How To Strengthen Your Pelvic Floor

My name is Nicolette and I am a doctor who specialises in women’s health.

I’ve spent years seeing clients in clinics who have a dysfunctional pelvic floor, which is impacting their quality of life and wanted to share information to help you understand all about it before the horse has bolted, so to speak.

I’ll cover what the pelvic floor is, how to tell if you need to work on your pelvic floor, what causes a weak pelvic floor (which is what most women have trouble with), how to exercise it and at what points it would be important to get additional help from a GP, pelvic floor physiotherapist or a urogynaecologist.

What is the Pelvic Floor?

The pelvic floor (sometimes called pelvic diaphragm) is a group of muscles and connective tissues that span the base of your pelvis. It supports pelvic organs like the bladder, intestines, and uterus, aids in urinary and bowel control, and plays a role in sexual function and stability of the spine and pelvis.

The Latin names for these muscles are; Puborectalis, Pubococcygeus and Ilieococcygeous.

Collectively they are called the levator ani which translates to ‘lifter of the ring’! Women have 3 rings in their levator ani:

• Urethral orifice
• Vagina
• Anal orifice

Because women give birth and have more perforations in their pelvic diaphragm, they are more predisposed to having problems with their pelvic floor.

How To Tell If Pelvic Floor Is Tight or Weak

Pelvic floor weakness might be very subtle, until menopause or perimenopause and then the loss of the female sex hormones reveals the underlying weakness.

The underlying weakness can also be revealed when a stressor comes along e.g. pregnancy.

Symptoms of a Weak Pelvic Floor

• Urinary incontinence (leakage when coughing, sneezing, or exercising)
• Bowel incontinence
• Pelvic organ prolapse (feeling of heaviness or bulge in the vagina)
• Pain during intercourse
• Lower back pain
• Difficulty with bowel movements

Symptoms such as urinary incontinence are examples of stress incontinence.

However, if you find that you suddenly need to rush to the bathroom because of the feeling of the need to pass urine (whether there is incontinence or not), that might indicate a different type of incontinence not linked to having a weak pelvic floor.

This is called urge incontinence and is linked to having an overactive bladder muscle (detrusor muscle).

Symptoms of a Tight Pelvic Floor

• Pelvic pain or discomfort
• Pain during intercourse (dyspareunia) or when inserting tampons
• Difficulty starting urination or a weak urine stream
• Incomplete emptying of the bladder
• Constipation or straining during bowel movements
• Pain during or after bowel movements
• Lower back pain
• You also might find that you cannot tense your pelvic floor muscles

There is also a link to a previous history of sexual abuse, which increases the risk of having tightness in the pelvic floor.

A good rule of thumb is to assume your pelvic floor is prone to being weak, unless you have symptoms suggesting a tight pelvic floor.

What Causes a Weak Pelvic Floor?

The causes of a weak pelvic floor are all related to increasing the strain on the muscles, or damage to the muscles e.g. tearing of the perineum during childbirth.

As said above, the consequences of the strain or damage might not reveal themselves until after menopause.

Examples of increased strain on the muscles:

• Pregnancy: this is partly due to the physiological changes that occur during pregnancy, as well as increased mechanical pressure on the levator ani muscles. It is very common; Up to 75% of women will experience urinary stress incontinence during pregnancy as a result of a weak pelvic floor^[1].
• Constipation: this is because of increased stress on the pelvic floor muscles through prolonged straining.
• Chronic cough and obesity: both increase intra-abdominal pressure, increasing the strain on the pelvic floor muscles, making them more likely to become weak.
• Damage to the muscles: childbirth and perineal tearing are the main causes of this.

To reduce the risk of damage to these structures being undetected, it is important to have the perineum inspected by a healthcare professional e.g. midwife or obstetric doctor after having had a vaginal birth.

This normally includes putting a finger in the back passage to determine if there has also been damage to the external anal sphincter which is incredibly important in maintaining continence of faeces.

70-90% of women who have a vaginal birth will have some form of perineal damage^[2]. It is also important to start pelvic floor exercises after delivery to ensure the muscles build back up their strength. These exercises are also safe to do during pregnancy.

What is Pelvic Floor Dysfunction

The definition of this depends on where you look.

A weakness in the pelvic floor is a dysfunction of the pelvic floor.

However when discussing a group of muscles dysfunctioning, it is useful to think about when they are contracted too much, so the opposite of a weak pelvic floor. We have talked about that while discussing if the pelvic floor is too tight.

Another type of pelvic floor dysfunction is where the pelvic floor contracts, rather than relaxes during defecation (opening bowels), so there’s a disco-ordination of the muscles. Another word for this is anismus.

It often presents as long-standing constipation i.e. over six months. There are other symptoms including a sensation that there is still more stool to pass, abdominal pain when opening the bowels and needing to insert a finger into the rectum or vagina to help remove stools. The stools themselves are hard and lumpy. It is important to remember there are other more common causes of constipation, mainly related to lifestyle factors such as too little dietary fibre.

Strengthening Your Pelvic Floor

If you have a weakened pelvic floor, you can do some exercises at home to help strengthen it. They don’t take very long and can have numerous benefits, such as:

• Improved sexual function by increasing vaginal sensitivity
• Improvement in continence and protection against the risk of developing incontinence in the future
• Improvement in mild prolapses and protection against the risk of developing prolapse in the future
• I would especially recommend starting before becoming pregnant. This is because if a weak pelvic floor is revealed through stress urinary incontinence, starting pelvic floor exercises after this point doesn’t then resolve the incontinence during pregnancy.
• An app which I and other healthcare professionals refer clients to is the Squeezy app. This is a useful resource in that it reminds you to exercise your pelvic floor and gradually builds up the strength of those muscles.

How to do Pelvic Floor Exercises

Step 1: Identify the Pelvic Floor Muscles

• Locate: Sit or lie down comfortably. Imagine you are stopping the flow of urine or preventing passing gas. The muscles you contract are your pelvic floor muscles.
• Check: To ensure you’ve found the right muscles, try to stop urination midstream once. Only do this for identification purposes.

Step 2: Get Comfortable

• Position: Find a comfortable position—either lying down, sitting, or standing.
• Relax: Ensure your thighs, buttocks, and abdomen are relaxed.

Step 3: Perform Kegel Exercises

• Contract: Tighten your pelvic floor muscles, lifting them upwards and inwards.
• Hold: Maintain the contraction for 3-5 seconds while breathing normally.
• Release: Relax the muscles completely for 3-5 seconds.
• Repeat: Aim for 10-15 repetitions per session.

Step 4: Progress Gradually

• Increase Duration: Gradually increase the hold time to 10 seconds as you gain strength.
• Increase Repetitions: Work up to three sets of 10 repetitions per day.

Step 5: Incorporate into Daily Routine

• Consistency: Perform Kegel exercises at least three times a day.
• Mindfulness: Integrate exercises into daily activities, like while brushing teeth, sitting at a desk, or during TV time.

Step 6: Avoid Common Mistakes

• Don’t Overdo It: Avoid holding your breath or tightening other muscles like your abdomen or buttocks.
• Be Patient: Improvement can take several weeks to months, so remain consistent.

It is important to keep your breathing the same and your abdominal muscles relaxed; you want to focus on the correct muscle group.

The relaxation component is equally as important as the contraction of these muscles. It ensures the muscles can be relaxed when needed e.g. during sexual intercourse or going for a poo. Otherwise, those muscles are at risk of becoming tight.

How often should you do them?

Aim to do this 3 times a day, and try to incorporate it into your daily routine e.g. going to and from work. Don’t worry; no one will know that you’re doing them!

What other things can be done to aid a healthy pelvic floor?

• Healthy diet: helps prevent constipation through the intake of fibre.
• Healthy weight: helps reduce the strain on the pelvic floor.
• Stop smoking: if there is a chronic cough related to smoking, then stopping smoking would reduce this.

How long does it take to see an improvement if you have signs of a weak pelvic floor?

These exercises are in for the long haul. It might be several months before things improve.

This is why it must become part of your routine, like brushing your teeth.

Exercise To Avoid If You Have A Weak Pelvic Floor

If you have symptoms of a weak pelvic floor e.g. urinary incontinence, then exercises that also increase the strain on those muscles might not help e.g. sit-ups.

One option is to replace these with strength-building exercises such as pilates, at least until symptoms of the weak pelvic floor have resolved with pelvic floor exercises. Then gradually reintroduce the exercises that have put a strain on the pelvic floor, and as long as your pelvic floor is happy and the pelvic floor exercises continue, see how things go.

Another option is to actively engage your pelvic floor before undertaking these exercises, especially if they are exercises that you cannot avoid e.g. lifting up heavy shopping bags!

However, if you do not have symptoms of a weak pelvic floor (but remember to assume there is a predisposition to weakness) then there aren’t any exercises to avoid.

What Is Pelvic Floor Therapy

Pelvic floor therapy involves the use of other tools to improve pelvic floor health. Examples of these include biofeedback therapy and hands-on therapy. It is normally provided by a pelvic floor physiotherapist.

When to Speak to Your GP

I would recommend you speak to your GP for more information or support if:

• If you have had a baby and you are still troubled by incontinence of either faeces or urine 6 weeks after delivery. Depending on circumstances, they might help you further with lifestyle modifications, refer to a pelvic floor physiotherapist for more directed pelvic floor muscle therapy, or refer you to a urogynaecologist or a colorectal surgeon.
• If you notice blood in either your faeces or urine.
• If you are in pain when passing faeces or urine.
• If you have noticed a change in your bowel habit – meaning how often you open your bowels and how soft or solid your poo/stool is.
• If you think you have a prolapse that is still affecting you despite pelvic floor exercises. They might try a pessary (an object that helps hold the cervix in place), recommend a more structured pelvic floor physio or refer you to a urogynaecologist.
• It is worth doing some research if you feel you require a pelvic floor physiotherapist, as sometimes you can refer yourself to them, without having to go through a GP. This is dependent on local provision.
• Another time to see your GP or a pelvic floor physiotherapist is if you find that you cannot contract or relax your pelvic floor, you cannot feel your pelvic floor or you have tried pelvic floor exercises but not noticing an improvement.