One Thousand Papercuts

It’s true.  People have issues in their back, hips, pelvis, bladder, urethra, genitals, vagina and rectum for a handful of reasons.  It doesn’t get that wild. It doesn’t. But, when one issue is kind of quiet, but persists and other issues are also occurring, then it all starts to add up. One moment you are OK, then the next you are not.  

I’ve listed super common reasons why people have pelvic issues. 


Muscle Tightness

The word “tightness” is frowned upon in academic circles, but I don’t know if it’s for good reason.  The only reason I’d frown upon that word is because I don’t think it is actually a word.  But, if we write to communicate, then I’m going to use communicate by using a non-word that communicates what I need to communicate!  Despite it’s lack of existence, everyone knows what I’m saying when I say muscle “tightness”.  When the pelvic floor muscles are tight, this causing pain.  It might not cause pain with fleeting tightness, but it will, inevitably, cause pain with muscles that stay tight.  This is true for my any muscle in the body, but it is especially true for pelvic floor muscles.

Tight muscles have reduced blood flow and oxygen.  Blood flow and oxygen are necessary for muscle and nerve health.  When any muscle is tight, it cannot perform it’s job because it is weak.  A tight muscle is not strong.  A tight muscle is weak.  This is a fact.  A muscle that never rests at a normal length is not going to be able to contract powerfully.  When a muscle isn’t strong enough to do it’s own job, then other muscles have to step in and take over.  This compensation creates a slew of new problems and new pains.  So, tight muscles cause pain because they are not healthy.  And, tight muscles cause pain because they force other muscles to do too much and move other body parts in a weird, unintentioned way.  Yet another non-word from a girl that likes to write.  If Shakespeare did it, Sara Sauder can do it too. 

Back Problems 

The spine is like a generator that helps everything else in the body light up.  The brain creates a signal to the spine and the spine has all these wires that light up different muscles and then the body appears to respond to the brain’s command.  The spine has all these levels.  It’s like a high rise with a ton of floors.  Imagine that each floor has a window has a zip line connecting it to one body part.  For example, the first floor zipline connects to the toes.  The 10th floor zip line connects to the pelvis.  The 22nd floor zip line connects to the fingers.  The occupant of each floor glides down their own zip line and tell their corresponding body part what to do.  The first floor occupant, her name is Betty and she glides to the toes and says “give me a wiggle”.  Wilma glides from the 10th floor to the abdomen and says “give me a jiggle” and Herb glides down from the 22nd floor super slowly and carefully (he is actually afraid of heights) and tells the fingers to “give me a sniggle” – it rhymed.  But, when these windows to open correctly, the occupants get frustrated.  They push and they pull and they shell out money for a cocky and overpriced maintenance guy to come in, charge a $95 service fee to apply a little 50 cent grease and watch the window slide open on command.  The occupant, now frustrated, humiliated and desperate for fresh air now buck and cuss their way down the zip line.  The zip line frays a bit under the jolted movement of the unhappy campers.  The high rise occupants are now so annoyed and disoriented that they no longer ask for a “wiggle” a “jiggle” or a “sniggle”.  Now they give a garbled mutter of a command.  And this, my friends, is confusing.  It’s not the clear, energetic signal that the toes, pelvis and fingers are used to getting and this confusion equates to pain. 

Was that the worst analogy of all time?  Possibly.

Nerves come out of your spine and if your spine isn’t moving nicely in all directions, it can cause a pinched nerve.  If that pinched nerve goes to your pelvis, this can cause pelvic pain.  Boom.

Connective Tissue Restriction

You know how when you rip the skin off of raw chicken, you see that iridescent, thin layer over the meat of the chicken?  That’s called fascia.  That thin layer runs all throughout the chicken.  It also runs all throughout…us.  There are four layers of fascia and the most superficial of our layers – the one you see on the chicken – is the pannicular layer.  This layer is so impactful in treating body pain, not just pelvic pain.  This is like a full body suit from head to toe and everything in between.  When one part of this pannicular layer of fascia isn’t sliding and gliding with ease and abandon, then you start to feel weird, ambiguous, though…sometimes extremely specific pain.  The ambiguous pain could feel like “I just feel a spreading ache” or the specific pain could feel like “I am so aware of the opening of my urethra, I cannot stand it!”.  This layer of fascia that we are talking about is found under skin, under fat and on top of muscle.  As physical therapists, we can access this and affect it.  We can make parts of it that are “stuck”, get “unstuck”.  We can make it glide and slide without abandon.  We can make it loosey and goosey and everything in between.  And this, for many people, eliminates their pain.


Trigger Points

In all honestly, I don’t know what a trigger point is.  Sometimes I feel these little bundles on my patient’s skin and it’s tender when I push on it.  Then I kind of hold my pressure and the tenderness goes away.  That’s a trigger point.  But, what is it?  Some say it is a small area of bundled muscle fibers, bundled fascia fibers, bundled something….  Others say that trigger points are nothing.  All I know is that sometimes I can feel these spots, but most of the time I cannot.  I also think that trigger points are given way too much attention.  I feel uneasy talking about trigger points.  I feel like I’m talking about something mystical, some soft science.  But, I use the term “trigger point”, because there are many times I don’t have another phrase to use to describe a tender spot on a person that becomes untender once I hold pressure on it.  Is something wrong with me?  Likely.  Does this haziness stop me from treating “trigger points”?  Not really.  I can’t explain everything.  I can explain some things. But, I’m really comfortable explaining that I can’t explain things.  Understand? 

Trigger points are weird.  Sometimes I hit a spot on someone’s thigh and they feel it in their tailbone.  Sometimes I hit a trigger point in the rectum and they feel it in their stomach.  If it works, I do it.  If it doesn’t, I don’t.


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You Must Drink Water Correctly



My husband and I were once at a gas station paying for a bag of beef jerky.  It was some organic super left-wing, not really meat, more like a meat imposter edible– it was horrible.  Don’t ever buy those.  If you want something that feels and smells like meat, then I suggest…meat.  So anyways, we are paying for this faux-meat when a man walks in and says to the cashier, “Hey!  Your sign outside says $1.59 a gallon (I don’t know what year this was or what oil prices were doing) and your pump just charged me $1.75 a gallon!  What gives?!?”.  The cashier looked up from my bag of desiccated tofu and made eye contact with the man.  He was probably wondering why he stocked that crap. He paused, then slowly opened his mouth and said “You must read the sign correctly.”  Turns out there was fine print with several exclusions.  The angry customer didn’t qualify for the $0.16 discount and he stormed off.  Ever since then, my husband and I like to tell each other to do things…correctly.  You must plant the flowers…correctly.  You must take a bath…correctly.  You must do the dishes….correctly.

In light of this story, it took me very few seconds to come up with the title “You Must Drink Water Correctly”.  Seriously.  This is a real problem. Can you imagine being bad at drinking water?  You might be.  Stop imagining, you might be living it.

So here’s the thing.  Here’s the “deal”. We get a lot of information about drinking water.  We know it’s healthy for our organs.  We know it affects how we feel.  We know it tampers with energy levels.  We know what happens when we don’t get enough. 

But, how does one drink water incorrectly and what happens when one does this?

Everything in moderation, man (or WOman). 

I’m getting a lot of patients who care about how much water they consume.  Nice! But, they don’t care when they consume it.  Not nice.  They will down 40 ounces of water in one hour and then ask me why they pee all the time.  If you drink a ton of water at once and then have to pee a lot, then you are what I call a “normal person”.  You bumrushed a balloon (your bladder) with water.  It wants to pop.  So, unless you go to the bathroom to relieve the pressure, it will burst!  A bursting of the bladder is basically urinary leakage.  You pee yourself.   If I did the same thing, I’d be peeing constantly too.   To avoid this, you just drink in moderation.  A gulp here.  A gulp there.  A bathroom break here.  A bathroom break there.  But, not, a bathroom break everywhere.

Drink during the day and sleep at night.

Then I have some patients who don’t drink much water during the day, but they get thirsty at night and drink a lot – all.  through.  the.  night.  So what happens to them?  They pee – all.  through.  the.  night.  A strong sensation to pee wakes them up and they don’t sleep well.  But, they don’t attribute the need to pee with drinking at night.  They attribute it to old age or a big prostate or their diuretics or being “bad” sleepers.  They think they don’t know how to sleep correctly, but really they don’t know how to drink water correctly.  This isn’t to say that people don’t have sleep apnea, really do have to wake up because of diuretic use, etc., but it does mean that drinking water at night is making them wake up to pee more often than they would otherwise.

Water is boring, get over it!

 Water is just water.  There is no flavor.  There is no fizz.  There is no trick to it.  It’s just wet stuff in your mouth.  When you “don’t like the taste” of water, it’s like saying “I don’t like the feel of “air” or I don’t like the “sensation” of breathing.  Your body needs unadulterated water.  Plain and simple!  Dr. Pepper does not substitute for water.  Coffee does not substitute for water.  Carbonated water does not substitute for water.  Flavored water does not substitute for water.  Only water is water.  Let me repeat that:  only water is water.  Without old fashioned, unassuming water you are more susceptible to the following: 

1.     Kidney stones

2.     Infections

3.     Green hands.

4.     Burning with urination

5.     Intense urges to urinate

6.     Speaking in a British accent.

7.     Urinating all the time

8.     Bladder pain

9.     Constipation

10.  Lower energy levels

Verily, I say to thee, if you don’t drink water correctly and then you start to drink water correctly – your life will change. 

You’ll be able to actually sit through a car drive without needing to stop.

You’ll wake up less at night.

You will probably leak less.

 Your urine stream will get better.

You will become more attractive.  The list goes on and on and it doesn’t stop until the early dawn.

So, follow my man’s advice…”You must read the sign…correctly.”

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Your First Visit


Don’t show up in work out pants.  They’re just going to come off.  That should put the “what do I wear” question to rest.  Pelvic floor physical therapy is unlike any other physical therapy you have been exposed to.  This is a much more invasive and intimate type of physical therapy.  On your first visit, we sit down with you and get to know your story.  Why are you here?  What do you want to get out of this course of treatment?  In understanding your symptoms, their source and how to intervene, we need to ask all sorts of socially inappropriate questions.  We need to know about what your bladder, your bowels and your sexual function.  These three things go hand in hand.  Often when someone is constipated, they also have issues with urinary leakage.  When someone has painful sex, they might also feel the need to urinate all the time. 

Within the first 60 seconds of meeting us, we’re going to get right to it.  Why are you here?  What’s up…down there?

We’re going to ask the following questions about your bladder:

·      Does it hurt to pee?

·      Does it hurt before or after you pee?

·      Do you pee too often?

·      Do you get intense sensations to pee?

·      Do you leak urine?

·      Do you wake up too much to pee?

·      Does your urine spray all over the place?

·      Does your bladder or urethra hurt? 

·      Do you even know where your bladder and urethra are? 

We’re going to ask the following questions about your bowels: 

·      Does it hurt to poop?

·      Does it hurt before or after you poop?

·      Do you poop too much? Not enough?

·      Do you have to wipe forever?

·      Do you get intense sensations to poop?

·      Do you leak poop?

·      Does your anus or your rectum hurt?

·      Does your tailbone hurt?


We’re going to ask the following questions about sex:

·      Does sex hurt?

·      Do you have weird symptoms or pain after sex?

·      Can you orgasm?

·      Does it take forever to orgasm?

·      Are your orgasms like “pfff” or are they like “oooooh yeah!” or are they non-existent?


We are going to ask random questions like:

·      Do you have any itching around your genitals, anus or in your rectum?

·      Do you get a lot of infections?  Real infections or “fake” infections?

·      Does it bother you to wear certain types of clothes or underwear?

·      Does it hurt to sit?

·      Do certain food or drink make your symptoms worse?

·      What is your political affiliation?

·      What medications have you been on?

·      Do you like Harry Potter?  If so, why? 

·      Do you have any hernias or hernia repairs?


All of this helps us get an idea of the root of your symptoms.  We want to figure out not just how to quiet the symptoms that bother you, but also how to squash the problem that is creating the symptoms in the first place.  After this painless interrogation…we ask for consent to do a pelvic exam.

This is unlike a gynecological exam and unlike a prostate exam.  This exam is done with primarily your comfort in mind.  If we were to impose pain during an exam, we’d get misinformation.  For example, when you are in pain, your pelvic floor muscles tense.  This is a primitive and reflexive reaction to pain.  We want to know how your muscles behave when they are as relaxed as possible…that is, as relaxed as possible while you are getting a pelvic exam. 

So, what is the pelvic exam?   

For a female, this is an exam of either the genitals and/or the tension in the vagina and/or the rectum.  If only the genitals are being examined, then a thorough screening with light and magnification is performed from the top down.  Checking out the hood of the clitoris, the clitoris itself, the flaps of the labia and the appearance and tenderness of the tissue at the opening of the vagina all tells a story.  What exactly is the story?  It’s different for everyone.  For some, it’s a story of how time has gone by and now perhaps some supplementary hormones could be helpful.  For others, it’s a story of how using soap on the genitals is cleaning too much, the good and the bad.  One of my favorite things to do is to guess the story before I see it.  It is one of the most exciting parts of my day.  I kid you not.

 For a female vaginal exam or a rectal exam for either a female or a male, one gloved, lubricated, warm-hearted finger is gently inserted into the orifice most likely corresponding to your symptoms.  Orifice.  That’s right.  It’s not a beautiful word, but, it does encompass the body parts I need it to encompass, so…orifice it is.  The pelvic floor muscles of the vagina and rectum are the same muscles.  They are just different aspects of the same muscles.  If I were to put pressure in the vagina or rectum and that created some discomfort, I would know that that is a problem.  A pressure on the muscles should feel like exactly that – a pressure, not a pain.  A pain means there is too much tension in the pelvic floor muscles.  Too much tension means not enough movement.  Not enough movement means not enough blood flow.  Not enough blood flow means not enough oxygen.  Not enough oxygen means too much lactic acid build up.  I’ll stop there.  Sometimes, this pain is actually the pain that you are seeking medical treatment for.  Sometimes the pain isn’t a “pain”, but it is your symptom, ie. your intense urge to urinate or your tailbone ache.  I might be figurative miles away from the bladder, urethra or the tailbone, and yet the muscle I am putting pressure on feels as if it is your actual bladder, urethra or tailbone.  And this, my reader, is where the magic begins.  The call is not always coming from the body part that talks the most.  And on this thought, I will leave you to think…. 

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