How to Strengthen Your Pelvic Floor

"Incontinence has been normalized, and so has prolapse, and those are both signs that something's wrong," says Amanda Olson, a doctor of physical therapy who specializes in pelvic floor disorders and is based in Medford, Oregon. "I don't think we should normalize it just because it's common. It's not normal."
People of any gender can experience pelvic floor issues. (In people with penises, the pelvic floor supports the bladder and bowel and can impact sexual function.) But the concern is especially great for those with a vagina. Two major risk factors for pelvic floor disorders include pregnancy and childbirth. Pregnancy can loosen up the muscles and connective tissue of the pelvic floor, thanks to hormones and the pressure of your growing baby (1).

How do you know if you have pelvic floor issues?

The following symptoms can indicate that your pelvic floor muscles are either too weak or too tight (2):

• Leaking pee
• Leaking stool
• Pain during sex
• Frequently needing to use the bathroom
• Constipation
• A sensation of heaviness in your pelvis, vagina, or rectum
• Lower back pain

If you're dealing with any of the above issues, especially in a way that significantly or regularly impacts your day-to-day life, seeing a pelvic health expert is a good idea.
Here's how to address a pelvic floor that's too tight or weak.

1. If you're dealing with pelvic floor issues, find an experienced pelvic health provider.

Find a doctor who understands the pelvic floor—a gynecologist, urologist, or urogynecologist, for instance—or a physical therapist who specializes in pelvic health. You can ask your usual gynecologist how experienced they are with these issues, ask a potential new gynecologist's office, or do the research online yourself. The American Physical Therapy Association (3) can help you to find a physical therapist who focuses on pelvic health.
Pelvic health physical therapy is available in various clinical settings, including hospitals, private practices, veterans affairs, and university health education systems.

2. Start pelvic floor muscle training if you can.

Multiple studies suggest that pelvic floor muscle training can effectively treat pelvic floor-related issues like urinary incontinence (4), fecal incontinence (5), and pelvic organ prolapse (6). Some people even find that consistent and correct pelvic floor muscle training helps them to have stronger orgasms (7). To begin a training routine, your pelvic health physical therapist will typically start with a mini anatomy lesson and initial evaluation, usually about 45 minutes to an hour. They'll manually assess the muscles of your pelvic floor, both outside and inside—the latter by gently inserting a gloved, lubed finger or a biofeedback device. (So expect to be undressed from the waist down and in a dressing gown for at least part of the appointment.) They may also ask you to do things like cough or simulate holding your pee so they can gauge your Kegel contractions. Other examples of exercises they may have you do include squeezing their finger to gauge your (2) strength or "tone" and ability to control and direct your movements and endurance (yup, they will challenge you to squeeze longer and stronger). You'll also get a plan for follow-ups and Kegel and breathing exercises to take home.

3. Perform Kegels on your own correctly.

There is promising research (8) that doing Kegels, also known as pelvic floor muscle training, can improve incontinence symptoms. However, many people are still not doing them correctly. Common mistakes are squeezing the wrong muscles, like your abs or butt cheeks.
Named after American ob-gyn Arnold Henry Kegel, who invented the exercise in the 1940s, Kegels aren't as simple as they seem.

A typical Kegels routine, which you can do twice a day for 5 to 10 minutes at a time, goes like this: In a comfortable position such as lying down (which puts less pressure on your pelvic floor than sitting or standing), contract for three to five seconds; rest for three to five seconds; repeat ten times. Or try "quick flicks," short two-to-three-second contractions and longer ones, gradually increasing the length of both contraction and relaxation for 10 seconds each.

Also, be aware that Kegels aren't for everyone. If your pelvic floor muscles are healthy or too tight, working them out could do more harm than good, says Amy Benjamin, M.D., a gynecologist and the director of the Center for Chronic Pelvic Pain and Vulvar Disorders at the University of Rochester. "Some people have so much tension in their pelvic floor muscles that trying to do Kegels actually just increases their tension and pain," she adds. If you notice more tightness or pain as you start your Kegels routine, stop and bring that up with your doctor or physical therapist. Exercises and treatment for tight pelvic floor muscles focus on relaxing the area instead of strengthening it.

4. Consider adding full-body movement.

Once you've got basic Kegels down, your physical therapist may ask you to "squeeze" them into more advanced exercises. While there is little research on combining Kegels with other exercises, some pelvic floor experts and Kegels-based fitness programs have a movement-based approach. This approach combines pelvic floor muscle training with simple exercises such as squats, lunges, and weight lifting, where you would need to turn those muscles on for support.

5. Try Kegel trainers if you like—and keep your expectations realistic.

Many products on the market promise to help tone your pelvic floor, including vaginal weights or Kegel balls that come in different sizes and styles. However, a Cochrane (9) review of the studies on vaginal weights for training the pelvic floor against urinary incontinence suggested they're no better than doing basic Kegel exercises. The British medical research organization analyzed the data from 23 small trials involving more than 1,800 women and consistently found that (3) while the use of vaginal weights was better than having no treatment, there were no apparent differences in the effectiveness of the weights versus pelvic floor muscle training without weights.
"Smart" Kegels-focused devices that use biofeedback technology, such as the popular Elvie and kGoal, are also gaining popularity. They look like mini vibrators that are egg- or pillow-shaped and connect to an app on your phone. Prompts on your screen show you how well you're doing your Kegels.

6. Connect your breath and the pelvic floor.

Your physical therapist will teach you how to breathe correctly during Kegels (by taking deep breaths and breathing out as you squeeze) and doing diaphragmatic "belly" breathing exercises or relaxation poses such as Child's Pose or Happy Baby to relax the pelvic floor muscles. "A lot of people don't adequately allow the pelvic floor muscles to rest, and it's important that people are aware that strengthening and lengthening are equally necessary," says Dr. Olson. Too tight muscles can cause pain and weakness because they can be exhausted from being overly engaged. "We need flexibility and mobility...and the ability to let go," she says.

Hypopressive exercises are another breathing technique that some people may find helpful for pelvic floor issues, although there isn't as much data to support it as there is for Kegels. Still, a recent randomized controlled trial published in the Journal of Clinical Medicine (19) found that both exercise types significantly reduced pelvic floor problem symptoms. The exercises are a series of postures done with coordinating breath, and breath holds to work out the core in a low-impact way.

If you're struggling with pelvic health problems, it also helps to find your people so you can feel less alone. Kim Vopni, who goes by The Vagina Coach (10), is a Vancouver-based certified personal trainer, certified pre- /postnatal fitness consultant, and the author of Your Pelvic Floor: A Practical Guide to Solving Your Most Intimate Problems. 11 started a private Facebook group called Box Talk, where members, including a few physical therapists, can ask questions, share TMI, and offer support and advice on all things pelvic floor. "Even when they're exploring and recognizing that there are solutions, there is hesitancy," says Vopni. "Pelvic health is talked about a lot more than it used to be, but it's still a sensitive and intimate topic, and not everyone is super open about it."