The pelvic floor is a group of muscles and connective tissues spanning the base of the pelvis, supporting the bladder, uterus, and bowel, controlling continence, and playing a central role in sexual function. It is one of the most poorly understood muscular systems in the body, despite being relevant to a wide range of conditions that affect a significant proportion of women at some point in their lives. The universal advice to do Kegel exercises for any pelvic floor problem is an oversimplification that actively harms women with hypertonic, or overly tense, pelvic floors.
The Two Types of Pelvic Floor Dysfunction
Pelvic floor dysfunction exists on a spectrum from hypotonic to hypertonic. Hypotonic pelvic floor, where the muscles are weak or have poor neural coordination, presents with stress urinary incontinence, pelvic organ prolapse, and reduced sexual sensation. This is the presentation for which Kegel exercises, progressive pelvic floor resistance training, are appropriate and well-evidenced. Hypertonic pelvic floor, where the muscles are chronically contracted and unable to fully relax, presents with pain during intercourse, vaginismus, chronic pelvic pain, difficulty with tampon insertion, and urinary urgency. Kegel exercises in this population worsen symptoms by increasing already excessive muscle tension.
The Role of Psychological Factors
Pelvic floor muscle tone is directly modulated by the autonomic nervous system. Chronic sympathetic activation, anxiety, and trauma history are all associated with elevated baseline pelvic floor tension. This is why pelvic pain and sexual dysfunction are more common in individuals with anxiety, post-traumatic stress, and adverse sexual histories, and why treatment of pelvic floor dysfunction without addressing these psychological correlates is frequently incomplete. The pelvic floor is not simply a muscular problem that requires a muscular solution.
Evidence-Based Assessment and Treatment
Pelvic floor physiotherapy performed by a specialist is the gold standard for assessment and treatment of both hypo- and hypertonic presentations. Internal examination by a trained physiotherapist provides objective muscle tone assessment that cannot be done by the patient or by non-specialist clinicians. Treatment includes progressive training for hypotonic presentations and manual therapy, biofeedback, and pelvic floor relaxation for hypertonic presentations. A systematic review found that physiotherapy-led pelvic floor rehabilitation significantly improved sexual function, pain scores, and continence in women with pelvic floor dysfunction.
- Do not assume Kegels are the right intervention: seek assessment by a pelvic floor physiotherapist first
- If intercourse is painful, tampon insertion is difficult, or you experience pelvic pain: hypertonic pelvic floor is more likely than hypotonic and requires different treatment
- Pelvic floor physiotherapy is available on the NHS and privately: referral through your GP is the standard route
- Slow diaphragmatic breathing promotes pelvic floor relaxation and is used therapeutically for hypertonic presentations
- Address anxiety and chronic stress as part of hypertonic pelvic floor treatment: the nervous system connection is direct and well-documented
Sources
- Bø, K., & Sherburn, M. (2005). Evaluation of female pelvic-floor muscle function and strength. Physical Therapy, 85(3), 269-282.
- Rosenbaum, T.Y. (2007). Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment. Journal of Sexual Medicine, 4(1), 4-13.