Pelvic Floor Dysfunction

Key Takeaways

Pelvic floor dysfunction is common and treatable
Both weak and overly tight pelvic floors can cause problems
Pelvic floor physical therapy is highly effective for most people
Kegels are not always the right solution—proper assessment is important

Understanding the Pelvic Floor

The pelvic floor is a group of muscles, ligaments, and connective tissue that form a supportive hammock at the base of the pelvis. These muscles play crucial roles in bladder and bowel control, sexual function, and core stability.¹

1 in 4

women experience pelvic floor disorders²

Pelvic Floor Functions

Support: Holds pelvic organs in place (bladder, uterus, rectum)
Sphincter control: Maintains continence for urine and stool
Sexual function: Contributes to arousal and orgasm
Stability: Works with core muscles for trunk support
Circulation: Assists blood and lymph flow

Types of Dysfunction

Hypertonic (overactive/tight):

Muscles too tight, unable to relax
Often associated with chronic pelvic pain
Common in endometriosis, vulvodynia, IC
Kegels can worsen this condition

Hypotonic (weak/underactive):

Muscles too weak to provide adequate support
May lead to incontinence or prolapse
Common after childbirth or with aging
Strengthening exercises may help

Incoordination:

Difficulty coordinating muscle contraction and relaxation
May cause voiding or defecation difficulties

Symptoms

Pelvic floor dysfunction can cause a wide range of symptoms:³

Urinary Symptoms

Urinary urgency or frequency
Difficulty starting urination
Incomplete emptying
Stress incontinence (leakage with coughing, sneezing)
Urge incontinence (leakage with strong urge)

Bowel Symptoms

Constipation
Straining with bowel movements
Feeling of incomplete evacuation
Fecal incontinence

Pain Symptoms

Chronic pelvic pain
Pain with intercourse (dyspareunia)
Vulvar or vaginal pain
Rectal pain
Lower back or hip pain
Tailbone (coccyx) pain

Other Symptoms

Pelvic pressure or heaviness
Sensation of something falling out (prolapse)
Difficulty with tampon use
Pain with gynecological exams

Hypertonic vs. Hypotonic: Why It Matters

Treatment differs significantly depending on whether your pelvic floor is too tight or too weak. Doing Kegels (strengthening exercises) when your pelvic floor is already too tight can worsen symptoms. This is why professional assessment is important before starting exercises.

Causes and Contributing Factors

Multiple factors can contribute to pelvic floor dysfunction:⁴

Physical Factors

Pregnancy and childbirth
Pelvic surgery
Chronic constipation and straining
Heavy lifting
High-impact exercise
Aging and menopause
Obesity

Conditions Associated with Pelvic Floor Dysfunction

Endometriosis
Interstitial cystitis/painful bladder syndrome
Vulvodynia
Irritable bowel syndrome
Chronic low back pain
Fibromyalgia

Psychosocial Factors

History of trauma or abuse
Chronic stress and anxiety
Habitual tension holding patterns

Diagnosis

Evaluation typically involves:⁵

Medical History

Detailed symptom assessment
Bladder and bowel habits
Obstetric and gynecologic history
Sexual function concerns
Previous treatments

Physical Examination

External pelvic examination
Internal examination to assess muscle tone and function
Assessment of pelvic organ support
Evaluation of muscle coordination

Additional Testing (If Needed)

Urodynamic studies
Defecography
Electromyography (EMG)
Imaging (ultrasound, MRI)

Providers Who Can Help

Pelvic floor physical therapists
Urogynecologists
Colorectal specialists
Gynecologists with pelvic pain expertise

Pelvic Floor Physical Therapy

Pelvic floor physical therapy is the first-line treatment for most pelvic floor dysfunction:⁶

What to Expect

Comprehensive evaluation of pelvic floor muscles
Internal and external manual techniques
Biofeedback to learn muscle control
Exercises tailored to your specific needs
Education on bladder and bowel habits
Home exercise program

Techniques Used

For hypertonic (tight) pelvic floor:

Manual release of trigger points
Stretching and lengthening exercises
Relaxation and down-training
Diaphragmatic breathing
Dilator therapy

For hypotonic (weak) pelvic floor:

Strengthening exercises (Kegels, when appropriate)
Coordination training
Biofeedback for muscle activation
Electrical stimulation (in some cases)

Effectiveness

Research shows pelvic floor PT is effective for:⁷

70-80% improvement in urinary incontinence
Significant pain reduction in chronic pelvic pain
Improved sexual function
Better bowel function

Self-Care Strategies

Breathing and Relaxation

The pelvic floor and diaphragm work together. Deep breathing helps relax a tight pelvic floor:

Lie down comfortably with knees bent
Place one hand on belly, one on chest
Breathe so belly rises on inhale
As you inhale, imagine pelvic floor gently descending
Exhale naturally, allowing pelvic floor to return
Practice 5-10 minutes daily

Bladder Habits

Avoid "just in case" urination
Do not hover over toilet seats—sit fully
Relax pelvic floor while urinating
Do not push to empty bladder
Stay hydrated (concentrated urine can irritate)

Bowel Habits

Respond to urge promptly
Use proper positioning (feet elevated, lean forward)
Avoid straining
Adequate fiber and fluids

Posture and Movement

Avoid prolonged sitting
Change positions frequently
Practice good posture
Gentle stretching, yoga, or walking

When NOT to Do Kegels

If you have pelvic pain, painful intercourse, or difficulty relaxing your pelvic floor, Kegels may worsen your symptoms. See a pelvic floor physical therapist for proper assessment before starting any pelvic floor exercise program.

Other Treatments

Medications

Muscle relaxants
Vaginal estrogen (for postmenopausal women)
Medications for overactive bladder
Pain medications when appropriate

Devices

Vaginal dilators for gradual stretching
Pessaries for prolapse support
Biofeedback devices

Procedures

Botox injections for overactive pelvic floor
Trigger point injections
Nerve blocks

Surgery

Surgery may be considered for:

Significant pelvic organ prolapse
Incontinence not responding to conservative treatment
Usually after trying other treatments first

Finding a Pelvic Floor Physical Therapist

Ask your doctor for a referral
Search APTA's pelvic health PT locator
Look for therapists with specialized pelvic health training
Many offer telehealth consultations

Questions to Ask

What pelvic health training have you completed?
How many pelvic floor patients do you see?
What techniques do you use?
What should I expect from treatment?

Related Conditions

Learn about conditions commonly associated with pelvic floor dysfunction.

Vulvodynia Guide

References

Messelink B, Benson T, Berghmans B, et al. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodyn. 2005;24(4):374-380.
Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311-1316.
Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc. 2012;87(2):187-193.
Bortolini MA, Padoa A, Nathorst-Böös J, et al. Descriptive study of the definition, causes and management of pelvic floor hypertonicity. Int Urogynecol J. 2021;32(3):565-574.
Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(3):321-328.
Wallace SL, Miller LD, Mishra K. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019;31(6):485-493.
Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;(10):CD005654.