I’m sure you’ve heard of the pelvic floor. If you’ve had children, you were probably told, in passing, to ‘do your pelvic floor exercises’, maybe without any other instruction or explanation. It’s not just after babies that the pelvic floor is important, however.  Women, and men, can experience pelvic floor issues at any stage in life and it can have a wide range of implications. So let’s look into it a bit further and see why the pelvic floor is so important.

What is it?

The pelvic floor is a group of muscles and connective tissue that attaches to the bottom of your pelvis, like a sling between your legs.  This sling supports your pelvic organs, including your bladder, uterus and rectum. 

The pelvic floor is part of the core muscle system, working closely with your transverse abdominus, multifidus and diaphragm to support your trunk.  This is your ‘core’ and contributes to back stability, postural strength and function.  

What problems can it cause?

Common problems arising from pelvic floor dysfunction are:

• Stress urinary incontinence – this is the name for leaking pee when you cough or sneeze and is often the reason that mums don’t go trampolining!  The pelvic floor can also be a factor in overactive bladder and urge urinary incontinence.

• Pelvic organ prolapse – this is when your pelvic organs are not supported fully and drop down into your vagina, and can sometimes protrude.  Women typically notice a heaviness in their pelvis on weight bearing activities and may notice a bulge from their vagina. 

• Sexual dysfunction – this could range from an inability to orgasm to discomfort during penetration to not being able to have sex due to pain.

• Pelvic pain syndromes – conditions such are vulvodynia, vaginismus and Bladder Pain Syndrome (interstitial cystitis) often have involvement of the pelvic floor muscle complex, which can contribute to pain and dysfunction.  

• Back pain – core weakness is a common factor in chronic or recurrent back pain. Working on core activation and strength have been shown to help reduce the severity of chronic back pain and reduce the incidence of episodes. 

• Diastasis rectus abdominus – this is the separation of abdominal msucles, usually due to pregnancy.  The pelvic floor is part of the core, and together they work to support your trunk.  The balance between your core muscles and external abdominals is what helps to improve this issue. 

What can go wrong?

The pelvic floor is a complex system of muscles.  Any muscle in your body needs strength to contract, flexibility to function and the ability to fully relax.  The pelvic floor needs to be able to balance its power and contractibility, with its relaxation and length in order to function comfortably and effectively.  

This muscle system can be weak or inactive.  This could be due to pregnancy, exercise, occupation, weight, age, the list goes on.  If the muscles are weak they will not be able to counteract downward forces through your trunk.  This may lead to bladder or bowel leaking, pelvic organ prolapse or sexual dysfunction (for example, inability to orgasm).  Weakness in the core muscle system can cause or be a factor in lower back pain and perpetuate diastasis rectus abdominus. 

The pelvic floor can also be overactive or shortened. This can be due to overtraining, stress or anxiety, infection, or as part of a trauma response.  Tension in these muscles can cause pain related to urination, sex, or defecation; even sitting down or wearing tight trousers can be problematic for some people. It can contribute to urinary retention or incontinence, overactive bladder, or bladder pain syndrome. Tension or pain in your pelvic floor can also influence the surrounding structures and can be felt in or contribute to hip leg or back pain. 

On examination, it is very routine to find that the pelvic floor muscles are both overactive and weak at the same time. If someone perceives a pelvic floor problem, for example a bit of leaking, the common advice is to ‘do your kegels’. Kegels are essentially strengthening exercises.  The problem with this arises when people don’t know if their pelvic floor is actually weak, how to do an effective pelvic floor contraction and how to relax the muscles in between.  The muscles need strength, but even more important is range (i.e. the ability to fully relax and then fully contract).  Without working on the length and full relaxation in your pelvic floor, you will never get an optimal contraction. 

What to do about it?

The research says that 65% of people who think that they’re doing their pelvic floor exercises correctly are in fact doing it incorrectly.   This may be due to an ineffective contraction (reduced fibre activation or reduced range for example) or it could be that they are working to bear down with their pelvic floor muscles, which is the opposite to what we want to achieve and can make problems worse. 

The only way to find out if you are contracting your pelvic floor correctly is to have an internal vaginal assessment with a specialist Pelvic Health Physiotherapist.  A vaginal assessment is very routine for those of us in the trade.  A pelvic floor examination involves feeling the muscles just on the inside of your vagina – feeling them contract, relax and what happens during a cough.  This should be entirely comfortable and pain-free.  We would also assess for signs of prolapse, in lying but also in standing if necessary.  

NICE Guidelines (NICE 2022) recommend supervised pelvic floor retraining as a first-line treatment for stress or mixed incontinence and for pelvic organ prolapse.  This means assessment and treatment with a specialist Pelvic Health Physiotherapist. 

If pain is your issue, please don’t be put off by talk of internal examinations.  They can be very helpful in diagnosis and treatment but are not imperative.  Pelvic pain issues are very complex and lots of progress can be made ‘hands off’.  It might be something to discuss and revisit during a subsequent appointment.  You are always welcome to say no at any point.

In a nutshell, we all have pelvic floors, and they can impact every aspect of life.  If you think you might have an issue with your pelvic floor, or would just like to check, do something about it and see a Pelvic Health Physio!