Pelvic Health during Pregnancy

Dr. Joanna Hess PT, DPT, PRC, WCS

It is no secret that the pregnant body changes to develop the fetus and prepare for delivery. We expect that the belly grows, feet swell, hair glows, brain function changes, and emotions intensify. Changes to the pelvis and pelvic floor during pregnancy are less known and many pregnant people find themselves unprepared and sometimes surprised by the impact of these changes on everyday life. In a culture that honors the vulva for its sexuality, but hides the purpose for childbirth, many pregnant people and their caregivers dismiss the “down there” transformation. During pregnancy, there are many changes to one’s pelvic health. The distinction between normal adaptation to pregnancy and warning signs of a more involved issue can be difficult to suss out. Learning more about these changes can help you to feel less isolated and embarrassed, as well as promote your ability to self-advocate and trust your body. In this blog we will go over warning signs of problems, what is considered normal, prevention and treatment techniques during pregnancy.

Normal Pregnancy Symptoms Versus Dysfunction

Summary of pelvic floor norms, dysfunction, and intervention of during pregnancy (adapted from Madsen)

Dysfunction Prevention and conservative intervention
Norms: frequency, urgency, nocturia
Stress urinary incontinence
Urinary frequency
Incomplete emptying
Painful urination
Pelvic floor muscle training with or without biofeedback*
Core stabilization
Intra-abdominal pressure management
Pelvic floor muscle training with or without biofeedback
Bladder and behavioral retraining
Manual therapy for overactive muscles
Norms: slower transit
Fecal incontinence
Incomplete emptying
Pelvic floor muscle training*
Fiber for bulking stool
Intra-abdominal pressure management
Dietary changes*
Behavioral modifications
Defecation mechanics
Manual therapy for overactive muscles
Visceral mobilization
Topical pain management
Norms: Decrease vaginal support and increased pressure, Pelvis widens, increased lumbar lordosis, increased anterior tilt of pelvis
Pelvic organ prolapse
Pelvic congestion syndrome
Pelvic floor muscle training*
Intra-abdominal pressure management
Postural training
Intra-abdominal pressure management
Compression stocking
Pain management
Norms: decreased sexual frequency, interest, arousal; changes perineal resting tone, increased genital hiatus, decreased sensation
Sexual dysfunction
Perineal pain
Pelvic floor muscle training
Sex therapy
Perineal massage*
Topical estrogen*
Pelvic floor muscle down-training
*Supported by research at level of systematic reviews or meta-analysis

Urinary Norms, Dysfunction, & Treatment

During pregnancy you can expect temporary changes to your urinary system. You may find an increased need to urinate, increased urge to urinate, and waking up to pee at night. These changes are caused by dilation of the ureters, increase in bladder muscle size, decrease in bladder muscle tone, increase in kidney size, and downward pressure caused by the growing fetus. All of these changes are temporary but you may notice some real differences in your urinary habits. (Madsen)

Pregnancy related stress urinary incontinence

You hear many folks talk about incontinence with and after pregnancy. Urinary incontinence is the involuntary loss of urine for any reason. We can get more specific and talk about stress urinary incontinence (SUI). This is what is occurring when folks talk about leaking a little with coughing, laughing, or sneezing in addition to other activities like running or lifting. This happens because the aforementioned activities create an absolute heap of downward pressure in the abdomen and pelvis. Folks who leak with these activities lack sufficient support from the pelvic floor and coordination of the abdominal muscles.

There are a lot of changes that occur in the body during pregnancy. Some of these changes can contribute to an increased risk of urinary symptoms. During pregnancy and the postpartum period, the fetus, enlarged uterus, decreased abdominal and pelvic floor support, changes to pelvic stability, increased bladder neck mobility all contribute to increased risk of SUI (Van Geelen). If you had stress urinary incontinence before pregnancy, the symptoms will likely continue or worsen during pregnancy. This tendency for worsening symptoms persists in late and past childbearing years. 76% of women with postpartum urinary incontinence reported incontinence at 12 years postpartum even if they temporarily improved symptoms immediately postpartum (MacArthur). Stress urinary incontinence treatment often addresses a weakness in the pelvic floor muscles, (think exercises like Kegels) but should also improve abdominal muscles coordination and fascial stiffness (Delancey).

Pelvic floor muscle training is the first-line intervention for pregnancy-related stress urinary incontinence (Schreiner). A recent systematic review concludes that pelvic floor muscle training in early pregnancy before symptoms begin, may prevent symptoms in late pregnancy and postpartum. However, pelvic floor muscle training as a treatment after symptoms start has less benefit during the prenatal and postpartum periods (Woodley). Pelvic floor muscle training is rarely prescribed in isolation and instead incorporated as part of a more comprehensive approach that is individualized for your own problems, lifestyle demands, and goals. As a general prescription, pelvic floor muscle training for stress urinary incontinence includes:

  • 3 sets of 8 almost maximum pelvic floor contractions held for 8 seconds every day
  • Using the cue to close and lift the vaginal opening as if to stop urine mid-stream (but not actually doing this while urinating)
  • Making sure to relax between contractions and not hold the breath
  • Contracting pelvic floor and lower abdominal muscles before activities that cause leakage
  • Decreasing downward pressure into the pelvic floor by sneezing and coughing “up” instead of down

Physical therapy also evaluates contributing causes of increased pressure on the bladder and decreased pelvic floor muscle support such as:

  • Postural changes
  • Decreased accessory (nearby) muscle activity, especially the inner thighs during pregnancy
  • Decreased core muscle activation
  • Previous perineal or pelvic floor muscle injury
  • Breath-holding tendencies
  • Decreased pelvic stabilizers
  • Poor pelvic floor muscle awareness

Pregnancy-related urge urinary incontinence

Urge urinary incontinence is urinary leakage occurring with a sudden and strong urge from abnormal bladder contractions caused by either bladder overactivity (motor problem) or hypersensitivity (sensory problem). You may experience this when unlocking the door to your home. A sudden urge to urinate will overtake you and you may leak a few drops to a full bladder of urine. This is why we also call urge incontinence “lock and key” incontinence. Fetal position/movement, changes in bladder sensitivity, altered peeing habits, increased stress, and pelvic floor muscle overactivity can contribute to pregnancy-related urge incontinence. About one-third of people in their late pregnancies and about one-third in the first three months postpartum experience urinary incontinence.

Prevention of urge urinary incontinence during pregnancy has not been studied.

The treatment for urge urinary incontinence depends on the cause and often involves an interdisciplinary team. In physical therapy, the treatment for urge urinary incontinence usually includes (Berghmans):

  • Avoiding bladder irritants which vary widely between people, but commonly include caffeinated drinks, alcohol, and citrus/acid foods.
  • Bladder training to decrease strong urges and increase the times between pees using:
  • Pelvic floor muscle training to up or down-train depending on how one presents
  • Relaxing of surrounding muscles like the inner thighs and abdominals that may contribute to the overall sensitivity of the bladder
  • Improving movement to decrease downward pressure that can increase bladder sensitivity

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Pregnancy-related overactive bladder

Overactive pelvic floor muscles often contribute to the cluster of overactive bladder (OAB) symptoms that include incomplete emptying, frequent urination, strong urge, and painful urination. Because these same symptoms can also be caused by pathology and systematic changes, overactive bladder treatment often requires a team approach. If the cause is musculoskeletal or neuromuscular, pelvic floor physiotherapy treatment usually includes:

  • Pelvic floor muscle down training
  • Postural adjustments
  • Movement assessment
  • Decreasing intra-abdominal pressure usually by promoting rib mobility and increasing abdominal muscle flexibility

Bowel Related Norms, Dysfunction, and Treatment

Pregnancy-related fecal incontinence

Fecal incontinence is the inability to control gas or feces. About one-fourth of people in their late pregnancies and about one-fifth in the first three months postpartum experience fecal incontinence. Loose stool, strong rectal contractions, increased fetal movements and pressure, hemorrhoids, and decreased pelvic floor muscle activation contribute to fecal incontinence during pregnancy. While stool consistency tends to be bulkier and drier during pregnancy, already existing irritable bowel syndrome or additional stress may make stool looser and difficult to control with increased demands on the pelvic floor and changes of the pelvis.

Prevention of fecal incontinence during pregnancy has not been explicitly studied. Decreasing risk factors for hemorrhoids (see next section), improving stool quality, and improving pelvic floor activity specifically in transitional movements (think getting up out of a chair) may help fecal incontinence depending on which factors contribute to the pregnant person’s fecal incontinence.

Improving stool quality

  • Enjoy some physical activity
  • Manage stress that is within your control
  • If your stool is too runny, increase insoluble fiber and decrease dietary irritants
  • If your stool is too dry and bulky, increase water intake and soluble fiber

Improving pelvic floor activity with movement

  • Gently exhale before and during transitional movements to engage the pelvic floor and abdominal muscles as well as decreasing downward pressure on the pelvic floor
  • Lean forward a little when moving from sit to stand to engage the legs and over-recruitment of core musculature

Pregnancy related constipation and incomplete emptying

Many factors throughout the pregnant body contribute to constipation and incomplete emptying. Changes in hormones that slow colonic transit (movement of the stool with digestion), decrease contractility of the rectum, over engage pelvic floor muscles, cause painful hemorrhoids, decrease physical activity, increase psychosocial stress, and decrease fluid intake can all exacerbate existing constipation and incomplete defecation (Wald). During pregnancy, about one third of pregnant people report constipation, particularly in the last trimester.

Physical therapy treatment of constipation and incomplete emptying primarily addresses the lack of coordination between the pelvic floor muscles to relax when you are trying to expel stool. Specifically, physical therapy treatment may address:

  • Dysfunction with tailbone and pelvic position and mobility which can increase pelvic floor muscles overactivity, particularly the puborectalis muscle
  • Changing defecation posture with increased hip bend that decreases resistance at the ano-rectal angle
  • Awareness of pelvic floor muscle activity
  • Pelvic mobility
  • Retraining abdominal muscles to efficient generate pressure
  • Mobilization of abdominal visceral and muscular structures
  • Dietary and behavioral modifications to facilitate colonic mobility. These include:
    • Keeping a diet diary to provide insight for patterns for stool consistency
      • Add specific types of fiber
      • Temporary removal of certain foods
    • Making gradual dietary changes to avoid excessive bloating
    • Using liquid iron supplements which are less constipating than pill
    • Timing bowel movement in the morning and after meals to take advantage of natural colonic mobility
    • Maintaining sufficient water intake
    • Chewing foods thoroughly


Hemorrhoids are rectal veins that enlarge inside or outside the anal opening. When hemorrhoids swell, they can cause pain with sitting and bowel movements, itching, burning, and sometimes bright red bloody stools. For many people with hemorrhoids, they report difficulty in wiping clean after a bowel movement. Hemorrhoids affect about 1/3 of pregnant people and tends to resolve 8-24 weeks postpartum. Pregnancy and vaginal delivery changes hormones, increases constipation, pressure into the perineum which increases the likelihood of hemorrhoids.

Common treatment of hemorrhoids includes:

  • Topical over-the-counter pain relief with witch hazel pads
  • Donut pillows to decrease pressure of the hemorrhoids
  • Softening the stool with medication or increased soluble fiber
  • Sitz baths to relax the muscles
  • Decreasing the tendency for bearing down in everyday life
  • Techniques to decreases straining during bowel movements

Pelvic physical therapy treatment for hemorrhoids has similar goals as constipation. In addition to previously mentioned treatment options, pelvic physical therapy treatment addresses behavioral tendencies for bearing down, especially breath holding, in everyday life that exacerbate hemorrhoids. The tendency to bear down gives us the clue that you may have some other PT issues to work on. Pelvic floor physical therapy also helps by decreasing some of the muscle tension developed as a response to pain and protection.

Pelvic Organ Prolapse and Rectal Prolapse

Pelvic organ prolapse (POP) occurs when the bladder (cystocele), uterus, small intestine (enterocele), or rectum (rectocele) relax into the vaginal vault. Rectal prolapse occurs when the rectum pushes out of the anus. POP affects 50-66% of pregnant and postpartum people, many of which do not have bothersome symptoms. Prolapses occur when the tissues that suspend the pelvic organs weaken and the pelvic floor muscles and surrounding structures cannot support the increased demand. POP causes symptoms of pressure, heaviness in the pelvis particularly with activity, sensation or feeling a bulge, complications with urinary and fecal incontinence, frequency, hesitancy, constipation, incomplete emptying, and pain. The risk factors for POP reflect the complexity of the contributing causes. The main risk factors include vaginal childbirth, advancing age (and decreased estrogen), and increased body weight. Studies associate POP with the loss of the curve in the low back and the position of the pelvis, which may cause the muscles to have to work harder. (Mattox, Nguyen).

The literature lacks solid information for the prevention of POP. However, decreasing risk factors for POP may also prevent POP. Risk factors include first vaginal delivery, especially with forceps (Cattani), increased body mass index and repetitive strenuous lifting (Vergeldt).

Treatment of prolapse include surgical intervention, mechanical support or pessary, pelvic floor muscle training and lifestyle modification (Braekken, Hagen, Li). The postpartum population often receives advice to delay surgical correction for prolapse until after completing childbearing in anticipation of continued mechanical stress on the organs of the pelvis during pregnancy and delivery. POP symptoms tend to improve during the first year postpartum, and particularly the first six months. Pelvic floor physical therapy shows benefit in reversing prolapse severity and symptoms of incontinence and heaviness, particularly for POP grade 2 and 3 during a 6-month intervention (Reimers).

In a small number 2010 study, researchers advised women to maximally contract pelvic floor muscles 24-36 times daily with regular check-ins with a physical therapist in addition to lifestyle modifications like avoiding straining and contracting pelvic floor muscles before increased intraabdominal pressure. The training group demonstrated improved pelvic floor muscle strength which was associated with upward movement of pelvic organs. However, improvement in strength was not directly associated with prolapse severity or symptoms leaving questions about other contributions to this presentation (Braekken).

Other lifestyle modifications as part physical therapy pelvic organ prolapse treatment addresses functional activity training, exercise for weight loss, exercise for general strengthening, decreasing constipation, and postural training.

  • Functional activity training modifies breath patterns, posture, muscle activation patterns, and addressing muscle weaknesses thereby decreasing the tendency for breath holding and downward pressure on the pelvic organs and pelvic floor. Julie Wiebe, a highly regarded clinician and researcher, gives an easy cue, “blow before you go,” to help manage excessive downward pressure and encourage pelvic floor support (Wiebe). When breath holding becomes the primary strategy for stability, conscious exhaling before and during movement decreases excessive downward pressure and allows for training new stability strategies.
  • Exercise for weight loss decreases risk of worsening prolapse symptoms. General strengthening improves the muscular system to meet the demands without using compensatory mechanisms like breath holding. Physical therapists develop safe exercise programs or modify current exercises that include individualized goals and strategies for consistency.
  • Postural training aims to increase the variability of the movement patterns so that pelvic inlet orients vertically which increases bony support of the pelvic organs in addition to muscular and fascial support.

Pelvic congestion syndrome

Pelvic congestion syndrome (PCS) occurs when dysfunctional valves in pelvic veins cause backup of blood, distenstention of veins, and sometimes pain within the pelvis. The symptoms include a dull achey pain is usually worse at the end of the day, after sex, during and after exercise, and with prolonged inactivity in upright positions. While PCS can start throughout the lifespan, symptoms are often noted during pregnancy when blood vessels temporarily lose their normal strength and blood volume increases. PCS can also cause varicose veins in the pelvis, perineum, buttocks, and upper legs.

PCS is often managed by hormonal and pain medications and if needed embolization by an interventional radiologist. While physical therapy management does not correct the faulty vein valves, physical therapy can help by improving secondary issues contributing to pain and incontinence. Reducing the symptoms and risk of PCS including regular exercise, diet that decreases constipation, wearing compression garments (Gavrilov), and keeping a healthy weight.

Sexual Function Norms, Dysfunction, and Treatment

Sexual function

Sexual function depends on the individual and couple’s physical and psychological experience in desire, arousal, orgasm, and pleasure. Factors that contribute to decreased sexual activity include changes in hormones that can increase pain or decrease sensation, breast tenderness, nausea, decreased mobility from changing body, guilt with sexual relations during pregnancy, altered body image, reduced attraction for partner, fear of injury to fetus, bleeding with vaginal tissue fragility, anxiety, and fatigue.

During pregnancy, up to 93% people report varying levels of sexual dysfunction (Sobghul), usually related to desire, 66.3% in the first trimester, 50.7% in the second trimester, and 69.2% in the third trimester (Bayrami). During the last trimester, 94.2% of women noted decreased clitoral sensitivity, 92.6% had decreased libido, and 81% had decreased orgasms (Erol). As a general trend, sexual interest gradually declines during pregnancy. Most couples continue intercourse into the 7th month, but then 25-50% continue into the 8th month, and 33% continue into the 9th month. Many couples prefer positioning side by side or receiving on top (Bratisl). Pleasure associated with sex typically decreases in the first trimester, improves in the second trimester, then decreases again in the third trimester.

Pelvic floor muscle training can improve sexual function through improvement of desire, arousal, orgasm, decreasing pain, lubrication, and satisfaction. However, research lacks for the specifics of PFMT improving sexual function during in the pregnancy phase (Ferriere, Sobghul). Pelvic floor muscle training increases sensation and awareness of the pelvic floor, improves circulation needed lubrication, arousal and orgasm, and increases strength for sensation and orgasm.

The changes of pregnancy may cause or exacerbate pain with penetration. Pelvic physical therapy treatment may help to improve tissue mobility, down-train overactive muscles, mobilize sensitive nerves, and address patterns of asymmetrical movement that increase abnormal demands on the pelvis.

Pelvic Health Physical Therapy in Pregnancy

The neglected pelvic floor during pregnancy needs not to sink to the bottom of the priority list. Take care of and marvel at the pelvic floor as you would the rest of the body and fetus. Like the rest of the body, the pelvic floor usually recovers well from the transient changes of pregnancy. But when your complex changes of the body give you warning signs, know that simple interventions in pelvic health physical therapy that can make a big difference during and beyond pregnancy.



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