Pelvic floor health

What it is

A hammock of muscle — principally levator ani (pubococcygeus, puborectalis, iliococcygeus) and coccygeus — spanning the pelvic outlet from pubic bone to tailbone. It supports bladder, bowel and uterus or prostate, maintains continence, and contracts rhythmically during orgasm.

Both weakness and excessive tension cause sexual problems, and they need opposite treatment. This is the single most important fact in the field, and the reason "just do Kegels" is often wrong advice.

Underactive pelvic floor

Signs: leaking urine when coughing, sneezing, laughing or exercising; urgency; a sense of heaviness or a bulge (prolapse); reduced sensation during penetration; weaker orgasm; leaking wind or stool.

Causes: pregnancy and vaginal birth, chronic constipation and straining, chronic cough, heavy lifting, obesity, ageing and falling oestrogen, prostate surgery, and connective tissue disorders.

Treatment: pelvic floor muscle training has strong evidence. Dumoulin et al.'s Cochrane review found women doing supervised training were around eight times more likely to report cure of stress urinary incontinence than controls. Effects appear over 3–6 months of consistent practice, not weeks. Supervised training with a pelvic health physiotherapist outperforms unsupervised, largely because roughly a third of people contract incorrectly when instructed by leaflet alone.

Technique: contract as though stopping wind and urine mid-flow, lifting inward and upward, without clenching the buttocks, thighs or abdomen and without holding your breath. A typical programme is 8–12 slow holds of up to 10 seconds, plus 8–12 quick contractions, three times a day. Do not practise by actually stopping urine mid-flow — repeated interruption of voiding is associated with incomplete emptying and infection.

Overactive (hypertonic) pelvic floor

Signs: pain on penetration, pain with tampons or speculum examination, urinary urgency and frequency without infection, incomplete emptying, constipation, tailbone or deep pelvic pain, pain after orgasm, and pain that worsens with Kegels.

Causes: chronic pain, endometriosis, prior trauma including sexual trauma, anxiety and habitual guarding, high-intensity core training, cycling, prior painful sexual experiences establishing a protective reflex.

Treatment is downtraining, not strengthening: diaphragmatic breathing with pelvic floor lengthening on the inhale, hip and adductor stretches, heat, internal manual release performed by a pelvic health physiotherapist, dilator therapy graded from the smallest size, and in some cases botulinum toxin injection or muscle relaxants. Kegels make hypertonic pelvic floors worse — the most common self-treatment error, and one frequently reinforced by non-specialist advice.

Vaginismus is the involuntary reflex contraction that prevents penetration and is a specific hypertonic presentation. It responds well to graded dilator therapy combined with psychological support: trials report high rates of successful penetration after structured programmes.

Assessment

A pelvic health physiotherapist assesses tone, strength, endurance, coordination and relaxation, usually with an internal examination and with consent at every step. This is the appropriate first referral for any persistent pelvic or sexual pain, and self-referral is available in many health systems. Persistent penetrative pain should never be dismissed as psychological without this assessment.

For people with a prostate

Pelvic floor training has good evidence for post-prostatectomy incontinence and, in several trials, for erectile function and premature ejaculation. Chronic pelvic pain syndrome (chronic non-bacterial prostatitis) is frequently a hypertonic pelvic floor problem and responds to downtraining rather than to repeated antibiotic courses.

Everyday habits

Do not strain on the toilet; use a footstool to raise the knees above the hips. Treat constipation, since straining is the most modifiable cause of pelvic floor damage. Manage chronic cough. Breathe out on exertion when lifting rather than bracing and holding.

Sources

• Dumoulin C, Cacciari LP, Hay-Smith EJC. "Pelvic floor muscle training versus no treatment for urinary incontinence in women." Cochrane Database of Systematic Reviews.
• Bø K. "Pelvic floor muscle training in treatment of female stress urinary incontinence, pelvic organ prolapse and sexual dysfunction." World Journal of Urology, 2012.
• NICE. Guideline NG123: Urinary incontinence and pelvic organ prolapse in women, and pelvic floor dysfunction guideline NG210.
• Fitzgerald MP et al. "Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness." Journal of Urology, 2012.
• ter Kuile MM et al. Trials of cognitive behavioural therapy and dilator therapy for lifelong vaginismus.
• Anderson RU et al. "Integration of myofascial trigger point release and paradoxical relaxation training for chronic pelvic pain syndrome in men." Journal of Urology, 2011.

Last reviewed: August 2026.