You might be thinking, “Why would I need to do this?” Well, even if you get regular exams, it’s very likely that your doctor has never tested the various functions of your pelvic floor muscles, as this is not standard medical practice. In fact, your pelvic muscles might not get any attention unless you complain about symptoms, and even then, a generalist might not even know about the benefits of pelvic floor therapy for your complaints, instead relying on pharmaceuticals or surgery that have poor success rates and unfortunate side effects. As a pelvic PT with a focus on wellness, I have to ask: why wait until you are bothered with symptoms that might have been prevented? Whether you identify as female, male, or transgender, we all have a pelvic floor and could benefit from getting to know it.
As a pelvic physical therapist, I’ve performed hundreds of vaginal and rectal examinations to determine how the pelvic floor muscles are working to support:
- The bladder, including control of urine, frequency of voiding, or post-void dribble
- The bowels, including control of gas or fecal matter
- The pelvic organs: bladder/urethra, uterus, small intestines and rectum (all of which can move downward with the force of gravity without adequate support, commonly referred to as a pelvic organ prolapse )
- Sexual satisfaction, including heightened arousal, sensation, erection and orgasm, and prevention of pain with sexual activity
- Regular elimination of toxins and ease of bowel movements
- Mechanical support of the pelvis, Sacroiliac Joints, and Lumbar spine
If any of these are an issue for you and no one has assessed whether your pelvic floor is functioning properly, I hope you will consider finding a pelvic floor specialist who can provide assessment and treatment to help you fill in the pelvic floor piece of the puzzle. Click here to find such a specialist near you.
It is often considered inappropriate to discuss pelvic functions, but we have to move past this to improve pelvic health. I’m not the first to do this, but I encourage you to consider the credibility of the information shared as there are an excess of pelvic floor myths floating around on the internet. What I share with you is evidence-based medicine (see references below) based on research studies and a decade of clinical experience.
Pelvic floor muscles make up the bottom of the core container. In many ways they are like muscles anywhere else in the body, and with with the right exercises, they can be conditioned for greater mobility, strength, and coordination to improve function and quality of life. They just happen to live in an area where their actions are not readily seen.
Early anatomists considered this and named the area the pudendum, which comes from the latin “pudere” (line over the 1st e), which means “to be ashamed.” As there is nothing anatomically shameful about the area, this term brings to light the social implication of taboo, embarrassment, and misogyny. Female genitalia were considered to be especially shameful, as evidenced by their more hidden, or inward orientation, compared to the more exposed male counterparts. Unfortunately, to this day Western Medicine perpetuates the use of the term pudendum to refer to female external genitalia.
I could go on about the detrimental effects of such thinking (and language) but instead, I’d like to offer you active steps toward reclaiming the integrity of your pudendum. Please forgive me for first giving these instructions in reference to female anatomy as I attempt to make up for a long history of ignoring and shaming women with the small act of giving female anatomy a position of importance here. Variations among sexes will be addressed, but for now I encourage you to consider that the functions of pelvic floor muscles are common to all.
Let’s start by using anatomically correct (and less shameful!) terminology. The female external genitalia, collectively, are referred to as the vulva. If you have a vulva, you will be able to see some of it by standing (bottomless) in front of a full-length mirror. From this full-frontal view, you can identify the mons pubis, which is the mound that lies over the pubic bones. You will also likely see the labia majora and labia minora, which translates as the major (outermost) and minor (innermost) lips. It is important to be familiar with your own anatomy so that you can alert your healthcare team of any changes that may require medical attention. Vulvar cancer is not as common as breast cancer, but just as you (hopefully) do a monthly breast exam, it would be wise to take a look at the vulva once a month to catch any changes early and report any concerns to your medical team.
Actions of the pelvic floor muscles, along with a full view of the vulva, are best seen via what I call the “undercarriage view,” so grab a handheld mirror. You might be thinking, “Is this really necessary?” In a word, yes! Human beings are incredibly visual creatures, and our brains establish better control of muscles when we can see their action in real-time (this is the basis of biofeedback, and if the mirror doesn’t do it for you, a pelvic floor specialist can hook you up to some high-tech equipment that will also be able to determine the action of your pelvic floor and provide real-time biofeedback.)
Standing with one foot up on a chair (or toilet with the lid down,) part the labia to view the vestibule, or opening of the vagina. At the top of the labia minora (closer to the mons pubis) lives the clitoris, which may be covered by a hood or fold of skin. Behind the vestibule (closer to your tailbone,) is the anus, where stool is eliminated from the body. Between the anus and the external genitalia (in all sexes) lives the perineum, which might not look very important from the outside, but under that patch of skin is a central tendon (anchor) for the pelvic floor muscles.
A strong contraction of the pelvic floor muscles will elevate the perineum, pulling it toward the abdomen. You may also notice that your clitoris moves slightly, or “nods,” with activation of the pelvic floor muscles. The anus will tighten and lift, which may appear as a puckering up. If you didn’t see these actions with an attempt to contract your PFM, it may help to think about stopping the flow of urination or preventing the passage of gas, as your brain knows that these events require a pelvic floor contraction.
Just as your muscles should contract on your command, they should also release at your will. When your brain tells these muscles to stop contracting, you should see your perineum drop down to resting level. If you bear down as if trying to pass stool when you are feeling constipated, you should see your perineum drop even lower. This downward movement of the pelvic floor demonstrates your ability to relax and stretch this area, which may be required for having a bowel movement, a baby, a pelvic exam or sexual activity without unnecessary pain.
Observe your pelvic floor at rest and continue to view your undercarriage as you fake a convincing cough. What action of your pelvic floor did you see? Ideally, you’ll see a quick squeeze around your sphincters, which indicates your pelvic floor is contracting as it should to prevent any downward descent of your pelvic contents. However, if you see your perineum or vaginal walls drop (which may appear as a bulge in the vagina,) you are at risk of developing symptoms of urinary leakage or pelvic organ prolapse (POP.) You can prevent these symptoms (heaviness, pressure or leakage) by training your pelvic floor. Even if you already have symptoms with a cough, sneeze, laugh, or physical activity, there is a good chance your symptoms will improve with a proactive treatment plan.
At initial assessment, most of my patients are lacking the strength and coordination to prevent this downward shift that occurs with the increased pressure of a cough– so perhaps it it’s no surprise that the majority of females will have symptoms of leakage or POP at some point in their lives. In fact, many people have normalized this phenomena to the extent that is a barrier to treatment. Some of my patients report they were even told their doctor, “oh, honey… you are just getting older! Nothing can be done about that.” However, for more than a decade good quality research has indicated that urinary leakage can be cured or at least improved with pelvic floor exercise. More recent research indicates that POP will improve or even reverse with pelvic floor exercise, if it is addressed early. Unfortunately, at the time of this post, it is not standard medical practice to assess pelvic floor muscle function in the US until symptoms have become severe. I believe this contributes to shockingly high rate of surgical intervention– currently one in five females in the US will undergo a surgical repair for stress urinary incontinence or pelvic organ prolapse, a number that is expected to increase by nearly 50% between 2010 and 2050.
How can we improve that number? Be informed about your body (reading this blog counts!) and advocate for your health by discussing your concerns with your medical team (if they don’t have good answers to your questions, ask them for a referral to a pelvic specialist who does!) You can also lower your risk of developing incontinence or prolapse by maintaining a healthy weight, not smoking, and exercising in moderation. Oh, and if your self-exam revealed that things aren’t staying put when you cough… you should probably get to know “the knack.”
Put simply, ‘the knack” involves consciously contracting your pelvic floor muscles prior to coughing, sneezing, lifting, jumping, crunching, or anything else that might create a downward pressure on your pelvic floor. A strong and coordinated pelvic floor will automatically contract to hold your pelvic contents (urine, gas, organs) in place. If you have symptoms of leakage, heaviness, or pressure with any of these activities, you need to get “the knack” of contracting your pelvic floor to prevent symptoms. If you are not sure if your pelvic floor needs this extra support during these activities, then by all means pull out your handheld mirror and take a look at what is happening down there as you crunch, jump, squat… but you might want to make sure the door is locked when you do.
Has your medical team ever had you stand up during a pelvic exam to observe the response of your pelvic floor to the gravitational pull of your organs? Or were you lying down, where your abdominal contents shift back and the pelvic floor is unloaded, rendering a mild pelvic organ prolapse undetectable? You don’t have to read the research studies to know that your organs head South when you are upright… although perhaps your doctor should.
The best way to get the help you need is to find a pelvic floor specialist who can do a thorough examination (and maybe even get you off the exam table!) Yes, this involves a direct examination of your pelvic floor (via vaginal or rectal exam) that includes an assessment of all the muscle functions I’ve described here. Pelvic floor muscles can be too tight, tender, or simply too uncoordinated to contract or relax well, and internal examination is the best way to determine why the muscles aren’t functioning properly and what needs to be done to improve the situation (hint: Kegels are not always the answer!)
If your pelvic floor does not happen to attach to a vulva, you can still observe the action of your pelvic floor. Anyone with a penis should be able to make it nod, much like the clitoris nods. If you have testicles, they should also pull upward with the perineum when you contract your pelvic floor. Studies have shown that erectile dysfunction can be prevented or reversed with pelvic floor training, and individuals (regardless of their sex organs) who exercise their pelvic floors often report increased “sexual appreciation,” which is medical speak for sexual satisfaction/enjoyment.
To quote Emily Nagoski in her fabulously entertaining and informative book Come as You Are: “Everyone’s genitals are made of the same parts, organized in different ways. No two alike… your genitals are normal and healthy and beautiful and perfect just as they are.” She goes on to state that you shouldn’t be concerned about the appearance of your genitalia unless you experience them as painful, in which case, seek medical attention. I would add that you may have to ask for a referral to see a specialist who can assess your pelvic floor muscles. My patients frequently report that they were in pain for years before someone finally points out that the neuromotor system (muscles and nerves) may be the culprit. Research indicates that unhappy abdominal and pelvic floor muscles refer to the genitals, but if your doctor hasn’t read this research, they might not think to send you to a pelvic floor physical therapist if your main complaint is pain in the genital or abdominal region.
I’m hopeful that we are recovering from a long history of ignoring and shaming the pelvic floor muscles and genitals. Considering all that they do for us, they deserve our attention and respect. I hope this self-exam helps you to see that your pelvic floor muscles need to contract, relax, bear down, and be timed well with other things going on in your body (like other forces coming from the pressure in your abdomen.) If you found this blog to be helpful, I hope you will kick the taboo and keep the conversation going. Comment below or share with the people you know with pelvic floors!
Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women.Cochrane Database Syst Rev. 2011 Dec 7;(12):CD003882.
Lonnée-Hoffmann RA, Salvesen Ø, Mørkved S, Schei B. Self-reported pelvic organ prolapse surgery, prevalence, and nonobstetric risk factors: findings from the Nord Trøndelag Health Study. Int Urogynecol J. 2015 Mar;26(3):407-14.
Wilkins MF, Wu JM. Lifetime risk of surgery for stress urinary incontinence or pelvic organ prolapse. Minerva Ginecol. 2017 Apr;69(2):171-177.