24: Why Your Pelvic Floor Could Be Causing Your Bloating with Guest: Susannah Stewart, Pelvic Floor Physio

Bloating, constipation, and that “I went, but I’m still not empty” feeling—could your pelvic floor be part of the puzzle?

In this episode of Team Gut Girls, pelvic floor physiotherapist Susannah Stewart joins Dr. Whitney Baxter, Dr. Christina Carew, and Dr. Dominique Vanier to explore an often-overlooked connection in gut health: how your pelvic floor, diaphragm, abdominal muscles, and nervous system work together to help you poop—and what happens when that coordination gets disrupted.

If you’re dealing with persistent bloating, straining, trapped gas, or incomplete bowel movements, this conversation offers a fresh perspective on what might deserve a closer look. And yes, you can poop every day and still have constipation.

We unpack:

• How pelvic floor tension and difficulty relaxing can contribute to constipation and abdominal discomfort.
• Why stress, anxiety, and pain can influence bowel function.
• Toileting posture and habits that can make emptying easier.
• Pelvic organ prolapse and its potential role in incomplete evacuation.
• Dyssynergic defecation—when the muscles involved in pooping aren’t coordinating—and where biofeedback fits.
• Why “just do Kegels” isn’t helpful advice for every pelvic floor.
• What to expect from pelvic floor physiotherapy, including consent, comfort, and options beyond an internal exam.
• Postpartum body image, core recovery, and moving beyond pressure to “bounce back.”

Expect practical insights, myth-busting, and an honest conversation about the things we don’t talk about nearly enough. Because understanding your bloating sometimes means looking a little farther south.

Follow Team Gut Girls for more conversations about gut health, hormones, and women’s health—and share this episode with someone who knows the frustration of a bathroom trip that feels unfinished.

This episode is for education and does not replace individualized medical advice.

CHAPTERS

00:00 Why Your Pelvic Floor Could Be Causing Your Bloating
01:01 Meet Pelvic Physiotherapist Susannah Stewart
02:12 What Is Pelvic Floor Physiotherapy?
04:38 The Pelvic Floor–Bloating Connection
07:52 Constipation and the Pelvic Floor Feedback Loop
10:31 Toileting Posture and Pelvic Floor Relaxation
12:06 Incomplete Evacuation: Signs You May Be Missing
16:00 Pelvic Organ Prolapse: Basics and Risk Factors
18:44 Ehlers-Danlos and Pelvic Venous Congestion
23:38 Postpartum Bloating, Body Image, and Diastasis Recti
27:46 Core Rehabilitation and Recovery Timelines
29:16 What to Expect at a Pelvic Physio Appointment
30:05 Internal Pelvic Exams, Consent, and Your Options
33:42 Pelvic Floor Biofeedback Tools Explained
35:43 How Virtual Pelvic Physiotherapy Can Help
37:02 Dyssynergic Defecation and Biofeedback
40:59 DIY Pelvic Floor Advice and the Kegels Myth
47:02 Referrals and Choosing a Pelvic Physiotherapist
49:24 Final Takeaways and Where to Find Susannah

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Resources:

Susannah Stewart, Pelvic Floor Physio – https://www.susannahstewart.ca/

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Transcript Episode 24

24: Why Your Pelvic Floor Could Be Causing Your Bloating

Guest: Susannah Stewart, Pelvic Floor Physiotherapist

Dr. Whitney Baxter, ND: Welcome to another episode of Team Gut Girls podcast. This is Whitney, and I’m joined by my naturopathic doctor co-hosts Dominique and Christina, and we are so excited today to welcome our first guest on the podcast, someone I’ve had the pleasure of working with in a clinical setting and putting our brains together for patient care.

We have Susu- Susannah Stewart with us. She, her, she is a pelvic physiotherapist who sees health equity as a social justice issue, and advocates for access to quality pelvic healthcare for people of all genders. She loves talking about the awkward stuff, the pee, poo, sex, and pain, and partnering with people to build safety in their body.

She works with an amazing team at Core Connection Mobile Physiotherapy, seeing people in their homes in Victoria, BC area. Welcome, Susannah. [00:02:00]

Susannah Stewart: So happy to be here with you all. It’s an honor to be your first guest.

Dr. Whitney Baxter, ND: Yes. Yes, yes, we’re so excited. Okay, so we obviously love talking about the awkward stuff, too.

What is Pelvic Floor Physiotherapy?

Dr. Whitney Baxter, ND: We are gut-focused naturopathic doctors. It’s our jam. so we understand the value of what you do, and what you bring for our, our patients. but for our listeners who may be unfamiliar with, pelvic floor physiotherapy, what does… how, how do you care for people? Tell us more.

What Pelvic Physios Do

Susannah Stewart: So as a pelvic health physiotherapist, we all start out as physiotherapists, so we do our physiotherapy training, and then we go and we do extra training in pelvic health.

So that is bladder, bowel, sexual function, pain, so it could be back pain, hip pain, pelvic pain. And then we also work a lot with people in pregnancy, postpartum, [00:03:00] perimenopause, menopause, a lot of those hormonal transition periods when pelvic health symptoms seem to ramp up. And so gut health and the pelvic floor are very intricately linked because the pelvic floor muscles are involved in pooping.

And so a lot of what we do is teaching people how to poop, which seems like it should be, you know, something we all learn when we’re kids, but we don’t necessarily. So as pelvic physios, we’re supporting people to have happy, healthy poops because that will also impact their bladder health. So people who have bladder leaks, for example, if they’re not pooping well, it makes their bladder leaks worse.

It can make back pain worse. So we’re always very concerned with making the poops as good as they can be, and collaborating with our medical and naturopathic colleagues to promote that gut health as best as we can.

Dr. Christina Carew, ND: We should call you the Below The Belly Button-

Susannah Stewart: Yes, I’ve [00:04:00] been called a magical vagina lady before too. Me too. Highlight of my life. That was a client. A former client of mine.

Dr. Whitney Baxter, ND: That’s a good one. That’s a good one.

Susannah Stewart: Take it, yeah. More than that. It’s more than that, but I’ll take it.

Dr. Whitney Baxter, ND: But that’s just it. I don’t think people understand, what a good poop is, right?

And why we bring it up, and maybe why we bring it up sooner, or in that pregnancy or preconception phase before, the pressure and when you would typically seeing, seek out a pelvic floor physio, or, like, when the bladder starts to leak. So that’s a good way to say it is, healthy poops. But we’ll get into it.

Pelvic Floor and Bloating

Dr. Christina Carew, ND: Okay, so,

Pelvic Floor & Bloating

Dr. Christina Carew, ND: our series right now has been all about bloating, and so we wanted to bring you on to talk about how pelvic floor dysfunction may make bloating, worse or even just feel worse. And so can you give us some insight, Susannah?

Susannah Stewart: So the pelvic [00:05:00] floor is at the bottom of the core canister, and at the top of that is your diaphragm.

So for people who can’t see, I’m using my hands right now. The diaphragm is at the bottom of the ribcage, and then the pelvic floor is at the bottom of your pelvic bowl, and those muscles move together kind of like a, a pump. When we breathe in, that pump descends, both the diaphragm and the pelvic floor drop down.

When we breathe out, they both come up. And in an ideal system, there’s good flexibility and movement so that the core, including the abdominals which wrap all the way around, and the muscles that support your spine at the back, that whole system of muscles needs to work together to manage pressure. So intra-abdominal pressure, that’s the pressure inside around the belly or between the ribcage and the pelvic floor.

And so if we have stiffness or tightness in any part of that system, the diaphragm, the pelvic floor, the abdominals, or the spine muscles, [00:06:00] then we can get issues with too much pressure in the system, and that can create more symptoms of bloating, like tension inside the abdominal wall.

Dr. Christina Carew, ND: Mm. So there’s four kind of walls, and like each one represents a function, and if it doesn’t move in harmony, then things are falling down.

Susannah Stewart: Exactly.

Dr. Christina Carew, ND: and that’s when we see people with like difficulty with relaxing or people that are too… pushing too much pressure. Awesome.

Susannah Stewart: Yeah. So in order to empty pee, empty poo, have penetration, all of those things, the pelvic floor needs to soften, open, drop, and relax. And so a lot of us ha- are carrying extra tension in the pelvic floor for a variety of reasons.

So one might be if I have pain in my back that lasts more than three months, I’m very likely to have a lot more tension and gripping in my pelvic [00:07:00] floor. If my nervous system is really upregulated with stress or anxiety or trauma history, I’m more likely to have a lot of tension and gripping in my pelvic floor.

Mm. And when I do have that tension, it’s gonna mean it might be harder for me to let poop out or let pee out or even let gas out, all of those things, because there’s not enough flexibility in the system to allow opening and dropping and emptying.

Dr. Domnique Vanier, ND: That’s so fascinating. Yeah, when we… I think about kind of, you know, how we operate in practice and, and maybe the first thoughts are diaphragm, pelvic floor, sometimes abdominal muscles, but not so much the back, right?

And we can see that we talk about all four as a compartment, that all are involved and everything needs to work harmoniously together.

Susannah Stewart: Mm-hmm. So one more thing- Can we talk- Go ahead

Constipation Feedback Loop

Dr. Domnique Vanier, ND: Yeah, I was gonna say the constipation piece, right? Like all of us see constipation so often in practice, and is it a chicken or egg effect?

Constipation & Pelvic Floor

Dr. Domnique Vanier, ND: Like I’m interested [00:08:00] in knowing kind of where things start. Is the constipation then affecting the four walls, the four walls affecting the constipation? Is it bidirectional feedback? Let’s talk more about, you know, that, the incomplete evacuation aspect. Yeah, tell us all about that.

Susannah Stewart: We’re going in. We’re going in.

Yeah.

so I feel like there’s a top down and a bottom up with pelvic health concerns in general and, and constipation included, meaning stress, anxiety, trauma informs the pelvic floor, tells the pelvic floor how much tension to hold or not hold. And then if we have injuries in the pelvic floor, in the low back, in the hips, that information goes back up to our brain.

So we actually wanna treat both ends of that, communication system in order to get the best results for constipation and, and other pelvic floor disorders. So that’s one of the reasons why when people come to see me, they get a bunch of questionnaires, and [00:09:00] those questionnaires are looking at their nervous system and what components of their nervous system are upregulated so we can target the nervous system as well as targeting the tissues in the pelvic floor and the back and the hips.

So top down and bottom up. And then it’s thinking about, okay, what’s causing this constipation? Is it, tension in the pelvic floor? Is it prolapse? Is it pain in the anus? if somebody has like a, a crack in the anus or a hemorrhoid in the anus that’s painful, then their pelvic floor tightens up, then they’re constipated.

So it can go in many directions, right? Or they get constipated, then they get a hemorrhoid, then they have pain. Until the pain in the anus is addressed, somebody’s very likely to continue having constipation because the muscles are … When we have pain in the pelvic floor, whether it’s vulvar pain, anal pain, [00:10:00] any pain in that zone, the pelvic floor muscles are likely to be gripping and not, emptying very well.

yeah, and then there’s- We see a lot of people in pregnancy who have constipation, and that’s okay, there might be hormonal components to that, and also are there mechanical components to that that we can address as pelvic physios, like the tension piece or how somebody is toileting?

Toilet Mechanics and Relaxation

Susannah Stewart: So I talk to people about, “Tell me how it is

Toileting Mechanics & Strategies

Susannah Stewart: How does it look when you’re sitting down to poop?” And people look at me like that’s a really bizarre question. But are they hovering over the toilet instead of sitting down? a lot of people don’t like pooing when they’re not at home. Mm. If they’re not at home, they might decide to hover over the toilet, and then the pelvic floor muscles are actually very active when you’re in that sort of hover position.

Dr. Christina Carew, ND: [00:11:00] Yeah.

Susannah Stewart: Makes it difficult to empty. So getting people to sit down and slow down, so taking more time with going poo, trying … You know, not rushing, and then thinking about their mechanics when they’re on the toilet. Are they … Are their knees above their hips? Are they in a bit of a squat-type position where their feet are supported?

That’s going to set them up better mechanically to empty the pelvic floor. So some of those things, and then teaching people what does it feel like to actually relax your pelvic floor? Most of us don’t know what that feels like. What’s it like when it’s lifted and contracted? What does it feel like when it’s dropped and relaxed?

And then working on the flexibility if it needs to be worked on, so that when someone’s sitting on the toilet, they, A, know what it feels like to drop and relax, and also, B, they have the flexibility in their muscles to be able to do that, and hopefully they’re sitting in a way that’s [00:12:00] mechanically gonna set them up for more success with emptying.

Dr. Domnique Vanier, ND: That’s really interesting, right?

Incomplete Evacuation Clues

Dr. Domnique Vanier, ND: ‘Cause I think a lot of conversations I’ve had, and I know we’ve chatted about this on our podcast before, is about, the incomplete evacuation piece, and a lot of people don’t even necessarily realize that they’re having an incomplete evacuation, and that goes, you know, to…

based on what you just said, that there’s so many different factors that can go into why that’s happening. you know, we talked a little bit about that dysenergia piece as well. So maybe we can talk, you know, more about how patients can identify when they’re incompletely evacuating, like what kind of things does their body tell them, and kind of strategies, strategies around that.

Susannah Stewart: What do you notice with incomplete evacuation with people? is it a volume thing if, if they are emptying a small volume?

Dr. Domnique Vanier, ND: It can be. It can also be, like, the, what I call the trickle-down effect later. So, more likely to see gas, bloating, food sensitivities later because they’re [00:13:00] just… It’s like a domino effect, right?

They’re not fully evacuating their bowels ideally in the morning- Mm-hmm … and then we’re kind of seeing this whole constellation picture. Um, but again, some people just don’t even have an… Ha- they, they don’t even know

Dr. Whitney Baxter, ND: Yeah, I would a- I would agree too. Yeah, we see people who are so uncomfortable and they think it’s bloating, and they’re not realizing they’re still having a bowel movement every day.

They don’t really understand what normal form should look like or how it should feel to feel k- empty and relaxed, ’cause life gets hectic and you don’t pay attention anymore, so they’re coming in with all these other symptoms.

Susannah Stewart: Yeah. I hear people say they feel like they haven’t emptied properly. So that might mean they go poo and they still feel like there’s a sensation of fullness in the rectum, and that could be for a number of reasons.

It could be because they didn’t empty properly, it could be because they have a lot of tension in the back half of their pelvic floor muscles and it’s creating a sensation of [00:14:00] fullness when there is no fullness there, or it could be that they have a prolapse, either a, a vaginal or a rectal prolapse that is causing that sensation of heaviness around the rectum, and also can, can get in the way of emptying.

So one of the strategies I teach people is vaginal splinting. So that’s… You can either do it externally and press up on the opening of the vagina when you’re pooping, or you can put a thumb inside the vagina while you’re pooping, or a tampon, as long as it’s not painful to insert something in the vagina.

And just see if that extra support between the wall of the vagina and the wall of the rectum allows a better path for the rectum to empty. ‘Cause when there’s a prolapse, there’s a bit of a, softening of the wall and a bit of a kink in the rectum tube, and that makes it more challenging for the rectum to fully empty.

So if people try a [00:15:00] vaginal splinting technique and they poop better, then I’m thinking they might benefit from a pessary, which is, a silicone device that goes inside the vagina to support the walls of the vagina, and supports the wall of the rectum as well, because the vagina and the rectum share a wall.

So that’s something that I’m, often asking about if people are saying they’re having trouble emptying. We get into the nitty-gritty of… I don’t just say to somebody, “How are your poops?” I’m like, “Okay, so how often do you poop? What does your poop look like? How… Are you straining at all? Do you have pain with poops?”

it’s really important that we ask those specific questions because people don’t even necessarily know what constipation means. if I say, “Are you constipated?” Someone might say no, but then in my definition I would, I would say, yes, you are constipated if I get into the details of that. So I wanna make sure I’m getting enough information to understand the reason and understand the, the treatment options.[00:16:00]

Pelvic Organ Prolapse

Prolapse Basics and Risks

Dr. Christina Carew, ND: What percentage of your patients do you think come in with sort of these prolapse type issues? It’s just like something we don’t really talk about. is this 25% of patients, 50%? I g- I know they’re already predisposed to coming in, right? They’ve already been screened and said, “Hey, you should see a pelvic floor physio by someone.”

I’m just curious how often it’s happening. I feel like this is something I’m missing in my practice.

Susannah Stewart: Ah. Well, prolapse, pelvic organ prolapse, I think the statistics are, like, 50 to 60% of people assigned female at birth, have some sort of degree of pelvic organ prolapse. And the, the risk factors include vaginal birth being a big one, connective tissue disorders, so like Ehlers-Danlos- Mm-hmm

will predispose people to prolapse. People who do a lot of, heavy lifting, and people who have a lot of straining. So if somebody has a [00:17:00] history of constipation, that can actually predispose them to developing a prolapse. So there’s a number, and it… Y- you can get a prolapse at any age. You know, it’s not a…

People think, oh, prolapses happen to old ladies, and actually no, that’s not the case. You can get a prolapse in your 20s as an athlete who’s never had a kid. You can get a prolapse in your 80s. The, the incidence does increase with age, though. as we get older, there’s, because of gravity on our system, we are more at risk for prolapse.

And some people are symptomatic with it, and some people have a prolapse and it doesn’t bother them at all. So the, the degree of prolapse has no relationship to how much it’s bothering the person.

Dr. Christina Carew, ND: What about men? I definit- I have this one kid for sure that with, a lot of straining, a lot of, bideting.

Dr. Whitney Baxter, ND: Yeah.

Susannah Stewart: [00:18:00] I imagine, I don’t see cis men in my practice now. I have seen men in the past. I haven’t seen any men with prolapse, but I would assume that rectal prolapse is still a thing that happens with men with straining, and, and the same, some of those same risk factors would apply to men too. We just as, assigned female at birth people, we’re higher risk ’cause we have more holes along the bottom-

Dominique: Mm-hmm

Susannah Stewart: of the pelvis, so we have a higher risk for… It’s basically like a hernia but in the downward direction instead of in the forward direction in the abdominal wall.

Dr. Christina Carew, ND: So funny, we know so much about hernias, but yet-

Susannah Stewart: Yeah …

Dr. Christina Carew, ND: so little about everything else.

Dr. Whitney Baxter, ND: I know.

Venous Congestion Support

Dr. Christina Carew, ND: Um,

Ehlers-Danlos & Venous Disorders

Dr. Christina Carew, ND: so you mentioned Ehlers-Danlos. So I see a patient population that’s, often comprised of people, with lots of complex chronic illness.

So I see lots of POTS and dysautonomia, lots of people who are either hypermobile [00:19:00] by genetic or because of things that have happened to them along the way. and we see a lot of impact in the pelvic floor of those people because things are, like, traveling down and not necessarily returning. we’re often screening them in, in my case, for, pelvic venous congestion, but are there things that…

sometimes those waits are really long. Are there things that they could do with a pelvic floor physio that could also give them some relief while they’re kind of waiting for those assessments? What kind- Is that something that you see in your office where you’re just like, “Hey, you might have something more than this”?

Susannah Stewart: What kind of symptoms are you thinking about?

Dr. Christina Carew, ND: so we actually, we did a podcast, and we had, this screening questionnaire, and we actually use that screening questionnaire now in my clinic, which is great. and so we ask them about, bloating that is unresolved or unrelated to food. We ask them about pelvic fullness, pain with intercourse.

we ask [00:20:00] them about, just feeling worse when they’re sitting, for a longer period of time, seeing fluid collection maybe in their legs or in their lower body. lots of people that will just be like, “I didn’t even eat today, and I’m still bloated.” those types of things where we’re seeing kind of things dynamically, like, collecting in an area of their body.

Susannah Stewart: Yeah. so pelvic venous disorders and circulation issues, in… As pelvic physios, we’re looking at A, the nervous system, and B, the kind of the mechanical system. So we were talking about earlier the core system with the diaphragm on the top, pelvic floor on the bottom, and then the ribcage above that.

So we’re interested in, optimizing the movement and the dynamic nature of that system. So if there’s tension and stiffness in the ribcage in any [00:21:00] direction, we want to make sure we can get more movement there because the diaphragm needs to be able to move well at the bottom of the ribcage. same thing goes for the pelvic floor.

We want it to move well, and we want it to be strong because it’s actually acting as a pump to circulate fluid through the pelvic floor. If it’s really tight, it’s not doing that up and down pumping motion, and it’s not helping to circulate blood flow. so same thing goes for the lower back and the hips.

Kind of that… Everything around that canister, we wanna make sure everything there is moving well and not stiff because stiffness is going to create m- a decreased circulation in, in the fluids in the area. And then another thing that we look at with people is compression garments. So, there’s a company called SRC Health, and I don’t work for them at all, but they make, really high quality compression garments for a lot of these pelvic symptoms.

So, [00:22:00] the pelvic venous disorders, the vulvar varicosities, which is something we see where s- people get varicose veins on their vulva. common- commonly comes up in pregnancy but can come up at other times as well. And the compression garments are either, a full length from the ankles to the waist or, a, a short type of version.

and they can help with prolapse symptoms as well, so, symptoms of heaviness, symptoms of pressure, downward pressure. so a lot of people with the venous disorder type presentation will, will feel relief with some compression as well.

Dr. Christina Carew, ND: Yeah, ’cause it would, instead of them having to do the guarding, it still feels like for them that it’s happening, but now you’re having more movement.

Susannah Stewart: Yeah. Mm-hmm. We wanna make sure everything’s moving well, and we also wanna make sure we’re supporting the venous system, so the v- the venous return. [00:23:00]

Dr. Christina Carew, ND: Okay, so I should send them anyways.

Dr. Whitney Baxter, ND: Yeah. Send them. Got it. That’s what I’m thinking too. I love your- Yeah … like we’re watching you, and if you guys are watch- if listeners are watching on YouTube, you can see Susanna is she used to walk into work with a pelvis, you guys, like in a basket.

And she would show up. It was the best. My Clarius in

Susannah Stewart: one hand- She’s got- … and my pelvis in the

Dr. Whitney Baxter, ND: other. Yeah.

Susannah Stewart: Yeah,

Dr. Whitney Baxter, ND: I- But it is, very visual, and like you’re even explaining the whole trunk and the system and how it needs to function fluidly.

Bloating Body Image Postpartum

Dr. Whitney Baxter, ND: In the bloating world, in the guidelines and in the research, there’s a term called abdominophrenic dyssynergia.

So in English, that means when the gut and brain aren’t communicating effectively, and where the diaphragm should move up to accommodate the abdominal wall, like all the things in our guts, the foods, and the gases, and the fluids should [00:24:00] come in, so it’s not always like bloating out. So this dys- this dysregulation or miscommunication is where the diaphragm isn’t accommodating up, so everything is kind of bloating out.

So Susanna and I were talking about this earlier. I was asking her, “Do you see this in your practice?” And she has explained it really well so far in the podcast today about like how this all should work as a system. But another thing that came up, like what, what do you think about when someone is coming in saying like they’re bloated by the end of the day?

Susannah Stewart: Yeah,

Body Image & Diastasis Recti

Susannah Stewart: it, it comes up a lot, because I work with mostly women. there’s a lot around how … what people are concerned about how their abdominal wall looks, how their belly looks, and people are wanting and expecting their belly to be flat. And it comes up a lot postpartum for people when they’ve gone through a major change in their body, [00:25:00] and they’re on the other side now, and they are wanting their body to look the same as it did before.

And oftentimes the reason it comes up with me is because they’re asking me about diastasis rectus abdominis. So that’s when the abdominal muscles, create more space. The rectus abdominis muscles widen. The, the space between them widens to accommodate for the baby growing in the belly. and there may be changes in the way the abdominal muscles work, the function of the muscles after, after giving birth and also the appearance of the abdominal wall.

So people are often asking me through that lens, “Why does my stomach look like this? I don’t want it to look like this. I want it to look flat. Can you fix this? Can you, you know, can you, can I strengthen this so that it doesn’t look this way anymore?” So that’s when I get curious, and I have a little bit of like a Spidey [00:26:00] sense for, body dysmorphia and for eating disorders because in the realm of bloating and constipation, eating disorders is one of the risk factors for those types of symptoms for people.

So I need to be aware that that could be going on for people and be delicate in the way that I approach somebody’s appearance because as a physiotherapist, my job isn’t to change your appearance. My job is to support your body to function in the best way possible and feel, feel as good as possible. So, you know, asking questions around, “Okay, what makes you think that your core is weak?

What makes you think that your body should look different than it is?” Is, are there feelings of discomfort physically that you’re experiencing, you know, feeling, tight in the, you know… Let’s say, you feel like your stomach’s blown up like a balloon and it feels very stiff and tight. that’s different from, “I don’t like how [00:27:00] it looks, but physically I feel fine and comfortable.”

So starting to tease out, you know, what- what’s the root of this question. Is it, is it I don’t like how I look, but actually my body feels fine and it functions well? Or is it my body doesn’t actually feel well, and what can we do to help your body feel more well? Does that make sense? Mm-hmm.

Dr. Whitney Baxter, ND: Mm-hmm. That makes a lot of sense.

Dr. Domnique Vanier, ND: Yeah. And conceivably it could be both, right? It could be that post-pregnancy there may be a bit of dysmorphia, and post-pregnancy, despite somebody’s best efforts, they’re still having doming and coning, and they’re still not able to get back to their level of activity that they maybe had- Mm-hmm … prior to pregnancy, right?

And, and we’ve c- have multiple things happening there.

Susannah Stewart: Absolutely. Yeah.

Core Rehab Timelines

Susannah Stewart: So supporting people to build that, the integrity in the front wall of the abdominals, that’s re- retraining core strength over time, and it does take time to build that back. [00:28:00]

Dr. Whitney Baxter, ND: Yeah, that’s a good reminder. Retraining, like rewiring.

Susannah Stewart: Mm-hmm.

Dr. Whitney Baxter, ND: And how long- It takes- … would you expect it to take? Like, if someone was following your prescription perfectly, like three days a week of exercises or… Yeah, what would you expect?

Susannah Stewart: it depends how much… I don’t love the word dysfunction, but let’s just use it here. how much dysfunction they have to begin with, like how much doming, how much coning, how much weakness, how much stiffness they have to begin with.

How long it’s gonna take for them to recover, as well as what kind of activity are they wanting to recover to. Are they going back to CrossFit? Are they going back to biking? Are they going back to gentle walking? that will determine how long it takes to get them back to the level of function that they wanna be at.

So if somebody has a high degree of dysfunction and they wanna get back to CrossFit, that might take six months to a year. if they [00:29:00] have very little dysfunction and they’re getting back to gentle walking and then it might take three months to get them back to where they need to be. So yeah, it depends on severity and the load that you’re asking the core to manage.

Dr. Christina Carew, ND: Okay,

What to Expect at a Visit

Dr. Christina Carew, ND: I think we have people bought in now. So let’s talk about what actually happens. So we know that there’s a lot of forms. You re- fill out some forms. You’re gonna be asked to talk about things and how you feel about them. What else can people expect in that first visit?

Susannah Stewart: Mm-hmm.

Dr. Christina Carew, ND: Or even any visit with you.

Like, what are the things that they need to be aware of that may happen?

Susannah Stewart: Mm-hmm.

Movement Screening Basics

Susannah Stewart: Yeah So we like to see how somebody’s body is moving in a global way. So we might ask people to squat and lunge and, you know, move their thoracic spine around and see, and also tell us how it feels. Like, when you move this way, how does that [00:30:00] feel?

Does it feel tight? Does it feel stiff? Does it feel painful? So kind of the global movement piece.

Internal Pelvic Exam Explained

Susannah Stewart: And then in pelvic physio, we’re specifically interested in the pelvic floor muscles as well. So we … One way of assessing the pelvic floor muscles is internal exam, so that’s one of the things we learn when we’re doing our training, and that’s with a finger.

So we don’t use a speculum or anything like that. We use gloves, and we use water-based gel, and we go inside the vagina or inside the anus. And we see, first of all, if there’s any tenderness or discomfort anywhere in the muscles and secondly, how are the muscles functioning. So are they able to lift and drop?

Is there a good range of motion? Is there good strength? Is there good endurance? and can they do quick and slow contractions of their pelvic floor? What’s their coordination like?

Consent Options and Red Flags

Susannah Stewart: So that can be, intimidating for people to think about, especially if they [00:31:00] have pain already in their pelvic floor, or people who have a trauma history.

It can be very intimidating to think about someone having a finger inside their body. So we can … Option one is we don’t do any, you know, visualization or palpation, so looking or touching of the pelvic floor. we do more of a global assessment, and we do education on the pelvic floor muscles, and we understand the person’s nervous system, and we go from there.

And we start trying some things that are more like global type movements that target the pelvic floor muscles. So that’s one way we can go where we’re not looking at the perineum or touching it. And then another option is I can look at your pelvic floor, and I can watch how it’s moving and, and not put my hands on it.

So if somebody’s like, “I’d rather you not touch me, but I’m okay with you looking,” then that’s one way I can get a bit of an idea. Are they going up when [00:32:00] they contract, and are they going down when they relax? That’s a good starting point, because most people don’t … If we just verbally give them the direction of how to use their pelvic floor, that’s a extremely unreliable way to teach it.

So a better way to teach it is if I’m looking at it or if I’m touching it, and I can give you actual specific cues as to how you’re, how you’re doing. and the pelvic floor exam, whether it’s external or internal, should not be painful. So my guideline usually is 3 out of 10 Or less of discomfort at any point, and that includes physical discomfort or emotional discomfort of any kind.

So I want people to know it shouldn’t hurt. If you have a pelvic physio that insists upon an internal exam, that would be a red flag, and if somebody is pushing through pain a- or ignoring your discomfort, then that would be another red flag. So that’s, [00:33:00] that’s not trauma-informed care if somebody’s insisting upon an internal exam and, and says that they can’t help you without it.

That’s not true. So just bearing that in mind when you’re choosing a pelvic physio. a lot of pelvic physios will do, a discovery call where you can chat with them for a few minutes and just get a feeling of, of who they are, and you can ask them questions. So those would be some questions you could ask, is, you know, “Do you require everyone to have a- an internal exam?”

And if they say yes, then I would move on to somebody else. you know, and if they say, “Oh, well, n- it’s gonna hurt a little bit. You just have to kind of get through the pain to get the benefit,” that would be another, eh, red flag.

Biofeedback Tools Overview

Dr. Christina Carew, ND: Is there, tools or machines or things that you use that give people, quantitative data, or is it usually sort of, like, your just relationship with each other?

Susannah Stewart: Usually for me in my practice- Mm-hmm … I don’t use machines. I use my hands, and I use my [00:34:00] eyes, and I use my words. But there are physios who have different machines. So one is you can put electrodes on the outside of the pelvic floor, and then you can have a screen in front of you. and when you’re contracting and relaxing, you can actually see on the screen what your pelvic floor is doing.

So for some people who, you know, if I try all the cues in the book and they’re not getting it, then that might be somebody… And that happens very, very rarely. Most people I can find the right cues to teach them how to use their pelvic floor effectively, but for the rare 1% of people that just can’t get it, then I would refer them out to a physio who uses biofeedback.

Or there’s a machine called the Perifit, which is inserted inside the vagina. So I would say if somebody has pain with vaginal insertion, that would not be appropriate for them. But if they have no pain and they can insert the device, then that’s [00:35:00] another way. You can see on your phone, you can play a game with it, and basically it teaches you what does it feel like to have your pelvic floor contracted and lifted, what does it feel like to relax your pelvic floor all the way down.

And for people who need the visual, feedback, those can be really helpful. I feel

Dr. Whitney Baxter, ND: it’s amazing. I think this is where you shine. I know you, have worked with you, and it’s so nice for you to share this with folks who are nervous about pelvic floor physios or they just haven’t accessed that type of care yet because the

like you said, there’s, there’s ways of approaching it based on their level that you can still really obviously help people. So thank you for walking us through- Mm-hmm … that part of what you do. Yeah. So important.

Virtual Pelvic Physio Works

Susannah Stewart: During, during COVID, we were not allowed to practice in person. We were practicing virtually only, and we could still help a lot of people with constipation because so much of it, as you all know, is behavioral, [00:36:00] behavioral And so if I’m helping somebody understand those lifestyle factors and those behaviors and habits, that could be 90% of it, and in some cases we resolve things that way and we haven’t done anything hands-on whatsoever.

so that’s something to remember is that virtual pelvic health physiotherapy is also, can also be really effective if people don’t wanna come in in person or they don’t want someone coming into their home to do work with them. if they’re feeling worried even of being in person with somebody, that’s another option for people to feel a bit safer and to address a lot of the underlying causes.

Dr. Domnique Vanier, ND: Mm-hmm. Mm-hmm. Yeah, I can imagine that this feels really comforting, right? ‘Cause certainly, a, a large part of my patient population anyway has pain, has… we’ve got the, the brain gut pain, we’ve got, you know, in perimenopause, like the changes to the mucosal area type pain. There’s so many different causes of pain, and then we guard, [00:37:00] and it can feel, it can feel…

Dyssynergic Defecation & Biofeedback

Dr. Domnique Vanier, ND: Somebody can feel really nervous, right, when they’re having to have evaluations in that area.

Dyssynergic Defecation Deep Dive

Dr. Domnique Vanier, ND: Um, so I wanna talk a bit more about this, dysenergic aspect because I would say, I think it’s a bit of a, a like can be a diagnostic dilemma for some patients where they don’t maybe respond to, osmotic laxatives or stimulant laxatives, or have paradoxical reactions, right, where they still have constipation and they’re not responding to, the conventional type of approach.

So dysenergic defecation, just for our listeners, we’ve talked about this a few times before, is again, this, b- brain pelvic floor issue where the muscles are not relaxing like they should. But maybe we can talk a bit more about that and, you know, how biofeedback is decided for, for this patient population and your experience there.

Susannah Stewart: Mm-hmm. So I’ll lead by saying I don’t do biofeedback, so I’m not an expert on it. Um, there is a type of biof- so there’s different [00:38:00] types of biofeedback. The one that I talked about before is that when electrodes are placed externally on the pelvic floor, that’s one type, and then another type is a balloon catheter that gets inserted inside the rectum, and so that’s a specific training.

You do extra training to be able to put a balloon catheter in someone’s rectum. and that’s to… You, you can inflate the balloon to help people connect with the sensation of fullness in the rectum, and also to help them practice relaxing the pelvic floor when they’re trying to allow poop to come out.

So there’s a, a number of issues that come in there. One is, is my pelvic floor flexible enough? Do we need to work on flexibility of the pelvic floor? Do I have a connection with my pelvic floor? Can I feel what’s happening? Can I feel when it’s tight? Can I feel when it’s relaxed? is there [00:39:00] underlying pain that hasn’t yet been treated that is perpetuating this whole cycle?

‘Cause it, I, I, I can’t tell someone to relax their pelvic floor if they’re still having painful hemorrhoids. The hemorrhoids need… That pain in the hemorrhoids needs to be treated before we can actually teach the pelvic floor to relax, because the pelvic floor is very protective and responsive to pain, and it will be tightened up if there’s, a tissue issue that’s going on in the anus or the perineum still.

Okay.

Dr. Domnique Vanier, ND: Yeah, it’s interesting ’cause, from a research standpoint, whenever it comes to dyssynergic defecation, it just says biofeedback therapy. But from what you’re saying, a lot of pelvic floor therapists, not just you, but I think kind of that’s my experience too with when I refer patients, is there are many things that can support them for this issue before you get to, before you get to the biofeedback part, if needed.

Yeah. Yeah.

Susannah Stewart: And there’s so many, like we were talking about, different types of biofeedback.

Dr. Domnique Vanier, ND: Mm-hmm. [00:40:00]

Susannah Stewart: And some are not gonna be appropriate for some people, meaning, if someone has pain with vaginal penetration, I wouldn’t recommend the Perifit to them. the external biofeedback is, is less… is gonna be less…

It’s not painful, right? It’s just little electrodes on the outside, so that’s better for people who are having pain. and then some people don’t want something up their anus. they just, they don’t want that, so we need to find other ways to help them. Mm-hmm. so it’s really we, we are tailoring the treatment plan to the person in front of us and their, their preferences and their comfort and their boundaries, and their nervous system because, you know, if we’re doing things that are scary to their nervous system, we’re not really helping their pelvic floor function better.

Absolutely.

Dr. Domnique Vanier, ND: Yeah, patient-centered care.

Safe DIY Tips and Kegels Myth

Dr. Domnique Vanier, ND: [00:41:00] Uh,

Practical Takeaways

Dr. Domnique Vanier, ND: Christina, I think you were gonna ask about strategies for listeners. Let’s talk maybe about, practical takeaways.

Dr. Christina Carew, ND: Yeah, so we know our listeners are going to ChatGPT this. And they’re gonna get a wide list of things that could be done. What are things that are safe for them to try on their own versus things that you definitely want to consult with someone before you try?

Susannah Stewart: So is this specifically relating to if somebody has bloating and they’re ChatGPT-ing that?

Dr. Christina Carew, ND: Well, if they’re like, “Hey, is my bloating related to my pelvic floor?” Say they, sort of p- enter that in, you know, are there things that they can start just even acknowledging and recognizing at home that would direct them to say, “Yeah, you probably need to see someone like Suzanne or Suzanne if you live near her”?

and there would also be things where you’re like, “Do not insert here [00:42:00] on your own.”

Susannah Stewart: This is a challenging question for me to answer without, a specific case, but I’ll do my best.

Dr. Christina Carew, ND: Well, just in general, what are s- types of things-

Susannah Stewart: Yeah, I’m not, I’m not great at the in general answer- … but I’ll do my best with this.

so if your problem- What’s that?

Dr. Christina Carew, ND: I said I should have ChatGPT’d it. I can tell you right now.

Susannah Stewart: For sure. if you’re having pain in your pelvis, come see us. Come see a pelvic physio. that’s something that’s gonna be more challenging to address on your own. probably see your doctor as well if you’re having a, change in your bowel habits- I mean, working with deep breathing is probably pretty innocuous for people, with the exception of some people who have trauma [00:43:00] history, and deep breathing for them is more agitating than relaxing.

And so for them, it, it might not help them. a lot of the … I, I get this question a lot, what are some general pelvic floor exercises people can do? And it’s like saying, “What are some general medications people can take?” I’m like, I … There is no answer- Mm-hmm … for me for that. It’s like I need to look at the person’s body, how it moves.

Because, for example, a deep squat or, a, a yoga squat on a bolster against a wall, that can be really supportive to help someone’s pelvic floor relax. But for other people, it flares their back up, it flares their hips up, it hurts their ankles, it hurts their knees. So in that case, I’m not going to be giving that exercise to that person because it’s not gonna do

It’s not going to achieve the goal that I’m trying to achieve, which is helping the pelvic floor relax. So everything that I give someone to do in terms of exercises is something that I’ve watched them do, and I’ve got feedback from them on how it feels in their body before I’ve decided whether I want them to do it.

Yeah. [00:44:00] and that’s

Dr. Christina Carew, ND: part of it. Well, and that’s probably, the perfect piece, right? you actually, you yourself, someone can’t recognize whether it’s tight or loose.

Susannah Stewart: Correct.

Dr. Christina Carew, ND: That you actually need someone to tell you that it’s-

Susannah Stewart: Well- …

Dr. Christina Carew, ND: tight or loose. Or, like- Mm-hmm … at least dropping or not dropping sta- things are stuck or stationary, that, the way it feels and the way it looks may be very different.

Susannah Stewart: Correct. People don’t usually feel like they have tension in their pelvic floor. Mm-hmm. but we have … When we’re screening somebody If they have back pain, hip pain, pelvic pain, already the likelihood of tension is very high. If they have high stress, high anxiety, trauma, again, likelihood is very, very high.

If they have urinary urgency, frequency, constipation, pain with sex, all those things are telling me, you know, high [00:45:00] tension in the pelvic floor, pain in the pelvic floor, like the likelihood is very, very high. Like we, we’re able to predict with pretty high level accuracy just through asking people questions what their pelvic floor is up to.

teaching them how to use it is a whole other ballgame though. like I said, the verbal instruction is not reliable. They’ve done, they’ve done research on this to see like if, if we give cuing based on what we’re seeing and feeling ver- versus just a verbal direction on how to use the pelvic floor, there’s no comparison.

Like people just do not, cannot follow the verbal direction in any reliable way.

Dr. Christina Carew, ND: Yeah. So it’s like don’t go run out and get your Kegel balls. That’s the first-

Susannah Stewart: If you have pain in your pelvis-

Dr. Christina Carew, ND: Uh-huh … or

Susannah Stewart: if you have constipation- … Kegel balls are not the place to start. That’s a, that’s a general statement from Susannah that you can take.

Dr. Christina Carew, ND: All right. [00:46:00] Amazing.

Susannah Stewart: Love that. I’m the queen of nuance and not the queen of generalities, unfortunately. Which is what medicine is. It’s, that’s, yes. Every person is

Dr. Whitney Baxter, ND: different. Yeah. We always, there’s always a section on our podcast of like myth busting or what’s going on in the reels this week because people are looking for those quick tips, right?

And it’s hard to describe how complex what we do is. Like it’s not, it’s more than just bloating or constipation or these symptoms that people are presenting. It’s, it’s so complex, so it, it’s hard to break it down and simplify it, until you work with them one on one and you can speak to who they are and what they need.

Susannah Stewart: Yeah. Um.

Dr. Whitney Baxter, ND: I see the 00:02

Susannah Stewart: was like take in so much information about that person, and then we distill it, and what’s distilled might actually be quite simple, but we’ve put a lot of data into that, into those recommendations before we make them

Dr. Whitney Baxter, ND: [00:47:00] Yes. Great.

Referrals and Choosing a Physio

Dr. Whitney Baxter, ND: Um, okay, so how, for our listeners who are practitioners, who want to refer someone to you or a pelvic floor physiotherapy, what information from a referring practitioner is helpful for you?

Susannah Stewart: I love hearing what diagnostics have been done. Like, if things have been ruled out, that’s great for me to know. what’s been tried, what hasn’t worked so that I don’t start rehashing a bunch of stuff that’s already been done. and how long, I guess, how long that person’s been working with you. If it’s like, “We’ve had one visit”- Mm-hmm

or, “We’ve been working on this for, six months,” that gives me a bit more information about where the person’s at.

Dr. Christina Carew, ND: Is there, a Rate My Pelvic [00:48:00] Floor Physiotherapist? How do people

Dr. Whitney Baxter, ND: figure out who to go to?

Susannah Stewart: I wish. How do we

Dr. Christina Carew, ND: do?

Dr. Whitney Baxter, ND: Yeah.

Susannah Stewart: I would say- Mm-hmm … if you can do a discovery call with somebody, that’s a great way to get a sense of, like, how do I feel about this person’s personality, first of all, ’cause you gotta feel really comfy with your pelvic physio.

You don’t wanna just be like, “Oh, I’ll just go to whoever.” no, it’s a pretty vulnerable part of the body and things t- to talk about. And then you can ask them those specific questions about, do you require an internal exam? is pain… Should I expect pain as part of the assessment or the treatment?

or how much pain should I expect? And those are some good screening questions to kind of screen out. And as well, I work from a biopsychosocial approach, and that’s why people fill out ques- questionnaires on their nervous system when they come to see me, and that’s not the case for all pelvic physios.

There are some pelvic physios that work from a biomechanical, [00:49:00] approach and not from a biopsychosocial approach. So that means they’re not really assessing your nervous system or treating your nervous system. They’re looking at more just the muscles and the joints and the movement and the… Uh, which for me is not a full picture, and for me is not gonna get you the best outcomes

Dr. Domnique Vanier, ND: Yeah.

Agreed. Yeah.

Key Takeaway and Wrap Up

Dr. Domnique Vanier, ND: So

Closing & Contact Info

Dr. Domnique Vanier, ND: in closing, if listeners remember one thing from this conversation, Susannah, what would you like it to be?

Susannah Stewart: Mm.

Dr. Domnique Vanier, ND: Knowing that you’re the queen of nuance and, uh, yeah, so let’s try to- Let us know what you’re thinking about. Gonna

Susannah Stewart: boil this down.

Dr. Domnique Vanier, ND: Yeah.

Susannah Stewart: I’m going to boil it down to pelvic physio should be gentle and responsive to your comfort, to your preferences, to your boundaries.

You should feel like you’re in the driver’s seat, and that you’re partnering with your physiotherapist, that it’s not, [00:50:00] them telling you what to do. It’s them listening, and it’s them partnering with you as you start to try things and as you start to see what works and what doesn’t work for your body How’d I do?

Dr. Christina Carew, ND: Good. Outstanding already.

Dr. Whitney Baxter, ND: Okay.

Susannah Stewart: Standing

Dr. Whitney Baxter, ND: ovation. You’ve visualized it all. Yes. Okay. Tell everybody how they can work with you, how they can learn more about what you do, where you work.

Susannah Stewart: Yeah. So I work with Core Connection Physio in Victoria area, and we do house calls. I’m actually gonna be taking training this month to learn how to fit pessaries, so we’re gonna be, as of November, offering pessary fittings in home, which is super cool.

we also do virtual care, so if you’re in BC, we can do virtual, I can do virtual care with you. I do a lot of teaching in the community as well, so teaching doctors, nurses, [00:51:00] pregnant people, whomever, sex therapists, everyone. I love teaching, so that’s, my website. Now I’m not gonna remember what my website is.

SusannahStewartPhysio.com. We’ll put it in the show notes, too. Yeah. We’ll put it- Yeah. We’ll link it. I know my own website

Dominique: address.

Susannah Stewart: I’m gonna put, I have the, the other podcasts that I’ve recorded are on there, too, so people can learn about some other topics. If they want, they can listen to other things.

yeah. That’s pretty much it.

Dr. Christina Carew, ND: Okay. We’ll have you on- Amazing … once you know more about peasantries. You can talk about that. Pessaries? Pessaries.

Dr. Whitney Baxter, ND: Yeah, we’ll have you back.

Susannah Stewart: Oh, yeah. P- Yeah … let’s, please let’s do a podcast- Oh my god. So much … on prolapse and pessaries. Mm. Yes. I would love that ’cause that’s…

It’s so common, and like, when I see people get fitted with a pessary, you know, 31 years old, postpartum, runner, stopped [00:52:00] running because they had so much urgency, urinary urgency. Got a pessary, no more urgency, running to her heart’s content. You know, things like that. It’s like-

Dr. Whitney Baxter, ND: Nice …

Susannah Stewart: life-changing. So that’s my jam, when I get to support people to live the, the life they wanna live.

Dr. Whitney Baxter, ND: The best. That’s the best. Well, Susannah, thank you so much for joining us today and being our first guest. You’re a wealth of knowledge, and I’m grateful I know you, so thank you so much. and for our listeners, we hope that you loved this episode as much as we did, because remember, better gut health, it changes everything.

Susannah Stewart: Happy poops for all.

Dr. Whitney Baxter, ND: Yeah.

Dr. Christina Carew, ND: That’s our new ending, happy poops for all.

Dr. Whitney Baxter, ND: You do.

Susannah Stewart: I call it the happy

snake.

Speaker 3: Thank you for joining Team Gut Girls. Like, follow, subscribe, and share our podcast with friends you think will wanna know more about their gut. You can also visit us at [00:53:00] teamgutgirls.com for show transcripts and more information. Because better gut health changes everything. See you next time.