• April 11, 2024

Episode 52: Pelvic Floor Problems and Eating Disorders

Welcome back to another episode of the Imbodi Health Podcast where we’re chatting pelvic floor problems and eating disorders.    […]

Welcome back to another episode of the Imbodi Health Podcast where we’re chatting pelvic floor problems and eating disorders. 



Today we’re joined by the wonderful Marnie Poiner from Healthy Peach Physio. Marnie is a Brisbane-based physiotherapist and is the director of Healthy Peach Physio. Marnie treats a variety of pelvic health conditions, with experience in treating persistent pelvic pain and sexual functioning issues. 

Marnie completed her Master’s of Science in Medicine, Sexual and Reproductive Health through the University of Sydney, expanding her role to include sexual education and psychosexual counselling. Marnie takes a gentle and open approach in her treatment, practicing through a trauma-informed lens.

Thank you so much for joining us, Marnie!

Q1. We always like to start our guest episodes with one question – what is something that most people don’t know about you?

The thing I thought of that most people don’t know is that I had cancer. I was diagnosed in 2019 with a neuroendocrine tumor in my appendix, and I ended up having to have half my bowel removed. 

I have a first-hand experience of what it feels like to be a patient, and I had lots of gut issues happening at the time. Obviously, I only have half a colon now, so I still have gut issues sometimes. I think it’s nice to be the patient because it definitely changes the way that you treat when you’re a practitioner.

It was tough. At the time, I fully dissociated and was just trying to get through it. I had my hemicolectomy in 2020, and I have to have a PET scan or a CT scan every year for the next 10 years to make sure it doesn’t come back. 

It was in 2021 that it really hit me that I’d had cancer, and I cried for like two weeks. After that, I felt like I’d processed it. It was tough, and I did that typical Type A personality thing where I decided to start my Master’s and a business. I’m glad I did all those things, but it did make my recovery harder.


Q2: You mentioned it’s interesting being a patient. How has it changed the way that you practice as a pelvic floor, physio and sexologist?

I think it changes the way that you have expectations of your patients.

When you come out of physio school, you expect your patients to listen to you and do what they say. Then when they don’t get better, it’s their fault because they didn’t do what you said. That’s not the real world. Having been a patient with lots of things going on, mental health issues, and experiencing extreme stress and the physical repercussions of that, you realise that it’s not their fault. 

Maybe it’s your fault because you didn’t give them what they needed or guide them in the way they needed, and they didn’t respond to what you did. It’s definitely changed my perspective. 

When someone comes back and says, “I didn’t do that thing you told me to do,” I take a more non-judgmental and curious approach. Why? Why didn’t you do it? Did it feel wrong? Did it not resonate with you? Do you have so many other responsibilities at home that doing physio exercises just isn’t feasible for you? And then how can we reframe that to make it work for you?

Patients often don’t receive the best treatment because they’re being told what to do rather than being involved in goal-setting and decision-making.


Q3. Can you explain to our listeners what pelvic floor dysfunction is and how physiotherapy can support someone dealing with it?

I might start by explaining what the pelvic floor is. We actually have two sets of pelvic floor muscles: a deep and a superficial set. 

The superficial set consists of muscles that surround the vagina and the urethra, as well as a muscle that encircles the anus. These muscles have a circular structure, and when they contract, they close off the vagina, the urethra, and the anus.

Then we have the deep set of muscles, which act more like a sling or a hammock. When they contract, they lift the space between the vagina and the anus upwards and also pull forward to close off the rectum, the vagina, and apply pressure to the back of the urethra.

So, considering the functions of these muscles: they support bladder and bowel health, aiding in maintaining continence, voiding, and defecating. Additionally, they play a role in childbirth and sexual enjoyment, both penetrative and non-penetrative. 

Anything hindering these functions is what we address. A pelvic floor physiotherapist might conduct an internal exam to assess these muscles, examining factors like their mobility, contraction efficiency, and their ability to prevent urine leakage during activities like coughing, sneezing, running, and jumping.

We also look at bladder sensation – can you feel when your bladder is filling? Do you act on those sensations appropriately to empty the bladder? Or do you experience frequent, urgent needs to urinate without much output?

Regarding bowel function, we examine issues like obstructed defecation and teach techniques to coordinate the muscles for effective rectal emptying. 

My specialty area is sexual functioning. If a pelvic physiotherapist is assisting someone with sexual functioning issues, it often pertains to pain — pain during penetration, whether it’s from a penis, fingers, or objects. The primary goal of a pelvic floor physiotherapist is to help individuals navigate and overcome this pain, enabling them to enjoy sex again, or perhaps for the first time.

Kiah: There’s so much that pelvic floor physiotherapists can do. I’m a big advocate for them—I’ve seen one myself for about four years. I think one of the reasons people might not seek out this kind of help is because sex, in general, remains a taboo topic. 

So, perhaps there’s not enough discussion about what pelvic floor physios do, how they can assist, and the signs indicating the need for their services. I often find myself telling everyone, “You should see a pelvic floor physio!”

Megan: As we were discussing before recording, many people are quick to blame diet or food for issues like constipation or diarrhea. However, there’s this whole other aspect, which many aren’t aware of, and that’s where you come in to help them.

Marnie: Yeah, definitely. When we think of the pelvic floor muscles as functional muscles, we’re referring to functional disorders and issues where the muscles aren’t functioning as they should. 

However, we also know that the pelvic floor muscles interact closely with our nervous system and psychological state. If someone is experiencing significant mental health issues or stress from life events, their pelvic floor can be affected as well. So, taking a holistic approach to treatment as a pelvic floor physiotherapist is crucial – otherwise, you might miss underlying issues.

Q4: Could you share more with our listeners about pelvic floor problems and eating disorders?

Eating disorders or disordered eating behaviors can affect the pelvic floor in various ways, and vice versa.

If a person is under significant psychological distress, their pelvic floor tends to remain active. The pelvic floor isn’t just a part of our musculoskeletal system but also an integral part of our nervous system, influenced by our limbic system—the part of the brain governing emotional health and stress responses. This system indirectly affects the pelvic floor.

I often use a puppy dog analogy to explain this concept: Humans used to have tails, and our pelvic floor would have controlled tail movements. A happy or relaxed puppy has its tail up and a relaxed pelvic floor, whereas a scared or unhappy puppy tucks its tail, indicating a contracted pelvic floor.

So, if we consider the link between someone experiencing an eating disorder and the associated distress, their pelvic floor remains constantly activated. 

In terms of functional gut issues, around 60% of people with eating disorders experience constipation. Most of these individuals also face obstructive defecation, which involves the pelvic floor muscles. 

Ideally, the pelvic floor muscles should relax during attempts to defecate. However, if they contract instead, it can lead to constipation and blockage. This can create a vicious cycle of constipation, pain during bowel movements due to hard stools, and difficulty relaxing the pelvic floor to defecate.

If we consider the pelvic floor muscles, especially when experiencing this upregulated muscle activity causing a blockage, we know the pelvic floor muscle can communicate with the rest of the gastric system, signaling it to stop sending. 

If the rectum is full and the pelvic floor won’t relax to allow defecation, the rectum sends signals to the colon, which then signals to the stomach to stop sending food. This backflow effect can increase bloating, abdominal distension, and pain, potentially causing gastric slowing. It might not necessarily be a motility disorder but an emptying disorder causing the slowing, significantly contributing to these issues.


Q5. For those experiencing constipation alongside their eating disorder, do you have any general tips or advice?

Assuming the constipation has elements of functional constipation, awareness of your own body is important. I can’t effectively teach someone defecation techniques without body awareness. 

It’s essential to draw attention to the pelvic floor muscles, understanding when they’re active, and how to lengthen them. Both defecation and sex aren’t about achieving a relaxed state, but rather a functional movement. 

The aim is to lengthen the pelvic floor, not just relax it. Many people get frustrated trying to relax, but the focus should be on lengthening. While relaxation can be beneficial, the primary skill to learn is lengthening the pelvic floor.


Q6. How can someone become more aware of their pelvic floor while sitting?

Sitting on a firm chair can help with awareness. Think about your sit bones on the chair; your pelvic floor sits between them. Consider whether this space feels flat against the chair or arched like a rainbow without contact. 

If the muscles are too active, you might only feel your sit bones and not the space between them. To help relax this area, try changing your breathing, adjusting your position, or relaxing your stomach slightly. Any action that increases contact or pressure between the sit bones is likely an effective way to relax the pelvic floor.

However, that connection doesn’t resonate with everyone. If you tried and felt nothing, especially if you’re dealing with functional constipation issues, you should see a pelvic floor physio.

Many people lack a connection to this area of their body for various reasons. If you’ve never had issues with it, it’s easy to overlook. However, if you’ve experienced trauma, you might have intentionally disconnected from this part of your body, making it challenging to reconnect without addressing those underlying issues. 

If you’ve completely disconnected from your pelvic floor, you likely need professional assistance to reconnect with it.


Q7. What impact does long-term laxative use have on the pelvic floor?

The impact varies based on the consistency of your stool. 

If you’ve been using laxatives long-term and your stool is predominantly watery, your pelvic floor will be constantly strained trying to prevent incontinence. The anorectal muscles weren’t designed to control liquid consistently. When dealing with liquid stools, both the closing and deeper layers of these muscles work overtime. This excessive strain can lead to fatigue, reducing their dynamic range of movement and potentially affecting blood flow and sensitivity. 

If you’ve been consistently holding back stool to prevent accidents, the muscles might lose coordination when you want them to perform the opposite function. So essentially, long-term laxative use with watery stools places significant strain on the pelvic floor.

It’s definitely not recommended to quit laxatives cold turkey, we recommend having assistance in gradually reducing their use if you’ve relied on them for an extended period. 

Also, laxatives aren’t inherently bad – their misuse is what’s concerning. For some people, they may offer relief and regularity, especially those with specific health conditions. It’s important to note that laxatives vary; they’re not just stimulants that speed up gut motility. Fiber-based laxatives or those that increase water content in the colon can also be beneficial.


Q8. Another aspect that comes up really often for clients, is around that body image piece and feeling like you always have to have a flat stomach. A lot of people are sucking in their stomachs all the time and trying to make it flat. How does that affect things?

A lot. I would say the hardest thing that we do is try to help people relax their stomachs.

One reason is that it’s challenging to unlearn chronic stomach-sucking behavior and become aware of when you’re doing it. Similar to not being aware when you’re gripping the pelvic floor, when you’re sucking in your stomach, you often don’t realise you’re doing it. So, unlearning that behavior is difficult. 

Chronic stomach-sucking affects the pelvic floor by essentially tensing it up. The muscles that pull the abdomen in also co-contract with the pelvic floor. So if you’re constantly pulling your stomach in and lifting the pelvic floor, it can lead to trunk dysfunction and stiffness. This affects movement, including spinal, pelvic, and hip movements. 

From a pelvic floor perspective, if you can’t relax your stomach or your pelvic floor, it can perpetuate issues like bladder and bowel dysfunction and pain during sex. 

Chronic stomach-sucking is a common issue across the board, not just among females. I often have to teach my male patients to relax their abdomens as well. Learning to relax the abdomen requires heightened awareness.


Q9. What’s something they could do now to bring that awareness to stop stomach-sucking?

If you’re wearing pads that are high enough, and you think about whether or not your stomach is pulling away from them, or if it’s relaxing into them, you’ll probably feel you’re not relaxing your stomach into your pants. So, you could definitely try!

I always sort of imagine we have this string from our spine to our belly button. And I want you to imagine that string is like lengthening or letting go. You’re sort of letting the belly button drift into your pants, that can sometimes help get the abdomen to relax. So, essentially give yourself a big belly, but without pushing. 

The biggest problem I have when I’m teaching people the skill of relaxing their abdomen is that they try and lengthen the abdomen, rather than letting it go. And so, if we’re bulging the abdomen, what we’re doing is actually like a lengthening contraction, which means that we’re actually contracting the pelvic floor still.

Q10: Can you tell us a little bit more about breathing?

There are so many different ways for us to breathe. But if you only breathe in one particular way, then your body only experiences breathing in that specific manner, which might not be the best way to relax your pelvic floor, for instance. 

So, from a functional perspective, your diaphragm sits at the top of the abdominal cavity, and your pelvic floor sits at the bottom. When you breathe in, your diaphragm expands into the abdominal cavity, reaching down, creating length in the pelvic floor. This results in a dropping away of the pelvic floor. 

When you breathe out, the diaphragm rises into the ribcage, and your pelvic floor follows by retracting back up. During an exam, I can literally feel when someone takes a good breath in and out; I can feel their pelvic floor ebbing and flowing, like a piston effect of this up and down movement. 

So if someone is breathing and creating this basal expansion of their ribcage—widening of their waist and ribcage, relaxing their abdomen—they’ll experience some passive stretching of the pelvic floor. For people with pelvic pain, sexual pain, or any holding conditions, learning how to breathe and create length with their breath can be a powerful strategy to relax and reduce tension in the pelvic floor.

I think we should all have multiple strategies for breathing. If you’re running, you’re not going to be doing this relaxed breathing because that’s unhelpful at that moment. Instead, we want all our accessory breathing muscles to help. But once you finish running and return to a restful state, your breathing should revert to a resting state.


Q11. Can you talk a bit more about how eating disorders might impact sexual function and sexual health? 

If we’re thinking from a psychosexual perspective, I would say body image is probably the number one issue. Whenever I’m addressing low desire, which is likely an outcome of poor body image in terms of sex, feeling undesirable is often a significant problem. 

So, from a purely sexual health or psychosexual perspective, we look at the concept of “brakes and accelerators.” 

The idea is that when it comes to sexual desire, we have accelerators that drive us towards it and brakes that either protect us or indicate it’s not the right time. So, accelerators can be different for everyone, and brakes can be anything – from a messy house, distracting thoughts about a child’s schedule, or negative body image thoughts. 

People with body image issues or distorted thinking patterns often have high brakes, preventing their accelerator from engaging. Even if they possess all the necessary accelerator skills, they can’t utilise them if their foot is on the brake.

Q11. How does someone identify their accelerator or brakes?
I often use a worksheet based on Emily Nagurski’s work. It involves reflecting on enjoyable experiences. 

If you had a positive sexual experience, think about what made it enjoyable. Was it the context, the person, the location, the activity, or the anticipation leading up to it? Identifying these factors can help determine your accelerators. 

For instance, maybe your partner helped around the house, you had a relaxing bath, and your accelerators engaged. Context plays a significant role in how certain actions, like a kiss, are perceived. A kiss can feel different based on the surrounding circumstances. So, understanding both your accelerators and brakes can be enlightening.


Q12. What about more of the anatomy side of things, or pelvic floor side of things with sexual function in eating disorders? How could that play a role?

Yeah, I guess it comes back to that sort of pelvic floor tension and being unable to create length and space in the pelvic floor region. 

If you’re distressed or experiencing high sympathetic nervous system activity, then your pelvic floor will be overly active. If you engage in penetrative activity, and your pelvic floor is tense or has poor flexibility due to prolonged tension, penetration can be painful. 

However, not everyone with an overactive pelvic floor will experience pain during sex. The genital arousal response we experience takes time, typically around 15 minutes for females. If you rush into things, your tissues might not be adequately prepared for penetration, which can result in discomfort.


Q13. At what point should someone book in with a pelvic floor physio? What are the flags to look for?

Clear indicators include pregnancy, regardless of delivery method, bladder issues like leaking or difficulty emptying, bowel problems such as constipation or inconsistent urges, and pain during sex. 

Some people experience initial pain during penetration, which may improve with continued activity. However, for others, this discomfort can worsen over time. If you’re experiencing persistent pain or discomfort, seeking help is important.

Megan: That’s really helpful. I’m asking because there’s a significant lack of awareness about these issues. Many people normalise pain or other problems, thinking it’s just how things are. It’s essential to recognize that it’s not normal and help is available.

Kiah: Sex remains a taboo topic, and issues like painful sex are rarely discussed openly. People often learn about sex from school-based programs that emphasize contraception and risk, or from porn, which may not represent a healthy view of sexual pleasure or health. 

This lack of comprehensive education leads many to live with painful or uncomfortable sexual experiences without seeking help or understanding that something can be done.

Marnie: This is a societal issue. From a young age, particularly as females or individuals who aren’t men, we aren’t taught that it’s okay to experience pleasure. Sex is for everyone involved to enjoy, regardless of how many people are participating.

However, many receive subliminal messages throughout their development suggesting that sex is primarily for men. Eventually, as we reach an age where we are considered “old enough,” we’re suddenly expected to embrace our sexuality, even though we’ve never been taught it’s okay. 

Often, we struggle to communicate with our partners about discomfort or pain during sex because of societal expectations.

Communication is key. It should be normal for partners to openly discuss and respect each other’s desires. Saying “no” should not lead to issues or insecurities within the relationship. 

Sex holds different meanings for different people, and while there’s no right or wrong way, the problem lies in the obligatory nature of it. If you’re not enjoying or desiring the sex available to you, and you’re not adequately aroused, it’s likely to be painful. 

One approach in my treatment plan for patients is to start with neutral sexual experiences, especially if they’ve never had pain-free sex. The goal is to create a safe and pain-free experience to retrain the brain that penetration can be safe. 

Once that’s achieved, we can explore arousal and how to genuinely enjoy penetration. Many find that external clitoral stimulation is more pleasurable than penetration, but it’s essential to ensure that penetration is safe and enjoyable.

If we were taught about our anatomy from an early age, we might not have as many issues. I often hear from my pelvic pain patients that they didn’t realize their symptoms weren’t normal, simply because their mothers had similar experiences and never talked about them. 

This perpetuates misconceptions. If someone’s first experience with sex is their friend telling them it’s painful, or they’ve been told it’s always painful the first time, it sets them up for long-term pelvic pain or sexual dysfunction. 

Sex shouldn’t be painful unless you want it to be, and this misconception can lead to long-term issues.

Kiah: It’s interesting because my partner, Matsen, is a Health and Physical Education teacher and discusses this topic. We often debate where the responsibility lies. He believes it’s not a teacher’s role to teach children that sex is pleasurable. However, many parents also avoid the conversation, which means there’s a need to break the taboo.

Marnie: I dream of running classes for young teenagers and their parents to foster better conversations about sex, including pleasure, sexual safety, and consent. 

Many parents want to educate their children but feel unequipped to do so accurately. We need comprehensive sex education in schools, but societal acceptance of such programs is lacking due to personal and cultural beliefs.

Megan: It’s challenging because children are learning about sex regardless—through peers, media, and early exposure to porn.


Q14: Let’s wrap it up – what is one key message you hope listeners take away from this episode where we have taken a deep dive into pelvic floor problems and eating disorders?

I hope listeners gain hope because many of these issues aren’t talked about enough. 

For instance, I had a patient today who had been dealing with incontinence for 20 years and only needed some exercises. Sometimes the solution isn’t as complicated as you might think. 

You should have hope and seek help because often there can be a good resolution to your symptoms.

Kiah: See a pelvic physio and address pelvic floor issues!


You can find Marnie at:

In person: The Healthy Peach in Grange
Instagram: @thehealthypeachphysio
Website: www.thehealthypeachphysio.com.au



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