After Pilates instructor Amanda Kassar had her first child, she noticed that she had little control over her bladder. The problem got better eventually, but after her second pregnancy, the issue recurred. "Every time I would cough or sneeze, I would fully pee," Kassar recalls. She discovered she had pelvic floor disfunction—a shock for somebody whose Pilates career revolved around having a strong abdominal core.
As a society, we ve just began to talk about the group of muscles known as the pelvic floor. Found in both women and men, the pelvic floor is responsible for bladder and bowel control, sexual function, and holding the organs in place. “About one in three women have pelvic floor dysfunction,” says Carine Carmy, cofounder and CEO of Origin, a pelvic heath therapy clinic with more than 20 locations across eight states, as well as an online platform. “The most common issues are incontinence, including bladder control, and painful sex, which can present in various ways. And prolapse, which is when your organs can descend through your pelvic and floor, and [in severe cases] if untreated over time, can require surgery. This is something that is affecting women and people with vaginal anatomy through every stage of life.”
So often, the conversation around the pelvic floor revolves around the Kegel exercise, which involves repeatedly contracting and relaxing the muscles that form part of the pelvic floor. But be warned: Not everyone needs to strengthen their pelvic floor—some have muscles that are too tense . Therefore, Kegels can exacerbate the issue.
One essential exercise everyone can do for their pelvic floor is diaphragmatic breathing: Take a deep breath all the way into your belly, allowing it to expand along with your lower ribs, as opposed to breathing into your chest and holding your belly tight. “The pelvic floor can have decreased tone, meaning the muscles are more relaxed or more stretched than we might want them to be,” says Lyndsey Harper, MD, FACOG, IF, and founder and CEO of Rosy Wellness, an app that focuses on sexual health. “That can show up through heaviness in the pelvic floor and it s also related to what we call stress urinary incontinence, meaning there s stress or pressure put on the bladder or the urethra through common things like laughing, coughing, sneezing, jumping, or running. If a woman has trouble with those things, that can be due to a relaxed pelvic floor. And then on the other side, there are women who have too much tone and their pelvic floor muscles are tense and feel tight at all times. That s where a dilator can come into play,” she explains, referring to a device that expands the tissue around the vagina, encouraging relaxation of the pelvic floor. Harper goes on to note that signs of pelvic floor dysfunction include pain in the area, or pain related to sex. "Additionally, you might want to go to a pelvic floor physical therapist if you have lower back pain, constipation, or other gastrointestinal issues,” she adds.
A pelvic floor exam is very different from an annual gynecologic exam. For example, a pelvic floor physical therapist will watch you walk to determine your range of motion, strength, and flexibility, and examine you externally and internally, paying attention to how the muscles and the pelvic floor behave. Are they contracted? Are they relaxed? Are they overreactive to touch? Then, the practitioner will prescribe a treatment plan.
“We re seeing over a 300% increase in searches for pelvic floor in the last couple of years,” says Carmy. “These issues are more common than seasonal allergies, more common than diabetes, and more common than hypertension. This is a pervasive healthcare issue that s impacting half the population. Now, because of social media, there s a surge of empowerment that we re seeing among women. They re taking control of their own health care.”
A session at Origin takes place in a private treatment room. A practitioner will look at the tissue in the pelvic area to see if there s scarring or irritation. Then they will assess the perineal body to get a general sense of the movement activity of the muscles, in order to understand the level of sensitivity and minimize discomfort during the exam. A pelvic floor exam can be conducted via either the vaginal or rectal walls. “The PT will start with one finger, with gentle palpation throughout to feel the muscles [which can happen externally or internally, however the patient is comfortable]," says Carmy. “That approach usually minimizes the pain and also allows the PT to be super-specific in understanding the quality of the muscles, and their strength, and if there is any pain, discomfort or muscle weakness. And that s how they can understand other trigger points over activity or maybe under activity causing those symptoms.”
Although specific to the patient, Origin recommends six to 12 visits per client. According to Carmy, it takes about six weeks to see muscle change. “Even after the first or second session, there can be a deep sense of relief, sometimes just from knowing that what you re experiencing has a name,” she adds.
Men, too, can experience pelvic floor issues related to stress, surgery, constipation, and more. “The incidence and prevalence is not documented to be as high in men as in women,” says Uchenna Ossai, PT, DPT, WCS, CSC, and founder of YouSeeLogic. “Most of our research has been done on cisgender men and women, so when I m speaking, I m speaking in that context, but hopefully applying it to everyone in between. For a big part of my career. I was seeing 80 percent men with post-prostatectomy, incontinence, erectile dysfunction, testicular pain, rectal pain, penile pain, abdominal pain, ejaculatory pain, and premature ejaculation.”
Pelvic floor physical therapy can be helpful universally—it s more about education and identifying the issue. “We are just now at the cusp of general awareness,” Harper says.