When your pelvic floor needs more than kegels

The advice almost every woman has received is the same: do your pelvic floor exercises. It's reasonable advice as far as it goes. The trouble is that it's given to everybody, for every symptom, without anyone checking what's actually happening.

Weak isn't the only problem

A pelvic floor can be weak. It can also be overactive, held in a state of low-grade tension that it can't fully release. Overactive pelvic floors are common in women with pelvic pain, painful sex, urinary urgency, difficulty emptying the bladder or bowel, and in people who have been diligently squeezing for years because they were told to.

If that's what's going on, more squeezing is the wrong prescription. Down-training, breathing work and manual techniques do far more.

There's also coordination, which is separate again. Some pelvic floors are strong enough but don't fire at the right moment: during a cough, a sneeze, a jump. That's a timing problem, and it's trainable.

Why an assessment matters

You can't tell which of these you have from your symptoms alone. Leaking, for instance, can come from weakness, from overactivity, from poor coordination, from bladder irritation or from a combination. Guessing has roughly a one-in-three chance of being right.

An assessment includes a conversation about your history, symptoms, bladder and bowel patterns and goals, and, with your consent, an examination to establish what your pelvic floor is actually doing. Real-time ultrasound can be used as a non-invasive alternative. Nothing happens that you haven't agreed to, and you can stop at any point.

Common things worth seeing someone about

• Leaking urine with coughing, sneezing, running or lifting, at any age, including in your twenties
• Urgency, or needing to plan your life around toilets
• A feeling of heaviness or dragging in the vagina
• Pain with sex, or with tampon use
• Pelvic girdle or low back pain during pregnancy
• Abdominal separation that isn't improving after birth
• Returning to running or lifting after a baby and not knowing where to start

None of these are things to accept as the cost of having children or getting older. Most respond well to treatment.

Prevention is the underrated part

The work we do before birth (teaching a pelvic floor to contract and, just as importantly, to let go, and preparing for the demands of labour) pays off afterwards. So does a proper assessment at around six weeks postpartum rather than a general clearance to "resume normal activity".

I'm a strong believer in village-style care, and this is why: your physiotherapy shouldn't be a separate project from your obstetric care. It should be one plan, run by people who talk to each other.

This article is general information and isn't a substitute for advice about your own situation.