The pelvic floor needs a public relations campaign. Or a marketing plan? Maybe good social media influencer on the job?
The pelvic floor is an unsung hero, quietly humming along in the background and doing its job, most of us never giving it a second thought. Even when something goes wrong with the pelvic floor, most people don’t know enough about it to even suspect that the pelvic floor could be the cause.
But knowing more about your pelvic floor is important, because what little you may have heard could be wrong or at least incomplete.
Sure, many people know that weakness in the pelvic floor can be a problem. Maybe you’ve heard that you should do Kegels or lock your bandha (if you are into yoga) or “keep the pelvic floor lifted, ladies” during your workout class.
You might reasonably think that more is better when it comes to tightening the pelvic floor. But nothing could be further from the truth. To see why, let’s look at that the pelvic floor is and what it does for you behind the scenes.
What is the pelvic floor?
The pelvic floor is formed by 14 muscles, as well as nerves and connective tissue, that cover the opening of the pelvic bones, between the tailbone and the pubic bone.
They form a hammock-like support for internal organs — the bowel, bladder, uterus and vagina — keeping them lifted and in alignment so that they function properly as you move about your day. This is the one thing most people know; the pelvic floor keeps things lifted so, for example, you are less likely to have urinary incontinence. This is really important stuff. No one likes a misaligned organ!
The pelvic floor muscles do not act alone but are intimately interconnected with the muscles of the abdomen, back, hip and diaphragm, all working together to create core strength and flexibility. In this way, the pelvic floor is also involved in maintaining posture and allowing for easeful leg movement.
But don’t forget that this area also includes the opening of the anus, the urethra, and the vagina. The pelvic floor muscles allow these openings to close when you need them closed and to open when you need them opened. No one wants an inadvertently open OR an unintentionally closed orifice at an inopportune time!
For the pelvic floor to perform all these complex functions, you must be able to easily tighten and relax in coordinated ways. Problems occur when these muscles are either too weak, too strong, and/or simply not functionally coordinated. Ultimately, a nimble pelvic floor is your friend! And crucial to being able to going to the bathroom with ease and having sex with maximal pleasure.
So, let’s give a shout out to the wonders of your pelvic floor!
How do things go wrong in the pelvic floor?
Muscles are collections of fibers that overlap to contract and pull apart to rest and lengthen. When these fibers are chronically pushed to overlap or to pull apart, they are prone to developing pain and dysfunction.
One way this can manifest is as a trigger point. You’ve probably felt a trigger point in you back, neck or shoulders after hunching over your computer or phone for hours on end. Trigger points are areas of involuntary muscle contraction. This involuntary contraction hurts and can be released through stretching and massage. It’s the same thing in the pelvis, except it is more difficult to stretch these muscles and they are harder to reach to massage.
Muscles that are chronically contracted can also lead to pain because the contraction causes restricted blood flow and nerve compression. Blood vessels and nerves flow in and around muscles as they provide blood supply and innervation to the muscle itself and to surrounding tissue. Compression of blood vessels restricts oxygen supply to the tissue and causes pain; nerve compression also causes pain.
Pelvic floor muscles are skeletal muscles, like the muscles in your arms or legs. Skeletal muscles are connected to joints that bend and contract to pull bones. Pelvic floor muscles are also connected to the immovable bones of the pelvis, which means that when they are even more prone to become chronically contracted because they can’t be released by moving the bones to which they are connected.
Chronic contraction or chronic lengthening of the muscles in the pelvic floor is bad. But how does this happen? There are many things that can cause dysfunction in these muscles; here are a few examples:
- Direct trauma to the muscle from something like falling on your tailbone or childbirth
- Intense exercise that activates the core muscles for stability
- Injuries to the leg or hip that alter your gait; remember these muscles are all interconnected.
- Surgeries like hysterectomies or prostactectomies
- Chronic constipation and straining
- Endometriosis, which causes inflammation that can contribute to muscle overactivation
- Hormonal changes that cause pain in the vulva. (See my menopause article.)
The truth is that we don’t always know how or why the muscle dysfunction started.
Some people may hold their pelvic floor tighter than others. Maybe it’s because they have always used their pelvic floor to help stabilize their core. I always think that, “No one tells you what to do with your pelvic floor when you are learning to walk.” Maybe their go-to move was to pull up on the pelvic floor.
Other folks may hold tension in the pelvic floor when they are stressed. Some folks raise their shoulders to their ears, others raise their pelvic floors to their belly buttons.
The final thing to note is that anything that causes pain in the pelvis can lead to pelvic floor muscle dysfunction. For example, let’s say it hurts when you pee. Maybe you have recurrent UTIs. The body wants to brace against pain, so the pelvic floor muscles will engage in an effort to protect you from pain.
What if you have had pain with penetrative sex? This is a major trigger for pelvic floor contraction as the body tries to prevent further pain by preventing further penetration. This is even true when the pelvic floor contraction is the original problem. This is how pelvic floor contraction begets pain begets more pelvic floor contraction.
What are the symptoms of pelvic floor troubles?
Symptoms of weakness in the pelvic floor are fairly well know:
- Urinary incontinence
- Difficulty controlling your bowel movements or leakage
- Pelvic organ prolapse (this is about more than just muscle weakness though)
What you may not know is that pelvic floor dysfunction (tightness, contraction, uncoordinated movements) can cause a whole host of symptoms.
Pelvic floor dysfunction causes so many types of symptoms that it should be just about the first thing you think of if you are having pain down there. It doesn’t mean that this is the problem, but it’s the first thing I would want to investigate. Don’t forget!
Here are some symptoms that can be related to dysfunctional pelvic floor:
- Vulva owners: Pain of any kind in the vulva, vagina, clitoris, perineum, or anus
- Penis owners: Pain in the penis, scrotum, perineum or anus, erectile dysfunction, post ejaculation pain
- Burning, itching, stabbing sensations in the genitals
- Pain at the opening to vagina with intercourse
- Urinary discomfort or frequency
- Pain with sitting
- Pain with orgasm or after orgasm, inability to orgasm
So, if it hurts when you pee and you don’t have a UTI, could be your pelvic floor.
If it hurts when you sit, could be your pelvic floor.
Hurt when you have sex? Definitely could be your pelvic floor.
However, when it comes to pain it is never as straightforward as just tissue injury or muscle contraction. Ultimately, pain does not originate in the body at all, but rather in the brain.
As a quick summary, the brain creates pain when it thinks that the body is in danger. However, the subconscious systems that monitor for danger and create pain can get wonky. The brain can start to perceive danger to tissue when there is none. This can happen in all sorts of ways. Perhaps there was an initial injury, but then the brain and the nervous system become overly sensitive, creating pain even after the initial injury has resolved. Again, pain isn’t about tissue injury; it’s about the brain perceiving danger.
What to do if you suspect pelvic floor trouble
First of all, you are not alone and you are not broken. An estimated 20% of women will have pelvic pain at some point in their lives, and an estimated two million men have chronic pelvic pain. Ultimately, this problem can affect anyone with a pelvic floor, all vulva owners and penis owners regardless of their gender.
If you suspect your symptoms could be related to pelvic floor dysfunction, you will need to seek support from someone who can do a pelvic floor muscle exam. If you normally see your primary care doctor for pelvic exams, they may be able to help you. Your gynecologist or urologist can also do this exam. However, your primary care doctor and even your gynecologist or urologist may not have been trained in how to examine these muscles or in all the ways they can cause problems. (See my post: What what your doctor doesn’t know about sex could hurt you.
I may be biased but if you have access to a licensed medical provider who is also a certified sex counselor, that would be an excellent place to start. This way you can have a full exam to evaluate for all causes of your pain or other sexual symptoms and a comprehensive plan for treatment can be created with you.
However, sex counselors like me are few and far between.
Perhaps the most important person you can have on your team is really a pelvic floor physical therapist. A pelvic floor physical therapist is just like any other PT, but they focus on issues connected to the pelvic floor. They are highly skilled and licensed providers who are specifically trained to support the musculoskeletal system; in this case, their expertise is the musculoskeletal system of the pelvis and related tissues.
What can you expect at a pelvic floor PT exam or treatment session? This will vary from person to person, but examining and treating the pelvic floor will typically require that the pelvic floor be accessed internally. Most often this means that a gloved lubricated finger will be placed in your vagina or anus to feel for and treat trigger points in the tissue of the pelvic floor.
Internal exams and treatment sessions might seem like a lot to contemplate. It’s certainly not anyone’s idea of day at the park. Pelvic PTs are trained for this and will support you to make you feel more comfortable throughout the session.
If “internal work” is not something you are willing to do now, a great pelvic PT can offer other strategies for supporting pelvic floor function.
Because pelvic floor PTs — and other professionals who has the privilege of helping people with internal exams or treatments — have a lot of responsibility with this sensitive subject, I recommend that you look for a pelvic floor PT who is certified and, if possible, only does pelvic floor work.
Here are some resources to help you find a qualified provider:
- International Pelvic Pain Society
- International Society for the Study of Women’s Sexual Health
- American Physical Therapy Association – Pelvic Health
Pelvic floor exercise: not just about kegels
Hopefully you will have access to a supportive professional if you are having issues that you suspect could be related to your pelvic floor. However, I know not everyone does or you may not feel comfortable with this yet.
What can you do?
There are some helpful exercises that you can explore along the way.
Most importantly, Kegel exercises are probably NOT the best idea, especially if you are having pain. Tightening your mula bandha during yoga may also be contraindicated (as much as I love all things yoga!). As I hope my discussion above has made clear, more tightening is just going to make things worse.
What you can do is begin by slowing down and start to bring your pelvic floor into awareness.
Where is your pelvic floor in space right now? Is it tight? Is it relaxed? This may seem like an odd question or even a nonsensical one. But stick with it, and see if you can become aware of how you are holding the pelvic floor.
One good way to do this is to bear down like you are having a bowel movement. This pressure will push the pelvic floor forward, stretching and relaxing it. Then squeeze the pelvic floor lightly like you are trying to stop the flow of urine. Gentle relaxation and contraction of this floor can help create greater awareness.
You can also use your breath to feel into the pelvic floor and to offer it some gentle “exercise.” The pelvic floor moves with your diaphragm as you breath in and out. Try taking a deep breath in. Move the breath into the belly, watching the belly rise and fall with each in and out breath. Can you also feel how the breath expands into the pelvic floor, creating gentle downward pressure or expansion? This belly breathing is a great exercise to do every day, not just for your pelvic floor but for your mind, your gastrointestinal system, and your nervous system.
Your pelvic floor is also connected to your throat. Professional singers know this well. You might notice this if you bear down like having a bowel movement. Do you feel how you may create pressure in the throat and hold your breath to do that? Ultimately, the throat and the diaphragm and the pelvic floor are all one interconnected pressure system. Bring gentle awareness to your breathing and speaking or singing to deepen your connection to your pelvic floor.
Other good exercises could include:
- Child’s pose or balasana
- Yogi Pose or malasana
If you feel like tightness in the floor is making sex painful, you can also use these exercises to more towards relaxing the pelvic floor before you have sex.
I also encourage you to feel empowered to explore your pelvic floor yourself. Hold your hand against your vulva or perineum as your press into the pelvic floor and release. Can you feel the subtle movement? Consider inserting one finger into the vagina or anus and then contracting and releasing the pelvic floor. Can you feel this movement? Or do you have pain in specific areas?
This exploration may bring up emotions. That is not unexpected. Just be gentle with yourself. Offer loving-compassion as much as possible along the way.
Ultimately the pelvic floor is an important source of physical grounding but it is also a place of deep emotions since it connects us to so many fundamental experiences of being human, not the least of which is sex.
This is your body’s core, the center of gravity, the source of movement. Called the hara, the chi center, the seat of kundalini energy in various ancient traditions. The chakra system seems to capture some of this when it describes this area, the root chakra, as being responsible for a sense of stability, grounding, safety and security. It is the foundation from which all the other chakras can move and grow.
I know that’s a lot of “woo.” But I do believe that this area is more than just a set of muscles and nerves; a more emotional or spiritual energy is available here, making it a place of great vulnerability.
So, give your pelvic floor some love. It really deserves it.