If you have ever mentioned a pelvic floor concern to a healthcare provider (leaking when you sneeze, pelvic pressure, painful intercourse, or a vague feeling that something “isn’t right” down there) there is a good chance the first thing they told you was: do your Kegels.

Kegels are the default recommendation. They are so widely prescribed that many women have been doing them for years without any improvement, and have come to the quiet conclusion that either the exercises are not working or their pelvic floor is just broken. Neither is true.

The issue is that Kegels address one specific function of the pelvic floor (contraction) and the pelvic floor can be dysfunctional in several ways that have nothing to do with insufficient contraction. Prescribing Kegels for every pelvic floor problem is like prescribing bicep curls for every arm problem. Sometimes it helps. Sometimes it makes things worse.

 

What the Pelvic Floor Actually Does

The pelvic floor is a group of muscles that forms the base of the pelvis. It functions as a hammock supporting the bladder, bowel, and uterus; as a sphincteric controller that manages continence; as a stabilizer that works with the deep abdominal and lumbar muscles to manage intra-abdominal pressure; and as a sexual function structure involved in arousal, penetration, and orgasm.

It needs to do two things: contract and release. And both require coordination, not just strength.

A pelvic floor that cannot contract adequately (called hypotonicity or underactivity) produces symptoms like stress incontinence (leaking with physical effort), pelvic organ prolapse, and reduced sensation. Kegels are the right tool for this presentation. They strengthen and build endurance in the contracting function.

A pelvic floor that cannot relax adequately (called hypertonicity or overactivity) produces symptoms like pelvic pain, painful intercourse, urgency incontinence (the sudden uncontrollable urge), constipation, and difficulty with tampon insertion. Giving this person more Kegels is like telling someone with a muscle cramp to squeeze harder. It makes the problem worse.

A pelvic floor that has lost coordination (the timing and sequencing of contraction and release relative to other movement) produces symptoms like leaking with lifting, jumping, or coughing, core instability, and low back or hip pain. This presentation needs coordination retraining, not just strengthening.

 

How to Know Which Applies to You

Honest answer: you usually cannot tell on your own. The symptoms overlap significantly between hypotonic and hypertonic presentations, which is why so many women have been treating the wrong pattern with the wrong tool.

What I look for in an evaluation:

Whether the pelvic floor can fully contract on request, and whether it can fully release.

Whether there is asymmetry in muscle activation or tension between the left and right sides.

Whether the symptoms are triggered by high-load activities (consistent with underactivity) or by baseline activity and rest (more consistent with overactivity).

Whether there is a history of trauma, difficult delivery, or chronic guarding patterns that may have produced an elevated pelvic floor tone.

The evaluation is the starting point. The prescription comes after.

 

What Treatment Actually Looks Like

For hypotonic presentations, progressive pelvic floor loading (Kegels done correctly, with adequate relaxation between contractions, and with coordination across movement) is appropriate. Correctly means: fully contract, hold, fully release, rest. Not a rapid flutter. Not held breath. Not global abdominal bracing.

For hypertonic presentations, treatment begins with downregulation, teaching the pelvic floor to release. Diaphragmatic breathing, positional work, manual therapy, and nervous system calming approaches come before any strengthening. Adding load to a pelvic floor that is already overactive creates more tension, not less.

For coordination-based presentations, the work is integrating the pelvic floor with the rest of the deep stabilizing system (the diaphragm, the transversus abdominis, and the lumbar multifidi. These four structures work together to manage intra-abdominal pressure. When the timing is off) when the pelvic floor fires too late or not at all before a cough or a jump, that is a coordination deficit, not a strength deficit.

 

The Nervous System Piece

This is the part of pelvic floor treatment that most people have never heard of, and it is the part I find most clinically significant.

The pelvic floor is exquisitely sensitive to the state of the autonomic nervous system. Under chronic stress, under threat, or after trauma, the pelvic floor tends to hold elevated tone as part of a global protective response. This is not voluntary. It is the nervous system doing what it does, protecting the core from perceived threat.

Until the nervous system feels safe, trying to strengthen or retrain a pelvic floor that is in a protective state is working against the body’s own protective response. The work has to include nervous system regulation alongside the muscular re-education.

This is why pelvic floor care done within a whole-person, nervous-system-informed framework (which is how I approach it) produces different outcomes than a purely mechanical protocol.

 

FAQ

How do I know if I have a tight or weak pelvic floor?

Both can cause leaking, which is the most confusing part. A hypotonic (weak) pelvic floor leaks because it cannot generate sufficient closure force. A hypertonic (tight) pelvic floor leaks because tension reduces its ability to respond quickly to pressure changes. Accurate assessment by a trained provider is the most reliable way to distinguish them.

Can I damage my pelvic floor by doing too many Kegels?

If the pelvic floor is already hypertonic, sustained Kegel practice can worsen tension, increase pain, and intensify urgency symptoms. This is why generic “do more Kegels” advice can make some women significantly worse.

Do men have a pelvic floor too?

Yes. Pelvic floor dysfunction in men (including pain, urinary urgency, and post-prostatectomy incontinence) is a real presentation that responds to the same assessment and treatment framework. The anatomy differs; the principles are the same.

 

If Kegels Have Not Helped

There is a reason. It is not that your pelvic floor is beyond help. It is that the Kegel prescription may not match the actual presentation.

Come in for an evaluation. We will assess what is actually happening (contraction, release, coordination, and nervous system tone) and build a plan that addresses what your specific body needs.

Schedule at cospineandjoint.com/schedule-appointment

With care,
Dr. Nisha Copeland, DC
Central Ohio Spine and Joint | Westerville, OH
cospineandjoint.com/schedule-appointment