Is all this pelvic floor content just fearmongering? (Part 1)
And how do you actually know your pelvic floor needs attention? (audio version available)
Last week, I received the following question from a reader:
How is one supposed to gauge the “health” or maybe “functioning” of their pelvic floor? I see so many posts about how to strengthen the pelvic floor, and almost as many about what to do if your pelvic floor is too tight. A lot of it reads/feels like scaremongering…can we get a post about that?
I was…very excited to see this question, to put it lightly. I don’t mean to be a pelvic floor hipster, but as the former fitness editor at Fit Pregnancy magazine and a perinatal exercise specialist for the past seven years, I’ve been cramming information about the pelvic floor into my brain since before it was cool. And it actually is getting kind of cool: in 2021, the Guardian declared that we were in a “pelvic floor revolution” with an explosion of books, programs, and apps designed to better your pelvic health; Google searches for “pelvic floor” have risen steadily over the past five years; and general awareness of the body region seems to be increasing as the taboo against discussing it decreases.
Of course, while more awareness of pelvic health is a great thing, the Internet has done its Internet thing and churned out a lot of content trying to freak you out into thinking everything you’ve ever heard about the pelvic floor is wrong. That is not necessarily true! But it is true that the pelvic floor, and pelvic floor function, can be a little complicated; and things many of us assumed or were taught about it might not be accurate or helpful. So let’s discuss a few important points. There is SO MUCH TO SAY here that I’m actually breaking this into two separate posts. Lots more to come next week, and there’s time to ask your own pelvic floor questions if you’d like me to try to address them in part 2.
Also: I thought this might be a helpful one to have an audio version of, so take a listen if you like. Same content in the audio as below.
Here we go!
First, who TF are you to be opining about the pelvic floor?
This is actually a very important question! There are many self-styled pelvic floor experts out there, and it can be hard to suss out who is truly knowledgeable and who is regurgitating other things they’ve read on social media. The gold standard for expertise in pelvic floor issues is a pelvic floor physical therapist, a urogynecologist, or a pelvic floor occupational therapist. Urogynecologists are OB/GYNs and/or urologists with additional surgical training who treat patients with pelvic floor disorders, typically either by recommending pelvic PT or OT and/or medication, or performing surgery. Pelvic PTs and OTs are physical or occupational therapists who have gone through additional training to specialize in the pelvic floor — although it should be noted that there’s no real regulation on who gets to call themselves a pelvic PT or OT, and some folks who have only taken very baseline training do refer to themselves as pelvic PTs, so know that expertise can definitely vary.
That isn’t to say no one else is allowed to talk about the pelvic floor! While (non-urogynecologist) OB/GYNs tend to be more focused on reproductive health and diseases of the pelvic organs than on muscular issues, some are still well versed in pelvic floor function. Those of us who are personal trainers with specialty education in pelvic floor health, and/or prenatal and postpartum exercise, can get a pretty great baseline as well, although obviously we cannot and should not do any internal work. (That said — and I can speak from lots of experience here! — specialty certification programs vary sooooo widely in terms of the quality and accuracy of the information they include on the pelvic floor. This is super hard to vet if you aren’t in the industry, and even if you are, but if you want to check someone’s certs out and see who is behind the education, it can help — i.e. does the trainer who runs the education program have a board of advisers that includes pelvic PTs, etc.?)
I don’t want you to go around turning your nose up at everyone who talks about the pelvic floor, but it’s good to hold some gentle skepticism (just like with any other wellness topic on the internet!). Experienced pelvic PT? Great. “Wellness expert” who claims to know all things pelvic floor because they’ve given birth? Mayyyybe not.
All that said: I’m not the world’s foremost expert on the pelvic floor. But I do have two perinatal exercise certifications, and I’ve been writing and editing guidance content on the pelvic floor — pretty much all backed by excellent pelvic PTs — for many years. I work closely with pelvic PTs all the time, both as a trainer (I actually collaborate super-closely with the PTs that my clients work with to help customize their programming, which is sooo fun) and as a content strategist, and I’m constantly asking them questions and brushing up on my knowledge.
What is the pelvic floor?
It’s a bowl-shaped group of muscles and connective tissue — generally from your pubic bone in the front to your tailbone in the back, and the more internal hip bones on the sides. This muscle group is meant to provide support to your abdominal and reproductive organs, and open and close as needed for things like peeing and pooping, penetrative sex, and childbirth. While pelvic floor dysfunction is more common among folks assigned female at birth, everyone who has a pelvis has a pelvic floor, and anyone with a pelvic floor can experience symptoms of pelvic floor dysfunction.
What is pelvic floor dysfunction?
It’s a very broad term that can refer to a whole lot of things! Most of us probably think of incontinence when we think of pelvic floor dysfunction (PFD), and that’s certainly a common form, but even within the “incontinence” umbrella there are quite a few different types (or combinations) of symptoms. Just some of the types of PFD:
Stress incontinence: leaking urine or feces when the pelvic floor experiences “stress,” aka pressure from laughing, coughing, running, jumping, etc.
Urge incontinence AKA urgency: experiencing a very sudden and/or very frequent need to use the bathroom, often with difficulty emptying fully.
Mixed incontinence: a combo of the above.
Pelvic organ prolapse: when one or more of the organs in your pelvis (such as the uterus or bowel) shifts from its normal position and begins to bulge into your vagina, if you have one, or rectum. (People who are assigned male at birth/AMAB can experience prolapse, too, but it is more common among those assigned female at birth/AFAB.)
And then there are things like pelvic pain, sexual dysfunction, constipation, and even hip and lower back pain — not all of these will always be caused or solely caused by pelvic floor issues specifically, but the pelvic floor does often play a role in these symptoms.
Who can experience pelvic floor dysfunction or need pelvic floor care?
Truly anyone, regardless of sex, age, or whether you’ve been pregnant or delivered a baby vaginally. The perinatal period is a common one for PFD to arise, given the major strain the pelvic floor can experience from the expanding uterus, and the stress of childbirth. And thanks to hormonal shifts and reduced muscle mass, AFAB people might experience PFD as they move through and beyond the menopause transition.
But these changes aren’t the only factors. Tension, stress, trauma, and genetics can have a major impact on your pelvic floor function. So can smoking, general muscle weakness or frailty, and conditions that cause chronic coughing. People undergoing gender-affirming health care, especially surgical procedures, may benefit from pelvic floor physical therapy as a pre-op and post-op support.
What does pelvic floor care look like?
In an ideal world, you’d see a trained pelvic PT (or OT) in person for a one-on-one, hands-on assessment. This is an internal assessment, and not the most comfortable experience in the world, but a good pelvic PT is great about making you as comfortable as possible, explaining what they’ll be doing, and getting your consent and checking in at each step. Many are trauma-informed and understand how difficult exams like this can be. If you encounter one who is not, find your way to the door.
It is not easy to find an in-person pelvic PT, depending on where you live! It may also be tricky insurance-wise, for reasons we can get into some other time. And of course, if you aren’t comfortable seeing someone in person, that’s totally valid. There are telehealth options for pelvic therapy, though you may have to do some research to find a platform you have access to (gentle and unpaid plug for one of my clients, Hinge Health, a digital musculoskeletal clinic with a pelvic health program).
Your PT will likely recommend a combination of manual therapy, if you’re working 1:1 in person (again, not super fun, but often very very helpful), and exercises, including stretches, breath work, and other exercises designed to engage and/or relax the pelvic floor muscles. They’ll teach you how to do these exercises and tell you how often to do them at home. They may also suggest dietary or lifestyle changes (for folks with certain conditions, things like too much caffeine or alcohol, acidic foods and drinks, or even not drinking enough water can worsen their symptoms), or using tools like dilators or pessaries depending on the condition.
Do I have to think about my pelvic floor?
I think this may be a little controversial, but in my opinion, if you aren’t experiencing symptoms of pelvic floor dysfunction (urinary or bowel issues, pelvic pain or pressure, sexual dysfunction, etc.) you probably don’t need to think about it all that much? I’m not of the school that believes you need to be doing specific pelvic floor exercises every day for maintenance — regular exercise, walking around, breathing, hanging from a bar if that’s your jam, and just generally moving through life are all probably just what an asymptomatic pelvic floor needs. But learning to tune into the types of symptoms we’ve discussed is still a great idea, because so much can change over time — if you learn to notice things like changes in your bathroom habits, leaks, pain, sexual issues, you’ll be able to detect PFD early, which should help make it a little easier to treat.
To answer the original reader Q, if you want to gauge the health of your pelvic floor, you consider symptoms like pain, how things are going in the bathroom and bedroom, and whether you’re experiencing any strange pressure, heaviness, or bulging in your crotch, especially during certain activities (or after doing an activity for a long stretch). These things can be so sneaky and so complicated. Pelvic pain can be such a frustrating mystery to solve — is it an infection? pelvic floor hypertonicity? stress or trauma? endometriosis or some other condition? — but learning to tune in to your symptoms, and keep track of them, is an important first step.
And if you have no symptoms, lovely!
What about the strength versus weakness thing?
This is probably the heart of the current Pelvic Floor Discourse! For so long, we were told that THEE pelvic floor problem is weakness and, like, looseness, probably from giving birth. And that the only fix for this was Kegel exercises — squeezing and releasing the pelvic floor muscles regularly. And in fact we should all be doing Kegel exercises all the time, because of course we all need to have as “tight” a pelvic floor as we possibly can.
There’s a lot of ew here, namely some majorly patriarchal sexual expectations, and complete erasure of lots of other reasons to care about your pelvic floor!
The truth is, yes, some pelvic floor dysfunction happens because some of the pelvic floor muscles are weak, especially things like stress incontinence and prolapse (though like all PFD those conditions are often multifactoral!). But some PFD comes from muscles that have trouble relaxing and stretching. (And some PFD comes from a combination of weak and tight muscles!)
Also: Just like in other muscles, there are different types of strength. So your pelvic floor may have excellent endurance, but poor reactivity (maybe you don’t get any symptoms when standing or walking for a super long time, but you leak if you jump or run; or vice versa).
My own pelvic floor tends to have trouble relaxing. What this means for me is that, when my symptoms flare, I experience urinary urgency — I feel like I have to pee all the time, and I have trouble emptying my bladder fully. I used to think I just had a “small bladder,” but it turns out it was my pelvic floor all along! My pelvic floor gets plenty of practice contracting while I’m lifting weights, doing Pilates, and practicing diaphragmatic breathing (more on that later), so I don’t do Kegels regularly, and I probably don’t need to. But if I start noticing my urgency symptoms popping up, I take extra care stretching and relaxing the area, especially through deep breath work. (Fun fact: My main trigger is stress! I actually sometimes don’t even realize my stress has gotten out of control until I notice my urgency returning.)
OK, phew! So much more to discuss, and we will next week, including: Are Kegels actually bad? What is diaphragmatic breathing? And why does your pelvic floor hate your taste in pants?
Questions and comments below. Talk soon!
xo
Anna
About me and How to Move:
How to Move is an anti-diet newsletter about exercise. Each Sunday paid subscribers receive Workout of the Week, a customizable workout (in both video and written/gif format) that you can make 15, 20, or 25 minutes. Other posts come about once a week and are free to all subscribers.
I am an award-winning journalist, former magazine editor, and certified personal trainer and Pilates instructor. I train clients, write articles for publications like The New York Times, and work as a content strategist for clients such as Hinge Health.
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Thanks for including us OTs in the conversation! I feel like our expertise is often missed.