The Pelvic Floor – it’s not just about strength

An anatomical model of the pelvis

This week is World Continence Week, and chances are, if you are reading this blog, you have seen me about a problem related to your pelvic floor muscles. We know that one in four Australians aged over 15 years suffer from bladder or bowel incontinence, and just under half of them are aged under 50. While rates of bowel incontinence are roughly similar between men and women, 80% of those with urinary incontinence are women.

If this sounds like you (or a loved one), surely the answer is simple - you just need to strengthen your pelvic floor muscles, right? Well, actually no – it’s not that simple.

There are definitely many cases where pelvic floor muscle strengthening may be needed. However, for most problems, pelvic floor muscle strengthening is only part of the solution, and there may be other things that are equally, or indeed more, important. In other cases, pelvic floor muscle strengthening is absolutely not the right answer and may make the problem worse! So, how do we know when pelvic floor strengthening is right for you?

Normal muscle function

First let’s understand some basics about normal muscle function. A well-functioning muscle needs to be able to both contract and relax. While some of our muscles maintain a certain amount of background action or tone, it is not normal, or indeed necessary, for us to walk around contracting any of our muscles strongly for the majority of the day. Rather we contract them when needed – ideally at the required strength and speed – and relax them when we don’t need them or when relaxation is required.

The pelvic floor muscles are no exception. They hold a small amount of background support which will increase a little when we are in more upright postures compared with lying down, or when our bladder is fuller and heavier, for example. If we suddenly add more load by coughing, sneezing or jumping, our pelvic floor muscles need to react both strongly enough and quickly enough to meet that load to prevent leakage. When we want to empty our bladder or bowels, we need the pelvic floor muscles to relax (among other things) to allow this to happen. This is a very simplified version of the process, but hopefully you get the idea.

When all is working well, we luckily do not have to think much about any of these processes – it all just happens automatically. However, when there are problems with these processes, we may need to look at how the pelvic floor muscles are working.

When pelvic floor muscle strength may help

There are definitely conditions for which pelvic floor muscle strengthening is an important part of the solution. If you have incontinence from either the bladder or bowel and you have been assessed as having weak pelvic floor muscles, then pelvic floor strengthening may be right for you. Similarly, if you have a pelvic organ prolapse, you may be given these exercises in many cases to help improve your symptoms.

For stress urinary incontinence (leakage with coughing, sneezing or exercise) and prolapse, pelvic floor strengthening aims to improve the support these muscles give to the bladder or other pelvic organs. Working on strength makes the muscles stiffer and bulkier (just like it does for other muscles in the gym). However, this is only part of the solution. For both stress incontinence and prolapse, being able to manage load appropriately and coordinate the muscles quickly enough is also vital. It’s no use having strong pelvic floor muscles that take 3 seconds to switch on when you suddenly sneeze!

When it comes to urinary urgency, pelvic floor muscle strengthening can also be helpful, but usually it is rarely be enough on its own. As most of my patients with urgency will report, they try to contract their pelvic floor when that sudden urge hits and it doesn’t help! In these cases, retraining of bladder habits and learning new behaviour patterns becomes important, along with other factors such as managing fluid intake and constipation.

Similarly, for bowel control problems, pelvic floor strengthening may be helpful, but there may need to be more emphasis on endurance and or coordination. It is also vital to improve the stool consistency and bowel emptying techniques in many cases.

As we can see, pelvic floor strengthening is only part of the answer in these cases.

When pelvic floor strengthening is not helpful

I see many women and men every week who really do not need to work on pelvic floor strengthening, despite having a problem with the function of their pelvic floor muscles. In these cases, their problems are often partly related to muscles that are working “too much” or have increased tone – that is, the muscles are holding too much tension, too much of the time. For others, the muscles may not be coordinating well at the right time, and may be “switching on” when we need them to “switch off”.

This is common to see in pain conditions. Muscles will typically contract or tighten as a protective response when we have pain, and the pelvic floor muscles are no exception to this. This excessive tightening can either occur intermittently or almost constantly, and typically without us realizing it is happening.

We can see this occurring intermittently, for example, when someone has an anal fissure or haemorrhoid making defecation painful. When bowel emptying becomes painful, the anal sphincter muscles may contract instead of relaxing, making evacuation of the bowels difficult or even impossible. This intermittent tension may also occur when we anticipate something MIGHT be painful. In the example above, the anal sphincter muscles may continue in this unhelpful pattern, even when the initial problem resolves. Many women who have found vaginal penetration to be painful in the past, even once, will find their pelvic floor muscles continue to automatically tense up before any penetration occurs.

For those with persistent pelvic pain, there may be a number of muscles, including the pelvic floor, which are tense, or contracted, a lot of the time. Just like any tense muscle, the pelvic floor can itself become tender or painful – and it also stops working well. So, if we ask these muscles to do a bit extra, such as contract when we sneeze, they may be unable to do this and some urine leakage may still occur. Think of how your shoulder muscles feel when they are tense – they can be tight and sore, but also feel weak when you try to lift something. Similarly, the pelvic floor muscles can still fail to be strong or coordinated enough to control the bladder or bowels, because they are too tense.

In all of these examples, pelvic floor muscle strengthening would very likely make everything worse. Often what is needed is to teach these muscles how to relax, coordinate well when needed, and stop being over-protective when the threat has abated. This will usually be only one part of a comprehensive pain management program.

My plea to you is therefore, if you have a pelvic floor disorder, please do not blindly follow the advice of (well-meaning) friends or a program you saw online. A cookie-cutter approach to conditions will only hit the mark in a small percentage of cases. Find a Pelvic Health Physio, who can assess your pelvic floor muscles and recommend what is right for you. That is the best recipe for success!

Yours in pelvic health,


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