Pelvic Floor Health for Women

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What is the Pelvic Floor?

The pelvic floor is a group of muscles that forms a supportive sling in the lower pelvis. This sling, made up of 14 different muscles arranged in three layers, attaches to the pelvic bones. In a woman’s body, the pelvic floor muscles surround the urethra, vaginal opening, and anus. In addition to keeping the pelvic organs in place and the pelvic bones stable, the pelvic floor muscles are also responsible for:

  1. The pleasurable muscle contractions felt in the genitals during orgasm. Orgasms feel bigger and stronger when the pelvic floor muscles are strong.
  2. Comfortable vaginal penetration. Flexibility of the pelvic floor muscles is important for comfortable penetration.
  3. Keeping urine inside the bladder at moments of unexpected belly pressure (laughing, coughing, lifting, sneezing, jumping).
  4. Keeping stool inside the rectum until you consciously relax your pelvic floor to allow it to pass.

Pelvic Floor Problems

A healthy pelvic floor is strong and flexible, and can contract and relax easily. Pelvic floor strength and flexibility vary from person to person. Some people go through life without problems, while others experience troublesome symptoms because their pelvic floor muscles are too weak, too tense, too inflexible, poorly coordinated, or a combination of these.
Pelvic floor problems can be divided into two broad categories: Low Tone Pelvic Floor Dysfunction (weakness of the pelvic floor), and High Tone Pelvic Floor Dysfunction (painful, tense pelvic floor). There are concrete steps you can take prevent or treat either type of problem.

Low Tone Pelvic Floor Dysfunction

Low Tone Pelvic Floor Dysfunction occurs when the pelvic floor becomes weak from disuse, damaged by surgery, or stretched without being reconditioned soon after. The muscles become too weak to sufficiently hold up the pelvic organs and to hold in urine and stool. Orgasms feel smaller or shorter, and the muscles tire more easily.

Who is at risk of developing Low Tone Dysfunction?

  • Women who have had one or more babies, and do not regularly do Kegels
  • People who have had pelvic surgery, particularly with access through the perineum, which can damage the pelvic floor muscles
People who do not have regular orgasms, because orgasmic contractions help keep the pelvic floor strong
  • People who carry a lot of body weight, which can stress the pelvic floor muscles
  • Athletes who experience injury to the perineum from water-skiing, bicycle racing, or equestrian sports
  • Women with a family history of pelvic organ prolapse
  • People who have had radiation treatment to the pelvic region

What are the symptoms of Low Tone Dysfunction?

  • weak or absent orgasms
  • stress incontinence (losing urine or stool when you sneeze, laugh, cough, lift, or
  • Pelvic organ prolapse or drop (uterus, bladder, or rectum)

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How can I treat or prevent Low Tone Dysfunction?

Learning to do Kegel exercises will help treat symptoms of a weak pelvic floor, prevent them from occurring in the future, and increase orgasmic intensity. These exercises, named Kegel exercises after the doctor who developed them, increase the strength of the pelvic floor muscles by intentionally contracting and relaxing them in a series of repetitions.

First, Find the Muscles

There are a number of ways to learn to feel and identify your pelvic floor muscles. The best way is to insert one or two lubricated fingers into your vagina, and then squeeze your pelvic floor muscles until you feel them tightening and lifting around your fingers. It can be a subtle sensation at first, but will become stronger and easier to identify as you practice. If you feel the muscles in your vagina tighten around your finger when you contract, you’re doing the exercise correctly.

If you are unsure whether you’ve found the right muscles, you can ask your health care provider to help you during your next pelvic exam, or ask for a referral to a Pelvic Floor Therapist for assistance. Once you’ve identified the muscles and can consciously tighten and relax them, you can do Kegels anywhere, any time. You may wish to occasionally insert a lubricated finger and contract so you can feel how your muscles are getting stronger. Some women like to use a specially designed tool—such as the Stone Exercise Egg or the Energie Exerciser—to help identify the muscles and strengthen them effectively. These are particularly helpful if you aren’t sure that you’re contracting at all, or can’t tell if you’re making progress. If you use a tool in the beginning, you may choose to discontinue using it once your exercise routine is under way and you’re comfortable doing Kegels without it.

If you decide to use a tool when doing Kegels, you’ll also need a lubricant. We recommend using one that does not contain oil or glycerin, to minimize the possibility of irritation and prevent stickiness. For more information on choosing a lubricant, feel free to contact us.

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Step-by-Step Kegels

  1. Lie down on your back in a comfortable place with your knees bent. Lying down takes the weight off your pelvic floor and leads to earlier success. Have your tool (if you are using one) and lubricant with you.
    • If you’re using a tool, coat it with lubricant and insert it into your vagina until it comfortably slips into place just behind the pubic bone. You can’t push it in too far; it cannot get lost inside of you.
    • If you’re using your finger(s), wash your hands first, then coat your finger(s) with lubricant. Next, insert your finger(s) about 2 inches into your vagina.
    • You can also practice Kegels with nothing at all inside your vagina, or a hand placed on your perineum, to feel the muscle contract from the outside.
  2. Contract your pelvic floor muscles. It will feel like you’re pulling up and in toward your belly button. Don’t push out, unless specifically advised by a health care provider. If you’re using a tool, you should feel it rise a bit. If you’re using your finger, you should feel a gentle tightening around the finger. Try to keep your leg, buttock, and abdominal muscles relaxed, and remember to breathe normally throughout the exercise.
  3. Hold the lift for a count of 5. If you’re using a tool, you can add resistance by pulling gently on it as you continue using your muscles to pull the tool inward and upward. Remember to breathe!
  4. Relax your muscles.
  5. IMPORTANT: After each contraction, take a deep belly breath. Inhale deeply and gently blow out the air while you relax your pelvis completely. This deep relaxation is just as important as the other steps, because the deep belly breath relaxes the muscles that are not under your conscious control.
  6. Congratulations, you have just done one Kegel.

Important Points to Remember:

  • If you forget to do your exercises for a few days, don’t fret—just get back to them when you get the chance.
  • If you have any pain in your pelvis that feels worse while doing the exercise, STOP and contact your health care provider.
  • If there’s no improvement in your symptoms after a month, contact a Pelvic Floor Therapist. It’s not uncommon to think you’re doing Kegels correctly but actually to be contracting buttock or abdominal muscles, or pushing out your pelvic floor muscles rather than pulling them up. If you think this might be the case, a Pelvic Floor Therapist can help you maximize your efforts.

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Common Questions

How many Kegels should I do every day?

Start out doing 2 sets of 5 twice a day, holding each contraction for 5 seconds. Gradually increase the length of the hold until you can hold it for 10 seconds. Next, increase the number you do each time until you can do 2 sets of 10, holding each for 10 seconds. It would go like this: contract and hold for 10 seconds (breathing normally), and then relax for 10 seconds (taking a deep belly breath). Repeat the sequence until you’ve completed 10 exercises. Rest for a few minutes and then do another set of 10 in the same way. Repeat this sequence again later in the day.

But I read I should do 100 Kegels really fast. Why do you recommend only 5-10?

The pelvic floor is made up of two kinds of muscle fibers: slow-twitch (70%) and fast-twitch (30%). Slow-twitch fibers respond best to slow, step-by-step engagement like the holds we have described. If you only do fast Kegels, you’re not strengthening the majority of the muscle fibers. That’s why it’s important to learn to do the Kegel “hold” as described above. The other 30% of muscle fibers are important too, so we recommend that once you’re comfortable with the Kegel “hold,” you learn Kegel “flicks.”
To do these, tighten your pelvic floor muscles the same way as before but more quickly, and then relax. The entire cycle should take about 3 seconds; you should breathe normally and keep the rest of your body relaxed throughout. Do about 20 twice a day, and finish the set with a deep belly-breath.
We certainly don’t recommend doing 100, or doing them more quickly. Doing too many too fast will overwork the muscles and lead to poor technique that could compromise your progress or lead to other problems.

Once I have my routine of two sets of 10 Kegel “holds” and 20 “flicks,” how should I progress from there?

If you began by using a tool, now is the time to learn to contract your pelvic floor muscles without the tool. It’s important to learn to exercise without it; you’ll want to do your exercises in different positions and during various activities to progress further. Once you’ve mastered holding for 10 seconds without the tool and without involving your buttock or abdominal muscles while lying down, the next step is to do your exercises sitting up. Once you can hold for 10 seconds sitting up, still using good technique (not involving other muscles, remaining relaxed, breathing normally) you may do them while standing. After that, you can do your exercises while you do functional tasks like lifting, walking up stairs, jumping, etc. It’s important to make sure you are able to contract and relax your pelvic floor muscles without involving other muscles in your body, and while breathing normally, so don’t rush the process! Guidance from a professional can help you be sure you’re doing Kegels correctly before moving to the next level; if you’re not sure, get help from a Pelvic Floor Therapist.

If you want to try some advanced exercises, you can use a tool to add weight or resistance while you do your exercises. Once you have mastered lying down, holding for 10 seconds with the tool inserted, and without involving other muscles, the next step is to hold the outside end of the Kegel tool with your hand and pull gently outward on it, using your pelvic floor muscles to hold the tool in. Once you can hold for 10 seconds, still using good technique (not involving other muscles, remaining relaxed, breathing normally) you can do this while standing. If you’re using the Exercise Egg, the weight of the egg itself will offer resistance.

If you wish to go further, you can put coins in the egg’s storage pouch, and hang it from the string attached to the egg. Add more coins to increase the weight.
I heard that to learn Kegels, I should try to stop the flow while I’m urinating. Is that true?

Purposely stopping the flow of urine can be uncomfortable, lead to urethral irritation, and “confuse” the bladder, making it harder to completely empty when you urinate. We don’t recommend it.

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High Tone Pelvic Floor Dysfunction

High Tone Pelvic Floor Dysfunction occurs when the pelvic floor muscles are overly tense, inflexible, or in spasm. The muscles are unable to move and stretch with daily activities. This causes uneven stress on the bones where they are attached, as well as uncomfortable stretching of the muscles themselves. The term “high tone” refers to the presence of high tension in the muscles. This can occur with either strong or weak pelvic floor muscles, and can cause a wide range of problems.

Who is at risk of developing High Tone Dysfunction?

  • People who do Kegels without adequate relaxation both during and in between exercises.
  • Athletes, gymnasts, and Pilates enthusiasts who work out with a focus on core strength without adequate focus on core flexibility and relaxation.
  • Women transitioning through menopause. Estrogen supports muscle function, and estrogen levels decrease during menopause, causing some menopausal women to gradually lose their pelvic floor flexibility.
  • Women who experience infrequent vaginal penetration. Relaxing to allow penetration helps keep the pelvic floor muscles flexible.
  • People with high-stress lifestyles and/or difficulty coping with stress, because this increases the likelihood of carrying tension in the pelvic floor muscles.
  • People who’ve had trauma to their pelvic floor either from surgery or sexual abuse.

What are the symptoms of High Tone Dysfunction?

  • Pain as sexual arousal builds
  • Pain with vaginal penetration
  • Pain with orgasm
  • Inability to tolerate wearing tampons or getting a pelvic exam
  • Constipation and/or pain with bowel movements
  • Painful urination and/or increased frequency of urination
  • Ache in the pelvis from constant muscle stress on the lower spine and tail bone

What should I do if I think I have High Tone Dysfunction?

There are many conditions that are easily confused with High Tone Dysfunction, so we recommend you see your health care provider to obtain an accurate diagnosis. Once a medical diagnosis of pelvic floor dysfunction is made, a Physical Therapist (PT) or Occupational Therapist (OT) who specializes in the pelvic floor can do a thorough assessment and determine the exact portions of the pelvic floor that need attention. The therapist can perform treatment as well as teach you a series of individualized exercises you can do at home, either alone or with the help of a partner, to facilitate normal coordination and flexibility of pelvic floor muscles. We recommend working with a therapist rather than attempting to treat this condition on your own.

Further Resources

Here on our website, you can browse our online store, download all of our brochures at no charge, and read articles about sex and sexual health.

Download a free PDF version of our How to Choose a Lubricant brochure for more information on personal lubricants.

“A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes,” 5th ed. by David Wise, PhD and Rodney Anderson, M.D. This book contains a lot of information about High Tone Pelvic Floor Dysfunction for both men and women.

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  1. […] Pelvic Floor Strength and Flexibility If you experience comfortable initial penetration (1 1/2 to 2 1/2 inches), but then “run into a wall”, one of two things might be happening. Your pelvic floor may have lost its ability to relax and flex enough to allow penetration (called High Tone Pelvic Floor Dysfunction), or, if you’ve previously experienced painful penetration, your pelvic floor may be contracting involuntarily to prevent penetration (called Vaginismus). The first step is to verify that your experience of pain is indeed the result of an overly tight or inflexible pelvic floor. There are many conditions easily confused with high tone pelvic floor dysfunction, so self-diagnosis is difficult. If you think you might have either of these conditions, we recommend that you start by seeing your health care provider and/or a pelvic floor Physical Therapist to obtain an accurate diagnosis. Any home-based therapy you attempt is likely to be more effective under the guidance of a pelvic floor physical therapist. For more information, take a look at our article, Pelvic Floor Health for Women. […]

  2. […] Although some skin tone and pelvic-floor tone is lost through pregnancy and childbirth, it is possible to gain most or all of it back. Breastfeeding releases a hormone called oxytocin, which naturally restores some of the tone of the pelvic floor muscles and ligaments. Pelvic-floor exercises (Kegels) will specifically strengthen these muscles. For a complete description, see our Pelvic Floor Health article. […]

  3. […] Maintain pelvic floor strength. Learn where your pelvic floor is and learn how to exercise it. This helps maintain your connection with the experience of sexual arousal. Tension of the pelvic floor is critical to most people’s experience of “feeling turned on.” When pelvic floor muscle strength starts to slip (which is accelerated by loss of estrogen), you may begin to feel as though “nothing happens down there anymore.” Strengthening your pelvic muscles is as easy as brushing your teeth (really), and it will put a big smile on your face! Read more about Pelvic Floor Health here. […]