Pelvic floor exercises are often presented as a universal solution for bladder leakage, prolapse symptoms, and postnatal recovery. While strengthening can be important, the assumption that more pelvic floor exercises are always better is not supported by clinical practice or contemporary evidence.
In some cases, increasing pelvic floor contraction work can worsen symptoms rather than improve them. Understanding why requires a more nuanced view of how the pelvic floor functions.
The pelvic floor is not just about strength
The pelvic floor muscles need to do more than simply contract strongly. They must be able to relax fully, coordinate with breathing, and respond appropriately to changes in pressure during daily activities such as walking, lifting, coughing, and exercise.
A muscle that is constantly held “on” may be functionally ineffective. This is often described as a high-tone or overactive pelvic floor, where resting muscle tension is elevated and relaxation is incomplete.
The overactive pelvic floor
Women with an overactive pelvic floor may present with a wide range of symptoms, many of which are not immediately recognised as pelvic floor related. These can include:
- Difficulty starting urination or feeling unable to fully empty the bladder
- Urinary urgency or frequency without clear bladder pathology
- Pain with intercourse, tampon use, or internal examinations
- Pelvic pain, tailbone pain, or deep hip discomfort
- Constipation, straining, or a sensation of incomplete bowel emptying
- Worsening bladder leakage despite diligent pelvic floor exercises
- A feeling of pelvic “tightness,” heaviness, or inability to let go
Importantly, some women with high pelvic floor tone also experience stress urinary incontinence.
Why strengthening alone can miss the problem
Traditional pelvic floor advice often focuses on repeated contractions. However, coordination, endurance, and relaxation capacity are just as important as strength.
For women with high tone, early rehabilitation often prioritises:
- Improving awareness of resting tension and “letting go” of the pelvic floor
- Restoring full relaxation between contractions
- Addressing breathing and pressure management
- Optimising bowel habits and toileting mechanics
- Reducing guarding driven by pain, stress or previous symptoms
Only once resting tone and coordination improve does targeted strengthening become effective.
A more individualised approach
This does not mean pelvic floor exercises are “wrong.” Rather, they must be prescribed appropriately and progressed in the right context. Some women need strengthening, some need down-training, and many need a combination of both over time.
Assessment by a Secret Women’s Business Physiotherapist allows for identification of:
- Resting muscle tone
- Coordination and timing
- Response to load and fatigue
- The influence of breathing, posture, and bowel function
From there, treatment can be tailored to the individual pelvic floor.
If you have been diligently doing pelvic floor exercises and your symptoms are not improving, or are worsening, the answer may not be to do more. Sometimes, progress starts not with squeezing harder, but with learning how to let go.
