Your stomach isn’t the only body part that stretches.
By Cassie Shortsleeve, SELF
If you’re pregnant, you might feel like people are constantly telling you how much the entire experience is going to suck or hurt or change your body forever. Or maybe people aren’t telling you that all the time, but you can’t imagine how that wouldn’t be the result.
It’s true that pregnancy and childbirth can bring about some major physical changes. The focus is often on external ones (ahem, a growing belly). But one of the biggest pregnancy and childbirth changes impacts an area that’s impossible to see from the outside: the pelvic floor. We won’t lie to you, pregnancy and childbirth can definitely do a number on this area. But for some people, a little thing called pelvic floor physical therapy may be able to help.
Here’s the truth about pregnancy, childbirth, your pelvic floor, and pelvic floor physical therapy.
If you’re pregnant, you might feel like people are constantly telling you how much the entire experience is going to suck or hurt or change your body forever. Or maybe people aren’t telling you that all the time, but you can’t imagine how that wouldn’t be the result.
It’s true that pregnancy and childbirth can bring about some major physical changes. The focus is often on external ones (ahem, a growing belly). But one of the biggest pregnancy and childbirth changes impacts an area that’s impossible to see from the outside: the pelvic floor. We won’t lie to you, pregnancy and childbirth can definitely do a number on this area. But for some people, a little thing called pelvic floor physical therapy may be able to help.
Here’s the truth about pregnancy, childbirth, your pelvic floor, and pelvic floor physical therapy.
Your pelvic floor anatomy
We can’t blame you if you’re like, “Excuse me, the anatomy of my what, now?” In general, people don’t talk about pelvic floors often, even in pregnancy and childbirth conversations.
“The pelvic floor is essentially a group of muscles integrated together to create a support structure for the intra-abdominal organs,” Angela Bianco, M.D., a maternal-fetal medicine specialist and associate professor of obstetrics, gynecology, and reproductive services at the Icahn School of Medicine at Mount Sinai, tells SELF.
These muscles work like a hammock to brace organs such as the uterus, bladder, and rectum. In doing so, the pelvic floor promotes healthy bowel and bladder control along with comfort during things like penetrative sex. If something goes wrong with your pelvic floor, it can mess with your ability to pee or poop normally, with your sex life, and with your general function in that region.
“The pelvic floor is essentially a group of muscles integrated together to create a support structure for the intra-abdominal organs,” Angela Bianco, M.D., a maternal-fetal medicine specialist and associate professor of obstetrics, gynecology, and reproductive services at the Icahn School of Medicine at Mount Sinai, tells SELF.
These muscles work like a hammock to brace organs such as the uterus, bladder, and rectum. In doing so, the pelvic floor promotes healthy bowel and bladder control along with comfort during things like penetrative sex. If something goes wrong with your pelvic floor, it can mess with your ability to pee or poop normally, with your sex life, and with your general function in that region.
Symptoms of pelvic floor dysfunction
Among other causes, pregnancy and childbirth can lead to pelvic floor dysfunction, the broader term for a collection of conditions known as pelvic floor disorders. Pelvic floor disorders crop up when muscles or connective tissues of your pelvic area weaken or are injured, according to the National Institutes of Health.
Urinary incontinence (when pee dribbles out of you during everyday activities such as walking, laughing, or coughing) is a common pelvic floor disorder, according to the Mayo Clinic. Then there’s fecal incontinence, or leaking stool. Pelvic floor dysfunction can also manifest as difficulty fully emptying your bladder (this is known as urinary retention) or rectum (the rudeness that is constipation). Or you could experience painful sex as a sign of pelvic floor problems.
Severe pelvic floor dysfunction can even lead to pelvic organ prolapse, which is when structures such as the bladder droop and press into or out of the vagina. In this case, you might see a bulge protruding from your vagina, feel like something is coming out of there, or notice an aching or “full” feeling, according to the American College of Obstetricians and Gynecologists (ACOG). Pelvic organ prolapse can also lead to those pee, poop, and sexual health problems we mentioned above.
So, how exactly can pregnancy and childbirth bring about pelvic floor dysfunction? Let’s get to it.
Urinary incontinence (when pee dribbles out of you during everyday activities such as walking, laughing, or coughing) is a common pelvic floor disorder, according to the Mayo Clinic. Then there’s fecal incontinence, or leaking stool. Pelvic floor dysfunction can also manifest as difficulty fully emptying your bladder (this is known as urinary retention) or rectum (the rudeness that is constipation). Or you could experience painful sex as a sign of pelvic floor problems.
Severe pelvic floor dysfunction can even lead to pelvic organ prolapse, which is when structures such as the bladder droop and press into or out of the vagina. In this case, you might see a bulge protruding from your vagina, feel like something is coming out of there, or notice an aching or “full” feeling, according to the American College of Obstetricians and Gynecologists (ACOG). Pelvic organ prolapse can also lead to those pee, poop, and sexual health problems we mentioned above.
So, how exactly can pregnancy and childbirth bring about pelvic floor dysfunction? Let’s get to it.
Pregnancy and your pelvic floor
Being pregnant can loosen up the muscles and connective tissues such as ligaments that need to work well for good pelvic floor function. (Ligaments are a type of tissue that helps organs stay put.)
This loosening effect is thanks to hormones that increase when you have a baby on the way, like progesterone, estrogen, and one literally called relaxin. “These hormones can act to soften the ligaments so that the muscles may not be as tightly interconnected together,” says Dr. Bianco. The point of this loosening is to eventually allow a baby to pass through the birth canal more easily.
Then there’s that growing belly part. As your uterus expands and you gain weight, more pressure bears down on your pelvic floor, which can contribute to a loss of support, Dr. Bianco says.
This loosening effect is thanks to hormones that increase when you have a baby on the way, like progesterone, estrogen, and one literally called relaxin. “These hormones can act to soften the ligaments so that the muscles may not be as tightly interconnected together,” says Dr. Bianco. The point of this loosening is to eventually allow a baby to pass through the birth canal more easily.
Then there’s that growing belly part. As your uterus expands and you gain weight, more pressure bears down on your pelvic floor, which can contribute to a loss of support, Dr. Bianco says.
Childbirth and your pelvic floor
As you’ve probably surmised, birthing a baby vaginally can definitely impact your pelvic floor. To sum it up: “You have a giant head going through a small vagina,” Lisa Dabney, M.D., director of urogynecology and pelvic reconstructive surgery in the department of obstetrics and gynecology at Mount Sinai, tells SELF.
Of course, the rest of the baby’s body passes through too. But, typically, the head will go first. In the process, pelvic floor muscles get shoved out of the way and sometimes tear. While doctors can usually repair such lacerations with surgery when necessary, it will take some time for your pelvic floor to recover (and sometimes it’s just a bit different forever). There may also be damage to the nerves that govern pelvic floor muscles and organs.
All of this can lead to postpartum issues like pain during sex, urinary or fecal retention, and urinary or fecal incontinence. (According to ACOG, childbirth is actually the most common cause of fecal incontinence.) Having a heavy baby who weighs more than 9 or 10 pounds may increase the risk of these problems, Roger Lefevre, M.D., director of Beth Israel Deaconess Medical Center’s female pelvic medicine and reconstructive surgery division, tells SELF.
You might be wondering about how having a cesarean section (C-section) would influence your odds of winding up with pelvic floor dysfunction. Having a C-section does appear to be linked with a significantly lower risk of pelvic floor disorders, but it doesn’t mitigate this risk entirely because you still have all of the factors from the pregnancy itself, Dr. Bianco explains. A C-section is still a major abdominal surgery that comes with its own intense healing process even if it doesn’t harm your pelvic floor in any big way.
Of course, the rest of the baby’s body passes through too. But, typically, the head will go first. In the process, pelvic floor muscles get shoved out of the way and sometimes tear. While doctors can usually repair such lacerations with surgery when necessary, it will take some time for your pelvic floor to recover (and sometimes it’s just a bit different forever). There may also be damage to the nerves that govern pelvic floor muscles and organs.
All of this can lead to postpartum issues like pain during sex, urinary or fecal retention, and urinary or fecal incontinence. (According to ACOG, childbirth is actually the most common cause of fecal incontinence.) Having a heavy baby who weighs more than 9 or 10 pounds may increase the risk of these problems, Roger Lefevre, M.D., director of Beth Israel Deaconess Medical Center’s female pelvic medicine and reconstructive surgery division, tells SELF.
You might be wondering about how having a cesarean section (C-section) would influence your odds of winding up with pelvic floor dysfunction. Having a C-section does appear to be linked with a significantly lower risk of pelvic floor disorders, but it doesn’t mitigate this risk entirely because you still have all of the factors from the pregnancy itself, Dr. Bianco explains. A C-section is still a major abdominal surgery that comes with its own intense healing process even if it doesn’t harm your pelvic floor in any big way.
When to check in with a doctor
The advice on when to talk to your doctor about your pelvic floor can change a bit depending on if you’re pregnant or postpartum.
If you’re pregnant: Routine pregnancy check-ups are a great time to discuss how your pelvic floor seems to be functioning. It might help to ask your doctor exactly what kinds of pregnancy and postpartum pelvic floor symptoms you should expect. That way, you’ll have a more personalized framework for when to get in touch with your doctor about any concerns.
If you’re postpartum: ACOG recommends having at least one comprehensive check-up four to six weeks after giving birth. (Ideally, that would be the start of a consistent, ongoing postpartum care relationship between you and your doctor, not just a one-time visit, ACOG says.) That’s the perfect opportunity to tell your doctor how things are feeling, ask if your pelvic floor function seems on track, and ask when to let them know if your symptoms are still persisting.
Honestly, it can be pretty confusing to know what’s normal when it comes to your postpartum pelvic floor situation, especially if you’re mainly dealing with urinary incontinence. A little bit of transient urinary incontinence when you’re postpartum is very common, Dr. Bianco says. Once your body is no longer exposed to the added weight of a baby in utero and that muscle-loosening hormone cocktail, pelvic issues usually improve, Dr. Bianco explains.
This can take anywhere from a few days to a few weeks or months, or longer than that for some people, Tanaka J. Dune, M.D., a urogynecologist at Weill Cornell Medicine and NewYork-Presbyterian Hospital, tells SELF. “I try to reassure postpartum women about the changes that can occur and not to fret if recovery is not right away,” Dr. Dune says. If you’re still having symptoms related to pelvic floor dysfunction 12 weeks after giving birth, check in with your doctor.
Whether you’re pregnant or postpartum: See your doctor whenever you’re really concerned that something you’re experiencing isn’t normal. We know that seeing a doctor is much easier for some people than it is for others and that so many factors can lower the odds of receiving compassionate, competent health care. This is especially true when it comes to people with vaginas, and even more so if you belong to multiple marginalized groups, like being a woman of color with a low income. While this is an unfortunate and frustrating reality, the important thing to keep in mind is that you deserve competent, empathetic care if something is off. We're about to go into some treatment options for pelvic floor disorders, and we know they may not be accessible for all. If these don't seem doable for you, know that getting care wherever and whenever you can is still better than nothing. This is one of those situations when it makes sense to seek the most trustworthy medical advice you can.
If you’re pregnant: Routine pregnancy check-ups are a great time to discuss how your pelvic floor seems to be functioning. It might help to ask your doctor exactly what kinds of pregnancy and postpartum pelvic floor symptoms you should expect. That way, you’ll have a more personalized framework for when to get in touch with your doctor about any concerns.
If you’re postpartum: ACOG recommends having at least one comprehensive check-up four to six weeks after giving birth. (Ideally, that would be the start of a consistent, ongoing postpartum care relationship between you and your doctor, not just a one-time visit, ACOG says.) That’s the perfect opportunity to tell your doctor how things are feeling, ask if your pelvic floor function seems on track, and ask when to let them know if your symptoms are still persisting.
Honestly, it can be pretty confusing to know what’s normal when it comes to your postpartum pelvic floor situation, especially if you’re mainly dealing with urinary incontinence. A little bit of transient urinary incontinence when you’re postpartum is very common, Dr. Bianco says. Once your body is no longer exposed to the added weight of a baby in utero and that muscle-loosening hormone cocktail, pelvic issues usually improve, Dr. Bianco explains.
This can take anywhere from a few days to a few weeks or months, or longer than that for some people, Tanaka J. Dune, M.D., a urogynecologist at Weill Cornell Medicine and NewYork-Presbyterian Hospital, tells SELF. “I try to reassure postpartum women about the changes that can occur and not to fret if recovery is not right away,” Dr. Dune says. If you’re still having symptoms related to pelvic floor dysfunction 12 weeks after giving birth, check in with your doctor.
Whether you’re pregnant or postpartum: See your doctor whenever you’re really concerned that something you’re experiencing isn’t normal. We know that seeing a doctor is much easier for some people than it is for others and that so many factors can lower the odds of receiving compassionate, competent health care. This is especially true when it comes to people with vaginas, and even more so if you belong to multiple marginalized groups, like being a woman of color with a low income. While this is an unfortunate and frustrating reality, the important thing to keep in mind is that you deserve competent, empathetic care if something is off. We're about to go into some treatment options for pelvic floor disorders, and we know they may not be accessible for all. If these don't seem doable for you, know that getting care wherever and whenever you can is still better than nothing. This is one of those situations when it makes sense to seek the most trustworthy medical advice you can.
The science behind pelvic floor physical therapy
Pelvic floor physical therapy is a way of trying to strengthen the area to alleviate symptoms under the guidance of a physical therapist who specializes in pelvic floor disorders. Just like you’d go to physical therapy if you tore your ACL, you might consider seeing a licensed physical therapist trained in certain techniques that some research suggests may help rehab your pelvic floor. This might sound really weird, but some experts believe pelvic floor physical therapy to be helpful in certain cases. In fact, pelvic floor physical therapy is commonly prescribed for newly postpartum parents in France, where it’s known as la rééducation périnéale.
A pelvic floor physical therapist might teach a person how to properly do Kegels (relaxing and tightening the pelvic floor muscles), go over proper posture so the pelvic floor muscles might work in a more coordinated fashion with the rest of the body, teach deep breathing work that attempts to stimulate the pelvic floor, and more, says Dr. Dune.
That's not to say pelvic floor physical therapy is guaranteed to fix pelvic floor dysfunction. The research on the efficacy of pelvic floor physical therapy is somewhat promising but not yet robust enough to claim it's definitely an effective treatment.
For instance, a July 2014 review in Cochrane Database of Systematic Reviews looked at 13 trials on 1,164 women with urinary incontinence. Some received pelvic floor muscle training (PFMT, like Kegels) in addition to other treatments such as bladder training or anti-incontinence drugs, and others received only other treatments without pelvic floor muscle training. The review concluded that there wasn't enough high-quality evidence to say how much (if at all) PFMT helped with urinary incontinence or quality of life in those who had it.
But a 2015 meta-analysis in the International Urogynecology Journal, which examined 13 studies with 2,340 patients experiencing pelvic organ prolapse, found that those who got PFMT experienced fewer and less severe symptoms than people serving as controls. And a 2018 review in Clinical Interventions in Aging looked at 24 studies analyzing how PFMT affected 2,394 women with urinary incontinence, finding that it led to significant improvement in their quality of life compared with control groups.
Basically, there's a lot more research to be done here before anyone can definitively say that pelvic floor physical therapy is the answer to pelvic floor dysfunction. But ACOG's practice bulletins on both pelvic organ prolapse and urinary incontinence do mention that the pelvic muscle exercises typically included in this type of therapy may be recommended for these types of issues. It's worth knowing what these types of appointments would involve if you were to seek them out.
A pelvic floor physical therapist might teach a person how to properly do Kegels (relaxing and tightening the pelvic floor muscles), go over proper posture so the pelvic floor muscles might work in a more coordinated fashion with the rest of the body, teach deep breathing work that attempts to stimulate the pelvic floor, and more, says Dr. Dune.
That's not to say pelvic floor physical therapy is guaranteed to fix pelvic floor dysfunction. The research on the efficacy of pelvic floor physical therapy is somewhat promising but not yet robust enough to claim it's definitely an effective treatment.
For instance, a July 2014 review in Cochrane Database of Systematic Reviews looked at 13 trials on 1,164 women with urinary incontinence. Some received pelvic floor muscle training (PFMT, like Kegels) in addition to other treatments such as bladder training or anti-incontinence drugs, and others received only other treatments without pelvic floor muscle training. The review concluded that there wasn't enough high-quality evidence to say how much (if at all) PFMT helped with urinary incontinence or quality of life in those who had it.
But a 2015 meta-analysis in the International Urogynecology Journal, which examined 13 studies with 2,340 patients experiencing pelvic organ prolapse, found that those who got PFMT experienced fewer and less severe symptoms than people serving as controls. And a 2018 review in Clinical Interventions in Aging looked at 24 studies analyzing how PFMT affected 2,394 women with urinary incontinence, finding that it led to significant improvement in their quality of life compared with control groups.
Basically, there's a lot more research to be done here before anyone can definitively say that pelvic floor physical therapy is the answer to pelvic floor dysfunction. But ACOG's practice bulletins on both pelvic organ prolapse and urinary incontinence do mention that the pelvic muscle exercises typically included in this type of therapy may be recommended for these types of issues. It's worth knowing what these types of appointments would involve if you were to seek them out.
Pelvic floor physical therapy appointments
So let's say you decide to see a pelvic floor physical therapist. They will usually take a full medical history from you and ask about your symptoms, Dr. Dune says. At some point, they may want to do an internal pelvic floor exam and internal manual therapy directly on your pelvic floor. This doesn’t necessarily need to be during your first appointment. The goal is to only get started on that part of your evaluation when you’re comfortable with it, and any medical professional who tries to pressure you into it is not the right person for you. You can also ask to have a second person in the room.
During the actual exam, your physical therapist will typically insert a gloved finger into your vagina or rectum and ask you to clench your pelvic floor muscles. Depending on what’s going on with your body, this may or may not be painful, Dr. Dune says.
Internal muscle tone is something you can try to evaluate by yourself. If you insert a finger into your vagina, tighten your muscles as if you’re holding in your pee, then let go, you should feel the muscles contract and move up and down, according to the U.S. National Library of Medicine. But you’ll only know your own baseline, Dr. Dune says, while a therapist is more likely to recognize where you fall in the overall anatomical standard.
Plus, a therapist will likely evaluate how some of your other body parts are working, too. “The pelvic floor isn’t isolated—it’s impacted by the hips, low back, knees, and other joints,” says Dr. Dune. “It’s important to get evaluated for bigger picture issues to know for sure what’s going on.”
If your physical therapist thinks you could benefit from a stronger pelvic floor, they will likely come up with a game plan to possibly help you retrain those muscles to contract and loosen appropriately. Then, you will typically start regular appointments to work on your pelvic floor muscles while your therapist tracks your progress.
Many people have appointments once to twice a week over a period of six to 12 weeks. It is generally accepted that some people will start to see differences within four to six weeks, Dr. Dune says. “Like any muscle in the body, retraining the pelvic floor muscles takes time, but it is…often very successful,” she says.
But unfortunately, pelvic therapy isn't a guaranteed success, and even when it might help with pelvic floor issues, you'll probably need to put in a fair amount of work. If you’re curious about checking in with a pelvic floor therapist anyway, you can touch base with your ob/gyn to see what they think and if they have recommendations. You can also visit the American Physical Therapy Association’s (APTA) Women’s Health website and plug in your zip code. It might help to search specifically for physical therapists who have APTAs Certificate of Achievement in Pelvic Health Physical Therapy (CAPP) or Women’s Health Clinical Specialist (WCS) certification. And here’s some information about how to choose the right physical therapist for you.
For some people, pelvic floor physical therapy may help sufficiently with pelvic floor problems. For others, surgery might be necessary to correct issues like pelvic floor organ prolapse.
During the actual exam, your physical therapist will typically insert a gloved finger into your vagina or rectum and ask you to clench your pelvic floor muscles. Depending on what’s going on with your body, this may or may not be painful, Dr. Dune says.
Internal muscle tone is something you can try to evaluate by yourself. If you insert a finger into your vagina, tighten your muscles as if you’re holding in your pee, then let go, you should feel the muscles contract and move up and down, according to the U.S. National Library of Medicine. But you’ll only know your own baseline, Dr. Dune says, while a therapist is more likely to recognize where you fall in the overall anatomical standard.
Plus, a therapist will likely evaluate how some of your other body parts are working, too. “The pelvic floor isn’t isolated—it’s impacted by the hips, low back, knees, and other joints,” says Dr. Dune. “It’s important to get evaluated for bigger picture issues to know for sure what’s going on.”
If your physical therapist thinks you could benefit from a stronger pelvic floor, they will likely come up with a game plan to possibly help you retrain those muscles to contract and loosen appropriately. Then, you will typically start regular appointments to work on your pelvic floor muscles while your therapist tracks your progress.
Many people have appointments once to twice a week over a period of six to 12 weeks. It is generally accepted that some people will start to see differences within four to six weeks, Dr. Dune says. “Like any muscle in the body, retraining the pelvic floor muscles takes time, but it is…often very successful,” she says.
But unfortunately, pelvic therapy isn't a guaranteed success, and even when it might help with pelvic floor issues, you'll probably need to put in a fair amount of work. If you’re curious about checking in with a pelvic floor therapist anyway, you can touch base with your ob/gyn to see what they think and if they have recommendations. You can also visit the American Physical Therapy Association’s (APTA) Women’s Health website and plug in your zip code. It might help to search specifically for physical therapists who have APTAs Certificate of Achievement in Pelvic Health Physical Therapy (CAPP) or Women’s Health Clinical Specialist (WCS) certification. And here’s some information about how to choose the right physical therapist for you.
For some people, pelvic floor physical therapy may help sufficiently with pelvic floor problems. For others, surgery might be necessary to correct issues like pelvic floor organ prolapse.
Preventive pelvic floor physical therapy
Some people decide to see a pelvic floor physical therapist while they’re pregnant instead of waiting until after giving birth. It’s essentially a way of trying to learn how strong your pelvic floor is and possibly get some tips for maintaining that strength throughout pregnancy and childbirth. This can be worthwhile for some people, Dr. LeFevre says.
However, pelvic floor physical therapy is definitely not a requirement during pregnancy. What’s more, it can be a luxury when it comes to both time and money. It will typically be harder to get pelvic floor physical therapy covered by insurance if you’re going preemptively rather than if you’re actually diagnosed with pelvic floor dysfunction, Dr. Dune says. When paying out of pocket, a session may cost between $150 to over $300, she notes, though this can vary based on your location and the specific practice. Even if you do get your session partially covered, you may still be on the hook for a co-pay. Plus, there’s all the time involved with actually going to these appointments.
Also, getting pelvic floor physical therapy while you’re pregnant is kind of like dealing with a moving target. “It might be more effective to wait until you don’t have the ongoing effects of pregnancy,” Dr. Bianco says.
If you want a quick and easy check on how your pelvic floor is doing while you’re pregnant, ask your ob/gyn if they can feel your muscles while you do a Kegel, Dr. Dabney says. See if they have any tips for keeping your pelvic floor strong during pregnancy, like the proper way to do Kegels if you’re not quite sure about your form.
It might be that your pelvic floor is totally fine and any symptoms you’re experiencing—hello, leaky bladder—are just par for the pregnancy course. But if you and your doctor have reason to think you might actually have pelvic floor dysfunction, they can help you identify any next steps to strengthen this important part of your body.
However, pelvic floor physical therapy is definitely not a requirement during pregnancy. What’s more, it can be a luxury when it comes to both time and money. It will typically be harder to get pelvic floor physical therapy covered by insurance if you’re going preemptively rather than if you’re actually diagnosed with pelvic floor dysfunction, Dr. Dune says. When paying out of pocket, a session may cost between $150 to over $300, she notes, though this can vary based on your location and the specific practice. Even if you do get your session partially covered, you may still be on the hook for a co-pay. Plus, there’s all the time involved with actually going to these appointments.
Also, getting pelvic floor physical therapy while you’re pregnant is kind of like dealing with a moving target. “It might be more effective to wait until you don’t have the ongoing effects of pregnancy,” Dr. Bianco says.
If you want a quick and easy check on how your pelvic floor is doing while you’re pregnant, ask your ob/gyn if they can feel your muscles while you do a Kegel, Dr. Dabney says. See if they have any tips for keeping your pelvic floor strong during pregnancy, like the proper way to do Kegels if you’re not quite sure about your form.
It might be that your pelvic floor is totally fine and any symptoms you’re experiencing—hello, leaky bladder—are just par for the pregnancy course. But if you and your doctor have reason to think you might actually have pelvic floor dysfunction, they can help you identify any next steps to strengthen this important part of your body.
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