Kim (00:01.422)
Hello, Hana, welcome. So happy to have you here. We are gonna be chatting all about the lovely topic of incontinence, mainly urinary, but we're gonna bring fecal in there because we have to consider that. We have to, it can come out both ends, right? Both holes.
Chana Ross (00:16.719)
I don't think I could think about a better intro. So thank you. Let's talk about peeing our pants. Let's do it. Thank you for having me. I'm excited to dive into all poo and all pee things.
Kim (00:19.682)
Thanks. Yeah.
Kim (00:24.441)
Yes.
Kim (00:28.674)
All poo and all pee, yes, that's the world that we work in. So please start out and let us know who you are, what you do, how you got into this world of poo and pee and helping people solve the poo pee problems.
Chana Ross (00:39.079)
Let's do it. So thank you for having me. My name is Hannah Ross. I'm a pelvic floor physio. I run a pelvic health clinic in Midtown Toronto called Vital Physiotherapy and Wellness. And I'm the mother to four children. And I really I think each of us have our own story. But my story, I'll take you back a long time ago, my kids are ages 15 to five.
Um, and so after my second, um, I was very gung ho. I was really that like, get your body back kind of mentality. Um, and I was writing five K's and 10 K's and I was really super into, um, the Tony Horton, um, DVD back in the day, uh, DVD set called P90X and, um, do your best and forget the rest. So.
Kim (01:29.496)
3, 2.
Chana Ross (01:34.099)
So one of those videos was plyometrics, and they had a whole bunch of bunch of jumping and really high impact activities. And I was doing it, my daughter was born in December, and I would say this is probably like May, June time after she was born. So, you know, five or six months postpartum. And I had my first baby at the age of 25. Everything was fine, five minutes later, was running. And I was 27 at this point. And...
She, I was doing this move called rockstar jumps. And a rockstar jump is when you jump up in the air and kick your bum to your feet and you like a really cool rockstar strum your guitar at the same time. And I peed my pants. Like I just, I could not do it without leaking. And I was not like, that was something I was like, hmm, I should do something about this. But for up to six months, I had already been having pain, low back pain.
hip pain, pain with sex. I had gone to my GP, I had an internal ultrasound and she was like, everything's fine, you're fine. And everything did not feel fine, but I was like, well, my doctor said I'm fine, so I'm fine. And when I couldn't perform the jumps, that's when I was like, this is like really starting to bother me. And there were very few people providing pelvic floor physio at that time. This was 13 years ago in Toronto. And a friend of ours was
her mind was starting to get trained and she was like, let's like come Julia was like, come and see me like I'm getting I just took this course. It's super cool because we all nerd out over new courses that we take. It's really cool. And it's been really helpful. And I was like, tell me more about it. She was like, Okay, so I can I'm gonna assess you vaguely. I was like, Nope, goodbye. You are not coming anywhere near me with your fingers. And it really did take some
Kim (03:06.858)
Mm-hmm.
Chana Ross (03:29.775)
coercion, we'll say, I was like, this is like the weirdest thing I've ever heard in my life. And I went to see her. And when I say it changed my life, I mean, it changed every part of my life, because I truly believed that there was something deeply wrong with me. I believed that there was something wrong with my body. I was looking at everybody else and I was seeing everybody else, quote unquote, bouncing back. I had already bounced back once, so there was something wrong
Chana Ross (03:59.571)
how to control my bladder. I was no longer having pain. I suddenly realized that maybe the medical system isn't what I thought it was. And I also recognized that like, I could talk about vaginas. So not only did it change physiologically like my belief in myself, it will changed my physical ability. I could go, I was doing all the things. I was back and doing all the things. But I was really.
seriously contemplating leaving physio at that time because I was just, I wasn't feeling fulfilled, helping people with their shoulders and their elbows and their wrists and that's very fulfilling for many people so I'm not speaking for all physios but it just, I was really seriously thinking about going back to do medicine at that point and this became this like, aha, like Oprah aha moment for me because I was like, I want to do pelvic floor physio and so I
really felt that I wasn't gonna have any other kids. Surprise, I had two more. They were both plans, let me just be clear. But I was nursing my son. I got pregnant, I had a third baby. I was seen prenatally for him, I was seen postpartum. Same for my fourth. Totally different experiences, completely empowering. And yeah, there was a long rehab process.
But there was no point where I was like, oh my God, out of touch with who I am and what my body can do. I understood the process. I understood what was happening. And I understood the misinformation around it too. And for me, that was like, I need to go out there and change the world like on pelvic floor at a time.
Kim (05:45.966)
Thank you. Yeah. Like it's amazing how many of us in pelvic health have got here from our own personal story and some sort of awakening that happens or experience that happens. And we are then called to do this work and help others. And so, yeah, so thankful for Julia coercing you and thankful for you then making the decision to help others because it's such a needed. And there's still, even though there's so many more pelvic physios from back from when I started.
And just to be clear for those listening who don't know, I am not a pelvic physio. But starting in this world of pelvic health, there still is a need. There still is a shortage. There are still significant wait times to see a pelvic floor physio. And my hope is that at some point in my lifetime, that this is something that our government will cover and that everybody would be able to have access to this, because it is such, as you say, it can be completely life transforming in so many different ways.
Chana Ross (06:36.572)
amazing.
Chana Ross (06:43.527)
Yeah. 100%. I think also like, there's a difference, like what I'm really recognizing and what I'm seeing when I'm on board, because now I run a clinic and I spend a lot of my time training new physios, is that at least here in Ontario, in Canada, you can take one weekend course in a roster with the college and then you can call yourself a pelvic physio. And the care that you're getting, again, like it's just like the more you know, the more you know.
Kim (06:44.758)
so many different ways.
Chana Ross (07:14.928)
I don't want to be receiving acupuncture from somebody who did a weekend course. I want to receive acupuncture from somebody who just does acupuncture. And the same is for pelvic floor physio. There's not only an issue in terms of the availability, but also in terms of the quality of care. And a lot of our, we see a lot of clients from other physios who think there's something deeply wrong with them. Again, it just reinforces that perspective because they saw a physio who just...
gave them Kegels essentially, and then they're like, well, physio didn't work for me. And I'm like, no, we need to start talking about what good quality physio looks like.
Kim (07:51.97)
Yeah. Okay. So let's, let's go down that path. What is, what would you say? Cause I get asked this question all the time too. And one thing that I do say is first, you need to be assured somebody could list pelvic floor on their website. But when you call or email to make an appointment, you want to make sure that person is licensed to do internals. You then can also look at their background and see other courses, other, like how long have they been doing this? There's other questions to ask.
And one other final thing is that even if you go, somebody could have been doing this for years and years, they could have all of the certifications, it still is, it's a very intimate therapy. And if you don't connect with that person, regardless of how long they've been doing it, it's just not the right person for you and you can go find somebody else. So what would you say if somebody was looking? What would you say is, what should people be looking for to find somebody who's really qualified or who you think would be the best person to see?
Chana Ross (08:33.607)
Yeah. Yes.
Chana Ross (08:46.235)
Yeah, I would spring word totally off of what you're saying. I would say here like our three, our values are care, excellence and passion. Like the care that you receive, the most important piece of it is your ability to feel safe with that person. And even within a clinic, there's different personalities, right? And so just because somebody comes highly recommended, if you don't jive with them,
I think that we need to start to learn how to trust ourselves and be like, there's not something wrong with me. Just like I need, I know what's best for me and I'm going to go and find somebody who's who connects with me. Or maybe you don't feel safe because you're not, you don't have never felt been able to tell your story before. And so you haven't told your full story. So the ability to feel like you can tell your full story is really, really important as well. And I always recommend that people ask your friends.
Like not only ask your friends and like, and when you find somebody that you love, tell your friends too, because maybe many of your friends have seen physios and they just don't feel comfortable telling you about it. But if they have seen somebody who they've really felt connected with and trusted, that's also a really good resource as well. There are some physios who have years and years of experience and people have negative like.
They have negative experiences with them. Like, I'm not going to, I'm not the right fit for everybody. You're not the right fit for everybody who you work with. Not all my physios are the right fit. The fit is the most important piece. That's number one. And number two, I would say is, anybody who approaches you, like you are a problem to be fixed, is to me that is a red flag. The most important thing that I learned when I did my physio, and that I,
train my therapist to do and that I talk to my clients about as well is a physio is not somebody who's able to fix you. Yes we've got amazing anatomy, amazing physiology, lots of life experience but you're not a problem who needs to be fixed. But we are somebody who comes and helps you facilitate your connection to yourself and to your body so that you can do the work so that you can build that self-trust with your body. A lot of us just don't trust our bladders. We just don't trust our public health to do what we need to do.
Chana Ross (11:07.715)
and learning how to trust and learning how to sense like, is this actually a full-blooder or is this not? Or is this just like my nervous system being like, upregulated and feeling anxious? Learning how to differentiate is the most important piece. And so if somebody's, if you are outsourcing your authority to somebody else or you're looking to do that, then that's to me is not somebody who's gonna actually help you. If you're somebody who's,
Coming in is like, please just fix me. You want to find someone who's like, you are whole, perfect and complete exactly as you are. And I'm going to help you function. I will help you to learn how to function better.
Kim (11:48.982)
Yeah, I love that. I love that. It's such a profound statement to say it the way that, you know, you are the ultimate authority and you need to put in some work. You just need to have somebody kind of direct you on terms of understanding the root cause, why this is happening, and here are the steps that you can take to help overcome that.
Chana Ross (12:06.223)
Yeah, 100%. I think the stories that we hear so often are people who've like, they've said like, oh, my doctor told me that this and this is wrong or they told me I was failure to like, during birth stories, like failure to progress, failure to this, failure to that. Like we come with these deep seated beliefs that our body is failing. And so I think that trusting somebody to help you find that that's not true is the most important thing that you can do.
Kim (12:18.85)
Yes, yes, yes.
Kim (12:32.718)
that. So when somebody has come to you and we're talking mainly today about incontinence as we talked about the pee poo. So somebody comes to you. Let's just say they've come to you because they're leaking like they were doing rockstar jumps, they were leaking and they've heard about pelvic physio, they come to see you. Some people come and they're like, I'm not sure why I'm here, but my friend told me that I should come or right. So how do you then how do you approach that person? What would they expect in terms of
Chana Ross (12:54.147)
Yes, I've heard that a lot.
Kim (13:00.886)
that first session and how do you help them uncover some of the reasons they may be leaking.
Chana Ross (13:06.367)
Okay, so the first thing that I like to do is I like to set up the stage that like this is going to be different than other physio. Like a lot of people come in with preconceived notions of what physio looks like and right away I'm like we do things differently here. I do, I will do anatomy with our clients, like I'll describe what the public floor does, but first and foremost like understanding what is somebody's goals. Like your friend said to you, okay so.
go see the physio, are you just like, well, my friend told me to, so that's why I do it? Like, what was that part of you that was like, hmm, maybe there's something here? Because I really want everybody to have like, the strongest, most flexible, most coordinated pelvic floor in the entire world and the ability to lift any weight without leaking. But if that's not my client's goals, then like, it really doesn't matter what I want, it matters what they want. So we spend a lot of time going through, like talking that first visit.
talking about like what are their goals? What is their history? What's their medical history? What are their beliefs about their bodies? What are their beliefs about themselves? What are their beliefs about medicine and health and wellness? We talk a lot about pillars of health, sleep, stress management, food, movement, you know connection with people. Do you have people who are going to support you as we go through this wellness journey? Are you going to?
state to your partner, I need to go down and do my pelvic floor physio exercises. They're going to be like, no, you have to do this and this. It's somebody who's going to support you to put yourself on that list of important people. It's really only after having conversations about your urological history, your gynecological history, your past pregnancies, your current physical activity, your hopes for physical activity, your hopes for sleeping through the night without pain, your hopes for...
You know, how often are you peeing? What are you drinking? Are you drinking as I'm sitting here with my coffee and my water? How much caffeine do you, are you taking in? You know, what are the bladder irritants that you're doing? Are you a frequent flier to the bathroom? What does that urge to go to the bathroom look like? Is it like, oh, I think I might have a full bladder or is it like, get me there right now? We go through like a really, really deep, subjective conversation that usually just feels like a conversation because it's very client led.
Chana Ross (15:29.084)
There's a lot of tell me more about that, tell me more, tell me more. And then we'll go through a physical assessment and that physical assessment is a basic orthopedic assessment. We'll look at squatting and lunging and walking and movements, low back movements, thoracic movements. And then if the client's up for it at that time, we'll do a pelvic floor assessment. But
we're mostly gonna be spending our physical assessment time looking at alignment, breathing, range of motion, like finding an easy breath. How are you breathing? Are you relaxing your pelvic floor when you need to? Are you engaging your pelvic floor when you need to? How is this system currently working? And what tweaks can we make? I really like to keep it simple. What simple, easy things can we do right now for you to get the most bang for your buck in terms of the goals that you've told us that you wanna achieve?
Kim (16:26.314)
Okay, so if somebody came in with the goal of they leak when they run, and they wanna be able to run without leaking, and you've gone through what the initial conversation would look like in terms of kind of coming to root causes, understanding their history, what then would you, after, so what would you potentially find? I know that there's many different things, but in that person who's running, let's just say she,
She's had two pregnancies, vaginal births. They're three and five. And she only leaks when she runs, nothing else. What could potentially be, let's say tearing with her first, not with her second. And right, yeah, very common, right? This is a very common story. Okay, so what then would you...
Chana Ross (17:11.919)
like every client that I've had. Yeah.
Kim (17:19.094)
What are some of maybe some of the additional questions you would have for this person? And then what would you send them away with after that first session in terms of homework and things that they could start working on?
Chana Ross (17:21.703)
Hmm.
Chana Ross (17:28.327)
So things that I want to know are at what point does she start to leak? Is it in a long run? Is it a short run? Is it with speed work? Is it, you know, with endurance work? Does she have any other symptoms? Is she feeling tired at that time? Does she notice any changes in her running pattern? I'd like to look at her walking and see what position is she walking. Usually the position you're standing in is the position that you walk in, is the position that you run in. So we would start with.
standing, breath work and pelvic floor work, then walking, and then we would move it into running as well. I really look at her breathing pattern. What we see a lot with that particular person is usually like rib flare, overactivity in the upper abs, not able to quite effectively use the entire abdominal wall. As they fatigue, they tend to start to breath holes.
or not breathe through the entire running pattern. And often what I'll do is I'll just, we'll find a position where their core, their breathing diaphragm, their pelvic floor, their inner abs, their inner back muscles are working well. And if for example, they're leaking after, you know, 10 minutes of running, probably about eight, I'll have them walk.
and do some breath work while they're walking and then go around again and then stop before eight. Like we'll start to get them before that critical moment and start to realign things and start to see how that's feeling. I don't like to take things away from people. I like to figure out how can we make it work for you.
Kim (19:13.634)
Yeah. And just based on everything that you just said there, that there's so much more to optimizing pelvic health than go home and do your Kegels, right? And, right.
Chana Ross (19:22.523)
Yeah.
Chana Ross (19:26.179)
Yeah, I don't really give people kegels, to be honest with you, unless it's with the specific cough and sneeze. Yeah.
Kim (19:32.406)
Yeah, so can you describe what is a Kegel and why don't you give it to people? And why would it only be specific to somebody with the cough sneeze as you just said?
Chana Ross (19:36.785)
Mm-hmm.
Chana Ross (19:45.587)
Okay, so a kegel is a pelvic floor muscle activation. So the pelvic floor muscles are the muscles at the bottom of the pelvis. They're involved in holding a urine. That's what we're talking about today. Healthy sexual function, stabilizing the pelvis and rib complex and the spine. They help pump blood back up to your heart and they're part of that inner core system. And so because they work together with the breathing diaphragm and the inner abs and inner back muscles,
we don't treat the pelvic floor alone without addressing the entire system. So it'd be like treating your fingers, like squeezing one finger and bending it if you tried to improve your grip strength, right? Many of the clients specifically that we see get a gold star when it comes to kegeling. So a kegel is a contraction of those muscles. It's a squeeze and a lift.
well functioning, really coordinated system. Every time you inhale, your diaphragm should relax and your pelvic floor muscles, so your diaphragm should contract and your pelvic floor muscles should relax and your abs should relax. And on a really well functioning pelvic floor core system, as you exhale, your diaphragm should relax, your pelvic floor should turn on and so should your abdominals. And what we see more often than not is,
that our clients are really, really good at the turning on the pelvic floor piece, and they're not really great on coordinating that release part. The same with the abs. They're really, really great at clenching their abs and holding them in all the time, and they're not really great at the relaxing and then the full range of motion. So when we're talking about training any muscle, we need to know that those muscles are strong. We need to know that they're flexible. We know that they can coordinate with the system. We need to know that they have endurance.
and that they're turning on at the right time. And so when we're just thinking Kegel, that just is a very, it's like a very, very focused specific concept around just making sure they're strong all the time. And that ignores the entire system and the importance of muscle training and specificity principles and learning how to get these muscles to work well. The majority of the clients that I personally work with that we see in the clinic,
Chana Ross (22:09.395)
tend to be high performers, type A women who just really get a lot done. We know the pelvic floor is really, really deeply tied to the nervous system as well. So when you're in fight or flight mode, when you're in go, that fight or flight sends a message to the pelvic floor muscles to just turn on. Cause when you're running away from a tiger, it really doesn't make sense to like sit and have like a really nice relaxing bell movement or to like grab a quickie with your partner.
We just grip those muscles and we go. And unless we intentionally spend time learning how to relax that system, how to get that system coordinated again, just turning on those muscles more is going to send them further down the road where we have gone. I always say like, if Kegels work, they would have worked for you at this point. And so we have to learn how to coordinate the breath with the pelvic floor.
Kim (23:01.026)
Bye.
Chana Ross (23:09.027)
and also how to use the muscles in and around the pelvis in synergy with those muscles. It's not, it's just a very narrow focus when we can take such a big holistic picture that is far easier and far more functional and more likely to work.
Kim (23:30.818)
So what about then, because what you've just described is so many people hear that now. And so I've been told I'm hypertonic. I've been told I have an overactive pelvic floor. I've been told my pelvic floor is too tight. So those are all different iterations of muscles that are more likely to be kind of gripping and tense. So then they say I've been told not to do Kegels, but I've been told to do reverse Kegels sometimes or I've been told only I just need to only focus on relaxing. And
Chana Ross (23:38.871)
Right. Yeah.
Kim (23:58.762)
So I think that there's limitations there as well. So from your interpretation of that, what do you, do you give people reverse Kegels or do you say go home and just focus on relaxing?
Chana Ross (24:10.547)
So we take a biopsychosocial approach, which means your biology, your muscles, interact with your psychology, where your head is at, and all the social determinants of health. So just sending somebody home with like, relax your pelvic floor, and then every time their kid cries, they're like, their whole system goes up, their nervous system revs up, is doing them a disservice because it's a bandaid solution. The question is, why are we clenching our pelvic floor all the time, not what is our pelvic floor doing? And so if we're...
persistently clenching because we hate our job, we're stressed all the time, what this tells me is that the nervous system needs capacity. And so not only do we have to train, we can train the pelvic floor to go through that range of motion, but if your nervous system is a cup that is full all the time and any extra drips into it is gonna make it spill over, I'm doing you a huge disservice by not addressing you as a human being and what your nervous system can do. So.
I talk about the nervous system more often than my clients would like. But, um, you know, we teach diaphragmatic breathing. The diaphragmatic breathing has value, not just for lengthening pelvic floor, not just for, um, getting into that, um, autonomic nervous system, not just for actually massaging the abdomen and helping the digestion, but it actually is the, it's the only, it's
actually is probably the only time that many of our clients actually stop. And I think that the biggest thing that I, uh, do we swear on this podcast? Okay. So the thing that I, the refrain that I say all the time is slow the fuck down. We cannot focus on our, on our pelvic health without focusing on our overall health. And if we're just, if we just keep trying to keep going, and then do a couple of breaths and go, go.
What we're doing is we're bypassing this entire area. There's the biggest piece of pelvic health that I think it's missed is like the being, the learning, the noticing. Like the reason why our pelvic floor is in that persistent state is because we've just clenched and kept pushing through. And at a certain point, the thing that has gotten us to here is not the thing that's gonna get us to there. And so we really need to spend some time being in our bodies and...
Chana Ross (26:36.867)
noticing those bladder signals, starting to pay attention to what is my pelvic floor doing? It was clenched and I had no idea. It was probably because I've just patterned that out of my brain. So building that area of our brain, that homunculus, where our brain can actually connect to those muscles so that we know what's happening, requires a slowing down process, but it's not just about doing reverse keels, moving on with your day. It's about being with your body.
Kim (27:05.934)
Yeah, I love that. So you've touched on a few things through that description that could potentially be contributors to that, I feel like you have to go to the bathroom. So let's talk first about the, before we get to why we leak, let's say why do we have the sensation of needing to go? And you talked earlier in the introduction, is it so, tell me about that. Do you just have to go or do you have to race because you're gonna...
you feel like it's gonna, you know, just unleash. So what are some of the reasons why our bladder signals us? And what would be some of the reasons why it would signal more strongly, maybe at certain times of the day or always, versus just a normal, I, you should maybe find a bathroom soon.
Chana Ross (27:56.979)
So our bladder is a muscle and it works together as equal and opposite job to the pelvic floor. So the pelvic floor has two different kinds of muscles in it, conscious and unconscious muscles. And so we're not really aware when the muscles around our urethra where our pee comes out of are just there clenched throughout the day while our bladder is filling. And in an ideal functioning situation, the bladder reaches its fill line, sends a signal to the brain that's like,
I'm done, I'm ready. And the brain sends a signal to the pelvic floor, okay, looks around, are we somewhere, i.e. on a toilet where it makes sense for us to go. And if not, in a really well-functioning system, then the pelvic floor, the muscles that we have conscious control over would kegel, quote unquote, which would relax the bladder until we're ready to go to the bathroom. We sit down on the toilet, the pelvic floor muscles would relax and that's.
bladder would turn on, would contract and squeeze, because of the muscle, and P, release all that out, all that urine. The kidneys are actually constantly producing urine. So that bladder is always going to be filling. So a lot of my frequent flyers, like they could just go to the bathroom all the time, and there will always be something there to release. Where this whole system gets impacted can happen at any single point.
in this relationship. So many of our clients have started just in casing. So they are, you know, it's kind of like how we teach our kids to pee, which is, question it, but like, that like, okay, we're going to go on a long road trip. So just go pee just in case. So now your bladder was really only full, but you've gone to pee and your brain goes, oh, is that where I'm supposed to tell you that you're, that it's full? So then you start to send that signal when your bladders.
Huffle and then maybe a little bit less next time. And then you're like, oh, I call this like Costco syndrome. Like, I have four kids, so I shop a lot at Costco. Okay, Kim? So, you know, I used to be like, okay, I gotta go to Costco. I'm gonna go pee before I go. And then I'd be getting ready and like, where are my keys? Spend some five minutes looking for my keys. Okay, I just looked at my keys. I'm just gonna pee one more time just in case. Okay, oh, where's my phone? Okay, I spent five minutes looking for my phone. I'm gonna pee just in case because I never wanted to be with a full Costco cart.
Chana Ross (30:22.427)
stuck in the middle of the store and being like, oh God, I have to pee now. So I would always just go just in case, just in case, just in case. And I really believed firmly that I had a small bladder. And I see lots of people who have quote unquote small bladders and yet we get them from peeing 20 times in a day to really peeing that six to eight times, which ideally is sort of where we want you to be. And they, if you're
training your bladder to send that signal earlier and earlier and earlier, it will do that. It will just let you know earlier that you have to pee. So that's one spot. Another place is if those pelvic floor muscles are in that persistent contracted state, if they're not, if your conscious pelvic floor muscles, if you can't clench to tell your bladder, no, I'm not ready, you're going to leak whether you're at the bathroom or not.
Chana Ross (31:20.811)
When we're in that revved up response, we know that like, that pain, many of us experience pain at any point in time, is an output of the brain. It's a signal of real or potential danger. We know that when the nervous system's upregulated, we also tend to experience more urgency. And urgency is that like, I got to go right now. And many people will have no urgency throughout the day, and then they'll have specific triggers when they get to the door to turn the key to get into the house.
when they turn on the shower and they hear the shower running, when they're walking in before they get to the door, when they have full, like their arms are full with groceries and kids. And that's when their nervous system is like all the way rolled up and that is an output of the brain that is not a response of the bladder, but it feels like you have to pee really, really badly. There's a whole bunch more different pieces
But I think like what we really need to focus on that there's a cognitive behavioral piece to it. There's a muscular component and an anatomical component, and there's also a nervous system component that is always involved.
Kim (32:34.59)
Mm-hmm. Before I go on to the next question, I just want to ask one thing based on what you said. There are so many people that say, oh, I just have a small bladder. Or they might say, yeah.
Chana Ross (32:43.955)
Yeah, yeah, I really deeply believe that too. I really believe that I really did. And I have yet to meet somebody that we have not frequency like the need to pee more than that six to eight times a day and urgency, which is like that zero to 100 whether it comes with leaking or not are my favorite things to treat because we can get such amazing results so quickly.
Kim (32:49.494)
Yeah, is that true? When people have a quote unquote small bladder.
Chana Ross (33:12.163)
And it really like that, that belief and that trust in yourself and in your body is so profound, so quickly. I have yet to meet somebody who comes in believing they have a small bladder, who I say, I'm really sorry, I can't help you. You have a small bladder.
Kim (33:27.19)
Yeah, yeah. And then from a sleeping perspective, there's also many people who are going frequently in the day, which then means usually those people are also waking frequently to pee in the, and then they're not sleeping well and lack of sleep can also interfere with optimal functioning, right? So how would you, if somebody says, you know, I don't leak through the day, yes, I go to the bathroom very frequently, I'm up four or five times a night, what would you say to that person?
Chana Ross (33:44.871)
or everything. Totally.
Chana Ross (33:57.703)
So after the age of 50, peeing one time a night is considered reasonable. Up until that point, you should be able to sleep through the night. Also after 50, you should be able to sleep through the night. But like we don't sound the alarm, I would say, if you're leaking past the age of 50. But sorry, whoo, leaking is never an alarm. Waking was the word I was looking for. What I often like to tell my clients is like, pay attention to that first pee of the day.
Kim (34:17.462)
Waking, yeah.
Chana Ross (34:28.379)
that first pee of the day is usually the longest. And that's gonna give you an indication of what your bladder capacity actually is. And even throughout the day and throughout the night, if you're peeing less than that, that is an indication that there's probably some cognitive behavioral stuff going. There's probably just some, I've just gotten used to doing this. And so therefore a lot of people who wake up due to other reasons.
go to pee because they think that's the reason, instead of trying to just fall back asleep. The ability to just try to fall back asleep without going to pee feels uncomfortable because of that lack of trust with their bladder. So usually we train during the day first, and then they have the trust to be able to practice it at night. But you should be able to sleep through the night.
And then there's a whole pair of menopause and menopausal hormonal piece that goes on top of that we can work on. But we need people sleeping. That's when healing happens. That's when tissue repair happens. Sleep is probably one of the primary things we need to work on before we even address anything.
Kim (35:28.066)
Yeah.
Kim (35:43.402)
Right, yeah. Yeah, can you expand on that? So why would, and I always ask that question too, how is your sleep? And if your sleep is not well, part of the reason may be because you're waking, but there could be other reasons, hot flashes, if we're talking to the perimenopause population, could be a snoring partner, it could be stress, it could be blood sugar. There's so many reasons why somebody could be waking up, but if they're not sleeping well, why does that contribute to an exacerbation of symptoms for some people?
Chana Ross (35:54.191)
Yeah.
Chana Ross (36:10.683)
because your nervous system gets upregulated. Like if you're tired, everything is worse. Like if you stub your toe after a full night's sleep, you're like, oh, I hate when that happens. You stub your toe after you haven't slept the whole day, it's like, oh my God, like everything is a bigger deal. Pain is worse when you haven't slept. Symptoms are worse when you haven't slept. So we really, really in order, and like the truth is your bed width is less when you haven't slept. So your willingness to try something different is less if you haven't slept.
So if I'm telling you that we're gonna like do some bladder retraining and I need you to wait five minutes when you have symptoms that you have, like you feel like you have to go pee, your patience with trying something new is going to be less if you're not sleeping at night.
Kim (36:55.178)
Yeah. And so you mentioned bladder training. So that's kind of leading me down the next path. So part of, I know you're perfect. Perfect, perfect segues. When somebody is, so somebody could be leaking and they could have those very strong urges. And sometimes the leaking could happen in conjunction with this strong urge or they could leak during exercise and then later they have strong. So they could have mixed, which is typically called mixed incontinence.
Chana Ross (37:00.559)
I'm just pulling you along, Kim. Here we go. Ha ha ha.
Kim (37:25.198)
Part of that is, as you said, it's the muscle training. You're going to have the cognitive component there as well, which is kind of the retraining, the bladder training piece of it. What does bladder training look like? It's kind of like, if you think we've, many people who we work with are mothers who potty trained, and it seems odd that we now have to go through our own potty training again, right?
Chana Ross (37:47.251)
Mm-hmm. Yeah, yeah. So what I'll say is like the majority of the pieces that help support leaking are not necessarily internal pelvic health things like we run a we run a course through survival as well. It's totally virtual. It's six weeks and most people's leaking improves without ever having an internal pelvic health assessment. So there's a lot of just basic bladder health
pieces that none of us have ever learned that I think that every person needs to know. So, blood array training really just one of the very basic ways of approaching it is looking at when the last time you peed was and if our goal is ideally to be peeing every one to two hours, if you're feeling the urge, first of all, I really encourage people to keep track of how much they're peeing because
as you start to try to change things, try to work on them, if you're somebody who's peeing 25 times a day and you start to put in this work and you're peeing 22 times a day, that is improvement, but it still feels exactly the same way as 22 times a day. It's still a lot, right? And so I think keeping things objective when you're doing this kind of work is really important so that you can actually celebrate each of your wins. We've been really, really trained to only celebrate when things are perfect.
But as you're making these improvements, celebrate every single step because it helps you start to build that trust, build that trust with self and acknowledge that the work that you're doing is really valuable. But ideally, if you've been peeing less more frequently than every one to two hours, for example, I have clients like they have meetings and in between every single one hour meeting they're going to pee. They shouldn't really have to go pee it, but they could get up and walk around.
Um, we have, we had our clients when they feel that urge to pee, just wait five minutes. That's it. If I minutes distract themselves, sometimes they can like, you know, use, they can do an email, they can use a physical distraction. Uh, we have different like nerve things they can do, like quad raise, um, calf raises, things like that. But simply just saying, I trust myself and walk getting used to walking.
Chana Ross (40:12.919)
slowly and calmly to the washroom, regardless of how long it's been. And positive self-talk, I've got this, I've got this, I've got this, we've got this, on the way to the washroom. It sounds super simple, it's massively game-changing. Not waiting, not trying to hold it out and wait for two hours. Even if you feel it, 45 minutes, you have to pee again. Like just start slow, like one step at a time.
actually snowballs really quickly.
Kim (40:45.526)
Yeah, I've been told that it's like a window of about two and a half to four hours would be considered normal voiding throughout the day. Is that what you would agree with?
Chana Ross (40:56.207)
Yeah, like I, you know, we do, I do see clients, like I've surgeons who are my clients and like they're not peeing for eight hours. Like that's the problem on the opposite end. If somebody's not peeing for hours, like I would start to look at like, are you dehydrated? Dehydration is a huge cause of incontinence as well. If your urine is really, really acidic, it irritates the bladder and we can often have leaking because of that as well. And it also causes constipation, which is, I know we're gonna.
We were talking about poo also today, but like, you know, we want to make sure that we're moving our bowels regularly as well. Like in that pelvic cavity, there's only so much room. Um, so if somebody is going four hours, if they're symptom free, I'd be like, great. But if they're having symptoms, my spidey sin starts to go off and say like, how much water are you actually drinking right now? Um, are you dehydrated?
Kim (41:50.762)
Okay, so you've segued into poop. When we think about this, when we think about fecal or anal incontinence, it can be gas or stool that we could have the same things. We could have urges, like very strong overwhelming urges. We could also have leakage. So we can't control our gas or stool. So similar, except what's coming out is different. Is it the same with regards to...
Chana Ross (41:53.821)
Yeah.
Kim (42:18.05)
contributing factors. So everything we've talked about from a biopsychosocial approach from a urinary perspective, would it be, would the same things apply to the anal incontinence as well?
Chana Ross (42:29.319)
So it's interesting. So bladder, so it's a yes and yes, we're still gonna look at behavior, at nervous system, at the muscles. The digestive system starts at your mouth and it ends in your anus. We're gonna start to look a little bit more specifically at your food, your fiber, your water intake when it comes to digestion and constipation. I speak to constipation specifically because
very often if we're leaking like wet stool, it's often because there's a bolus of stool that's stuck or because you've got something going on in your digestive system and your intestines are irritated and you're producing diarrhea specifically. And so we are going to look a little bit more specifically at those pieces, but very, very often in both our clients with both
urea incontinence, we tend to see overactivity of the posterior pelvic floor. So a clenching of the external anal sphincter and the parts of the pelvic floor that are closer towards your rectum and to your coccyx and behind. And that's often because of positioning. People who sit in a tucked under position tend to have a really, really tight pelvic floor, often in the back piece part.
It's also because a lot of us just grew up thinking never fart in front of people. We really, really clenched rectally for that's how a lot of us grew up. So we've just trained that system to be clenched there. But it's also if somebody, when we see somebody postpartum, they also tend to be clenched posteriorly as well because they just spent so much time thinking about their vagina, thinking about their urethra.
we often neglect that whole second half of the pelvic floor. And so learning how to relax, literally the door for your stool to come out is really, really important piece. And not just, it's not just about the food and the water, it's also about allowing that stool to fully evacuate. And so, you know, we've got a bunch of like really fun things that we can use, like the squatty potty. I highly recommend everybody go watch their video. It's really great, but like positionally.
Chana Ross (44:59.127)
Learning how proper positions for evacuation is really, really important. Learning to not bear down, just try to push out your stool, which is like a little mini micro birth every time you go to the bathroom. And that negatively impacts the pelvic floor as well. We really talk a lot about movement when we're talking about fecal incontinence and war constipation. Because...
part of helping your digestive system. We need movement every single day. Doesn't have to be exercise per se, but gentle movement. And like different than the bladder when it comes to moving your bowels, we've often, a lot of people are really nervous about going to poo in public. And so what they've done is they started to neglect that sensation that they have to go to the bathroom.
Kim (45:49.028)
Mm-hmm.
Chana Ross (45:55.015)
Whereas when we pee, when they have frequency or urgency, they're paying attention to every single signal. We've actually down-regulated our ability to pay attention to the signals that we have to move our bowels. So starting to learn, pay attention to that urge and that call to stool becomes really, really important. And that, not surprisingly, requires slowing down.
Kim (46:17.962)
Mm-hmm, slow the fuck down. Yeah, let's make a shirt. Just before we wrap up, I'm kind of running over time here, but if I can ask one more question with regards to scar tissue, because I know that can be, is very commonly associated with some of these, some of the symptoms that somebody may have, or some of the, maybe they're being hindered in their capacity to control the openings. So.
Chana Ross (46:19.907)
Yeah, amen.
Chana Ross (46:44.211)
Hmm.
Kim (46:45.442)
How would you handle somebody who came in with scar tissue, maybe from a surgery or maybe from a vaginal childbirth, and that could even be a caesarean scar as well?
Chana Ross (46:53.615)
Yeah, I think like scar tissue is like, gets a really bad rap. I actually got a question today or someone was told by their doctor, well, you have scar tissue, that's why this is happening. And I just left it at that as a scar tissue is something that's negative. Scar tissue is really great. Like it's our body's glue. It's the job of the scar tissue to connect the two sides that were separated either due to surgery, due to tearing, but it's also the job of that scar tissue to connect the two sides.
but not connect to the tissue below it or the tissue below that or the tissue below that. And so when I think about scar tissue, I think about two things. Number one is we don't want it to be adhesed down to other layers of tissue, so making sure that it's mobile, but then also training it to function like the tissue that it's supposed to function like. So making sure that scar tissue is functional is really, really important. But I do want to mention one more thing
Chana Ross (47:51.175)
some trauma associated with that scar tissue. And so even like C-sections that were unplanned or tearing, vaginal tearing during birth or any other surgery that was, that person associates with something negative. In and around scars, like sometimes we just start to like ignore that area. So for a lot of our clients with abdominal rehab, but when they're leaking and they've got scar tissue,
One of the first things that is really, really important is actually like looking into a mirror and like mapping safety around those areas. Like really acknowledging that I'm safe, but there's, there isn't any danger anymore in those, in that, um, along that scar because you cannot train an area that your brain doesn't want to acknowledge exists.
Kim (48:39.662)
Yeah, that is so helpful. Where can people find you potentially to come and receive a treatment from you if they were in Toronto, but also learning about the courses that you have?
Chana Ross (48:50.579)
So they can go to vitalphysiotherapy.com. We are on Instagram at Vital Physiotherapy and Wellness. So you can find me at KhanarasPT, that's a C-H-A-N-A-R-O-S-S-P-T. I love telling people about all things pelvic health. On our Vital Instagram, we also have a bunch of videos that are there for free. And I would love to hear from you.
Kim (49:20.906)
and you also have a podcast as well.
Chana Ross (49:22.627)
I do. That's true. It's called She Has the Audacity. Thanks for reminding me. And Kim was on it.
Kim (49:28.494)
I'll have the links to everything. Yeah, thank you so much for sharing your wisdom. And again, thank you for making the choice to not leave physio and actually go deeper. And I guess that sounds a little bit odd, but.
Chana Ross (49:28.595)
Because she does have the audacity.
Chana Ross (49:42.888)
I'm both intended and not intended.
Kim (49:44.47)
Intended but not intended. Yes, but helping so many women and explaining it in such a beautiful way that really helps Solidify that this is not just about go home and do your Kegels and everything's gonna be fine. It's a it's a whole body mind body spirit Thing and getting to more optimal wellness involves all those layers and you described it so beautifully. So thank you so much
Chana Ross (50:08.467)
Thank you for having me and thank you for being such a big part of my personal um, physiotherapy experience and learning.
Kim (50:16.01)
Yeah, likewise.
