Updated: Jun 26
Today's post comes to us generously from a featured guest expert, Physical Therapist Laura Malnati Chambers founder of Peak Wellness. Enjoy!!
The pelvic floor (PF) is a very unique grouping of muscles, and given its proximity to intimate
areas of the body, it can be an intimidating set of muscles. Unlike most of our other muscles, we can’t really see these muscles (unless we use a mirror) or don’t tend to touch them to figure out how they’re feeling.
Unfortunately, that also means very few women understand their pelvic floors, how to condition them, or what to do when things just don’t feel right. Let’s dive in and demystify this misunderstood group of muscles.
Pelvic Floor Anatomy
The term “pelvic floor” is usually used to describe the grouping of muscles that reside on the
underneath side of our pelvis. These muscles attach to our pubic bone, tail bone, sits bones,
and the hips bones. From these locations the pelvic floor can contract (tighten) and relax to
create support and control for our pelvic organs, to stabilize these bony attachments, and to
support the rest of our core.
There’s one more important anatomy component that is often left out of the
conversation—fascia. The pelvic floor is not as simple as just muscle to bone attachments. The
muscles as well as the pelvic organs it helps to support (rectum, urinary bladder, and uterus)
are enmeshed in many layers of fascia. This fascia is like strong webbing that helps anchor the
pelvic organs in place, helps attach the muscles to the bones, and helps translate pelvic floor
contraction to pelvic organ support.
This is important for several reasons. First, often in injury situations, this fascia may be what’s
impacted as much as or more so than the pelvic floor muscles. If this tissue is stretched and not
properly supporting the organs and muscles, the pelvic floor muscles will be working at a
Focusing on pelvic floor muscle retraining alone will not be sufficient.
How do you heal fascia if it doesn’t contract like a muscle? You give it time, as much nutrition as
possible (hydration, proper nutrient intake), and avoid overstressing it. Fascia takes longer to
heal than muscle…a lot longer. It can take months to even years to fully remodel injured fascia.
This is why sometimes issues stemming from lack of fascial support (like pelvic organ prolapse)
may take years to slowly change.
A key during this healing time is stress on that fascia. Initially, this means minimizing the stress placed on that fascia with early activity modification. For example, if you’ve been “cleared” for activity 6 weeks postpartum but you can feel or see a prolapse bulge into the vaginal canal when you do heavier activity, you probably need to ease off. If you consistently push through activities that promote prolapse, the fascia that supports those pelvic organs can’t heal.
In the meantime, what you can work on is reducing the pressure your body forces down into your pelvic floor. Our bodies use different strategies to create enough force to move, and one of those is to bear down into the pelvic floor for stability which excessively stresses the pelvic floor fascia. Conversely, you can train your body to create pressure more evenly throughout the whole core muscular system which shares that pressure amongst a much bigger area and larger muscles. This allows you to progressively do heavier activities without over-stressing the pelvic fascia. (more on this inside THIS article)
If you’re concerned about your fascial system, you may want to be evaluated by a medical
practitioner because there are situations in which the fascial injury can be severe and need
medical attention, but in the majority of cases, healing can take place conservatively.
Let’s return to the pelvic floor muscles themselves. Compared to the large muscles that
surround them in the hips, abdomen, and spine the PF muscles are actually quite small. Too
often when there’s dysfunction in the pelvis (urine leaks, pain, prolapse, etc), we immediately
assume we need to strengthen the pelvic floor, but when there is heavy work to be done, those
large muscles are much better equipped to handle it.
That means if one or more of those surrounding larger muscles isn’t working optimally, the
pelvic floor may try to overwork to pick up that slack. Similarly, if there are joint issues going on
in a hip, the spine, or pubic bone, the pelvic floor may either not function optimally or may
again overwork trying to compensate.
So, while there are definitely occasions in which we need to strengthen the pelvic floor, there
are equal times when we need to offload these overworked muscle. In fact, sometimes
symptoms of an overactive pelvic floor can mimic symptoms of weakness.
Example 1: If these muscles are working way harder than they’re intended to work all day to compensate for other issues, when it comes time for them to do their job-- like hold back urine or support the bladder, they don’t have the strength left to accomplish those tasks.
Example 2: overactive PF muscles can feel like pressure within the pelvic floor. This pressure feeling is often misinterpreted as pelvic organ prolapse because it’s mistaken as something pressing into the vaginal canal when it’s really just tensed, tired muscles. On that note, sometimes women are so fearful of pelvic organ prolapse that they hold constant tension in their pelvic floor muscles trying to prevent organs from dropping but inadvertently create a PF overactivity issue by this constant squeezing. As mentioned in the previous section, prolapse is often more about fascia and pressure bearing down than it is PF muscle strength, and excessively tightening the pelvic floor can actually become more problematic.
How Can I Tell if My Pelvic floor is Weak or Overactive?
General Signs/Symptoms of Pelvic Floor Tightness:
(these do not “diagnose” tightness but often go along with it)
Difficulty starting the stream of urine or needing a “second” pee
Pain with penetration
Increased UTI risk or feelings of a UTI
Leaking with sneeze, cough, jump
Trouble controlling gas
Feeling weak when trying to contract
Difficulty getting a full breath in
Holding a kegel makes it worse
SI joint, hip, low back pain
General Signs/Symptoms of Pelvic Floor Weakness:
Leaking with sneeze, cough, jump
Troubling holding in gas
Trouble with tampon falling out
Sex “doesn’t feel like it did before having kids”
SI joint, hip, low back pain
Heavy or pressure feeling
Self-Assessing Pelvic Floor Health
As you can see in the lists above, there’s a fair bit of overlap which can make knowing what to do
difficult. Here are a few self-assessments you can also do to help determine if you may fall
more on the weakness or overactive side:
Lying on your back, contract your pelvic floor. You can do this by trying to tighten the muscles
you would use to hold back urine or by thinking of trying to pull a jellybean into the vaginal
canal. To warm-up try a few contractions, hold for about 1 second then relax.
For the assessment, perform one fairly strong squeeze, hold 1 second, then fully relax.
Can you contract without feeling your butt muscles or inner thighs contract? If not, you may have weakness or need to work on control.
Can you feel an immediate, full relaxation after the 1 second hold? If not, you may have overactivity.
If You Think You May Have Weakness
Take it one step farther: contract your PF at only a 25% intensity, hold 3 seconds, fully relax. Then contract at 50% intensity, hold 3 seconds, fully relax. Do the same at 75% intensity and then again at 100%. (note: at 75-100% intensity you may also feel your abs kick in, that’s normal).
Can you do that whole sequence with good control? You probably have good PF control for day-to-day life.
If not, but you can still feel the relaxations each time, you probably need to work on PF strength and control.
Soft Tissue Assessment
Overactive muscles are often sore to touch. Think about the last time you did heavy activity and
woke up the next day with sore muscles. That’s what an overactive PF may feel like all the time.
You can roughly check for this externally by sitting on a ball and letting it sink into your pelvic
floor, assessing for soreness.
Find something between the size of a golf ball and a tennis ball. Place the ball on a chair and sit to that the ball is directly on your “sit bone”- the boniest part of your seat. Then let the ball roll just off that bone toward your anus (without pressing directly on the anus). Tilt your pelvis forward and backward so that the ball rolls between the soft tissue space between the sit bone and the tail bone, the anus, and the vagina. Repeat on the other leg as well. If any of these locations is notably tender, you may have overactivity of your pelvic floor.
One important side note: having strong pelvic floor muscles isn’t correlated with difficulty during
childbirth. Overactive muscles have been correlated with longer pushing phase but not more risk
of needing medical intervention to assist birth. While it can be advantageous to learn pelvic floor relaxation and take steps to reduce your pelvic floor tension, you’re not necessarily doomed for complications if you go into labor with some tightness.
What You Can Do From Home
Once you have a better idea about whether you have pelvic floor tightness or weakness, you
can start working on this on your own.
Overactive Pelvic Floor
If you determine that your pelvic floor is overactive, your goal is to incorporate relaxation
exercises. Your pelvic floor can be both overactive and weak, but it’s important to address the
overactivity before trying to do strengthening. There are 3 main strategies you can use at home
to address overactivity: awareness, breathing, and stress management.
Some women may be stress tension holders in their pelvic floors, just like others hold tension in their necks or stomachs or maybe grind their teeth. This is often a subconscious activity that we’re not even aware we’re doing.
Periodically in the day, bring your attention to your pelvic floor and notice if you seem to be contracting like a kegel. If you have trouble telling, try actively tightening your pelvic floor muscles (again, like a kegel) for a second or two then totally relaxing that contraction. Does your pelvic floor feel different than it did when you first tuned in? Sometimes full relaxation comes better after conscious contraction, so if you’re subconsciously contracting your pelvic floor muscles, you may need to add an intentional contraction before you can fully get those muscles to relax.
The diaphragm is oriented above the pelvic floor in the abdomen. If you breathe using your
diaphragm, this forces a small amount of pressure into the pelvic floor. It’s not enough to overly
stress the fascia, it just encourages relaxation and gentle stretching of the pelvic floor.
This can be powerful for resetting overactive muscles. The key is to learn to breath well using your diaphragm instead of other muscles and to find positions that allow you to best feel the breath
push pressure gently into the pelvic floor.
First, to breathe with your diaphragm, place your hands on either side of your lower rib cage. If
you’re fully using your diaphragm, your ribs should expand out to the sides pushing your hands
out when you breathe in. At the same time, you shouldn’t feel your shoulders or neck shrugging.
Practice feeling relaxation in your upper body while your lower ribs widen on each breath in, then relax and just let the exhale happen without forcing it.
To help direct the pressure from the diaphragm contraction toward your pelvic floor, you can
try a few different positions. One of the best is a yoga happy baby pose, but if that doesn’t work
for you, you can try child’s pose, deep squatting (sitting on something low so you’re relatively
relaxed), or lying on your side in the fetal position. In this position, breathe in using your
diaphragm and pay attention to your pelvic floor. The goal is to feel a gentle pressure pushing
into the pelvic floor allowing it to drop or stretch just a small amount. As you exhale just relax.
Your pelvic floor and diaphragm will naturally return to their resting positions.
Stress management techniques may also be helpful because there is a connection between our
“fight or flight” nervous system (the sympathetic nervous system- the one that’s more activated
when we’re stressed) and our pelvic floor.
In stress mode there are more signals being sent to your pelvic floor to contract. Conversely, the “rest and digest” nervous system (the parasympathetic nervous system- the one that’s more activated when we’re at ease) sends signals to our pelvic floor to relax and let go. Managing stress is definitely easier said than done, but if you have symptoms of an overactive pelvic floor, it can be important.
Strengthening the Pelvic Floor
If strengthening is your primary goal, the first step is often gaining awareness and control in the
pelvic floor. A great way to do this is with the assessment described above in which you
contract at a 25% then 50% then 75% and finally 100% effort. Hold each for about 3 seconds
and then fully relax.
You’re training your brain to connect more with your pelvic floor; you’re training your pelvic floor to work at varying intensities; and you’re training the endurance to hold at those intensities for several seconds.
From there you can continue to build strength and endurance through holding longer kegels,
but you’ll actually work your PF harder with exercises that recruit it together with other
muscles of the core like leg lifts, bridges, and pallof presses.
However, as we discussed in the fascia section, these higher level exercises may come at the expense of more pressure bearing down into the pelvic floor if the body isn’t coordinating all the core muscles together well. Monitor your pelvic floor and back off if you’re feeling lots of extra bearing down pressure during higher level exercises.
Be sure to jump to the second part of this teaching series on the pelvic floor, Beyond Kegels: How the Whole Core Works Together to Support the Pelvic Floor.
Laura is a wife, a mom, a stepmom, a coach, a PT, a runner, a gardener, a farmer, a lover of exercise, a former collegiate athlete, and a person on a mission to create a life that balances her professional passions with her hobbies and the family that she loves.
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