By Dr. Nicole Fleischmann, Urologist
Dr. Nicole Fleischmann, a board-certified urologist with deep expertise in pelvic surgery and urogynecology, has devoted her career to women’s pelvic health. While her first love was pelvic surgery—honed through eight years of post-medical school training—her recent passion has turned toward helping women adapt to the changes that occur in the pelvic floor during pivotal life transitions such as postpartum, perimenopause, and menopause.
In clinical practice, Dr. Fleischmann sees countless menopausal women reporting a frustrating array of symptoms: nighttime urination, recurrent urinary tract infections, painful intercourse, and difficulty making it to the bathroom in time. While many patients attribute these issues to hormonal decline, they are often surprised to learn that lower urinary tract dysfunction (LUTD) is primarily a neuromuscular disorder that estrogen had masked for years. Once hormone levels drop, long-standing dysfunction is unmasked—and that is actually good news. Because only once revealed can it finally be addressed.
Pelvic floor dysfunction is not merely a byproduct of aging or tissue weakening. According to Dr. Fleischmann, it often reflects a breakdown in communication between the brain and the lower core muscles—particularly the pelvic floor muscles. Many of these problems originate in childhood. A common developmental issue known as bowel and bladder dysfunction begins during early toilet training. Children often learn to contract their pelvic floor muscles to avoid accidents, a necessary developmental stage. However, problems arise when this habit is never fully reversed, and the ability to relax those muscles is not properly learned.
Neurological readiness to voluntarily release these muscles doesn’t typically emerge until middle school, leaving a gap where children learn to strain against a tight pelvic floor. Though the strategy may appear to work, it establishes dysfunctional voiding patterns that persist into adulthood—manifesting as constipation, bedwetting, urgency, and other issues. Contrary to widespread assumptions, most children do not simply outgrow these patterns. Instead, they adapt to them, carrying the dysfunction forward.
These compensatory strategies often go unnoticed until a major stressor—anxiety, trauma, or menopause—removes the body’s ability to compensate. That’s when the subtle signs become impossible to ignore.
Dr. Fleischmann introduces patients to a new anatomical perspective to build awareness. She invites them to imagine the vagina as a mouth: the back vaginal wall as the jaw, and the tailbone as the chin. With breath and postural awareness, women can learn to “open the mouth” of the pelvic floor—an essential mechanism for healthy urination. Unfortunately, this natural opening ability is neither commonly taught nor instinctively retained.
True pelvic floor awareness extends beyond anatomical education. It’s about neurophysiological awareness—learning to sense whether the pelvic muscles are bracing or clenched throughout the day. Most women don’t realize they unconsciously engage these muscles, especially under stress. This habitual tension stems from an automatic guarding mechanism known as the tendon guard reflex—a protective response triggered by perceived threat. This reflex keeps the pelvic floor in a chronic state of contraction, which inhibits proper elimination. As a result, women often resort to pushing or holding their breath to urinate, falsely believing this effort is normal. Over time, this becomes ingrained as the default pattern, and many are never advised to stop pushing.
Adding to the problem, standard advice such as “just do Kegels” often makes things worse. This recommendation assumes muscle weakness is the core issue. But Dr. Fleischmann explains that many women suffer from hypertonicity, a condition in which the pelvic floor is already overly tense. More contractions only intensify the problem.
A hypertonic pelvic floor:
· Cannot contract effectively when needed
· Cannot fully relax to allow for urination, bowel movements, or comfortable sexual activity
· Tends to cause urgency, incomplete emptying, and pain
The origin of this hypertonic state is often traced to years of habitual behaviors: sucking in the belly, clenching the glutes, holding in urine, shallow breathing, and poor posture. These patterns are not the woman’s fault—they’re coping strategies learned in a world that favors tension over release.
So what helps?
The first step, Dr. Fleischmann emphasizes, is proper evaluation. A referral to a pelvic floor physical therapist (PT) can be life-changing. These specialists assess muscle tone, coordination, breathing, and pressure regulation. Many women assume they’re weak—but more often, they’re unknowingly tense. In fact, physical therapists frequently report how difficult it is to convey this to patients.
The second step is breathwork. The pelvic floor and diaphragm function as a team. Chest breathing keeps the pelvic floor braced, but intentional nasal inhalation, belly softening, and diaphragmatic expansion can initiate a powerful neurological release. This isn’t just mindfulness—it’s anatomical mechanics.
Third, Dr. Fleischmann recommends low-dose vaginal estrogen. This localized therapy restores tissue hydration, elasticity, and resilience with minimal systemic absorption. It has proven highly effective in addressing urgency, vaginal dryness, and infections.
Fourth, women must learn to let go of the chronic habit of stomach sucking. Though commonly practiced for posture or appearance, it compresses the organs, restricts circulation, misaligns the hips, and disrupts autonomic balance. “Sucking in your stomach doesn’t make you thinner,” Dr. Fleischmann often tells patients, “but it can make you lose bladder control.”
Finally, she encourages women to trust their sensations. If the body feels tight, disconnected, or blocked, it is not simply a function of age—and it is certainly not imagined. Reconnection is possible, even after decades of disconnection.
Menopause does not cause the pelvic floor to fail. Rather, it exposes long-ignored issues that can finally be addressed. The hormonal decline simply strips away the buffer that once masked dysfunction.
But it’s not too late to intervene. For those experiencing leakage, urgency, pain, or tension—Dr. Fleischmann offers this reminder: don’t give up. Don’t settle. Don’t default to a million Kegels. Instead, listen to your body. Relax. Breathe. And finally give your pelvic floor the attention it’s been asking for all along.
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