Keeping the Pelvic Floor Healthy Before, During, and After Menopause

What is the pelvic floor?

The pelvic floor muscles change as we go through different phases of life. Unfortunately, little attention is paid to the pelvic floor until it starts to let us down. This guide will help you take a closer look at your own pelvic floor.

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Our Author:

Camille Moreno, DO, NCMP

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Dr. Moreno is a women’s health specialist practicing in North Carolina. She is a certified menopause practitioner and is also board-certified in family medicine. 

This guide is based on guidelines and recommendations set by The American College of Obstetrics & Gynecology (ACOG), American Urogynecologic Society (AUGS), and the North American Menopause Society (NAMS). In addition, Dr. Moreno consulted with experts in the field on their clinical practice. 

What are the pelvic floor muscles?

The female pelvic floor consists of a group of strong muscles, tissues, and ligaments that form a “sling” to support your internal pelvic organs. These organs include the bladder, the vagina, and the bowel. The pelvic floor holds everything in place: It keeps the pelvic organs in the correct position while preventing them from dropping and falling out of place.

Find your pelvic floor muscles

The pelvic floor, also known as the pelvic diaphragm, is a funnel-shaped structure that is made up of strong muscular bands that attach to your pubic bone, tail bone, and pelvis. These strong muscular bands are called sphincters. They surround the vaginal, urethral, and anal openings, and help them open and shut.

The pelvic floor consists of the following muscles:

• Levator ani

• Coccygeus

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You can find your own pelvic floor muscles and get familiar with them. Try these simple exercises:

• Insert one or two fingers into your vagina and try to squeeze it around your finger(s).

• Think of urinating and stopping your flow midstream.

• Think of stopping yourself from passing wind and squeezing your bottom tightly (without moving your butt cheeks).

What do the pelvic floor muscles do?

The pelvic floor muscles help you control the release of your urine, feces, and flatus (gas). When you use your pelvic floor muscles, the pelvic organs are lifted and the sphincters tighten the openings of the vagina, bladder, and anus, preventing the passage of urine, feces, and flatus. In contrast, relaxing the pelvic floor allows these to easily pass.

Your pelvic floor muscles also play a role in sex. In people with male anatomy, they help with erection and ejaculation. In people with female anatomy, voluntary squeezing of the pelvic floor increases sexual sensation and strengthens orgasms.

Pregnancy and childbirth put an enormous strain on your body and can loosen the muscles and ligaments that make up your pelvic floor. During pregnancy, your pelvic floor muscles support the weight of the growing baby. They are stretched and strained under pressure and weaken from being weighed down, and are affected by changes in female hormones during pregnancy that loosen these muscles and ligaments, allowing a baby to pass through the birth canal more easily.

Does pelvic floor weakness cause incontinence?

Incontinence or loss of bladder control is a common symptom of a weakened pelvic floor. This happens when the muscles and ligaments supporting the bladder weaken over time or involuntarily spasm.

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How common is pelvic floor weakness

About 24% of women have symptoms related to symptoms of pelvic floor weakness:

• 15.7% have urinary incontinence

• 9% have fecal incontinence

• 2.9% have symptoms of pelvic organ prolapse (more on that later)

What are pelvic floor disorders?

A pelvic floor disorder is a condition when your pelvic floor muscles weaken, leading to bladder control problems, bowel control problems, and pelvic organ prolapse.

The three main pelvic floor disorders include:

• Urinary incontinence, or weak bladder control

• Fecal incontinence, or weak bowel control

• Pelvic organ prolapse

Pelvic organ prolapse is a condition in which one or more of your internal pelvic structures drops through the pelvic floor and bulges out of the vaginal opening. These structures include your:

• Vagina

• Cervix

• Uterus

• Bladder

• Urethra

• Rectum

Do you have pelvic floor weakness?

If your pelvic floor muscles are weak, your internal pelvic organs are not well supported.

The symptoms of pelvic floor weakness that you experience will depend on the type of pelvic floor disorder you have. You can have any of these symptoms or a combination of these symptoms.

Symptoms of urinary incontinence: 

• Leaking urine with coughing, hard laughing, sneezing and exercising

• Not making it to the toilet in time

• Urge to urinate

Symptoms of bowel incontinence: 

• Constipation and/or straining with bowel movements

• Passing wind from the vagina with bending and lifting

Symptoms of pelvic organ prolapse:

• Pressure or a sense of heaviness in the vagina

• Bulge or protrusion through or out of the vaginal opening

You might also experience: 

• Pain or discomfort

• A decreased ability to orgasm

• Tampons that fall out

What does pelvic floor pain feel like?

Pelvic pain related to these conditions can feel like heaviness and/or cramping in the area below your belly button. The pain can be brought on by a pelvic prolapse or with penile–vaginal intercourse. It can feel like your pelvic floor muscles are contracting or tightening. The pain may feel like cramping that you feel with your menstrual period, but is typically not related to your cycle. The pain is often associated with problems of bladder or bowel control.

Who is most at risk for pelvic floor disorders?

Anyone can have pelvic floor weakness. Some people are at more risk than others.

Any of the following can increase your risk of having a pelvic floor disorder:

• Being pregnant or recently having a baby

• Having had trauma to the pelvic floor or surgeries such as a hysterectomy

• Having a family history of pelvic floor disorders

• Being in menopause

• Being obese or overweight

• Having a chronic cough

• Having chronic constipation

• Heavy lifting on a regular basis

Causes of pelvic floor weakness

Every woman’s pelvic floor muscles weaken with age. This is caused by the changes in hormone levels that come with perimenopause and menopause.

The pelvic floor can be also be weakened by:

• Overstretching the muscles during pregnancy

• Childbirth

• Having an enlarged uterus from fibroids

• Gaining weight

• Chronic constipation and excessive straining to empty your bowel

• Persistent and excessive coughing

• Heavy lifting

• Pelvic floor surgery

Benefits of a healthy pelvic floor

There are many benefits of a healthy pelvic floor. Strong pelvic floor muscles help with:

• Pregnancy

• Childbirth

• The postpartum period

• Sex

• Intimacy

• Menopause

Pregnancy

During pregnancy, you need a healthy pelvic floor to support the weight of the baby and to support your own body. A strong pelvic floor will also give you a head start.

During the 9 months of pregnancy, delivery, and beyond, your pelvic floor will work harder than normal and will be pushed to its limit. This is true whether you give birth vaginally or by caesarean. During a vaginal birth, your pelvic floor muscles and ligaments are stretched out and strained. In a caesarean, a surgeon cuts through multiple muscle layers leading to a weakened abdominal wall and pelvic floor. The pelvic floor can also be impacted by how long you are in labor.

Pelvic floor exercises before, during, and after pregnancy can help with this. Start on your own by downloading a Kegel exercise app, many of which are free. It can teach you Kegel exercises and remind you to do them regularly. It can also help set your goals and track your progress. If you’re unsure if you’re doing the exercises correctly, you can ask your healthcare provider or a yoga instructor for help. Even better, seek the expertise of a pelvic floor physical therapist.

Postpartum

The pelvic floor muscles unsurprisingly also play an important role after a birth — especially after a vaginal birth. In fact, giving birth vaginally is linked to a high rate of urinary leakage in the first few months after pregnancy, also called the postpartum period. This is true even for people who may not have had any issues with urinary leakage during their pregnancy. A strong pelvic floor helps you heal faster after birth by improving blood flow to your pelvic and genital areas and lowering the amount of swelling there.

Sex

Research shows that a strong pelvic floor and mental awareness of your own pelvic floor muscles increase sexual pleasure and strengthens orgasm. Working on pelvic floor exercises and certain yoga poses that bring your awareness to that area not only increase sexual sensation, but can also lessen vaginal and pelvic pain during sex for those who experience this.

Overall, the more familiar you can get with your anatomy, and the more in tune you are with your muscles, the more enjoyable sex is likely to be for you.

Menopause

Your pelvic floor muscles weaken as you get older. Estrogen, your female hormone, plays a big role in keeping the muscles and ligaments strong and stretchy. As estrogen levels lower in menopause, your pelvic floor muscles become less flexible and less strong — resulting in pelvic floor weakness. Maintaining a strong and healthy pelvic floor as you go into menopause will keep you ahead of the curve.

Strengthening the pelvic floor

Everyone can benefit from doing pelvic floor — or Kegel — exercises. You can do them just about anytime, starting at any age and time in your life. If you are planning to have a baby, are currently pregnant, or have been pregnant in the past, it is especially important to strengthen your pelvic floor muscles.

The goals of doing routine Kegel exercises include:

• Enhancing sexual pleasure and the ability to orgasm

• Reducing pelvic or vaginal pain and/or pain with intercourse

• Strengthening and conditioning muscles to make childbirth easier

• Improving some types of urinary leakage or incontinence

• Preventing constipation and straining with bowel movements

• Preventing pelvic organ prolapse

How can I strengthen my pelvic floor?

Pelvic floor exercises, also known as Kegels, involve squeezing (or lifting) the pelvic floor muscles and relaxing them with control in time with your breath. Being able to lift your pelvic floor and hold it while squeezing it is just as important as being able to relax it fully. For many people, learning to relax the pelvic floor takes as much practice as strengthening it does.

Using the right muscles to lift, squeeze, and relax is the key to doing these exercises correctly. You should not be using your stomach muscles or your bottom muscles.

Here’s how to exercise your pelvic floor muscles:

1. Sit, stand, or lie comfortably and take a few deep breaths to help your body relax completely. For many women, pelvic floor exercises are easiest when lying down.

2. Lift and squeeze your pelvic floor slowly, imagining you are zipping up a tight pair of jeans from your anus through to your belly button.

3. Hold firmly for 5 to 10 seconds, then release slowly. Breathe normally without holding your breath! It might take some practice to keep lifting your pelvic floor while breathing in and out.

4. Relax for 5 to 10 seconds between each exercise. If you don’t, your next pelvic floor lift will be weak.

5. Repeat up to 10 times or until your muscles feel tired.

You can also do a round of quick lifts:

1. Sit, stand, or lie comfortably and take a few deep breaths to help your body relax completely.

2. Lift and squeeze your pelvic floor in 1 second, then release again in 1 second.

3. Repeat 10 to 20 times or until your muscles feel tired.

You can do your Kegels lying down, sitting, or standing — anywhere and anytime. They will feel different in different positions. Be sure to have an empty bladder before starting.

At the beginning, you might need to concentrate quite hard on what you are doing. Just breathing in and out while exercising your pelvic floor might be a challenge. Once you’ve gotten the hang of the exercises, you can fit them into your daily routine. For example, you can do them while:

• Driving

• Sitting at your desk

• Brushing your teeth

• Watching TV

How long does it take to strengthen the pelvic floor?

You may be doing pelvic floor exercises for 6 to 12 weeks before you notice any improvement. Ideally, you should be doing Kegel exercises 3 times per day. If you do not notice any improvement in your pelvic floor despite regularly exercising, it may be due to the following:

• You are not doing the exercises correctly.

• Your pelvic floor is too weak to contract.

• You have a pelvic organ prolapse.

• You have not recovered from an injury from pregnancy or childbirth.

Common pelvic floor disorders

The pelvic floor muscles provide support to the pelvic organs — so if the pelvic floor is weakened, you can run into problems with any of those pelvic structures.

Getting a diagnosis

Your healthcare provider will most often be able to diagnose a PFD based on your symptoms and a physical exam.

You will probably be asked about:

• Previous pregnancies

• Pelvic floor surgeries

• Symptoms of pelvic pain

• Medications

• Bladder and bowel control problems

The physical exam will involve an internal pelvic — and sometimes rectal — exam. Some parts of the exam are not comfortable, but it should not be painful.

During a pelvic exam, your provider will insert a lubricated and gloved finger inside your vagina to test how well you can squeeze or contract your pelvic floor muscles, as well as to feel for any knots, spasms, or pain in these muscles.

You will probably also have a speculum exam, which is when your provider slides a lubricated, sterile instrument made of metal or plastic into the vagina to separate the walls and tissues of the vagina and look inside the vaginal canal.

You will probably be asked to strain or cough during the exam to see if there is any urine leak, or bulges.

Your provider might have you take other tests to check your bladder and bowel control. More than likely, you’ll need to have these tests on a different day in a specialized clinic. These tests ensure there are not other conditions or diseases that could be causing — or contributing to — your symptoms.

Bladder testing procedures include:

• Cystoscopy: This test allows your provider to examine the insides of the bladder and the tube that carries urine called the urethra. It can detect bladder stones, tumors, or inflammation.

• Urinalysis: This urine test allows your provider to determine if you have a bladder infection, kidney problems, or diabetes.

• Urodynamics: This test measures how well your bladder and urethra hold and release urine. Results from this test can be used to plan for surgery to treat certain bladder control problems.

Bowel testing procedures include:

• Anal manometry: This test measures how well the anus and bowels are working.

• Colonoscopy or sigmoidoscopy: This procedure allows your provider to examine the inside of the entire colon or the sigmoid (the part of the bowel near the rectum) using a camera to look for signs of disease or inflammation, polyps, and cancer.

• Dynamic defecography: This test examines your pelvic floor and rectum while you’re having a bowel movement.

Getting professional help

Depending on the cause of your pelvic floor disorder and your healthcare coverage, it may be possible to receive a full work-up and care by a team of specialists.

The team of specialists who treat pelvic floor disorders includes:

• Your general practitioner

• A gynecologist

• A pelvic floor physical therapist

• A urologist or urogynecologist

Ask your provider about all of your treatment options — surgical and nonsurgical.

Treatments for pelvic floor disorders

In most cases, symptoms related to pelvic floor disorders are mild or moderate and can improve with nonsurgical treatments.

Nonsurgical treatment plans

• Pelvic floor or Kegel exercises: successful in about 56% of pelvic floor disorders

• Pelvic floor physical therapy and muscle training: successful in about 89% of pelvic floor disorders after 13 sessions

• Weight loss support (if needed): successful in 47% to 65% of pelvic floor disorders

• Bladder training: successful in 10% to 15% of pelvic floor disorders

• Vaginal pessaries: successful in 89% to 92% of pelvic floor disorders

• Medications: shown to decrease episodes of urge urinary leakage by one episode per day

If these options do not work and if your symptoms are severe, you may want to consider surgery.

Pelvic floor physical therapy

Pelvic floor physical therapists are specifically trained to rehabilitate pelvic floor muscles and provide a non-surgical treatment option for those who have a pelvic floor disorder. A common evaluation and treatment plan would include:

• Flexibility and strength assessment

• Pelvic area internal and external muscle assessment and treatment: Your provider will insert a lubricated, gloved finger inside your vagina to test how well you can squeeze or contract your pelvic floor muscles. They will also test for sensation and pain by touching the outer lips of your vagina.

• Pelvic floor muscle surface EMG (or biofeedback): A device will use special sensors that are attached to your abdomen and anal canal to measure your muscle activity.

• Postural exercises: These exercises will strengthen your low back (lumbar spine) and core strength.

• Myofascial release: This involves mobilizing the soft tissue for relaxation of the muscles and manual stimulation of the pelvic floor’s trigger points, which are tensed areas of muscle tissue that radiate pain to other areas of your body.

• Relaxation techniques and diaphragmatic breathing: During these breathing exercises, you focus on your stomach rising and falling with each breath to practice relaxing and engaging your pelvic floor muscles.

Finding a pelvic floor physical therapist
You can visit APTA Pelvic Health or Pelvic Rehab to find the right therapist for you.

Is physical therapy for pelvic floor disorders covered by insurance?

Pelvic floor physical therapy is covered by insurance, but coverage varies. Please contact your insurance provider to confirm coverage. There are support groups and forums available online for those who don’t have insurance coverage but would like to learn from others living with symptoms related to pelvic floor disorders.

Mechanical devices

Mechanical devices that strengthen the pelvic floor muscles help with urinary leakage and can be used at home or with your pelvic floor physical therapy. One type is a vaginal cone that is inserted into the vagina, which you contract your muscles around to hold it in place. A study found that weighted vaginal cones were better at alleviating symptoms than was no treatment in women with stress incontinence, and that using vaginal cones could work as well as pelvic floor physical therapy and pelvic exercises.

Another device that improves the muscles is an automatic Kegel exerciser. This device can relax the muscles of the bladder, improving symptoms related to an overactive bladder. It can also stimulate your pelvic floor muscles and perform Kegel exercises for you.

Behavior changes

Some lifestyle changes can help you manage pelvic floor weakness and urinary incontinence.

These are recommended for those who have mild or moderate symptoms of urinary incontinence:

• Keep a fluid and urination diary: Include information about how much fluid you drink, what type of fluid, daytime leaks, and nighttime leaks. It’s recommended that people with no other health conditions drink at least 6 glasses of fluid (about 48 ounces) every day. Avoid drinking after dinner.

• Avoid citrus, coffee, and alcohol: Foods and drinks high in acid such as citrus fruits, caffeinated drinks, and alcoholic drinks should be avoided.

• Schedule your bathroom breaks: If you struggle with urgently needing to pee, try to schedule your restroom visits. This is also known as timed voiding. Start your day by urinating on a fixed schedule, whether or not you feel the need to urinate. If you have the urge to urinate between timed voiding, then you should resist the urge by using a practiced distraction strategy. For example, you could sit down and do three slow Kegels. By doing this, you can gradually teach your brain not to panic when you get the urge to pee, and learn to hold your urine for longer periods of time.

Vaginal pessaries

A vaginal pessary ring is a silicone device that is inserted into the vagina to provide support to the pelvic floor. It can be used for people with symptoms of stress urine leaks. Your healthcare provider can fit a pessary during a simple pelvic examination.

Medications

Prescription medications are available for those who have the urgency to urinate and cannot make it to the bathroom in time.

These anticholinergic medications are a group of medications that help control involuntary bladder contractions, decreasing your urge to pee. These medications are tablets that are taken by mouth. Oxybutynin is also available as a cream or skin patch.

• Oxybutynin (Ditropan XL, Oxytrol)

• Tolterodine (Detrol)

• Darifenacin (Enablex)

• Solifenacin (Vesicare)

• Trospium

• Fesoterodine (Toviaz)

Sacral neuromodulation

Electrical stimulation of the bladder uses a mild electric current that excites the nerves in the pelvis or lower back that controls the release of urine. The stimulation makes the pelvic muscles contract, producing a similar effect to Kegel exercises. It may encourage the growth of new nerve cells that contract the muscles. For those with severe urge incontinence, this is an option that can be done in the clinic or at home.

Bladder Botox

Botox injections for the bladder calm spasms in the bladder muscles that contribute to urge incontinence. The injections are given in a clinic. They can also be helpful for people with conditions such as Parkinson’s disease or multiple sclerosis.

Pelvic stimulation

Pelvic stimulation devices are non-invasive units inserted into the vagina or anus that can be used in the comfort of your home. They activate and train your pelvic floor muscles based on preprogrammed settings.

Surgical treatments for pelvic floor weakness

Surgical treatment is mainly for pelvic organ prolapse that causes very bothersome symptoms, for example when the prolapse bulges outside the vaginal opening.

Sometimes, a person with pelvic floor weakness that has not improved with non-surgical treatments may be a candidate for surgery, too.

The type of surgery that is recommended depends on which organs have prolapsed and the symptoms caused by prolapse. Ultimately, it is your choice after talking to your provider about the risks and benefits of the surgery and how well the surgery will work for you.

• Reconstructive surgery: This involves lifting the pelvic floor structures back to their correct position. You can still have sex after recovering from this procedure.

• Obliterative surgery: This involves closing off the top of the vaginal canal, preventing the pelvic organs from dropping into the vagina. It is an easier procedure to recover from, but penetrative sex is no longer possible after this surgery.

Surgeries for pelvic organ prolapse can be performed through a cut in the vagina, through one large cut in the abdomen, or through several smaller cuts in the abdomen (also known as keyhole surgery).

Some surgeries — but not all — use something called surgical mesh to lift and support the pelvic structures. If you're considering surgery that involves surgical mesh, be sure to have your provider explain all of your options, as well as their possible risks and benefits.

What is a FPMRS specialist or urogynecologist?

A female pelvic medicine and reconstructive surgery (FPMRS) specialist or a urogynecologist is a doctor who has gone through advanced training and certification in order to diagnose and treat urinary incontinence, pelvic organ prolapse, and pelvic floor disorders.

They perform innovative procedures that include:

• Sacrocolpopexy

• Burch procedure

• Mid-urethral sling

• Fascia pubovaginal sling

Keep in mind

Urinary incontinence has become an economic burden worldwide. It’s associated with significant medical and nonmedical expenses. In the U.S., the total yearly cost of urinary incontinence was estimated to be around $35.5 billion in 2007. More recent data is lacking, but the number is unlikely to have gone down.

Pelvic floor disorders in people with male anatomy

People with male anatomy are also affected by pelvic floor disorders. They have pelvic floor muscles that help with bladder, bowel, and sexual functions just like people with female anatomy do. For example, maintaining an erection requires contraction of the pelvic floor muscles to block the blood from leaving the penis. When the muscles become weak, the blood flow decreases, resulting in erectile dysfunction. Premature ejaculation can be prevented by learning how to relax and contract the muscles.

Symptoms of pelvic floor weakness in people with a penis include:

• Erectile dysfunction

• Pain in the testicles and/or penis

• Painful ejaculation

• Premature ejaculation

Why trust our experts?

Written by:

Camille Moreno, DO, NCMP

Camille Moreno, DO, NCMP, is a women’s health specialist currently practicing at Duke University Medical Center in obstetrics and gynecology. She earned her bachelor of science degree in biology from Virginia Tech and her Doctor of Osteopathic Medicine from Virginia College of Osteopathic Medicine.

Edited by:

Sophie Vergnaud, MD

Sophie Vergnaud, MD, is the Senior Medical Director for GoodRx Health. An experienced and dedicated pulmonologist and hospitalist, she spent a decade practicing and teaching clinical medicine at academic hospitals throughout London before transitioning to a career in health education and health technology.

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