Pelvic Floor Health 101: What to Look For and When to Seek Help by Nicole Guappone

The folks here at Betty’s Toy Box told me that they have a lot of women asking what—other than kegels—they can do for their pelvic floor. We hear a lot about the pelvic floor and how age or being postpartum can affect it, but did you know that anyone of any age can experience pelvic pain? And that, depending on what kind of pelvic floor issues you may have, kegels can make it worse?

That’s the kind of pelvic floor dysfunction I had: hypertonic/high-tone, meaning my muscles were too tight and in spasm. This made intercourse painful, sitting and standing for long periods of time painful, and even mimicked the symptoms of a UTI. It was a type of chronic pain I didn’t expect to experience as a 28 year old, childfree woman. Pelvic pain can be caused by various things, including age and pregnancy/childbirth, but some lesser known causes are sports injuries, injuries during sex (specifically for people with penises), or attempting to have vaginal intercourse despite pain (ie during a yeast infection or UTI or after a traumatic experience).

It is hypotonic (low-tone) pelvic floor dysfunction—weak pelvic floor muscles—that we hear the most about and that kegels are generally recommended for. But what if you’re experiencing pelvic pain and you aren’t sure which it is? How do you know if it’s time to see a professional? I reached out to pelvic floor physical therapist Stephanie Prendergast, co-founder of the Pelvic Health Rehabilitation Center and co-author of Pelvic Pain Explained to get some answers.

Prendergast said that pelvic floor dysfunction can manifest in a number of ways. “High-tone or too tight disorders,” she says, “can manifest as vaginal, clitoral, vulvar, perineal, or anal pain; painful, diminished, or absent orgasm; urinary urgency/frequency; difficulty starting the urine stream; difficulty evacuating bowels; and painful sex.” I actually experienced all of these symptoms at one point or another! How do you know if you have low-tone pelvic floor dyfunction? Prendergast continues: “It may manifest as urinal or fecal incontinence, pelvic organ prolapse (bladder, uterus, rectum pooching into or out of the vagina), diminished orgasm, and/or painful sex.” Generally speaking, she says, low-tone disorders may appear in perimenopause/menopause and in the postpartum period. “All postpartum women should see a pelvic floor physical therapist,” she says. “And all of these symptoms warrant an evaluation with a pelvic PT.” (To learn more about pelvic physical therapy, see this blog post from Pelvic Guru: What IS Pelvic Physical Therapy and When Doesn’t EVERYONE Know About It?)

There are still many professionals—gynecologists included—who don’t understand pelvic floor dysfunction or have a hard time diagnosing pain that they can’t see. I was diagnosed with a yeast infection and a couple different UTIs by a general physician as well as a third UTI by a gynecologist. It wasn’t until I saw a urogynecologist who specializes in chronic pelvic pain, UTIs, and female sexual dysfunction that I got a referral for pelvic floor physical therapy after a quick internal exam (in which she felt tense pelvic floor muscles).

Ideally, you’ll find a pelvic pain specialist within four to six months of experiencing pelvic pain, however, the average time it takes someone with pelvic pain to find someone who can really help them is five to seven years, according to Amy Stein of Beyond Basics Physical Therapy and author of Heal Pelvic Pain.

And unfortunately, a lot of people can’t afford the necessary assessments or physical therapy for their pelvic pain. I asked Prendergast what someone could do in the meantime to care for their pelvic floor and try not to make it worse (especially those with high-tone muscles). She says: “People with hypertonic pelvic floor muscles generally can benefit from gentle foam rolling exercise to the leg and hip muscles, and pelvic floor relaxation exercises, such as the pelvic floor drop. Also, generally speaking, it may be useful to avoid exercises for fitness that increase abdominal pressure (like crunches) until one can voluntarily relax the pelvic floor muscles. Different people will have different aggravating and alleviating factors but generally these apply to most people with hypertonic muscles.”

And what would Prendergast say to the person who asks what they can do for their pelvic floor “besides kegels”? “If a person is specifically looking to strengthen pelvic floor muscles it is helpful to learn how to maximize pelvic floor muscle function by coordinating the contraction with their breath and core. The pelvic floor lengthens during inhalation and rises during exhalation. To maximize function, one can exhale slowly and while exhaling draw the belly button towards the spine to activate the transversus abdominus muscle and then tighten the pelvic floor. Exercises that strengthen the external hip rotators such as sidelying leg lifts will also activate the pelvic floor muscles. Internal rotation exercises will do the same. In general, exercises the increase intra-abdominal pressure will cause the pelvic floor muscles to tighten.”

The one piece of advice nearly every pelvic floor physical therapist will give: if you’re doing kegels or trying to strengthen the pelvic floor, it is just as important to learn how to consciously relax those muscles as well. And this is where it can get tricky! It took me more than a few weeks of physical therapy to truly understand how to consciously work the different sets of muscles that make up the pelvic floor.

Remember, EVERYONE has a pelvic floor and anyone can experience pelvic pain—cis people; trans, non-binary, and gender non-conforming folx; and even children. While it’s usually talked about from the perspective of and with cis women in mind, the field is starting to embrace inclusivity. Pelvic Guru offers a course for professionals with a trans focus and I hope to see even more of that in the future.

The pelvic floor is so complicated that it can sometimes take a village to treat pelvic pain. Many people work with a team of professionals, including general physicians, gynecologists, urologists, physical therapists, and even psychotherapists. Alternative treatments such as acupuncture and pilates/yoga can also play a part in recovery.

If you’re looking for sex toys you may still be able to use with pelvic pain, check out a couple of pieces I wrote here. One details external toys (including the Eroscillator, which Betty’s Toy Box generously offered for review during my recovery) and the other reviews internal toys. Another  piece should be up soon and will include a review of TOUCH, which was super helpful during at-home physical therapy exercises.

Here are links to curated collections of kegel exercisers and dilators from Betty’s Toy Box (you can just use dildos of varying sizes as well)! Lube is always great, but it’s even MORE important if you experience pelvic pain. (Remember to stay away from glycerin(e), parabens, and certain other ingredients if you’re especially sensitive. Dangerous Lilly has a fabulous guide to lube here. Silicone lube is commonly recommended to those with pelvic pain.)

About the Author:

Nicole Guappone is a freelance writer living in Chicago, and has been previously published by Rolling Stone, Glamour, The Rumpus, The Establishment, and more. Much of her writing and research focuses on sex, sexuality, and kink. She writes a sex toy review column for Chicago-based Rebellious Magazine. Nicole earned her MFA in nonfiction writing from Columbia College Chicago. Her Twitter/Instagram handle is @nicoleguappone.