Erections, Orgasms & More! Advice from a Pelvic Floor Specialist

Got sexual and pelvic health questions? We’ve got answers! Dr. Rachel Gelman, Doctor of Physical Therapy and pelvic floor specialist returns to answer your questions related to sex, pleasure and pelvic floor functioning including:

• What is bumper sex?
• What can I do about leaking when I laugh?
• How do bowel movements affect pelvic floor function and sexual response?
• Why is anal pleasure so much hotter after my second child?
• What causes painful erections and how do you treat them?
• How do you promote stronger erections — for penises & clitorises?
• How does sitting at your desk all day affect sexual functioning?
• Why does oral feel so good after childbirth?
• How can changing the way you breathe promote pelvic floor function?

Learn more about Dr. Rachel Gelman at www.pelvicwellpt.com and follow her on social:
IG: @pelvichealthsf
twitter: @rachelgdpt
FB: @pelvicwellpt

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Rough Transcript:

This is a computer-generated rough transcript, so please excuse any typos. This podcast is an informational conversation and is not a substitute for medical, health or other professional advice, diagnosis or treatment. Always seek the services of an appropriate professional should you have individual questions or concerns.

Episode 210: Erections, Orgasms & More! Advice from a Pelvic Floor Specialist

 (00:02):

You're listening to the Sex with Dr. Jess podcast. Sex and relationship advice you can use tonight.

Brandon (00:10):

Welcome to the Sex With Dr. Jess podcast I'm your co host Brandon Ware here with my lovely other half Dr. Jess.

Dr. Jess (00:17):

Hey hey.

Brandon (00:18):

Hey, how’re you doing?

Dr. Jess (00:20):

Good good. Today we’re talking about some hot topics. We're talking stronger erections, oral sex, anal sex, and how it changes after childbirth. I don't know about that. But I want to hear about that. Leaking when you laugh. Do you leak when you laugh?

Brandon (00:33):

I do not leak when I laugh.

Dr. Jess (00:36):

Do you laugh?

Brandon (00:37):

I mean I'm hilarious, so I laugh all the time.

Dr. Jess (00:39):

You laugh at your own jokes.

Brandon (00:40):

I do. You know I woke up last night laughing to a dream.

Dr. Jess (00:44):

Do you not remember that I actually thought you were crying? So I was like, “baby it's okay” and you're like laughing.

Brandon (00:50):

I was laughing for real. I woke up. It was something, somebody farted in my dream. And I thought it was funny.

Dr. Jess (00:54):

Is that true?

Brandon (00:55):

Yeah that's the truth. I don't know who farted. But it was real funny. That's all it takes. That's all it takes to make me laugh. So if you ever see me chuckling, I'm probably thinking of somebody farting okay?

Dr. Jess (01:05):

So you don't leak when you laugh but you laugh in your sleep when someone farts?

Brandon (01:09):

Yes.

Dr. Jess (01:10):

Well that's funny because we're also going to be talking about bowel movements and constipation. We're going to be talking about bumper sex, the pussy pocket.

Brandon (01:19):

I'm thinking of bumper cars now.

Dr. Jess (01:21):

I just pictured people walking around with erections bumping each other.

Brandon (01:25):

I feel like that could be so painful so quickly.

Dr. Jess (01:27):

That's probably why it's so funny to me.

Brandon (01:30):

Maybe to you yeah.

Dr. Jess (01:31):

All right we're going to be chatting all these things with Dr. Rachel Gelman, a doctor of physical therapy and a pelvic floor specialist. And she's actually been on the program before long, long, ago when we first started and I learned so much chatting with her. So I'm really excited for this conversation. Now before we kick things off I want to shout out our new sponsor http://www.adamandeve.com. They are offering our community fifty percent off one item, plus a slew of free gifts, including free shipping with code DRJESS this month. So if you're in the market for anything erotically related, whether it's dildos, vibes, penis rings, lube, fetish wear, sex swings, I think they sell sex swings, you name it, head over to http://www.adamandeve.com and please use code DRJESS to save.

Brandon (02:18):

Hold on though, before we move forward, going back to that new sponsor you said “a whole slew of things.” Isn't that a Canadian term?

Dr. Jess (02:25):

No, I don't think so. “Whack” is Canadian. Yeah.

Brandon (02:31):

So don’t worry, American listeners. You get a whole slew of Adam And Eve products.

Dr. Jess (02:36):

And for Canadian listeners, you can get a whole whack. I only learned that whack was a Canadian, because in one of my books an editor flagged it and was like, “I don't know what this means.” I don't know why they didn’t just Google it right? I mean I see American spelling all the time, and American words, I pick up on it. Anyhow. we have so many questions to get to today about everything from, Oh we're going to talk about penis pain.

Brandon (03:04):

Great, amazing. Leaking and penis pain and bumper sex all in one episode.

Dr. Jess (03:09):

We're going to relieve penis pain, not create penis pain. We're also gonna talk about vulval massage. I think I'm gonna share something about my own stuff to work on. So let's dive right in with our guest. Welcome Dr. Rachel Gelman. Thank you so much for being here today.

Dr. Rachel Gelman (03:25):

Thanks so much for having me. I'm excited to be back.

Dr. Jess (03:28):

Now pelvic floor therapists, pelvic floor specialists are probably among our favourite people to talk to and learn from. Brandon, you learned so much from pelvic floor therapists.

Brandon (03:39):

I definitely have. And I am looking forward to post pandemic visiting a pelvic floor therapist because it wasn't something that was on my list but it has since become something that I'm looking forward to trying.

Dr. Jess (03:53):

Now Dr. Rachel does treat many people with penises. What's the split for you and your office, in terms of vaginas versus penises?

Dr. Rachel Gelman (04:02):

I do. I’d say it’s usually fifty-fifty. Honestly I think right now might be more penises than vaginas. At the moment, I feel like I have a pretty big population of people with penises that I treat, so it's usually about fifty-fifty.

Dr. Jess (04:21):

Interesting. Now, we’re going to be speaking about sex after kids. I know this is another area of specialty for you. But since we're on the penis topic, and you know I get stuck on a penis. What are some of the common challenges you're seeing lately, anything that might surprise us for your penis patients.

Dr. Rachel Gelman (04:37):

I see right now, a lot of people with penises coming in that have pain with erections, pain with ejaculation, urinary, urgency, frequency, almost similar to feeling like, they never say it feels like a UTI, but usually they are concerned they have an STI or STD. What they report is that they've had multiple STD tests and they've all come back negative, so those are the ones the big ones.

I definitely see a lot of people have pain with sitting right now in the pandemic, because everyone's working from home which you know, they’re sitting a lot more, even more so than when they were in office. But those are kind of the big ones right now. And I kind of think through who I am seeing, pain with sexual function and urinary dysfunction are the big ones.

Dr. Jess (05:28):

And so pain with erection, what might that be related to?

Dr. Rachel Gelman (05:32):

It can be related to lot of different things. Same thing for people who have a vagina. But what I'm working on are the pelvic floor muscles, so just like a person with a vagina, people with a penis, have the same muscular bowl inside of their pelvis that support their pelvic organs. And then there are muscles that attach at the base of the penis that help obtain and maintain an erection. And so if those muscles have become dysfunctional, they’re in spasm, they’re guarded, they’re tensing up. If they're trying to have an erection, those muscles have to be able to relax and then contract to maintain the erection. So if there's any dysfunction in that, in those muscles, it can become painful. It can also irritate nerves that pass through those muscles that then go to the penis. So there's several different things that could be going on, but those kind of things that I'm thinking about as a physical therapist.

Dr. Jess (06:23):

And then what are some of the treatment options, knowing it obviously depends on the diagnosis. But what type of treatments are available?

Dr. Rachel Gelman (06:30):

So as a physical therapist, I’d be treating obviously the muscles, the connective tissue, the soft tissue all around the pelvis. So I work on the muscles in the legs, the abdomen, the back, the hips, the glutes. Because all of those can relate to what's going on at the pelvic floor. And then I'd also be working on the pelvic floor muscles, obviously if the patient consents to it, I'd be working on those muscles internally through the rectum. That's the only way I can access those muscles directly. And so working on those muscles, doing things like soft tissue mobilization connect myofascial release, also just working on re-educating the muscles, because if they don't know how to relax, that's going to limit erections and can cause pain with erections. We'll work on trying to teach the muscles to relax, how to move through their proper range of motion. But depending if I don't find a lot that I personally work on, than I would refer someone to a urologist, so there might be medical management that's involved. Working with a sex therapist can sometimes be beneficial, acupuncture. There's all sorts of different treatment modalities that might be beneficial. So just really would depend on the person.

Dr. Jess (07:43):

And what about pain post orgasm? So some people have what they would call “regular sexual functioning." They get turned on, they get an erection, they orgasm, maybe ejaculate. But then, and this is for people with penises, and people with vaginas, and then they have pain after the orgasms. The whole experience is super pleasurable, but they can become fearful because they know they're going to experience, or they worry that they're going to experience pain post orgasm. How does orgasm, and/or ejaculation potentially lead to pain?

Dr. Rachel Gelman (08:15):

Yeah that's a good question, and very common. So the pelvic floor muscles will relax to allow blood flow to get in, to allow for an erection, either a clitoral or a penile erection, and the muscles contract to maintain that erection. And then when orgasm happens those muscles contract and relax in repetition. And so again, if those muscles are dysfunctional all of that movement of that repetitive contract/relax/contract/relax can really irritate the muscles that are already in, for lack of a better word, “unhappy place”. And so they're getting all this activity, they are already kind of cranky, and that kind of makes them even more unhappy. Again, if a nerve that's traveling through those muscles is already irritated, and there's all that movement around it, that can lead to pain. So there's several different reasons why a person could experience pain after orgasm, and you kind of spoke to the, a feedback loop that can start. Then they're afraid to have an orgasm because they're afraid it's going to be painful, and rightly so. And that leads to more guarding in preparation for what they expect to be painful. And that kind of teaches the brain that this is a painful situation and that the brain tells the muscles to contract to prevent something bad from happening. And you got this whole feedback loop of contracting leading to more pain, leading to more tensing up, and it becomes kind of a vicious cycle.

Dr. Jess (09:38):

That makes sense to me. Now, you mentioned erections for the clitoris and the penis, and oftentimes we talk about how to have better erections. But we're almost always talking about the penis. So in terms of circulation in the pelvic region for the clitoris, what can we do in our in our lifestyle, whether I don't know, is it diet, is it stress, is it exercises? What can we do to facilitate clitoral erections?

Dr. Rachel Gelman (10:06):

Yeah so one, just exercise in general. So it doesn't have to be anything specific to the pelvis. I mean people always talk about kegels. I have very strong opinions about how kegels are over prescribed, because really any movement is going to engage the pelvic floor muscles, because these muscles are supporting the pelvic organs. They are providing overall core stability. So just doing any type of low impact cardio walking, jogging, swimming. Anything that gets the heart rate up is going to increase blood flow everywhere including the pelvis and the clitoris. So that's that's the first thing I talked to people about is making sure they have some sort of exercise routine. It doesn't need to be over the top, which I feel like our society and culture is all about trying to make everything as intense and strenuous as possible. It doesn’t need to be the most intense strenuous exercise, it can just be like I said, a really nice twenty-thirty minute brisk walk. And that will again, get the heart rate up, increase circulation, which is what helps with erections, including clitoral erections. Another thing that I am a big fan of is just masturbation and stimulating that area. Engaging in self pleasure and stimulation is a great way to increase blood flow to the clitoris in the genitals.

Brandon (11:30):

You mentioned at the beginning, the idea that there are things that we're doing now that we didn't do before. Zoom meetings, and sitting all the time. I'm finding myself sitting down way more often. And I also wouldn't think about coming to see a pelvic floor therapists had it not been as a result of meeting all these pelvic floor therapists and talking about the benefits of it. What are we doing now, that’s making us more like tighter in that region, or reasons that you're seeing people more? Is it a result simply of sitting? And also very much appreciate that you talked about just any form of physical activity being beneficial. Because I think there has really been for, at least for me, a real focus on every time I'm being physically active, I'm working out, it’s “go harder, go stronger.” So it's good to hear that just anything is beneficial. So what is it, that I'm thinking about myself, what am I doing now, that is causing more people to see people like you?

Dr. Rachel Gelman (12:29):

So definitely, sitting. And people are often, seeing that I’m in San Francisco, most of my patients are working in tech or silicon valley, so they were taking the bus down to Google and Facebook and sitting. You know, a lot. And so, I'd always bring that up to them and they would kind of get it, but back before the pandemic, people at least would leave work for a few hours to go do their ironman gym class or whatever. And so they are definitely getting up, walking from their desk to go to a meeting. So there's definitely a lot more sitting now, and just that amount of pressure on the pelvis is just not very healthy. And we're just not designed as human beings to sit, especially sit for the amount of time that we do. Sitting is definitely a big one. But also it's a very uncertain time, very stressful, and stress and anxiety are definitely big causes of pain in general, but especially pelvic pain and pelvic floor dysfunction. So people are just feeling a lot of pressure and stress during these very difficult times, and add that with being inside more, we’re not getting a lot of sunshine, we’re lacking Vitamin D, we’re sitting. We’re not being able to see people. There's just so many factors that are going to play into the body getting a lot of stress, and the body doesn’t know where to put that, so it gives us a pain signal or makes us feel like we have to pee all the time, it comes out and in a lot of different ways. Some people are getting headaches or neck pain, and so it definitely is just the state of the world right now, that I feel like is definitely to blame.

Dr. Jess (14:13):

So if sitting is bad for us, and can actually affect our sexual functioning, do you suggest people get up and just move around every thirty minutes, set set an alarm or something like that. just to stand up?

Dr. Rachel Gelman (14:24):

Yup. Yeah, I'm definitely a big fan of the sit to stand desks, if people can get those for their home office. But yeah I am always on people to try to set an alarm and get up at least. If someone can limit their sitting to two hours, that’s my max that I usually suggest. But if they can get up every hour, that'd be amazing. If they can even get up and maybe walk outside for a little bit, because again I think getting actual sunshine and fresh air is really beneficial just for people in general. But if they can get up just move around. I also tend to tell people if they can just be drinking water throughout the day, because they're going to probably have to pee at some point and that's going to force them to get up. So those are definitely suggestions that I give patients.

Dr. Jess (15:16):

Well Brandon has been taking all of his phone meetings outside, like he just goes for a walk, I call it around the block, it's not really a block. It's around the park near our house. And I think that movement, it's interesting we think of it as obviously good for our mental health and physical health, but it's all tied in to our sexual health. So you know, when people have low desire or difficulties with arousal or difficulties with orgasm or trouble getting in the mood, oftentimes they think, “oh if I use a toy, if there's a magic pill" but it really is tied to our lifestyle. And I can tell you know, since the onset of the pandemic my desire for sex has really gone up and down and, I think that I can see that it's in line with my movement, because in my previous life I was always walking every day, in the airport, dragging my suitcase, getting exercise. And I don't have that anymore. So I I'm sure you're hearing you know, speaking of low desire, from so many parents who have lost desire for sex or dealing with sexual issues post childbirth or after having kids. So I did want to ask you about that because I have a number of questions from listeners. We put it out on instagram. So if you're open to that, I’d love to ask you a few questions?

Dr. Rachel Gelman (16:29):

No of course.

Dr. Jess (16:31):

Okay great. So this person says, “Since baby, I prefer oral to anything else, like toys and penetration. Nothing is painful. It's just my preference. Why might this have changed post baby?

Dr. Rachel Gelman (16:46):

Yeah that's a great question. I mean there, I want to ask this person a lot more follow up questions. And first, things can just change. Preferences can change in general. So it's possible that this was just something that's changed for them. And it doesn't necessarily have anything to do with having a baby, because throughout our life our preferences, including our sexual preferences, do change. But if we're thinking in terms of postpartum, you know there could be just the fact that there is a lot of blood flow to the clitoris and the pelvis, as a result of having a baby, and as a result there just might be more sensation in the area. And they're just finding that more pleasurable. So the fact that there's no pain is great, but they might just be having increased sensation in the area now, and that is proving to be more pleasurable for them. I'd also be curious if they're having negative thoughts towards their vagina. Maybe not like consciously, but because they just had a baby perhaps you know, they're thinking like “oh that's where the baby came out of” and they're trying to avoid that area, and finding that just staying with more external or oral stimulation is more pleasurable. But again, I definitely would wanna ask a few more follow up questions, but those are the first things that came to mind when I heard this question.

Dr. Jess (18:19):

Yeah and I think that's great. I mean if oral is working for you go ahead and do it. I was also wondering if you know with children you have less time on your hands and oral may just be a more direct route to orgasm. And I mean folks with vaginas are more likely to have orgasms consistently from things like oral and manual and toys anyway, but we've made penetrative kind of our standard. So, I wonder if there's also you know perhaps an awakening or the capacity to say what you like even more? So I think if something feels good, go ahead and do it. And we don’t, it's nice to explore explanations, but we don't always have to have an explanation right? However, this next person has a sort of similar question but down a different road about anal sex. So this person says, “anal sex used to be a special occasion chore.” That doesn't sound so fun. “But now, I get more out of it after my second child and I seem to crave it. Why might this be?” So we see this pattern of people wanting to understand, which is perfectly fine. So thank you for asking.

Dr. Rachel Gelman (19:30):

Yeah no, I mean the first reaction was like, “Oh like that's great, enjoy.” And it's interesting that we are definitely curious creatures and we always want to know why instead of just may be saying, “Oh this is great. I'm just gonna enjoy this” and have that be it. But I'm happy to explore and question the why with them. But the first thing again, is just maybe that you know it's something they did before, so it's not something new and maybe it's just become something they now enjoy more, and that's just you know things change and it's hard to know why things change. And if it's attached having a baby you know, it might or might not be, but again it could be just after having a baby there can be a change in lubrication at the vaginal opening. So it could just be again something to do with what vaginal sex feels like now compared to what anal penetration feels like. I'd be curious what their pelvic muscles were feeling like. If there's been a change in muscle tone, and that now the the anal canal feels you know, better. There's more sensation there, compared to what they're feeling vaginally. So I definitely would have a lot more follow up questions, versus being able to give a straightforward answer. But again I think it just goes back to, I think they should just enjoy what feels good.

Dr. Jess (21:02):

I love it. I love it. Now on the flip side, this isn't something that feels good. This person asks about leaking. So they say, “I'm leaking whenever I laugh, but also when I stand up quickly or do anything that involves jumping like jumping jacks.” And they said they don't have access to insurance or physio, so they're wondering if there's anything they can do at home to help themselves with, I guess leaking our continents.

Dr. Rachel Gelman (21:30):

Yes definitely. So the first thing, I always think when I hear any type of urinary dysfunction, whether it's peeing too often or leaking, is work on having better bowel movements. Constipation plays a huge role in pelvic health, especially urinary function. So the thing I always wanted to make sure is that people are having good healthy bowel movements, that they're drinking enough water, and that when they're going to have a bowel movement that they're not pushing, they're not straining, so really trying to make sure they're being mindful about that. And they can get something like The Squatty Potty or putting a little step stool under their feet. So that way they're in the proper position to have a bowel movement that doesn't involve pushing or straining. So that's the first thing I always think off the bat of a not necessarily simple solution, but something to start doing, that is indirectly involved with leaking.

Dr. Jess (22:26):

What is the squatty potty, can you explain what it is to us?

Dr. Rachel Gelman (22:29):

It’s basically a little step stool that fits around the base of the toilet. And you pull it out when you need to use it, you put your feet up on it and when your feet are on the steps stool it basically put your knees above your hips, so you're in a squat like position. So as human beings, we’re not meant to sit on a toilet to have a bowel movement, we’re meant to squat. That's how we’re meant to defecate. And so we're more in a squat like position that helps facilitate relaxation of the pelvic floor, specifically the puborectalis muscle, which wraps around the colon, the rectum kind of like a slingshot. So when we squat, that muscle naturally relaxes, and it's easier to have a bowel movement.

Dr. Jess (23:14):

I don't know how old this is, because I have some older family members and that's on my Chinese side, where we have these kinds of, it's what you described, but their wooden, and so I'm imagining that. They've been around for centuries and centuries, just not as not branded as The Squatty Potty. We didn't have the rhymes.

Dr. Rachel Gelman (23:33):

Yeah no I mean, I usually just reference The Squatty Potty because a lot of people have seen their commercials or their posts on instagram, because they have very funny accounts and funny memes and stuff like that. But yeah no, this is not a new development. It's definitely been around for a long time, to use some sort of squat device or squat toilet. So it's definitely not a new technology by any means.

Dr. Jess (23:58):

But now I'm gonna get all the ads on my instagram because you said that and my iPhone is listening. So okay. If we go back to leaking, you began with making sure your bowel movements, and that's interesting. Because it's interesting that you know pee, you’re telling us to start with the poo. So what comes after that, what else can this person consider?

Dr. Rachel Gelman (24:17):

Definitely consider how they're breathing. Especially when they go to pick up their baby or move, if they notice that they're holding their breath a lot that's going to increase a lot of pressure in their abdomen, which is going to put a lot of pressure on their pelvic floor. So you know making sure, they’re not holding their breath, that they're breathing gently in through their nose, out through their mouth, and trying to time there breath with their movements. So when they go to pick up their baby, that's when they should exhale. Because they get a natural lift in their pelvic floor. Same thing when they go to stand up, when they can exhale because they'll get a natural, again, lift in their pelvic floor as well. Depending on if they feel comfortable, they could insert a finger vaginally or rectally, and see what it feels like when they tried to contract their pelvic floor versus relax it, like do a kegel. Because I don't like as I said in the past, I don't like telling people to just start doing kegels without an assessment, so if they don't have access to a provider, if they feel comfortable feeling those muscles themselves, and seeing what happens when they try to contract. And if they're able to do that and they can feel themselves fully contract around their finger and fully relax, they could definitely start trying to practice those pelvic floor contractions at home. And try to think about contracting the pelvic floor when they feel like they're going to sneeze, or they feel like they're going to cough. Because sometimes it's not the lack of strength. It's just the muscles need to be reeducated to know that they should contract before those different things. So before they stand up, they think about doing a little pelvic floor contraction. Before they sneeze, they think about doing a little pelvic floor contraction. They just have to consciously think about it so that way, their brain remembers like “oh, we need to do this before we do all those different movements.”

Dr. Jess (26:08):

Interesting, okay. And so for folks who are postpartum, leaking aside, are there any exercises or stretches that you recommend for them to do at home? I mean I know that to have a proper program, they need to have an assessment. But postpartum for people who give birth vaginally, are there exercises that are universally helpful? Or is that maybe not a fair question to talk about, being mostly useful?

Dr. Rachel Gelman (26:34):

Yeah I think again, it's really hard. And I think that's why it's always difficult, because people want that one you know pill, or one answer they can do and it's not so straightforward. Again, I always go back to pooping, I swear I'm not like obsessed with poop, but really does make such a big difference to have a better bowel movement. I see patients all the time who come in with pain with sex, after having a baby or leaking or things like that and the first thing I always work on is bowel movements. And that definitely makes a difference without me even addressing the other stuff. So I do really recommend that, especially after having a baby, constipation is a big issue that is not really talked about. I mean the moms are usually given some like Colace or stool softener when they're discharged, and told they're gonna probably have a hard time with their first bowel movement. But usually it is a big issue especially if they're breastfeeding, their body just needs a lot more fluid, or a lot more water than it used to, and constipation is just really common. And constipation again, it’s just gonna lead to things like pelvic floor dysfunction which can cause leaking, it can cause pain with sex, so I always kind of go back to that, as being not necessarily an exercise but something people can do. And going back to just gentle cardio, trying to be moving, trying to go for walks or doing like some sort of a Baby and Me yoga, or something that's fun and makes them feel good, and is also can increase blood flow, it’s just a great place to start. There really doesn't have to be a specific exercise or stretch, but I want people to be moving and doing things that feel good for them and their body.

Dr. Jess (28:32):

I love that. So get your poop in order to you know, deal with postpartum. So my understanding, definitely not being a poop expert, obviously we want fibre in our diet. We wanna stay hydrated. You talked about squatting, as opposed to pushing, and movement. Is there anything I've missed, in terms of getting your poop in order to get your sex life in order?

Dr. Rachel Gelman (28:56):

No, those are the big ones. I mean people want you know, there to be something more magical or sexy thing. But for me, I think having a better bowel movement, is just a good good option. Yeah just make sure you're drinking enough water, especially if you increase your fibre, because if you just eat a ton of fibre and you don't drink enough water, you're just gonna have a big old ball of fibre in your colon that’s just sitting there, and that does not feel good. So you need to increase your water if you increase fibre. But yeah, you pretty much covered my big recommendations for better bowel movements.

Dr. Jess (29:36):

Okay perfect. And then, I was reading, I don't know if it was your instagram or on your website, you were also talking about scar massage, postpartum. Tell us a little bit about that.

Dr. Rachel Gelman (29:47):

Yeah for sure. So I see a lot of people who have recently had a C section and they come in and they're always so surprised that they're having pain with with or you know symptoms that they thought would only be if they had a vaginal delivery. And having a C section scar and the kind of abdominal surgery that happened with cesarean can still bring about the same types of symptoms as vaginal delivery. I see people who have pain with sex, people have leaking. So making sure once they get clearance from the doctor, that they're actually touching their scar. Because a lotta people just avoid the scar, they don't wanna touch it, and that leads to more sensitivity in that area but if they feel comfortable trying to massage it a little bit, or seeing a provider who will teach them how to massage correctly. Because if you're not getting good movement in that scar tissue, even though it's in the abdomen, and people kind of think it's away from their vagina or their clitoris. The muscles and the connective tissue that runs under that scar, goes down into the pelvis. So it's all connected, and so if we don't address that scar tissue, that restricted area, it can really impact what's going on with the pelvic floor. So I really recommend that people who've had a C section, don't ignore their scars, they at least, like I said, try to touch the area once the stitches are gone and their doctors said everything looks good, to start at least touching it. Because if you avoid it, it's going to increase how sensitive it is. And again, trying to work with someone who can teach them how to massage it correctly. And that's the same case for if people have torn during vaginal delivery. You really want to work on that scar tissue. Which usually people kind of understand more because obviously, if there's a scar at the vaginal opening it makes sense that there's going to be pain with penetration. People are sometimes surprised when they've had a C section and are now having pain with sex, they don't really understand how that can go together. But there's a really big connection between the scar that's happened in the abdomen and what's going on in the pelvic floor.

Dr. Jess (31:59):

And so when you talk about scar massage it makes me think a little bit about vulval  or vaginal massage. I don't know how to say this. So I like to put my hand along my vulva, almost creating like a pocket, And it's not sexual at all, it's not erotic, it’s more just a comfort thing like you know, a kid holds themselves when they have to pee? I just like that feeling of you know, safety or warmth or comfort. Just the way I like weight on me when I'm sleeping, like I either sleep with pillows on top of me or I like a little bit of a weighted blanket. I find it very soothing and comforting and relaxing to just put my fingers along the outside, so the palm of my hand sort of goes on my pubic mound and then the fingers fold over the lips. So this sounds a lot like an oral or manual sex technique that I teach, which is the pussy pocket. Where your hand goes on the pubic mound, your fingers fold over the lips, and you kind of just slide and glide and pulse, and whatever your partners into. But what I'm talking about right now, looks the same, but I'm not talking about it in a sexual sense. I just wanted to bring up that I get this sense of just comfort, and it feels so good. So I'm curious if massaging of the labia, or even massaging of the vaginal canal is something that people use postpartum to either relax or reconnect with their body or alleviate symptoms or reduce stress. And again, I'm not talking in an erotic sense. I mean if it turned into something erotic that's fine too, with no judgment, but is that something you see or is it ever indicated?

Dr. Rachel Gelman (33:40):

It's definitely something that I recommend, of just trying to like stimulate the area, get more comfortable with the area. But unfortunately what I hear, and I think this was what your question was, but what I hear a lot from people after they've had a baby, they don't want to go anywhere near that part of their body. They don't wanna look at it, they don't want to touch it, and again there's obviously outliers, people who are not, you know it's a bell curve. And I'd say it's the majority I see, it's majority of people who report that, saying they don't want anyone to see it. They are concerned it doesn't look good anymore. And there's definitely a lot of negative thoughts and feelings, reports that I hear in relation to that area of the body after baby which is very unfortunate. Because it's not true. Every time I look at a person's vulva after every new baby, and they asked me if it looks normal and I'm like, "yep looks like a vulva and has all the parts and it looks fine.” So I would say, I definitely end up encouraging the things that you just described. And because people are often trying to avoid that area, it almost becomes like a black box to them. And so that's when I want them to just start you know, touching their pubic bone, touching you now that whole area and it doesn't necessarily, like you said have to be sexual or erotic, if it is that’s fine, but I usually just want people to just get comfortable with that area even just looking at it with a hand mirror so they can have a more positive relationship with their vulva.

That's a case for, sadly I'd say for people, who haven't had babies too. But definitely after childbirth, it’s something I really talk to people about.

Dr. Jess (35:31):

I think part of the problem is not only that we have all these negative associations, not only are our bodies treated like ovens, not only is there sometimes a lack of sensitivity toward our bodies within the medical profession. And so we're just exhausted by it all. And then there's the potential physical trauma for some people via childbirth. But I think the other issue is that we only ever used that area or pay attention to that area for sex right? We don't necessarily see it as functional. We don't see it like we see our hands or ears or even our knees. And so I appreciate that you're recommending to people In either an erotic or non erotic sense. It just seems so reasonable to me now for other people who are experiencing pain during penetration. And we've talked about this on previous podcast, that of course penetration is not the end all be all, there are many of us who could do without penetration and many of us who orgasm more intensely through external rubbing and touching. Having said that many people do want to have penetrative sex. And I've heard you talk about a product called the Ohnut. Can you tell us about the Ohnut?

Dr. Rachel Gelman (36:341):

Yes I love the Ohnut. I've been helping with Emily, she's the founder and the creator, since it was in beta testing. And it's a really great product. It's comes in a set of four rings, and it’s stackable, and you can remove the rings, you can just use one or you can use all four. And it goes around the penis, the dildo, whatever is going to be used to penetrate. And it basically acts like a bumper, so it limits the depth of penetration without changing the sensation for the person with the penis, or it doesn't change anything. And it basically makes it so that limits again, the depth of penetration. So if someone has pain with deeper thrusting or if someone recently had a baby and they’re kind of nervous about jumping back into penetration. This could be a nice way to kind of resume, and feeling like they're not gonna go in too far. They're going to have a little bit of a buffer which, that's what it is. And so it's really a great product and I found it really great for patients that again, have pain with deeper penetration.

Dr. Jess (38:00):

I love it. It's donut for your dick-sickle. Or, a donut for your dildo or a donut for your dick-sickle. I love it. And also cause, I don't love deep penetration, and I do find that I either use my body as a buffer or my hands, or I kind of just guide you, but with the Ohnut, you can have sex kind of, I don't wanna say full force, but Brandon for example could feel like he's moving to his full capacity. Whereas I could keep it a bit shallower and I think that's so important. And again with porn, with a lack of comprehensive sex education, with a lack of opportunities to see full depictions of a range of sexual pleasure approaches, we get hung up on deeper is better. And that's definitely not the case. Before I let you go, is there anything you want people to know about the pelvic floor in light of the body or sexuality? Something that you wish we could change or reframe?

Dr. Rachel Gelman (38:59):

Oh man, so many things. I think I've been a broken record before and talked about how people hear pelvic floor, and they automatically think kegels, and that their pelvic floor needs to be tighter, their vagina needs to be tighter. And that is not the case. The pelvic floor needs to be able to move through its full range of motion, so it should be able to contract, relax, and lengthened. So it's a really dynamic muscle, and so instead of focusing so much on making it tighter and stronger, I'd rather have focused on making it more mobile and more functional and not thinking so much about like “oh it needs to be tighter” but that it needs to be able to move better. Because these muscles again are involved in so many functions including yes, stopping and starting urination, but it's involved in orgasms, involved bowel movement, so it needs to have movement in order to do all of those things successfully.

Dr. Jess (39:53):

I love that. Yeah the getting hung up on being tighter is such a concerning approach, because sometimes being you know tight can cause problems, and we've talked about that before we've done a number of episodes on not doing kegels and them not being a cure-all, so I appreciate you bringing that up. Well thank you so much for your time folks. Make sure you're following along with Dr. Rachel. Gelman, a doctor of physical therapy and pelvic floor specialist, we’ll put all of your handles in the show notes and folks can find out more about the clinic “Pelvic Wellness and Physical Therapy.” And you're on IG at @PelvicHealthSF, like San Francisco. So thanks so much for chatting with us today.

Dr. Rachel Gelman (40:36):

Yeah, thank you.

Dr. Jess (40:39):

Thanks so much for joining us. If you are new here, please be sure to subscribe to the podcast, on any podcast platform and if you like it, please feel free to leave us a review, especially to the long time community members. Please do. And don’t forget that http://www.Adamandeve.com is offering fifty percent off one item, plus a bunch of bonus gifts for our community, so check them out http://www.adamandeve.com and use code DRJESS to save.

(41:05):

The Sex With Dr. Jess podcast, sex and relationship advice you can use tonight.