esser MD: Right. That's right. Laura Bunso, PT, MTC: But you when you understand the mechanics of something, you don't suffer anymore with it. But when you don't understand it, it is when you attribute other things that much more complicated. Because to have pain or to have anything going on in this area between I this is I anything between here and the and the mid-thigh. Stephan Esser MD: Right. Laura Bunso, PT, MTC: If you have something hurt in there, anything in there that is bothersome to you, are so many things, it's the center of the universe, basically. It's procreation, it's where of action of ⁓ our sort unmentionables happen. And it's very scary. And that's a space, for example, if were to go to a doctor, if you're female and you go to a gynecologist and they say, you gotta have hysterectomy. You know, whatever the thing is, you gotta have it. one no one ever questions anything. You gotta have a bladder attack. You gotta have a whatever, you whatever the thing is. you need this medication. No one ever takes a look at it. It's just the way that we've sort of evolved in our medical community. Even the even the clinicians, they're not that they're not open to it. it's just not Stephan Esser MD: Right. Laura Bunso, PT, MTC: We just have to have more conversation and education about it. We have to educate our primary care doctors about it, those are the really the gatekeepers in our healthcare system right now. and ⁓ and general population that there might be other things. That's not to dismiss or say so you know, if you have something really sinister going on and you need to have that done. But I'm talking about the things that are yeah, that that's sort of the the guesswork of, well, let's just take it out or let's just tack it up so that we can try it, see if that, see if that helps. That there's not a second opinion, but you'll get one for your back. If you if you're gonna have back surgery, if you're like, let me see what else I can do, I don't know, or shoulder surgery. But if it's in that space, there's just a more fear and a lot less Stephan Esser MD: Right. Laura Bunso, PT, MTC: A lot less fe a lot I think a a I d I don't know how to say this, a lot less of a feeling of that maybe I I have something that I can do in this space that I can that I can work on or I can seek out or I can learn to help me address this. Stephan Esser MD: Yeah. Well, I'm hearing, you know, knowledge is power. And that's certainly what this ⁓ podcast is all about, right? It's I mean so many people, right, go get their rotator cuff surgeries for their partial tears, and yet, know, 80%, 90% are better with just good PT, right? For a small partial tear. And but people don't know that until they've experienced that. So so valuable to kind of have you on today and sharing about that. You know, ⁓ I to leave our viewers with a a number of valuable sort tangible things. So just kind of maybe three or four things that you would say to all of our viewers. Laura Bunso, PT, MTC: Yeah. Stephan Esser MD: That can improve their pelvic health and function, that they can try to integrate right away and maybe any resources that you can point them toward. I know you've got a lot of great stuff that you you know put online, et cetera. ⁓ any of those resources. And we can add that to the show notes as well. But if you could share some good tangible tips as we're getting toward our closing with ⁓ with our viewers, that'd be awesome. Laura Bunso, PT, MTC: Okay, so the first thing that I would say that could be really powerful you're having a difficulty with any of these things is first to find it. Find your pelvic floor. if you if you're okay with it, most people are, but you know, some cultures are are are not. But when you're taking a shower or if you're lying down in bed, just put your finger ⁓ at the perineum. The perineum is a space, so if if this is the vagina and this is the anus, the perineum is a space in between. It's where get an epesiotomy if you were to get an episiotomy. On men, it's the space behind the testicles in front of the anus. ⁓ it's in it's a little bit bigger area there. If you're if you're having pain in the abdominal area, or you're hurting, like you have that, it's like a deep ache, almost like a toothache, or if you're leaking, any of those things. ⁓ For females, ⁓ could just the finger just inside the vagina if you feel comfortable with that and see if you can contract. The muscle. See if you close it, it'll feel just like my hand closing around my finger or letting go. So it will close and it should have a close and lift to it, and then lower and open, just like the thing I was describing earlier, the cloth. For men, can put your finger ⁓ the perineum and you can contract. and then relax. There is an involuntary component to it that not everyone has. Most women who've had a vaginal birth that don't have it. But if you cough, like a good cough, you might feel it ⁓ contract, like reflexively contract. Or if you do a gentle bulge, so the lower and open. Gentle bulge, not push out, not strain. You should feel it come down into your fingers. So you can try to think about that close and lift and lower and open. So the first thing is just to find it. If you're hurting, you can rub it, you can massage it. You're not going to hurt yourself. can just rub it, massage it. If you've got long nails, you don't do you know trim them ⁓ you do it. Stephan Esser MD: Hm, okay. Laura Bunso, PT, MTC: Do not sit a golf ball to massage them or so. That's it's too hard. Don't that. You can just massage them. And then if you do find them and you like or you're you're having symptoms, see if you can go through that full range of motion. So you can sit up tall in the chair and try to contract and lift and then lower and open. You've got to be able to do that full component of If you can't Do those things, it can't we can't give you homework or anything, right? You got to go do pelvicord therapy and go see someone. ⁓ then if you can do them, if you feel like you're like because some people are like, ⁓ I can I get I get it, I I felt I feel it, I can feel it. You can't see them, so it helps to touch it. Then you can actually exercise them and do some contract, relax, and on strengthening and conditioning them, just like you do any of the other muscle groups in your body. Stephan Esser MD: Right. Laura Bunso, PT, MTC: And then of course do all the other things. Regular exercise, drinking water, keeping moving, all of those things. Keep and keeping your weight under control. What you know, every pound extra on your belly exponentially increases the load on your bladder. So you're the you those systems are pretty unforgiving for us undisciplined. So Stephan Esser MD: ⁓ okay. Laura Bunso, PT, MTC: Drink mostly water, things like caffeine, artificial sweeteners, alcohol are all irritants for your for your bladder. Doesn't mean you can never have them, but just, you know, if you if you're gonna you're gonna throw back a few glasses of wine with your girlfriends on a Friday night, you're gonna be your vants by the end of the night, whenever you're you're when you're you guys are cutting up and and laughing. So, you know, you can at least go into it knowing. that you know maybe you drink a glass of water before you start and you have you know every up you glass of wine and then a glass of water instead of another glass of wine and just limit limit it or glass of water before you have a cup of coffee and just have one instead of having two. Stephan Esser MD: So kind of the muscular aspect of things and then all the nutritional lifestyle modifications, the hydration, keeping that the bowels moving, you know, well, et cetera. So, I mean, there's so much going on down there. And I really appreciate you taking the time today to walk us through the anatomy of it well as kind of the aspect, the psychology a little bit of kind of, you know, the struggle that's real. And want all of our viewers today just to recognize that there are amazing public flora therapists out there like Laura. You know, who are there to help and you're you're not in this alone and you don't have to keep this as a secret or a hiding this away, you know, et cetera. You know, if you're dealing with urinary incontinence or bowel incontinence, make sure that you get a good evaluation and then and recognize that pelvic floor PT, I can tell you, right, having gone through medical school, residency, et cetera, you know, all too often it's not talked about enough. And so many physicians themselves are not even as aware. And that's what I love about Laura, who's been educating the medical community here in Jacksonville for a decade. Plus, you know, kind of about all of the value of this for people's health. So Laura, thank you so much for joining on the podcast today and for sharing your passion and all the awesome work you do. All of Laura's contact stuff will be ⁓ below, kind of in the show notes. no, she has an awesome podcast as well that you all can go listen to and learn more about pelvic health as well. ⁓ ⁓ love it. That's awesome. Well, thank you, Laura, for joining us today. Laura Bunso, PT, MTC: Yes, pelvic like it is. Yeah. Yes. All right. Thank you for having me, Dr. Esther. It was such a pleasure. Stephan Esser MD: We'll see you all again at the next NHA Today podcast. Laura Bunso, PT, MTC: Right.