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In this interview, we talk with Dr. Nicole Cozean, PT, who is changing the way we treat people during pregnancy, postpartum, and those who struggle with interstitial cystitis. Interstitial Cystitis, similar to painful bladder syndrome, benefits from an integrative approach that Dr. Cozean wrote an entire book about.
Throughout the conversation, she shares her own experiences with infertility, navigating an unmedicated birth, and all of the lessons she has learned through her personal and professional life in the world of pelvic health. She started working with people diagnosed with Interstitial cystitis early in her career, and saw firsthand the enormous benefit of using an integrative approach for her patients.
While the research stated IC was a life long chronic disease with no help available, her patients were seeing full or near full return to a normal life. This is the main message we want to communicate to all women everywhere. You don’t have to live with pain and you can recover fully after labor (regardless of the type of delivery).
Want to find out how? Check out this interview with Dr. Ginger Garner and Dr. Nicole Cozean.
Dr. Nicole founded PelvicSanity to provide the type of care she believes all people with pelvic health deserve. In the seven years since it’s inception, PelvicSanity has become one of the best-known clinics in the country, with complex patients routinely flying in for treatment.
Nicole is also one of the foremost educators in pelvic health. She has trained more than 1,500 clinicians in the PelvicSanity treatment approach, runs a teaching group for 10,000+ practitioners and runs an annual conference in Atlanta (“PelviCon”) for pelvic rehab professionals.
The award-winning author of The Interstitial Cystitis Solution, Nicole has been an advocate for patients and better care for almost two decades. She personally handpicks and trains each member of the staff to ensure every patient at PelvicSanity is getting world-renowned care.
Nicole makes her home in San Clemente with her husband (Jesse), son (Clay) and cats (Mitty & Ziggy).
HR 2480 Congressional Bill Information – It takes 2 minutes to contact your congress member and ask them to cosponsor or simply support this bill. It will save moms’ lives and quality of life. Love your mom and take 2 minutes, we thank you!
0:00 Dr. Ginger Garner: Hi everyone and welcome back. I am here with a guru of many things today. I want to introduce you guys to Dr. Nicole Cozean. Welcome. Yeah.
0:14 Dr. Nicole Cozean: Thank you so much. Ginger it’ss so great to be here and thanks for having me.
0:18 Dr. Ginger Garner: Thanks for being here. My face is about to split off cause I’m so happy that you’re here because you, you’re an expert at so many things. So you guys, for those of you who do not know Nicole, I want to give you a little introduction to her and we are just going to be off and running with so many good things that we have to talk about.
She’s the founder of a bunch of stuff. Pelvic Sanity for one, which is in Southern California. That’s her clinical practice. And Pelvic PT Rising, which is business coaching and continuing education and all things elevating the status of pelvic care and healthcare in the U.S. and beyond, really. She’s also the author of the IC Solution, that is Interstitial Cystitis, for those of you who don’t know. She runs the Pelvic PT Rising podcast, because she needs hobbies, and the Pelvic PT Huddle, which is a great group online. Which I have interacted with quite a bit. She’s also the co-founder of Pelvicon, which is the first conference of its kind because it’s by and for pelvic rehab, which is fantastic. And I think it sold out like right away, again.
1:33 Dr. Nicole Cozean: again, three years in a row.
1:35 Dr. Ginger Garner: Yeah. All right. Um, she was named the ICNPT of the year and the first PT to sort of serve on the ICA board of directors. And is a Chapman University Alumni of the Year, which is, of course, where you graduated. Yes. All right. That’s a mouthful.
1:54 Dr. Nicole Cozean: I know. Thanks for that. I know sometimes when you see all of the things, it’s kind of like, oh man, I’ve done a lot of stuff.
2:03 Dr. Ginger Garner: Feel good about yourself today. Yeah.
2:05 Dr. Nicole Cozean: It’s like a good start to today.
2:07 Dr. Ginger Garner: And the next day. And that is a perfect place to start because here is, here’s the deal, or here’s what I think the deal is. And you can correct me if I’m wrong. I think that as, because you’re a new mom, Congratulations.
2:24 Dr. Nicole Cozean: Thank you.
2:25 Dr. Ginger Garner: As a woman, as a new mom, as a small business owner, and as a therapist, that’s a special kind of caregiver, I think. As a therapist, we grow up with this conditioning of achievement and caregiving and leaning in, and you can do all the things that you want. And then, that’s kind of a full sentence. It’s like, and then, you make choices and you realize that, you know, maybe as a woman, you’ve got to work harder or be a little smarter or speak a little louder or do it in uncomfortable heels or whatever.
And then you notice, and I’m pretty transparent with my story too about struggling with everything that happened with, you know, I had infertility for such a long time. I thought, well, I’ll adopt or, my patients are my kids, you know, my business is my kids, that kind of thing. There are so many pressures on women and in the United States, a complete lack of actual support for moms and families because we’re moms where mama ain’t happy. Nobody is happy.
3:31 Dr. Nicole Cozean: Yes.
3:32 Dr. Ginger Garner: And since we don’t have any maternal and paternal leave and support, That’s a lot of stress. It’s a lot of pressure. And it’s not just on the moms. It’s also on the dads. It’s on dad’s day home, so mom’s day home. So let’s just start there. You have Clay, who is, I can’t wait to meet him someday. Welcome to the world, Clay. He’s almost one year, you said, already?
3:54 Dr. Nicole Cozean: Yeah. Yes.
3:55 Dr. Ginger Garner: Oh my gosh, this is where I wish that you could just like flash the cute picture, but we don’t want to put our kids all over media, that’s for sure, but I can’t wait to see them. Tell me a little bit about that story and your progression, because with everything that you have done, I do seriously want you to like stop and give yourself credit for that, and then tell me how hard it was.
4:17 Dr. Nicole Cozean: Right. Give me the real scoop. Well, so first of all, I think one of the biggest realizations that I’ve had to sort of grapple with and am still grappling with is that when you go from being on point, on your schedule, on I can do all the things. I can schedule whatever I want. I can do whatever I want. I’m crushing, objectively crushing at a lot of things.
And then boom, you think that postpartum is just going to be this period of time that you have to get to, right? And whatever that is, is it three months? Is it six months? Is it what ACOG says of 12 to 18 months? Like you just feel like you just have to get to this one point and then it will all be better. I just have to get through this period. And what I’ve really come to realize with quite a rude awakening is that It’s changed forever now. In terms of the lack of control you have over your own life, schedule, and things just become a little bit harder.
I actually joke a little bit. It’s actually not very funny, but some of my staff, I used to be understanding, as much as I could be understanding, of my patients that were new moms. That were calling, that were late canceling, that were saying, my child care fell through. I can’t come in. And being admittedly slightly annoyed at that sometimes and being like, oh, people in this postpartum phase, if they would just put themselves first, that’s what they need to be doing.
And I had a big meeting with my staff. I mean, it’s like, hold on. comical now that I look back and I was saying that, but I had a meeting with my staff, you know, in that early postpartum phase and I was like, okay. First of all, we need to change all of our birth prep and pregnancy program at Pelvic Sanity. Secondly, we need to switch all of the postpartum program. But thirdly, what I really wanted to sort of hone in on was that, man, it is a miracle that any mom can make it to any appointment and even think that they’re trying to maybe put themselves first in that first you know, for sure year and beyond, honestly.
Because what’s shocking to me is the amount of immediate feelings of, it’s not about you. That suddenly your priorities are completely turned up on side their head. And for someone like me, who’s I’m a little bit of an, you know, quote unquote, wonderfully geriatric age pregnancy.
7:21 Dr. Ginger Garner: I know about that too.
7:22 Dr. Nicole Cozean: Cringe, cringe, right? But, you know, objectively I’m like, you know, older mom. I had some fertility struggles. We had miscarriages and loss and we had to do IVF and all the things. And I’ve talked openly about that on the podcast. So, but having been through all of that, you know, in, even that didn’t prepare me for the immediate change in priority and just the realness that that brings. And it’s been actually really challenging for me with having all of those, all the things that you just mentioned are just now used to be like top thing and now they’re just not.
And so I’m sort of starting to like recalibrate what’s important and how I’m going to be able to still get it all done. So thank God for my husband, Jesse, I have a great family. I have wonderful support, but it, even with that, it’s still really, really hard. And thanks to my mental health therapist. That I had to that right now, dude, shout out because honestly, and thank goodness that I took that leap. I did it. I did mental health therapy and EMDR all through my fertility struggles and miscarriages and stuff. And that has, that really gave me, I think, a great foundation for being able to, to have this, these challenges and be okay with being like, I think I need some help still. I think that journey is not over. So 100% love my therapist and really I’m thankful that I have the ability to, to see them.
9:13 Dr. Ginger Garner: Yeah. So for there’s like two points here. One is for, for mom’s listening. You can stop beating yourself up now, because if you’re listening to two pelvic PTs talk, and we didn’t even talk about doing the pelvic PT, that’s required postpartum. Right. And if it’s hard to get to do all that, and we have freaking degrees in this stuff, then you can, we can all just exhale a little bit and go, ‘Okay, all right, I’m not going to beat myself up.’
And, and the second thing that I hear to you saying is, and I want to say to everyone who pays mothers less for every child they have, and for the gender pay gap out there, that is a real thing and exists, it’s so freaking backwards because for every kid you have, you know, sometimes pets can be included with that. They’re kind of high maintenance too. You are a taskmaster. You have to become more organized. You have to be, you have to have better structure, better infrastructure. Your time management is just, it’s like razor sharp and, and it’s out of necessity.
You know, so that’s the other piece of that as is we get more competent, not what the research shows that society thinks and pays us for, which is less competence. Men with children get paid more. Women with children get paid less. It’s like, OK, well, let’s just speak to that now. No way you become, you know, multitasking does exist. Yeah, that’s what mothers do. So I just want to shout out to all the moms out there to you, Nicole, for you know, you’re already working on those kind of razor sharp skills of getting it all done, of running a clinic, of running a continuing education and coaching company and putting yourself out there with a podcast and with the conference and everything that you’re doing and continuing to write because, you know, those are the things that you love, but it’s also, it’s all, it’s also born out of, I think the passion that you have, particularly for IC.
11:27 Dr. Nicole Cozean: Yeah, absolutely. The one other thing I’ll add to that, Ginger, because that was a great summary, is that I don’t want anybody else either. One of the things that I had to, I came to have a real self-realization about was that, you know, I thought that maybe there was going to be a part of me that was going to want to be stay at home mom and really, really put my focus there. And I was able and had the luxury of being able to take an extended maternity leave because I have an amazing staff and we worked really hard to be able to take as much time as I wanted and needed away from at least the brick and mortar clinic.
But there’s a lot to wanting to go back and wanting to still continue to do those things. And then the mom guilt comes with like, well, if you really think about it, the priority is Clay. But also it’s okay to have goals and aspirations outside of taking care of him. And so that’s another thing that I’ve been working really hard on is to allow that to be okay. And that, yes, it’s okay to have childcare and still have those professional aspirations, that’s okay. Those things can coexist.
So for any working mom out there that has any of that guilt filled in to be like, oh, should I stay home? Am I missing out? What should I be doing? I just want to say, it’s okay to have those goals and aspirations. And it doesn’t mean you’re a bad mom and it doesn’t mean you don’t want all of the things for your professional life. Because those things can coexist. It just takes a lot of work and a lot of self-awareness and support. So that’s one of the things too, I was very surprised at where I was like, you know what, like I do want to still continue to crush at this other stuff. Like I want to keep doing it all. So we need to have a little bit different expectations about what that’s going to look like. Um, but also it’s okay to still have those, those goals.
13:48 Dr. Ginger Garner: Yeah. I think that, you know, if we, if we consider this is 2023, Look back to 1923, you know, 100 years ago when even hand washing between birth deliveries was being made fun of, like, it wasn’t a thing. That’s a whole other story in itself. If you look at the origins of childbirth in the United States, along the lines of not even knowing what hygiene is, comes that heavy social conditioning that women’s only identity was to give birth. And so that’s like epigenetically, it’s like code written into us.
And so I think of the guilt that I used to have, like a piece of luggage, like, oh, it’s time to pack the guilt bag for the day. How heavy is this damn thing gonna be today? We can swear, by the way.
14:38 Dr. Nicole Cozean: Oh, cool. Unleash.
14:40 Dr. Ginger Garner: This is what we do get passionate about. It’s our lives, it’s our livelihood, and it’s important. It’s important enough to swear. And I had to give myself permission, like literal, verbal permission. I was going on a trip. It was 20 or so years ago, and I was about to teach a course. It was probably a California thing where I had to go a long way. Yes, it was. And I was going with my middle son. He was still nursing. He was like six months old. I can’t leave him. I have to take him. And I had to say out loud, I can do both of these things. This is not outlandish. This is not selfish because I want to work.
Nobody says that to dads, right? Oh, you want to work and have a kid? You can’t have it all. Nobody says that. So I hope that, you know, and we’ve heard this stuff before, like put down the guilt and all that, but I think we need to hear it again and again and again, to kind of banish it out of the, you know, the kind of the epigenetic impact that it has on us as women, because we all know what that feels like. As soon as you say that, you know, the guilt thing and giving yourself permission, we’re all like, yeah, yeah.
15:53 Dr. Nicole Cozean: Yeah. You know, one of the really cool moments of this last Pelvicon, and you mentioned Pelvicon. Pelvicon’s a big pelvic health rehab conference that I co-founded with one of my really good friends, Jessica Reale of Southern Pelvic Health. So we, so Clay was eight months old or so, at the 2023 Pelvicon, the 2022 Pelvicon, I had to go, I was actually in the middle of a high risk pregnancy. Right. So, uh, had to like talk to my, my maternal fetal medicine doctor about like, so why Why do you say I can’t travel right now?”
And then I made the decision to still go, with his blessing of course, but reluctantly. So he was in my uterus then, and then it was a very triumphant moment in 2023 where he was there. We had, we actually changed the game a little bit. We actually had a breastfeeding, feeding family room, right outside the conference. We live streamed the conference into that room so that anybody that was, had a little one, needed some family time could come right there, not miss anything of the conference either.
And so, but one of the most triumphant moments of 2023 for me was to introduce somebody in the pelvic rehab field who was sort of paving the way in terms of fertility is Yeni Abraham. So I got to, to, um, introduce her on stage with Clay. And I was like, this is like such a cool full circle moment of your mom. You are, you’re, you’re still here. You’re running this huge conference with him and. Um, it was, it was a really cool moment. And then after, right after I, right after I introduced, uh, her, I like ran into that feeding room and did my, and breastfed him and then, and then handed him off to, uh, someone that was helping me take care of him for that conference week. And then, uh, went right back out onto the stage. So it was a really cool just moment of like, yeah, you know what? We, we made it work. We can do it. We, we, we did it, you know, we’re doing it.
18:10 Dr. Ginger Garner: Yeah. Yeah. I’m already thinking of like the the adrenaline high from after that. I’m like, did you sleep for the next three days? Yeah. Now it is after you speak or something. You’re like you’re up there.
18:22 Dr. Nicole Cozean: Yeah, totally. Yeah.
18:25 Dr. Ginger Garner: Oh, my gosh. So talk to us, how was the birth process? I mean, for you? Because it’s, it’s one thing to talk about it, you know, mom to mom, but we’re talking about it, pelvic PT to pelvic PT, you know, also on top of it. Yeah. How was it?
18:44 Dr. Nicole Cozean: You know, it’s so funny. It’s like, you know, we do this for a living. We have a birth prep program at public sanity. We teach people how to push. We, we teach people how to, you know, advocate for themselves during the process. And we do the birth preferences and the partner things and all of the stuff, right. We do the labor positions where your pelvic floor is the most relaxed, and we do perineal massage. We do all of it. And I will tell you, I was so frigging humbled during this whole process.
My birth was, I had the goal of doing an unmedicated vaginal birth, and I was able to do that. And it was, the birth itself was really amazing. But one of the things that surprised me the most, and I did all my birth prep with some of the PTs at my clinic, I was feeling super confident. I worked with a really great doula who helped me with my mindset and all the things. And my labor was actually from start of contractions to Clay in my arms was only five hours. And for a first time, that’s a first time birth. [That’s fast.]
Yes. I just kind of don’t even realize that that was happening at the time and got to the hospital. It was already 10 centimeters. They were like, okay, in the wheelchair, I was getting the urge to push and all the things. So, but what was interesting is that my pushing phase was actually a little longer than I would have probably anticipated on paper if it would have been a multiple choice test. I could not, even with all of my experience, I literally do this for a living. I’ve been doing it for 18 years, teaching people how to have a vaginal birth. I could not figure out how to generate that type of force.,
And so what was interesting about that whole process for me, I had a hard time. I finally figured it out and then he popped out a couple of pushes later, but it took me like an hour to figure out what I needed to do. My midwife was amazing. She let me do all kinds of positions. The position that I thought I wanted to be in wasn’t it. So all of that prep work of the mental prep work of really just letting go and being prepared for everything and nothing at the same time was really what ended up happening. I barely tore. It was on paper, it was awesome. But then I came back and I was like, man, why could I not figure that out? I cannot believe it. I can’t believe that, right? I cannot believe that it took me an hour to figure out what the hell was going on with that pushing phase.
And I ended up actually popping a freaking blood vessel in my eye because I… literally like I was breath holding, I was doing all kinds of stuff. All the things you weren’t supposed to do, right? But, and I put that in quotes, like weren’t supposed to do. I feel like one of the major changes we’ve made at Pelvic Sanity with our birth prep now is that we now talk about an optimal birth, an optimal way to push. But at the end of the day, when you’re in that moment, sometimes that might not be the way.
And I think to myself now, I’m like, gosh, we need to really make sure our language is on point so that we don’t make people feel about not being able to, to figure something out the right, the right way, or, you know, open glottis pushing. We all talk about, you know, being able to breathe your baby out. Well, if that’s not working, then what? And in my mind, as my midwife was trying to coach me in. I needed to generate some downward pressure in order to get Clay to move to a different position. And I remember being like, no, no, no, I don’t want to do that.
You know, because it’s like those things in your head are like opposite. And then I was like, actually, I’m just going to fricking go for it. And then I did it the quote unquote wrong way, you know, and he popped out. So I don’t know. I just, for any practitioner listening, I feel like it’s a great lesson in, you know, when you’re in the moment, Or I think about how I was before when I hadn’t had that experience. I hadn’t had a baby yet.
And not to say that you have to have any experience to be a good practitioner. You absolutely don’t. I believe that you can have any sort of experience and still help people well. But there’s a little bit of a difference. I think we need to prepare people for if things don’t go the way that we exact want them to, or the exact way that is optimal that we’re teaching, that it’s okay to move to this other type of way.
24:00 Dr. Ginger Garner: Yeah. I liken it to, I’m just thinking about my birth experiences when you were saying that my first was 36 hours, but the second one was four. Yeah, feeling your fast and furious birth. And the third one was five hours. So it was also fast and furious. And I’m thinking about the pushing phase when you also feel like and I tell all my mom’s this. And it’s almost like I get really close to the mic and a little quieter when I tell them this. I’m like, you’re gonna want to give up when you get to transition. Just just saying I don’t care, like every single birth, I coach it all the time, you know, and then I’ve given birth three times. I still thought that I could somehow quit and not finish the birth process because you’re in another place.
You’re in that place where the eye’s a little glazed over, you are tired, even if it’s only been two, three, four, five hours, that’s still a marathon. You’ve been running that marathon for four or five hours. You’re still exhausted. And so you get to a place where your body like you physically are depleted, even if like you can eat, you can drink, you can do all the things that used to be air quotes for those of you guys listening that used to be, you know, not allowed. Of course, you know, is now and you can still just physically not have, you know, the “umph” to do it.
It’s kind of like, If I had to, or anyone, I think the most nerve wracking thing you can do, in addition to giving birth in public with lots of people around you, is yeah, bear down and push this out. And with everyone looking at you is to sing, you know, in public, like the national anthem where everyone is staring at you and, and you’ve got to get it right. Like, I might as well be pushing a baby’s head out of my vaginal canal with a mic, you know? Yeah. And when you got to hit that night in the note, because like something like the National Anthem is so big in range, it hits my whole range, top range to bottom range. It really doesn’t matter how you get that note out. If you are singing that in front of six, 8000 people, it’s like you’re going to get the note, even if you slightly do it wrong. Yeah, yeah. Go back and revisit that later.
26:27 Dr. Nicole Cozean: Right, right. We can debrief about that. We can debrief.
26:30 Dr. Ginger Garner: But in the moment you got to get it out, you know, whether it’s the note, the baby, the whatever. And so I’m, I think about a music analogy, you know, vocal analogy with that. Um, not to mention that the voice is so important, you know, for the pelvic floor. Absolutely. Yes. Yeah. Oh my gosh.
26:50 Dr. Nicole Cozean: So a lot of changes though, from, um, from having the experience and, and. And I think there’s advantages to both. At Pelvicon last year,, a really awesome physio named Taryn Hallam spoke and said, we were doing like an ask me anything panel. And she said something so cool. She said, you know, if you haven’t had the experience of having a baby, the cool thing about that is that you’re not biased. Your experience isn’t biased how you speak to patients or how you teach birth prep, right? And then if you’ve had that experience, then you can use that, you know, to your advantage.
And there is something different about having been through it, even though my N is only one, right? Your N is three. So there is something to be said for advantages on both sides of that. And I thought that was such a cool way to look at it. One is not necessarily better than the other, but it is interesting to know it. And as a patient, it’d be interesting to know like, hey, you know, do you have, experience, or do you not? Because then that can influence how you train patients. It can influence what you say to people either way. And so it’s kind of good to just know who you’re learning from in that way. I think that would be a great question for anybody to ask. And as a practitioner, you shouldn’t take offense if anybody asks that, right? It’s just information.
28:24 Dr. Ginger Garner: It’s part of people’s preferences, and they have that right to choose. And people may want to choose a practitioner for different reasons. Absolutely. Yeah. So yeah, shout out to Taryn Hallam for her awesome work with pessary fitting and just in all things knee deep and research. Yes. Yeah. Which is fantastic.
So let’s talk a little bit about, wait, let me, let me back up two steps and shore up that last piece of the conversation because there was one more point and I just, it’s going to linger like back burner in my mind, unless I say it. And that is, I think that the physical prep for birth. That’s like, you know, whether it’s all the lifestyle medicine pieces of staying healthy and feeling good prenatally and preparing to push and doing birth coaching, which you guys, you guys listening, I highly recommend you seek out. a pelvic PT or OT because they’re going to give you the most customized, compassionate, open-minded, evidence-based care when it comes to birth prep.
A lot of people think, I’ll just go to the hospital class. Well, the hospital class is really about preparing you for hospital policy. It’s not really preparing you for birth. Not that they can’t have that there. They can. But historically, that’s not what the hospital classes were necessarily about. And so when you seek that independent voice, you are really getting your goals met, you know, for whatever kind of birth you want, that pelvic PT or OT is going to help you accomplish that. Absolutely. So just shout out for that. But the other piece that I wanted to shore up was all that physical prep is so important. But I think the mental health prep is equally as important.
30:22 Dr. Nicole Cozean: A thousand percent. Yes. So however somebody wants to do that, mental health therapy, hypnobirthing, Bradley, doula, whatever, it just needs to be something. And hopefully it’s a doula that matches with your personality and all of your other alignments in your life. Hopefully that person can help, but man, highly recommend that.
And there’s a lot of pelvic floor rehab providers now that are adding doula type services to their repertoire, which is awesome. I love that as well. So it’s just a good other little lens to look at, but man, that mental health prep, whoo, important.
31:08 Dr. Ginger Garner: It takes a village. And you might be able to, for those of you listening, you might be able to just simply ask your pelvic PT or OT because everyone who is in practice typically has team members that they go to. Because we realize how important it is to have a village that nobody can do all the stuff alone. We just can’t. Nobody’s good at everything.
Which is a good segue to ask about your whole experience with treating IC and the whole explaining that to the audience of, you know, painful bladder syndrome and what is that and how did you get into it? How did you develop such a passion for it and decide, you know, I think I’m going to pop out a book on this.
31:58 Dr. Nicole Cozean: You know, it was actually a really organic process with that. So when I first went into pelvic floor physical therapy, I had the luxury of being trained really well, really early. And part of that was because I was hired, actually not for pelvic health, for ortho, and then asked to build the pelvic program at this hospital.
So I reluctantly at that point said, yes, ended up falling in love with the specialty like most of us do. Just with the way that we can impact people in a different way. I think then, oh, my knee hurts. It’s very different to have someone come in with vaginismus, which is a painful penetration, involuntary spasming of the pelvic floor muscles. The person like that coming back to saying, I cannot only have pain-free sex now, but I’m also pregnant. I mean, those are the kinds of things that… That’s just the best. The best, right.
So I ended up getting paired with, at the hospital, a urogynecologist who was also really sort of up and coming in the local medical sort of realm in Orange County. And his passion at that time was interstitial cystitis. And so he was doing some sort of newer, he was doing bladder cocktail type installations before those were really like a big thing. and recommended by the AUA and stuff. And so he was really doing some neat bladder centered treatment, which is what they can do, right?
So I was sent a lot of interstitial cystitis patients from this urogynecologist that we worked really closely with. And so I happened to not only be a newer pelvic health PT, but also then got these really chronic pain complex people really early on in my career.
34:15 Dr. Ginger Garner: Tough to treat straight out of the gate.
34:17 Dr. Nicole Cozean: Yeah, really tough. And so I had a great mentor. Um, I had had some really good training and I also at the time had the luxury of time, right? So I would go home and I would just do deep dive research into, man, this person seems really bad. Like I don’t know what to do. And, and they said this one thing and does that make sense? And so I would do my own independent research. And what I ended up finding was, was insane.
All of the misinformation that patients were essentially reading about interstitial cystitis. I would look at the PubMed research articles and some of the other things. And I’d be like, well, that’s not, that doesn’t match up. And so I started to really question some of the things that I was seeing. I was like, well, my patients seem to be really doing well when we’re assessing, when we’re addressing the pain component of the condition and the pelvic floor component of the condition. And they’re getting good, really good medical care for anything that they need to on that end. So why is when I’m reading, does it say this is an incurable disease that, you know, all these doom and gloom things about…
35:35 Dr. Ginger Garner: Yeah, catastrophic.
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35:37 Dr. Nicole Cozean: Yes. And so that’s what initially was my impetus to put out a resource that was not only evidence-based, but it was hopeful and helpful and practical information that people could use. So I wrote it for patients, but I also, in the back of my mind, wanted any practitioner that picked it up I wanted them to see that, like, we had done a really good job researching all of the conditions as well, and actually diving into the research about them. Right.
For just to give you one example of something that we ended up finding is that, you know, a lot of people would say, Oh, it’s a women’s condition. There’s, you know, the average age of diagnosis is 40 and women in their forties are typically people that get interstitial cystitis. And you look back at the little superscript about, let me actually go to that article, the one that they’re citing. And most often, anybody that was quoting that stat, it came from one article that was one county over a 20-year period of, I’m not joking, like less than 20 people. And the majority of those people happen to be women. And that’s what everybody was just quoting.
And then when you start to look at the chronic prostatitis type literature and the fact that those conditions are very likely overlapping, if not the exact same thing. And so now all of a sudden it’s like, well, men get it too. And if you look at the actual prevalence of bladder symptoms and the concurrence with pelvic pain, the overlap is much greater and the numbers actually come out to be a lot more similar for both genders.
And so, you know, it started to really enlighten us to those kinds of things. And I think that that’s been my passion for a long time is making sure that people have positive practical evidence-based information. about a condition and even though interstitial cystitis is a chronic pelvic pain condition that people can still live really well, to use your phrase, can live really well with it and can even come out of it symptom-free.
And I feel like that in and of itself, the belief change that now becomes a growth mindset instead of fixed mindset. I have this condition, it’s going to be like this forever. I have to learn to live with it versus I can change my symptoms. My symptoms can have the ability to significantly decrease, if not go away. Is just a, that in and of itself, I think is therapeutic.
And so that’s really why I have the passion for the condition. I love treating it because people get better. And it’s so amazing to see the change in their demeanor, the change in their life, when they realize that their life isn’t over and they can do whatever they want despite their “diagnosis.”
38:43 Dr. Ginger Garner: When you first started to tell your story, I was like, I wanted to jump in there and go, yes, for decatastrophizing what basically, and we I’m not necessarily blaming, like, we’re going to blame the medical profession. We’re going to blame the journals. We’re going to blame. It’s not about blame really. It’s about the mindset that our healthcare system has had in its tiny little evolution of a hundred years or so, right?
Is that you have worked to end that catastrophization of a condition that never had to be that way to begin with, which women and men alike, um, and any person who would get it might have before felt like it was a, it was the end of their normal life as they knew it, you know, like a death sentence and it really isn’t. Because when you talk about some of the symptoms, and that’s my next question, is just, you know, give people an idea of what it feels like for someone to have it. Because in seeing patients that come into my practice, to see their faces go from that, you know, devastation, I’ve seen three or four people, I’m never going to get better to, them coming in and going, you know, feel pretty good lately. I don’t really know if we need to do much today. Can we just talk about some prevention? You know, like I want to I’m going to wherever I want to prevent a flare, you know, let’s talk about nutrition or whatever. So tell me what people come in feeling like.
40:20 Dr. Nicole Cozean: Yeah, so the overwhelming majority I think of symptoms that we hear people say is that I feel like I have a UTI times like 1000 and what can be really sort of difficult is that maybe it started as a UTI. The UTI clears and then the symptoms stay and persist. I think some of the more severe cases are, it feels like there’s glass shards in my bladder or urethra. It just burns like crazy. It either hurts to pee or I feel like I have to pee every minute. And if I don’t go, even though I go a trickle, it is starts to become painful. Like I like it’s the fullest bladder I’ve ever had. Those are, and those are really like distressing symptoms. Those are awful. I mean, you, we all have had at least one experience where our bladder is actually been full and it creates pain, right. On a long car ride, we can’t go somewhere, whatever.
41:27 Dr. Ginger Garner: Um, and we’ve all most had a UTI. That’s a familiar feeling, yeah.
41:31 Dr. Nicole Cozean: Yeah, that’s a familiar feeling, at least for most people. And man, having that all the time, you can- [Can’t function.] Can’t function. And the thing that I talk to my patients about, it’s like, we’re neurologically wired to care about that more than if my elbow is hurting. So it’s not surprising that we end up with all of the brain changes with the chronic pain part of it, because your body’s paying attention more to a really, really important organ of our body.
Not to mention that it has some of the most high density of nerves in the nervous system. Your bladder is like a really sensitive organ just to begin with. And so that is, I think, what people mostly come in with. The technical definition is that you have to have two major things. You have to have some sort of irritative voiding symptoms, so urinary urgency frequency. Meaning you either have to pee a lot, you feel like you have to pee a lot or you actually are peeing a lot in the presence of, and this is key, in the presence of some sort of pelvic pain.
And that’s why sometimes it’s called painful bladder syndrome, bladder pain syndrome. There’s a million acronyms and it’s all confusing. And then the United States, it’s different. So we call it IC, most everywhere else, it’s only IC if you actually have ulcerations to the bladder lining. But all that being said is that there are those two major hallmark signs of the pain part and the some sort of bladder symptom part.
But one of the things that I feel like most people, I always just mention this and I want to shove it down everyone’s throat, is that just because the symptoms are primarily bladder does not mean that there’s anything wrong with the organ itself in the majority of people. And that’s, I think, another major mindset shift for patients because it’s like, I feel like that’s happening. I feel like there’s something wrong with my bladder.
What do you mean? It can be my pelvic floor, my nervous system, you know, they, that, that is like, but, but I have bladder symptoms. So something must be very, very wrong. And that’s your brain talking, right? Because your brain is making it seem like that. So you pay attention, but the actual cause of bladder pain syndrome can be, and in the majority of cases is at least in part pelvic floor related and how your nervous system is responding to that sensation.
So, um, but that’s one of the really amazing things about it is because then we know what to, we know we can treat, we know what to do. And it’s also why a lot of bladder centered treatments and installations and all kinds of other stuff, like they don’t always work super well because they’re targeting an area that’s actually not, that doesn’t have a problem.
44:51 Dr. Ginger Garner: Yes, their leaned up against the wrong wall.
44:54 Dr. Nicole Cozean: Yes, totally. So, but that’s why I’m so passionate about this is just because there’s so much misinformation we can help patients. And I’m not saying it’s that simple. You know, IC is actually a very complex condition. So I’m not saying it’s easy, but it’s certainly possible.
45:15 Dr. Ginger Garner: Yeah. Well, and to mention to listeners too, that, you know, not only do you treat it, but you took, you teach a course on it and other courses, other continuing ed courses too. So that’s incredibly helpful because, you know, you’ve trained, you know, thousands of PTs and OTs to be able to treat IC. So There’s a lot of people spread out across the country and the world that are able to treat IC. But if you’re looking for training, you know, you know where to go. And if you’re looking for treatment too, because I think you have a Find a Therapist listing as well. Right?
45:52 Dr. Nicole Cozean: Yeah. Yeah, yeah, yeah. So, um, we have a practitioner map, um, and that’s, that’s a more generalized map. That’s not necessarily anybody that’s taken any of my courses, but people can, can just reach out to me and DM me. We know a lot of people around that have. And that was just one of the interesting things, right?
When I wrote the IC solution, I wrote it to patients and my big thing there was that it’s not only a bladder problem. Pelvic floor rehab can really help, pelvic floor PT, pelvic floor OT can help. And then I was getting a ton of like hundreds of messages back being like, well, I went to pelvic floor therapy and then I was given only pelvic floor contractions, only Kegels, all the things. And so that’s what really was the next impetus for me to actually be like, well, now I need to teach other people what the research says. What I’m doing, and then also, and then have that be sort of my propagation of good in the world. And that’s been really exciting to sort of make sure that people are really learning about the condition in the way that we can help patients the best with all that evidence. So that’s sort of the impetus to do that too.
47:15 Dr. Ginger Garner: So public health point for everyone listening, you know, if you have bladder symptoms where the ones that Nicole has mentioned. One of the things that she mentioned was that if you’ve tried pelvic PT or OT before and all they did was like pass over a list of pelvic floor strengthening exercises aka Kegels to do, that’s typically the antithesis of what needs to be happening and it’s not that it isn’t indicated in other issues.
And you can speak to this, Nicole, obviously, but I just wanted to mention that because I think a lot, there’s a huge misconception. I mean, if you just Google pelvic PT and you look at what some of the more prominent medical websites have to say about it, it’s basically Kegels.
48:07 Dr. Nicole Cozean: So frustrating.
48:08 Dr. Ginger Garner: Exercises. I was just breezing through the internet, you know, down the street of the internet last night, looking for something different. And I scrolled by a prominent hospital systems’ definition of pelvic PT, and I just had to stop and hold my head in my hands and just want to combat that kind of misinformation.
But, you know, for everyone listening, if you do have, IC symptoms or you’ve been diagnosed with it and pelvic PT or OT hasn’t worked, and that was their approach. Nicole, you can completely speak to this now.
48:43 Dr. Nicole Cozean: It’s okay to find another. Yeah, just find another person. I think one of the biggest, really awesome things that happened in 2022, the American Neurological Association guidelines were revised. And one of the things that it said is that Kegel should not be prescribed now, For IC. Now, I will say that, that kegeling, right, doing that drawing up and in of the pelvic floor, right? Isolated pelvic floor muscle contractions, voluntary ones. There are other forms of pelvic floor muscle strengthening.
So it’s not to say that pelvic floor muscle strengthening should never take place with somebody that has interstitial cystitis, but as a patient, if you are having a bladder problem and someone says, do those things and you do them and they make your symptoms worse: That’s the reason why we don’t want to give those blanket advice to people.
49:57 Dr. Ginger Garner: Yeah. I’ve also had people come in and try to just self-treat it. Like, oh, I just read online and I ordered ABCD pelvic tools and I started using them and it made it worse. So yeah.
50:09 Dr. Nicole Cozean: Right. And then we also have to acknowledge that you might have interstitial cystitis with stress urinary incontinence or prolapse or something else. And so now all of a sudden that’s where you really need a true pelvic rehab provider to help you to decide how are we going to strengthen your pelvic floor? Do we need to? Is it actually, is that the problem? Yeah. or what are we going to do about your symptoms first, and then we can sort of create an individualized plan that makes sense for you and your symptoms.
But I was pleased when we at least had the AUA backing up that blanket like, you know, 1970s looked like it just typed on a typewriter handout to folks that talk about don’t eat acidic foods and do Kegels. And it’s like, Oh my gosh, there could be, there’s so many things wrong with that type of blanket advice. Right. And the same thing goes for, I know that you’re, you’re very passionate about, you know, nutrition and stuff like that as well. And that’s another thing that we see with folks with interstitial cystitis is that they’re scared to eat anything. They read that they’re not supposed to eat these you know, acidic foods.
And now all of a sudden it’s like, they don’t know what they’re, they’re thinking that they have all this, these food triggers when in fact they have pelvic floor dysfunction and a nervous system dysregulation problem. And it’s not the food at all, but now we have this scapegoat that allows us to not, not get in nutrition and you’re scared to eat. And that’s a whole nother issue that we have to address. And so, that’s one of the reasons why I feel like got to get that individualized evidence-based approach to what is actually happening and make sure that your practitioner is up to date on science, you know?
52:01 Dr. Ginger Garner: Yeah, absolutely. And, and it’s kind of full circle. It brings us full circle background too. We were talking about with birth, with giving birth, which is like one of the most sacred experiences of your life. that it is equal parts physical and equal parts mental, emotional, spiritual, psychological. And so is IC, you know, if someone has made you afraid to eat, or if you read enough on the internet, and you were misinformed, then we I know, I think I speak for both of us, we don’t want to let fear be the driver for creating you know, the program for you.
It should be liberating when you go to someone and they go, you can do this and this and this. And, you know, and they really listen to your goals, because if someone’s not prioritizing your goals, then well, your needs aren’t being met.
52:55 Dr. Nicole Cozean: Absolutely. Yeah. And I, I really, you know, I’ve, I, I’ve had so many patients that are now in like a disordered eating type of scenario. Right. Because they’re so trying to figure out that kind of stuff.
53:14 Dr. Ginger Garner: Um, And so prevalent anyway, for particularly women to have body dysmorphia issues and eating issues that, yeah, the last thing that we want to do is be responsible for making that worse.
53:24 Dr. Nicole Cozean: Absolutely. So, again to anyone out there that is maybe struggling with that, make sure that your practitioner, I love what you said, is listening to you and creating an individualized plan for you and your pelvic health history and your actual history that includes help on all of those fronts. I mean, that’s the beauty of, I know that the “biopsychosocial approaches” is sometimes overused in my opinion as like a little bit of a buzzword. But if you really think about what you should be expecting of a practitioner and what we should all be striving for as practitioners is to look at somebody in front of you with those different lenses and then treat each of those things as a whole. I think that that really is where we all need to be striving to be either in receiving services or, or administering them.
54:24 Dr. Ginger Garner: Right. Yeah. So there’s just a lot of messages for, if you’re listening as a clinician, if you’re listening as a patient and, you know, as a clinician, we’re both, you know, we are also patients all the time too. That you want to feel like you’re seen and heard and that you’re a practitioner standing with solid science. So to that end, speaking of solid science and compassionate care, make sure that you visit PelvicSanity.com. And if you’re looking for training Pelvic PT Rising, And you’re on Instagram, but what is your handle? Tell us what your handle is.
55:03 Dr. Nicole Cozean: So all my patient-facing stuff is at Pelvic Sanity. And if you’re a clinician or a practitioner, you’re probably better served following @NicoleCozeanDPT. But you can DM me on there. You can find all my contact information on there for both my clinic. We have remote consultations. We have an out of town program. We have a really awesome team of people that we have PTs and OTs on staff at Pelvic Sanity, which is great. That’s the brick and mortar clinic in Orange County. And then obviously all my online education stuff is Pelvic PT Rising.
55:43 Dr. Ginger Garner: Yeah. So you guys, please check out the show notes. We’ll be dropping some links in there, so it makes it really easy for you to visit. And Nicole, thank you so much for joining me today.
55:53 Dr. Nicole Cozean: Thank you so much. What a wonderful conversation. I really appreciate all of your work and everything that you do. And thanks for having me.
55:59 Dr. Ginger Garner: Thank you.
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