Why Strengthening Might Not Be What Your Pelvic Floor Needs
The leakage itself wasn’t the biggest problem. The biggest problem was how much space it was taking up in her mind.
A woman came to see me recently because she was worried about her bladder. She had started wearing a pad when she went out “just in case”. If she laughed too hard, sneezed unexpectedly or bent down to pick something up. She worried she might leak a little. The amount wasn’t large, but it was enough to make her think twice before ordering another coffee or accepting another glass of wine when she was out with friends.
She also found herself going to the loo “just in case” before leaving the house, even when she didn’t really need to go. If she knew she would be out for a few hours, it felt safer that way. None of these things were dramatic on their own, but together they occupied more of her thoughts than she wanted them to.
When I asked her what she was hoping to get out of physiotherapy, she didn’t hesitate.
“I think I just need some pelvic floor strengthening exercises.”
Or, to put it another way:
“I think I need Kegels.”
It’s one of the most common assumptions I hear in clinic, and it’s completely understandable. For years, women have been told that if they leak urine, if they have had a baby, or if something doesn’t feel quite right, they should simply strengthen their pelvic floor. The message is everywhere, and on the surface it sounds logical: if something isn’t working properly, surely it just needs to be stronger.
What If the Problem Isn’t Weakness?
It was a perfectly reasonable assumption. After all, if a muscle isn’t doing its job properly, surely it needs to become stronger. Yet one of the things that surprises many women is that pelvic floor symptoms are not always caused by weakness.
During a pelvic health assessment, I often explain that a muscle can struggle for two very different reasons. It may not be strong enough to generate force when it is needed. Equally, it may be working so hard, for so long, that it no longer functions efficiently. In both cases, the symptoms can look remarkably similar. A woman may experience urgency, leakage, or a feeling that she cannot fully trust her bladder, yet the underlying problem may be completely different.
The way I often explain it is by comparing the pelvic floor to any other muscle in the body. Imagine carrying heavy shopping bags all day. Even if your arm is strong, there comes a point when the muscles become tired and stop performing efficiently. The pelvic floor is no different. A muscle that is constantly gripping, bracing or holding tension can become fatigued over time. Sometimes the problem isn’t that the muscle cannot contract. Sometimes the problem is that it no longer knows how to relax.
This is one of the reasons assessment matters. Symptoms alone do not always tell us whether a pelvic floor is weak, overactive, or a combination of both. While an internal pelvic health examination is never mandatory and is always performed with informed consent, it can provide valuable information about how the muscles are functioning and help guide treatment more accurately. Before we decide what the pelvic floor needs, we first need to understand what it is doing.
The Pelvic Floor Doesn’t Work Alone
This is where breathing becomes such an important part of rehabilitation. The diaphragm and the pelvic floor are designed to move together. As we breathe in, the diaphragm gently descends and the pelvic floor lengthens and relaxes beneath it. As we breathe out, both structures naturally recoil.
It is a beautifully coordinated system, yet many women have never been taught how it works. In clinic, I often find that women instinctively tighten when I ask them to breathe in. Some grip their abdominals, others hold their breath, and many have difficulty recognising when their pelvic floor is relaxed at all.
For this reason, one of the most valuable things we can do is not necessarily to strengthen first, but to restore awareness. Before we can improve the function of any muscle, we need to understand how it behaves. Can it relax? Can it move? Can it respond appropriately to the demands placed upon it? Strength is important, but strength without coordination is rarely the full answer.
Why So Many Women Struggle to Relax
This is something I see frequently, particularly in women who are juggling multiple responsibilities. Modern life asks a lot of us. We work, we care for our families, we manage households, we respond to messages, we organise appointments, and somewhere in the middle of all of that we are expected to look after ourselves as well.
Many women spend so much time focusing on what needs to happen next that they gradually lose touch with what is happening in their own bodies. They become experts at coping, but less aware of the tension they carry every day.
This is particularly true during the postnatal period. Becoming a mother is one of the most profound transitions a woman can experience. Alongside the physical recovery from pregnancy and birth comes sleep deprivation, changes in identity, concerns about feeding, worries about whether the baby is developing well. As well as the enormous responsibility of caring for a tiny human being who depends entirely on you.
It is hardly surprising that many women spend months, or even years, living in a state of heightened tension without ever realising it. If the body spends long periods bracing, guarding and preparing for the next demand, the pelvic floor often reflects that tension.
Sometimes one of the most important things I teach in a women’s health appointment isn’t how to contract the pelvic floor.
It’s how to relax it.
How to feel it.
How to trust it again.
More Than Just Strength
Perhaps that is why I feel so strongly about women’s health assessments. They are not simply about checking for prolapse, measuring pelvic floor strength, or addressing leakage. They are an opportunity for women to reconnect with their bodies; to ask questions, and better understand what they are experiencing.
Sometimes the outcome is a strengthening programme. Sometimes it is learning how to let go of unnecessary tension. More often than not, it is a combination of both.
A healthy pelvic floor is not simply a strong pelvic floor. It is a pelvic floor that can contract when needed, relax when appropriate, and work in harmony with the rest of the body. Before we decide what it needs, we first need to understand what it is doing.
So, to Kegel or not to Kegel?
The answer is that it depends.
And often, the first step is not squeezing harder, but learning to breathe, move, and reconnect with your body.
Book your Women’s Health Assessment with Giuliana here!
