Lindsey Karamihalis treats problems that can be hard to talk about.

Urinary and fecal incontinence, constipation, pain during pregnancy and postpartum, painful intercourse – all are within the pelvic health physical therapist’s purview. And they are issues that affect millions of people who could significantly improve their quality of life with some treatment.

Lindsey Karamihalis, a physical therapist, is wearing her graduation robes over a pink dress.
Lindsey Karamihalis
Karamihalis (pronounced kara-MI-hal-is) recently began practicing at Novant Health Rehabilitation Center in Shallotte, North Carolina and is building a program at Brunswick Medical Center. She’s a natural at putting patients – men, women and nonbinary people – at ease. “Physical therapy after gender-affirming surgery is really important,” she said.

Her easygoing demeanor helps her patients relax. “If patients are super nervous to talk about these things, I don't pry,” she said. “I don't want people to feel uncomfortable. I want people to know these problems are extremely common.”

Much of her work centers on helping patients get in tune with and control their pelvic muscles, which can be at the center of incontinence, painful sex and other unpleasant problems.

Patients need a referral to Karamihalis and other pelvic floor therapists. That doesn’t mean you have to schedule an appointment with your primary care provider, though. Karamihalis said it may just involve a phone call or secure chat with your primary care provider.

People considering surgery often see Karamihalis to try to stave it off or avoid it entirely. Her patients might be candidates for bladder slings and suspensions, hemorrhoid surgery and more. In addition, she often sees patients after they’ve had cancer surgery to remove tumors in the vaginal and rectal areas.

A visit with Karamihalis starts with a conversation. She gets to know her patients’ health history and is likely to ask:

  • Does the patient have low back and hip pain that could be contributing to a pelvic health issue? She can perform an orthopedic evaluation of the musculoskeletal system as it relates to pelvic health.
  • Are there lifestyle factors involved, such as how often they’re emptying their bladder? If so, she may recommend “bladder retraining."
  • Do they have a strong bladder urge? In that case, they could benefit from urgency reduction strategies.
  • Are they drinking bladder irritants?
  • Do they have trouble emptying their bowels? If so, they may benefit from a new bowel routine and colon massage.
  • Are there lifestyle or behavioral modifications that might alleviate the patient’s issue?
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The conversation and an exam – if there is one – take place in a private, one-on-one treatment room. “I tell my patients they're in control,” she said. “I don’t even have to do an internal exam, although we do often have better outcomes if there is one. But it’s always a choice.”

The conversations are, by nature, personal. She often discusses with patients the best way to have a bowel movement. (There is a “best way,” although there’s no single best way for everybody. Strategies Karamihalis might suggest include elevating the feet on a stool, leaning forward, deep breathing and generating top-down pressure.)

Prolapse — where an organ droops or shifts from its normal position — is a common problem. Often in those cases, she’ll stress: No pushing. “If someone is pushing to empty their bladder or bowels, they may cause the prolapse to worsen,” she said.

For an internal exam – often recommended for urinary incontinence, frequency and urgency; pelvic pain; pelvic floor weakness and more – the patient lies on a mat table surrounded by pillows. During the manual exam, she’s trying to isolate the pelvic floor muscles. “You can get a ‘knot’ or trigger point in your pelvic muscles just as you can in your upper back or elsewhere in your body,” Karamihalis said. “Manual therapy can help those muscles relax and provide tactile feedback for muscle retraining.”

Karamihalis performs internal vaginal and rectal exams. “They're not super-scary,” she promised. “They're not supposed to be painful, but some people experience pain if they have a tight pelvic floor. Those exams give me a good idea if patients are isolating the right muscles.”

Biofeedback is another tool she uses. A non-invasive technique, biofeedback is used in pelvic floor PT for evaluation and as a treatment. Sensors are placed on the muscles and display the signal of the muscles on a computer screen as muscles contract and relax. It’s most useful in fine-tuning pelvic muscle control and improving coordination, endurance and strength.

The number of pelvic floor physical therapy visits a patient might need depends on how their body responds. It could take anywhere from two to 12 visits. “We may have to try a couple of different strategies to find the one that works,” Karamihalis said.

Treating women

Many of Karamihaliswomen patients come to her to strengthen their pelvic floor. “If someone gets a strong urge to go to the bathroom but can’t make it in time without leaking, their pelvic floor muscles may be weak,” she said.

Sometimes, though, they need to relax rather than tighten.

“I focus a lot on stress management and relaxation techniques,” she said. “A lot of patients I see – men and women – are stuck in a fight-or-flight response. Their bodies are in a state of constant stress, which translates to muscle-holding patterns. They may be holding the pelvic floor muscles really tight and not even realize it. So, they're basically walking around doing Kegels 24/7.”

Kegels, exercises that strengthen the pelvic floor muscles, are a frequent topic for Karamihalis and her female patients. But she doesn’t always prescribe them. They’re not right for pelvic pain, for instance.

“There’s a big misconception that every woman should be doing Kegels,” she said. “Sometimes what you need is the opposite of Kegels.”

Kegels are advised for people with prolapse – of the urethra, vagina or rectum – and those who don’t quite have the power to stop a stream of urine. Two of the more common reasons for prolapse are incorrect pushing during childbirth and pushing to have a bowel movement with constipation.

Pre- and postpartum moms are among those Karamihalis sees most often. “My career goal is to be able to see moms in the hospital after they give birth and give them strategies for muscle recovery and function after both C-sections and vaginal deliveries as well as strategies on how to have a bowel movement and empty the bladder,” she said.

Ultimately, she’d like to meet with pregnant woman before they give birth. “There's a lot of education that could make moms-to-be more comfortable,” she said. “I can teach them how to push in the right way and not bear down on their pelvic floor, which can cause prolapse.”

Treating men

Karamihalis sees a lot of men in her practice, too. “Men sometimes have testicular and pelvic pain that appears to be prostatitis, but the symptoms don’t get better with treatment,” she said. “Often, it can be the pelvic muscles causing the pain.” The treatment might include muscle relaxation, stretching and mobility exercises.

Men can do Kegels, too, although Karamihalis generally refers to them as pelvic floor contractions with her male patients. If men experience urinary incontinence after having their prostate removed, pelvic floor contractions might help.

After they've had their prostate removed, men often experience urinary incontinence or leakage. Karamihalis hopes to establish a “pre-hab” program at the coast that involves seeing men before they have a prostatectomy. Such a program already exists in Winston-Salem.

Erectile dysfunction (ED) is also classified as a pelvic floor disorder. If the cause of ED is impeded blood flow, pelvic floor physical therapy can be an effective treatment.

Karamihalis doesn’t treat children, although there are some pelvic floor therapists who do. Karamihalis’ youngest patients have been 18, and her oldest was 98. Pelvic floor problems can happen at any age, she stresses.

“There's a misconception that pelvic floor problems like incontinence are to be expected as you age,” she said. “But you don’t have to live with these issues.”

Karamihalis’ aim: give patients their life back.