Adapted from episode 161 of The Perfect Stool podcast and edited for readability with, Aleece Fosnight, MSPAS, PA-C of The Fosnight Center for Sexual Health in Asheville, NC and Lindsey Parsons, EdD.
Lindsey Parsons:
I’m excited to talk to you and hear more about urology related topics that we don’t talk about all that much, but that comes up, inevitably, with a lot of my clients.
Aleece Fosnight:
Yes, yes, absolutely. It’s kind of funny, right? We all have bladders, and it’s something that we do every single day, but we don’t actually have a conversation about what that should look like.
Lindsey Parsons:
So I see a decent number of people with gut health issues, obviously, but who also have something like interstitial cystitis, or they have frequent bladder infections or bladder pain, or they have trouble with high oxalate foods. So I’m wondering maybe if we could actually start by talking about what interstitial cystitis is and what other diagnoses might be overlooked when that might be the diagnosis, but in fact it’s not really, and how that might relate to gut health?
Aleece Fosnight:
Yeah, absolutely. So interstitial cystitis, or bladder pain syndrome, has been around for a really long time, and back 20 years ago, we really thought that it had a lot to do with the GAG layer, so the glycosaminoglycanprotein layer that helps to protect the lining of the bladder from urine. Urine is a waste product that our body doesn’t need anymore. It’s helping to balance the fluid levels in our body. So as we’re trying to get rid of some of that, those waste products can be really irritating to the bladder. So there’s this protective protein layer that is there for whatever reason – could be genetics, could be, again, idiopathic, just some reason that it happens that that the GAG layer breaks down and can be patchy. And then the urine bumps up more against that mucus membrane of the bladder and causes irritation, so that people feel their bladder, meaning that there’s a lot of pressure that’s associated with it. Sometimes there can be pain associated with a full bladder that is typically relieved with urination, so most of the time when the bladder is empty, you’re not having any kind of irritation or symptoms. But that was just one thought, as we have evolved and we’ve learned more about research and what’s happening, there’s a multitude of subtypes when it comes to interstitial cystitis.
So one of them can actually be that the bladder is just a byproduct from an overactive or dysfunctional pelvic floor, so that it can mimic some of those same symptoms that we traditionally had talked about. It could also be that there was a nerve that was damaged during either a surgery or during a vaginal delivery or even just being pregnant, there could have been an injury to that nerve that is now causing those same symptoms to the bladder. You could also have what are called Hunter’s ulcers, which when the protein layer breaks down so much, you actually have ulcers in your bladder. What is very interesting, and I’m sure she wouldn’t mind me saying this, but my grandmother had Hunter’s ulcers and interstitial cystitis. So I remember just how much pain and discomfort she was having. We wouldn’t go to social gatherings. She actually had her bladder removed in 2000 so had a cystectomy secondary to these Hunter’s ulcers.
But what I found really fascinating is that her pain necessarily didn’t go away, which is what leads us into, again, exploring that there’s other options that are out there that are causing and mimicking these same symptoms. The other really big one that we are investigating right now in medicine is mast cells and the role of histamine and its response. Because one of the interesting things when I started learning about interstitial cystitis 14 years ago was that people typically, in the spring and fall, would have more symptoms. And we were all wondering why is that happening? Maybe seasonal allergies, right? Histamine responses are happening. So that’s another interesting thing that we are investigating with that, and that there are some researchers that have taken biopsies of the bladder lining and stained it for mast cells, and it comes back positive.
So it’s really interesting how we’re kind of seeing all of these overlaps. We see interstitial cystitis more in our female identified populations, or assigned female at birth individuals, but we can see this for our assigned male at birth individuals too, and most of the time, they have been misdiagnosed with chronic prostatitis. And again, pelvic floor, a nerve that has gone to the bladder could be causing this. It was very rare that we actually see the protein layer break down in those male identified individual patients. So they tend to not have Hunter’s ulcers, which is pretty rare for them to have. But could they also have some sort of histamine reaction that’s causing it directly to their bladder act? Absolutely.
So it is really a multitude of symptoms that are associated with it, but again, where is the underlying factor coming from? And so oftentimes, like I said, the bladder is the bystander that gets the brunt of the symptoms, and we feel it as if it’s our bladder. But there can be so many other things that are going on, and having somebody who is willing as a provider to explore what those other options look like and really listen to what’s happening with that patient and when their symptoms are worse, when they get better, can really help to understand where the root cause of it, because I’m a root cause girl, this ain’t no band aids, right? We’re not just trying to bypass, or, you know, abate the symptoms by okay, well, take some aloe vera, and maybe that’ll help. I really want to know why and what is the reason that we’re having this? Not only is that helpful for patients to understand and have more awareness of what’s happening and why it’s happening to their body, but then narrowing in on treatment options that we’re not just throwing spaghetti at a wall and hoping that something sticks. No, we want to be very purposeful when we are talking about different treatment modalities.
Lindsey Parsons:
Yeah, my father recently underwent an operation for an attack of diverticulitis that turned into an abscess. Well, it turns out his bowel was all inflamed, and there was pus and mucus and adhesions, and it was all attached to his bladder, which would explain why recurrent UTIs, frequent urination, all the kinds of things that come with that. And who would have known if they hadn’t gone in there?
Aleece Fosnight:
Yeah, absolutely, yeah.
Lindsey Parsons:
So you mentioned the the mast cells and the histamines, which is interesting to me, because, I had this one client, and she ordered the MicroGenDX test (which does DNA sequencing of all the DNA bacteria and fungi in your bladder) with recurrent UTIs and interstitial cystitis symptoms, and they found Klebsiella pneumoniae, which is a histamine-producing bacteria and Enterococcus facalis. I don’t know if that one is, but maybe you do.
Aleece Fosnight:
I’m not as familiar, but Klebsiella for sure, yes.
Lindsey Parsons:
So I’m wondering, number one, if this is a test that you commonly use, and how common those bugs are in UTIs, and would they have been found on a regular urine culture?
Aleece Fosnight:
Gotcha. So the most common urinary tract infection is from E. coli. The next one is going to be a tie between Klebsiella and Enterococcus. But again, it just really depends on that individual. And then Proteus is going to be your next one down the road, and typically is associated with kidney stones; we see bladder stones or urinary tract stones that you typically see with that one. Klebsiella should be detected with your basic run of the mill urine culture that is out there, but not all the time, especially if it is the beginning stages, and you have somebody who’s just very sensitive to the irritation of their bladder, so you may catch it at the very beginning, and may not have enough of that bacteria to colonize and to grow out on that culture, so you can miss it.
We know that there is something called a biofilm that is there too, that is secondary to a variety of things. Again, it can be just that person. It can be because of recurrent infections where, now that’s almost like the body is trying to protect itself and build up this biofilm. But it’s really sticky, so bacteria, how I look at it is it’s kind of hiding in these little nooks and crannies. And so even when you urinate or give us a sample, we’re not necessarily getting that one little piece that is in there. So yes, and MicroGenDX is one of the ones that I use quite frequently, especially when I have folks who have had these recurrent urinary tract infections and again, has just been pacified with here’s another antibiotic prescription so we’ve got to really figure out what’s going on with your symptoms and why. And so that MicroGenDX, and I don’t have any ties to that company, but I do find that it can be really be helpful in finding answers for that individual.
Lindsey Parsons:
Yeah, really useful, because they give you that culture and sensitivity that tells you which antibiotics are actually going to work. Because I remember in her results, there were four that weren’t going to work. And those were, of course, the first line ones.
Aleece Fosnight:
So, yep, exactly. And the difference too, is your traditional cultures, you’re growing something out anywhere between 48 and 72 hours. 72 hours really should be the gold standard, but sometimes they don’t grow it out for longer. So that MicroGenDX actually has the ability to let things sit and simmer for a longer period of time, because sometimes those bacteria take longer for them to actually culture out through that process. So having something that gives you a little bit more time, we are always so rushed, and I know that can be really frustrating for somebody to have to wait even longer, right? We want answers like Amazon Prime, answers. But we can’t rush what is happening to that bacteria that is in that bladder. So having that option to send it off, and I’m gonna say that it sucks because insurance doesn’t cover it. You have to pay for it out of pocket. So it really is sometimes unfortunate that it can’t be accessible to everybody. Now you can use your FSA or HSA to be able to purchase that, and you might be able to send that bill over to your insurance, but we can’t guarantee that it’s going to get covered.
Lindsey Parsons:
Yeah, but you can order it yourself too. That’s the nice thing. So you don’t have to have a doctor order it. So if you’re just kind of at the end of your line, and nobody’s helping out, it’s out there, and I know they have the one that’s the combo- the vaginal/urine one. It’s only 20 or $40 more or something to get that extra. And I’m just like, might as well do them both at the same time, right?
Aleece Fosnight:
Well, yeah, to think about your microbiome and the vagina and how that can contribute to bladder health is so important to have that piece of information. So I always tell my patients I can geek out with all of the tests. So the more information that we have, the better, so that we know exactly what’s happening.
Lindsey Parsons:
Yeah. So tell me a little bit more about that, the vaginal microbiome and how it impacts the bladder.
Aleece Fosnight:
Yeah. So we know that the top part of the vagina, the anterior vaginal wall and the bottom part of the bladder and the urethra are all made out of the same embryologic tissues. So as you are getting older, you go through puberty, there are some major hormonal changes that are occurring during that time frame, and then some hormonal changes also that are occurring going through perimenopause and menopause, that can shift that microbiome from a rich ecosystem, to now an area where the pH becomes lower in the vagina, and that is going to kill off all of those beautiful lactobacilli that are supposed to be in there. We want those Lactobacilli. That is what’s helping to keep the pH of the vagina low. It’s what gets rid of all of the bacteria that shouldn’t be in there. So those are all your bacterial vaginosis strains. It could be yeast that’s in there, Enterococcus, mycoplasms etc. So all of these things, although what is very interesting is that we can’t, unlike the gut, right, where most of the floor is the same, and you could do fecal transfers, you cannot do vaginal microbiome transfers, because everybody’s microbiome is so different and unique.
There was a study that came out, probably 10 plus years ago, and what they did is they swabbed 100 vaginas of asymptomatic patients, and they looked at what’s the microbiome in each one of it, and it’s a rainbow- it’s all over the place. There were some people who had yeast in there but had no issues. There were some people who had Gardnerella, which is one of your most common bacterial vaginosis strains. So this thought of, oh, we could just do some transfers, or just do specific probiotics for the vagina actually is not as inclusive as we were thinking. So I love the uniqueness that everybody brings to it, which is why I tell people, unless you’re symptomatic, either with a vaginal concern or a bladder concern or both, we just don’t want to treat it just because it’s there. So this may be your body’s own microbiome. The biggest thing I want to see is to make sure that there are enough of the three different types of Lactobacilli that are in there, because that’s going to be what’s really important to diversify that microbiome, to keep it robust and allow for the body not to be susceptible to other pathogens that might get in there for a variety of reasons, and that spills over that into the bladder.
And so we see that when there are changes to the microbiome in the vagina, that I actually will have patients that also present with some bladder irritant symptoms. They might have some urgency, frequency, but it’s inflammation, right? You talked about inflammation earlier with your dad and diverticulitis and having this abscess, and just inflammation everywhere. That inflammation from the vagina is so close to the bladder that that can also spill over and again, that bladder is this bystander for those changes in that microbiome of the vagina, yeah.
Lindsey Parsons:
And so those strains that are supposed to be in the vagina are like L. gasseri and L. crispatus . . .
Aleece Fosnight:
Yes, L.iners and L. johnsonii.
Lindsey Parsons:
I know there’s both oral vaginal probiotics, and now there’s at least one vaginal suppository probiotic. Do you recommend those?
Aleece Fosnight:
Here’s the fun science of things. They have studied oral probiotics for vaginal health for years, and there have been no studies that have been statistically significant to show that any oral probiotic will help the vaginal microbiome. You have to go directly to the vagina in order to have, again, that robust microbiome, or help to rebuild it. Because part of the problem is we are giving people antibiotics for whatever reason, and that is killing off all of the bacteria, good bacteria, bad bacteria, even if you’re treating a vaginal infection, and again, one of the most common is bacterial vaginosis. You’re killing off all of that good bacteria.
So there’s this window of opportunity where you’re trying to have your own body build back those Lactobacilli, and then boom, something else happens, and you get a trigger where then you’re back to square one again, which is why recurrence is so high. So you have to be thinking about, how can I rebuild my microbiome in this interim, while I’ve killed off all of this good bacteria, and I’m trying to get over to this good microbiome that I’m supposed to have with all this good bacteria, so a probiotic vaginally can be really helpful. Seed* is one of the ones that my patients absolutely love. It’s probably one of my favorites. And again, I have no ties to Seed, but I listened in on a webinar with one of their main scientists, and geeked out with all of the data that they had done, all the third party testing, and they have this wonderful Seed gut oral probiotic and prebiotic that, once they were like, forget it. We can’t get to the vagina through the oral route. And when they started doing that, and really, they saw just a tremendous improvement with their product.
Lindsey Parsons:
Yeah, yeah. No, I used it a little bit. I found it a little bit irritating. But, I mean, I suppose if you’re putting anything in your vagina, it could be irritating.
Aleece Fosnight:
So, right, yeah, some of the other things that you can do, in the interim, to help calm things down, would be sometimes boric acid*, but that can be a little irritating too, or ascorbic acid, like your vitamins. That’s a go-to for me. And those are something that, again, over the counter, that you can quickly have accessible to you.
Lindsey Parsons:
Yeah, yeah. So are there any other obscure bacteria that might be causing a UTI?
Aleece Fosnight:
So there are. It’s hysterical. I am in the medical field, but I have the hardest time saying medical terms. It’s just hysterical. So we kind of touched on a few of them. I had talked about mycoplasm, right? And mycoplasm can definitely be, again, a normal variant in your microbiome. It’s only when there is an issue, or you’re having these recurrent symptoms that it’s a problem. Urea plasm is going to be another one we talked about, the Gardnerella vaginalis, that is like your big key player in your bacterial vaginosis. Actinotignum schaalii is another one, and the reason I bring this up is because we find this typically in our older patients who can be in our nursing home facilities. This is going to be something that is very missed in a lot of cultures because it doesn’t have the traditional processing that you would normally see and how it grows out of that culture. So that’s going to be one for that MicroGenDX. Helobacter is another really interesting one, but again, a rare one. And your Haemophilus, especially after your H. influenza. So if somebody has an infection of the upper respiratory and then they start having bladder symptoms, it’s very possible that they could have that in their bladder as well.
The other things that we don’t necessarily think about, but yeast can also get into the bladder, and then Aspergillus is another one, but that typically is going to be for your immunocompromised individual. So again, something else to think about there as well. But those are big, big ones. There is Corynebacterium urealyticum, and again, that one has a very strong ammonia odor that goes along with it. So again, if we’re thinking about odor, right, our urine is naturally going to have a little bit of that ammonia. It’s one of those waste products that we are urinating out. But if it is very strong, or the person in the stall next to you can smell it, then there may be something going on. Because we also have to think about as we get older, our immune system isn’t as robust as it once was, so you’re not going to always have those typical symptoms of a urinary tract infection, so urgency, frequency, burning with urination, and it could just be the odor or the cloudiness of the urine that you may notice. So being able to talk to your provider, because I’m a big prevention girl, we don’t want you to keep getting hit after hit with these urinary tract infections.
Lindsey Parsons:
Yeah, no, I have a friend whose mother died from a UTI, so, yeah, watch your urine. Older people may not feel the UTI.
Aleece Fosnight:
Yeah, exactly. And then we don’t talk also about the mental health and cognitive changes that occur when you have a urinary tract infection, and you never get that level back after you have a urinary tract infection, and it’s treated. So it’s not like, oh, it’s just an infection. Just give them antibiotics. No, we don’t realize that that individual is getting a hit on their cognitive function every time they have a urinary tract infection, right? A lot of our older patients get confused with a urinary tract infection, and so that’s another reason to prevent urinary tract infections in the first place.
Lindsey Parsons:
So you’re saying that after the UTI is healed, they don’t recover the cognitive function they lost?
Aleece Fosnight:
Correct not back to 100%. And if you’re getting hit after hit, then that is also layering in that their cognitive function is having a harder time, again, recovering every single time. So this again, we see this in the majority of our older patients and there’s a lot of potential reasons for that. If they were prolonged in treatment – they didn’t get treatment right away for it, and or, again, their immune system is more susceptible that it is getting either into their bloodstream, where, again, that’s getting up into their brain, so when they’re becoming septic or having upper tract infections, again, is another reason we worry.
Lindsey Parsons:
Is there a certain number of UTIs, say, per year, where somebody should be seeing more of a specialist and not just going to their GP or family doctor and just getting antibiotics each time?
Aleece Fosnight:
Yeah, so I usually tell people right one time, okay, let’s figure out maybe there’s a culprit or a reason that happened twice and happening within a short amount of time. It means within three or four months if you’re having a second one, I’m starting to think about maybe we should be talking to a urology specialist; if you have three or more urinary tract infections in a year. And so even within six months, if somebody’s got three urinary tract infections, it’s an automatic referral over to a urology provider. That is what should be happening, because we need to figure out what’s going on. So three or more, or even if you are seeing blood in your urine, like visually seeing blood in your urine, that one also should be an automatic referral over to a urologist to have a further evaluation.
Lindsey Parsons:
Okay, so if somebody does have Klebsiella pneumoniae on a stool test and recurrent UTIs, is it reasonable to suspect that the UTI issue is probably caused by Klebsiella pneumoniae?
Aleece Fosnight:
Probably, yeah. I mean, we would want to make that connection, but it most likely is causing it, yeah.
Lindsey Parsons:
Okay, so back to something you said earlier about the dysfunctional pelvic floor. Can you just kind of define what that means? I hear that a lot about seeing pelvic floor specialists, but I actually don’t really know what all that means.
Aleece Fosnight:
Yeah, gotcha. So everybody has a basin of muscles in their pelvis, and it attaches from the pubic bone, wraps around the urethra for people who have a vagina. They wrap around the prostate for people of prostates, and then wrap around the rectum and attach to the coccyx, or butt bone in the back, and then fans out to the sides to the hips, to support all of those pelvic organs. But it is also very much a part of your core, so it is helping to stabilize the hips. It’s helping you to walk. It’s helping you to urinate again, urinate or not urinate. So it’s wrapping around that urethra, supporting the bladder, wrapping around the rectum, so it’s letting relaxing whenever you are defecating, having a bowel movement, and then for any kind of penetration, vaginally, if it’s receptive penetration, it’s part of your sexual function also. But these pelvic floor muscles should be in a neutral position.
And the way that I explain it is, if you are walking into a building and you want to get on an elevator, the elevator is at the ground floor, right? It’s sitting in a neutral position. But if you’re taking that elevator and you’re going up to that second or third floor, that is when those pelvic floor muscles are contracted and they’re tight and they’re putting pressure below, so that your bladder or the rectum or even the vagina and the uterus are getting extra pressure from below, and that can cause you to have urgency and frequency, not empty out your bladder as well.
Versus the other piece of it, where, again, that elevator, instead of on the ground floor, if you have weak pelvic floor muscles that could lead to prolapse, so it’s when that elevator is now in the basement, right? So it is more lax and you’re not having the strength of those pelvic floor muscles cells in order to hold up all of those pelvic organs. Again, we typically see that for folks assigned female at birth, having a pregnancy or a vaginal delivery isn’t the only reason. So we can have nulliparous individuals and people who have never had babies also could have a weak pelvic floor that can lead to prolapse. When we say dysfunctional, it means that those pelvic floor muscles should relax when you go to try to urinate, and then they should go back to neutral when you’re not urinating. But when you have dysfunctional pelvic floor muscles, they don’t want to relax when you need to pee, so you kind of force that urine, you push against it, and then it spasms and realizes, like, hey, maybe this isn’t what we’re supposed to be doing, and tries to then stop that urine. So it’s spasming and causing this high tone pelvic floor as well. And when we mean high tone, it also means shortening of those muscles, and that shortening you can’t really do a squeeze or a kegel. And I highly recommend everybody who has any pelvic health concerns or urinary concerns, whether, again, you are assigned female at birth individual or assigned male at birth individual, your pelvic floor therapists can do wonders to help that. The majority of what’s happening with those urinary symptoms is secondary to that pelvic floor.
Lindsey Parsons:
Okay, so Kegels, you mentioned, even when you’re pregnant, they teach you how to do those things. So basically, just like squeezing like you would if you were stopping the urine flow. So what’s the best way – I know you can overdo them and then end up with too tight of a pelvic floor. So what’s the correct amount of Kegels?
Aleece Fosnight:
Yes, gotcha. So the majority of us are not fans of Kegeling, and the reason is because most people don’t do them correctly. Okay, one of the things that I do when I’m doing my pelvic floor examinations during a pelvic exam is I place one finger in the vagina and I will have patients, I’ll say, alright, try to squeeze those muscles around my finger. We want to isolate those muscles. But what happens is they squeeze their belly, they squeeze their butt cheeks, they push out, they squeeze their legs in, so they’re actually not engaging in those correct muscles and really isolating what that should look like. So again, I think we people who are in pelvic health should assess all of the pelvic floor muscles to make sure that people understand where those muscles are and can then appropriately engage them and then relax them too.
So seeing a pelvic floor therapist is actually one of the very first things to do. And the reason I send people to pelvic floor therapy is because I want them to have an assessment from nipples to knees, because that’s your core. So if you have weak abdominals, your pelvic floor muscles are trying to compensate, so you may not actually be able to squeeze those muscles, which is one of the reasons why you were squeezing everything else during the exam. They could have a weak lower back, and that is actually then pulling and straining on those pelvic floor muscles to try to stabilize the sacrum and your hips. So being able to have somebody to really do a good, thorough assessment of your core muscles and then check your pelvic floor muscles, they are trained on examining your pelvic floor so getting you undressed from the waist down, placing a finger vaginally or on the perineum or even rectally to assess all of our muscles is something they are very much qualified to do, but that is the best way to actually assess it. If you are somebody who says, I don’t really have any urinary concerns, but I want to make sure that I’m doing everything that I can to make sure that I have a strong pelvic floor, right? I don’t use the word tight, because, again, those tight muscles are shortened muscles, and they’re not working the way that they’re supposed to. But in our society, we have been programmed to have a tight vagina, but that’s something we can talk about later.
So anyways, if you are wondering if you’re doing it correctly, one of the things I have people do is sit in a chair. It’s the easiest thing to put your feet flat on the floor, sit nice and tall. And what I want you to do is, keep a very neutral belly to not try to suck it in, don’t push it out. But I want you to think about if, again, if you are somebody who has a vulva, think about where the vaginal opening is. And I want you to try to use a string and pull that opening of the vagina all the way up through your cervix, like through the vagina, through the cervix, through the uterus, and up towards your belly button. So that can be very visual. I like the string right kind of pulling it, trying to pull it up. The other thing you can do is think about squeezing around. So if you put your finger in your vagina, you can try to squeeze around those, the finger to engage those muscles as well. If you are somebody who has a scrotum, you can do kind of the same thing, but you’re imagining pulling your scrotum up, like through your pelvis to your belly button, and that can. There is another way to do that, but it is also very important. After you have squeezed and lifted, you want to get back to neutral. So you want to be able to slowly release that muscle so that again, it’s not sitting at that high contracted. Think about when you’re doing a bicep curl, right? You don’t do a bicep curl and just hold it here, right? You slowly let it back down so you’re back to neutral.
Lindsey Parsons:
And so how many times would one want to do that max in a given day, or in a given session or and for how long?
Aleece Fosnight:
Yeah, you can do 10 squeezes. You do 10 slow squeezes and work your way up. So don’t feel like you’re not being able to optimize because you can only do three squeezes. So, don’t fatigue your muscles out. These are tiny muscles. So a little bit goes a long way. So maybe start with three or four kinds of first things, they were nice, slow squeezes and then relaxing. And then you can work your way up more frequently during the day. You can also work your way up to squeeze and hold, that’s also a really good one. And then release. You can hold it for a couple of seconds. And then you can also do what are called quick flicks, so just quick squeezes and releases. So you’re working different muscle fibers in those pelvic floor muscles to activate and engage all of them.
Lindsey Parsons:
And what signs might somebody have that they have a dysfunctional pelvic floor?
Aleece Fosnight:
So urinary concerns, difficulty with inserting like a tampon or insertive sexual activity, difficulty with bowel movements, straining for bowel movements, those would be the ones that I would recommend the most. Most insurances don’t require you to have a referral to a pelvic floor therapist, so you can always call them up and see if they take your insurance, and if you go ahead and schedule an appointment, you don’t always have to have a referral from a provider.
Lindsey Parsons:
And so when somebody’s searching their insurance database, are they looking for a pelvic floor specialist, or is there some other title?
Aleece Fosnight:
So they’re looking for physical therapy, but not all physical therapists do pelvic floor therapy, so that might be having to really look at your plan and what physical therapy places are near you, and then having and then calling them up or looking on their website. And one of the things that I encourage lots of people to do is calling someone up and saying, do you have a pelvic floor therapist? And then I would ask, what kind of training has that pelvic floor therapist had? Because you’re not going to get that therapy, that training in your basic Doctorate of Physical Therapy, you actually have to go on and get a certification or extra training. So I want to know, did they get it? Where did they get it? Herman and Wallace, Pelvic Global?
There’s some other courses that are good for those individuals to have. And then also asking, do you know if that physical therapist does an internal exam? Because I have found internal exams are so crucial when you’re talking about the pelvic floor and I have sent patients to what I thought was a pelvic floor therapist. And when I came back, I said, talk to me about what you did. And they’re like, oh, we just did some stretches, and then they did some exercises. And I said, well, what did they find on the internal exam? And she was like, they never did an internal exam. I said, well, remember that one spot, like a trigger point? Because you can have trigger points in your pelvic floor, which are those knots that you get in your back, you can get knots in your pelvic floor. And I’ll say, remember, we checked that, and we checked that, and they did do an internal exam. So I have learned over the years that you need to ask to make sure that they do an internal pelvic exam. Even again, for my male patients, they can do an internal exam, or at least do some sort of pelvic exam where they’re checking that perineum.
Lindsey Parsons:
Yeah, yeah, no, I’m picturing physical therapy places I’ve been to, and they’re definitely not set up for internal exams, so it would definitely have to be somebody who had specialist training and a proper office for that. Yeah, usually you’re out in a big gym with a bunch of people. Can’t picture that.
Aleece Fosnight:
Yeah, that’s not in the middle of the gym on a yoga mat. Nope, that’s not what’s happening, exactly.
Lindsey Parsons:
Okay, so talk to me about the connection between constipation and the bladder.
Aleece Fosnight:
Oh, yes. So constipation is the fullness of the rectum, and when you were thinking about the pelvis and how much space you have in there, when that rectum is full, it is sitting right behind the bladder, so it’s putting pressure up against the bladder, and so the bladder can’t fill as much as it would like to. So you might feel more urgency, more frequency to go to the bathroom, maybe less volume every time that you go to the to the bathroom. One of my patients said it very eloquently, and she’s a realtor, so she said, so my stool is taking up more real estate than what my pelvis can hold. So yes, you’re not actually getting as much room for that bladder.
Lindsey Parsons:
Okay, and so are there good foods that help both the bowel and the bladder function?
Aleece Fosnight:
Yeah? So fiber, right. Because in order to have good bladder function, you want to have good bowel function. So what that means is, again, fiber intake and avoiding constipation, you actually want to be hydrated as much as you can. And that sounds maybe a little counterintuitive, in order to drink more water, but you’re going to the bathroom more frequently. But again, that water is helping to soften the stool and it’s also helping to dilute your urine, so it’s not causing as much irritation. I love berries.Those are your antioxidants most of the time. There are low histamine, low low oxalate options, too. Some of your beans or lentils could be good also for fiber intake, and typically are a little bit safer for the bladder.
When we talk about foods, and I’m sure that you talk about this for the gut and FODMAPs and figuring out what your triggers are, there can be some common bladder irritants that we see like your citrus, spicy foods, caffeine, alcohol, carbonation, but sometimes it doesn’t always bother individuals. When you’re starting to get into the nitty gritties of the foods, I have a patient, for instance, who can eat tomatoes just fine, but ketchup causes irritation. Now we think that there can be some of the additives that are in like ketchup, but that it was just ones that we think about, but most of the time we talk about, especially for interstitial cystitis or people who have overactive bladder, thinking about those bladder irritants can be a little tricky, too, but finding what works the best for you, typically is where we’re going, but any of those high fiber foods and hydrating foods would be good.
Lindsey Parsons:
Okay, so I always think of something that prevents UTIs, cranberries, is that true?
Aleece Fosnight:
So cranberries? Yes. So right there is. It’s called PAC, and for the life of me, I cannot remember what that stands for right now, but it’s the PAC that is in that cranberry.
Lindsey Parsons:
Proanthocyanidins, maybe?
Aleece Fosnight:
Yes. Okay, thank you. Yes, yes, yes. Again, I thought I could see it but yes, it is. It is that element that is in the cranberry that is essential in helping to prevent urinary tract infections. And the reason that it does that is it helps, again, to coat the lining of the bladder, to make it super slippery, so that the bacteria can’t attach to it. But if you are taking just a general cranberry supplement over the counter, or you’re trying to drink cranberry juice, it is not necessarily as effective. So I know Solve Wellness is a company that makes a product that has a higher level that of the PAC from that cranberry. It has been tested to actually show and be researched to have lower risk of those urinary tract infections without it necessarily being irritating, because sometimes, again, it’s the additives in that, like cranberry juice. I have people all the time that are like, oh, but I drink all this cranberry juice.
Lindsey Parsons:
Like all that sugar.
Aleece Fosnight:
I know. And I’m like, No, that’s really, actually not. And then if you’re just trying to drink even like cranberry concentrate, you’re still going to have to drink quite a bit of that product in order to get the amount that you need. So yes, it’s called gennaMD* by SolvWellness. And I love it because it has 36 milligrams of that proanthocyanidins in there, and you need that higher amount in order to have that protection. So yes, it does help, but you want to make sure that you have a high enough concentration.
Lindsey Parsons:
Okay, so is that like a one a day type of pill for prevention of UTIs?
Aleece Fosnight:
Sometimes I will have people take twice a day. Usually we start with once a day. I want to make sure that they can tolerate it and see what happens. And then if we have to increase it to twice a day, if they are at higher susceptibility, we could do that too.
Lindsey Parsons:
Okay, so is going to the bathroom frequently, in and of itself, a cause for concern, especially for people who drink a lot?
Aleece Fosnight:
So what goes in must come out. And so if you are drinking a lot of fluid, then your body is going to filter it. And again, it’s those checks and balances for fluid regulation. So you’re going to be going to the bathroom and urinating a little bit more frequently. So if I’m concerned about somebody coming in and they’re saying, I just feel like I could go to the bathroom all the time, and I asked them, how much water are you drinking, or what are the fluids that you’re drinking. Doing a bladder diary can be a great way for both the patient to visually see how much they’re drinking and going to the bathroom as well as you, as the provider, to be able to go, okay, maybe we are drinking a little much. Oh my gosh, it looks like you’re drinking 20 ounces of water right before you go to bed. That might be one of the reasons that you’re getting up two or three times a night. So it’s a great way for you to visually see exactly what’s happening. There’s apps that you can use.There are paper printouts that you can find online. Just type in a bladder diary, and that should give it all to you, but it’s a really good way to see if you’re having those checks and balances. Okay, I’m drinking 100 ounces of water every day and I’m urinating out 85. That’s pretty close, right? Because you’re sweating, some of it goes into the gut. So it’s not going to be a complete equal equation, but should be relatively close.
Lindsey Parsons:
Okay, so provided there is nothing else wrong with you, and you’ve had that assessed, is there anything you can do to train yourself to go to the bathroom less often?
Aleece Fosnight:
Bladder training is a great way to do that, meaning that if you just went to the bathroom 30 minutes ago, and you are feeling the urge to go to the bathroom. You’re like, I just went and I haven’t drunk a whole lot of fluids. I know that I don’t have to go. One of the things that you can do is distract yourself and say, Okay, I’m going to give myself five minutes. If I still feel like I have to go to the bathroom after five minutes, then I’ll go to the bathroom. But I’m going to try to distract myself, do something and see if that feeling goes away. So kind of that distractibility can be helpful in delaying you going on average, every two to three hours is the frequency that somebody should be going to the bathroom if they are hydrated. You could even get by with 90 minutes to two hours. If you have somebody who’s pretty well hydrated, but overall that’s a good average.
So again, somebody who’s going a little bit more frequently, it’s one of those things going, okay, I’m going to just let myself go a little bit longer. You don’t necessarily have to hold it another half hour. Do again, little increments, and that bladder diary, too can be really helpful. And going, oh my gosh, I’m drinking it again these 20 ounce Big Gulps every couple of hours, and then it fills your bladder pretty fast, and then that urgency for you to have to go. So that can be really helpful. And visually going, okay, I need to just do small sips throughout the day to get that other thing to do too, this is where the Kegel does come into play. So again, if you just went to the bathroom and 30 minutes later, you feel like you have to go, you can do a very small Kegel. And what that does is it sends that signal up back to your brain to say, Nope, we are not anywhere near your bathroom. We don’t have to go to the bathroom, and we’re going to sit here and chill for a little bit, a little bit longer, so that’s a great way to incorporate a key goal into that practice.
Lindsey Parsons:
Okay, good. So for someone who has incontinence, what kinds of exercises would you recommend?
Aleece Fosnight:
So it really depends on the type of incontinence that they have. But again, what the research shows is that pelvic floor physical therapy can improve and/or cure up to 70% of individuals who are having some sort of urinary incontinence. It’s a big percentage of individuals. So somebody who has stress urinary incontinence, which is where you leak urine with cough, sneezing or exercise, one of the things that you can do is make sure that your bladder is always empty before you go and exercise. Kegeling can be one of the things as long as you’re doing a proper Kegel, because remember, those pelvic floor muscles are wrapping around that urethra, so we want to make sure that they are nice and tight and strong around that that urethra. But this is also thinking about your core. Again, if you have a weak core and you go to sneeze, right? What happens when you sneeze? You get the pressure from your diaphragm that just elicited that sneeze, and that’s going to put pressure on your abdominals.
And so if your abdominals are weak and can’t hold back that pressure, it’s going to go down to the pelvic floor too. So that’s where that pelvic floor therapist can really isolate and look at again, head to toe, what’s happening with your body to help support you through that process. On an urgency side of things, if it’s urgent continence, this is where you feel like you have to go to the bathroom, and you’re making your way to the bathroom and you leak on your way to the bathroom, that urgency could be food related. It could be constipation. The other one to think about, this is where the high tone pelvic floor muscles are coming into into play, because, again, those muscles are tight and shortening and putting extra pressure on the bottom part of that bladder, which creates an increase of that bladder pressure making you feel like you have to go urgently. And then it’ll spasm or squeeze, and that squeeze increases the pressure to overcome those pelvic floor muscles, because those are tight pelvic floor muscles, not strong pelvic floor muscles. And tight pelvic floor muscles are weak, so they don’t have the capacity to hold back that pressure from that bladder.
Lindsey Parsons:
Okay, so I have sent some people who had incontinence to look at videos for hypopressives. What can you tell me about those?
Aleece Fosnight:
Yeah, gotcha. I want to make sure that I understand what you’re talking about. Are you talking about the diaphragm and the type of breathing?
Lindsey Parsons:
Yes, yeah, like you let out all your breath and then you pull upwards, yeah.
Aleece Fosnight:
Right, yeah. Because what you’re trying to do is, essentially, is allowing your abdominal pressure to pull up those pelvic floor muscles to help strengthen them. Again, I would want people to do that under the guidance of a pelvic floor therapist or under a provider, to make sure that there wouldn’t be any other reason that they wouldn’t want to do that again, these high tone pelvic floor muscles, and I will tell you, the majority of people have high tone pelvic floors. It really isn’t a weak pelvic floor. So again, making sure for prolapse, absolutely for those weak pelvic floor muscles, there has been some data that has supported hyperpressive therapies and being able to help to decrease even by one grade of prolapse.
Lindsey Parsons:
Okay, cool. I have friends who have or have had an issue with getting a UTI pretty much every time they have sex. So is there anything you can do about this, other than prophylactic antibiotics when you’re having sex?
Aleece Fosnight:
So thinking about one of the first things I ask is, are you using any lubricant? It’s going to be the biggest- lubricants can cause inflammation. So that’s going to be the biggest one. I’m going to ask about types of practices, before and after. Are they urinating before? Are they urinating afterwards? We have to remember that the anatomy makes, again, assigned female at birth individuals a little bit more susceptible, because that urethra is right there and it’s shorter, so it’s easy for that bacteria to get in there. Making sure that they’re drinking plenty of fluids before and after can be really helpful. You can use a warm wash cloth to help wipe away any of that bacteria afterwards, also thinking about the duration of sexual activity. So sometimes, the longer that sexual activity goes on, the more bacteria can get in there. And then we continually talk about that female partner. But again, if this is a partner who has a partner with a penis, a lot of times, are they circumcised? Are they intact? That can definitely cause more bacteria to get in or around that urethra. I’m also asking about condom use, so sometimes just the ejaculation can cause an imbalance to that pH. And remember, if there’s a change in the vagina, there could be a change in the bladder.
So having those conversations, we’re really just trying to nitty gritty this, and to really come up with what is exactly happening for you with this. This would be also where that cranberry supplement that I said with that PAC can be a really great option for those individuals that are getting these with recurrent sexual activity. If they’re using a toy, I want to make sure, how often are you washing that sexual aid or toy? You would be surprised how many people just throw it back into the drawer and don’t ever wash it. So, you know that’s one of those big things that we want to think about. And then, that would be if we’re still struggling with recurrent urinary tract infections after sexual activity, we’re going to start really investigating. Is this some sort of partner swap? This is where that MicroGenDX comes into play. Is there some sort of mycoplasm, ureaplasm, that y’all keep passing back and forth to one another, and that’s causing this? Is it that Klebsiella? Do you have a biofilm where, then that’s where we start going down that path of what and why is this happening?
Lindsey Parsons:
Oh, okay. And is this a scenario where then you need to test the man as well?
Aleece Fosnight:
Presumably, yeah.
Lindsey Parsons:
Okay, yeah, got it. So what happens to the pelvic floor in menopause?
Aleece Fosnight:
Oh, my. So in menopause, we have a shift of the hormones that are there in the pelvis. We have to remember that the two big hormones that I think about are both estradiol and testosterone. Everybody has testosterone, and testosterone is really important for lean muscle mass, and if those pelvic floor muscles are muscles, we need testosterone to help keep that strength and the ligaments and the connective tissue in that in that area, and so as you are losing testosterone, as you are losing estrogen, estrogen is what helps to keep the vaginal microbiome and the vaginal layering of those tissues thick and creating lubrication. This could then lead to thinning of those pelvic floor muscles and prolapse can happen. And when you have prolapse and that bladder falls, it puts a little kink in the urethra, which makes it more difficult for you to empty out your bladder fully. That could also mean that there is a little bit more urgency, as those pelvic floor muscles are not as strong.
I always think about a trampoline; you get up and move and it doesn’t have the support or the structure anymore for that. So doing some local hormone therapy can be really helpful. We also have what we call the genitourinary syndrome of menopause, which is, again, those hormonal changes that are happening both to the vulvovaginal systems and that lower urinary tract. Again, it’s that embryologic tissue, right, that they share that you’re having both that, and you have estrogen and testosterone receptors in the bladder. So it is not uncommon for people, as they’re going through the menopause transition, to have changes in their urinary function, urgency, frequency, even burning with urination.
And then we have a ton of research out there that shows the connection between loss of hormones in the genitourinary tissues and recurrent urinary tract infections. And there is a ton of research out there that shows that local vaginal estrogen cream can reduce those urinary tract infections by over 50%; it’s uncanny of how common and how easy a fix. I think that was one of the very first things that I remember learning coming into the urology practice, like I said, 14 years ago, was these recurrent urinary tract infections. And the urologist that I was working with at the time, he said, well, just give them vaginal estrogen. And it was still one of those things that sticks out in my mind, is that you should be able to use it. And we have a wonderful new guideline that just came out from the American Urology Association specifically on genitourinary syndrome and menopause, and that 99% of people are candidates for local vaginal estrogen therapy. So we don’t have the scary things when it comes to breast cancer or other kinds of gynecological cancers that are out there, very little of any of that estrogen spills over into the system. Obviously, talk to your healthcare provider and your oncologist to make sure that it’s an appropriate option for you. But this saves lives, right? You talk about your friend’s mother who died from a urinary tract infection, so vaginal estrogen can save lives by preventing a urinary tract infection.
Lindsey Parsons:
Yeah, so I just took a Hormone Zoomer test and got my results back. I looked at them yesterday, and it also tests chemicals – estrogen mimicking chemicals and hormone disrupting chemicals – and one of them that was elevated for me was parabens. And I dug through all my products that I use, and then it came down to the estrogen cream and that, I mean, I haven’t actually looked at the bottle, but it seems like the standard ones you get from the doctor have these chemicals in them, in a highly absorbent surface, that, yeah, what are the alternatives? Compounded?
Aleece Fosnight:
Yes, yeah, yeah. And, or, one of my favorite options is actually not even vaginal estrogen is actually vaginal DHEA. So there’s a product called prosterim. The brand name is Intrarosa, and they are vaginal suppositories that are made. There’s two ingredients in there. It’s a yam base, which is awesome and my understanding, but please double check around this, is that there aren’t any parabens in this product. And then the DHEA. So DHEA is the precursor to testosterone and estrogen. We have testosterone receptors in three key areas, at least in the vagina, so the clitoris, the vaginal opening, and then that top part of that vaginal canal, which shares, again, that same embryonic tissue with the bladder. And so by using the DHEA, not only are you flooding the estrogen receptors, but you’re flooding those testosterone ones too. And that can be really important for somebody who’s having difficulty, maybe with arousal during sexual activity, or they’re having difficulty reaching orgasm, or they’re having pain at their vaginal opening during penetrative sexual activity. Those are all again, rich with more testosterone receptors than estrogen ones.
And if you look at how those steroids are made in your body, they want to go downhill, right? So they start at DHEA, then testosterone and then estrogen. So it’s very hard for estrogen to go back to testosterone. So just by applying estrogen cream, it’s hard to get that testosterone. So one of my favorites, and you can ask my patients and my whole team here, I love Prasterone (Intrarosa) prescription around for that reason is because you’re getting so much more robust stimulation to all of those receptors. Now, DHEA does not have the same data set points that estrogen does in terms of preventing those urinary tract infections, so we can’t necessarily say that that’s the case, but if it turns into estrogen, and we know that estrogen locally helps to prevent urinary tract infections, you could make that correlation, but we don’t have the data just yet.
Lindsey Parsons:
And is that over the counter?
Aleece Fosnight:
I wish it was, but it’s a prescription.
Lindsey Parsons:
Oh, really. Oh, okay. Well, that’s even better, because then, in theory, it might be covered by insurance.
Aleece Fosnight:
Yes, yeah, I will say yes, covered by insurance or have copay cards, or some offices will carry some samples so that you can actually try it before you buy it. That’s my rule. I like for you to be able to use it to see if you can tolerate it. But yes, you’re right about the parabens. I found that out, a little over a year ago on the Estrace, yeah.
Lindsey Parsons:
I’ve been thinking about it because I read that there’s this sodium laurel sulfate or something in there too. Or I can’t remember what I remember reading on there, or maybe I’m confusing that with what’s in laxatives anyway, but, I remember seeing something in there that was not a good one.
So I’ve noticed in some people that have recurrent yeast infections or vaginal itching, they can’t eat any sweets at all, like not even fruit. So I’m wondering, other than prescription antifungals, be they creams or pills, what else can be done about that?
Aleece Fosnight:
Yeah, gotcha. So this one is fascinating, and I love this question because so many people are trying to avoid certain foods, but it’s how, again, your body processes. So it’s not necessarily the sugars or the carbs, it’s just how your body processes that causes more of this change for yeast and these vaginal yeast infections. I always think about like, what’s our trigger, right? I want to prevent it. Let’s find out what the culprit is. What’s the root cause of this? Is it that you were just in a hot tub? Is it that you were in a warm, moist area? Was it that you have urinary incontinence and you’re wearing pads, and those pads are causing a warm, moist area that’s now, you know, letting you harbor yeast and letting that colonize.
Do you have undiagnosed diabetes? I think that’s one of the biggest things. Is I’m always asking patients if they have a yeast infection, is, you know, talk to me about the last time that you had a Hemoglobin A1C checked, or that you were checked for diabetes, because that can be one that is actually easy to miss, especially for people who have recurrent yeast infections. The biggest thing with yeast infections is this disruption to that microbiome and that pH. So again, keeping that good lactobacilli in there is going to be really helpful. That’s where this boric acid*, the ascorbic acid, and the vitamin C suppositories* come into play. You could also use the Seed probiotics, the VS1* there as well. So again, those would be some of the things that I would talk to patients about. But again, it’s trying to find what was that trigger, and then how can we prevent or avoid that trigger for that individual.
Lindsey Parsons:
I haven’t heard about the ascorbic acid suppositories. Tell me more about that.
Aleece Fosnight:
Yeah, so vitamin C, right. So it also helps to keep the pH low for those individuals. So I have some patients where they find that the boric acid is more irritating to them and that the vitamin C may be a little softer, so that can be again, another vaginal suppository that you can use.
Lindsey Parsons:
Okay, yeah, because I do worry about the quantity of boron that I might be absorbing with the boric acid.
Aleece Fosnight:
And now, if I have some folks who really like boric acid, and that is their go-to, I will have them alternate just a little bit back and forth.
Lindsey Parsons:
Yeah, yeah, okay, that’s good to know. Yeah. Well, I’ll find some on the internet.
Aleece Fosnight:
Yes, I was gonna say, yeah, there’s definitely some options that are out there, again, looking at the ingredients and making sure there are as few ingredients as possible.
Lindsey Parsons:
Yeah, of course, anything final you would like to say before we get off?
Aleece Fosnight:
Oh, I don’t think so. We covered a lot of information, and I think understanding that it isn’t one size fits all. I love medicine, and trying to come up with algorithms for each individual and trying to fit make people fit into these boxes, doesn’t always work. And I really do feel like that’s why we miss a lot of things, because it’s really easy for somebody to go to urgent care, say that they have a vaginal itch or that they feel like they have a urinary tract infection and just get thrown antibiotics, and then that’s it.
And people get lost a lot of times in follow up, or nobody’s keeping track of how many times that they have had urinary tract infections. So really, being your advocate can be really helpful in asking, Hey, I had two infections this past year. I’m concerned about this frequency, or I’m concerned that your test or your urine culture maybe didn’t catch everything. Is it possible that there’s a biofilm that I’m dealing with, and how do we check for that? So I think about asking those questions. There has been a huge shift in the amount of information that is available to patients now, and I love it and the reason for it, and I really recognize that I’m unique in that perspective, because it gives us some talking points. And I love to help to understand why my patient went down that Google rabbit hole to figure out what’s going on with them. Most of the time, because somebody isn’t listening to them. They’re not getting answers from that provider. They’re really frustrated with what’s happening to them and that they are ready to just take it by their reins, and just do it themselves. So finding a provider that will listen to you, that will be willing to think outside the box, is really important.
And again, this is one of the reasons I got into medicine, because everybody is their own unique individual. And I love that so much about people can be really frustrating because they’re, I don’t know, I don’t think it’s frustrating. It’s frustrating sometimes for the for the patients, and they just want an answer, but it’s a puzzle, and one of my sweet patients calls me the private investigator, no pun intended. And I’m just trying to figure out what’s going on, because everybody is a puzzle, and nobody comes with their own manuals to figure out what’s going on. But it’s really important to be listened to and to be validated. And so often, some of my patients have been gaslit, especially my female identified folks. And so you are worth it, and it’s worth finding a provider that is going to listen to you and validate your concerns.
Lindsey Parsons:
Yeah, yeah. Well, thank you so much for all this great information. It wasn’t super bowel focused, but you know what, I have a lot of female clients, a lot of females out there with issues, and males, for that matter, who have issues of this nature, too. So I think it’s good information.
Aleece Fosnight:
Oh yes, yeah, absolutely. And again, it’s all connected, so I definitely think it has a good overlap. But yes, awesome.
Lindsey Parsons:
Okay, well, thank you for your time.
If you’re dealing with gut health issues of any type (diarrhea, constipation, bloating, SIBO, IMO, H2S SIBO/ISO, IBS, IBD, gastritis, GERD, H pylori, diverticulitis, candida, etc.) or have an autoimmune disease and need some help, I see individual clients to help them resolve their digestive issues or reverse autoimmune disease naturally, You’re welcome to set up a free, 30-minute breakthrough session to see if you’d like to work with me. I also have my own two products, Tributyrin-Max, which is particularly helpful for loose stool and diarrhea as it slows your motility and firms up your stool, and SBI powder, which is an all around gut pathogen binder, which is super safe and won’t harm beneficial bacteria, and is usually the first line of treatment I educate my clients about in order to avoid stronger antimicrobial herbs.
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