And when you should — and shouldn’t — do kegels.
You can’t see your pelvic floor, but that doesn’t mean you haven’t heard all about it — from your gynecologist, your book club friends, or the internet. As Katie’s OB/GYN Rebecca Brightman, MD, told us in 2021, the pelvic floor is “a group of muscles that acts sort of like a hammock” — a very important hammock that supports the function of important organs like your bladder, bowel, uterus, and vagina. It also helps with urination, defecation, sexual activity, and childbirth.
But you’ve also heard — or realized firsthand — that the pelvic floor is prone to disorders that can range from uncomfortable to life-disrupting. Enter pelvic floor physical therapy (PT) — a specialized type of physical therapy that can rehabilitate those important muscles. But how does that recovery actually work?
To better understand the ins and outs of pelvic floor physical therapy, we spoke to Sonia Bahlani, MD, an OB/GYN who specializes in pelvic pain, and Aurore Dorsinville-Jean, PT, DPT, a pelvic floor physical therapist at the University of Rochester Medical Center. We’ve got all the info on how to tell if you need pelvic floor PT, what the process is like, common causes of pelvic dysfunction, and how you can seek help.
How to know if you have pelvic floor dysfunction
The most common symptoms are pain with urination or defecation and pain during or after intercourse, says Dorsinville-Jean. “In addition, urine leakage when coughing, sneezing, and laughing. Low back and abdominal pain are also common symptoms that can be indicative of pelvic floor dysfunction. Another indication can be feeling the urge to urinate and defecate but being unable to do so or feeling pressure and numbness in the pelvic floor,” she explains.
“You might also seek a pelvic floor therapist for prenatal as well as postnatal care to help minimize complications during pregnancy, delivery, and postpartum, or if you’ve been diagnosed with organ prolapse, if you have sexual dysfunction, if you need post-operative care, or have any kind of incontinence.”
Pelvic floor disorders can be tough to spot
According to Dr. Bahlani, pelvic floor dysfunction symptoms can mimic those of common urological issues, like UTIs. “Especially in our peri and post-menopausal female patients, because there can be a lot of hormonal changes to that area that cause issues with the pelvic floor,” she says. “I’ve had so many patients come into my office who were given antibiotics for recurrent UTIs without doctors hormonally taking a look at what’s going on in the vagina that’s affecting their pelvic floor.”
What does the pelvic floor have to do with the urinary tract, you ask? “When the bladder contracts and the pelvic floor doesn’t relax, it spasms. You don’t completely empty, you leave a little bit of urine in the bladder. That’s what causes those symptoms of frequency, urgency, or incontinence issues — especially in peri- and post-menopausal women.”
Pelvic floor disorders can also present as gynecological issues like recurrent bacterial vaginosis (BV) or recurrent yeast infections. “They can also present as discomfort in the vaginal area, wearing tight clothing, putting in tampons, or sitting for long periods of time. And they can also present as rectal or gastrointestinal symptoms — so pain after pooping, or pain with sitting.”
What happens in pelvic floor PT
Obviously, it depends on where you go and your diagnosis. At Dorsinville-Jean’s practice, during the first visit, “the physical therapist will ask questions about a patient’s symptoms and medical history. The patient will be educated about the anatomy and how the pelvic floor functions. The PT will do an external exam.” She adds, “Depending on the comfortability of the client, the PT may also perform an internal exam on the first or at later visits for a more comprehensive assessment. Upon findings, the PT will prescribe the appropriate exercises.”
During subsequent visits, you may work on exercises with your PT or medical professional. “In our office, we do certain exercises, stretches, and physical therapy depending on which pelvic floor muscles are affected,” Dr. Bahlani says. “Then we move on to medications. Do we need to relax the pelvic floor? Do we need to strengthen the pelvic floor? Because that’s going to affect what medications you use. And then sometimes, procedures need to be done. But I’m always of the mindset of starting with the most conservative approach because it’s amazing to me how simple stretches, exercises, and physical therapy can make a world of a difference.”
The types of exercises you’ll see in pelvic floor PT depend on what your body needs. “Let’s say you notice that your symptoms are exacerbated by certain exercises like spinning or heavy lifting, then you need exercises that help you open your hips. So I’ll suggest things like child’s pose, pigeon pose, cat-cow, or anything else that’s going to release and lengthen the pelvic floor musculature,” she says.
“Everyone was sitting during [quarantine]. What are you doing when you’re sitting? You’re contracting your pelvic floor. All of these hip opener exercises are really important for patients sitting for long periods.” Pro tip: Get a pillow to hold your coccyx up so that it’s not hard against the chair, which can cause those muscles to contract, according to Dr. Bahlani.
Kegels can also cause issues. “For the vast majority of my patients, either they’re not doing Kegels correctly, or that’s not the exercise they need to relax their pelvic floor. Everyone talks about Kegels, but half the time, it’s not what someone needs,” Dr. Bahlani says.
Dorsinville-Jean agrees: “Kegels are usually a good strengthening exercise to address incontinence, but if clients feel pain during or after intercourse or if they have trouble urinating/defecating, they may need relaxation techniques instead of strengthening exercises.”
In terms of how long you might be in treatment, Dorsinville-Jean says if pelvic floor exercises are performed daily, “after 4 to 6 weeks, most people notice some improvement.”
Pelvic floor PT tools
Both experts believe there are tools out there to help ease symptoms but urge you to consult a medical professional to learn which one is best for you and how to use it properly. “It’s like me having a tennis racket versus Andre Agassi having a tennis racket. We both have the same tools; it’s just how we use them,” says Dr. Bahlani.
“Dilators and wands are particularly helpful for releasing the pelvic floor,” she notes. “They often work great with certain medications to release the muscles,” she notes. Dorsinville-Jean says, “Pelvic wands can help release pain/tension from the muscle within the vaginal/rectal canal. Vaginal cones help strengthen pelvic floor muscles. Vaginal dilators will help stretch vaginal tissues and relieve pelvic floor spasms.” Dr. Bahlani cautions that vaginal weights can be “problematic” for pelvic floor dysfunction. “You should find a provider that can teach you how to use these tools properly,” she says.
Beyond those traditional PT tools, Dr. Bahlani recommends warm baths for high-tone pelvic floor or hypertonic pelvic floor. “Heat relaxes muscles. I really like to use Aveeno oatmeal baths with that; I also like epsom salts.” If you’re constipated, supplements like magnesium can help release and relax the pelvic floor and also make you poop, she says.
The benefits of Squatty Potties for the pelvic floor
It’s safe to say Dr. Bahlani swears by Squatty Potties. “If I took you on a tour of my house right now, you would see five different Squatty Potties because we have one in every single bathroom.” She believes they’re necessary for pelvic floor relief. “They shouldn’t even be optional. Every person should be pooping and peeing with a Squatty Potty. It even alters the angle of the urethra in women so that it’s easier to eliminate. And when you’re pooping, it makes it so you don’t put as much pressure on that area to poop.”
How to care for your pelvic floor
We can do a few things without a PT to improve our pelvic floor health. But let’s start with something you shouldn’t do: “just in case” (JIC) peeing, Dr. Bahlani calls it. This is when you try to urinate, even if you don’t have to, just to avoid an inconvenience later. You say to your kids or even spouse, “We’re getting in the car — go pee again.” Dr. Bahlani warns, “What are you going to do when you try to go pee again but you don’t have to go? You’re going to push and build a pelvic floor disorder.”
One of the best things we can do is diaphragmatic breathing. “Our diaphragms and lower abdominal areas put pressure on our pelvic floor,” she notes. “Diaphragmatic breathing is a form of box breathing where you’re really breathing from the diaphragm. So you’re inhaling for three, exhaling for seven. You exhale for longer periods of time. That diaphragm releases, you’re decreasing intraabdominal pressure, then decreasing pressure on the pelvic floor. That’s really important when we’re learning how to retrain that pelvic floor.”
