Ultimate Guide: Pelvic Floor Health

Do you pee when you cough or sneeze? Does it hurt to have sex? Do you have pain or heaviness in your pelvis?

These symptoms can all be signs of pelvic floor dysfunction. It’s time to make pelvic floor health a normal part of pregnancy and postpartum conversations. Many postpartum people struggle with pelvic floor complications post-pregnancy, but there are actionable steps you can take to heal your pelvic floor and reduce symptoms. 

Let’s explore the importance of pelvic floor health, common postpartum pelvic floor problems and symptoms, and strategies to address those problems and maintain optimal pelvic floor function.

Our bodies are strong and resilient, but bringing a child into this world is a lot of work! No matter your delivery method, your pelvic floor works hard and can experience trauma during labor and delivery. The physical toll of childbirth can cause pelvic floor muscle weakness, incoordination, tension, or pain, sometimes all at once. These changes can make basic physical activities like sitting down, walking, using the toilet, and sneezing more difficult or uncomfortable. 

Research shows that many birthing people report symptoms of pelvic floor dysfunction after birth, including urinary incontinence (55.8%), fecal incontinence (10.4%), symptomatic uterine prolapse (14.0%), and pelvic pain (18.7%). Other symptoms include sexual dysfunction, lower abdominal pain, or feelings of vaginal fullness, heaviness, or pressure.

If you’re a mama who struggles with any of these symptoms, know that you are not alone. Postpartum pelvic floor problems are common, but this doesn’t mean they are your new normal. There are many actionable steps you can take to reduce discomfort and rehabilitate your pelvic floor. 

Pelvic organ prolapse (POP) is a common pelvic floor complication in postpartum moms. Nearly 50% of women will experience it in their lifetime, although some people may never have symptoms. 

The internet is full of scary information about pelvic organ prolapse, which often leaves new moms feeling anxious and alone. Given how common this condition is, it’s time to destigmatize conversations about POP. Let’s learn more about it!

Pelvic organ prolapse is an umbrella term for the descent of pelvic organs into a lower position inside the pelvis. POP may involve the bladder, rectum, lower intestines, and/or uterus. 

Pelvic organ prolapse occurs when the pelvic floor muscles and vaginal walls are weakened and unable to support the organs. This lack of support allows the pelvic organ(s) to descend and press against the walls of the vaginal canal.

People with symptomatic prolapses often describe a feeling of heaviness, fullness, or bulging inside the vagina or pelvis. Some people describe feeling as though they have “an egg inside the vagina” or like they are “sitting on a golf ball.” These sensations may be worse when the person is upright (standing, walking, etc.) because gravity is pulling downward on the organs.

Vaginal childbirth is the biggest risk factor for developing POP. As your baby passes through your vaginal canal during delivery, it can stretch and strain the supportive structures there. If you have several vaginal deliveries or if your birthing team needs to use forceps or a vacuum to assist delivery, the risk of POP increases.

You might be thinking “If vaginal delivery stresses my pelvic floor so much, why don’t I just have a C-section?” Compared to people who give birth vaginally, the risk of developing POP is lower among those who have a C-section. However, pregnancy itself can strain the pelvic structures, particularly as your baby grows and exerts more pressure on your pelvic floor. C-sections carry their own risks, and they don’t guarantee you’ll be POP-free after childbirth. 

One study of postpartum people reported that at one year after delivery, most study participants had some degree of prolapse (89% uterine, 90% bladder, 70% rectum). However, 80% had no symptoms or problems – so keep this in mind! Even if you develop mild POP after childbirth, you may not have problems related to it.

Other factors can increase the developing POP. These include:

• Chronic constipation and straining to poop
• Obesity
• Generalized connective tissue disorders like the Ehlers-Danlos syndromes
• Previous pelvic surgeries
• Performing heavy manual work
• Certain genetic factors

The most commonly reported symptoms of pelvic floor prolapse are: 

• A sense of heaviness or pressure in the pelvis or vaginal area.
• A sensation of a bulge, or "something falling out" through the vagina or rectum
• Difficulty emptying the bladder or bowels.
• Urinary or fecal incontinence (loss of bladder or bowel control).

Recall that some people with POP may not have obvious symptoms. If you’ve been told you have a prolapse but do not have symptoms, you may still benefit from seeing a pelvic physical therapist to be sure you’re moving in the right direction!

If you were to use a mirror and take a look at your pelvic floor, you might see a bulge coming down toward the vaginal opening. Depending on the severity, that bulge may be very obvious, or it might be hard to see.

For people with mild to moderate pelvic organ prolapse, pelvic floor muscle exercise and pelvic physical therapy (PT) are first-line treatments. Pelvic PT can help you establish pelvic floor strength, coordination, and mobility to better support your pelvic organs. It can also help reduce the symptoms of POP, including bladder and bowel disruptions. 

Pelvic floor muscle exercise involves much more than “just doing your kegels.” To function optimally, your pelvic floor muscles must be strong, agile, and coordinated. This involves more than just contracting and holding your pelvic muscles. Additionally, about 25% of people perform pelvic floor contractions incorrectly without realizing it.

A pelvic physical therapist has specialized training to help you learn how to do pelvic floor exercise correctly and tailor it to your unique needs.

Here are some other things you can do to manage the symptoms of POP:

• Manage pressure inside your abdomen and pelvis. Certain movements and activities, such as holding your breath while lifting something heavy, can increase pressure on your pelvic floor. Pay attention to your body when performing these common movements:
  • Standing up from a chair
  • Bending over to pick something up off the floor
  • Straining or pushing hard as you pass a bowel movement
  • Holding your breath or straining while exercising

If you notice that you’re holding your breath or straining during any of these movements, try gently exhaling to relieve internal pressure on your pelvic floor.

• Improve your toilet habits. Straining to poop creates extra pressure on your pelvic floor. Rather than holding your breath and pushing as hard as you can, try the following:
  • Place a stool under your feet to elevate your knees above your hips. This squat-like angle aligns your rectum optimally for emptying.
  • Inhale through your nose and fill your belly with air. Think: “belly big, belly firm”.
  • Exhale and visualize your sitting bones spreading apart: this helps your pelvic floor muscles relax to allow stool to leave your body.
  • If you need to bear down a bit, exhale as you do so. Letting air out through your mouth and nose helps relieve internal pressure on your pelvic floor.
• Avoid sitting on the toilet too long. If nothing is happening within 3-5 minutes, call it quits and get off the toilet. You can try again later!
• Consider a pessary for extra structural support. A pessary is a medical device that you insert into your vagina, a bit like inserting a tampon. These devices come in all shapes and sizes to match variations in internal anatomy, so you’ll need a professional fitting from your healthcare provider. Talk to your OB/GYN or pelvic physical therapist; they can help you determine the right product for you. Even if your pelvic PT doesn’t fit pessaries, they can help you find a provider who does.
• Ask your doctor if a topical estrogen prescription could help. Topical estrogen creams can help maintain the integrity and flexibility of your vaginal tissues. It’s particularly helpful for peri- and postmenopausal people because the menopause transition causes your local estrogen levels to decrease. Topical estrogen can also be beneficial for breastfeeding parents who are in a similar hormonal state. Hormones are complex chemicals and they aren’t right for everyone, so talk to your healthcare provider to see if topical estrogen is appropriate for you.
• If necessary, you can get surgery to restore structural support inside the pelvis. Because surgery comes with its own set of risks and limitations, it is typically reserved for severe cases in which all other methods have failed. 

If you know you already have POP and you’re expecting a baby, you’re probably wondering if your prolapse will worsen during delivery. As your baby travels through the vaginal canal, the pressure certainly taxes those tissues. 

There is no guarantee that you can prevent prolapse through the methods below. However, a you prepare for labor and recovery:

• Whenever possible, exhale as you push during labor. Holding your breath increases intra-abdominal pressure. Increased internal pressure pushes down on your already strained pelvic floor and organs.
• Take steps to reduce the severity of perineal tears. Perineal tearing is a common result of vaginal childbirth. It injures the pelvic floor muscles and reduces their ability to support your pelvic organs. Some research shows that perineal massage can help reduce the severity of tears if performed starting at 36 weeks of pregnancy and continued until labor. Your pelvic PT, midwife, or doula can teach you how to perform perineal massage at home.
• Support your body as you recover. Consider wearing postpartum support garments, compression shorts, or leggings that cover your abdomen for the first few weeks after birth. Compression can reduce the sensation of pressure in the perineum as it is healing.
• Be intentional about how you move your postpartum body. Taking the time to gently build up your pelvic floor and abdominal strength after birth will prepare your pelvic floor to manage the day-to-day stresses of life as a new parent. Support your body now, and it will pay off in the decades to come. 

Pelvic organ prolapse is a structural change that is a common complication of vaginal birth, but there are plenty of tools to help you improve your symptoms. 

If you think you may have POP, reach out to your healthcare provider and find a pelvic floor physical therapist near you. You can also search for pelvic PTs through pelvic rehab or the American Physical Therapy Association’s directory.

Some people don’t experience the symptoms of POP after delivery, and that’s great news! However, there are other symptoms of pelvic floor dysfunction that may emerge during the postpartum period. Here’s what to know:

Perineal tearing is the most common form of birth injury: up to 80% of first-time moms and 40% of second-time moms will experience some degree of tearing during vaginal delivery. Most experience a first- or second-degree tear involving the skin around the vaginal opening, or a small amount of perineal muscle, respectively. Most second-degree tears require stitches, but many first-degree tears don’t. These types of tears, while uncomfortable, generally heal within the first few weeks postpartum. 

Third- and fourth-degree tears involve more perineal tissue and muscles. Third-degree tears extend into the anal sphincter muscle. Fourth-degree tears extend through the anal sphincter and into the rectum. These tears require more healing time and follow-up care. 

Even the smallest amount of scar tissue can remain sensitive after the wound heals. Gently massaging the scar tissue can help desensitize and soften the area. If the pain around the scar lingers or affects anything you enjoy—including intercourse—it may be time to seek the support of a pelvic health physical therapist.

Other types of birth injuries can involve pelvic nerves and bony structures. The following symptoms may indicate a nerve problem: 

• Stinging, burning pain in the pelvis or lower body
• Numbness or tingling in the pelvic area or lower body that doesn’t resolve worsens with time 

Injuries to the bony pelvis during birth are often more visually apparent. Your healthcare provider may diagnose a bony injury while you’re still in the hospital or during initial postpartum care.

If you have any of the following symptoms during the postpartum period, call your healthcare provider immediately: 

• Fever, body aches, and/or chills
• Malaise (a general feeling of being unwell)
• Redness, swelling, or heat at the site of a wound such a C-section scar or perineal tear
• Increased vaginal bleeding
• Intense, worsening pelvic pain. 

Your healthcare provider should evaluate any pelvic floor or functional recovery concerns during the earliest weeks of postpartum recovery. The sooner they assess you, the sooner they can rule out more urgent issues and diagnose any pelvic floor disorders. 

For other pelvic concerns that aren’t as urgent or immediately obvious, you should follow up with a physical therapist or pelvic floor specialist who can perform a full physical evaluation. Ask your healthcare provider for a recommendation, or seek out a consultation with a physical therapist on your own. In most states, you can have an initial PT consultation without a referral.

Time to bust some of the most common myths we’ve heard about the pelvic floor. Let’s debunk each and discuss what to know instead:

Fact: Everyone with a pelvis has a pelvic floor. This includes people of all sexes, genders, ages, and backgrounds, including those who have never been pregnant. Just as we take care of other parts of our bodies, we should care for our pelvic floors.

Men and people with penises can develop pelvic floor problems, including urinary or fecal incontinence, pelvic or back pain, constipation, and sexual dysfunction. A pelvic rehabilitation practitioner can address each of these concerns (and many more!) with an individualized approach. 

Even children can struggle with pelvic floor concerns. Bedwetting, chronic constipation, and frequent urination are common pediatric pelvic floor problems. 

At its most basic, your pelvic floor is a group of muscles: like all other muscles, it helps you move and function in daily life. Just like any other muscles in your body, the pelvic floor requires maintenance and training to stay healthy!

Fact: The pelvic floor functions just like any other muscle group in the body. Would you grip your biceps, your jaw, or your abdominal muscles all day long on purpose? Probably not. The pelvic floor is no different. 

The pelvic floor cycles on and off all day long according to what you’re doing and how much support your body needs. Imaging shows that your pelvic floor moves slightly up and down in the same direction as your diaphragm as you breathe. 

If you’re breathing and moving at the same time, the pelvic floor anticipates your movements. Just like your eyelids blink at exactly the right moment when something is heading toward your face, your pelvic floor kicks on at the right moment—just before your foot strikes the ground—without any additional effort on your part! 

If your pelvic floor is stuck in a tense, contracted state, it won’t be able to move freely and support your body as it should. Ideally, pelvic muscle exercises help you build pelvic floor awareness, strength, and coordination as you’re doing them. When you’re finished “working out,” you should let the muscles return to their baseline and do their jobs (without extra effort) for all the rest of the day. 

Many people unconsciously “grip” or “clench” their pelvic floor muscles—pain, trauma, habit, and structural issues can all contribute to this tendency toward tension. See a pelvic physical therapist in person to get to the root cause and the best solution for you.

Fact: Have you ever heard that running or jumping is bad for the pelvic floor? Or that you can permanently damage the pelvic floor with these activities? Though high-level athletes often experience incontinence, so do individuals who are sedentary. As with all things, there’s a balance.

Studies of pelvic floor function in high-level athletes show that their pelvic floors are not necessarily stronger or weaker than the general population. Athletes who were interviewed years after their competitive training days were over were not more likely to be incontinent than the general population. This suggests two things: endurance or impact activity like running or jumping won’t necessarily make your pelvic floor super strong, but it also won’t necessarily damage or weaken it for the long term. 

It’s still a good idea to address any impairments you might notice as you increase your impact-type exercise. For example, if you’re leaking pee or feeling vaginal pressure or heaviness while exercising, your pelvic floor is trying to tell you something. You may need to work on your pelvic floor strength, endurance, agility, or coordination (or all of the above). Additionally, muscle imbalances in your hips, core, and beyond may be contributing. By addressing these factors in pelvic floor rehab, you can address your symptoms and protect other pelvic structures without compromising your training plan.

Fact: The word “kegel” is an umbrella term for an isolated contraction and relaxation of the pelvic floor. If a healthcare provider, friend, or family member has told you to “just do your kegels while you’re driving,” you’re not alone.

Pelvic floor function is much more complex than many people realize. Like all other muscles, the pelvic floor muscles do more than turn on and off. Did you know that your pelvic floor contracts slightly before all kinds of movements? It acts as part of your core stabilization system so that your body is ready for whatever it is you’re about to do. Catch a ball? Check. Pick up a heavy box? Check. Laugh with your friends? Check. 

These tasks don't necessarily require a maximal pelvic floor contraction. A healthy pelvic floor isn’t just strong—it also has fine control, good endurance, and responds quickly to changes. All these elements must be functioning optimally so you can use your pelvic floor muscles just the right amount, at just the right time. 

Fact: Sex can be painful for people of any gender, any time, for many reasons. One of those reasons may be related to pelvic floor dysfunction, including excessive muscle tension.

However, even if excess muscle tension is part of the problem, there’s nothing less relaxing than being told to “just relax.” If you’ve heard this advice before, don’t worry—”just relaxing” isn’t the only solution. 

The pelvic floor muscles are essential for sexual arousal, comfort during sex, and even reaching/enjoying a pain-free orgasm. Excessive tension in those muscles can cause pain during any type of sex, penetrative or otherwise. For some people with excess pelvic floor tension, arousal and/or orgasm can be painful even without external touch or penetration.

When it comes to sex, the mind does matter. The pelvic floor muscles naturally tense up when we experience fear or stress. A negative, painful experience of sex can make you feel more nervous or fearful in subsequent encounters, and this can create a vicious cycle of fear and pain. 

However, this does NOT mean that painful sex is “all in your head.” Even among people whose mental and emotional experiences contribute to painful sex, there are usually physical contributors, too. Fortunately, pelvic physical therapists are trained to help people address physical barriers holding them in the pain-fear-pain cycle.

Helpful interventions might include manual therapy to release any specific trigger points in the pelvic floor muscles or nerve entrapments contributing to painful sensations. Along similar lines, circulation keeps tissues healthy and improves lubrication, so sitting on a heating pad, using vibration regularly, and doing hip stretches and pelvic floor release exercises can also be helpful.

A pelvic physical therapist can identify muscular trigger points or nerve entrapments that may be contributing to pain. They can teach you to perform stretches, exercises, and various hands-on techniques on your own to address these areas of concern. They may also suggest other tools, like gentle heat, vibration, and specific breathing exercises, to help your pelvic floor prepare for sex. 

Vaginal dryness can also cause sex, particularly penetration, to be painful. You can combat dryness with longer-lasting lubricants, such as Uberlube’s silicone-based lube, and vaginal moisturizers that you apply internally like lotion. For those with dryness and reduced vaginal elasticity, topical estrogen cream (by prescription) can boost tissue health and reduce friction. If you experience pain primarily during deeper penetration, buffer tools like the OhNut can help tremendously.

Painful sex is an excellent reason to seek out a pelvic floor physical therapist. There may be more going on than you can figure out on your own (and more tools available that you haven’t heard of yet!), so don’t give up if you haven’t had luck by “just relaxing." This is not the end of the road!

Fact: Though urinary incontinence (leaking urine) is very common among postpartum people, it’s not something you have to live with. It is very treatable!

Even a small amount of leakage is a sign that there is some kind of imbalance in the systems related to the pelvic floor, and a pelvic floor physical therapist can help you address it. For example, you might experience leakage if you have muscle weakness, a pelvic nerve injury, bladder irritation, posture changes that increase pressure on the bladder, or a combination of these. 

There are several types of urinary incontinence, and each requires different treatment strategies. 

• Stress urinary incontinence occurs when the pelvic floor muscles can’t stop the flow of urine when the bladder is under pressure. Examples: leaking when you cough, sneeze, laugh, jump, or exercise.
• Urge urinary incontinence is leaking due to a sudden, intense urge to pee that you can’t delay.
• Mixed incontinence is a combination of stress and urgent incontinence.

Bladder problems like this are complex and require an individualized treatment approach. If you’re experiencing postpartum urine leakage that’s bothering you, an individualized evaluation and treatment plan with a pelvic floor physical therapist is an excellent next step.

Fact: In most cases, you don’t need to see your physician before heading to a pelvic physical therapist. All 50 states permit direct access to a physical therapy evaluation and some amount of treatment without a physician's referral. Your physical therapist will be able to inform you of any requirements specific to your state. 

This development has allowed patients to access physical therapy care faster and with fewer steps (and expenses!) along the way. Note that some insurance plans still require a referral for PT treatment. If you want to use your insurance to pay for physical therapy, check their requirements before your first visit. 

Some clinics may also require a referral before scheduling you for pelvic PT services, but that’s usually the exception and not the rule. You can find out more about your local requirements by calling your pelvic physical therapy provider and asking what you need to do to get started. 

If you are experiencing pelvic organ prolapse or any other problem with your pelvic floor, remember that it is treatable. Your body will continue healing for many months postpartum. As you learn about your postpartum body, take comfort in knowing there are resources for the challenges you’re facing. You’ve got this, mama!

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