The pelvic floor is easy to ignore until it isn’t.
Anna Pancheshnikov, MD
The can’t-ignore part comes when the fear of leaking with a cough, laughter or workouts starts making decisions for you. When errands get planned around the cleanest bathrooms. Or when pressure in the vagina feels less like something to brush off and more like something is falling out.
For years, women have been told the cure-all is Kegels – those exercises where you squeeze like you’re trying to stop yourself from peeing.
Kegels may be what everyone has heard of. But that’s not the same as knowing when and how to do them or whether they are the right answer to a pelvic-health problem, says Cooper University Health Care urogynecologist and pelvic reconstructive surgeon Anna Pancheshnikov, MD.
“Just do some Kegels, strengthen your muscles – that is not enough sometimes,” Pancheshnikov says. “And sometimes, more importantly, it’s even the wrong thing to do.”
Here’s what “just do Kegels” misses.
1. Pelvic floor issues are not just “down there”
Women may spend years managing symptoms before anyone connects the dots to the pelvic floor, says Inspira Health urogynecologist Fabiana Kreines, MD.
“Everyone knows about back muscles and abdominal muscles,” Kreines says. “But many people don’t even realize the pelvic floor exists and that it’s connected to all of your other core muscles.”
Fabiana Kreines, MD
The pelvic floor is a hammock of muscles that supports the bladder, vagina, urethra, rectum and uterus. Depending on what’s happening with those muscles – weakness, tightness or poor coordination – symptoms may show up as leaking, urgency, constipation, pain with sex, vaginal pressure or aching that feels deeper in the hips, pelvis or lower back.
Childbirth, especially vaginal delivery, is a major risk factor. But symptoms can appear years later, often around menopause, and they can affect women who have never given birth. Constipation, family history, diabetes and high-impact exercise can also contribute.
One reason symptoms are more noticeable around menopause is the drop in estrogen.
“The wear and tear on the pelvic floor can be masked by estrogen,” Kreines says. “Then once you reach menopause and that band-aid is gone, all the pelvic floor injuries that have accumulated throughout your life suddenly show themselves.”
About 1 in 3 women has pelvic floor symptoms, Pancheshnikov says. But many never seek help, often because they don’t realize they can do something about it.
“We have one group of women that says, ‘It’s normal. My mom had it, my sister had it, everyone has it, my girlfriends joke about it,’” she says. “Then this other group of patients says, ‘I’m abnormal. What is happening to me?’”
Common does not mean inevitable, Pancheshnikov adds.
2. It’s not all just “leaking”
Pelvic floor problems can overlap, but they are not interchangeable.
Stress incontinence is the urinary leak that comes with pressure – coughing, sneezing, laughing, jumping or working out.
Urgency is the sudden “I have to go right now,” feeling, sometimes before the bladder is full. It can mean leaking on the way to the bathroom, running to the bathroom repeatedly or waking up at night to pee.
Constipation can also be tied to the pelvic floor, especially when the muscles are not relaxing or coordinating the way they should. Similarly, painful sex can also come from muscles that are too tight or in spasm, Kreines says.
Then there’s prolapse – pressure, heaviness or a bulge in the vagina, which Kreines describes as essentially a hernia of the vagina.
“People will say it feels like a tampon is always hanging out,” she adds. “Or there’s pressure or heaviness, like something’s falling out.”
3. Pelvic floor PT is not gym class
Pelvic floor physical therapy is often where treatment begins. Depending on the symptom, it may be all a woman needs.
Still, the phrase can stop people cold. Kreines says many women hear “physical therapy” and picture something very different from the reality of pelvic floor care.
“People think physical therapy and imagine a bunch of people in a room with exercise equipment,” Kreines says. “This is not that.”
Therapists are specialized in the pelvic floor, she notes. Treatment is private, individualized and may include exercises, breathing, posture help, bladder retraining, biofeedback or lessons in how to relax muscles that are too tight – not just in how to strengthen weak ones, she says.
Beyond PT, treatment depends on the symptom. Overactive bladder may improve with medication, Botox or nerve stimulation. Stress incontinence and prolapse may improve with a pessary, a removable device placed in the vagina for support. Sometimes the solution is injections or a procedure to support the urethra for leaking. Surgery is an option too.
When symptoms are tied to estrogen loss, Pancheshnikov adds, vaginal estrogen – a cream, tablet or ring – can help with issues including dryness and painful sex. Unlike hormone therapy by pill or patch, it works locally.
4. Kegels are not the cure-all
A Kegel is a squeeze-and-release of the pelvic floor muscles. When those muscles are weak, they can help strengthen support and relieve some symptoms.
But weakness is not always the problem. Sometimes the muscles are already too tight or not relaxing when they should, which can contribute to painful sex and constipation, Kreines says.
“If your main issue is that you’re having pain from pelvic floor muscle spasms, if you sit there tightening the muscles, doing Kegels, that can make it worse,” Kreines says.
Even when Kegels are right, Pancheshnikov says, many women are doing them wrong by not isolating the pelvic floor from the muscles around it.
Pelvic floor PT takes out some of the guesswork.
“Firstly, they teach you how to engage the pelvic floor muscles correctly,” she says. “They can give you feedback about that. Secondly, they teach you about the other muscles, how your posture relates. There’s so much more to it than just doing Kegels.”
