As a doctor of physical therapy who specializes in pelvic floor dysfunction, I am thrilled pelvic floor sex ed is getting the limelight it deserves. Yes, we still have a very long way to go, but this is a solid start. The challenge is that the focus has been one sided and predominantly on weak pelvic floor muscles. Think symptoms such as peeing your pants during exercise, laughing, or sneezing (aka peezing) or just not being able to hold in gas after having a baby. However, there is a flip side which is much more common than you might think! While the recent focus on the pelvic floor has been around “muscle weakness,” I’m here to illuminate another page in the book: pelvic floor “muscle tightness.” So let’s discuss what this actually means, what it may feel like, and what you can do about it. Just like those other symptoms, these symptoms are Common, but NOT normal!
Did you know at least 1 in 3 women will experience pelvic pain in her lifetime? That is too many women. This pain may be caused by tight pelvic floor muscles. Quick recap: Your pelvic floor is a sling of muscles that support organs such as your bladder, uterus, bowel, and ovaries. It plays a key role in bladder, bowel, and sexual function. If these muscles are not functioning properly, the most common side effects impact your sex life, your bladder, and your bowels. These side effects are profoundly intimate. They may be extremely uncomfortable and embarrassing.
Now, let’s talk about why nobody discusses the flip side:
Many women have been conditioned to believe the misogynistic tropes that you need to have a “tight vagina” to be that sexual goddess or great in bed and therefore “worthy.” Many of us have been programmed to believe that our sensuality and sexuality define us. Notice this has nothing to do with a woman’s pleasure; that has historically never been part of the picture. (Yes, we need to work on that, too!) The other harmful trope is that post pregnancy, most vaginas become too loose and need to be “fixed” or else they may never be the same again. As a result, many of my patients were initially hellbent on having a “tight vagina” ASAP postpartum. If the pelvic floor muscles are weak, strengthening the vagina under the care of a pelvic floor PT or OB/GYN is completely appropriate here. However, let’s set the record straight! Tight and strong are two very different concepts.
What do we want?
We want strong pelvic floor muscles. We want the muscles to function optimally. We want pelvic floor muscles that can hold in urine, gas, and not allow for pelvic organ prolapse. We don’t want Mama in diapers, we don’t want Mama wearing pads all day long “just in case”. We want you feeling strong internally, we want sex to feel amazing, and most of all, we don’t want you feeling like you have an alien vagina post partum (this is verbatim from multiple patients)….but that doesn’t mean you start kegeling ASAP. We need to first assess if there is any tightness.
If the pelvic floor muscles are too tight, we need to release and lengthen them first before working on their strength. Imagine a bicep muscle. What if it is locked in a tight position? It won’t be able to move and lift because it’s too tight and doesn’t have the range of motion it needs to function properly. Does being tight make it strong? Absolutely not. In fact, it is likely weak. Your pelvic muscles function just like any other muscles in your body, but shame and stigma related to sexuality and anatomy have sadly misinformed many people that the muscles “down there” are in their own group entirely. Tight muscles are typically painful….and tight muscles are typically weak, so you have to release them first before working to strengthen them.
Let’s get into it!
What are typical symptoms of pelvic floor muscle tightness? Pain during and after sex (lasting for a few seconds to days), pain with gynecological exam, pain with inserting tampons, lower abdominal and rectal pain, difficulty moving your bowels, constipation, or feeling like you are not completely emptying out if you do go. The list goes on, but in my years of professional experience, clinically these are most common. Again, Common, NOT normal! Sex is never ever supposed to hurt. Gynecological exams should never hurt. Tampons should never hurt. If this sounds like you, or a woman you know, let’s fix it. Sadly, many women are ashamed and embarrassed to admit when sex hurts and they are not enjoying it or it is painful when they go to the bathroom. I think because this does not dovetail with their concept of being a woman (I am referring to self-identifying cis, straight women here), sadly, nobody talks about it and instead suffer in silence. The number of women, young and old, who grin and bare sex because they feel they should or want to please their partners is staggering. It is uncomfortable, embarrassing, and can do major damage to one’s sense of self and ability to enjoy intimacy with themselves and others. I’m here to tell you that the more we talk about it, the more we tear down the stigmas, the shame, the silence, and help each other feel better.
Let’s compound this problem with the fact that women’s magazines and many healthcare professionals and pseudo-wellness professionals advocate kegels as the antidote for all “feminine wellness” issues. The kegel has somehow become the most popular girl in school… but she is not a good friend to everyone, especially those with a tight pelvic floor! Kegels will actually exacerbate tightness and cause increased symptoms. Luckily, if you’ve had a baby, if you are postmenopausal, if you’ve always had pain during sex, if you have Endometriosis, if (insert another reason)…You are not destined for a life of pain.
Mamas, this advice does not just pertain to you. Please share it with your daughters, your friends, your friends’ daughters. Gynecologists are now referring more and more young women with pelvic pain to PT, but the older women I treat typically have a history of pain going back for DECADES. They could have been enjoying sex for DECADES! They could have not shied away from intimacy for Decades. They could have been going to the bathroom comfortably for Decades and not had their bodies ravaged by side effects from laxatives, pain meds, drugs, and self medicating behavior. Oh, how I wish this could have been avoided.
What we can do.
Make an appointment with your OB/GYN to have the pelvic floor muscles assessed to rule out other causes of pain. If your doctor determines that the cause of pain is musculoskeletal and has ruled out everything else, yet says anything to the extent of: You’re just stressed, take a bath, this is normal, have a glass of wine, breathe and you’ll be ok or it’s just anxiety (my fave)….Please, find a smarter doctor! You deserve a gynecologist that is educating herself or himself. Pelvic floor PT is not new, so let’s use it! It has been around for over 20 years. Your physical therapist will work on the muscles, inside and out, just like any other muscle group in your body. Whether it is simply tight muscles that need to be lengthened, scar tissue that needs to be mobilized, or re-educating your pelvic floor muscles to contract and relax in coordination, your PT will be the guide you need. If you’ve had a baby and had a natural tear during delivery or an episiotomy, the scar itself can be mobilized so that it is no longer painful. Your PT will educate you on what exactly is happening in your body, what interventions can be used to help resolve symptoms, and the tools and exercises you can use at home to expedite this process. It is shameful that women are told to endure pain when there are so many tools to help alleviate and resolve it. If the gynecologist is still perplexed or questioning? Let me know! I am happy to share top tier evidence based practice and research proving the efficacy of pelvic floor PT. It is out there and it is prolific. There are many research journals dedicated to this topic. Let’s educate our doctors so more women do not suffer due to ignorance. I work with MANY of gynecologists, urologists, and OB/GYNs that are brilliant (and readers!) and are aware of the pelvic floor muscles and how they can present if they are not functioning properly. Great doctors are out there, you just need to make sure you are seeing one.
Making sure you are not walking through life with a clenched jaw and sucked in stomach (oh you’ve been doing this since you were 14 years old?, yeah it is a hard habit to break, but we can do it!!) If your jaw and abs are clenched, other muscles like your pelvic floor are likely clenched which will make them tighter. Also, lube. Lube is your best friend. All lubes are not created equal though, so more on that later. At the gynecological exam, ask your OB/GYN for lots of lube and the pediatric speculum. Yes, there is a pediatric speculum and it can be used on adults. It is much more comfortable and just as effective!! Also, if given the choice between old school metal speculum and plastic, ask for plastic! Breathing and trying to actively release muscles is very effective. Anticipating pain will make you clench your entire body including your pelvic floor muscles. We want to tamp down that “fight or flight” response and encourage muscle relaxation. Meditation also helps to tamp down that flight or fight response. So these are some tips to start. Remember, you are not alone. You are one in three, and together, we can help you not just get rid of the pain, we can also prevent other women from years of pain and diminished self worth!
Dr. Francesca Warner is a physical therapist specializing in women’s and men’s Pelvic Floor health and dysfunction, including pre-natal and post-partum conditions, chronic pelvic pain, Diastasis Recti, urinary frequency/urgency, incontinence, Interstitial Cystitis, prolapse, pain with sex, sexual dysfunction, gastrointestinal dysfunction, and more. She received her doctorate from New York University and has studied with the Herman & Wallace Pelvic Rehabilitation Institute. As an identical twin, she was born on a team. Consequently, she loves building strong bonds with her patients and championing their progress. She treats all pronouns.