By Womaness Editors 6-Minute Read
You’ve heard the term pelvic floor. You’ve probably heard you should be doing Kegels. And if leaking, constipation, painful sex, or even an inexplicably cranky lower back has entered the chat, someone may have suggested pelvic floor physical therapy.
Which raises a pretty reasonable question: What even is pelvic floor physical therapy?
To help us get back to basics, we turned to Dr. Amy Stein, MPT, DPT, BCB-PMD, founder of NYC-based Beyond Basics Physical Therapy and author of Heal Pelvic Pain: The Proven Stretching, Strengthening, and Nutrition Program for Relieving Pain, Incontinence & I.B.S, and Other Symptoms Without Surgery and Beating Endo: How to Reclaim Your Life from Endometriosis; as well as the digital download Healing Pelvic and Abdominal Pain.
First: What exactly is the pelvic floor?
The pelvic floor is a group of muscles at the base of the pelvis that helps support your pelvic organs—including the bladder, rectum, and uterus—and plays a role in bladder, bowel, and sexual function.
But it doesn’t work in a vacuum. Those muscles connect and work with muscles in your hips, core, and back, which is one reason pelvic-floor trouble can sometimes show up in places you might not immediately connect to your pelvis. Pelvic-floor dysfunction can be associated with pain in the hips, abdomen, lower back, tailbone, and legs as well as bowel, bladder, and sexual symptoms.
In other words, there’s a lot more going on down there than just bladder control.
There’s a lot more going on down there than just bladder control.
And what exactly is pelvic floor physical therapy?
It’s a specialty within physical therapy focused on helping the muscles, tissues, and nerves of the pelvic floor work the way they should.
Just like muscles elsewhere in the body, pelvic-floor muscles can become weak, tight, injured, or overused. Pelvic floor PT starts by figuring out what isn’t working properly, then uses an individualized combination of hands-on treatment, movement, exercises, and other techniques to improve function.
That distinction matters, because pelvic-floor dysfunction doesn’t necessarily mean your muscles simply need to become stronger.
Your pelvic floor can be weak. But it can also be too tight.
Stein says pelvic-floor problems generally fall into two broad categories: muscles that have become overstretched and weak, or muscles that are overactive, tight, and/or shortened.
And an overactive pelvic floor isn’t necessarily a stronger one. Those shortened and tight muscles can also become weak…and can contribute to significant pain.
Pregnancy and vaginal delivery can affect the pelvic floor, but they’re hardly the only culprits. Stein points to chronic constipation and straining, chronic coughing, abdomino-pelvic surgery, back or hip injuries, endometriosis, IBS, and other conditions involving the pelvis as potential contributors.
Beyond Basics Physical Therapy also points to injury, sports, poor alignment or posture, overuse, and improper movement patterns as possible factors.
Which brings us to the pelvic-floor advice nearly every woman has heard…
So should we all be doing Kegels?
Not necessarily.
“We rarely recommend Kegels to our patients with tight, shortened, and overactive pelvic-floor muscles,” Stein says, because pelvic-floor problems frequently involve much more than simply contracting and strengthening those muscles.
“The pelvic floor never works in isolation,” she explains.
(Straightforward stress incontinence and decrease sexual response may require kegels, Stein also says. "But you need to make sure you're doing them correctly.")
Depending on what’s actually causing the problem, therapy may need to address weakness or tension elsewhere in the body, including the abdominal muscles, hips, back, and even neck. Breathing matters, too: Stein emphasizes diaphragmatic breathing as part of healthy pelvic-floor mobility and function.
So if your pelvic floor is already tight and overactive, repeatedly telling it to squeeze harder may not be the assignment.
The better question isn’t simply, “How strong is my pelvic floor?” It’s: “Is it functioning the way it should?”
“Pain is never normal, nor should it be tolerated.”
What are signs your pelvic floor might need support?
This is where pelvic-floor dysfunction gets surprisingly broad. Stein points to symptoms including:
• Abdominal and/or pelvic pain
• Lower-back, hip, abdominal, vaginal, rectal, or tailbone pain
• Bladder or bowel leakage
• Urinary or bowel urgency or frequency, difficulty emptying
• Difficulty starting urination or defecation
• Constipation or incomplete bowel movements
• A feeling of heaviness or pressure in the pelvis
And while it can be tempting to write off a little leaking, constipation, or discomfort as another annoying side effect of getting older (or even for our teens and young adults), Stein recommends seeking help when you notice something feels off.
“Pain is never normal, nor should it be tolerated,” she says. She also stresses that even small amounts of leakage aren’t simply something women should assume they have to live with.
Yep, changing hormones can enter the picture
Pelvic-floor health can become especially relevant during perimenopause and menopause.
Vaginal dryness or discomfort and pelvic-floor dysfunction are among the physical changes women may experience during this stage of life. At Stein’s Beyond Basics PT practice, they also treat concerns such as pelvic pain, discomfort during intimacy, and changes in bladder or bowel function as part of its perimenopause and menopause care.
That doesn’t mean every new ache, leak, or uncomfortable sexual experience automatically has a pelvic-floor cause. But it does mean these symptoms are worth bringing up rather than simply chalking them up to getting older.
Vaginal dryness is a good example. Beyond Basics notes that pelvic-floor PT may support circulation and tissue health, while more significant dryness or vaginal atrophy may call for additional medical management in collaboration with a gynecologist.
In other words, sometimes more than one thing is happening—and more than one kind of care may help.
Melt For You
OK, but what actually happens at pelvic floor therapy?
First: You talk.
At Beyond Basics, for example, an initial appointment starts with a conversation about your medical history, current symptoms, what seems to make your symptoms better or worse, and what you’ve been experiencing. Then comes a hands-on physical evaluation tailored to those symptoms.
That assessment may involve external muscles, internal muscles, or both as the therapist works to identify the source of the problem. Internal techniques can involve the pelvic-floor muscles and other structures within the pelvis. And importantly, you can decline any part of an examination or treatment at any time.
Once therapy begins, your treatment is highly individualized. You may expect external or internal manual therapy along with techniques such as myofascial release, trigger-point work, connective-tissue release, biofeedback, mobilization, gentle stretching and stability exercises, and customized exercises to practice at home.
Stein’s own at-home recommendations can also include stretching, connective-tissue release, diaphragmatic breathing, bladder retraining, and toileting positions designed to reduce straining. (Take a look at her book to learn a few!)
Translation: Pelvic-floor PT is a whole lot more than lying on a table and doing Kegels.
Because the pelvic floor never works alone
That may be the most useful takeaway. We tend to think of the pelvic floor as one mysterious set of muscles that only becomes relevant after childbirth, when we leak, or when sex hurts.
But pelvic-floor dysfunction can involve the bladder, bowel, sexual function, pelvis, hips, core, back—plus the way all of those systems work together.
And during perimenopause and menopause, changes happening in the tissues and elsewhere in the body can add another layer. Beyond Basics takes a whole-body approach to this stage, combining pelvic-floor care with attention to movement, core strength, lifestyle, and—when appropriate—collaboration with other medical providers.
Stein believes musculoskeletal causes are among the important contributors to pelvic pain and emphasizes finding a physical therapist who understands pelvic-floor dysfunction.
So if something hurts, leaks, feels unusually tight, or simply doesn’t feel like it used to? You don’t necessarily have to accept it as part of getting older.
It may be worth finding out what your pelvic floor is trying to tell you.
A Womaness Note: When Dryness Is Part of the Issue
Pelvic-floor dysfunction isn’t the only reason things can feel uncomfortable down there. During perimenopause and menopause, changing hormones can also contribute to vaginal dryness and irritation. Beyond Basics specifically recognizes dryness as part of the picture and notes that women may need a combination of pelvic-floor support and other approaches depending on what’s causing their symptoms.
That’s where vaginal skincare can play a role.
Melt For You is Womaness's hormone-free, applicator-free vaginal insert made with 5mg of medical-grade hyaluronic acid to support vaginal hydration. It melts at body temperature and is designed to be used every two to three days as part of an ongoing hydration routine.
Think of it as one tool for one part of the problem: targeted hydration when vaginal dryness is contributing to discomfort—not a replacement for pelvic-floor therapy or medical care when you need them.
Melt For You
Get More Answers
What to Know About Pelvic Health
5 Things a Pelvic Floor Therapist Wants Women to Know
Why UTIs Become More Common in Midlife
