An Expert Guide to Pelvic Floor PT Exercises

Not long ago, the pelvic floor was a mysterious muscle group that was seldom discussed in public or at all. But as we move past the stigma surrounding pelvic health and begin to embrace our entire bodies, the pelvic floor is finally getting the attention it deserves.

The only downside to the pelvic floor's newfound popularity? The not-so-accurate tips and exercises popping up in our social media feeds. While some pelvic floor exercises are appropriate for everyone, most are not one-size-fits-all. Depending on the condition of your pelvic floor (is it tight? weak? or uncoordinated?), doing the wrong exercises can be worse than not exercising at all.

Of course, that doesn't mean you should go back to ignoring your pelvic floor. Given all that it's responsible for (from stabilizing your spine to providing bladder and bowel control), your pelvic floor requires ongoing TLC.

To help you make the best choices for your unique body, we've created this detailed guide to pelvic floor exercises, starting with some must-know basic info.

First things first: What exactly is your pelvic floor?

The pelvic floor is a group of interwoven muscles that form a bowl at the base of your pelvis. These muscles attach to your tailbone, pubic bone, and sit bones, and surround your vaginal, anal, and urethral openings, as shown in the diagram below.

As with all muscle groups, your pelvic floor muscles have two relatively simple jobs to do: contract and relax. But because they're located in this intimate and multi-purpose area of your body, their ability to contract and relax has a huge impact on your day-to-day life.

When your pelvic floor muscles contract, they work to:

• Hold in urine, gas, and bowel movements
• Support and uplift your internal organs including the bladder, uterus, and rectum
• Stabilize your pelvic joints for walking and movement

When your pelvic floor muscles relax, they allow you to:

• Pass a bowel movement
• Empty your bladder
• Insert a tampon or menstrual cup/disk
• Engage in penetrative sex
• Deliver a baby

When the pelvic floor muscles aren't functioning properly, it can lead to sexual, bladder, bowel, or movement dysfunction. The upshot: to stay comfortable and happy, your pelvic floor has to be in good shape.

How do you know if your pelvic floor is working properly?

One of the best ways to determine if your pelvic floor muscles are working well is to understand what normal bladder, bowel, and sexual function looks like. If something is off, it may be a signal that you have pelvic floor dysfunction. Talking to your primary care provider is typically the best first step to determine if a referral to pelvic floor physical therapy would be helpful for you.

Check in with your bladder

When it comes to urinary function, your pelvic floor is directly involved in maintaining continence (aka not leaking). The pelvic floor muscles that surround the urethra will contract to close the urethral opening so that you do not leak urine when you cough, sneeze, jump, or lift a heavy weight. They will also relax to allow your bladder to empty when it is appropriate.

Typical bladder function allows storage of around 1.5 cups of urine without discomfort, which translates to peeing every 3-4 hours during the day and a maximum of one time during the night (if at all). If a bathroom isn't available, a person should be able to hold their urine as needed without leaking. Finally, when a person does void (aka pee), they should have a strong steady stream with complete emptying and without the need to push to empty. Frequent urination with small volumes, difficulty emptying, and difficulty storing urine can all be signs of pelvic floor dysfunction.

Pay attention to your bowels

Normal bowel function relies on the pelvic floor to contract to hold in gas and stool, as well as relax to pass a bowel movement. Because diet is extremely varied, there is a wide range of what is considered normal as it relates to bowel movements.

Having anywhere from three bowel movements per day to one bowel movement every three days is considered the normal range. Bowel movement consistency is typically recommended to be soft but well formed; when looking at the Bristol Stool Form Scale, typically between 3-4 is considered "ideal." Increased urgency, straining, and incomplete emptying can all be signs of pelvic floor dysfunction.

Consider your sexual function

Sexuality is different for everyone, which makes "normal functioning" much harder to define in this area. Still, there are physiological norms that apply to almost everyone, including the ability to experience pain-free penetration and have an orgasm. Other normal physiological processes during sex include increased blood flow to the genitalia, increased lubrication within the vagina, and increased relaxation of the vaginal smooth muscle.

Changes related to these physiological processes can often lead to sexual dysfunction. While many of these processes are directly related to the function of a person's cardiovascular, reproductive, and endocrine systems, pain or difficulty experienced with vaginal penetration, deeper penetration, and orgasm can all be signs of pelvic floor dysfunction.

What is pelvic floor dysfunction?

When it comes to understanding pelvic floor dysfunction, it helps to remember that we're still talking about a muscle so there are only so many things that can be "wrong" with it.

Pelvic floor dysfunction occurs when the pelvic floor muscles:

• Have trouble contracting
• Don't fully contract
• Lack endurance
• Don't contract at the right time
• Have trouble relaxing
• Don't fully relax
• Don't relax at the right time
• Have a shortened range of motion

Pelvic floor dysfunction can also occur when certain structures that surround the pelvic floor and help support pelvic floor functions are compromised. For example, if ligaments and fascia that once held a pelvic organ in place are no longer working, then the pelvic floor muscles have to work much harder to "hold it up." Depending on the severity of the damage to those structures, the pelvic floor may not be able to compensate, and that organ may sink lower in the pelvis (otherwise known as pelvic organ prolapse).

What types of exercises relax your pelvic floor?

Diaphragmatic Breathing

This special form of breathing can encourage your pelvic floor to gently lengthen down toward your feet when you inhale. When you exhale your pelvic floor will automatically return to its current resting position. The key is to not activate or force your pelvic floor muscles to move as you breathe, instead, allow it to move naturally with your breath. This can take focus and practice.

How to do diaphragmatic breathing:

1. Find a comfortable spot and lie down on your back, with your hands on the sides of your belly, right beneath your ribs.
2. Breathe in, keeping your chest still and letting your belly expand outward and into your hands. Feel the air fill your lungs, pelvis, and back as if a balloon is inflating inside of your body. As you do this, your pelvic floor will naturally lengthen down toward your feet (you don't need to force it).
3. Exhale, releasing the air from your body and letting your belly gently move back toward your spine.

Hip Stretches

The obturator internus muscle, one of your hip rotators, shares a large fascial connection with the muscles of the pelvic floor. Performing exercises that encourage hip rotation, like the piriformis stretch shown below, can help improve mobility, flexibility, and range of motion in the pelvic floor.

How to stretch your piriformis muscle:

1. Lie on your back with your knees bent and feet flat on the ground.
2. Lift one foot and place the outside of your ankle on the opposite knee. (For a deeper stretch, clasp your hands behind the thigh of your bottom leg.)
3. Gently pull your bottom leg toward your chest, lifting its foot off the ground.
4. Hold the stretch and take deep breaths. You should feel the stretch in the outer hip of your top leg.

Tip: Keep your shoulders relaxed and away from your ears throughout the stretch.

Massage & Dilator Therapy

While not exactly exercises, both pelvic floor massage and dilator therapy are proven techniques that help relax your pelvic floor. Massaging the muscles of the pelvic floor can help reduce trigger points, alleviate pain, and promote blood flow to the area. Check out this post for a detailed guide on how to give yourself an internal pelvic floor massage.

With the guidance and support of a physical therapist, vaginal dilator therapy can improve the range of motion in the pelvic floor muscles and allow the muscles surrounding the vaginal opening to stretch more comfortably. This can help reduce any pain you might experience with vaginal penetration due to overly tight pelvic floor muscles. Learn more about how to use vaginal dilators here.

What types of exercises strengthen your pelvic floor?

The first pelvic floor strengthening exercise you're likely to think of is kegels, but they're far from your only option. To support pelvic floor contractions, you'll also want to strengthen your hips, core, and glutes.

Hip Strengthening Exercises

Activation of hip muscles has been shown to increase pelvic floor activity and further add to pelvic floor strengthening. For example, those who have undergone hip surgery have noticed improved incontinence symptoms by doing hip-strengthening exercises alone. Clamshells (shown below) are a perfect example of a pelvic floor-friendly hip-strengthening exercise.

How to do a clamshell:

1. Lie on your side with your knees bent and your bottom arm supporting your head.
2. Align your feet with your hips and shoulders, maintaining a 90-degree bend in your knees.
3. Tighten your core by drawing your belly button toward your spine to stabilize your pelvis.
4. Lift your top knee toward the ceiling while keeping your feet together. Tip: Make sure your pelvis doesn't roll back; consider having a wall behind you to prevent pelvis movement.
5. Return to the starting position by bringing your top knee back onto the bottom knee.

Tip: Feel the stretch in the muscles of your top outer hip.

Core Strengthening Exercises

The pelvic floor, transversus abdominis, rectus abdominis, and internal obliques have been found to co-contract with the pelvic floor, contributing to pelvic floor muscle activation. Bird dogs with toe taps, as shown below, are an excellent way to strengthen your entire core.

How to do bird dogs with toe taps:

1. Begin on your hands and knees, ensuring your hands are under your shoulders and your knees are under your hips.
2. Engage your core by drawing your belly button toward your spine.
3. Keep your pelvis level as you extend one leg straight behind you and reach the opposite arm straight in front, maintaining level shoulders.
4. Exhale as you return to the starting position, tapping your opposite knee with your elbow along the way.
5. Alternate arms and legs as you repeat the motion.

Tip: Keep your abs tight, gently tuck your chin, and avoid shrugging your shoulders or rotating your trunk during the exercise.

Glute Strengthening Exercises

Along with the pelvic floor, your glutes help to stabilize your pelvis in standing and moving; they will often co-contract with the pelvic floor further helping to encourage strengthening of the pelvic floor muscle group. Hip thrusts, shown below, are an easy but effective way to build glute strength.

How to do hip thrusts:

1. Sit on the floor facing a stable surface, like a couch, with your shoulder blades just above its edge. Place your feet on the floor, hip-width apart, and bend your knees at a 90-degree angle.
2. Activate your core by pulling your belly button toward your spine.
3. Lift your bottom off the floor by pushing through your toes and squeezing your glutes. Your shoulder blades will roll onto the surface, creating a straight line from your knees to your shoulders. Tip: Keep your spine aligned, moving as one unit from head to tailbone. Transition your gaze from the wall in front of you to the ceiling above you.
4. Slowly lower back down to the starting position.

Kegels

And, of course, we have kegels, which is a catch-al term for controlled pelvic floor contractions. Important tip: Before each contraction, take a few deep breaths to fully relax your pelvic floor so that you are strengthening the entire muscle group with each squeeze and lift motion.

Strengthening routines created by pelvic floor PTs usually involves a combination of high-intensity short contractions, moderate-intensity longer holds, as well as kegels incorporated with movement.

How to do a beginner kegel:

1. Sit in a chair with your feet flat on the floor and hip-width apart.
2. Inhale deeply, allowing air to fill the bottom of your lungs. Feel a gentle stretch in your lower abdomen, low back, and pelvic floor as you breathe in.
3. Exhale and perform a kegel contraction by lifting and pulling in your pelvic floor muscles. Move your belly button towards your spine.
4. Relax your pelvic floor on the next inhale.

Tip: Once you find this comfortable, practice contracting and relaxing your pelvic floor muscles while breathing normally.

What's the most effective way to do kegels?

Kegels are the foundation for building pelvic floor muscle strength and restoring function. Before you start a regimen for pelvic floor muscle exercise, it's important to learn how to do them effectively and correctly, ideally with the guidance of a pelvic floor PT. Your PT can make sure you're engaging and relaxing your pelvic floor and prescribe a kegel workout that's specific to your symptoms and goals.

Let's break down the kegel: A kegel is a pelvic floor muscle contraction, followed by a relaxation— in the same way that a bicep curl is a bicep muscle contraction that fully bends the elbow, followed by relaxation that fully straightens the elbow.

Whenever you "activate," "squeeze," "lift" or "engage" your pelvic floor, you are doing a kegel. Other common cues to encourage contraction of the pelvic floor include:

• "Squeeze as though you are trying to stop the flow of urine, midstream."
• "Imagine you are trying to lift a blueberry with your vulva."
• "Squeeze as though you are trying to bring your sit bones towards each other."
• "Squeeze as though you are trying to hold in gas."

If you feel a better contraction with holding in gas instead of holding in pee, keep in mind that the pelvic floor muscles work as a unit and fire together so you will be building strength in the entire muscle group, regardless of what cue you follow. But when you first begin doing kegels, do your best to isolate the pelvic floor from other muscles like your glutes and abdominal muscles as you squeeze and lift; this can help to improve your awareness and coordination of the pelvic floor before progressing to more advanced kegels.

Next comes the part that most people miss: In order for kegels to be effective, there must be a complete relaxation following every contraction.

Consider the bicep curl analogy. Imagine if after a curl you only relaxed your muscle enough to bring your elbow into a 90-degree angle. Your muscle will not have adequate rest between repetitions and the next curl would be less effective. The recommendation to allow for muscle recovery between contractions and strength building is a 1:1 or 1:2 contract:relax ratio (i.e. 5 second hold: 5-10 second rest). If you are doing short holds, consider still allowing a 5-10 second rest until you are more familiar with the sensation of a complete relaxation of your pelvic floor.

Pelvic floor exercises are typically initially encouraged beginning in a supine or lying down position because this position elicits the greatest relaxation and is a great position for building confidence in the ability to isolate and control these muscles. As your kegels become better coordinated and stronger, moving from lying down into an upright position to do kegels will challenge those muscles even further.

This is true because the less supported the pelvis, the more work the pelvic floor must do to support and stabilize. So greater pelvic floor muscle activation is typically seen in sitting positions compared to supine (lying down on your back), in unsupported sitting compared to supported sitting (for example, when leaning against the bak of a chair), and in standing positions compared to sitting. Finally, even more pelvic floor muscle activation happens while running as compared to walking.

Gradually progressing pelvic floor muscle exercises from lying down to standing to doing them while you move is an effective way to increase the amount of load or work given to those muscles and will effectively increase strength.

How do you know if you're doing a kegel right?

If you still aren't confident that you're doing a kegel correctly, consider using biofeedback to try to increase your pelvic floor awareness. Biofeedback is a treatment strategy that aims to give a person greater awareness of their body's physiological functions with the goal of improving control over that function. Biofeedback can take on many different forms but below are a few examples of how you may use it to improve your kegel ability.

4 Ways to Check Your Kegel

1. See a physical therapist: A pelvic floor physical therapist will work with you to build your awareness and confidence in performing kegels. Some examples of biofeedback they may include in your plan of care are squeezing and releasing your pelvic floor muscles around a finger, or contracting and relaxing your pelvic floor while wearing electrodes near your perineum and watching a number on a screen rise or fall.

2. Grab a mirror: Take a look at your pelvic floor, your perineum and your vulva and watch what happens when you contract, relax, cough and bear down. Find out if what you see happening, aligns with what you are trying to make happen. If not, keep practicing. You can even wash your hands and insert one finger to perform your own self-assessment of those muscles to gather more information and build greater awareness and understanding of your body.

3. Lift weights: Vaginal weights are shaped somewhat like a tampon and are inserted into your vagina to provide biofeedback during kegels and activity. Feeling the weight rest on your pelvic floor can be a great tool to increase your awareness and control of the area. See if you can lower the weight with a pelvic floor relaxation or push the weight out by bearing down or if you can hold the weight in by doing a kegel. Once again, keep practicing until your pelvic floor movements match up with your commands.

4. Experiment with a pelvic floor strengthening device: A device will usually include a tool that is inserted in the vagina and an app that registers your muscle activity. The app may have something like a bar on your screen that rises when you squeeze and falls when you relax. Some tools will also have a feature that causes the inserted tool to vibrate as you squeeze the pelvic floor. Both of these are forms of biofeedback, letting you know that when you engage or relax the pelvic floor. Unfortunately, these devices are not perfect: they only measure pressure changes which means if you squeeze your glutes instead of your pelvic floor or if you bear down instead of contract, you may see the bar raise and feel the tool vibrate even though you aren't actually doing a kegel.

How many kegels should you do?

Now that you know how to do a kegel, you may be wondering about how many kegels you should do and how often. There is a lot of variety when it comes to developing and recommending a pelvic floor muscle exercise program. When you work with a pelvic floor physical therapist, they can provide a protocol that is specific to your body, your needs and your goals.

For those interested in a generic guide, most research that addresses pelvic floor strengthening includes some version of the following protocol:

• High intensity kegels with 2-3 second hold and 4-6 seconds rest
• Moderate intensity kegels with 5 second hold, gradually building up to 10-20 second holds, followed by 10-20 seconds of rest
• 8-15 repetitions of each for 2-3 sets
• 3-5 times per day for up to 2-6 months
• Progress how you perform this protocol: lying down to sitting up to standing to standing with movement or walking

There are also plenty of apps now (both for free or for purchase) that can guide you through a pelvic floor protocol. They do not provide biofeedback or strategies for progression but they do provide regular notifications and reminders to do your kegels, which is sometimes the hardest part about being compliant with a pelvic floor exercise program.

When should you see a pelvic floor physical therapist?

If you have any pelvic symptoms, are pregnant, postpartum, in menopause, or simply want to strengthen your pelvic floor the way you strengthen other muscles in your body, connect with a pelvic floor physical therapist who can evaluate your pelvic floor function and guide you toward the best exercises for your body.

At Origin, we've helped thousands of women and individuals with vaginal anatomy learn about their pelvic health and feel more confident in their skin. Don't hesitate to book a visit — there's really no wrong time or reason to get started.