Pelvic health 101: dysfunction symptoms, treatment options, and more
“Can you feel your sitz bones spreading?”
My workshop partner stood patiently to the side as I leaned into my wide-legged forward fold, trying to focus on breathing deeply into my pelvis, instead of on the fact that a stranger was staring intently at my displayed — if clothed — vaginal opening.
In September 2019, I found myself one of 25 yoga teachers, doulas, nurse practitioners, and physical therapists who had flown to Oakland, California, to learn about the magical and mundane group of muscles that governs three of 11 essential bodily functions: the pelvic floor. What could cause any sane woman to use a week of vacation time, buy a $300 plane ticket, and spend 20 hours with strangers comparing notes on pelvic pain?
Shitty sex. That’s what.
By the time I landed in the Pelvic Floor Yoga teacher training in 2019, I was no novice to the landscape of my pelvis. Five years prior, I began a slow descent into the rabbit hole of understanding why sex hurt for me. Some of it was user error (I was 25, after all). But, I knew it wasn’t just that. This just doesn’t feel right.
Turns out, I was right. And it only took me about three years of digging to figure out why.
Why no one ever told you about your pelvic floor
I don’t know about you, but I grew up Southern Baptist. The one with purity rings? I have no idea where my ring got to, but I can tell you that I didn’t pick up a damn thing about pelvic health in my abstinence-only sex education classes in the Deep South.
It’d be easy to blame my evangelical upbringing for neglecting to instill in me the basic principles of pelvic sovereignty, but I also left my queer-friendly, sex-positive liberal arts college without knowing I had a pelvic floor, much less how to care for it. (And, I went to the sex toy parties, OK.)
Unless you’ve experienced a prolapse after a difficult birth or worked with your doctor to manage incontinence, you too may be sitting here thinking, my pelvic <i>what</i>? One of the reasons you’re reading this article is because it took me years of slightly naughty Googling in order to piece together why sex hurt for me and how I could heal myself.
This glaring gap in women’s health largely stems from the fact that no single doctor owns end-to-end pelvic health. Incontinence issues? See a urologist. Sexual dysfunction? Maybe you need a sex therapist to deal with childhood trauma. Having sciatica or low-back pain? Maybe you need to see a sports physical therapist.
While it’s rewarding to build a team of experts to support you in your healing, finding these experts can feel like a maze. It’s not always clear who to lean on when you have problems with the basic human functions of pooping, peeing, and having sex. Even doctors who specialize in women’s health aren’t always skilled in (or comfortable with) assessing overall pelvic health. As Rachel Rubin, a D.C.-based urologist pioneering women’s sexual medicine, points out, “When was the last time your gynecologist asked you if you could orgasm?”
The Midst is here to equip you to be your own best advocate when it comes to your pelvic health.
What is the pelvic floor, and how do I know if I have pelvic floor dysfunction?
At the end of the day, the pelvic floor is a group of skeletal muscles layered across the bottom of your pelvis — plain and simple. They function exactly the same way other skeletal muscles (like your biceps or quads) do. In order to keep skeletal muscles healthy, you follow a pretty straightforward formula:
- Stress
- Rest
- Repeat
In the course of your everyday life, you might follow that formula by going to the gym, picking up heavy things, and then putting them down. There. Now you’re stronger.
Your pelvic floor muscles are no different. To strengthen your pelvic floor, you’ll want to contract the muscles (stress), relax the muscles (rest), and repeat that process as much as your life requires.
The problem is that many women get stuck in one part of the cycle. Some women can’t contract their pelvic floor at all (hypotonicity). Other women can’t relax their pelvic floor and remain in a contracted state all 👏🏻 the 👏🏻 time 👏🏻 (hypertonicity).
And, to make matters more complicated, your pelvic floor is a group of muscles, not just one. So, some of your pelvic floor muscles can be hypertonic (unable to relax), while others are hypotonic (unable to contract). This means you can end up with seemingly conflicting symptoms like urinary frequency (i.e. your pelvic floor is so tight you feel like you need to pee all the time) and stress incontinence (i.e. your pelvic floor isn’t able to hold it all together, so you pee a little bit sometimes).
The good news is that there are physical therapists, occupational therapists, yoga teachers, and other pelvic health practitioners out there trained to help you heal from pelvic floor dysfunction. There’s also a TON you can do on your own at home to heal your pelvic floor once you’ve been properly diagnosed.
Symptoms (some surprising!) of pelvic floor dysfunction
- Sex is painful
- Peeing a little while exercising or… coughing
- Needing to pee all the time
- Planning your errands around how far away from a bathroom you’ll be
- Pain in pelvis, pubic bone, tailbone, or sacroiliac joint
- IBS or chronic constipation / diarrhea
- Walking farts
- Low back pain
- Sciatica
- Painful episiotomy or cesarean scars
- Cramps and really bad PMS
Is it pelvic floor dysfunction or perimenopause?
If you’ve already read up on our perimenopause guide, you may have noticed some overlap in the list of symptoms. How do you know what’s causing what?
Go see a pelvic floor physical therapist or occupational therapist. Pelvic floor PTs and OTs can diagnose pelvic floor dysfunction or rule it out. In most states, you can see these practitioners without needing a referral from your doctor, otherwise known as direct access.
Shouldn’t I just do kegels?
Probably not. Most women don’t need kegels…
*gasp*
…at least, not at first.
Kegels are a specific exercise (like bicep curls or squats) that are meant to strengthen your pelvic floor. But, if you’ll remember the formula for strengthening muscles, you can only contract a muscle that’s at rest.
FAST FACT: ARE YOU HYPERTONIC AND DON’T KNOW IT?
Lots of women are walking around with chronically contracted pelvic floors without realizing it. That was me five years ago. A study from the Mayo Clinic Proceedings readily admits, “Nonrelaxing pelvic floor dysfunction is not widely recognized. Unlike in pelvic floor disorders caused by relaxed muscles (eg, pelvic organ prolapse or urinary incontinence, both of which often are identified readily), women affected by nonrelaxing pelvic floor dysfunction may present with a broad range of nonspecific symptoms.”
Why are so many women finding themselves with hypertonic pelvic floors? We’re just now developing the vocabulary and understanding about pelvic floor dysfunction to address it properly. Additionally, we live the most sedentary lifestyles we ever have as humans. So, the moving, stretching, squatting, and walking long distances that would have naturally stretched the muscles of our pelvic floor just aren’t happening. Instead we’re sitting in our chairs or cars all day with our tailbones tucked underneath us, which shortens our pelvic floors front-to-back into a contracted state.
Kegels further contract (shorten) already shortened muscles in your pelvic floor.
Before kegels can be effective as a strengthening exercise, we must first learn how to stretch, relax, and release our pelvic floor muscles. Then, we can introduce kegels and learn how to do them properly, instead of “squeezing and hoping for the best,” as my teacher Leslie Howard, founder of Pelvic Floor Yoga™, likes to say.
Can pelvic floor dysfunction be caused by sexual trauma?
Absolutely.
Our bodies are brilliant. At any given moment, your unconscious mind is devising ways to keep you safe, and it recruits your muscles to power these strategies. If you’ve experienced sexual trauma, your pelvic floor was likely the direct target of the attack. Your body remembers that experience long past the event itself and can become vigilant in guarding against a similar attack. Your pelvic floor may remain constantly contracted to protect you.
Healing pelvic floor dysfunction after sexual trauma is an act of bravery and hope. I recommend Bessel van der Kolk’s The Body Keeps the Score to learn more about long-term effects of trauma on the body.
Will I have better sex after healing pelvic floor dysfunction?
It’s highly likely.
While working with Pelvic Floor Yoga™ clients, I’ve heard two primary complaints about sex: “It hurts,” or “I can’t really feel anything.”
Pain and lack of sensitivity during sex can point to pelvic floor dysfunction. By working with the pelvic health practitioner or doing Pelvic Floor Yoga™ on your own at home, you’ll begin to build a relationship with muscles you may not have spent much time with. Even learning some basic breathing techniques teaches you to tune into your pelvic floor and access a new range of sensations. By relaxing your hypertonic pelvic floor or strengthening your hypotonic pelvic floor, you’re setting yourself up for penetration (if you want that) with pliable, sensitized, lubricated muscles.
What are treatment options for pelvic floor dysfunction?
Pelvic floor physical therapists and occupational therapists
If you’re facing debilitating symptoms that you think may be related to pelvic floor dysfunction, I recommend finding a pelvic floor PT or OT as soon as possible. They will be able to diagnose your exact pelvic floor dysfunction and get you on a path to healing. To locate a practitioner, check out:
Licensed massage therapists trained in pelvic health
In some states (e.g. California, Oregon, and Colorado), LMTs are able to provide internal manual therapy after completing the appropriate professional training. In all states, LMTs are able to work externally on the glutes, low back, and other muscles connected to the pelvic floor. My LMT was a core member of my team in healing my pelvic floor issues, so I highly recommend finding one you trust! You might want to search Google for LMTs in your area trained in Holistic Pelvic Care™, Sexological Bodywork, or Myofascial Release.
Do your due diligence when finding the right LMT. I had to go through many, many before I found a practitioner who was the perfect blend of professional, warm, with just a dash of woo-woo.
Pelvic Floor Yoga instructors
If you’d like to take a DIY approach to healing your pelvic floor, you can’t go wrong by starting out with the breathing exercises and pelvic floor stretches found in Pelvic Liberation by Leslie Howard. You can also connect locally with a Pelvic Floor Yoga instructor in your area if you’d like 1:1 guidance.
How do I choose a pelvic health practitioner that’s right for me?
Pelvic health practitioners come in all shapes and styles. Here’s what I’d recommend before you go in for your first visit:
- Read your practitioner’s website to see if you jive with them. Some are woo-woo. Some are clinical. Find someone you’ll be able to trust with your most precious parts.
- Find out from their website or from the practitioner directly what type of therapies they are trained in. Seeing a practitioner trained in Myofascial Release is a very different experience than one who relies exclusively on biofeedback.
- Search YouTube for “pelvic floor therapy” plus whatever modality your therapist is trained in (Myofascial Release, biofeedback, manual therapy, etc.). Watch a few videos in order to understand what your first visit might look like.
- Once you find a practitioner you’re interested in, contact them and ask if you need a referral in order to see them. Some states do not require a referral (direct access) and other states do.
- Check with your insurance company to see if the therapy will be covered. If you’re seeing a physical therapist (PT or DPT) or an occupational therapist (OT), there’s a good chance your insurance company will cover it. If you’re seeing an LMT, it’s less likely your insurance will cover it, unless the LMT works in a medical setting.
How yoga can help with pelvic floor dysfunction
Before I launch into how Pelvic Floor Yoga™ changed my life, let me back up and talk about what yoga <i>is</i>. To me, yoga is the practice of understanding your internal state, sometimes with the help of a teacher.
So, what’s the internal state of someone with pelvic floor dysfunction? I can only speak from my own experience, but, as someone diagnosed as having a hypertonic pelvic floor, I oscillated between numbness and pain in my pelvic floor, depending on the day.
The poses of Pelvic Floor Yoga aren’t magic. They are an excuse to have a conversation with your pelvic floor muscles that you may have never had. A few days into my Pelvic Floor Yoga Teacher Training, I was sore in parts of my pelvis I didn’t know existed. In fact, when I went to bed on night two of the training, I had night terrors, replaying flashes of my assault. Awakening your pelvic floor—while it may sound ridiculous—is no joke. Mine had been numb and contracted for good reason.
Pelvic Floor Yoga has given me the framework to metabolize the physical and emotional tension in my pelvis. Pairing yoga with support from my therapist and reiki practitioner, I’ve been able to reclaim my pelvis as my own.
Can pelvic floor dysfunction cause infertility?
In short, no. I haven’t come across evidence that pelvic floor dysfunction causes infertility. That said, if you’re having pain with sex, it bears noting that you might be less inclined to have sex in the first place.
Pelvic floor dysfunction does sometimes accompany other causes of infertility, such as endometriosis or PCOS. These conditions are often characterized by chronic pelvic pain, which can result in a protective tightening of the pelvic floor muscles, leading to hypertonicity.
FAST FACT: CAN PELVIC FLOOR THERAPY HELP WITH INFERTILITY?
While pelvic floor dysfunction doesn’t cause infertility, there is some very hopeful research coming to light that manual therapy for the pelvic floor could reverse infertility caused by occluded fallopian tubes, endometriosis, hormone dysregulation, and PCOS.
Incontinence isn’t inevitable
According to University of Chicago’s Medicine Center for Pelvic Health, “While pelvic floor disorders become more common as women get older, they are not a normal or acceptable part of aging.”
I’ll say it again for the people in the back: Incontinence and other pelvic floor dysfunction like prolapse and urinary urgency are not normal, nor acceptable.
So, why are almost half of all women over 60 suffering from some kind of pelvic floor dysfunction?
Probably for the same reason it’s difficult to get treatment for pelvic floor dysfunction in the first place. Very few are talking about pelvic health in the mainstream, so you might not even know that incontinence (or pelvic floor dysfunction, generally) is something you don’t need to endure.
