Beginner's guide to pelvic floor physical therapy

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Dr. Kelly Sadauckas has specialized in Pelvic Health for over 15 years since graduating with honors from Marquette University's esteemed Doctor of Physical Therapy Program. Her current project, Pelvic Floored, involves an upcoming print book and online video series that aims to reduce financial, geographic and psychosocial barriers to access to pelvic health physical therapy care.

You can learn more about Dr. Sadaukas and her work here.

Physical Therapists are specialists in the musculoskeletal system—how the muscles and bones of our body work together to allow us to function in our daily lives with strength and without pain. Pelvic Floor Physical Therapists have undergone significant additional training in how to assess and treat the specific muscles of the pelvic region, in order to assist in your recovery from injury, childbirth, or sometimes, just to connect you to these groups for the first time in your life! The success rate of pelvic floor PT for conditions like incontinence, pelvic organ prolapse, and back injuries rivals that of surgery, with considerably less cost and minimal potential side effects. The pelvic floor muscles are a hammock of amazing muscles at the bottom of our pelvis. They have tons of different functions, but primarily those functions are:

• Sphincteric: control things going in or out when we want them to
• Supportive: support weight of our abdominal fat and organs
• Sexual: the fun parts, as well as the harder parts like birthing

The pelvic muscles are unique. Just like we have a left arm and a right arm, we have a left pelvic floor and a right pelvic floor. And it’s not just one muscle—in fact, there are more than six per side on the outer layers alone!

The muscles, which start about 1 knuckle width deep in the vaginal or rectal vaults, at rest ought to feel like a little donut, ‘resting’ in a more elongated position than a contracted one, near the bottom quarter of their available range, and feel soft and springy, like a trampoline. They do hold some amount of normal resting tension with daily activities, just like your other postural muscles…too much or too little resting tension is problematic, so if the muscles feel like a solid brick wall, or like a bruise on an apple or pear, you have some work to do.

When you breathe in a relaxed fashion, with each inhale, they should passively elongate and drop down towards your heels a bit, and with each exhale, they should passively rebound up and into the resting position. When we forcefully breathe, they assist with exhalation. With powerful activities, they contract to aid in stabilizing our pelvis and low back.

When you “kegel” in the traditional sense of the word, it is like “you are stopping the flow of urine” if you have female anatomy, “lifting the twigs and berries out of cold water” if you have male anatomy, or “lifting up the rectum” if you have either anatomy. The resting donut of pelvic floor muscles, constrict and lifts up towards the belly button, ideally with equal contraction contribution from left and right sides, and front and back muscles. They ought to remain there as long as you tell them to, then when you relax, the muscles should return to their usual resting state, about 75% elongated and nicely springy.

And that’s just half the battle. From this resting position, there is a SECOND contraction the pelvic muscles can do—it’s called ‘Bearing Down’ and is an eccentric (contracting while elongating) contraction. From the resting position, you GENTLY push down with JUST YOUR BIKE SEAT, while your tummy is relaxed. The bike seat muscles elongate to the bottom, or longest part of their range. They are now 100% lengthened. Regardless of female or male anatomy, your cue is that your rectum is now long and low, and you maintain this contraction for 3-5 seconds. Then you relax again, but this time, ‘relaxation’ is a passive tightening-lifting that brings the pelvic floor back ‘up’ to its proper resting position .

Phew. Crazy huh? That’s why this training is so important. As a licensed pelvic floor physical therapist, I can verbally cue you to the best of my ability, and will be studying the effects of better cues in the near future, but nothing can replace having hands on these parts of your body to tell you if you’re doing them correctly or not. But if you want to tackle these exercises at home, try these exercises as a start, preferably with one hand on your lower abdomen and one hand touching your bike seat parts, to get a better sense of what’s happening down there. If you are having urgency or leakage or overactive pelvic floor muscles, practice bearing down many times a day, as it is likely that pelvic floor muscle hypertonicity is contributing. There is also additional "uptraining" of the abs and butt that is vital here, but that should be addressed with the help of a licensed pelvic floor therapist.

Relaxed (Diaphragmatic) Breathing:

In a comfortable position, RELAX your core and breathe. In this relaxed breathing, your diaphragm will contract down into your belly, your belly and pelvic floor should passively expand outwards with each inhale, then passively rebound back in and up on the exhale. There should be minimal to no movement in the chest here, and the neck should be relaxed. Often after injury, we lose this, and the pelvic floor specifically, becomes stiff and rigid, and doesn’t move like it should in relaxed breathing.

Stiff isn’t strong, and we need to reconnect the brain to the pelvic floor, so with your next inhale, tune in to your bike seat: does it passively press down into your seated surface (or down towards your heels if you are laying down) with each inhale? Does it rebound back up, passively, with each exhale? Take 5-10 breaths to tune in to this. This is how your body ought to breathe as you sleep and rest.

Supported Exhale

Now that we’ve reminded your brain that the diaphragm is for relaxed breathing, let’s teach the brain that the abs are for stabilizing your lumbar spine, not breathing. When your brain doesn’t understand this, you end up holding your breath when you exercise, which isn’t good. In this exercise, you inhale with a relaxed belly and pelvic floor, then as you exhale, you gently draw in your lower abdomen (near belt line) like you are trying to pull your belly button in towards your spine, or zip into a tight pair of pants. Your pelvic floor should be relaxed here. You tighten the lower tummy as though you are pushing the air out of your lungs gently, then relax it as you inhale again. Do this 5-10x, keeping your neck and your pelvic floor relaxed.

Here’s the money maker. Appropriately doing kegels is one of the hardest things anyone could ever do, which is also why they get a bad rep.

When kegels ‘don’t work’ for individuals, it is usually because they are missing EVERYTHING except the up and in contraction, which is only a small piece of the pie. The bigger piece is ensuring that the muscles of the abdomen and pelvic floor and hips can activate independently of each other, as well as together, as well as ensuring that the abdomen or gluteals can remain engaged while the pelvic floor relaxes. I just blew your mind, didn’t I? I know. Happens every day.

So, after you’ve mastered exercises 1 and 2 above, you are ready to try a Kegel. Put one hand on your lower abdomen and one hand on your bike seat parts, please. Or, if you’re sitting, sit on a towel, or the edge of a sofa.

1. Gently tighten the lowest abdominal muscles, so that your belly button comes close to your spine. This takes the weight of the organs off your pelvic floor. You should still be able to breathe here. If you can’t, stay with the above 2 exercises until you can do this while still breathing. Your pelvic floor should not have moved here at all.
2. To this abdominal brace, add a Kegel contraction, picturing the muscles that lay between your sit bones, and contract them, and only them, to pull your sit bones together underneath you. The muscles pull your pubic bone towards your tail bone, and lift your bike seat parts up and away from whatever your sitting on….but the butt shouldn’t move…the head shouldn’t bob. There should be ZERO physical evidence that you are kegeling, if you do it well. The only physical evidence is that if you have a finger inserted in your vagina or rectum, that you feel those muscles tighten like a donut and attempt to pull your finger inwards. You’re still breathing. You hold this contraction for 3-5 seconds.
3. Then you MAINTAIN your deep ab contraction, and relax your pelvic floor back to the starting point. This is hard. Many of you will say, ‘nope’, not happening. Do your best to try to keep abs engaged and relax your pelvic muscles….try for 5-10 seconds.
4. Then relax your abs. Were you accidentally holding some tension in your pelvic floor along with your abs? Welcome to the club. Many individuals with pelvic complaints have this ‘dissociation deficit’ where they cannot relax the pelvic floor muscles independently once they fire with abs or glutes. This is a huge contributor to your functional limitations.
5. From this resting position, now elongate the pelvic floor and Bear Down, pressing down NOT with the belly, but just with your bike seat parts. Hold this for 3-5 seconds, then ‘relax’ and notice the muscle passively return to their resting contraction level (which, in this case is a slight tightening).

Told you that was hard! I love what I do, and I hope you are able to get some help from this post. If you need more help, though, please don’t be afraid to reach out to a pelvic floor PT in your area, or check out my website. You are not alone, and you are not permanently broken.