Pelvic floor physical therapist Dr. Alexandra DiGrado and sex & couples therapist Dr. Rebecca Howard Eudy get real about sexual health, intimacy, and the stuff we didn't learn about our body in school. From the clitoral hood to parenthood, no topic is off-limits. Each episode blends a combined 30 years of clinical experience with compassionate advice and humor, giving you trusted knowledge, practical tools, and the confidence to take charge of your health and relationships.
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You cough and your belly button doesn't go back in after it pops out. Or you’re lifting heavy at the gym and suddenly feel a weird bulge in your groin. Both can be signs of a hernia, when fat or part of an organ pushes through a weak spot or opening in the muscles or connective tissue of the abdominal wall (it may look or feel like a soft lump under the skin). When a hernia needs repair, surgery is the only way to fix the opening itself (some small hernias that don’t cause symptoms may just be carefully monitored instead). However, pelvic floor PT can still play an important role in preparing for surgery and supporting recovery afterward.
In this listener-requested episode, pelvic floor physical therapist Dr. Alex DiGrado and sex & relationship therapist Dr. Rebecca Howard Eudy discuss how pelvic floor physical therapy fits into hernia care - from retraining how your diaphragm and core work together to addressing toilet straining and improving breathing mechanics. As Dr. Alex points out, nobody gets knee surgery and skips PT afterward - a hernia repair deserves the same care and follow-through.
What you’ll learn:
Why hernias aren't just a “weightlifter problem”
The difference between an ordinary postpartum “outie” belly button and a possible umbilical hernia
The connection between hernias, prolapse, constipation, and bloating
How hernias affect two opposite ends of the movement spectrum: “Grippers" and "Deconditioned"
Tune in if you've ever thought:
"My hernia pain comes and goes. Does that mean it's not a big deal, or should I still see someone about it?”
"I've had chronic constipation for years. Could that be connected to this weird bulge I'm noticing?"
"I've heard the term 'strangulated hernia.' What does that mean? How do I know if I have one?”
Welcome to Under the Hood. I'm Dr. Alex DeGrotto, your pelvic floor physical therapist. And I'm Dr. Rebecca Howard Uti, your sex and relationship therapist.
SPEAKER_01
Hey Rebecca. Hi, Alex. I'm excited for this one. Another listener has requested a topic, and this is so fun for us. So thank you to those of you who have requested topics because we love to hear from you, and it's fun for us to learn what people are interested in hearing about. So the topic for today is hernias, and is there a role for pelvic floor PT and kind of what is the gold standard for management of a hernia? So I'll just dive right in. Yeah. Pelvic floor PT cannot fix the fascial defect of a hernia. So the hernia is when the fascia has a tear in it and there's a little bit of something sticking through. Sometimes you can see it in your belly button when you cough. It's really common in postpartum people. The inguinal area, which is that thigh area, is another really common spot. And you can get an MRI, and sometimes they can do it in an ultrasound. They can see, you know, how big it is. And so surgery with a hernia specialist is the gold standard for treatment. But pelvic floor PT does play a role because if you think about why the hernias are there in the first place, we can help with breath holding, excessive abdominal pressure, if someone's straining on the toilet and that's why, or if they're lifting mechanics or, oh, you know, we can help to retrain that relationship between the diaphragm and the abdominal wall. So the other thing is if someone is truly deconditioned and the abdominal wall doesn't have enough support. So it's kind of the two ends of the spectrum. So we can definitely look at people who are just gripping, gripping, gripping, and that's contributing to it because that pressure management system is off. And then we can also look at people who don't have a lot of tensile strength in their abdominal wall and help them with their transverse abdominis, that deep core, activating it and getting it back kind of online. And in both of those cases, we would still either do watchful waiting, if that's what the surgeon's recommending, if it's small and it's asymptomatic, or they would go through their surgery, they would follow their postdoc protocol, and we would work with them either before as prehab or afterwards to kind of get back to the function that they were at, but maybe with healthier mechanics.
SPEAKER_00
So I think of hernia's being something like I when you say hernia, I imagine like a weightlifter for somebody who is like that can happen. Yeah. So you said postpartum as well. And then a number of other reasons.
SPEAKER_01
Yes, because the abdominal wall, the linea alba, which is the fascial connection between the two sides of your rectus abdominis, which is your six pack abs, that stretches out and thins out so much during pregnancy. And sometimes, you know, when people say, Oh, you're all belly, that area gets thin, thin, thin, thin, thin. And then a little umbilical hernia can happen from that. So it can really happen.
SPEAKER_00
The umbilical hernia is a belly button. Correct. Yes, the belly button. Yeah. It's like an outie. Yeah, yeah. So if you had an innie before you were pregnant, and then your belly button does that thing where it pops. Most people's does. It's not necessarily a hernia.
SPEAKER_01
But if it doesn't go back, well even yeah, no, I think most people's, you're right, it does go back if it was if it was an inny. But if you cough and then it bubbles out again, that's like the little hernia. You know what I mean? So you can kind of feel it or see it. And you can imagine people who have a chronic cough or who are chronically straining, they're more at risk because of that.
SPEAKER_00
That makes sense. Yeah. So you said that there's symptomatic and asymptomatic hernias.
SPEAKER_01
Yes. So if the protrusion, if whatever's poking through, stays poking through, it can become strangulated, and that's that's not good at all.
SPEAKER_00
And you say whatever, it's like a piece of your intestine or something, right? Correct.
SPEAKER_01
It can be, yes, exactly. And so that's where the risk happens. And I did have a patient recently who, you know, they're they were in excruciating pain and they immediately went for surgery. It was inguinal. And so that happens, you know, but typically when people are aware that they have one, they are getting good monitoring with their provider. So they're they're saying, okay, we've done imaging. This is the centimeter, let's say it's four centimeters by one and a half centimeters, whatever. Now this is what we recommend based on that. And I don't personally know what the centimeters need to be before they say it's best for us to do surgery, but obviously the size matters and then the symptoms matter. So if you're symptomatic, I think they're certainly more likely to say, let's do something about this.
SPEAKER_00
And symptomatic means you're in extreme pain.
SPEAKER_01
Sometimes, yes. And other times it's intermittent. You know, it could be fluctuating. And even still, I think to be cautious, they're saying, well, you know, this is a sign that perhaps we should go the surgical route. And certainly I'm not sitting in on those consults, so I don't actually know what the criteria is for choosing to do surgery. It's not my wheelhouse. But when we see people who have had hernia in the past or who have one and are doing watchful waiting or they're trying to, you know, figure out what they're gonna do, we really think about the coordination between the pelvic floor, the diaphragm, and the transverse abdominis. So if they're a butt gripper, if they're a power peer, if they're a shallow breather, you know, breathing up here and not really into the diaphragm, we really work on those things. And then also, if you think about that canister, your diaphragm sits on the top and your pelvic floor sits on the bottom. We want to make sure there's enough mobility in the sides and in the back. A lot of times what happens is people lose that thoracic rotation, like that mid-back rotation. And so they're so stiff that all the pressure just goes straight into that inguinal area or into the belly button area. So we do a lot of mobility work to try and help the pressure spread out throughout the body. And that's especially important during pregnancy, which is why we do so much of that lateral work. And people with abdominophrenic dysinertia, which we've done an episode on, is when that disconnection between the abs and the diaphragm causes a major pressure manager. It can cause terrible bloating in the absence of something like small intestinal bacterial overgrowth or other things that you would think of when you think of bloating. It's literally paradoxical breathing strategies. Like, do you know when someone sucks in when they're breathing in? In reality, when you breathe in, we should be expanding out the air. You think about the air like water, it would fill the canister. And then when we breathe out, we want it to go out. But they're doing it the opposite way. You know, they're breathing in like that's not where the air goes, you know? And so yeah. Yeah, exactly. And so that creates problems. And that's something that we try and and help in these folks, especially.
SPEAKER_00
Yeah. So do you find that people come to you because of their hernia, or do you find that people might come to you for other things and then they also have a great question or they Yeah, it sometimes goes part in parcel with other issues.
SPEAKER_01
And I also have had, I have had one patient who saw me in the past for prolapse and then came back to consult with me about a hernia and kind of what I thought about an intervention. And and that sort of makes sense, right? Because a lot of times the prolapse is a pressure management thing too. And so that was great because we did a big tune-up on how to lift and breathe and move. And then, you know, she worked with her surgeon to decide whether or not surgery was an appropriate intervention. And so either way, I felt like we could help her to be functioning better and more safely and not doing the things like the chronic straining, right? You know, with the constipation. So we really aggressively manage the constipation and that helped to reduce the strain.
SPEAKER_00
It makes sense. Yeah. It seems like this might be an area where, like so many other things, like you've talked about, where sometimes people don't come to you for a sexual issue. Correct. I mean, maybe with pain with sex, they've gotten referred to. No, but you're so right. But then once you start seeing them, it turns out that that's also there. That they come to you for one thing, and then you because you look holistically, that's right. You're like, well, actually, we can work on this too. Or what we're doing to support this other thing actually is also helping.
SPEAKER_01
Yeah. Definitely. I think it's an adjunct therapy, definitely. And so I'm I'm I'm really happy that the person that requested this requested it because I do think there is a role, but it's important to know that we're not going to fix the hernia itself. And that it is important to consult with a hernia specialist, you know, because you want to track it and know how big it is and if it's changing and getting larger. And so that's sort of where we work together.
SPEAKER_00
Yeah. Yeah. I mean, it's like if you had if you needed like ACL or something like that. Yeah, knee surgery. It's like there is a an absolute PT. Totally, yes. Like nobody would be like, no, I'm gonna get the knee surgery and never I mean, people say the knee surgery and then don't do their PT, but nobody recommends that, yeah. Right. And so, of course, you're not gonna fix the hernia if it's a surgical issue, but it also makes a ton of sense given all that you do with the diaphragm and the canister and everything, that PT would be supportive.
SPEAKER_01
Exactly.
SPEAKER_00
Okay. Thanks, Alex. You're welcome. Thanks to our listener.
SPEAKER_01
Thank you for listening to Under the Hood. If you liked this episode, please take a minute and leave us a review. And we'd love to hear from you. If you have any ideas for future episodes, please let us know.
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