Jandra Mueller, DPT, MS earned her Doctorate in Physical Therapy in 2012 and has been involved in treating pelvic health conditions for the past eight years. She is currently the clinic director for The Pelvic Health and Rehabilitation Center in Enc… — Jandra Mueller, DPT, MS earned her Doctorate in Physical Therapy in 2012 and has been involved in treating pelvic health conditions for the past eight years. She is currently the clinic director for The Pelvic Health and Rehabilitation Center in Encinitas, CA. She recently completed her Master’s of Science in Integrative Health and Nutrition with a focus on Human Clinical Nutrition from Maryland University of Integrative Health (MUIH) and focuses on a holistic approach in managing both women and men with chronic pelvic pain conditions as well as general pelvic health. Jandra has presented to various audiences on pelvic health and is involved in both teaching and developing courses for Alcove Education and The Pelvic Health and Rehabilitation Center. She has also been published as a co-author in a case study in *Physical Therapy Case Files: Orthopedics* and author of a case study in the journal *Practical Pain Management.*

A much anticipated topic here on the blog and I am honored to have Jandra here to answer your top 9 questions about the pelvic floor. Jandra is currently the clinic director for The Pelvic Health and Rehabilitation center in Encinitas, CA. Shout out to my good friend Liz K’Mali, who connected us and speaks so highly of the work Jandra does.

She is sharing her knowledge to help you better understand your pelvic floor —everything from kegels and incontinence, to orgasms and sexual health, to pelvic prolapse and perineal stretching. Be sure to leave a comment or send her a message if you have any questions or want to set up an appointment for pelvic floor physical therapy!

“Leaking urine is NEVER normal. Painful sex is NEVER normal. This is important because it is so normalized in the post partum population because it is so COMMON.”

— Jandra Mueller, DPT, MS

What exactly is my pelvic floor and why is it important to my health?

Your pelvic floor is a group of muscles at the base of your pelvis. They play many important roles in the body including support for the pelvic organs, core support (they are part of your deep core muscles), bowel and bladder health, and of course sexual appreciation.

Your core muscles are going to be what help to keep you upright, support your lower back during lifting, pushing, and pulling and overall postural support in sitting and standing. When the core does not function properly, this may result in low back pain, alignment issues, weakness, etc. The pelvic floor muscles are at the base and they include our sphincter muscles which help us not to leak urine or feces when it is not appropriate. These connections begin to develop as we are potty trained. In those with uterus’, these muscles support the bladder, urethra, uterus, and colon, and in those without, the prostate and the colon. Yes, men have pelvic floor muscles too! They also play a role in sexual function and appreciation. They help to provide support to your organs so penetrative sex (including digital penetration if you do not participate in penile penetrative sex). They have connections to the clitoris to help with stimulation and stimulate glands to produce lubrication. They also contract and relax to help with orgasm, which is of course one of the best benefits of sex!

2. Why should I exercise my pelvic floor?

Exercising your pelvic floor can mean many things. For some, it may mean kegels, but not for everyone! In those that have had babies, this may be an important exercise for you to help maintain the proper support after your pregnancy and delivery, even if you haven’t had a vaginal delivery. Vaginal delivery is the most important risk factor for developing prolapse. Prolapse is where there is not enough muscular or fascial support for the pelvic organs and these start to drop down and can cause heaviness, pain, urinary leakage and bowel issues.

Just like any muscle in your body, exercise is good to keep these muscles healthy and have good blood flow so that they can do their job! Doing kegels, or pelvic floor contractions is only one part though. It is important to also know how to relax your pelvic floor from a tensed position, as well as bulge or lengthen your pelvic floor muscles like when you have a baby or have bowel movements. When there is an issue with any one of those issues, it can result in dysfunction and/or pain.

These muscles are a bit unique in the sense that while we have voluntary control over them, there is some degree of tone there automatically. This is important to hold our pee so that we aren’t constantly dribbling urine. But this is where we have control, we need to be able to hold our pee when we aren’t near a bathroom, we have that ability to then tighten our muscles when we feel that urge so that we don’t have an accident.

There are two categories of conditions I see, low tone disorders where there is not enough tone, and high tone disorders where there is too much and we cannot relax them. Both cause dysfunction and sometimes those dysfunctions overlap, this can be in the case of urine leakage. Our muscles can become ‘weakened’ even if they are too tight and this can result in that little bit of dribble when we get that really bad urge to pee. Those with high-tone disorders should be evaluated by a pelvic floor PT to understand which exercises are appropriate - kegels are DEFINITELY not the answer in this case.

3. What can you do during pregnancy and postpartum to maintain healthy pelvic floor muscles?

The number one thing is to seek out help from a pelvic floor PT (PFPT). I cannot stress enough how important it is to have a proper evaluation so that you aren’t that person that is told to do Kegels and you unknowingly have a high tone pelvic floor and then develop problems. I see this ALL the time. If you don’t have access to a PFPT, there are many resources online and many people doing digital health sessions, thankfully more companies are providing this now due to the pandemic (one good thing that has come from this situation!)

Besides seeking individualized care from a PFPT, there is more than just kegels to work your pelvic floor muscles, remember they are part of the core. Maintaining healthy core strength and doing exercises like planks and even just having good sitting posture help to ‘turn on’ your muscles. This is true for when you do regular exercise like squats, lunges, lifting, pushing, pulling. Anytime you use your core, those muscles fire (or should fire).

Deep breathing exercises. The pelvic floor functions with the diaphragm and when you take a nice deep belly breath this allows the pelvic floor to lengthen and expand and helps with good blood flow and lymphatic drainage and circulation through the pelvic floor. It also helps to relax those muscles if you’ve been clenching them because of habit, stress, etc.

In those ready to give birth, perineal stretching with either your fingers or a dilator can be part of your preparation in the last 4-6 weeks prior to delivery. This helps you to become more connected with this part of your body, helps to bring blood flow, and may have benefits with reduced tearing during vaginal delivery.

During the postpartum period, again, an evaluation with a pelvic floor PT is so important! In other countries, like France, this is standard of care. In the US, ACOG released a statement a few years back also endorsing this, but it really hasn’t become part of the process yet. This is true even if you feel that nothing is wrong. Pelvic PTs can help identify if you have a diastasis recti (where your ab muscles separate), screen you for prolapse, work on scar tissue from tearing, and help to identify any hormonal deficiencies in your tissue which may cause painful or unpleasureable sex.

4. What causes weakened pelvic floor muscles?

Many things can cause issues with the pelvic floor. Trauma is a big one, this includes vaginal delivery. Trauma can also mean a fall from a bike, a car accident, surgery, and sexual trauma. Weakened core muscles can also be a big one, you may begin to rely more heavily on your pelvic floor for support if your abdominals are weak. Too much intra-abdominal pressure, like when you strain to have a bowel movement or suffer from constipation, or if you are lifting heavier weight than your body can handle. You may also have weakened pelvic floor muscles from your muscles being too tight like I mentioned above. There may be no known cause for this, but stress and clenching, which may also have resulted from some sort of trauma can cause your muscles to not function properly. This may not show up as true weakness, but more of a lack of coordination and inability to properly use your muscles. Hormones are another cause and we often see this in our elderly population. We need hormones for those muscles to work properly and stay healthy. Birth control pills, Accutane, and spironolactone (an acne medication) can also cause issues related to hormone depletion and can change your vulvar tissues and ultimately affect your pelvic floor. THIS. IS. IMPORTANT. How many of you are on, or have been on birth control or you have friends that are on birth control. Some people do fine, but this is one of the main issues I see in the patients I treat!

5. How do I strengthen my pelvic floor?

If you have true weakness, kegels, or pelvic floor contractions may be appropriate along with other exercises like core strengthening exercises. I tend to avoid giving crunches, and sit ups as many of us do them poorly and don’t have the right activation of the muscles and actually end up straining them. If you are someone that suffers from high tone, then learning relaxation exercises will help you to have strong healthy muscles again.

6. How do I know if I need postpartum pelvic floor physical therapy?

Everyone needs postpartum physical therapy. It may mean just one visit to see where you are at and get some education of what to work on or look for. Or it may mean many sessions to address specific symptoms like urinary or fecal incontinence (leakage), pelvic pain, core weakness, and prolapse issues. Leaking urine is NEVER normal. Painful sex is NEVER normal. This is important because it is so normalized in the post partum population because it is so COMMON. Yes, sometimes it is transient and goes away on its own, but not everyone has these issues postpartum and it is an indication something is not right.

7. I had a c-section, do I need to worry about my pelvic floor?

Absolutely! Although vaginal delivery is a major risk factor for prolapse, carrying a child for nine months is no easy feat! Additionally, you now have a decent size scar on your abdomen that can also cause issues like poor muscle contraction, scar tissue, and pain and pelvic floor PTs are excellent at scar tissue mobilization! Your body changed dramatically during that nine months, and maybe you didn’t plan to have a c-section and you still pushed for hours, that can also have an impact on your pelvic floor health.

8. I’m not pregnant yet, should I start pelvic floor exercises now?

Not necessarily. Remember, not everyone needs to do kegels. If you do basic exercises and you are not leaking urine or have pelvic pain it may not be necessary. It is a good idea to get checked if you are worried about your pelvic floor prior to pregnancy because you have a history of pelvic floor issues. Typically I recommend seeing a pelvic floor PT during your pregnancy, after the first trimester, even if you aren’t having issues so that you can be proactive and address any findings that may put you at risk, and understand what you may need to do during pregnancy and to know what to expect in the postpartum period.

9. How to exercise your pelvic floor properly

It is tricky to know if you have high-tone pelvic floor vs. low tone pelvic floor muscles, so specific exercises are tricky to generally give. If you have not been pregnant or delivered a baby and you are experiencing urinary leakage, bladder pain, urgency, sexual pain, it is likely that you fall more into the high tone category and really should not start to do kegels before seeing a pelvic floor PT because the symptoms may worsen. If you are post-menopausal, have had a baby or are pregnant, you may more likely fall into the low-tone category and need to do kegels. But this still should be something you should be shown how to do properly. There are different ways to do them, and it has been shown in research that the majority of those verbally told to do kegels, do them wrong.