Lichen sclerosus (LS) may be a skin condition, but it affects much more than our skin. Even after you’ve managed LS symptoms like skin plaques and itching, the effects of the condition can show up in other areas of your body. Based on some research I did with LSSN members, people with lichen sclerosus often deal with other issues like constipation, urinary incontinence, fibromyalgia, and TMJ disorder at higher rates.
I spoke with Holly Horikawa, a pelvic physical therapist, to learn more about why constipation and urinary incontinence are common among those with LS. If you'd like to see the full interview with Holly, join the LSSN Membership to get access to the replay and more.
Why do people with LS have pelvic floor issues?
“Skin doesn’t exist separately from the internal organs, from our nervous system, or our vascular system. Everything is connected,” Holly explained.
If you have pelvic floor issues like constipation and incontinence, it’s not all in your head. Holly says there’s a physiological explanation for what you’re feeling.
“Over time, you could have tightened up internally as a response to pain. That’s what our body likes to do: tighten up when we’re in pain to protect that area,” she explains. “So we need to break the cycle and try to get that area comfortable again.
What is pelvic physical therapy like?
Holly says she starts with an internal vaginal exam to evaluate and treat. She uses gloves, coconut oil for lubrication, and just a single digit to feel the muscles that create the vaginal and rectal canals.
By doing this, she can address tight spots, trigger points, and even scar tissue that has formed. She compares these problem areas to roots. Think of the plaques, fissures, and tears on your skin as plants above the surface. These issues also cause problems in the muscles and connective tissue below the surface, like the roots of a plant. These “roots” can stick around even after the outer skin has healed. Pelvic physical therapy can’t get rid of scar tissue, but it can help the tissue have more flexibility. The increase in blood flow helps your body heal from the inside out.
It turns out there’s a lot you can help treat from the inside. A pelvic PT can access the outside muscles supporting the urethra and part of the bladder. Sometimes, the bladder or the urethra may be pulled to the left or the right. Or it may be tight and not move properly. If things don’t move properly, then they don’t function properly. So a PT can use internal manipulation to help relax muscles and help them work properly again.
But it’s not all internal manipulation. Pelvic PTs can help address issues from the outside, too.
“One class that’s changed my whole practice has been the visceral manipulation training that I’ve done,” says Holly. “So visceral means organ. The manipulation is working on the fascia and working on the connective tissue to try to restore movement and restore function.”
With this gentle, hands-on therapy, Holly can address the movement of the organs in the body. For instance, she can feel where the colon may be backed up and where the sphincters, or parts connecting the different parts of the colon, are closed or sluggish.
How do you treat constipation?
Everyone has different bowel habits. In a perfect world, we’d be back to our baby-like state, where we have a bowel movement after every meal. But that’s rare once we’re adults. Pooping once a day and feeling like you’re entirely emptying is the next best thing. Some physicians may say that every other day — or even every third day is ok, but it depends. Many people don’t always feel like they have emptied; they feel like it’s not all out or there’s something there creating pressure. That’s part of constipation, too.
In addition to pelvic PT, there are some things that you can do to help keep your digestion and bowel movements healthy. Holly suggests drinking water, managing stress, doing stretches, eating fiber and having a little help when you’re on the toilet.
Managing stress looks different for everyone. For you, it may look like exercise, meditation, journaling, praying, or deep breathing. Holly says it’s best to work with a therapist so that they can help you address your stress on a personal level.
Deep belly breathing can help you manage stress and relax the pelvic floor. “The abdominal diaphragm — the one that helps you breath — and your pelvic diaphragm — the one that creates your vaginal and rectal canal, your pelvic floor — they move in unison,” explains Holly. “When you breathe in and out, those diaphragms are moving together. The contraction and relaxation help you release some stress and tension in the pelvic floor.”
Stretching and Massage
If you’re familiar with yoga, stretching positions like the happy baby pose and child’s pose can help extend the pelvic floor. They can also help with arm movement and massage the abdomen because you’re in a deep squat.
You can also do a really easy abdominal massage. Holly explains it: “The colon runs right to left. So starting at the bottom, your right hip bone in the front and your abdomen coming up towards your rib cage, across to the left, down to the left, pelvic bone on the left, and then across to the middle. You’re just making a big circle, right to left, clockwise, with gentle pressure.”
An even simpler version is just gently rubbing right to the left. You can do this with some coconut oil or lotion to stimulate the colon to move, especially if you’re feeling backed up. You can even use it as a moving meditation.
Holly says that everyone’s needs are different when it comes to using fiber. If you’re concerned about the amount of sugar in it, you’ll want to check the labels. Some people also can’t handle too much magnesium.
Just remember that if you’re going to take extra fiber, you also have to make sure you are drinking enough water. Fiber may help you go to the bathroom, but if you take too much, it may cause constipation without enough water. You could try a bowel tracker with your therapist to see if there are any triggers with the type or amount of fiber you take and certain foods you eat.
When you’re actually on the toilet, using a tool like the Squatty Potty can be helpful. This little step fits around the base of the toilet and allows your knees to be a little bit higher to be similar to a squatting position.
“Like the happy baby pose and child’s pose, this helps the angle of the pelvic floor and allows it to give the muscles a better chance of relaxing while you’re sitting on the toilet,” explains Holly.
If you don’t have a Squatty Potty, a small stepstool can work, too. Just keep it in the bathroom for easy access.
How do you treat urinary incontinence?
“Urinary incontinence is basically unwanted bladder leakage, whether it’s from a bladder that gets too full or from an extra force on the bladder, like a cough or a sneeze,” explains Holly.
There are different amounts and variations of urinary incontinence. Some people may not be able to empty their bladder fully. Others have complete incontinence, where they lose their whole bladder. Others may have some leakage when performing certain activities.
Holly tells her patients they should be able to sit through a nice meal or movie every couple of hours without running to the bathroom. If you can’t make it through a movie or a relaxing dinner or are waking up to pee more than once a night, it may be a problem. Some people may get used to frequently waking up to pee, but it’s really disruptive, and your body needs the rest.
Urinary Incontinence From Chronic Pain
If you have urinary incontinence, you may be tempted to try Kegel exercises to strengthen your muscles. But Holly warns that if chronic pain is the underlying issue, incontinence may occur because your muscles are already too tight. It’s like a tightened bicep that can’t squeeze anymore.
“Pelvic floor therapy helps you relax those muscles to a normal resting length. Then, when you need to squeeze, you can squeeze more and stop that leakage,” she says. “You really need to work with someone for urinary incontinence because we don’t know if it’s because of tightened muscles or loosened muscles.”
A pelvic floor therapist can evaluate and assess your pelvic floor's tone and instruct you on how to do Kegels correctly. Learning how to do Kegels correctly is critical because up to 80% of the population do them incorrectly, even after being taught how to do them correctly.
You know those quick bathroom breaks you’re taking? Holly says it’s time to slow down when you have to go. Pushing or bearing down to get the pee out will tighten your pelvic floor. Try to relax and empty the bladder fully by giving it a couple of minutes instead of 20 seconds. You can take deep breaths, move around gently like you’re trying to wring out the bladder, and use your hands on your bladder to push down to the pubic bone.
Retraining the Bladder
If you’re heading to the bathroom when you don’t have to go, you could worsen your bladder issues.
“You absolutely don’t want to go when you don’t need to go. You can actually train your bladder to then be smaller; your bladder is going to think it’s full when it’s not full yet,” explains Holly. “You’re basically resetting when you’re doing bladder retraining. You’re trying to reset the sensors of the bladder.”
Holly suggests tracking your urination to see if you have an issue with using the bathroom too much. A common issue is using the bathroom when you leave the house, even if you don’t have to. If you find yourself going more than once every couple of hours, start at home, so you feel more confident.
If it’s only been 30 minutes since the last time you went, try to find out if the urgency is real or just in your mind. Try to relax and get the urge to go away, even if you’re buying yourself five minutes at a time. And then, if you still have to go, go to the bathroom. That’s why it’s more helpful if you’re at home. You have that confidence that you can make it to the bathroom, but just buying yourself five minutes, 10 minutes, 15 minutes — then pretty soon you’re up to two hours, and you have normal habits again.
Don’t wait to get help for your constipation and urinary incontinence!
If you’re dealing with constipation or urinary incontinence, it’s important to remember that you don’t have to live with it. When you’re dealing with constipation and urinary problems, it increases the stress on your body and affects your overall health. Empower yourself, educate yourself, and ask for what you need. If your insurance requires a referral to a pelvic physical therapist, ask your doctor if you can have a referral.
Let us know in the comments if you suffer from constipation or urinary incontinence and what has helped you overcome it.
About our Guest
Dr. Holly Horikawa received her B.S. in BioKinesiology from Chapman University in 2001 and continued on to
Duke University where she graduated in 2005, with her Doctor of Physical Therapy degree.
Holly has been practicing within the specialty of women’s health since 2006 and has morphed traditional physical
therapy with other modalities like visceral and neural manipulation to treat the whole person. She has completed various pelvic health-related continuing education courses and over 150 hours of training to become a Certified Lymphedema Therapist.
Holly has provided various educational lectures for Physicians and the community regarding pelvic physical therapy, breast health & wellness, and physical therapy following cancer treatments.
If you'd like to work with Holly reach out to her on her website at lokahiphysicaltherapy.com.