What exercises are best for my pelvic floor

Dr. Fiona McMahon PT,DPT
I would argue that all of us want a healthy and strong pelvic floor, whether we know it or not. Our pelvic floors do so much for us. The muscles of our pelvic floor are constantly working in the background to ensure our bathroom habits, sexual function, and whole body are moving efficiently and correctly. Although the pelvic floor muscles are a bit more in vogue now, many of us don’t think about taking care of these muscles until something goes wrong. Many of us think that only postpartum folks have to worry about a healthy pelvic floor and that’s not true! A healthy pelvic floor is vital for your health now and will serve you throughout your lifespan.

Why Care About the Pelvic Floor?

If you care about continence, sexual function, healthy blood flow, and the stability of your core, you already care about your pelvic floor. The pelvic floor is an integral part of every single one of these functions. Without a healthy pelvic floor, the above functions would be severely impaired if not fully impossible.

The pelvic floor is a group of skeletal or voluntary muscles that live between your pubic bone and tailbone. They are called voluntary muscles, not because they are so helpful and volunteer to do so much for us, but because you can volitionally contract and relax them by closing your vagina or rectum. You probably just did a little pelvic floor squeeze just now, as you were thinking about these muscles. One easy way to locate your pelvic floor is to think of the area that touches a bicycle seat. That is where your pelvic floor lives!

The pelvic floor is one of the most important areas of the body for regulating our urine and bowel movements. Many folks who have had babies, might complain that they cannot hold their urine as well as they used to prior to having their kiddos. This is most likely due to dysfunction in the pelvic floor and it can be improved. What you may not know is that urinary and/or fecal incontinence caused by pelvic floor dysfunction can occur at any age, or gender, irrespective of whether or not you have had children. The pelvic floor can also cause issues with going too much (frequency) or not being able to delay making a potty trip (urgency).

The pelvic floor also works to support our abdominal and pelvic viscera. The viscera are our organs. Without proper pelvic floor support, our organs can droop into our vagina and rectum causing prolapse, which can present as a sensation of heaviness or fullness in the pelvis which typically worsens after activity and towards the end of the day. The pelvic floor can also be too stiff, meaning that you have to push harder to have a bowel movement, which can place excessive strain on the ligaments supporting our organs and eventually worsen the symptoms of prolapse.

Sexual function is another hallmark responsibility of the pelvic floor. No matter your setup downstairs, the pelvic floor plays an enormous role in sexual health. A healthy pelvic floor works to make sure the clitoris or penis can fill up with blood for sexual activity, and is also responsible for the pleasurable and rhythmic contractions associated with orgasm. For those of you who engage in receptive sex whether anally or vaginally, the pelvic floor muscles must be able to stretch without pain to ensure pleasurable penetrative sex.

Here’s what our esteemed co-author, Joanna Hess, found in the research about the impacts of pelvic floor dysfunction in folks with female anatomy. Remember many of these symptoms can also be experienced by people with any type of anatomical set up downstairs.

Over a lifetime, one in three people with female anatomy experiences pelvic floor dysfunction, including urinary urgency, incontinence, and prolapse. Pelvic pain lasting more than six months is reported by 5-25% of people with female anatomy which accounts for 10% of gynecological visits. Pelvic floor muscle function often contributes to both the problem and solution for these folks.

Research does show that when indicated, pelvic floor muscle training can be used to help:

  • Stress urinary incontinence
  • Urge incontinence
  • Low-grade pelvic organ prolapse
  • Sexual dysfunction (particularly difficult with orgasm and decreased lubrication)
  • During and after pregnancy for prevention of incontinence
  • Around and after menopause for genitourinary syndrome of menopause

Again, pelvic floor muscle training is not the solution for every pelvic floor dysfunction. Sometimes, they can make the symptoms worse. Almost everyone with pelvic floor dysfunction would benefit from seeing a trained professional who specializes in pelvic floor issues for individualized diagnosis and treatment. Often, pelvic floor muscle training is only part of the treatment.

Where to Start with Pelvic Floor Exercises

Pelvic floor dysfunction typically comes in two primary presentations. It is really important to know how your pelvic floor is behaving prior to starting a course of pelvic floor strengthening. Pelvic floors that aren’t working correctly can either be too tight or too loose. Both can present as weak. You might also hear the word hypertonic being batted around to describe a tight pelvic floor. A pelvic floor that is too loose and weak can also be problematic as well. The fancy folks will call this version of pelvic floor dysfunction, hypotonic.

Before starting pelvic floor-specific exercises it is wise to know what you are dealing with, especially in the case of pelvic floor hypertonia or tightness.

As a general rule, if you are having pain or difficulty pooping or peeing, it is likely you may be experiencing pelvic floor tightness and it would be advisable to avoid Kegels, as excessive Kegels may make these symptoms worse. That said, we can also see pelvic floor hypertonia (tightness) present as incontinence or weakness in and about the pelvic floor. If you aren’t sure what you are dealing with, I’d strongly advise meeting with your local pelvic floor physical therapist to see if you are dealing with a tight or weak pelvic floor.

Pelvic Floor Relaxation- Four Point Breathing

Even the strongest powerlifters stretch their muscles or at least they should! Regardless of whether you have a tight weak pelvic floor or a loose and weak pelvic floor, the following exercises are safe to do and won’t overstretch loose muscles.

My most often prescribed exercise, my greatest hit if you will, is an exercise I call four point breathing. I love this exercise. It is something you can do practically anywhere. In addition to helping to provide a little bit of movement to the pelvic floor, it can also provide a relaxing and meditative break in your day. You can do this exercise whenever you feel like it. Personally, I find it helpful when experiencing pain or stress. In sitting, become aware of your pelvis and think of it as having four individual points, the pubic bone in front, the ischial tuberosities (sit bones) on the sides, and the tail bone in the back. As you breathe in, without bearing down, bring awareness to these 4 points. As you breathe in, imagine those four points expanding away from each other. As you breathe out, imagine the four points recoiling back to their original position. You can try 10 deep breaths or set a timer for 2-5 minutes. This exercise is designed to be super gentle and relaxing. For folks with tight and weak muscles, it can be a great way to start teaching the pelvic floor muscles to relax. For those individuals with loose and weak pelvic floors, it can provide gentle movement which can help lymph and blood circulate more effectively and deliver much-needed nutrition to those weak muscles.

Starting with hip stretching and hip opening is another wonderful way to keep your pelvic floor nice and healthy. The hip and pelvic floor are close cousins. The obturator internus is a key hip muscle that has both pelvic health related functions and hip related functions. The obturator internus works to provide stability to the hip as well as provide the lateral supports to the bladder. Issues with the hip can translate into issues with the pelvic floor and vice versa. Gentle stretching of the hamstrings, glutes, quadriceps, and adductors can all meaningfully support a happy and healthy pelvic floor.

Strengthening Exercises

Even if your pelvic floor muscles are tight and weak, the pelvic floor does have to contract throughout the day to keep you continent, as well as blood and lymph circulating in the pelvis, and the spine and organs supported. You don’t have to be afraid of a pelvic floor contraction here and there, but I still wouldn’t perform excessive Kegels if your pelvic floor is not weak and tight, because it can make symptoms worse. Strengthening the muscles surrounding the pelvic floor can be helpful to take the burden off of the pelvic floor if it is overworking to support the spine and can also teach it to “play nice” with the other core muscles.

Conversely, exercises that offer a little more “bang for your buck” or benefit for your time can be helpful for those who have loose and weak pelvic floors. In addition, these exercises can be added to an existing workout routine to ensure that they do in fact get done. Bridges, clamshells, squats, and pliés have been found to offer pelvic floor activation similar to that of a kegel but also have the added benefit of strengthening other muscle groups. Remember the health of your hips and pelvic floor are intimately related! For those who wish to do these exercises but suspect their pelvic floor is tight, I would suggest a round of the four-point breathing described earlier to help the pelvic floor relax after it has been activated, through these exercises. Also remember not to skip your stretches! I am saying this just as much for me as I am for you. For those experiencing pain, I would wait until you see a pelvic floor physical therapist before engaging in these exercises.

If you wish to try out your Kegel game, there are a few ways to optimize your results. The most common cue for pelvic floor strengthening is “ try stopping the flow of urine”. I am so “meh” on this cue. Sure, you are using the correct muscles with this action, but there are a few drawbacks. One, you can interrupt your ability to empty your bladder at that moment. Activating the pelvic floor can inhibit the detrusor (bladder squeezer muscles) which can limit your ability to fully empty your bladder. It’s fine to do once or twice, but I certainly would not suggest doing it regularly as it can really disrupt your pee habits.

The other drawback of kegels while peeing, is that it simplifies a complex movement. A correctly performed kegel is a mix of two distinct movements, a squeeze or closure of the vagina/rectum and a lift. Oftentimes when folks practice stopping the flow of urine, they omit the lift part. The lift part is so important and is vital in reducing the experience of stress incontinence, prolapse and other pelvic floor symptoms. A cue that I really like is to imagine your pelvic floor like an elevator. You must close the doors, ( your vaginal or anal sphincter), before lifting the carriage. Close your anus or vagina, then lift your pelvic floor up. You can get really fancy by envisioning going up slowly floor by floor and you can also practice the all-important relaxation portion by slowly lowering the pelvic floor back to the ground floor and then opening the doors (relaxing vagina or rectum).

Curious about vaginal weights? Read what Joanna Hess had to say about them in her blog “What do Vaginal Weights do?”

I don’t want to make things worse, when should I avoid vaginal weights?

Vaginal weights can worsen pelvic floor dysfunction symptoms particularly for people who already have overactive and tight pelvic floor muscles. Overactive and tight pelvic floor muscles work too hard, have difficulty relaxing, and often sit higher in the pelvic cavity. Oddly enough, an overactive pelvic floor can seem weak because the muscles cannot generate sufficient tension. Overtightening or lack of relaxation when using vaginal weights can also increase discomfort, even with underactive pelvic floor muscles.

Overactive and tight pelvic floor muscles correlate with symptoms like pelvic pain, urinary urgency, constipation, hemorrhoids, incomplete emptying, and hesitation. If you have these symptoms, hold off on any vaginal weights or pelvic floor muscle training until you see a trained professional who can offer specific recommendations.

When to call in the big guns aka when to go to Physical Therapy?

If you are asking this question, I would highly suggest you make at least one visit to a pelvic floor physical therapist. They can be instrumental in figuring out exactly what you need in terms of exercise. If you prefer to go it alone, keep in mind you should see some change in your symptoms in about 6-8 weeks. I would not expect to be 100% better in 6-8 weeks, but you should have noticed some signs that you are headed in the right direction.

If you are noticing pain or your symptoms are worsening, discontinue exercise and see a physical therapist straight away. It is so helpful in treating pelvic floor pain to get help sooner rather than later.

Also, pelvic floor problems can be multifactorial. For example, you may experience urinary leakage because of a weak pelvic floor alone, but you also may be experiencing urinary leakage secondary to poor shock absorption due to weak trunk and leg muscles or excess downward pressure on your bladder with everyday movements. If you have diligently strengthened your pelvic floor but are still noticing symptoms, it may be wise to call in the experts to see what else you can do to ease your symptoms.

Physical Therapy at Beyond Basics Physical Therapy

Our therapists are uniquely poised to help you develop a healthy and strong pelvic floor. At both locations, we have a diverse group of practitioners whose approach can be tailored to meet your needs for a truly bespoke experience. Our therapists have backgrounds in marathon running, Pilates, yoga and you are sure to find your perfect therapeutic match at Beyond Basics.

During our private hour one on one session, your physical therapist will work to determine the best course of care that most closely aligns with your individual goals, whether that be completing a triathlon to wearing pants and sitting comfortably without pain. With regular visits and solid adherence to the home exercise plan, most of our patients should expect to see improvement in their symptoms in 6-8 visits.

If you feel that treatment at Beyond Basics is right for you, but still have questions please call us so that we may arrange a one-on-one phone consultation to help answer any questions you may have and get you ready to start feeling a whole heck of a lot better.

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