We're partnering with Expectful to provide our Solly Baby community with resources + support in all different facets of motherhood. This month, it's our pleasure to introduce you to Dr. Marysa Warnhoff, DPT, who we've tapped to shed light on all the most pressing pelvic health-related topics—including postpartum sex and peeing when you sneeze. 

Tell us a little about yourself and your practice.

Hello! My name is Marysa Warnhoff and I’m a doctor of physical therapy and pelvic health specialist. I have been practicing for 9 years and have been 100% focused on pelvic health for the past 6.

I’m a mom of a 2-year-old and 3-year-old and my practice has changed so much since becoming a mother. In the logistical sense, I have shifted from a 40-hour workweek in a fast-paced setting to my own practice with longer visits and more time freedom to allow me to be more present with my family. In the professional sense, I have developed a strong passion for helping pregnant and postpartum clients. This phase of life is such a massive transformation, and the right support and guidance can make all the difference—not just during this acute time period, but for the rest of your life!

My private practice is located in Sioux Falls, SD. I also work for Expectful providing virtual 1:1 coaching services as well as bi-weekly office hours.

Our community includes a lot of expecting and new moms. What can they be doing proactively to promote pelvic floor health?

I love this question! Being proactive about your health, especially during this pivotal time, is so beneficial. When I think of pelvic health, I think of bladder and bowel function. To keep these systems working well I recommend drinking plenty of fluids. Ideally aim for half of your body weight in ounces. The majority of your fluids should be water. Take it easy on caffeine and carbonated beverages as these can aggravate bladder symptoms. In addition to hydration, the addition of a foot stool in your bathroom can be a game changer! You should be positioned on the toilet with your knees higher than your hips for optimal pelvic floor relaxation during evacuation.

Now I’m sure you are wondering how many kegels you should do each day. I’m here to tell you that it depends. Kegels should not be recommended for everyone and can be contraindicated for many. We want our pelvic floor to be functional to support your organs, your baby, and your body, but also relax to allow baby to exit and allow for normal bowel and bladder function. Recommendations for pelvic floor exercises should be given on an individual basis and getting an assessment from a pelvic health therapist is important.

Let's get right to it: Is it normal for postpartum sex to be painful?

Absolutely not! Sexual activity should never be painful, but unfortunately postpartum is a time when many have this experience. There are several reasons why sex could be painful postpartum.

The first is excessive muscle tension in the pelvic floor. When the muscles are too tense, there is a lack of blood flow and a restriction in the normal mobility of the tissues. This causes pain! The anticipation of pain can further tighten your pelvic floor, so be sure to take a few deep breaths and soften your muscles.

The second reason is scar tissue. Whether you gave birth vaginally or had a belly birth, you are likely to have scar tissue in the pelvic region. Scars are less flexible and elastic than normal tissue. They also pull and attract fascia and other soft tissue toward it which creates imbalance and tension. Where there is imbalance, the potential for pain exists.

Another cause of painful sex postpartum is a lack of estrogen. Estrogen is responsible for keeping the vulvar and vaginal tissues plump and lubricated. When you are breastfeeding (or pumping), estrogen is suppressed. This can lead to atrophy in the tissues and dryness. No fun! Be sure to use a high quality lubricant with postpartum sexual activity, even if you’ve never found it necessary before.

The final and most overlooked reason for painful postpartum sex is the mental load of new motherhood. Sleep deprivation, being on high alert for baby noises, and learning to be confident in a new body are all challenges to libido and pleasure. My advice is to be patient with yourself, communicate with your partner about how you are feeling, and seek out support when you can.

What signs or symptoms, especially postpartum, might suggest a need for pelvic floor therapy?

The indications for needing pelvic floor therapy are the same for everyone. Postpartum is a common phase of life for pelvic floor symptoms to pop up because of the immense changes your body went through during pregnancy and the stresses of childbirth. Here are 10 symptoms that, if they persist past 6 weeks, would warrant pelvic floor therapy:

1. Leaking of any kind. Nope, never normal
2. A feeling of heaviness in the pelvis or seeing/feeling a bulge in the vagina
3. Difficulty emptying your bladder
4. Pain in your tailbone, back, vagina, pelvis, neck, shoulder, etc.
5. Painful intercourse
6. Abdominal weakness and/or abdominal muscle separation
7. Constipation or straining on the toilet
8. Feeling wobbly and/or weak
9. C-section scar discomfort
10. If you suffered a third- or fourth-degree perineal tear

I believe that everyone should see a pelvic floor therapist after childbirth for an assessment. Even if you aren’t having symptoms, I can almost guarantee you will learn something beneficial. You will understand how to support your postpartum body as you start doing new mom activities and get back to the activities you love.

What should someone do if their care provider isn't taking their symptoms seriously?

Find someone who will listen. Not all providers are well versed in pelvic floor dysfunction. Some may still promote the idea that “things change after childbirth” and you need to live with it. Unfortunately, pregnancy and postpartum are very vulnerable time periods for your health yet many myths and barriers make it difficult to know who to listen to. Listen to your body and advocate for yourself. In all 50 states you can see a physical therapist for at least an evaluation without a doctor’s referral. You can also reach out to a pelvic health therapist online! We are trained to know when we can help and who you might need to see if we can’t.

What if someone is a year (or decade!) postpartum and still peeing when they sneeze—is it too late to turn things around?

It’s never too late! Your body has the capacity to improve strength, function, and mobility until you are very old and very grey. Urinary incontinence often improves with some behavioral changes, strengthening exercises, and coordination exercises. If you are willing to put in the effort, you will see results!

Thank you, Dr. Warnhoff!

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