Kim (00:02.25)
Welcome to this week's episode. I am super excited to be joined by Dr. Nicole Cozine, who's a pelvic floor physical therapist in California. And we are gonna be talking about all things to do with IC interstitial cystitis or bladder pain syndrome. And she's just told me as before we started recording that there's been a reclassification as well. So I'm excited to hear a little bit more about that. But first of all, welcome. Thank you so much for joining me.
Nicole Cozean (00:27.72)
Yeah, thanks so much Kim. I really appreciate being on and I'm excited to talk about IC. This is my jam. I love treating it. I love talking about it and I love busting some myths about IC. So I'm excited to be here.
Kim (00:34.806)
Mm-hmm.
Kim (00:43.174)
Yeah, I chose you for a reason. I know you've been talking about it for so long and I've been I've been I've loved watching the journey of everything that you share about it. So I guess let's start first of all with who you are, what you do and what brought you into first of all pelvic health but then also focusing on this. I know this isn't just what you do but this is a kind of a passion part of what you do with regards to I see.
Nicole Cozean (01:05.836)
Yeah, so I am a pelvic floor physical therapist. So for those of you who guys don't know, to get into pelvic physical therapy, at least in the States anyways, you go to four years of undergrad and then you do three years of a doctorate program in physical therapy school, come out with your doctorate, but you are definitely a generalist at that point. And then you have to take continuing education courses and specialize in the pelvic component of it.
Even then, though, you specialize in pelvic and then you do pregnancy and postpartum and you learn about pain conditions and you learn about bladder conditions and bowel conditions and prolapse. And again, you're a little bit of a generalist. So backing up, I got out of PT school. I worked at a large hospital program. They said, do you want to start the pelvic floor program? And I said, definitely not. I do not want to do that.
Kim (01:59.714)
Hahaha
Nicole Cozean (02:02.216)
Um, you know, now it's a growing field. I think that everybody has probably at least heard the phrase pelvic floor. But back then, it was like 17 years ago, it was like, will you do what? Uh, I, no, I don't want to do that. So they essentially bribed me with a bunch of continuing education courses and said, if you do this, then you can go to Africa and do all these things. So I took a lot of pelvic floor rehabilitation courses.
early on and really condensed. I also did a fellowship program at that time, so I like dove in, not thinking that I was ever going to be a pelvic floor physical therapist. I thought I was just going to get my free things from the hospital and then move on into whatever I was going to do, right? Resume building and sure, I was going to train the people to take it over.
Kim (02:49.078)
Move on.
Nicole Cozean (02:56.46)
Well, that didn't happen, obviously. I fell in love with the specialty. I fell in love with treating patients. I fell in love with being able to help people that didn't think that there was a way out or a cure for whatever they were suffering with. And the pelvic floor and physical therapy is just such a match sort of made in heaven that not very many people.
knew about then and more people are getting to know about now but I think there is still so much to learn. So I then worked for another clinic around here in Orange County and then I started my own clinic called Pelvic Sanity in 2016 and it is a pelvic floor physical therapy clinic. We actually hired an occupational therapist as well that specializes in pelvic floor. So we're a
that's all we do is pelvic floor conditions. So everything ranging from pregnancy and postpartum conditions to pelvic pain conditions. I got interested in interstitial cystitis because way back in the beginning days of the hospital program that I was building in pelvic floor, was actually paired with a urogynecologist who at that time was sort of on the cutting edge of interstitial cystitis treatments.
And so I happened to, at that point, just see a lot of pelvic pain patients, which was a little bit of a different journey than a lot of people that go into pelvic floor therapy get. A lot of times you start off with the quote unquote, and I don't really believe this is true, but they're the simple people, right? The people that have, oh, just a little bit of incontinence or are recovering from birth and they'll be done pretty soon. You usually don't.
dive right into the world of pelvic pain like I did. And so I just so happened to be paired with this guy and he was a great urogynecologist and I still keep in touch with him to this day. And that's sort of how I got my initial in and that's sort of where at that time I was just seeing so many patients that were getting the run around from the medical system.
Nicole Cozean (05:12.728)
They were misunderstanding what pelvic floor pain was, what interstitial cystitis was, and it was a big area for me as a new therapist where I was like, I'm not just gonna sit here and believe that there's no cure for this. This is just nonsense. I'm seeing people in front of my eyes get better. So what's going on? And then that led me down a whole nother path, and we're gonna talk a lot today about what it is.
who gets it, who doesn't, all that kind of stuff. But that's sort of where my initial passion sort of was lit, was seeing patients who didn't think that they can get better. I was treating them, and even as a new grad physical therapist was helping patients. And I was like, where's that disconnect? And that led me down my interstitial cystitis knowledge road.
Kim (06:06.022)
Mm-hmm. That's awesome. Okay, super exciting. And I love I love hearing people's origin story and how it's in and so many pelvic PTs will say I absolutely didn't want to do pelvic PT and then once they actually got in and understood What was how vital it is to so many things that just became this turning point and they never looked back So that's awesome. But okay, so I see
So if we can start out with defining what is interstitial cystitis and why is it called sometimes bladder pain syndrome? And you mentioned a reclassification. So what is it? What are the terms that people may have heard? And is it generally classified under the pelvic pain realm or not?
Nicole Cozean (06:32.809)
I see.
Nicole Cozean (06:38.564)
Yes.
Nicole Cozean (06:52.596)
Yeah, and this is one of the most interesting things, and we're gonna bust myth right now, so interstitial cystitis is made up of two words, and the actual meanings of the words is interstitial, meaning like in and around the tissues, and cystitis refers to the bladder. So in and of itself, the name is actually a misnomer. Most people,
over 90% of people that have been diagnosed with interstitial cystitis or have symptoms of interstitial cystitis do not have anything wrong with their bladder. And that's like mind blowing to some folks because the bladder symptoms that people have are just so real. And I mean, they exist. It's urgency and frequency to the max.
Kim (07:33.399)
Mm-hmm.
Nicole Cozean (07:44.548)
feeling like you have a UTI times 100 all the time, and it's really frustrating because a lot of the times you'll get negative UTI test after negative UTI test or an occasional positive UTI test, and then it goes away, but the symptoms persist. So it feels like a UTI, and so there's the urgency and frequency part and also the pelvic pain part. So those are the two real definitions of...
What is it and how is it diagnosed? So the first thing I want you to take away from this talk is that it's not a bladder condition. In 10%, less than 10% of people, it can be, and we'll go into that here in a second, but for most people, even though it feels like your bladder's on fire and your bladder is having a huge problem, there is nothing wrong.
So that's what makes it so frustrating because you go into the urogynecologist or the gynecologist or your GP and you're like, I feel like I have a UTI. And you go in, they say it's negative. And you're like, well, I don't know what to tell you, but I'm still having a huge problem. And they're like, I don't know what to tell you. It's, I mean, are you stressed out? And then we go down the, oh, you must just be overreacting. I don't know what to tell you, there's nothing here.
Maybe we'll get a cystoscopy, which we can go into that here in a second, but that's just a camera that looks up into your bladder. That comes back negative. It's fine. Nothing's wrong. And then that's where a lot of physician's knowledge ends as well. And that's where it's frustrating because you're left with, well, I can tell you that there's nothing wrong with your bladder, but you still are left with all these symptoms. So what is it? So
The American Urological Association, which is the thing that the governing body over all of the urologists, at least in America, obviously, American Urological Association, has set the definition of interstitial cystitis as something that, so a perceived bladder pain problem that has both two components, pelvic pain and urinary urgency frequency.
Nicole Cozean (10:01.388)
and then in the absence of any other identifiable cause. So no UTI, no cancer, no other weird thing of your bladder lining, nothing. So that's what the definition is, and that's what the symptoms primarily are. And the problem is, is that...
That's the end of the road in terms of testing. There is no other, there's no single test that says you have interstitial cystitis. It's you have these symptoms, and then we're gonna test you for all the other things that it could be, and if it's not that, then we can diagnose you with interstitial cystitis. So, and one other thing I'll say about that, and then we'll pause for regrouping questions, but a lot of people think that there is a test for it.
And a lot of urologists will say, well, we can do a cystoscopy to look at your bladder. And that's not necessary per the American Urological Guidelines. You don't have to have that to get diagnosed with interstitial cystitis. So interstitial cystitis itself can be diagnosed on symptoms alone. So you can walk into your physician and you can say, I have...
urinary urgency, I'm peeing all the time and it feels like I really have to go really bad and I have some pelvic pain, urethral pain associated with it, and they can say, do a UTI test, it comes back negative, they can say you have interstitial cystitis. They can also say you have bladder pain syndrome, you have painful bladder syndrome, you, we don't know what you have, good luck, and or then they can offer you some other things. They can offer a cystoscopy, but
on cystoscopy, you're not going to be able to tell. There's nothing to look at. There's only things to look at that aren't IC that would also give you those symptoms. I hope that makes sense.
Kim (12:03.806)
Yeah, absolutely. And I guess one thing I do want to clarify is, again, it's partly this name that and this happens in a lot of things with regards to medicine in our bodies is it painful bladder or bladder pain syndrome, but you've used more of the term pelvic pain. So the pain isn't necessarily in the bladder, you mentioned maybe the urethra, but could it be pain elsewhere in the pelvis?
Nicole Cozean (12:34.356)
Yeah, so this is a really good point and distinction. So I would say that the majority of people with interstitial cystitis have some form of abnormal, let's call it an abnormal sensation of the bladder. So painful urination, painful filling, urethral irritation, feeling like you have that UTI, that's considered some sort of bladder pain-like symptoms.
If though you have symptoms of urinary urgency and frequency and someone says, I don't really have pain, but I also have painful intercourse or painful gynecological exams or this deep ache deep into my pelvis or pain right over the pubic bone, kind of right where your bladder is, then that is also classified as this pelvic pain.
that deems you able to be diagnosed with interstitial cystitis.
Kim (13:35.126)
Got it. Okay.
Nicole Cozean (13:36.836)
So the other little piece that I want to just carve out, though, is we didn't talk, that's 90% of people, we didn't talk about the 10% of people that actually do have a bladder lining issue, and that is called Hunter's lesions, and only call in Hunter's lesions. So if somebody, if a doctor goes up with that camera and looks in the bladder and says,
Nicole Cozean (14:03.396)
That does not mean that you have Hunter's lesions. Hunter's lesions are actually like diagnosable ulcerations of the bladder lining. That now is a whole separate condition. And in most other countries, this is where it gets confusing. In most other countries, they'll call people with, people that have Hunter's lesions and bladder pain, they'll call that interstitial cystitis.
And if you don't have Hunter's lesions, but you have all of the other symptoms, they'll call that bladder pain syndrome or painful bladder syndrome. And so in the United States, to make everything more confusing, we just decided to call it IC slash BPS and confuse everyone. So, but it still exists though that the medical management treatment for people that have Hunter's lesions is very different than the medical management.
if you don't have Hunter's lesions. And then that's where we come to the pelvic floor. I'm sure we'll talk about that here in a second. But I hope that clears up a little bit of what's going on.
Kim (15:04.352)
Yeah.
Kim (15:09.638)
Yeah, and I know that this will probably come up, but my mind is because the population of people that I work with primarily now is in the perimenopause-menopause realm, I'm thinking, you know, frequency, burning, irritation, pain, like those are also very common around the perimenopause or menopause transition with regards to...
estrogen decline mainly but that can be other things. So I guess I feel like the more I know about this perimenopause menopause transition there's so much in there that could be a thyroid condition. It could be hormones. It could be muscle related. It could be estrogen related. There's so much overlap especially in this population so I can appreciate that it's already confusing with regards to the definitions that you just shared.
Nicole Cozean (15:56.162)
Yes.
Kim (16:05.322)
And then if you add the layer of this perimenopause transition that some people don't even know what perimenopause or that they're even in that phase of life can also maybe be thinking they have painful bladder, but maybe it's maybe it's menopause, right?
Nicole Cozean (16:19.852)
Yes, totally. And I'm glad you brought that up because here's another myth of interstitial cystitis and it kind of goes right into this. So there was one paper a long, long time ago that started this whole myth that most people that had IC were women and they were diagnosed in their 40s. So you say the genitourinary symptoms of menopause or...
things like vaginal burning, urethral burning, urethral irritation, irritation around the vulvar opening, urinary urgency, urinary frequency, literally every single painful intercourse, dry pain with intercourse, right? So every single symptom of interstitial cystitis can also be menopausal-like symptoms.
perimenopause can be earlier, even people into their 30s. So I think that before we were starting to talk a lot more about this stuff, it could be that. And one of the things that I look at as a pelvic floor physical therapist is the health of the vulvar vaginal tissues. Because I will say this, that a lot of times people will come would have been diagnosed with interstitial cystitis, they go on to...
the internet and it's like my life is over and it's because it was missed by an OBGYN or a urogynecologist or a urologist that you have like really significant de-estrogenization of those tissues, meaning a lack of estrogen at the vulvar tissue level, and that's what's causing all of these symptoms. And you can get frequent UTIs from that. So
It is a huge differential diagnosis that needs to be taken into consideration. And even somebody that's not in the perimenopause age, you can have deestrogenization of your tissues even if you're in your 20s for a variety of reasons. And so it's one of the things that we always will look for in a pelvic floor exam is just look at the tissues because a lot of we have more time to do that.
Nicole Cozean (18:44.648)
Even if it's not 100% of the problem, a lot of times it's a significant portion of the problem. So, and especially if you're in that age of perimenopause-menopause, that's one of the first lines of defense, because it's like we have to get that taken care of first, and then we'll figure out what persists after that, and then we can treat from there. The other thing that is super confusing about this whole thing is that...
literally, and I am not joking, literally every single one of the symptoms of interstitial cystitis that we've been talking about, urinary urgency, frequency, pelvic pain, painful intercourse, urethral burning, all of that, can also be caused by overactivity or a tense, tight pelvic floor. And so now it's like, well, what do I have? I get this question all the time in the clinic, which is, well,
I was reading about interstitial cystitis, and I think I might have that, but I also think I might have pelvic floor dysfunction. Which one do I have? And that's a really hard question to answer because all of the symptoms of pelvic floor dysfunction can cause interstitial cystitis symptoms. Interstitial cystitis can cause all the symptoms of pelvic floor dysfunction. And then you bring in all the facts about 90% of people.
with interstitial cystitis have pelvic floor dysfunction already. So it's like very likely that you have at least pelvic floor dysfunction along with your symptoms of interstitial cystitis, which is the bladder urgency, frequency, and pelvic pain. So the cool thing about what we do and the cool thing about treatment, and we can go into this
is that the muscles and the nerves of your pelvic floor have a really close friends with the bladder. They talk to the bladder all the time. They also talk to your brain. And so a lot of times the common denominator between a lot of the symptoms that we're having is if you take out the estrogen piece for a second, it can still be the pelvic floor, your pelvic floor muscles.
Nicole Cozean (21:04.296)
and any dysfunction that you have going on there can cause all symptoms of pelvic, of bladder pain and this bladder pain syndrome collection of symptoms that you have. And that's one of the biggest things that we can help you with, with pelvic floor physical therapy, pelvic floor therapy in general, is figuring out essentially what percentage of stuff is causing all of your symptoms. So is it,
Kim (21:17.759)
Right.
Nicole Cozean (21:33.888)
estrogens lack or lack thereof? Is it pelvic floor dysfunction? Is it recurrent UTIs? Is it your nervous systems upregulated? And there's a direct link from your nervous system down to the pelvic floor and bladder and that's a problem that's contributing. Is it food? Is it what is? Is it inflammation? Like what is it? And that's one of the things that we can hope with.
and help you guys figure out beyond what physicians can do, which is the amazing piece of it.
Kim (22:10.77)
Yeah. And I know you followed my stuff and most people who listen follow me and I'm ad nauseam saying we should all we would all benefit from seeing a pelvic or physiotherapist or physical therapist at least once a year for checkup, just like we go to the dentist for our teeth, like to have the same practice in place to help screen for these things. But also, I do I really truly believe that if there is something that feels off or weird or strange in and around your pelvis.
Pelvic floor physical therapy should be the first line of defense, in my opinion.
Nicole Cozean (22:44.132)
Absolutely, and the thing is, is like that's not weird to say in other areas of medicine. So if you think about orthopedics, for instance, you know, you go to your doctor and you say, hey doc, I got some back pain. Their option is usually, well, we can throw some anti-inflammatories at it and go to physical therapy. If you have a knee problem, it's like go to PT. If you have any sort of other issue that deals with muscles, nerves, joints, ligaments, bones,
Then you say, go to physical therapists, because we're the ones that can assess you with function and get you back to doing stuff, get you out of pain, enhancing your activity and movement. And the pelvic floor is no different there, right? And so I think that one of my big battle cries of all women and really anybody, honestly, because everybody has a pelvic floor, every single person that has a pelvis has a pelvic floor, is to do these
is to at least get referred if you go in with some symptoms like this that can affect the pelvic floor. But then also, yeah, I mean, I envision a world where everybody is, yeah, hey, doc, let me check my pelvic floor, just like we go to the, your general practitioner, your GP. There's just so much more than, than physicians learn there. You'll be, everyone will be shocked to know that the average OBGYN, the average urologist doesn't get
hardly any training in the pelvic floor muscles themselves. They know that they exist, but they don't know how they function in everyday life. And so for any condition that affects your bowel, your bladder, your sexual health, and even some research showing that anything that happens with low back pain and SI joint pain has to do with your pelvic floor, they're so interrelated and so close.
And who else better to go to then, than a person that has studied for years on how those muscles, nerves, bones, ligaments work in the pelvis itself and around those urogynecological and urological issues. So it's a great specialty. It's something that I think that everybody should have access to and everybody should...
Kim (24:56.767)
Yep.
Nicole Cozean (25:04.496)
think about as a differential in terms of if I have these types of issues, yes, physicians are great to make sure that there's nothing else serious going on and that your organ itself and the physiology itself is great. And also there's muscles and nerves that also need to be addressed. And that's what we do. That's our jam.
Kim (25:24.886)
Yeah, I feel like the pelvic floor physical therapy coming in as the first line of defense, you spend, first of all, usually a lot more time than a physician appointment would be. It's much more thorough and you can then assess even if it takes a few sessions because you're going to be ruling out a few things with estrogen or that type of thing. If it's medical and then refer on, but I don't feel like the reverse happens very as often.
it can, I'm seeing it more and more now where physicians are referring to pelvic floor physical therapy, which is super exciting to me, but it doesn't happen as much as we both would feel that it should. And, um, and so having kind of changing our thinking and that if there's something weird going on with our pelvis, instead of going to our doctor, let's go to a doctor of pelvic floor, physical therapy.
Nicole Cozean (26:12.532)
Yes, I would love that. And I think the evidence is there to support it as well. So we had talked a little bit before about the American Neurological Association. In May of 2022, they actually revamped their whole interstitial cystitis guidelines and looked at all of the evidence for all of the treatments and things. And pelvic floor physical therapy is the only thing on the whole guidelines that is given an evidence grade of A. So a bunch of smart people.
Kim (26:40.17)
Wow.
Nicole Cozean (26:42.048)
looked at all the things and all the treatments about what's the best care for folks and we get an A+. I mean, it's, it should, so the frustrating thing for patients is that if that's true, then it should be an automatic referral and it's not. And that's where I'm just like, we have handouts. We've got all kinds of things that show that is exactly what the American Urological Association is advocating for.
Kim (26:50.647)
Nice.
Nicole Cozean (27:11.46)
but there's not very much carryover and carry through to get that to happen. And so, you know, we've started, that's why this podcast is amazing. And this video format is amazing to get out there to more people that you can advocate for that and you can ask for that. And there's evidence from organizations that it's not a weird ask. It's actually makes a ton of sense to do that.
Kim (27:35.862)
Yep.
Nicole Cozean (27:36.908)
And the other reclassification that happened in 2022 was that it was now reclassified as a pelvic pain condition and not a bladder condition. So that kind of makes sense now from what we talked about before, but it's primarily a pelvic pain condition that has bladder symptoms versus what we thought for years and what we were looking for years, like what's wrong with the bladder? And we couldn't find anything. And so now when you reclassify it as a pain condition,
Then you need to make sure from your medical standpoint that nothing actually is wrong with the bladder because we don't want to miss anything big. But at the point where they say you're good to go, then that's where, okay, cool. Well, then now who would we go to for muscle, nerve, pain? And that's where for every other category of stuff that we have, we go to physical therapists. So we have pelvic floor specialists that can help you through.
all of the symptoms that you are feeling with this.
Kim (28:38.814)
Yeah. So you've mentioned a few things with regards to what you would be ruling out. So we talked about estrogen and that is something that, you know, for the female urologists, Kelly, Dr. Kelly Kaspersen, Dr. Rachel Rubin, I follow them. They shared loads of evidence about, you know, most of the recommendations are generally from the age of 45 onwards, starting on vaginal estrogen for the rest of our life to help reduce the risk of UTIs. Whatever. So that's one piece of it.
Nicole Cozean (28:52.632)
Yes, yes.
Kim (29:05.878)
But you mentioned some other things that can be contributing factors. And one thing you said was overactivity, non relaxing, hypertonic. These are all terms are too tight. My pelvic floor is too tight. These are all terms that people could potentially have heard or been told or have read about. So you being the physical therapist, how would you assess for that to determine if somebody has overactivity in the pelvic floor?
Nicole Cozean (29:05.998)
Yes.
Kim (29:33.05)
and then how would you treat that? Or why would that bring on the symptoms, I guess, first of all, and then how would you treat that?
Nicole Cozean (29:39.368)
Yes, okay, so this is where it gets exciting. This is our jam. So your pelvic floor muscles are essentially a group of muscles that go from your pubic bone to your tailbone and your sit bone to your sit bone. So if you're sitting right now, you're sitting essentially on your pelvic floor. And your pelvic floor muscles are part of your core.
So any other thing that affects your core can also affect the pelvic floor muscles. So for instance, people understand that with low back pain, sometimes like those stabilizing back muscles, they sort of turn off. They're trying to like stabilize and like don't move because I'm scared that if I move, then it's gonna hurt more. And I'm not really sure why it's hurting, so I'm gonna go into protect mode. So we can kind of see that from like a back pain perspective or even something if you have a hip,
pain, you're like you're not wanting to go out and walk, your body is sort of shutting down that joint to sort of be like, let me see what's going on, let me try to get this inflammation out of here, let me assess, don't make it worse until we figure it out. And that same thing happens with the pelvic floor. So if you have back pain, if you have hip pain, if you have a history of tailbone pain,
Those are areas that have affected your core musculature, it's affected those joints, and then it also, because they're so closely related as part of your core, and literally just related in close proximity to those areas, your pelvic floor can also be basically trying to do the job of more than one thing. So in a perfect world,
your pelvic floor, we wouldn't be thinking about our pelvic floor, it functions automatically, it helps us to pee, it keeps pee in, it helps us to poo, it keeps poo in. It opens up if you want to insert something in there for sexual activity or a tampon or a gynecological exam, and then it also helps your pelvic organs to have support, and then it also helps to stabilize those joints that we talked about, your SI joint, your hip, and your low back.
Nicole Cozean (31:56.116)
So one of the reasons why your pelvic floor muscles also can cause bladder issues is because those muscles wrap around the urethra, the vaginal opening and your anus, all kind of in this one figure eight sort of picture. And so if those muscles are overactive for some other reason, they can.
irritate the structures that they are right next to. What's even one more piece interesting on top of that is that if you look down into the pelvis, and I know some people are listening and some people are watching, but if you look down into the pelvis, where your bladder sits right behind the pubic bone, there's some muscles that come up right behind the pubic bone as well, and your bladder's literally sitting on that.
And so if your pelvic floor muscles are tense and tight, your bladder can also get irritated. And if your bladder is getting like irritated from those muscles, then your bladder is like, well, something's bugging me and I only know how to say two things. I only know how to say I hurt or I have to pee. So it gives you those two signals and it makes you pay attention. But it doesn't say,
it's just my pelvic floor that's bothering me. I can just calm down, right? It sends a message up to your brain that says like, hey, there's some big time going on here and I'm not sure what's happening, so I'm gonna tell you about it. And your brain's like, oh my gosh, what the heck? And so then we try to make sense of this thing and then you try to urinate and you don't go that many ounces of pee.
And now everyone's all confused. Your brain's confused, your bladder's confused, your pelvic floor is tight. And it's kind of this like feedback loop that everyone's confused and we just need a pelvic floor therapist to be like, hey, pelvic floor, are you tense and tight? Bladder, are you good? And if, and this is the key, if the pelvic floor is tense and tight and causing bladder problems,
Nicole Cozean (34:10.336)
Now we need to figure out why that's happening because it's not enough to just say, your bladder's tense, that's probably what's, or your pelvic floor is tense, that's why your bladder's mad. It's not enough to say that, we have to figure out why. And that's where a pelvic floor therapist really can shine, is in that differential diagnosis. So you asked about how do we assess this? So a good pelvic floor therapy evaluation.
and really treatment should be a full body approach because the pelvic floor is so intricately involved in the low back, the mid back through breathing, the hips, and then everything that's connected to that stuff, which is literally can go all the way from your foot all the way up to the top of your head. We need to do what we call an orthopedic exam first of all of those things. So we look at your back, your hip, your foot, your inner thighs, your glutes.
your back muscles, how you breathe, then we have to look at your rib cage and we look at all of those things and we put a picture together of like, okay, what do we feel like could be affecting the pelvic floor function? And then a pelvic floor therapy specialist is extra trained in assessing the pelvic floor muscles. And the tricky thing about pelvic floor muscles is that they're not really easily accessible from external. So we do use the holes that you have
If you have a vagina, we can go in vaginally. If you have an anus, we can go through rectally. And so we can actually feel the tenseness of the pelvic floor muscles. We can feel where those pelvic floor nerves might be coming around. We can feel the tailbone really well from there. And we can actually feel a hip muscle, a couple of hip muscles from inside the pelvic floor as well. And so we can actually see, hey,
Are these tense overactive? If so, we can start to get clues as to why. And do they happen to also create some bladder symptoms? So I can be, it's very common that I can be internal on a pelvic floor muscle and they'll say, oh my gosh, I have to pee. And I'm saying, I'm not anywhere near your bladder. I'm actually pressing on a pelvic floor muscle that is confusing your brain and bladder to be like, ah, help.
Nicole Cozean (36:37.248)
and then it's sending a message up that I have to pee. So we can then get clues as to where are those muscles a problem? If they're tense and tight, why are they like that? And that usually involves both internal and external approach to both evaluation and treatment of the pelvic floor area.
Kim (36:59.991)
Can you elaborate a little on the why? So, you know, I say now I'll ask your opinion, but I hear from many therapists and I hear from many people who are told their pelvic floor is too tight. So I feel like it's if you were to take two groups, tight versus not. So maybe tight versus lax. There's a lot more people in the tight. Is that your experience? And if so, what are you?
in your kind of problem solving and looking at root causes, what are some of the, you know, say top contributors to the development of tight pelvic floor muscles.
Nicole Cozean (37:34.912)
Yes, so I would say that it is my experience that more people are in the tense and tight category than not. Mostly for the reasons that we explained a little bit before. I mean, your pelvic floor is a secondary stabilizer to a lot of your back and hip and an SI joint and you know, if anybody, there's a ton of prevalence of those types of pain conditions and so you...
I mean, there's actual evidence to show that 95% of people with low back pain have some form of pelvic floor dysfunction, even if they don't have pelvic floor symptoms, which is mind blowing. So the pelvic floor is involved a lot. So yes, I would say it is my experience that it's more tense and tight. The other reason why I feel like that is, is that the majority of your pelvic floor muscles is innervated by a nerve.
that is a special nerve that not only carries the signals to make the muscles work, but it also carries nerve fibers that are directly related to the fight, flight, freeze nervous system. And so that's called sympathetic nervous system innervation. You guys have heard people talk about the stress response or upregulated nervous system.
But essentially, if our nervous system is in a state of fight, flight, freeze mode, even if it's not like I'm running away from a lion, even if it's just like, oh my gosh, I have to pick up my kids and my husband's being a jerk and my job sucks and my boss is a jerk and all the things like that type of I am not safe in my environment type of irritant is also directly innervating your...
pelvic floor muscles. And so you asked about, you know, what are the things that we look at? Why is it like that? I think because the pelvic floor muscles are so involved in the orthopedic part that we talked about and they're special in that they are directly innervated by our autonomic fight, flight, freeze nervous system, we have a tendency, all of us, towards that overactivity. Now,
Nicole Cozean (39:55.992)
Just because they're overactive doesn't mean that they are super strong. So you can have an overactive pelvic floor that also has some of the symptoms that we typically think of as low tone pelvic floor, incontinence, prolapse. It can still, I usually just say that the muscles are tense and tight, therefore they're not doing their job well, whatever that is. It doesn't have to be that your muscles are these like.
floppy muscles for you to have in continence and prolapse. And in fact, I see quite the opposite most of the time, that we actually have tense and tight pelvic floors. They're not activating well, either because they physically can't or because they're in this state of like protect mode that doesn't allow them to go through their full range of motion and do all of the jobs that it needs to do. So...
Kim (40:49.506)
Mm-hmm.
Nicole Cozean (40:50.708)
I hope that answered your question. So yes, I feel like it's more tight. People tend to be more on the tense side, and those are the two whys that I think I see most common.
Kim (41:01.31)
Mm hmm. Yeah. And the other challenging part of that is there is the upregulated nervous system as you're talking like different terminology. And then if the person may have the incontinence or prolapse or is guarded, then you get in this vicious cycle of being afraid to relax, not knowing how to relax, maybe pain contributing to more, you know what I mean? So it's just you get in that vicious cycle. So then from a.
You know, people say, I'm trying, I'm trying to relax. How do I relax my pelvic floor? It is not as easy as just relax your pelvic floor. So how does exactly, exactly. So there's that, that cycle that people get in. So from a treatment perspective, how would you guide that person to start unraveling these layers of this upregulated nervous system and so on?
Nicole Cozean (41:37.432)
Right, you're stressed out about not relaxing. Yeah.
Nicole Cozean (41:54.516)
Yeah, so I think this is where I'm going to put a big huge plug for just individualized care, because every single person's why is different. I will say this, that somebody needs to be looking at all of those different aspects to see, I like to talk a lot about it in percentages, and in fact in my clinic, I have this like pie chart that at the end of their evaluation, and it might take a couple visits, we have like a picture.
you know, where we are hypothesizing essentially. I think it's probably a 70-ish percent pelvic floor. I think it's 10 percent estrogen. I think it's 20 percent. Is that, does that go right? Whatever the percentage up to, obviously has to equal 100. But, but is that inflammation? Is it a history of your tailbone fall that you had when you were 20 at snowboarding that you didn't think was a problem and now it's...
Tended you towards overactivity and now on top of it. You have a little bit of lack of estrogen and on top of it Your kids in high school and you're having a problem with that, right? So is there so we try to like come at it from a multifactorial approach So that we can't address it from all angles I don't think that there's no I don't feel like I feel like I've ever treated somebody with IC or bladder pain syndrome or anything
like that, where I've been like it's been one thing. I think that it's always multifactorial and sometimes people get scared with that. They're like, well, if there's so many things, like how am I even gonna get started? And it's like, right, but if there's a lot of things contributing, then we can make small improvements in every single little one of those and we can make a big improvement. So like little changes can add up to be a big change.
Kim (43:50.242)
Mm-hmm.
Nicole Cozean (43:51.4)
So I would just say that from everybody's why, there's usually, we try to figure out, like hypothesize, like a primary driver, and then we have a bunch of secondary and tertiary drivers from that. So for somebody, it might be really focusing on constipation and tailbone pain, or pelvic floor muscle releases around the tailbone as related to their...
bladder stuff. For somebody else, it might be working on perineal scar tissue that has been irritated since their, you know, grade three, Taren childbirth. For some people, it's actually starting with breath and rib expansion and pelvic floor relaxation and that kind of stuff, but an indirect way to get the pelvic floor to relax.
For some people it starts with manual therapy to the actual pelvic floor muscles themselves. I would say that by the end of the time that I'm treating somebody or that my team is treating somebody, we have addressed every single one of those areas. We just have to decide, help you to decide which ones we're going to focus on, which is going to give us the biggest bang for our buck, and then how are we going to help you in these other areas?
Kim (45:14.412)
Yeah.
Nicole Cozean (45:14.744)
And it's not as easy as the stress management piece is not as easy as just like, I just relax a little bit. Why don't you just get that stressor out of your life? It's not that easy. Um, as we know, human beings are complex. Relationships are complex. And so, but there are some really cool things that we can do with the nerve. That that's called the Vegas nerve, the nerve that, um, is the opposite of that upregulated fight flight free state.
It's the rest, relax, digest state that we can help to encourage that to like to ramp on a little bit and we can help the other sympathetic nervous system ramp down. There's some physical things that we can do treating from head to toe with that. So I think that is also a really big piece of the puzzle that a lot of people miss. And...
if you're just getting your information on TikTok and they're talking pelvic floor equals Kegels and stuff like that, it's like, well, no, hang on. We don't want to do more of that. We don't want to tense up more. We need to relax, but from all of the other aspects so that your pelvic floor can release so that it then can do all of its functions without being in this freeze state.
Kim (46:30.77)
Mm hmm. You mentioned diet and you've also mentioned inflammation. And I think inflammation gets talked about a lot nowadays, you know, in the health and wellness space and the biohacking space. And people are even now saying, inflammation. And so inflammation, what is inflammation? And how would this and cystitis, so bladder inflammation, how could?
inflammation in and around our whole body, but also specific to the pelvis maybe, how could that be, why does that contribute to symptoms and how could we like, what's, what guidance do we provide people in terms of addressing or reducing their inflammation in, in hopes that it would help relieve some of their symptoms?
Nicole Cozean (47:18.696)
Yeah, and this is actually an interesting thing to talk about, especially in the context of interstitial cystitis, because I think that one of the other big myths that we need to bust about IC is that, and you go on even some prominent websites, I mean, I was just on a website that everybody would know, and there's wrong information about diet and interstitial cystitis. So the name interstitial cystitis...
is confusing because it feels like there's inflammation in the bladder itself. And we know that that's not true. So now we're talking more about global inflammation. Can global inflammation cause symptoms of interstitial cystitis? And I would say yes. Those global inflammation can irritate muscles, it can irritate nerves, it can override your lymph...
system and that's something that clears a lot of inflammation out of your body. So, but the real question that I get from a lot of people is like, well if that's the case shouldn't diet be my primary thing? I heard that if I take out all of these lists of like a million different foods that should make my bladder symptoms go away, right? And the research over the last
20 to 30 years really has shown that the average person with interstitial cystitis symptoms, urinary urgency, frequency, and pelvic pain, the average person only has about five to seven foods that might trigger their symptoms. So it's not necessarily about the inflammation of the bladder itself, and I think that's a hard thing for people to sort of divorce themselves of.
And it's something that takes a lot of time for people to believe me when I say that. So we work really hard in pelvic floor rehab with that, we're working with that. So then you ask, well, should I just take away bladder irritants? And yeah, I think taking away bladder irritants can really help. Now, if you are someone that just absolutely loves coffee and oh my gosh, I would die if I couldn't have my coffee, then there are certainly workarounds for that.
Nicole Cozean (49:40.98)
in the short term, and then there are almost all of my patients with interstitial cystitis can eventually eat and drink whatever they want to. So I usually talk a lot of times about inflammation making everything more sensitive. So we got to get the global inflammation down so that...
We, I call in the book, in the Interstitial Society Solution that I wrote, I call it the dip cycle, the dysfunction, inflammation, pain cycle. They're all interrelated. And so I think that by globally decreasing your inflammation by things like stress management, getting better sleep, changing your diet, not so much in getting really nutso about every single little thing that you put in your mouth, but I'm talking like,
Can we eat more vegetables? Can we stop with the processed foods? Can we take away some of the big known things that increase inflammation, right? So the gold standard for changing some of your diet with interstitial cystitis has now become the elimination diet. And for some folks, some people need to go down that road. For other folks, they don't. And so I usually start small.
because we know all the things about interstitial cystitis that it's not necessarily the bladder, it's not what's going in equals what's coming out of your bladder, that like just physiologically doesn't happen that way. And so we wanna take the fear out of food, we want to decrease global inflammation so everything isn't so sensitive, and then we wanna look at some of the other root causes like pelvic floor dysfunction, nervous system upregulation.
any orthopedic thing that might be making your pelvic floor muscles tense and tight, and we kind of go from there. And some folks will end up needing more targeted treatment with diet and nutrition. I'm not saying that that's not the case for everybody. So some people do need more of that, but I always like to start with the things that we know are true for most everybody.
Nicole Cozean (52:01.208)
And then we do that. And then if we find that like, ooh, actually I'm seeing that we did do some of these big changes and that didn't work, you might be appropriate for talking to a dietician, doing some food sensitivity testing, that kind of stuff. But I think one of the big mistakes I see people do is go online, read about IC, think your life is over because it says, all of these things that I love, I can't eat anymore. And now we're in this huge.
Problem where I'm not doing anything. I love I can't have sex I hate my life and also you took away all of the fun things that I was doing with food and Now we're in this state of despair and that's what I really want to bust That myth as well that not everybody needs to be on the icy diet. In fact, the term icy diet doesn't even exist There is no such thing
Kim (52:58.038)
Got it. Yeah. And the sound just froze there for a second, but you said when people go online and they research and then they find this terminology like icy diet, is that sort of where you started that conversation or that? Yeah. Okay.
Nicole Cozean (53:07.672)
Yeah, yeah, yeah. And that's a term that the story behind that actually is it was good meaning things by the Interstitial Cystitis Association, which I had been a board member of for nine years. Back in the day, they did a survey that just said, hey, everybody with IC, what foods can't you eat? And that list became the IC diet. Well.
Kim (53:21.601)
Mm-hmm.
Nicole Cozean (53:36.28)
That's just a bunch of people saying like, hey, this bothered me. Which is good information that yeah, a lot of people have some sort of food sensitivity, but the reality is, is why is that? And sometimes, so it's not just that, and it happens to be that a lot of bladder irritants are also acidic foods, and so that became another huge piece that people misconstrue. Oh, I can't eat anything acidic. And...
Kim (53:38.966)
Yes, not science. Yeah.
Nicole Cozean (54:04.796)
and acid in doesn't equal acid out of your bladder. So it's very, I get why people are confused because there's a lot of misinformation out there. But I wanna take, for everybody listening to this, if someone asked me is diet important if you have interstitial cystitis, I would say yes, but not for the reason you think it is. And I usually take a more global approach first for...
what can decrease global inflammation, because that's gonna be good for everything. And then if we need to get more specific, we can. And that's it.
Kim (54:40.586)
Yep, yep. Okay. So before we wrap up, and we've gone a little bit over time, I apologize, but I want to just, I guess, end it with, is there a cure? Do you see people who come in who have this diagnosis, who walk out however many sessions later, timeframe later, where they no longer would be considered or would not, if they were to go and talk to somebody, they wouldn't have this diagnosis of...
of IC or painful bladder syndrome.
Nicole Cozean (55:10.924)
Yeah, and you know, this is my, the last myth of IC, where there's eight of them that I talk about. We've talked about almost all of them here, but that last myth is that, you know, IC is an incurable disease, and it truly is a myth. I think that if you look at the mechanism behind what interstitial cystitis is, it's a chronic pain condition, and it's not a bladder condition, and it's pelvic floor problem.
and it's a nervous system connection between your brain and bladder problem. Those things can totally be helped. The symptoms can be eliminated, I would even say. For most people, they would be down to the point of being imperceptible or a mild annoyance at best. I think it's possible. I think it's probable that most people can get all of those symptoms gone.
Um, I think that it's challenging. It's certainly challenging for sure. It sucks. Like having a pain condition sucks. It takes a long time to reset all of the things that need to be reset in order for those symptoms to be down. Um, but I think that if we take, if we, if we trust what we know about the research and the American neurological association and
all of the really smart people that have been studying this condition for like 30 to 40 years, if there was a bladder origin to the problem, we would have found it. And so when we can shift our brain into, it's a pain condition and I can, that can be managed and fixed and it's a pelvic floor and I know how to help my pelvic floor and they're a specialist for me. If we change that to be our mantra, then
I'm never going to be able to, they're never going to find a cure for the bladder problem that I have, then if we change it that way, then I would say absolutely, there is, I mean, many people live their lives without pain from I.C., without urinary symptoms from I.C. That is possible for most, if not all, folks. And again, I just want to say it's not, I'm not saying it's easy.
Nicole Cozean (57:37.988)
but it is possible. And so I think that you just have to find a good team that is up to date with the research, that a pelvic floor therapist needs to be on that team, somebody that knows how to deal with chronic pelvic pain conditions. And then we can set up a plan for you to figure out why is this happening in your body? There's always usually an answer.
Kim (58:02.558)
Yeah, yeah, I love leaving on that message of hope. And, you know, as you say, it's not necessarily an overnight, easy, quick, easy fix here and there. But but it is absolutely possible. And and I love that. So where can people find more? You mentioned a book that you have, I'm sure a lot of people would want to have access to be able to get that resource. So where can people find you?
Nicole Cozean (58:24.132)
So the easiest place is to, I'm on Instagram. For people that have the condition, the people that think they might have it, all of my patient-focused stuff is on at Pelvic Sanity. There there is a link to my book, which can be found on Amazon. It's called the Interstitial Cystitis Solution. And then I also have a website that's very specific to interstitial cystitis that goes over all of this.
And that is called icroadmap.com. There's some free guides on there as well. And on Instagram, there's also a story highlight that goes through all of these myths as well. So that's probably the easiest way to find me. And I really appreciate you having me on and letting me talk about something I'm so passionate about. And I'm so glad we ended on that really, really positive note that thousands of people live happy, healthy, pain-free lives.
despite being diagnosed with IC. And I hope that's you.
Kim (59:27.23)
Yeah, yeah, yeah. And I guess I said earlier, I picked you for reason. And I really appreciate the knowledge that you bring and dispelling those myths and, and everything that you've created to help people. I think it's absolutely amazing. So all of those resources will be posted in the notes below. And thank you so much for sharing your time and your wisdom with us.
Nicole Cozean (59:47.632)
Thanks so much for having me.
Kim (59:51.707)
That was so good.
