346: Pelvic Floor Health, Incontinence, Bladder Botox and Vaginal Birth Trauma - Postpartum Facts with Dr. Jocelyn Fitzgerald

DR J. FITZGERALD: 00:00

A lot of bladder irritants, and not everyone, like some people have no issues with coffee, they have no issues with alcohol, but a lot of women do, and they walk around all day drinking Diet Coke, and it's giving them really bad bladder spasms. And so that is something I spend a lot of time telling people to stop doing.

ELLA: 00:20

Welcome. You're on air with Ella, where we share simple strategies and tips for living a little better every day. If you're interested in mindset and wellness, or healthy habits and relationships, or hormone health, aging well, and eating well, honestly, if you're into just living better and with more energy, then you're in the right place. Welcome to real, honest, no-fluff conversations about creating a better you. We're not here for perfect. We're here for a little better every day. Let's go. Hey, you're on air with Ella. And today I am joined by Dr. Jocelyn Fitzgerald. Hey, Dr. Fitzgerald. How are you? Hi, Ella.

DR J. FITZGERALD: 01:00

Thank you for having me. I'm so happy to be here.

ELLA: 01:02

Dr. Fitzgerald, the last time I chased someone down in Twitter with whom I had no pre-existing relationship and said I need to have you on the show was actor Jenna Elfman. Do you know who she is? Oh, my God.

DR J. FITZGERALD: 01:15

Yeah, of course. Dharma and Greg, right? Yes!

ELLA: 01:19

We love Dharma and Greg, and now she's on, like, The Walking Dead, I think. But you are only the second person in history, Dr. Fitzgerald, that I was like, hey, you don't know me, but trust me, we need to talk. So thanks for trusting me. I appreciate you. I'm very honored. Would you kindly tell us who you are and what you do?

DR J. FITZGERALD: 01:38

Absolutely. So I am a type of specialist surgeon called a urogynecologist. So that means that I am both board certified in obstetrics and gynecology and OBGYN, which most people know what an OBGYN is. But OBGYN is actually made up of probably around eight or so subspecialties that people don't always know exist. It's an enormous field of medicine. And so my second board specialization is in urogynecology, which for many years was called female pelvic medicine and reconstructive surgery. So essentially we kind of pick up where urology and gynecology are unable to come together for female pelvic floor and bladder issues. I should also say that I am an assistant professor of OBGYN and reproductive sciences at the University of Pittsburgh School of Medicine.

ELLA: 02:31

Dr. Fitzgerald, you've already touched on one of the reasons I needed to have you on, and that is just by the sheer fact of your specialization. You said that you are a urogynecologist and reconstructive pelvic surgeon. Urogynecologist. I have been alive for several decades now, and I have doctors in the family. I've been in women's wellness, women's wellness adjacent, I suppose, for 10 years. I have never in my life heard of a urogynecologist. Can you tell us a bit more about what a urogynecologist does?

DR J. FITZGERALD: 03:11

Yes, absolutely. And I, while it makes me very sad that you don't know, you know, or hadn't heard of a urogynecologist, I'm not surprised. I hear that all the time. My patients search for me for years before they're referred to the right place. We're also a relatively young specialty in terms of like our board certification. We've only maybe been around for like 20 years or so, maybe a little more before we kind of like were formally recognized as a need for like a totally separate subspecialty. And we can get into more probably in the podcast, my sort of theorized reasons for why people don't know we exist. But I'll start with this and I'll say, I think the biggest reason people don't know we exist is because we would have to admit as a society why we have to exist. Because when you hear what we fix, It's something that people like I think globally don't want women to know that we repair birth trauma and that millions and millions of women have trauma from birth trauma that causes incontinence trauma that causes pelvic floor and pelvic organ prolapse. which is basically when your uterus, bladder or rectum bulges out of the vagina. We fix recurrent urinary tract infections, pain with sex, lots of chronic pelvic pain. That's just like the tip of the iceberg, but that's kind of our our bread and butter. And so, yeah, I think a lot of people don't know we exist because we're always in salvage mode, like we're always just trying to pick up the pieces instead of to prevent up front. We don't really tell women we exist until They're postpartum and they need us.

ELLA: 04:53

That is exactly why I wanted to speak with you today. So if you will all indulge me, I'm going to read a tweet of Dr. Fitzgerald's. Actually, several tweets, if you'll humor me.

DR J. FITZGERALD: 05:07

I'm spicy on the internet.

ELLA: 05:10

You said, I'm convinced that nobody goes into pregnancy knowing what a urogynecologist is because then we'd have to admit up front why urogynecologists need to exist and why there's a six-month waiting list to see one. I honestly feel bad sometimes telling people what I do for a living because they realize how common pelvic floor disorders are that a whole doctor type exists to treat them now. Surprise! It's because vaginas fall out, bladders leak, sex hurts, and anal tears lead to accidents. Anyone who sells the fantasy that vaginas just come out of expelling a seven-pound person unscathed is living in a fairy tale. Now the good news. And this is the remainder of your quote. The good news is there are treatments available. The problem is that we only tell women about these on the back end after they've suffered and delayed care. This is now damage control mode. Women deserve to go into birth armed with what resources are available to them postpartum. Dr. Fitzgerald, first of all, thank you for putting that out there. Secondly, that postpartum can be six months, six years, 16 years later. Am I correct?

DR J. FITZGERALD: 06:29

60 years. I mean, postpartum is how most women spend the majority of their life. Women spend 2% of their life pregnant and the rest of it is postpartum. And we think postpartum is six weeks and it's like, then you can have sex again. Congratulations. That is not what it is. Postpartum is like a lifelong thing. And I don't want to discount, like I treat a lot of patients who have never had babies, who have a lot of pelvic floor disorders. So I hope no one thinks I'm erasing them in this conversation. But the Biggest risk factor for incontinence and prolapse, which is the majority of what I do, is vaginal birth. You know, people don't like to talk about that. That's what I'm sort of talking about in my tweet. And there have been studies on this. There's this old idea in OBGYN that like, why would we scare women by telling them the truth, basically? Like what good is it going to do? They're just going to have their babies anyway and all you're going to do is make them anxious. And turns out the opposite is true. There's actually research on this that shows it actually makes women less anxious because first of all, women are not dumb. And second of all, women have the Internet. So they look this stuff up and women also talk to each other. So it's actually been shown to decrease anxiety, to send women into birth with the full set of information and the knowledge that if XYZ, a tear, urinary retention, incontinence happens to you, pain. There's somewhere you can go and you don't just need to feel like you're broken or you're an anomaly.

ELLA: 07:52

Yeah, and I think, I mean, in this case, truly information is power. The more you know going in, I'll ask you if there's anything that people should be doing preemptively, but so many women come out of the experience of vaginal birth and something is not right, something has changed, and they are not given the resources, much less the information, that that change can be in some cases resolved and in every case it can be addressed. Dr. Fitzgerald, I want kind of the 101 on vaginal birth trauma, on pelvic floor health, and on the drivers behind incontinence, and then I have some listener questions for you. But can you give us a quick TED Talk on what we need to know about vaginal birth trauma and pelvic floor health?

DR J. FITZGERALD: 08:45

Well, I'd say the first thing is that it's extremely common. It's extremely common. It happens to almost all women. And we definitely have this sort of snapback culture, both for women's abdomens, women's bodies after birth, but also their pelvic floor and their vagina. And there's lots of pretty gross discourse about both vaginas being loose after childbirth or You know, there's like the male perspective on that, and the female perspective on that, and a lot of like misinformation. And the truth is somewhere in the middle. Like, it would totally be disingenuous of any doctor to say that your vagina will not be different after you give birth. Now, not everyone, there are definitely some women who are like, my vagina is exactly the same, and that's really nice for you, but most vaginas are not like that. That being said, not all of them are, like, falling apart. There's just changes. That's all. We just need to acknowledge, like, the normalcy of changes. You would never go through, like, I'm trying, I often try to think of an example, and the only ones I can really ever come up with that resonate with people are, like, sports injuries. Like, if you had a sports injury, and then you heal that sports injury with physical therapy, and I'm gonna talk about that a little bit in a minute, will that sports injury ever be, like, exactly the way it was before you injured it? no but like will it be functional and can it be rehabbed absolutely and that's what happens with the pelvic floor i actually here i'll i save this for i know there's a video component i have my like my pelvis here with all we have a model organs there's a model but anyway like these this is the pelvis the female pelvis and these are all the muscles the pelvic floor is your hips and your sacrum, it makes this bowl and it's literally lined with muscle. And then this bowl of muscle holds your uterus and vagina, bladder and your rectum. These muscles are no different really than the muscles in your shoulder. Like if you tore your rotator cuff or you tore your pelvic floor muscles, you would go to physical therapy and you would rehab that and you would learn how to get your function back. So I think that's like the first thing I would say is that just knowing that Obviously, head and body like fits out of here. There's so much remodeling that happens that you can go to a special physical therapist that specializes in pelvic floor to help you after you give birth. Do you absolutely have to do that if you feel fine and you feel great? No, but you should know that it exists and that it's very common and we should be paying for it. We should be protecting it in other countries. In Europe, it's just part and parcel. You immediately go postpartum. It's just kind of part of the deal. But it's not here in the US, and I think it should be.

ELLA: 11:18

You're saying that in many countries, it is completely normal, built in, baked into the process that after delivering a baby, you then head on over to pelvic floor therapy. Did I hear that correctly?

DR J. FITZGERALD: 11:32

Yes. I'm pretty sure that in France, it's like a universal thing that all women do. It's just part of their postpartum care.

ELLA: 11:40

It wasn't even mentioned when I had my son, not even mentioned. Right.

DR J. FITZGERALD: 11:44

I'm sure it's not. At this point, even like the people who get referred that we see, we I mean, it's really amazing. We have a special a special postpartum clinic for people who have really severe tears. Those people get routinely sent to pelvic floor physical therapy. But we don't send the people who have easier normal deliveries and those patients still go through like this absolutely insane metamorphosis and still trauma to a major muscular system. And there aren't too many other muscular systems in your body that are also responsible for keeping you continent. So, you know, it's like one thing to rehab your knee, but your knee doesn't have like your bladder and your rectum running through it. So there's like a lot to worry about there.

ELLA: 12:31

Let me ask you a really basic question, if you don't mind, but you may have deduced by now that we have real basic questions because nobody told us about this stuff. So, Dr. Fitzgerald, tell me what actually happens when you deliver a baby vaginally. Does everything rip? Are your muscles meant to open up and sometimes they don't? What is the damage?

DR J. FITZGERALD: 13:01

Yeah, so I'll hold my model up again. for anyone who's watching these. But basically, I will share the video, folks, I'll share the video. So this is like the pelvic brim. These are your hip bones. And this is your tailbone and your sacrum. And then this is your pubic bone. And the baby's head has to come down through your birth canal, the vaginal opening, which here is, you know, the size of like a nickel has to open enough that a baby's dead. I know it's so small. Every time I've seen a baby be born, I am always like, there's no way. There's no way this is happening. I can't believe this is happening. I've delivered hundreds of babies. I don't deliver babies anymore. But every single time I was like, there is no way. And in my head, like, obviously, as I'm having this poor woman push, And then it would come out and I'd be like, how is this happening? This is insane. It's like building a ship in a bottle, but like in reverse. It's a miracle that honestly we aren't all like ripped in half by having children. Like I just, it's insane. And so like all of this soft tissue, like all of these muscles and nerves and like also the skin, is very sensitive to like the hormonal very rapid by the way like labor I mean if you tried to like stretch your arm out over the course of like 24 hours of labor like your arm would rip off your body but your pelvic floor is hormonally sensitive enough that it can like stretch and change like rapidly in real time and the same thing happens to like your hip joints like your hip joints literally like pull away from your sacrum this is why a lot of people have like so much like hip and lower back this is called your sacroiliac joint like a lot of pain there and people that get like a lot of like pubic bone pubic symphysis pain because this also this cartilage here like pulls apart sometimes up to like four centimeters to let like a baby head through. And it's just totally nuts. So anyway, so all of that just like kind of is all happening. All these crazy hormonal and like metabolic things are occurring as you transition through labor. And then it's all kind of stretches apart and if all goes well, you know, the baby fits out and it's fine. But you can see that like where classically the tears occur is between the vagina and the rectum. The rectum is not far away and there's usually only a couple centimeters of space. So your perineum, as this is called, has to stretch quite a bit to not tear. It almost always does. So this is where we do most of the repairs, is in repairing these muscles in between the perineum. But what some people don't know is that some women, not all, not all, this doesn't always happen, will have a tear. You see how these muscles like here on the floor attach to the back of the pubic bone? When the baby's like coming through, it can rip those muscles right off the back of the pubic bone. And that is something called a levator avulsion. And that's not something that we can even see or fix at the time. It's not something you can even fix later because there isn't really a good way to like reattach this muscle to the back of the pubic bone. And the women that have that happen to them are at very high risk of having prolapse in the future because they lose a lot of the structural support of the bowl.

ELLA: 16:10

That is a second question that I have when we're talking about the damage done. And don't worry, guys, we're going to get to the so what do I do about it bit. But Dr. Fitzgerald, what is a prolapse?

DR J. FITZGERALD: 16:21

The bladder sits like on top of the vagina, the rectum sits in the pelvis under the vagina. And so prolapse is when basically the vagina sags inward or turns inside out. So basically the front wall of the vagina will weaken and the bladder will like sag outwards. And it's covered in vaginal skin, so it's not like this bladder just plops out, but basically the vagina weakens and it sags.

ELLA: 16:49

So what is being held in delicate balance droops inside the body, it sags inside the body, is that right?

DR J. FITZGERALD: 16:58

Yes, the tube of the vagina comes inside out like it just like sags downwards like a hernia. The reason that men don't get prolapse is because it won't. I don't have the weakest part of their body in terms of like when you have an increase in your abdominal pressure is like your inguinal hernia or your abdominal wall. Like men get hernias in their abdomen and some women do too. But women are more likely to get hernias in their vagina because that's like the weakest, the weakest part of their body. So if something's going to bulge out, that's going to be it.

ELLA: 17:28

Does that make sex very painful? I would think it would.

DR J. FITZGERALD: 17:32

You'd think actually, but prolapse in general does not make sex very painful. I mean, prolapse doesn't hurt that much unless it's like really bad and bleeding or you have like you've really bad vaginal dryness. I know that you wanted to talk about vaginal estrogen so we can rope that in too. But in general, prolapse does not make sex uncomfortable. Some women, they are uncomfortable like mentally, but physically, no.

ELLA: 17:56

Okay, last clarifying question before we get into our rapid fire listener questions. What is the predominant reason that all of this or any of this would result in incontinence specifically? Because so many women suffer from that, be it very bad, I'm sure you have proper language to describe this, but very, very pronounced incontinence or, you know, I just pee a little when I laugh or I can't do a jumping jack to save my life because it would be a mess. Anywhere on that scale, why does it happen?

DR J. FITZGERALD: 18:29

There are two main types of incontinence that I see women for. There's a few much smaller subsets, but let's just stick to the main two. And you kind of touched on them. So there's what's called stress incontinence, which has nothing to do with being stressed out. It has everything to do with like physical stress on your bladder. Those are people who can't do jumping jacks. They can't jump on a trampoline. When they cough or sneeze, they leak. That is usually caused by a very similar mechanism to the prolapse. Basically, Birth trauma weakens the ligaments in the pelvic floor that are meant to support the urethra and keep urine inside. And if they are like not under tension, urine just sprays right out. So that's stress incontinence. Urge incontinence, which a lot of women have, is when you hear the story like they just can't make it to the toilet in time or they're always running to the toilet and can barely make it. That also probably has a lot to do with childbirth and particularly like nerve injuries that happen. in the, from either like a baby's head, like sitting on the nerves for a while while you're in labor or tearing or stretching during delivery. But also there's a lot of other like medical conditions that can make urge incontinence happen. But in terms of like birth, those are the ways in which incontinence is contributed to. So the most common one is probably stress incontinence. Almost, I feel like almost every woman that's ever had a baby leaks a little bit when they cough.

ELLA: 19:51

Okay, thank you for that. Now, let's shift into what the hell can we do about it, because as ignorant as we can be about the problem, I would say we're even more so unaware of what the resolutions may be. So, Dr. Fitzgerald, I have several specific questions for you, but in general, can you overview some of the ways that we can deal with some of these conditions that we've just outlined?

DR J. FITZGERALD: 20:21

And I mean, I'll go back to one of the earliest and best interventions I've already mentioned, which is pelvic floor physical therapy. Pelvic floor physical therapy, there is mixed research on this. Whenever I tweet about this, there's a lot of people who love to say like, oh, you're trying to scare women out of having babies. All they need to do is go to physical therapy and they'll be fine. And that is not true. And that also is like very damaging for women who have gone to physical therapy and then still got prolapsed or still had incontinence. Physical therapy is not a cure all, nor does it if you do physical therapy like before pregnancy, eliminate your risk of having these things happen afterwards. It's not really very preventative, which is a little bit sad, but it absolutely is a great treatment for both stress and urge incontinence. So I recommend it to all of my patients. And then prolapse, it does work for prolapse only up to a point. Like more severe prolapses, ones that actually are bulging like beyond the opening of the vagina, beyond the hymen, those ones don't respond as well because that tissue has been damaged and stretched and no amount of like muscle training is probably going to help with that. But less severe prolapses do respond well to physical therapy. So that's like the first thing is physical therapy is easy.

ELLA: 21:36

Let me ask you a question about where to access pelvic floor therapy, because obviously there are practitioners who specialize in that, and you can get those references through your doctor, through your OBGYN, whomever. I'm starting to see that a lot on the internet. And I think that's great. And I think it's risky. What's your take on what we should be watching out for when we look at resources for pelvic floor therapy?

DR J. FITZGERALD: 22:04

That's a great question. I'm more inclined always to believe or follow someone who cites their sources, who provides their credentials, who's open to, you know, the literature and changing their mind if, like, new information is presented. And definitely no one, anybody who's offering you some sort of, like, miracle fix or quick fix or they say something works 100% of the time, nothing is 100%.

ELLA: 22:30

Hey, wherever you're listening to this show, would you mind making sure that you're subscribed? That just means if you're in Apple Podcasts, you're not looking at a plus sign, you're looking at a check mark when you look at the show. In Spotify, you click on follow. Wherever you're listening, just make sure you're connected, you're subscribed, you're following so that you get new episodes the moment they drop. Thanks. Okay. Dr. Fitzgerald, what is the difference between vaginal estrogen and like just menopause hormone therapy estrogen? And why would we use vaginal estrogen? I know this is prevalent in your practice. Please help us understand the differences.

DR J. FITZGERALD: 23:12

I love vaginal estrogen. It is amazing. It really does more for my patients than almost anything else that I do. Vaginal estrogen is used to treat a condition called genitourinary syndrome of menopause, which many people have called vaginal atrophy or vaginal dryness in the past. That is just one symptom of genitourinary syndrome of menopause. Genitourinary syndrome of menopause or GSM is this whole constellation of changes that happen to the bladder and the vagina after estrogen has gone away. So it includes urgency, frequency, dryness, pain with sex, recurrent urinary tract infections, which is probably the most stunning use, I think, of vaginal estrogen because that is a plague in older women that they get UTI after UTI after UTI. Lots of antibiotics, they get resistance, but you can break that cycle or prevent it from ever happening by putting a patient on vaginal estrogen early. You also treat vaginal dryness in a big way. I mean, I mentioned dryness, but like in terms of your vagina's ability to make its own natural lubrication, those are just like a few of the things that it can treat. And you mentioned you wanted to know the difference between that and like normal hormone replacement therapy or estrogen replacement after menopause. And a lot of people have that question, like, why do I need vaginal estrogen? I'm taking, I have a hormone patch. And, you know, I don't think we know the exact answer to why that is, but Systemic estrogen or like full body estrogen with a pill or patch just does not seem to have the same effect on the vaginal and bladder tissues as directly applying the estrogen to the urethra, vagina, and vulva as compared to taking it by mouth. And there have been research studies on that that show that that's the case. So we do both if women need both.

ELLA: 25:09

My understanding is that vaginal estrogen does not raise nearly as many yellow flags for people who are prone to or have suffered from breast cancer. It's much less of a risk factor. Am I saying that correctly? Please educate us.

DR J. FITZGERALD: 25:27

You are. And I'm glad that you brought that up because that's the first thing I hear from most of my patients is that they don't want to take estrogen because their sister had breast cancer or they're afraid of breast cancer. And vaginal estrogen cream has been shown in many really large and excellent studies at this point, does not increase the risk of breast cancer at all. And we actually use it in women who have had breast cancer, especially because a lot of the medications that are used to treat breast cancer actually make GSM worse. and women can suffer horrible side effects from things like tamoxifen and arimidex. And so we often need to give them some estrogen back so that they can treat their UTIs and they can treat really severe pain in their vaginal tissue. Sometimes it can crack and bleed and it's just really awful. So it's very, very safe. It does not cause blood clots. A lot of the sort of, and I will say myths even that have been perpetuated about full body estrogen, which in the proper patient, well selected, is very, very safe and a great tool for menopausal symptoms. A lot of the bad rap that full body menopause has got has trickled down to vaginal estrogen and frankly, we all maybe need to move to Europe where there's pelvic floor therapy and vaginal estrogen is over the counter because it's really safe.

ELLA: 26:48

I am really grateful that you, first of all, explained why vaginal estrogen is so very different than the patch or whole body estrogen. Equally, that you correctly shared with us not to be frightened of whole body estrogen either. The study that scared generations of women off of menopause hormone therapy have been widely debunked in the way that they've been interpreted by now. We've talked about it a million times. We won't go into that today, but I just want to make sure that because of the way I pose the question about the lack of risk with vaginal estrogen, that I was not implying that there was some severe risk with whole body estrogen. So thank you for making that distinction. Okay. I saw something on your site or in your materials about bladder Botox injections, and I have no idea why someone would do that. Would you please tell me what that is? Yes.

DR J. FITZGERALD: 27:45

Okay, great, because now we can kind of go back to the question about how do you treat incontinence. There's a lot more than just pelvic floor therapy, which is amazing, but does not fix everything. So I mentioned before there's stress incontinence and there's urge incontinence. So urge incontinence, stress incontinence, cough, laugh, sneeze, leakage, is treated mostly with some sort of procedural intervention where you have to implant something into or under the urethra to give it more support or substance so that when you cough, laugh, sneeze, you don't leak. And so we do that with two things. I know you asked about Botox, but I'll just say this while I'm here. Instead of Botox, we treat this with fillers. For anyone who knows what Botox and fillers are for your face, we use Botox and fillers for your bladder. It's just that we put the fillers down here near the urethra, which is the opening of the bladder, to make it smaller so you don't just shoot pee out when you cough. But the Botox goes inside your bladder, right into the muscle at the top. And that is because urgency incontinence is caused by this muscle of the bladder. The bladder, for those of you who aren't watching the video component, looks literally like a water balloon. And your sphincter and your urethra is like the neck of the water balloon. And your muscle of your bladder is like the top of the water balloon. And when the top of the water balloon is overactive and has spasms, That is when you feel like you're not going to get to the toilet in time. And so we inject Botox into this muscle to paralyze it, just like in your forehead, so that you can have some bladder relaxation while you get to the toilet in a reasonable amount of time. So we do that with a tiny camera that we put through the urethra, and then we inject with a tiny little needle into this muscle, and we do it about once every six months. And it's a treatment for urgency incontinence. It's a very good one.

ELLA: 29:37

Never heard of it.

DR J. FITZGERALD: 29:39

Well, it works. We usually try, in addition to physical therapy, a medication first. A lot of women have heard of overactive bladder medications, but they're not always covered by insurance and a lot of them have a lot of side effects and risks. And so if we can't, you know, find an appropriate medication, we move on to Botox. And a lot of women love it because you only have to have it once every six months. You don't take a pill every day. It's very effective and it's covered by insurance usually.

ELLA: 30:08

Amazing. Okay, what what other therapies do we need to know about for pelvic floor health?

DR J. FITZGERALD: 30:14

Yeah, so I've talked about a lot of the incontinence treatments, at least the ones that I use the most. The only thing I kind of skipped over when I was talking about stress incontinence from least invasive to most invasive, least invasive is physical therapy. We also have pessaries and inserts that can go into the vagina that put some upward pressure under the bladder to sort of like hold it shut. And that's something called a pessary. I wish I had one here I could show you, but it's basically a ring with a little knob on it and it's flexible. It goes in the vagina and it puts some upward pressure. I use that for patients who maybe they still want to have more kids, so they don't want to have like a surgery yet and or they just leak a little bit when they work out, they'll put it in to exercise. So that's like a temporary thing a patient can manage themselves. And then after that, we move on to those the filler injections, as they're called. Urethral bulking is another name for those. or something called a made urethral sling, which is probably the most invasive but still not a very invasive surgery. A lot of people have heard of slings. They're made out of mesh and they get put in surgically under anesthesia. So that's like stress incontinence. Urge incontinence, I've mentioned most of the treatments, physical therapy. A big thing that people miss is you need to watch what you drink. A lot of people think number one, as I sit here with my like Stanley cup that You need to drink like a bucket of water every day and you do not. And people also like, especially, I mean, I'm the same way. We all love to have our Starbucks and then like a mimosa and then like a seltzer and a Diet Coke and like all of them lined up and a brunch or whatever. And that is like a perfect recipe to have bladder spasms. Why? A lot of bladder irritants and not everyone like some people have no issues with coffee, they have no issues with alcohol but a lot of women do and they walk around all day like drinking diet coke and it's giving them really bad bladder spasms and so that is something I spend a lot of time telling people to stop doing.

ELLA: 32:13

Wait, what's bad about it? Which is the bad element?

DR J. FITZGERALD: 32:18

Diet Coke is really bad. So like as an example, because it has artificial sweeteners in it, it has caffeine, and it is very acidic because of the carbonation and like the other chemicals that are in it. And all those things are very irritating to your bladder, like all three of those ingredients. Teas are the same way, like people always have an iced tea in their hand. Coffee is a really bad one. Coffee is probably as bad as it gets. I always joke that like the worst thing someone could drink would be like a spicy margarita made with like Mountain Dew. Diet Mountain Dew. I'm like trying to see if I can put everything bad in one drink.

ELLA: 32:57

So it's the acidity, the caffeine and alcohol.

DR J. FITZGERALD: 33:02

and alcohol and artificial sweeteners and spicy things.

ELLA: 33:08

Okay, people do not know this. Dr. Fitzgerald, they do not know this. I am so glad we're having this conversation today. Okay, and we're running out of time and I have so many questions for you. So let me hit you with some rapid fire questions. Is there anything that we can do before giving birth? Is there anything we can do preemptively that you would recommend?

DR J. FITZGERALD: 33:26

I think the most important thing is to just know what the risks are, because there's very little you can do to prevent. birth injury necessarily. I know this is a lightning round, so I don't want to get too much on a high horse and say something very controversial that we don't have time to get into, but I would definitely ask your doctor about the risks of the various modes of delivery. Vaginal delivery by itself versus a vacuum delivery versus a forceps delivery versus a C-section. Those all come with very different risks. And I would really urge women to learn what those are before they are in an emergency situation. That's my best advice.

ELLA: 34:10

I feel like I have to ask this. What about the women who are now mad at me because I've made this sound really scary? Wouldn't we rather know what can happen so that we are prepared? But also, I'm not trying to fear monger, and I know you're not either. What is your usual response to that?

DR J. FITZGERALD: 34:29

First of all, if all it takes is knowing the risks of childbirth to make a woman say, you know what, motherhood is not for me, you're welcome. I have done you a favor. I'm serious. Like if that's all it takes to talk you out of motherhood, motherhood is like a calling. It's a very important job that people should probably think long and hard about. And if having all the information makes you decide it's not for you, then I have done a service. Second, women who really want to be mothers, you know, nothing is going to stop them. And information about how to thrive in motherhood is definitely not going to stop them. I don't know a single woman on earth who'd be like, I'd rather not know what could happen. Women are smart and strong and capable. And if you give them a bunch of possibilities and give them the real risks of those things happening and tell them that there is hope and help and treatments and we are going to help you not have to like suffer through years of feeling like your birth was an anomaly when in fact something that happened to you happens to millions of women, then I have done my job. And anyone who says that I'm fear-mongering women out of having babies doesn't know women very well because women are going to do what they want to do and it's my job to give them information and also why would I want to stop women from having babies? I'm a urogynecologist. I make my money off of people having more babies. So I literally for a living treat these problems. If women didn't have kids, I probably wouldn't have a job. So that that criticism has never made sense to me. I don't want any woman in damage control. I want her in, in control.

ELLA: 36:12

So here, here. OK, two super, super short questions. Is there a link between Pilates and the pelvic floor? I understand a lot of people are turning toward a certain type of Pilates to address their pelvic floor health. Do you have anything to say about that?

DR J. FITZGERALD: 36:28

Yeah, I'm trying to think if I've seen a specific study on Pilates. I've seen specific studies on things like bar workouts that are very helpful for the pelvic floor. And I mean, I do yoga and Pilates and know a lot about the pelvic floor. And I can tell you that the chances are they're very, very helpful. Because anything that is good for your core and good for your hip mobility is going to be good for your pelvic floor. So I would say please keep doing Pilates. Pilates is so good for you. and just in general like your full body health, like having low inflammation because you're exercising, good mental health, like those things affect your pelvic floor too. What about running? There are no studies that show that running harms your pelvic floor. Like I'm a runner, I love to run. What ends up happening more often is that women step away from running postpartum because they leak when they run, or they have pain when they run or some sort of like pelvic instability, or, or a loss of their core strength, which then leads to back pain and their, their hips and like kind of all of it is out of alignment. So I would never say like, don't run because it's not good for your pelvic floor. I would say that if you have pain with running or incontinence with running, please see a specialist. And I know a lot of pelvic floor therapists who specialize in that exact thing, like getting women back to physical activity despite a pelvic floor injury.

ELLA: 38:00

Okay. I have, you know, the one thing that I just keep thinking as we're having this conversation, women are freaking amazing.

DR J. FITZGERALD: 38:08

Yeah, they are. Yeah. I saw a tweet this morning that actually retweeted And it says, it's from a woman who tweeted and she goes, random men, childbirth isn't that bad. Women do it multiple times. No, you just underestimate the extensive grit and determination that women possess. So like women make this insanely difficult thing look easy and I won't say all men, but random men, like she said in the tweet, will say like, it's so easy. Women do it all the time. Yeah, women do a lot of really hard things all the time, and they make them look easy because no one is there to support them and help them, but they're going to do it anyway.

ELLA: 38:49

Dr. Fitzgerald, thank you for this conversation and thank you for everything that you are doing to help women help themselves and that there is help out there that you don't have to, quote, live like this. I think that's the most important thing that we can share today. And I'm just so grateful that you're here to share it. Thank you.

DR J. FITZGERALD: 39:06

Where do you like to be found? I am easiest to find on X, formerly known as Twitter or Instagram or LinkedIn, for those of you who want professional connection. X and Instagram handles are the same. It's at JJ Fitzgerald MD. Thanks, Dr. Fitzgerald. Thank you for having me. Thank you for sharing your platform.

ELLA: 39:29

Okay, if you enjoyed today's show, please share it with someone you care about. And be sure to check out our new YouTube channel and head to onairella.com for today's show notes. You can also learn about how to work with me there, onairella.com. And I would love to hear from you, so if you DM me on Instagram, I promise I will reply. P.S. All the links you need for us to connect are right here in your podcast app, in the description for today's episode. Check them out. Thanks for listening, and thanks for inspiring me. You are, quite simply, awesome.