Why Should You Care About Your Pelvic Floor

Most of us are familiar with our pelvis, the lower part of the torso. But what exactly is the pelvic floor? Well, this base of muscles in the pelvis covers the pubic bone to the tailbone, and is an area to which you should be paying close attention to.

Dr. ​Karyn Eilber, MD, professor of urology and the associate professor of obstetrics and gynecology at Cedars-Sinai Medical Center, as well as the co-founder of Glissant Intimate Wellness, says the pelvic floor is a group of muscles that form a bowl-like structure to support the pelvic organs (bladder, uterus, rectum). She says pelvic floor issues are an important topic, as they affect millions of women. “About 10% of women have surgery for urinary incontinence or prolapse [descending or drooping of pelvic floor organs] in their lifetime,” she says to TZR. “And 9.7% of women aged 20 to 39 years reported [some type of] pelvic floor disorder, which increased to 49.7% for women aged 80 years or older.”

Dr. Jessica Babich has her own pelvic floor physical therapy practice in New York City and is the co-founder of Chelsea Method, an online rehab program for new moms. She tells TZR that the pelvic floor muscles serve five critical functions. The first is sphincteric function — in other words, your pelvic floor muscles control your bladder and bowel movements. “These muscles need to relax and lengthen to have efficient bowel movements and urinate easily,” she says. “They also need to contract around your urethra and anus to prevent leaking. This should happen automatically.” Next is organ support. “Your pelvic floor muscles act like a hammock to support your pelvic organs (bladder, rectum, and uterus) against gravity and pressure within your abdominal cavity,” she says. “Excessive strain on your pelvic floor or weakness can contribute to pelvic organ prolapse. This is when your pelvic organs protrude through your anal or vaginal opening.”

The pelvic floor also helps with core support. “Your pelvic floor muscles form the bottom of your core and set the foundation for strong, efficient movement strategies,” Babich explains. “If you’re trying to strengthen your core, your pelvic floor needs to be a part of your training program.” Fourth, your pelvic floor comes into play regarding sexual function. “Your pelvic floor muscles need to have sufficient strength and appropriate tension to achieve and sustain an erection, allow for penetration, and it’s necessary for orgasm,” she says. “Deficits in the strength and tone of your pelvic floor can impact sexual pleasure and can contribute to pain during or after intercourse.”

Circulation is the fifth critical function of your pelvic floor. “The muscles act like your calf muscles in that they help to pump blood and lymphatic fluid back toward the heart,” she says. “A loss of this ‘sump-pump’ action in the pelvis can contribute to swelling/pelvic congestion.” But what is the cause of pelvic floor dysfunction? Dr. Kecia Gaither, MD, double board-certified in OB/GYN and maternal fetal medicine and director of perinatal services at NYC Health + Hospitals/Lincoln in the Bronx, says there are many different causes to this loss of circulation. “These include trauma to the pelvic area, pregnancy/birthing large babies, prior pelvic surgery, obesity, advanced age, straining (leading to poor muscle coordination), chronic coughing, and heavy lifting,” she tells TZR in an email.

How To Know If Something Is ‘Wrong’ With Your Pelvic Floor

Babich says that if you have any problems with the above five functions, you could have a pelvic floor disorder. Or, your health care provider can discover it during an exam. Some telltale signs include: bowel and bladder control issues (urinary and bowel urgency, frequency, incontinence, constipation); core weakness (weak during movements, pain in low back and hips); pain with sex (whether penetration is superficial or deep, difficulty achieving orgasm); pelvic and/or tailbone pain; painful menstruation/ovulation; and/or abdominal/pelvic bloating and congestion. “Also, if you are pregnant or postpartum, it is helpful to see a pelvic floor physical therapist — not only to help prepare your body for birth, but to help recover postpartum to try and avoid any of these issues,” she says.

Dr. Heather Jeffcoat, pelvic health physical therapist and founder of Fusion Wellness and Femina Physical Therapy notes that, although pelvic floor muscles stretch over 300% during vaginal delivery, being pregnant increases your risk of pelvic floor dysfunction regardless of how you deliver. “This is because pregnancy itself causes postural and hormonal changes that increase the risk of bladder leaks,” she tells TZR in an email. “That’s why I recommend all women have a plan for postpartum pelvic floor physical therapy and stock up on pads/liners to manage their healing process.”

Dr. Suzanna Wong, DC, a chiropractic doctor and owner of Twin Waves Wellness Center, says people often know there is something not quite right when they experience leaks or incontinence. “A lot of people with pelvic floor problems experience a loose pelvic floor — one of the most common things that happens is that you leak urine when you cough, laugh, sneeze, or exercise,” she tells TZR in an email. “This is called stress urinary incontinence — and you can do something about it. We normally see it as people get older, or post child birth,” she says.

So your pelvic floor can be too loose — but it can also be too tight — and treatment varies depending on which pelvic floor disorder you have. Amanda Shipley, founder of Renew Pelvic Health in Atlanta, GA and creator of the online pelvic health course “What's Normal 'Down There?,” says you may experience other signs, too. “You might also have issues with your pelvic floor if you have low back, lower abdominal, groin, or butt pain that hasn’t gone away with ‘traditional’ (orthopedic) physical therapy or other treatments,” she tells TZR in an email.

Menopause can also cause the pelvic floor muscles to weaken. And Dr. Rachel Gelman, owner of Pelvic Wellness & Physical Therapy, says that the biggest thing people can do at home to help with their pelvic floor health is avoid pushing and straining with bowel movements. “Using a toilet stool or a Squatty Potty is the optimal position to defecate,” she tells TZR in an email. “Stay well-hydrated and avoid constipation.”

When Your Pelvic Floor Is Too ‘Loose’

When your pelvic floor is too loose — hypotonic — Babich says there is so much you can do to help improve its tone and strengthen it. “I always recommend patients train their glutes and core, as well as be mindful of their posture and controlling their breath,” she says. “Your pelvic floor doesn’t work in isolation — it is part of a larger system. Your posture and breath directly impact the tone and strength of your pelvic floor muscles.”

This is where Kegel exercises come into play wherein you practice tightening your pelvic muscles. Babich says they can be a great tool for pelvic floor strengthening, as well as using vaginal weights. “However, I always recommend making sure they are appropriate for your training program by seeing a pelvic floor physical therapist,” she explains. “Kegels themselves are not a functional exercise and shouldn't be the star of the show.”

Babich says that when people think of the pelvic floor, they often think of Kegels, “the one-size-fits-all exercise for all your pelvic problems.” But she explains this is far from the truth. “Kegeling alone will not fix your problems,” she says. “In fact, if used inappropriately, they can make your problems worse. Although they can be helpful and beneficial for the right person, they should be prescribed appropriately as part of a bigger, more comprehensive training plan by a pelvic floor physical therapist. These muscles don't work in isolation. It is important to consider your posture and position, how you engage, how you move, and how your core and pelvic floor muscles work together as a system.”

Dr. Jill Purdie, medical director and OB/GYN at Northside Women’s Specialists, part of Pediatrix Medical Group, says Kegel exercises work by helping to strengthen the muscles of the pelvic floor by voluntarily contracting, and then relaxing, the muscles. “To keep them strong, you want to try and do three sets of 10 contractions per day,” she tells TZR in an email. She says they are best done sitting or lying down so that you can keep your abdominal and buttocks muscles relaxed while you squeeze the pelvic muscles. “It will generally take about three months to see a difference in symptoms,” she says.

Shipley adds that people used to be instructed to “stop the flow of urine” while practicing Kegels, but she says this is typically not recommended anymore, as it can lead to urinary tract infections and other problems. “Instead, we now teach how to do a more complete pelvic floor muscle contraction by considering all of your openings — you want to try to close those openings (anus, vagina, and urethra) and pull them up inside your body. That is a proper pelvic floor muscle contraction.” She says that if you start doing Kegels and experience symptoms such as increasing pain, pressure, urinary frequency, leaking, and so on, then definitely stop doing them and consult a pelvic physical therapist. “Generally, if they cause problems. then it means you might have pelvic floor muscle tightness, and should not be doing Kegels at this point.”

Chelsea Waldkirch, pelvic health physical therapist and owner of Renew Physical Therapy in Bentonville, Arkansas, adds that pelvic physical therapists can also provide you with specific exercises that can be completed in the clinic and at home. “At home, you can try looking at your pelvic floor in a mirror and seeing if you can squeeze the vaginal muscles and fully relax them,” she says. “This will give you an idea about their function.” Eilber says that in some cases, people may need surgery, as often it's not just the muscles but the supporting ligaments that are also weakened or torn, mainly as the result of vaginal birth.

When Your Pelvic Floor Is Too ‘Tight’

Your pelvic floor may not be too “loose,” but too “tight” — hypertonic — in which case you need to relax and decrease the tone first, Babich says. “These muscles tend to be weak because they are in a shortened position and can’t get a good contraction,” she says. “It is very important to get the pelvic floor muscles to relax first before you try to strengthen them. The best way to do this is by being mindful of your posture and connecting your breath to your pelvic floor.”

This way, once these muscles are relaxed or have more length, you can work on rebuilding strength to address any weakness you have. In many cases, stress and emotional and physical trauma may contribute to pelvic pain and tightness in the pelvic floor, adds Dr. Gina Cunningham, board-certified women’s specialist and director of the Pelvic Floor Physical Therapy Program at Axia Women’s Health. “Just like when we tense our neck and shoulders, it’s common to tense our pelvic floor muscles when we’re stressed,” she tells TZR in an email. “They can also become too tight due to orthopedic imbalances in your hips, lower back, or pelvis.”

Eilber says that treatments for any muscles that are too tight can be applied to the pelvic floor: self-directed relaxation techniques, muscle relaxants, physical therapy, and even Botox injected into the pelvic floor. And Waldkirch notes some additional things you can do at home include diaphragmatic [belly] breathing, yoga, and hip-opener stretches, which a pelvic physical therapist can show you.

Shipley stresses that getting personal guidance from a pelvic physical therapist is best, but generally you would want to start with connecting with your body and with your breath. Also, ask yourself if you can tell if your pelvic floor muscles are tight and when you’re holding tension elsewhere in your body during the day. “You could start by focusing on your jaw and butt muscles since both of these are closely related to the pelvic floor,” she says. “When you feel tension being held there, try to relax it. Then add in some gentle hip, inner thigh, and butt stretches to your day. Make sure to balance out hard workouts with recovery and restorative ones, like stretching and yoga.” Daily meditation or deep breathing is always helpful, too, and worth making time for.

How To Treat A Pelvic Floor Disorder

Melissa McElroy, partner/clinic director at Dunn Physical Therapy in Louisville, Kentucky, says symptoms might not always be the best way to determine true pelvic floor function. “The only true way to distinguish if the pelvic floor is ‘too loose’ or ‘too tight’ is to have an assessment performed by a trained healthcare professional,” she tells TZR in an email. “Pelvic health physical therapists are the most trained healthcare professionals in regard to this particular set of muscles.” With urinary incontinence, for example, one might think that the muscles are “too loose” and weak, and doing Kegels is the answer. “However, your pelvic floor tissues could be weak and tight — and the inability for the muscles to activate properly is the reason for the leakage.” And Kegels are not the solution for a tight pelvic floor.

Cunningham agrees, noting that pelvic floor physical therapy is often the first step in the process of treating common pelvic floor disorders. “During a pelvic floor physical therapy session, and with your consent, your provider will perform an internal vaginal exam to identify any trigger points,” she says. “Your provider can help address those trigger points through internal and external massage, as well as relaxation techniques. It is best to find out why a muscle is too tight to help it maintain its function.”

And during a pelvic floor physical therapy session, the provider will practice isolating and engaging the pelvic floor through breathwork and abdominal exercises, she explains. “We may also incorporate different strength tools, like weights, exercise bands, and kettlebells to help activate the pelvic floor,” she says. “It’s important to not only focus on strengthening the pelvic floor muscles, but also the coordination of the muscles within the rest of the body.” After the visit, the pelvic floor physical therapist will usually provide their patients with simple, functional exercises they can do at home. “This could include something as simple as holding a squat while brushing their teeth,” she says. “Whether you realize it or not, your pelvic floor muscles are postural muscles and are always working, so it’s easy to incorporate the exercises into your daily routine.”

Shipley adds that it’s important to take care of your pelvic floor health. “Leaking urine (or urinating frequently, more than once every couple of hours) is not normal or good for your body, even if you don’t mind it and you don’t leak much, quantity-wise,” she says. “Pain with sex is also not normal and you don’t have to deal with it. Lastly, it is healthy to move your bowels at least once a day.” Any of these may indicate that you have pelvic floor dysfunction, and you deserve to get it taken care of and feel good, she says. She recommends checking out PelvicRehab.com or PelvicGuru.com to find a pelvic physical therapist near you. Waldkirch adds that many women experience pelvic floor dysfunction and may be too embarrassed or ashamed to talk about it: “I want everyone to know that there is help for these conditions, and if you experience pelvic floor dysfunction, you are not alone,.”